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THE    JOURNAL 


American  Medical  Association 


COXTAIXIXG 


THE   OFFICIAL   RECORD   OF   ITS   PROCEEDINGS. 


REPORTS  AND  PAPERS   PRESENTED   IX  THE  SEVERAL  SECTIONS. 


J.  C.  CULBERTSOX,  Editor. 


VOLUME   XVI. 
JANUARY— JUNE.  ^^  \o 

1 891. 


CHICAGO  : 

prixted  at  the  office  of  the.associatiox. 

i8qi. 


"  The  American  Medical  Association,  though  formally  accepting  and  publishing 
the  reports  of  the  various  Standing  Committees  (and  Sections),  holds  itself  wholly 
irresponsible  for  the  opinions,  theories,  or  criticisms  therein  contained,  except  other- 
wise  decided  by  special  resolution." — Transactions,  1851. 

R 

is 

f\h% 
v.  16 

cap. £ 


EDITORIAL  WRITERS  FOR  VOLUME  XVI. 


J.    C.    CfLBERTSON,    CHICAGO,    ILL.,    EDITOR    AND    MANAGER. 


S.  T.  Armstrong,  New  York  City. 

W.  E.   Casselberry,  Chicago,  111. 

G.  H.  Cleveland,  Chicago,  111. 

T.  D.  Crothers,  Hartford,  Conn. 

J.  C.   Culbertson,  Chicago,  111. 

X.  S.  Davis,  Chicago,  111. 

Win.  B.  Dewees,  Salina,  Kan. 

Richard  J.  Dunglison,  Philadelphia,  Pa. 

W.  G.  Eggleston,  Springfield,  111. 

Henry  Gradle,  Chicago,  111. 


John  H.  Hollister,  Chicago,  111. 
Bayard  Holmes,  Chicago,  111. 
S.  J.  Jones,  Chicago,  111. 
F.  H.  Martin,  Chicago,  111. 
Frank  Montgomery,  Chicago,  111. 
Harold  N.  Moyer,  Chicago,  111. 
R.  Harvey  Reed,  Mansfield,  O. 
John  Shrady,  New  York  City,  X.  Y. 
William  L.  Worcester,  Little  Rock,  Ark. 
R.  M.  Wyckoff,  Brooklyn,  X.  Y. 


CONTRIBUTORS  TO  VOLUME  XVI. 


Henry  B.   Baker,  Lansing,  Mich. 

Henry  Banga,  Chicago,  111. 

Simon  Baruch,  New  York  City,  X.  V. 

S.  S.  Bishop,  Chicago,  111. 

Young  H.  Bond,  St.  Louis,  Mo. 

Edw.  Borck,  X.  St.  Louis,  Mo. 

J.  Wesley  Boyce,  Washington,  D.  C. 

Wm.  T.   Briggs,  Xashvilie,  Teun. 

Daniel  R.  Brower,  Chicago,  111. 

Bedford  Brown,  Alexandria,  Va. 

Swan  M.  Burnett,  Washington,  D.  C. 

Peter  A.   Callan,  Xew  York  City.  X.  Y. 

J.  W.  Carhart,  Lampasas,  Tex. 

J.  G.  Carpenter,  Stanford,  Ky. 

Hiram  Corson,  Plymouth  Meeting,  Pa. 


W.  E.  Casselberry,  Chicago,  111. 
Archibald  Church,  Chicago,  111. 
Augustus  P.   Clarke,  Cambridge,  Mass. 
T.  D.  Crothers,  Hartford,  Conn. 
N.  S.  Davis,  Chicago,  111. 
Wm.  B.  Davis,  Cincinnati,  O. 
Wm.  B.  Dewees,  Salina,  Kan. 
Francis  Dowiing,  Cincinnati,  O. 
Richard  J.   Dunglison,  Philadelphia,  Pa. 
Henry  E.  Dwight,  Philadelphia,  Pa. 
C.  R.   Earley,  Ridgway,  Pa. 
J.  H.  Etheridge,  Chicago,  111. 
Geo.  E.  Fell,  Buffalo,  N.  Y. 
Christian  Fenger,  Chicago,  111. 
James  M.   French,  Cincinnati,  O. 


CONTRIBUTORS. 


Harry  Friedenwald,  Baltimore,  Md. 

E.  J.  Chapin  Minard,  New  York  City. 

Henry  D.  Fry,  Washington,  D.  C. 

J.  S.  Nowlin,  Shelbyville,  Tenn. 

W.  J.  Galbraith,  Omaha,  Neb. 

Chas.  T.  Parkes,  Chicago,  111. 

Heneage  Gibbes,  Ann  Arbor,  Mich. 

W.  W.  Parker,  Richmond,  Va. 

Geo.  M.  Gould,  Philadelphia,  Pa. 

F.  J.  Parkhurst,  Danvers,  111. 

Edw.  Guhman,  St.  Louis,  Mo. 

Asa  F.  Pattee,  Boston,  Mass. 

Henry  Bixby  Hemenway,  Evanston,  111. 

0.  G.  Pfaff,  Indianapolis,  Ind. 

W.  J.  Herdman,  Ann  Arbor,  Mich. 

F.  Peyre  Porcher,  Charleston,  S.  C. 

Br  yard  Holmes,  Chicago,  111. 

William  Porter,  St.  Louis,  Mo. 

C.  R.  Holmes,  Cincinnati,  0. 

Geo.  J.  Preston,  Baltimore,  Md. 

C.  H.  Hughes,  St.  Louis,  Mo. 

James  J.  Putnam,  Boston,  Mass. 

E.  Fletcher  Ingals,  Chicago,  111. 

B.  Alex.  Randall,  Philadelphia. 

Edward  Jackson,  Philadelphia. 

F.  C.  Raynor,  Brooklyn,  N.  Y. 

S.  K.  Jackson,  Norfolk,  Va. 

R.  Harvey  Reed,  Mansfield,  0. 

W.  W.  Jaggard,  Chicago,  111. 

Henry  A.  Riley,  New  York  City. 

J.  F.  Jenkins,  Tecumseh,  Mich. 

John  B.  Roberts,  Philadelphia. 

S.  J.  Jones,  Chicago,  111. 

H.  Russell,  Superior,  Wis. 

A.  B.  Judsou,  New  York  City. 

J.  Schenck,  Mt.  Carmel,  111. 

Thomas  W.  Kay,  Scranton,  Pa. 

N.  Senn,  Chicago,  111. 

Robert  A.  Kitto,  Racine,  Wis. 

Geo.  Erety  Shoemaker,  Philadelphia. 

Carl  H.  von  Klein,  Dayton,  0. 

E.  L.  Shurly,  Detroit,  Mich. 

Robt.  Koch,  Berlin,  Germany. 

J.  W.  Small,  New  York  City. 

S.  P.  Kramer,  Cincinnati,  O. 

Solomon  Solis- Cohen,  Philadelphia. 

D.  S.  Lamb,  Washington,  D.  C. 

Dr.  Sorineuberg,  Berlin,  Germany. 

Benjamin  Lee,  Philadelphia. 

Chas.  F.  Stillman,  Chicago,  111. 

I.  N.  Love,  St.  Louis,  Mo. 

I.  S.  Stone,  Washington,  D.  C. 

Henry  M.  Lyman,  Chicago,  111. 

Flavel  B.  Tiffany,  Kansas  City,  Mo. 

Henry  0.  Marcy,  Boston,  Mass. 

Victor  C.  Vaughan,  Ann  Arbor,  Mich. 

John  S.  Marshall,  Chicago,  111. 

A.  L.  Wagner,  South  Bend,  Ind. 

Franklin  H.  Martin,  Chicago,  111. 

A.  B.  Walker,  Canton,  0. 

L.  D.  Mason,  Fort  Hamilton,  L.  I. 

William  Wotkyns  Seymour,  Troy,  N.  Y. 

Joseph  M.  Mathews,  Louisville,  Ky. 

H.  V.  Wurdeman,  Milwaukee,  Wis. 

Wm.  McCoIlom,  Brooklyn,  N.  Y. 

John  A.  Wyeth,  New  York  City. 

Theo.  A.  McGraw,  Detroit,  Mich. 

Joseph  Zeisler,  Chicago,  111. 

Dan  Millikin,  Hamilton,  O. 

T  1 1  E 


Journal  of  the  American  Medical  Association. 

EDITED  UNDER  THE  DIRECTION  OF  THE  BOARD  OF  TRUSTEES. 

PUBLISHED    WEEKLY. 


Vol.  XVI. 


CHICAGO,  JANUARY  3,   1891. 


No  1. 


ADDRESSES. 


THE  PRESIDENT'S  ADDRESS. 

rtienth    Annual  Meeting   of   the   American 
ne,  held  at  Philadelphia,  December 3,  1&90. 

BY  S.  J.  JONES,  A.M.,  M.D.,  LL.D., 

OF  CHICAGO,  ILL. 

On  this  interesting  occasion,  when  we  are 
felicitating  ourselves  on  the  re-assembling  of  the 
Academy  in  the  place  of  its  birth,  we  find  added 
interest  in  the  fact  that  it  was  here  that  the  first 
medical  college  in  America  was  organized,  and 
that  the  teaching  which  was  so  well  begun  in 
Colonial  days  has  not  been  allowed  to  lag  in  the 
onward  movement  of  the  intervening  years;  that 
here  the  American  Medical  Association  completed 
its  organization  in  the  interest  of  liberal  medical 
education  and  elevation  of  the  medical  profession, 
and  its  first  report  on  medical  education  was 
made;  and  here,  during  the  Centennial  Medical 
Congress,  the  work  of  the  medical  profession  of 
America  for  a  century  was  portrayed,  showing 
its  achievements  and  its  defects,  and  making  ap- 
parent its  needs. 

This  occasion,  therefore,  is  of  more  than  ordi- 
nary interest  to  us. 

It  was  fitting  that  an  organization  having  an 
object  such  as  that  of  this  Academy  should  have 
originated  here  and  amid  the  influences  which 
surrounded  that  Congress. 

The  founders  of  the  Academy  were  inspired  by 
the  greatness  of  our  calling,  with  its  possibilities 
for  good,  and  encouraged  by  the  achievements  of 
our  predecessors, —  often  accomplished  under 
most  adverse  circumstances.  They  were  also  ad- 
monished by  knowledge  of  our  shortcomings, 
which  had  been  rendered  apparent  in  the  numer- 
ous formal  reports  on  Medical  Education  made  at 
the  annual  meetings  of  the  American  Medical 
Association  between  the  years  1847  and  1873,  as 
also,  in  the  carefully  prepared  addresses  delivered 
before  the  Centennial  Medical  Congress.  Thus, 
with  an  appreciation  of  the  difficulties  of  the  work 
yet  to  be  accomplished  in  fulfilling  its  mission, 
the  Academy  entered  upon  its  undertaking  with 
limited  numbers  but  in  such  manner  as  in  the 
state  ofliterary  and  medical  education, at  that  cime, 
seemed  best  suited  to  remedy  existing  defects.  As 


that  Centennial  Congress  afforded  a  favorable 
occasion  for  review  of  the  work  of  the  whole  pro- 
fession in  the  preceding  century,  so  our  return 
here,  to-day,  suggests  a  retrospect  of  the  work  of 
the  Academy  in  the  fourteen  years  of  its  existence, 
and  it  may  not  be  unprofitable  to  consider,  briefly, 
its  aims  and  its  present  needs  for  fruitful  endeavor 
in  the  future.  Great  and  gratifying  as  were  the 
results  that  had  been  accomplished  by  our  profes- 
sion in  the  century  preceding  that  congress,  it  was 
apparent  that  much  yet  remained  to  be  done, 
especially  in  the  matter  of  preparatory  education 
of  students  of  medicine.  Since  that  time  such  in- 
creased facilities  have  continually  been  added  in 
their  teaching,  in  the  best  equipped  medical  col- 
leges, that  it  is  within  the  limits  of  accuracy  to 
assert  that  at  no  other  time  within  the  history  of 
the  world  have  such  opportunities  been  afforded 
students  of  medicine  as  in  the  present  day,  and  to 
this  end  the  efforts  of  this  Academy  have  doubt- 
less contributed. 

In  order  that  students  may  be  enabled  to  com- 
prehend and  to  fully  profit  by  such  instruction, the 
need  of  proper  mental  discipline,  before  entering 
upon  their  medical  studies,  is  so  undoubted  as 
neither  to  require  or  admit  of  argument,  but  em- 
phasizes the  importance  of  the  Academy's  mission 
and  the.  usefulness  of  its  efforts. 

In  its  organization  the  fact  was  recognized  that 
elevation  of  the  medical  profession  must  primarily 
rest  upon  liberal  education,  with  implied  mental 
discipline,  as  the  foundation  on  which  to  build 
successfully. 

Already  many  changes  have  occurred  in  the 
matter  of  education,  literary  and  medical,  espe- 
cially since  the  Colonial  times  with  the  medical  ap- 
prentice system  and  the  primitive  educational 
efforts  of  those  earlier  days. 

In  the  rapidly  shifting  scenes  by  which  we  are 
surrounded,  and  in  the  onward  march  of  science 
that  characterizes  the  age  in  which  we  are  liv- 
ing, it  is  no  small  undertaking  to  move  apace 
with  those  events  and  to  keep  our  educational 
institutions  abreast  of  that  advance,  and  so  ad- 
justed as  to  meet  the  demands  of  these  progres- 
sive times. 

Especially  in  the  latter  part  of  the  present  cen- 
tury has  wonderful  advance  been  made  in  science 
and  art  and  the  humanities.      As  is  meet,  medi- 


PRESIDENT'S  ADDRESS. 


[January  3, 


cine,  which  has  been  called  "the  link  that  unites 
science  and  philanthropy,"  seeks  to  keep  pace 
with  those  advances.  Being  a  liberal  profession  as 
well  as  an  art,  it  should  ever  be  in  the  forefront 
in  the  progress  of  civilization.  It  is  the  aim,  and  j 
it  has  been  the  effort,  of  the  Academy  to  secure 
higher  preliminary  and  medical  education  as  be- 
ing in  the  direction  of  further  advancement  of 
the  profession  whose  purposes  are,  first  to  pre-  j 
vent  conditions  which  lead  to  disease,  suffering  j 
and  untimely  death,  and,  next,  to  alleviate  dis- 
ease  and  the  suffering  of  our  fellow  men  so  far  as  j 
it  lies  within  the  power  of  man  to  do.  That  the 
efforts  of  the  Academy  have  not  been  unavailing 
in  its  laudable  endeavor,  seems  apparent  in  the 
increasing  numbers  which  are  yearly  being 
added  to  the  roll  of  its  fellows,  and  in  the  esti- 
mate in  which  it  is  held  by  the  medical  profes- 
sion, even  among  those  who  are  not  eligible  to 
fellowship  under  the  prescribed  conditions,  but 
who  indorse  its  aim  and  its  work. 

At  the  time  of  its  organization  almost  the 
only  degree  conferred,  at  graduation,  by  the 
literary  colleges  •  of  this  country  was  that  of 
Bachelor  of  Arts,  and  the  Academy  adopted  that 
degree  as  offering  presumptive  evidence  of  liberal 
education,  and  made  it  a  sine  qua  non  of  fellow- 
ship. 

Since  that  time  many  of  the  prominent  literary 
colleges  of  our  country  have  modified  their  cur- 
ricula of  study,  and  they  now  confer  other  de- 
grees, after  a  course  equivalent  to  that  which  is 
required  to  obtain  the  degree  of  Bachelor  of  Arts. 
Acting  upon  the  recognized  fact  that  the 
Academy  desires  not  merely  the  possession  of 
any  particular  literary  degree,  but  such  mental 
discipline  as  qualifies  for  profitable  study  of  medi- 
cine, its  council  at  its  last  annual  meeting,  after 
careful  consideration  of  the  subject  in  its  many 
bearings,  recommended  that  the  conditions  of 
fellowship,  which  required  the  possession  of  that 
degree  received  in  course,  be  so  modified  that  ap 
plicants  giving  evidence  of  equivalent  preparatory 
liberal  education,  or  having  other  literary  de- 
grees, conferred  upon  them  in  course,  and  after 
having  completed  a  curriculum  of  study  equiva- 
lent to  that  required  for  obtaining  the  degree  of 
Bachelor  of  Arts,  as  determined  by  the  Council 
and  upon  its  recommendation,  should  be  eligible 
to  election.  The  Academy  so  amended  its  Con 
stitution  and  placed  itself  en  rapport  with  the 
progress  of  the  immediate  present,  untrammeled 
by  too  conservative  traditions  of  the  past,  and, 
on  the  other  hand,  guarding  against  such  radical 
change  as  might  lead  to  belief  that  it  had 
abandoned  the  very  corner  stone  of  its  founda- 
tion, and  its  raison  d'etre.  But  additional  pro- 
vision is  needed,  to  enable  it  to  meet  the  require- 
ments of  the  near  future  because  of  the  changes 
that  are  yearly  being  made  regarding  the  practice 
of  medicine. 


For  the  last  two  years  an  effort  has  been  in 
progress,  through  committees  appointed  for  that 
purpose,  to  ascertain  the  names  and  addresses  of 
all  physicians  in  the  United  States  who  are  eligi- 
ble to  Fellowship  under  the  prescribed  condition 
of  having  the  degree  of  Bachelor  of  Arts.  That 
work  has  shown  that  but  a  very  small  proportion 
were  eligible ;  so  small,  in  fact,  that  the  Academy 
cannot  with  its  comparatively  limited  Fellowship 
at  present,  nor  could  it,  if  all  who  were  eligible 
by  reason  of  possessing  that  degree  should  unite 
with  us,  become  the  power  for  good  that  it  should 
be,  nor  exert  the  influence  necessary  to  the  ac- 
complishment, at  an  early  date,  of  the  purpose 
for  which  it  was  designed. 

Since  its  aim  is  that  of  a  missionary  seeking  to 
accomplish  the  greatest  good  for  mankind,  it 
would  seem  to  be  the  part  of  wisdom  not  only  to 
persevere  in  the  line  of  the  good  work  that  it  has 
been  doing,  but  to  admit  to  Fellowship,  immedi- 
ately on  graduation,  all  physicians  who  meet  its 
literary  and  professional  requirements,  and,  in  ad- 
dition, to  widen  its  sphere  by  bringing  into  affili- 
ation with  it  and  securing  the  active  cooperation 
of  the  better  element  of  our  profession  that  have 
not  enjoyed  the  advantages  of  a  literary  course 
such  as  has  heretofore  been  necessary  to  entitle 
to  Fellowship,  but  who,  without  such  preliminary 
training,  have  attained  a  useful  and  honorable 
position  in  our  profession  ;  men  whose  character 
and  acquirements  make  them  representative  mem- 
bers of  our  calling  in  different  sections  of  our 
country ;  men  who,  though  not  thus  made  eligi- 
ble to  Fellowship,  are  broad  enough  in  their  views 
not  to  join  in  the  charge  that  has  been  made  by 
some  that  this  Academy,  by  restricting  its  condi- 
tions of  Fellowship,  aims  to  establish  an  illiberal 
mutual- admiration  society,  whose  motto  is  "  I  am 
holier  than  thou."  To  us  it  is  well  known  that 
the  charge  is  alike  groundless  and  unjust,  but  it 
must  be  admitted  that  among  those  less  familiar 
with  the  Academy  and  its  work  it  has  not  been 
without  a  degree,  though  perhaps  slight,  of  in- 
fluence adverse  to  its  principles  and  its  endeavors. 
If  by  any  proper  means,  as  by  construing  liber- 
ally the  present  requirements  for  Fellowship,  or 
by  changing  the  conditions  requisite  for  honorary 
membership,  or  by  establishing  associate  fellow- 
ship, we  can  identify  with  the  Academy  that  bet- 
ter element,  a  powerful  ally  in  our  missionary 
work  can  be,  and  should  be,  secured. 

This  subject  is  not  new  to  the  Academy,  for  in 
different  forms  it  has  been  considered  for  several 
years,  nor  is  it  so  old  and  trite  that  it  may  not 
be  further  discussed  and  considered,  that  our 
thoughts  may  be  more  crystallized,  and  so  form- 
ulated that  an  end  may  be  readied  which  is  gen- 
erally recognized  as  being  desirable,  if  proper 
means  of  accomplishing  it  can  be  adopted.  Many 
of  these  men  realize  the  advantage  that  it  would 
have  been  to  them  in  their  struggles  to  reach  their 


1891.J 


PRESIDENT'S  ADDRESS. 


present  positions  in  the  profession,  if  they  could 
have  had  opportunity  of  protracted  mental  disci- 
pline before  beginning  the  study  of  medicine. 
Their  greater  difficulty  in  prosecuting  their  pro- 
fessional  study;  the  embarrassments  attending 
their  practice  in  after  years,  and  the  seemingly 
impossible  task  of  compensating  for  that  defect, 
have  made  them  keenly  appreciative  of  the  ad- 
vantages which  they  were  denied,  and  they  are 
among  the  strongest  advocates  of  the  Academy's 
purpose.  In  the  belief  of  the  desirability,  the  im- 
portance and  the  advantage  to  our  cause,  of  form- 
ing a  union  with  them,  at  as  early  a  time  as  it  is 
feasible  to  accomplish  it,  due  consideration  of  the 
subject  at  this  meeting  is  respectfully  urged. 

With  the  many  medical  organizations,  National 
and  local,  general  and  special,  that  have  been  cre- 
ated since  the  founding  of  the  Academy,  ample 
provision  has  been  made  for  the  presentation,  else- 
where than  in  this  Academy,  of  all  scientific  pa- 
pers relating  to  medicine  which  the  Fellows  may 
desire  to  present,  and  this  session  seems  an  ap- 
propriate time  for  the  Academy  to  consider 
whether,  henceforth,  it  had  not  better  restrict  its 
efforts  exclusively  to  missionary  work,  having  as 
its  mission : 

i.  Fostering  of  preliminary  education,  as  being 
now,  even  more  than  ever  before,  indispensable 
for  students  of  medicine. 

2.  Advocating  higher  medical  education  and 
upholding  medical  colleges  which  afford  the  great- 
est facilities  for  proper  medical  education,  and 
which  demand  a  high  standard  of  qualification  of 
their  students,  and 

3.  Advocating  State  control  of  the  license  to 
practice  medicine,  regardless  of  the  possession  of 
diplomas  issued  by  medical  colleges  —  making 
colleges  what  they  should  be,  simply  teaching 
bodies,  thus  stimulating  to  rivalry  for  the  best 
teaching  rather  than  for  the  largest  classes,  and 
affording  the  public  better  opportunity  of  judging 
of  the  qualifications  of  physicians  than  the  pres- 
ent system  of  granting  diplomas  gives. 

Such  a  course  would  give  to  the  Academy  a 
distinctive  character,  which  would  avoid  its  con- 
flicting with  any  other  organization,  and  would 
commend  it,  yet  more  fully,  to  the  better  element 
of  our  profession  and  to  the  thoughtful  consider- 
ation of  the  laity  as  well. 

If  the  voting  public,  the  chief  source  from  which 
medical  legislation  must  be  secured,  can  be  made 
to  understand  that  the  medical  profession  is  not 
actuated  by  purely  personal  motives,  but  that  it, 
and  this  Academy  as  well,  aims  to  secure,  for  the 
benefit  of  the  people,  men  of  liberal  education  for 
the  physicians  of  our  country,  their  sympathy  will 
be  enlisted,  and  their  feeling  of  self-interest  would 
be  an  impelling  motive  to  procure  such  legislative 
enactments  as  are  essential  for  the  welfare  of  the 
citizen,  for  the  protection  of  the  health  of  the 
public,  and  for  just  appreciation  of  the  usefulness, 


the  dignity,  and  the  self-respect  of  the  medical 
profession.  They  should  be  made  to  comprehend 
the  fact  that  to  that  end  strict  requirements  should 
be  placed  upon  medical  colleges,  instead  of  con- 
tinuance of  the  present  reckless  mode  of  charter- 
ing them,  and  that  each  State  should  establish  by 
law  a  uniform,  minimum,  degree  of  professional 
attainment  to  entitle  one  to  the  right  to  practice 
medicine  within  its  borders,  regardless  of  the 
source  of  the  knowledge — thereby  securing  qual- 
ified physicians  and  declaring,  by  official  certifi- 
cate for  public  registration,  the  standard  reached 
in  such  an  examination. 

That  "  no  nation  can  be  truly  great  if  unmind- 
ful of  the  sanitary  condition  of  its  citizens"  '  is 
evident  to  all,  but  how  best  to  care  for  its  citizens 
is  not  so  definitely  settled  in  the  minds  of  our 
people.  The  established  facts  of  sanitary  science 
have  led  to  the  adoption  by  Governments — our 
own  among  the  number — of  many  measures  de- 
signed to  preserve  the  public  health.  Owing  to 
our  form  of  Government,  which  is  not  paternal 
in  character,  much  that  relates  to  the  welfare  of 
the  people  devolves  upon  the  individual  States 
which,  under  the  police  power  that  it  has  been 
judicially  affirmed  they  have,  can  legislate  for  the 
protection  of  the  citizen  in  matters  that  do  not 
devolve  upon  the  general  Government.  This  in- 
cludes the  subject  of  legislation  regarding  condi- 
tions entitling  physicians  to  the  right  to  practice 
medicine.  Already  a  number  of  the  States  have 
passed  laws  of  this  character  defining,  in  various 
ways,  the  conditions  essential  to  secure  for  physi- 
cians a  right  to  practice,  in  each  of  those  States, 
and  establishing  boards  consisting,  in  part  at 
least,  of  physicians  who  are  charged  with  the 
duty  of  securing  compliance  with  the  law's  re- 
quirements for  the  protection  of  the  public  from 
unqualified  medical  men.  Under  the  laws  of  some 
of  these  States  no  diploma  of  a  medical  college  is 
recognized  as  entitling  its  owner,  or  holder,  to  a 
right  to  enter  upon  the  practice  of  medicine  within 
those  States.  In  others  such  right  is  conceded 
under  certain  declared  limitations.  This  legisla- 
tion, though  of  comparatively  recent  origin,  has 
already  made  progress  which  augurs  well  for  the 
future  of  the  principles  which  this  Academy  ad- 
vocates. It  moreover  affords  the  Academy  an  ex- 
tended field  of  usefulness  through  its  Fellows  resi- 
dent in  the  different  States. 

When  a  uniform  standard  of  examination  of 
all  applicants  for  license  to  practice  medicine  in 
any  State  is  established,  equal  justice  is  done  to 
all.  No  ground  remains  for  charges  of  unjust 
discrimination  against  any.  It  is  in  the  interest 
of  scientific  medicine,  and  therefore  of  the  public, 
that  every  State  should  enact  such  laws,  and  it  is 
but  natural  that  the  medical  profession,  because 
of  their  greater  familiarity  with  the  subject,  should 
lead  in  formulating  and  advocating  the  passage  of 


THE  HYGIENE  OF  SCHOOL  STUDIES. 


[January  3, 


such  laws  for  their  State  as  their  experience  and 
wisdom  lead  them  to  believe  to  be  best  suited  to 
secure  the  health  and  well  being  of  the  people  of 
their  State.  An  efficient  means  to  that  end  lies 
in  securing  for  the  State  qualified  physicians,  and 
banishment  of  the  unqualified. 

To  effect  reforms  organized  effort  is  required, 
and  the  more  systematically  the  work  is  done  the 
better  prospect  of  success  attends  it.  Should 
the  Academy  deem  it  expedient  to  constitute 
the  Fellows  resident  in  each  State  a  special 
committee  for  that  State  to  represent  it  in  advo- 
cating its  principles,  and  seeking  cooperation  of 
the  medical  organizations  of  such  State  to  secure 
medical  legislation  having  in  view  the  proper  pro- 
tection of  the  people,  by  requiring  adequate  pre- 
liminary and  medical  education  to  procure  a  li- 
cense to  practice,  it  seems  probable  that  the 
usefulness  of  the  Academy  could  be  materially 
increased ;  its  work  rendered  efficient  ;  its  aims 
practically  realized,  and  the  people  as  well  as  our 
profession  be  benefited.  It  may  be  assumed  that 
the  Academy  was  not  organized  solely  for  the 
benefit  of  the  student  of  medicine,  nor  even  for 
the  welfare  of  the  medical  profession,  alone,  but 
to  secure  for  the  public  well  qualified  physicians, 
the  accomplishment  of  which  would  also,  inci- 
dentally, redound  to  the  credit  of  our  profession. 
Therefore  it  would  seem  to  be  eminently  proper 
that  this  Academy  should  advance  still  further  in 
pursuit  of  its  purpose,  and  give  to  its  work  this 
additional  and  practical  direction,  which  would  be 
in  keeping  with  the  spirit  of  progress  which  has 
recently  been  given  additional  impetus  because 
the  medical  profession  and  the  public  alike  are 
demanding  some  remedy  for  abuses  that  are  at- 
tendant upon  the  transitional  state  in  which  the 
practice  of  medicine  has  been  for  the  last  several 
years.  It  is  perhaps  not  essential  that  now  or 
here  it  should  be  attempted  to  explain  why  this 
unfortunate  state  exists,  but  more  profitable  to 
recognize  the  fact  of  its  existence  and  the  general 
demand  for  some  remedy  for  it.  If  a  practicable 
plan  can  be  adopted  by  this  Academy  by  which 
it  can  efficiently  contribute  toward  the  accom- 
plishment of  a  result  so  much  desired,  it  will  still 
further  demonstrate  its  usefulness,  and  additional 
reason  for  continuance  of  its  existence. 


Dr.  Prentiss  at  a  meeting  of  the  International 
Medical  Congress  at  Berlin,  related  the  case  of  a 
lady,  .H.  25,  who  had  thin  blonde  hair,  and  who 
suffered  from  uraemic  symptoms  depending  on  an 
affection  of  the  kidneys.  Frequent  injections  of 
pilocarpine  were  given.  In  one  month  the  hair 
had  become  changed  to  a  chestnut  color,  and 
after  two  months  il  was  found  to  be  a  deep  black; 
the  hair,  moreover,  being  much  fuller  and  thicker 
than  before. 


ORIGINAL  ARTICLES. 


THE  HYGIENE  OF  SCHOOL  STUDIES. 

Read  be/oi  e  the  Medii  ol  Society  of  the  District  of  Columbia ,  November 
BY  D.  S.  LAMB,  M.D., 

OF   WASHINGTON,  D.  C. 

This  paper  lays  no  claim  to  originality.  The 
ground  has  been  repeatedly  gone  over  and  worked 
up.  The  territory  covered  by  the  name  "School 
Hygiene"  is  large  and  full  of  details.  I  have 
chosen  only  the  "Hygiene  of  School  Studies." 
The  others  are  of  equal  importance;  they  are  all 
interdependent.  The  literature  is  immense, 
especially  that  of  the  last  ten  years.  This  inquiry- 
represents  the  opinion  of  this  country,  Canada, 
Great  Britain,  France  and  Belgium;  and  it  is  fair 
to  assume  can  hardly  differ  from  that  of  other 
European  countries. 

Herbert  Spencer  says  that  success  in  the  world 
depends  on  energy  rather  than  information  ;  a 
policy  which  crams  with  information  undermines 
energy  and  defeats  itself.  Information  rapidly 
acquired  is  rapidly  lost ;  and  the  cramming 
method  unfits  the  brain  for  healthy  spontaneous 
work.  The  acquisition  of  knowledge  is  only  part; 
it  is  the  organization  of  knowledge,  requiring 
time  and  thought,  which  is  useful.  Spencer  also 
compares  knowledge  which  is  simply  stored  up, 
to  so  much  intellectual  fat;  it  must  be  intellectual 
muscle  to  be  of  value. 

The  object  of  education  is  to  prepare  for  what 
is  commonly  called  ".our  life  work;"  and  the  test 
of  the  value  of  an  educational  course  is  whether 
it  fulfils  that  end.  To  paraphrase  Spencer's 
words  by  those  of  another  author,  man  must  be  a 
good  animal  to  succeed  in  life.  Abnormal  use  of 
the  intellectual  part  leads  to  premature  arrest  of 
the  physical.  The  physical,  mental  and  moral 
must  be  developed  together.  If  either  is  neglected 
or  overworked,  manhood  and  womanhood  will  be 
ill-balanced  and  defective.  A  normal  exercise  of 
each  is  reflected  beneficially  upon  the  others;  a 
normal  exercise  of  all  improves  the  quality  of 
each.  Old  Hippocrates  said  that  the  strength  of 
the  mind  increases  with  that  of  the  body. 

The  first  requisite  then  of  a  child  is  to  be  well; 
for  the  child  as  a  child;  as  the  promise  of  a  future 
man  or  woman;  and  as  a  coming  industrial  in- 
dividual. There  cannot  be  a  sound  mind  in  an 
Unsound  body. 

In  all  countries  pretending  to  any  degree  of 
civilization,  past  and  present,  the  schoolmaster 
has  been  and  is  an  important  member  of  society. 
It  has  been  found  most  convenient  and  satisfac- 
tory by  the  majority  of  the  people  to  delegate  at 
least  secular  education  of  their  children  to  one 
who  makes  a  specialty  of  that  work,  and  who, 
inferentially,  is  best  qualified  to  do  it.  Among 
the  Greeks  he  was  called  Paidagogos,  a  leader  of 


i8gi.] 


THE  HYGIENE  OF  SCHOOL  STUDIES. 


boys;  afterwards  a  teacher  of  children,  boys  and 
girls.  He  often  walked  about  with  his  scholars 
in  the  open  air,  asking  and  answering  qui 
Thus  they  acquired  knowledge  and  health  to- 
gether. The  spilling  of  the  word  changed  from 
paid  toped  would  suggest  this  custom  of  leading 
the  children  afoot;  as  if  from  the  latin  pes,  pedis, 
a  foot.  With  this  in  mind  if  I  might  coin  a  word. 
I  would  say  that  pedagogue  expresses  the  modern 
custom  of  teaching  children,  while  sitting.  The 
schoolmaster  sits  down  with  his  scholars  in  a 
class  room,  properly  or  improperly  lighted. 
heated  and  ventilated ;  conducing  to  mental 
effort  or  mental  inertia. 

I  question  whether  by  less  session  and  more 
motion  the  scholar  may  not  acquire  as  much  use- 
ful knowledge  of  men  and  things  in  less  time  and 
at  less  cost  to  health.  At  the  same  time  it  must 
not  be  forgotten  that  the  disabilities  under  which 
children  labor,  are  often  due,  at  least  in  part,  to 
faulty  regulations  or  absence  of  regulations  at 
home.  The  first  question  is  as  to  the  maximum 
time  a  child  may  be  required  or  permitted  to 
study  during  any  one  day;  for  the  present,  ex- 
cluding home  stud}'.  Many  of  the  writers  ex- 
press the  conviction  that  except  for  kindergarten 
work,  children  should  not  enter  school  before  the 
age  of  8  years;  that  besides  acquiring  a  greater 
measure  of  health  up  to  that  age,  and  diminish- 
ing very  greatly  the  liability  to  contract  conta- 
gious diseases,  a  child  will  learn  as  much,  indeed 
more,  after  that  age,  than  if  he  began  his  school 
studies  earlier. 

From  the  age  of  7  to  9,  the  maximum  number 
of  hours  of  daily  study  should  not  exceed  three. 
From  9  to  12  years,  not  more  than  four.  The 
State  Medical  Society  of  Rhode  Island  has  ex- 
pressed its  opinion  that  three  is  enough.  From 
12  to  15  years,  five  to  six  hours.  From  15  to  18 
years,  eight  hours.  These  statements  are  based 
on  those  of  Drs.  Newsholnie  of  London,  Chan- 
cellor and  Rohe  of  Baltimore.  Dr.  Newsholme 
is  a  graduate  of  the  Department  of  Public  Health 
of  the  University  of  London,  and  Health  Officer 
of  Clapham;  and  the  author  of  a  work  on  "School 
Hygiene,"  London,  1887.  Dr.  Rohe,  of  Baltimore, 
is  the  author  of  a  "Text-Book of  Hygiene,"  Phil- 
adelphia and  London,  1890.  Dr.  Chancellor  was 
and  may  yet  be  the  Secretary  of  the  Maryland 
Board  of  Health,  and  read  a  paper  on  "School 
Hygiene,"  published  by  the  Board  in  its  7th  Re- 
port, 1888. 

The  New  York  Medico-Legal  Society  has  de- 
clared its  opinion  that  in  primary  schools  three 
hours  a  day  of  study  is  enough. 

In  England  it  is  stated  that  good  voluntary 
attention  in  children  from  10  to  12  years  of  age, 
is  exhausted  by  four  varied  lessons,  requiring 
mental  effort  of  half  an  hour  each,  in  the  fore- 
noon, with  intervals  of  relief.  After  the  midday 
meal,  the  capacity  of  voluntary  attention  is  gen- 


erally reduced  one-half;  and  not  more  than  two 
half  hour  lessons  requiring  mental  effort  can  be 
given  with  profit.  This  makes  three  hours  of 
actual  mental  work  in  six  hours  of  school  time 

The  experience  often  to  twelve  thousand  pupils 
covering  twelve  to  fifteen  years,  shows  that  the 
general  average  school  time  is  fully  double  the 
psychological  limit  of  the  capacity  of  the  average 
child,  for  lessons  requiring  mental  effort.  Beyond 
that  limit,  instruction  is  profitless.  In  England 
there  are  what  are  called  half-time  schools,  for 
children  who  are  at  work  part  of  the  day  in 
factories,  etc.  They  have  the  same  curriculum 
as  the  whole  or  six-hour  scholars.  The  book 
attainments  of  the  three-hour  scholars  are  fully 
equal  to  those  of  the  six.  More  than  that,  the 
three-hour  children  get  through  the  fourth  stan- 
dard or  grade  by  the  nine  and  a  half  year;  while 
the  six-hour  children,  with  double  the  time  de- 
voted to  the  same  studies,  fail  to  get  through  be- 
fore the  ten  and  a  half  to  the  eleventh  year.  The 
cost  of  the  long  time  schools  is  about  double  that 
of  the  short. 

More  than  that,  the  half-time  scholars  show  a 
greater  aptitude  of  application,  superior  alertness 
and  efficiency. 

In  this  connection  I  would  mention  Roth's 
"Elements  of  School  Hygiene,"  London,  1886; 
and  especially  the  veteran  Edwin  Chadwick,  the 
well  known  sanitarian,  who  died  so  recently;  his 
book  called  "The  Health  of  Nations,"  reviewed 
by  Benjamin  Ward  Richardson;  2  vols,,  1887. 

The  French  law  prescribes  three  hours  in  the 
morning  and  the  same  in  the  afternoon.  The 
School  Commission  of  the  Academy  of  Medicine, 
Paris,  reported  in  1888,  that  in  the  primary 
schools,  which  are  divided  into  three  grades  and 
include  children  from  6  to  13  years,  those  in  the 
lowest  school  should  have  daily  but  three  and  a 
half  hours,  in  the  middle  school  four  and  a  half, 
and  in  the  upper  school  five  and  a  half  hours  of 
mental  work  with  two  hours  of  bodily  exercises. 
But  there  should  be  no  study  at  home.  The 
"Hygiene  Scolaire"  of  Dr.  Riant,  Professor  of 
Hygiene,  Paris,  1884,  is  an  authoritative  work. 
The  time  is  longer  in  Sweden,  Denmark  and  Ger- 
many. I  would  here  call  attention  to  the  article 
of  Prof.  Axel  Key,  of  Stockholm,  in  the  Popular 
Science  Monthly  for  November.  It  is  a  transla- 
tion of  his  paper  read  before  the  International 
Medical  Congress  at  Berlin,  1890,  subject, 
"School  Life  in  Relation  to  Growth  and  Health." 

Opinions  differ  as  to  the  limit  of  daify  mental 
work  in  adults.  Dr.  Bain,  of  Aberdeen,  says 
that  in  that  city  are  as  hard  heads  and  as  hard 
workers  as  in  any  other  part  of  Great  Britain,  but 
that  four  hours  steady  mental  labor  are  as  much 
as  is  good  for  them.  Cuvier  was  usually  en- 
gaged for  seven  hours  daily  in  his  scientific  re- 
searches; but  they  were  not  of  a  nature  to  require 
continuous  thought.     Walter  Scott  declared  that 


THE  HYGIENE  OF  SCHOOL  STUDIES. 


[January  3, 


he  worked  for  three  hours  with  pleasure,  but  be- 
yond about  four  hours  he  worked  with  pain.  Dr. 
Dally,  of  Paris,  says  that  a  man  20  years  old  can- 
not do  intellectual  work  with  profit  beyond  eight 
hours  daily.  Beyond  this  limit  there  will  be 
fatigue,  cerebral  anaemia  or  congestion,  disgust 
and  impossibility  to  work.  Generally  it  is  neces- 
sary to  limit  the  time  to  six  hours  or  even  less. 

In  a  conference  of  the  Board  of  Health  of  Bal- 
timore a  few  years  since,  Dr.  Chancellor  and 
Prof.  Hill  stated  that  their  own  children  were 
being  taught  at  home.  Dr.  Chancellor  said  that 
his  children  had  begun  their  studies  at  eight 
years  of  age,  at  which  time  they  scarcely  knew 
the  alphabet.  From  that  time  to  the  ages  of  12 
and  13  respectively  they  studied  for  not  more 
than  two  hours  daily  five  days  in  the  week, 
and  nine  months  in  the  year.  They  were 
well  up  in  the  English  branches,  could  read, 
write,  and  speak  fluently  the  French  and  Ger- 
man, and  translated  fairly  Italian;  were  making 
good  progress  in  Latin  and  Greek,  geometry  and 
the  natural  sciences. 

Prof.  Hill  gave  similar  testimony.  His  chil- 
dren studied  only  in  the  morning;  had  begun  at 
8  years  of  age ;  but  were  quite  as  far  advanced  as 
school  children  who  had  begun  at  5  or  6.  Prof. 
Newell  believed  that  with  two  hours  in  the  morn- 
ing and  one  in  the  afternoon,  the  children  would 
learn  as  much  and  probably  more  than  with  the 
present  arrangement. 

The  subject  of  home  studies  or  preparation  for 
school,  has  engaged  the  attention  of  school  hy- 
gienists.  Circular  letter  No.  26  of  the  State 
Board  of  Health  of  Pennsylvania  recommends 
that  no  scholar  under  12  or  13  years  of  age  should 
be  required  to  study  at  home.  I  have  already 
quoted  from  the  report  of  the  Commission  of  the 
Academy  of  Medicine  of  France  against  home 
studies.  M.  Beurier  said  that  it  was  the  evening 
work  at  home  or  elsewhere  which  was  responsible 
for  over-pressure. 

Dr.  Crichton-Brown,  in  his  report  of  inspection 
of  the  elementary  schools  of  London,  18S4,  is 
especially  caustic  in  his  condemnation  of  home 
studies  for  young  children.  He  says  the  princi- 
ple is  bad.  Even  when  the  labor  is  small  in 
quantity,  it  stirs  up  and  irritates  an  exhausted 
and  feeble  brain,  and  interferes  with  sleep.  It 
worries  and  torments  the  child,  and  prevents  the 
relaxation  and  entire  diversion  of  the  current  of 
thought  which  ought  to  follow  the  dismission 
from  school.  lie  says  it  is  resorted  to  nine  times 
in  ten  because  the  year's  work  cannot  be  done  by 
holars  in  the  regular  school  hours. 

Dr,  Roth  believes  thai  the  preparation  of  the 
lessons  should  be  made  in  school  hours.  News- 
bolme  is  more  moderate.  He  says  that  home 
lessons  should  be  reduced  to  a  minimum;  should 
quire  to  be  done  in  the  evening;  should 
rather   take    the  form  of  recapitulation   of  work 


done  during  the  day,  than  break  into  new  work. 
That  parents  can  best  judge  whether  home  les- 
sons are  doing  harm,  and  should  at  once  inform 
the  teacher.  These  lessons  often  leave  too  little 
time  for  meals  and  recreation. 

It  is  not  to  be  supposed  that  the  school  hours 
are  devoted  to  continuous  mental  labor;  or  that 
the  same  subject  is  pursued  continuously  for 
hours  together.  Sustained  effort  in  one  direction 
is  quite  limited,  and  beyond  that  limit,  dangerous. 

As  to  how  much  of  a  six-hour  school  day 
should  be  given  to  mental  labor  and  how  much 
to  manual  work  and  recreation,  opinions,  as 
might  be  supposed,  differ;  and  yet  most  school 
hygienists  may  be  divided  into  two  classes; 
namely,  those  who  demand  one-third  of  the  time 
for  manual  work  and  recreation,  and  those  who 
demand  one-half.  The  latter  view  was  taken  by 
a  unanimous  vote  of  the  Congress  of  the  French 
Association  for  the  Advancement  of  Science,  of 
1883. 

For  continuous  mental  work  the  maximum 
time  should  be,  according  to  Chadwick:  5  to  7 
years  of  age,  fifteen  minutes;  7  to  10  years, 
twenty  minutes;  10  to  12  years,  twenty- five  min- 
utes; 12  to  15  years,  thirty  minutes.  Newsholme 
says  that  these  limits  are  too  restricted  for  higher 
ages  and  interesting  subjects,  but  that  the  princi- 
ple is  most  important.  The  standard  of  mental 
labor  may  be  set  at  arithmetic;  for  the  average  of 
school  children,  under  skilful  teaching,  the  time 
should  be  restricted  to  the  hours  named. 

The  model  school  of  Brussels  has  adopted  a 
uniform  system  for  all  classes,  of  three-quarter 
hour  lessons  and  one-quarter  recreation.  Lessons 
in  the  natural  sciences,  physics,  chemistry,  and 
mechanics  never  more  than  a  half-hour.  Chan- 
cellor believes  that  there  should  be  a  ten  minutes 
interval  at  the  end  of  every  hour.  He  also  sug- 
gests that  Wednesday  be  the  holiday  instead  of 
Saturday. 

The  indication  is  to  vary  the  subjects  of  in- 
struction from  hour  to  hour.  Thus  the  mechanical 
work  of  writing  may  be  followed  by  object  les- 
sons and  experimental  lectures.  Language  or 
history,  which  exercises  the  memory,  may  alter- 
nate with  mathematics,  which  exercises  the  reason. 

The  capacity  of  attention,  though  of  course 
limited,  increases  with  age  and  the  growth  of  the 
body,  and  also  with  skilful  teaching.  Some 
teachers,  though  good  students  and  hard  workers, 
are  unable  to  impart  knowledge.  The  capacity 
of  attention  is  also  increased  by  at  least  one-fifth 
by  good  lighting,  heating  and  ventilating.  And 
the  morning  hours  are  found  to  be  better  for 
mental  work  than  those  of  the  afternoon.  The 
alternation  of  physical  and  mental  work  relieves 
the  eyes,  diminishing  the  danger  of  myopia; 
awakes  attention:  preserves  the  strength  of  the 
body,  and  rests  the  mind. 

From  what   has  already  been  said,  it  may  be 


i89i.] 


THE  HYGIENE  OF  SCHOOL  STUDIES. 


deduced  that  at  least  ten  minutes  of  the  class 
hour  should  be  given  up  to  bodily  exercise  in 
some  form.  And  in  every  three  consecutive 
school  hours  there  should  also  be  from  fifteen  to 
thirty  minutes'  recess.  Newsholme  also  suggests 
a  few  minutes'  break  in  the  middle  of  a  Study. 

Where  practicable  the  recreation  should  be  in 
thi  open  air.  In  this  particular  teachers  are  not 
as  positive  as  they  should  be.  Children  are  per- 
mitted to  remain  in  the  school  rooms  and  even 
attend  to  some  mental  work,  instead  of  being  re- 
quired, if  their  health  permit,  to  clothe  them- 
selves according  to  the  season  and  weather,  and 
spend  the  recess  in  the  open  air.  For  this  pur- 
pose of  course  playgrounds  are  necessary,  and  in 
choosing  a  site  for  a  schoolhouse,  the  matter  of 
sufficient  playground  should  be  one  of  the  first 
requisites. 

Of  the  forms  of  manual  labor,  I  may  speak 
only  in  a  general  way.  A  carpenter's  shop  is 
the  form  usually  adopted.  It  well  repays  the 
cost  of  any  expense  and  labor  bestowed  upon  it. 
Under  the  supervision  of  the  instructor  the 
scholars  can  refit  the  woodwork  of  the  building 
itself. 

Cooking  is  useful,  especially  for  girls,  though 
not  them  alone,  for  many  boys  also  take  the  in- 
struction. Where  practicable,  housekeeping  also. 
A  writer  of  note,  whose  name  I  have  forgotten, 
strongly  recommends  a  model  nursery,  as  part  of 
the  education  of  girls,  in  all  finishing  schools 
and  training  colleges.  He  calls  attention  to  the 
ignorance  of  young  married  women  in  the  man- 
agement of  infants,  and  says  it  is  a  cause  of  the 
unnecessarily  high  death-rate  among  them. 

Of  recreations  there  is  a  great  variety.  The  sim- 
plest is  the  promenade;  using  the  muscles  of  the 
limbs, trunk,  abdomen  and  neck.  The  military  drill 
is  much  recommended  and  extensively  used.  It  is 
liked  by  the  boys;  it  corrects  to  some  extent 
some  bodily  defects;  promotes  a  sense  of  duty, 
order,  obedience  to  command, m  self-restraint, 
punctuality,  and  patience;  and  gives  suppleness 
to  the  joints,  making  the  action  promptand  easy. 
It  is  found  that  the  drill  is  more  effectively  and 
permanently  taught  in  the  infantile  and  juvenile 
period  than  in  adolescent  and  adult  age. 

Beside  the  immediate  benefit  to  the  child, 
there  is  a  large  saving  of  time  and  expense  in 
after  life,  when  the  grown  man,  with  a  calling  in 
life,  becomes  a  member  of  the  National  Guard. 
It  has  been  found  too  that  the  use  of  firearms  is 
more  quickly  and  perfectly  acquired  by  the  edu- 
cated than  the  ignorant.  It  is  estimated  that  in 
England  it  costs  as  much  to  properly  drill  and 
teach  and  keep  an  ignorant  farm  hand  as  fifty 
school  lads.  Chadwick  proposes  that  after  the 
acquisition  of  the  drill  in  the  juvenile  period,  en- 
couragement should  be  given  for  volunteer  exer- 
cises in  the  use  of  firearms.  It  is  believed  that 
the  mixed  physical    and   mental  training  would 


add  one- third  to  the  civil  force  of  the  country, 
and  more  than  a  third  to  its  military  power. 

In  England  the  naval  drill  is  also  used;  and  it 
can  be  readily  understood  that  besides  the  ad- 
vantages derived  from  the  military  drill,  there 
are  those  obtained  by  the  use  of  the  muscles  in 
climbing.  The  cavalry  drill  has  been  recom- 
mended for  the  middle  and  higher  classes,  where 
practicable. 

Leaping,  running,  ball  play,  cricket,  are  other 
forms  of  recreation  more  or  less  available.  And 
fencing  is  useful  as  developing  the  muscles  of  the 
trunk  and  limbs;  and  requiring  great  activity  of 
mind  and  quickness  of  vision. 

Singing  and  instrumental  music  are  useful, 
charming  the  mind.  Singing  develops  and 
strengthens  the  muscles  of  the  chest;  increases 
the  breathing  power  of  the  lungs,  preventing  pul- 
monary disease  to  some  extent;  and  lays  the 
foundation  of  a  correct  modulation  of  the  voice. 

Excursions  into  the  country  are  strongly 
recommended  by  writers  as  having  many  ad- 
vantages. There  is  an  opportunity  to  learn  val- 
uable lessons  in  natural  history  and  become 
familiar  with  ordinary  plants.  The  faculty  of 
observation  is  developed,  and  the  association  of 
teacher  and  scholar  awakens  feelings  of  compan- 
ionship and  accord;  the  occasion  is  looked  for  as 
a  time  of  pleasure;  to  be  deprived  of  it  is  a  pun- 
ishment or  misfortune.  In  Austria  the  boys  are 
taught  gardening;  the  grounds  around  the  school 
being  partly  used  for  that  purpose. 

Visits  to  museums  and  other  places  of  public 
interest  afford  a  large  field  for  useful  and  pleas- 
ureable  instruction. 

There  is  another  most  useful  recreation  which 
I  have  long  thought  should  form  part  of  the 
school  curriculum.  It  is  swimming.  This  of 
course  includes  bathing,  which  to  some  school 
children,  is  perhaps  a  novelty.  The  advantages 
of  the  teaching  go  without  saying.  The  mus- 
cles are  developed;  the  circulation  and  nerve 
power  improved;  there  is  much  pleasure  in  the 
exercise ;  children  become  accustomed  to  the 
water;  their  fears  are  diminished,  and  many  un- 
fortunate accidents  would  be  prevented.  News- 
holme  strongly  insists  on  it  ;  also  Sir  Charles 
Reed,  in  his  report  to  the  Educational  Council  of 
London;  Janssen,  the  Medical  Officer  of  Health 
of  Brussels,  and  Dr.  Riant,  of  Paris.  I  do  not 
know  as  a  fact  that  any  school  board  has  adopted 
it  as  a  part  of  the  teaching;  but  the  evident  in- 
terest in  the  subject  indicates  that  it  will  be 
adopted. 

Many  of  the  forms  of  recreation  named  are 
more  or  less  available  for  girls;  so  that  there  is 
no  good  reason  for  their  failing  to  develop  a  good 
physique. 

Where  gymnastics  can  be  had,  the  Swedish 
system,  or  system  of  Ling,  is  that  most  highly 
recommended. 


THE  HYGIENE  OF  SCHOOL  STUDIES. 


[January  3, 


At  this  point  I  would  call  attention  to  what  I 
believe  to  be  a  new  feature  in  the  recreations  of 
children.  In  the  English  Illustrated  Magazine 
for  November  is  a  short  article  describing  how 
some  of  the  public  school  buildings  of  London 
have  been  opened  iu  the  evenings  from  7  to  9:30 
o'clock,  for  the  children  to  play;  no  study  being 
allowed.  The  results  have  been  gratifying.  I 
am  also  told  that  the  Boston  school  playgrounds 
were  opened  during  the  last  summer  for  a  similar 
purpose.  This  action  is  very  desirable  in  cities, 
where  otherwise  the  children  play  upon  the 
streets. 


and  3,000  girls.  It  appears  that  children  grow 
rapidly  from  March  to  July  or  August,  with  but 
little  increase  in  weight;  then  to  November  gain 
rapidly  in  weight,  but  not  much  in  height.  From 
November  to  March,  again,  the  growth  is  small. 
The  prevalence  of  myopia  or  nearsightedness 
among  school  children  is  well  known.  Some 
statistics  are  simply  appalling;  such  as  that  100 
per  cent,  of  students  at  Heidelburg  are  myopic; 
while  on  the  contrary,  Widmark's  examination 
of  school  children  at  Stockholm,  under  7  years  of 
age,  showed  a  total  absence  of  myopia.  The 
causes  are  well  known;  bad  light,  bad  air,  over- 


As  to  the  evil  effects  of  over-pressure,  that  is  heating,  unsuitable  desks  and  benches,  bad  print 
an  excess  of  school  hours  or  lessons  beyond  the  and  small  type,  Some  form  of  ear  disease,  or- 
capacity  of  the  scholar,  it  may  be  said  in  a  gen-  gauic  or  functional,  was  found  in  23  per  cent,  of 
eral  way  that  if  a  boy  or  girl  eats  heartily  and  6,000  Berlin  school  children,  and  Drs.  Sexton,  of 
sleeps  well,  it  is  scarcely  possible  that  there  is  New  York,  and  Percival,  of  Baltimore,  are  said 
overwork.  The  average  amount  of  sleep  required  \  to  have  arrived  at  similar  results.  Spinal  curva- 
from  4  to  7  years  of  age  is  eleven  hours;  7  to   10  ture  due   to    improperly  constructed  desks  and 


years,  ten  and  a  half  hours;   10  to   15  years,  nine 
to  ten  hours;   15  to  20  years,  nine  hours.      This 


seats  and  bad  positions  of  body.   Pulmonary  con- 
sumption is  said   to  originate  frequently  during 


implies  that  the  child  sleeps  in  a  well  ventilated  school    life  from   bad   ventilation,    over- heating 

and  properly  heated  room.      It    must  be  noted  !  cold  draughts,  improper  position  of  body,  insuffi- 

that  parents  are  to  some  extent  responsible  for  1  cient  food  and  excessive  mental  strain.   Digestive 


loss  of  sleep  by  their  children,  in  permitting  them 
to  spend  their  evenings  in  amusements  which  de- 
tain them  to  a  late  hour  and  are  often  otherwise 
insanitary. 

The  more  brain  work  a  child  does,  the  more 
food  it  requires.  Half  starved  children,  though 
attaining  high  standing  in  their  classes,  are  apt 
to  be  small  in  stature  and  feeble  of  muscle.  If 
the  food  is  plain  and  wholesome,  the  best  guide 
to  the  quantity  required  is  the  child's  own  appe- 
tite. The  midday  luncheon  is  better,  at  least  in 
the  winter  time,  if  it  can  be  had  warm.  In  Paris, 
the  Director  of  Education  authorizes  janitors  to 
provide  and  sell  to  the  children  warm  food.  It 
seems  to  me  that  with  a  little  effort,  the  same  de- 
sirable result  might  be  attained  here. 

Parents  are  in  many  cases  responsible  for  their 
children  attending  school  without  breakfast  and 
sometimes  without  luncheon.  That  thtse  chil- 
dren should  soon  become  fatigued  and  listless 
may  rightly  be  expected 


disturbances  are  frequent  from  the  use  of  improper 
food,  irregularity  of  meals  and  insufficient  closet 
accommodations. 

Diseases  of  the  nervous  system  point  more 
directly  to  over- pressure  in  the  absence  of  other 
recognizable  cause.  Headaches  are  frequent  ; 
listeria  and  imitative  affections  ;  found  oftener 
in  girls  than  boys.  Dr.  McLane  Hamilton  says, 
that  over  20  per  cent,  of  the  school-children  of 
New  York  City  have  chorea.  Dr.  Crichton- 
Brown  says,  that  there  is  an  increase  of  nearly 
35  per  cent,  in  the  mortality  from  hydrocephalus, 
and  the  increase  is  in  children  over  5  years  of  age. 
And  this,  too,  in  face  of  the  fact  of  a  generally 
diminished  mortality  in  children.  I  would  refer 
again  to  Prof.  Key's  statistics  showing  large  per- 
centages of  illness  in  school  children. 

Many  writers  advocate  the  appointment  of 
Medical  Inspectors  of  schools.  There  has  been 
such  a  medical  service  in  Paris  since  1836.  The 
city  of  Brussels  is  a  model  in  this  respect.     The 


A  further  test  of  the  absence  of  pressure  is  in   officer  looks  after  whatever  pertains  to  the  sub- 
the  increase  in  the  weight  of  the  child.   Dr.  Bow-  Iject  of  school  hygiene,    and  makes  report  upon 


ditch,  of  Boston,  made  14,000  examinations  of 
boys,  and  11,000  of  girls  between  the  ages  of  5 
and  16.  The  yearly  increase  in  weight  of  the 
boys  was  4,  4,  5,  5,  6,  5,  7,  8,  10,  12,  14  pounds; 
of  the  girls,  3.5,  4,  4.5,  5,  5,  6.5,  9.5,  10.5,  10, 
7.5,  6  pounds.  Should  a  scholar  fail  to  reach 
these  averages  it  becomes  desirable  to  inquire 
into  his  food,  clothing,  amount  of  sleep  and  ex- 
ercise. If  these  appear  to  be  sufficient,  then 
whether  there  is  mental  strain. 


the  same.  In  those  cities  also,  he  gives  treat- 
ment to  scholars  who  are  in  need.  Elmira,  N.  Y., 
and  Boston,  each  has  its  Medical  Inspector,  who 
not  only  oversees  the  school  hygiene,  but  is  an 
instructor  of  the  teachers  on  the  subject.  The 
advantages  of  having  such  an  officer  are  obvious. 
Much  school  study  is  dry  and  dull.  Effort 
should  be  made  to  have  it  pleasurable.  Children 
come  to  school  with  cheerfulness  and  mirth. 
These  may  be  developed   and   utilized  for  educa- 


Prof.  Key,  in  the  article  mentioned,  furnishes  tional  purposes.  Over  strict  silence  exacted  in 
some  useful  information  in  regard  to  growth  and  some  schools  is  Limply  painful;  it  is  the  sup- 
weight,  based  on  an  examination  of  15,000  boys  |  pression  of  joyousness,  the  product  of  fear,  and 


I8gi.] 


HEREDITARY  ALCOHOLIC  ENTAILMENT. 


incompatible  with  a  health}'  influence.  No  child 
can  be  healthily  developed  without  gladness. 

Examinations  have  been  severely  criticised  by 
many  school  hygienists.  Prof.  Hallowell  thinks 
that  the  wear  and  tear  of  examinations  is  very 
injurious,  especially  to  girls.  Chancellor  says 
that  in  the  last  quarter  of  the  year  the  pressure- 
begins  ;  and  as  a  result,  we  have  nervous  prostra- 
tion, fainting  spells,  nasal  haemorrhages,  St. 
Vitus'  dance,  etc. 

Dr.  Crichton-Brown  says  that  examinations, 
instead  of  being  tests  of  school  work,  have  been 
to  a  great  extent  the  aim  and  guiding  principle ; 
and  whatever  educational  fruits  they  may  have 
yielded,  they  produce  a  large  crop  of  nervousness. 
Prof.  Huxley  calls  examinations  the  educational 
abomination  of  the  present  day,  in  that  the 
young  people  are  stimulated  to  work  at  high 
pressure  by  the  incessant  competition. 

Examinations  have  an  educational  value,  when 
•well  conducted  ;  they  detect  weak  points  ;  they 
show  how  future  efforts  may  be  made  more  suc- 
cessful. They  are,  however,  only  means  to  an 
end,  and  a  temptation  to  over-pressure.  They  do 
not  show  the  best  result  of  a  teacher's  work  ;  his 
personal  influence  in  the  training  of  the  mental 
and  moral  faculties  ;  and  the  influence  of  an  up- 
right and  consistent  example.  And  they  should 
be  limited  to  the  work  actually  done  by  the 
scholar. 

The  following  description  by  Charles  Dickens, 
of  Dr.  Blimber's  school,  will  bear  repetition : 
It  "  was  a  great  hot-house  in  which  there  was  a 
forcing  apparatus  constantly  at  work.  Mental 
green  peas  were  produced  at  Christmas  and  in- 
tellectual asparagus  all  the  year  round.  Nature 
was  of  no  consequence  at  all  ;  no  matter  what  a 
young  gentleman  was  intended  to  bear,  Dr.  Blim- 
ber  made  him  bear  to  order,  somehow  or  other. 
This  was  very  pleasant  and  ingewious,  but  the 
system  of  forcing  was  attended  with  the  usual 
disadvantages  ;  there  was  not  the  right  taste  to 
the  premature  productions,  and  they  did  not 
keep  well.  And  people  did  say  that  the  doctor 
had  rather  overdone  it  with  young  Toots,  who 
when  he  had  whiskers,  left  off  having  brains." 


THE     PSYCHOPATHIC     SEQUENCES    OF 
HEREDITARY  ALCOHOLIC  ENTAIL- 
MENT. 


•Read  be/ore  the  Mis. 


sippi  Valley  Medical  Association,  at  Louisville, 
A'v.,   October  oth,  1890. 


BY  C.  H.  HUGHES,  M.D., 

PROFESSOR     OF     PSYCHIATRY     AND     NEUROLOGY.    MARION    SIM? 

MEDICAL    COLLEGE   OF   MEDICINE,    LATE    SUPERINTENDENT 

OF  THE   MISSOURI  STATE   LUNATIC   ASYLUM   No.    I.    ETC. 

Nothing  in  neuropathology  is  now  plainer  than 
the  retrograde  heredity  of  chronic  alcoholics. 
The  alcoholic  poison  interferes  with  the  highly 
organized  physiological  movements  of  the  psy- 


chical centres,  arrests  and  perverts  the  complex 
activities  of  the  cerebral  cortex  and  begins  a 
decadent  and  perverted  neural  metamorphosis 
that  goes  on  from  one  stage  of  instability  to  an- 
other, until  the  final  ending  of  all  neural  insta- 
bility is  reached  (unless  fortuitously  arrested)  in 
dementia  or  imbecility  and  death,  when  even  per- 
verted neural  force  can  no  longer  be  evolved. 
The  evolution  of  the  cerebro-psychical  centres 
thus  arrested  or  perverted,  ends  in  final  dissolu- 
tion and  extinction  of  type. 

The  neuropathic  thrall  of  entailed  alcoholism 
is  no  new  theme  to  neurologists.  It  was  familiar 
to  Benjamin  Rush,  and  the  researches  of  Morel  in 
the  field  of  neuropathic  degeneracy  sequent  to 
ancestral  alcoholic  excess,  have  been  so  often 
affirmed  and  reaffirmed  by  credible  medical  testi- 
mony that  no  doubt  now  remains  in  the  medical 
mind  of  the  power  of  excessive  ancestral  alco- 
holic indulgence  to  pervert  neuropsychic  func- 
tion in  the  descendants  of  victims  of  this  vicious 
disease. 

We  need  not  dispute  the  point  as  to  whether 
alcoholism  is  a  vice  or  disease,  for  it  is  and  it 
may  be  both  or  either,  and  whether  it  in  the  be- 
ginning be  one  or  both  its  ending  is  always  in 
disease,  which  is  either  the  beginning  or  continu- 
ance of  a  transmitted  neuropathic  or  neuro- 
psychopathic heritage. 

If  the  first  generation,  as  Morel  has  observed, 
shows  immorality,  alcoholic  excess  and  brutal 
degradation,  the  second  one  will  usually  show, 
as  he  also  observed,  hereditary  drunkenness, 
maniacal  attacks  and  general  paralysis  or  some 
similar  psychopathic  affection.  The  third  gener- 
ation may  show  sobriety,  but  instead  of  the 
transmitted  drunkenness,  the  hereditary  neuro- 
pathic perversion  will  probably  reveal  itself  as 
Morel  saw  it,  in  hypochondria,  mania,  lypemania 
and  tendency  to  homicide  and  suicide  ;  and  we 
shall  see  in  the  fourth  and  after-coming  genera- 
tions feeble  intelligence,  stupidity,  early  insanity 
and  the  beginning  of  the  end  of  the  family  in 
extinction. 

All  alienists  have  confirmed  this  observation  of 
Morel,  and  the  fatal  heritage  of  chronic  alcoholic 
toxaemia  is  proven  upon  those  living  within  the 
walls  of  asylums  for  the  insane  the  world  over, 
and  in  every  walk  of  life  without,  and  upon  the 
cadavers  of  those  who  have  died  under  the 
power  of  this  neurotoxic  force.  We  no  longer 
need  the  extensive  clinical  observations  of  Mag- 
nan  nor  the  later  pathological  researches  of 
Bevan  Lewis  for  proof.  The  diseased  arterioles, 
the  granular  degenerations  of  the  nerve  cells, 
pericellular  and  perivascular  nuclei  proliferation, 
aneurismal  dilatations  and  exudative  and  indura- 
tive cerebral  changes,  are  too  familiar  now  to  be 
longer  doubted,  and  witnesses  too  many  to  be 
here  enumerated,  embracing  all  who  have  clinic- 
allv   studied   inebrietv,   attest  the  fact  that  the 


HEREDITARY  ALCOHOLIC  ENTAILMENT. 


[January  3, 


habitual  long- continued  use  of  alcohol  as  a  bev- 
erage in  excessive  quantity  in  one  generation 
makes  an  indelible  impress  upon  the  nerve  sta- 
bility of  the  generations  that  follow. 

It  has  the  undoubted  power  of  engendering 
neuropathic  and  psychopathic  conditions  directly 
in  the  individual,  besides  a  great  number  of  extra- 
neural  morbid  conditions,  as  the  oft-observed  and 
no  longer  doubted  delirium  tremens,  epilepsy,  in- 
sanit}'  and  imbecility,  paralysis  and  the  neuritides 
of  drunkards  show,  and  the  morbid  entailments 
of  alcoholic  excess  do  not  stop  with  the  individual 
as  we  have  seen.  They  pass  over  in  greater 
force  to  his  descendants.  This  is  the  gospel  of 
science.  These  morbid  endowments  of  the  drink 
habit  are  more  apparent  in  the  drunkard's  pro- 
geny, for  the  reason  that  his  children  come  into 
the  world  dowered  with  less  power  of  neurotic 
resistance  to  the  depressing  and  perverting  as- 
saults of  alcohol  and  its  compounds  upon  the  in- 
tegrity of  the  ganglion  cells  of  the  cerebrum  and 
the  nervous  centres  of  the  whole  cerebro-spinal 
axis  and  sympathetic  system. 

By  reason  of  a  better  organic  heritage  and  the 
greater  inherent  power  of  vital  resistance,  the 
drinking  person  may  show  but  little  of  the  in- 
roads his  alcoholic  excesses  are  making  upon  the 
physiological  soundness  of  his  cerebro-spinal  and 
ganglionic  centres.  An  occasional  or  single  epi- 
leptic seizure  during  a  debauch,  or  none  at  all, 
during  a  life  given  to  drink,  some  perversions  of 
disposition  or  mental  depression,  or  a  day  or  two 
of  trance  following  a  prolonged  spree  once  or 
twice  in  a  life-time,  or  none  of  these  evidences  of 
cerebro-psychical  damage  may  so  markedly  ap- 
pear. (The  subject  of  alcoholic  trance  is  largely  a 
subject  to  be  tteated  here  as  its  forensic  merits 
require.  On  this  subject  we  content  ourself 
now  with  a  simple  note  :   vide  finis.') 

None  of  these  positive  and  more  directly  per- 
ceptible consequences  of  alcoholic  damage  may 
appear  directly  in  the  individual.  He  may  go 
through  life  moderately  full  of  alcohol,  able  to 
attend  in  a  fairly  good  manner  to  the  routine  de- 
mands of  his  business,  to  be  cut  off  prematurely 
under  some  slight  extra  organic  strain  (for  one  of 
his  extraordinary  hereditary  endowment  of  nerve 
resistance),  by  an  apoplexy — cerebral  or  pul- 
monary— which  another  less  strongly  endowed 
for  resistance  by  nature,   would   have  withstood. 


causation  than  that  of  which  his  non-drinking 
fellow  in  the  next  bed  promptly  recovers.  He 
may  die  prematurely  of  an  over-worked  kidney 
or  an  over-taxed  liver,  by  reason  of  ganglionic 
paralysis  (and  I  believe  that  over- distension  of 
the  renal  circulation  from  the  general  vascular 
hypersemia  of  over-brain-strain  and  alcoholic 
stimulation  combined,  are  the  remote  causative 
factors  of  Bright's  disease),  and  neither  he  nor 
his  friends  may  think  that  alcohol  has  done  him 
harm. 

But  look  at  the  drinking  man's  children  !  He 
may  have  been  himself  a  very  proper  and  ap- 
parently healthy  citizen,  beginning  in  early  life  a 
regular  business,  and  having  acquired  and  filled 
a  regular  and  honorable  business  place  in  the 
world,  and  never  seriously  sick  till  the  last  acute 
illness  that  suddenly  carries  him  off  before  his 
physiologically  appointed  time. 

Why  is  one  child  an  idiot  or  imbecile,  another 
erratic,  moody,  violent,  visionary,  melancholic, 
or  insane,  epileptic  choreic,  or  suddenly  criminal 
despite  the  best  of  training  and  environment, 
especially  among  his  latest  offspring,  while  only 
the  children  born  of  his  loins  earlier  in  life,  when 
alcoholic  excess  had  made  no  organic  impress 
upon  him,  are  ordinarily  healthy  in  mind  and 
body? 

The  habitual  disturbances  of  organic  function 
— morbid  physiological  exaltation  and  reactionary 
morbid  depression,  through  increased  vascular 
relaxation  and  consequent  capillary  congestion 
may  not  materially  affect  the  integrity  of  func- 
tion in  the  matured  cells  of  the  psychical  centres 
of  the  parent  of  sober  lineage,  so  as  to  markedly 
modify  their  matured  and  long-established  habit 
of  acting,  but  in  the  drunkard's  child  who  starts 
unstably  endowed  by  hereditary  neuropathic  en- 
tailment resulting  from  an  ancestor's  alcoholic 
excess,  the.  resistence  power  of  the  parent  or 
parents  in  early  life  is  not  in  the  child's  orgauism. 
He  is  a  step  lower  than  his  father  or  mother,  or 
both,  if  they  were  habitual  drinkers,  in  the  scale 
of  organic  degradation,  and  has  in  consequence 
feebler  resistance  to  the  assaults,  not  only  of 
alcohol  from  within,  but  of  adverse  environments 
from  without,  and  they  reveal  this  hereditary 
organic  degradation  in  erratic  actions,  morbid, 
insane  and  criminal  conduct — conduct  which  in 
them  is  always  the  offspring  in  whole  or  in  part, 


His   ganglionic    centres    fail   him    in   some   vital    of  disease — disease  within.      Their  environment 


crisis,  and  the  "silver  cord  is  loosed"  forever. 

The  nerve  mechanism,  which  never  escapes  in 
the  habitual  or  periodic  excessive  drinker,  but 
more  especially  in  the  regular  so-called  moderate 
social  drinker  (who  never  sprees,  though  seldom 
when  asked  to  drink,  who  takes  his  regu- 
lar evening  night-cap  and  morning  eye-opener 
and  tri-daily  appetizer)  is  the  vasu  motor  system. 
This  failure  causes  the  pneumoniae  to  die  from 
an  attack  of  lung  fever  of  no  greater  severity  of 


leads  them  irresistibly  into  crime,  like  the  cir- 
cumstances without  which  cause  in  them  disease 
their  parents  had  not  shown,  and  crime  their 
parents  would  have  resisted.  Upon  them,  con- 
sequently,  influences  without  their  organisms  re- 
sisted by  others  have  an  overpowering  force. 

The  drunkard's  child's  crime  is  not  all  his  vol- 
untary crime,  nor  his  vice  engendered  disease,  all 
disease  of  his  own  making.  His  father,  or  his 
father's  father  or  mother   may    have  deliberately 


iSqi.] 


HEREDITARY  ALCOHOLIC  ENTAILMENT. 


chosen  that  which,  with  all  its  voluntary  seeming 
in  the  boy,  is  become  to  him  an  inexorable  morbid 
fate,  appearing  as  immoral  conduct.  ''The 
fathers  have  eaten  sour  grapes,  and  the  children's 
teeth  are  set  on  edge." 

With  this  loo  cursory  preliminary  review  of 
what  we  know  of  the  hereditary  neurotic  enthrall- 
meut  of  alcohol,  we  record  an  interesting  hypo 
thetical  case,  which  we  will  suppose  to  cover  the 
facts  in  an  important  medico-legal  record  of  en- 
tailed alcoholic  disease  and  crime  perpetrated 
under  its  fatal  sway. 

HYPOTHETICAL    CASE. 

Suppose  a  young  man  approaching  his  major- 
ity, naturally  kind  of  heart,  not  reared  in  crime 
nor  in  the  slums  of  a  city's  poverty  quarters, 
but  in  comfortable  circumstances,  and  fairly  edu- 
cated among  correct  people,  commits  an  unpro- 
voked murder  of  one  of  the  dearest  and  nearest 
of  his  friends.  In  his  family  the  following  ab- 
normal traits  appear:  On  the  maternal  side  a 
grandfather  is  a  man  of  excess  in  eating,  drink- 
ing, etc.;  inebriate  and  melancholy,  and  he  dies 
of  apoplexy.  An  only  son  survives  him  long 
enough  to  develop  inebriety  and  die  of  drink  in 
his  youth.  A  brother  is  like  himself,  and  dies  a 
drunkard.  Sisters  and  cousins  in  varying  de- 
grees, according  to  environment,  exhibit  the 
same  failing.  A  grandmother  at  an  early  age 
drank  liquor  to  excess,  and  died  prematurely  in 
consequence  of  excessive  drink.  All  the  sons  of 
the  grandmother's  sisters  died  young  in  conse- 
quence of  drink.  Of  the  remaining  ancestry  of 
this  alcohol- tainted  organism,  one  uncle  was, 
from  early  youth,  addicted  to  alcoholic  indul- 
gence, his  thirst  for  drink  becoming  finally  in- 
satiable, and  he  died  of  delirium  tremens  in  early 
manhood,  after  previous  attacks  of  acute  alcoholic 
insanity.  Another  uncle  was  also  addicted  from 
his  early  youth  to  the  use  of  alcohol  to  inebriety, 
and  final  melancholia  and  insanity  with  delusions 
of  dread  and  suspicion.  Several  sisters  of  these 
two  men  were  victims  of  the  hereditan-  failing, 
among  them  the  mother  of  the  supposed  young 
man  we  are  considering.  The  boy's  father,  too, 
was  in  early  life,  before  the  boy's  birth,  an  in- 
temperate man,  and  the  boy  himself  was  from 
earl}r  puberty  intemperate,  unstable  and  choreic, 
and  had  suffered  in  childhood  from  a  physical 
shock  to  his  nervous  system,  caused  by  a  violent 
fall.  This  young  man  in  question,  when  under 
the  influence  of  liquor,  was  a  markedly  changed 
man,  and  when  the  time  of  one  of  his  periodically 
recurring  sprees  would  come  around,  he  was  like- 
wise very  different  from  his  natural  self,  being 
moody,  listless,  drowsy  and  melancholy :  and 
after  indulging  in  his  inordinate  craving  and  un- 
natural appetite,  he  would  become  exhilerated, 
reckless  of  danger,  excessively  cheerful  at  times, 
and  extremely  violent  towards,  and  suspicious  of 


his  best  friend,  filled  with  morbid  fears  and 
dreads  and  suspicious.  When  sober  he  was 
nervous,  restless  and  unhappy,  and  whenever  he 
got  a  taste  of  liquor  he  would  invariably  drink  to 
excess — drinking  to  exhaustion,  prostration  and 
illness  in  consequence  of  his  excesses.  Suppose 
for  five  or  ten  years  the  life  of  such  a  person  was 
almost  one  continual  succession  of  sprees — sup- 
pose such  a  man  after  such  a  life,  and  at  the  close 
of  a  several  weeks'  prolonged  spree,  takes  the 
life  of  his  best  friend  by  manual  violence  while 
struggling  to  get  money  from  this  friend  who  had 
refused  it,  and  with  the  aid  of  an  accomplice 
takes  money,  jewelry  and  other  valuables  from 
his  person,  pawns  some  of  the  things  for  liquor, 
making  no  attempt  to  escape,  and  not  appearing 
to  remember  or  realize  the  enormity  of  the  crime 
committed,  remains  in  the  neighborhood  of  the 
murder  intoxicated  until  arrested,  remembering 
the  fact  of  the  robbery,  but  not  believing  the 
party  robbed  and  maltreated  was  dead  or  seri- 
ously injured. 

This  is  a  common  kind  of  inebriate  crime. 
This  picture  would  answer  for  the  ordinary  por- 
traiture of  the  average  inebriate  criminal  ar- 
raigned in  our  courts  of  justice.  It  is  of  neces- 
sity so  drawn  as  not  to  describe  personal  cases 
that  have  come  uuder  my  professional  care,  but 
it  is  true  to  inebriate  nature,  as  I  have  seen  it  all 
too  pitiably  and  painfully  portrayed,  and  will 
answer  well  for  a  composite  picture  of  morbid,  as 
contradistinguished  from  purely  immoral  in- 
ebriety and  crime.  The  picture  is'  not  overdrawn, 
but  is  faithfully  true  to  nature. 

I  have  purposely  put  in  a  criminal  motive  in 
the  above  hypothesis  that  the  natural  semblance 
to  crime  may  appear  just  as  it  appears  in  many 
cases  of  insanity.  The  inebriate  and  the  insane 
person  act,  unless  totally  demented,  from  motive 
more  or  less  apparent,  but  the  hidden  springs  of 
human  conduct  in  both  are  different  from  those 
in  the  rational  and  healthy  mind.  A  different 
combination  of  morbid  influences,  ancestral  and 
immediate,  in  the  nervous  organism  of  the  chronic 
inebriate  or  the  periodic  inebriate  unites  with  his 
environment  in  the  drink-enthralled  man,  from 
that  which  influences  and  determines  ordinary 
human  conduct  in  sane  and  temperate  men. 

i.  Assuming  the  above  hypothetical  case  to  be 
true,  what  would  be  your  judgment  as  to  the  ex- 
istence or  non  existence  of  hereditary  alcoholic 
degeneracy  and  impairment  of  the  brain,  and  the 
existence  or  non-existence  of  dipsomania,  or  in- 
voluntary and  resistless  impulse  to  drink  alco- 
holic liquors  to  excess,  in  the  case  of  the  sup- 
posed youth,  and  degree  of  irresponsibility  from 
drink? 

2.  What  was  the  mental  condition  of  the  sup- 
posed person  when  he  committed  this  unlawful 
deed? 

3.  What  is  the  effect  on  the  mind  and  on  the 


HEREDITARY  ALCOHOLIC  ENTAILMENT. 


[January  3, 


will  of  such  an  inherited  taint,  united  with  the 
state  of  chronic  alcoholism,  as  in  the  case  of 
such  a  supposed  youth  ? 

Such,  with  more  or  less  completeness  of  specific 
detail,  is  the  character  of  the  hypothetical  case 
and  interrogatories,  of  late  years  propounded  in 
our  courts  to  the  expert  in  psychiatry,  for  the 
neuropathic  entailments  of  chronic  ancestral  al- 
coholism. Thanks  to  an  enlightened  judiciary 
in  some  of  the  American  States,  aided  by  the 
wise  and  judicious  efforts  of  our  medico-legal  so- 
cieties, inebriety  has  become  a  recognized  ex- 
tenuation and  often  complete  and  just  excuse  for 
crime  perpetrated  under  its  potent  and  often  re- 
sistless morbid  influence,  and  the  following  or 
something  like  them,  are  still  the  customary  in- 
terrogatories propounded,  pro  forma  by  the 
counsel  for  the  State  : 

1.  Is  it  your  opinion  that  such  a  supposed 
person  was  unable  to  distinguish  between  right 
and  wrong? 

Or,  perchance,  the  more  enlightened  and  just 
interrogatory  like  the  following  is  offered  by  the 
State  : 

' '  Will  you  say  that  a  person  so  affected  could 
not  tell  that  an  act  which  he  committed  was 
wrong,  or  if  conscious  that  it  was  wrong — is  it 
your  opinion  that  he  was  incapable  of  resisting 
the  impulse  to  commit  it  bj*  reason  of  disease 
hereditarily  entailed  or  acquired?" 

It  were  fortunate  for  the  unfortunate  victim  of 
the  faulty  and  imperiously  unstable  neuropathic 
heritage  of  long-continued  or  hereditarily  trans- 
mitted alcoholic  indulgence,  if  a  wise,  humane 
and  considerate  counsel  and  court  secure  such 
just  instructions  in  such  clear  conformity  with  the 
facts  of  clinical  observation  and  experience  as  the 
last  interrogatory  would  warrant,  for  inebriety 
either  in  its  periodic  or  continuous  forms  is  a 
disease,  as  much  so  as  the  recognized  and  ac- 
knowledged phases  of  insanity,  epilepsy,  idiocy 
and  imbecility  it  both  directly  and  indirectly  en- 
genders, and  while  in  considering  it  in  its  medico- 
legal relations,  we  have  also  to  consider  the  ac- 
companying factor  of  a  once-normal  volition,  we 
have  in  the  inebriate  a  mind  and  will,  always 
more  or  less  modified,  perverted,  deranged  by 
disease.  Alcohol  being  itself  a  directly  toxic 
agent,  in  its  influence  on  the  brain  and  allied 
nervous  system  as  well  as  potently  poisonous  to 
the  blood  itself  in  any  considerable  quantity,  and 
especially  so  as  all  experience  proves,  when  long 
continued,  in  excess,  in  either  the  individual  or 
his  ancestors. 

It  is,  indeed,  a  strange  phenomenon  of  the 
human  mind  in  its  forensic  relations  that  an 
agent  which  the  world  recognizes  and  acknowl- 
edges as  the  parent  of  pauperism,  insanity  and 
crime,  and  the  chief  direct  or  indirect  populator 
of  penal,  eleemosynary  and  correctional  institu- 
tions, and  the  proven  cause  of  so  much  disease, 


misery  and  death,  should  be  held  responsible  to 
the  extent  it  is  before  our  judicial  tribunals,  when 
the  hapless  and  often  hopeless  and  helpless  vic- 
tims of  its  vicious  power  are  arraigned  to  answer 
for  crime  committed  through  its  influence  over 
their  involuntarily  enslaved  organisms — organ- 
isms often  prenatally  predestined  to  pathological 
perversion  (as  most  of  the  unfortunate  inmates  of 
asylums  for  the  insane  are  organically  prede- 
termined to  an  aberrant  course  of  life  conduct), 
through  the  alcoholic  excesses  or  other  neuro- 
pathic disorders  of  ancestors,  or  through  a  pre- 
cocious drink-craving,  however  engendered, 
whether  ancestrally  or  self-acquired,  and  pre- 
maturely and  excessively  indulged,  to  the  harm 
of  the  delicate  machinery  of  the  brain. 

The  force  of  physiological  habit  is  recognized 
in  all  of  our  dealings  with  men.  Why,  then, 
should  courts  ignore  the  power  of  that  neuro- 
pathic thralldom  which  alcohol  undoubtedly  en- 
genders in  certain  individuals,  to  their  harm  and 
the  harm  of  the  world  about  them,  enchaining, 
enslaving  and  perverting  conduct,  until  the  un- 
fortunate slave  of  its  vicious  sway  is  no  more  in 
harmony  with  his  natural  self,  unperverted  by 
this  disease,  than  the  lawfully  and  justly  con- 
signed inmate  of  a  lunatic  asylum  is  ? 

The  dipsomaniac  is  as  sureiy  perverted  and  de- 
ranged in  his  brain  and  connected  nervous  sys- 
tem as  any  other  lunatic,  and  the  confirmed  in- 
ebriate claims  our  sympathy  and  succor  and  the 
kindly  consideration  of  the  law,  because  he  is 
the  victim  of  disease.  It  is  for  humanity  and 
law  to  decide  in  each  individual  instance,  how- 
ever, how  far  on  the  one  hand  inebriety  should 
extenuate  crime,  and  to  what  extent  on  the  other 
it  should  punish  the  volition  that  may  have  en- 
gendered the  disease.  It  is  a  plain  proposition, 
which  admits  of  no  doubtful  interpretation,  that 
acute  alcoholism  voluntarily  and  premeditatively 
induced,  or  even  voluntarily  yielded  to,  for  the 
purpose  of  committing  or  shielding  from  crime, 
is  as  culpable  as  any  other  criminal  intent,  while 
on  the  other  hand  a  diseased  propensit}*  to  drink, 
indulged  in  obedience  to  the  promptings  of  a  re- 
sistless organic  aptitude  handed  down  from  father 
to  son,  or  transmitted  through  the  womb  of  an 
alcoholized  or  otherwise  neuropathic  mother, 
should  receive  a  different  consideration,  just  as 
any  other  neuropathic  heritage  causing  psycho- 
pathic perversion,  extenuates  even  the  most  hei- 
nous of  crimes  in  the  eye  of  the  law  and  in  the 
judgment  of  courts. 

Our  ancestors  in  the  medical  profession  rescued 
the  lunatic  from  the  neglect  and  violence  of 
ignorance  ;  let  us  protect  and  save  the  nerve  de- 
generate inebriate. 

NOTE.— A  correspondent  of  the  Courtier  des 
/■'tats- 1  'nis  sends  from  Paris,  under  date  of  Sep- 
tember 20,  1890,  the  following  mention  of  a 
recent  trial  for  homicide,  committed  in  that  city 


i89i.] 


MEDICAL  PROGRESS. 


'3 


MEDICAL   PROGRESS. 


under  somewhat  peculiar  circumstances,  and  of 
the  prompt  acquittal  of  the  accused  on  the 
ground  of  mental  irresponsibility.  We  present 
to  our  readers  a  translation  :  •  Py0ktanin.  -Thelterature  regarding  the  use 

On  April  20th  last,  at  11  o'clock,  a.m.,  a  cry  for  belp  of  these  new  antiseptics  of  Stilling-Merck  is  rap- 

was  suddenly  heard  to  proceed  from  a  house  in  Park  ^    increasing,  and  as  usual  the  unfavorable  or 

Royal  Street,  an  apartment  of  which  was  occupied  bv  a  ,      ,.f  ,  ,°     „_„    .-.       i„t.-,.   «._    o^^^o^       riu 

widow,  *t.  27  years,  named  Bohringer.     The  neighbors  doubtful  results   are  the  latest  to    appear.     Dr. 

met  a  man  on  the  threshold  of  her  room,  who  remarked-.  LlNDSTROEM  (  I  ratc/l,  1890J  has  treated  seventeen 

"  You  can  enter.     It  is  all  over  with  her.     There  she  is,"  cases  of  gonorrhoea  with    1:2000  or    1:4000   solu- 

— at  the  same  time  pointing  to  the  young  woman,  who  tions.      In  no  case  was  there  anything  like  abor- 

lav  stretched  on  the  floor  in  a  pool  of  blood.     The  victim  ..  ..  , ,        T„     ,,    1      .     r_,,_    „ococ    «.y,_ 

had  been  struck   with    a   finely  sharpened   cold-chisel.  tlve  actlon  observed.      In  all   but    four   cases   the 

After  being  conveyed  to  the  hospital  St.  Louis,  she  was  discharge  became  more  abundant  and   irritating 


Eleven  chancres  were  treated  with  pyoktanin 
mixed  with  chalk — the  results  were  much  infer- 
ior to  those  obtained   with   the  use  of  iodoform 


able  to  speak  but  a  few  intelligible  words,  and  died  after 
au  agony  of  a  few  days. 

The  assassin,  named  Joseph  Hahn,  a  widower,  and  the 
father  of  three  children,  had  long  paid  assiduous  court 
to  the  deceased,  with  the  expectation  of  marriage.  That  ,  and  calomel 
he  had  premeditated  the  crime,  was  patent  from  the  fact 
that  he  had  hired  a  cutler  to  sharpen  the  chisel,  the  day  WARM  SUBLIMATE  SOLUTIONS.  — I)R.  AHL  has 
before.  It  was  satisfactorily  shown,  before  the  court,  found  on  the  ground  of  numerous  bacteriological 
that  Hahu  was  a  skillful  workman,  that  his  probity  was  and  ci;njcai  experiments  that  an  application  of 
Slngtahe'b^  iS^S:Sv,;S  ^at  to  sublimate  solutions  increases  their  anti- 
injuring  whatever  was  within  reach.  septic  powers,  and  at  the  same  time  diminishes 

At  first  sight,  the  tranquil  face  of  Hahn  in  110  way  be-    their  poisonous   and  corrosive  effects.      His  con- 
tokened  insanity  ;    but  his  attitude  before  the  court  and  :  clusions  are   as   follows:      I.     The    antiseptic    ac- 

!neth^ardWaS  SO  ^^^  M  Pr°Perly  t0  ^  &  tion  of  a  solution  is  increased  by  heating  it  above 

The  following   were  his  replies  to   questions  by  the    400  C.      2.    A  solution  of  1-20,000   or   even    I-IO, 

court :  >,  heated  to  400  C,  may  be  used  without  dan- 

Coitrt.     The   police  report  represents   you  to  be  an  !  ger  jn  penetrating  wounds  of  the  lung,  pleura  or 

hS„maVes,  I  have  always  been  honest.    I  have  never  |  peritoneum.     The  bactericidal  effect  corresponds 

in   my  life   intentionally  done  harm  to  any   one.     But    to  that    of  a  I-500  cold  solution.      3.     A  solution 

sometimes  I  drink  too  much,  and  then  it  affects  my  head,    heated    to    above    400    stimulates    the    formative 

so  that  I  know  no  longer  what  I  do.  j  properties  of  the  tissues  and  accelerates  the  heal- 

H.   BehcJaus°e  l°aUm  obliged  to  associate  with  the  public  '  ™Z  process.  On  the  other  hand,  a  cold  solution  of 

in  order  to  procure  work.  1- 1 ,000  has  less  antiseptic  action  than  a  warm  so- 

C.    You  met  the  Bohringer  woman  in  a  Roquette street    lution  of  I-IO.OOO,   because  the    latter  penetrates 

restaurant.     Did  you  know  that  she  had  a  lover  ?  more  deepiv    4     The  Cut  surfaces  unite  more  rapid- 

CD^ou^roTosemlrriagetoher?  ly  than  when  acold  solution*  1-500  has  been  em- 

H.    No':  it  was  she  who  proposed  it  to  me.     We  were   ployed,  because  of  the  absence  of  caustic  ettects. 

to  be  married  at  the  end  of  her  term  of  mourning.     We    5.   Warm  and  weak  sublimate   solutions    ma}"  be 

had  but  two  months  more  to  wait.  use(j  w[x,h.  perfect  safety  as  regards  poisonous  and 

To  SrqSn   iShn'^rst. replied,    "I   do  not  \  toxic  effects.-/*/, 
know:"  and  then,  gesticulating  wildly,   he  said,   amid 
loud  sobs,  ' '  I  loved  that  woman  as  I  did  my  eyes  ;   she 
deceived  me.     She  had  an  accepted  lover  and  I  did  not 
know  i 
longi: 

prisoner!"  "Hahn,"  he  said,  "  occupied  the  very  border-  count  of  six  cases  in  which  absorption  of  ovarian 
land  of  insanity ;  he  is  of  so  hysterical  a  temperament  growths  was  produced  by  the  application  of  the 
that  he  does  not  enjoy  the  full  possession  of  his  faculties. ' '    paracJic  current 


Medici 

Treatment  of  Ovarian  Cyst  with  the  In- 


wit.     She   gave   me  by  mistake  a  handkerchief  be-    DUCED    CURRENT.  —  NOEGGERATH    (Cenlralblati 
jing  to  that  lover.     She  had  consumed  mv  money."      ...        _       . ,    .      .      0      .        ,  ,o„„\    „;— Qt,    nr,    o^ 

t.  Ball  testified  to  the  limited  responsibility  of 'the  J'"'  Gynakologte,  September    i S90)  gnes  an  ac- 


The  jury  rendered  a  verdict  of  acquittal.  On  the  read- 
ing of  the  verdict  Hahn  appeared  astounded  and  stupe- 
fied for  several  minutes. 


The  basis  of  this  treatment  is  expressed  in  the 
following  sentences :  The  current  employed  has 
the  character  of  quantity  ;  that  is,  the  induced 
power  is  strong,  as  is  generally  found  in  the  best 
Bequests  to  New  York  Hospitals. — Under  apparatus.  The  negative  pole  of  the  secondary 
the  will  of  the  late  Mr.  D.  B.  Fayerweather,  of  current  is  introduced  into  the  vagina  mounted  on 
New  York  City,  several  charitable  institutions  ]  an  insulated  handle  and  covered  with  a  wet  sponge, 
will  be  generously  remembered.  The  Presbyte- ,  while  the  positive  pole  is  connected  with  a  large 
rian,  St.  Luke's  and  Manhattan  Eye  and  Ear  Hos-  plate  electrode  covered  with  moist  sponge  and 
pitals  will  fall  heir  to  $25,000  each,  while  the  placed  over  the  abdomen.  The  current  should 
Mount  Sinai  and  Woman's  State  Hospitals  get :  only  be  strong  enough  to  be  perceived  by  the  pa- 
$10,000  each.  tient,  each  seance  should  last  from  one-half  to  one 


■4 


MEDICAL  PROGRESS. 


[January  3 


hour,  and  be  repeated  about  three  times  each  week. 
In  one  case  presenting  adhesions,  the  current 
was  broken  at  intervals  of  one  second  in  the  hope 
of  obtaining  more  energetic  action,  and  in  this 
way  to  reach  the  larger  growths.  Treatment 
should  be  continued  from  six  to  eight  weeks. 
The  most  favorable  cases  are  those  presenting 
mono-  or  multilocular  cysts  (myxadenoma)  of 
medium  size.  In  this  class  of  cases  the  results 
are  much  more  radical  than  in  the  use  of  the 
constant  current  in  fibromata,  as  the  tumors  dis- 
appear completely.  Of  course,  it  has  no  effect 
upon  malignant  growths. 

Acute  Epidemic  Bright's  Disease. — Kies- 
singer  {Gazette  Midicale  de  Paris)  contributes  a 
series  of  fourteen  cases,  of  what  he  regards  as  an 
acute  infectious  inflammation  of  the  kidneys. 
He  admits  the  possible  relation  of  the  poison  of 
scarlet  fever  to  this  trouble,  but  thinks  that  it  is 
excluded  from  the  absolute  absence  of  that  dis- 
ease from  the  neighborhood.  It  is,  of  course, 
difficult  to  determine  the  infectious  agent.  M. 
Roux  has  obtained  from  the  urine  a  bacillus 
similar  to  that  found  by  Eberth  ;  it  proved  harm- 
less to  rabbits,  whether  it  is  pathogenic  for  man 
has,  of  course,  not  been  determined. 

Prevention  of  Purulent  Ophthalmia  in 
the  Xew-born. — This  subject  is  perennial,  it 
no  sooner  seems  definitely  settled  than  some  one 
questions  the  method  or  results.  Recently  M. 
Puech  has  {Archives  de  Tocologie)  contributed 
his  results  with  both  the  method  of  Crede  and 
Hegar-Kohrn.  He  attributes  the  trouble  to 
some  infection  from  the  vaginal  discharges  of  the  i 
mother.  That  absence  of  vaginal  discharge  con- 
stitutes such  a  marked  exception  in  pregnant 
women  makes  it  necessary  that  precautions 
should  be  taken  in  every  instance.  He  has  used 
alternately  the  nitrate  of  silver  solution,  one  part 
to  fifty,  and  the  cotton  pledgets  saturated  with  a 
solution  of  sublimate.  Results  have  been  equally 
favorable  with  each  method.  The  latter  he  con- 
siders the  simpler  and  most  easily  used  in  gen- 
eral practice.  The  former  recommends  itself  for 
hospital  use  where  the  risk  of  infection  is  much 
greater. 

Infectious  Inflammation  of  the  I.' 
Osthof  {Munchener  Med.    Wockenschr.)   reports 
observed  in  the  prison  of  Zweibriicken  a 
large  number  of  cases  of  what  he  regards  as  "in- 
fectious "   inflammation   of  the   lung,  but   which 
in  their  general  type  did  not  differ  from  the  ordi- 
:111s  of  croupous  pneumonia.      Out  of  307 
inmates,    twenty-seven   were   attacked    and    two 
died.     The  greatest  proportion  was  furnished  by 
mger  prisoners.    The  cause  of  the  epidemic 
is  referred  by  Osthof  to  the  unhygienic  condition 
of  the  quarters  occupied  by  the  young  men.    The 


attacks  were  characterized  by  the  extraordinary 
severity  of  the  general  symptoms,  wThich  presented 
the  type  of  a  severe  infection. 

Snrgery. 

Treatment  of  Hemorrhoids. — The  ex- 
treme difficult j-  experienced  in  dealing  with 
prolapsed  and  engorged  haemorrhoids  makes 
anything  that  will  deal  successfully  with  the 
symptoms,  pain,  itching,  tenesmus  and  con- 
tracture of  the  sphincter,  of  great  importance. 
An  operation  in  many  cases  cannot  be  under- 
taken until  these  symptoms  subside,  or  the  pa- 
tient will  often  not  submit  to  radical  procedures. 
Under  these  circumstances  Alvin  {La  Semaine 
Medicate)  recommends  the  application  of  a 
sponge,  that  is  mounted  upon  a  handle  and  dip- 
ped in  very  hot  water,  (53  to  66°  C.)  to  the  anal 
region.  This  proceeding  is  repeated  five  or  six 
times  at  each  seance.  He  claims  that  under  this 
treatment  all  of  the  troublesome  symptoms  cease, 
the  tumors  are  gradually  reduced,  and  if  the 
remedy  is  persisted  with  for  some  weeks  the 
tumors  finally  disappear,  and  with  this  comes  a 
sensible  diminution  of  the  anal  contracture. 

Traumatic  Suppuration  in  the  Pelvis. — 
The  obscurity  surrounding  the  diagnosis  of  these 
conditions  is  illustrated  in  a  case  reported  by 
Regnier  {Revue  Medicate  de  Z.' Est)  in  which  a 
young  soldier  suffered  a  traumatic  ostitis  of  the 
ascending  ramus  of  the  pubes.  with  the  develop- 
ment of  a  retro-peritoneal  phlegmon.  The  ob- 
scure symptoms  led  to  an  exploratory  opening  of 
the  abdomen,  but  with  negative  results.  The 
patient  died  forty-two  days  after  the  operation. 

Extirpation  of  the  Bladder.  —  Pawlik 
(Centralblatt  fur  Gyncekologie)  describes  an  in- 
teresting example  of  this  rare  operation.  The 
patient  presented  herself  for  the  first  time  in  con- 
sequence of  a  severe  and  persistent  haematuria. 
Catheterization  of  both  ureters  demonstrated  that 
the  blood  came  from  the  bladder.  Palpation  and 
endoscopic  examination  revealed  a  pedunculated 
polypus  that  was  removed  by  galvano-cautery, 
through  an  opening  in  the  vesico-vaginal  wall; 
later  this  was  closed  and  the  patient  left,  appar- 
ently We!!. 

At  the  end  of  a  year  she  again  presented  her- 
self with  the  statement  that  for  eight  months  the 
hiematuria  had  ceased  but  lately  had  reappeared. 
Endoscopic  examination  showed  numerous  ses- 
sile papilloma  which  were  declared  to  be  malignant, 
as  was  afterwards  confirmed  by  the  microscopic 
examination.  A  few  weeks  later  an  operation 
was  made  establishing  communication  between 
the  ureters  and  vagina.  At  a  later  operation  the 
bladder  was  completely  removed;  first  a  supra- 
pubic incision  that  did  not  open  the  peritoneum 
was  made,  the  bladder  freed  from  its  attachments 
and  finally  removed  through  a  transverse  incision 


iS9i.] 


MEDICAL  PROGRESS. 


in  the  anterior  vaginal  wall  just  above  the 
urethra.  Several  efforts  were  made  to  close  the 
vagina,  but  they  were  only  partially  successful, 
a  small  fistula  remained  that  allowed  the  urine  to 
dribble.  This  the  writer  thinks  can  be  closed, 
when  a  good  degree  of  urinary  continence  will 
be  secured.  On  the  whole  the  operation  was  a 
great  success. 

Hydatid  Cyst  of  the  Spleen. — Chaixtre 
(Revue  de  Chirurgie)  describes  an  interesting  case 
in  which  a  laparotomy  was  done,  followed  by  fix- 
ation of  the  spleen  to  the  abdominal  wall,  drain- 
age of  the  pouch,  and  recovery. 

The  patient  presented  himself  at  the  Hotel- 
Dieu  of  Lyons,  suffering  from  severe  pain  in  the 
left  side  and  shoulder  ;  later  a  smooth  round  tu- 
mor was  found  in  the  left  flank,  extending  into 
the  pelvis.  The  general  condition  of  the  patient 
was  fair,  but  the  intense  pain  and  loss  of  rest 
had  considerably  reduced  his  flesh  and  strength. 
An  examination  of  the  urine  showed  nothing  ab- 
normal; the  blood  presented  the  usual  proportion 
of  red  and  white  corpuscles;  there  was  no  evi- 
dence of  malaria  or  other  cachexia;.  The  tumor 
increased  in  size,  and  three  months  after  admis- 
sion an  exploratory  puncture  was  made  that  evac- 
uated about  one  pint  of  clear,  slightly  albumin- 
ous fluid.  Microscopic  examination  was  nega- 
tive, as  it  did  not  betray  any  hooklets.  An  hour 
after  the  puncture  the  patient  had  a  severe  gen- 
eral urticaria,  but  no  rise  of  temperature.  De- 
cided amelioration  in  the  patient's  condition  per- 
mitted him  to  leave  the  hospital  and  journey 
to  Paris,  where  he  was  admitted  to  the  Hotel- 
Dieu,  where  a  diagnosis  was  made  of  hydatid  of 
the  left  lobe  of  the  liver,  but  intervention  was  not 
deemed  practical.  The  patient  returned  to  Ly- 
ons and  attempted  to  resume  his  occupation,  when 
the  pain  in  arm  and  shoulder  returned,  accompa- 
nied by  frequent  vomiting,  complete  loss  of  ap- 
petite, and  disturbed  sleep.  July  20,  six  months 
after  the  patient's  first  admission,  an  operation 
was  made.  It  consisted  of  an  incision  ten  centi- 
metres in  length,  in  the  left  side,  over  the  most 
prominent  part  of  the  tumor.  A  digital  explora- 
tion showed  conclusively  that  the  spleen  was  the 
organ  involved.  On  opening  the  cyst  a  small 
quantity  of  purulent  fluid  escaped.  The  cyst  was 
stitched  to  the  abdominal  wall  and  a  drainage 
tube  inserted.  His  condition,  after  the  operation, 
was  good,  and  one  month  later  he  left  the  hospi- 
tal with  only  a  slight  fistula.  By  the  following 
October  this  was  completely  healed,  since  which 
time  the  man  has  been  in  excellent  health  and 
able  to  follow  his  occupation. 

The  author  closes  with  a  brief  description  of 
the  few  published  cases  of  hydatid  of  the  spleen. 

<i.yneoolojty. 

Persistence  of  the  Embryonal  Cloaca  in 
an  Adult  Woman. — G.  Spinelli  (Re:  is/a  Chir, 


Clin,  e  Terap.)  presents  an  instance  of  this  rare  de- 
formity. Cases  in  which  the  bladder  empties  into 
the  vagina  are  comparatively  frequent,  and  again 
those  in  which  the  rectum  communicates  with  the 
vagina,  but  a  persistence  of  the  embryonal  cloaca 
involving  a  deficiency  in  both  of  these  septa  pre- 
sents a  subject  of  great  interest  in  the  develop- 
ment of  the  embryo. 

G.  F.,  31  years  of  age;  first  menstruation  at 
18,  accompanied  by  much  pain,  a  slight  discharge 
of  pale  blood  for  four  or  five  months.  Coitus  at 
15:  the  first  approach  painful,  but  causing  no 
haemorrhage.  Mammas  small,  flaccid  and  atro- 
phic ;  slight  depression  in  the  hypogastric  region, 
where  upon  deep  palpation  a  small,  smooth  body 
may  be  felt,  resembling  a  uterus.  Mons  veneris 
very  prominent,  clitoris  well  developed,  labia  ma- 
jora  atrophied,  labia  minora  hypertrophied,  ab- 
sence of  the  navicular  fossa  and  of  all  vestiges  of 
a  hymen.  No  urinary  meatus  or  tubercle.  The 
orifice  of  the  vagina  is  funnel-shaped,  ending  in 
a  folded  pocket,  lightly  bathed  with  urine.  Ab- 
sence of  the  anus.  The  finger,  resisted  by  a  ro- 
bust sphincter,  penetrated  the  vulva  with  diffi- 
culty, encountering  a  large  and  intricate  cavity. 
In  the  anterior  wall,  3.5  centimetres  above  the 
entrance,  an  oval  opening  was  found,  that  com- 
municated with  the  bladder.  The  cervix  was 
small  and  conical  and  could  be  felt  with  difficulty. 
owing  to  the  complete  anteversion  of  the  uterus. 
In  the  posterior  wall.  2  centimetres  above  the 
vulva,  the  finger  entered  an  opening  leading  into 
the  rectum. 

Slight  incontinence  of  urine  in  the  erect  posture 
and  at  the  moment  of  falling  asleep.  Solid  faeces 
are  readily  retained,  but  there  is  some  inconti- 
nence of  liquid  faeces.  The  profession  of  the 
woman,  that  of  a  prostitute,  indicates  the  state 
of  the  sexual  functions. 

The  writer  thinks  that  we  have  in  this  case  an 
example  of  arrest  of  development  in  the  second 
month.  Absence  of  the  anus  he  attributes  to  de- 
fect in  the  formation  of  the  recto-vaginal  septum 
and  not  to  atresia.  Absence  of  the  hymen  speaks 
in  favor  of  the  theory  that  it  is  but  a  prolongation 
of  the  vagina. 

Contractions  of  the  Uterus  Induced  by 
Electricity. — Amann  {Centralblatt  fur  Gynte- 
kologie)  has  tried,  in  Winckel's  clinic,  the  appli- 
cation of  the  constant  current  after  the  method  of 
Freund.  The  writer  had  a  "cupping  electrode" 
fabricated  by  the  same  man  who  made  that  of 
Freund.  At  the  tame  two  pregnant  women  were 
in  the  house  upon  whom  premature  labor  should 
be  induced.  The  first  was  that  of  a  multipara, 
with  deformed  pelvis,  so  that  a  well  formed  child 
could  not  be  born  at  term.  Upon  examination 
the  os  would  admit  the  end  of  the  finger.  The 
kathode  was  connected  with  a  small  sponge 
(diameter  212  cm.)  contained  in  a  cupping  glass 


i6 


MEDICAL  PROGRESS. 


[January  3, 


that  was,  with  the  aid  of  a  spirit  lamp,  applied  to  after  muscular  tonus  had  returned,  strong  con- 
the  nipple.      The  anode  with  an  area  of  ten  cm.  I  tractions  could  be  induced  and  the  uterus  would 
was  placed  upon  the  abdomen  just  over  the  uterus,    empty  itself. 
The  current  was  closed  three  times  in  five   min-  Obstetrics. 

utes.  One  minute  after  the  last  closure  a  distinct  j  Secretion  of  Milk  in  the  Newborn. — Va- 
labor  pain  came  on  that  lasted  for  one-half  min- ;  RIOT  (Remarques  sur  la  secretion  lactee  chez  les 
ute.  A  current  of  seven  milliamperes  was  em-  nouveau-n&s,  Gazette  Medicate  de  Paris)  has  ob- 
ployed.  Several  times  the  current  was  made  and  !  served  a  mammary  secretion  in  quite  a  number  of 
broken,  each  time  causing  some  contractions  of  j  children  of  both  sexes,  varying  in  age  from  three 
the  uterus;  in  one  instance  a  series  of  four  con-  days  to  nine  months.  In  two  cases  the  secretion 
tractions.  The  patient  also  had  pain  in  the  lum-  was  obtained  in  sufficient  amount  to  permit  of  a 
bar  region.  A  small  eschar  was  produced  upon  quantitative  examination,  which  showed  that  it 
the  nipple  where,  owing  to  the  too  strong  sue-  contained  the  characteristic  ingredients  of  milk, 
tion  of  the  cupping  glass,  the  skin  was  brought  |  butter,  casein  and  lactose.  Out  of  thirty-two  in- 
in  contact  with  the  metal  rim  surrounding  the  fants  only  six  were  found  to  present  no  mammary 
sponge.  Unfortunately  the  patient  would  not  secretion,  though  in  many  of  the  remaining  cases 
submit  to  further  treatment,  and  the  result  of:itwas  very  slight  indeed,  and  in  some  did  not 
these  first  trials  were  negative.  ,  present  a  milky  appearance.   The  terms  the  author 

A  second  case  was  that  of  a  quadipara  in  the  |  Uses,  while  not  seemingly  accurate,  yet  show  a 
eighth  month,  in  whom  the  current  was  employed  ;  wjde  variation  in  the  character  of  the  secretion, 
for  from   one  to  one  and  one-half  hours   twice       The  writer  regrets  that  he  is  not  able  to  enter 
each  day,  with  a  current  strength  of  fifteen  mil-   i„t0  the  immediate  cause  and  signification  of  this 
liamperes.      This  method  was  employed  for  five  '  peculiar  and  temporary  function  in  the  newborn. 


days  without  the  slightest  success,   as  no  labor 

pains  could  be  induced.     The  current  was  well 

borne  and  the  patient  only  complained  of  some 

pain  in  the  back  and   a  burning  feeling  in  the  ™unt  of  f.  c,ase„?f  thlf  °ature 

nipples.     On  the  sixth  day  a  catheter  was  intro- 


Fatal  Poisoning  with  Male  Fern. — An  ac- 

given  in    the 
Therapeutische  Monatshefte,    in    which  death  en- 


duced  that  rapidly  induced  labor.  While  the ; sued  "Pon  *he  administration  of  two  drachms  of 
writer's  paper  was  in  press  he  employed  the  the  ethereal  extract  of  male  fern,  given  as  an  an- 
method  in  a  third  case,  but  without  success.  theltnmthic.     A  child,  five  years  and  a  half  old. 

Results,  while  so  poor  in   inducing  premature   wa*  |iven    the  amount  named,   within  an  hour 
labor,  yet  they  were  excellent  when  the  current !  a,nd  three  quarters,  in  three  doses 


was  used  at  term   in   delayed   labor  and  during  the  tapeworm  was   expelled  in    an  hour   and    a 


labor  before  and  after  the  discharge  of  the  pla 
centa.  A  primipara  presented  herself  at  the  clinic 


half;  then  vomiting  set  in,  followed  by  somno- 
lence, twitching,  and  trismus  lasting  ten  minutes. 


for  examination  just  at  the  end  of  gestation.  The  j  Death  took  P,ace  \n  five  hours  af*er  the  lastr  dose 
internal  examination  did  not  give  the  appearance  was  glvfn".  Arl  ,tbf  necropsy  there  was  found 
of  one  in  labor.  The  current  was  employed  in  a  tuberculosis  of  the  lungs  and  abdominal  glands  ; 
strength  of  from  six  to  eight  milliamperes,  after  and  the  unusual  results  from  a  dose  of  the  ex- 
the  third  closure  a  pain  was  induced  that  lasted  I tract'  su^h  as  wa?  £\veu<  were  Presumably  due  in 
fifty  seconds.  Two  pains  followed  spontaneously  Part  to  the  impaired  resistance  to  the  action  of 
after  opening  the  current.  The  current  was  em-  , the  druf.  incident  to  a  physique  broken  by  tuber- 
ployed  several  times  at  intervals  of  ten  minutes.  |  culous  d'sease-—  ^  •  '  •  Medical  Journal. 
The  pains  then  became  regular  and  more  fre- 
quent. Examination  at  this  time  showed  a  nearly 
terminated  first  stage. 


Experimental  Peritonitis. — Waterhouse 
(  /  trchow's  .  Irckiv.  —  Ceniralblatt fur  Klin.  A/ed.) 


The  method  was  employed  in    several  cases  j  in  a  series  of  twelve  observations  confirmed  the 

where  the  pains  were  weak  and  uncertain.     One,  results  of  Grawitz,  and   negatived  those  of  Paw- 

a  case  of  consumption,  another  of  heart  failure,  lowsky,  that  a  considerable  quantity  of  a  viru- 

and  a  third  nephritis  with  great  oedema.       In  all  lent  culture  of  the   staphylococcus  aureus  might 

of  these  cases  stronger  and  more   frequent  con-  be   injected   into    the  abdominal   cavity  without 

tractions  were  produced;  in  some  of  them  it  was  causing    peritonitis.      Also    wTheu    the    staphy- 

necessary  to  increase  the  current  strength   from  lococcus    is    mixed   with   an   untried    medium    it 

time  to  time.  causes  no  disturbance  if  the  mass  can  be  readily 

The  current  was  employed  in  several  cases  to  I  absorbed  ;  the  greater  the  difficulty  of  absorption 
expel  the  placenta,  the  results  were  largely  de-  the  more  certain  the  production  of  peritonitis. 
pendent  upon  the  period  when  it  was  used.  Im-  Trials  were  made  with  agar-agar,  gelatine  and 
mediately  after  the  birth  the  uterus  reacted  but  coagulated  blood,  each  containing  the  staphy- 
feebly  to  the  current,  and  the  pains  were  too  weak  lococcus,  and  the  results  were  positive.  Pus  con- 
to  expel  the   placenta.      One  to  two  hours  later  taining  the  staphylococcus  possessed  strong  pyo- 


i»9i.] 


MEDICAL  PROGRESS. 


:: 


genie  properties,  due,  the  writer  thinks,  more  to 
its  contained  chemical  substances  than  to  its 
microorganisms.  The  observation  of  Grawitz, 
that  when  the  infection  was  introduced  through  a 
wound  in  the  abdominal  wall  peritonitis  followed 
was  not  confirmed.  When  the  wound  was 
penciled  with  turpentine  an  abscess  was  produced, 
but  only  in  cases. where  the  wound  involved  the 
peritoneum,  if  it  extended  only  to  that  mem- 
brane and  not  through  it,  no  abscess  was  caused. 
When  artificial  defects  were  produced  in  the  peri- 
toneum injections  of  the  staphylococcus  caused 
peritonitis  ;  a  similar  effect  was  produced  in  ani- 
mals affected  with  ascites.  A  strangulation  of 
the  intestine  for  some  hours,  similar  to  that  pro- 
duced by  a  hernia,  invariably  caused  peritonitis 
after  the  injection  of  the  staphylococcus  into  the 
abdomen  or  blood-vessels.  The  same  result  was 
reached  if  the  coccus  was  injected  subcutane- 
ously,  but  not  if  it  was  placed  in  the  intestine. 
A  few  observations  upon  man  has  shown  that  the 
staphylococcus  may  be  injected  under  the 
healthy  skin  without  danger,  but  that  suppura- 
tion follows  if  the  absorption  is  hindered  or 
the  normal  conditions  are  altered  by  passive 
hyperaemia. 

Of  the  Positive  Polar  Action  of  the 
constant  Galvanic  Current  on  Microbes 
and  more  Particularly  on  the  Bacteria  of 
Anthrax. — (A  note  presented  to  the  Academy 
of  Medicine,  Paris,  April  28,  1890,  by  Apostoli 
and  Laguerriere.)  The  antiseptic  and  microb- 
cidic  action  of  the  galvanic  current  observed  by 
one  of  us  in  1886  has  been  the  object  of  our 
common  investigations  for  the  last  two  years. 

In  a  sealed  note  deposited  with  the  Academy 
of  Sciences  August  12,  1889,  we  have  laid  down 
the  first  results  of  the  experiments  undertaken  in 
placing  the  two  poles  at  the  two  extremities  of 
the  same  test  tube  containing  bouillons  of  culture, 
and  at  short  distances  from  each  other.  All  our 
experiments  have  had  the  control  of  cultures  and 
of  inoculations  into  animals  (rabbits  or  guinea 
pig).  Here  are  our  first  and  principal  conclu- 
sions : 

1.  The  action  of  the  constant  galvanic  current 
on  cultures  is  in  direct  rapport  with  the  intensity 
of  the  current  measured  by  milliamperes. 

2.  For  a  like  intensity,  and  all  other  things 
being  equal,  the  length  of  the  application  is  of 
little  importance.  The  intensity  of  the  current 
remains  all  the  time  the  principal  factor. 

3.  A  current  of  300  milliamperes  and  more  ap- 
plied for  5  minutes  kills  invariably  the  bacteria 
of  anthrax.  The  further  cultivation,  attempted 
with  a  culture  so  treated,  remained  sterile  ;  the 
inoculation  into  guinea  pigs  without  eifect. 

4.  A  current  of  200  to  290  milliamperes  ap- 
plied for  five  minutes  does  not  destroy  so  surely 
and  so  certainly  the  virulence  ;  some  guinea  pigs 


will  still  die,  but  in  a  much  longer  period  of  time, 
i.  e.,  more  slowly,  than  the  control  animal  inocu- 
lated with  the  culture  before  it  was  subjected  to 
the  current. 

5.  A  current  of  100  milliamperes  and  less  after 
an  application  of  thirty  minutes  does  not  destroy 
the  virulence  ;  an  attenuation  is  produced  which 
augments  with  the  intensity  of  the  current,  and 
which  manifests  itself  in  this,  that  the  animals 
so  inoculated  die  a  day  or  two  later  than  the  con- 
trol animals. 

Since  that  period  we  have  established  that 
these  effects  are  independent  of  the  thermic  in- 
fluence which  accompanies  electrolysis.  And  we 
have  studied  the  isolated  influence  of  the  poles 
and  of  the  interpolar  portion  of  the  circuit. 

We  can  formulate  the  following  complimentary 
conclusions : 

1 .  The  chlorific  effects  of  the  current  can  be 
suppressed  and  nevertheless  the  destruction  or 
attenuation  of  the  microbian  vitality  be  obtained. 

2.  The  positive  polar  alone  destroys  or  attenu- 
ates the  vitality  of  the  pathogenic  organisms,  for 
whom  the  inter-polar  action  and  that  of  the  nega- 
tive pole  is  indifferent. 

3.  The  antiseptic  action  of  the  positive  pole 
(in  a  distinct  culture  medium,  entirely  separated 
from  the  negative  pole)  is  exercised  in  smaller 
electric  doses  than  in  the  first  experiments  (where 
the  two  poles  being  contiguous  attenuate  their 
reciprocal  action. 

Thus  the  positive  pole  does  not  destroy  at  90 
milliamperes  applied  for  a  period  varying  from 
nine  to  thirty  minutes,  but  above  that,  attenua- 
tion commences  and  progresses  gradually,  to  be- 
come constant  with  100  to  190  milliamperes  from 
the  first  five  minutes. 

4.  The  general  conclusion  to  be  arrived  at  from 
our  investigations  is  this,  that  the  continued  cur- 
rent in  so-called  medical  doses  (that  is,  from  90 
to  300  milliamperes)  has  no  action  sui  generis  on 
the  microbian  cultures  in  a  homogenous  medium, 
and  that  its  unique  positive  polar  action  is  limited 
to  the  development  of  acids  and  of  oxygen,  as 
we  shall  demonstrate  in  a  future  paper. — In. 
Medic,  d.  Can  ad. — Cincinnati  Medical  News. 

Salpingitis  Gonorrhoica. — Menge  (Cen- 
tralblait  fur  Gyntekologie)  has  examined  bacterio- 
logically  the  contents  of  the  tube  sack  in  twenty- 
six  cases  of  salpingitis  that  have  been  operated 
in  Martin's  clinic  in  Berlin.  In  eight  cases 
microorganisms  were  found  ;  two  presenting  the 
streptococcus  pyogenes,  one  the  staphylococcus 
pyogenes  albus,  and  a  third  a  saprophytic  rod, 
that  was  cultivated  upon  agar-agar.  One  case 
presented  a  diplococcus  that  could  be  stained  by 
Gram's  method  ;  in  the  remaining  three  cases 
the  gonococcus  of  Xeisser  was  found.  In  eight- 
een other  cases  the  contents  of  the  tube  proved 
to  be  absolutely  sterile. 


18 


MEDICAL  PROGRESS. 


[January  3, 


In  one  of  the  cases  a  ruptured  tube  sack  al-  kaline  liquid,  precipitate  again,  and  then  dissolve 
lowed  the  gonorrhceal  pus  to  escape  into  the  peri-  the  precipitate  in  ether.  This  is  dried  with  steam 
toneum,  and  raised  the  question  as  to  whether  over  ether  when  it  appears  as  oily  drops  that  soon 
the  gouococcus  could  cause  a  specific  peritonitis,  harden  into  yellow  fat-like  masses,  insoluble  in  wa- 
This  has  been  variously  answered  by  different  I  ter  and  acid  solutions,  but  dissolved  by  ether  and 
writers.      Bumm  claims  that  the  gonococcus  only  j  alkaline  solutions.   The  amount  of  this  substance 


invades  cylinder  epithelium,  and  negatives  the 
existence  of  such  specific  disease  of  the  peri- 
toneum ;  Koch  says  the  question  is  still  unsettled. 
The  writer  regards  the  position  of  Bumm  as  un- 
tenable because  of  the  fact  that  gonococci  have 
been  found  in  the  knee-joint,  a  sack  that  closely 
resembles  the  peritoneum.  It  is  possible  that  in 
old  cases,  the  cocci  may  have  to  a  great  extent 
lost  their  virulence,  due  to  the  various  saprophytic 
germs  with  which  they  have  been  brought  in 
contact,  or  to  antiseptics,  these  may  not  be  able 
to  start  a  specific  peritonitis  while  the  fresh  vigor- 
ous germ  might  prove  very  dangerous. 

A  Pathogenic  Bacillus  in  Decomposed 
Urine.-  Krogius  (Surun  bacille  pathogene  trouvi 
dans  les  urines  pat/iologique — La  Semaine  Medi- 
cal, No.  31)  has  found  a  bacillus  in  the  purulent 
urine  of  old  cases  of  stricture,  cystitis,  and  pye- 
lonephritis, which  he  thinks  plays  an  important 
role  in  urine  infection.  Out  of  ten  cases,  the  ba- 
cillus, which  has  not  yet  been  described,  was 
found  three  times.  It  belongs  to  the  rod-like 
forms,  the  length  varying  from  1.8  to  3.6  it.  with 
rounded  ends.  It  does  not  produce  spores,  and 
is  easily  stained  by  the  aniline  colors,  which  are 
easily  removed  by  the  method  of  Gramm.  It 
liquefies  gelatine,  and  gives  off  the  ammoniacal 
smell  peculiar  to  decomposed  urine.  Urea  is  rap- 
idly changed  into  carbonate  of  ammonium  and 
water.  Pure  cultures  injected  into  the  veins  or 
peritoneum  of  a  rabbit  produced  death  in  from 
two  hours  to  a  few  days.  With  age  the  culture 
increases  in  virulence.  After  vaccination,  the 
part  is  reddened,  swollen,  and  later  gangrenous, 
after  which  the  dead  portion  is  cast  off,  accom- 
panied by  an  ammoniacal  odor,  fever  convulsions, 
and  coma.  Sterilized  filtrates  obtained  with  a 
porcelain  filter  present  the  same  toxic  symptoms. 
The  writer  names  this  germ  the  icro-bacillus  lique- 
faciens  opticus. 

The  Cholera  Poison. — The  Journal  has  of 
late  frequentl}'  referred  both  in  "Progress"  and 
editorially  to  the  advances  that  have  been  made 
in  isolating  the  peculiar  toxic  substances  produced 
by  certain  pathogenic  microorganisms.  Re- 
searches of  this  kind  have  followed  so  rapidly  of 
late,  that  it  is  hardly  possible  to  keep  our  readers 
fully  informed  on  these  important  topics. 

WINTER  and  I.hs.m.K  {Contribution  it  I 'etude 
d it  poison  e/10/e/ii/ue,  Bulletin  Med.,  No.  29)  have 
obtained  a  peculiar  toxic  substance  from  bouillion 
cultures  of  the  cholera  bacillus.  They  first  pre- 
cipitate with  sulphuric  acid,  redissolve  in  an  al- 


obtained  from  a  given  culture  is  directly  depend- 
ent upon  its  virulence. 

Small  doses  of  this  substance  (o.ooi  to  100. 
grams  body  weight)  in  watery  solution  injected 
into  the  stomach  of  a  guinea  pig  produces  a  chill 
and  rigidity  in  from  four  to  six  hours,  followed 
by  death  at  the  end  of  twenty-four.  With  larger 
doses  the  fall  in  temperature  comes  in  one- half  or 
one  hour,  and  death  in  from  twelve  to  twenty 
hours.  With  weaker  doses  a  slight  reaction  is 
produced  and  at  the  end  of  twenty- four  hours  the 
animal  is  again  in  a  normal  condition.  If  it  is 
examined  during  this  period  it  presents  typical 
cholera  lesions.  Rabbits  react  but  slightly  to 
intra-venous  injections.  The  toxic  substance 
can  be  recovered  from  the  muscles,  liver,  kidneys 
and  urine.  Rabbits  are  killed  only  by  repeated 
injections  when  they  also  present  the  typical 
cholera  lesions.  Owing  to  the  fact  that  the  sub 
stance  is  insoluble  in  acid,  it  was  found  that  when 
lactic  acid  was  given  within  five  hours  after  the 
toxic  dose,  the  animal  was  saved. 

>iew  Instruments. 

A  New  Nasal  Douche.— E.  Pius  {Re/.  Cor- 
rcspoiidcuz-Blatt  fur  Schweizer  Aerzte)  describes 
a  new  form  of  nasal  douche  which  he  says  is,  in 
a  measure,  free  from  some  of  the  difficulties  and 
dangers  attendant  upon  the  use  of  Weber's  or 
Politzer's  instruments.  It  is  extremely  simple 
in  construction,  consisting  of  a  flask  with  perfor- 
ated cork  containing  two  glass  tubes,  one  termi- 
nating near  the  top  of  the  flask,  and  the  other 
extending  nearly  to  the  bottom.  Both  tubes  are 
bent  to  a  convenient  angle,  the  longer  one  termi- 
nating at  the  external  end  in  a  bulb  that  readily 
fits  the  nostril.  The  method  of  using  is  simply 
to  fill  the  flasks  with  liquid  and  then  blow  into 
the  short  tube,  thus  increasing  the  pressure  in  the 
flask  so  that  the  liquid  is  forced  into  the  nostril 
back  into  the  nasopharynx,  whence  it  escapes 
by  the  opposite  passage.  The  writer  claims  sev- 
eral advantages  for  his  instrument :  first,  it  is 
cheap  and  easily  constructed  ;  second,  it  is  free 
from  the  difficulty  that  many  persons  experience 
in  using  the  douche  ;  third,  pressure  is  limited  to 
the  force  exerted  by  the  respiratory  muscles ; 
fourth,  the  contraction  of  the  palate  muscles,  as 
well  as  the  forcible  elevation  of  the  palate,  tend 
to  assist  in  closing  the  Eustachian  tubes.  He 
says  that  a  considerable  quantity  of  fluid  (1  to  3 
litres)  may  be  comfortably  blown  through  the 
nose  with  but  little  danger.  In  thirty  patients 
with  over  100  injections,  he  had  never  seen  any 
unpleasant  consequences. 


i8qi.]  EDITORIAL.  19 


THE  if  true,  are  to  be  verified.      New   methods  are  at 

J '  nirnal  of  the  A  merican  M  edical  Association  hand  in  every  department  of  medicine  and  surgery. 

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=  ;      The  brilliant  achievements  recently  made  in 
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With  this  first  number  of  its  sixteenth  volume  and  if  possible  better,  work  ;  not  more  in  lines 
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The  unsolved  questions  which  confront  the  lands  as  well.  To  the  furtherance  of  its  interests 
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so  profound,  as  they  are  today.  The  eminent  stands  peculiarly  committed.  A  harmony  of  pur- 
men  engaged  in  their  solution  were  never  before  pose  is  essential  to  the  highest  interests  both  of 
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service.  Original  research  and  experimentation  motion  of  this  end  we  shall  also  address  ourselves, 
in  many  and  varied  ways  will  be  the  character-  confident  that  such  service  will  command  the 
istic  labor  of  the  coming  period.  A  most  pro-  hearty  sympathy  of  the  members  of  the  Associa- 
found  impression  has  been  made  upon  the  public  tion,  without  whose  cordial  cooperation  The 
mind  by  reason  of  the  alleged  discovery  of  new  Journal  can  not  succeed,  and  with  which,  it  can- 
and  most  remarkable  methods   of  cure.      These,    not  fail. 


AMERICAN  ACADEMY  OF  MEDICINE. 


January  3, 


AMERICAN  ACADEMY  OF  MEDICINE. 

The  Academy,  at  its  annual  meeting,  held  at 
Philadelphia,  manifested  additional  and  practical 
evidence  of  its  continued  interest  in  the  subject  of 
liberal  preparatory  education  of  students  in  med- 
icine. It  showed  active  work,  also,  in  the  cause 
of  higher  medical  education. 

Acting  upon  a  recommendation  in  the  presi- 
dent's annual  address,  the  Academy  voted  to  con- 
fine its  efforts  in  future  exclusively  to  its  mission- 
ary work.  Other  medical  organizations  have  be- 
come so  numerous  since  the  Academy  was  estab- 
lished that  ample  opportunity  is  afforded  else- 
where for  the  presentation  of  all  papers  on  purely 
medical  subjects.  This  action  on  the  part  of  the 
Academy  makes  it  the  only  medical  body  in  this 
country  devoted  exclusively  to  medical  mission- 
ary work.   It  thus  acquires  a  distinctive  character. 

Beginning  its  efforts  at  the  foundation  for  prof- 
itable medical  study, — proper  preliminary  mental 
training, — it  has  outlined  a  curriculum  of  study 
which  it  advises  as  qualifying  to  begin  the  study 
of  medicine.  One  of  its  committees  has  been  in- 
vestigating the  curricula  of  the  different  liter- 
ary colleges  of  the  United  States,  with  a  view  to 
ascertaining  their  relative  advantages  and  the 
comparative  value  of  the  literary  degrees  which 
those  colleges  confer.  A  report  made  by  this 
committee  at  the  Academy's  recent  meeting 
showed  great  differences  in  both  respects. 

Other  committees  report,  from  year  to  year, 
upon  subjects  connected  with  preliminary  and 
medical  education — such  as  the  amount  of  prepar- 
atory mental  discipline  required  by  the  different 
medical  colleges  for  matriculation  of  students  of 
medicine,  and  their  methods  of  determining  that 
fact.  Another  committee  reports  each  year  upon 
the  laws  of  the  different  States  to  determine  the 
qualifications,  professional  and  otherwise,  of  can- 
didates fc  license  to  practice  medicine  where  such 
laws  exist — including  the  standard  adopted  by 
those  States,  the  method  of  ascertaining  the  qual- 
ifications of  applicants,  the  mode  of  enforcing 
the  laws,  requirements,  penalties  for  violations 
and   kindred  subjects. 

Having  thus  begun  by  judicious  encourage- 
ment to  young  men  to  pursue  such  preparatory 
courses,  and  seeking  to  give  reliable  direction  in 
their  medical  study,  and  evincing  appreciation  of 
the  medical  colleges  which  afford  the  best  facil- 
ities for  their  students,  the  Academy,  in  accord- 


ance with  another  of  the  president's  recommenda- 
tions, decided  to  take  an  additional  step  in  ad- 
vance. It  will  endeavor  to  secure,  through  its 
Fellows  resident  in  the  different  States,  coopera- 
tion of  the  medical  organizations  of  each  State 
looking  to  legal  enactments  of  all  of  the  States  to 
regulate  the  practice  of  medicine  by  granting, 
hereafter.licenses  to  practice  onlj'  on  examination, 
and  regardless  of  the  possession  of  diplomas  issued 
by  medical  colleges.  Such  enactments  have  a  two- 
fold effect :  They  make  colleges,  in  effect,  simply 
teaching  bodies — which  is  their  proper  function — 
and  they  secure  in  future,  for  the  protection  of 
the  people,  physicians  who  are  required  to  de- 
monstrate to  the  constituted  authorities  of  the 
State  their  qualification  for  the  work  in  which 
the>-  are  seeking  to  engage,  and  they  expose  the 
pretensions  of  the  unqualified.  Such  legislation 
accomplishes,  by  enforcing  its  requirements,  what 
the  Academy  has  been  seeking  to  effect  by  other 
means  in  the  interest  of  scientific  medicine,  which 
means  interest  in  the  health  and  welfare  of  the 
people  of  the  States.  Thus  it  becomes  an  instru- 
ment for  conserving  the  material  interests  of  the 
States  themselves. 

It  is  an  encouraging  feature  of  the  times  that 
some  six  hundred  of  those  who  are  recognized  as 
being  amongst  the  most  liberally  educated  of  the 
physicians  of  our  country  are  united  in  a  volun- 
tary effort,  and  proceeding,  at  their  own  expense, 
in  an  unostentatious  and  systematic  manner  in 
an  effort  to  remedy  recognized  educational  de- 
fects, and  thus  to  elevate  the  profession  of  medi- 
cine, thereby  benefiting  mankind. 

In  such  an  unobtrusive  manner  has  much  of 
the  Academy's  preliminary  work  been  done  that 
it  has  attracted  comparatively  little  attention. 
What  has  been  accomplished  merits  recognition 
and  commendation.  Its  efforts  are  such  as  should 
receive  the  cordial  and  energetic  support  of  the 
medical  profession  of  the  whole  country.  Well 
considered  and  just  legislation  in  this  regard  in 
all  of  the  States  would  prove  advantageous  to  the 
public  and  creditable  to  the  profession  which  ad- 
vocated and  aided  it.  Work  having  such  objects 
in  view  commends  itself  to  The  Journal. 


Deserved  Honor. — The  King  of  Greece  has 
aamed  Professor  Brouardel,  the  eminent  French 
medical  jurist,  Commander  of  the  Order  of  the 
Saviour. 


I89i.] 


MAJOR  VERSUS  MINOR  GYNECOLOGY. 


MAJOR  VERSUS  MINOR  GYNECOLOGY. 
It  would  be  regarded  as  a  strong  corroboration 


lessness,  that  a  flank  movement  attacking  minor 
gynecology  and  holding  it  responsible  as  a  causal 
agent  in  the  production  of  surgical  diseases,  may 


of  the  popular   view  as  to  the  disagreement  of  ^^  attention  int0  another  field.     We  are  sure, 
medical  men,  if  a  paper  recently  read  before  the   howeveri  that  the  writer  0f  the  paper  in  question 


Philadelphia  County  Medical  Society,  arraigning 
minor  gynecology  as  a  potent  factor  in  the  pro 


was   honest  in  his  animadversions,  and  had  no 
such  motive  in  view;  but  we  are  greatly  surprised 


duction  of  morbid  conditions  necessitating  major  th^  .q  tfae  discussion  in  the  Philadelphia  Society- 
gynecological  operations,  should  find  its  way  into  whi'ch  followed  its  reading,  some  of  the  excellent 
the  columns  of  the  lay  press.  The  idea  deduced  minor  gynecologists  0f  that  city,  whose  ability, 
from  it  by  the  casual  reader  might  be  that  much  gkm  ^  emdite  touch  are  reCognized,  did  not  rise 


of  this   kind   of   operative  work,   performed  by 
young  and  inexperienced  meddlers,  or  by  others 


to  the  full  measure  of  the  occasion  and  speak  a  few 
ood  words  of  commendation  of  the  benefits  to  suf- 


who  might  be  good  enough  operators,  but  not  fering  humanity  sometimes  derived  from  minor  op 
sufficiently  discriminating  as  to  times  or  methods,  erationsjudiciousiv  performed,  or  of  condemnation 
or  as  to  personal  aptitudes  of  the  patient,  would  q{.  tfae  ^.j  effects  'of  often  jn-timed  and  startling 
lead  eventually  to  virtual  failure,  after  which  the  surgical  exploits.  Certainly  more  might  be  said  in 
sufferers  would  naturally  seek  advice  and  assis-  defense  of  sensible  minor  gynecology  than  was 
tance  from  those  occupying  a  higher  plane   of  elicited  at  this  meeting.     Perhaps  on  some  future 


surgical  skill  and  manipulative  proficiency 

The  inference  from  perusal  and  study  of  this 
paper  was  inevitable,  that  there  are  two  distinct 
classes  of  gynecological  practitioners  :  i ,  those 
who  habitually  practice  Emmet's  operation,  in- 
troduce uterine  sounds,  electrodes  and  caustics, 


occasion  the  other  side  may  have  an  opportunity 
to  make  itself  heard. 


THE  SITUATION  AT  BERLIN. 
There  is  so  far  but  little  change  in  affairs  at 
under  the  least  pretense,  and  frequently  with  no  gerjjn  unless  there  be  a  waning  subsidence  of 
better  plea  than  that  they  do  not  know  what  other  ^  excitement.  Koch,  according  to  the  secular 
treatment  to  adopt ;  and  2,  those  who  rarely  in-  presS!  as  the  recipient  of  an  enormous  mail,  and 
dulge  in  any  of  these  expedients,  but  perform,  in  the  daily  besetnients  of  applicants  for  relief  from 
the  surgical  diseases  of  women,  bold  and  intricate  all  parts  of  the  worjd  has  been  compelled  to  be- 
operations,  which  have  been  rendered  necessary  by  take  himself  to  the  Hartz  Mountains  for  a  two 
the  blunders,  inexperience  and  lack  of  judgment  of  wee]-s>  vaCation,  leaving  Ewald  in  command  of 
the  first- mentioned  class.  the  pressirjg  hosts  at  home.     Meanwhile  his  per- 

These  are  matters,  however,  which  must  be  set-  gonal  desjre)  as  persistently  iterated,  is  for  the  op- 
tled  by  the  gynecologists  themselves.  It  would  portunity  t0  investigate  in  other  fields  and  to 
be  considered  an  act  of  presumption  for  those  who  comp]ete  his  arrangements  with  the  Prussian 
are  without  the  pale  of  this  specialty  to  sit  in  un-  Qovernment  for  the  preparation  of  his  "lymph." 
solicited  judgment  upon  the  merits  of  the  question  He  styj  c]aims  no  discovery  of  a  cure,  and  pleads 
at  issue.  Doubtless  minor  gynecology  is  respon-  for  more  time  t0  m]ly  verify  his  experiments.  In 
sible,  in  many  instances  of  meddlesome  surgery,  t]ae  trying  ordeal  of  so  dizzy  a  reputation  he  sus- 
for  the  persistence  and  augmentation  of  suffering  tains  himself  grandly,  avoids  press  interviews  and 
and  the  postponement  of  the  healing  process ;  but '  remains  the  same  simple,  honest  man  of  yore, 
it  is  a  question  whether  the  advanced  surgeon  g0  far  as  the  situation  at  home  is  concerned,  many 
may  not  be  throwing  too  much  discredit  upon  the  new  names  are  heralded  in  the  prints  of  the  day, 
minor  gynecologist  (admitting,  for  a  moment  only,  many  shadowy  opinions  are  broached,  some  insin- 
the  existence  of  two  such  distinct  classes  of  sur-  uatjons  0f  dishonest  acquisition  of  the  "lymph," 
geons),  and  laying  too  little  stress  upon  the  in-  and  a  controversy  regarding  the  dose  as  bitter  as 
tensity  of  the  original  morbid  condition.  the  contest  between  the  Big-enders    and  Little- 

There  has  been  so  much  outspoken  criticism  of  enderS)  has  become  somewhat  of  an  incident— all 


major  gynecology,  its  boldness  and  apparent  reck- 


1  See  The  JorRXAL.  p.  656.  Vol.  xv. 


of  which  prove  that  the  East  is  not   always  the 
source  of  wisdom.     Until  we   can   fairly  distin- 


EDITORIAL  NOTES. 


[January  3, 


guish  between  voices  and  echoes,  as  well  as  learn 
to  respect  the  physicians  extra-ordinary  to  the 
public,  we  prefer  to  withhold  our  verdict  as  to  the 
permanent  results. 


EDITORIAL  NOTES. 

Population  of  the  United  States. — The 
Census  Bureau  has  declared  the  population  of  the 
United  States  in  June,  1890,  to  have  been  62,- 
480,540,  exclusive  of  white  persons  in  the  Indian 
Territory,  Indians  on  reservations,  and  the  people 
of  Alaska.  If  these  figures  are  correct,  the  ab- 
solute increase  in  the  population  of  the  country 
since  1880  was  12,324,757,  and  the  percentage  of 
increase  24.57. 

Faith  Cure  in  Africa. — Several  Americans 
who  had  gone  out  to  Africa  as  missionaries,  de- 
pending upon  miraculous  aid  to  resist  the  climate, 
have  sickened  and  died.  They  were  attacked 
with  fever,  and  refused  to  employ  medical  aid. 
The  number  of  such  cases  being  likely  to  increase, 
the  Governor  of  Sierra  Leone  has  issued  a  procla- 
mation that  the  climatic  conditions  are  adverse 
to  believers  in  faith-cure,  and  that  hereafter  white 
people  will  be  compelled  when  ill  to  accept  the 
services  of  a  physician. 

The  Heart  in  Athletics. — A  British  sur- 
geon states  that  of  5,000  decrepit  or  aged  soldiers 
that  have  been  brought  under  his  notice,  fully 
80  per  cent,  were  suffering  from  cardiac  trouble 
in  one  form  or  another,  due  to  forced  exertion. 
Ke  predicts  that  as  large  a  percentage  of  the 
athletes  of  to-day  will  be  found  twenty-five  years 
hence  to  be  the  victims  of  the  same  causes  en- 
gendered by  muscular  strains.  With  regard  to 
the  effect  of  exercise  on  the  prolongation  of  life, 
it  may  be  said  that  there  are  more  people  living 
in  France  who  have  passed  the  age  of  60  than 
there  are  in  England,  the  home  of  athletic  sports, 
and  there  is  probably  no  nation  in  Europe  more 
averse  to  muscular  cultivation  for  its  own  sake 
than  the  French.  Great  athletes  die  young,  and 
a  mortality  list  of  Oxford  men  who  had  rowed  in 
the  'varsity  races,  shows  that  a  comparatively 
small  percentage  of  them  lived  out  the  allotted 
time. 

A  Bn.i.  has  been  introduced  in  the  Georgia 
legislature  to  prohibit  physicians  and  drug  clerks 
who  are  addicted  to  the  use  of  whiskey  or  opium 
from    practicing  their   profession.     For  the  first 


conviction  of  being  drunk  a  fine  of  $200  is  im- 
posed, and  for  the  second  the  license  to  practice 
is  revoked. 

Proposed  Law  Against  Hypnotism. — The 
following  legislative  measure  has  been  introduced 
to  the  Chamber  of  Deputies  of  Belgium  by  the 
Minister  of  Justice  :  Article  1.  Whoever  makes 
a  public  exhibition  of  a  person  hypnotized  by 
himself,  or  anyone  else,  will  be  punished  by  im- 
prisonment from  fifteen  days  to  six  months,  and 
with  a  fine  of  from  26  to  1,000  francs.  Article 
2.  Whoever,  not  being  qualified  to  exercise  the 
healing  art,  hypnotizes  a  person  who  has  not  at- 
tained the  full  age  of  18  years,  or  who  is  not 
sound  of  mind,  will  be  punished  by  imprison- 
ment from  fifteen  days  to  one  year,  and  to  a  fine 
of  from  26  to  1,000  francs,  even  if  the  hypnotized 
person  has  not  been  exhibited  in  public.  Arti- 
cle 3.  The  punishment  of  imprisonment  will  be 
used  against  any  person  who,  with  a  fraudulent 
or  malicious  intention,  makes  a  hypnotized 
person  write  or  sign  an  act  stating  any  agree- 
ment, disposition  or  declaration.  The  same 
punishment  will  be  applied  to  those  who  take  ad- 
vantage of  agreements  so  attained. 

Immunity  of  Jews  from  Tuberculosis. — 
Dr.  G.  A.  Heron  has  just  published  a  work  on 
"Evidences  of  the  Communicability  of  Con- 
sumption" (Longmans).  He  dwells  upon  the 
immunity  from  tuberculosis  of  carefully  conform- 
ing Jews,  whose  meat  is  inspected  in  a  manner 
which  would  require  the  rejection  of  the  entire 
carcase,  if  any  speck  of  tubercle  were  discovered. 
Dr.  Heron  believes  about  4  per  cent,  of  the  ani- 
mals slaughtered  for  food  in  Great  Britian  are 
more  or  less  affected  by  tuberculosis.  He  admits 
there  is  probably  no  room  for  doubting  that  a 
complete  sacrifice  of  the  infected  animals,  such  as 
would  be  required  by  the  law  and  practice  of  the 
Jews,  or  even  in  some  Gentile  communities  in 
which  an  inspection  of  meat  is  rigidly  enforced, 
would  become  by  the  diminution  of  disease  which 
it  would  bring  about,  a  distinct  source  of  saving 
to  the  public. 

The  Insane  Poor  of  New  York. — The  new 
State  Hospital  for  the  Insane  at  Ogdensburg, 
New  York,  has  accommodations  for  200  patients, 
but  when  completed  will  hold  1,500.  It  will  be 
occupied  during  the  current  month  by  pauper  in- 
sane drafted   from   the-   county  almshouses  along 


189I-] 


EDITORIAL  NOTES. 


23 


the  northern  tier  of  counties.  It  will  be  known 
as  the  St.  Lawrence  State  Hospital.  The  ap- 
pointments have  been  partly  filled.  Dr.  P.  M. 
Wise  being  Medical  Superintendent  and  Dr.  J. 
M.  Mosher,  First  Assistant ;  this  class  of  ap- 
pointments is  now  under  the  regulation  of  the 
Civil  Service  Commission  of  the  State,  after  free 
competitive  examination.  It  remains  to  be  seen 
if  the  count}-  authorities  will  obey  the  orders  of 
the  Lunacy  Commission  to  transfer  patients  to 
the  State  Hospitals.  In  one  county  at  least  the 
superintendents  of  the  poor  seek  to  evade  such 
an  order  by  protesting  that  there  are  no  funds  at 
their  command  with  which  to  meet  the  expenses 
of  removal.  Instead  of  obtaining  an  appropria- 
tion the  matter  was  referred  to  legal  counsel  for 
the  purposes  of  opposing  the  order. 

Another  Post- Graduate  School.  —  The 
medical  profession  of  Brooklyn.  X.  Y..  will  next 
year  have  the  advantage  of  a  post-graduate  hos- 
pital and  school.  The  plans  of  its  conductors  in- 
clude an  institution  that  will  in  the  end  afford 
practical-  instruction  to  three  hundred  or  more 
students.  The  college  will  be  governed  by  a 
medical  board  of  regents.  Every  branch  of  med- 
icine and  surgery  will  eventually  come  within  the 
teaching  programme  of  its  faculty. 

The  Post-graduate  Medical  School  of 
Chicago  has  recently  added  to  its  faculty:  J. 
Frank,  M.D.,  and  Edmund  Andrews,  M.D.. 
Surgery;  Stanley  P.  Black,  M.D.,  Wm.  E.  Quine, 
M.D.,  Norman  Bridge,  M.D.,  General  Medicine; 
W.  W.  Jaggard,  M.D.,  Obstetrics  and  Gynecol- 
ogy; D.  R.  Browe"r,  M.D.,  Neurology:  J.  Nevins 
Hyde,  M.D., Frank  Montgomery,  M.D., Dermatol- 
ogy; Henry  Gradle,  M.D.,  Otology;  Charles  W. 
Purdy ,  M.  D. .  Renal  Diseases,  and  Rosa  Englemann, 
M.D.,  Diseases  of  Children.  The  School  has  recent- 
ly moved  into  its  new  building  in  the  business  cen- 
tre of  the  city  from  whence  the  various  hospitals 
and  dispensaries  can  be  most  readily  reached. 
The  building  contains  a  dispensary,  hospital  and 
operating  rooms  for  clinical  teaching  in  all  de- 
partments of  medicine  and  surgery;  chemical, 
microscopical  and  experimental  laboratories  for 
the  stud}'  of  toxicological  chemistry  and  urinaly- 
sis, histology,  pathology  including  bacteriology, 
experimental  physiology,  pathology  ctnd  surgery, 
and  a  dissecting  room  for  operative  work  on  the  ca- 
daver and  living  animals.  An  amphitheatre  adapted 


for  lectures  to  large  evening  classes — a  reading 
room  during  the  day.  In  addition  to  the  daily 
clinical  instruction  throughout  the  year  the  school 
will  give  four  special  four  weeks'  courses,  de- 
signed to  afford  unusual  opportunity  for  very 
complete  study  for  clinical  diagnosis,  pathological 
diagnosis,  operative  surgery,  the  histology,  phy- 
siology,pathology, and  surgery  of  the  eye,  ear.nose 
and  throat.  The  demand  for  post  graduate  clin- 
ical study  is  beyond  question.  The  Post-Gradu- 
ate  Medical  School  provides  the  above  special 
courses  in  exceptional  completeness,  believing 
the}'  will  be  sought  by  many  students  who  de- 
mand thorough  work. 

Ax  Embryo  Medical  College  ix  Mid- 
Chixa. —  At  Hang-Chow,  in  mid-China,  there 
exists  a  large  mission  hospital  under  the  charge 
of  Dr.  Duncan  Main.  The  Chinese  appear  to 
have  no  word  descriptive  of  a  hospital  so  the 
name  commonly  given  by  them  to  this  institution 
is  "The  Universal  Benevolent  Healing  Office,"  a 
title  that  is  not  unmerited  as  to  the  gratuitous 
and  tireless  work  that  is  performed  by  its  con- 
ductors. A  medical  class,  ernbryo  of  a  possible 
future  college,  is  in  constant  training  at  the  hos- 
pital, and  last  year  eight  of  its  students  were 
graduated  at  the  end  of  a  five  years'  course,  and 
all  are  setting  forth,  in  turn,  to  do  medical  mis- 
sionary work  among  their  countrymen.  An  illus- 
tration, from  photograph,  of  the  present  hospital 
shows  it  to  be  a  commodious  and  truly  handsome 
structure  ;  it  was  erected  especially  for  hospital 
purposes  in  1SS5. 

Apoplectiform  Neuritis.  —  Recently  there 
have  been  reported  several  cases  designated  under 
the  name  above  given.  The  disease  was,  in  every 
instance,  limited  to  the  brachial  plexus,  and  was 
characterized  by  a  very  sudden  and  complete  loss 
of  sensation  and  motion  in  the  arm  of  the  affected 
side.  This  was  quickly  followed  by  wasting  of 
the  muscles,  and  the  electrical  reactions  were  those 
of  degeneration.  Dejerine  has  recently  reported 
a  case  where  death  occurred  in  consequence  of 
some  pulmonary  disease,  and  where  a  post  mor- 
tem examination  of  the  brachial  plexus  revealed 
the  fact  of  a  former  hsernorrhage  into  that  plexus. 
This  condition  was  not  anticipated,  but  it  very 
fully  explains  the  apoplectiform  mode  of  onset, 
and  also  demonstrates  that  a  haemorrhage  may 
occur  into  the  peripheral  as  well  as  into  the  cen- 
I  tral  nervous  system. 


24 


TOPICS  OF  THE  WEEK. 


[January  3, 


TOPICS  OF  THE  WEEK. 


THE    VENTILATION  OF  CHURCHES. 

Nowhere  have  the  problems  of  ventilation  been  found 
to  be  more  difficult  of  solution  than  in  large  public  build- 
ings. We  might  say  in  regard  to  many  if  not  most  of 
these  that  in  this  particular  matter  bad  is  the  best  result 
that  has  been  attained.  It  must  also  be  admitted  that 
the  state  of  churches  generally  proves  the  rule  above 
stated,  but  not  by  way  of  exception.  We  may  well  ask, 
Why  is  this?  Surrounded  with  spacious  windows, 
furnished  with  ventilating  panes,  with  several  doors,  and 
with  a  high  and  arched  roof,  why  is  it  that  their  atmos- 
phere during  times  of  worship  is  so  often  offensively 
close  ?  In  different  cases  we  should  probably  find  differ- 
ent structural  deficiencies  contributing  to  this  result, 
with,  however,  the  same  consequence  in  all — defective 
aeration.  One,  if  not  the  principal,  fault  in  construction 
in  many  of  the  older  buildings  is  the  want  of  outlets,  or 
of  a  sufficient  number  of  them.  Such  openings  as  do  ex- 
ist are  better  fitted  to  act  as  inlets  than  as  exits.  In 
buildings  thus  constructed  a  change  for  the  better  would 
be  most  fittingly  inaugurated  by  the  formation  of  two  or 
more  large  roof  outlets  with  revolving  cowls.  The 
allotment  of  floor  space  is  also  an  important  considera- 
tion. This,  however,  is  a  rule  contrived  with  a  reasona- 
ble regard  for  health  considerations.  It  is  only  in  the 
event  of  overcrow-ding  that  all  individual  rights  are  over- 
whelmed in  the  common  crush,  and  wholesome  breathing 
air  becomes  more  scarce  than  standing  room.  The 
gallery  system,  also,  if  adopted  on  any  considerable 
scale,  is  open  to  adverse  criticism.  By  accommodating 
more  sitters  it  necessarily  increases  what  we  may  call  the 
breathing  surface,  while  at  the  same  time  it  lessens  the 
available  air  space.  If  constructed  at  all,  the  gallery 
ought  to  be  of  the  lightest  description  compatible  with 
due  stability.  The  correction  of  the  evils  we  have  thus 
briefly  touched  upon,  and  especially  the  formation  of 
roof  outlets  to  promote  the  escape  of  heated  and  impure 
air,  will  go  far  to  obviate  such  occurrences  as  that  of 
ladies  fainting  in  church,  which  under  present  conditions 
is  only  too  common. — Lancet. 


THE  USE  AND    ABUSE  OF  HOSPITALS. 

With  regard  to  general  hospitals  of  large  size,  there  is  a 
growing  feeling  both  within  the  medical  profession  and 
among  practical  sanitarians  and  administrators  that  they 
are  open  to  many  objections.  In  the  first  place,  they  are 
an  unscientific  anachronism,  the  crowding  together  of 
such  a  vast  number  of  diseased  persons  being  as  much 
out  of  place  in  cities  as  intramural  burial  of  the  dead. 
Indeed,  it  is  extremely  likely  that  the  germs  derived  from 
such  accumulation  of  every  form  of  disease  are  more 
dangerous  to  the  community  than  those  which,  after 
several  years,  may  emanate  from  dead  bodies.       There  is 

qo  doubt  that  patients  suffering  from  different  kinds  of  dis- 
ease, poison  the  air  with  their  exhalations  and,  in  many 
cases,  exchange  microbes,  till  recovery  becomes  difficult 
even  for  the  strongest. 

The  second  objection  to  large  hospitals  is  that,   for 


practical  purposes,  the  relief  which  the)-  afford  may  be 
said  to  be  indiscriminate.  This  feature,  from  its  inevit- 
able tendency  to  engender  and  foster  habits  of  improvi- 
dence in  the  poorer  classes,  makes  it  stink  in  the  nostrils 
of  economists.  I  do  not  hesitate  to  say  that  the  out-pa- 
tient department  in  hospitals,  where  the  patients  con- 
tribute nothing  towards  the  expense  of  their  treatment, 
is  the  greatest  pauperizing  agency  at  present  existing  in 
this  country. 

The  third  objection  to  general  hospitals,  as  at  present 
organized,  is  their  cruel  hardship  which  their  indiscrim- 
inate charity  inflicts  on  the  medical  practitioners  in  their 
neighborhood.  These  men  find  the  competition  of  the 
hospitals  simply  ruinous;  for,  however  they  may  lower 
their  fees,  they  must  still  be  in  the  same  position  rela- 
tively to  those  institutions,  as  the  gentleman  who  stole 
the  raw  material  to  make  his  baskets  was  to  his  rival  who 
'conveyed"  his  baskets  ready  made. 

The  out-patient  department  is  defended  by  the  hospital 
authorities,  on  the  ground  that  a  large  selection  of  cases 
is  necessar)'  for  the  training  of  medical  students.  This 
sounds  very  plausible,  but  it  will  not  bear  examination. 
The  educational  plea  is  only  a  pretext.  The  real  reason  of 
the  laxity  in  admitting  out-patients  is  the  desire  to  make 
a  goodly  show  of  work  in  the  eyes  of  the  public,  with  the 
object — perfectly  legitimate  in  itself — of  attracting  sub- 
scriptions. 

The  objections  that  have  been  raised  to  special  hos- 
pitals are  numerous,  though  careful  consideration  will 
show  that,  in  the  main,  they  are  unfounded.  The  supe- 
rior persons  who  advance  these  objections,  ground  their 
opposition  on  the  alleged  fact,  that  the  special  institu- 
tions draw  many  cases  away  from  the  general  hospitals, 
and  thus  often  leave  iusufficient  material  for  the  teaching 
of  students.  It  may,  however,  be  asked,  how  it  is  that  the 
special  hospitals  attract  from  the  older  charities  persons 
suffering  from  particular  diseases.  The  obvious  answer 
is,  that  the  patients  find  that  they  are  more  quickly 
cured  in  the  special  hospitals.  The  only  question,  there- 
fore, to  be  decided  is,  whether  the  interests  of  the  patient 
or  those  of  the  teachers  of  the  healing  art  are  to  be  con- 
sidered as  the  more  weighty.  I  have  little  doubt  my- 
self, that,  in  the  opinion  of  the  public  generally  and  of 
the  subscribers  to  the  hospitals,  the  welfare  of  the  pa- 
tients will  take  the  first  place. 

A  more  practical  objection  to  special  hospitals  is,  that 
they  are  supposed  by  some  people  to  divert  subscriptions 
from  the  general  hospitals.  I  do  not  believe,  however, 
that  this  objection  is  well  founded. 

The  bad  effects  of  gratuitous  medical  relief  have  been 
abundantly  shown,  and  it  is  not  denied  that  they  exist, 
to  a  very  large  extent,  not  only  in  London,  but  prac- 
tically everywhere  throughout  the  country.  The  time 
has  come  when  the  abuse  must  be  abolished.  But  how 
is  this  to  be  done? 

fed  practitioners,  who  have  had  the  bread  taken 
out  of  their  months  by  the  hospitals,  have  sometimes 
said  in  their  haste,  that  the  out-patient  department 
should  be  reformed  altogether  out  of  existence.  This 
drastic  remedy,  however,  would  probably  defeat  its  own 
object.     The  real  remedy   for  the  congestion  of  the  out- 


i89i.] 


TOPICS  OF  THE  WEEK. 


25 


patient  department  is  depletion.  All  cases,  in  which  a 
genuine  claim  to  the  receipt  of  gratuitous  hospital  relief 
cannot  be  established,  should  be  eliminated.  For  this 
purpose  two  things  are  necessary — viz.,  a  definite  water- 
line  of  poverty,  above  which  charity  is  not  permitted  to 
extend,  and  an  adequate  system  of  inquiry  to  prevent 
imposture.  The  difficulties  of  such  a  system  of  inquiry 
are  great.  But  at  Manchester,  in  the  course  of  a  few 
years,  a  well-organized  system  of  investigation  has  re- 
duced the  proportion  of  cases  in  which  hospital  charity 
is  abused  from  42.32  to  about  6  per  cent. 

I  approve  of  the  Prussian  law,  by  which  all  workmen 
are  compelled  to  insure  against  sickness.  The  amount 
of  insurance  is  1  'z  per  cent,  of  the  wages  earned.  Of 
this,  one-third  is  defrayed  by  the  employer,  the  remain- 
ing two-thirds  being  deducted  by  him  from  the  work- 
men's wages  before  they  are  paid.  My  own  plan  would 
be  that  the  Poor  Law  infirmaries,  the  hospitals  and  the 
provident  dispensaries  should  be  combined,  so  as  to  form 
one  large  system  of  eleemosynary  medical  relief,  some- 
what on  the  lines  of  the  French  Assistance  Publique, 
under  the  control  of  which  are  all  the  hospitals  and  dis- 
pensaries in  France.  I  am  strongly  of  opinion  that  a 
small  charge  to  out-patients  at  hospitals,  carefully  gradu- 
ated according  to  the  patient's  means,  would,  of  itself, 
do  much  to  diminish  the  evils  now  existing.  In  the 
Prussian  hospitals  payment  is  universal.  All  sorts  and 
conditions  of  patients  are  freely  admitted,  and  patients 
are  divided  into  three  classes,  according  to  the  rate  of 
payment. — Sir  Morell  Mackenzie.  The  Contemporary 
Review,  London,  October,  1S90. 


risnis  in  schools,  had  all  to  be  "  pressed  into  the  service  " 
as  means  to  awaken  the  public  mind  to  the  importance 
of  vaccination.  A  specimen  of  the  "  Vorschriften  zum 
Schonschreiben "  by  which  the  juvenile  intellect  was 
weaned  from  the  dread  of  the  prophylactic  innovation  is 
the  following,  taken  from  a  publication  at  Coburg  and 
'  Leipsic  in  the  year  1805:  "Ignorant  and  ill-disposed 
\  people,  who  will  neither  understand  nor  adopt  what  is 
i  good,  have  spread  abroad  lies  of  all  kind  against  health- 
giving  vaccination."  At  Magdeburg  about  the  same 
time,  "The  Cow-pox,"  a  family  scene  in  one  act,  was 
produced  and  dedicated  by  the  author,  Professor  Ram- 
bach,  to  Dr.  Welper,  as  the  "savior  of  his  children," 
the  piece  closing  with  the  introduction  on  the  stage  of 
the  children  in  question,  each  with  well-developed  vac- 
,  cination  marks  on  his  arm.  By  such  methods  had  the 
1  good  German  public,  at  the  beginning  of  the  nineteenth 
century,  to  be  educated  out  of  their  well-grounded  dread 
of  inoculation,  and  into  a  heart}-  adoption  of  vaccination. 
With  Koch's  discovery,  on  the  contrary,  the  profession  is 
laboring  to  tone  down  a  too  roseate  expectancy,  and 
thinks  it  has  scored  a  point  when  the  question  has  come 
to  be  asked:  "  At  what  stage  of  tuberculosis  is  cure  pos- 
sible? "  Meanwhile  Koch  himself,  who  is  in  no  way  to 
blame  for  the  unreasoning  enthusiasm  his  discoverv  has 
evoked,  continues  to  perfect  the  system  which  has  al- 
ready cost  him  sixteen  years'  work. — Lancet. 


JENXER  AXD  KOCH 

Habcnt  sua  fata  magistri;  the  reception  and  diffusion 
of  Jenner's  great  discovery  was  different  from  that  of 
Koch  by-  all  the  differentiation  between  the  close  of  the 
eighteenth  and  the  close  of  the  nineteenth  centuries. 
Jeuner,  after  twenty-one  years  spent  in  maturing  and  per- 
fecting his  idea,  had  Jo  wait  long,  in  those  days  of  slow 
traveling  and  undeveloped  journalism,  before  it  became 
public  property.  Koch,  on  the  other  hand,  has  positively- 
had  to  suffer  from  the  feverish  haste  with  which  his 
"cure"  has  been  caught  up  and  applied.  Vaccination 
had  for  years  to  struggle  with  opposition  and  distrust; 
the  injection  of  the  Koch  liquid  has  been  so  promptly- 
appreciated  and  put  in  practice  that  it  is  already  sharing 
the  reaction  inseparable  from  too  sanguine  expectation. 
It  is  in  Germany  that  the  contrast  in  the  fortunes  of  the 
two  discoveries  is  most  keenly  felt,  and  Strieker's  classic 
monograph  on  vaccination  is  appealed  to  for  points  of 
dissimilarity  between  the  slow-  advance  of  the  one  and 
the  "leaps  and  bounds  "  of  the  other.  It  was  not  till 
July,  1S01,  that  the  Prussian  Medical  Department,  for  the 
first  time  on  the  Continent,  issued  instructions  to  all 
"Collegia  Medica  et  Sanitatis "  to  give  vaccination  a 
trial.  In  June,  1S02,  the  same  official  authority  lent  its 
imprimatur  to  the  practice,  and  in  October  of  the  same 
year  the  Anti-Small-pox  Vaccination  Institute  was  estab- 
lished at  Berlin.  Popular  literature,  sermons  from  the 
pulpit,  dramatic  representations,  and  copy-book  apho- 


A  TRIBUTE  TO  THE  PROFESSION. 

In  Fargeon's  story,  contributed  to  the  Christmas  num- 
ber of  All  the  Year  Round,  there  is  a  graceful  reference 
to  the  profession.  Some  of  our  best  novelists  have  writ- 
ten in  a  similar  strain:  "I  cannot  refrain  here  from  pav- 
ing a  tribute  to  this  kind  gentleman,  whose  life  is 
an  honor  to  the  profession  he  adorns.  But,  indeed,  in 
what  ranks  of  professional  labor  can  more  unselfish 
kindness  be  found  than  in  the  ranks  of  those  who  min- 
ister to  the  sick  ?  Surely  there  must  be  some  beneficent 
influence  in  the  work  they  do  that  humanizes  and  softens 
the  heart,  that  makes  it  respond  willingly  and  cheerfully 
to  the  appeals  of  those  who  suffer?  Xumberless  are  the  in- 
stances that  can  be  adduced  of  the  wonderful  goodness 
of  doctors,  renowned  and  eminent,  who  sacrifice  their  time 
without  expectation  or  desire  of  return  for  the  inestimable 
services  they  render.  I  have  no  hesitation  in  saying  that, 
of  all  arts,  it  is  the  most  ennobling  and  beautiful,  and 
that  its  record  of  kind  deeds  is  matchless  and  unap- 
proachable. With  all  my  heart  I  say,  'Heaven  bless  the 
doctors  for  the  good  they  do,  for  the  good  they  are  en- 
abled to  do  !  '  " 


MEDICAL  FEES  IN  RUSSIA. 

According  to  a  contemporary,  the  Medical  Council  of 
St.  Petersburg  has  under  consideration  a  project  to  fix 
the  fees  of  medical  men.  It  is  intended  to  divide  patients 
into  three  classes,  according  to  their  pecuniarv  capacitv; 
and  again,  to  divide  towns  into  three  categories,  accord- 
ing to  population.  In  accordance  with  this  classification 
there  will  be  nine  fees,  ranging  from  about  twentv-five 
cents  to  five  dollars. 


26 


PRACTICAL  NOTES. 


[January  3, 


PRACTICAL   NOTES. 


must  not  rely  upon  the  pulse,  that  is  influenced 
too  much  by  anxiety  or  emotion  to  be  trustworthy; 
it  is  the  thermometer  alone  which  will  unerringly 
BEEF-TEA  AS  A  nutrient.  guide  us  in  these  cases.      The  temperature  is  al- 

ways  a   little  raised  during  the  first  three  days, 
Dr.  E.  B.   Ward    {American    Lancet,   Novem-   and  one  of  ^  rising  perhaps   to   IOO°  h]   the 

ber,  1890)  vigorously  condemns  beef-tea  as  a  eveningi  may  hardly  attract  the  attention  of  the 
delusion,  and  sums  up  111  the  following  words  :  doctor)  especially  as  the  patient  feels  perfectlv 
"Thousands  of  sick  people  have  been  starved  to  well  and  the  pulse  is  natural .  but  there  is  danger 
death  on  this  diet,  and  I  want  to  enter  my  solemn  ■  at  hand]  nevertheless,  and  unless  care  be  taken, 
protest  against  it  before  it  is  everlastingly  too  late.  its  source  determined  and  removed,  it  mav  be- 
What  you  want  is  the  albumen  and  fibrin  of  the  come  very  serious  indeed.  Therefore,  when  in 
meat.  ...  The  moment  you  coagulate  these  in-  attendance  in  these  cases,  never  neglect  the  ther- 
gredients  by  heat  you  render  them  practically  in-  m0meter;  there  is  no  adviser  so  faithful,  no  reac- 
digestible.  .  .  .  Good  milk  is  preferable  always,  tion  more  deiicatei  and  above  a\\t  uo  previsor  so 
but  if  you  must  give  beef-tea,  never  boil  it.  Lie-  ■  certain  as  this.— Provincial  Med.  Jour. 
big  savs  1200  F.   is  the  highest  temperature  to 


which  it  should  be  subjected.  It  is  not  very  in- 
viting in  its  general  aspect,  but  it  holds  in  solu- 
tion the  ingredients  that  you  want  and  which  are 
rendered  useless  for  a  weak  digestion  by  boiling. 
Liebig's  plan  is  to  add  a  little  hydrochloric  acid." 


MENTHOL     IN    THE     VOMITING     OF     PREGNANCY. 

Menthol  has  been  recommended  {Repertoire  de 
Pkarmacie,  February  10,  1890)  in  the  treatment 
of  the   obstinate   vomiting  of  pregnancy.      One 
He  thinks  good  rich  milk  punch,  however,  is  far   part  of  menthol  should   be   dissolved   in  twenty 
preferable.  1  parts  of  alcohol  and  thirty  parts  of  simple  syrup, 

one   teaspoonful  being   given   each    hour.     This 
disinfection  of  the  hands.  prescription  is  claimed  to  be  extremely  success- 

Ball  has  carefully  investigated  the  subject  of  fl>'  in  arresting  nausea   and   vomiting.  —  Thera- 
disinfection  of  the  hands,  in  order  to  establish  a  Peutlc  irazette. 
routine  which   shall   be  sufficiently  thorough  to  j 


be  sure  of  complete  sterilization  even  with  previ- 1  leucorrhcea    and  blennorrhcea  in    women. 
ously  infected  hands,  and  at  the  same  time  suffi- 


ciently simple  to  be  properly  carried  out  by  any 
one.  His  experiments  show  that  the  following 
method  answers  these  requirements  better  than 
any  other,  and  that  if  the  details  are  completely' 
carried  out,  all  microorganisms  are  removed  : 

1.  The  finger-nails,  whether  long  or  short,  are 
first  freed  from  any  visible  dirt  with  a  knife  or 
scissors. 

2.  The  hands  and  nails  are  then  scrubbed  with 
a  nail-brush  for  three  minutes  with  warm  water 
and  a  potassium  soap. 

3.  The  hands  are  then  washed  for  half  a  min- 
ute in  a  3  per  cent,  carbolic  acid  solution  and 
then  in  a  1-2,000  solution  of  corrosive  sublimate. 

4.  Finally  the  places  under  and  around  the 
nails  are  rubbed  with  iodoform  gauze,  previousl) 
soaked  in  a  5  per  cent,  solution  of  carbolic  acid. 
— Boston  Medical  and  Surgical  Journal. 


Dr.  Luaud,  in  Jour,  dc  Med.  de  Paris. 

ft      Creolin,  gtt.  xxx. 

Ext.  fluid  hydr.  canad.  fl.  drachm  ijss. 
Sig.     Two  teaspoonfuls  in  a  pint  of  warm  water  to  be 
used  at  one  injection. 

As  an  urethral  injection  the  following  formula 
is  used  : 

ft      Rxtr.  fluid  hydrast.  canad.,  gtt.  xxx. 

Creolin,  gtt.  x. 

Aquae,  11.  drachm  vij. 
Sig.     Use  pure  as  an  urethral  infection. 

— Archives  of  Gynecology, 


TREATMENT  OF  A 


COLD 

SODA. 


BY  SALICYLATE  OF 


The  Memphis  Medical  Journal  says  of  this  rem- 
edy: Salicylate  of  sodium  in  free  doses  give  as 
satisfactory  results  in  the  treatment  of  "bad  colds" 
as  it  does  in  cutting  short  tonsillitis.     Sodii  sali- 
cylatis,  5ss;  syr.  auranti  cort.,  §ss;  aquae,  menth. 
piper.,    ad.   ,siv.       "K      Sig.      A   dessertspoonful 
every  three  or  four  hours.      A  dose  every  three 
H.  Stapfer  (  Revista  de  C  'iencias  Midicas)  :   Since  !  hours  until  a  free  specific  influence  of  the  salicy- 
1874  Siredey  taught  that  there  is  danger  ahead  if  late — tinnitus  aurium — is  observed  will  so  farcon- 
the  temperature  rise  during  the   puerperal  state   trol  the  symptoms  that  the  aching  of  the  brow, 


THE  THERMOMETER  IN  THE   EARLY  RECOGNITION 
OF   PHLEGMASIA. 


before  the  fifth  day,  and  that  the  peril  is  extreme 
if  the  breasts  remain  empty  or  subside.  And 
W'idal  says:  "After  long  and  rigorous  exam- 
ination we  may  affirm  that  septic  mischief  is  al- 
ways preceded  by  a  febrile  condition."      But  we 


eyes,  nose,  etc.,  will  cease.  The  sneezing  and 
"running  from  the  nose"  will  also  abate  and  will 
disappear  in  a  few  days,  not  leaving,  as  is  usual 
under  other  treatment,  a  cough,  from  the  exten- 
sion of  the  inflammation  to  the  bronchial  tubes. 


i89i.] 


SOCIETY  PROCEEDINGS. 


27 


SOCIETY   PROCEEDINGS. 


American  Academy  of  Medicine. 

Fourteenth  Annual  Meeting,  held  in  Philadelphia, 
December  j  and  4,  1S90. 

Wednesday — Morning  Session. 

The  American  Academy  of  Medicine  met  at 
Philadelphia  on  Wednesday,  December  3,  1890, 
in  the  hall  of  the  College  of  Physicians,  at  10 
o'clock  a.m.,  Dr.  S.  J.  Jones,  A.M.,  LL.D., 
President,  in  the  Chair.  In  the  absence  of  Dr. 
Dunglison,  Secretary,  from  sickness,  on  the  first 
day,  Dr.  Charles  Mclntire,  Jr.,  of  Easton,  Pa., 
Assistant  Secretary,  acted  as  Secretary.  The 
names  of  the  following  applicants  for  Fellowship 
were  reported  as  approved  by  the  Council,  and 
were  elected  as  Fellows  of  the  Academy  : 

AV.'i'  /r//o;i 'i. — Herman  Kiefer,  Detroit,  Mich.;  Gros- 
veuor  R.  Trowbridge,  Danville,  Pa.;  John  Carroll  Irish, 
Lowell,  Mass.;  Alfred  C.  Haven,  Lake  Forest,  111.;  El- 
mer Lee,  Chicago,  111.;  Arthur  William  Hnrd,  Buffalo, 
N.  Y.;  Edgar  D.  Wing,  Galesburg,  111.;  Walter  David- 
son Bidwell,  Leavenworth,  Kan.;  Beunet  Jason  Bristol, 
Webster  Groves,  Mo.;  Adolf  Alt,  St.  Louis,  Mo.;  Chas. 
B.  Mayberry,  Danville,  Pa.;  Benj.  J.  Milliken,  Cleve- 
land, O.;  Edwin  J.  Gardiner,  Chicago,  111.;  James  Au- 
brey Lippincott,  Pittsburg,  Pa.;  W.  Hubert  Dunlap, 
Syracuse,  N.  Y.;  Win.  H.  Browning,  Brooklyn,  N.  Y.; 
Nathaniel  S.  Cheeseman,  Scotia,  N.  Y.;  Charles  R. 
Whitcombe,  Boston,  Mass.;  J.J.  B.  Vermyne,  New  Bed- 
ford, Mass.;  George  Eben  Thompson,  Boston,  Mass.; 
Henry  W.  Cattell,  Philadelphia,  Pa.;  Leonidas  Lemay 
Mial,  Morris  Plains,  N.  J.;  George  Fales  Baker,  Phila- 
delphia, Pa.;  William  H.  Hawkes,  Washington,  D.  C; 
E.  Baldwin  Gleason,  Philadelphia.  Pa.;  Edward  South- 
worth  Fitz.  South  Seaville,  N.  J.;  Hans  H.  Sinne,  Tren- 
ton, N.J.;  Henry  Smith  Noble, Middletown,  Conn.;  Peter 
N.  K.  Schwenk,  Philadelphia.  Pa.;  Walter  Temple  Good- 
ale,  Saco,  Me.;  Archabald  McLaren,  St.  Paul,  Minn.; 
Reynold  Webb  Wilcox,  690  Madison  Ave.,  New  York, 
N.  V.;  William  James  Herdman,  Ann  Arbor,  Mich.; 
Charles  Sumner  Musser,  Aarousburgh,  Pa.;  William 
Flynn,  Marion,  Ind. ;  George  Mason  Fosket,  North 
Dana,  Mass.;  J.  M.  Maurer,  Shamokin,  Pa.;  Charles 
Wetherill  Gumbes,  Oakes,  Pa.;  Nathaniel  B.  Emerson, 
Honolulu,  Hawaiian  Island;  John  Van  Duyn,  Syracuse, 
N.  Y. ;  Niles  Harrison  Shearer,  York,  Pa.;  Earnest  Lap- 
lace, Philadelphia,  Pa.;  Titus  Munsou  Coan,  New  York, 
N.  Y. ;  Levi  Ives  Shoemaker,  Wilkesbarre,  Pa,;  Woods 
Hutchinson,  Des  Moines,  Iowa;  William  Norris  Hub- 
bard, New  York,  N.  Y.;  William  Edward  Conroy,  Sag- 
inaw, Mich.;  Ferdinand  J.  S.  Gorgas,  Baltimore,  Md.; 
Reginald  Hall  Sayre,  New  York,  N.  Y.;  Arthur  R.  Sim- 
mons, Utica,  N,  Y;  Hermou  G.  Matzinger,  Buffalo,  N. 
Y.;  Johann  Flintermann,  Detroit,  Mich. ;  Sylvanus  Todd 
Lowrj-,  San  Antonio,  Tex. ;  Daniel  Lewis,  New  York, 
N.  Y ;  Arthur  Prince,  Jacksonville,  111.;  Frank  Eugene 
Sleeper,  Sabatis,  Me.;  Sherman  Willard  Boons,  Presque 
Isle,  Me.;  John  H.  Moore,  Bridgeton,  N.J. 

At  the  meeting  in  Chicago  in  1889,  an  amend- 
ment to  the  constitution  was  adopted,  which  ad- 
mits others  than  the  possessors  of  the  A.B.  degree 
as  Fellows,  provided  they  furnish  evidence  of  pre- 
liminary education  equivalent  to  that  necessary 
for  obtaining  the  degree  of  Bachelor  of  Arts. 

Dr.  McIntire  read  a  paper  on  The  I  "aluc  of 
the  A.B.  Degree,  which  showed  a  marked  differ- 


ence in  the  various  colleges  in  this  country  in  the 
requirements  for  that  degree,  and  in  the  value, 
therefore,  which  it  possesses  as  an  index  of  the 
amount  of  educational  discipline  the  individual  is 
supposed  to  have  received.  This  subject  will  be 
still  further  investigated  by  Dr.  Mclntire.  An 
appropriation  was  made  by  the  Academy  for  this 
purpose,  and  the  paper  was,  on  motion  of  Dr. 
Gihon,  ordered  to  be  printed  as  a  preliminary  re- 
port on  the  subject,  and  distributed  to  every  col- 
lege and  medical  journal. 

A  communication  was  read  from  Dr.  Dunglison, 
Secretary  and  Treasurer  of  the  Academy,  declin- 
ing re-election  to  those  positions,  on  account  of 
other  important  duties  and  positions  requiring  his 
attention. 

The  President  appointed  as  the  Committee 
on  Nominations  Drs.  A.  L.  Gihon,  Leartus  Con- 
nor, and  Benjamin  Lee. 

Dr.  Connor  proposed  to  amend  the  Constitu- 
tion, Art.  3,  Sec.  4,  by  omitting  the  clause  "shall 
have  had  an  experience  of  three  years  in  the  prac- 
tice of  medicine  in  one  or  more  of  its  recognized 
departments."  Thus  amended,  Section  4  would 
read,  "  The  Fellows  shall  have  a  good  moral  and 
professional  character." 

Dr.  J.  Cheston  Morris  proposed  an  amend- 
ment to  Article  VII,  "  Revenue,"  to  require  an- 
nual dues  of  three  dollars  from  every  Fellow. 

Dr.  Justin  E.  Emerson,  of  Detroit,  chairman 
of  the  Committee  on  Eligible  Fellows,  presented 
his  report.  The  action  of  the  Academy,  at  the 
previous  annual  meeting,  in  admitting  to  Fellow- 
ship those  who  could  present  evidences  of  prelim- 
inary education  equivalent  to  that  required  for 
the  A.B.  degree,  gave  this  Committee  the  addi- 
tional labor  of  discovering  who  were  eligible,  as 
the  Committee  on  the  Value  of  the  Academic 
Degree  was  to  report  at  this  meeting  of  the  Acad- 
emy. The  Committee  on  Eligible  Fellows  re- 
ported the  nature  of  the  labor  undertaken  by 
them  and  the  methods  adopted  to  obtain  the 
names  of  medical  men  who  possessed  literar}-  de- 
grees, and  to  secure  the  cooperation  of  the  Fellows 
of  the  Academy  as  to  their  endorsement,  etc. 
Suggestions  were  made  as  to  the  best  methods  of 
carrying  out  the  Committee's  work  in  the  coming 
year.  The  personal  aid  of  every  Fellow  of  the 
Academy  in  obtaining  the  names  of  eligible  Fel- 
lows and  recommending  them  to  the  Academy 
was  solicited.  An  appropriation  was  made  for 
the  use  of  this  Committee. 

Afternoon  Session. 

When  the  Academy  again  convened  at  3  o'clock 
p.m.,  Dr.  Gihon,  U.  S.  N.,  chairman  of  Commit- 
tee on  Publication  of  the  Transactions,  reported 
adversely,  deeming  it  advisable  that  the  Academy 
should  rather  issue  a  volume  of  important  papers 
that  had  been  read  at  various  meetings  strictly 
germane  to  its  objects,  than  a  volume  of  Transac- 


28 


SOCIETY  PROCEEDINGS. 


[January  3, 


tions  to  include  all  the  papers  of  recent  date  only. 
The  Committee  was  instructed  to  present  a  table 
of  contents  of  such  a  volume  at  the  next  meeting. 

Dr.  Traill  Green,  of  Easton,  Pa.,  read  a 
paper  entitled  The  Profession' s  Call  for  a  Better 
Preliminary  Education  of  its  Members,  which  was 
directly  in  the  line  of  the  Academy's  aim  and 
work,  citing  illustrations,  from  the  results  of  ex- 
aminations by  State  Boards  of  Examiners  for  li- 
cense to  practice,  making  apparent  great  deficien- 
cies in  many  thus  examined. 

A  paper  by  Dr.  Frederic  H.  Gerrish,  of 
Portland,  Me.,  was  read,  in  his  absence,  by  the 
Secretary,  entitled : 

TITHING-MEN  WANTED, 

in  which  he  referred  to  the  custom,  in  olden  times  in 
New  England,  of  annually  electing  certain  officers, 
who  were  called  tithing-men,  a  principal  part  of 
whose  duties  was  to  wake  up  the  sleepers  in  the 
congregation  during  Divine  service.  With  a  long 
wand  they  would  tap  the  slumberers  on  the  head, 
or  poke  them  in  some  easily  accessible  and  sensi- 
tive part  of  the  person,  thus  recalling  the  drowsy 
to  a  sense  of  their  ghostly  obligations,  and  keep- 
ing them  in  the  path  of  salvation.  He  thought 
the  President  and  Secretary  of  the  Academy  should 
be  impressed  with  the  importance  of  stirring  up 
the  sleepy-heads  to  the  important  objects  of  the 
Academy,  in  whose  work  they  should  take  an 
active  interest,  that  its  mission  might  be  better 
understood  by  the  profession  at  large,  and  its 
work  rendered  more  effectual. 

The  President,  Dr.  S.  J.  Jones,  of  Chicago, 
then  delivered  his  Address  (See  page  1),  which 
was  full  of  important  suggestions  looking  to  the 
future  prosperity  of  the  Academy.  The  address 
was  referred  to  the  Council,  who  subsequently  re- 
ported favorably  to  the  Academy  as  to  the  mat- 
ters contained  in  it.  If  carried  out  by  the  Fellows 
they  would  give  increased  importance  and  influ- 
ence to  the  work  of  the  Academy.  The  interest- 
ing discussion  that  followed  the  reading  of  this 
address  showed  a  marked  appreciation  by  the 
Fellows  present  of  its  admirable  suggestions. 

Dr.  Edward  Jackson,  of  Philadelphia,  read 
a  paper  entitled 

WHAT  CAN  BE  DONE  TO   SAVE    THE    EYES  DURING 
SCHOOL  LIFE. 

He  stated  that  myopia  is  always  a  defect,  al- 
most always  a  concomitant  and  symptom  of  seri- 
ous organic  intra- ocular  disease,  that  under  un- 
favorable conditions  it  generally  tends,  pari  passu 
with  its  accompanying  diseases,  to  become  pro- 
gressively worse,  and  that  these  unfavorable  con- 
ditions are,  as  things  now  go,  more  constantly 
furnished  in  school  life  than  under  any  other  con- 
ditions. The  paper  discussed  the  various  means 
available  to  prevent  the  occurrence  of  this  mor- 
liiil  condition,  such  as  correction  of  the  modes  of 
lighting,  as  to  location  and  planning  of  the  school- 


house  and  its  seats,  its  methods  of  artificial  light; 
the  recognition  and  proper  correction  of  ametro- 
pia; the  confinement  of  the  work  attempted  within 
the  limits  of  the  visual  apparatus ;  the  care  of 
general  health  and  nutrition,  etc.  Particular 
stress  was  laid  on  the  necessity  of  continuous,  in- 
telligent supervision  of  children  during  school 
life  to  avoid  the  morbid  condition  referred  to,  and 
especially  to  the  necessity  of  providing  for  the 
education  of  those  whose  capacity  for  eye-work 
falls  temporarily  or  permanently  below  a  fair  gen- 
eral minimum. 

In  the  evening  the  annual  collation  took  place 
at  Boldt's  Restaurant,  and  was  participated  in  by 
a  large  number  of  the  Fellows.  It  was  a  novelty 
to  have  this  entertainment  in  the  eighth  story, 
but,  as  remarked  by  one  of  the  Fellows,  it  was 
one  of  the  specified  objects  of  the  Academy  to 
elevate  the  profession. 

Thursday — Morning  Session. 

The  Academy  reconvened  on  Thursday  at  10 
o'clock,  and  selected  Washington  as  the  next 
place  of  the  annual  meeting,  and  May  2  as  the 
time.  After  electing  Fellows,  and  receiving  the 
Treasurer's  report,  and  its  approval  by  an  auditing 
Committee,  reports  of  committees  were  next  in 
order. 

Dr.  Dunglison,  Secretary  of  the  Academy, 
read  his 

ANNUAL    REPORT    ON     LAWS      REGULATING    THE 
PRACTICE   OF  MEDICINE  IN  THE  UNITED 
STATES  AND  CANADA. 

After  some  interesting  preliminary  remarks  on 
the  subject,  in  which  he  quoted  a  number  of  ab- 
surd replies  to  questions  as  elicited  from  the  ex- 
perience of  Boards  of  Medical  Examiners  in  the 
various  States,  he  read  extracts  from  letters  re- 
ceived by  him  from  gentlemen  directly  interested 
in  the  working  of  these  laws  in  all  parts  of  the 
country.1 

Dr.  Dunglison,  Committee  on  Preparation  of 
the  Catalogue  of  Fellows  and  Honorary  Members 
of  the  Aeadeni3%  reported  that  circulars  had  been 
sent  out  since  the  last  annual  meeting,  prepared 
exactly  in  accordance  with  the  plan  adopted  by 
the  Academy  at  the  annual  meeting  in  1888,  upon 
the  suggestion  of  President  F.  H.  Gerrish,  in  his 
annual  address;  and  that  a  large  amount  of  in- 
formation had  been  collected.  The  pecuniary 
condition  of  the  treasury  had  not,  however,  al- 
lowed of  its  publication,  other  important  commit- 
tee work  of  the  Academy,  looking  to  an  increase 
of  its  numerical  strength  and  to  an  investigation 
of  the  value  of  the  academical  degree  in  different 
literary  colleges,  having  received  the  first  consid- 
eration in  expenditures  by  the  Treasurer. 

Dr.  J.  Ciieston  Morris  read  a  paper  on  Inter- 
ference of  Molecular  Vibrations  as  Explanatory  of 


1  This  Report  will  be  published  in  full  in  The  Journal  at  an 


i89i.]  SOCIETY  PROCEEDINGS.  29 


the  Phenomena  of  Zymotic  Diseases  and  Diseases       Dr.  J.  Cheston  Morris,  of  Philadelphia,  read 

■rition.  which  was  of  a  very  scientific  char-   a  paper  on 

acter,  and  was  so  discussed  by  the  Fellows,  as  to  THE  pathology  of  influenza. 

show  the  interest  it  elicited.  in  whicb  he  took  the  ground   that  influenza  or 

Dr.  Gihon  proposed  an  amendment  to  Article       -  is   a  paresis  or  partial  paralvsis  of   the 

IV  of  the  constitution,  which  specifies  that  officers  pneumo_o-astric  nerve   depending  probablv  upon 

of  the  Academy  shall  be  elected  from  those  who  such  a  cbange  in  the  atmospheric  ocean,  at  the 

are  in  attendance  ;  the  words    'in  attendance       bottom  of  whjcri  we  nve.  as  involves  an  increased 

to  be  omitted.  expenditure  of  force  in  maintaining  circulation 

The  Committee  on  Nominations  made  their  re-   and  respiration        HenCe  follow  the  phenomena 

port,  which  was  adopted,  the  Secretary  being  in-   of    cardiac    faiiure    and    pulmonarv   congestion 

structed  to  cast  the  ballot  for  the  election  of  the  which  we  tOQ  often  ^j,^  .  or  th0se  of  gastro- 

officers  named.  intestinal  trouble,   or   of  the  intense  neuralgias 

officers.  which  supervene  in  various  parts  of  the  body. 

President— Theophilus  Parvm.    A.M..    M.D.,    ^ud  as  a  logical  sequence  we  find  the  best  reme- 

LL.D..  Philadelphia,  Pa.    Vice- Presidents -Hen-   dieg    are  str  excito-motor   stimulants— chief 

ry  M.  Hurd.  A.M..  M.D..  Baltimore.  Md.;  Alonzo   affi         thes£  strvchnine.  Caffein.  alcohol  and  am- 

Garcelon.    A.M.,   M.D..  Lewiston.  Me.;    Robert   mQnia      since  he  adopted  the  above  views  and 

Lowiy  Sibbett,  A.M.,  M.D.,  Carlisle.  Pa. :  Richard   treated  his  patients  with  five  to  ten  drops  of  tinct- 

J.  Dunglison,  A.M.,  M.D.,  Philadelphia.  Pa.   Sec-    ure  of  nus  yomic2L  every  three  or  four  hours.  he 

retary— Charles  Mclntire.  Jr..  A.M..  M.D..  Eas-   has  often  been  surorised' at  the  promptness  with 

ton,  Pa.     Assistant  Secretary— Edgar  M.  Green.    whkh  Aev  have  r"anied    and  the  aimost  unfail- 

A.M.,  M.D..  Easton,  Pa.     Treasurer— J.  Cheston   {ncr  success  of  the  method.     He  continued  the 

Morns.  A.M.,  M.D.,  Philadelphia,  Pa  treatment  for  two  or  three  weeks,  then  gradually 

Dr.    Henry   E.    Dwight,    of  Phi  adelphia,-   abated  it.  or  resumed  it  in  case  of  relapse.       He 

read  a  paper  entitled  The  Influence  oj  the  German   wQuld  str        lv  its  adoption   bv  his  fellow 

r,!i:  ln  whlch-  atter  practitioners   even  in  extreme  cases,  or  in  those 

defining  the  characteristics  of  a  Lmversity,  he   of  patients  evidentlv  depressed  below  the  par  of 

alluded  to   the   peculiar   features   which   distin-   vkal  activitv  without  well  defined  svmptoms. 

guished   the    L  niversities   01    Germany.      Much 

valuable  information  was  given  as  to  the  Gym-  Afternoon  session. 

nasia,  the  Real  Schools,  etc.,  and  deductions  were  ^t  tbe  afternoon  session  the  Academy  adopted 
made  as  to  the  influence  throughout  the  world  of  tbe  suggestions  of  the  President's  Address,  all 
the  teachings  and  scientific  knowledge  imparted.    0f  which0  had  been  approved  by  the  Council,  that 

Dr.  H.   M.   Sell,   of  Allentown.  Pa.,  supple-   trje  Fellows  of  the  Academy,  in  their  owe  S 
mented  this  paper  with  some  interesting  remarks   sbouid  take  the  initiative  in 

on  the  five  years'  curriculum  of  Norway  and  x  Continuous  effort  in  securing  liberal  prelim- 
Sweden,  education. 

Dr.   Benjamin  Lee.   Secretary  of    the  State        2    Requirement  of  a  high  standard  of  medical 
Board  of  Health  of  Pennsylvania,  read  a  paper  attainments. 

entitled,  -    state  control  of  the  practice  of  medicine,  by 

an  analysis  of  the  statistics  of  41,500        granting  licenses  to  practice  based  on  uniform 
cases  of  epidemic  influenza.  examinations  and  disregarding  diplomas  issued 

He  referred  to  the  recent  invasion  of  this  disease,    by  medical  colic  _ 

which    beginning  in    Europe    soon    visited    the       Dr.  Perry  H.  Millard,  of  Minnesota,  was  elected 
United  States  and  prostrated  so  manv  thousands  an  honorary  member  of  the  Academy, 
of  the  people.     He  considered  differentiallv  the       Dr.    D~  Secretary,   read,   in  the  ab- 

disease  under  consideration  and  dengue,  with  sence  of  its  author.  Dr.  H.  O.  Marcy.  of  Boston, 
which  many  had  compared  it.       The  prog     ss        Mass..  a  paper  entitled 

the  epidemic  in  this  country  was  sketched,  ex-  THE  COROner  system  in  the  united  states. 
hibiting  its  universalitv,  and  the  writer  then  out-  ...  ,    ,     ,         .     -         .    ., 

lined  the  nature  of  the  work  undertaken  bv  the  m  ^ich  he  examined  the  laws  m  lorce  in  Massa- 
health  authorities  of  Pennswania  to  secure  chusetts  and  other  States  01  the  I  mon,  and  in 
accurate  statistical  accounts  "  of  the  epidemic,  foreign  countries,  beanng  upon  the  duties  of  the 
This  interesting  paper  concluded  with  the  view  coroner  and  his  relations  to  the  public  semce. 
that  the  morbffic  influence  spent  itself  directly   He  arrived  at  the  mllowmg  conclusions  or  sug- 

upon  the  nervous  svstem.  and  more  especiallv  up-   gesti°ns: 

on  the  pneumo-gastric  nerve  and  its  associated        *■  To  abolish  the  office  of  coroner. 

ganglia  with  partial    implication  of  the  spinal       2.  To  dispense  vnth  jury  service. 

lorifi  3.  To  separate    the    medical  from    the    legal 

=  This  paper  will  appear  in  full  ia  The  Jocrn  al  at  an  ear'.y  -  paper  will  appear  in  full  in  The  Jovkxa  c 


3° 


SOCIETY  PROCEEDINGS. 


[January  3, 


duties   in   a!l   cases   involving  the    examination 
into  the  causes  of  death  where  crime  is  suspected. 

4.  To  entrust  the  medical  examination  only  to 
competent  medical  officers  properly  trained  in 
their  work. 

5.  To  make  the  number  of  these  medical  offi- 
cers as  small  as  consistent  with  the  proper  dis- 
charge of  their  duties. 

6.  To  consign  all  questions  of  law  only  to  prop- 
erly qualified  legal  magistrates. 

7.  To  remove  the  appointment  of  these  officers 
entirely  from  the  question  of  political  considera- 
tion; and  to  be  based  only  upon  their  possession 
of  the  requisite  and  proper  qualifications. 

Upon  some  basis  of  this  character  he  thought 
the  coroner's  laws  should  be  revised,  the  result 
being  that  much  useless  expenditure  of  time  and 
money  would  be  avoided,  great  sorrow  and 
anxiety  prevented,  and  the  ends  of  justice  better 
served. 

The  President-elect,  Dr.  Parvin,  was  then 
introduced  by  Drs.  Steiner  and  Sibbet,  who  were 
appointed  by  the  president  for  that  purpose,  and 
delivered  brief  and  eloquent  remarks  on  taking 
the  chair. 

Dr.  J.  E.  Emerson,  of  Detroit,  and  Dr.  J.  Taber 
Johnson,  of  Washington,  D.  C,  were  appointed 
additional  members  of  Council  for  the  ensuing 
year.  Dr.  Emerson  was  also  appointed  Chair- 
man of  the  Committee  on  Eligible  Fellows;  the 
other  members  of  that  committee  to  be  appointed 
later. 

Dr.  Dunglison  was,  on  motion,  appointed  to 
continue  the  series  of  Reports  on  Laws  Regulat- 
ing the  Practice  of  Medicine,  which  as  Secretary 
he  had  annually  presented  to  the  Academy. 

The  report  on  Requirements  for  Preliminary 
Education  hi  Medical  Colleges,  by  Dr.  John  H. 
Rauch,  of  the  Illinois  State  Board  of  Health,  was 
read  by  title,  not  being  received  in  time  for  the 
meeting,  but  will,  on  motion,  constitute  a  part  of 
the  proceedings. 

On  motion  of  Dr.  J.  Cheston  Morris,  the  thanks 
of  the  Academy  were  tendered  the  retiring  Sec- 
retary and  Treasurer,  Dr.  Dunglison,  for  his  long 
and  faithful  services  to  the  Academy,  through  a 
series  of  years,  and  to  the  cause  of  education. 
The  retiring  President,  Dr.  Jones,  stated  that  he 
cordially  endorsed  and  seconded  the  resolution. 

The  Academy,  after  thanking  the  retiring  pres- 
ident, the  resident  Fellows,  and  the  press  of  Phil- 
adelphia for  their  excellent  reports  of  the  meet- 
ing, then  adjourned. 


The  sale  of  poisons  in  Japan  is  regulated  by  a 
series  of  new  and  stringent  regulations.  No 
poison  can  be  sold  for  industrial  purposes  without 
any  order  from  a  professional  man,  stating  the 
purpose  for  which  it  is  required  and  the  name 
and  address  of  the  person  who  gives  the  order. 


New    York   Academy    of    Medicine. 

SECTION  ON  ORTHOP.EDIC  SURGERY. 

Stated  Meeting,  November  21,  iSgo. 
V.  P.  Gibney,  M.D.,  Chairman. 

DR.   BEELY'S  APPARATUS  FOR    MEASURING  THE 
THORAX. 

Dr.  N.  M.  Shaffer  exhibited  one  of  these  in- 
struments which  had  been  presented  to  him  while 
he  was  in  Berlin,  by  the  inventor,  Dr.  Beely.  A 
somewhat  similar  apparatus  had  been  called  by 
Dr.  Nebel,  a  kyrtograph.  The  apparatus  consists 
of  a  series  of  narrow  parallel  steel  bars,  placed 
closely  together,  and  sliding  in  a  rectangular 
metal  frame.  Each  bar  terminates  in  a  blunt 
point,  near  the  end  of  which,  on  the  under  sur- 
face, is  a  metallic  point  or  stylus.  This  arrange- 
ment of  bars  looks  not  unlike  a  huge  comb.  Ou 
bringing  the  pointed  ends  against  the  chest,  or 
any  similar  object  having  an  irregular  outline, 
the  bars  adjust  themselves  in  the  frame,  so  that 
the  pointed  ends  form  an  outline  identical  with 
that  of  the  object  against  which  they  were  placed. 
A  simple  cam  movement  then  clamps  them  in  this 
position.  The  instrument  is  next  laid  upon  a 
piece  of  paper  resting  on  a  sheet  of  felt,  and  the 
points  on  the  under  surfaces  of  the  bars  are  made 
to  puncture  the  paper  by  passing  a  small  roller 
over  all  the  bars  successively.  In  this  way,  the 
desired  outline  is  recorded  on  paper  as  a  series  of 
small  punctures,  about  one- fifth  of  an  inch  apart. 
When  taking  a  tracing  from  a  patient  while  stand- 
'  ing,  an  erect  position  is  secured  by  means  of  a 
plumb-line  fastened  to  a  belt,  which  is  buckled 
'  around  the  body.  In  order  to  secure  still  greater 
accuracy,  the  instrument  is  provided  with  a  spirit- 
level.  The  exact  level  at  which  this  transverse 
tracing  of  the  chest  is  taken,  may  be  marked  with 
nitrate  of  silver,  so  that  tracings  taken  at  differ- 
ent times  may  be  readily  compared.  With  the 
patient  in  the  prone  position,  the  instrument  may 
be  used ;  but  a  longitudinal  tracing,  as  of  the 
spinal  column,  with  the  patient  erect,  is  not  with- 
in the  contemplated  scope  of  the  instrument.  Dr. 
Shaffer  said  that  he  had  made  several  tracings 
with  this  instrument,  and  he  had  been  very  favor- 
ably impressed  with  its  action  and  accuracy. 

Dr.  John  Ridlon  said  that  he  had  seen  Dr. 
Beely  using  it  with  the  patient  in  the  prone  posi- 
tion, and  that  he  had  understood  that  its  action 
was  only  satisfactory  when  employed  in  this  way. 
At  the  Berlin  Congress,  Dr.  Nebel  had  exhibited 
a  much  cheaper,  but  less  accurately  made  instru- 
ment, constructed  on  the  same  principle.  A  se- 
ries of  round  rods  were  placed  parallel  to  each 
other,  and  made  to  slide  through  a  large  round 
bar.  The  small  bars  terminated  in  buttons,  which 
were  applied  to  the  chest.  The  outline  was  then 
transferred  to  paper  by  laying  the  machine  ou  the 
paper,  and  passing  a  pencil  along  the  buttons. 


i89i.] 


DOMESTIC  CORRESPONDENCE. 


31 


Dr.  A.  B.  Judson  admired  the  mechanical  fea- 
tures of  the  instrument,  but  thought  that  such 
tracings  of  cases  of  lateral  curvature  were  of  little 
value  in  view  of  the  fact  that  the  changes  in  con- 
tour occurred  from  day  to  day  as  a  result  of  dif- 
ferences in  the  general  tone  of  the  patient. 

A  CASE  OF  SUPPOSED  EVACUATION  OF  A  PSOAS  OR 
LUMBAR  ABSCESS  THROUGH  THE  VAGINA. 

Dr.  Samuel  Ketch  presented  such  a  case.  A 
child,  5*4  years  of  age,  of  healthy  parentage,  and 
having  a  good  family  history,  was  admitted  to  the 
hospital  on  October  22,  1890,  with  the  history  of 
a  fall  six  or  eight  weeks  prior  to  her  admission. 
Two  weeks  before  she  was  presented  for  examin- 
ation, she  was  first  noticed  to  walk  peculiarly, 
and  she  complained  of  "  pain  in  her  feet."  She 
was  thought  to  be  suffering  from  hip-joint  disease 
by  her  attending  physician.  At  the  time  of  the 
examination,  her  general  condition  was  fair,  and 
there  was  no  pain,  and  the  motions  of  the  hip- 
joint  were  normal,  with  the  exception  of  a  slight 
limitation  of  extension  on  the  right  side,  when 
the  patient  was  in  the  prone  position.  Close  ex- 
amination revealed  a  small  kyphos  in  the  lower 
lumbar  region ;  the  right  hip  was  prominent  and 
relatively  larger,  and  there  was  a  feeling  of  fluc- 
tuation on  that  side.  There  was  a  discharge  of 
pus  from  the  vagina.  The  case  was  of  interest, 
both  on  account  of  the  unusual  mode  of  evacua- 
tion of  the  pus,  and  because  of  the  symptoms 
which  had  led  to  the  diagnosis  of  hip-joint  disease. 

Dr.  Shaffer  had  seen  the  case  just  reported. 
He  had  met  with  cases  where  the  abscesses  of 
Pott's  disease  opened  into  the  rectum,  vagina, 
and  bladder;  and  in  one  case  of  disease  in  the 
dorso-lumbar  region,  which  had  extended  over  a 
period  of  about  twenty  years,  pus  was  discharged 
from  the  bladder  at  intervals  of  a  few  months,  ac- 
companied by  the  usual  symptoms  of  acute  ab- 
scess formation.  The  cases  in  which  the  abscess 
had  opened  in  these  unusual  situations  had  all 
done  well,  and  he  attributed  this  to  the  valvular 
opening  through  which  the  pus  was  discharged. 
In  one  of  his  cases,  an  abscess  was  found  pointing 
into  the  rectum,  and  was  purposely  evacuated  at 
this  point  by  means  of  a  trocar.  The  result  had 
been  extremely  satisfactory.  A  similarly  favor- 
able prognosis  could  not  be  given  where  abscesses 
ruptured  into  the  lungs.  He  had  seen  several  of 
these  cases,  and  in  one,  now  under  observation, 
which  he  considered  unique,  a  boy  with  mid-dor- 
sal disease  suffered  at  intervals  from  fever,  accom- 
panied by  the  expectoration  of  pieces  of  the  can- 
cellous portion  of  bone. 

Dr.  R.  H.  Sayre  said  that  anatomical  consid- 
erations would  lead  one  to  expect  that,  owing  to 
better  drainage,  abscesses  opening  into  the  ali- 
mentary canal  would  pursue  a  more  favorable 
course  than  those  which  ruptured  into  the  lung. 
He  recalled  a  case  where  an  abscess,  situated  on 


each  side  of  the  vertebras,  suddenly  enlarged,  and 
caused  fatal  asphyxia.  The  autopsy  showed  that 
a  "saddle  bag"  abscess  was  situated  at  the  bi- 
furcation of  the  trachea. 

Dr.  J.  K.  Young,  of  Philadelphia,  said  that 
Ik*  had  recently  seen  a  case  of  lumbar  Pott's  dis- 
ease, in  which  the  abscess  had  been  evacuated 
through  the  vagina,  and  also  through  the  abdom- 
inal walls.     It  had  pursued  a  favorable  course. 

Dr.  Thomas  H.  Manley  had  once  treated  a 
case  of  abscess  in  the  mid-dorsal  region,  where 
evacuation  had  occurred  through  the  umbilicus. 
It  made  a  good  recovery. 

Dr.  Agramonte  suggested  that  the  exact  con- 
dition present  in  Dr.  Ketch's  case  could  not  be 
affirmed  until  the  vaginal  discharge  had  been  ex- 
amined for  gonococci. 

The  Chairman  thought  that  such  an  examina- 
tion was  highly  important,  and  suggested  that 
search  should  also  be  made  for  the  opening 
through  which  the  pus  was  discharged. 

Dr.  Ketch,  in  closing  the  discussion,  said  that 
he  was  aware  that  the  report  of  the  case  was 
somewhat  premature,  and  had  only  been  present- 
ed at  the  request  of  the  Chairman  for  clinical  ma- 
terial. He  had  not  been  able  as  yet  to  make  the 
examinations  suggested  ;  but  the  rational  symp- 
toms, and  the  clinical  history  of  the  case,  seemed 
to  warrant  the  position  which  he  had  taken.  In 
an  experience  of  thirteen  years  at  the  Orthopaedic 
Dispensary,  he  had  never  before  met  with  such  a 
case,  and  had  only  seen  one  case  in  private  prac- 
tice, and  in  this  one,  Dr.  L.  A.  Sayre  had  verified 
the  condition.  In  this  case,  there  was  a  favorable 
termination. 


DOMESTIC  CORRESPONDENCE. 


LETTER  FROM  BALTIMORE. 

The  Admission  of  Won/en  to  the  Johns  Hopkins 
Medical  School — The  Historical  Club — Death  of 
Dr.  John  R.  Quinan — Semi- Annual  Meeting  of 
the  Medical  and  Chirurgical  Faculty. 

You  have  already  been  informed  by  me  of  the 
success  of  the  movement  inaugurated  in  this  city 
about  the  first  of  last  May,  for  raising  a  fund  of 
$100,000  to  secure  the  admission  of  women  into 
the  Johns  Hopkins  Medical  School  upon  the  same 
terms  as  men.  This  cannot  but  be  regarded  as 
marking  an  epoch  in  the  literary  and  professional 
advancement  of  women.  With  a  courage  and  an 
aspiration  which  was  not  to  be  daunted  by 
prejudice  or  opposition,  the  managers  of  the  pro- 
ject, stimulated  by  that  determined  advocate  of 
educational  equality,  Miss  Mary  Garrett,  boldly 
knocked  at  the  door  of  the  most  modern  and  ad- 
vanced of  American  colleges,  "an  institution," 
in  the  language  of  President  Stanley  Hall,  of 
Clark  University,  "  which  in  the  less  than  fifteen 


32 


DOMESTIC  CORRESPONDENCE. 


[January  3, 


years  of  its  existence,  has  done  a  work  in  stimu- 
lating other  institutions  and  in  advancing  the 
highest  standards,  which  is,  as  I  think  all  cheer- 
fully admit,  beyond  comparison  in  the  recent 
history  of  higher  education  in  this  country." 
The  language  used  in  the  correspondence  of  Mrs. 
Henry  Winter  Davis,  in  transmitting  the  gift,  and 
that  of  the  Trustees'  minute  on  receiving  it,  is 
significant.  It  is  the  "most  advanced  medical 
education''  that  is  stipulated  for,  and  the  previ- 
ous training  must  be  equivalent  to  the  "pre- 
liminary medical  course  prescribed  for  men."  It 
is  also  "understood  and  declared"  that  "such 
preliminary  training  in  all  its  facts  shall  be  ob- 
tained in  some  other  institution  of  learning  de- 
voted in  whole  or  in  part  to  the  education  of 
women,  or  by  private  tuition."  Further,  the 
fund  is  not  to  be  immediately  used,  but  is  to  be 
invested  until  with  additions  and  interest  it 
reaches  the  sum  of  $500,000,  which  is  deemed 
"  sufficient  for  the  establishment  and  maintenance 
of  a  medical  school,  worthy  of  the  reputation  of 
this  University  and  fully  sufficient  as  a  means  of 
complete  medical  instruction." 

Nothing  could  illustrate  better  the  high 
standard  contemplated  for  the  coming  school,  and 
it  will  effectually  exclude  any  but  a  very  few  se- 
lect individuals  from  entrance.  The  preliminary 
requirements  will  be  guaged  by  the  preliminary 
medical  course  at  the  University  which  requires 
three  years  to  complete,  and  of  which  biology, 
chemistry  and  physics  form  the  groundwork. 
This  is  one  of  the  courses  leading  to  the  degree 
of  A.B.  At  present  female  students  are  de- 
barred from  entering  the  Academic  department 
of  the  University,  and  hence  the  minute  of  the 
Trustees  provides  that  they  shall  obtain  this  part 
of  their  training  elsewhere  or  by  private  tuition. 
This  will  add  to  the  difficulties  of  the  candidates, 
since  instruction  of  such  a  high  order  (much 
higher  than  ordinary  college  graduates  receive, 
and  including  thorough  laboratory  courses)  can 
be  obtained  at  only  two  or  three  institutions  in 
the  country.  So  that,  as  Professor  Osier  recently 
remarked  to  the  writer,  the  training  requisite  for 
the  Hopkins  medical  degree  will  really  extend 
over  seven  years  of  study  of  medicine  and  its 
cognate  branches.  Hence,  it  is  evident  that  the 
Hopkins'  school  will  hardly  enter  into  competi- 
tion with  the  woman's  medical  colleges  now  in 
existence,  but  will  stand  more  in  the  relation  of 
a  higher  school  for  post-graduate  instruction. 
That  this  is  understood  and  appreciated  by  those 
engaged  in  the  teaching  of  women  is  witnessed 
by  the  heartiness  with  which  the  success  of  the 
late  movement  has  been  welcomed  by  those  who 
are  connected  with  the  woman's  medical  colleges 
now  in  operation. 

We  learn  from  a  letter  of  President  Gilmau 
to  Mrs.  Davis,  which  appeared  in  the  daily 
papers,  that  the  advice  of  the  University  Trustees 


with  reference  to  accepting  the  $ico,ooo  on  the 
conditions  imposed  was  a  unanimous  one.  With 
that  consummate  tact  for  which  the  President  is 
famous  he  concludes  his  letter  with  the  remark, 
that  "  it  would  be  a  noble  act,  a  memorable  event 
in  the  history  of  higher  education,  if  the  women 
of  this  county  should  coniDlete  the  endowment 
which  they  have  so  successfully  initiated."  In 
another  letter  from  Judge  Dobbin,  the  President 
of  the  University  Trustees,  it  is  hoped  "  that  the 
zeal  of  the  women  now  interested  in  our  behalf 
will  continue  unabated  until  the  necessary  en- 
dowment is  obtained.  We  do  not  doubt  that 
their  influence  and  example,  and  the  importance 
and  necessity  of  the  work  to  be  accomplished, 
will  bring  to  their  and  our  aid  men  blessed  with 
abundant  wealth,  whose  liberality  will  complete 
that  permanent  endowment  of  the  school  which 
is  necessary  for  its  present  usefulness  and  future 
development." 

Encouraged  by  these  words  and  stimulated  by 
the  success  of  their  first  attempt,  the  Baltimore 
ladies'  committee  determined  to  prosecute  their 
work  of  collecting  funds  to  its  completion.  Sub- 
committees were  appointed  in  Washington,  Chi- 
cago and  California  with  Mrs.  President  Har- 
rison, Mrs.  Potter  Palmer  and  Mrs.  Senator 
Hearst,  respectively,  at  their  head.  An  invita- 
tion was  extended  to  the  local  committees  to 
visit  the  hospital,  and  Mrs.  Harrison,  on  their 
behalf  accepted  and  named  November  14,  as  the 
day  of  their  visit.  On  that  day  a  large  number 
of  distinguished  women  assembled  at  the  hos- 
pital where  they  were  received  by  its  officers  and 
the  Trustees  and  presented  to  Mrs.  Harrison. 
They  then  partook  of  an  elegant  lunch  and  at  its 
close  heard  brief  addresses  from  Mr.  Francis  T. 
King,  President  of  the  Hospital  Trustees,  Dr. 
Mary  Putnam  Jacobi,  of  New  York,  and  Prof. 
Henry  H.  Hurd,  Superintendent  of  the  institu- 
tion. All  these  addresses  referred  to  the  character 
of  the  proposed  school,  which  they  said  was  to 
be  on  a  plane  beyond  anything  hitherto  attempted 
here.  At  their  close  the  guests  were  escorted 
through  the  building  and  had  ample  opportunity 
to  see  its  perfect  arrangements  and  equipments. 
It  is  stated  that  the  lot  is  ready  for  the  buildings 
as  soon  as  the  requisite  endowment  is  secured.  It  is 
on  the  corner  direct^  across  the  street  from  the 
hospital,  and  is  300  feet  square. 

As  has  already  been  stated  in  this  corre- 
spondence provision,  was  made  in  Johns  Hopkins' 
will  for  the  medical  school  in  connection  with  the 
University,  but  owing  to  pecuniary  losses  and 
failures  of  investments,  the  funds  are  lacking  for 
carrying  out  this  part  of  his  design.  Hence  the 
inauguration  of  this  movement.  It  is  said  that 
numerous  contributions,  large  and  small,  have 
been  received  since  the  $100,000  was  presented 
and  that  the  interest  is  wide-spread  and  growing. 
One  subscription  came  from   200  contributors  in 


iS9i.] 


SPECIAL  CORRESPONDENCE. 


33 


Gardiner,  Maine,  and  another  of  $2,500  was  sent 
to  defray  the  expense  of  the  collections. 

The  exercises  at  the  Hospital  were  concluded 
in  the  evening  by  a  reception  at  Miss  Garrett's 
elegant  residence,  corner  Monument  and  Ca- 
thedral St.,  which  was  attended  by  the  dis- 
tinguished visitors  and  by  the  elite  of  the  city. 
By  the  way,  Miss  Garrett's  great  liberality  in  con- 
nection with  this  movement  deserves  to  be  known 
and  appreciated.  Recognizing  the  importance  of 
making  the  offer  to  the  Trustees  at  this  time, 
owing  to  the  greater  likelihood  of  its  being  ac-  \ 
cepted  now  than  later  on,  when  she  saw  that 
the  project  lagged  owing  to  the  doubt  in  the 
minds  of  ladies  as  to  its  acceptance,  she  increased 
her  subscription  from  $10,000  to  S48,ooo,  thus 
completing  the  sum  of  $100,000  which  was  the 
minimum  amount  determined  on  as  presentable 
to  the  Trustees.  The  Trustees  of  the  Woman's 
Medical  College  of  Baltimore  have  had  occasion 
to  experience  Miss  Garrett's  interest  and  liberality 
in  less  degree  on  several  occasions.  Besides  do- 
nations to  their  institution,  which  were  most  op- 
portune, it  was  to  her  that  the  senior  class  of  the 
institution  have  owed  the  enjoyment  of  equal 
privileges  in  the  clinical  advantages  of  the  Lying- 
in  Hospital  of  the  University  of  Maryland  with 
the  undergraduates  of  that  school. 

The  writer  had  the  pleasure  of  attending  the 
inaugural  meeting,  at  the  Johns  Hopkins  Hospi- 
tal on  November  10,  of  the  "Historical  Club," 
an  association  which  meets  monthly,  and  whose 
object  is  to  stimulate  an  interest  in  the  subject  of 
the  history  of  medicine  and  medical  literature. 
Prof.  Welch  is  the  President,  and  the  following 
papers  have  been  presented.  By  Prof,  Welch  : 
1.  Introductory  Remarks  concerning  the  Study 
of  the  History  of  Medicine.  2.  Writers  and 
Books  on  the  History  of  Medicine.  By  Prof.  Os- 
ier :  American  Medical  Classics.  1.  A  Discourse 
upon  the  Institution  of  Medical  Schools  in  Amer- 
ica, by  John  Morgan,  Philadelphia,  1765  ;  2.  In- 
troductory to  the  Course  of  Clinical  Instruction 
at  the  Pennsylvania  Hospital,  by  Thomas  Bond. 
By  Prof.  Kelly :  Notes  upon  Early  Gynecologi- 
cal Works.  By  Dr.  John  N.  Mackenzie :  Some 
Points  in  the  Ancient  History  of  Rhinoscopy. 
By  Dr.  Finney:  Sketch  of  John  Archer,  M.B., 
the  first  Graduate  in  Medicine  in  the  United 
States.  The  two  meetings  were  well  attended 
and  the  proceedings  highly  interesting. 

I  learn  that  the  Pathological  and  Bacteriologi- 
cal Department,  under  Prof.  Welch,  is  so  crowded 
that  additional  accommodations  have  had  to  be 
provided  for  those  attending  it.  Bacteriology  is 
especially  popular,  nearly  forty  students  or  physi- 
cians engaged  in  special  research,  being  enrolled 
in  that  division.  Dr.  A.  C.  Abbott  has  been  sent 
to  Berlin  as  the  representative  of  the  Hospital,  to 
investigate  Koch's  late  discoveries. 

Weekly  clinics  are  now  held  at  the  Hospital  by 


Professors  Osier,  Halstead  and  Kelly,  to  which 
the  physicians  of  Baltimore  and  Maryland  are 
"cordially  invited."  At  Dr.  Osier's  last  clinic 
an  interesting  ca>e  wa>  presented.  It  was  one  of 
dysentery  in  which  the  amoeba  coli  was  found  in 
both  stools  and  sputa.  This  was  considered  to 
justify  the  diagnosis  of  abscess  of  the  liver,  al- 
though there  were  no  local  signs  of  that  affection. 

Dr.  John  R.  Quinan,  a  well-known  ph 
of  this  city,  died  suddenly  November  1 1  of  apo- 
plexy. He  was  an  ex- President  of  the  Medical 
and  Chirurgical  Faculty  of  Maryland,  and  a  local 
antiquarian  of  some  note.  His  most  important 
wurk  was  "The  Medical  Annals  of  Baltimore 
from  1608  to  1880,"  prepared  by  direction  of  the 
State  Society  as  a  memorial  of  the  League's  Cen- 
tennial Anniversary  of  the  founding  of  Baltimore. 
It  is  a  storehouse  of  information  relating  to  the 
profession  of  this  State,  but  owing  to  enforced 
haste  of  publication,  it  abounds  with  errors  which 
detract  much  from  its  value  and  from  the  credit 
due  the  author,  who  devoted  a  large  amount  of 
time  and  labor  to  its  preparation. 

The  Medical  and  Chirurgical  Faculty  held  an 
interesting  semi-annual  meeting  at  Cambridge, 
on  the  Eastern  Shore  of  Maryland,  on  November 
n  and  12.  A  large  number  of  members  went 
down  on  the  boat  from  this  city,  but  I  understand 
the  attendance  and  participation  of  the  local  pro- 
fession was  not  large  or  encouraging.  The  pre 
gramme  was  a  varied  and  interesting  one,  em- 
bracing papers  by  Drs.  Atkinson,  Michael,  Mac- 
kenzie, Ashby,  Winslow,  Earle,  Merrick,  Brinton, 
Gardner,  Harlan,  Preston,  Woods,  Chunn,  Cham- 
bers, Rohe  and  Canfield.  Under  the  energetic  Pres- 
idency of  Dr.  Thos.  A.  Ashby  the  old  society  is 
showing  signs  of  redoubled  vigor;  there  have  been 
large  accessions  lately  to  its  membership,  and  sev- 
eral thousand  dollars  have  been  contributed  to- 
wards a.  medical  building. 

We  are  at  last  to  have  a  morgue.  The  City 
Council  has  appropriated  $4,000  and  a  site  has 
been  selected  near  the  harbor.  The  building  will 
I  be  18  x  40  feet  and  two  stories  high.  We  have 
long  been  sadly  in  need  of  such  an  institution. 

E.  F.  c. 


SPECIAL  CORRESPONDENCE. 


"  The  Wisdom  of  Koch.." 

To  the  Editor: — It  seems  to  me  that  The  Jour- 
nal, as  the  official  mouth- piece  of  the  largest, 
and  oldest,  large  organized  body  of  physicians 
in  America,  should  be  more  conservative  in  its 
utterances  than  appears  in  the  current  number 
editorially  under  the  above  caption. 

In  the  first  place,  there  is  an  objection  to  ex- 
travagant praise  of  Prof.  Koch  in  connection  with 
his  new  treatment  of  lupus  and  tuberculosis,  be- 


34 


SPECIAL  CORRESPONDENCE. 


[January  3, 


cause,  as  he  himself  admits,  its  value  is  so  far  an 
unknown  quantity.  The  profession  has  in  the 
past  properly  refused,  and  should  now  and  in  the 
future  refuse,  to  endorse  any  method  which  has 
not  had  the  test  of  time,  and  in  numerous  hands. 
Prof.  Koch  has  made  wonderful  and  valuable  con- 
tributions to  scientific  medicine,  but  in  this  new 
field  of  endeavor,  the  logical  outgrowth  of  his 
pathological  discoveries,  we  must  not,  simply  on 
the  basis  of  his  success  in  pathological  research, 
follow  him  blindly.  When  a  case  of  tuberculosis 
treated  by  his  method,  after  the  lapse  of  one  year, 
remains  well,  there  will  be  time  enough  to  prepare 
the  laurel  crown. 

In  the  second  place,  there  is  an  objection  to 
extravagant  praise  of  Dr.  Koch  in  this  connection, 
because,  disguise  it  as  we  may,  it  still  remains 
disagreeably  patent  that  the  failure  to  tell  now 
what  the  medicament  is  and  how  it  is  made,  when 
apparently  sufficient  data  have  been  collected  to 
warrant  its  use  upon  the  human  subject,  and  the 
accepta>ice  of  a  fee  therefor,  smacks  too  much  of 
quackery.  In  plain  terms,  it  is  vaunting,  using 
and  selling  a  secret  nostrum. 

So  long  as  Prof.  Koch  confined  himself  to  ex- 
perimental use  of  his  new  remedy  upon  the  lower 
animals,  or  to  a  limited  and  reasonable  degree, 
upon  the  human  subject,  withoutfee,  no  one  would 
dispute  his  moral  and  legal  right  to  keep  his  knowl- 
edge to  himself.  But  when  once  a  fee  has  been  ac- 
cepted for  the  service,  and  a  willingness  expressed 
to  serve  others  on  the  same  terms,  the  experimen- 
tal plea  must  be  abandoned.  And  in  the  light  of 
rumors  of  extortion,  and  charges  by  those  always 
uncharitable  to  medical  men,  that  nothing  will  be 
revealed  until  the  few  interested  have  made  for- 
tunes, further  silence  not  only  gives  rise  to  further 
suspicion  of  Prof.  Koch's  professional  honesty, 
but  casts,  by  inference,  discredit  upon  the  medi- 
cal profession  at  large. 

Finally,  there  is_  an  objection  to  extravagant 
praise  of  Prof.  Koch  in  this  connection,  because, 
outside  of  the  question  of  value  and  outside  of 
the  suggestion  of  quackery,  this  praise  gives  an 
undesirable  boom  to  empiricism  in  medicine.  Only 
a  few  days  ago  it  was  estimated  that  two  thousand 
physicians  had  already  come  from  foreign  parts  to 
Berlin  to  observe  Prof.  Koch's  treatment,  and  by 
to-day's  paper  I  see  that  in  spite  of  the  poor  sat- 
isfaction experienced  by  those  already  there,  the 
list  of  daily  arrivals  shows  no  decrease.  Think  of 
it!  Thousands ui'physicians — Germans,  Austrians, 
Italians,  Russians,  English  and  Americans  (and 
possibly  those  of  other  nations),  flocking  to  Ber- 
lin to  see  Prof.  Koch's  treatment,  scrambling  for 
places,  and  offering  fabulous  prices  for  a  few  drops 
of  the  liquid  whose  composition  they  do  not  know 
and  cannot  find  out !  And  when  asked  why  they 
want  it,  reply,  "  Because  Koch  thinks  it  will  cure 
tuberculosis  !"  When  has  the  practice  of  medi- 
cine witnessed  such  a  spectacle?    And  The  Jour- 


nal's praise  of  Koch's  wisdom  is  helping  to  swell 
this  crowd  ! 

Hitherto  the  great  fault  of  American  physicians 
in  the  eyes  of  our  European  brethren  has  been 
this  very  thing — empiricism.  In  fact,  we  have 
been  charged  wTith  having  a  monopoly  of  it. 
Now,  of  course,  by  this  concourse  of  all  nations 
in  Berlin,  we  know  that  this  charge  is  false,  and 
I  submit  it  to  you — would  it  not  be  better,  in  view 
of  all  this,  for  The  Journal,  instead  of  encour- 
aging, to  caution  its  supporters  ?  commending  to 
their  careful  consideration  the  refusal  of  the 
French  customs  officer  to  allow  the  passage  of 
the  remedy  sent  to  M.  Pasteur,  because  the  Gov- 
ernment of  his  country  (an  excellent  law)  pro- 
hibited the  admission  of  such  things  without  a 
declaration  of  their  composition. 

By  all  means  let  us  leave  the  further  cultiva- 
tion of  empiricism  to  our  German  and  English 
brethren,  now  that  it  has  sprouted  so  vigorously 
among  them.  H.  B.  Young,  M.D. 

Burlington,  la.,  November  29,  1890. 


Euphorbia  Pilulifera  for  Astlima. 

To  the  Editor: — Quite  recently,  at  the  sugges- 
tion of  my  friend  Dr.  E.  T.  Sabal,  of  Jacksonville, 
Florida,  I  have  used  the  remedy  above  named, 
euphorbia  pilulifera,  for  the  relief  of  a  most  stub- 
born case  of  hereditary  asthma,  and  the  results 
are  such  that  I  feel  warranted  in  calling  the  at- 
tention of  the  profession  to  it,  and  also  making 
an  effort  to  compile  some  statistics  which  will  be 
of  service  to  us  in  the  future.  It  is  a  popular 
domestic  remedy  in  Australia,  where  it  is  found 
as  a  common  roadside  weed,  and  has  been  used 
for  the  relief  of  coughs,  colds  and  other  like  dis- 
turbances of  the  air-passages,  but  more  especially 
in  the  treatment  of  asthma.  Dr.  Sabal  advised 
me  that  he  had  used  it  in  a  number  of  very 
marked  dases  which  had  resisted  the  usual  treat- 
ment in  Florida,  and  he  thought  it  might  prove 
equally  valuable  in  our  northern  climate.  The 
only  case  in  which  I  have  employed  it  this  far,  is 
one  which  is  developed  apparently  from  an  ordin- 
ary cold,  and  has  proven  most  intractable  during 
foggy  weather,  or  when  the  relative  humidity 
was  great.  Heretofore,  under  the  treatment  of 
other  physicians,  in  this  country  and  in  England, 
and  Australia,  the  attacks  would  last  from  one  to 
three  weeks,  and  even  then  he  would  require  the 
liberal  use  of  hypodermatics  of  morphine  and 
atropine.  In  the  course  of  twenty-four  hours 
after  the  first  symptoms  appeared,  the  malady 
would  be  fulh-  developed,  and  the  patient,  a 
young  man,  would  be  compelled  to  sit  up  until 
the  disease  had  exhausted  itself.  With  the  ex- 
ception of  myself,  all  his  previous  attendants  had 
used  ipecac  freely,  and  he  had  come  to  dread  the 
attacks  on  account  of  the  nausea  produced  by  the 
treatment.      By    the    cautious    employment    of 


i89i.] 


MISCELLANY. 


35 


atropine,  morphine,  and  nitroglycerine,  and  the 
liberal  use  of  oxygen  gas,  I  had  succeeded  in 
lessening  the  severity  and  shortening  the  period 
to  less  than  a  week,  but  the  results  were  much 
less  satisfactory  than  when  euphorbia  was  used, 
together  with  the  above  described  combination 
subcutaneously.  For  hypodermatic  use  the  follow- 
ing was  employed: 

ft — Morphina;  sulphas,  gr.  1-4. 
Atrophia?  sulphas,  gr.  1-150. 
Trinitrin,  gtt.  1.     n£ 

Sig.     For  subcutaneous  use;  for  one  dose. 

The    formula   adapted   for    the    exhibition  of 
euphorbia  as  follows: 

R— Ext.  euphorbae  pilulifera  (P.  D.  &  Co's.). 

Glyceriui,  aa  fl.  oz.  ij.     "E 
Sig.     Take  one  teaspoonful  every  three  hours. 

If  those  who  have  had  experience  with  this 
remedy  will  kindly  communicate  the  results  of 
their  observations  to  me,  I  will  be  glad  to  give 
them  credit  in  the  form  of  a  collective  report. 
John  Aulde,  M.D. 

1910  Arch  street,  Philadelphia,  Dec.  12,  1890. 


A  Correction. 


To  the  Editor: — In  the  issue  of  The  Journal 
containing  the  report  of  the  Mississippi  Valley 
Medical  Association  meeting  at  Louisville,  refer- 
ring to  my  paper  upon  "Certainty  in  the  Diag- 
nosis of  Tuberculosis"  I  am  quoted  as  saying: 
"The  disease  is  void  of  the  slightest  tendency  to 
self-limitation."  This  I  certainly  did  not  say, 
nor  did  Dr.  Porter,  of  St.  Louis,  in  his  interesting 
paper  published  in  the  same  number  of  The 
Journal,  take  any  such  extreme  grounds.  He 
called  in  question  Flint's  doctrine  of  self-limita- 
tion, restricting  the  skepticism  to  cases  which 
had  advanced  so  far  that  the  presence  of  disease 
could  be  established  by  physical  signs.  It  was 
upon  a  series  of  such  cases  that  Flint's  teaching 
was  based.  Owing  to  pressure  of  time  neither 
Dr.  Porter's  paper  nor  mine  was  discussed,  but 
in  conversation  with  him  afterward  he  clearly  ex- 
plained his  position,  and  I  think  I  am  correct  in 
stating  it.  Tuberculosis,  advanced  to  the  pro- 
duction of  distinct  subjective  and  objective  signs 
is  one  thing;  the  incipient  local  disease,  which, 
in  many  cases  at  least,  can  now  be  detected  by 
skilful  application  of  the  bacteriological  test,  is 
clinically  quite  another.  So  far  as  experiments 
upon  animals  can  throw  light  upon  the  question, 
there  is  good  reason  to  believe  in  the  self-limita- 
tion, and  I  would  not  like  to  go  on  record  with 
such  a  sweeping  statement  as  that  quoted.  I 
wrote  as  follows:  "Tuberculosis  is  a  disease 
which,  once  well  under  headway,  is  not  in  any 
marked  degree,  as  compared  with  other  infec- 
tions, self-limited.  Self-limitation  is  an  uncer- 
tain staff  upon  which  to  lean.  We  can  not 
deserve  the  name  of  workers,  nor  realty  win  bat- 
tles nor  advance  to  higher  fields,  nor  even  pre- 


serve our  self  respect,  by  supineiy  resting  upon 
such  support  and  awaiting  a  possible  victory." 
Respectfully,  Theodore  Potter,  M.D. 

Indianapolis,  Ind. 


Shall  The  Journal  be  Removed  to 
Washington? 

To  the  Editor: — Please  place  my  vote  on  the 
list,  as  in  favor  of  The  Journal  remaining  at 
Chicago.  Q.  C.  Smith,  M.D. 

Austin,  Tex.,  December  23,  1S90. 


To  the  Editor: — About  the  removal  of  The 
Journal  and  building  a  house  of  our  own ;  I 
think  it  advisable  to  do  so,  and  would  suggest 
Louisville,  which  is  neither  an  Eastern,  Western, 
Northern  or  Southern  city,  but  truly  a  central 
one.  J.  W.  Davis,  M.D. 

Smyrna,  Tenn.,  December  23,  1890. 


To  the  Editor: — The  writer's  subscription  (as 
have  those  for  every  former  one)  for  Vol.  xv  of 
The  Journal  will  soon  be  forthcoming,  and  for 
the  fact  above  he  would  regret  a  break  in  the  file. 
To  the  ordinary  observer  the  proposition  to  re- 
move The  Journal  to  the  Capital  or  elsewhere 
must  have  in  its  favor  some  occult  reason  or 
grounds,  so  palpable  and  strong  are  the  objec- 
tions. In  all  forms  of  journalism  the  argument 
for  a  central  place  of  publication  is  vital,  but  in 
the  special  case  of  The  Journal,  it  is  tenfold 
stronger.  The  word  "Association"  gives  the  key 
to  this  statement.  Surely  reasons,  at  the  present 
sufficient,  and  daily  augmenting — not  to  mention 
success — would  induce  the  common  mind  to 
think  and  say  "The  Journal  is  exactly  where 
it  should  be."     Yours  truly, 

H.  C.  Markham,  M.D. 
Independence,  Iowa,  Dec.  27,  1890. 


MISCELLANY. 


The  Mattison  Prize. — With  the  object  of  advancing 
scientific  study  and  settling  a  now  mooted  question,  Dr. 
J.  B.  Mattison',  of  Brooklyn,  offers  a  prize  of  $400  for  the 
best  paper  on  "Opium  Addiction  as  Related  to  Renal 
Disease,"  based  upon  these  queries: 

Will  the  habitual  use  of  opium,  in  any  form,  produce 
organic  renal  disease  ? 

If  so,  what  lasion  is  most  likely  ? 

What  is  the  rationale? 

The  contest  is  to  be  open  for  two  years  from  Dec.  1, 
1890,  to  either  sex,  and  to  any  school  or  language.  The 
prize  paper  is  to  belong  to  the  American  Association  for 
the  Cure  of  Inebriety,  and  to  be  published  in  a  New  York 
medical  journal,  Brooklyn  Medical  Journal,  and  Journal 
oj  Inebriety.  Other  papers  presented  are  to  be  pub 
lished  in  some  leading  medical  journal,  as  their  authors 
may  select.  All  papers  are  to  be  in  possession  of  the 
Chairman  of  Award  Committee,  on,  or  before  January  1, 
1893. 


36 


MISCELLANY. 


[January  3,  1890. 


The  Committee  of  Award  will  consist  of  Dr.  Alfred  L.        Bv  direction  of  the  Secretary  of  War.     Par.  18,  S.   0. 
Loomis,  President  N.  V.  Acad,  of  Medicine,   Chairman;        2S9,  A.  G.  O.,  Washington,  December  11,  1S90. 
Drs.  H.  F.  Formad,  Phila.:    Ezra  H.  Wilson,  Brooklvn;    Major  Stevens  G.  Cowdrey,  Surgeon,  extension  of  leave 
Geo.  F.  Shrady,  and  Jos.  H.  Ravmoud,  editor  Brooklyn        of  absence  granted  in  S.  O.  263,   November  10,  1890, 
Medical  Journal.  j      from  this  office,  is  further  extended  ten  days  on  ac- 

count  of  sickness.     By  direction  of  the  Secretary  of 

War.     Par.  4,  S.  O.  293,  A.   G.  O.,  December  16,  1890. 
Golden   Belt   District   Medical   Society.  —  The  |  Capt.   Marcus  E.   Taylor,  Asst.  Surgeon,  par.   17,  S.  O. 
winter  meeting   of  the  Golden    Belt   District    Medical;      287,  December  9,  1890,  from  this  office,  relating  to  him 


Society  will  be  held  in  Salina,  Kan.,' Jan.  8,  1891,  for 
the  mutual  benefit  and  entertainment  of  the  profession. 
A  general  invitation  to  members  of  the  profession  is  cor- 
dially extended  to  be  present.  The  following  papers 
will  be  read:  "Report  of  a  few  cases  of  Complete  Perineal 
Lacerations,"  by  W.  S.  Harvey,  M.D.,  Salina;  "Laxa- 
tives and  Cathartics,  and  their  Application,"  by  J.  F. 
Brewer,  M.D.,  Minneapolis;  "Report  of  a  Surgical  Case," 
by  P.  Daugherty,  M.D.,  Junction  City;  "The  Therapeu- 
tic Value  of  Rest  in  Affections  of  the  Joints,"  by  A.  L. 
Blesh,  M.D.,  Hope;  "The  Menopause;  its  Relation  to 
Disease,"  bv  J.  W.  Feltv,  M.D.,  Abilene;  "Injuries  of  the 
Eye,"  by  G.  A.  Wall,  M.D.,  Topeka. 


The  New  Surgeon-General. — Dr.  Charles  Suther- 
land has  been  nominated  to  the  office  of  Surgeon-General 
by  the  President.  He  entered  the  Medical  Service  of  the 
Army  in  1852,  and  is  the  Ranking  Colonel  in  that  depart- 
ment. He  served  with  distinction  in  the  late  war  and 
was  breveted  Lieutenant-Colonel  and  Colonel  for  meri- 
torious service.  Since  1S66  he  has  held  the  position  of 
Assistant  Medical  Purveyor.  His  eminent  ability  and 
his  efficient  services  render  his  appointment  to  the  high- 
est position  in  his  department  eminently  befitting,  and  he 
will  doubtless  fulfil  the  duties  of  his  new  position  with 
fidelitv  to  the  Government,  and  with  honor  to  himself. 


Official  List  of  Changes  in  the  Stations  and  Duties  of 
Officers  Serving  in  the  Medical  Department,  U.  S. 
Army,  from  December  13,  i8go,  to  December  26, 1890. 

Major  Charles  Smart,  Surgeon,  is  detailed  as  a  delegate 
to  represent  the  Medical  Department  of  the  Army  at 
the  annual  meeting  of  the  American  Public  Health  As- 
sociation, to  be  held  at  Charleston,  S.  C,  December  16 
to  19,  1890.  He  will  proceed  to  Charleston,  according- 
ly, and  upon  the  final  adjournment  of  the  Association, 
return  to  his  station  in  this  city.  Bv  direction  of  the 
Secretary  of  War.  Par.  2,  S.  O.  290J  A.  G.  O.,  Wash- 
ington, December  12,  1890. 

Capt.  William  O.  Owen,  Jr.,  Asst.  Surgeon,  now  on  leave  of 
absence,  will  report  in  person,  without  delay,  to  Col. 
Eugene  A.  Carr.'Sixth  Cavalry,  at  Rapid  City,  S.  Dak., 
for  duty  with  troops  in  the  field,  and  by  letter  to  the 
commanding  General.  Dept.  of  Dakota.  By  direction 
of  the  Secretary  of  War.  Par.  17,  S.  O.  291,  A.  G.  O., 
Washington,  December  13,  1890. 

Capt.  Walter  Reed,  Asst.  Surgeon,  now  on  duty  at  Balti- 
more, Md.,  will  report  in  person,  without  delay,  to  the 
commanding  officer,  Ft.  Keogh,  Mont.,  for  temporary 
duty  at  that  station,  and  by  letter  to  the  commanding 


is  so  amended  as  to  direct  him  to  report  to  the  com- 
manding officer,  Vancouver  Bks. ,  Wash.,  for  duty  as 
post  surgeon,  relieving  Col.  Barnard  D.  Irwin,  Sur- 
geon, of  that  duty.  Capt.  Rudolph  G.  Ebert,  Asst. 
Surgeon,  will  be  relieved  from  duty  at  Vancouver  Bks., 
Wash.,  upon  the  arrival  of  Capt.  Taylor,  and  will  then 
proceed  to  Ft.  Huachuca,  A.  T.,  and  report  in  person 
to  the  commanding  officer  of  that  post  for  duty.  Wash- 
ington, December  17,  1S90. 

First  Lieut.  Thomas  U.  Raymond,  Asst.  Surgeon,  having 
been  ordered  to  temporary  duty  at  Vancouver  Bks., 
Wash.,  by  the  commanding  General,  Dept.  of  the  Col- 
umbia, is  assigned  to  duty  at  that  post,  and  relieved 
from  further  duty  at  Ft.  Sherman,  Idaho.  S.  O.  294, 
A.  G.  O.,  Washington,  December  17,  1890. 

Capt.  Robert  J.  Gibson,  Asst.  Surgeon,  now  on  leave  of 
absence,  will  report  in  person,  without  delay,  to  the 
commanding  officer,  Ft.  Meade,  S.  Dak.,  for  duty  with 
the  Seventeenth  Infantry  in  the  field,  reporting  by  let- 
ter to  the  commanding  General,  Dept.  of  Dakota.  By 
direction  of  the  Secretary  of  War.  Par.  6,  S.  O.  297, 
A.  G.  O.,  Washington,  December  20,  1890. 

Capt.  John  J.  Cochran,  Asst.  Surgeon,  is  granted  leave  of 
absence  for  six  months  on  surgeon's  certificate  0/  dis- 
ability, with  permission  to  leave  the  Dept.  of  Texas. 
By  direction  of  the  Secretary  of  War.  Par.  2,  S.  O. 
298,  A.  G.  O.,  December  22,  1S90. 

First  Lieut.  Freeman  V.  Walker,  Asst.  Surgeon,  leave  of 
absence  granted  in  S.  O.  85,  Dept.  Platte,  November 
11,  1890,  is  extended  one  month.  By  direction  of  the 
Secretary  of  War.  Par.  9,  S.  O.  298,  A.  G.  O.,  Decem- 
ber 22,  1S90. 


Official  List  of  Changes  in  the  Medical  Corps  of  the  (  '.  S. 
Navy  for  the  Week  Ending  December  20,  1890. 

Asst.  Surgeon  Sheldon  G.  Evans,  ordered  to  Naval  Acad- 
emy, Annapolis,  Md. 

P.  A.  Surgeon  Corbin  J.  Decker,  detached  from  Naval 
Academy,  and  ordered  to  Naval  Hospital,  Philadel- 
phia, Pa. 


Official  List  of  Changes  of  Stations  and  Duties  of  Medi- 
cal Officers  of  the  U.  S.  Marine-Hospital  S,  1  ... 
for  the  Two  Weeks  Ending  December  20,  1S90. 

Surgeon  Walter  Wyman,  granted  leave  of  absence  for 
twenty  days.  December  11,  1890.  To  attend  meeting 
of  American  Public  Health  Association.  December 
12,  1890. 

Surgeon  W.  H.  Long,  granted  leave  of  absence  for  seven 
days.     December  20,  1S90. 

Surgeon    R.   D.    Murray,   granted   leave   of  absence  for 


thirty  days.     December  20,  1S90. 
General,  Dept.  of  Dakota.     By  direction  of  the  Secre-  j  Surgeon  Fairfax   Irwin,   detailed   for  special   temporary 


tary  of  War.  S.  O.  291,  A.  G.  O.,  Hdqrs.  of  the  Army 
Washington,  December  13,  1890. 

Capt.  William  Stephenson,  Asst.  Surgeon,  is  granted 
leave  of  absence  for  fourteen  days,  to  take  effect  on  or 
about  December  20,  1890.  Par.  18,  S.  O.  291,  A.  G.  O., 
December  13,  1890. 

Capt.  Francis  J.  Ives,  Asst.  Surgeon,  now  on  leave  of  ab- 
sence, will  proceed  to  Rapid  City,  S.  Dak.,  and  report 
in  person  to  Col.  Eugene  A.  Carr,  Sixth  Cavalry,  for 
duty  with  troops  in  the  field,  relieving  First  Lieut.  Wil- 
liam B.  Banister,  Asst.  Surgeon,  and  reporting  also  by 
letter  to  the  commanding  General,  Dept.   of  Dakota. 


duty  at  M.-H.  Bureau.     December  10,  1890. 
P.  A.  Surgeon  H.  R.  Carter,  to  attend  meeting  of  Amer- 
ican Public  Health  Association.     December  11,  1890. 
P.   A.  Surgeon  Eugene   Wasdin,  to   attend  meeting   of 

Aim  in. in    Public  Health  Association.     December  11, 

1890. 
P.  A.  Surgeon  J.  J.   Kinyoun,  granted  leave  of  absence 

for  thirty  days,  with  permission  to  go  abroad.     Decein- 

lii  t   1  1,  1S90. 
Asst.  Surgeon  II.  D.  Gcddings,  upon  expiration  of  leave 

to  proceed  to  New  York,  N.  Y.,  for  temporary  duty. 

December  18,  1890. 


T  1 1  E 


J  ournal  of  the  American  Medical  Association. 

EDITED  UNDER  THE  DIRECTION  OF  THE  BOARD  OF  TRUSTEES. 

PUBLISH  ED    WEEKLY. 


Vol.  XVI. 


CHICAGO,  JANUARY   10,    1891. 


No  2. 


ORIGINAL  ARTICLES. 


SOME  DISPUTED  POINTS    IN   THE   COR- 
RECTION OF  REFRACTION  ERRORS. 

Read  in  the  Section  of  Ophthalmology  at  the  Forty-first  Annual  Meet- 
ing of  the  American  Medical  Association,  at  Nashville, 
Tenn.,  May,  1800. 

BY  B.  ALEX.  RANDALL,  A.M.,  M.D., 

OPHTHALMIC   AND  AURAL  SURGEON    TO   THE   EPISCOPAL   AND   CHIL- 
DREN'S HOSPITALS.  PHILADELPHIA. 

In  the  entire  range  of  ophthalmology  there  is 
probably  no  question  as  important  as  that  of  how 
to  deal  with  errors  of  refraction.  The  sum  total 
of  discomfort,  disease  and  impaired  vision  fairly 
ascribable  to  ametropia,  is  unapproachable  by 
that  due  to  any  of  the  grave  disorders  to  which  the 
eye  is  subject ;  and  glasses  are  being  prescribed 
with  ever-increasing  frequency  and  by  a  rapidly 
widening  circle  of  medical  men.  Yet  it  is  very 
unfortunate  to  note  the  wide  divergence  in  the 
views  of  men  who  ought  to  be  authorities  in  such 
matters;  and  the  acrimonious  criticism  with  which 
some  of  them  assail  the  work  of  others,  attacking 
them  even  before  the  laity  with  a  vigor  which  ill 
accords  with  professional,  or  even  common  cour- 
tesy, and  can  be  justified  only  by  scientific  dem- 
onstrations, as  yet  lacking,  that  the  treatment 
thus  condemned  is  unwise  and  harmful. 

As  there  are  many  whose  views  in  this  matter 
are  not  very  definite,  I  have  felt  that  in  placing 
on  record  the  conclusions  that  I  have  reached  in 
ten  years  of  close  and  conscientious  study,  I  may 
perhaps  aid  some  in  reaching  clearer  views  and 
more  satisfactory  results.  Without  claiming  any 
originality,  then,  but  apologizing  to  those  who 
may  be  bored  by  this  retravelling  of  much-trod- 
den paths,  I  will  touch  upon  some  of  the  points 
in  dispute. 

First,  as  to  the  frequency  of  ametropia.  There 
are  probably  few  now  remaining  who  will  uphold 
the  old  view  that  the  majorit}-  of  people  are  em- 
metropic. The  investigations  of  the  eyes  of  in- 
fants and  school-children  have  proven  beyond 
any  reasonable  doubt  that  the  young  human  eye 
is  almost  invariably  hypermetropic,  that  astigma- 
tism is  extremely  common,  although  not  always 
easily  uncovered,  and  that  myopia — the  bugbear 
of  our  German  cousins  especially — is  almost  in- 


variably developed  during  the  school  age.1  But 
from  this  point  wide  divergence  begins.  The  rule 
that  has  been  proven  for  children,  is  quite  gener- 
ally held  to  be  inapplicable  to  adults.  It  is  con- 
sidered entirely  natural  that  the  immature  child 
should  present  the  undeveloped  type  of  eye;  but 
also  that  he  should  outgrow7  it  later,  as  he  does 
many  other  childish  things.  The  general  existence 
of  emmetropia  in  adult  life  is  claimed  upon  this  a 
priori  ground,  and  has  really  been  but  rarely  ques- 
tioned ;  yet  it  needs  only  a  rational  questioning  of 
the  view  to  show  that  it  is  baseless.  Hardly  one 
cornea  in  twenty  is  free  from  measurable  astigma- 
tism, as  the  modern  hand)7  ophthalmometers  clear- 
ly show  (Javal,  Nordenson,  Schiotz,  Burnett,  et. 
al).  So,  too,  as  to  axial  ametropia,  the  few  investi- 
gations made  among  adults,  falling  far  short  of 
the  whole  truth  as  they  generally  do,  still  show 
that  not  one-half  could  be  looked  on  as  emme- 
tropic. Incomplete  as  the  demonstration  is,  it  is 
quite  enough  to  throw  the  burden  of  proof  upon 
those  who  would  maintain  the  a  priori  view. 
Thus,  it  has  been  demonstrated  by  Seggel  that 
among  the  common  soldiers  in  Munich,  40  per 
cent,  of  the  3,052  eyes  studied  had  manifest  hy- 
permetropia,  and  only  46  per  cent,  appeared  em- 
metropic ;  yet  these  were  healthy  young  adults 
from  among  whom  all  notably  abnormal  had  been 
excluded  by  the  enlistment  examination.  Stricter 
study  would  have  greatly  reduced  this  group  of 
apparent  emmetropes,  just  as  Roosa2  found  among 
20  eyes  carefully  selected  as  free  from  manifest 
hypermetropia  only  6  which  were  actually  emme- 
tropic under  atropia — the  rest  revealing  hyperme- 
tropia of  .65  to  1.5  D.  In  a  study  of  the  eyes 
of  medical  students,  I  found  with  the  test  glasses, 
among  142  eyes,  51  apparently  emmetropic,  54 
myopic,  and  only  37  with  manifest  hypermetro- 
pia ;  yet  the  ophthalmoscope  and  other  methods 
proved  that  full  92  were  hypermetropic,  only  19 
myopic,  and  at  most  31  emmetropic.3  Of  the  51 
eyes  which  rejected  convex  glasses  and  seemed 
emmetropic,  only  16  appeared  so  by  other  tests; 
and  the  use  of  a  mydriatic  would  have  reduced 
even  this  list  nearl)-  to  the  vanishing  point.    Only 


■Randal!,  "  The  Refraction  of  the  Human  Eye,"  Amer.  Jour. 
Med.  Sciences,  July.  1885. 

-Trans.  Am.  Oph.  Society.  1S78. 

3  Randall,  "  Eyes  of  Medical  Students,"  Trans.  Pennsylvania 
State  Med.  Soc.  1885. 


38 


CORRECTION  OF  REFRACTION  ERRORS. 


[January  io, 


32,  or  18.8  per  cent,  of  the  total  180  eyes  exam- 
ined could  be  regarded  as  free  from  ametropia, 
manifest  even  to  the  incomplete  investigation. 

So,  too,  the  refraction  work  in  our  clinics  gives 
a  showing  of  the  ametropia  that  cau  be  robbed  of 
little  of  its  force  by  the  claim  that  eve  patients  do 
not  fairly  represent  the  general  population.  One- 
third  of  the  work  done  at  the  Wills  Eye  Hospital 
in  Philadelphia  among  its  10,000  annual  patients, 
is  the  correction  of  refraction  errors  ;  and  the  pro- 
portion is  nearly  one-half  in  the  Eye  Clinic  of  the 
University  of  Pennsylvania.  Let  it  be  shown  by 
competent  investigation  that  any  large  group  of 
adults  presents  a  considerable  proportion  of  em- 
metropia,  and  then  only  will  such  facts  as  these 
be  at  all  in  need  of  confirmation.  If  we  look  at 
any  group  of  people  whose  refraction  has  been 
measured  in  order  to  seek  the  relation  of  refrac- 
tion error  to  other  disease— be  it  chorea,  epilepsy, 
glaucoma  or  anything  else— we  find  results  that 
vary  only  with  the  method  and  care  of  the  exam- 
iner. Dr.  de  Schweinitz  found,  as  did  Stevens,  a 
high  proportion  of  ametropia  among  choreic  chil- 
dren, but  not  more  than  Risley  found  in  1,200  of 
the  general  school  population  of  Philadelphia. 
In  the  latter  investigation  the  emmetropes  re- 
mained practically  unvarying  in  the  ages  from  6 
to  21  years.  The  study  of  adults  reaches  parallel 
results. 

Those  who  would  uphold  the  assumption  of 
the  prevalence  of  emmetropia,  must  fall  back 
upon  a  series  of  unproven  and  reallv  untenable 
explanations  of  why  the  facts  conflict  with  their 
theory.  They  must  exclude  all  low  grades  of 
error  as  unimportant  and  physiologically  normal 
—a  point  which  experience  in  correcting  small 
errors  fully  disproves.  Small  grades  of  ametropia 
are  quite  as  often  the  cause  of  asthenopia  as  the 
larger  ones  ;  and  while  far  from  asserting  that  the 
weak  glasses  of  my  test  case  are  the  most  impor- 
tant, I  must  needs  recognize  that  this  neglect 
ot  the  low  grades  of  refraction  error  is  one  of  the 
few  points  in  which  Donders'  great  treatise  has 
been  found  imperfect.  One  stronghold  remains, 
but  it  is  difficult  to  see  how  anything  but  blind 
prejudice  can  deem  it  impregnable.  It  is  claimed 
by  some  that  mydriatics  give  us  a  false  view  of 
the  refractive  condition  of  the  eye,  that  paralysis 
of  the  accommodation  is  accompanied  by  a  ficti- 
tious decrease  of  the  refraction,  and  that  the 
measurements  so  obtained  must  be  "  discounted" 
111  order  to  arrive  at  the  true  static  refraction  or 
condition  of  entire  rest.  Merely  negative  evi- 
dence can  be  adduced  in  support  of  this  view,  and 
abundant  positive  evidence  to  the  contrary  is 
readily  accessible.  The  oft-quoted  statement  of 
Donders  is  cited,  that  "a  tone  of  accommoda- 
tion "  to  the  extent  of  .37  to  .90  D.  is  usual  and 
can  be  relaxed  only  by  accommodative  paralysis 
—a  view  from  which  he  did  not  publicly  recede, 
so  far  as  I  know.     Vet  he  wrote  to  me  as  to  this 


in  1885:  "The  difference  is  slighter  than  I  had 
supposed  and  may  be  neglected  for  the  myopic 
eye.  Another  question  is  whether  it  depends  on 
the  tone  of  accommodation,  which  can  only  be 
supposed  (as  existing  generally  in  not-striped 
muscular  tissue),  but  not  proved." 

The  resting  points  for  this  view  are  the  facts 
that  a  mydriatic  often  shows  a  lower  myopia  or  a 
higher  hypermetropia  than  is  discoverable  before 
or  after  its  use,  and  that  most  people  complain  of 
blurred  distant  vision  if  the  full  mvdriatic  correc- 
tion is  given.'  Most  persons  certainly  do  at  first, 
or  at  least  most  hypermetropes ;  but  it  is  exceed- 
I  ingty  pertinent  to  ask  why  all  do  not,  and  why 
I  myopes  are  rarely  much  troubled  in  this  regard. 
The  answer  is  reallv  self-evident — the  myope  has 
generally  established  no  habitual  accommodative 
tension  ;  if  it  is  present  in  any  case,  every  one 
recognizes  it  as  an  "accommodative  cramp,"  not 
a  "  tone. ' '  The  hypermetrope,  on  the  other  hand, 
has  so  long  maintained  his  accommodation  tense! 
even  in  distant  vision,  that  he  finds  it  hard  to  un- 
learn the  habit  when  it  becomes  no  longer  neces- 
sary. What  ophthalmoscopist  ever  found  it  easy 
at  once  to  relax  all  accommodative  effort,  or  even 
after  he  has  learned  to  relax,  finds  it  always  pos- 
sible to  do  so?  An  eye  whose  accommodation 
has  long  been  cramped  is  apt  to  return  to  its 
cramp  when  the  mydriatic  wears  off,  and  will, 
therefore,  see  imperfectly  at  a  distance  with  the 
totally  correcting  glass.  If  such  a  difficulty  lasts 
more  than  a  fortnight,  as  it  will  in  a  very  few 
cases,  it  is  almost  invariably  because  of  muscular 
insufficiency  which  has  not  been  corrected.  The 
essential  question  here  to  be  considered  is  whether 
the  mydriatic,  pushed  to  total  paralysis  of  the  ac- 
commodation, invariably  gives  an  untrue  picture 
of  the  refraction  and  causes  an  artificial  hyper- 
metropia, as  has  been  claimed.  From  two  points 
of  view  this  claim  cau  be  distinctly-  disproved. 
First,  the  cases  are  not  very  rare  in  which  full 
mydriatic  paralysis  gives  identically  the  same  re- 
sult as  was  obtained  with  active  accommodation  ; 
and  secondly,  a  large  number  of  cases  can  be 
taught  fully  to  relax  their  accommodation  and 
obtain  full  vision  with  a  glass  totally  correcting 
the  defect  revealed  under  the  mydriatic.  The 
length  of  time  and  the  amount  of  annoying  blur- 
ring before  this  is  gained  vary  in  different  cases; 
and  the  question  must  always  present  itself  to  the 
practitioner,  whether  the  benefits  may  not  be  fully 
gained  and  the  discomfort  lessened  by  giving  an 
under-correcting  glass.  But  this  is  a  question  of 
expediency,  not  of  necessity  ;  and  those  who  ha- 
bitually give  total  corrections  and  insist  upon 
their  constant  wear,  fail  in  few  cases  to  obtain  the 
desired  result. 

In  the  appended  table  of  cases  will  be  found, 
first,  a  group  where  the  refraction  was  unchanged 


;  v-  '"    rackson  has  pointed  out,  full  correction  for  5  metres  is 
really  0.3  Dovei  correction  for  distance,  a  point  usually  forgotten. 


r89i.] 


CORRECTION  OF  REFRACTION  ERRORS. 


39 


l>v  the  mydriatic;  second,  those  who  obtained  full 
vision  with  totally  correcting  glasses  ;  and  third, 
a  series  to  show  how  far  astray  the  manifest  error 
was  from  the  true  refraction.  Of  the  first  class 
of  these  cases,  where  the  refraction  was  the  same 
before  and  with  the  mydriatic,  I  have  few  acces- 
sible records,  and  1  cannot,  like  Roosa,  cite  6 
eyes  out  of  20  which  remained  absolutely  emme- 
tropic under  atropine.  Yet  every  one  who  has  put 
this  matter  to  a  fair  test  has  met  such  cases,  not 
only  in  middle  life,  but  even  in  childhood.  In  the 
school  examinations,  Cohn  reports34caseswho.se 
manifest  hypermetropia  was  absolutely  unchanged 
by  total  atropine  mydriasis;  and  Diirr  obtained 
like  results  under  homatropine.  Such  cases,  if  not 
common,  are  not  the  less  emphatic  in  their  teach- 
ing. Of  those  who  have  received  totally  correct- 
ing glasses  and  with  them  have  obtained  full  vis- 
ion, dozens  might  be  cited,  although  I  have  not 
tested  and  recorded  the  ultimate  vision  in  even 
one-half  of  those  who  ceased  to  complain  of  blur- 
ring for  distance,  and  have  chosen  only  hyperme- 
tropes  here  as  illustrations.  Of  the  third  group 
only  a  few  are  brought  forward,  because  no  one 
who  has  ever  used  a  mydriatic  can  doubt  that,  in 
a  large  proportion  of  cases,  the  true  result  cannot 
possibly  be  obtained  without  it.  These  are  all 
recent  cases  from  my  private  record. 

And  here  let  me  say  as  to  my  refraction  work, 
that  it  is  all  done  under  conditions  practically- 
identical,  with  good  uniform  illumination  on  the 
test  card,  that  the  mistake  of  even  a  single  letter 
in  a  long  line  has  been  signified  by  a  question 
mark,  that  the  minutest  errors  and  discrepancies 
have  been  noted,  and  that  full  mydriatic  paralysis 
has  not  been  assumed  merely7  because  a  mydriatic 
had  been  several  times  instilled,  but  proven  by- 
careful  tests  both  for  distance  and  for  near.  In 
the  latter  case  an  artificial  far-point  of  25  cm.  has 
been  generally  used,  and  as  the  test  object  the 
finest  of  type  or  Burchardt's  dots. 

While  a  mydriatic  has  been  habitually  employ- 
ed, it  has  been  always  regarded  as  a  disagreeable 
measure,  which  should  be  avoided  if  possible ; 
and  accordingly,  among  the  last  250  cases  on  my 
record,  I  find  that  there  were  175  of  refraction 
error  (exclusive  of  presbyopia),  and  in  101  of 
these  a  mydriatic  was  used.  Of  the  remainder, 
there  were  53  patients  less  than  45  years  of  age  to 
whom  no  mydriatic  was  given.  This  was  not  al- 
ways from  choice,  for  there  were  some  of  these 
cases  where  the  mydriatic  was  advised,  and  the 
manifest  glass  was  given  only  tentatively  and 
under  protest.  There  were  also  a  few  cases  where 
I  refused  to  give  a  glass  without  full  use  of  a 
mydriatic,  and  thereby  lost  the  patient :  but  these 
have  not  been  included  here.  The  method  of  em- 
ployment has  depended  upon  the  mydriatic  and 
the  case.  With  hyoscyamiae  sulphate,  which  I 
much  prefer,  a  2-gr.  solution  has  been  prescribed, 
to  be  instilled  one  drop  in  each  eye  at  bedtime 


and  again  on  rising,  with  perhaps  another  instil- 
lation before  the  measurement.  Dark  coquilles 
or  a  thick  veil  have  been  worn  to  shade  the  eyes 
from  glare,  and  the  examination  generally  re- 
peated, with  continued  instillation,  on  several 
days.  Retinoscopy  with  the  plane  mirror  at  4 
metres  distance,  and  the  ophthalmoscope,  have 
been  used  as  control  tests — the  former  being 
specially  valuable,  since  with  it  discrepancies  of 
.25  D.  or  of  50  in  cylinder  axis  can  hardly  be 
overlooked. 

As  a  mydriatic,  hyoscyamine  is  probably  un- 
equalled. Chemically  identical  with  duboisine, 
it  yet  seems  distinctly  less  inclined  to  exert  the 
toxic  action  which  too  often  made  the  latter  drug 
a  treacherous  ally  ;  and  in  a  strength  of  2  grs.  to 
the  ounce  it  rarely-  causes  any  constitutional  symp- 
toms. Its  action  is  more  prompt  and  energetic 
than  that  of  atropia  in  stronger  solutions,  and  its 
full  action  is  obtained  in  about  half  an  hour. 
Even  after  a  single  instillation  there  is  little  or 
no  diminution  in  its  effect  for  about  seventy  hours, 
while  the  troublesome  period  of  returning  accom- 
modation is  only  about  two  days.  Recovery  from 
its  effect  is  as  complete  in  five  days  as  on  the  tenth 
day  after  the  use  of  the  atropia,  although  the 
grasp  of  the  latter  drug  begins  to  waver  much 
earlier,  while  the  hyoscyamine  is  still  in  full  con- 
trol. A  week  can  generally  be  set,  therefore,  as 
the  time  during  which  near  work  must  be  aban- 
doned on  its  account,  while  the  similar  period  for 
atropia  is  quite  two  weeks.  This  is  a  strong  point 
in  its  favor,  since  it  is  quite  trouble  enough  to 
disable  the  patient  for  the  shorter  period  ;  but  its 
highest  value  lies  in  the  unvarying  grasp  upon 
the  accommodation  for  about  three  days  after  the 
last  instillation,  so  that  the  rest  which  it  enforces 
is  generally  absolute.  As  this  "  putting  the  ac- 
commodation in  splints"  is  one  of  the  special 
indications  for  the  use  of  a  mydriatic,  and  one  in 
which  the  atropia  gives  at  most  two  days  of  rest, 
the  superiority  of  the  shorter- lived  mydriatic  is 
manifest.  No  value  of  this  sort  attaches  to  the 
use  of  homatropine  ;  but  in  eyes  that  are  not  very 
irritable,  total  paralysis  can  be  obtained  by  several 
instillations  of  a  6  gr.  solution,  and  it  has  much 
value  in  its  narrow  field. 

When,  with  or  without  a  mydriatic,  a  glass  is 
found  which  gives  the  best  attainable  vision  and 
is  confirmed  by  the  retinoscopy  and  ophthalmo- 
scope, there  is  room  for  judgment  as  to  whether 
it  shall  be  ordered  as  it  stands  or  be  modified  to 
meet  some  special  indication  of  the  case;  but  there 
is  in  few  cases  anything  but  disadvantage  in  wait- 
ing until  the  mydriasis  has  wholly  disappeared 
before  ordering  the  glass.  The  accommodation 
and  muscular  condition  should  be  determined  at 
the  first  examination,  and  furnish,  with  the  his- 
tory, the  only  data  which  legitimately  influence 
the  decision  as  to  the  glass  to  be  given.  Upon 
one  general  rule  I  should  like  to  insist,  because 


4o 


CORRECTION  OF  REFRACTION  ERRORS. 


[January  io, 


it  would  seem  to  be  followed  by  few,  and  that  is 
that  the  total  correction  should  be  given  unmodi- 
fied, except  for  clear  and  definite  cause.  It  is  not 
always  wise  to  give  full  correction  to  myopes  ;  but 
I  am  persuaded  that  if  our  European  colleagues 
would  do  more  of  it,  with  careful  correction  of 
astigmatism,  they  would  see  far  less  progressive 
myopia.  As  has  been  said,  it  is  sometimes  very 
difficult  to  get  a  hypermetrope  to  accept  the  total 
mydriatic  correction  ;  and,  in  the  absence  of  stra- 
bismus or  asthenopia,  policy  may  dictate  a  reduc- 
tion of  the  convex  spherical  by  .25  or  .5  D.  In- 
sufficiency of  convergence,  especially  for  distance, 
generally  makes  the  use  of  the  total  correcting 
glass  impossible  unless  it  is  combined  with  a  pris- 
matic correction.  This  latter  can  often  be  most 
satisfactorily  obtained  by  modification  of  the  cen- 
treing of  the  lenses.  Inattention  by  oculists  and 
opticians  to  this  matter  of  precise  centreing  is  a 
prolific  source  of  unsatisfactory  results,  which  very 
little  care  could  wholly  avoid ;  and  the  oculist 
should  specify  the  exact  distance  between  the  op- 
tical centres,  and  make  a  point  of  verifying  the 
strength  and  fit  of  every  glass  he  orders,  if  pos- 
sible. 

While  there  is  little  in  the  foregoing  that  can 
make  the  least  claim  to  novelty,  since  most  of  it 
has  been  previously  and  better  said,  it  contains 
much,  I  believe,  which  is  at  present  accepted  and 
applied  in  practice  by  only  too  small  a  minority. 
I  beg  leave,  therefore,  in  closing,  to  reiterate  the 
following  points  and  to  urge  their  importance 
upon  all  who  are  doing  ophthalmological  work  : 

1 .  Errors  of  refraction  are  present  in  the  great 
majority  of  cases,  but  need  correction  in  only  a 
portion  of  those  who  suffer  with  eye-trouble. 

2.  In  all  correction  of  refraction  errors,  the 
manifest  refraction  is  as  uncertain  a  basis  as  a 
quicksand,  and  the  static  refraction  is  the  only 
true  basis  on  which  to  work. 

3.  A  mydriatic  is  often  required  in  order  to  give 
the  eye  a  needed  rest  and  to  measure  correctly 
the  refraction,  and  it  must  be  used  to  the  extent 
of  total  ciliary  paralysis  to  meet  this  end,  as  a 
small  remnant  of  accommodation  is  sufficient  to 
mask  astigmatism  as  well  as  hypermetropia. 

4.  The  glass  as  determined  under  full  mydri- 
atic paralysis  measures  the  true  static  refraction 
of  the  eye. 

5.  The  glass  given  should  accord  with  the 
static  refraction  of  the  eye,  being  modified  only 
for  good  and  definite  cause. 

6.  The  minutest  accuracy  is  desirable  as  to  the 
strength  and  fitting  of  the  glasses,  and  the  width 
of  the  optical  centres  should  be  exactly  prescribed. 

7.  The  balance  of  the  ocular  muscles  should 
be  strictly  studied  in  every  case,  since  these  rela- 
tions have  important  bearings  upon  the  ordering 
of  lexises. 

8.  If  these  matters  have  been  properly  studied 
'  when  the  case  is  first  seen,  there  is   rarely  any 


need  of  delaying  the  ordering  of  the  glasses  until 
the  accommodation  has  returned. 

Cases   illustrating   refraction    unchanged    by   full 
mydriasis  : 

1.  Miss  Kate  S.,  aged  24;  Right  eye  V.  =  £  +, 
no  astigmatic  lines  chosen,  near-point  for  D  =. 
50  13  cm.,  with  +  .75  spherical  V  =  f  ?+;  under 
homatropine  with  +.90  or  .75  sph.  V=|: 
Left  Eye  V  =  f  +,  with  +.  65  cylinder  axis  1800 
V=  £  ?  +,  under  horn,  with  +.  65  cyl.  axis 
1800  %. 

2.  Miss  Mary  W.,  aged  24  ;  R.  E.  %,  with  -  10. 
sph.  T\  +,  no  lines  chosen  ;    under  hyoscyamine 

-  10.  (with  or  without  -  .50  cyl.  axis  150)  f  y2  ?  : 
L.  E.  S,  -  10.  sph.  T%  +;  under  the  mydriatic-  10. 
s-  (C_-5°  cyl.  axis  1500?)  4?  Without  glass 
D  =  .50  5  to  10  cm.  each. 

3.  George  B.,  aged  16,  R.  E.  VV,  no  lines,  D 
=  .50  read  from  8  to  .25,  cm.,  with  -  3.25  sph.  f ; 
under  homatropine  with -3.25  £:  L,.  E.  T6ff,  no 
lines,  same  accom.,  with -4.  sph.  f  ;  under  horn., 

-  4.  sph.  (or  -3.5  s.  3  -  -50  c.  axis  1800  ?)  £ . 

Cases  illustrating  full  vision  through  the  totally 
correcti?tg  lens  : 

1.  John  W.,  aged  10  ;  Right  Eye  V  =  ,%,  lines 
chosen  at  180°,  near-point  11  cm.  for  D.  .50,  eye 
hypermetropic  but  vision  made  worse  by  any 
convex  glass ;  under  hyoscyamine  with  +2.5 
sph.  O  +  -9°  cyl-  a3"s  9°°  tV  The  left  eye  gave 
an  identical  result,  before  and  after  the  mydriatic. 
Six  months  later  he  came  with  the  glasses  broken 
and  claiming  to  see  better  without  them  ;  but  saw 
T\  and  T6?  without,  and  T62  each  with  them.  A  few 
months  later  his  vision  had  risen  to  §}i  ?  each 
through  the  glass,  and  accom.  was  normal. 

2.  Robert  E-,  aged  17,  R.  E.  f,  lines  at  1800, 
near-point  10  cm.,  with  +  1.  s.  3  +  -37  c.  axis 
900  I  +  :  L,.  E.  same  vision  and  accom.,  with  + 
.90s.  C  +  -37  c.  axis  900  £  +.  Hyoscyamine 
showed  R.  +  1.25  s.  Q  +:  25  c.  90°  f,  and  L.  + 
1.25  s.  O  +  -37  c-  9°°  I !  aQd  the  result  has  re- 
mained unchanged  since,  although  a  low  grade 
of  exophoria  is  present. 

3.  Richard  S.,  aged  33,  R.  E.  l}4,  lines  170°, 
near-point  22  cm.,  with  -  .50  cyl  .80°  £;  under 
hyosc.  + .  65  c.  1800  gave  -J  j i ,  which  became  later 
f  ? ;  L.  E.  %  ?  +,  with  -  .50  c.  ioo°  £  ;  under  my- 
driatic +  .  25  s.  O  .50  c.  1500  gave  $}&,  later  £. 

4.  Flora  J., aged  13,  R.  E.  £,  no  lines,  near-point 
11  cm.,  H.  m.    +.65  s.  £;  under  hyosc.    +.75  s. 

0  +  -05  c.  900  gave  f:  L.  E.  460,  no  lines,  D=i.50 
read  at  17  cm.,  +  2.  s.  Q  +  2.5  c.  900  3';,T  ?  ; 
under  hyosc.  +  2.  s.  Q  +  3.  c.  900  gave  {',  ?  +  . 
A  month  later  the  vision  was  still  $  +  on  the 
right  and  ,'1,  ?  +  on  the  left. 

5.  Sadie  D.,  aged  26,  R.  E.  ;>_■?,  lines  1800, 
near  point  15  cm.,  with  +  2.5  s  Q  +  .64  c.  900 
; ;?;   under  hyosc.  +   3.25  s.  Q  +  .50c.  90°!?: 

1  E .  '  '     ',  same  lines  and  near  point,  with  +  2.5 


t39i.] 


CORRECTION  OF  REFRACTION  ERRORS. 


4i 


s.  O  +  -25  c-  90°  f  ?i  under  hyosc.  +  3.25  s. 
Q  .50  c.  900  f.  As  this  seemed  a  slight 
over-correction  +  3.  s.  3  +  .50  c.  900  was  given, 
and  with  it  three  months  later  each  eye  saw  J  ? 
Agnew  had  given  sphericals  +  2.75  and  2.5 
several  years  previously. 

6.  Miss  M.,  aged  23,  R.  E.  \y*  ?,  no  lines, 
near- point  22  cm.,  H.  m.  +  .90  s.  f  %  ?  ;  under 
hyosc.  +  1.5  s.  O  +  .37  c.  900  \]/2  ?;  L,.  E.  |  ?,  no 
lines,  same  accom.,  with  +  .90s.  |  ?;  under  the 
mydriatic  with  +  1.5  s.  Q  +  .37  c.  900  i}4  ?  +. 
She  was  still  able  to  read  many  of  |  with  each 
eye  when  seen  after  the  mydriatic  had  disap- 
peared, and  has  remained  comfortable  with  con- 
stant wear  of  her  glass. 

7.  Mrs.  L,. ,  aged  34,  R.  E.  f  ?,  no  lines,  H.  m. 
+  .25,  same  vision;  under  hyosc.  with  +  .25  c. 
90°  I?;  later  f  full:  L.  E.  &,  lines  150,  with  +  3.5 
c.  axis  1050  T6g|  under  mydriatic  +  .5  s.  3  +  4-5 
c.  axis  1000  rV  same  vision  after  return  of  accom. 

8.  Mrs.  W.,  aged  44,  R.  E.  26T,  lines,  1500, 
with  +  1.  s.  3  +  .50  c.  axis  6o°  f\  ?;  under 
hyosc.  with  +  1.5  s.  |  ?.  later  f:  L.  E.  56ff,  lines 
at  300,  with  +  1.25  s.  O  +  .50  c.  axis  1200  rV?; 
under  hyosc.  with  +  1.75  s.  Q  +  -65  c,  axis 
90°  f  j4  + ;  later  f  ?. 

9.  Mrs.  H.,  aged  30,  R.  E.  tto?.  improved  by 
no  glass,  lines  1650,  read  D  =  .5  at  15  cm.;  under 
hyosc.  with  +  .25  s.  Q  1.5  c.  axis  900  y?  ?  +, 
later  T6F?:  L,.  E.  yV  lines  900,  D  =  .5  from  30  to 
45  cm.,  with  +  2.  s.  ,%;  under  hyosc.  with  + 
3.5  s.  |-,  later  §■  +.  The  lowered  vision  was  due 
to  hazy  and  irregular  corneae,  worse  on  the  right. 

10.  Mary  C,  aged  16,  R,  E,  f,  no  lines,  near- 
point  12  cm.,  with  +  .65  s.  %%;  under  hyosc. 
with  +  1 .  s.  O  +  •  5°  c-  axis  8o°  f ;  L.  E.  f ,  no 
lines,  same  near-point,  with  +  .90  s.  iyi  ;  under 
mydriatic  with  +  .9  s.  3  +  .65  c.  axis  100° 
%%  + .  As  these  seemed  slightly  over-correcting, 
+  .75  s.  was  given  in  combination  with  the  cylin- 
der for  each  eye;  and  when  last  seen  the  right 
had  V  =  f  ?,  left  f  full. 

Cases  illustrating  marked  differences  betwee?i  the 
manifest  and  true  refraction. 

1.  Mrs.  C,  aged  38,  R.  E.  f\?  +,  lines  chosen 
at  1050,  near-point  indeterminate,  with  —  2.  c. 
axis  8o°  yV?  +  ;  under  hyoscyamine  with  +  2.25 
•c.  axis  1200  il'2  ?  +  ;  L.  E.  TV?  +,  lines  at  1050 
near  point  18  cm.  for  D  =  .5,  with  — 2.  c.  axis 
1650  T64  ? ;   under  hyosc.  with  +   2.   c.  axis  8o° 

2.  Lizzie  K.,  aged  23,  R.  E.  {'„,  lines  at  1200, 
large  print  spelled  with  difficulty,  with  —  3.  s.  Q 

—  2.5  c.  axis  350  &  ?  ;  under  hyoscine  with  —  1. 
s.  O — 4.5  c.  axis  450  iyi  ?  +  :  L.  E.  -&>  lines  at 
6o°,  large  print  at  10  cm.,  with  — 4.  s.  Q  —  2.5 
c.   axis  1500  -26ff  ? ;  under  hyoscine  with  —  1.  s.  3 

—  5  c.  "axis  1500  ri  ?  +.  These  seemed  accurate, 
but  the  cylinders  alone  were  ordered  ;  and  with 
them  she  had  a   month  later  T6y  ?  each.     Three 


years  later  she  returned  with  {'z,  most  of  I;,  on 
the  right  and  yV  on  the  left,  with  these  glasses. 
Her  glasses  had  been  frequently  strengthened  be- 
fore coming  to  me,  and  she  was  wearing  —  6.5 
sphericals  given  by  an  optician  "professor." 

3.  Miss  M.,  aged  34,  R.  E.  y'V  ?  +,  lines  at  1050, 
large  print  at  35  cm.,  with  +  .65c.  axis  1050  !;  ??; 
under  hyoscyamine  with  +  3.  s.  $■  ?? :  L.  E.  £  ??, 
no  lines,  near-point  25  cm.,  all  glasses  rejected; 
under  hyosc.  with  +  2.  s.  |  ?  These  were  given, 
but  worn  little  except  for  near  work  ;  with  them 
when  last  seen  £  ??  right,  and  |  ??  left. 

4.  Miss  Minnie  C,  aged  22,  R.  E.  yV,  with 
—  .75  c.  axis  105°  1%  ;  under  homatr.  with  +  1.  s. 
C  +  -50  c.  axis  200  f  +  :  L-  E.  y'V,  with  —  .25  c. 
axis  750  r6?  +  ;  under  hom.  with  +  1.  s.  Q  +  .75 
c.  axis  1600  f  +.  Some  exophoria,  and  she  had 
worn  concave  glasses. 

5.  Mrs.  G.  R.,  aged  22,  R.  E.  g6,;,  lines  at  750, 
chose  — 3.  s.  3  —  2-  c.  axis  1650  ;  under  hyosc. 
with  —  .75  s.  C  —3-5  c-  axis  ^o0  y\ :  L.  E.  T%, 
lines  at  ioo°,  chose  —  1.  s.  3 —  !-5  c-  axis  io°  ; 
under  hyosc.  with — 2.75  c.  axis  io°|?  With 
these  the  vision  was  slightly  better  when  last 
seen. 

Dr.  Lippincott  :  In  the  main  I  agree  with 
the  conclusions  reached  by  Dr.  Randall,  because 
he  distinctly  states  that  the  ametropia  is  to  be 
fully  corrected  provided  there  is  not  some  suffi- 
cient reason  for  not  following  this  rule.  In  my 
opinion,  cases  presenting  such  conditions  are  not 
very  unfrequently  met  with.  For  example :  I 
sometimes  find  that  the  distortion  of  retinal  im- 
ages observed  after  correcting  ametropia  is  so 
great  that  it  becomes  necessary  to  refrain  from 
prescribing  completely  correcting  glasses.  This 
is  especially  noticeable  in  the  case  of  artists  af- 
fected with  astigmatism  of  comparatively  high 
degree  and  with  axis  oblique. 

Dr.  Jackson  :  The  explanation  of  the  period 
of  complete  rest  of  accommodation  seems  to  me 
due  to  the  excess  of  the  dose  used  over  the  dose 
required  to  produce  barely  complete  paralysis  with 
the  mydriatic  used.  I  would  confirm  the  reader's 
estimate  of  the  benefit  of  giving  the  correcting 
lenses  while  the  eyes  are  still  under  a  mydriatic. 
A  point  not  generally  understood  is  that  it  is 
often  as  hard  for  the  patient  to  become  accus- 
tomed to  partial  correction  as  to  a  full  correction, 
if  the  correction  be  for  more  than  the  manifest 
hyperopia.  In  some  cases  that  have  failed  to  see 
clearly  with  a  partial  correction  of  hyperopia,  the 
full  correction  has  been  promptly  accepted. 

Dr.  de  Schweinitz  agreed  entirely  with  the 
essayist,  except  in  his  choice  of  mydriatics,  as  he 
believed  atropine  was  more  efficient  than  hyoscy- 
amine. In  addition  to  the  value  of  a  strong 
mydriatic  in  aiding  the  determination  of  the  re- 
fractive error  accurately,  this  drug  —  atropine 
preferably,  he  thought — had   a  distinct  therapeu- 


4- 


THE  PREVENTION  OF  MYOPIA. 


[January  io, 


tic  influence  upon  the  low-grade  retino-choroidal 
irritations  so  commonly  present  in  ametropic  eyes 
— an  influence,  moreover,  unattainable  by  a  mere 
disuse  of  the  eye  without  the  local  application  of 
the  dru?. 


THE  PREVENTION  OF  MYOPIA. 

Read  at  the  Sixteenth    Annua!  Meeting  of  the  Mississippi    I 'alley 
Medical  Association  at  Louisville,  Ky.,  Oct.  9,  1890. 

BY  FRANCIS  DOWLING,  M.D., 

OF   CINCINNATI.   O. 

The  simplest  and  at  the  same  time  the  most 
concise  definition  of  myopia  is  given  by  my 
friend  and  former  teacher,  Dr.  Landolt,  of  Paris, 
when  he  says  that  "  myopia  is  present  whenever 
the  retina  is  situated  behind  the  focus  of  the 
dioptric  system  of  the  eye." 

Before  proceeding  with  the  remarks  on  the 
means  of  preventing  or  limiting  the  development 
of  myopia  or  near  sight  it  will  be  well  to  give  a 
brief  outline  of  some  of  the  principal  causes  of 
the  affection,  and  for  this  purpose  I  have  looked 
up  the  leading  authorities  on  the  subject. 
Schweigger,  of  the  University  of  Berlin,  is  of  the 
opinion  that  in  the  majority  of  cases  myopia  is 
congenital,  or  inherited,  or,  at  least,  there  is  a 
predisposition  to  it  contracted  through  the 
parents.  It  occurs  in  early  childhood  and  shows 
with  the  increase  of  years  a  progression  both  in 
frequency  and  degrees  of  development.  Myopia 
may  remain  stationary  through  life,  or  at  an  ad- 
vanced age  it  may  show  an  apparent  or  actual 
decrease  ;  the  apparent  decrease  is  due  to  the  con- 
traction of  the  pupil  by  which  the  circles  of 
diffusion  are  made  smaller  and  the  images  of 
distant  objects  more  distinct.  In  other  cases  the 
affection  is  rapidly  progressive  during  a  period  of 
life,  generally  up  to  about  the  twenty-fifth  year, 
and  after  that  remains  stationary.  Finally,  in  a 
small  percentage  of  cases,  the  trouble  is  progres- 
sive through  life. 

Cases  of  myopia  in  children  before  the  eighth 
year  are  extremely  rare.  On  the  other  hand, 
previous  to  this  age,  hypermetropy  generally  ex- 
ists. The  trouble  commences  to  manifest  itself 
about  the  tenth  year,  and  from  that  time  on  un- 
til the  eighteenth  year  makes  its  greatest  progress. 

The  accompanying  table  will  serve  to  prove 
this  fact.  They  are  taken  from  the  schools  in 
the  countries  named  : 


Gerj 

IANV. 

Xf.w 

York. 

Paris. 

Age. 

Per  cent. 

Age. 

Per  cent. 

Age. 

Per  ce 

6-8 

II 

6-8 

3 

7-9 

6 

9-10 

15 

9-I0 

5 

9-13 

6 

IO-II 

20 

II-I2 

10 

»-I3 

6 

13-14 

25 

I5-I6 

'5 

IO-I9 

8 

15-16 

40 

I7-I8 

20 

IO-15 

13 

16-17 

45 

18-I9 

25 

13-15 

4 

17-18 

50 

20-2I 

26 

13-16 

23 

18-19 

55 

15-18 

25 

19-20 

60 

15-19 

5° 

20-21 

62 

17-19 

75 

It  has  been  proven  by  statistics  that  myopia 
increases  both  in  frequency  and  degree  as  one 
goes  from  the  lower  to  the  higher  classes  in 
schools.  This  might  be  explained  by  the  fact 
that  the  age  increases  as  one  ascends  in  the 
classes,  but  statistics  show  that,  irrespective  of 
age,  this  increase  in  the  frequency  and  degree  of 
myopia  bears  a  pretty  regular  ratio  to  the  number 
of  working  hours.  In  this  regard,  Erismann,  of 
St.  Petersburg,  gives  the  following  statistics  : 

Among  scholars  occupied  two  hours  per  day, 
17  per  cent,  myopia. 

Among  scholars  occupied  four  hours  per  day, 
29  per  cent.  Among  scholars  occupied  six  hours 
per  day,  40  per  cent,  and  so  on. 

Prof.  Donders,  of  Utrecht,  thinks  that  myopia 
is  not  equally   prevalent   in   all  countries,  but  is 
more  particularly  met  with  in  cultivated  nations, 
and  further,   that  among  the  countries  visited  by 
him,  he  no  where  met  with  so  many  near-sighted 
I  people  as  in  Germany.     This  tallies  with  my  own 
experience :    I    witnessed    proportionately    more 
'  near-sighted   people  in   the   eye   clinics  of  Ger- 
:  many    than    in    any    other    country   of  Europe. 
!  Another  thing  I  noticed  was  that  the  intellectual 
centres,  or  in  other  words,  the  universitv  towns, 
I  had   proportionately   more    near-sighted    people 
than  other  places  not  university  seats.      Hence  I 
infer  that  the  very  high  educational  standard  in 
Germany,  particularly  in  the  college  centres,  b)- 
causing  over-work  of  the  eyes  causes  the  greater- 
percentage  here  than  elsewhere. 

Myopia  is  not  usually  directly  transmitted  from 
:  parents  to  children,  but  only  a  predisposition  to 
the  affection  ;  in  other  words,  all  the  conditions 
necessary  to  the  production  of  the  affection  are 
inherited  from  the  parents,  needing  only  the  ad- 
dition of  some  exciting  cause,  such  as  over-exer- 
cise of  the  eyes  in  study,  etc.,  to  develop  the 
affection  in  children,  just  as  children  of  tubercu- 
lous parents  inherit  no  consumption  directly,  but 
only  the  flat  chest,  the  narrow  shoulders,  a  weakly 
constitution,  a  tendency  to  contract  colds,  etc., 
in  short,  a  predisposition  to  the  disease. 

It  has  been  observed  that  in  the  transmission 
of  this  predisposition  to  myopia  from  the  parents 
to  the  children,  a  father,  as  a  general  thing, 
transmits  to  sons  only,  and  a  mother  to  daughters. 
Cohn,  in  an  analysis  of  some  twenty-eight  cases, 
found  this  rule  to  hold  good.  It  is  also  found 
that  in  this  hereditary  transmission  the  affection 
usually  confines  itself  to  one  sex  ;  for  instance, 
we  often  find  that  all  the  daughters  in  certain 
families  are  near-sighted,  while  the  sons  have 
normal  vision. 

In  cases  where  both  parents  are  myopic,  the 
disease  in  being  transmitted,  manifests  itself  in  a 
lighter  degree  in  the  children  than  in  that  of 
either  parent,  and  very  often  it  corresponds  in  de- 
gree to  the  sum  of  that  found  in  both  parents. 
The  time  allotted  for  my  paper  is  not  sufficient 


1891.]  THE  PREVENTION  OF  MYOPIA.  43 


to  enable  me  to  enter  into  anything  like  an  the  way  of  illumination,  fresh  air,  better  printed 
elaborate  consideration  of  the  causes  of  myopia,  books,  a  judicious  abbreviation  of  the  school 
for  this  reason  it  will  be  sufficient  to  state  here  hours,  etc.,  were  the  results  of  the  agitation.  As 
that  the  weight  of  testimony  seems  to  show  that  a  consequence  there  was  a  marked  reduction  of 
the  causation  of  myopia  depends  on  two  essential  the  percentage  of  myopia  among  the  scholars  in 
factors,  the  first  of  which  is  an  inherent  predis-  the  schools  where  the  reforms  were  carried  out. 
position  on  the  part  of  the  person,  inherited,  or  In  speaking  of  this  subject,  Florscheutz  says 
otherwise;  the  second  a  determining  cause,  that  the  number  of  myopic  pupils  fell  from 
which  may  be  looked  upon  as  a  species  of  seed  21  to  15  per  cent,  three  years  after  the  building 
which  when  planted  in  the  prepared  soil  of  pre-  of  the  Coburg  schools,  according  to  hygienic 
disposition,  causes  the  development  of  the  disease,  principles,  and  Von  Hippie,  in  an  address  at  the 
Among  the  predisposing  causes  may  be  men-  anniversary  of  the  foundation  of  the  University 
tioued  arrests  of  development  of  the  sclerotic  of  Giesen,  made  the  statement  that  he  found 
coat  of  the  eye,  a  peculiar  conformation  of  the  only  34  per  cent,  of  myopia  in  the  new 
globe,  and  chief  of  all,  the  disease  called  choroi-  schools  of  Giesen  compared  with  40  per  cent., 
ditis  in  its  various  forms.  In  this  connection  it  which  was  the  usual  average  in  the  old  buildings, 
will  be  well  to  mention  that  in  cases  of  heredi-  Considering  all  the  information  that  is  at  our 
tary  predisposition  there  is  a  congenital  weakness  disposal  in  regard  to  the  factors  that  enter  into 
of  the  sclerotic  coat,  and  more  especially  in  its  the  causation  of  myopia,  both  in  its  starting  point 
posterior  half.  The  contents  of  the  globe  of  the  and  developing  stage,  no  one  ought  to  doubt 
eye,  under  any  undue  exertion  of  the  organ,  that  the  prime  factor  in  this  causation  is  work 
causes  pressure  on  this  naturally  weak  spot ;  this  with  the  eyes  at  near  range  ;  therefore,  it  stands 
pressure  causes  the  membrane  to  stretch  and  give  to  reason  that  the  only  way  to  prevent  or  restrict 
way  in  a  measure,  and  thus  are  started  many  of  the  affection  is  to  limit  or  prevent  altogether  this 
the  cases  of  so-called  progressive  myopia,  near  work  with  the  eyes  during  the  years  that  are 
Among  determining  causes  may  be  mentioned  known  as  progressive  ones  for  the  disease,  viz.: 
the  acts  of  convergence  and  accommodation  in  from  the  tenth  to  the  sixteenth  year,  and  for  this 
using  the  eyes  for  near  work,  as  for  example,  in  purpose  I  would  make  the  following  suggestions: 
reading,  writing,  sewing,  etc.,  as  both  these  acts  1.  A  child  who  shows  any  marked  predisposi- 
tend  to  increase  the  intraocular  pressure  of  the  tion  to  myopia,  and  whose  parents,  one  or  both, 
eye,  and  the  pressure,  spending  its  force  princi-  were  affected  with  the  disease,  should  never  be 
pally  on  the  membranes  of  the  eye  causes  them  sent  to  the  public  schools,  as  they  are  now  consti- 
to  stretch  and  give  way,  particularly  in  their  tuted,  but  should  be  sent  rather  to  some  private 
posterior  sections,  and  in  this  way  the  majority  class  where  the  number  of  hours  of  study  and 
of  cases  of  myopia  are  started,  and  if  the  cause  the  tasks  could  be  arranged  to  suit  the  condition 
is  kept  up,  of  course  the  trouble  will  continue  to  of  the  scholar's  eyes.  Of  course,  the  lighter  the 
increase  in  degree.  tasks  and  the  fewer  the  hours,  the  better  it  will 
The  first  endeavors  to  find  out  the  causes  of  be  for  the  eyes ;  this,  in  any  given  case,  could  be 
myopia,  were,  it  seems,  made  in  German}',  where  regulated  by  the  family  physician. 
the  trouble  prevails  to  a  greater  extent  than  in  While  on  the  subject  it  occurs  to  me  that  it 
most  other  countries.  In  this  country-  Dr.  Cohn  would  be  a  move  in  the  line  of  progress,  if  a  corn- 
examined  the  eyes  of  some  ten  thousand  children,  petent  medical  man  could  be  appointed  by  our 
and  found  that  one  thousand  of  them  were  more  school  authorities,  particularly  in  our  large  cities, 
or  less  near-sighted.  He  also  found  that  the  who  should  have  general  charge  of  the  sanitary 
trouble  steadily  increased,  both  in  regard  to  the  regulation  of  our  public  schools,  and  who  should 
number  of  cases,  and  in  the  degree  of  refraction,  pay  particular  attention  to  regulating  the  tasks 
as  he  went  in  his  examination  from  the  ele-  and  the  number  of  study  hours  for  such  of  the 
mentary  to  the  higher  schools.  Another  dis-  pupils  as  showed  any  predisposition  to  myopia, 
eovery  which  he  made  was  that  there  were,  rela-  To  me  it  seems  very  unjust  to  have  a  uniform 
tively,  more  cases  of  myopia  in  badly  lighted  system  of  tasks  and  working  hours  for  all  pupils 
schools  than  in  those  that  were  more  favorably  alike  in  the  same  grade,  irrespective  of  the  physi- 
arranged  in  this  respect.  The  publication  of  cal  peculiarities  of  the  individual  scholars,  for  one 
these  facts  by  Dr.  Cohn  caused  quite  a  stir  in  who  inherits  a  weakly  constitution,  weak  eyes, 
the  school  boards  of  Europe.  Lord  Montague  etc.,  will  necessarily  deteriorate  physically  in  try- 
brought  the  matter  before  the  British  Parliament,  ing  to  keep  abreast  of  a  colleague,  who  may  be 
and,  although  nothing  definite  was  done  by  that  naturally  endowed  with  stronger  eyes,  and  strong- 
august  body,  still  the  official  notice  of  the  facts  er  physical  powers.  Examples  of  this  may  be 
in  this  way  attracted  to  the  matter  the  attention  seen  even-  day.  If  we  look  at  the  myopic  schol- 
I  of  educators  at  large,  and  whatever  could  be  ars,  for  example,  in  our  public  schools,  particu- 
1  done  to  bring  about  a  better  state  of  affairs  was  larly  in  our  own  country  where  the  rapid,  high 
done,  and  a  better  condition  of  school  rooms,    in  pressure  system  of  education  is  in  full  vogue,  and 


44 


THE  PREVENTION  OF  MYOPIA. 


[January  io, 


wljere  the  standard  is  entirely  too  high,  we  find 
that  a  large  percentage  of  these  scholars  are  sub-  ] 
jects  with  wean'  eyes,  with  pale,  thin  faces,  in 
which  the  story  is  plainly  written  that  the  mind  is 
being  educated  at  the  expense  of  the  body. 

2.  The  sanitary  condition  of  the  schools  should 
be  first- class,  ventilation,  light,  etc.,  should  be  as 
near  perfect  as  possible,  and  our  school  boards 
should  spare  no  expense  in  keeping  up  this  con- 
dition of  things,  for  it  has  an  immense  influence 
both  on  the  condition  of  the  eyes  as  well  as  the 
general  physical  condition  of  the  scholars. 

3.  Whenever  the  system  of  one  affected  with 
or  predisposed  to  myopia,  becomes  at  all  relaxed,  j 
all  work  with  the  eyes  should  be  suspended,  until  i 
the  health  is  again  entirely  restored  to  its  normal  I 
condition  ;  for  it  must  be  borne  in  mind,  that  it  is 
during  lowered  conditions  of  the  system  that  cer- 
tain forms  of  myopia  make  their  greatest  progress. 

In  this  connection  it  will  be  well  to  state,  that 
from  my  own  observations,  especially  in  the  clinics 
of  Germany  and  France,  a  large  percentage  of 
those  affected  with  myopia  are  burdened  with 
some  constitutional  taint,  such  as  the  tubercu- 
lous, scrofulous,  etc.,  owing  to  which,  the  powers 
of  life  are  usually  below  a  healthy  standard,  and 
this,  in  itself,  is  a  potent  factor  in  furthering  the 
development  of  the  myopia,  and  singularly  enough, 
it  is  especially  during  the  years  that  myopia  makes 
its  greatest  progress,  viz. :  from  the  tenth  to  the 
twentieth  year,  that  turberculosis  and  its  near  re- 
lation, scrofula,  make  their  greatest  advances, 
therefore  the  condition  of  the  general  health  of  a 
young  person  predisposed  to  myopia  should  re- 
ceive the  most  careful  attention  on  the  part  of  the 
medical  adviser. 

4.  Young  persons,  who  may  be  predisposed  to 
myopia,  should  never  study  at  night  time,  all 
near  work  with  the  eyes  should  be  done  by  good 
clear  sunlight.  If,  however,  artificial  light  is  used 
for  this  purpose,  the  electric  light  is  the  best  of 
all  its  competitors,  such  as  gas,  oil,  etc.,  being  far 
less  injurious  to  the  eyes,  for  the  reasons  that  in 
point  of  color  it  more  nearly  approaches  that  of 
the  sun,  than  any  other  artificial  light  known: 
Then  its  volume  is  more  uniformly  distributed 
throughout  the  room,  and  by  virtue  of  the  great 
strength  of  its  illuminating  focus,  it  can  be 
placed  high  above  the  head,  and  still  be  of  uni- 
form service  ;  and  lastly,  the  light  does  not  viti- 
ate the  atmosphere  of  the  room,  like  gas,  oil,  etc 
If  means  could  be  invented  to  render  the  light 
steady,  it  would  be  the  prince  of  all  artificial 
lights  for  near  work  with  the  eyes. 

5.  The  books  from  which  one  predisposed 
to  myopia  should  study,  ought  to  be  printed 
with  tolerably  large  type,  and  the  Latin  letters 
are  the  best  of  all  others,  as  they  are  less  fa- 
tiguing to  the  eyes  than  the  German,  etc.  This 
fact  is,  probably,  the  reason  why  most  scien- 
tific works    and    students'    manuals   throughout 


the  world  are  now  printed  in  Latin  letters,  and 
one  thing  that  surprises  me  is  that  Germany,  with 
all  her  intellectual  progress,  still  retains  the  old, 
crooked  German  letters  in  book  printing,  and 
particularly  in  the  daily  papers,  which  are  the 
poorest  printed  of  any  in  Europe,  and  the  bulk 
of  the  population  have  to  read  this  miserable 
print,  b}r  the  equally  miserable  light  of  a  candle, 
as  gas  light  is  only  enjoyed  by  the  few  in  Ger- 
many. This  fact  struck  me  as  one  of  the  causes 
of  the  great  amount  of  myopia  that  is  found,  par- 
ticularly among  the  middle  and  poorer  classes  of 
that  country.  But  to  return  to  our  subject :  in 
reading,  writing,  etc.,  the  eyes  should  be  kept  at 
a  distance  of  about  30  centimetres  from  the  text, 
and  the  reading,  etc.,  should  be  frequently  in- 
terrupted, so  as  to  rest  the  eyes,  the}'  should  be 
closed  for  five  minutes  or  so  at  a  time,  or  directed 
at  some  far  away  point. 

6.  In  cases  where  the  myopia  is  at  all  marked, 
all  work  with  the  eyes,  such  as  study,  etc.,  should 
be  postponed  until  the  sixteenth  year.  The  child 
should,  if  possible,  be  sent  to  live  in  the  country, 
where  the  range  of  vision  is  longer  than  in  the 
city,  and  then  it  should  be  kept  outdoors,  in  the 
fresh  air,  as  much  as  possible. 

7.  The  wearing  of  glasses  by  a  myope  is  op- 
tional, at  least  for  distant  vision,  as  they  have 
very  little,  if  any  influence  in  checking  the  prog- 
ress of  the  affection.  They  are  only  useful  as  a 
means  of  enabling  the  wearer  to  recognize  more 
clearly  his  surroundings,  and  when  worn  should 
be  of  a  weaker  refractive  power  than  that  neces- 
sary to  correct  the  actual  degree  of  myopia  pres- 
ent, and  they  should  not,  as  a  general  thing,  be 
put  on  before  the  fourteenth  year. 

If,  however,  the  myopia  is  beyond  a  certain 
degree,  say  three  dioptrics,  then  the  use  of  proper 
concave  glasses  for  reading  and  all  other  near 
work,  may  limit  in  a  measure  the  progress  of  the 
disease  by  relieving  the  strain  on  the  muscles  of 
convergence,  and  in  this  way  lessening  the  tension 
on  the  globe  of  the  eye,  which  is  one  of  the  great 
factors  in  furthering  the  march  of  the   affection. 

8.  In  tolerably  pronounced  degrees  of  myopia 
I  have  found  paracentesis  of  the  cornea  by  means 
of  a  fine  needle  to  do  a  great  deal  of  good.  It 
relieves  the  intraocular  pressure  that  is  often  very 
marked  in  such  cases,  and  thus  retards  the  prog- 
ress of  the  myopia;  then  another  thing,  it  lessens 
the  chances  of  detachment  of  the  retina,  which 
often  takes  place  in  high  degrees  of  the  affection. 
In  practicing  the  operation,  after  making  the 
puncture  in  the  cornea,  I  usually  cause  the  fluid 
to  escape  from  the  anterior  chamber  slowly,  by 
pressing  on  the  cornea,  alternately,  with  the  lower 
and  upper  eyelid.  Twice  a  week  is  as  often  as  I 
practice  this  treatment  in  any  given  case.  The 
great  advantage  in  letting  the  fluid  escape  slowly, 
is  that  the  shock  to  the  eye  is  not  as  great  as  whei 
it  is  emptied  rapidly. 


I89I.J 


THK  PREVENTION  OF  MYOPIA. 


45 


Qr.  Harold  X.  MOYER,  of  Chicago,  in  open- 
ing the  discussion,  said  :  While  I  do  not  claim 
to  be  competent  to  discuss  this  paper,  yet  I  feel 
that  something  ought  to  be  said  because  of  its 
evident  value.  There  is  certainly  no  subject 
in  the  range  of  ophthalmology  of  greater  prac- 
tical importance  than  the  one  to  which  this 
paper  has  been  addressed.  It  is  an  able  contri- 
bution—one that  should  be  widely  read  by  the 
general  profession.  I  trust  that  the  writer  will 
not  have  it  printed  in  the  Archives  of  Ophthalmol- 
ogy or  in  some  equally  specialized  journal,  but 
publish  it  in  some  widely  circulated  journal,  so 
that  it  can  be  read  by  the  whole  profession ;  for 
it  seems  to  me  it  will  do  a  vast  amount  of  good 
if  it  is  put  into  the  hands  of  the  general  practi- 
tioner. In  this  way  the  subject  can  be  brought 
before  the  various  school  boards  in  small  as  well 
as  large  country  towns,  and  indeed  in  every'  large 
city. 

Dr.  C.  H.  Hughes,  of  St.  Louis,  Mo.:  Inas- 
much as  other  gentlemen  do  not  manifest  a  desire 
to  discuss  this  interesting  question,  I  can  hardly 
permit  such  a  paper  to  pass  without  expressing 
my  appreciation,  as  a  general  observer  in  medi- 
cine and  a  practitioner  of  thirty  one  years'  active 
dailv  experience,  of  the  value  of  the  position 
taken  by  the  author  of  the  paper  in  regard  to  the 
best  methods  of  preventing  and  ameliorating  this 
condition  among  our  school  children. 

Germany  has  become  largely  a  nation  of  myo- 
pics,  and  I  hope  that  will  never  be  the  fate  of 
America.  There  is  something  in  the  organic 
aptitude  of  the  individual  that  develops  myopia. 
To  illustrate:  It  is  not  necessary  that  either  of 
the  parents  should  be  myopic,  and  this  question 
comes  as  near  home  to  me  as  any  one  in  medicine, 
for.  belonging  to  a  family  that  never  had  to  wear 
glasses  prematurely  ;  married  to  a  lady  none  of 
whose  family  had  to  wear  glasses  prematurely, 
there  has  developed  in  my  family  (in  one  of  my 
children)  this  trouble.  All  of  the  other  members 
of  the  family  are  free  from  it.  I  never  wore  a 
glass  of  any  kind,  nor  my  father  or  mother,  until 
from  43  to  45  years  of  age,  and  these  are  the 
circumstances  under  which  myopia  appeared  in 
my  child. 

At  the  age  of  6  years  the  child  became  the 
victim  of  an  exhausting  fever — scarlatina.  He 
convalesced  tardily  so  far  as  the  restoration  of 
general  vigor  was  concerned.  There  were  no 
aural  sequelae,  but  there  was  evidence  of  damage 
done  to  the  central  (neural  ganglionic)  influences 
which  preside  over  the  nutritional  processes  of 
the  organism,  and  it  was  with  the  utmost  diffi- 
culty that  I  succeeded  in  rescuing  my  boy  from 
decline.  It  became  necessary  to  resort  to  all  the 
therapeutic  resources  which  would  occur  to  a  so- 
licitous father  practically  familiar  with  the  re- 
sources of  our  art.  He  was  carefully  and  thor- 
oughly nourished,  he  was  tranquilized  at  night, 


so  that  he  did  not  lose  the  sleep  he  required  for 
recuperation,  his  digestion  was  taken  care  of,  and 
I  traveled  with  him  into  invigorating  atmos- 
pheres ,  but,  in  spite  of  all  care,  myopia  devel- 
oped. It  is  the  first  case  that  has  shown  itself  in 
my  family.  There  is  no  ancestral  history  which 
would  lead  us  to  expect  it  to  appear  in  the  family. 

There  is  a  great  deal  more  behind  myopia  than 
is  dreamed  of  in  our  present  philosophy.  We  are 
very  apt  to  explain  it  by  attributing  it  to  congen- 
ital deficiencv  of  development  alone,  though  it 
undoubtedly  "is  the  direct  and  immediate  causa- 
tive factor.  But  what  is  it  in  the  organism  of  the 
child  that  singles  out  one  of  a  family  and,  in  the 
process  of  evolution  from  infancy  up  through 
childhood,  causes  the  appearance  of  this  defi- 
ciency? Of  course,  it  is  a  failure  in  the  central 
nutritional  processes.  There  is  a  minus  condition 
there  instead  of  that  plus  process.  There  is  a 
neuratrophic  predisposition  which  makes  the  se- 
quent myopia  a  possibility  in  myopics,  and  this 
may  be  either  congenital  or  acquired.  Myopic 
eyes  are  like  congenitally  shortened  limbs,  or  like 
those  trophic  lesions  that  follow  certain  nerve 
trunk  or  nerve  injuries,  only  in  lessened  degree. 
The  methods  of  treatment,  to  be  successful,  must 
extend  bevond  the  eye,  and  the  oculist  who  satis- 
fies himself  with  the  immediate  rectification  of 
the  condition  of  the  eye  alone  that  presents  itself, 
will  have  onlv  final  failure  for  his  pains. 

Xow,  since  the  doctor  advises  outdoor  exercise 
and  all  the  conditions  necessary  for  the  proper 
evolutionary  and  developmental  processes  going 
on  in  the  child,  I  would  like  to  have  him  observe 
in  the  practice  of  his  cases  in  the  future  the  result 
of  that  treatment,  and  to  find  out  how  many  of 
them  are  arrested  and  what  proportion  are  ever 
cured.  It  is  a  question  that  becomes  interesting 
when  it  strikes  one's  o*vn  family,  and  there  is  no 
doubt  in  mv  mind  that  myopia  is  just  as  much  a 
product  of  abnormal  and  inadequate  nutritional 
processes  in  the  organism  as  the  defective  condi- 
tions in  neurotics  are,  and  the  ophthalmologist, 
like  the  neurologist,  otologist,  or  any  other  man 
who  does  special  work  in  medicine,  is  the  most 
successful  practitioner  who  extends  his  range  of 
observation  and  treatment  beyond  his  immediate 
environment  or  practical  work. 

Dr.  C.  W.  McIxtyre,  of  New  Albany,  Ind.:  I 
do  not  know  whether  or  not  the  writer  of  the  paper 
called  attention  to  the  fact,  that  one  of  the  prin- 
cipal causes  of  mvopia  is  absence  of  proper  light 
in  residences  as  well  as  in  school  houses,  but  I 
know  that  to  be  true  from  experience.  Myopic 
patients  come  to  my  office  and  consult  me,  and, 
after  inquiry,  they  inform  me  that  their  residences 
and  workshops  are  not  properly  lighted  as  I  think 
they  should  be,  and  it  is  really  necessary  for  our 
school  boards  to  look  after  the  sanitary  condition 
1  of  the  schools  in  so  far  as  they  are  properly 
1  lighted,  etc. 


46 


UTERINE  MYOMA. 


[January  io, 


I  differ  with  the  essayist  in  one  particular,  and 
that  is,  that  the  electric  light  is  preferable  to  the 
other  lights  which  he  mentioned.  I  think  an  ex- 
treme light  is  just  as  damaging  to  the  eye  as  in- 
sufficient light.  We  know  that  a  number  of 
myopic  patients  trace  their  condition  to  improper 
glasses  used  in  reading  or  working.  If  our  sani- 
tan-  officers  were  to  look  after  this,  we  would  have 
less  myopia  in  this  country.  If  there  is  not  more 
done  in  the  future  than  there  has  been  in  the  past, 
I  fear  we  will  get  into  a  condition  like  Germany. 
It  is  necessary  for  every  physician  to  take  this 
matter  into  consideration. 

As  Dr.  Mover  said,  the  paper  should  be  placed 
in  the  hands  of  not  only  every  specialist  who  de- 
votes himself  to  ophthalmology,  but  it  should 
reach  the  eye  of  every  local  practitioner,  because 
we  all  have  more  or  less  of  this  class  of  patients 
which  require  our  attention. 

I  wish  to  emphasize  the  fact  that  the  absence 
of  proper  and  sufficient  light  in  residences  and 
school  houses  is  one  of  the  principal  causes  of 
myopia  as  well  as  amblyopia. 

Dr.  Dowling.  in  closing  the  discussion,  said : 
Something  should  be  done  to  prevent  this  grow- 
ing trouble.  I  am  satisfied  that  were  it  not  for 
intermarriages,  especially  in  university  centres, 
it  would  only  be  a  question  of  time  when  we 
would  all  become  myopics  in  this  country.  Were 
it  not  for  the  fact  that  people  from  the  country 
intermarry  with  those  of  the  city,  myopia  would 
be  more  prevalent  than  it  is.  This  intermarriage 
is  the  only  thing  that  saves  us  from  becoming 
myopics.  It  occurs  to  me  that  it  is  becoming 
more  and  more  frequent,  especially  in  children, 
in  our  large  cities.  Take,  for  instance,  Cincin- 
nati, or  any  other  large  city,  and  we  will  meet 
with  a  large  number  of  cases. 

I  believe  that  the  appointment  of  a  private 
medical  officer  would  be  a  step  in  the  right  direc- 
tion. I  spoke  to  my  friend,  Dr.  Culbertson,  not 
long  ago  about  this,  and  he  said  the  health  officer 
was  supposed  to  attend  to  it.  The  average  health 
officer  has  no  time  to  attend  to  such  matters.  In  a 
large  city  with  perhaps  twenty- five  or  more  school 
districts,  it  would  take  up  a  good  deal  of  time ; 
nevertheless  I  maintain  that  a  medical  practitioner 
should  be  appointed  to  look  after  the  sanitary 
condition  of  the  students  and  regulate  their  hours 
of  study,  etc. 


THE  CLINIC. 


Ix  order  that  the  changes  produced  in  tubercu- 
lous tissues  by  Koch's  fluid  may  be  determined 
as  accurately  as  possible,  the  directors  of  the 
Charite  Hospital  at  Berlin  have  given  orders  that 
the  bodies  of  any  patients  who  may  die  after 
having  been  treated  by  the  new  method  shall  be 
examined  as  soon  after  death  as  the  law  permits. 
Koch  found  such  early  examinations  a  great  help 
in  his  investigations  on  cholera. 


UTERINE     MYOMA— RENAL     CALCULUS 

AND  SURGICAL   OPERATIONS  UPON 

THE  KIDNEY. 

A   Clinical  Lecture  Delivered  at  the  Regular  Surgical  Clinic  at 
Rush  Medical  College,   Chicago.    Thursday,   Oct.  2,  l&go- 

BY  CHARLES  T.   PARKES,  M.D., 

PROFESSOR    OF    SURGERY. 

Gentlemen  : — The  patient  before  you,  Mrs.  J. 
F.,  set.  37,  is  suffering  from  an  abdominal  tumor 
which  has  been  present  a  number  of  years,  all 
the  time  gradually,  and  of  late,  rapidly  increas- 
ing in  size,  until  it  has  reached  the  large  growth 
which  you  see  fills  the  entire  abdomen  now  that 
it  is  displayed  to  view.  It  is  a  source  of  serious 
trouble  and  annoyance  to  her  and  the  burden  of 
it  is  sureh-  undermining  her  general  health. 

She  has  faithfully,  during  the  last  five  years, 
tried  various  remedies  and  treatments,  but  they 
have  proved  of  no  avail  ;  so  under  our  advice, 
she  has  come  to  obtain  relief  by  the  removal  of 
the  mass. 

Quite  a  variety  of  opinions  have  been  ex- 
pressed by  different  physicians  whom  she  has 
consulted,  as  to  the  nature  of  the  tumor  ;  and 
this  diversity  of  opinions  increases  the  item  of 
doubt  which  surrounds  all  extensive  growths 
concealed  by  the  abdominal  walls. 

Some  have  decided  that  it  is  an  ovarian  tumor, 
cystic  in  character ;  others  have  supposed  it  to 
be  an  outgrowth  from  the  uterus  itself,  forming 
what  is  called  a  fibroid  tumor  or  myoma.  The 
difference  between  these  two  varieties  of  tumor  is 
very  wide  indeed,  and  usually  there  is  no  diffi- 
culty attending  the  diagnosis  between  them. 

It  makes,  also,  a  very  great  difference  to  the 
patient  whether  the  tumor  is  connected  with  the 
ovary  solely  or  with  the  uterus.  If  connected 
with  the  ovary  it  is  usually  easily  and  safely  re- 
movable ;  if  an  outgrowth  of  the  uterus,  it  is  re- 
moved many  times  with  great  difficulty,  and  the 
removal  is  dangerous  to  the  patient,  for,  in  the 
majority  of  cases,  the  uterus  and  its  appendages 
must  be  removed  with  the  tumor. 

Now  we  will  go  over  the  salient  points  in  the 
diagnosis  of  this  tumor. 

i.  It  has  been  slow  of  growth,  giving  a  history 
of  several  years'  duration,  commencing  low  down 
in  the  midline  of  the  abdomen  where  it  was  first 
discovered  as  a  small  hard  mass.  Its  growth  has 
been  unattended,  until  within  the  last  year,  with 
any-  serious  interference  in  any  way  with  the  pa- 
tient's general  health.  Its  growth  for  the  first 
year  was  accompanied  with  a  very  noticeable  in- 
crease in  the  amount  of  blood  lost  at  each 
menstrual  period,  but  the  amount  of  blood  lost 
has  never  been  extremely  severe. 

2.   Palpation  of  the  abdomen  shows   that  the 


r89i.] 


UTERINE  MYOMA. 


V) 


tumor  is  considerably  larger  than  the  uterus  at 
full  term  ;  that  it  is  smooth,  even  and  regular  all 
over  the  surface  ;  that  it  is  very  hard  and  re- 
sistant to  the  touch  ;  that  it  is  "non-elastic  and 
does  not  fluctuate  as  a  whole  or  in  circumscribed 
areas.  It  is  freely  movable  as  a  mass  from  side 
to  side  within  small  boundaries. 

3.  Percussion  gives  an  absolutely  flat  sound  all 
over  the  surface,  with  a  boundary  of  resonance 
above  it  and  in  the  post-lumbar  regions. 

4.  Yaginal  examination  determines  that  the 
cervix  is  of  normal  size  and  length,  and  in  proper 
position,  rather  high,  as  if  lifted  up.  The  finger, 
by  pushing  the  vaginal  walls  upward,  shows  the 
cervix  to  seemingly  grow  upwards  into  a  dense 
mass  which  cannot  be  limited.  With  the  finger 
on  the  cervix,  any  and  every  motion  made  in  the 
tumor  by  pressure  through  the  abdominal  walls 
is  immediately  transmitted  to  the  cervix  and  it  is 
moved  accordingly. 

All  of  these  signs  together  lead  me  to  the  con- 
clusion that  we  have  to  deal  with  a  uterine 
tumor  or  myoma.  The  patient  has  been  so  in- 
formed, and  she  has  been  made  thoroughly  ac- 
quainted with  the  dangers  attending  the  removal 
of  tumors  of  this  variety. 

Well  aware  of  the  uncertainty  in  diagnosis  ac- 
companying all  abdominal  growths  of  large  size, 
there  will  be  some  anxiety  attending  the  dis- , 
closures  of  the  abdominal  incision.  As  soon  as 
this  is  made  the  diagnosis  cau  be  definitely  set- 
tled. The  tumor's  removal  can  only  be  ac- 
complished by  this  incision  which  will  now  be 
made. 

The  opening  through  the  abdominal  walls 
should  be  made  in  the  line  of  the  linea  alba  from 
just  below  the  umbilicus  toward  the  pubis  by  a 
free  use  of  the  knife,  and  without  a  director,  until 
the  transversalis  fascia  is  reached,  as  has  just 
been  done.  Its  length  at  first  should  be  at  least 
three  inches,  subsequently  prolonged  to  reach  the 
requirements  of  every  special  case. 

When  this  deep  fascia  is  uncovered  to  the  full 
length  of  the  opening  through  the  skin,  vou 
should  stop  long  enough  to  control  the  bleeding 
points  in  the  wound.  This  is  done  temporarilv 
by  the  application  of  these  forceps  ;  usually  be- 
fore the  operation  is  completed,  their  pressure  has 
permanently  controlled  the  bleeding.  This  also 
prevents  the  blood  from  entering  the  peritoneal 
cavity  when  it  is  opened. 

The  opening  through  the  remaining  tissues, 
the  transversalis  fascia  and  the  peritoneum, 
should  be  made  carefully,  in  order  to  avoid 
wounding  the  bladder  which  is  very  likely  to  be 
carried  up  from  its  normal  position  into  the  line 
of  the  incision,  in  the  development  of  a  uterine 
tumor.  It  will  also  avoid  wounding  the  tumor 
itself,  or  any  other  important  viscus  which 
may  lie  on  the  anterior  surface  of  the  tumor  or 
between  it  and  the  abdominal  wall. 


This  is  best  accomplished  in  all  cases,  by  the 
plan  usual  with  us,  which  we  will  now  illustrate. 
With  these  dissecting  forceps  the  tissues  at  the 
extreme  upper  end  of  the  abdominal  incision,  are 
seized  by  the  operator  and  raised  ;  at  the  same 
time  the  assistant,  with  similar  forceps,  raises 
them  on  the  opposite  side.  With  a  free  stroke 
of  the  knife  an  incision  is  made  between  the 
forceps.  This  procedure  is  repeated  until  a  small 
opening  is  made  into  the  peritoneum. 

As  soon  as  this  is  accomplished,  one  is  fre- 
quently made  aware  of  it,  by  the  flow  of  peri- 
toneal fluid  through  the  opening,  and  a  sight  of 
the  tumor.  By  this  method  the  opening  through 
the  peritoneum  is  least  likely  to  endanger  the 
bladder. 

The  opening  is  very  small,  the  tumor  can  just 
be  seen  through  it,  and  yet  I  am  satisfied  that 
the  diagnosis  of  myoma  is  the  correct  one, 
principally  on  account  of  the  color  of  the  tumor, 
which  is  dark  red  and  vascular  looking.  Cystic 
tumors  are  steel  white  and  shining. 

With  the  finger  inside  the  cavity,  as  a  guide, 
the  peritoneum  is  divided  to  the  full  length  of 
the  external  incision.  Now  it  is  possible  to  see 
and  feel  the  entire  tumor  and  its  relations.  It 
has  no  adhesions — the  bladder  is  not  attached  to 
its  anterior  surface.  The  broad  ligaments  are 
elongated  and  carried  up  to  the  highest  point  of 
the  tumor  on  either  side.  One  can  see  the  im- 
mensely enlarged  veins  coursing  between  their 
layers.  Here  are  the  enlarged  and  elongated 
Fallopian  tubes  and  the  ovaries  carried  from 
their  normal  position  high  up  into  the  abdominal 
cavity. 

There  can  now  be  no  doubt  as  to  the  character 
of  the  tumor.  It  cannot  be  drawn  out  through 
this  small  incision,  so  this  must  be  enlarged 
upwards  beyond  the  umbilicus  sufficiently  before 
the  tumor  can  be  delivered  through  the  wound. 
Before  doing  this  it  is  best  to  introduce  into 
the  abdomen  this  large,  thin,  flat  sponge,  and  to 
spread  it  out  smoothly  over  the  intestines,  be- 
tween them  and  the  abdominal  walls,  in  order  to 
protect  them  and  to  keep  them  from  bulging  into 
the  wound  as  it  is  increased  in  length. 

This  has  been  done  and  the  incision  made,  con- 
trolling the  bleeding  as  at  first.  A  pair  of  snap 
forceps  is  put  upon  the  peritoneal  edge  here  and 
there  to  keep  it  from  retracting  or  being  pushed 
off  the  muscles  of  the  abdomen.  You  notice 
that  the  sponge  protects  the  intestines  perfectly 
and  enables  the  assistant  to  keep  them  up  in  the 
cavity  of  the  abdomen,  well  out  of  the  way  of 
operative  manipulation,  in  a  manner  entirelv 
isolating  the  pelvis — this  is  a  very  necessary 
procedure. 

As  yet  it  is  impossible  for  me  to  lift  the  tumor 
out  of  the  pelvis  so  as  to  get  at  the  proper  point 
for  its  division.  So  that  the  next  procedure  con- 
sists in   securing  and  dividing   the  broad  liga- 


UTERINE  MYOMA. 


[January  io, 


ments  on  either  side,  for  they  bind  the  tumor 
down  into  the  pelvis.  This  is  called  technically 
"tieingoff"  the  broad  ligaments  and  requires 
great  care,  in  order  to  avoid  opening  any  of  the 
large  veins  and  to  enable  one  to  apply  ligatures 
to  the  ligament  for  the  permanent  closure  of  all 
the  vessels  included  in  its  folds. 

It  is  done  by  seizing  the-  broad  ligament  as 
close  as  possible  to  the  uterus  with  the  thumb 
and  finger  of  the  left  hand  at  a  point  about  half 
way  down  its  lateral  wall,  and  pulling  the  in- 
cluded tissues  away  from  the  uterine  wall.  With 
the  right  hand  a  pair  of  blunt  pointed  forceps  are 
thrust  through  the  ligament  between  the  fingers 
and  the  uterus  and  opened  laterally,  in  this  way 
a  separation  is  made  close  to  the  uterus  without 
opening  any  large  vessels. 

Through  this  opening  a  needle  armed  with  a 
long  double  thread  is  passed.  As  soon  as  it  is 
drawn  well  through,  a  sufficient  length  of  it  is 
cut  off  to  answer  the  purpose  of  tieing  that  por- 
tion of  the  ligament  which  is  left  attached  to  the 
tumor  and  towards  its  top.  This  ligature  is  tied 
as  close  to  the  top  of  the  tumor  as  it  can  be 
drawn,  and  prevents  bleeding  from  the  uterine 
side  of  the  broad  ligament. 

The  needle  is  still  threaded  and  lies  inside  of 
the  outer  portion  of  the  ligament.  The  thread  is 
drawn  through  the  needle  far  enough  to  make  a 
second  double  ligature.  The  needle  is  then  car- 
ried through  the  remaining  outer  portion  of  the 
broad  ligament,  at  a  non-vascular  point,  and  this 
portion  is  tied  in  halves,  just  as  one  would  tie  the 
pedicle  of  an  ovarian  tumor.  In  this  way  all  the 
vessels  are  securely  fastened,  and  as  the  stump  of 
the  broad  ligament  is  bisected  by  the  ligature,  it 
is  very  secure  and  little  likely  to  slip. 

This  procedure  is  repeated  in  securing  the 
broad  ligament  on  the  other  side,  and  now  the 
mass  can  be  lifted  out  of  the  pelvis  and  we  are 
ready  to  proceed  to  the  next  step  of  the  opera- 
tion, which  is  to  permanently  close  the  vessels  in 
the  uterus  and  tumor  previous  to  its  separation. 
This  is  done  by  tieing  around  the  lower  part  of 
the  tumor  this  piece  of  rubber  tubing.  The  rub- 
ber tube  is  as  large  as  the  middle  finger,  and 
when  in  position,  should  be  drawn  as  tight  as 
your  strength  will  permit,  its  ends  crossed  once 
and  secured  temporarily  at  the  point  of  crossing 
1)\   a  Nelaton  forcep. 

The  determination  to  practice  the  intra-  or 
extra-abdominal  method  of  treating  the  stump 
was  made  before  the  operation  was  begun.  In 
this  case  we  will  adopt  the  extra- abdominal 
method  because  it  has  given  the  largest  number  of 
recoveries.  The  tube  is  applied  at  such  height 
on  the  tumor,  so  that  when  the  abdomen  is 
closed,  the  rubber  tube  will  be  outside  of  the  ab- 
dominal cavity  without  an}'  tension  on  the 
stump.  It  is  now  in  position  tnd  fastened  so 
that  we  can  divide  the  uterus  and  remove  the 
tumor. 


It  is  very  essential  to  ascertain  the  position  of 
the  bladder  before  the  rubber  tube  is  fastened,  in 
order  to  avoid  including  this  viscus  in  its  grasp. 
If  the  bladder  is  drawn  upwards  on  to  the  an- 
terior surface  of  the  tumor,  it  must  be  carefully 
dissected  away  from  the  tumor  before  the  rubber 
is  applied. 

In  cutting  awaj'  the  tumor,  the  incision  should 
be  made  sufficiently  far  away  from  the  rubber  to 
leave  tissue  enough  outside  of  it  to  prevent  the 
rubber  from  slipping  over  the  end  of  the  stump. 
It  is  proper  to  introduce  a  strong  pin  through  the 
substance  of  the  stump  outside  of  the  rubber 
cord,  to  further  guard  against  the  occurrence  of 
any  such  accident. 

Cases  in  which  the  tumor  develops  low  down 
and  implicates  the  cervix  to  such  an  extent  as  to 
prevent  apparently  the  formation  of  a  pedicle, 
can  be  managed  safely  in  the  following  manner  : 

i.  Apply  the  rubber  cord  as  low  down  as  pos- 
sible, near  to  the  vaginal  juncture,  to  control 
haemorrhage  temporarily. 

2.  Remove  the  tumor  by  an  incision  through 
its  substance,  without  reference  to  its  size,  high 
enough  to  make  the  pedicle  sufficiently  long. 

3.  Enucleate  from  the  stump  all  the  separate 
myomata,  if  there  be  any,  or  the  pieces  of  myo- 
matous tissue  that  may  be  found  in  it. 

4.  Apply  the  permanent  ligature  at  the  proper 
height  and  remove  the  temporary  ligature. 

Cases  of  myoma  are  not  infrequently  met  with 
in  which  a  true  myomotomy  can  be  done.  In 
these  cases  the  tumor  is  moderate  in  size,  grows 
in  the  anterior  or  posterior  wall  of  the  uterus, 

It  is  uncovered  by  an  incision  through  the  thin 
layer  of  uterine  tissue  investing  it,  when  it  can 
be  shelled  out  or  enucleated  by  the  finger  with 
ease,  without  opening  the  uterine  cavity.  The 
walls  of  the  cavity  thus  left  are  brought  together 
securely  by  a  series  of  interrupted  catgut  sutures, 
commencing  at  the  bottom  ;  and  the  peritoneal 
edges  are  united  by  a  continuous  catgut  suture. 
In  such  cases  neither  the  uterus  nor  its  ap- 
pendages are  disturbed. 

Haemorrhage  is  controlled  temporarily  by  the 
rubber  cord  drawn  over  the  uterus  and  broad 
ligaments  below  the  tumor.  The  cord  is  re- 
moved as  soon  as  the  wound  is  thorough^ 
sutured. 

Now  that  the  tumor  is  removed  we  see  that 
the  uterine  cavity  is  opened.  We  proceed  at  once 
to  disinfect  this  cavity  by  the  use  of  the  actual 
cautery  or  pure  carbolic  acid  in  order  to  avoid 
infection  from  this  source.  After  this  is  done  the 
stump  is  entirely  shut  off  from  the  abdominal 
cavity  by  sewing  the  peritoneal  covering  of  the 
stump  to  the  peritoneum  of  the  abdominal  walls, 
at  the  lower  end  of  the  wound.  This  is  ac- 
complished by  a  continuous  catgut  suture  en- 
circling the  entire  circumference  of  the  stump, 
closely  approximating   these  peritoneal  surfaces. 


i89i.] 


R  KXAL  CALCULUS. 


49 


Adhesions  soon  form  and  entirely  occlude  the 
abdominal  opening  at  this  point,  preventing  sub- 
sequent infection. 

The  peritoneal  cavity  is  carefully  cleaned  of  all 
blood  clots,  and  if  the  large  flat  sponges  have 
been  properly  placed,  there  is  very  little  manipu- 
lation required  for  this  purpose  ;  as  they  have 
kept  every  thing  out  of  the  cavity. 

Xow  make  a  careful  survey  of  the  entire  field 
of  operation  to  see  that  all  the  vessels  are  secure. 
also  have  all  the  sponges  counted.  You  should 
kuow  absolutely  how  many  there  should  be,  and 
it  is  well  to  get  into  the  habit  of  using  the  same 
number  for  even-  abdominal  operation. 

The  rubber  tube  is  now  permanently  fastened, 
previously  removing  the  Xelaton  forceps,  by  a 
silk  thread  carried  through  the  tube  at  the  point 
at  which  the  ends  are  crossed,  and  securely  tied. 
Xext  the  abdominal  wound  is  closed  by  a  series 
of  interrupted  silk  stitches  passed  through  all 
the  tissues  of  the  abdominal  walls  at  intervals  of 
about  half  an  inch.  It  is  well  to  have  the  last  I 
stitch  above,  and  the  first  below  the  stump,  in- 
clude some  of  the  stump  tissue,  thus  making 
sure  the  isolation  of  the  stump  from  the  cavity. 
Last  of  all  the  dressing  :  The  free  surface  of] 
the  stump  is  mummified  by  a  large  quantity  of 
iodoform  powder,  or  by  the  use  of  the  actual 
cautery.  In  this  case  we  use  the  iodoform.  A 
narrow  piece  of  iodoform  gauze  is  placed  around 
and  beneath  the  projecting  borders  of  the  stump  ; 
the  abdominal  wound  and  the  entire  abdominal 
■walls  are  covered  with  a  free  dressing  of  iodoform, 
iodoform  gauze,  and  cotton  batting,  retained  in 
position  by  a  broad  abdominal  bandage. 

The  operation  is  now  complete  and  the  patient 
is  in  good  condition,  showing  no  signs  of  shock 
or  exhaustion.  The  perils  the  patient  has  to  en- 
counter are  first,  from  haemorrhage  caused  by 
some  fault  in  controlling  the  vessels  ;  and  second, 
from  septic  peritonitis.  There  is  little  fear  from 
the  former  on  account  of  the  care  we  have  taken. 
From  the  latter  source  the  danger  is  greater,  for 
in  extensive  operations  of  this  kind  the  danger 
from  infection  is  extreme,  and  cannot  always  be 
avoided  even  when  practicing  the  most  vigilant 
care  to  prevent  it.  If  we  have  not  infected  the 
patient  she  will  recover  from  the  operation  with 
little  trouble. 

The  specimen  is  a  beautiful  example  of  uter- 
ine myoma.  It  shows  how  these  tumors  are  often 
multiple,  and  how  easily  the  separate  masses  can 
be  enucleated  out  of  their  bed  or  capsule  of  con- 
densed connective  tissue.  You  will  have  an  op- 
portunity to  examine  it:  you  will  be  impressed 
with  its  density  and  hardness,  so  that  in  the  fur 
ture  this  sign  of  its  character  can  be  easih-  recog- 
nized by  you. 

The  patient  will  be  put  into  an  even,  smooth, 
well  warmed  single  bed,  with  bottles  of  hot  water 
about  her  under  the  cover. 


In  order  to  relax  the  abdomen  and  remove  all 
possible  tension  from  the  recent  and  tender  wound, 
a  pillow  should  be  placed  under  the  bended  knees, 
and  her  shoulders  slightly  elevated. 

The  bladder  should  be  emptied  every  six  or 
eight  hours,  by  means  of  a  thoroughly  aseptic 
catheter,  unless  the  patient  herself  can  empty  it 
without  discomfort. 

If  the  anaesthetic  causes  nausea,  this  will  be 
best  controlled  by  keeping  the  stomach  absolute- 
ly empty,  still  occasionally  this  distressing  con- 
dition is  relieved  by  teaspoonful  doses  of  very  hot 
water. 

Thirst  and  dryness  of  the  tongue  and  mouth, 
is  in  part  controlled  by  wetting  the  lips  and 
mouth  frequently  with  cold  water.  If  all  goes 
well,  these  symptoms  will  pass  away  inside  of 
forty-eight  hours,  during  which  time  the  patient 
must  be  encouraged  by  cheerful  attention.  Xo 
feeding  should  be  attempted  until  they  have  sub- 
sided, after  which  the  patient  can  be  fed  any 
kind  of  bland  nourishment,  gradualh-  increasing 
its  strength  to  normal  diet. 

It  is  a  good  plan  to  secure  an  evacuation  of  the 
bowels  at  least  on  the  third  or  fourth  day,  or 
sooner,  if  the  nausea  persists  and  there  is  some 
tympanitis  present.  This  can  be  accomplished 
by  administering  teaspoouful  doses  of  sulphate 
of  magnesia  or  Tarrant's  aperient,  at  intervals  of 
three  hours,  until  four  doses  are  given,  unless  the 
desired  effect  is  produced  sooner.  This  result 
may  be  assisted  by  glycerine  enemata. 

If  the  patient  has  much  pain,  my  partiality  is 
the  use  of  an  injection  containing  thirty  drops  of 
deod.  tinct.  of  opium,  one  drachm  of  whisky  and 
two  ounces  of  beef  tea.  Repeated  if  required  by 
the  severity  of  the  distress. 

The  external  wound  will  need  no  attention  if 
there  be  absence  of  rise  of  temperature,  until  the 
seventh  da}-,  when,  if  union  is  complete,  the 
stitches  may  be  removed  and  new  dressings  ap- 
plied. 

Just  as  much  care  must  be  used  to  prevent  in- 
fection during  the  dressings  as  during  the  opera- 
tion. The  stump  will  probably  be  separated  en- 
tirely by  the  third  week,  when  it  can  be  removed 
and  the  remaining  excavated  ulcer  dressed  with 
ordinary  care,  until  it  is  filled  up  with  granula- 
tions and  cicatrized  over. 

After  as  severe  an  operation  as  this,  the  patient 
should  be  kept  in  the  recumbent  or  semi-recum- 
bent position,  for  at  least  four  weeks. 

RENAL    CALCULUS    AND    SURGICAL    OPERATIONS 
UPON    THE    KIDNEY. 

The  next  patient  has  this  history:  Three  years 
ago  she  was  taken  with  severe  pain,  suddenly 
coming  on,  referred  to  the  left  side  of  the  abdo- 
men in  the  neighborhood  of  the  left  kidney.  The 
pain  extended  over  the  front  of  the  abdomen, 
after  a  time,  and  spasms  of  it,  described  as  shoot- 


5° 


RENAL  CALCULUS. 


[January  io, 


ing,  ran  down  towards  the  left  side  of  the  pubis. 
After  lasting  for  a  few  hours  it  ceased  quite  as 
suddenly  as  it  began. 

During  the  presence  of  the  pain  the  patient  felt 
a  frequent  desire  to  pass  urine,  but  discharged 
only  a  tablespoon ful  or  so  at  every  attempt  to 
evacuate  the  bladder,  and  its  passage  was  accom- 
panied with  considerable  tenesmus  and  a  severe 
burning  pain.  When  the  attack  ended  the  urina- 
tion was  accomplished  easity  and  attended  with 
a  large  flow  of  urine. 

In  addition  to  the  agonizing  pain  which  marked 
the  onset  of  this  attack,  and  which  persisted  dur- 
ing its  continuance,  the  patient  suffered  from 
nausea  and  vomiting.  There  was  also  great  pal- 
lor of  countenance;  the  features  were  pinched; 
the  skin  was  bathed  in  clammy  perspiration;  and 
all  these  were  associated  with  symptoms  of  pro- 
found constitutional  disturbance  of  the  circula- 
tion and  nervous  system. 

This  aggregation  of  symptoms  accompany  the 
passage  of  a  renal  calculus,  or  kidney  stone,  from 
the  pelvis  of  the  kidney  into  the  ureter  or  through 
it  into  the  bladder. 

The  pain  commences  as  soon  as  the  stone  en- 
ters the  ureter,  and  does  not  cease  until  it  either 
falls  back  into  the  pelvis  of  the  kidney  or  is 
forced  by  the  accumulation  of  urine  behind,  aided 
by  the  contractions  of  the  muscular  fibers  of  the 
ureter,  through  the  length  of  this  tube  into  the 
bladder.  Knowing  this  you  can  readily  under- 
stand the  special  character  of  the  accompanying 
pain,  in  that  it  commences  suddenly  and  ends  as 
quickly.  This  cycle  of  events  is  termed  technic- 
ally an  attack  of  renal  colic. 

Remembering  that  there  is  a  fair  sized  cavity 
at  the  renal  end  of  the  ureter,  consisting  of  the 
pelvis  of  the  kidney,  and  a  very  large  cavity  at 
the  opposite  end,  in  the  shape  of  the  bladder,  you 
are  prepared  to  understand  how  a  stone  or  a  shred 
of  tubercular  tissue,  or  a  dense  clot  of  blood, 
may,  on  the  other  hand,  just  enter  the  ureter  and 
be  displaced  therefrom  by  some  sudden  movement 
of  the  patient.  The  renal  colic  caused  by  its  im- 
pinginent  in  the  ureter  suddenly  ceases  when  it 
falls  back  into  the  pelvis. 

As  well  can  you  understand  how  the  attack  of 
colic  is  far  more  severe  and  more  prolonged  if 
either  of  the  foreign  bodies  mentioned  is  com- 
pelled to  make  the  long  transit  through  the  en- 
tire ureter  into  the  bladder,  when  the  pain  will 
also  cease  suddenly. 

Such  like  attacks  of  colic  will  occur  at  intervals 
so  long  as  calculi  form  in  the  calices  of  the  kid- 
ney, and  are  displaced  therefrom,  and  take  up 
their  journey  to  the  bladder,  as  is  the  condition 
in  quite  a  number  of  individuals. 

Similar  attacks  may  occur  if  there  is  present  in 
any  patient  certain  other  pathological  conditions 
of  the  kidney,  such  as  tuberculosis,  or  cancer,  or 
papilloma,  etc.      It  is   true    also    that  calculous 


formations  are  very  apt  to  be  associated  with 
these  pathological  conditions. 

We  find  in  this  patient,  that  she  was  free  from 
any  return  of  the  attack  until  eighteen  months 
after  the  first  manifestation  described,  since  then 
she  has  suffered  from  them  as  often  as  once  in 
every  two  or  three  months.  Since  the  second 
attack,  the  urine  has  contained  gravelly  concre- 
tions of  urinary  salts,  some  of  them  of  consider- 
able size,  as  large  as  a  kernel  of  wheat,  or  larger. 
The  urine  has  shown  the  presence  of  pus  and 
blood  in  some  quantity;  of  late  the  pus  has  been 
present  in  large  quantities. 

The  patient's  general  health  has  suffered  very 
much,  until  now  she  is  emaciated,  weak  and 
broken  down  in  spirits  and  physical  strength,  and 
is  practically  a  confirmed  invalid. 

Some  time  ago  her  attending  physician,  while 
making  an  examination  of  the  painful  region  du- 
ring an  attack  of  colic,  discovered  a  tumor  occu- 
pying the  situation  of  the  left  kidney,  and  now 
you  can  see  this  tumor,  showing  as  a  slight  pro- 
jection of  the  abdominal  walls  on  the  left  side 
over  the  neighborhood  of  the  kidney.  It  is  quite 
easy  to  feel  it  with  the  fingers  of  one  hand  pressed 
against  the  tissues  between  the  last  rib  and  the 
crest  of  the  ilium,  while  the  other  hand  is  pressed 
against  the  front  of  the  abdominal  walls. 

It  is  slightly  movable,  semi-elastic,  smooth  and 
even  of  surface,  and  is  the  left  kidney  distended 
with  fluid  of  some  kind.  Probably  the  fluid  is 
pus,  as  such  a  large  quantity  of  this  material  is 
found  in  the  urine,  and  its  presence  is  due  to  in- 
fection with  the  pus  microbe  through  the  genito- 
urinary tract. 

It  is  my  belief  also,  that  there  is  present  one  or 
more  calculi,  and  this  is  based  upon  the  fact  that 
so  many  calculous  concretions  have  been  passed 
in  the  urine,  as  well  as  upon  the  fact  that  renal 
calculi  are  very  sure,  sooner  or  later,  to  be  accom- 
panied by  an  accumulation  of  pus  through  infec- 
tion. 

It  is  scarcely  possible  that  this  will  prove  to  be 
a  kidney  affected  with  tuberculosis  either  with 
or  without  a  stone,  because  it  is  unusual  to  have 
no  other  manifestations  of  the  tubercular  infec- 
tion than  is  present  in  this  one  kidney,  besides 
the  bacillus  of  tuberculosis  has  not  been  found. 

The  diagnosis  in  this  case  is  renal  calculus  with 
suppurating  kidney. 

It  is,  as  well,  certain  to  me  that  the  substance  and 
capswleof  thekidney  is  intact, because  had  destruc- 
tion of  these  taken  place  by  ulceration  or  tissue  ne- 
crosis, a  peri-nephritic  abscess  would  have  formed, 
with  the  usual  signs  of  accumulation  in  and  bulg- 
ing of  this  space  between  the  rib  and  ilium. 

A  few  days  ago,  we  had  occasion  to  direct  you 
that  whenever  a  patient  came  under  your  charge 
suffering  from  indications  of  bladder  disease,  never 
to  think  your  examination  is  complete  until  a  sound 
has  carefully  searched  every  portion  of  the  blad- 


I89i.] 


RENAL  CALCULUS. 


der  cavity.  In  this  case  we  have  an  additional 
caution  to  give:  never  to  be  satisfied  with  an  ex- 
amination of  a  case  of  disease  of  the  genito-urin- 
ary  apparatus,  without  a  rigorous  inquiry  into 
the  condition  of  the  kidneys,  by  resorting  to  in- 
spection and  palpation  of  the  organs  themselves, 
as  well  as  their  entire  neighborhood,  just  as  care- 
fully as  you  would  examine  their  secretions  mi- 
croscopically, and  by  all  known  tests,  for  evidence 
of  change  from  normal  condition. 

In  all  these  operations  the  primary  incision  to  ex- 
pose the  kidney  is  made  in  exactly  the  same  way, 
and  all  the  steps  will  be  illustrated  to  you  upon 
this  patient;  and  as  we  will  no  doubt  find  a  calculus 
and  remove  it — this  will  be  a  nephrolithotomy. 

The  direction  is  given,  in  order  to  make  the 
diagnosis  in  such  cases  absolute,  to  sound  the 
kidney  by  means  of  an  exploring  needle  carried 
into  the  substance  of  the  kidney,  with  the  hope 
of  having  it  come  in  contact  with  the  stone — to 
strike  the  stone  as  it  is  termed — a  very  positive 
confirmation,  if  it  can  be  elicited.  It  is  even  ad- 
vised to  go  so  far  as  to  introduce  the  needle  into 
the  organ  in  several  different  directions  for  this 
purpose;  and  the  trial  has  often  been  made  before 
the  primary  incision  uncovers  the  kidney,  but  of 
course  oftener  with  failure  than  with  success  at- 
tending its  practice. 

Even  after  the  kidney  is  to  be  seen  at  the  bot- 
tom of  the  external  wound,  the  exploring  needle, 
or  the  probe,  or  even  the  finger  introduced  into 
the  pelvis  of  the  kidney  or  through  its  substance, 
sometimes  fails  to  find  the  calculus;  especially 
when  it  is  small  and  hidden  in  an  expanded 
calyx.  Consequently  you  are  not  to  conclude 
hastily  thai:  there  is  no  stone  present  if  this  test 
fails  even  when  the  kidney  itself  is  under  inspec- 
tion; certainly  not,  if  the  trial  does  not  deter- 
mine its  presence  when  the  instrument  is  intro- 
duced without  an  incision. 

Given  pointed  and  unmistakable  evidence  ofthe 
foreign  body,  as  indicated  by  the  occurrence  of 
repeated  attacks  of  renal  colic. — with  deep-seated 
and  continuous  pain  referred  to  one  kidney — 
with  pus  or  blood  or  both,  in  the  urine,  even  in 
comparatively  small  quantities,  yet  constantly 
discoverable:  with  the  history  of  the  passage  of 
concretions  of  urinary  salts;  certainly  if  several, 
or  all,  of  these  signs  are  present  in  a  marked  de- 
gree, the  surgeon  is  justified  in  exposing  the  kid- 
ney and  incising  its  walls  freely,  in  order  that  the 
pelvis  can  be  explored  in  all  directions  and  por- 
tions, by  the  finger — truly  the  only  reliable  probe. 

It  is  true  that  even  this  crucial  procedure  some- 
times fails  to  bring  forth  the  calculus  or  to  dis- 
cover its  presence  The  kidne3f  has  been  ex- 
posed a  number  of  times  and  the  pelvis  explored 
without  finding  a  stone.  The  renowned  Mr. 
Henry  Morris,  of  England,  relates  a  case  in 
which  failure  followed  his  search,  but,  so  well 
convinced  was  he  of  the  presence  of  the  foreign 


body,  on  account  of  the  marked  symptoms  of  his 
patient,  that  he  proceeded  to  do  a  nephrectomy 
and  found  the  stone  in  one  of  the  calices  of  the 
after  the  organ  had  been  removed  from 
the  body.  Mr.  Morris  was  among  the  first,  if  not 
the  first,  to  diagnose  the  presence  of  a  stone  in 
the  human  kidney  and  to  deliberately  plan,  and 
successfully  execute,  an  operation  for  its  removal. 

It  has  happened  to  me  to  fail  to  find  a  calculus 
on  two  occasions.  In  one  a  large  calculus  had 
been  removed  from  the  other  kidney  a  year  pre- 
viously; in  the  other  it  seemed  certain  that  the 
stone  was  lodged  low  down  in  the  ureter.  We 
may  be  able  to  get  at  it  yet. 

If  an  operation  is  done  merely  to  expose  the 
kidney  and  incise  it,  the  operation  is  termed  a 
nephrotomy.  If,  in  addition,  the  operation  is  done 
to  remove  a  calculus  from  the  kidney,  it  is  termed 
nephrolithotomy.  If  the  operation  is  to  relieve 
•the  distressing  symptoms  due  to  the  extreme  mo- 
bility of  the  organ,  called  a  movable  kidney,  in 
which  the  organ  is  first  exposed  and  then  fastened 
in  some  way  to  the  edges  of  the  wound,  it  is 
termed  a  nephrorraphy.  If  the  operation  is  done 
to  remove  the  entire  kidney  through  the  tissues 
of  the  back,  it  is  termed  lumbar  nephrectomy. 

Prognosis. — The  successful  ending  ofthe  many 
operations  already  done  and  being  done  upon  the 
kidney  for  a  variety  of  diseases,  is  leading  sur- 
geons to  the  conclusion  that  the  operations  are 
not  especially  hazardous.  My  own  experience, 
embracing  all  the  operations  performed  upon  this 
organ,  and  including  several  repetitions  of  some 
of  them,  points  in  the  same  direction.  There  has 
been  but  one  death,  and  that  followed  the  most 
formidable  of  them — a  nephrectomy  for  a  greatly 
enlarged  suppurating  kidney.  All  of  the  opera- 
tions short  of  nephrectomy  have  ended  favorably 
and  with  rapid  recovery.  The  simpler  procedures 
of  exposing  and  exploring  the  organ  are  not  at- 
tended with  much  danger,  if  such  rigorous  asep- 
tic precautions  are  taken  as  are  recognized  by 
even-  surgeon  as  necessary  in  all  operations. 

You  understand  that  the  incisions  which  we 
will  make  in  this  case,  are  exactly  the  same  in 
ever},-  respect  as  those  which  are  necessary  for  the 
execution  of  a  nephrotomy,  a  nephrorraphy  or  a 
nephrectomy.  The  external  incision  should  be 
about  four  inches  in  length,  and  made  parallel 
with  the  last  rib  and  fully  half  an  inch  below  its 
lower  border;  commencing  posteriorly,  a  little 
behind  the  prominent  ridge  marking  the  external 
border  of  the  erector- spinas  muscle.  The  course 
of  the  incision  should  always  be  made  as  directed, 
at  the  distance  mentioned  below  the  border  of 
the  last  rib,  on  account  of  the  dangers  of  open- 
ing the  pleural  cavity  in  any  case  in  which  the 
pleura  descends  below  that  rib  or  in  such  cases 
as  there  is  present  a  supernumerary  rib,  or  in 
which  one  rib  is  absent,  and  the  normal  relations 
:  of  the  pleura  thereby  altered. 


52 


MEDICAL  PROGRESS. 


[January  io, 


The  patient  should  be  placed  in  the  position 
here  illustrated,  on  the  sound  side,  with  a  tightly- 
rolled  pillow,  covered  with  an  oil-cloth  having  an 
aseptic  towel  over  it,  placed  under  the  opposite  loin; 
thus  the  side  to  be  operated  upon  will  be  made 
very  prominent,  and  the  interval  between  the  rib 
and  the  crest  of  the  ilium  increased  to  its  fullest 
extent. 

The  first  incision  should  be  carried  with  a  free 
hand  through  all  the  tissues  and  fasciae  down  to 
the  anterior  layer  lumbar  fascia.  The  length  of 
the  incision  through  the  deep  tissues  being  the 
same  as  that  through  the  skin.  The  operator 
should  avoid  opening  the  sheath  of  the  erector- 
spinae  muscle.  All  bleeding  vessels  are  secured. 
The  anterior  layer  of  the  lumbar  fascia  is  then 
opened  and  divided  to  the  extent  of  the  wound. 
As  soon  as  this  is  done,  there  will  bulge  into  this 
opening,  the  peri-nephritic  tissue  in  which  the 
kidney  rests.  Its  investing  connective  tissne 
should  be  opened  and  the  operator  will  then 
readily  recognize  the  peculiar  white  fat  surround- 
ing this  organ.  A  portion  of  this  fat  ma}'  be 
pulled  out  and  snipped  away,  or  its  spaces  opened 
and  torn  by  the  fingers,  as  you  now  see  me  do, 
after  which  the  kidney  can  be  readily  felt  by  the 
finger  or  seen  with  the  eye,  as  a  darkish  red  body, 
moving  slowly  up  and  down  with  each  respira- 
tory act. 

If  the  kidney  is  not  now  easily  found,  as  is  fre- 
quently the  case  if  it  is  not  enlarged  to  any  ex- 
tent, it  can  be  hrought  into  view  sometimes  by  a 
simple  procedure.  An  assistant  introduces  two 
fingers  into  the  wound  and  pulls  strongly  upward 
against  the  last  rib.  This  widens  the  wound  and 
at  the  same  time  stretches  the  peri  nephritic  tis- 
sues towards  the  wound.  The  assistant  with  his 
disengaged  hand  should  also  press  strongly  back- 
wards through  the  anterior  abdominal  wails  over 
the  region  of  the  kidney,  thus  pushing  it  into  the 
wound. 

The  space  for  operative  manipulations,  in  cases 
of  enlarged  kidney,  can  be  greatly  increased,  and 
with  safety,  by  a  vertical  incision  commencing 
in  the  one  already  made,  and  carried  downwards 
towards,  and  forward  parallel  with,  and  close  to 
the  crest  of  the  ilium.  With  the  finger  deep  in 
the  wound  as  a  guide,  this  latter  incision  can  be 
rapidly  made  without  danger  of  opening  the 
peritoneum. 

It  was  used  upon  one  occasion  successfully  by 
myself  in  the  removal  of  a  kidney  enlarged  to  the 
size  of  a  cocoanut;  and  made  a  space  large 
enough  for  all  the  necessary  manipulations  with- 
out difficulty. 

After  the  kidney  is  exposed  in  the  manner  de- 
scribed and  brought  fairly  under  the  touch  of  the 
and  the  sight  of  the  eye,  by  the  removal 
of  its   investing  fat,  the  next  step  will  depend 
upon  the  operation  which  is  being  performed. 
In  this  case  the  object  is  to  remove  a  stone  from 


the  kidney  and  evacuate  what  other  accumula- 
tions may  be  present.  So  we  will  now  first  in- 
troduce the  finger  into  the  wound  and  palpate 
the  kidney  over  its  anterior  and  posterior  surfaces, 
reaching  as  far  beyond  the  pelvis  as  possible  in 
both  directions. 

The  best  command  of  the  kidney  can  be  ob- 
tained in  these  cases,  by  the  finger  passed  over 
its  posterior  surface.  The  finger  used  in  this 
way  will  sometimes  detect  the  stone  in  the  kid- 
ney, or  determine  a  noticeable  bulging  and  hard- 
ness in  some  portion  of  its  surface  which  may  in- 
dicate its  presence. 

( To  be  concluded.) 


MEDICAL    PROGRESS. 


Therapeutics  and  Pharmacology. 

Remarks  on  Laparotomy  for  Peritoneal 
Tuberculosis.  —  Lauenstein  (Centralblatt  fin 
Chirurgie)  thinks  that  it  is  remarkable  that  the 
usefulness  of  this  operation  should  have  been  ac- 
cidentally discovered,  and  that  it  should  have  been 
practiced  empirically  to  the  extent  which  it  has. 
He  would  refer  the  good  effects  to  two  facts  in 
the  life  history  of  the  bacillus :  it  requires  mois- 
ture, and  is  rapidly  killed,  even  by  a  few  minutes' 
exposure  to  the  direct  rays  of  the  sun.  He  thinks 
that  both  of  these  factors  may  explain  some  of 
the  good  effects.  In  operating  he  allows  the  di- 
rect rays  of  the  sun  to  fall  upon  the  abdomen  and 
its  contents.  Of  course,  the  operation  relieves 
the  ascites  always  present  in  these  cases,  and  so 
lessens  the  amount  of  fluid  surrounding  the  tu- 
bercular process. 

Effect  of  Strychnine  on  the  Cerebral 
Cortex. — For  years  strychnine  has  been  used  in 
certain  convulsive  disorders,  especially  epilepsy, 
not  only  alone  but  as  an  ingredient  in  several  pop- 
ular formulas.  Its  value  has  been  questioned  by 
many,  but  it  has  been  held  to  be  of  use  by  several 
eminent  clinicians. 

Recently  Biernacki  (Therap.  Monatshe/te,  Au- 
gust, 1890)  by  his  experiments  has  thrown  con- 
siderable light  on  the  action  of  this  drug.  The 
first  of  these  experiments  related  to  the  action  of 
the  drug  when  given  hypodermically.  The  ani- 
mal was  first  trephined,  and  after  waiting  for  the 
normal  excitability  to  return,  a  dose  of  strychnia 
was  given.  It  was  found  that  a  current  which 
would  produce  violent  tetanic  spasms,  would  under 
strychnia  be  reduced  to  a  faint  tremor.  The  de- 
gree of  reduction  was  directly  dependent  upon 
the  dose  employed.  A  second  series  of  experi- 
ments was  made,  in  which  the  strychnia  was  di- 
rectly applied  to  the  cortex.  At  first  marked 
contraction  of  the  vessels  was  produced,  which 
soon  passed  off.     The  effect  on   electrical  excita- 


i89i.] 


MEDICAL  PROGRESS. 


53 


bility  was  the  same  as  when  the  drug  was  inject- 
ed under  the  skin.  Compared  with  cocaine  or 
morphine,  when  directly  applied  to  the  cortex, 
the  effect  of  strychnia  is  very  slow,  it  taking  from 
twenty-seven  to  thirty  minutes  for  its  action  to 
appear,  and  in  each  instance  symptoms  of  spinal 
irritation  appeared  before  the  depressing  effects 
of  the  strychnia.  From  these  facts  the  author 
argues  that  strychnia  does  not  directly  depress 
cortical  activity,  but  only  indirectly  by  stimula- 
ting the  action  of  the  cord. 

Certainly  the  observations  are  of  interest,  as 
they  furnish  an  objective  basis  for  a  treatment 
that  has  been  heretofore  employed  empirically. 

Galactorrhcea. — Braun  (L'  Union  Midicale) 
recommends  in  excessive  secretion  of  milk  the  ap- 
plication of  a  compressing  bandage  to  the  breasts, 
low  diet,  interdiction  of  beer,  derivation  to  the 
intestine  by  means  of  a  saline  purgative.  In  case 
these  measures  prove  ineffective  the  following 
mixture  may  be  given  : 

ft.     Iodide  of  potassium,  2. 
Syrup  raspberry,  20. 
Distilled  water,  100. 

Sig.     A  tablespoonful  three  times  daily. 

Quinine  in  Sea  Sickness. — Richert  has  rec- 
ommended large  doses  of  sulphate  of  quinine  as 
a  specific  in  seasickness.  Recently  one  of  his 
pupils  has  written  him  a  letter  (Marcel  Boudovin, 
Le  Progrcs  Medical  \  in  which  he  notes  the  utter 
inefficacy  of  this  treatment  in  his  own  case.  It  is 
to  be  noted,  however,  that  Boudovin  did  not  fol- 
low strictly  the  injunctions  of  the  teacher  to  re- 
main as  quiet  as  possible  in  the  recumbent  position. 

SanTONINOxime. — This  is  the  name  of  a  sub- 
stance  prepared  by   M.    Cannizzaro  (/our.  de 
Med.  de  Paris)  by  the  action  of  chlorhydrate  of 
hydroxylatnine  on  santonine.     Santoninoxime  is  , 
a  white  crystalline  substance,  soluble  in  alcohol 
and  ether,  but  dissolving  in  water,  whether  acid  | 
or  alkaline,  with  difficulty.      C.  M.  Coppola  has 
found  that  this  substance  possesses  the  same  ac- 
tion in  the  intestine  as   santonine,  but  owing  to ! 
its  lessened  solubility  it  is  much  less  poisonous, 
and  it  should  therefore  be  preferred  to  the  santo- 
nine.     Its  dose  as  an  anthelmintic  is  three  times 
as  large  as  that  of  santonine. 

Medicine. 

Pruritus  Essentia  lis. — Feinberg  {Central- 
Matt  fur  Gyntzkologie)  describes  two  cases  of 
idiopathic  pruritus. 

On  the  1st  of  April,  18S8,  F.  was  consulted  by 
a  young  woman,  who  requested  that  she  might 
be  given  a  certificate,  to  the  effect  that  she  was 
not  affected  with  any  venereal  disease.  The 
woman  had  been  married  two  months,  and  was 
suffering  from  an  intense  pruritus  of  the  external 
genitals  and  adjacent  parts.     The  itching  caused 


intense  mental  depression.  It  appeared  to  be 
connected  with  menstruation,  coming  on  a  day 
or  two  before,  and  disappearing  a  couple  of  days 
after  each  period.  An  examination  showed  a 
pale  mucosa,  with  abundant  marks  of  old  and 
recent  excoriations  on  the  external  genitals. 
The  deep  mucosa  was  in  consistence  and  general 
appearance  normal,  but  very  sensitive  to  the 
touch  (hyperaesthetic).  The  author  having  ex- 
cluded all  other  causes  came  to  the  conclusion 
that  he  had  to  deal  with  a  purely  nervous  dis- 
turbance. He  prescribed  bromide  of  potassium 
internally  with  the  application  of  a  hot  solution 
(1:4000)  of  corrosive  sublimate  to  the  external 
genitals.  The  patient  improved,  and  he  saw 
nothing  of  her  until  eleven  months  later,  when 
he  was  again  called  and  found  a  frightful  pru- 
ritus that  had  extended  from  the  pudendum 
almost  over  the  entire  body.  This  had  come  on 
during  delivery  ;  after  a  few  days  it  subsided  and 
not  again  return. 

A  second  case  was  that  of  a  multipara  who  for 
the  past  two  years  had  suffered  from  vaginal 
pruritus  during  menstruation.  During  an  abor- 
tion the  pruritus  had  extended  over  the  body, 
but  it  ceased  as  soon  as  the  fcetus  was  expelled. 
In  consequence  of  a  severe  mental  emotion  she 
was  taken  with  uterine  haemorrhage,  which  was 
followed  by  a  severe  general  pruritus.  Feinberg 
found  the  patient  sitting  on  the  side  of  the  bed 
in  great  agitation,  scratching  first  one  portion  of 
the  body  and  then  another,  convinced  that  an 
abortion  was  about  to  take  place. 

The  writer  thinks  that  in  these  two  cases,  we 
have  examples  of  nervous  pruritus  not  dependent 
on  secondary  causes.  This  position  is,  however, 
negatived  by  some  writers  who  thinks  that  pru- 
ritus essentialis  has  no  existence. 

Acute  Purpura. — Zanetti  (Atti e Rendiconti 
della  Academia  Medico  Chirurgica  di  Perugia)  re- 
ports the  case  of  a  woman  23  years  of  age,  who 
had  had  pains  in  the  lumbar  region  and  buttocks, 
associated  with  slight  cephalalgia  for  some  time. 
Of  late  these  symptoms  had  become  worse,  and 
at  the  time  he  saw  the  patient  intense  pain  had 
developed  in  the  sacral  region,  attended  by  con- 
siderable prostration,  elevation  of  temperature, 
(38.4  C.)  haemateinesis,  sub  conjunctival  haemor- 
rhages, punctiform  haemorrhages  on  the  arms, 
buttocks  and  neck,  lenticular  haemorrhages  on 
the  belly,  genitals  and  inner  surface  of  the  thighs. 
The  cutaneous  haemorrhages  extended  rapidly 
accompanied  by  haematuria  and  metrorrhagia, 
followed  by  death  from  syncope  on  the  third  day. 
The  autopsy  revealed  extensive  sub- peritoneal 
haemorrhages  with  extravasation  into  the  peri- 
toneal cavity  and  ventricles  of  the  brain,  in- 
testinal haemorrhage,  spleen  slightly  enlarged 
and  friable,  beginning  fatty  degeneration  of  the 
liver. 


54 


MEDICAL  PROGRESS. 


[January  io, 


In  the  absence  of  all  signs  of  poisoning  and  of 
general  conditions  capable  of  explaining  the 
multiple  haemorrhages,  the  author  arrives  at  the 
conclusion  that  the  case  is  one  of  morbus  macu- 
losus  Werloffi,  notwithstanding  that  the  course  of 
this  disease  is  ordinarily  chronic,  and  the  termina- 
tion favorable. 

Cancerous  Strictures  of  the  (Esophagus. 
— The  problem  of  feeding  a  patient  in  deep 
seated  carcinomas  of  the  oesophagus  is  very  diffi- 
cult ;  gastrostomy  has  been  tried,  but  it  is  a 
delicate  and  dangerous  operation,  and  one  that 
can  never  in  any  way  prove  popular  because  it  is 
not  in  any  sense  curative.  The  introduction  of 
a  permanent  sound  that  shall  keep  the  stricture 
dilated  and  through  which  the  patient  may  be 
fed,  has  been  attended  with  success.  Recently 
an  article  in  the  Lyon  Medical,  {Gazette  Midicale 
.  i  favors  the  permanent  sound,  claiming 
that  it  is  easily  introduced  if  done  sufficiently 
early.  The  writer  of  this  article  prefers  the  long, 
soft  sound  with  stylet  to  the  short,  hard  canulas 
recommended  especially  by  some  German  writers. 
The  chief  dangers  are  from  haemorrhage  and 
ulceration.  The  writer  uses  a  long,  soft  sound 
that  is  brought  out  of  the  nose.  At  first  it  ex- 
cites considerable  reflex  spasm  and  may  cause 
vomiting,  but  the  parts  soon  become  accustomed 
to  the  foreign  body,  which  then  causes  no  further 
trouble. 

Surgery. 

Brain  Abscess,  Aphasia,  Operation. — A. 
Sanger  and  C.  Sick  (Deut.  Med.  Wochenschr. 
Centralblatt fur  Klin.  Med.)  describe  an  interest- 
ing case  of  brain  abscess  with  operation.  A  man 
52  years  of  age,  with  left-sided  chronic,  purulent 
otitis  media,  had  an  exacerbation  of  his  trouble 
— severe  pain  in  the  left  ear  and  side  of  head,  dis- 
turbance of  the  general  health,  pressure  symptoms 
and  disturbance  of  speech,  characterized  by  for- 
getfulness  of  words  and  clumsiness  of  expression. 
The  patient  expressed  his  ideas  frequently  in 
writing.  Later  choked  disc  presented  itself,  with 
left  facial  paresis.  A  diagnosis  of  circumscribed 
abscess  in  the  left  temporal  lobe  was  made.  An 
operation  was  performed,  and  by  the  exploratory 
puncture  1  drachm  of  thick  pus  was  removed  from 
sterior  third  of  the  left  frontal  convolution. 
After  the  operation  the  patient's  speech  ami  gen 
eral  condition  improved.  At  the  end  of  a  few 
months  the  patient  was  apparently  as  well  as  ever. 
with  the  exception  of  a  slight  weakness  of  memory. 

Subacute  Cervical  Adenitis  of  Intestinal 
Origin.  —  M.  Nicaise  {Revue de  Chirurgie,  Sep- 
tember 10,  1890)  last  \ear  attended  a  woman, 
aged  So.  who  suffered  from  a  swelling  in  the  right 
supraclavicular  region.  The  >kin  was  violaceous, 
tense  at  certain  points,  and  on  palpation  obscure 
fluctuation  could  be  felt.      Pain  was  severe,  and 


the  arms  could  not  be  moved.  The  swelling  had 
lasted  for  three  months;  it  began  during  convales- 
cence from  severe  enteritis,  and  the  patient  had 
never  regained  her  former  health.  Three  separate 
lymphatic  glands  had  first  been  affected,  and  they 
had  slowly  increased  till  they  formed  one  tumor. 
At  first  the  disease  looked  like  simple  degenera- 
tion of  the  glands,  and  it  was  long  before  any 
fluctuation  could  be  felt.  An  exploratory  punc- 
ture was  made,  and  pus  exuded,  confirmiug  M. 
Nicaise's  diagnosis  of  suppurative  adenitis.  Then 
an  incision  was  made.  The  pus  was  thick ;  the 
cavity  whence  it  issued  was  tortuous.  A  counter- 
opening  was  made,  the  cavity  was  washed  out 
with  an  antiseptic  solution  and  drained,  and  cov- 
ered with  antiseptic  dressings.  Cicatrization  was 
very  rapid,  although  the  patient  was  so  old,  and 
she  regained  her  health  as  before  the  enteritis. 
The  adenitis  seemed  to  be  a  kind  of  critical  phe- 
nomenon which  freed  the  organism  from  the  poi- 
son with  which  it  had  been  infected  in  the  course 
of  the  intestinal  disease.  Chronic  adenitis  of  the 
cervical  glands  is  not  rare  in  old  age ;  any  other 
disease  predisposes  them  to  inflammation.  Troi- 
sier has  already  pointed  out  that  enlargements  of 
the  cervical  glands  are  sometimes  observed  in 
cases  of  cancer  of  one  of  the  abdominal  viscera, 
and  M  Nicaise  has  diagnosed  the  latter  condition 
through  the  presence  of  enlarged  lymphatics  in 
the  neck. — Brit.  Med.  Jour. 

Obstetrics  and  Disease*  of  Women. 

Immediate  Repair  of  the  Perineum. — T. 
H.  Hance,  M.D.,  in  a  paper  read  before  the  New 
York  Academy  of  Medicine,  advocated  the  im- 
mediate repair  of  injuries  to  the  pelvic  floor, 
where  the  laceration  had  not  extended  through 
into  the  rectum,  that  is,  in  cases  where  there  was 
either  a  clean  cut  through  the  perineum,  or 
through  the  skin  and  perineum  to  one  side  or 
other  of  the  median  line.  In  those  cases  where 
the  posterior  vaginal  wall  had  been  ruptured 
without  laceration  of  the  skin,  the  operation  also 
offered  good  results.  He  thinks  that  there  ought 
to  lie  110  difficult}'  in  recognizing  the^e  incomplete 
lacerations  at  or  just  before  delivery  (by  digital 
examination)  thus  gaining  time  to  make  prepara- 
tions to  repair  them  at  once.  He  introduces  the 
first  suture  high  up  in  the  vagina  above  the  tear, 
in  order  to  avoid  the  formation  of  pockets;  he  also 
thinks  that  this  method  offers  the  best  results  for  the 
restoration  of  the  pelvic  floor.  If  the  laceration  has 
extended  up  on  both  sides,  they  are  to  be  repaired 
separately.  The  patient's  legs  are  kept  tied  to- 
gether for  twenty  four  hours  after  the  operation, 
and  the  bowels  are  moved  on  the  third  day.  He 
says  that  two  points  ought  to  be  closely  observed 
in  order  to  insure  success,  that  is  the  careful 
adaptation  of  the  lips  of  the  wound,  numbering 
the  sutures  to  individual  requirements;  and 
secondly,  the  observance  of  strict  antiseptic  pre- 


i89i.] 


MEDICAL  PROGRESS. 


55 


cautions,  including  the  use  of  antiseptic  douches 
before  and  after  the  operation,  antiseptic  pad,  etc. 
All  members  taking  part  in  the  discussion  ex- 
pressed themselves  as  in  favor  of  immediate  op- 
eration.— Archives  of  Gynecology. 

Treatment  of  Inoperable  Uterine  Car- 
cinoma with  Chloride  of  Zinc. — Haberlin 
(Correspondenz-blatt  fur  Schwt .  recom- 

mends the  use  of  a  paste  composed  of  chloride  of 
zinc.  He  agrees  with  Meyer.  Schrceder  and  Leo- 
pold that  the  total  extirpation  of  the  carcinoma- 
tous uterus  presents  about  all  that  is  required  for 
an  operation  both  in  its  effectiveness  and  mortal- 
ity, he  also  agrees  with  Leopold  that  in  the  cases 
in  which  we  have  a  recurrence,  the  disease  is 
milder  and  more  easily  endured.  It  is,  however, 
in  those  cases  in  which  the  cancerous  process  has 
affected  other  organs  and  a  certain  amount  of 
affected  tissue  must  be  left  that  it  is  well  to  study 
the  effect  of  other  remedies.  He  places  the  mor- 
tality of  these  cases  at  20  per  cent,  or  over.  Kal- 
tenbach  claims  that  even  where  a  considerable 
portion  of  the  morbid  growth  is  left  an  operation 
is  still  justified,  as,  by  that  means,  the  pain,  dis- 
charge and  itching  are  lessened,  while  sleep  and 
appetite  are  improved,  thus  rendering  life  more 
endurable.  The  same  result  can  be  achieved  by 
a  less  blood}-  and  safer  operation,  which  may  be 
employed  in  cases  in  which  total  extirpation  is 
out  of  the  question. 

The  author  gives  the  histories  of  five  patients 
that  amply  attest  the  correctness  of  his  views. 
They  were  all  treated  by  the  application  of  chlor- 
ide of  zinc  paste,  and  in  each  case  there  was 
marked  amelioration  in  the  local  symptoms  and 
improvement  in  general  health.  In  only  one 
case  did  severe  haemorrhage  follow,  and  that  was 
one  in  which  the  patient  was  allowed  to  leave 
the  clinic  before  cicatrization  was  complete.  Dis- 
charges were  greatly  lessened  in  each  case,  and 
in  some  they  ceased  entirely. 

Chloride  of  zinc  has  been  used  in  the  form  of 
solution  and  as  paste.  A.  Martin  tried  as  early 
as  1879  the  paste  recommended  by  Labbe  (chlor- 
ide of  zinc  and  starch,  equal  parts).  Yobwinkel 
used  a  similar  mixture  composed  of  chloride  of 
zinc  four  parts,  farina  three  parts,  oxide  of  zinc 
one  part.  Ely  van  dc  YVarker  in  1SS4  recom- 
mended solutions  of  30  and  50  per  cent.  From 
the  observations  of  Ehlers  it  is  clear  that  the 
proper  localization  of  the  remedy  is  very  difficult 
if  it  is  in  solution.  For  these  reasons  the  writer 
has  confined  his  experience  to  the  use  of  a  paste 
which  is  made  by  rubbing  equal  parts  of  chloride 
of  zinc  with  a  small  quantity  of  water.  A  quan- 
tity corresponding  to  the  defect  to  be  treated  is 
placed  upon  a  cotton  tampon,  and  carried  into 
the  cervix.  To  fix  the  tampon  and  protect  the 
vagina  iodoform  gauze  is  placed  about  the  cervix. 
The  time  that  the  tampon  is  allowed  to  remain 


varies  according  to  the  reaction;  after  it  is  re- 
moved the  vagina  is  irrigated  with  an  antiseptic 
solution.  The  technic  of  the  operation  is  of  the 
simplest. 

What  is  the  danger  of  this  operation  ?  A. 
Martin  has  observed  cauterization  of  the  bladder, 
rectum  and  perforation  of  the  peritoneum;  one 
patient  died  from  haemorrhage.  The  author's 
patients  have  for  the  most  part  borne  the  opera- 
tion well,  notwithstanding  the  cauterizations 
have  been  very  energetic;  it  is  naturally  difficult 
to  determine  just  how  deep  to  go;  but  they  have 
been  governed  to  some  extent  by  the  amount  of 
pain  produced;  if  greater  than  could  be  overcome 
by  an  injection  of  0.01  of  muriate  of  morphia,  the 
tampon  is  removed,  when  if  it  is  found  that  the 
action  has  not  been  sufficient,  it  is  again  renewed. 

Five  to  eight  days  after  the  application  of  the 
paste,  a  thick  (5  mm.)  eschar  separates,  leaving 
a  granulating  surface  that  bleeds,  when  touched, 
but  not  spontaneously.  While  the  theory  of 
Van  de  Warker  that  zinc  chloride  has  a  SDecific 
action,  in  that  it  coagulates  carcinomatous  tissue, 
and  produces  an  inflammation  in  normal  tissue, 
has  been  negatived  by  Ehlers,  yet  it  is  equally 
true  that  it  is  the  very  best  cauterant  that  can  be 
used,  as  no  other  produces  so  perfect  an  eschar. 

The  writer  closes  with  the  following  sentences: 
"In  cases  of  carcinoma  where  all  of  the  diseased 
tissue  cannot  be  removed  the  hope  of  improve- 
ment is  very  slight  as  compared  with  the  dan- 
gers of  the  operation.  My  own  cases,  while  few 
in  number,  prove  that  we  have  a  simpler  and  less 
dangerous  method  in  these  doubtful  and  certain- 
ly inoperable  cases,  from  which  the  most  favor- 
able results  may  be  expected.  While  we  exclude 
total  extirpation  as  a  palliative  measure,  we  must 
not  stand  with  our  hands  in  our  laps,  but  begin 
a  careful  palliative  treatment  in  the  use  of  chlor- 
ide of  zinc  that  is  capable  of  giving  to  these  pa- 
tients many  comfortable  days,  even  when  the 
circumstances  are  relatively  unfavorable." 

Ophthalmology. 

A  Case  of  Double  Sided  Hemianopsia. — 
Forster  ([ahres-Berichf  der  Schlcsischcn  Gesell- 
schaft  fur  vaterlandische  Culture,  1890)  describes 
the  case  of  a  postal  secretary  who  had  suffered 
from  right  haemianopsia  for  four  years  without 
any  disturbance  of  the  general  health.  The  di- 
viding line  between  the  defective  and  functionary 
halves  of  the  visual  fields  was  in  a  vertical  meri- 
dian, though  it  deviated  about  20  toward  the 
right  or  affected  side.  The  patient  had  continued 
his  occupation  notwithstanding  the  visual  defect, 
but  in  August,  1SS9,  he,  in  the  course  of  three 
days,  lost  vision  in  the  left  half  of  the  field,  also 
without  any  disturbance  of  the  general  health. 
In  November  the  patient  when  moving  presented 
the  appearance  of  one  totally  blind.  Examination 
showed  a  visual  field  of  30  horizontal  and  2 :  ver- 


56 


MEDICAL  PROGRESS. 


[January  io, 


tical,  at  the  fixed  point,  with  acuity  of  vision 
about  one-third.  Four  months  after  the  second 
attack  the  papilla  optica  did  not  present  a  trace 
of  atrophy.  Optical  memory  was  good,  though 
the  color  sense  was  completely  absent,  as  was  the 
ability  to  grasp  or  reproduce  topographical  con- 
ditions {topographische  I  "brslellungen) — this  last 
defect  was  so  great  that  the  patient  after  some 
weeks  was  not  orientated  in  his  own  room;  fur- 
ther, he  was  unable  to  reproduce  the  boundaries 
of  countries  or  the  routes  that  he  had  frequently 
traveled.  The  author  regards  the  condition  as 
due  to  a  thrombus  of  the  cortical  vessels.  The 
deviation  of  the  dividing  line  towards  the  defec- 
tive side  which  is  often  observed  in  haemian 
opsia,  he  attributes  not  to  a  mixing  of  the  nerve 
elements  at  the  fixation  point,  but  to  a  richer 
blood  supply  in  the  cortex  corresponding  to  the 
greatest  acuity  of  vision.  The  case  further  teaches 
that  in  the  occipital  lobe  we  have  the  seat  of  the 
topographical  remembrance  and  not  that  of  visual 
memory. 

The  Corrosive-Sublimate  Treatment  of 
Granular  Conjunctivitis. — The  treatment  of 
different  forms  of  granular  conjunctivitis  with 
various  strengths  of  corrosive  sublimate  solution 
seems  to  have  given  good  results  in  the  hands  of 
Guaita  {Annates  d'oculistique).  The  details  of 
the  treatment  are  published  in  the  I  'nion  Midicale. 
The  sublimate  is  used  in  strengths  of  from  I  to 
300  to  1  to  500,  and  is  applied  to  the  palpebral 
conjunctiva  with  a  camel'shair  brush  every  two 
hours,  or  according  to  the  severity  of  the  case.  If 
the  disease  is  slight,  a  collyrium  of  1  to  1,000  is 
given.  There  have  been  no  symptoms  of  poison- 
ing or  complications  to  the  cornea  from  this 
method,  but  very  prompt  amelioration  of  the 
symptoms  has  followed  its  employment  in  every 
instance. — N.   Y.  Med.  Journal. 

Physiology  . 

Investigation  on  the  Sense  of  Taste. — 
Oehrwai.i.  {Skandin.  Arck.f.  Physiol,  II,  p.  1, 
1890)  like  other  observers,  recognizes  four  kinds 
of  taste,  namely,  sweet,  saline,  bitter  and  acid. 
There  does  not  seem  to  be  any  transition  between 
these  four  varieties,  so  that  the  author  regards 
the  differences  between  them  as  those  of  modality, 
and  not  as  qualitative  differences  of  one  sense. 
When  cocaine  was  applied  to  the  tip  of  the 
tongne  the  sensibility  for  adequate  stimuli,  that 
is,  sapid  bodies,  disappeared,  and  even  tin  elec 
trical  current  failed  to  excite  a  sensation  of  taste. 
It  is  remarkable,  however,  that  there  remained 
only  a  sensation  of  heat  or  cold.  The  chief  part 
of  the  communication  deals  with  punctiform 
stimulation  of  the  individual  papillae  by  means 
of  fine  brushes.  There  are  marked  functional 
differences  amongst  the  papillae.  The  fungiform 
papillae  are  excessively  sensitive  to  tactile,  ther- 
mal,   and    cold    impressions,    so   that    by    simply 


touching  one  such  papilla  a  very  complex  sensa- 
tion results,  first  that  of  contact,  nearly  simul- 
taneously cold,  and  then  the  taste  sensation  fol- 
lows. Electrical  stimulation  may  excite  acid  or 
other  tastes.  Goldscheider  and  Schmidt  have 
also  investigated  this  subject  {Ccntralhlatt  f. 
Physiol.,  vol.  iv.  No.  1,  1890).  They  find  that 
certain  parts  lying  between  the  papillae  do  not 
excite  the  sensation  of  taste,  and  that  the  several 
papillae  are  not  all  equally  capable  of  exciting 
the  several  tastes.  In  many  individuals  the  taste 
of  "sweet"  alone  is  developed  near  the  middle 
line  on  the  hard  and  soft  palate.  Acid  tastes  are 
less  developed  in  the  circumvallate  papillae  than 
on  the  anterior  part  of  the  tongue.  At  the  an- 
terior part  of  the  tongue  only  the  tip  and  sides 
seem  to  excite  taste.  The  so-called  alkaline 
taste  excited  by  a  constant  current  seems  to  be  a 
composite  result,  due  to  a  mixture  of  bitter  and 
saline  tastes  with  stimulation  of  sensory  nerves 
as  well.  Between  the  papillae  there  is  never  any 
sensation  of  taste.  It  is  possible  to  fatigue  the 
papillae  for  one  taste,  for  example,  the  circum- 
vallate papillae  may,  by  repeated  application  of 
quinine,  cease  to  detect  bitter,  while  still  capa- 
ble of  responding  to  sweet  substances.  Stimu- 
lation with  acid,  however,  diminishes  the  excita- 
bility for  all  stimuli.  It  would  seem  from  these 
mearches  that  there  are  four  different  kinds  of 
gustatory  sensations — bitter,  saline,  acid,  and 
sweet ;  that  each  seems  to  be  related  to  a  special 
form  of  peripheral  end  organ,  and  that  the  papillae 
are  supplied  in  different  proportions  with  these 
several  fibres  or  nerve  endings,  so  that  it  appears 
that  the  doctrine  of  the  specific  energy  of  nerves 
is  also  applicable  to  the  sense  of  taste. — British 
Medical  Journal. 

Bacteriology. 

Pasteur  Institute  of  Paris.  — In  the  Octo- 
ber 19  issue  of  the  Journal  de  Midicine  de  Paris, 
three  deaths  were  reported  to  have  taken  place 
after  the  preventive  inoculation. 

On  the  6th  of  September  last,  in  Ille  sur-la-Tet, 
arrondisement  of  Prades,  a  mad  dog  bit  Jean  Do- 
menech,  7  years  of  age,  and  Sebastian  Yidalon, 
aged  46  years,  the  last  having  had  his  lips  and 
part  of  his  face  torn  away  by  the  fangs  of  the  en 
raged  animal.  The  department  sent  both  |  1 
tients  to  the  Pasteur  Institute,  where  they  were 
treated,  and  returned  home  apparently  Well.  A 
letter  from  Perpignan  under  the  date  of  October 
10  states  that  both  unfortunate  victims  had  dud 
after  the  most  atrocious  suffering. 

A  little  citizen  of  Guyotville,  14  years  of  age, 
had  !>Lcn  at  the  Institute  for  one  month  in  con- 
sequence of  a  bite  received  September  S.  He 
died  tlu  morning  of  the  12th  of  October,  after  a 
night  oi  horrible  suffering.  The  wound  had  not 
been  cauterized,  and  the  boy  presented  himself 
foi   treatment  five  days  after  receiving  the  bite. 


I89i.] 


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Address 

Journal  of  the  American   Medical   Association, 
No.  6S  W  abash  Ave  . 

Chicago,  Illinois. 
All  members  of  the  Association  should  send  their  Annual  Dues 
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London  Office,  57  and  59  Ludgate  Hill. 


SATURDAY,  JANUARY   10,    1891. 


THE    SURGICAL    TREATMENT    OF    LARYNGEAL 
TUBERCULOSIS. 

Surgical  intervention  in  certain  cases  of  tuber- 
culosis of  the  larynx  marks  an  epoch  in  laryngol- 
ogy- When  Heryng.  of  Warsaw,  and  Krause, 
of  Berlin,  first  promulgated  their  methods  and 
results,  laryngologists  were  generally  skeptical. 
They  bethought  themselves  of  the  numerous  in- 
stances of  conjoined  laryngeal  and  advanced  pul- 
monary tuberculosis  in  whom  to  scrape  and  inject, 
to  cut  and  cauterize,  seemed  unnecessary  and  even 
cruel. 

But  other,  more  sthenic  cases  exist,  with  who-n 
the  lungs  are  "  not  appreciably  "  or  but  slightly 
infiltrated,  without  fever  and  cachexia — patients 
otherwise  capable  of  resisting  the  attack  of  the 
bacillary  monster,  at  least  for  years,  but  for  a 
laryngeal  complication. 

At  times  the  deposit  of  tubercular  foci  excites 
the  laryngeal  epithelium  to  proliferative  activity, 
producing  mammillated  or  villous  neoplastoid  pro- 
jections, which  cover  by  preference  the  inter- ary- 
tenoid region,  but  which  may  extend  to  other 
parts  of  the  larynx,  and  so  encroach  upon  its  lu- 
men as  to  present  a  choice  only  between  intra- 
laryngeal  surgical  intervention,  tracheotomy,  or 
death  hastened  by  dyspncea.  Again,  tuberculous 
ulceration,  especially  of  the  epiglottis  or  aryte- 
noid region,  by  rendering  deglutition  excrucia- 
tingly painful,  may  present  the  alternative  only  of 
surgical  intervention  to  promote  healthy  cicatriza- 
tion or  death  hastened  by  dysphagia.  To  these 
graver   complications,   dyspncea    and  dysphagia 


may  be  added  also  aphonia  as  a  third  indication 
for  the  surgical  method.  Nor  need  the  actual 
presence  of  such  distressing  states  be  awaited, 
but  one  should  operate  also  in  the  early  stages, 
on  the  principle  of  prophylaxis. 

By  "surgical  treatment"  is  meant  the  removal 
of  exudative  and  proliferative  material  by  the 
curette,  cutting  forceps,  or  punch,  and  the  curette- 
tnent  of  tuberculous  ulcerated  areas,  each  followed 
by  the  application  of  lactic  acid  as  a  mild  eschar- 
otic,  which  is  believed  to  exert  a  specially  favor- 
able influence  in  promoting  cicatrization.  The 
mere  application  of  lactic  acid  without  previous 
preparation  by  incision  or  scraping  of  the  part,  is 
not  conceded  to  be  within  the  scope  of  the  term 
"surgical,"  although  a  60  to  100  per  cent,  lactic 
acid  solution  alone,  may  suffice  when  the  ulcers 
are  already  well  exposed. 

The  many  papers  and  discussions  before  the 
Sections  of  Laryngology,  respectively,  of  the 
Tenth  International  Medical  Congress  and  the 
recent  meeting  of  the  British  Medical  Associa- 
tion, witness  the  importance  of  this  subject.  At 
Berlin.  Heryng,  Stork  and  Scheinmann  spoke 
favorably  of  the  method,  and  Krause  exhibited 
cases  apparently  cured.  At  Birmingham.  Mr. 
Charters  J.  Symoxds.  of  Guy's  Hospital,  read 
the  opening  paper.  He  approached  the  subject 
from  the  standpoint  of  a  surgeon  having  to  deal 
largely  with  the  eradication  of  tubercle  from 
joints,  bones,  skin,  etc.,  and  while  recognizing 
the  greater  difficulties  surrounding  operative  in- 
terference in  the  larynx,  parts  of  which  are  not 
readily  accessible,  he  held  that  with  skill,  and 
the  instruments  now  in  use,  these  difficulties 
could  be  surmounted. 

In  opening  the  discussion  Dr.  G.  Hun- 
ter Mackenzie,  whilst  deprecating  heroic  meas- 
ures in  individuals  with  extensive  pulmonary  par- 
ticipation, advocated  in  suitable  subjects,  the 
surgical  removal  of  papillomatous  or  exudative 
material  and  the  stimulation  of  ulcers  to  more 
healthy  action  by  lactic  acid,  menthol,  or  iodo- 
form, although  he  asserted,  from  prolonged  ex- 
perimentation, that  the  action  of  these  agents 
upon  the  bacilli  was  absolutely  nil,  and  believed 
that  they  were  not  superior  for  the  purpose  to 
chloride  of  zinc,  carbolic  acid,  and  other  mate- 
rials. Mr.  Lennox  Browne  insisted  that  it  was 
important  to  apply  the  lactic  acid  with  some  fric- 
tion and  that  the  surgical  treatment  was  then  ben- 


58 


CHLOROFORM  VERSUS  ETHER. 


[January  io, 


eficial  in  cases  of  ulcerations  and  granulations 
peculiar  to  the  chronic  stage  of  this  disease. 

In  estimating  results  it  must  not  be  forgotten 
that  laryngeal  disease  in  tuberculosis,  may  be 
tubercular,  non-tubercular,  or  mixed.  Such  pa- 
tients are  prone  to  simple  laryngitis,  and  non- 
tuberculous  exudation  and  even  superficial  ulcer- 
ation can  ensue,  which,  of  course,  would  readity 
heal.  Further,  that  spontaneous  cicatrization  of 
real  tuberculous  ulcers  has  been  observed. 

But  with  all  due  allowance,  the  cases  in  which 
either  material  amelioration  or  a  local  cure  has 
been  induced  by  the  observers  mentioned,  as  well 
as  by  Gougenheim  and  Luc,  in  France,  justify 
the  following  conclusions: 

That  the  surgical  treatment  of  laryngeal  tuber- 
culosis may  be  advantageously  undertaken: 

i.  In  all  cases  in  which  there  is  little  or  no 
evidence  of  pulmonary  disease. 

2.  In  those  accompanied  by  dyspnoea,  dys- 
phagia, aphonia,  or  severe  cough,  with  existing 
but  not  rapidly  advancing  pulmonary  participa- 
tion, 

That  asthenic  cases  of  conjoined  laryngeal 
and  advanced  pulmonary  tuberculosis  ought  not 
to  be  subjected  to  violent  local  treatment,  but 
should  receive  only  mildly  stimulating  and  seda- 
tive applications  in  the  form  of  sprays,  powders 
or  pigments. 


CHLOROFORM  VERSUS  ETHER. 
The  report  of  the  Hyderabad  Commission  on 
this  subject  is  doubtless  fresh  in  the  minds  of  our 
readers.  It  will  be  remembered  that  the  unani- 
mous conclusion  of  the  members  of  that  body, 
after  very  elaborate  investigation,  was,  that  in 
death  from  chloroform  respiration  always  ceased 
before  any  dangerous  failure  of  the  heart  took 
place,  and  that  its  effects  were  precisely  similar 
to  those  of  ether,  except  that  the  dose  of  ether 
needed  to  be  much  larger.  Naturally,  a  view  of 
the  subject  so  opposed  to  the  opinions  of  a  large 
proportion  of  the  profession  could  not  be  ex- 
pected to  meet  with  immediate  acceptance,  and, 
as  a  matter  of  fact,  it  was  quickly  controverted 
in  various  quarters.  An  important  contribution 
to  the  subject  has  just  been  made  by  Dr.  J.  A. 
McWiluams,  in  a  report  to  the  Scientific  Grants 
Committee  of  the  British  Medical  Association, 
published  in  the  British  Medical  Journal,  which 


goes  far  to  show  that  the  conclusions  of  the 
Hyderabad  Commission  are  -not  applicable  to  all 
animals,  and  that  there  is  some  ground  for  the 
belief,  heretofore  widely  held,  that  chloroform 
has,  in  some  cases,  a  pernicious  influence  on  the 
heart  that  is  not  shared  by  ether. 

Dr.  McWilliams  began  his  experiments  in 
1888,  at  a  period,  therefore,  long  before  the  re- 
port of  the  Commission,  and  continued  them  at 
intervals  down  to  a  recent  time.  The  animals 
employed  were  principally  cats,  and  the  aim  of 
the  investigation  was  specially  to  observe  di- 
rectly the  effects  of  the  drugs  upon  the  heart. 
For  this  purpose,  the  chest  was  opened,  under 
suitable  precautions  against  haemorrhage,  and  an 
automatic  recording  apparatus  attached  to  the 
heart,  artificial  respiration  and  the  administra- 
tion of  the  anaesthetic  being  effected  by  means  of 
a  bellows  connected  with  a  canula  inserted 
in  the  trachea.  By  this  means,  it  was  pos- 
sible to  watch  the  action  of  the  heart  during 
the  experiments,  while  the  circulation  went  on 
undisturbed,  except  for  the  effects  of  the  drugs 
administered.  It  was  found  that  dilatation  of  all 
the  cavities  of  the  heart  frequently  occurred 
under  the  influence  of  chloroform,  at  an  early 
period,  in  many  cases  before  the  cornea  became 
insensible,  and  without  interference  with  the 
regularity  of  the  heart's  action.  This  was  usu- 
ally associated  with  a  fall  of  blood-pressure,  but 
bore  no  constant  relation  to  it.  In  some  cases  a 
periodical  depression  of  the  ventricular  action 
was  also  noticed.  Neither  of  these  effects  was 
observed  from  the  administration  of  ether,  even 
when  pushed  to  the  extent  of  completely  abolish- 
ing the  conjunctival  reflex.  In  man}'  cases  the 
drugs  were  repeatedly  administered,  alternately 
to  the  same  animal,  with  the  result  that  dilata- 
tion of  the  heart  uniformly  took  place  under 
chloroform,  and  was  as  uniformly  absent,  with  an 
equal  or  greater  degree  of  anaesthesia,  when 
ether  was  used. 

To  meet  the  objection  that  these  results  might 
be  in  some  way  due  to  the  opening  of  the  chest, 
chloroform  was,  in  a  number  of  cases,  given  in 
the  ordinary  way,  and  the  chest  quickly  opened, 
when  the  heart  was  found  dilated,  as  in  the  other 
experiments. 

In  three  cases  cats  became  suddenly  collapsed 
during  the  administration  of  chloroform  prelim- 
inary to  the  insertion  of  the  canula,  while  natural 


I89i.j 


IMPORTANT  PRELIMINARY   WORK. 


59 


respiration  was  going  on  regularly  and  efficiently. 
The  pulse  was  found,  in  each  case,  to  be  imper- 
ceptible, and,  after  respiration  had  gone  on  for 
some  time,  the  heart  was  found,  in  each  case,  on 
opening  the  chest,  to  he  contracting  so  feebly  as 
to  be  entirely  ineffectual  nn  propelling  the  blood. 
All  the  animals  were  resuscitated  by  rhythmic 
compression  of  the  heart  with  the  thumb  and 
finger.  As  a  general  rule,  however,  in  death  by 
chloroform,  respiration  ceased  before  any  such 
failure  of  the  heart's  action  as  to  be  incompatible 
with  life. 

It  was  found  that,  with  a  given  proportion  of 
chloroform  in  the  inspired  air,  changes  in  the 
rapidity  of  respiration  had  a  marked  effect  upon 
its  absorption.  An  amount  of  chloroform  that 
could  be  given  with  safety  during  quiet  respira- 
tion, speedily  produced  alarming  symptoms  when 
respiration  became  rapid  and  deep. 

The  most  effectual  way  of  increasing  the  blood- 
pressure  in  the  carotid,  when  it  had  fallen  to  a 
dangerous  degree,  was  found  to  be  firm  compres- 
sion of  the  abdominal  aorta. 

The  practical  bearing  of  these  facts  is  obvious. 
The  value  of  such  investigations  as  those  that 
led  to  their  discovery  is  equally  so.  Among  the 
thoughts  which  they  suggest  is  the  question  how 
soon  such  researches  will  be  carried  on  with 
funds  contributed  by  the  American  Medical  As- 
sociation. 


KOCH  AND  HIS  CRITICS. 

In  the  blame  which  has,  in  various  quarters, 
been  freely  bestowed  on  the  man  who  is,  just 
at  present,  the  most  prominent  figure  in  the  med- 
ical profession,  for  not  at  once  making  all  the  de- 
tails of  his  discovery  public,  the  important  cir- 
cumstance has  been  ignored  that  he  does  not 
seem  to  have  been  altogether  a  free  agent  in  the 
matter. 

Dr.  Koch  is  a  salaried  officer  of  the  German 
government.  The  Hygienic  Laboratory,  in  which 
his  researches  have  been  carried  on,  is  supported 
by  public  funds,  and  the  investigations  them- 
selves were  a  part  of  the  work  for  which  he  is 
paid.  Under  such  circumstances,  it  would  not 
be  merely  politic,  but  eminently  fitting,  that,  as 
long  as  he  retains  his  office,  he  should  pay  a  good 
deal  of  regard  to  the  wishes  of  his  official  superi- 
ors.    There  have  been  reports  that  it  was  in  def- 


erence to  pressure  from  that  quarter,  and  against 
his  own  judgment,  that  he  made  his  announce- 
ment in  the  International  Medical  Congress. 
However  that  may  he,  the  Minister  of  Public  In- 
struction, Gossler,  stated,  in  reply  to  an  en- 
quiry made  of  him  in  the  Prussian  Diet,  that 
Koch's  wish  was  to  publish  all  the  details,  but 
that,  on  account  of  the  difficulty  of  preparation  of 
the  remedy,  and  the  harm  that  might  result  from 
the  use  of  imperfect  and  irresponsible  imitations, 
he  had  prevailed  upon  Koch  to  defer  publication 
of  its  nature,  a  step  for  which  he  assumed  the 
entire  responsibility. 

Of  the  necessity  of  such  a  course  probably  no 
one  can  be  a  competent  judge  who  is  not  ac- 
quainted with  all  the  reasons  which  led  to  the  de- 
cision. No  one  can  doubt  that  if  the  method  of 
preparing  the  remedy  were  made  public,  the  mar- 
kets of  the  world  would  soon  be  flooded  with  the 
products  of  competing  manufacturers,  some  of 
whom  might  not  be  able,  with  the  best  disposi- 
tion in  the  world,  to  judge  as  to  the  quality  of 
their  wares.  The  tests  which  have  been  made  of 
various  brands  of  pepsin  may  serve  as  an  illus- 
tration of  the  varying  quality  of  articles  going 
under  the  same  name.  It  is  of  the  utmost  im- 
portance that  the  remedy  shall  be  tested  in  such 
a  way  as  shall  be  conclusive  in  regard  to  its 
value,  and  the  gratification  of  a  legitimate  curi- 
osity is  of  very  little  moment  in  comparison. 
Whatever  may  be  thought  of  the  reasons  for 
secrecy  in  this  case,  the  responsibility  for  it  should 
be  placed  where  it  belongs,  and  that  is  evidently 
not  with  Dr.  Koch,  but  with  his  superior  officer. 


IMPORTANT   PRELIMINARY  WORK. 

But  four  months  intervene  before  the  Annual 
Meeting  of  the  Association  at  Washington.  Those 
most  interested  in  its  welfare  need  not  to  be  ad- 
vised that  the  value  of  these  annual  meetings  lies 
not  so  much  in  the  work  accomplished  in  General 
Sessions  as  in  that  which  is  done  in  the  Sections. 
By  the  quality  of  Sectional  work  the  real  value 
of  the  Association  must  be  estimated.  By  this 
its  future  success  or  failure  will  be  assured. 

The  Association  is  especially  fortunate  in  the 
selection  of  its  officers  which  are  to  supervise  the 
work  in  the  various  Sections  for  the  coming  year. 
In  each  department  men  of  ability,  and  whose 
work  in  the  past  is  a  guarantee  of  success,  are  in 


6o 


EDITORIAL  NOTES. 


[January  io, 


command.  To  these  we  look  for  that  thorough 
preliminary  preparation  which  is  absolutely  es- 
sential. To  this  end  The  Journal  will  venture 
a  few  brief  suggestions  : 

i.  To  determine  as  nearly  as  may  be  the  num- 
ber of  papers  which  can  be  properly  presented 
and  discussed  in  a  given  Section  during  the  sev- 
eral sessions  of  the  Annual  Meeting.  2.  That 
men  specially  qualified  for  the  work  be  secured  in 
sufficient  number  to  prepare  the  papers  which 
shall  meet  this  requirement.  3.  That  the  atten- 
tion of  each  writer  be  called  to  the  fact,  that  pa- 
pers submitted  to  the  Sections  become  the  property 
of  the  Association  for  its  exclusive  use,  and  are 
not  at  the  option  of  the  writers,  for  publication 
elsewhere.  4.  That  all  papers  be  fully  completed 
when  they  are  presented,  and  pass  immediately 
from  the  readers  to  the  Secretaries  of  the  Section 
in  which  they  are  read. 

The  papers  thus  prepared  and  submitted  will 
determine  the  value  of  the  "Original"  depart- 
ment of  The  Journal  to  its  readers  for  the  com- 
ing year.  By  these  papers  the  status  of  our  As- 
sociation is  justly  to  be  adjudged  not  only  by  the 
profession  at  home,  but  also  in  other  lands.  We 
know  that  those  upon  whom  the  responsibilities 
rest  are  fully  equal  to  their  work,  and  we  confi- 
dently anticipate  that  the  programme  for  the  pres- 
ent year  will  exceed  any  one  that  has  gone  before. 


In  the  meantime  let  the  reasons  for  and  against 
removal  be  carefully  considered,  and  in  the  order 
in  which  they  may  be  forwarded  for  publication 
The  Journal  will  present  them  to  its  readers. 


SHALL  "THE  JOURNAL"  BE  REMOVED  TO 
WASHINGTON? 

Thus  far  but  a  limited  number  ol  replies  to 
this  question  have  been  received.  It  seems  de- 
sirable that  the  reasons  for  and  against  such  a 
movement  should  be  fully  stated.  If  possible  the 
wishes  of  the  entire  membership  should  be 
known,  and  in  the  settlement  of  the  question, 
the  will  of  the  majority  should  govern. 

If  possible  the  question  should  be  promptly 
and  permanently  decided  at  the  next  Annual 
Meeting,  and  in  such  manner  as  not  to  divert  the 
attention  of  the  members  from  the  important 
work  in  the  Sections,  nor  trench  upon  the  time 
allotted  to  them. 

The  views  of  the  members  upon  this  question 
should  have  full  expression  before  the  Annual 
Meeting,  and  with  positive  conviction  upon  that 
subject  it  need  not  require  any  considerable  time 
to  come  to  definite  conclusions. 


EDITORIAL  NOTES. 

A  Coming  Vacancy  in  the  U.  S.  A.  Medi- 
cal Department. — The  single  colonel  of  staff 
who  retires  in  1891,  by  reason  of  age  limitation, 
is  Dr.  Edward  P.  Vollum,  who  is  stationed  in 
New  York  City,  and  acting  chief  medical  pur- 
veyor, pending  the  Senate's  confirmation  of  his 
appointment  last  August.  He  was  candidate  for 
the  surgeon-generalship  after  Dr.  Baxter's  death. 
He  is  a  New  York  man  with  a  long,  active  record, 
and  is  at  present  president  of  the  Army  Medical 
Board  in  that  city.  His  original  commission  is 
dated  May  12,  1862.   He  retires  on  September  11. 

Forty-Five  Days  of  Fasting. — Succi  had 
rendered  himself  famous  in  London  by  a  fast  of 
forty  days,  which  he  completed  in  May  last. 
Later  he  came  to  America.  On  November  15  he 
commenced  a  fast  of  forty-five  days,  in  New  York 
City,  completing  the  same  December  20.  At  the 
commencement  of  the  fast  his  weight  was  147 }(. 
lbs.,  at  the  end  of  the  forty-five  days  he  had  lost 
42 ':  lbs.,  or  nearly  one  pound  for  each  day.  At 
the  conclusion,  the  final  medical  examination, 
his  condition  is  reported  as  follows:  temperature 
normal;  pulse  62;  respiration  90  (?);  dynamom- 
eter 44;  tongue  clear,  moist  and  steady;  general 
condition  weak;  urine  eight  ounces  in  twenty- 
four  hours;  specific  gravity  1.022;  reaction  acid, 
clear.  Of  drinks  during  the  forty-five  days  he 
took  291  ounces  of  croton  water;  799  ounces  of 
mineral  water,  and  64  ounces  of  ice.  Of  his 
elixir,  which  is  composed  of  morphia,  canabis  in- 
dica,  chloroform,  sulphuric  ether  and  alcohol,  he 
took  during  that  time  710  drops.  His  sufferings 
during  the  last  few  days  were  intense,  and  when 
the  forty-five  days  were  ended  he  had  reached 
the  limit  of  his  endurance. 

Unostentatious  Charity. — A  resident  of 
Lowell,  Mass.,  whose  name  is  withheld,  has 
pledged  $25,000  towards  the  new  free  hospital  to 
be  established  there.  A  board  of  officers  was 
elected  on  the  29th  ult. 

Death  Following  Inoculation  for  Lupus. 
— According  to   the    Wiener  Klinische    Wbchen- 


189I-] 


EDITORIAL  NOTES. 


61 


sehrift,  a  girl  17  years  of  age  died  after  an  injec- 
tion of  two  milligrams  of  Koch's  lymph.  The 
injection  was  made  at  9  a.m.;  at  3  p.m.  the  char- 
acteristic appearances  were  observed  upon  the 
affected  portion  of  the  face.  The  local  manifest- 
ations were  more  and  more  pronounced.  The 
bright  red  zone  became  more  and  more  livid; 
dyspncea  and  heart  failure  ensued  and  the  patient 
died  thirty-six  hours  after  the  injection. 

Dr.  Milan  Baker,  a  graduate  in  1855,  of  the 
Medical  Department,  University,  Buffalo,  N.  Y., 
and  an  original  member  of  the  New  York  State 
Medical  Association,  died  at  his  home  in  Buffalo, 
December  29th  last,  aged  62  years.  He  was  a 
member  of  the  original  commission  which  located 
the  State  asylums  for  the  insane,  and  at  the  time 
of  his  death  was  one  of  the  managers  of  the 
State  insane  hospital  in  Buffalo. 

Spurious  Koch's  Fluid. — It  is  already  re- 
ported that  spurious  Koch's  fluid  is  being  manu- 
factured in  Berlin,  and  that  medical  men  are 
being  deceived  in  their  effort  to  secure  the  genuine 
article.  There  hardly  seems  a  limit  to  the  de- 
ceptions which  will  doubtless  be  attempted  in 
this  direction,  and  the  medical  profession  will 
need  to  be  everywhere  on  the  alert  to  protect  the 
people  from  the  evil  to  be  averted,  and  from  the 
frauds  which  unprincipled  venders  may  seek  to 
perpetrate. 

Quarantine  against  Cholera. — The  sug- 
gestions of  Dr.  J.  H.  Rauch,  Secretary  of  the 
Illinois  State  Board  of  Health,  upon  this  subject 
are  timely,  and  should  receive  most  careful  con- 
sideration. He  predicts  a  serious  invasion  of 
cholera,  unless  efficient  quarantine  regulations 
are  adopted.  In  Abyssinia  10,000  people  have 
died  of  cholera  during  the  last  six  months.  In 
India  it  is  epidemic.  It  is  not  yet  extinct  in 
Spain.  In  the  Asiatic  provinces  of  Russia,  in 
Corea  and  Japan,  80,000  people  have  recently 
died  of  this  disease,  and  he  urges  that  our 
Pacific  coast  be  especially  subject  to  the  strictest 
of  quarantine  supervision. 

Unwarrantable  Jealousy. — It  seems  incred- 
ible that  such  an  intensity  of  hatred  should  be 
manifested  on  the  part  of  German  physicians  as 
that  they  should  seek  to  prevent  so  eminent  a 
man  as  Morell  Mackenzie  from  obtaining  a  rea- 
sonable supply  of  Koch's  fluid  for  the  purpose  of 


testing  its  alleged  virtues.  Medicine  and  the  al- 
leviation of  human  ills  are  supremely  above  the 
petty  differences  and  jealousies  of  men,  and  the 
effort  thus  to  control  the  use  of  the  lymph  for  the 
gratification  of  petty  or  personal  spite,  is  unwor- 
thy of  the  most  degenerate  member  of  the  profes- 
sion, either  in  Germany  or  elsewhere.  For  the 
good  name  of  the  profession  in  Berlin  we  sincere- 
ly hope  that  the  charge  is  totally  untrue. 

Dr.  Charcot,  who  has  recently  finished  a  long 
series  of  experiments  with  hypnotism,  gives  as 
his  opinion  that  not  more  than  one  person  in 
100,000  would  be  likely  to  be  benefited  by  this 
mode  of  treatment. 

Dr.  Ernest  Hardy. — Le  Progres  Medical  of 
September  27  contains  an  account  of  the  death 
of  this  eminent  scientist.  He  was  a  member  of 
several  important  medical  and  scientific  bodies 
and  contributed  many  important  monographs, 
especially  those  upon  the  physiological  actions  of 
jaborandi  and  strophanthus. 

"Confraternite." — Under  this  heading  Le 
Progres  Medical  describes  an  incident  occurring 
in  the  town  of  Fehraltorf.  A  citizen  of  the  place 
having  trouble  with  his  foot,  three  physicians 
were  called  in  who  decided  that  an  amputation 
was  necessary;  a  Doctor  Ries  undertook  to  cure 
the  foot  without  an  operation,  and  the  patient 
dying,  he  wrote  upon  the  death  certificate,  "Dead 
from  the  bad  treatment  of  the  physicians."  He 
further  declared  that  his  colleagues  were  ignorant 
of  surgery.  For  this  and  the  monumental  death 
certificate  he  was  compelled  to  pay  1,200  francs 
damages.  It  is  onl5'  in  this  latter  part  that  they 
do  these  things  better  in  France. 

The  German  Government  and  Koch's  Ma- 
terial.— After  going  to  press  we  received  the 
following  cable  from  Dr.  Harold  Ernst,  in  Berlin, 
under  date  of  December  10:  "The  secret  of 
making  Koch's  material  has  been  turned  over  to, 
and  kept  by  the  German  Government  only  until 
a  thorough  trial  can  be  made.  The  effect  in  lu- 
pus and  surgical  tuberculosis  is  most  striking, 
because  the  results  can  be  seen.  The  most  won- 
derful property  is  the  selective  affinity  for  tuber- 
culous nidus,  often  making  latent  centres  active. 
Pulmonary  tuberculosis  will  have  to  be  under  ob- 
servation for  a  long  time  still  before  permanent 
result  is  determined.  The  action  of  the  material 
is  certainly  as  wonderful  as  that  of  any  known 
medicine. — Boston  Med.  and  Surg.  Journal. 


62 


TOPICS  OF  THE  WEEK. 


[January  io, 


TOPICS  OF  THE  WEEK. 


RESEARCHES  ON  MALARIA. 

So  much  importance  is  now  attached  to  the  action  of 
bacteria  upon  the  system  in  the  production  of  disease, 
that  we  need  not  apologize  for  placing  before  our  readers 
the  results  of  the  researches  of  Dr.  Bernardo  Schiavuzzi 
on  malaria  in  Pola,  which  seem  to  have  culminated  in  the 
discovery  of  one  at  least  of  the  microorganisms  that  are 
capable  of  inducing  ague.  Pola  is  an  ancient  city  of  Is- 
tria,  on  the  east  coast  of  the  Adriatic,  long  decaying,  but 
now  again  rising  in  importance  as  a  naval  station,  built 
on  chalk,  on  which  is  a  stratum  of  red  earth,  about  9  feet 
thick,  which  is  of  submarine  volcanic  origin,  and  was 
cast  up  in  the  miocene  period.  Its  isotherm  is  14. 1 7°  C, 
with  wide  extremes,  its  yearly  rainfall  amounts  to  937  mm. , 
whilst  its  physical  conditions  are  favorable  to  the  devel- 
opment of  malarial  fevers,  which  are  endemic. 

In  the  year  1S66,  Dr.  Salisbury  believed  he  had  discov- 
ered the  cause  of  malaria  in  an  alga  of  the  group  of  pal- 
mella,  to  which  he  gave  the  name  of  "  palmella  gemi- 
asma,"  and  which  he  had  found  in  some  of  the  marshy- 
districts  of  Ohio.  In  1869,  Balestra  examined  the  waters 
of  the  Pontine  marshes,  and  satisfied  himself  that  an  alga 
which  he  named  "alga  miasmatica,"  and  which  was 
either  an  cedogonium  or  a  cladophora,  was  the  active 
agent  in  producing  ague.  Salisbury  grounded  his  belief 
on  the  circumstance  that  a  young  and  healthv  couple 
sleeping  in  a  room  with  a  few  boxes  containing  this  alga 
were  attacked  with  malaria,  whilst  Balestra  induced  an 
attack  in  himself  by  smelling  some  water  containing  the 
alga  miasmatica.  Safford  and  Bartlett,  Archer  and  Bar- 
zelliui,  severally  called  attention  to  the  probability  of  va- 
rious algae  being  the  active  agent,  but  only  on  the  ground 
that  such  algae  were  abundant  in  malarial  regions;  and 
objections  were  raised  to  their  statements  when  further 
investigations  showed  that  in  each  instance  the  alga  in 
question  was  abundantly  present  in  perfectly  healthy  re- 
gions. In  1873  Griffini  injected  into  the  veins  of  dogs 
and  rabbits  the  dew  which  he  had  collected  in  marshy 
grounds  and  paddy  fields;  but  though  the  temperature  of 
the  animals  rose  a  degree  or  two,  the  spleen  remained 
unaffected,  and  health  was  soon  restored.  Lanzi  and 
Ferrigi  were  led  from  their  inquiries  to  think  that  the 
malarial  poison  was  the  product  of  some  kind  of  vegeta- 
ble decomposition;  and  experimenting  with  the  mud  of 
the  marshy  districts  of  Ostia,  which  they  injected  into  the 
vessels  of  guinea-pigs,  the\-  observed  a  rise  of  tempera- 
ture to  400  C,  enlargement  of  the  spleen  and  liver,  and 
the  presence  of  pigment  in  these  organs  and  in  the  blood. 
After  the  meeting  of  biologists  in  Kassel  in  1S7S,  Klebs  and 
Corrado,  and  Tommasi-Crudeli  examined  by  means  of  spe- 
cial apparatus  the  air,  the  water,  the  mud  and  the  earth  of 
the  Campagna,  and  endeavored  to  cultivate  the  algse 
naturally  present.  They  obtained  a  great  number  of  mi- 
nute bacilli  with  fine  fibres,  small  rounded  granules  like 
micrococci,  and  other  microorganisms,  which  they  care- 
fully cultivated;  whilst  they  at  the  same  time  made  ana- 
tomical investigations  on  the  size  of  the  spleen  in  healthy 


white  rabbits;  then,  having  inoculated  the  animals,  they 
arrived  at  the  conclusion  that  they  had  discovered  the 
malarial  poison  in  a  schizomycetous  fungus,  to  which 
they  gave  the  name  of  "bacillus  malariae."  In  1880 
Tommasi-Crudeli,  Cuboni,  and  Marchiafava  repeated  and 
confirmed  these  observations,  since  they  could  produce 
an  affection  similar  to  or  identical  with  the  malarial  fever 
with  this  bacillus,  and  because  they  found  numerous  sim- 
ilar bacilli  together  with  roundish,highly  refractile  gran- 
ules or  spores  in  the  blood.  The  spores  were  contained 
in  large  numbers  in  the  interior  of  the  white  corpuscles. 
Thev  presented  lively  oscillating  movements,  and  became 
more  numerous,  whilst  the  bacilli  were  fewer,  as  the  tem- 
perature of  the  animal  increased.  In  18S1  Laveran  made 
a  special  study  of  the  pigmental  bodies  which  are  found 
partly  free  in  the  blood  plasma  of  malarial  patients,  and 
partly  embedded  in  clumps  of  protoplasm  or  in  white 
corpuscles,  and  arrived  at  the  conviction  that  they  were 
parasitical  elements  in  various  stages  of  development  and 
decay. 

Schiavuzzi's  experiments  extended  over  several  years, 
and  consisted  in  obtaining  pure  cultures  of  a  bacillus, 
which  he  found  abundantly  present  in  the  air  of  Pola,  a 
place  where  malaria  is  endemic,  and  which  agreed  in  its 
characters  with  that  described  by  Klebbs  and  Tommasi- 
Crudeli.  With  this  he  infected  rabbits,  and  in  the 
memoir  he  has  just  published  in  Cohu's  Beitrage  zur 
Biologieder  Pflanzen  he  gives  charts  of  the  temperature 
and  figures  copied  from  photographs  of  the  bacilli  he 
found  in  the  animals.  The  bacillus  is  rarely  present  in 
the  waters  of  the  endcuiically  affected  district.  It  is 
aerobic,  and  develops  on  the  surface  of  nutritive  gelatine 
in  the  form  of  a  whitish  and  tolerably  resistent  coat.  In- 
fection of  this  baciflus  produced  intermittent  fever  in 
tame  white  rabbits  of  the  tertain  and  quotidian  tvpes. 
but  without  pernicious  character  in  any  case.  It  occa- 
sioned enlargement  of  the  spleen  and  formation  of  the 
characteristic  black  pigment  in  the  spleen  and  in  the  ab- 
dominal glands,  and  the  blood  corpuscles  presented  the 
changes  shown  by  Marchiafava  and  Celli  to  be  pathog- 
nomonic of  malarial  infection;  whilst  a  development  of 
bodies  exactly  resembling  the  spores  of  the  bacillus  took 
place  in  the  blood.  From  all  these  circumstances  Schia- 
vuzzi and  Tommasi-Crudeli,  who  fathered  Schiavuzzi's 
memoir  at  the  meeting  of  the  Academy  dei  Lincei,  enter- 
tain uo  doubt  that  the  bacillus  malariae  is  the  active 
agent  in  causing  intermittent  fever.  The  care  with  which 
these  experiments  were  made  is  deserving  of  great  credit. 
In  each  experiment  the  following  details  were  attended 
to:  The  precise  spot  from  which  the  air  was  obtained, 
with  its  height  above  the  sea  level;  the  date;  the  reading 
of  the  barometer  and  thermometer;  the  direction  and 
strength  of  the  wind;  the  relative  moisture  of  the  air, 
the  actual  amount  of  moisture  it  contained;  the  reading 
of  the  heliograph  on  the  day  when  the  specimen  was  ob- 
tained; the  amount  of  ozone  in  the  air;  the  rapidity  of 
evaporation;  and  the  temperature  of  the  earth.  The 
statements  require  confirmation;  but  the  etiology  of 
malaria  may  now  be  referred  with  tolerable  certainty  to 
the  growth  and  development  of  a  microorganism  of 
vegetable  origin  in  the  system. — Editorial,  Lancet. 


i89i.] 


TOPICS  OF  THE  WEEK. 


63 


MEDICAL  CLASS  IN  JAPAN. 

The  following  appears  as  an  editorial  in  The  Seii- 
Kwai  Medical  Journal,  published  monthly  in  Tokyo, 
Japan,  under  date  of  Nov.  22,  1S90: 

We  may  fairly  divide  the  medical  profession  in  Japan 
into  four  classes  viz.:  1,  Kanpo-ka  (Chinese  school), 
2,  Kan-ran  settii-ka  (China-Dutch  school  I,  3,  Seiyo-ka 
(European  school).  4,  Senmon-ka  [specialist). 

Those  who  belong  to  Chinese  school  are  old  in  age, 
most  of  them  over  50  years,  and  got  the  license  by  virtue 
of  professional  tradition  from  their  forefathers ;  their 
knowledge  consists  of  reading  Chinese  pseudo-physics ; 
they  have  never  seen  the  inside  of  humau  subject  nor 
use  any  instrument  for  the  aids  of  diagnosis.  Their 
medicines  compose  of  herbs,  barks,  and  roots  of  various 
plants  which  are  always  given  as  decoction  and  prescrip- 
tions of  some  coarse  minerals  are  seldom  used. 

Their  numbers  at  present  overrate  than  the  other 
classes  and  show  figures  of  at  least  20,000  out  of  40,000 
whole  number,  but  their  numbers  are  decreasing  year  by 
year  as  they  either  die  or  retire  on  account  of  their  old 
age,  as  were  stated  before,  and  they  never  have  chance 
to  grow  up,  because  the  present  system  of  granting 
licentiate  is  strict  and  candidates  must  pass  a  hard  exam- 
ination. Those  belonging  to  China-Dutch  school  are 
mostly  over  middle  age ;  they  have  studied  Chinese 
medicine,  but  the  event  of  intercourse  with  Dutch 
nationality  provoked  them  to  stud}-  Dutch  medicine  as 
■well ;  in  those  days  they  could  not  read  Dutch  books, 
and  those  very  few  people  who  could  hardlv  understand 
them  endeavored  to  translate  them  into  Japanese,  by 
means  of  that,  most  of  this  class  possessed  an  outline  of 
European  medicine,  but  their  knowledge  is  quite  stale 
nowadays,  having  passed  30  to  35  years. 

Their  numbers  are  about  10,000  and  their  licenses  were 
granted  exactly  in  similar  way  as  that  of  Chinese  class. 
They  treat  patients  much  in  similar  manner  as  Chinese 
school,  but  often  use  mixtures,  pills  or  powders  which 
contain  one  or  more  drugs,  such  as  opium,  calomel, 
iron,  soda,  assafoetida,  aloes,  santonine,  etc.  Indeed  we 
owe  much  the  progress  of  European  medicine  in  Japan 
to  encouragement  of  certain  persons  in  this  class. 

Moreover  certain  number  of  this  class  followed  the 
progress  up  to  present  by  their  indefatigable  energy,  and 
they  hold  high  reputations  and  respects  both  in  private 
and  public  works. 

The  third  class  belong  to  European  school  (Seiyo-ka); 
they  have  undergone  a  good  education  either  in  uni- 
versity, colleges  or  schools  properly  instituted  under  the 
inspection  of  the  government,  their  numbers  do  not  ex- 
ceed more  than  5,000  including  those  who  have  studied 
medicine  in  Europe  or  America,  indeed  the  reformation 
of  Japanese  medicine  is  the  task  of  them,  for  this  object 
they  join  to  constitute  medical  societies  and  respective 
society  endeavors  to  publish  their  journal.  The  chairs 
of  university,  and  of  colleges  are  occupied  by  the  mem- 
bers of  this  class,  and  the  surgeons  of  Imperial  Navy 
and  Army  are  chosen  amongst  this  class,  indeed  the  im- 
portant situations  both  in  public  and  private  are  entirelv 
held  by  them.  Instead  of  their  honors  and  reputations 
they  are  burdened  with  a  heavy  obligation  that  is  for  the  I 


welfare  of  future  medicine  of  Japan,  to  meet  these  obli- 
gations, for  instance  they  started  some  years  ago  the 
Private  Sanitary  Association  of  Japan,  and  carried  their 
works  to  a  great  satisfaction  both  to  laymen  as  well  as 
the  professional  ;  moreover  the  principal  leaders  in 
Tokyo  caused  themselves  to  start  a  medical  association 
for  the  object  of  which  they  have  to  gather  all  the  med- 
ical brethren  111  every  province  of  the  Empire  and  to  ex- 
change their  knowledges. 

The  endeavor  of  them  brought  this  scheme  to  born  in 
April  last  under  the  name  of  the  First  Japanese  Medical 
Association,  the  meeting  was  held  in  Tokyo  for  a  week 
and  was  closed  with  every  success.  It  was  hoped  to  hold 
this  association  in  future  once  every  four  years. 

The  4th  class  belong  to  specialist,  viz. :  oculist,  ob- 
stetrician, dentist,  bonesetter,  vaccinator,  etc.  Some  of 
them  are  well  educated  under  the  new  school,  but  most 
of  them  follow  the  profession  by  the  tradition  and  could 
not  be  called  specialist  under  the  proper  sense. 


THE  RISKS  OF  KOCH'S  TREATMENT. 

In  the  very  interesting  communication  from  our  Special 
Commissioner  at  Berlin  reference  is  made  to  the  danger- 
ous symptoms  which  may  attend  the  use  of  injections 
with  Professor  Koch's  liquid;  and  although  he  explains 
the  fatality  in  some  of  the  fatal  cases  to  be  due  to  the  or- 
dinary course  of  the  disease  under  treatment,  there  can 
be  little  doubt  that  in  a  few  regrettable  instances  there 
has  been  evidence  of  disastrous  results.  The  fact  is,  the 
profession  have  been  placed  in  possession  of  a  most  power- 
ful poison,  and  that  as  yet  experience  of  its  effects — 
which,  like  all  poisons,  vary  in  individuals  according  to 
their  special  idiosyncrasies — is  so  small  as  to  necessitate 
the  utmost  cautious  employment  of  it;  this,  too,  quite 
apart  from  cases  of  pulmonary  and  laryngeal  tubercle, 
where  the  local  reaction  set  up  by  it  may  of  itself  produce 
alarming  and  dangerous  symptoms.  Therefore  we  en- 
dorse fully  our  correspondent's  view  as  to  this  being  an 
agent  (and  it  is  still  to  be  proved  that  its  action  is 
curative)  which  should  not  be  employed  in  general  prac- 
tice, but  only  under  circumstances  admitting  of  the 
strictest  continuous  medical  surveillance.  A  like  con- 
clusion is  stated  in  the  excellent  report  drawn  up  by 
Drs.  Saundby,  Simon,  and  Barling  [Birmingham  Medi- 
cal Review,  December),  who  urge  the  greatest  circum- 
spection in  dosage  and  conditions  of  administration.  We 
believe,  for  example,  that  it  is  rash  to  commence  the 
treatment  of  lupus  with  as  much  as  0.01  grm.,  as  recom- 
mended by  Professor  Koch,  the  severity  of  the  local  and 
general  reaction  being  in  many  cases  so  extreme. — 
Lancet. 


I.UNIVERS  MEDICAL. 

A  new  journal,  with  the  title  L' Univers  Medical,  is 
about  to  appear  in  Paris  under  the  editorship  of  Dr. 
Sexeno,  a  pupil  of  Dr.  Apostoli's.  It  is  understood  to 
be  an  outcome  of  the  Berlin  Congress,  and  will  have  for 
its  object  the  promotion  of  professional  solidarity  among 
medical  men  of  all  countries,  and  the  furtherance  of 
international  cooperation  in  matters  of  hygienic  reform. 


64 


PRACTICAL  NOTES. 


[January  io, 


PRACTICAL  NOTES. 


trendelenberg's  flexible  DRESSING. 

Prof.  Trendelenberg  has  been  using  at  his 
clinic  a  gelatin  paste,  recommended  by  Unna, 
that  is  designed  to  be  substituted  in  those  cases 
where  flexible  collodion  or  india-rubber  solutions 
have  formerly  been  employed.  It  will  hold  dress- 
ings in  place  while  permitting  free  motion  of  the 
parts.  It  is  not  friable  nor  very  stiff,  and  is  not 
so  adherent  to  the  cuticle  as  to  interfere  with  the 
excretory  functions  of  the  skin.  It  therefore 
does  not  cause  the  peeling  off  of  the  upper  layers 
of  the  epidermis,  upon  being  removed,  and  the 
tendency  to  eczema  in  consequence.  It  is  pre- 
pared in  two  degrees  of  consistence  :  the  thick 
paste  contains  gelatin,  glycerine  and  water  each 
thirty  parts,  with  oxide  of  zinc  ten  parts.  The 
thin  paste  has  gelatin  twenty  parts,  glycerine 
thirty,  water  forty,  with  oxide  of  zinc  ten  parts. 
Heat  is  necessary  when  the  pastes  are  com- 
pounded ;  it  is  also  needed  to  liquefy  them  when 
the)-  are  used.  The  pastes  are  readily  removed 
with  warm  water. 


ICHTHYOL    IN    GYNAECOLOGY. 

Ichthyol  is  strongly  recommended  by  Dr. 
Freuud  in  the  treatment  of  inflammatory  diseases 
of  the  female  genital  organs.  Its  action  is  su- 
perior to  that  of  all  other  remedies  hitherto  in 
use.  Locally,  it  acts  as  an  antiseptic  and 
analgesic ;  internally,  it  improves  the  general 
health,  increases  appetite,  improves  digestion, 
and  regulates  the  action  of  the  bowels.  Dr. 
Freund  has  treated  with  success  cases  of  chronic 
parametritis,  chronic  and  sub-acute  perimetritis, 
chronic  metritis,  salpingitis,  erosions  of  the  cer- 
vix, cicatrices  of  the  vagina,  and  prurigo  of  the 
external  genitals.  He  prescribes  its  internal  and 
local  use  simultaneously. — L'  Union  Medicale. 


TREATMENT  OF  H.-EMORRHOIDS    BY  COLD  WATER. 

The  treatment  by  very  cold  water  of  haemor- 
rhoids is  advocated  anew  by  Dr.  Alvin,  in  La 
Semaine  Medicale.  His  method  is  the  simple  one 
of  applying  the  water  to  the  anal  region  by 
means  of  a  sponge,  but  the  method  will  not  suc- 
ceed unless  the  sponging  is  kept  up  for  a  number 
of  days.  If  this  is  done  the  growths  will  di- 
minish in  size,  and  there  will  be  a  general  relief 
of  the  ordinary  unpleasant  symptoms,  such  as 
pain,  tenesmus,  pruritus  and  spasm  of  the 
sphincter  muscle  of  the  anus,  when  provoked  by 
congested  haemorrhoids.  The  systematic  use  of 
cold  water  directly  after  the  daily  evacuation, 
and  again  at  bedtime  should  be  the  initial  treat- 
ment, An  enema  of  cold  water  should  be  used 
once  or  twice  daily,  if  internal  haemorrhoids  ex- 


ist. These  internal  growths  tend  early  to  yield 
under  this  treatment  unless  they  have  attained  to 
an  excessive  size,  or  have  been  strangulated  by 
reason  of  frequent  inflammations  and  systematic 
neglect.  The  neglected  cases  will,  as  a  matter  of 
course,  require  a  longer  continuance  of  the  water 
treatment,  but  the  number  which  in  the  end  will 
demand  surgical  interference  will  be  small. 


UNCONTROLLABLE  VOMITING  OF  PREGNANCY. 

Drs.  Henske  {St.  Louis  Clinique  and  Archives  of 
Gynecology,  August,  1890)  and  Gottschalk  have 
found  menthol  efficacious  in  stopping  the  uncon- 
trollable vomiting  of  pregnancy.  Fifteen  grains 
are  dissolved  in  five  ounces  of  distilled  water,  to 
which  five  drachms  of  rectified  spirit  are  added. 
A  tablespoonful  of  this  mixture  is  given  hourly 
till  the  vomiting  ceases.  The  editor  of  the 
Archives  of  Gynecology  states  that  he  has  had  an 
opportunity  of  trying  the  efficacy  of  this  mixture. 
Vomiting  ceased  after  the  fourth  tablespoonful. 
Dr.  Gottschalk  reports  two  cases  with  similar  re- 
sults.— Brit.   Med.  Journal. 


DRY    CUPPING  FOR  INFANTILE  CONVULSIONS. 

Dr.  T.  J.  Heard  says  :  In  19  cases  out  of  20, 
infantile  spasms  or  convulsions  may  be  arrested 
in  one  minute  by  the  application  of  one  or  two 
dry  cups  on  the  back  from  the  seventh  cervical 
to  the  first  dorsal  vertebra  This  will  secure  a 
remission,  during  which  emetics,  purgatives,  or 
anything  else  that  indications  require,  may  be 
used. — N.   V.   Med.    Times. 


THE    ANTISEPTIC    PROPERTIES    OF    CHLOROFORM. 

Kirchner,  in  the  Zeitschrifl fur  Hygiene,  writes 
that  he  has  found  that  small  quantities  of  chloro- 
form act  destructively  and  promptly  upon  the 
bacilli  of  cholera  and  typhoid  fever.  For  this 
reason  he  would  recommend  that,  during  the 
epidemic  prevalence  of  these  diseases,  this  drug 
should  be  added  to  drinking  water  and  milk,  in 
the  proportion  of  1  or  2  per  cent.  He  believes 
that  this  precautionary  measure  will  be  entirely 
free  from  danger  as  well  as  inexpensive.  The 
addition  of  chloroform  to  lotions,  used  in  surgical 
practice,  would  be  useful,  but  more  especially  in 
mouth-washes  and  gargles,  for  the  reason  that 
the  buccal  cavities,  even  of  healthy  persons, 
often  contain  pathogenic  microorganisms. 


KPISTAXIS. 


Dr.  Jonathan  Hutchinson  recommends  for  the 
treatment  of  epistaxis  the  plunging  of  the  feet 
and  hands  of  the  patient  into  water  as  hot  as  can 
be  borne.  He  declares  that  the  most  rebellious 
cases  have  never  resisted  this  mode  of  treatment. 
—  Boston  Medical  and  Surgical  Journal, 


i89i.] 


SOCIETY  PROCEEDINGS. 


65 


SOCIETY   PROCEEDINGS. 


The  Harlem  Medical  Association. 

Third  Regular  Meeting,   Session  1890-gi,    held 
Wednesday,  Dec.  j,  at  5  IV.  I2jth  street, 
New  York. 

E.  Fridenburg,  M.D.,  President,  in  the 
Chair. 

Dr.  E.  L.  Cocks  presented  a  patient,  S.,  male, 
30  years,  truck  driver,  whom  he  first  saw  May 
11,  1889.  Family  history  negative.  Complained 
of  numb  feeling  over  right  eye  including  the  tem- 
poral and  molar  regions;  also  tingling  sensations 
starting  just  in  front  of  the  right  ear,  running 
across  the  nose  and  including  the  right  half  of 
the  upper  lip.  He  did  not  feel  the  eyelid  on 
winking  nor  a  piece  of  cotton  passed  over  the 
cornea.  The  eye  protruded  so  that  it  was  on  a 
line  with  the  nasal  bone.  He  first  noticed  that 
the  right  eye  was  growing  larger  three  months 
previous  to  his  first  visit.  Could  not  close  the 
lid  over  the  right  eye.  On  pressing  over  this  eye 
backwards  and  slightly  downwards  a  tumor  as 
large  as  a  hazel  nut  could  be  felt.  It  was  immov- 
able and  quite  hard.  Its  depth  could  not  be  de- 
termined. The  cornea  was  clear  but  anaesthetic. 
The  pupil  was  fully  dilated  but  did  not  respond 
to  light.  Vision  in  right  eye  entirely  absent. 
Left  eye  \%.  The  ophthalmoscope  showed  the 
veins  much  enlarged  but  the  arteries  smaller. 
The  optic  nerve  atrophied.  He  complained  of 
nocturnal  headaches.  Six  months  previous  to 
his  first  visit  his  hair  commenced  to  fall  out  and 
he  had  sore  throat.  He  denies  all  knowledge  of 
syphilis,  and  claims  never  to  have  had  an  erup- 
tion of  any  kind.  On  examination,  inguinal  and 
cervical  glands  were  enlarged  and  a  syphilitic 
ulcer  was  found  on  the  leg.  The  tibia  is  painful 
on  pressure.  No  signs  of  initial  lesion.  Diag 
nosis,  gumma  of  orbit  pressing  on  optic  nerve 
and  vessels.  Mixed  treatment  instituted,  push- 
ing the  iodide  in  hopes  of  preventing  a  complete 
degeneration  of  the  optic  nerve.  After  three 
weeks  of  treatment  headache  better,  appetite 
good,  and  he  now  feels  the  eyelid  moving,  also 
the  cotton  passed  over  the  cornea.  The  vessels 
are  now  normal.  The  exophthalmia  is  much 
less.  The  tumor  is  sensibly  melting  away-.  By 
July  1  the  eye  resumed  its  normal  position. 
There  was  a  small  ulcer  of  the  cornea  which  dis- 
appeared under  treatment  with  hot  water  and 
atropine.  The  sight  has  not  returned.  The 
nerve  is  in  the  same  condition  of  atrophy  as  at 
the  beginning  of  treatment.  The  patient  does 
not  know  the  exact  period  when  his  sight  be- 
came lost  in  the  right  eye,  but  states  his  vision 
was  good  before  the  time  when  his  hair  began  to 
fall  out.  His  business  did  not  require  accurate 
vision;  if  it  had  he  would  have  made  the  discov- 


ery earlier.  Had  the  patient  been  placed  under 
proper  treatment  when  the  vision  first  be- 
gan to  fail  it  might  have  been  restored.  But, 
under  the  circumstances,  the  result  of  treatment 
is  good. 

Dr.  Mayer  inquired  if  there  were  any  evi- 
dences of  syphilis  in  the  throat;  also,  if  the  ini- 
tial lesion  had  existed  on  the  lip  or  tongue? 

Dr.  E.  L.  Cocks  replied  there  had  been  mu- 
i  cous  patches  in  the   mouth  but  no  evidences  of 
the  initial  lesion. 

Dr.  R.  Van  Santvoord  stated  that  this  case 
illustrated  the  fact,  so  often  noted,  that  while  the 
growths  due  to  syphilis  can  be  removed  by 
proper  treatment,  the  injury  done  to  the  nervous 
structures  by  these  masses  cannot  be  so  easily 
remedied. 

Dr.  G.  H.  Cocks  thought  the  destruction  of 
utility  of  the  optic  nerve  was  due  to  pressure.  He 
spoke  of  two  cases  of  gumma  of  the  iris  coming 
under  his  observation  which  yielded  to  treatment 
so  far  as  the  gumma  was  concerned,  but  the  re- 
sult was  that  the  iris  was  immovable. 

Dr.  E.  Fridenberg  called  attention  to  the 
fact  that  the  principle  point  of  interest  was  that 
the  gumma  was  located  in  the  orbit  as  well  as  its 
large  size.  This  condition  is  rare.  That  the 
cornea  is  now  clear  is  a  good  result.  Another 
interesting  point  is  that  the  patient  was  not  aware 
of  his  loss  of  vision.  Frequently  patients  have  im- 
perfect vision ,  or  perhaps  no  vision  in  one  eye  and  are 
made  aware  of  it  only  by  some  accident.  A  case  came 
under  his  notice  recently  where  the  patient  had 
been  assaulted  and  the  eye  injured.  He  came  to 
New  York  for  expert  examination  before  begin- 
ning a  suit  for  damages  for  loss  of  sight.  Exam- 
ination proved  that  the  lens  was  dislocated  and 
there  were  other  signs  of  long-standing  lesions, 
certainly  antedating  the  injury. 

Dr.  C.  B.  Meding  suggested  the  possibility  of 
a  specific  local  neuritis  independent  of  the  pres- 
sure caused  by  the  gumma.  He  believed  it  pos- 
sible for  the  nerve  to  recover  after  the  pressure, 
as  all  nerves  are  possessed  of  great  vitality. 

Dr.  E.  L.  Cocks  thought  it  strange  that  one 
particular  nerve  should  become  the  seat  of 
neuritis  while  the  other  nerves  of  the  orbit  es- 
caped. 

Dr.  Fridenberg  said  the  suggestion  of  Dr. 
Meding  had  engaged  the  attention  of  oculists, 
because  it  was  well  known  that  neuritis  was  often 
the  result  of  small  tumors  in  the  brain.  However, 
he  did  not  think  the  case  under  consideration  re- 
quired that  explanation. 

Dr.  W.  F.  Martin  presented  photographs 
illustrating  the  following  case:  A  boy,  set.  16, 
first  came  under  treatment  in  June,  1890,  suffer- 
ing from  alopecia  areata  over  a  considerable 
space.  Galvanism  was  employed  three  times  a 
week  for  six  weeks  with  no  improvement.  Small 
fly  blisters  were  then  employed,  three  at  a  time, 


66 


FOREIGN  CORRESPONDENCE. 


[January  io, 


to  remove  the  epidermis.  The  electrodes  were 
now  dipped  into  a  bichlor.  sol.  1-3,000,  and  gal- 
vanism employed.  From  time  to  time  the  posi- 
tion of  the  blisters  was  changed,  but  were  kept 
near  the  denuded  area.  After  ten  days  a  very 
fine  growth  of  hair  began  to  appear,  but  only 
where  the  blisters  had  been  situated.  This  growth 
gradually  became  more  marked  and  abundant. 
In  three  months  the  case  was  entirely  cured.  It 
is  remarkable  that  in  ordinary  cases  the  hair  be- 
gins to  grow  from  the  periphery,  but  in  this  case 
it  began  in  the  centre,  which  was  probably  due 
to  the  treatment. 

Dr.  E.  L.  Cocks  had  seen  a  case  in  Dr.  Buck- 
ley's clinic  which  had  existed  five  months.  The 
patient  went  to  bed  suffering  from  a  headache, 
and,  on  rising  in  the  morning  found  two  bald 
spots  on  the  scalp  which  were  also  anaesthetic. 
Carbolic  washes  had  been  used  and  the  hair  had 
appeared  on  one  spot  but  not  on  the  other. 

Dr.  Meding  called  attention  to  the  fact  that 
one  theory  of  the  cause  of  alopecia  was  that  it 
was  due  to  the  accumulation  of  dandruff.  It  was 
commonly  known  that  solutions  of  the  bichloride 
of  mercury  were  useful  in  this  condition.  Per- 
haps the  solution  had  more  to  do  with  the  cure 
of  Dr.  Martin's  case  than  the  galvanism. 

Dr.  Knickerbocker  inquired  of  Dr.  Martin 
how  he  explained  the  fact  that  the  hair  came 
back  over  the  whole  surface,  whereas  the  bichlor- 
ide solution  had  only  been  applied  to  limited 
areas  ? 

Dr.  Martin  had  no  explanation  to  offer,  he 
only  knew  that  the  hair  commenced  to  grow  only 
on  the  surfaces  denuded  byr  the  blisters  and  then 
gradually  spread. 

Dr.  G.  H.  Cocks  presented  to  the  Association 
a  patient  26  years  old,  a  fireman  on  the  elevated 
railroad.  On  November  15  last,  while  at  his 
work,  he  noticed  a  very  peculiar  numb  feeling 
extending  over  the  entire  left  side  of  his  body. 
This  feeling  lasted  only  a  very  few  minutes.  One 
week  later,  while  working  on  his  engine,  he  felt 
a  severe  pain  his  left  eye,  as  if  a  coal  or  spark 
had  entered  it.  The  muscles  of  the  jaw  became 
contracted  and  he  fell  forward  unconscious  on  the 
boiler,  receiving  superficial  burns  on  the  wrists 
of  both  hands.  The  engineer  did  not  notice  any 
convulsions  or  frothing  of  the  mouth.  He  was 
unconscious  about  half  an  hour.  The  important 
question  is  as  to  diagnosis,  and,  if  these  attacks 
are  likely  to  recur.  He  is  in  line  of  promotion, 
but  does  not  feel  disposed  to  become  an  engineer 
if  these  attacks  are  to  be  repeated. 

Dr.  Van  Santvoord  was  inclined  to  consider 
the  case  one  of  epilepsy  having  the  usual  aura 
and  loss  of  consciousness.  There  may  have  been 
convulsive  movements  present  although  these 
were  not  recognized  at  the  time. 

Dr.  Mayer  was  inclined  to  leave  the  diagnosis 
open  to  see  if  there  is  a  return  af  the  attacks.    In 


the  meantime  he  did  not  consider  it  proper  for 
the  patient  to  assume  a  perilous  position. 

Dr.  Malleson  inquired  if  the  urine  had  been 
examined? 

Dr.  Cocks  replied  that  he  regretted  that  he 
had  not  examined  it.  He  had  carefully  exam- 
ined the  heart  and  found  that  normal. 

Dr.  Van  Santvoord  had  a  case  of  convulsions 
occurring  in  a  woman  suffering  from  albuminuria 
of  pregnancy.  The  albumen  was  not  found  just 
before  or  after  the  attack.  It  appeared  some 
twenty- four  hours  after  the  convulsive  attack. 

Dr.  Fridenberg  believed  it  impossible  to 
make  a  positive  diagnosis  in  the  case  under  con- 
sideration at  the  present  time.  We  must  wait 
until  the  case  develops.  It  is  possible  for  an  at- 
tack of  this  character  to  be  due  t  j  some  peripheral 
irritation.  He  related  the  instance  of  his  brother, 
a  young  man  23  years  old,  who  had  two  attacks 
of  loss  of  consciousness  with  some  convulsive 
movements  lasting  a  few  minutes.  Vomiting  fol- 
lowed. These  seizures  were  due  to  the  eruption 
of  a  wisdom  tooth. 


FOREIGN    CORRESPONDENCE. 


LETTER  FROM  LONDON. 

(FROM   OUR   OWN   CORRESPONDENT.) 

Sulpkicktkyolic   Acid   and   its  Preparations   in 
ttii      Treatment     of    Inflammatory     Diseases     of 
Women — The     Leprosy     Commission    in    India — 
Spasmodic    Dysmenorrhea — Disinfection     af   In- 
fected Premises — Miscellaneous  Gleanings. 

When  ichthyol  was  first  introduced  into 
therapy  it  made  a  very  considerable  reputation, 
and  was  found  by  experiment  to  have  a  con- 
tractile influence  upon  the  vascular  system  so 
that  hyperemia,  inflammation  and  pain  in  any 
situation  were  relieved  by  its  application.  The 
disorders  caused  by  or  associated  with  dilation  of 
the  vascular  system  or  anomalies  of  the  circula- 
tion being  so  numerous,  the  remedy  ran  some 
risk  of  being  regarded  as  put  forward  as  a 
panacea.  This  was  even  more  the  case  when  the 
substance  began  to  be  used  internally  against 
organic  affections  or  disordered  functions,  which 
could  be  regarded  as  due  to  or  intimately  con- 
nected with  a  dilated  vascular  condition.  yuite 
a  new  direction  for  the  display  of  the  peculiar 
properties  of  sulphichthyolic  acid  and  its  prepara- 
tions have  been  tried  and  it  is  now  employed 
internally,  nut  only  in  various  skin  affections, 
but  also  in  the  inflammatory  diseases  of  women. 
Against  these  latter  it  is  found  to  be  generally 
more  effective  than  any  remedies  previously  in 
use.  The  results  are  found  to  be  extraordinarily 
satisfactory  as  far  as  pain  soothing  and  dispersing 
properties  go.     As  regards  methods  of  applica- 


i89i.] 


FOREIGN  CORRESPONDENCE. 


tion,  that  generally  found  sufficient  externally 
was  a  10  per  cent,  solution  in  glycerine,  some- ; 
times  suppositories  or  ointment  of  ichthyol  is  also 
used.  Internally  the  remedy  is  given  in  pills. 
Out  of  one  hundred  recent  cases,  thirty-four  were 
completely  cured,  thirty-nine  were  considerably 
improved,  and  fifteen  underwent  a  more  or  less 
pronounced  change  for  the  better.  In  only 
twelve  out  of  the  whole  number  was  ichthyol 
without  success.  The  remedy  has  been  found  to 
be  convenient  in  application  and  favorable  in 
action. 

The  members  of  the  Leprosy  Commission, 
consisting  of  Dr.  G.  A.  Buckmaster,  Rad- 
cliff  Fellow  of  Magdalen  College,  Oxford,  Dr. 
A.  Kanthank,  of  St.  Bartholomews  Hospital, 
and  Dr.  B.  N.  Rake,  Government  Medical 
Officer  of  the  Leper  Asylum,  Trinidad,  have  ar- 1 
rived  in  Bombay  and  will  at  once  commence  their 
work.  The  interest  awakened  in  India  by  this 
commission  is  likely  to  extend  to  every  place  in 
the  British  possessions  where  this  rualady  exists. 
The  final  report  is  to  be  subjected  to  a  severe 
scientific  analysis.  The  commission  has  been 
welcomed  in  India  with  every  demonstration  of 
approval  and  sympathy. 

Dr.  Champneys,  in  his  lecture  on  Painful  Men- 
struation, delivered  before  the  Harveian  Society, 
considered  spasmodic  dysmenorrhoea  to  be  the 
only  real  dysmenorrhoea.  The  mechanical  causes 
of  the  complaint  he  summarized  under  the  heads 
of  the  theory  of  flexion,  stenosis,  and  chronic 
congestion  produced  by  flexion,  but  he  thought 
this  theory  was  inadequate.  With  regard  to  the 
question  as  to  whether  flexions  were  essentially 
associated  with  dysmenorrhoea,  a  large  number 
of  examinations  made  by  observers  in  virgins, 
multiparae  and  mothers,  showed  conclusively  that 
anteflexion  was  not  the  usual  cause  of  spasmodic 
dysmenorrhoea.  As  to  treatment,  he  thought 
that  division  of  the  os  led  to  an  alleviation  of  the 
pain  by  setting  at  rest  the  irritated  uterine  fibres. 
Pregnane}',  followed  by  parturition,  appeared  to 
be  the  physiological  remedy.  Hygienic  meas- 
ures, with  plenty  of  Epsom  salts,  was  the  best 
prophylactic  treatment.  Division  of  the  external 
os  was  always  useless  in  such  cases,  but  incision 
of  the  internal  os,  although  it  was  a  highly  dan- 
gerous proceeding,  was  sometimes  attended  with 
good  results,  as  was  also  dilatation  of  the  cervix, 
when  this  operation  was  performed  midway  be- 
tween the  menstrual  periods. 

Among  the  most  useful  provisions  of  the  In- 
fectious Diseases  (Prevention)  Act  of  last  ses- 
sion, are  those  relating  to  disinfection  of  infected 
premises.  Hitherto  the  officers  of  sanitary  bodies 
have  been  hampered  in  their  endeavors  to  check 
the  spread  of  infectious  sickness  among  the  poor- 
er sections  of  the  community  by  reason  of  the 
difficulties  attending  the  adequate  disinfection  of 
living-rooms,    it  may   be   already   overcrowded. 


But  power  is  now  placed  in  the  hands  of  all  local 
sanitary  bodies  who  choose  to  use  it,  of  providing 
members  of  a  family  in  which  infectious  disease 
has  appeared,  with  temporary  shelter  or  house 
accommodation,  when  they  have  been  compelled 
to  leave  their  dwelling  for  purposes  of  disinfec- 
tion by  the  sanitary  authority.  Up  to  now  such 
expenditure  has  not  been  a  legal  charge  upon  the 
district. 

The  refusal  to  admit  women  to  medical  exam- 
inations at  Oxford  gives  just  now  somewhat  in- 
creased interest  to  the  signal  success  which  the 
students  of  the  London  School  of  Medicine  for 
Women  have  attained  at  the  recent  examination 
at  the  University  of  London.  There  were  nine 
female  candidates  for  the  M.B.  degree,  and  all 
have  passed — five  in  the  first  and  four  in  the  sec- 
ond division  ;  of  the  sixty  male  candidates  fifty- 
two  were  successful.  Among  the  medical  schools 
University  College  and  Guy's  Hospital  take  the 
first  place,  each  having  eleven  successful  candi- 
dates. Next  come  St.  Bartholomew's  with  ten, 
the  London  Hospital  with  seven,  and  King's  Col- 
lege with  six  successful  candidates.  The  total  , 
number  of  MB.  degrees  granted  by  the  London 
University  this  year  is  eighty,  the  largest  num- 
ber yet  attained.  Last  year  the  number  was 
sixty-four.  The  increase  has  been  made  not- 
withstanding complaints  from  some  of  the  medi- 
cal schools  with  respect  to  the  severity  of  the  re- 
quirements of  the  University.  It  is  stated  that 
the  scheme  of  reconstitution,  of  which  the  Senate 
has  resumed  the  consideration,  does  not  progress 
very  favorably,  and  gives  no  great  promise  of  a 
satisfactory  issue. 

Mr.  Lennox  Browne  has  had  under  his  charge 
a  curious  case,  which  must  have  troubled  various 
physicians  and  surgeons.  A  middle-aged  female 
patient  was  sent  to  him  from  the  Provinces,  and 
from  her  debilitated  condition  the  supposition 
was  that  her  malady  was  either  phthisis  or  lar- 
yngeal cancer.  The  woman  was  tall  and  large 
boued,  yet  her  weight  was  only  90  pounds.  Mr. 
Browne  ascertained  that  the  real  cause  of  her 
emaciation  was  the  lodgement  of  a  plate  of  arti- 
ficial teeth,  which  had  become  firmly  imbedded 
in  the  larynx,  and  had  there  remained  twenty- 
two  months.  The  patient  remembered  that  one 
night  she  had  been  seized  with  a  violent  fit  of 
coughing,  and  that  her  artificial  teeth  disappeared 
somehow  during  the  paroxysms.  Difficulty  of 
breathing  and  pain  in  swallowing  resulted  from 
that  very  day.  The  obstacle  having  been  dis- 
lodged, the  patient  has  speedily  recovered. 

At  the  first  meeting  of  the  committee  on  hyp- 
notism the  following  headings  were  decided  upon 
as  a  basis  for  carrying  out  investigations:  1. 
The  Nature  of  Hypnotism  and  its  Nervous  and 
Mental  Relations.  2.  Its  General  or  Limited 
Applicability  as  a  Therapeutic  Agent  in  different 
classes  of  disease.      3.    The  Degree  and  Mode  of 


68 


DOMESTIC  CORRESPONDENCE. 


[January  io, 


its  Influence  on  Morbid  Conditions.  4.  Its 
Dangers  and  the  Necessary  Safeguards.  Dr. 
Needham,  the  President  of  the  Section  of  Psy- 
chology at  the  annual  meeting  of  the  Association 
in  Birmingham,  was  unanimously  elected  Chair- 
man of  the  Committee. 

At  one  of  the  London  Hospitals  antiseptic 
sponges  are  prepared  by  plunging  thoroughly 
clean  and  bleached  sponges  in  a  liquid  composed 
of  carbolic  acid  10  grams,  alcohol  at  900  20 
grams,  distilled  water  100  grams,  and  essence  of 
lavender  30  drops.  After  being  left  in  this  liquid 
for  a  few  days  they  are  washed  with  distilled 
water,  which  carries  off  the  excess  of  carbolic 
acid.  Very  great  antiseptic  powers  are  claimed 
for  the  essence  of  lavender,  which  is  not  added 
merely  for  its  agreeable  odor. 

Dr.  Thorne  Thorne  will  deliver  the  Milroy 
Lectures  on  Public  Health  at  the  Royal  College 
of  Physicians  on  February  17,  19,  24,  and  26. 
The  subject  selected  being  Diphtheria,  its  Natural 
History  and  Prevention.  G.  o.  m. 


DOMESTIC  CORRESPONDENCE. 


LETTER  FROM    NEW  YORK. 

(from  ottr  own  correspondent.) 

New  York  Physicians  and  the  Koch  Lymph— 
Dr.  J.  H.  Tyndale  and  the  Treatment  of  Tubercu- 
losis by  Inoculation — Statistics  of  Phthisis  and  Pneu- 
monia— Dr.  Oliver  Wendell  Holmes  on  Academies 
—  The  State  Commissian  on  Lunacy — A  History 
of  Legislation  for  the  Insane  in  the  State  of  New 
York — Public  Baths  for  Winter  Use — Miscellane- 
ous Gleanings. 

During  the  past  month  quite  a  number  of  New 
York  physicians,  the  most  of  them  acting  as  rep- 
resentatives of  medical  schools  and  hospitals,  have 
gone  to  Berlin  to  made  a  personal  study  of  the 
inoculation  method  of  Koch.  The  first  consign- 
ments here  of  ' '  lymph  ' '  from  Germany  were  re- 
ceived about  the  same  time  at  the  Hospital  for 
Ruptured  and  Crippled,  St.  Luke's  Hospital  and 
Mount  Sinai  Hospital,  and  the  physicians  of  these 
institutions  have  been  assiduously  experimenting 
with  it  upon  appropriate  cases.  At  the  first-  named 
hospital  the  patients  treated  have  been  principally 
children  suffering  from  spinal  caries,  hip-joint  dis- 
ease, and  other  similar  affections. 

In  connection  with  the  subject  of  the  treatment 
of  tuberculosis  by  inoculation,  it  may  be  of  inter- 
est to  mention  that  at  the  November  meeting  of 
the  New  York  County  Medical  Association,  Dr. 
J.  H.  Boldt  called  attention  to  the  work  in  this 
direction  which  has  been  accomplished  by  one  of 
the  members  of  the  Association,  Dr.  J.  Hilgard 
Tyndale.  For  a  number  of  years,  he  said,  Dr. 
Tyndale  has  been  pursuing  experimental  investi- 


gations in  the  same  line  as  Koch,  and  during  the 
past  year  and  a  half  he  has  met  with  excellent 
results  from  the  inoculation  of  tuberculous  pa- 
tients with  bovine  virus  diluted  in  a  saline  solu- 
tion. Among  the  results  noted  have  been  the 
following:  Cough  diminished  very  rapidly,  hectic 
disappeared,  the  bacilli  decreased  in  the  sputa, 
the  weight  increased  and  the  general  health  im- 
proved. As  in  the  case  of  Koch's  inoculations, 
the  constitutional  symptoms  immediately  result- 
ing from  inoculation  were  quite  severe.  It  is  ex- 
pected that  Dr.  Tyndale  will  present  a  detailed 
account  of  his  experiments  and  their  results  to 
the  Association  at  an  early  day. 

In  view  of  the  special  interest  now  attaching  to 
the  matter  of  consumption,  Dr.  John  T.  Nagle, 
of  the  Bureau  of  Vital  Statistics  of  the  Health 
Department,  has  prepared  a  table  which  shows 
the  number  of  deaths  from  phthisis  and  from 
pneumonia  occurring  in  this  city  during  the  last 
ten  years ;  the  deaths  from  both  causes  being 
given  for  the  reason  that  cases  of  phthisis  some- 
times terminate  in  pneumonia,  and  many  cases  of 
pneumonia  are  of  a  chronic  character,  although 
this  is  not  always  stated  in  the  death  certificates. 
This  table  is  as  follows  : 

Deaths  from        Deaths  from         Deaths  from 
Phthisis.  Pneumonia.  all  Causes. 

1880 4,7o6  2,822  31,937 

l88l 5,312  3,261  38,624 

IS82 5,247  3,472  37.924 

1S83 5,290  3,409  34.0II 

18S4 5,235  3,159  35.034 

1885 5,196  3,649  35.682 

1886 5,477  3,657  37,351 

1887 5,260  3,707  38,933 

188S 5,260  4,288  40,175 

18S9 5,179  4,075  39.697 

Total 52.162  35.499  369,35° 

The  table  shows  that  the  percentage  of  the 
deaths  from  phthisis  to  the  total  deaths  in  the  city 
in  these  ten  years  was  14.12. 

There  can  be  no  question  that  the  most  attrac- 
tive feature  of  the  ceremonies  recently  held  at  the 
formal  opening  of  the  new  building  of  the  Acad- 
emy, was  the  reading  of  the  characteristic  and 
noble  letter  sent  by  Dr.  Oliver  Wendell  Holmes,  of 
Boston,  who  was  unable  to  be  present  in  person  on 
this  occasion.  It  was,  in  part,  as  follows:  'Acad- 
emies have  been  too  often  thought  of  as  places  of 
honorable  retirement  and  dignified  ease — roosts 
where  emeritus  professors  and  effete  men  of  let- 
ters, once  cocks  of  the  walk,  could  sit  in  quiet 
rows,  while   the   fighting,  the  clucking  and  the 

crowing  were  going  on  beneath  them But 

the  academy  which  fulfils  its  true  functions  is  a 
working  body.  It  deals  with  living  subjects  ;  it 
handles  unsettled  questions ;  it  sets  tasks  for  its 
members  and  furnishes,  so  far  as  it  can,  the  ap- 
pliances for  their  prosecution  ;  it  offers  rewards 
for  meritorious  performances  and  sits  in  judgment 
on  the  efforts  of  aspirants  for  distinction.      It  fur- 


<•] 


DOMESTIC  CORRESPONDENCE. 


69 


nishes  the  nearest  approach  we  can  expect  to  a  1 
fixed  standard  of  excellence  by  which  the  work 
of  new  hands  and  the  new  work  of  old  hands  can 
be  judged.  It  is  a  barrier,  a  breakwater,  against 
the  rush  of  false  pretensions  which  are  constantly 
attempting  to  find  their  way  into  public  confidence. 

"  Nowhere  is  such  a  defense  more  needed  than 
in  the  sciences  and  arts  which  deal  with  the  health 
of  the  community.  The  public  is  so  ready,  so 
eager  to  be  deceived,  and  the  traders  in  deception 
are  so  willing,  so  hungry  to  deceive  those  who 
will  listen  to  them,  that  it  needs  a  solid  wall  of 
resistance,  a  close,  united  phalanx  of  men  of  rec- 
ognized sense,  knowledge  and  character  to  stand 
against  them.  The  various  forms  of  what  I  will 
venture  to  christen  as  pseudo-pathy  and  pseudo- 
therapy — -though  they  are  known  to  the  public 
by  other  names — can  never  loosen  the  intelligent, 
thoroughbred  physician,  or  the  enlightened  mem- 
bers of  society,  so  long  as  the  best  heads  of  the 
profession  are  banded  together  in  a  noble  in- 
stitution like  this  Academy.  We  look  to  this 
great  and  able  body  of  men  to  guard  the  sacred 
avenues  to  the  temple  of  science  against  all  wor- 
shipers of  idols.  The  medical  profession  will  al- 
ways have  to  fight  against  the  claims  of  wrong- 
headed  and  too  often  dishonest  individuals,  and 
'  schools,'  as  they  call  themselves.  A  portion  of 
every  community  will  always  run  after  the  false 
prophets.  There  are  a  certain  number  of  squint- 
ing brains,  as  there  are  of  squinting  eyes,  among 
every  thousand  of  our  population.  There  will 
always  be  a  corresponding  number  of  persons 
calling  themselves  physicians  ready  to  make  a 
living  out  of  them.  Long  may  it  be  before  the 
wholesome  barriers  are  weakened  that  separate 
the  thoroughbred  and  truly  scientific  practitioner 
from  the  plausible  pretender  with  his  pseudo- 
pathy  and  his  pseudo-therapy." 

It  would  certainly  seem  to  be  well  that  some  of 
our  New  Code  friends  among  the  officials  as  well 
as  Fellows  of  the  Academy,  who  have  done  all  in 
their  power  to  break  down  these  ' '  wholesome 
barriers,"  should  ponder  deeply  these  wise  coun- 
sels of  the  genial  and  venerable  Autocrat. 

The  State  Commission  in  Lunacy  has  adopted 
two  orders  which  it  is  believed  will  be  of  consid- 
erable benefit  to  the  welfare  of  the  patients  in  the 
State  hospitals  for  the  insane.  The  first  provides 
that  each  insane  patient  shall  be  permitted  to  write 
to  some  friend  or  relative  at  least  ever}'  two  weeks, 
and,  in  the  case  of  patients  unable  for  any  reason 
to  write,  the  medical  superintendent  of  the  hos- 
pital must  direct  some  proper  person  to  wTrite  for 
such  patients  at  suitable  intervals,  if  they  so  de- 
sire. All  letters  of  insane  patients  which  are  de- 
tained must  be  forwarded  to  the  Commission, 
accompanied  by  a  statement  of  the  reasons  for 
such  detention  ;  and  all  letters  addressed  to  State 
officers,  judges  of  courts  of  record,  and  district 
attorneys,  must  be  immediately  forwarded  with- 
out examination. 


The  second  order  states  that,  in  view  of  a  cus- 
tom which  has  long  prevailed  of  permitting  pa- 
tients to  temporarily  leave  institutions  for  the  in- 
sane to  visit  friends,  or  to  go  out  "on  trial  "  for 
an  indefinite  period,  and  it  also  having  been  made 
to  appear  that  due  diligence  has  not  always  been 
exercised  to  ascertain  the  whereabouts  of  insane 
patients  who  have  escaped,  and  to  promptly  se- 
cure their  return,  and  as  in  cases  where  long  in- 
tervals elapse  between  the  date  of  parole  or  escape 
and  the  return  of  patients  to  an  institution,  the 
possibility  may  arise  of  their  being  reconfined 
when  not  insane  by  reason  of  their  recovery  dur- 
ing such  interval,  it  is  ordered  that  no  insane  pa- 
tient, while  in  the  custody  of  an  institution,  be 
permitted  to  go  upon  parole  who,  in  the  judgment 
of  the  medical  superintendent,  is  dangerous,  either 
to  himself  or  others ;  that  no  parole  be  granted 
for  a  longer  period  than  thirty  days ;  that  upon 
the  escape  of  a  patient  prompt  and  vigorous 
measures  be  taken  to  secure  his  return ;  that  a 
patient  who  has  been  paroled  or  who  has  escaped, 
if  not  returned  to  the  institution  by  the  thirtieth 
day  thereafter,  must  be  discharged  from  the  books 
of  the  institution  upon  that  day,  and  a  notice  of 
such  discharge  must  be  forwarded  to  the  Commis- 
sion ;  and  that  such  patient  must  not  be  readmit- 
ted except  upon  a  new  medical  certificate  of  lu- 
nacy, the  cost  of  which  (except  in  the  case  of  a 
private  institution,  by  special  agreement),  must 
be  borne  by  the  institution. 

In  view  of  efforts  which  are  now  being  made 
by  certain  interested  parties  to  bring  to  bear  such 
influence  upon  the  State  Legislature  as  will  ren- 
der null  and  void,  as  far  as  possible,  the  benefi- 
cent provisions  of  the  act  establishing  State  care 
for  the  insane  poor  passed  at  its  last  session,  an  able 
writer  in  Utica  has  prepared  an  interesting  his- 
tory of  legislation  for  the  insane  in  this  State, 
and  the  opposition  which  the  friends  of  reform 
have  had  to  encounter  during  the  last  quarter  of 
a  century.  From  this  it  appears  that  twenty- five 
years  ago  the  Legislature  passed  an  act  little  less 
than  revolutionary  as  far  as  the  preconceived  ideas 
of  many  were  concerned,  which  had  for  its  object 
the  freeing  of  the  insane  poor  from  the  thralldom 
of  the  brutal  and  ignorant  keepers  of  the  county 
almshouses.  The  passage  of  this  act  was  the 
culmination  of  a  fierce  struggle  between  the 
friends  of  humanity  and  intelligence  on  the  one 
side,  and  those  of  ignorance,  viciousaess  and  cu- 
pidity on  the  other. 

It  is  worthy  of  note,  however,  that  the  measure 
j  was  opposed  by  one  man  of  great  eminence  as  an 
alienist,  who  for  many  years  was  Superintendent 
of  the  State  Asylum  at  Utica,  and  who  received 
the  high  honor  of  being  made  the  second  Presi- 
dent of  the  New  York  State  Medical  Association, 
the  late  Dr.  John  P.  Gray.  He  did  so  not  because 
he  wTas  hostile  to  a  higher  ideal  of  treatment  for 
the  insane  poor,  but  because  he  contended  that 


70 


DOMESTIC  CORRESPONDENCE. 


[January  io, 


the  act  was  based  upon  a  wrong  theory,  for  the 
reason  that  it  confirmed  a  policy  of  the  State 
which  he  regarded  as  highly  detrimental,  name- 
ly :  that  which  declared  that  after  a  certain  length 
of  time  or  under  certain  circumstances  insanity 
was  incurable,  and  provided  that  the  insane  poor, 
after  a  short  period  of  treatment — usually  less  than 
two  years — might  be  sent  to  the  asylum  proposed 
to  be  established  under  the  act  and  cared  for  as 
"chronic  insane."  Dr.  Gray  did  not  live  along 
to  see  the  Legislature  of  the  State  come  to  his 
way  of  thinking;  but  it  is  gratifying  to  those  who 
hold  his  memory  dear  that  this  brilliant,  accom- 
plished and  humane  man  was  nearly  twenty- five 
years  in  advance  of  his  contemporaries  on  a  ques- 
tion involving  such  profound  human  sympathies. 

This  act  provided  for  the  establishment  of  a 
State  Asylum  for  the  Chronic  Insane,  and  that 
all  of  the  so  called  chronic  insane  in  the  poor- 
houses  at  that  time  should  be  transferred  to  it  as 
soon  as  the  buildings  were  completed;  but  the  men 
who  profited  by  the  care  of  these  individuals  soon 
showed  that  they  were  not  to  be  so  easily  de- 
prived of  their  spoils.  With  great  cunning  they 
changed  their  tactics,  and  under  the  guise  of  pa- 
triotism and  unselfish  desire  to  relieve  the  tax- 
payer, they  defeated  from  year  to  year  the  passage 
of  appropriations  for  the  enlargement  of  the  Wil- 
lard  Asylum  for  Chronic  Insane.  After  a  few 
years  of  such  tactics  they  came  before  the  Legis- 
lature with  statements  like  the  following :  "  Now, 
you  see  that  this  asylum  will  not  be  enlarged  rap 
idly  enough  to  accommodate  all  the  insane  as  fast 
as  they  ought  to  be  provided  for.  We  propose 
that  you  give  these  county  people  another  chance. 
They  mean  well.  These  insane  poor  live  in  their 
midst,  and  the}-  are  tenderly  attached  to  them. 
They  desire  that  their  friends  shall  have  the  op- 
portunity of  frequently  visiting  them,  and  it  is 
wicked  to  remove  them  farther  from  their  homes. 
Now,  why  not  provide  a  scheme  whereby  certain 
of  the  '  good  '  counties  can  be  exempted  from  the 
operation  of  this  statute  so  long  as  they  care  for 
these  poor  people  properly  ?  You  can  at  least  try 
them,  and  if  you  find  that  they  are  not  honorably 
living  up  to  their  promises,  then  the  exemptions 
can  be  revoked.  This  plan  will  relieve  the  State 
and  at  the  same  time  will  satisfy  the  counties." 

This  sophistry  prevailed,  and  the  proposed  plan 
was  carried  out.  Much  that  had  been  gained  was 
lost.  The  principle  ostensibly  contended  for  was 
practically  abrogated,  and  the  old  abuses  of  the 
system  of  county  care  were  rapidly  revived.  The 
exemptions  continued  to  be  granted  until  twenty 
counties  were  relieved  from  the  necessity  of  send- 
ing their  chronic  insane  to  the  Willard  State  Asy- 
lum; and  for  many  years  the  evils  attendant  upon 
the  confinement  of  insane  patients  in  local  poor- 
houses,  with  utterly  inadequate  medical  care, 
continued  unabated.  About  four  years  ago,  how- 
ever, the  State  Charities  Aid  Society  turned  its 


attention  to  the  condition  of  the  insane  in  the 
county  almshouses  and  in  the  so-called  county 
asylums  of  the  State,  and  the  result  of  its  inves- 
tigations was  to  instigate  prompt  measures  for  the 
remedying  of  this  great  abuse  once  more.  With 
this  end  in  view  legislative  action  was  sought, 
and  the  heroic  efforts  of  this  philanthropic  organ- 
ization, backed  by  the  press  and  by  numerous 
medical  societies,  as  well  as  the  great  mass  of  the 
medical  profession,  are  now  well  known.  Each 
winter  up  to  1890  these  efforts  were  defeated  by  a 
most  vicious  combination  of  meanness,  greed  and 
petty  politics ;  but  in  1889  the  Society  came  near- 
ly to  the  point  of  success,  its  bill  providing  for 
State  care  of  the  insane  poor  being  defeated  by 
only  a  few  votes. 

At  this  juncture  another  potent  factor  was 
brought  forward,  namely  :  the  State  Commission 
in  Lunacy,  a  central  board  endowed  with  ample 
powers,  which  was  created  in  1889,  after  a  ten 
years'  struggle  in  the  Legislature  by  the  advo- 
cates of  such  a  commission.  The  first  report  of 
the  Commission,  with  Dr.  Carlos  P.  MacDonald, 
a  physician  with  twenty  years'  asylum  experi- 
ence, at  its  head,  fully  confirmed  all  that  the 
State  Charities  Aid  Society  had  previously  re- 
ported in  regard  to  the  disgraceful  condition  of 
the  insane  poor  in  the  various  county  institutions; 
and  it  was  no  doubt  largely  due  to  this  that  the 
act  now  in  force  was  passed  last  winter.  This 
act,  it  will  be  remembered,  provides  for  the  care 
in  State  Hospitals  of  all  the  insane  poor,  including 
both  acute  and  chronic  cases,  in  the  State,  with 
the  exception  of  New  York,  Kings  and  Monroe 
Counties.  For  the  first  time  in  the  history  of  the 
State  it  is  legally  recognized  that  the  insane  are 
wards  of  the  State  ;  and  the  act  also  recognizes 
the  principle  that  insanity  is  a  disease,  and  as 
such  is  amenable  to  treatment  like  other  diseases. 

As  in  1865,  so  in  1890,  the  friends  of  the  county 
poorhouses  and  asylums,  with  a  brazen  effrontery, 
are  at  work  to  undo  as  far  as  possible  the  good 
that  has  been  accomplished;  but  they  are  not 
very  consistent  in  their  talk.  They  insist  that 
they  want  to  do  nothing  more  than  care  for  what 
they  are  pleased  to  term  the  chronic  or  incur- 
able insane,  and  yet  in  the  same  breath  the}-  state 
— an  assertion  not  very  creditable  to  their  vaunted 
intelligence — that  they  cure  more  of  these  in 
their  local  institutions,  and,  it  must  be  remem- 
bered, without  any  appliances  or  any  medical 
skill  worthy  the  name,  than  the  State  hospitals 
provided  with  all  the  most  approved  modern 
facilities  for  the  treatment  of  the  insane.  Their 
plan  of  campaign  is  being  rapidly  arranged. 
Thus,  the  Board  of  Supervisors  of  one  of  the 
counties  in  the  central  part  of  the  State  at  a  re- 
cent session  issued  a  circular  calling  upon  the 
similar  boards  of  other  counties  to  aid  them  in 
the  movement,  and  to  ask  for  the  repeal,  and 
failing  in  that,  the  modification  of  the  new  law 


I89i.] 


DOMESTIC  CORRESPONDENCE. 


7' 


establishing  State  care  for  the  insane  poor.  By 
the  term  modification  it  is  not  clearly  shown 
what  is  meant,  but  it  is  intimated  that  the  old 
tactics  of  1865  are  to  be  again  employed,  and 
that  an  effort  is  to  be  made  to  exempt  certain  of 
the  "good"  counties  from  the  operation  of  the 
statute,  and,  if  this  should  fail,  to  defeat  all  ap- 
propriations for  carrying  out  its  provisions.  It  is 
a  fact  that  the  count}'  authorities,  now  that  this 
act  has  been  passed,  decline  to  take  any  steps 
whatever  towards  bettering  the  condition  of  the 
insane  poor  still  remaining  under  their  charge. 
Now  they  propose  to  prevent  the  appropriation 
of  money  for  their  removal,  and  if  they  are  suc- 
cessful the  result  can  only  be  that  the  condition 
of  these  people,  bad  as  it  is  now,  will  grow 
worse. 

A  curious  feature  of  this  movement  is  that  the 
whole  contention  is  over  only  about  one-fourth 
of  the  insane  poor  of  the  counties  of  the  State  ex- 
clusive of  New  York,  Kings  and  Monroe  Coun- 
ties. In  the  other  fifty -seven  counties,  there  are, 
according  to  the  report  of  the  Commission  in 
Lunacy,  considerably  less  than  eight  thousand 
people  of  this  class.  Over  five  thousand  of  these 
patients  are  now  provided  for  in  the  State  hospi- 
tals, so  that  the  effort  is  directed  to  preventing 
less  than  one-fourth  receiving  the  same  care  and 
treatment  as  the  other  three-fourths;  the  osten- 
sible pretext  for  this  being  that  the  one-fourth  are 
incurable  insane,  have  been  declared  so  by  statute, 
by  lapse  of  time,  and  by  the  opinions  of  the  super- 
intendents I  By  the  1st  of  October,  1891,  with 
the  appropriations  which  have  already  been  made 
by  the  legislature,  it  is  estimated  that  the  num- 
ber of  insane  poor  still  left  unprovided  for  in  the 
State  hospitals  will  not  exceed  1,200. 

The  subject  of  public  baths,  for  winter  as  well 
as  summer  use,  is  just  now  receiving  considerable 
attention,  especially  in  view  of  the  fact  that  many 
of  the  city's  free  summer  baths  along  the  Hud- 
son and  East  Rivers  are  adjacent  to  the  mouths 
ot  sewers  and  in  consequence  endanger,  to  a 
greater  or  less  extent,  the  health  of  the  bathers. 
At  a  recent  meeting  of  the  Section  on  Hygiene, 
Public  Health  and  State  Medicine,  of  the 
New  York  Academy  of  Medicine,  Dr.  Simon 
Baruch,  who  has  given  much  attention  the  sub- 
ject, read  a  paper  entitled  "A  Study  of  the  Pub- 
lic Baths,  together  with  an  Inexpensive  Method 
for  their  Hygienic  Utilization,"  and  in  it  he  pro- 
posed a  plan  for  the  establishment  of  public 
shower  baths,  such  as  are  now  in  use  in  Berlin 
and  Vienna.  Acting  on  the  suggestions  of  Dr. 
Baruch,  the  Society  for  Improving  the  Condition 
of  the  Poor  have  determined  to  erect  on  a  site  in 
the  midst  of  a  down-town  crowded  tenement  dis- 
trict which  has  been  offered  them  by  the  City 
Mission  and  Tract  Society,  a  two-story  building, 
27x61  feet,  in  which  it  is  proposed  to  have  a 
reading-room  with  an  open  fire-place  and  twenty- 


four  large  apartments  for  bathers.  Only  shower 
or  spray  baths  will  be  provided,  these  being  be- 
lieved to  be  the  most  efficient  for  the  preserva- 
tion of  health;  and  each  apartment  is  to  have  a 
subdivision  to  be  used  as  a  dressing  room. 
Tickets  entitling  the  holder  to  a  bath  and  the  use 
of  soap  and  towels,  will  be  sold  for  five  cents  to 
those  able  to  pay  for  them,  and  given  free  to 
others,  and  hot  coffee  will  be  given  to  those  who 
desire  it  on  leaving  the  bath  during  the  winter 
months.  It  is  estimated  that  one  thousand  per- 
sons can  bathe  each  day,  and  on  three  days  of 
the  week  the  building  will  be  reserved  exclusively 
for  females. 

Football  has  never  been  so  strongly  and  so 
brilliantly  played  in  this  country  as  in  the 
great  games  between  Harvard  and  Yale,  and 
Yale  and  Princeton  during  the  past  month; 
and,  better  than  this,  these  games  have  satisfac- 
torily proved  that  football  can  be  a  gentlemanly 
game  and  not  the  brutal  exhibition  of  prize-ring 
methods  that  have  so  often  disgraced  it  in  the 
past.  It  is  well  that  the  game  has  achieved  that 
character  with  the  general  technical  improve- 
ment that  is  manifested  in  the  way  in  which  it 
is  played;  and,  in  fact,  football  has  now  taken  a 
place  in  the  front  ranks  of  athletic  sports,  both 
as  regards  the  character  of  the  young  men  who 
engage  in  it,  the  perfection  of  skill  displayed  in 
the  playing,  and  the  popular  interest  manifested 
in  it. 

The  women  of  New  York  are  determined  not 
to  let  their  London  sisters  surpass  them  in  zeal 
for  the  support  of  the  hospitals,  and  while  they 
may  perhaps  never  adopt  the  plan  of  street  col- 
lections so  popular  in  that  city,  where  even 
ladies  of  the  highest  social  position  do  no  think 
it  beneath  their  dignity  to  charge  themselves 
with  the  care  of  a  sidewalk  collection  stand  on 
"Hospital  Day,"  they  have  this  year  organized 
a  Women's  Auxiliary  of  the  Hospital  Saturday 
and  Sunday  Association  by  means  of  which  they 
hope  to  materially  increase  the  amount  of  the  an- 
nual public  collection  for  the  hospitals.  Their 
special  object  is  to  carry  out  the  work  of  the 
charity  more  thoroughly  than  ever  before  in  all 
branches  of  the  retail  trade,  and  for  this  purpose 
eighteen  different  committees  of  ladies  have  been 
appointed. 

A  young  man  recently  arrested  here  on  the 
charge  of  theft  adopted  a  very  clever  ruse  for 
making  his  escape.  On  arriving  at  the  station 
house  he  stated  that  he  had  taken  a  large  dose 
of  laudunum,  and  under  the  circumstances  an 
ambulance  call  was  sent  out.  The  ambulance 
surgeon,  on  his  arrival,  thought  it  would  be  ad- 
visable to  make  use  of  the  stomach-pump,  and  on 
asking  for  some  hot  water,  the  two  officers  in 
charge  of  the  prisoner  left  him  to  get  it  from  the 
stove.  No  sooner  were  their  backs  turned,  how- 
ever, than  the  agile  prisoner  dashed  out  through 


72 


MISCELLANY. 


[January  io,  1891. 


the  back  door,  which  chanced  to  be  open,  and 
before  the  astonished  officers  had  recovered  their 
senses  he  had  climbed  over  the  wall  of  the  yard 
and  made  good  his  escape.  p.  b.  p. 


SPECIAL  CORRESPONDENCE. 


Shall  The  Journal  be  Removed  to 
Washington? 

To  the  Editor: — Anent  the  question  of  remov- 
ing The  Journal,  I  would  vote  for  its  going  to 
Louisville,  Ky.,  because  of  its  central  location; 
this  would  assure  the  best  attendance  at  meetings 
of  the  Association  I  think.  W.  C.  Dorset. 
Columbia,  Tenn.,  January  5,  1891. 


ASSOCIATION  NEWS. 


Permanent  Members. — From  the  list  of 
Permanent  Members  of  the  Association  published 
in  The  Journal  for  December  27,  1890,  the 
following  names  were  unintentionally   omitted  : 

Caunaday,  C.  G.,  Roanoke  City,  Va.,  1890. 

Duffield,  George,  Detroit,  Mich., 

Way,  Eugene,  Dennisville,  N.  J.,  1889. 

Woodruff,  L.,  Alton,  O.,  1883. 

In  revising  and  copying  so  many  names  by  the 
Secretary  and  Treasurer,  there  may  have  occurred 
other  omissions  ;  if  so,  we  will  supply  the  defect 
by  publishing  all  additional  names  to  which  our 
attention  may  be  called. 


mond.  Ky.;  Dr.  S.  J.  Bridenstine,  Weston,  Ore.;  Dr. 
John  Langon  Sullivan,  Maiden,  Mass.;  Dr.  Leslie  W. 
Weedon,  Tampa,  Fla.;  A.  C.  Davis,  Ann  Arbor,  Mich.; 
Dr.  T.  Wertz,  Evausville,  Ind.;  Dr.  Wm.  M.  Kaull,  Wa- 
tertown,  la.;  Dr.  E.  J.  Buck,  Platteville,  Wis.;  Dr.  Henry 
B.  Baker,  Lansing,  Mich.;  Dr.  J.  R.  Hinkle.  Sullivan, 
Ind.;  Dr.  Alfred  Mercer,  Syracuse.  N.  Y.;  Dr.  Geo.  Dock, 
Galveston,  Tex.;  Dr.  Robert  Levy,  Denver,  Col.;  Dr. 
Chas.  Gardiner,  Emporia,  Kan.;  Dr.  H.  B.  Henienway, 
Evanstou,  111.;  Dr.  E.  C.  Kinney,  Norwich,  Conn.;  Dr. 
S.  N.  Hamilton,  Comiersville,  Ind.;  Dr.  L.  Woodruff, 
Alton,  O.;  Dr.  G.  G.  Guenther,  Ottawa,  111.;  Dr.  Ashley 
Thompson,  Oshkosh,  Wis.;  Dr.  J.  Simonson,  Pittsville, 
Wis.;  J.  Astier,  Paris,  France;  Dr.  H.  Orlady,  Durand, 
Wis.;  Dr.  J.  A.  Webb,  Providence,  R.  I.;  Dr.  C.  G.  Can- 
naday,  Roanoke  City,  Va.;  J.  E.  Heaton,  New  Haven, 
Conn.;  Dr.  Z.  Rouleau,  Manteno,  111.;  Dr.  Eugene  Way, 
Dennisville,  N.  J.;  Ontario  Med.  Library  Ass'n,  Ontario, 
Can.,  Dr.  L.  C.  Moore,  Buffalo,  la.;  Dr.  M.  E.  Cunning- 
ham, Garnett,  Kan.;  Dr.  C.  Brvan,  Prestonburg,  Ky.; 
Ross,  Daniels  &  Co.,  Buffalo,  N.  Y.;  Dr.  R.  F.  Harre'll, 
Mt.  Lebanon,  La.;  Dr.  Wm.  B.  Canfield,  Baltimore.  Md., 
National  and  Surgical  Institute,  Atlanta,  Ga.;  Wm.  J. 
Haddock,  Dr.  C.  M.  Hobby,  Iowa  City,  la.;  Moore's  Sub- 
scription Agency,  Brockport,  N.  Yr. ;  Dr.  Geo.  R.  Wells, 
Livingston,  Mont.;  Dr.  Robert  McCorkle,  Ponchatoula, 
La.;  Dr.  T.  A.  McGraw,  Detroit,  Mich.;  Dr.  J.  B.  Matti- 
son,  Brooklyn,  N.  Y. ;  Dr.  Chas.  McLean,  Griswold,  la.; 
Dr.  W.  B.  Henderson,  Pittsburgh,  Pa.;  Dr.  W.  M.  Sprigg, 
Washington;  Dr.  H.  Gradle,  Dr.  W.  F.  Coleman,  Sub- 
scription News  Co.,  Dr.  J.  A.  Robison,  Dr.  F.  C.  E.  Mat- 
tison,  Chicago;  J.  F.  Madden,  Dr.  A.  H.  Leary,  Frank, 
Kiernan  &  Co.,  E.  Steiger  &  Co.,  A.  L.  Chatterton  &  Co., 
Dr.  A.  H.  Goelet,  W.  H.  Schieffelin  &  Co.,  J.  A.  Hill  & 
Co.,  Meyrowitz  Bros.,  T.  C.  Morgan   &  Co. 


MISCELLANY. 


LETTERS   RECEIVED. 

Dr.  Joseph  Smith,  San  Jose,  Cal.;  Dr.  Paul  Paquiu, 
Columbia,  Mo.;  Damrell  &  Upham,  Doliber-GoodaleCo., 
Codman  &  Shurtleff,  S.  R.  Niles,  Boston,  Mass.;  Dr.  C. 
D.  Watson,  Ontario,  Cal.;  Dr.  W.  A.  Scott,  Swanton,  O.; 
Roberts  and  Allison,  Indianapolis,  Ind.;  Dr.  F.  E.  Udell, 
Katharmon  Chemical  Co.,  St.  Louis,  Mo.  ;  Mutual 
Library  Co.,  Bellevue  Hospital  Medical  College,  C.  L. 
Topliff,  Thos.  Leeming  &  Co.,Jas.  F.  Madden,  J.  H. 
Bates,  G.  E.  Stechert,  New  York  City;  Dr.  D.  S.  Lamb, 
Dr.  C.  R.  Greenleaf,  Dr.  Irving  C.  Rosse,  Washington, 
D.  C;  Dr.  Wm.  B.  Atkinson,  University  of  Pennsylvania 
Press,  P.  Blakistou,  Son&Co.,  Dr.  Richard  J.  Dunglison, 
Phila.,  Pa.;  Parke,  Davis  &  Co.,  Detroit,  Mich.;  Dr.  W. 
B.  Canfield,  Baltimore,  Md.;  Plimpton  Mfg.  Co.,  Hart- 
ford, Conn.;  Dr.  C.  H.  Hunt,  Stanwood,  la.;  Dr.  J.  H. 
Kellogg,  Battle  Creek,  Mich.;  Dr.  G.  L.  Knapp,  Mt. 
Vernon,  Mo.;  Dr.  G.  O.  Ward,  Worcester,  Mass.;  Dr. 
W.  W.  Pierce,  Waukegan,  111.;  Bank  of  Washburn,  Dr. 
R.  L.  Nourse,  Washburn,  Wis.;  Dr.  L.  L.  Leeds,  Lin- 
coln, Neb.;  Subscription  News  Co.,  National  Mailing 
Co.,  W.  F.  Keener,  Dr.  W.  F.  Coleman,  Publishers'  Com- 
mercial Union,  Dr.  John  Davis  Hartley,  Dr.  H.  Wardner, 
Chicago;  Dr.  F.  D.  Haldeman,  Ord,  Neb.;  Dr.  W.  A. 
Reed,  Necedah,  Wis.;  Dr.  J.  P.  Stoddard,  Muskegon, 
Mich.;  Dr.  G.  Owen  Mead,  Newmarket,  Eng.;  Cincin- 
nati Hospital  Library.  Cincinnati,  O. ;  Dr.  Ashley 
Thompson,   Oshkosh,  Wis.;  Dr.  Jno.   M.  Foster,   Rich- 


Official  List  of  Changes  in  the  Stations  and  Duties  of 
Officers  Serving  in  the  Medical  Department,  U.  S. 
Army,  from  December  27,  i8go,  to  fanuary  2,  i8gi. 

Capt.  William  J.  Wakeman,  Asst.  Surgeon,  is  relieved 
from  the  further  operation  of  par.  13,  S.  O.  254,  A.  G. 
O.,  October  30,  1890,  and  telegraphic  instructions  of 
the  16th  inst.,  from  this  office,  transferring  him  from 
Ft.  Bidwell,  Cal.,  to  Ft.  Huachuca,  Ariz.  Ter.,  and  he 
will  return  from  Reno,  Nevada,  to  Ft.  Bidwell,  for  fur- 
ther duty  at  the  latter  post.  By  direction  of  the  Sec- 
retary of  War.  Par.  3,  S.  O.  300,  A.  G.  O.,  December 
24,  1890. 

First  Lieut.  Ogden  Rafferty,  Asst.  Surgeon,  is  relieved 
from  duty  at  Ft.  Sam  Houston,  Tex.,  and  will  report  in 
person  to  the  com'dg  officer,  Camp  Eagle  Pass,  Tex., 
for  duty  at  that  station,  reporting  by  letter  to  the  com- 
manding General,  Dept.  of  Texas.  Bydirection  of  the 
Secretary  of  War.  Par.  2,  S.  O.  301,  A.  G  O.,  Decem- 
ber 26,  1890. 

Major  Stevens  G.  Cow-drey,  Surgeon,  extension  of  leave 
of  absence  on  account  of  sickness  granted  in  S.  O.  293, 
December  16,  1890,  from  this  office,  is  still  further  ex- 
tended one  month  on  account  of  sickness.  By  direc- 
tion of  the  Secretary  of  War.  Par.  S,  S.  O.  302,  A.  G. 
()..  Washington,  December  27,  1890. 

Major  John  S.  Lauderdale,  Surgeon,  now  on  duty  at  Ft. 
Ontario,  N.  Y.,  will  proceed  to  Pine  Ridge  Agency,  S. 
Dak.,  without  delay,  and  report  in  person  to  Brig  ( ,ru. 
John  Brooke,  for  duty  in  the  field,  and  by  letter  to  the 
commanding  General,  Dept.  of  Dakota.  By  direction 
of  the  Secretary  of  War.  I'ar.  8,  S.  O.  303,  A.  G.  O, 
Washington,  December  29,  1890. 

Official  List  of  Changes  in  the  Medical  Corps  of  the  I '.  S. 

Xazy  for  the  Week  Ending  fanuary  3,  i8gr. 
Asst.  Surgeon  G.    McC.  Pickrell,  detached  from  U.  S.  R. 

S.   "Minnesota"  and  wait  orders. 
Asst.  Surgeon  A.  M.  D.  McCormick,  ordered  to  the  U.  S. 

R.  S.   "Minnesota"  as  Dr.  Pickrell's  relief. 


T  1 1  E 


Journal  of  the  American  Medical  Association. 

EDITED  UNDER  THE  DIRECTION  OF  THE  BOARD  OF  TRUSTEES. 

PUBLISHED    WEEKLY. 


Vol.  XVI. 


CHICAGO.  JANUARY    17,    1891. 


No  3. 


ADDRESSES. 


SANITATION  IN  1890. 

The  President's  Address  to  the  American  Public  Health  Association, 

at  its  Eighteenth  Annual  Meeting,  Charleston,  S.  C, 

Dec.  id,  1800, 

BY  HENRY  B.  BAKER,   A.M.,  M.D., 

OF   LANSING,    MICH. 

Members  of  the  Association,  Ladies  and  Gentlemen: 
In  accordance  with  the  custom  in  this  Associa- 
tion, this  address  is  now  presented  in  order  to 
supply  a  general  view  of  the  present  status  of 
public-health  work  in  this  country,  to  bring 
briefly  before  us  a  review  of  some  of  the  progress 
made,  especially  since  the  last  meeting  of  this 
Association,  and  to  suggest  directions  in  which 
effort  seems  to  be  needed  in  order  that  progress 
shall  be  most  satisfactory  and  promising  for  the 
future. 

Many  of  you  are  as  familiar  as  I  am  with  these 
several  topics,  but  as  each  member  of  our  Asso- 
ciation views  them  from  a  different  standpoint, 
there  is  reason  for  a  hope  that  what  is  presented 
in  this  address  may  not  be  tiresome,  and  I  do  not 
forget  that  there  are  some  present  to  whom  pub- 
lic health  topics  must  be  new.  To  such  persons 
I  may  say  that,  although  many  of  its  members 
are  physicians,  this  Association  is  not  a  medical 
association;  although  many  of  its  members  are 
especially  well  informed  on  subjects  relating  to 
personal  hygiene,  yet  personal  hygiene  is  not  the 
subject  which  is  uppermost  in  the  minds  of  mem- 
bers of  this  Association.  If  you  ask  what,  then, 
are  the  objects  of  this  Association,  the  reply  is 
found  in  its  name, — "The  American  Public 
Health  Association," — and  in  its  constitution 
wherein  it  is  stated:  "The  objects  of  this  Asso- 
ciation shall  be  the  advancement  of  sanitary 
science,  and  the  promotion  of  organizations  and 
measures  for  the  practical  application  of  public 
hygiene." 

The  founders  of  this  Association  recognized 
the  fact  that  in  civilized  society  the  life  and 
health  of  every  person  is  more  or  less  bound  up 
with  the  life  and  health  of  every  other  person, 
that  not  only  is  man  his  "brother's  keeper,"  but 
on  each  person    there  rests    some  responsibility 


for  the  welfare  of  all, — some  responsibility  for  the 
public  health;  and  each  person  has  a  vital  inter- 
est in  the  public  health,  because  of  its  bearing 
upon  self-preservation. 

We  have  all  heard  that  "self-preservation  is 
the  first  law  of  nature;"  but  I  think  we  must  ad- 
mit that  it  is  not  the  first,  but  more  frequently 
the  last  law  of  the  law- maker.  Laws  for  the 
preservation  of  human  life  and  health,  in  accord- 
ance with  sanitary  science,  are  of  slow  growth, 
and  an  important  object  of  this  Association  is  "the 
promotion  of  organizations"  "for  the  practical 
application"of  sanitary  science  forthe  public  good, 
and  such  organizations  for  the  public  good  can, 
as  a  rule,  best  exist  only  through  public  law,  and 
the  ordinary  governmental  methods. 

Governmental  methods  differ  somewhat  in  the 
different  parts  of  America,  and  we  must  remember 
that  this  Association  includes  representatives  not 
only  from  the  several  States  of  this  Union,  but 
also  from  the  Provinces  and  the  Dominion  of 
Canada,  and  I  am  happy  to  say  that  this  year 
marks  a  new  epoch,  for  we  have  with  us  officially 
appointed  representatives  from  the  general  gov- 
ernment of  Mexico,  eminent  members  of  its  Su- 
perior Council  of  Health. 

If,  then,  this  address  is  to  deal  with  those  ob- 
jects for  which  this  Association  was  organized,  it 
must  deal  with  the  advancement  of  sanitary 
science,  and  the  promotion  of  sanitary  organiza- 
tions; and,  in  the  United  States,  the  most  perfect 
"organizations"  for  the  practical  application  of 
measures  for  the  public  good  must  conform  to 
our  form  of  government,  "of  the  people,  for  the 
people,  by  the  people."  In  my  opinion,  there 
should  be  such  a  sanitary  organization  for  the 
United  States  and  for  each  other  general  govern- 
ment, for  each  of  the  several  States  and  Provinces, 
and  for  each  of  the  numerous  local  governments. 

Advancement  of  Science.  The  Causation  of  Dis- 
eases.— It  seems  evident  that  no  great  and  substan- 
tial progress  can  be  made  toward  the  prevention 
or  avoidance  of  a  disease  until  we  have  knowl- 
edge of  its  causation.  Therefore  the  work  which 
it  is  most  important  shall  be  first  accomplished  is 
that  which  shall  yield  us  knowledge  of  the  causa- 
tion of  each  disease.  Within  recent  years  much 
progress  has  been  made  in  this  important  funda- 
mental knowledge,  thanks  especially  to  two  en- 


74 


SANITATION  IN  1890. 


[January  17, 


lightened  governments — Germany  and  Great 
Britain. 

It  should  be  clearly  held  in  mind  that  there 
are  seldom  less  than  three  important  factors, 
neither  of  which  can  be  neglected  in  studying 
the  causation  of  a  disease.  For  instance,  there 
is  (1)  the  "specific"  cause,  (2)  what  (when  deal- 
ing with  atmospheric  conditions)  I  have  called 
the  "controlling"  cause,  and  (3)  the  "predispos- 
ing" cause. 

Causation  of 'Consumption . — By  all  means  the 
most  important  addition  to  our  knowledge  in 
this  field,  is  that  for  which  we  are  chiefly  in- 
debted to  Dr.  Robert  Koch,  of  the  Imperial 
Board  of  Health  of  Germany, — the  definite  knowl- 
edge of  the  tubercle  bacillus — the  "specific" 
cause  of  consumption,  the  disease  which  causes 
the  greatest  mortality,  in  this  country,  and 
throughout  the  world. 

Every  year  there  is  being  rapidly  added  to  our 
knowledge,  details  of  the  controlling  conditions, 
predisposing  causes,  and  modes  of  spread  of  that 
most  important  disease — knowledge  which  will  en- 
able us  to  explain  the  methods  by  which  this 
most  dread  disease  may  be  prevented. 

Causation  of  Pneumonia. — The  necessity  for 
further  knowledge  of  the  causation  of  a  disease  than 
is  supplied  by  knowledge  of  its  "specific"  cause  is 
exemplified  in  the  case  of  pneumonia,  which  dis- 
ease, it  is  believed,  can  be  artificially  produced 
in  lower  animals  by  means  of  its  specific  cause,1 
yet  the  causation  of  which  in  man  and  in  ani- 
mals is  certainly  proved  (by  statistics  and  by 
direct  experiments)  to  be  controlled,  in  great 
part,  by  conditions  of  the  atmosphere.2 

One  attempt  to  harmonize  the  facts  from  these 
two  very  different  sources,  is  that  by  Dr.  William 
B.  Canfield,  who  says:  "In  the  light  of  recent 
studies  made  by  Metschnikoff,3  Baumgarten,*  Os- 
ier and  others,  it  is  more  than  probable  that  the 
phagocytes  in  a  healthy  individual, having  healthy 
movements,  are  able  to  seize  and  assimulate  the 
invading  organisms,  and  it  is  only  when  an  in- 
dividual not  well  when  the  phagocytes  lose  the 
power  to  battle  against  the  specific  organism  of 
pneumonia  from  prolonged  exposure  to  cold,  that 
pneumonia  sets  in."6 

But  experiments  more  recent  than  those  re- 
ferred to  by  Dr.  Canfield,  by  Nutall,  Buchner, 
Nissen,  Lubarsch,  Prudden  and  others,  indicate 


'  Report  of  Sec.  of  the  State  Hoard  of  Health,  Mich.,  1SS6,  p.  315; 
also  II  Morgagni,  Oct.,  Nov.,  Dec,  [888:  also  Trans.  Md.  Med.  and 
Chirurg.  Fac,  April,  1889,  p.  112;  also  Ilulletin  General  de  Thera- 
peutique,  Paris,  Dec.  15,  1889,  p.  520;  also  Boston  Med.  and  Surg. 
Jour.,  Jan.  23,  [890;  also  Therapeutic  Gazette,  Vol.  xiv.,  No.  2,  Feb. 
15,  's90, p.  14a. 

-  "The  Causation  of  Pneumonia,"  Report  Mich.  State  Board  of 
Health,  1SS6,  pp.  246-324;  also  Reports  and  Papers,  Amer.  Public 
Health  ASSOC,  1887.  p.  ;  also  Bulletin  General  de  Therapeutique, 
Paris,  Dec.  15,  1889.  p.  520;  also  Boston  Med.  and  Surg.  Jour.,  Jan. 
25,  1890;  also  Therapeutic  Gazette,  Vol.  xiv..  No.  2.  Feb.  15,  1S90, 
p.  142. 

Virchow's  Archiv..  Vol.  xcvi  and  xcvii. 

<  Zeitschrift  f.  Kl.  Medicin,  Bd.  xv.,  t  and  2. 

5  N.  Y.  Medical  Record,  April  13.  1889. 

6  Trans.  Md.  Med.  and  Chirurg.  l-'ac,  April,  1SS9,  p.  112. 


that  the  blood  serum,  even  more  than  the  leu- 
cocytes, is  concerned  in  the  destruction  of  patho- 
genic microorganisms.7 

Causation  of  Diphtheria. — Evidence  has  been 
accumulating,  and  it  now  seems  to  be  established 
that  the  bacillus  discovered  by  Loefner  is  a  speci- 
fic cause  of  diphtheria.  Dr.  Klein,  F.R.S.,  Eon- 
don,  has  demonstrated  that  in  the  cow  inoculated 
with  diphtheria,  the  bacillus  passes  into  the 
milk.  This  may  account  for  the  spread  of  diph- 
theria in  some  cases,  otherwise  unaccountable. 
In  the  trachea  of  cats  the  bacillus  is  alleged  to 
have  caused  pneumonia,8  which  was,  I  suppose, 
diphtheritic.  Some  experiments  with  doves  by 
Babes  and  Piscariu9  seem  to  have  been  especially 
well  planned,  and  to  have  yielded  results  espe- 
cially important.  They  found  that  the  bacillus 
— the  specific  "germ" — promptly  caused  diph- 
theria in  doves  whose  throats  were  scarified  be- 
fore the  application  of  the  bacilli,  but  did  not 
cause  the  disease  in  doves  with  perfectly  healthy 
throats.  That  something  analogous  to  this  is 
true,  as  a  rule,  concerning  diphtheria  in  man, 
was  claimed  to  have  been  indicated  by  myself 
some  years  ago,  especially  in  my  paper  on  the 
"Causation  of  the  Cold  Weather  Diseases."10  The 
hypothesis  which  I  then  published  I  still  believe 
to  be  the  true  explanation,  as  to  the  way  in 
which  the  throat  is  irritated  and  made  sore,  and 
consequently  susceptible  to  diphtheria  and  other 
diseases,  by  exposure  to  the  inhalation  of  air  un- 
usually cold  and  dry.  But  Dr.  K.  E.  Wagner 
(Annates  de  V Institut  Pasteur,  p.  570,  No.  9,  t.  4, 
Sept.  25,1890)  has  repeated  Pasteur  s  experiments, 
producing  anthrax  in  fowls  by  lowering  their  tem- 
perature by  cold  water,  and  has  found  that  it  can 
be  done  if  the  lowering  is  by  means  of  antipyrin. 
His  experiments  indicate  that  when  the  temper- 
ature is  lowered  the  rate  of  destruction  is  less 
than  the  rate  of  reproduction  of  the  anthrax 
bacilli,  while  at  the  normal  temperature  of  fowls, 
and  especially  when  raised  by  the  injection  of  the 
bacilli,  the  rate  of  destruction  of  the  bacilli  is 
greater  than  their  reproduction,  in  the  bodies  of 
fowls,  especially  in  the  blood.  Outside  the  body 
at  such  temperature  (420  C.  to  430  C.)  the  an- 
thrax bacilli  do  not  form  spores,  and  are  killed  in 
nine  days." 

Experiments  are  needed  to  prove  whether  what 
is  true  of  anthrax  is  also  true  of  the  other  diseases 
which  I  have  shown  to  be  most  prevalent  after 
the  cold  weather.12 

Whether  or  not  my  hypothesis  shall  be  found 
to  be  the  correct  explanation  relative  to  the  en- 


IS.,1, 


T.    Mitchell  Prudden,  MD.in  Med.  Record,  N.  Y.,  Jan.  25, 


Public  Health,"  Minnesota  State  Bd.  of  Health,  Vol.  vi„  No. 
4,  June,  1890,  p.  33. 

9  Zeit.  fiir.  Hygiene  Vol.  viii,  part  3rd:  The  Sanitary  Inspector, 
Maine,  July,  1800.  p.  6-7. 

"  Report  Mich,  state  Board  of  Health,  1887,  pp.  197-211. 

"  Supplement  to  the  British  Med.  Jour.,  Nov.  29.  1890,  p.  72. 

"  Report  Mich.  State  Board  of  Health,  [888,  pp.  143-169;  Jour. 
Amer.  Med.  Assoc,  Jan.  is  and  25,  1S90.  pp.  73-S4,  116-129. 


iSqi.J 


SANITATION  IN  1890. 


7- 


trance  of  diphtheria,  experiments  indicate  that  it 
is  true,  in  part  at  least,  relative  to  pneumonia," 
and  the  fact  now  seems  to  be  established  that 
diphtheria,  small-pox,  pneumonia,  and  some 
other  diseases  that  usually  enter  the  body  by  way 
of  the  throat  or  air  passages  are  increased  in  pre- 
valence at  such  times  as  people  are  exposed  to 
cold  atmosphere. 

Quarantine.  —  It  is  significant  of  great  progress, 
I  think,  that  the  diseases  which  it  now  seems 
most  important  to  dwell  upon,  are  not  the  same 
as  in  former  times.  Comparatively  little  is  now 
said  of  small-pox,  cholera,  or  yellow  fever.  In 
this  country  these  diseases  are  not  such  important 
causes  of  death  as  consumption,  diphtheria  or 
scarlet  fever.  For  this  result,  general  progress 
in  sanitary  administration  must  receive  much 
credit;  but  I  think  that,  in  this  country,  much 
credit  must  also  be  due  to  the  greatly  increased 
efficiency  of  the  quarantine  services,  notably  at 
such  important  ports  as  Xew  Orleans,  Quebec, 
and  New  York.  Here,  in  Charleston,  the  effi- 
ciency has  been  greatly  increased. 

The  United  States  Government,  also,  has,  in 
recent  years,  done  very  much  more  than  ever  be- 
fore for  the  establishment,  equipment  and  main- 
tenance of  quarantine  stations. 

A  continuance  of  this  work  is  desirable;  but, 
for  substantial  progress,  something  more  than 
merely  continuing  the  present  methods  of  quar- 
antine is  needed.  Diphtheria  and  scarlet  fever 
should  be  excluded  by  quarantines;  but  the  en- 
tire country  is  permeated  with  those  diseases, 
and  with  the  still  more  important  one— consump- 
tion; and  a  Health  Department  of  the  Interior  is 
needed  to  be  established  at  Washington,  even 
more  than  is  a  continuance  of  quarantine. 

Cholera. — To  be  forewarned  should  be  to  be 
forearmed;  but  our  long  continued  immunity 
from  cholera  in  this  country  has  led  to  a  general 
belief  that  there  is  no  longer  danger  from  cholera 
in  the  United  States, — a  belief  which  may  be 
true,  but,  in  my  opinion,  is  not  fully  supported 
by  facts.  The  constant  presence,  throughout  the 
United  States,  of  typhoid  fever, — a  disease  which 
is  believed  to  be  spread  in  almost  the  same  ways  in 
which  cholera  is  spread  s\\qm\&.,  it  seems  to  me,  teach 
us  more  humility  as  to  the  assumed  sanitary  supe- 
riority of  our  people  and  their  surroundings,  and 
should  lead  us  to  urge  the  people  to  adopt  those 
measures  which  are  now  known  to  be  restrictive 
and  preventive  of  both  cholera  and  typhoid  fever. 

It  should  not  be  forgotten  that  our  greatly  im- 
proved systems  of  quarantine  at  our  leading  sea- 
ports do  not  yet  ensure  us  against  the  introduc- 
tion of  cholera  in  the  same  manner  in  which  it 

'3  Dr.  Vito  Platania,  in  Italy— Giornale  intern,  delle  scienze 
mediche.  fascicule  v.;  also  Bulletin  General  de  Therapeutique, 
Paris.  Dec  is.  i-Sg,  p.  520;  also  Boston  Med.  and  Surg.  Jour.,  Jan. 
23,  1890;  also  Therapeutic  Gazette.  Vol.  xiv.  No.  2,  Feb.  1^,  1890, 
p.  142. 

"Eighteenth  Annual  Report  of  the  Local  Gov.  Board.  Eng., 
1883-9.  Supplement  containing  Med.  Officer's  Report  for  188S;  pp. 


was  introduced  in  1873  when  three  distinct  out- 
breaks of  cholera,  in  widely  remote  parts  of  the 
United  States,  were  traced  to  the  unpacking  of 
personal  effects  of  immigrants, — at  Carthage, 
Ohio;  Crow  River,  Minnesota,  and  Yankton,  Da- 
kota. So  long  as  conditions  are  permitted  to  re- 
main which  result  in  the  annual  spread  of  typhoid 
fever  in  every  State  of  this  Union,  there  is  good 
reason  to  believe  that  cholera  would  spread,  if 
introduced  at  a  season  of  the  year  favorable 
thereto. 

It  should  be,  but  is  not,  generally  understood 
that  there  is  coming  to  be  a  thickly- populated 
area  in  a  portion  of  this  country  in  which  by  rea- 
son of  alkaline  waters  the  inhabitants  are  prob- 
ably especially  liable  to  typhoid  fever,  cholera, 
or  other  diseases  propagated  by  microorganisms 
which  enter  the  body  by  way  of  the  alimentary 
canal,  and  which  microorganisms  are  generally 
destroyed  by  the  normal  acid  of  the  healthy  hu- 
man stomach."  It  is  not  probable,  but  it  is  pos- 
sible that  if  cholera  should  become  once  thor- 
oughly established  in  the  warmest  portion  of  the 
region  of  alkaline  waters  in  this  country,  it 
might  possibly  find  there  a  permanent  home,  as 
it  has  in  the  brackish  waters  of  the  Ganges  in 
India. 

The  bare  possibility  of  such  a  calamity  as  the 
permanent  addition  of  cholera  to  the  diseases  con- 
stantly present  in  this  country  should  prompt  the 
United  States  government  to  a  thorough  investi- 
gation of  the  subject,  lest,  through  careless  dis- 
regard of  such  duties  by  the  government,  the 
lives  of  thousands,  perhaps  millions  of  our  peo- 
ple should  be  jeopardized. 

Typhoid  Fever. — But,  after  all,  is  cholera  a 
more  fatal  disease  or  one  more  to  be  dreaded  than 
its  twin  destroyer — typhoid  fever?  The  number 
of  deaths  from  typhoid  fever  reported  as  having 
occurred  in  the  United  States  during  the  census 
year  1880,  was  22,854;''  and  it  is  probable  that 
not  much  more  than  half  of  the  deaths  were  re- 
ported, because  the  method  of  collecting  the  sta- 
tistics of  death  for  the  U.  S.  Census  is  known  to 
be  very  defective.  We  are  apt  to  look  with  con- 
tempt upon  the  East  Indians  for  living  under 
conditions  which  permit  their  destruction  by  chol- 
era ;  while  at  the  same  time  our  own  people  are 
permitted  to  be  swept  off  by  the  thousands  in 
every  year  by  a  disease  which  we  believe  to  be 
propagated  in  almost  preciseh^  the  same  manner 
that  cholera  is,  and  our  National  Government  is 
doing  absolutely  nothing  to  prevent  its  continu- 
ance— does  not  even  grant  to  its  National  Board 
of  Health  a  dollar  to  investigate  and  report  on 
the  best  methods  for  the  prevention  of  this  great 
waste  of  life  and  treasure  that  continues  to  go  on 
notwithstanding  the  belief  of  leading  sanitarians 
that  in  great  part  it  is  unnecessary,  and  might 
easily  be  prevented  without  the  use  of  more  money 


i;U.  S.  Census.  Vital  Statistics,  Vol.  xii.  part  ir.  p.  366. 


76 


SANITATION  IN  1890. 


[January  17, 


than  is  annually  wasted  through  preventable  sick- 
ness from  this  disease. 

I  think  it  is  important  that  the  Government 
should  investigate  the  reason  for  the  prevalence 
of  typhoid  fever,  "mountain  fever."  etc.,  in  the 
region  of  the  Rocky  Mountains,  and  especially  in 
the  region  of  alkaline  waters.  Such  an  investi- 
gation might  throw  much  light  upon  the  subject 
of  the  causation  and  better  means  of  prevention 
of  fevers  throughout  the  entire  country. 

Causation  of  Yellow  Fever. — Are  not  all  the 
facts  known  relative  to  yellow  fever,  compatible 
with  the  belief  that  the  disease  is  caused  by  the 
inhalation  (or  otherwise  taking  into  the  human 
body)  of  the  products  of  the  growth,  reproduc- 
tion, or  life  processes  of  some  organism,  probably 
microscopic  in  size,  which  organism  may  not  be 
capable  of  reproduction  within  the  human  body, 
but  is  capable  of  reproduction  in  filth  outside  the 
body,  at  high  temperatures,  but  which  organism 
is  destroyed  by  a  freezing  temperature  ? 

If  there  is  such  compatibility  in  the  facts,  is 
it  not  desirable  that  the  United  States  Govern- 
ment should  take  such  measures  as  shall  ensure 
the  thorough  searching  for  such  hypothetical  mi- 
croorganism, not  in  the  bodies  of  yellow  fever  pa- 
tients, but  in  localities  known  to  be  infected  ? 

Is  not  the  importance  of  this  subject,  either  as 
affecting  the  lives  of  citizens  of  this  country,  or 
as  affecting  the  money  interests  of  our  people, 
sufficient  to  warrant  the  employment  of  a  number 
of  investigators,  and  the  expenditure  of  consider- 
able sums  of  money  for  investigations  in  the  di- 
rections indicated  by  the  facts  in  the  possession 
of  physicians  and  sanitarians? 

It  has  been  found  that  without  the  presence  of 
oxygen  (as  in  the  human  body)  the  cholera  bac- 
teria produce  their  poison  more  energetically  and 
more  quickly  than  in  the  presence  of  air ;  but 
when  developed  in  the  absence  of  oxygen  the 
cholera  bacteria  are  much  more  sensitive,  traces 
of  acid  being  sufficient  to  destroy  them.  When 
the)-  first  leave  the  body  they  are,  therefore,  easily 
destroyed  by  the  gastric  juice  in  the  healthy  hu- 
man stomach,  and  cannot  reach  their  habitat  in 
the  intestine,  but  if  developed  outside  the  body, 
in  the  presence  of  air,  the  bacteria  soon  become 
aerobic  and  not  so  easily  destroyed.  This  seems 
to  explain  why  cholera  (like  typhoid  fever  and 
yellow  fever)  is  only  seldom  directly  contagious, 
and  why  the  disease  is  contracted  in  an  infected 
locality."  Something  similar  or  analogous  to  this 
being  true  in  typhoid  fever,  and  a  noticeable  fact 
in  yellow  fever,  the  facts  respecting  the  cholera 
bacteria  may  aid  in  the  search  for  the  specific 
cause  of  yellow  fever. 

A  Possibility  of  the  Prevention  of  Cancer. — A 
study  of  the  locations  of  7,881  primary  carcino- 
mata,'7  as  illustrating  the  probability  of  a  cancel- 


's Amer.  Jour.  Med.  Sci..  July.  1890,  p.  77. 

■7"  1.  Other  things  being  equal,  primary  carcinoma  is  most  fre- 


ous  microbe,  has  led  Dr.  Edmund  Andrews,  of 
Chicago,  111.,  to  believe  that  the  facts  he  has  col- 
lected and  presented  make  it  probable  that  a  mi- 
crobe exists,  and  prove  the  importance  of  search- 
ing out  the  microbe;  also  that  much  can  probably 
now  be  done  towards  preventing  this  disease,  by 
measures  looking  to  the  prevention  of  access  of 
microbes  to  those  parts  of  the  body  most  suscep- 
tible to  primary  cancer,  especially  the  lower  lip. 
its  liability  to  primary  cancer  being  "  8,448  times 
greater  than  a  similar  area  of  the  intestine."  " 

In  this  connection  may  be  held  in  mind,  an 
epidemic  or  outbreak  of  cancer  attributed  to  the 
use  of  cider  in  the  making  of  which  water  from 
an  impure  source  was  used." 

Inflammation — A  p>  oposed general  advance  "  all 
along  the  line." — It  is  coming  to  be  the  general 
belief  of  physicians,  and  especially  of  surgeons, 
that  nearly  all  inflammations  are  caused  by  the 
presence  of  microorganisms.  (Some  of  the  most 
common  of  these  pus  generators  are  the  round 
ones — the  micrococci,  sometimes  grouped  by  twos, 
and  in  chains,  etc. — staphylococci,  and  streptococci 
pyogenes,  three  varieties  of  each:  the  albits,  aure- 
us and  citreous.) 

Some  of  these  microorganisms  are  now  very 
widely  and  generally  distributed  in  thickly  in- 
habited places,  while  in  sparsely  inhabited  re- 
gions, especially  in  mountainous  regions,  they 
are  not  so  generally  found.  I  think  we  should 
put  with  this  fact  another  one — that  most  new 
States  and  localities  are,  apparently,  good  health 
resorts.  I  remember  well  that,  many  years  ago, 
certain  States  in  this  Union  were  considered  ex- 
ceptionally healthful  as  regards  diseases  of  the 
lungs,  while  now  the  mortality  statistics  in  those 
States  show  the  greatest  proportion  of  the  deaths 
to  be  from  diseases  of  the  lungs.  Part  of  this 
change  may  be  due  to  a  change  in  the  average 
age  of  the  inhabitants,  but  I  think  a  part  of  it  is 
due  to  the  fact  that  the  microscopic  causes  of  in- 
flammation have  constantly  been  increasing,  so 
that  now  the  carpets  and  upholstered  furniture  in 
most  residences,  the  floors  of  most  public  assem- 
bly rooms,  the  clothing,  hair,  beard  and  hands  of 
most  of  the  inhabitants,  are  infected  with  these 
microscopic  causes  of  inflammation. 


rfaces  which,  by  their  position.  Wi  uld  be  most  ac- 
•ituming  microbes  or  spores  derived  from  without 


quent  on  those  < 
cessible  to  free-s 
the  body. 

"  2.  The  liability  to  cancer  is  increased  if  the  epithelial  surface 
is  so  situated  that  the  spores  can  remain  upon  it  for  at  least  some 
hours  without  being  swept  away,  as  on  the  lower  lip;  but  the  lia- 
bility is  greatly  diminished  if  the  parts  are  frequently  swept  off.  as 
the  globe  of  the  eye  by  winking,  or  the  oesophagus  by  swallowing 
food  and  drink. 

"  3.  The  liability  to  cancer  is  great  if  the  membrane  has  vast 
numbers  of  deep  glandular  follicles,  into  which  the  spores  can  pen* 
etrate  and  lie  free  from  disturbance,  and  have  direct  access  to  the 
more  delicate  epithelial  cells,  as  at  the  pyloric  end  of  the  stomach 
and  the  follicles  of  the  mammary  glands 

"  1  Those  portions  of  the  skin  which  art-  usually  uncovered  are- 
oftencr  attacked  than  those  covered  with  clothing  and  constantly 
brushed  by  its  friction.    The  skin  of  the  face,  for  instance,  produces 

;  9  111. ui  all  the  covered  portions  of  the  integnir 
bined." — Joi'R.  of  the  Amer.   Med.  ASSOC.,    November  23.    1889, 


'■Jour,  of  the  Amer.  Med.  Assoc.  November  23,  18 
■    Vol.  riv.,  No.  342,  August  23,  1S89,  p.  129. 


.  P-  742. 


«89i.] 


SANITATION  IN  1890. 


77 


The  surgeons  have  been  acting  upon  this  com- 
paratively recent  addition  to  our  knowledge,  and 
to  those  of  us  who  practiced  surgery  only  as  long 
ago  as  during  the  late  war,  the  successes  in  recent 
surgery  are  marvelous.  Not  long  since,  I  listened 
to  the  recital  of  the  details  of  fifty-two  successive 
surgical  operations,  each  involving  the  opening 
into  the  abdominal  cavity,  and  each  was  success- 
ful. (Trans.  Mich.  Med.  Soc.  1890,  p.  349.)  My 
belief  is  that  much  of  such  wonderful  success  as 
is  now  achieved  by  the  leaders  in  surgery  is  clue 
to  the  advance  of  our  knowledge  upon  what  was 
formerly  known  as  ' '  the  germ  theory  of  disease," 
which  gave  rise  to  what  was  known  as  "antiseptic 
surgery,"  which  is  now  giving  place  to  what  is 
known  as  "  aseptic  surgery."  The  septic  micro- 
organisms are  now  kept  out  of  wounds,  pus  does 
not  form,  inflammation  does  not  occur,  the  wounds 
heal,  and  the  patient  recovers. 

What  I  am  about  to  propose  may  seem  to  some 
of  you  at  first  as  Utopian,  but  I  hope  to  be  able 
to  enlist  your  enlightened  sympathies  in  the  di- 
rection of  a  movement  designed  to  do  away  with 
all  inflammatory  diseases  of  man,  in  a  manner 
analogous  to  what  has  been  done  by  the  leading 
surgeons  in  doing  away  with  inflammations  fol- 
lowing surgical  operations.  Let  us  glance  at  the 
stupendous  character  of  the  suggestion — to  grad- 
ually but  eventuall}-  do  awray  with  all  inflamma- 
torv  diseases  !  Xo  more  consumption,  pneumo- 
nia, bronchitis,  laryngitis,  pharyngitis,  tonsillitis, 
rheumatism,  etc.,  including  nearly  all  the  dangeV- 
ous  communicable  diseases. 

So  far  as  relates  to  the  dangerous  communica- 
ble diseases,  such  as  small-pox,  scarlet  fever  and 
diphtheria,  sanitarians  now  know  how  to  restrict, 
and  perhaps  to  stamp  out  most  of  them,  and  they 
are  doing  this  as  fast  as  they  are  supported  in 
doing  it  by  Governments,  but  the  measures  I 
have  to  suggest  would,  I  think,  tend  to  aid  great- 
ly in  that  work,  and,  in  addition,  would  aim  to 
place  at  once  all  inflammatory  diseases  on  the  list  of 
preventable  diseases — diseases  which  we  think  we 
know  how  to  prevent  just  as  soon  as  the  people 
generally  shall  come  to  understand  the  methods 
proposed,  and  shall  generally  cooperate  in  the 
employment  of  those  methods. 

Without  elaboration, ■"  my  proposition  may  be 
put  in  the  form  of  preamble  and  questions,  thus: 

Since  nearly  all  suppurative  inflammations  are 
breeding-places  for  microorganisms  which,  when 
they  gain  entrance  into  another  living  body  (or 
into  another  weak  or  injured  spot  in  the  same 
body),  are  capable  of  again  starting  the  inflam- 
matory process,  therefore, 

Should  not  all  purulent  discharges,  and  all  pus 
which  is  accessible,  be  destroyed  or  disinfected .' 
Should  not  the  aim  be  thus  to  restrict  the  spread, 


and  eventually  to  stamp  out  all  inflammations? 

Immunity  through  inoculation  of  attenuated  vi- 
rus, albumens  and  ptomaines. — It  has  long  been 
known  that  all  animals  constantly  give  off  poisons 
which,  if  accumulated,  are  fatal  to  their  own  ex- 
istence. 

Certain  vegetable  ferments  which  produce  alco- 
hol, are  said  to  be  rendered  inactive  by  the  pres- 
ence of  no  more  than  2  per  cent,  of  alcohol. n 

Pasteur  says:  "Many  microbes  seem  to  give 
rise  in  their  cultures  to  substances  which  have  the 
property  of  being  harmful  to  their  own  develop- 
ment.' 

There  seems  to  be  a  universal  law  that  all  liv- 
ing organisms  form  poisons  to  themselves:  and 
there  is  good  foundation  for  the  hope  that  there 
may  be  found  methods  of  using  those  poisons  for 
the  destruction  of  those  microorganisms  which 
cause  diseases  of  man,  or  otherwise  for  the  pre- 
vention of  those  diseases. 

Immunity  against  Rabies. — Prof.  Welch  savs  : 
' '  There  can  be  no  doubt  whatever  that  it  is  pos- 
sible to  render  animals  immune  against  rabies 
both  before  and  after  inoculations  which  would 
otherwise  cause  the  disease.  The  independent 
and  careful  experiments  of  Ernst  in  this  countrv 
are  free  from  all  partisan  bias,  and  have  fully  con- 
firmed the  statements  of  Pasteur  and  others  upon 
this  point."  "3 

Prof.  Henry  Sewall,  of  the  Michigan  Univer- 
sity, demonstrated  the  possibility,  through  injec- 
tion of  snake  poison,  of  rendering  the  organism, 
immune  to  the  bite  of  the  rattle-snake. ■' 

The  experiments  and  practices  of  Pasteur  and" 
others,  for  the  purpose  of  securing  for  mankind 
immunity  from  dangerous  communicable  diseases, 
through  the  inoculation  of  the  body  with  the  at- 
tenuated virus  of  such  diseases,  have,  for  several 
years,  kept  this  subject  before  the  people,  and 
there  has  seemed  ground  for  the  hope  that  even- 
tually success  would  crown  the  efforts  being  made 
in  this  direction,  and  if  once  the  principle  is 
learned  with  reference  to  one  disease,  then  there 
is  hope  with  reference  to  the  other  diseases.  But 
nearly  all  such  efforts  have  been  made  by  indivi- 
dual workers,  at  their  own  expense,  and  in  such 
irregular  times  as  they  are  able  to  take  from  their 
regular  avocations  by  which  they  maintain  them- 


=°I  hold  clearly  in  mind  methods  which  if  adopted,  would.  I 
.  think,  probably  be"  effective,  but  the  statement  of  them  cannot  be 
attempted  here.  Among:  the  most  important  measures  would  be 
the  disinfection  of  all  sputa,  pocket  handkerchiefs,  etc. 


21  "  Immunity  through  Leucomaines,"  by  Eusebio  Giiell  Bacig- 
alupi.  Translated  from  the  second  French  Edition  bv  R.  F.  Rafael 
M.D.    J.  H.  Vail  &  Co..  New  York.  1889. 

—  Comptes  Rendus,  Seance  du  26  October,  1885,  p.  771.  M.  Pas- 
teur said: 

"  As  far  back  as  the  year  1SS0.  I  hadinstituted  research  in  order 
to  establish  the  fact,  that  the  microbe  of  chicken  cholera  produced 
a  sort  of  poison  of  this  microbe. 

' '  One  would  say,  that  immediately,  there  springs  into  existence 
a  product  which  arrests  the  development  of  the  microbe,  whether 
cultivated  in  contact  with  the  air.  or  in  a  vacuum. 

■'  Mr.  Raulin.  my  former  assistant,  to-day  Professor  to  the  Fac- 
ulty of  Lyons,  has  shown,  in  the  remarkable  thesis  which  he  sus- 
tained at'Paris  March  22,  iS7o.  that  the  vegetation  of  the 
his  nigt-r  develops  a  substance  which  arrests,  in  part,  the  production 
of  this  mold  when  the  nutritive  medium  does  not  contain  salts  or 

-;  William  H.  Welch.  M.D..  Trans.  Maryland  Med.  and  Chirurg. 
Faculty,  April.  1889,  pp.  170.  171. 

-4  Mentioned  in  British  Med.  Jour.,  November  29,  iScc.  p.  1264. 


78 


SANITATION  IN  1890. 


[January  17, 


selves.  A  few  workers  have  been  employed  by 
Governments,  but  there  is  no  such  Governmental 
support  of  such  investigations  as  the  immense  im- 
portance of  the  subject  demands,  and  especially 
not  in  our  own  country.  The  United  States  Gov- 
ernment can  be  commended  for  what  it  does  in 
this  direction  relative  to  the  health  of  domestic 
animals,  but  what  can  one  say,  by  way  of  apology 
for  a  Government  that  appropriates  hundreds  of 
thousands  of  dollars  to  study  the  causes  of  dis- 
eases of  domestic  animals,  and  then  fails  to  appro- 
priate as  much  to  do  a  similar  work  for  the  lives 
of  the  people?  I  wish,  however,  to  commend 
what  has  already  been  done  by  the  U.  S.  Govern- 
ment.83 I  have  already  mentioned  what  it  has 
done  for  quarantine;  but  I  believe  there  is  promise 
of  great  good  to  the  human  species  as  a  result  of 
the  Governmental  researches  into  the  causation 
of  diseases  of  animals.  The  work  of  Drs.  Sal- 
mon, Smith  and  Schweinitz,  of  the  U.  S.  Depart- 
ment of  Agriculture,  looking  to  the  production  of 
immunity  in  animals  exposed  to  hog  cholera,  has 
added  greatly  to  our  knowledge  of  the  underlying 
principle  in  the  production  of  immunity  to  dan- 
gerous communicable  diseases  of  animals  and  of 
man. 

Dr.  Welch  has  said:  "  That  immunity  against 
infectious  diseases  may  be  secured  by  the  injection 
of  chemical  substances  produced  hy  the  growth  of 
specific  bacteria,  was  demonstrated  first  by  Sal- 
mon and  Smith  in  the  case  of  hog  cholera,  and 
has  since  been  demonstrated  by  Roux  and  Cham- 
berland  for  malignant  oedema,  and  by  Wooldridge 
for  anthrax,"  "  both  dangerous  diseases  of  man 
as  well  as  animals. 

Published  accounts  of  experiments  by  Dr. 
Schweinitz,'-7  and  also  by  Frederick  G.  Novy, 
Sc.  D.,  at  the  Michigan  State  Laboratory  of  Hygi- 
ene, indicate  that  by  the  inoculation  of  an  animal 
with  the  albumens  and  ptomaines  formed  in  culture 
liquids  by  the  life- processes  of  the  germs  of  hog 
cholera,  the  animal  becomes  insusceptible  to  hog 
cholera,  whether  exposed  to  the  disease  by  inoc- 
ulation or  by  direct  contact  and  association  with 
animals  sick  with  the  disease.  Dr.  Schweinitz 
■was  even  able  to  produce  immunity  in  an  animal 
by  inoculation  with  a  pure  chemical  prepared 
synthetically  in  the  laboratory.  The  results  of 
these  experiments  are  in  harmony  with  facts  al- 
ready known.8*  Perhaps  the  term  "attenuated 
virus  "  may  still  be  used  if  we  consider  that  the 
"  attenuation  "  consists  in  the  destruction  of  the 
germ,  and  in  the  saving  of  its  products  for  use  in 
the  production  of  immunity.  Of  course  much  re- 
mains to  be  done  before  this  knowledge  can  be 


foi  k.  of  the  Amer.  Med.  Assoc,  July  5,  1890,  p.  1. 
'  William  11.  Welch,  M.D.,  Trans.  Maryland  Med.  and  Chirurg. 
Fac,  18S9.  p.  172. 

27  Med.  News,  Philadelphia,  September  6, 1890,  pp.  231-9,  and  Oc- 
tober 4,  1890,  pp.  332-5. 

1  he  Suostaace  used  by  Dr.  Koch  for  the  eradication  of  con- 
sumption is  not  yet  made  known,  but  it  may  be  expected  to  be  in 
line  with  those  facts. 


made  directly  available  in  the  prevention  or  re- 
striction of  dangerous  communicable  diseases  of 
man,  and  the  sooner  that  work  is  done  the  sooner 
the  thousands  of  human  lives  now  lost  through 
those  diseases  may  be  saved.  Such  work  is  for 
the  general  good,  and  should  be  done  by  the  Gen- 
eral Government.  It  should  be  done  with  refer- 
ence to  diseases  of  man,  and  not  confined  to  dis- 
eases of  animals,  nor  even  to  diseases  which,  like 
rabies,  affect  man  and  animals. 

Is  it  not  time  that  human  life  should  be  recog- 
nized as  a  proper  object,  and  the  most  important 
object  of  solicitude  on  the  part  of  the  National 
government  of  the  United  States  ? 

It  will  be  a  great  gain,  however,  if  it  can  be 
brought  about  that  the  government  shall  do  such 
work,  even  if  only  for  the  saving  in  money  values 
to  the  people,  which,  undoubtedly,  would  be  im- 
mense. 

Antidotes  to  Diseases  Already  Acquired.- — At  the 
recent  International  Medical  Congress  in  Berlin, 
Dr.  Koch,  of  the  Imperial  Board  of  Health,  re- 
ferring to  his  now  famous  consumption  cure,  said: 
"  My  researches  on  this  substance,  therefore,  al- 
though they  have  already  occupied  me  for  nearly 
a  year,  are  not  yet  completed,  and  I  can  only  say 
this  much  about  them,  that  guinea  pigs,  which, 
as  is  well  known,  are  extraordinarily  susceptible 
to  tuberculosis,  if  exposed  to  the  influence  of  this 
substance,  cease  to  react  to  the  inoculation  of  tu- 
berculous virus,  and  that  in  guinea  pigs  suffering 
from  general  tuberculosis  even  to  a  high  degree, 
the  morbid  process  can  be  brought  completely 
to  a  standstill,  without  the  body  being  in  any 
way  injuriously  affected."  .  .  .  "This  opens 
up  an  eft-promised  field  of  work,  with  problems 
which  are  worthy  to  be  the  subject  of  an  inter- 
national competition  of  the  noblest  kind."  .  .  . 
"Allow  me,  therefore,  the  expression  of  a  wish 
that  the  nations  may  measure  their  strength  on 
this  field  of  labor  and  in  war  against  the  small- 
est, but  the  most  deadly,  foes  of  the  human  race; 
and  that  in  this  struggle  for  the  weal  of  all  man- 
kind, one  nation  may  always  strive  to  surpass 
the  other  in  the  successes  which  it  achieves."'9 

Certainly  we  can  all  join  with  Dr.  Koch  in 
such  wishes  for  National  effort  for  life  saving 
work  ;  but  I  think  that,  among  all  the  countries 
represented  at  the  International  Congress,  there 
are  few  governments  which  occupy  such  an  en- 
lightened position  on  the  subject  of  sanitary  re- 
searches as  does  the  German  Empire.  If  our  own  j 
National  Government  would  even  do  as  much  as 
to  publish  and  thoroughly  disseminate  among 
our  people  the  important  results  of  the  researches 
made  by  the  German  Imperial  Board  of  Health, 
our  people  would  have  cause  to  rejoice,  and  prob- 
ably thousands  of  human  lives  would  be  saved 
through   the   knowledge   thus  obtained.     Sorne- 


«  Journal  of  the  Am.  Med.  Association,  Vol.  xv,  No.  10,  Sept.  6, 
1890,  p.  370. 


i89i.] 


SANITATION  IN  1890. 


79 


thing  in  the  direction  of  such  publication  has  re- 
cently been  done  by  the  U.  S.  Marine- Hospital 
Service.  But  much  more  than  has  yet  been  at- 
tempted should  certainly  be  done  in  that  line. 
And  if  our  government  were  to  wake  up  to  the 
importance  of  doing  what  the  highest  interests  of 
its  constituents  demand — cause  researches  to  be 
made  for  the  creation  of  such  knowledge — it  can 
find  as  bright  intellects  and  as  faithful  workers 
among  our  own  scientific  men  as  there  are  in  an}' 
country  ;  and  in  a  short  time  the  world  might  be 
as  much  indebted  to  the  United  States  Board  of 
Health  for  life-saving  knowledge  as  it  now  is  to 
the  Imperial  Board  of  Health  of  Germany. 

While  we  accord  great  honor  to  Dr.  Koch,  who 
discovered  the  specific  cause  of  consumption,  and 
who  now  thinks  he  has  discovered  its  antidote, 
let  us  not  forget  that  it  was  an  honored  member 
of  our  own  Association,  our  President  in  1887, 
Dr.  Sternberg,  of  the  U.  S.  Army,  who  first  dis- 
covered the  specific  cause  of  pneumonia,  a  dis- 
ease which,  as  a  cause  of  mortality  in  this  coun- 
try, ranks  only  a  little  lower  than  consumption  ; 
and,  if  the  subject  were  followed  up,  it  should 
yet  yield  results  somewhat  comparable  with  those 
reached  by  Dr.  Koch  with  reference  to  the  some- 
what similar  disease  which  he  seems  to  have  con- 
quered. 

Let  us  consider  for  a  moment  the  prospective 
importance  of  such  a  discovery  as  that  suggested 
by  Dr.  Koch:  It  is  not  claimed  that  all  deaths 
are  reported  in  this  country,  but  the  reported 
deaths  in  the.United  States  from  that  one  disease, 
consumption,  in  the  single  census  year  1880  were 
91,270;  without  doubt  more  than  100,000  such 
deaths  occur  in  the  United  States  in  each  year. 
If,  as  stated  by  Dr.  Koch,  "in  guinea-pigs  suffer- 
ing from  general  tuberculosis  even  to  a  high  de- 
gree, the  morbid  process  can  be  brought  to  a 
standstill,  without  the  body  being  in  any  way 
injuriously  affected,"  there  is  certainly  ground 
for  the  hope  that  something  approaching  that  can 
be  done  for  the  human  being,  and  that,  if  suffi- 
cient intelligent  effort  be  put  into  the  research, 
the  substance  which  will  do  this  can  be  found, 
even  if  it  has  not  already  been  found  by  Dr. 
Koch.  Let  us  suppose  that  our  own  National 
Government  were  to  pay  for  such  researches,  and 
that  annually  the  lives  of  one-half,  or  even  of  one- 
fourth  of  the  100,000  of  our  people,  who  otherwise 
would  have  prematurely  died,  were  to  be  saved. 
How  would  that  compare  with  the  work  of  the 
Agricultural  Department  of  our  government,  for 
the  distribution  of  garden  seeds  ?  How  would 
provision  for  such  work  by  Congress  compare 
with  its  work  for  the  protection  of  our  infant  in- 
dustries ?  How  would  it  compare  with  any  work 
that  has  been  done  by  Congress  during  the  past 
twenty  years  ?  I  admit  that  in  1S79  it  established 
a  National  Board  of  Health;  but  the  government 
failed  to  sustain  the  Board  long  enough  to  per- 


mit of  many  such  researches  as  those  I  suggest, 
although,  as  long  as  it  was  sustained,  it  did  ex- 

!  cellent  work. 

In  comparing    public-health  work    with    the 

1  work  of  the  U.  S.  Agricultural  Department,  I  do 
not  forget  that — 

That  art  on  which  a  thousand  millions  of  men  are  de- 
|  pendent  for  their  sustenance,  and  two  hundred  millions 
i  of  men  expend  their  daily  toil,  must  be  the  most  im- 
portant, of  all, — the  parent  and  precursor  of  all  other 
I  arts.30 

But  all  must  concede  that  agricultural  art  has 
now  made  such  wonderful  progress  that  there  is 
no  longer  need  for  more,  to  fully  sustain  not 
only  the  necessities  of  man,  but  to  supply  many 
luxuries.  Superfluous  effort,  therefore,  might  well 
be  diverted  from  agriculture,  to  supply  those  pro- 
visions for  public-health  work  for  the  want  of 
,  which  hundreds  of  thousands  of  our  people  actu- 
,  ally  prematurely  perish,  and  hundreds  of  thou- 
sands more  drag  out  a  miserable  existence. 

So  many  of  our  people  are  now  raising  farm 
products,  that  that  is  claimed  to  be  a  compara- 
tively unprofitable  occupation. 

Apparently,  then,  this  country  needs  fewer 
farmers,  more  sanitarians. 

We  welcome  to  our  ranks,  however,  not  only 
farmers,  but  all  good  people. 

They  have  departed,  but  their  zvorfcs  C07itinue. — 
Custom  and  humanity  dictate  that  there  shall  be 
public  recognition  of  the  services  of  those  who 
have  publicly  labored  with  us,  and  who  have 
ceased  their  labors,  but  whose  good  work  will  go 
on  down  through  the  ages.  Considering  our 
numbers,  and  the  average  age  of  our. members,  it 
is  to  be  expected  that  in  every  year  death  will  over- 
take some  of  us.  Before  the  time  for  our  next 
meeting,  some  of  us  will  have  passed  over  to  the 
"great  majority."  Since  the  last  meeting,  so 
far  as  I  know,  only  three  of  our  members  have 
died:  Dr.  Charles  Linnaeus  Allen,  Secretary  of 
the  State  Board  of  Health  of  Vermont,  who  was 
elected  a  member  of  this  Association  in  1888:  Dr. 
J,  H.  Baxter,  Surgeon-General  of  the  U.  S.  Army, 
a  member  of  this  Association  since  1876;  and  Dr. 
William  Brodie,  President  of  the  Board  of  Health 
of  Detroit,  Michigan,  a  member  of  this  Associa- 
tion since  1873.  Dr.  Brodie  had  long  been  a 
prominent  member  of  the  medical  profession;  he 
had  been  President  of  the  State  Medical  Society 
of  Michigan  ;  and  President  of  the  American 
Medical  Association.  It  was  largely  through  his 
work  that  this  Association  held  its  successful 
meeting  in  Detroit  in  1S83.  Dr.  Brodie  was 
President  of  the  first  Sanitary  Convention  held 
under  the  auspices  of  the  Michigan  State  Board 
of  Health. 

I  trust  that  a  committee  or  the  Secretary  of 
this  Association  will  make  fittting  records  of  the 

3°  James  F.  W.  Johnston. 


8o 


SANITATION  IN  1890. 


[January  17, 


services  of  our  deceased  brothers,  and  of  tributes 
to  their  memory. 

Death  of  Sir  Edwin  Chad-wick. — Since  our  last 
meeting,  sanitary  reform  has  lost  an  able  advo- 
cate, in  the  death  of  Sir  Edwin  Chadwick  in 
England.  In  recording  his  death,  the  British 
Medical  Journal  said  : 

Few  men  have  deserved  better  of  their  country  than 
the  veteran  sanitarian  whose  death,  at  the  advanced  age 
of  91,  we  have  to  record.  His  investigations  of  the  san- 
itary condition  of  London,  dating  back  to  1S47,  were  the 
official  starting  point  of  a  reorganization  of  the  Health 
Department,  and  laid  the  public  legislative  basis  of  the 
first  of  a  series  of  sanitary  reforms  which  have  been  of 
inestimable  value  during  the  last  half  century  in  the  sav- 
ing of  life  and  diminution  of  sickness  and  disablement. 
His  subsequent  services  to  the  cause  of  army  health  re- 
form, and  his  continuous  devotion  to  great  and  small 
questions  of  public  and  personal  sanitation,  placed  him 
quite  in  the  first  rank  of  non-medical  sanitarv  reformers. 
It  has  been  aptly  observed  that  had  he,  as  a  mil- 
itary man,  succeeded  in  destroying  one-hundredth  part 
of  the  lives  which  he  was  prominent  in  assisting  to  save, 
his  statue  would  have  been  erected  long  since  in  more 
than  one  of  the  great  cities  of  the  empire,  and  he  would 
have  been  loaded  with  honors  and  titles.  As  it  is,  it  was 
not  until  he  attained  the  age  of  90  that  he  received  the 
honor  of  knighthood.31 

Practical  Application  of  Sanitary  Science. — I 
have  already  touched  that  subject  which  was  de- 
clared the  second  object  of  this  Association,  but 
mainly  to  show  that  the  most  rapid  advancement 
•of  sanitary  science  is  made,  and  is  to  be  expected, 
•where  governmental  aid  is  most  complete  and 
abundant ;  in  other  words,  where  the  people  as  a 
whole  contribute,  according  to  their  means.  Hav- 
ing left  the  subject  of  advancement  of  science,  I 
■will  briefly  consider  such  "organizations  and  meas- 
ures for  the  practical  application  of  public  hy- 
giene." 

State  Boards  of  Health. — There  is  reason  for  a 
high  degree  of  pride  in  the  wonderful  develop- 
ment, in  this  country,  of  the  State  Boards  of 
Health.  Although  none  of  them  have  anything 
approaching  the  resources  which  are  placed  at 
the  disposal  of  the  Imperial  Board  of  Health  of 
Germany,  or  of  the  Government  Board  of  Eng- 
land, and  it  must  be  confessed  that  the  debt  which 
humanity  owes  to  Dr.  Robert  Koch,  of  the  Ger- 
man Board,  is  perhaps  greater  than  to  any  man 
in  this  country,  in  any  field  of  human  effort,  still 
I  think  it  can  fairly  be  claimed  that  some  of  the 
State  Boards  in  the  United  States  rival  the  boards 
of  health  in  the  general  governments  of  the  most 
■enlightened  countries  in  the  world — rival  them 
in  the  amount  of  useful  services  which  they  are 
continually  performing  for  their  own  people  and 
for  the  general  sanitary  enlightenment  of  the 
world  ;  especially  do  they  rival  them  in  the  im- 
mediate practical  results  of  their  work. 

For  instance,  statistics  which  appear  to  be  trust- 
worthy, seem  to  prove  that  in  one  State,  and  ap- 
parently through  measures  inaugurated  and  mais- 


1  British  Med.  Jour.,  No.  1541,  July  12,  1890,  p. 


tained  by  the  State  Board  of  Health,  the  deaths 
from  small-pox  have  been  so  reduced  that  more 
than  one  thousand  five  hundred  persons  have  con- 
tinued to  live  who  would  have  died  from  that  dis- 
ease if  its  mortality  rate  had  continued  as  it  was 
before  the  establishment  of  the  State  Board  of 
Health.  A  thousand  five  hundred  lives  saved 
from  small- pox  means  a  saving  also  of  at  least 
six  thousand  cases  of  sickness  from  that  loath- 
some disease.32 

In  that  same  State,  also,  the  vital  statistics 
seem  to  prove  that  through  similar  though  not 
identical  work,  there  has  already  been  a  saving 
of  life  from  scarlet  fever  equal  at  least  to  five 
thousand  persons,  and  (if  the  death-rate  was  ten 
per  cent.)  a  probable  saving  of  fifty  thousand 
cases  of  sickness  from  that  disease.33 

Nor  is  this  all ;  statistics  indicate  that  at  least 
one  life  a  day  is  being  saved  in  that  State  by  meas- 
ures started  and  maintained  by  its  State  Board  of 
Health  for  the  restriction  of  diphtheria.31  As  the 
death-rate  is  about  twenty-four  per  cent.,  at  least 
fifteen  hundred  cases  of  sickness  from  diphtheria 
are  prevented  annually. 

At  least  one  other  State  (Massachusetts)  has 
undertaken  statistical  effort  to  learn  the  effect  of 
such  work,  and  similar  saving  has  been  made  ap- 
parent. 

It  seems  desirable  that  other  States,  in  which 
similar  work  has  been  done,  should  collect  and 
publish  evidence  of  the  results  of  their  work. 

The  Value  and  Importance  of  Statistics. — On 
many  questions  of  public  policy,  no  useful  con- 
clusion can  be  reached  without  a  thorough  knowl- 
edge of  the  facts  involved.  And  frequently  it  is 
important  to  have  accurate  knowledge  respecting 
several  classes  of  facts.  For  instance,  in  order 
to  know  what  disease  it  is  most  important  that 
we  shall  strive  to  prevent,  it  is  necessary  to  know 
what  disease  causes  the  most  deaths,  or  the  most 
suffering  among  the  people.  Mortality  statistics 
supply  this  knowledge.  Again,  in  order  to  know 
whether  a  disease  which  is  an  important  cause  of 
death  is  itself  caused  by  climatic  or  meteorologi- 
cal conditions,  it  is  necessary  to  have,  and  to 
compare  with  the  statistics  of  deaths  and  of  sick- 
ness, other  statistics  relating  to  the  various  me- 
teorological conditions. 

For  several  years  we  had  at  Washington  a 
United  States  Commissioner  of  Labor,  and  he  has 
col  lected  valuable  statistics  on  the  various  branches 
of  the  subject  of  human  labor.  We  ought  to 
have  at  Washington  an  officer  charged  with  the 
duty  of  collecting  statistics  relating  to  those  sub- 
jects which  bear  directly  upon  human  life  and 
health. 

There  is  now  a  "  Department  of  Labor"  in  the 


3^  Proceedings  of  Sanitarv  Convention  at  Vicksburg,  Michigan, 
9.  P-  56- 

^  Proceedings  of  Sanitarv  Convention  at  Vicksburg,  Michigan, 
9,  P-  58. 

34  Proceedings  of  Sanitary  Convention  at  Vicksburg,  Michigan, 
9,  p.  62. 


I89i.] 


SANITATION  IN  1890. 


Si 


United  States  Government.  Should  there  not  be 
a  "  Department  of  Life  and  Health?" 

Statesmanship.— -This  is  an  age  of  organiza- 
tions among  the  people,  for  the  general  benefit  of 
all.  People  generally  are  coming  to  have  that 
degree  of  intelligence,  education  and  culture, 
which  fit  them  for  self-government.  The  daily- 
papers,  the  magazines,  the  excellent  postal  facili- 
ties, the  telegraph  and  the  telephone,  have  served 
greatly  to  equalize  the  intelligence  of  the  people 
generally  ;  they  have  served  greatly'  to  do  away 
with  famines,  with  continual  warfare,  and,  I  be- 
lieve, with  great  wars  ;  and  certainly  they  have 
done  much  to  make  the  old-time  plagues  and  pes- 
tilences horrors  of  the  past. 

Yet,  although  the  general  governments  of  coun- 
tries are  making  progress  toward  conforming  to 
the  actual  conditions  among  the  people,  old  cus- 
toms and  precedents  have  a  powerful  influence  in 
restraining  progress  ;  and  I  think  this  is  more 
noticeable  to  members  of  this  Public  Health  As- 
sociation than  to  any  other  class  of  people  ;  for 
the  reason  that  sanitary  science  is  a  comparatively 
new  science,  and  has  not  for  so  long  a  time  been 
available  for  spreading  its  knowledge  among  the 
people.  But  already  the  leading  minds  in  sev- 
eral of  the  most  civilized  countries  have  recog- 
nized the  fact  that  the  greatest  good  to  the  great- 
est number  of  citizens  consists,  first  of  all,  in  se- 
curing to  them  life  and  health.  Thus,  for  in- 
stance, Disraeli  said  that  action  in  this  direction 
' '  is  the  wisest  statesmanship. ' '  Gladstone  has 
expressed  himself  similarly.  And,  through  the 
lead  of  such  statesmen,  England  has  its  useful 
general  board  of  health — the  - '  Local  Govern- 
ment Board,"  with  its  corps  of  medical  officers. 
Some  of  the  important  work  of  the  German  Im- 
perial Board  of  Health  is  well  known. 

In  our  own  country,  the  framers  of  the  Declar- 
ation of  Independence  declared  that  "  life,  liberty 
and  the  pursuit  of  happiness"  are  "among  the 
unalienable  rights,"  to  secure  which  "  govern- 
ments are  instituted  among  men." 

In  times  past,  the  minds  of  men  and  of  govern- 
ments have  been  kept  so  occupied  with  protecting 
the  lives  of  their  citizens  from  the  dangers  caused 
by  the  battling  of  other  men,  hostile  tribes,  and 
foreign  governments,  that  little  time  or  energy 
has  been  left  to  devote  to  the  protection  of  life 
and  health  from  ordinary  preventable  causes  of 
death  and  sickness.  Now  that  men  and  nations 
are  coming  to  be  less  destructive  of  each  other,  it 
is  rapidly  coming  to  be  seen  that  by  organized 
effort  and  general  cooperation  a  great  proportion 
of  the  premature  deaths,  and  of  the  sickness  from 
the  most  common  diseases,  and  the  resulting  pau- 
perism, insanity  and  crime,  can  easily  be  pre- 
vented ;  and  this  without  any  radically  new  prin- 
ciple of  government,  but  by  an  extension  of  the 
principle  of  protection  of  life  and  property,  into 
new  systems  of  effort.      The  constitution  gives 


Congress  the  power  to  "  provide  for  the  common 
defense  and  general  welfare  of  the  United  States." 

It  is  the  same  now  as  when  the  book  of  Hosea 
was  written — our  ' '  people  are  destroyed  for  lack 
of  knowledge,""  and  a  government  has  only  to 
collect,  search  out,  and  disseminate  among  its 
people  "knowledge"  of  the  causation  of  disease, 
its  modes  of  spread,  and  how  to  avoid  causes  of 
deaths  and  the  spreading  of  epidemic  diseases,  to 
make  it  possible  for  its  people  to  have  safety  to 
"life"  and  that  "pursuit  of  happiness"  which 
is  only  possible  to  persons  in  health.  This  im- 
plies, however,  that  the  government  must  con- 
stantly maintain  statistical  investigations  and  sci- 
entific researches  into  the  causation  of  diseases, 
and  such  a  complete  and  thorough  system  of 
prompt  notification  of  the  outbreak  of  every  dan- 
gerous communicable  disease  within  its  own  coun- 
try—  and  also  in  all  parts  of  the  world  where  it 
may  readily  spread  to  its  own  country — that  the 
government  shall  be  able  to  and  shall  in  fact 
promptly  warn  ail  its  people  endangered,  and  not 
only  warn  them,  but  shall  at  the  same  time  place 
before  them  the  best  that  is  known  or  can  be 
learned  concerning  the  exact  methods  for  avoid- 
ing the  dangers  to  life  and  health  from  that  par- 
ticular disease  which  at  the  time  is  threatening. 
Only  by  some  such  modification  of  governmental 
methods  is  it  possible  to  do  for  a  people  that  ser- 
vice which  it  is  the  highest  function  of  a  govern- 
ment to  perform. 

We  hear  much  about  the  wisest  statesmanship 
as  applied  to  such  questions  as  relate  to  our  com- 
mercial dealings  with  other  nations,  questions 
whether  it  is  wiser  to  have  "free  trade"  or  "pro- 
tection" of  home  industries  ;  yet  these  are  ques- 
tions of  small  consequence  to  the  people  of  any 
country  when  compared  with  questions  which  in- 
volve the  protection  of  the  lives  and  the  health  of 
the  people  themselves  ;  because  the  people  can  get 
sufficient  food  and  other  necessaries  for  subsis- 
tence under  "free  trade"  or  under  "protection  ;" 
but  under  neglect  of  proper  governmental  protec- 
tion of  life  and  health,  a  large  proportion  of  the 
people  prematurely  die,  and  still  larger  proportions 
suffer  sickness,  life-long  pain,  and  physical  and 
mental  degradations,  from  causes  which  under 
proper  governmental  protection  are  easily  pre- 
ventable. That  this  is  true,  there  is  no  longer 
question  ;  incontrovertible  facts  are  on  record 
proving  that  it  is  strictly  true.  As  soon  as  this 
knowledge  comes  to  a  majority  of  the  people, 
they  will  surely  demand  that  the  government 
shall  no  longer  neglect  its  highest  functions  ;  and 
we  may  confidently  look  forward  to  a  "  good  time 
coming"  when  the  safety  of  life  to  our  people  shall 
be  the  first  and  most  important  concern  of  the  en- 
lightened government  of  these  United  States ; 
when  the  most  important  officer  in  this  country, 
whether  he  is  called  Commissioner  of  Health, 

I         33  Hosea,  chapter  iv,  verse  6. 


X2 


BORACIC  ACID  AND  MASSAGE  IN  PANNUS. 


[January  17, 


Secretary  of  the  Health  Department,  or  President 
of  the  United  States,  shall,  at  all  events,  be  its 
wisest  sanitarian,  or  at  least  its  most  competent 
public  health  administrator.  And  you,  the  mem- 
bers of  this  Association,  are  and  should  be  laying 
the  foundations,  and  fitting  yourselves  for  the  per- 
formance of  such  highest  and  most  sacred  duties; 
for,  in  these  days  of  rapid  advances  in  the  spread- 
ing and  equalizing  of  knowledge,  we  know  not 
how  soon  the  clamor  of  our  people,  for  the  protec- 
tion of  their  lives,  may  force  upon  our  own  Na- 
tional government  the  proper  performance  of  its 
highest  duties,  which  it  has  so  long  neglected. 


ORIGINAL  ARTICLES. 


BORACIC   ACID  AND  MASSAGE  IN 
PANNUS. 

Read  in  the  Section  of  Ophthalmology  at  the  Forty-first  Annual  A 
ing  of  the  American  Medical  Association,  held  at  Nashville, 
Tenn,,  May,  1800. 


ITHALMIC 


PROFESSOR 


BY  C.    R.   HOLMES,  M.D. 

URGEON    TO    THE    CINCINNATI 
[  DISEASES  OF  THE  EYE,  MIAMI 
'    OPHTHALMOLOGY   TO    THI 
HOSPITAL   MEDICAI 


CLINICAL 
MEDICAL  COLLEGE; 
WOMAN'S   STATE 


The  treatment  of  a  limited  number  of  affec- 
tions of  the  eye  and  its  appendages  by  massage 
is,  as  is  well  known,  not  new,  and  to  Donders  be- 
longs the  honor  of  having  first  proposed  it,  at 
the  Ophthalmological  Congress  in  London  in  1872. 

Massage  has  been  practiced  with  or  without  the 
addition  of  ointment ;  but  Landolt  was,  so  far  as 
I  know,  the  first  to  systematical!}'  use  boracic  acid 
and  massage  in  granular  affections  of  the  con- 
junctiva and  cornea.1  Acting  on  this  suggestion, 
I  began  last  year  to  make  observations  on  a  num- 
ber of  cases,  and  present  herewith  the  results. 

New  methods  and  remedies  are  too  often  lauded 
far  above  their  real  worth,  but  after  nearly  a 
year's  trial,  I  am  satisfied  that  in  the  treatment 
of  pannus,  whether  acute  or  chronic,  it  is  most 
valuable,  especially  when  used  in  connection  with 
one  or  more  of  the  standard  remedies  directed 
toward  curing  the  lid  affection.  Its  chief  value 
lies  in  the  rapidity  of  its  action,  a  few  days  fre- 
quently giving  as  good  and  often  much  better  re- 
sults than  as  many  weeks  by  the  usual  methods. 

I  have  also  tried  it  in  cases  of  granular  and 
follicular  conjunctivitis  where  there  was  no  cor- 
neal affection,  selecting  cases  where  the  inflam- 
mation was,  so  far  as  I  could  determine,  equal  in 
both  eyes,  treating  one  eye  with  boracic  acid  pow- 
der and  friction,  and  the  other  with  the  usual  as- 
tringents. For  a  few  days  after  instituting  the 
comparative  treatment,  the  eye  receiving  massage 
would  appear  more  improved  than  the  other,  but 
after  that  the  treatment  by  astringents  would  lead 
while  the  other  would  either  appear  stationary  orl  gard  it  as  malignant 


recede,  till  the  plan  was  abandoned,  and  the  old 
reliable  remedies  used  in  both  eyes. 

I  now  use  a  5  or  10  per  cent,  solution  of  co- 
caine as  an  anaesthetic,  then  evert  the  lids  and 
separate  them  as  much  as  possible  with  one  hand, 
while  with  the  other,  by  means  of  a  camel's  hair 
brush,  as  much  powder  is  dusted  into  the  eye  as 
it  will  contain.  Then,  by  grasping  the  edge  of 
the  upper  lid  with  thumb  and  index  finger,  re- 
place the  lid  in  such  a  manner  that  the  powder 
will  be  retained  between  the  cornea  and  the  lids. 
With  the  index  finger  or  thumb  massage  is  then 
begun.  I  do  not  anoint  the  finger  as  has  been 
recommended  for  simple  massage,  for  we  desire 
the  friction  movement  to  take  place  between  the 
lid  and  the  globe,  which  at  best  is  only  limited  if 
the  globe  is  stationary.  Cocaine  gives  the  pa- 
tients, as  a  rule,  control  of  the  movements  of  the 
eye,  and  I  direct  them  to  look  in  such  direction 
as  will  bring  the  cornea  under  the  finger.  In 
many  cases  the  cornea  rolls  upwards,  and  we 
must  endeavor  to  follow  the  position  with  the 
finger. 

The  friction  should  be  continued  from  one  to 
five  minutes  to  each  eye,  the  duration  depending 
upon  the  density  of  the  pannus  and  whether  it 
be  of  long  or  short  standing. 

My  cases  are  about  equally  divided  between 
private,  hospital  and  clinic  patients. 

Case  1. — Master  B.,  aet.  12,  a  typical  case  of 
severe  granular  conjunctivitis  of  four  years'  stand- 
ing, with  dense  pannus.  During  last  three  months 
had  to  be  led  about.  Much  photophobia  and  lach- 
rymation  present  on  examining  the  eyes.  Can 
only  see  movement  of  the  hand  in  front  of  his 
face.  The  sulphate  of  copper  crystal  and  atro- 
pine was  used  two  weeks,  with  improvement  of 
lids  but  not  of  cornea.  Changed  to  boracic  acid 
and  friction,  and  from  day  to  day  we  could  see 
the  cornea  clearing  up.  In  one  week  vision  be- 
came VW  The  lids  during  this  week  received  no 
other  treatment  and  began  to  look  worse,  when 
the  mixed  treatment  was  continued  from  that  on 
until  his  cornese  were  clear  and  he  went  to  his 
home  in  the  country.  Duration  of  treatment  ten 
weeks.  When  discharged  he  could,  with  a  little 
effort,  read  ordinary  print. 

Case  2. — Mr.  R.,  set.  45.  Contracted  granular 
conjunctivitis  four  years  ago.  Status  Prcesens  : 
Lids  present  the  ordinary'  cicatricial  alterations  of 
a  well-marked  case,  having  almost  completed  its 
course.  But  the  upper  third  of  cornea,  especially 
outer  quadrant,  is  covered  by  a  thick,  flesh-col- 
ored mass  extending  upon  the  sclera  for  a  dis- 
tance of  '4  inch,  where  it  gradually  begins  to 
become  thinner.  At  this  point  the  follicles  be- 
come plainly  visible,  assuming  a  straw  color, 
gradually  fading  into  the  normal  ocular  conjunc- 
tiva. The  family  physician  was  inclined  to  re- 
The  other  cornea  showed 


1  See  Annual  of  Universal  Medical  Science,  1889,  Vol.  iv.,  p.  B,  70. 


the   effects  of  pannus  in  the   form  of  extensive 


I89i.] 


BORACIC  ACID  AND  MASSAGE  IN   PANNUS. 


83 


nebulae  becoming  denser  in  the  upper  third,  but  lens  without  iridectomy.     Lens  very  large,  black 

there  is   no  acute  inflammation   about  this  eye.  and  hard,  when  placed  on  a  piece  of  white  paper 

Boracic    acid    and   friction   was    instituted    twice  only  the  very  margin  permitted  any  light  to  be 

daily,  duration  five  minutes  at  each  sitting,  pain  transmitted.      Healing  process  not  attended  with 

controlled  by    repeated    instillations  of  cocaine,  the  slightest  inflammatory  reaction.    On  the  third 

After  each  treatment  there  was  great  vascular  ac-  day  patient  was  permitted  to  sit  up,  pupil  respond- 

tivitv.  which   soon  subsided.     After  three   days  '  ing  to  light.      Discolored  capsule  gives  pupil  a 

one    could   notice    slight  improvement.      Patient  grayish  appearance. 

returned  home,  where  his  physician   carried  out  November  10.     Under  cocaine   made  a  liberal 

the  treatment  once   daily  for  three  weeks,  when  but  distinctly  corneal  incision  upwards  ;  liberal 

he  returned  with  the  mass  three-fourths  absorbed,  because,  in  extracting  the  right  lens,  I  underes- 

Another  two  weeks'   treatment  at  my  office  was  timated   its  size   and   hardness,  making  its    exit 

sufficient  to  remove  the    mass  entirely,   leaving  through  the  corneal  incision  somewhat  difficult, 

central  portion   of  cornea   clear,   upper   portion  After  lacerating  the  capsule  and  beginning  ma- 

slightly  cloudy,  but  quite  smooth.  nipulation  for  expulsion  of  lens,  a  hernia  of  iris 

I  have  the  records  of  fifteen  other  cases  treated  and  vitreous  presented  in  the  wound. 

by  this  method,  but  will  not  take  your  time  nor  I    at    once    made    iridectomy,   and  delivered  a 

try  your  patience  by  a  repetition  of  results,  but  I  large,  black  and  hard  lens  without  further  com- 
only  say  in  conclusion,  that  I  am  fully  aware  of  plications.     There  was  only  slight  bleeding  from 

the  fact  that  but  little  value  can  be  placed  upon  the   cut  iris,  the   blood  being  readily  expelled, 

conclusions  drawn  from  treatment  of  a  few  cases,  leaving  a  black  keyhole  pupil.      Figure  of  8  ban- 


I  only  offer  them  for  your  consideration,  being 
the  result  of  careful,  painstaking  observation;  and 
hope  during  the  coming  year  to  continue  my  in- 
vestigations, profiting  by  the  views  and  experi- 
ence of  others. 


dage  was  applied.  The  eye  felt  comfortable  till 
two  hours  after  the  operation,  when  patient  had 
an  unpleasant  feeling  in  the  eye,  became  sick  at 
her  stomach  and  vomited,  pain  in  the  eye  becom- 
ing very  severe.     The  interne  found  the  bandage 


The  good  results  I  have  obtained  from  this  saturated  with  blood,  some  of  it  trickling  clown 
method  of  treatment.  I  attribute  to  a  mechanical  her  cheek.  The  pain  was  controlled  by  hvpo- 
cause,  viz.:  the  friction,  thus  bringing  about  in- '  dermics  of  morphine.  Next  morning  \  found 
creased  arterial  and  venous  circulation,  breaking  swelling  of  lids,  and  on  exposing  the  globe  dis- 
down  degenerated  epithelial  masses  and  forcing  |  covered  a  large  mass  of  blood  stained  vitreous 
open  occluded  lymph  channels,  thereby  prepar-  '•  protruding  from  the  corneal  wound  and  slight 
ing  the  way  for  rapid  absorption  of  pathological  bleeding  still  going  on.  The  hernia  was  not  ab- 
products.  seised  for  several  da5s  because  patient  refused  to 

I  believe  that  any  other  powder  equally  palpa-  have  it  done.  There  was  slight  oozing  of  blood 
ble  and  unirritatin.g;  would  do  as  well  as  boracic   for  five  days.     No  microscopic  examination  was 


acid. 

HEMORRHAGE     FOLLOWING      EXTRACTION    OF     A 

BLACK  CATARACT  IN  A  HIGHLY  MYOPIC  EYE, 

PROBABLY'  ASSOCIATED  WITH  CHOROIDAL 

CHANGES  ;   ENUCLEATION. 

Margaret  S.,  aet.  53.  widow,  good  physique, 
habitual  user  of  strong  drink,  admitted  to  Cincin- 
nati Hospital  October  23,  1888.  States  she  has 
been  very  nearsighted  since  childhood.  About 
six  years  ago  she  noticed  vision  failing  in  the 
right  eye,  and  since  four  years  the  left  has  slowly 
followed  the  same  course.  By  ordinary  inspec- 
tion with  pupils  dilated  by  a  mydriatic,  cataract  count  of  my  experience  with  the  other  eye,  I  de- 
appeared,  almost  black  in  the  right  and  grayish-  laved,  and  when  later  on  I  sent  for  her  to  go  into 
black  in  the  left  eye.  Cornea,  aqueous  humor.  |  the  hospital  to  have  the  operation  made,  I  found 
iris  and  tension  normal  in  both  eyes.  The  oph-  she  had  left  the  city.  I  regret  having  lost  sight 
thalmoscope  reveals  total  opacity  of  both  lenses,  of  the  case,  as  I  was  desirous  of  obtaining  a  good 
by  candle  test  field  of  vision  is  very  defective  cen-  view  of  the  fundus  in  order  to  determine  the  ex- 
trally,  fair  at  periphery  in  the  left  eye.  while  in  istence  or  non-existence  of  choroidal  alterations, 
the  right  she  is  unable  to  locate  the  candle  over  Whether  the  color  of  the  cataracts  was  due  to 
a  large  portion  of  the  right  half  of  field.  Heart,  former  intraocular  haemorrhage,  or  to  simple  den- 
lungs  and  urine  normal.  Isification  of  all  the  cortical  substance,  I  am  un- 

October  2j.    Under  cocaine  I  extracted  the  right  |  able  to  state. 


made  of  the  abscised  hernia,  and  I  am  unable  to 
state  whether  or  not  it  contained  portions  of  the 
retina.  The  shrunken  globe  was  tender  and  irri- 
table, enucleation  was  advised,  but  refused  at  first. 
Six  weeks  later  she  consented  to  enucleation,  as 
the  tenderness  still  continued.  The  eye  was  re- 
moved by  Dr.  Robert  Sattler,  who  was  then  on 
duty. 

When  seen  three  months  later  the  capsular 
opacity,  in  the  pupil  of  the  right  eye,  was  still 
sufficiently  dense  to  prevent  seeing  the  details  of 
fundus.  In  this  condition  her  vision  was  about 
Yst> — not  improved  by  convex  lenses.  Discission 
was  of  course  the  proper  thing  to  do,  but  on  ac- 


THE  COLITIS  OF  INFANTS. 


[January  17, 


THE  COLITIS  OF  INFANTS. 

A  Paper  prepared  for  Ike  Cincinnati  Academy 

BY  JAMES    M.   FRENCH,   A.M.,   M.D., 


LECTURER    ON  MORBID  ANATOMY  AND  DEMONSTRATOR  OF   PATHOL- 
OGY AT  THE  MEDICAL  COLLEGE  OF  OHIO;    PHYSICIAN  TO  ST. 
MARY'S  HOSPITAL.  CINCINNATI.  O. 

Acute  colitis,  in  the  sense  of  an  acute  catarrh 
of  the  large  intestine,  occurs  in  infants  as  a  pri- 
mary disease  or  as  a  part  of  the  affection  which 
has  received,  among  other  names,  the  designation 
entero-colitis.  If,  in  what  I  have  to  sa}-  of  it  in 
the  latter  connection,  I  shall  appear  to  make  an 
unnatural  separation  of  usually  associated  lesions, 
I  hope  to  be  excused  on  the  ground  that  I  believe 
that  colitis  is  a  part  of  the  disease  which  is  too 
often  lost  sight  of,  particularly  in  the  treatment 
of  it. 

It  is  in  this  connection  with  catarrh  of  the  small 
intestine  that  the  disease  is  most  frequently  en- 
countered. It  then  occurs  as  a  sequence  of  chol- 
era infantum,  or  of  an  acute  dyspeptic  diarrhoea.1 

In  its  primary  form  colitis  is  usually  due  to  er- 
rors in  diet,  especially  when  it  affects  infants 
which  have  passed  the  weaning  period.  Occa- 
sionally it  complicates  other  diseases,  as  the  acute 
exanthemata,  or  arises  from  the  irritation  of  for- 
eign bodies  or  parasites  in  the  bowel.  It  begins, 
in  some  cases,  gradually,  and  runs  a  mild,  nearly 
or  quite  afebrile  course  of  a  few  days'  duration  ; 
in  other  cases,  it  begins  with  sudden  alarming 
symptoms,  rapid  rise  of  temperature  to  103°  or 
1050,  great  prostration,  nervous  excitation,  even 
convulsions,  with  frequent,  small,  bloody  stools, 
consisting  largety  of  mucus.  *  It  may  then  speed- 
ily terminate  in  death,  or  may  last  for  weeks  or 
months.  It  so  much  resembles,  in  its  general 
features,  the  dysentery  of  adult  life,  that  some 
authors  have  used  the  latter  term  in  its  descrip- 
tion.    True  dysentery  is.  however,  rare  in  infants. 

The  entero-colitis  which  follows  the  acute  stage 
of  cholera  infantum  is  like  a  broken  truce,  or  the 
siege  which  follows  an  unsuccessful  engagement. 
The  more  alarming  symptoms  of  the  disease  have 
passed  away.  The  temperature  has  returned  to 
the  normal :  the  nervous  phenomena  have  sub- 
sided ;  strength  and  appetite  have  in  part  re- 
turned; the  stools  have  become  more  consistent, 
and  the  child's  appearance  has  begun  to  indicate 
that  convalescence  is  near.  But  the  child  con- 
tinues restless,  begins  to  have  pain  and  is  peevish. 
Fever  again  appears,  ranging,  as  a  rule,  from  1010 
to  1020.  The  stools  become  smaller  and  more 
frequent.  They  consist  of  undigested  food,  mucus, 
and  as  a  rule,  a  variable  amount  of  blood.  The 
odor  is  fetid  in  proportion  to  the  quantity  of  un- 
digested and  decomposed  food  which  they  contain. 
The  disease  now  has  a  tendency  to  persist,  or  to 
recur  at  short  intervals,  and  often  presents  the 
features  of  inflammation  of  the  large  bowel,  rather 


■  Holts   classification   is  here  followed.     "Cyclopaedia  of  the 
>>f  Children."  Vol.  iii,  p.  134. 


[  than  of  the  small.  When  it  is  persistent,  the 
frequent,  small,  painful,  bloody  stools  continue 
day  and  night.  The  little  patient  gets  no  rest, 
until,  if  the  disease  be  not  checked,  after  from 
I  three  to  six  weeks,  he  is  relieved  by  death.  When 
I  the  disease  is  more  remittent  in  character,  there  is  a 
j  gradual  failure  in  strength  and  loss  of  flesh,  until 
the  little  sufferer  has  become  extremely  emaciated. 
His  facial  expression  is  that  of  an  aged  person, 
and  his  integument,  often  dry  and  scaly,  seems 
too  large  for  his  wasted  frame.  The  duration  of 
the  disease  in  this  form  is  indefinite.  Beginning 
early  in  the  summer,  or  under  fault}'  hygienic 
conditions,  it  usually  continues  until  the  season 
or  these  conditions  have  changed.  Ordinarily  re- 
covery is  slow,  and  relapse  is  exceedingly  common. 
When  entero-colitis  begins  with  the  so-called 
dyspeptic  diarrhoea,  there  often  appears  to  be  al- 
most from  its  inception  a  catarrhal  condition  of 
the  entire  intestinal  tract,  commencing  in  the 
stomach  and  passing,  like  a  wave,  along  the  en- 
tire mucous  membrane.  The  symptoms  are  vom- 
iting, followed  almost  immediately  by  diarrhoea, 
which,  after  from  a  few  days  to  a  week,  almost 
always  presents  features  characteristic  of  catarrh 
of  the  large  bowel,  the  frequent,  small,  bloody, 
mucus  stools  that  I  have  described. 

Entero-colitis  is  therefore  a  disease  which  com- 
mences in  the  upper  portion  of  the  alimentary 
canal  and  progresses  downward,  rather  than  one 
that  affects  all  portions  at  the  same  time.  After 
the  brief  initiatory  period,  it  as  a  rule  affects  only 
the  lower  third  of  the  ileum  and  a  greater  or  less 
portion  of  the  colon.  Unfortunately,  the  lesions 
which  are  found  post-mortem  in  both  cholera  in- 
fantum and  entero-colitis  are  not  sufficiently  con- 
stant to  be  entirely  characteristic.  Moderate  hy- 
persemia,  if  it  exist,  is  a  condition  which  largely 
disappears  at  death,  and  extreme  hypersemia,  al- 
though the  rule,  is  by  no  means  constant.  Loss 
of  intestinal  epithelium,  a  much  more  constant 
finding  in  such  cases,  occurs  as  a  rule  in  from 
six  to  ten  hours  after  death,  and  is  not  pathog- 
nomonic of  intestinal  disease.  But  intense  in- 
flammatory processes  soon  lead  to  permanent 
changes.  Follicular  ulceration,  and  cellular  in- 
filtration of  the  mucosa,  the  submucosa  and  deep- 
er tunics  of  the  bowel  are  the  common  results  of 
the  prolonged  catarrhal  process  under  considera- 
tion. The  point  that  I  desire  most  to  emphasize 
is  the  fact  that  lesions  occur  in  the  large  intestine 
not  only  in  a  brge  proportion  of  these  cases,  but 
that  their  character  indicates  a  severity  of  the 
diseased  process  which  in  most  cases  quite  exceeds 
that  found  in  the  ileum. 

That  the  mucous  membrane  of  the  colon  should 
be  thus  often  involved  in  the  morbid  process  is 
almost  axiomatic,  since  into  the  colon  must  pass 
the  products  of  all  pathological  processes  situated 
in  the  upper  alimentary  tract.  Cholera  infantum 
is  variously  accounted  for,  but  owing  to  the  fre- 


I89i.] 


THE  COLITIS  OF  INFANTS. 


85 


quency  with  which  microorganisms  are  found  in 
the  dejections  and  in  the  intestines  after  death,  it 
has  been  pretty  generally  accepted  that  the  dis- 
ease is  due  to  the  action  of  bacteria  which  have 
not  yet  been  isolated.  By  those  who  accept  this 
theory,  the  symptoms  are  supposed  to  be  due, 
for  the  most  part,  to  the  ptomaines  produced  by 
these  bacteria.  The  local  inflammatory  process 
in  the  large  bowel  is  doubtless  in  part  due  to  the 
action  of  the  same  bacteria  and  ptomaines,  but  it 
is  probably  in  part  a  result  also  of  the  abnormal 
fermentation  of  intestinal  contents  caused  by  other 
germs  or  by  no  germs.  Chemical  changes  in  all 
probability  occur.  The  evidences  of  most  intense 
inflammatory  action  are  found  in  those  portions 
of  the  colon  in  which  the  contents  remain  longest 
in  contact  with  the  mucous  membrane,  namely : 
in  the  caecum,  the  transverse  colon  and  in  the 
sigmoid  flexure.  In  the  primary  form  of  the  dis- 
ease, the  lesions,  the  same  in  character  as  those 
described,  are  found  for  the  most  part  in  the  sig- 
moid flexure  and  rectum. 

The  treatment  of  colitis  is  to  be  considered 
apart  from  that  of  affections  of  the  small  intestine 
only  in  the  comparatively  infrequent  primary  form 
of  the  disease.  But  even  in  cases  of  this  nature, 
attention  must  be  given  to  the  character  of  the 
gastric  and  intestinal  digestion.  Incomplete  di- 
gestion or  abnormal  fermentation  of  any  kind 
may  act  either  as  an  exciting  cause  of  inflamma- 
tion, or  may  tend  to  prolong  its  duration  when 
once  it  has  begun.  Errors  in  diet  must  therefore 
be  carefully  rectified,  and  a  diet  suitable  to  the 
age  of  the  patient  must  be  selected.  Only  liquid 
food — milk  and  beef  or  mutton  broths,  is  to  be 
permitted.  If  constipation  has  preceded  the  at- 
tack, or  if  from  the  history  of  improper  diet,  the 
presence  of  flatus,  or  the  character  of  the  stools, 
the  presence  of  abnormally  fermented  matter  or 
other  irritant  substances  be  suspected,  calomel  in 
doses  of  from  T'„  to  'j  gr.  may  be  given  every 
three  hours  until  purgation  is  produced.  In  a 
majority  of  cases,  little  or  no  other  treatment  is 
required.  Severe  cases,  however,  require  more 
active  measures,  in  the  manner  to  be  described. 

The  treatment  of  entero-colitis  is  often  exceed- 
ingly difficult,  for  here  we  have,  in  addition  to 
the  disease  of  the  colon,  an  inflammatory  state  of 
the  lower  third  of  the  ileum.  Within  a  few  days 
from  the  onset  of  the  disease  the  little  patient  be- 
comes prostrated  and  the  signs  of  emaciation  begin 
to  appear.  As  the  large  intestine  becomes  in- 
volved, the  frequent,  often  constant  desire  to  defe- 
cate, the  tormina  and  tenesmus,  prevent  sleep, 
and  the  condition  often  becomes  alarming.  How, 
then,  can  we  relieve  the  patient  from  these  symp- 
toms, and  what  can  wTe  do  to  arrest  the  inflamma- 
tory process  ?  The  essential  feature  of  the  treat- 
ment at  this  stage  is  to  so  change  the  character 
of  the  intestinal  contents  that  they  shall  no  longer 
be  irritating  in  character,  and  to  give  rest  to  the 


inflamed  mucous  membrane.  This  is  to  be  ac- 
complished by  correcting  errors  of  diet,  by  over- 
coming defective  digestion,  and  by  arresting  ab- 
normal fermentation. 

For  the  correction  of  errors  of  diet  much  is  to 
be  considered,  the  recitation  of  which  would  here 
be  out  of  place.  It  is  necessary  that  the  child 
shall  receive  the  proper  quantity  of  the  right  kind 
of  food  at  the  right  intervals  for  its  age.  Not 
seldom  the  error  will  be  found  to  consist  in  the 
too  early  resort  to  a  mixed  diet,  too  frequent 
uursing,  or  the  use  of  such  inferior  substitute  for 
mother's  milk  as  impure  cow's  milk,  condensed 
milk,  or  an  inferior  quality  of  artificial  food,  or 
the  use  of  improperly  prepared  food.  The  diet 
should  consist  of  articles  of  food  which  are  most 
certain  to  undergo  easy  and  complete  digestion, 
leaving  as  little  residue  as  possible.  The  passage 
of  healthy  faeces  from  the  small  intestine  into  the 
large  in  these  cases  is  sufficient  to  excite  peristal- 
sis. For  this  reason,  we  must  also  carefully  guard 
against  over-feeding.  Cold  drinks  must  be  pro- 
hibited, except  the  taking  of  an  occasional  tea- 
spoonful  or  two  of  water  to  relieve  the  excessive 
thirst  which  is  always  present.  A  copious  draught 
of  cold  water  is  almost  inevitably  followed  by  an 
evacuation  of  the  bowel.  Digestion  may  be  facil- 
itated by  the  administration  of  an  active  pepsin 
or  pancreatine  ;  and  the  addition  of  a  small  quan- 
tity of  calomel  tends  to  arrest  abnormal  fermenta- 
tion. I  have  rarel}'  employed  any  medicines  other 
than  those  contained  in  the  following  prescriptions: 

R.     Pepsini  (F.  &  F.,  or  P.  D.  &  Co.),  gr  xij  to  \xiv. 

Hydrargyri  chlor.  mitis,  gr.  ss  to  j. 

Sacch.  lactis  q.  s. 
i^j;.  ft.  chartas  Xo.  xii. 
S.    One  powder  every  three  hours. 

Or,  in  cases  in  which  the  intestinal  digestion 
appears  to  be  at  fault : 

B.     Extract!  pancreatis  (F.  and  F.),  Jss  to  j. 

Hydrarg.  chlor.  mitis,  gr.  ss  to  j. 

Sacch.  lactis  q.  s. 
n)>.  ft.  chart.  No.  xii. 
S.    One  powder  every  three  hours. 

It  is  better  to  give  explicit  directions  that  the 
powders  be  given  immediately  before  or  after 
nursing,  and  not  ofteuer  than  once  in  three  hours, 
as  it  is  in  this  way  possible  to  more  completely 
rectify  the  error  of  too  frequent  feeding  than  by 
any  other  means,  for  our  instructions  as  to  the 
giving  of  medicine  are  more  likelj^  to  be  obeyed 
than  are  those  pertaining  to  the  correct  manner 
of  feeding  the  infant,  a  subject  on  which  every 
mother  has  her  own  ideas.  Naphthaline  has 
been  highly  recommended  for  arresting  decompo- 
sition, but  although  I  have  had  excellent  results 
from  it  in  adults,  I  have  used  it  in  but  two  or 
three  children.  Its  odor  makes  it  difficult  of  ad- 
ministration. The  advice  of  some  writers  to  give 
small  quantities  of  nourishment  at  short  intervals  is 
not  judicious,  as  it  both  tends  to  embarrass  diges- 


86 


RENAL  CALCULUS. 


[January  17, 


tion  and  to  increase  peristaltic  action.  Ordinarily 
the  diet  of  nursing  infants  may  be  restricted  to  the 
mother's  milk,  and  that  of  infants  that  have  been 
weaned,  to  sterilized  cow's  milk.  But  in  severe 
cases,  it  is  necessary  to  discontinue  even  cow's 
milk,  for  a  time.  By  this  means  alone  are  we 
able  to  free  the  inflamed  bowel  from  the  influ- 
ences which  keep  up  the  inflammation.  The  re- 
moval of  food  is  by  no  means  an  easy  task  in 
most  cases.  Something  must  be  given  both  to 
provide  nourishment  and  to  satisfy  thirst.  Mel- 
liu's  food  prepared  with  water  instead  of  milk  is 
well  suited  to  this  purpose,  as  it  furnishes  ample 
nutriment  and  leaves  almost  no  residue  in  the 
bowel.  In  addition  to  this,  an  occasional  tea- 
spoonful  of  freshly  expressed  beef  juice  and  a  few 
drops  of  brandy  may  be  given. 

When  the  symptoms  of  catarrh  of  the  large  in- 
testine greatly  preponderate,  thorough  irrigation 
of  the  bowel  is  beneficial,  even  in  young  infants. 
It  may  be  practiced  with  lukewarm  water,  a  weak 
solution  of  common  salt  or  alum,  mercuric  chlo- 
ride (1  : 4,000),  or  nitrate  of  silver.  The  latter 
two  remedies  should  be  used,  I  think,  only  for 
their  action  on  such  parts  as  may  be  reached  by 
the  introduction  of  a  recurrent  catheter,  the  sig- 
moid flexure  and  rectum,  owing  to  the  danger  of 
their  retention.  In  some  cases  I  have  injected, 
after  a  short  interval  succeeding  the  irrigation, 
from  1  to  2  ozs.  of  warm  starch  water  containing 
from  i  to  5  drops  of  laudanum,  in  infants  of  an 
age  to  justify  the  experiment.  A  much  needed 
night's  rest  has  thus  been  secured  and  the  tide  of 
the  disease  effectually  turned.  This  procedure  is, 
of  course,  not  to  be  thought  of  until  all  products 
of  decomposition  have  disappeared  from  the  stools. 
The  same  result,  so  far  as  arrest  of  the  symptoms 
is  concerned,  would  follow  the  administration  of 
an  opiate  by  the  mouth,  but,  although  this  prac- 
tice has  received  the  sanction  of  high  authority, 
I  cannot  discern  its  propriety  ;  since  with  the 
beneficial  action  will  occur  an  arrest  of  digestion. 
In  extreme  cases  I  have  used  hypodermatically 
minute  doses  of  morphia  with  atropia.  The 
worst  cases  that  are  encountered  are  those  in 
which  opium  has  been  injudiciously  used  in  the 
early  course  of  the  disease. 

By  no  means  the  least  difficult  period  in  the 
management  of  the  case  is  that  of  convat 
As  the  more  severe  symptoms  subside  the  little 
patient  develops  a  ravenous  appetite,  the  gratifi 
cation  of  which  is  one  of  the  most  frequent  causes 
of  relapse.  Weeks  or  months,  rather  than  days, 
are  to  be  consumed  in  the  return  to  the  diet  of 
health.  The  Srst  step  in  the  gradual  restoration 
of  diet  in  those  cases  which  have  required  the 
□sion  of  all  food,  is  the  gradual  addition  of 
milk  to  the  artifii  ial  food,  until  the  normal  pro- 
portion is  reached.  This  then  should  constitute 
the  diet  foi  ■  ks. 

Hygienic  treatment  must  of  course  be  pursued, 


the  chief  item  of  which  is  frequent  bathing.  If 
circumstances  permit,  the  removal  of  the  child 
from  the  city  to  the  country  will  greatly  hasten 
recovery. 


THE  CLINIC. 


UTERINE     MYOMA— RENAL     CALCULUS 

AND  SURGICAL   OPERATIONS  UPON 

THE  KIDNEY. 

1 

1S90. 

BY  CHARLES  T.   PARKES,   M.D., 

PROFESSOR   OK  SURGERY. 

Concluded  pom  page  52.) 
If  no  information  is  gained  by  this  examina- 
tion, the  kidney  is  fixted  as  much  as  possible  in 
the  wound  by  pressure  through  the  anterior  walls 
of  the  abdomen,  and  by  forceps  grasping  the  peri- 
nephritic  tissue  ;  then  a  grooved  director  is  thrust 
through  its  substance  towards  and  into  the  pelvis, 
which  is  examined  thoroughly  in  all  directions  by 
changing  the  direction  of  the  probe,  until  the 
stone  is  struck,  or  none  is  found.  Of  course,  if, 
as  in  this  patient,  the  tissue  of  the  kidney  and  its 
pelvis  is  distended  with  pus,  as  soon  as  the  direc- 
tor enters  the  cavity  the  pus  will  flow  through  its 
groove,  as  you  see  it  does  in  this  instance. 

The  blunt-pointed  director  is  the  best  instru- 
ment to  use  in  this  trial ;  it,  or  any  other  cutting 
instrument,  should  always  be  introduced  into  the 
kidney  some  little  distance  above  the  lower  end 
of  the  organ,  on  account  of  the  frequency  of  the 
presence  of  the  artery  aberrans  entering  the  organ 
at  this  point,  and  the  iree  haemorrhage  attending 
the  wounding  of  it.  It  is  also  said  that  fatal 
heemorrhage  has  followed  the  use  of  the  pointed 
aspirator  used  for  this  purpose,  the  needle  being 
thrust  so  far  forward  as  to  puncture  the  main 
renal  artery  or  vein. 

No  attempt  should  be  made  to  fix  the  kidney 
by  means  of  forceps  attached  to  its  substance,  or 
by  threads  passed  through  it,  because,  owing  to 
the  structure  of  the  kidney  tissue — its  softness 
and  brittleness — they  will  surely  tear  out;  no  fix- 
ation will  be  obtained,  merely  unnecessary  damage: 
done  the  organ.  It  can  sometimes  lie  fixed  very 
well  by  passing  the  linger  behind  it  in  the  wound. 
In  case  no  pus  escapes  along  the  groove  of  the 
director,  as  not  infrequently  happens  when  the 
nol  much  increased  in  size,  and  it  is 
thought  necessary  to  make  further  exploration  a 
seal]. el  1^  cai  1  ied  along  the  groove  <-  f  the  director 
through  tl'.e  substance  of  the  kidney,  making  an 
incision  large  enough  to  admit  the  linger  easily; 
the  linger  is  passed  through  it  into  the  pelvis  of 
the  kidney  and  a  careful  search  made  in  all  direc- 
tions for  the  foreign  body. 


i89i.] 


RENAL  CALCULUS. 


87 


If  the  stone  is  of  large  size,  filling  and  distend- 
ing the  cavity  of  the  pelvis,  the  examination  by 
palpation  of  its  entire  surface,  as  already  de- 
scribed, will  have  probably  discovered  its  pres- 
ence ;  in  which  event  the  knife  is  carried  directly 
through  the  substance  of  the  kidney  to  the  stone, 
and  the  proper  incision  made.  If  the  stone  is 
discovered  by  the  use  of  the  director,  without 
any  flow  of  pus,  an  opening  is  made  by  the  knife 
sufficiently  large  to  admit  the  finger. 

In  this  patient,  in  which  pus  is  found  to  be 
present,  after  the  introduction  of  the  director, 
the  incision  should  be  made  as  free  as  possible, 
not  only  for  the  removal  of  the  stone,  but  especi- 
ally to  lay  open  freely  the  pouches  which  are  so 
apt  to  be  present  in  these  cases.  This  will  pro- 
vide for  free  drainage  and  prevent  the  retention 
of  pus  in  these  pockets,  as  the  kidney  contracts 
after  operation,  leading  to  the  occurrence  of 
secondary  abscesses  so  common  in  the  history  of 
suppurating  kidneys. 

How  will  you  proceed  after  the  finger  has 
touched  the  stone,  no  matter  by  what  method  it 
has  reached  it?  The  calculus  is  carefully  and 
slowly  loosened  from  its  bed,  by  keeping  the 
pulp  of  the  finger  in  contact  with  it,  and  push- 
ing the  investing  tissue  away  from  it  by  the 
finger  nail  carried  in  all  directions,  until  the 
stone  lies  perfectly  loose  in  the  cavity.  Then  a 
pair  of  dressing  forceps  introduced  along  the 
finger,  is  made  to  seize  the  stone  firmly,  and  it  is 
drawn  quietly  and  slowly  through  the  wound 
until  its  removal  is  accomplished. 

The  directions  about  removing  the  stone  are 
thus  minutely  given,  because  it  is  especially  de- 
sirable to  remove  it  entire,  and  thus  avoid  leav- 
ing any  small  pieces,  which,  owing  to  its  brittle- 
ness,  can  be  easily  broken  off.  They  often  avoid 
the  most  rigorous  search  and  become  the  nucleus, 
around  which  may  form  other  stones  in  the  future. 

Besides,  the  calculi  are  frequently  very  irregular 
in  shape,  having  off-shoots  developing  from  the 
main  stem,  in  different  directions,  like  pieces  of 
coral.  These  offshoots  are  firmly  embedded  in 
the  calices  of  the  organ  or  accidental  pouches,  so 
that  they  are  easily  broken  off,  and  may  remain 
embedded  in  these  pockets  if  any  forcible  at- 
tempts are  made  to  withdraw'  the  stone  before  it 
is  entirely  loosened  by  means  of  the  finger. 

Of  course  many  times  the  stone  or  stones,  are 
found  loose  in  the  pelvis  of  the  kidney,  or  in  the 
cavity  of  the  abscess,  or  the}'  are  smooth  of 
surface  and  even  and  regular  in  their  develop- 
ment, in  which  case  there  is  no  difficulty  attend- 
ing their  removal. 

In  this  patient,  you  notice  that  I  have  con- 
siderable difficulty  in  loosening  the  stone  which 
we  have  found,  and  I  am  compelled  to  enlarge 
the  opening  in  the  kidney  very  much,  because 
the  stone  is  of  large  size  and  very  rough  and  ir- 
regular in  its  shape.     Now   I   think   I    have  it 


loosened  and  the  incision  made  long  enough  to 
allow  ot  it.     Introducing  this  pair  of 

forceps,  the  stone  is  seized,  and  while  extracting 
it  slowly  and  carefully,  with  my  finger  I 
the  kidney  substance  away  from  its  irregular 
surfaces.  Unfortunately  I  have  broken  this 
piece  in  the  grasp  of  the  forceps,  away  from  the 
main  portion  of  the  stone,  which  accident,  not 
only  spoils  the  beauty  of  the  specimen,  but 
shows  you  how  brittle  the  concretion  may  be 
and  how  carefully  it  must  be  handled.  There  is 
no  fear  of  this  fragment  causing  any  subsequent 
trouble  because  I  have  it  on  the  outside.  The 
stone  is  seized  again  with  the  forceps,  at  a  larger, 
denser  Dortion  of  its  surface,  and  with  the  same 
careful  method  of  extraction,  it  is  finally  re- 
moved entire. 

The  specimen  is   fully   three  inches  long  and 

over  an  inch  in  width  at  its  widest  portion.      It 

is    very    irregular   in    formation  and  shows   the 

presence  of  the  offshoots,    to   which   your  atten- 

j  tion  has  already  been  directed. 

The  haemorrhage  is  very  free  following  the 
first  incision  made  into  the  kidney  substance, 
but  in  my  experience,  it  has  never  been  hazard- 
ous or  sufficient  to  cause  any  anxiety,  for  the 
pressure  of  the  finger,  introduced  through  the 
'  wound,  soon  causes  it  to  cease. 

The  manner  of  treating  the  wound  is  different 
according  to  whether  pus  be  present  or  not.  If 
there  be  no  pus  and  the  kidney  not  much  en- 
larged, very  little  special  treatment  is  required. 
A  large  size  drainage  tube,  long  enough  to 
reach  into  the  pelvis  of  the  kidney,  should  be 
introduced  and  left  for  a  few  days  to  provide  for 
the  easy  exit  of  bloody  serum  and  urine,  which 
will  flow  immediately  after  the  operation  and  as 
a  consequence  of  it.  The  external  wound  is 
closed  up  to  the  drainage  tube,  by  means  of  in- 
terrupted silk  sutures  passed  through  all  the  tis- 
sues of  the  edges  of  the  wound  in  the  same 
manner  as  in  the  abdominal  operation,  although 
in  this  operation,  there  is  no  peritoneum  to  be 
included  in  them. 

The  drainage-tube  prevents  the  probability  of 
the  occurrence  of  urinary  infiltration. 

After  a  few  days  clear  urine  will  flow  through 
the  tube,  when  it  can  be  removed  and  the  result- 
ing sinus  will  rapidly  close  and  securely  heal  by 
cicatrization,  leaving  nothing  to  mark  the  occur- 
rence of  such  a  severe  operation,  but  the  external 
scar.  The  urine  passed  from  the  bladder,  will 
show  the  presence  of  blood  in  a  greater  or  less 
quantity  for  a  few  days,  gradually  resuming  its 
normal  condition.  This  symptom  has  its  ad- 
vantage, because  it  proves  that  the  ureter  is 
patulous. 

If  pus  is  present,  the  several  pockets  in  which 
it  is  apt  to  be  contained  are  usually  found  to 
be  separated  from  each  other  by  incomplete 
trabeculse   of   connective  tissue  or   kidney  sub- 


RENAL    CALCULUS. 


[January  17, 


stance.  These  are  broken  down  with  the  finger, 
thus  converting  the  many  into  one  cavity  ;  this 
cavity  is  then  thoroughly  irrigated  and  washed 
with  some  mild  antiseptic  solution,  such  as  boric 
acid  or  with  sterilized  water. 

It  is  to  be  remembered,  that  solutions  of  power- 
ful antiseptics,  especially  mercuric  bichloride, 
contain  in  themselves  the  elements  of  extreme 
danger,  in  that  they  may  poison  the  general  sys- 
tem or  seriously  impair  any  normal  tissue  which 
may  remain  in  the  organ  itself.  Hence,  if  used 
at  all,  great  care  should  be  practiced  and  the 
cavity  thoroughly  washed  out  with  sterilized 
water  after  their  use.  The  use  of  bichloride  of 
mercury  sometimes  leads  to  acute  granular  de- 
generation of  the  kidney. 

The  ragged  portions  of  debris  are  then  re- 
moved, and  when  thoroughly  and  satisfactorily 
cleaned,  the  cavity  is  packed  to  the  bottom  with 
iodoform  gauze.  No  attempt  being  made  to 
close  the  wound  by  suture.  This  treatment  is 
advised,  because  it  is  m}r  belief  that  it  is  least 
likely  to  be  followed  by  secondary  abscesses.  In 
all  conditions,  the  external  dressing  consists  of 
the  application  of  masses  of  loose  iodoform  gauze 
and  borated  cotton,  held  in  place  by  a  body 
bandage. 

The  operation,  as  you  see,  is  prolonged,  and 
hence  likely  to  be  attended  with  evidences  of 
shock,  therefore  every  provision  should  be 
adopted  to  counteract  the  dangers  which  ac- 
company such  conditions  by  the  administration 
of  quinine  or  whiskey  before  the  operation  ;  by 
keeping  the  patient's  body  covered  with  blankets 
during  the  operation  and  by  providing  artificial 
heat  through  radiation  after  the  patient  is  put 
to  bed. 

The  profession  has  come  to  the  conclusion  that 
chloroform  is  the  best  anaesthetic  to  use  during 
all  operations  upon  the  kidney,  but  no  matter 
what  anaesthetic  is  used,  the  ansesthetizer  should 
be  careful  to  give  as  little  of  it  as  possible. 
Often  allowing  the  patient  to  breathe  freely  of 
fresh  air,  by  the  removal  of  the  cone,  in  this  as 
well  as  in  all  operations  which  are  prolonged  and 
exhaustive  in  character. 

Kidney  stones  are  developed  from  the  salts  of 
urine,  which  are  normally  held  in  perfect  solu- 
tion and  are  oftenest  found  to  consist  of  the 
crystals  of  uric  acid.  Many  are  made  up  of  oxa- 
late of  lime,  while  some  are  composed  of  phos- 
phatic  salts.  They  are  found  in  both  sexes  and 
at  all  ages  of  life ;  they  vary  immensely  in 
number  and  size,  thus  they  may  be  so  small  as 
to  pass  easily  through  the  ureters  when  loosened, 
and  escape  from  the  bladder  ;  or  so  large  as  to 
change  very  greatly  the  shape  of  the  kidney 
which  is  expanded  about  them.  In  form  they 
may  be  smooth  and  even,  or  rough  ;  or  possess 
the  greatest  diversity  in  shape  and  irregularity  of 
surface. 


The  symptoms  indicating  their  presence  have 
already  been  described  to  you  as  forming  the 
history  of  an  agonizing  attack  of  renal  colic. 
Still  there  may  be  no  signs  present  indicating 
their  existence,  other  than  a  steady,  persistent, 
deep-seated  pain,  sometimes  burning  in  character, 
referred  to  the  region  of  the  kidney,  accompanied 
by  the  persistent  presence  of  blood  or  pus  in  the 
urine.  The  suffering  in  these  cases  bears  no  re- 
lation to  the  size  of  the  calculus — one  patient 
from  whose  kidney  I  removed  a  concretion  not 
larger  than  the  end  of  the  little  finger,  suffered 
repeatedly  with  excruciatingly  severe  attacks  of 
renal  colic,  while  in  another  with  a  larger  calculus 
than  the  one  removed  to-day,  the  pain  during 
such  attacks  was  not  severe. 

These  formations  may  take  place  in  both 
kidneys  at  the  same  time,  and  when  this  occurs 
there  is  great  difficulty  in  forming  a  conclusion 
on  which  kidney  to  operate,  or  whether  to  resort 
to  surgical  interference  or  not. 

In  all  these  cases,  the  microscopical  examina- 
tion of  the  urine  is  very  apt  to  show  the  salts  of 
which  the  stone  is  composed,  present  in  the  urine 
in  large  quantities. 

If  there  is  present  a  tumor  in  the  region  of  the 
kidney,  with  the  history  of  previous  attacks  of 
renal  colic,  there  can  be  no  doubt  as  to  the 
diagnosis,  and  surgical  interference  should  be 
practiced. 

Treatment. — The  treatment  of  these  cases  must 
be  considered  under  three  heads  :  prophylactic, 
palliative,  and  surgical.  The  latter  has  been 
illustrated  to  you  in  the  operation  performed 
upon  the  patient  before  you. 

Prophylactic  treatment  consists  in  directing 
your  patient's  diet — avoiding  the  use  of  meats  ; 
and  advising  the  free  use  of  water,  especially 
such  mineral  waters  as  are  known  to  have  a  bene- 
ficial effect  upon  the  condition  of  the  system, 
termed  lithiasis.  The  mineral  water  possessing 
the  best  effect  is  probably  the  one  containing  a 
large  per  cent,  of  the  salts  of  lithia.  It  is  my 
belief  that  large  quantities  of  distilled  water  are 
beneficial.  It  is  generally  supposed  that  people 
living  in  countries  in  which  the  water  used  for 
all  purposes  contains  a  large  portion  of  lime,  are 
most  likely  to  suffer  from  these  troubles.  It  is 
also  supposed  that  in  children  poor  and  improper 
food  accompanied  with  faulty  assimilative  powers, 
have  much  to  do  with  the  production  of  the 
disease. 

The  palliative  treatment  has  reference  particu- 
larly to  the  management  of  the  attacks  of  renal 
colic,  the  pain  of  which  is  controlled  by  the  use 
of  the  preparations  of  opium,  particularly  the 
hypodermic  injection  of  morphia,  in  doses  of 
such  si/e  and  sufficiently  often  repeated  as  is  re- 
quired to  control  the  pain. 

Frequently  in  severe  attacks  the  careful  admin- 
istration of  chloroform  or  ether  to  partial  or  com- 


i89i.] 


RENAL  CALCn.rs. 


89 


plete  anaesthesia  is  necessary  to  at  least  tem- 
porarily assuage  the  patient's  agony  until  the 
foreign  body  has  passed  the  ureter. 

Hot  fomentations  freely  applied  over  the  pain- 
ful area  and  the  use  of  hot  baths  are  beneficial. 
We  know  of  no  remedy,  the  administration  of 
which  through  the  mouth,  will  dissolve  or  in  any 
way  diminish  the  size  of  these  renal  concretions. 
No  permanent  relief  can  be  given  in  am  othei 
way  than  by  the  removal  of  the  offending  body 
by  surgical  interference. 

Renal  calculi  occasionally  become  lodged  in 
some  portion  of  the  ureter  ;  the  most  common 
place  of  stoppage  seems  to  be  near  the  point  of 
termination  of  the  tube  in  the  bladder  :  at  least 
quite  a  number  of  instances  are  on  record  in 
which  the  calculus  forming  in  women,  has  been 
located  in  this  position  by  vaginal  examination, 
and  their  removal  attained  by  operation. 

If  the  stone  becomes  arrested  at  other  points 
and  cannot  be  located  as  in  women,  catheteriza- 
tion of  the  ureters  can  locate  it ;  or  if  the  kidney 
has  become  exposed  in  search  of  it,  the  passage 
of  a  sound  from  above  will  fix  its  position. 
When  found  it  must  be,  and  can  usually  be  safely, 
removed  hy  any  operation  which  will  expose  its 
position.  Of  course  any  operation  for  this  con- 
dition should  be  post-peritoneal. 

The  urinary  fistula  following  such  procedure  is 
not  usually  permanent,  but  heals  kindly  and 
rapidly  ;  every  precaution  for  free  drainage 
should  be  used  to  prevent  urinary  infiltration  into 
the  loose  tissues  in  which  the  necessary  incision 
is  made. 

Suppuration  in  the  kidney  and  accumulation 
of  pus  dependent  upon  any  other  causes,  such  as 
tuberculosis  or  other  degenerative  changes,  some- 
times lead  to  the  formation  of  various  enlarge- 
ments or  tumors  of  the  kidney  which  fluctuate 
freely. 

The  condition  of  distention  of  the  kidney  sub- 
stance and  its  pelvis  with  pus,  is  technically 
called  "pyo-nephrosis,"  and  for  its  relief  requires 
exposure  of  the  kidney  in  the  manner  just  illus- 
trated. The  abscess  is  then  opened  by  free  in- 
cision through  the  kidney.  This  operation  is 
called  nephrotomy.  The  treatment  after  the  in- 
cision is  the  same  as  for  cases  of  stone  with  pus 
accumulation.  A  similar  distention,  frequently 
reaching  great  size,  follows  injuries  or  diseases 
which  occlude  the  ureter  and  there  occurs  the 
formation  of  a  fluctuating  tumor,  the  contents  of 
which  are  clear,  pale  in  color,  and  contain  a 
slight  evidence  of  the  presence  of  urinary  salts. 
This  condition  is  called  "  hydro- nephrosis." 

While  the  pus  cases  always  show  severe  con- 
stitutional disturbance,  with  sweatings,  chills, 
high  fever,  and  other  evidences  of  septic  infec- 
tion, hydro- nephrosis  causes  very  little  or  no 
trouble  until  the  increase  in  size  calls  attention 
to  the  tumor,  and  produces  a  varying  amount  of 
discomfort. 


Aspiration,  with  a  complete  emptying  of  the 

cyst  (for  the  kidney  substance  is  so  attenuated 
and  thinned  out  it  forms  nothing  but  a  cyst  wall; 
will  sometimes  cure  a  hydro-nephrosis,  at  other 
times  a  cure  will  only  follow  free  incision  and 
e  of  the  tumor  by  means  of  a  nephrotomy. 

In  cases  of  pyo- nephrosis,  as  the  result  of 
pressure  necrosis  or  ulceration  from  accumula- 
tion, the  capsule  of  the  kidney  is  destroyed  and 
the  pus  leaks  out  into  the  surrounding  cellular 
tissue,  forming  a  peri-nephritic  abscess,  with  the 
Local  -igns  of  bulging  of  the  space  between  the 
rib  and  crest  of  the  ilium  ;  with  hardening  and 
infiltration  of  all  the  tissues  of  the  back  in  this 
space  ;  with  redness  of  the  surface  and  cedema 
and  finally  circumscribed  fluctuation.  The  ab- 
scess points  and  breaks  of  its  own  accord  or  the 
surgeon  incises  it.  Sometimes  the  opening  in 
the  kidney  can  be  found,  at  other  times  not.  If 
a  fistula  persists  after  the  opening  of  the  abscess, 
always  suspect  the  presence  of  a  calculus  in  the 
kidney.  Expose  and  remove  it  by  the  proper 
surgical  operation. 

Pyo-nephrosis  and  hydro-nephrosis  are  classi- 
fied under  the  head  of  cystic  tumors. 

There  occasionally  forms  in  connection  with 
the  kidney,  simple  serous  cysts,  and  also  those 
dependent  upon  the  presence  of  the  echinococcus 
or  hydatid.  Both  of  these  conditions  are  suc- 
cessful^ treated  by  exposing  the  tumor,  incision 
and  drainage  or  sometimes  by  simple  aspiration. 

It  is  quite  surprising  how  seldom  urinary 
fistulae  persist  even  after  very  extensive  incisions 
and  bruising  of  the  kidney.  The  urine  may  flow 
through  the  wound  in  the  back  for  a  few  days  or 
weeks,  but  if  the  ureter  is  patulous,  they  are 
quite  certain  to  close.  Wounds  of  this  organ 
heal  quite  as  rapidly  and  as  permanently  as  those 
of  any  other  tissue  of  the  body. 

The  operation  of  nephrectomy  or  complete  re- 
moval of  the  organ,  is  a  very  serious  one  pri- 
marily, and  has  dangerous  sequelae  attending  it, 
even  if  the  patient  recovers  from  the  operation, 
for  the  remaining  kidney,  called  upon  to  do 
double  duty,  is  particularly  liable  to  the  occur- 
rence of  diseases  apt  to  be  fatal. 

It  should  always  be  remembered  that  the  ab- 
normality of  one  kidney  is  not  very  infrequent, 
or  that  the  two  may  be  joined  together  in  the 
peculiar  formation  of  a  horse-shoe  kidney,  some- 
times found  present.  A  nephrectomy  under 
these  conditions  would  necessarily  prove  fatal. 
The  operation  should  not  be  advised  or  under- 
taken except  under  the  most  pressing  need,  that 
is,  in  cases  in  which  the  disease  or  injury  is  of 
more  menace  to  the  life  of  the  patient,  than  this 
hazardous  operation. 

It  should  also  be  remembered  that  even  in  ad- 
vanced disease  of  the  organ,  in  many  cases,  there 
still  remains  a  considerable  portion  of  the  kidney 
substance,  able  to  perform  a  portion  of  the  normal 


9o 


RENAL  CALCULUS. 


[January  17, 


function  of  the  organ  ;  a  patient  with  a  badly  Haemorrhage  can  be  avoided  by  special  care 
damaged  kidney,  is  in  less  danger,  if  some  por-  I  in  the  management  of  blood-vessels  ;  sepsis  pre- 
tion  remains  to  do  duty,  than  after  the  entire  re-  vented  by  the  usual  aseptic  or  antiseptic  precau- 
moval  of  the  organ.  Every  means  possible  tions  rigorously  carried  out ;  uremia  counteracted 
should  be  resorted  to,  to  determine  the  existence  by  elimination  and  derivation  through  other 
of  the  abnormality  of  one  kidney  before  the  op-  emunctories  ;  and  shock  diminished  to  a  great 
eration  is  done.  Some  surgeons  recommend  the  extent  by  free  stimulation  and  protection  of  the 
catheterization  of  the  ureters,  in  order  to  estab- '  patient  from  loss  of  body  heat, 
lish  this  fact ;  others  favor  what  is  termed  ab- ,  The  lumbar  incision  for  nephrectomy  calls  for 
dominal  incision — anterior  operation — so  that '  exactly  the  same  incision  in  all  its  details,  as  the 
after  opening  the  abdomen  both  kidneys  can  be  one  just  practiced  before  you  to-day,  carried  so 
found,  before  either  is  removed.  far  as  to  expose  the  tumor.      After  the  organ  is 

The  first  successful  nephrectomy  was  done  by  :  exposed  it  is  loosened  with  the  finger  from  its 
Simon,  of  Germany,  for  an  incurable  fistula  bed  of  perinephritic  fat.  As  soon  as  this  is  ac- 
following  a  difficult  parturition.  complished,  the  blood-vessels  entering  the  hilus 

The  disease  for  which  the  operation  is  recom-   are  carefully  isolated  and  a  needle  armed  with  a 


mended,  are  destruction  of  the  kidney  from  sup- 
puration resulting  from  any  cause  ;    or  tubercu- 


double  ligature  of  sterilized  silk  is   carried   be- 
tween the  vein   and  artery,  through  the  pedicle 


losis,  if  confined  to  one  kidney  ;  or  cysts  other-  made  by  these  vessels,  dividing  it  into  halves, 
wise  incurable  ;  for  the  removal  of  solid  tumors  and  it  is  securely  tied.  The  ureter  is  then  sought 
developing  in  this  organ,  and  for  such  injuries  after,  temporarily  secured  with  forceps  and  di- 
as  are  followed  by  a  persistent  and  incurable  vided  between  them.  The  pedicle  is  then  cut 
fistula ;  or  which  absolutely  destroy  the  organ  through,  sufficiently  far  away  from  the  ligatures 
itself,  such  as  gunshot  wounds.  not  to  endanger  their  security,  and  the  kidney  is 

The  solid  growths  which  we  find  developing   removed, 
in   the    kidney    are,     rhabdo-myoma,     adenoma,        In  cases  of  suppurating  kidney,    the  organ   is 
papilloma,  carcinomas  and  sarcoma;  the  sarcomas   often  so  firmly  imbedded  in  vascular  adhesions 
and  rhabdomyomas  occur  oftenest  in  infancy  or  1  that  bleeding  is  dangerously  free  during  its  separ- 
childhood.        Adenomas      and     carcinomas     are   ation.      If  this  be  the  case  it  is  best  to  ligate  the 


growths  oftenest  found  in  adult  life.  The  sar- 
comas develop  very  rapidly  and  grow  to  a  large 
size.     Their  removal  is  attended  with  many  diffi- 


main  vessels  first. 

After  the  removal  of  the  organ,  the  ureter  may 
be  managed  in  either  of  two   ways.      Its  free  end 


culties,  and  even  if  not  primarily  fatal,  does  not  is  made  thoroughly  aseptic  by  the  application  of 
add  materially  to  the  patients  tenure  of  life.  The  the  actual  cautery  or  pure  carbolic  acid,  and  it  is 
same  is  true  with  the  carcinomas  with  the  ex-  drawn  out  and  fastened  to  the  most  dependent 
ception  that  they  never  attain  a  great  size,  be-  part  of  the  external  wound  ;  or  its  extremity 
cause  their  malignancy  leads  rather  early  to  a  [  may  be  inverted  into  its  lumen,  like  the  finger  of 
fatal  issue.  a    glove,    and  the  peritoneal  edges   fastened   by 

The  adenoma  are  simple  tumors  ;    can  be  re-   sutures. 
moved  safely,  and  the  patient's   life  may  be  pro-        Quite  large  and  vascular  growths  of  this  organ 
longed  ill  comfort  for  years.  I  can  be  safely  removed  through   the  lumbar   in- 

There  are  two  methods  of  performing  a  ne-  cision,  by  first  securing  the  base  of  the  mass  with 
phrectomy:  first,  the  lumbar ;  second,  the  abdom-  a  temporary  rubber  ligature,  drawn  tight  enough 
inal.  The  lumbar  is  the  one  most  commonly  to  close  the  blood-vessels.  The  tumor  is  then 
chosen;  the  operative  manipulations  are  exe- 1  cut  away  piece- meal  without  bleeding  until  it  is 
cuted  outside  the  peritoneum;  free  and  perfect  j  so  far  reduced  in  size  that  the  permanent  ligature 
drainage  is  easily  carried  out ;  and  for  these  rea-  j  may  be  easily  applied  inside  the  rubber  tube,  in 
sons  it  is  best  adapted  for  cases  of  suppuration  the  usual  manner.  The  elastic  tube  is  then 
in  the  kidney,  and  all  tumors  of  moderate  size.        rtmoved. 

The  abdominal  method  is  of  diagnostic  value  Some  operators  include  the  ureter  and  the 
in  enabling  the  operator  to  at  once  decide  posi-  blood  vessels  in  the  same  ligature,  but  the  better 
tively  that  both  kidneys  are  present:  it  neeessi-  plan  seems  to  be  to  tie  them  separately. 
tales  an  abdominal  section,  hence  opens  the  If  no  pus  is  present,  the  wound  is  perfectly 
peritoneal  cavity —and  no  drainage  can  be  prae-  closed  after  providing  for  drainage  by  means  of  a 
ticed  unless  a  counter  opening  is  made  through  large  size  drainage  tube.  If  pus  is  present,  the 
the  loin.  It  is  best  adapted  to  the  removal  of  wound  is  best  treated  by  the  iodoform  tampons 
tumors  of  large  size,  as  it  allows  perfect  control  as  already  described  and  illustrated  to  you  to-day. 
of  the  growth.  The  dangers  attending  both  op-  The  dangers  of  this  operation  are  increased  by 
erations  are  first,  haemorrhage;  second,  infec-  opening  the  peritoneum,  and  this  accident  should 
tion  ;  third,  uremia  from  insufficient  elimination  be  carefullj  avoided. 
of  urine:   fourth,  shock.  When  the  abdominal   method    is  practiced,  an 


i89i.] 


RENAL  CALCULUS. 


91 


incision  is  made  through  the  linea  semilunaris 
in  the  usual  manner  common  to  all  operations 
which  open  the  peritoneal  cavity.  The  intes- 
tines are  pushed  out  of  the  way  by  means  of  a 
large  flat  sponge. 

As  the  tumor  is  behind  the  posterior  layer  of 
the  peritoneum,  this  layer,  too,  must  be  incised 
before  the  tumor  is  exposed.  The  colon, 
in  these  cases  usually  lies  on  top  of  the  tumor, 
and  the  incision  which  opens  the  posterior  layer 
of  the  peritoneum  should  be  made  some  distance 
away  from  the  outer  edge  of  the  colon  and  paral- 
lel to  it.  It  must  be  of  sufficient  length  to  allow 
the  operator  to  have  complete  control  of  the  tu- 
mor, and  to  provide  for  its  easy  removal.  The 
sponge  is  then  withdrawn;  and  the  inner  edge  of 
the  incision  of  the  posterior  layer  of  the  peri- 
toneum is  sewed  securely  to  the  inner  edge  of  the 
incision  through  the  abdominal  walls  ;  in  this 
way  shutting  off  completely  the  peritoneal  cavity 
from  the  field  of  operation.  The  blood-vessels 
entering  the  tumor  are  now  sought  after  and  lig- 
ated.  The  ureter  is  found  and  secured  tempor- 
arily by  forceps,  the  tumor  separated  from  its 
attachments  and  removed. 

It  is  just  as  well  if  the  tumor  is  rather  large 
and  the  space  limited,  to  secure  the  blood-vessels 
temporarily  by  long  jawed  forceps,  as  they  can  be 
ligated  inside  of  these  after  the  removal  of  the 
tumor. 

It  seems  best  to  always  provide  for  drainage 
through  the  posterior  lumbar  region;  this  can  be 
-easily  done  and  without  fear  of  haemorrhage  by 
thrusting  a  pair  of  scissors  directly  backwards  to 
the  interval  between  the  last  rib  and  the  crest  of 
the  ilium  and  expanding  their  blades  to  make  an 
•opening  through  which  a  large  drainage  tube  can 
be  easily  drawn. 

The  ureter  is  managed  in  either  of  the  ways 
that  have  already  been  described  in  the  directions 
for  lumbar  nephrectomy. 

After  the  tumor  is  removed  and  the  manipula- 
tions mentioned  are  satisfactorily  carried  out,  the 
edge  of  the  posterior  layer  of  the  peritoneum 
which  was  sewed  to  the  abdominal  wound  is  un- 
fastened by  snipping  the  sutures.  The  sponge  is 
again  used  to  keep  the  intestines  out  of  the  way 
while  the  incision  in  the  posterior  layer  of  the 
peritoneum  is  secured  closely  by  means  of  the 
continuous  catgut  suture,  thus  perfectly  isolating 
the  peritoneal  cavity  from  the  large  space  recently 
occupied  by  the  tumor.  The  abdominal  wound 
is  sutured  in  the  usual  manner,  the  sponge  re- 
moved, and  the  external  wound  closed. 

Nephrorraphy  is  the  name  given  to  the  opera- 
tion practiced  for  the  relief  of  the  symptoms  ac- 
companying a  freely  movable  kidney. 

It  has  only  been  during  a  few  years  past  that 
the  profession  has  adopted  the  belief  that  any  op- 
eration is  required  for  the  cure  or  attempted  cure 
of  such  cases.     It  is  possible  that  it  can  be  justly 


said  that  it  is  only  within  a  few  years  that  the 
condition  of  a  movable  kidney  has  been  recog- 
nized  as  the  causi  rtain  array  of  symptoms 

which  interfere  materially  with  the  health  and 
comfort  of  a  patient  suffering  with  this  affliction. 

Such  patients  as  hive  come  under  my  care 
have  complained  of  quite  serious  trouble  and  have 
shown  well  marked  evidences  of  failing  health. 
them  have  become  aware  of  the  prtsence 
of  the  movable  body  and  have  insisted  that  the 
movements  of  the  organ  were  the  cause  of  much 
pain,  at  times  even  severe,  and  that  the  stomach 
was  disarranged  in  its  function — that  the  appe- 
tite was  either  lost  or  very  much  impaired — and 
that  they  had  lost  flesh  noticeably  and  rapidly. 

All  of  these  cases  had  borne  children — no 
doubt  the  condition  occurs  oftenest  in  women 
who  have  borne  children,  still  the  condition  is 
met  with  in  men. 

We  know  that  normally,  the  kidney  is  not  ab- 
solutely fixed  in  its  position — that  it  is  movable 
to  a  slight  extent  in  its  surrounding  loose  cellu- 
lar tissue.  For  some  reason  or  other  after  ex- 
treme distension  of  the  abdomen  its  mobility  be- 
comes increased  in  these  cases,  occasionally  to  a 
considerable  degree;  a  true  meso-nephron  is  de- 
veloped, at  the  end  of  which  the  organ  has  a 
range  of  motion  in  proportion  to  the  length  ot 
the  peritoneal  fold.  Probably  such  cases  as  pos- 
sess a  complete  meso-nephron  are  the  ones  in 
which  the  severest  pain  is  felt:  which  may  be 
due  to  a  twisting  of  the  vessels  and  the  ureter. 

In  some  cases  the  kidney  can  be  displaced 
downwards  as  far  as  the  ilium,  or  inwards  as  far 
as  the  median  line.  It  moves  upon  the  slightest 
touch,  and  can  always  be  replaced  into  the  posi- 
tion in  the  back  which  it  properly  occupies. 

The  well  known  shape  and  contour  of  the  mov- 
able kidney  can  usually  be  readily  palpated  with 
the  fingers  through  the  loose  and  flabby  abdom- 
inal walls,  and  hence  as  a  rule  can  be  positively 
differentiated  from  any  other  growth. 

If  the  kidney  is  only  movable  in  the  loose  post- 
peritoneal  fat,  even  if  the  area  of  motion  is  con- 
siderable, the  operation  for  its  relief  is  much 
more  simple  than  in  the  cases  in  which  the  kid- 
ney is  invested  on  all  sides  by  the  peritoneum, 
and  has  a  long  meso-nephron  developed  from 
this  tissue. 

In  the  first  condition,  probably  a  nephrorraphy 
will  bring  about  a  cure;  in  the  latter,  probably 
a  nephrectomy  will  be  required  if  any  operation 
is  demanded. 

.Most  often  the  kidney  is  normal  in  every  way 
except  its  freedom  of  displacement.  At  times  it 
is  diseased  and  enlarged,  and  this  may  necessitate 
the  more  radical  operation.  The  long  meso- 
nephron  makes  it  very  difficult  or  quite  impos- 
sible to  uncover  the  posterior  surface  of  the  kid- 
ney for  the  application  of  sutures  without  open- 
ing the  peritoneum,  an   accident   to  be  avoided. 


92 


MEDICAL  PROGRESS. 


[January  i* 


This  condition  greatly  increases  the  difficulty  of 
finding  or  fixing  the  organ  at  the  bottom  of  the 
wound  made  to  expose  it. 

The  prognosis  as  to  the  operation  is  favorable 
— in  the  matter  of  permanent  cure  it  should  be 
guarded.  The  operation  has  not  been  done  often 
enough,  the  cases  subjected  to  operation  have  not 
been  sufficiently  long  under  observation  in  all  in- 
stances, to  enable  us  to  speak  very  positively 
about  them.  In  my  experience,  they  have  all 
been  noticeably  improved  at  first,  the  appetite 
has  been  better,  the  food  better  assimilated  and 
the  pain  relieved.  But  this  favorable  result  fol- 
lowed during  the  confinement  of  the  patient  in 
the  recumbent  position,  with  little  or  no  disposi- 
tion to  displacement  or  interference  with  the 
organ. 

It  remains  yet  to  be  seen  whether  the  adhesions 
formed  as  the  result  of  the  operation,  are  suffi- 
ciently firm  to  withstand  the  weight  of  the  organ 
and  the  influence  of  the  movements  of  the  body, 
when  the  patient  assumes  the  erect  position  and 
performs  ordinary  duties. 

It  is  quite  fair  to  mention  the  fact  that  quite  a 
number  of  cases  have  been  reported  by  surgeons,  in 
which,  even  after  a  lapse  of  two  years,  there  has 
been  no  return  of  the  displacement,  and  the  gen- 
eral health  of  the  patient  has  been  permanently 
benefited.  The  primary  incision  for  nephrorrha- 
phy  is  exactly  similar,  in  all  details,  to  that  al- 
ready illustrated  to  you  to-day  for  exposing  the 
kidney  in  the  nephro  lithotomy  just  finished.  As 
soon  as  the  peri- nephritic  fat  is  uncovered,  the 
kidney  is  found.  Usually  the  assistant  is  able  to 
fix  the  kidney  in  its  normal  position,  by  pressure 
against  the  organ  through  the  anterior  abdomi- 
nal walls,  so  that  it  can  be  easily  exposed  to  view 
by  separating  and  displacing  the  surrounding  fat. 
The  posterior  surface  should  be  widely  uncovered. 
Its  capsule  should  then  be  incised  for  a  length  of 
two  inches,  and  the  edges  of  the  divided  capsule 
stripped  off  the  surface  for  a  short  distance  in  op- 
posite directions  so  as  to  uncover  the  small  por- 
tion of  cortical  substance.  Then  the  edges  of 
the  elevated  capsule  should  be  sutured  with  silk 
to  the  edges  of  the  deep  portion  of  the  external 
wound.  The  needle  should  be  full  curved  with 
a  blunt  edge,  and  it  should  be  introduced  so  as 
to  take  up  a  fair  amount  of  the  kidney  substance. 
It  should  be  introduced  very  carefully,  as  the 
kidney  substance  is  very  soft  and  brittle,  and  eas- 
ily torn  :  the  silk  suture  should  be  drawn  care- 
fully after  the  needle,  and  without  any  tension  on 
the  kidney,  for  it  is  easily  torn  through  the  in- 
cluded portion  of  the  organ. 

Sutures  should  be  placed,  at  least,  at  the  upper 
and  lower  ends  of  the  opening  in  the  capsule,  ami 
a  third  or  fourth  one  may  lie  applied  near  its  cen- 
ter. When  these  sutures  are  satisfactorily  in 
place,  the  external  wound  should  be  closed,  as 
has  already  been   explained   and   illustrated,  ex- 


cept that  a  narrow  strip  of  iodoform  gauze  is  to 
be  placed  in  the  centre  of  the  wound,  reaching 
from  the  exposed  surface  of  the  kidney  to  the 
outer  surface  of  the  body.  This  strip  of  gauze 
is  left  in  position  for  some  time,  and  is  said  to 
answer  the  excellent  purpose  of  establishing  a 
band  of  cicatricial  tissue  from  the  surface  of  the 
kidney  to  the  outer  surface  of  the  wound,  perma- 
nent in  character,  which  acts  powerfully  in  fixing 
the  organ  in  position.  In  one  case  in  which  I 
adopted  this  plan,  there  remains  in  the  centre  of 
the  scar  a  deep  depression,  which  draws  the  skin 
inwards,  and  is  no  doubt  produced  by  the  cica- 
tricial track  left  by  the  gauze  used  in  this  way. 

The  external  dressings,  the  same  as  those  ap- 
plied in  the  case  before  you  to-day,  are  designed 
to  keep  the  wound  perfectly  aseptic  until  the 
healing  process  is  complete. 

The  wound-stitches  can  be  removed  at  the  end 
of  the  week,  when,  if  the  case  has  followed  a 
course  free  from  infection,  the  wound  will  be 
found  united.  The  deep  stitches  have  given  rise 
to  no  trouble  in  the  cases  operated  upon  by  my- 
self, and  are  left  to  take  care  of  themselves. 

The  patient  should  be  confined  to  the  recum- 
bent position  for  several  weeks,  so  as  not  to  in- 
terfere by  dragging  upon  the  newly  formed  and 
easily  torn  adhesions. 

Some  surgeons  claim  that  they  are  able  to  con- 
trol all  the  symptoms  incidental  to  the  presence 
of  a  movable  kidney,  without  operation,  by  a 
properly  fitting  pad  applied  to  the  abdominal 
wall  against  the  organ,  after  returning  it  to  its 
normal  situation,  and  holding  the  pad  in  position 
by  a  body  bandage. 

The  operation  of  nephrorrhaphy  is  not  a  dan- 
derous  one,  and  further  experience  with  it  may 
give  to  it  a  definite  and  positive  position  among 
the  surgical  operations  upon  the  kidney. 


MEDICAL    PROGRESS. 


Therapeutics  and  Pharmacology. 

Salicylic  Acid  for  the  Prevention  of 
Scarlet  Fever. — In  the  Centralblattfurklinische 
Median,  for  October,  are  quoted  by  Dr.  G. 
Stickkk,  some  of  the  clinical  experiences  of  Dr. 
G.  de  Rosa,  an  Italian  physican,  in  an  effort  to 
curtail  an  epidemic  of  scarlet  fever  by  the  internal 
administration  of  salicylic  acid.  Out  of  sixty- 
six  children  exposed  to  infection — twenty-seven 
patients  being  down  with  the  disease  in  the  same 
building — only  three  contracted  the  fever,  after 
tlu-  -  ilu  \  in-  plan  of  treatment  had  been  put  into 
operation,  and  in  these  three  cases,  the  failure 
was  ascribed  to  the  fact  that  there  had  probably 
been  a  longer  exposure  to  the  infection  than  in 
the  other  set  of  cases.      It  is  recommended  that 


x89i.J 


MEDICAL  PROGRESS. 


93 


the  drug  should  be  given  promptly  after  there 
has  been  danger  of  infection,  the  dose  being  one 
to  five  grains  daily  until  the  exposure  has  passed 
by.  Isolation  is  not  regarded  as  necessary,  if 
all  susceptible  material  shall  be  brought  prompt- 
ly under  the  influence  of  the  drug. 

Koch's  Treatment  of  Tuberculosis  :  Gen- 
eral Effects. — In  a  clinical  lecture  delivered  at 
the  H&pital  Laennec  on  December  14,  Prof. 
Cornii.  (Semaine  Medicate,  December  17)  gave 
the  results  of  further  observation  of  the  cases  in 
which  he  had  employed  Koch's  treatment.  With 
regard  to  the  three  patients  in  whom  the  first  in- 
jection had  caused  albuminuria — in  two  of  them 
there  was  then  (a  fortnight  after  its  first  occur- 
rence) no  trace  of  albumen  in  the  urine;  the  third 
still  showed  slight  traces  thereof,  but  it  is  not 
quite  certain  that  he  was  entirely  free  from  it  be- 
fore the  treatment  was  begun.  In  the  case  of 
another  patient  suffering  from  diabetes  and  cal- 
culous pyelo-nephritis,  as  well  as  tolerably  ad- 
vanced phthisis,  the  urine  became  rather  less 
purulent  after  the  injection  of  very  small  doses. 
These  cases  seemed  to  M.  Cornii  to  show  that 
the  renal  complications  caused  by  Koch's  fluid 
are  merely  temporary,  and  that,  even  when  the 
kidneys  are  diseased,  the  treatment  is  not  abso- 
lutely contraindicated,  although  it  must  be  used 
with  extreme  care.  With  regard  to  the  reaction, 
Prof.  Cornii  pointed  out  that  it  is  a  mistake  to 
suppose  that  after  the  injection  the  temperature 
simply  rises  to  a  greater  or  less  height,  and  then 
falls  to  the  normal  point.  In  his  cases  the  tem- 
perature was  taken  on  the  rectum  every  two  or 
three  hours.  In  one  case  an  injection  at  11  A.M. 
was  followed  at  7  p.m.  by  a  temperature  of  39. 4° 
C.  Two  hours  later  it  had  fallen  to  37. 40  C, 
but  on  the  following  day,  though  no  further  in- 
jection had  been  given,  it  again  rose  39. 50  C, 
afterwards  falling  gradually  and  with  slight  oscil- 
lations to  normal.  The  type  was  that  of  quotid- 
ian fever,  lasting  two  days.  In  a  second  case 
an  injection  of  three  milligrams  sent  the  temper- 
ature up  to  40.8  C.  on  the  second  day,  to  390  on 
the  third  day,  and  to  39. 50  on  the  fourth,  the 
record  being  almost  normal  in  the  intervals.  It 
was,  in  fact,  an  example  of  intermittent  quotidian 
fever  lasting  three  days.  In  a  third  case,  that  of 
a  child,  the  injection  at  first  caused  a  slight  fall 
of  temperature,  and  it  was  not  before  the  third 
day  that  it  reached  39. 40,  after  which  deferves- 
cence took  place  gradually.  These  three  patients 
suffered  from  circumscribed  lupus  of  the  face, 
and  were  all  in  good  health,  without  any  abnor- 
mality of  temperature  before  the  treatment.  M. 
Cornii  insists  that  these  irregularities  in  the 
course  of  the  reaction  should  be  borne  in  mind, 
and  that  a  sufficient  interval  should  always  be 
allowed  between  the  injections  so  as  to  avoid  any 
danger  of  cumulative  action.    In  a  patient  suffer- 


ing from  lupus  erythematosus  the  general  action 
was  extremely  intense,  while  there  was  no  sign 
of  local  reaction.  In  six  patients  suffering  from 
syphilitic  lesions,  inoculated  by  M.  Humbert  in 
in  the  Hopital  du  Midi,  no  reaction  took  place. 
M.  Cornii  then  gave  a  summary  of  M.  Henocque's 
spectroscopic  examination  of  the  blood  (see  ab- 
stract, p.  98),  and  expressed  the  opinion  that  the 
amount  of  oxyhemoglobin  gives  a  fair  measure 
of  the  effect  of  the  injections,  and  adds  that  it 
cannot  be  doubted  that  where  it  is  diminished 
the  patient's  general  condition  becomes  worse, 
and  it  may  be  concluded  that  the  injections  are 
doing  harm.  While  not  venturing  as  yet  to  pro- 
nounce a  final  judgment  on  the  value  of  the 
method,  Prof.  Cornii  says  that  with  proper  care 
there  is  little  risk  of  doing  any  harm  to  patients 
by  the  injections;  that  in  certain  forms  of  tuber- 
culosis,  notably  in  lupus,  "appreciable  improve- 
ment" is  produced;  and  therefore  a  further  trial 
of  the  treatment  is  justifiable. — Brit.  Med.  Jour. 

Hypnal.1 — Tersely  told,  hypnal  is  the  product 
of  combining  equal  parts  of  hydrate  of  chloral 
and  antipyrine.  It  is  an  oily  liquid  of  ether  odor 
and  chloral  taste.  Brought  out  last  year  in 
France,  by  Blainville,  it  was  noted  later  by  Behal 
and  Choay,  who  found  three  distinct  compounds, 
one  of  which  was  worthless  ;  the  others  were 
called  monochloral  antipyrin  and  bichloral  anti- 
pyrin.  Reuter,  testing  one,  gave  it  the  dreadful 
name  of  mouo-tri-chloral- acetyl  dimethyl-phenyl- 
parazolone,  and  declared  it  inert.  He,  however, 
used  the  non-active  product.  Dr.  Bardet.  of  the 
Cochin  Hospital,  made  the  first  medical  experi- 
ments, and — Heaven  bless  him  1 — called  it  hyp- 
nal. He  reported  twenty -two  cases  in  which  one- 
gram  (fifteen- grain)  doses  acted  well  as  a  sedative, 
soporific,  and  anodyne,  and  especially  useful  in 
insomnia  due  to  cough  or  pain. 

Frankel — whose  paper  in  the  September  num- 
ber of  the  Bulletin  gen .  dc  Theiapeutique  is  the 
latest  from  foreign  sources — after  thirty-three 
trials,  wrote  in  its  favor.  Schmidt  commends  it; 
so,  too,  Quintard. 

Theconsensus  of  opinion  among  Continental  ob- 
servers is  that  hypnal  is  an  efficient  sedative, 
soporific,  and  analgesic;  it  is  more  hypnotic  and 
less  depressing  than  chloral;  it  is  not  caustic  like 
chloral  nor  irritant  like  antipyrin,  and  it  is  more 
readily  taken,  being  more  tasteless  than  either. 

On  respiration  it  is  much  like  chloral;  on  cir- 
culation it  is  less  disturbing  than  chloral.  It  is 
antipyretic,  and  non-irritant  by  mouth,  bowel  or 
skin. '  It  is  said  to  be  particularly  adapted  to  child- 
ren, and  to  patients  with  phthisis,  lessening  fever, 
pain, insomnia, and  unrest.  Schmidt  found  that  fif- 
teen grains  equalled,  in  sleeping  effect,  about  nine 
grains  of  chloral. 

■  Selections  from  a  paper  read  before  the  Medical  Society  of 
the  County  of  Kings,  by  J.  B.  Mattison. 


94 


MEDICAL  PROGRESS. 


[January  17, 


The  dose  named  by  writers  noted  is  fifteen  to 
thirty  grains.  I  have  given  fifteen  to  sixty  by 
mouth,  double  if  by  bowel,  and  fifteen  hypoder- 
mically.  It  can  be  given  in  capsule  or  solution 
-  preferably  the  former.  If  the  latter,  twice  the 
amount  of  alcohol  should  be  added  to  the  elixir 
of  syrup.  By  bowel,  in  gum  arabic.  Subcutane- 
ously,  direct.     Convenient  formulae : 

R—  Hypnal,  tt\,  xv. 

Alcohol,   nvlx. 

Elixir  or  syrup,  ad  n\,  ccxl. 
M.     Sig. :  One  dose;  one-third  tumbler  water  after. 
R — Hypnal,  "V  xxx. 

Mucilag.  acacia?.,  ,5  j. 
M.     Sig.:  One  injection. 

R — Hypnal,  tr^  xv. 

M.     Sig.:  One  dose,  hypodermically. 

— Medical  Record. 

Resorcin  in  Diphtheria. — Andeer  has  re- 
cently collected  evidence  in  regard  to  the  useful- 
ness of  resorcin  as  an  antiseptic,  and  especially 
with  reference  to  its  employment  in  diphtheria. 

Recent  investigations  have  shown  that  this 
drug  is  a  very  active  antiseptic,  and  harmless 
even  in  solutions  containing  10  per  cent,  of  it. 
A  10  per  cent,  solution  in  glycerine  penetrates 
the  tissues  rapidly.  At  the  St.  Lazare  Hospital 
it  has  proved  serviceable  in  diphtheria. 

It  should  be  used  every  one  or  two  hours,  day 
and  night,  locally  to  the  diseased  spot.  A  spray 
of  a  5  per  cent,  solution  should  be  kept  up  in  the 
patient's  room,  and  further,  two  to  four  teaspoon- 
fuls  of  a  2  per  cent,  solution  of  resorcin  in  sjrr. 
terebinth,  should  be  administered  daily. 

In  diphtheria  of  the  larynx  resorcin  is  of  little 
value. — Centralblatt  f.  d.  gcsammte  Therapie, 
Heft.  9,  1890. — Am.  Jour.  Sled.  Science. 

Hedicine. 

The  Effects  of  Extirpation  of  the  Pan- 
ckkas — Dr.  Boccardi,  of  Naples,  remarking 
that,  though  a  good  many  researches  have  been 
published  by  various  observers  of  experiments  in 
which  the  pancreas  has  been  removed  with  the 
result  of  producing  glycosuria,  no  detailed  ac- 
count of  the  pathological  condition  of  the  tissues 
and  organs  had  appeared,  determined  to  remedy 
this  defect  in  our  knowledge,  and  undertook  a 
new  research  on  the  subject  in  the  anatomical  in- 
stitute of  the  Naples  University.  A  preliminary 
note  has  just  been  published  by  him  in  the  Ri- 
forma  Medica,  in  which  he  describes  the  anatom- 
ical appearances  in  animals  after  deprivation  of 
the  organ  in  question.  All  or  nearly  all  were 
greatly  emaciated,  notwithstanding  plenty  of  nu- 
tritious food  after  the  operation.  No  boils  01 
other  cutaneous  affections  were  found.  There 
were  no  morbid  changes  in  the  salivary  glands, 
nor  in  the  oesophageal  and  buccal  glands,  nor 
were  there  any  modifications  in  the  conditions  of 
renewal  of  the   glandular  elements.     There  was 


little  or  no  change  in  the  stomach.  Brunner's 
glands  were  always  normal,  but  Lieberkuhn's 
glands  in  many  cases  presented  an  increase  in 
the  karyokinetic  changes  of  their  epithelium  ; 
sometimes  the  epithelium  was  much  enlarged 
and  altered,  goblet  cells  being  only  discoverable 
at  rare  intervals,  and  the  whole  had  somewhat 
the  appearance  of  Brunner's  glands.  There  were 
practically  no  changes  in  the  oesophagus  or  in 
the  nervous  elements  in  the  coats  of  the  digestive 
tract.  The  liver  always  presented  morbid 
changes,  even  in  a  dog  which  had  been  operated 
on  only  four  days  before  it  was  killed,  and  had 
only  just  begun  to  pass  sugar  in  the  urine.  Most 
frequently  these  were  fatty  degeneration  and  sim- 
ple atrophy  ;  sometimes  also  there  was  a  vacuolar 
condition  of  the  cellular  protoplasm,  ending  in 
complete  destruction  of  the  cells.  The  hepatic 
blood-vessels  were  frequently  distended  and  filled 
with  blood,  and  sometimes  small  hemorrhagic 
spots  were  seen.  The  spleen,  thyroid,  and  supra- 
renal capsules  did  not  present  any  definite  mor- 
bid changes.  In  the  kidneys  only  slight  and 
occasional  changes  were  found.  There  was  never 
any  glycogenic  infiltration  of  the  epithelium  ; 
this  condition  also  was  entirely  or  almost  entirely 
absent  in  the  liver.  Herein  Dr.  Boccardi  believes 
the  main  distinction  lies  between  natural  and 
artificial  diabetes.  The  cardiac  plexus  was 
normal.  In  six  out  of  twelve  cases  examined 
there  was  atrophic  degeneration  of  the  pyramidal 
tracts  of  the  spinal  cord,  most  marked  in  the 
neighborhood  of  the  cervical  enlargement.  No 
neuritis  or  degeneration  was  found  in  the  splanch- 
nics  or  pneumogastrics,  or  in  the  anterior  and 
posterior  roots.  In  one  case  only  was  any  mor- 
bid change  detected  in  the  sciatic  nerve.  No 
important  change  was  found  in  the  brain  or  me- 
dulla, or  in  the  muscular  system.  It  would  thus 
seem  that  various  lesions  are  produced  in  a  short 
time  after  the  extirpation  of  the  pancreas.  The 
state  of  the  spinal  cord  would  appear  to  be  of 
special  interest  in  the  light  of  Charcot's  recent 
researches. — La?icet. 

Points  to  be  Observed  by  Elderly  Males. 
— Dr.  R.  Harrison  offers  the  following  advice 
to  elderly  men  :  1.  To  avoid  being  placed  under 
circumstances  when  the  bladder  cannot  be 
emptied  at  will.  Nothing  is  so  bad  for  a  large 
prostate,  though  it  may  be  working  satisfactorily, 
as  an  enforced  retention.  It  is  often  the  first 
cause  of  a  permanent  atony.  2.  To  avoid  check- 
ing perspiration  by  exposure  to  cold,  and  thus 
throwing  additional  work  on  the  kidneys.  In 
climates  like  our  own,  elderly  persons  should, 
both  in  summer  and  winter,  wear  flannel  next 
the  skin.  3.  To  be  sparing  of  those  wines  and 
spirits  (if  used  at  all)  exercising  a  marked  diu- 
retic effect  either  by  their  quantity  or  quality  ; 
select   those   which    promote   digestion  without 


i89i.] 


MKDICAL  PROGRESS. 


95 


palpably  affecting  the  urinary  organs.  A  glass 
of  hot  gin  and  water,  or  a  potent  dose  of  sweet 
spirit  of  nitre,  will  not  do  anything  to  remove 
the  residual  urine  behind  an  enlarged  prostate. 
4.  To  be  tolerably  constant  in  the  quantity  of 
fluids  daily  consumed.  As  we  grow  older  our 
urinary  organs  become  less  capable  of  adapting 
themselves  to  extreme  variations  in  excretion. 
Therefore  it  is  desirable  to  keep  to  that  average 
daily  consumption  of  fluids  which  experience 
shows  to  be  sufficient  and  necessary.  How  often 
has  some  festive  occasion,  where  the  average 
quantity  of  fluid  daily  consumed  has  been  largely 
exceeded,  led  to  the  over-distention  of  bladder 
long  hovering  between  competency  and  in- 
competency. The  retention  thus  occasioned  by 
suspending  the  power  of  the  bladder,  has  fre- 
quently been  the  first  direct  step  toward  establish- 
ing a  permanent,  if  not  a  fatal,  condition  of 
atony  or  paralysis  of  this  organ.  5.  It  is  im- 
portant that  from  time  to  time  the  reaction  of  the 
urine  should  be  noted.  When  it  becomes  alka- 
line or  offensive,  the  use  of  the  catheter  may  be 
necessary.  When  a  catheter  is  required  it  is 
most  important  that  its  selection  should  not  be 
left  entirely  to  the  instrument-maker.  There  are : 
other  points  to  be  considered  beyond  the  fact  that 
it  is  to  serve  as  an  artificial  outlet  for  the  urine 
from  the  bladder.  An  unsuitable  catheter  in  a 
prostatic  case  may  do  much  permanent  harm.  6. 
Some  regularity  as  to  the  time  of  performing 
micturition  should  be  inculcated.  We  recognize 
the  importance  of  this  in  securing  a  regular  and 
healthy  action  of  the  bowels,  and  though  the 
conditions  are  not  precisely  analogous,  yet  a  cor- 
responding advantage  will  be  derived  from  carry- 
ing out  the  same  principle  in  regard  to  micturi- 
tion.— Medical  Press  and  Circular. 


Antagonism  between  Bacilli  of  Anthrax 
and  "'Blue  Pus." — Dr.  X.  Blagovestchen- 
skv  I  Annates  de  I'Institut  Pasteur,  Tome  iv.  No. 
2,  November,  1890),  gives  an  account  of  some 
experiments  of  which  the  following  are  the  most 
important  results:  Simultaneous  inoculacions  into 
the  anterior  chamber  of  the  eye  of  the  rabbit  with 
the  bacillus  pyocyaneus  and  anthrax  bacillus  are 
accompanied  by  a  destruction  of  the  latter,  the 
animal  not  succumbing  to  anthrax.  Such  inocu- 
lation does  not,  however,  except  in  very  rare 
cases,  render  the  animal  immune  from  a  later  at- 
tack of  anthrax.  If  the  bacillus  pyocyaneus  and 
the  authrax  bacillus  are  not  inoculated  at  the 
same  point  the  effect  of  the  pyocyaneus  bacillus 
is  less  marked,  and  more  of  the  animals  die  from 
anthrax.  When  anthrax  spores  are  introduced 
along  with  the  blue  pus  bacillus  their  develop- 
ment is  interfered  with.  As  the  result  of  main- 
experiments  the  author  concludes  that  the  ster- 
ilized products  of  the  blue  pus  bacillus  can,  as 


Woodhead  and  Cartwright  Wood  pointed  out.  in- 
fluence to  a  certain  degree  the  development  of  the 
anthrax  bacilli,  but  that  it  requires  a  considerable 
quantity  to  effect  this  result,  as  where  the  inocu- 
lations were  made  into  the  eye  simply,  the  quan- 
tity of  blue  pus  products  was  small  and  many  of 
the  animals  succumbed  to  anthrax.  He  also  shows 
that  even  outside  an  animal  the  blue  pus  bacilli 
exercise  a  very  marked  inhibitory  action  on  the 
development  of  anthrax  bacilli,  and  he  explains 
the  fact  that  his  experiments  do  not  agree  with 
Frendenreich  '.ion  that  Frenden- 

reich  was  working  with  cultivations  of  too  great 
an  age,  as  exceedingly  young  cultivations  and 
very  old  ones  (more  than  five  weeks  appear  to 
have  little  retarding  effect  on  the  development  of 
spores  or  on  the  growth  of  bacilli.  From  other  ex- 
periments that  he  made  in  moist  chambers,  he  is 
convinced  that  the  substance  that  inhibits  the  ac- 
tion of  the  bacillus  is  a  volatile  substance  that 
readily  escapes  on  exposure  to  air.  He  gives  full 
descriptions  of  sixty-seven  most  careful  experi- 
ments, all  of  which  were  made  under  Metchni- 
koff's  guidance  and  advice. — Brit.  Med.  Jour. 

Action  of  Living  Blood  on  Bacteria. — 
Prof.  Bonome  has  recorded  the  results  of  his 
researches  on  the  following  points :  Whether 
physiological  alterations  in  the  blood  play  anv 
part  in  modifying  its  destructive  action  on  bacte- 
ria ;  whether  it  is  possible  to  produce  alterations 
in  the  composition  of  the  blood  of  such  a  nature 
that  the  normal  inimical  action  against  bacteria 
may  be  altered ;  and  whether  it  is  possible  to  de- 
rive any  reliable  data  that  will  throw  light  on  the 
subject  of  immunity.  As  a  result  of  his  experi- 
ments he  comes  to  the  conclusion  that  staphylo- 
cocci introduced  directly  into  the  blood  are  de- 
stroyed in  from  ten  to  twenty-five  minutes ;  more 
rapidly  in  the  blood  of  young  rabbits  than  in  older 
animals  of  the  same  species.  He  then,  by  inject- 
ing the  poison  obtained  from  the  pus  of  an  old 
empyema  or  a  chronic  abscess  in  small  quantities 
into  healthy  rabbits,  proved  that  the  bacteria-de- 
stroying activity  of  the  blood  is  increased,  the  or- 
ganisms used  being  staphylococcus  aureus,  albus 
and  citreus.  He  holds,  however,  that  the  intro- 
duction of  such  poison  does  not  appear  to  exert 
any  influence  upon  the  similar  activity  of  the 
fixed  tissues.  Poison  from  acute  pus  obtained  in 
a  similar  manner  appears  to  exert  not  the  slight- 
est influence  on  the  destructive  action  of  the  blood: 
while,  owing  to  its  effect  upon  the  tissue-elements, 
it  diminishes  their  power  of  destroying  such  organ- 
isms as  the  staphylococci  above  mtntioned.  Simi- 
lar poison  from  p3-ogenic  staphylococcus  cultures 
does  not  increase  this  destructive  power  of  the  blood 
against  the  above-mentioned  organisms,  and  anv 
immunity  that  is  produced  depends  not  on  the 
rapidity  and  certainty  with  which  the  blood  de- 
stroys the  organisms  introduced  into  its  stream,  but 


96 


MEDICAL  PROGRESS. 


[January  17, 


rather  upon  a  greater  resistance  which  the  tissue 
elements  exert  against  the  bacteria  poison,  when 
they  have  become  accustomed  to  the  action  of  the 
poison  by  remaining  in  contact  with  the  metabolic 
products  of  the  same  bacteria.  He  also  gives  ex- 
periments to  show  that  water  injected  into  the 
veins  can  diminish  this  destructive  activity  of  the 
blood  to  a  certain  extent,  but  never  completely  ; 
for,  although  the  animals  so  injected  and  control 
animals  died  about  the  same  time,  those  in  which 
water  had  been  injected  usually  showed  small  pu- 
rulent deposits  in  the  kidneys  and  myocardium, 
and  more  or  less  fatty  degeneration  of  the  epithe- 
lium of  the  kidneys,  so  that  he  considers  that, 
in  addition  to  this  slight  diminution  in  the  de- 
structive activity  of  the  blood,  there  is  some  al- 
teration of  the  protoplasm  of  the  cells,  probably 
due  to  the  absence  of  salts  and  the  cutting  off  of 
the  full  oxygen  supply  by  the  presence  of  water, 
by  which  their  resistance  is  considerably  dimin- 
ished in  certain  areas,  and  owing  to  which  they 
are  more  readily  attacked  by  the  injected  staphy- 
lococci.— Brit.  Med.  Jour. 

Bacteriology. 

Effect  of  High  Temperature  on  the  Ty- 
phoid Bacillus. — Dr.  Janowski  (Central!'/,  f. 
Bakt.  u.  Parasitenk.,  Bd.  viii,  Nos.  14  and  15, 
1890)  in  the  course  of  his  experiments  on  the  ac- 
tion of  high  temperature  on  the  typhoid  bacillus, 
says  that,  with  the  exception  of  Sternberg's  ex- 
periments, there  are  none  that  can  be  taken  as 
entirely  satisfactory,  the  results  being  vitiated  by 
more  or  less  imperfect  methods.  By  the  use, 
however,  of  a  double-walled  vessel,  the  inner 
chamber  containing  water,  the  outer  a  layer  of 
hot  air,  and  the  outer  wall  surrounded  by  felt, 
except  where  the  Bunseu  is  applied  to  heat  the 
air,  he  obtained  a  vessel  in  which  the  radiation 
and  conduction  were  so  equalized  that  the  water 
remained  at  the  same  temperature  throughout  for 
a  considerable  length  of  time.  By  placing  test 
tubes  within  this  chamber,  and  heating  the  gela- 
tine contained  in  them  to  a  required  height  before 
introducing  the  material  to  be  tested,  he  was  able 
to  get  extremely  satisfactory  results.  Using  ty- 
phoid bacilli  grown  for  three  days  on  gelatine, 
or  from  four  to  five  days  on  potatoes  (so  that 
spores  might  be  present),  he  exposed  these  to  va- 
rious temperatures,  ranging  from  400  up  to  8o° 
C,  for  peri' ids  of  from  five  to  ten  minutes,  and 
then  made  "tube-plate"  cultivations  according 
to  Esmarch's  method.  Down  to  550  C,  when 
exposed  lor  ten  minutes,  the  cultivations  were 
always  sterile — that  is,  the  bacilli  had  been  de- 
stroyed, but  550  C.  for  five  minutes  was  not  suffi- 
cient to  prevent  their  germination  when  again 
placed  under  favorable  conditions.  In  only  one 
case,  after  an  exposure  to  560  C.  for  ten  minutes, 
were  three  colonies  developed.  In  all  other  cases 
complete  destruction  of  the  typhoid  bacillus  was 


obtained  at  this  point,  and  he  therefore  looks 
upon  560  C.  as  the  temperature  fatal  to  its  devel- 
opment. In  this,  his  experiments  agree  with 
Sternberg's.  As  regards  low  temperatures,  from 
a  large  number  of  experiments  that  he  made  on 
typhoid  bacilli,  both  by  submitting  these  to  nat- 
ural and  artificial  cold,  in  broth,  and  dry  on 
threads,  he  came  to  the  conclusion  that,  although 
the  results  vary  somewhat  in  different  cases,  ac- 
cording to  the  conditions  in  which  the  bacillus 
exists  during  the  period  that  it  is  exposed  to  the 
cold,  the  extreme  degree  of  cold,  especially  when 
continued  for  some  time,  or  where  frequently  re- 
peated, has  a  markedly  injurious  effect  upon  the 
vitality  of  the  typhoid  bacillus,  a  temperature  of 
—  14°  C.  being  sufficient  completely  to  destroy 
the  bacillus  in  a  fluid  medium.  In  the  dry  con- 
dition this  does  not  always  hold  good. — Brit. 
Med.  Jour. 

otolosy. 
Microbes  in  Otitis  Media. — Drs.  A.  Mag- 
Giora  and  G.  Gradenigo  (Cehtralbl.  fiir  Bakt. 
11.  Parasitcnk.,  Band  viii,  No.  19,  October  30, 
1890),  mention  the  results  of  researches  of  pre- 
vious authors,  and  then  give  their  own  methods 
of  examination.  They  find  that  by  covering  and 
plugging  the  end  of  a  silver  sterilized  Eustachian 
catheter,  it  may  be  passed  into  the  Eustachian 
tube,  without  becoming  contaminated  by  the 
nasal  mucus.  The  plug  is  withdrawn  by  means 
of  a  thread,  and  a  celluloid  bougie — which  had 
been  sterilized  by  repeated  energetic  rubbing  with 
sterilized  cotton  wool — is  introduced  for  at  least 
1  centimetre  into  the  tube.  The  bougie  is  with- 
drawn, and  then  placed  in  tubes  containing  gela- 
tine and  agar,  and  plate  cultivations  are  prepared 
in  the  ordinary  manner.  In  thirteen  cases  of 
chronic  middle  ear  catarrhal  inflammation  with 
thickened  membrane,  fifteen  ears  were  examined 
with  the  following  results  :  Micrococcus  candi- 
cans  was  found  in  six  out  of  the  fifteen  cultiva- 
tions ;  saccharomyces  roseus  in  four ;  saccharo- 
ruyces  ellipsoideus,  bacillus  subtilis,  micrococcus 
cereus  albus,  penicillium  glaucum,  and  diplococ- 
cus  citreus  conglomeratus  in  two  each  ;  sarcina 
lutea,  micrococcus  citreus  (II),  bacillus  albus, 
micrococcus  cereus  flavus,  sarcina  alba,  merismo- 
pedia  aurantiaca,  and  micrococcus  opalescens  in 
one  each.  In  one  case  nothing  was  found,  and 
in  one  non-pathogenic  organisms  that  liquefied 
gelatine  were  met  with.  The  authors  conclude 
thai  in  the  later  chronic  or  dry  stages  of  middle 
ear  inflammation  there  is  no  evidence  of  the  pres- 
ence of  pathogenic  organisms,  as  all  those  men- 
tioned above  may  be  looked  upon  as  entirely  in- 
nocuous. As  regards  the  earlier  stages,  although 
there  is  nothing  proved  as  yet,  they  consider  it  is 
quite  possible  that  specific  infective  organisms 
may  play  some  part,  as  their  experiments  are  not 
at  ail  inconsistent  with  such  a  condition. — Brit. 
Mut.  Jour. 


i89i.] 


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SATURDAY,  JANUARY   17,    1S91. 


THE  TREATMENT  OF  ACUTE  AN.EMIA. 

So  plainly  indicated  a  procedure  as  transfusion 
of  blood  would  not  be  neglected  were  it  not  for 
the  dangers  which  attend  its  execution.  These 
dangers  have  again  and  again  been  illustrated  in 
the  practice  of  every  advocate  of  direct  transfu- 
sion, and  the  most  enthusiastic  of  them  have  been 
compelled  to  abandon  the  method  and  substitute 
defibrinated  blood  or  the  injection  or  infusion  of 
artificial  solutions.  So  dramatic  a  procedure  as 
direct  transfusion  of  blood  appeals  to  the  common 
mind,  and  it  is  not  wonderful  that  it  has  been  urged 
and  even  practiced  not  only  for  acute  traumatic  an- 
aemia, but  for  pernicious  anaemia,  for  chlorosis,  for 
the  anaemia  of  the  chronic  infectious  diseases,  and 
for  sepsis  and  old  age. 

Death  in  acute  anaemia  is  due  to  an  anaemia  of 
the  brain.  This,  in  turn,  may  be  the  result  either 
of  failure  of  the  heart  to  propel  the  properly 
oxygenated  and  nutrient  blood  to  the  brain  cen- 
tres, or  to  the  deficient  quality  of  the  fluid  still 
properly  supplied.  The  heart  itself  is  able  to 
beat  for  some  time  after  its  nutrition  has  been 
wholly  shut  off.  The  failure  of  this  organ  in  sud- 
den loss  of  blood  is  due  to  the  inadequate  filling  of 
its  cavities,  and  the  resulting  mechanical  incompe- 
tency of  the  motor  apparatus  of  the  heart.  Thus 
we  conceive  the  possibility  of  two  forms  of  anaemia 
of  the  brain,  the  one  quantitative,  the  other  qual- 
itative. 

The  blood  and  the  lymph  are  found  in  the  bod}' 
in  nearly  equal  proportions.  Whenever  there  is 
a  deficiency  in  one  of  these  fluids  that  deficiency 


is  supplied  from  the  other.  The  rapidity  with 
which  the  loss  of  a  small  quantity  of  blood  is  re- 
stored has  often  been  noticed.  Even  in  twenty 
minutes  after  the  loss  of  10  per  centum  of  the  en- 
tire bulk  of  the  blood,  the  arterial  tension  will 
have  in  this  way  nearly  regained  itself.  Not  SO 
the  quality.  Micn.icz  (1890)  has  shown  by 
clinical  experiment  and  observation  that  in  the 
otherwise  healthy  the  haemoglobin,  and  presum- 
ably the  corpuscles,  are  restored  in  a  loss  of  5  per 
centum  of  the  blood,  only  after  five  days.  An 
additional  five  days  is  required  to  repair  the  loss 
of  each  further  twentieth.  In  his  experiments 
on  animals,  RoSENBURG1  found  that  a  rapid  loss 
of  two-fifths  the  total  quantity  of  the  blood  was 
usually  borne ;  the  loss  of  more  than  two-fifths 
and  less  than  one-half  was  sometimes  fatal,  while 
the  loss  of  more  than  one-half  the  blood  was  in- 
variably followed  by  death.  He  also  found  that 
the  subcutaneous  infusion  of  a  0.6  per  cent,  salt 
solution  temporarily  resuscitated  animals  that  had 
suffered  a  loss  of  more  than  one-half  the  total 
quantity  of  their  blood,  but  that  they  invariably 
perished  subsequently  in  spite  of  the  infusion. 
This  is  certainly  all  very  significant.  HUNTER2 
has  shown  us  the  fate  of  intra-peritoneal  injec- 
tions of  blood.  Following  such  an  injection  the 
intravascular  blood  becomes  rapidly  concentrated 
from  the  effusion  of  serum  into  the  injected  blood, 
this  is  some  hours  later  followed  by  the  restora- 
tion of  the  circulating  blood  to  its  normal  quan- 
tity and  concentration,  and  still  later  by  the  slow 
migrations  into  the  circulation  of  the  injected 
blood.  Its  presence  may  be  noticed  for  several 
days  by  the  increased  number  of  corpuscles. 

The  first  indications,  then,  in  severe  acute  anaemia 
is  to  fill  the  blood-vessels  in  the  three  vital  parts, 
the  brain,  the  heart  and  the  lungs,  by  maintain- 
ing the  most  favorable  position  of  the  body  of 
the  patient.  The  same  result  may  be  attained 
more  tardily,  though  more  conveniently,  by  tem- 
porarily shutting  off  from  the  circulation  the 
larger  extremities  and  the  abdomen  by  means  of 
the  elastic  bandage.  These  two  procedures  have 
been  termed  autotransfusion. 

When  the  anaemia  is  so  excessive  that  auto- 
transfusion is  inadequate  to  restore  the  mechan- 
ical necessities  of  the  circulation  the  anaemia  is 
fatal,   but  autotransfusion   ma}-  temporarily  re- 


1  Virchow's  Archiv.  Bd.  cxii. 
-  Journal  of  Anatoi 


THE  ETIOLOGY  OF  TUBERCULOSIS. 


[January  17, 


store  the  functions  of  the  heart  and  fail  to  meet 
the  needs  of  life.  Then  there  is  but  one  source 
of  relief.  This  is  to  be  found  in  the  lymph.  The 
rapidity  with  which  the  blood  pressure  is  raised 
is  remarkable.  It  is  usually  complete  at  the  end 
of  an  hour  or  two.  Therefore,  when  the  symp 
toms  of  a  low  blood  pressure  remain  after  this 
time  and  the  mechanical  necessities  of  the  circu- 
lation are  unmet,  washing  out  the  remaining 
lymph  by  means  of  a  subcutaneous  infusion  of  a 
neutral  salt  solution  meets  the  indication  of  the 
case.  The  amount  of  salt  solution  as  well  as  its 
concentration  need  not  be  very  exact  nor  need 
the  temperature  to  be  so  well  regulated  as  in  in- 
fusion directly  into  a  vein,  for  the  tissues  act  as 
a  sort  of  a  ballast  and  reduce  the  infusion  to  a 
proper  concentration  and  temperature.  They  re- 
tain also  any  excess  in  the  quantity  of  the  infu- 
sion until  the  blood  pressure  is  reduced  again  by 
excretion. 

After  the  mechanical  needs  of  the  circulation 
are  met  the  quality  of  the  blood  may  be  so  im- 
paired that  a  vital  equilibrium  cannot  be  attained, 
and  the  patient  sinks  into  a  state  of  rapid  disso- 
lution. For  such  severe  anaemias  the  infusion  of 
the  salt  solution  should  be  followed  by  the  injec- 
tion of  blood  or  by  the  transfusion  of  defibrinated 
blood. 


THE  ETIOLOGY  OF  TUBERCULOSIS. 
Some  important  researches  on  this  subject  have 
been  published  in  the  Medical  Record  by  Dr.  H. 
P.  LOOMIS,  of  New  York.  Starting  from  the 
well-known  facts  that  tubercular  deposits  are 
sometimes  found  in  the  bronchial  glands  of  per- 
sons who  give  no  evidences  of  tuberculosis  of 
other  organs,  and  that,  in  some  cases  of  pulmo 
nary  consumption,  tubercles  of  apparently  older 
date  in  the  bronchial  glands  seem  to  have  been 
the  starting  point  of  the  infection,  he  undertook 
to  determine  in  how  large  a  proportion  of  persons 
who  wei  ;  al  tuberculosis  the  bron- 

chial glands  contained  the  infecting  element.  For 
this  purposi  h<  b  ted  the  bronchial  glands  of  for- 
ty-eight persons,  dying  from  accident  or  acuti  dis 
ease,  by  triturating  the  glands,  with  due  precau- 
tions against  contamination,  in  distilled  water,  and 
injecting  the  mixture  into  the  pleurae  <>t'  rabbits. 
The  rabbits  were  killed  aftei  the  lapse  of  a  suffi- 
cient  time,  and,  in   case   of  their   presenting  the 


appearances  of  tuberculosis,  the  nature  of  the  le- 
sions was  still  further  tested  by  inoculating  other 
rabbits  from  them  in  the  same  manner.  Only  in 
case  of  the  success  of  inoculations  of  this  second 
series  was  it  assumed  that  the  glands  used  for  the 
first  inoculation  were  tuberculous.  In  none  of 
the  cases  used  for  inoculation  were  tubercles 
found  in  any  other  organs  than  the  bronchial 
glands.  In  several  of  them  the  macroscopic  ap- 
pearances of  glandular  tubercles  were  found;  some- 
of  these,  however,  gave  negative  results  by  inoc-' 
ulation.  In  a  few,  the  tubercle  bacillus  was  found 
in  the  tissue  by  microscopical  examination. 

Eighteen  of  the  rabbits  inoculated  died  too  soon 
to  determine  as  to  the  success  of  the  inoculation. 
Of  the  remaining  thirty,  eight  developed  the  le- 
sions of  tuberculosis,  the  character  of  which  was 
confirmed  by  the  success  of  inoculations  on  other 
rabbits.  Three  others  caused  lesions  so  strongly- 
resembling  tuberculosis  that  secondary  inocula- 
tion was  required  to  determine  their  non-tubercu- 
lar nature.  In  five  of  the  successful  cases,  death 
occurred  suddenly  from  accident,  while  the  per- 
sons were  in  apparent  health. 

The  material  for  the  experiments  was  mostly 
taken  from  hospital  patients,  and  the  author  sug- 
gests that  they  are  probably  more  exposed  to  in- 
fection than  persons  living  in  more  favorable  hy- 
gienic surroundings. 

Two  of  the  cases  were  of  special  interest.  One 
was  that  of  a  prize-fighter,  who  had  come  to  New 
York  to  give  exhibitions,  and  died  of  pneumonia 
on  the  seventh  day  of  the  disease.  At  the  au- 
topsy, all  of  the  organs  were  found  normal,  ex- 
cept the  lower  lobe  of  the  left  lung,  which  pre- 
sented the  lesions  of  the  second  stage  of  lobar 
pneumonia,  and  an  enlarged  bronchial  gland. 
The  other  was  a  woman  70  years  of  age,  who 
had  been,  for  more  than  a  year,  a  helper  in  the 
wards  of  Bellevue  Hospital,  where  there  were 
many  tuberculous  patients,  and  had  always  seem- 
ed 01  enjoy  good  health  apart  from  the  infirmity 
incident  to  her  age.  She  died  suddenly,  from 
apoplexy,  and  at  the  post-mortem  examination 
the  lungs  were  found  entirely  normal,  with  the 
exception  of  abundant  pigment.  One  bronchial 
gland  was  much  enlarged.  In  both  cases  the  an- 
imals inoculated  developed  the  lesions  of  tuber- 
culosis,  in  the  latter,  of  a  very  virulent  character. 

In  three  of  the  cases  giving  negative  results, 
calcareous    nodules,   and    in    two   others   cheesy 


I89i.] 


BERI-BERI. 


99 


masses,  presenting  to  the  naked-eye  appearances 
of  tubercle,  were  found  in  bronchial  glands.  The 
failure  of  the  inoculation  experiments  in  these 
cases  was  thought  to  show  the  death  of  the  ba- 
cilli, in  case  the}-  had  ever  been  present. 

These  experiments  seem  to  show  that  it  is  pos- 
sible for  the  infection  of  tubercle  to  remain  latent 
in  the  bronchial  glands  for  an  indefinite  length  of 
time,  and,  on  the  other  hand,  probable  that,  after 
a  long  period  of  latency,  it  may  enter  into  the 
circulation  and  infect  vital  organs.  The  thought 
that  any  of  us  may  be  carrying  around  in  our 
bodies  the  germs  of  such  a  disease  is  not  exactly 
a  cheering  one,  although  it  is  not  probable  that 
the  knowledge  adds  anything  to  the  risk  in  a 
given  case,  and  it  is  open  to  every  one  to  hope 
that  even  if  such  is  the  case,  he  may  be  one  of 
the  lucky  ones  in  whom  it  is  destined  to  go  no 
farther. 


BERI-BERI  IX  THE  GRAND  BANKS  FISHING 
FLEET. 

Dr.  W.  S.  Birge,  of  Provincetown,  Mass., 
has  written  to  the  Boston  Medical  and  Sur- 
gical Journal  a  brief  note  regarding  the 
occurence,  during  the  past  two  years,  of 
cases  of  beri-beri  among  the  fishermen  of  the 
fleet  sailing  from  his  town  to  the  Grand  Banks. 
In  the  Autumn  of  1889,  he  was  called  upon  to 
attend  seven  cases,  coming  from  two  different 
vessels,  which  have  the  interest  of  rarity  in  that 
these  cases  originated  in  a  quarter  of  the  globe 
where  the  disease  has  not  been  supposed  to  exist. 
In  October,  1890,  also,  as  many  as  twenty  cases 
have  been  landed  at  Provincetown  from  vessels 
arriving  from  the  Grand  Banks,  eleven  cases 
occurring  on  one  vessel,  out  of  a  crew  of  thirteen. 
Two  of  these  cases  died  within  twenty- eight 
hours  after  having  been  brought  ashore.  Some 
of  the  cases  have  been  received  at  the  United 
States  Marine-Hospital  at  Chelsea,  while  others 
were  treated  at  their  homes.  The  symptomatol- 
ogy is  described  as  quite  uniform  in  this 
series  of  cases,  the  prominent  signs  being  general 
oedema,  shortness  of  breath  with  precordial  dis- 
tress, numbness  of  the  lower  limbs,  shuffling  gait 
with  decided  inability  to  lift  the  leg  at  the  knee. 
Only  one  case  was  confined  to  his  bed,  hydro- 
thorax  having  supervened  upon  the  general 
oedema.     This  man  died,  five  days  after  his  re- 


turn home,  with  the  symptoms  of  heart  failure 
and  pulmonary  oedema.  The  other  cases,  after 
a  period  of  two  to  six  weeks,  recovered.  It  was 
reported  that  a  case  had  died  on  the  voyage 
home,  the  symptoms  of  which  were  described  as 
similar  to  the  one  above  referred  to  as  fatal.  Al- 
buminuria was  present  in  only  one  case  and  there 
was  some  doubt  if  that  was  properly  attributable 
to  this  disease.  The  spleen  was  greatly  enlarged 
in  three  cases  and  the  bowels  in  all  were  consti- 
pated, but  probably  not  more  so  than  might  be 
expected  among  men  who  go  fishing  to  the 
Grand  Banks,  a  condition  that  no  doubt  results 
from  the  kind  of  food  furnished  on  such  voyages 
and  a  very  general  neglect  among  the  fishermen 
to  attend  the  functions  of  their  bowels.  The  di- 
gestive organs  seemed  to  be  but  little  affected  by 
the  disease,  the  appetite  being  fairly  good  in 
nearly  all  the  cases;  one  case  only  presented  the 
symptoms  of  nausea  and  vomiting.  The  temper- 
ature was  normal  in  all  the  cases  that  subsequent- 
ly recovered.  The  knee-jerk  was  in  two  cases 
entirely  lost,  and  in  all  diminished.  There  was, 
as  reported  by  the  patients  themselves  pro- 
dromic  period  marked  by  depression,  muscular 
weakness  and  indisposition  to  work,  also,  by  an 
cedematous  condition  of  the  areolar  tissue  of  the 
anterior  aspect  of  the  legs;  some  cases  had  severe 
cramps  and  pains  of  a  neuralgic  character.  The 
apparent  cause  for  all  these  cases  was  defective 
food-supply.  In  the  case  of  two  vessels  it  was 
found  out  that  they  had  been  poorly  fitted 
for  the  voyage;  the  two  previous  years  had  not 
been  prosperous  ones  to  their  owners  so  that  the 
outfit  was  cut  down  in  every  possible  way;  the 
salt  beef  was  of  a  poorer  quality  than  usual  and 
the  supply  of  fresh  vegetables  was  very  meagre. 
The  catch  of  fish  was  at  irregular  intervals,  so 
that  the  possession  of  this  article  of  diet,  in  a 
fresh  state,  was  not  a  frequent  occurrence.  The 
majority  of  the  cases,  in  which  the  disease  oc- 
curred, were  strong,  able-bodied  men,  in  whom 
there  were  no  recognizable  traces  of  constitutional 
impairment.  The  treatment  was  almost  wholly 
limited  to  a  dietary  management  in  which  the 
chief  ingredients  were  the  coarsely  prepared 
grains  as  oat  meal  and  wheaten  meal,  along  with 
a  liberal  allowance  of  fresh  beef,  diuretics  and 
hydrogogue  cathartics  were  used  in  some  cases 
where  the  oedema  was  most  marked. 


IOO 


EDITORIAL  NOTES. 


[January  17, 


editorial  notes. 
The  Secretary  of  the  Section  of  Surgery 
and  Anatomy  of  the  American  Medical  Associa- 
tion is  Dr.  W.  E.  B.  Davis,  of  Birmingham,  Ala., 
not  Dr.  John  B.  Deaver,  of  Philadelphia,  as 
erroneously  announced. 

Electro  -  Therapeutic  Association.  —  A 
convention  of  American  Physicians  interested  in 
electro- therapeutics  has  been  called  to  meet  at 
the  Academy  of  Medicine,  No.  17  West  43d 
Street,  New  York,  on  the  22d  inst.,  at  11  a.m., 
for  the  purpose  of  organizing  an  American 
Electro-therapeutical  Association.  A  general  at- 
tendence  of  those  interested  is  invited. 

The  Ohio  Medical  University. — This  is 
the  name  of  a  new  institution  that  has  recently 
been  incorporated  in  Ohio,  and  which  is  to  be 
located  at  Columbus,  the  thriving  Capital  of  that 
State.  The  new  University  will  consist  in  a  De- 
partment of  Medicine  and  Surgery,  a  Department 
each  of  Dentistry,  Pharmacy,  Midwifery,  and  a 
Training  School  for  Nurses  ;  and  will  be  supple- 
mented by  a  large  new  hospital,  the  gift  of  a 
number  of  the  wealthy,  philanthropic  protestants 
of  that  city,  and  which  is  said,  will  cost  about 
$200,000,  when  completed. 

The  incorporators  of  this  new  school  are  :  Mr. 
George  M.  Peters,  a  prominent  millionaire  ;  Mr. 
Williatn  M.  Mutchmore,  an  influential  druggist  ; 
Dr.  J.  F.  Baldwin,  Editor  of  the  Columbus  Med- 
ical Journal;  Dr.  John  W.  Wright,  Oculist  for 
the  Columbus,  Hocking  Valley  &  Toledo,  and 
B.  &  O.  Railroads ;  Dr.  R.  Harvey  Reed,  Treas- 
urer of  the  National  Association  of  Railway 
Surgeons,  Mansfield,  O. ;  Dr.  A.  E.  Evans,  Sur- 
geon of  the  C.  C.  C.  &  St.  L.  R.  R.,  Columbus  ; 
Dr.  A.  F.  Enninger,  a  prominent  dentist  of 
Columbus,  and  Dr.  S.  L.  McCurdy,  Surgeon  of 
the  Pa.  R.  R.,  Dennison,  O.  One  of  the  prom- 
inent features  of  the  new  University  will  be  the 
abandoning  of  the  old-fashioned  system  of  in- 
struction by  lectures,  and  adopting,  instead,  the 
"  new  plan  "  of  "class  teaching"  similar  to  the 
methods  now  employed  in  the  literary  colleges. 
A  graded  course  of  three  years  of  nine  months 
each  is  to  be  adopted,  which  will  include  daily 
examinations  and  grading  of  the  students,  thus 
doing  away  with  the  necessity  of  a  final  ex- 
amination. 

This  new  method    of  teaching  medicine,    and 


allied  sciences,  has  been  agitated  for  years  in  a 
majority  of  the  leading  medical  journals  of  this 
country  and  Europe,  but  we  believe  this  is  the  first 
school  to  organize  on  the  new  plan.  It  is  ex- 
pected to  have  every  thing  in  readiness  to  open 
the  new  University  about  the  first  of  October 
next. 

A  Large  Prize. — The  Academy  of  Medicine 
of  Turin  has  just  offered  a  prize  of  18,000  francs 
for  the  best  work  on  the  "Nature  and  Prophy- 
laxis of  the  Infectious  Diseases  of  Man."  Essays 
must  be  in  Latin,  French  or  Italian. 

Dr.  W.  W.  Dawson,  the  eminent  surgeon  of 
Cincinnati,  ex- President  of  the  American  Medi- 
cal Association,  recently  expressed  a  thought  in 
a  most  terse  and  pointed  way  which  is  worthy  of 
preservation.  He  said  :  ' '  Anaesthetics  are  as  es- 
sential to  surgery  as  the  knife.  Both  are  danger- 
ous, but  neither  can  be  ruled  out  in  consequence 
of  their  danger." — Ex. 

Lady  Dufferin  Zenana  Hospital,  Calcut- 
ta.^— The  building  of  the  Lady  Dufferin  Zenana 
Hospital  at  Calcutta  is  now  making  satisfactory 
progress.  The  main  hospital  of  two  stories  will 
contain  thirty-six  beds,  there  being  separate  wards 
for  Hindus  and  Mohammedans.  A  ward  will  also 
be  set  apart  for  children,  and  a  sum  of  Rs.  25,000 
has  already  been  subscribed  for  its  support.  Synd 
Mehdi  Hussein  Khan,  of  Patna,  recently  gave  Rs. 
1,000  in  aid  of  the  building  fund  of  the  hospital, 
but  at  least  Rs.  20,000  is  still  required  to  com- 
plete the  work. 

A  report  recently  issued  by  the  Pennsylvania 
Board  of  Health  shows  that  there  are  8,318  regis- 
tered medical  practitioners  in  that  State,  of  whom 
641  are  of  foreign  birth,  every  nation  except  Spain 
being  represented  in  the  list. 

According  to  an  American  missionary,  Bom- 
|  bay  is  a  promising  field  for  dentists,  especially  if 
they  be  of  his  own  nationality.  There  is,  he 
says,  only  one  good  dentist  in  the  city,  and  he 
charges  $7.50  for  drawing  a  tooth. 

Onerous  Restrictions  on  Medical  Prac- 
tice in  Certain  States. — A  recent  law  of  New 
Jersey  prohibits  physicians  from  other  States  prac- 
ticing their  profession  within  that  State's  limits. 
A  large  number  of  New  York  medical  men  have 
tuus  been  cut  off  from  their  fields  of  practice  at 
the  various  sea- side  resorts  so  much  frequented 


1891.]  EDITORIAL  NOTES. 


by  the  citizens  of  New  York  during  the  summer  tients  in  the  presence  of  Professor  Koch.  All 
season.  It  is  reported  that  the  Long  Branch  local  the  cases  are  said  to  be  doing  well, 
physicians  were  the  originators  of  this  piece  of  ^  order  ^  ^  changes  produced  in  tubercu. 
legislation.  In  some  other  States  laws  have  ^  ^^  fay  Koch,s  fluid  may  be  determined 
within  the  past  few  years,  been  adopted  which  as  accuratcly  M  pQSsMe  the  directors  of  the 
seem  to  place  somewhat  odious  restrictions  upon  ^^  KospiUd  at  Berlin  have  given  orders  that 
the  practice  of  even  the  most  worthy  and  eminent  tfae  bodies  rf  ^  ^.^  wfao  may  die  after 
members  of  the  profession.     It  is  stated  that  in   faa  been  ^^  by  tfae  new  method  shall  ^ 

New  York  State  a  physician  who  was  regularly  examined  as  SQOn  after  death  ^  the  law  permits. 
licensed  to  practice  in  Brooklyn  was  arrested  in    Koch  found  ^  early  examinations  a  great  he]p 
one  of  the  towns  of  the  northern  part  of  the  State   .fl  hig  investigations  on  cholera. 
for  giving  medical  advice  to  some  one  whom  he  | 

met' while  traveling,  when  his  name  was  not  duly  Dr-  A-  F-  Hoi-T,  Surgeon-General  of  Massa- 
registered  with  the  comity  officers  of  the  particu-  chusetts,  died  December  28,  in  Martin,  Fla.  Dr. 
lar  county  through  which  he  was  then  journeying.    Holt  resided   at  Cambridge,  Mass.,   and  left  for 

!  the  South  about  a  month  ago  for  the  benefit  of 
MEDICAL  ITEMS.  ,.,,,,,•  a-  r  -d  ■    u*i     a-* 

his  health,  he  being  a  sufferer  from  Bright  s  dis- 

The  Leprosy  Commission  in  INDIA.-From  ]  eage       He   wag  bom  in  Lvndeborough,  N.  H.. 

Calcutta   it  is  reported  that  the  Leprosy   Com-    December    l6     lS3S      He   obtained  his  medical 


education  at  the  Harvard  Medical  School  and 
University  of  Vermont,  and  served  with  distinc- 
tion during  the  war  as  hospital  surgeon.  In 
January,     1884,    he     was     appointed     Surgeon- 


mission  has  examined  many  cases  at  Hyderabad, 

and  it  is  stated  that  a  few  of  them  were  declared 

to  be  unequivocal  examples    of   leprosy.     It   is 

understood   that  the  commission,  after  spending 

six  months  inspecting  cases  in  the  plains,  will   Q^^'tf  Massachusetts. 

pass  six  months  at  Simla  carrying  out  experi- 

ments  in  connection  with   the  cultivation  of  the  I      Cholera  in  JAPAN.-The  epidemic  of  cholera 

leprosy  bacillus.  wbich  is  at  Present  n&n8  in  JaPan  ls  one  of  ex" 

I  traordinary  severity.  It  is  said  to  have  followed 
Owing  to  the  cholera  scare  in  Egypt,  the  i  an  outbreak  of  influenza  which  commenced  in 
Khedive  has  by  special  decree  granted  a  free ;  February  last  and  reacned  its  climax  in  April, 
pardon  to  all  prisoners  undergoing  sentences  not  dying  away  towards  the  beginning  of  summer, 
exceeding  three  months.  This  means  the  libera-  As  soon  ag  the  influeuza  disappeared,  however, 
tion  of  about  two  thousand  prisoners  throughout  cholera   seems     tQ     have    been    imported   from 


Egypt.     More  than   350  prisoners  ha%-e  already 
been  set  at  liberty  in  Cairo. 

The    Senate     of    Calcutta    University    has 


China,  and,  as  the  Sei-i-Kwai  Medical  Journal, 
of  October  25,  says,  "  furiously  invaded  with 
tremendous  rapidity."     The    terrible   nature   of 


adopted  a  resolution  to  make  the  LTniversity  a  the  visitation  may  be  judged  from  the  fact  that 
teaching  as  well  as  an  examining  body  by  adding  ;  up  to  October  2,  33,863  persons  had  been  at- 
certain  professorships.  The  scheme  has  been  j  tacked,  of  whom  22,560  died.  Owing  to  the 
forwarded  to  the  Government  for  its  favorable  vigorous  efforts  of  the  sanitary  authorities  the 
consideration.  1  epidemic  is  now,  according  to  our  contemporary, 


By  decree  dated  December  4,  Dr.  Giulio  Biz- 
zozzero,  Professor  of  General  Pathology  in  the 
University  of  Turin,  and  Dr.  Ottavio  Morisani, 
Professor    of    Obstetrics    in    the    University    of 


"  rather  rapidly  fading  away." 

The  surgical  treatment  of  peritonitis  by  drain- 
age does  not  seem  to  have  found  so  muc'J  favor 
in  France  as  it  has   in   England  or  in  Germany, 


Naples,  were  named  Senators  of  the  Kingdom  of  and  the  cases  which   are  recorded  are  not  very 


Italv. 


Professor  Sonnenburg  has  begun  the  sur- 


numerous. 

Minkowski's  discovery  that  extirpation  of  the 


gical  treatment  of  pulmonary  cavities  in  the  \  pancreas  produces  glycosuria  has  suggested  to 
Section  for  Tuberculosis  in  the  Moabit  Hospital  [  clinical  observers  the  possibility  of  diseases  of  the 
at  Berlin,  and  has  already  operated  on  four  pa-  \  pancreas  in  man  as  a  cause  of  diabetes. 


TOPICS  OF  THE  WEEK. 


[January  17, 


TOPICS  OF  THE  WEEK. 


PERFECTED  OBSTETRICS. 

Dr.  Alfred  L.  Carroll,  discussing  "the  influence  of  a 
more  perfected  obstetric  science  on  the  biological  and 
social  conditions  of  the  race,"  has  some  very  pertinent 
observations  on  the  number  of  cases  of  "still-births"  and 
the  effect  of  the  present  conditions  of  obstetrical  science. 
For  instance,  he  says: 

It  is  to  be  regretted  that  the  registration  of  vital 
statistics  is  so  imperfect  in  this  country  as  to  preclude 
any  attempt  to  classify  by  months  the  mortality  under 
one  year;  but  the  data,  such  as  they  are,  indicate  that, 
in  the  United  States  generally,  about  25  per  cent,  of  live- 
born  children  die  during  the  first  twelve-month. 

It  would  not  be  unreasonable,  perhaps,  to  assume  that 
at  least  half  of  the  deaths  under  one  month  are  attribu- 
table to  accidents  in  parturition, and  that  a  large  residuum 
of  those  occurring  in  the  first  year  has  a  similar  origin; 
but  the  admirable  reports  of  Farr  may  enable  us  to  go  a 
step  farther  in  the  field  of  inference.  The  death-rate 
under  one  year  per  10,000  births  in  England,  for  the 
three  years  ending  with  1875,  was  1,527.  Of  these  95 
were  ascribed  to  the  acute  zymoses,  29  to  "teething,"  171 
to  diarrhcea,  263  to  "lung  diseases,"  98  to  tuberculosis, 
128  to  prematurity,  267  to  "atrophy,''  14  to  "suffocation," 
and  251  to  convulsions,  leaving  211  "not  stated."  The 
deaths  from  prematurity,  "atrophy,  "and  convulsions  con- 
stitute nearly  half  of  the  mortality,  all  of  the  former  and 
a  considerable  proportion  of  the  latter  two  being  refer- 
able to  the  time  or  act  of  parturition,  and  some  of  the 
pulmonary  disorders  having  their  predisposition,  if  not 
their  origin,  in  atelectasis  at  birth.  In  Farr's  March  of  an 
English  Generation,  based  on  the  labor  of  over  thirty 
years,  he  computes  that  the  average  deaths  per  million 
under  one  year  will  be  149,493,  of  which  30,637  will  be 
from  diseases  of  the  nervous  system,  and  21,995  from 
respiratory  maladies.  West,  taking  a  wider  view  of 
"nervous"  disorders,  ascribes  to  these  30.5  per  cent,  of 
all  the  deaths  under  one  year,  and  to  convulsions  alone 
73.3  per  cent,  of  the  "nervous  system"  mortality — equiva- 
lent to  33,421  to  the  million  births.  Nor  is  he  any  less 
cogent  in  his  reasoning  than  in  his  statistics.  The  con- 
clusions which  he  draws  respecting  the  social  conditions 
have  the  sound  of  true  earnestness  which  is  refreshing. 
Under  this  head  he  says:  "As  regards  social  conditions, 
I  have  little  to  say  beyond  expressing  the  belief  that 
misery  rather  than  midwifery  is  responsible  for  most  of 
the  degradation  which  blots  our  vaunted  civilization.  It 
may  be  that  in  some  cases  such  misery  is  the  outcome  of 
physical  disability  dating  from  birth  or  parturition,  but 
in  more  instances  it  is  the  result  of  acquired  vicious 
habits.  Social  statistics  show  that  the  numbers  of  mur- 
ders, suicides,  and  other  kinds  of  crime  bear  about  the 
same  proportion  to  population  every  year;  but  of  the 
etiology  of  criminality  nothing  can  be  positively  affirmed. 
Even  those  who  dogmatically  ascribe  all  the  ill-doings  of 
the  world  to  alcohol  have  still  to  find  some  antecedent  fac- 
tor, and  to  explain  why  the  vast  majority  of  consumers  of 
alcoholic  beverages  refrain  from  crime.  Inebriety  is  often 


the  excitant,  but  the  predisposition  must  be  sought  be- 
hind it.  "In  vino  Veritas"  has  a  wider  philosophical 
meaniag  than  they  who  quote  it  ordinarily  wot  of. 

The  vexed  question  of  heredity  (not  so  much  of  dis- 
ease as  of  proclivity  to  disease)  has  little  relation  to  ob- 
stetrics, save  as  it  has  led  some  enthusiasts  to  imagine 
an  impossible  prophylaxis  by  forbidding  the  marriage  of 
physically,  mentally,  or  morally  unhealthy  persons,  and 
in  this  way  diminishing  obstetric  practice,  except  in 
illegimate  births;  and  it  is  doubtful  if  anything  but  a  de- 
structively retrogressive  midwifery  or  an  increasing  pre- 
valence of  oophorectomy  can  materially  reduce  hered- 
itary morbidity,  since  delicate,  and  especially  consump- 
tive, women  seem  to  be  more  apt  to  conceive  and  less 
likely  to  miscarry  than  their  more  robust  sisters.  As  a 
"glittering  generality"  it  may  be  asserted  that  every  ob- 
stetric advance  which  saves  mothers  from  invalidism 
and  children  from  incapacity  for  future  effort  must  pro- 
mote the  social  condition  of  the  race,  but  politico-econ- 
omic rules  and  the  inexorable  operation  of  natural  laws 
will  probably  always  overshadow  in  this  respect  the  in- 
fluence of  medical  science,  or  even  of  Congressional  leg- 
islation.—  Times  and  Register. 


THE  CHOLERA  AND  THE  MECCA  PILGRIMS. 

A  correspondent,  writing  to  a  local  paper  fromjeddah, 
says:  "The  epidemic  is  completely  finished.  On  Octo- 
ber 17,  thirty  days  after  the  occurrence  of  the  last  case 
of  cholera,  Dr.  Vaume  allowed  free  pratique.  Almost  all 
the  pilgrims  have  left.  I  say  nearly  all,  because  there  al- 
ways remain  a  thousand  or  so  of  beggars  who,  having 
nothing  but  starvation  before  them  in  their  own  coun- 
tries, prefer  dying  in  the  sacred  land,  as  being  so  much 
nearer  to  the  gates  of  Paradise.  Now  is  the  time  to 
make  up  the  accounts  of  the  pilgrimage — to  estimate  the 
number  of  those  who  have  died.  Iu  my  estimation — and 
I  have  formed  a  very  modest  one — the  deficit  among  the 
returning  pilgrims  must  be  put  down  at  35  per  cent. !  In 
ordinary  years,  when  there  is  no  epidemic,  about  20  per 
cent,  die;  this  year  the  cholera  has  added  15  per  cent,  to 
the  total  number  of  victims.  This  estimation  of  20  per 
cent,  in  ordinary  years  is  by  no  means  too  high  when 
one  considers  the  great  number  of  old  people  taking  part 
in  the  pilgrimage,  combined  with  the  fact  that  the  jour- 
ney  from  Mecca  to  Yambo,  via  Madeira,  is  an  excessive- 
ly trying  one,  and  that  all  the  people  who  perform  it  have 
passed  one  day  at  Arafat  and  three  at  Monna  with  heads 
bare,  exposed  to  an  ardent  sun.  They  commence  the  re- 
turn journey,  consequently,  in  a  worn-out  state,  and,  once 
started,  caravans  do  not  stop  for  the  treatment  of  sick, 
and  laggards  soon  die  of  thirst,  or  are  murdered  by  the 
Hedouins.  The  poor  people  must  keep  perpetually  mov- 
ing on;  those  who  cannot  keep  up  are  abandoned,  and 
then  the  vultures  take  charge  of  public  salubrity.  Al- 
though one  may  have  seen  many  such  things  during  a 
long  existence,  I  doubt  if  any  one  could  form  an  idea  of 
the  state  of  affairs  during  an  epidemic  at  the  time  of  the 
pilgrimage  without  being  an  eye-witness  thereof.  Thou- 
sands of  men  arrive  on  camels  each  morning  at  the  gate 
of  the  town ;  the  number  of  empty  saddles  is  seldom  less- 
than  10  per  cent.    A  man  dismounts,  staggers  a  few  steps. 


I89i.] 


TOPICS  OF  THE  WEEK. 


103 


-writhes;  his  limbs  contract,  and  lo!  in  an  hour  he  is  dead. 
Another  drags  himself  towards  the  walls  so  as  to  die  in 
the  shade;  but  soon  appears  a  citizen  who  seizes  the  un- 
fortunate wretch  by  the  foot,  and  drags  him  to  a  distance; 
were  he  to  die  close  to  the  town  the  smell  would  be  ob- 
jectionable! As  soon  as  a  pilgrim  falls  sick  the  passers-by 
precipitate  themselves  upon  him  and  relieve  him  of  the 
belt  wherein  he  carries  his  little  stock  of  cash,  but  no 
one  dreams  of  attempting  to  afford  him  relief.  It  is  a 
disgrace  to  humanity."  This  we  believe  to  be  substan- 
tially correct.  It  is  time  that  civilized  Europe  should 
take  steps  to  put  a  stop  to  these  atrocities,  and  at  the 
same  time  prevent  the  spread  of  cholera. — Brit-  Med. 
Jour. 


of  considerations  which  underlie  the  etiquette  of  the 
profession.  We  repeat,  we  are  not  unreasonable.  The 
magnitude  of  Koch's  expressed  hopes  may  perhaps  ex- 
cuse some  haste  and  premature  publicity  in  newspapers. 
But  they  should  not  be  abetted  and  encouraged  by  mem- 
bers of  a  profession  who  cannot  with  impunity  prescribe 
through  newspapers  or  adopt  them  as  media  for  the  dis- 
cussion of  the  profoundest  questions  in  pathology  and 
therapeutics. — Lancet. 


Till.   1HSCUSSION    OF    MEDICAL    SUBJECTS  IN  THE  NEWS- 
PAPER PRESS. 

Some  medical  men,  and  even  some  newspapers,  seem 
to  be  somewhat  disturbed  by  our  remarks  on  the  con- 
tributions to  newspapers  on  the  Koch  treatment  of 
tuberculosis.  We  are  not  unreasonable  or  unpractical. 
The  etiquette  of  the  profession  has  good  grounds  for  its 
existence  in  reason  and  in  the  nature  of  things.  And 
any  departure  from  it  is  sure  to  be  followed  sooner  or 
later,  and  generally  quickly,  by  consequences  bad  for  the 
person  violating  the  rules  of  professional  custom,  bad  for 
others  who  are  led  to  follow  an  evil  example,  and  bad  for 
the  public,  who  are  hopelessly  misled  by  vague  news- 
paper statements  of  disease  and  its  remedies.  In  some 
of  our  colonies  men  of  high  qualifications  and  good  pro- 
fessional history  have  taken  to  the  most  unblushing  ad- 
vertisement of  themselves  as  prodigies  of  skill  for  curing 
all  sorts  of  disorders.  In  connection  with  this  matter  "i' 
Koch  an  Austrian  physician  is  announced  in  the  news- 
papers as  curing  consumption  by  "  Dr.  Brown-S£quard's 
fluid"  more  effectually  than  Koch.  The  following  is 
taken  from  a  daily  provincial  contemporary  as  a  prom- 
inent paragraph,  and  corresponds  with  an  advertisement 
±0  a  similar  effect  in  another  issue  of  the  paper  : 

"Dr.  Koch's  Treatment  for  Tuberculosis. — Mr. 

,  one  of  the  medical   staff  of   the Hospital, 

yesterday  received  a  supply  of  Dr.  Koch's  fluid,  sufficient, 
•we  understand,  to  serve  for  upwards  of  five  hundred  in- 
jections. There  will  be  a  demonstration  of  the  applica- 
tion of  the  treatment  at  the Hospital  on  Thursday 

before  a  medical  audience." 

There  can  be  no  defence  of  such  communications  to 
newspapers.  If  the  design  was  to  communicate  with  the 
profession,  the  post  or  the  medical  journals  would  have 
been  the  proper  medium.  The  most  unseemly  uses  have 
been  made  of  Dr.  Koch's  kindness  in  supplying  his  fluid. 
Such  things  are  not  only  a  breach  of  professional  eti- 
quette and  tradition,  but  in  the  long  run  the  public 
suffers  and  suffers  most.  It  is  misled.  Statements  that 
need  checking  and  correction  are  put  forth  with  confi- 
dence. Every  day  is  showing  more  clearly  what  an  in- 
justice has  been  done  to  Koch  by  the  forced  premature 
disclosure  of  his  great  discovery — for  great  it  is,  what- 
ever may  be  the  limitations  of  it.  But  this  is  nothing 
compared  with  the  cruel  disappointment  created  for 
those  who  are  led  to  expect  more  of  the  discovery  than 
he  has  ever  promised  or  could  promise.     This  is  the  kind 


ITALIAN  HONORS  TO  GERMAN  PHYSICIANS. 

An  Italian  correspondent  writes:  "At  the  meeting  of 
the  Accademia  Medica  di  Roma  on  the  7th  ult.,  the  Pres- 
ident, Professor  Guido  Baccelli,  forwarded  to  Dr.  Koch 
the  following  telegram,  which  had  been  voted  with  ac- 
clamation: '  The  Royal  Medical  Academy  of  Rome  sends 
to  its  illustrious  Honorary  Fellow,  Robert  Koch,  its  tri- 
bute of  applause  and  admiration  for  his  profoundly  sci- 
entific and  humanitarian  discovery.'  At  the  same  meet- 
ing the  Royal  Medical  Academy,  again  at  the  instance  of 
its  President,  seconded  by  the  acclamation  of  the  assem- 
bled associates,  set  aside  ad  hoc  its  formal  regulations  to 
nominate  Rudolf  Virchow  a  '  Socio  d'Onore  '  (Honorary 
Fellow),  and  resolved  to  contribute  500  lire  (£io)  to  the 
fund  for  the  gold  medal  which  is  to  be  struck  for  this 
'  maestro  dei  maestri '  (master  of  masters)  on  the  ap- 
proaching completion  of  his  seventieth  year." 


LITERARY  INTELLIGENCE. 

It  is  announced  that  Professor  Mathias  Duval  will  for 
the  future  be  associated  with  Dr.  G.  Pouchet  in  the 
editorship  of  the  Journal  de  V  Anatomic  et  de  la  Physi- 
ologic Normales.  This  well-known  periodical,  which 
was  founded  by  Professor  C.  Robin,  has  now  entered  on 
its  twenty-seventh  year,  quite  a  respectable  antiquity  for 
a  journal  of  so  high — not  to  say  dry — a  class  which  ap- 
peals to  an  audience  which  must  in  the  nature  of  things 
be  "  few,"  however  "  meet." — The  Revue  Philosophique, 
which  now  enters  on  its  sixteenth  year,  is  remarkable  as 
being  probably  the  only  periodical  in  the  world  which 
can  boast  of  a  Minister  of  Cabinet  rank  as  its  editor.  M. 
Ribot,  however,  is  something  more  than  a  mere  Minister 
for  Foreign  Affairs  ;  he  is  Professor  in  the  College  de 
France,  and  a  philosopher  of  credit  and  renown,  not  only 
among  politicians,  but  among  philosophers.  A  note- 
worthy feature  of  the  Revue  Philosophique  is  the  prom- 
inence given  to  such  subjects  as  the  nervous  system, 
mental  pathology,  anthropology,  etc.  Both  the  peri- 
odicals just  mentioned  are  published  by  Felix  Alcau, 
who,  it  may  be  added,  also  plays  the  part  of  Lucina  to 
the  Revue  de  Mcdecine  and  the  Revue  de  Chirurgic— 
On  January  I,  1891,  will  appear  the  first  number  of  a 
new  journal  devoted  to  stammering  and  speech  affections 
generally.  It  is  to  be  entitled  Medicinisch-padagogische 
Monatsschrift  fur  die  Gesammte  Sprachheilkunde.  and 
will  be  edited  by  Herr  Albert  Gutzmann,  and  Dr.  Her- 
.  mann  Gutzmann,  of  Berlin. — It  is  announced  that  in 
January,  1S91.  a  new  series  of  the  Journal  0/  Laryngology 
will  be  commenced.  Dr.  John  Macintyre,  of  Glasgow, 
will  be  associated  with  Dr.  Xorris  Wolfenden  in  the 
editorship,  and  these  gentlemen  will  have  "the  active 
aid  and  cooperation  of  Drs.  Dundas  Grant,  Barclay  J. 
Baron,  Hunter  Mackenzie,  and  Sir  Morell  Mackenzie" 
in  their  labors.  The  publisher  is  Mr.  F.  A.  Davis,  of 
I  Berners  Street,  W  ,  and  Philadelphia. — Brit.  Med.Journ. 


104 


FOREIGN  CORRESPONDENCE. 


[January  17-,. 


FOREIGN    CORRESPONDENCE. 


LETTER  FROM  BERLIN. 

(from  our  own  correspondent.) 

To  the  Editor: — I  have  been  carefully  watching 
the  experiments  now  being  made  with  Prof. 
Koch's  "Heilmittel  gegen  Tuberculose"  which 
have  drawn  so  many  physicians  to  Berlin  from 
all  parts  of  the  globe,  not  among  the  least  of  these 
from  America.  I  will  endeavor  to  give  you  an 
idea  of  the  action  of  the  lymph  and  also  by  a  few 
cases  which  I  have  selected  from  a  number  as  be- 
ing typical,  give  you  an  idea  as  to  what  results 
have  been  arrived  at  up  to  the  present  time.  As 
you  know,  according  to  Prof.  Koch's  paper  in 
the  Deutsche  Med.  Wochenschrift  of  the  13th  of 
November  a  dose  of  0.25  ccm.  of  the  lymph  will 
cause  considerable  febrile  reaction  and  symptoms 
in  a  healthy  person,  and  a  dose  of  0.01  ccm.  will 
in  some  persons  produce  a  slight  reaction.  In 
tubercular  patients  the  reaction  is  as  follows: 
From  four  to  six  hours  after  an  injection  of  a  full 
dose  (from  0.0005  to  0.01  ccm.  according  to  age 
and  condition  of  patient,  and  inversely  to  the  ex- 
tent of  the  tubercular  infection)  the  temperature 
begins  to  rise,  often  accompanied  by  a  chill, 
reaching  its  maximum  about  the  tenth  or  twelfth 
hour.  The  temperature  usually  reaching  from 
39°  C.  (102. 20  F.)  to  400  C.  (1040  F.),  but  in  some 
cases  it  reaches  as  high  as  410  C.  (105. 8°  F.).  The 
height  to  which  the  temperature  rises  seems  to  be 
proportional  to  the  extent  of  the  tubercular  pro- 
cess, hence  great  care  must  be  taken  regarding 
the  dose  when  the  lungs  are  involved.  In  all 
cases  of  lupus  and  other  external  tubercular  affec- 
tions, the  lungs  should  be  carefully  examined 
physically,  and  the  sputum  for  bacilli.  With  the 
rising  temperature  there  is  often  vomiting  and 
considerable  depression,  headache,  and  sometimes 
unconsciousness.  The  pulse  ranges  from  120  to 
140,  and  sometimes  as  high  as  180.  After  reach- 
ing its  maximum  the  fever  gradually  falls,  and 
in  from  twenty-four  to  thirty- six  hours  that  which 
was  induced  by  the  injection  disappears  entirely. 
The  fever  curve  with  its  attendant  symptoms 
strikingly  resemble  an  acute  sepsis. 

In  some  cases  an  eruption  appears  over  the 
body  much  like  that  of  scarlatina;  this,  however, 
disappears  with  the  fever. 

The  local  reaction  is  the  more  striking  and  re- 
markable, especially  in  external  tubercular  affec- 
tions, where  it  can  be  best  studied.  Seemingly, 
and  as  far  as  has  yet  been  proven  in  the  great 
number  of  patients  experimented  upon,  it  only 
appears  in  the  pathological  processes,  due  to  the 
tubercle  bacillus,  attacking  old  cicatrices  where 
long  before  tubercular  glands  had  been  removed, 
often  demonstrating  the  presence  of  lupus  nodules 
where  they  had  not  previously  been  observed  or 


suspected  as  showing  where  a  tubercular  boa& 
process  lay  latent. 

Lupus. —  As  the  temperature  rises  the  lupus, 
patch  becomes  swollen.  In  all  the  cases  which  I 
have  seen  tubercular  glands  and  the  like,  if  pres- 
ent, also  become  swollen  and  painful.  The- 
lupus  takes  on  a  red  color  which  deepens  with' 
the  rising  temperature  until  it  is  of  an  erysipela- 
tous hue.  From  the  nodules  rays  of  redness  go. 
out  into  the  surrounding  tissue,  and  about  the- 
entire  patch  a  light  line  of  anaemic  skin  forms  &. 
line  of  demarkation  between  the  healthy  and  dis- 
eased tissue.  On  the  surface  of  the  lupus  small 
vesicles  form,  from  which  a  light  colored  serum 
exudes,  at  times  tinged  with  blood;  this  forms 
a  thin  crust  which  in  from  twelve  to  thirty-eight 
hours  begins  to  scale  off,  leaving  under  them 
what  seems  to  be  a  fine  delicate  skin.  This  re- 
action takes  place  after  each  injection,  but,  as  a 
rule,  to  a  less  degree  each  time,  though  the  dose 
be  increased.  One  case  of  lupus  of  the  nose  and 
face  which  I  have  in  mind  was  still  reacting  after 
the  fifteenth  dose.  In  this  patient  the  diseased 
patch  looked  much  improved  though  not  yet  free 
from  its  pathological  condition.  From  its  looks 
I  think  it  may  possibly  be  well  before  very  long. 
A  great  number  of  similar  cases  may  be  seen  in 
the  wards. 

Coxitis. — The  local  reaction  manifests  itself  in 
a  swelling  about  the  affected  joint  which  beconu  - 
exceedingly  painful  to  movement  or  to  the  touch. 

The  following  two  cases  of  coxitis  have  ceased 
to  react  to  ordinary  doses  of  the  lymph: 

Case  1. — Willie  Z.,  set.  3  years,  coxitis  (left). 
Reaction  set  in  on  an  injection  of  o. 0001  ccm.  (or 
o.  1  ccm.  of  the  1  per  cent,  solution  which  is  used). 
Reaction  slight  on  tenth  dose  of  0.005  ccm.;  did 
not  react  on  eleventh  dose  of  0.005  ccm.,  nor  on 
twelfth  dose  of  0.01  ccm.  At  the  time  of  the  first 
injection  (November  6)  the  joint  was  very  pain- 
ful both  to  palpation  and  to  movement,  now  the 
child  voluntarily  moves  his  limb  and  would 
stand  upon  it  were  it  not  in  a  perverse  position 
(adducted  and  flexed). 

Case  2. — Osker  S.,  set.  3  years,  coxitis  (right). 
Did  not  react  after  last  four  doses.  Though  the 
joint  is  not  painful  on  movement  it  is  still  pain- 
ful to  touch  and  deep  fluctuation  can  be  detected. 

How  much  of  the  improvement  in  the  above 
two  cases  is  due  to  the  remedy  and  how  much  to> 
the  quiet  rest  in  bed  is  a  question,  perhaps,  not 
easily  answered. 

Case  j. — C.  S.,  set.  41  years,  tuberculosis  of 
pharynx  and  of  larynx.  The  patient  entered  the 
hospital  with  large  ragged  ulcers  on  both 
pharynx  and  larynx,  which  were  at  first  thought 
to  be  syphilitic  in  their  nature,  but,  on  the  in- 
jection of  0.002  ccm.  of  the  lymph,  he  reacted! 
both  locally  and  generally,  so  that  the  diagnosis 
of  tubercular  ulcers  was  arrived  at. 

I  mention  this  case  more  to  show  what  an   aid 


1891.]  FOREIGN  CORRESPONDENCE. 


105 


to  diagnosis  the  lymph  may  prove  to  be.  Per-  I  think  this  rapidly  written  letter  will  give 
haps  its  main  curative  effect  may  be  in  this  early  I  you  somewhat  of  an  idea  of  the  state  of  the  ex- 
diagnosis,  though  I  must  say  that  it  seems  to  periments  and  what  has  been  done  so  far,  at 
have  a  curative  effect  in  itself,  especially  in  lu-  least  as  I  see  them. 

pus.    Prof,  von  Bergmann,  Prof.  Israel,  Prof.  Ger-  Maurice  I.  Rosenthal,  M.D. 

hardt  and  many  other  eminent  men   in   the  pro-  Berlin,  Dec.  S,  1890. 
fession  seem  to  expect  great  curative  results  from 
the  remedy.     I  have  seen  but  one  case  in  which 

no  reaction  took  place  after  a  number  of  doses  Koch's  Metbod  In  Pulmonary  Tuberculosis. 
1  his  was  in  a  case   ot  spondylitis  presented   by 

Prof.   Jolly.     Tubercle  bacilli  had  been  demon-  Dr.  E.   Fletcher  Ingals,  of  Chicago,   furnishes 

strated  a  few  weeks  before  the  injections  were  the  following  clinical  notes  just  received  from  Dr. 

made.      Prof.  Jolly  at   the   same   time  presented  Corwin,  now  in  Berlin  : 

another  parallel  case;  in  this  both  local  and  gen-  December    16,    1890.      Charite  Hospital,   con- 

eral  reaction  took  place  after  the  first  injection.  sumptive  wards  of  Dr.    Gerhardt.        Kaschuer, 

Case  4. — Max   B.,   aet.    19  years,   tuberculosis  painter,  set.  24,  married,  weight  135  lbs.,  mother 

pulmoni.  The  initial  dose  was  quite  small,  0.002  and  father  both  died  of  quick  consumption.     Pa- 

ccm.,  as  it  should  be  in  all  cases  of  lung  tuber-  tient,    as  a  child,    had  typhoid,    measles,  scarlet 

culosis,  for  in  these  cases  the  lymph  is  a  danger-  fever.     September  last  he  began  to  cough,  with 

ous  remedy.       The  reason  is  apparent   if  we  but  some  expectoration.     At  end   of  September  had 

imagine  such  a  local  reaction  as  occurs  in  a  case  haemoptysis  (half  cup).   Had  night  sweats,  chills 

of  lupus  taking  place  in  the  lungs.     From  what  in  evening,  some  fever.     Entered  hospital  Octo- 

I  have  seen  in  the  wards  and  upon  the  post-mor-  ber  30.     Cough,  weakness,  chest  pains  on  deep 

tern  tables  I  believe  that  no  case  of  far  advanced  inspiration.       Has  good  physique,   dry  skin,  no 

lung    tuberculosis    should    be    treated    by    this  gland  trouble.     Pulse  was  regular,  72;  appetite 

method,    at  least   not  until  further  experiments  fair,  tongue  coated.     Physical  examination  gave: 

have  exactly  defined  the  danger  limit.  percussion  note  short  at  leftapex  (supra-  and  infra- 

In    this  case  the    patient   feels    much   better,  clavicular  spaces),  also  behind  in  supraspinous 

night   sweats  diminished,   and  he    has    slightly  fossa  of  left  side.     Bronchial  breathing  in  above 

gained  in  weight.                                                             ,  locality,  many  moist  rales  on  expiration  and  pos- 

The  above  cases  were  from  the  wards  of  Prof,  teriorly,    from  seventh    down    evident    pleuritic 

von  Bergmann's  and  Prof.  Gerhardt's  clinics.  friction  sounds.      Vocal  fremitus  some  weaker. 

I  have  seen  but  three  post-mortems,  though  Heart  normal.     Vital   capacity   2,000  cc.  (3,500 

more  have  been  made.      One  a  case  of  basilar  cc.  normal). 

meningitis.     The  treatment   by  Koch's  method  November  6.  Small  ulceration  on  left  arytenoid 

began  very  late  in  the  disease.     No  demonstrable  body  noticed. 

changes  were  found  in  the  tubercular  processes.  November  10.  Physical  signs  about  same  as 
The  second,  a  case  of  far  advanced  lung  tuber-  above,  and  left  lower  lobe  behind  shows  signs  of 
culosis,  the  entire  upper  lobes  of  both  lungs  hav-  receding,  catarrhal  inflammation,  tubercular  ba- 
ing  been  involved.  No  changes  due  to  the  lymph  cilli  quite  numerous.  From  October  31  to  No- 
could  be  demonstrated  in  the  tubercular  masses,  vember  18  temperature  always  normal  substan- 
The  third,  a  case  also  of  very  far  advanced  lung  tially.  Physical  signs  same  as  November  10, 
tuberculosis.     This  patient  had  received  but  two  and  weight  same  (126  lbs.). 

injections,  one  of  0.002  and  one  of  0.003  ccm.,  November  18  received  injection  of  two  milli- 
the  last  injection  having  been  given  seven  days  be-  grams  (0.002)  of  lymph,  9  a.m.  Temperature 
fore  death.  After  the  second  dose  the  temperature  gradually  rose  to  380  C.  at  5  p.m.,  390  at  6:30, 
rose  and  continued  at  390  C.  until  death.  In  39. 5°  at  8:30,  390  at  9:30,  38. 30  at  10,  gradually 
this  case  the  upper  lobes  were  entirely  destroyed  falling  off  in  next  twenty-four  hours  to  36.40  on 
and  the  rest  of  the  lungs  in  a  state  of  caseous  morning  of  November  20.  The  signs  of  first  re- 
pneumonia.  In  the  larynx  a  small  ulcer  seemed  action  were  (injection  at.  9  a.m.):  At  12  m.  face 
to  be  cicatrizing,  otherwise  no  changes  due  to  became  hot  and  flushed;  at  5  p.m.,  pains  in  the 
the  lymph  injections  could  be  demonstrated  in  left  tibia  and  appearance  of  measly  exanthema 
the  tubercular  processes.  on   face,    with   itching;  7   p.m.,   sweating,   pulse 

On  all  sides  cases  of  marked  improvement  have  ;  dicrotic,  conjunctiva  injected,  subjective  feeling 

been  reported,  but  time  alone  will  tell  the  real  of  heat  not  so  evident,  exanthema  more  marked; 

value  of  the  remedy.      No  doubt  many  impor-  8  p.m.,  lancinating  pain  in  left  apex, 

tant  developments  will  soon  follow,  and  I  will  en-  November  20.     He  feels  well,    vital   capacity 

deavor  to  keep  you  posted.  1,800.       Received     injection    three     milligrams 

I  hope  that  I  have  not  underrated  the  value  of  (003),  no  reaction  of  temperature  therefrom;  but 

this  '  'great  discovery. ' '  I  have  been  careful  not  slight  constitutional  disturbance,  cough  increased, 
to  overrate  it,  as  is  the  general  tendency  at  pres- 1  Exanthemata  became  quite  marked  in  evening; 
ent. 


io6 


FOREIGN  CORRESPONDENCE. 


[January  17, 


sputum  amounted  to  40  cc.  in  twenty-four  hours. 

November  21.  Right  arytenoid  body  shows 
grayish  white  discoloration. 

November  22,  Injected  0.005  (5  m&-)>  no 
particular  temperature  reaction  (37°),  none  of 
pulse  or  respiration.  Bacilli  found  in  not  very 
large  numbers  and  without  morphological  change; 
pains  in  neck,  left  side;  slight  dyspnoea. 

November  24.  Injection  .008  at  9  a.m.*  (as 
usual);  reaction  of  temperature  38. 50  with  slight 
constitutional  disturbance;  right  arytenoid  body 
but  slightly  ulcerated;  both  vocal  cords  congested; 
sputum  60  cc. 

November  26.  Injection  0.010  (10  rag.)  9 
a.m.;  hardly  any  temperature  reaction,  37.3°; 
sputum  formerly  uumulated  and  purulent,  be- 
come mucopurulent,  frothy,  30  cc.  in  amount. 

November  27.  Exanthema  on  face  very 
marked  in  morning;  ulceration  on  right  arytenoid 
body  still  present;  V.  C.  cords  less  congested 
(has  receded);  sputum  10  cc. 

November  28.  Injection  0.0150,  slight  re 
action  of  temperature  following  (38. 40),  slight 
constitutional  disturbance,  sputum  40  cc. 

November  30.  Injection  0.020,  reaction  slight, 
38. 20.  In  the  sixth  slide  examined  (specimen  of 
sputum)  only  one  bacillus  tubercle  found. 

Lung  Changes. — Some  dulness  still  present  on 
left  side,  clavicular  region.  Bronchial  breathing 
confined  to  upper  part  of  left,  supra-spinous 
space;  mucous  rales  rare,  but  heard  in  fossa  in- 
fra-clavicular, left  side. 

December  2.  Injection  .025,  9  a.m.,  reaction 
of  temperature  very  slight,  38.  i°;  pulse  and  res- 
piration unchanged,  catarrhal  condition  of  larynx 
greatly  receded,  ulceration  but  little  evident. 

December  3.  Anterior  pillars  of  fauces  very 
red,  large  number  of  small  inflamed  patches  ap- 
pear on  them  (probably  herpes?). 

December  4.  Injection  .030,  temperature  re- 
action slight;  38. 30  in  evening;  sputum  20 
cc,  but  slight  disturbance  generally,  weight  131 
lbs. 

December  5.    Sputum  largely  increased,  80  cc. 

December  6.  Injection  .040  (40  mg.)  temper- 
ature reaction,  38. 50,  sputum  40  cc,  four  slides 
(specimens)  examined  for  tuberculous  bacilli, 
none  found. 

December  8.  Injection  0.50,  reaction  of  tem- 
perature quite  marked,  sputum  20  cc 

December  10.  Injection  0.060,  hardly  any  re- 
action, 38. 8°;  sputum  20  cc.  A  new  appearance 
of  exanthema  on  face.  Ulceration  in  larynx  bet- 
ter, visible  again,  no  bacilli  found  in  the  one 
specimen  examined,  vital  capacity  1,980. 

December  12.  Injection  .070,  very  typical  re- 
.  i<  tn  >n  of  temperature,  30. 400, accompanied  by  night 
sweats  Dulness  at  left  apex  still  evident,  ix> 
longer  bronchial  breathing,  only  occasional  rales, 
20  cc.  sputum.    Severe  headache. 

December    14.      Injection   0.070,    temperature 


38.4°  in  evening;  general  disturbance  very  slight. 
December  16.  Injection  .080,  temperature  in 
evening,  38. 90.  Since  December  10,  only  10  cc.  of 
sputum  per  twenty-four  hours;  catarrhal  condi- 
tion at  apex  almost  gone.  Sputum  now  entirely 
mucus,  only  small  spot  of  slight  bronchial  respir- 
ation. No  more  night  sweats.  Bacilli  could  not 
be  found  in  several  specimens  examined.  Weight, 
132  pounds;  appetite  good.  Will  report  further 
as  the  case  progresses. 

This  is  but  one  of  very  many  similar  cases 
which  give  evidence  by  disappearance  of  night 
sweats  and  bacilli,  purulent  sputum  and  local 
signs  of  a  constant  improvement  under  Koch's 
treatment  alone,  combined  with  the  usual  dietary 
measures  and  recovery.  And  when  it  be  remem- 
bered that  in  the  past  history  of  Charity  hospital's 
consumptive  wards,  improvement  and  recovery 
have  been  very  rare  exceptions,  and  a  gain  in 
weight  of  five  to  eight  pounds  in  two  weeks  never 
before  reported,  such  cases  as  the  above  are  the 
more  significant.  In  two  or  three  instances  pa- 
tients effected  with  lupus  of  many  years  standing 
have  been  discharged  from  Bergmann's  clinic 
cured  so  far  as  present  appearances  go,  after  a 
treatment  of  from  three  to  six  months.  Like  dis- 
eased tissue  when  deep  seated,  as  in  the  lung, 
must  necessarily  take  longer  for  removal  when 
separated  by  action  of  the  "  lymph"  as  it  would 
seem,  so  that  we  may  hope  for  a  very  fair  deter- 
mination of  the  pros  and  cons  of  this  certainly 
wonderful  remedy  in  the  next  few  months,  espe- 
cially as  the  number  of  patients  exhibiting  all 
varieties  of  the  disease  is  enormous  in  Berlin 
alone.  It  is  very  fortunate,  too,  that  the  "  lymph" 
is  being  tested  among  Germans  on  German  pa- 
tients, for  certainly  America  would  never  allow 
this  amount  of  experimentation  involving  death 
in  some  instances,  without  what  might  become 
troublesome  investigations.  But  Germans  are 
asking  very  few  questions  and  the  doctors  are  tell- 
ing very  few  lies  about  the  deaths  of  those  few 
patients  fortunate  enough  to  be  hastened  on  a 
painfully  lingering  way.  The  syringe  first  recom- 
mended by  Koch  has  become  already  obsolete, 
superseded  by  the   ordinary   piston  hypodermic 

He  goes  on  to  say  that  abscesses  have  resulted 
from  using  these  syringes,  though  never  from 
using  the  ordinary  syringe  when  it  is  properly 
cleansed. 

My  impressions  gained  thus  far,  lead  me  to  be- 
lieve in  the  beneficial,  if  not  ultimately  curative 
action  of  the  new  remedy,  in  cases  of  lupus  and 
those  cases  of  incipient  pulmonary  disease  and 
of  laryngeal  involvement  where  the  patient  is  of 
fair  strength,  especially  among  males.  The  pa- 
tient must  be  able  to  bear  the  repeated  induced 
toxaemia  (of  the  lymph)  and  to  throw  off  the 
tiseased  and  disintegrated  tissue  as  it  is  set  free. 
Though  the  weight  of  evidence  seems  to  be  favor- 
able, untoward  results  have  been  not  a  few  among 


i89i.] 


FOREIGN  CORRESPONDENCE. 


107 


weak  patients,  females  and  those  far  advanced  in 
the  disease. 

The  following  case  was  of  interest  as  illustra- 
tive of  the  intense  reaction  manifested  at  times  : 

Emilie  Ricter,  aet.  19,  seamstress,  entered  Hos- 
pital Charite  and  examined  November  19.  Mother 
died  of  "pleurisy  "  (probably  tubercular),  father 
from  "accident."  One  healthy  brother;  three 
other  members  of  family  died  of  lung  trouble. 
Patient  had  diphtheria  at  16.  Menses  regular, 
no  childbirth,  no  abortion.  Anaemia  for  last  five 
years.  Felt  well  till  two  years  ago,  when  she 
changed  occupation  from  maid  to  seamstress. 
For  last  year,  pains  in  chest  on  right  side ;  dry, 
hacking  cough,  no  expectoration.  Ten  weeks 
ago  (beginning  of  September)  had  "pneumo- 
nia," high  fever  eight  days,  since  then  severe 
cough  and  expectoration,  no  haemoptysis.  Night 
sweats  last  ten  weeks,  appetite  poor,  great  gen- 
eral weakness. 

Physical  Examination. —  Suffering  expression 
of  face — small  woman,  weakly.  Non-pigmented 
anaemic  skin,  not  dry.  No  exanthemata,  con- 
junctiva and  lips  very  anaemic.  Glands  not  en- 
larged. Left  apex  two  fingers'  breadth,  right 
apex  one  finger's  breadth  above  clavicle.  Dul- 
ness  at  right  apex  down  to  fourth  dorsal  verte- 
brae (hence  more  consolidated  on  right  side), 
dulness  down  to  second  rib  (anteriorly),  particu- 
larly. Bronchial  breathing  and  moist  rales  on 
left  and  dulness  over  left  clavicle.  Posteriorly  no 
distinct  dulness.  Over  left  spine  of  scapula  very 
harsh  breathing  and  occasional  crackling.  Heart 
normal,  except  systolic  anaemic  murmur.  Spleen 
normal,  larynx  normal.  Patient's  weight  before 
injection  40  ^  kilos.  Tubercular  bacilli  in  enor- 
mous quantities.  Hectic  fever,  generally  rising 
to  38. 6°  C.  in  the  evening  and  falling  to  37. 50  in 
the  morning.  From  November  20  to  23  lost  2 
kilos,  in  weight  (indicating  rate  of  loss). 

November  24.  .002  (2  mg.)  injected  at  10  a.m. 
Temperature  37°  C,  rose  to  39. 50  at  6  p.m.,  39.  i° 
at  9  p.m.,  and  fell  to  37.2°  at  6  a.m.  During  re- 
action pulse  went  up  from  100  to  120,  respiration 
from  20  to  25.  A  chill  at  5  p.m.  (November  24), 
lancinating  pains  in  right  chest,  vomiting,  nau- 
sea, headache  and  dizziness.  Cough  not  in- 
creased, but  expectoration  doubled. 

November  25.  Rose  to  390  at  6  p.m.  without 
new  injection,  fell  to  36. 50  at  9.  Respiration  and 
pulse  unchanged.  Complains  of  pain  in  chest, 
and  arytenoid  bodies  show  slight  discoloration. 

November  26.  Injected. 005  at  11  a.m.  Tem- 
perature at  370,  rises  to  40.40  (104.60  F.)  at  6  p.m., 
where  it  remains  for  three  hours,  falling  to  38. 50 
at  midnight.  Pulse  during  reaction  went  up  from 
100  to  130.     Respiration  from  22  to  60  at  6  p.m. 

Examinatio7i  of  Lungs. — No  change  in  right 
upper  lobe.  Posteriorly,  left  upper  lobe  now 
shows  very  distinct  dulness  to  spine  of  scapula, 
with  bronchial  breathing  and  numerous  metallic 


rales.  Patient  on  this  day  (November  26)  had 
a  severe  chill  from  12:30  to  2  o'clock.  From  4 
to  5:30  another  chill.  During  reaction  no  sweat, 
but  great  feeling  of  warmth.  Greater  tendency  to 
cough,  more  expectoration,  which  is  more  mucus. 

November  27.  Temperature  normal  in  morn- 
ing, respiration  normal.  In  evening  former  hec- 
tic, 38. 40.     Feels  well,  but  no  change  in  lung. 

November  2S.  Injected  .008  at  9  A.M.,  with 
normal  temperature.     39.4°  at  6  p.m. 

November  29.  No  injection ;  usual  hectic  in 
evening,  expectoration  much  increased.  At  left 
apex  bronchial  breathing  has  given  place  to  harsh 
vesicular  type.  Consonant  rales  no  longer  heard. 
Dulness  less  extensive 

November  30.     Injected  .010  at  10  a.m.    Tem- 
perature normal.     At  6  p.m.   temperature  39.5  .. 
falling  to  normal  at  3  a.m.     Repeated  examina- 
tion  shows  at  posterior  left  apex    no  bronchial 
breathing ;  dulness  far  less  evident. 

December  1.     Hectic  rises  in  evening  to  38. 6°. 

December  2.  .01  (1  centigram)  injected  at 
9:45.  Temperature  370,  at  6  p.m.  temperature 
39. 8°.  She  complains  as  usual  during  reaction 
of  headache,  nausea  and  a  feeling  of  great  warmth, 
no  swTeat,  sleeps  well. 

December  3.     Hectic  rises  to  38. 8°  at  6  p.m. 

December  4.  At.  12  injected  .015.  Tempera- 
ture 38. 20,  fever  rises  up  to  40.  i°  at  6  p.m.  Res- 
piration 60  at  9  p.m.,  temperature  and  respiration 
normal  at  6  a.m. 

December  5.     Hectic  rises  to  39.2  at  6  p.m. 

December  6.  Injected  .015  at  9:30  a.m.,  tem- 
perature, pulse  and  respiration  normal,  6  p.m., 
temperature  39. 50,  slight  dyspncea;  9  P.M.,  tem- 
perature 39.3°,  respiration  72,  pulse  120.  Intense 
pain  in  chest,  nausea,  vomiting,  night  sweats, 
cough  and  expectoration  not  increased.  Morning 
weakness.  Tubercle  bacilli  very  numerous,  no 
lung  change  to  be  detected. 

December  7.     9  p.m.,  hectic  low  again,  38.2. 

Decembers.  Injected  .015.  Temperature  38.1°, 
rises  to  39. i°  at  6  p.m.,  respiration  to  52,  accom- 
panied with  chill,  night  sweats,  pain  in  left  shoul- 
der— no  lung  change. 

December  9.     Hectic  at  6  p.m.,  38. 70. 

December  10.  Injected  .015  at  9:30  a.m.,  at 
12  pulse  at  40,  at  6  p.m.  temperature  39. 6°,  no 
dyspncea  particularly,  though  respiration  40. 

December  11.  Hectic  of  39. 70,  pulse  125.  res- 
piration 42.  Dulness  increased  anteriorly  down 
to  third  rib  on  both  sides.  Tubercular  bacilli  still 
present  in  large  numbers. 

December  12.  37. 20  a.m.,  39.20  p.m.  Patient 
complains  of  little  sleep,  headache,  great  weak- 
ness. Cough  increased.  Slight  hypostasis  in 
base  of  left  lung,  axillary  region. 

Decemper  13.     Temperature  37. 6°  a.m.,  39. 2° 

P.M. 

December  14.  Temperature  37. 2°  6  a.m.,  38. 6° 
12  M.,  380  at  3  p.m.,  and  39. 6°  at  6  p.m. 


io8 


MISCELLANY. 


[January  17,  1891. 


December  15.  Temperature  38. 2°  at  6  a.m., 
38. 8°  at  12  m.,  39.4°  at  6  p.m. 

December  16.  Temperature  380  at  6  a.m.,  39.3° 
at  9,  38. 2°  at  12,  40.1°  at  3. 

December  17.  Temperature  37. 6°  at  6  a.m., 
38. 20  at  6  p.m. 

From  December  11  to  16  a  cavity  has  been 
forming  at  right  apex,  of  which  the  high  hectic 
between  injections  is  expressive. 

Temperature  in  these  cases  taken  in  axilla, 
every  fifteen  minutes. 


SPECIAL  CORRESPONDENCE. 


Shall  The  Journal  be  Removed  to 
Washington? 

To  the  Editor: — In  my  opinion,  the  idea  of  re- 
moving The  Journal  from  Chicago  should  never 
have  been  entertained  at  all,  and  I  believe  it  is 
the  desire  of  a  majority  of  the  members  that  it 
remain  where  it  is.  Chicago  is  near  the  geograph- 
ical centre  of  the  United  States,  is  a  great  medical 
centre,  and,  being  by  far  the  greatest  railroad  city 
in  the  country,  is  better  able  than  any  other  to 
distribute  The  Journal,  speedily,  in  all  direc- 
tions. 

If,  however,  this  question  is  to  be  acted  upon, 
let  us  not  wait  until  the  next  meeting  of  the  As- 
sociation, and  allow  it  to  be  decided  by  a  sectional 
vote,  but  submit  it  to  the  entire  membership  and 
allow  us  all  to  have  a  voice  in  the  matter. 

I  suggest  that  you  inform  us,  through  the  col- 
umns of  The  Journal,  at  what  time  the  vote  will 
be  taken ;  then  send  a  blank  with  each  copy  of 
one  issue  of  The  Journal,  and  impress  upon  the 
members  the  importance  of  filling  it  at  once,  before 
it  is  lost  or  forgotten,  and  sending  it  either  to  the 
Secretary  of  the  Association,  or  to  a  committee 
appointed  to  count  the  votes. 

It  seems  to  me  that  this  is  the  only  just  way  to 
settle  the  matter,  for  we  are  all  interested,  and 
entitled  to  a  vote,  whether  we  be  country  doctors 
in  Illinois  or  Dakota,  or  city  physicians  in  Phila- 
delphia, New  York  or  Washington. 

F.  W.  Dimmitt,  M.D. 

Oneida,  111.,  January  6,  1S91. 


To  the  Editor: — Let  The  Journal  remain  in 
Chicago.  B.  F.  Hart,  M.D. 

310  Front  St.,  Marietta,  O. 


To  the  Editor: — The  Journal  should  remain 
in  Chicago: 

First.  Because  Chicago  is  centrally  located  for 
mailing  facilities. 

Second.  Because  Chicago  will  soon  be  as  well 
supplied  with  library  advantages  as  any  citv  in 
the  United  States. 


Third.  Because  Chicago  is  nearer  the  centre  of 
the  membership  of  the  American  Medical  Associ- 
ation, and  consequently  more  in  touch  with  them. 

Fourth.  We  are  opposed  to  moving  it  to  the 
East  from  the  West.         H.  B.  Tanner,  M.D. 

South  Kaukauna,  Wis.,  January  9,  1S91. 


To  the  Editor: — I  am  satisfied  with  our  Jour- 
nal's present  location. 

Chas.  W.  Rook,  M.D. 
San  Antonio,  Tex.,  January  8,  1891. 


To  the  Editor: — My  vote  is  for  The  Journal 
of  the  A.  M.  A.  to  remain  in  Chicago,  for  the 
simple  reason,  that  said  city  is  near  the  centre  of 
this  "  Great  Republic."  Any  of  the  large  West- 
ern cities  would  be  preferable  to  the  city  of  Wash- 
ington, D.  C.  "Westward  the  star  of  empire 
rolls."  David  S.  Booth,  M.D. 

321  X.  Jackson  St.,  Belleville,  111.,  January  9,  1891. 


To  the  Editor: — I  say  yes.  Washington  is  not 
a  place  of  common  trade  or  manufacture,  as  are 
other  cities  of  our  country.  It  is  our  capital,  with 
its  many  attractions,  the  pride  of  the  American 
citizen.  It  should  be  made  the  headquarters  of 
the  arts  and  sciences.  The  Journal  should  be 
placed  with  the  Medical  Museum  and  Library, 
and  all  physicians  should  have  pride  enough  for 
their  profession  and  country  to  cheerfully  support 
it,  so  as  to  make  it  the  peer  in  medical  literature 
of  the  journals  of  any  country. 

What  The  Journal  most  needs  and  should 
have  is  the  united  support  of  the  medical  profes- 
sion. Joseph  Waggoner,  M.D. 

Ravenna,  O. 


MISCELLANY. 


Official  List  of  Changes  in  the  Stations  and  Duties  of 
Officers  Serving,  in  the  Medical  Department,  U.  S. 
Army,  from Januat  1  ,-,  /So/,  to  January  9,  1S91. 

By  direction  of  the  Secretary  of  War.  the  following- 
named  medical  officers  will  proceed  without  delay  to 
Pine  Ridge  Agency,  S.  Dak.,  and  report  in  person  i" 
the  commanding  General,  Dept.  of  the  Platte,  for  duty 
in  the  field:  Capt.  Henry  S.  Kilbourn,  Asst.  Surgeon; 
Capt.  Edwin  F.  Gardner,  Asst.  Surgeon;  Capt.  Edward 
Everts,  Asst.  Surgeon.  Par.  9,  S.  O.  304,  A.  G.  O., 
December  30,  1     ,<  1, 

Brigadier  General  Charles  Sutherland,  Surgeon  General, 
will,  as  soon  as  practicable,  repair  to  this  city,  and  as- 
sume tin  duties  of  his  office.  By  direction  of  the  Sec- 
retary of  W.u.  Par.  9,  S.  O.  2,  A.  G.  O..  Washington, 
January  3,  1891. 

Majoi  fames  P.  Kimball,  Surgeon,  assignment  to  duty  at 
Ft.  Supply,  Ind.  Ter.,  in  S.  i).  132,  Dept.  of  the  Mis- 
souri, Septembei  24,  1890.  by  direction  of  the  Secre- 
tary of  War.  Par.  6,  S.  O.  4,  A.  G.  O.,  January  6,  1891. 
APPOINTMENT. 

Col.  Charles  Sutherland,  Surgeon,  to  be  Surgeon  Gen- 
eral, with  the  rank  of  Brigadier  General,  December  23, 
1890.     Vice  Baxter,  deceased. 


THE 


Journal  of  the  American  Medical  Association. 

EDITED  UNDER  THE  DIRECTION  OF  THE  BOARD  OF  TRUSTEES. 

PUBLISHED     WEEKLY. 


Vol.  XVI.  CHICAGO,  JANUARY  24.   1891.  No  4. 

ORIGINAL    ARTICLES.  learned  and  deeply  studied  in  phvsick."     And 

yet  we  are  startled  occasionally  by  the  retrograde 

movement  visible  even  in  medical  teachers  of  re- 

REPORT    OX    LAWS    REGULATING        putable  schools,  one  of  which  institutions  recent- 
MFDICAL  PRACTICE  *  made  this  frank  statement  in  its  annual  an- 

nouncement: 

Head  before  the  American  Academy  of  Medicine,  at  its  Fourteenth         r\.  j»  «.  i_       i  j  ■  r        > 

Annual  Meeting,  at  Philadelphia,  December  4, 1800.  0ur    graduates  may  not  be  classed  as   scientific  phy- 

dv  DTrwipn  1    m-x-r-TTcnv-    am     ,,  n  sicians;  they  may  not  be  able  to  locate  cerebral  diseases 

H\    K1LHAKU  J.   Dl.NOLIbON.  A.M.,  M.D.,  with  the  accuracy  with  which  the  old  phrenologists  could 

of  Philadelphia.  place  the  mental  faculties;  their  abdominal  surgery  mav 

secretary  of  the  academy.  lack  the  boldness  of  'Jack  the  Ripper;"  thev  may  no't 

The    changes    in    the     laws   of   medical    prac-    (iistinguish  the  bacterium  termo  from  the  coinma-bacil- 

-i-;,,^     A.^^^r,     *Un     ;.,4-Q„.„i      *i,„t      1, ~i„~„    ,    lus,  but  they  will  in  a  few  years  be  able  to  apply  the  re- 

tice  during  the  interval  that  has  elapsed  sources  of  iedical  scienee'and  treat  the  peculiar  diseases 
since  the  last  annual  meeting  of  the  Acad-  of  their  localities  with  a  practical  shrewdness  -which 
emy  at  Chicago,  have  not  been  numerous  or  would  astonish  those  of  more  ambitious  training, 
worthy  of  any  lengthy  notice.  As  the  committee  The  published  questions  and  answers  of  the 
whose  duty  it  has  been  to  make  the  usual  inquiry  state  Board  of  Examiners  of  Virginia  are  ocea- 
from  gentlemen  in  each  State  familiar  with  the  sionally  to  be  found  in  the  medical  press  of  the 
subject,  I  submit,  with  a  few  preliminary  re-  country,  and  present  some  of  the  strongest  argu- 
marks,  some  brief  extracts  from  the  letters  of  ments  that  can  ^  advanced  in  favor  of  restrictive 
such  of  my  correspondents  as  have  graciously  medical  legislation.  The  profession,  and  espe- 
responded.  It  will  be  seen  that  restrictive  legis-  c;any  the  public,  are  to  be  congratulated  on 
lation  is  progressive  and  that  the  various  State  the  fact  that  in  that  State  at  least  it  will  not  be 
laws  are,  as  a  rule,  working  harmoniously  and  possible  for  those  who  made  the  following 
satisfactorily  to  the  benefit  of  the  public  and  the  responses  to  legitimate  questions  to  practice  med- 
credit  of  the  medical  profession   which  has    so  icine  • 

zealously  and  actively  interested  itself  in  these  Svmptoms  of  cedema  of  the  glottis  are  that  the  patient 
statutory  enactments  for  the  protection  of  com-  feels  husky  and  has  sore  throat.  I  -would  amputate  it  if 
munities  and  individuals.  It  has  been  stated  necessary.  I  would  do  the  operation  within  three  or 
that  nine  of  the  different  States  of  the  Union  now  four  months  if  it  was  a  bad  case 

_„„...•..„ «-»„„,! *.i.  1   i  The  dose  of  moronia  sulph.  for  a  child  of  five  years, 

require  an  attendance  upon  three  complete  courses  hvpodermicallv,  would  be  one-fourth  grain,  and  if  that 
ot  lectures  and  graduation  to  entitle  the  holder  to  doesn't  give  relief.  I  would  give  one-half  grain, 
practice  medicine  in  their  limits.     Five  out  of  the       The  dose  of  antipyrin  for  a  child  five  years  old  is  fif- 

above  number    are    Southern    States    and   were  teen  g1"3"15  eTeT three  hours. 

.i„    *-     .    t„   „i  _  .,  •  c  The  kidney  is  a  muscular  formation,  in  shape  oolong, 

among  the  first  to  make  the  requirement  of  a  color  quite  dark,  weight  about  one  pound  to  one  and  a 
more  thorough  medical  education.  half,  but  may  vary  considerable. 

Dr.  John   H.  Rauch,    the  efficient   secretary   of       The  sympathetic  svstem  is  composed  of  all  the  filament 

the  Illinois  State  Board  of  Health,  is  of  the  opin-  of  uerT^s  that  start  ix°™  the  sPinal  cord\  a?d  are  dist.ri" 

^™  4.1.  „  *  H4.i,„ 1 fa                            r  1     4    v.  buted  to  all  parts  of  the  svstem.  especially  the  brain. 

ion  .hat     the  rule  of  three  courses  of  lectures  be-  The  cervic£a  ^ortion  ramifie^  t^  encephalon  in  general. 

fore  graduation  is  already  assured  of  general  ob-  The  dorsal  portion  ramifies  the  anus. 

servanee."1      Perhaps  in  the  not  verv  distant  fu-  Extra  uterine  pregnancy  may  be   a  fungoid  groth  or 

ture  we  mav  Still  further  advance   to   the  princi-  tumor  fibroid  in  its  character  or  any  extra  groth  in  the 

_i_    1    -j  j            •                           fTT           ....      r -w-y  utrous  would  be  called  extra  uterine  pregnancy. 

pies  laid  down  in  a  statute  of  Henry  MI,  of  Eng-  A  breech  presentation  mav  be  known  %.  xhe  sense  of 

land,    which    reads   as   follows:    "The  practice  of  touch,  the  buttox  being  different  in  formation  from  the 

the  healing  art  should  be  limited  to  those  persons  cranium.     The  anus  is  different  from  the  mouth,  absence 

that  be  profound,    sad    and    discreet,    groundly-  of  tongue  and  nose.      Get  your  finger  in  the  inguinal 

~ reagion  soon  as  possible  and  assist  your  patient  by  term 

■  The  chief  work  of  reference  for  all  inquirers  as  to  the  provis-  but  Kental  tention. 
'     ing  medical  practice  is,  of  course,  the  Report  JJr     Tohn  B.  R 

Illinois  State  Board  of  Health,  especially  its  '  J  .  .     ,      -  .  _r     ,.       , 

Academy,   in   a  paper  read  before  the    Medical 


LAWS  REGULATING  MEDICAL  PRACTICE. 


[January  24, 


Jurisprudence  Society  of  Philadelphia,  last  win-  [  been  amended  or  changed,  although  we  have  at  every  ses- 
ter,    referred   to   the   same   subject,  and    related    a    sion  of  the  legislature  made  earnest  efforts  to  do  so.      It 
'    ,  .     .,       .,,  .       J    ,  .  establishes  Countv  Boards  of  Examiners,  and  an  apph- 

number  of  similar  illustrations  of  ignorance,  some  cant  passing  any  'county  board,  however  careless  and  iu- 
of  which  were  quoted  from  an  interesting  paper  different  it  may  be  to  the  interests  and  welfare  of  the 
presented  some  time  since  to  the  American  Med- 1  people,  is  granted  the  license  or  privilege  of  exercising, 
iml  Association  hv  Medical  Director  Albert  T  or  ratlier  practicing,  in  any  other  county  in  the  State, 
ical  Association  D>  Medical  director  AlDert  L,.  \Some  counU.  examiners,  therefore,  who  are  liberal  for 
Glhon,    U.   S.    Navy,    a    tormer   President   Ol   our    M,/,^,  do  most  all  the  examining,  and  thereby  injure  'the 


Academy  : 

The  normal  temperature  of  the  human  body  is  from 
1120  to  1400. 

The  temperature  of  the  system  is  variable.  In  health 
the  cuticle  stands  at  70°. 

The  average  respirations  are  70  per  minute. 

The  best  way  to  facilitate  the  expulsion  of  the  placenta 
is  to  let  the  woman  get  up  and  walk  about  the  room, 
allowing  five  minutes  to  elapse  after  delivery  before  re- 
quiring her  to  get  up  and  walk. 

Phymosis  is  the  result  of  old  age 


profession.  We  hope  to  accomplish  something  in  the 
way  of  a  change  this  winter,  the  legislature  convening 
in  January,  1S91. 

In  regard  to  California,  a  recent  editorial  in 
the  Pacific  Medical  Journal  (August,  1890)  makes 
the  following  pointed  remarks  : 

California  needs  a  new  medical  law  because  her  stand- 
ard is  too  low,  and  there  is  no  other  way  by  which  to  ele- 
vate it.  It  is  much  lower  thau  that  required  by  manv 
other  States  in  the  Union,  by  Cauada  and  by  most,  if  not 


The  difference  between  galvanism  and  electricity  is  !  all,  European  countries.     The  result  is  plaiuly  apparent. 

that  one  of  them  is  the  substance  itself  and  the  other  its  '  California  will  become  the  dumping  ground  for  third-rate 

use.  practitioners  who   cannot  receive  recognition   in   other 

Phosphorus  burns  and  makes  nitrogen  gas.  I  places.     The  pro  rata  of  physicians  to  the  population. 

The  technical  name  of  rhubarb  is  columbo.  \  already  high,  will  assume  frightful  proportions,  and  this, 

,_.,      ,,.  _         ,  ,  ,  ,,.  ,      ,  ]  coupled  with  the  fact  that  manv  of  these  have  been  forced 

The  Minnesota  Board  has  also  published  some   from  otber  places  because  thev  were  illy  qualified,  or  un- 

of  the  far  Irom   brilliant  replies  of  applicants   in    scrupulous,  or  both,  puts  the  medical  future  of  California 

that  State  {North-  Western  Lancet,  May    1.   1890).    in  no  flattering  position.     The  people  will  be  in  a  great 

The  public  should  feel  happier   in    the   exclusion  '  measure  at  the  mercy  of  ignorant  and  bad  men    and  the 

r         r,  cr .         ri,  j      medical  profession  will  suiter  disgrace  and  defeat.     This 


from  the  opportunity  to  practice  of  such  a  respond 
ent  as  he  who  stated,  in  reply  to  a  question,  that 
"the  gland  penis  passes  through  the  prostate 
gland;"  or  that  "in  cases  of  death  from  suffocation 
the  bronchia  remain  in  situ  quo;  "  or  that  "  one 
of  the  principal  symptoms  of  scarlet  fever  is  mal- 
ice on  the  part  of  the  child  .  .  .  the  sequelae  may 
be  death  or  recover)'-" 

Perhaps  if  education  should  ever  approach  in  its 


is  not  an  admission  that  scientific  medicine  is  not  able  to 
take  care  of  itself.  It  means  that  we,  as  a  State,  cannot 
afford  to  be  behind  all  others  and  be  compelled  to  receive 
and  use  the  material  v>  hich  they  cast  out  as  refuse.  France 
has  one  physician  to  every  3,000  people,  Germany  one  to 
1,500,  the  United  States  one  to  600,  and  California,  that 
boasts  of  her  climate  and  the  good  health  of  her  people, 
one  to  500.  A  year  ago,  Los  Angeles  had  one  physician 
to  301  people,  and  San  Jose  one  to  221. 

From  Dr.  Frank  H.  Caldwell,  Secretary  of  the 


completeness  that  said  to  be  now  required  by  the  Orange  Co.  Board  of  Health,  Fla.,  we  learn  that: 
University  of  Coimbra,  there  would  be  hope  that  There  has  been  no  change  in  the  laws  regulating  the 
even  these  aspirants  for  a  place  in  the  ranks  of  practice  in  Florida.  The  law  in  the  Seventh  Judicial 
qualified  medical  practitioners  might  in  time  be  !  District  llas  b^en  effective:  we  have  succeeded  in  convict- 

^     ,,    ,  .  r  .    ,.     „^    .  Y  ■  ing  several  who  were  endeavoring  to  practice  without  the 

enabled  to  pass  a  respectable  State  s  examination;  neces?arv  iicense.  our  Board  will  meet  on  December  12 
for   we   learn   that    in    that    institution     fourteen  ;  and  there  are  quite  a  number  of  applicants  for  certificates, 

years'  study  are  exacted;  six  spent  in   obtaining  Our  standard  is  80  per  cent     As  soon  as  I  can  get  out 

an  ordinary  education,    three  in   a    preliminary  the  questions  for  examination  1  will  forward  you  a  copy; 

....       J  j     <•  •  1  j-     1  and  I  feel  assured  that  vou  will  recognize  the  fact  that 

scientific   course,    and    five     in    purely    medical 

studies. 

We  will  now,  as  briefly  as  possible,  pass  the 


recognize 
none  but  qualified  practitioners  will  be  able  to  pass  the 
examination  which  we  give. 

The  report  of  the  State  Board  of  Health  of  II- 


various  States  in  review,  quoting  the  opinions  of  linojs  for  l8g9  illustrates  the  efficacy  of  its  laws 


recognized  authorities,  as  exhibited  in  their  per- 
sonal correspondence  up  to  the  latest  possible 
date. 


for  the  regulation  of  medical  practice.  When  the 
law  went  into  effect  there  were  in  the  State,  en- 
gaged in  practice,  7,400  persons.     Of  these  3,600 


Dr.  Jerome  Cochran,  Senior  Censor,    Medical   were  graduates  from  some  medical  college,  while 
Association  State  of  Alabama,  writes  as  follows:    3,800  were  non- graduates.     In  other  words,  the 

Xo  change  has  yet  been  made  in  our  law  to  regulate  j  graduates  constituted  only  48  per  cent,  of  all  en- 
the  practice  of  medicine,  but  efforts  to  have  the  law  d  .     practice      Qn  January  1,  1890,  the  per- 

amended  are  now  pending  before  the  General  Assembly,    "   °  v  ,        J  ;  ,     ,  , 

with  the  prospect  111  our  favor.  '     centage  of  non- graduates  to  the  whole  number 

We  understand  that   additional   legislation  is  was  ***  9-     From  3.800  the  number  has  been 
required  in  that  State  to  enforce  the  penalty.  reduced  to  575      The  total  number  of  physicians 

Dr.  R.  G.  Jennings,  Secretary  of  the  Arkansas   m  the  State  ls  less  now  lhan  ]t  was  twelve  >ears 
Industrial  University,  at  Little  Rock,  writes  as 
follows: 


In  [881  was  passed  an   Act  "To   Regulate   the   Practice 
of  Medicine  and  Surgery  in  the  State."  This  Act  has  not 


ago. 

Dr.  J.  F.  Kennedy,  Secretary  of  the  Iowa  State 
Board  of  Medical  Examiners,  writes : 

The  only  change  iii  the  Medical  Practice  Act  of  this- 


i89i.] 


LAWS  REGULATING  MEDICAL  PRACTICE. 


State  since  its  passage  was  an  amendment  to  issue  certi- 
ficates to  those  who  had  passed  satisfactory  examinations 
before  other  State  Boards.  The  law  originally  did  not 
admit  this.  Our  law  is  working  well.  Its' beneficent  pro- 
visions are  thwarted  somewhat  by  our  pharmacy  law 
which  allows  the  Commissioners  of  Pharmacy  to  issue  a 
•vendors  permit  to  itinerating  medicine  proprietors  wheth- 
er physicians  or  not.  Under  this  permit  they  practice  the 
grossest  charlatanism.  Our  medical  law  is" yearly  "row- 
ing in  favor.  It  is  too  liberal  in  that  it  allows  all  kinds 
of  advertising  and  takes  no  cognizance  of  professional  or 
moral  character,  except  that  it  permits  the  revocation  of 
a  certificate  upon  the  conviction  of  a  felon  v  in  connection 
with  his  practice. 

Dr.  J.  N.  MeCormack,  Secretary  State  Board 
of  Health  of  Kentucky,  states  that  the  law  has 

met  with  general  favor  with  both  the  medical 
profession  and  people.  He  calls  especial  atten- 
tion to  the  provision  which  prohibits  traveling 
empirics  from  registering  or  practicing  at  ant- 
place  in  the  State.  His  best  information  is  that 
it  has  forced  about  400  to  either  retire  from  prac- 
tice or  leave  the  State. 

Dr.  Lucien  F.  Salomon,  Secretary  of  the  Lou- 
isiana State  Board  of  Health,  writes  that  no 
changes  have  recently  been  made  in  the  laws 
regulating  the  practice  of  medicine,  and  adds  : 

In  regard  to  my  views  as  to  the  working  of  the  present 
Act  regulating  practice  in  this  State,  I  have  nothino-  to 
add  to  what  I  have  already  expressed  in  a  previous  com- 
mumcation,  except  that  time  has  to  a  great  extent  cured  ! 
the  defect  which  existed  under  section  3  of  Act  iSS->  of 
the  General  Assembly  of  Louisiana  the  law  under  which 
we  are  now  working!.  It  is  verv  seldom  that  we  now 
have  an  application  from  any  one  to  be  registered  without 
a  diploma  and  having  been  engaged  in  the  practice 
of  medicine  for  a  period  of  five  years  prior  to  the  passage 
of  the  Act,  as  provided  in  said  section. 

At  the  last  session  of  the  Legislature  efforts  were  made 
to  have  the  present  law  amended,  but  without  result  \ 
bill  was  introduced  providing  for  the  appointment  of  an 
Examining  Board  and  other  regulations,  but  was  killed 
in  committees,  owing  to  the  efforts  of  the  homceopathists 
■who  had  friends  in  the  Legislature. 

From  Dr.  A.  G.  Young.  Secretary  of  the  Maine 
State  Board  of  Health,  we  learn  that  there  have 
been  no  changes  as  to  laws  regulating  the  prac- 
tice of  medicine,  and  that  there  are  no  laws  what- 
ever bearing  upon  this  point.  Some  of  the  legis- 
lators who  will  meet  in  January  are  said  to  be 
interested  in  doing  something  in' this  direction. 

Dr.  George  H.  Rohe,  of  Baltimore,  Md.,  writes 
that  the  last  Legislature  of  Maryland  passed  a 
new  medical  law,  but  the  Governor  failed  to  sign 
it.  They  are  therefore  living  under  the  old  law 
passed  in  188S.  which  is  not  enforced. 

Dr.  H.  B.  Baker,  Secretary  of  the  State  Board 
of  Health  of  Michigan,  writes  as  follows  : 

I  think  the  profession  in  Michigan  are  much  nearer  an 
agreement  on  what  should  be  done,  than  ever  before 

At  the  October,  1S90,  meeting  of  the  State  Board  of 
Health,  the  subject  of  an  attempt  to  stop  the  continued 
influx  of  unqualified  practitioners  was  brought  up,  through 
a  communication  from  George  DufEeld.  51  D  Secretary 
of  a  committee  of  the  State  Medical  Society,  whereupon 
the  following  preamble  and  resolutions  were  adopted- 

Y\  hereas,  It  is  agreed  by  all  classes  of  people  that 
the  public  health  would  be  much  better  protected  if  none 
but  properly  qualified  persons  were  permitted  to  practice 


I  medicine,  and  thus  to  have  in   their  keeping  measures 
relative  to  life  and  death. 

I.  That  it  is  believed  to  be  practicable,  through 
judicious  legislation,  to  so  organize  the  present  legal  medi- 
cal practiti.,„er>  in  M  ..     h    * 

cted  by  thei  shall  guard  the  en- 

trance to  the  professi,  .mination 

oi  students  aud  a  final  examination  of  gradual,  - 
leges  and  of  proposed  practitioners  who  come  from  other 
Suites   so  that  the  entire  medical  profession  of  tl 
shall  be  united  in  the  effort  to  improve  the  qualifications 
ot  its  new  members. 

That  the  Secretary  of  this  Board  be  directed 
Dsmit  a  copy  of  the  foregoing  preamble  and  reso- 
lution to  the  chairmen  of  the  committees  on  public  health 
in  the  Senate  and  House  of  Representatives  in  the  State 
Legislature,  as  soon  as  it  is  in  session. 

Dr.  Arthur  Sweeney.  Secretary  of  the  State 
Board  of  Medical  Examiners  of  Minnesota,  writes 
as  follows : 

No  changes  have  taken  place  in  the  Minnesota  Medical 
Act  s:,;ce  its  passage  in  1SS7.     The  three  vears  of  legis- 
lation in   Minnesota  have  demonstrated  the  wisdom  of 
the  tramers  of  our  law.     During  the  two  years  from  July 
•-.  to  July  i,  1887,  429  licenses  were'granted  bv  the 
■  former  Board,  under  the  law  which  recognized  diplomas 
from  reputable  schools  and  exacted  examinations  only 
trom  non-graduates.    During  the  three  vears  of  the  pres- 
ent law  223  applicants  have  been  examined,  of  whom  138 
I  were  hce/Jsed  161.92  per  cent.  |  and  85  rejected  |  -,S.oSper 
This  lessened  number  of  applicants  is  due  in 
1  part  to  a  wholesome  fear  of  not  being  able  to  pass  the 
examination  on  the  part  of  poorly  educated  physicians 
and  in  part  to  that  provision  of  the  law  which  "requires 
that  candidates  having  graduated  later  than  1SS7  "  must 
present  evidence  of  having  attended  three  courses  of  lec- 
tures of  at  least  six  months  each."  thereby  excluding 
graduates  from  short  term  medical  scho 

The  law  has  passed  the  stage  of  opposition,. its  benefi- 
cial operation  awakening  a  public  sentiment  in  its  favor 
which  ensures  its  permanency.  The  law  is  administered 
not  in  the  interest  of  the  physician,  but  for  the  benefit  of 
the  community,  in  order  that  the  public  mav  be  assured 
of  the  character,  ability  and  education  of  its  physicians 
It  has  proven  a  bulwark  against  quackery  and'the  less 
obvious  peril  of  ignorance  and  incompetency,  and  has 
practically  rendered  Minnesota  free  from  "cancer  doc- 
tors." itinerant  medicine  vendors  and  other  mounte- 
banks that  disgrace  so  many  States.  It  has  operated 
with  severity  upon  half  educa'ted  and  incompetent  phy- 
sicians, and  has  mercilessly  driven  from  the  State  all  ex- 
cept those  whose  ability  and  fitness  were  demonstrated  bv 
rigid  examination.  The  law  has  reduced  the  number  of 
"irregulars"  1  those  who  were  non-graduates  or  who 
were  licensed  by  reason  of  practice  prior  to  the  passage 
of  the  law  1,  from  351  in  1SS3  to  263  in  iSSS,  and  to  149  in 
1S90.  This  is  due  to  the  fact  that  the  advent  of  a  better 
educated  and  more  scientific  class  of  physicians  has 
driven  to  the  wall  the  larger  part  of  that  dangerous  ele- 
ment. 

The  especial  benefit  of  the  law  is  in  the  fact  that  the 
standing  of  the  physician  in  the  eyes  of  the  public  is  im- 
proved, for  practically  the  license'of  the  Board  is  a  cer- 
tificate of  ability  and  competency. 

My  experience  leads  me  to  believe  that  the  best  results 
_  the  line  of  higher  medical  education  can  be  derived 
from  compulsory  preliminary  examination  by  medical 
colleges,  the  lengthening  of  the  term  of  instruction,  and 
the  separation  of  the  diploma-granting  body  from' that 
which  gives  the  instruction.  The  establishment  of  a 
uniform  medical  law  in  all  States,  on  the  basis  of  that 
recommended  by  the  American  Medical  Association, 
would  be  a  great  benefit:  but  unfortunately,  the  time 
has  not  yet  come  to  render  it  feasible. 

In  conclusion  I  would  say  that  the  Minnesota  medical 


LAWS  REGULATING  MEDICAL  PRACTICE. 


[January  24, 


law  has  proven  its  efficiency,  has  raised  the  standard  of 
medical  education  within  the  borders  of  the  State,  has 
driven  out  and  prevented  the  influx  of  quacks,  has  pro- 
moted harmonv  among  physicians,  and  has  protected  the 
public.  I  would  call  your  attention  to  the  fact  that  North 
Dakota  has  adopted  a  law  identical  with  ours,  and  that 
Washington  has  one  based  upon  it. 

Dr.  George  S.  Homan,  Secretary  of  the  State 
Board  of  Health  of  Missouri,  reports  that  no  chan- 
ges have  been  made  in  the  law  regulating  the 
practice  of  medicine  in  that  State  since  its  enact- 
ment in  1883.  In  his  opinion  the  change  desir- 
able to  be  made  would  be  in  the  direction  of 
placing  this  duty  exclusively  in  the  hands  of  the 
medical  profession  of  the  State  through  a  body 
chosen  by  themselves— briefly  the  right  of  self- 
government. 

The  Boston  Medical  and  Surgical  Journal,  Oc- 
tober 9,  1890,  states  that  the  new  law  of  the  State 
of  New  Jersey,  which  went  into  operation  recent- 
ly, contains  some  features  worthy  of  note. 

The  execution  of  the  law  is  vested  in  a  Board  of  nine 
members,  appointed  by  the  Governor  for  terms  of  three 
years.  It  is  provided  that  the  Board  "shall  consist  of 
five  old  school,  three  homoeopaths,  and  one  eclectic," 
and  further,  that  "  no  member  of  any  college  or  univer- 
sity having  a  medical  department  shall  be  appointed  to 
serve  as  a  member  of  said  Board."  The  new  regulations 
apply  only  to  those  who  commence  practice  in  the  State 
after' the  passage  of  the  Act,  preceding  practitioners  being 
already  registered  under  a  previous  law. 

All  examinations  are  to  be  in  writing  and  both  "  sci- 
entific and  practical,  but  of  sufficient  severity  to  test  the 
candidate's  fitness  to  practice  medicine  and  surgery.  If 
the  applicant  intends  to  practice  homoeopathy  or  eclecti- 
cism, the  member  or  members  of  the  Board  of  those 
seh. "'Is  shall  examine  said  applicant  in  materia  medica 
and  therapeutics."  A  license  shall  not  issue  unless  the 
applicant  passes  an  examination  satisfactory  to  all  the 
members  of  the  Board. 

A  somewhat  peculiar  feature  of  the  law  provides  that 
any  applicant  refused  a  license  by  the  Board  "  for  failure 
on  examination,  may  appeal  from  the  decision  of  said 
Board  to  the  appointing  power  thereof,  who  may  there- 
upon appoint  a  medical  committee  of  review  consisting 
of  three  members,  one  from  each  school  of  medicine, 
who  shall  examine  the  examination  papers  of  the  said 
applicant,  and  from  them  determitie  whether  a  license 
should  issue,  and  their  decision  shall  be  final.  If  said 
commission  by  an  unanimous  vote  reverse  the  del.  11111 
on  of  the' Hoard,  the  Board  shall  thereupon  issue  a 
license  to  the  applicant.  The  expense  of  said  appeal 
shall  be  borne  by  the  applicant." 

The  Board  may  by  a  unanimous  vote  refuse  to  grant  a 
license  for  the  following  causes:  "Chronic  and  persis- 
tent inebriety,  the  practice  of  criminal  abortion,  convic- 
tion of  crime  involving  moral  turpitude,  or  for  publicly 
advertising  special  ability  to  treat  or  cure  diseases  which, 
in  the  opinion  of  said  Board,  it  is  impossible  to  cure-." 

The  power  of  the  Board  is  evidently  very  great,  but  it 
would  be  difficult  to  arrange  a  greater  number  oi 
guards.     Cn  fact,  it  may  be  a  question  whetherthe  safe- 
1  possible  injustice  are  not  so  great  as  to 
hamper  the  action  of  the  Board. 

In  New  York  State,  it  was  mentioned,  editorial- 
ly, in  Thk  Journal  of  the  American  Medk  u 
Association,  that: 

The  law  approved  by  the  Governor  on  Jum 
wiH  Hi  .1 1   a  new  era  not  only  in  New  York,  but,  im  idi  a 
tally   in  the  entire  country.  .  .  .  The  first  cardinal  point 
wbii  I.  oci  urs  to  as  is  this:  that  the  State  presumes  to  re 


affirm  and  to  emphasize  the  fact  that  it  alone  has  juris- 
diction over  the  practice  of  medicine  within  its  own  lim- 
its. It  may  not  only  determine  as  to  who  may  practice 
medicine,  but  it  also"  presumes  to  assert  what  the  qualifi- 
cations of  its  practitioners  shall  be.  In  the  exercise  of 
this  power  it  recognizes  the  responsibilities  which  it  as- 
sumes, and  seeks  to  make  the  best  provision.  In  the 
second  place,  it  proposes  to  redeem  the  profession  from 
illiteracy  by  the  requirement  of  a  satisfactory  prelimi- 
nary education  as  a  condition  to  an  entrance  upon  the 
study  of  medicine.  In  the  third  place,  it  provides  for  a 
definite  and  uniform  standard  of  examinations,  and  each 
and  every  student  must  attain  to  that  standard  as  a  con- 
dition to  graduation.  In  the  fourth  place,  it  divorces 
medical  teaching  from  the  licensing  power.  To  this  end 
the  Examining  Boards  are  under  the  supervision  of  spe- 
cial  examiner's,  who  are  appointed  by  the  Regents,  and 
who  themselves  cannot  be  members  of  those  Boards. 
And  finally,  it  compels  the  colleges  to  teach  their  stu- 
dents three  years,  instead  of  two. 

We  have,  then,  in  this  single  bill,  the  requirements  of 
preliminary  education;  a  definite  standard  for  examina- 
tions; a  separation  of  teaching  from  the  licensing  power; 
and  a  three  years'  college  course.  Thus  grandly  has  the 
State  redeemed  itself  from  what  had  threatened  her  as  a 
sad  misfortune. 

The  Medical  Record,  in  an  editorial  written  soon 
after  the  approval  of  the  bill,  is  not  wholly  satis- 
fied with  its  provisions.      It  states  that : 

The  law  allows  any  person  who  wishes  to  matriculate 
as  a  medical  student,  to  pass  his  preliminary  examination 
at  any  time  during  his  lust  three  years  of  study.  This 
practically  nullifies  the  law,  and  permits  any  man  to 
enter  upon  the  study  of  medicine  without  a  test  of  his 
educational  fitness.  The  law,  as  it  stood  before,  had  some 
defects  which  could  have  been  easily  remedied.  The  pres- 
ent amendment  totally  destroys  its  force.  It  was  secured, 
as  is  well  known,  through  the  political  influence  of  the 
managers  of  certain  medical  colleges  of  this  city,  and 
against  the  wishes  and  judgment  of  the  medical  profes- 
sion of  the  State  as  a  whole.  The  second  piece  of  per- 
nicious legislation  was  the  enactment  of  a  law  establish- 
ing three  Boards  of  Medical  Examiners.  This  was  .1.  ine, 
also,  despite  the  protests  of  the  vast  majority  of  the  med- 
ical profession,  including  even  many  prominent  homoeo- 
paths. We  trust  that  next  winter  there  will  be  concerted 
action  to  secure  the  repeal  of  the  triple  board  law.  A  law 
was  passed  providing  that  physicians  who  come  from  an- 
other State  must  pass  a  qualifying  examination  before 
beginning  to  practice  here.  This  law  is  a  wise  and  prop- 
er one. 

Dr.  W.  J.  H.  Bellamy,  of  Wilmington,  N.  C, 
writes  as  follows : 

No  one  can  now  practice  medicine  in  North  Carolina 
unless  licensed  by  our  Board  of  Medical  Examiners. 
The  penalty  lor  violation  of  law  is  tine  and  imprisonment. 
All  physicians  had  to  register  prior  to  January  i.  [890. 
Since  that  time  only  licentiates  can  register.  The  law 
seems  to  he  working  well. 

According  to  the  new  law  regulating  medical 
practice  in  North  Dakota,  no  one  can  practice 
medicine  until  he  has  passed  an  examination  in 
all  the  primary  and  final  branches.  No  one  will 
be  admitted  to  such  examination  until  he  has 
taken  at  Least  three  courses  of  lectures  of  six 
months  each. 

Oregon  has  a  Medical  Practice  Act,  and  it  was 
not  long  in  force  before  it  drove  from  one  of  the 
uities  a  certain  advertising  specialist.  A  local 
paper  commented  upon  this  result  as  follows  : 

Upon  what  hypothesis  the  Board  rejected  his  diplomas 


i89i.] 


LAWS  REGULATING  MEDICAL  PRAQTICE. 


113 


we  can't  .In  me.    Dr.  A is  one  of  the  oldest  specialists 

on  the  American  Continent,  and  seventeen  years  a«ohe 
ticed  in  tins  city  for  a  period  of  four  veins  He  has 
practiced  in  San  Francisco,  Philadelphia,  Chicago,  and 
many  other  cities  of  like  importance,  and  is  recognizi  .1 
as  .,nr  ,,1  the  greatest  eve  and  ear  physicians  of  this  age 
This  unfortunate  circumstance  will  certainly  be  an  un- 
welo  news  to  the  press  of  this  coast,  as  the 

doctO  lie  heaviest,  and  most   extensive  adver- 

tising physicians  in  America,  and  had  be  located  in  Port- 
land, as  he  expected  to  do,  he  would  have  advertised  in 
every  newspaper 'on  the  coast,  and  probably  spent  $50,000 
the  tirst  year  with  newspapers. 

The  Medical  Record  recently  referred  as  follows 
to  legislation  in  Oregon  : 

In  a  bill  to  regulate  the  practice  of  medicine,  recently 
introduced  111  the  Ore-,.,,  Legislature,  there  is  a  clause. 
providing  for  the  revocation  of  licenses  for  '-unprofes- 
sional conduct.''  which  is  defined  in  the  bill  as  follows' 
First,  the  procuring,  or  aiding  or  abetting  in  procuring 
a  criminal  abortion.  Second,  the  employing  <  if  what  are 
known  as  "cappers"  or  "steerers."  Third,  the  obtaining 
of  any  fee  on  the  assurance  that  a  manifestly  incurable 
disease  can  be  permanently  cured.  Fourth,  the  wilfully 
betraying  of  a  professional  secret.  Fifth,  all  advertising 
of  medical  business  in  which  untruthful  and  improbable 
statements  are  made.  Sixth,  all  advertising  of  any  med- 
icines or  of  any  means  whereby  the  monthly  periods  of 
women  can  be  regulated  or  the  menses  reestablished  if 
suppressed.  Seventh,  conviction  of  any  offence  involv- 
ing moral  turpitude.     Eighth,  habitual" intemperance. 

At  the  last  annual  meeting  of  the  Pennsylvania 
State  Medical  Society,  it  was  decided  that  the 
presidents  of  the  State  and  county  medical  soci- 
eties should  constitute  a  legislative  committee 
"to  secure  the  passage  of  a  medical  law  that  will 
give  protection  to  the  people  of  this  State  against 
incompetent  practitioners  of  medicine."  The 
present  registration  law  has  never  been  regarded 
as  anything  more  than  a  stepping-stone  to  re- 
strictive laws  of  greater  force  and  character. 

Dr.  H.  D.  Fraser,  Secretary  of  the  State  Board 
of  Health  of  South  Carolina,  reports  that  the  laws 
regulating  the  practice  of  medicine  have  under- 
gone no  recent  changes.  The  profession  is  satis- 
fied with  them,  as  they  seem  to  be  all  that  is 
necessary. 

Dr.  D.  E.  Nelson,  Secretary  of  the  State  Med- 
ical Society  of  Tennessee,  states  that 

The  only  laws  that  have  ever  been  passed  bv  the  legisla- 
ture of  this  State  were  passed  two  years  ago,  and  al- 
though imperfect  as  you  will  see.  or  have  seen,  thev 
work  a  great  deal  of  good,  and  I  think,  after  some  mod- 
ifications, which  we  hope  to  secure  at  this  winter  session 
of  the  legislature,  will  do  a  great  deal  more  of  good 
There  is  no  rebelling  against  the  law.  There  are  two 
points  in  our  law  which  I  think  should  be  changed.  One 
is  that  any  one  can  act  as  a  midzoife;  the  other  is  that 
all  parties  should  be  subjected  to  an  examination,  for, 
as  we  all  do  well  know,  some  unworthy  men  are  allowed 
to  practice  with  a  diploma  from  what  stands  as  a  <*ood 
school.  s 

Dr.  George  Cupples,  the  efficient  Chairman  of 
the  Committee  on  Legislation  of  the  Texas  State 
Medical  Association,  has  prepared  a  circular  let- 
ter to  the  medical  profession  of  that  State  in  refer- 
ence to  the  total  neglect  of  preventive  medicine 
in  Texas,  through  the  failure  of  previous  legisla- 
tures to  frame  enactments  on  sanitation,  notwith- 


,  standing  the  earnest  and  repeated  prayers  of  the 
I  profession;  the  widefelt  necessity  for  such  legis- 
lation, has  placed  that  great  and  wealthv  State 
I  in  a  contrast  anything  but  honorable,  with  the 
J  position  occupied  in  this  matter  by  no  less  than 
thirty-five  States  which  have  created  Boa 
Health,  charged  with  the  care  of  the  public 
health,  and  with  the  care  of  admitting  none  but 
competent  physicians  to  practice  medicine  and 
surgery  in  their  limits.  A  draft  of  a  law  is  offered 
by  this  committee  which,  it  is  hoped,  will  be 
adopted  by  the  legislature  when  it  convenes. 

The  Medical  Examining  Board  of  the  State  of 
Washington  consists  of  nine  members,  appointed 
by  the  Governor,  three  only  of  whom  are"  regular 
physicians.  A  committee  of  the  State  Medical 
Association  was  appointed  to  draft  a  communi- 
cation to  the  Governor  protesting  that  over  700 
of  the  800  practicing  physicians  in  the  State  are 
regular,  yet  the  profession  is  in  a  minority  on  the 
board,  and  asking  that  a  redistribution' may  be 
made  whereby  they  may  have  a  pro  rata  repre- 
sentation in  that  body. 

A  correspondent  of  the  Medical  Ne-^s,  under 
date  of  August  16,  1890,  referring  to  the  exami- 
nation in  that  State,  writes  that 

Laying  aside  all  prejudices,  a  perusal  of  some  of  the  ques- 
tions,,: tlie  "physio-medic"  and  eclectic  members  will 
show  the  injustice  of  having  men  of  that  class  ou  the 
board.  During  the  examination  the  writer  carefully 
copied  the  questions,  and,  in  some  instances,  the  sp* 
—for  the  question-sheets  came  to  us  in  the  handwriting 
of  the  members  by  whom  thev  had  been  prepared  The 
"physio-medic"  asked,  "What  is  pertusses?"' saA  also 
the  very  comprehensive  question.  "What  does  del 
dentition  prognosticate  ?"  To  this  last  I  could  not  'an- 
swer, nor  could  the  two  or  three  members  of  the  board, 
to  whom  I  afterward  repeated  the  question.  In  Dise 
of  Women  he  questioned  upon  "-leucarrhcea,"  "atnen- 
arrhcea,' '  and  '  'dysmenorrhea. ' '  Other  questions  of  his 
were,  "Define  mammary  obsess,"  and  "What  is  pelvic 
obsess?"  while  the  last  question  was  upon  "lacerated 
peroneum." 

The  eclectic  prepared  questions  on  anatomv  and  phy- 
siology, one  of  which  read  as  follows:  "Xame  the  divis- 
ions of  the  abdominal  aorta,  large  branches,  and  from 
where  does  the  lower  extremities  derive  there  blood  sup- 
ply?" Another  asked.  "What's  the  peremtory  condition 
of  pepsin  in  the  stomach?"  to  which  we  afterward  discov- 
ered he  wished  us  to  answer  "Hydrochloric  acid."  An- 
other question  was.  "What's  the'  effect  of  too  muc/i  red 
corpuscles  in  the  blood?" 

Under  the  heading  of  Preventive  Medicine  in  the  list 
of  questions  prepared  by  a  homceopath,  we  found  two  as 
follows:  "What  means  would  you  take  to  resuscitate 
from  an  overdose  of  chloroform?"  and  "How  would  you 
treat  a  case  of  poisoning  from  opium  or  morphia?"  He 
evidently  looks  at  the  subject  broadly,  and  thinks  that 
any  means  of  preventing  death  should  be  placed  under 
the  head  of  preventive  medicine. 

Dr.  T.  A.  Harris,  Parkersburg,  W.  Va.,  says  : 
I  think  that  with  time  the  laws  regulating  the  practice 
of  medicine  in  this  State  are  being  enforced.  At  first 
there  was  some  difficulty,  but  I  think  with  each  year 
that  difficulty  has  grown  less,  and  year  by  year  there  is 
less  objection  manifested  and  less"  disposition  to  evade 
them:  and  further,  the  body  of  the  people,  the  laity,  are 
more  and  more  disposed  to  support  them.  At  first  there 
was  a  feeling  that  certain   doctors  had  gotten  the   law 


ii4 


THE  BASIS  OF  SCIENTIFIC  MEDICINE. 


[January  24, 


passed  for  their  personal  advantage,  but  the  people  are 
coming  to  see  the  true  purpose  of  the  law;  and  it  is  cer- 
tain that  neither  this  nor  any  law  can  be  enforced,  in 
face  of  a  decided  popular  opposition. 

Dr.  J.  T.  Reeve,  Secretary  of  the  Wisconsin 
State  Board  of  Health,  writes  that  there  have 
been  no  new  laws  enacted  and  no  recent  changes 
have  been  made  in  the  laws  of  that  State. 

Dr.  Francis  W.  Campbell,  Secretary  of  the 
College  of  Physicians  and  Surgeons,  Province  of 
Ouebec,  states  that  the  present  Medical  Act  has 
been  in  force  in  this  Province  for  ten  years,  and 
seems  to  give,  upon  the  whole,  good  satisfaction. 
Dr.  R.  A.  Pyne,  Registrar  of  the  College  of 
Physicians  and  Surgeons,  of  Ontario,  Dominion 
of  Canada,  writes  as  follows: 

There  have  not  been  auv  changes  made  in  our  Medical 
4.ct  since  the  year  1S87,  when  we  got  some  amendments 
the  important  features  of  which  are.  limiting  the  time  of 
action  in  cases  of  malpractice.  The  other  part  of  the 
amendment  refers  principally  to  the  erasing  of  names 
for  unprofessional  conduct;  some  similar  powers  exist 
in  the  Imperial  Medical  Act,  and  every  year  they  strike 
the  names  of  practitioners  from  the  list  for  irregular  un- 
professional conduct. 

This  paper  concludes  the  series  of  annual  re- 
ports in  regard  to  "Laws  Regulating  Medical 
Practice  "  which  it  has  been  my  pleasant  duty  to 
prepare  'and  offer,  as  Secretary  of  the  Academy, 
annually  for  your  consideration,  and  which,  by 
my  resignation  of  the  office,  it  will  become  the 
duty  of  "my  successor  to  continue.-  A  retrospec- 
tive glance  at  these  annual  sketches,  from  their 
inception,  would  exhibit  evidence  of  gratifying 
progress  in  the  different  States  of  this  country  111 
the  effort  to  repress  quackery  and  to  protect  the 
public  against  the  imposition  of  the  ignorant  and 
incompetent. 


THE  BASIS  OF  SCIENTIFIC  MEDICINE 

AND  THE  PROPER  METHODS  OF 

INVESTIGATION. 

du< ,  ,  „td  in  the  tost- Graduate  Medical  School 

of  Ch;  ■  lg9'- 

BY  N.    S.   DAVIS.   M.D.,   I.I..D.. 

UF   CHICAGO,  ILL. 

Gentlemen  and  Members  of  the  Medical  Profession: 
We  have  assembled  this  evening  to  inaugurate 
the  first  formal  course  of  post-graduate  medical 
instruction  in  this  building,  recently  completed 
and  dedicated  to  the  interests  of  the  sick  and  to 
an  important  department  of  medical  education— 
a  department,  indeed,  that  had  its  first  beginnings 
in  this  city  and  in  connection  with  the  Chicago 
Medical  College. 

At  the  close  of  the  regular  annual  college  term 
of  the  Chicago  Medical  College  in  the  spring  of 

,t,:iiu.!i:.l  im-.-ting  Decembei  1    ■    (    appointed  0 


OHC   IU   >  .Mm....--    ...     ■ 

toting  m<  llA.W    \ 


1880    the  faculty  inaugurated  a  well   arranged 
course  of  four  or  six  weeks'  duration,  exclusively 
for  the  benefit  of  practitioners  or    graduates  in 
medicine.     The  course  was  largely  clinical  and 
practically  demonstrative,  but  included  also  a  re- 
view of  whatever  was  new  in  etiology,  pathology 
and  therapeutics.     It  was  attended  by  thirty -nine 
practitioners  from  this  and  seven  of  the  surround- 
ing States,  and  was  repeated  annually  for  several 
years      Its  marked  success  attracted  general  at- 
tention, and  speedily  led  to  the  institution  of  sim- 
ilar courses  in  connection  with  the  Rush  Medical 
College,  and  with  several  of  the  leading  medical 
colleges  in  other  cities.     This  rapid  increase  in 
the  number  of  such  courses  in  different  cities,  and 
nearly  at  the  same  season  of  the  year,  so  divided 
the  number  of  practitioners  who  could  afford  to 
leave  their  practice,  that  the  number  in  any  one 
college  was  too  limited  to  make  it  profitable  to 
maintain  them,  which  naturally  led  those  teach- 
ers connected  with  the  several  schools  and  hos- 
pitals to   unite  in  forming  separate   schools  for 
post-graduate  instruction,  in  which  short  courses 
to  limited  classes  could  be  given,  in  nearly  all 
parts  of  the  year,  and  on  all  practical  subjects  of 
importance.     The  important  department  of  post- 
graduate medical  education,  thus  inaugurated  in 
i  this  city  only  ten  or  eleven  years  since,  has  not 
I  only  demonstrated  its  importance  and  established 
j  its  "permanent  institutions,  called  polyclinics  and 
I  post  graduate  schools,  in  the  leading  cities  of  this 
I  country,  but  the  same  is  now  beginning  its  devel- 
opment in  London  and  other  places  in  Europe. 
1  It  is  appropriate,  therefore,  that  I  should  embrace 
this  opportunity  to  emphasize  both  its  origin  and 
gratifying  progress,  before  entering  upon  the  dis- 
cussion of  the  topic  announced  for  this  evening. 
What  constitutes  the  basis  of  scientific  medi- 
cine, and  what  methods  of  investigation  are  best 
adapted  for  its  study  and  more  complete  develop- 
ment, are  questions  worthy  of  most  thoughtful 
consideration.     There  are  still  those,  both  in  and 
out  of  the  profession,  who  deny  that  medicine  has 
any  scientific  character,  and  who  talk  and  write 
of  old  and  new   "schools  of  medicine"  consist- 
ing of  the  theoretical  dogmas  of  some  dreamers 
of  past  generations.     But  in  doing  so  they  only 
betray  the  .shallowness  of  their  own  attainments, 
and  especially  their  ignorance  of  the  real  medi- 
cine of  to-day. 

If  there  be  no  scientific  basis  for  modern  medi- 
cine, then  there  are  no  sciences  known  to  the 
human  family  except  those  of  pure  mathematics; 
for  the  facts  and  materials  that  constitute  the  dif- 
ferent branches  of  medicine  are  taken  or  segre- 
gated from  every  other  science  or  department  of 
human  knowledge.  Some  sciences,  as  the  math- 
ematical, are  composed  of  such  facts  and  proposi- 
tions as  are  capable  of  being  so  placed  in  relation 
to  each  other  as  to  admit  of  the  deduction  of  fixed 
and    uniform    conclusions,  and  hence    are  called 


i89i.] 


THE  BASIS  OF  SCIENTIFIC   MEDICINE. 


"deductive  sciences."  Others  are  composed  of 
so  great  a  variety  of  facts  or  elements,  many  of 
which  are  influenced  by  varying  or  unstable 
causes,  that  they  admit  only  of  careful  compari- 
son and  classification  in  such  manner  as  to  admit 
of  conditional  inductions  or  inferences  instead  of 
uniform  conclusions.  Hence,  since  the  days  of 
Bacon,  they  have  been  called  "inductive  sci- 
ences." To  this  division  belong  geolo^ 
any,  and,  indeed,  all  ihe  branches  of  knowledge 
concerning  the  vegetable  and  animal  kingdoms 
of  nature.  No  one  of  these  branches  of  knowl- 
edge or  natural  sciences  are  complete.  That  is, 
all  the  facts  and  relations  belonging  to  any  one 
of  them  have  not  been  fully  observed  and  clas- 
sified ;  yet  no  one  denies  the  propriety  of  call- 
ing them  sciences,  incomplete,  it  is  true,  but  each 
progressing  towards  completion  with  every  addi- 
tional accurately  observed  fact  or  improved  means 
and  method  of  investigation.  Every  recognized 
branch  or  department  of  modern  medicine  is  com- 
posed of  facts  and  principles  belonging  to  the 
wide  domain  of  natural  and  physical  sciences  and 
their  application  to  the  relief  of  human  suffering, 
and  consequently  is  fully  entitled  to  the  name  of 
' '  inductive  science. ' '  Until  full  and  accurate  dis- 
sections had  revealed  all  the  structures  of  the  hu- 
man body  and  their  relations  to  each  other,  and 
observation  and  experiment  had  revealed  the  uses 
or  functions  of  each  part,  there  could  be  no  sci- 
ence of  human  anatomy  or  physiology.  And 
until  the  progress  of  elementary  and  organic 
chemistry  had  revealed  the  composition  of  the 
fluids  and  solids  of  the  human  body  in  health 
and  disease,  there  could  be  no  science  of  med- 
ical chemistry  and  materia  medica.  All  these 
have  had  their  origin  and  development  during 
the  last  three  centuries.  And  yet  human  an- 
atomy and  physiology  including  histology,  and 
medical  chemistry  and  materia  medica,  constitute 
the  basis  of  all  scientific  medicine.  All  that  is 
valuable  or  established  in  etiology  and  sanitation 
has  resulted  from  the  application  of  medical  chem- 
istry and  histology  to  the  study  of  the  causes  of 
disease  ;  pathology  and  pathological  anatomy  are 
but  abnormal  physiological  and  anatomical  con- 
ditions ;  therapeutics  consists  in  the  adjustment 
of  the  materials  of  materia  medica  to  the  control 
of  pathological  processes  ;  and  the  details  of  op- 
erative surgery  and  midwifery  are  but  the  appli- 
cation of  anatomical  and  physiological  knowledge 
to  the  correction  of  deformities,  the  relief  of  in- 
juries and  the  removal  of  obstructions  to  which 
the  human  body  may  be  liable. 

Hence,  I  repeat  that  those  departments  of  the 
great  fields  of  natural  and  physical  sciences  known 
as  anatomy,  histology,  physiology,  pathology, 
medical  chemistry  and  materia  medica,  constitute 
the  acknowledged  basis  of  modern  medicine;  while 
therapeutics  or  practical  medicine,  surgery,  and 
sanitation  or  preventive  medicine,  are  strictly  ap- 


plied sciences  developed  by  the  same  methods  of 
observation,  experiment  and  induction  that  have 
brought  into  existence  ill  the  other  inductive  sci- 
Di.  W.  X.  Broadbent,  in  his  interesting 
address  before  the  British  Medical  Association  at 
its  recent  meeting  in  Birmingham,  on  "Thera- 
peutics as  an  Applied  Science,"  says  "  that  ther- 
apeutics must  always  belong  to  the  order  of  ap- 
plied sciences,  and  will  bear  much  the  same 
relation  to  physiology  in  an  extended  sense  as 
engineering  to  mathematics.  Just  as  engineering 
is  applied  mathematics,  therapeutics  will  be  ap- 
plied physiology."  If  in  the  foregoing  paragraph, 
and  throughout  his  address.  Dr.  Broadbent  had 
substituted  the  word  pathology  for  physiology, 
his  declarations  would  appear  to  me  far  more  cor- 
rect. Physiology  is  the  science  that  embraces  all 
the  facts,  principles  and  laws  relating  to  the  healthy 
or  normal  processes  or  changes  taking  place  in 
living  beings ;  and  may  be  properly  styled 
the  science  of  health.  Pathology  is  the  science 
that  embraces  all  the  known  facts,  principles 
and  laws  relating  to  such  deviations  from  the 
normal  or  physiological  processes  as  constitute 
disease,  and  is,  therefore,  physiology  applied  to 
the  study  of  abnormal  conditions.  Therapeutics 
relates  to  the  application  of  remedies  for  the  con- 
trol, not  of  healthy  or  physiological  processes, 
but  of  morbid  or  pathological  conditions,  and  is 
consequently  applied  pathology. 

Dr.  Broadbent  fairly  concedes  this  when  in  an- 
other part  of  his  address  he  says:  "By  thera- 
peutics we  mean  all  those  measures  by  which  we 
combat  and  endeavor  to  subdue  disease,  and  if  we 
ask  what  would  fulfil  the  conditions  of  therapeu- 
tics as  a  science*  the  answer  would  be,  a  complete 
knowledge  of  the  processes  of  disease  on  the  one 
hand,  and  of  the  mode  of  action  of  remedies  on 
the  other." 

This  is  a  concise  and  correct  statement  of  the 
real  relations  of  therapeutics  to  pathology,  and 
clearly  points  to  those  methods  of  investigation 
by  which  the  scientific  character  of  both  can  be 
rendered  more  nearly  complete.  As  the  "processes 
of  disease"  (pathology)  are  simply  deviat: 
some  direction,  from  the  normal  standard  of  the 
processes  of  health  (physiology),  a  successful 
study  of  the  former  must  have  for  its  basis  or 
point  of  departure  a  complete  knowledge  of  the 
latter.  In  other  words,  our  knowledge  of  the 
physiological  or  natural  processes  taking  place  in 
every  organ  and  structure  of  the  human  body, 
and  the  agencies  by  which  they  are  maintained, 
must  be  complete,  before  we  can  appreciate  with 
clearness  and  certainty  the  pathological  or  abnor- 
mal processes  taking  place  in  the  same  structures, 
and  the  causes  that  may  produce    them. 

The  present  advanced  condition  of  organic  and 
analytical  chemistry,  with  the  varied  instruments 
of  precision  founded  on  mathematical  and  physical 
laws,  furnish  the  means,  if  correctly  and  patiently 


n6 


THE  BASIS  OF  SCIENTIFIC  MEDICINE. 


[January  24, 


directed  in  the  proper  lines  of  experimental  re- 
search, for  making  our  knowledge  of  human  physi- 
ology as  complete  as  an  inductive  science  can  be 
made.  And  the  same  means,  applied  with  the  same 
accuracy  and  patience  to  the  investigation  of  the 
morbid  processes  constitutingdisease,  wouldspeed- 
ily  render  our  knowledge  of  pathology  sufficiently 
complete  to  constitute  a  reliable  basis  for  an  ap- 
plied science  of  therapeutics. 

I  will  go  one  step  farther,  and  venture  the  as- 
sertion that  if  the  same  modern  chemical,  philo- 
sophical and  mathematical  resources  for  observa- 
tion and  experimental  research,  were  carefully 
and  accurately  directed  to  the  study  of  etiology, 
or  the  causes  of  disease,  that  important  depart- 
ment of  the  great  field  of  medicine,  hitherto  filled 
with  a  chaotic  aggregation  of  partially  observed 
facts,  fanciful  speculations  and  false  assumptions, 
would  soon  attain  all  the  characteristics  of  a  true 
science,  and  furnish  a  more  reliable  basis  for  san- 
itation, preventive  medicine,  and  one  of  the  most 
important  indications  or  purposes  in  the  treatment 
of  disease. 

One  of  the  most  important  obstacles  to  real 
progress  in  scientific  development  and  accuracy 


is  dissipated,  and  that  the  natural  temperature  is 
the  balance  or  average  result.  Consequently,  ab- 
normally high  temperature  must  result  either 
from  a  diminution  of  the  processes  of  heat  dissi- 
pation, or  from  an  increase  of  those  of  heat  pro- 
duction, or  from  an  unequal  alteration  of  both. 
It  follows  that  one  remedial  agent,  when  prop- 
erty used,  will  act  as  an  antipyretic  by  increasing 
heat  dissipation,  and  another  by  diminishing  the 
heat  production  ;  and  the  true  scientific  basis  for 
choice  of  remedies  in  a  given  case  of  pyrexia,  is 
a  clear  knowledge  of  the  modus  operandi  of  the 
remedial  agents,  and  an  equally  clear  apprecia- 
tion of  the  processes  on  which  the  abnormal  tem- 
perature depends. 

Another  serious  obstacle  to  scientific  progress 
consists  in  the  frequent  formulation  of  inductions, 
or  more  properly  assumptions  for  practical  guid- 
ance, founded  on  an  inadequate  number  of  facts, 
and  sometimes  on  mere  analogies.  Thus,  when 
in  the  progress  of  organic  and  physiological  chem- 
istry, it  had  been  fully  demonstrated  that  the  chief 
proximate  elements  of  our  food  could  be  divided 
into  two  classes,  one  of  which  was  composed  es- 
sentially  of  oxygen,   carbon   and  hydrogen,  and 


is  the  want  of  perseverance  on  carefully  devised  |  the  other  of  these  three  with  the  addition  of  ni- 
plans  for  insuring  completeness  of  investigation   trogen,  the  first  were  called  hydro  carbonaceous 


before  announcing  results 

Almost  every  problem  within  the  domain  of 
etiology,  pathology  and  therapeutics,  is  complex 
from  the  number  of  the  elements  requiring  con- 
sideration for  its  correct  solution,  and  soriietimes 
the  coincident  work  of  different  individuals  to 
secure  the  same  end.  Very  much  of  our  scientific 
and  experimental  work  is  done  in  fragments,  and 
necessarily  results  in  the  development  of  isolated 
facts  and  partial  views,  filling  the  pages  of  our 
literature  with  ever  changing  and  often  contradic- 
tory inductions.  For  example,  during  the  last 
two  decades  of  time  it  has  been  claimed  that  ab- 
normal temperature  or  pyrexia  is  the  chief  patho- 
logical factor  in  the  general  fevers;  and  by  logical 
inference  that  antipyretics  constitute  the  chief 
remedies.  Hence,  as  often  as  the  pharmaceutical 
laboratories  developed  a  new,  complex,  artificial 
compound  of  the  coal-tar  series,  and  the  experi- 
mental therapeutist  proved  it  capable  of  reducing 
the  temperature  of  the  body,  it  was  applied  with 
the  greatest  freedom  for  the  control  of  the  pj  rexia 
of  all  general  fevers.  The  two  isolated  facts  of 
high  temperature  and  the  antipyretic  property  of 
the  remedy,  were  the  sole  guides  of  the  physician, 
and  in  many  instances  to  the  ultimate  detriment 
of  his  patients.     That  complete  knowledge  of  the 


and  the  latter  nitrogenous  foods.  And  as  the  or- 
ganized elements  of  animal  tissues  were  composed 
of  the  same  four  elements,  it  was  assumed  that 
the  nitrogenous  elements  of  food  were  appropri- 
ated to  the  growth  and  repair  of  such  tissues;  and 
as  oxygen  disappeared  through  the  air-cells  of 
the  lungs  and  was  replaced  largely  by  carbonic 
acid,  as  in  combustion  out  of  the  body,  it  was  <w- 
suiued  with  equal  positiveness  that  the  hydro-car- 
bonaceous food  elements  united  with  oxygen  in 
the  living  bod}',  resulting  in  the  formation  of  car- 
bonic acid  and  water  and  the  evolution  of  heat, 
and  hence  were  called  respiratory  foods. 

The  only  facts  clearly  demonstrated  by  experi- 
mental investigation  were  that  the  oils,  starch, 
sugar  and  gum  in  our  food  were  hydro  carbons, 
and  that  the  albumen,  fibrin,  casein,  gluten,  etc., 
were  nitrogenous,  on  the  one  side ;  and  on  the 
other,  that  the  living  animal  structures  were  ni- 
trogenous, with  a  constant  consumption  of  oxy- 
gen and  liberation  of  carbonic  acid  and  heat. 
The  inductions  from  these  facts,  that  the  carbona- 
ceous food  elements  only  were  converted  into  car- 
bonic acid,  water  and  heat  :  and  that  the  nitroge- 
nous were  converted  into  tissues,  were  simple 
theoretical  assumptions,  without  the  support  of  a 
single  well  devised  series  of  experiments  for  their 


processes  of  disease  mentioned  by  Dr,  Broadbent,  demonstration,  while  many  accurately  observed 

requires  not  only  the  fact  of  high  temperature  or  facts    militate  against  their  correctness.     These 

pyrexia,  but  also  the  processes  by  which  it  is  pro-  theoretical   assumptions  were  not  limited  to   the 

duced  in  each  variety  of  fever.      Physiology  has  food  elements  I  have  named,  all  of  which  are  the 


taught  us  that  in  the  living,  healthy  animal  body 
there  are  in  constant  operation  processes  by  which 
heat  is  produced,  and  other  processes  by  which  it 


products  of  vegetable  or  animal  growth,  but  were 
extended  to  main  other  substances  of  entirely  dif- 
ferent origin  merely  on  account  of  analogous  chem- 


I89i.] 


THE  BASIS  OF  SCIENTIFIC  MEDICINE. 


117 


ical  composition.  For  example,  the  chemist  read- 
ily demonstrated  that  all  the  varieties  of  alcohol 
were  composed  of  oxygen,  hydrogen  and  carbon, 
and  consequently  were  chemically  pure  hydro  car- 
bons ;  and  as  the  ethylic  or  common  alcohol  was 
being  largely  used  in  fermented,  and  distilled 
drinks,  it  was  directly  assumed  that  it  united 
with  oxygen  in  the  living  system,  resulting  in 
the  production  of  carbonic  acid,  water  and  heat; 
and  was  placed  in  the  front  rank  of  respiratory 
foods.  These  simple  theoretical  assumptions, plau- 
sibly illustrated  by  many  supposititious  chemical 
formulae,  have  occupied  a  prominent  position  on 
the  pages  of  both  medical  and  general  literature 
from  the  days  of  Baron  Liebig  to  the  present  time. 
And  yet,  all  the  carefully  devised  and  patiently 
executed  experiments  of  the  chemico-physiolo- 
gists  of  Europe  and  America  have  only  proved 
that  the  hydro-carbons  derived  from  vegetable 
and  animal  growth  undergo  molecular  or  meta- 
bolic changes  in  passing  through  the  digestive 
organs  before  appearing  as  natural  elements  of 
the  blood,  while  those  derived  from  fermentation 
or  retrograde  processes  undergo  no  such  mole- 
cular changes  in  the  digestive  organs,  but  are 
rapidly  imbibed  and  appear  unchanged  in  the 
blood,  thereby  demonstrating  that  mere  analogy 
of  chemical  composition  can  afford  no  safe  ba- 
sis for  the  inference  that  the  same  analogy  will 
apply  to  their  behavior  when  taken  into  the  liv- 
ing body.  I  may  add  that  these  numerous  ex- 
perimental researches,  aided  by  all  the  modern 
instruments  of  precision,  have  failed  to  develop 
any  evidence  that  the  presence  of  the  alcoholic 
class  of  hydro- carbons  in  the  living  system  is  pro- 
ductive of  either  carbonic  acid,  water,  heat  or  any 
other  kind  of  force,  but  the  reverse.  Indeed,  the 
plain  tendency  of  present  experimental  researches 
is  towards  demonstrating  the  fact  that  the  vege- 
table kingdom  only  can  assimilate  and  grow  from  j 
inorganic  matter  and  the  products  of  retrograde 
■or  destructive  processes,  while  the  animal  king- 
dom assimilates  and  appropriates  to  itself  only 
the  products  of  vegetable  and  animal  growth. 

Still  another  potent  hindrance  to  scientific  pro- 
gress,is  the  constant  tendency  to  concentrate  all  at- 
tention on  the  results  of  any  new  line  of  investiga- 
tion that  may  be  started  to  the  neglect  or  rejection  of 
facts  and  inductions  previously  well  established, 
and  their  value  verified  by  abundant  clinical  ob- 
servation. Up  to  the  close  of  the  first  quarter  of 
the  present  century  the  processes  of  disease  were 
studied  and  classified  by  a  patient  and  close  ob- 
servation of  the  actual  symptoms  or  phenomena 
of  disease  at  the  bedside  of  the  patient; -and  the 
effects  of  remedies  were  determined  by  careful  study 
of  the  results  of  their  empirical  use  with  only  the 
limited  aid  offered  by  general  chemistry.  The 
same  methods  of  observation  were  applied  to  the 
study  of  the  causes  of  disease,  especiall}'  in  rela- 
tion to  the  conditions  of  the  climate,  soil,  water, 


seasons  of  year,  age,  sex  and  occupation.  It  was 
preeminently  the  era  of  symptomatology  and 
acti\  e  medication,  during  which  were  established 
many  important  facts  in  both  pathology  and 
therapeutics,  and  was  accompanied  by  fair  suc- 
cess in  the  treatment  of  disease  as  reliable  records 
will  show.  But  with  the  second  quarter  of  the 
century  came  the  brilliant  studies  in  morbid 
anatomy  led  by  Louis,  Chomel,  Gerhard  and 
others,  resulting  in  more  accurate  differentiation 
of  diseases  and  more  exact  knowledge  of  the 
structural  changes  in  the  several  stages  of  their 
progress. 

To  this  was  soon  added  the  application  of  the 
microscope  to  the  study  of  minute  anatomy,  both 
normal  and   abnormal;  and   hence  the  study  of 
morbid   processes  at  the    bedside    rapidly   gave 
place  to  the  study  of  the  results  of  morbid  pro- 
cesses in  the  morgue  and  in   the  laboratory,  cul- 
minating in  the  evolution  of  the  cellular  pathol- 
ogy of  Virchow  and  the    substitution  of  path- 
ological  anatomy   for  pathology    proper.      Just 
in  proportion  as  these  structural  changes  and  the 
associated  cell  proliferations  came  to  occupy  the 
attention   of  the  profession,  carrying  with  them 
the  thought  that  diseases  were  fixed  processes  of 
development,  maturity  and  decline;  in  the  same 
ratio  active  interference  with  remedies  was  dis- 
couraged and  an  era  of  therapeutic  skepticism, 
expectancy,  or  faith  in  the  vis  medicatrix  natures 
as  presented  in  the  popular  writings  of  Bigelow, 
Forbes  and  Holmes,  ensued.  All  the  active  ther- 
apeutic measures  of  the  preceding  era  were  de- 
clared unnecessary  or  injurious  and  were  super- 
seded by  fresh   air,  more  cleanliness,  more  food, 
and  patience  until  the  climax  was  reached  in  the 
declaration  of  Chambers,  that  all  disease  is  a  dim- 
inution of  life,  and  all  proper  treatment  is  to  sustain 
or  support  the  life.  Consequently  food  and  so  called 
stimulants  became  as  popular  as  depletion  and  evac- 
uants  had  been  during  the  precedingera.  But  only  a 
few  decades  were  allowed  to  pass  before  the  con- 
tinued use  of  the  microscope  in  the  study  of  path- 
ological anatomy,  revealed  the  fact  that  in  all  the 
protracted  fevers,  or  acute  general  diseases,  ex- 
tensive molecular  and  tissue  degenerations  were 
developed  with  an  increasing  ratio  of  mortality. 
This  led  to  the  erroneous  opinion  that  the  pro- 
tracted high  temperature  of  pyrexia  was  the  cause 
of  such  general  molecular  degeneration,  and  as  a 
necessary  inference,  that  the  most  important  pur- 
pose to  be  gained  by  treatment  was  to  hold  the 
temperature   in   check  by  antipyretic  measures. 
The  cold  douche,  the  cold  bath,  the  cold  spong- 
ing; sedative  or  large  doses   of  quinine,  salicin, 
and  other  antipyretic  remedies  were  so  rapidly 
brought  into  use.  that  the   third   quarter  of  the 
century  had  hardly   closed  before  acute  diseases 
were  being  treated  with  more  active  agents  and 
more  heroic  doses  of  medicine  than  during  any 
part  of  the  first  quarter.      This  reaction  towards 


u8 


THE  BASIS  OF  SCIENTIFIC  MEDICINE. 


[January  24, 


heroic  medication  has  been  greatly  increased  by 
the  application  of  the  microscope  to  the  study  of 
etiology,  and  the  consequent  rapid  increase  of 
knowledge  concerning  the  relation  of  certain 
microorganisms  to  the  prevalence  of  diseases. 

The  discoveries  of  Pasteur,  Koch,  Eberth  and 
many  others,  in  this  field,  have  so  completely 
concentrated  the  attention  of  the  profession  on 
bacteriology  and  pathogenic  microorganisms,  and 
the  consequent  search  for  antiseptics  and  germi- 
cides as  therapeutic  agents,  that  the  bacteriology 
and  bacteriological  therapeutics  of  to  day  have  as 
full}-  superseded  the  pathological  anatomy  with  its 
therapeutic  skepticism  of  thirty  years  since,  as 
did  the  the  latter  symptomatology  and  antiphlo- 
gistic therapeutics  of  the  first  half  of  the  century. 
And  the  century  bids  fair  to  close  with  the  pro- 
fession combating  disease  not  only  with  as  active 
or  heroic  measures,  but  also  with  many  of  the 
same  remedies  that  were  most  relied  upon  at  its 
beginning.  Then,  opiates,  to  relieve  pain,  the 
two  chlorides  of  mercury  and  iodine  to  control 
morbid  processes,  and  quinine  and  kindred  alka- 
loids to  subdue  fevers,  were  the  chief  remedies  in 
the  hands  of  the  general  practitioner;  and  now, 
under  the  names  of  anodynes,  antipyretics,  anti- 
septics and  germicides  these  same  remedies  are 
being  used  with  even  greater  freedom  than  at  any 
former  period  in  medical  history.  It  is  not  the 
adoption  and  vigorous  prosecution  of  these  suc- 
cessive methods  of  investigation  during  the  pres- 
ent century  that  constitutes  an  evil,  for  each 
was  necessary  and  has  added  greatly  to  the  stock 
of  most  important  medical  knowledge.  But  the 
evils  result  from  the  spirit  of  exclusiveness,  dog- 
matism and  indulgence  in  positive  inductions 
from  insufficient  facts  that  characterize  their  pur- 
suit, and  the  consequent  neglect  or  disparage- 
ment of  all  that  had  been  done  before.  It  is  the 
indulgence  of  this  spirit,  that  makes  those  enter- 
ing the  profession  during  any  given  era,  regard 
its  methods  of  investigation  and  their  results,  as 
the  chief  topics  worthy  of  their  attention  and 
strongly  encourages  the  neglect  of  medical  his- 
tory and  begets  a  narrowness  of  mental  vision 
highly  detrimental  to  true  medical  progress.  In 
stead  of  permitting  every  new  appliance  or 
method  of  inquiry  that  opens  before  US  a  new  or 
additional  field  for  investigation  to  displace  or 
supersede  all  others  and  engross  our  whole  atten- 
tion, the  true  philosophical  spirit  of  inquiry  re- 
quires us  to  hold  all  the  facts  and  inductions  that 
have  appeared  well  established  in  one  era  until 
those  of  the  next  have  been  studied  in  all  their  as- 
pects and  relations  to  each  other  and  to  all  that 
had  preceded.  A  close  adherence  to  this  rule 
would  effectually  check  the  strong  tendencj  t<> 
draw  hasty  conclusions  from  an  inadequate  num- 
ber of  facts  or  observations,  and  the  results  of 
every  new  line  of  inquiry  would  constitute  real 
additions  to  our  knowledge,  supplying   previous 


defects,  enabling  us  to  make  new  or  more  accur- 
ate applications  of  old  remedies  or  facts,  and 
sometimes  furnishing  both  new  and  valuable  agents 
and  new  principles  to  guide  their  practical  applica- 
tion. All  the  departments  of  medicine  would 
thus  progress  in  more  harmony,  and  medical  lit- 
erature would  become  more  free  from  mere  theo- 
retical assumptions  and  contradictory  statements. 
A  more  thorough  study  of  the  history  of  medi- 
cine, and  in  consequence, a  greater  familiarity  with 
the  successive  steps  or  stages  in  the  development  of 
its  several  branches,  would  enable  us  to  see  more 
clearly  the  real  relations  and  value  of  any  new 
fact,  induction,  or  remedial  agent  that  might  be 
proposed.  It  would  also  enable  us  to  avoid  a  com- 
mon error  of  regarding  facts,  propositions  and 
remedies  presented  under  new  names,  as  really 
new,  when  they  had  been  well  known  and  used 
long  before,  but  in  connection  with  other  names 
or  theories.  Such  errors  are  of  frequent  occur- 
rence and  occupy  prominent  places  in  the  med- 
ical literature  of  to-day.  The  true  spirit  of  scien- 
tific investigation  welcomes  every  new  fact,  sug- 
gestion, or  remedy,  but  holds  it  under  careful 
scrutiny  until  all  its  relations,  chemical,  histolog- 
ical, physiological  and  pathological  have  been  well 
considered.  Is  a  new  remedy  proposed  for  the 
treatment  of  an  important  and  well  known  dis- 
ease, we  need  to  know  its  chemical  composition 
and  affinities  or  reactions,  its  histological  devel- 
opment if  of  organic  origin,  and  its  relation  to- 
other substances  of  similar  character,  to  enable 
us  to  proceed  intelligently  and  safely  with  its 
therapeutic  use.  Otherwise  our  use  of  the  rem- 
edy must  be  purely  empirical  or  blindly  experi- 
mental. 

A  remarkable  instance  of  this  kind  is  at  pres- 
ent occupying  the  attention  of  the  entire  profes- 
sion and  a  large  part. of  the  public.  The  emi- 
nent bacteriologist,  Dr.  Koch,  has  prepared,  and 
presented  for  use,  a  remedy  that  he  thinks  will 
cure  pulmonary  tuberculosis,  especially  in  its 
earlier  stages,  and  specifies  the  dose,  the  mode  of 
administration,  and  the  symptoms  or  effects  pro- 
duced by  it,  but  positively  declines  to  reveal  its 
chemical  composition,  its  mode  of  preparation,  or 
even  the  class  of  substances  to  which  it  belongs. 
Consequently  members  of  the  profession  must  use 
it  conscious  that  they  are  groping  in  the  dark,  or 
they  must  adhere  to  the  time  honored  rule  against 
using  secret  remedies  and  let  it  alone  until  the 
author  and  his  immediate  advisers  fully  make 
known  the  nature  and  preparation  of  the  remedy 
and  the  clinical  proof  of  its  efficacy.  Taking  the 
remedy,  however,  simply  as  proposed  by  the  au- 
thor, it  will  require  a  most  careful  and  connected 
clinical  experimentation  through  a  period  of  five 
or  ten  years,  to  determine  its  actual  value  as  a 
remedy  for  tuberculosis.  A  few  weeks  of  its  ad- 
ministration is  said  to  remove  the  more  obvious 
symptoms,  as  cough,  expectorating,  etc.;  but  the 


i89r.J 


THE  BASIS  OF  SCIENTIFIC  MEDICINE. 


ng 


physical  signs  of  tubercular  accumulations  in  the 
lungs  or  elsewhere  cannot  be  expected  to  entirely 
disappear  in  less  than  from  six  to  twelvemonths, 
and  the  question  of  relapses  cannot  be  reliably 
determined  until  from  three  to  five  years  have 
passed.  Should  relapses  occur,  as  seems  probable 
from  some  indications  already  reported,  the  col- 
lateral effects  of  the  remedy  on  the  kidneys,  the 
blood,  and  the  nervous  system,  when  resorted  to 
every  few  weeks  or  months  to  arrest  such  relapses 
will  be  required  to  be  studied  with  equal  care. 

The  general  symptoms  produced  by  the  hypo- 
dermic use  of  the  remedy, as  described  by  Dr.  Koch 
and  his  co-laborers,  strongly  resemble  those  of  an 
actively  poisonous  ptomaine  or  peptotoxiue,  and 
hence  it  is  generally  supposed  to  be  derived  from 
the  cultures  of  the  tubercular  bacilli.  Onlvtwo  rea- 
sons have  been  assigned  for  refusing  to  publish  a 
complete  statement  of  the  composition  and  mode 
of  preparation  of  the  remedy.       These,  as  given 
more  fully  by  Von  Gossler  as  the  official  repre- 
sentative of  the  Prussian  government,  are,  first, 
that  the  actively  poisonous  nature  of  the  remedy 
makes  it  necessary  that  the  utmost  care  and  skill 
be  exercised  both  in  its  preparation  and  use;  and 
second,  that  Dr.  Koch  has  thus  far  not  been  able  to 
render  his  process  of  manufacture  sufficiently  com- 
plete to  obtain  hisjiuid  of  uniform  strength  or  qual- 
ity and  must  consequently  test,  by  actual  trial, each 
product  before  it  can   be  given  out  for  clinical 
use.     The  first  of  these  reasons  is  the  same  as 
that  urged  by  every  manufacturer  of  proprietary 
and  trade  mark  medicines  throughout  Christen- 
dom, namely,  their  superior  skill  in   manipulat- 
ing the  process  of  manufacture  and  the  danger 
that  ignorant  parties  would   injure  someone  °bv 
attempting  to  compete  with  them   if  their  pro- 
cesses were  given  freely   to   the    world.       The 
second  reason,  however,  is  one  of  real  importance, 
and  should  have  caused  Dr.  Koch   to  adhere  to 
his  own  alleged  inclination  not  to  announce  the 
remedy  at  all,  until  his  processes  for  its  produc- 
tion were  sufficiently  complete  for  reliable  "results. 
The  present  status  of  chemico-bacteriological  in- 
vestigations show  that  there  are  various  active 
or  poisonous  ptomaines  and  albumose  in  bacteri- 
ological cultures,  morbid  products,  and  in  normal 
secretions,  the  isolation  and  preservation  of  which 
can  generally  be  accomplished  only  by  compli- 
cated and  delicate  processes.     And  if  Dr.  Koch's 
remedy   belongs  to  this  class  of   substances,    it 
would  not  be  strange  if  its  author  should  find 
himself  unable  to  perfect  any  process  by  which 
it  can  be  produced  in  sufficient  quantity  and  suf- 
ficiently uniform  quality  to  be  entrusted  on  the 
market  as  a  remedial  agent. 

Investigations  have  thus  far  indicated  but  four 
methods  of  treating  directly  diseases  produced  by 
pathogenic  germs. 

The  first  is  by  such  remedies  as  are  capable  of 
destroying  the  germ  by  direct  contact;  the  sec- 


ond, such  as  if  introduced  into  the  living  system 
prior  to  any  active  influence  of  the  specific  germs, 
are  capable  of    exhausting   it>   susceptibility  to 
them,  and  thereby  preventing  the  disease,  as  in 
the   methods  of  Jenner  and   Pasteur;  third,   by 
when  introduced  into  the  svstem  during 
the  progress  of  the  disease  so  actively  attacks  and 
destroys  the  living  plasma  or  tissue  material   on 
which  the  propagation  of  the  germs  depend,  that 
their  progress  is  arrested  witli  a  rapid  subsidence 
of  the  morbid  processes  and  exfoliation  or  excre- 
tion of  the  necrosed  material;  and  the  fourth,  by 
simply  accumulation  of  an  excess  of  the  ptomaine 
or  product  of  the  germ   itself  as  illustrated   in 
vinous  fermentation   when  the  alcohol  accumu- 
lates beyond  a  certain  ratio  and  stops  the  process 
although  there  mav  be  present  plenty  of  ferment- 
able material  in  the  liquid.     The  remedy  pro- 
posed by  Dr.  Koch  evidently  belongs  to  the  third 
class,  creating  prompt  general  irritation  or  febrile 
acti.-n   followed   by  decided   necrosis  or  dissolu- 
tion of  the  tissue  affected  by  the  bacilli,  thereby 
diminishing  their  food  and  carrying  away  large 
numbers  of  them  with  the  debris',  but  not  directly 
destroying  the  vitality  of  the  germs.     It  is  ap- 
parent that  the  action  of  such  a  remedy  might  be 
both  safe  and  efficient  in  the  treatment  of  external 
varieties  of  tubercular    disease,  as    lupus,   etc.. 
but  it  is  equally  apparent  that  in  cases  of  exten- 
sive tubercular  development  in  important  internal 
organs  as  the  lungs,   brain,  and  abdominal  vis- 
cera,  very    severe  or  even   speedy  fatal    results 
might  follow  the  necrosis  of  so  much  affected  tis- 
sue with  no  ready  mode  of  exit  or  exfoliation. 
These  inferences  from  the  modus  operandi  of  the 
remedy,  have  been  verified  by  direct  clinical  ex- 
perience as  set  forth  by  its  author,  who  properly 
enjoins  the  greatest  caution  in  its  use,  especially 
in  the  advanced  stages  of  pulmonary  and  cerebral 
tuberculosis.     Consequently  it  is  better  that  the 
profession  generally  should  wait  patiently  until 
the  processes  of  manufacture  have  been  made  re- 
liable, and  the  results  of  clinical  work  by  compe- 
tent parties  have  had  time  to  develop  their  real 
value.     In  the  meantime,  let  every  general  prac- 
titioner endeavor  to  acquire  the  utmost  skill  in 
making  an  early  diagnosis  of  tubercular  diseases, 
at  which  time  a  judicious  use  of  such  hygiene, 
climatic,    and   remedial    means   as    are    clearly 
known,  will  arrest  the  progress  of  a  large  propor- 
tion of  the  cases;  and  he  will  be  fully  prepared 
to  make  the  most  judicious  and   efficient  use  of 
Dr.   Koch's  remedy  whenever   it   shall    become 
available;  for  such   is   the  nature  of  pulmonary 
tuberculosis,  that  it  is  only  in  the  earlier  stages 
of  its  development  and  progress  that  any  reallv 
curative  treatment  can  be  expected  to  succeed  in 
effecting  a  permanently  favorable  result. 

In  conclusion,  I  will  mention  two  popular  er- 
rors, prominent  in  both  medical  and  general  lit- 
erature, that  do  injustice  to  the  character  of  the 


THE  BASIS  OF  SCIENTIFIC  MEDICINE. 


[January  24, 


profession.  The  first  is,  the  very  common  asser- 
tion that  all  great  discoveries  in  the  science  and 
art  of  medicine  have  met  with  unreasonable  op- 
position and  prejudice  at  the  time,  and  the  dis- 
coverers persecuted  and  sometimes  ruined  in  their 
practice  and  professional  standing.  In  my  read- 
ing of  medical  history  I  have  failed  entirely  to 
find  adequate  proof  of  these  assertions.  Perhaps 
the  greatest  discoveries  in  medicine  during  the 
three  last  centuries,  have  been  the  discovery  of 
the  circulation  of  the  blood,  by  Wm.  Harvey  ; 
the  discoveries  in  the  physiology  of  the  nervous 
system,  by  Sir  Charles  Bell  and  his  contempora- 
ries ;  the  discovery  of  the  cow-pox,  with  the  pro- 
tective value  of  vaccination,  by  Edward  Jenner  ; 
the  discovery  of  anaesthesia  and  its  applications 
in  surgery,  medicine  and  obstetrics,  by  Wells, 
Morton,  Jackson  and  Simpson  ;  and  the  applica- 
tions of  the  microscope  to  studies  in  etiology, 
histology  and  pathology  in  our  own  time. 

Wm.  Harvey  made  his  principal  discovery  con- 
cerning the  circulation  of  the  blood  in  161 9,  but 
used  efo-ht  years  more  in  accumulating  proofs  of 
its  correctness,  and  then,  1628,  published  a  full 
account  of  it  to  the  world  ;  and  instead  of  perse- 
cutions, his  report  rapidly  gained  the  approval 
of  the  learned  both  in  and  out  of  the  profession  ; 
he  was  accorded  official  positions  in  hospital  and 
college  and  only  four  years  later  he  was  made 
phvstcian  in  ordinary  to  Charles.  I,  with  whose 
fortunes  he  became  identified.  The  King  was 
soon  after  defeated  by  the  parliamentary  forces, 
and  deposed,  which  caused  Harvey  to  be  dis- 
placed from  his  hospital  position,  but  left  him 
still  in  the  college,  and  with  a  rapidly  increasing 
reputation.  Less  than  twenty  years  after  he  had 
the  gratification  of  seeing  a  statue  erected  in  Col- 
lege Hall  to  his  honor,  with  his  important  dis- 
coveries indelibly  inscribed  thereon. 

Edward  Jenner  discovered  the  cow-pox  as  early 
as  1770  but  spent  the  next  twenty  years  in  pa- 
tiently studying  its  relation  to  sores  on  the  hands 
of  milk- maids  and  their  exemption  from  small- 
pox apparently  counseling  with  no  one  but  his 
friend  John  Hunter,  by  whom  he  was  encouraged. 
In  1796  he  ventured  to  vaccinate  his  own  son; 
and  in  1798  published  a  full  report  of  all  his  in- 
vestigations. Before  the  end  of  the  same  year 
his  views  were  practically  tested  by  Mr.  Cline 
and  received  the  cordial  public  endorsement  of 
seventy-three  of  the  leading  physicians  ot  Lon- 
don Within  two  years  his  report  had  been 
translated  into  nearly  every  language  in  Europe 
and  his  views  approved  and  practically  adopted 
by  the  profession  not  only  in  Europe,  but  also  in 
the  Colonies  of  America.  Within  the  short  space 
,,f  five  years  he  was  receiving  testimonials  in 
abundance  from  most  of  the  crowned  heads  and 
scientific  bodies  then  in  existence.  That  he  was 
denounced  in  intemperate  language  by  here  and 
there  a  medical  or  clerical  crank,  is  true.   And  the 


same  is  just  as  true  even  at  this  day,  as  the  sayings 
and  doings  of  existing  anti -vaccination  societies 
prove.  But  no  one  would  now  think  of  quoting 
the  doings  of  these  societies  as  evidence  that  the 
regular  medical  profession  is  either  opposed  to 
vaccination  or  indifferent  to  the  reputation  of  one 
of  the  greatest  benefactors  of  his  race. 

Indeed,  so  far  from  receiving  the  announcement 
of  new  discoveries  with  prejudice  and  opposition, 
by  the  medical  profession,  it  would  be  extremely 
difficult  to  find  a  single  important  new  fact,  prin- 
ciple, remedy,  or  mode  of  practice,  fairly  pub- 
lished to  the  world  during  these  last  three  cen- 
turies, that  has  not  been  respectfully  received, 
promptly  acted  upon,  and  in  less  than  ten  years 
assigned  to  its  proper  place  with  due  credit  to  its 
author.  Instead  of  delay  and  prejudice,  the  prin- 
cipal evils  have  resulted,  as  I  have  previously 
said,  from  immature  announcements  and  too  much 
haste  in  their  practical  appropriation. 

The  second  popular  error  consists  in  presenting 
the  extravagancies,  both  in  doctrines  and  prac- 
tice, of  each  medical  era,  as  evidence  of  the  char- 
acter of  the  medical  men  and  practice  of  that 
time.  Every  age  or  generation  has  its  extrem- 
ists who  become  extravagant  in  the  practical  ap- 
plication of  whatever  rules  or  remedies  they 
adopt ;  and  their  extravagancies  are  sure  to  be 
recorded  on  the  pages  of  the  current  literature, 
and  to  be  quoted  by  all  subsequent  generations 
as  characteristic  of  that  time  ;  while  the  great 
mass  of  active  practitioners  never  copy  or  follow 
such  excesses.  Thus,  during  the  first  half  of  the 
present  century,  for  every  excessive  venesection- 
ist  like  Bouillaud,  there  were  ninety  and  nine  in- 
telligent practitioners  who  never  practiced  vene- 
section except  in  the  first  stage  of  acute  diseases, 
and  then  rarely  more  than  once.  And  yet,  I  have 
not  listened  to  a  discussion  concerning  the  prac- 
tice of  that  period  during  the  last  quarter  of  a 
century,  that  Bouillaud  and  his  few  imitators 
were  not  quoted  as  the  representative  men  of  the 
time.  The  same  rule  will  be  found  true  in  re- 
gard to  the  extremists  and  the  conservative 
masses  of  the  profession  in  every  subsequent  era. 
The  only  remedy  for  these  popular  and  unjust 
errors  is  a  frequent  recurrence  to  the  standard 
authors  of  the  past  generations,  or  in  other  words, 
an  honest  and  thorough  study  of  the  history  of 
medicine  as  a  necessary  branch  of  medical  edu- 
cation. 


The  Medical  Club  of  Louisville.— At  a 
recent  meeting  of  the  leading  physicians  of  Louis- 
ville, Ky.,  it  was  decided  to  construct  a  building, 
in  which  meetings  of  the  dlub  are  to  be  held, 
and  in  which  a  medical  library  is  to  be  located. 
In  its  construction  every  possible  convenience 
will  be  assured.  It  is  anticipated  that  this  move- 
ment will  command  the  generous  support  of  the 
entire  medical  profession  of  that  city. 


I89I.J 


ECTOPIC  PREGNANCY. 


ECTOPIC    PREGNANCY.    WITH    REPORT 
OF  TWO  CASES. 

Read  before  the  Gynecological  Society  of  Chicago,  Septeur 
BY  HENRY  BANGA,   M.D., 

OF    CI!:. 

On  June  23.  1890,  a  lady  called  at  my  office 
complaining  of  bloatedness,  backache,  and  con- 
stipation. She  gave  her  age  as  27,  was  of  Ameri- 
can birth,  had  enjoyed  perfect  health  up  to  her 
marriage  four  years  ago  :  pregnant  once  three 
years  ago,  labor  at  full  term,  normal.  Right 
after  she  got  up  from  confinement  she  had  ulcera- 
tion of  the  womb,  for  which  she  was  treated  over 
a  year  in  Milwaukee.  It  is  an  exacerbation  of 
this  womb  trouble  (she  thinks)  that  now  com- 
pels her  to  consult  a  physician.  Upon  examina- 
tion I  found  the  cervix  neither  lacerated  nor 
ulcerated.  In  the  region  of  the  right  ovary  there 
was  a  painful  swelling  ;  a  thorough  examination, 
however,  was  impossible,  on  account  of  the  tense- 
ness of  the  abdominal  walls.  I  told  the  patient 
that  part  of  her  complaint  was  no  doubt  due  to 
constipation,  and  that  I  would  first  try  to  relieve 
this  and  paj-  more  attention  to  the  womb  later  ; 
I  prescribed  accordingly.  About  a  week  later, 
on  the  30th  of  June,  she  again  called  at  the  office 
on  account  of  constipation  and  intense  bearing- 
down  pains.  I  again  examined  and  found  the 
uterus  decidedly  larger  than  normal,  the  cervix 
peculiarly  soft  and  doughy  ;  the  swelling  on  the 
right  side  of  the  womb  seemed  also  somewhat 
easier  to  be  felt.  I  told  the  patient  I  thought 
she  was  pregnant,  and  the  bearing- down  pains 
might  indicate  a  miscarriage.  She  repudiated 
the  idea,  as  she  noticed  no  subjective  symptoms 
of  pregnancy,  and  as  she  had  always  been  regu- 
lar with  her  periods.  She  had  menstruated  last 
on  the  7th  of  June,  and  expected  surely  to 
menstruate  again  on  the  7th  of  July. 

On  July  3d  I  was  called  to  the  patient's  house. 
She  suffered  excruciating  pains,  beginning  in  the 
lower  part  of  the  abdomen  and  radiating  down 
the  thighs  ;  the  pains  were  steady  and  there  were 
on  intermittent,  labor-like  pains.  Enemata  op- 
ened the  bowels,  but  did  not  remove  the  pains, 
which  were  only  controlled  by  morphia.  There 
was  no  nausea,  no  fever ;  appetite  wonderfully 
good.  In  this  way  she  passed  a  miserable  time 
up  to  the  7th  of  July,  the  date  of  the  next  ex- 
pected menstrual  period.  For  the  first  time  in 
three  years  the  menstrual  flow  failed  to  appear. 
On  the  1 2th.  however,  there  was  a  show,  and  on 
the  13th  she  flowed  quite  freely.  Meanwhile  I 
had  made  up  my  mind  that  she  was  undoubtedly 
pregnant;  and  in  order  to  satisfy  myself  as  to 
what  had  become  of  the  swelling  on  the  right  side, 
I  examined  on  the  14th.  There  was  no  doubt 
that  it  had  decidedly  increased  and  had  pushed 
the  uterus  over  to  the  left  and  somewhat  forward. 
It  was  exceedingly  painful.  To  all  appearances  1 1 


had  to  deal  with  a  case  of  extra-uterine  preg- 
nancy. I  thus  informed  the  husband,  and  we  de- 
cided to  call  Dr.  Jaggard  in  consultation. 

On  the  18th  we  examined  the  patient  under 
I  chloroform,  and  found  the  uterus  enlarged,  espe- 
cially so  in  its  antero-posterior  diameter,  pushed 
forward,  and  somewhat  to  the  left.  The  cervix 
had  the  soft,  doughy  touch  characteristic  of  preg- 
nancy. To  the  right  of  the  uterus,  in  a  somewhat 
downward  and  backward  direction,  an  elastic  tu- 
mor of  the  size  of  a  child's  fist  was  felt.  Between 
the  uterus  and  tumor  there  was  room  enough  to 
put  in  a  finger.  Dr.  Jaggard  confirmed  my  diag- 
nosis and  also  concurred  with  me  in  recommend- 
ing immediate  operation.  This  I  did  at  the  Mich- 
ael Reese  Hospital,  Dr.  Jaggard  being  present,  on 
the  25th  of  July. 

After  opening  the  abdomen  the  bowels  appear- 
ed slightly  stained  with  bloody  serum.  Pushing 
these  back,  the  whole  situation  could  be  taken  in 
at  a  glance.  Having  introduced  a  colpeurynter 
into  the  rectum  (as  I  am  in  the  habit  of  doing,  in 
order  to  lift  up  small  tumors  situated  deep  down 
in  the  pelvis),  I  at  once  reached  the  tumor.  There 
was,  to  the  left,  the  uterus,  twice  its  normal  size 
and  very  turgescent  The  left  tube,  very  much 
hypertrophied,  as  thick  as  the  index,  exhibited 
large  veins.  The  right  tube  was  still  larger;  its 
middle  part  especially  showed  an  immense  hyper- 
trophy of  its  muscular  elements,  which  spread  like 
a  fan  over  a  tumor.  The  latter  was  of  the  size  of 
a  child's  fist;  it  was  glued  by  soft  attachments  to 
the  uterus,  the  rectum,  small  intestines,  caecum, 
and  right  side  of  pelvis.  These  adhesions  were 
so  loose  that  they  easily  broke  down  under  the 
finger.  Yen-  little  haemorrhage  followed.  After 
thus  freeing  the  bulk  of  the  tumor  a  pedicle  was 
easily  formed.  I  first  ligated  the  uterine  end  of 
the  tube,  then  I  secured,  by  threelinked  ligatures, 
the  fimbriated  end  of  the  tube  and  part  of  the 
broad  ligament,  including  also  the  ovary.  After 
removing  the  tumor  there  was  an  annoying  ooz- 
ing from  a  separated  adhesion  to  the  rectum,  so 
much  so  that  I  decided  to  use  a  tobacco-bag  tam- 
pon with  iodoform  gauze,  after  Mikulicz.  The  pa- 
tient rallied  very  readily  from  the  operation. 
There  was  considerable  bloody  discharge  through 
the  tampon  during  the  first  two  days.  The  tam- 
pon was  removed  on  the  sixth  da}-.  For  a  num- 
ber of  days  the  temperature  rose  to  ioi3  in  the 
evening,  which  elevation  was  due  to  the  iodo- 
form as  was  clearly  demonstrated  by  the  prompt 
return  of  normal  temperature  as  soon  as  we  began 
using  oxide  of  zinc  and  later  on  balsam  of  Peru. 
There  is  still  (on  October  26)  a  small  fistula  left, 
at  the  bottom  of  which  I  think  a  ligature  keeps 
up  a  little  discharge;1  otherwise  the  patient  is 
well.  She  began  menstuating,  the  first  time  af- 
ter the  operation,  on  September  iSth. 

Examination  of  the  specimen  showed  that  it 

1  November  nth.  ligature  extracted  through  fistula. 


ECTOPIC  PREGNANCY. 


[January  24, 


was  a  case  of  tubal  pregnancy.  The  ovisac  proper 
was  situated  in  the  middle  of  the  tube,  while  the 
upper  wall  of  the  tube — i.e..  the  part  next  to  the 
anterior  abdominal  wall — showed  immense  hyper- 
trophy of  its  muscular  fibres  (they  were  as  large 
bundles  of  a  strong  biceps).  The  opposite  side  of 
the  tube  was  thinned  out  so  much  that  it  seemed 
as  though  the  ovum  was  ready  to  break  through, 
out  of  the  tube,  into  the  cul-de-sac  of  Douglas. 
The  amnion  was  intact;  it  contained  about  an 
ounce  of  fluid,  and  the  fetus  well  differentiated 
and  apparently  about  five  weeks  old.  The  ovary, 
which  was  removed  together  with  the  tubes,  con- 
tained a  cyst  of  the  size  of  a  small  apple,  being 
filled  with  a  chocolate-colored,  thin  fluid. 

Shortly  after  the  preceding  case  had  left  the 
hospital  another  was  brought  in,  of  which  the 
house  physician,  Dr.  M.  Goodkind,  has  furnished 
me  with  the  following  history  :  Patient  set.  40, 
menstruated  at  14;  menstruation  every  four 
weeks  up  to  five  years  ago,  when  the  flow  became 
irregular,  sometimes  occurring  twice  a  month  ; 
generally  lasts  seven  days,  without  pain  and  of 
fair  quantity.  Patient  menstruated  last  three 
months  ago  (May  20th).  Married  seventeen  years; 
three  confinements,  all  full  term,  normal  labors; 
eldest  child  13  years  old,  youngest  5.  Six  weeks 
ago  (July  1 6th),  while  washing  she  experienced 
sudden  and  excruciating  pains  in  neighborhood 
of  genitals,  causing  unconsciousness  which  per- 
sisted for  an  hour.  When  she  emerged  from  this 
condition  she  described  sensations  of  vertigo,  tin- 
nitus aurium,  pain,  dj'spnea,  and  utter  prostra- 
tion, causing  such  intense  distress  that  she 
beeam'e  incapable  of  any  exertion  and  took  to  bed. 
Accompanying  these  S3-mptoms  she  had  alternat- 
ing chills  and  fever,  anorexia,  nausea,  and  vom- 
iting. A  week  after  she  began  to  menstruate 
slightly,  and  has  done  so  to  date.  These  various 
symptoms  caused  a  rapid  deterioration  in  health, 
and  on  August  27th  she  entered  M.  R.  Hospital. 

Status  presens  :  Patient  of  strong  build  but 
extremely  anaemic;  has  a  haggard  and  careworn 
expression.  She  suffers  with  intense  bearing- 
down  pains.  Abdomen  presents  a  symmetrical  en- 
largement extending  from  the  symphysis  to  one 
inch  below  the  umbilicus,  of  fairly  hard,  elastic 
consistence.      No  fetal  sounds. 

By  bimanual  exploration  we  found  the  cervix 
pushed  up  behind  the  symphysis  by  a  round- 
shaped  tumor  resembling  a  small  head  descending 
down  upon  the  floor  of  the  pelvis.  It  was  impos- 
sible to  properly  locate  the  fundus  uteri,  its  out- 
lines being  lost  in  the  tumor,  which  extended 
from  the  posterior  cul-de-sac  along  the  region  of 
the  left  broad  ligament  to  within  an  inch  below 
the  umbilicus.  It  seemed  to  fluctuate,  and,  in 
fact,  to  present  all  the  symptoms  of  a  haematocele. 
I  inserted  an  aspirator  needle,  but  did  not  get  any 
fluid.  The  following  days  the  patient  had  a  lit- 
tle fever,  the  temperature  ranging  in  the  evening  be- 


tween ioo°  and  1020;  the  pains  were  controlled  by 
morphia,  but  the  tutnor  seemed  to  rather  increase, 
causing  retention  of  the  urine,  necessitating  fre- 
quent use  of  the  catheter.  I  deemed  it  necessary  to 
do  something  radical  to  relieve  the  patient,  and  so  I 
decided  upon  laparotomy.  Our  junior  gynecolo- 
gist, Dr.  Frankeuthal,  agreed  with  me  in  the  diag- 
nosis— haematocele,  probably  caused  by  the  burst- 
ing of  an  ectopic  ovisac.  September  4th  was  set 
for  the  operation. 

After  opening  the  abdomen  the  omentum  and 
bowels  appeared  tinged  with  a  peculiar  yellow- 
brown  color,  which  revealed  at  once  the  bloody 
nature  of  the  tumor.  The  tumor  la}'  hidden  un- 
der the  small  intestines,  which  were  easily  loos- 
ened by  the  finger  and  pushed  back  with  a 
sponge,  so  that  the  apex  of  the  tumor  was  brought 
to  view.  After  sponge  packing  all  around  it,  in 
order  to  protect  the  abdominal  cavity  against  an 
overflow  of  possibly  poisonous  liquid,  I  first  tried 
to  aspirate  ;  but,  failing  to  get  any  fluid,  I  cut  in- 
to it  with  a  knife,  making  an  incision  wide 
enough  to  admit  a  half  hand.  It  contained  black, 
semi-coagulated  blood,  which  I  scooped  out  with 
the  hand.  Thus  far  I  thought  I  had  to  deal  with 
a  simple  haematocele,  and  that  the  uterus  lay 
pushed  over  to  the  left  side.  While  manipu- 
lating to  get  the  last  coagula  out  I  loosened  what 
I  considered  to  be  the  womb  ;  it  proved  to  be  a 
hard,  solid  coagulum,  which  was  hanging  attached 
to  a  few  loose  shreds  from  the  left  horn  of  the 
uterus.  The  uterus  proper  I  found  in  the  me- 
dian line  and  of  normal  size.  After  thoroughly 
cleansing  the  abdomen  and  the  sac,  I  stitched  the 
latter  to  the  peritoneum  and  packed  it  with  iodo- 
form gauze.  The  patient  rallied  nicely  from  the 
operation.  On  the  second  day,  however,  the  tem- 
perature went  up  to  1030,  the  abdomen  became 
tympanitic,  pulse  weak,  130.  Gases  had  failed  to 
pass  so  far,  in  spite  of  laxatives,  rectal  tube,  and 
turpentine  enemata.  We  really  thought  the  pa- 
tient in  great  danger  of  beginning  peritonitis, 
and  in  order  to  give  her  a  chance  we  took  her  at 
9  o'clock  in  the  evening  to  the  operating  room,  in 
order  to  relieve  a  possible  retention  of  the  wound 
secretions.  While  she  was  on  the  table,  and  be- 
fore I  had  done  any  mischief  to  the  wound,  the 
first  flatus  passed  coram  publico.  From  that  time 
on  she  began  to  feel  better.  She  is  still  in  our 
ward  and  has  no  fever;  the  wound  discharges 
very  little,  and  is  becoming  smaller  from  day  to 
day. 

In  this  case  tubal  pregnancy  had  occurred,  the 
ovisac  burst,  first  causing  haemato-salpinx,  then 
haematoma  of  the  broad  ligament,  finally  tearing 
and  disintegrating  the  whole  tube,  the  remnants 
of  which  were  hanging  down  in  shreds  from  the 
left  cornu  uteri.  Eater  on  there  was  renewed 
liccmorrhage  into  the  pouch  of  Douglas,  causing 
haematocele.  The  sac,  which  I  stitched  to  the 
abdominal   incision,    was   organized    blood,    not 


I89i.] 


ECTOPIC  PREGNANCY. 


123 


peritoneum.  The  original  ovisac,  represented 
by  the  hard  coagulum  covered  with  villi,  lay  in- 
side of  the  haematocele. 

I  now  wish  to  add  a  few  general  remarks  : 
1.  Diagnosis  of  Ectopic  Pregnancy. — It  must  be 
easy  to  make  a  correct  diagnosis  after  the  fourth 
month  and  before  rupture  of  the  sac,  because  we 
feel  the  living  foetus  or  hear  the  heart  sounds. 
Before  the  fourth  month  there  might  sometimes 
be  a  doubt  left,  especially  if  the  physician  sees 
the  patient  perhaps  only  once,  or  if  he  be  unable 
to  get  an  intelligent  history.  Besides  the  well- 
known  and  generally  accepted  signs  of  pregnancy 
(subjective  and  objective  ones),  I  would  derive 
the  most  valuable  help,  in  making  a  diagnosis, 
from  a  close  history.  There  will  always  be  some 
irregularity  in  the  menstrual  flow — either  cessa- 
tion or  too  early  recurrence  of  the  periods — while 
formerly  the  menstruation  has  been  regular. 
This  irregularity  resembles  very  closely  the  flow 
in  a  case  of  abortion.  Another  valuable  symp- 
tom will  be  intense,  excruciating  bearing-down 
pains,  mostly  one-sided.  These  are  not  labor-like 
pains,  but  are  more  stead}-.  They  are  no  doubt 
caused  by  distention  of  the  tube,  due  to  the  rapid 
growth  of  the  tumor.  If  we  add  to  this  the  ob- 
jective symptoms — the  enlargement  of  the  uterus, 
that  characteristic  dough}'  touch  of  the  cervix, 
the  presence  of  a  gradually  increasing  tumor 
somewhere  in  the  region  of  the  broad  ligament — 
then  I  think  there  should  be  sufficient  reason  to 
-warrant  the  diagnosis  of  ectopic  pregnancy.  My 
first  patient  illustrates  this  symptomatology  most 
conclusively.  She  is  a  woman  who  has  always 
menstruated  regularly  to  the  day.  Fourteen 
days  after  her  last  menstruation  she  begins  to  ex- 
perience intense  bearing-down  pains,  starting  in 
the  right  hypogastric  region  ;  then,  for  the  first 
time  in  three  years,  she  goes  over  her  time  six 
days  ;  then  a  free  flow  sets  in  for  ten  days,  shreds 
of  decidua  pass.  With  all  that  there  is  no  fever 
and  no  other  cause  to  explain  the  pain.  By 
digital  exploration  we  find  an  enlarged  uterus 
giving  that  characteristic  doughy  feel  of  preg- 
nancy, together  with  a  steadily  increasing  tumor 
situated  near  the  womb  in  the  region  of  the  broad 
ligament.  There  was,  however,  one  classical 
symptom  of  pregnancy  wanting,  namely,  the  pa- 
tient herself  had  not  the  slightest  idea  of  being  a 
gravida. 

Now,  how  about  the  diagnosis  of  rupture  of 
the  ovisac  ?  Those  cases  constitute  two  different 
classes,  namely  :  (a)  Rupture  causes  acute  inter- 
nal haemorrhage.  Now,  since  there  is  hardly  any 
other  trouble  but  ectopic  pregnancy  causing  in- 
ternal haemorrhage,  we  may  diagnose  it  at  once 
if  a  patient  shows  the  well-known  symptoms  of 
acute  internal  haemorrhage,  (b)  Rupture  causes 
peritonitis,  sepsis.  If  a  patient  had  not  been  un- 
der observation  before  the  accident,  it  might  often 
be  impossible  to  differentiate   a  ruptured  ovisac 


from  a  ruptured  pyo-salpinx,  ovarian  cyst,  or  the 
like.     About  hematocele  see  further  on. 

2.  Anatomy. — You  know  that  Lawson  Tait 
claims  that  the  different  varieties  of  ectopic  preg- 
nancy described  in  the  text  books  are  mere  theo- 
retical classifications,  and  that  all  cases  are  origi- 
nally tubal,  becoming  ovarian,  interstitial,  or  ab- 
dominal only  after  rupture  of  the  tube  and  migra- 
tion of  the  ovum  to  a  new  resting  place.  The 
simplicity  of  this  theory  recommends  it.  All  the 
recently  published  cases  were  tubal  pregnancies, 
as  were  the  two  cases  related  this  evening.  The 
first  case  also  clearly  demonstrates  by  the  thin- 
ning out  of  the  tube  the  possibility  of  an  ovum 
slipping  out  of  such  an  opening. 

3.  Frequency. — Late  publications  go  to  show 
that  ectopic  pregnancy  occurs  much  more  fre- 
quently than  we  have  generally  thought,  a  great 
number  of  cases  of  so  called  /hematocele  retro- uter- 
ina  and  hasmatoma  of  the  broad  ligament  being 
nothing  but  cases  of  ruptured  ectopic  pregnancy. 
Martin,  Olshausen  (of  Berlin)  have  described 
many  such  cases.  Sure  enough,  they  never 
found  the  foetus,  but  were  able  in  every  instance 
to  demonstrate  the  true  nature  of  the  disorder  by 
the  presence  of  decidua  cells.  Orthmann  who 
published  Martin's  cases)  says  that  if  in  a  baema- 
tocele  we  find  an  organized,  well  defined  coagu- 
lum, we  may  feel  sure  that  this  coagulum  was 
originally  an  ovisac.  Upon  its  microscop- 
ical examination  we  will  find  villi  or  decidua 
cells.  Our  second  case  wonderfully  corroborates 
this  statement.  In  situ  yet  of  the  torn  and  bursted 
left  tube,  and  surrounded  by  the  semi-coagulated 
blood  accumulated  in  the  haematocele  sac,  we 
found  a  coagulum  of  the  size  of  an  apple,  being 
covered  with  villi  and  enclosing  the  shrunken 
remnants  of  an  otherwise  well-differentiated  foetus. 

4.  Predisposition  to  Ectopic  Pregnancy. — It  is 
worth  while  to  repeat  here  that  the  first  patient 
had  been  ailing  for  years  (after  her  first  confine- 
ment) with  pains  in  the  right  ovarian  region,  and 
that  an  ovarian  cyst  of  the  size  of  a  small  apple, 
containing  thin,  chocolate-colored  fluid,  was  re- 
moved together  with  the  ovisac,  right  ovary  and 
tube. 

5.  Treatment. — There  is  hardly  any  possible 
difference  of  opinion  about  what  to  do  if  a  physi- 
cian is  called  to  treat  a  patient  showing  the  symp- 
toms of  a  bursted  ectopic  ovisac.  We  have,  of 
course,  to  perform  laparatomy  at  once — in  the 
one  case  to  stop  an  otherwise  fatal  haemorrhage; 
in  the  other  case  to  remove  decomposed  matter 
which,  if  left  in  the  abdominal  cavity,  will  un- 
doubtedly set  up  fatal  peritonitis.  (See  also  the 
remarks  about  haematocele.)  What  shall  we  do 
with  a  case  where  the  sac  is  still  intact?  Let  us 
first  ask  what  will  become  of  the  patient  if 
left  to  her  fate.  The  sac  might  burst  at  any  time, 
thus  giving  the  patient  a  chance  to  die  either 
from  haemorrhage  or  from  sepsis  ;  or  if  she  should 


I24 


MEDICAL  PROGRESS. 


[January  24, 


escape  both,  and  the  fcetus  undergo  mummifica- 
tion (lithopedion),  she  might,  after  years  of  suf- 
fering, see  the  fcetus  make  its  way  out  of  the  ab- 
domen by  perforating  bladder,  vagina,  and  rec- 
tum. Such  being  the  case,  I  think  the  best  way 
to  deal  with  an}'  case  of  extra-uterine  pregnancy 
is  to  extirpate  the  ovisac  as  soon  as  the  diagnosis  is 
made.  For,  even  if  we  succeed  in  killing  the  fcetus 
by  electricity,  aspiration,  or  injection  of  morphine, 
we  are  by  no  means  sure  that  no  sepsis  or  haemor- 
rhage will  follow,  or  that,  years  after,  a  lithope- 
dion  will  not  cause  trouble  necessitating  an  oper- 
ation. 

In  an  early  month  the  operation  will  amount  to 
nothing  more  but  a  laparotomy  for  a  small  ovar- 
ian tumor  or  salpingitis. 

Thomas  has  warmly  advocated  the  use  of  elec- 
tricity, not  only  with  a  view  to  killing  the  fcetus 
and  waiting  for  its  resorption,  but  also  with  a 
view  to  arresting  placental  circulation,  thereby 
minimizing  the  danger  from  haemorrhage  in  a 
subsequent  laparotomy.  This  would  seem  a  very 
good  plan  if  the  action  of  electricity  were  sure; 
but  since  it  is  not,  it  seems  more  rational  to  oper- 
ate at  once  and  not  allow  the  placental  circulation 
to  increase  by  a  delay  due  to  futile  efforts  to  ar- 
rest it.  In  my  first  case  Dr.  Jaggard  and  I  dis- 
cussed the  propriety  of  a  trial  with  electricity,  but 
we  decided  to  gain  time  over  an  increase  of  the 
placental  circulation  by  immediate  operation,  and 
we  really  had  no  difficult}-  in  controlling  haemor- 
rhage. 

However,  as  gestation  progresses  the  danger 
from  haemorrhage  increases.  There  being  no 
contractile  tissue  to  stop  the  gush  of  blood  issu- 
ing from  the  placental  insertion,  it  is  of  the  great- 
est importance  not  to  disturb  the  placenta.  In 
such  a  more  advanced  stage  of  ectopic  gestation 
where  rupture  occurs  less  frequently.  I  would  try 
Thomas'  plan  with  electricity  as  the  first  prepar- 
atory step  to  a  later  laparotomy.  In  case  preg- 
nancy, for  some  reason  or  another,  has  been  al- 
lowed to  go  on  to  near  full  term,  the  child  has  al- 
so some  claim  for  consideration.  Here,  in  order  to 
save  a  viable  child,  we  might  put  off  laparotomy 
until  labor  begins,  being  ready,  however,  to  oper- 
ate at  any  time  if  symptoms  of  rupture  of  the  sac 
should  demand  it.  The  safest  way  to  treat  with 
the  placenta  in  such  a  case  seems  to  be  not  to  at- 
tempt to  detach  it,  but  stitch  the  sac  to  the  ab- 
dominal wound,  pack  with  iodoform  gauze,  and 
■Ant  foi  spontaneous  loosening  of  the  after-birth. 
In  case  of  hematocele  the  proper  treatment 
would  be  to  first  wait  for  natural  resorption  of  the 
1  (Fusion  ;  second,  aspiration;  third,  open- 
ing through  the  pouch  of  Douglas,  if  the  tumor 
does  not  reach  high  enough  to  allow  it  to  be 
sewed  to  the  abdominal  walls;  fourth,  laparotomy, 
if  the  tumor  touches  the  anterior  wall  of  the  ab- 
domen.  Laparotomy  seems  the  most  rational 
procedure,  because  if    Slows  us  to  properly  locate 


the  extent  and  surrounding  parts  of  the  hemato- 
cele. Whenever  incision  is  resorted  to,  the  open- 
ing should  be  made  wide  enough  to  get  all  the 
coagula  out.  In  the  last  easel  doubt  whether  it 
would  have  been  possible  to  get  the  large  coagu- 
lum  out  through  the  vaginal  opening. 


MEDICAL    PROGRESS. 


Tlierapeul  i<  *  and  Pharmacology. 

A  New  Disinfectant. — The  list  of  disinfect- 
ants that  has  grown  so  rapidly  of  late,  has  received 
a  further  addition  under  thename  disinfectol  (des- 
in/ectot).  According  to  Lowenstein  {Revue 
Hebdomadaire  de  TkSrapeutique')  it  consists  of  a 
combination  of  iodine  phenol  and  different  hydro- 
carbons. It  is  a  liquid  of  considerable  consistence 
which  in  odor  and  properties  approaches  closely 
to  creoline,  of  alkaline  reaction  and  miscible  with 
water  in  all  proportions,  forming  a  clear  or  grey 
emulsion  according  to  the  proportions  employed. 
M.  Beslin  in  testing  the  antiseptic  value  upon 
faeces  found  that  in  the  proportion  of  .5  it  disin- 
fected an  equal  volume  of  fecal  matter  in  eighteen 
hours.  In  the  strength  of  10  per  cent,  an  equal 
volume  of  faeces  were  completely  sterile  at  the  end 
of  fifteen  minutes.  The  bacillus  typhoidal  was 
destroyed  by  a  two  per  cent,  solution.  The  five 
per  cent,  solution  was  equal  in  disinfecting  power 
to  one  of  12.5  of  creoline,  hydro-chloric  acid  33,. 
carbolic  acid  5,  sublimate  2. 

Rapid  Effects  of  Koch's  Remedy  in  Laryn- 
geal Phthisis. — Prof.  Oppenheimer,  of  Hei- 
delberg, reports  the  following  case  {.Deutsche  Med. 
Wochenschr.,  December  4th,  1890): — The  patient 
was  a  woman,  aged  28,  who  had  been  ill  for  two 
years.  She  had  infiltration  of  the  right  tipper 
lobe,  dulness  at  the  left  apex,  bronchial  breath- 
ing, moist  rales,  and  bacilli  in  the  sputum.  Since 
September  of  the  present  year  she  had  continual 
fever,  with  evening  exacerbations  and  night 
sweats.  She  complained  of  irritation  in  the 
throat,  which  brought  on  paroxysms  of  coughing 
from  six  to  eight  times  a  day,  and  made  her  vomit 
most  of  her  food.  This,  and  the  hoarseness  of 
her  voice,  made  Professor  Oppenheimer  suspect 
that  the  lavrnx  was  implicated  in  the  disease,  but 
laryngoscopic  examination  was  impossible,  owing 
to  the  irritability  of  the  throat,  which  even  the 
free  use  of  cocaine  could  not  subdue.  She  was 
very  weak  when  Koch's  fluid  (1  milligram) 
was  injected  for  the  first  time  on  November  22nd. 
Reaction  was  slight  ;  the  coughing  and  vomiting 
C  mlimied  during  the  day  as  before.  On  Novem- 
ber 23d  she  was  again  injected  (1  milligram). 
Nine  hours  afterwards  the  temperature  rose  from 
37. 6°  to  39°  C.    During  the  following  night  there 


i89i.] 


MEDICAL  PROGRKSS. 


was  much  sickness,  with  headache,  and  cough- 
ing ;  expectoration  was  diminished.  On  the  24th 
1  milligram  was  again  injected.  In  about  six 
hours  the  temperature  again  rose  to  390  C.  and 
the  patient  complained  of  giddiness,  shortness  of 
breath,  with  a  feeling  of  contraction  in  the  throat: 
there  was  no  difficulty  in  swallowing,  the  cough 
was  less,  but  the  voice  was  somewhat  hoarser 
than  before.  With  great  difficulty  a  laryngo- 
scopy examination  was  made,  and  it  was  setn 
that  on  the  fore  part  of  the  right  vocal  cord  there 
was  a  bluish  red  excrescence  of  the  size  of  a  mil- 
let seed,  the  rest  of  the  cord  being  greyish  red  in 
color,  but  otherwise  normal.  The  ventricular 
bands  and  arytenoid  cartilages  were  normal.  On 
the  following  day  the  excrescence  had  disappear- 
ed, and  only  redness  and  slight  swelling  of  the  vo- 
cal cord  remained.  From  that  day  the  paroxysms 
of  coughing  and  vomiting  entirely  ceased,  and  up 
to  the  date  of  the  report  (December  1st)  never  re- 
curred. The  only  thing  the  patient  complains 
of  is  slight  pain  in  the  region  of  the  larnyx, 
which  comes  on  from  eight  to  ten  hours  after  each 
injection,  and  lasts  from  three  to  four  hours.  Xo 
improvement  has,  however,  taken  place  up  to  the 
present  in  the  lung  symptoms. — Brit.  Med.  Jour. 

Pyoktanin. — Prof.  Stilling  has  given,  in 
three  recent  numbers  of  Mock's  Bulletin,  a  valua- 
ble report  upon  pyoktanin.  He  summarizes  its 
qualities  in  the  following  terms  :  1.  Pyoktanin  is 
an  antiseptic  surpassing  all  remedies  of  this  kind 
heretofore  known  in  regard  to  both  development- 
arresting  and  germ-destroying  effect.  The  two 
strongest  antiseptics  employed  in  medical  practice 
are  sublimate  and  iodoform.  The  bacteriological 
researches  have  shown  blue  pyoktanin  to  be 
about  three  times  as  strongly  antiseptic  towards 
anthrax  bacilli  as  sublimate  is,  and  to  be  quite  as 
efficacious  as  sublimate  towards  the  staphylococ- 
cus aureus;  while  the  inefficacy  of  iodoform  to- 
wards pus  cocci  is  a  generally  acknowledged  fact. 

2.  Pyoktanin  is  an  absolutely  non-toxic  sub- 
stance. Herein  it  possesses  a  most  desirable  ad- 
vantage over  all  the  other  antiseptic  remedies, 
whose  toxic  effects  are  known  to  hold,  generally, 
a  pretty  direct  ratio  to  their  anti-bacterial  action. 

3.  In  consequence  of  this  non-toxicity  of  pyok- 
tanin it  is  a  matter  of  indifference  in  very  many 
cases  whether  somewhat  weaker  or  stronger  solu- 
tions, or  even  the  pure  drug,  be  employed.  (This 
principle  is  good  pre-eminently  in  the  treatment 
of  wounds  and  ulcers  ;  but  of  course  it  cannot  ap- 
ply to  ophthalmology ).  4.  Pyoktanin  does  not 
coagulate  albumen — a  negative  quality  of  high 
value  physiologically,  which  pertains  to  not  a 
single  one  of  the  antiseptics  heretofore  known. 
5.  Pyoktanin  possesses  an  extremely  high  degree 
of  diffusibility  ;  it  permeates  the  interior  of  the 
eye  like  atropine,  and  acts  similarly  in  other  tis- 
sues.    As  far  as  surgery  is  concerned,  Professor 


Stilling  believes  that  his  researches  have  demon- 
strated that  suppuration  can  be  cut  short  by  bring- 
ing pyoktanin  into  intimate  contact  with  the  sup- 
purating tissues.  After  giving  details  of  his  ex- 
perience of  this  substance  in  many  branches  of 
ophthalmological  work,  he  concludes  by  remark- 
ing that  even  here,  though  somewhat  less  so  than 
for  general  medicine  and  surgery,  the  entire  mat- 
ter is  still  in  statu  nascendi. — Lancet. 


Arsenic  and  Pemphigus. — Mr.  Jonathan 
Hutchinson's  address  in  the  Dermatological 
Section  of  the  British  Medical  Association  re- 
ferred to  the  opportunities  offered  in  connection 
with  skin  diseases  for  the  study  of  general  thera- 
peutics and  for  observations  on  the  action  of 
drugs.  As  reported  in  the  Lancet  he  offered  a 
striking  illustration  of  this  proposition  in  the  be- 
havior of  arsenic,  which  has  long  stood  in  the 
forefront  among  those  remedial  agents  regarding 
which  have  been  collected  many  important 
and  even  astonishing  facts.  And  he  adds: 
' '  There  is  no  more  wonder  -  producing  fact 
in  the  whole  range  of  therapeutics  than  the  ease 
and  rapidity  with  which  arsenic  contracts  and 
cures  common  pemphigus.  There  may  occa- 
sionally be  exceptions,  but,  as  a  rule,  not  another 
bulla  appears  after  that  remedy  has  been  com- 
menced. We  have,  indeed,  ceased  to  see  any 
cases  of  chronic  pemphigus  ever  since  this  fact 
has  been  made  known."  There,  however,  he 
complains,  the  knowledge  ends,  for  no  one  has 
yet  been  able  to  discover  how  the  drug  acts,  and 
we  are  still  ignorant  also  of  the  real  nature  of 
the  malady  that  so  generally  succumbs  before  that 
drug.  It  does  not  always  cure  the  malady  but  it 
always  changes  it  for  the  better.  He  who  would 
completely  unravel  the  mystery'  of  how  the  bul- 
lous eruption  comes  to  be  healed,  and  the  scaly 
one  changed,  how  the  skin  may  be  made  to  clear 
up  in  one  case  or  to  become  muddy  and  brown  in 
another,  how  peripheral  neuritis  may  be  pro- 
duced to  end  finally,  unless  prevented,  in  some 
severe  form  of  paralysis  and  death,  and  how  in 
rare  instances  the  nutrition  of  the  skin  may  be 
so  influenced  that  keratosis  and  even  cancer  may 
be  the  result,  will  certainly  find  that  he  has  his 
work  cut  out  for  many  years.  Only  the  founda- 
tion of  the  subject  has  as  yet  been  laid. 

Treatment  of  Diabetic  Coma. —  Schmitz 
(Berliner  klin.  U'ochcnschr.)  recognizes  two  dis- 
tinct forms  of  diabetic  coma.  In  one  there  is 
heart  failure  and  in  the  other  a  toxaemia.  In  the 
first  class  of  cases  we  have  a  diabetic  who  is  often 
fat  but  whose  muscles  are  soft  and  flabby,  the 
gait  is  insecure,  and  breathlessness  is  produced 
by  slight  exertion.  In  these  cases  the  heart,  like 
other  muscular  structures,  is  poisoned  by  the  ex- 
cess of  sugar  in  the  blood.     After  a  time  distinct 


126 


MEDICAL  PROGRESS. 


[January  24, 


heart  failure  appears,  manifested  by  a  quick,  fee-  toms.  Two  of  these  cases  recovered.  There  was 
ble  pulse,  obscure  or  absent  first  sound,  with  in-  one  case  of  intracranial  haemorrhage  without  frae- 
creased  area  of  dulness  at  the  base.  The  heart's  I  ture.  Trephining  was  performed  six  days  after 
action  finally  becomes  weaker,  somnolence  comes  j  the  injury,  and  5  ozs.  of  coagulated  blood  were 
on  and  the  heart  may  strike  work  suddenly  or  removed  from  between  the  skull  and  dura  mater, 
gradually.      The  treatment  of  these  cases  should  The  patient  recovered 


be  an  avoidance  of  all  undue  over-stimulation  and 
over-taxing  the  heart.  A  nutritious  and  easily 
digested  dietary;  of  course,  the  general  diabetic 
condition  must  not  be  overlooked.  In  acute  cases, 
where  cardiac  failure  is  imminent,  the  patient 
should  be  kept  in  a  recumbent  position  and  heart 
tonics  administered.  One  of  the  best  is  black 
coffee  together  with  musk  and  camphor  hypoder- 
mically  if  there  is  nausea.  The  greatest  danger 
lies  in  allowing  the  patient  to  get  up  too  soon. 
He  should  be  kept  on  his  back  until  the  first 
sound  of  the  heart  becomes  clear  and  distinct. 

The  second  form  of  diabetic  coma  he  regards 
as  an   acute  auto-infection  named,  but  not  cor 


There  were  two  cases  which  received  no  benefit 
from  operation.  One  was  a  case  of  supposed  an- 
cient intracranial  haemorrhage  and  the  other  a 
case  of  epilepsy. 

The  lateral  ventricles  were  tapped  for  effusion 
in  one  case.  The  method  of  operating  was  that 
proposed  by  Keen.  The  trephine  was  placed  1% 
inch  behind  the  meatus  and  \%  inches  above 
Reid's  base  line;  the  puncture  being  made  toward 
a  point  2T2  inches  directly  above  the  opposite 
meatus.  A  considerable  quantity  of  serous  fluid 
was  removed  in  this  way  ;  the  patient,  however, 
died  in  seven  hours.  The  reporter  is  of  the  opin- 
ion that  death  was  due  to  compression  from  haem- 


rectly,  acetoinaetnia.     The  symptoms  principally  '  orrhage,  which  was  caused  by  the  operation.      No 


relate  to  the  digestive  tube,  lack  of  appetite, 
eructations  of  foul  gases,  constipation  usually, 
but  sometimes  diarrhoea,  together  with  heaviness 
and  drowsiness.  This  state  may  last  for  some 
days,  but  eventually  the  patient  becomes  more 
and  more  stupid.  The  temperature  rises  and  the 
pulse  increases  in  frequency,  colicy  pains  are 
present,  frequently  accompanied  by  vomiting  of 
dark  or  greenish  colored  fluid.  The  pupils,  as  a 
rule,  are  contracted  and  react  but  feebly  to  light. 
Towards  the  end  violent  clonic  convulsions  ap- 
pear, deep  coma  supervenes  to  be  followed  by 
death. 

The  colic,   high  temperature  and  clear  heart 
sounds  serve  to  distinguish  this  last  from  the  first  j  caution  he  took  to  prevent  the  mishap  ;    and  he 
variety.      The  writer  thinks  that  this  poison  is  \  strongly  urges   that  these   cases   should    be    at- 


autopsy  was  made.  There  was  one  successful 
case  of  trephining  for  epilepsy,  which  followed 
traumatism  four  years  previous  to  operation. 

Finally,  there  was  a  fatal  case  of  operation  for 
brain  tumor.  The  tumor  was  not  discovered  at 
the  operation.  The  autopsy  showed  it  to  be  a 
cyst  which  had  its  origin  at  the  apex  of  the  pe- 
trous portion  of  the  temporal  bone. — Amer.  Jour. 
Med.  Sciences. 

Obstetrics  and  Diseases  of  Women. 

Kinkead  on  Ruptured  Perin.eum. — The 
author  records  three  cases  of  ruptured  perinaeum 
which  occurred  in  his  practice,  in  spite  of  every 


absorbed  from  the  intestinal  canal,  and  recom- 
mends that  in  all  of  these  cases  free  purging  with 
castor  oil  should  be  resorted  to.  It  makes  no 
difference  whether  diarrhoea  is  present  or  not,  if 
the  oil  is  given  a  number  of  dark  foul  stools  re- 
sult, which  are  quickly  followed  by  an  ameloria- 
tion  in  all  of  the  symptoms.  The  author  gives 
an  account  of  eight  cases  of  equal  severity,  in 
four  of  which  oil  was  given  and  in  four  not; — 
the  former  all  recovered,  while  the  latter  all 
died. 

Surgery  . 

Brain  Surgery.— Walker  {Med.  and  Surg. 

Reporter,  Vol.  lxiii,  No.  8,  p.  213)  reports  eleven 
cases  of  brain  surgery, 


tended  to  at  once,  and  not  allowed  to  heal  by 
chance.  The  author  states  that  the  neglect  to 
repair  arises  from  two  causes  :  1 .  The  notion 
that  if  the  laceration  is  not  extensive,  union  may 
take  place  by  means  of  rest,  position,  and  clean- 
liness ;  and  if  extensive,  so  that  the  rectum  is  in- 
volved, it  is  useless  to  suture  the  wound,  as  union 
is  not  likely  to  take  place.  2.  The  idea  that 
laceration  of  the  perinaeum  is  an  indication  of  in- 
competence or  neglect,  and  likely  to  prejudice  the 
patient  against  the  practitioner.  Dr.  Kinkead 
describes  three  cases,  in  which  he  shows  that  the 
rupture  was  extensive  in  each  case,  in  spite  of 
great  caution,  and  perfect  union  occurred  after 
suturing  the  wound  with  deep  sutures,  though  in 
one  case  the  rent  extended  into  the  anus,  and  for 


There  were  two  cases  of  compound  fracture  of  j  an    inch    up  the   rectum.     Whether    it    be    that 
the  skull  in  which  fragments  of  bone  were  driven    higher    education    and    social    progress    produce 


through  the  dura  mater  into  the  brain.  Trephiu 
ing  was  performed  and  the  fragments  of  bone  were 
removed,  with  recovery  in  both  cases.  There  were 
three  cases  of  fracture  of  the  base  of  the  skull  ac- 
companied by  intracranial  haemorrhage.  The  in- 
dications for  trephining  were  the  pressure  symp- 


larger  foetal  heads,  or  render  the  perinaeum  more 
friable,  the  author  is  unable  to  say,  but  he  states 
that  he  finds  it  more  impossible  to  preserve  the 
perinaeum  intact  than  he  did  when  he  began 
practice. — London  Medical  Record. 


i89i.] 


EDITORIAL. 


127 


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SATURDAY,  JANUARY   24,    1S91. 


NBW  SOCIAL  REMEDIES. 

The  physical  and  medical  side  of  pauperism, 
criminality,  and  associate  evils  have  received  a 
great  uplift  in  Gex.  Booth's  work,  "On  Dark- 
est England  and  the  Way  Out." 

The  purpose  of  this  work  is  to  bring  out  the 
fact,  that  one-tenth  of  the  London  population 
are  paupers,  criminals,  lunatics  and  outcasts  gen- 
erally and  are  called  the  "submerged  tenth"; 
also  that  all  remedies  and  means  to  reach  and 
correct  this  evil  are  failures  unless  especially  ad- 
dressed to  the  physical  side.  Another  fact  sel- 
dom realized,  yet  terribly  true,  is  that  pauperism 
and  its  associate  disorders  are  indigenous,  and 
when  once  they  take  root  in  a  town  or  city,  repro- 
duce themselves  through  heredity,  surroundings 
and  conditions  of  life,  with  a  persistence  that  de- 
fies all  missions,  churches  and  free  charities.  The 
so-called  charities  in  most  cases  increase  the 
very  evils  they  are  intended  to  relieve.  This 
is  illustrated  in  many  of  the  dispensaries  so  gen- 
erously supported  by  physicians,  that  are  literally 
schools  of  pauperism. 

Gex.  Booth's  "way  out,"  or  remedy,  is  to 
draft  out  this  terrible  army  of  defectives,  in  work- 
houses established  in  the  worst  centers.  These 
places  are  to  furnish  good  rooms,  food,  clothing 
and  mental  change,  in  return  for  services  of  some 
kind.  After  residence  and  training  here  they  are 
to  be  transferred  to  form  colonies,  with  larger  op- 
portunities for  more  comfort  and  better  living  and 
a  chance  to  make  a  surplus  beyond  food  and 
clothing.     From  a  longer  residence  here  they  are 


to  be  sent  to  foreign  colonies,  and  helped  to  make 
home  centers  for  themselves.  These  foreign  col- 
onies to  be  cooperative  and  care  for  those  who  are 
unable  to  be  independent:  thus  these  parasites  of 
society  are  to  be  lifted  out,  trained  and  taught  to 
work  and  give  some  return  for  food,  and  all  the 
comforts  of  a  better  home.  The  first  great  lesson  is 
to  be  independent,  and  to  earn  under  the  direction 
of  others,  the  joys  of  better  conditions  of  life  and 
living.  In  this  way  a  large  majority  of  the  de- 
fective paupers  and  criminals  who  are  prevented 
from  rising  by  surroundings  and  conditions  of  life, 
are  lifted  out  of  their  breeding  places,  and  placed 
in  new  mental  and  physical  environments,  and 
trained  to  appreciate  this  change,  and  be  restrained 
from  falling  back  again. 

By  this  appeal  to  the  physical  side,  the  way  to 
the  higher  controlling  forces  is  reached,  and  the 
man  who  would  have  become  a  burden  becomes  a 
producer.  The  common  methods  are  to  break  up 
pauper  centers  and  scatter  the  inmates,  who  with 
unconscious  certainty  proceed  to  form  other  and 
more  dangerous  centers.  This  plan  is  to  draw 
out  such  defects  and  give  them  a  chance  to  rise  to 
better  conditions  of  life.  Gex.  Booth  calls  for  a 
million  dollars  to  begin  this  scheme,  in  London,  a 
third  of  which  is  already  subscribed.  This  indi- 
cates that  the  public  mind  responds  quickly  to 
methods  that  are  rational  and  along  the  line  of 
scientific  research. 

The  new  criminalogy  and  sociology  of  evolu- 
tion sustains  the  practical  character  of  this  plan. 
This  work  is  exciting  most  inteuse  interest  among 
all  classes  of  laymen,  but  beyond  this  it  has  a 
medical  aspect  which  has  not  been  noticed  yet. 
The  London  paupers,  criminals  and  outcasts  are 
growing  up  in  all  our  large  towns  and  cities,  and 
are  identically  the  same  classes,  only  varying  in 
degree.  When  these  classes  are  studied  scien- 
tifically they  are  found  to  follow  certain  lines  of 
causation,  and  conditions  of  heredity  and  envi- 
ronment, that  can  be  traced  and  predicted  with 
absolute  certainty.  They  are  the  products  of 
heredity  and  physiological  development  and  non- 
development,  that  in  certain  conditions  and  sur- 
roundings of  life  will  merge  into  the  criminal 
pauper  and  defectives,  and  become  the  dangerous 
classes. 

So  far  all  the  studies  of  these  cases  have  been  by 
theologians,  lawyers  and  philanthropists,  entire- 
ly from   a  theoretical  standpoint,  and  of  course 


128 


COMPOSITION  OF  KOCH'S  LYMPH. 


[January  24, 


the  remedies  have  been  strangely  empiric  and 
largely  failures.  No  clinical  study  of  these  cases 
in  their  haunts,  or  in  reformatories  or  prisons  has 
been  made.  Only  a  few  fragmentary  articles 
have  appeared.  One  or  two  reform  prisons  have 
demonstrated  the  great  changes  that  will  follow 
physical  training  and  culture,  and  the  possibility 
of  curing  criminals  and  sending  them  back  to 
society  useful  law  abiding  citizens.  These  irreg- 
ular studies  show  that  all  these  so- called  dangerous 
classes  are  bred  and  cultivated  from  germs  and 
germ  soils,  that  they  grow  up  and  develop  in 
conditions  that  can  be  recognized  and  prevented. 
The  educated  physician  is  the  most  competent  of 
all  persons  to  study  and  point  out  the  true  remedies. 
Gen.  Booth's  plan  recognizes  this  fact  in  the 
materialistic  character  of  the  means  for  relief. 

This  entire  subject  of  the  pauper  and  dan- 
gerous classes  is  along  the  line  of  sanitary  science 
and  preventive  medicine.  Here  the  physician 
rises  above  the  lower  level  of  drug  dealing,  and 
becomes  a  student  and  teacher  of  the  laws  and 
forces  which  control  the  evolution  or  dissolution 
of  individual  life.  What  Gen.  Booth  proposes 
to  do  in  London  may  not  be  carried  out  prac- 
tically, but  it  suggests  possibilities  that  can  be 
put  in  operation  in  every  city  in  the  country.  It 
suggests  new  fields  of  medical  research  and  med- 
ical activity,  that  will  close  free  dispensaries  and 
dangerous  charities,  and  change  the  police  courts 
and  jails  from  training  schools  of  crime  to  homes 
of  growth  and  preparation  for  better  life  and  liv- 
ing. 

Medical  men  in  every  community  must  study 
these  dangerous  classes,  and  advise  and  direct  the 
remedies  for  restoration  and  prevention.  A  prac- 
tical knowledge  in  this  direction  will  be  liberally 
rewarded  by  the  public,  and  raise  the  physician 
to  the  realm  of  leadership  in  a  new  field  of  work 
for  humanity.  Each  new  advance  of  scientific 
research  reveals  the  possibility  of  escape  from 
epidemics  and  widespread  fatal  diseases,  and 
every  new  study  of  these  dangerous  classes  re- 
veals certainty  of  finding  means  of  prevention 
and  cure.  Pauperism  including  criminality,  and 
all  the  associate  defects,  are  medical  problems  to 
be  studied  from  the  physical  side,  and  treated  by 
physical  remedies,  not  drugs,  but  by  the  applica- 
tion of  laws  and  forces  that  will  help  the  victim 
back  to  health  again. 

Everywhere  there   are  intimations  of  a  great 


revolution  in  our  knowledge  and  treatment  of 
these  cases.  The  losses  and  burdens  they  en- 
tail on  every  community  bring  the  study  of  rem- 
edies and  means  of  prevention  into  great  prom- 
inence, and  calls  for  the  best  talent  of  the  pro- 
fession in  every  section. 


THE  COMPOSITION  OF  KOCH'S  LYMPH. 

Professor  Koch  has  made  a  third  report  of 
his  work  under  date  of  January  15.  His  reasons 
there  given  for  withholding  from  the  public  to 
the  present  time  the  exact  composition  of  the 
fluid  used  in  the  treatment  of  tuberculosis,  should 
be  satisfactory  to  the  medical  profession.  The 
modest  manner  in  which  he  now  refers  to  his  pre- 
vious labors,  and  the  methods  employed  by  which 
he  has  reached  his  present  conclusions,  commands 
approval,  and  the  unreserved  manner  in  which  he 
now  gives  to  the  public  the  results  of  his  labors 
must  surely  disarm  those  who  were  disposed  to 
criticise  the  withholding  of  his  discover}'  from  an 
exacting  and  impatient  multitude. 

"The  remedy,"  says  Professor  Koch,  "which 
is  used  in  the  new  treatment,  consists  of  a  glycer- 
ine extract  derived  from  the  pure  cultivation  of 
tubercle  bacilli." 

This  extract  contains  not  only  the  effective  sub- 
stance derived  from  the  bacilli,  but  such  other 
substances,  consisting  of  salts,  coloring  material 
and  extractive  matters,  as  would  be  soluble  in  a 
fifty  per  cent,  solution  of  glycerine.  Their  elim- 
ination is  of  no  practical  importance,  since  they 
exert  no  essential  influence  upon  the  human  or- 
ganism. Combined  with  other  extractive  material 
the  effective  matter  is  precipitated  by  alcohol,  in 
which  it  is  insoluble,  and  can  be  isolated  from 
other  substances  in  a  comparatively  pure  and 
concentrated  form  and  with  increased  potency. 

■  Regarding  the  composition  of  the  effective  sub- 
stance, as  he  terms  it,  Professor  Koch  says 
that  for  the  present  only  surmises  can  be  enter- 
tained. He  believes  it  to  be  derivative  from  al- 
buminous bodies  and  having  close  affinity  to  them. 
That  it  does  not  belong  to  the  group  of  tox-albu- 
mens,  he  argues  from  the  fact  of  its  tolerance  of 
high  temperature  and  of  its  behavior  in  the  dialy- 
ser.  So  far  as  can  be  estimated,  the  percentage 
of  the  active  principle  in  this  solution  is  exceed- 
ingly small,  being  rated  at  a  fraction  of  one  per 
cent.  It  is  evident  that  we  here  have  to  do  with 
a  remedy  which,  considering  the  effects  which  it 


I89i.] 


EDITORIAL  NOTES. 


129 


produces,  is  far  more  potent  than  any  drug  hith- 
erto employed. 

Various  views  are  entertained  as  to  the  manner 
in  which  the  substance  produces  its  effects. 

It  is  known  that  tubercular  bacilli,  when  grow- 
ing in  living  tissues,  produce  substances  which 
affect  unfavorably  and  in  concentrate  form  pro- 
duce necrosis  of  living  tissue.  In  this  necrotic 
tissue  the  bacillus  fails  to  obtain  its  needed  nour- 
ishment, ceases  its  development,  and  sometimes 
dies. 

Thus  the  very  environment  of  the  bacillus  is 
inimical  to  its  development  and  multiplication. 
If  now  a  substance  be  introduced  that  can  develop 
the  necrotic  environment  still  further,  and  limit 
the  possibilities  of  its  growth,  by  so  much  the 
more  will  its  limitation  and  destruction  be  assured. 

It  may  be  as  yet  impossible  to  explain  the 
manner  in  which  this  remedy  exerts  its  specific 
influence  upon  tuberculous  tissue.  Nor  can  we 
yet  understand  the  remarkable  rapidity  with 
which  its  effects  are  produced.  Nor  does  time 
yet  suffice  to  determine  as  to  the  permanency  of 
alleged  favorable  results.  Instances  are  cited 
where  the  tubercular  bacilli  disappeared  from  the 
sputa  of  patients  while  under  treatment,  and  at 
the  end  of  three  months  had  not  reappeared,  the 
patients  in  the  meantime  improving  in  health, 
the  physical  signs  of  phthisis  having  disappeared. 


EDITORIAL  NOTES. 
Diphtheria  at  Halifax,  N.  S. — The  Mari- 
time Medical  News  for  January  comments  editori- 
ally on  the  high  mortality  of  diphtheria,  during  the 
last  fifteen  months,  at  Halifax.  The  exact  amount 
of  the  death-roll  cannot  be  stated,  but  the  editorial 
writer  estimates  that  as  man}-  as  250  deaths  wTere 
due  to  the  cause  named,  and  the  end  is  not  yet. 
These  deaths  were  mostly  among  children,  caus- 
ing an  abnormally  high  infant  mortality.  And 
yet  Halifax  has  very  much  in  its  favor  as  regards 
its  geological  and  geodetic  conditions,  washed  by 
the  sea  on  every  side,  and  furnished  with  a  water- 
supply  that  is  above  suspicion.  But  the  city  is 
uncleanly  within,  as  was  shown  by  an  inspection 
made  last  summer,  under  pressure  of  public  opin- 
ion and  against  the  opposition  or  inertia  of  a 
cumbersome  health  machine.  This  inspection 
revealed  premises  innumerable  reeking  with  do- 
mestic filth,  saturated  and  overflowing  cesspits, 


uncleaned  streets,  uncollected  garbage  and  an  in- 
adequate sewer  system.  The  economic  loss  to 
the  city  has  already  been  great,  as  the  sensitive- 
tide  of  summer  travel  has  already  begun  to  be 
diverted  by  the  impression  made  by  the  bad  bills 
of  health  shown  by  the  city.  The  Board  of  Health 
is  lacking  in  its  proportion  of  medical  men  of  alert- 
ness and  modern  training. 

The  Overworked  Physician's  Luncheon. 
— Dr.  Allan  McLean  Hamilton  contributes  to  the 
Dietetic  Gazette  some  dietetic  suggestions  in  nerv- 
ous and  mental  diseases,  one  of  which  will  in- 
terest all  those  busy  practitioners  who  give  them- 
selves no  time  for  a  uiidday  repast.  His  advice 
would  be  to  lay  in  a  goodly  supply  of  fresh 
almonds,  and  to  have  some  of  them  constantly 
within  reach  and  to  eat  freely  of  them  during  the 
spare  moments.      He  writes  as  follows  : 

Acting  upon  a  hint  given  by  my  friend,  Dr.  Lauder 
Hrunton,  I  have  directed  some  of  my  patients  to  eat 
freely  of  fresh  almonds,  which  are  rich  in  oil  and  exceed- 
ingly nutritious,  containing  as  they  do  54  per  cent,  of 
fixed  oil.  According  to  Pavy  they  contain  2.677  of  nitro- 
gen and  40  per  cent,  of  carbon.  It  is  a  custom  of  Dr. 
Bruutou  and  several  other  London  physicians,  when 
hurried  and  tired  after  their  morning  consulting  hours, 
to  make  a  luncheon  simply  of  this  kind.  In  cases  of 
diabetes,  when  digestion  is  not  too  weak,  it  will  be  found 
that  biscuits  of  almond  flour  are  exceedingly  nutritious 
and  palatable  and  may  take  the  place  of  gluten  bread. 

*  Poetry  about  a  Milwaukee  Surgeon. — A 
little  versification  now  and  then  is  relished  by 
the  sternest  of  medical  men,  especially  if  it  be 
about  Professor  Senn.  Dr.  G.  Dewey,  a  Mis- 
sourian  poet,  has  composed  the  following  lines 
regarding  specialism  in  medicel  practice  : 
"  The  body  has  been  parcelled  out. 

For  doctors'  benefit,  no  doubt, 

Divided  up  so  very  nice 

That  every  one  can  get  a  slice. 

To  one  they  gave  the  fingers,  one  the  toes, 

Another  gets  the  eyes  and  nose  ; 

A  third,  more  greedy  for  his  part, 

Has  gobbled  up  the  lungs  and  heart. 

For  his  untiring,  ceaseless  pen, 

Thev  gave  the  pancreas  to  Senn." 

Medical  Practice  in  Minnesota. — The  re- 
sults of  seven  years  operation  of  the  Medical 
Practice  Acts  in  that  State  have  been  to  reduce 
the  proportion  of  physiciaus  to  1  in  1 ,250  persons; 
whereas  it  formerly  was  1  in  650.  Some  hundreds 
of  pretenders  have  been  forced  to  quit  the  State,, 
and   have  gone  into  Michigan  and  other  unpro- 


130 


EDITORIAL  NOTES. 


[January  24, 


tected  States.  The  present  examination  act  has 
been  in  force  three  years,  and  in  that  time  only 
205  candidates  have  presented  themselves  for  ex- 
amination, of  these  77,  or  36  per  cent.,  were 
rejected. 

Earth-worms  and  African  Fevers. — The 
Kew  Bulletin  in  an  article  on  the  work  of  the 
earth-worm  in  the  coast-regions  of  Western  Africa, 
says  that  there  is  an  unmistakable  comparative 
freedom  from  dangerous  malarial  fevers  in  the 
country  called  Yoruba  land,  and  that  many  there 
believe  that  this  freedom  is  due,  in  part  at  least, 
to  the  great  activity  of  earth-worms  in  ventilating 
the  soil  and  in  bringing  to  the  surface  the  earth 
in  which  the  malarial  germs  live  and  breed.  The 
quantity  of  soil  thus  brought  to  the  surface  yearly 
is  enormous  ;  but  whether  or  not  the  diligence  of 
the  earth-worms  of  Yoruba  is  greater  than  in  ad- 
joining territory,  that  is  smitten  with  the  malarial 
fevers,  is  not  stated.  We  are  left  to  infer  that 
it  is. 

Koch's  New  Laboratory. — The  government 
at  Berlin  has  ordered  the  construction  of  a  new 
institute  for  Dr.  Koch.  It  is  to  include  a  sani- 
tarium as  well  as  scientific  institution  ;  in  the 
former  all  required  cases  of  infectious  diseases 
will  be  cared  for  and  treated  under  the  direction 
of  Koch,  the  human  test-cases  in  conformation  of 
his  researches  ;  in  the  latter  the  usual  laboratory 
investigations  in  bacteriology  and  other  preven- 
tive methods,  both  in  old  and  new  directions. 
Professor  Koch  will  be  the  director  of  the  insti- 
tute, with  two  heads  of  departments  under  him 
and  twenty  or  more  practical  assistants.  An  ad- 
junct sanitarium,  for  the  benefit  of  the  poor  of  the 
city,  has  been  promised  by  a  private  citizen,  at  a 
cost  of  $200,000.  The  sanitarium,  to  be  con- 
structed by  the  government,  will  have  a  capacity 
of  150  bed's.  Dr.  Brieger  has  been  named  as  the 
probable  first  director  of  this  department. 

Generous  Gift  to  a  Pension  Fund  for 
Nurses.— The  family  of  the  late  Junius  S.  Mor- 
gan, formerly  of  Hartford,  Conn.,  has  presented 
the  National  Pension  Fund  for  Nurses,  England, 
with  over  $38,000  to  supplement  a  collection 
made  by  the  nurses  among  themselves,  amount- 
ing to  about  $12,000,  this  being  their  spontaneous 
tribute  to  the  memory  of  their  departed  benefac- 
tor. This  fund  will  bear  Mr.  Morgan's  name,  as 
a  part  of  the  benevolent  endowment  for  the  bene- 


fit of  nurses,  which  already  amounts  to  $200,000. 
Mr.  Morgan,  during  his  lifetime, 'had  taken  a 
warm  personal  interest  in  the  movement  and  had 
subscribed  liberally,  not  less  than  $50,000,  for  its 
encouragement. 

Proposed  Medical  Legislation  in  Michi- 
gan.— At  the  last  annual  meeting  of  the  Michi- 
gan State  Medical  Society,  a  committee  of  nine 
of  its  representative  men  was  appointed  to 
formulate  appropriate  measures  and  to  influence 
the  profession  in  the  State  to  secure  from  the  in- 
coming Legislature — "the  enactment  of  just  and 
wise  measures,  calculated  to  elevate  the  standard 
of  medicine  in  Michigan,  and  to  protect  the  peo- 
ple from  the  cruel  and  dishonorable  practices  of 
ignorant  and  unscrupulous  pretenders." 

At  the  meeting  of  that  committee  recently  held, 
the  conclusions  reached  were  as  follows  : 

1.  That  the  objects  to  be  sought  in  a  medical 
law  were  three-fold  :  preliminary  training,  pro- 
fessional training,  and  the  enforcement  of  these 
requirements. 

2.  The  securing  of  these  objects  by  a  legal  or- 
ganization of  the  entire  medical  profession  of  the 
State  under  legislative  authority — by  means  of  a 
legally  constituted  council  by  whom  those  begin- 
ning the  study  of  medicine  shall  be  examined 
with  reference  to  preliminary  education,  and  by 
whom  alone  a  license  to  practice  medicine  in  the 
State  shall  be  issued,  and  that  no  other  diploma 
shall  entitle  the  holder  to  practice  in  the  State. 

We  confidently  believe  that  if  the  men  who 
have  this  matter  in  charge  shall  secure  the  legis- 
lation they  desire  that  Michigan  will  stand  in  the 
foremost  rank  of  States  as  regards  the  quality  of 
its  medical  service. 

The  Koch  Treatment  in  the  Post-Grad- 
uate  Medical  School,  Chicago. — During 
the  past  week  the  Koch  lymph  treatment 
was  successfully  instituted  at  the  Post- Grad- 
uate Medical  School  of  Chicago.  This  in- 
stitute, through  Dr.  Robert  H.  Babcock,  has  also 
fitted  a  room  with  all  the  necessary  appliances  for 
the  treatment  advised  by  Dr.  Shurly  of  Detroit. 
Several  patients  are  under  treatment  by  both 
methods  and  careful  notes  are  taken  of  the  prog- 
ress in  each  instance  with  the  idea  of  comparing 
the  relative  value  of  the  two  methods. 


i89i.] 


TOPICS  OF  THE  WEEK. 


131 


TOPICS  OF  THE  WEEK. 


THE  REVIEWER  [H 

The  following  are  a  few  samples  of  what  reviewers  had 
to  say  about  books  in  [831: 

"So  many  plates,  etchings,  lithographs,  and  copper- 
plates bestrew  our  table  that  we  scarcely  know  whither  to 
turn  to  avoid  them.  Every  day  sees  the  birth  of  some 
production.  If  the  public  buy  them  all  then  happy  are 
the  authors."  This  might  apply  to  1S91,  as  well  as  the  fol- 
lowing: '.'Within  the  last  few  years  compilations,  sys- 
tems, manuals  and  guides  of  all  descriptions  for  the  use 
of  students,  yonng  and  old,  have  multiplied  beyond 
enumeration.  If  mind  is  on  the  march  it  is  encumbered, 
like  our  English  armies,  with  a  monstrous  quantity  of 
baggage  and  camp  followers." 

What  would  the  reviewer  have  said  if  he  had  been 
spared  to  the  fin  de  siede.  The  quotations  we  have 
given  only  lament  the  quantity  of  books:  the  following 
extract  might  have  been  penned  to-day:  "To  those  who 
have  made  themselves  intimate  with  the  medical  litera- 
ture of  the  last  thirty  years,  and  have  traced  with  care 
the  progress  of  its  advancement  in  some  departments, 
and  the  cause  of  its  decline  in  others,  nothing  can  have 
appeared  more  amazing  than  the  unphilosophical,  un- 
connected trash  which  has  been  teeming  in  volumes  of 
every  size  from  the  medical  press  of  this  country.  A  few 
observations  most  hurriedly  made:  a  few  new  fancies 
most  rudely  arranged;  or,  if  you  will,  a  few  facts  care- 
fully collected  are  laid  down  as  the  framework  of  a  mo- 
mentous publication,  in  which  general  systems  are  dis- 
sected ami  condemned,  preceding  authorities  are  swept 
into  annihilation  by  broad  and  dogmatic  assertions,  and 
a  new  creed  is  proposed  for  adoption  which  contests 
not  only  its  superiority  over  all  that  has  gone  be- 
fore, but  its  perfect  adaptation  for  all  future  ages,  na- 
tions and  constitutions."  The  extracts  are  from  the 
Medico-Chirurgical  Review,  1S32,  p.  30,  and  evidently 
the  state  of  the  profession  fifty  years  ago,  as  regards  the 
the  production  of  books,  was  as  bad  as  it  is  nmv.-flii 
vincial  Med.  Journal. 


side  of  a  policeman  going  home  at  night  and  seen  him 
blow  his  whistle  and  I  never  could  hear  it,  although  it 
could  be  heard  by  others  half  a  mile 
heard  the  upper  notes  of  the  piano,  violin,  or  other  mu- 
sical instruments,  although  I  would  hear  all  the  lower 
notes."— Cleveland  Med,  < 


THE  OWNERSHIP  01  THE  PRESCRIPTION 
This  question  has  been  settled  by  law  in  New  York, 
I S,  .m.l  a  lew  other  States.  They  all  give  the 
prescription  to  the  druggist.  Some  time  ago  a  judge  of 
a  court  in  Berlin,  Germany,  gave  a  similar  decision.  The 
text  of  the  decision  from  the  judge  of  the  supreme  court 
of  one  of  our  States  is  as  follows  :  "The  question  be- 
fore the  court  seems  to  be  very  simple,  indeed.  A  pa- 
tient applies  to  a  physician  and  receives  from  him  cer- 
tain advice.  l"..r  which  he  tenders  a  fee.  The  phvsieian 
hands  a  piece  of  paper  to  the  patient,  purporting  to  be  a 
written  order  for  certain  goods  called  drugs,  which  order 
is  filled  by  a  merchant  or  apothecary.  The  payment  of 
the  fee  and  the  delivery  of  the  goods  or  drugs,  terminates 
the  verbal  contract,  and  the  druggist  keeps  the  prescrip- 
tion as  an  evidence  that  the  contract  has  been  fulfilled, 
as  far  as  he  is  concerned.  The  druggist  can,  if  I 
please,  on  his  own  responsibility,  renew  the  drugs,  fur  he 
is  but  a  merchant,  and  has  a  perfect  right  to  sell  drugs 
to  any  one  and  in  any  shape.  He  need  not  keep  the 
prescription,  nor  is  he  bound  to  give  a  copy,  but  should 
error  occur,  he  has  no  protection  in  case  of  suit. ' 
Pharmaceutical  Era. 


DEAFNESS  FOR  HIGH  NOTES. 

Mr.  Edwin  Cowles,  editor  of  the  Cleveland  Leader. 
who  died  last  March,  had  a  peculiar  form  of  deafness. 
He  never  heard  the  sound  of  a  bird's  note,  and  until  he 
grew  to  manhood  he  always  thought  the  music  of  the 
bird  was  a  poetical  fiction.  "You  may  fill  the  room  with 
canary  birds,"  he  once  said,  "and  they  may  all  sing  at 
once,  and  I  would  never  hear  a  note,  but  I  would  hear 
the  fluttering  of  their  wings.  I  never  heard  the  hissing 
sound  in  the  human  voice;  consequently,  not  knowing 
of  the  existence  of  that  sound,  I  grew  up  to  manhood 
without  ever  making  it  in  my  speech.  A  portion  of  the 
consonants  I  never  hear,  yet  I  can  hear  all  the  vowels. 
About  a  quarter  of  the  sounds  in  the  human  voice  I 
never  hear,  and  I  have  to  watch  the  motion  of  the  lips 
and  be  governed  by  the  sense  of  the  remarks  in  order  to 
understand  what  is  said  to  me.      I  have  walked  by  the 


THE  TEX  COMMANDMENTS  OF  ABDOMINAL  SURGERY. 

i.  The  arrest  of  haemorrhage.  2.  The  avoidance  of 
mechanical  irritation.  3.  The  guarding  against  infec- 
tion. 4.  The  proper  apposition  of  the  edges  of  the 
wound.  5.  The  provision  of  necessary-  drainage.  6.  To 
aPP'y  gentle  pressure  to  prevent  exudation.  7.  To  give 
perfect  physiological  rest.  8.  To  secure  the  best  possible 
position  of  the  parts  to  promote  comfort  and  healing. 
9.  To  provide  for  hygienic  surroundings.  10.  To  attend 
to  the  patient's  general  health.— Dr.  Grijfiths. 


A  NEW  SOCIAL  DANGER. 

Opponents  of  dancing  have  had  a  somewhat  novel  ar- 
gument suggested  to  them.  Some  person  whom  we  can- 
not but  regard  as  over-cautious  has  discovered  that  even 
the  drawiug-room  carpet  is  the  home  of  dangerous  mi- 
crobes, and  must  not  be  disturbed,  lest  the  infective 
swarm  should  arise  and  poison  the  atmosphere.  With 
every  allowance  for  the  unknown  components  of  dust, 
the  objection  is,  in  our  opinion,  certainly  as  whimsical 
as  it  is  probably  original.  Such  regular  cleansing  as  a 
carpet  undergoes  ought  to  free  it  from  any  si 
morbific  influence,  the  more  so  that  a  dancing  room  is 
less  than  any  other  exposed  to  such  mischievous  agency. 
Far  more  real  is  the  disqualification  from  which  this 
otherwise  healthy  form  of  amusement  has  always  suf- 
fered in  the  opinion  of  medical  men  in  consequence  of  its 
customary  methods.  The  excessively  late  hours,  the  in- 
digestible suppers,  the  needless  glass  of  wine,  the  close 


132 


TOPICS  OF  THE  WEEK. 


[January  24, 


ieated  air,  and  the  frequent  after  chill,  though  by  no 
means  essential  to  dancing,  have  done  far  more  to  injure 
its  repute  among  reasonable  people  than  any  fancied 
bacillus  or  morbid  spore  is  likely  to  do. — Lancet. 


THE  ADVANCE  IN  LIFE-VALUES. 

Dr.  B.  W.  Richardson,  in  his  abridgment  of  "  The 
Health  of  Nations, "  by  the  late  Sir  Edwin  Chadwick, 
under  the  heading  "  Progressive  Health,"  compares  the 
mortality  in  the  Elizabethan  and  Victorian  eras: 

According  to  John  Grauut's  reports,  from  the  parish 
registers,  the  condition  of  the  whole  city  of  London 
in  the  time  of  Queen  Elizabeth  was  very  much  that 
of  a  "slum."  The  death-rate  was  in  fact  that  of  a 
slum:  it  was  more  than  40  per  1,000;  but  now,  under  some 
advance  toward  unity  and  centralization,  it  is  about  20 
per  1,000,  still  including  upward  of  one- third  of  preven- 
table deaths.  The  death-rate  then  largely  exceeded  the 
birth-rate,  while  now  the  reverse  is  the  case.  The  death- 
rate  of  the  children  under  5  years  was  then  one-third,  or 
33  per  100.  It  is  now  27  per  100,  and  grievously  too 
heavy.  The  deaths  from  old  age,  or  the  age  then  called 
old,  of  70,  were  7  per  cent.;  they  are  now  sadly  too  low, 
but  even  in  the  city  proper  they  are  18  per  cent.  As  to 
personal  security,  John  Graunt  boasted  that  not  more 
than  one  in  2,000  was  then  murdered  annually,  which  he 
ascribes  to  good  local  government.  At  the  same  rate 
now  murders  in  the  whole  of  the  metropolis  should 
amount  to  no  less  than  2,500  annually,  whereas  they  ac- 
tually amount  to  an  average  of  no  more  than  12  for  the 
whole  5,000,000 — a  population  which  approaches  to  that 
of  the  whole  kingdom  of  England  and  Wales  in  the  time 
of  Elizabeth. 


LISTER'S  METHOD  DISCARDED  BY  LISTER! 

"Who  could  have  foreseen  the  short  existence  of  the 
world-renowned  system  of  Lister,  which  has  been  for 
years  the  ideal  of  modern  surgeons?  Who  could  have 
dreamed  that  the  idol  would  be  one  day  broken  by  him 
who  had  placed  it  on  a  pedestal  of  bronze  and  polished 
brass?  "  Such  are  the  questions  with  which  Has  Journal 
d?  Hygiene  begins  the  announcement  of  the  present  status 
of  I.isterism,  and  goes  on  to  remark:  "  It  is,  however, 
an  historical  fact.  The  dictum  of  Lister  and  his  antisep 
tic  doctrine  have  ceased  to  exist.  In  his  remarkable  com 
muuication  to  the  Congress  at  Berlin,  on  the  actual  con 
dition  of  the  antiseptic  treatmeut  of  wounds,  the  eminent 
English  surgeon  has  given  the  following  judgment: 

"  As  regards  the  spray,  I  feel  ashamed  that  I  should 
have  ever  recommended  it  for  the  purpose  of  destroying 
the  microbes  of  the  air.  If  we  watch  the  formation  of 
the  spray,  and  observe  how  its  narrow  initial  cone  ex- 
pands  as  it  advances,  with  fresh  portions  of  air  continu- 
ally drawn  into  its  vortex,  we  see  that  many  of  the  mi 
crobes  in  it,  having  only  just  come  under  its  influence, 
cannot  possibly  have  been  deprived  of  their  vitality.  Yet 
as  a  time  when  I  assumed  that  such  was  the  case 
and  trusting  the  spray  implicitly,  as  an  atmosphere  free 
from  living  organisms,  omitted  various  precautions  which 
1  had  befon    supposed  to  be  essential." 

Lawson   Tait,   of   Birmingham,   Bantock,   of    London, 


and  Bergmann,  of  Berlin,  in  reviewing  their  vast  experi- 
ence, are  not  afraid  to  affirm  that  antiseptic  treatment 
must  now  yield  the  place  to  the  aseptic  method! 

Water  boiled  or  sterilized,  a  brush  and  soap  are  the 
simple  means  which  have  enabled  these  eminent  sur- 
geons to  perform  a  series  of  one  hundred  ovariotomies 
without  a  single  death. — Cincinnati  Med.  News. 


THE  VALUE  OF  TIME. 

A  correspondent,  writing  from  a  large  commercial  city, 
informs  us  that  he  remembers  seeing  many  years  ago  the 
following  in  some  mercantile  offices:  "  Call  upon  a  bus- 
iness man  at  business  time  only,  and  on  business.  Trans- 
act your  business  and  go  about  your  business,  in  order  to 
give  him  time  to  finish  his  business."  Our  correspondent 
feelingly  asks  whether  a  notice  similar  to  the  above,  with 
the  necessary  modifications,  might  not  be  hung  up  in  the 
consulting-room  and  surgery  of  ever}'  busy  consultant  or 
general  practitioner.  Much  has  been  said  as  to  the  ra- 
pidity with  which  the  out-patients  of  hospitals  are  dis- 
posed of.  But  this  rapidity  is  perfectly  compatible  with 
correctness  of  diagnosis,  prognosis,  and  prescribing  by 
an  experienced  practitioner,  and  there  is  something  to  be 
said  on  the  other  side — the  time  wasted  by  patients  in 
prolix  descriptions  and  tedious  repetitions.  The  quaint 
story  of  the  lady  who  consulted  Abernethy  and,  knowing 
his  impatience  of  such  verbosity,  held  out  her  wounded 
finger  and  answered  in  monosyllables,  is  well  known,  and 
the  example  might  be  followed  with  great  advantage. 
The  ladj-  in  question  was  rewarded  by  Abernethy's  im- 
promptu praise,  that  she  was  the  most  rational  woman 
he  had  ever  met  in  his  life.  Those  patients  who  are  most 
considerate  for  their  doctor's  time  are  certainly  the  most 
welcome. — Lancet. 


THE  TIME  OF  DAY  FOR  OPERATIONS. 

There  is  considerable  difference  of  opinion  amongst 
surgeons,  as  to  whether  it  is  best  to  operate  early  in  the 
morning  or  in  the  afternoon.  Many  prefer  the  morning. 
They  say  that  the  patient  is  saved  the  suspense  of  being 
kept  waiting  till  the  afternoon,  and  the  surgeon  has  the 
better  chance  of  a  good  supply  of  sunlight  or  of  its 
equivalent  in  this  country.  Both  these  reasons  have  con- 
siderable force.  Other  surgeons  maintain  that  early  op- 
erating implies  a  sleepless  previous  night.  The  shades 
of  evening,  a  greater  promotor  of  sleep  than  blinds  and 
screens,  come  on  sooner  when  the  operation  is  performed 
in  the  afternoon.  This  physical  fact  also  implies  greater 
chances  of  rest  in  another  respect,  for  there  is  less  fear  of 
subsequent  disturbance  from  noises  inside  or  outside  the 
house  when  the  surgeon  operates  late.  Long  operations 
may  seriously  tax  the  surgeon's  strength  and  nerve,  and 
in  this  respect  again  the  afternoon  is  better  for  operating 
than  the  morning.  In  private  practice  and  wherever 
freedom  from  noise  and  plenty  of  warmth  can  be  en- 
sured, the  morning  is  probably  the  best  time,  especially 
in  summer.  As  far  as  light — a  most  important  factor — is 
concerned,  the  time  of  day  makes  little  difference  at  this 
time  of  the  year  in  London,  though  the  danger  of  a  sud- 
den darkening  of  the  atmosphere  is,  perhaps,  greatest  in 
the  afternoon. — British  Medical  Journal. 


I89i.] 


PRACTICAL  NOTES. 


133 


PRACTICAL  NOTES. 


CHRONIC    CONSTIPATION. 

At  the  meeting  of  the  Berlin  Medical  Society, 
Herr  Flatau  introduced  a  new  method  of  treating 
chronic  constipation  due  to  torpor  of  the  colon. 
This  consists  in  applying  about  three  grams  of 
boric  acid.  In  those  cases  in  which  the  lower 
edge  of  the  rectum  protrudes  through  the  anus 
and  when  this  remains  visible  after  powerful  con- 
tractions of  the  levator  ani  and  sphincters,  the 
quantity  of  boric  acid  mentioned  is  either  to  be 
dusted  on  or  rubbed  on  the  mucous  membrane  in 
sight.  In  cases  in  which  the  mucous  membrane 
is  not  visible,  it  must  be  insufflated.  It  is  impor- 
tant that  the  medical  attendant  should  carry  out 
the  procedure  himself,  at  any  rate  at  the  com- 
mencement. The  patient  should  then  keep  quiet 
for  a  time.  In  from  an  hour  to  three  hours,  per- 
istaltic action  will  be  observed  in  the  colon.  He 
has  never  seen  a  failure  from  this  method  of  treat- 
ment, nor  had  he  seen  a  case  where  the  patient 
got  so  accustomed  to  it  that  it  ceased  to  be  effec- 
tive. On  the  contrary,  if  carried  out  systematic- 
ally daily,  permanent  improvement  in  time  takes 
place,  and  normal  peristalsis  is  returned  to.  He 
had  tried  a  number  of  other  substances  but  none 
had  the  same  useful  effect. — Medical  Press. 


muth  ointment  used  instead.  The  author  affirms 
that  with  this  dressing  cicatrization  proceeds  rap- 
idly, and  there  is  less  discomfort  than  when  any 
other  dressing  is  employed.  Despite  the  large 
quantities  of  bismuth  that  have  been  applied  no 
toxic  symptoms  have  been  noted  in  consequence 
of  its  use. — Med.  Press  and  Circular. 


A  NEW  DIURETIC 

Dr.  Gram,  of  Copenhagen,  has  lately  intro- 
duced a  new  drug  known  as  diuretin.  It  is  made 
by  combining  theobromin  in  such  a  way  as  to 
make  it  exceedingly  soluble,  of  rapid  absorption, 
and  very  pleasant  to  take.  It  has  been  tested 
clinically  in  Strasburg;  is  found  to  act  directly  on 
the  kidneys  without  any  action  on  the  heart  or 
nervous  system,  such  as  we  have  in  digitalis  and 
caffeine. — Dietetic  Ga~ette. 


SYCOSIS. 

K  Iodoform,  4  parts;  lanolin,  30  parts.  Leache 
recommends  the  above  to  be  applied  even-  night, 
and  to  be  washed  off  in  the  morning  with  hot 
water. 


MALIC    ACID     LOZENGES    AS    AN    ANTICATARRHAL 
REMEDY. 

Malic  acid  lozenges  have  recently  found  con- 
siderable favor  in  England  as  a  remedy  for  sore 
throat  and  bronchial  cough.  They  are  reported 
as  efficient  not  only  in  excessive  secretion  of 
mucus  and  cough,  but  also  in  catarrhal  conditions 
of  the  bowels  and  in  haemorrhoids. 


THE  TREATMENT  OF    BURNS. 

Bardeleben  treats  burns  after  the  following 
plan.  The  injured  part  is  first  thoroughly  washed 
with  carbolic  acid  solution  from  2 1 2  to  3  per  cent., 
or  with  a  solution  of  salicylic  acid  about  3  in 
1,000.  All  the  bullae  are  then  punctured  and  the 
serum  allowed  to  escape,  after  which  the  whole 
part  is  thoroughly  dusted  with  finely  powdered 
nitrate  of  bismuth,  and  a  thick  layer  of  cotton 
wool  applied.  The  latter  is  changed  whenever  it 
is  -  impregnated  with  the  discharges  from  the 
wound.  If  the  burn  is  a  very  extensive  one,  the 
powdered  bismuth  may  be  set  aside,    and   a  bis- 


TREATMENT  OF  SYCOSIS  YULGASIS. 

Dr.  Rosenthal  proposes  a  method  of  treating 
sycosis  which  presents  three  great  advantages  : 
the  absence  of  pain,  relatively  rapid  cure,  and  fa- 
cility of  application.  The  diseased  parts  must  be 
carefully  scraped  every  da}- ;  and  morning  and 
evening,  and  also  three  times  during  the  da}-,  the 
following  pomade  should  be  applied : 

Tannic  acid,  1  gram. 
Milk  of  sulphur,  2  grams. 
Vaseline,  20  grams. 

The  face  of  the  patient  remains  uncovered  during 
the  day.  At  night,  after  friction,  an  emollient 
paste  is  applied:  Wilson's  zinc  ointment,  salicylic 
paste,  or  Hebra's  diachylon  ointment.  With  the 
latter  pomade,  if  the  dressing  be  carefully  made, 
the  formation  of  a  sulphate  of  lead  is  not  to  be 
feared.  The  author  has  lately  employed  with 
success  the  following  paste  : 

Tannic  acid.  5  grams. 
Milk  of  sulphur,  10  grams. 
Oxide  of  zinc,  17.5  grams. 

Starch,  17.5  grams. 
Vaseline,  50  grams. 

This  is  applied  morning  and  evening,  gauze  being 
placed  above  the  dressing.  Epilation  is  rendered 
unnecessary  by  this  treatment. — A/males  de  Derm, 
et  de  Syph.,  No.  4,  1890. 


MENSTRUAL  COLIC. 

Dr.  J.  C.  Da  Costa  prescribed  the  following  in 
a  case  of  menstrual  colic  : 

R.     Chloroform  .pur.  . 

Spir.  camphorae,  aa  f§ss. 

—  aether  nitrosi. 

—  aather  comp..  aa  fjjss.     "T. 

Sig.     f^ss-j  in  sj  of  water,  containing  3j  of  sr: 
menti,  every  half-hour  for  three  doses. 


134 


SOCIETY  PROCEEDINGS. 


[January  24 


SOCIETY   PROCEEDINGS. 

Gynecological  Society  of  Chicago. 

Regular  Meeting,  Sept.  26,  iSpo. 

The  President,  James  H.  Etheridge,  M.D., 
in  the  Chair. 
Dr.  Henry  Banga  read  a  paper  on 

ECTOPIC  PREGNANCY,  WITH  REPORT  OF  TWO 
CASES. 

(See  page  121.) 

Dr.  C.  T.  Parkes  :  With  all  of  you  I  have 
been  very  much  interested  in  these  eases  present- 
ed by  Dr.  Banga.  I  certainly  was  in  favor  of  the 
opinion  that  all  cases  of  extra- uterine  pregnancy 
should  pass  into  the  hands  of  the  laparotomist 
for  treatment  ;  but  in  looking  up  the  cases  I  have 
had  under  my  charge,  somewhat  to  my  surprise 
I  came  across  two  which  were  not  treated  by  op- 
erative procedure,  and  which  recovered.  I  have 
had  seven  cases  under  my  charge,  which  I  think 
were  all  cases  of  ruptured  extra- uterine  pregnan- 
cy, with  the  exception  of  the  last  one,  which 
went  on  the  full  term  and  three  months  beyond 
full  term  ;  she  came  under  my  care  with  a  dead 
foetus  and  well-marked  symptoms  of  septic  poi- 
soning. The  first  two  cases  came  to  me  some 
years  ago,  and  in  looking  over  my  notes  of  these 
cases  I  am  confirmed  in  the  supposition  I  had 
then,  that  they  were  cases  of  extra-uterine  preg- 
nancy. This  supposition  was  mainly  based  upon 
the  symptoms  mentioned  by  Prof.  Banga  as  in- 
dicative of  that  condition,  namely  :  1.  Acute 
and  severe  pain  in  the  pelvis;  2.  The  usual 
symptoms  of  great  loss  of  blood;  3.  A  previous 
history  of  several  or  many  years  of  sterility;  4. 
Interruption  of  previously  regular  menstruation; 
5.  Enlargement  of  the  uterus;  6.  The  presence 
of  a  tumor  circumscribed  in  character,  to  be  de- 
termined on  one  side  or  the  other  of  the  uterus  if 
examined  before  rupture.  If  after  rupture,  the 
discovery  of  a  large  mass,  doughy  and  inelastic, 
in  the  pelvis  and  lower  abdomen;  7.  The  pres- 
ence of  a  blood}-  vaginal  discharge. 

With  this  array  of  symptoms  it  seems  hardly 
possible  that  the  condition  can  be  mistaken,  and 
yet  in  contradistinction  to  that  we  must  bear  in 
mind  the  testimony  of  a  man  who  has  perhaps 
seen  the  greatest  number  of  these  cases — Mr.  Tait. 
He  says  he  has  never  seen  a  case  of  extra-uterine 
pregnancy  before  rupture  ;  that  every  case  that 
has  come  to  him — thirty-seven  in  all — has  been  a 
case  of  rupture.  So  I  must  object  a  little  to  the 
idea  that  it  is  an  easy  thing  to  recognize  the  pre- 
sence of  extra-uterine  pregnancy.  Thirty-seven 
cases  occurring  in  the  practice  of  one  man  would 
rather  indicate  that  physicians,  as  a  rule,  are  able 
to  recognize  the  condition  only  in  its  history,  or 
1  aware  of  the  value  of  these  symptoms  in 
all  cases.      In  the  first  two  cases  I  referred  to,  one 


presented  all  the  symptoms  that  I  have  passed  in 
review  and  which  were  previously  mentioned  by 
Professor  Banga  ;  but  she  was  not  operated  upon, 
because  as  that  time  I  do  not  think  much  operat- 
ing was  done  for  these  cases.  She  was  treated 
for  what  was  supposed  to  be  a  hasmotocele,  and 
she  went  on  in  great  danger  for  days  and  weeks, 
until  I  finally  aspirated  through  the  abdominal 
wall  and  withdrew  a  large  amount  of  bloody  fluid. 
I  aspirated  three  or  four  times  and  she  finally  got 
well.  The  second  case  presented  all  these  symp- 
toms, and  I  would  now  without  hesitation  advise 
operation,  as  a  case  of  extra  uterine  pregnancy. 
In  this  case  an  opening  was  made  through  the 
vagina  and  the  extravasated  blood  and  remnants 
drawn  away,  and  the  patient  recovered. 

These  are  two  cases  of  recovery  in  which 
laparotomy  was  not  done.  The  cases  out  of  the 
seven,  presenting  symptoms  of  ruptured  tubal 
pregnancy,  in  which  laparotomy  was  done  fol- 
lowed by  recovery,  I  have  already  presented  to 
this  Society.  The  sixth  case  was  a  lithopedion, 
which  I  removed  through  the  posterior  walls  of 
the  uterus,  and  reported  the  case  and  exhibited 
the  specimen  to  this  Society.  The  seventh  and 
last  case  was  that  of  a  lady  who  went  three 
months  beyond  full  term  with  an  extra-uterine 
pregnancy  and  was  taken  with  septic  s)'mptoms. 
I  operated  upon  her  and  removed  the  entire  sac 
and  contents  together.  This  case  again  proved 
what  Mr.  Tait  says  is  so  necessary  to  believe  in 
these  cases  as  a  rule — that  they  are  always  out- 
side of  the  peritoneum — and  which  is  proven  also 
by  the  frozen  section  described  so  beautifully  by 
Mr.  Hart.  All  the  organs  inside  the  peritoneum 
are  shoved  to  one  side  and  the  pregnancy  is  out- 
side, hence  the  method  of  treatment  of  the  latter 
period  of  extra- uterine  pregnane}'.  The  going 
to  full  term  is  a  matter  of  grave  consideration 
and  should  be  well  understood.  The  method 
spoken  of  by  Dr.  Banga  has  been  the  one  usually 
adopted — that  is,  opening  down  into  the  sac, 
sewing  it  to  the  wound  of  the  abdominal  walls, 
removing  the  foetus,  and  then  packing  the  cavity 
with  antiseptic  gauze.  Most  of  these  cases, 
previous  to  antiseptic  days,  died  of  septic  peri- 
tonitis. Since  antiseptic  precautions  have  been 
adopted  there  has  been  a  decided  improvement  in 
the  death-rate. 

The  method  of  treating  the  placenta  is  an  item 
of  great  importance  in  such  cases — that  is,  wheth- 
er it  should  be  left  or  removed.  Lately  an  article 
from  the  pen  of  Dr.  Braun  has  appeared  in  the 
German  Archives  of  Gynecology,  in  which  he  re- 
ports two  cases.  In  the  first  he  opened  the  sac, 
sewed  it  to  the  abdominal  wall,  removed  the  child , 
and  then  tried  to  ligate  the  vessels  of  the  placenta 
inside  the  sac  and  remove  the  placenta.  The  pa- 
tient died  from  loss  of  blood.  In  the  second  case 
he  opened  and  sewed  the  sac  to  the  abdominal 
walls,  but  ligated  the  vessels  outside  of  the  sac 


i89i.] 


SOCIETY  PROCEEDINGS. 


135 


by  means  of  stitch  ligation,  and  removed  the  pla- 
centa with  no  loss  of  blood.  The  patient  recov- 
ered. I  think  where  the  pregnancy  has  gone  to 
full  term,  it  is  not  best  to  wait  until  there  is  loss 
of  blood  from  separation  of  placenta  and  inabil- 
ity to  control  it,  but  to  follow  the  suggestion  of 
Dr.  Braun  and  primarily  ligate  the  vessels  outside 
of  the  sac,  as  can  be  done  by  means  of  a  needle 
and  ligature,  then  remove  the  placenta  and  pack 
the  cavity  with  gauze  dressing.  That  seems  the 
safest  way. 

This  is  an  important  subject,  and  I  certainly 
think  the  doctor's  first  patient  was  very  fortunate 
in  many  ways,  especially  in  that  she  fell  into  such 
skilful  and  efficient  hands,  with  gentlemen  who 
were  familiar  with  such  cases  and  able  to  recog- 
nize them  early  ;  because  I  believe,  as  a  rule,  it  is 
a  condition  not  easy  to  recognize.  And  she  was 
still  more  fortunate  in  that  she  had  the  confidence 
a  patient  should  have  in  the  attending  physician, 
and  consented  to  an  early  operation.  One  cannot 
help  for  a  moment  agreeing  that  it  is  better  to  do 
laparotomy  before  than  after  rupture. 

Dr.  W.  W.  Jaggard  :  I  have  listened  to  the 
reading  of  Dr.  Banga's  paper  with  great  interest. 
I  wish  to  restrict  my  remarks  to  early  tubal  preg- 
nancy, before  and  after  rupture.  In  the  diagno- 
sis of  Dr.  Banga's  first  case  there  were  two  signs 
of  pregnancy  present  that  I  do  not  remember  hav- 
ing heard  the  essayist  mention.  One  was  the  blue 
discoloration  of  the  anterior  vaginal  wall,  which 
was  more  marked  in  this  case  than  I  am  accus- 
tomed to  see  it,  even  in  normal  pregnancy. 
Chadwick,  in  a  very  excellent  paper  read  before 
the  American  Gvuecological  Society  several  years 
ago,  calls  attention  to  the  diagnostic  significance 
of  the  blue  discoloration  of  the  anterior  vaginal 
wall  below  the  meatus  urinarius.  The  second 
point  was  Hegar's  sign — the  softening  and  com- 
pressibility of  the  lower  uterine  segment ;  com- 
pressed between  the  hand  on  the  abdomen  and 
the  finger  in  the  vagina,  the  lower  uterine  seg- 
ment felt  as  thin  as  cardboard.  A  few  days  since, 
in  conversation  with  Dr.  Gehrung,  of-  St.  Louis, 
he  narrated  a  case  in  which  the  lower  uterine 
segment  was  so  thin  and  compressible  that  five 
prominent  physicians  of  St.  Louis  diagnosticated 
the  case  to  be  one  of  tubal  pregnancy  :  it  turned 
out  to  be  a  case  of  normal  pregnancy.  What  was 
supposed  to  be  the  uterus  was  merely  the  vaginal 
portion  ;  the  lump  in  the  abdomen,  the  corpus 
uteri,  was  separated  by  a  long  isthmus,  the  com- 
pressible, lower  uterine  segment. 

The  only  condition  that  closely  resembles  early 
tubal  pregnancy,  in  my  experience,  is  pregnancy 
in  a  retroflexed  uterus.  During  the  last  summer 
I  saw  a  case  (which  a  member  of  this  Society  had 
examined  very  carefully  bimanually)  .and  found  the 
vaginal  portion  of  the  cervix  very  much  elongated, 
the  lower  uterine  segment  very  thin  and  compressi- 
ble, so  much  so  that  one  would  not  notice  it  at 


all  unless  attention  was  called  to  it  :  behind  the 
vaginal  portion,  a  tumor.  The  woman  had  pain; 
slight  haemorrhage,  bearing  down,  and  a  dis- 
f  something  that  was  mistaken  for  decid- 
ua.  Under  the  genu-pectoral  position  for  a 
week,  the  nature  of  the  tumor  was  disclos 
was  a  case  of  pregnancy  in  a  retroflexed  uterus. 
The  woman  is  now  in  her  eighth  month  and  ex- 
pects to  be  confined  soon. 

In  justice  to  the  gentleman  who  first  examined, 
it  must  be  said  that  careful  examination  under  an 
anaesthetic  would  have  disclosed  at  once  the  na- 
ture of  this  retro-uterine  tumor.  He  did  not 
make  a  positive  diagnosis,  but  begged  for  an  ex- 
amination under  an  anaesthetic,  which  was  de- 
clined ;  and  the  patient  came  under  the  observa- 
tion of  Dr.  Webster,  of  Evanstou,  and  myself. 
As  a  general  rule,  when  the  conditions  for  biman- 
ual palpation  are  favorable — that  is.  when  the  ab- 
dominal walls  are  thin  and  relaxed,  particularly 
when  the  patient  can  be  anaesthetized — I  do  not 
think  there  is  much  difficulty-  in  the  diagnosis  of 
tubal  pregnancy  before  rupture.  Moreover.  I 
think  there  are  usually  present  symptoms  enough 
to  attract  the  woman's  attention  to  her  condition 
and  lead  her  to  apply  to  a  physician  before  rup- 
ture takes  place. 

I  wish  to  congratulate  Dr.  Banga  on  his  diag- 
nostic skill  in  this  case.  It  is  certainly  the  first 
case  in  Chicago  operated  upon  at  so  early  a  date 
and  before  rupture  of  the  sac. 

As  regards  treatment  of  tubal  pregnancy  before 
rupture,  I  think  the  weight  of  evidence  and  of  re- 
sponsible opinion  is  in  favor  of  laparotomy  with 
extirpation  of  the  sac.  It  is  true  that  fceticide  by 
means  of  electricity  is  defended,  more  particularly 
in  the  Eastern  United  States.  I  do  not  think  this 
practice  can  be  upheld  on  rational  grounds  nor 
upon  the  results  that  have  followed  the  use  of 
this  method.  The  oue  individual  to  whom  honor 
is  due  for  establishing  laparotomy  before  rupture 
is  J.  Yeit,  of  Berlin,  who  has  operated  success- 
fully on  some  seven  cases. 

The  universal  proposition  that  laparotomy 
should  be  performed  in  every  case  of  ruptured  tu- 
bal pregnancy  cannot  be  accepted  at  the  present 
day.  The  natural  history  of  tubal  pregnancy 
shows  that  in  the  majority  of  cases  recovery  re- 
sults ;  there  are  five  favorable  terminations  to  one 
unfavorable.  In  the  first  place,  the  tube  may 
rutiture  into  the  broad  ligament,  and  we  have 
the  formation  of  a  haematoma,  or  a  broad  ligament 
pregnancy,  both  relatively  favorable  terminations 
for  the  time  being.  Sometimes  the  tube  ruptures 
and  the  egg  remains  in  situ,  acting  as  a  tampon — 
also  a  favorable  termination.  Then  we  have  the 
tube  rupturing,  and  the  product  of  conception,  and 
blood,  forming  a  retro- uterine  baematocele — a 
relatively  favorable  termination  not  demanding  a 
primary  laparotomy.  I  think  the  essayist  goes  a 
little  too  far  when  he  says  all  retro-uterine  haem- 


r3° 


SOCIETY  PROCEEDINGS. 


[January  24, 


atoceles  are  the  results  of  tubal  pregnancy.  That 
view  was  advanced  years  ago  by  Dr.  Gallard,  but 
it  has  been  sifted  down  to  about  75  per  cent,  due 
to  ruptured  tubal  pregnancy.  Finally  we  have 
the  tube  ruptured,  with  free  intraperitoneal  haem- 
orrhage, the  woman  dying  either  of  primary 
haemorrhage  or  from  secondary  peritonitis.  There 
is  only  one  among  all  these  terminations  that  is  un- 
favorable, and  I  think,  therefore,  it  is  not  right  to 
say  perform  laparotomy  in  every  case  of  ruptured 
tubal  gestation.  Perform  laparotomy  when  there 
are  signs  of  free  intraperitoneal  haemorrhage, 
when  there  is  evidence  that  peritonitis  will  likely 
ensue.  It  must  be  borne  in  mind  that  in  case  of 
rupture  before  the  third  month  the  ovum  is  sterile 
and  all  its  surroundings  are  commonly  sterile,  and 
in  some  cases  even  of  intraperitoneal  haemorrhage 
the  blood  and  foetus  will  be  dissolved. 

Dr.  D.  T.  Nelson:  The  subject  has  been  so 
freely  discussed  that  it  is  hardly  worth  while  for 
me  to  take  the  time  to  discuss  it  more,  especially 
as  I  can  hardly  differ  from  the  expressions  already 
made.  However,  I  will  refer  to  one  case  which  I  saw 
five  or  six  years  ago.  This  case  was  just  beyond 
term,  or  perhaps  exactly  at  term — it  was  diffi- 
cult to  determine  the  exact  date  of  pregnancy. 
But  she  had  had  a  kind  of  false  labor,  thought 
herself  in  labor,  sent  for  a  physician,  who  found 
there  was  some  difficulty  in  a  normal  delivery 
and  suspected  extra-uterine  fcetation.  The  fol- 
lowing day  I  saw  the  patient  in  consultation; 
there  could  be  no  question  but  that  the  woman 
was  pregnant,  and  no  question  that  the  foetus  was 
outside  the  uterus.  After  making  an  examina- 
tion I  became  satisfied  that  the  foetus  was  alive, 
but  so  very  feeble  that  it  seemed  to  me  there  was 
no  hope  of  saving  the  child  by  operation;  and 
then  I  had  the  thought,  as  I  have  now,  that  it  is 
not  the  best  time  to  operate  at  full  term  unless 
you  can  save  the  foetus.  In  this  case  there 
seemed  no  hope  of  doing  this,  because  there  were 
only  the  slightest  movements,  while  the  day  be- 
fore they  had  been  fairly  strong,  and  the  day  be- 
fore that  well-marked  and  active.  I  advised 
against  operation  at  that  time,  as  I  thought  there 
would  be  more  likelihood  of  saving  the  mother 
by  waiting  until  the  placental  circulation  had 
diminished  very  considerably,  as  I  believe  it  does 
after  the  death  of  the  fcetus.  What  has  become 
of  the  patient  I  am  unable  to  say. 

Dk  Frank i. in  H.  Martin:  I  should  like  to 
make  a  few  remarks  on  the  power  of  electricity 
to  destroy  the  foetus  in  these  cases.  I  think  it  is 
a  little  too  radical  to  say  that  no  other  treatment 
than  laparotomy  should  be  used  for  the  treatment 
of  tubal  pregnancy;  I  believe,  with  those  who 
have  spoken  to-night,  that  laparotomy  should  be 
performed  fe?r  this  condition  if  the  diagnosis  is 
reasonably  certain,  and  the  consent  to  an  opera- 
tion of  all  parties  concerned  can  be  obtained.  If 
the  patient  has  the  confidence  in   her  physician 


that  the  patient  exhibited  in  this  case,  and  the 
operation  can  be  done,  then  perform  laparotomy. 
There  are  cases,  however,  where  laparotomy 
will  not  be  tolerated.  Thomas  in  the  lead,  we 
have  pretty  good  authority  for  the  substitution 
of  electricity  in  these  particular  cases. 

In  connection  with  this  subject  I  have  made 
some  experiments.  They  are  not  extensive  nor 
conclusive,  but  certainly  suggestive;  they  are  in 
the  direction  of  determining  which  current  to 
choose,  if  we  decide  to  use  electricity  in  these 
cases,  I  believe  that  Thomas  and  others  recom- 
mend the  faradic  current  in  preference  to  galvan- 
ism. It  has  always  seemed  to  me  that  it  is  desir- 
able to  employ  every  precaution  against  ruptur- 
ing the  sac;  if  this  be  so,  and  the  fceticidal  effects 
of  galvanism  and  faradism  are  the  same — that  is, 
if  they  are  equally  efficacious — I  should  say  un- 
der those  circumstances  use  galvanism;  because, 
if  employed  with  an  absolute  gradual  rheostat  so 
as  to  produce  no  break,  it  can  be  applied  with  the 
minimum  abdominal  muscular  contraction  or 
other  muscular  contractions  which  favor  the  rup- 
ture of  the  sac.  The  experiments  that  I  made 
were  for  the  purpose  of  determining  the  relative 
fceticidal  value  of  the  two  currents.  The  experi- 
ments were  conducted  by  the  employment  of  in- 
cubating hens' eggs.  A  given  number  of  fresh  eggs, 
all  obtained  from  as  near  the  same  source  as  pos- 
sible, were  placed  in  an  incubator  and  placed  un- 
der the  charge  of  an  expert  chicken  breeder. 
These  eggs  were  divided  previously  into  four 
divisions,  and  properly  marked.  At  the  end  of 
one  week  after  the  eggs  were  set  two  portions  of 
the  eggs  were  operated  upon  by  electricity;  one 
portion  by  a  very  strong  (as  strong  as  could  be 
tolerated  by  an  unanaesthetized  patient)  faradic 
current  passing  for  five  minutes;  the  other  por- 
tion by  a  20-milliampere  current,  electrode  4  sq. 
cm.  in  area,  also  passing  for  five  minutes.  The 
galvanic  current  was  applied  by  means  of  a  grad- 
ual rheostat  in  such  a  manner  as  to  produce  no 
make  or  break  in  the  flow. 

At  the  end  of  two  weeks  of  the  incubation  the 
other  two  portions  of  the  eggs  were  treated  by 
electricity  in  the  same  manner,  with  the  excep- 
tion that  the  faradic  current  was  made  much 
stronger  (such  as  would  be  tolerated  only  by  an 
anaesthetized  patient)  and  the  galvanic  current 
increased  to  50  milliamperes. 

When  the  eggs  had  passed  the  allotted  time  for 
hatching,  about  80  per  cent,  of  the  first  lot  acted 
upon  by  the  faradic  current  hatched,  while  not 
one  of  those  treated  by  the  galvanic  current 
hatched.  Of  the  second  lot  about  60  per  cent. 
remained  undestroyed,  while  not  one  of  the  chicks 
treated  by  galvanism  succeeded  in  piercing  its 
shell. 

This  proved  to  my  mind  quite  conclusively,  as 
far  as  chicks  are  concerned,  that  electricity  in  the 
form  of  galvanism    is   much    more  efficient  than 


i89i.] 


SOCIETY  PROCEEDINGS. 


137 


faradization;  in  fact  faradization  had  little  effect 
upon  the  eggs.  If  this  same  ratio  of  value  should 
exist  in  the  power  of  electricity  to  destroy  the 
human  ovum,  we  have  an  additional  scientific 
advantage  in  galvanism  in  being  able  to  regulate 
our  dose.  One  can  cause  to  pass  through  a  foetus 
encased  in  its  sac  exactly  the  same  dose  and  the 
same  density  that  caused  the  destruction  of  the 
foetus  in  these  eggs,  and  I  have  no  doubt  what- 
ever that  a  foetus  of  three  or  four  months'  growth 
would  be  deprived  of  life  as  effectually  as  the 
chicks  were  at  the  end  of  two  weeks  of  incuba- 
tion. 

Dr.  Christian  Fenger:  Mr.  Chairman,  Gen- 
tlemen of  the  Society:  I  have  heard  the  paper 
with  a  great  deal  of  interest,  and  congratulate 
Dr.  Banga  on  his  very  successful  operations.  The 
subject  of  ectopic  gestation  in  general,  particular- 
ly the  later  stages,  is  too  large  for  discussion  in 
one  evening. 

It  is  remarkable  how  of  late  years  the  number 
■of  reported  operations  for  extra-uterine  pregnancy 
has  increased.  Let*is  take  the  last  three  years, 
1887,  1888,  1889.  In  1887  there  were  about  50 
operations  recorded,  in  1888  there  were  70  opera- 
tions, and  in  1889  no. 

Of  the  70  cases  reported  in  1888,  15  were  of  tu- 
bal pregnancy  in  which  the  early  operation  was 
performed — that  is,  before  rupture — with  3  deaths, 
a  mortality  of  20  per  cent.  In  two  of  the  fatal 
cases  the  sac  was  fastened  in  the  abdominal 
wound.  In  the  remaining  13  cases  total  extirpa- 
tion of  the  tube  with  its  contents  was  practiced  ; 
the  operation  was,  as  a  rule,  comparatively  easy, 
and  the  results  consequently  better. 

Sixteen  cases  were  operated  upon  at  the  time  of 
rupture,  with  5  deaths,  a  mortality  of  31  per  cent. 
or  much  greater  than  the  mortality  when  the  op- 
eration was  performed  before  rupture  of  the  sac. 
We  may  here  mention  Lawsou  Tait's  28  cases 
with  only  1  death,  a  mortality  of  only  3  '  per 
cent  From  the  report  of  these  cases,  however, 
it  cannot  be  seen  whether  the  operation  was  per- 
formed at  the  time  of,  or  some  time  after,  rupture. 

Ten  cases  were  operated  upon  several  weeks 
after  rupture,  and  only  1  died,  a  mortality  of  10 
per  cent.  At  this  time  the  patient  has  recuper- 
ated to  a  certain  extent.  This,  of  course,  does 
not  mean  that  the  operation  should  not  be  done 
at  the  time  of  rupture. 

Then,  again,  come  the  6  cases  Dr.  Jaggard  has 
mentioned,  where  nothing  was  done  and  only  1  of 
which  died.  Dr.  Parkes  and  Dr.  Jaggard  have 
mentioned  that  the  contents  of  the  sac  in  early 
tubal  pregnancy  are  aseptic  and  will  not  cause 
peritonitis. 

In  1889  there  are  on  record  75  cases  operated 
upon  in  the  first  half  of  pregnancy,  of  which  10 
died,  a  mortality  of  13  per  cent.  Twenty-eight 
of  these  were  operated  upon  before  the  rupture  of 
the  sac,  all  of  which  recovered  ;  21  were  operated 


upon  at  the  time  of  rupture,  with  17  recoveries 
and  4  deaths,  a  mortality  of  19  per  cent.;  26  were 
1  upon  some  time  after  rupture,  when  the 
patient  had  recovered  from  its  immediate  effects, 
with  20  recoveries  and  6  deaths,  a  mortality  of 
23  per  cent. 

The  entire  mortality  for  the  first  half  of  preg- 
nancy in  1888  was  26  per  cent.,  while  in  1889  for 
the  same  class  of  cases  it  was  13  per  cent.  The 
rapid  increase  in  the  number  of  cases  reported 
show--  cither  that  now  an  earlier  diagr.' 
more  frequently  made  or  that  laparotomy  is  now 
more  readily  resorted  to  for  peri-uterine  tumor, 
whether  a  positive  diagnosis  of  tubal  pregnancy 
can  be  made  or  not.  We  also  see  that  early  op- 
eration in  extra-uterine  pregnancy  has  given  bet- 
ter results  each  succeeding  year. 

The  rest  of  the  statistics  belong  to  the'  later 
periods  of  pregnancy,  and  I  shall  not  meution 
them  in  this  connection,  because  it  really  does 
not  come  under  the  subject  of  the  paper — "  Early 
Tubal  Pregnancy,  its  Symptoms  and  Treatment.'' 
My  own  experience  is  almost  none.  I  ha\ 
one  case  where  the  sac  had  ruptured  and  very 
severe  hfemorrhage  had  set  in,  but  in  which, 
under  expectant  treatment,  the  patient  finally 
recovered. 

In  1S88,  the  statistics  gathered  by  Harris,  of 
Philadelphia,  showed  twenty-seven  cases  of  lapa- 
rotomy with  living  children.  Of  these,  twenty- 
five  mothers  died,  and  of  the  twenty-five  living 
children  thirteen  died  within  fifty  hours.  This 
frightful  mortality  led  Litzman  to  give  the  advice, 
based  upon  a  record  of  twenty-six  cases  with  six 
deaths,  not  to  operate  until  the  child  was  dead 
and  the  placental  circulation  had  ceased,  so  as  to 
avoid  placental  haemorrhage. 

Lawson  Tait  was  the  first  to  take  up  a  strong 
position  against  the  practice  of  sacrificing  chil- 
dren. He  has  recorded  three  cases  of  operation 
with  living  children,  in  which  he  saved  all  the 
children  and  two  mothers.  He  further  argues 
against  Harris  as  to  the  lack  of  vitality  in  the 
children  of  extra-uterine  pregnancy,  stating  that 
the  three  children  above  mentioned  were  living 
and  healthy,  so  much  so  that  one  of  the  children 
he  saved  by  this  operation  is  his  adopted  son  and 
prospective  successor. 

The  operations  recorded  for  1889  show*a  great 
improvement  in  the  results  of  operations  in  the 
last  half  of  pregnancy,  inasmuch  as  thirty- five 
cases  had  only  six  deaths,  or  1 7  per  cent.  Further- 
more, the  operations  with  living  children  for  the 
last  two  years  tend  to  bear  out  Harris  in  his  as- 
sertion that  the  regard  for  the  child  miM  be  a 
secondary  one,  inasmuch  as  in  eleven  operations 
— six  in  iS^S,  and  five  in  1889 — only  four  living 
children  were  saved,  and  as  four  out  of  the  eleven 
mothers  died,  a  mortality  of  36  per  cent. 

As  to  the  fate  of  the  mothers  when  operating 
after  placental  circulation  has  ceased,  there  were 


138 


SOCIETY  PROCEEDINGS. 


[January  24, 


reported,  in  1888,  eighteen  cases  with  six  deaths; 
in  1889,  twenty-six  cases  with  three  deaths;  in 
all,  forty-four  cases  with  nine  deaths,  or  a  mor- 
tality of  about  20  per  cent.  Thus  it  is  safer  for 
the  mother,  as  Litzman  proposes,  as  against 
Lawson  Tait,  to  wait  until  the  child  is  dead  and 
the  placental  circulation  has  ceased. 

In  this  connection  I  will  also  say  that  five  years 
ago  I  thought  exactly  as  Dr.  Nelson  does,  and  I 
think  so  now,  and  in  a  case  of  extra-uterine  preg- 
nancy present  low  down  in  the  vagina,  waited 
until  the  foetus  had  died,  and  then  waited  six 
weeks  longer  until  the  placenta  had  ceased  to 
pulsate,  and  then  still  two  weeks  more  in  order 
to  be  safe.  I  then  removed  the  child,  which  was 
at  full  term,  through  the  vagina.  The  case  has 
been  mentioned  in  this  Society,  as  Dr.  Holmes 
was  kind  enough  to  see  the  case  at  the  time  with 
a  view  of  determining  whether  such  a  foetus  was 
septic  or  aseptic. 

I  do  not  see  that  we  have  time  to  discuss  the 
details  of  the  value  of  these  late  operations  in 
extra-uterine  pregnancy,  whether  through  the 
vaginal  wall  or  through  the  vagina. 

Dr.  C.  W.  Earle  :  In  the  very  brief  remarks 
which  I  will  make  I  desire  more  particularly  to 
speak  regarding  the  diagnosis  of  these  cases.  In 
the  discussion  up  to  this  time  it  would  seem  that 
about  the  only  thing  to  be  done  is  to  stop  the 
growth  of  the  foetus  either  by  electricity  or  mor- 
phine, or  remove  the  sac  by  laparotomy.  The 
most  important  but  difficult  question,  in  my 
judgment,  is  to  arrive  at  a  correct  diagnosis.  Dr. 
Jaggard's  remarks  reminded  me  of  a  case  to  which 
I  was  called  in  consultation  a  few  months  ago. 
It  was  believed  to  be  a  case  of  extra-uterine 
pregnancy,  and  the  gentleman  who  asked  me  to 
see  the  case  with  him  thought  an  operation  would 
be  necessary.  He  based  his  diagnosis  upon  the 
points  Dr.  Jaggard  made — that  is,  the  tbin  con- 
dition of  the  wall  found  by  digital  examination  ; 
the  wall  that  separated  the  finger  from  the  fcetus 
did  not  seem  thicker  than  a  sheet  of  paper,  and 
yet  after  careful  examination  we  both  agreed  that 
the  foetus  was  inside  the  uterus,  and  the  case 
went  on  to  .1  safe  delivery  at  full  term.  A  few 
minutes  before  I  started  for  this  meeting  I  took 
Winckel's  last  work,  translated  by  Edgar,  and 
jotted 'down  the  symptoms  upon  which  he  based 
his  diagnosis.  While  he  considers  that  it  is  a 
difficult  condition  to  diagnosticate,  he  believes, 
after  an  experience  in  thirteen  cases,  that  he  can 
usually-  arrive  pretty  closely  at  a  correct  conclu- 
sion. He  bases  his  diagnosis  upon  these  Symp- 
lons :  First,  the  cessation  of  normal  menstrua 
tion,  previously  normal  ;  second,  hypersemia  and 
secretion  of  the  breasts  ;  third,  hypersemia  and 
Iividity  of  the  vulva  (this  symptom  has  been 
thoroughly  discussed  by  Dr.  Kanga  and  Dr.  Jag- 
gard);  fourth,  strong  pulsation  of  blood-vessels 
in  the  vault  of  the  vagina;    fifth,  softening  en- 


largement, and  displacement  of  the  womb  ;  sixth, 
a  clearly  defined  and  growing  tumor  ;  and  lastly, 
a  murmur  or  souffle  above  the  symphysis,  heard 
at  rather  an  early  period.  He  insists  on  frequent 
observations  and  examinations,  so  that  he  can 
determine  the  rapidity  of  the  growth  of  the 
tumor.  I  think  Dr.  Jaggard's  statement  that  all 
authorities,  except  Americans,  believe  in  early 
laparotomy  in  these  cases,  is  a  little  too  positive. 
In  Winckel's  book  he  states  decidedly  that  he 
believes  there  is  a  chance  for,  first,  electricity  ; 
secondly,  for  a  trial  with  morphine  or  some  of 
the  other  poisons  that  will  destroy  the  life  of  the 
child. 

Dr.  Bayard  Holmes  :  The  mother  is  ex- 
posed in  extra-uterine  pregnancy  to  an  immedi- 
ate and  to  a  remote  danger.  The  immediate 
danger  is  fatal  anaemia  when  rupture  of  a  tube 
takes  place,  and  the  remote  danger  is  sepsis  in  a 
limited  haematoina  or  in  a  retained  dead  foetus. 
For  the  anaemia  there  seems  to  be  an  indication 
for  transfusion  which  may  prove  valuable.  In  a 
study  of  the  bacterial  condition  of  dead  extra- 
uterine fcetuses  which  I  presented  to  this  Society, 
my  attention  was  called  to  the  great  danger  of 
sepsis.  Haematomata  in  other  parts  of  the  body- 
are  ordinarily  removed  without  any  febrile  dis- 
turbance, except  that  early  and  transient  rise 
which  has  been  attributed  to  "  ferment  intoxica- 
tion." The  case  is  very  different  in  those  pelvic 
haematomata  which  are  due  to  extra- uterine 
fetation.  Both  the  retained  dead  fetuses  and  the 
haematomata  in  this  region  become  infected,  in 
the  great  proportion  of  cases,  within  six  mouths, 
and  a  large  percentage  of  the  remainder  by  the 
end  of  a  year.  This  fact,  I  believe,  is  to  be  ex- 
plained by  the  cause  of  extra-uterine  fetation, 
which  there  is  great  reason  to  believe  lies  in  an 
antecedent  infective  inflammation  in  the  tubes  or 
the  endometrium. 

In  order  that  an  extra-uterine  pregnancy  may 
take  place,  there  must  be  some  malformation  or 
deformity  in  the  sexual  apparatus.  It  does  not 
take  place  in  the  normal  condition  of  the  tubes 
and  uterus.  That  it  may  be  a  malformation  we 
can  readily  see,  because  the  present  condition  of 
the  human  uterus  is  evolved  from  a  very  large 
and  divided  uterus  which  is  exhibited  in  the 
lotus  and  the  lower  animals.  We  may  expect 
an  occasional  reversion  to  the  original  type,  and 
hence  a  risk  of  extra-uterine  fetation.  Such  an 
arrest  of  development  cannot  often  occur,  because 
anatomists  do  not  find  these  deformities  frequently. 

Most  cases  of  extra-uterine  pregnancy  are  pre- 
ceded In  a  long  term  of  sterility  following  an  un- 
healthy puerperium,  which  in  itself  points  to 
some  deformity  in  the  sexual  apparatus  arising 
from  one  cause  or  another.  It  is  probable  that 
most  of  these  cases  of  deformity  are  due  to  a  pro- 
cess of  inflammation,  and  that  inflammation  is 
due  to  sepsis,  and  sepsis  is  due  to  infection  ;   that 


iSqi.] 


SOCIETY  PROCEEI  >INGS 


accounts  for  the  presence,  in  close  proximity  to 
this  extra-uterine  fcetus,  of  septic  material,  and 
it  is  the  presence  of  that  septic  material  which 
converts  the  haematoma  into  an  abscess.  Of 
course  we  must  always  consider  the  possi- 
bility of  pressure  atrophy  between  the  heavy, 
dead  foetus  and  the  contents  of  the  bowel  (hard 
faeces)  opening  a  communication  between  the 
bowel  and  the  fcetus  and  producing  infection  in 
that  way.  That  must  be  considered  in  these 
cases,  but  it  cannot  well  be  considered  in  cases 
of  large  accumulations  of  blood.  We  cannot 
consider  the  possibility  of  suppuration  or  any  sep- 
tic decomposition  of  a  large  mass  of  blood  with- 
out infection  ;  that  is  impossible.  Infection  is 
rare  through  the  circulation,  but  it  is  not  wholly 
unknown.  Therefore  I  look  upon  the  indica- 
tion to  be  these  two  :  The  dangers  from  haemor- 
rhage and  the  dangers  from  sepsis.  But  the  dan- 
ger from  sepsis  is  imminent  on  account  of  the 
probable  etiology  of  extra-uterine  fetation. 

Dr.  E.  W.  Sawyer:  I  will  add  but  one 
thought,  which  was  brought  to  my  mind  by  the 
remarks  of  Dr.  Nelson — that  is,  that  a  sort  of 
false  labor  sometimes  appears  at  term.  This  re- 
minded me  of  a  case  I  attended  in  1874,  with  Dr. 
Justice,  of  Denver,  in  a  little  village  in  the  foot- 
hills of  Colorado  called  Boulder.  The  woman 
had  expected  to  be  delivered  two  years  before  our 
visit,  and  was  visited  by  a  very  intelligent  atten- 
dant who  described  a  series  of  phenomena  near- 
ly approaching  normal  labor,  which  extended 
through  a  period  of  nearly  twenty  four  hours; 
then  everything  subsided.  She  carried  her  size 
for  about  a  year,  when  she  grew  smaller  and  be- 
came active  again.  She  was  the  wife  of  the  pro- 
prietor of  the  single  hotel  there,  and  we  visited 
her  for  the  purpose  of  performing  laparotomy. 
The  details  of  the  operation  shock  me  now  as 
compared  to  the  precautions  taken  to-day.  We 
operated  and  removed  a  fetus  which  weighed  4 -■  + 
lbs.  Its  tissue  was  converted  into  a  sort  of  adi- 
pocere,  so  that  in  flexing  the  elbows  the  tissues 
cracked.  The  sac  contained  much  pus,  and  the 
precautions  against  sepsis  were  not  to  any  degree 
■observed.  The  poor  woman  died  at  the  end  of 
about  three  days. 

Dr.  H.  W.  Banga,  in  closing  the  discussion, 
said :  As  to  the  diagnosis  of  these  cases,  Dr. 
Jaggard  mentioned  a  case  of  retroverted  uterus 
that  was  taken  for  extra-uterine  pregnancy,  and 
remarked  that  probably  b)'  using  an  anaesthetic 
the  true  condition  of  the  case  would  have  been 
revealed  at  once;  so  I  would  repeat  that  for  a  cor- 
rect diagnosis  it  is  absolutely  necessary  to  use  an 
anaesthetic,  as  I  think  we  ought  to  do,  and  prob- 
ably most  of  you  do  if  in  doubt  about  the  nature 
of  any  pelvic  disorder.  Dr.  Jaggard  took  excep- 
tion to  my  statement  that  laparotomy  should  be 
performed  in  all  cases  of  rupture.  I  see  I  did  not 
make  my  statement  plain  enough.    I  had  in  view 


what  was  /i»7«(v/i'  called  extra-uterine  pregnancy, 
thus  excluding  beforehand  the  cases  of  haemato- 
cele.  Up  to  a  few  years  ago  haematocele  was  not 
described  as  one  of  the  outcomes  of  a  case  of  tu- 
bal pregnancy,  and,  as  far  as  its  clinical  aspect  is 
concerned,  it  takes  an  entirely  different  run  from 
free  rupture  into  the  abdominal  cavity.  Since  I 
have  listened  to  Dr.  Holmes'  remarks  I  am  more 
than  ever  convinced  that  laparotomy  is  the  thing 
to  be  done  in  the  latter  cases. 

I  should  think  it  only  proper  to  try  in  this  man- 
ner to  stop  the  haemorrhage  if  the  symptoms  show 
that  internal  haemorrhage  is  the  prime  danger,  or 
to  remove  a  septic  fetus  and  wash  out  the  perito- 
neal cavity  if  sepsis  is  the  more  prominent  symp- 
tom. In  relation  to  this  question  of  doing  lapar- 
otomy, we  must  always  bear  in  mind  that  from 
year  to  year  laparotomy,  as  such,  becomes  less 
dangerous  ;  and  we  all  know,  too,  that  as  each  of 
us  sees  more  of  these  cases,  we  also  have  more 
personal  confidence  in  being  able  to  control  sep- 
sis I  must  say  that  I  consider  the  dangers  inci- 
dent to  the  operation,  as  such,  to  be  very  small. 
I  further  refer  Dr.  Jaggard  to  what  I  said  about  the 
treatment  of  haematocele.  I  did  not  recommend  any 
immediate  surgical  interference  in  those  cases.  I 
said  I  would  first  wait  for  resorption,  because  I 
knew  that  resorption  is  the  rule  in  a  case  of  haema- 
tocele; should  it  fail  to  occur  I  would  try  an  opera- 
tion. Dr.  Parkes  related  a  case  that  he  cured  by 
aspirating;  I  have  had  a  similar  one.  Then,  if  the 
symptoms  warranted  it,  I  would  open  and  evacu- 
ate, either  through  the  abdomen  or  through  the 
vagina.  In  my  second  case,  the  steady  increase  of 
the  tumor,  causing  intense  pain,  and  the  displace- 
ment of  the  bladder  away  above  the  symphysis, 
so  that  the  patient  was  entirely  unable  to  pass 
water,  were  the  direct  indications  for  operating. 
In  cases  of  haematocele  there  is  very  little  danger 
of  the  patient  bleeding  to  death,  because,  no 
doubt,  the  beginning  of  the  haemorrhage  occurs 
into  the  distended  tube  or  between  the  folds  of 
the  broad  ligament.  During  the  first  hours  or 
days  it  is  a  haematoma,  and  only  after  the  tension 
of  the  bloody  tumor  has  become  such  that  the  cov- 
ering peritoneum  finalty  tears  will  there  be  a  free 
effusion  of  blood  into  the  abdominal  cavity.  This 
was  quite  plain,  I  think,  in  my  second  case.  There 
was  a  haematocele  filling  out  the  Douglas  cul-de- 
sac  up  to  near  the  umbilicus,  and  inside  of  this 
sac  was  what  we  might  call  a  haematoma  of  the 
left  broad  ligament,  or  rather  a  haematomo-sal- 
pinx.  because  the  big  coagulum  corresponded  to 
the  middle  of  the  left  tube,  both  ends  of  which 
were  torn  by  the  accumulation  of  blood  within. 
Hardly  ever  is  there  any  immediate  danger 
from  haemorrhage  in  case  of  haematoma  or  haem- 
atocele, because  the  coagulum  which  forms  at  the 
seat  of  the  first  oozing  acts  as  a  compressing  tam- 
pon on  the  ruptured  blood-vessels.  But  where 
the  sac  ruptures  freely  into  the  abdominal  cavity. 


140 


SOCIETY  PROCEEDINGS. 


[January  24, 


the  patient  is  liable  to  bleed  to  death,  either  in  a 
few  hours  or  a  few  days.  I  remember  about  nine 
years  ago  having  seen  such  a  case.  It  was  a  very 
hot  day  in  July.  The  lady  was  getting  ready  to 
go  down  town,  and  while  she  was  standing  before 
the  glass,  giving  the  finishing  touch  to  her  toilet, 
she  was  suddenly  seized  with  vertigo  and  a  sharp 
pain  in  her  abdomen ;  she  began  to  vomit,  and 
had  all  the  symptoms  of  cholera  morbus.  Sev- 
eral physicians  were  sent  for,  and,  as  she  had  di- 
arrhoea and  tenesmus  within  an  hour  of  the  first 
attack,  they  took  it  for  a  case  of  cholera  morbus. 
This  occurred  about  10  o'clock  in  the  morning, 
and  I  was  called  in  about  9:30  in  the  evening. 
At  that  time  I  was  making  reports  from  German 
periodicals  for  Dr.  Munde,  and  there  was  much 
discussion  going  on  about  extra-uterine  pregnan- 
>  that  when  I  saw  the  patient  I  at  once 
thought,  "  I  wonder  if  this  is  not  a  case  of  rup- 
ture of  an  extra-uterine  ovisac?"  She  was  al- 
most bloodless ;  the  lips  and  conjunctiva  had  lost 
all  color;  she  was  breathing  heavily,  had  no  pulse; 
the  skin  looked  waxy  and  was  covered  with  a 
cold  sweat ;  she  was  apparently  dying.  By  digi- 
tal examination  I  found  the  posterior  cul-de-sac 
bulging  down,  giving  a  peculiar  doughy,  soft 
touch,  which  to  me  plainly  demonstrated  an  ac- 
cumulation of  something  like  coagulated  blood.1 
While  I  was  there  the  patient  died.  I  was  so 
much  interested  to  know  what  it  was  that  I  got 
permission  of  the  husband  to  make  a  post-mor- 
tem. On  opening  the  abdomen  the  black,  half- 
coagulated  blood  welled  out,  and,  after  removing 
it,  I  found  a  tubal  ovisac  about  as  large  as  a  big 
plum,  which  had  burst,  thus  causing  unhindered 
oozing  of  blood,  and  death.  The  patient  had 
been  married  eight  weeks  ;  had  gone  two  weeks 
over  her  last  menstruation. 

I  should  think  it  impossible  to  confound  a  case 
of  free  haemorrhage  into  the  abdominal  cavity, 
and  a  case  of  haematoma  or  haematocele  retro- 
uterina. 

To  Dr.  Parkes  I  would  say  I  did  not  leave  any 
coagula  in  the  haematocele  sac ;  I  opened  it  and 
scooped  it  out  with  my  hand.  Of  course  there  is 
nothing  so  apt  to  undergo  quick  disintegration  as 
blood. 

FCETUS  PAPYRACETS. 

Dr.  W.  W.  Jaggard:  My  friend  and  former 
pupil,  Dr.  A.  E.  Froom,  of  Chicago,  gave  me  the 
specimen  that  I  have  the  honor  to  present. 

History. — May  1st,  1S90,  Dr.  Froom  was  called 
to  -.cc  Mrs.  M  ,  age  21  years, recently  married;  three 
months  advanced  her  in  first  pregnancy  ;  suffering 
from  nausea  and  vomiting.  The  complaint  not 
yielding  at  once  to  the  usual  simple  remedies 
prescribed,  the  patient  applied,  but  without  bene- 


■  Veil  Bince,  claims  that  it  is  impossible  to  diag- 

nose by  digital  examination  an  accumulation   of  coagulated  blood 
I  iminal  cavity. 


fit,  to  several  prominent  physicians.  Finally, 
about  the  fifth  month,  she  returned  to  Dr.  Froom. 
At  this  time  the  woman  was  in  a  most  distressing 
condition  —  incessant  vomiting  and  retching, 
diarrhoea,  bloody  stools,  tormina  and  tenesmus, 
fainting  spells.  The  woman  complained  of  in- 
tense vulva  and  anal  pruritus,  and  upon  exami- 
nation Dr.  Froom  discovered  a  "a  scaly  eruption 
about  the  parts,"  and  infiltration  of  the  inguinal 
glands  ou  both  sides.  Alopecia  was  also  observed. 
The  diagnosis  of  syphilis  was  made,  although  a 
careful  search  failed  to  reveal  the  initial  lesion. 

Under  the  exhibition  of  mercury  the  woman 
showed  immediate  and  marked  improvement. 

August  1 2th  patient  fell  in  premature  labor. 
Patient  had  not  been  able  to  perceive  fcetal  move- 
ment for  the  week  previous,  and  the  heart  tones 
were  not  perceptible.  After  four  hours  of  labor  a 
macerated  foetus,  corresponding  to  the  seventh 
month,  was  expelled ;  it  was  followed  in  ten 
minutes  by  the  placenta.  Dr.  Froom  was  about 
to  irrigate  the  uterine  cavity  when  he  noticed  the 
intact  membranes  of  a  second  ovum  presenting  at 
the  os  externum.  This  second  ovum,  correspond- 
ing to  the  third  month,  was  easily  expressed. 
Puerperium  normal ;  uterus  is  single.  The  father 
admits  syphilitic  infection  three  years  ago. 

The  specimen  consists,  as  you  see,  of  a  twin 
pregnancy. 

The  first  twin,  female,  length  35  cm.,  weight 
1 172  gm.,  with  its  macerated  epidermis,  is  a  typ- 
ical example  of  the  fcetus sanguinolentus  (E.  Mar- 
tin). It  corresponds  to  the  seventh  month.  It 
also  presents  certain  objective  signs  of  syphilis 
that  are  perfectly  distinct  from  mere  cadaveric 
changes.  These  are:  1.  The  line  of  syphilitic 
osteo-chondritis  at  the  junction  of  the  diaphvsis 
with  the  epiphysis  in  the  long  bones,  described 
by  Wegner.  In  this  specimen  you  can  see  this 
line  in  the  upper  and  lower  epiphyses  of  the  fe- 
mur. 2.  The  spleen  is  greatly  increased  in  vol- 
ume, consistence,  and  weight.  It  weighs  12  gm., 
or  0.98  per  cent,  of  the  total  weight  of  the  fcetus, 
while  the  average  normal  weight  of  the  spleen  at 
birth  is  9  gm. ,  or  0.3  per  cent,  of  the  body  weight. 
According  to  Ruge,  in  normal  foeti,  under  2,000 
gm.  the  weight  of  the  spleen  is  Tiff  of  the  body 
weight;  in  non-syphilitic  macerated  foeti,  ;, ,,; 
in  syphilitic  macerated  foeti,  , ,',  ,.  In  this  case 
the  spleen  is  -}=  of  the  body  weight.  3.  The  liver 
weighs  52.5  gm.  According  to  Ruge,  in  normal 
foeti  under  2,000  gm.  the  weight  of  the  liver  is  fe 
of  the  body  weight ;  in  non-syphilitic  macerated 
:  in  macerated  syphilitic  foeti,  _.' j-.  In 
this  case  tin-  liver  is  about  .,'.  of  the  body  weight. 

No  gross  lesions  were  detected  in  the  cord, 
lungs,  liver,  spleen,  and  these  organs  have  not 
vet  been  examined  microscopically. 

Unfortunately,  the  placenta  was  thrown  out  by 
the  nurse.  Dr.  Froom  said  the  cord  was  oedema- 
tous  (?),  and  that  an  amber-colored,    transparent 


I89i.] 


SOCIETY  PROCEEDINGS. 


14' 


substance,  of  the  consistence  of  jelly,  was  attached 
to  the  membrane. 

.  The  ovum  of  the  second  twin  is  intact ;  its 
weight  is  88.5  gm.,  and  it  presents  an  instance 
of  niutnmification — the  usual  post-mortem  change 
in  fceti  between  the  third  and  sixth  months  in 
titer 0.  The  placenta,  fully  formed,  is  flattened 
and  compressed  into  a  solid  disc  10  cm.  in  diam- 
eter. The  liquor  amuii  has  disappeared.  The 
foetus,  about  three  months  old,  male,  13  cm.  in 
Length,  is  a  typical  example  of  the  foetus papyra- 
ceus — the  form  commonly  observed  when  a  dead 
foetus,  retained  in  utero  for  a  considerable  period, 
is  strongly  compressed  and  flattened  out,  as  the 
name  implies.  The  conditions  for  this  peculiar 
mode  of  compression  are  best  supplied  in  twin 
pregnancy,  in  which,  while  one  foetus  dies,  the 
twin  goes  on  to  complete  development. 

The  points  of  interest  in  this  specimen  that  I 
beg  to  mention  are : 

1.  These  fceti— each  with  its  own  placenta, 
chorion  and  amnion ;  the  one  female,  the  other 
male — contained  within  the  same  single  uterine 
cavity,  are  probably  the  resultants  of  the  simulta- 
neous fecundation  of  two  ova.  These  ova  may 
have  come  from  the  same  Graafian  follicle,  or  from 
the  same  ovary,  or  from  both  ovaries.  According 
to  the  old  view,  the  fact  that  the  placentae  are 
entirely  separate  would  indicate  that  the  ova  did 
not  come  from  the  same  ovary.  For  some  cause, 
not  now  discoverable,  the  ovum  containing  the 
male  was  crowded  to  the  wall  by  the  other,  and 
converted  into  this  fiattened-out,  paper-like  mass. 

The  specimen,  probably,  is  not  an  example  of 
superimpregnation.  While  the  possibility  of  su- 
perfecundation — that  is,  the  successive  fecunda- 
tion of  two  or  more  ova  out  of  the  same  ovulation 
period — in  the  human  animal  must  be  admitted, 
its  actual  occurrence  has  never  been  demonstrated. 
The  not  uncommon  occurrence,  1,  of  a  white  wo- 
man having  twins,  one  a  mulatto,  the  other  white; 
and  2,  of  a  black  woman's  twins,  one  black, 
the  other  a  mulatto,  does  not  prove  successive 
fertilization  by  different  men.  Kussmaul  has 
correctly  pointed  out  that  in  the  crossing  of 
races  the  offspring  may  resemble  most  closely 
either  parent,  so  that  a  white  infant  born  of  a 
white  woman  may  be  the  legitimate  child  of  a 
negro.  Schultze  emphasizes  this  opinion,  and 
demands,  for  the  demonstration  of  superfecunda- 
tion,  two  different  children  of  a  white  woman 
after  cohabitation  with  two  men  differing  in  race  1 
from  each  other  and  from  the  mother.  Such  an 
observation  up  to  the  present  has  not  been  re- 
corded. Undoubtedly  superfecundation  occurs  in 
mares,  bitches  and  cats,  among  the  lower  animals, 
but  then  multiple  pregnancy  is  the  normal  among 
these  animals,  while  it  is  exceptional  and  closely 
allied  to  the  abnormal  in  the  human  animal. 
Conclusions  drawn  from  observation  of  the  lower 
animals  accordingly  cannot  be  applied  directly  | 
to  human  beinsrs. 


The  principal  arguments  against  super/ 
— that  is,   conception  &\  nancy — lie  in 

the  suppression  of  ovulation  and  the  disappear- 
ance of  the  cilia  of  the  epithelium  of  the  endom- 
etrium during  gestation,  and  finally  the  entire 
absence  of  observations,  that  would  make  this 
hypothesis  plausible. 

2.  First  pregnancies  are  seldom  multiple  preg- 
nancies. 

3.  The  objective  philis  in  the  macer- 
ated foetus,  that  are  perfectly  distinct  from  the 
cadaveric  changes  of  non-syphilitc  inacera',' 
retained  within  the  cavum  uteri.  I  venture  to 
emphasize  this  point,  because  it  is  a  common 
error  to  regard  all  macerated  fceti  as  syphilitic. 
Indeed,  between  70  and  80  per  cent,  of  such  cases 
are  syphilitic,  but  there  remains  a  certain  num- 
ber in  which  the  foetus  sanguinolenlus  is  merely 
the  result  of  cadaveric  change.  In  some  of  these 
cases  of  the  latter  class,  it  is  very  difficult  to 
make  an  anatomical  diagnosis,  since  the  relative 
increase  in  the  weight  of  the  viscera  is  not 
an  absolutely  certain  sign  of  syphilis,  and  the 
normal  line  of  Guerin  may  come  to  resemble  the 
ostea-chondritis  described  by  Wegner. 

EXHIBITION  OF  BROMIFORM. 

Dr.  Ciias.  W.  Eaki.e:  I  want  to  occupy  two 
or  three  minutes  of  the  time  of  the  Society  in  the 
consideration  of  a  very  unpopular  procedure — 
that  is,  the  administration  of  medicine — and  in- 
troduce to  your  notice  bromiform,  the  latest  rem- 
edy for  whooping  cough.  About  six  weeks  ago 
my  attention  was  called  to  this  drug  by  an  article 
in  a  German  paper,  and  about  that  time  an  article 
was  also  published  in  the  Medical  Record  by  Dr. 
Fischer,  reporting  some  sixteen  cases  to  which  he 
had  administered  it  with  marked  benefit.  By 
this  time  I  had  procured  the  medicine,  and  have 
now  had  experience  with  it  in  six  cases.  In  five 
cases  there  has  been  marked  improvement,  al- 
though it  was  not  a  fair  trial,  because  they  had 
passed  pretty  well  along  into  the  second  stage 
and  had  commenced  to  recover.  In  some  of  these 
cases  there  were  thirty  paroxysms  a  day  previous 
to  administering  the  drug,  and  in  four  days  the 
paroxysms  had  been  reduced  to  ten.  It  has 
rather  a  sharp,  pungent  odor,  and  it  is  best  ad- 
ministered in  syrup  of  acacia.  I  usually  com- 
bine it  with  a  little  paregoric.  The  dose  for  a 
child  two  years  of  age  is  two  drops,  a  child  four 
years  old  four  or  five  drops.  Usually  the  admin- 
istration from  twenty  to  sixty  drops  in  five  or 
six  days  lessens  the  number  of  paroxysms.  It  is 
best  given  after  meals;  and  the  children  to  whom 
I  have  administered  it  have  made  no  objection  to 
taking  it.  It  is  recommended  by  several  of  the 
leading  practitioners  in  Vienna,  and  I  bring  it 
before  the  Society  because  we  are  having  consid- 
erable whooping  cough  and  I  think  it  would  be 
well  to  a:ive  it  a  trial. 


142 


SPECIAL  CORRESPONDENCE. 


[January  24, 


SPECIAL  CORRESPONDENCE. 


Treatment  of  Blepharospasm. 

To  the  Editor. — In  the  last  number  of  The 
Journal  (December  27.  1890),  under  the  head- 
ing of  "Treatment  of  Blepharospasm,"  Giraud, 
(  Thise  dc  Paris)  is  quoted  as  treating  this  annoy- 
ing and  at  times  intractable  affection  by  forcible 
dilatation,  using  a  pair  of  retractors  or  a  spring 
speculunr — the  separation  of  the  lids  being  car- 
ried to  a  degree  of  exposing  the  conjunctival  cul- 
de-sac — and  keeping  the  eyelids  in  this  position 
for  three  or  four  minutes.  For  several  years  I 
have  been  using  a  similar  method  in  my  clinic  at 
the  New  York  Eye  and  Ear  Infirmary — with  the 
difference  that  I  do  not  forcibly  put  the  orbicu- 
laris palpebrarum  on  the  stretch.  The  good  re- 
sults, not  from  stretching,  but  from  the  exposure 
of  the  sensitive  cornea  to  daylight — the  natural 
stimulus  of  the  eye.  In  all  cases  of  conjunctival 
or  corneal  trouble  this  procedure  cures  the  bleph- 
arospasm if  it  exists.  The  speculum  is  put  be- 
tween the  eyelids  and  opened  so  as  to  expose  the 
cornea.  Patient  is  kept  with  the  eye  exposed  to 
diffuse  daylight  from  five  to  ten  minutes.  I  find 
that  most  of  the  cases  occur  in  children  and  are 
due  to  phlyctenular  keratitis.  In  many  of  the 
cases  the  photophobia  is  very  great,  and  the  chil- 
dren avoid  light  with  might  and  main.  The  little 
sufferer  buries  its  face  in  the  pillow  or  the  moth- 
er's breast.  With  this  condition  existing  for  a 
few  weeks — the  room  darkened,  perhaps — it  is 
easy  enough  to  imagine  how  a  blepharospasm 
comes  on.  If  the  child  is  placed  in  an  upright 
position  or  put  on  its  back,  the  chances  are  that 
it  will  begin  to  sneeze.  This  is  due  to  the  change 
in  temperature  that  takes  place  in  the  nose.  When 
the  head  is  buried  in  the  breast  or  pillow  the  nose 
is  kept  unduly  warm  by  the  breath,  but  on  chang- 
ing from  the  bent  position,  so  that  the  breath  does 
not  unduly  heat  the  nose,  the  sneezing  begins, 
the  slight  change  in  temperature  is  sufficient.  In 
this  connection  I  may  add  that  it  is  not  the  light 
which  causes  the  child  to  sneeze,  as  some  suppose. 

With  regard  to  the  suggestion  of  using  an  eye 
speculum  in  blepharospasm,  the  credit,  if  I  am 
not  mistaken,  belongs  to  the  late  Dr.  C.  R.  Ag- 
new.     Very  truly, 

Peter  A.  Callan,  M.D. 

New  York,  December  29,  1890. 


Shall  The  Journal  be  Removed  to 
Washington? 

To  the  Editor: — I  cannot  see  any  valid  reason 
for  changing  the  locality  of  publication  of  The 
JOURNAL.  If  at  any  time  it  could  be  shown  that 
the  interest  of  The  Journal  and  of  the  members  of 
the  Association   would   be  enhanced,  then  I  am 


ready  to  cooperate  with  the  members  in  such 
action.  It  seems  to  me  removal  to  Louisville, 
Cincinnati  or  New  York  would  be  just  as  good 
as  Washington.  Facilities  of  mail  are  such 
that  subscribers  will  receive  The  Journal  with- 
in a  few  hours  as  soon  from  Chicago  as  any  other 
point.  N.  Holton,  M.D. 

Harkers  Corners,  111.,  Jan.  13,  1891. 


To  the  Editor: — By  all  means  do  not  remove 
The  Journal  office.  Chicago  I  consider  by 
odds  the  very  best  place  for  the  office  for  several 
splendid  reasons ;  the  first  I  consider  enough 
— "that  it  is  so  easy  of  access  from  any  part  of 
the  United  States."  I  also  think  that  there  area 
good  many  other  good  reasons  in  favor  of  Chicago, 
but  do  think  this  one  enough,  especially  when 
compared  with  Washington,  which  place  I  think 
has  no  good  reason  in  favor  of  such  a  removal. 
H,  K.  Tefft,  M.D. 

Topeka,  Kan., Jan.  II,  1S91. 


To  tk".  Editor: — I  am  opposed  to  the  proposi- 
tion made  to  move  the  publication  office  and  man- 
agement of  The  Journal  of  the  Association  to 
Washington  City.  I  vote  Chicago  to  be  con- 
tinued as  its  permanent  home  because  it  is  most 
central  and  has  unexcelled  mail  facilities  to  all 
parts  of  the  country,  and  because  it  is  now  and 
will  continue  to  be  nearer  the  centre  of  population, 
and  destined  to  be  the  greatest  medical  centre  of 
the  United  States. 

I  would  formulate  a  ballot  and  distribute  to 
every  member  of  the  Association,  requesting  his 
vote  on  location,  with  signature  and  P.  O.  ad- 
dress, to  be  returned  to  the  committee  having  the 
question  of  location  in  charge.  This  seems  to  be 
the  legitimate  way  to  satisfactorily  settle  the 
issue.  •  W.  W.  Hester,  M.D. 

3640  Cottage  Grove  Ave.,  Chicago,  Jan.  16,  1891. 


To  the  Editor: — While  there  appear  so  many 
reasons  for  keeping  The  Journal  where  it  is,  I 
oppose  the  question  of  removal.  It  would  seem 
that  the  facility  of  distribution  which  the  present 
location  affords  should  decide  the  matter  if  noth- 
ing else  does. 

I  second  Dr.  Dimmitt's  motion  that  a  vote  be 
taken  at  an  early  date.  This  will  give  every 
member  a  chance  to  express  his  opinion. 

W.  E.  Ward,  M.D. 
255  North  ave.,  Chicago,  111.,  Jan.  17,  1S91. 


To  the  Editor: — I  am  opposed  to  moving  The 
Journal  to  Washington  or  any  other  city.  The 
suggestion  of  Dr.  Dimmitt's  (January  17)  is  a 
good  one.  J.  N.  Dixon,  M.D. 

Springfield,  111.,  Jan.  19,  1S91. 


To  the  Editor: — There  is  no  citv  in  the  United 


i89i.] 


NECROLOGY. 


143 


States  more  suitable  for  the  publication  of  The 
Journal  than  Chicago.  It  is  unwise  to  move 
and  it  is  the  height  of  folly  to  move  The  Jour- 
nal from  a  large,  rapidly  growing  city  with  its 
large  material  for  journalism,  to  a  small  town 
even  though  it  be  the  capital  of  the  country. 
-r  !.«•..  J-  F.Jenkins,  M.D. 

recumseh,  Mich.,  Jan.  19,  1891. 

To  the  Editor.— 1&  The  Journal  remain  where 
lt  ls-  I.  N.  Brainerd,  M.D. 

Alma,  Mich.,  January  19,  1891. 


nor  expense  to  address  The  Journal  at  Chicago 
than  at  Washington.  Then  what  is  to  be  gained 
by  removing  it  to  Washington  ? 

W.  F.  Rochelle,  M.D. 
Jackson,  Teun..  January  19,  1891. 


To  the  Editor.— -From  a  common-sense  view  of 
the  subject,  it  does  appear  that  a  petty  rivalry 
plays  a  prominent  part  in  the  controversy. 

If  there  is  one  cause  more  patent  than  all  oth- 
ers why  The  Journal  should  be  moved  it  per- 
haps lies  in  this  query  :  Is  it  more  profitable  to 
cater  to  the  whims  of  one  faction  rather  than  ob- 
^fj^  °ld  adage>  "letwell  enough  alone?" 
Whilst  it  is  probable  that  The  Journal  would 
receive  an  additional  support,  both  in  contributors 
and  readers,  if  moved,  yet  this  gain- would  most 
likely  be  at  the  expense  of  losing  some  of  the 
present  support. 

But  for  a  solution  of  this  problem,  much  of 
course  depends  on  a  proper  appreciation  of  the 
rivalry  existing  between  the  two  sections,  and  the 
bearing  of  this  rivalry  on  the  medical  profession  I 
A  medical  journal  in  any  section  of  the  coun- 
try,  receives  most  of  the  support  from  the  near 
surroundings,  and  becomes  identified  with  the1 
writers  of  that  section.  A  journal  in  the  East  is 
supported  mainly  by  Eastern  writers,  in  the  WTest 
by  U  estern,  and  in  the  South  by  Southern  writers 
This  is  all  well  enough  generally,  but  when  a 
journal  belongs  to  a  National  Association  such  a 
tendency  to  become  identified  with  any  one  sec- 
tion to  the  exclusion  of  all  others,  is  detrimental ! 
I  * ,!  1 ettfT  interests  °f  the  Association,  and 
should  be  thwarted  in  its  incipiency 

To  argue  that  The  Journal,  if  moved  to  the 
East,  would  not,  in  after  years,  become  identified 
with  Eastern  writers  to  a  very  great  extent,  seems 
contrary  to  our  past  observation. 

Chicago  is  neither  Eastern,  Southern,  nor  ex- 
tremely Western,  and  should  be  taken  as  a  liberal 
compromise. 

To  let  it  remain  would  only  disappoint  a  small 
number  of  the  Eastern  members  of  the  Associa- 
tion, but  to  remove  it  to  Washington  would  meet 
mm  almost  the  unanimous  opposition  of  the  North 
South  and  West.  The  postal  facilities  are  such 
that  it  makes  but  little  difference  whether  The 
Journal  is  printed  in  Maine  or  California. 

Should  it  be  removed  to  Washington  the  East 
era  correspondents  would  have  to  send  their  com- 
munications and  receive  their  Journal  by  mail 
just  the  same  as  at  present.    It  is  no  more  trouble 


NECROLOGY. 


Dr.  Archibald  O.  Ameden,  formerly  of 
Ticonderoga  and  health  officer  of  Glens  Falls,  N 
Y.,  died  suddenly  in  his  office,  November  28,  of 
cardiac  disease.  He  graduated  from  the  Medical 
Department  of  the  University  of  Vermont  in 
1865,  and  was  a  member  of  the  Warren  County 
Medical  Society. 

Dr.  Glover  Perin, Colonel  and  Assistant  Sur- 
geon General,  U.S.A.,  retired,  died  at  his  home  in 
St.  Paul,  Minn.,  December  15.  He  was  appointed 
Assistant  Surgeon  U.  S.  A.,  from  Ohio,  Decem- 
ber 4,  1847,  and  attained  the  rank  of  Surgeon 
and  Major  May  21,  1861.  His  experience  cov- 
ered the  Mexican  and  Civil  Wars.  He  was  Med- 
ical Director  of  the  Department  of  the  Cumber- 
land, headquarters  at  Louisville,  Ky.,  during  the 
latter  contest,  in  which  capacity  he  displayed 
great  administrative  ability,  and  later  he  was  in 
charge  of  one  of  the  general  hospitals  in  Evans- 
j  ville,  Ind.  After  the  close  of  the  war  he  served 
as  Medical  Director  of  the  Department  of  the 
Missouri  for  six  years,  and  the  Department  of 
the  Dakota  from  1883  to  his  retirement  in   1887. 

Dr.  Frederick  Salzer,  one  of  the  Professors 
of  Surgery  at  the  University  of  Vienna,  died 
somewhat  unexpectedly  on  Nov.  30.  He  had 
been  just  twenty  years  in  the  professorate.  The 
Brit  Med.  Journal  says:  "In  him  consummate 
surgical  skill  was  associated  with  remarkable  good 
luck  in  respect  of  the  results  that  followed  his 
operations,  two  things  that  do  not  always  go  to- 
gether. He  did  not  wield  the  pen  with  the  same 
facility  as  he  used  the  knife,  and  he  contributed 
comparatively  little  to  surgical  literature."  He 
was  sixty-three  years  of  age. 


Dr.  Alfred  F.  Holt  died  in  Martin,  Fla.,< 
whither  he  had  gone  in  quest  of  health,  Dec.  28, 
1890.  He  was  graduated  from  the  Medical  De- 
partment of  the  University  of  Vermont  in  i860, 
and  joined  the  30th  Massachusetts  Infantry  a 
year  afterward,  as  Asst.  Surgeon,  but  was  pro- 
moted Nov.  26,  1862,  to  be  Surgeon  of  the  1st 
Texas  cavalry,  and  was  mustered  out  as  the 
Lieut. -Colonel  commanding  of  the  latter  regiment 
May  20,  1865.  He  performed  many  acts  of  per- 
sonal heroism  in  carrying  wounded  soldiers  off 
the  field  of  battle,  and  was  commended  in  gen- 
eral orders  for  his  bravery.     At  the  time  of  his 


144 


MISCELLANY. 


[January  24,  1891. 


•death  he  was  Surgeon- General  of  the  Massachu- 
setts Volunteer  Militia,  having  been  appointed 
by  Gov.  Robinson  Jan.  3,  1884,  and  also  U.  S. 
Pension  Examiner  for  Cambridge,  Mass. 


MISCELLANY. 


List  of  Permanent  Members. — The  following  names 
-were  omitted  from  the  List  of  Permanent  Members  :  Dr. 
M.  H.  Burton,  Troy,  N.  Y.;  Dr.  J.  R.  Hinkle,  Sullivan, 
Ind.;  and  Dr.  S.  J.  Wright,  Tallmadge,  O. 


Health  in  Michigan. — For  the  month  of  December, 
1890,  compared  with  the  preceding  month,  the  reports 
indicate  that  puerperal  fever,  cholera  infantum,  pleuritis, 
membranous  croup,  pneumonia,  inflammation  of  bowels, 
inflammation  of  brain,  measles  and  whooping-cough  in- 
creased, and  that  typhoid  fever  and  scarlet  fever  decreased 
in  prevalence. 

Compared  with  the  preceding  month  the  temperature 
was  lower,  the  absolute  humidity  was  less,  the  relative 
humidity  was  slightly  more,  the  day  ozone  and  the  night 
ozone  were  more. 

Compared  with  the  average  for  the  mouth  of  December 
in  the  four  years  1S86-1889,  pleuritis,  membranous 
croup,  influenza,  puerperal  fever,  cholera  infantum, 
bronchitis  and  cholera  morbus,  were  more  prevalent, 
and  measles,  typho-malarial  fever,  whooping-cough,  and 
typhoid  fever  were  less  prevalent  in  December,  1890. 
'  For  the  month  of  December,  1890,  compared  with  the 
average  of  corresponding  months  in  the  four  years  1SS6- 
18S9,  the  temperature  was  slightly  lower,  the  absolute 
humidity  and  the  relative  humidity  were  slightly  less, 
the  day  ozone  was  slightly  less  and  the  night  ozone  was 
more. 

Including  reports  by  regular  observers  and  others, 
diphtheria  was  reported  present  in  Michigan,  in  the 
mouth  of  December,  1890,  at  70  places,  scarlet  fever  at  100 
places,  typhoid  fever  at  41  places,  and  measles  at  33 
places. 

Reports  from  all  sources  show  diphtheria  reported  at 
5  places  more,  scarlet  fever  at  32  places  more,  typhoid  fever 
at  9  places  less,  and  measles  at  10  places  more  in  the 
month  of  December,  1890,  than  in  the  preceding  mouth. 


B.  Baker,  Atlanta,  Ga.;  Dr.  Chas.  McLean,  Griswold,  la.; 
Dr  R  Galloway,  Bloomington,  Ind.;  Dr.  H.  T.  Bahn- 
son  Salem,  X.  C;  Dr.  T.  E.  Schenck,  Harvey ville, 
Ivans.;  Dr.  S.  S.  Stewart,  Allegheny,  Pa.;  Dr.  G.  M.  B. 
Maughs,  San  Francisco,  Cal.;  Dr.  Rowland  G.  Freeman, 
Dr  D  A.  McMichel,  Dr.  J.  I.  Bluestone,  J.  H.  Bates,  A. 
W.  Jackson,  Dr.  M.  E.  Van  Fleet,  'Women's  Medical 
College  American  and  Continental  Sanitas  Co.,  Lehn  & 
Fink  J.  Movius  &  Son,  N.  Y.  City  ;  F.  B.  O'Conner,  Dr. 
R.  M.  Wyckoff,  Brooklyn,  N.  Y.;  Dr.  Dowhng,  Cincinnati, 
O-  Rio' Chemical  Co.,  Dios  Chemical  Co.,  St.  Louis; 
Do'liber-Goodale  Co.,  Boston;  Dr.  C.  R.  Greenleaf, 
Washington,  D.  C;  Dr.  W.  E.  Quine,  Dr.  Z.  P.  Hanson, 
Rush  Medical  College,  Lord  &  Thomas,  Dr.  G.  Frank 
Lvdstou,  C.  M.  Moore,  Subscription  News  Co.,  Chicago; 
I  The  Philadelphia  Polyclinic,  Dr.  AY.  B.  Atkinson,  \Vm.  R. 
Warner  &  Co.,  Dr.  R.J.  Dunglison,  Philadelphia;  Tarrant 
&Co.,  Dr.  W.  M.  Beckwith"  Dr.  M.  R.Klein,  Dr.  Mary 
H.  Cotton,  New  York  City;  H.  A.  Jones,  Dr.  W.  J. 
Delahanty,  Worcester.  Mass.;  Dr.  G.  W.  Browne,  St. 
Louis,  Mo.;  A.  J.  Cook,  Dr.  A.  L.  Hummel,  G.  H.  Rigby, 
Philadelphia;  New  Table  Co.,  St.  Louis,  Mich. 


LETTERS   RECEIVED. 


Dr.  F.  W.  Samuel,  Louisville,  Ky.;  Dr.  M.  W.  Scott, 
Emerado,  N.  Dak.;  Canton  Surgical  &  Dental  Chair  Co., 
Canton,  O.-  Dr.  J.  J.  Winn,  Norwood,  O.;  Dr.  W.  E.  B. 
Davis,  Birmingham,  Ala.;  Dr.  B.  W.  Davis,  Montgomery, 
Vt.;  Dr.  E.  B.  Woodruff,  Auburn,  N.  Y. ;  Dr.  E.  P.  Rob- 
inson, Orange  City,  Fla.;  Valentine's  Meat  Juice  Works, 
Richmond,  Va.;  Dr.  M.  A.  Bogie,  Kansas  City.  Mo.;  In. 
W.  H.  Siebert,  Steelton,  Pa.;  Miss  Mary  D.  Troye,  South 
Manchester,  Conn.;  Dr.  A.  ( ).  Oilman,  St.  Cloud,  Minn.; 
Worcester  District  Med.  Association.  Worcester,  Mass.; 
Di  I,  «',.  North,  Tecumseh,  Mich.;  Dr.  E.  H.  Dudley, 
Janesville,  Wis.;  I>r.  G.  W.  Murphy,  Danbury.  la.;  1  Us. 
I  \V.  and  R.  La  Grange,  Marion.  la.;  Dr.  John  Casson, 
aria,  La.;  Dr.  R.  Harvey  Reed,  Mansfield,  <>.; 
Dr.  C.  II.  Bruner,  Greenfield,  Ind.;  Kegau  Paul,  Trench, 
i  &  Co.,  London,  Eng.;  Horlick's  Food  Co.,  Ra- 
cine, Wis.;    Sharp  &    Dohme,    Baltimore,   ML;    Di     I.   A. 

McSwain,  Paris,  Tenn.;   Dr.  J.  H.  Thompson,  Lansing, 

la.;  Dr.  I.  Win.  Trabert,  Annville,  Pa.;    Dr.  F.  W.  Dim 

mitt.  Oneida,  111.;    Dr.    ]',.    P.  Hart,  Marietta,  ().;    Dr.  II. 

ii.  i,    South    Kaukauna,    Wis.;    Dr.    C.    W.     Rook, 

San  Antonio,  Texas ;  Dr.  D.  S.  Booth,  Belleville,  111., 
Dr.  W.  T-  Robinson.  Lapeer,  Mich.;  Dr.  I,.  II.  Calloway, 
Mevada,  Mo.;  Dr.  Henry  Baker,  Lansing,  Mich.;    Dr.  A. 


Official  List  of  Changes  in  the  Stations  and  Duties  of 
Officers  Serving  in  the  Medical  Department,  U.  S. 
Army,  from  January  io,  iSgt,  to  January  /6,  1891. 

First  Lieut.  Henry  D.  Snyder,  Asst.  Surgeon,  is  relieved 
from  duty  at  Ft.  Reno,  Oklahoma  Ter.,  and  will  report 
in  person  to  the  commanding  officer,  Camp  Guthrie, 
Oklahoma  Ter..  for  duty  at  that  station,  relieving  Capt. 
John  L.  Phillips,  Asst.  Surgeon.  Capt.  Phillips,  on 
being  so  relieved,  will  report  in  person  to  the  com- 
manding officer.  Ft.  Reno,  Oklahoma  Ter.,  for  duty  at 
that  station.  Bv  direction  of  the  Secretary  of  War. 
Par.  16,  S.  O.  i'i,  A.  G.  O.,  Washington,  January  14, 
1S91. 

PROMOTIONS. 

To  be  Asst.  Surgeon  with  the  rank  of  Captain,  after  five 
years'  service,  in  accordance  with  the  Act  of  June  23, 

1874: 
Asst.  Surgeon  Henry  S.  T.  Harris,  January  5.  1891. 
Asst.  Surgeon  Leonard  Wood,  Januarys,  1891.    A.  G.  O., 

Washington,  January  12,  1S91. 

Official  List  oj  Changes  in  the  Medical  Corps  of  the  I '.  S. 

'     Navy  for  the  two  Weeks  Ending  January  17,  189/. 
Surgeon  M.  L.  Ruth,  ordered  to  the  U.  S.  S.."  Newark," 
February  2,  1S91.  ,„..'■.>  T-     c     c 

P    A    Surgeon  W.   H.    Rush,    detached  from  L.    S.   fa. 

'"Saratoga,"  and  to  the  U.  S.  S.   "Newark,"  February 

P.  A.  Surgeon  Richard  Ashbridge,  ordered  to  the  O.  S.  S. 

"  Saratoga."  .  , 

Medical  Director  W.  T.  Hord,  ordered  as  President  of 

Medical    Board,    to    relieve    Medical    Director   J.    \. 

MecHcalDirector  R.  C.  Dean,  detached  from  hospital, 
Chelsea,  and  to  Medical  Board,  Washington. 

Medical  Director  J.  Y.  Taylor,  to  be  placed  on  the  Re- 
tiro!  List  January  22. 

1'.  A.  Surgeon  W.  H.  Rush's  orders  to  the  "Newark  are 
revoked.  .         0 

P.  A.  Surgeon  Richard  Ashbridge's  orders  to  the  Sara- 
toga "  revoked,  and  wait  orders. 

P.  A.  Surgeon  A.  G.  Cabell,  detached  from  ironclads  and 
to  the    "Newark."  '  . 

P.  A.  Surgeon  G.  P.  Lumsdcn,  ordered  to  the  ironclads 
at  Richmond,  Ya. 


CORRIGENDA, 
m  the  list  ..f  Permanent  Members  published  in  The  Journal 

the  address  of  brTRienzi   Robinson   should  read   DanuhonvtlU, 
Robinson,  Lapeei    Mich.,  and  that  of  Dr. 
E.  Paul  Sale,  Memphis,  Tenn. 


T  1 1  E 


J  ournal  of  the  American  Medical  Assi  datii  in. 

EDITED  UNDER  THE  DIRECTION  OF  THE  BOARD  OF  TRUSTEES. 

PUBLISH  E  I)    WEEKLY. 


Vol.  XVI. 


CHICAGO,  JANUARY  31,   1891. 


No  5. 


ADDRESSES. 

THE  PHYSICIAN  AS  A  MAN  AND  A 
CITIZEN. 

The  Presidential  Address  delivered  before  ietyof  the 

District  of  Columbia  on  December  17th, 

BY  SWAN  M.   BURNETT,   M.D.,    Ph.D., 

PROFESSOR   OF     OPHTHALMOLOGY   AND    OTOLOGY   IN   GEORGETOWN 
UNIVERSITY.  OPHTHALMIC     AND    AURAL   SURGEON    TO   THE    GAR- 
FIELD, THE  PROVIDENCE.  AND  THE    CHILDREN'S  HOSPITALS. 
DIRECTOR  OF  THE  EYE  AND   EAR   CLINIC   AT    THE    EMER- 
GENCY HOSPITAL  AND  CENTRAL  DISPENSARY. 
WASHINGTON. 

Fellow  Physicians  :  The  revival  of  an  old  cus- 
tom of  the  Medical  Society  of  the  District  of  Col- 
umbia has  imposed  upou  me,  as  its  retiring  Presi- 
dent, the  responsibility  of  this  occasion. 

Though  feeling  keenly  my  inability  to  do  full 
justice  to  the  opportunity,  I  am  yet  glad,  in  so 
far  as  it  allows  me  thus  publicly,  at  the  close  of 
our  year's  labor  together,  to  express  my  person- 
al thanks  to  you  for  the  efficient  manner  in 
which  you  have  seconded  all  my  endeavors,  as  your 
presiding  officer,  in  furthering  the  work  of  the 
Society,  and  to  congratulate  you  upon  the  char- 
acter and  amount  of  the  work  accomplished. 

The  work  of  the  year  1890  has  equalled,  if  not 
surpassed,  in  importance,  in  both  these  particu- 
lars, that  of  any  preceding  year  in  the  history  of 
the  Society.  The  papers  have  been  large  in  num- 
ber and  varied  in  their  subject  matter,  and  have 
been  discussed,  as  a  rule,  freely,  but  always  in 
the  friendliest  spirit  of  purely  scientific  interest. 
For  all  this  I  am  happy  to  take  this  opportunity 
of  placing  the  credit  where  it  justly  belongs, 
namely,  to  the  untiring  energy  of  the  Committee 
on  Essays, — and  particularly  its  most  efficient 
Chairman,  and  to  the  ready  and  generous  re- 
spouse  the  members  have  given  to  the  calls  made 
on  them  for  essays  and  discussions. 

I  desire  also  to  express  again  my  profound  ap- 
preciation of  the  honor  you  conferred  upon  me  in 
electing  me  to  preside  over  your  deliberations  for 
©ne  year.  It  was  an  expression  of  confidence 
which,  I  assure  you,  I  shall  always  retain  among 
the  pleasantest  memories  of  rny  professional  ca- 
reer. I  have  received  at  your  hands,  nothing 
but  the  most  respectful  consideration  and  kind- 
ness ;  and  the  problem  of  this  evening's  perform- 
ance, in  which  I  am  expected  to  discharge  in   a 


measure  this  obligation,  has,  I  must  confess, 
weighed  not  a  little  upon  me.  I  carried  it  with 
me  on  my  summer's  vacation  beyond  the  sea  and 
revolved  it  oft-times  in  my  mind  as  I  speeded 
along  between  ocean  and  sky,  trying  to  find  the 
theme  most  fitting  to  the  occasion.  Not  that 
there  are  not  plenty,  and  to  spare,  of  problems  in 
medicine,  which  are  awaiting  discussion  and  so- 
lution at  our  hands,  but  for  ten  months  in  the 
year  we  are  struggling  with  these  scientific  ques- 
tions and  fighting  inch  by  inch  toward  the  goal  of 
truth  in  the  diagnosis,  etiology,  pathology  and 
therapeutics  of  disease.  It  is  but  nature,  there- 
fore, that  you  should,  for  the  nonce,  become 
somewhat  weary  of  these,  and  desire  a  change  in 
the  trend  of  thought. 

We  are  physicians  and  we  love  our  noble  call- 
ing but  the  questions  must  often  come  to  us.  Are 
we  physicians  and  nothing  more  ?  Are  we  mere 
diagnosticating  and  healing  machines,  grinding 
out  opinions  and  advice  as  the  grist  comes  from 
the  mill  ?  Is  our  outlook  upon  the  world  only  on 
perverted  function  and  diseased  and  disordered 
action  ?  Is  humanity  only  one  vast  museum  of 
pathological  specimens  for  our  contemplation  and 
study  ?  And  the  thought  came  to  me  as  it  has 
often  come  before,  that  neither  we  ourselves,  nor 
the  world  at  large,  are  wont  to  regard  sufficiently 
the  importance  and  the  needs  of  the  man  back  of 
the  physician.  And  as  I  saw  and  mingled  more 
with  that  immense  congregation  of  medical  men 
which  convened  at  the  German  capital,  and  was 
able  to  study  them  collectively  both  at  work  and 
at  recreation,  the  more  was  impressed  upon  me 
the  necessity  of  calling  a  halt  and  taking  stock  of 
ourselves,  as  it  were,  and  considering  whether  or 
not  we  are  in  danger  of  allowing  the  profession  to 
dwarf  man}-  of  the  essentials  of  our  true  manhood. 

I  have  therefore  thought  it  might  redound  to 
our  advantage  if,  for  this  one  night  in  the  year, 
we  laid  aside  the  consideration  of  technical  ques- 
tions and,  under  the  bond  of  our  association,  re- 
garded ourselves  in  the  light  of  men  and  citizens. — 
coequal  with  men  in  other  callings  and  other  citi- 
zens interested  in  the  common  weal  of  the  State. 

This  proposition  would  seem  so  self-evident  as 
to  require  only  its  simple  statement  to  find  a  gen- 
eral acceptance  of  its  truth  and  necessity  :  and 
theoretically  it  probably  is  accepted  by  a  large 


146 


THE  PHYSICIAN  AS  A  MAN  AND  A  CITIZEN.        [January  31, 


part  of  the  thinking  members  of  our  profession 
who  have  reflected  ou  the  matter  at  all,  but  only, 
I  fear,  in  a  general  and  very  indefinite  way  ;  and 
besides,  there  comes,  from  time  to  time,  from 
some  of  the  wiseacres  of  the  profession,  a  counsel 
to  the  younger  men  and  a  warning  to  the  older 
men,  to  beware  of  being  anything  besides  doctors. 
The  community,  it  is  said,  looks  with  suspicion  on 
the  physician  who  feels  and  manifests  an  interest 
in  anything  outside  of  his  calling,  to  attend,  phy- 
sically, to  the  sick  ;  that  our  great  and  noble  art 
is  a  jealous  mistress  and  will  tolerate  no  rival  in 
her  love  and  devotion.  All  of  which  is  regarded 
as  very  fine  sentiment,  no  doubt,  by  those  who 
promulgate  it ;  and,  it  must  be  confessed,  that 
the  manner  in  which  the  practice  of  medicine  is 
sometimes  tacked  on  to  some  other  vocation  like 
the  tail  to  a  kite,  is  calculated,  and  very  properly 
and  justly,  to  bring  discredit  upon  the  one  who 
thus  far  fails  to  recognize  the  duties  of  life,  either 
as  regards  himself  or  the  community  in  which  he 
lives.  Of  him  and  to  him  we  have  nothing  to 
say.  Being  joined  to  his  idol  we,  wisely,  let  him 
alone.  But  to  the  army  of  earnest  workers  in  our 
profession,  who  have  by  their  labors  and  self-sac- 
rificing devotion  brought  it  to  the  high  level 
which  it  at  present  occupies,  there  is  something 
to  be  said  on  the  other  side,  which  I  believe  will 
lead  to  their  own  personal  advantage,  and  that 
of  the  profession  in  general  and  to  the  lasting 
benefit  of  the  State. 

Man  is  distinctively  a  social  creature.  In  that 
fact  lies  his  preeminence  among  created  beings, 
because  in  that  he  has  the  power  which  no  other 
of  the  animal  creation  can  use  to  the  same  extent, 
of  each  working  for  all  and  all  for  each.  And  not 
only  that,  but,  under  a  proper  organization  of  so- 
ciety, it  is  permitted  of  one  generation  to  reap 
and  enjoy  the  fruits  of  the  labors  of  the  genera- 
tions that  have  preceded  it,  and  of  planting  for 
the  harvest  of  its  successors. 

So  important  is  this  organization  for  the  wel- 
fare not  only  of  society  itself,  but  of  every  indi- 
vidual member  of  it,  that  it  has  come  to  be  recog- 
nized as  a  fundamental  law  in  sociology  that  a 
man's  first  duty  is  to  the  State,  his  second  to  his 
family  and  his  last  to  himself.  Now,  we  are 
each  of  us,  first,  and  above  all  other  things,  mem- 
bers of  this  organized  society  which  we  call  the 
State,  or  government,  and  we  are  men  and  citi- 
zens before  we  are  doctors,  or  lawyers,  or  preach- 
ers, or  merchants,  or  laborers  in  any  special  field 
of  activity,  and  our  first  duty  is  for  the  preserva- 
tion of  that  organization  and  its  advancement  in 
that  direction  which  shall  secure  to  each  mem- 
ber thereof  those  rights,  privileges  and  oppor- 
tunities, which  shall  lead  to  the  greatest  good  to 
himself  and  the  community  at  large.  Even  from 
the  most  selfish  standpoint  this  cannot  but  seem 
reasonable  and  its  truth  must  appear  axiomatic  in 
its  simplicity. 


This,  then,  being  true,  even  if  we  have  per- 
formed our  duties  faithfully  as  physicians,  we 
may  have  yet  failed  in  the  first  requisite  of  good 
citizenship  if  we  have  neglected  to  let  our  voice 
be  heard  in  the  management  of  affairs.  I  am 
well  aware  that  in  this  opinion  I  shall  be  opposed 
by  a  certain  and  quite  numerous  class  both  in  the 
profession  and  out  of  it,  who  hold  that  so  long  as 
a  man  has  fulfilled  his  professional  or  business 
obligations  he  can,  with  a  clear  conscience,  fold 
his  hands  and  thank  God  that  he  is  not  mixed  up 
with  the  turmoil  of  politics  or  public  affairs  of 
any  kind,  and  that  it  is  derogatory  to  the  dignity 
of  the  profession  to  allow  extraneous  matters  of  a 
public  character  to  obtrude  themselves  upon  the 
time  and  attention  of  the  physician  who  has  al- 
ready as  great  a  load  of  responsibilty  as  he  can  be 
expected  to  carry.  A  moment's  reflection  will 
show  that  this  is  a  very  narrow  conception  of 
man's  duties,  and  a  view  of  life's  responsibilities 
from  a  very  low  plain.  Because  a  man  is  a  phy- 
sician he  is  not  thereby  absolved  from  his  duty  as 
a  citizen  any  more  than  are  those  in  other  call- 
ings. There  are,  of  course,  certain  of  these  gen- 
eral duties  which  come  in  direct  conflict  with  the 
proper  performance  of  his  purely  professional  ac- 
tivities, but  outside  of  these  there  is  no  reason 
why  a  physician  should  hold  himself  aloof  from 
the  affairs  which  concern  the  community  at  large 
of  which  he  forms  a  part. 

It  will  be  instantly  said  by  some  :  ' '  You  would 
not  have  a  doctor  dabble  in  politics,  contaminate 
himself  with  party  squabbles  and  lower  himself  in- 
to the  sloughs  of  party  chicanery  and  corruption  ?' ' 
He  who  asks  such  a  question  can  have  no  proper 
conception  of  his  duties  as  a  citizen.  If  all  men 
who  follow  callings  which  are  classed  as  respect- 
able, and  all  men  belonging  to  the  learned  pro- 
fessions and  the  cultured  class  kept  themselves 
away  from  affairs  of  State  and  took  no  interest  in 
the  workings  of  the  government,  then  indeed 
would  the  advance  of  civilization  be  in  peril. 
But  no  man  need  lower  or  bemean  himself  by  as- 
suming his  proper  position  as  a  member  of  the 
State  organization.  The  discharge  of  no  duty 
can  be  degrading,  and  if  politics  in  this  country 
have  become  a  byword  of  reproach  and  a  synonym 
for  dishonesty  and  intrigue,  it  is  because  decent, 
intelligent,  and  well-informed  men  have  failed  to 
take  their  part  in  the  proper  organization  and 
conduct  of  the  parties  representing  the  different 
views  on  matters  pertaining  to  legislation.  Of 
course  it  is  not  to  be  supposed  that  every  doctor 
should  turn  active  politician,  but  it  should  be  ex- 
pected that  even'  citizen  who  has  the  good  of  his 
country  at  heart  will  keep  himself  well  informed 
on  all  matters  subject  to  legislation  by  his  repre- 
sentatives and  that  he  will  let  his  opinions  be 
heard  and  felt  when  occasion  demands. 

Time  was  when  the  governing  class  was  a  dis- 
tinct and  a  very  small  one,  and  when  it  was  deem- 


.J  THE  PHYSICIAN  AS  A  MAN   AND  A  CITIZEN. 


M7 


ed  undignified  for  the  medical  profession  to  med-  Greece's  philosophers  were  also  her  soldiers,  and 
die  in  such  matters.  That  system  may  have  had  her  soldiers  her  philosophers.  Her  statesmen 
its  advantages  under  the  old  forms  of  govern-  were  her  scholars,  and  her  artists  took  the  jave- 
ment,  but  in  the  grand  experiment  of  self  gov-  lin  or  the  chisel  indifferently  as  the  needs  of  the 
eminent,  which  is  being  carried  out  in  this  wes-  State  demanded.  Sophocles  was  not  only  the 
tern  world,  the  duty  of  every  man,  be  he  physi-  writer  of  the  greatest  tragedies  the  world  has  ever 
cian  or  not,  is  to  feel  and  assume  his  individual  known,  but  was  also  a  senator  and  served,  as  a 
responsibility  as  a  citizen  in  its  highest  and  most  general  with  Pericles  in  the  Saman  war  :  and  So- 
important  and  best  function.  If  that  were  done  crates,  beginning  life  as  a  sculptor,  did  his  duty 
there  would  be  no  occasion  for  politics  to  be  syn-  with  conspicuous  bravery  as  an  Athenian  citi- 
onymous  with  fraud  and  dishonesty.  zen,  at  Delium  and  Amphipolis,  and   by   his  per- 

I  conceive  it  to  be  the  duty  which  the  medical  sonal  courage  saved  the  life  of  Alcibiades  at  Poti- 

profession  in  this  country  owes  to  itself,  and  to  daae.      The  Grecian  of  culture  touched   life  on 

the  community,  to  endeavor  to  have  a  larger  rep  all  sides  and  the  result  was  that  he  grew    in  all 

resentation  in  our  various  legislative  assemblies,  directions  and  became  a  symmetrical  being,  and 

Questions  relative  to  public  health,  sanitation  and  intellectually  the  model  for  men  of  all  time.   The 

hygiene   are   constantly  before  these    bodies  for  law  of  intellectual  growth  and  development  is  not 

consideration,  and  for  their  intelligent  action  they  different  to-day  from  what  it  was  in  the  time  of 

should  have  the  counsel  and  advice  of  those  who,  of  Socrates,    Xenophon,     Aristotle.     Sophocles, 

by  training  and  education,   are  best  prepared  to  Phidias  and  Pericles  and  the  hosts  of  others  who 

give  it.     It  cannot  be  derogatory  to  the  dignity  laid  the  foundation  stones  upon  which  we  have 

of  any  profession  to  thus  put  itself  and  its  accum-  budded  our  structures  in  philosophy,  in  literature, 

ulated  experiences  at  the  service  of  the  State,  and,  in  art  and  morals  and  to  a  large  extent,  our  mod- 

by  so  doing,  in  the  proper  manner,  it  elevates  it-  ern  science,  in  which  latter  alone  it  is  that  we  can 

self  in  the  opinion   of  the  community,    and,    by  claim   any    sort  of  superiority.       If  we  wish   to 

this  added  respect,  is  enabled  to  work  to  greater  grow  mentally  we  must  enlarge  our  intellectual 

advantage  in  its  own  special  field  of  activity.  hi  rizon, — we  must   open  up  the    ways  into   the 

It    was    not    Virchow's    scientific  work  alone,  many  and  various  avenues  of  thought  and  expe- 

great  as  that  is,  which  made  him  president  of  the  rience.   We  must  give  every  faculty  its  full  power 

last  International  Congress,  but  the  reputation  he  of  development  by  furnishing  it,  as  far   as  in   us 

had  earned  as  a  man  of  affairs  and  the  ability    he  lies,  with  a  suitable  opportunity      That   is  what 

has  always  displayed  in  dealing  with  men  ;  and  was  done   in   Greece  on  a  system  more  extensive 

it  is  the  qualities  which  have  made  him  conspic-  than  has  ever  been  tried  elsewhere,  with  the  re- 

uous  as  an  Italian  senator  and  statesman,  which  suit  that  the  individual  as  a  whole  was  developed 

will  make  Baccelli  president  of  the  next  Congress,  to  the  farthest  extent  of  his  power  and  capacity, 

which  meets  at  Rome.     And   no   physician   who  After  all,  the  function  of  all  good  government  is 

heard  the  oration  he  so  eloquently  delivered  in  the  protection  of  the  individual,  and  that  is   the 

Latin  at  the  opening  of  the  Berlin   Congress   but  best  government  in  which,  in  its  truest  sense,  the 

must  have   felt  a  thrill  of  pride  in  the  thought  individual  is  allowed  the  fullest  scope  for  the  ex- 

that  this  man  of  culture  was  a    member  of   the  ercise  of  all  his  mental  powers.      In   this   system 

same  profession  as  himself.  there  is  much  less  danger  of  having  "  lop-sided 

Culture  is  power.    It  is  the  power  which  moves  men,"  except  as  natural  deformites.     This  is.  per- 

eivilization  onwards,  because  it  is  not  only  knowl-  haps,  an  ideal  state,  a  Utopian  conception,  but  if 

edge  acquired,  but  knowledge  refined,  assimilated  it  were  attainable  in  a  large  measure  in  a  pastciv- 

and  properly  adjusted  to  all  other  knowledge  and  ilization,  we  should  not  despair  of  its  realization 

to  the  higher  requirements  of  our  more    compli-  in  this  one  which  offers   many  additional  advau- 

cated  life.       And  I  claim  that  the  more  freely  we  tages  for  the  attainment  of  that  end. 
mingle   in  the  affairs  which  affect   and  pertain  to       It  is,  of  course,  understood  that  I  am  not  advo- 

man  in  the  mass,  the  more  our  sympathies  and  eating    the   mingling    of    the    physician    in    the 

the   higher  parts  of  our  nature  will   be  elevated  wrangle  of  political  strife,  as  we  too  commonly  see 

and  the  broader  will  be  the  view  we  take  of  those  it.     Much  of  that  is  not  seemly  for  any   man  of 

things  which  belong  to  the  daily  work  of  our  lives,  refinement  and  culture,  but,  if  we  would   change 

When  we  look  to  find  the  highest  development  all  that,  and  I  conceive    that  it  is    our  duty  to 

of  man  in  his  physical  and   mental  attributes  we  work  to  that  end,  we  should  let  the  hand  of  the 

are  led  at  once  to  ancient  Greece.      Never  in  the  physician  be  felt  as  a  citizen  in  the  workings  of 

history  of  the  world  has  there  been  presented  finer  the  machinery  of  government,  whose  sole  object 

types  of  men,  singly  or  collectively,  than  at  that  should  be  the  greatest  good  to  the  largest  number, 

period   when  Athens  was  truly  the  center  of  the  But  organized  Society,  such  as  we  would  have  it, 

world.     To  the  Grecian  of  that  era  the  welfare  of  embraces  much  besides  the  matters  of  mere  legis- 

the   State  was  the  first  thought,  and  his  greatest  lation,  and  there  are  many  other  duties  and  obli- 

ambition    was   to    serve    her    in    any    capacity,  gations  which  man  owes  to  the  community,  in  its 


148 


THE  PHYSICIAN  AS  A  MAN  AND  A  CITIZEN.        [January  31, 


minor  and  subsidiary  organizations.  The  ques- 
tion of  education  in  its  broadest  sense,  the  pre- 
paration intellectually  and  physically  of  the  youth 
for  the  battle  of  life,  is  one  of  the  greatest  impor- 
tance, not  only  to  this,  but  to  all  the  succeeding 
generations.  The  institution  of  the  Church  and 
of  societies  of  various  kinds  for  ethical  and  moral 
advancement,  and  all  organized  charities  for  the 
relief  of  human  suffering,  are  provinces  in  which 
the  physician  is  above  all  men  best  prepared  by 
his  life  training  to  work  with  wisdom  and  judg- 
ment. Every  school-board  should  have  a  repre- 
sentative of  the  medical  profession  upon  it,  and 
nowhere  is  the  broad  humanity  of  the  true  physi- 
cian felt  more  than  in  those  congregations  of  men 
instituted  for  the  cultivation  and  advancement  of 
his  moral  and  religious  nature  ;  and  even  in  our  I 
boards  of  trade  he  should  find  his  place  beside  the 
lawyer  and  the  merchant.  And  when  it  comes  to 
public  charities  there  is  no  one  better  qualified 
both  by  his  technical  skill  and  general  qualifica- 
tions to  advise  than  the  doctor.  In  the  special 
matter  of  hospital  management  it  would  appear  to 
the  unbiased  observer  that  he  was  the  one  par  ex- 
cellence  to  whom  should  be  intrusted  the  control 
of  all  matters  pertaining  to  the  care  of  the  sick 
and  the  internal  management  of  the  hospital  gen- 
erally. And  yet  there  is  an  opinion  current 
among  the  lay  members  of  hospital  management 
that  the  medical  man  has  not  enough  business  ca- 
pacity to  attend  to  matters  which  pertain  directly 
to  his  professional  duties,  and  some  hospitals  have 
even  gone  so  far  as  to  make  the  fact  of  a  man's 
being  a  practicing  physician  a  disqualification  for 
service  on  the  board  of  hospital  direction.  This 
is  something  more  than  a  slur  on  our  profession. 
It  is  a  hindrance  to  the  proper  and  best  results  of 
hospital  treatment,  and  has  led  in  many  instances 
to  an  enormous  waste  of  monies  that  were  needed 
to  carry  on  the  legitimate  functions  of  a  hospital. 
It  must  be  confessed  that  we  of  the  profession  are 
largely  responsible  for  this  state  of  feeling  towards 
us.  We  have  neglected  to  make  ourselves  felt  as 
men  of  affairs  and  it  has  reacted  upon  us  in  ham- 
pering our  power  for  good  in  our  own  special  line 
of  work.  There  was  never  a  greater  mistake  than 
to  suppose  that  because  a  man  is  engaged  in  the 
practice  of  medicine  he  has  thereby  lost  his  power 
of  judgment  or  faculty  of  drawing  conclusions 
from  facts.  It  may  be  true  that  many,  if  not 
most  physicians  do  not  manage  their  own  bus- 
iness :ilTairs  to  the  best  advantage — for  themselves; 
but  that  is  more  largely  because  of  their  liberal- 
mindedness  and  charity  than  for  want  of  capacity. 
It  is  true  they  are  not  schemers,  apt  in  the  laying 
of  plans  on  the  hazard  of  success,  indifferent  as  to 
the  general  effects  and  the  final  results,  and  are 
not  skilled  in  the  process  of  over-reaching,  which 
seems,  in  the  eyes  of  many,  to  constitute  true 
"  business  ability,"  the  "ability"  too  prevalent 
on  the  mart  and  in  the  street.     The  training  of 


their  profession  has  taught  them  caution,  has 
taught  them  to  avoid  haste  in  drawing  their  con- 
clusions until  all  the  data  are  in,  but  has  given 
them,  withall,  the  courage  to  act  firmly  and 
promptly  on  their  convictions  when  they  are  once 
formed.  Wherever  a  special  pleader  is  wanted, 
wherever  a  champion  for  partisan  aggrandize- 
ment is  in  demand,  where  bigotry  is  to  be  Hpheld, 
it  must  be  confessed,  that  the  training  of  the  med- 
ical man  in  his  earnest  and  constant  search  after 
the  truth  but  badly  fits  him  for  a  position  of 
prominence.  He  cannot  compete  in  these  fields 
with  others  whose  training  has  been  otherwise. 

It  has  been  the  custom  in  certain  quarters  to 
consider  the  doctor  more  than  ordinarily  deficient 
in  executive  ability,  as  lacking  in  the  power  to 
deal  with  masses  of  men  and  with  diverse  and 
widely  separated  interests.  In  refutation  of  that 
charge  we  can  point  with  pride  to  the  manage- 
ment of  the  medical  departments  of  the  army  and 
navy  throughout  the  civilized  world.  In  no  point 
of  organization  or  efficient  working  has  the  med- 
ical department  of  either  arm  of  the  service  been 
behind  that  of  the  line,  and  there  was  developed, 
during  the  late  civil  war,  an  amount  of  ability  in 
the  medical  staff,  which,  if  it  had  been  surround- 
ed by  the  glamour  of  arms,  would  have  made 
many  of  them  heroes  of  renown  ranking  with  the 
first.  Wherever  courage,  coolness,  and  the  shifts 
of  expediency,  and  a  commanding  example  are 
needed,  we  have  a  representative  of  our  profes- 
sion. In  the  ice-locked  regions  of  the  north  we 
have  a  Kane,  and  an  Ambler ;  and  in  the  wilds 
of  Africa  a  Livingstone,  an  Emin  and  a  Parke. 
And  indeed,  everywhere  where  the  faculty  to  or- 
ganize or  the  ability  to  execute  is  needed,  as  in 
the  management  of  our  colleges,  libraries  and 
museums,  we  find  it  forthcoming  in  the  medical 
man.  And  yet  a  collection  of  second  or  third- 
rate  lawyers  and  ordinary  tradesmen  will  assume 
that  in  the  management  of  a  hospital  the  men 
who  do  the  work  for  which  the  institution  is 
founded,  and  without  whom  it  woidd  be  a  mere 
pile  of  bricks  and  mortar,  and  who  are  more  con- 
versant with  its  needs  and  requirements  than  any 
other  men  could  possibly  be,  are  incompetent  ad- 
visers in  its  direction.  In  the  conditions  of  soci- 
ety at  one  time  existent  in  Europe  it  was  ques- 
tioned whether  a  physician  might  be  a  gentleman, 
but  in  this  country,  in  some  minds,  there  seems 
to  be  no  doubt  as  to  his  being  an  idiot.  And  for 
this  general  and  current  opinion  I  claim  that  we, 
as  members  of  the  profession,  are  to  blame.  If 
we  mingled  more  in  the  affairs  of  common  life, 
and  took  a  more  active  part  in  the  management 
of  its  concerns,  the  capacity  of  the  medical  man 
to  deal  with  matters  other  than  those  purely  pro- 
fessional would  soon  be  impressed  upon  the  com- 
munity, and  our  opinions  on  those  matters  which 
are  of  general  interest  would  have  the  respect 
and  weight  given  to  them  which  they  are  deserv- 


l8yl.] 


THE  PHYSICIAN  AS  A  MAN  AND  A  CITIZEN. 


149 


ing  of.  To  place  ourselves,  as  individual  mem- 
bers of  a  learned,  liberal  and  scientific  profession, 
upon  such  a  plane,  I  conceive  to  be  a  duty  we 
owe  to  that  profession  and  the  Nation,  and  to 
ourselves. 

But  aside  from  these  general  obligations  ami 
responsibilities  as  citizens,  there  are  other  oppor- 
tunities of  widening  our  minds  and  ini 
our  breadth  of  view.  The  das-  has  gone  by  when, 
unless  he  would  lose  caste  in  the  community,  a 
doctor  must  be  nothing  beside  a  doctor,  with  his 
knowledge  limited  to  what  he  knows  of  - 
and  the  remedies  therefor.  That  tradition  should 
have  passed  away  with  the  gold  headed  cane  and 
creaky  boots  which  were  the  outward  token  of 
the  physician  fifty  or  more  years  ago.  The  bar- 
riers between  special  and  general  knowledge  have 
been  overborne  by  the  corning  of  the  higher  cul- 
ture which  finds  the  necessity  for  an  extent  of  ac- 
complishment which  is  not  attained  by  knowing 
everything  of  something,  even  were  that  pi 
To  know  something  of  at  least  a  great  many 
things  that  are  worth  knowing,  is  the  surest  road 
to  knowing  everything  that  can  be  known  of  any- 
one thing.  Human  knowledge  on  any  one  sub- 
ject is  not  so  circumscribed  that  it  cannot  be  illu- 
minated and  made  clearer  by  the  light  thrown 
upon  it  from  the  knowledge  of  other  subjects  out- 
side. The  man  who  makes  clay  pipes  can  make 
them  better  if  he  knows  something  of  the  laws  of 
chemistry  and  physics,  and  can  convert  them  into 
objects  of  beauty  if  he  has  cultivated  his  aesthetic 
sense.  Of  all  the  so-called  liberal  professions  I 
think  that  of  medicine  is  the  only  one  that  can  be 
properly  thus  named.  The  law  is  hampered  by 
statute  and  precedent,  and  the  Church  has  no  ex- 
istence if  not  based  upon  tradition.  Ours  is  the 
only  one  which  bids  defiance  to  tradition,  boldly 
questions  authority  and  sets  precedent  at  uaught. 
There  is  absolutely  no  intellectual  restraint  upon 
us.  Our  goal  is  Truth,  and  to  attain  to  it  we 
may  follow  any  path  that  seems  open  and  invit- 
ing. And  as  all  roads  were  said  to  lead  to  Rome, 
so  I  think  all  knowledge  sends  its  quota  to  the 
practitioner  of  the  healing  art.  Nothing  can  come 
amiss  to  the  scientific  practitioner — all  knowledge 
can,  in  one  way  or  another,  be  made  available. 
It  is  not  only  wise,  then,  but  our  imperative  duty 
to  open  up  as  many  of  these  avenues  of  culture 
and  wisdom  as  is  possible. 

In  conversing  with  a  medical  man,  some  time 
ago,  on  this  topic,  he  said  he  did  not  like  doctors 
for  companions  because  they  were  so  narrow.  I 
disagreed  with  him  in  toto.  There  are,  of  course, 
doctors  and  doctors,  and,  particularly  under  our 
American  methods  of  education,  there  are,  tin 
fortunately,  a  large  number  of  physicians,  who 
are  such  in  name  only.  But  even  under  our  per- 
nicious system,  I  claim  that  the  average  doctor  is 
the  peer  in  intellect  and  culture  of  the  average 
man  in  any  other  profession.     But  what  I  claim 


for,  and  demand  of  him  is  that,  on  account  of  his 
better  advantages  and  more  enlarged  opportuni- 
ties, he  should  be  superior.  "  But,"  the  thought 
instantly  arises-in  the  minds  of  many  amon 
"we  are  so  engrossed  in  the  toil  of  our  strictly 
professional  activities  that  we  have  not  the  time 
for  the  pursuit  of  this  culture."  My  friends,  time 
will  always  be  found  to  do  the  things  that  we 
earnestly  wish  to  do.  The  great  difficulty  in  this 
case  is,  that  we   fai  he  desirability  and 

need  of  it ;  and  if  I  shall  have  been  able  through 
this  presentation  of  the  case  to  arouse  in  you  some 
serious  thought  on  the  subject,  I  shall  consider 
that  my  speaking  has  not  been  in  vain.  I  hold 
that  a  man  who  knows  medicine  and  nothing  else 
cannot  know  that  as  it  ought  to  be  known,  and  I  am 
not  one  of  those  who  deem  it  derogatory  to  a  mem- 
ber of  our  profession  that  he  should,  even  openly, 
vindicate  his  claim  in  other  fields  of  culture, 
whether  it  be  in  science,  literature  or  art.  In 
other  special  fields  of  intellectual  activity  it  is  by 
no  means  uncommon.  Because  Gladstone  is  one 
of  the  greatest  statesmen  of  the  age  it  does  not 
lessen  the  value  of  his  opinion  as  an  authority  on 
Homer,  and  a  single  review  by  him  of  a  work  of 
fiction  is  sufficient  to  give  it  the  widest  popularity. 
Professor  Tyndall  goes  home  from  a  lecture  on  the 
latest  discoveries  in  science  at  the  Royal  Institu- 
tion, to  write  an  article  on  the  Irish  question,  and 
Mr.  Ruskin — well,  it  would  be  hard  to  say  what 
Mr.  Ruskin  has  not  written  on — and  entertain- 
ingly and  well.  The  medical  man  has  just  as 
much  time  to  give  to  the  cultivation  of  these  out- 
side subjects,  apart  from  his  strictly  professional 
work,  as  other  men,  and  when  we  once  have  the 
sincere  desire  for  it,  the  opportunity  will  not  be 
lacking.  It  is  true  that  our  profession  is  consid- 
ered the  least  regulated  of  any.  Other  men  are 
considered  to  have  some  time  which  they  can  call 
their  own.  Not  so  with  the  doctor.  And  yet, 
even  in  so  exacting  a  field  of  labor  as  ours,  a 
great  deal  may  be  accomplished  by  a  proper  sys- 
tem. With  us,  as  with  other  men,  the  busiest 
is  always  the  one  who  has  the  time  to  do  the 
thing  to  be  done.  It  will  not  be  supposed  for  an 
instant  that  I  am  advocating  general  culture  at 
the  expense  of  strictly  professional  study.  That 
should  always  come  first  and.  with  every  consci- 
entious man,  will  have  primary  consideration  al- 
ways. But  the  human  mind  is  not  a  machine 
that  can  be  worked  in  one  groove  all  the  time, 
and  its  best  and  most  satisfactory  rest  is  change. 
It  is  said  of  John  Stuart  Mill  that  when  he  took 
a  vacation  he  wrote  an  article  on  political  econ- 
omv,  and  in  fact  all  his  enormous  production  in 
the  fields  of  politics  and  sociology  was  done  out- 
side of  his  hours  at  the  Indian  Office,  which  were 
as  exacting  as  those  of  any  Government  office  in 
this  country.  Lord  Beaconsfield,  whose  career  as 
a  politician  and  diplomat  was  as  brilliant  as  it  was 
remarkable,  is  said  to  have  remarked  on  one  oc- 


15° 


THE  PHYSICIAN  AS  A  MAN  AND  A  CITIZEN. 


[January  31, 


casion  that  when  he  wanted  to  read  a  novel  he 
wrote  one.  It  is  these  hours  of  freedom  from  pro- 
fessional work  and  care  which  are  so  necessary 
for  the  maintenance  of  clear  perception  and  sound 
judgment  that  can  be  advantageously  given  to 
the  cultivation  of  these  tastes  for  general  and 
comprehensive  knowledge — tastes  that  have  char- 
acterized the  vigorous  and  advanced  minds  of  all 
ages.  There  has  been  in  those  minds  an  aspira- 
tion for  knowledge  and  a  desire  for  development 
which  has  surmounted  all  obstacles,  and  they 
have  not  grown  in  one  direction  at  the  expense 
of  another.  The  mind,  like  any  other  organ  of 
the  body,  is  rendered  stronger  and  more  supple 
by  constant  and  regular  exercise,  and  is  weakened 
or  disabled  by  irregular,  unsystematic  or  forced 
action.  It  is  worry  and  not  work  which  wears 
out,  and  to  have  some  congenial  occupation  into 
which  to  divert  the  mind  when  it  is  liable  or  like- 
ly to  be  overburdened  with  work,  is  the  best  safe-, 
guard  the  brain  worker  can  have.  That  man  is 
always  safest  who  has  a  hobby — and  who  does 
not  trifle  with  it.  A  hobby  conscientiously  pur- 
sued, as  every  genuine  hobby  should  be,  is  always 
a  serious  matter  —  to  the  one  who  follows  it, 
and  in  that  seriousness  lies  its  power  for  good  to 
him.  It  is  the  one  thing  in  the  world  which  he 
values  more  than  time  or  money;  and,  in  the  rush 
and  crush  of  modern  civilization,  anything  that 
restrains  avarice  or  clogs,  even  temporarily,  the 
whirling  wheels  of  time  so  as  to  allow  a  man  to 
think  of  something  which  does  not  lead  to  ma- 
terial gain,  is  a  boon  to  society  as  well  as  a  sal- 
vation to  the  man. 

I  am  always  inclined  to  be  suspicious  of  a  man 
who  has  no  hobby  and  who  takes  no  interest  in 
anything  outside  of  the  narrow  field  of  labor 
which  has  by  accident  fallen  to  him.  And  of  all 
men  the  doctor  is  the  one  who  needs  such  diver- 
sion most.  He  less  than  any  other,  should  be 
narrow  and  restricted  in  his  resources,  or  allow 
himself  to  fall  into  the  slough  of  despond,  or 
sink  beneath  a  load  of  responsibilities.  There 
are  so  many  paths  leading  outward  that  hardly 
any  taste,  but  can  find  some  congenial  pursuit. 
If  it  be  that  books  do  not  attract,  there  are  paint- 
ings, etchings,  engravings,  bric-a-brac  and  other 
object  of  art  and  virtu,  the  study  of  some  favorite 
branch  of  science  ;  the  practice  of  some  art — as 
drawing,  painting,  or  sculpture,  or  some  literary 
pursuit,  as  the  writing  of  fiction,  or  of  essays  on 
social,  literary  and  scientific  subjects,  or  poetry, 
when  that  gift  is  in  possession ;  the  practice  of 
the  art  of  music,  vocal  or  instrumental  ;  in  fact, 
there  can  be  no  occupation  of  the  mind  which  is 
serious  and  requires  the  acquisition  of  some 
special  knowledge,  or  which  cultivates  the  finer 
qualities  of  our  nature,  but,  in  one  way  or  an- 
other, can  be  made  of  practical  utility  in  the 
practice  of  our  noble  calling.  For,  let  the  fact 
sink  deep  into  the  hearts  of  us  all,  we  do  good  to 


our  patients  as  much  by  what  we  are,  as  by  what 
we  know  of  their  diseases.  The  man  helps  quite 
as  much  as  the  physician,  oft-times  more. 

The  history  of  our  profession  is  not  without 
brilliant  examples  of  such  cultured  men — of  men 
who,  in  addition  to  high  professional  attainments, 
have  done  most  acceptable  work  in  other  fields  of 
intellectual  labor.  Mr.  Seymour  Haden  is  not 
any  the  less  a  surgeon  of  ability,  because  he  is 
the  most  renowned  etcher  since  Rembrandt,  and 
it  was  during  one  of  those  forced  vacations  oc- 
casioned b}*  overwork  that  he  published  in  Paris 
that  set  of  plates  which,  actually,  in  one  day 
made  him  famous  ;  and  Sir  Henry  Thompson  is 
quite  as  well  known  in  the  literary  and  artistic 
circles  of  Loudon  as  in  the  surgical  society. 

In  this  country  we  are  always  proud  to  mention 
among  others  in  this  connection  our  own  beloved 
and  inimitable  Holmes,  and  Weir  Mitchell,  who, 
not  only  is  a  great  authority  on  nervous  diseases, 
but  ranks  high  as  a  general  literateur  and  poet. 
The  list  could  be  largely  extended,  and  you  can 
each  call  to  mind  men  of  your  own  acquaintance 
who  either  have  done,  or  are  capable  of  doing 
most  creditable  work  in  fields  which  are  only'  re- 
motely connected  with  the  practical  art  of  their 
profession. 

But  if  I  were  called  upon  to  designate  the  man, 
who,  more  nearly  than  any  other  that  I  have 
known,  fills  my  conception  of  the  ideal  physician, 
I  would  mention  the  name  of  one  who  is  still  liv- 
ing and  passing  his  declining  years  in  dignity 
and  peace  among  the  beautiful  hills  of  Southern 
England.  There  is  probably  no  man  within  the 
sound  of  my  voice  to  whom  the  name  of  William 
Bowman  is  unfamiliar,  certainly  no  man  who 
studied  medicine  twenty  or  thirty  years  ago.  His 
researches  in  anatomy  and  physiology  in  his 
earlier  years  placed  him  in  the  front  rank  in  both 
of  these  departments,  and  his  achievements  in 
general  surgery,  before  he  was  actually  forced 
into. ophthalmology  by  his  acknowledged  superior 
skill  in  that  specialty,  are  such  as  to  give  him 
prominence  in  that  line,  and  in  the  pathology  of 
that  period  his  name  will  always  be  found  as- 
sociated with  thoroughly  accurate  and  scientific 
investigation.  There  was  no  man  of  his  time 
who,  by  thorough  training  in  the  principles  of 
medicine  and  surgery,  actual  knowledge  of  anat- 
omy and  physiology,  was  better  prepared  than 
he  to  take  the  part  he  did  in  founding  modern 
ophthalmology.  When  the  genius  of  Helmholtz 
threw  the  light  of  the  ophthalmoscope  upon  the 
world  it  revealed  three  men,  who,  each  in  his 
different  way,  was  destined  to  have  his  nana-  as- 
sociated with  ophthalmology  for  all  coming  time. 
One  was  the  great  clinician  at  Berlin,  the  youth- 
ful von  Graefe;  another  a  physiologist  in  Holland, 
the  late  lamented  Douders,  who  laid  the  founda- 
tion for  our  clinical  optics  ;  and  the  other  was 
William     Bowman,    surgeon    at    the    Moorfield 


»89i.] 


THK  PHYSICIAN  AS  A  MAX  AND  A  CITIZEN. 


Ophthalmic  Hospital  in  London.  These  three 
men  were  not  only  the  founders  of  the  most  ad- 
vanced and  scientific  department  of  medicine,  but 
intimate  personal  friends  in  the  most  ideal  way. 
The  work  of  the  two  first  named  is  more  widely 
and  generally  known  than  that  of  Bowman,  per- 
haps, for  they  both  wrote  extensively,  but  the 
lasting  impress  of  Bowman  upon  the  men  of  his ! 
time,  and  upon  succeeding  generations,  is  certainly 
equal  to  that  of  either  of  the  others,  and  that,  as 
much  by  the  personal  character  of  the  man.  as  by 
the  ability  of  the  surgeon  and  teacher.  No  one  i 
who  has  stood,  as  I  have,  day  after  day.  by  his 
desk  at  the  great  clinic  at  Moorfield's,  and  heard 
his  careful  and  logical  analysis  of  cases,  and  the  ■ 
lucid  explanation  of  complicated  conditions,  and 
has  followed  him  to  the  amphitheater,  and  seen 
him  operate  with  skill  of  brain  and  deftness  of 
hand,  but  must  have  been  impressed  with  the 
fact  that  here  was  a  man  who  had  not  only  culti- 
vated all  his  faculties  widely,  but  had  them  under 
his  perfect  control.  He  must  have  felt  in- 
stinctively that  this  special  ability  was  based 
vipon  a  broad  culture,  and  that  back  of  it  all 
there  was  the  well-rounded  character  of  the  man. 
When  1  was  in  England,  something  more  than 
a  year  ago,  it  was  my  pleasure  to  meet  him  again 
on  his  invitation  at  his  charming  country  place 
in  Surrey,  and  the  memory-  of  those  hours  will 
always  remain  among  the  most  treasured  recollec- 
tions of  my  life.  It  was  one  of  those  exception- 
ally lovely  August  days,  which  sometimes  come 
in  that  English  isle,  when  the  brightness  of  the 
sky  and  the  rich  greenness  of  the  fields  combine 
with  the  softness  of  the  air  to  make  the  perfec- 
tion of  climate.  We  talked  of  many  and  various 
things,  and  there  was  revealed  to  me  in  this  dis- 
course, more  than  ever  before,  the  cause  and 
reason  of  his  greatness.  A  few  years  before  his 
queen  had  honored  herself  by  conferring  a  bar- 
onetcy upon  him,  but  long  before  that  the  pro- 
fession to  which  he  had  given  the  best  labor  of 
his  life  had  ennobled  him  with  its  enduring  trust 
and  reverence.  He  had  retired  from  the  active 
practice  of  his  profession,  but  his  interest  in  all 
things  pertaining  to  its  advancement  was  as  earn- 
est and  eager  as  in  those  years  when  he  was  at 
the  head  of  ophthalmology  at  the  world's  capital. 
As  we  sat  there  that  balmy  afternoon  on  the 
grassy  slope  facing  the  south  Downs,  with  a 
silvery  strip  of  sea  stretching  beyond,  on  which 
ever  and  anon  the  sunshine  showed  the  glint  of  a 
passing  sail,  the  discourse  drifted  into  diverse 
channels,  breadth  of  view  and  extent  of  general 
knowledge,  which  made  him  the  man  he  was. 
He  talked  of  the  political  situation  in  the  United 
States  with  which  he  was  familiar,  of  our  form  of 
government,  its  strength  and  its  defects,  without 
cynicism,  or  the  pessimism,  which  so  frequently 
mars  the  latter  days  of  some  otherwise  great  men. 
In  a   modestly    apologetic    manner,    because   he 


thought  that  my  interest  was  genuine,  he  went 
over  the  history  of  his  earlier  medical  education 
and  told  me  how  his  choice  of  the  study  of  medi- 
cii  •,  was  an  accident  caused  by  an  injury  to  his 
thu.nb  while  a  school-boy  at  Birmingham.  He 
was  attended  by  a  Mr.  Hodgson,  a  celebrated 
surgeon  of  that  city,  and  was  so  charmed  by  the 
personality  of  the  man  and  the  skill  with  which 
he  treated  him,  that  after  the  custom  of  that  day, 
he  asked  to  be  apprenticed  to  him,  and  very  soon 
afterwards  entered  the  Birmingham  Hospital. 
The  character  of  the  man  was  here  foreshowed 
in  the  youth.  He  showed  me  afterwards  in  the 
library  the  notebooks  he  made  during  those  years 
of  hospital  work  and  study  with  the  carefully  de- 
tailed clinical  histories  of  the  cases  and  the  ac- 
curate drawings  of  the  pathological  conditions 
found,  which  could  almost  be  said  to  represent  a 
complete  history  of  the  surgery  and  pathology  of 
that  day.  For  several  years,  I  think  he  told  me, 
he  either  made,  or  was  present  at  every  autopsy 
during  his  stay  in  the  institution.  What  a 
groundwork  on  which  to  build  the  enduring  pro- 
fessional career  that  followed  ;  and  what  a  lesson 
in  patient  industry  for  the  medical  student  of  our 
day,  and  what  a  rebuke  to  the  aspiring  specialist 
of  this  era  who  ventures  upon  his  work  with 
only  the  merest  smattering  of  the  general  princi- 
ples of  either  physiology  or  pathology  and  with 
no  experience  in  the  practice  of  general  surgery. 
But  mingled  in  with  these  were  the  sketches 
which  he  had  made  of  the  places  of  interest  he 
had  visited  during  his  vacations,  for  he  loved  to 
enlarge  his  mind  with  travel  and  to  mingle  with 
men  of  pursuits  widely  separated  from  his 
Among  his  friends  were  all  the  literary,  artistic 
and  scientific  men  of  prominence  of  his  time. 

He  talked  of  Graefe  and  of  Donders.  who 
went  from  his  house  only  a  few  months  before 
with  the  illness  that  finally  led  to  his  death,  of 
the  medical  men  of  the  past  and  the  younger  and 
more  promising  men  of  to-day.  His  thought  had 
reached  out  in  every  domain  in  which  intelligent 
humanity  holds  any  interest,  whether  of  men,  of 
books,  or  of  affairs.  And  he  was  at  home  in  all 
matters  pertaining  to  literature,  art  and  science. 
And  as  I  regarded  this  man,  passing  thus,  in  dig- 
nified repose,  his  evening  of  life,  amid  the  flowers 
which  he  had  gathered  from  all  quarters  of  the 
globe,  and  which  he  attended  with  such  loving 
hands,  I  felt  it  the  fitting  rounding  up  of  a  life  as 
nearly  ideal  as  our  humanity  can  offer,  and  I  tried 
to  take  the  lesson  to  my  heart,  that  I  now  offer 
to  vou.  that  the  highest  usefulness  in  life  can  be 
realized  only  by  a  cultivation  of  all  the  faculties 
of  our  minds  on  the  broadest  scale  and  in  the 
most  liberal  manner. 

But  aside  from  these  general  considerations 
and  in  addition  to  the  benefit  to  flow  to  the  com- 
munity  from  our  increased  possession  of  human 
sympathy  and  mental  enlargement,  there  comes 


152 


EARLY  VAGINAL  HYSTERECTOMY. 


[January  31, 


to  the  individual  by  a  cultivation  of  those  higher 
faculties,  a  respect  for  himself  and  an  increase 
in  his  sources  of  pleasure,  and  a  widening  of  his 
capacity  for  enjoyment  which  nothing  else  can 
bring.  To  the  man  with  a  broadly  cultivated 
mind  there  is  no  time  or  place,  with  freedom  of 
mind  and  body,  when  he  need  suffer  from  ennui. 
He  is  ever  prepared,  alike,  for  work  or  recreation. 
To  him  the  world  offers  always  its  best,  and  it  is 
to  be  had  for  the  taking.  To  him  Nature  lays 
bare  the  beauties  hidden  from  the  eyes  that  have 
not  learned  to  see.  The  artists  of  all  past  times 
have  wrought  their  ideas  into  lasting  forms  for 
his  pleasure,  and  the  accumulated  literature  of 
all  ages  is  at  hand  for  his  instruction  and  enter- 
tainment. The  processes  of  civilization  as  seen 
from  his  higher  vantage  ground  have  a  unity,  a 
relation  and  a  connected  purpose  to  an  end  which 
are  in  gratifying  and  hopeful  contrast  to  the 
workings  of  the  world  as  seen  from  the  lowlands 
of  narrowmindedness  and  desponding  and  de- 
spairing wonderment  at  the  apparently  purpose- 
less scheme  of  the  universe. 

But,  my  friends,  in  the  garment  of  life  which 
we  wear  for  this  brief  season  here  upon  earth, 
there  must  needs  be  not  only  the  warp  of  joy  but 
also  the  woof  of  sorrow.  The  sun  of  prosperity 
and  peace  shines  not  always,  and  in  the  lives  of 
all  of  us  there  are  periods  when  the  dark  clouds 
of  despondency  cast  themselves  athwart  his 
smiling  face.  In  the  course  of  nature  there 
must  come  times  when  the  sky  is  no  longer  blue, 
and  the  sunlight  has  lost  its  brightness  ;  when 
the  color  has  faded  from  the  flowers  and  there  is 
no  music  in  the  laughter  of  children  ;  when 
affliction  takes  up  its  abode  on  our  hearth-stone, 
and  when  grief  becomes  our  constant  companion; 
when  life  means  only  the  beginning  of  death  ; 
when  we  stand  alone  in  this  vast  universe  with 
no  human  hand  to  sustain  and  the  arm  of  God 
seems  afar  off.  It  is  then  that  we  must  look 
within  for  that  power  which  must  hold  us  up  if 
we  would  not  fall.  It  is  then  that  our  higher 
manhood,  with  its  understanding  widened  by 
culture  and  deepened  by  sympathy,  and  the  aspir- 
ations of  that  which  makes  us  what  we  are,  give 
us  glimpses  of  what  the  awful  Mystery  may  mean, 
and  the  light  of  Duty  shines  upon  the  path  we 
are  to  follow.  It  is  that  only  which  can  save  us 
from  despair  and  give  us  the  courage  to  live  and 
to  do  as  faithfully  as  we  can  the  work  that  is  at 
our  hands  to  do.  The  world  wants  not  less  now 
than  it  has  ever  done,  that  courage  and  that  faith 
which  can  only  come  from  the  liberal  culture  of 
the  nobler  and  higher  elements  of  our  nature, 
and  nowhere  can  they  work  for  greater  good  than 
in  the  daily  duties  of  the  profession  which  it  is 
our  honor  to  follow.  There  is  need  not  only  of 
physicians,  but  men  ;  and  the  nobler  the  man  the 
greater  the  physician. 


ORIGINAL  ARTICLES. 


A  PLEA  FOR  EARLY  VAGINAL  HYSTER- 
ECTOMY FOR  CANCER  OF  THE 
UTERUS. 

Read  in  the  Section  of  Obstetrics  and  Diseases  of  Women,  at  the 
Forty-fii  st  Annual  Meeting  of  the  American  Medical  As- 
m,  held  in  .Ya'shvil/e,   Tenn.,  May,  jSoo. 

BY  FRANKLIN    H.  MARTIN.   M.D., 


It  is,  at  present,  a  generally  conceded  fact  that 
cancer  can  be  permanently  eradicated  from  the 
human  body  if  the  parts  of  primary  development 
and  subsequent  invasion  can,  early  in  the  prog- 
ress of  disease,  be  absolutely  separated  and  re- 
moved from  the  surrounding  normal  tissue.  This 
implies  that  the  operation  for  cancer  which  will 
go  the  farthest  beyond  the  diseased  limits,  is  the 
one  most  liable  to  accomplish  absolute  removal, 
consequently  the  one  by  which  the  most  satisfac- 
tory curative  results  must  be  expected.  With 
this  fact  well  established,  we  can  have  no  hesitancy 
in  making  the  assertion  that  the  operation  which 
will  obtain  the  best  ultimate  results  in  cancer  of 
any  portion  of  the  uterus  is  the  one  which  will  ac- 
complish its  total  removal,  together  with  as  much 
of  the  tissue  which  lies  in  close  proximity  to  it  as 
can  be  removed  without  unduly  increasing  imme- 
diate mortality. 

Hence  my  first  proposition  is  :  J  'aginal  hys- 
terectomy is  the  most  justifiable  surgical  procedure 
we  ret  know  for  the  cure  of  cancer  of  the  uterus. 

A  second  fact  which  is  as  incontrovertible  as 
the  first,  and  one  made  obvious  from  the  very  na- 
ture of  the  first,  is  that  the  earlier  cancerous  tissue 
is  removed  in  the  process  of  its  development,  the 
greater  are  the  probabilities  of  a  non  return  of  the 
disease.      Hence  my  second  proposition : 

\  'aginal hysterectomy  should  be  attempted  for  the 
(/ire  of  cancer  of  the  uterus,  at  the  earliest  possible 
mo  men  I  after  the  disease  is  diagnosed. 

Thus  it  shall  be  the  effort  of  the  author  of  this 
paper  not  only  to  convince  his  hearers  that  vaginal 
hysterectomy  is  the  most  justifiable  operation  for 
cancer  of  any  part  of  the  uterus,  but  that  it  is  an 
operation  which  should  be  resorted  to  early  in  the 
progress  of  the  disease. 

The  facts  to  be  proven  in  support  of  these  prop- 
ositions, in  order  to  make  them  acceptable,  must 
be  as  follows  : 

1 .  That  vaginal  hysterectomy  will  remove  the 
entire  disease  in  cancer  in  any  portion  of  the 
uterus,  in  a  greater  proportion  of  cases  than  will 
any  other  surgical  procedure  now  recommended. 

2.  That  vaginal  hysterectomy  for  cancer  of  the 
uterus  will  enable  an  operator  to  go  farther  beyond 
the  diseased  tissue  into  healthy  tissue,  than  will 
any  other  surgical  procedure  now  recommended. 

3.  That  vaginal  hysterectomy  is  a  more  ideal 
surgical  operation,  and  leaves  the  remaining  tis- 


i89i.] 


EARLY  VAGINAL  HYSTERECTOMY. 


153 


sues  in  a  less  favorable  condition  for  the  return  of 
the  disease,  than  will  any  other  surgical  procedure 
now  recommended. 

4.  That  vaginal  hysterectomy  for  cancer  of  the 
uterus  will  give  in  the  future  an  immediate  mor- 
tality sufficiently  low  to  make  it  preferred  to  all 
other  surgical  procedures. 

1.  Will  vaginal  hysterectomy  remove  the  entire 
disease  in  cancer  of  any  portion  of  the  uterus  in 
a  greater  proportion  of  cases  than  will  any  other 
surgical  procedure  ? 

Let  us  first  examine  the  uterus,  and  then  the 
other  possible  operations  which  might  possibly 
be  selected. 

The  uterus  is  divided  arbitrarily  into  two  por- 
tions, the  body  and  the  neck.  The  body,  which 
represents  two-thirds  of  the  entire  organ,  is  sup- 
ported and  suspended  upright  in  the  centre  of  the 
pelvis  by  numerous  connecting  bands,  with  its 
two  branching  arms  of  tissue,  which  have  a  direct 
continuity  with  itself,  reaching  out  into  the  folds 
of  the  peritoneum  from  either  side,  all  covered 
with  peritoneum,  all  closely  associated  with  other 
important  organs,  the  rectum  behind,  the  bladder 
in  front,  the  ovaries  on  either  side,  the  intestines 
above  and  the  vagina  below,  and  with  an  elabo- 
rate connecting  network  of  veins,  arteries,  lym- 
phatic vessels  and  glands  distributed  throughout 
its  entire  structure. 

The  neck  of  the  uterus,  which  in  anatomical 
structure  is  a  direct  continuation  of  the  uterus 
and  represents  but  one-third  of  that  organ,  is  sus- 
pended from  its  uterine  attachments  above  into 
the  vaginal  tube  below,  where  it  is  free  from  all 
direct  tissue  communication  with  its  surroundings 
except  as  it  is  supplied  from  the  body  and  the 
vaginal  attachment  above. 

The  operations  which  may  be  urged  as  possi- 
ble rivals  of  vaginal  hysterectomy  :  the  cautery 
—chemical,  actual,  Paquelin  or  electro — curet- 
ting, amputation  and  abdominal  hysterectomy. 
When  it  is  remembered  that  at  this  stage  of  the 
paper,  we  are  considering  whether  vaginal  hys- 
terectomy will  remove  the  entire  disease  in  can- 
cer of  any  portion  of  the  uterus  in  a  greater  pro- 
portion of  cases,  than  will  am-  of  the  above  named 
operations,  it  becomes  obvious  at  once,  that  the 
only  one  which  can  compete  with  vaginal  hyster- 
ectomy at  all  in  this  respect  is  abdominal  hyster- 
ectomy. It  must  be  admitted,  however,  that  ab- 
dominal hysterectomy,  when  performed  so  as  to 
remove  the  entire  uterus,  including  the  cervix  and 
Fallopian  tubes,  will  accomplish  the  same  end  in 
the  same  proportion  of  cases  as  will  vaginal  hys- 
terectomy :  but  the  operation  has  other  disadvan- 
tages which  are  obvious  to  niany  which  render 
it  inferior  to  vaginal  hysterectomy,  and  which 
will  be  touched  upon  under  the  heading  of  mor- 
tality. I  do  not  care  to  bring  an  array  of  argu- 
ments to  prove  obvious  facts.  I  will  therefore 
pass  to  our  second  consideration. 


2.  Will  vaginal  hysterectomy  for  cancer  of  the 
uterus  enable  an  operator  to  go  farther  beyond 
the  diseased  tissue  into  healthy  tissue  than  any 
other  surgical  procedure  ? 

The  cautery  can  be  employed  in  these  cases  to 
follow  out  the  limits  of  the  disease,  if  it  is  con- 
fined to  the  cervix,  and  possibly  the  lower  portion 
of  the  body  and  any  encroachment  on  the  vaginal 
walls  which  has  not  involved  deep  underlying' 
tissues.  Much  can  be  accomplished  in  cancer  of 
the  cervix  with  this  remedy,  but  when  the  disease 
begins  to  involve  the  body  of  the  uterus,  the  dan- 
gers of  subsequent  haemorrhage,  from  the  imper- 
fect closure  of  those  large  vessels  which  must  be 
destroyed  in  reaching  those  portions,  makes  one 
tremble  for  the  result.  When  cautery  is  employ- 
ed to  its  fullest  extent,  however,  we  are  still  far 
short  of  what  is  accomplished  in  total  removal  of 
the  uterus. 

Curetting. — With  curetting,  from  the  nature  of 
the  instruments  employed,  we  do  not  expect  to  go 
any  great  distance  beyond  the  friable  tissue  made 
so  by  the  march  of  the  disease.  Dull  curettes  do 
not  remove,  readily,  healthy  tissue  which  it  is 
necessary-  to  get  into  beyond  the  diseased  portions, 
and  sharp  ones  possess  no  remedy  for  the  haemor- 
1  rhage  they  produce.  So,  with  this  remedy,  we 
'  cannot  hope  to  go  far  beyond  the  limits  of  the 
disease,  and  never  approach  anything  like  the 
i  amount  of  tissue  removal  that  is  accomplished  by 
hysterectomy. 

High  Amputation. — High  amputation  of  the 
cervix  can  accomplish  the  removal  of  consider- 
able tissue  if  it  is  properly  performed.  The  vag- 
inal mucous  membrane  can  be  removed  to  the 
extent  of  l/z  to  2  inches  from  the  vaginal  attach- 
ments. Ligatures  may  transfix  the  base  of  the 
'  broad  ligament  at  least  an  inch  away  from  the 
uterus,  and  a  corresponding  amount  of  tissue  be 
1  removed.  The  amputation  may  extend  well  into 
the  body  of  the  uterus,  and  with  great  care  to 
suppress  the  haemorrhage,  the  fundus  may  be 
pretty  well  approached.  Here,  however,  we  reach 
the  limit  of  our  possibilities  with  high  amputation. 

Abdominal  Hysterectomy.  —  With  abdominal 
hvsterectomy  the  ovaries  and  the  tubes  can  be 
removed  with  the  body  of  the  uterus ;  and  by 
performing  a  very'  unusual  abdominal  hysterecto- 
my the  cervix  may  be  included  with  the  body. 
It  would  not  be  practicable,  however,  for  one  to 
remove  very  much  of  the  vaginal  mucous  mem- 
■  brane. 

Vaginal  Hvstereetom \y.  —With  this  operation 
the  whole  upper  portion  of  the  vagina  to  the  ex- 
tent of  i1 2  or  2  inches  from  its  cervical  attach- 
ment can  be  severed  at  the  outset,  to  be  included 
in  the  tissues  to  be  removed.  After  separating 
well  the  bladder  from  the  uterus,  and  carrying 
the  separation  well  to  the  side,  so  as  to  certainly 
dissect  the  ureters  from  the  broad  ligaments,  the 
base  of  the  broad  ligaments  can  be  ligated  well 


'54 


EARLY  VAGINAL  HYSTERECTOMY. 


[January  31, 


out  to  their  pelvic  attachments,  by  first  drawing 
the  cervix  forcibly  to  the  opposite  side.  When 
the  base  of  one  broad  ligament  is  ligated  and  the 
uterus  well  drawn  down  upon  that  side,  the  large 
broad  ligament  lock  forceps  (Byford's  pattern) 
can  be  adjusted  to  the  remaining  portion  of  the 
ligament,  and  at  such  a  distance  from  the  uterus 
as  to  leave  the  ovary  and  tube  attached  to  the 
latter  ready  to  be  removed  with  the  diseased  tis- 
sue. When  one  broad  ligament  is  severed,  the 
uterus  can,  ordinarily,  be  delivered.  It  is  an 
easy  matter  then,  by  commencing  to  ligate  at  the 
upper  margin  of  the  broad  ligament,  which  re- 
mains intact,  to  get  well  away  from  the  uterus, 
and,  by  carefully  ligating  and  severing  by  sec- 
tions, each  ligature  being  crowded  farther  away 
from  the  uterus,  it  is  possible  to  get  the  ligatures, 
which  are  applied  to  the  base,  well  out  to  the  side 
of  the  pelvis.  To  summarize  then,  without  un- 
duly complicating  the  operation  we  may,  when 
necessary,  remove  the  following  tissues  with  vag- 
inal hysterectomy  :  the  uterus  entire,  the  upper 
portion  of  the  vagina  for  a  distance  of  2  inches 
from  its  uterine  attachments,  both  broad  liga- 
ments to  a  distance  of  1  to  2  inches  from  the 
uterus,  both  Fallopian  tubes  and  both  ovaries. 

Compare  with  this,  what  is  accomplished  with 
the  most  thorough  cauterization,  curretting,  or 
high  amputation  which  can  be  made.  It  will  be 
found  after  these  operations,  that  we  have  re- 
maining, the  fundus  of  the  uterus,  the  Fallopian 
tubes,  the  ovaries  and  much  cellular  tissue  sur- 
rounding them  which  must  be  removed  in  the 
most  ordinary  vaginal  hysterectomy.  The  points 
of  comparison  are  so  apparent,  and  the  compari- 
son so  favorable  to  vaginal  hysterectomy  under 
this  heading,  that  I  feel  it  superfluous  to  go  into 
further  detail. 

3.  Is  vaginal  hysterectomy  a  more  ideal  sur- 
gical operation,  and  does  it  leave  the  remaining 
tissues  in  a  less  favorable  condition  for  a  return 
of  the  disease  ?  This  interrogation  seems  to  me 
somewhat  axiomatic.  I  shall,  therefore,  employ 
but  little  time  in  its  discussion. 

With  vaginal  hysterectomy  an  organ  in  its  en- 
tirety  is  removed.  With  curetting,  cauterizing, 
or  amputation,  only  a  portion  of  an  organ  is  re- 
moved and  crushed,  cauterized,  or  cut  surfaces  of 
a  tissue  remains  to  be  cared  for  which  previously 
had  a  direct  continuity  with  the  diseased  tissue. 
With  vagina]  hysterectomy  satisfactory  and  safe 
Stumps  are  secured  which  contain  all  bleeding- 
vessels  of  importance  and  also  all  channels 
through  which  absorption  of  infectious  material 
may  occur.  Witli  curette,  cautery  or  amputation 
no  regular  stumps  are  secured,  and  large  ugly 
-  of  tissue  are  left  exposed  which  stand 
ready  to  absorb  infectious  matter.  To  tin.  ex 
tent,  too,  that  the  stumps  arc  imperfect  to  that 
extent  is  the  security  against  haemorrhage  im- 
perfect.    With  vaginal  hysterectomy  the   facil- 


ities for  drainage  are  almost  imperfect,  while  with 
the  other  operations,  the  very  nature  of  the 
remedy  employed  against  haemorrhage,  viz. : 
packing  or  tamponing  may  oftentimes  interfere 
with  satisfactory  drainage. 

The  above  remarks  do  not  appl}'  to  abdominal 
hysterectomy.  With  this  operation,  however, 
we  have  an  additional  complication  of  an  ab- 
dominal incision,  and  the  responsibility  of  treat- 
ing two  openings  into  the  peritoneal  cavity  in- 
stead of  one  as  in  vaginal  hysterectomy.  The 
difficulty  of  securing  the  broad  ligaments  in  their 
entirety  from  an  abdominal  incision  is  much 
greater  than  when  they  are  handled  from  below. 

4.  Will  vaginal  hysterectomy  for  cancer  of  the 
uterus  give  in  the  future  an  immediate  mortality 
sufficiently  low  to  make  it  preferable  to  all  other 
surgical  procedures  ? 

I  shall  leave  the  subject  of  abdominal  hyster- 
ectomy for  cancer  out  of  my  calculations  here  be- 
cause we  have  seen  that  it  is  really  not  an  ap- 
propriate operation  for  the  difficult}-  under  con- 
sideration, and  also  because  of  a  recognition  of 
this  fact,  in  this  connection  it  has  been  almost 
entirely  abandoned. 

In  discussing  this  question  I  shall  take  the 
liberty  of  assuming,  that  the  older  operation — 
curetting,  cauterization  and  amputation — have 
for  years  been  out  of  their  experimental  stage, 
while  with  vaginal  hysterectomy,  recent  sta- 
tistics only  are  of  any  value  in  determining  the 
future  of  the  operation. 

With  partial  removal  of  the  uterus,  or  high 
amputation  in  the  hands  of  expert  American  op- 
erators, recently  reported,  an  immediate  mor- 
tality of  more  than  41 2  per  cent,  has  been  the 
result.  These  represent  the  fifty-five  cases  re- 
ported by  Reamy  in  1S88,  with  two  deaths  or  a 
mortality  of  3.6  per  cent.,  and  of  thirty  cases  re- 
ported by  Reeves  Jackson  in  January,  1890,  with 
two  deaths  or  a  mortality  of  6.6  per  cent.  This 
mortality  seems  rather  high  for  an  operation 
which  at  its  best  is  considered  but  a  con- 
servative method  for  treating  a  grave  disease. 
It  is  considerably  lower,  however,  than  we 
get  from  our  foreign  brethren,  for  instance : 
Yerneuil  in  January,  1889,  records  twenty- 
two  cases,  with  two  deaths,  or  a  mortality 
of  9  per  cent.  Hofmeier's  table  of  ninety-six 
Berlin-cases,  gives  a  mortality  of  7.4  per  cent. 
'finis,  with  the  best  statistics  which  can  be  ob- 
tained for  the  so-called  conservative  treatment  of 
cancer  of  the  uterus,  we  must  grant  a  mortality 
of  3.6  per  cent.,  while  with  the  two  best  records, 
a  mortality  of  more  than  4.5  per  cent,  is  obtained. 
In  the  face  of  these  statistics  from  expert  op- 
erators, can  I  be  said  to  be  unfair,  if  I  assume 
the  legitimate  mortality  of  partial  removal  of  the 
uterus  to  he  at  least  5  per  cent.? 

What  is  the  present  mortality  of  vaginal  hys- 
terectomy?    The   published  statistics  of  this  op- 


i89i.] 


EARLY  VAGINAL  HYSTERECTOMY. 


Name  of  Operator. 


Manner  op  Opbrattng. 


-  Citv.  5 


Epithelioma  of  cervix.  Ligature  to  br 


•  ne  side,  clamp 
one  side. 
Clamp 


-rrence. 


58  Kpith.  cerv.  and  body! 

•  cervix 

1  body  &  1.  ovary 
60  Canoe  r  I 

Cancer  cervix.    .    . 


Ball, 
w  York  City 


Epithelioma  cervix. 


Prolapse  uterus. 


1  H.  T.  Byford.  r    cervix Ligatures 

2  Chicago.  111.  57  Papilloma  cer. 

3  -  -sarcoma  of  uter 
4 

45  Three  small  ribr 

Cancer  cervix Forceps  and  ligat 


:nyc 

52  Sarcoma  uterus.  . 
39Carcinoma  cervix. 


Carcinoma  cervix. 


-noma  of  cervix 
r  ids  of  corpus. . 
cer  of  cervix. 


Ligatures  and  forceps. 


.    .    . 
■  Coe,  _       55  Epithelioma  uterus 

cervix. 

;entia 

::oma  Clamp .  . 
corpus  uterus, 
nicer  corp.  uterus.  . 
thelioi 


iu,  1    - 
A.  B.  Carpenter       44  Cancer  of  uterus  .   .      Clamp.. 

Cleveland.  O 
A.  Palmer  Dudley.  4S  Epithelioma  cervix..   L '■. 
New  York  City. 

E.  C.  Dudley,  .-.•:  Carcinoma Silk  ligatu 

Chicago.  51  Sarcoma F01 

arcinoma 




Forceps . 

Ligature  and  forceps 


E.  W.  Cushing         6fc  Malig.  adenoma  corp.  Clamp. 
Boston.  uterus. 

Carcinoma  cervix.  .   . 


- 
- 


'  -ence. 


.-: 


nt  refused  to  eat 


: 


1  recurrence. 


'  operat'n. 
Became  insane  and  died  4 


omy,  4th 


S 


.noma. 
R  Said  I  •Memo. 


loth*  day  of  cerebral 
--1    when 
in  full  c  - 


.  Alive,  but  has  cancer  in 


ra  con* 


3S  Cancer  cervix 

Carcinoma   fundus.    .  Freund method  .    .    . 

[Cancer  cervix Ligatures 

,6  Epithelioma Ligature- 


Cancer  of  cervix. 


Silk  ligatures  . 
Clamp 


■.rrence  ; 


Note— Died  tenth  day  from  hsemorrhage.    The  patient  was  doing  exceedingly  well  up  to  three  minutes  before  death  occurred. 


156 


EARLY  VAGINAL  HYSTERECTOMY 


[January  31, 


Name  of  Operator.   J 


Edward  J.  Ill, 

Newark,  N.  J. 
Charles  N.  Dixon 
Jones,  New  York. 


J.  Tabor  Johnson, 
Washington,  D.C. 


H.  Graff, 

Eau  Claire,  Wis 
Paul  F.  Munde, 
New  York  Citv. 


K     E.    Montgome- 
ry, Philadelphia. 


Daniel  T.  Nelson 
Chicago 
J.  S.  Pinkhain, 

Lynn,  Mass 


Cancer  uteri. 


Partial  extirpation  .  . 
Ligatures  and  forceps. 
Forceps 


Ligatures . 
Clamps  .    . 


Car.  cervix  and  vagina 

Epith.  cervix 

"  and  vagina 


Carcinoma  body. 
Epith.  cervix 
"      body  .    .    . 

Fibroid  

Cancer 


Clamp  forceps 


Interstitial  myoma.   . 

Adenoma 

Cancer  cerv,  and  body, 

45  Cancer  cervix 

••  .  .  .  . 
30         "  "        .   .   .   . 

3+  "  "         .    .    .    . 


47  Carcinoma  .   .    . 
r  "         .  .  . 

66  Sarcoma 

i8  Cancer  of  cervix 
38 

'    of  body  . 
Cancer  ...".. 


C.  A.  von  R  a  m 
dohr,  N.  Y.  Citv 
J.  Algernon  Teiir 
pie,  Toronto,  Out 
Alex.  J.  C.  Skeeue 
Brooklyn 


33  Sarcoma  of  cervix.  .  . 
Epithelioma  of  cervix 
Epithelioma  of  body  . 


Masher  of  Operating.      Date.       <*  -J  Cause  of  Death 


Clamp  and  ligatures  . 


Ligatures . 
Clamp.   .   . 


Silk  ligatures 
Forceps.    .   . 


Clamp.  .   .   . 

Silk  ligature. 
Clamp.  .  .  . 
Forceps.  .   . 


Jan.  4.  '87.  R. 
April  15,  'S6R. 
May  30.  '86.  R. 
■ 
April  25,  'S9  R. 
[885. 
[886. 
1887 

Dec.,  '88. 
Nov.  '88. 
1S90. 

fan,  30,  '85. 
Feb   2,  '87. 

Oct.  io,  '88. 

April  10,  '8£ 

I 

July  is,  '-9 

Ian    20.  'go, 
July,  '87. 
Sept.  20,  'S; 


Sept.  20,  'S7 
Sept.  21,  'S; 
April  24,  '8c 
Dec.  26,  '89' 
Jan    14,  '89 

April  18,  '89 

April  22 

Oct.  23,  'Sf 

Dec.  26,  'Sc 
Jan.  4,  '90 
April  is,  '8 
lune  is,  »8g 
July  18,  '89. 
Sep't.  6,  'S9 

1SS5. 
1S85. 


June  1,  '86 
Aug,  6,  '88 
Dec,  '88. 


Peritonitis,  6th  day 
Peritonitis,  3d  day 


Peritou.,  14th  day 


Shock  .  .   . 
Death  in  12  hours 
from  hamiorrh 


Recovery  slow  . 


Uriemic  coma. 


Return  and  death  iu  20  mo. 


Well  two  years  after. 
Died  6  mos.  after  operat'n 


Well. 
Well. 
Well 
Died 


[turn  of  disease, 
year  later  from  re- 


Operated  upon  by  Dr.  Au- 
gust Martin,  of  Berlin, 
while  visiting  the   I".  S. 


Still  well. 
Well. 
Well. 
Still  Well. 
Cancer  returned. 
Death  in  8  mos.  from  ret. 
[a  vear. 
Relapse  and  death  within 
Relapse  and  death  within 

14  months. 
Not  returned. 
Returned. 

Pat.  now  in  good  health. 

Not  known. 

Had  symptoms  of  return. 

In  good  health. 

At  this  writing  ioof  the  12 
subjects  are  dead.  In  S 
cases  recurrence  in  less 
than  12  mos.  In  1  case 
within  13  mos..  1  within 

15  mos.  Of  the  two  re- 
maining cases,  1  will,  in 
my  opinion,  have  no  re- 
currence. The  last  one 
is  too  recent  to  be  con- 
sidered. 


ne  mouths  later. 


eration  have  shown  a  gradual  lowering  of  mor- 
tality since  1880.  The  statistics  of  all  published 
cases,  gathered  by  Dr.  S.  E.  Post,  showed  for  the 
cases  published  before  1880  an  immediate  mor- 
tality of  37  per  cent. ;  for  those  published  in 
1880  and  1881  26.5  per  cent.;  for  additional  ones 
to  the  end  of  1882,  27  per  cent.;  for  additional  ones 
to  the  end  of  1885,  24  Per  cent-  I  while  the  addi- 
tional ones  to  the  end  of  1887,  gave  a  mortality 
of  only  20  per  cent.  The  above  statistics  are 
valueless  to  prove  the  legitimate  ultimate  mor- 
tality of  this  operation.  First,  because  they  con- 
tain the  records  of  operators  of  experience,  not 
only,  but  also  those  of  scores  of  operators  with 
their  first  one  or  two  cases  and  the  result  of  all 
their  inexperience  ;  second,  because  these  sta- 
tistics are  the  records  of  operations  performed 
while  the  procedure  was  iu  its  primative  and  ex- 
perimental stage,  and,  too,  many  of  the  results 
represent  work  performed   before   the   establish- 


ment of  the  present  antiseptic  surge^'.  In  order 
to  get  more  nearly  at  the  present  status  of  this 
operation  in  this  county,  and  to  be  able  to  forecast 
with  greater  accuracy  the  future  immediate  mor- 
tality of  this  operation,  I  sent  circular  letters  to 
many  of  the  leading  operators  of  this  country  re- 
questing them  to  fill  out  enclosed  blanks  with 
histories  of  all  operations  of  vaginal  hysterectomy 
performed  by  them  since  January,  1885.  I  re- 
ceived replies  from  twenty -five  operators,  repre- 
senting 134  operations,  with  20  deaths,  or  a  mor- 
tality of  less  than  15  per  cent.  Of  the  25  who 
responded,  4  had  operated  but  once,  3  twice, 
2  three  times,  3  four  times,  5  five  times,  2  six 
times,  1  eight  times,  1  twelve  times,  1  thirteen 
times,  1  fifteen  times  and  1  twenty  times. 

The  average  mortality  of  the  four  highest  op- 
erators is  just  10  per  cent.  The  operator  having 
the  greatest  number  of  operations  to  his  credit, 
has  also  the  lowest  average  mortality.     Themor- 


i89i.] 


TESTS  FOR  VISUAL  ACUTE:. 


'57 


tality  being  but  5  per  cent,  with  twenty  cases. 
The  operator  having  the  next  highest  number  of 
cases,  has  also  the  next  lowest  mortality,  or  6;  3 
per  cent,  in  fifteen  cases. 

These  figures  are  all  significant.  Tin 
conclusively  that  vaginal  hysterectomy  is  no  ex 
ception  to  the  rule,  that  with  experience  in  op- 
erating comes  proficiency  and  lowering  of  death 
rate.  They  demonstrate,  to  my  mind,  that  the 
legitimate  death-rate  among  good  surgeons, 
ought  not  to  exceed  10  per  cent.,  and  that  the 
death-rate  with  the  expert  will  not  exceed  5 
per  cent. 

This  then,  is  the  burden  of  my  proof:  With 
the  best  record,  in  this  country,  for  the  so-called 
conservative  treatment,  we  have  a  mortalitv  of 
3.6  per  cent.,  while  the  best  record  for  the  rad- 
ical operation  is  but  1.4  higher,  or  5  percent. 
With  the  next  best  record  for  the  conservative 
treatment,  we  have  a  mortality  of  6.6  per  cent., 
while  for  the  radical  operation  we  have  but  6.6 
per  cent.  Thus,  we  find,  without  any  manipu- 
lating of  statistics,  the  comparative!}-  new  opera- 
tion of  vagiual  hysterectomy  presents  a  mortality, 
which  is  but  a  shade  higher  than  the  old  and  im- 
perfect so  called  conservative  method. 

I  will  leave  this  subject  now  with  the  society. 
I  am  aware  that  not  all  the  proof  which  I  have 
been  able  to  array,  in  support  of  my  propositions, 
has  been  conclusive  ;  they  do,  however,  repre- 
sent my  honest  convictions. 

GENERAL     SUMMARY : 

i.  Vaginal  hysterectomy  is  the  most  justifiable 
surgical  procedure,  we  yet  know,  for  the  cure  of 
cancer  of  the  uterus. 

2.  Vaginal  hysterectomy  should  be  attempted, 
for  the  cure  of  cancer  of  the  uterus,  at  the  earli- 
est possible  moment  after  the  disease  is  diag- 
nosed. 

The  following  facts  are  given  in  support  of  the 
foregoing  proposition : 

a.  Vaginal  hysterectomy  will  remove  the  en- 
tire disease  in  cancer  of  any  portion  of  the  uterus 
in  a  greater  proportion  of  cases  than  will  any 
other  surgical  procedure  now  recommended. 

b.  Vagiual  hysterectomy  for  cancer  of  the 
uterus  will  enable  an  operator  to  go  farther  be- 
yond the  diseased  tissue  into  healthy  tissue  than 
will  any  other  surgical  procedure  now  recom- 
mended. 

c.  Vaginal  hysterectomy  is  a  more  ideal  sur- 
gical operation,  and  leaves  the  remaining  tissue  in 
a  less  favorable  condition  for  the  return  of  the 
disease,  than  will  any  other  surgical  procedure 
now  recommended. 

3.  Vaginal  hysterectomy,  for  cancer  of  the  uterus, 
will  give  in  the  future,  an  immediate  mortality 
among  general  operators  of  not  more  than  10  per 
cent.,  while  in  the  hands  of  experts  it  will  not 
exceed  5  per  cent. 


TESTS  FOR  VISFAL  AC  THF.IR 

ILLUMINATION;  AND  THE  STAND- 
ARD OF   NORMAL  VISION. 

Read  in  the  Section  of  Ophthalmology  at  the  Forty-first  Annual  Meet- 
ing of  (lit    :  :!le, 
Venn 

BY  EDWARD  JACKSON,  A.M.,   M.D.. 

.    THE    PHILADELPHIA  POLY- 
CLINIC. SURGEON  Tip  WILLS'   EYE  HOSPITAL,  OIHTIIAL.V 
B    BOSPI1  u.. 

The  adoption  of  a  definite  series  of  tests  for  vis- 
ual acuteness,  constitutes  an  important  advance 
in  the  diagnosis  of  ocular  conditions.  The  Jaeger 
scale  and  method  of  notation  added  greatly  to  the 
defiuiteness  of  our  knowledge.  But  the  work  of 
Snellen  brought  a  further  advance,  of  perhaps 
equal  importance;  and  his  series  of  test  type,  and 
system  of  fractional  notation  have  almost  entirely 
supplanted  their  predecessors.  Probably  most  of 
us  have  realized  that  the  Snellen  system,  too,  is 
not  perfect;  and  whether  or  not  we  are  prepared 
to  at  once  supersede  it,  a  discussion  of  its  defi- 
ciencies, leading  to  a  more  exact  appreciation  of 
them,  will  certainly  be  profitable. 

We  use  tests  of  visual  acuteness  for  two  pur- 
poses, the  determination  of  visual  power  of  the 
eye,  and  the  ascertaining  what  lens  from  the  trial 
set  best  corrects  its  error  of  refraction.  For  the 
former  use  we  require  of  our  standard  that  it  shall 
have  a  fixed  and  definite  significance.  Variabili- 
ty and  indefiniteness  in  our  standards  are  abso- 
lutely fatal  to  scientific  accuracy.  For  the  latter 
use  we  require  a  test  that  shall  not  mislead  us  into 
resting  satisfied  with  an  imperfect  correction  when 
a  better  one  is  obtainable. 

The  observation  on  which  the  Snellen  scale  was 
based  was,  that  in  healthy  eyes  free  from  mani- 
fest ametropia,  two  points  to  be  seen  as  separate 
points  must  be  far  enough  apart  to  subtend  an 
angle  of  one  minute,  or  a  little  less.  This  obser- 
vation has  been  abundantly  verified,  and  for  the 
great  mass  of  eyes  its  substantial  correctness  can- 
not be  questioned.  Snellen,  experimenting  and 
reasoning  on  this  subject,  came  to  the  conclu- 
sions that  only  a  block  letter  can  have  all  its  dif- 
ferent parts  equally  visible,  and  that  to  have  each 
of  the  component  parts  of  a  letter  visible  to  the 
normal  eye,  each  of  these  parts  must  subtend  the 
angle  of  one  minute.  He  also  found  that  in  some 
of  the  capital  letters  of  the  alphabet,  as  B  and  S, 
to  make  the  letter  at  all  complete  there  must  be 
at  least  five  component  parts  both  vertically  and 
horizontally.  Therefore  he  constructed  his  test- 
type  on  such  a  scale  that  each  letter  should  occu- 
py a  square,  each  side  of  which  should  subtend 
\  an  angle  of  five  minutes  at  the  nodal  point  of  the 
eye. 

But  the  majority  of  the  letters  of  the  alphabet 
do  not  require  that  five  component  parts  shall  be 
seen  in  order  that  the  letter  shall  be  recognized, 
O  will  be  recognizable  if  the  angle  it  subtends  is 
but  three  minutes,   and  an  L  can  be  constructed 


158 


TESTS  FOR  VISUAL  ACUTENESS 


[January  31, 


that  can  be  positively  identified  by  eyes  with  or- 
dinarily perfect  vision  under  a  visual  angle  of 
about  two  minutes.  Block  letters  of  equal  size 
then,  are  very  unequally  visible;  to  be  equally 
visible,  they  must  be  of  very  different  sizes.  Den- 
nett carefully  worked  this  subject  out,  (see  Trans. 
American  Ophthalrnological  Society  for  1885), 
and  proposed  that  the  letters  on  any  one  line  of 
our  test- cards  should  be  made  of  such  unequal 
sizes  that  they  should  really  be  equally  visible, 
at  any  given  distance. 

Other  methods  of  meeting  this  difficulty  have 
been  resorted  to.  As  in  a  card,  published  by 
Bouschur  and  Holmes  of  Philadelphia,  letters  like 
the  O,  C,  G,  and  O,  that  are  liable  to  be  confused 
with  one  another,  are  printed  on  the  same  line. 
In  Oliver's,  and  many  other  cards,  only  certain 
letters  are  employed,  the  others  being  excluded; 
one  author  selectingcertain  letters,  another  choos- 
ing certain  others.  About  three  years  ago  I  ar- 
ranged a  card  on  which  the  letters  were  each 
made  to  subtend  an  angle  of  four  and  one-half 
minutes,  instead  of  five,  the  letters  more  easily 
seen  befhg  placed  at  the  beginning  of  each  line. 
And  since  then  cards  have  been  arranged  by  Dr. 
Chas.  M.  Culver,  and  Dr.  James  Wallace,  with 
letters  subtending  an  angle  of  four  minutes  each. 

The  card  last  alluded  to,  which  is  published  by 
Wall  &  Ochs,  of  Philadelphia,  is  on  the  whole  the 
most  satisfactory  card  of  test  letters  that  I  have 
used;  and  yet  it  is  very  far  from  furnishing  a  per- 
fect standard  for  the  determination  of  visual  acute- 
ness.  The  raising  of  the  standard  does  not  even 
do  away  with  hyper-normal  vision.  Of  one  hun- 
dred consecutive  cases  of  ametropia  tested  with 
this  card  at  the  distance  of  four  metres,  after  the 
correction  of  their  ametropia  : 

1  could  read  only  the  12  metre  line;  3  could 
read  only  the  7.5  metre  line:  3  could  read  only 
the  6  metre  line;  13  could  read  only  the  5 '  metre 
line;  29  could  readonly  the  4  metre  line;  24  could 
read  most  of  the  3  metre  line;  20  could  read  nearly 
all  of  the  3  metre  line;  7  could  read  all  of  the  3 
metre  line. 

That  is,  51  per  cent,  of  these  patients  had  vis- 
ion distinctly  better  than  \,  when  tested  by  letters 
subtending  the  angle  of  only  four  minutes. 

It  is  possible  that  still  smaller  letters  would  do 
as  well,  or  even  better  for  practical  work  with  the 
trial-glasses,  but  what  has  been  said  is  sufficient 
to  show  that  no  visual  test  embracing  such 
varied  and  complex  forms  as  the  letters  of  the 
alphabet  can  give  us  a  standard  of  such  scientific 
definiteness  and  accuracy  as  we  have  the  right  to 
demand.  Such  a  standard  is  only  made  possible 
by  recourse  to  some  simple,  constant,  geometrical 
figure. 

A  NEW  TEST. 

The  figure  I  have  chosen  for   this  purpose   is 

here  shown. 


c  a  n  u 


It  is  an  incomplete  square,  each  side  of  which 
snbteuds  the  angle  of  three  minutes;  the  incom- 
plete side  being  turned  in  the  various  directions, 
and  the  patient  required  to  indicate  its  direction. 
This  is  based  on  the  same  observation  asSnellen's 
test,  that  points  to  be  seen  as  separate  points 
must  be  separated  by  an  angle  of  one  minute,  but 
it  furnishes  a  test  that  conforms  as  nearly  as  any 
test  may  to  the  scientific  requirements  of  con- 
stancy and  definiteness.  A  card  of  such  test  fig- 
ures, arranged  for  use  at  the  distance  of  four  me- 
tres, has  been  published  by  H.  C.  Boden  &  Co., 
of  Philadelphia,  and  may    be  obtained   of  them. 

I  have  also  found  very  useful  as  a  test  of  visual 
acuteness  that  could  be  carried  in  the  vest  pocket, 
one  of  these  same  incomplete  squares  printed  in 
the  centre  of  a  square  card.  It  can  be  turned  in 
any  direction  and  the  patient  required  to  indicate 
its  direction.  There  is  only  one  chance  in  four 
of  his  guessing  right,  and  a  few  trials  give  cer- 
tain evidence  as  to   the  visual  acuteness. 

I  do  not  offer  these  tests  expecting  them  to  su- 
persede the  use  of  test-letters  for  the  ordinary  cor- 
recting of  ametropia.  But  if  we  will  use  them 
simply  for  determining  and  recording  the  visual 
acuteness  in  each  case,  we  will  obtain  records  ot 
far  greater  scientific  and  practical  value,  than  are 
obtainable  with  the  various  letter-tests  that  claim 
to  be  founded  on  the  Snellen  basis. 

ILLUMINATION  OF  THE    TEST  CARD. 

The  results  obtained  with  the  four  minute  test- 
type,  referred  to  above,  may  strike  some  as  ex- 
traordinary. But  I  am  satisfied  that  they  will  not 
be  found  exceptional,  provided  the  ametropia  is 
perfectly  corrected,  and  the  test  card  well  illumi- 
nated. This  matter  of  the  illumination  of  the 
test-card  is  not  sufficiently  appreciated.  Proba- 
bly the  greatest  harm  that  comes  to  us  from  ac- 
cepting as  normal  Snellen  ?,",  which  is  often  not 
three-fourths  of  normal  vision,  is  the  tendency  it 
breeds  to  tolerate  an  utterly  inadequate  illumina- 
tion. 

We  all  understand  that  the  visibility  of  any 
test  varies  with  its  illumination,  but  no  one  who 
has  not  worked  by  a  constant  [artificial]  illumina- 
tion can  appreciate  the  enormous  variations,  not 
only  from  day  to  day  but  even  from  hour  to  hour 
or  minute  to  minute,  in  the  ordinary  diffused  day- 
light. Then,  under  the  best  conditions  diffuse 
daylight  gives  a  too  feeble  illumination,  unless 
the  card  be  directly  exposed  to  a  large  expanse  of 
unobstructed  sky,  or  the  reflection  of  direct  sun- 
light from  a  white  or  other  light  colored  surface. 

In  estimating  ametropia  with  the  test-lenses 
and  letters,  we  appreciate  the  uncertainty,  the 
widening  of  the  limits  of  probable  error,  that 
come  from  amblyopia  due  to  haziness  of  the  me- 
dia, or  disease  of  the  retina.      Yet  very  often   the 


I89i.] 


SIMPLE  OVARIOTOMY, 


159 


same  uncertainty  and  increased  chance  of  error  is 
permitted  through  imperfect  illumination.  In 
one  of  the  largest  ophthalmic  hospitals  of  this 
country,  the  surgeons  and  their  assistants  have  to 
put  (iciwn  on  dark  days  '•'..  or  ,'  |  as  the  best  ob- 
tainable vision  for  the  majority  of  persons,  and  are 
satisfied  with  any  illumination  that  gives  it. 
There  can  be  no  doubt  that  all  refraction  work 
done  under  conditions  where  fjj  to  ||;  is  the  best 
obtainable  vision  is  vitiated  with  great  probability 
of  error.  To  render  evident  the  slighter  depart- 
ures from  perfect  vision,  the  slighter  departures 
from  perfect  correction  of  the  ametropia,  strong 
illumination  is  essential. 

Brightness  aids  in  securing  practical  constancy  of 
illumination.  When  the  light  is  feeble  a  slight 
change  in  its  quantity  makes  a  notable  change  in 
the  visibility  of  the  test;  but  as  the  illumination 
is  made  brighter  the  amount  of  light  that  must 
be  added  to  cause  such  a  change  must  be  much 
greater;  until  finally  a  point  is  reached  beyond 
which  the  indefinite  increase  of  the  light  adds 
practically  nothing  to  the  visibility  of  the  test. 

For  some  years  I  have  used  the  illumination 
from  an  argand  gas-burner,  placed  fifteen  inches 
from  the  test  card.  This  is  brighter  than  can  be  | 
obtained  by  diffuse  daylight,  except  through  a 
large  skylight,  for  a  small  part  of  an  especially  ; 
bright  day.  And  a  somewhat  brighter  illumina- 
tion still  would  be  a  little  better.  Such  an  illumi- 
nation  is  subject  to  slight  variations,  but  they 
are  quite  insignificant  as  compared  with  those  of 
diffuse  daylight;  and  the  somewhat  yellowish  col- 
or of  the  light,  by  lessening  irradiation,  is  very 
favorable  to  clearness  of  vision. 


THE  CLINIC. 


SIMPLE  OVARIOTOMY.' 

BY  O.   G.   PFAFF,   M.D., 

CLINICAL   LECTURER   ON    DISEASES    OF    WOMEN     IN    THE     MEDICAL 
COLLEGE  OF    INDIANA;   GYNECOLOGIST   TO  THE   INDIAN- 
APOLIS CITY   DISPENSARY",    ETC. 

Gentlemen:  What  I  shall  have  to  say  to-day 
concerns  chiefly  simple  methods  of  work  as  applied 
to  the  general  run  of  cases,  and  it  is  not  at  all  de- 
signed to  be  a  detailed  description  of  the  work  of 
any  particular  man.  On  the  contrary,  I  have 
seen  many  operators  at  work  and  I  think  I  can 
see  that  those  whose  operations  are  marked  by 
rapidity  and  simplicity  obtain  the  best  results; 
and  it  shall  be  my  aim  to  simply  emphasize  cer- 
tain points  which  observation  and  experience  have 
taught  me,  constitute  the  first  principles  of  in- 
telligent clearheaded  work,  and  the  key-note  to 
success. 

In  undertaking  any  operation  wherein  the  ab- 


dominal cavity  is  to  be  invaded,  we  should  have 
as  a  part  of  our  equipment,  two  basins;  one  to 
contain  a  very  few  instruments  which  are  always 
required,  the  other  to  contain  those  which  may 
be  needed;  many  cases  will  be  thoroughly  well 
done,  and  quickly  too,  by  means  of  a  scalpel,  a 
grooved  director,  a  pair  of  dissecting  forceps  and 
a  Hagadorn  needle;  but  in  the  complicated  cases 
our  supply  must  equal  the  demand;  the  best  rule 
is  to  use  one  instrument  for  as  many  purposes  as 
due  regard  for  efficiency  and  economy  of  time 
will  permit. 

Make  a  quick  incision,  taking  care  not  to  cut 
too  deeply,  aiming  directly  for  the  linea  alba, 
which  is  the  line  almost  universally  accepted  as 
the  only  proper  route  to  the  peritoneal  cavity; 
however,  I  believe  it  makes  no  difference,  and 
the  only  reason  for  making  the  cut  through  the 
linea  alba  is,  that  it  chances  to  be  the  median 
line,  and  therefore  most  naturally  invites  incision. 
If  the  linea  alba  be  not  directly  reached,  authori- 
ties generally  agree  that  we  should  carefully  dis- 
sect for  it;  to  do  so  is  but  to  sacrifice  precious 
seconds  without  the  possibility  of  any  compensa- 
tion whatever;  on  the  contrary,  it  but  compli- 
cates the  first  steps  of  the  operation;  there  is 
more  bleeding  from  the  muscle  wound  than  oc- 
curs from  the  regulation  incision,  but  this  is  ot 
no  consequence  at  all  as  it  is  instantly  and  per- 
fectly controlled  by  compression  forceps.  This 
incision  has  a  positive  advantage  in  healing,  for 
as  Dr.  Robert  Morris  truly  says,  a  cut  through 
muscular  fibre  heals  much  more  readily  and 
firmly  than  does  a  cut  through  fibrous  tissue. 

Having  reached  the  peritoneum,  picked  it  up 
with  the  dissecting  forceps,  knicked  it  with  the 
knife  which  you  have  not  as  yet  laid  down,  it  is 
to  be  opened  on  a  grooved  director  with  the  same 
knife  to  the  extent  of  the  external  wound;  in  a 
very  large  majority  of  cases  it  is  by  this  time  ap- 
parent whether  the  abdominal  wound  is  to  be  en- 
larged or  not;  in  case  it  is  decided  to  extend  the 
cut,  it  is  the  custom  of  most  operators  to  do  so  by 
means  of  scissors,  protecting  the  abdominal  vis- 
cera from  injury  by  a  grooved  director  guiding 
the  under  blade.  A  quicker,  neater  and  more 
surgical  way  is  to  simply  insert  two  fingers 
through  the  abdominal  wound,  letting  them  oc- 
cupy a  position  directly  beneath  the  line  of  pro- 
posed incision,  and  with  the  knife,  still  held  in 
the  hand,  with  its  point  following  the  groove  be- 
tween the  two  fingers,  enlarge  the  opening  to  the 
extent  desired,  above  and  below. 

After  evacuating  the  cyst,  with  the  patient 
always  on  her  side  for  this  purpose,  and  the  cyst 
wound  again  closed  with  catch  forceps,  the  ad- 
hesions must  be  attacked  with  the  utmost  deter- 
mination, as  there  is  but  one  rule;  they  must  be 
broken  up;  and  we  are  justified  in  using  a  great 
deal  of  force  to  accomplish  that  most  necessary 
result,  even  if  the  bladder  or  intestines  be  torn  as 


i6o 


SIMPLE  OVARIOTOMY. 


[January  31, 


the  result  of  determined  effort  at  separation;  these 
injuries  properly  repaired  and  the  cyst  complete- 
ly removed,  the  woman's  chances  for  ultimate  re- 
covery are  far  brighter  than  they  could  possibly 
be  were  the  cyst  allowed  to  remain  and  the  vain 
attempt  to  cure  by  drainage  made;  such  attempts 
amount  simply  to  tapping  and  end  in  disapoint- 
nient  and  disgust. 

The  enucleation  of  certain  tumors  is  practi- 
cable and  may  be  resorted  to  as  the  quickest  and 
safest  method  of  removal;  I  am  aware  of  the  fact 
that  when  adhesions  are  very  extensive  and  firm 
there  has  usually  been  inflammation  of  the  cyst 
and  that  its  layers  cannot  be  separated,  but  in  a 
recent  case  where  I  had  undertaken  the  removal 
of  a  large  multilocular  cyst,  the  woman  having 
had  several  attacks  of  peritonitis,  I  encountered 
adhesions  so  extensive  and  firm  that  it  seemed  im- 
possible to  break  them  up  without  the  almost  cer- 
tain result  of  serious  damage  to  the  abdominal 
viscera;  I  made  the  attempt  to  enucleate,  and 
the  ease  and  rapidity  with  which  I  accomplished 
the  mauceuver  amounted  to  a  positive  delight. 

In  treating  the  pedicle,  the  clamp  is  more  often 
a  hindrance  than  a  help,  and  should  be  dispensed 
with  whenever  it  is  possible  to  do  so,  its  applica- 
tion and  removal  consumes  valuable  time  and  its 
employment  does  not  simplify  the  operation. 

The  pedicle  is  to  be  tied  in  two  or  more  sec- 
tions by  crossed  ligaturesof  No.  1 1  braided  silk, pre- 
pared for  the  purpose  by  six  hours  immersion  in 
mehed  yellow  wax,  according  to  Skene's  method. 
The  simplest  manner  of  introducing  the  liga- 
ture is  with  a  slightly  curved  Hagadorn  needle 
held  between  the  thumb  and  finger,  although  the 
small  ligature  forceps  of  Keith  are  convenient, 
and  also  those  of  Cleaveland.  When  securely 
tied  and  neatly  divided,  the  edges  of  the  stump 
will  be  everted  and  curl  back  over  the  ligature 
forming  a  capsule  for  it,  thereby  effectually  dis- 
posing of  the  question  of  subsequent  irritation  as 
far  as  that  particular  ligature  is  concerned. 

Following  the  removal  of  a  tumor,  or  diseased 
ovaries,  or  the  performance  of  any  other  abdom 
inal  work,  the  cavity  is  to  be  thoroughly  flushed 
with  strained,  boiled  water  at  a  temperature  of 
several  degrees  above  that  of  the  blood,  poured  in 
a  strong  stream  from  an  ordinary  pitcher,  as  this 
can  be  more  rapidly  done  than  if  the  fountain 
irrigator  be  employed;  and  also  in  the  pitcher  we 
have  constantly  presented  for  inspection  the 
whole  quantity  of  water  to  be  used,  this  is  of 
practical  importance  as  I  have  known  of  a  fly  to 
drop  into  the  fountain  reservoir,  the  mouth  of 
which  had  been  carelessly  left  uncovered. 

This  irrigation  should  be  practiced  in  every 
case,  no  matter  how  simple  the  operation  nor  how 
clean  the  cavity,  and  I  believe  that  in  a  large 
majority  of  instances,  the  chief  benefit  to  be  de- 
rivi  d  from  this  process  of  hot  water  irrigation 
comes  of  the  fact  that  it  prevents  shock  or  coun- 
teracts its  effects. 


While  assistant  to  my  preceptor,  the  lamented 
Harvey,  whose  proportion  of  terrible  cases  can 
scarcely  be  matched,  and  who,  as  an  operator, 
judged  by  the  results  in  suck  cases,  had  few  peers, 
and  no  superiors,  I  have  seen  the  hot  watei 
poured  into  the  pelvic  cavities  of  patients  in  a 
state  of  collapse  from  the  effects  of  the  prolonged 
and  complicated  operations,  and  these  patients 
had  the  scale  turned  at  once  in  their  favor  and 
most  of  them  got  well  when  they  would  otherwise, 
many  of  them,  have  undoubtedly  succumbed  im- 
mediately to  the  effects  of  the  operation.  If  it 
does  so  much  in  such  cases  as  were  Harvey's,  the 
use  of  hot  water  in  simple  cases  is  but  to  insure 
the  lives  of  our  patients. 

In  closing  the  abdomen,  the  Peaslee  needle  or 
some  modification  of  it  is  very  generally  used, 
but  I  think  this  is  because  of  the  tardy  arrival  of 
the  Hagadorn  needle;  the  clumsy  "see-saw" 
motion  necessary  with  the  Peaslee  needle  has 
driven  it  from  the  perineum  and  it  is  but  the  re- 
sult of  progress  that  it  should  take  its  place  along 
with  silver  ware  on  the  retired  list  with  full  hon- 
ors, to  be  called  on  for  service  only  in  time  of 
emergency. 

I  have  devised  a  needle  forceps  which  will 
hold  a  Hagadorn  needle  of  any  size,  straight  or 
curved,  at  any  angle  desired.  With  this  instru- 
ment I  grasp  the  slightly  curved  No.  2  Hagadorn 
needle  near  the  eye,  holding  it  directly  on  a  line 
with  the  instrument,  and  push  it  through  the  ab- 
dominal walls,  completing  the  suture  as  in  any 
other  wound;  I  believe  a  still  better  method  is  to 
hold  the  needle  between  the  thumb  and  finger, 
passing  it  directly  through  as  described  without 
the  aid  of  any  forceps  whatever,  this  is  my  cus- 
tom in  suturing  the  perineum,  and  I  have  tried 
it  in  laparotomy  with  much  comfort. 

The  sutures  and  dressings  which  I  have 
adopted  are  both  Skene's,  and  are  described  by 
him  in  his  recent  work,  however,  I  will  give  a 
few  points  which  I  received  from  him. 

Braided  silk  is  used  for  all  sutures  and  ligatures 
in  this  and  all  other  surgical  operations;  its  chief 
merit  lies  in  the  fact  that  braided  silk  cannot  un- 
twist, because  it  is  not  twisted,  therefore  its  fibers 
cannot  become  separated  thereby  favoring  the 
accumulation  of  blood  clots  or  other  debris  which 
might  decompose.  The  proper  size  for  the  ped- 
icle is  No.  n;  for  ligating  strong  adhesions  or 
large  blood  vessels,  No.  3;  and  for  the  abdominal 
walls,  No.  4. 

The  braided  silk  is  prepared  for  use  by  the 
surgeon  himself;  or  a  super-conscientious  assist- 
ant. I  first  wind  it  loosely  around  a  small,  clean 
piece  of  pine  wood,  the  diameter  of  a  pencil  and 
three  or  four  inches  long;  it  is  then  put  into  a 
small  basin  with  sufficient  yellow  wax  (which  is 
more  pliable  than  white  wax )  to  cover  it  when 
melted;  it  is  then  placed  in  a  hot  water  bath 
where  it  must  remain  for  full  six  hours,  this  time 


i89i.] 


MEDICAL  PROGRESS. 


161 


being  required  for  the  thorough  saturation  of 
every  fibre  with  the  wax.  The  silk  is  now  to  be 
drawn  through  a  earbolized  sponge  to  remove  the 
surplus  wax,  whin  it  is  to  be  wound  upon  suitable 
spools  and  kept  in  a  closed  bottle:  silk  so  pre- 
pared is  absolutely  aseptic,  and  so  far  as  its  body 
is  concerned  it  must  remain  so,  as  it  can  no  more 
absorb  anything  than  can  silver  wire:  when  re- 
moved after  the  healing  of  wounds  and  examined 
by  experts,  the  silk  has  been  repeatedly  found  to 
be  still  aseptic:  for  the  sake  of  insuring  an  asep- 
tic condition  of  the  surface  of  the  sutures,  they 
must  be  placed  in  antiseptic  solution  at  the  time 
of  the  operation  just  as  is  the  custom  when  silver 
wire  is  employed. 

In  tying  the  sutures  it  will  facilitate  the  work 
to  first  smear  the  portion  which  is  to  form  the 
knot  with  a  little  purified  vaseline. 

The  dressing  is,  I  think,  perfection,  both  in 
simplicity  and  efficiency:  no  iodoform,  no  bis- 
muth, no  oiled  silk,  nor  patent  protectives  of  half 
a  dozen  layers,  but  simply  one  square  yard  of 
ordinary  cheesecloth  boiled,  and  then  soaked 
over  night  in  a  I21.-  per  cent,  solution  of  carbolic 
acid  in  glycerine:  wring  this  out  with  the  hands 
when  it  is  to  be  used,  fold  it  to  a  convenient  size, 
about  6xio  inches,  adjust  neatly  over  the  wound, 
cover  it  with  a  good  thick  pad  of  cotton  and  ap- 
ply an  ordinary  binder;  when  this  dressing  is  re- 
moved at  the  end  of  a  week,  it  will  be  as  sweet 
and  clean  as  when  first  applied. 

The  after  treatment  is  as  important  as  it  is 
simple  and  should  be  commenced  before  the  op- 
eration; that  is  a  saline  laxative  just  before  the 
anaesthetic  securing  an  action  of  the  bowels 
directly  after  the  operation,  and  I  insist  on  daily- 
evacuations  for  at  least  four  days,  thereby  pro- 
viding most  efficient  drainage,  preventing  fever 
and  abolishing  pain. 

Fever  and  pain  generally  mean  sepsis,  and 
drainage  by  the  bowel  is  the  remedy,  not  quinine 
and  opium.  If  in  spite  of  everything,  serious, 
general  peritonitis  should  supervene,  and  refuse 
to  yield  to  the  free  administration  of  salines,  the 
patient  is  entitled  to  one  more  chance,  open  the 
wound,  wash  out  the  cavity^  freely  again  with 
hot  water,  suture  it  closely  and  apply  a  fresh 
dressing. 

For  extraordinary  and  persistent  pain  I  give  an- 
odynes, and  for  very  high  and  stubborn  fever  I  give 
antipyretics,  but  in  the  main  patients  suffering 
from  the  effects  of  operations  must  be  treated 
mechanically,  and  if  they  cannot  be  saved  by- 
such  treatment  they  must  die. 


Prince  Alexander  of  Oldenburg  has  con- 
tributed a  sum  of  400,000  roubles  (about  S230,- 
ooo")  towards  the  establishment  of  a  hospital  for 
patients  suffering  from  tuberculosis  in  St.  Peters- 
burg. 


MEDICAL    PROGRESS. 


Tberapeattea  »ixl  Pharmacol) 
Creolin. — In  an  inaugural  dissertation  at  Bres- 
law,   in    1890  '  Centralbla 

Bitter  gives  a  resume  of  the  use  of  creolin  in 
over  two  thousand  puerperal  cases  in  the  Bre-dau 
Lying- in- Hospital.  In  three  women  who  were 
having  uterine  douches  of  creolin  solution  symp- 
toms of  intoxication  suddenly  appeared,  such  as 
anxiety,  nausea  and  fainting.  All  complained 
of  a  taste  of  tar  or  smoke  in  the  mouth.  The 
taste  was  persistent  for  a  time,  but  the  other 
symptoms  disappeared  immediately  on  interrupt- 
ing the  douches.  A  fourth  woman  was  very  rest- 
less and  felt  weak  for  several  days.  Thirty-six 
hours  after  the  attack  in  these  cases,  the  urine 
drawn  with  catheter  was  dark  brown  and  con- 
tained albumen.  The  color  disappeared  in  a  few 
days,  but  the  albuminuria  persisted  for  a  short 
time.  The  author  favors  creolin  on  account  of 
its  anti-bacterial  properties  and  its  relative  harm- 
lessness  to  patients.  It  is  a  good  deodorizer,  ir- 
ritates the  skin,  mucous  membranes  and  wound 
surfaces  but  little.  It  has  no  anti-haemorrhagic 
action.  Its  disadvantages  are  that  the  solutions 
or  emulsions  are  not  transparent,  and  the  prepar- 
ation is  not  always  reliable. 

Koch's  Treatment  in  Lupus  ;  Fatal  Re- 
sult.— Jarisch  {Wiener  klin.  Wochenschr.,  Xo. 
50,  1890),  gives  the  following  details  of  the  case 
of  lupus  in  which  death  recently  followed  the  in- 
jection of  Koch's  fluid  at  Innsbruck.  The  pa- 
tient was  a  girl,  aged  17,  who  had  been  under 
treatment  in  the  Dermatological  Clinic  for  a  year 
and  a  half  for  lupus  exulcerans  of  the  face.  The 
general  state  of  nutrition  was  good.  The  skin  of 
the  face  was  for  the  most  part  transformed  into  a 
reticulated  scar,  isolated  lupus  nodules  projecting 
in  the  meshes  of  the  cicatricial  network.  The 
alae  nasi  were  completely  eaten  away,  the  nares 
narrowed  so  as  barely  to  admit  a  quill,  the  mouth 
narrowed  so  that  examination  of  its  interior  was 
impossible.  There  was  ectropion  on  the  left  side  ; 
the  cervical  and  submaxillary'  glands  were  en- 
larged. Examination  of  the  thoracic  and  ab- 
dominal organs  gave  negative  results  ;  there  was 
no  albumen  in  the  urine.  On  December  3,  at 
9.30  a.m.,  an  injection  of  2  milligrams  of  ear- 
bolized Koch's  fluid  was  given  Local  reaction 
was  very  marked.  During  the  rigor  the  lupus 
scars  on  the  face  became  livid.  About  3  p.m.  the 
lower  parts  of  the  face  at  the  edges  of  the  cica- 
trices became  swollen,  the  scars  themselves  being 
surrounded  to  the  extent  of  a  finger's  breadth  by 
a  bright  red  inflammatory  halo.  The  cheeks  and 
nose  showed  no  marked  changes,  but  the  upper 
lip  was  livid.  About  5  p.m.  all  the  cicatrized 
parts  were  swollen,  tense,  and  surrounded  with 


l62 


MEDICAL  PROGRESS. 


[January  31, 


the  intense  red  zone  as  before.  The  lupus  nodules 
appeared  more  prominent  and  were  bright  red  in 
color,  most  of  them  being  still  isolated,  but  their 
inflammatory  halos  were  confluent  in  some  cases. 
At  9  A.M.,  on  December  4,  the  swelling  and  red- 
ness were  more  diffused,  the  whole  of  the  face 
being  involved,  especially  in  the  lower  parts. 
The  bright  red  had  given  place  to  a  livid  color. 
In  addition  to  the  other  ordinary  signs  of  local 
reaction,  it  was  noticed  that  the  ectropion  was 
markedly  diminished  ;  and  the  conjunctiva,  pal- 
pebral and  ocular,  of  both  eyes  was  intensely  red 
and  secreted  copiously.  On  the  day  of  injection 
the  temperature  rose  to  39. 6°  C.  at  2.30  p.m.,  and 
to  40. 30  C  at  4.30  p.m.  At  5.30  p.m.,  the  pa- 
tient began  to  vomit,  and  at  6  p.m.,  she  became 
drowsy.  At  midnight  the  temperature  was  410, 
reaching  its  highest  point — 41.5° — at  3  a.m.,  on 
December  4.  At  9  A.M.  on  that  day  the  pulse 
was  very  small  and  intermittent,  and  could  not 
be  counted  ;  the  respiration  was  40.  In  spite  of 
the  free  exhibition  of  stimulants  the  patient  con- 
tinued to  sink,  and  died  at  9.45  p.m.,  on  Decem- 
ber 4.  The  post-mortem  examination,  which 
was  made  by  Professor  Pommer  twelve  hours 
after  death,  gave  striking  evidence  of  the  ener- 
getic action  of  the  remedy  on  all  the  tuberculous 
foci.  There  was  swelling  with  redness  in  the 
scars  and  in  the  neighborhood  thereof,  and  also 
round  the  ulcers  in  the  mouth,  mucous  membrane 
of  the  palate  and  epiglottis  ;  and  great  swelling 
of  the  sub  maxillary  and  .cervical  lymphatic 
glands,  and  of  those  along  the  trachea,  and  be- 
neath the  bifurcation  of  that  tube  and  the  roots 
of  the  lungs.  These  glands  were  caseous,  and 
presented  in  their  interior  numerous  typical  tuber- 
culous foci.  There  were  extensive  ulcerated 
areas  in  the  large  and  small  intestine.  In  both 
lungs  there  were  numerous  disseminated  patches 
of  pneumonic  infiltration  with  cedema  round 
about ;  there  was  also  great  cedema  of  the  brain 
and  spinal  cord  ;  acute  swelling  of  the  spleen, 
which  was  14  centimetres  in  length,  9'.-  in 
breadth,  and  4*4  to  5  in  thickness  ;  and  slight 
parenchymatous  swelling  of  the  liver  and  kid- 
neys. There  were  capillary  haemorrhages  in  the 
pleurae,  the  parietal  layer  of  the  pericardium,  the 
thymus,  and  in  several  parts  of  the  spinal  cord. 
Among  the  chronic  changes  found  in  the  body 
in  addition  to  the  lesions  of  lupus  and  tubercu- 
lous bronchitis  there  was  callous  atrophy  of  the 
superficial  parts  of  the  apices  of  both  lungs  ;  in 
these  spots  there  was  no  sign  of  reaction.  There 
was  also  slight  stenosis  of  the  left  ostium  atrio- 
ventriculare,  eccentric  hypertrophy  of  the  right 
side  of  the  heart,  and  hemorrhagic  pachymen- 
ingitis. There  was  neither  stenosis  nor  oedema 
of  the  larynx,  and  there  were  no  tuberculous 
formations  in  the  lungs. — British  Medical  Journal. 


Vaughan  on  the  Chemical  Study  of  the 
Summer  Diarrhoeas  of  Infancy. — The  author 
has  long  maintained  that  the  microorganisms 
which  produce  the  catarrhal  or  mucous  diarrhceas 
of  infancy  are  merely  putrefactive,  or  saprophytic, 
in  character,  and  that  they  prove  harmful  by 
forming  chemical  poisons.  Booker  Escherich, 
and  other  able  bacteriologists,  have  made  a  care- 
ful study  of  the  bacteria  found  in  the  intestines 
and  stools  in  these  diseases,  and  all  agree  that  no 
specific  organism  is  found.  From  a  study  of  the 
researches  of  others,  and  from  his  own  investiga- 
tions, Vaughan  draws  conclusions  which  he  form- 
ulates in  the  following  propositions:  (1)  There 
are  many  germs,  any  one  of  which,  when  intro- 
duced into  the  intestines  of  the  infant,  under  cer- 
tain favorable  conditions,  may  produce  diarrhoea. 
(2)  Many  of  these  germs  are  probably,  truly, 
saprophytic.  (3)  The  only  digestive  secretion 
which  is  known  to  have  any  decided  germicidal 
effect  is  the  gastric  juice  ;  therefore,  if  the  secre- 
tion be  impaired,  there  is  at  least  the  possibility 
that  the  living  germ  will  pass  on  to  the  intestine, 
will  there  multiply,  and  will;  if  it  be  capable  of 
so  doing,  elaborate  a  chemical  poison  which  rnay 
be  absorbed.  The  chief  reason  why  the  breast- 
fed child  has  a  better  chance  for  life  than  the  one 
fed  upon  cow's  milk,  lies  in  the  fact  that  the 
former  gets  its  food  germ  free  ;  but  a  second  rea- 
son is  to  be  found  in  the  larger  amount  of  acid  re- 
quired to  neutralize  the  cow's  milk,  as  has  been 
pointed  out  by  Escherich.  The  gastric  juice  is 
the  physiological  guard  against  infection  by  way 
of  the  intestines.  (4)  Any  germ  which  is  capa- 
ble of  growing  and  producing  an  absorbable  poi- 
son in  the  intestine  is  a  pathogenic  germ.  (5) 
The  proper  classification  of  germs,  in  regard  to 
their  relation  to  disease,  cannot  be  made  from 
their  morphology  alone,  but  must  depend  largely 
on  the  products  of  their  growth.  If  these  deduc- 
tions be  true,  we  will  try  to  avoid  the  introduc- 
tion into  the  alimentary  canal,  not  only  of  the  so. 
called  specific  pathogenic  germs,  but  of  all  toxi. 
cogenic  microorganisms. — London  Med.  Recorder 

Tkkatmkntof  Gonorrhoea  in  the  Female. 
—  M.  Schmitt  {Revue  wed.  def  Est)  uses  the  fol- 
lowing method  in  combatting  gonorrhoea  in  the 
female  :  rest  in  bed  and  cauterization  of  erosions 
with  solution  20  per  cent,  of  nitrate  of  silver.  Ab- 
scesses of  the  vulvo-vaginal  glands,  if  present 
should  be  freely  incised.  Injections  once  or  twice 
each  day  of  at  least  two  litres  of  a  1  :  10,000  solu- 
tion of  corrosive  sublimate;  this  is  to  be  followed 
by  an  injection  of  the  biniodide  of  mercury 
(1  .  40001  with  the  hips  somewhat  elevated.  This 
last  injection  should  be  retained  for  a  few  min- 
utes and  the  vagina  then  packed  with  cotton  sat- 
urated with  iodoform  and  glycerine,  in  the  be- 
ginning of  the  affection,  and   later  by   a   tampon 


I89i.] 


MEDICAL  PROGRESS. 


i63 


saturated  with  tanium.  Under  this  management 
the  inflammation  commonly  subsides  in  from  ten 
to  fifteen  days.  When  the  urethra  is  affected  ni- 
trate of  silver  may  be  employed  with   advantage. 

Hypertrophy  of  one-half  of  the  Fack. — 
Kiw.u.i.  (Fortsckr.  d  Med.  |  describes  an  exceed- 
ingly interesting  case  of  this  rare  condition,  oc- 
curring in  an  eighteen  year  old  girl.  The  trou- 
ble had  existed  from  birth,  soon  after  which  a  pe- 
culiar fullness  of  the  right  side  of  the  face  was 
noted,  which  in  time  increased.  At  the  time  she 
came  under  observation  the  enlargement  extend- 
ed from  the  forehead  of  the  affected  side  to  the 
throat,  the  tongue  was  also  hypertrophied  upon 
the  right  side.  The  bones  as  well  as  the  soft 
parts  were  involved.  A  portion  of  the  upper  lip 
excised  for  microscopic  examination  showed  that 
the  hyperplasia  affected  only  the  connective  and 
adipose  tissues,  while  the  muscular  fibres  appear- 
ed atrophic. 

Snrycr>. 

Ischias  Scholiotica. — LauensTEIN,  of  Ham- 
burg {Centralblatt  fur  Chirurgie)  cites  from  a 
Swedish  author  the  case  of  a  man  who  had  a  se- 
vere sciatica  on  the  left  side.  In  consequence  a 
scoliosis  developed,  with  convexity  towards  the 
left  lumbar  portion,  and  in  the  dorsal  and  cervi- 
cal part  of  the  right  side.  After  improving  the 
sciatica  by  means  of  warm  baths,  electricity, 
massage  and  antifebrin,  the  scoliosis  disappeared. 

Chronic  Mastitis  Simulating  Carcinoma. 
— Phocas,  Verneuil,  LeDentu  and  Tillaux 
{Gas.  des  Hopitaux)  have  all  observed  cases  of 
chronic  mastitis  in  women  at  the  second  climac- 
teric, which  simulated  carcinoma.  The  swelling 
of  axillary  glands,  emaciation,  weakness  and  an- 
aemia were  all  usually  present,  Phocas  recom- 
mends the  application  of  carbolic  spray  for  a  time 
in  doubtful  cases,  and  has  seen  cases  subside  under 
its  use. 

Concussion  of  the  Spine. — Smaus,  of  Mu- 
nich {Cetxtralblatt  fur  Chirurgie),  has  made  some 
experiments  on  animals  to  study  the  pathology  of 
spinal  concussion.  The  animals  were  struck  on 
the  spine  with  a  hammer,  and  lived  from  twenty 
days  to  eight  months.  At  the  autopsy  there 
were  found  in  some  circumscribed  foci  of  soften- 
ing in  the  spinal  cord ;  in  others  gliomata  were 
imbedded  in  the  cord,  and  some  of  the  conduct- 
ing fibres  were  destroyed  by  pressure.  These 
were  considered  direct  traumatic  degenerations, 
because  no  haemorrhage,  myelitis  or  other  cause 
was  found.  The  microscopic  examination  of  parts 
of  cord  corresponding  to  the  location  of  the  blows 
showed  swelling  and  degeneration  of  axis  cylin- 
ders, and  in  some  cases  of  the  nerve  sheaths  and 
connective  substance.  The  striking  inconsistency 
between  the  clinical  history  and  the  microscopic 


appearances  shows  that  more  nerve  fibres  are  de- 
stroyed by  concussion  than  can  be  found  with  the 
microscope  to  be  degenerated. 

Ununited  Fractures. — The  Centralblait  fur 
Chirurgie  gives  a  synopsis  of  the  fractures  treated 
in  the' Zurich  clinic  from  1881  to  1888.  Of  the 
489  fractures  presented  during  those  years  there 
were  sixteen  which  healed  very  slowly,  and  six 
which  gave  place  to  false  joints.  In  addition, 
eight  cases  of  pseudartbrosis  came  to  the  clinic 
for  treatment.  Cases  of  pseudarthrosis  of  the 
olecranon,  patella  and  neck  of  the  femur  are  not 
included  in  the  enumeration.  In  no  case  was  a 
constitutional  cause  found  for  pseudarthrosis 
among  these  fourteen  cases.  The  causes  were  dis- 
location of  diagonal  fractures  and  interposition 
of  muscular  tissue,  etc.  These  cases  were  found 
to  agree  with  Brun's  statistics  to  the  effect  that 
pseudarthrosis  is  rarer  in  children  than  in  middle 
life.  Two  of  these  cases  were  healed  by  iron 
nails  driven  into  the  connective  tissue  callus. 
Four  treated  by  ivory  pegs,  with  one  unsuccess- 
ful result.  Nine  were  resected,  with  one  unsuc- 
cessful result. 

Ob*telri<"s  and  Diseases  of  Women. 

Double  Pregnancy  in  a  Case  of  Uterus 
Septus  Duplex  et  Vagina  Duplex. — Althex 
(C'litralb/att  fib  G\uaA-e>/e>o-ie)describes  an  inter- 
esting example  of  this  condition.  A  woman  31 
years  of  age  was  delivered  of  a  four  and  one-half 
mouths  foetus.  On  the  following  day  a  foetus  of 
like  development  was  born,  but  the  placenta  was 
retained.  Althen  was  sent  for  on  the  following 
day  to  remove  the  after  birth.  Examination 
showed  a  complete  vaginal  septum,  that  separated 
two  distinct  vaginal  canals,  which  extended  up- 
wards where  they  terminated  each  in  a  separate 
cervical  canal.  By  examination  a  communication 
could  be  determined  between  the  cervical  cavities. 
The  placentas  were  removed  with  difficulty,  each 
from  its  special  uterine  cavity.  The  writer  thinks 
that  both  vaginal  cavities  were  used  in  coitus 
though  the  right  was  somewhat  smaller.  The 
opening  between  the  cervices,  was  he  thinks 
caused  by  the  labor.  Unfortunately  both  foeti 
had  been  taken  to  the  cemetery,  so  he  could  not 
determine  positively  if  there  was  a  difference  in 
their  ages.  The  patient  says  that  she  menstru- 
ated regularly  at  intervals  of  two  and  one-half 
weeks,  alternately  2  to  4.  and  again  six  days  in 
length.  From  this  fact  the  writer  concludes  that 
there  was  an  alternation  in  this  function  by  both 
uteri. 

H.EMOPHILIA  AT    THE  MENSTRUAL  PERIOD. — 

Dr.C.  Towxsend  (Bos/on  Med.  and  Surgical  Jour- 
nal, November  26)  had  recently  under  his  care  a 
healthy,  w-ell  developed  and  intelligent  girl  of 
thirteen.  Some  of  her  family  were  "bleeders." 
When  an  infant,  the  slightest  bruise  caused  con- 


164 


MEDICAL  PROGRESS. 


[January  31, 


siderable  subcutaneous  effusion  of  blood.  She 
bled  freely  when  a  little  child  when  cut,  or 
when  bitten  by  insects.  Epistaxis  was  frequent, 
but  ceased  after  the  safe  and  successful  removal 
of  mucous  polypi.  The  joints  never  became 
swollen.  A  "show"  appeared  at  thirteen,  and 
three  napkins  were  stained  two  weeks  later.  A 
week  later  serious  menorrhagia  set  in,  with 
blanching  and  faintness.  Restlessness,  nausea, 
vomiting  and  intense  thirst,  with  rise  of  temperature 
occurred;  as  she  tossed  in  bed  ecchymoses  formed 
on  the  shoulders  and  elbows.  As  the  patient  be- 
came dangerously  exhausted  and  as  the  vomit- 
ing continued,  an  enema  (one  raw  egg  with  three 
ounces  of  peptonized  milk)  was  given  every  three 
hours.  Milk  and  lime  water  was  administered 
when  the  vomiting  ceased,  and  by  the  end  of  the 
week  she  took  beef  tea  and  milk  as  well  as  the 
enemata.  The  thirst  did  not  diminish  until  the 
fifth  day  of  treatment.  A  tampon,  inserted  when 
the  flooding  was  severe,  was  removed  three  days 
later;  a  slight  discharge  continued  for  nearly  a 
week.  At  the  end  of  ten  days  the  girl  was  fairly 
well.  It  is  not  stated  whether  the  troubles  re- 
curred at  succeeding  periods.  Osier  has  already 
noted  that  in  female  members  of  haemophilic 
families  neither  menstruation  nor  parturition  is 
specially  dangerous,  and  Dr.  Townsend  notes 
that  other  authorities  are  of  the  same  opinion, 
according  to  their  own  experience. — Brit.  Med. 
/our. 

Antiseptics  for  Midwives. — MM.  Bour- 
goin,  Bronardel,  Gueniot,  Nocard,  Tar- 
nier  and  Budin,  a  committee,  have  reported  to 
the  Minister  of  the  Interior,  (extr.  du  Bull,  de  /' 
Acadimie  de  Med.)  the  following  disinfection 
methods  for  midwives  :  The  hands  of  the  mid- 
wife, and  genitals  of  the  patient  should  be 
cleansed  by  a  mixture  of  corrosive  sublimate  0.25, 
tartaric  acid  1.0,  bordeaux  red  0001;  on  the 
package  should  be  be  printed  "Sublimate  1.25 
for  a  liter  of  water,  poisonous."  Metal  instru- 
ments should  be  sterilized  by  boiling.  Sublimate 
vaseline  1 :  1000  is  also  allowed.  For  simplicity 
in  the  disinfection  regulations  carbolic  acid  is 
omitted. 

Absorbing  Power  of  Uterus  and  Vagina. — 
Dr.  L-  Landau  {Berlin,  klin.  Wochenschr.,  No- 
vember 10th,  1890)  has  found  from  experience 
that  the  vaginal  mucous  membrane  has  but  a  fee- 
ble absorbing  power,  whilst  the  uterine  mucous 
membrane  possesses  that  power  to  a  very  high  de- 
gree. This  fact  is  of  extreme  importance  in 
gynaecology,  as  strongly  medicated  tampons  may 
fail  to  act  if  inserted  into  the  vagina,  whilst  if 
passed  into  the  uterus  they  may  set  up  grave 
complication.  The  vaginal  mucous  membrane  is 
really  skin,  and  becomes  true  dry  skin  in,  cases  of 
prolapse.     The    free   surface    of  the   cervix   has 


hardly  any  power  of  absorption.  Dr.  Landau 
demonstrates  from  cases  how  different  it  is  with 
the  endometrium.  After  the  introduction  of  a 
solid  10  per  cent,  preparation  of  resorcin  into  a  ut- 
erus, severe  and  long  standing  uterine  colic  was 
set  up.  The  introduction  of  a  1  per  cent,  cocaine 
compound  caused  the  pains  to  cease.  The  cocaine 
was  absorbed  and  by  paralyzing  the  sensory 
nerves  it  produced  anaesthesia. — Brit.  Med.  Jour. 

Bacteriology. 

Scholl  on  Investigations  into  Cholera- 
TOXINES. — The  conclusions  of  the  author's  ex- 
periments, made  in  the  Hygienic  Institution  of 
the  (German)  University  of  Prague,  are  as  fol- 
lows :  "The  toxic  peptone  which  I  have  pro- 
duced from  genuine  albumen,  after  its  destruction 
by  anaerobiosis,  is  quite  distinct  from  Petri's 
toxo  peptone  (formed  by  aerobiosis),  because  the 
latter  is  not  destroyed  by  boiling,  while  mine  is 
rendered  inert.  My  choleraicpepto-toxine  shows 
far  more  poisonous  and  characteristic  properties 
than  the  toxines  of  Brieger  and  Petri  formed  by 
aerobiosis  in  peptone  solutions,  for  the  toxine 
which  I  procured  (by  the  cultivation  of  cholera 
bacilli)  from  a  single  egg  was  sufficient  to  kill 
ten  guinea-pigs  in  ten  minutes  with  acute  paralytic 
symptoms.  The  assertion  of  Hueppe  and  Wood, 
that  more  and  stronger  toxines  are  formed  by 
cholera  bacilli  by  anaerobiosis  than  by  aerobiosis, 
is  fully  confirmed  by  my  experiments,  which 
negative  the  opposite  assertions  of  Petri." — Lon- 
don Medical  Recorder. 

Ophthalmia  in  a  Puerperal  Woman, 
caused  by  an  embolus  containing  strep- 
TOCOCCI.— The  Zcitschrift  fur  Geburtshilfe  und 
Gynakologie  describes  the  case  of  a  woman,  who, 
a  few  hours  after  confinement  had  a  high  fever, 
pain  and  photophobia  in  the  left  eye.  On  the 
third  day  thereafter  there  was  conjunctival  and 
ciliary  injection,  chemosis,  opacity  of  the  cornea 
and  vitreous.  The  anterior  chamber  was  deep- 
ened, the  iris  discolored  and  loosened  from  its  at- 
tachment and  the  lens  luxated.  On  this  day  the 
patient  could  still  discern  light,  but  on  the  fourth 
day  total  blindness  supervened  in  this  eye.  On 
the  sixth  day  the  patient  died  of  pyaemia  and  the 
eye  was  removed  for  microscopic  examination. 
The  fact  that  the  retina  was  found  destroyed  with 
the  exception  of  two  small  islets,  that  the  central 
artery  and  vein  in  the  papilla,  the  vessels  of  the 
iris,  the  ciliary  body  and  sclera  were  filled  with 
streptococci,  led  to  the  conclusion  that  the 
streptococci  came  from  emboli  ;  and  as  there  were 
no  appearances  of  inflammation  in  the  heart  or 
mi  its  valves  it  was  inferred  that  the  streptococci 
came  by  metastasis  direct  from  the  genitals. 
Suppuration  started  in  the  retina  which  it  de- 
stroyed;  then  the  vitreous  was  fluidified,  the 
lens  sank  backward,  its  capsule  became  eroded, 
pus  entered  and  tilled  the  capsule. 


i89i.] 


EDITORIAL 


165 


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Address 

Journal  of  the  American    Medical  Association, 

No.  68  Wabash  Ave.. 

Chicago.  Illinois. 
All  members  of  the  Association  should  send  their  Annual  Dues 
to  the  Treasurer,  Richard  J.  Dunglison,  M.D.,  Lock  Box  1274,  Phila- 
delphia, Pa. 


London  Office,  57  and  59  Ludgate  Hill. 


SATURDAY,   JANUARY  31,    1S91. 


CEREBRAL  SURGERY. 
In  no  department  of  the  healing  art  has  there 
been  a  more  surprising — it  may  fairly  be  said, 
revolutionary  change  in  the  last  decade  than  in 
the  surgery  of  the  central  nervous  system.  Two 
circumstances  have  concurred  to  bring  about  this 
result.  On  the  one  hand,  the  precision  of  diag- 
nosis has  been  vastly  increased  by  the  discoveries 
in  cerebral  localization  inaugurated  by  Fritsch 
and  Hitzig,  and  amplified  by  so  many  investi- 
gators, experimental  and  clinical,  that  an  enu- 
meration of  them  would  be  either  invidious  or 
tedious.  On  the  other  hand,  improvements  in 
surgical  technique,  which  have  their  scientific 
basis  in  Paste rit's  discoveries  of  the  relation  of 
microorganisms  to  fermentation  and  putrefaction, 
and  Lister's  application  of  the  facts  to  the  in- 
fective processes  in  wounds,  have  almost  abol- 
ished the  risks,  in  competent  hands,  of  the  sec- 
ondary troubles  which  formerly  constituted  the 
chief  peril  of  operations  in  which  the  cranium 
was  opened.  As  Mr.  Tait  has  said  that  he 
would  as  soon  put  his  fingers  into  the  peritoneum 
as  into  his  pocket,  so  Mr.  Victor  Horsley, 
judging  from  a  paper  read  by  him  at  the  Berlin 
Medical  Congress,  would  probably  have  no  more 
hesitation  in  putting  his  fingers  inside  the  crani- 
um than  into  his  hat.  Among  the  rather  start- 
ling proposals  that  he  makes  are,  trephining  in 
cases  of  obstinate  headache,  referred  to  the  bone, 
and  incurable  by  means  of  drugs ;  in  all  cases  of 
cerebral  tumor,  syphilitic  and  malignant  as  well 
as  benign,  and  whether  accessible  or  not,  as  he 


claims  that  the  operation,  by  diminishing  the  in- 
tracranial pressure,  relieves  pain,  and  prolongs 
life;  operation  for  focal  epilepsy,  by  excision  of 
the  portion  of  the  cortex  that  is  found,  by  elec- 
trical  stimulation,  to  be  the  starting-point  of  the 
spasm  ;  the  same  operation  in  athetosis ;  and,  per- 
haps the  most  likely  of  all  to  provoke  adverse 
criticism,  ligation  of  the  common  carotid  in  all 
cases  of  cerebral  haemorrhages  seen  in  the  early 
stage,  when  the  flow  of  blood  may  be  presumed 
not  to  have  ceased.  With  regard  to  this  last 
proposition,  it  was  objected,  in  the  discussion 
that  followed  the  reading  of  the  paper,  that  the 
diagnosis  of  cerebral  haemorrhage  at  that  stage 
is  not  a  very  easy  matter.  The  ligature  would 
not  be  likely  to  work  well  in  cases  of  thrombosis 
or  embolism. 

Operations  for  cerebral  tumor  have  hitherto 
only  been  proposed  in  cases  in  which  there  was 
thought  to  be  some  hope  of  removing  the  growth, 
and  the  results  can  hardly  be  said  to  be  of  a  char- 
acter to  excite  much  enthusiasm,  as  Mr.  Hors- 
ley himself  reports  four  deaths  from  shock  out 
of  eight  operations.  In  this  aspect  of  the  sub- 
ject, a  paper  recently  published  by  Oppexheim, 
in  Archiv  fur  Psychiatrie,  is  of  interest.  Out  of 
twenty-one  cases  of  cerebral  tumor  in  which  au- 
topsies were  made,  he  concluded  that  five  were 
unsuited  for  operation  on  account  of  multiplicity 
or  malignancy,  seven  on  account  of  the  situation 
of  the  growths,  six  on  account  of  the  absence  of 
localizing  symptoms,  and  one  on  account  of  the 
syphilitic  nature  of  the  tumor,  and  one  on  account 
of  its  size,  leaving  only  three  in  which  operation 
would  have  held  out  a  reasonable  hope  of  success. 
Horsley  is  of  the  opinion  that  gummata  should  be 
excised,  as  he  believes  the  iodide  treatment  to  be 
only  palliative,  never  curative.  If  as  much  reliet 
of  symptoms  as  he  hopes  for  can  be  obtained  by 
trephining  in  cases  in  which  the  tumor  cannot  be 
removed,  the  operation  would  seem  to  be  justifi- 
able, but,  taking  the  most  favorable  view  of  it, 
we  can  hardly  expect  that  it  will  rival  ovariotomy 
in  its  results. 

The  above  propositions  will  probably  strike 
most  of  our  readers  as  sufficiently  venturesome, 
but  they  by  no  means  satisfy  the  ambition  of  some 
operators.  Trephining  has  been  practiced  for  gen- 
eral paresis  by  Cripps,  in  England,  in  two  cases, 
both  of  which  were  said,  at  the  time  they  were  re- 
ported, to  show  decided  improvement  subsequently 


i66 


PEDAGOGY  IN  MEDICINE. 


[January  31, 


to  the  operation,  and  by  Wagner  in  this  coun- 
try, with  some  apparent  temporary  relief,  the  pa- 
tient dying  about  two  months  after  the  operation. 
In  view  of  the  desperate  nature  of  the  disease, 
there  is  probably  no  serious  objection  to  such  a 
procedure,  however  little  prospect  there  may  seem 
to  be  of  permanent  benefit.  The  case  seems  rather 
different  with  the  operations  of  which  Burk- 
hardt  gave  an  account  at  the  Berlin  Congress. 
He  excised  portions  of  the  brain  from  the  regions 
that  he  judged  to  be  specially  affected  in  cases  of 
insanity  without  gross  lesion.  For  hallucinations 
of  hearing,  for  instance,  he  removed  portions  of 
the  first  temporal  and  second  frontal  convolutions, 
and  in  a  case  of  excited  dementia  of  syphilitic 
origin,  portions  of  the  frontal  lobes.  Aphasia 
and  word  deafness  followed  in  some  of  his  cases, 
and  one  patient  out  of  six  on  whom  he  operated, 
died,  apparently  as  the  result  of  the  operation. 

Dr.  Holmes  characterizes  those  of  our  fellow- 
citizens  commonly  known  as  "cranks"  as  the 
possessors  of  squinting  brains.  At  the  present 
rate,  we  may  perhaps  expect  that  operations  for 
cerebral  strabismus  will  become  as  common  as  for 
squint-eye.  Few  of  us,  probably,  can  pretend  to 
an  absolutely  symmetrical  mental  organization, 
and  if  harmony  could  be  brought  about  by  a  lit- 
tle judicious  paring  of  our  brains,  here  and  there, 
it  would  be  a  consummation  devoutly  to  be  wished. 
Whether,  in  case  the  difficulties  of  operative  pro- 
cedure can  be  overcome,  it  would  be  desirable,  in 
any  cases,  to  extirpate  the  cerebral  hemispheres 
completely,  need  not  be  decided  at  present.  There 
are  some  persons  who  could,  apparently,  be  little 
injured  by  such  an  operation. 


PEDAGOGY  IX  MEDICINE. 
Most  of  us  remember  but  little  of  our  teachers. 
At  the  best  only  a  few  names  loom  up  with  a 
background  of  gratitude,  and  these  represent 
those  whose  hearts  were  in  their  work.  Exclud- 
ing the  many  who  taught  in  a  perfunctory  way 
as  the  means  to  some  end,  the  idea-imparters  may 
be  counted  upon  the  fingers  of  a  hand.  The  few 
excluded  from  the  category  are  they  who  sought 
to  make  us  equal  to  themselves,  not  so  much  in 
extent  of  knowledge  as  in  the  sources  from  which 
it  was  derived.  They  are  those  who  taught  us 
to  classify  and  aimed  not  to  merely  present  a  mass 
of  verbiage  in  a  well- padded  discourse  to  kill 


time.  How  can  we  deify  the  conventional  lec- 
turer whose  eyes  seldom  leave  the  manuscript, 
which  for  years  has  done  duty  with  a  persever- 
ance worthy  of  a  better  cause  ? 

Now  that  didactic  teaching  appears  to  be 
threatened  with  extinction  and  the  art  of  the 
pure  clinician  has  come  into  favor,  what  have  our 
teachers  to  present  in  return  for  the  prerequisites 
which  have  been  gained  after  so  much  distress  to 
the  aching  purse  ?  What  are  the  advantages 
offered  in  return  for  so  much  sacrifice  ?  The 
student,  aware  of  his  rights  in  the  premises,  and 
vacillating  between  ambition  and  necessity,  re- 
plies but  little  if  anything.  Too  often  is  he  con- 
scious that  he  receives  only  a  modicum  in  jargon 
or  dogmatism  in  return  for  his  confidence,  and 
that  his  diploma  is  to  be  flanked  by  crude  theories 
and  mal- assimilated  facts.  Much  that  he  may 
have  learned  he  finds  that  he  cannot  make  prac- 
tical, and  that  the  mannerisms  of  his  preceptors 
are  inapplicable  beyond  the  class  room.  The 
aphorisms,  which  have  been  dinned  into  his  ears 
he  is  fain  to  discard  because  the  amplitude  of 
argument  with  which  they  were  enforced  was 
grounded  in  error.  And  so  he  goes  on  until  his 
revisions  make  a  new  text,  and  for  the  matter  of 
that  a  new  sermon. 

Are  the  teachers  of  the  day  impressed  with  a 
sense  of  their  responsibilities?  We  fear  not. 
We  hold  that  only  the  few  appreciate  the  im- 
portance of  their  mission,  and  that  of  these  few 
only  a  very  small  minority  walk  with  their  pupils. 
And  what  of  the  majority?  Do  they  not  satisfy 
themselves  with  wasted  words  and  crude  princi- 
ples ?  Why  we  ask  also  ruay  not  every  branch 
of  our  science  be  made  interesting  ?  We  claim 
that  it  it  is  beyond  doubt  possible  — that  demon- 
stration, illustration,  simile,  anecdote  and  apo- 
thegm may  be  pressed  into  service.  Further  than 
all  this  we  are  ready  to  endorse  what  has  so  often 
been  said,  that  teaching  is  quite  enough  of  a 
specialty  to  attract  the  best  of  minds.  But  then 
we  also  must  in  duty  offer  the  corollary  that  every 
instructor  should  make  his  subject  presentable, 
and  be  made  aware  that  he  cannot  afford  to  de- 
ceive the  yearners  after  truth  who  pit  the  brevity 
of  life  against  the  gravity  of  the  work  before 
them. 

Above  all  else,  the  student  should  be  taught 
courage.  With  the  responsibilities  that  are  to 
confront  him,  he  can  hardly  be  expected  to  be 


lS9l.] 


EDITORIAL  NOTES. 


in- 


armed cap-a-pie  and  yet  be  uuready  for  the  fight. 
He  is  entitled  to  the  hope  of  glory,  which  is  to 
be  gained  certainly  not  without  an  effort,  and 
even  in  spite  of  a  studied  dampening  of  all  youth- 
ful ardor.  This  duty  of  stimulation  can  belong 
to  none  others  than  the  college  faculties  with 
which  our  country  abounds.  A  few  endowments 
scattered  among  the  more  worthy  of  the  institu- 
tions, might  mend  matters  somewhat,  but  as  long 
as  there  is  so  much  fighting  of  the  wolf  at  the 
door,  we  fear  that  pessimistic  views  will  prevail. 
Still  there  is  much  room  for  hope,  and  to  the  fu- 
ture we  look  for  a  more  complete  solution  of  the 
problem. 


BACTERIOLOGICAL  RESEARCH 
It  is  not  now  possible  to  estimate  the  enormous 
impulse  given  to  experimental  patholog3r  by 
Koch's  discovery.  We  may  doubt  that  a  cure 
for  tuberculosis  has  been  discovered,  indeed  we 
may  affirm  that  it  is  only  a  remedy  or  mode  of 
treatment.  But  if  it  has  not  been  discovered  it  will 
be  sooner  or  later.  Koch  is  said  to  have  used 
the  words  "  ich  habe  es  gefunden"  in  makingl 
the  preliminary  announcement  to  his  medical 
friends.  Not  for  years  had  he  doubted  but  that 
the  cure  was  ever  awaiting  upon  discovery. 

The  zymotic  origin  of  most  of  the  epidemic  and 
infectious  diseases  has  been  accepted  by  many  for 
3-ears,  indeed  the  probabilities  were  so  strongly  in 
favor  of  it  that  the  views  were  accepted  long  be 
fore  the  demonstrations.  When  they  came  they 
were  adopted  almost  as  a  matter  of  course,  by 
some,  and  denied  by  others.  This  is  but  a  repe- 
tition of  the  history  of  similar  discoveries,  for  it 
is  now  apparent  that  certain  diseases,  notably  an- 
thrax and  tuberculosis,  are  as  conclusively  proven 
to  be  due  to  microbic  infection  as  that  the  law  of 
gravity  acts  when  an  object  falls  to  the  earth. 

Another  proposition,  while  not  as  conclusively 
proven,  is  still  rendered  highlj-  probable,  that  is 
the  bacilli  are  perhaps  harmless  in  themselves, 
only  exceptionally  do  they  act  in  a  mechanical 
way  in  obstructing  vessels,  or  interfering  with 
the  nutrition  of  tissues.  Their  chief  disturbing 
influence  seems  to  be  due  to  substances,  toxiues, 
ptomaines,  or  tox-albumens  formed  by  them, 
which  exert  a  local  destructive  action,  or  by  rea- 
son of  dissemination  through  the  blood  eau=e  a 
general  toxaemia.      Several  of  these  bodies  have 


been  isolated  from  pure  cultures  of  various  patho- 
genic bacilli,  now  it  is  apparent  that  these  sub- 
stances circulate  in  greater  or  less  abundance  in 
the  blood  and  doubtless  also  appear  in  the  urine. 
Ehruch's  test,  or  the  so-called  diazo-reaction, 
demonstrates  that  in  the  urine  of  a  typhoid  fever 
patient  there  is  a  substance  present  which  is  not 
found  in  healthy  urine.  Unfortunately  the  re- 
action is  also  found  in  cases  of  phthisis  and  sep- 
ticaemia. Is  it  not  probable  that  identical  sub- 
stances are  not  present  but  they  all  give  the  same 
reaction,  just  as  some  reagents  will  precipitate 
several  elements?  What  we  now  need  is  a  care- 
ful study  of  these  products,  and  if  possible  their 
recognition  by  simple  chemical  tests  so  that  in 
the  future  all  that  will  be  necessary  is  to  deter- 
mine, by  examining  the  urine  or  other  fluids, 
what  ptomaine  is  present  and  then  apply 
the  proper  antidote.  All  this  is  beautifully 
simple,  but  it  is  probable  that  it  will  be  some 
months  before  it  will  be  an  accomplished  fact. 
Still  in  the  light  of  the  discoveries  of  the  last  few 
years  it  seems  well  within  the  bounds  of  the  pos- 
sible. 

One  lesson  it  ought  to  teach  and  that  is  the 
boundless  reach  of  science.  In  medicine  more 
facts  have  been  learned  since  1850  than  were  pre- 
viously known,  and  yet  each  discovery  only 
teaches  us  how  much  more  there  is  to  be  learned. 
While  the  bacteriologist  now  seems  to  be  in  ad- 
vance, he  but  points  the  way  for  the  chemist  aud 
pathologist. 


EDITORIAL  NOTES. 

An  Old  Adage  Regarding  Typhoid  Fever. 
— In  an  article  by  Dr.  S-  C.  Benedict  of  Athens, 
in  the  Georgia  State  "Transactions"  for  1890, 
just  published,  the  writer  calls  to  mind  a  long 
forgotten  adage  of  that  "sage  of  Baltimore,''  Dr. 
N.  R.  Smith,  that  in  the  treatment  of  typhoid  fe- 
ver there  were  mainly  needed  three  things,  "a  vial 
of  laudanum,  a  bottle  of  turpentine  and  a  hogs- 
head of  buttermilk."  This  is  a  propos  to  the 
note  printed  on  page  907  of  our  last  volume, 
where  we  quoted  the  recommendation  of  Dr.  H. 
C.  Wood  in  favor  of  a  return  to  the  turpentine 
treatment  of  fifty  years  ago. 

A  Russian  Anthropological  Prize. — Dr. 
Parnowski,  a  female  physician  of  Russia,  has  re- 
cently been  awarded  a  gold  medal,  as  a  prize,  for 


i68 


EDITORIAL  NOTES. 


[January  31, 


her  essay  on  the  anthropology  of  prostitutes  and 
female  thieves.  The  award  was  made  by  the 
Moscow  Society  of  the  Friends  of  Natural  Science, 
Anthropology  and  Ethnography. 

Kings  County  Medical  Association. — The 
anniversary  meeting  of  this  society  was  held  at 
Brooklyn,  N.  Y.,  January  13,  when  the  follow- 
ing officers  were  elected  for  the  ensuing  year : 
John  D.  Rushmore,  president;  A.  R.  Paine,  vice- 
president  ;  John  R.  Vanderveer,  treasurer  ;  J.  C. 
Bierwirth,  Secretary  ;  H,  B.  Reed,  corresponding 
secretary  aud  S.  H.  Benton,  member  of  executive 
committee. 

A  new  Secretary  for  the  Section  of 
State  Medicine. — Dr.  Benjamin  Lee  has  been 
appointed  Secretary  of  the  Section  of  State  Medi- 
cine of  the  American  Medical  Association  in  lieu 
of  Dr.  Bascum,  who  has  resigned  on  account  of  ill 
health.  Dr.  Lee  requests  that  all  physicians  de- 
siring to  participate  in  its  discussions  or  to  pre- 
sent papers  should  forward  him  their  names  as 
early  as  possible.  All  papers  should  be  in  his 
hands  not  later  than  April  15th,  1891.  Dr.  Lee's 
address  is  1532  Pine  St.,  Philadelphia,  Pa.  « 

For  a  Woman's  Scientific  College. — Dr. 
Henry  Muirhead,  recently  president  of  the  Glas- 
gow Philosophical  Society,  has  bequeathed  the 
sum  of  $125,000  for  the  erection  and  endowment 
of  a  scientific  college  which  shall  be  devoted  en- 
tirely to  the  instruction  of  women  in  surgery, 
dentistry,  electricity  and  chemistry. 

The  Chicago  Policlinic.  —  Experimental 
work  with  Koch's  lymph  has  been  in  progress  for 
two  weeks  or  more  at  this  institution.  A  num- 
ber of  typical  cases  of  tuberculosis  have  been  se 
lected,  and  the  results  as  they  shall  be  reached 
will  be  under  the  observation  of  men  alike  compe- 
tent and  reliable  for  the  rendering  of  just  conclu- 
sions. It  is  yet  too  soon  to  record  results;  when 
ample  trials  shall  have  been  made,  our  readers 
will  be  interested  to  know  the  measure  of  their 
success. 

A  Modified  Programme. — In  the  absence  of 
Dr.  Norman  Bridge,  the  Faculty  of  the  Chica- 
go Post  Graduate  Medical  School  invited  Pro- 
fessor Gibbs,  of  the  Michigan  University,  Ann 
Arbor,  Mich.,  and  Professor  E.  L.  Shurley,  of 
the  Detroit  College  of  Medicine,  to  occupy  the 
evening  assigned   to  Dr.    Bridge   in   the    regular 


course  of  lectures,  and  to  give  their  views  of  the 
pathology  and  treatment  of  phthisis  pulmonalis. 

It  will  be  remembered  that  Dr.  Gibbs  ignores 
the  bacillus  as  the  primal  cause  of  phthisis,  and 
that  Dr.  Shurley  is  conducting  a  series  of  exper- 
iments upon  animals,  by  means  of  inhalation  of 
chlorine  gas  in  the  presence  of  the  vapor  of  chlo- 
ride of  sodium,  the  results  of  which  he  is  as  yet 
not  prepared  to  state. 

An  invitation  to  the  medical  profession  of  Chi- 
cago to  listen  to  the  addresses  of  these  gentlemen 
met  with  a  prompt  and  general  response,  and  a 
large  audience  of  the  leading  physicians  of  Chi- 
cago was  in  attendance.  Such  reports  as  we  were 
able  to  secure  of  their  impromptu  addresses  will 
be  given  in  a  later  issue  of  The  Journal. 

The  Maritime  Medical  Association.  — 
This  is  the  fitting  name  provisionally  adopted 
for  a  new  Canadian  medical  society  which  will 
organize  in  July,  1891,  at  St.  John.  Three  great 
seaboard  provinces  have  united  for  its  formation 
in  the  hope  of  creating  a  powerful  body  in  influ- 
encing medical  legislation  and  strengthening  the 
profession  within  and  without.  According  to 
the  Maritime  Medical  News  the  following  officers 
of  organization  have  been  chosen:  President,  Dr. 
William  Bayard  of  St.  John;  Vice-President  for 
New  Brunswick,  Dr.  Thomas  Walker  of  St.  John; 
for  Nova  Scotia,  Hon.  Dr.  D.  McN.  Parker  of 
Halifax;  and  for  Prince  Edward  Island,  Dr. 
Richard  Johnson  of  Charlottetown;  Secretary  and 
Treasurer,  Dr.  Arthur  Morrow  of  Halifax;  Local 
Committee,  Drs.  Bruce,  Daniel,  Christie  and 
Hetherington.  The  time  and  place  of  meeting 
corresponds  with  the  annual  session  of  the  New 
Brunswick  Medical  Society,  by  which  the  initia- 
tive of  this  movement  was  made  in  1888.  The 
older  provincial  societies  will  not  be  interfered 
with  by  the  new  Association. 

The  Maritime  Medical  News. — This  bright 
little  journal  is  launching  forth,  with  the  begin- 
ning of  its  third  volume,  in  the  form  of  a  month- 
ly. Its  able  editor  is  Dr.  Arthur  Morrow,  Argyle 
street,  Halifax,  N.  S. 

German  Congress  of  Internal.  Medicine. 
— The  tenth  Congress  of  Internal  Medicine  will 
be  held,  April  6  to  9,  at  Wiesbaden,  under  the 
presidency  of  Dr.  Leyden  of  Berlin.  Fiirbringer 
of  Rerlin,  with  Naunyn  of  Strasburg,  will  intro- 
duce the  clinical   relations    of  hepatic  calculus; 


i89i.] 


MKDICAL  N<  )Ti;s. 


169 


Fraenkel  and  Vierordt  will  treat  of  angina  pec- 
toris, while  addresses  will  he  presented  hy  Schott 
and  Kahler. 

MKDICAL  ITEMS. 
Early  Marriages  IN  Lndia. — The  Govern- 
ment of  India  has  decided  to  legislate  on  the  sub- 
ject of  the  age  of  consent  by  a  simple  amendment 
to  the  penal  code,  substituting  the  age  of  twelve 
for  that  of  ten.  It  had  been  wisely  determined  to 
couple  the  announcement  with  the  assurance  that 
no  interference  with  social  or  religious  customs 
affecting  early  marriage  is  contemplated,  a  course 
which  it  may  be  hoped  will  satisfy  those  who  saw 
in  the  suggested  reform  a  covert  attack  on  ancient 
customs. 

The  Koch  Treatment  in  Leprosy. — The 
condition  of  the  three  lepers  recently  inoculated 
at  Madrid  with  Dr.  Koch's  liquid  in  the  Hospital 
of  St.  Jean  de  Dieu  is  stated  to  be  satisfactory. 

Processor  Virchow,  lately  elected  by  accla- 
mation an  honorary  member  of  the  Regia  Accad- 
emia  Medica  di  Roma,  has  just  acknowledged  the 
compliment  paid  to  him  in  a  letter  to  the  presi- 
dent, Dr.  Guido  Baccelli — "  I  am  proud  and  hap- 
py to  find  myself  so  united  by  a  new  tie  to  Italy 
— proud  to  be  affiliated  in  Rome  to  a  body  so 
learned  and  so  distinguished,  happy  to  feel  my- 
self among  new  friends." 

Chicago  as  a  Place  for  Doctors. — The 
secretary  of  the  Illinois  State  Board  of  Health,  in 
his  recent  quarterly  report,  states  that  there  has  for  the  erection  of  an  art  museum.  In  addition, 
never  been  such  a  rush  of  medical  men  to  Chicago  Mrs-  FoSg  bequeaths  her  late  husband's  Japan- 
as  during  the  past  three  months.      More  than  two- 1  ese  and  East  India  collection,  valued  at  Sioo.ooo, 


Practice  Act.  New  York,  not  having  the  World's 
Fair,  will  take  pleasure  in  sending  on  her  medical 
men   that   will  not    be    missed    here. — Medical 

Proposed  Medical  Legislation  in  Penn- 
sylvania. The  present  registration  law  of 
Pennsylvania  is  said  to  be  almost  a  total  failure. 
According  to  the  Times  and  Register  another  at- 
tempt will  be  made  during  the  coming  session  of 
rislature  to  procure  the  passage 
of  an  act  creating  a  Board  of  Medical  Examiners. 
The  proposed  bill  places  the  appointment  of  mem- 
bers entirely  in  the  hands  of  the  governor;  the 
only  restrictions  to  this  choice  being  those  relating 
to  legality  and  date  of  graduation,  and  freedom 
from  alliances  with  medical  colleges.  A  new 
clause  provides  that  no  two  of  the  nine  examiners 
shall  be  residents  in  the  same  county.  This 
opens  the  field  to  the  country  members,  and  cuts 
Philadelphia,  with  her  2,000  physicians  out  of 
8,000  in  the  State,  down  to  a  single  representative. 
— Med.  Record. 

Mrs.  Fogg's  Bequests. — By  the  will  of  Mrs. 
Fogg,  the  widow  of  a  rich  merchant  in  the  China 
trade,  the  New  York  Hospital  receives  $20,000, 
the  Metropolitan  Hospital  Si 0,000,  and  the 
Children's  Aid  Society  $55. 000;  and  among  the 
many  other  institutions  benefited  are  the  New 
York  Diet  Kitchen  and  the  Training  School  for 
Nurses  of  Bellevue  Hospital.  The  largest  be- 
quest is  to  Harvard  University,  namely,  $200,000 


thirds  of  the  certificates  issued  were  to  physicians 


and  the  sum  of    520,000,   to  be    applied   to  the 


who  wished  to  practice  in  Chicago.  And  never  current  expenses  of  the  museum  and  the  purchase 
before  in  the  same  length  of  time  have  so  many  of  works  of  art.—  Boston  Med.  and  Surg.  Journal. 
professional  frauds  attempted  to  obtain  a  foothold  '  Thh  seventh  annual  meeting  of  the  Fifth  District 
in  Chicago.  It  is  evident  that  the  increase  of  Branchofthe  N .  Y.  State  Medical  Association  will 
population,  and  especially  the  coming  World's  be  held  in  Brooklyn  on  Tuesday  May  26th,  1891. 
Fair,  are  the  attractions.  Eleven  applicants  were  AU  Fellows  desiring  to  read  papers  will  please 
refused  licenses  because  they  had  diplomas  from  notify  the  Secretary,  E.  H.  Sqibb,  M.D.,  P.  O. 
schools  not  in  good  standing,  because  their  pro  j^ox  Q ,  Brookivn 
fessional  records  had  been  tarnished  elsewhere,  or 

because  they  could  not  comply  with  the  require-  The  Journal  of  Inebriety  says  :  "The  physician 
ments  of  the  Board.  The  anxiety  to  settle  in  of  all  others  should  be  the  last  one  to  use  spirits 
Chicago  is  also  manifest  in  the  incorporation  of  in  moderation  or  excess.  The  use  of  alcohol  as  a 
so-called  medical  companies,  medical  associations,  !  beverage,  is  direct  evidence  of  igorance  of  the 
and  dispensaries,  thus  taking  advantage  of  the !  teachings  of  modern  science,  and  failure  to  keep 
lax  laws  and  attempting  to  evade  the    Medical ;  up  with  the  growth  of  medical  advance." 


170 


TOPICS  OF  THE  WEEK. 


[January  31:, 


TOPICS  OF  THE  WEEK. 


FERDINAND  COHN  AND  ROHERT  KOCH. 

At  a  time  when  all  the  world  is  talking  or  has  just  been 
talking  about  Robert  Koch,  the  following  word  portrait 
of  him  by  a  distinguished  man  of  science  who  has  known 
him  for  many  years  is  likely  to  interest  many.     It  is  from 
the  January   number   of   the   Deutsche  Revue,   and   its 
author  is  the  famous  botauist,  Professor  Ferdinand  Cohn. 
of  Breslau.      "When   I  made  Koch's  acquaintance,"  he 
writes,  "he  was  already  the  great  investigator  whom  all 
the  world  now  knows  and  admires.     On  the  22d  of  April, 
1S75,  I  received  a  letter  from  the  district  physician,  Dr. 
Robert  Koch,  of  Wollstein,    in   the   district  of  Bornst,  in 
the  grand-duchy  of  Posen,  asking  whether  I  would  allow 
him  to  visit  me  in  Breslau,   and   perform  before  my  eyes 
the  chief  experiments  relating  to  anthrax  and  its  charac- 
teristic bacilli,  the  histor}-  of  the  development  of  which 
he  believed  he  had  now  discovered  after  prolonged  in- 
vestigations, and  with  it  the  etiology  of  that  destructive 
disease.     I  had  been  myself  engaged  for  years  past  with 
bacteriological    investigations,    and    had    consequently 
often  received  announcements  from  dilettanti  of  their  al- 
leged discoveries  in  that  field,  which  was  then  being  cul- 
tivated with  but  little  precision  ;  the  expectations,  there- 
fore, which  that  letter  from  an  utterly  unknown  physician 
in  a   Polish  country  town   inspired   in   me,  were  of  the 
smallest.     I   of  course   wrote,   however,  that  I  should  be 
very  glad  if  Herr  Koch  would  visit  me  and  show  me  his 
things  ("  seine  Sachen  ").     Koch  came  to  my  institute 
on  April  30,  and  I  can  truly  boast  that  in  the  first  hour 
of  our  intercourse  I   recognized   in   him  an   unequalled 
master  of  scientific  investigation  ;    his  method,  proceed- 
ing with  rigid  consistency  from  step  to  step,  the  elegance 
and  certainty  of  his  experiments,  the  classic  clearness  of 
his  statements,  were  all  as  perfect  in  his  first,  then  just 
completed,  work  on  anthrax  as  in  all  his  later  researches. 
For  Koch's  works  are  distinguished  from  those  of  most 
investigators  by  the  circumstance  that  he  does  not  pub- 
lish them  till  they  are  finished  to  the  last  point.     Other.-, 
c.irt  up  stones  to  be  used  in   the  building  up  of  science, 
01  di  ' ",     1   Hi  w  plan  or  add  a  new  wing,  a  new  story,  a 
new  roof,  but  they  finish   only  the  brickwork,  and  leave 
it  to  others  to  complete  the  building  and  make  it  habita- 
ble.    Koch,  on  the  other  hand,  does  not  let  his  scientific 
fabrics  leave  his  hands  till  he  has  made  them  completelj 
fit  ill  all  their  details,  as  well  as  in  the  main,  for  tin  use  "I 
others,  who  have  then  nothing   more  to   do  than  to  add 
tins   or   the   other  little  furnishing.     All    Koch's   works 
1  ompletein  form  and  contents  thai  nothing 
remained  fi>r  those  that  followed  but  to  confirm  them, 
for  it  wai   aol  po    ible  to  add  anything  essential.     Such 
were  tin-  first  work   of  1875  on   anthrax,  that  on  wound 
infection,  tin-  numerous  treatises  in  tin-  communications 
of  tlie   Imperial   Office  of    Health,   the  magnificent    n 
rele  and  cholera  bacilli,  and  such  be- 
t  discovery  will   prove.     1  in  his  first 
visit  in   May,    [8;  i     Koch   stayed  only  a  short   time   in 
Breslau,   tud  1   <\  tiled  myself  of  the  opportunity  to  make 
my  Breslau  coll  onallj   acquainted   with  him 


and  his  researches.  I  then  remained  for  years  in  oc- 
casional correspondence  with  him.  His  letters  generally 
filled  several  sheets.  He  repeated  his  visits  to  Breslau 
too  ;  and  when  the  place  of  a  medical  expert  in  the  law- 
courts  there  fell  vacant  in  the  summer  of  1879,  we  suc- 
ceeded in  getting  him  appointed  to  it,  with  the  prospect 
of  an  extraordinary  professorship  in  the  University.  But 
already  in  January,  1879,  the  medical  faculty  of  the  Uni- 
versity of  Berlin  had  of  its  own  accord  proposed  to  the 
Minister  Koch's  appointment  to  an  extraordinary  pro- 
fessorship, and  the  establishment  of  an  institute  for  him. 
Some  papers  say  that  Koch  wished  to  establish  himself 
as  a  private  lecturer  in  Breslau,  but  was  refused  permis- 
sion.    That  is  utterly  untrue. 

The  proposal  of  the  Breslau  faculty  had  been  made 
without  Koch's  knowledge.  His  work  as  a  medical  ex- 
pert in  the  law  courts  could  not  satisfy  him  either  scien- 
tifically or  pecuniarily,  and  he  returned,  after  a  few 
months,  to  Wollstein,  where  his  place  as  district  physi- 
cian had  been  kept  open  for  him.  That  he  did  not  re- 
main there  long,  but  was  called  to  the  newly  founded  Im- 
perial Office  of  Health  in  Berlin  in  1S80,  did  great  honor 
to  the  German  Government,  and  was  of  great  advantage 
to  science — nay,  to  all  mankind.  But  if  you  ask  me  for 
reminiscences  of  conversation  w'th  Kooh,  I  can  only  say 
that  in  personal  intercourse  Koch  makes  the  same  over- 
powering impression  as  in  his  writings  by  the  clearness, 
depth  and  novelty  of  his  thoughts,  only  that  this  impres- 
sion is  greatly  enhanced  by  the  simplicity  and  amiability 
of  his  manners,  the  look  of  his  deep-set  eyes,  his  fine 
smile,  and  the  euphony  of  his  voice.  In  conversation 
with  Koch,  one  is  often  positively  dazzled  by  00 
remarks  or  short  questions,  indicating  still  unknown  re- 
searches that  he  has  been  working  at  for  years,  and  re- 
vealing new  scientific  horizons.  But  of  details  of  the  con- 
versation which  I  anil  my  then  assistant,  Dr.  Eidam,  had 
with  Koch,  and  which  sometimes  lasted  deep  into  the 
night,  I  have  no  remembrance." — Correspondence  of 
The  Lancet. 


UK.   HENRY  J.   BIGELOW  AND  THE  DISCOVERY  OF 
ANESTHESIA. 
In  a  speech  delivered  at  a  memorial  meeting  of  the  Bos- 
ton Society  for  Medical  Improvement,  on  the  occasion  oi 
the  death  ..1  Dr.  Henry  J.    Bigelow,  Dr.  O.  W.  Holmes 
said: 

Dr.  Bigelow  sometimes  paid  me  the  compliment  of  .isU 
pinion  of,  and  my  criticism  upon,  an  essay  or  a 
lecture  he  was  about  to  read  or  publish.     On  an  evening 
ofDecember,  1846,  he  called  upon  me  with  a  paper  which 
ised    leading    the    next   evening    at   the    regular 
meeting  of  the  American  Academy  of  Arts  and  Si 
He  began  bv  telling   me    that    a  great  discovery  had  just 
been  made  and  practically  demonstrated  in  the  operating 
theatre  ol  tin    Massachusetts  General  Hospital.     He  pro- 
ceeded to  read  the  paper,  which  was  the  first  formal  pre- 
si  11t.1t  i<  111  to  the  world  oi  the  successful  use  of  artifieially 
pi  oduced  anaesthesia  in  a  capital  operation.     He  had  the 
Mit\  to  see  the  fai  reaching  prospects  of  the  new  dis- 
covery, the  courage  as  well  as  the  shrewdness  to  suppoi  c 
tile  claims  of  the  adventurous  dentist's  startling,  at  first 


i89r.] 


TOPICS  OK  THK  WEEK. 


171 


almost  incredible,  announcement.  Every  possible  effort 
was  made  to  dislodge  the  infaut  anaesthesia  from  its  cra- 
dle in  the  Massachusetts  Hospital,  but  there  remains  the 
fact  that  all  over  the  wide  world  patients  were  shrieking 
under  the  surgeon's  knife  anil  saw — operator  and  victim 
alike  ignorant  of  the  relief  in  store  for  them,  at  the  very 
time  when  Dr.  Bigelow  was  unfolding  in  my  library  the 
first  paper  ever  written  on  the  subject,  and  saying  to  me 
as  he  did  so,  that  within  a  fortnight  the  news  of  the  dis- 
covery  would  be  all  over  Europe.  From  the  first,  Dr. 
Higelow  was  the  steady,  unflinching  advocate  of  ether  as 
the  safest  of  the  anaesthetics,  and  his  views,  though  not 
universally  accepted,  have  had  a  very  wide  and  lasting 
influence. — Northwestern  Lancet. 


MEDICAL   EDUCATION'  IN  BELGIUM. 

The  Scalpel  is  endeavoring  to  impress  upon  the  more 
highly  gifted  of  the  young  Belgian  medical  graduates  the 
desirability  of  their  forming,  as  they  have  the  right  to 
do,  extra  classes  for  the  instruction  of  students  and 
legally,  but  not  practically,  qualified  men;  also  for  older 
practitioners  who  wish  to  keep  abreast  of  the  latest  de- 
velopments of  science.  The  example  of  Germany  is 
quoted,  where  it  is  admitted  that  the  course  of  study  is 
much  better  than  in  Belgium,  no  one  being  allowed  to 
practice  without  having  undergone  a  "very  severe" 
State  examination,  but  where,  notwithstanding,  numbers 
of pi  ivat-docenten  open  courses  on  almost  every  conceiv- 
able subject,  to  which  students  and  practitioners  flock  in 
order  to  qualify  themselves  still  better  for  practice.  The 
same  kind  of  system  obtains  in  Paris,  where  thi 
hold  numerous  and  well-attended  classes.  In  Belgium, 
however,  "owing  to  the  competition  in  higher  educa- 
tion, our  Uuiversities,  in  order  to  attract  students,  have 
only  to  show  themselves  more  lenient  and  less  severe 
than  their  rivals,  and  they  will  surpass  all  others  in  their 
student's  roll." — Lancet. 


The  Sceptre  Life  Association  was  also  inst 

and  in  this  office  in  the  General 
during  the  last  six   years  569 

43.I  occurred=;6  per  cent.;  in  the  Temperate  Section  249 
deaths  were  expected,  and  143  occurred,  01 

age  of  those  dying  in   the 
General  Section  was  51  ::i;,crance 

Section  44.2  years — a  result,  as  «as  explained  in  the  dis- 
cussion— due  to  the  fact  that  the  average  age  of  abstain- 
ers is  at  present  much  below  that  of  all  males.  He  also 
noted  the  fact  that  several  accident  insurance  offices  re- 
duce the  premium  to  abstainers,  the  secretary  of  one  hav- 
ing explained  this  as  not  so  much  due  to  the  number  of 
accidents  being  slightly  less,  but  to  the  fact  that  abstainers 
recover  more  quickly.  He  also  compared  the  rates  of 
mortality  in  the  Foresters  and  Rechabites,  showing  a 
constant  difference  in  favor  of  the  latter  at  every  age. 
The  days  of  sickness  per  member  were  for  the  Rechabites 
6.16,  for  the  London  Grand  Division  of  the  Sons  of  Tem- 
perance 5.5,  and  for  the  Oddfellows  10.5  days.— Brit. 
Med.  Jour. 


HEALTH  AND  LONGEVITY  OF   ABSTAINERS. 

At  the  last  meeting  of  the  British  Medical  Temperance 
Association,  a  paper  was  read  by  Dr.  C.  R.  Drysdale,  in 
reply  to  some  doubts  as  to  the  superior  health  and  lon- 
gevity of  total  abstainers  from  alcohol.  He  referred  to 
the  report  of  the  Collective  Investigation  Committee  of 
the  British  Medical  Association  on  alcoholic  habits  and 
mortality,  which  is  still  being  used  extensively  by  op- 
ponents of  total  abstinence  inspite  of  the  disclaimer  of 
Dr.  Owen  and  the  explanations  given  by  others.  After 
quoting  the  statistics  by  Dr.  Ogle,  Mr.  Nelson  and  others, 
which  showed  the  very  high  mortality  of  persons  en- 
gaged in  the  liquor  traffic,  he  instanced  the  results  of  the 
United  Kingdom  Temperance  and  General  Provident  In- 
stitution, which  showed  that,  from  1S66  to  1SS9,  6,894 
deaths,  and  claims  for  ,£1,470,147,  were  expected  in  the 
General  Section  (non-abstainers |,  and  that  6,645  deaths 
oeeurred=96  per  cent.,  and  .£1,428,671  were  claimed  in 
the  Temperance  Section  (total  abstainers),  4,542  deaths, 
and  claims  for  ,£983,307  were  expected,  and  3,19s  oc- 
curred=7o  per  cent.,  and  ,£664,832  were  claimed,  show- 
ing an  immense  difference  in  favor  of  the  total  abstainers. 


MEDICAL  SCHOOLS  MUST  BE  ENDOWED. 

The  following  timely  words  are  the  conclusion  of  an 
editorial  in  the  Cincinnati  Lancet  Clinic,  January  3: 

The  time  is  rapidly  slipping  by  when  medical  schools 
and  colleges  can  be  carried  on  and  conducted  solely  by 
the  enterprise  of  a  'faculty  made  up  mainly  of  hard- 
worked  and  often  poorly  supported  physicians.  Medical 
schools  must  be  endowed  in  order  to  most  efficiently 
carry  on  their  work.  The  best  teachers  are  often  the 
most  impecunious  of  men.  Their  thoughts  are  not 
given  to  the  making  of  money,  however  necessary  this 
may  be.  but  in  other  channels  they  may  be  doing  a  much 
greater  and  a  much  better  work  for  the  world,  than  the 
man  who  writes  his  signature  as  president  of  a  bank  or 
railroad. 

.There  are  men,  and  women  too,  whose  lives  have  been 
prolonged  and  made  more  comfortable  through  the  skill- 
ful application  of  the  art  and  science  of  medicine.  The 
presented  bill  of  the  attending  physician  may  have  been 
promptly  paid,  but  a  debt  to  science  remains  unsettled  ; 
a  science  that  has  made  it  possible  for  the  attending  phy- 
sician to  afford  the  longed  for,  the  hoped  for  relief  from 
pain  and  suffering.  Those  who  are  possessed  of  large 
means  should  remember  this,  and  remember  that  they 
are  but  stewards,  and  that  in  a  broad  sense  they  are  their 
brother's  keeper.  They  are  responsible  for  the  well- 
being  and  refinement  of  all  the  people.  They  are  like- 
wise to  be  rewarded  in  unmeasured  gratitude  for  the  good 
deeds  they  may  perform  in  efforts  made  to  elevate  those 
less  fortunate  than  themselves.  Free  education  is  the 
chief  bulwark  of  our  free  republic.  Free  education 
lessens  crime  and  makes  the  impossible,  possible. 

It  is  eminently  just,  right  and  proper,  that  the  entire 
people  should  contribute  according  to  their  means  for 
the  common  school  education  of  every  child  ;  while 
there  is  just  as  great  a  moral  obligation  on  the  part  of  the 
wealthy  to  contribute  of  their  super-abundance  towards 
the  higher  educational  schools.  Among  these  the  med- 
ical schools  are  among  the  most  important,  and  their 
claims  should  be  set  forth  by  those  who  know  them  best. 

Phvsiciaus  should  present  this  subject  to  their  clients 
at  every  opportunity. 


172 


PRACTICAL  NOTES. 


[January  31, 


PRACTICAL   NOTES. 


SULPHOXAL    IN    DIABETES. 

Dr.  Casarelli,  of  Pisa,  mentions  the  favorable 
action  of  sulphonal  in  diabetes  (Lance/).  The 
drug  diminishes  the  quantity  of  sugar  in  the 
urine,  also  reducing  the  polyuria  and  the  thirst. 
These  results  were  obtained  by  doses  of  from  5 
to  30  grains  per  diem,  but  not  to  so  marked  a  de- 
gree as  with  doses  of  45  grains  continued  for  sev- 
eral days.  The  30-grain  doses  could  be  admin- 
istered for  some  time  without  any  ill  effects  ;  but 
although  the  40-grain  doses  at  first  caused  no  dis- 
turbance, it  was  found  that,  when  they  were  con- 
tinued for  any  lengthened  period,  the}-  caused 
giddiness  and  excessive  sleepiness,  which  disap- 
peared when  the  drug  was  discontinued. — Med- 
ical Record. 


CHRYSAROBIN    IN    HEMORRHOIDS. 

A  Paris  correspondent  of  the  Pharmaceutical 
Record,  April  7,  1890,  states  that  extraordinary 
success  has  been  reported  with  chrysarobin  in  the 
treatment  of  haemorrhoids.  For  the  external 
variety  he  prescribes  the  following  ointment,  to 
be  applied  several  times  daily  after  a  washing  in 
a  1  to  50  solution  of  phenic  acid,  or  a  1  to  100 
solution  of  creolin  :  Chrysarobin,  80  ctgr. ;  iodo- 
form, 30  ctgr. ;  ext.  belladonna,  60  ctgr. ;  vaseline, 
25  gm.;  for  external  use.  For  internal  use,  the 
formula  is  as  follows :  Chrysarobin,  8  ctgr. ; 
iodoform,  2  ctgr.;  ext.  belladonna,  1  ctgr.;  cacao 
butter,  2  gm.;  make  one  suppository.  In  three 
or  four  days  pain  and  haemorrhage  are  said  to 
disappear,  and  it  rarely  happens  that  the  most 
obstinate  cases  are  not  cured  within  two  or  three 
months. — College  and  Clinical  Record. 


ICHTHYOL  IN   THE   TREATMENT  OF  GONORRHOEA. 

K5ster  (  Wiener  Medizinische  Presse,  November 
23,  1890)  writes  enthusiastically  of  the  use  of  a 
i-per  cent,  solution  of  ammonium  sulph-ichthyo- 
late  in  gonorrhoea.  He  has  used  it  in  three  cases 
of  gonorrhoea  in  men  and  in  one  case  of  gon- 
orrheal cystitis  in  a  woman.  In  the  cases  of 
gonorrhoea  he  employed  injections  of  the  solution 
three  times  daily.  On  the  second  day  of  treat- 
ment the  painful  micturition  and  the  painful  noc- 
turnal erections  disappeared.  The  discharge 
ceased  permanently  in  from  four  to  twenty  days. 

In  the  case  of  cystitis,  in  which  the  symptoms 
were  severe,  four  and  one-half  ounces  of  the  so- 
lution were  injected  twice  daily  for  eight  days  by 
means  of  an  irrigator,  the  solution  being  retained 
in  the  bladder  for  five  minutes,  and  then  per- 
mitted to  escape  through  the  urethra.  After  the 
second  day  of  treatment  the  pus  disappeared  from 
the  urine  and  there  was  no  longer  severe  pain. — 
Medical  News. 


SOLVENT    FOR     DIPHTHERITIC    MEMBRANE; 
B.     Pepsinas,  3jss. 

Ac.  hydrochlor.  dil.,  Tt\j. 
Aq.  dest., 

Glvcerinse   aa  5  ss.     njj. 
Sig.     Paint. 

— Canada  Lance/. 


BRONCHIAL    ASTHMA: 

B.     Arumonii  iodid.,  ,"  ij. 

Extract,  grindeliae  robust,  fluid.,  f  3  ss. 
Extract,  glycyrrhizae  fluid.,  f  5  iv. 
Tinct.  lobt ', 

Tinct.  belladonna?,  aa  f  3  ij. 
Syrup,  tolu,  q.  s.  ad  f  5  iv.     tJ!- 
Sig.     A  teaspoonful  t.  d.    Extra  dose  to  be  given  dur- 
ing a  paroxysm. 

— Amer.Journ.  of  Med.  Sciences. 


CREOLIN    IN    ERYSIPELAS    AND    ECZEMA. 

Dr.  Rothe  (Attenburg  ;  Memorabilien.  9;  Brit. 
fourn.  of  Derm..  November,  1890),  has  used  in 
the  treatment  of  erysipelas  a  creolin  ointment 
containing  creolin  1.5,  cret.  praep.  axung  pore, 
aa  150,  ol.  menth.  pip.  gtt.  v.  This  is  spread 
in  the  thickness  of  the  blade  of  a  knife  over  the 
diseased  parts  twice  or  three  times  a  day,  a  thin 
layer  of  c<  itton  wool  being  applied  as  a  covering. 
In  from  twelve  to  twenty- four  hours  improvement 
was  always  apparent,  and  the  disease  was  cured 
in  three  or  four  days.  The  same  ointment  also 
did  good  service  in  a  case  of  weeping  eczema  of 
the  face,  as  also  in  several  cases  of  eczema  in 
children.  A  patient  suffering  from  scabies  was 
treated  with  a  thorough  washing  with  soft  soap 
and  inunction  of  this  ointment,  with  Mich  a  de- 
cided effect,  that  Dr.  Rothe  considers  creolin  to 
be  undoubtedly  a  specific  for  the  disease. — British 
Medical  Journal. 


SOLUTION    FOR    THE     ECZEMA    OF    DENTITION: 

R.     Hydrochlorate  of  cocaine  2  grains. 
Bromide  of  potassium  15  grains. 
Pure  glycerin       |  of  cach  , ,  omlce.     ,nv 
Distilled  water      i  A 

Rub  thoroughly  together,   and  apply  to  the  parts  with 
the  soil  part  of  the  finger.      If  insomnia  is  present,  owing 
to  the  itching  produced  by  the  eruption,  a  teaspoonful  of 
a  syrup  made  up  as  follows  will  be  found  useful : 
R.     Bromide  of  potassium  7  grains. 
Syrup  of  orange  I  ounce.     "t\ 
Tor  the  cure  of  the   condition,  an  ointment   composed 
of  oxide  of  zinc,  1  drachm,  and  vaseline,  3  drachms,  may 
.  ed  with  advantage. 

— Medical  , 


EXCESSIVE  MENSTRUATION. 

R — Ergot  dialysat,  Jx. 

Glycerin.,  ,~\ . 

Acid  salicylic,  gr.  xxx. 

Aquae  destillat.,  i~%  ijss.     m; 
Sig.      Inject  into  the  rectum  once  a  day   a  teaspoonful 
of  this  mixture,  diluted  with  three  teaspoonfuls  of  water. 


I89i.] 


SOCIETY  PROCEEDINGS. 


SOCIETY   PROCEEDINGS. 


w 


is  rarely  the  outcome  of  this  disease,   and   -. 

not  expect  so  favorable  an  ending.     We  expect, 

...      ,  ,.         ,.    ,,    ,.  however,  that  his  circulation   will    improve,    and 

Allegheny  County  Medical  Society.  ,1  .,,  ^     L:n  n  j 

tnat  .it.-  will  then  have  a  moderate  dropsv  onlv, 

Special  Meeting,  November  iS,  1890.  and  will  have  a  fair  degree  of  health  and  perhaps 

S.  Foster,  M.D.,  President,  in  the  Chair,   again  become  a  useful  member  of  society. 


ENORMOUS  DROPSY  OF  THE  BELLY. 


Dr.  Lange  :  I  have  a  patient  here,  aged  48 
years,  who  has  been  sick  18  months.  I  present 
him  because  I  believe  him  to  have  the  largest 
amount  of  ascites  ever  recorded.  He  has  inter- 
stitial hepatitis,  or  cirrhosis  of  the  liver,  and  was 
tapped  this  morning,  this  being  his  ninety  ninth 
tapping,  at  each  of  which  there  has  been  evacu- 
ated from  four  to  six  gallons  of  serum.  A  year 
ago  he  required  tapping  every  two  or  three  days  ; 
at  the  present  time  we  tap  him  once  in  five  days. 
Once  he  went  six  days.  Averaging  the  evacua- 
tion of  serum  at  five  gallons  at  a  tapping  will  give 
a  total  of  495  gallons  of  serum  which  we  have 
drawn  from  this  man.  or  twelve  and  a  half  bar- 
rels, counting  forty  gallons  to  the  barrel.  His 
general  health  is  moderate.  As  you  see,  he  does 
not  look  very  anaemic.  He  is  not  very  sick.  His 
functions  are  all  fairly  well  performed.  His  ap- 
petite and  digestion  are  fairly  good  and  he  sleeps 
well.  If  he  could  get  rid  of  his  dropsy,  he  would 
be  in  comparatively  good  health.  He  has  no 
complications.  His  kidneys  are  normal  ;  the 
same  is  true  of  his  heart,  and  he  has  no  pachy- 
meningitis. The  reason  he  has  a  greater  amount 
of  ascites  than  is  common  in  cirrhosis  of  the  liver, 
is  because  his  collateral  circulation  is  not  as  good 
as  it  usually  becomes  early  in  this  disease.  This 
lack  of  development  of  the  collateral  circulation  is 
the  cause  of  his  greater  than  ordinary  amount  of 
dropsy.  The  blood  in  his  portal  vein  being  de- 
nied admittance  to  the  liver,  greatly  over  distends 
the  mesenteric  veins,  and  this  intra-venous  pres- 
sure is  the  direct  cause  of  his  dropsy.  The  collat- 
eral circulation  established  is  by  anastomosis  of 
the  mesenteric  with  the  abdominal  veins,  the  cor- 
onary vein  of  the  stomach  with  the  veins  of  Glis- 
son's  capsule  on  the  one  hand,  or  with  the  phrenic 
veins  on  the  other,  the  internal  haemorrhoidal 
with  the  hypogastric,  and  finally,  as  pointed  out 
by  Baumgarten,  enlargement  of  the  not  yet  oblit- 
erated umbilical  vein  in  the  ligamentum  teres. 
By  all  these  ways  the  blood  from  the  portal  sys 
tem  reaches  the  abdominal  veins — a  direct  reverse 
to  the  normal,  and  the  greater  or  lesser  perfection 
of  this  collateral  circulation  determines  a  small  or 
a  large  ascites.  In  thiscasethe  abdominal  veins, 
and  the  caput  Medusae,  too,  are  not  as  large  as 
usual,  and  as  a  consequence,  the  dropsy  is  so 
much  larger.  If  this  collateral  shall  improve,  his 
dropsy  will  become  more  moderate  ;  if  it  become 
perfect,  this  dropsy  will  disappear.  But  we  do 
expect  this  latter  to  happen.  Dr.  Flint  reported 
two   cases   in    which    it   did  happen.     But    this 


CASK    OF  LUMBO-COLOTOMY. 

Dr.  LANGE  :  The  other  case  is  of  lumbo-colot- 
omy  for  cancer  of  the  rectum.  This  lad- 
years  of  age.  The  cancer  was  removed  last  April. 
Its  return,  however,  was  very  rapid,  and  :. 
tated  this  operation,  which  is  rather  rare,  forty- 
seven  cases  being  all  I  can  find  recorded.  The 
lady  whom  I  will  show  you  in  a  few  moments 
passed  absolutely  nothing  through  her  rectum  for 
a  period  of  seven  weeks.  She  was  so  tender  and 
distended  that  peritonitis  was  suspected.  She 
vomited  constantly,  could  take  no  nourishment 
nor  drink  three  weeks  before  consent  to  operation 
could  be  obtained.  It  was  obvious  that  she  must 
die  or  submit.  The  operation  was  done  6  weeks 
ago  today.  There  was  no  peritonitis.  The  only 
drawback  that  she  has  experienced  is  prolapse  of 
the  gut,  which  she  now  prevents  by  this  little 
cushion  and  bandage.  She  has  grown  strong  and 
eats  and  sleeps  well.  The  operation  was  done 
with  the  observation  of  all  antiseptic  precautions 
— until  the  opening  of  the  gut.  Two  double  lig- 
atures were  passed  through  the  gut  before  it  was 
opened,  and  by  them  it  was  lifted  to  the  surface 
of  the  wound.  It  was  then  opened,  and  so  great 
was  the  discharge  of  fecal  matter,  that  the  whole 
wound  was  soiled.  The  opening  into  the  gut  was 
i'j  inches  long,  and  the  edges  were  secured  to 
the  skin  by  eight  sutures.  All  the  sutures,  how- 
ever, suppurated  out,  and  after  ten  days  there 
was  no  union  between  the  gut  and  the  skin.  This 
is  not  to  be  expected  in  this  operation.  The  su- 
tures are  only  intended  to  temporarily  hold  the 
gut  in  position  until  there  is  union  deep  in  the 
wound  between  the  muscles  and  fasciae,  and  not 
the  edges,  but  circumference  of  the  gut.  This  is 
here,  as  you  see,  perfect,  and  no  danger  that  the 
gut  may  recede  exists.  I  am  indebted  to  Drs. 
Hamilton  and  Herron  for  advice  and  assistance 
during  the  operation. 

Dr.  Buchanan  :  I  would  ask  Dr.  Lange 
whether  he  took  into  consideration  the  advan- 
tages of  inguinal  colotomy,  the  drawing  of  the 
sigmoid  flexure  of  the  colon  forward,  and  making 
an  anterior  instead  of  a  lumbar  incision.  This 
operation  would  answer  as  well  as  the  operation 
which  he  performed,  and  it  has  the  great  advan- 
tage that  one  is  able  to  make  it  an  antiseptic  op- 
eration throughout,  which  he  was  not  able  to  do 
in  this  case.  Of  course  this  case  turned  out  as 
well  as  could  be  wished.  But  by  bringing  the 
gut  through  the  abdominal  walls  and  keeping  it 
there  until  adhesions  have  taken  place  before  it  is 
opened,  he  gains  a  perfect  adhesion  without  dan- 


174 


SOCIETY  PROCEEDINGS. 


[January  31. 


ger  of  soiling  his  wound.  Then  when  adhesion 
has  been  established,  the  gut  is  opened  and  its 
contents  allowed  to  escape.  It  seems  to  me  this 
is  rather  a  better  operation  than  the  lumbar  oper- 
ation, and  safer,  and  the  control  of  the  fasces  is 
very  much  better  than  in  the  lumbar  operation. 

Dr.  Eange:  Answering  the  doctor,  I  would 
say  that  the  operation  in  front  involves  opening 
the  peritoneal  cavity;  the  lumbar  region  does  not. 
Until  in  the  last  few  years  it  has  not  been  consid- 
ered superior  to  the  lumbar  operation.  This  has 
come,  of  course,  because  of  antisepsis.  The  lum- 
bar operation  should  be  absolutely  safe,  because 
the  probability  of  opening  the  peritoneum  is  just 
about  as  great  as  of  entering  the  peritoneal  cav- 
ity by  puncture  of  a  full  bladder.  It  sometimes 
happens  that  in  the  puncture  of  a  full  bladder  the 
peritoneum  is  opened  by  the  trochar,  and  the 
opening  of  the  gut  in  the  lumbar  region  is  on  a 
par  with  that  for  danger.  There  is  very  little 
danger.  The  operation  in  front,  it  seems  to  me, 
is  more  dangerous,  despite  all  antisepsis,  because 
of  the  opening  of  the  peritoneum.  I  understand 
Dr.  Buchanan  to  advise  waiting  some  days  for 
adhesion  after  opening  the  belly,  before  opening 
the  gut.  There  was  no  time  for  that  in  this  case. 
The  operation  was  postponed  by  the  patient  as 
long  as  it  was  possible.  When  it  was  absolutely 
necessary  to  have  it  performed,  with  death  as  an 
alternative,  she  consented  to  it. 

Dr.  Allyn  :  At  the  last  meeting  Dr.  Bane 
read  a  paper  relating  a  case  of  an  hysterical  child. 
I  have  seen  a  case  quite  similar.  A  girl  14  years 
old,  recovering  from  sickness,  complained  of  her 
eyes  failing  her  in  reading.  She  was  taken  to  a 
physician,  and  finally  came  under  my  charge.  I 
put  the  card  the  proper  distance;  she  failed  to  see 
anything  with  any  clearness.  Putting  on  glasses 
of  different  strengths,  I  reduced  the  strength 
to  piano.  Then  she  read  the  card  perfectly. 
Taking  the  glasses  off,  she  no  longer  saw  anything. 
Fearing  there  might  be  paralysis  of  the  ocular 
muscles,  I  tested  her  for  close  use.  In  this  case, 
she  saw  nothing  until  glasses  were  applied  and 
finally  reduced  to  piano,  when  she  read  diamond 
type  with  perfect  ease.  I  told  the  mother  noth- 
ing was  the  matter  practically  with  the  eyes.  I 
told  her  the  girl  had  hysteria;  and  since  that  time 
she  has  been  taken  with  hysteria. 

Dr.  Ljppincott  :  I  saw  yesterday  morning  a 
similar  case.  Curiously  enough,  nearly  all  the 
cases  I  have  seen  have  been  girls  of  about  10 
years.  I  do  not  think  they  vary  more  than  a 
year  or  two  either  way.  This  child  that  I  saw 
could  not  see,  apparently,  any  letters  across  the 
room  at  all.  By  putting  up  the  large  letters  which 
can  In-  read  at  200  feet,  she  managed  to  read.  The 
next  size  she  thought  she  saw  dimly.  She  called 
M,  I.  I  thought  instantly  she  was  shamming, 
as  her  answers  were  not  compatible,  and  I  got 
her  confused  by  giving  her  a  whole  battery  of 


questions  and  answers  at  once.  She  was  thrown 
off  her  guard  and  saw  the  very  finest  letters. 
These  cases  are  not  very  uncommon.  I  have  seen 
half  a  dozen.  This  child  yesterday  was  a  type 
of  a  pretty  large  class.  Dr.  Holland,  of  Phila- 
delphia, called  attention  to  this  a  number  of  years 
ago.  I  think  the  majority  of  cases  are  in  girls, 
showing  that  the  trouble  is  probably  hysterical. 
Dr.  T.  D.  Davis  :  The  following  cases  will 
illustrate 

THE  WONDERFUL  RECUPERATIVE   POWER  OF  THE 
HUMAN  SYSTEM. 

John  T.,  a  young  Italian,  set.  20  years,  was 
admitted  to  St.  Francis'  Hospital  with  a  badly 
crushed  ankle.  With  the  hope  of  saving  the  foot, 
it  was  put  at  rest  and  the  usual  treatment  applied. 
The  tarsal  bones,  however,  were  so  badly  crushed 
that  they  failed  to  unite.  After  some  weeks  si- 
nuses formed,  and  spicula  of  bone  being  dis- 
charged, he  was  put  under  an  anaesthetic  and  a 
quantity  of  diseased  bone  removed,  but  without 
much  benefit.  He  came  under  my  care  about 
uine  months  after  the  injury.  He  was  thin,  pale 
and  much  reduced  in  strength.  His  ankle  was 
enormously  swollen,  with  numerous  openings  of 
sinuses,  from  which  flowed  copious  discharges  of 
unhealthy  pus.  He  had  persistently  refused  to 
have  the  foot  removed,  and  it  was  only  when  he 
was  compelled  to  choose  between  his  foot  and 
death,  that  he  consented  to  an  amputation.  I 
first  tried  a  Syme,  but  so  fearfully  disorganized 
and  pus-infiltrated  were  the  tissues  that  they  sep- 
arated by  their  own  weight.  Finding  the  articu- 
lar portion  of  the  tibia  also  diseased,  I  finally 
amputated  at  the  middle  of  the  leg,  using  only 
the  antiseptic  precaution  of  clean  instruments  and 
boiled  water!  The  wound  healed  by  the  first  in- 
tention, and  in  ten  days  I  found  him  being  meas- 
ured for  an  artificial  leg.  From  the  day  the  foot 
was  removed  he  improved  in  weight  and  strength. 

Case  2  was  also  a  young  Italian,  who  was  ad- 
mitted to  Mercy  Hospital  with  a  compound  com- 
minuted fracture  of  the  lower  third  of  the  leg. 
The  lower  portion  of  the  tibia  projected  an  inch 
or  so  through  the  wound  and  was  impacted  there. 
He  had  been  injured  three  weeks  before,  and  one 
week  of  the  time  he  had  spent  in  the  Homceo- 
pathic  Hospital.  His  friends  had  taken  him  home 
from  there  and  I  suppose  had  tried  to  cure  him 
themselves.  When  I  saw  him  first  he  was  fear- 
fully reduced,  with  an  immense  bed-sore  on  his 
back,  half  of  his  foot  gangrenous  and  emitting  a 
must  sickening  odor.  The  wound  at  the  seat  of 
fracture  was  in  a  most  foul  and  unhealthy  condi- 
tion. Pus  had  infiltrated  the  tissues  in  every  di- 
rection. He  was  given  '4  gr.  of  morphine  hypo- 
dermatically,  the  A.  C.  E.  mixture  administered, 
and  the  leg  amputated  at  the  middle.  He  made 
a  speedy  recovery,  the  leg  being  healed  before  the 
bed-sore.     A  large  phlegmonous   abscess  formed 


iSgu] 


SPECIAL  CORRESPONDENT!-:. 


over  his  left  breast,  but  healed  promptly  after  free 
evacuation  and  bichloride  injection. 

Case  3  was  a  most  desperate  one.     A  man  52 


water  so  hot  that  it  instantly  seared,  as  it  were, 
the  ends  of  the  cut  vessels,  and  afterwards  drench- 
ed the  sinuses  time  and  again  with  water  as  hot 


years  of  age  was  admitted  to  Mercy  Hospital,  as  I  could  bear  my  hand  in,  and  dusted  the  whole 
with  a  compound  fracture  of  the  lower  third  of  freely  with  iodoform.  The  flaps,  of  course,  were 
the  femur.  He  was  emaciated  to  the  most  ex-  left  open,  He  reacted  slowly,  but  Dr.  McManus 
treme  limit,  his  face  haggard  and  eyes  wild,  but  gave  him  hypodermics  of  whisky  and  ether  al- 
glazed  and  sunken  in  their  sockets  :  his  skin  cold  most  every  half  hour  during  the  night,  and  ene- 
and  moist,  and  his  pulse  small,  thin,  frequent  and  mas  of  hot  milk  and  whisky,  with  all  the  artifl- 
very  difficult  to  count  ;  his  tongue  dry  and  cial  heat  he  could  get  around  him.  He  rallied 
parched,  could  scarcely  be  protruded  through  his  perfectly,  and  although  his  convalescence  was 
bloodless  lips.  He  had  an  immense  bed  sore  long  and  tedious,  he  recovered,  eventually,  with 
over  the  lumbar  region,    extending  down   to  the   a  new  lease  of  life. 

coccyx  and  over  the  buttocks.  His  right  leg  be-  It  seems  astonishing  in  all  three  of  these  cases, 
low  the  knee  was  discolored  and  had  a  large,  foul  and  especially  the  last,  that,  notwithstanding  the 
ulcer.  His  left  leg  was  twice  its  normal  size,  great  quantity  and  deadly  quality  of  the  pus,  na- 
At  the  seat  of  fracture,  at  the  lower  third  of  the  ture  had  so  carefully  guarded  them  from  pyaemia, 
femur,  were  two  large  openings  communicating  It  is  also  noteworthy  that,  although  antiseptic 
with  the  bone,  and  through  which  was  a  rubber  precautions  were  almost  impossible,  yet  the  an- 
tube  half  an  inch  in  diameter,  and  at  least  a  yard  tiseptic  dressings  of  the  wounds  certainly  had 
in  length,  this  extending  almost  a  foot  and  a  half  much  to  do  in  the  success  of  the  operation, 
outside  of  each  of  the  wounds  !  Below  the  knee  Dr.  Koenig  :  I  feel  like  congratulating  Dr. 
the  leg  was  immensely  cedematous  and  was  con-  Davis  on  the  result  of  his  surgical  interference, 
fined  in  a  large  wooden  crate,  or  cradle,  extend-  but  I  also  feel  like  asking  him  to  change  the  sub- 
ing  from  the  knee  to  the  ankle.  At  the  lower  ject  of  his  paper.  He  stated  that  he  simply 
part  it  had  cut  through  until  the  tendo  Achillis  wanted  to  give  us  an  evidence  of  the  recupera- 
was  exposed,  although,  well  padded  at  the  sides  1  tive  power  of  nature.  It  seems  to  me  the  subject 
ontrivance,  which  looked  something  like  should  be  the  life-saving  power  of  mercury.  We 
the  boxes  they  transport  peaches  in,  was  so  ar-  have  all  seen  how  nature  bungles,  how  she  is  uu- 
ranged  as  to  swing  the  limb,  and  hence  keep  up  able  to  save  life  without  the  aid  of  the  scientific 
all  the  motion  possible  at  the  seat  of  fracture,  physician.  I  think  we  should  divide  the  credit, 
The  stench  from  the  wounds  was  almost   unbear-   giving  a  large  portion  of  it  to  mercury,  or  other 


able,  and  they  were  literally  alive  with  maggots, 
even  the  immense  so  called  drainage  tube  being 
absolutely  occluded  with  them. 

This  poor  man  had  been  injured  nearly  five 
weeks  before,  and,  I  say  it  with  shame,  had  been 
attended  daily  all  that  time,  by  two  men  called 
doctors.  He  lived  about  thirty  miles  from  the 
city,  and  the  day  before  his  "doctor"  had  told 
his  friends  "he  had  done  all  he  could  for  him  and 
they  had  better  take  him  to  the  city."      And  he 


antiseptics,  and  less  to  nature. 

V  concluded.  I 


SPECIAL  CORRESPONDENCE. 


Differential  Criticism  of  ilu-  Spinal  Cord. 

To  the  Editor: — Nearly  three-fourths  of  a  century  ago 
Longet,  by  very  careful  experimental  research,  concluded 


had  endured  the  long  trip  in  this  awful  condition,  a^t  sensory  impressions  were  conducted  solely  by  the 

With    but    the  faintest  hope  of  doing  him  any  posterior  column  of  the  spinal  cord  to  the  brain,  and  in 

good    I  gave  him   several  drachms  of  whiskv  hv-  Ins  day  this  theory  was  generally  accepted      Soon  after 

Piratically,   and   administered   the  A.   C.  E  Longer  *£*££«& £^^14^5 

anaesthetic.      On  examining  the  wound,  we  found  conductea  to  the  brain  through  the  gray  matter  of  the 

that  the  whole  thigh  was  infiltrated  with  the  most  cor(j  exclusively, 
putrid  pus  infested  with  maggots.      Not  less  than       Flint,  in  bis  text-book.  p.  67S.  makes  the  following  m- 

r    _        c   ...  1  . |„_„«  nuiiies-      1     Does  or  does  not  the  white  substance  of  the 

two   quarts  of  this  was   expressed    as  two  large  ^^  ^^  of  the  cord  conduct  sensor,- impressions 

sinuses  extended,  one  in  front   to  Poupart  S   llga-  ^  ^  Draul?     2.   Does  the  entire   substance  of  the  cord 


ment,  and  the  other  far  up  in  the  gluteal  region 

These  sinuses  were  an  inch  or  two  in  diameter,  . 

j  j    j       -*u         r  .  1     ™„..;,-v,  Ki„„l-  rior  column  act  as  conductors,  or  does  either  one  act  to 

and  were  surrounded  with  a  foul,  grej  ish-black  r>°™umf0n  of  the  other? 


act  as  a  conductor  of  sensibility?     3.   Does  both  the  gray- 
matter  of  the  cord  and  the  white  substance  of  the  poste- 


membrane.     The    bone    was    broken    in    several 


the  exclusion 

"These  questions,"  he  further  says,  "may  now  be 
fragments,  which  were  lying  loose  in  the  wound,  considered  as  definitely  answered  by  the  most  positive 
Although  I  had  not  contemplated  amputation,  as    and  unmistakable  results  of  experiments  upon  living  an- 

t,  .V      ..  ,...         r     if  j      -..         \  t  <.-l„ i,*    imals   which  leave  no  doubt  with  regard  to  the  part  ot 

the  patient's  condition  forbade  it,  yet  I  thought  ™f ^which  acts  as  conductors  of  sensorv  impres- 
it  worse  than  useless  to  try  to  rally  him  under  his  sions  >■  jo  the  first  query  he  says  that  whatever  may- 
present  condition,  and  so  amputated  at  the  upper  be  the  function  of  the  posterior  white  columns,  they  do 
third   of  the    thi°-h       I    washed  the  wound    with     not  serve  as  conductors  of  sensory  impressions.    The  sec- 


176 


SPECIAL  CORRESPONDENCE. 


[January  31, 


oud  question  is  as  positively  answered  in  these  words 
''  When  the  gra}'  matter  is  divided  with  very  slight  in- 
jury to  the  white  substance,  sensibility  in  the  parts  below 
the  point  of  section  is  totally  destroyed."  And  the  an- 
swer to  the  third  question  is  deduced  from  the  answers  to 
the  first  two.     What  can  be  more  positive! 

Again,  Ranney.  "Applied  Anatomy  of  the  Nervous 
System,"  p.  300,  says,  "The  sensory  fibres  found  in  the 
posterior  root  (of  the  spinal  cord!  ascend  in  the  column 
of  Kurd. nil  for  a  short  distance  only,  when  they  pass  into 
the  gray  matter  of  the  posterior  half  of  the  cord." 

Other  American  authors  are  equally  positive  in  stating 
that  the  sensory  tract  of  the  spinal  cord  is  the  gray  mat- 
ter, and  almost  certainly  that  portion  of  the  gray  sub- 
stance near  the  central  canal. 

As  students  of  medicine  and  seekers  of  truth,  we  have 
accepted  this  without  mental  reservation. 

In  opposition,  however,  to  the  foregoing",  Byron  Bram- 
well,  of  Edinburgh,  in  his  recent  work  on  the  spinal  cord, 
is  positively  contradictory. 

By  examining  this  work  it  will  be  found  that  Figs.  29, 
30,  31,  3S,  59  and  61,  distinctly  show  the  sensory  tract  of 
the  cord  to  be  the  posterior  white  column,  or  the  column 
of  Burdach,  and  not  the  gray  substance,  according  to 
Flint,  Hammond,  Ranney  and  others. 

The  explanatory  text  in  Bramwell  confirms  the  cuts  in 
every  instance.  I  am  after  the  truth,  if  it  is  known. 
Who  is  right?  Stewart  Leroy  McCcrdy,  M.D. 

Dennison,  O. 


shall    The  Journal  In-  Removed  to 
Washington  ? 

To  the  Editor: — I  prefer  Chicago. 

Wm.  T.  Corlett,  M.D. 
Cleveland  <  1. 


To  the  Editor: — I  have  waited  until  the  present  before 
expressing  my  opinion  upon  the  action  of  the  Trustees 
of  The  Journal,  at  their  late  meeting,  advising  that  at 
the  end  of  the  present  year,  The  Journal,  should  be 
permanently  established  in  a  central  office  at  Washing- 
ton. The  only  argument  offered  in  favor  of  the  change 
was  by  one  of  the  new  Trustees  who  stated  that  he  voted 
for  it  because  lie  was  pledged  to  that  course  of  action  be- 
fore his  appointment. 

Few  know  better  than  myself  the  events  which  led  to 
the  establishment  of  The  Journal  and  its  location  in 
Chicago.  It  was  but  natural  to  expect  that  there  would 
exist  a  rivalry  between  the  leading  centres  of  our  great 
country  for  its  possession,  since  it  is  easy  to  understand 
the  power  and  influence  which  such  a  journal  might  exert  if 
made  the  exponent  of  local  interests.  Fortunately  for  the 
Association  and  the  Nation,  the  guardians  of  the  interests 
of  The  JOURNAL  have  thus  far  been  enabled  to  hold  in 
restraint  all  ulterior  influences,  and  have  treated  the  in- 
terests of  the  <  lions  of  our  country  with  im- 
partial justice. 

There  can  be  no  doubt  that  a  very  much  better  jour- 
nal could  have  Ik  en  furnished  by  the  expenditure  of  a 
much  larger  sum  of  money,  but  no  one  can  now  question 
the  wisdom  of  tin-  Trustees  and  the  self-sacrificing  econ 
0U1  first  editor,  Dr.  Davis,  ill  adopting  the 
"]m\    as  you  go  s\  stem." 

Iii  us  rapid  growth  and  development,  our  journal  is 
now  justl  v  considered  the  peer  of  any  of  the  greal  ■■  ■  el 
lies  of  tin-  Eastern  cities,  and  under  wise-  and  i 
control  it  should  become  the  leading  exponent  of  the  best 
i  With  such  a  history  and 
such  a  promise  of  future  good,  what  gain  is  to  be  ex 
peeted  by  a  change  of  location  to  Washington? 

Is  it   because  Washington  is  the  capital  city  and  the 
i  1  lie  political  influences  of  our  country  ?     Some 
the  greatest  danger  to  out    \ 
i:  hi    tnd  its  journal  lies  in  the  fact  that  a  political  ele 


ment  has  entered  into  its  organization  and  is  seeking 
control.  If  there  is  reason  for  apprehension  in  this 
direction,  it  would  be  a  strong  argument  for  its  removal 
from  Washington  had  it  been  established  there  instead 
of  at  Chicago. 

Is  it  because  Washington  is  a  greater  literary,  medical, 
or  educational  centre  than  Chicago?  We  have  all 
watched  with  amazement  the  wonderful  growth  of  Chi- 
cago, until  she  has  become  the  second  great  city  of  our 
country,  and  great  as  she  is  in  wealth  and  commercial 
activity,  those  who  know  her  best,  know-  that  she  is  lav- 
ishing lur  money  upon  libraries,  art  collections,  univer- 
sities, and  schools  of  learning,  until  we  in  the  East  look 
with  jealous  eye  at  our  fast  departing  preeminence.  No 
city  in  the  world  has  equalled  her  in  growth  and  pros- 
perity, and  none  give  greater  promise  for  the  future. 

As  a  center  for  ease  of  access,  or  for  rapid  distribution, 
Washington  offers  nothing  in  consideration.  Whatever 
else  may  be  said  of  medical  journalism  iu  common  with 
every  other  publication,  it  must  be  considered  as  a  busi- 
ness enterprise.  "Can  it  be  made  to  pay?"  was  the 
doubtful  question  asked  at  the  baptism  of  our  journal. 
"What  are  the  profits  already?"  is  the  query  meeting 
ever}  suggestion  for  improvement,  and  "is  it  possible  to 
defray  the  necessary  expenditure?"  The  income  of  The 
Journal  is  dependent  upon  two  factors,  the  subscription 
list  and  the  advertising  sheet.  Can  the  Trustees  show 
that  in  either  respect  the  iucome  is  likely  to  be  increased 
by  its  removal  to  Washington?  The  subscription  list 
will  depend,  in  a  very  large  degree,  upon  the  character 
of  The  Journal,  and  no  one  can  doubt  that  its  interest 
and  value  can  at  least  be  made  equal  in  its  present  loca- 
tion to  that  of  any  other.  I  do  not  suppose  that  any  one 
will  advance  the  argument  that  it  is  really  necessary  to 
remove  The  Journal  to  Washington  iu  order  to  provide 
for  it  a  competent  editor. 

It  is  equally  clear  that  The  Journal  can  be  pub- 
lished as  economically  in  Chicago  as  in  any  other  of  the 
great  centres  of  our  country. 

When  we  take  into  consideration  the  legitimate  in- 
come to  be  derived  from  the  advertising  department,  it 
requires  little  proof  for  the  demonstration  that  the  larger 
the  local  centre  from  which  a  journal  emanates,  the 
greater  is  the  value  of  that  journal  for  advertisers.  On 
this  account  our  journal  is  especially  fortunate  in  having 
its  home  in  Chicago,  and  we  cannot  help  thinking  that 
it  would  be  most  unfortunate  and  detrimental  to  its  in- 
terests to  remove  it  to  Washington. 

Boston,  New  York,  Philadelphia,  Baltimore,  Cincin- 
nati, Louisville,  Nashville,  St.  Louis,  each  have  their 
medical  weeklies  dependent  largely  upon  local  interests. 
Remove  our  journal  from  Chicago  and  the  field  will  be 
open  for  the  establishment  of  another  weekly  medical 
journal  dependent  in  a  large  degree  for  its  support  upon 
its  legitimate  advertising. 

Let  tin  business  interests  of  our  journal  continue  to  be 
transacted  upon  strictly  business  principles;  secure  for 
its  management  the  best  talent  to  be  obtained  and  trust 
the  future  for  its  greatly  increased  usefulness.  When 
the  time  comes  that  our  finances  will  warrant  the  ex- 
penditure of  a  large  sum  of  money  for  buildings  and  the 
accessories  for  .1  large  publication  house,  then,  and  not 
till  then,  let  the  Association  discuss  the  question  of  an 
elaborate  home.  For  the  present,  at  least,  our  Trustees 
have  more  vital  subjects  demanding  their  attention  in 
increasing  the  value  of  The  b  11  knai.  and  making  it  the 
worthy  repository  lor  the  Inst  medical  thought  and 
new   world. 

I  I  1  m;\    0.    Marcy,   M.D. 

ll6Boylston  st.,  Boston,  Mass., 
January  10,  1891, 


To  the  Editor: — Let  'I'm  J01  RN  \i.  remain  in  Chicago. 
11  is  certain  that  the  place  wherein  it  is  published  will 
largely  impress  its  own  character  upon  it.     'flu-  fact  that 


i89i.] 


SPECIAL  CORRESPONDENCE. 


i" 


-  is  11  ■  >t  only  IA«  geographic  and  railroad  ■ 

utry,    1  >iit   is  also    a  great  metropolis,    with    ini- 
i  mil   constantly  increasing  medical,  litei 

interests   springing    up  within    tl    and   flowing 
toward   it  from  all  parts  .>f  the  Union,  will  givi 

i  lat  and  high   profi  I  ii  >n,  that 

will  add  greatlj  to  its  power,  and  widen  its  infli 
ynuil  anything  that  co  be  hoped  for 

fixture  in  Washington. 

It   is  appropriate  that  the   representative   of  American 
medicine  should  have  its  home  in  the  representative  Am- 
erican city,  which  is  Chicago.     This  citi 
at  the  disposal  "f  the  management  a  wealth  of  resource 
second  to  but  one  in   this  if  not   now  will 

a  I"-  first  in  this  resjiect.     In   comparison  with 
this  anything  V  offer  would  seem 

poverty  stricken.  ARTHUR  YOUNG,  M.I>. 

PreSCOtt,  Wis.,  January.  1S9I. 


To  the  Editor: — As  an  old  member  of  the  Ass 
I  implore  all  those  who  are  in  fa\  val  to  let 

Tin:  \q\  rn  u.  remain  in  Chicago. 

D.  if  "i.YiN,  M.D. 

Civile.  X.  Y.,  Jan.  20,  1891. 


To  the  Editor: — As  the  question  of  the  removal  of 
The  Journal  to  Washington  seems  to  he  agitating  the 
subscribers  of  same  at  present.  1  would  join  my  voice 
with  those  wishing  it  to  remain  in  Chicago,  as  this  city- 
will  without  doubt  become  the  "centre"  of  the  North 
American  Continent  in  time. 

D.  1..  S  HJERHERING,   M.D. 

Wausau,  Wis..  Jan.  21,  1S91. 


To  the  Editor: — Please  record  my  vote  in  favor  of  con- 
tinuing the  publication  in  Chicago. 

Geo.  E.  Feu.,  M.D. 
Buffalo,  N.  Y.,  Jan.  21,  1891. 


To  the  Editor: — In  regard  to  removing  The  Journal 
to  Washington,  I  prefer  it  to  remain  in  Chicago,  and  be- 
lieve that  the  entire  membership  should  have  a  vote  when 
the  question  is  decided.  Frank  DeYilbiss.  M.D. 

Spring  Garden,  Mo.,  Jan.  24,  1 


To  the  Editor: — As  the  question  of  the  removal  of  The 
JOURNAL  from  Chicago  to  Washington  is  forced  upon  the 
members  of  the  Association,  it  is  clearly  plain  to  me  that 
Dr.  Dimmitt's  plan,  as  offered  in  The  Journal  of  Jan- 
nary  17,  is  the  only  safe  and  true  plan  of  procedure.  In 
this  manner  alone  can  all  the  members  have  a  voice  upon 
this  most  important  question;  audit  will  beat  the  Aus- 
tralian method  of  voting  altogether. 

In  my  opinion  The  Journal  should  remain  in  Chicago, 
where  it  is  now  prosperous  and  self  sustaining.  Certain- 
ly let  it  remain  where  it  is  long  enough  for  the  colored 
gentleman  now  in  the  woodpile  to  get  a  good  crop  of 
wool  on  his  head.  Herbert  Judd,  M.D. 

Galesburg,  111.,  Jan.  24,  1S9T. 


To  the  Editor: — Why  should  the  place  of  publication 
of  The  Journal  be  changed  to  Washington? 

What  reasons  have  we  to  suppose  its  financial  and  edi- 
torial success  would  be  more  certain  in  Washington  than 
at  Chicago? 

Why  should  the  list  of  subscribers  be  increased  because 
The  Journal  is  published  at  Washington? 

For  what  reasons  may  we  expect  more  business  sagaci- 
ty, and  greater  editorial  skill  in  its  management  at  Wash- 
ington, than  at  Chicago? 

These  are  practical  questions,  which  cannot  be  answer- 


ed by  assertions.     The  ,"■!>•;  Joiknai 

now,  and   a   certainty;   but   it 

rtainty;  but  only  ind 
tioiis  and  opini 

who  desire  it  cl  -hington.  wi. 

anteed  fund  oi  -  -.  there  will  be 

a  tang: 

As  a  purely  business  matti  innot  be 

provide 

this?     This  li  mall,  or 

very  sern  tertuine — but  who  will   take 

the  risk?  If  The  Journal  had  a  surplus  fund  ol 
it  could  insure  itself,  but  without  this,  who  will 
sponsible? 

The  JOURNAL   must   be   conducted   and   managed  the 
saine  as  any  other  business  en 

ciples.     All  charj  of  pub- 

.nciples, 
and  not  on  individual   opiuious  or  personal  preferences. 
What  all  members  of  the  Association  should  have  are 
positive  I  u.  will  be  more  prosperous 

in  Washington  than   at  present;    facts  beyond  all    reason- 
able question  or  doubt;  then  it  is  a  quest:    1 
not  of  prejudic 

When  such  evidences  are  presented  I  shall  vote  for  a 
s  a  duty.     But  until  they  are,  it  is  equally  my 
;ipose  any  change  that  has  not  the  best  of  busi- 
ness reasons  and  assurances  of  su< 

T.  D.  Crothers,  M.D. 
Hartford.  Conn. 


To  the  Editor: — The  question  of  the  place  of  publica- 
tion of  Tin:  Joiknai.  should  -  frankly,  with- 
mal  or  personal  prejudice,  and  with  reference  to 
these  two  considerations: 

1.  Where  can  T hi:  Journal,  other  things  being  equal, 
be  best  edited? 

2.  How  can   The  JOURNAL,  other  thing-,  being  equal, 

•  ve  the  highest  interests  of  the  A 
Taking  up  first  the  question  as  to  how  Tin;  Journal 
can  best  serve   the  interests  of  the  Association,  the   an- 
swer is; 

1.  By  not  identifying  itself  with  any  local  interest 
whatsoever. 

Upon  this  head,  one  needs  only  to  consult  the  files  to 
see  that  THE  JOURNAL  has  persistently  debased  itself  to 
the  level  of  a  local  Chicagoan  journal,  both  in  editorial  and 
news  columns.  Were  ii  to  do  the  same  thing  in  Wash- 
ington, Philadelphia.  New  York  or  Boston— or  any  other- 
where— it  would  be  equally  reprehensible. 

2.  By  presenting  the  best  work  of  the  best  men  in 
America  in  the  columns  devoted  to  original  communica- 
tions. 

Whosever  the  fault  may  be,  one  needs  only  to  consult 
the  tiles,  to  see  that  THE  JOURNAL  has  not  attracted  the 
best  work  of  the  best  men.  North.  South,  East  or  West. 
Undoubtedly  it  has  had  very  many  super: 
very  many  superior  men — but  the  proportion  of  such  pa- 
per's has  never  been  what  it  ought  to  be  in  The  Journal 
of  the  American  Medical  Association— an 
tion  which  numbers  among  its  members  "the  best  men 
in  America." 

3.  Bv  rejecting  papers  which  fail  to  come  up  to  the 
high  standard  of  a  leading  medical  journal. 

eds  only  to  consul',  the  files  to  see  papers  which 
present  nothing  new  and  nothing  useful,  and  do  it  in  a 
very  tedious  manner.  No  questions  of  policy  should  per- 
mit the  entrance  of  one  such  paper  into  the  columns  of 
The  Journal,  which  stands  as  the  representative  of  the 
thought  and  knowledge  of  the  physicians  of  America. 
us  should  read  such  a  paper  at  a  meeting,  the 
editors  should  be  empowered  to  suppress  it,  or  at  least  to 
present  it  in  abstract  onlv. 

4.  Bv  presenting  full,  concise,  well-edited  abstracts  of 
the  important  communications  in  other  journals,  Ameri- 


i7S 


NECROLOGY. 


[January  31, 


can  and  foreign;  which  abstracts  should  be  specially  pre- 
pared by  competent  men,  and  should  be  reasonably  timely 
in  their  appearance.  Nonsensical  and  worthless  commu- 
nications to  other  journals  should  not  be  quoted. 

One  has  only  to  consult  the  files  to  see  that  The  Jour- 
nal has  from  the  first  been  lamentably  weak  in  this 
department.  Latterly  there  has  been  improvement,  but 
even  now  the  majority  of  the  abstracts  are  second-hand 
or  even  third-  and  fourth  hand — and  ridiculously  inade- 
quate. 

5.  By  presenting  well-informed  and  thoughtful  edito- 
rial comment  upon  questions  of  importance. 

This  is  and  always  has  been  the  strongest  feature  of 
The  Journal  as  at  present  conducted. 

Summing  up,  then,  we  find  that  in  its  present  location 
The  Journal  has  not  been  best  edited. 

Would  removal  improve  matters  ?  It  seems  to  me  that 
it  would  for  the  following  reasons: 

1.  Washington  is  the  National  Capital.  It  belongs  to 
all  sections  alike,  and  the  temptation  to  debase  The 
Journal  into  a  local  organ  would  not  exist. 

2.  At  Washington  the  treasures  of  the  Surgeon-Gen- 
eral's Library  and  the  National  Museum  would  be  at  the 
disposal  of  the  editorial  staff.  This  inestimable  advantage 
to  competent  editors  exists  nowhere  else. 

3.  At  and  near  Washington  are  many  of  the  best 
equipped  students  and  investigators  who  could  be  called 
upon  for  special  assistance  when  necessary,  and  who 
would  have,  as  already  stated,  the  proper  facilities  for 
rendering  valuable  assistance. 

4  As  soon  as  the  best  men  saw  that  the  editorial  status 
of  The  Ji  tURNAL  was  raised  they  would  be  only  too  glad 
to  have  their  best  work  appear  in  its  columns.  North. 
South,  East  and  West  would  alike  contribute,  and  North, 
South,  East  and  West  would  alike  subscribe.  Increased 
revenue  would  mean  ability  to  improve  still  further. 

5.  Only  by  concentration  can  the  best  work  be  done. 
America  must  have  a  scientific  centre.  Let  New  York, 
Philadelphia,  Chicago  and  other  local  centres  improve 
themselves  to  the  highest  point  possible  for  local  centres 
— and  all  unite  to  improve  to  the  utmost  the  one  National 
centre — Washington. 

Finally  as  the  defects  in  The  Journal  1  which  are  not 
now  mentioned  for  the  first  time,  but  have  been  forcibly 
shown  year  after  year  by  at  least  one  Western  physician  of 
deserved  eminence,  Prof.  Comegys  of  Cincinnati  I — as  these 
defects  are  not  due  to  the  personnel  of  the  editorial  staff 
[which  could  not  be  better)  they  must  be  due  to  restric- 
tions imposed  upon  the  editors  by  the  locality.  These 
restrictions  would  be  equally  great  at  New  York,  Phila- 
delphia, Boston  or  Baltimore,  as  at  Chicago.  They 
would  not  exist  at  Washington.  With  equally  good 
unhampered  by  locality,  The  Journal  would 
soon  be  what  it  ought  to  be. 

In  this  very  frank  communication,  I  have  had  no  desire 
to  reflect  in  any  way  upon  the  able  editorial  staff,  for  I 
must  admit  that  with  the  limitations  imposed  upon  them, 
they  have  done  much  better  than  any  one  had  the  right 
to  expert.  Solomon  Solis-Cohen,  M.D. 

Philadelphia,  Jan.  26,  1891. 


NECROLOGY. 


Dr.  Friedkich  Sai.zer,  of  the  Vienna  School, 
died  suddenly  November  30,  at  the  age  of  63 
years.  For  twenty  years  he  had  been  one  of  the 
professors  of  surgery,  and  in  recent  years  had 
been  chief  of  the  second  division  of  the  AJlgemeine 
Krankenhaus  to  which  institution  the  death  of 
Dr.  Salzer  will  be  a  heavy  loss.     He  was  one  of 


those  fortunate  men  in  whom  a  consummate  sur- 
gical skill  was  joined  to  a  remarkable  success  in 
the  results  of  his  operations,  a  conjunction  that  is 
by  no  means  always  present  among  those  who 
wield  the  knife.  Salzer  did  not  have  the  same 
facility  with  the  pen  as  with  the  scalpel,  and  con- 
tributed comparatively  little  to  surgical  literature. 
One  of  his  sons,  Dr.  Fritz  Salzer,  is  at  the  present 
time  professor  of  surgery  at  the  University  of 
Utrecht. 

Dr.  John  Davis,  of  Cincinnati,  died  Decem- 
ber 25,  aged  sixty-six  years.  He  was  a  graduate 
of  the  Medical  College  of  Ohio  in  1843.  He  was 
prominent  in  public  affairs  in  his  city,  having 
been  until  quite  recently  president  of  the  law  and 
order  league. 

Mr.  Hugh  Owen  Thomas,  the  surgeon  of 
Liverpool,  died  January  6,  1891.  He  was  an  or- 
thopaedist of  the  first  rank,  whose  writings  and 
appliances  have  long  been  known  in  every  quar- 
ter of  the  civilized  world.  In  recognition  of  the 
value  of  his  accomplishments  in  his  difficult  spe- 
cialty he  was  elected  an  honorary  member  of  the 
American  Orthopaedic  Association  in  September 
last. 

Surgeon  Henry  M.  Martin,  U.  S.  N.,  died  in 
Philadelphia  Jan.  16.  He  was  commissioned  assist- 
ant surgeon  March  21, 1 870,  and  made  his  first  cruise 
in  the  West  Indies  in  the  Congress.  He  served  in 
the  Nantasket  and  the  Colorado  on  the  North  At- 
lantic station,  i87ito  1873,  was  promoted  to  passed 
assistant  surgeon  in  June,  1874;  served  in  the 
Alert,  Asiatic  station,  1875  to  1878,  and  in  the 
Brooklyn,  South  Atlantic  station,  1881  to  1884,. 
and  was  promoted  to  surgeon  in  April,  1884. 
His  last  cruise  was  in  the  Swatara,  Asiatic  sta- 
tion, 1887  to  1890,  from  which  ship  he  recently 
returned  in  ill  health  and  was  placed  on  the  re- 
tired list. 

Dr.  Alexander  T.  Augusta,  who  died  in 
Washington,  D.  C,  December  21,  was  a  native 
of  Pennsylvania,  and  a  graduate  in  1856  of  the 
Trinity  Medical  College,  Toronto,  Canada.  He 
was  the  only  one  of  his  race  during  the  Civil 
War  who  received  a  commisson  as  surgeon,  his 
command  being  the  Seventh  U.  S.  Colored  In- 
fantry, which  was  organized  at  Baltimore,  Md., 
to  serve  three  years.  He,  among  numerous  offi- 
cers who  had  distinguished  themselves,  received 
a  brevet  March  13,  1865 — in  his  case  that  of 
Lieut. -Colonel,  and  at  once  devoted  himself  to 
the  duties  of  his  profession. 

Dr.  Charles  A.  Miller,  who  received  his 
degree  from  the  Medical  College  of  Ohio,  in  1862, 
and  who  was  mustered  out  of  the  U.  S.  Service 
on  expiration  of  term  of  service  September  13, 
1864,  as  Assistant  Surgeon  of  the  34th  Ohi'>  Vol. 
Infantry,    died   November   21    at  the   Longview 


i89i.] 


BOOK  REVIEWS. 


179 


Asylum  for  the  Insane,  near  Cincinnati,  O.  He 
was  born  in  Hamilton  County,  Ohio,  and  edu- 
cated in  Cincinnati,  where  he  engaged  in 
practice, soon  after  the  war,  and  there  remained  until 
appointed  Superintendent  oftheLongview  Asylum 
nine  years  ago.  Dr.  Miller  was  a  naturalist  of  na- 
tional reputation  and  had  one  of  the  finest  geo- 
logical cabinets  in  the  country.  He  had  been 
long  in  poor  health,  suffering  mainly  from  dia- 
betes, to  which  was  added  a  gangrenous  condi- 
tion of  one  foot.  From  this  latter  complication 
he  recovered,  but  without  benefit  to  his  general 
■constitution. 

Dr.  James  L.  Stewart,  of  Erie,  died  Decem- 
ber 7,  aged  65  years.  He  was  of  Scotch- Irish 
descent  and  born  near  Pittsburg.  He  graduated 
from  the  University  of  Pennsylvania  in  1848,  and 
went  to  Erie  just  forty  years  ago.  During  the 
late  war  he  served  four  years  as  a  surgeon  of  vol- 
unteers, having  charge  during  a  portion  of  that 
time  of  one  of  the  large  army  hospitals  near 
Washington.  He  was  prominent  in  pension  mat- 
ters for  niauy  years  and  in  many  societies,  both 
medical  and  charitable.  He  was  repeatedly  the 
president  of  the  medical  organization  of  his 
county  and  of  the  State  Medical  Society  in  1879. 
He  was  chief  surgeon  of  the  St.  Vincent's  Hos- 
pital and  of  the  county  correctional  buildings. 
Surgery  was  his  favorite  field  of  practice,  in  which 
he  did  some  notable  work,  especially  in  the  ex- 
section  of  nerves. 

Dr.  Henry  Salyin  Gill,  born  in  Allston, 
England,  38  years  ago,  died  in  New  York  of 
pneumonia,  January  16.  He  was  a  graduate  of 
the  University  of  Edinburgh  and  of  the  College 
of  Physicians  and  Surgeons.  X.  V.  He  was  a 
cousin  of  the  Archbishop  of  York. 

Dr.  Joshua  Kendall,  of  Seymour,  Conn., 
died  at  his  home  January*  19,  at  the  age  of  84.  He 
settled  in  Seymour  in  1832  immediately  after  his 
graduation  from  the  Castleton  Medical  College, 
Yt,  and  resided  there  ever  since.  He  was  one 
of  the  best  known  men  in  the  county.  His  death 
was  the  result  of  an  operation  for  the  removal  of 
cancer. 

Dr.  Joseph  Parrish,  of  Burlington,  X.  J., 
died  on  January  15.  He  was  a  son  of  the  cele- 
brated Dr.  Joseph  Parrish,  of  Philadelphia,  and 
graduated  at  the  University  of  Pennsylvania  in 
1844.  He  organized  the  Pennsylvania  Sanitar- 
ium for  the  Cure  of  the  Inebriates,  located  at 
Media,  and  was  also  at  the  head  of  a  similar  in- 
stitution in  Burlington.  He  was  the  founder  of  the 
American  Association  for  the  Study  and  Cure  of 
Inebriety,  established  in  1870,  which  awakened 
interest  in  England,  and  in  1872  a  committee  of 
the  Houses  of  Parliament  was  appointed  to  inves- 
tigate the  subject,  and  Dr.  Parrish,   and  the  late 


Dr.  Dodge,  of  Xew  York,  were  summoned  to  ap- 
pear and  testify  as  to  their  knowledge  of  the  treat- 
ment of  inebriates.  He  was  a  member  of  the 
American  Medical  Association  since  1847. 


BOOK  REVIEWS. 


Epilepsy  :  Its  Pathology  and  Treatment. 
Being  an  Essay  to  which  was  awarded  a  prize 
of  four  thousand  francs  by  the  Academic  R03'- 
ale  de  Medecine  de  Belgique,  December,  1889. 
By  Hobart  Amory  Hare,  M.D.,  etc.  Phil- 
adelphia and  London  :  F.  A.  Davis.  1890. 
Pp.  228.     51.25. 

This  little  volume  is  Xo.  7  of  the  Physicians 
and  Students  Reference  Series,  and  is  well  de- 
serving of  the  prize  accorded  it.  The  author  dis- 
plays a  fair  and  judicial  spirit  in  treating  the 
many  conflicting  opinions  and  theories  which 
confront  a  consideration  of  the  subject  and  from 
an  enormous  mass  of  literature  has  gotten  that 
which  is  most  reliable  and  of  practical  value.  To 
anyone  having  the  management  of  a  single  case 
of  epilepsy  this  monograph  would  be  invaluable. 

The  International  Medical  Annual  and 
Practitioner's  Index  for  1890.  Edited  by 
PAY. Williams, M.D.,  Secretary  of  Staff,  assisted 
by  a  corps  of  thirty-six  collaborators — Euro- 
pean and  American — specialists  in  their  several 
departments.  600  octavo  pages.  Illustrated. 
S2.75.  E.  B.  Treat,  Publisher,  ,5  Cooper  Un- 
ion, Xew  York. 

The  eighth  yearly  issue  of  this  handy  reference 
one- volume  manual  is  at  hand.  In  its  Alphabet- 
ical Index  of  Xew  Remedies  and  its  Dictionary 
of  New  Treatment  it  richly  deserves  and  perpet- 
uates the  well- earned  reputation  of  its  predeces- 
sors. In  this  volume  its  corps  of  department  ed- 
itors has  been  largely  increased,  and  important 
papers  upon  Thermo-Therapeutics,  Electro-Ther- 
apeutics, Sanitary  Science  in  city  and  country, 
and  the  Medical  Examiner  in  Life  Insurance  are 
features  of  special  interest.  It  is  truly  a  helpful 
volume,  a  risiimS  of  the  year's  progress  in  medi- 
cine, keeping  the  busy  practitioner  abreast  of  the 
times  with  reference  to  the  medical  literature  of 
the  world.  While  there  is  a  generous  increase  in 
size  and  material,  the  price  remains  the  same, 
S2.75. 

A  Practical  Treatise  on  Impotence,  Steril- 
ity and  Allied  Disorders  of  the  Male 
Sexual  Organs.  By  Samuel  \V.  Gross, 
A.M.,  M.D.,  etc.  Fourth  edition.  Revised 
by  F.  R.  Sturgis,  M.D.  Philadelphia:  Lee 
Brothers  &  Co.  1890.  8vo,  pp.  173.  >i-5°- 
The  subject  matter  of  this  small  volume,   so 

generally  neglected  or    not  even   mentioned  by 


i8o 


MISCELLANY. 


[January  31,  1891. 


medical  teachers  and  writers  is  carefully,  plainly 
and  suitably  handled  by  the  author.  The  chap- 
ters are  on  Impotence,  Sterility,  Spermatorrhoea 
and  Prostatorrhcea  respectively,  embracing  many 
clinical  reports  which  give  vitality  to  the  work. 
The  statement  is  made  that  of  barren  marriages 
one  in  six  is  due  to  sterility  on  the  part  of  the 
husband,  an  opinion  amply  sustained  elsewhere, 
the  importance  of  which  'is  self  evident.  It  is 
possible  that  undue  weight  is  attached  to  irritable 
and  sensitive  conditions  of  the  deep  urethra 
which,  in  the  author's  experience,  are  almost  in- 
variably found,  and  to  the  correction  of  which 
his  energy  is  always  primarily  directed.  The 
book  is  heartily  commended  to  all  and  without 
doubt  deserves  the  popularity  which  has  pro- 
duced a  fourth  edition  in  so  short  a  time. 

Irregularities  of  the  Teeth   and   their 
Treatment.     By  Eugene  S.  Talbot,  M.D., 
D.D.S.,    etc.      Second   edition.     Revised    and 
Enlarged  with  234  Illustrations,  169  of  which 
are  original.     Philadelphia:  P.  Blakiston,  Son 
&  Co.,- 1890.     Pp.261.     $3.00. 
When  a  technical  work  goes  to  the  seeond  edition 
its  value  cannot  be  disputed.     The  book  is  got- 
ten up  in  an  excellent  form  and  the  author  writes 
in  a  smooth,  clear  style  that  is  often  sought  in  vain 
in  dental  writings.  The  present  volume  is  in  num- 
ber of  pages  nearly  twice  as  large  as  the  first  edi- 
tion and  divided  into  Part  I  Etiology,  and  Part 
II  Treatment.     It  is  readily  to  be  seen  that  "con- 
stitution causes  for  irregularities  of  the  teeth"  is 
the  writer's  hobby,  and  to  it  he  devotes  eighty- 
six  pages,  presenting  in  an  interesting  and  read- 
able way  a  mass  of  data  from   a  wide  variety  of 
sources.       Consanguinity,  maternal    impressions 
and  some  kindred  topics  are  made  to  give  sup- 
port to  his  theories  in  a  way  that  the  unsettled 
state  of  knowledge  regarding  them  scarcely  war- 
rants, and  the  allegation  that  advanced  civiliza- 
tion is  largely  responsible  for  dental  malformations 
seems  open   to  debate.      The  chapters  on  treat- 
ment contain  practical  and  well  illustrated  direc- 
tions that  can  not  fail  of  proper  appreciation  by 
practicing  dentists. 


ing  officer  of  the  troops  there  stationed,  and  will  then 
return  to  New  York  City  and  resume  his  leave  of  ab 
sence.  By  direction  of  the  Secretary  of  War.  Par  9 
S.  O.  17,  A.  G.  O.,  Washington,  January  21,  1S91. 

Official  List  of  Changes  in  the  Medical  Corps  of  the  U.  S 
Navy  for  the  Week  Ending  fanuary  24,  i8gi. 

Surgeon  R.  C.   Persons,  ordered  to  the  U.  S.  S.   "Con- 
cord "  February  10. 


LETTERS  RECEIVED. 
J.  W.  Raeder,  Wilkesba 


Iir    I. 


',  Ky. 
Dak. 
Trowbridge,  Parke 


Davis  &  Co.,  Detroit, 


MISCELLANY. 


Official  List  of  Changes  in  the  Stations  and  Duties  of 
Officers  Serving  in  the  Medical  Department^  I'.  S. 
Army,  front  fanuary  //,  1S91,  to  fanuary  2j,  1891. 

Capt.  Edwin  F.  Gardner,  Asst.  Surgeon,  is  relieved  from 
duty  at  Pine  Ridge  Agency,  S.  Dak.,  and  will  proceed 
without  delaj  t<>  Ft.  Riley,  Kan.,  and  report  for  tem- 
porary duty  t"  the  commanding  officer  of  that  post. 
By  direction  of  the  Secretary  of  War.  Par.  10,  S.  O. 
17,  A.  G.  O.,  Washington,  January  21,  [891, 

Capt.  Francis  J.  tves,  Asst.  Surgeon,  is  relieved  from  tem- 
porary dutj  at  Pine  Ridgi  Vgency,  S.  Dak.,  to  take  ef- 
fect when  his  services  can  be  spared  by  the  connnand- 


Seargent,  Hopkinsvil 
C.  Neer,  Park  Ridge,  N.  J. 
i   Spooner,  Lake  Preston,  i 
J.  Tidd.  Clark  P.  O.. 
Dr.  E.  P.  Noel,  L.  S. 

Dr   H.  Haberlin,  Roberts  &  Allison,  Indianapolis,  Ind. 

Dr.  L.  A.  W.  Alleman,  Long  Island  College  Hospital,  Brooklyn, 
N    Y 

Dr  A  L.  Hummel,  Hance  Bros.  &  White,  Dr.  R.  J.  Dunghson, 
Dr.  B.  Alex.  Randall,  Dr.  W.  B.  Atkinson,  P.  Blakiston,  Son  &  Co., 
Philadelphia,  Pa. 

Chicago  Evening  Journal,  Dr.  C.  T.  Parkes,  Dr.  F.  H.  Martin. 
Chicago  Public  Library.  W.  T.  Keener.  Dr.  H.  Harmes,  Dr.  J.  C. 
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in    1     . ,    cannadav,  Roanoke  City,  Va. 

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ii,.    i      ..  la  i  i  i  ,i  ,  Dayton,  0. 
In     |    11    Andr 


W.  G 
Iir.  II    K.Tcfl 
in    E   Paul  Si 
!•   E  Tarb  1,  Fail  hi 
ihes  &  Co 
:i,    i    i     sundberg 
Iir.  Robt.  McC.  1 
in    E.  C.  Kinnej 


Musk 
pek  i 


x. 


.  Mich. 


CUV,  Wo 
.  W.  Va. 


Dr.  I    II    in'  1-   Camden,  N 

Dr.  C.  L.  Humphi 

n,    11   judd   Galesburg    in 


T  1 1  E 


Journal  of  the  American  Medical  Association. 

EDITED  UNDER  THE  DIRECTION  OF  THE  BOARD  OF  TRUSTEES. 

IT  BLISH  E  I)    WEEKLY. 


Vol.  XVI. 


CHICAGO,  FEBRUARY  7,   1891. 


No  6. 


ORIGINAL  ARTICLES. 


A  STUDY  OF  STERILITY,  ITS  CAUSES 
AND  TREATMENT. 

Bring  tin  Essay  -which  received  the  First  Put,-  of  the  Alumni  Associ- 
ation of  the  College  of  Physicians  and  Surgeons,  Baltimore. 

.  BY  THOS.  W.  KAY,   M.D., 

OF  SCRANTON,  PA. 

INTRODUCTORY. 

General  Remarks. — "  Be  fruitful,  and  multiply, 
and  replenish  the  earth,"  was  the  first  command 
given  to  man,  and  it  is  as  binding  today  as  it 
was  at  the  close  of  the  creation,  for  a  neglect  of 
its  fulfilment  necessarily  implies  an  extinction  of 
the  species.  It  is  the  desire,  unconscious  it  may 
be,  to  fulfil  this  command  that  prompts  man  to 
seek  the  society  of  woman.  The  late  Dr.  Carpen- 
ter, of  England,  says  "love"  is  based  on  the 
innate  desire  for  offspring.  This  fact  was  recog- 
nized as  early  as  the  time  of  Soranus,  who  says, 
"As  most  marriages  are  not  contracted  for  love, 
but  to  beget  offspring,  it  is  unwise,  in  the  choice 
of  a  wife,  to  consider  her  social  standing  and 
riches  ratherthan  her  fitness  for  bearing  children." 

Sterility  is  one  of  the  most  potent  factors  in 
producing  domestic  unhappiness,  and  was  so  as 
long  ago  as  the  time  of  Abraham,  when,  having 
begotten  a  child  by  Hagar,  Sarai  "was  despised 
in  her  eyes  "   because  of  her  unfruitfulness. 

Historical. — Though  Jacob  loved  Rachel  better 
than  Leah,  he  turned  his  affection  to  his  less 
comely  wife  after  she  had  borne  him  a  son.  After 
having  brought  forth  several  children,  Leah  ex- 
claims :  "  Happy  am  I,  for  the  daughters  of  men 
will  call  me  blessed.  God  hath  endowed  me  with 
a  good  dowry,  for  I  have  borne  him  six  sons." 
The  barren  Rachel,  feeling  keenly  her  disgrace, 
cries  in  her  anguish,  "Give  me  children  or  I 
die,"  after  which  we  are  told  that  "  the  Lord  saw 
that  she  was  hated  and  opened  her  womb." 
Among  the  ancient  Greeks,  as  among  the  Jews, 
sterility  was  considered  a  disgrace,  and  was  a  fre- 
quent cause  for  divorce,  the  unfortunate  woman 
being  looked  upon  as  a  lower,  or  imperfectly  de- 
veloped, being.  Travelers,  among  the  inhabi- 
tants of  nearly  all  uncivilized  countries,  remark 
that  the  pregnant  women  take  pains  to  show,  and 


frequently  point  with  pride-  to,  their  enlarged  ab- 
domens.  In  Angola,  says  Livingstone,  sterility 
is  such  a  disgrace  and  such  a  cause  for  ridicule, 
that  the  unfortunate  women  are  frequently  driven 
to  suicide.  Pallas  states  that  the  well- to  do  Cir- 
cassians give  a  dowry  to  their  daughters  only 
after  they  have  proved  themselves  fruitful. 

Among  the  Moslem  inhabitants  of  Turkey,  di- 
vorces are  very  common,  and  in  most  cases  steril- 
ity is  found  to  be  the  cause.  It  is  from  the  ranks 
of  these  unfortunates  that  the  native  prostitutes 
are  obtained. 

Sterility  and  fecundity  were  frequent  themes 
for  the  ancient  historians  and  poets.  In  the  Sus- 
ruta,  a  book  of  ancient  India,  conception  is  said  to 
"  take  place  easiest  at  the  menstrual  period,  for  at 
this  time  the  mouth  of  the  womb  is  opened  like 
the  blossom  of  the  water-lily  in  the  sunshine." 
In  the  Bible  we  find  sterility  frequently  mention- 
ed, and  examples  of  it  are  recorded,  with  remedies 
for  its  relief.  The  Talmud  also  makes  man}'  al- 
lusions to  it  and  its  remedies.  Sterility  is  fre- 
quently mentioned,  and  discussed  at  some  length, 
in  the  works  of  Hippocrates.  Celsus,  Pliny  and 
Aristotle  also  devote  some  space  to  it,  but  enter 
into  the  subject  less  fully  than  Hippocrates.  Pau- 
lus  Agineta  has  much  to  say  on  the  subject,  and 
devotes  some  space  to  the  subject  of  diseases  of 
the  female  organs  of  generation.  From  the  works 
of  Maimonides,  we  know  that  the  subject  was  fre- 
quently mentioned  in  the  writings  of  the  Arabs. 

We  see,  then,  the  importance  that  has  been  at- 
tached to  it  from  the  earliest  times  to  the  Middle- 
Ages,  and  from  that  time  to  the  present  the  ques- 
tion has  been  gaining  in  weight. 

But  what  is  it  ? 

Definition. — The  term  "sterility"  is  applied  to 
both  the  male  and  the  female,  and  must  not  be 
confounded  with  impotence,  which  indicates  a 
physical  inability  on  the  part  of  the  male  to  ful- 
fil the  marital  rights. 

Sterility  may  be  congenital,  where  the  woman, 
after  reaching  the  age  of  puberty,  has  maintained 
the  marital  relations  for  three  years  without  be- 
coming pregnant ;  or  acquired,  where,  after  hav- 
ing borne  one  or  more  children,  she  remains  three 
years,  while  subject  to  intercourse,  without  re- 
j  conceiving.  By  some  the  term  has,  in  a  wider 
sense,  been  applied  to  all  who,  though  becoming 


182 


A  STUDY  OF  STERILITY. 


[  February  7, 


pregnant,  are  unable  to  bring  forth  a  healthy  liv- 
ing child. 

Some  English  writers  use  the  term  ' '  only  child 
sterility  "  to  designate  sterility  acquired  after  the 
first  birth. 

In  very  few  fruitful  marriages  is  the  first  birth 
postponed  later  than  the  third  year.  Kisch  col- 
lected the  histories  of  556  fruitful  marriages  and 
found  that,  in  156  of  these,  the  first  birth  occurred 
in  ten  months  after  marriage;  in  199,  it  occurred! 
between  the  eleventh  and  fifteenth  months ;  in 
115,  between  the  sixteenth  and  twenty-fourth 
months ;  in  60,  between  the  twenty-fourth  and 
thirty-sixth  months;  and  in  onl\  26,  or  2.6  per 
cent.,  did  it  occur  after  the  third  year.  Duncan 
gives  seventeen  months  as  the  average  time  be- 
tween marriage  and  the  first  birth  for  the  women 
of  Edinburgh  and  Glasgow.  Ansell  places  it  at 
sixteen  months,  and  finds  that  less  than  5  per 
cent,  bear  their  first  child  after  the  third  year. 
The  justice,  then,  of  classing  those  women  as 
sterile  who  have  not  become  pregnant  during  the 
first  three  years  of  married  life,  is  apparent. 

It  may  also  be  remarked,  from  the  above  sta- 
tistics, that  impregnation  at  the  first  approach  of 
the  male,  the  rule  in  brutes,  is  the  exception  in 
man. 

Frequency. — The  frequency  of  sterility  is  much 
greater  than  it  is  generally  supposed  to  be.  Of 
495  marriages  among  the  English  aristocracy, 
Simpson  found  81,  or  about  16  per  cent.,  sterile. 
Kisch  inquired  into  the  histories  of  626  marriages 
among  the  royalty  and  highest  classes  of  Europe, 
and  found  sterility  in  70,  or  nearly  12  per  cent. 
The  figures  for  England  are  large  because  of  the 
necessity,  among  the  nobility,  of  marrying  near 
relatives.  Ansell,  Sims,  Simpson  and  Wells  place 
the  general  average  of  sterility,  for  marriages  in 
all  classes,  at  about  12.5  per  cent.  Hedin  thinks 
this  too  high  for  Sweden,  where  he  claims  only 
one-tenth  of  the  marriages  are  sterile. 

Griinewaldt  has  collected  some  very  interesting 
statistics  on  this  subject.  After  excluding,  from 
1,500  women  suffering  from  uterine  diseases,  all 
virgins,  widows,  and  those  over  35  years  of  age, 
there  remained  900  married  women,  of  whom  500 
were  sterile.  In  about  200  of  these  the  sterility 
was  congenital,  while  it  was  acquired  in  the  re- 
maining 300.  This  gives  uterine  disease  as  the 
cause  of  60  per  cent,  of  the  cases  of  sterility,  and 
one  of  every  three  m  arried  women,  who  suffer 
from  uterine  disease,  will  become  sterile. 

One  must  not  always  look  for  the  causes  of 
sterility  in  the  female,  for,  as  has  frequently  been 
the  experience  with  all  gynecologists,  after  hav- 
ing subjected  the  female  to  a  long  course  of  treat- 
ment, the  male  has  been  found  to  be  the  one  at 
fault.  Of  40  unfruitful  marriages,  Kehrer  found 
the  man  at  fault  in  16,  or  about  35  per  cent.,  and 
he  claims  that  in  a  still  larger  per  cent,  the  male 
is  the  indirect  cause  by  transmitting  the  gonor- 1 


rhceal  or  syphilitic  poison  to  the  female,  thus  set- 
ting up  changes  which  militate  against  conception. 

Courty  gives  the  relative  frequency  of  the  seat 
of  the  causes  of  sterility  in  the  male  and  female 
as  1:10,  Duncan  gives  it  as  1  :  8,  and  Noegge- 
rath  places  it  as  high  as  8  :  14. 

Fatal  Development  of  Genital  Organs. — To  un- 
derstand fully  the  causes  and  treatment  of  steril- 
ily,  it  is  necessary  to  have,  at  least,  a  rudimentary 
knowledge  of  the  development  of  the  organs  of 
generation.  About  the  end  of  the  third  week, 
after  the  ovum  becomes  impregnated,  the  allantois 
begins  to  develop,  and  communicates,  by  the  ura- 
chus,  with  the  primitive  intestine.  As  the  sixth 
week  approaches,  the  urachus  dilates  in  its  lower 
portion,  so  as  to  form  the  bladder,  which  commu- 
nicates with  the  rectum  by  a  canal — the  future 
urethra.  The  Wolffian  bodies  are  found,  as  early 
as  the  third  week,  on  either  side  of  the  primitive 
vertebrae.  At  first  they  act  as  primitive  kidneys, 
their  ducts  emptying  into  the  bladder,  but  later 
on  they  disappear,  with  the  exception  of  a  small 
portion  of  each,  which  can  be  seen,  between  the 
ovaries  and  Fallopian  tubes,  as  the  organs  of  Ro- 
senmiiller.  Between  the  fifth  and  sixth  weeks, 
two  small  glandular  bodies,  formed  from  the  ger- 
minal epithelium,  begin  to  make  their  appearance 
to  the  inner  side  of  the  Wolffian  bodies.  These 
are  the  genital  glands,  and  they  are  covered  by 
the  peritoneum  which  attaches  them,  as  a  mesen- 
tery, to  the  Wolffian  bodies.  With  time,  the  gen- 
ital glands  develop,  and  at  the  end  of  the  sixth 
week  they  can  be  recognized  as  ovaries.  They 
remain,  however,  in  the  abdominal  cavity  till  the 
ninth  month,  when  they  descend  into  the  pelvis. 
Developing  contemporaneously  with  the  ovaries, 
we  find  the  conduits  of  Miiller,  situated  in  front 
of  and  to  the  inner  side  of  the  Wolffian  ducts. 
It  is  from  the  upper  portions  of  these  conduits, 
extending  from  their  superior  closed  extremities 
to  that  point  where  the  lumbar  ligament  is  at- 
tached to  the  Wolffian  bodies,  that  the  Fallopian 
tubes  are  formed.  In  their  lower  portions  the 
conduits  of  Miiller  unite,  in  a  common  body,  with 
the  Wolffian  ducts,  to  form  the  genital  cord,  in 
which  the  conduits  of  Miiller  are  situated,  to  the 
rear  and  separated  from  each  other  by  a  partition. 

The  absorption  of  this  partition  forms  the  ute- 
ro-vaginal  canal,  in  which,  until  about  the  fifth 
month,  no  distinction  can  be  made  between  the 
uterus  and  vagina.  It  is  from  those  parts  of  the 
conduits  of  Miiller,  situated  between  the  genital 
cord  and  the  lumbar  ligament,  that  the  cornua  of 
the  uterus  are  formed.  At  first  there  is  no  lower, 
external,  opening  to  the  intestine,  but  gradually 
an  involution  of  the  epithelium  dips  down,  and, 
about  the  fourth  week,  the  septum  disappears. 
At  this  time  the  intestine,  behind,  and  the  ura- 
chus, in  front,  open  into  the  common  cloaca. 
About  the  sixth  week,  a  transverse  septum  is 
formed  across  the  cloaca,  dividing  it  into  the  rec- 


I89i.] 


A  STUDY  OF  STERILITY. 


183 


turn,   posteriorly,   and   the   urogenital    opening, 

anteriorly.     The    upper  portion   of  the    bladder 

the  two  ureters,  while  the  conduits  of 

Miiller   and   the  duefs  of  Wolff  empty  into  its 

lower    portion.      That     portion    situated    between 

the  openings  of  the  four  ducts  and  the  point 
where  the  bladder  empties  into  the  cloaca  is  the 
uro-genital  sinus,  which  forms  the  vestibule  of 
the  \  agina.  At  the  junction  of  the  vestibule  and 
the  vagina,  a  fold  of  mucous  membrane — the  hy- 
men— is  finally  formed,  which,  partially  or  whol- 
h  ,  i  loses  the  opening  to  the  vagina.  From  these 
foetal  parts  all  the  organs  of  reproduction  of  the 
female  are  developed,  and,  bearing  them  in  mind, 
it  will  be  easy  to  account  for  all  malformations  of 
the  female  genitals,  a  common  cause  of  sterility. 

Ovulation. — No  organs  of  the  body  exert  as 
great  an  influence  over  physical  development  as 
the  ovaries.  At  birth  they  are  small,  smooth 
and  flat,  but  as  age  advances  they  enlarge,  and 
become  oval  and  tense.  This  is  in  large  part 
due  to  the  increase  in  size  and  approach  to  the 
surface  of  the  Graafian  follicles,  to  allow  their 
easy  rupture  for  the  discharge  of  the  ova — ovu- 
lation. 

Menstruation.  —  Menstruation  usually  begins 
about  the  same  time  and  accompanies  ovulation 
throughout  the  child-bearing  period.  It  consists 
of  a  discharge  of  blood  and  detritus,  which  comes 
from  the  uterus,  and  is  probably  due  to  a  disinte- 
gration of  the  uterine  mucous  membrane,  prepar- 
atory for  the  implantation  of  the  ovum. 

After  ovulation  has  been  established,  the  ova- 
ries assume  a  nodular  appearance  due  to  cicatri- 
ces left  after  the  discharge  of  the  ova,  and  this 
condition  remains  till  late  in  life,  when  they  atro- 
phy and  present  the  appearance  of  short  and 
thickened  bands. 

Puberty. — As  the  time  for  the  first  menstiual 
period  approaches  we  find  the  breasts  enlarging, 
the  nipples  becoming  more  prominent,  the  vagina 
growing  more  roomy,  and  the  uterus  increasing 
in  size.  The  pelvis  broadens  out,  the  hips  and 
thighs  increase  in  size  and  become  rounder,  and 
hair  begins  to  make  its  appearance  011  the  pubes. 
This  is  pubert)',  which  indicates  the  time  about 
which  impregnation  first  becomes  possible. 

Relation  of  Ovulation  to  Menstruation. — The 
relation  of  menstruation  to  ovulation  has  often 
been  discussed,  and  is  still  an  unsettled  question, 
but  it  can  be  asserted  with  certainty  that  men- 
struation is  due  to  ovulation,  while  the  latter  is 
independent  of  the  former.  Conception  may  take- 
place  in  girls,  before  the  menses  have  made  their 
appearance ;  in  nursing  women,  while  they  are 
absent,  or  in  females  after  the  establishment  of 
the  menopause.  In  all  women,  however,  with 
few  exceptions,  a  suppression  of  menstruation  is 
established  vers-  soon  after  the  removal  of  both 
ovaries. 

The  age  at  which  conception  becomes  possible 


varies  greatly  in  races  and  individuals.  In  Per- 
sia menstruation  is  established  by  the  ninth  to 
tenth  year;  in  Syria  by  the  tenth  to  eleventh  year; 
and  on  the  Guinea  Coast  by  the  eighth  or  ninth 
year. 

Taylor  reported  a  case  of  conception  in  a  girl 
of  12  years  ;   Molitor,  one  in  a  girl  of  9  years  5 

Riittel,  one  in  a  girl  of  9  years 
Kussmaul  one  in  a  girl  of  8  years.  I  have  met 
with  a  case  of  twins  in  a  girl  of  13  years,  and  I 
have  had  reported  to  me,  on  pretty  good  author- 
ity, the  case  of  a  Damascus  Jewess  who  became 
a  grandmother  at  2 1  years. 

Maturation  of  the  female  is  early  in  hot,  and 
late  in  cold  countries.  Rich  food  also  stimulates, 
while  insufficient  or  poor  nourishment  retards  it. 
Girls  nurtured  in  cities,  where  it  is  hot  and  the 
mental  excitement  is  great,  mature  at  an  earlier 
age  than  their  country  cousins.  Heredity  is  a 
most  important  factor  in  this  connection,  and  it 
is  not  uncommon  to  know  of  many  successive 
generations  developing  at  an  early  age. 

Menopause. — The  menopause  is  established  be- 
tween the  46th  and  50th  years,  at  which  time  we 
see  something  of  a  return  to  the  masculine  type 
— the  voice  becoming  harsher,  the  breasts  under- 
going atrophy,  and  more  or  less  hair  appearing 
on  the  chin  and  lip.  Those  influences  which 
have  been  mentioned  as  affecting  the  establish- 
ment of  menstruation  affect  also  the  establish- 
ment of  the  menopause.  The  length  of  the 
child-bearing  period  is  pretty  definite,  for  where 
puberty  is  early  the  menopause  will  be  early,  and 
vice  versa. 

A  few  remarkable  cases  of  child-bearing  at  an 
advanced  age  have  been  recorded.  Rush  report- 
ed one  in  a  woman  of  60  years ;  Dewees,  oue  in 
a  woman  of  61  years;  Haller,  one  in  a  woman  of 
70  years;  and  Thibaut  de  Chauvalou  reported  one 
in  a  woman  of  Martinique  of  90  years. 

Copulation.  —During  copulation,  in  most  of  the 
lower  vertebrata,  the  relative  position  of  the  two 
participants  is  back-to-belly,  the  part  played  by 
the  female  being  passive  throughout ;  but  in  man 
she  is  more  of  an  active  agent,  this  being  ren- 
dered possible  by  the  belly-  to-belly  position.  This 
position  also  brings  the  most  sensitive  parts  of 
the  genital  organs  of  each  sex  in  contact.  The 
engorged  and  sensitive  clitoris  is  drawn  down  by 
muscular  action  so  as  to  come  in  contact  with  the 
penis,  while  the  corona  gland  is  of  that  organ 
causes  friction  against  the  roughened  folds  of  the 
anterior  vaginal  wall. 

In  many  married  women,  and  some  virgins,  I 
have  found  that  that  part  of  the  anterior  wall  of 
the  vagina  situated  just  behind  the  symphysis 
pubis,  is  as  sensitive  as,  and  in  some  cases  more 
sensitive  than,  the  clitoris.  As  friction  is  con- 
tinued all  of  the  female  organs  of  generation  be- 
come engorged  with  blood,  and  muscular  action 
is  excited.     The  uterus  enlarges,  becomes  more 


A  STUDY  OF  STERILITY. 


[  February  7, 


I 
cylindrical,  and  straightens  out  the  axis  of  its  I 
canal.  Its  external  os  becomes  dilated  and  round, 
while  the  plug  of  mucus  normally  closing  that 
opening  is  expelled.  With  these  changes  we 
have  a  slight  descent  of  the  uterus  towards  the 
ostium  vagina?,  while  it  is  tilted  back  nearer  the 
sacrum,  so  as  to  bring  the  utero- vaginal  axis  closer 
to  a  right  line.  When  orgasm  approaches  the 
contents  of  the  vulvo- vaginal  glands  is  discharged 
in  jets,  and  the  vagina  and  uterus  take  on  a  rhyth- 
mical contractile  action,  which  probably  assists 
the  entrance  of  the  seminal  fluid,  as  it  is  ejacu- 
lated over  the  cervix,  into  the  uterine  cavity.  It 
is  not  improbable  that  the  uterine  terminations  of 
the  Fallopian  tubes  may  also  be  opened  by  these 
rhythmical  contractions  of  the  uterus.  On  more 
than  one  occasion  I  have  satisfied  myself  as  to 
the  existence  of  this  uterine  action,  when  making 
a  not  over- careful  digital  examination  of  very  am- 
orous females.  In  examining  a  woman  with  pro- 
lapsus uteri,  J.  Beck  noticed  that  the  os  uteri, 
during  sexual  excitement,  opened  and  closed 
convulsively,  five  or  six  times,  after  which  it  be- 
came firmly  contracted.  This  rhythmic  action 
has  been  observed  by  Brundell  in  the  vaginae  of 
rabbits,  while  in  heat. 

Seminal  Fluid. — The  seminal  fluid,  as  it  leaves 
the  penis,  is  composed  of  secretions  of  the  testes, 
the  prostate,  and  Cowper's  glands,  with  a  small 
quantity  of  mucus  derived  from  the  urethra.  If 
examined  under  the  microscope  many  different 
objects  are  seen,  but  the  moving  spermatozoa, 
only,  are  necessary  for  impregnation.  These  pro- 
gress, according  to  Lott,  at  the  rate  of  36  milli- 
metres a  minute.  Mayrhofer  claims  that  for 
impregnation  it  is  necessary  that  the  spermatozoa 
be  deposited,  during  coitus,  in  the  cervical  canal 
where  the  reaction  is  alkaline.  Sims  found  that 
they  died  in  the  vaginal  secretions  within  twelve 
hours,  but  in  the  cervical  canal  he  found  them 
alive  forty  hours  after  intercourse,  and  Percy  re- 
ports a  case  where  he  found  them  alive  as  long  as 
eight  and  a  half  days  after  coitus.  The  cilia  in  the 
upper  part  of  the  cervical  canal  may  assist  them  in 
entering  the  uterus,  but  their  passage  through  the 
Fallopian  tubes  is  due  to  their  inherent  mobility, 
as  the  cilia  of  the  tubes  move  in  an  opposite  di- 
rection. 

Impregnation. — The  seat  of  impregnation  is  dif- 
ficult to  settle.  In  the  lower  animals  it  is  known 
to  frequently  take  place  in  the  Fallopian  tubes, 
and  the  frequency  of  extra- uterine  pregnancy  in 
woman  leads  ns  to  infer  that  it  may  take  place  in 
both  the  tubes  and  the  ovaries.  LSwenthal  ad 
vances  the  hypothesis  that  about  every  four  weeks 
an  unimpregnated  ovum  passes  to  tin-  uterus  and 
becomes  imbedded  in  the  mucous  membrane, 
where  it  is  impregnated  or  degenerates.  If  this 
hypothesis  were  true,  extra-uterine  pregnane} 
would  tie  almost  unknown. 

Impregnation  consists  in  the  entrance  of  one  or 


more  spermatozoa  into  the  substance  of  the  ovum. 

In  the  ova  of  the  lower  animals,  where  obser- 
vations can  be  made  with  facility,  the  presence  of 
only  one  spermatozoon  has  been  recorded,  but 
several  spermatozoa  have  been  observed  in  the 
ovum  of  the  rabbit.  Keber  was  the  first  to  re- 
cord, in  the  ova  of  the  fresh-water  muscle,  an 
opening,  or  microphyte,  for  the  entrance  of  the 
male  element.  This  has  been  observed  in  the 
ova  of  other  animals,  and  the  ova  of  some  of 
the  lower  orders  has  the  power  of  throwing  out 
processes,  or  pseudopodia,  with  which  they  seize 
and  draw  in  the  spermatozoa,  but  none  of  these 
phenomena  have  been  observed  in  the  mammalia. 

Passage  of.  Ova  to  Uterus. — The  old  theory  of 
the  fimbriated  extremities  of  the  tubes  applying 
themselves  to  the  ovaries  so  as  to  receive  the  ova, 
is  now  known  to  be  only  partially  true.  In  many 
animals  the  distance  between  the  extremities  of 
the  tubes  and  the  ovaries  is  too  great  to  permit 
of  this.  It  is  now  a  well  established  fact  that  the 
motion  of  the  cilia  in  the  tubes  creates  a  slow 
current  of  fluid  in  both  tubes  and  peritoneal  cav- 
ity. Oldham,  Rokitansky,  Scanzoni  and  others 
have  recorded  cases  where  the  serum  passed  from 
the  ovary  of  the  one  side  into  the  tube  of  the  op- 
posite side.  This  was  proved  by  the  absence  or 
closure  of  the  tube  on  the  side  where  the  corpus 
luteum  existed. 

Of  four  rabbits  from  which  Leopold  removed 
the  ovaries  of  the  one  and  the  tubes  of  the  other 
side,  two  subsequently  became  pregnant. 

When  the  impregnated  ovum  reaches  the  cav- 
ity of  the  uterus,  it  is  arrested  by  the  folds  of  the 
mucous  membrane,  becomes  attached  and  begins 
to  grow,  but  if  it  should  fail  to  become  impreg- 
nated it  degenerates  and  is  cast  off. 

Necessary  Conditions  for  Impregnation.  — For 
reproduction,  then,  three  conditions  are  necessary, 
viz.:  1.  A  production  of  healthy  ova  and  sperm- 
atozoa ;  2.  The  union  of  the  ova  and  spermato- 
zoa ;  3.  The  implantation  of  the  impregnated 
ovum  in  a  uterus  fitted  for  its  development.  All 
influences  acting,  directly  or  indirectly,  so  as  to 
prevent  the  fulfilment  of  one  or  more  of  these 
conditions,  will  produce  sterility. 
[To  be  eon  tin  ued  A 


Lupus. — Peter  Eade,  M.D.,  writes  to  the  Lon- 
don Lancet  as  follows  :  "It  seems  to  be  of  inter- 
est to  record  the  fact,  with  which  experience  lias 
long  made  me  familiar,  that  the  external  remedy 
which  has  proved  the  most  potent  and  effective 
in  promoting  the  healing  of  lupoid  ulcers  is  the 
common  yeast,  applied  to  the  sore,  either  in  its 
pure  stale  or  made  into  a  poultice  with  enough 
hot,  soaked  linseed  to  make  the  application  warm 
and  pleasant,  and  this  used  continuously  for  days 
or  weeks. 


i8qi.] 


MANAGEMENT  OF  MAJOR  AMPUTATIONS 


•85 


THE    MANAGEMENT  OF   MAJOR    AMPU- 
TATIONS. 

Read  in  the  Section  o/Surgeiv  and  A  natomy  at  the 

Meeting  oftheAmen  an   \fedzcal    I         a    «i  ■     va  hvil/e, 

'/'fill..  May  to,  i&oo. 


BY  JOHN  A.  WYETH,   M.D., 


I'K-ll     1     -.-.I   M 


The  prevention  of  haemorrhage  is  the  chief 
point  in  the  management  of  amputations.  Second 
to  this  the  preservation  of  as  much  of  the  length 
of  a  limb  as  possible. 

I  will  presume  that  in  this  day  the  question  of  the 
aseptic  or  antiseptic  management  of  all  wounds  is  no 
longer  open  for  discussion  among  scientists  ;  and 
that  as  to  the  question  of  amputating  during  the 
period  of  shock,  it  is  no  more  permissible  when 
applied  to  injury  of  an  extremity  than  when  it 
follows  a  perforating  wound  of  the  abdominal 
viscera,  and  where  is  the  surgeon  who,  except 
for  the  arrest  of  haemorrhage  rapidly  exhausting 
his  patient,  will  add  to  the  shock  of  accident  the 
shock  of  deliberate  surgical  interference  ? 

I  desire  to  submit  to  you  two  amputations  in 
major  amputations  which  I  have  devised  and 
successfully  executed  : 

1.  Bloodless  amputation  of  the  hip. 

2.  Bloodless  amputation  of  the  shoulder. 

i.  Hip  Joint. — It  is  well  known  that  the  ter- 
rible death  rate  after  hip-joint  amputation  is 
chiefly  due  to  haemorrhage.  Compression  of  the 
aorta  or  common  or  external  iliac  has  not  ren- 
dered the  operation  less  dangerous.  The  figure- 
of-eight  elastic  bandage  of  Esmarch  carried  above 
the  iliac  crests  or  around  the  abdomen,  and  the 
transfixion  by  a  single  needle  passed  in  front  of 
the  neck  of  the  femur  and  beneath  the  vessels, 
over  the  ends  of  which  a  rubber  cord  is  carried 
only  in  front  of  the  thigh,  as  advised  by  Tren- 
delenburg, or  the  figure-of  eight  rubber   spico  of 


an  Esmarch  bandage  applied  to  drive  the  con- 
tained blood  toward  the  heart.  The  bandage 
should  not  lie  tightly  put  on  over  the  seat  of  the 
disease  for  fear  of  driving  septic  matter  into  the 
circulation.  With  the  rubber  bandage  still  in 
position,  the  needles  are  next  introduced. 

Two  steel  mattress  needles,  three  sixteenths  of 
an  inch  in  diameter  and  a  loot  long,  are  used. 
inserted  an  inch  and  a  half 
below  the  anterior  superior  spine  of  the  ilium  and 
slightly  to  the  inner  side  of  this  prominence,  and 
is  made  to  traverse  the  muscles  and  deep  fascia, 
passing  about  half  way   between  the    great    tro- 


Fourneaux-Jourdan,  are  improvements  on  older 
methods,  but  are  far  from  satisfactory.  Without 
going  into  the  history  of  this  amputation  I  sub 
rnit  my  method  as  follows  : 

The  patient  being  placed  in  position,  with  the 
hip  of  the  side  to  be  operated  on  well  over  the 
corner    of  the    table,    the    foot    is    elevated  and 


chanter  and  the  iliac  spine,  external  to  the  neck 
of  the  femur  and  through  the  substance  of  the 
tensor  vaginae  femoris,  coining  out  just  back  of 
the  trochanter.  About  four  inches  of  the  needle 
should  be  concealed  by  the  tissues. 

The  point  of  the  second  needle  is  entered  an 
inch  below  the  level  of  the  crotch  internally  to 
the  saphenous  opening,  and,  passing  through  the 
adductors,  conies  out  about  an  inch  and  a  half  in 
front  of  the  tuber  ischii.   X  i  e  endangered 

by  these  needles.  The  points  are  protected  by 
corks  to  prevent  injury  to  the  operator's  hands. 

A  piece  of  strong  white  rubber  tube  half  an 
inch  in  diameter  and  long  enough  when  tight- 
ened in  position  to  go  five  or  six  times  around 
the  thigh,  is  now  wound  very  tight  around  and 
above  the  fixation  needles  and  tied. 

The  Esmarch  bandage  is  removed  and  five 
inches  below  the  tourniquet  a  circular  incision 
(Fig.  i  |  is  made,  and  a  cuff  which  includes  the 
subcutaneous  tissues  down  to  the  deep  fascia  is 
dissected  off  to  the  level  of  the  lesser  trochanter, 
at  which  level  the  muscles  and  vessels  are  divided 
squarely  and  the  bone  sawed  through  (Fig.  2). 
All  vessels  including  the  veins  >  which  can  be 
seen  are  tied  with  catgut  and  the  smaller  bleed- 
ing points  can  be  discovered  by  slightly  loosen- 
ing the  tourniquet. 

The    remaining  portion  of   the  femur  is  now 


i86 


MANAGEMENT  OF  MAJOR  AMPUTATIONS. 


[February  7, 


easily  removed  by  dividing  the  attached  muscles 
close  to  the  bone  and  opening  the  capsule  as  soon 
as  it  is  reached.  On  lifting  the  end  of  the  bone 
in  the  direction  of  the  patient's  navel  and  divid- 
ing the  cotyloid  ligament  posteriorly,  the  air  en- 
ters the  cavity  of  the  acetabulum  and  greatly  facil- 
itates the  division  of  the  ligamentum  trees 
(Fig.  3)- 


The  closure  of  the  wound,  with  proper  drain- 
age, follows  (Fig.  4).  The  entire  proceeding  re- 
quires the  strict  asepsis  of  modern  surgery. 

One  other  important  point  I  wish  to  emphasize 
— viz.,  the  advisability  in  certain  cases  of  doing 
this  operation  in  two  sittings. 

In  one  of  my  cases  the  patient  was  greatly  ex- 
hausted, and  after  dividing  the  femur  at  the 
trochanter  and  securing  the  vessels,  fearing  the 
supervention  of  shock  as  indicated  by  the  pulse, 
I  closed  the  wound,  which  healed  by  first  inten- 
tion. At  the  first  dressing  (on  the  seventeenth 
day),  the  remaining  portion  of  the  bone  was  re- 
moved by  an  incision  over  the  trochanter  major. 
The  recovery  was  uninterrupted. 

I  should  prefer  to  complete  the  operation  at 
one  sitting,  but  cases  will  occur  where  the  danger 
of  shock  may  be  obviated  by  stopping  short  of 
enucleation,  leaving  this  for  a  week  or  two,  when 
reaction  and  convalescence  are  assured. 

In  neither  of  my  cases  was  there  any  bleeding, 
and  in  two  additional  operations  by  this  method, 
very  recently  performed  by  two  distinguished 
surgeons  of  this  city,  there  was  perfect  immunity 
from  haemorrhage  and  rapid  recovery.  Jn  /art, 
amputation  at  the  ///'/>  joint  is  now  a  bloodless  op- 
eration. 

2.  Shoulder  Joint. — I  have  also  applied  this 
same  method  at  the  shoulder.  One  needle  is 
made  to  transfix  the  anterior  axillary  fold 
away  from  the  vessels,  and  nerves  tak- 
ing firm  hold  in  the  tendon  of  the  pectoralis 
major.  The  other  pierces  the  deltoid  just  below 
the  acromion  process  and  is  pointed  backward. 
The  arm  having  been  emptied  of  blood,  the  rub- 


ber tube  is  tightly  wound  around  the  shoulder 
above  the  needles.  A  circular  skin  flap  is  made 
and  rolled  back  to  within  three  inches  of  the 
acromion,  at  which  point  the  muscles  and  bone 
are  divided  and  the  vessels  all  secured.  The 
tourniquet  is  removed  and  the  remaining  portions 
of  the  humerus  enucleated. 

PRESERVING  THE  LENGTH  OF  LIMB  IN  AMPUTAT- 
ING FOR  OSTITIS  AND  OSTEO  MYELITIS. 

Within  two  years  it  has  occurred  to  me  twice 
to  amputate  just  above  the  knee  for  osteo -my- 
elitis of  the  femur  secondary  to  destructive  osteo- 
arthritis in  the  knee  joint. 

Upon  sawing  through  the  femur  the  medulla, 
broken  down  to  the  consistency  of  thin  soup, 
escaped  like  so  much  thin  pus.  The  canal  was 
much  larger  than  normal,  owing  to  absorption  of 
the  inner  surfaces  of  the  compact  substance.  In 
one  case  I  could  have  crushed  the  bone  easily 
between  my  thumb  and  finger.  In  these  two  in- 
stances, with  a  long  Volkmann's  spoon,  I  scraped 
out  the  canal  thoroughly  as  high  as  the  trochan- 
ter where  it  ended.  I  then  inserted  into  the  canal 
a  rubber  drainage  tube  with  a  single  lateral  per- 
foration one  inch  from  the  upper  or  inserted  end. 
This  end  reached  the  level  of  the  trochanter 
minor. 

The  wound  was  closed  as  usual  leaving  this 
long  tube  projecting  through  the  flap  opposite 
the  medullar}-  canal.  At  intervals  of  from  four 
to  six  days  the  canal  was  irrigated  with  1  to  3000 
sublimate  solution,  by  forcing  it  into  the   end  of 


the  tube  in  a  continuous  stream  until  it  Bowed 
out  through  the  canal  outside  the  tube.  The 
tube  was  withdrawn  from  one-half  to  one  inch 
each  week,  and  the  canal  gradually  filled  up  with 
healthy  granulation  tissue  which  later  was 
changed  into  bone. 

Both  patients  recovered  with  stumps  of  the 
fullest  possible  length. 

Although  not  novel,  as  I  have  since  learned, 
I  had  not  known  of  this  method  until  after  it  had 
been  put  into  practice  in  these  two  instances. 


I89I.J 


RELATION  OF  LIFE  INSURANCE  TO  INEBRIETY. 


[87 


THE  RELATION  OF  LIFE  INSURANCE 
TO  INEBRIETY. 

10,  1S90. 

BY  T.  D.  CROTHERS,  M.D., 


As  introductory  to  a  brief  study  of  this  subject 
some  general  experience  will  make  clear  the  con- 
clusions which  I  wish  to  urge.  During  1 
fourteen  years  I  have  been  exclusively  engaged 
in  the  institutional  cure  and  treatment  o! 
ates.  In  the  large  number  of  persons  of  this 
class  who  have  come  under  my  observation  many 
of  them  have  been  insured  for  large  amounts  in 
the  best  life  insurance  companies  of  the  country. 
I  have  no  statistics  of  the  exact  number,  but  I 
am  confident  that  from  a  third  to  one-half  of  all 
the  inebriates  under  my  care  carry  insurance  pol- 
icies of  greater  or  less  amount. 

While  the  object  of  all  companies  is  to  insure 
only  sound  healthy-  lives,  it  is  evident  that  this 
is  not  the  fact  in  a  large  number  of  cases.  It  has 
come  to  my  knowledge  that  many  of  these  cases 
have  been'insured  after  they  became  inebriates. 
In  one  case  a  man  who  had  been  twice  under  my 
care  for  periodical  inebriety,  secured  an  insurance 
of  fifty  thousand  dollars,  in  the  aggregate,  in  dif- 
ferent companies.  This  man  has  drink  parox- 
ysms and  requires  treatment  every  year.  In 
another  case  an  incurable  son  (of  an  influential 
man)  who  had  been  under  my  care  a  number  of 
times,  died  from  pneumonia  following  a  drink 
paroxysm;  insurance  policies  of  thirty  thousand 
dollars  were  paid  on  his  life.  In  another  case  an 
inebriate  of  twenty  years'  duration,  secured  fifteen 
thousand  dollars  in  different  companies,  shortly 
after  being  under  my  care  for  four  months. 
Within  a  year  he  died  from  some  obscure  brain 
lesion,  which  came  from  a  drink  paroxysm.  The 
iusurance  was  paid. 

In  a  general  classification  of  the  cases  I  have 
seen  who  were  insured,  something  like  the  fol- 
lowing seems  to  be  very  common:  The  largest 
class  appear  to  be  invalid  or  silent  partners  of 
mercantile  houses;  broken  down  merchants  or 
clerks;  men  who  had  occupied  business  positions, 
or  been  prominent  in  professional  circles,  but 
have  withdrawn  for  some  reason.  Most  of 
these  cases  acknowledge  moderate  drinking, 
and  give  no  evidence  of  excesses  in  public  or  in 
appearances.  Many  of  these  cases  are  secret 
drinkers,  others  are  periodical  and  anticipate  the 
paroxysm  by  providing  for  its  secret  indulgence, 
away  from  home  in  some  distant  city.  After  the 
attack  they  are  temperate  for  a  distinct  time  and 
give  little  evidence  of  their  real  condition.  Often 
these  cases  are  strong  temperance  workers,  and 
make  a  public  exhibition  of  their  faith,  and  after 
the  sudden  disappearance  to  indulge  in  a  drink 


paroxysm  appear  more  enthused  than  ever  for  the 
cause. 

A  prominent  temperance  lecturer  is 
illustration.  He  has  always  two  or  three  "drink 
storms"  a  year,  of  a  week's  duration.  The  inter- 
vals are  filled  with  most  enthusiastic  work  for 
reformation  of  others.  He  has  a  large  insurance 
policy  on  his  life  and  is  considered  a  sound, 
healthy  man.  In  another  case  a  clergyman  with 
rich  relatives,  has  a  fifty  thousand  dollars  on  his 
life,  and  is  a  prominent  prohibitionist,  works 
with  great  energy  and  is  a  leader  of  much  influ- 
ence. This  man  has  drink  paroxysms  in  secret 
every  spring  and  fall  of  the  year.  Many  cases  of 
active  business  and  professional  men  drink  to 
great  excess  at  irregular  times  and  away  from 
home.  They  come  often  to  institutions  for  a  short 
time  under  an  assumed  name,  and  go  away  re- 
stored. These  cases  always  carry  large  insurance, 
and  no  doubt  acknowledge  moderate  or  occasional 
drinking  to  the  medical  exairliner.  In  all  prob- 
ability these  men  recognize  the  future  peril  which 
may  grow  out  of  their  secret  excesses  and  thus 
seek  protection  from  insurance. 

In  some  of  these  cases  the  companies  are  at 
fault,  in  others  the  examiners;  often  the  insured 
parties  have  not  covered  up  or  concealed  the  fact 
of  drinking,  but  the  drink  storms  have  not  been 
mentioned.  Other  cases  are  men  of  family,  with- 
out business,  having  wealth,  and  living  leisure 
lives.  They  are  wine  and  beer  drinkers  at  the 
table  and  claim  to  be  only  moderate  users  of 
spirits.  Often  they  carry  large  amounts  of  insur- 
ance divided  up  among  many  companies.  Often 
they  are  club  men  who  are  comparative  fast  livers, 
and  while  they  seem  not  to  be  excessive  drinkers, 
they  are  undoubtedly  so  in  secret.  They  are 
generally  incurable  cases  when  they  come  for 
treatment.  Recently  a  man  of  this  class  who  had 
consulted  me  for  drink  excesses  died,  and  his 
family  received  fifty  thousand  dollars  insurance. 

These  cases  are  common  in  my  experience.  I 
fully  recognize  the  fact  that  notwithstanding  all 
the  care  and  precautions  of  companies  and  exam- 
iners, a  certain  number  of  persons  will  obtain  in- 
surance who  are  bad,  dangerous  risks.  Compan- 
ies who  admit  moderate  drinkers,  and  those  who 
leave  the  question  of  risks  in  these  cases  to  the 
judgment  of  examiners,  will  always  have  a  large 
number  of  these  dangerous  risks,  and  a  larger 
mortality.  One  such  company  became  alarmed 
at  their  death  rates,  and  from  the  report  of  a 
special  examiner  on  risks,  over  ten  thousand, 
cancelled  in  one  year  thirty-one  policies  of  pro- 
nounced inebriates,  who  had  been  insured  as 
sound  and  healthy.  Another  company  who  had 
practically  refused  moderate  drinkers,  but  left  the 
question  open  and  depended  on  the  judgment  of 
examiners,  cancelled  twenty-six  cases  of  the  same 
character  all  carrying  large  policies.  The  reason 
for  these  errors  and  mistakes  is  evident  from  the 


RELATION  OF  LIFE  INSURANCE  TO  INEBRIETY.       [February  7, 


medical  instruction  to  examiners  by  some  com- 
panies. This  is  illustrated  in  the  advice  to  draw 
a  line  in  cases  of  moderate  drinking  at  what  is 
termed  "Anstie's"  limit  of  daily  allowance, 
"equivalent  to  one  and  a  half  ounces  of  absolute 
alcohol;  three  ounces  of  ardent  spirits;  two  wine 
glasses  of  wine;  one  pint  bottle  of  claret,  cham- 
pagne, or  other  light  wine;  three  tumblerfuls  of 
ale  or  porter;  four  or  five  tumblerfuls  of  ale  or 
light  beer."  This  is  the  limit  of  moderation  in 
the  use  of  spirits,  beyond  this  there  is  risk  of 
health  and  longevity,  and  this  amount  daily  does 
not  peril  the  health  or  life  risk. 

In  face  of  the  late  advances  in  chemico-ph3-sio- 
logical  science  concerning  the  action  of  alcohol  on 
the  system  such  instructions  are  at  least  very  start- 
ling. Nothingcan  be  more  theoretical,  and  assurnp- 
tious,  and  flatly  contradicted  by  both  facts  and  ex- 
perience. The  attempt  to  map  out  lines  of  health 
and  safety  in  the  use  of  spirits  is  literally  impos- 
sible. ManjT  of  tfle  most  incurable  cases  under 
my  care  have  rarely  exceeded  one  and  a  half 
ounces  of  absolute  spirits  daily.  Many  steady 
drinkers,  who  are  incurable,  seldom  drink  more, 
and  in  the  majority  of  cases  this  is  only  an  early 
stage  of  inebriety.  Moderate  drinking  in  this 
countr}'  is  impossible,  in  the  majority  of  cases. 
The  excitement  and  revolutions  of  civilization, 
climate  and  strains,  either  precipitate  the  drinker 
into  an  inebriate  of  some  sort,  or  end  in  acute 
organic  disease  The  moderation  seen  among 
the  people  of  Europe  is  cxo/ic  in  this  country 
and  only  exists  a  short  time,  except  as  a  marked 
exception  to  the  rule.  Boundary  lines  of  mod- 
eration and  health  in  the  use  of  any  form  of 
spirits  as  a  beverage  is  like  drawing  boundary 
lines  in  the  twilight  between  night  and  day. 
From  my  experience  I  believe  there  are  many  in- 
ebriates who  could  pass  a  good  physical  examin- 
ation and  truthfully  allege  that  they  drank  less 
per  day  than  this  limit  of  Anstie's. 

Recently  a  gentleman  who  has  had  two  attacks 
of  alcoholism,  with  pronounced  delirium  and  de- 
lusions, and  has  drank  for  years  at  night  at  horue^ 
was  examined  and  given  a  large  policy.  He  an- 
swered truthfully  that  he  drank  moderately,  at 
night,  for  years.  This  the  examiner  thought  of 
little  importance  for  the  reason,  probably,  that  he 
discovered  no  organic  lesions  to  indicate  any  in- 
jury from  this  use  of  spirits.  How  far  such  errors 
of  judgment  are  made  in  the  wella]  >inted  com- 
panies is  difficult  to  determine,  but  the  assump- 
tion that  any  moderate  use  of  spirits  is  free  from 
peril,  reflects  on  the  business  soundness  and  sci- 
entific accuracy  of  the  management  of  the  com- 
pany. Another  source  of  error  is  apparent  in 
those  companies,  where  the  question  of  risks  is 
left  to  the  judgment  of  the  medical  examiner.  As 
a  rule,  such  examiners  are  among  the  best  physi 
cians  in  the  country,  and  while  they  are  thor- 
oughl3  ad    conscientious,   may  not   be 


familiar  with  the  latest  teachings  of  science  as 
to  the  action  of  alcohol  on  the  system.  The  reason 
of  this  is,  often  such  men  are  moderate  or  occa- 
sional users  of  spirits,  and  have  formed  fixed  con- 
victions concerning  the  use  and  effects  of  alcohol. 
Anstie's  limit  of  health  and  moderation  is  to  them 
a  final  truth  because  along  the  line  of  personal 
experience. 

Not  unfrequeutly  such  men  have  been  follow- 
ers of  the  Todd  and  Bennett  school,  and  their 
earlier  impressions  of  the  value  of  alcohol  are 
more  or  less  final.  Should  the  medical  exam- 
iner drink  to  excess  occasionally,  he  reasons  from 
his  own  experience,  and  readily  concludes  no 
harm  can  come  from  it,  and  that  the  will  power* 
is  sufficient  to  restrain  the  use  of  spirits  at  any 
time.  If  such  a  man  has  drank  to  excess  in  early 
life,  and  had  delirium,  then  abstained  in  a  large 
degree,  his  judgment  of  the  impaired  health  of 
persons  in  similar  conditions  will  always  be  based 
on  his  own  feelings,  and  that  honestly  and  con- 
scientiously. Such  a  man  will  readily  pass  an  ap- 
plicant who  is  a  moderate  drinker,  or  one  who 
may  have  had  delirium  tremens,  who  gives  no 
evidence  of  organic  trouble.  Such  men  never 
read  any  new  literature  on  this  subject;  but 
consider  it  settled,  and  all  new  views  fanatical 
and  unworthy  of  confidence.  I  have  seen  such 
men  who  challenged  me  to  prove  the  bad  risk  of 
a  moderate  or  previously  excessive  user  of  spirits, 
because  they  exhibited  no  evidence  of  organic 
trouble.  In  the  South  this  is  more  common  be- 
cause the  use  of  spirits  is  more  general;  therefore, 
I  conclude  that  medical  men  who  use  alcohol  in 
moderation,  or  have  used  it  in  excess  in  the  past, 
have  "astigmatized  judgment,"  and  however 
acute  they  may  be  in  other  directions,  are  not,  as 
a  rule,  capable  of  deciding  the  health  risk  of 
those  who  use  spirits.  The  companies  can  not 
provide  against  this,  and  no  exhaustive  physical 
examination  can  do  much  to  relieve  the  burdens 
of  such  dangerous  risks. 

To  diverge  a  moment.  It  is  the  repetition  of 
all  psychological  advances,  that  the  errors  con- 
cerning alcohol,  and  its  action  on  the  system, 
should  "live  so  long  and  die  so  hard."  Even  to- 
day authors  continue  to  repeat  theories  which 
never  had  any  real  scientific  foundation,  and  even 
their  seeming  reality  was  a  mere  shadow,  which 
1  study  would  have  dissipated.  Most  of 
the  theories  respecting  alcohol  have  come  down 
entirely  on  the  respectability  of  authors,  who 
have  repeated  them,  and  are  accepted  as  facts 
unchallenged  and  unknown  scientifically.  While 
the  real  tacts  concerning  the  action  of  alcohol  Can 
all  be  put  on  a  single  printed  page,  the  literature 
covers  hundreds  of  volumes. 

The  question  of  the  use  and  abuse  of  alcohol 
from  the  standpoint  of  life  insurance  should  be  no 
theory  but  one  of  unquestioned  fact.  Not  opin- 
ions or  theories,  however  eminent  the  authority 


i8gi.] 


RELATION  OF  LIFE  ENSURANCE  TO  INEBRIETY. 


189 


may  be  who  endorses  them,  but  facts  and  con-  Inebriety,  like  in  appear 
elusions,  sustained  by  every  day's  experience,  at  any  time  from  the  application  of  its  peculiar 
and  demonstrated  with  all  the  certainty  of  our  exciting  causes,  and  should  be  regarded  as  these 
present  knowledge.  From  this  point  of  view  diseases  are.  The  theory  of  wilful  voluntary 
science  has  but  one  clear  conclusion,  namely,  contraction  of  this  state  has  no  support  in  the 
moderate  drinking  in  any  degree  is  perilous  to  scientific  history  of  cases.  Recently  a  temperate 
health  and  longevity,  and  greatly  increases  the  and  very  reputable  lawyer  became  an  inebriate 
liability  to  disease.  This  is  a  fact  that  can  be  after  fifty  years  of  age.  He  had  carried  a  large 
demonstrated  by  figures.  If  companies  continue  insurance  policy  for  years  and  had  been  temper- 
to  issue  policies  on  the  lives  of  moderate  drinkers,  ate  up  to  the  time  of  the  drink  impulse.  One 
or  persons  who  acknowledge   the  use  of  spirits  company  cancelled  his  policy,  another  company 


occasionally  or  regularly,  the  rates  should  be 
made  proportional  to  the  risks.  Thus  a  moderate 
drinker  at  twenty  would  have  the  same  compara 


more  honorable  continued  its  insurance  on  the 
promise  of  the  policy  holder  and  his  friends,  that 
every  effort  should  be  made  for  lus  recovery.    He 


tive  longevity  as  a  temperate  man  at  fifty,  and  a    finally  recovered  and  is  in  active  life  to-day.       It 
moderate  drinker  at  thirty  would  live  as  long  as    is  an  injustice  for  a  company  to  refuse  to  carry  out 
temperate     man    at    sixty.       These    figures   a  contract  simply  because  a  sudden  peril  comes 


bring  out  the  fact  that  where  both  are  free  phy 
sically  from  traces  of  organic  disease,  the  liabil- 
ity to  disease  and  death  in  the  moderate  drinker, 
at  a  certain  age  would  be  increased  to  a  certain 
definite  rate,  represented  by  age,  and  he  should 
in  strict  justice  pay  for  this,  the  same  as  hazard- 
ous occupations  are  charged  increased  rates. 
While  the  moderate  drinker  may  not  become  an 
excessive  user  of  spirits,  there  can  be  no  question 
of  his  increased  liability  to  disease,  and  dimin- 
ished vital  resources,  also  natural  capacity  to  re- 
sist disease.  In  an  epidemic  the  moderate  and 
excessive  users  of  spirits  are  the  first  to  suffer  and 
die.  In  accidents  the  spirit  drinkers  recover 
more  slowly,  have  a  longer  convalescence,  and 
are  more  like  to  die  than  temperate  persons.  The 


to  the  life  of  the  insured  as  in  this  case.  A 
gentleman  who  had  been  temperate  and  well 
up  to  the  sudden  death  of  his  wife,  began 
to  drink  to  great  execs-.  He  had  fiftj  thou- 
sand on  his  life,  and  one  large  company  made 
unseemly  haste  to  cancel  its  policy.  Later  this 
man  died  of  paralysis;  his  spirit  drinkin 
only  a  symptom  of  this  disease.  An  action  was 
begun  against  this  company  and  finally  settled 
by  a  compromise.  The  failure  of  this  company 
and  its  medical  examiners  to  comprehend  the  first 
principles  of  science  and  equity  in  this  case  is  a 
certain  promise  of  their  future  failure.  Another 
instance  where  a  temperate  man,  after  an  attack 
of  typhoid  fever,  developed  acute  dipsomania  and 
two  years  later  died  of  some  obscure  affection  of 


experience  of  the  accident  insurance  companies  the  brain.  Two  out  of  three  companies  who  held 
abundantly  confirm  this  statement.  Hospital ,  policies  on  his  life  annulled  them,  and  the  medical 
statistics  in  every  large  city  show  that  beer  and  director  ofone  company  was  emphatic  in  his  opinion 
spirit  drinkers  who  seem  to  be  in  excellent  health  that  this  man  was  only  giving  way  to  a  vice  which 
and  vigor  have  a  limited  degree  of  vital  he  could  stop  any  moment.  This  physician  was  him- 
power  and  a  special  tendencv  to  acute  or-  self  a  moderate  drinker.  The  third  company  contiu- 
ganic  disease  from  slight  exciting  causes.     They  j  ued  its  policy,  its   management  recognizing  the 


purely  physical  nature  of  the  case.  Another 
question  has  come  to  me  many  times  in  the  past 
few  years.  Where  men  who  have  drank  to  great 
excess  and  reformed,  for  years  living  lives  of 
strict  •sobriety,  apply  for  life  insurance.  The 
physical  examination  reveals  no  organic  disease 
..  and  the  question  of  the  character  of  the  risk  IS 
after.  A  spirit  drinker  suffered  a  slight  exposure  variously  considered  by  medical  examiners  and 
from  an  alarm  of  fire  in  his  house,  and  died  from  companies.  The  facts  which  should  govern  in 
pneumonia  in  a  few  days.  Each  of  these  cases  i  these  cases  are  these:  The  disease  of  inebriety 
carried  life  insurance  policies  and  two  of  them  manifest  in  excessive  use  of  spirits  is  thoroughly 
had  been  insured  recently  as  good  risks  and  curable. 
healthy   cases.       When   temperate   healthy   men 


are  unable  to  bear  strains  and  shocks  of  any 
kind.  They  die  from  apparent  inadequate  causes, 
where  others  suffering  in  the  same  way  recover. 
Recently  a  moderate  spirit  drinker,  from  a  fall 
fractured  the  femur.  He  died  from  shock  and 
fever  two  weeks  later.  A  beer  drinker  had  his 
hand    crushed    and    died    from    gangrene    soon 


are  insured  in  a  company,  and  afterwards  become 
inebriates,  the  policy  should  not  be  cancelled   or 


and  nerve  strain,  with  cardiac  weakness,  and 
lowered  vitality,  remain.  The  drink  craze  and 
impulse  may  die  out,  and  the  man  be  a  total  ab- 


invalidated,  unless  it  can  be  shown  that  decep-  stainer  for  life,  but  his  longevity  is  impaired,  his 
tion  was  used  when  the  policy  was  made  out.  liability  to  disease  is  increased.  Correct  personal 
All  such  cases  should  be  treated  as  those  suffer-  habits  and  careful  hygienic  living  may  do  much 
ing  from  organic  disease  contracted  after  the  pol-  to  restore  the  lost  capacities,  and  even  a  most 
icy  was  issued,  and  from  conditions  and  exciting  minute  physical  examination  will  tail  to  tind 
causes  that  could  not  have  been  anticipated  when  traces  of  this  brain  and  nerve  strain,  yet  they  ex- 
the  insurance  was  placed. 


i  go 


MONOMANIA 


[February  7 


ist  and  any  strain  or  exigencies  will  bring  them 
out  again.  My  advice  in  such  cases  is  to  issue  a 
policy  at  such  rates  as  are  charged  old  men, 
along  some  approximate  table  of  disease  and 
mortality  probabilities.  The  following  case  illus- 
trates this:  A  man  of  good  heredity  was  an  ine- 
briate during  the  war  and  for  some  time  after, 
then  reformed.  Twenty  years  later  he  was  re- 
fused a  policy,  from  the  fact  that  he  had  drank 
to  excess  for  a  period  long  ago.  He  was  forty- 
eight  years  of  age  and  free  from  apparent  disease. 
I  think  a  policy  issued  at  the  rates  charged  for 
temperate  men  of  sixty-five  or  seventy  would 
have  been  fair  and  just  to  all.  I  think  no  fact  is 
clearer  than  this,  the  inebriate  and  moderate 
drinker,  to  a  greater  or  less  degree,  have  and  are 
wasting  their  vital  resources,  and  ageing  them- 
selves beyond  all  present  indications.  These  in- 
juries do  not  appear  from  any  coarse  physical  ex- 
amination, and  when  this  fact  is  applied  to  ex- 
cessive users  of  spirits  it  is  not  disputed,  but  it  is 
not  so  clear  in  the  case  of  moderated  and  occa- 
sional users  of  spirits.  Yet  it  is  the  same  only 
varying  in  degree.  In  many  ways  this  fact  is 
sustained  by  the  experiences  of  the  sick  room  and 
hospital,  and  should  be  fully  recognized  in  prac- 
tical life.  Every  advance  in  our  knowledge  of 
the  action  of  alcohol  on  the  brain  and  nerve  cen- 
tres brings  additional  confirmation. 

Beyond  all  question  there  is  much  confusion  in 
the  theory  and  practice  of  both  companies  and 
medical  examiners  in  this  direction.  An  officer 
of  a  large  company  said  that  millions  of  dollars 
were  lost  every  year  from  ignorance  of  the  risks 
in  these  cases  alone.  Both  companies  who  issue 
policies  on  moderate  users  of  spirits  and  those 
who  refuse  to  do  so,  are  plunged  into  confusion  of 
theory  and  practice,  when  these  cases  appear, 
they  follow  lines  of  action,  that  are  both  pecuniar- 
ily and  morally  of  damage  to  both  company  and 
insured.  From  a  scientific  standpoint  there  are 
some  general  conclusions,  which  point  to  a  way 
out  of  this  difficulty,  and  promise  if  followed  up 
to  develop  some  new  lines  of  facts  of  the  greatest 
possible  value. 

1.  The  moderate  or  excessive  user  of  spirits 
who  can  pass  a  good  physical  examination  should 
be  given  a  policy,  on  some  basis  proportional  to 
the  length  of  time  he  has  drank,  and  the  extent 
of  his  drinking.  Comparative  accurate  tables  of 
mortality  could  be  formulated  on  these  cases 
which  would  fairly  represent  the  probable  dura- 
tion of  life.  This  would  necessitate  an  accurate 
study  of  a  large  number  of  such  cases,  the  conclu- 
sions of  which  would  be  of  the  greatest  value  to 
both  science  and  the  companies. 

2.  Policy  holders  previously  temperate,  who 
become  inebriates,  should  be  the  object  of  person- 
al solicitude  by  the  medical  examiners,  and  re- 
quired to  use  all  rational  means  for  recovery. 
Failure  and   neglect  on  the  part  of  the  friends  to 


use  ordinary  means  for  restoration  should  be  the 
only  reason  for  annulling  the  policy.  This  would 
also  require  accurate  medical  examination  of  such 
cases,  and  reveal  lines  of  causes  and  conditions  of 
disease  which  would  enlarge  the  bounds  of  science, 
and  bring  a  degree  of  accuracy  where  doubt  and 
confusion  exists  at  present. 

3.  Companies  who  refuse  absolutely  all  policies 
on  persons  who  have  used  spirits  in  the  past,  or 
do  so  at  present,  attempt  too  much,  and  fail  in 
many  cases.  Such  refusal  should  be  based  on  the 
results  of  physical  examination,  and  the  question 
of  the  use  of  spirits  should  be  regarded  as  an 
increased  risk,  requiring  increased  rates.  This 
would  prevent  the  deception  and  losses  which 
follow,  and  enable  the  company  to  determine 
rnany  of  the  questions  now  left  to  the  changing 
judgment  of  its  medical  examiners. 

4.  The  object  of  all  companies,  to  minimize 
the  uncertainty  and  risks  of  all  polic}'  holders, 
and  make  the  question  of  the  mortality  of  its  in- 
sured a  reasonable  certainty,  is  a  reality  when  the 
facts  of  alcoholic  degeneration  are  studied  above 
the  level  of  opinions  and  theories.  The  greatest 
peril  to  life  insurance  to-day  is  the  confusion  of 
theory  relating  to  the  nature  and  action  of  alco- 
hol. Every  policy  holder  has  to  pay  for  this  ig- 
norance in  the  increased  rates.  The  companies 
are  periled,  and  a  degree  of  uncertainty  exists, 
which  a  larger  and  more  accurate  study  of  alco- 
hol would  remove.  Companies  whose  managers 
and  medical  advisers  are  moderate  drinkers,  are 
on  the  road  to  failure.  Companies  who  assume 
that  this  question  is  settled  and  the  lines  of  health 
and  disease  can  be  mapped  out,  are  failures  al- 
ready. Companies  who  regard  this  peril  from  al- 
cohol as  one  requiring  the  most  careful  scientific 
study,  and  cautious  application  of  the  apparent 
facts  of  today,  will  arrive  at  some  rational  lines 
of  successful  solution  of  the  problem.  Finally. 
the  alcoholic  question,  from  every  point  of  view, 
demands  a  new  and  more  exact  study,  to  lift  it 
out  of  the  fogs  and  moss-covered  superstitions  of 
the  centuries. 


MONOMANIA. 

Read  before  the  Chicago  Medico-Legal  Society,  December  c 
BY  HENRY  M.  LYMAN,  M.D., 

PROFESSOR  OF  PRINCPI.F.S   AND  PRACTICE    OF  MEDICINE,  RUSH   MKIt- 
ICAL  COLLEGE,  ETC.,  CHICAGO. 

Monomania  is  a  term  that  has  long  been  in  use 
in  medicine,  but  the  signification  that  has  been 
attached  to  it  is  rather  vague  on  the  part  of  the 
general  public,  especially  so  in  consequence  of 
the  fact  that  it  is  supposed  to  denote  a  form  of  in- 
sanity in  which  a  person  is  perfectly  sane  and 
sound  in  mind  and  body  on  every  subject  but 
one,  and  upon  that  particular  subject  he  enter- 
tains some  irrational  ideas  that  dominate  his 
thoughts.     That   is  the    popular   idea  of  mono- 


J89i.] 


MONOMANIA. 


191 


mania,  but  it  is  well  known  by  intelligent  physi- 
cians and  alienists  who  have  given  much  time  to 
the  study  of  these  eases  that  there  is  no  such 
thing  possible  as  a  person  perfectly  sound  in  mind 
and  body  and  sane  upon  all  subjects  but  one.  It 
is  recognized  by  alienists  that  cases  which  have 
been  called  monomania  are  persons  who  are 
really  insane  and  who  are  unsound  in  mind  and 
body,  for  the  one  implies  the  other,  and  that  their 
insanity  and  their  unsoundness  of  mind  is  more 
especially  conspicuous  in  one  or  more  directions 
than  in  others.  It  is  rather  an  emphatic  form  of 
insanity  in  a  particular  direction  and  about  par- 
ticular subjects,  than  an  instance  of  simple  delu- 
sion in  a  sound  mind  and  body.  The  tendency  is 
to  limit  still  further  this  term  and  to  restrict  the 
idea  that  is  conveyed  by  the  word  "monomania" 
to  a  particular  class  of  patients  ;  not  characteriz- 
ing by  that  term  persons  who  manifest  a  particu- 
lar delusion,  or  system  of  delusions  that  are  more 
prominent  in  certain  directions  than  in  others, 
but  restricting  the  word  monomania  to  those  per- 
sons, who  manifest  an  unsound  mind— unsound 
as  a  consequence  of  hereditary  causes — and  un- 
sound in  a  way  that  produces  delusions  and  false 
reasoning  about  certain  topics.  And  in  order  to 
do  away  with  the  confusion  which  attaches  to  the 
use  of  the  word  "monomania,"  alienists  now  are 
in  favor  of  giving  it  up  and  of  substituting  a  term 
that  has  been  long  used  in  medicine,  though  not 
made  conspicuous  in  alienistic  science  until  lately; 
that  is  the  term  "paranoia." 

The  term  "paranoia"  signifies  a  disturbance  of 
the  mind,  and  it  is  employed  to  signify  a  consist- 
ent derangement  regarding  particular  subjects. 
Within  the  last  few  years  there  has  been  a  great 
deal  of  writing  and  discussion,  and  there  has  de- 
veloped a  good  deal  of  difference  among  authors 
as  to  the  restrictions  that  should  attach  to  the 
term  "paranoia."  This  difference  of  opinion, 
however,  seems  to  grow  principally  from  differ- 
ences of  opinion  as  to  whether  there  should  be  a 
limitation  of  the  use  of  this  term  to  cases  that  are 
congeuitally  defective,  or  whether  there  should 
be  included  together  with  the  congenitall}'  defec- 
tive patients,  those  that  have  become  defective  as 
a  consequence  of  other  diseases  of  the  brain.  This 
opens  a  very  wide  door  for  difference  of  opinion 
and  discussion  as  to  what  shall  be  the  true  signi- 
fication of  the  term  "paranoia:"  but  you  will 
find  a  disposition  to  classify  the  cases  that  used 
to  be  called  monomania  into  two  great  categories: 
those  that  are  congenitally  defective,  and  those 
that  have  become  defective  as  a  consequence  of 
cerebral  disease,  or  through  other  diseases  than 
insanity,  operating  upon  the  brain  in  such  a  way 
as  to  produce  insane  ideas.  The  great  character- 
istic of  the  majority  of  cases  of  paranoia  is  delu- 
sion. English  authors  still  incline  to  the  use  of 
the  term  delusional  insanity:  and  a  very  large  num- 
ber of  ca^es  can  be  assigned  to  this  class,  because 


there  arc  really  very  few  patients  who  do  not  at 
one  time  or  another  exhibit  some  form  of  delu- 
sion. Nevertheless,  I  think  we  are  now  in  a  po- 
,  sition  to  restrict  the  use  of  the  term    ' '  paranoia' ' 

■  to  persons  who  are  congenitally  defective,  and 
1  who  are  dominated  by  one  or  more  systematized  de- 
!  lusions,  in  such  a  way  that  their  reasoning  facul- 
ties remain  in  a  large  measure  intact,  and  their 
general  health  unimpaired  to  any  serious  degree  ; 
and  the  principal  difficulty  in  their  cases  lying  in 

1  the  fact  that  they  reason  wrongly  from  certain 
data  which  are  presented  to  their  hampered 
minds. 

When  we  proceed  further  to  examine  these 
cases,  we  find  that  they  rank  themselves  into 
sub-varieties  :  We  will  say,  there  is  the  genus 
paranoia  ;  then  there  are  species  of  paranoia  in 
which  certain  forms  of  delusion  are  most  promi- 
nent ;  for  example,  there  are  patients  dominated 
by  delusions  of  an  expansive  character,  the  delu- 
sions which  they  entertain  are  those  that  are  fre- 
quently termed  in  medicine   "grand  delusions." 

■  Then,  there  is  another  class  of  patients  in  whom 
I  the  delusions  are  of  a  depressive  character,   these 

approach  in  many  respects  the  delusions  of  mel- 
1  ancholia  :  then,  there  are  cases  in  which  the  pa- 
;  tient  takes  on  the  characteristics  of  both  these 
!  classes  and  is  dominated  by  delusions  of  an  ex- 
pansive character,  which  are  also  of  a  somewhat 
1  depressing  nature.  He  is  dominated  by  the  idea 
of  persecution,  believes  that  people  are  in  a  con- 
spiracy against  him,  and  that  his  life  is  being 
ruined  by  such  persecution.  These  patients  some- 
times turn  upon  their  supposed  enemies  and  in- 
stead of  remaining  persecuted  they  become  per- 
|  secutors.  They  fancy  that  they  have  a  mission 
to  set  wrongs  right  and  to  pursue  evil  doers,  and 
sometimes  they  do  a  great  deal  of  mischief  in  so- 
ciety. Then  again,  the  delusions  may  assume  an 
emotional  character  that  is  usually  either  of  a  re- 
ligious or  of  an  erotic  nature.  There  are  many 
conspicuous  examples  in  the  history  of  the  world 
I  of  patients  whose  delusions  have  been  of  a  grand 
and  noble  character,  tinged  strongly  with  a  relig- 
1  ious  coloring  :  perhaps  with  the  consequence  that 
they  have  played  a  very  important  part  in  the 
history  of  the  world  as  religious  leaders,  as  found- 
ers of  schools  of  thought,  as  authors  of  schemes, 
for  the  regeneration  and  elevation  of  humanity. 
Indeed  it  seems  to  me  rather  difficult  sometimes 
to  draw  the  line  between  a  paranoiac  of  this  char- 
acter and  an  individual  of  sound  mind  and  body 
who  is  dominated  by  benevolent  impulses,  not  of 
unsound  character.  Again,  there  are  those  whose 
delusions  take  an  erotic  turn,  and  who  are  im- 
pelled by  certain  erotic  notions  that  do  not  always 
assume  the  form  of  obscenity  or  unchastity.  but 
show  a  preponderance  of  sexual  passion  and  in- 
clination in  some  form  or  other.  It  is  in  this  way 
that  the  disease  usually  manifests  itself.  Were 
time  sufficient  it  would  be  easy  to  illustrate  the 


192 


MONOMANIA. 


[February  7, 


different  forms  of  paranoia  with  which  we  meet, 
but  I  will  only  hint  at  two  or  three  cases.  I 
think  they  are  cases  with  which  my  friends,  Dr. 
Brower  and  Dr.  Church  are  very  familiar,  and 
about  which  they  probably  know  more  than  I  do, 
as  they  have  had  an  opportunity  of  becoming 
more  fully  acquainted  with  them,  and  I  hope 
they  will  give  us  some  particulars  with  regard  to 
them. 

I  will  allude  in  the  first  place  to  the  case  of  the 
young  man,  who  on  one  occasion  in  this  city  as- 
saulted a  very  distinguished  actor  in  the  theater, 
firing  a  pistol  at  him  from  the  gallery  with  the 
view  of  committing  murder,  under  the  influence 
of  the  insane  delusion  that  he  was  the  son  of  the 
actor,  that  he  was  a  gifted  tragedian  himself, 
though  not  recognized  by  the  world,  that  his 
mother  had  been  ruined  by  this  actor,  and  it  was 
his  mission,  not  only  to  assert  his  own  dignity 
and  superiority  as  an  actor,  but  to  bring  to  justice 
the  aggressor  upon  the  rights  of  his  family.  I 
think  this  was  a  very  good  illustration  of  the 
form  of  paranoia  we  sometimes  meet,  in  which 
there  are  what  we  call  "  grand  delusions"  of  su 
periority  and  greatness  ;  and  with  that,  as  in  this 
case,  may  be  joined  a  disposition  to  right  wrongs. 

There  was  another  noted  case,  which  I  think 
Dr.  Church  had  under  his  observation  at  Elgin. 
It  was  the  case  of  Joel  Henry  Wells,  with  whose 
history  I  am  not  well  acquainted,  that  is,  I  am 
not  acquainted  with  his  family  history  and  the 
hereditary  influences  that  were  brought  into  ac- 
tion in  his  case.  He  was  a  man  who  was  appar- 
ently of  sound  mind  and  body  when  I  saw  him, 
and  evidently  gifted  with  large  reasoning  powers 
and  great  acuteness  of  observation,  adroitness  and 
ingenuity  ;  but,  nevertheless,  was  dominated  by 
a  most  singular  delusion  of  the  grand  type.  He 
was  really  the  son  of  a  modest  unassuming  farmer, 
but  he  believed  that  he  was  no  such  person,  but 
the  son  of  a  foreign  nobleman,  and  he  constructed 
a  most  intricate  and  complicated  history  to  ac- 
count for  all  his  course  of  action  during  a  long 
period  of  time. 

With  regard  to  these  delusions  there  is  another 
point  I  must  mention,  that  the)'  are  characterized 
by  remarkable  consistency.  Delusions  are  ex- 
ceedingly common  among  insane  people,  but  as  a 
rule  their  delusions  are  not  homogenous.  They 
arise  as  the  clouds  go  across  the  sky,  assuming 
all  sorts  of  shapes  and  forms,  and  vanishing  as 
quickly,  but  it  is  not  so  with  the  delusions  of  the 
paranoiac.  He  starts  out  with  some  dominating 
delusion,  and  as  that  delusion  proceeds  it  assumes 
definite  shape  and  form,  and  the  actions  that  are 
based  upon  that  delusion  are  as  consistent  as  are 
the  daily  actions  of  a  person  of  a  sound  mind  ;  so 
that  they  differ  entirely  in  this  characteristic  from 
the  ordinary  delusions  of  mania  or  melancholia, 
or  any  other  variety  of  insanity.  To  distinguish 
them  from  the  shifting  half-formed  and  impotent 


delusions  of  ordinary  insanity  they  are  generally 
spoken  of  as  systematized  delusions.  I  think  Dr. 
Church  can  give  us  in  the  history  of  some  of  his 
patients  very  interesting  examples  of  the  consist- 
ent form  which  the  delusion  will  take  in  the 
brain  of  the  paranoiac  patient. 

A  number  of  years  ago  I  was  visited  by  a  fam- 
ily from  the  country,  respectable  people,  the 
father,  mother,  and  a  young  man  of  about  22 
years  of  age.  The  young  man  appeared  perfectly 
well,  there  seemed  to  be  nothing  whatever  the 
matter  with  him.  I  conversed  with  him  and  he 
talked  like  any  other  person  in  a  perfectly  reason- 
able way.  I  could  discover  in  bis  conversation 
no  evidence  of  a  disordered  mind.  Why  had  they 
come  to  see  me?  Conversation  with  the  parents 
revealed  the  fact  that  he  was  laboring  under  the 
delusion  that  they  had  become  Mormons  and  were 
carrying  on,  as  he  said,  Mormon  practices  in  their 
house  and  the  neighborhood.  Expostulation  on 
the  part  of  his  parents  and  friends  produced  little 
or  no  effect.  He  would  acquiesce  in  everything 
that  was  said,  but  in  a  little  time  his  acquiescence 
would  be  forgotten  entirely,  and  the  delusion 
would  press  upon  him  again.  He  went  to  the 
sheriff  of  the  County,  and  talked  with  him  about 
the  steps  that  would  be  necessary  for  breaking  up 
this  Mormon  nest  in  the  household.  When  I  was 
informed  of  this  delusion  I  talked  with  him  about 
it,  and  asked  him  if  it  was  true  ;  he  said  he  sup- 
posed it  was  all  a  mistake,  he  had  thought  it  was 
so,  but  he  didn't  think  it  was  so  now,  and  proba- 
bly he  was  mistaken ;  he  was  willing  to  ad- 
mit that  he  had  been  the  victim  of  a  delusion.  I 
cautioned  his  parents  about  his  condition,  told 
them  what  it  probably  meant  and  what  might  be 
the  outcome,  warned  them  of  the  possible  conse- 
quences of  living  in  such  a  way  ;  and  advised 
them  by  all  means  to  have  the  young  man  placed 
in  safety.  They  went  away  and  I  heard  nothing 
more  of  the  matter  for  a  considerable  time.  One 
day  I  picked  up  a  paper  and  read  the  account  of 
a  murder  which  had  taken  place  in  that  locality, 
and  learned  that  this  young  man  was  the  murder- 
er ;  he  had  murdered  his  mother.  He  was  out  at 
work  in  the  field  when  he  made  some  excuse, 
went  back  to  the  house,  took  up  a  gun  and  shot 
his  mother  dead.  The  delusion  had  come  upon 
him  in  full  force,  and  under  its  influence  he  had 
gone  to  work  to  do  justice  upon  his  supposed 
Mormon  mother.  That  is  the  way  with  these 
paranoiacs,  they  may  appear  perfectly  rational, 
and  may  talk  in  a  way  to  deceive  the  very  elect. 

I  remember  on  a  notable  occasion  in  the  case  of 
Joel  Henry  Wells,  of  whom  I  spoke  a  little  while 
ago,  he  was  brought  into  court,  and  members  of 
his  family  came  to  testify  before  the  court  that  he 
was  a  perfectly  sane  man  ;  but  before  many  days 
they  all  admitted  that  they  had  been  deceived  and 
that  he  was  insane.  So  these  persons  may  de- 
ceive the  very  elect  in  a  casual  conversation.     It 


■89i] 


RECENT  MEDICAL  CASES  IX  THE  COURTS. 


'93 


may  require  considerable  ingenuity   and  an  ex- 
tended acquaintance  with  a  patient  to  detect  the 
existence  of  a  delusion  ;  and  when  that   delusion 
is  presented  it  will  be  found  so  plausible,  so  con- 
sistent in  all  its  parts,  that  unless  you  have  infor- 
mation in  regard  to  the   individual   and   his  sur- 
roundings you  may  be  deceived.      In  the  instance 
of  the    man  just    referred  to,  when  he    took  the 
stand  and  told  his  story  he  told  it  in  such  a  con- 
sistent, interesting  manner  that  a  bystander,  un- 
less he  knew  some  reason   for  disbelieving  the 
narrative,  would  accept  it  ;  the  Judge  himself  was 
completely    puzzled.      At    last  the    veracity   and 
probability  of  the  story  turned  entirely  upon  the 
determination  of  the  actual  fact  of  an  incident  that 
he  related.      He  told  of  a    marriage    which    had 
taken  place  in  a  certain   church,  in  a  certain  city 
and  at  a  certain  time.     It   happened  to  be  a  Ro 
man  Catholic  church  where  it  is  customary  to  keep 
a  record  of  such  events.     The  judge  at  once  rec- 
ognized the  possibility  of  testing  the  truth  of  this 
apparently  plausible  narrative,   so  he  sent  to  the 
church  indicated  for  information  as  to  the  truth 
or  falsity  of  this  statement,  whether  such  a  mar- 
riage had  taken  place  or  not.     Word  came  back 
that  no  such  marriage  had   ever  taken  place  in 
that  church,   and  this  showed  at  once  that  the 
whole  story  was  a  delusion  ;  vet  it  was  so  con- 
sistent in  all  its  parts  that  without  a  knowledge  of 
the  history  of  the  patient  it  would  have  been  im- 
possible for  a  stranger  to  detect  the  falsity  of  the 
narrative  or  the  fact  of  the  delusion. 

I  will  not  take  up  more  time  as  Dr.  Brower  and 
Dr.  Church  can  undoubtedly  contribute  a  great 
deal  more  on  this  subject  than  I  can. 

(For  discussion,  see  Society  Proceedings.) 


[conduct,  at  not  less  than  the  minimum  of  impris- 
onment provided  by  law.  and  if  sentenced  for 
more  than  one  successive  term  for  separate  of- 
to  remit  the  succeeding  term  or  terms  at 
the  close  oi  the  first.  Similar  Acts  were 
by  New  York  and  Michigan  in  i88y,  but  with 
further  provision  for  allowing  prisoners  so  sen- 
tenced to  go  at  large  on  parole,  subject  to  be  re- 
taken and  imprisoned  for  violating  its  conditions 
A  Kentucky  statute  limits  the  number  of  peni- 
tentiary prisoners  who  mav  be  paroled  in  any 
oik-  year  to  five  per  cent.  An  Iowa  statute  pro- 
vides for  shortening  the  time  of  convicts  as  a  re- 
ward for  good  conduct,  at  the  rate  of  one  month 
tor  the  first  year  and  an  additional  month  for  suc- 
ceeding years  until  one  half  is  remitted,  but  such 
'  good  time"  to  be  forfeited  for  misconduct  or  at- 
tempted escape  ;  and  another  Act  of  that  State 
appropriates  Siooo  to  be  expended  by  the  Iowa 
Prisoners  Aid  Association  in  helping  discharged 
convicts  to  an  honest  life. 


RECENT  MEDICAL  CASES  IN  THE 

COURTS. 

BY  HENRY  A.  RILEY,  ESQ., 

OF  NEW   YORK    CITY. 

RECENT    LEGISLATION  TO    REFORM  CRIMINALS. 

A  summary  of  legislation  concerning  the  public 
health  and  the  public  morals  was  published  not 
long  since,  covering  the  statutes  enacted  in  the 
various  States  during  the  previous  twelve  months, 
and  that  portion  relating  to  crime  is  of  general  in- 
terest. The  writer  says  :  "the  statutes  of  several 
States  reflect  the  humane  and  growing  sentiment 
that  the  punishment  of  criminals  should  contem- 
plate, and  as  far  as  possible  provide  for  their  ref- 
ormation." 

Ohio  authorizes  general,  or  what  are  known  as 
intermediate  sentences  for  all  persons  for  the  first 
time  convicted  of  felony  below  murder  in  the  sec- 
ond degree,  the  board  of  managers  of  the  peni- 
tentiary being  authorized  to  terminate  the  impris- 
onment of  any  person  so  sentenced  in  case  of  good 


EXTRADITION    AND     THE     NIHILIST     PADLEWSKI. 

The  murder  of  General  Seliveskoff  at  Paris  by 
the  Nihilist  Padlewski  has  caused  renewed  at- 
tention to  be  paid  to  extradition  laws,  and  some 
of  the  Governments  of  Europe  have  made  great 
efforts  to  secure  legislation  more  suited  to  the  free 
extradition  of  persons  charged  with  offences  more 
or  less  political. 

Considerable  interest  has  been  felt  in  the  posi- 
tion of  Switzerland,  which  countrv  has  long  been 
known  as  a  safe  asylum  for  persons  charged  with 
political  offenses.  It  has  been  said  that  a  recent 
law  was  a  concession  to  the  reactionary  party  and 
would  permit  the  extradition  of  such  persons. 

The  text  of  the  law  does  not  seem  to  warrant 
such  a  statement,  and  in  realitv  maintains  the 
traditionary  position  of  Switzerland. 

It  says  :  ' '  Extradition  Shall  not  be  granted  for 
political  crimes  and  misdemeanors.  Still,  when- 
ever the  accused  person  shall  plead  political  mo- 
j  tives  or  aims,  extradition  shall  be  granted  if  the 
act  for  which  it  so  demanded  is  one  of  the  graver 
crimes  or  misdemeanors  under  the  common  law. 
"The  Federal  tribunal  shall  examine  the  facts 
and  decide  upon  the  nature  of  the  act.  When- 
ever  extradition  shall  have  been  granted,  the  Fed- 
eral Council  shall  demand  that  the  person  to  be 
extradited  shall  be  neither  charged  with  nor  pun- 
ished for  political  crime,  and  also  the  punishment 
shall  not  be  made  the  more  severe  because  some 
political  motive  or  aim  might  be  laid  to  the 
charge  of  the  accused  persDn." 

A    DEFINITION  OF    DELIRIUM    TREMENS'. 

In  a  recent  case  in  Indiana  an  insurance  policy 
freed  the  company  from  liability  where  the  as- 
sured "shall  become  so  far  intemperate  as  to  im- 
pair his  health  seriously  or  permanentlv  or  induce 
delirium  tremens,"  and  the  Court  held' that  delir- 


i94 


LARYNGEAL  PAPILLOMATA. 


[February  7, 


ium  tremens  was  "  that  diseased  condition  of  the 
brain  said  to  be  produced  by  the  excessive  and 
prolonged  use  of  spirituous  liquors." 

The  insurance  company  objected  to  this  defini- 
tion of  the  disease  but  the  Appellate  Court  was  of 
the  opinion  that  it  was  correct  and  as  favorable 
to  the  company  as  could  be  asked  for. 

PHYSICIANS   ON    A  STRIKE. 

Many  of  the  physicians  of  Dutchess  Co.,  New 
York,  have  inaugurated  a  strike  against  the  Board 
of  Supervisors.  They  have  sent  in  a  petition 
very  largely  signed  in  which  they  say  that  they 
believe  $10  to  be  a  just  and  fair  charge  for  an  ex- 
amination of  a  dead  body  before  a  coroner  ;  $25 
a  just  charge  for  ordinary  autopsical  examinations, 
and  $10  a  just  charge  for  an  ordinary  examina- 
tion in  lunacy. 

They  further  declare:  "We  do  hereby  agree 
not  to  perform  the  duties  of  coroner's  physician  or 
as  examiner  in  lunacy  for  a  less  sum  than  stated  ; 
and  we  would  respectfully  ask  your  Board  to  fix 
the  above  charges  as  legitimate  rates." 

WHEN   A   HOUSE   IS   UNTENANTABLE. 

The  ordinary  rule  in  house  tenancy  is  that  the 
lessee  is  liable  for  rent  even  though  the  building 
become  rickety  and  poor.  In  some  of  the  States, 
however,  as  in  New  York,  the  lessee  is  freed  from 
his  obligation  if  the  property  becomes  "  unten- 
antable and  unfit  for  occupancy."  This  limita- 
tion naturally  comes  up  frequently  for  construc- 
tion in  disputes  between  landlord  and  tenant,  and 
a  recent  decision  shows  certainly  that  the  tenant 
in  one  case  was  entitled  to  abandon  his  lease.  It 
appeared  from  the  evidence  that  the  building  was 
shaken  b3'  repeated  explosions,  which  caused  the 
walls  and  ceilings  to  crack,  the  plaster  to  fall, 
clocks  to  stop  ;  that  the  building  was  declared  by 
the  public  authorities  to  be  unsafe  and  dangerous, 
and  that  the  rooms  were  at  times  so  filled  with 
coal  gas  and  smoke  as  to  make  the  inmates  sick. 
The  landlord  ventured  the  cheerful  opinion  that 
the  explosions  were  the  result  of  dynamite  being 
exploded  somewhere  in  the  house.  The  Court  de- 
cided that  the  tenant  was  having  a  hard  time  and 
that  he  was  constructively  evicted  and  need  not 
pay  rent.  It  must  not  be  understood  however, 
that  he  could  continue  to  occupy  the  premises  and 
not  pay  rent.  He  must  go  out  if  he  did  not  want 
to  pay  rent. 

HYPNOTISM   IN    CINCINNATI. 

The  Common  Council  of  Cincinnati  has  just 
an  ordinance  making  it  a  misdemeanor  to 
give. hypnotic  exhibitions.  Dr.  J.  W.  Prendergast, 
Health  Officer  of  that  city,  is  of  the  opinion  that 
hypotism,  when  applied  indiscriminately,  is  inju- 
rious, as  it  affects  the  mental  health  of  the  sub- 
ject, and  recommended  the  enactment  of  the  or- 
dinance. A  lecturer  on  hypnotism  was  refused 
a  license  and  obliged  to  leave  the  city. 


HEALTH    ORDINANCES    IN    THE  SOUTH. 

Not  long  since  a  Southern  town,  desirous  to 
secure  the  title  and  emoluments  of  a  health  re- 
sort, passed  an  ordinance  declaring  that  no  land 
within  the  city  limits  exceeding  an  eighth  of  an 
acre  should  be  cultivated  by  any  one  person  ex- 
cept for  flower  gardens,  the  grape,  and  trees  of  all 
kinds,  and  absolutely  forbidding  the  cultivation 
of  rice  under  any  circumstances.  This  ordinance 
came  before  the  State  Supreme  Court  for  review 
and  was  held  valid  under  the  general  power  held 
by  all  communities  to  legislate  for  the  health  of 
the  town.  It  is  evident  that  the  South  is  bound 
to  secure  the  reputation  of  being  healthy  even  if 
food  has  to  be  imported  from  other  sections,  on 
account  of  the  non  cultivation  of  the  soil. 

FEDERAL  LAWS  ON  IMMIGRATION. 

The  subject  of  controlling  undesirable  legisla- 
tion will  occupy  considerable  attention  at  the 
present  session  of  Congress,  and  one  of  the  main 
objects  will  be  to  amend  the  laws  so  as  to  pre- 
vent paupers,  criminals  and  insane  immigrants 
from  entering  the  United  States  by  way  of  Can- 
ada. A  bill  has  just  been  reported  in  the  House 
of  Representatives  on  the  subject,  but  as  it  con- 
tains no  reference  to  Canada  will  require  amend- 
ment. One  section  of  the  bill  imposes  a  fine  of 
$1000  or  imprisonment  on  any  person  who  brings 
into  the  country  an  alien  not  entitled  to  land. 
This  requires  almost  supernatural  knowledge  on 
the  part  of  the  Captains  of  transatlantic  steamers 
and  will  no  doubt  have  to  be  changed. 


THE  CLINIC. 


LARYNGEAL  PAPILLOMATA  IN  A  CHILD 

THREE  YEARS  OF  AGE ;  ENDO- 

LARYNGEAL  REMOVAL. 

A  Clinical  Lecture  in  the  Rush  Medical  College.  Chicago,  Oct.,  iSgo. 
BY  E.   FLETCHER  INGAI.S,   A.M.,   M.D., 

PROFESSOR   OF   LARYNGOLOGY. 

Gentlemen  :  I  have  to  show  you  to  day  a  lit- 
tle boy  who  was  recently  sent  to  me  from  New 
Mexico  because  of  aphonia  and  difficulty  in  res- 
piration. The  mother  gives  me  the  following 
history  :  The  boy,  who  is  now  3  years  of  age, 
has  never  been  able  to  speak  aloud,  and  was 
always  troubled  with  difficulty  in  breathing 
whenever  he  took  cold,  indeed  there  has  been 
something  peculiar  in  his  respiration  ever  since 
birth.  When  he  was  2  years  of  age  the  parents 
noticed  enlarged  tonsils,  which  it  was  thought 
might  l>e  the  cause  of  his  difficulty  in  breathing. 
He  was  then  taken  to  a  physician  who  gave  him 
some  local  and  internal  treatment,  with  the  hope 
of  reducing  the  size  of  these  glands.     About  last 


I89i.] 


LARYNGEAL  PAPILU  <MATA 


Christmas  his  breathing  became  much  worse,  and 
continued  to  grow  more  and  more  difficult  until 
about  the  middle  of  February,  when  he  was 
taken  with  an  acute  inflammation  of  the  larynx, 
the  result  of  a  cold,  which  was  attended  by  the 
symptoms  of  croup.  For  this  he  was 
emetics  that  caused  the  vomiting  of  a  considera- 
ble amount  of  mucus,  which  seemed  to  relieve 
him  for  the  time  being.  But  about  a  week  later 
tracheotomy  became  necessary  to  prevent  suffo- 
cation. Shortly  afterward  it  was  found  that  he 
was  unable  to  breathe  at  all  through  the  larynx, 
and  about  the  middle  of  March  and  extending 
over  a  period  of  six  weeks,  several  attempts  were 
made  by  the  local  physicians  to  relieve  the  ob- 
struction, but  without  any  very  satisfactory-  re- 
sults. He  was  finally  brought  to  my  office  dur- 
ing my  absence  from  the  city  and  was  examined 
by  my  assistant,  Dr.  J.  E.  Rhodes,  who  told  me 
that  by  pressing  the  tongue  down  firmly  he  was 
enabled  to  see  a  portion  of  the  tumor  rising  above 
the  tip  of  the  epiglottis.  A  few  days  later  I  saw 
the  child  for  the  first  time  ;  his  experiences  had 
been  such  that  he  began  to  cry  and  fight  the 
moment  he  was  brought  into  my  consultation 
room,  and  therefore  I  found  it  useless  to  try  to 
inspect  the  larynx.  By  closing  the  tracheal  tube 
I  found  that  no  air  could  pass  through  the  larynx. 
I  placed  a  gag  in  the  child's  mouth  and  passed 
my  forefinger  behind  the  epiglottis,  where  I 
could  distinctly  feel  a  large  mass  completely  fill- 
ing the  vestibule  of  the  larynx.  This  was  soft, 
had  a  granular  or  uneven  surface,  and  felt  in  all 
respects  like  a  papillary  tumor. 

It  was  impossible  to  remove  an}-  portion  of  this 
tumor  with  the  finger  nail,  therefore  I  selected  a 
pair  of  short,  strong  laryngeal  forceps  with  spoon- 
shaped  cutting  blades,  which  I  passed  into  the 
larynx,  guided  by  the  index  finger  of  my  left 
hand.  With  these  I  succeeded  in  removing  at 
one  bite  a  mass  of  the  tumor  as  large  as  a  filbert. 
Introducing  the  forceps  two  or  three  times  more 
I  removed  other  pieces  of  this  growth,  so  as  to 
practically  free  the  vestibule  of  the  larynx.  By 
this  time  there  was  so  much  blood,  and  the  child 
was  so  exhausted  from  his  continual  struggle 
that  I  postponed  further  operation  until  another 
sitting. 

Subsequently  with  forceps  cutting  antero-pos- 
teriorly  or  laterally  I  removed  piece  after  piece 
until  the  vestibule  of  the  larynx  appeared  free. 
I  then  passed  the  forceps  through  the  glottis  and 
removed  several  masses  from  below  the  cords, 
thus  at  four  or  five  sittings  the  tumor  was  ap- 
parently entirely  removed,  but  still  the  boy  could 
not  breathe  when  the  tracheal  canula  was  closed. 
This  was  due,  partially  at  least,  to  granulation 
tissue  springing  from  just  above  the  tracheal 
canula.  I  removed  this,  but  when  the  patient 
returned  some  days  later  I  found  him  unable  to 
breath  through  the  mouth,  the  glottis  being  ap- 


parently closed  by  adhesions  of  the  vocal  cords. 
With  my  finger  in  the  larynx  as  a  guide  I  then 
forced  between  the  cords  a  forceps  opening  antero- 
posteriorly  ;  then  holding  the  blades  open  I  with- 
drew the  forceps,  thus  dilating  the  glottis  through- 
out its  entire  length.  Four  or  five  days  later  the 
condition  had  returned  and  the  same  operation 
was  repeated.  At  a  recent  sitting  I  attempted  to 
place  an  intubation  tube  in  the  larynx,  which  I 
hoped  to  leave  until  healing  of  the  cords  had  oc- 
curred, but  the  opening  in  the  trachea  had  been 
made  so  high  up  that,  although  the  tube  had 
been  shortened  for  the  purpose,  it  was  impossible 
to  introduce  it  without  striking  the  tracheal 
canula  before  its  head  had  reached  the  vestibule 
of  the  larynx,  therefore  I  was  obliged  to  abandon 
the  plan. 

All  varieties  of  abnormal  growths  have  been 
found  in  the  larynx,  but  the  most  frequent  of 
these  are  papillary-  tumors,  about  75  per  cent.; 
next  to  these  come  the  fibrous,  and  next  to  these 
the  fibro-cellular  growths,  and  after  these  are 
scattering  cases  of  adenoma,  angioma  and  sar- 
coma. In  most  of  the  cases,  that  we  can  exam- 
ine laryngoscopically,  the  tissues  are  found  con- 
gested, and  tumor  springing  from  the  edges  or 
upper  surface  of  the  vocal  cords,  but  sometimes 
they  grow  from  the  under  surface  near  the  an- 
terior commissure,  or  from  the  ventricular  bands. 
In  the  case  which  I  have  shown  you  the  tumor 
seemed  to  grow  not  only  from  the  epiglottis, 
ventricular  bands,  and  edges  of  the  cords,  but 
also  from  the  sub-glottic  portion  of  the  larynx. 
Such  growths  are  generally  attributed  to  repeated 
or  continued  hyperemia  of  the  larynx,  and  some- 
times they  result  from  the  laryngitis  following 
measles,  scarlet  fever,  croup  or  diphtheria. 
Rarely  they  are  congenital,  as  seems  to  have  been 
the  case  in  this  patient. 

The  usual  symptoms  of  laryngeal  tumors  are 
dyspnoea,  dysphonia  or  aphonia,  dysphagia,  and 
occasionally  pain.  These  of  course  vary  with 
the  size  and  location  of  the  growth.  Cough  is 
occasionally  present,  but  is  not  apt  to  be  trouble- 
some unless  the  tumor  is  large  and  involves  the 
epiglottis,  or  unless  it  bleeds  easily.  When  pres- 
ent the  cough  is  frequently  of  a  croupy  character, 
as  was  observed  in  the  case  which  I  have  shown 
you.  Dysphonia  or  aphonia  is  one  of  the  most 
common  symptoms.  It  was  present  with  this 
patient  from  the  very  beginning,  and  was  the 
first  symptom  to  attract  the  parents'  attention. 
It  depends  upon  the  position  of  the  growth  and 
the  amount  of  concurrent  inflammation,  and  will 
therefore  vary  from  time  to  time.  It  is  some- 
times intermittent,  because  of  changes  in  the  in- 
flammation or  the  position  of  the  tumor. 
Dvsphagia  is  comparatively  frequent  in  malignant 
tumors  of  the  larynx,  but  does  not  often  occur 
with  benign  growths  excepting  when  the  tumor 
involves  the  epiglottis  or  the  posterior  lar 


196 


LARYNGEAL  PAPILLOMATA. 


[February  7, 


wall.  Pain  is  not  often  present  excepting  with 
malignant  growths,  though  a  sensation  as  of  a 
foreign  body  or  a  slight  uneasiness  in  the  throat 
is  not  uncommon,  especially  upon  deglutition. 

Diagnosis. — Upon  a  satisfactory  laryngoscopic 
examination  of  the  larynx  these  tumors  may  be 
readily  detected,  though  it  is  impossible  in  all 
cases  to  be  certain  of  their  true  character  until 
portions  have  been  subjected  to  microscopic  ex- 
amination, and  even  then  the  diagnosis  may  re- 
main in  doubt,  for  sometimes  laryngeal  growths 
which  present  a  malignant  histological  appearance 
may  have  a  benign  history  from  beginning  to 
end.  In  very  young  children,  however,  satis- 
factory laryngoscopy  is  seldom  attained,  and 
then  the  examination  must  be  made,  as  in  this 
case,  by  palpation.  However,  even  in  children 
a  good  view  of  the  larynx  may  sometimes  be  se 
cured  if  the  tongue  is  pressed  downward  and  at 
the  same  time  drawn  forward  by  Mount  Bleyer's 
depressor,  as  recommended  by  that  gentleman  in 
forcible  laryngoscopy  during  diphtheritic  croup. 

The  affections  which  are  most  liable  to  be  mis- 
taken for  benign  growths  of  the  larynx  are 
syphilitic  or  tubercular  laryngitis,  and  malig- 
nant tumors.  None  of  these  are  likely  to  occur 
in  young  children,  though  the  possibility  of 
syphilitic  laryngitis  must  not  be  overlooked  and 
critical  inquiry  must  be  made  into  the  history 
before  an  accurate  diagnosis  can  be  arrived  at. 
Specific  condylomata,  although  rare,  ma}'  possi- 
bly be  mistaken  for  a  tumor  of  the  larynx.  These 
consist  of  slightly  raised  irregular  prominences 
of  a  whitish  color  situated  on  the  congested  mu- 
cous membrane.  They  usually  occur  within  five 
or  six  weeks  after  inoculation  and  rapidly  disap- 
pear under  anti  syphilitic  treatment  and  the  local 
application  of  astringents,  whereas  a  laryngeal 
tumor  is  little  affected  by  these  measures.  Tuber- 
cular laryngitis  is  attended  by  swelling,  ulcera- 
tion, severe  pain,  and  grave  constitutional  symp- 
toms which  are  not  present  in  the  cases  under 
consideration. 

Malignant  tumors  oi  the  larynx  may  not  be 
easily  distinguished  at  first,  but  may  be  suspected 
when  there  is  decided  localized  congestion  and 
the  growth  appears  to  involve  the  whole  thick- 
ness of  the  mucous  membrane,  and  the  submu- 
cous tissues.  Later  they  are  characterized  by 
thickening  and  distortion  of  the  parts,  more  or 
less  pain,  and  finally  before  many  months  by 
marked  cachexia  and  constitutional  symptoms, 
in  which  respects  they  differ  much  from  most  be- 
nign growths. 

Papillomata  are  usually  located  on  the  upper 
surface  or  the  free  margin  of  the  vocal  cords,  but 
they  may  occur  in  other  portions  of  the  larynx, 
as  in  the  case  that  I  have  shown  you.  They  are 
generally  of  a  light  pink  color,  but  may  be  white 
or  even  red.  They  usually  have  an  irregular 
cauliflower  or  raspberry   like  surface,   and  may 


vary  in  size  from  a  few  millimetres  in  diameter 
to  a  mass  large  enough  to  completely  occlude  the 
larynx,  as  in  the  child  I  have  presented  to-day. 
Though  sometimes  pedunculated  they  usually 
spring  from  a  broad  base  and  several  tumors  may 
exist  in  the  same  case.  These  tumors  are  soft 
and  may  be  readily  torn  or  crushed  with  forceps, 
as  in  this  patient. 

Fibrous  growths  are  small,  round  and  firm, 
and  could  scarcely  be  confounded  with  papillary 
tumors.  Other  varieties  of  intra-laryngeal  growths 
are  so  uncommon  that  in  case  of  a  child  like  this 
they  could  hardly  affect  the  question  of  diagnosis. 

Prognosis. — The  tendency  of  these  growths  is 
to  steadily  progress  until  the  voice  is  lost  and 
respiration  more  or  less  interfered  with.  In 
children  they  are  very  likely  sooner  or  later  to 
cause  suffocation  unless  efficient  treatment  is 
adopted. 

Treatment. — Although  these  tumors  have  been 
known  to  disappear  without  operative  procedure, 
there  is  no  reason  to  believe  that  any  internal 
medication  is  of  any  value  in  their  reduction,  and 
it  is  doubtful  whether  the  local  application  of 
astringents  has  any  influence  upon  their  progress. 
Therefore  the  only  treatment  to  be  recommended 
is  the  removal  of  the  growth  by  suitable  instru- 
ments. Intubation  as  recommended  by  Dr. 
Joseph  O'Dwyer,  for  diphtheritic  croup,  has  been 
practiced  with  some  success  in  a  few  cases  for  the 
relief  of  papillary  growths  in  the  larynx,  but  is 
a  method  of  treatment  that  can  hardly  prove  cura- 
tive in  the  majority  of  cases. 

Various  tube  forceps  have  been  recommended 
for  removing  these  growths,  but  I  prefer  common 
forceps  bent  to  suit  the  larynx,  opening  antero- 
posteriorly  or  laterally,  with  crushing  or  cutting 
blades  according  to  the  nature  of  the  growth. 
These  are  commonly  known  as  Mackenzie's  for- 
ceps, various  modifications  of  which  I  have  had 
made  to  suit  special  cases.  Guillotines  and  snares 
have  also  been  recommended,  and  they  are  admi- 
rably suited  to  certain  cases.  Voltolini's  method 
of  rubbing  the  growth  firmly  with  a  sponge  at- 
tached to  a  suitable  staff  will  be  found  effectual 
in  some  cases,  and  is  especially  to  be  recommend- 
ed in  young  children,  when  the  growths  are  soft. 
The  galvano  cautery  has  also  been  employed  for 
the  destruction  of  these  neoplasms,  but  it  should 
never  be  used  excepting  by  those  whose  hands 
are  steady  and  experience  large.  When  it  is  used, 
the  platinum  point  should  be  made  of  fine  wire 
which  will  heat  or  cool  very  quickly,  so  that  other 
portions  of  the  larynx  will  not  be  injured  Chem- 
ical caustics  are  also  recommended  for  the  destruc- 
tion of  these  growths;  the  ones  most  frequently 
employed  being  the  nitrate  of  silver  and  chromic 
acid,  either  of  which  may  be  fused  upon  a  probe 
so  that  there  is  no  danger  of  the  caustic  dropping 
into  the  trachea.  Nitrate  of  silver  I  have  never 
found  of  much  value  excepting  for  cauterizing  the 


I89i.] 


LARYNGEAL  PAPILLOMATA. 


197 


base  after  a  tumor  has  been  removed,  but  chromic 
acid,  used  in  small  quantities,  is  very  efficient. 
In  applying  it  I  fuse  a  small  portion  of  the  acid. 
amounting  to  not  more  than  twice  the  bulk  of  an 
ordinary  pin's  head,  upon  the  end  of  an  alumin- 
ium probe.  I  slip  down  over  this  a  short  sec- 
tion of  small  rubber  tubing,  which  is  prevented 
from  falling  off  by  a  silk  thread  attached  to  it 
and  wound  about  the  probe  and  brought  up  to 
the  handle.  Where  I  wish  to  cauterize  with  the 
end  of  the  probe  the  tubing  is  passed  down  slight- 
ly beyond  it,  and  is  crowded  back  by  slight  pres- 
sure as  the  probe  touches  the  part  to  be  cauter- 
ized. When  I  wish  to  cauterize  with  the  side  of 
the  end  of  the  probe,  a  small  piece  is  cut  out  of 
the  rubber  tubing  in  the  proper  locality.  The 
larynx  is  very  apt  to  contract  immediately  after 
the  growth  is  touched,  but  this  section  of  rubber 
tubing  prevents  the  acid  from  being  smeared  upon 
other  parts  as  the  probe  is  withdrawn.  In  using 
forceps  they  should  be  applied  accurately  to  the 
growth  by  the  aid  of  the  throat  mirror  whenever 
this  is  possible.  But,  as  in  the  case  which  I  have 
shown  you.  it  will  sometimes  answer  to  apply 
them  guided  only  by  the  finger  and  a  knowledge 
of  the  condition  of  the  parts.  General  anaesthe- 
sia is  not  usually  practicable  in  operations  of  this 
kind,  though  it  might  sometimes  be  admissible  in 
young  children  when  tracheotomy  has  first  been 
performed.  Ordinarily  local  anaesthesia  should 
be  induced  by  the  application  of  a  10  to  25  per 
cent,  solution  of  cocaine,  before  an  operati6n  of 
this  kind  is  attempted,  but  in  children  great  care 
should  be  exercised  that  too  much  of  the  drug  is 
not  used. 

Whatever  operation  is  performed,  cold  applica- 
tions to  the  neck  should  be  directed  for  twelve  or 
thirty-six  hours  afterward  in  case  any  soreness 
residts,  and  the  operation  should  not  be  repeated 
until  three  or  four  days  after  all  tenderness  which 
may  have  been  caused  by  the  first  operation  has 
disappeared.  The  patient  should  be  cautioned 
to  use  the  voice  as  little  as  possible  until  all  con- 
gestion has  subsided.  The  application  of  astrin- 
gent sprays  daily  or  three  times  a  week  will  aid 
in  the  reduction  of  the  inflammation. 

The  indications  for  extra-laryngeal  operations 
consist  of  large,  dense,  or  inaccessible  growth  or 
growths  in  young  children  where  the  inter-laryn- 
geal  method  cannot  be  practiced.  But  this  meth- 
od should  not  be  tried  until  a  skilful  laryngolo- 
gist  has  failed  to  remove  the  growth  by  the  natural 
passage  and  should  never  be  tried  simply  for  the 
relief  of  the  voice,  but  only  when  the  growth  en- 
dangers life,  because  laryngotomy  is  itself  a  pos- 
itive danger  to  life  and  the  operation  very  seldom 
restores  the  voice,  besides,  recurrence  is  quite  as 
common  after  operation  done  in  this  way  as  after 
the  laryngeal  method.  Laryngeal  growths  have 
occasionally  been  removed  in  children  by  the  fin- 
ger-nail alone,  but  in  cases  where  all  or  a  part  of 


the  growth  is  attached  low  down  it  would  be  im- 
possible to  accomplish  this  result  without  the  aid 
of  forceps.  In  this  patient  I  believe  that  all  of 
the  tumor  has  been  removed,  and  it  is  my  our- 
pose  to-day  to  take  out  the  tracheotomy  tube  and 
to  insert  an  O'Dwyer's  intubation  tube  which 
will  be  allowed  to  remain  for  a  few  days  until  the 
parts  appear  to  have  healed.  The  intubation  you 
will  observe  is  performed  the  same  as  for  diph- 
theritic croup. 

Upon  withdrawing  the  tracheotomy  tubeT  now 
find  a  mass  of  granulation  tissue  above  it  which 
I  will  remove  by  means  of  a  punch-like  cutting  for- 
ceps which  I  had  made  for  a  similar  case.  It  is  very 
difficult  to  remove  these  growths  with  ordinary 
forceps  as  the  granulations  slip  away  from  the 
blade  into  the  trachea  upon  every  attempt  to  seize 
them.  Having  removed  the  granulation  mass  I 
will  now  introduce  into  the  larynx  a  pair  of  or- 
dinary laryngeal  forceps  in  order  to  ascertain 
whether  the  glottis  is  patent;  I  find  this  to  be  the 
case  and  you  may  readily  see  the  end  of  the  for- 
ceps through  the  tracheal  opening.  I  will  now 
introduce  one  of  the  smaller  sized  Schroetter's  di- 
lators, a  No.  5.  This  is  large  enough  to  fill  the 
trachea  and  will  therefore  crowd  down  to  the 
tracheal  opening  any  granulations  above  it.  I 
find  the  passages  perfectly  clear— the  child  now 
breathes  easily— I  will  now  introduce  the  O'Dwy- 
er's tube  suited  for  a  child  three  or  four  years  of 
age.  This  done,  the  head  of  the  tube  rests  in 
the  larynx,  and  the  body  may  be  seen  through  the 
tracheal  opening.  I  now  cut  and  withdraw  the 
string,  and  the  tube  is  left  in  the  larynx,  where 
it  will  remain  until  the  tracheal  opening  has 
closed. 

I  regret  that  the  original  opening  had  not  been 
made  farther  below  the  larynx,  as  that  would 
have  allowed  us  to  introduce  the  intubation  tube 
and  leave  it  until  we  were  assured  the  larynx  was 
in  a  healthy  condition  before  removing  the 
tracheotomy  canula,  as  it  is  if  our  present  plan  does 
not  succeed  it  will  be  necessary  to  again  open  the 
trachea.  During  the  next  few  days  this  child 
may  be  fed  upon  soft  solids  or  fluids,  but  fluids 
must  alwavs  be  given  with  the  body  in  a  reclin- 
ing position  of  about  forty-five  degrees,  the  head 
being  lowest,  so  that  the  liquid  cannot  run  into 
the  trachea. 

Xote.  —The  intubation  tube  was  removed  seven 
days  later.  The  tracheal  wound  had  then  been  closed 
for  six  davs  and  the  child  breathed  perfectly  after 
the  laryngeal  tube  had  been  taken  out.  He  had 
never  spoken  aloud  in  his  life  and  made  no  effort 
to  do  so  for  about  three  weeks,  but  the  whisper 
grew  louder  after  a  few  days. 

December  2 1 ,  at  the  end  of  six  weeks,  the  tu- 
mor was  again  found  to  be  growing— portions 
,  were  removed  and  an  intubation  tube  inserted 
I  but,  finallv,  a  mass  which  grew  from  the  under 
surface  of  the  epiglottis,  and  which  could  not  be 


MEDICAL  PROGRESS. 


[February  7, 


removed  excepting  with  the  curette,  necessitated 
the  reintroduction  of  the  tracheal  canula,  which 
was  put  in  to-daj'  lower  down  so  that  it  will  not 
interfere  with  a  short  laryngeal  tube,  which  will 
be  needed  after  future  operations  to  prevent  adhe- 
sions of  the  cords. 

Two  days  later  a  severe  bronchitis  developed, 
which  proved  fatal  in  about  ninety-six  hours. 
No  post-mortem  could  be  obtained. 

70  State  street. 


MEDICAL    PROGRESS. 


Therapeutics  and  Pharmacology. 

Treatment  of  High  Temperature  in  Ty- 
phoid Fever  and  Phthisis  Pulmonum  with 
small  frequently  repeated  doses  of  anti- 
febrin. — Dr.  August  Favrat  has  treated  a 
large  number  of  cases  in  the  wards  of  Professor 
Sahli,  in  Berne,  with  small,  frequently  repeated 
doses  of  antifebrin  {Dent.  Archiv.  j.  klin.  Med., 
Hft.  6,  511).  He  is  strongly  in  favor  of  antipy- 
retic treatment,  as  it  greatly  increases  the  com- 
fort of  the  patient,  and,  by  lessening  metabolism, 
tends  to  husband  the  strength.  The  author  points 
out  at  some  length  that  most  antipyretics  are  de- 
pressing, and  that  many  of  the  newer  ones  are 
used  rashly  in  practice,  before  we  are  thoroughly 
acquainted  with  their  dangers,  their  doses,  and 
the  most  effective  ways  of  exhibiting  them.  When 
one  reflects  how  long  it  has  taken  us  to  become 
even  imperfectly  versed  in  the  possibilities  to  be 
attained  with  digitalis,  opium,  etc.,  we  must  con- 
clude that  new  medicines  are  too  lightly  intro- 
duced, and  in  many  cases  too  lightly  cast 
aside.  These  considerations,  and  the  fact  that 
antifebrin,  although  a  sure  and  active  antipyretic, 
has  certain  drawbacks,  such  as  the  production  of 
collapse,  cyanosis,  etc.,  have  induced  Professor 
Sahli  and  the  author  to  try  if  they  could  not  ob- 
tain the  antipyretic  action  and  at  the  same  time 
avoid  these  drawbacks  by  giving  the  medicine  in 
small  repeated  doses,  instead  of  in  a  single  large 
dose,  as  is  customary.  The  advantages  of  such 
a  plan  are  obvious,  as  am  unpleasant  effects  may 
be  at  once  observed  and  the  medicine  stopped  be- 
fore serious  harmhasbeen  done.  Antifebrin  acts 
rapidly,  and  is  therefore  specially  suited  for  ex- 
hibition in  small  repeated  doses,  whereas  a  slow- 
ly acting  antipyretic,  such  as  quinine,  either  has 
no  action  in  small  doses,  or  causes  a  cumulative 
action  after  several  doses  have  been  given,  thus 
losing  the  advantages  to  be  derived  from  a  di- 
vided dosage.  In  typhoid  fever  antifebrin  was 
given  in  >.  t<>  i1  grain  doses  hourly  in  four 
In  no  case  was  more  than  20  grains  given 
during  the  twenty-four  hours.  The  action  was 
satisfactory,  and  in  all  cases  the  temperature  fell 
more  markedly  the  higher  it  was.    In  sewn  cases 


in  which  similar  doses  were  given  every  two  hours 
the  reduction  of  temperature  was  scarcely  suffi- 
cient. When  the  morning  temperature  was  not 
over  101.50  F.,  however,  a  two  hourly  dose  was 
found  quite  sufficient  (four  cases).  Similar  doses 
kept  the  temperature  about  normal  in  cases  of 
phthisis.  Neither  in  typhoid  fever  nor  in  phthisis 
did  antifebrin  exert  any  specific  action  on  the 
course  or  duration  of  the  disease.  In  all  these 
cases  antifebrin  was  well  borne  ;  a  gentle  antipy- 
retic effect  was  maintained  ;  in  several  cases 
sweating  was  present,  but  only  in  two  was  there 
the  least  sign  of  cyanosis  or  rigors.  In  no  case 
was  the  patient  ever  much  disturbed,  and  there 
were  never  any  alarming  symptoms.  In  conclu- 
sion the  author  gives  a  warning  against  the  use 
of  large  doses,  3  grains  being  reckoned  as  such. 
Although  much  larger  amounts  are  often  well 
borne,  yet  in  certain  cases  fatal  results  have  ensued. 
A  number  of  such  cases  are  cited. — Brit.  Med. 
Journal . 

Pilocarpin  in  Skin  Diseases  — Dr.  Klotz 
(fount,  of  Cut.  and  Genito- Urin.  Dis..  November, 
i8qo)  treated  cases  of  eczema  with  daily  hypo- 
dermic injections  of  ten  to  fifteen  drops  of  1  per 
cent,  solution  of  muriate  of  pilocarpin.  The  first 
case  was  that  of  a  man,  aged  28,  who  had  suffered 
for  several  years  from  eczema.  The  skin  showed 
no  great  infiltration  in  any  part  of  the  body,  but 
was  dry,  hard,  resistent,  and  slightly  scaling. 
After  the  first  injections  the  reaction  was  very 
slight,  moderate  moisture  appearing  on  some  of 
the  less  affected  portions,  but  it  generally  became 
more  distinct,  and  after  about  twelve  injections  a 
general  secretion  of  sweat  was  produced.  The  pa- 
tient left  the  hospital  after  the  seventeenth  injec- 
tion. The  scales  had  almost  entirely  disappeared, 
the  skin  was  much  softer  and  more  pliable,  and 
showed  "more  natural  turgor  and  elasticity," 
itching  having  become  very  insignificant.  The  sec- 
ond patient,  aged  21,  suffered  from  eczema  squa- 
mosum and  rimosum  of  both  palms,  which  were 
covered  with  a  very  hard  and  thick  horny  skin 
divided  by  numerous  cracks.  Other  treatment 
having  failed,  daily  injections  of  pilocarpin  were 
given,  the  patient  at  that  time  being  unable  to 
bend  or  close  his  fingers.  After  nineteen  injec- 
tions perspiration,  which  had  previously  appeared 
on  the  forearms,  wrists,  and  backs  of  the  bauds, 
now  appeared  for  the  first  time  on  the  palms.  On 
June  1st  the  horny  condition  of  the  surface  of  the 
palms  hail  entirely  disappeared,  the  skin  looked 
natural,  showed  all  the  ridges  and  indentations 
of  the  surface,  and  was  soil  and  pliable,  and  the 
] patient  could  move  and  close  the  fingers  without 
pain  or  difficulty.  A  third  patient  suffered  from 
a  general  papular  eczema,  which  was  attended 
with  considerable  thickening  on  the  llexor  aspects 
of  both  elbows.  Over  the  chest  and  abdomen 
and  in  a  milder  degree  011  the  extremities  the  skin 


I89i.] 


MEDICAL  PROGRESS. 


199 


was  bard,  dry,  slightly  scaling,  dark  brown  in 
color,  vvitb  numerous  small  bard  papules  of  a 
somewhat  lighter  color.  Tbe  patient  left  the  hos- 
pital  after  eight  injections,  at  which  time  tbe 
skin  had  lost  a  great  deal  of  tbe  dryness  and 
hardness,  the  papules  bad  been  greatly  reduced 
in  size,  and  tbe  itching  had  almost  disappeared. 
In  the  discussion  at  the  meeting  of  the  American 
Dermatological  Association  whicb  followed  the 
reading  of  this  paper  Dr.  Hardaway  stated  that 
his  experience  of  this  treatment  in  ichthyosis, 
eczema,  alopecia,  and  pruritus  was  not  such  as  to 
lead  bim  to  continue  it. 

Injections  of  Pyoktanin  in  Cystitis. — Dr. 
Leon  Nencki,  of  Warsaw,  reports  (Gaseta  Lekar- 
ska,  No.  32,  1890,  p.  642)  four  cases  of  exceed- 
ingly obstinate  chronic  cystitis  ( three  of  gonor- 
rhoea!, one  of  rheumatic  origin),  in  which,  after 
ordinary  measures  bad  completely  failed,  tbe  in- 
jection of  a  1  in  1,000  and  1  in  500  solution  of 
blue  pyoktanin,  repeated  twice  daily,  was  follow- 
ed by  cure  in  from  ten  to  fourteen  days.  In 
every  one  of  the  cases,  a  very  marked  ameliora- 
tion (decrease  in  turbidity  of  tbe  urine,  disap- 
pearance of  alkaline  reaction  and  pain,  etc.),  took 
place  in  a  couple  of  days  after  tbe  beginning  of 
the  treatment. 

Medicine. 

Points  in  the  Dietetic  Management  of 
Children. — Rachford  formulates  the  following 
rules,  whicb  will  aid  us  very  much  in  selecting  a 
diet  when  it  becomes  advisable  to  discontinue 
milk  temporarily  :  1.  Avoid  albuminous  food,  a, 
when  marktd  constitutional  symptoms  are  pres- 
ent ;  b,  when  in  doubt  as  to  tbe  character  of  tbe 
fermentation  causing  tbe  disease ;  c,  when  the 
stools  are  putrid  ;  d,  when  tbe  stools  contain  mu- 
cus and  blood  ;  <-,  when  the  nausea  is  constant 
and  not  relieved  by  vomiting.  2.  Avoid  carbo- 
hydrates as  a  food,  rt,  when  there  are  no  marked 
constitutional  symptoms  present,  and  tbe  stools 
are  continuously  acid;  b,  when  there  is  much  fla- 
tus, pain  or  urticaria.  3.  When  tbe  albumens 
are  to  be  avoided,  the  carbohydrates- are,  as  a 
rule,  indicated ;  and  when  the  carbohydrates  are 


pbdermically  every  four  hours,  until  slight  sali- 
vation  is  produced,  is  sufficient.  Locally  be  uses 
repeated  poultices  and  constant  steaming  by  means 
of  boiling  water  near  the  patient's  head.  Inter- 
nally, tartar  emetic  in  do  gr.  to  adults 
every  two  hours  lias  given  him  more  uniformly 
good  results  than  any  other  drug,  not  excepting 
sodium  salicylate.  If  any  depression  follows  the 
use  of  tbe  tartar  emetic,  which  is  unusual,  am- 
monium carbonate  or  strophanthus  may  tw 
Of  stimulants  he  think-  port  wine  tbe  bes 
believes  that  it  has  some  local  beneficial  ac- 
tion upon  tbe  inflamed  tonsils.  Guaiac  mix- 
ture is  sometimes  very  useful  in  relieving  the 
shooting  pain  often  complained  of  during  the  act 
of  swallowing.  It  is  usually  good  practice  to 
begin  treatment  by  the  administration  of  a  mer- 
curial followed  by  a  saline  purge.  Dr.  Hebirhas 
repeatedly  seen  marked  relief  follow  a  simple 
puncture  or  small  incision  of  the  tonsil,  and  this 
should  be  done  whenever  the  gland  is  greatly 
swollen.  It  is  much  preferable  to  the  use  of 
leeches  in  the  submaxillary  region.  He  believes 
that  strong  astringent  gargles  are  of  very  little 
use  during  the  acute  stage,  but  that  tepid  anti- 
septic gargles  may  be  beneficial. — Medical 

Surgery. 

A  Modification  of  Senn's  Method  of  Es- 
tablishing Lateral  Intestinal  Anastomo- 
sis. —  Dr.  W.  Sachs,  assistant  to  Professor 
Kocher,  of  Berne,  describes  (Centralblatt  fur  Chi- 
rurgie,  October  4)  a  modification  of  Senn's  meth- 
od of  forming  lateral  anastomosis  between  two 
separated  portions  of  intestine.  Senn's  procedure 
of  applying  two  bone  plates  is  held  to  be  not  free 
from  danger.  The  sutures  with  which  the  plates 
are  armed,  after  they  have  been  passed  through 
the  intestinal  walls  and  tied  together,  are  en- 
closed within  punctured  walls,  through  which 
capillary  communication  may  be  established  be- 
tween the  interior  of  the  intestine  and  the  peri- 
toneal cavity.  A  small  abscess  may  be  set  up 
around  one  of  tbe  threads  cut  very  short  and  en- 
on  every  side  by  the  opposed  serous  sur- 
faces of  the   two  portions  of   the    gut.     Another 


to  be  avoided,  the  albumens  are,  as  a  rule',  indi-  danger,  pointed  out  by  Helferich,  is  ga"pne  of 
cated.  4.  Give  foods,  such  as  cream,  beef-broths  the  intestinal  wal^due  to  pressure  ol  ^he  bone 
and  whisky,  a,  when  the  foods  prescribed  accord- 


ing to  the  above  rules  disagree  ;  b,  during  the  first 
twenty-four  hours  in  severe  acute  cases;  c,  when 
in  doubt  as  to  the  character  of  the  food  indicated. 
— Archives  of  Pediatrics. 

Treatment  of  Acute  Tonsillitis. — Sur- 
geon Hehir  {Indian  Med.  Gazette,  November, 
1890),  in  cases  of  acute  tonsillitis  recommends 
the  administration  of  pilocarpine  to  relieve  the 
distress  caused  by  the  accumulation  of  tenacious 
pharyngeal  mucus.  One-eighth  of  a  gr.  in  a  tea- 
spoonful  of  water  every  two  hours,  or  %  gr.  hy- 


plates.  Sachs  proposes  the  use  of  an  appliance 
resembling  in  form  a  sleeve  stud  perforated  in  tbe 
middle.  This  is  made  up  of  two  bone  plaU 
together,  yet  separated  to  a  small  extent  from 
each  other  as  far  as  the  uniting  portion  immedi- 
ately around  tbe  central  perforation.  A  longitu- 
dinal incision  having  been  made  in  each  of  the 
1  portions  of  intestine,  each  disc  is  insert- 
ed into  the  intestinal  canal  on  either  side,  and  tbe 
intestinal  anastomosis  is  thus  readily  and 
ily  established.  Sutures  are  then  applied  through 
the  serous  membrane  on  each  side  wherever  there 
is  a  tendency  to  protrusion  of  the  mucosa.     The 


MEDICAL  PROGRESS. 


[February  7, 


following  advantages  are  claimed  for  this  method, 
which,  however,  has  as  yet  been  tested  only  in 
experiments  on  rabbits:  1.  The  interior  of  the 
intestine  is  not  exposed  for  so  long  a  time  as  it  is 
in  Senn's  operation.  2.  The  margins  of  the  in- 
testinal wound  rest  in  the  deep  annular  groove 
between  the  joined  discs,  and  are  thus  protected 
against  infection  and  the  results  of  pressure.  3. 
There  is  no  risk  of  the  cut  edges  adhering  to- 
gether. 4.  It  is  unnecessary  to  pass  any  suture 
through  the  whole  thickness  of"  the  intestinal 
wall. — Brit.  Med.  Jour. 


OI>st<>tri<*«. 


Albuminuria  in  Pregnancy. — Ehrhardt 
and  Fanre  (Nouvelles  Archives  d' Obstet.  et.  de 
GyrtSc:,  September,  1890)  discuss  this  subject  in 
relation  to  a  mild  attack  of  puerperal  diphtheria 
in  the  Paris  Maternite.  They  sum  up  past 
theories  which  have  influenced  treatment.  Rayer 
traced  the  albuminuria  to  hydraemia,  which  ex- 
ists during  pregnancy.  He  had  noted  that  injec- 
tions of  water  into  the  veins  of  an  animal  caused 
albuminuria,  but  this  fact  does  not  prove 
his  theory.  Claude  Bernard  traced  albu- 
minuria to  a  state  of  superalbuminosis  in  preg- 
nancy. Injections  of  white  of  an  egg  into  the 
circulation  caused  albumen  to  appear  in  the  urine. 
Gothwald  and  Monas  held  that  the  phenomenon 
was  caused  by  increased  blood  pressure,  the 
gravid  uterus  compressing  the  aorta  below  the 
renal  arteries.  Others  believed  that  the  uterus, 
by  pressure  on  the  ureters,  caused  renal  disease. 
Lastly  some  pathologists  traced  the  albuminuria 
to  nerve  influences  carried  on  by  communications 
between  the  uterine  and  renal  plexuses.  None 
of  these  theories,  says  Drs.  Ehrhardt  and  Favre, 
explain  why  pregnant  women  suffer  from  albu- 
minuria only  in  exceptional  cases.  They  trace 
the  complication  to  local  disease.  They  exam- 
ined 300  placentas.  Of  these  20  were  from  cases 
of  albuminuria.  In  19  of  these  placentae  white 
infarcts  were  detected,  and  all  the  patients  except 
two  were  subject  to  severe  leucorrhcea  when  not 
gravid,  and  often  to  colicky  pains  during  men- 
struation, symptomatic  of  endometritis.  Colo- 
nies of  bacteria  were  found  in  the  infarcts,  and 
when  some  germs,  taken  from  infarcts  in  the 
placentae  of  patients  who  had  suffered  from 
eclampsia  as  well  as  albuminuria,  were  injected 
into  the  veins  of  rabbits  and  guinea  pigs,  par- 
enchymatous nephritis  was  set  up.  Thus  the 
morbid  changes  in  the  decidua  which  cause 
placental  infarcts  are  induced  by  the  same 
agency  that  induces  the  nephritis  of  preg- 
nancy. This  agency  is  the  presence  of  germs 
in  the  placenta,  which  germs  produce  in  non- 
pregnant patients  leucorrhoea  and  other  symp- 
toms of  chronic  endometritis.  The  focus  of  infec- 
tion being  the  uterine  mucous  membrane,  that 
structure  requires  attention  and  treatment.   When 


it  is  unhealthy  the  patient  may  repeated  bear 
foetuses  which  die  before  birth  through  disease  of 
the  placenta — that  same  disease  which,  in  the 
opinion  of  Drs.  Ehrhardt  and  Favre,  cause  the 
nephritis  of  pregnancy  with  consequent  albumin- 
uria. They  intend  shortly  to  describe  the  pre- 
cise nature  of  the  disease  in  the  kidneys  in  these 
cases.  The  moral  they  would  draw  is — Never 
neglect  uterine  discharges. — Brit.  Med.  Jour. 


Croupous  Pneumonia. — John  Peayfair, 
M.D.,  in  Edinburgh  Med.  Jour., — The  treatment 
should  be  mainly  expectant,  and  therefore  little 
need  be  said  of  it.  Continuous  hot  moist  appli- 
cations to  the  chest  were  not  employed.  Such 
applications  I  believe  do  harm.  They  impede 
the  movements  of  the  chest  by  their  weight,  tend 
to  increase  fever,  and  generally  are  anything  but 
comfortable. 

All  the  counter-irritation  required  is  secured  by 
the  application,  to  the  back  of  the  chest,  of  a 
few  hot  linseed  meal  poultices  sprinkled  over 
with  a  little  mustard.  Each  poultice  should  be 
kept  on  for  about  twenty  minutes,  and  in  the  in- 
tervals the  chest  enveloped  in  a  light  layer  of  cot- 
ton wool.  Internally,  if  the  cough  is  trouble- 
some, an  occasional  dose,  according  to  age,  of  a 
mixture  of  equal  parts  of  syrup  of  tolu  and  syrup 
of  chloral  should  be  given.  If  the  patient  seems 
to  be  getting  exhausted,  and  the  pulse  becoming 
rapid  and  feeble,  the  chloral  and  tolu  mixture 
should  be  stopped,  and  a  mixture  of  carbonate  of 
ammonia,  tincture  of  digitalis,  and  infusion  of 
senega  given  instead.  This  mixture  is  often  re- 
quired about  the  time  of  the  crisis  or  immediately 
after,  as  already  mentioned.  Alcohol  was  also 
usually  given  at  this  time. 

As  regards  antipyretics,  I  find  tepid  sponging 
is  by  far  the  safest  and  most  effective  means  of 
bringing  down  temperature  in  children.  It  is 
easily  carried  out,  and  a  skilful  nurse  can  sponge 
the  patient  as  often  as  necessary  without  in  the 
least  disturbing  or  exposing  him.  My  rule  is  to 
sponge  whenever  the  temperature  reaches  103 '  j°, 
and  to  do  so  every  two  hours  till  the  fever  is  re- 
duced two  degrees.  Antipyretics,  such  as  anti- 
pyrin  and  antifebrin,  are  given  in  some  cases 
also,  and  usually  with  good  effect.  Occasionally, 
however,  the  effect  is  greater  than  expected,  and 
the  consequent  exhaustion  more  pronounced  than 
desirable.  For  that  reason,  chiefly,  I  prefer  the 
sponging,  unless  in  a  case  of  hyperpyrexia,  as  in 
cases  where  the  temperature  runs  up  to  1060  and 
1070,  when  antipyrin  and  antifebrin  should  be 
used  atid  the  wet  pack  also  resorted  to.  I  prefer 
antipyrin  to  antifebrin  as  being  decidedly  less  de- 
pressing. 

During  convalescence,  iron,  maltine,  and  cod- 
liver  oil  are  the  chief  medicinal  agents  relied 
upon. — Archives  of  Gynecology. 


I89i.] 


EDITORIAL. 


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Address 

Journal  of  the  American  Medical  Association, 

No.  68  Wabash  Ave.. 

Chicago,  Illinois. 
All  members  of  the  Association  sho,-,j  send  their  Annual  Duel 
to  the  Treasurrr,  Richard  J.  Dunglison,  M.D.,  Lock  Box  12-4,  Phila- 
delphia, Pa. 


SATURDAY,  FEBRUARY  7,   1891. 


THE  TREATMENT  OF  THE  INFECTIOUS  DIS 

EASES. 
Up  to  the  present  time,  two  methods  have  been 
proposed  and  successfully  practiced  in  the  treat- 
ment of  the  so-called  infectious  diseases.  Three 
of  these  diseases,  smallpox,  anthrax  and  hydro- 
phobia, we  believe,  are  successfully  stayed  in  their 
destructive  course  by  the  immunity  which  follows 
an  infection  with  the  attenuated  virus  of  the  re- 
spective disease.  For  small-pox,  we  have  two 
methods  equally  successful,  "inoculation"  and 
"  vaccination."  They  are  practically  illustrations 
of  attenuation  of  infection  produced  in  two  differ- 
ent ways. 

Only  one  of  the  chronic  infectious  diseases, 
syphilis,  has  so  far  been  successfully  treated,  and 
by  a  method  radically  and  entirely  different. 
The  remedial  effect  of  mercury  and  iodine  upon 
this  disease  is  as  anomalous  as  it  is  unparalleled. 
It  is  not  to  be  compared  with  the  treatment  of 
malaria  by  quinine.  To  state  the  matter  simply  : 
three  acute  infectious  diseases  are  successfully 
treated  by  attenuated  infection,  and  one  chronic 
infectious  disease  is  treated  successfully  by  the 
use  of  mineral  alteratives.  No  other  mycotic 
infectious  disease  pretends  to  an}^  preventive  or 
curative  treatment. 

From  so  limited  a  datum,  it  would  perhaps  be 
unwise  to  draw  very  positive  deductions,  but  it 
maybe  worth  while  to  speculate  on  the  presump- 
tions of  the  cure  for  tuberculosis  lately  proposed. 
This  disease  is  to  be  classed  with  syphilis  among 
the  chronic  infectious  diseases.  It  is  essentially 
an  obligate  parasite  of  the  warm  blooded  animals, 
as  syphilis  is  a  close  parasite  of  man.     It  would 


seem  from  analogy  that  some  alterative  medica- 
tion might  be  instituted  in  this  disease  as  success- 
ful as  the  application  of  mercury  in  syphilis. 
Therefore  we  are  not  bound  by  our  previous 
knowledge  to  look  with  suspicion  upon  the  hy- 
podermic medication  proposal  by  Shtkly  and 
GiBBS.  They  recommend  a  well  tried  and  a 
surer  way  of  administrating  such  remedies  as  are 
too  unstable  to  be  absorbed  unchanged  by  the 
stomach.  Their  claims  are  not  sensational  and 
their  methods  are  unobscured  by  secrecy  or  re- 
serve. 

The  injection  of  the  products  of  parasitic  my- 
cotic growth  advocated  by  Robert  Koch  is  a 
line  of  treatment  which  has  no  parallel  in  our  ex- 
perience. It  can  not  be  compared  with  inocula- 
tion to  which  it  is  most  closely  related,  and  it  is 
wholly  different  in  principle  and  action  from  the 
treatment  so  successfully  practiced  in  our  only 
other  chronic  infectious  disease.  It  rests  then 
wholly  on  the  authority  of  the  author  who  has 
not  yet  had  an  opportunity  to  demonstrate  it--  ac- 
tion and  ultimate  value.  If  it  succeeds,  we  shall 
have  added  to  our  therapy  another  method,  be- 
fore the  promises  which  inoculation  offers  have 
been  demanded  by  investigation  and  fulfilled  by 
experience. 

There  still  remains  perhaps  the  saddest  category 
of  ills  to  which  civilization  has  exposed  man  in 
the  facultative  parasitic  diseases, — the  "  filth  dis- 
eases." Of  these  only  one  class  has  yet  been 
conquered,  the  infective  wound  diseases.  Sup- 
puration, erysipelas,  malignant  oedema  and  other 
hospital  diseases  have  become  so  rare  that  they 
are  objects  of  curiosity  in  our  large  clinics,  but 
typhoid  and  diphtheria  remain  with  us,  the  cause 
of  almost  five  per  centum  of  all  deaths  in  our 
larger  American  cities. 

Is  it  unreasonable  in  us  to  expect  that  every 
acute  infectious  disease  will  ultimately  be  over- 
come and  its  ravages  stayed  by  the  immunity 
which  follows  inoculation  with  an  attenuated 
virus,  and  that  each  of  the  chronic  infections  will 
be  disarmed  by  some  such  alterative  as  we  have 
found  so  efficient  in  syphilis,  and  that  the  filth 
diseases  will  disappear  when  an  educated  intelli- 
gence guides  our  individual  and  collective  life? 
In  some  distant  country,  there  are  those  in 
high  position  who  seriously  doubt  the  efficacy  of 
vaccination,  and  it  is  rumored  that  antivaccina- 
tion    societies   exist   there.     Even   in   our    own 


UTERINE  MEDICATION. 


[February  7, 


country  some  good  people  doubt  the  propriety  of 
using  mercury  for  syphilis,  and  Pasteur's  treat- 
ment for  hydrophobia.  Is  it  wonderful,  then, 
that  the  most  stinging  sarcasm  is  exhibited 
against  Shurly  and  Gibbs  to  whom  attention 
has  been  drawn  by  the  more  startling  and  almost 
coincident  announcement  of  Robert  Koch  ? 
Prejudice  should  not  have  an  audience  and  there 
should  be  nothing  ^.r  cathedra  in  medicine. 


SIR  ANDREW  CLARK'S    PATIENT:    A    CLINICAL 
SKETCH. 

Sir  Andrew  Clark  has  an  apt  and  deft  way 
of  lighting  up  his  subjects  by  means  of  clinical 
illustration.  Not  long  since  he  was  led  to  make 
public  some  of  his  views  regarding  the  non-tuber- 
cular and  non-cardiae  haemoptysis  of  elderly  per- 
sons, when  he  brought  forward  the  following 
illustrative  cases: 

Some  seven  years  ago,  Dr.  Wilson  Fox,  Sir  William 
Jenner  and  I  were  summoned  to  consult  together  about 
a  lady  suffering  from  an  incoercible  haemoptysis.  She 
was  a  Jewish  lady,  over  60  years  of  age,  very  stout,  very 
rheumatic  and  always  ailing.  She  had  nodular  finger- 
joints,  frequently  recurring  bronchial  asthma,  and  occa- 
sional outbreaks  of  either  eczema  or  urticaria.  Ten  days 
before  our  visit,  when  suffering  from  ordinary  catarrh 
without  any  accompanying  fever,  the  patient  began  to 
suddenly  cough  up  blood  and  had  continued  to  do  so,  in 
small  quantities,  at  intervals  of  three  or  four  hours  since 
that  time.  The  patient  had  a  somewhat  large  heart,  but 
there  was  no  murmur,  and  there  was  no  evidence  of  sys- 
temic arterial  disease.  Within  the  two  days  previous  to 
our  consultation  the  pulse  had  become  more  frequent 
and  quick  and  the  temperature  had  risen  to  100°  nearly. 
In  the  lungs  there  were  signs  of  a  generalized  bronchial 
catarrh,  of  emphysema  and  of  basic  congestion.  The  pa- 
tient complained  of  frequeut  cough,  of  great  oppression 
of  the  chest  and  of  a  growing  difficulty  of  expectoration. 
She  had,  furthermore,  a  loaded  tongue,  thirst,  loss  of  ap- 
petite, a  swollen  liver,  and  all  the  signs  of  a  gastro- 
enteric catarrh.  She  had  been  carefully  treated  by  ab- 
solute rest,  fluid  food,  ice  to  the  chest,  and  in  succession 
by  had,  gallic  acid,  and  the  hypodermic  injection  of 
ergotin.  After  full  discussion  it  was  determined  that 
another  method  of  treatment  should  be  tried.  The  pa- 
tient was  ordered  to  have  a  light  and  rather  dry  diet,  to 
ng  in  the  use  of  liquids,  to  discontinue  the  ice, 
to  have  a  calomel  pill  at  night,  followed  by  a  saline 
cathartic  on  the  following  morning,  and  to  take  an  alka- 
line mixture  with  ammonia  between  meals  twice  a  day. 
Within  thirty-sis  hours  the  haemoptysis  had  ceased  and 
the  patient  ma  ind  complete  recovery.  Aboul 

a  year  ami  a  half  ago  the   lady  again   consulted   me   on 
account  of  a  subacuti  Mhritis.      She  told  me 

that  since  she  saw  me    first   she    had    had    one   attack    ot 


bleeding  and  it  had  yielded  promptly  to  calomel  and 
salines.  The  contention  of  Dr.  Clark  in  regard  to  haem- 
orrhages of  this  type  is  that  they  are  liable  to  occur  and 
recur  in  elderly  persons  of  a  rheumatic  diathesis,  but 
who  are  free  from  organic  disease  of  the  heart  and  lungs, 
that  they  arise  out  of  minute  structural  alterations  in  the 
terminal  blood  vessels  of  the  lungs,  which  alterations 
are  akin  to  the  vascular  changes  found  in  the  osteo- 
arthritic  articulations,  and  are  themselves  of  an  arthritic 
nature,  and  that  while  this  haemoptysis  may  at  times 
lead  to  a  fatal  result,  it  usually  subsides  without  super- 
vention of  any  coarse  anatomical  lesion  of  either  heart 
or  lungs.  The  use  of  astringents  in  large  doses  appears 
to  be  productive  of  harm  chiefly  for  the  reason  that  it 
tends  to  create  great  thirst,  for  the  allaying  of  which  the 
patient  resorts  to  an  unrestricted  indulgence  in  liquids 
which  seems  to  perpetuate  the  trouble. 


UTERINE  MEDICATION  AND   UTERINE 
SURGERY. 

At  the  meeting  of  the  Philadelphia  Obstetrical 
Society,  December,  1S90,  Dr.  Charles  P.  No- 
ble presented  a  paper  upon  "  Minor  Uterine  Sur- 
gery," which  seems  to  us  timely,  since  it  is 
neither  on  the  one  hand  excessively  conservative, 
nor  on  the  other  unduly  aggressive,  in  its  recom- 
mendation of  surgical  procedures. 

It  might  be  inferred,  he  says,  that  gynecology 
had  been  so  fully  occupied  with  the  surgery  of 
its  appendages  that  the  uterus  itself  had  been 
neglected,  perhaps  from  the  fact  that  the  methods 
of  the  treatment  of  that  organ  had  been  placed 
upon  an  enduring  basis  and  needed  no  restate- 
ment. But  since,  in  a  recent  paper,  the  accepted 
methods  of  uterine  treatment  are  called  in 
serious  question,  he  believes  himself  warranted  in 
a  review  of  generally  accepted  teachings. 

He  insists  that  a  sharp  distinction  should  be 
made  between  diseases  of  the  uterus  and  diseases 
of  its  appendages,  and  this  distinction  is  rendered 
the  more  emphatic,  since  it  will  control  rational 
conclusions  as  to  operative  procedures. 

Barring  neoplasms,  he  claims  that  uncompli- 
cated diseases  of  the  uterus  seldom  or  never 
threaten  life.  Not  so,  when  its  appendages  are  in- 
volved. When  these  are  diseased,  to  tamper  with 
the  uterus  is  often  but  seriously  to  chance  more 
aggravated  conditions  of  diseased  append 

Referring  to  the  use  of  the  uterine  sound,  he 
regards  the  field  lor  its  use  as  a  limited  one,  and 
believes  that  more  harm  than  good  comes  from  it, 
as  used  to-day.  It  is  serviceable  in  the  diagnosis 
el  obscure  morbid  conditions  of  the  pelvis,  but 
Ik-  holds  that  the  size,  shape  ami  position  of  the 


I89i.] 


EDITORIAL  Ni 


203 


uterus  can  be  far  more  accurately  determined  by 
bimanual  examination  than  by  its  use.  As  to 
intra-uterine  medication,  be  deprecates  the  free- 
dom with  which  it  is  practiced,  and  considers  tbe 
cases  rare  in  which  benefit  is  derived  from  the 
application  of  remedies  within  the  internal  os 
uteri. 

The  dilatation  of  the  cervix  is  advised  in  the 
cure  of  obstructive  menstruation  for  sterility  due 
to  flexion  of  the  uterus,  for  the  removal  of  polypi, 
small  fibroid  tumors,  and  the  retained  products 
of  pregnancy.  Rapid  dilatation  is  advised  and  the 
steel  dilators  of  Dr.  Goodell's  pattern  are  pre- 
ferred. 

The  curette  is  considered  indispensable  in  the 
treatment  of  uterine  fungosities  for  the  removal 
of  endometrium,  in  certain  cases  of  obstruction 
and  congestive  dysmenorrhcea,  and  for  the  re- 
moval of  necrotic  tissue  after  incomplete  miscar- 
riages. 

But  the  utmost  care  is  enjoined  as  to  the  man- 
ner of  its  use — the  cervix  having  been  previously 
dilated,  and  the  finger  preceding  and  guiding  in 
application.  The  patient  during  its  employment 
should  be  thoroughly  anaesthetized  and  antisep- 
sis is  to  be  carefully  maintained. 

The  subject  of  the  medical  and  surgical  treat- 
ment of  lacerations  of  the  cervix,  we  think,  is 
exceptionally  well  considered,  but  space  does  not 
permit  its  reproduction.  The  discussions  to  which 
the  paper  gave  rise  were  able  and  instructive  and 
we  hope  they  will  pave  the  way  to  a  more  ex- 
tended consideration  of  the  subject  in  the  special 
Section  at  the  next  meeting  of  the  Association. 


I'RAGIUTAS  OSSIUM. 
Dr.  Roddick,  of  Montreal,  has  had  an  un- 
usual case  of  this  affection,  which  is  noted  in  the 
Montreal  Medical  Journal,  November.  The  pa- 
tient, a  boy,  aged  13  years,  had  received  a  frac- 
ture of  the  right  thigh  when  1  year  old,  and 
again  when  3  years  old  the  surgeon  had  been 
called  to  set  a  second  breakage  in  the  same  bone. 
Since  that  time  the  boy  had  not  had  less  than 
twenty  fiv,e  other  fractures  of  the  bones  of  the 
lower  extremities,  the  left  femur  being  at  present 
ununited.  Dr.  Roddick  purposes  at  a  near  date 
to  amputate  both  limbs,  as  they  are  in  their  pres- 
ent condition  quite  useless  and  extremely  atro- 
phied.     There  has,  as  a  rule,  been  an  entire  ab- 


sence of  pain  in  the  setting  of  the  fractures.  So 
far  as  could  be  learned,  there  had  been  no  history 
of  goitre  in  any  member  of  the  family  ;  the 
brothers  and  sisters  of  the  patient  were  in  good 
health.  Union  of  the  broken  bones  at  fir- 
plaee  with  an  abundant  new  growth  of  osseous 
material,  but  the  more  recent  fractures  have  re- 
fused to  unite  so  readily.  The  fractures  were 
produced  by  a  very  slight  amount  of  violence 
and  were  attended  with  little  or  no  pain.  The 
bones  of  the  trunk  and  upper  extremities  have 
shown  no  defective  tendency.  Dr.  Mills,  com- 
menting upon  this  case,  adverted  to  an  analogous, 
though  less  marked,  defect  often  seen  in  certain 
of  the  larger  breeds  of  dogs,  such  as  the  St. 
Bernards,  mastiffs  and  great  Danes,  which  were 
now  bred  of  enormous  proportions  ;  the  quantity 
of  bone  produced  is  relatively  disproportionate 
to  its  quality,  hence  an  imperfect  osseous  develop- 
ment in  puppy-hood,  and  an  occurrence  of 
permanent  deformities,  especially  in  the  hind 
limbs. 


EDITORIAL  NOTES. 

A  Xeedful  Correction.  — We  very"  much  re- 
gret that  our  esteemed  confrere  of  the  Cincinnati 
Lancet  Clinic  should  have  been  so  unfortunate  as 
to  the  sources  of  his  information  with  reference  to 
the  circulation  of  The  Journal  in  Chicago. 

It  should  be  premised  that  in  no  instance  is 
The  Journal  furnished  either  as  a  perquisite  or 
as  a  gratuity  to  any  individual  connected  with 
either  its  editorial  or  publishing  department. 

We  are  at  a  loss  to  know  how  the  Lancet-Clinic 
could  have  been  so  misinformed,  as  to  state 
that  the  Chicago  circulation  of  The  Journal  is 
one  hundred  and  sixty-two  copies  per  week, 
whereas  a  reference  to  the  mailing  list  shows  the 
exact  number  to  be  two  hundred  and  sixty-seven. 

The  writer  also  argues  a  greater  interest  for 
The  Journal  in  his  city,  from  the  fact  that  one 
physician  in  every  six  in  Cincinnati  takes  The 
Journal.  The  exact  number  of  copies  taken  in 
Cincinnati  is  ninety-four.  This  estimate  would 
give  to  that  city  only  five  hundred  and  sixty-four 
physicians,  a  much  less  number  than  we  had 
supposed. 

It  is  neither  our  purpose  to  vaunt  the  praises  of 
the  medical  profession  in  Chicago  nor  to  discuss 
the  question  of  the  removal  of  the  The  Journal 
to  Washington.      But  when  the  effort  is  made  to 


204 


EDITORIAL  NOTES. 


[February  7, 


discredit  The  Journal  and  the  place  of  its  pub- 
lication— that  effort  by  so  far  as  it  is  successful 
can  only  bring  damage  to  our  advertising  inter- 
est to  an  extent  which  we  are  confident  the  Lan- 
cet-Clinic  does  not  intend.  Competing  interests 
are  so  sure  to  avail  themselves  of  such  statements 
that  our  duty  to  The  Journal  requires  that  we 
make  the  correction.  We  know  of  no  instance  in 
which  The  Journal  has  not  the  kind  wishes  of 
the  medical  men  of  Chicago,  and  without  any  I 
boastful  spirit  we  deem  it  our  duty  to  state  that 
of  the  income  of  The  Journal  derived  from  all 
sources,  in  the  entire  United  States,  one-seventh  of 
that  amount  comes  from  Chicago  alone. 

Provision  for  Nurses. — The  members  of  I 
the  medical  profession  are  quick  to  recognize  ser- 
vices rendered  by  competent  and  well  trained 
nurses.  Patients  who  appreciate  their  services  are 
grateful  for  such  care  as  they  alone  can  render. 
It  must  not  be  forgotten  that  these  nurses  in  the 
faithful  performance  of  their  duties  are  broken  of 
rest,  often  overtaxed  in  the  performance  of  their 
arduous  duties,  closely  confined  in  the  sick  room, 
and  are  especially  exposed  to  its  contagions. 

It  can  not  be  a  matter  of  surprise  that  not  in- 
frequently they  themselves  become  the  victims 
and  require  medical  care  and  skilful  nursing.  It 
would  bring  cheer  to  many  of  these  if  they  knew 
that,  whether  they  had  means  or  not,  a  place  of 
rest  and  treatment  awaited  them,  in  case  of  sick- 
ness. 

The  Philadelphia  Polyclinic  has  taken  a  step 
in  this  direction,  which  wTe  hope  will  stimulate 
to  similar  action  in  every  American  city.  During 
the  past  year  four  free  beds  have  been  endowed 
and  arrangements  have  been  made  with  the 
Nurses'  Beneficial  Association  whereby  any  mem- 
ber taken  sick  while  practicing  her  calling  is 
cared  for  free  of  cost. 

It  is  a  good  thing  to  endow  free  beds  in  our 
hospitals  ;  and  it  is  a  specially  good  thing  to  pro- 
vide for  those  who  imperil  their  lives  in  the  service 
of  the  sick.  Will  the  benevolent  men  and  women 
of  our  country  bear  in  mind  the  needs  of  our  val- 
uable nurses? 

Prof.  Vaughan's  Alleged  Discovery  of  a 
Typhoid  "Lymph." — Immediately  before  going 
to  press  with  this  issue  a  "special"  from  Ann 
Arbor,  Mich.,  appeared  in  the  public  print  herald 
ing  the  discovery  by  Prof.  Vaughan  of  the  micro- 


organisms of  typhoid  and  cholera  infantum,  and 
representing  that  the  medical  world  was  upon  the 
eve  of  another  sensation — from  inoculation  results 
— not  unlike  that  so  recently  occurring  at  Berlin. 
Upon  telegraphic  communication  with  Prof. 
Vaughan  an  unqualified  denial  has  just  been  re- 
ceived by  The  Journal  ;  yet  the  evil  and  annoy- 
ing effects  of  the  first  report  will  scarcely  be  un- 
done. That  experiments  are  being  carried  on  in 
the  direction  indicated,  and  under  the  careful 
eye  of  this  investigator,  is  well  known  ;  but  the 
time  has  not  yet  arrived  for  the  advancement  of 
the  strong  statements  just  put  forth. 

Special  Committee. — The  following  gentle- 
men are  named  as  the  Committee  on  Organization 
and  by-laws  of  the  National  Association  of  Med- 
ical Colleges  :  Dr.  P.  H.  Millard,  of  St.  Paul, 
Chairman,  Dr.  William  Osier,  of  Philadelphia, 
and  Dr.  Samuel  Logan,  of  New  Orleans.  The 
Committee  will  report  at  the  forthcoming  meet- 
ing to  be  held  in  Washington. 

Section  of  Neurology  and  Medical  Juris- 
prudence.— The  Secretary  of  the  Section  on 
Neurology  and  Medical  Jurisprudence,  desires  to 
call  the  attention  of  members  to  the  fact  that  the 
scope  of  this  Section  has  been  enlarged,  and 
neurological  contributions,  that  formerly  belonged 
to  the  Section  on  Practice  of  Medicine,  may  now 
be  read  in  the  new  Section.  The  Secretary's 
address  is  Dr.  Harold  N.  Mover,  434  West  Adams 
St.,  Chicago,  111. 

Worthy  Recognitions. — Three  new  chairs 
have  been  recently  created  in  the  Philadelphia 
Polyclinic  and  College  of  Graduates  in  Medicine, 
in  the  department  of  surgery,  and  Drs.  John  B. 
Deaver,  S.  D.  Risley  and  Arthur  W.  Watson 
have  been  called  to  their  occupancy. 

Dr.  Koch  as  a  Country  Doctor. — The  New 
Review,  December,  contains  a  sketch  of  Dr.  Koch 
while  he  was  a  country  practitioner  in  Posen. 
"To  eke  out  a  respectable  living  he  pursued  the 
career  of  a  family  physician.  On  many  a  Polish 
winter  night,  jolting  in  a  Polish  rural  car  along 
1  a  Polish  country  road,  the  indefatigable  man 
!  would  drive  about  to  look  after  a  coughing  child 
or  an  expiring  boor,  having  previously  torn  him- 
self away  from  his  books  to  render  what  assistance 
he  could  and  earn  what  little  fee  he  might.  A 
m  rious,  unostentatious  and  dutiful  man  through- 


i89i.] 


MEDICAL  ITEMS. 


205 


out,  he,  in  this  and  in  every  other  part  of  his  ca- 
reer, commanded  the  respect  of  his  fellow-citizens, 
without,  however,  eliciting  any  very  ardent  feel 
ings  in  his  behalf.  He  never  spoke  much,  though 
his  actions  might  always  be  relied  on.  He  never 
displayed  a  tendency  nor  indeed  a  wish  to  shine, 
though  he  certainly  was  a  proficient  in  the  rare 
art  of  doing  good.  Night  and  day,  in  Nick-room 
and  in  hospital,  he  had  little  time  to  devote  to 
the  society  of  his  equals,  and  in  that  half  Scla- 
vonic province  was  certainly  more  popular  as  a 
doctor  than  as  a  visitor  or  a  host." 

Bacilli  Tuberculosis  in  the  Sputum. — 
That  the  discovery  of  bacilli  tubeiculosis  in  the 
sputum  may  now  be  said  to  unquestionably  indi- 
cate the  presence  of  the  peculiar  pathological  con- 
dition we  have  so  long  helplessly  considered, 
stands  quite  without  fear  of  contradiction  ;  yet  it 
seems  by  no  means  certain  that  the  absence  of 
microorganism  will  at  once  lift  the  veil  of  appre- 
hension. Dr.  Ludwig  Weiss,  of  New  York,  states 
(New  York  Medical  Journal)  that  he  has 
labored  with  no  less  than  forty  different  specimens 
in  the  same  case  before  "  the  long-sought  for  lit- 
tle red  bacilli  could  be  brought  to  view  under  the 
microscope,"  and  his  argument  at  once  comes 
that  in  "the  lack  of  tubercle  bacilli  is,  therefore, 
not  an  evidence  of  the  absence  of  tuberculosis." 

This  fact  should  only  tend  to  lead  still  more  to 
the  reliance  vouchsafed  from  the  reaction  pro- 
duced by  the  "  lymph"  injection. 

MEDICAL  ITEMS. 

The  Hypnotic  Limit. — According  to  Charcot, 
not  more  than  one  in  100,000  is  subject  to  the 
hypnotic  influence. 

English  Charity. — On  hospitals  alone  the 
English  people  spent  ,£598,220  in  the  last  year. 
Taking  into  account  home  and  foreign  missions, 
religious  and  benevolent  societies,  along  with 
provident  dispensaries  and  convalescent  institu- 
tions, it  is  computed  that  even-  man,  woman  and 
child  in  the  United  Kingdom  contributes  three 
shillings  a  vear. 


Factory  Medical  Service  in  Russia. — The 
Russian  Government  is  about  to  issue  an  order 
according  to  which  :  1,  every  factory  or  mill 
situated  at  S  versts  (about  %%  kilometres)  or 
more  from  a  town  shall  have  a  hospital  of  its 
own,  containing  from  ten  to  seventy  beds,  accord- 


ing to  the  number  of  hands  employed  by  the  pro- 
prietor, as  well  as  its  own  dispensary;  2,  a  special 
doctor  and  a  medical  assistant  (Feldshcr)  must 
also  be  in  attendance  ;  3,  the  district  medical  offi- 
cer must  exercise  sanitary  control  of  all  factories 
and  mills  existing  in  his  district. 

Medical  Director  John  v.  Taylor,  who 

has  been  President  of  the  Naval  Examining  Board 
for  a  long  time,  has  just  been  retired  from  active 
service  on  account  of  age.  If  we  are  correctly 
advised,  Medical  Inspector  Grove  S.  Beardsley 
will  be  promoted  to  the  vacancy,  and  Surgeon 
Edward  Kershner,  on  duty  at  the  Marine  Ren- 
dezvous, New  York,  to  Medical  Inspector,  and 
Passed  Assistant  Surgeon  Samuel  H.  Dickson, 
with  the  "Atlanta,"  will  be  promoted  to  Surgeon. 

Resection  of  the  Liver, — On  December  8, 
Professor  Iginio  Tansini,  of  Modena,  performed 
total  extirpation  of  a  hydatid  cyst  of  the  liver,  at 
the  same  time  excising  a  portion  of  that  organ. 
There  was  very  free  haemorrhage  from  the  large 
cut  surface  of  the  liver,  which  was  controlled  by 
catgut  ligatures.  The  wound  in  the  liver  was 
closed  by  means  of  sixteen  sutures,  partly  silk, 
partly  catgut.  The  operation  was  followed  by  no 
rise  of  temperature,  and  the  patient  (a  woman) 
was  quite  well  in  less  than  a  fortnight.. 

Professor  Bartholow's  Successor. — The 
Trustees  of  Jefferson  Medical  College  have  elect- 
ed Dr.  A.  P.  Brubaker  as  the  successor  to  Prof. 
Bartholow  in  the  Chair  of  Materia  Medica  and 
General  Therapeutics. 

The  Relation  of  Albuminuria  to  Puerpe- 
ral Eclampsia. — Dr.  Wm,  S.  Gardner  (Lecturer 
on  Obstetrics  in  the  College  of  Physicians  and 
Surgeons,  Baltimore)  in  a  paper  on  this  subject, 
arrives  at  the  following  conclusions,  which  are 
based  upon  a  number  of  cases  cited  : 

1.  The  presence  of  albumen  in  the  urine  of  a 
pregnant  woman  is  no  sufficient  cause  upon  which 
to  base  a  prognosis  of  probable  eclampsia. 

2.  The  failure  to  find  albumen  in  the  urine  of 
a  pregnant  woman  is  no  evidence  of  the  absence, 
or,  at  least,  of  the  continuance  of  the  absence,  of 
the  condition  that  gives  rise  to  puerperal  convul- 
sions. 

3.  Albumen  is  so  frequently  found  in  consider- 
able quantities  in  the  urine  of  patients  immedi- 
ately after  the  appearance  of  puerperal  convul- 
sions, thatwe  arejustified  in  making  the  statement 
that  the  convulsions  are  the  probable  cause  of  the 
albuminuria. 


206 


TOPICS  OF  THE  WEEK. 


[February  7, 


TOPICS  OF  THE  WEEK. 


DR.  KOCH  AND  THE  GERMAN  GOVERNMENT. 

A  well-informed  correspondent  writes:  During  the 
last  fortnight  various  rumors  have  been  telegraphed  from 
Berlin  as  to  the  arrangements  made,  or  about  to  be  made, 
between  the  German  Government  and  Professor  Koch 
with  regard  to  the  future  production  of  his  remedy  for 
tuberculosis,  and  it  must  be  admitted  that  these  rumors 
have  been  of  a  somewhat  disquieting  character.  It  has 
been  said  that  Dr.  Koch  and  each  of  his  assistants,  had 
accepted  a  large  immediate  payment,  and  that  they  were 
to  receive  a  royalty  upon  all  sales  in  the  future.  Thus 
stated,  the  arrangement,  it  must  be  admitted,  would  par- 
tal*  far  too  much  of  the  commercial  transaction  to  be 
agreeable  to  the  traditions  of  the  medical  profession,  or 
the  customs  of  men  of  science.  It  is,  however,  easy  to 
give  an  unfavorable  complexion  to  a  transaction  really  of 
an  honorable  nature  by  inverting  the  steps  by  which  the 
final  results  have  been  obtained  and  so  misrepresenting 
their  character.  It  may  be  well  to  recall  the  circum- 
stances under  which  the  lymph  has  been  discovered,  and 
the  position  of  Dr.  Koch  in  relation  to  the  German  Gov- 
ernment. Dr.  Koch  has  been  for  many  years  the  di- 
rector of  the  Hygienic  Laboratory  in  Berlin.  This 
laboratory  is  a  Government  institution,  maintained  by 
the  Educational  Department  of  the  German  Government, 
and  Dr.  Koch,  as  its  director,  has  been  an  offieer  of  that 
department.  All  the  earlier  experiments  for  the  discov- 
ery of  the  now  famous  lymph  were  conducted  in  Dr. 
Koch's  own  laboratory  in  the  Hygienic  Institute,  and 
there  the  observations  upon  guinea-pigs  and  other  ani- 
mals, which  emboldened  Dr.  Koch  to  proceed  to  inocu- 
late human  beings,  were  made.  The  laboratory,  how- 
ever, presented  no  facilities  for  making  these  investiga- 
tions upon  human  beings,  and  Dr.  Koch  holds  no  official 
position  with  regard  to  any  of  the  Berlin  hospitals.  He 
therefore  found  himself  in  a  practical  dilemma,  inas- 
much as  if  he  were  to  make  his  experiments  in  a  public 
hospital  it  was  feared  that  the  premature  and  eager  dis- 
cussion of  incomplete  observations  and  immature  results 
might  easily  tend  to  interfere  materially  with  the  investi- 
gations and  to  produce  evil  results.  Dr.  Koch  conse- 
quently hired  a  private  house  at  his  own  expense,  and 
obtained  the  assistance  of  two  gentlemen  with  whom  he 
had  private  acquaintance — Dr.  Libbertz,  an  old  school- 
fellow, and  Dr.  Pfuhl,  his  own  son-in-law.  The  lymph 
was  prepared  in  considerable  quantities  in  this  private 
house  by  these  two  gentlemen  under  Dr.  Koch's  super- 
vision, and  the  earliest  injections  in  man  were  made  in 
the  private  hospitals  of  Drs.  Cornet  and  Levy.  It  soon 
rident,  however,  that  the  interest,  both  among 
lal  public  and  in  the  medical  profession,  was  too 

keen  to  permit  of  the  continuance  of  the  investigation 
upon  thes<  line  ;  and  Di  Koch,  acting  on  the  advice,  or 
perhaps  it  might  be  correct  to  say  upon  the  instructions, 
issler,  tlu-  Minister  of  Education,  published 
tin-  now  liminary  paper,  and  distributed  th< 

lymph  to  certain  of  the  hospitals  in  Berlin.      Mcanw  bile, 
tin-  manufacture  of  the  lymph  was  carried  on  in  the  pri- 


vate house  by  Dr.  Koch  and  his  two  personal  private  as- 
sistant-.. Recently  this  arrangement  has  ceased  ;  the 
house  in  which  the  lymph  is  manufactured  has  been 
taken  over  by  the  Education  Department  of  the  German 
Government,  and  Drs.  Pfuhl  and  Libbertz  have  become 
officers  of  that  department.  The  Koch  Institute,  which 
the  German  Government  are  now  erecting,  will  consist 
of  two  parts — a  laboratory  and  a  clinical  department 
containing  150  beds.  The  clinical  department  will 
probably  be  under  the  direction  of  Professor  Brieger. 
The  observation  and  treatment  of  the  patients  received 
into  it,  it  is  hoped,  will  afford  in  the  future  opportunities, 
for  Dr.  Koch  to  prosecute  his  studies  with  regard  not 
only  to  tuberculous  diseases,  but  to  tetanus,  diphtheria,, 
and  typhoid  fever.  In  this  way  the  inconvenience  which 
has  arisen  from  his  having  no  clinical  wards  of  his  own 
will  be  avoided. 

In  the  laboratory  bacteriological  investigations  will  be 
carried  on,  and  at  the  earliest  possible  date  the  laboratorv 
for  the  preparation  of  the  anti  tuberculous  liquid  will  be 
transferred  to  this  department  of  the  Koch  Institute. 
The  director  of  this  bacteriological  department  has  not 
yet  been  appointed,  but  the  whole  institute  will  be  under 
the  general  direction  of  Dr.  Koch,  who  will  remain  an 
officer  of  the  Education  Department.  It  is  probable  that 
the  German  Government  will  offer  to  Dr.  Koch  some 
recognition  of  the  great  services  he  has  rendered  while 
acting  as  a  German  official,  such  as  was  voted  to  Jenner 
for  his  services  in  a  cognate  research,  and  more  recently 
to  Pasteur,  in  France.  Large  national  awards  have  re- 
peatedly been  made  to  successful  generals  in  Germany 
and  in  other  countries,  and  it  is  felt  that  there  is  no- 
reason  why  a  man  of  science,  who  has  worked  for  the  re- 
lief of  human  suffering,  should  hesitate  to  accept  a  re- 
ward which  the  destroyers  of  men  have  never  felt  the 
hast  difficulty  in  receiving.  As  to  the  further  rumor 
that  Dr.  Koch  and  his  assistants  may  receive  a  payment 
as  it  were  by  results  in  the  future,  it  may  be  hoped  that 
this  rumor  is  unfounded.  Anything  like  the  sale  of  a 
secret  or  the  paying  of  royalties  on  a  remedy  would  be 
contrary  to  the  Hippocratic  tradition. — British  Medical 
Journal. 


GROWING  KNOWLEDGE. 
The  editor  of  the  Educational  Times  has  been  insisting 
in  a  recent  article  upon  the  importance,  as  he  puts  it.  of 
" growing  knowledge  "  in  the  minds  of  children.  The 
less.  >n  is  one  which  teachers  as  a  body  are,  perhaps,  slow  to> 
learn,  but  it  has  certainly  obtained  a  considerable  amount 
of  recognition  in  recent  times.  But,  notwithstanding,. 
tin-  parable  of  the  Educational  Times  is  always  seasou- 
able.  It  is  pointed  out  that  knowledge  must  be  appre- 
hended, appropriated  and  assimilated  by  the  mind  verj 
much  as  the  elements  of  vegetable  tissue  are  apprehend- 

I  and  assimilated  by  a  plant.      Thou-  is  . 
sense  in  which    every   student   may  adopt   the    aphorismi 

\  attributed  to  the  "  Muster  of  Baliol  t 
that 

"\\  1  n  isn't  knowledge."  i 

■  iii.it  theorj   is  useful  information   for  anybody  . 
and  indi   i  owledge  to  the  mathematician,   bat 


I89I.] 


TOPICS  OF  THE  WEEK. 


to  such  as  have  but  little  mathematical  faculty  it  is  in- 
formation, and  nothing  more.  So  with  the  Greek  syntax 
or  Latin  composition.  To  the  classic  they  are  elements 
of  knowledge,  to  the  pedant  mere  shreds  of  information 
which  never  germinate  in  his  mind,  and  are  incapable  of 
ever  becoming  fused  into  a  coherent  habit  or  scheme  of 
thought  In  the  acquisition  of  such  indigestible  materi- 
als there  is  much  pain  and  very  little  profit,  and  it  can- 
not, tin  ti  often  ortoo  forcibly  brought  to  the 
minds  of  teachers  that  theit  true  function  is  not  to  fill  a 
vacant  mind,  but  to  preside  over  the  birth  and  develop- 
ment of  nascent  faculties.  If  the  faculties  are  supplied 
with  suitable  pabulum  they  will  spontaneously  exercise 
themselves  upon  it.  The  wise  teacher  is  he  who  happily 
discerns  what  faculties  are  dominant  in  his  pupil,  and 
what  treatment  is  best  adapted  to  stimulate  and  develop 
them.  This  view  of  a  teacher's  work  receives,  we  be- 
lieve, a  much  more  general  and  effective  recognition  at 
the  present  than  at  any  former  period,  and  we  are  glad  to 
lind  -it  from  time  to  time  put  prominently  forward  in  the 
accredited  organs  of  the  teaching  profession. — Lancet. 


TREATING  CONSUMPTION  BY  MEANS  OF  INHALATIONS. 

In  the  December  number  of  the  Harper  Hospital  Bulle- 
tin, Dr.  Shurly  publishes,  with  illustrations,  his  method 
of  treating  consumption  by  means  of  inhalations.  Chlo- 
,  in  the  presence  of  the  vapor  containing  chloride 
of  sodium,  forms  an  important  element  in  the  treatment, 
and  he  is  sanguine  his  plan  possesses  great  curative  vir- 
tues. He  reports  a  number  of  cases  illustrating  the  vari- 
ati  ins  in  applying  the  method.  It  does  not  appear  that 
he  neglects  the  provision  of  a  pure  atmosphere,  of  suit- 
able food,  and  all  the  other  well-known  agents  by  which 
this  disease  has  been  combated;  so  that  the  question  re- 
specting his  specific  treatment  is  to  determine  the  bene- 
fit derived  from  the  old  measures,  plus  the  faith  awakened 
by  the  use  of  the  new,  and  the  new  by  itself.  When  he 
is  able  to  show  this  then  the  profession  will  be  in  posi- 
tion to  determine  the  exact  value  of  the  new  features 
which  he  has  contributed.  We  shall  all  hope  that  these 
are  equal  if  not  greater  thau  Koch's  claims  for  his 
"  lymph."  Too  many  remedies  for  the  cure  of  con- 
sumption cannot  be  given  the  profession. — American 
Lancet. 


the  protection  of  the  employes  alone,  but 
rial  protection  of  the  incorporations  from  • 
fraudulent  claims. 

Allowing  an  average  of  but  ten  - 

i  m  it  would  require  an  army  of  6,000  surgeons 
to  perform  the  the  railroads  of  our 

country,  which  esthnati  rtain  is  far  below    the 

reality. 

We   doubt   whether   the   standing   army  of  th( 
day  number-  1  men,  or  in  othi 

an  average  of  about  one  soldier  to  every  forty  railroad  em- 
ployes, and  the  soldier  in  time  of  peace  is  not 
to  even  one-fortieth  of  the  physical  danger  that  the  average 
railroad  employe  is  subjected  to;  and  yet  the  fed( 
eminent  has  long  since  settled  the  question  of  the 
of  maintaining  a  well  organized  and  well  paid 
corps  of  surgeons,  not  for  the  protection  of  the  soldiers 
alone,  but  for  the  protection  of  the  government  against 
fraudulent  claims  for  pensions;  and  notwithstanding  all 
this,  the  government  is  to-day  undoubtedly  paying  many 
questionable  pension  claims  every  quarter. 

Of  course  there  are  railway  companies  even  at  this  late 
daj  which  do  not  employ  regular  surgeons,  but  that  does 
not  prove  that  it  is  economy  not  to  do  so,  or  that  their 
success  is  due  to  such  policy.  Not  long  since  we  were 
told  by  the  general  manager  of  one  of  the  largest  rail- 
wav  svstems  in  this  country,  a  gentleman  whose  success 
as  a  railway  executive  is  unquestioned,  that  he  "would 
just  as  soon  think  of  parting  with  his  freight  department 
as  to  dispense  with  his  department  of  surgery 
went  on  to  say  that  he  spoke  from  years  of  experience 
that  had  proven  to  him  the  facts  on  which  he  had  based 
his  opinion;  and  we  will  add  in  addition  to  what  he  has 
said,  that  no  better  system  of  surgery  is  conducted  on 
anv  railroad  in  this  country  thau  on  the  road  he  repre- 
sents.— Railway  Age. 

A  NOBLE   RECORD. 

It  is  said  of  Dr.  Kerr,  a  medical  missionary  of  the 
Presbyterian  Board  at  Canton,  that  he  has  in  the  past 
thirty-six  years  treated  over  520,000  patients  and  has  pre- 
pared twenty-seven  medical  and  surgical  books.  He  has 
trained  100  medical  assistants,  chiefly  Chinese. 


IMPORTANCE  OF  A  DEPARTMENT  OF    RAILWAY 
SURGERY. 

The  railway  surgeon  has  long  since  served  the  proba- 
tionary period  once  allotted  him  and  is  now  a  fixed 
fact.  He  has  already  proved  himself  a  financial  reality 
and  has  come  to  stay.  When  we  consider  that  notwith- 
standing all  the  consolidations  of  various  railroad  lines 
into  great  systems,  and  thereby  the  abolition  of  many 
lesser  lines,  there  are  still,  in  round  numbers,  about  606  in- 
dependent systems  of  railroads  in  this  country  employ- 
ing almost  1,000,000  men  daily,  who  are  in  constant  dan- 
ger to  a  greater  or  less  extent,  according  to  the  position 
they  hold,  of  receiving  personal  injuries,  saying  nothing 
of  passengers  and  others  subject  to  the  same  dangers,  it 
is  certainly  very  easy  to  see  the  necessity  of  maintaining 
regularly  organized  departments  of  surgery,  not  only  for 


SANITATION  AND  BACTERIOLOGY  IN  AUSTRIA. 

The  Chamber  of  Deputies  in  the  Austrian  Parliament 
considered  on  December  12  the  report  of  a  commis- 
appointed  to  inquire  into  the  proposals  made  by  a  Dep- 
ute, Dr.  Roser,  for  the  creation  in  Austria  of  an  Imperial 
Sanitarv  Bureau,  after  the  model  of  the  institute  estab- 
lished at  Berlin  for  the  whole  of  Germany.  The  report 
recommended  the  adoption  of  a  series  of  resolutions  de- 
manding the  foundation  of  chairs  of  hygiene  and  bac- 
:n  the  faculties  of  medicine,  the  introduction 
of  hygiene  into  the  medical  curriculum  as  an  obligatory 
subject,  the  improvement  of  the  public  sanitary  service 
by  an  increase  of  the  number  of  doctors  nominated  by 
the  State,  and  a  general  reform  of  the  pharmaceutical 
department.  In  the  course  of  the  debate  attention  was 
drawn  to  the  advantages  which  Dr.  Koch  had  enj 
the  Imperial  Sanitarv  Bureau  at  Berlin,  and  satisfac- 
tion was  expressed  at  the  recent  decree  of  the  Austrian 
Minister  of  Instruction  dealing  with  the  question  of  hy- 
giene in  schools. — Brit.  Med.  Jour. 


208 


SOCIETY  PROCEEDINGS. 


[February  7, 


SOCIETY    PROCEEDINGS. 


given 


Chicago  Medico-Legal  Society. 

Regular  Meeting,  December  6,  iSpo. 

Edmund  J.  Doering,  M.D.,  President 

the  Chair. 
Dr.  Henry  M.  Lyman  read  a  paper  on 

MONOMANIA. 

(See  page  190.) 

Dr.  D.  R,  Brower  :  Dr.  Lyrnan  has 
the  most  salient  feature  of  this  most  interesting 
form  of  insanity,  and  so  scientifically  that  there 
is  really  very  little  to  be  added.  There  is  one 
point  for  which  I  wish  especially  to  commend  the 
doctor,  and  that  is  his  objection  to  the  term 
"monomania,"  the  designation  by  which  these 
cases  are  known  by  most  of  the  American  and 
English  alienists.  As  he  has  stated  to  you,  there 
is  nothing  about  these  unfortunate  people  sugges- 
tive of  mania.  As  a  rule,  there  is  no  mental  dis- 
turbance manifest  in  their  daily  talk — they  are 
cool,  calm  and  collected,  seemingly,  as  the  ma- 
jority of  persons  in  this  audience ;  and  the  mono 
part  of  the  designation  is  scarcely  clinically  true, 
because  it  is  an  exceedingly  uncommon  thing  for 
any  of  these  insane  people  to  have  their  insane 
disturbances  manifested  only  in  a  single  direction. 
I  commend  Dr.  Lyman  especially  for  his  prefer- 
ence for  the  word  "paranoia."  Paranoia,  going 
back  to  its  derivation,  simply  means  a  disturbed 
mind,  and  does  not  express  any  especial  feature 
in  the  clinical  history  of  these  cases,  but  then  it 
has  the  advantage  of  not  teaching  error.  So  far 
as  it  teaches  anything  it  teaches  the  truth ;  they 
are  persons  of  disturbed  minds.  There  is  about 
these  cases  of  monomania  so  much  plausibility, 
so  much  reasoning  capacity,  so  much  ingenuity 
in  pressing  home  their  vagaries,  that  they  will  pass, 
under  almost  any  ordinary  circumstances,  as  per- 
sons of  perfectly  sound  mind.  The  great  majority 
of  them  are  not  in  the  insane  hospitals.  They  are 
to  be  met  with  by  observing  people  very  frequently; 
they  are  to  be  seen  in  our  own  profession.  My  at- 
tention was  called  the  other  day  to  the  case  of 
quite  an  eminent  medical  gentleman  of  this  city 
who  is  undoubtedly  a  paranoiac,  and  yet  he  is  a 
successful  practitioner  of  medicine,  not  only  in 
regard  to  the  results  of  treatment  but  in  the 
financial  success  that  has  attended  his  efforts. 
Quite  recently  he  has  been  doing  things  that,  to 
say  the  least,  are  very  remarkable.  He  happened 
to  meet  casually  a  lady  of  this  city  of  high  social 
standing  and  undoubted  virtue,  ami  became  1  n 
amored  of  her  at  once,  without  any  acquaintance 
with  her.  He  began  sending  her  presents,  he 
sent  her  several  valuable  diamonds,  bouquet  after 
bouquet,  tickets  to  the  theatre,  and  so  on.  She 
did  not  know  from  whom  these  things  came,  they 
were  left  at  the  door  by  a  messenger,  and  that 


was  all  that  was  known  about  them.  The  door 
bell  would  ring,  the  servant  would  receive  them 
and  the  messenger  depart.  This  man  never  had 
any  conversation  with  her,  but  he  became  pos- 
sessed with  the  idea  that  she  was  in  love  with 
him,  as  he  thought  he  was  with  her.  The  thing 
became  so  annoying  to  her  that  finally  the  mes- 
senger was  detained  until  a  policeman  was  sent 
for,  and  in  that  way  the  identity  of  our  doctor 
was  determined. 

I  saw  only  a  day  or  two  ago  a  young  lady  of 
this  city,  a  paranoiac,  who  is  a  most  admirable 
stenographer;  she  is  engaged  to-day  in  the  of- 
fice of  one  of  our  prominent  law3'ers,  and  she 
must  do  her  work  in  that  office  well  or  this  legal 
gentleman  would  not  employ  her.  She  has  been 
in  his  service  for  a  number  of  years,  and  I  do  not 
suppose  that  he  suspects  her  mental  vagaries. 
She  is  one  of  those  paranoiacs  who  are  continu- 
ally afraid  of  being  befouled ;  she  never  touches 
anybody's  person  if  she  can  help  it,  never  shakes 
hands  with  any  one,  and  if  she  should  be  so  un- 
fortunate as  to  be  compelled  to  do  so  her  hands 
must  be  irnmediatel}-  washed.  She  carries  with 
her  always  what  she  regards  as  a  powerful  anti- 
septic, and  after  she  washes  her  hands  she  cleanses 
them  with  this  antiseptic.  Some  few  years  ago 
it  seemed  as  if  it  would  be  necessary  to  deprive 
her  of  her  liberty.  She  has  now  and  then  perse- 
cutory delusions  about  her  famil}- — she  won't  live 
with  her  parents,  she  sometimes  lives  with  a  sis- 
ter, but  frequently  changes  her  place  of  residence 
on  account  of  the  persecutory  delusions  that  spring 
up.  It  is  a  surprise  to  me  how  she  has  so  long 
and  faithfully  pursued  her  occupation  without  her 
vagaries  being  suspected.  As  Dr.  Lyman  has  told 
us,  very  many  of  these  paranoiacs,  or  monoma- 
niacs, while  they  are  possessed  of  these  delusions, 
yet  outside  of  that  the3r  have  a  great  deal  of  men- 
tal power,  and  some  of  them  have  done  a  great 
deal,  in  various  ages,  towards  modeling  society 
and  forming  religious  societies.  There  are  some 
that  I  scarcely  dare  mention  in  this  community 
because  I  would  be  afraid  of  the  storm  that  might 
be  raised  about  my  ears,  but  we  mention  Mahom- 
et ;  you  must  all  regard  him  as  one  of  these  para- 
noiacs. I  think  Peter  the  Hermit  belongs  there 
also,  and  Louis  Riel,  of  Canada.  And  some  of 
you  must  admit  that  Charles  J.  Guiteau  is  of  the 
same  class.  The  case  of  Guiteau  was  one  of  the 
most  interesting  that  has  been  tried  recently.  In 
that  trial  the  great  leaders  of  psychological  med- 
icine were  arrayed  against  each  other;  my  distin- 
guished and  einiin.nl  friends  Dr.  Gray  on  dne  side 
and  Dr.  Spitska  on  the  other;  two  great  giants 
hological  medicine  arrayed  against  each 
other.  Many  facts  in  the  history  of  Guiteau  were 
ascertained  after  the  trial  that  more  fully  brought 
but  his  paranoiac  characteristics  than  anything 
that  appeared  at  the  trial,  and  I  presume  some  of 
the   distinguished   psychological   gentlemen  who 


i89i.] 


SOCIETY  PROCEEDINGS. 


21  9 


e  on  the  side  of  the  prosecution  might  have 
thought  differently  had  they  been  aware  of  these 
facts. 

This  brings  up  another  very  interesting  ques- 
tion in  reference  to  these  paranoiacs,  and  that  is 
as  to  their  responsibility.  That  is  a  branch  of 
the  subject  upon  which  Dr.  Lyman  touched  very 
lightly,  but  is  very  important.  While  I  am  wil- 
ling to  class  under  this  designation  of  paranoia 
B  very  great  many  persons  who  are  outside  of  the 
insane  asylums,  yet  I  believe  that  the  great  ma- 
jority of  paranoiacs  have  at  least  a  certain  degree 
of  legal  responsibility,  and  had  I  been  on  that 
Guiteau  jury  I  don't  know  that  I  would  have 
brought  in  a  verdict  of  hanging,  exactly,  but  I 
certainly  would  have  insisted  upon  imprisonment 
for  life.  I  think  these  paranoiacs  should  be  held 
to  a  certain  degree  responsible  for  crime.  They 
have  a  certain  measure  of  control  of  themselves — 
more  than  they  are  very  often  willing  to  exercise. 
The  degree  of  responsibility  should  be  determined 
in  each  case. 

The  paranoiacs  are  more  or  less  dangerous  peo- 
ple. Some  one  has  said  that  if  they  lived  long 
enough  they  would  all  of  them  be  homicidal,  and 
certainly  there  is  more  or  less  tendency  in  all  to 
acts  of  violence,  and  they  require  restraint  of  some 
kind  ;  I  do  not  think  they  are  safe  people  to  be  at 
large  in  anything  like  the  proportion  in  which  I 
believe  they  are.  Let  the  occasion  arouse  their 
imperative  conceptions,  and  their  impulses,  grow- 
ing out  of  their  delusions,  may  lead  to  acts  of 
violence,  and  the  danger  of  this  is  greater  with 
their  advancing  years.  Then  there  is  another 
point  about  these  paranoiacs  that  Dr.  Lyman 
dwelt  upon  very  lightly,  but  which  is  very  im- 
portant; that  is  the  fact  that  most  of  these  para- 
noiacs have  other  defects  than  the  mental  ones. 
The  great  majority  of  them  come  into  the  world 
with  such  defective  construction  that  we  can  easily 
recognize  them.  There  are  defects  in  their  general 
configuration,  defects  in  the  shape  of  the  head,  in 
the  facial  lines,  in  the  arms,  or  in  the  legs.  These 
departures  from  normal  structure  are  often  im- 
portant aids  to  diagnosis. 

I  am  very  glad  to  have  been  present  and  heard 
Dr.  Lyman's  admirable  exposition  of  this  impor- 
tant subject. 

Dr.  Archibald  Church:  In  view  of  the  fact 
that  the  subject  has  been  very  thoroughly  pre- 
sented by  my  masters,  the  gentlemen  who  have 
preceded,  it  would  not  be  becoming  in  me  to 
detain  you  long  with  an  attempt  at  further  ex- 
position of  this  matter.  It  is,  however,  one  of 
great  interest  and  of  great  importance.  The  dif- 
ficulties arising  from  it  are  illustrated  in  Dr. 
Brower's  remarks:  He  spoke  of  the  legal  respon- 
sibility in  these  cases  and  said  that  in  the  major- 
ity of  instances  a  certain  degree  of  responsibility 
must  be  attributed  to  them  before  the  law.  He 
also  told  us  that  in  the  majority   of  instances  a 


il  tendency  would  sooner  or  later  be  de- 
a  tendency  for  which  they  are  not  re- 
sponsible. I  am  inclined  to  believe  that  in  this 
form  of  disease  there  is  a  large  degree  of  irre- 
sponsibility from  the  first,  and  this  leads  me  to 
emphasize  Dr.  Brower's  recommendation  that 
more  of  these  paranoiacs  should  be  under  control. 

It  is  not  necessary  for  me  to  go  into  the  ter- 
minology of  the  affection  except  to  point  out  that 
in  some  instances  it  has  run  wild.  By  some  Ger- 
man authors  every  variation  in  the  disease  has 
received  a  special  designation:  for  instance,  an  in- 
dividual who  had  the  peculiarity  of  stealir 
men's  shoes  was  classified  under  the  term  "frau- 
enschuhstehtmonomanie." 

These  paranoiacs  are  the  people  who  are  known 
in  their  communities  as  the  "peculiar  people," 
they  are  the  men  who  ride  their  hobbies  rough 
shod  over  everybody:  they  are  called  "cracked," 
and  somebody  has  said  that  through  these  cracks 
sometimes  light  has  been  shed  on  the  world,  and 
that  is  true.  Peter  the  Hermit,  John  Bunyan, 
Swedenborg  were  all  paranoiacs.  It  is  in  these 
cases  that  genius  is  akin  to  madness. 

In  the  case  Dr.  Lyman  mentioned,  the  young 
man  who  considered  himself  the  son  of  the  actor 
Booth,  and  who  not  being  recognized  by  him, 
after  following  and  persecuting  him  with  his  at- 
tentions for  a  number  of  years,  from  one  of  the 
galleries  of  a  theatre  here  fired  his  pistol  at  the 
actor  on  the  stage,  clung  to  his  delusions  until 
death.  He  believed  himself  a  great  actor,  and 
subsequently  sought  vengeance  against  those 
whom  he  considered  his  oppressors.  The  man 
Joel  Henry  Wells,  who  presented  in  his  family 
history  well  marked  evidences  of  insane  heredity, 
also  to  the  day  of  his  death  clung  to  his  delusions 
of  grandeur,  which  fortunately  in  his  case  never 
took  on  the  persecutory  type.  He  believed  him- 
self the  descendent  of  a  noble  French  family  and 
up  to  the  time  of  his  death  signed  himself  Henri 
de  Travis.  After  his  liberation  from  the  Elgin 
asylum,  done  by  legal  process  under  habeas  cor- 
pus proceedings,  and  when  he  was  pronounced 
sane  and  capable  of  caring  for  his  property,  by 
the  judge,  he  entered  into  business  in  Chicago 
and  conducted  it  satisfactorily,  maintaining  him- 
self and  family  comfortably,  but  always  signing 
himself  Henri  de  Travis,  and  always  insisting 
that  he  had  been  abused  and  persecuted.  Scarcely 
a  month  passed  that 'the  hospital  did  not  receive 
some  communication  from  him  threatening  prose- 
cution and  suits  for  damage,  and  probably  there  is 
not  a  prominent  lawyer  in  this  city  but  has  been 
approached  by  him  with  requests  to  take  up 
these  suits.  At  his  death  he  bequeathed  an 
enormous  property  which  was  as  imaginary  as 
his  name.  The  peculiarity  in  this  malady  has 
been  tersely  expressed  by  Seglas  as  an  hypertro- 
phy of  the  ego.  With  these  people  it  is  always 
the  great   I  am.     This  peculiarity  distinguishes 


SOCIETY  PROCEEDINGS. 


[February  7, 


thein  when  they  become  depressed,  this  enlarge-  [ 
ment  of  the  ego  still  persists. 

The  melancholic  individual  believes,  on  the 
other  hand,  that  he  has  committed  some  crime  or 
done  some  misdeed,  that  the  blame  is  his  own, 
but  the  paranoiac  fancies  that  he  has  been  sinned 
against  and  that  because  of  his  importance  a  eon- 
siracy  has  been  formed  to  keep  him  down;  they 
look  at  the  situation  from  diametrically  opposite 
standpoints.  Clouston  tells  of  an  old  man  of 
benevolent  character  and  generous  impulses,  with 
a  very  liberal  education,  to  whom  was  entrusted 
in  his  asylum  the  keeping  of  the  books  and  a 
large  share  of  the  records.  You  might  know  this 
man  for  months  and  in  his  ordinary  conversation 
he  would  never  manifest  any  peculiarity,  but  he 
believed  that  two  and  two  made  four  and  a  quar- 
ter. In  deference  to  the  prejudices  of  the  asylum 
management  he  kept  their  books  by  the  old 
method,  but  for  himself  he  established  a  new  sys- 
tem of  arithmetic  and  mathematics;  he  con- 
Structed  enormous  tables  of  logarithms,  and 
carried  his  theory  through  the  higher  branches  of 
mathematics  and  left  immense  manuscript  vol- 
umes to  the  University  of  Oxford,  that  his  dis- 
coveries might  not  be  lost  to  the  world.  It  is 
these  individuals  who  make  so  much  trouble  in 
the  courts;  it  is,  as  you  can  all  see,  a  matter  of 
great  difficulty  to  determine,  sometimes,  not  only 
their  insane  state,  but  beyond  that  to  determine 
how  much  they  may  be  trusted  with  their  liberty 
provided  they  are  considered  of  unsound  mind. 
A  case  which  probably  has  many  times  come  to 
your  attention  is  the  young  man  who  pursued 
Mary  Anderson  for  many  years,  being  possessed 
with  a  platonic  love  for  her  and  believing  that 
love  was  returned.  He  was  finally  apprehended 
in  New  York  and  committed  to  the  asylum;  he 
clung  tenaciously  to  this  idea  but  in  every  other 
respect  he  seemed  to  be  perfectly  sane,  yet  this  idea 
dominated  his  conduct  and  mental  methods  com- 
pletely. Eventually  he  was  liberated  from  the 
institution,  contrary  to  the  wishes  of  the  manage- 
ment, and  only  a  few  weeks  ago  he  returned  to 
the  asylum,  full  of  the  idea  that  he  had  been  un- 
justly persecuted  and  deprived  of  his  liberty,  and 
with  a  revolver  fatally  shot  one  of  the  assistant 
physicians.  His  expressed  intention  was  to  shoot 
the  whole  staff. 

I  might  point  out  to  you  that  the  great  crimes 
done  by  insane  men  are  done  by  those  who  are 
trusted.  An  insane  man  is  dangerous,  I  believe, 
in  proportion  as  he  is  trusted.  If  you  know  he 
is  dangerous  you  will  guard  against  him,  but  if 
you  believe  him  trustworthy  he  has  the  opportu- 
nity of  perpetrating  terrible  deeds.  I  am  of  the 
opinion  that  we  should  take  greater  pains  and  make 
more  strenuous  efforts  to  put  insafekeepingthe.se 
paranoiacs  who  now  are  going  about  the  streets. 
There  is  another  point  I  wish  to  call  to  your 
attention;  these  individuals,  in  the  vast  majority 


of  cases,  are  afflicted  with  hallucinations  of  the 
senses,  and  very  often  of  the  sense  of  hearing. 
They  hear  the  voices  of  people  on  the  street  call- 
ing after  them  with  abusive  epithets  or  in  libel- 
lous terms;  they  hear  commands  from  on  high, 
as  did  John  Bunyan;  they  may  hear  orders  from 
the  Almighty  to  kill.  Whenever  you  find  sys- 
tematized, persisting  delusions  with  hallucina- 
tions of  hearing  you  will  be  safe  in  giving  an  un- 
favorable prognosis,  because  nine  times  out  of 
ten  they  pertain  to  paranoiacs  the  majority  of 
whom  die  in  the  insane  hospitals. 

Dr.  Henry  M.  Lyman  :  I  hardly  think  I  can 
add  anything  to  what  has  been  said,  the  ground 
has  been  very  thoroughly  covered.  If  there  were 
time  it  would  be  interesting  to  introduce  cases, 
but  the  details  of  the  subject  have  been  well  pre- 
sented to  the  Society  by  my  associates.  One 
point  suggested  itself  to  my  mind  with  regard  to 
Joel  Henry  Wells  which  it  seems  to  me  would 
throw  light  upon  some  of  the  conflicting  opinions 
in  reference  to  the  relation  of  pananoia  to  other 
insanity,  it  being  the  opinion  of  some  that  all 
cases  of  systematized  delusion  should  be  called 
paranoia  whether  they  be  primary  or  secondary  to 
other  forms  of  insanity  ;  but  others  claim  that 
paranoia  is  always  congenital  and  that  it  is  heredi- 
tary. There  was  this  fact  in  the  history  of  Wells: 
he  was  committed  to  the  asylum  in  a  state  of  very 
great  exaltation,  acute  mania  was  his  condition 
practically  at  the  time  he  was  sent  to  the  asylum, 
and  his  delusions  assumed  their  greatest  import- 
ance after  that  period  of  excitement.  But  this 
thing  was  brought  out  on  the  trial  of  the  patient — 
the  explosion  of  mania,  which,  if  it  had  been  an 
initial  symptom  and  if  there  had  been  no  history 
of  any  hereditary  defect  in  the  family,  would  have 
been  looked  upon  as  the  starting  point  for  the 
evolution  of  secondary  paranoia  ;  was  shown  to 
be  only  an  incident  in  the  course  of  disease,  as  the 
man  had  years  before  manifested  symptoms  of  an 
unsound  mind,  having  had  delusions  in  regard  to 
the  location  of  property.  His  brother-in-law  said 
that  the  first  thing  he  noticed  wrong  was  when 
he  was  going  to  build  a  house,  that  he  insisted 
upon  putting  the  house  on  the  next  lot  to  his 
own,  he  would  have  it  that  the  house  should  lie 
built  upon  another  lot.  At  that  time  his  friends 
looked  upon  that  circumstance  as  evidence  of  un- 
soundness of  mind.  I  have  no  doubt  it  was  evi- 
dence of  the  congenital  defect  originating  in  anti- 
natal  influences,  which  at  that  time  first  showed 
themselves,  for  it  is  usual  after  the  individual  has 
grown  up  and  reached  man's  estate  for  these  to 
become  most  conspicuous. 

Then  the  fact  of  there  being  marked  symptoms 
of  insanity  without  bodily  disease  is  also  worthy 
of  note,  for  I  think  careful  observation  will  in 
the  vast  majority  of  these  cases  show  a  very  grave 
defect  in  the  development  of  the  body,  so  much 
so  that  when  I  see  a  person  with  certain  marked 


i89i.] 


SOCIETY  PROCEEDINGS. 


s  of  form,  feature,  and  cranial  develop- 
in  nt  I  am  almost  instinctively  led  to 
existence  of  mental  obliquity,  at  least.  These 
cases  are  of  the  paranoiac  type,  and  the  disease 
seems  to  bear  a  relation  to  other  insanity  very 
much  like  that  borne  by  congenital  idiocy  ;  and 
it  should  be  classified  with  idiocy,  since  the  ob- 
liquity of  character  and  the  development  of  pecu- 
liarities is  dependent  not  so  much  upon  the  act- 
ual existence  ol  disease  of  the  brain  as  upon  the 
workings  of  a  badly  formed  and  ill  constituted 
brain.  The  matter  of  hallucinations  is  really 
very  important,  for  it  is  sometimes  the  only  evi- 
dence of  the  existence  of  this  defect.  A  gentleman 
walked  into  my  office  the  other  day,  who  to  all 
appearances  was  a  man  of  excellent  health  and 
fairly  well  developed  body,  but  it  came  out  upon 
inquiry  that  he  had  been  subject  for  years  to  par- 
oxysms of  suspicion.  He  would  walk  upon  the 
street,  and  on  reaching  home  would  insist  that 
somebody  had  insulted  him,  that  somebody  had 
looked  at  him  in  such  a  way  as  to  show  that  they 
meant  mischief;  he  had  heard  people  whispering 
about  him  as  he  passed  them,  which  led  him  to 
believe  that  they  had  designs  against  him.  On 
one  occasion  a  friend  came  to  his  room  on  bus- 
iness, and  without  any  provocation  this  man 
leaped  from  his  chair  and  dealt  his  friend  a  blow 
in  the  face,  and  a  few  days  afterwards  meeting 
him  on  the  street  he  apologized  for  the  act.  I  am 
convinced  from  the  family  history  and  character- 
istics of  other  members  of  the  family  that  this  is 
a  case  of  indubitable  paranoia — the  incipient  stage 
of  paranoia,  which  may  result  suddenly  s<  >me 
day  in  a  violent  explosion.  These  hallucinations 
of  hearing  that  Dr.  Church  has  spoken  of  are  also 
very  significant.  I  know  a  case  in  this  city  to- 
day of  a  professional  man  who  presents  in  his 
general  appearance  all  the  characteristics  of  per- 
fect health  ;  he  is  a  large,  well  formed,  muscular 
looking  person,  and  yet  that  man  is  and  has  been 
for  a  long  time  under  the  delusion  that  somebody- 
is  speaking  to  him.  I  have  a  number  of  letters 
from  him  telling  how  people  are  speaking  and 
telephoning  to  him,  and  he  has  at  last  discovered 
that  it  is  a  conspiracy  on  the  part  of  the  Jesuits 
to  convert  him  to  Roman  Catholicism,  and  these 
are  the  means  which  they  take.  In  every  other 
respect  he  appears  like  a  man  of  good  health,  he 
is  intelligent,  talks  freely  about  his  case,  but  will 
not  admit  that  he  is  insane.  So  it  is  with  many 
of  these  cases.  Dr.  Brower  has  well  said  that 
they  exist  in  all  grades  of  severity  from  the  dan- 
gerous homicide  down  to  the  person  who  simply 
labors  under  the  delusion  that  there  is  a  snake  in- 
side of  him,  or  that  there  is  some  constant  con- 
spiracy working  against  his  welfare.  They  are 
the  cranks,  the  cracked  persons,  the  eccentrics  of 
society.  Many  of  them  by  their  very  eccentrici- 
ties, the  one-sided  nature  of  their  characters,  have 
accomplished  a  great  deal  of  good  in  the  world  as 


well  as  a  great  deal  ol  harm.  I  think  that  in  this 
State  we  are  laboring  under  the  injustice  of  a  law 
regarding  the  committment  o!"  the  insane  that 
was  procured  by  one  of  tl  utory  parano- 

iacs. 


AU.-ii.ns  County  Medical  Society. 

W.  S.  Foster,  M.D.,  President,  in  the  Chair. 
{Concluded from  page 
Dk.  MURDOCH  reported  the  following  case: 

DISLOCATION  OF  THE    HIT    REDUCED  BY    MANUAL 
EXTENSA 

S.  B.,  a  powerful  young  man,  was  brought  to 
the  Western  Pennsylvania  Hospital  last  Friday 
(Nov.  14),  presenting  the  usual  symptoms  of  an 
upward  and  backward  dislocatiou  of  the  head  of 
the  femur.  •  He  stated  that  two  hours  previous  to 
his  admission,  while  engaged  in  pushing  a  car 
loaded  with  coke  along  the  track,  bend; - 
ward  and  exerting  all  his  force,  another  loaded 
car  unexpectedly  came  up  behind  and  struck  him 
with  great  force  upon  the  buttock,  forcing  him 
against  the  car  which  he  had  been  pushing. 
When  he  had  been  disengaged  from  the  position 
in  which  he  had  been  caught,  he  found  that  he 
was  disabled  in  the  hip.  A  number  of  physicians 
had  been  immediately  called,  and  an  attempt 
made  to  reduce  the  dislocation.  This  attempt 
having  failed,  he  was  at  once  sent  to  the  hospital. 

Upon  examining  the  patient,  it  was  evident 
that  the  head  of  the  right  femur  was  dislocated 
upon  the  dorsum  of  the  ilium.  The  patient  was 
a  very  powerfully  built  young  man,  with  unusual 
development  of  the  muscles,  especially  those  of 
the  gluteal  region.  For  this  reason,  before  any 
attempt  at  reduction  was  made,  he  was  most  pro- 
foundly anaesthetized.  An  effort  was  then  made 
at  reduction  by  the  methods  recommended  by 
Reed,  of  Rochester,  and  Bigelow,  of  Boston.  The 
leg  was  flexed  upon  the  thigh,  and  the  thigh  upon 
the  pelvis  in  an  adducted  position.  It  was  then 
strongly  abducted,  rotated  and  extended.  This 
manipulation  was  repeated  several  times,  with  a 
complete  failure  each  time.  Other  manipulations 
were  tried,  with  no  better  success,  until  the  oper- 
ators were  entirely  exhausted. 

I  then  resolved  to  make  use  of  extension,  which 
had  often  before  succeeded  in  my  hands.  A  young 
medical  student  who  was  present  was  asked  to  re- 
move his  boot,  and  placing  the  foot  on  the  peri- 
neum against  the  ramus  of  the  ischium  as  a  coun- 
ter extending  force,  extension  was  made  with  the 
hands  grasping  the  thigh  and  leg.  the  direction 
of  the  extension  being  across  the  middle  of  the 
sound  thigh.  In  this  position  the  thigh  of  the 
dislocated  limb  is  flexed  almost  to  a  right  angle 
with  the  pelvis.     The  surgeon  is  also  called  to 


SOCIETY  PROCEEDINGS. 


[February  j, 


assist  in  the  extension  by  standing  behind  the  as- 
sistant who  had  his  foot  on  the  perineum.  The 
surgeon  can  also,  while  in  this  position,  change 
the  direction  of  the  force  and  rotate  the  limit  as 
may  be  necessary.  In  this  manner,  at  the  very 
first  effort,  and  without  much  force  being  used, 
the  head  of  the  bone  slipped,  with  a  sensation 
which  could  be  felt,  into  acetabulum.  Upon  in- 
spection and  movement,  the  deformity  had  en- 
tirely disappeared. 

While  it  has  been  my  fortune  to  see  a  good 
many  dislocations  of  the  hip  reduced  by  manipu- 
lation alone,  still  this  is  the  seventh  case  of  which 
I  have  knowledge  when  it  has  failed,  and  when 
extension  applied  in  this  simple  manner  has  been 
successful. 

A  few  years  ago,  I  reported  to  the  Medical  So 
ciety  of  the  State  of  Pennsylvania  a  history  of  six 
cases  of  this  kind.  This  report  may  be  found  in 
the  Transactions  of  our  State  Society  for  1886. 
From  the  experience  which  I  have  had  in  these, 
and  other  cases,  I  am  persuaded  that  this  simple 
method  of  extension  and  counter-extension  should 
always  be  resorted  to  before  making  the  effort  by 
manipulation. 

The  method  by  manipulation  is  not  so  harm- 
less as  some  of  its  advocates  assert.  The  shaft 
of  the  femur  which  is  made  use  of  when  manipu- 
lation is  resorted  to,  is  the  long  arm  of  the  lever, 
the  Y  ligament  is  the  fulcrum,  and  the  neck  of 
the  femur,  with  the  force  which  can  be  applied 
to  it,  is  liable  to  give  way.  Fracture  of  the  neck 
of  the  femur  has,  in  this  manner,  been  produced 
by  some  of  our  best  surgeons.  Such  men  as  Jas. 
R.  Wood,  Post,  and  Markoe,  of  New  York,  and 
many  others,  have  had  this  accident  happen 
while  attempting  to  reduce  dislocations  of  the  hip 
by  manipulation.  But  even  if  no  fracture  is  pro- 
duced, the  sweeping  round  the  acetabulum  of  the 
head  of  the  femur,  as  occurs  during  this  manipu- 
lation, lacerates  and  bruises  the  capsular  ligament 
and  other  structures  in  an  unnecessary  degree. 

The  violence  produced  by  extension  in  the  man- 
ner which  I  have  indicated,  cannot  produce  such 
injury;  and  is,  as  I  believe,  more  likely  to  suc- 
ceed. 

To  Henry  J.  Bigelow,  the  distinguished  Pro- 
of  Surgery  in  the  Medical  School  of  Har- 
vard University,  we  are  indebted  for  teaching  us 
hew  important  a  part  the  anterior  capsule  of  the 
hip  joint  1  viz. :  the  Y  ligament  I  plays  in  luxation. 
He  has  taught  the  profession  that  to  reduce  the 
dislocation  it  is  first  necessary  to  relax  this  liga- 
ment. This  is  accomplished  by  the  method  I  ad- 
vise, because   the   thigh    is  first   flexed    Upon    the 

pelvis  before  any  extension  is  made.  Moreover, 
we  now  know,  that  in  nearly  all  dislocations  of 
the  hip,  that  it  is  thelower  and  inferior  portion  of 
the  capsule  which  gives  way.  It  is  here  that  the 
ilum  is  most  shallow  and  the  ligament  has 
least  strength. 


It  is  the  opinion  of  our  best  modern  surgeons 
that  nearly  all  dislocations  of  the  hip  are  prima- 
rily downward,  and  that  when  the  head  of  the 
femur  is  found  in  any  other  position,  whether 
upon  the  dorsum  ilii,  into  the  sciatic  notch,  or 
upon  the  pubes,  that  this  position  is  secondary 
to  the  downward. 

If  this  be  so,  and  there  is  little  doubt  of  its 
truth,  it  surety  seems  likely  that  the  pulling  the 
head  of  the  bone  downward  to  the  place  where 
the  rent  in  the  capsular  ligament  has  occurred,  is 
the  best  direction  in  which  to  apply  the  force. 

In  other  words,  the  dislocated  head  of  the  fe- 
mur must,  in  order  to  find  its  place  in  the  ace- 
tabulum, retrace  the  steps  which  it  took  after 
leaving  it. 

I  would,  therefore,  advise  that  in  the  reduction 
of  a  dislocation  of  the  hip,  no  matter  what  the 
position  may  be,  after  thoroughly  anaesthetizing 
the  patient,  the  attempt  at  reduction  should  be 
made'  in  the  manner  indicated. 

It  is  probable  that  much  of  the  popularity 
which  the  method  by  manipulation  has  received, 
is  owing  to  the  fact  that  anaesthetics  came  into 
general  use  by  the  profession  about  the  same  time 
that  Reed,  of  Rochester,  described  his  method  of 
reducing  dislocations  by  rotation  and  circumduc- 
tion. 

Dr.  Buchanan  :  I  wish  to  say  that  I  heartily 
agree  with  Dr.  Murdoch  in  the  position  he  has 
taken  relative  to  the  choice  of  methods  of  reduc- 
tion, for  the  shoulder  as  well  as  the  hip.  I  think 
the  effort  by  extension  should  be  tried  first,  for 
the  reason  that,  as  Dr.  Murdoch  well  expresses 
it,  by  extension  and  without  the  use  of  pulleys. 
simply  manual,  no  harm  can  be  done  ;  whereas, 
any  man  who  has  ever  held  a  patient's  thigh  and 
put  the  head  of  the  bone  into  its  socket  by  the 
method  of  manipulation,  could  not  but  have  felt 
grateful,  when  the  head  of  the  bone  passed  in  its 
place,  that  he  had  not  broken  the  femur.  If  he 
fails  by  extension,  he  feels  that  he  has  done  110 
harm,  but  if  he  fails  in  his  trial  by  manipulation, 
he  feels  that  he  may  have  done  much  harm.  I 
think  that  the  resistance  of  muscular  tissues  and 
fibrous  tissues,  when  the  patient  is  thoroughly 
under  the  influence  of  an  anaesthetic,  is  very 
much  over-rated.  Within  a  couple  of  weeks,  I 
have  put  in  two  shoulder-joints  by  the  method  of 
extension  without  anaesthesia,  and  with  no  trou- 
ble whatever,  almost  lifting  the  head  of  the  bone 
into  place.  One  was  an  exceedingly  muscular 
man,  and  I  am  satisfied  that  if  I  had  put  the  pa- 
tient under  an  anaesthetic  and  attempted  the 
method  of  manipulation.  I  would  have  had  much 
more  trouble  and  might  have  done  a  great  deal 
oi    harm. 

Dr.  STEVENSON:  I  think  the  fact  that  sur- 
geons of  equal  eminence  and  experience  differ  so 
widely  is  proof  that  cases  differ.  Some  cases  are- 
more  easily  reduced  by  one  method,  other  cases 


ligi.] 


SOCIETY  PROCEEDINGS 


2>3 


can  be  reduced  by  another  and  by  that  alone. 
Dr.  Murdoch's  idea  of  dislocation  taking  place  at 
the  lower  part  of  the  acetabulum  would  seem  to 
coincide  with  my  experience  in  reducing  them. 


rather  limited,   but    it   goes  to  show  that 
cases  are  reduced  readily  by  one  method  while 
others  apparently  arc  very  easily  reduced  by  an- 
other.    While  resident  at  the  West  Pennsylvania 


They  seem  to  return  at  that  part  of  the  acetabu-  hospital,  a  case  of  dislocation  of  the  femur  wa> 
lum.  A  gentleman  invited  me  to  go  with  him  brought  in.  and  being  very  anxious  to  try  my 
to  witness  the  reduction  of  a  dislocated  hip  by  hand  at  what,  if  I  remember  aright,  I  had 
the  pulley.  He  said  his  brother  had  seen  the  case  never  seen  done  before,  I,  together  with  the  other 
about  six  o'clock  in  the  morning,  and  made  a  resident,  then  serving  with  me,  attempted  to  re- 
very  continuous  effort  at  reduction,  and  had  duce  that  dislocation  by  manipulation  under 
failed,  and  he  had  asked  me  to  accompany  him.  ether.  The  first  attempt  I  made  was  un- 
There  had  been  an  unsuccessful  attempt  made  ful,  but  the  second  one,  much  to  my  surprise, 
for  two  hours  to  reduce  the  dislocation,  and  it  was  attended  with  success  with  the  use  of  but 
was  concluded  that  it  was  impossible  to  reduce  it  little  force.  Lately  a  dislocation  of  the  shoulder 
without  pulleys.  I  took  hold  of  the  limb,  which  presented  itself  at  the  Dispensary,  and  I  at- 
was  rigidly  fixed  ;  it  would  not  go  in,  it  would  tempted  to  reduce  it  by  extension,  possibly  not 
not  go  out.  I  asked  the  doctor  if  he  had  any  quite  after  the  easy  method  which  has  been  de- 
objection  to  my  trying  to  reduce  it  by  manipula-  tailed  by  Dr.  Buchanan  ;  reduction,  however, 
tion.  None  at  all.  So  I  flexed  the  foot  on  the  !  proved  unsuccessful  to  me.  But  in  the  hands  of 
thigh,  flexed  the  thigh  well  up  on  the  abdomen,  one  of  my  colleagues  it  was  easily  accomplished, 
carried  it  across  the  body,  carried  it  down  and  Dr.  Murdoch:  I  do  not  claim  to  have  greater 
straightened  it  out,  and  the  head  of  the  bone  experience  in  the  dislocation  of  the  hip  than 
slipped  into  place.  This  case  was  not  etherized,  others,  though  I  have  seen  a  good  many  disloca- 
We  had  just  come  in  and  this  was  done  prepara-  tions.  One  of  the  first  cases  I  ever  saw,  was  in 
tory  to  commencing  the  operation  with  pulleys,  the  army  of  the  Potomac,  where  a  powerful 
I  saw  another  case  in  which  the  femur  was  dis-   teamster   had    dislocated   his   femur,   and  where 


k>cated,  the  leg  was  thrown  across  the  other 
limb.  I  reduced  that  in  the  same  way.  That 
was  done  without  any  anaesthetic.  All  cases 
could  not  be  reduced  in  this  way  ;    I  do  not  pre- 


there  were  probably  three  hundred  surgeons  pres- 
ent, and  an  effort  had  been  made  by  manipula- 
tion to  reduce  it  for  a  couple  of  hours  before  I 
happened   to  join   the  company.      When    I   got 


tend  to  the  skill  in  surgical  operations  that  I  there,  the  patient  was  thoroughly  anaesthetized, 
know  my  friend  Dr.  Murdoch  has.  His  experi-  By  very  slight  effort,  I  took  hold  of  it  and  it 
ence  is  much  greater  than  mine.  I  saw  a  case  went  back  into  the  joint.  I  received  quite  an 
while  practicing  in  Westmoreland  county  in  ovation.  I  believe  as  Dr.  Stevenson  says,  that 
which  three  or  four  doctors  worked  an  hour  and  the  majority  of  surgeons  have  until  recently 
a  half,  effecting  the  reduction  by  means  of  ex-  thought  the  method  of  manipulation  should 
tension  and  counter  extension,  and  that  was  always  be  tried  first,  and  that  has  been  the  case 
twenty-five  years  ago,  before  this  method  of  at  the  West  Pennsylvania  hospital,  and  the  resort 
manipulation  was  well  understood.  I  have  no  to  manipulation  has  usually  been  successful, 
doubt  that  in  all  these  dislocations  it  is  the  liga-  The  rule  is  that  success  is  reached.  But  as  I  say 
ment  of  the  hip-joint  that  holds  the  limb  rigidly  we  have  found  seven  cases  there  in  which  we 
fixed  in  its  place.  It  is  not  so  much  the  muscles  failed,  and  which  were  very  readily  reduced  by 
as  the  ligament.  Now,  if  the  head  can  be  made  the  method  of  extension  and  counter-extension, 
to  retrace  the  path  that  it  took  in  getting  into  Dr.  Stevenson  says  he  cannot  conceive  how  a 
the  false  position,  I  think  there  is  no  injury  done  man  can  do  much  injury  in  manipulation.  I 
to  the  ligament.  I  think  there  is  no  injury  done  I  give  him  cases  of  four  fractures  of  the  neck  of 
to  the  joint.  The  idea  of  manipulation  is  not  the  femur.  I  think  it  does  not  take  much  power 
force :  it  is  handling,  coaxing — taking  the  thigh  of  imagination  to  see  how  this  powerful  lever 
and  so  handling  it  as  to  make  the  head  of  the  may  break  the  bone.  The  point  I  desire  to  make 
bone  retrace  the  course  it  took  in  passing  into  the  is,  that  the  amount  of  extension  which  can  be 
position  in  which  we  find  it.  made  by  the  unaided  hands  should  be  tried  first. 

I  cannot  conceive  that  manipulation  done  I  am  beginning  to  believe  that  it  is  the  proper 
cautiously  and  carefully  can  do  any  particular  in-  course  and  that  much  damage  may  be  saved  by 
jury  to  the  hip  joint,   but   I  can  conceive  that  a   such  a  rule. 

man,  or  two  or  three  men.  pulling  with  vigor  Dk.  McCann  :  I  agree  with  Dr.  Murdoch  in 
and  violence,  and  using  counter  force  rnay  do  the  main.  From  one  part  of  his  remarks  I  must 
great  injury  to  a  joint.  I  would  feel  disposed,  dissent  ;  that  is,  that  dislocation  does  not  occur 
from  the  experience  I  have  had,  to  try  the  ma-  at  any  other  place  than  at  the  lower  and  anterior 
nipulation  first.  If  it  fail,  then  resort  to  some-  j  portion  of  the  acetabulum.  I  have  had.  in  my 
thing  else.  experience,   an  example   in   which   the    capsular 

Dr.  Koenig  :    My  experience  in  dislocation  is   ligament  was  torn  anteriorly  to  the  outer  side  in 


2-4 


SOCIETY  PROCEEDINGS. 


[February  7, 


a  case  of  dislocation,  a  case  in  which  the  patient 
died  shortly  after  an  accident  and  in  which,  after 
his  death,  effort  was  made  to  reduce  the  disloca- 
tion, which  was  effected  by  manipulation.  I 
think  that  in  the  majority  of  cases  it  is  wise  to 
resort  to  extension  in  trying  to  reduce  a  disloca- 
tion, but  I  look  with  horror  upon  the  pulleys, 
and  have  never  resorted  to  them.  I  have  seen 
them  used  with  a  patient  under  the  influence  of 
an  anaesthetic,  and  have  seen  an  awful  amount  of 
force  used  to  put  the  head  back  into  its  normal 
position — more  force  than  I  have  seen  used  in 
manipulation.  I  have  seen  some  of  the  cases  to 
which  Dr.  Murdoch  refers.  I  admit  there  are 
cases  where  this  is  the  proper  method,  and  it 
may  be  proper  to  resort  to  it  always,  but  to  rely 
upon  or  go  back  to  the  old  method  of  extension 
is  a  step  backward.  Now,  as  to  manipulation, 
whenever  that  degree  of  force  is  used  which  will 
fracture  the  femur,  it  is  improper.  There  should 
be  no  force  used.  The  weight  of  the  limb  guided 
by  the  hand  should  put  it  in. 

Dr.  Murdoch  :  I  would  like  to  say  to  Dr. 
McCann  when  he  speaks  about  going  back  to  ex- 
tension that  those  gentlemen  who  think  manipu- 
lation is  a  modern  method  do  not  know  history. 
The  method  of  manipulation  was  used  by  Hippo- 
crates. It  has  had  advocates  all  the  way  down  the 
ages  from  time  to  time,  has  been  used  and  aban- 
doned. Manipulation  is  the  older  method  of  the 
two.  Sir  Astley  Cooper's  method  of  reducing  a  dis- 
location was  to  suspend  his  patient  by  the  dislo- 
cated limb  to  the  branch  of  a  tree,  aud  if  this  was 
not  successful,  the  surgeon  might  add  his  own 
weight.  Now  I  hope  I  have  not  been  understood 
as  advocating  the  use  of  pulleys  or  any  other 
powerful  mechanical  means.  I  have  been  careful 
to  say  that  such  extension  should  be  made  by  the 
unaided  hands.  w 

Dr.  McCann  :  This  morning  I  had  to  reduce 
an  old  dislocation  of  the  shoulder,  which  had  been 
out  of  place  for  seven  weeks.  It  is  a  curious  fact 
that  men  will  overlook  dislocations  of  the  shoul- 
der joint.  Many  physicians  will  not  take  the 
trouble  to  anaesthetize  patients  and  to  employ  the 
well-known  rules  to  establish  the  diagnosis.  It 
is  my  opinion  that  the  old  dislocation  is  not  a  safe 
thing  to  deal  with,  because  of  adhesions  which 
fix  the  head  of  the  bone  in  the  new  position.  Ad- 
hesions are  liable  to  implicate  the  artery  and  vein 
and  nerves.  Manipulation  then  in  an  effort  to 
reduce  such  a  dislocation  is  liable  to  be  followed 
by  serious  accidents.  Injury  to  artery,  vein  and 
nerves  may  happen.  Then  there  is  another 
thing  ;  the  binding  down  the  head  of  the  bone 
may  be  so  linn  that  unwonted  and  unusual  efforts 
to  reduce  the  dislocation,  to  force  the  head  of  the 
bone  back  into  its  normal  position  results  in  a 
fracture  of  the  bone  itself.  These  are  the  dan 
gers.  The  method  which  I  pursue  is  first  to  en- 
deavor to  loosen  the  head  of  the  bone  thoroughly 


from  adhesions  by  passive  motion  ;  to  break  down 
the  adhesions  by  moving  the  arm  in  all  directions 
until  you  feel  that  everything  is  loose.  This 
will  require  several  minutes,  five  or  ten  or  more 
minutes  may  be  thus  consumed.  Then  I  begin 
the  reduction  proper,  usually  by  drawing  the  arm 
directly  upward  in  a  line  with  the  body.  By 
this  method  I  have  succeeded  in  reducing  dislo- 
cations, six,  seven,  twelve  and  sixteen  weeks  old. 
I  have  never  had  any  accident. 

Dr.  Beatty  :  I  understood  Dr.  McCann  to 
say  the  physician  would  not  take  the  trouble  to 
make  the  necessary  examination.  I  would  ask 
whether  he  would  advise  that  the  patient  be  put 
under  an  anaesthetic  so  as  to  complete  examina- 
tion in  a  dislocation  of  the  shoulder  ? 

Dr.  McCann  :  I  would  simply  say  that  when 
you  are  in  doubt,  it  is  always  a  good  plan  to  make 
certain  ;  it  is  always  a  good  plan  to  call  in  some 
friend  as  counsel,  anaesthetize  the  patient,  make 
yourself  sure  that  you  have  a  dislocation  or  that 
you  have  not.  I  think  this  is  safe  practice  and  I 
believe  it  proper  it  should  be  pursued  in  every 
case  of  injury  of  the  joint  in  which  there  is  doubt. 

Dr.  Beatty  :  I  explain  why  I  made  this  in- 
quiry. A  short  time  ago  I  was  called  to  see  an 
aged  lady  who  was  very  fleshy  about  the  shoul- 
der and  had  all  the  characteristic  symptoms  of  dis- 
location. She  was  able  to  put  her  hand  upon  her 
opposite  shoulder,  and  she  could  do  many  other 
things  that  led  me  to  suppose  that  she  had  not  a 
dislocation  of  the  shoulder,  and  being  an  aged 
woman,  I  seriously  thought  we  had  better  let  her 
alone.  She  was  so  fleshy  that  I  could  not  find 
the  head  of  the  bone.  I  concluded  that  the  best 
thing  to  do  was  to  put  my  patient  under  the  influ- 
ence of  ether  and  then  make  an  examination.  I 
had  the  assistance  of  a  nurse,  got  the  old  lady 
under  the  influence,  made  the  examination  ;  the 
thing  slipped  in  and  the  dislocation  almost  re- 
duced itself.  Had  I  not  etherized  my  patient 
she  would  probably  have  gone  with  that  shoul- 
der dislocated  the  rest  of  her  days. 

Dk.  Rigg  :  It  occurs  to  me  that  a  very  frequent 
cause  of  overlooking  dislocation  of  the  shoulder 
joint  is  the  statement  of  the  patient.  That  has  been 
brought  forcibly  to  my  mind  twice.  Once  a  mil- 
ler had  his  arm  caught  ill  the  belting  of  his  mill. 
He  paid  no  attention  to  it,  being  subject  to  mus- 
cular rheumatism  ;  he  went  to  the  office  of  a 
neighboring  physician  and  told  him  he  had  a  se- 
vere attack  of  rheumatism  in  the  arm,  and  would 
like  him  to  inject  morphia.  The  physician  made 
no  examination,  injected  the  morphia,  and  gave 
the  man  something  for  rheumatism.  The  man 
went  around  with  his  arm  in  this  shape  for  months. 
This  was  in  March.  About  the  middle  of  August 
I  was  passing  his  house  one  day  and  he  asked  me 
to  stop  and  look  at  his  arm.  I  went  in.  I  had 
seen  him  frequently  on  the  street  and  always  in 
that  position,  he  never  seemed   to  move  his  arm. 


i89i.] 


SPECIAL  CORRKSI'UNDKNCK 


215 


I  thought  he  must  be  suffering  from  a  dislocation, 
and  asked  him  to  allow  me  to  examine  the  joint. 
I  did  not  give  him  ether  in  the  reduction  of  it.  I 
told  him  we  would  first  break  up  the  adhesions  if 
he  was  willing  to  stand  it.  He  agreed  to  this, 
and  after  the  adhesions  were  broken  up,  the  dislo- 
cation was  reduced  very  readily.  I  did  not  give 
an  anaesthetic.  Another  case,  a  man  fell  from  a 
moving  train,  falling  on  his  shoulder  and  simply 
stated  to  the  physician  that  he  had  fallen  off  the 
train  and  struck  his  shoulder.  The  physician  did 
not  look  for  a  dislocation.  It  was  allowed  to  go 
for  about  ten  clays.  So  that  I  think  it  is  always 
necessary  to  inquire  carefully,  and  in  some  cases 
to  use  an  anaesthetic  when  in  doubt. 


practitioners  beneath  the  sun,  and  if  we  are  nol 
grace  the  Yankee  name.  1:  Chewhry,  M.D. 

65  Chandler  St.,  Boston,  Mass.,  Jan.  27,  I 


To  the  Editor:— Please  record  tny  vote  in  favor  of  con- 
tinuing the  publication  of  this  journal  in  Chi( 

J.  G.  BEMIS,  MI). 
161  \V.  Madison  St.,  Chicago,  January  30, 


To  the  Editor: — Please  register  my  vote  against  mov- 
ing Tin-;  Journal  to  Washington  or  anywhen 

r.  E.  Yoaki  M,  M.I). 
Shreveport,  La..  January  29,  1891, 


SPECIAL  CORRESPONDENCE. 


shall  The  Journal  be  Removed   to 
Washington  ? 

To  the  Editor. — As  a  member  of  the  Association  I  op- 
pose the  removal  of  The  Journal  to  Washington  City. 
I  cannot  see  any  advantage  to  be  gained  from  the  more 
central  point — Chicago. 

If  a  removal  is  demanded,  and  the  convenience  of  the 
members  is  to  be  considered,  why  not  seek  a  central 
point,  and  establish  headquarters  at  St.  Louis,  Mo.? 

Jno.  W.  Trader,  M.D. 

Sedalia,  Mo.,  Jan.  26,  1S91. 


To  the  Editor: — Views  of  Dr.  W.  F.  Rochelle,  in  No. 
4,  January  24,  endorsed.  Keep  The  Journal  in  Chicago. 
Nothing  to  be  gained  bv  the  change. 

T.  R.  Luff,   M.D. 

Cincinnati,  O.,  Jan.  27,  1S91. 


To  the  Editor: — The  pride  of  the  American  phvsician 
consists  in  his  success,  his  success  in  his  advantages,  and 
his  advantages  of  reading  THE  Journal  at  an  early  date 
will  be  greater  if  allowed  to  remain  in  Chicago  than  if 
taken  to  Washington.  I  mean  the  M.D's  of  the  West. 
J.  H.  Lyon,  m.D. 

Roslyn,  Washington,  Jan.  22,  1S91. 


To  the  Editor: — If  I  remember  rightly,  the  proposition 
was  made,  at  a  recent  meeting  of  the  Association,  to  select 
a  permanent  location  for  our  annual  meetings;  I  do  not 
remember  decision,  but  if  in  the  affirmative,  I  certainly 
deem  said  place  to  be  the  proper  one  at  which  to  pub- 
lish The  Journal,  otherwise,  I  cannot  see  any  benefit, 
pecuniary  or  other,  to  be  derived  by  moving  from  Chi- 
cago.    I  therefore  vote  that  no  change  be  made. 

A.  Parker  Champlin,  M.D. 

Biloxi,  Miss.,  Jan.  27,  1S91. 


To  the  Editor: — I  prefer  that  The  Journal  should 
stay  where  it  is;  for  it  is  in  the  midst  of  a  thriving,  stir- 
ring medical  people,  and  it  is  all  the  time  growing  fuller 
and  richer  in  practical  ideas.  To  be  sure  we  have  a  great 
body  of  cold  science  in  the  East,  but  it  needs  to  come  to 
life  and  be  clothed  for  practical  work.  Now  the  free, 
warm  spirit  of  the  great  West  is  just  the  thing  to  move 
upon  the  medical  bones  of  the  East  to  cause  them  to 
stand  up  and  give  an  efficiency  to  American  practice  that 
beats  the  world;  for  with  our  constitutional  make-up, 
with  proper  training,  and  with  the  most  wide-awake 
journals  in  our  hand,  we  ought  to  be  the  ablest  bedside 


To  the  Editor: — In  the  last  issue  Dr.  Solis-Cohen  con- 
siders the  matter  of  the  removal  of  The  Journal.  A 
careful  perusal  of  his  letter  shows  it  to  be  a  conglomerate 
admixture   of  argument  and  assertion,  seasoned  with   a 

Dr.  Cohen  in  his  letter  starts  with  the  question,  where 
can  Tin".  Journal  be  best  edited  and  best  serve  the  inter- 
ests of  the  Association.  Then  he  proceeds  to  find  fault 
with  the  management  of  The  Journal,  stating  that  it 
has  identified  itself  with  local  interests,  that  it  has  not 
attracted  the  work  of  the  best  men,  that  it  has  not  been 
sufficiently  careful  in  rejecting  poor  papers,  and  finally, 
that  its  abstracts  and  selections  have  not  been  up  to  stan- 
dard. The  editorial  department  he  considers  to  have 
been  one  of  the  strongest  features  of  Tin  Joi  knal. 

With  this  sufficiently  perspicuous  statement  of  the 
shortcomings  of  The  Journal,  the  writer  proceeds  to 
find  a  cause  for  it  in  the  fact  that  the  home  of  THE  Joi  R- 
xal  has  been  in  Chicago.  That  it  must  be  due  to  some 
evil  and  malign  influences  that  surround  the  publication 
in  its  present  location,  the  doctor  thinks  is  attested  by 
the  fact  that  the  personnel  of  the  editorial  staff  could  not 
be  better,  and  therefore  it  must  be  due  to  local  restric- 
tions. It  should  be  gratifying  to  the  profession  in  Chi- 
cago, as  misery  is  said  to  love  company,  to  know  that  the 
same  peculiar  miasm  is  present  in  Philadelphia.  New 
York,  Boston  and  Baltimore.  We  cannot  refrain  from 
congratulating  the  profession  of  Washington  upon  their 
singulai  exemption  from  this  kind  of  infection.  We  had 
supposed  that  there  were  some  fairly  representative  jour- 
nals published  in  this  country,  notably  the  American 
Journal  of  the  Medical  Sciences,  but  it  is  only  necessary 
to  read  Dr.  Cohen's  letter  to  be  convinced  that  its  influ- 
ence is  purely  local,  and  that  it  would  have  had  a  wide 
and  grand  success  had  it  only  been  removed  to  Washing- 
ton. 

Granting,  for  the  sake  of  argument,  that  the  doctor's 
strictures  regarding  the  management  of  The  Jo'  kn  \l 
are  true,  what  guarantee  have  we  that  if  it  is  moved,  lo- 
cal influences  or  the  advancement  of  individual  interests 
will  not  dictate  its  conduct  in  its  new  home?  Have  the 
profession  of  Washington  alone  those  self-effacing  quali- 
ties that  will  allow  them  to  remain  invisible  while  they 
conduct  Tin-;  Journal  into  higher  and  ever  widening 
plains  of  usefulness?  What  covenant  will  they  enter  into? 
What  bond  will  they  give  that   such  shall   come  to  pass? 

The  reasons  in  favor  of  Washington  are  delightfully 
simple.  The  removal  would  immediately  relieve  local 
influences,  and  this  would  raise  the  standard;  this  im- 
provement would  attract  the  best  minds,  and  so  all  would 
go  on  in  ever  increasing  grandeur.  As  near  as  we  can 
analyze  Dr.  Cohen's  statement,  there  seems  to  be  in 
Washington  a  great,  intangible,  psychic  entity,  that  has 
its  being  as  an  incorporeal  body  working  in  and  for  the 
good  of  the  but  not  of  it,  for  they  are  of  the  earth,  and 
this  is  of  the  spiritual  and  invisible.  For  convenience 
we  may  name  this  influence  the  Great  Good,  just  as  we 
may  call  that  other  equally  intangible  thing  existing  in 
Chicago,  New  York,  Philadelphia  and  Baltimore,  the 
Great  Ex  il. 


2l6 


MISCELLANY. 


[February  7,  1891. 


In  conclusion,  Mr.  Editor,  I  would  like  to  say  that  I 
regard  the  removal  of  the  Association  storm-centre  from 
Chicago  to  Washington  as  a  simple  change,  and  not  in 
any  sense  as  a  solution  of  whatever  real  or  imaginary  ills 
inav  affect  The  Journal. 

If  The  Journal  is  not  up  to  what  it  could  be  made, 
let  the  Trustees  see  to  it  that  it  is  improved.  Nothing 
will  be  gained  by  a  simple  transfer  of  editing,  printing, 
press-work  or  binding  to  either  Washington,  Oshkosh  or 
Kalamazoo.  Harold  N.  MOVER,  M.D. 

Chicago,  January  31,  1891. 


To  the  Editor: — Permit  me  through  the  columns  of 
your  journal  to  ask  our  friend  Dr.  Solomon  Solis-Cohen 
to  please  verify  his  assertion  under  No.  1,  to  point  out 
the  Vol.,  No.  and  page  of  The  Journal  of  the  Ameri- 
can Medical  Association  in  which  said  journal  has 
debased  itself  either  in  its  editorial  or  news  columns  as 
he  alleges  it  to  have  done. 

While  the  doctor  is  on  the  stand  we  would  be  glad  to 
have  him  enlighten  the  thousands  of  readers  of  The 
Journal  on  his  2nd  proposition  and  tell  us  in  what  re- 
spect Chicago  debars  the  best  scientific  men  in  the 
country  from  sending  the  best  productions  thev  can  pro- 
duce to  The  Journal  of  the  National  Association,  or  in 
what  respect  Washington  would  have  any  greater  mag- 
netic attraction  for  these  articles  than  the  great  metrop- 
olis of  the  west.  Certainly  Washington  has  nevershown 
any  great  distinction  in  the  literary  field,  either  in  the 
past  or  present;  surely  not  in  the  newspaper,  notwith- 
standing it  is  the  Capital,  on  which  the  doctor  puts  so 
much  stress  in  his  remarks. 

We  will  be  glad  to  have.the  doctor,  while  he  has  the 
stand,  explain  to  us  in  what  respect  Washington  would 
facilitate  the  ejection  of  the  worthless  papers,  any  more 
than  Chicago  ?  To  say  that  The  Journal  of  the 
American  Medical  Association  has  not,  and  does  not 
present  anything  new  to  its  readers  is  a  severe  criticism 
on  the  doctor  himself,  who  has  been  a  contributor  to  its 
columns  in  the  past,  saying  nothing  of  the  work  of  such 
men  as  Senn,  Parkes,  Fenger,  Connor,  McGraw,  Van 
Deveer,  Wood,  and  scores  of  other  eminent  American 
investigators  and  writers  who  have  contributed  to  its 
columns  from  time  to  time  some  of  the  ablest  articles  of 
the  age. 

In  what  respect,  pray  tell  us,  will  the  removal  ofcTHE 
Journal  to  Washington  improve  its  abstract  column  ? 
Certainly  a  useless  expenditure  of  money  for  its  removal, 
together  with  the  loss  of  advertising  patronage  by  its  re- 
moval would  not  in  any  mauner  aid  in  the  securing  of 
better  abstracts  or  a  higher  class  of  reviews. 

In  reading  No.  5,  one  would  imagine  that  Washington 
was  the  only  place  where  "well  informed  and  thoughtful 
editorial  comments  upon  questions  of  importance"  could 
be  manufactured;  if  this  is  true  it  does  seem  strange  that 
Washington  has  never  been,  and  is  not  now  a  medical 
centre  in  any  sense  of  the  word. 

In  regard  to  No.  1  of  his  second  series;  if  the  doctor 
had  said  that  Washington  belonged  to  the  political  par- 
ties alike,  and  the  temptation  to  debase  statemanship 
by  rings  and  factions  for  personal  interests  was  rife  in 
that  city,  he  would  have  hit  the  nail  on  the  head  exactly. 
Surely  it  is  a  trifle  hazardous  to  the  real  interests  of  The 
Journal  to  have  it  surrounded  with  an  atmosphere  that 
is  so  impregnated  with  political  strife,  and  one  that  is  so 
frequently  disturbed  by  multitudes  of  ambitious  whirl- 
winds that  are  liable  to  affect  even  a  great  National  med- 
ical journal. 

In  No.  2  he  refers  to  the  treasures  of  the  Surgeon-Gen- 
eral's Library  in  the  National  Museum;  very  good;  but 
tin-  new  library  of  Chicago,  when  completed,  will  excel 
the  Surgeon-General's  Library  for  real  value  as  far  as 
lightning  beats  a  sheep;  while  the  National  Museum  is 
not  of  a  great  deal  of  benefit  for  the  production  of  orig- 


inal thought,  or  investigation  such  as  the  doctor  has 
dwelt  on  so  much  in  his  caustic  letter. 

In  No.  3  may  I  be  permitted  to  ask  him,  and  that  with 
all  due  respect  to  the  medical  profession  in  Washington, 
to  point  me  out  one  single  member  of  the  same  who  has 
distinguished  himself  by  his  original  investigation,  of 
original  subjects,  and  thereby  produced  something  new 
(such  as  he  claims  should  only  enter  the  columns  of  The 
JOURNAI,)  for  the  enlightenment  and  benefit  of  the  pro- 
fession ? 

In  reply  to  No.  4  it  is  difficult  to  see,  under  all  the 
circumstances  and  present  evidence,  how  the  removal  of 
The  Journal  from  the  second  largest  city  of  our 
country,  to  one  scarcely  ONE-FIFTH  as  large,  would  raise 
the  editorial  status  of  the  same,  or  be  any  greater  incen- 
tive to  attract  able  papers  from  the  best  members  of  our 
profession;  and  hence  we  would  be  glad  to  have  the  doc- 
tor proceed  to  explain  the  philosophy  of  this  kind  of 


Then,  in  No.  5,  he  goes  on  to  say  that  only  by  concen- 
tration the  best  work  can  be  done,  and  yet  in  his  pre- 
vious breath  he  advocates  the  removal  of  The  Journal 
from  the  great  western  metropolis  which  is  the  largest 
railroad  centre  in  the  world,  to  a  diminutive  city  as  com- 
pared with  Chicago  in  any  particular,  with  only  three 
railroads,  and  then  claims  that  that  is  concentration,  and 
is  conducive  to  medical  elevation;  especially  when  two- 
thirds  of  all  the  members  of  our  Association  live  west  of 
the  Allegheny  mountains,  and  only  one-third  east  of  the 
Appalachian  range. 

Now,  doctor,  this  is  a  strictly  business  transaction,  and 
should  be  regarded  as  such  by  all  who  are  interested  in 
thf  welfare  of  The  Journal,  and  I  will  now  close  by  ask- 
ing you,  if  Washington  is  such  a  great  centre,  why  busi- 
ness men,  wholesale  dealers,  manufacturing  establish- 
ments, railroads  and  commerce  in  general,  are  not  centred 
there?  If  other  business  interests  have  not  found  that  a 
profitable  centre  for  them,  and  newspapers  and  maga- 
zines have  not  flourished  there,  how  can  you  expect  our 
National  Medical  Journal  to  fare  any  better? 

Let  us  hear  from  you,  doctor,  aud  let  us  have  a  rational 
solution  of  this  question,  in  a  logical  manner. 

R.  Harvey  Reed,  M.D. 

Mansfield,  O.,  Jan.  31,  1891. 


MISCELLANY. 


List  of  Permanent  Members. — The  names  of  Dr.  J. 
H.  Lyon,  Roslyn,  Wash.,  and  Dr.  Karl  von  Ruck,  Ash- 
field,  N.  C,  were  omitted  from  the  List  of  Members  in 
our  December  issue. 


( VA.  ial  List  of  <  'kangei  in  the  Medical  Co>f>s  of  the  ('.  S.  Mm  i .  fm 
tin-  Week  Ending  January  31, 189Z. 

Asst.  Surgeon  R.  P.  Crandal!,  ordered  to  examination  preliminary 

to  promotion, 
r   A.  Surgeon  T   A.  Berryhill,  detached  from  the  "  McArthur  "  and 

wait  ordns  to  the  "  Marion." 
Surgeon  W.  II.  Jones,  detached  from  the  *'  Swalara,"  proceed  home 

and  granted  six  weeks'  leave. 

QMctalLi  I  ■    Stations  and  Duties  0/ Medical  Officers  0/ 

the  U.  S.  Marine-Hospital  Service,  fat   the  Fom   Weeks  Ending 
January  24,  1S91. 

Surgon  P.  H.  Itailhache,  granted  leave  of  absence  for   seven  days. 

January  ia,  1891. 
111  jeon  <  reorge  Purviance,  to  proceed  to  Pittsburgh  and  Erie,  Pa., 

Cleveland  and  Toledo,  O.,  Detroit,   Mich.,  and  Buffalo,  N.   Y.,  as 

[nspe<  toi      1  >'  cembei   19,  [890, 
P.  A.  Surgeon  1'.  M.  Harrington,  granted  leave  of  absence  lor  seveu 

days      ranuarv  [6,  [891. 
\sst    Sin  genu    H    D.  GeddingS,  to  report  in   person  to  the  Supervis- 
ing Surgeon-General,  January  16,  [891.      Detailed  for  specialduty, 

poal  o!    Geoi  getown,  D.  C,  January  i<>,  1891, 
Asst,  Surgeon  \V.  G.  Stimpson,  to  proceed  to  New  Orleans,  l.a  ,  tor 

temporary  duty.     January'',  189I, 


T  1 1  E 


J  ournal  of  the  American  Medical  Association. 

EDITED  UNDER  THE  DIRECTION  OF  THE  BOARD  OF  TRUSTEES. 

PUBLISHED    WEEKLY. 


Vol.  XVI. 


CHICAGO,  FEBRUARY  14,   1891. 


NO  7. 


ORIGINAL  ARTICLES. 


ANEURISMAL    TUMOR    OF   THE    RIGHT 

ALVEOLAR  PROCESS   AND  VAULT 

OF  THE  MOUTH  TREATED  BY 

IXJECTK  >N. 

BY  JOHN  S.   MARSHALL,   M.D., 

PROFESSOR     OF     ORAL     SURGERY.    UNIVERSITY     DENTAL    COLLEGE; 

VISITING  ORAL  SURGEON    TO  ST.  LUKE'S  FREE   HOSPITAL 

AND    MERCY    HOSPITAL.     CHICAGO,    ILL. 

Mr.  C.  B.  H.,  of  Chicago,  American,  aged  26 
years,  occupation  traveling  salesman,  was  referred 
to  me  December  26,  1888,  for  counsel  and  treat- 
ment by  Dr.  M.  Stout,  of  Chicago,  with  the  fol- 
lowing history :  Some  eighteen  or  twenty 
months  previous  to  this  examination  the  gentle- 
man had  submitted  to  the  extraction  of  all  his 
superior  teeth,  except  the  central  incisors.  The 
operation  was  performed  under  nitrous  oxide  gas; 
the  mouth  was  badly  bruised  and  lacerated  on 
account  of  the  difficulty  in  extracting  the  teeth. 
A  few  weeks  afterwards  he  noticed  a  swelling 
upon  the  inner  side  of  the  right  alveolar  ridge, 
which  continued  to  enlarge  as  the  months  went 
by,  and  prevented  the  making  of  the  artificial 
denture,  which  he  was  anxious  to  have  placed  in 
his  mouth.  There  was  no  pain  or  uncomforta- 
ble feeling  about  the  tumor,  except  when  en- 
gaged in  vigorous  exercise  ;  at  such  times  pulsa- 
tion 111  the  part  would  become  very  marked  and 
disagreeable. 

According  to  his  own  statement  he  had  "consult- 
ed several  dentists  (?)  in  relation  to  the  character 
of  the  swelling  ;  some  did  not  know  what  it  was  ; 
one  said  it  was  an  accumulation  of  pus,  another 
that  it  was  a  '  water}  tumor,'  and  a  third  that  it 
was  a  '  vrind'  and  asked  the  privilege  of  letting 
it  out."  This  very  kind  offer,  however,  was  de- 
clined, much  to  the  permanent  benefit  and 
longevity  of  our  patient. 

Examination  of  the  mouth  revealed  the  superior 
teeth  all  gone  except  the  central  incisors,  and  a 
pulsating  tumor  about  one  and  one  half  inches 
in  length,  by  one  inch  in  width,  egg-shaped  in 
form,  with  the  small  end  pointing  forwards,  and 
occupying  the  right  side  of  the  vault  of  the 
mouth,  from  the  outer  wall  of  the  alveolar  pro- 
cess, to  the  median  line,  and  from  t,he  tuberosity 


of  the  maxilla  forward  to  a  line  drawn  through 
the  cuspid  region. 

In  character  it  was  soft,  fluctuating,  compressi- 
ble and  with  very  marked  pulsation.  In  color  it 
was  slightly  deeper  in  tint  than  the  surrounding 
mucous  membrane  Upon  puncturing  it  with  an 
exploring  needle,  a  jet  of  arterial  blood  followed 
its  withdrawal,  and  continued  to  spurt  for  about 
half  a  minute,  when  the  haemorrhage  ceased. 

The  diagnosis  was  aneurismaJ  tumor  of  the 
posterior  palatine  artery,  with  possible  anas- 
tomosis with  some  branch  of  the  superior  maxil- 
lary artery,  the  result  of  injury  in  the  extraction 
of  the  teeth.  An  operation  was  advised,  and  the 
gentleman  agreed  to  report  in  about  two  months. 
Cast  No.  1   is  a  copy  of  the  upper  jaw  at  this 


period.  Business  engagements  prevented  his 
keeping  this  appointment,  and  when  he  next 
called  to  arrange  for  the  operation,  I  was  out  of 
town  on  my  summer  vacation.  He  was  also  on 
vacation,  and  could  not  wait  my  return,  and 
therefore  sought  other  advice. 

October  10,  18S9,  I  saw  him  again,  at  which 
time  he  gave  me  the  following  additional  history: 
That  in  July  he  had  been  operated  upon  for  the 
removal  of  the  tumor  and  had  nearly  died  under 
the  operation,  from  haemorrhage,  and  was  after- 
wards confined  to  his  bed  for  two  months,  with 
blood-poisoning. 

The  cast  which  I  now  show  you,  Xo.  2,  is  a 
copy  of  his  upper  jaw  taken  on  December  17, 
1889,   a  few  days  before   1  operated   upon  him. 


218 


ANEURISMAL  TUMOR 


[  February  14, 


You  will  see  by  this  that  there  was  no  improve- 
ment in  the  condition  as  described  in  the  exami- 
nation made  a  year  previously,  but  that  the  tumor 
was  larger. 


The  surgical  treatment  of  aneurisms  is  by  li- 
gating  the  artery  near  the  cardiac  or  distal  extrem- 
ity of  the  sac,  or  both  ;  by  compression  either 
instrumental  or  digital ;  by  the  introduction  of 
foreign  substances  into  the  sac,  like  catgut,  borse 
hair  or  fine  iron  or  silver  wire ;  by  manipulation  ; 
by  acupuncture  ;  by  galvanopuncture ;  by  the 
injection  of  coagulating  fluids,  and  in  the  case  of 
small  anastomosing  or  cirsoid  aneurisms,  by  dis- 
section. 

The  particular  method  adopted  heing  controlled 
by  the  character  and  location  of  the  aneurisms, 
the  chances  of  danger  to  life,  the  possibilities  of 
a  cure,  and  the  individual  preferences  of  the  op- 
erator. In  all  such  cases,  as  are  susceptible  of 
ligation,  this  is  by  far  the  most  satisfactory 
surgical  procedure  But  in  those  which  from 
their  location  cannot  be  reached  by  this  method 
some  one  of  the  other  means  may  be  employed. 

In  the  case  under  consideration  treatment  by 
ligation,  compression,  manipulation,  acupuncture 
or  dissection  was  out  of  the  question  ;  the 
means  at  our  command  were  therefore  limited  to 
three  methods  :  the  introduction  of  foreign  sub- 
stances, like  wire,  etc.,  galvano-puncture,  and 
injection. 

Treatment  by  the  introduction  of  foreign  sub- 
stances, either  animal  or  metallic,  seemed  slow 
and  unsatisfactory,  and  gave  little  hope  of  suc- 
cess, tor  I  had  been  unable  to  find  a  single  case 
on  record  of  a  cure  by  this  means,  while  the 
dangers  from  embolism  were  great. 

Galvano-puncture  was  considered  too  tedious 
an  operation,  from  the  fact  that  several  would 
most  likely  be  required  to  effect  a  cure,  while  the 
dangers  from  embolism  and  from  haemorrhage  as 
a  result  of  sloughing  at  the  points  of  puncture, 
made  it  seem  extremely  hazardous.  I  therefore 
decided  to  treat  the  case  by  injection,  though  this 
method  is  by  no  means  free  from  the  dangers 
already  enumerated.      The  injection   method   in 


aneurisms  of  large  arteries  is  generally  considered 
positively  unsafe ;  and  in  those  occurring  in 
terminal  branches  of  arteries,  it  has  not  met  with 
much  favor  by  the  profession,  chiefly  for  the  rea- 
son that  several  fatal  results  from  embolism  were 
recorded  soon  after  its  introduction,  and  thus 
deterred  many  from  giving  it  a  trial  in  those 
cases  which  might  be  considered  favorable. 

The  danger  of  this  method  in  aneurisms  con- 
nected with  small  arteries,  it  seems  to  me  are  not 
in  the  method  itself,  but  in  the  kind,  and  strength 
of  the  coagulating  fluids  used. 

The  agents  which  have  been  suggested  are 
numerous,  among  which  are  acetate  of  lead, 
acetic  acid,  iodine,  ergotine,  and  the  perchloride 
of  iron.  The  perchloride  has  generally  been 
given  the  preference,  used  in  small  quantities  and 
weak  solutions  of  1  to  2  per  cent. 

The  injection  of  solutions  in  the  above  quan- 
tity and  strength,  produce  very  slow  coagulation, 
and  when  the  clot  is  formed,  it  is  soft  and  fria- 
ble, as  a  consequence  it  is  easily  broken  up,  and 
floated  away,  giving  rise  to  embolism  in  remote 
parts  of  the  circulatory  system,  with  all  its  ac- 
companying dangers.  The  dangers  in  acupunc- 
ture, galvano- puncture,  and  the  introduction  of 
foreign  substances  into  the  sac,  are  for  the  same 
reasons  equally  great. 

The  perchloride  of  iron  is  a  vigorous  coagulent, 
and  quite  escharotic  and  antiseptic  when  used  in 
full  strength.  A  1  or  2  per  cent,  solution  is  very 
mild  in  its  styptic  and  coagulent  qualities  ;  is  not 
escharotic,  and  has  no  value  as  an  antiseptic. 

What  is  needed  in  the  treatment  of  this  class 
of  cases,  is  to  produce  a  firm  clot,  instantane- 
ously if  possible,  and  to  maintain  it  in  an  aseptic 
condition,  without  the  dangers  of  sloughing  or 
haemorrhage. 

In  the  perchloride  solution  of  proper  strength 
it  would  seem  that  we  had  all  these  requirements. 

By  the  production  of  instantaneous  and  com- 
plete coagulation  of  the  blood  in  aneurisms  of 
this  class  and  nevi,  the  dangers  from  embolism 
in  remote  parts' of  the  body,  would  seem  to  be 
entirely  overcome,  and  thus  one  great  objection 
to  this  method  removed  ;  at  least  this  was  my 
thought  upon  the  matter,  and  I  determined  to 
try  it  in  this  case,  in  preference  to  the  other 
methods  which  might  have  been  chosen. 

In  order  to  produce  a  complete  and  firm  coagu- 
lum.  instantaneously,  it  would  be  necessary  to 
;  use  a  solution  of  much  greater  strength,  than  had 
I  been  previously  recommended. 

From  the  size  of  the  tumor,  I  concluded  that 
in  all  probability  it  contained  from  one  to  one 
ami  a  half  ounces  of  blood,  and  that  the  intro- 
duction of  five  minims  of  the  following  solution, 
perchloride  of  iron  one  part,  water  four  parts, 
would  not  be  sufficiently  escharotic  to  do  any 
mischief,  when  diluted  with  this  quantity  of 
blood. 


i89i.] 


COFFEK.   ITS  USE  AND  ABUSE. 


219 


COFFE]  rD  ABUSE. 

BY  I.  N.  LOVE,   MI'.. 


On  December  22,  1889,  I  injected  into  the 
tumor  five  minims  of  the  above  solution,  which 
produced  instantaneous  coagulation,  making  the 
tumor  feel  as  firm  as  a  fibroma  ;  considerable  pain 
followed  the  injection,  but  this  gradually  sub- 
Sided  after  a  few  minutes,  but  he  complained  for  vl" 
some  nours  01  a  strange  iullness  of  the  right  side 
of  the  head.  On  withdrawing  the  hypodermic 
needle,  a  little  oozing  occurred  which  immedi- 
ately discolored  the  mucous  membrane  for  a  little 
distance  around  the  puncture  made  by  the  needle. 
No  other  unpleasant  symptoms  followed. 

December  28,  the  mucous  membrane,  at  the 
point  punctured  by  the  needle,  sloughed,  leaving 
an  opening  into  the  sac,  about  the  size  of  a  silver 


NINTH    IN- 
ThKNATICiNA! 

iHMiKKN.    CUNJ  AND 

HVGII- 

IAN, 
CIT\     HOSPITAL,    ST.     LOCIS:    EDITOR 

I  shall  not  attempt  to  present  a  history  of  the 
coffee  plant,  but  rather  give  a  few  of  the  virtues 
it  possesses,  and  draw  attention  to  the  fact  that 
hairdimerexposfnVTh^hard  'ckrt  ^There"was  the1commonPlace  is  often  overlooked  in  our  desire 
not  the  slightest  hemorrhage,  but  considerable  t0  dls,covf  that  which  is  new,  striking  and  sensa- 
anxietv  was  felt,  for  fear  of  such  an  occurrence  tlODa1,  l  Iteca11  a  remark  that  l  heard  made  a  year 
Tiersch's  antiseptic  solution  was  constantly  ortwoaS°  b-v  a  very  worthy  but  somewhat  censo- 
used  as  a  mouth  wash  during  the  whole  progress  "ous  member  of  our  profession,  to  the  effect  that 
of  the  case,  and  after  the  slough  occurred?  the  he  dld  uot,  Pr0P0S,e  to  a"empt  to  address  the  pro- 
sac  was  syringed  with  the  same  solution  at  short  feS,sl°n  U~  *e  h,ad  somethu?S  absolutely  origi- 
intervals   day  and  night  ual  t0  olier-     In  this  connection,  I  venture  this 

December  31,  the  clot  was  broken  up  and  re-  tbou£bt  :  that  which  is  good  and  true  will  bear 
moved,  when  it  was  found  that  the  aneurism  also  ^petition  and  it  is  rarely  original, 
occupied  the  antrum  of  highmore,  and  had  pro-  In  .Southern  Abyssinia  the  coffee  plant  grows 
duced  absorption  of  the  palatine  process,  of  the  w,ld  m  P.rofusl01?;  aad  has  been  «  «*  from  very 
superior  maxillary  bone,  and  the  nasal  wall  of  anient  times.  The  name  is  probably  taken  from 
the  antrum,  leaving  a  large  opening  into  the  ^,offa'  tbe  name  of  a  district  south  of  Abyssinia, 
nasal  fossa.  The  case  progressed  without  a  single  J  c°ffee-Producil,&  belt  of  the  world  l.es  be- 
drawback  from  this  time  onward.  The  openino-  tween  latitudes  25  north  and  30  south.  The  coffee 
into  the  antrum  and  floor  of  the  nasal  fossa  fIaut  doe0s  "ot  thr,lve  where  the  temperature  is  - 
finally  closed.  There  has  been  no  recurrence,  below  55  hence  the  cultivation  is  chiefly  in  the 
and  the  patient  considers  himself  perfectly  well.    *°P1CS'  the  principal  countries  being  Brazil,  Java, 

Leylon,  Abyssinia,  \\  est  Indies,  Central  America, 
Peru,  Bolivia,  etc.  It  would  be  interesting  to 
present  a  succinct  history  of  the  plant  and  the 
gradual  development  of  its  virtues  during  ages 
past,  but  that  is  not  the  purpose  of  this  short 
paper.  The  fact  that  there  is  imported  annually 
into  the  United  States  nearly  800,000,000  lbs.  of 
coffee,  indicates  its  importance  as  an  article  of 
diet.  It  is  an  odd  and  interesting  fact  that  the 
active  principle  of  all  the  domestic  beverages  of 
the  world  is  practically  the  same,  viz.:  caffeine 
in  coffee,  theine  in  tea,  theobroma  in  cocoa. 

The  best  coffee  of  commerce  is  Mocha,  the  next 
in  order  being  Java.  A  mixture  of  equal  parts 
of  the  two  is  really  the  best  and  most  agreeable 
in  flavor.  The  coffee,  in  order  to  be  in  form  for 
use,  must  be  roasted,  and  much  depends  upon  its 
treatment.  In  order  to  secure  an  infusion  of 
Remarks.—  The  sloughing  of  the  mucous  mem-  roasted  coffee  in  its  perfection,  it  should  be  boiled 
brane  at  the  point  of  puncture,  proves  that  the  in  a  closed  vessel  carefully,  so  as  not  to  be  over- 
strength  of  the  solution  was  too  great  for  abso-  done'  onb'  the  amount  necessary  to  be  immedi- 
lute  safety,  and  should  I  be  called  upon  to  treat  ately  used  ;  by  this  means  the  rich  aroma  of  the 
another  case  of  this  class,  I  should  not  feel  war-  coffee,  which  gives  it  its  most  delicious  flavor,  is 
ranted  in  using  a  solution  stronger  than  one  in   preserved. 

six  or  eight  parts  of  water.     This,  I  think,  would       I  venture  the  opinion,  that  there  is  no  beverage 
produce  the  desired  results,  without  the  dangers   on  the  earth  today  which,  used  in  moderation, 
of  causing  a  slough,  and  possible  haemorrhage,    expresses  more  comfort,  contentment  and  calm- 
No.  9 Jackson  St.,  Corner  Michigan  Boulevard.  Iltss  to  the  cerebral   centres,  than    coffee;  but  iu 


Cast  No.  3,  shows  his  present  condition. 


COFFEE,  ITS  USE  AND  ABUSE. 


[February  14, 


excess,  it  is  undoubtedly  most  dangerous.  I 
doubt  if  the  victims  of  alcoholic  excess  are  as 
numerous  as  those  who  over-indulge  in  coffee. 
Alcohol  has  two  advantages  in  that  it  is  a  food 
and  its  excessive  use  is  disgraceful.  The  infusion 
of  coffee  in  proper  quantities  aids  digestion,  and 
is  a  safe  cerebro- spinal  stimulant  which  is  not  fol- 
lowed by  perceptible  reaction.  Liebig  drew  at- 
tention first  to  the  fact  that  this  beverage  con- 
tains the  elements  which  stimulate  the  flow  of 
bile.  It  is  a  decided  laxative,  a  pronounced  diu- 
retic. The  fact  that  the  coffee  belt  of  the  world 
is  also  the  "  bilious" belt  "  and  the  malarial  belt, 
as  well  as  the  field  where  noxious  germs  and  sup- 
purative processes  do  most  abound,  is  evidence  of 
the  fitness  of  things.  No  one  better  than  the 
denizens  of  the  hot  regions  of  the  world,  know  the 
value  of  coffee  to  open  up  the  secretions  which 
have  been  checked  by  excessive  heat  or  the  mala- 
rial influence.  They  know  well,  and  have  known 
for  centuries,  that  which  has  recently  been  receiv- 
ing much  attention  in  the  medical  world,  particu- 
larly in  Germany,  viz.:  the  antiseptic  properties 
of  coffee. 

Apropos  to  this  point,  Carl  Luderitz,  in  the 
Zeitschrift fur  Hygiene,  has  recently  presented  an 
interesting  report  concerning  the  influence  of  in- 
fusions of  coffee  on  microorganisms,  of  which  the 
New  York  Medical  Journal  of  May  3,  1890,  pre- 
sents a  brief  epitome  as  follows : 

Luderitz  details  a  careful  series  of  experiments  iu  which 
he  determined  the  influence  of  coffee  infusions  of  differ- 
ent strength  (varying  from  10  to  30  percent.)  upon  the 
growth  of  various  forms  of  pathogenic  and  non-patho- 
genic microorgaaisms.  The  coffee  used  iu  these  experi- 
ments was  roasted  Java,  and  the  infusion  was  made  by 
adding  from  ten  to  thirty  parts  of  coffee  by  weight  to 
seventy  or  ninety  parts  of  boiling  hot  water.  The  coffee, 
freshly  roasted  and  ground  fine,  was  covered  with  boil- 
ing water,  and  the  infusion  thus  prepared  was  placed  in 
a  closed  flask  in  a  water-bath  for  about  ten  minutes,  and 
was  then  filtered  through  a  sterilized  filter.  This  infu- 
sion was  used  in  part  for  making  gelatin  and  in  part  di- 
rectly. Where  nutrient  gelatin  was  made  with  this  as  a 
menstruum,  it  was  inoculated  with  various  forms  of  fungi 
and  other  microorganisms,  to  determine  the  possibility 
of  their  growth  in  such  a  medium.  In  other  cases  the 
organisms  were  added  directly  to  the  infusion  of  varying 
strength,  and  after  different  periods  of  time  inoculations 
were  made  from  the  infusions  into  other  nutrient  media. 
Luderitz  found  that  the  forms  of  fungi  experimented  with 
showed  more  or  less  growth  iu  the  coffee  gelatin,  but  the 
abundance  of  growth  was  in  many  cases  distinctly  less 
than  in  other  media.  The  other  microorganisms  he  used 
for  his  experiments  were  the  staphylococcus  pyogenes 
aureus,  the  streptococcus  erysipelatosus,  the  typhoid  ba- 
cillus, the  spirillum  of  cholera  Asiatica,  the  bacillus  an- 
thracis,  the  bacillus  prodigiosus  and  the  proteus  vulgaris. 
All  these  forms  of  microorgaaisms  were  greatly  influ- 
enced in  their  life  and  growth  by  exposure  to  the  infu- 
sions of  coffee,  but  some  were  far  more  susceptible  than 
others.  The  bacillus  prodigiosus  was  totally  destroyed 
only  after  exposure  in  a  10  per  cent,  infusion  for  four 
days,  or  in  a  30  per  cent,  infusion  for  one  day.  The  ty- 
phoid bacillus  was  completely  destroyed  after  exposure 
in  a  5  per  cent,  infusion  for  three  days,  in  a  10  per  cent, 
infusion  for  from  one  to  three  days,  or  in  a  30  per  ci  at. 
infusion  for  one  or  two  days.  The  proteus  vulgaris  was 
killed  after  an  exposure  for  four  days  iu  a  10  per  cent. 


infusion.  The  staphylococcus  pyogenes  aureus  was  de- 
stroyed only  after  an  exposure  for  six  days  in  a  10  per 
cent,  infusion,  and  for  three  days  in  a  30  per  cent,  infu- 
sion. The  streptococcus  erysipelatosus  was  destroyed 
after  an  exposure  of  one  day  iu  a  10  per  cent,  infusion. 
The  bacillus  of  Asiatic  cholera  was  destroyed  in  a  1  per 
cent,  infusion  after  seven  hours'  exposure,  in  a  5  per  cent, 
infusion  after  four  hours,  and  in  a  30  per  cent,  infusion 
after  two  hours.  The  bacillus  anthracis  was  destroyed 
in  a  10  per  cent,  infusion  after  three  hours,  and  in  a  30 
per  cent,  infusion  after  two  hours.  The  spores  of  the  an- 
thrax bacillus  were  only  destroyed,  for  the  most  part, 
after  three  weeks'  exposure  in  20  and  30  per  cent,  infu- 
sions. 

Aside  from  these  experiments,  others  were  made  with 
decomposing  meat  bouillon,  which  was  swarming  with 
various  forms  of  microorganisms.  The  results  obtained 
from  these  showed  that  while  the  viability  of  the  spores 
contained  iu  the  fluid  was  greatly  diminished  after  a 
short  exposure,  it  was  not  completely  destroyed  until 
after  an  exposure  of  many  days.  The  cholera  spirillum 
was  by  far  the  most  susceptible  of  the  organisms  used  in 
the  experiments,  and  next  to  it  stood  the  anthrax  bacil- 
lus without  spores. 

At  this  moment  a  recollection  of  the  fact  comes 
to  my  mind  that  Dr.  C.  H.  Hughes,  of  St.  Louis, 
not  less  than  fifteen  years  ago,  drew  attention  to 
the  antiseptic  properties  of  coffee.  Since,  how- 
ever, the  grand  moguls  of  Germania  have  taken 
snuff  on  the  coffee  question,  undoubtedly  the  Ger- 
maniacs  of  science  on  this  side  of  the  Atlantic 
will  all  sneeze  simultaneously. 

The  fact  that  coffee  blunts  sensation  and  in- 
creases secretion,  would  suggest  that  we  educate 
the  laity  in  the  direction  of  at  once  giving  the 
victims  of  accident  a  good  cup  of  hot  coffee, 
rather  than  the  usually  over-stiff  whisk}'  toddy, 
which  in  many  cases,  given  in  excess  as  it  is, 
places  the  individual  not  only  in  an  unfavorable 
condition  physically,  but  also  renders  him  liable 
to  the  charge  later,  from  those  not  familiar  with 
the  facts,  of  having  been  injured  on  account  of 
drunkenness.  I  recall  the  case  of  a  young  lady 
horseback  riding  in  the  suburbs  of  St.  Louis  some 
years  ago,  thrown  from  her  horse,  leg  fractured, 
taken  in  by  good  Samaritans  close  at  hand.  On 
being  summoned,  I  at  once  responded,  and  rec- 
ognized the  victim  as  being  one  of  the  "  swellest 
set  "  of  St.  Louis'  best  society.  I  placed  the  pa- 
tient in  my  carriage  and  removed  her  to  her  home. 
She  was  dead  drunk,  and  before  we  reached  her 
home,  there  was  not  a  space  three  inches  square 
in  the  carriage  which  was  not  covered  with  that 
which  had,  prior  to  the  accident,  been  part  of  the 
contents  of  her  stomach.  Those  unfamiliar  with 
the  fact  of  her  having  been  filled  to  the  brim  with 
whisky  by  the  good  Samaritans  who  took  her  in, 
might  have  seriously  reflected  upon  her  character. 
A  good  cup  of  black  coffee  would  have  done  her 
better  service  and  risked  her  character  less.  So 
to  the  public  we  would  say,  give  to  those  who 
have  been  injured  a  good  cup  of  coffee  in  the 
name  of  humanity,  but  no  whisky. 

The  custom  which  prevails  in  New  Orleans, 
and  generally  through  the  South,  of  taking  a  cup 
of  strong  black  coffee  iu  the  early  morning,  is  an 


'89I-] 


COFFEE,  ITS  USE  AND  ABUSE. 


intelligent  one.  The  people  of  those  malarious 
regions  have  long  since  demonstrated  the  fact 
that  the  custom  referred  to  is  of  great  advantage 
as  a  prophylactic.  The  individual  experience  of 
the-  writer  for  five  or  six  years  past,  is  strongly  in 
favor  of  the  taking  of  a  liberal  cup  of  black  cof- 
fee withoutcream  or  sugar,  sandwiched  in  between 
two  glasses  of  hot  water,  a  few  minutes  before 
rising  every  morning,  at  least  one  hour  before 
breakfast.  The  various  secretions  are  stimulated: 
the  nervous  force  is  aroused;  an  hour  later,  a 
hearty  meal  is  enjoyed  and  the  day's  labor  is 
commenced  favorably,  no  matter  how  the  duties 
of  the  day  and  night  preceding  may  have  drawn 
upon  the  physique.  Another  cup  of  coffee  at 
four  in  the  afternoon  is  sufficient  to  keep  the  en- 
ergies unflagged  for  many  hours  thereafter. 
Taken  in  this  manner,  the  full  effect  is  secured; 
the  stimulant  devotes  itself  strictly  to  business, 
none  of  it  is  lost,  and  if  the  proper  diet  be  taken 
at  the  proper  times  between  (and  the  ideal  diet  for 
those  who  make  large  drafts  upon  their  nervous 
systems  and  expect  to  have  them  honored,  is  hot 
milk)  if  the  above  regimen  be  followed  and  ac- 
companied by  at  least  eight  hours  sleep  out  of 
every  twenty-four  hours,  the  capacity  for  work  is 
almost  unlimited,  How  many  of  our  patients 
who  are  the  victims  of  disease,  are  ever  consulted 
as  to  whether  they  have  been  accustomed  to  the 
habitual  use  of  coffee,  or  not?  Take,  for  in- 
stance, typhoid  fever;  a  long  seige  of  suffering; 
a  racked  and  wrecked  nervous  system;  the 
chances  largely  in  favor  of  the  patient  having 
been  an  habitual  drinker  of  coffee,  but  whether 
so  or  not,  the  coffee  is  usually  not  given,  though 
strongly  indicated,  for  the  reason  that  it  sustains 
and  supports  weary,  worn  nerves,  aids  digestion, 
keeps  the  alimentary  canal,  which  is  swarming 
with  germs  and  putrefactive  material,  in  a  more 
or  less  antiseptic  condition  (it  has  previously 
been  shown  that  coffee  is  peculiarly  destructive 
to  the  typhoid  bacillus),  helps  to  gently  open  the 
sewers  of  the  system,  being  as  it  is  a  diuretic,  a 
stimulator  of  the  bile  flow  and  other  secretions, 
allays  the  sense  of  fatigue  and  lessens  tissue  waste, 
braces  up  the  heart's  action  and  raises  arterial 
tension.  We  all  know  that  to  prevent  a  chill, 
nothing  is  superior  to  a  cup  of  strong  black  cof- 
fee. As  an  antagonist  to  opium  narcosis,  strong 
black  coffee  stands  preeminent.  This  brief  and  dis- 
jointed paper  would  be  unfinished  unless  a  refer- 
ence were  make  to  the  injury  likely  to  follow  the 
excessive  use  of  coffee.  In  excess,  it  disorders 
digestion,  removes  the  desire  for  food,  creates  an 
indisposition  to  sleep,  excites  headache,  vertigo, 
mental  confusion  and  disturbed  heart  action. 

In  this  connection  I  recall  the  case  of  Mrs.  S., 
whom  I  was  called  to  see  in  consultation  some 
miles  from  St.  Louis  about  three  years  ago.  A 
mother  of  five  children  all  born  within  eight 
years,  one  or  more  of  them  sick  half  the  time 


from  the  time  of  their  birth.  Mother  conscien- 
tious and  ever  alert  to  her  duty,  suddenly  taken 
down  with  heart  tn  ■  h  nervous  symp- 

toms as  to  apparently  imperil  life.  Upon  exam- 
ination, d  an  almost  woman 
with  a  heart  beating  irregularly  but  so  fast  as  to 
be  almost  beyond  counting.  hunted 
down  expression  of  face  and  physique;  no  fever; 
an  utter  inability  to  sleep;  no  appetite  for  weeks 
past.  The  history  which  I  soon  elicited  demon- 
strated the  fact,  which  had  been  overlooked  by 
her  attendant,  but  which  I  suspected  from  seeing 
a  coffee  pot  upon  the  table  by  the  bedside,  viz., 
that  the  mother  in  order  to  bear  up  under  the 
burdens  placed  upon  her,  had  been  for  six 
absolutely  living  upon  black  coffee.  The 
desire  for  food  or  ability  to  digest  it  had  long 
since  gone.  The  blood  had  become  impoverished 
from  lack  of  sustenance.  Like  the  indiscreet 
owner  of  the  thoroughbred  roadster,  she  had  been 
constantly  feeding  with  the  whip  instead  of  oats. 
Her  cerebro-spinal  centres,  the  acceleratory 
nerves  of  her  heart,  would  have  soon  been 
whipped  to  the  point  of  exhaustion.  Opiates  and 
digitalis,  whisky  and  pre-digested  milk,  good 
sleep,  a  check  rein  upon  her  circulatory  organ, 
oats  instead  of  the  whip,  in  the  form  of  nutrition 
easy  to  assimilate,  gradually  brought  the  patient 
around  to  a  condition  of  health.  It  may  not  be 
uninteresting  to  state  that  this  excellent  woman, 
although  a  coffee  drunkard,  was  a  member  of  the 
local  Temperance  Union. 

After  years  of  extended  observation  and  pro- 
nounced personal  experience  I  feel  justified  in 
announcing : 

i.  The  world  has  in  the  infusion  of  coffee,  one 
of  its  most  valuable  beverages. 

2.  As  a  prompt  diffusible  stimulant  either  by 
the  stomach  or  by  injection  into  the  rectum,  it  is 
in  all  cases  of  shock,  preferable  to  alcohol. 

3.  It  is  antagonistic  to  malaria  and  specially 
destructive  to  the  typhoid  bacillus  and  cholera 
germ,  and  for  this  reason  it  is  an  admirable  re- 
medial agent  in  these  conditions,  both  as  a  direct 
stimulant,  an  antiseptic  and  an  encourager  of 
elimination. 

4.  One  of  its  chief  advantages  in  health  and 
disease  is  in  the  fact  that  it  aids  in  the  secure- 
ment  of  that  psychical  satisfaction  which  is  con- 
ducive to  hope,  comfort,  good  digestion,  great 
power  of  resistance  and  rapid  recuperation. 

5.  In  season,  it  supports,  tides  over  dangers, 
helps  the  appropriative  powers  of  the  system, 
whips  up  the  flagging  energies,  enhances  the 
endurance,  but  is  in  no  sense  a  food,  and  for 
these  reasons  and  many  others,  it  should  be  used 
temperately,  as  should  all  of  nature's  benign  gifts. 

6.  In  excess,  it  is  even  more  dangerous  than 
alcohol,  for  it  is  not,  like  the  latter,  a  nutrient, 
nor  is  the  effect  of  its  excessive  use  so  apparent 
or  unrespectable. 


A  STUDY  OF  STERILITY. 


[February  14, 


A  STUDY  OF  STERILITY,  ITS  CAUSES 
AND  TREATMENT. 

J>t'in£  an  !  eived  Ike.  First  Prize  of 'ike  Alum 

aiion  of  ike  College  of  Physicians  and  Surgeons,  Baltimore. 

BY  THOS.  W.  KAY,   M.D., 

OF  SCRANTON,  PA. 

(Continued  from  page  184.) 
CAUSES. 

/.  Non-production. — Non-production  of  healthy 
ova  and  spermatozoa  may  be  caused  by  (a)  ab- 
sence, non-development  or  malposition  of  the 
genital  glands ;  (b)  inflammatory  troubles  pro- 
ducing atrophy  or  destruction  of  those  organs ; 
(<r)  tumors  or  new  growths  affecting  the  nutrition 
of,  or  directly  invading,  the  gland  substance;  and 
(</)  all  influences  which  affect  the  glands  indi- 
rectly by  altering  the  general  condition  of  the 
body. 

In  all  barren  marriages  where  symptoms  of 
uterine  disease  are  not  well  pronounced,  we 
should  first  make  a  microscopical  examination  of 
the  spermatic  fluid.  This  can  be  easily  obtained 
by  withdrawal  of  the  organ  as  orgasm  approach- 
es, or  by  collecting  the  fluid,  by  means  of  a  small 
syringe,  from  the  vagina  after  the  act  has  been 
completed.  The  best  method,  however,  is  the 
use  of  a  condum  during  coitus. 

Male. — The  quantity  of  the  seminal  fluid  de- 
pends on  the  size  of  the  testes  and  the  habits  and 
physical  condition  of  the  male.  Sims  places  the 
average  quantity  at  about  2  drachms.  It  is  not 
the  quantity,  however,  but  the  quality,  that  con- 
cerns the  physician,  for  though  there  may  be  a 
normal  quantity  of  fluid  discharged,  the  sperma- 
tozoa may  be  entirely  absent — azoospermia. 

Should  there  be  no  discharge — aspermia — it  is 
useless  to  look  for  spermatozoa,  but  they  may 
exist  in  large  quantities  and  in  a  perfectly  healthy 
condition  when  only  a  small  quantity  of  fluid  is 
discharged.  Either  of  the  above  conditions  may 
be  congenital  or  acquired.  The  congenital  vari- 
ety, as  a  rule,  is  permanent,  but  the  acquired  form 
is  either  permanent  or  temporary. 

(a.)  In  the  congenital  variety  there  is  an  ab- 
sence or  imperfect  development  of  the  testes, 
which  prevents  the  production  of  the  spermatic 
fluid.  The  absence  of  one  testis — monorchism 
— is  of  little  moment,  but  the  absence  of  both 
testes  from  the  scrotum — cryptorchidism — gener- 
ally indicates  sterility.  This,  though,  is  not  al- 
ways the  case,  for  one  or  both  testes  may  exist 
in  the  abdominal  cavity  and  be  in  a  healthy  con- 
dition. 

(£.)  The  most  common  cause  of  the  acquired 
form  is  orchitis,  due  to  external  injury,  mumps, 
gonorrhoea,  syphilis,  or  other  troubles  in  which 
an  atrophy  of  the  glandular  elements  is  caused 
by  the  inflammatory  process. 

(r.)  Hernia,  hydrocele,  varicocele,  and  all  be- 
nign  tumors  disturb  the  nutrition  of  the  testes  by 


pressure  or  by  dragging  on  the  blood-vessels,  and 
thus  produce  atrophj'.  Cystic  diseases,  tubercle 
and  malignant  tumors  destroy  the  testis  by  a  di- 
rect invasion  of  its  glandular  structure. 

(d.)  All  fevers  and  inflammatory  or  wasting 
diseases  affect  the  testis  temporarily  by  impairing 
the  general  health.  The  sterility  due  to  exces- 
sive venery,  masturbation,  and  affections  of  the 
nervous  system,  is  usually  temporary,  but  may 
become  permanent  through  organic  changes  tak- 
ing place  in  the  testes.  Heredity,  consanguinity, 
and  many  other  agencies  affect  the  reproductive 
organs  of  the  male,  but  in  exactly  the  same  way 
iu  which  they  affect  those  of  the  female.  At 
what  time  senile  sterility  is  established  in  the 
male  is  not  definitely  known,  but  as  his  develop- 
ment is  less  rapid  than  that  of  the  female,  so  is  his 
loss  of  power  postponed  till  later  in  life.  In  tem- 
perate climates  the  reprocreative  power  may  be 
established  as  early  as  the  14th  year  and  be  main- 
tained, in  persons  of  robust  constitutions,  as  late 
as  the  70th,  80th  and  90th  year. 

Female. — (a.)  The  ovaries  may  be,  one  or  both, 
congenitally  absent  or  imperfectly  developed.  The 
absence  of  one  is  of  little  importance,  for  the  other, 
if  healthy,  is  sufficient  to  furnish  ova  for  impreg- 
nation. 

Congenital  absence  or  defect  of  both  ovaries  is 
generally  accompanied  by  other  abnormal  condi- 
tions of  both  the  internal  and  external  organs  of 
generation.  Many  interesting  cases  of  this  kind 
are  found  in  all  works  on  gynecology.  Pro- 
lapse of  the  ovaries  may  affect  their  nutrition 
and  set  up  inflammatory  changes  which  result  in 
atrophy  and  destruction  of  the  Graafian  follicles. 

(6.)  Aristotle  seems  to  have  been  the  first  author 
to  point  out  the  fact  that  early  marriages  are  a 
frequent  cause  of  sterility,  and  the  statistics  col- 
lected by  Duncan  and  Kisch  show  conclusively 
that  not  only  is  sterility  more  frequent,  but  the 
birth  of  the  first  child  is  postponed  longer  in  those 
marriages  where  the  woman  is  15  to  19  years  of 
age  than  where  she  is  20  to  24  years  of  age.  This 
is  due  to  inflammatory  changes  caused  by  injury 
during  coitus  or  at  childbirth,  to  imperfectly  de- 
veloped genital  organs.  The  researches  of  Slav- 
jansky  have  shown  that  inflammation,  with  sub- 
sequent atrophy  of  the  Graafian  follicles,  may 
occur  in  rickets,  scrofula,  tuberculosis,  pneumo- 
nia, typhoid  fever,  and  all  inflammatory  and  wast- 
ing diseases.  In  both  acute  and  chronic  ovaritis 
there  may  be  an  absorption  of  the  follicular  con- 
tents, followed  by  a  collapse  and  adhesion  of  the 
follicular  walls,  which  results  in  atrophy  of  the 
ovaries.  It  is  in  a  different  way  that  pelvic  peri- 
tonitis acts.  Here,  the  inflammatory  products 
thrown  out  contract,  and  both  dislocate  and  com- 
press the  ovaries  so  as  to  disturb  their  blood  sup- 
ply. Syphilis  causes  atrophy,  directly,  by  affect- 
ing the  ovaries,  and  indirectly,  by  setting  up 
peritoneal  inflammation. 


I89i.] 


A  STUDY  OF  STERILITY. 


223 


(c.)  All  new  growths  of  the  ovaries— cystic 
(follicular,  multilocular,  dermoid,  papillary  and 
myxo- polypoid),  and  solid  (papilloma,  fibroma, 
fibromyxoma,  sarcoma,  carcinoma  and  enchon- 
droma)  induce  sterility  by  destroying  the  struc- 
ture of  or  producing  atrophy  of  the  ovaries.  As 
long,  however,  as  a  healthy  portion  of  the  ovary 
remains,  conception  is  possible.  Schroder  took 
advantage  of  this  in  operating,  and  would  always 
leave  a  piece  of  healthy  ovary  when  it  was  possi- 
ble. The  possibility  of  spayed  sows  getting  with 
pig  has  long  been  known  to  stock-raisers,  and  I 
have  seen  several  examples  of  it  in  my  own  neigh- 
borhood. Schatz  reported  a  case  where  a  young 
woman  of  20.  on  whom  double  ovariotomy  had 
been  performed,  conceived.  In  all  of  these  cases 
a  part  of  the  ovary  must  have  been  left,  or  it  may 
be  that  a  supernumerary  or  accessory  ovary  ex- 
isted, as  in  cases  reported  by  Biegel,  Klebs,  Ols- 
hausen,  Winckel  and  others.  In  the  female,  as  in 
the  male,  varicocele  may  exist,  about  the  organs 
of  Rosenmiiller,  and  produce  atrophic  changes  by 
disturbing  the  circulation  of  the  ovaries,  but  this 
affection  is  exceedingly  rare. 

(d.)  In  females  suffering  from  diabetes,  anaemia, 
chlorosis,  and  chronic  affections  of  the  nervous 
system,  conception  is  rare,  because  of  lack  of  suf- 
ficient energy  to  produce  healthy  ova.  It  is  prob- 
ably in  the  same  way  that  the  excessive  or  long 
continued  use  of  alcoholic  stimulants,  opiates  and 
other  drugs  prevent  conception.  The  causative 
influence  of  obesity  in  producing  sterility  is  very 
doubtful.  It  does  not  prevent  the  production  of 
healthy  ova,  but  indicates  a  lack  of  vigor  and  a 
sluggish  condition  of  the  general  system  unfavor- 
able to  ovulation.  The  ova  are  discharged  peri- 
odically about  once  a  month,  and  it  is  about  that 
time  that  impregnation  is  most  apt  to  occur.  Of 
248  cases,  in  which  the  time  of  copulation  was 
definitely  known,  Hasler  found  that  conception 
took  place  in  86  per  cent,  during  the  first  ten 
days  after  the  cessation  of  the  menstrual  flow. 
Capellman  advises  sexual  abstinence  for  fourteen 
days  after  the  cessation  of,  and  three  or  four  days 
before  the  appearance  of  the  menstrual  flow,  if 
one  desires  to  avoid  conception.  The  Jews,  the 
most  prolific  of  all  people,  allow  five  days  for  the 
menstrual  flow  and  to  this  add  seven  days,  mak- 
ing in  all  twelve  days,  from  the  first  appearance 
of  the  menses,  during  which  coitus  is  forbidden. 

The  season  of  the  year  also  affects  conception, 
and  we  find  it  occurring  much  more  readily  in 
spring  and  summer  than  in  autumn  and  winter. 
Haycroft,  who  has  carefully  studied  the  subject, 
finds  that  in  Scotland  the  number  of  women  who 
conceive  increases  with  the   rise   of  temperature. 

The  quantity  and  quality  of  the  food  materially 
affects  conception,  it  being  a  well  known  fact  that 
more  children  are  born  during  years  of  plenty  than 
during  famines.  Women  in  moderate  circum- 
stances,   however,   are  more  prolific  than   those 


who  live  in  luxury  and  idlene-  □  points 

out  the  fact  that  melons  and  cucumbers  are  more 
productive  when  raised  in  the  shade  and  furnish- 
ed with  moisture  than  when  exposed  to  the  sun 
and  a  dry  heat,  and  argues  that  women  are  af- 
fected, to  a  certain  extent,  by  the  -ame  1 

We  saw  that  this  was  so  when  speaking  of  food 
and  temperatures,  and  it  is  even  more  noticeable 
in  the  lower  animals  than  it  is  in  man.  Pigeons 
are  much  more  prolific  when  well  housed  and  lib- 
erally fed  than  when  they  are  allowed  to  look  out 
for  themselves.  Indoor  confinement  or  change  of 
long  established  habits  will  tend  to  cause  sterility 
in  both  the  lower  animals  and  in  man.  All  show- 
men know  that  wild  animals  are  remarkably  un- 
productive when  deprived  of  their  accustomed 
freedom. 

In  France  it  has  been  shown  that  of  eggs  laid 
by  uncooped  hens  only  20  per  cent,  are  sterile, 
but  this  figure  rises  to  60  per  cent,  when  they  are 
closely  confined.  Darwin  calls  attention  to  the 
fact  that  mares  rarely  get  in  foal  just  after  being 
taken  from  the  stable  and  turned  to  pasture. 

In  what  way  consanguinity  acts  in  causing  ster- 
ility is  not  known,  but  it  is  a  common  cause  in 
both  the  lower  animals  and  man.  Interbreeding 
of  stock  will  cause  the  most  improved  br< 
degenerate  in  a  very  short  time,  and  in  families 
we  see  the  same  result,  the  progeny  becoming 
sterile,  deformed  or  mentally  deficient.  Mitchell 
points  out  the  fact  that  this  can  be  partly  averted 
by  good  food  and  hygienic  surroundings. 

Galton.  who  has  studied  the  question  of  hered- 
ity in  all  of  its  bearings,  more  thoroughly  than 
any  one  else,  finds  that  it  is  a  potent  factor  in 
producing  sterility.  In  England,  where  only- 
child  sterility  is  as  frequent  as  one  in  every  thir- 
teen marriages,  Susell  finds  heredity  one  of  its 
chief  causes.  The  absence  of  menstruation  has 
been  given  by  some  authors  as  a  cause  of  sterility, 
but  this  cannot  be,  for  it  only  indicates  a  condi- 
tion of  the  ovaries  unfavorable  for  ovulation,  and 
should  be  considered  as  a  symptom.  When  it 
exists  up  to  the  20th  year,  it  is  usually  a  sign  of 
non-development  or  atrophy  of  some  of  the  inter- 
nal organs  of  generation.  From  the  fort; 
to  the  fiftieth  year  it  usually  becomes  permanently 
established  and  indicates  the  presence  of 
sterilitv.  The  menses  may  also  be  arrested  by 
catching  cold,  by  Bright,  or  by  any  great  physical 
or  mental  excitement,  and  generally  indicates  a 
condition  unfavorable  for  conception. 

2.  Non-union. — Non  union  of  healthy  ova  and 
spermatozoa  may  be  caused  by  (a)  absence,  ste- 
nosis, atresia  or  dilatation  of  any  part  of  the 
course  traversed  by  the  human  germs;  ( fr)  by  dis- 
eased conditions  of  the  passages  which  tend  to 
impair  the  vitality  of  either  ova  or  spermatozoa  ; 
(c)  by  artificial  means  employed  to  prevent  con- 
ception ;  (d)  by  all  influences  tending  to  hasten, 
prevent  or  retard  orgasm. 


224 


A  STUDY  OF  STERILITY. 


[February  14, 


Male. — («.)  The  possible  existence  of  the  ova- 
ries,  with  the  absence  or  imperfect  development 
of  one  or  all  of  the  remaining  internal  organs  of 
generation — those  developed  from  the  Wolffian 
bodies  and  the  conduits  of  Miiller — is  well  known, 
and  it  is  but  reasonable  to  suppose  that  the  cor- 
responding portions  of  the  male  genital  tract — 
the  ducts  from  the  testes  to  the  urethra — can  also 
be  absent  or  undeveloped  while  the  testes  are 
present.  Such  a  condition  must  prevent  the  en- 
trance of  semen  into  the  urethra. 

Dunley  found  that  in  old  age  an  obliteration  of 
the  ducts  took  place,  probably  before  the  testes 
ceased  to  generate  spermatozoa.  Pressure  from 
tumors  of  the  cord  may  also  cause  occlusion  of 
the  ducts.  Epispadias,  hypospadias  and  urethral 
fistula,  unless  situated  near  the  glans  penis,  will 
allow  the  escape  of  the  semen  before  it  enters 
the  vagina,  and  in  those  cases  where  it  is  depos- 
ited in  the  vagina  it  fails  to  be  ejaculated  against 
the  cervix. 

Stricture  of  the  urethra  is  a  very  common  cause 
of  sterility.  When  narrow7  and  situated  in  the 
anterior  portion  of  the  urethra,  it  obstructs  the 
canal  during  erection  so  as  to  dam  up  the  semen 
till  the  organ  becomes  flaccid,  when  it  gradually 
oozes  out.  Should  the  stricture  be  situated  far 
back,  a  regurgitation  of  the  fluid  may  take  place 
into  the  bladder,  and  be  passed  only  as  the  urine 
is  voided.  When  a  slight  stricture  is  present, 
impregnation  may  be  affected  by  a  (jhange  in  the 
normal  spiral  direction  of  the  urethra.  This,  as 
a  rule,  twists  from  right  to  left,  as  can  be  seen 
when  passing  urine  from  a  healthy  urethra,  and 
it  can  also  be  demonstrated  by  passing  a  large 
olivary  bougie  well  back  into  the  canal  and  with- 
drawing it  by  a  small  thread  attached  to  its  end. 
In  connection  with  this  it  is  interesting  to  note 
what  Courty  says,  in  speaking  of  the  ' '  arbor 
vitse "  of  the  cervical  canal.  "The  posterior 
tree,"  says  he,  "  deviates  to  the  left  in  proportion 
as  it  approaches  the  superior  orifice.  The  ante- 
rior tree  is,  on  the  contrary,  directed  towards  the 
right."  It  will  be  observed,  then,  that  when  the 
meatus  urinarius  is  applied  to  the  external  os 
uteri,  the  spiral  is  continuous  to  the  cavity  of  the 
uterus.  Phimosis  and  stenosis  of  the  meatus  uri- 
narius have  the  same  effect  as  stricture,  and  a  too 
large  meatus  acts  in  the  same  way  as  hypospadias. 
(6.)  Levy  has  shown  that  catarrhal  secretions, 
when  containing  many  pus  corpuscles  and  much 
epithelial  detritus,  destroy  the  vitality-  of  the 
spermatozoa  in  a  very  short  time,  but  it  is  not 
probable  that  urethritis,  simple  or  specific,  will 
directly  cause  sterility  in  many  cases,  as  it  is  such 
a  short  time  in  contact  with  the  spermatic  fluid. 
I  recall  a  case  in  my  own  practice  in  which  im- 
pregnation and  gonorrhoea]  infection,  in  all  prob- 
ability, took  place  from  the  same  individual  at 
the  same  time. 

(c.)  Little  need  be  said  about  the  artificial  means 


used  by  the  male  to  prevent  conception.  The 
practice  of  "  withdrawing"  as  orgasm  approach- 
es and  the  use  of  the  condum  are  only  too  well 
known  to  all  classes,  both  married  and  single. 

In  some  parts  of  France  and  Syria,  the  prosti- 
tutes adopt  a  practice  not  generally  known  in 
America.  It  consists  in  tightly  compressing  the 
male  urethra  in  front  of  the  prostate,  as  orgasm 
approaches,  so  as  to  cause  a  regurgitation  of  se- 
men into  the  bladder. 

(d.)  Many  men  of  excitable  dispositions,  when 
first  beginning  to  gratify  the  sexual  appetite,  are 
unable  to  control  themselves  and  have  a  prema- 
ture emission,  sometimes  even  before  entrance 
into  the  vagina  has  been  gained.  One  individual 
under  my  care,  who  has  since  married  and  begat 
children,  would  have  a  seminal  discharge  as  soon 
as  his  limbs  came  in  contact  with  those  of  a  fe- 
male, even  when  sitting  at  meals. 

Different  neuroses  of  the  genital  tract  may  re- 
tard or  prevent  orgasm,  and  in  one  case  which 
came  to  ruy  notice  I  had  reason  to  believe  that 
spasmodic  stricture  of  the  urethra  caused  seminal 
regurgitation  into  the  bladder.  These  neuroses 
are  found  in  persons  who  have  been  addicted  to 
excessive  venery  or  to  masturbation,  and  in  those 
who  have  suffered  from  frequent  or  long-continued 
nocturnal  emissions.  In  all  debilitated  individu- 
als, from  any  cause  whatever,  or  in  those  suffering 
from  affections  of  the  nervous  system,  the  reflex 
centres  governing  the  ejaculatory  act  may  lose 
their  excitability,  so  that,  though  erection  takes 
place,  there  will  be  no  discharge  of  semen.  It  is 
a  not  uncommon  complaint  of  sterile  women  that 
they  feel  no  discharge  from  the  man  during  coi- 
tus. Non-erection  prevents  orgasm,  and  this  may 
be  caused  by  physical  or  mental  affections.  In 
some  cases  a  too  rapid  flow  of  blood  through  the 
dorsal  veins  of  the  penis  may  bring  this  about. 

Female. — (a.)  Congenital  defects,  preventing 
the  union  of  the  ova  and  spermatozoa,  may  lie 
found  in  any  part  of  the  female  genital  tract. 
Kisch  calls  attention  to  an  abnormal  thickness  of 
the  tunica  albuginea  as  an  obstacle  to  the  escape 
of  the  ova,  and  Schenk  has  seen  the  cellular  cov- 
ering of  the  zona  pellucida,  as  it  escapes  from  the 
Graaffian  follicle,  act  as  an  obstacle  to  the  en- 
trance of  the  spermatozoa,  in  rabbits. 

Should  the  outer  portions  of  the  conduits  of 
Miiller,  one  or  both,  fail  to  develop,  or  their  blind 
extremities  neglect  to  open,  there  may  be  an  en- 
tire absence  or  a  rudimentary  development  of 
either  or  both  of  the  tubes,  or  it  may  result  in  a 
closed  termination  where  the  fimbriated  extremi- 
ties should  be.  If  an  imperfect  fusion  of  the  lower 
portion  of  the  conduits  of  Miiller  take  place,  it 
will  result  in  some  abnormal  shape  in  the  body 
of  the  uterus,  but  this  does  not  prevent  concep- 
tion, nor  does  the  imperfect  condition  arising  from 
lack  of  development  of  one  of  the  conduits  of 
Miiller. 


l8o!.J 


A  STUDY  OF  STKklUTY. 


225 


The  septum  dividing  the  conduits  may  persist 
in  all  or  any  part  of  its  course,  and  cause  the  for- 
mation of  a  double  uterus  or  double  vaginae,  but 
this  is  an  impediment  to  impregnation  only  when 
it  prevents  copulation — conception  being  possible 
in  either  or  both  sides  of  the  uterus.  Should  the 
conduits  fail  to  develop  or  should  they  be  ar- 
rested in  their  growth,  the  result  will  be  an  ab- 
sence or  malformation  of  both,  either,  or  any  part 
of  the  uterus  or  vagina,  and  any  of  these  condi- 
tions may  exist  in  females  who  are  apparently 
well  developed. 

Examples  of  entire  absence  of  the  uterus  are 
quite  numerous,  its  diagnosis  being  easily  made, 
on  the  living  individual,  by  introducing  the  fin- 
ger of  one  hand  into  the  rectum  and  a  probe,  cath- 
eter, or  finger  of  the  other  hand  into  the  bladder. 

Total  or  partial  absence  of  the  vagina  may 
exist  when  the  uterus  is  present  or  when  it  is 
absent,  and  this  abnormal  condition  can  be  diag- 
nosed in  the  same  way  as  the  abnormal  conditions 
of  the  uterus.  Should  only  the  lower  portion  of 
the  vagina  be  absent,  it  does  not  necessarily  cause 
sterility,  for  the  genital  canal  may  open  into  the 
urinary  or  intestinal  tracts,  and  there  are  cases 
of  this  kind  on  record  where  impregnation  took 
place  through  the  anus  or  the  urethra.  If,  dur- 
ing fcetal  development,  the  free  edges  of  the  hy- 
men unite  so  as  to  entirely  close  the  opening  to 
the  vagina,  sterility  must  result.  In  all  other 
anomalies  of  the  hymen  impregnation  is  possible, 
though  the  penis  may  not  gain  access  to  the  va- 
gina, and  many  cases  of  impregnation  without 
penetration  have  been  recorded,  the  spermatozoa 
having  found  their  way  through  the  opening  into 
the  cervix  uteri.  Congenital  malformations  of 
the  vulva  are  also  found  occasionally,  in  which 
coitus  is  impossible.  It  may  be  abnormally  small, 
or  there  ma}r  be  adhesion  of  either  the  labiae  ma- 
jors or  the  nymphae.  This  union  may  be  simply 
between  the  epithelial  surfaces  and  easily  over- 
come by  traction,  or  it  may  be  firm  and  require 
operative  interference. 

A  small  vagina,  as  a  rule,  is  not  a  serious  draw- 
back to  conception,  and  Kisch  calls  attention  to 
the  fact  that  small  women  with  large  husbands 
— presumably  where  the  fit  is  tight — are  more 
prolific  than  where  the  two  are  of  the  same  size, 
or  the  woman  is  larger  than  the  man.  The  above 
statement  is  borne  out  by  my  own  observations. 
Congenital  atresia  of  the  cervical  canal  may  exist 
in  any  part  or  all  of  its  course.  If  situated  only 
at  the  external  os,  as  is  most  frequently  the  case, 
it  usually  consists  of  a  continuation  of  the  mu- 
cous membrane  across  that  opening,  and  is  easily 
remedied,  but  when  more  extensive  it  is  difficult 
to  treat.  It  usually  attracts  attention  about  pu- 
berty by  the  formation  of  a  haernatometra.  Ac- 
quired atresia  of  the  cervical  canal  is  quite  a  com- 
mon occurrence  in  women  after  they  have  passed 
the  menopause,  but  here  it  is  usually  at  the  in- 


ternal os,  and  is  due  to  adhesion  following  degen- 
erative changes. 

Stenosis  of  the  cervical  canal  may  occur  at 
either  the  external  or  internal  os,  and  can  be  de- 
termined by  the  failure,  in  any  uterus  of  normal 
position,  to  pass  a  good-sized  uterine  sound  with 
ease.  Olshausen  calls  attention  to  the  fact  that 
in  women  who  bear  their  first  child  long  after 
marriage  a  second  birth  follows  close  on  the  firi,t, 
and  he  accounts  for  this  by  the  stenosed  os  be- 
coming larger  after  the  child  has  been  born.  A 
lady  of  my  acquaintance  was  barren  for  six  years 
after  her  marriage,  since  which  time  she  has  given 
birth  six  times  in  nine  years.  Stenosis  of  the 
cervix  is  a  common  cause  of  sterility  not  only  in 
man  but  also  in  the  lower  animals.  The  Arabs 
use  the  hand  and  various  hard  instruments  for 
dilating  the  cervical  canal  in  mares  that  are  un- 
fruitful, and  the  Tyrolese  incise  the  cervix  of  bar- 
ren cows,  in  both  cases,  it  is  said,  with  successful 
results.  The  intra-vaginal  portion  of  the  cervix 
may  be  abnormally  short  or  entirely  absent,  and 
in  either  case  may  cause  sterility  by  prevent- 
ing the  application  of  the  glans  penis  to  the  cer- 
vix uteri.  Hypertrophy  of  the  vaginal  portion, 
if  general,  results  in  an  elongation  of  the  cervix, 
which  is  so  great  in  some  cases  as  to  prevent  coi- 
tus. This  great  length  is  exceedingly  rare,  but 
moderate  elongation  is  quite  common,  and  causes 
the  cervix  to  be  displaced  as  the  seminal  discharge 
takes  place.  If  the  hypertrophy  is  confined  to 
one  side  it  results  in  flexion,  so  that  the  os  is 
tilted  towards  the  vaginal  wall  during  coitus. 
The  conical  and  the  nozzle-shaped  cervices  indi- 
cate an  abnormal  condition  of  the  muscular  struc- 
tures, and  probably  prevent  an  active  participa- 
tion of  that  part  of  the  uterus  in  the  act  of  co- 
ition. 

Where  the  cervix  is  torn  or  everted,  sterility 
may  be  caused  by  the  granulations  closing  the 
canal  so  as  to  prevent  the  passage  of  the  sperma- 
tozoa, by  the  cervix  allowing  the  escape  of  the 
semen  after  it  has  entered  the  canal,  or  by  a 
catarrhal  condition  of  the  lining  membrane  caus- 
ing a  change  in  the  normal  secretion  which  is 
unfavorable  to  the  life  of  the  spermatozoa.  A 
lacerated  perineum  also  favors  the  escape  of  the 
semen  and  promotes  secondary  changes  in  the 
internal  genital  organs  unfavorable  for  reproduc- 
tion. 

All  uterine  displacements,  whether  from  a  re- 
laxed condition  of  the  ligaments,  from  increased 
weight  or  external  pressure,  or  from  the  contrac- 
tion of  inflammatory  deposits,  tend  to  prevent  the 
entrance  of  semen  to  the  ova. 

In  inversion  of  the  uterus  conception  is  neces- 
sarily impossible,  and  next  to  this  versions  are 
most  certain  to  produce  sterility,  for  not  only  is 
the  cervix  tilted  out  of  the  way  but  the  os  is 
covered  by  the  vaginal  wall  as  with  a  lid.  In 
flexions   the  obstruction  is  in   the  canal   at  the 


226 


A  STUDY  OF  STERILITY. 


[February  14 


point  of  greatest  convexity,  but  this  is  somewhat 
overcome  by  the  congestion  and  erection  taking 
place  during  coitus. 

In  prolapse,  unless  complete,  there  is  nothing 
to  prevent  conception  except  the  debilitated  con- 
dition of  the  uterus  and  vagina,  for  the  penis 
naturally  pushes  the  organ  back  towards  its  normal 
position  as  it  comes  in  contact  with  the  cervix. 

Hervey  relates  an  interesting  case  of  prociden- 
tia uteri  where  coitus  took  place  through  the 
dilated  cervical  canal  and  was  followed  by  con- 
ception. 

As  the  uterus  becomes  displaced  it  draws  upon 
and  displaces  the  tubes  to  a  certain  extent,  and 
in  this  way  the  entrance  of  semen  into  their 
uterine  extremities  or  of  the  ova  into  their  fim- 
briated extremities  may  be  retarded. 

Displacements  may  also  prevent  conception  by 
producing  congestion  and  thickening  of  the  lin- 
ing membrane  of  both  the  uterus  and  the  tubes  so 
as  to  occlude  these  channels. 

Contracted  pelvis  may  also  prevent  the  union 
of  ova  and  spermatozoa  by  hindering  coitus,  and 
Hofmann  has  recorded  an  example  of  this  kind 
where  connection  was  impossible. 

Atresia  or  stenosis  of  any  part  of  the  genital 
tract  may  be  brought  about  by  inflammatory 
trouble.  All  pelvic  inflammations — salpingitis, 
ovaritis,  peri-metritis,  para-metritis,  etc.,  properly 
included  by  Dr.  Georges  Apostoli  under  the 
term  "salpingo-ovaritis"  —  originate  almost  al- 
ways in  the  uterine  mucous  membrane  and  spread 
from  there,  through  the  tubes,  to  the  surrounding 
organs  where  inflammatory  products  are  thrown 
out,  the  contraction  of  which  results  in  a  disloca- 
tion of  the  uterus,  of  the  ovaries,  or  of  the  tubes, 
or  in  a  closure  of  the  lumen  of  the  tubes.  The 
lining  membrane  of  the  tubes  also  becomes  thick- 
ened and  when  closure  takes  place  in  two  or  more 
places  so  as  to  prevent  the  escape  of  the  secre- 
tions into  the  uterine  or  peritoneal  cavities  there 
results  a  haemato  ,  hydro-,  or  pyosalpinx. 

Inflammation  of  the  fimbriated  extremities  is 
quite  common,  and  a  dropsical  condition  may  be 
found  which  causes  an  obstruction  to  the  entrance 
of  the  ova  into  the  tubes.  In  a  case  of  laparotomy 
where  I  removed  the  right  ovary  the  end  of  the 
tube  was  found  inflamed,  adherent  to  the  ovary 
and  closed,  but  it  was  healthy  in  all  the  rest  of  its 
course. 

Tubercular  disease  may  attack  the  tube,  but 
the  most  common  cause  of  salpingitis  is  an  en- 
dometritis of  gonorrhceal  origin. 

Acquired  stenosis  or  atresia  of  the  cervix  may 
follow  injuries  during  labor,  or  it  may  be  due  to 
syphilitic  ulceration.  In  follicular  endo-cervititis 
the  canal  may  be  entirely  closed  by  the  enlarged 
follicles,  or  ulceration  and  contraction  may  take 
place,  thus  causing  atresia  or  stenosis  and  pre- 
venting the  entrance  of  the  semen. 

The  application  of  the  sharp  curette  or  of  too 


strong  medicinal  applications  may  bring  about 
the  same  results  through  cicatrization.  Vaginal 
stenosis  or  atresia  may  be  due  to  injuries  during 
delivery  or  to  syphilitic  ulceration.  Diphtheria 
may  also  cause  sloughing  and  subsequent  con- 
traction. Simpson  has  seen  simple  vaginitis  in 
children  result  in  stenosis,  due  to  an  epithelial 
denudation  with  subsequent  adhesion  of  the  vag- 
inal walls. 

Vaginismus  is  a  hyperaesthetie  condition  of  the 
genitals,  usually  in  virgins,  causing  a  spasmodic 
contraction  of  the  muscles  of  the  perineum  and 
vagina.  It  may  be  due  to  the  small  size  of  the 
vagina,  to  ulcers  and  fissures,  to  irritability  of 
the  hymen,  and  to  organic  disease  of  the  uterus. 
Winckel  reports  cases  in  which  subperitoneal 
fibroids  seem  to  have  been  the  cause  of  it,  and  Mar- 
tin gives  cold  as  one  of  the  causes.  In  many  cases 
self-abuse  in  childhood  seems  to  have  produced  a 
congested  and  hyperaestheticcondition  of  the  parts. 
This  was  the  only  cause  that  I  could  find  in  a 
married  lady  of  nineteen,  who  had  been  married 
for  nine  months  without  ever  having  had  connec- 
tion. The  hymen  was  elastic  and  normal  in  ap- 
pearance, but  when  any  attempt  was  made  to  in- 
troduce the  finger  into  the  vagina,  intense  pain  was 
experienced  and  a  splastic  closure  of  the  sphinc- 
ter vaginas  would  occur. 

E.  Davis  reported  an  interesting  case  where  he 
was  sent  for  by  a  gentleman  to  separate  his 
coachman  and  maid,  and  this  could  only  be  ac- 
complished after  chloroform  had  been  adminis- 
tered to  the  woman.  The  liberated  organ  showed 
that  there  had  been  a  constriction  at  the  sphincter 
and  one  higher  up  in  the  vagina. 

Hypertrophy  or  new  growths  of  any  of  the  ex- 
ternal genitals  may  be  an  obstacle  to  coitus  and 
thereby  a  cause  of  sterility. 

The  clitoris  may  be  so  developed  as  to  prevent 
the  access  of  the  male  to  the  female.  Hyrtl  states 
that  in  certain  of  the  African  tribes  the  size  of 
the  clitoris  is  so  great  that  it  is  fastened  to  the 
perineum  by  rings  so  as  to  act  as  a  protection  to 
virginity.  It  was  most  likely  on  account  of  its 
size  that  circumcision  was  formerly  practiced  in 
certain  parts  of  Egypt,  and  is  now  in  parts  of  the 
Turkish  dominions.  Elephantiasis  of  the  vulva 
is  sometimes  a  cause  of  sterility,  and  hypertrophy 
of  the  nymphse  is  said  to  be  a  frequent  cause 
among  the  Hottentots,  Bushmen  and  Abyssin- 
ians.  A  large  accumulation  of  fat  on  the  pubes 
and  around  the  vulva  is  a  not  infrequent  cause  of 
sterility  in  persons  of  somewhat  advanced  age. 
Benign  and  malignant  growths  of  the  perineum 
will  prevent  the  introduction  of  the  penis  into  the 
vagina.  In  a  girl  of  16  years,  from  whom  I  re- 
moved a  large  angioma  of  the  right  labia  majora, 
coitus  would  have  been  almost  impossible. 

The  vagina  may  also  be  so  obstructed  as  to 
prevent  the  union  of  the  ova  and  spermatozoa. 
This   may   be  caused   by   cysts,    fibrous  tumors, 


■  ]  A  STUDY  OF  STERILITY.  227 

polypi,  and  malignant  tumors  of  the  vagina;  by  the  entrance  of  semen  into  the  cervical  canal, 
pressure    from  ovarian   or  rectal   tumors;  or  by   Other  means  arc  u-  1  ly  the  vitality  of 

cystocele,  rectocele,  or  enterocele.  Kisch  reports  the  spermatozoa.  Among  these  may  be  men- 
a  case  in  which  a  mass  of  hardened  faeces  in  the  tioned  injections  of  hot  and  cold  water,  and  solu- 
rectutn  prevented  coitus,  and  Schulze  had  a  case  tions  of  irinegar,  alum,  boracic  acid  and  other 
in  which  the  perineum  of  a  14  year  old  girl  was  medicinal  substances.  These  methods  are  not  as 
developed  to  such  an  extent  that  the  urine  was  sure  and  much  more  injurious  than  the  former, 
passed  with  difficulty.  Abstinence   from  coitus   for  fourteen  days  after 

Tumors  of  the  uterus  may  prevent  conception  the  last  menstrual  period  and  for  three  or  four 
by  occluding  either  the  os  uteri  or  the  openings  days  before  the  appearance  of  the  next  flow  is 
of  the  tubes;  they  may  also  cause  displacement  also  a  pretty  safe  practice,  there  being  no  ovum 
of  the  ovaries  and  tubes,  and  when  very  large   in  the  tract  at  that  time. 

they  may  draw  the  uterus  up  so  as  to  be  out  of  The  sexual  desire  in  the  male  is  much  stronger 
reach  of  the  glans  penis.  Indirectly  uterine  than  it  is  in  the  female,  and  in  some  females  it  is 
tumors  may  cause  congestion  or  inflammation  of  entirely  absent.  I  have  questioned  many  women 
the  genital  tract  producing  a  condition  un favor-  on  the  subject  and  have  frequently  been  told  that 
able  to  the  passage  of  the  spermatozoa.  it  was  months,  and  in  some  cases  years  after  max- 

Hennig  has  recorded  an  interesting  case  in  j  riage  before  they  could  look  on  sexual  intercourse 
which  hydrocele  seems  to  have  been  the  cause  of  with  any  feeling  but  disgust.  This  has  been  told 
sterility.  Ovarian  tumors  may  prevent  the  en-  j  me  so  often  that  I  am  inclined  to  think  that  the 
trance  of  the  spermatozoa  either  by  causing  com-  desire  among  the  more  highly  educated  women 
pression  or  by  drawing  up  the  uterus,  as  in  the  is  educated  and  not  natural.     This  also  accounts 


case  of  large  uterine  tumors,  and  the  same  is  true 
of  tumors  of  the  broad  ligaments. 

(b.)  The  normal  vaginal  secretion  is  slightly 
acid,  and  as  stated  before,  unfavorable  to  the  life 
of  the  spermatozoa,  while  that  of  the  cervical 
canal  is  alkaline  and  will  preserve  their  vitality 
for  several  days.  Should,  however,  an  inflamma- 
tion of  any  part  of  the  genital  tract  be  set  up,  the 
spermatozoa,    as  has  been  shown  by  Lott,  lose 


for  the  fact  that  the  first  birth  among  the  better 
classes  is  postponed  longer  than  among  the  labor- 
ing classes.  Most  likely  this  is  due  to  the  devel- 
opment of  the  cerebrum  at  the  expense  of  the 
cerebellum,  and  in  time  it  is  possible  that  the 
better  class  of  American:;  may  become  extinct,  as 
have  the  cliff-dwellers,  in  whom,  judging  from 
their  crania,  the  "organ  of  philoprogenitiveness" 
was  poorly  developed.     Many  women  claim  to  be 


their  vitality  and  die  in  a  short  time.  This  may  '•  able  to  tell  the  exact  time  at  which  impregnation 
be  caused  by  vaginitis,  endocervicitis,  endometri-  occurs,  and  there  seems  to  be  good  grounds  for 
tis,  or  salpingitis.  It  is  probable  that  the  ova  accepting  these  statements  as  true.  This  is  prob- 
are  also  injured  by  coming  in  contact  with  diseased  ably  due  to  the  perfect  orgasm  taking  place  in 
secretions,  but  on  this  point  our  knowledge  is  both  parties  at  the  same  time.  I  have  ascertained 
not  definite.  from    many    prostitutes    that    though    the}-    go 

There  are  many  causes  which  may  produce  in-  through  all  the  motions,  when  having  intercourse, 
flammation  of  the  genital  tract,  but  the  most  fre-  they  allow  orgasm  to  take  place  only  when  they 
quent  of  all  is  gonorrhoea.  Xbggerath  thinks  are  with  their  lovers.  To  this  cause  they  ascribe 
that  "latent  gonorrhoea"  is  the  cause  in  90  per  the  fact  of  not  becoming  pregnant  and  also  of  re- 
cent, of  all  cases  of  sterility.  This  figure  seems  taining  their  health  for  a  long  time.  A  married 
too  high,  but  it  may  be  correct  for  the  inhabit-  j  woman,  whose  husband  is  now  suffering  from 
ants  of  large  cities.  syphilloderma,  informs  me  that  she  has  escaped 

Diseased  conditions  of  the  genital  tract  produce  contracting  the  disease  by  not  allowing  her  pas- 
sterility  more  frequently  by  offering  a  mechanical  sions  to  be  aroused,  and  by  bearing  down  and 
obstruction  to  the  entrance  of  the  sperm,  or  by  forcing  out  the  seminal  fluid  after  the  act  has 
rendering  the  endometrium  unfit  for  the  implant-   been  accomplished. 

ation  of  the  ova  than  by  destroying  the  vitality  We  see  then  that  orgasm  is  more  or  less  under 
of  the  germs.  the  will-power,   so  that  it  can  be  hastened,  re- 

Urinary  and  faecal  fistula  of  the  genital  tract  tarded  or  kept  in  abeyance.  It  is  also  affected 
prevent  conception  not  only  because  of  the  sense  by  all  influences  which  debilitate  the  body  or  the 
of  disgust  connected  with  them,  but  also  by  pro-  nervous  system.  All  agents  then  which  tend  to 
ducing  a  diseased  condition  of  the  mucous  mem-  prevent  complete  and  simultaneous  orgasm  in  the 
brane.  two  individuals  are  causes  of  sterility. 

(c.)  Among  the  artificial  means  used  by  wo-  3.  Nonimplantation. — Xonimplantation  of  the 
men  to  prevent  conception  may  be  mentioned  impregnated  ovum  in  a  healthy  uterus  may  be 
sponges  and  tampons  of  cotton  introduced  into  due  to  disease  of  the  tubes  or  of  the  uterus.  After 
the  vagina  against  the  cervix.  Small  rubber  caps  the  ovum  has  become  impregnated,  most  likely 
are  also  used  by  placing  in  the  vagina  so  as  to  fit  in  the  outer  part  of  the  tubes,  it  is  carried  by  the 
as  a  cap  over  the  cervix  uteri  and  thus  prevent  current  in  the  tubes,  which  is  caused  by  the  mo- 


228 


A  STUDY  OF  STERILITY. 


[February  14, 


tion  of  the  ciliated  epithelium  and  which  is  prob- 
ably assisted  by  a  peristaltic  action  of  the  tubes, 
to  the  uterus.  The  uterus  is  also  lined  with  cili- 
ated epithelium  whose  motion  is  towards  the 
tubes.  This  motion  probably  assists  the  entrance 
of  the  spermatozoa  into  the  tubes  and  also  acts  as 
an  impediment  to  the  downward  passage  of  the 
ovum.  We  have  seen  before  that  ovulation  and 
menstruation  are  closely  connected,  so  that  by 
the  time  the  ovum  has  reached  the  uterine  cavity 
the  endometrium  has  become  swollen  and  its 
outer  layer,  at  leas't,  has  been  thrown  off  as  de- 
tritus so  as  to  offer  a  suitable  nidus  for  the  ovum. 
Here,  if  all  is  favorable,  the  impregnated  ovum 
becomes  attached  and  remains,  undergoing  de- 
velopment, till  normal  delivery  takes  place. 

The  frequent  arrest  of  the  ova  in  the  tubes  is 
shown  by  the  number  of  cases  of  ectopic  gesta- 
tion. Mr.  Tait  claims  that  all  cases  of  exra-uter- 
ine  pregnancy  are  primarily  of  tubal  origin.  He 
admits  the  possibility  of  ovarian  pregnancy,  but 
denies  that  it  is  possible  to  have  a  case  of  primary 
abdominal  pregnancy,  and  his  assertions  are 
borne  out  by  recent  investigations. 

The  arrest  of  the  ovum  in  the  tube  may  be 
caused  by  peritoneal  or  cellular  inflammation,  in 
which  a  constriction  is  brought  about  by  the  con- 
traction of  the  inflammatory  products;  by  pres- 
sure from  tumors  and  new  growths;  by  catarrh 
and  swelling  of  the  lining  membrane,  which  may 
also  affect  the  ciliary  motion  of  the  epithelial  lin- 
ing or  the  peristaltic  motion  of  the  tubes,  and  by 
pouches  or  dilatations  in  the  tubes  where  the 
action  of  the  current  is  lost. 

The  uterus  may  be  sufficiently  developed  to  re- 
ceive the  ovum  and  yet  be  unsuitable  as  a  seat 
for  future  development.  An  arrest  of  growth 
may  take  place  in  foetal  life,  before  the  uterus 
and  vagina  have  become  differentiated,  giving 
the  "uterus  fcetalis,"  or  its  growth  may  be 
arrested  in  infancy  while  the  cervix  is  very  long 
and  the  body  undeveloped,  which  results  in 
"uterus  infantilis,"  which,  according  to  Biegel, 
is  as  frequent  in  cases  of  sterility  as  4:155. 
Winckel  has  shown  that  foetal  inflammation  is  a 
frequent  cause  for  non-development  of  the  uterus. 
Atrophy  of  the  uterus  may  also  be  acquired,  as  in 
the  condition  known  as  "primary  atrophy," 
which  occurs  in  girls  before  the  period  of  puberty, 
when  they  suffer  from  wasting  constitutional  dis- 
eases, from  anaemia  or  from  chlorosis.  In  weak 
mothers,  who  have  suffered  from  puerperal  com- 
plications, it  is  not  uncommon  to  find  the  menses 
suppressed  and  the  uterine  walls  in  a  thin  and 
flaccid  condition.  This  is  known  as  "puerperal 
atrophy"  of  the  uterus.  A  condition  of  the  uterus 
which  is  unfavorable  for  implantation  or  devel- 
opment of  the  ovum  may  be  brought  about  by 
inflammation  of  the  peritoneum  and  cellular  tis- 
sue surrounding  the  uterus;  by  inflammation  of 
the  uterine  parenchyma,  or  by  inflammation  of 
the  endometrium. 


Peri-  and  para-uterine  inflammations  may 
spread  to  the  uterine  tissue  itself,  but  most  fre- 
quently they  contract  and  produce  displacements 
of  the  uterus  or  bind  it  down  so  that  when  the 
ovum  enlarges  abortion  follows.  They  may  also 
prevent  the  return  of  the  venous  blood  from  the 
parenchyma  of  the  uterus,  which  results  in  hyper- 
plasia, with  a  subsequent  catarrh  of  the  endom- 
etrium. Hyperplasia  may  also  be  produced  by 
disturbances  of  the  circulation  due  to  valvular 
disease  of  the  heart,  but  it  most  frequently  fol- 
lows the  first  birth  and  is  caused  by  subinvolu- 
tion. 

The  constant  excitement  due  to  excessive 
venery  results  in  hyperplasia,  and  we  find  flex- 
ions producing  the  same  results,  but  by  arresting 
the  return  of  the  venous  blood. 

In  all  cases  of  hyperplasia  the  endometrium  is 
found  congested  and  the  secretion  from  its  glands, 
and  the  glands  of  the  cervix,  much  more  profuseand 
watery  than  when  in  a  normal  condition.  It  is  prob- 
ably in  this  way  that  hyperplasia  acts,  for  in  many 
cases  where  the  endometrium  is  not  too  much 
diseased  pregnancy  occurs  in  spite  of  the  thick- 
ened uterine  walls.  Hyperplasia  may  run  into 
chronic  metritis  where  true  inflammatory  pro- 
ducts are  thrown  out,  and  this  will  prevent  the 
development  of  the  ovum  even  though  it  become 
attached. 

As  stated  above,  the  inflammations  around  or 
within  the  uterus  may  extend  to  the  muscular 
tissue  proper,  in  which  condition  we  find  haem- 
orrhages from  the  endometrium  quite  common, 
and  in  this  way  the  ovum,  after  having  reached 
the  uterine  cavity,  may  be  washed  out.  The 
cavity  of  the  uterus  also  becomes  larger  than 
normal  so  that  there  is  less  chance  for  the  arrest 
of  the  ovum,  the  nutrition  of  the  endometrium  is 
more  or  less  disturbed  so  that  implantation  of  the 
ovum  is  not  likely  to  take  place,  and  the  irrita- 
bility of  the  nerve  supply  is  favorable  to  uterine 
contraction,  which  frequently  results  in  the  ex- 
pulsion of  the  ovum. 

Inflammation  of  the  endometrium  is  the  most 
frequent,  directly  or  indirectly,  of  all  causes  in 
producing  sterility.  We  have  seen  how  it  may 
produce  changes  which  prevent  the  entrance  of 
or  are  injurious  to  the  vitality  of  the  spermatozoa. 

We  have  also  seen  how  most  para-  or  peri-uter- 
ine inflammations  start  from  the  endometrium, 
and  either  affect  the  production  of  the  ova  or  pre- 
vent their  union  with  the  spermatozoa.  It  now  re- 
mains to  consider  how  inflammations  of  the  en- 
dometrium may  prevent  the  implantation  of  or 
development  of  the  impregnated  ovum.  In  en- 
dometritis there  is  a  production  of  many  small 
round  cells  which  are  deposited  between  the 
glands,  so  that  compression  of  the  glands  takes 
place  and  results  in  atrophy,  not  only  of  the 
glands,  but  also  of  the  mucous  membranes.  With 
this  the  secretion   becomes  thin  and  watery  and 


iXgl.] 


DRAINAGE 


its  reaction  is  altered,  while  the  ciliated  epithe- 
lium is  thrown  off  and  replaced  by  cylindrical 
and  polyhedral  epithelium.  This  gives  a  smooth 
and  slick  condition  to  the  endometrium  so  that 
the  arrest  of  the  ovum  in  the  uterine  cavity  is 
very  difficult,  or,  should  it  be  arrested  and'  be- 
come implanted,  the  atrophied  condition  of  the 
mucous  membrane  with  the  alterations  in  the 
subjacent  tissues  will  favor  its  early  expulsion. 

All  intra  uterine  growths,  whether  submucous 
fibroids,  polypi,  malignant  or  other  tumors,  pre- 
vent implantation  or  favor  early  abortion  by  alter- 
ing the  condition  of  the  mucous  membrane,  or 
by  offering  a  mechanical  resistance  to  the  devel- 
opment of  the  ovum. 

Growths  in  the  muscular  tissue  also  alter  the 
condition  of  the  mucous  membrane,  but  they  act 
chiefly  by  preventing  the  uniform  enlargement  of 
the  uterus  as  the  ovum  develops.  The  subserous 
growths  may  produce  a  condition  closelv 
bling  vaginismus  and,  if  impregnation  occur,  the 
excitable  condition  of  the  nerves  may  cause  early 
abortion.  Intra-abdominal  tumors  may,  if  large, 
bean  obstacle  to  the  development  of  the  ovum  by 
directly  compressing  the  uterus,  as  is  sometimes 
seen  in  cases  of  multilocular  ovarian  cysts. 

Cancerous  tumors  act  by  infiltrating  the  tissue 
of  the  uterus  as  well  as  by  preventing  copulation 
through  the  sense  of  disgust  connected  therewith. 
Should  laceration  of  the  cervix  extend  nearly  up 
to  the  internal  os  it  causes  infiltration  of  the 
uterine  tissue,  which  results  in  a  loss  of  the  rela- 
tion between  the  ovum  and  uterus  as  develop- 
ment progresses,  of  which  abortion  is  the  conse- 
quence. Membranous  dysmenorrhcea  is  in  some 
cases  a  cause  for  the  discharge  of  the  ovum,  but 
not  in  all  cases,  for  many  examples  of  child-bear- 
ing have  been  reported  in  women  who  were  suf- 
fering from  that  trouble.  Another  cause  for  nou- 
lmplantation  of  the  ovum,  which  is  probably  more 
frequent  than  is  generally  supposed,  is  the  appli 
cation  of  the  sharp  curette  or  strong  medicinal 
substances  to  the  endometrium  by  unskilful 
hands.  Their  value,  in  .suitable  cases,  when 
carefully  applied,  can  not  be  over-estimated,  but 
if  the  mucous  membrane  be  destroyed  in  its  entire 
thickness  it  must  be  replaced  by  cicatricial  tissue 
unsuitable  for  the  implantation  of  or  nourishment 
of  the  ovum. 

To  enter  into  the  subject  of  abortion  would  be 
rather  foreign  to  the  present  subject,  and  it  would 
require  too  much  space  for  the  present  paper. 
Suffice  to  say  that  where  habitual  abortions  occur, 
if  neither  the  father  nor  the  mother  show  as- 
signs of  syphilis,  attention  should  at  once  be 
directed  to  the  uterus.  I  have  under  m  v  care  now  a 
lady  who  has  aborted  five  times,  and  "it  was  only 
in  her  last  accident,  the  first  in  which  I  attended 
her,  that  a  large  uterine  polypus  was  discovered. 
The  trouble  was  supposed  to  be  due  to  "habit." 
( To  be  concluded.) 


2:9 


IX  WHAT  CLASS  OF  WOUNDS  SHALL  WE 

USE  DRAINAGE  ?  AND  THE  PRESENT 

POSITION'  op    ANTISEPTIC 

SURGERY. 

BY  HENRY  < ».   MARCY,  A.M.,  M.D.,  I.  I 

Dr.  Marcy  considered  at  length  the  subject 
viewed  from  the  standpoint  of  the  recent  discus- 
sion at  the  International  Medical  Congre- 
111  Berlin.  He  reviewed  in  detail  the  observa- 
tions ot  Metschnikoff  upon  the  power  of  the  leu- 
cocytes to  surround  and  destroy,  to  dige-t 
speak),  the  bacteria  when  circumstances  are  fa- 
vorable. It  seemed  to  the  writer  quite  too  early 
to  draw  general  deductions  from  these  premises 
and  declare  that  here  the  entire  solution  of  the 
problem  is  found.  There  is  every  reason,  how- 
ever, to  believe  that  this  is  an  important  discov- 
ery of  a  power  which  the  organism  brings  to  res- 
cue it  under  favorable  conditions  from  impending 
danger.  The  practical  deduction  of  the  lesson  is 
that  we  seek  to  place  the  wound  in  such  a  condi- 
tion that  the  phagocytes  of  Metschnikoff  may  be 
made  the  active  allies  of  the  surgeon.  All  this 
helps  also,  in  a  measure,  to  explain  the  successes 
which  surgeons  have  obtained  by  means  which 
seemed  directly  opposite  in  their  methods  of 
wound  treatment. 

Dr.  Marcy  carefully  reviewed  our  present 
knowledge  of  the  histological  changes  which  go 
on  in  an  aseptic  wound,  and  showed  that  the  so- 
called  phagocytes  had  long  been  known  to  science 
as  the  leucocytes  which,  under  favorable  circum- 
stances, develop  into  germinating  tissue-cells 
with  the  newly  formed  capillars-  vessels,  etc.  A 
somewhat  similar  series  of  observations  of  equal 
interest  and  importance  are  seen  to  ensue  about 
the  ligature  of  an  artery  in  continuity  when  the 
surrounding  parts  are  maintained  in  an  aseptic  or 
healthy  condition.  Here  repair  takes  place  by 
the  host  of  little  workers  leading  up  their  forces 
in  different  directions.  The  blood-clots  in  the 
extremity  of  the  occluded  vessel  undergo  changes 
not  unlike  those  already  referred  to  in  other  loca- 
tions, while  the  leucocytes  speedily  surround  and 
shut  in  the  material  used  as  a  ligature,  forming 
a  capsule.  At  an  early  period  this  may  be  lifted 
away  from  the  thread,  more  or  less  distinctly  as  a 
layer,  and  little  or  no  change  has  taken  place  in 
the  constricting  material,  although  this  mav  dif- 
fer very  widely  in  character.  Even  when  applied 
to  the  vessels  of  very  young  animals,  after  a  con- 
siderable period,  the  silk  ligature  is  comparative- 
ly unchanged.  Often  at  the  end  of  three  or  four 
weeks  it  may  be  found  intact,  although  firmly 
shut  in  by  a  sheath  of  new  connective-tissue  cells. 
When  the  tissues  are  held  at  rest,  the  same 
general  condition  may  be  observed,  if  silk-wr.rm 
gut  or  silver  wire  has  been  used.     After  a  period 


DRAINAGE. 


[FEBRUARY    14 


of  some  weeks,  the  silk  ligature  may  have  com- 
pletely disappeared,  and  the  changes  which  have 
led  up  to  this  are  traced  in  an  invasion  of  leuco- 
cytes between  the  strands  and  fibres  of  the  silk, 
slowly  separating  them  and  causing  their  disinte- 
gration. If  these  conditions  are  interfered  with 
in  a  mechanical  way,  this  process  seems  to  be 
held  in  abeyance. 

The  cell  changes  which  should  go  on  in  the  de- 
velopment of  connective  tissue  fail,  and  then  the 
little  army  of  workmen  invade  the  surrounding 
tissues,  and  the  processes,  earlier  called  prolifer- 
ating, ensue,  and  the  constricting  material  is 
thrown  off  as  a  foreign  body.  When  an  aseptic 
animal  ligature  has  been  used,  catgut  or  tendon, 
and  the  parts  about  maintained  in  a  healthy  state, 
the  ligature  material  becomes  invaded  by  leuco- 
cytes, which  utilize  it  for  their  own  development, 
causing  it,  little  by  little,  to  disappear.  So 
marked  is  this  process  that  an  aseptic  animal  su- 
ture, introduced  into  various  parts  of  a  healthy 
young  animal,  may  for  a  considerable  period  be 
traced  by  a  line  of  newly-developed  connective 
tissue,  although  not  a  single  vestige  of  the  origi- 
nal material  remains.  These  processes  have  for  a 
long  time  been  recognized  in  a  general  way  and 
accepted,  and  yet  we  are  all  familiar,  almost 
equally  so,  with  the  reverse  of  the  picture,  where 
any  considerable  colony  of  micrococci  develop  in 
the  line  of  a  wound. 

Here  this  process  may  be  completely  local  ; 
that  is  to  say,  the  leucocytes  surround  and  shut 
in  the  invading  army  with  a  wall  of  living  gran- 
ulation cells  until,  little  by  little,  it  is  forced  to 
surrender  and  a  localised  abscess  is  the  sum  total 
of  damage.  The  most  of  us,  however,  who  were 
surgeons  of  an  earlier  day  recall  the  too  common 
and,  I  am  sony  to  admit,  even  at  present,  not 
rare  experience  in  the  every-day  work  of  many — 
the  foul  suppurating  wounds  and  general  system- 
ic poisoning.  In  such  wounds  the  feeble  bar- 
riers of  leucocytes,  thrown  up  against  an  invad- 
ing army,  fail  to  protect  the  organization,  and  the 
much-dreaded  "blood  poisoning"  supervenes. 

If  it  may  be  accepted,  in  a  general  way,  that 
the  above  observations  are  correct,  let  us  use  them 
as  basic  and  fundamental  from  which  to  draw 
further  conclusions.  If  we  find  in  the  so-called 
phagocytes  of  Metschuikoff  the  familiar  leuco- 
cytes above  mentioned,  we  certainly  have,  in  a 
very  considerable  measure,  an  explanation  of  the 
vital  resisting  power  of  the  individual  organism. 
II,  under  favorable  circumstance,  these  cannibal- 
istic little  workmen  not  alone  surround,  but  actu- 
ally eat  up  their  enemies,  we  have  the  best  of 
reasons  for  understanding  why  the  comparatively 
few  germs  in  the  atmosphere  of  a  healthy  localit} 
are  far  less  dangerous  to  wounds  than  was  earlier 
supposed.  Again,  too,  we  see  that  in  the  so- 
called  surgically  clean  wound,  that  is  a  wound 
where  great  care  is  taken  to  exclude  foreign  ma- 


terial, where  blood-clots  are  removed,  and  the 
comparatively  uninjured  clean-cut  surfaces  are 
closely  approximated — the  reparative  processes  go 
on  steadily,  and  rapid  recovery  supervenes,  al- 
though in  a  strict  scientific  sense  the  wound  is 
not  aseptic. 

In  wounds  where  the  surrounding  tissue  is  de- 
vitalized these  favorable  conditions  are  not  main- 
tained, and  here  the  germination  of  bacteria  goes 
on  much  as  seen  in  laboratory  culture  experi- 
ments. 

Dr.  Marcy  then  reviewed  at  length  ths  import- 
ant contribution  of  Sir  Joseph  Lister,  delivered 
before  the  Medical  Congress  in  Berlin,  and  Mr. 
Tait's  reply  to  the  same  holding,  as  usual,  oppo- 
site views,  he  declaring  that  the  whole  basis  of 
antiseptic  surgery  is,  "  an  absolute  and  ludicrous 
logical  error."  Dr.  Marcy  closed  his  address  with 
the  conclusion,  that  the  unbiased  student  must 
observe  in  the  recent  progress  in  wound  treat- 
ment a  fundamental  truth  based  upon  the  re- 
peated observation  of  abundant  facts.  This  con- 
sists of  three  factors  :  1.  The  condition  of  the 
patient,  the  so-called  vital  resistant  power;  2. 
The  bacterial  infection,  the  seeding  of  the  field  ; 
3.  The  condition  of  the  soil,  the  pabulum  neces- 
sary for  the  growth  of  the  direful  harvest.  Upon 
this  tripod  at  present  rests  the  scientific  basis  of 
wound  treatment.  There  are  many  workers 
equally  earnest,  equally  thoughtful.  It  is  better 
they  should  make  their  observations  as  independ- 
ent original  investigators.  Much  profit  comes 
from  the  results  of  such  heroic  workers,  as  Mr. 
Tait,  Dr.  Bantock,and  many  others  we  could  men- 
tion. The  recent  teachings  of  those  who  advo- 
cate the  so  called  dry  treatment  of  wounds  con- 
vey another  side  view  of  the  great  fundamental 
truth  of  much  value.  Here  primary  union  is 
prompt  and  there  is  little  effusion  which  seems  to 
require  drainage.  It  will  be  noted  that  Sir  Joseph 
Lister  looks  forward  to  the  possible  abandon- 
ment of  drainage,  which  he  has  during  the  last 
three  years  greatly  lessened.  On  the  contrary, 
Mr.  Tait,  as  may  be  inferred  from  his  writings, 
elevates  drainage  to  a  most  important  factor  of 
wound  treatment,  and  at  the  late  International 
Medical  Congress,  both  he  and  Dr.  Bantock  pre- 
dicted a  greatly  extended  use  of  the  drainage- 
tube.  They  disregard  the  bacterial  infection, 
but  insist  upon  the  withdrawal  of  all  material 
which  could  aid  in  its  possible  development. 

The  ideal  of  wound  treatment  is  surely  to  re- 
store the  condition  of  the  parts  to  as  nearly  their 
primal  state  as  possible.  If  this  can  be  assuredly 
aseptic,  then  there  is  no  bacterium  to  remove  ;  if 
surgically  clean,  with  accurate  coaptation  of 
the  sundered  parts,  then  there  is  no  material  which 
needs  removal,  nothing  to  drain.  If,  as  we  have 
seen, the  leucocytes  go  promptly  to  work  under  such 
favorable  conditions,  the  first  series  of  the  repair 
processes  takes  place,   which  ends   in  a   prompt 


I89i.] 


DRAIXAGK. 


231 


and  speedy  restoration.  This  should  be  effected 
under  a  dressing  which  will  permit  of  the  intro- 
duction of  no  foreign  factorage.  To  this  end 
Lister  has  unweariedly  labored,  for  nearly  a  quar- 
ter of  a  century.  The  various  antiseptic  dress- 
ings, now  so  generally  employed,  have  a  value  in 
wounds  necessarily  drained,  which  must  be  con- 
sidered open  to  a  possible  infection,  but  in  a 
wound  that  is  closed  without  drainage  they  are 
unnecessary,  expensive,  and  cumbersome.  Lis- 
ter's ideal  protective  varnish  is  found  in  the  clos- 
ure of  the  wound  with  iodoform  collodion. 

My  last  five  years  of  experience  in  the  treat- 
ment of  aseptic  wounds  of  every  variety,  closed 
in  layers  with  buried  tendon  sutures  and  treated 
in  no  other  way  than  by  a  protective  layer  of  col- 
lodion, is  cited  in  ample  proof.  Even  in  the  ma- 
jor amputations,  such  wounds  go  on  to  a  speedy 
repair  without  pain  or  oedema  of  the  surrounding 
parts.  Call  the  various  methods  adopted  to  se- 
cure the  end  obtained  by  whatever  name  you 
will,  the  great  fundamental  principles  of  anti- 
septic surgery,  as  enunciated  by  Sir  Joseph  Lister 
many  years  ago,  rest  upon  a  sure  foundation, 
and  the  results  in  modem  wound  treatment  are 
the  marvel  of  our  age. 

From  this  brief  review  of  well-known  facts,  it 
is  obvious  that  the  real  object  of  drainage  is  not 
so  much  the  removal  of  the  serum,  blood,  and  de- 
vitalized tissues,  as  it  is  to  remove  any  possible 
bacterial  infection  which  may  have  invaded  the 
•wound  ;  for  it  is  quite  impossible  to  divide  and 
rejoin  tissues  without  the  effusion  of  blood  and 
serum,  and  in  a  greater  or  less  degree  devitaliz- 
ing the  adjacent  structures.  Since  these  are  very 
important  factors,  it  is  of  the  first  consideration 
on  the  part  of  the  surgeon,  that  he  minimize  as 
much  as  possible  these  conditions,  for  the  reason 
that  they  render  it  very  probable  that  the  intro- 
duction of  bacterial  seed  into  such  a  soil  will  be 
followed  by  direful  results. 

Is  the  present  state  of  operative  procedure 
sufficiently  accurate  to  warrant  the  assurance  that 
such  complications  are  not  to  supervene  ?  This 
is  the  question  which  must  first  be  satisfactorily 
answered  before  we  are  in  a  position  to  determine 
at  all  positively  when  we  are  to  use,  if  always,  or 
rot  at  all,  the  drainage-tube,  in  the  hope  thereby 
to  remove  the  fermenting  material,  so  dangerous 
if  allowed  to  remain. 

It  is  certainly  clear  that  the  experience  of  the 
last  twenty  years  has  been  leading  to  the  solution 
of  this  problem,  until  now  it  seems  demonstrated 
beyond  a  doubt,  that  an  aseptic  wound  may  be 
made  in  aseptic  tissues,  and  maintained  aseptic 
until  restoration  is  complete.  If  this  is  true,  the 
modus  operandi  of  modern  wound  treatment  must 
be  mastered  as  the  ritual  service  of  a  higher  re- 
ligion, before  the  surgeon  is  competent  to  enter 
upon  the  serious  responsibility  of  his  office.  If 
aseptic    conditions  are  maintained,  then  we  may 


safely  conclude  that  the  drainage  of  the  wound 
will  not  be  necessary,  and  if  unnecessary,  cer- 
tainly undesirable.  At  the  best  the  drainage-tube 
is  a  foreign  body,  and  its  presence  in  the  wound 
prevents  primary  union  of  *hat  portion  of  the  tis- 
sues which  enclose  it.  It  keeps  the  wound,  to  a 
certain  extent,  an  open  one,  and  as  such  makes 
secondary  infection  so  probable  that  the  most 
careful  antiseptic  dressings  are  advised  to  absorb 
and  disinfect  secretions  and  prevent  atmospheric 
contamination.  In  an  aseptic  wound,  after  the 
removal  of  the  tube,  the  final  closure  of  the  tract 
is  comparatively  slow,  and  by  granulation.  These 
are  well-recognized  objections,  and  efforts  have 
been  made  to  overcome  them  by  many  ingenious 
designs. 

If  drainage  is  to  be  discontinued  in  aseptic 
wounds,  it  must  be  accepted  that  the  greatest  care 
shoald  be  exercised  in  leaving  as  little  devitalized 
tissue  as  possible,  and  in  evenly  coaptating  the  di- 
vided parts.  The  wound  should  be  clean  and  dry: 
the  different  layers  of  the  tissues  should  be  joined 
with  as  little  injury  as  possible,  and  the  external 
wound  should  be  protected  from  infection.  Irri- 
gation should  be  employed  with  a  minimum  of 
sponging,  and  joining  of  the  tissues  by  light, 
running  buried  animal  sutures,  preferably  tendon. 
The  skin  is  evenly  coaptated  by  a  similar  suture, 
taken  from  within  outward  through  the  deeper 
layer  only.  Then  the  wound  is  sealed  with  a 
germ-proof  layer  of  iodoform  collodion  reinforced 
by  a  few  fibers  of  cotton.  Such  wounds  go  on 
rapidly  to  repair  without  oedema  of  the  tissues, 
pain,  or  tenderness. 

"  Are  all  aseptic  wounds  to  be  thus  treated?  I 
unhesitatingly  say  yes,  even  to  the  major  ampu- 
tations ;  abdominal  operations  included." 

As  a  matter  of  fact,  I  find  in  my  last  forty  ab- 
dominal sections  I  have  not  once  used  drainage, 
and  have  noted  no  reason  to  regret  not  employing 
it. 

The  seed  and  the  aril,  and  the  varying  conditions 
of  each,  must  ever  be  kept  in  consideration. 
When  in  doubt  of  infection  in  a  wound,  especial- 
ly when  its  character  will  be  likely  to  be  attend- 
ed with  an  abundant  albuminoid  secretion,  drain  ; 
but  let  the  surgeon  ever  remember  that  the  high- 
est theoretic  condition  of  wounds  is  their  n 
tion,  as  nearly  as  possible,  to  the  normal  relation 
of  the  tissues,  and  their  retention  at  rest  in  an 
aseptic  condition.  This,  in  a  great  majority  of 
wounds,  renders  drainage  not  only  unnecessary, 
but  when  applied,  it  will  be  a  positive  detriment 
and  a  source  of  danger.  I  am  assured  that  the 
better  knowledge  of  the  conditions  of  wounds  will 
restrict  the  use  of  the  drainage-tube  to  septic 
wounds,  and  that  operative  wounds  in  aseptic 
tissues  will  be  aseptically  maintained  by  primary 
closure  without  drainage. 

(For  discussion  see  Society  Proceedings.) 


232 


DEATH  UNDER  CHLOROFORM. 


[February  14, 


DEATH    DURING  CHLOROFORM  ADMIN- 
ISTRATION. 

Read  before  in  Society  of  Chicago,  Dec.  6,  i8go. 

BY  C.  T.   PARKES,   M.D., 

PROFESSOR     OF    SURGERY     RUSH     MEDICAL    COLLEGE,     ATTENDING 
SURGEON   PRESBYTERIAN   HOSPITAL,    ETC.,   CHICAGO. 

The  case  which  I  desire  to  report  to-night  is 


followed  by  unexpected  death  in  individuals  who 
were  healthy  as  well  as  in  those  who  were  dis- 
eased, and  the  post-mortem  examinations  made 
after  death  have  in  no  case  shown  satisfactorily 
the  cause  of  death,  so  we  do  not  understand  ab- 
solutely why  they  die. 

In  this  case  the  anaesthetic  was  commenced  in 


rather  a  notorious  one,  and  I  have  concluded  to  i  the  room  which  the  parents  of  the  child  occupied, 
report  it  at  the  request  of  the  President,  without  |  and  was  given  by  an  interne,  Dr.  Gill,  of  the 
preparation,  because  it  is  of  great  interest  to  the  Presbyterian  Hospital.  At  first  the  child  ex- 
profession,  and  because  I  am  quite  sure  there  is  !  hibited  no  more  excitement  and  no  more  opposi- 
no  one  who  will  better  remember  the  circum-  j  tion  to  taking  the  chloroform  than  do  other  pa- 
stances  attending  the  case  or  who  will  be  less  tients,  and  not  nearly  as  much  as  many.  It  is 
likely  to  forget  them.  It  is  a  case  of  death  the  constant  experience  of  physicians  that  they 
which  resulted  in  a  child  under  the  influence  of !  are  compelled  often  to  use  physical  force  for  some 
chloroform  during  the  month  of  November  last.  \  time  before  the  patient  is  anaesthetized  ;  that  was 
These  cases  are  always  doubly  unfortunate.  I  not  so  in  this  case.  I  was  a  little  anxious  about 
They  are  unfortunate  in  the  first  place,  and  be- 1  the  case  and  was  ready  to  do  the  operation,  but  the 
yond  all  other  reasons,  on  account  of  the  death  patient  did  not  appear,  so  I  sent  a  second  interne, 
of  the  individual,  and  the  terrible  news  which  is  Dr.  Jay,  to  see  what  the  trouble  was.  He  did 
so   suddenly   brought   to    the    bereaved   friends.  [  not  return  for  some  time  and  I  sent  the  chief  as- 


They  are  unfortunate  because  they  remind  the 
profession  of  the  fact,  which  cannot  be  disproved, 
that  physicians  have  not  found  an  absolutely  safe 
anaesthetic.  All  anaesthetics  are  dangerous,  and 
all  of  them  occasionally  cause  death,  and  the 
most  astounding  part  about  it  to  outside  indi- 
viduals is,  that  doctors  cannot  tell  why  the  pa- 
tients die  under  these  circumstances.  These 
cases  of  death  under  anaesthetics  are  always  un- 
expected, and  in  the  vast  majority  of  cases  un- 
avoidable. 

This  patient  was  a  bright,  perfectly  healthy  little 
girl,  about  u  years  of  age.  She  had  on  her  face 
a  large  mole  covering  the  greater  portion  of  the 


sistant,  Dr.  Ochsner,  and  in  a  few  minutes  the 
child  was  brought  into  the  room  quietly  asleep. 
The  anaesthetic  was  then  given  into  the  hands  or 
the  oldest  interne,  Dr.  Albright,  and  he  admin- 
istered it  carefully  during  the  operation.  The 
operation  required  about  twenty-five  minutes  ;  it 
was  about  the  face,  and  my  hands,  which  are  not 
very  small,  were  over  the  child's  face  all  the  time 
and  consequently  the  anaesthetic  was  not  used 
steadily,  very  little  chloroform  was  given  to  the 
child.  The  instrument  used  for  giving  the  anaes- 
thetic was  Esmarch's  inhaler,  a  wire  frame  cov- 
ered with  flannel,  with  which  it  is  impossible  to 
absolutely  prevent  the  entrance  of  air.     The  child 


surface  of  the  cheek,  measuring  more  than  two   made  no  demonstration  of  any   kind  that   would 


and  one-half  inches  in  one  direction  and  over  one 
inch  in  another.  It  was  dark  in  color  and  had 
on  it  a  large  growth  of  coarse  hair.  It  was  a 
source  of  very  great  annoyance  to  the  child,  in- 
creasing her  timidity,  and  of  great  trouble  to  the 
friends.  I,  and  other  physicians  who  saw  the 
case,  recommended  its  removal  because  we  had 
had  experience  in  such   matters,  had  done  such 


attract  attention.  The  operation  was  practically 
completed  ;  the  pigmented  naevus  was  removed 
and  pieces  of  skin  taken  from  the  thigh  for  trans- 
plantation, to  cover  the  defects  and  diminish  the 
amount  of  scar,  were  being  put  in  position  ; 
when,  without  any  warning,  without  the  admin- 
istration of  any  chloroform  for  at  least  five  min- 
utes, the  child  was  seized  with   general  convul- 


operations  safely,  and  because  it  could  not  be  re- :  sions  ;  she  ceased  to  breathe,  her  heart  ceased  to 

moved  in  any  other  way  than  by  surgical  opera-  beat,  she  gave  a  few  gasps  and  was  dead.     Every 

tion.     There  was  nothing  in   the  appearance  of  effort  was  made  for  an  hour  and  a  half  to  restore 

the  child  upon  examination   that  would  counter-  circulation   and   respiration,  by  artificial  respira- 

indicate  the  use  of  an  anaesthetic  in  any  way,  and  tion,   injection   of  ether  and  whisky  and  nitrite 

chloroform  was  chosen  ;  because,  personally,  I  do  of  arnyl,  and  the  use  of  electricity,  but  all  efforts 

not  believe  there  is  a  noticeable  amount  of  differ-  failed. 


ence  between  the  two  anaesthetics,  chloroform 
and  ether.  The  difference  which  seems  to  exist 
I  believe  is  based  upon  the  fact,  that  a  larger 
number  of  physicians  use  chloroform  than  use 
ether.  And  although  the  number  of  deaths  re- 
corded as  following  the  use  of  chloroform  are 
greater  than  from  the  use  of  ether,  it  is  dependant 
upon  the  fact  that  chloroform  is  used  oftener  than 
ether.  But  the  fact  still  remains  that  all  anaes- 
thetics and  all  combinations  of  them   have   been 


The  case  is  interesting  to  all  medical  men,  and 
to  all  lay  people.  To  medical  men  because  it 
shows,  as  I  have  said,  that  ether  and  chloroform 
are  dangerous  anaesthetics,  and  it  confirms  the 
experience  of  every  physician,  that  when  such  an 
unfortunate  happening  as  this  comes  upon  him, 
it  is  unexpected,  and  no  matter  what  care  he  may 
u.->e  and  what  attention  he  rnay  give  to  the  case, 
such  accidents  do  occur.  It  is  a  well-known 
fact  among  my  friends  that  I  am  especially  care- 


I89i.] 


MEDICAL  PROGRESS. 


233 


ful  about  anaesthetics,  that  I  dread  all  of  them. 
I  never  have  a  patient  put  to  sleep  without  watch- 
ing them  personally,  no  matter  who  is  my  anaes- 
thetizer  My  mind  was  on  it,  as  well  as  the  op- 
eration in  this  case,  and  I  gave  advice  repeatedly 
during  the  administration  of  the  chloroform  as  to 
the  necessity  of  ceasing  to  give  it  or  of  giving  a 
little  more.  The  death  in  this  case  was  truly 
and  absolutely  an  unavoidable  occurrence,  such 
as  may  meet  the  physician  any  time  and  under 
any  circumstances  while  using  an  anaesthetic.  It 
showsthe  necessity  of  medical  men  fully  protecting 
themselves  against  unjust  suspicions  and  attacks 
on  the  part  of  any  one,  by  never  giving  an  anaes- 
thetic, under  any  circumstances,  unless  one  is  able 
to  prove  that  the  circumstances  attending  the 
case  were  proper  in  every  way. 


MEDICAL    PROGRESS. 


Medicine. 

The  Oil-Silk  Jacket  en  Asthma. — Dr.  S. 
C.  Bcsey,  of  Washington,  has  used  the  oil-silk 
jacket  in  bronchial  asthma  with  good  results,  and 
recommends  it  for  further  trial  especially  in  that 
type  of  cases  which  is  under  the  influencing  con- 
trol of  climatic  and  atmospheric  conditions.  In 
the  case  of  one  patient  the  regularly  recurring 
winter  paroxysm  has  been  apparently  kept  well 
under  control  whenever  the  jacket  has  been 
adopted  at  the  onset  of  an  attack  ;  from  October, 
1889,  to  January,  1890,  the  jacket  had  been  worn 
continuously  ;  when  it  was  removed,  about  Jan- 
uary 1,  1890,  because  of  the  discomfort  incident 
to  a  period  of  unseasonably  warm  weather.  Since 
its  last  removal  the  patient  has  had  numerous 
very  slight  attacks  of  dyspnoea,  coming  on  dur- 
ing the  early  morning  hours  but  disappearing  af- 
ter sunrise  ;  none  of  these  attacks  were  noticed 
during  the  time  of  its  being  worn.  How  far 
idiosyncracy  influenced  the  good  effects  obtained 
by  Dr.  Busey,  he  admits  that  there  is  room  for 
doubt,  but  the  suggestion  is  offered  by  him  in  the 
good  faith  that  the  treatment  ma}-  be  tested  by  a 
more  extensive  trial,  and  thus  found  a  useful  ex- 
pedient to  some  of  those  who  suffer  from  asthmat- 
ic and  bronchial  complications. 

Fibrillary  Chorea. — Dr.  Morvan 
Hebd.^has  observed  five  cases  of  peculiar  fibrillar}- 
tremor  to  which  he  has  given  the  name  "choree 
fibrillaire,"  and  which  he  thinks  constitutes  a 
new  clinical  group.  His  first  case  was  a  young 
peasant  who  had  always  been  well  but  who  com- 
plained of  a  peculiar  trembling  in  the  buttocks 
and  a  general  feeling  of  weakness.  The  tremor 
increased  and  involved  successfully  the  thighs, 
back,  shoulders  and  arms.  The  contractions  were 
confined  to  the  single  muscle  bundles  and  so  did 


not  produce  movements  of  the  limbs  ;  they  were 
irregular  so  that  the  skin  over  the  muscles  rose 
and  fell  like  the  keys  of  a  piano.  The  patient 
could  perform  all  of  the  usual  movements,  and 
during  voluntary  contraction  the  abnormal  ceased. 
The  affected  muscles  were  painful,  and  pain  was 
felt  in  the  legs  when  in  the  upright  position. 
Temperature  was  normal  but  the  pulse  was  very 
rapid.  The  contractions  became  more  frequent 
and  were  especially  marked  in  the  buttocks  and 
deltoid.  The  face,  hands  and  feet  remained  free. 
Three  weeks  after  the  beginning  of  the  disease 
albuminuria  was  found,  and  a  few  days  later  de- 
lirium came  on  and  the  patient  died  comatose. 

Another  case  was  that  of  a  boy  16  years  of  age 
who  had  similar  fibrillar}-  contractions,  especially 
in  the  buttocks  and  thighs.  With  the  use  of 
warm  baths  at  the  end  of  four  weeks  the  con- 
tractions ceased.  The  disease  returned  early  in 
the  summer  of  each  of  the  next  three  years. 

A  young  woman,  23  years  of  age,  was  similar- 
ly affected,  associated  with  general  weakness  and 
chlorosis.  Recover}-  at  the  end  of  four  months, 
and  three  years  later  a  slight  attack  of  the  same 
trouble.  Two  additional  cases  are  given,  both 
young  girls  with  a  history  similar  to  the  one 
above  described.  In  each  of  these  the  contrac- 
tions were  confined  to  the  legs. 

Surgery. 

Aphasia  due  to  Abscess  of  the  Braix. — 
S.Exger  and  Sick  {Deutsche  vied.  Wochensch.  ; 
Ctrlbl.  f.  Chir..  Xo.  40.  1S90)  report  a  case  which 
is  interesting  because  the  location  of  the  abscess 
in  the  posterior  third  of  the  left  temporal  lobe 
was  diagnosticated  by  the  presence  of  sensory- 
aphasia.  The  patient,  a  man  fifty-  years  of  age, 
seemed  to  be  suffering  from  some  psychical  trou- 
ble. He  did  not  answer  the  questions  which 
were  asked  him.  but  simply  pointed  to  his  left 
ear,  which  was  so  much  swollen  that  the  external 
meatus  was  nearly  closed.  In  three  days  this 
swelling  had  become  sufficiently  reduced  to  reveal 
the  discolored  drum  membrane,  through  a  per- 
foration in  which  a  small  quantity  of  foul- smell- 
ing pus  escaped.  He  lay  silent  and  not  appear- 
ing to  notice,  but  when  excited  he  talked  much 
in  incomprehensible  language.  He  could  not 
give  the  right  name  to  objects,  but,  instead,  gave 
a  roundabout  description  of  them.  The  pulse 
was  slow,  48  to  56  a  minute  ;  he  suffered  from 
headache,  periodical  vomiting,  and  stubborn  ob- 
stipation. Finally  a  right-sided  facial  paralysis 
appeared,  together  with  a  weaker  power  of  pres- 
sure in  the  right  hand.  The  wife  of  the  patient 
said  that  her  husband  had  for  several  years  had  a 
discharge  from  his  left  ear,  and  for  the  last  fort- 
night had  complained  of  pain  in  the  ear  and  head- 
ache. From  these  circumstances — that  there  was 
a  chronic  suppurative  inflammation  of  the  middle 
ear,  acute  symptoms  of  pressure  on  the  brain,  and 


234 


MEDICAL  PROGRESS. 


[February  14, 


aphasicdisturbance-the  diagnosisof  abscess  of  the 
brain  in  the  posterior  third  of  the  first  temporal 
convolution  of  the  left  side  was  made,  and  this 
diagnosis  was  confirmed  b}'  operation.  The  re- 
sult of  the  operation  was  pronounced  "ideal" 
nearly  three  months  afterward,  in  spite  of  a  small 
hernia  cerebri  which  complicated  the  convales- 
cence. 

The  writers  maintain  that  only  two  cases  have 
hitherto  been  reported  in  which  the  diagnosis  of 
abscess  of  the  brain  was  made  from  the  presence 
of  aphasia. — Ar.   }'.  Med.  Journal. 

Carcinoma  Mammas.  —  Bihler  (Munchener 
Dissertation,  1890)  reports  the  results  of  forty  op- 
erations made  by  Angerer.  In  each  case  the  en- 
tire gland  was  removed,  and  the  axillary  space 
was  cleaned  out  whether  the  enlarged  glands 
could  be  felt  or  not.  In  most  of  the  cases  the 
pectoral  fascia  was  removed  and  in  the  later  cases 
a  portion  of  the  muscle  itself.  In  cases  of  relapse 
the  masses,  if  movable,  were  removed  with  the 
knife,  when  the  gland  was  affected,  and  with 
large  tumors,  they  were  excised  with  the  thermo- 
cautery after  the  method  of  Nussbaum. 

The  results  to  date  are:  Dead  65  per  cent., 
12.5  per  cent,  live  but  the  disease  has  returned. 
In  20  per  cent,  there  has  been  no  return  of  the 
trouble,  among  these  are  three  in  whom  more 
than  three  years  have  elapsed  since  operation, 
and  two  in  which  more  than  two  years  have 
passed. 

ACTIMOMYCOSIS     OF     THE     SKIN.  —  TlLANUS 

{Munchen,  Med.  Wochenschr.')  reports  a  case  in 
which  the  skin  of  the  face  was  alone  affected,  the 
muscular  structures  and  mucous  membrane  of  the 
mouth  remaining  free.  Two  similar  cases  have 
been  reported,  one  by  Albert,  the  other  by  Ma- 
jocchi. 

The  history  of  the  case  was  briefly  as  follows: 
A  young  woman  22  years  of  age  presented  a  swell- 
ing of  the  right  half  of  the  face  that  slowly  in- 
creased and  later  opened  in  several  places;  finally 
the  whole  region  from  the  external  angle  of  the 
eye  and  including  the  side  of  the  neck  as  far  as 
the  angle  of  the  lower  jaw.  The  skin  of  the  part 
presented  red  prominent  masses  interspersed  with 
patches  of  healthy  tissue,  with  here  and  there  an 
ulcer,  which  discharged  a  sero  purulent  fluid. 
w  remaining  teeth  were  carious  and  were 
removed.  Treatment  consisted  in  thoroughly 
curetting  the  affected  skin,  and  free  applications 
of  a  solution  of  corrosive  sublimate. 

The  etiology  of  the  trouble  was  obscure,  but 
the  author  thinks  the  carious  teetli  played  an  im- 
portant role  in  the  production  of  the  disease. 

Dr.  Lesser,  of  Halle,  contributes  to  the  Arch. 
fin  Klin.  Chir.  three  cases  of  actinomycosis 
hominis  in  which  the  skin  alone  was  affected. 
The  first  was  that  of  a  salesman  35  years  of  age 


who  had  suffered  from  toothache  for  one  year, 
and  had  eighteen  extracted.  For  six  months  has 
had  an  ulcerated  swelling  of  the  forearm.  A  care- 
ful examination  revealed  similar  ulcerations  upon 
the  right  side  of  the  head,  in  the  right  infra- 
clavicular grove,  and  the  left  side  of  abdomen. 

A  second  was  that  of  a  34  year  old  man,  who 
for  several  days  had  presented  two  swellings  on 
the  right  calf.  The  enlargements  were  painful 
and  the  patient  had  rigors  with  high  fever.  The 
subcutaneous  lymphatics  were  not  involved. 

A  third  was  that  of  a  locksmith,  who  six  weeks 
previously  had  been  lightl}'  burned  upon  the  right 
leg.  In  this  region  a  slight  swelling  appeared, 
which  rapidly  increased,  followed  by  ulceration 
and  the  discharge  of  some  pus. 

All  three  cases  made  a  rapid  recovery  after  ex- 
cision, curetting  and  cauterizing.  The  diagnosis 
in  each  case  was  confirmed  by  the  finding  the 
strahlempilz  in  the  discharges  of  the  wound. 

The  author  says  that  it  is  of  special  importance 
to  note  the  great  variability  in  the  clinical  pic- 
ture presented  by  actimomycosis  of  the  skin  in 
man.  At  times  the  process  may  be  sub- acute  ; 
again,  it  may  be  acute  with  marked  disturbance  of 
the  general  health.  As  a  rule,  swelling  of  the 
regional  lymph  glands  is  not  present. 

Obstetries. 

Bromides  in  Vomiting  of  Pregnancy. — 
Dr.  Wertheimer,  of  Freiburg  (Ccntralbl.  /. 
Gynak.,  December  20,  1890),  describes  the  case 
of  a  woman,  aged  33,  who  had  borne  eight  chil- 
dren, who  had  required  artificial  abortion  at  the 
third  and  fourth  month  respectively  in  two  labors, 
on  account  of  uncontrollable  vomiting.  She  once 
more  became  pregnant,  and  violent  sickness  set 
in  only  fourteen  days  after  conception.  No  nour- 
ishment could  be  taken,  and  she  soon  became 
dangerously  exhausted.  Belladonna  and  mor- 
phine failed  to  influence  the  sickness.  Bromide 
of  potassium  checked  it  slightly.  Dr.  Wertheimer 
then  gave,  every  two  hours,  half  an  ounce  of  a 
mixture  consisting  of  three  parts  of  bicarbonate 
of  soda,  two  of  bromide  of  potassium,  two  of  bromide 
of  sodium,  and  one  of  bromide  of  ammonium,  dis- 
solved in  thirty  parts  of  syrup  of  orange  peel,  and 
one  hundred  and  twenty  of  distilled  water.  The 
vomiting  ceased,  the  patient's  strength  increased, 
and,  at  the  time  of  the  report,  the  patient  had 
passed  the  fifth  month  of  pregnancy  without  any 
return  of  the  sickness. — Brit.  Med.  Journal. 

Treatment  ok  Placenta  Pr.evia. — Drs. 
W.  J.  Kolff  and  Treub  (Nouvelles  Archiv. 
d'Obstet.,  September,  1890)  record  the  results  of 
this  malpresentation,  as  observed  by  them  at 
Leyden.  Between  1856  and'  1879  26  cases  of 
placenta  prsevia  were  noted  by  Dr.  Kolff,  with  a 
mortality  of  42  per  cent.  On  the  other  hand  be- 
tween   1887   and    1889  Professor  Treub   has  ob- 


i89i.] 


MEDICAL  PROGRESS. 


235 


served  13  cases.  In  all  of  this  series  he  performed 
combined  version,  losing  only  one  patient.  The 
fatal  case  cannot  fairly  be  attributed  to  the 
method  of  delivery,  for  the  woman  died  of  pyae- 
mic  phlebitis,  set  up  by  a  dirty  sponge  which  the 
midwife  introduced  into  the  vagina  to  check  the 
haemorrhage  before  version  was  performed.  Hence 
the  mortality  did  not  amount  to  8  per  cent.  Of 
the  children  8  (or  61  per  cent.)  died,  but  4  must 
be  subtracted  as  the  heart  sounds  could  not  be 
heard  before  version;  thus  the  precise  mortality 
was  30  per  cent.  During  childbed  bad  re- 
sults were  observed  only  in  cases  that  had  been 
previously  examined  by  midwives,  except  in  one 
instance,  where  the  vagina  had  been  plugged 
with  sterilized  absorbent  gauze  instead  of  iodo- 
form gauze.  The  great  principle  of  practice  at 
Leyden  is  to  separate  version  from  extraction. 
The  former  is  undertaken  in  order  to  save  the 
mother.  It  is  only  in  cases  of  subsequent  haem- 
orrhage that  extraction  by  the  feet  is  carefully 
undertaken.  Dr.  Kolff  praises  that  practice,  as 
it  renders  interference  practicable  very  early  in 
the  labor,  before  the  mother  is  exhausted  by 
haemorrhage,  saves  her  from  the  risks  of  pro- 
longed plugging,  and  allows  the  later  part  of 
labor  to  continue  slowly  and  yet  without  danger. 
The  risk  of  postpartum  haemorrhage  is  thus 
greatly  lessened.  The  risk  to  the  child  is  theo- 
retically great,  yet  the  above  statistics  prove  that 
the  infantile  mortality  is  not  very  high. — Brit. 
Mat.  Journal. 

The  Management  of  the  Menstrual 
Epoch. — Dr.  A.  W.  Parsons,  of  Northampton, 
Mass.  {Netio  York  Medical  Journal),  says:  "Dur- 
ing the  past  few  months  I  have  adopted  a  proced- 
ure which  has  afforded  me  the  heartfelt  gratitude 
of  even-  woman  who  employs  it.  For  obvious 
reasons  its  use  will  be  largely  confined  to  mar- 
ried women.  A  full-sized  tampon  of  antiseptic 
cotton,  to  which  a  string  is  attached,  is  inserted 
into  the  vagina  through  a  speculum  as  soon  as  the 
premonitory  symptoms  of  the  approaching  men- 
strual epoch  are  noted.  It  may  beleft.ra  situ  for 
twenty- four  hours,  unless  the  uterine  discharge 
begins,  when  it  should  be  removed  as  soon  as  it 
is  saturated,  and  the  vagina  washed  out  with  a 
warm  antiseptic  solution  by  means  of  a  fountain 
syringe,  and  a  fresh  tampon  introduced.  This 
procedure  should  be  continued  until  the  flow 
ceases.  The  principal  disadvantage  of  this  meth- 
od is  the  difficulty  of  using  the  speculum  and 
preparing  and  introducing  the  tampon  ;  but  I 
have  met  with  no  case  where  one  or  two  lessons 
did  not  teach  the  woman  the  modus  operandi. 
Its  advantages  are  many.  There  is  entire  ab- 
sence of  odor,  no  necessity  of  wearing  the  napkin, 
and  the  sense  of  support  to  the  uterus  afforded  by 
the  tampon  is  immediate,  and  exceedingly  grate- 
ul." — Medical  Record. 


Patholog-j  . 

Relation  of  Stomach  Disorders  to  Affec- 
tions >>r  tiik  Male  Genital  Organs. — Peyer 
{Sam m lung  Klin.  Vortrage)  claims  to  have  dem- 
onstrated reflex  neuroses  of  this  kind  in  over  300 
cases.  He  points  out  the  close,  and  frequently 
observed  connection  between  disease  of  the  fe- 
male generative  organs  and  the  stomach,  and 
claims  that  a  similar  relation  is  to  be  observed  in 
the  male.  The  principal  cause  of  these  neuroses 
he  finds  in  onanism,  abusus  sexualis  and  coitus 
reservatus.  The  symptoms  relating  to  the  stom- 
ach are  atony,  gastroplegia,  nervous  vomiting, 
eructations,  cramps,  and  the  secondary  disturb- 
ances of  these  conditions.  The  diagnosis  is  often- 
times difficult,  but  may  be  made  by  the  presence 
of  the  products  of  chronic  urethritis  (urethralja- 
den  I,  and  the  so  called  Hodeneylinder  in  the  sper- 
matic urine. 

Therapy  is  to  be  especially  directed  to  relieving 
the  local  sexual  disorders,  and  the  condition  of 
the  nervous  system. 

Virulence  of  the  Supra-Renal  Capsules 
in  Rabies. — Bombicci  (Riforma  Medica)  has  de- 
termined that  the  adrenals  contain  a  considerable 
quantity  of  the  rabic  virus,  though  less  than  is 
1  found  in  the  central  nervous  system.  When  por- 
tions of  the  capsules  are  injected  into  healthy  an- 
imals it  produces  the  characteristic  phenomena  of 
rabies,  but  the  disease  is  milder  than  when  por- 
tions of  the  cerebro-spinal  axis  are  used. 

The  writer  determined  experimentally  that  there 
was  a  true  ante-mortem  accumulation  of  the  poi- 
son in  these  organs,  and  not  a  simple  post-mortem 
diffusion. 

Bacteriology. 

The  Products  of  Pathogenic  Bacteria. — 
During  the  past  two  years  great  progress  has  been 
made  in  the  study  of  the  action  of  pathogenic  bac- 
teria. This  work  has  chiefly  been  carried  on  by 
Koch  and  Pasteur  on  the  Continent,  and  by  Drs. 
Sidney  Martin  and  Hankin  in  England.  In  the 
Revue  de  Midecine,  1890,  Xo.  7,  Dr.  Charles 
Bouchard  publishes  an  article  on  the  properties 
of  the  substances  secreted  by  pathogenic  micro- 
organisms. It  contains  the  chief  part  of  his  ad- 
dress before  the  Tenth  International  Congress  on 
the  "Mechanism  of  Infection  and  Immunity." 
After  an  exhaustive  summary  of  all  that  is  known 
concerning  the  action  of  products  of  metathesis 
with  which  we  are  acquainted,  Bouchard  relates 
a  series  of  thirty-one  experiments  which  he  made, 
partly  in  order  to  investigate  the  power  which 
blood-serum  possesses  of  destroying  bacteria,  and 
partly  to  ascertain  how  far  their  products  confer 
an  immunity  against  similar  or  other  bacteria. 
Many  experiments  demonstrated  the  influence  of 
the  same  products  on  phagocytosis.  The  space 
here  is  too  limited  to  enter  into  the  details  of  this 
interesting  paper,  but  the  general  results  of  Bou- 


236 


MEDICAL  PROGRESS. 


[February  14, 


chard's  investigations  are  as  follows:  Among  the 
substances  secreted  by  the  microbes  are  some 
which  have  an  inhibitory  action  on  them — that 
is  to  say,  these  products  tend  to  retard  the  devel- 
opment, increase  and  characteristic  action  of  the 
microorganisms ;  other  substances  are  favorable 
to  their  growth.  These,  however,  only  act  indi- 
rectly by  modifying  the  material  upon  which  the}' 
grow  (peptones,  etc.).  Such  products  may  be 
favorable  or  unfavorable  for  other  microbes. 
Some  organisms  produce  poisonous  substances 
upon  which  depends  their  virulency.  Amongst 
pathogenic  microbes  are  some  which  secrete  sub- 
stances that  confer  upon  animals  inoculated  with 
them  an  immunity  against  these  particular  germs; 
this  they  do  not  by  their  presence  only,  but  by 
modifying  the  animal  organism,  so  that  it  forms 
a  less  favorable  pabulum  for  the  development  and 
growth  of  the  bacteria,  and  causes  the  leucocytes 
to  perform  the  process  of  diapedesis  more  rapidly, 
and  to  assume  their  functions  as  phagocytes  more 
energetically.  If  an  animal  be  inoculated  with 
these  substances,  together  with  a  pure  culture  of 
the  same  bacilli  from  which  they  were  obtained, 
the  disease  runs  a  more  rapid  course,  whilst  its 
development  will  be  delayed  or  prevented  if  the 
animal  be  inoculated  a  few  days  before  the  injec- 
tion is  made.  If  bacteria  which  act  antagonisti- 
cally towards  one  another  be  cultivated  together 
in  a  test-tube,  the  soluble  products  of  the  "  strong- 
er "  can  be  made  to  retard  the  development  of  the 
"weaker"  organism.  So  that  if  an  animal  be 
inoculated  with  the  products  of  metathesis  of  the 
"stronger"  at  the  same  time  as  the  active  prin- 
ciple of  the  "weaker,"  the  action  of  the  latter 
will  be  delayed  and  weakened.  Some  microbes 
appear  to  assist  the  action  of  others ;  these  Bou- 
chard terms  ' '  auxiliary  microbes. ' '  By  this  means 
an  animal  may  be  infected  with  a  disease  which  it 
would  otherwise  resist. — La?icet. 

Germicide  Action  of  the  Gastric  Juice. — 
In  the  Vratch,  Nos.  38,  40  and  41,  1890,  p.  894, 
Dr.  Boris  I.  Kianovsky,  of  St.  Petersburg, 
publishes  a  valuable  paper  on  the  subject,  em- 
bodying his  elaborate  experiments  on  fifty  per- 
sons, some  of  whom  were  healthy,  some  suffering 
from  gastric  cancer,  dilatation  of  the  stomach, 
etc.  The  author's  essential  results  maybe  sum- 
marized somewhat  as  follows : 

1.  A  fasting  healthy  stomach  always  contains 
great  numbers  of  microbes  of  various  species. 

2.  The  numerical  strength  of  such  microbes  as 
are  found  in  the  gastric  contents  an  hour  or  so 
after  a  meal  stands  in  a  direct  relation  to  the 
number  of  microbes  in  swallowed  food,  drink,  air, 
etc. 

3.  The  gastric  juice  possesses  distinct  antimy- 
cotic  properties,  which  are  to  be  attributed  main- 
ly to  the  presence  of  a  free  hydrochloric  acid. 

4.  "  Given  a  gastric  juice  of  a  normal  average 


general  acidity,  and  with  a  normal  average  pro- 
portion of  free  hydrochloric  acid,  the  secretion 
kills  the  bacteria  in  a  systematic  manner — that  is, 
the  longer  it  remains  in  contact  with  the  microbes 
the  greater  number  of  the  latter  are  destroyed." 

5.  In  the  case  of  the  juice  of  a  subnormal  acid= 
ity,  however,  the  bacteria  continue  to  steadily 
grow  in  number. 

6.  The  microbes  do  not  seem  to  take  any  part 
in  the  gastric  digestion. 

7.  In  such  sick  persons  whose  gastric  juice  still 
continues  to  contain  a  sufficient  proportion  of  free 
hydrochloric  acid,  the  secretion  proves  to  possess 
the  same  germicide  properties  as  in  healthy 
people. 

8.  Such  sick  persons  whose  stomach  elaborates 
but  trifling  amounts  of  free  hydrochloric  acid,  are 
liable  to  be  infected  through  the  organ  to  a  great- 
er degree  than  healthy  subjects. 

9.  ' '  Nobody  should  allow  his  stomach  to  re- 
main empty  for  a  long  stretch  of  time  after  morn- 
ing rising  ;  especially  medical  practitioners  should 
take  care  in  this  regard." 

10.  "In  times  of  epidemics  {e.g.,  cholera) 
everybody  should  avoid  fasting  for  a  long  period. 
It  is  advisable  to  arrange  one's  meals  in  such  way 
that  the  stomach  could  always  contain  a  certain 
quantity  of  food  (sterilized,  if  possible)." — Pro- 
vincial Med.  Journal. 

Microorganisms  in  Leukemia. — Dr.  Clau- 
dio  Fermi  (Centralbl.  fi'ir  Bakt.  u.  Parasitcnk., 
Band  viii,  No.  18,  1890)  was  able,  some  eighteen 
months  ago,  to  separate  from  the  enlarged  spleen 
of  a  man,  aged  55,  who  died  of  leukaemia,  with 
enlargement  of  the  various  organs  and  of  the 
peritoneal,  mesenteric  and  axillary  glands,  pure 
gelatine  plate  cultivations  of  an  organism  which 
appeared  as  rounded  or  oval,  white,  non-liquefy- 
ing colonies.  Inoculated  into  gelatine  in  tubes, 
the  growth  appeared  principally  at  the  surface  in 
the  form  of  a  milky-white,  thickish  layer,  grow- 
ing moderately  rapidly,  and  gradually  giving 
rise  to  slight  liquefaction  beneath.  These  col- 
onies were  made  up  of  short,  thick  rods  with 
rounded  ends,  the  centre  of  the  rod  remaining 
unstained.  At  first  he  was  inclined  to  assign  no 
special  role  in  the  production  of  leukaemia  to 
these  organisms,  but  as  he  was  unable  to  find 
them  in  similar  positions  in  twelve  other  bodies 
that  he  examined — cases  of  pleurisy,  meningitis, 
nephritis,  sarcoma,  diphtheria,  tetanus  and  ty- 
phoid fever — he  came  to  the  conclusion  that  they 
must  have  some  definite  relation  to  the  disease. 
Kelsch  and  Vaillard  have  since  then  shown  that 
these  organisms  are  pathogenic  to  rabbits,  and 
that  after  the  death  of  the  inoculated  rabbits  they 
may  be  found  in  the  blood. — Brit.  Med.  Jour. 


i89i.] 


EDITORIAL. 


237 


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Journal  ok  the  American   Medical  Association, 

No.  68  Wabash  Ave., 

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London  Office,  57  and  59  Ludgate  Hill. 
SATURDAY,   FEBRUARY    14,    1891. 


THE  HIGHLANDS  OF  MEDICINE. 

There  is  a  certain  class  of  medical  literature 
and  teaching  that  is  made  so  positive  and  dog- 
matic, as  to  create  doubts  and  suspicions  of  its 
reliability.  Many  very  good  teachers  err  in  sup- 
posing that  unless  they  state  the  facts  of  medi- 
cine in  the  most  positive  way,  it  never  can  im- 
press the  student.  Often  medical  text-books  are 
written  in  this  spirit,  and  students  and  readers 
who  accept  them  as  final,  have  much  to  unlearn 
in  after  life.  While  it  is  not  quite  true  that  the 
positive  dogmatic  man,  on  questions  of  science,  is 
a  quack,  it  is  true  that  empiricism  depends  on 
the  positiveness  by  which  it  is  proclaimed.  Dar- 
win expressed  the  truth  when  he  said  :  "Ignor- 
ance more  frequently  begets  confidence  than  does 
knowledge ;  it  is  those  who  know  little  and  not 
those  who  know  much  who  so  positively  assert 
that  this  or  that  problem  can  never  be  solved  b}' 
science." 

The  leading  teachers  and  writers  in  all  the  ex- 
act sciences,  are  particularly  noticeable  for  their 
modest  statements  of  facts,  only  claiming  that 
from  their  experience  and  the  evidence  before 
them  such  facts  appear  to  be  true.  Often  these 
leaders  of  science  differ  widely,  and  the  reasons 
for  it  are  stated,  and  the  facts  become  a  matter  of 
study  and  criticism,  in  a  spirit  and  evident  con- 
sciousness, that  on  wider  knowledge  may  show 
the  errors  of  both.  This  does  not  appear  so 
clearly  in  the  science  of  medicine.  To-day  there 
are  far  too  many  medical  teachers,  authors,  and 
journals  and  books,  that  are  down  on   the  very 


lowlands  of  science,  who  assume  that  a  fact  which 
seems  apparent,  is  final  and  unchanging;  that 
there  are  certain  great  basal  truths  in  medicine 
absolutely  fixed,  and  to  these  there  should  be  a 
steady  accumulation.  To  such  men  the  science 
of  medicine  is  merely  a  hunt  for  new  fixed  facts. 
If  certain  phenomena  occur  in  their  experience 
often,  they  conclude  that  it  is  an  absolute  fact, 
and  become  warm  defenders  of  it.  Such  men 
never  have  broad  comprehensive  views  of  medi- 
cine. They  do  not  realize  that  medicine  like 
other  sciences  is  still  very  far  down,  and  in  the 
infancy  of  its  growth.  The  anatomy  of  the  body, 
outside  of  a  few  facts,  is  unknown;  practically 
the  physiology  is  a  mass  of  unproved  hypothesis; 
the  phenomena  of  disease  and  diseased  changes 
are  equally  hypothetical  and  unknown.  In 
chemistry,  the  atomic  theory  is  still  vague  and 
uncertain,  and  altogether  theoretical.  In  materia 
medica  a  most  bewildering  mass  of  statements 
and  theories  follow  each  other,  like  the  shifting 
scenes  of  a  panorama.  Surgery  and  practice  of 
medicine  and  all  the  newer  theories  that  come  up 
in  a  night,  are  like  the  troubled  waters  of  the 
ocean,  incessantly  changing,  and  taking  on  new 
and  old  aspects.  Yet  with  all  these  theories, 
and  confused,  hypothetical  apparent  facts,  there 
is  a  tremendous  movement  towards  some  great 
central  truth,  or  ranges  of  truths,  which  can  only 
be  seen  from  a  higher  point  of  view.  Every 
medical  man  who  has  gone  up  far  on  the  frontiers  of 
medical  research  realizes  this,  and  is  startled  by 
the  fact  that  all  this  theory  and  hypothesis  in 
medicine,  are  but  stepping-stones  and  roads  of 
advance,  to  be  abandoned  farther  on.  The  phy- 
;  sician  who  from  his  inner  consciousness,  or  from 
a  mass  of  statistics,  brings  out  some  new  theory 
j  which  is  accepted  because  of  its  reasonableness, 
or  the  author's  reputation,  is  sadly  deluded  if  he 
j  supposes  he  has  found  a  final  truth.  A  few  years 
j  and  it  is  replaced  by  other  wider  theories,  and  if 
we  believe  the  modern  doctrine  of  evolution,  this 
birth  and  death  of  theories  is  only  the  advance  of 
mind  towards  the  manhood  and  Godhood  of  the 
race. 

These  views  are  illustrated  in  the  present  ex- 
citement of  a  new  remedy  for  consumption. 
Many  of  the  journals,  essays,  lectures,  and  edi- 
torials, on  this  topic  have  startled  the  reader  by 
their  positive  completeness,  and  clear  conclusion 
that  almost  a  millennium  had  arrived  for  the  poor 


238 


VARIOLA  AND  TUBERCULOSIS. 


[February  14, 


victims  of  phthisis.  Credulity  and  expectancy 
merged  into  sharp  rivalry,  to  usher  in  this  new 
era.  The  broad  scientific  statement  of  the  dis- 
coverer that  so  far,  there  were  many  reasons  for 
supposing  that  such  and  such  results  would  fol- 
low the  application  of  such  and  such  means,  and 
giving  the  experimental  evidence  on  which  he 
ventured  such  a  general  opinion,  was  the  true 
voice  of  a  scientist.  While  the  positive  excited 
statements  which  followed,  were  but  the  noise 
and  roar  of  those  far  down  in  the  valley,  unable 
to  comprehend  what  this  master  of  research,  had 
seen  higher  up. 

Most  of  the  real  advances  in  medicine  have 
come  silently,  and  after  a  time  it  becomes  diffi- 
cult to  find  the  exact  source.  Many  real  workers 
in  different  parts  have  reached  similar  conclu- 
sions, from  different  points  of  view,  and  from 
their  quiet  conservative  statements,  new  ranges 
of  facts  have  appeared.  The  noisy,  assertive 
student  who  makes  out  a  complete  theory,  and 
defends  it  sharply  in  journal  or  volume,  is  rarely 
a  true  sqientist. 

The  medical  man  who  is  on  the  highlands  of 
science  to-day,  is  never  dogmatic  or  positive,  all 
his  conclusions  and  opinions  are  stated  as  only 
apparent  truths  at  present,  but  subject  to  con- 
stant revision  and  change,  from  the  application 
of  new  facts  and  evidence.  Medical  science  is 
really  a  study  of  the  laws  of  human  evolution 
and  dissolution,  and  all  our  knowledge  of  neces- 
sity must  be  imperfect  and  open  to  error,  and 
subject  to  constant  change.  What  is  most  need- 
ed is  a  judicial  analytical  method  of  study.  Not 
a  crowding  of  statements  and  theories,  but  educa- 
tion of  the  mind  to  discern  and  compare  the  ap- 
pearances and  phenomena  of  human  life.  Hence 
positive  text  books,  lectures,  journals  and  essays 
which  assume  completeness,  in  their  theories  and 
statements,  are  obstructive  to  science.  New  dis- 
coveries, and  new  theories  and  methods  of  treat- 
ment, are  to  be  welcomed  always,  but  never  as 
final  absolute  truths.  If  this  could  be  realized 
literally,  we  should  have  no  /ads  in  medicine,  no 
popular  delusions  or  theories,  that  would  die 
away  only  to  give  place  to  others.  The  ba<  ill; 
and  each  new  theory  would  pass  the  gauntlet  of 
critical  examination,  and  quietly  take  its  place  as 
an  open  door  to  wider  realms  of  study.  Car- 
i.ysi.k's  criticism  is  unfortunately  not  untrue,  for 
many  of  the  profession  :   "  Doctors,  like  tin- masses 


of  mankind,  keep  down  in  the  valley  of  knowledge 
and  science  ;  only  a  few  ever  climb  up  the  high- 
lands and  see  the  race  march  with  the  eye  of  true 


NON-ISOLATION  IN  TYPHUS  FEVER. 
Dr.  Fl  rbringer  reports  to  the  Berlin  Medical 
vSociety  the  principal  data  concerning  the  late 
epidemic  of  typhus  fever  in  the  city  above  named. 
The  disease  sprang  up  in  January,  1890,  and  ran 
for  a  period  of  seventy-five  days.  There  were, 
in  all,  155  cases  received  at  the  hospital  ;  67  were 
males,  75  females,  and  13  were  children  under  12 
years.  The  deaths  were  males  12  percent.,  fe- 
males 8  per  cent.,  and  children  15.5  per  cent. 
Many  of  the  males  who  died  had  a  history  of  ex- 
cessive drinking.  Isolation  was  not  practiced 
with  an}'  rigidity,  and  yet  no  other  patients  con- 
tracted the  fever  ;  only  four  of  the  sisters  of 
mercy  took  the  fever,  and  one  other  attendant, 
with  no  deaths  among  the  latter.  The  excreta 
were  removed  or  destroyed  without  delay,  and 
this  Dr.  Furbringer  holds  is  the  main  point  of 
prophylaxis  whether  in  private  or  in  hospital 
practice  ;  in  importance,  it  far  outweighs  all  at- 
tempts at  isolation.  Forty-two  of  the  patients, 
when  convalescent,  were  sent  to  the  convalescent 
homes,  affiliated  with  the  general  hospital,  and 
with  good  results.  The  above  is  a  brief  abstract 
from  the  Berlin  letter  to  the  London  Lancet. 


VARIOLA  AND  TUBERCULOSIS. 
In  the  British  Medical  Journal  of  January  24, 
Dr.  Lawrence  cites  two  instances  of  remarka- 
ble recovery  from  advanced  stages  of  tuberculosis, 
seemingly  as  the  result  of  virulent  forms  of  small- 
pox. The  patients,  he  says,  were  both  young 
nu'ii  in  the  last  stages  of  pulmonary  consump- 
tion. In  each  case  there  were  large  vomicae  and 
the  patients  were  much  emaciated.  Both  the 
young  men  were  attacked  with  virulent  small- 
pox, with  very  high  temperatures.  They  were 
supported  with  stimulants  and  a  nourishing  diet, 
and  as  they  recovered  from  small-pox  the  pul- 
monary symptoms  in  each  case  began  to  disap- 
pear. They  each  made  good  recovery  and  are 
now  in  robust  health.  In  these  instances  so  well 
attested  it  becomes  a  question  of  deepest  interest 
as  to  the  manner  in  which  such  results  were  ac- 
complished. Is  there  a  small-pox  bacillus  which 
controls  the  situation,  and  is  the  weaker  bacillus 


i89i.] 


EDITORIAL  NOTES. 


239 


of  tuberculosis  overpowered  and  driven  out?  or 
by  reason  of  the  new  disease  did  the  phagocytes 
takt-  on  increased  activity  and  destroy  the  tuber- 
culous bacilli  ?  These  questions  raised  by  the 
writer  are  sure  to  attract  attention  and  in  our 
future  bacteriological  studies  we  must  confront 
the  question  as  to  how  tuberculosis  is  modified  or 
controlled  by  small-pox,  if  such  shall  be  found  to 
be  a  fact. 


EDITORIAL  NOTES. 

DISPUTED  Diagnosis. — At  a  recent  monthly 
meeting  of  the  Albany,  (N.  Y.)  Health  Board, 
Dr.  Lewis  Balch,  the  City  Health  Officer  and 
Secretary  of  the  State  Board  of  Health,  reported 
that  during  January  203  cases  of  t}'phoid  fever 
had  been  reported  to  him,  and  that  eighteen 
deaths  had  been  caused  by  it.  He,  however,  in- 
sisted that  there  was  very  little  true  typhoid 
fever  among  all  the  reported  cases.  Although 
admitting  that  it  was  more  prevalent  than  usual, 
he  said  he  did  not  know  what  to  call  the  prevail- 
ing disease,  but  still  inclined  to  the  belief  that 
defective  drainage  caused  it. 

Other  physicians,  however,  hold  that  with  but 
few  exceptions  the  alleged  cases  of  typhoid  fever 
have  occurred  in  a  section  of  the  city  that  is  sup- 
plied with  water  from  the  Hudson  River.  As 
the  fever  has  been  prevalent  in  the  cities  up  the 
river,  which  drain  into  it.  the  general  belief  is 
that  the  water  has  caused  the  disease. 

Trained  Nursing  for  the  Poor.  — At 
Brooklyn,  New  York,  there  has  been  organized, 
on  a  small  scale,  a  nursing  department  of  the  Red 
Cross  Society.  One  district  nurse  has  begun 
duty,  and  others  will  follow  if  the  plan  works 
satisfactorily  ;  she  gives  her  services  free  of  all 
charge  to  those  who  are  unable  to  employ  a  nurse. 
Her  attendance  upon  the  sick  poor  must  be  at 
the  request  of  the  attending  physician,  whose  in- 
structions are  the  invariable  guide  for  her  action. 

The  Effects  of  Koch's  Lymph. — It  is  al- 
ready evident  that  this  liquid  exerts  a  powerful 
pyroteginous  influence,  and  is  capable  of  exciting 
congestions  throughout  the  whole  system.  It  is 
stated  by  investigators  that  it  is  impossible  to  de- 
termine which  organs  shall  most  markedly  feel 
its  effects,  and  that  in  the  same  person  different 
inoculations  affect  them  differently.  Diseased 
organs  are  most  likely   to  suffer,  but   it  is   not 


necessary  that  the  affection  shall  be  of  tubercu- 
lous character.  Organs  apparently  healthy  may 
take  on  intense  congestion.  The  lungs  and 
bronchi  are  frequently  found  to  be  inflamed. 
Cases  of  myocarditis  and  endocarditis  are  reported 
in  connection  with  the  use  of  the  "lymph." 
Swelling  of  the  spleen,  and  albuminuria  are  re- 
ported as  resulting  from  inoculation,  and  several 
cases  of  haematuria  are  reported  as  lasting  from 
three  to  four  days  each.  Evidently  tuberculous 
subjects  are  not  alone  affected  by  the  inoculation 
of  the  "lymph." 

Pasteur  Institute  at  New  York. — The 
Directors  of  this  institution  held  a  meeting  Janu- 
ary 30,  to  receive  the  report  of  Dr.  Gibier,  regard- 
ing the  proposed  enlargement  of  his  accommoda- 
tions. The  building  now  occupied,  No.  178 
West  Tenth  St.,  is  most  of  the  time  over-crowded 
with  patients,  and  almost  daily  applicants  have 
to  be  turned  away.  The  Directors  voted  to  take 
steps  to  provide  more  commodious  quarters  with- 
out delay. 

The  Chicago  Medical  Society,  whose  ac- 
tion on  the  question  of  the  removal  of  The  Jour- 
nal to  Washington  appears  in  this  issue,  has  a 
membership  of  494  members. 

MEDICAL  ITEMS. 

A  recent  enumeration  places  the  number  of 
doctors  in  Vienna  at  1,315,  about  one  to  every 
1,000  of  its  inhabitants. 

The  Tubercle  Bacillus  seems  to  differ  from 
the  other  bacteria  from  the  fact  that  albumens 
alone  are  insufficient  as  nourishing  media,  but 
that  the  presence  of  glycerine  and  carbohydrates 
are  essential  to  its  growth. 

The  Death  of  Surgeon  General  Balfour, 
Honorary  Physician  to  the  Queen  of  England, 
occurred  at  Wimbledon  Park  January  17,  at  the 
age  of  78  years.  For  many  years,  and  nearly  up 
to  the  time  of  his  death,  he  had  been  a  highly 
valued  contributor  to  the  columns  of  the  London 
Lancet.  He  had  held  many  important  positions 
and  was  universally  esteemed.  The  English  jour- 
nals have  only  words  of  sorrow  and  of  profound 
respect  for  one  who  could  remember  Walter 
Scott,  and  Jeffrey  and  Allison,  Chalmers.  Wil- 
son, Christison  and,  not  least,  John  Brown,  who 
wrote  of  "  Rob  and  his  Friend," 

Bacteriological  Research  in  India. — The 


240 


MEDICAL  ITEMS. 


[February  14, 


Provincial  Medical  Journal  says  we  learn  from 
the  Indiafi  Medical  Gazette  that  Professor  Lin- 
gard,  who  has  arrived  in  India  to  take  up  the 
new  office  of  bacteriological  research  at  the  Poona 
College  of  Science,  has  been  appointed  on  the 
recommendation  of  Dr.  Cook,  after  consulting 
the  best  authorities.  The  appointment  is  made 
on  the  basis  of  a  three  years'  engagement,  and 
the  establishment  of  a  new  and  fully  equipped 
laboratory  at  Poona  is  an  event  of  very  consider- 
able interest  to  the  whole  of  India.  Dr.  Alfred 
Lingard  has  devoted  many  years  to  bacteriologi- 
cal science,  and  was  a  lecturer  on  the  subject, 
both  elementary  and  advanced,  at  the  Birkbeck 
Institution,  besides  having  also  lectured  on  phy- 
siology. Before  leaving  Europe  he  visited  the 
great  Continental  laboratories,  including  those  of 
Berlin  and  Leipsic,  for  the  purpose  of  inspecting 
the  newest  methods  of  research. 

The  American  Electro-therapeutic  As- 
sociation held  its  first  meeting,  for  organization, 
at  the  New  York  Academy  of  Medicine,  on  Thurs- 
day, January  22d.  Officers  were  elected  as  fol- 
lows :  President,  Dr.  G.  Betton  Massey,  of  Phila- 
delphia ;  vice-presidents,  Dr.  W.  J.  Morton  and 
Dr.  A.  H.  Goelet,  of  New  York  ;  secretary,  Dr. 
W.  H.  Walling,  of  Philadelphia  ;  treasurer,  Dr. 
George  H.  Rohe',  of  Baltimore  ;  councillors,  Dr. 
Horatio  R.  Bigelow,  of  Philadelphia,  Dr.  F.  H. 
Martin,  of  Chicago,  Dr.  W.  F.  Hutchinson,  of 
Providence  ;  Dr.  Frederick  Peterson,  of  New 
York,  and  Dr.  C.  D.  Palmer,  of  Cincinnati. 

The  Amsterdam  Society  of  Natural  His 
Tory  and  Medicine  celebrated  the  centenary  of 
its  foundation  on  October  15th,  when  the  gold 
medal  awarded  every  ten  years  to  the  investiga- 
tor who  has  done  the  best  microscopic  work  in 
that  time  was  presented  to  Professor  E.  Haeckel, 
of  Jena,  for  his  researches  on  deep  sea  zoology. 

The  New  Building  of  the  Medical  De- 
partment of  the  Arkansas  Industrial  Uni- 
versity.— On  the  5th  ult.  the  elegant  and  com- 
modious new  building  of  the  medical  department 
of  the  Arkansas  Industrial  University  was  occu- 
pied for  the  first  time.  There  was  no  unusual 
ceremony  attending  the  event,  but  it  marks  an 
event  of  more  than  ordinary  importance  to  the 
medical  profession  of  the  Southwest.  For  twelve 
years  the  school  has  occupied  a  handsome  build 
ing  in  Little  Rock,  on  Second,  between  Louisiana 


and  Main  Sts.,  but  as  the  structure  had  been 
erected  for  other  purposes,  the  faculty  never  felt 
quite  comfortable  in  it,  and  long  ago  determined 
to  build  an  edifice  that  would  be  a  model  of  its 
kind — handsome,  commodious,  comfortable.  The 
new  college  is  on  the  corner  of  Second  and  Sher- 
man streets,  situated  on  a  lot  50x100  feet,  the 
Duilding  being  40  X  100,  and  three  stories  high. 
The  first  story  has  a  large  lecture  hall  capa- 
ble of  seating  comfortably  250  students.  In  the 
rear  of  this  are  a  number  of  rooms  suitable  for 
all  the  uses  for  which  such  apartments  in  a  med- 
ical college  are  usualty  set  apart.  On  the  sec- 
ond story  is  the  model  amphitheatre,  as  capa- 
cious as  the  lower  lecture  room,  and  affording 
students  every  facility  and  comfort  for  witnessing 
surgical  clinics  and  demonstrations  of  all  kinds. 
Surrounding  and  in  the  rear  of  the  operating  am- 
phitheatre are  more  rooms,  well  adapted  for  the 
uses  for  which  each  has  been  selected.  On  the 
third  floor  is  one  of  the  largest,  best  lighted,  and 
most  convenient  dissecting-rooms  to  be  found  any- 
where. The  building  is  splendidly  lighted  and 
ventilated,  supplied  with  water,  gas  and  electri- 
city, and  has  a  fine  elevation. 

The  lecture- room  and  amphitheatre  are  sup- 
plied with  comfortable  and  substantial  opera 
chairs.  A  contract  has  already  been  let  for  pav- 
ing East  Second  street  through  its  entire  length. 
When  this  is  completed  the  college  will  be  pleas- 
antly accessible  by  vehicle  in  the  worst  weather, 
as  it  is  now  by  the  street  cars,  which  pass  within 
one  block.  The  patrons  of  the  college  have  in- 
creased in  numbers  and  intelligence  ever}'  year, 
until  at. the  present  there  are  nearly  a  hundred 
students  in  attendance.  The  faculty  have  done 
their  work  conscientiously,  quietly  and  well,  and 
the  thanks  of  the  doctors  in  all  thi^  part  of  the 
country  ought  to  be  given  them. — Journal  State 
Med.  Soc.  Arka?isas. 

Responsibilities  of  the  Railroad  Sur- 
geon.— The  services  demanded  by  railway  com- 
panies of  their  surgeons  are  most  exacting. 
Railway  injuries  require  immediate  attention, 
whatever  the  needs  of  the  surgeon's  private  pa- 
tients may  be.  The  injured  employe  is  never 
backward  in  exacting  services  that  cost  him 
nothing.  Under  the  impression  that  the  compa- 
ny foots  the  bill  he  is  determined  to  have  all  in 
the  way  of  attention  possible.  The  responsibili- 
ties assumed  by  the  surgeon   are  of  the  gravest 


I8yi.] 


MEDICAL  ITEMS. 


241 


nature.  If  the  injured  fails  in  making  a  case 
against  the  company,  his  next  step  is  to  com- 
mence action  against  the  surgeon,  if  he  can  find 
some  shyster  of  an  attorney  who  can  see  his  fees 
in  the  suit,  and  the  cost  of  these  suits  must  be 
borne  by  the  surgeon,  not  the  company.  The 
order  of  skill  required  of  the  railway  surgeon  is 
of  the  highest.  Of  whom  is  demanded  greater 
knowledge,  experience  and  ingenuity  than  the 
surgeon  called  to  attend  the  injured  in  a  serious 
railway  accident?  Quick  judgment,  ready  knowl- 
edge, a  skilful,  trained  hand  and  eye  are  all  requi- 
site to  one  called  upon  to  meet  an  emergency 
where  injuries  of  every  nature  and  extent  are  to 
be  met  with  and  their  necessities  relieved. — Rail- 
road Age. 

Impure  Ice  as  a  cause  of  Disease. — The 
State  Board  of  Health  of  Xew  York  has  come  to  the 
following  conclusions  as  .to  the  effects  of  impure 
ice  in  causing  disease:  "  Ice  formed  in  impure 
water  has  caused  sickness  ;  it  may  contain  from  S 
to  10  per  cent,  of  organic  matter  dissolved  in  the 
water,  and  in  addition  a  very  large  amount  of  or- 
ganic matter  that  had  been  merely  suspended  or 
floating  in  it ;  it  may  contain  living  animals  and 
plants  ranging  in  size  from  visible  worms  down 
to  the  minutest  spores,  and  the  vitality  of  these 
organisms  may  be  unaffected  by  freezing." 

Hospitals  for  Alaska.  -Dr.  Clarence  Thwing, 
of  Brooklyn,  has  accepted  an  invitation  to  estab- 
lish one  or  more  missionary  hospitals  in  the  Ter- 
ritory of  Alaska,  beginning  at  Sitka. 

A  British  Institute  of  Preventive  Med- 
icine.— Under  the  stimulus  of  the  great  discov- 
ery of  Koch  a  kind  of  uprising  has  taken  place 
in  England  in  favor  of  an  active  physiological, 
pathological  and  bacteriological  institute  for  re- 
search that  shall  be  worthy  to  be  called  a  national 
institution.  At  the  head  and  front  of  this  enter- 
prise is  Sir  Joseph  Lister,  with  numerous  influ- 
ential seconders,  such  as  Sir  Andrew  Clark,  Sir 
Spencer  Wells,  Sir  George  Paget,  Sir  James  C. 
Brown,  Jonathan  Huchinson,  Ernest  Hart, 
Professors  Humphry  Horsley,  Watson  Cheyne, 
Ray  Lankester,  Huxley.  Sir  Henry  Roscoe  and  C. 
S.  Roy.  The  exact  nature  and  scope  of  the  work 
carried  on  in  the  institute  will  necessarily  depend 
on  the  liberality  of  the  public  subscribers  to  the 
fund  or  on  the  support  granted  by  the  govern- 
ment; but  if  possible  it  is  proposed  that  the  new 


institute  shall  be  on  the  same  general  plan  as  the 
Institut  Pasteur,  which  is  also  the  plan  upon  which 
the  new  institute  for  Koch  is  in  process  of  build- 
ing at  Berlin;  that  is  it  will  not  be  exclusively 
for  research  on  the  infective  diseases  of  man  and 
animals,  but  also  for  providing  inoculant  material 
for  such  diseases  as  tuberculosis,  hydrophobia  or 
anthrax.  The  Executive  Committee  has  already 
sent  their  representative,  Mr.  E.  H.  Hankin,  to 
Berlin  for  the  purpose  of  learning  directly  from 
Koch  the  method  of  preparing  the  antitubercu- 
lous  lymph  ;  Mr.  Hankin  has  already  made  an 
enviable  name  for  himself  by  his  original  work 
on  the  means  of  conferring  immunity  against 
anthrax.  He  is  already  at  work  at  Koch's  labor- 
atory. 

The  Electric  Light. — It  is  currently  re- 
ported that  the  Queen  of  England  has  discontin- 
ued the  use  of  the  electric  light  in  her  private 
apartments,  on  the  ground  that  it  is  injurious  to 
the  eyes.  We  are  inclined  to  believe  that  this  is 
founded  on  some  misapprehension,  for  when 
properly  protected  by  opal  glass  or  by  shades,  the 
electric  light  can  be  toned  down  to  any  desired 
extent,  and  it  certainly  possesses  manj^  advan- 
tages over  gas.  It  is  more  easily  lighted  and  ex- 
tinguished, less  dangerous,  more  cleanly,  free 
from  odor,  gives  off  little  heat,  does  not  spoil  the 
air,  is  quite  as  steady,  and,  so  far  as  we  can  see, 
has  only  one  drawback — that,  namely,  of  being 
more  expensive. 

The  Imperial  Russian  Institute  of  Pre- 
ventive Medicine. — The  Institute  of  Experi- 
mental Medicine,  founded  in  St.  Petersburg  by 
Prince  Alexander  Petrovitch,  of  Oldenburg,  at  a 
personal  cost  of  about  200,000  roubles  G623,- 
000),  was  formally  opened  and  handed  over  to 
the  Imperial  Government  on  December  20.  The 
ceremony,  which  partook  largely  of  a  religious 
character,  was  attended  by  the  Ambassadors, 
several  members  of  the  Czar's  family,  and  by  M. 
Chamberland,  representing  M.  Pasteur ;  Dr. 
Pfuhl,  representing  Professor  Robert  Koch  ;  and 
Mr.  Watson  Cheyne,  representing  Sir  Joseph 
Lister.  The  Prince  of  Oldenburg  was  thanked 
by  imperial  rescript  and  appointed  Governor  of 
the  Institute,  and  the  three  delegates  having  de- 
livered brief  addresses  each  in  his  own  tongue, 
the  proceedings  terminated  with  an  entertain- 
ment given  at  the  Oldenburg  Palace. 


242 


TOPICS  OF  THE  WEEK. 


[February  14. 


TOPICS  OF  THE  WEEK. 


THE  ETHICS  OF  EXPERIMENTATION  UPON  LIVING 
ANIMALS. 

Cruelty  may  be  defined  as  the  infliction  of  suffering 
without  sufficient  reason.  To  be  humane  is  an  expres- 
sion of  the  highest  type  of  manhood  And  surely  less 
inhumanity  can  be  traced  through  the  records  of  science, 
than  can  be  found  in  the  annals  of  either  religion  or 
philosophy.  Who  is  more  altruistic,  more  practically 
philanthropic,  than  a  physician  of  the  better  class  in  his 
daily  intercourse  with  suffering  mankind?  Yet  these  men 
are  periodically  assailed  by  well-meaning  if  not  well-in- 
formed persons,  and  stigmatized  as  wantonly  cruel  for 
performing  what,  in  the  majority  of  instances,  are  but 
painless  operations  upon  otherwise  useless  animals.  An 
action  is  good,  bad  or  indifferent,  in  direct  ratio  to  its 
consequences.  Now,  those  best  able  to  judge  admit  that 
vivisection  furthers  the  progress  of  scientific  investiga- 
tion, and,  therefore,  concede  its  defensibility.  At  the  same 
time,  when  merely  a  matter  of  idle  curiosity,  it  is  held  to 
be  most  reprehensible.  Frequent  repetition  of  painless 
experiments,  however,  finds  its  justification  in  the  neces- 
sity for  objective  instruction.  No  person  will  deny  that 
science  has  conferred  incalculable  good  upon  mankind. 
Nay,  more,  the  burdens  of  the  lower  animals  are  daily 
being  lifted  by  this  modern  offspring  of  the  human  intel- 
lect. Were  it  not  possible  to  specify  an  individual  dis- 
covery directly  due  to  vivisection,  nevertheless  the  fact 
would  remain  that  the  crucial  test  of  all  hypotheses  is 
experimentation.  And  it  was  not  until  verification  be- 
came the  anchor  of  all  research  that  knowledge  ceased 
to  drift  hither  and  thither  upon  the  treacherous  sea  of 
speculation.  But  one  of  the  most  important  steps  iu  the 
advancement  of  physiological  inquiry,  the  discovery  of 
the  inhibitory  function  of  the  pneumogastric  nerve  by 
Weber,  was  the  result  of  an  experiment  upon  a  living 
animal,  audit  could  have  been  demonstrated  in  no  other 
manner.  Moreover,  this  same  method,  iu  the  hands  of 
Pasteur,  has  bestowed  sufficient  benefit  upon  the  animals 
themselves  to  more  than  compensate  for  the  suffering  in- 
flicted upon  them  in  the  interest  of  science. 

Unbridled  Nature  is  the  personification  of  cruelty,  ami 
the  few  victims  of  scientific  investigation  that  are  sacri- 
ficed for  the  welfare  of  man  are  as  nothing  compared  to 
the  multitude  that  meet  with  apparently  purposeless  de- 
struction. Certain  facts  are  beyond  the  reach  of  the 
physiologist,  except  through  these  experiments  ;  but 
since,  in  many  instances,  pain  is  a  disturbing  element, 
its  abolition  may  be  relied  upon  from  this,  if  from  no 
higher  motive.  Thehighest  order  of  man  feels  unwilling 
to  inflict  needless  suffering  upon  any  living  creature. 
How  much  right  we  have  t.>  the  lives  of  the  lower  ani- 
mals remains  an  open  question.  Ami  though,  at  this 
stage  "i  our  civilization,  it  seems  to  be  the  g<  neral  opin 
ion,  at  least  as  expressed  by  man,  that  the  animal  shall 
be  slam  for  our  needs,  still  the  causing  of  unnecessary 
pain  is  justly  reprobated.  Nearly  all  vivisections,  as 
suredly  in  our  country,  are  pet  tunned  after  tin- animals 
havi    been    rendered    insensible;    but   where  sentiment 


blindly  forms  convictions,  reason  appears  to  hold  no 
sway,  hence,  despite  the  facts  of  the  case,  these  perennial 
crusades  agaiust  a  very  necessary  method  of  experi- 
mentation. Ultra-humanitarianism  in  its  opposition  to 
scientific  advancement  is  liable  to  lapse  into  insipid  senti- 
mentality.— Dr.  Stephens.  Burt  in    The  Post-GraJuate. 


THE  CURVE  OF  HEALTH. 

Oliver  Wendell  Holmes  says  in  the  Atlantic  Monthly: 
Let  me  tell  you  one  thing.  I  think  if  patients  and  phy- 
sicians were  in  the  habit  of  recognizing  the  fact  that  I 
am  going  to  mention  both  would  be  gainers.  The  law  I 
refer  to  must  be  familiar  to  all  observing  physicians,  and 
to  all  intelligent  persons  who  have  observed  their  own 
bodily  and  mental  conditions.  This  is,  the  curve  of 
health.  It  is  a  mistake  to  suppose  that  the  normal  state- 
of  health  is  represented  by  a  straight  horizontal  line.  In- 
dependently of  the  well-known  causes  which  raise  or  de- 
press the  standard  of  vitality,  there  seems  to  be — I  think 
I  may  venture  to  say  there  is — a  rhythmic  undulation  in 
the  flow  of  the  vital  force.  The  "dynamo"  which  fur- 
nishes the  working  powers  of  consciousness  and  action 
has  its  annual,  its  monthly,  its  diurnal  waves,  even  its 
momentary  ripples,  in  the  current  it  furnishes.  There 
are  greater  and  lesser  curves  iu  the  movement  of  every 
day's  life — a  series  of  ascending  and  descending  move- 
ments, a  periodicity  depending  on  the  very  nature  of  the 
force  at  work  in  the  living  organism.  Thus  we  have  our 
good  seasons  and  our  bad  seasons,  our  good  days  and  our 
bad  days,  climbing  and  descending  in  long  or  short  un- 
dulations, which  I  have  called  the  curve  of  health.  From 
this  fact  springs  a  great  proportion  of  the  errors  of  med- 
ical practice.  On  it  are  based  the  delusions  of  the  vari- 
ous shadowy  systems  which  impose  themselves  on  the 
ignorant  and  half-learned  public,  as  branches  or 
"schools"  of  science.  A  remedy  taken  at  the  time  of  the 
ascent  in  the  curve  of  health  is  found  successful.  The 
same  remedy  taken  while  the  curve  is  in  its  dowrrward 
movement  proves  a  failure.  So  long  as  this  biological 
law  exists  so  long  the  charlatan  will  keep  his  hold  on 
the  ignorant  public.  So  long  as  it  exists  the  wisest  prac- 
titioner will  be  liable  to  deceive  himself  about  the  effect 
of  what  he  calls,  and  loves  to  think  are,  his  remedies. 
Long-continued  and  sagacious  observation  will,  to  some 
extetrt,  undeceive  him;  but  were  it.  not  for  the  happy- 
illusion  that  his  useless  or  even  deleterious  drugs  were 
doing  good  service  many  a  practitioner  would  give  up 
his  calling  for  one  itr  which  he  could  be  more  Certain 
that  he  was  really  doing  good  to  the  subjects  of  his  pro- 
fessional dealings. 

B  \K<  IN  KAUSSMANN. 
The  death  of  Baron  Haussruann,  recorded  recently,  is 
not  only  a  political  event,  but  concerns  all  who  are  in- 
terested itr  the  cause  of  sanitary  reform.  From  1853  t*  > 
[870  Baron  Haussmann  held  the  reins  of  office  as  Prefect 
ol  the  Seine  ;  and,  in  those  days  of  absolutism,  then- 
was  no  popular  control  to  check  his  actions.  The  En*. 
peioi  Napoleon  111  gave  him  a  free  hand,  and  he  set  to 
work,  regardless  oi  expense,  to  regenerate  Pans.  Broad 
boulevards  were  cut  right  through  overcrowded  districts. 


[891.] 


TOPICS  OF  THE  WEEK 


243 


Light  and  air  were  let  in  upon  quarters  where  epidemic 
diseases  had  become  endemic.  So  mighty  were  the 
changes  wrought,  that  a  new  word  had  to  be  coined  to 

describe  the  work,  and  all  Europe  talked  of  the  Hauss- 
uianni/.ation  of  Paris.  The  great  changes  effected  have 
not,  however,  proved  an  unmixed  blessing.  The  financial 
situation  they  created  supplied  M.  Jules  Terry  with  the 
lis  for  the  pamphlet  which  first  brought  him  into 
political  fame,  and  which  he  humorously  entit! 
Comptes  Fantastiques  de  M.  Haussmanu."  The  debts 
then  incurred  are  now  so  great  a  burden  that  they  pre- 
vent the  realization  of  sanitary  reforms  more  urgent  than 
those  achieved  by  Baron  Haussmann.  It  is  not  for  us  to 
criticise  the  artistic  faults  and  merits  of  the  new  Paris 
Baron  Haussmann  built.  The  aesthetic  side  of  the  ques- 
tion is  not  our  phase  of  the  subject.  Though  opinions 
widely  differ  among  artists,  sanitarians  can  only  mete 
praise  for  the  giving  of  lungs  to  the  town  by  creating  the 
beauties  and  attractions  of  the  Bois  de  Boulogne  and  the 
Buttes  de  Chaumont,  etc.  The  splendid  markets, 
slaughter-houses,  and  similar  buildings  of  public  utility 
Baron  Haussmann  caused  to  be  built,  have  greatly  con- 
tributed to  the  improvement  of  public  health.  But,  on 
the  other  hand,  there  can  be  no  doubt  as  to  the  evil 
tendency  of  sacrificing  to  external  appearances  financial 
resources  that  should  be  devoted  to  internal  improve- 
ments. The  magnificent  dwellings  raised  on  the  new 
boulevards  are  constructed  in  defiance  of  all  laws  of 
hygiene,  while  but  little   was  done  to  improve  the  sani 


and  commodious.  The  appearance  they 
present  to  the  eye  -a  combination  of  early  Gothic  archi- 
tecture, extremely  well  executed,  surrounded  by  beauti- 
ful trees  and  shrubs— is,  especially  in  summer  time,  pic- 
turesque and  pleasing.  During  the  past  year  no  fewer 
than  fifty-four  bodies  have  been  cremated.  Among  them 
may  be  named  the  late  James  Nasmyth,  the  distinguished 
engineer,  a  generous  supporter  of  the  Society;  the  well- 
known  Rev.  J.  Mai  -Naught,  of  Liverpool;  and  the  late 
Baron  Huddleston,  on  which  last  occasion  the  service, 
performed  iu  the  Society's  chapel  by  the  Rector  of  Ascot, 
was  attended  by  a  distinguished  assembly  of  relatives  and 
friends.  The  Society  is  earnestly  asking  for  support  to 
complete  their  plau  of  erecting  cloisters  for  the  recep- 
tion of  cinerary  urns.  I'or  this,  and  also  for  the  purpose 
of  promoting  the  interest  of  cremation,  by  publishing, 
lecturing,  etc.,  the  Council  of  the  Society  earnestly  ap- 
peals to  the  public  for  donations  and  annual  subscrip- 
tions. It  maybe  as  well  to  add  that  a  payment  often 
guineas  constitutes  the  donor  a  member  for  life,  and  en- 
titles him  to  be  cremated  without  charge  after  death. 
Since  the  beginning  of  the  present  year.  1891,  the  re- 
mains of  Kinglake,  the  historian,  and  of  his  Grace  the 
Duke  of  Bedford,  K.G.,  have  been  cremated.  —  British ' 
Medical  Journal. 


DR.   KOCH. 


Dr.  Koch  is  47  years  old.    After  graduating  at  the  Uni- 
versity of  Gottingen,  he  commenced  practice   in   a  little 
tary  condition  of  the  old  houses  left  standing.     Judged    villa„e  near  Hanover,  but  failed  to  make  a  living.      He 
by  external  appearances,  nothing  can  be  more  vast,  more    then  trjed  Rack„.itz>  a  sman  malarious  town  in   Prussian 


splendid  and  sweeping  than  the  new  thoroughfares  pierced 
by  Baron  Haussmann.  The  eye  is  fascinated,  the  imag- 
ination exalted,  by  these  changes,  realized  so  rapidly  as 
to  suggest  the  wave  of  a  magician's  wand  rather  than  the 
slow  evolution  of  municipal  progress.  But  there  is  a 
theatrical  element  about  this  that  fails  to  satisfy  the  scien- 
tific mind.  The  worse  consequence,  however,  was  the 
spread  of  Haussmannizatiou  to  provincial  towns,  and 
especially  to  health  resorts.  For  instance,  at  such  towns 
as  Cannes,  Nice,  etc.,  the  public  money  was  freely  spent 
to  cut  broad  boulevards,  to  raise  handsome  theatres  and 
casinos,  but  the  sewers  were  left  in  a  deplorable  condi- 
tion, and  domestic  drainage  utterly  neglected.  To  the 
credit  of  the  Third  Republic  it  must  be  acknowledged 
that  more  interest  is  now  taken  in  real  sanitary  improve- 
ments and  less   is  expended    on    mere  external   show. 


Poland,  with  no  better  results.  Finally  he  settled  in 
Wollstein,  and  in  1SS0  attracted  much  attention  by  his 
analyses  and  medical  testimony  in  the  famous  Speichert 
poisoning  case.  In  1SS2  he  discovered  the  bacillus  of 
tuberculosis,  and  in  1S83  the  germ  of  cholera  while  act- 
ing as  the  head  of  the  medical  commission  sent  by  the 
German  Government  to  Egypt  and  India  to  study  the 
causes  and  prevention  of  cholera.  On  his  return  to  Ger- 
inauv  he  received  an  honorarium  of  100,000  marks,  the 
rank  of  Privy  Councillor,  and  the  Rectorship  of  the  Im- 
perial Institute  of  Hygiene. 


DEATH  AFTER  INOCULATION  FOR  LUPUS 


Dr.  Janisch  reports  in  the    Wiener  klinische  Wochen- 
schri/t,  No.  50,  a  case  of  death  in  a  girl  of  1 7,  after  a  single 

Nevertheless,  and  iu  spite  of  all  and  numerous  criticisms    injection  of  two  milligrams  of  Koch's  lymph.     Local  re- 


to  which  Baron  Haussmann  exposed  himself,  he  gave  an 
immense  impetus  to  the  cause  of  municipal  progress. 
All  the  errors,  the  extravagances  committed,  the  political 


action  had  been  very  prompt.  The  injection  was  made 
at  nine  o'clock  iu  the  morning,  and  by  three  iu  the  after- 
noon the  region  of  the  affected  portion  of  the  face  was 


motives  that  may  have  inspired  some  of  the  improve-  swollen,  turgescent,  and  surrounded  by  a  bright  red  iu- 
ments  initiated  by  Baron  Haussmann,  will  not  suffice  to  flammatory  zone  of  the  width  of  the  finger.  The  upper 
efface  the  glorious  record  of  great  works  achieved  by  the  lip  was  livid.  These  local  manifestations  became  more 
late  Imperialist  Prefect  of  the  Seine.—  Lancet.  pronounced,  and  by  the  next  morning  the  swelling  had 

become  more  diffuse.     The  bright  red  had  given  place  to 
a  livid  color,  and   in    many   places   yellow   crusts   were 
PROGRESS  OF  CREMATION  IX  ENGLAND.  noticeable.      Dyspnoea   came  on,    weakness  of  the  heart, 

The  Cremation  Society  of  England  has  now  existed    and  death  on  the  same  evening, 
seventeen  years.     The  crematorium  and  the  building  at    injection.— Medical  R 
Woking  have  been  thoroughly  tested,  and  are  in  every 


244 


PRACTICAL  NOTES. 


[February  14, 


PRACTICAL   NOTES 


CURE    FOR    MORPHINISM. 

W.  I.  Cottel  during  the  past  six  years  has  had 
excellent  success  with  the  following  formula  : 
A  mixture  from  which  the  patient  is  easily 
weaned,  when  the  opiate  is  withdrawn  (Am. 
Pract.). 

Morphia  sulphate  or  tincture  of  opium,  q.  s. 
Fluid  extract  viburnum  prunifolium,   '2  oz. 
Elixir  of  ammonium  valerianate,  3  oz. 
Elixir  sodium  bromide  (5  grains  to  the  dr.). 
q.  s.  to  make  6  oz. 

Dose,  a  teaspoonful  when  required.  In  smell  and  taste 
this  mixture  is  truly  diabolical,  and  many  patients  are 
glad  to  give  up  the  horrible  stuff  long  before  the  opiate 
is  entirely  excluded. 


EPILEPTIC     MIXTURE. 

R.     Potass,   bromidi.  1-- 

Sodii  bromidi.      /  aa  &■  x- 

Ammonii  bromid.,  gr.  x. 

Sodii  bicarb.,  gr.  ij. 

Liq.  potassii  arsenit.,  m.  j. 

Aquce.,  ad.  JJj.     it);. 
S.     Dose,  3j. 


-Phar.  Record. 


INHALATION    IN    WHOOPING   COUGH. 

R.     Thymolis,  gr.  xx. 
Acid,  carbolici, 
Ol.  sassafragis, 
Ol.  eucalypti  kaa,  f3VJ- 

Picis  liquidfe 
Ol.  terebinthinse  J 
Aetheris,  f  5  iv. 
Alcoholis,  q.  s.  ad.  f  5  iij.     njj. 

Put  about  30  drops  upon  a  pad  of  such  a  size  as  to  be 
conveniently  hung  around  the  child's  neck,  renewing  the 
application  every  two  or  three  hours. 

In  severe  cases  the  inhalation  treatment  is  supple- 
mented by  the  internal  administration  of 

R.    Acid,  carboiici  grs.  iij. 
Sodii  bromidi  gr.  i. 
Tinct.  belladonnas  gtt.  xx. 
Glycerini,  f  3  iij. 
Aqua.',  q.  s.  ad.  f  §  ij.     njj. 

Sig.  Teaspoonful  for  a  child,  3  or  4  years  of  age,  oc- 
casionally. 

— Dr.  Beall,  Daniel ' s  Med.  Jour. 


free  from  the  discharges  of  the  wound.  If  the 
burn  is  very  extensive,  an  ointment  of  bismuth  is 
sometimes  substituted  for  the  powder. 


BISMUTH    TREATMENT    FOR    BURNS. 

Dr.  Bardeleben,  of  Berlin,  recommends  (Thera- 
peutic Gazette,  November,  1890),  the  following 
treatment  based  on  an  extensive  experience : 
Wash  the  burn  with  a  2  or  3  per  cent,  solution  of 
carbolic  acid,  or  a  3  in  1,000  solution  of  salicylic 
acid.  A  little  later  open  the  blisters  and  cover 
the  entire  surface  with  bismuth  subnitrate  in  very 
fine  powder,  and  over  this  a  thin  layer  of  ab- 
sorbent cotton.  Renew  the  dressing  as  often  as 
needed,  which  means  to  keep  the  parts  dry  and 


ECZEMA. 
R.    Zinci  oxidi,  1  ounce. 
Glycerinae,  2  ounces. 
Mucilag.  acacise,  aa,  2  ounces,     itj>. 
In  extensive  patches  of  eczema  this  paste  is  very  agree- 
able.     If  itching  is  severe   1   per  cent,  of  carbolic  acid 
may  be  added. 

— Courier  of  Medicine. 

AN    OINTMENT    FOR    CARBUNCLE. 

R.     Ichthyol,  I  drachm. 

Camphorated  lard,  l/z  ounce.     '^R. 

This  salve  is  to  be  applied  three  times  a  day 
around  the  inflamed  area,  and  if  the  surface  has 
become  broken  the  tissues  are  to  be  touched  with 
nitrate  of  silver.  It  is  said  that  the  ichthyol  di- 
minishes pain,  favors  the  resolution  of  the  swell- 
ing, and  aids  in  cicatrization. — Medical  News. 


PEROXIDE     OF     HYDROGEN     IN     CUTANEOUS 
THERAPEUTICS. 

Unna  is  quoted  by  the  Canadian  Pharma- 
ceutical Journal,  as  recommending  the  treatment 
of  comedones  by  the  following  prescription  : 

R.    Sol.  hydrogen  peroxide 

Vaseline,  of  each  2  ounces. 

Lanolin,  1  ounce. 

Acetic  acid,  1  drachm. 
Mix  thoroughly  and  perfume  as  desired. 


DELIRIUM    TREMENS    MIXTURE. 


Potass,  bromid.    1 
Sodii  bromid.        j 
Chloral,  hydrat,  gr.  x. 
Tinct.  zingiberis,  m.  x. 
Tinct.  capsici,  m.  v. 
Sp.  ammonii  arom.,  3j. 
Aqua;,  q.  s.  ad.  3  ij.     ^K 
Dose,  3  ij. 


aa  gr.  xv. 


-Phar.  Record. 


VOMITING    IN    PREGNANCY. 

R.    Bicarb,  soda,  grams  3. 

Potassium  bromide,  grams  2. 

Sodium  bromide,  grams  2. 

Ammonium  bromide,  grams  I. 

Syrup,  aurantii  carb.,  grams  30. 

Aquae  distillatae,  grams  120.    Tig. 
S.    Tablespoonful  every  two  hours  until  relieved. 

— Dr.  Wertheimer. 


INDIGESTION    WITH    FLATULENCE. 

R.    Bismuth  subnit. 
Sodium  bicarb. 
Sacch.  alba. 
Pulv.  acacia. 

Pulv.  zinzebri,  aa  .iij.     "E. 
S.    Teaspoonful  of  the  powder  dissolved  in  a  little 
water  after  eating. 


i89i.] 


SOCIETY  PROCEEDINGS. 


-45 


SOCIETY   PROCEEDINGS. 



Gynecological  Society  <>f"  Boston. 

The  215th  regular  meeting  of  the  Gynecolog- 
ical Society  of  Boston  was  held  at  No.  19  Boyls- 
ton  Place,  on  Thursday,  Oct.  9,  1890,  at  4  o'clock 
p.m.,  with  the  President.  W.  Symington  Brown, 
M.D.,  in  the  Chair. 

Thomas  P.  Jefferson,  M.D.,  of  Lowell,  Mass.. 
was  elected  to  active  membership. 

Joseph  Eastman,  M.D.,  of  Indianapolis,  Ind., 
was  elected  to  corresponding  membership. 

Dr.  Henry  O.  Marcy  read  a  paper  entitled 

IN     WHAT     CLASS     OF     WOUNDS     SHALL     WE     USE 

DRAINAGE  ?    AND    THE    PRESENT    POSITION 

OF    ANTISEPTIC    SURGERY. 

(See  page  229.) 

Dr.  Frank  L.  Burt  said  it  is  very  evident 
that  whether  we  drain  or  not  depends  altogether 
on  the  case.  We  cannot  treat  all  cases  after  the 
same  method,  vet  it  is  desirable  that  we  find  as  . 
good  a  method  as  possible  and  use  it  till  we  find 
one  decidedly  better.  There  is  no  doubt  that 
many  cases  are  drained  which  should  rather  be 
curetted  thoroughly,  so  as  to  remove  all  diseased 
tissue  and  the  surfaces  be  brought  together  by 
subcutaneous  suturing  so  as  to  get  healing  by 
first  intention.  Tissue  around  a  fistulous  tract 
should  be  removed  and  treated  in  this  manner. 
Some  abscesses,  fistulas,  tumors  of  the  breast, 
operations  on  hernia,  etc.,  can  be  treated  in  this 
way  without  drainage.  Care  should  be  taken 
against  too  much  tension  on  the  skin  and  drain- 
ing the  sutures  so  tight  as  to  strangulate  the  tis- 
sues. Oozing  of  blood  underneath  the  skin  does 
not  need  to  be  removed  by  drainage  if  it  is  from 
a  surface  which  is  aseptic.  It  is  not  always 
necessary-  to  provide  for  clots  of  blood  by  drain- 
age as,  if  aseptic,  they  need  not  cause  sepsis  and 
may  organize  or  be  absorbed.  Many  who  for- 
merly used  three  or  four  tubes  in  breast  cases  now 
use  only  one.  In  my  later  cases  I  have  used  no 
drainage  and  have  been  better  satisfied  with  the 
results.  I  advise  closure  of  the  surface  entirely 
as  I  have  described  before.  In  abdominal  surgery 
we  will  find  that  some  cases  require  drainage 
while  others  do  not.  Some  surgeons  do  not  drain 
at  present  as  often  and  in  such  cases  as  in  the 
past. 

If  there  are  many  adhesions  giving  rise  to  a 
considerable  oozing,  drainage  may  be  necessary. 
Also  bad  cases  of  pyosalpinx  or  abdominal  ab- 
scess may  cause  the  operator  to  feel  easier  if 
drained.  If  blood  oozes  into  the  abdominal  cav- 
ity or  pus  enters  it,  as  thorough  a  removal  as 
possible  b>-  means  of  absorption  had  better  be 
done  first. 

There  are  cases  which  seem  to  require  flushing 
with  hot  water.     In  case  this  is  done,  care  should 


be  taken  lest  some  of  the  pus  or  debris  which  is 
localized  should  be  washed  up  among  coils  of  in- 
testines causing  mere  points  of  sepsis.  When 
there  is  pus  or  much  blood  so  that  flushing  is  re- 
quired, drainage  had  better  be  used.  Glass  or 
rubber  tubes  are  serviceable.  The  fluid  which 
accumulates  should  be  removed  frequently  by  ab- 
sorption, cotton  on  a  wire  being  introduced  into 
the  tube,  or  if  a  rubber  tube  is  used,  which  seems 
to  me  preferable,  the  contents  can  be  sucked  up 
with  a  syringe. 

It  may  be  supposed  that  the  abdominal  wounds 
would  require  drainage  as  much  as  any,  but  if 
closed  properly,  the  method  of  suturing  in  layers 
with  animal  ligature  being  the  best,  no  drain  is 
necessary  and  the  surfaces  adhere  perfectly.  It 
is  very  evident  that  a  great  advance  has  been 
made  of  late  in  respect  to  this  subject  of  drainage. 

Dr.  Chas.  K  Cutter,  of  Charlestown,  a  guest 
of  the  society,  said  that  in  his  opinion,  locality 
has  a  great  influence  on  the  presence  of  germs. 
e.g. ,  in  the  poorer  quarters  of  the  cities-  wounds 
do  not  do  as  well  as  in  the  country  where  there 
is  less  dust  and  other  material  floating  about  in 
the  air.  Although  he  regards  cleanliness  as  an 
essential  feature,  he  could  not  help  recalling  op- 
erations in  which  he  had  formerly  assisted  a 
Charlestown  physician  who  had  sometimes  opened 
the  abdominal  cavity  without  even  taking  the 
natural  precautions  of  washing  his  hands  and  no 
antiseptics  were  used.  He  remembered  one  op- 
eration in  which  four  assisting  physicians  had 
successively  introduced  their  fingers  into  the 
wound  to  establish  a  diagnosis  and  the  patient 
recovered.  He  always  uses  drainage  after  open- 
ing a  mammary  abscess.  He  referred  to  the  re- 
markable antiseptic  properties  of  Merck's  new 
substance,  pyoktanin,  and  spoke  of  se\-eral  in- 
stances in  which  he  had  seen  it  successfully 
applied. 

Dr.  Geo.  W.  Jones  said  that  he  had  been 
much  interested  in  the  paper,  and  that  he  agreed 
with  the  ideas  of  Dr.  Marcy  on  the  matter  of 
drainage  as  expressed  therein. 

Dr.  A.  L.  Xorris  said  that  he  had  of  late 
used  drainage  very  little  indeed,  and  if  he  has  had 
recourse  to  any  thing  he  has  used  for  this  purpose 
a  few  strands  of  catgut  ligature.  He  referred  to 
the  operations  which  he  had  seen  Mr.  Tait  per- 
form in  Berlin. 

Dr.  C.  E.  Prior  said  that  he  had  watched 
with  much  interest  the  wordy  war  which  has 
been  waged  over  antiseptics.  He  believes  that 
the  followers  of  both  Tait  and  Lister  are  on  the 
same  ground  however  much  they  may  seem  to 
differ.  Both  cleanliness  and  excellent  surgical 
skill  are  essential  to  good  results. 

Dr.  James  P.  Elliott  believes  that  both 
cleanliness  and  good  judgment  are  necessary  to 
obtain  union  by  first  intention. 

Dr.  C.  W.  Stevens  thinks  that  the  statement 


246 


SPECIAL  CORRESPONDENCE. 


[February  14, 


that  all  abscesses  should  be  drained  is  too 
broad.  Large  ones  should  be  drained,  but  small 
ones  should  not.  It  is  possible  to  withdraw  the 
pus  by  means  of  a  hypodermic  needle,  after 
which  the  cavity  can  be  washed  out  with  a  solu- 
tion of  corrosive  sublimate,  1  to  4000,  and  then 
with  iodoform  emulsion. 

Dr.  A.  E.  McDonald  recently  treated  two  ab- 
scesses on  the  same  child.  The  one  treated  with 
drainage  did  better  than  the  one  treated  without 
drainage. 

Dr.  H.  C.  White  said  that  Dr.  Marcy  gives 
his  opinions  boldly  and  clearly,  and  that  his  suc- 
cess in  treating  wounds  is  due  to  the  same  bold- 
ness and  clearness,  as  exampled  by  the  closure 
layer  by  layer,  even  the  edges  of  the  skin  being 
accurately  approximated.  There  can  hardly  be 
haemorrhage  possible  when  the  operation  is  done 
in  this  way.  Perfect  coaptation  just  tight  enough 
and  not  too  tight  is  important.  The  discussion 
between  Tait  and  Lister  is  now  chiefly  of  words 
and  not  pi  opinions.  Both  believe  in  clean  asep- 
tic wounds.  Marcy  has  made  advances  and  got, 
ahead  of  his  teacher,  Mr.  Lister. 

Dr.  W.  S.  Brown  said  that  Sir  Joseph  Lister's 
modesty  and  thorough  honesty  is  admirable. 

Dr.  Marcy  in  closing  the  discussion  said  that 
he  had  seen  much  of  these  men  (Tait  and  Lister) 
during  the  past  summer,  They  have  agreed  to 
disagree.  Tait  has  fought  every  one  who  has 
disagreed  with  him.  Dr.  M.  believes  that  Tait 
is  now  broadening  in  spirit. 

PATHOLOGICAL  SPECIMENS. 

Dr.  Burt  presented  a  specimen  of  double  ova- 
rian tumors.  The  case  was  of  special  interest 
because  of  the  difficulty  of  diagnosis.  It  had  been 
considered  for  several  months  as  a  case  of  version 
which  did  not  improve  under  treatment  by  means 
of  applications,  tampons,  pessaries,  etc.  The 
uterus  was  found  rather  high  up,  toward  the  right 
and  forward.  The  left  ovary  could  be  outlined, 
enlarged  to  the  size  of  au  egg,  and  somewhat 
prolapsed.  No  ovary  could  be  detected  on  the 
right  side.  A  mass,  the  size  of  a  fcetal  head,  was 
found  behind,  below  and  to  the  left  of  the  uterus, 
seeming  to  be  in  the  left  broad  ligament.  This 
large  mass  was  the  right  ovary  with  cyst,  which, 
being  displaced  had  become  adherent  so  as  to 
appear  to  be  on  the  left  side.  The  relief  after 
operation  was  as  usually  experienced  in  such 
cases. 

Dr.  I*.-,  u  [o  Martinez,  of  Laredo,  Texas,  at 
one  time  a  general  in  the  Mexican  Army,  a  politi- 
cal exile,  a  great  traveler  and  an  author  of  ability, 
while  making  the  rounds  among  his  patients  on 
the  morning  oi  February  3,  was  waylaid  by  two 
mounted  men  near  the  Mexican  National  I 
and  shot  to  death.  The  assassins,  supposed  to 
have  come  from  Mexico,  escaped. 


SPECIAL  CORRESPONDENCE. 


Hypnotism— Facts  and  Reports  of  Cases  in 

the  Early  Experience  of  one  of  its 

Former  Practitioners. 

To  the  Editor: — Several  articles  have  of  late  appeared 
in  The  Journal  upon  hypnotism,  and  there  seems  to  be 
a  general  interest  among  the  profession  upon  this  sub- 
ject. Though  a  permanent  member  of  the  American 
Medical  Association  for  man)*  years,  and  an  attentive 
reader  of  every  number  of  The  Journal,  I  have  never 
contributed  anything  to  its  columns.  I  come  forward 
now  and  offer  this  communication  with  great  reluctance 
and  onlv  because  I  deem  it  a  duty  to  my  professional 
brethren,  to  give  them  some  benefit  of  my  investigations 
and  experience  in  the  therapeutic  application  of  this  po- 
tent and  subtle  agent. 

In  the  year  1841,  while  an  under  graduate  and  a  hospi- 
tal attendant,  in  the  ward  where  I  was  employed  one  of 
the  patients  was  a  sea  captain,  wdiose  home  was  in  an 
obscure  New  England  town.  This  captain  couceived  a 
strong  attachment  for  me,  and  when  ready  to  leave  for 
home,  insisted  that  I  should  accompany  him.  Being 
weary  with  several  months' close  confinement,  I  obtained 
leave  of  absence  and  went.  Once  there,  he  dubbed  me 
"Doctor"  and  introduced  me  as  such  to  his  neighbors 
and  some  three  or  four  practicing  physicians  in  his  own 
and  surrounding  hamlets. 

I  was  soon  called  upon  to  treat  the  sick  and  was  com- 
pelled to  engage  in  practice,  or  to  ignominiously  desert 
my  friend  and  forego  his  hospitality.  I  chose  the  former. 
This  I  did  by  the  advice  and  promised  aid  of  one  of  the 
most  skilful  and  popular  physicians  in  that  neighbor- 
hood. 

This  physician,  in  addition  to  the  usual  drug  treatment, 
practiced  hypnotism,  or  as  it  was  then  called,  mesmer- 
ism, or  animal  magnetism.  Becoming  close  friends,  we 
spent  much  time  together,  visiting  patients  and  receiv- 
ing and  imparting  information.  One  of  the  most  fruitful 
subjects  of  our  discussion  was  animal  magnetism,  and  he 
finally  persuaded  me  to  engage  in  experimental  exam- 
ination of  it. 

By  his  instructions  and  assistance,  I  was  soon  not  only 
practicing  medicine  but  mesmerism  as  well.  For  five 
years  that  followed  I  was  one  of  the  most  industrious 
practitioners  of  the  healing  art  in  that  section  of  the 
country.  Then,  my  trusted  friend,  teacher,  and  con- 
fi  derate  suddenly  departed  between  two  days,  leaving  .1 
wife  and  children  unprovided  for,  but  taking  with 
him  one  of  his  female  mesmeric  subjects.  This 
occurrence  was  au  overwhelming  blow  to  me,  and 
gathering  up  my  available  means  departed  ;  attended 
medical  a  >llege,  graduated  and  wended  my  way  westward, 
and  have  since  pursued  the  regular  practice  of  medicine, 
at  time  I  have  never  publically  practiced,  or  ad- 
vocated hypnotism  under  any  of  its  aspects  or  names. 

This  narrative  seems  .1  necessan  introduction  to  what 
I  wish  1"  contribute  for  the  benefit  of  those  who  are  in- 
terested ill,  and  are  now  investigating  modern  hypnotism. 

Had  I  made  and  preserved  full  notes  of  all  the  cases  I 
treated  b)   this  agent,  in  those  live  fruitful  years.  I  would 
be    able    now    to  give    many    interesting    and    instructive 
1  cases  that,  in  the  lapse  of  nearly  half  a  cen- 
tury,  have  either  entirely  faded   from   my   memory,  or 
1  much  obscured  as  to  render  an  accurate  ac- 
count of  them   now  impossible.     Many    of  these  cases, 
it  men  t  and  the  results  are,  however,  indelibly 
ed  upon  my  memory;  and  from  these  I  can  bring 
it    variety  and   number  to  illustrate  the  more 
prominent  qualities  of  therapeutical  hyp- 
notism. 

During  the  prevalence  of  an  epidemic  of  111a- 
dj  sentery,  a  lad  of  9  Fected   with 


i8oi.] 


SPECIAL  CORRESPuXDKNCK. 


24; 


this  nialadv  had  been  given  up  as  incurable  bv  physician  before,  and  after  a  persistent  effort  finally  engaged  her 

and  family  and  not  erpected  to  survive  the  ensuing  night  attention  and  -non  had  her  under  hypnotic  influence,  m 

The  boy  insisted  that  I  should  be  called,  and  on  reaching  which  condition   she  was  put  to  bed  and  kept  in  it  un- 

his   bedside   and  making   a  careful  examination,  I  told  der  observation  for  fifteen  hours;  all  this  time  remaining 

him   if  he  could    yield  to   me  and  sleep,  I  thought  he  perfectly  quiet.     Her  temperature,  pulse  and  respirations 

would  recover.      Placing  one  hand  on  his  abdomen  and  gradually  returned  to  normal.       Before   awakening  she 

the  other  011  his  head,  I  exerted  all  my  will  power  in  the  was  told  ami  impressed  that  she  must  take  absolute  rest 

effort  to  hypnotize  him.      The  tormina  soon  grew  less,  for  a  week,  and  only  think  of  the  painful  occurrence  that 

restlessness  abated  and  in  half  an  hour  he  was  bypnot-  gave  her  the  shock   as  something  that  happened  long 

iaed.      I  sat  bv  his  bed  and  kept  him  asleep  forsix  hours,  ago.     After  she  awoke  she  remained  quiet  and   self-pos- 

On  awaking  a  bilious  evacuation  followed,  with  neither  sessed.  and  made  a  speedy  and  complete  recovery  with- 

blood  nor  mucus.      I  then   again  hypnotized  him  and  out  anv  medicatiou. 

kept   him  asleep  the  whole  night.    '  He  awoke  in  the  Other  cases  might  be  given,  but  these  will  suffice  for 

morning  more  decidedly  convalescent,  rapidly  recovered  the  present. 

with  no  medication,   except  some  placebos  and  proper  This  narrative  and  report  of  cases  are  but  an  introduction 

diet,  and  is  living  to-day.  a  man  of  wealth  an   influence  orprefaceto thesubject.asitappearstome.  Thefield opens 

in  both  Church  and  State.  broad  and  fruitful  and  will  amply  repay  the  careful  and 

Oat  ?.— A  voung  lady,  about  19  years  of  age,  had  been  thorough  explorer.      If  those  members  of  the  profession 


under  treatment  for  more  than  a  year,  by  two  good  phy- 
sicians, and  was  considered  incurable.  Her  disease  was 
a  very  severe  case  of  bronchitis,  thought  to  be  of  tuber- 
cle origin  and  her  lungs  already  involved.     She  coughed 


who  are  interested  in  this  subject  desire  it,  more  may  be 
said,  in  which  the  principles,  modes  of  application,  the 
possibilities  of  its  therapeutic  employment,  and  the  moral 
and    physical    responsibilities   resting    upon    those    who 


almost  incessantly  while  awake  and  did  not  sleep  to  exceed    would  practice  it,  will  be  discussed 


thirty  minutes  at  a  time,  on  this  account;  was  expector- 
ating freely  and  rapidly  emaciating.  At  this  stage  of  her 
case  I  was  called  in  to  make  a  trial  of  hypnotism.  After 
a  few  sittings  she  was  profoundly  hypnotized — the  con- 
stant cough  and  expectoration  greatly  interfering  in  its 
accomplishment.  I  kept  her  asleep  some  two  hours  at 
first,  during  which  there  was  neither  cough  or  expector- 


Quincy,  111. 


M.  F.  BASSETT,  M.D. 


Chromic  Acid  Treatment  of  Chronic  En- 
largements of  tlie  Tonsils. 

To   the   Editor: — Miss   G.   M.,  at.   17,  very  small   in 
anon^GaveYe'rdaUysitttara^  stature,  been  delicate  for   several  years.     Tonsils   very- 

period  of  sleep,  then  leaving  her  in  that  condition  with  large,  caused  breathing  through  the  mouth  nearly  entire- 
instructions  to  wake  at  a  certain  time,  which  she  always  1>'.  They  pressed  against  each  other  closely.  Made  a 
did.  Then  I  changed  the  sittings  to  the  hour  of  bed-  puncture  with  a  small  bistoury  in  one  tonsil,  then  with 
time  and  told  her  to  sleep  till  morning.  While  this  treat-  ;  a  regular  acid  probe  I  heated  or  melted  chromic  acid 
ment  was  progressin 


there  was  a  constant  daily  im- 
provement in  all  her  symptoms.  At  length  she  was  so 
much  under  control  that  she  would  obey  me  by  falling 
asleep  at  a  future  hour  and  remaining  in  it  as  long  as 
directed.  Finally  she  would  fall  asleep  and  wake  on  speci- 
fied times,  each  day.  for  three  days  in  succession,  with- 
out being  visited,  which  greatly  lightened  my  labors.    In 


crystals  over  a  gas  jet,  until  I  had  a  nice  smooth  ball 
about  the  size  of  a  small  pea.  which  I  carried  into  the 
punctured  tonsil.  Letting  it  remain  a  very  short  time 
after  taking  the  probe  out,  I  took  up  all  excess  of  acid 
about  the  tonsil  with  absorbent  cotton.  The  third  day 
the  patient  presented  herself  with  a  large,  deep  slough 
from  the  centre  of  tonsil.     After  that  healed  I  repeated 


less  tban'three  months  a  perfect  cure  was  effected  in  this  the  operation  in  the  other  tonsil,  and  continued  until  I 
aggravated  case,  without  anv  medication:  and  I  mav  add  '  had  reduced  them  three  fourths  their  size.  I  have  used 
that  more  than  thirty  years  afterward  I  saw  this  patient  this  remedy  in  six  or  eight  equally  severe  cases,  and  with 
with  husband  and  grown  children,  a  perfect  picture  of,  equally  good  results.  Let  us  know  if  others  have  had  a 
health,  and  was  assured  bv  her  that  she  had  not  in  all  Hke  experience.  Mine  were  cases  where  the  patients 
these  vears  suffered  from  'anv  disease  whatever.  would  not  submit  to  excision.     As   there  was   no   pain 

Case 3.— A  middle  aged  m'an,  far  advanced  iu  pulmon-    with  this  mode  of  treatment,  it  mav  commend  itself  to 
tuberculosis,  applied  to  me  for  hypnotic  treatment,    others  where  surgical  procedure  is  denied, 
examination  I  told  him  there  was'no  cure  known  for  F    E-   1OAKIM. 


ary 

( >n  exauiiu 

his  case.  He  replied  that  he  was  fully  aw  are  of  that,  but 
from  what  he  had  learned,  thought  his  condition  and 
sufferings  might  be  ameliorated  by  hypnotism.  I  found 
him  an  easy  subject  and  hypnotized  him  daily  for  several 
weeks,  and  every  sitting  improved  his  condition.  The 
small  haemorrhages,  of  which  he  ha  i  had  many  at  short  in- 
tervals,  ceased.      The  amount  of  pus  expectorated  de 


Shreveport,  La. 


Snail  The  Journal  he  Removed  t<> 
Washington  ? 

THE  ACTION  OF  THE  CHICAGO  MEDICAL  SOCIETY. 

To  the  Editor: — At  the  January  19  meeting  of  the  Chi 
creased:   night  sweats  and   diarrhoea  disappeared;  diges-    Cago  Medical  Society  a  committee  was  appointed  to  con 
tiou  improved  and  he  materially  increased  in  flesh  and 
strength        I  found  the  treatment  of  this  case  very  ex- 


hausting to  me  and  a  severe  drain  upon  my  vitality.       I 
lost  flesh  and  strength  and  other  symptoms  alarmed  me 


sider  the  matter  of  removing  The  Journal  of  the 
American  Medical  Association  from  its  present  loca- 
tion. After  considering  the  matter  the  committee  re- 
ported at  the  February  2  meeting  and   recommended  the- 


and  caused  me  to  suspend  my  hypnotic  efforts  in  his  be-  I  passage  of  the  following  resolutions,  which  were  unani 

half     With  some  medication,  he  went  on  improving  for    mously  adopted  : 

a  time,   and   he   thought   he   was   recovering.       Several 

months  afterwards,  while  fishing  in  a  skiff,  he  hooked  a 

very  large  one,  and  in  the  effort  to  capture  it  a   violent 

haemorrhage  came  on  and  he  died  before  his  companion 

could  pull  the  craft  to  land. 

Case  4. — A  married  woman,  about  30  years  of  age.  after 
a  long  seige  of  house  cleaning,  received  a  severe  mental 
shock.  She  was  seized  with  a  sudden  and  severe  chill 
followed  by  fever  and  delirium.  The  next  day  she  was 
violent  and  unmanageable  and  I  was  called.  It  was  then 
a  case  of  acute  mania.     I  had  hypnotized  hersome  years 


That  the  Chicago  Medical  Society  as  a  body  is  opposed 
to  the  removal  of  The  Association  Journal,  deeming  that  such 
change  is  unnecessary,  at  the  present  time,  and  contrary  to  the 
best  interests  of  The  Journal  and  the  Asss.  ciation,  and  be  it 

That  the  delegates  from  this  Society  to  the  forthcoming 
meeting  of  the  American  Medical  Association,  be  and  are  hereby 
instructed  to  oppose  such  removal,  and  be  it  further 

That  the  committee  appointed  at  the  last  meeting  be 
continued  to  take  such  action  as  they  deem  wise,  in  furthering  the 
object  of  this  res->lution.  also  that  a  copy  of  these  resolutions  be 
spread  upon  the  records,  and  transmitted  to  the  medical  press  o£ 
the  country. 

J.  C.  Hoac.  M.D.,  Sec'y. 

Chicago.  Feb.  6.  1S91. 


248 


SPECIAL  CORRESPONDENCE. 


[February  14, 


To  the  Editor: — I  am  of  the  opinion  that  there  is  no 

good  reason  for   moving   The  Journal  office.     I   think 

Chicago  is  the  most  suitable  place  for  it.       I   vote  for  it 

to  remain  in  Chicago,  for  that  to  be  its  permanent  home. 

H.  H.  Dark,  M.I). 

Caldwell,  Texas,  Jan.  30.  1S91. 


To  the  Editor: — I  prefer  to  see  The  Journal  continue 
its  publication  in  Chicago.  Besides  the  superior  facili- 
ties of  communication  with  all  parts  of  the  country,  the 
ambition  to  excel  all  competing  cities  in  laudable  enter- 
prises that  give  prosperity  to  a  city,  which  prevai 
may  sharpen  editorial  energy  to  make  it  the  best  medi- 
cal journalin  the  world.  \V:.i.  Lom  ax.  M.D. 

Marion,  Iud.,  Feb.  2,  1S91. 


To  the  Editor: — I  prefer  Chicago  as  the  location  and 
home  of  our  journal  for  one  good  reason,  in  addition  to  the 
many  others  already  stated  by  numerous  correspondents.  I 
believe  the  Eastern  members  of  our  profession  are  tainted 
with  heretical  opinions  as  to  the  propriety  and  practica- 
bility of  our  "Code  of  Medical  Ethics"  as  a  guide  to  the 
highest  honor  and  truest  success  of  the  profession.  Wit- 
ness the  heterodox}-  through  which  we  have  only  recently 
passed  and  fresh  in  the  minds  of  all. 

This  reflection  is  not  meant  to  impugn  the  characters  of 
Eastern  members  generally — simply  as  a  statement  of  a 
deplorable  fact,  as  to  a  few  in  high  places. 

GUSTAVDS  S.  Franklin.  A.M.,  M.I). 

Chillicothe,  O.,  Feb.  3,  1S91. 


To  the  Editor: — Though  living  in  the  East  and  wish- 
ing it  to  prosper;  yet  I  wish  to  be  understood  as  advo- 
cating Chicago  as  the  place  for  The  Journal.  i.  Be- 
cause of  its  central  location.  2.  Because  it  is  a  great 
medical  centre.  3.  Because  the  next  decade  will  witness 
it  the  largest  city  in  America.  4.  Because  The  Journal 
is  ablv  edited  in  Chicago  and  is  prosperous,  not  political 
nor  prejudicial  to  sections.         C.  G.  Cannaday,  M.I). 

23  Salem  ave.,  Roanoke,  Va.,  Feb.  3,  1S91. 


To  the  Editor: — I  do  not  think  the  time  has  come,  or 
in  fact,  ever  will  come,  when  our  journal  should  be  re- 
moved from  Chicago.  This  child  of  our  creation  was 
born  under  trying  circumstances,  and  I  hope  it  has 
passed  all  the  straits  of  its  birth,  and  now  at  an  age  well 
on  its  feet,  walking  alone.  Chicago,  I  believe,  should  be 
its  home.  Thomas  H.  Briggs,  M.D. 

Battle  Creek,  Mich.,  Feb.  5,  1S91. 


To  the  Editor: — In  the  absence  of  any  sufficient  reason 
for  changing  the  publication  office  of  The  Journal  OF 
Tin:  American  Medical  Association  from  Chicago  to 

Washington,  I   wish   to  record  my   vote   in   favor  of  its 
present  location.  J.  W.  Ferguson,  M.D. 

Canaan,  O.,  Feb.  7,  1891. 


'To  the  Editor: — I  am  greatly  surprised  at  the  letter  of 
Dr.  Solis-Cohen  in  The  Journal  of  January  31.  I  ad 
mit  that  Tin.  Journal  has  not  reached  the  standard  "I 
excellence  which  the  profession  have  a  right  to  expect. 
I  am,  however,  satisfied  that  "sectional  prejudice"  and 
personal  ambition  in  Philadelphia,  New  York  and  Wash- 
ington, have  had  not  a  little  to  do  with  this  lowering  nf 
idard.  I)r.  Solis-Cohen  makes  the  assertion  that 
the  removal  to  Washington  would  overcome  all  the  pres- 
ent difficulties. 

Washington  is  not,  and  cannot  be  a  centre  for  this 
country.  Even  the  political  conventions  are  not  held 
there,  and  the  only  thing  that  preserves  it  as  the 
National  Capital  is  the  amount  of  money  expended  in 
permanent  government  improvements. 


Perhaps  The  Journal  would  not  in  Washington  be 
debased  to  a  "  local  "  organ,  but  what  assurance  would 
we  have  that  it  would  not  be  practically  debased  to  the 
uses  of  some  one  service  of  the  government.  For  ex- 
ample :  With  the  official  organ  of  the  profession  under 
control  how  easily  might  a  Marine-Hospital  surgeon  an- 
nihilate a  National  Board  of  Health.  For  one  I  prefer  a 
"local  "  medical  journal  to  the  tool  of  a  political  ring. 

I  am  opposed  to  removal  of  The  Journal  : 

1.  Because  such  removal  of  plant  would  be  expensive. 

2.  Because  such  removal  would  result  in  loss  of  adver- 
tising patronage. 

3.  Because  there  is  not  the  slightest  assurance  that 
such  removal  would  improve  the  personnel  of  the  edi- 
torial board. 

4.  Because  such  removal  would  not  increase  facilities 
for  good  work. 

5.  Because  such  removal  would  cause  loss  of  sub- 
scribers. 

6.  Because  such  removal  would  make  The  Journal  a 
local  journal,  out  of  sympathy  with  the  profession  of  the 
country. 

The  East  has  three  good  medical  weeklies,  the  Medical 
News,  the  New  York  Medical  Journal,  and  the  Medical 
Record.  The  West  has  none.  The  removal  of  The 
Ji  M  kNAi.  to  Washington  would  immediately  result  in  the 
establishment  of  a  high  grade  Chicago  weekly,  which 
would  largely  decrease  the  advertising  and  subscription 
patronage  of  The  Journal. 

Permit  me  to  suggest  that  The  Journal  would  be 
more  improved  by  having  an  editor  for  each  Section  of 
the  Association,  than  by  its  removal.  These  sectional 
editors  should  take  turn  in  getting  out  successive  num- 
bers of  The  Journal,  under  the  supervision  of  the 
Editor-in-Chief,  until  the  work  of  the  meeting  is  finished, 
and  thereafter  these  sectional  editors  should  have  super- 
vision of  papers  in  their  special  departments.  If,  for  ex- 
ample, at  a  sectional  meeting  there  are  five  papers  read 
on  peritonitis,  publish  them  together,  followed  by  dis- 
cussion, as  is  done  in  the  British  Medical  Journal. 

Henry  B.  Hkmknway,  M.D. 

Evanston,  111.,  Feb.  9,  1891. 


To  the  Editor : — I  am  profoundly  opposed  to  the  re- 
moval of  The  Journal.  Chicago  is  central  and  has 
talent  to  edit  the  same  as  well  as  Washington,  Boston  or 
New  Ysrk.  A.  G.  PORTER,  M.D. 

Lebanon.  Ind.,  Feb.  9,  1S91. 


To  the  Editor: — As  a  member  of  the  A.  M.  A.  I  am  de- 
cidedly opposed  to  the  removal  of  The  Journal  to 
Washington,  or  to  any  other  point  at  present.  I  am  also 
opposed  to  locating  our  annual  meeting  at  any  one  point. 
By  all  means  let  the  Association  remain  National  in  char- 
acter, and  let  it  itinerate,  gathering  new  members  from 
all  parts  of  our  country.  To  permanently  locate  the 
annual  meeting  somewhere  in  the  East  or  South,  would 
be  practically  inviting  our  brethren  on  the  Pacific  slope 
to  withdraw,  which  they  would  probably  do. 

I  yote  to  let  The  Journal  remain  in  Chicago  until 
after  the  Columbian  exposition  at  least,  and  let  special 
inducements  be  offered  all  visiting  physicians  in  good 
standing   to   visit    the    editor    and    subscribe    for    The 

Ji'I    RNAL. 

I  have  no  fault  to  find  with  the  present,  or  past,  man- 
agement of  The  Journal.  C.  N.  I'dkll,  M.D. 
Blakesburg,  Iowa,  Feb.  9,   1S91. 


To  the  Editor.— The  fact  that  Washington  City,  with 
all  her  macroscopic  advantages,  has  never  produced  a 
mi  dical  journal  "National"  either  in  character  or  repu- 
tation, is  the  very  reason  why  she  is  just  the  place 
which  can  do  it.  Every  process  attending  the  production 
of  a  journal,  composing,  printing,  sewing,  etc.,  is  directly 


•  8oi.] 


SPECIAL  CORRESPONDENCE. 


249 


the  result  ol  bai  terial  action  on  the  part  of  germs  which 
are  indigenous  to  certain  t>  pographical  and  other  trades 
unions.  Likewise  towns  are  permeated  and  dominated 
by  microorganisms  which  determine  the  character  of 
their  habitat — c.  g.,  Chicago  money  is  infested  by  mi- 
crobes which  stimulate  commercial  activity,  while  the 
New  York  microbe  inhibits  the  building  of  monuments, 
etc.  The  patent  fact  that  for  seven  and  one  half  years 
The  Journal  has  succeeded  measurably  in  1 
the  very  reason  whj  it  cannot  succeed  there;  because  the 

entire  environment  is  now  reeking  with  these  ptomaines 
produced  by  these  provincial  and  "wild  and  wooley" 
microbes,  the  alkaloidal  intoxicants,  resulting  from  past 
editorial  and  business  management,  as  it  wen-,  and  even 
though  the  Trustees  may  succeed,  that  success  is  onh 
clinical,    and   flies    directly   in    the    face   of    all   scientific 

prognosis. 

This  may  not  be  perfectly  clear  to  some,  but 
ber,  Mr.  Editor,  this  is  a  contribute  t1  bacteri- 

ology and  must  be  made  to  harmonize  with  all  | 
tradictory  investigations  as  well  as  to  anticipate  all  future 
discoveries.  Xo  man  knows  what  discovery  he  may  de- 
sire to  claim  before  another  moon  wanes.  Now,  Wash- 
ington City  is  aseptic,  is  tree  from  Nationalmedicaljour- 
nalism.  and  if  a  bran  new  publication  plant— sterilized — 
be  set  up  in  properly  disinfected  quarters,  and  the  man- 
agement be  inoculated  with  a  lymph  derived  from  only  the 
■worst  features  of  the  mi  1st  pn  ivincial  medical  journals  until 
they  cease  to  show  reaction  under  the  treatment,  I  think 
success  would  be  assured.  I  fear  but  one  thing;  infection 
by  the  pathogenic  germ  of  the  Congressional  Globe. 
Doubtless  some  such  idea  as  this  actuated  Dr 
Cohen,  for  he  certainly  would  not  be  guilty  of  an  ad  cap- 
tandutn  argument. 

Seriously,  but  two  considerations  should  weigh  in  an- 
swering the  question  of  removal:  the  success,  financial 
and  otherwise,  of  The  Journal,  and  the  preference  of  a 
majority  of  its  owners. 

In  their  report  made  at  the  Nashville  meeting  the  Pub- 
lication Board,  composed  of  nine  eminent  gentlemen 
representing  the  country  from  Maine  to  Arkansas,  and 
including  Washington  City,  stated  that  although  they 
"have  at  different  times  invited  competitive  bids  for  its 
publication  in  other  cities,  but  always  with  this  uniform 
result,  that  it  can  be  issued  cheaper  in  Chicago  than  else- 
where."— The  Journal,  Vol.  xiv,  page  799. 

Again,  an  editorial  note  in  The  Journal.  Vol.  xvi, 
page  204,  states  that  of  the  total  income  of  The  Journal 
from  all  sources  in  the  entire  United  States,  "one-seventh 
of  that  amount  comes  from  Chicago  alone."  A  compari- 
son between  the  two  cities  in  this  respect  would  be  un- 
just to  both  places.  Probably  in  no  other  city  could  The 
Journal  attain  the  relative  business  success  it  has  in 
Chicago,  because  of  competition  already  occupying  the 
field  elsewhere. 

The  claim  that  leader  writing  cannot  be  done  as  well 
and  as  easily  under  one  set  of  circumstances  as  under  the 
other  does  not  deserve  serious  consideration.  Eurqpean 
exchanges  reach  Chicago  less  than  eighteen  hours  later 
than  their  arrival  at  Washington. 

Personally,  I  would  like  to  see  more  clinical  matter 
printed  ;  more  abstracts  from  foreign  periodicals,  and 
this  work  can  be  printed  as  well  one  place  as  another, 
while  Chicago  certainly  offers  a  fine  field  for  an  active 
clinical  reporter. 

As  long  as  it  represents  a  volume  of  Transactions  The 
Journal  will  have  unsatisfactory  features.  Just  as  the 
Quakers  often  suffer  because  of  a  mistaken  "concern  " 
on  the  part  of  some  self-"  called  "'  speaker,  so  will  the 
Association  listen  to  papers  which  might  have  been 
burned  without  irreparable  loss  to  the  profession,  and 
The  Journal  must  print  a  certain  proportion  of  such. 
Change  of  publication  office  will  not  cure  this  evil. 

Whe  own  The  Journal,  and  who  should  vote  on  a 
proposition  to  remove  it  farther  east?  Divide  the  country 
by  giving  Washington  all  the    Eastern  States  and  the 


Southern  States  as  far  West  as  the  Mississippi  and  let  us 
study  the  matter  statistically.  In  the  List  of  Permanent 
Members,  published  in  No.  26  of  Vol.  xv,  I  take  at 
random  first  column  on  pages  929,  930,  and  931,  and,  lest 
oliarity  lie  in  the  alphabetical  arrangement,  the 

first  column  on  page  940,  making  a  total  of  joo  names. 
With  these  as  a  basis  for  an  estimate  I  find  that  of  the 
total  present  membership  of  the  Association,  12  percent. 
are  nun  from  the  Eastern  and  Southern  States  who  were 
in  the  Association  when  THE  JOURNAL  was  started,  while 
of  Western  men  whose  admission  antedates  that  time, 
there  are  iS%  percent  The  West  certainly  assisted  at 
the  accouchement.  Of  the  total  membership,  . 
cent,  "l  Eastern  and  Southern  men  have  joined  since 
The  Journal's  birth,  while  during  the  same  time  $\L 

per  cent,  of  Western  men  have  come  in.  Total  Eastern 
and  Southern  members  33^  percent.,  of  Western  mem- 
bers 66-4  per  cent.  Of  contributors  to  Vol.  xv,  from  the 
two  sections  of  country,  there  were  respectively  66  and 
78.  Whether  it  be  regarded  as  a  local  or  a  National  pub- 
lication, The  JOURNAL  may  properly  be  regarded  as  the 
organ  of  an  Association  which  is  largely  tributary  to 
Chicago,  and  no  change  can  justly  be  made  on  a  vote 
taken  at  Washington  in  May.  Let  us  have  the  postal 
card  vote  by  all  means. 

Chas.  a.  Hoi  gh,  M.Ij. 
Lebanon,  Ohio,  Feb.  7,  1S91. 


To  the  Editor: — Now  that  the  question  of  changing 
the  location  of  The  Journal  is  under  consideration,  it 
is  important  that  no  time  be  lost  in  plainly  laving  before 
our  readers  and  members  the  reasons  uhv  its  removal 
should  be  demanded,  and  there  is  no  place  or  no  medium 
through  which  the  matter  can  be  better,  fairer  or  more 
sidered,  than  in  that  weekly,  which  is  the  prop- 
erty of  us  all;  for  it  may  as  well  be  generallv  known  that 
this  transference  of  location  cannot  be  consummated  ex- 
cept through  specious,  delusive  argument,  wily  manipu- 
lating and  shrewd  diplomacy,  with  the  aid  of  sharp  par- 
liamentary tactics;  in  other  words,  by  a  genuine  coup 
d'etat.  Our  membership  is  bound  "by  no  alliances, 
can  afford  to  act  independently,  and  must  be  prepared  to 
meet  and  neutralize  by  a  compact  and  concentrated  ma- 
jority. 

So  far  I  have  not  seen  a  single  valid  reason  why  we 
should  move  East;  on  the  other  hand,  the  indications 
point  the  other  way;  that  if  another  location  is  selected, 
it  must  be  in  the  direction  of  the  Occident,  for  the  bone 
and  muscle — so  to  speak — and  the  brain,  too,  of  the 
American  Medical  Association,  come  from  the  West. 

True,  we  have  at  the  present  time  greater  literarv  cen- 
tres east  of  the  Alleghanies;  more  books  and  professors. 
So  with  the  "late  unpleasantness" — the  South  had  the 
generals  and  the  gentlemen,  but  the  North  had  the  men 
and  money. 

To-day,  the  West  has  the  natural  wealth,  with  an  enor- 
mous and  rapidly  multiplying  population,  and  the  time 
has  now  arrived,  in  medicine  as  in  politics,  when  the 
voice  of  that  section  must  be  respected  in  our  councils. 

It  has  been  intimated  that  ours  is  a  sort  of  a  third-rate 
journal;  indifferently  edited  and  behind  the  times.  Now, 
the  contrary  is  incontestably  the  fact.  Subscribing  for 
nearly  all  our  leading  medical  weeklies,  there  is  not  one 
which  I  read  with  greater  relish  and  profit  than  The 
Journal.  What  should  particularly  commend  it  to  us, 
is  that  it  is  out  and  out  American.  Its  pages  are  not 
stuffed  and  padded  with  abstracts  from  other  exchanges, 
which  have  often  nothing  to  justify  their  appearance, 
except  because  they   "are  foreign,  you  know." 

The  pages  of  our  journal  are  open  to  the  best  Ameri- 
can thought;  to  the  humble  plodder,  as  well  as  to  the 
more  pretentious  professor.  Its  present  status  is  one  of 
prosperity,  its  future,  conducted  on  the  same  lines,  is 
unquestionably  one  of  unparalleled  success. 

Let  us,  then,  stand  together,  regardless  of  section,  and 


250 


BOOK  REVIEWS. 


[February  14, 


insist  on  no  removal  from  Cliicago;  a  city  for  its  size  and 
importance,  the  most  centrally  located  and  accessible  in 
the  United  States. 

Let  those  satisfied  with  the  present  regime,  and  its  pub- 
lishing centre,  move  early,  and  see  to  it  that  their 
friends  are  in  their  places  at  the  next  meeting  of  the  As- 
sociation in  Washington,  D.  C. ,  to  maintain  their  posi- 
tion and  cast  their  ballots. 

Thomas  H.  Manley,  M.D. 

New  York,  February  9,  1891. 


ASSOCIATION  NEWS. 


American  Medical  Association. 

The  forty -second  annual  session  will  be  held  in 
Washington,  D.  C,  on  Tuesday,  Wednesday, 
Thursday  and  Friday,  May  5,  6,  7  and  8,  com- 
mencing on  Tuesday  at  11  a.m. 

"The  delegates  shall  receive  their  appointment 
from  permanently  organized  State  Medical  Soci- 
eties, and  such  County  and  District  Medical 
Societies  as  are  recognized  by  representation  in 
their  respective  State  Societies,  and  from  the  Med- 
ical Department  of  the  Army  and  Navy,  and  the 
Marine- Hospital  Service  of  the  United  States. 

"Each  State,  County,  and  District  Medical 
Society  entitled  to  representation  shall  have  the 
privilege  of  sending  to  the  Association  one  dele- 
gate for  every  ten  of  its  regular  resident  members, 
and  one  for  every  additional  fraction  of  more  than 
half  that  number  :  Provided,  however,  that  the 
number  of  delegates  for  any  particular  State,  ter- 
ritory, county,  city,  or  town  shall  not  exceed  the 
ratio  of  one  in  ten  of  the  resident  physicians  who 
may  have  signed  the  Code  of  Ethics  of  the  Asso- 
ciation." 

Members  by  Application. — Members  by  Appli- 
cation shall  consist  of  such  Members  of  the  State, 
County,  and.  District  Medical  Societies  entitled  to 
representation  in  this  Association  as  shall  make 
application  in  writing  to  the  Treasurer,  and  ac- 
company said  application  with  a  certificate  of 
good  standing,  signed  by  the  President  and  Sec- 
retary of  the  Society  of  which  they  are  members, 
and  the  amount  of  the  annual  membership  fee, 
five  dollars.  They  shall  have  their  names  upon 
the  roll,  and  have  all  the  rights  and  privileges 
accorded  to  permanent  members,  and  shall  retain 
their  membership  upon  the  same  terms. 

The  following  resolution  was  adopted  at  the 
session  of  1888 : 

That  in  future-  each  delegate  or  permanent  member 
shall,  when  he  registers,  also  record  the  name  of  the  Sec- 
tion, if  any,  that  he  will  attend,  and  in  which  he  will  cast 
his  vote  for  Section  officers. 

Secretaries  of  Medical  Societies,  as  above  desig- 
nated, are  earnestly  requested  to  forward,  at  once, 
lists  of  their  delegates. 

Also,  that  the  Permanent  Secretary  may  be  en- 
abled to  erase  from  the  roll  the  names  of 
those  who  have   forfeited  their  membership,  the 


Secretaries  arc,  by  special  resolution,  requested  to 
send  him,  annually,  a  corrected  list  of  the  mem- 
bership of  their  respective  societies. 

AMENDMENTS  TO  THE  BY-LAWS. 

Offered  by  Dr.  A.  L.  Gihon,  United  States. 
Navy  : 

That  the  first  day  of  the  meeting  of  this  Association 
shall  be  the  first  Wednesday  of  May  or  June  respectively, 
instead  of  Tuesday. 

By  Dr.  X.  C.  Scott,  Ohio  : 

That  the  Committee  on  State  Medicine  be  abolished, 
inasmuch  as  the  Section  on  State  Medicine  occupies  the 
entire  ground. 

By  Dr.  E.  A.  Wood,  Penn.: 

That  the  word  Physiology  be  stricken  from  Section* i, 
and  a  new  Section,  entitled  the  Section  on  Dietetics  and 
Physiology,  be  formed. 

By  Dr.  J.  C.  Culbertson,  Ohio  : 

That  the  State  and  Geographical  District  Societies  in 
affiliation  at  this  time  with  this  Association,  having  a 
membership  of  100  or  more,  shall  be  recognized  as 
branches  of  the  American  Medical  Association. 

That  all  members  of  said  Societies  enjoy  all  the  rights 
and  privileges  now  accorded  to  delegates. 

By  Dr.  Wm.  H.  Daly,  Penn. : 

That  in  future  the  permanent  members  have  all  the 
rights  of  delegates. 

ADDRESSES. 

On  General  Medicine,  by  Dr.  E,  L.  Shurly,. 
Detroit,  Mich. 

On  General  Surgery,  by  Dr.  Jos.  M.  Mathews, 
Louisville,  Ky. 

On  State  Medicine,  by  Dr.  W.  L.  Schenck, 
Topeka,  Kan 

Committee  on  Arrangements :  Dr.  D.  C.  Pat- 
terson, Chairman,  019  I  street,  N.  W.,  Washing- 
ton, D.  C.  William  B.  Atkinson,  M.D. 

Permanent  Secretary* 


BOOK  REVIEWS. 


Principles  of  Surgery.     By  N.  Senn,  M.D., 
Ph.D.,  Milwaukee,  Wis.     Illustrated  with  ioc> 
wood  engravings.      Philadelphia  and  London  : 
F.  A.  Davis,  publisher.      1890, 
Principles  of  surgery,  surgical   pathology  and 
general  surgery  are  synonymous  terms.     This  is 
the  soul,  the  brain,  of  the  science  of  surgery.      It 
is  the  red  thread  that  runs  through  the  surgeon's 
every  action,  and  leads  and  guides  him  in  diag- 
nosis, in  prognosis,  and  in  treatment  as  well.      It 
lays  down  broad  general  laws  and  truths,  which 
are  the  same  everywhere,  in  an)-  number  of  de- 
tails of  a  given  case. 

Special  surgery  is  a  conglomerate  mass  of  de- 
tails, of  anatomy,  technique  of  operating  and  va- 
ried forms  of  special  diseases  in  special  regions, 
it  is  impossible  for  any  surgeon  to  remember  and 
know  by  heart  all   of  these  at  one  time.     Thus;, 


i89i.] 


BOOK  REVIKWS. 


251 


he  has  his  books  in  which  to  find  the  detailed 
•description  of  a  disease  or  operation  when  he 
meets  a  case  requiring  this  special  knowledge. 

General  surgery,  on  the  other  hand, — the  broad 
general  laws  of  Nature, — the  student,  the  prac- 
titioner, the  surgeon,  must  have  ever  present  in 
his  memory.  It  must  be  a  part  of  his  every-day 
thought  and  reasoning.  He  must  know  the  gen- 
eral laws  by  heart,  because  he  has  to  use  them  in 
his  every-day  work.  The  principles  of  surgery  is 
the  most  important  part  of  the  science  of  surgery. 

Since  the  appearance  of  Billroth's  "Surgical 
Pathology,"  twenty  years  ago,  no  book  has  ap- 
peared covering  this  special  field. 

Too  little  space  is  devoted  to  general  surgery 
in  the  modern  textbooks,  Tillmanns,  Fischer  and 
■others.  Koenig's  otherwise  excellent  work  is  too 
old  as  regards  this  branch  of  the  subject,  except- 
ing Part  II.  published  in  1S89,  written  by  Riedel, 
■which  is  most  excellent  and  entirely  modern,  but 
which  covers  only  part  of  the  field.  Besides  this, 
Koenig's  Surgery  is  not  as  yet  translated  into 
English. 

In  the  last  twenty  years  general  surgery-  has 
been  revolutionized  by  the  development  of  bac- 
teriology and  Lister's  antiseptic  method.  Bacte- 
riology has  revolutionized  pathology,  which  is  now 
written  in  an  entirely  new  language,  incompreher. 
sible  to  the  readers  of  twenty  years  ago.  New  edi- 
tions of  Billroth's  work  have  entirely  failed  to 
bring  it  up  to  date.  The  Lister  method  has  rev- 
olutionized treatment  just  as  much.  Thus,  the 
views  of  treatment  even  of  as  apparently  simple 
an  affection  as  a  furuncle  or  felon  have  changed 
•entirely,  and  so  much  the  more  in  graver  affec- 
tions. The  advice  given  in  the  general  surgery 
•of  to-day  is  in  many  respects  diametrically  op- 
posed to  the  advice  of  twenty  years  ago,  and  many 
a  procedure,  which  at  that  time  seemed  hazardous 
or  aggressive,  is  to  day  not  only  legally  permissi- 
ble, but  imperative,  is  the  rational  treatment,  and 
adherence  to  the  old  conventional  methods  must  be 
-considered  as  neglect,  and  even   as  malpractice. 

In  the  first  chapter,  on  regeneration,  the  author 
draws  a  sharp  line  between  this  process  and  in- 
flammation, defining  regeneration  as  a  formative 
process  in  contradistinction  to  inflammation,  a 
destructive  one.  In  this  chapter  he  takes  strongly 
the  ground  of  homology  in  cell  development  as 
opposed  to  the  metaplasia  of  Virchow.  I  think 
this  point  is  well  taken  in  a  text-book  for  stu- 
dents, in  which  it  is  important  to  have  as  distinct 
landmarks  as  possible,  in  order  to  facilitate  com- 
prehension. 

The  results  of  modern  investigation  in  such 
processes  as  karyokinesis,  vascularization,  cica- 
trization and  epidermization,  are  fully  described, 
and  lead  to  a  number  of  practical  remarks  on  the 
aseptic  and  antiseptic  treatment  of  wounds,  which 
are  most  important  for  the  surgery  of  to  day. 

In  the  chapters  on  blood-vessels  and  fractures, 


the  author  speaks  with  the  authority  of  an  origi- 
nal investigator. 

In  the  chapter  on  inflammation,  the  author 
holds  that  inflammation  is  always  caused  by  one 
or  more  kinds  of  microbes,  thus  entering  another 
field,  where  the  previous  valuable  writings  of  the 
author  make  him  perfectly  at  home.  A  careful 
consideration  of  the  modern  histology  of  all  the 
tissues  concerned  in  inflammation  makes  this 
chapter  most  important  and  interesting.  The 
modern  field  of  phagocytosis  is  ably  considered, 
and  the  author  believes  that  there  is  positive  evi- 
dence of  the  potency  of  this  process  in  limiting 
or  combating  infective  invasions. 

Chronic  inflammation,  the  granulomata  of  old, 
which  is  always  due  to  the  action  of  specific  mi- 
crobes, is  ably  discussed  in  its  various  forms,  and 
a  comprehensive  light  shed  upon  the  variety  of 
course  and  symptoms,  by  a  careful  consideration 
of  the  mixed  infectious  as  the  cause  of  abscess 
formation  in  these  diseases.  By  inserting  practi- 
cal points  in  diagnosis  and  treatment  where  mod- 
ern research  has  made  it  possible,  this  otherwise 
rather  dry  and  uninteresting  subject  has  been 
made  much  easier  for  the  student,  and  very  at- 
tractive. 

In  the  chapter  on  the  treatment  of  inflamma- 
tion, the  author  is  entirely  modern,  and  does  away, 
it  is  hoped  for  all  time,  with  the  legion  of  cata- 
plasms and  counter-irritants  of  times  gone  by,  as 
well  as  with  a  number  of  useless  drugs,  which 
must  give  place  to  the  healthy  stimulants.  Among 
these  otherwise  very  critical  considerations.  I  am 
surprised  to  find  the  author's  unexpected  faith 
in  cold  applications. 

The  important  subject  of  pathogenic  bacteria 
has  received  an  exhaustive  consideration,  as  would 
be  expected  from  the  author  of  the  most  complete 
monograph  on  surgical  bacteriology,  which,  as  it 
well  deserves,  has  been  already  translated  into 
several  languages.  The  chapter  is  short,  clear, 
and  is  not  burdened  by  details.  This  is  a  diffi- 
cult task,  on  account  of  the  mass  of  literature 
now  existing,  and  evidences  just  criticism  in  an 
author  conversant  with  the  whole  literature  of 
the  subject. 

The  subject  of  necrosis  in  all  its  pathological 
and  clinical  varieties,  is  entirely  modern,  and  has 
been  made  an  exceedingly  valuable  chapter  to  the 
practitioner  by  elaborately  detailed  practical  ad- 
vice, given  from  cases  of  every- day  occurrence. 
The  descriptions  are  made  such  life-like  pictures 
of  cases  that  we  meet  with  that  any  practitioner 
will  recognize  them  when  he  reads  them,  and  they 
will  constitute  for  him  a  valuable  guide  in  diag- 
nosis and  treatment,  such  as  I  have  not  yet  found 
in  any  of  the  text-books  on  general  surgery. 

The  subject  of  suppuration  is  probably  the 
most  important  chapter  in  modern  surgery.  We 
find  in  this  book  a  clear  expose  of  the  intricate 
connection  between  the  different  forms  of  sepsis 


252 


MISCELLANY. 


[February  14,  1891. 


and  the  different  microbes,  with  their  relations  to 
etiology',  clinical  symptoms,  and  treatment.  The 
landmarks  in  history  also  receive  due  considera- 
tion. The  detailed  advice  for  the  treatment  of 
each  individual  form,  from  the  small  localized 
felon  up  to  the  acute,  rapidly  progressing  fatal  sep- 
sis, is  exceedingly  important  to  the  practitioner. 

In  the  chapter  on  osteo- myelitis,  the  author 
himself  has  made  a  valuable  addition  to  the  pro- 
gress in  modern  treatment  in  the  filling  of  bone 
cavities  by  antiseptic  decalcified  bone  chips. 

The  chapter  on  intra-cranial  suppuration  is  ex- 
ceedingly interesting  and  practical,  clear  in  differ- 
ential diagnosis,  exhaustive  in  advice,  and  found- 
ed on  the  manifold  researches  and  observations  in 
this  modern  field  of  surgery. 

The  author  follows  suppurative  inflammations 
through  all  the  tissues  of  the  body,  giving  for  each 
territory  the  results  of  modern  research  as  to  eti- 
ology and  the  modern  operative  methods  as  well. 

The  important  subjects  of  septicaemia,  pyaemia, 
and  septico-pyaemia,  almost  incomprehensible  as 
they  are  in  all  other  works  up  to  date,  can  be  read 
in  this  work  with  great  interest,  as  the  author  has 
been  especially  fortunate  in  drawing  comprehen- 
sive lines  and  pointing  out  landmarks  founded  on 
modern  investigation  and  leading  to  advice,  also 
entirely  modern,  in  the  war  against  these  diseases, 
which  are,  we  might  say,  the  most  formidable 
enemies  of  the  surgeon. 

The  chapter  on  surgical  tuberculosis  belongs 
exclusively  to  modern  surgery.  The  rapid  strides 
forward  of  the  last  one  or  two  decades  have  revo- 
lutionized the  diagnosis  and  treatment  of  this  ex- 
tensive field  of  surgery,  which  includes,  we  may 
say,  the  greatest  number  of  every- day  cases  for 
operation.  With  the  exception  of  Koenig  and 
Riedel,  who  are  not  accessible  to  English  readers, 
we  find  in  this  work  the  first  exhaustive  and  com- 
prehensive description  of  surgical  tuberculosis,  in 
all  its  varied  forms  and  treatment.  This  is  emi- 
nently practical  also  in  this  book,  as  the  exam- 
ples cited  of  tuberculosis  of  joints,  glands,  etc., 
are  the  typical  ones  of  every-  day  surgery,  and  the 
operative  treatment,  as  described,  is  so  clear  and 
exhaustive,  that  it  is  a  safe  guide  for  any  operator. 

The  little  chapter  on  fascial  tuberculosis  is  en- 
tirely new,  and  is  based  on  original  observations 
of  the  author,  which,  so  far  as  I  know,  have  not 
before  been  published. 

In  a  review  it  is  impossible  to  do  more  than  to 
point  out  here  and  there  what  strikes  the  reader 
most  markedly.  Thus,  a  multitude  of  subjects 
can  receive  no  mention.  In  general,  I  will  say 
that  each  subject  has  been  discussed  exhaustive- 
ly. If  we  take  at  random  one  of  the  smaller  sub- 
jects, as,  for  instance,  actinomycosis,  we  find,  as 
a  proof  of  the  comprehensiveness  and  complete- 
ness with  which  the  subject  has  been  treated, 
each  of  the  following  points  distinctly  discussed  : 
History;  description  of  microbe;  cultivation  ex- 


periments; inoculation  experiments;  sources  of 
infection;  pathology  and  morbid  anatomy;  clini- 
cal varieties,  including  cutaneous  surfaces,  ali- 
mentary canal,  respiratory  organs  and  brain  ; 
symptoms ;  diagnosis;  prognosis  and  treatment. 

As  a  teacher  of  surgery,  I  have  for  a  long  time 
felt  the  need  of  a  work  on  general  surgery  short 
enough  to  be  read  by  the  student,  complete  enough 
and  modern  enough  to  bring  the  subject  up  to 
date.  Such  a  work  we  have  in  the  book  before 
us.  It  has  been  written  with  just  discrimination 
in  the  selection  of  the  grains  of  gold  in  the  enor- 
mous mass  of  the  modern  literature  of  the  subject. 

It  is  an  important  aid  to  the  teacher,  enabling 
him  to  do  away  with  the  tedious,  didactic  lecture, 
and  the  plowing  through  the  enormous  literature 
to  find  what  the  student  of  to-day  needs.  I,  for 
one,  intend  to  use  the  book  as  a  text-book  for  the 
students  to  learn,  using  the  lecture  hour  for  quiz- 
ing  and  demonstrations,  supplemented  by  remarks 
on  matters  of  interest  in  the  current  literature  ot 
the  subject. 

To  the  practitioner  and  surgeon  this  work 
brings  the  subject  of  modern  surgery  up  to  date, 
in  a  comprehensive  form,  and  he  will  find  it  a 
valuable  and  safe  guide  in  his  everyday  work  in 
diagnosis,  prognosis  and  treatment. 

The  illustrations  are  numerous,  well  chosen 
and  well  executed,  and  the  publisher  deserves 
credit  for  the  appearance  of  the  work. 

Chr.  Fengek. 


MISCELLANY. 


( Official  List  of  Changes  in  the  Stations  and  Duties  of  Officers  Set  ving 
!/t  th?  Medical  Department,  i ".  S.  Ai  my •,  from  January  rS,  /#©/,  to 
January  24,  iSqi. 

Major  William  H.  Gardner,  Surgeon,  is  relieved  from  further  duty 
in  the  field,  and  will  return  to  his  proper  station.  By  direction  of 
the  Secretary  of  War.  Par.  2,  S.  O.  19,  A.  G.  O  ,  Washington,  Jan- 
uary 23,  1S91. 

Majoi  St<  \<  ns  G.  Cowdrey,  Surgeon,  extension  of  leave  of  absence 
on  account  of  sickness  granted  in  S.  O.  302,  December::,  iSqo. 
from  this  office,  is  -^t ill  further  extended  two  months,  on  surgeon's, 
certificate  oi  disability.  Bv  direction  of  the  Secretary  uf  War. 
Par.  13,  S.  O.  19,  A.  Go     Washington,  January  23,  1*91. 

Capt.  Walter  Reed,  Asst.  Surgeon,  is  relieved  from  temporary  duty 
at  Ft.  Keogh,  Mont.,  to  take  effect  as  soon  as  his  services  i  an  m 
spared  by  the  commanding  officer  of  that  post,  and  will  then  re- 
turn to  Baltimore,  Md..  and  resume  his  duties  in  that  city  as  at- 
tending surgeon  and  examiner  of  recruits.  By  direction' of  the 
Secretaryof  War.  Par  ;,  s.  o  20,  a.  G.  <>.,  Washington,  January 
24,  1S91. 

Capt.  William  C.  Owen,  Jr.,  Asst.  Surgeon,  is  relieved  from  tempo- 
rary duty  with  troops  in  the  field,  to  take  effect  as  soon  as  his 
services  can  be  spared,  and  will  then  return  to  Muskogee.  Ind. 
I '(  ]  and  resume  his  leave  of  absence.  By  direction  of  the  Secre- 
tarj  --I   War.     Par.  3,  s.  o.  20,  A.  G.  O..  Washington,  January  24. 

Capt.  Charles  M.  Gandy,  Issl  Surgeon,  is  relieved  from  temporary 
duty  in  the  field,  to  take  effect  when  his  services  can  be  spared  by 
the  commanding  officer  of  the  troops  with  which  he  is  serving, 

a  nd  will  tlim    w.Uini  to  (  i.v;iii  View,  Cape  Ma  v  Co  ,  N     1,  and  1  e- 

sume  his  leavi  oi  absenci  i'\  direction  ot  the  Secretary  of  War. 
i.n    e,  S   O.  21,  A.  G.  O.,  Washington,  January  26,  [891. 

I    ipl    Robert  (.Gibson,  Asst.  Surgeon,  is  relieved  from  further  tem- 

p  dutj  in  the  field,  to  take  effect  as  soon  as  his  services  can 

1  '1  by  the  officer  commanding  the  troops  with  which  he  is 

serving, and  will  then   return  to  New  Haven,  Conn,,  and  resume 

nee      By  direction  ol  the  secretary  of  War.    Par. 

6,  S.  O.  22,  A.  G   <  >. ,  Washington,  January  n,  1891. 

Capt.  William  Stephenson  A --4  Surgeon,  will  proceed  without  de- 
la  \  from  Columbus  Bks.,  O  to  it  Wayne,  Mich.,  and  report  in 
person  to  thi  o  immanding  office]  of  thai  post  for  temporary  duty, 
and  upon  completion  thereof  will  return  to  his  proper  station. 
By  direction  of  the  Secretary  of  War     Pai    13,  S  O  23,  A.  G.  0.„ 

Washington,   lanuarv.'S,  i8qi. 


T  1 1  E 


J  ournal  of  the  American  Medical  Association. 

EDITED  UNDER  THE  DIRECTION  OF  THE  BOARD  OF  TRUSTEES. 
IT  HUSHED     WEEKLY. 


Vol.  XVI. 


CHICAGO,  FEBRUARY  21,   1891. 


No  8. 


LECTURES. 

PATHOLOGY  OF   PHTHISIS  PUL- 
MONALE. 

Lecture    delivered  at    the    Post-Graduate   Medical  School   of 
Chicago,  January  23,  1801. 

BY  HEXEAGE  GIBBES,  M.D., 

PROFESSOR   OF  PATHOLOGY,   UNIVERSITY   OF   MICHIGAN. 


Mr.  President,  Ladies  and  Gentlemen  : — I  must 
first  say  that  when  I  left  home  last  evening  I  was 
not  aware  of  what  was  before  me  ;  I  have  not 
come  prepared  to  make  a  set  speech  this  evening, 
and  if  you  find  what  I  say  rather  disconnected, 
I  hope  you  will  excuse  me. 

What  I  want  to  say  in  connection  with  this 
subject  is  on  the  part  of  the  pathology  and  eti- 
ology of  the  disease,  and  how  we  have  arrived  at 
the  place  we  now  are,  in  which  we  consider  we 
have  done  something  towards  curing  the  disease 
called  consumption  ;  I  use  the  word  consumption 
in  the  generic  sense  as  applied  to  those  diseases 
that  are  found  associated  with  consolidation  and 
decay  of  the  lungs,  together  with  wasting  and 
emaciation  of  the  body.  We  know  that  in  mak- 
ing a  post-mortem  examination  of  a  case  of  dis- 
ease of  the  lungs  we  find  a  variety  of  changes 
there,  appearances  indicating  in  some  cases  that 
the  disease  has  not  progressed  very  far,  while  in 
others  we  find  large  consolidations,  and  in  some 
parts  large  cavities  caused  by  breaking  down  of 
this  consolidation.  So  far  we  have  only  seen, 
■with  the  naked  eye,  one  appearance  which  is  con- 
stant, and  that  is  consolidation.  Now  if  we  stop 
there,  at  the  naked  eye  appearance,  we  have 
simpl3'  one  form  of  disease,  consolidation  of  the 
lung  with  breaking  down  afterwards  and  forma- 
tion of  cavities  ;  but  when  we  bring  in  the  aid  of 
the  microscope,  and  prepare  sections  cut  from  the 
lungs,  we  find  a  totally  different  state  of  things. 
I  think  this  is  one  of  the  most  important  prob- 
lems that  we  have  before  us  at  the  present  time, 
that  is  to  say,  whether  we  are  to  believe  in  the 
iinit}-  or  duality  of  this  disease.  We  know  that 
the  unit}-  of  this  disease  has  been  taught  by  a 
large  number  of  men  who  full}-  believed  in  it, 
but  I  have  been  working  on  this  subject  for  a 
number  of  years,  and  I  simply  cannot  satisfy  my- 
self that  it  is  so.     I  would  point  out  that  if  you 


take  those  cases  where  there  is  consolidation  of 
the  lungs,  and  carefully  harden  those  lungs,  cut 
sections  from  them,  stain  and  prepare  them  for 
the  microscope,  and  examine  them,  you  will  find 
that  they  divide  themselves  into  two  kinds. 
You  will  find  that  the  one  is  inflammatory,  and 
the  other  a  new  growth  in  the  lungs,  which  is 
tubercle.  I  have  taken  these  photographs  from 
cases  of  acute  miliary  tuberculosis,  in  which  you 
can  see  the  process  in  the  early  stage,  and  I  think 
they  will  show  you  the  distinction.  It  seems  to 
me  that  at  the  present  time  it  is  an  important 
question  as  to  whether  there  are  two  distinct  dis- 
eases or  not.  You  are  aware  that  some  dogmatic 
writers  have  insisted  upon  the  unity  of  phthisis, 
but  I  have  no  hesitation  in  saying,  from  a  care- 
ful study  of  diseases  of  the  lungs,  that  this  is 
not  the  case.  There  are  two  distinct  forms  of 
disease  in  the  lungs,  one  the  inflammatory  break- 
ing down,  the  other  a  new  growth.  I  would 
therefore  as  a  basis,  divide  lung  diseases  into  two 
kinds,  the  inflammatory  and  the  tubercular. 
And  I  would  then,  as  a  kind  of  sub  class  to 
these,  add  acute  miliary  tuberculosis,  which  must 
be  distinguished  from  these  because  its  symptoms 
are  so  different ;  it  does  not  run  a  long  course. 
It  never  causes  ulceration  into  the  respiratory- 
passages,  and  in  cases  of  acute  miliary  tubercu- 
losis you  never  get  bacilli  in  the  sputum,  there- 
fore I  would  make  a  sub-class  of  this.  Take  the 
inflammatory  form  of  phthisis  ;  we  all  know  the 
form  of  pulmonic  phthisis  where  you  have  in  the* 
first  place  a  catarrhal  pneumonia,  there  may  be 
bronchitis,  and  extension  of  that  into  the  lungs 
and  an  inflammatory  condition  of  the  lungs 
which  ends  in  consolidation  there.  This  consoli- 
dation may  clear  up  and  leave  the  lungs  as  whole 
as  they  were  before,  provided  the  damage  done  by 
the  inflammatory  process  has  not  been  so  great  as 
to  destroy  the  vitality  of  that  part  of  the  lungs 
affected  ;  but  if,  on  the  other  hand,  consolidation 
has  gone  on  and  the  flow  of  blood  through  the 
parts  has  been  arrested  by  the  inflammatory  pro- 
cess, and  the  damage  to  the  lung  is  so  great  that 
a  part  of  it  is  destroyed,  that  is  dead,  we  then 
have  retrograde  changes  resulting  in  what  we 
call  caseation.  There  is  then  the  inflammatory 
form  ;  this,  if  carried  out  to  the  destruction  of 
the   parts,    ends  in   caseation    and    liquefaction, 


254 


PATHOLOGY  OF  PHTHISIS  PULMONAUS. 


[February  21, 


which  ejected  through  the  bronchi  leaves  a  cav- 
ity in  the  lung.  That  seems  to  me  perfectly 
clear  ;  I  think  that  is  the  experience  of  all  of  us. 
In  the  case  of  tuberculosis  we  have  a  totally 
different  thing,  we  have  there  the  formation  of 
tubercles.  Now  I  must  explain  what  I  mean  by 
tubercles.  It  is  a  new  growth  in  the  lungs  com- 
posed of  a  fibroid  tissue ;  I  call  it  fibroid  tissue 
because  I  am  not  clear  that  it  is  fibrous  tissue. 
The  reaction  is  exactly  the  same  as  that  found  in 
fibrous  tissue  ;  it  is  distinctly  a  new  formation  in 
the  lungs,  and  it  is  not  of  an  inflammatory 
character,  it  contains  one  or  more  giant  cells. 
This  is  distinctly  a  new  formation  ;  in  a  well- 
stained  specimen  it  looks  something  like  an 
elastic  tissue,  but  I  do  not  think  it  is  ordinary 
fibrous  tissue.  There  is  this  peculiarity  in  re- 
gard to  tuberculosis,  you  do  not  get  a  large 
tubercle,  when  you  first  see  the  consolidation  it  is 
not  one  single  tubercle,  but  an  aggregation  of 
small  tubercles.  A  tuberculosis  grows  in  the 
lungs  by  beginning  as  one  or  two  small  ones  to- 
gether, which  gradually  increase  in  size,  and 
numerous  smaller  ones  are  formed  around  the 
edges,  so  you  get  a  large  mass  which  looks  like  a 
consolidated  form  of  pneumonic  phthisis.  This 
tissue  is  peculiar,  it  has  this  characteristic  that  it 
readily  breaks  down,  and  for  this  reason  it  has 
been  included  in  the  infective  class,  together  with 
the  lesions  of  syphilis.  Now  we  know  there  is  a 
kind  of  tissue  formed  in  syphilis  which  varies 
very  much,  but  still  it  is  a  new  growth,  and  we 
know  that  under  certain  drugs  this  can  be 
changed  and  destroyed  and  broken  down,  leaving 
nothing  behind  but  destroyed  tissue.  In  tubercu- 
losis we  also  have  a  new  tissue,  but  of  a 
more  stable  character.  We  know  that  in  small 
tubercles,  after  they  have  grown  to  a  certain  size, 
the  centre  indicates  the  beginning  of  necrosis, 
and  on  the  outside  we  have  the  reticular  tissue 
containing  the  giant  cell.  The  next  stage  is  that 
the  whole  or  a  part  begins  to  break  down,  and 
then  it  passes  into  what  we  call  caseation,  be- 
•  cause  we  do  not  know  any  better  name.  The 
chemists,  who  ought  to  be  able  to  support  us  in 
this,  never  do  so  ;  we  have  not  yet  had  the 
composition  of  caseous  matter  worked  out.  What 
I  want  to  know  is  whether  the  caseation  in 
phthisis  is  the  same  as  that  of  the  breaking  down 
of  tuberculosis.  If  that  was  shown  we  would 
have  more  data  to  go  on  in  forming  an  idea  of 
the  disease  than  at  present.  In  these  two  forms 
we  have  consolidation  as  one  cause  of  inflamma- 
tion, and  in  the  other  a  new  growth,  both  result- 
ing in  breaking  down  and  the  formation  of  what 
we  may  call  caseation.  The  result  of  these  two 
diseases  is  the  same,  that  is  to  say,  formation  of 
cavities  in  the  lungs,  while  the  beginning  is 
totally  different. 

Before  I  speak  of  the  formation  of  tubercles  in 
the    lungs    I    would    pass    on    to    acute  miliary 


tuberculosis.  Every  case  of  acute  miliary  tuber- 
culosis that  I  have  been  able  to  get  during  the 
last  nine  years  I  have  examined  carefully,  and 
have  found  always  the  same  results.  I  have  had 
to  place  them  in  two  classes,  the  inflammatory 
and  the  tubercular.  So  we  have  acute  miliary 
tuberculosis  differing  so  much  from  either  chronic 
phthisis  or  the  more  chronic  form  of  pulmonary 
disease,  still  being  the  same  clinically ;  it  is 
almost  impossible  at  present  to  discriminate  be- 
tween the  two  forms  of  acute  miliary  tuberculosis. 
In  post-mortem  examination  of  the  lungs  you 
cannot  tell  them  apart,  yet  when  we  study  these 
small  nodules  in  the  lungs  we  find  two  kinds,  the 
inflammatory  and  the  tubercular,  and  in  this  con- 
dition we  can  study  them  perfectly.  But  this  is 
the  difficulty  we  have  to  contend  with  in  studying 
the  disease  and  the  lesions  produced  by  that  dis- 
ease ;  we  cannot  get  at  the  initiation  of  the  dis- 
ease in  the  ordinary  forms,  but  we  can  in  acute  rnil- 


Fig.  1. —Typical  reticular  tubercle  (essential  type  of  tuberculc 
Payne).     Fibroid  tissue,  giant  cells,  necrosed  centre.     From  r  ' 

of  pulmonary  tuberculosis  v1 "  **--  *- 

ture.  and  no  tubercle  bacilli 


--  e  all  the  lesions  l 
uld  be  found. 


iary  tuberculosis.  Figs.  1  and  2  are  photographs 
of  cases  of  children  that  died  of  acute  miliary 
tuberculosis.  The  disease  lasted  about  the  same 
time,  and  the  children  were  of  the  same  age,  the 
physical  signs  and  symptoms  were  alike  and  were 
diagnosed  as  miliary  tuberculosis.  As  far  as  I 
have  gone,  and  I  am  certainly  within  bounds  in 
saying  that  I  have  cut  over  a  thousand  sections 
of  these  lungs,  and  stained  and  examined  them, 
I  have  never  found  any  section  made  from  either 
one  of  these  lungs  that  did  not  absolutely  put 
itself  into  one  class  or  the  other,  inflammatory  or 
tuberculous.  So  also  in  the  more  chronic  form 
the  division   is   absolute   between  the  two,  you 


I89i.] 


PATHOLOGY  OF  PHTHISIS  PULMOXALIS. 


255 


may    divide    the     disease    absolutely    into   two 
classes,  tubercular  and  inflammatory- 

With  regard  to  the  tubercle.  I  may  say  this  : 
It  has  been  said  that  the  reason  why  ther 
difference  of  opinion  between  some  observers  is 
that  some  take  one  form  of  tubercle  and  some  an 
other,  on  which  to  form  their  basis  as  to  what  a 
tubercle  is.  That  is  utterly  wrong  ;  you  may 
make  fifty  or  one  hundred  or  more  sections  of  the 
lungs  in  cases  of  acute  miliary  tuberculosis  of  the 
tubercular  kind,  and  you  will  never  find  two  that 
are  exactly  alike.  There  is  always  this  sharp 
difference  between  the  two  forms :  you  have  on 
one  side  an  inflammatory  process,  with  no  attempt 
at  structural  formation  :  in  the  other  thi 
reticular  structure,  a  new  growth.  Now.  coming 
to  the  initiation  of  these  two,  and  finding  out  the 
earliest  stages  in  their  growth,  and  finding  that 
these  two  begin  in  the  one  form  inflammatorv 


Fig.  2.— Caseous  tubercle  in  kn?  of  child  in  case  of  acute  miliary 
toberculosis  (so-called-.  Centre  of  mass  contains  a  large  number 
of  tubercle  bacilli. 

from  the  commencement,  and  in  the  other  reticu- 
lar, we  are  justified  in  deciding  that  these  must 
be  two  distinct  diseases,  this  the  inflammatory- 
condition,  and  that  the  tubercular.  (Figs.  3  and 
4.)  This  photograph  shows  that  the  commence- 
ment of  the  one  is  reticular  from  the  beginning  ; 
you  may  see  where  a  small  tubercle  is  commenc- 
ing, and  you  see  this  is  formed  from  a  new  growth, 
and  that  is  to  be  found  in  the  very  commence- 
ment ;  while  the  other  is  nothing  but  a  collection 
of  inflammatory  cells.  I  have  said  enough  to 
show  that  these  are  two  diseases. 

Unfortunately.  I  am  not  on  the  fashionable 
side,  and  what  I  have  done  on  this  subject  is  ig- 
nored ;  but  I  think  we  have  come  to  a  time  when 
we  cannot  afford  to  ignore  this.     This  is  a  more 


highly  magnified  specimen,  showing  the  tuber- 
cular structure,  with  large  giant  cells  in  it. 

Now.  in  regard  to  the  etiology  of  these 'two  dis- 
eases; it  seems  to  me  that  there  ought  to  be  no  dif- 
ficulty in  working  out  the  etiology  of  the  inflam- 
matory form  of  phthisis;  it  begins  in  inflammation 
and  ends  in  the  ordinary  way  ;  it  simply  breaks 
down.  But  the  tendency  is  to  consider  what  was 
formerly  called  causative  as  now  only  predisposi- 
tion, that  leads  one  only  into  difficulty,  because 
now  we  have  to  face  the  question  of  the  relation- 
ship of  the  tubercle  bacillus  to  this  process.  Com- 
ing to  the  earliest  stage  of  the  disease  as  shown 
in  these  two  photographs,  we  are  told  by  many 
observers  of  the  present  time,  that  the  tubercle  ba- 
cillus is  the  virus  of  the  disease.  That  phthisis 
pulmonalis  and  tuberculosis  are  one  and  the  same 
disease :  that  wherever  the  tubercle  bacillus  is 
found,  there  is  tuberculosis.  Therefore,  if  we 
want  to  find  the  starting  point,  we  must  examine 
the  earliest  stage  of  the  disease  ;  but  when  we 
look  at  the  very  commencement  of  these  two 
forms  and  look  for  the  tubercle  bacillus,  what  is 
We  cannot  find  it.  I  can  say  that 
in  all  the  cases  I  have  examined  I  have  never 
been  able  to  find  the  tubercle  bacillus  at  the  com- 
mencement of  the  process  in  the  human  lung.  I 
have  carefully  picked  out  from  the  earliest  cases 
what  seemed  to  be  representative  ones,  and  pho- 
tographed them,  so  that  you  can  see  what  is  there. 
This  is  the  commencement  of  the  disease,  and  the 
virus  of  the  disease,  the  thing  which  starts  it,  is 

-  nt.  There  is  another  little  difficulty  in  con- 
nection with  it :  that  is,  in  these  two  forms  in 
acute  miliary  tuberculosis  you  will  never  find  the 
tubercle  bacilli  in  the  sputum.  But  you  will 
never  examine  one  of  the  inflammatory  type  of 
that  disease  without  finding  in  the  centre  of  the 
inflammatory  mass  a  large  number  of  tubercle  ba- 
cilli. Hamilton  has  described  this  peculiar  form 
very  well ;  he  calls  it  '  'disseminated  catarrhal 
pneumonia;''  and  he  says  that  not  a  few  cases 
recover  from  this.  He  says  that  in  this  form  you 
will  find  no  trace  of  tubercular  formation,  no  or- 
ganization, no  structure  whatever.  That  agrees 
exactly  with  what  I  call  the  inflammatory  form 
of  acute  miliary  tuberculosis,  and  you  will  see  in 
these  specimens  that  the  centre  of  the  inflamma- 
tory mass  contains  a  large  number  of  tubercle 
bacilli.  In  the  tubercular  form  I  have  examined 
many  cases  where  there  were  no  tubercle  bacilli 
at  all  to  be  found,  not  only  at  the  commencement 
of  the  disease,  but  all  the  way  through  it.  There 
were  none  to  be  found  in  many  hundred  sections 
I  had  made  of  that  condition:  and  others  have  put 
it  on  record  that  they  had  been  unable  to  find 
them.  Further  than  that.  I  have  had  cases  of 
tuberculosis  in  the  more  chronic  form,  where  the 
disease  existed  for  a  long  time,  under  observation, 
and  where  there  were  no  bacilli  in  the  sputum  ; 
where  the  post-mortem  examination  showed  large 


256 


PATHOLOGY  OF  PHTHISIS  PULMONALIS 


[February  21, 


cavities  in  the  lungs,  and  sections  of  the  lungs 
showed  large  tubercle  breaking  down  and  form- 
ing cavities,  but  without  one  single  bacillus  in 
them.  So  if  the  tubercle  bacillus  is  the  virus  of 
the  disease,  as  far  as  I  can  see,  it  is  absent  from 
the  commencement  of  the  process  in  both  forms  ; 
and  even  absent  throughout  the  whole  course  of 
the  disease  in  some  of  these  forms  of  tuberculosis. 
The  next  thing  which  is  supposed  to  show  the 
tubercle  bacillus  in  its  position,  is  the  effect  when 
inoculated  in  animals.  It  has  been  stated  posi- 
tively, and  on  this  is  founded  a  great  deal  of 
what  has  been  laid  down  dogmatically,  that  the 
lesion  produced  by  inoculating  tubercular  mate- 
rial is  identical  with  the  small  tubercle  you  find 
in  the  lungs  ;  that  is  to  say,  it  is  a  growth  of 
fibroid  tissue  containing  giant  cells.  I  must  dis- 
agree entirely  with  this.     I   have  never  seen  in 


the  inoculated  animal ;  that  is  to  say,  the  new 
condition  is  inflammatory,  and  goes  on  to  break- 
ing down.  These  are  photographs  of  the  lung 
of  a  monkey  inoculated  with  pulmonary  phthisis; 
there  the  change  is  exactly  what  you  find  in  the 
inflammatory  form  of  acute  miliary  tuberculosis  ; 
that  is  to  say,  there  is  no  effect  on  the  connective 
tissues  of  the  lung,  there  is  no  attempt  at  new 
formation,  and  if  this  is  the  case  it  is  a  very  im- 
portant thing,  because,  on  the  other  hand,  inoc- 
ulation with  tubercular  material  has  produced  in 
the  lung  of  a  monkey  an  entirely  new  condition. 
This  photograph  is  taken  from  the  spleen,  where 
the  monkey  was  killed  eleven  days  after  the  in- 
oculation, and  in  the  centre  of  the  Malpighian 
corpuscle  of  the  spleen  is  seen  a  mass  of  large 
cells,  which  are  exactly  similar  to  those  found  in 
a  strumous  cervical  gland.      You  know  in  the 


Fig.  3.— Inflammatory  tubercle  commencing.  I,ung:  of  child. 
Case  diagnosed  as  acute  miliary  tuberculosis.  Lung  injected  with 
Berlin  blue. 

the  lung  of  inoculated  animals  a  true  tubercle, 
that  is  to  say,  the  reticular  formation  with  giant 
cells,  such  as  you  will  find  in  acute  miliary  tu- 
berculosis of  the  tubercular  form,  and  which, 
Payne  says,  is  the  essential  type  of  the  disease, 
and  what  we  have  always  been  taught  to  believe 
a  tubercle.  This  fibroid  tissue  with  giant  cells 
you  will  not  find  in  inoculated  animals,  therefore 
the  disease  does  not  reproduce  itself  in  animals. 
I  have  been  doing  work  lately  in  studying  the 
changes  produced  by  inoculation,  where  I  could 
prove  that  the  inoculating  material  was  taken 
from  pulmonary  phthisis  and  pulmonary  tuber- 
culosis, and  although  I  cannot  speak  positively, 
I  believe  that  the  result  produced  by  inoculation 
of  caseous  products  from  pulmonary  phthisis  pro- 
duces a  condition  similar  to  that  in  the  lung  of 


Fig.  4.— Reticular    tubercle    commencing,    from  a  case  of  acute 
miliary  tuberculosis. 

strumous  cervical  gland,  which  is  one  of  the 
lymphatic  glands,  you  have  a  number  of  masses 
of  adenoid  tissue,  and  between  this  physiological 
mass  and  capsule  there  is  a  lymph  space  forming 
a  sinus  there,  the  effect  of  the  disease  on  one  of 
these  glands  alters  it  entirely  by  the  formation 
of  these  large  cells,  and  the  lymphatic  tissue  is 
entirely  changed  into  masses  of  large  cells  with 
a  number  of  giant  cells  in  them  with,  after  a  time, 
caseation  and  breaking  down  in  parts,  which  ends 
so  often  in  suppuration.  Now  the  effect  produced 
in  the  monkey's  spleen  by  the  inoculation  of  tu- 
bercular matter  has  been  to  produce  the  formation 
of  cells  very  similar  to. those  found  in  struma  or 
scrofula,  there  is  certainly  a  strong  resemblance, 
but  as  I  have  said,  I  have  not  had  sufficient  data 
as  yet  to  speak  positively  on  this.     However,  I 


iiyi.J 


PATHOLOGY  OF  PHTHISIS  PULMONAUS. 


257 


am  endeavoring  to  carry  out  the  investigation, 
but  I  have  to  take  the  sputum  from  cases  and  in- 
oculate guinea  pigs,  and  trust  to  providence  to 
give  me  a  post-mortem,  and  I  can't  get  one  post- 
mortem in  twenty,  so  I  am  wasting  guinea  pigs. 
But  I  would  like  to  give  you  the  idea,  because  it 
seems  to  me  there  must  be  something  in  this  con- 
dition, but  whether  it  will  be  ultimately  proved 
that  there  is  any  connection  between  scrofula  and 
this  tubercular  inoculation  I  can't  say  as  yet. 

The  next  point  is  as  to  the  relation  of  the 
tubercle  bacillus  to  the  disease,  and  the  proof  of 
inoculation  by  pure  culture  of  it  in  the  produc- 
tion of  tuberculosis.  I  don't  think  those  who 
have  worked  in  this  have  given  any  statements 
whatever  as  to  what  the  products  were ;  we  have 
had  the  bald  statement  that  histologicallv  the 
lesion  produced  by  inoculation  was  identical  with 
that  found  in  the  lungs.  And  this  has  been 
stated  by  men  who  knew  nothing  whatever  about 
normal  histology.  I  have  met"  it  so  often  that 
I  feel  convinced  that  such  is  the  case,  and  I  think 
it  is  materially  hindering  our  investigations, 
especially  in  diseases  of  the  lungs. 

One  other  point  I  would  like  to  mention  is  the 
consolidation  produced  in  the  lungs  by  other  dis- 
eases. I  have  spoken  so  far  of  catarrhal  pneu- 
monia, caseation  and  the  new  formation  tubercle, 
and  then  of  the  minor  class  of  acute  miliary 
tuberculosis  which  divides  itself  into  two  forms. 
But  there  are  other  conditions,  lesions  of  syphilis 
and  hydatids  which  sometimes  are  included  in 
consolidations  of  the  lungs.  And  another  one  is 
croupous  pneumonia  ;  we  certainly  sometimes  get 
a  consolidation  produced  by  acute  pneumonia  re- 
maining in  the  lung.  While  it  remains  in  the 
lung  as  a  solid  mass  it  does  not  do  much  harm 
and  gradually  dries  up,  but  it  seems  that  some 
change  will  take  place  which  produces  an  irritat- 
ing action  around  the  edge  of  the  consolidated 
mass,  and  this  may  be  either  acute  or  chronic. 
If  chronic,  it  does  what  chronic  inflammatory 
action  always  does  throughout  the  body,  causes 
an  increase  in  the  fibrous  tissue,  and  we  know 
what  the  result  is;  we  have  the  formation  of 
fibrous  bands  of  tissue  in  the  lung  caused  by  the 
chronic  inflammatory  action.  But  on  the  other 
hand,  there  may  be  an  acute  inflammatory  pro- 
cess set  up  which  results  in  the  liquefaction  of 
more  or  less  of  this  consolidation,  with  the  forma- 
tion of  a  cavity  from  that,  and  here  we  have  an- 
other way  by  which  cavities  are  formed  in  the 
lung,  and  it  certainly  has  no  intimate  relation 
with  either  inflammatory  or  acute  tuberculosis. 
In  regard  to  the  clearing  up  of  these  different 
lesions  in  the  lungs,  we  may,  instead  of  having 
acute  breaking  down  there  and  the  formation  of 
a  cavity,  have  the  mass  dry  up,  and  act  as  a 
chronic  irritant  in  the  lung,  producing  the  usual 
chronic  inflammation,  with  the  result  that  it  is 
isolated  by  fibrous  tissue  ;  and  we  have  a  chronic 


cystic  tissue  in  the  lung  which  will  either  leave 
a  cicatrix  there  or  else  a  fibrous  capsule  with  a 
mass  of  caseous  material  in  the  centre. 

With  regard  to  those  specimens,  I  cannot  say 
what  the  condition  originally  was,  the  mass  in  the 
center  is  simply  caseous,  and  whether  it  was  a 
gumma  or  a  tubercle,  I  cannot  say.  Whatever 
was  there  is  broken  down  and  all  struetun  is  lost, 
but  still  it  has  produced  the  same  effect  of  setting 
up  chronic  inflammatory  action. 

I  would  ask  if  I  were  going  to  kill  the  tuber- 
cles, What  would  become  of  them?  Do  they  re- 
main in  the  lungs  as  foreign  bodies  and  by  their 
irritation  set  up  these  little  fibrous  cysts  which 
contract  on  their  contents2  If  so,  it  would  seem 
to  me  that  the  last  state  of  that  man  would  be 
worse  than  the  first,  the  remaining  lung  tissue 
would  be  put  upon  the  stretch  so  that  there 
would  be  a  kind  of  mechanical  emphysema  pro- 
duced which  he  could  hardly  sustain. 

In  regard  to  the  argument  in  favor  of  tubercle 
bacillus  being  the  virus  of  phthisis;   if  you  make 
a  pure  cultivation  of  bacilli  and  keep  cultivating 
that  from  one  tube  to  another,  extending  over  a 
number  of  years  even, — it  will  not  do  to  go  too 
far  or  they  will  loose  their  vitality — you  are  sup- 
posed to  free  them  entirely  from  anything  which 
may  have  been  introduced  in  the  first  place  from 
the  organ  that  they  were  taken  from,  and  vou  are 
supposed  then  to  have  a  pure  culture,  and'  that  if 
you  inoculate  an  animal  with  this  it  will  produce 
a  characteristic  lesion.     It  will  produce  a  change 
in  the  lung  of  the  inoculated  animal;  this  is  a 
rather  difficult  thing  to  get  over,  because  that, 
together  with  the  histological  consideration  of  the 
introduced  lesion,  are  the  main  points  on  which 
the  position  of  the  virus  of  tuberculosis  rests.      I 
would  ask  if  it  has  been  proved  to  demonstration 
that  the  cultivation  of  tubercle  bacilli  are  abso- 
lutely pure?  if  nothing  is  carried  from  this  mass 
on  which  they  are  cultivated  ?      Has  there  been 
any  attempt  to  prove  that?     That  is  a  question 
which  is  very  difficult  to  answer;  but  unless  it  is 
answered  by  exact  science  we  may  doubt  it.    We 
ought  to  consider  all  honest  opinions,  but  we  do  not 
want  to  have  opinions  rammed  down  our  throats  as 
facts  until  they  are  proven.     If  this  to  be  consid- 
ered as  the  virus  of  the  disease  it  must  have  its 
basis  absolutely  sure  and  certain  before  we  accept 
it.     Now  take  the  example  of  the  jequirity  bacil- 
lus, which  was  found  in  an  infusion  of  the  beans 
sold  in  India  as  prayer  beans.      If  you  take   an 
infusion  of  them  and  inoculate  it  into  the  eyes  of 
animals  you  will  produce  an  intense  ophthalmia.  It 
is  used  by  the  natives  for  trachoma,  and  produces 
an    intense    inflammation    which    lasts    two   or 
three  days,  and  then  all  trace  of  the  disease  is 
gone.       It  has  been  found  by  investigation  that 
after  making  this  infusion  and  keeping  it  for  two 
or  three  days,  when  it  was  examined  it  would  be 
found  teeming  with  bacilli.     This  bacillus  was 


258 


THE  TREATMENT  OF  PHTHISIS. 


[February  21, 


cultivated  in  the  same  way  as  tubercle  bacillus. 
Generation  after  generation  was  cultivated  by  a 
man  as  careful  as  Sattler  was  known  to  be. 
Klein  made  these  cultivations  and  worked  it  out 
thoroughly,  and  I  recall  his  saying  to  me,  "If 
there  is  any  one  case  in  which  it  is  proved  to  de- 
monstration that  the  bacillus  is.  the  virus  of  dis- 
ease it  is  this. ' '  He  made  an  infusion  of  the  bean 
in  sterilized  water,  with  every  precaution  against 
contamination,  and  inoculated  the  eyes  of  eight 
rabbits,  and  eight  tubes  of  sterilized  peptones. 
He  examined  them  every  day  for  twTo  or  three 
weeks  and  not  a  trace  of  microorganisms  grew  in 
them,  but  these  animals  got  such  an  inflamma- 
tion that  they  died  with  their  heads  swelled  to  an 
enormous  size.  He  next  took  an  infusion  of 
jequirity  bean  teeming  with  bacilli  and  heated  it 
to  ioo°  centigrade  and  kept  it  so  for  a  minute  un- 
til the  heat  had  destroyed  all  formed  bacilli.  He 
then  took  the  spores  from  that  and  cultivated 
them  until  he  grew  bacilli  morphologically  iden- 
tical with  the  bacillus  he  had  before,  but  on  in- 
oculating the  eyes  of  animals  with  it  it  had  no 
effect  whatever.  Prof.  Warden  succeeded  in  iso- 
lating the  alkaloid,  not  only  from  the  beans,  but 
the  leaves,  stems  and  root  of  the  plant,  and  it  was 
that  which  was  doing  all  the  mischief;  it  was 
shown  beyond  any  doubt,  in  a  case  where  it 
would  seem  to  be  absolutely  proven  that  the  ba- 
cillus was  the  virus  of  disease,  that  the  bacillus 
had  nothing  to  do  with  it. 

Now  I  do  not  think  we  ought  to  take  it  as  be- 
ing absolutely  true  that  the  tubercle  bacillus  is 
the  virus  of  the  disease  from  the  production  of  a 
lesion  by  an  inoculation  of  so  called  pure  cul- 
ture, and  work  on  that  line.  Dr.  Shurly  and 
I  have  always  held  the  view  that  there  is 
something  there  beyond  the  bacillus,  and  we  have 
never  troubled  the  bacillus  except  to  find  when 
it  has  gone  out  in  the  sputum  of  the  patient 
treated.  We  have  not  worried  that  bacillus  at 
all,  others  have  been  doing  that.  We  have  been 
working  on  the  line  that  there  was  some  morbid 
product  there  which  could  be  combined  with 
some  chemical  and  rendered  inert.  We  com- 
menced work  with  that  idea,  and  we  certainly  did 
succeed  by  using  iodine,  and  we  got  to  that  stage 
the  year  before  last  where  we  could  inoculate  a 
guinea  pig  with  tuberculosis  and  prevent  the  de- 
velopment of  it;  prevent  anything  developing  be- 
yond an  abscess  at  the  seat  of  inoculation,  where 
we  would  find  fluid  pus  full  of  bacilli,  but  with 
no  lesions  except  fatty  change  in  the  liver,  but 
which  showed  different  conditions  from  ordinary 
fatty  change,  which,  as  you  know,  is  generally 
around  the  periphery  of  the  lobule.  It  was  not 
necessarily  confined  to  one  lobule  but  sometimes 
running  through  the  middle  and  changing  into 
this  fatty  infiltration,  so  that  when  you  held  a 
section  up  you  could  pick  out  the  patch  that  had 
undergone  this  change.     We  considered  that  we 


were  not  justified  in  doing  this  to  human  beings 
and  we  then  turned  our  thoughts  to  other  sub- 
jects. Dr.  Shurly  worked  on  animals  while  I 
worked  on  pure  cultures  of  tubercle  bacillus,  un- 
til by  using  a  number  of  things  we  found  a  way 
in  which  we  could  render  the  tubercle  bacilli  in 
the  cultivation  absolutely  inert  so  far  as  the  gross 
lesion  in  the  guinea  pig  was  concerned,  although 
it  was  not  dead.  We  considered  we  had  done 
this  by  using  some  chemical  which  would  com- 
bine with  the  morbid  product  which  we  thought, 
and  still  think,  must  exist  in  these  cultures,  and 
that  we  have  rendered  that  innocuous  by  form- 
ing a  combination  of  substances.  The  one  I 
found  most  efficacious  was  chloride  of  gold  and 
sodium.  By  using  chloride  of  gold  I  killed  the 
bacilli  right  off.  I  communicated  with  Dr.  Shurly 
on  the  results  and  he  was  struck  with  the  idea  of 
injecting  this  substance.  We  had  before  been 
giving  insufflations  of  different  drugs,  and  he 
thought  that  by  injection  we  could  introduce  this 
fluid  in  such  a  way  as  to  be  carried  to  these  parts 
where  the  morbid  product  especially  existed,  and 
that  it  would  act  in  the  same  way.  We  found 
we  were  justified  in  that  by  the  effect  on  animals, 
and  from  that  we  went  on  trying  the  effect  011 
human  beings. 

From  what  I  have  said  I  think  you  will  see  I 
am  at  kastjustified  in  corning  before  such  an  assem- 
bly as  this.  I  can  assure  you  that  it  was  with  a 
great  deal  of  trepidation  that  I  began.  I  did  not 
know  whether  I  would  be  allowed  to  go  on  ta 
the  end.  I  have  been  sat  down  on  so  unmerci- 
fully on  the  other  side  that  I  feel  considerably  re- 
duced in  height  in  consequence.  I  hope  you  will 
not  think  I  have  been  too  dogmatic,  but  will  par- 
don me  when  I  say  these  conclusions  are  the  re- 
sult of  careful  work  extending  over  eight  or  nine 
years.  If  you  prove  that  I  am  wrong  I  hope  you 
will  let  me  down  gently. 


THE  TREATMENT  OF  PHTHISIS. 

A  Lecture  delivered  at  the  Post-Graduate  Medical  School  of  Chicago, 
January   2j,  1891. 

BY  E.  L.  SHURLY,  M.D., 

PROFESSOR   OF  LARYNGOLOGY     AND    CLINICAL   MEDICINE, 
DETROIT,   MICH. 

Mr.  President,  Ladies  and  Gentlemen  :  I  will 
not  occupy  your  time  very  long  as  my  colleague 
has  gone  pretty  thoroughly  into  the  explanation 
of  our  work  in  giving  you  our  pathological  ideas; 
I  shall  speak  to  you  only  from  a  clinical  stand- 
point. It  is  the  predominating  opinion  of  physi- 
cians that  the  bacillus  tuberculosis  is  the  specific 
and  only  cause  of  the  several  forms  of  disease 
known  as  tuberculosis,  and  from  its  behavior  it  is 
a  very  hard  thing  to  explain  away.  But  when 
we  consider  from  a  clinical  standpoint  this  bac- 


i89i.] 


THE  TREATMENT  OF  PHTHISIS. 


259 


terium,  as  the  cause  of  the  several  conditions, 
known  as  tuberculosis,  phthisis  pulinonalis,  in 
its  several  forms,  tuberculous  joint  disease,  scrof- 
ulosis,  so-called  tubercular  skin  diseases,  bone  dis- 
ease, some  forms  of  leprosy,  besides  other  com- 
plex affections,  it  must  strike  any  one  who  will 
think  of  it  for  a  moment,  as  being  impossible  ! 

With  regard  to  the  bacillus,  of  course  its  spe- 
cific character  we  do  not  question  at  all  ;  nor  its 
value  as  a  diagnostic  sign.  The  results  observed 
are  explained  on  the  theory  that  it  should  have  a 
nidus,  and  upon  this  nidus  develop  the  disease,  or, 
that  it  may  remain  latent  in  the  body,  constitut- 
ing animal  parasitism,  a  condition  which  was 
foreshadowed  by  Dr.  Lionel  Beal,  twenty  years 
ago,  or  that  the  bacillus  is  imbibed,  exists  for  a 
time  in  a  latent  state  and  is  then  eaten  up  by 
leucocytes  or  by  other  microbes  —  phagocytosis. 
Now  if  the  bacillus  be  the  cause  of  these  complex 
conditions  we  must  recognize  one  or  the  other  or 
all  of  these  theories. 

We  have  in  phthisis  pulmonalis,  as  you  are 
well  aware,  three  distinct  clinical  types  of  dis- 
ease. It  is  almost  impossible,  so  far  as  I  know, 
to  distinguish  acute  phthisis  from  miliary  tuber- 
culosis, the  course  is  rapid  in  both,  the  temperature 
makes  about  the  same  range  in  each,  about  the 
same  class  of  individuals  are  effected  and  present 
about  the  same  symptomatology,  which  I  will  not 
detain  you  by  describing.  There  is  another  form 
which  we  may  properly  denominate  the  subacute 
form,  in  which  the  patient  has  a  distinct  catarrhal 
inflammation,  existing  for  a  certain  length  of 
time,  in  the  mucous  membranes  of  the  bronchial 
tubes,  with  little  or  no  constitutional  disturbance 
at  first,  but  simply  local  disturbance,  cough  and 
respiratory  sensations,  while,  sooner  or  later  con- 
stitutional disturbances  come  on,  and  we  find,  if 
we  make  frequent  observations  by  physical  exam- 
ination that  the  inflammation  is  extending  to  the 
smaller  tubes,  and  involving  the  air  cells  ;  finally, 
if  the  process  goes  on  there  is  continued  wasting, 
more  pronounced  constitutional  disturbance,  hy- 
perpyrexia, etc.,  and  breaking  down  of  the  tissue, 
involving  bronchii  and  alveoli  of  the  lung  and 
resulting  in  that  peculiar  suppuration  called  casea- 
tion, if  we  examine  such  a  patient  at  the  end,  up- 
on the  post-mortem  table,  we  find  cavities,  case- 
ous matter,  indurated  places  and  other  evidences 
of  inflammation.  There  is  still  another  form, 
called  chronic,  in  which  there  is  the  same  result 
but  the  march  is  much  slower,  the  constitutional 
disturbance  also  is  put  off  for  a  long  period,  but 
after  awhile,  if  the  patient  live  long  enough,  the 
same  condition  of  breaking  down — caseation  and 
induration  occurs,  and  we  have  about  the  same 
morbid  anatomy  for  chronic  phthisis  pulmonalis. 
Now  it  occurred  to  us  in  common  with  many  that 
these  several  conditions  could  not  possibly  be 
identical  with  either  that  condition  of  bone  or 
peritoneal  disease  where  no  bacillus  is  found,  or 


with  general  tuberculosis,  a  general  or  constitu- 
tional disease  which  exists  from  the  beginning. 
It  occurred  to  us  also  that  phthisis  pulmonalis 
could  not  be  exactly  the  same  clinically  as  the 
disease  in  the  lower  animals  which  is  induced 
by  inoculation,  and  therefore  we  began  to  look 
about  for  some  other  cause  or  causes.  In  other 
words,  it  seemed  incomprehensible  to  me  as  a 
clinician,  and  to  Dr.  Gibbes  as  a  pathologist,  that 
this  one  bacterium  could  possibly  be  alone,  the 
cause  of  these  several  complex  diseases,  because, 
as  you  know,  reasoning  from  analogy  that  each  of 
the  specific  fevers  and  like  diseases  show  pretty 
constant  phenomena,  and  so  on,  are  alike  or 
nearly  so,  and  although  there  may  be  a  seeming 
connection  between  some  forms,  perhaps,  as  be- 
tween the  typhoid  condition  and  typhoid  fever, 
yet  the  causes  are  not  necessarily  alike.  We 
therefore,  while  not  contending  against  the  uni- 
versal existence  of  the  bacillus  tuberculosis,  think 
it  probable  that  it  is  more  of  a  concomitant  or  re- 
sultant in  determining  certain  conditions.  This 
thought,  however,  is  not  new  ;  that  something 
else  beside  the  bacillus  operates  in  this  disease, 
for  it  was  suggested  by  our  worthy  presiding 
officer.  Dr.  N.  S.  Davis,  in  1882,  in  a  paper  before 
the  American  Medical  Association,  in  which  he 
said  that  there  must  be  some  chemical  or  bio- 
chemical action  besides  this  bacterium  to  account 
for  such  conditions  and  courses  ;  and  many  other 
clinicians  have  expressed  the  same  doubt.  But 
the  thing  is  to  work  it  out.  One  more  word, 
concerning  the  infectious  character  of  the  disease; 
it  is  argued  by  clinicians  in  Europe  and  a  great 
many  in  this  country,  that  dr.v  sputum  when 
breathed  by  an  animal  or  man  will  produce  phthi- 
sis pulmonalis!  this  is  true!  for  we  have  pro- 
duced the  disease  in  monkeys  by  insufflation  of 
sun-dried  sputum  In  this  way  we  have  pro- 
duced true  acute  and  subacute  phthisis  pulmonal- 
is, the  disease  being  located  in  the  lungs,  while 
by  inoculation  of  monkeys  the  disease  produced 
has  been  general,  infecting  the  spleen,  liver  and 
other  organs,  and  least  or  not  much  at  all,  the 
lungs. 

It  is  stated  by  several  bacteriologists  and  pathol- 
ogists, even  by  Koch,  I  think,  that  if  you  dry 
sputum  in  the  sun  the  virulence  of  the  bacillus  is 
destroyed.  We  have  also  found  this  to  be  true. 
Vet  we  have  thus  dried  the  sputum  in  the  sun, 
and  been  able  to  produce  the  disease  in  monkeys 
by  insufflation.  Does  not  this  seem  to  indicate  that 
there  must  be  something  back  of  the  bacterium 
which  is  an  active  agent?  Will  the  absolutely 
dead  and  destroyed  bacillus  produce  this  effect? 
We  were  therefore  by  this  led  strongly  to  think 
that  there  is  a  bio-chemical  action  in  this  disease, 
determining  the  particular  sort  of  degeneration 
and  suppuration,  known  as  caseation.  This  then 
is  the  main  idea  in  our  view  and,  moreover,  we 
I  consequently  believe  that  when    the  d 


26o 


THE  TREATMENT  OF  PHTHISIS. 


[February  21, 


the  lung  tissue  there  the  poison  is  generated, 
induced  by  long  continued  inflammatory  changes 
having  taken  place.  We  also  believe  that  or- 
dinary subacute  phthisis  pulmonalis  and  some 
other  forms  are  perhaps  similar  in  their  nature 
to  what  was  called  in  the  old  fashioned  parlance, 
scrofulosis.  Now  with  such  views  we  began 
using  different  things  locally  by  inhalation  to 
stop  if  possible  the  formation  of  the  caseating 
process  and  source  of  chemical  action. 

It  is  unnecessary  for  me  to  tell  you  of  the 
large  number  of  experiments,  mostly  failures, 
which  we  have  instituted  ;  we  used  the  several 
gases  disseminated  in  different  ways,  hydrogen, 
oxygen,  carbonic  acid,  hydrofluoric  acid,  etc.,  with 
sulphuretted  hydrogen  ;  through  accident,  we 
discovered  that  it  is  a  most  virulent  and  subtle 
poison,  one  of  our  assistants  in  the  laboratory 
was  almost  killed  by  it,  besides  a  couple  of  mon- 
keys killed  outright.  So  we  went  on  trying  the 
gases,  and  finally  settled  upon  chlorine,  first  used 
in  1828.  From  a  study  of  its  chemical  nature  as 
far  as  known,  and  from  the  fact  that  it  is  more  or 
less  combined  with  so  many  of  the  well  known 
chemical  reagents  that  are  in  use,  it  seemed  to  sug- 
gest itself  to  us  as  being  very  desirable  for  our  pur- 
pose, but  by  causing  so  much  irritation  when  in- 
haled, inducing  so  much  inflammation  by  contact 
with  animal  tissues,  it  became  a  question  whether 
we  could  introduce  it  or  not;  we  tried  a  great  many 
methods.  First,  mixed  with  air  in  small  propor- 
tion and  so  on,  and  after  killing  a  few  monkeys 
and  guinea  pigs,  we  found  after  awhile  that  these 
animals  could  inhale  the  gas  in  the  proportion  of 
1-40,000  of  air  ;  but  this  dilution  we  discovered 
was  not  sufficient  to  destroy  the  virility  of  the 
sputum,  so  we  increased  the  quantity  of  the  mix- 
ture until  obtaining  one  that  would  destroy  the 
activity  of  sputum,  so  that  an  animal  inoculated 
with  it  was  not  affected.  We  found  that  with  a 
mixture  of  about  1-4000,  (by  exposure  for  a  few  mo- 
ments) we  would  destroy  the  virulence  of  sputum, 
so  that  we  could  inoculate  animals  with  such 
sputum  without  producing  any  disease.  Observ- 
ing, as  we  thought,  that  hydrochloric  acid  and 
hypochlorous  acid  was  evolved  very  soon  after 
the  liberation  of  chlorine  gas  in  the  air,  probably 
accounted  for  its  irrespirability  and  was  the  cause 
of  the  irritation,  because  the  monkeys  died  from 
common  inflammation  of  the  whole  respiratory 
lining.  This  afforded  very  good  study,  however, 
because  there  was  general  broncho- pneumonia 
produced,  therefore  we  felt  as  though  we  must  go 
on  very  carefully  and  not  induce  such  a  condition 
in  the  human  being. 

After  trying  many  different  things  to  neutral- 
ize the  by-products  we  succeeded  in  accomplish- 
ing the  purpose  by  using  a  solution  of  chloride  of 
sodium.  We  began  with  chlorine  water  spray, 
but  found  by  experiments  with  guinea  pigs  in  a 
gas  cage  that  sprays  did  not  penetrate  into  the 


lungs  readily,  that  is  without  very  long  exposure 
although  gas  was  evolved,  all  of  which  seemed  to 
be  unsatisfactory.  It  is  possible,  however,  that 
the  local  effect  of  anything  may  be  continued  for 
a  long  time  on  the  respirator}'  tract,  beyond  the 
place  of  contact,  but  we  could  get  no  chemical  re- 
actions in  animals'  lungs  by  using  sprays,  unless 
we  used  some  substance  subsequently  giving  off 
the  gas.  We  obtained  some  effect  from  the  spray 
of  peroxide  of  hydrogen,  which,  after  being  dif- 
fused in  the  air  of  the  gas  cage,  seemed  to  split 
up;  also  with  chlorine  water,  which  after  awhile 
left  the  chlorine  gas  in  the  air,  but  we  could  not 
thus  destroy  the  sputum.  We  therefore  continued 
with  our  experiments  in  the  use  of  chlorine  gas, 
and  found  that  with  chloride  of  sodium  spray  well 
diffused,  animals  could  inhale  chlorine  for  a  con- 
siderable length  of  time  ;  and  after  trying  it  thor- 
oughly on  animals  we  began  experiments  on  hu- 
man beings  with  satisfactory  results.  Our  idea 
was  to  stop  the  formation  of  the  virus,  whatever 
it  might  be,  whether  a  ptomaine,  a  leucomaine  or 
a  toxalbumin,  etc.,  and  thus  to  stop  the  progress 
of  the  disease  at  these  points,  believing  that  phthi- 
sis pulmonalis  is  esse?itially  a  local  disease.  But 
we  found  after  awhile  that  this  plan  would  not 
slop  the  process  altogether  although  it  would  check 
it  !  In  the  monkey,  it  would  only  feebly  act  in 
checking  the  course  of  the  inoculated  disease.  But 
if  we  could  manage  to  set  up  phthisis  pulmonalis 
in  monkeys  by  exposure,  or  from  the  insufflation 
of  the  dried  sputum,  or  in  menageries,  we  could 
prolong  the  course  of  the  disease  very  much  in- 
deed by  the  gas.  Constitutional  disturbances 
would  come  on  after  awhile,  however. 

Turning  attention  toward  meeting  constitutional 
effects,  the  iodides  of  a  great  many  chemicals  were 
used,  also  chlorides  and  sulphides.  We  at  first 
used  them  by  the  mouth,  which  brought  serious 
events.  On  account  of  the  changes  which  chemi- 
cals undergo  in  the  stomach  and  intestinal  caual 
we  thought  it  better  to  use  them  by  hypodermic 
injection  if  possible.  There  are  reports  in  the  lit- 
erature of  medicine  from  the  last  century,  that 
iodine  was  valuable,  but  an  irritant,  and  would 
produce  abscesses,  which  it  did  in  our  experience. 
We  thoroughly  tried  it,  but  had  abscesses,  which 
caused  the  death  of  the  animals,  but  we  found  by 
accident  that  the  abscesses  were  due  to  chemical 
impurities.  After  having  the  iodine  resublimated 
by  Dr.  Clark  we  had  no  difficulty  from  abscesses, 
unless  we  used  enormously  large  doses  on  ani- 
mals. The  same  thing  we  found  to  be  true  of  the 
chloride  of  gold  and  sodium  and  permanganate 
of  potassium.  The  idea  of  using  iodine  came  to 
us  first  from  the  fact  of  its  resolvent  action  upon 
the  lymphatic  glands  and  tissues  generally  in  all 
of  those  diseases  which  so  closely  resemble  phthi- 
sis pulmonalis  clinically.  We  have  used  also 
the  arsenite  of  potassium,  but  found  that  the 
poisonous  effect  was  so  great  that  it  could  not  be 


'»9i.] 


THE  TREATMENT  OF  SYPHILIS. 


261 


continued  for  any  considerable  length  of  time. 
We  observed  that  after  using  iodine  a  certain 
length  of  time,  a  certain  condition,  iodism,  took 
place  which  prohibited  its  further  use  ;  animals 
and  man  would  have  diarrhoea,  vomiting,  and 
would  refuse  food,  etc.  It  is  astonishing  how 
much  a  little  animal  like  a  guinea  pig  can  stand  of 
these  chemicals.  These  symptoms  coming  on 
soon  made  it  necessary  to  have  something  else 
to  hold  the  effect  as  it  were.  Taking  our  ex- 
perience in  the  action  of  chloride  of  gold  and  so- 
dium on  dead  tissues  in  general,  we  hit  upon  that, 
after  failure  with  bichloride  of  mercury  and  other 
salts,  and  used  it  locally  and  by  injection.  Al- 
though it  is  said  by  surgeons  that  if  you  use  hy- 
podermic injections  asepticallv  no  abscess  will 
follow,  yet  you  will  find  that  bichloride  of  mer- 
cury used  hypodermically  may  produce  abscess. 
This  is  not  the  case  with  chloride  of  gold  and 
sodium  if  chemically  pure,  which,  as  you  know, 
has  been  used  for  years  as  an  alterative.  We 
began  by  small  doses  and  gradually  increased 
them.  We  inoculated  a  number  of  guinea 
pigs,  first  with  these  chemicals,  one  series  with 
iodine  and  one  series  with  gold,  and  after  do- 
ing that  for  a  week  or  so  until  we  noted  physi- 
ological effects,  we  then  inoculated  them  with 
well  known  virulent  sputum  and  found  to  our  as- 
tonishment that  the  pigs  did  not  take  the  disease. 
We  repeated  this  with  another  series,  with  the 
same  effect,  until  we  have  now  a  number  of  very 
healthy  pigs  that  have  been  inoculated  with 
iodine  and  gold  and  with  undoubted  virulent 
sputum  as  proven  by  control  animals.  Just  which 
is  the  better,  of  course  has  not  been  determined 
yet,  for  there  are  a  great  many  things  to  learn. 
Unfortunately,  the  further  we  go  into  such  a  sub- 
ject the  more  we  appreciate  that  we  know  but  lit- 
tle. We  have  been  trying  since,  in  continuance 
of  our  work,  to  trace  out  the  poison,  whatever  it 
is.  If  we  are  right  in  this  idea  that  it  is  a  toxal- 
bumin,  a  ptomaine,  or  a  leucomaine,  we  want  to 
isolate  it.  We  want  to  get  it  out  so  that  we  can 
show  it  and  test  it  and  have  it  exposed  in  its  true 
form,  just  as  we  can  get  crystals  of  strychnine,  and 
we  do  not  feel  that  the  work  is  done  unless  the 
poison  can  be  thus  shown.  We  therefore  feel 
that  we  are  in  the  first  part  of  the  work  only  until 
we  can  show  what  part  of  these  extracts  lie  at  the 
bottom  of  the  causation. 

We  are  now  engaged  in  making  extracts — I 
can  only  hint  at  it,  can  only  say  that  some  of  the 
results  we  have  had  from  these  extracts  have 
been  astonishing  to  ourselves,  and  if  we  can  con- 
tinue and  perfect  these  investigations  the  proba- 
bility is  that  in  a  year,  or  perhaps  less,  we  may 
be  able  to  isolate  the  particular  poison  or  poisons 
which  produce  this  disease,  or  which  are  gener- 
ated in  the  body  and  keep  up  the  disease.  These 
extracts  will  produce  it  in  the  guinea  pig  ;  but 
whether  they  will   do   it  every  time  we   do  not 


know  ;    we  have  not  had  time  to  test  it   thor- 
oughly. 

I  suppose  some  of  you  may  want  to  know 
what  success  we  have  had  with  human  beings. 
We  have  tried  to  be  very  careful  about  making 
promises,  although  we  have  been  published  in 
the  papers  very  much  more  than  we  anticipated 
or  desired  and  there  have  been  a  great  many  ex- 
aggerated statements  made.  But  of  course  you 
would  like  to  know  what  success  we  have  had 
thus  far.  I  cannot  give  you  the  details  of  the 
cases  to-night,  we  expect  to  publish  some  case 
histories  in  a  short  time.  Of  the  cases  of  so-called 
general  tuberculosis  we  have  treated  altogether 
about  four  well-marked  cases  ;  two  of  which  died 
without  showing  any  effect  of  treatment,  one  of 
them  is  certainly  very  much  better,  and  the  other 
case  is  simply  held  in  abeyance,  so  far  as  we  can 
observe.  We  have  treated  a  number  of  cases  of 
phthisis  pulmonalis,  including  what  Dr.  Gibbes 
spoke  of  as  the  tuberculous  form  and  the  pneu- 
monic form.  We  have  had  in  all  about  twenty- 
two  cases  under  observation  for  about  two  to  three 
mouths  with  about  six  so  called  cures,  taking  all 
the  several  cases  together,  but  there  has  not  been 
time  enough  to  tell  whether  these  people  have 
been  thoroughly  cured  or  not.  In  one  case  there 
was  very  decided  laryngeal  ulceration,  which 
was  seen  by  several  medical  gentlemen,  in 
that  case  the  cicatrix  was  so  complete  that  it 
could  be  seen  with  the  laryngoscope,  just  before 
she  went  home  about  Christmas  practically  well ; 
her  physician  continues  the  hypodermic  injection 
about  once  a  week.  One  case  I  have  in  mind  was 
a  man  in  whom  the  upper  left  lung  was  breaking 
down,  as  was  evidenced  by  moist  and  gurgling 
rales,  so  that  there  could  be  no  mistake  about  it. 
He  was  examined  by  two  or  three  others  besides 
myself.  This  man  has  been  under  treatment  since 
September  and  he  has  now  an  injection  about 
once  a  week  or  ten  days,  but  has  practically  gone 
from  under  the  treatment.  Another  case,  that  of 
a  young  girl,  who  has  gone  home,  seems  to  be 
lasting,  the  last  advice  is  that  she  has  remained 
well  with  scarcely  any  cough,  merely  a  little  hack- 
ing in  the  morning.  In  her  case  the  diagnosis  had 
also  been  made  out  by  physicians  before  she  came 
to  us.  Another  case  is  that  of  a  teacher  who  has 
resumed  her  school  duties  since  January,  she  still 
coughs  a  little  in  the  morning  but  has  no  eleva- 
tion of  temperature  now  and  is  gaining  flesh  and 
strength.  Another  case  was  that  of  a  man  whose 
disease  was  of  a  more  chronic  form  ;  he  left  the 
hospital  in  a  very  much  better  state;  he  eats  well 
and  has  no  elevation  of  temperature  whatever,  no 
nocturnal  diaphoresis,  or  anything  of  that  kind. 
Of  course  this  does  not  prove  anything  until  more 
time  elapses. 

We  have  now  about  thirty-five  cases  under 
treatment,  some  of  which  are  doing  very  well ! 
There  are  two  or  three  of  them  termed  ' '  caseous 


26; 


A  REMEDY  FOR  TUBERCULOSIS. 


[February  2 1 . 


pneumonia,"  that  are  not  doing  very  well.  The 
one  case  of  tuberculosis  which  I  mentioned  is  a 
case  which  several  gentlemen  outside  the  staff 
saw  in  the  hospital;  we  thought  of  giving  up  the 
treatment,  because  there  was  no  chance,  for  it  is 
undoubtedly  a  case  of  general  tuberculosis.  But 
after  one  or  two  relapses  she  has  been  getting 
better,  and  when  I  left  home  she  had  been  sitting 
up  considerably  for  a  number  of  days  past  ;  al- 
though she  has  elevation  of  temperature  she  has 
no  nocturnal  diaphoresis,  her  appetite  has  re- 
turned and  she  expectorates  only  about  two 
drams  of  mucous  ill  twenty-four  hours,  with  no 
pus.  We  have  one  case  of  a  young  boy  in  the 
hospital,  which  is  very  promising  and  very  inter- 
esting inasmuch  as  the  probability  is  that  he  had 
pneumonia  followed  by  abscesses  of  the  lungs 
first,  and  then  caseation  of  the  lung.  Another 
case  was  of  pneumonic  abscess  followed  after  a 
time  by  the  presence  of  tubercle  bacilli  in  the 
sputum;  on  account  of  the  deep  location  of  the 
abscess,  I  did  not  open  into  the  lung.  I  was 
afraid  to  cut  through  such  a  large  amount  of 
lung  tissue  to  reach  it.  I  therefore  put  him  under 
this  treatment,  and  he  is  slowly  recovering  from 
the  abscess  of  the  lung. 

There  are  some  other  chemicals  we  have  been 
using  lately  that  may  prove  more  valuable  than 
iodine  and  chloride  of  gold.  Of  course  the  ex- 
perimentation is  far  from  complete,  but  one  of 
them  especially  bids  fair  to  be  more  promising 
than  gold.  The  general  plan  of  treatment  seems  to 
us  to  hinge  on  the  use  of  chlorine  gas  to  stop  the 
caseation  as  far  as  possible,  and  cut  off  the  origin 
of  the  poison,  which  thence  is  circulating  through 
the  system.  In  the  early  stage  of  disease,  before 
much  caseation,  we  do  not  think  it  is  necessary 
to  use  the  chlorine  gas  too  freely,  but  instead  the 
iodine,  for  its  well  known  effect  upon  chronic  in- 
flammation. 

I  would  say  in  regard  to  the  manipulation  of 
chlorine  gas  that  it  is  a  very  simple  thing  but  it 
needs  some  care.  The  chloride  of  sodium  spray 
should  be  put  into  the  room  first,  and  the  air 
thoroughly  laden  with  it  before  the  chlorine  gas 
is  evolved.  At  the  hospital  we  use  about  1-20,000 
up  to  1-4000.  The  first  dose  should  be  quite 
small  for  cases  of  laryngeal  phthisis.  In  cases 
where  there  is  ulceration  chlorine  gas  in  a  room 
seems  much  the  better  way.  If,  however,  there  is 
only  tumefaction  the  mixture  of  sol.  of  chloride 
of  sodium  and  chlorine  water  chemically  pure,  is 
quite  sufficient  from  an  inhaler.  The  mixture  of 
the  two  was  suggested  to  us  by  Dr.  Ingals,  of 
your  city.  Before  that,  we  used  two  tubes  one 
containing  chlorine  water  and  the  other  the  chlor- 
ide of  sodium  solution.  We  had  tried  mixing 
them  before  but  had  always  obtained  a  precipitate, 
and  we  therefore  thought  the  two  were  incompat- 
ible, but  we  found  out  afterwards  that  it  was 
because  of  exposure  to  light  and  long  standing,  | 


and  if  the  mixture  be  used  immediately  we  could 
get  good  results.  So  in  cases  of  laryngeal  phthi- 
sis of  all  forms,  we  should  recommend  that  an  in- 
haler be  used. 

We  are  certainly  very  much  obliged  to  the  pro- 
fession of  Chicago  for  the  attention  that  has  been 
shown  us.  When  we  started  out,  we  had  no  idea 
that  we  were  going  to  interest  the  profession  of 
Chicago  to  such  an  extent,  and  as  I  said,  we 
are  very  grateful  for  the  attention  we  have  re- 
ceived, and  feel  that  we  do  not  deserve  it.  We 
have  not  accomplished  anything  as  yet,  we  have 
only  started  !  We  have  nothing  definite  to  prom- 
ise and  we  only  hope  that  all  of  you  may  aid  us 
in  every  way  possible  by  your  criticisms  and  by 
your  crucial  tests,  for  that  is  the  only  way  in 
which  this  problem  can  be  solved. 


ORIGINAL  ARTICLES. 


ADDITIONAL  COMMUNICATIONS  CON- 
CERNING A  REMEDY  FOR 
TUBERCULOSIS.1 
BY  PROFESSOR  R.  KOCH, 

The  following  translation  of  Mr.  Doctor  McDill  repre- 
sents perfectly  the  original  treatise. 

Prof.  Ehrlich  for  Prof.  Koch. 
Berlin,  Jan.  17,  1891. 

Since  the  publication,  two  months  ago,  (see 
Deutsche  Med.  Wochenschr.,  No.  46  a)  of  my  ex- 
periments with  a  new  method  of  cure  for  tuber- 
culosis, many  physicians  have  obtained  the  rem- 
edy and  have  thereby  been  enabled  t  ~>  become  ac- 
quanted  with  its  properties  b}-  personal  experi- 
ences. As  far  as  I  review  the  publications  which 
have  appeared,  together  with  the  communications 
to  me  by  letter  on  this  subject,  my  statements 
have,  upon  the  whole,  found  full  corroboration. 

It  may  be  considered  as  generally  accepted  that 
the  remedy  has  a  specific  action  upon  tuberculous 
tissue  and  that  it  consequently  can  be  utilized  as  a 
very  subtle  and  reliable  reagent  for  the  bringing 
to  light  of  the  hidden,  and  the  diagnosing  of  the 
doubtful  tuberculosis  processes.  Also  regarding 
the  curative  effect  of  the  remedy,  it  is  reported 
by  the  majority  of  observers  that,  despite  the 
comparatively  short  duration  of  the  treatment,  a 
more  or  less  extensive  improvement  has  occurred 
in  many  cases.  In  not  a  few  cases  that  have 
been  reported  to  me  a  positive  cure  is  claimed. 
Only  here  and  there  has  been  made  the  statement 
that  the  remedy  might  not  only  prove  dangerous 
in  cases  too  far  advanced,  as  will  be  readily  ad- 

1  Translated  from  the  Deutsche  Medicinishe  Wochenschrift  ot 
January  15,  iSqi,  bv  John  R.  McDill,  M.D.,  of  Milwaukee,  Wis.,  now 
in  Berlin. 


•  ] 


A  REMEDY  FOR  TUBERCULOSIS. 


263 


mitted,  but  that  it  directly  favors  the  tuberculous 
process  and  is  therefore  per  se  harmful.  I  myself 
have  for  the  past  month  and  a  half  had  anoppoi 
tunity  of  gaining  further  experience  concerning 
the  curative  effect  and  diagnostic  uses  of  the 
remedy,  by  the  observation,  in  the  City  Hospital 
in  Moabit,  of  about  150  cases  of  the  most  varied 
forms  of  tuberculosis,  and  can  only  state  that  all 
that  I  have  seen  of  late  agrees  with  my  former 
tion,  and  that  I  have,  no  alteration  to 
make  in  my  previous  report.' 

As  long  as  it  was  a  question  of  testing  the  cor- 
rectness of  my  statements,  it  was  not  necessary  to 
know  what  the  remedy  contained  or  whence  it 
originated.  On  the  contrary,  the  trial  was  likely 
to  prove  the  more  unbiased  the  less  was  known 
of  the  remedy  itself.  But  now  that  the  proof  has, 
as  seems  to  me,  been  offered  in  sufficient  quantity 
and  has  resulted  in  establishing  the  value  of  the 
remedy,  the  next  problem  to  be  worked  out  will 
be,  to  stud}'  the  remedy  beyond  the  extent  to 
which  it  has  hitherto  been  applied,  and  if  possi- 
ble, to  employ  the  principles  which  have  led  to 
its  discovery,  in  other  diseases.  This  problem 
requires,  self-evidently,  a  full  knowledge  of  the 
remedy,  and  I,  therefore,  consider  that  the  time  has 
arrived  to  make  the  necessary  statements  in  this 
direction  and  which  will  appear  in  the  following. 
Before  I  touch  upon  the  remedy  itself,  I  think  it 
advisable  to  the  better  understanding  of  its  mode 
of  action,  to  shortly  indicate  the  road  by  which  I 
arrived  at  its  discovery. 

When  a  healthy  guinea  pig  is  inoculated  with 
a  pure  culture  of  tubercle  bacilli  the  inoculation 
wound,  as  a  rule,  closes  and  appears  to  heal  dur- 
ing the  first  few  days,  but  in  the  course  of  ten  or 
fourteen  days  there  forms  a  hard  nodule  which 
soon  breaks  open  and  becomes  an  ulcerating  sur- 
face which  persists  until  the  death  of  the  animal. 
But  the  case  is  very  different  when  a  guinea  pig 
is  inoculated  which  already  has  tuberculous 
disease.  For  this  purpose  are  best  suited  ani- 
mals which  four  to  six  weeks  beforehand  were 
successfully  inoculated.  In  such  an  animal  the 
small  wound  of  inoculation  closes  at  the  begin- 
ning, no  nodule  forms  there,  however,  but  on  the 
next  or  second  day  a  peculiar  change  takes  place 
at  the  injection  spot.  This  place  grows  hard 
and  becomes  of  a  darker  color,  and  then  this 
change  is  confined  not  merely  to  the  vaccina- 
tion site,  but  spreads  about  its  neighboorhood  to 
a  diameter  of  0.5  to  1  cm.  During  the  following 
days  it  appears  more  and  more  evident  that  the 
skin  thus  changed  is  necrotic;  it  is  finally  thrown 
off  and  there  remains  a  superficial  ulceration 
which   usually   heals    rapidly   and    permanently 


-  Regarding  the  permanency  of  the  cure.  I  should  like  to  men- 
tion here  that  of  the  patients  which  I  had  for  the  time  being  pro- 
nounced cured,  two  have  returned  to  the  Moabit  Hospital  for  fur- 
ther observation,  and  that  for  the  last  three  months  no  bacilli  have 
been  found  in  their  sputa;  the  physical  signs  also  have  gradually 
disappeared  in  these  cases. 


without  the  neighboring  lymph  glands  becoming 
Infected. 

The  inoculated  tubercle  bacilli  thus  act  quite 
differently  upon  the  skin  of  a  healthy  than  upon 
that  of  a  tuberculous  guinea  pig.  Now  this 
striking  effect  does  not  by  any  means  belong  ex- 
clusively to  the  living  tubercle  bacilli,  for  it  is 
brought  about  in  much  the  same  manner  by  the 
dead  ones,  and  it  is  unessential  whether  they  are 
destroyed,  as  in  my  first  attempts,  by  low  tem- 
perature of  long  duration,  by  boiling  heat  or  by 
certain  chemicals. 

After  this  peculiar  fact  was  found,  I  have  fol- 
lowed it  out  in  all  directions,  and  there  then  fur- 
ther resulted  that  (abgetodet)  pure  cultures  in 
which  the  tubercle  bacilli  have  been  killed,  after 
having  been  triturated  and  suspended  in  water, 
could  be  injected  in  large  quantities  under  the 
skin  of  healthy  guinea  pigs  without  anything  en- 
suing beyond  a  local  suppuration.3  Tuberculous 
guinea  pigs  on  the  other  hand  are  killed  by  the 
injection  of  even  very  small  quantities  of  such 
suspended  cultures,  and  this  occurs,  according  to 
the  dose  applied,  in  from  six  to  forty- eight  hours. 
A  dose  which  is  just  insufficient  to  kill  the  ani- 
mal can  cause  an  extensive  necrosis  of  the  skin, 
about  the  place  of  injection.  Now,  if  the  suspen- 
sion (Aufschuemmung)  be  still  further  diluted 
until  it  is  barely  visibly  turbid,  then  the  animals 
remain  alive,  and  if  the  injections  are  continued 
at  intervals  of  one  or  two  days  there  soon  occurs 
a  marked  improvement  in  their  condition;  the 
ulcerating  inoculation  wound  grows  smaller  and 
finally  cicatrizes,  this,  without  such  treatment, 
never  is  the  case;  the  swollen  lymph  glands  dim- 
inish in  size;  the  general  nutrition  improves  and 
if  the  disease  process  is  not  too  far  advanced  and 
the  animal  does  not  die  of  adynamia,  it  comes  to 
a  stop. 

Hereby  was  given  the  foundation  for  a  cura- 
tive treatment  of  tuberculosis.  To  the  practical 
application,  however,  of  such  suspensions  (Auf- 
schuemmungen)  of  "killed  off''  (abgetodet)  pure 
cultures  of  tubercle  bacilli,  the  objection  offered 
itself  that  at  the  sites  of  injections  the  tubercle  ba- 
cilli are  not  absorbed,  nor  do  they  in  any  other  way 
disappear,  but  that  they  remain  lying  unchanged 
for  a  long  time  and  form  greater  or  smaller  sup- 
puration foci. 

That  which,  in  this  proceeding,  has  the  heal- 
ing influence  on  the  tuberculous  process  had  con- 
sequently to  be  a  soluble  substance,  which,  by  the 
fluids  of  the  body  surrounding  the  tubercle  bacilli, 
is  in  some  manner  extracted  and  then  quite 
rapidly  brought  into  the  circulation,  while  that 
which  has  the  suppurative  effect  apparently  re- 
mains behind  in  the  bacilli,  or  goes  into  solution, 
but  very  slowly. 

The  main  point,  therefore,  was  to  institute  out- 

3  Injections  of  this  nature  are  among  the  simplest  and  surest 
means  of  producing  suppurations  which  are  free  "from  living  bac- 
teria. 


264 


A  REMEDY  FOR  TUBERCULOSIS. 


[February  21, 


side  of  the  body  the  process  which  took  place 
within,  and  if  possible  to  extract  and  isolate  from 
the  tubercle  bacilli  the  healing  substance.  This 
problem  has  required  much  trouble  and  time,  but 
I  finally  succeeded  in  separating  the  efficacious 
material  from  the  bacilli,  with  the  help  of  a  40 
per  cent,  to  50  per  cent,  of  glycerine  solution.  It 
is  with  fluids  thus  procured  that  I  have  made  the 
further  experiments  on  animals  and  finally  on 
human  beings;  these  fluids  have  been  given  to 
other  physicians  for  the  repetition  of  the  experi- 
ments. 

The  remedy  with  which  the  new  treatment  for 
tuberculosis  is  carried  on  is  therefore  a  glycerine 
extract  of  the  pure  cultttres  of  the  tubercle  bacilli. 

Out  of  the  tubercle  bacilli  there,  of  course, 
passes  into  this  simple  extract  not  the  efficacious 
substance  alone,  but  also  all  the  other  substances 
which  are  soluble  in  a  50  per  cent,  glycerine  solu- 
tion, and,  therefore,  there  are  found  in  it  a  cer- 
tain quantity  of  mineral  salts,  coloring  matters 
and  other  unknown  extractive  matters.  Some  of 
these  ingredients  can  be  rather  easily  separated. 
The  efficacious  substance  is  insoluble  in  and 
can  be  precipitated  by  absolute  alcohol,  to  be  sure 
not  pure,  because  together  with  it  are  precipitated 
other  extractive  materials  which  are  also  insolu- 
ble in  the  alcohol.  The  coloring  substance  it  is 
true  can  be  removed,  so  that  it  is  possible  to  pro- 
cure from  the  extract  a  colorless  dry  substance 
containing  the  active  principle  in  a  more  concen- 
trated form  than  the  original  glycerine  solution. 
For  practical  application,  this  purification  of  the 
glycerine  extract  offers,  however,  no  advantage, 
because  the  substances  thus  removed  are  indif- 
ferent to  the  human  organism  and  therefore  the 
purifying  process  would  only  render  the  remedy 
unnecessarily  more  expensive. 

The  constitution  of  the  efficacious  material  is 
so  far  a  mere  matter  of  conjecture.  It  appears  to 
me  to  be  a  derivative  of  albuminous  bodies  and 
clearly  related  to  them,  and  does  not  belong  to 
the  group  of  so-called  tox-albumins,  because  it 
bears  high  temperatures  and  passes  easily  and 
rapidly  through  the  membrane  of  the  dialyzer. 
The  quantity  of  the  substance  contained  in  the 
extract  is  apparently  very  small;  I  estimate  it  at 
fractions  of  1  per  cent.  We  have  then,  if  my 
supposition  is  correct,  a  substance  the  effect  of 
which  on  tuberculously  diseased  organisms  far 
surpasses  what  is  known  to  us  of  the  most  power- 
ful drugs. 

As  to  the  manner  in  which  we  have  to  imagine 
the  specific  action  of  the  remedy  on  tuberculous 
tissue,  different  hypotheses  can,  of  course,  be  en- 
tertained. Without  wishing  to  assert  that  my 
opinion  affords  the  best  explanation,  I  believe 
the  process  to  be  the  following:  The  tubercle  ba- 
cilli produce  by  their  growth  in  living  tissues, 
the  same  as  in  artificial  cultures,  certain  sub 
stances  which  influence  the  living  elements,  the 


cells,  in  their  neighborhood  in  varied  but  always 
harmful  manner.  Among  them  there  is  one  sub- 
stance, which  in  certain  concentration,  kills  liv- 
ing protoplasm  and  so  changes  it  that  it  passes 
into  the  state  termed  by  Weigert  coagulation  ne- 
crosis. In  the  tissue  grown  necrotic  the  bacillus 
then  finds  such  unfavorable  conditions  of  nutri- 
tion that  it  is  unable  to  keep  on  growing  and  un- 
der certain  circumstances  even  dies  off.  In  this 
manner  I  explain  to  myself  the  striking  coinci- 
dence that  in  organs  recently  affected  with  tuber- 
culous disease, — for  instance,  in  a  guinea  pig's 
spleen  or  liver,  which  is  full  of  disseminated  gray 
nodules — we  find  numerous  bacilli,  while  they 
are  scarce  or  altogether  absent  when  the  enor- 
mously enlarged  spleen  consists  almost  entirely 
of  white  substance  in  a  state  of  coagulation  ne- 
crosis, as  is  often  found  after  the  death  of  guinea 
pigs  from  tuberculosis.  Therefore  the  individual 
bacillus  is  unable  to  cause  necrosis  to  any  great 
distance,  for  as  soon  as  the  necrosis  has  reached 
a  certain  extent,  the  growth  of  the  bacillus  de- 
creases and  thereby  also  the  production  of  the 
necrotizing  substance;  hence  there  results  a  kind 
of  mutual  compensation  which  causes  the  vegeta- 
tion of  individual  bacilli  to  remain  so  remarkably 
limited,  c.  g.,  in  lupus  and  scrofulous  glands, 
etc.  In  such  cases  the  necrosis  ordinarily  con- 
cerns only  a  part  of  the  cell,  which  then  in  its 
further  growth  takes  the  peculiar  form  of  the 
giant  cell;  I  thus,  from  this  point  of  view,  accept 
the  explanation  first  given  by  Weigert  of  the 
formation  of  giant  cells. 

If  the  quantity  of  necrotizing  substance  was 
now  artificially  increased  around  the  bacillus,  the 
necrosis  would  extend  to  a  greater  distance  and 
thereby  the  conditions  of  nutrition  for  the  bacillus 
would  become  much  less  favorable  than  usually 
is  the  case.  On  the  one  hand,  then,  the  tissue 
grown  necrotic  to  a  greater  or  less  extent  would 
perish,  become  detached  and  wherever  possible 
j  carry  away  with  it  and  extrude  the  enclosed  ba- 
cilli; on  the  other  hand  the  bacilli  would  be  so 
!  greatly  disturbed  in  their  vegetation  that  they 
J  would  be  much  more  liable  to  die  off  than  under 
ordinary  circumstances. 

The  working  of  the  remedy  to  me  seems  to 
consist  in  the  production  of  just  such  changes. 
It  contains  a  certain  quantity  of  the  necrotizing 
substance,  a  sufficiently  large  dose  of  which  dam- 
ages certain  tissue  elements  also  in  the  healthy 
subject — possibly  the  white  blood  corpuscles  or 
cells  closely  related  to  them,  and  thereby  pro- 
duces fever  and  the  entire  complex  symptoms. 
In  the  tuberculous  subject,  however,  a  very  much 
smaller  quantit}'  suffices  to  cause  in  certain  places, 
namely,  where  tubercle  bacilli  vegetate  and  have 
already  impregnated  their  surroundings  with  the 
same  necrotizing  substance,  necrosis  of  cells,  more 
or  less  extensive,  and  in  connection  therewith 
consecutive  symptoms  in    the  whole  organism. 


I89i-J 


A  STUDY  OF  STERILITY. 


265 


In  this  way  we  can,  at  least  for  the  present,  ex- 
plain the  specific  influence  which  the  remedy,  in 
quite  definite  doses,  exercises  on  tuberculous  tis- 
sue; next  the  possibility  of  raising  these  doses  so 
remarkably  fast;  and  finally  the  curative  effect 
which  undeniably  exists  in  those  cases  which  are 
but  moderately  favorable. 


A  STUDY  OF  STERILITY,  ITS  CAUSES 
AND  TREATMENT. 

Being  an  Essay  which  received  the  First  Prize  of  the  Alumni  Associ- 
ation 0/  the  College  of  Physicians  and  Surgeons,  Baltimore. 

BY  THOS.  W.  KAY,   M.D.. 

OF  SCRANTON,  PA. 

{Concluded  from  page  229.) 
TREATMENT. 

i.  Nonproduction. — Male. — (a.)  Should  the 
testes  of  the  male  be  congenitally  absent  from  the 
scrotum  there  is  a  possibility  of  their  being  pres- 
ent in  the  abdominal  cavity,  but  in  either  case  if 
aspermia  or  azoospermia  exists,  treatment  is  use- 
less. Should  spermatozoa  exist  in  small  quan- 
tities the  same  remedies  can  be  used  that  are  em- 
ployed in  early  decay.  These  can  also  be  used  in 
cases  of  retarded  development. 

(£.)  Where  inflammatory  or  other  troubles  have 
produced  destruction  of  the  glandular  structure, 
restoration  of  the  destroyed  tissue  is  impossible; 
but  under  iodides  and  mercurials  with  counter- 
irritants  and  electricity,  the  inflammatory  de- 
posits may  be  absorbed  and  the  arrested  secretion 
from  the  remaining  healthy  portions  reestablished. 

(c.)  When  sterility  in  the  male  is  accompanied 
by  atrophy  or  softening  coincident  with  varicocele, 
hernia,  or  other  benign  tumors,  the  prognosis  is 
good,  if  the  individual  will  submit  to  surgical 
treatment  in  time.  The  tumors  should  be  extir- 
pated and  the  testes  injured  as  little  as  possible. 
In  all  cases  of  hernia  where  a  truss  is  not  suit- 
able the  radical  cure  should  be  undertaken.  Of 
all  the  methods  used  for  varicocele  the  best  is 
ligating  the  veins  above  and  below,  by  the  open 
method,  and  dividing  them  between.  Hydrocele 
should  be  first  treated  by  withdrawing  the  fluid 
and  injecting  irritating  substances,  after  which,  if 
a  cure  is  not  effected,  more  radical  measures  can 
be  adopted.  For  malignant  tumors,  thorough 
extirpation  has  to  be  resorted  to  and  the  prog- 
nosis is  very  unfavorable  for  future  posterity. 

(</.)  If  sterility  is  subsequent  to  some  consti- 
tutional disease,  attention  must  be  directed  to 
building  up  the  general  health.  A  sea  voyage, 
a  trip  to  the  mountains,  sea  bathing,  or  a  stay  at 
some  chalybeate  springs  will  be  found  beneficial 
in  anaemic  or  debilitated  persons. 

In  obese  and  plethoric  subjects  the  saline 
springs  will  be  preferable,  while  a  course  of  lax- 
atives, careful  dieting  and  regular  exercise  will 
exert  a  beneficial  influence.      Should  the  cause 


be  traced  to  masturbation  or  excessive  venery, 
bromides  must  be  used,  while  the  will  power  is 
appealed  to  and  the  patient  removed  as  far  as  pos- 
sible from  all  exciting  causes. 

Debility  of  the  sexual  organs  can  be  best  over- 
come by  cold  douches  and  electricity,  while  the 
phosphides,  nux  vomica,  and  cantharides  are 
employed  internally. 

Female. — (a.)  Congenital  absence  of  the  ova- 
ries can  not,  of  course,  be  remedied,  and  non-de- 
velopment is  almost  as  hopeless,  though  there  is 
reason  to  believe  that  the  use  of  electricity  and 
massage,  long  continued,  may  stimulate  the  de- 
velopment of  the  glands.  Where  dislocation  of 
the  ovaries  depends  on  uterine  displacements  it 
should  be  treated  by  attending  to  the  false  uterine 
position.  If  the  ovary-  alone  is  dislocated  it  can 
frequently  be  treated  by  a  pessary,  unless  in  the 
inguinal  canal,  when  it  should  be  replaced  and 
supported  by  a  proper  fitting  truss. 

(6.)  Little  can  be  done  when  atrophy  of  the 
ovaries  follows  wasting  diseases,  except  to  use 
tonics  and  such  remedies  as  are  used  in  atrophied 
testes,  hoping  thereby  to  cause  development  of 
such  follicles  as  ha%Te  escaped  the  inflammatory 
process.  Much,  however,  can  be  done  to  pre- 
vent inflammatory  troubles  by  preventing  early 
marriages.  Women,  as  a  rule,  unless  well  de- 
veloped, should  not  marry  under  twenty  years  of 
age,  and  in  man3'  cases  it  is  best  to  wait  until 
the  twenty-second  year.  In  pelvic  inflammations, 
where  exudation  has  taken  place,  it  is  well  to 
withdraw,  by  aspiration,  what  fluid  can  be  ob- 
tained and  thus  abort  the  trouble.  Dr.  Hardon, 
of  Atlanta,  Ga.,  speaks  highly  of  this  treatment, 
and  I  have  seen  the  happiest  results  follow  its 
use.  Where  due  to  syphilitic  infection  the  in- 
flammatory deposits  must  be  treated  by  iodides 
and  mercurials  while  tonics  are  given  to  build  up 
the  general  health.  Where  atrophy  of  the  ovaries 
is  due  to  contraction  of  inflammatory  deposits, 
which  dislocate  or  compress  the  ovaries,  much 
benefit  can  be  obtained  from  the  long-continued 
use  of  hot  water  vaginal  injections,  massage  and 
galvanism.  Yaginal  and  rectal  suppositories, 
containing  iodine,  iodoform,  or  one  of  the  iodides, 
can  also  be  used  with  advantage.  With  the 
local  treatment  we  should  also  use  tonics  and 
such  remedies  as  are  best  calculated  to  build  up 
the  constitution. 

(V.)  Where  malignant  growths  affect  the 
ovaries,  early  and  complete  removal  must  be  re- 
sorted to,  but  if  the  growth  is  benign,  the  opera- 
tor should,  if  possible,  leave  as  much  of  the  ovary 
as  appears  to  be  healthy,  in  the  interest  of  future 
generations. 

(rf.)  The  sterility  attending  anaemia,  chlorosis 
and  other  constitutional  affections  must  be  treated 
on  general  principles.  Tonics,  baths,  chalybeate 
waters,  voyages,  change  of  scenery  and  surround- 
ings, can  all  be  used,  while  good  and  nutritious 


266 


A  vSTUDY  OF  STERILITY. 


[February  21, 


food  must  be  furnished  and  regular  out-door  ex- 
ercise enjoined.  Where  the  persons  are  addicted 
to  the  use  of  drugs  they  will  have  to  be  gradually 
weaned  off  and  some  substitute  used  till  the  phy- 
sical and  moral  nature  is  sufficiently  strong  to 
enable  them  to  abstain. 

In  cases  of  obesity,  rich,  saccharine,  fatty  and 
starchy  foods  must  be  forbidden,  regular  and 
daily  out-door  exercise  required,  and  sea  bathing 
and  saline  waters  advised.  In  the  way  of  med- 
ication aloes,  iron,  nux  vomica,  and  phosphorus 
can  be  employed  advantageously.  Despres  re- 
lates cases  where  the  application  of  electricity 
produced  sexual  excitement  with  a  discharge  of 
vaginal  and  uterine  secretions,  and  it  is  more 
than  likely  that  the  same  agent  will  be  found  of 
use  where  non- production  of  ova  is  due  to  a  slug- 
gish condition  of  the  female  genitalia.  Little 
can  be  done  by  the  physician  in  inherited  sterility 
except  to  pay  attention  to  the  general  functions 
of  the  body,  but  he  should,  wherever  he  can  act 
as  the  family  adviser,  impress  on  his  patients  the 
evils  of  inter-marriage,  and  do  all  that  he  can  to 
prevent  such  unions. 

2.  Nonunion.  Male. —  (a.)  Any  absence  or 
occlusion  of  the  ducts  situated  between  the  testes 
and  the  urethra  is  naturally  out  of  reach  of  the 
surgeon,  unless  the  occlusion  is  due  to  pressure 
from  a  tumor  of  the  cord  or  elsewhere,  in  which 
case  it  can  be  readily  removed.  The  causes  of 
non-union  in  the  male  are  fortunately  situated, 
as  a  rule,  in  the  urethra,  and  these  can  gen- 
erally be  remedied.  In  urethral  fistula,  epispa- 
dias, and  hypospadias,  the  defect  can  be  reme- 
died by  a  plastic  operation.  Phymosis,  stenosed 
meatus  and  dilated  meatus  can  also  be  easily 
remedied  by  simple  operations.  It  is  in  strict- 
ures of  the  urethra,  however,  that  the  surgeon  has 
to  employ  his  ingenuity,  and  wide  differences  of 
opinion  exist  as  to  the  best  methods  to  employ. 
Soft  stricture  usually  yields  readily  to  dilatation, 
but  the  fibrous  stricture  should  be  treated  by 
urethrotomy  and  electrolysis.  Otis,  of  New  York, 
prefers  internal  urethrotomy;  Stein,  of  New  York, 
thinks  gradual  dilatation  best;  Keyes,  of  New 
York,  practices  external  urethrotomy  for  strictures 
from  injuries;  Lavaux,  of  Paris,  claims  a  new 
method  which  he  calls  "divulsion  progressive," 
where  a  cure  can  be  effected  in  eight  days;  and 
every  town  of  any  size  now  has  its  ardent  advo- 
cate of  electrolysis.  Should  the  breadth  of  a 
fibrous  stricture  be  narrow  it  may  be  advantage- 
ously excised  by  external  urethrotomy  and  the 
two  portions  of  the  urethra  carefully  drawn  to- 
gether and  united  by  sutures. 

(b.)  Though  the  gonorrhoeal  poison  is  one  of 
the  most  potent  factors  in  producing  sterility, 
yet  it  probably  affects  the  vitality  of  the  sperma- 
tozoa very  little  as  they  pass  through  the  urethra. 
It  is  well,  though,  in  every  case  to  check  the  dis- 
charge as  soon  as  possible,  and  for  this  I  have 


found  injections  of  creolin  or  of  sublimate  solu- 
tions among  the  best  remedies. 

(c.)  The  use  of  artificial  means  by  the  male  to 
prevent  conception  can  not  be  too  severely  con- 
demned, for  they  are  injurious  both  morally  and 
physically.  Abstinence  from  coitus,  and  coitus 
only  about  midway  between  the  two  monthly 
periods  are  the  only  legitimate  means  to  be  em- 
ployed, where  there  is  a  desire  to  avoid  concep- 
tion. 

((/.)  In  individuals  of  excitable  dispositions, 
where  orgasm  comes  on  before  that  of  the  female, 
bromides  can  be  given,  but  in  time  each  individ- 
ual will  learn  the  other's  disposition  and  be  able 
to  hasten  or  delay  orgasm  till  the  proper  moment. 
If  this  is  not  accomplished  in  a  reasonable  length 
of  time,  it  may  be  well  to  separate  the  parties  for 
a  longer  or  shorter  period,  at  the  end  of  which 
time  the  difference  in  disposition  will  probably 
not  be  as  great.  Where  neuroses  of  the  genital 
tract  exist  there  will  generally  be  found  some 
tenderness,  or  it  ma;-  be  a  stricture  of  the  urethra. 
In  either  case  attention  must  be  directed  to  the 
seat  of  the  trouble.  If  orgasm  seems  to  be  re- 
tarded by  exhaustion  of  the  nerve  centres  nothing 
will  be  found  better  than  phosphide  of  zinc  and 
nux  vomica.  Where  the  trouble  seems  to  be  due 
to  a  dilatation  of  the  dorsal  vein  of  the  penis,  sub- 
cutaneous injections  of  ergotin  by  the  side  of  the 
vein  will  be  found  useful.  Jamin,  of  Paris,  re- 
ported a  case  where  imperfect  erection  was  cured 
by  the  surgical  treatment  of  an  accompanying 
varicocele.  Yidal  de  Cassis  reported  a  similar 
case  and  I  have  succeeded  in  curing  another  case 
by  the  same  treatment. 

Female. — (a.)  All  abnormal  conditions  of  the 
ovaries  and  of  the  ova  which  prevent  the  escape 
of  the  ova  or  the  subsequent  entrance  of  the  sper- 
matozoa are  irremediable.  So  also  is  absence  or 
imperfect  development  of  the  tubes  and  absence 
of  the  uterus.  In  cases  of  double  uterus  opera- 
tive interference  is  not  called  for,  nor  is  it  in 
double  vagina  unless  the  septum  prevents  coitus. 
Where  there  is  partial  or  complete  absence  of  the 
vagina,  with  a  normal  uterus  present,  an  artificial 
vagina  can  be  made  by  carefully  dissecting  be- 
tween the  bladder  and  rectum  so  as  to  avoid 
injury  to  these  organs.  In  unmarried  females 
tents  will  have  to  be  used  occasionally  to  keep  it 
from  contracting,  but  after  marriage  the  male 
organ  will  usually  render  the  use  of  the  tent  un- 
necessary. 

The  discovery  of  an  imperforate  hymen  is  usu- 
ally made  at  puberty,  and  is  easily  remedied  by 
incising,  but  all  antiseptic  precautions  must  be 
used  to  prevent  septic  absorption.  Should  coitus 
be  prevenUd  by  a  rigid  hymen  or  an  abnormal 
condition  of  the  vulva,  a  slight  and  harmless  sur- 
gical operation  will  set  all  to  rights. 

Atresia  of  the  cervical  canal  is  best  operated  on 
by   a   trocar,    and  dilators  used   afterwards.      If 


I89i.] 


A  STUDY  OF  STERILITY. 


267 


hsematometra  is  present  the  same  care  must  be 
used  as  recommended  in  operating  on  haemato- 
colpas,  for  septic  poisoning  is  exceedingly  easy 
after  the  operation.  Stenosis  of  the  cervical  canal 
can  be  treated  by  incision,  or  by  dilating  with 
instruments  for  that  purpose,  but  the  best  and 
most  permanent  results  are  obtained  from  the 
occasional  use  of  tents. 

For  absence  or  abnormal  shortness  of  the  intra- 
vaginal  portion  of  the  cervix  there  is  no  remedy. 
Where  uniform  elongation  or  hypertrophy  of  the 
cervix  exists  amputation  must  be  resorted  to,  but 
in  the  operation  care  should  be  used  to  unite  the 
mucous  membrane  of  the  cervical  canal  to  that 
surrounding  the  cervix  so  as  to  prevent  subse- 
quent stenosis.  In  sterility  due  to  stenosis  or 
flexions  the  "Outerbridge  dilator"  will  be  found 
of  service,  if  introduced  several  days  before  the 


gives  the  best  results  in  cases  of  simple  retrover- 
sion, but  has  been  used  in  nearly  all  displace- 
ments. Picque,  following  the  operation  Olshau- 
sen,  has,  where  the  uterus  was  bound  down, 
opened  the  abdomen,  divided  the  bands  and  at- 
tached the  uterine  ligaments  to  the  abdominal 
parietes.  The  result  was  good,  but  it  might  be 
well  to  adopt  the  method  of  Erich  and  forcibly 
separate  the  adhesions  by  a  large  steel  sound  in- 
troduced into  the  uterine  cavity.  It  seems  also 
that  the  safety  of  these  operations  might  be  in- 
creased by  incising  only  as  far  as  the  peritoneum 
and  suturing  without  opening  the  abdominal 
cavity.  Contracted  pelvis  is  a  rare  cause  of  im- 
pediment to  the  entrance  of  the  semen,  and  when 
it  is  can  not  be  remedied. 

Acquired  stenosis  or  atresia  of  the  genital  tract 
must  be  treated  in  the  same  way  as  the  congeni- 


menses  make  their  appearance.  Where  hyper- ;  tal  form,  and  usually  gives  better  results, 
trophy  of  the  cervix  is  confined  to  only  one  side,  !  The  evil  results  of  inflammatory  deposits  about 
amputation  can  be  practiced  or  the  convex  por- 1  the  uterus  and  its  appendages  have  been  dwelt 
tion  of  the  cervix  can  be  incised  so  as  to  remove  j  on  in  speaking  of  the  causes  of  sterility.  When 
the  obstruction.  Conical  and  nozzle-shaped  cer- ;  the  acute  stage  has  passed  such  remedies  should 
vices  must  also  be  amputated.     In  cases  of  lacer-   be  used  as  will  favor  the  absorption  of  the  de 


ated  cervix  or  lacerated  perineum  the  duty  of  the 
surgeon  is  to  repair  the  injured  part  as  soon  as 
possible. 


posits.  Copious  injections  of  hot  water,  in  both 
vagina  and  rectum,  are  found  very  serviceable  in 
producing  these  results,  but  they  must  be  long 


Iu   all  displacements  of  the  uterus  an   effort !  coutinued  to  produce  the  best  results.     Tampons 


should  be  made  to  restore  the  normal  position 

Prolapse  can  be  treated  by  massage,  hot 
douches,  astringent  tampons,  pessaries,  sup- 
porters, or  some  of  the  surgical  procedures  to  be 


of  glycerine  with  or  without  iodine,  or  iodide  of 
potash  also  exert  a  favorable  influence.  Rectal 
and  vaginal  suppositories  of  iodine,  iodide  of 
potash,   or  iodoform  have  yielded  excellent  re- 


mentioned  hereafter.     Where  flexions  exist  tents  suits  in  my  hands,  when  combined  with  tonics 

should  be  used  to  soften  the  uterine  tissue  and  and  hot-water  injections. 

straighten  out  its  axis,  after  which   intra-uterine  In  some  cases  local  blood-letting  will  be  found 

stems,   tampons  or  pessaries  should  be  used  to  serviceable.      With  all  these  remedies  absolute 

keep  it  in  its   normal    position.      Versions   can  abstinence  from  sexual  excitement  must  be  en- 


often  be  treated  by  tampons  and  pessaries,  and 
Bouill}',  of  Paris,  recently  reported  eighty  cases 
of  retro-deviations  treated  successfully  by  pes- 
saries; of  this  number  three  had  subsequently  be- 
come pregnant.  Should,  however,  the  displace- 
ments be  of  long  standing  it  will  be  well  to  re- 
sort to  surgical  interference.      Alexander  has  de- 


joined. 

Electricity  has  been  introduced  by  Dr.  Georges 
Apostoli  in  the  treatment  of  these  affections,  and 
its  long  continued  use  in  chronic  and  subacute 
cases  has  been  followed  by  the  most  excellent  re- 
sults. 

Engelmann  and  many  others,   both  here  and 


vised  a  means  of  shortening  the  round  ligaments  abroad,  testify  to  its  efficacy, 
of  the  uterus,  which  has  been  modified  somewhat  Major  Thure  Brandt,  of  Stockholm,  was  the 
by  Polk  and  Wylie.  This  operation  gives  the  first  to  use  massage  in  uterine  affections,  after 
best  results  for  simple  retro-deviations,  but  it  has  which  it  was  practiced  by  Dr.  Sahlin  of  the 
also  been  used  in  prolapse.  In  the  latter  case  it  Stockholm  medical  school.  In  1870  Dr.  Nos- 
is  best  to  accompany  it  by  some  operation  for ',  trdm,  of  Paris,  became  interested  in  the  subject, 
narrowing  the  vagina  or  increasing  the  perineal '  and  after  carefully  studying  it  introduced  it  into 
support.  In  a  case  of  prolapse  Freuud,  of  Strass-j  Paris  in  1872,  since  which  time  it  has  been  dif- 
bourg,  opened  Douglas'  cul-de-sac  and  attached  fused  over  the  whole  civilized  world. 
the  fundus  uteri  to  the  peritoneum  of  the  sacrum.  It  has  been  used  for  uterine  displacements, 
This  he  calls  retro -fixation.  Yentro-fixation  con-  metritis  and  ovaritis,  but  its  most  satisfactory  re- 
sists in  opening  the  abdominal  cavity  and  attach-  suits  have  been  made  in  peri-uterine  exudates  of 
ing  the  uterus  "to  the  abdominal  parietes.  It  is  longstanding.  Semiauikoff,  of  St.  Petersburgh, 
steadily  growing  in  favor  and  has  the  hearty  sup-  reports  favorably  of  it,  as  do  also  Profs.  Jackson 
port  of  such  men  as  Lucas-Championniere,  and  Martin,  of  Chicago,  Drs.  Smith  and  Athdl,  of 
Polaillon,  and  Terrier,  of  Paris;  Sanger,  of  Ger- ,  England,  and  many  others.  Boldt,  of  New  York, 
many;  Kellv,  of  America,  and  many  others.      It  |  calls  attention  to  the  fact  that  great  care  must  be 


268 


A  STUDY  OF  STERILITY. 


[  February  21, 


used  where  accumulations  of  fluid  exist  in  the 
tubes.  To  get  satisfactory  results  massage  must 
be  carried  out  by  the  gynecologist  himself,  and 
persevered  in  for  a  long  time.  Only  chronic  and 
subacute  cases  should  be  subjected  to  treatment, 
and  where  the  finger  of  the  operator  is  not  long 
enough  to  reach  the  deposits  he  may  resort  to 
the  obturator  of  Wissenberg,  the  end  of  which 
may  be  covered  with  rubber  if  much  tenderness 
is  experienced. 

When  hydro-,  hsemato-,  or  pyo-saipinx  exist, 
they  may  be  overcome  by  putting  the  patient 
under  an  anaesthetic,  dilating  the  uterus,  break- 
ing up  what  adhesions  exist,  and  thoroughly 
curetting  the  endometrium,  especially  around  the 
openings  of  the  tubes.  Intra- uterine  galvanism 
is  also  useful,  and  cases  have  been  reported  where 
the  obstruction  in  the  tube  has  been  overcome  in 
this  way.  In  the  early  stages  of  salpingitis  it  is 
well  to  follow  the  treatment  of  Dr.  Mangan,  of 
Marseilles—  use  rest,  sedatives,  and  cold  to  the  j 
abdomen,  while  hot  vaginal  injections  are  em- 
ployed, and  when  the  case  becomes  more  chronic 
apply  medicated  glycerine  tampons  to  the  cervix 
and  iodoform  pencils  to  the  interior  of  the  uterus. 
With  these  remedies  it  is  well  to  combine  tonics 
and  baths. 

Should  vaginismus  be  the  cause  of  sterility  the 
remedies  employed  must  be  adapted  to  the  cause 
of  the  vaginismus.  Solutions  of  lead,  silver  and 
zinc  may  be  employed  for  the  inflammatory  pro- 
cess, while  cocaine,  belladonna  and  morphia  will 
relieve  the  irritation  and  pain.  Coitus  under 
chloroform  has  been  advised  but  does  not  relieve 
the  trouble.  Gradual  dilatation  with  specula  has 
been  used,  but  probably  the  best  remedy  is  to  ex- 
cise the  hymen  close  to  its  insertion.  When  vag- 
inismus is  due  to  uterine  fibroids  galvanism  will 
usually  effect  a  cure  if  sufficiently  long  continued. 

In  all  cases  where  non-union  of  the  ova  and 
spermatozoa  is  due  to  hypertrophy  or  tumors  of 
either  the  external  or  internal  organs  of  genera- 
tion, the  surgeon  should  remove  the  cause  if  pos- 
sible. The  fact  of  sterile  women  becoming  preg- 
nant after  the  removal  of  uterine  or  ovarian  tu- 
mors is  well  known  to  all. 

Should  the  acid  secretions  of  the  vagina  be  in- 
jurious to  the  spermatozoa,  boracic  acid  will  be 
found  to  be  an  excellent  remedy.  Potter,  of  Buf- 
falo, employs  vaginal  tamponnement  with  this  rem- 
edy in  cases  of  sterility,  and  claims  good  results 
from  its  use.  Kisch  recommends  a  warm  aque- 
ous saccharine  solution  rendered  alkaline  by 
caustic  potash,  and  Chassier  uses  a  solution  of 
white  of  egg  and  phosphate  of  soda,  in  which  the 
spermatozoa  are  said  to  live  for  a  long  time. 

Where  the  impediment  seems  to  be  due  to  a 
thickened  cervical  secretion,  it  will  be  well  to  in- 
troduce a  tampon,  saturated  with  glycerine,  sev- 
eral hours  before  coitus,  and  remove  it  before  the 
act  is  accomplished. 


Vaginal  catarrh  can  be  best  remedied  by  injec- 
tions of  solutions  of  corrosive  sublimate,  creolin 
and  boracic  acid,  though  the  astringent  metallic 
salts  can  be  used  with  advantage,  and  where  much 
pain  exists  sedatives  and  demulcents  should  be 
employed.  Parvin,  of  Philadelphia,  and  Jules 
Cheron,  of  Paris,  speak  in  the  highest  terms  of 
the  use  of  creolin,  employed  either  in  solution  or 
as  an  ointment. 

The  diagnosis  of  acute  endometritis  is  usually' 
easy,  but  where  chronic  endometritis  is  suspected 
it  is  best  to  follow  the  advice  of  Schultze,  of  Jena. 

This  consists  in  inserting  a  glycerine  tampon 
against  the  external  os  at  night,  which,  on  re- 
moval in  the  morning,  will  have  a  small  quantity 
of  pus  on  it,  if  endometritis  is  present.  The  cure 
of  simple  catarrhal  endometritis  may  be  effected 
by  glycerine  tampons,  and  hot  douches  as  rec- 
ommended by  Hermann,  of  London  ;  or  a  solu- 
tion of  morphine  may  be  employed  with  success, 
according  to  Siviecceki.  Where  the  cases  are 
more  obstinate  solutions  of  nitrate  of  silver,  sul- 
phate of  copper,  tr.  of  iodine,  carbolic  acid  or 
creasote  can  be  used  with  advantage,  but  better 
results  are  obtained  from  introducing  crayons 
made  from  tragacanth  dissolved  in  glycerine  and 
water,  which  contain  iodoform,  corrosive  subli- 
mate, creolin,  resorcin  or  salol.  Where  the  en- 
dometritis has  become  chronic,  Dumontpallier 
uses  Canquoin's  paste,  and  Rheinstaedter,  of  Co- 
logne, Dorff,  of  Belgium,  and  Brose,  of  Berlin, 
speak  in  the  highest  terms  of  a  50  per  cent,  solu- 
tion of  chloride  of  zinc  applied  to  the  endome- 
trium, which  can  be  followed  in  a  few  weeks 
by  a  20  per  cent,  solution.  With  the  above 
remedies  tonics  must  be  used,  and  all  agents  that 
are  calculated  to  build  up  the  general  system. 
The  treatment  of  salpingitis  has  been  spoken  of 
before,  and  the  line  of  treatment  mapped  out. 

Where  fistulae  exist,  surgical  procedures  must 
be  resorted  to,  and  it  is  well,  where  it  is  possible, 
to  follow  Tait's  operation,  as  it  probably  gives 
better  results  than  any  other. 

(c.)  Nothing  need  be  said  about  the  artificial 
means  used  by  women  to  prevent  conception,  ex- 
cept to  condemn  them  as  injurious  and  unnatural. 

(d.)  It  is  rare  that  the  physician  is  called  in  to 
treat  cases  of  retarded  orgasm  or  the  contrary  con- 
dition, and  when  he  is,  little  can  be  done  except 
to  appeal  to  the  moral  power  while  the  functions 
of  the  body  are  put  in  order.  In  some  cases  a 
separation  of  the  man  and  wife  for  a  lengthy  pe- 
riod of  time  will  be  found  to  be  very  beneficial  to 
both  parties,  and  will  overcome  the  trouble. 

3.  Non-implantation. — Non-implantation  after 
impregnation  is  due  to  some  trouble  in  the  tubes 
or  the  uterus.  The  treatment  of  diseased  tubes 
has  been  spoken  of  while  discussing  the  union  of 
the  ova  and  the  spermatozoa,  and  it  now  remains 
to  consider  briefly  the  affections  of  the  uterus. 

The  prognosis  in  the  undeveloped  or  atrophied 


I89i.] 


A  STUDY  OF  STERILITY. 


269 


uterus  is  poor,  and  yet,  with  the  long  continued 
use  of  tents,  stimulating  crayons,  hot  douches, 
electricty,  massage,  emmenagogues,  and  strict  at- 
tention to  the  general  health,  much  good  can  be 
obtained.  The  treatment  of  peri-  and  parauterine 
deposits  has  been  spoken  of  in  connection  with 
uterine  displacements,  and  endometritis  was  treat- 
ed of  when  considering  agencies  injurious  to  the 
life  of  the  spermatozoa.  It  remains  to  say,  how- 
ever, that  in  exceedingly  obstinate  cases  of  chronic 
endometritis,  with  or  without  fungous  or  other 
growths  of  the  endometrium,  the  application  of 
the  blunt  curette  will  be  found  most  useful.  After 
its  application  a  solution  of  the  subsulphate  or 
the  perchloride  of  iron  should  be  applied  to  the 
endometrium,  as  recommended  by  Kay,  of  Scran- 
ton,  or  the  iodized  phenol  can  be  substituted  with 
advantage,  according  to  Roony,  of  Quincy. 

In  curetting  the  uterus  it  is  well  to  remember 
that  paralysis  of  the  muscular  walls  sometimes 
takes  place,  and  the  instrument  seems  to  pass  into 
blank  space.  Cases  of  this  kind  have  been  re- 
ported by  Doleris  and  Geijl.  For  implantation 
of  the  ovum  it  is  necessary  to  remove  all  intra- 
uterine growths,  but  where  they  are  subserous  or 
situated  in  the  muscular  tissue,  the  application  of 
electricity  should  be  persevered  in,  as  its  results 
are  excellent  and  little  danger  attends  its  appli 
cation.  Ergot  has  been  used  subcutaneously,  but 
little  good  has  been  obtained  from  its  use.  If 
sterility  is  due  to  compression  of  the  uterus  from 
intra-abdominal  growths,  laparotomy  must  be  re- 
sorted to  to  remove  the  trouble.  If  cancer  of 
the  cervix  is  taken  in  time,  its  removal  will 
justify  a  favorable  prognosis,  but  where  the  dis- 
ease has  attacked  the  body  of  the  organ  nothing 
can  be  done  in  the  interest  of  child-bearing. 

In  cases  of  membranous  dysmenorrhcea  the  cav- 
ity of  the  uterus  can  be  dilated  and  various  me- 
dicinal substances  applied  to  its  interior.  The  cu- 
rette has  also  been  used  with  success,  and  Wiuckel 
has  had  good  results  from  the  application  of  leech- 
es to  the  cervix  uteri.  But  in  many  cases  all 
treatment  fails  to  relieve  the  trouble,  and  all  that 
can  be  done  is  to  see  to  the  general  health  while 
sedatives  and  opiates  are  employed  as  required. 
In  menorrhagia  and  metrorrhagia  the  cause  must 
be  looked  for  and  the  case  treated  accordingly. 

LITERATURE. 

Apostoli,  G.,  "The  Treatment  of  Salpingo-ovaritis  by 
Electricity,"  The  Journal,  June  27,  18S9. 

Athill,  "  Massage  in  Gynecological  Practice,"  The 
Journal.  June  15,  18S9. 

Barnesfather,  "On  the  Menstrual  Discharge,"  Cincin- 
nati Med.  Jour.,  August,  18S9. 

Beauni  et  Bouchard.  "  Xouveau  Elementes  d'Auatomie 
descriptive  et  d'Embriologie,"    Paris,  18S5. 

Biegel,  "  Pathologische  Anatomie  der  wieblichen  Un- 
fruchtbarkeit,"  Braunschweig,  1S78. 

Bouillv,  "Traitement  des  retrodeviations  uterine," 
La  Semaine  Medicate,  April  17,  1SS9. 

Boldt,  "Advances  in  Diseases  of  Women,"  The  Jour- 
nal, October  12,  1889. 


Brose,  P.,  "Traitement  du  catarrhe  uterine  par  Us 
badigeonnages  au  chlorure  de  zinc,"  La  Semaine  Midi- 
cole,  March 

.  ■  lhnann.     •Facultative  Sterilitat  ohne  Verlitzung 
der  sittengesetze,"  Aachen, 

Carpenter,  "Handbook  of  Physiology, "  Lond.,  lasted. 

Charrier,  "  Du  traitement  par  les  alcalins  d'une  cause 
peu  connue  de  stcrilite,"   Paris,  1880. 

Chcron,  Jules.  "Creolin  in  Gynecology,"  Maryland 
Med.  Jour.,  June  15.  18S9. 

Davis,  E.,  Deutsche  Med.  Zeitung,  1885. 

Despres,  "  Traitement  electrique  des  fibroms,"  La  Se- 
maine Med.,  August  ,,  18S9. 

Doleris,  "The  Curette  and  Paralysis  of  the  Uterus," 
Maryland  Med.  Jour.,  September  21.  , 

I  lorn,  •'Traitement  du  catarrhe  uterine  par  les  badige- 
chlorure   de  zinc,"  La  Semaine  Medicate, 
March  2' 

Duncan,  "Sterilitat  l>ei  Krauen,"  Uebersetzt  von  S. 
Hahu,  1SS4. 

Duiilcv.  .!/,•(/.  Times  and  Gazette,  June  28,  1856. 

Dumo'ntpallier,  "  Traitement  de  la  metrite  chronique 
par  la  cauterisation  avec  des  crayons  a.  la  pate  de  can- 
quoin,"  La  Semaine  Med.,  June  12,  1889. 

Engelmann,  "  Advances  in  Diseases  of  Women,"  The 
Journal.  October  12,  [889. 

Erich,    A.   F.,    "Some    Cases   of  Retroflexion   of  the 

Uterus  with  Peritoneal  Adhesions  of  the  Fundus  in  the 

Hollow  of  the   Sacrum,  Treated   by  Forcible  Separation 

lesions,"   Am.  Jour,  oj  Obst.  and  Dis.  of  Women 

and  Children,  October,  1880. 

Freund,  W.  A.,  "  R&rofixati'on  utdrine,"  La  Semaine 
Mid.,  June  19,  18S9. 

Geijl,   "The  Curette  and  Paralysis  of  the  Uterus,"  Ma- 
ryland Med.  four.,  September  21,  1S89. 
'  Griinewaldt,    "  Ueber  die  Sterilitat  geschlechtskranker 
Frauen,"  Archives  fur  Gyndk.,  P.d.  viii,  is  7  5 . 

Hardon,  V.  O.,  "The  Abortive  Treatment  of  Acute 
Pelvic  Inflammation,"  New  York  Med.  Jour.,  December 

Hasler,  "  Ueber  die  Dauer  der  Schwangerschaft,  Zu- 
rich, 1S76.  ...   , 

Humig,  "  Ueber  Hydrocele  Muliebrum,"  Tagblatt  der 
Naturforscherversammlung  in  Madgeburg,  1NS4. 

Hensen,   "  Phvsiologie  der  Zeugung." 

Hermann,  "  Endometrite  au  corps  de  l'uterus,"  La 
Semaine  Med.,  September  11.  1SS9. 

Hofmeier.  "  Ueber  den  Eiufluss  des  Diabetes  mellitus 
aufdie  Function  der  Weiblichen  geschlectsorgaus,"  Ber- 
lin. Klin.  Wochenschr.,  [883.  . 

Jackson,  A.  Reeves,  "Massage  in  Gynecological  Prac- 
tice," The  Journal,  June  15,  1S89.  . 

Janvrin.  Rob't..  "  Impuissanse  due  a  un  varicocele, 
guerisou  par  le  traitement  chirurgicale,"  La  Semaine 
Med.,  March  6,  1SS9. 

Kav.  T.  W.,  "The  Blunt  Curette  m  Uterine  Haemor- 
rhage "  N.  Y.  Med.  Jour.,  November  2,  1SS9. 

Kehrer,  "  Beitrage  zur  Klin,  und  expenmentellen 
Gyniikologie,"  Bd.  4,  Giessen,  1S79.  . 

Kelly  H  "  The  Surgical  Treatment  of  Posterior  Dis- 
placement of  the  Uterus,"  -V.    >'.  Med.  Jour.,  October 

Keyes  E.  L.,  "De  la  cure  radicale  au  rdtrecissement 
ur^thral'profond,  '-La  Semaine  Mfd.Jnne  12,  1889. 

Kisch    "  Die  Sterilitat  des  Weibes,"  Leipzig,  1S86. 

Klebs'   "Monatsschr.  fiir  Geburtskuude,  xxm,  p.  4°5- 

Lavaux  "Divulsiou  progressive  des  retrecissements 
de  l'urethre,"  La  Semaine  Mid.,  October  16,  1S89. 

Leopold.  "Untersuchungen  iiber  Menstruation  und 
Ovulation,"  Arch,  fur  Gyndk.,  18S3. 

Lew,  -Mikroskop  und  Sterilitat,"  Bayer  arztl.  Intel- 
ligenzbl.,  18S9.  .  ..,_., 

Lolt,  "  Zur  Anat.  u.  Phys.  d.  Cervix  I  ten.     Erlangen, 

Lowenthal.  "  Eine  neue  Deutung  des  Menstruations 
Processes,"  Arch.Jur  Gyndk..  1883. 


270 


MEDICAL  PROGRESS. 


[February  21, 


Lucas-Championniere,  "  Traitemeut  des  retro-ck'via- 
tions  uterine,"  La  Semaine  Mid.,  April  19,  1889. 

Mangin,  "Annotations,"  The  Times  and  Register, 
October  19,  1889. 

Martin,  Efl.,  "  Ueber  Dysmenorrhea  u.  Sterilitat"  Zeit- 
schrift  fiir  Geburtshiilfe  u.  Frauenkranklieiten,  Bd.  i, 
1S76. 

Martin,  F.  H.,  "Massage  in  Gynecological  Practice," 
The  Journal,  June  15,  1SS9. 

Olshausen,  "Ueber  chronische  hyperplasirende  Endo- 
metritis des  Corpus  Uteri,"  Arch,  fiirGynak.,  Bd.  viii. 

Otis,  F.  N.,  "Strictures  of  the  Male  Urethra,"  Put- 
nam, N.  Y. 

Pallas,  "Voyage  en  Crimee." 

Parvin,  F.,  "  Creolin  in  Obstetrics  and  Gynecology," 
The  Journal,  Sept.  28,  1S89. 

Picque,  "Retroflexion  uterine  irriductible:  operation 
<V  Olshausen,  Guerison,"  Bult.  et  mem.  de  la  Soc.  de 
Chir.  de  Paris,  T.  xiv. 

Polaillon,  "Ventrofixation,"  La  Semaine  JAW.,  Tan. 
20   18S9. 

Polk,  W.  M.,  "The  Surgical  Treatment  of  Posterior 
Displacement  of  the  Uterus,"  J\r.  Y.  Med.  /our..  October 
5.  18S9. 

Playfair,  "System  of  Midwifery,"  London. 

Potter,  W.  W.,  "Note  011  some  Gyuecic  Uses  of  Boracic 
Acid,"  TheJournal,  July  13,  1889. 

Rooney.  A.  F.,  "Use  of  Curette  in  Puerperal  Metri- 
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Rheinstaedter,  "  Traitemeut  du  Catarrhe  uterine  par 
les  badigeonnages  au  chlorure  de  zinc,"  La  Semaine 
Mid.,  March  20,  18S9. 

Sanger,  "Ventrofixation  de  l'uterus,"  La  Semaine 
mid  ,  June  19,  1S89. 

Sahlin,  "  Le  massage  de  l'uterus  technique;  indica- 
tions et  contraindications,"  La  Semaine  Mid.,  October 
30,  18S9. 

Scanzoui,  "  Beitrage  z.  Geburtskunde  und  Gvnakol- 
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Schultze,  "  La  tampon,  la  valeur  comme  moyen  du  di- 
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Med.,  May  15,  1889. 

Schenk,  "Das  Saugethierei  kiinstlich  bifuchtit,"  Wien., 
187S. 

Sehlen,  "  Beitrage  zur  Lehre  von  d.  Micropyle,"  Diss, 
'".in-.,  Gottingen,  18S9. 

Sunianikoff,  "Del'emploi  du  massage  en  gvnecologie, 
particulieremeut  dans  le  traitemeut  des  exudate  peri- 
uterine," LaSemaine  Mid.,  June  23,  1889. 

Sims,  "  Klinik  der  Gebarmuttischirurgie,"  Deutseh 
von  Bngel,  2  Aufl.,  1870. 

Siviecceki,  "Uterine  Catarrh— Local  Applications  of 
Morphine,"    The   Times  and  Register,  October  19,  1889. 

Smith,  S.,  "Massage  in  Gynecology, "  The Jqurnal, 
June  1 

Stein,  S.  \V.,  "  Aphorismes  sur  le  traitemeut  des  retre- 
cissements  de  l'urethre,"  La  Semaine  Med..  June  12, 
«88p.  .  >  j  • 

Taylor,  "Medical Jurisprudence,"  II.  C.  Lea,  Phila 
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Tayloi       1  onceptioti  Before  the  Appearance 

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Trelat,  '*  Traitemeut  des  r&ro-deviations  uterine,"  La 
Semaine    Hid.,  April  [O,   1      9 

Terrier,  "Hi  La  Semaine  Mid.,  February 

Terrillon,  "  Traitemeut  des  retrodeviations  uterine," 
La  Semaine  Mid.,  April  to,  [889. 

Wissenl  im    Massage,"  Amer.  Jour  of  the 

August,  1889. 

Winckel,  "  Lehrbuch  der  Frauenkrankheiten,"  Leip- 
zig. ' 

Zweifel,  "  Lehrbuch  des  Geburtshiilfe,"  Stuttgart,  1887. 


MEDICAL    PROGRESS. 


Therapeutics  ami  Pharmacology. 

A  New  Mode  of  Exhibiting  Sulphonal. — 
Dr.  David  D.  Stewart,  of  Philadelphia  (Med- 
ical  News),  says  that  unquestionably  the  great 
disadvantage  of  sulphonal  over  other  recently- 
introduced  hypnotics  is  its  insolubility  and  con- 
sequent slowness  of  action.  As  ordinarity  ad- 
ministered, dry  upon  the  tongue,  or  suspended  in 
mucilage,  etc.,  the  result,  in  most  cases,  is  un- 
satisfactory. Even  after  a  decided  dose  hours 
often  elapse  before  sleep  is  obtained,  and,  usually, 
a  condition  of  very  annoying  semi-somnolence  is 
maintained  throughout  the  greater  part  of  the 
subsequent  day.  Unpleasant  effects  of  this  sort 
are  so  frequent  that  many  physicians  are  deterred 
from  prescribing  what  has  proved  in  my  hands 
the  most  satisfactory  of  the  newer  hypnotics. 
These  effects  obtain  because  of  the  very  slow 
diffusion  of  the  drug  when  taken  in  a  state  of 
simple  suspension,  the  whole  amount  not  entering 
the  circulation  for  many  hours  after  its  ingestion. 

I  desire  to  call  attention  to  a  more  satisfactory 
mode  of  administering  sulphonal ;  a  method  that 
occurred  to  me  when  having  occasion  to  take  the 
drug  a  year  or  more  ago,  and  one  which  has  sub- 
sequently afforded  me  results  in  practice  not  in 
the  least  obtainable  by  its  use  in  the  common 
way.  My  method  is  as  follows  :  I  direct  that 
just  before  retiring  the  sulphonal  powder  be  well 
stirred  in  a  glass  two- thirds  full  of  boiling  water 
(about  six  fluid  ounces)  until  entirely  dissolved. 
The  water  must  be  boiling,  and  to  insure  that  it 
is  at  the  boiling-point  when  brought  in  contact 
with  the  sulphonal,  it  had  better  be  heated  on 
the  spot.  It  can  be  boiled  in  a  tin- cup  over  the 
gas,  or  over  a  spirit-lamp.  After  the  sulphonal 
has  entered  into  solution,  which  will  occur  in  a 
moment  or  two  if  it  be  well-stirred,  cold  water 
may  be  very  cautiously  added  to  reduce  the  liquid 
to  a  drinkable  temperature,  which,  if  the  patient 
is  accustomed  to  taking  hot  fluids,  will  be  one  not 
sit  indent  to  cause  the  slightest  precipitation  of  the 
drug  :  or  the  hot  solution  of  sulphonal  may  be 
permitted  to  cool  to  this  temperature,  the  cooling 
process  being  facilitated  by  continued  stirring. 
To  insure  success  the  sulphonal  must  be  taken 
wholly  dissolved,  and  the  hotter  the  solution  is 
drunk  the  better.  It  is  surprising  to  one  ac- 
customed to  prescribing  this  hypnotic  in  suspen- 
sion several  hours  before  bed-time,  to  allow  for 
what  has  been  called  the  period  of  therapeutic 
incubation,  to  note  the  prompt  and  satisfactory 
result  of  this  simple  manoeuvre.  The  hot  solu- 
tion dilates  the  gastric  vessels  and  stimulates 
them  to  rapid  absorption,  so  that  diffusion  takes 
place  from  the  stomach  probably  before  slight  or 
any  precipitation  of  the  drug  occurs ;  entirely 
unlike  the  result  that  follows  when  the  sulphonal 


I89l.] 


MEDICAL  PR<  )GRESS. 


271 


is  ingested  in  a  state  of  simple  suspension.  In 
the  latter  case  gastric  absorption  can  scarcely  oc- 
cur, and  hours  are  perhaps  consumed  before  the 
whole  amount  taken  enters  the  blood.  The 
period  of  therapeutic  incubation  is  practically 
done  away  with.  Sleep  results  in  most  cases  in 
a  very  few  moments,  and  seems  to  be  more  pro- 
found and  dreamless  than  that  from  a  larger  dose 
taken  in  the  ordinary  way,  and  the  annoying 
condition  of  drowsiness  usually  present  on  the 
subsequent  day  is  scarcely  felt  if  the  dose  be- 
properly  graduated.  The  hot  solution,  which 
has  a  slightly  unpleasant  taste  from  the  dissolved 
sulphonal,  may  be  rendered  decidedly  palatable 
by  the  addition  of  a  tablespoonful  of  some  such 
liqueur  as  crime  de  menthe  ("green  mint"), 
which,  apart  from  its  efficiency  in  this  direction, 
will  probably  tend  to  promote  still  more  rapid  ab- 
sorption of  the  drug.  To  obtain  an  immediate 
and  altogether  satisfactory  result  from  this  method 
it  is  desirable  that  the  stomach  be  empty  or  at 
least  comparatively  free  from  food,  so  that  pre- 
cipitation be  not  favored  and  absorption  delayed 
by  the  entanglement  of  particles  of  sulphonal 
and  undigested  food,  but  as  it  is  unnecessary  to 
take  the  dose  until  the  retiring  hour  there  will 
usually  be  no  difficulty  from  this. 

Koch's  Treatment  :  Experiments  on  Cat- 
tle.— Professor  Bollinger,  of  Munich,  gives 
(Munich  med.  Wbchensckr.,  January  13,  1891),  a 
summary  of  some  experiments  with  Koch's  fluid 
made  in  the  Veterinary  Institute  at  Dorpat  by 
W.  Gutmanu  on  three  tuberculous  cows.  The 
disease  was  diagnosed  partly  by  physical  exam- 
ination, partly  by  the  presence  of  tubercle  bacilli 
in  the  bronchial  mucus  and  in  the  milk,  and 
partly  by  changes  in  the  lymphatic  glands. 
Relatively  large  doses  were  employed,  o.  1  g. 
being  injected  into  one  animal,  0.2  g.  into  a 
second,  and  0.3  g.  into  a  third.  The  injections 
were  made  behind  the  shoulder-blade.  The  tem- 
perature was  taken  every  hour  on  the  day  of  the 
injection  and  the  following  day  and  night.  In 
all  three  animals  the  temperature  began  to  rise 
about  eleven  hours  after  the  injection.  The  re- 
action corresponded  to  the  amount  of  the  remedy 
exhibited,  the  maximum  attained  in  the  first  ani- 
mal being  400  C,  in  the  second  40. 8°,  and  in  the 
third  41. 70.  The  duration  of  the  fever  in  the 
three  cases  was  four,  nine,  and  ten  hours  re- 
spectivety.  In  the  first  cow-  another  injection  of 
0.3  g.  was  given  four  days  after  the  first  ;  reac- 
tion came  on  in  from  eleven  to  twelve  hours  and 
lasted  four  hours.  In  all  three  animals  during 
the  febrile  period  there  was  some  difficulty  of 
breathing  and  loss  of  appetite,  but  the  next  day 
they  took  their  food  well  and  rumination  was  ac- 
tive as  usual.  No  rise  of  temperature  followed 
the  injection  of  0.3  g.  in  two  healthy  bulls  which 
were  used  as  "control"  subjects.     Twenty-four 


hours  after  the  injection  they  were  slaughtered 
and  all  the  organs  were  found  to  be  perfectly 
normal.  Gutmann,  therefore,  concludes  that 
Koch's  remedy  is  a  most  valuable  aid  to  diag- 
nosis in  the  case  of  cattle  suspected  of  tubercle. 
In  this  view  Professor  Bollinger  agrees  with  him. 
— British  Medical  Journal. 

Surgery. 

Com  pound  Comminuted  Complicated  FRACT- 
URE   OK    THE    DlSTAX     EXTREMITY    OF      FEMUR. 

Recovery  without  Amputation. — The  Mon- 
treal Medical  Journal,  February,  has  a  brief  re- 
port of  a  case  of  the  above  named  accident  re- 
ported by  Dr.  James  Bell.  The  patient,  male, 
aged  30,  was  brought  into  the  hospital  with  so 
severe  a  fracture  of  the  lower  third  of  the  thigh, 
and  with  so  much  laceration  of  the  soft  parts  that 
amputation  was,  upon  consultation,  recommended. 
To  this  the  patient  would  not  consent,  so  that  con- 
servative surgery  was  perforce  resorted  to.  Under 
ether  the  wound  was  thoroughly  cleansed,  several 
small,  loose  fragments  of  bone  were  removed, 
which,  with  a  portion  of  the  bone  excised, 
equalled  about  four  inches  of  the  femur-shaft. 
The  articular  end  had  been  split  and  the  condyles 
driven  asunder  by  the  violence  of  the  accident; 
these  latter  were  brought  together  and  pinned 
with  Macewen's  pins  for  the  excision  of  the  knee- 
joint.  The  patient  rallied  well  after  the  opera- 
tion and  no  troublesome  symptoms  arose.  The 
temperature  at  no  time  exceeded  99. 5?  F.  The 
patient  was  discharged  at  the  end  of  three  months 
and  twenty  days  with  a  good  union  and  a  con- 
siderable amount  of  mobility  at  the  knee-joint, 
which  will,  without  doubt,  be  increased  by  passive 
exercise,  the  patient  being  at  an  age  when  this 
can  be  insisted  upon  rigorously  and  to  some  pur- 
pose. The  shortening  amounted  to  three  and  a 
half  inches.  A  better  result  than  this  is  seldom 
seen  either  in  private  or  hospital  practice,  and 
may  serve  as  a  landmark  for  surgeons  who  need 
encouragement  in  their  pursuit  of  conservative 
methods. 

Painless  Circumcision.—  G.  W.  Overall 
( Medical  Record)  says:  For  the  past  fifteen  years 
I  have  performed  circumcision  quite  frequently 
for  the  relief  of  various  nervous  disturbances. 
Since  the  introduction  of  cocaine  I  have  used  it 
almost  exclusively  in  men,  and  frequently  in 
children,  by  injecting  it  beneath  the  integument 
in  the  prepuce  (having  previous^  placed  a  rub- 
ber band  around  the  penis  half  an  inch  or  more 
back  of  the  corona  to  limit  its  effect  to  the  pre- 
puce). 

The  pain  attending  the  introduction  of  the 
needle  into  the  sensitive  skin  has  been  a  serious 
objection  in  men,  and  almost  as  bad  in  children, 
as  the  operation  itself.  Then  I  have  had  various 
postponements,  and  often  complete  abandonment 


272 


MEDICAL  PROGRESS. 


[February  21, 


of  it,  because  I  could  not  promise  "that  it  would 
not  hurt."  Now  I  can  promise  an  operation 
where  a  child  would  not  even  know  it  until  it 
was  performed. 

I  do  not  want  my  patient  to  see  the  operation, 
and  in  the  case  of  a  child  I  conceal  the  instru- 
ments. I  then  place  the  patient  upon  his  back 
and  lay  a  small  pillow  on  his  chest  so  that  he 
cannot  see  over  it.  I  then  adjust  the  rubber  band, 
take  a  freshly  prepared  30  per  cent,  solution  of 
cocaine  and  inject  with  a  small  blunt-pointed 
syringe  a  few  drops  into  the  preputial  orifice,  at 
the  same  time  I  hold  the  end  of  the  prepuce  with 
my  left  hand,  to  prevent  the  escape  of  the  fluid. 
I  then  press  upon  the  fluid  with  my  right  hand 
to  enable  it  to  come  in  contact  with  the  entire 
mucous  membrane.  I  hold  it  for  five  or  six  min- 
utes, when  the  mucous  membrane  is  completely 
anaesthetized.  I  then  introduce  carefully  my  hy- 
podermic needle  through  the  preputial  orifice  and 
penetrate  the  mucous  membrane  and  inject  a  few 
drops  of  cocaine.  I  then  move  it  to  another  part 
and  repeat  the  injection.  It  necessarily  requires 
caution  to  prevent  puncturing  the  integument, 
which  would  cause  pain.  I  operated  upon  a  child 
six  years  old,  very  small,  nervous  and  excitable, 
while  he  was  discussing  with  his  mother  the  kind 
of  toys  he  would  get  for  Christmas.  I  also  op- 
erated upon  a  boy  14  years  old  that  came  from  an 
adjacent  town  (using  silk- gut  ligature; ,  he  did 
not  feel  the  slightest  prick  of  the  needle.  He 
returned  home  the  same  evening  and  recovered 
without  a  bad  symptom.  It  is  always  better  to 
use  a  ligature  that  does  not  require  to  be  removed. 

Bacteriology. 

The  Effect  of  Koch's  Remedy  upon  the 
Internal  Organs. — Prof.  Virchow  {Berliner 
Klinische  Wochensckrift,  January  12,  1891),  re- 
ports the  results  of  autopsies  made  at  the  Patho- 
logical Institute.  Twenty-one  of  these  cases  oc- 
curred before  the  close  of  last  year,  and  six  or 
seven  were  added  to  the  list  previous  to  his  report 
(January  7).  Of  the  first  twenty-one  cases  six- 
teen were  in  the  strict  sense  of  the  term  phthisical, 
with  the  process  localized  in  the  lungs,  the  re- 
maining five  were  made  up  of  one  case  of  bone 
and  joint  tuberculosis,  a  peculiar  case  of  carcino- 
ma of  the  pancreas  with  an  old  lung  complica- 
tion, one  of  empyema,  one  of  old  rectal  fistula, 
and  lastly  a  case  of  arachnitis  tuberculosa.  The 
visible  effects  of  Koch's  remedy  show  it  to  be  an 
irritant,  producing  redness  and  swelling,  which  is 
also  present  in  the  internal  organs,  and  frequently 
in  the  severest  forms.  In  the  case  of  the  tuber- 
cular arachnitis,  a  child  from  the  wards  of  Prof. 
Henoch  in  whom,  sixteen  hours  before  death,  an 
injection  had  been  made,  showed  a  greater  degree 
of  hyperaemia  and  injection  of  the  brain  and  its 
membranes,  than  Virchow  had  ever  before  ob- 
served.    He  also  carefully  examined   and  could 


not  determine  any  alteration  in  the  tubercular 
process.  This  acute  hyperaemia  and  swelling  was 
frequently  observed  in  other  organs.  The  walls 
of  old  cavities  were  often  red,  and  infiltrated  with 
blood. 

A  case  is  described  in  which  death  took  place 
from  anaemia  after  severe  haemoptysis.  In  this 
case  the  process  was  not  confined  to  a  sirriple  hy- 
peraemia and  swelling,  but  it  was  possible  to  de- 
termine an  active  cell  proliferation.  This  cell 
proliferation  was  especially  well  marked  upon  the 
wall  of  the  cavity  as  well  as  in  the  affected  bron- 
chial and  mesenteric  glands.  The  swelling  some- 
times takes  on  a  dangerous  character,  especially 
in  the  throat,  where  it  may  cause  phlegmonous 
tonsillitis  or  pharyngitis,  or  erysipelatous  oedema 
of  the  glottis.  It  is  difficult  to  say  whether  this 
inflammation  is  caused  by  the  injection  or  not. 
The  changes  in  the  lungs  are  divided  into  two 
classes — the  first  presenting  the  common  picture 
of  caseous  pneumonia.  Prof.  Virchow  did  not 
remember  to  have  seen  in  years  so  extraordinary 
a  case  of  caseous  hepatization  as  was  presented 
in  one  of  the  specimens  shown.  The  lung  ap- 
peared like  a  blood  sausage,  with  here  and  there 
pieces  of  pork  distributed  through  it.  In  this 
case  six  injections  were  employed,  the  last  one 
four  weeks  before  death,  the  treatment  having 
been  discontinued  when  the  pneumonic  process 
appeared.  Pneumonia  in  phthisis  commonly  pre- 
sents itself  in  three  forms,  the  fibrinous,  caseous 
and  catarrhal.  The  fibrinous  was  not  observed 
in  any  of  the  cases.  Eleven  of  the  cases  closely 
resembled  the  catarrhal,  and  yet  there  were  mark- 
ed differences.  The  exudate  was  cloudy,  gelati- 
nous, resembling  the  caseous  but  without  its  char- 
acter; frequent  vacuoles  were  seen,  with  a  ten- 
dency to  coalesce,  a  similar  appearance  to  that 
presented  in  gangrenous  pneumonia. 

Death  from  Koch's  Lymph. — Prof.  Gras- 
set,  of  the  Hopital  Saint  Eloi  {La  Semaine  Medi- 
cate, January  21),  reports  the  death  of  a  young 
man  following  the  lymph  injection.  The  patient 
presented  the  signs  of  a  circumscribed  pleuro- 
pulmonary  tuberculosis  situated  in  the  upper  por- 
tion of  the  right  lung,  that  was  not  accompanied 
by  fever.  The  injection  produced  a  rapid  change 
for  the  worse,  with  the  formation  of  large  cavi- 
ties, and  the  rapid  extension  of  the  tubercular 
process  through  the  same  lung  and  to  its  fellow. 
A  careful  description  of  the  autopsy  is  given  with 
an  account  of  some  pulmonary  lesions  that  they 
attribute  to  the  lymph,  among  others  the  "injec- 
tion pneumonia  of  Virchow." 

The  writers  conclude  that  the  lymph  converted 
an  apyretic  circumscribed  tuberculosis  into  a 
case  of  "galloping  phthisis,"  with  severe  haem- 
orrhage and  high  temperature.  The  patient  died 
ten  days  after  the  injection. 


'891.] 


EDITORIAL. 


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Address 

Journal  of  the  American  Medical  Association, 

No.  6S  Wabash  Ave.. 

Chicago.  Illinois. 
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to  the  Treasurer,  Richard  J.  Dnnglison.  M.D..  Lock  Box  127*.  Phila- 
delphia, Pa. 

London  Office.  57  and  59  Lcdgate  Hill. 
SATURDAY,  FEBRUARY  21.    1S91. 


THE  REPORT  ON  MEDICAL  EDUCATION. 

The  seventh  Report  on  Medical  Education 
of  the  Illinois  State  Board  of  Health,  just 
received,  is  the  most  complete  work  of  its  kind 
that  has  ever  been  issued  by  the  Board.  It  in- 
cludes not  only  all  the  medical  colleges  in  the 
United  States  and  Canada,  as  heretofore,  but  a 
summary  of  the  requirements  in  foreign  countries 
as  to  preliminary  education,  a  list  of  the  teaching 
institutions  and  their  requirements  in  all  foreign 
countries,  and  the  regulations  in  these  countries 
as  regards  the  license  to  practice. 

It  is  evident  from  the  report  that  there  is  an 
upward  movement  in  higher  medical  education, 
and  it  gives  to  the  Chicago  Medical  College  the 
credit  for  having  taken  the  first  step  in  this 
country  for  the  three  years'  graded  course — in 
1868.  It  was  not  until  1881,  however,  that  there 
was  a  decided  movement  in  this  matter.  In  this 
year  the  Illinois  State  Board  of  Health  first  clas- 
sified the  medical  colleges  of  the  United  States 
and  Canada  in  a  Report  on  Medical  Education. 
One  year  before  this  the  Board  had  adopted  its 
schedule  of  minimum  requirements,  to  go  into 
effect  after  the  session  of  1882-83.  Since  1882 
the  movement  for  higher  medical  education  has 
acquired  more  and  more  momentum,  as  will  be 
seen  from  some  figures  taken  from  the  Report.  In 
1882  there  were  but  45  colleges  requiring  certain 
educational  qualifications  for  matriculation;  in 
1886  there  were  114:  in  1S89,  117;  in  1S90,  124; 
and  now  there  are  129.  In  1882  the  number  of 
colleges  requiring  attendance  on  three  or  more 


courses  of  lectures  before  graduation  was  22;  41 
in  1886;  47  in  1889;  64  in  1890;  and  85  at  pres- 
ent. Since  1880  the  length  of  the  lecture  terms 
has  beeu  increased  from  an  average  of  23.5  to  26.3 
weeks.  In  1882-S3  there  were  eight  colleges  that 
had  lecture  terms  of  but  sixteen  weeks.  In 
1882-83  only  42  colleges  had  terms  of  six  months 
or  more;  in  1883-84  the  number  was  49;  in 
1889-90  it  was  76;  now  it  is  111. 

One  of  the  very  suggestive  features  of  the  Re- 
port is  a  table  showing  the  results  of  the  examin- 
ations by  the  medical  examining  boards  of 
Alabama.  Minnesota,  New  Jersey,  North  Caro- 
lina, South  Carolina  and  Virginia.  Of  the  insti- 
tutions represented  before  these  boards  77  are  in 
the  United  States,  5  in  Canada,  and  12  are  for- 
eign. Our  77  colleges  were  represented':  j 
candidates  (graduates),  of  whom  898  passed  and 
and  285  failed  to  pass.  It  is  noteworthy  that 
there  is  a  great  difference  in  the  percentage  of 
rejections  before  the  different  boards.  Excluding 
the  results  before  the  New  Jersey  Board,  which 
examined  only  1 1  candidates,  the  Alabama 
Board  rejected  7.84  per  cent.,  the  Minnesota 
Board  29.81,  the  North  Carolina  Board  20.64, 
and  the  South  Carolina  and  Virginia  Boards  28.82 
and  29.51  per  cent,  respectively.  The  variation 
is  not  so  great,  however,  as  in  the  case  of  the 
nine  Prussian  examination  commissions  in  1890, 
the  extreme  limits  of  rejections  before  these  com- 
missions being  9.3  and  40.09  per  cent.  It  is  sug- 
gested in  the  Report  that  the  several  State 
boards  hold  a  meeting  for  consultation,  and  that 
thej-  adopt  some  plan  by  which  examination  pa- 
pers may  be  exchanged,  since  it  is  important  that 
the  work  of  these  boards  should  be  as  uniform  as 
possible. 

Two  tables  show  the  marks  of  the  candidates 
rejected  by  the  Virginia  Board  in  September, 
1890,  and  of  the  candidates  that  passed  the  New 
Jersey  Board  in  October,  1S90.  It  is  a  some- 
what remarkable  fact  that  a  non-graduate  re- 
ceived the  highest  mark  of  any  candidate  rejected 
by  the  Virginia  Board.  The  names  of  the  col- 
leges from  which  these  candidates  were  graduated 
are  given.  It  is  suggested  that  each  board  of 
examiners  prepare  a  table  of  this  kind  at  each 
examination,  since  the  publication  of  such  statis- 
tics will  undoubtedly  have  a  powerful  effect  on 
colleges.  The  lowest  marks  received  by  the  re- 
jected candidates  were  in  chemistry,  anatomy  and 


274 


PROPHYLAXIS. 


[February  21, 


surgery.  Before  the  New  Jersey  Board  the  low- 
est average  (by  successful  candidates)  was  in  sur- 
gery and  surgical  anatomy. 

The  Report  calls  attention  to  the  value  and  in- 
creasing number  of  courses  preparatory  to  the 
study  of  medicine,  now  offered  by  some  of  the 
largest  universities  in  the  country.  There  is  un- 
doubtedly a  tendency  towards  beginning  the  edu- 
cation for  the  work  of  life  earlier,  and  it  is  now 
more  than  ever  recognized  that  the  foundation  for 
a  proper  study  of  medicine  should  be  laid  before 
the  student  actually  begins  to  study  medicine. 

The  Report  is  earnestly  commended  to  the  care- 
ful attention  of  all  the  colleges,  as  well  as  to  all 
interested  in  higher  medical  education.  It  shows 
that  there  is  no  longer  any  doubt  that  four  years 
of  medical  study  and  three  courses  of  lectures  is 
to  be  the  rule  in  this  country  until  a  still  higher 
standard  is  adopted.  Some  of  the  colleges  have 
arrayed  themselves  against  the  higher  standard. 
It  is  evident  they  must  accept  it  or  join  the  long 
roll  of  extinct  medical  colleges. 


THE  SUPPRESSION  OF  SYPHILIS. 

It  will  be  of  no  small  interest  to  our  philan- 
thropists— and  there  are  not  a  few  in  the  ranks 
of  our  profession,  be  it  said  to  our  credit — to 
learn  that  the  outcome  of  measures  put  forth  of 
late  years  on  the  continent  of  Europe,  with  regard 
to  the  regulation  of  prostitution,  have  proved  un- 
availing, from  both  a  moral  and  sanitary  point  of 
view. 

Morally,  the  effort  to  regulate — and  thereby, 
in  a  measure,  stop — the  vice  of  prostitution,  has 
only  resulted  in  a  more  than  compensating  clan- 
destine recourse,  which  appears  more  penetrating 
in  its  effects,  and  evil  in  its  consequences,  than 
maintained  previously.  And  through  this  result, 
and  in  the  aversion  of  the  syphilitics  in  the  regu- 
lated houses  to  being  hospitaled  for  long  time  as 
such,  it  is  believed  that  a  wider  dissemination 
has  been  given  to  this  poison. 

So  thoroughly  convinced  upon  this  point  is  a 
recent  writer  to  the  Westminster  Review  that  his 
one  conclusion  is  this  : 

As  a  means  of  lessening  the  amount  of  the  diseases 
associated  with  the  practice  of  prostitution,  the  system 
of  legal  recognition,  toleration,  and  regulation,  always 

has  proved  and  always  must  prove  a  complete  failure. 

This  only  tends  the  more  to  illustrate  that  law 


cannot  answer  for  enlightenment  ;  that  progress 
in  the  direction  of  moral  and  physical  elevation 
of  the  race  must  ever  depend  upon  a  proper  and 
widely-extended  teaching.  If  ignorance  of 
danger  does  not  immediately  lead  to  syphilitic  in- 
fection in  all  or  many  cases,  then  that  careless- 
ness and  animalism  born  where  ignorance  and  sin 
prevail  is  accountable  for  all  the  other  factor  fails 
to  cover. 

Such  training  as  will  in  the  best  manner  open 
to  the  mind  of  "budding"  youth  the  principles 
of  sexual  hygiene  will  no  doubt  prove — when  it 
becomes  sufficiently  recognized — the  most  suc- 
cessful means  of  combating,  not  only  this,  but 
kindred  influences  of  a  widely-evil  nature. 


PROPHYLAXIS. 


As  a  means  of  markedly  invigorating  the  en- 
tire organism,  and  rendering  thereby  the  system 
less  prone  to  the  influence  of  all  external  disease- 
producing  agencies,  an  English  physician  reports, 
in  a  recent  number  of  the  British  Medical  Journal, 
the  benefits  of  a  daily  morning  cold  bath.  The 
bath  used  is  cold.  Often  the  ice  has  to  be  broken 
before  the  bath  can  be  taken.  Then  the  skin  is 
toweled  thoroughly.  This  physician  says  he 
never  has  a  "cold;"  never  wears  an  overcoat — 
whatever  the  weather  may  be  ;  has  had  no  illness 
for  many  years  ;  and  would  as  soon  think  of 
stopping  his  meals,  as  to  drop  off  the  customary 
cold  "  tubbing." 

In  this  connection  might  be  mentioned  the  still 
more  radical  system  of  Father  Kneipp,  the 
villiage  priest  of  Voerishofen,  Bavaria.  It  is 
said  that  he  is  well-regarded  by  the  medical  pro- 
fession, and  that  many  doctors  go  to  him  to  learn 
his  method  of  cure  and  care.  The  features  of 
this  so-called  method  are  not  at  all  new  of  them- 
selves, and  it  is  more  the  combination  of  require- 
ments, together  with  the  rigidness  of  procedure, 
which  commands  attention. 

Father  Kneipp  is  simply  a  health  reformer, 
and  as  such  he  declares  strongly  against  all 
woolen  garments  next  the  skin.  The  under- 
clothing he  recommends  is  made  of  strong, 
coarse  linen.  Next  of  his  requirements  is  the 
cold  bath,  which  is  to  be  taken  quickly,  and 
without  subsequent  drying  of  the  skin.  The 
linen  garments  are  to  be  put  on  at  once,  while 
the  moisture  of  the  bath  is  still  upon  the  body. 


I8yi.] 


DOCTORS  AND  ADVERTISING. 


275 


Then  conies  the  practice  of  walking  or  running 
barefooted  in  wet  grass  in  cold  weather,  or  in 
freshly- fallen  snow.  The  village  of  Voerishofen 
lies  in  a  valley  where  green  meadows  abound, 
and  is  therefore  particularly  adapted  to  this  form 
of  exercise.  After  running  in  the  wet  in  this 
fashion  the  patient  puts  on  coarse  linen  socks,  and 
boots,  and  walks  briskly  for  a  spell.  Then  as  to 
internal  attention  tea  and  coffee  are  absolutely 
prohibited,  and  animal  food  is  discouraged. 
Bread,  fruit,  vegetables  and  milk  are  the  sub- 
stances permitted.  "There  are  few  better  meals," 
says  this  man,  "  than  plenty  of  fresh  fruit  and  a 
piece  of  bread." 

The  patients  are  advised  to  drink  before  eating, 
never  while  eating,  and  after  eating  only  when  it 
seems  necessary  ;  and  then  moderately.  Hard 
beds  ;  cool,  well-ventilated  rooms ;  and  the  use 
of  good  things — without  their  abuse — quite  com- 
pletes this  hygienic  plan. 


then  heated  it  in  the  water-bath  and  added  10 
per  cent,  of  glycerine,  then  added  a  concentrated 
warm  solution  of  Russian  isinglass,  in  the  pro- 
portion of  1  to  4  of  the  gelatine,  the  product 
being  a  glyeero-gelatine  that  dried  more  quickly 
than  any  other  combination  experimented  with 
by  hi  111,  and  that  left  a  firmer  coating  on  the  skin 
when  applied  directly  thereon. 


UNNA'S  PASTES   AND  PASTE-STICKS. 

LASCAR  has  contributed  an  article  to  the  Phar- 
maceutical Record,  January  5,  giving  the  results 
of  a  vast  number  of  trials  with  all  the*  ointment 
bases,  new  and  old,  especially  with  the  gelatine 
ointments  and  pastes  of  Unna.  Many  of  the  lat- 
ter have  as  their  base  arnylurn  and  gum  arabic, 
and  Unna  has  found  it  serviceable  to  bring  such 
pastes  to  a  consistency  so  that  they  can  be  formed 
into  sticks,  and  he  is  in  the  habit  of  incorporating 
in  them  a  variety  of  medicaments,  as  iodoform 
40  per  cent.,  salicylic  acid  10  to  40  per  cent.,  re- 
sorcin  the  same,  corrosive  sublimate  5  to  10  per 
cent.,  oxide  of  sulpho-carbolate  of  zinc  20  per 
cent.,  or  pyrogallic  acid  40  per  cent.  These  paste 
sticks  require  to  be  moistened  when  applied  to 
the  skin.  They  are  not  to  be  confounded  with 
the  salve-sticks  which  resemble  the  well-known 
cosmetic  sticks  of  French  origination.  Their 
consistency,  however,  is  about  the  same  as  that 
of  the  ordinary  cosmetic  stick,  and  their  base  is 
spermaceti  or  wax  with  olive  oil.  The  parafine 
oils  are  not  suitable  for  these  purposes. 

One  word  in  regard  to  the  gelatine  unguents  of 
Unna  may  be  added  here  from  the  observations 
of  Lascar.  Being  an  entire  novelty  to  him,  he 
encountered  no  little  difficulty  in  obtaining  a  su- 
perior article.  He  used  the  Cox  gelatine  and 
macerated  it  with  cold  water   until  it   swelled, 


DOCTORS  AND  ADVERTISING. 

The  London  Daily  News,  in  an  article  with  the 
above  caption,  puts  in  a  special  plea  "  regarding 
the  severity  of  the  unwritten  law  of  professional 
etiquette."  It  claims  that  medical  men  "are 
constantly  under  suspicion  of  advertising  them- 
selves when  they  are  really  doing  nothing  of  the 
sort."  "  If  the  committee  of  the  local  literary 
and  scientific  institute,"  says  our  secular  brother, 
"will  print  the  name  of  'Dr.  Abernethy  Astley 
Cooper  Jones  '  in  big  type,  with  a  whole  row  of 
initials  after  it,  is  it  fair  to  make  him  responsible 
for  that?  "  Aye,  there's  the  rub  !  Were  the  cap- 
itals, as  we  suppose  them  to  have  been,  the  meas- 
ure of  self-conceit,  or  only  the  expansion  of  the 
manager's  admiration?  Or  did  they  act  as  a  bait 
for  the  public,  pretty  much  as  "The biggest  show 
on  earth?"  We  do  these  things  much  better  in 
America.  We  are  careful  never  to  submerge  self 
in  profession,  college,  hospital  or  association. 
Happily,  too,  we  are  more  ingenious  in  our  meth- 
ods and  have  a  much  wider  choice,  such  as  the 
carefully  written  interview,  with  its  patronizing 
tone  and  convenient  avenues  of  escape  ;  the  soci- 
ety item,  with  one's  diamond- bedecked  wife  and 
stunning  equipage  ;  the  summer  movement  to  se- 
cure a  much-needed  rest;  the  fag-end  of  "  Among 
the  distinguished  persons  present  we  noticed;" 
the  summons  from  a  distance  or  an  enormous  fee; 
a  gratuitous  diagnosis,  broadcast  among  the  laity; 
and  last  of  all,  for  even  the  humblest  brother  we 
have  provided  the  anecdote  and  the  lugubrious 
office  of  pall- bearer. 

A  medical  correspondent  of  The  Lancet,  quotes 
the  News,  confesses  to  finding  ' '  intense  pleasure 
and  relaxation  in  addressing  ar^  intelligent  audi- 
ence," but  he  had  to  endure  "the  darts  of  slan- 
der. "  Is  it  possible  that  ' '  the  intelligent  audi- 
ence ' '  can  have  no  redress  in  a  damage  suit  ? 
But  oh,  men  of  many  talents  !  these  are  the  strug- 
gles of  genius,  and  we  need  not  multiply  exam- 


276 


EDITORIAL  NOTES. 


[February  21, 


pies.  Perhaps  your  wares  are  no  better  than  your 
customers.  Wise  men  of  the  East,  know  ye  not 
that  there  is  a  way  to  sail  under  false  colors,  not- 
withstanding your  incorruptible  newspapers,  your 
immaculate  municipalities,  and  your  poor  but 
honest  street-sweepers?  Many  know  the  route, 
and  many  have  returned  safely  to  a  haven  of 
comfortable  competence. 

A  friend  of  this  luminous  man  of  "  intelligent 
audience"  proclivities,  "can  make  ten  guineas 
by  one  evening  address,  and  earn  as  much  in  an 
hour  and  a  half  as  his  detractors  can  do  in  a 
week,  but  owing  to  the  intolerable  priggish  atti- 
tude of  his  fellow  practitioners,  he  is  obliged  even 
to  cease  his  gratuitous  efforts  on  behalf  of  the 
churches,  chapels  and  local  charities."  We  hope, 
persecuted  man  that  he  evidently  is,  that  he  has 
never  bored  his  hearers  or  made  them  a  means  of 
improvement  in  oratory.  Demosthenes  may  have 
been  (still,  we  do  not  know),  more  considerate  in 
betaking  himself  to  the  sea-shore.  However, 
despite  the  temptation,  we  shall  spare  him  our 
Western  story  of  "  poor  pay  and  poor  preach." 

Briefly  and  seriously,  in  regard  to  the  whole 
matter,  let  us  state  that  these  "  reading  notices  " 
which  we  have  in  mind  are  costly,  sometimes 
profitable  and  not  infrequently  disastrous.  To 
the  adventurer  and  charlatan  there  may  be  a  ne- 
cessity for  elbowing,  but  society  in  the  one  case 
has  furnished  him  with  the  crowd,  and  the  pro- 
fession in  the  other  has  begotten  for  him  the  con- 
fidence. To  our  weak  brother  we  can  only  say 
that  medicine  as  a  vocation,  being  personal  in  its 
limitations,  cannot  be  over-lucrative.  Rather  say 
in  its  proper  column  what  you  desire  without  fear 
of  the  blue  pencil,  and  take  your  place  among  the 
other  honest  tradesmen. 


came  collapsed;  with  this  there  was  the  extrusion, 
through  the  umbilical  fistula,  of  a  calculus  meas- 
uring four  inches  in  circumference.  Two  months 
later  the  fistula  had  healed  and  there  was  a  com- 
plete absence  of  local  tenderness,  and  the  patient 
was  restored  to  her  former  measure  of  health. 


LARGE    BILIARY     CALCULUS    DISCHARGED 
THROUGH  AN  UMBILICAL  FISTULA. 

In  the  New  York  Medical  Journal,  January  31, 
Dr.  Colegrove  reports  the  passage  of  an  extra- 
ordinarily large  biliary  calculus  by  the  way  of  an 
umbilical  fistula.  A  lady,  aged  83,  had  an  abscess 
around  the  umlylicus, attended  with  a  great  amount 
of  disturbance,  pain,  loss  of  sleep  and  appetite;  it 
communicated  externally  by  means  of  a  fistula, 
through  which  pus  was  discharged  for  a  week  or 
more.  One  night  she  was  suddenly  taken  with 
an  increase  of  the  pain,  so  intense  that  she  be- 


EDITORIAL  NOTES. 

The  Office  of  Coroner. — The  London  Law 
Journal,  "  referring  to  the  approaching  abolition 
of  the  office  of  coroner  throughout  the  United 
States,"  says:  "The  coroner's  inquest  in  an 
average  American  State  seems  to  have  been  sim- 
ply a  costly  and  tedious  way  of  doing  nothing ; 
the  verdict  of  the  jury  was  not  only  not  conclu- 
sive, it  was  not  even  evidence,  and  the  subse- 
quent trial  proceeded  without  any  reference  to  it 
whatsoever."  All  this  is  written  in  the  past 
tense,  as  of  an  accomplished  fact,  and  without 
the  theory  of  the  preliminaries  of  an  indictment. 
Meanwhile  the  Massachusetts  experiment  of  med- 
ical examiners  works  admirably,  and  has  stimu- 
lated reformatory  discussions  in  our  well  popu- 
lated communities. 

It  is  pertinent  to  allude  in  this  connection  to 
the  usage  of  most  European  nations,  which  is  to 
commit  "the  sudden  death  inquiries"  to  the 
public  prosecutors,  with  the  option  of  medical 
aid.  Here,  as  everywhere  in  the  civilized  world, 
the  certificate,  barring  suspicions  of  crime  or  the 
fixation  of  responsibility,  is  held  to  be  final. 
The  ruling  of  the  law  appears  to  be  that  an  opin- 
ion, however  erroneous,  cannot  be  a  misdemeanor 
even  in  the  mildest  sense  of  the  term.  Were  this 
otherwise,  but  few  articles  on  medical  education 
would  need  to  be  written,  since  none  would  be 
rash  or  Quixotic  enough  to  court  an  unnecessary 
doom. 

The  World's  Congress  Auxiliary  of  the 
World's  Columbian  Exposition. — Extensive 
preparations  for  International  Congresses  during 
the  Exposition  are  being  made  by  the  World's 
Congress  Auxiliary  of  the  World's  Columbian 
Exposition.  The  officers  of  the  Auxiliary  are 
Charles  C.  Bonney,  President;  Thos.  B.  Bryan, 
Vice-President;  Lyman  J.  Gage,  Treasurer;  Ben- 
jamin Rutterworth,  Secretary.  These  officers 
have  been  working  three  months  on  the  subject 
in  hand,  and  have  presented  to  the  directory  a  re- 
port showing  that  they  had  enlisted  the  sympathy 


i89i.] 


EDITORIAL  NOTES. 


277 


and  cobperatian  of  distinguished  men  in  politics, 
science,  religion,  education,  moral  and  social  re- 
forms, literature,  law,  and  the  artistic  and  learned 
professions.  The  work  outlined  is  on  the  broad- 
est scale,  and  congresses  of  the  representatives  of 
all  the  branches  indicated  have  been  provided 
for.  It  is  the  intention  to  bring  to  Chicago  not 
merely  a  few  distinguished  people,  but  a  large 
number  of  cultivated  and  intelligent  persons  from 
all  parts  of  the  world.  Much  difficult)-,  the  re- 
port says,  was  experienced  in  the  work  of  form- 
ing a  list  of  standing  committees  and  assigning 
and  specifying  their  work.  The  standing  com- 
mittee on  Medical  and  Surgical  Congresses,  in- 
cluding Dentistry,  Pharmacy,  Public  Health,  and 
Private  Sanitation,  with  a  special  committee  for 
each  organization  of  this  class — Dr.  N.  S.  Davis, 
Dr.  H.  A.  Johnson,  Dr.  H.  M.  Lyman,  Dr.  J.  S. 
Mitchell,  Dr.  R.  Ludlam,  Dr.  R.  X.  Foster,  Prof. 
Oscar  Oldberg,  and  Benjamin  Butterworth,  Sec- 
retary. 

Army  Medical  Examination.  —  Surgeon- 
General  Sutherland,  of  the  U.  S.  A.,  has  issued 
the  following  notice  : 

An  Army  Medical  Board  will  be  in  session  in  New 
York  City  during  April,  1S91,  for  the  examination  of 
candidates  for  appointment  in  the  Medical  Corps  of  the 
United  States  Army,  to  fill  existing  vacancies. 

Persons  desiring  to  present  themselves  for  examina- 
tion by  the  Board  will  make  application  to  the  Secretary 
of  War,  before  April  1,  1S91,  for  the  necessary  invitation, 
stating  the  date  and  place  of  birth,  the  place  and  State  of 
permanent  residence,  the  fact  of  American  citizenship, 
the  name  of  the  medical  college  from  whence  thev  were 
graduated,  and  a  record  of  service  in  hospital,  if  any, 
from  the  authorities  thereof.  The  application  should 
be  accompanied  by  certificates  based  on  personal  knowl- 
edge, from  at  least  two  physicians  of  repute,  as  to  pro- 
fessional standing,  character,  and  moral  habits.  The 
candidate  must  be  between  21  and  2S  years  of  age,  and  a 
graduate  from  a  regular  medical  college,  as  evidence  of 
which,  his  diploma  must  be  submitted  to  the  Board. 

Further  information  regarding  the  examinations  may 
be  obtained  by  addressing  the  Surgeon-General  U.  S. 
Army,  Washington,  D.  C. 

Nicakaugua  Canal  Hospital  at  Grey- 
town. — A  hospital  has  been  organized  at  Grey- 
town,  having  125  beds.  It  has  its  regular  staff 
of  surgeons,  apothecary,  trained  nurses  and  hos- 
pital steward.  Its  roof  and  sides  are  constructed 
of  corrugated  iron  with  a  view  of  minimizing  the 
dangers  by  fire  and  febrile  infection.  Every  suit- 
able modern  hospital  appliance  has  been  requisi- 


tioned and  supplied.  Subsidiary  hospital  sta- 
tions have  been  established  up  in  the  interior  at 
two  points  where  large  bodies  of  canal  workmen 
are  employed.  These  have  an  assistant  surgeon 
and  druggist  at  each. 

Removal. — We  regret  to  learn  that  by  reason 
of  the  ill  health  of  his  family  Dr.  James  A.  Lyd- 
ston,  late  Chief  of  Eye  aud  Ear  Department  of  the 
Pension  Bureau,  Washington,  D.  C,  has  been 
obliged  to  relinquish  the  Professorship  of  Chem- 
istry in  the  Chicago  College  of  Physicians  and 
Surgeons.  He  will  resume  the  practice  of  his 
specialty  in  Denver,  Colo. 

Longevity  in  the  Society  of  Friends, 
England. — A  recent  report  of  the  vital  statistics 
of  this  Society  in  the  United  Kingdom  is  com- 
mented upon  in  The  Lancet,  January  3.  The 
membership  of  this  bod}-  is  stated  at  15.500,  and 
the  mortality  during  the  past  three  years  is  given 
at  an  average  of  256  deaths  per  annum,  or  about 
16.5  per  1,000.  A  remarkable  feature  of  this 
mortality  is  the  high  age  of  the  deceased :  of  the 
769  persons  dying  in  three  years,  480  or  61  per 
cent,  were  60  years  old  or  upwards.  Another 
noteworthy  point  is  the  small  mortality  among 
young  children.  In  the  year  1889,  there  were  only 
fifteen  deaths  of  children  under  5  years  of  age. 
This  statement  may  be  taken  to  show  the  ab- 
normally low  rate  of  mortality,  but  in  the  ab- 
sence of  statistics  showing  the  number  of  persons 
living  in  the  various  age  periods,  it  rnay  also  be 
taken  to  show — that  which  is  probably  the  true 
state  of  the  case — an  abnormally  small  number  of 
young  children  in  the  Society.  The  Lance:  very 
properly  points  out  the  desirability  of  making 
such  future  reports  more  instructive  by  a  sta- 
tistical division  by  periods  of  age  of  the  15.500 
members,  so  many  of  whom  are  given  to  lives  of 
peace,  sobriety  and  good  works. 

The  Medical  Society  of  the  Missouri 
Valley. — The  next  meeting  of  this  Society  will 
convene  at  Omaha.  Neb.,  March  17,  at  7:30  p.m. 
It  has  an  enrollment  of  about  300  members. 
The  Secretary,  Dr.  F  S.  Thomas,  of  Council 
Bluffs,  la.,  will  be  pleased  to  communicate  with 
those  who  propose  to  present  papers  at  that 
meeting. 

Professor  Pfuhl,  Professor  Koch's  son-in- 
law,  is  to  have  charge  of  the  new  institute  for  ex- 
perimental medicine  in  St.  Petersburg. 


TOPICS  OF  THE  WEEK. 


[February  2r> 


.OPICS  OF  THE  WEEK. 


THE  PROGRESS  OF  SURGERY  IN  1890. 

In  the  last  year  there  has  possibly  been  a  slight  lull  in 
the  cumulation  of  surgical  discoveries,  and  yet  we  are 
unable  to  look  back  upon  the  progress  of  the  year  that 
has  just  expired  without  feeling  that  there  is  ample 
ground  for  congratulations  to  the  medical  profession  upon 
the  strides  that  have  been  made. 

The  great  event  of  the  year  was  the  Medical  Congress 
at  Berlin,  where  the  large  attendance  of  men  most  prom- 
inent in  our  art  andscience,  from  all  parts  of  the  civilized 
world,  brought  together  a  wealth  of  facts  and  views  that 
are  now  crystalizing  into  a  valuable  mass  of  information. 

'I  nere  has  been  noticed  in  the  year  gone  by  that  reac- 
tion which  was  bound  to  follow  the  enthusiastic  preva- 
lence of  intra-abdominal  operations  during  the  last  few 
years.  The  matchless  skill  of  the  leaders  in  these  pro- 
cedures has  taught  us  a  technique  that  can  scarcely  be 
improved  upon  ;  while  the  number  of  operations  per- 
formed has  become  less,  through  more  perfect  discrim- 
ination in  the  selection  of  cases  absolutely  requiring 
such  measures.  In  the  matter  of  operations  for  the  re- 
lief of  disorders  due  to  inflammatory  conditions  of  the 
vermiform  appendix,  the  main  points  developed  have 
been  chiefly  in  the  line  of  improved  diagnosis,  and  in  a 
general  belief  in  the  advisability  of  early  interference. 

The  study  of  intestinal  anastomosis  first  evolved  by 
Senn  has  been  taken  up  by  a  host  of  men,  though, 
strange  to  say,  its  practical  applications  are  still  limited 
too  much  to  our  own  country.  The  monograph  written 
by  Professor  Senn  upon  the  subject  of  the  Diagnosis  and 
Operative  Treatment  of  Gunshot  Wounds  of  the  Stom- 
ach and  Intestines,  bids  fair  to  become  one  of  the  classics 
of  surgery  for  years  to  come.  No  better  illustration  of 
the  progress  made  in  this  domain  of  surgery  can  be 
given  than  the  brilliant  results  obtained  by  Professor 
Bernays  in  a  series  of  seven  cases  of  gunshot  wounds  of 
the  abdomen,  which  formerly  would  have  been  regarded 
as  hopeless  and  left  to  die  without  surgical  interference. 

The  methods  of  skin  grafting  and  transplantation  de- 
vised by  Thiersch  have  proven  their  value  in  many  hands 
during  the  past  year,  and  now  are  fully  admitted  among 
the  established  surgical  procedures  of  common  oc- 
currence. 

Mr.  Horsley's  experiments  in  the  transplantation  of 
the  thyroid  gland  of  animals  to  the  human  subject  have 
been  followed  by  a  practical  application  of  the  procedure, 
and  bid  fair  to  add  one  more  to  the  many  splendid  re- 
sults attained  by  this  indefatigable  experimenter. 

In  the  surgery  of  the  joints  a  more  conservative  tend- 
ency is  becoming  manifest  ;  and  in  Germany,  especially, 
the  injection  of  iodoform  emulsions  in  tuberculous  joints 
has  been  employed  with  much  success  as  a  substitute  for 
more  radical  procedures. 

Among  the  improvements  brought  about  in  the  tech- 
nique of  special  operative  procedures,  the  bloodless 
method  of  amputation  at  the  hip  joint,  devised  by  Pro- 
fessor Wyeth,  of  New  York,  and  performed  with  success 
by  himself  and  others,  takes  high  rank. 


Operations  upon  the  nerve-centres  and  the  nerves 
themselves  have  greatly  multiplied,  and  operations  of 
un-heard-of  magnitude  have  this  year  been  reported,  by 
which  the  brain  and  cord  have  become  a  far  wider  oper- 
ative field  than  had  ever  been  previously  thought  pos- 
sible. 

The  discovery  with  which  Koch  startled  the  medical 
world  a  few  months  since  has  not  been  sufficiently  de- 
veloped to  permit  of  positive  deductions  regarding  its 
value  in  the  various  forms  of  surgical  tuberculosis, 
although  from  present  indications  it  will  supersede  all 
other  methods  for  the  treatment  of  lupus. 

Such  are  a  few  of  the  results  of  the  past  year,  and,  iu 
this  marvellous  age  of  progress,  we  are  left  to  wonder  at 
what  we  may  have  to  chronicle  for  another  year,  though 
we  are  conscious  that  the  last  one  has  marked  a  decided 
era  of  improvement  in  our  methods  and  knowledge. — • 
International  Journal  of  Surgery. 


ANOMALIES  OF  BRAIN  AND  SKULL  IN  CRIMINALS. 

Professor  M.  Benedikt  having  commenced  to  study  an- 
thropological!)' the  "great  criminals"  of  Vienna,  has 
communicated  some  results  of  his  examination  of  the 
brain  and  skull  of  Hugo  Schenk,  a  notorious  murderer  of 
women,  to  the  Wiener  medizinische  Blatter,  January  I, 
1891.  The  brain  presents  much  that  is  interesting.  In 
each  hemisphere  the  internal  parieto-occipital  fissure- 
shows  no  direct  adjunction  to  a  common  stem  with  the 
calearine,  but  enters  the  latter  by  an  irregular  lateral  offset. 
The  calearine  sulcus  communicates  with  the  fissure 
(termed  "limbic"  by  the  author)  separating  the  gyrus, 
hippocampi  from  the  temporal  convolutions.  This  lim- 
bic sulcus  further  joins  the  collateral,  and  by  its  rectilin- 
ear form  evidences  aplasia  of  the  gyrus  hippocampi,  as. 
has  frequently  been  observed  in  epileptics.  The  separa- 
tion of  the  gyrus  hippocampi  from  the  lobulus  lingualis. 
by  a  fissure,  instead  of  conjunction  by  a  wide  bridge,  is, 
entirely  opposed  to  the  type  of  gyrencephalous  animals; 
and  of  normal  man;  it  always  points  to  a  great  disturb- 
ance iu  the  balance  of  the  constructive  force.  The  con- 
fluence of  the  calearine  fissure  with  the  limbic  must  also 
be  regarded  as  a  stigma  of  high  grade.  On  the  mesial 
surface  of  the  left  hemisphere  aplasia  of  the  quadrate 
lobule  is  noticeable  through  operculation.  On  the  right 
hemisphere  a  branch  of  the  collateral  fissure  courses 
around  the  lower  outer  margin  and  joins  the  first  tem- 
poral sulcus.  On  the  outer  surface  of  this  hemisphere 
the  anterior  central  and  the  angular  are  the  best  devel- 
oped gyri.  The  outer  aspect  of  the  left  hemisphere  re- 
veals arrested  growth  of  the  frontal  lobe,  with  high  de- 
velopment of  the  two  central  gyri.  A  double  connection 
of  the  central  fissure  with  the  first  frontal  sulcus  insu- 
lates the  lower  part  of  the  upper  half  of  the  anterior  cen- 
tral convolution.  The  parietal  lobe  and  two  external 
annectants  are  markedly  hypoplastic.  In  strong  contrast 
therewith  is  the  bulky  development  of  the  occipital  lobe 
and  adjacent  parts  of  the  second  temporal  convolution. 
This  very  unequal  development  of  the  various  brain  seg;- 
meuts  indicates  defective  cerebral  equilibrium.  Taking 
into  account  the  extraordinary  development  of  the  sexual 


I89I.] 


TOPICS  OF  THE  WEEK. 


279 


passion  in  this  murderer.it  was  specially  interesting  to  dis- 
cover what  parts  of  the  brain  showed  a  preponderence  of 
growth,  and  to  consider  whether  those  parts  could  be 
associated  with  the  cortical  sexual  life.  In  this  case  it 
would  appear  that  the  most  important  seat  of  the  corti- 
cal sexual  existence  is  in  the  left  occipitotemporal  lobe. 
The  cranium  bears  as  strong  evidence  of  degeneracy  as 
the  brain;  it  is  grossly  asymmetric — the  right  fronto- 
parietal and  frouto  temporal  and  left  occipito-parietal 
and  occipito-temporal  regions  being  prominent,  and  the 
whole  base  of  the  occiput,  particularly  on  the  left  side, 
bulging  downwards.  Internally  and  externally  the 
cranial  sutures  are  almost  obliterated. — British  Medical 
Journal. 


THE  LEGAL  VIEW  OF  INSANITY  COMMITMENTS. 

Judge  David  McAdam,  the  President  of  the  Society  of 
Medical  Jurisprudence  (New  York),  in  a  recent  discussion 
said  that  the  law  relative  to  commitments  of  insane  per- 
sons was  not  generally  understood.  He  would  venture 
the  assertion  that  of  the  17,000  persons  now  in  custody 
in  New  York  State  on  charges  of  insanity  not  more  than 
1,000  had  been  committed  according  to  process  of  law. 
He  declared  that  a  certificate  signed  by  two  physicians 
and  attested  by  a  judge  did  not  constitute  a  process  of 
law.  Before  a  person  could  be  legally  deprived  of  his 
liberty  he  was  entitled  to  a  hearing,  a  trial  before  a  jury, 
and  an  adjudication  of  his  case. 

The  common  law  defined  what  should  be  done  in  such 
cases.  The  statute  law  merely  defined  certain  things 
that  should  not  be  done.  A  magistrate's  indorsement 
on  a  certificate  of  insanity  signed  by  two  doctors  sim- 
ply attested  the  respectable  standing.  His  signature 
added  no  force  to  the  commitment,  and  should  a  person 
thus  committed  prove  to  be  sane,  he  or  she  would  have 
a  good  cause  of  action  against  the  doctors  for  perjury, 
conspiracy,  and  civil  damages. 


these  three  pints  in  under  five  minutes'  time — in  fact,  in 
half  the  time  it  took  the  other  man.  No  wonder  this 
man,  when  he  started  to  go  home,  lost  his  way  in  the 
darkness  and  fog,  and  that  when  he  fell  into  the  canal  he 
was  unable  to  help  himself  out.  The  beer  drunk  by  the 
Germans  and  Kavarians  is  a  much  lighter  beverage,  and 
therefore  probably  contains  less  alcohol.  Could  not  the 
British  brewer  concoct  a  beverage  which  would  be  less  in- 
toxicating? It  is  a  popular  uotioathat  no  harm  can  result 
from  the  use  of  beer,  that  delirium  a  potu  never  follows 
its  employment.  But  this  is  a  delusion;  gastric  and 
hepatic  derangements  are  common  from  its  abuse,  and  in 
the  cases  of  continuous  beer-drinkers,  such  as  beer-sellers 
and  draymen,  delirium  tremens  is  not  unknown. — Lancet. 


THE  PAUPER  INSANE  OF  NEW"  YORK  STATE. 

The  bill  before  the  legislative  bodies  of  New  York,  ap- 
propriating the  necessary  money  for  carrying  into  effect 
the  law  passed  last  year  making  the  pauper  insane  a 
State  charge,  has  probably  at  the  present  writing  become 
a  law.  For  a  wonder,  party  lines  and  selfish  schemes 
have  been  inoperative.  When  New  York  decided  last 
year  to  remove  the  insane  from  the  poorhouses  and  place 
them  in  State  asylums  she  ought  to  have  provided  the 
funds  for  making  the  transfer.  But  reforms  move  slowly. 
Those  who  had  charge  of  the  bill  of  1S90  felt  that  they 
had  done  the  best  they  could  in  securing  its  passage  with- 
out the  means  to  make  it  effective.  This  year  they  have 
introduced  the  supplemental  measure.  The  appropria- 
tion asked  for  is  a  modest  one,  while  the  amount  of  good 
which  it  will  conserve  can  hardly  be  over-estimated. 


BEER-DRINKING  EXTRAORDINARY. 

Beer-drinking  amongst  students  in  Germany  and  other 
Continental  countries  is  proverbial,  and  we  may  say  that 
the  average  Englishman  is  a  beer-drinker  if  not  a  teeto- 
taler. In  Ireland  and  Scotland  alcohol  in  the  form  of 
spirits  is  the  chief  beverage.  In  the  prosperous  times  of 
1873  and  1S74  in  this  country,  the  working  collier  was 
said  to  have  forsaken  his  beer  and  taken  to  drinking 
champagne,  but  the  ensuing  depression  soon  put  an  end 
to  this.  Now,  however,  with  a  return  of  prosperity  in  the 
coal  trade,  we  find  his  beer-drinking  propensities  devel- 
oping. An  extraordinary  state  of  matters  was  proved  to 
have  taken  place  at  Ince,  near  Wigan  (during  an  inquiry 
by  Mr.  Brighouse,  the  county  coroner,  into  the  death  of 
a  man  who  had  been  drowned  in  the  Leeds  and  Liverpool 
canal).  A  comrade  of  the  deceased  stated  that  he  had 
seen  him  the  previous  afternoon,  and  up  to  that  time  he 
might  have  had  a  dozen  pints  of  beer  (six  quarts).  At 
night  they  had  two  glasses,  and  afterwards  four  small 
glasses  of  whisky.  It  was  further  shown  that  in  the 
course  of  the  afternoon  and  evening  the  deceased  and 
another  man  had  a  wager  as  to  who  could  drink  three 
pints   of  beer  in  the   shortest  time,  and  that  he  drank 


A  MEMORIAL  TO  PIROGOFF. 

During  the  Congress  of  Russian  Medical  Men  recently 
held  at  Moscow,  a  sketch  of  the  proposed  memorial  by 
the  Russian  Academician,  Mr.  Sherwood,  was  exhibited 
in  the  hall  of  the  University.  The  great  surgeon  is  rep- 
resented as  seated  on  a  chair,  with  a  skull  in  his  hand 
and  an  open  book  at  his  feet.  The  sides  of  the  pedestal 
are  adorned  with  crowns  of  laurel,  and  on  the  front  of  it 
is  the  inscription  in  Russian,  "To  Nicolai  Iwanowitsch 
Pirogow,  the  Thinker-Surgeon.     1810-1S81." 


LEPROSY  IN  RUSSIA. 

The  municipal  authorities  of  Riga  are  about  to  erect  a 
leper-house  at  a  distance  of  from  six  to  seven  versts  from 
that  city,  at  an  estimated  cost  of  55,800  roubles.  This 
includes  a  house  for  the  medical  superintendent  and  one 
for  the  warden,  besides  a  post-mortem  room,  etc.  Al- 
though the  number  of  lepers  in  Riga  and  its  neighbor- 
hood amounts  to  about  100,  the  new  lazaretto  will  con- 
tain only  40  beds.  As  isolation  is  not  compulsory,  it  is 
thought  likely  that  accommodation  thus  provided  will  be 
sufficient  for  the  lepers  who  voluntarily  seek  admission. 
It  is  expected  that  a  hospital  for  lepers,  with  accommo- 
dation for  40  or  50  patients,  will  be  opened  some  time  in 
the  spring,  at  Nennal,  a  place  about  70  versts  from  Dor- 
pat.  A  branch  institution,  with  10  or  15  beds,  will  also 
be  established  in  the  immediate  neighborhood  of  that 
city,  which  will  serve  the  purpose  of  a  receiving  house 
for  the  hospital  at  Nennal. 


28o 


PRACTICAL  NOTES. 


[February  21, 


PRACTICAL  NOTES. 


s. 


SCIATIC    TABLETS. 
Tinct.  colchici         "] 
Tinct.  cimicifugae      --  ,, 

Tinct.    aconiti  aa,  m.  ^. 

Tinct.  belladonna   J 
One  tablet. 


m;. 


— Star  on  Nervous  Diseases. — Pharm.  Record. 


AMYLHYDRATE. 


The  dose  of  this  liquid  is  about  a  drachm,  but 
it  is  not  very  soluble  in  water.  A  small  teaspoon- 
ful  may  be  given  in  a  glass  of  beer,  or  the  follow- 
ing may  be  used : 

R.    Amylhydrate,  JJij. 

Aq.  destill.,  1  _-    _.. 

Aq.  flor.  aurant.,/aa'  alJ- 
Syr.  cort.  aurant.,  ^j.  "JJ. 
Sig.     One-half  at  night. 

— Corrcspondcnzblatt  f.  Schweizer  Aerzte. 


ARREST    OF    WHOOPING    COUGH    BY    MANIPULA- 
TION   OF    HYOID    BONE. 

Naegely  in  La  Scniaine  Medicale  September  3, 
reports  on  a  new  manipulative  method  of  arrest-  i 
ing  the  paroxysms  of  whooping  cough  and  of  re- 
lieving neuralgia  of  the  fifth  nerve.  Over  fifty 
patients  have  been  treated  successfully  by  the 
following  procedure  :  the  operator  stands  in  front 
of  the  patient  and  with  his  thumbs  elevates  the 
greater  cornua  of  the  hyoid  bone,  a  purchase  for 
the  index  fingers  being  obtained  by  resting  them 
behind  and  above  the  ears  of  the  patient ;  the 
other  fingers  rest  upon  the  neck.  Relief  having 
followed  the  use  of  this  method  in  a  number  of 
cases  of  pertussis,  Naegely  next  applied  it,  with 
very  general  success,  in  a  number  of  other  cases 
of  nervous  disorders,  such  as  neuralgia  of  the 
fifth  nerve,  migraine,  globus  hystericus  and 
nausea  of  nervous  origin.  According  to  his  ex- 
periments, a  single  application  of  elevation  of  the 
hyoid  and  larynx,  maintaining  them  in  that  po- 
sition for  a  minute  to  a  minute  and  a  half,  has 
frequently  sufficed  to  remove  the  pain  or  distress 
completely  but,  in  some  cases  the  procedure  has 
had  to  be  repeated  several  times.  The  scientific 
explanation  of  such  results  as  these  is  not  very 
tangible  ;  but  Naegely  inclines  to  the  opinion 
that  those  results  depend  upon  one  of  those 
phenomena  of  inhibition,  so  well  formulated  by 
Brown-Sequard,  but  the  exact  mechanism  of 
which  remains  to  be  determined. 


epileptiform  nature  of  the  night  terrors  of  chil- 
dren. A  certain  proportion  of  these  cases  are 
beyond  question  an  evidence  of  nocturnal  petit 
vial,  and  those  are  the  cases  in  which  diurnal 
epilepsy  ultimately  supervenes.  It  was  in  this 
view  that  Trousseau's  method  of  treatment  by 
the  administration  of  belladonna  in  epilepsy  was 
tried  in  a  severe  and  protracted  case  of  night 
terrors.  Various  other  means  had  been  tried  and 
had  failed,  when  there  were  given  the  patient,  a 
boy  of  4  years,  five  drops  of  the  tincture  of  bella- 
donna at  night.  The  dose  was  increased  one 
drop  each  night  until  ninety  drops  were  given  at 
one  time.  The  father  of  the  patient  was  in- 
structed to  be  careful  and  exact,  and  he  was  faith- 
ful and  persistent.  The  results  were  most  satis- 
factory ;  not  one  severe  attack  of  the  terrors  was 
experienced  after  the  beginning  of  the  treatment. 
The  severity  of  the  attacks  gradually  diminished; 
when  no  symptoms  whatever  of  the  nervous 
trouble  had  appeared  for  more  than  two  months, 
the  dose  was  decreased  ten  drops  each  night. 
The  relief  was  almost  immediate,  and  there  has 
never  since  been  any  recurrence  of  the  trouble. 
The  general  final  history  of  all  such  cases  is  less 
favorable,  ending  as  they  so  often  do  in  epilepsy 
proper,  preceded  by  a  lack  of  vivacity  or  a  transi- 
tory beclouding  of  the  intellect  during  the  day  as 
the  disease  extends  from  the  night  to  the  day- 
time. 


NIGHT   TERRORS    SUCCESSFULLY    TREATED    BY 
BELLADONNA. 

Dr.  Lorenzo  Hale,  of  the  Albany  Medical  An- 
nals, writes  in  its  December  issue  regarding  the 


INFANTILE    DIARRHCEA. 


R.     Ferri.  sulph., 

Sod.  salicyl.,  aa,  gr.  x. 
Glycerinii,   JJiij. 
Aq.  dest,  Sijss.     *%■ 


Si. 


A  teaspoonful  every  one,  two,  or  three  hours. 
— Canada  Lancet. 


HEMORRHOIDS. 


The  following  is  suggested  in  the  Medical  Mir- 
ror as  an  excellent  salve  : 

B.    Cocain.    muriat.,  gr.  xx. 
Morphinae  sulph.,  gr.  v. 
Atrophia;  sulph.,  gr.  iv. 
Acid   tannic,  pulv.,  gr.  xx. 
Vaseline,  ,5j. 
Olei  rosae,  q.  s.     Ttjj. 


Sig.     Apply  after  each  evacuation, 
must  be  kept  soluble. 


Contents  of  bowels 


SEMINAL   EMISSIONS. 

As  a  direct  means  of  diminishing  the  frequency 
of  nocturnal  emissions,  Bumstead  recommends  : 

B.  Potassi  broniidi,  ,iy. 
Tr.  ferri  chlor.,  ^j. 
Aquae  pur.,  Jjiij.     '<K. 

Sig.     One  or  two  teaspoonfuls   in  water  an  hour  after 
meals  and  .-it  bed-time. 

— Canada  Lancet. 


I89I.] 


FOREIGN  CORRESPONDENCE. 


281 


FOREIGN    CORRESPONDENCE. 


LETTER    I  PROM     I'AlilS. 
(from  our  own  correspondent.) 

Koch's  Treatment  of  Tuberculosis — The  late  Dr. 
Baillarger- — A  French  Rejoinder  to  the  Edmunds 
Bill — Another  Cure  for  Consumption — Death  of 
Baron  Haussmann — An  Important  Legal  Pro- 
nouncement— Is  Cocaine,  employed  as  a  Local  An- 
arsthetic,  Dangerous .' 

In  this  medical  centre,  as  elsewhere,  the  new 
remedy  for  tuberculosis  has  been,  and  is  being, 
extensively  studied  at  the  various  hospitals.  In 
a  series  of  admirable  lectures,  Professor  Cornil 
has  given  a  faithful  account  of  the  results  of  in- 
oculations on  his  own  patients  of  the  Laennee 
Hospital.  These  results  do  not  differ  materially 
from  those  recorded  by  other  observers,  if  we  ex- 
cept the  occurrence  of  albuminuria  in  certain  in- 
stances. The  dose  did  not  generally  exceed  1 
milligram,  and  this  commendable  caution  has 
been  imitated  by  most  operators  in  Paris.  At 
the  St.  Louis  Hospital  a  committee  of  physicians 
and  surgeons  has  been  appointed  to  report  on  the 
effect  of  the  lymph  on  the  various  forms  of  tuber- 
culosis, and  their  report  will  soon  be  forthcoming. 
So  far  as  one  can  gather  from  the  opinions  ex- 
pressed by  those  most  competent  to  judge,  the 
lymph,  however  marvelous  its  diagnostic  proper- 
ties in  a  large  proportion  of  cases,  and  however 
great  the  amelioration  produced  by  it  in  lupus  may 
be,  has  not  hitherto  fulfilled,  as  a  curative  agent, 
the  expectations  raised  at  its  debut.  A  leading 
article  in  the  Paris  Medical  of  January  10  bears 
this  significant  title:  "Resurrection  du  tubage 
du  Larynx.  Enterrement  des  injections  de  la 
lymphe  de  Koch."  The  writer  recalls  the  suc- 
cessful resuscitation  by  O'Dwyer  of  an  idea  ema- 
nating originally  from  a  Frenchman  thirty-two 
years  ago,  and  prophesies  that  thirty-two  years 
hence  Koch's  treatment  will,  on  the  contrary, 
have  passed  into  the  limbo  of  things  forgotten. 
The  writer  avers,  on  Debove's  authority,  that  in 
fourteen  indubitable  cases  of  tuberculosis,1  the 
lymph  failed  to  provoke  any  reaction  whatever. 
He,  finally,  adduces  as  a  reason  for  the  renuncia- 
tion of  the  method  the  fact  that,  while  the  rem- 
edy has  failed  to  cure  a  single  case,  it  has  al- 
ready caused  the  death  of  more  than  twenty 
patients:  seventeen  in  Germany,  four  in  Austria, 
one  in  Paris  and  one  in  Brussels — one  fatality  oc- 
curring in  a  case  of  lupus. 

M.  Leon  Petit  (Soc.  de  Med.  Pratique,  Decem- 
ber 18,  1890)  gives  it  as  his  opinion  that  Koch's 
lymph  should  be  relegated  to  the  laboratory  until 
its  range  of  action  can  be  properly  verified.  Hav- 
ing, in  collaboration  with  MM.  Ceremonie  and 
Gautrelet,  found  by  analysis  that  the  active  prin- 

1  Observed  bv  R£mond  at  Berlin. 


ciple  of  Koch's  liquid  is  an  amine,  he  has  suc- 
ceeded in  fabricating  a  lymph  possessing  identi- 
cal properties.  This  product  he  has  denominated 
"la  lymphe  Francaisc,  "  and  he  promises,  when 
the  results  of  experiments  now  in  course  of  exe- 
cution on  tuberculous  and  normal  animals  of  dif- 
ferent species  shall  have  been  rigidly  checked 
and  controlled,  that  he  will  publish  the  mode  of 
preparation  of  this  new  product. 

The  eminent  alienist,  Dr.  Baillarger,  died  on 
the  last  day  of  1890,  at  the  ripe  age  of  82.  One 
of  the  last  survivors  of  the  pupils  of  the  famous 
Esquirol,  whose  interne  he  was  at  Charenton, 
he  was  for  a  long  period  physician  to  the  Sal- 
petriere  Hospital,  and  had  attained  to  the  crown- 
ing dignity  of  President  of  the  Academy  of  Med- 
icine. To  his  indefatigable  industry  we  owe  a 
great  number  of  works  on  mental  medicine  which 
have  become  classical.  These  have  recently  been 
collected  into  two  volumes,  and  they  cover  pretty 
nearly  the  whole  range  of  the  various  manifesta- 
tions of  mental  derangement.  Melancholia  with 
stupor,  folic  a  double  forme,  hallucinations,  gen- 
eral paralysis,  the  unfolding  of  the  brain  in  men- 
tal development,  the  normal  structure  of  the  cor- 
tex, cretinism — these  are  a  few  of  the  subjects 
treated  and  elucidated  by  him  in  a  masterly  man- 
ner. His  obsequies  took  place  on  January  4,  in 
the  presence  of  the  newly  elected  President  of  the 
Academy  of  Medicine  (Professor  Tarnier),  and  a 
large  gathering  of  representative  men. 

In  a  leader  in  the  Gazette  Hcbdomadaire- of  Jan- 
uary 10.  M.  Lereboullet  calls  attention  to  the 
warning  issued  by  Professor  Graudeau,  Director 
of  the  Eastern  Agronomic  Station,  on  the  danger 
attending  the  importation  into  France  of  Ameri- 
can meat,  and  with  it.  of  actinomycosis.  It  is 
stated  that  the  supervision  exercised  at  Chicago 
is  totally  inadequate,  as  two  inspectors  are  re- 
sponsible for  the  examination  of  an  average  of 
10,000  oxen  and  20,000  pigs  a  day.  The  Ed- 
munds Bill  conferring  on  the  President  plenary 
retaliatory  powers  on  foreign  nations  whose  tra- 
ders export  into  the  States  articles  intended  for 
human  consumption  found  to  be  adulterated,  M. 
Lereboullet  hopes  that  France  will  not,  in  her 
turn,  be  behindhand  in  instituting  like  measures 
to  protect  her  citizens  against  the  introduction  of 
actinomycosis. 

The  eclat  attending  the  appearance  of  Koch's 
liquid  in  the  therapeutical  arena  has  not  failed  to 
stimulate  the  inventive  faculties  of  would-be  em- 
ulators of  the  learned  Teuton.  Some  two  months 
ago,  the  lay  press,  headed  by  the  widely  read 
Petit  Journal,  heralded,  with  a  flourish  of  trum- 
pets, the  discovery  by  a  hitherto  unknown  French 
practitioner  named  Mathieu.  of  the  obscure  vil- 
lage of  Estissac,  of  an  infallible  cure  for  pulmo- 
nary consumption.  The  remedy  was  said  to  con- 
sist mainly  of  a  kind  of  electricity  generated  by 
plants.     The  happy  discoverer,  finding  Estissac 


282 


DOMESTIC  CORRESPONDENCE. 


[February  21, 


too  narrow  a  field  for  the  display  of  his  energies,  j  declared  that  the  collecting  of  money  for  such  a 
has  migrated  to  Paris,  where  he  has  founded  a  ,  purpose  is  a  contravention  of  the  law. 
clinique.  He  is  said  to  be  now  earning  2,000  On  the  2d  of  December,  1890,  M.  Hallopeau 
francs  a  day  !  Unlike  Koch,  he  makes  no  secret ,  reported  to  the  Academie  de  Medecine  a  case  of 
of  the  composition  of  his  remedy ;  anyone  ma}-  chronic  cocaiuism  induced  by  a  single  injection 
read  it  in  the  Annales  <V electro  dosimetre.  Here 
it  is ! 


Formula  No.  5  de  M.  Mathieu  pour  la  tuberculose: 
Electricite  verte,  30  globules. 
Pectoral2,  30  globules. 
P4,  20  globules. 
P4,2  aa,  10  globules. 
C3,4,10  aa,  10  globules. 
Febrifuge1,2  aa,  5  globules. 
A1.  A4  aa,  5  globules. 
Vermifuge1,'-'  aa,  5  globules. 
S1  S2,  5  globules. 

The  nature  of  the  ingredients  of  this  somewhat 
cabalistic  remedy  will,  doubtless,  prove  a  puzzle 
to  your  readers,  but  that  does  not,  it  appears,  pre- 
vent M.  Mathieu  having  hosts  of  adherents  among 
the  public  of  "la  ville  lumiere." 

If  the  late  Emperor,  Napoleon  III,  was  not 
uniformly  happy  in  his  choice  of  instruments  to 
carry  out  his  will,  no  sanitarian  will  accuse  him 
of  having  committed  a  mistake  in  selecting  Baron 
Haussmann  as  Prefect  of  the  Seine.  Every  one 
knows  how  this  much-reviled  functionary  "hauss- 
manized ' '  Paris,  creating,  with  an  audacity  we 
must  all  admire,  new  broad  boulevards,  uprooting 
rookeries  and  foul  dens  into  which  pure  air  never 
penetrated,  and  transforming  Paris  into  the  airy, 
well-lighted  capital  that  now  ranks  second  in  Eu- 
rope in  point  of  health.  This  modest  sanitary  re- 
former has  just  died  at  the  advanced  age  of  92. 
It  says  much  for  his  integrity  that,  since  his  re- 
tirement in  1870,  he  had  subsisted  on  a  paltry 
pension  of  less  than  $1,500  a  year.  His  auto- 
biography appeared  recently.  Being  a  Protest- 
ant, he  was  interred  at  the  Church  of  the  Re- 
demption, in  the  rue  Chauchat,  with  military 
honors. 

Charlatanism  of  the  good  old-fashioned  type  is 
exceedingly  rife  in  certain  country  districts  in 
France,  and  many  of  these  irregular  practitioners 
attain  to  a  degree  of  popularity  the  practical  dem- 
onstration of  which  may,  as  in  the  following  in- 
stance, lead  their  admirers  into  serious  trouble. 
In  the  month  of  March,  1890,  Jean  Sibuet,  bone- 
setter  and  Councillor-General  of  his  canton,  was 
sentenced  to  pay  a  fine  for  having  illegally  prac- 
ticed the  medical  art.  His  enlightened  admirers 
immediately  convened  an  indignation  meeting  at 


into  the  gum  of  8  centigrams  of  hydrochlorate 
of  cocaine.  From  a  study  of  this  case,  he  be- 
lieves himself  authorized  to  deduce  the  following 
conclusions : 

A  single  injection  of  cocaine,  even  in  a  small 
dose,  may  not  only  produce  immediate  toxic 
symptoms  of  a  grave  character,  but  may  give  rise 
to  symptoms  persisting  for  several  months.  These 
distant  symptoms  are  analogous  to  those  perceived 
sometimes  immediately  after  the  injection,  viz.: 
obstinate  headache,  insomnia,  numbness  of  the 
extremities,  attacks  of  faintuess,  dizziness,  pros- 
tration, loquacity  and  a  state  of  great  agitation. 
These  accidents  are  chiefly  observed  in  very  ex- 
citable subjects. 

In  the  current  number  of  La  Medecine  Modenie, 
M,  Reclus,  who  employs  cocaine  largely,  endeav- 
ors to  controvert  these  statements  of  M.  Hallo- 
peau, and  asserts  that,  properly  managed,  this 
valuable  anaesthetic  is  innocuous.  The  rules  to 
be  followed  in  the  management  of  this  drug  are, 
according  to  M.  Reclus,  as  follows : 

1.  The  quantity  of  cocaine  injected  should 
never  exceed  12  centigrams,  2,  4,  6,  or  exception- 
ally 8  centigrams  sufficing  for  most  minor  opera- 
tions. 

2.  Employ  a  weak  solution  (2  per  cent.). 

3.  Avoid  the  introduction  of  the  drug  into  the 
interior  of  a  blood-vessel.  The  best  way  to  avoid 
the  evil  consequences  of  such  a  contretemps  is  to 
push  the  needle  into  the  tissue  slowly,  and  while 
so  doing  to  press  on  the  piston  rod  at  the  same 
rate.  In  this  manner,  even  if  a  vessel  be  pierced, 
only  a  small  proportion  of  the  solution  can  min- 
gle with  the  blood  contained  in  the  wounded  ves- 
sel. J.  h.  B. 


DOMESTIC  CORRESPONDENCE. 


LETTEK  PROM    STEW  YORK. 

(FROM   OT-R   OWN   CORRESPONDENT.) 

Experimental  Koch  Inoculations— Hypodermic 
Injections  of'  Aniline  and  Sterilized  Oil  in  the 
Treatment' ol  Phthisis— The  New  York  County 
Medical .  Issociation—TAe  New  York  Medico-Legal 

a  cafe,  and  opened  a  public  subscription  1  to  cover  ^  Hypnotism- American  Electro-  Thera- 

the  amount  demanded  of  their  idol  by  the  exac-    x     ,.-  t-.....,..  -    ,,.• . .. 

tic  ins  of  a   tyrannous  law,  any  surplus  to  be   de- 


voted to  the  erection  of  a  statue  to  Sibuet's  father, 
who  was  also  a  famous  bone-setter.  The  o  inven 
ersofthis  meeting  were,  in  their  turn,  prosecuted, 
and  mulcted  in  various  sums.  This  judgment 
being  appealed  against,  the  Chambery  Court  has 
confirmed  the  finding  of  the  lower  tribunal,  and 


!',  /,,':,  Society — Miscellaneous  Items. 

While  it  is,  of  course,  far  too  soon  to  judge  of 
the  ultimate  results  of  the  treatment,  the  very  ex- 
tended  series  of  experiments  with  the  Koch  inoc- 
ulations which  have  now  been  carried  on  in  this 
city  have  apparently  been  attended  with  effects 
for  the  most  part  corresponding  with  those  re- 


i89i.] 


DOMESTIC  CORRESPONDENCE 


283 


ported  from  Germany.  There  can  be  no  ques- 
tion, however,  that  the  warning  note  sent  out  by 
Virchow  has  very  properly  had  the  result  of  mak- 
ing our  hospital  physicians  proceed  with  marked 
caution  in  the  matter,  and  it  is  probably  safe  to 
say  that  in  cases  of  tubercular  meningitis,  for  in- 
stance, the  lymph  will  not  again  be  employed. 
There-  appears  to  be  sufficient  ground  for  the  be- 
lief that  pulmonary  tuberculosis  in  the  earls- 
stages  of  the  disease  is  checked,  and  may  be 
cured  by  the  injections,  and  there  seems  to  be  a 
general  agreement  as  to  their  beneficial  effect  in 
cases  of  lupus. 

But  even  in  lupus,  according  to  Dr.  P.  A.  Mor- 
row, the  well  known  dermatologist,  while  the 
observations  made  would  seem  to  show  that  the 
results  thus  far  obtained  may  be  regarded  as  sat- 
isfactory and  promising,  they  cannot  be  called 
conclusive  in  any  sense  as  yet.  There  should  be 
much  hesitation,  he  claims,  about  declaring  that 
there  has  been  a  cure  effected  in  a  case  of  lupus, 
as  it  is  well  known  how  prone  the  disease  is  to 
break  out  again  after  apparent  disappearance.  A 
relapse  being  liable  to  occur  after  six,  twelve,  or 
even  eighteen  months,  he  would  not  be  satisfied 
that  a  cure  had  really  been  made  until  the  patient 
had  been  under  observation  a  very  long  time. 

For  some  time  past  Dr.  George  F.  Shrady,  edi- 
tor of  the  Medical  Record,  has  been  experiment- 
ing with  the  lymph  on  cancer  cases  at  the  New 
York  Cancer  Hospital,  and  it  is  even  said  that 
it  has  been  used  in  leprosy  in  this  city,  but  it  does 
not  seem  at  all  likely  that  any  very  definite  re- 
sults will  be  obtained  in  such  cases.  William 
Degan,  the  consumptive  selected  by  Dr.  Shrady 
from  the  St.  Francis  Hospital  to  be  sent  to  Ber- 
lin for  treatment,  has  returned  to  New  York,  and 
is  again  at  the  hospital  undergoing  injections.  It 
is  reported  that  his  condition  is  now  considerably 
improved,  but  whether  this  improvement  will 
continue  or  not  is  somewhat  problematical,  as  it  is 
thought  that  the  disease  was  perhaps  too  far  ad- 
vanced in  his  case  to  afford  ground  of  hope  for 
the  best  results. 

In  New  Haven,  Conn.,  where  the  Koch  treat- 
ment was  employed  for  the  first  time  in  this 
country,  the  injections  having  been  begun  on 
December  3,  Prof.  Francis  Bacon  is  reported  as 
having  said  recently:  "The  original  representa- 
tion in  regard  to  the  curative  effect  of  the  lymph 
on  lupus  are  confirmed,  so  far  as  the  present  ex- 
periments have  gone,  but  I  can  hardly  say  as 
much  regarding  its  effect  on  pulmonary  tubercu- 
losis. I  do  not  care  to  express  an  opinion  regard- 
ing each  individual  case,  but  I  will  say  that  there 
has  been  an  improvement  in  the  condition  of  the 
patients,  or,  in  other  words,  that  they  are  better 
than  they  were  before  the  use  of  the  remedy  was 
begun.  It  is  hardly  time  yet  to  demonstrate  the 
full  efficacy  of  the  lymph,  but  enough  is  known 
to  assure  us  that  it  is  a  most  powerful  agent." 


For  some  time  past  very  encouraging  reports  have 
been  made  concerning  the  treatment  of  phthisis  at 
the  House  of  Rest  for  Consumptives,  of  this  city.by 
Dr.  C.  E.  Bruce,  and  at  the  last  meeting  of  the 
Medical  Society  of  the  County  of  New  York  that 
gentleman  reported  some  of  the  results  obtained 
by  him,  and  gave  an  explanation  of  his  method. 
the  essential  point  of  which,  it  seems,  is  the  hy- 
podermic injection  of  aniline  and  sterilized  oil  in 
increasing  doses.  The  plan  of  treatment,  he 
states,  is  the  result  of  an  extended  course  of  in- 
vestigation into  the  nature  of  the  tubercle  bacil- 
lus, and  long  before  the  announcement  of  the  dis- 
covery of  Koch's  remedy,  he  was  engaged,  assisted 
by  Drs.  J.  S.  Healy  and  T  W.  Rogers,  in  study- 
ing the  effects  of  various  substances  upon  the  ba- 
cillus. He  received  his  first  clue,  as  it  might  be 
called,  from  a  German  medical  journal,  and  this 
leading  his  thoughts  in  a  special  direction  finally 
resulted  in  the  experiments  with  the  remedy 
named.  These  experiments  have  been  very  sat- 
isfactory as  far  as  they  have  gone,  but  sufficient 
time  has  not  elapsed  to  speak  of  the  results  at 
all  definitely.  Should  these  eventually  prove  as 
encouraging  as  Dr.  Bruce  hopes,  he  thinks  a  rem- 
edy will  be  in  the  hands  of  the  profession  which 
will  be  free  from  many  of  the  objections  which 
have  been  made  against  Koch's  lymph.  Thus, 
it  is  an  entirely  harmless  material  which  can  be 
readily  furnished  to  any  practitioner  in  the 
j  country,  there  being  no  necessity  for  culture,  as 
in  the  case  of  an  organic  substance  like  the  lymph. 
Its  use  can  be  safely  undertaken  without  the 
special  experiment  and  careful  watching  which 
the  employment  of  the  latter  demands,  and 
another  point  in  its  favor  is  that  as  far  as  the  ex- 
periments thus  far  made  with  it  go  to  show,  it 
seems  to  be  most  effective  in  the  advanced  stages 
of  phthisis,  where  the  lymph  is  apparently  least 
beneficial.  Since  the  first  of  January  patients 
side  by  side  in  the  House  of  Rest  for  Consump- 
I  tives  have  been  treated  respectively  by  the  Koch 
and  Bruce  methods,  and  the  results  reported  have 
been  decidedly  in  favor  of  the  latter.  In  this  in- 
stitution, it  is  to  be  remembered,  that  the  sub- 
jects are,  as  a  rule,  in  the  advanced  stages  of  the 
'  disease.  The  profession  has  naturally  learned  to 
be  somewhat  skeptical  in  regard  to  reported  rem- 
edies in  phthisis,  but  further  developments  in 
\  this  matter  will  be  awaited  with  interest. 

At  the  annual  meeting  of  the  New  York 
County  Medical  Association  the  following  officers 
were  elected:  President,  Dr.  S.  B.  W.  McLeod; 
Vice  President,  Dr.  Wm.  T.  White  ;  Recording 
Secretary,  Dr.  P.  Brynberg  Porter;  Recording  and 
Statistical  Secretary,  Dr.  Augustus  D.  Ruggles; 
Treasurer,  Dr.  John  H.  Hinton;  Members  of  the 
Executive  Committee,  Drs.  Edward  Sanders, 
N  J.  Hepburn,  Wm.  B.  De  Garno,  and  George 
T.  Harrison.  The  report  of  the  Statistical  Secre- 
S  tary,  Dr.  Ruggles,  showed  the  Association  to  be 


284 


DOMESTIC  CORRESPONDENCE. 


[February  21, 


in  a  most  flourishing  condition.  One  year  ago 
there  were  430  members  on  its  roll.  During  the 
year  it  lost  by  death  three  members,  including 
the  President,  Dr.  Charles  S.  Wood,  and  by 
removal  and  other  causes  fifteen  members.  On 
the  other  hand,  it  received  an  accession  of  171 
new  members,  so  that  there  are  now  on  its  roll 
583  active  members. 

At  the  last  meeting  of  the  Academy  of  Medi- 
cine there  was  a  general  discussion  on  chronic 
cervical  adenitis  in  children,  under  the  auspices 
of  the  Section  on  Paediatrics;  the  discussion  on 
etiology,  symptomatology  and  diagnosis  being 
opened  by  Dr.  A.  Jacobi,  that  on  medical  tieat- 
ment  by  Dr.  Wm.  H.  Thomson,  and  that  on  sur- 
gical treatment  by  Dr.  Frank  Hartley.  On  this 
occasion  Dr.  Alfred  L,.  Eoomis  was  re-elected  Presi- 
dent and  Dr.  Edward  L.  Keyes  was  elected  a 
Vice-President  of  the  Academy. 

At  a  recent  meeting  of  the  New  York  Medico- 
Legal  Society  a  special  committee  on  hypnotism, 
of  which  Dr.  E.  Morgan,  Jr.,  was  chairman,  re- 
ported that  after  a  year's  consideration  of  the  sub- 
ject they  regarded  it  safe  to  say  that  the  follow- 
ing facts  had  been  established  : 

1.  Hypnosis,  or  artificial  trance  sleep,  is  a  sub- 
jective phenomena,  and  may  be  self- induced 
through  expectation  alone,  through  fright,  by  re- 
ligious ecstacy,  or  any  enrapturing  emotion. 

2.  Hypnotism  is  not  in  itself  a  disease. 

3.  Hypnotism  is  recognized  in  three  stages — 
lethargy,  somnambulism,  and  catalepsy.  The 
transition  may  be  immediate. 

4.  Hypnotism  has  been  serviceable  in  medical 
and  surgical  practice,  both  as  a  therapeutic  agent 
and  in  some  cases  as  an  efficient  and  safe  anaes- 
thetic. 

5.  The  illusory  impressions  created  by  hypno- 
sis may  be  made  to  dominate  and  tyrannize  the 
subsequent  actions  of  the  subject. 

In  the  latter  part  of  January  there  was  organ- 
ized, at  the  New  York  Academy  of  Medicine,  the 
American  Electro-Therapeutic  Association,  com- 
posed of  physicians  in  different  parts  of  the  coun- 
try who  are  specially  interested  in  the  various 
forms  of  electrical  medical  and  surgical  treatment. 
The  following  officers  were  elected  ;  President, 
Dr.  G.  Betton  Massey,  of  Philadelphia  ;  Vice- 
Presidents,  Drs.  W.  J.  Morton  and  A.  H.  Goelet, 
of  New  York;  Secretary,  Dr.  Wm.  H.  Walling, 
of  Philadelphia;  Treasurer,  Dr.  Geo.  H.  Rohe,  of 
Baltimore;  Executive  Committee,  Drs.  H.  R.  Big- 
elow,  of  Philadelphia,  F.  H.  Martin,  of  Chicago, 
Wm.  II.  Hutchinson,  of  Providence,  R.  I.,  and 
C.  D.  Palmer,  of  Cincinnati. 

The  report  of  the  Health  Department  of  the 
city  of  Brooklyn,  recently  transmitted  to  Mayor 
Chapin,  shows  that  the  total  number  of  deaths 
there  during  the  year  1890  was  19,773,  as  com- 
pared with  18,480  in  1889.  The  deaths  from 
phthisis  amounted  to  2,161,  and  from  pneumonia 


to  2,319.  A  much  larger  number  of  cases  and 
deaths  were  reported  from  diphtheria  than  any 
other  contagious  disease,  and  not  a  single  case  of 
small-pox  was  reported.  Fifteen  thousand  births 
were  reported — about    1,000  more  than  in  1889. 

The  records  of  the  State  Board  of 'Health  show 
that,  as  usual,  November  was  the  healthiest  month 
of  the  year.  It  has  been  found  to  be  the  case 
that  invariably  the  death-rate  in  the  State  is  lower 
in  this  than  in  any  other  month.  The  average 
daily  mortality  for  the  past,  five  years  has  been 
260,  while  that  of  November  has  been  225.  In 
1889  there  were  42  less  deaths  daily  in  Novem- 
ber than  the  daily  rate  for  the  year;  in  1888  there 
were  52  less,  in  1887,  21  less,  and  in  1886,  9  less 
per  day.  The  average  number  of  deaths  per  day 
in  1890  was  305,  and  during  November  257,  or 
nearly  56  less  per  day.  From  zymotic  diseases 
the  mortality  in  November,  1890,  reached  only 
146  in  every  1,000  deaths  from  all  causes,  and 
this  is  lower  than  the  average  for  the  month  of 
November,  which  is  182  per  1,000. 

The  26th  of  January  was  a  proud  and  happy 
day  for  the  Italian  colony  here.  On  this  occa- 
sion there  was  inaugurated,  with  appropriate  cer- 
emonies, under  the  auspices  of  Baron  Fava,  the 
Italian  Minister  at  Washington,  the  "  Iustitutio 
Italiano,"  or  Italian  Home.  This  institution  is 
located  on  Second  avenue,  and  occupies  a  four- 
story  building  fronting  on  the  avenue  and  a  two- 
stoty  building  in  the  rear.  Within  these  quar- 
ters are  contained  a  hospital,  with  wards  for  both 
men  and  women;  a  benevolent  bureau  for  the  re- 
lief of  the  poor,  a  school  for  the  purpose  of  pre- 
paring Italian  children  for  the  public  schools,  and 
a  bureau  for  the  protection  of  Italian  immigrants 
and  the  promotion  of  Italian  colonization.  The 
idea  of  a  benevolent  enterprise  of  this  kind  has, 
for  a  number  of  years,  been  in  the  minds  of  the 
leading  Italian  residents  of  this  city,  but  it  was 
only  when  the  Chevalier  Riva — who  is  now  the 
Honorary  President  of  the  institution — came  here 
as  Consul-General  of  Italy  in  1888,  that  the  pro- 
ject assumed  definite  shape.  At  his  call  more 
than  $20,000  was  subsrcibed'iu  less  than  a  year 
by  the  Italians  of  the  United  States.  This  amount 
was  considerably  increased  by  the  dues  of  those 
becoming  members  of  the  Institute,  and  the  Ital- 
ian Government,  having  been  made  interested  in 
the  patriotic  scheme,  sent  a  contribution  of  $2,- 
000.  The  promoters  of  the  Home  were  therefore 
able,  in  September  last,  to  purchase  the  property 
now  occupied  for  $31,500. 

(hi  the  first  floor  of  the  Home  are  the  mana- 
ger's office,  dispensary,  pharmacy,  waiting-rooms 
and  an  ambulance  entrance.  The  second  floor 
has  looms  for  the  Secretary  and  other  officers  of 
•hi;  institution,  a  medical  board  room,  a  library 
and  a  reception  room.  The  latter  is  a  handsome 
apartment,  gratuitously  frescoed  by  a  firm  of  Ital- 
ian decorators,  and  contains  a  beautiful  piano,  the 


I89i.] 


DOMESTIC  CORRESPONDENCE. 


285 


gift  of  Italian  piano-makers.  All  the  rest  of  the 
furnishing  of  the  room  was  presented  by  Signor 
Salvatore  Cantoni,  President  of  the  Home,  and 
among  the  pictures  are  portraits  of  Washington, 
Garibaldi,  Mazzini,  and  the  King  and  Queen  of 
Italy.  On  the  third  floor  are  the  hospital  accom- 
modations for  women — twenty-seven  beds  in  four 
rooms — and  all  facilities  and  conveniences  for  pa- 
tients, physicians  and  nurses,  and  the  fitting- up 
of  this  floor  has  been  chiefly  paid  for  by  M.  Bar- 
satti,  editor  of  the  Italian  paper  //  Progresso,  in 
memory  of  a  deceased  daughter.-  The  fourth 
floor  is  similar  in  its  appointments,  and  is  de 
signed  for  male  patients.  The  first  floor  of  the 
rear  building  contains  a  large  assembly  hall  for 
the  meetings  of  the  institution,  capable  ot  seating 
250  people,  and  it  was  in  this  that  the  inaugura- 
tion ceremonies  were  held.  On  the  second  floor 
are  rooms  for  the  managing  boards  of  the  various 
departments  of  the  institution,  and  a  large  room 
intended  especially  for  sick  Italian  sailors.  Alto- 
gether the  arrangements  of  the  new  Home  are 
very  complete  and  satisfactory,  and  reflect  much 
credit  on  its  philanthropic  founders.  It  is  esti- 
mated that  the  property  is  now  worth  $50,000, 
and  there  can  be  no  question  that  the  institution 
will  accomplish  a  most  excellent  work. 

In  January  there  died  at  Flushing,  Long  Is- 
land, a  Mrs.  Stillwaggon,  who  was  probably  the 
oldest  person  in  the  State.  She  is  said  to  have 
reached  the  age  of  105  years  and  4  months ;  it 
being  stated  that  she  was  born  on  September  18, 
1785.  Her  birthplace  was  Tarrytown,  on  the 
Hudson,  and  she  came  of  long-lived  ancestors, 
her  grandmother,  it  is  said,  having  attained  the 
great  age  of  106.  Until  she  reached  the  age  of 
96  Mrs.  Stillwaggon  did  all  her  own  housework 
and  made  her  own  dresses,  and  on  her  io2d  birth- 
day she  made  a  cake  for  a  church  fair. 

That  inveterate  smoking  does  not  always  short- 
en the  span  of  human  life  would  seem  to  be  shown 
by  the  case  of  one  Isaac  Brandenstein,  who  re- 
cently celebrated  his  one  hundredth  birthday  in 
this  city.  Although  very  moderate  in  the  use  of 
liquors,  he  states  that  he  has  smoked  habitually 
and  freely  ever  since  he  was  14  years  of  age.  He 
can  even  now  smoke  most  of  the  day,  provided 
the  tobacco  used  is  of  good  quality,  and  his  only 
complaint  is  that  good  tobacco  is  too  expensive 
in  New  York.  On  getting  up  in  the  morning  he 
goes  down  to  the  street  door  and  smokes  a  couple 
of  cigars,  after  which  he  eats  his  breakfast.  Then 
he  takes  a  pipe,  and  alternates  this  with  cigars, 
with  brief  intervals  of  rest,  until  6  o'clock  in  the 
evening,  when  he  has  supper.  He  does  not  take 
any  meal  in  the  middle  of  the  day.  He  says  he 
feels  somewhat  "weak  and  stiff  in  the  joints," 
but  on  the  whole  his  health  is  remarkably  good 
for  a  centenarian,  and  on  the  last  Day  of  Atone- 
ment, being  a  devout  member  of  the  Jewish  faith, 
he  went  to  the  synagogue  early  in  the  morning 


and  staid  there  until  night,  and  ate  nothing  what- 
ever from  6  o'clock  in  the  morning  until  sunrise 
on  the  following  clay.  Still,  notwithstanding  all 
thi>,  we  would  hardly  advise  anyone  who  was 
anxious  to  attain  the  age  of  one  hundred  years  to 
smoke  all  day  as  the  best  way  of  attaining  this 
end. 

In  regard  to  the  agitation  existing  in  various 
parts  of  the  country  on  the  oleomargarine  ques- 
tion, Professor  Charles  F.  Chandler,  the  eminent 
chemist,  who  was  for  a  number  of  years  President 
of  the  New  York  Board  of  Health,  remarks  very 
sensibly  :  "There  is  more  unceasing  and  unreas- 
onable opposition  to  this  perfectly  healthy  and 
pure  product  than  I  know  of  in  any  other  such 
direction.  Oleomargarine  is  prepared  from  beef 
suet,  and  it  contains  precisely  the  same  chemical 
constituents  as  butter  made  from  cow's  milk  ;  the 
only  difference  is  that  it  is  produced  by  a  chemi- 
I  cal  process  entirely,  instead  of  partly  by  the  inter- 
mediation of  the  cow.  The  strong  opposition  to 
oleomargarine  is  instituted  for  the  most  part  by  the 
farmers  who  produce  butter,  aided  by  the  dealers, 
I  who  find  larger  profits  from  the  sale  of  butter  than 
they  possibly  could  obtain  from  the  handling  of 
oleomargarine.  The  people  who  pretend  to  find 
fault  with  this  beef  suet  product,  however,  find 
no  fault  whatever  with  precisely  the  same  mate- 
rial in  mince-pies  or  plum-puddings.  Some  of 
the  State  Legislatures  have  enacted  very  extreme 
laws  against  oleomargarine  in  deference  to  the 
'  farmer  vote,'  and  the  General  Government  has 
discriminated  against  it  and  against  our  poorer 
citizens  by  placing  an  internal  revenue  tax  upon 
it — like  the  tax  upon  whisky  and  tobacco — pre- 
sumably with  the  idea  that  its  consumption  is 
detrimental,  like  the  too  liberal  consumption  of 
tobacco  and  spirituous  liquors.  Really,  it  is 
1  politics  '  pure  and  simple  that  prevents  our  peo- 
ple from  enjoying,  at  a  nominal  price,  a  perfect 
substitute  and  equivalent  for  butter,  the  high 
price  of  which  renders  the  latter  an  unwarranted 
extravagance  to  many.  And  all  for  the  votes  of 
the  farmers  and  dealers  !  ' ' 

The  reports  from  the  Saturday  and  Sunday 
hospital  collection  thus  far  received  show  the  very 
handsome  sum  of  nearly  <55.ooo,  and  the  returns 
are  still  incomplete.  p.  b.  p. 


Strychnine  in  Snake-Bite. — A  controversy 
is  raging  in  Australia  on  this  subject.  The  treat- 
ment of  snake-bite  by  the  hypodermic  injection 
of  strychnia  was  introduced  by  Dr.  Mueller,  and 
evidence  of  its  success  has  been  adduced  by  other 
medical  men  who  have  tried  the  plan.  Dr.  T.  L. 
Bancroft  has  found,  by  experiments  on  guinea 
pigs,  that  the  method  is  useless.  Recovery  from 
snake-bite,  it  is  well  known,  does  imply  cure,  and 
it  is  not  easy  in  particular  cases  to  distinguish 
the  one  from  the  other. 


SPECIAL  CORRESPONDENCE. 


[February  21, 


SPECIAL  CORRESPONDENCE. 


Report  of  a  Case  of  Malformation  of  tlie 
Female  Generative  Organs. 

To  the  Editor: — Without  going  into  the  history  of  the 
subject  or  discussing  the  various  classifications  of  uterine 
and  vaginal  malformations,  I  desire  to  report  the  follow- 
ing case: 

The  patient  is  46  years  old,  married  for  many  years, 
about  5  feet  10  inches  in  height,  strongly  built,  and  with 
a  decided  masculine  appearance  and  voice.  Her  men- 
struation has  always  been  regular  and  easy. 

In  November,  1890,  she  had  a  fall  to  the  ground,  alight- 
ing in  a  sitting  posture,  after  which  she  complaiued  of 
severe  pain  in  the  back  and  coccygeal  region,  and  from 
these  facts  I  was  led  to  make  an  examination.  The  dis- 
covery which  I  made  shed  no  particular  light  on  the 
cause  of  the  pain,  but  it  proved  to  be  a  matter  of  interest 
to  me,  and  explained  to  the  patient  the  cause  of  her 
sterility.  In  making  a  digital  examination  I  found  the 
vagina' to  be  roomy,  and  with  two  fingers  I  could  reach 
its  upper  extremity,  but  I  was  wholly  unable  to  find  any 
trace  of  the  cervix  uteri.  A  bimanual  examination 
proved  the  absence  of  the  uterine  body.  While  con- 
ducting this  examination  a  forcible  and  expulsive  con- 
traction of  the  vagina  took  place,  and  at  the  same  time 
the  patient  complained  of  excruciating  pain  in  the  back. 
In  a  few  days  I  made  the  second  examination,  this  time 
with  a  Brewer's  speculum.  After  the  blades  were  fairly 
well  separated  a  contraction  as  above  mentioned  took 
place,  causing  great  pain,  and  with  such  force  that  I  fear- 
ed the  blades  of  the  speculum  would  be  bent  or  broken 
before  I  could  run  the  button  back,  allowing  the  bladder 
to  close. 

From  the  facts  recited  I  arrived  at  the  following  con- 
clusion: The  vagina  and  uterus  are  continuous,  and 
there  is  no  line  of  demarkation  indicating  where  the 
vagina  and  uterus  uuite.  It  might  be  as  well  to  say  that 
there  is  no  uterus,  but  the  vagina  is  supplied  with  thick 
muscular  walls,  which  are  capable  of  wide  dilatation  and 
forcible  contraction.  J.  T.  McSHANE,  M.D. 

Carmel,  Ind. 


some  hundreds  to  a  small  fraction  of  one  hundred.  That  of 
three  test  cases  of  laryngeal  tuberculosis,  with  but  little 
involvement  of  the  lungs,  under  observation  for  some  five 
or  six  weeks,  and  considered  favorably  at  the  beginning, 
two  have  died  and  the  third  is  fast  after  them;  that  re- 
cently one  case  of  lupus  was  operated  upon  surgically 
without  any  accompanying  injection  treatment.  Berg- 
mann  says  nothing  against  the  Koch  method,  but  this 
action  is  perhaps  significant.  I  myself  am  inclined  to 
place  confidence  in  Koch  and  his  opinion,  with  all  due 
allowance  for  his  personal  bias,  and  think  we  should  be 
very  slow  to  condemn  it  until  we  know  what  he  knows." 
At  all  events,  it  is  better  for  the  public  to  be  disappointed 
now,  even  to  an  exaggerated  extent,  before  more  time 
and  strength  is  spent  in  vain. 

E.  Fletcher  Ingals,  M.D. 
Chicago,  Feb.  10,  1S91. 


Snail  The  Journal  be  Removed  to 
Washington  ? 

To  the  Editor: — As  a  member  of  the  Association  for 
thirty-six  years,  I  am  in  favor  of  The  Journal  being 
published  at  Chicago.  Chas.  G.  BACON,  M.D. 

Fulton,  N.  Y.,  Feb.  10,  1891. 


To  the  Editor: — Keep  The  Journal  in  the  central  city 
of  the  country  by  all  means.     No  other  city  presents  bet- 
ter advantages  for  making  it  a  success  than  Chicago. 
Hugh  McColl,  M.D. 

Lapeer,  Mich.,  Feb.  12,  1S91. 


The  Present  Status  of  the  Koch  Treatment 
in  Germany. 

To  the  Editor:— I  have  just  received  a  letter  from  Ber- 
lin, some  quotations  from  which  I  think  will  be  of  special 
interest  to  your  readers  as  indicating  the  present  status 
of  the  Koch  treatment  in  Germany.  He  says:  "Dr. 
Koch's  remedy  is  still  with  us,  but  becoming  less  popu- 
lar daily,  if  I  may  judge  from  students  and  others  who 
have  an  opportunity  of  witnessing  the  treatment.  Be- 
side the  French  and  not  a  few  Germaa  opponents  who 
are  animated  by  feelings  of  rivalry  or  the  like,  some  there 
are  of  late  who,  closely  observing  the  matter,  do  not  hesi- 
tate to  condemn  the  treatment  as  both  fruitless,  dangerous 
and  unscientific,  since  it  seems  to  diminish  the  patient's 
strength  and  physical  resistance  by  its  local  and  general 
powerful  action,  and  hence  a  condition  favorable  to  the 
extension  of  tuberculosis.  Koch's  announcement  of  Jan- 
uary 15,  besides  the  disclosure  concerning  the  composition 
of  the  substance,  gives  little  more  than  a  repetition  of  his 
first  declaration  for  the  worth  of  his  discovery  Quite  posi- 
tive indeed  is  his  renewed  assertion,  but  yet,  he  gives  us 
in.  additional  matter  to  substantiate  his  position  and  en- 
courage the  public.  A  friend  of  mine,  candid  and  intel- 
ligent, who  is  taking  a  private  course  in  physical  diagno- 
sis under  one  of  Gerhardt's  assistants,  and  seeing  much 
of  the  cases,  gives  very  unfavorable  reports.  An  assistant 
of  Bergmans ?s  also  informs  me  that  the  number  of  tuber- 
cular patients  treated  in  his  hospital  has  decreased  from 


To  the  Editor: — The  question  of  the  best  location  for 
the  publication  of  The  Journal  should  be  discussed 
with  fair  argument  and  common  sense. 

Does  the  advertising  department  greatly  assist  the 
financial  success  of  a  medical  publication  ?  To  this  ques- 
tion there  is  but  one  answer,  and  wherever  published,  its 
advertising  pages  would  not  probably  be  increased  be- 
yond  their  present  number,  if  equalled. 

Would  the  number  of  subscribers  be  increased  if  re- 
moved ? 

From  no  city  could  it  be  distributed  more  rapidly  nor 
directly  than  Chicago. 

Would  the  aspiring,  disaffected  authors  of  very  impor- 
tant original  productions  all  see  their  names  at  the  head 
of  papers  in  the  first  issue  after  the  annual  meeting  of 
the  A.  M.  A.  if  published  in  Washington,  Kalamazoo,  or 
Oshkosh?  It  seems  there  has  been  much  nonsense  in 
that  line. 

Looking  at  the  subject  from  the  standpoint  of  a 
country  doctor,  the  editorial  work  compares  favorably 
with  the  very  best  of  medical  journalism. 

Let  us  keep  it  in  Chicago.  O.  A.  Rea,  M.D. 

Marmont,  Ind.,  Feb.  12,  1891. 


To  the  Editor: — I  have  read  with  much  interest  the  dis- 
cussion in  regard  to  removing  The  Journal  to  Washing- 
ton. The  scheme — for  it  is  a  scheme — is  not  a  new  one;  I 
know  that  certain  medical  politicians  have  had  it  in  view 
since  1SS6.  The  chief  idea  in  view  has  not  yet  been 
brought  out  in  the  discussion,  and  perhaps  it  is  just  as 
well  to  delay  the  exposure  of  it  until  the  next  meeting, 
in  May.  But  as  yet  no  one  has  put  forward  a  single  sub- 
stantial argument  in  favor  of  removal. 

The  most  frequently  reiterated  argument  is  that  asTHK 
JOl  k\\i.  is  a  national  journal  it  should  be  published  at 
the  Capital  of  the  Nation.  This  is  well  enough  for 
Kourth-of-July  talk,  but  it  lacks  a  commonsense  basis;  it 
is  silly,  and  its  silliness  has  not  even  the  doubtful  merit 
of  sentimentality.  One  may  ask,  why  is  none  of  the  money 
of  this  country  coined  at  Washington  ?  for  the  coinage 
is  a  National  affair.      Why  not  do  it  all  at  the  Capital  of 


I89i.] 


SPECIAL  CORRESPONDENCE 


287 


the  Nation  ?  Harrisburg  is  the  capital  of  Pennsylvania; 
not  Lea  Brothers  &  Co.  remove  their  business 
and  their  journals  to  the  State  Capital  ?  For  the  simple 
reason  that  they  are  business  men  anil  know  that  the  fact 
that  Harrisburg  is  the  capital  of  the  State  will  not  in- 
crease their  business.  If  it  were  possible  to  move  the 
Yellowstone  Park  to  Washington  there  is  no  doubt  that 
some  would  be  in  favor  of  such  a  move;  and  when  sifted 
to  the  bottom  it  would  be  found  that  personal  and  pri- 
vate interests  were  at  the  bottom.  Just  so  with  the 
scheme  to  remove  Tin;  Journal,  as  will  be  made  clear 
when  the  matter  comes  up  at  the  meeting  in  May.  I 
think  I  know  as  much  of  the  inside  history  of  The 
JOURNAL  and  of  this  movement  as  anyone,  and  my  in- 
formation is  for  publication  at  the  proper  time. 

But  the  question  under  consideration  is  a  simple  busi- 
ness proposition,  and  I  wish  to  discuss  it  from  that 
standpoint.  The  American  Medical  Association  is  in 
business  as  a  publisher.  No  publisher  can  conduct  a 
business  successfully  except  in  a  business  centre.  There 
is  no  publisher  in  Washington.  Why  haven't  some 
gone  there  "because  it  is  the  National  Capital?"  Be- 
cause successful  publishers  are  business  men.  There 
are  several  newspapers  in  Washington,  but  they  cannot 
be  compared  with  the  Boston,  New  York,  Philadelphia 
and  Chicago  papers.  It  would  cost  more  to  publish  The 
Journal  in  Washington  than  it  costs  in  Chicago.  I 
make  this  assertion  because  I  am  familiar  with  printing 
office  details. 

For  the  benefit  of  the  readers  of  The  Journal  that 
have  not  access  to  such  information  I  will  show  them  how 
many  business  (trade)  journals  are  published  in  Washing- 
ton as  compared  with  Chicago.  The  following  list  is  taken 
from  Rowell's  Newspaper  Directory  for  1S90.  Since  it 
was  published  some  other  journals  have  been  brought  to 
Chicago  from  New  York  and  places  in  the  East: 


CLASS   PUBLICATIONS  IN   CHICAGO. 

Religion 51 

Agriculture.    Bee     Keeping,     Dairying, 

Horticulture.  Livestock.  Poultry '.   .   .  26 

Medicine  and  Surgerv .  16 

Deaf,  Dumb  and  Blind I 

Children  and  Young  People 

Humorous 3 

Law 4 

Real  Estate  and  Immigration 2 

Building  Loan  Associations 2 

Science.  Electricity.   Mining.  Engineer- 
ing. Mechanics.  Stilling 14 

Numismatics,  Philately I 

Sporting 10 

Music  and  Drama 5 

Fashions 3 

Household 3 

Army  and  Navy o 

Freemasonry. I 

Knights  of  Labor 1 

Oddfellowship 2 

Other  National  Societies 3  ' 

Railway  Employes 2 

Miscellaneous  Societies 8 

Temperance  and  Prohibition 5 

Negro 4 

Commerce  and  Finance 18 

Architecture  and  Building 6 

Art.  Decorating  and  Furnishing  ....  I 

Books  and  Newspapers 3 

Brewing,  Bottling,  Liquors  and  Wine    .  6 

Carriages 2 

Clothing.  Furnishing  Goods,  Tailoring 

and  Ladies'  Wear,  etc 3 

Coal  and  Gas I 

Drugs,  Paints  and  Painting 5 

Exporting 1 

Firemen 2 

Furniture,  Carpets.  Cabinet  Making,  etc.  3 

Groceries.  Confectionery,  etc 4 

Hardware,  Crockerv.  Glassware  etc.    .   .  4 

Hotels ' 3 

Jewelry  and  Watchmaking 3 

Inventions  and  Patents o 

Leather  and  Leather  Products 4 

Lumber 3 

Maritime I 

Mercantile  Pursuits 1 

Metals  and  Machinery 4 

Photography    .   .   .    .* 1 


WASH- 
CHICAGO.      INCTON. 

Plumbing  and  Sanitary 1  0 

Postal  3 

-t.itionery,  Printing,  etc.   .   .  o 

Railroads.  .   .  o 

Sewing  Machines o 

Laundr\  o 

Brickmaking o 

Tombstones I  o 

Further  than  this,  many  class  journals  that  have  the 
main  office  in  New  Yurk  have  a  branch  office  in  Chicago, 
and  do  a  large  part  of  the  business  through  the  \ . 
office.  Many  of  these  class  journals  are  as  national  as  is 
The  JOURNAL.  Why  are  not  more  organs  of  business  in- 
terests published  in  Washington  ?  For  the  same  reason 
that  the  same  kind  of  publications  in  St.  Louis  are  not 
taken  to  Jefferson  City. 

It  has  been  said  that  the  business  management  of  The 
Journal  under  Mr.  White  is  not  what  it  should  be.  But 
the  fact  remains  that  the  income  of  The  JOURNAL  from 
advertisements  is  now  300  per  cent,  greater  than  it  was 
when  Mr.  White  took  charge  five  years  ago.  when  The 
Journal  was  unpopular  with  advertisers.  The  income 
from  advertisements  should  be  greater,  but  it  cannot  be 
until  certain  restrictions  now  in  force  are  removed.  If 
Mr.  White  were  allowed  to  conduct  the  advertising  busi- 
ness on  the  liberal  basis  of  the  Lancet  or  the  British 
Medical  Journal,  the  income  from  advertisements  could 
be  increased  about  50  per  cent,  or  more,  in  a  year,  and 
no  one  would  be  injured  by  it.  As  the  matter  stands  now 
The  Journal  refuses  many  advertisements  that  would 
be  taken  by  the  best  and  most  prosperous  journals  on 
earth — the  Lancet  and  the  British  Medical  Journal.  To- 
my  own  knowledge  one  of  the  most  vigorous  objectors  to 
a  more  liberal  policy  in  regard  to  advertisements  is  a 
professor  in  a  two-course  medical  college.  Such  a  man 
has  no  right  to  declaim  about  the  morale  of  the  profession 
until  he  resigns  his  Chair  or  induces  his  school  to  reform. 
No  one  can  conduct  a  business  of  any  kind  on  sentiment. 
No  one  can  conduct  a  weekly  medical  journal  in  this 
country  without  advertisements. 

It  has  been  said  that  the  list  of  subscribers  to  The 
Journal  has  not  been  increased  to  the  extent  that  it 
should  have  been.  The  fact  is,  canvassers  have  been 
sent  out,  but  each  one  has  stumbled  up  against  the  "  no 
commission  for  members  by  application,"  become  dis- 
gusted and  quit.  No  commission  is  paid  for  such  sub- 
scribers, and  of  course  no  canvasser  will  work  on  such 
terms. 

Again,  the  amount  of  trouble  that  has  been  caused  by 
the  fact  that  the  Secretary  and  the  Treasurer  of  the  As- 
sociation are  almost  a  thousand  miles  from  the  office  of 
The  Journal,  has  been  and  must  be  very  great.  Dr. 
Dunglison  and  Dr.  Atkinson  surely  know  that  I  say  this 
from  no  personal  motive.  But  I  am  stating  a  fact,  and 
what  is  necessarily  a  fact. 

But  there  is  another  and  a  most  important  point. 
Should  The  Journal  be  removed  to  Washington,  it  will 
cease  to  be  of  value  as  an  advertising  medium  to  a  very- 
large  percentage  of  its  best  advertising  patrons,  and  it 
cannot  replace  these  by  others.  Any  one  that  knows 
even  a  very  little  about  advertising  and  the  business 
management  of  a  journal  can  see  this,  because,  with  all 
the  journals  published  in  the  East,  it  would  be  unbusi- 
nesslike for  firms  to  make  use  of  a  Washington  journal, 
and  these  firms  don't  do  foolish  things. 

The  Journal  has  the  field  in  the  West.  If  it  vacate 
the  field  it  has  won  to  occupy  one  already  more  than  full, 
its  place  here  will  be  taken  very  soon,  for  Chicago  will 
have  a  weekly  medical  journal.  The  Journal  cannot 
afford  to  drop  a  substance  to  grasp  at  a  shadow. 

Finally,  before  it  is  determined  to  remove  The  Jour- 
nal, and  before  the  matter  is  brought  up  at  the  meeting, 
let  us  know  who  is  to  be  editor  in  Washington.  The 
Journal  should  have  an  experienced  editor.  There  are 
no  medical  editors  in  Washington,  for  none  of  the  medi- 
cal men  there  have  had  editorial  experience.  Before 
going  down  into  a  well  it  is  a  safe  plan  to  have  a  strong 


288 


MISCELLANY. 


[February  21,  1891. 


man  at  the  windlass.     A   tyro,  however  titled,  has  no 
place  at  the  head  of  an  exploring  expedition. 

William  G.  Eggleston,  M.A.,  M.D. 
Springfield,  111 ,  February  16,  1S91. 


To  the  Editor: — If  The  Journal  is  to  be  removed 
from  Chicago  I  am  in  favor  of  removing  it  to  Pittsburgh. 
Next  to  Chicago  Pittsburgh  is  the  greatest  railroad  cen- 
tre in  the  count™-,  and  this  is  a  very  important  consider- 
ation in  these  times  of  blizzards  and  railroad  obstruc- 
tions; besides  among  our  more  than  two  hundred  phy- 
sicians, any  one  of  whom  is  just  as  capable  to  edit  a 
medical  journal  as  any  one  of  a  like  number  of  physicians 
in  any  other  locality  in  the  country,  either  North  or 
South,  East  or  West.  But  if  The  Journal  cannot  come 
to  Pittsburgh,  then  I  am  in  favor  of  it  remaining  in 
Chicago,  for  it  was  born,  cradled  and  grew  to  be  a  man 
there,  and  there  is  where  it  ought  to  stay.  It  is  also 
ably  edited  there,  besides,  Chicago  is  the  most  central 
place  in  the  country.  Transplanting  sometimes  does 
well,  oftener  not.  Therefore,  let  The  Journal  remain 
in  Chicago.  Johx  M.  Batten,  M.D. 

Pittsburgh,  Pa. 


change  National  Bank,  F.  W.  Christern,  C.  X.  Crittenton,  J.  H 
Bates.  Chas.  H.  Phillips  Chemical  Co.,  R.  W.  Gardner.  Thos.  Leem- 
ing  &  Co.,  Dr.  G.  Duraud,  Publishers'  Commercial  L'nion,  J.  F. 
Madden,  Herbert  Booth,  King  and  Bro..  Med.  Dept  Mutual  Life 
ins.  Co.,  W.  P.  Cleary. 

Paris,  Kv. :  Pans  Medicine  Co. 

Philadelphia:  Dr.  W.  B.  Hopkins,  Dr.  A.  L.  Hummel,  Dr.  R.  J. 
Dunglison.  J.  B.  Lippincott  Co..  Univ.  of  Pennsylvania  Press,  P. 
Blakiston.  Son  &  Co.    Wm    R.  Warner  &  Co. 

Pittsburgh.  Pa.:  G.  L.  Webb. 

Revere,  Mass.:  Dr.  S.  X.  Kelson. 

Rochester,  N.  \\:  E.  S.  Jackson. 

St.  Louis.  Mo.:  Henry  Bernd  &  Co.,  Provident  Chemical  Works, 
Dr.  Justin  Steer,  Dios  Chemical  Co..  Dr.  A.  Biittner. 

St.  Paul,  Minn.:  Dr.  S.  D.  Flagg. 

Salem.  Mass.:  Dr.  W.  T.  Parker. 

San  Frarcisco:  Bancroft  Co. 

Springfield.  Mass.:  G.  and  C.  Merriam  &  Co. 

Walpole,  111.:  Dr.  J.  S.  Williams. 

Washington.  D.  C:  Wm.  Ballantyne  &  Sons,  Dr.  J.  W.  Shrively, 
Dr.  C.  H.  A.  Kleinschmidt. 

Westfield.  X.  Y.:  Dr.  T.  D.  Strong. 


To  the  Editor: — In  regard  to  the  removal  of  The 
Journal  to  Washington  I  am  of  the  opinion  that  it 
would  be  a  great  mistake.  The  Jourxal  is  not  only 
centrally  located,  but  is  ably  edited,  and  a  financial  suc- 
cess. Under  all  these  circumstances  I  am  of  the  decided 
opinion  that  it  should  remain  just  where  it  is. 

Solox  Marks,  M.  D. 

Milwaukee,  Wis.,  Feb.  17,  1891. 


To  the  Editor: — In  regard  to  the  removal  of  The  Jour- 
nal— Washington  is  not  centrally  situated.  The  Capital 
should  have  been  more  centrally  located.  Let  The  Jour- 
nal remain  where  it  is.  P"  C.  Remoxdixo,  M.D. 

San  Diego,  Cal.,  February  12,  1891. 


MISCELLANY. 


letters  received. 

Aetna,  Tenn.:  Dr.  C.  Slavdon. 

Bethany.  Mo.:  Dr.  T.  B.  "Ellis, 

Boston:  Doliber-Goodale  Co.,  Dr.  A.  C.  Garratt,  G.  W.  Campbell. 

Braddyville.la.:  J.B.  Crain 

Brockport.  N   Y.:  Moore's  Subscription  Agency. 

Buffalo,  N.  Y.:  F.  C.  Schottin. 

Burlington,  X.  J.:  Dr.  Wm.  J.  Parrish. 

Burlington,  Vt.:  Dr.  A.  J.  Willavd. 

Chicago:    Kenyon  Subscription   Co.,  Dr.  C.  T.  Parkes,  Dr.  G 
"Frank  Lvdston. 

Chilton,  Wis.:  Dr.  D.  La  Count. 

Cincinnati,  O.:  Dr.  Wm   D.  Hamilton,  Dr.  F.  Dowling,  Cincin- 
nati Sanitarium.  Robert  Clarke  &  Co. 

Council  Bluffs,  la.:  Dr.  J   C.  Robertson. 

Cuba,  N.  Y.:  Dr.  D.  J.  Tlllotson. 

Denver,  Col.:  Jas.  Black. 

Detroit.  Mich.:  Parke,  Davis  &.  Co.,  Citizens'  Savings  Bank,  Dr. 
-£..  L.  Shurlv. 

Easton.  Pa.:  Dr.  Chas    Mclntire. 

Eaton,  <>  ;  Dr.  A.  H   Stephens. 

Evansville,  tnd     i>r.  A    M.  inten. 

Fort  Dodge.  la.:  Dr.  H.  G.  Ristine. 

Fort  Worth,  Texas:  Dr.  A.Guthrie. 

Friendship,  Tenn.:  Dr.  J.  A.  Hintou. 

Genesc...  Ill      Dr.  W.  C.   Brown. 

Greencastle,  Pa.:  Dr.  J.  F.  Nowell. 

Hartfoi  l    D.  Crothers. 

Hickory  Crick,  Texas:  Dr.  J.  F.  J.  Stroud. 
Indianapolis,  Iml     Dr.  O.  w.  pfaff. 

Jersey  City,  N  J.:  Dr.  G.  K.  Dickinson. 
Kansas  (  ity,  Mo     l>r.  J.  H.  Thompson. 
Kipple,  Pa.:  Dr.  A.  B.  Frazur. 
Lincoln,  Neb  :  Dr.  G.  0.  W.  Farnham. 

Louisville,  Kv  ;  Cal.  Fig  Syrup  Co.,  Dr.  T    M.  Raw 

Nashville,  Tenn.:  Dr.  j.  D.  Plunket,  Dr.'  E.  M.  Jenkins. 

New  York  City    M.  vbikmann,  Henry  A.  Riley,  Merchants'  Ex- 


Official  List  of  Changes  in  the  Stations  and  Duties  of  Officers  Serving 
m  the  Medical  Department ,  C  S.  Arm y,  from  January  24, 1801,  to 
February  ij,  rSgi. 
Major  Julius  H.  Patozki,  Surgeon,  granted  leave  of  absence  for  six 
months,  with  permission  to  go  beyoad  sea.     By  direction  of  the 
Secretary-  of  War.     Par.  5,  S.  O.  24,  A.  G.  O.,  Washington,  January 
29,  1891. 
Capt.  William  Stephenson,  Asst.  Surgeon,  will  proceed  without  de- 
lay from  Columbus  Bks..  O.,  to  Fort  Wayne,  Mich.,  and  report  in 
person  to  the  commanding  officer  ol  that  post  for  temporary-  duty, 
and  upon  the  completion  thereof  will  return  to  his  proper  station. 
Bv  direction  of  the  Secretary  of  War.     Par.  13,  S.  O.  23,  A.  G.  O., 
Washington,  January  25,  1891. 

Major  Calvin  De  Witt,  Surgeon,  is  relieved  from  duty  at  Ft.  Han- 
cock, Tex.,  and  will  report  in  person  to  the  commanding  officer. 
It  Sim  Houston,  Tex.,  for  duty  at  that  station.  Bv  direction  of 
the  Secretary  of  War.  Par.  1,  S.  O.  27,  A.  G.  O.,  Washington, 
February  3,  1891. 

Capt.  Alotizo  R.  Chapin.  Asst.  Surgeon  (Ft.  Yates,  N.  D.),  is  grant- 
ed leave  of  absence  for  one  month,  with  permission  to  apply  to 
the  Adjutant  General  of  the  Army  for  an  extension  of  one  month. 
Par.  3.  S.  O.  17.  Dept.  of  Dakota.  St.  Paul.  Minn.,  January  31,  1891. 

Capt.  William  B.  Davis.  Asst  Surgeon  U.  S.  A.,  leave  of  absence 
for  seven  days  granted  by  O.  2,  Ft.  Preble,  Me..  February  4,  1891, 
is  herebv  extended  twenty-three  days,  with  permission  to  apply 
to  the  Ailjutaut  General  of  the  Army  for  a  further  extension  of 
one  month.  Par.  2,  S.  O.  22,  Hdqrs.  Div.  Atlantic,  Governor's  Is- 
land, X.  Y.,  February  5,  1S9L 

Capt.  James  C.  Merrill,  Asst.  Surgeon,  is  relieved  from  duty  at  Ft. 
Reno,  Oklahoma  Ten,  and  will  report  in  person,  at  the  earliest 
practicable  date,  to  the  Surgeon-General  U.  S.  A.,  in  this  city,  for 
dutv  in  his  office.  Bv  direction  of  the  Secretary  of  War.  Par.  5, 
S.  6.  20   A    G.  O.,  Washington,  Februarys,  1891- 

Major  William  D.  Wolverton,  Surgeon  U.  S.  A.,  granted  leave  of 
absence  for  one  month,  to  take  effect  on  or  about  February  15, 
iSgt.    Par.  2,  S.  O.  15.  Dept.  Platte,  Omaha.  Neb.,  February  7,  1891. 

Asst.  Surgeon  R.  W.  Johnson,  D.  S.  A,  gTanted  leave  of  absence  for 
one  month,  to  take  effect  on  or  about  February  10,  inst.  Par.  1,  S. 
O.  16,  Dept.  Ariz.,  Los  Angeles,  Cal.,  February  4,  1891. 

Official  List  of  Changes  in  the  Medical  Corps  of  the  U.  S.  Navy,  for 

the  Week  Ending  February  14,  1891. 
P.  A.  Surgeon  E.  W.  Auzal,  detached  from  U.  S.  S.  "Boston,"  and 

to  TJ   S    S.  "  Lancaster." 
P  A.  Surgeon  T.  C.  Craig,  detached  from  "  O.  S.  S.  "  Vesuvius,"  and 

to  U.  S.  S.  "Boston." 
Asst   Surgeon  W.  C    Braisted.  detached  from  hospital,  Hot  Springs, 

and  tot".  S.  S.   "Vesuvius 
r.  A.  Surgeon  H.  B.  Fitts,  ordered  to  the  Army  and  Navy  Hospital, 

Hot  Springs. 
Asst    Surgeon  W.  F.  Arnold,  ordered  to  the  U.  S.  S.  receiving  ship 

v-  rmonf" 
Asst.  Surgeon  X.  J.  Blackwood,  detached  from  the  U.  S.  S.  "Ver- 
mont." and  to  "  Newark." 
p,  A.  Surgeon  Richard  Ashbridge,  ordered  to  the  Navy  Yard,  New 

York 
Asst    Surgeon    T.    H    North,  detached  from  Navy  Yard.  New  York, 

and  to  the  U.S.  S    "  Lancaster." 

Official  List  of  Changes  of  Stations  and  Duties  of  Medical  Officers  of 
the  l'\  S.  Marine-Hospital  Service,  for  the  7><o  Weeks  Ending 
Fet>  . 

-  awtelle,  detailed  as  member  of  Board.  Revenue 
Marine  Service,  January  26,  1S91. 

.    W.  Austin,  detailed  as  Chairman  of  Board  for  physical 
■  of  Revenue  Marine  Service.    January  28 
and  February  6,  1891. 
!•   A.  Surgeon  W.  A.  Pettus,  detailed  as  Medical  Inspector  of  Immi- 
grants. Port  of  Boston    Mass     ranuan 
P.  A  Surgeon  G.  M    Magruder,  detailed  as  Recorder  of  Hoards  for 
physical  examination  of  officers  of  Revenue  Marine  Service,  Jan- 
1  ml  February  6,  iSqi. 

1111,  detailed  for  special  duty  at  Berlin,  Ger- 
main   )  anuai  v  26,  1S91. 

nevelt,  to  proceed  to  Cap<  Charles  Quaran- 
tine f>  1891. 


T  1 1  E 


J  ournal  of  the  American  Medical  Association. 

EDITED  UNDER  THE  DIRECTION  OF  THE  BOARD  OF  TRUSTEES. 
PUBLISHED    WEEKLY. 


Vol.  XVI. 


CHICAGO,  FEBRUARY  28,   1891. 


No  9. 


ORIGINAL  ARTICLES. 


THE    KOCH    TREATMENT    COMBINED 
WITH  SURGICAL  PROCEDURES.1 

From  the  Surgical  Department  of  the  Moabit  City  Hospital,  Berlin. 
BY  PROFESSOR  DR.  SONNENBURG, 

OF  BERLIN- 
ARTICLE     II. — THE      SURGICAL     PROCEDURES     AS 
APPLIED  TO  TUBERCULOSIS  OF  THE  GLANDS, 
BONES    AND  JOINTS. 

Surgeons  naturally  seem  to  be  of  different  opin- 
ions as  to  the  procedures  which  are  indicated  in 
surgery  of  tuberculous  bones,  joints  and  glands, 
•when  they  have  been  subjected  to  the  Koch  treat- 
ment. 

I  will  attempt  in  the  following,  with  the  help  of 
a  few  specially  selected  cases,  to  outline  our  prin- 
ciples in  the  treatment  of  such  patients. 

First  of  all,  it  is  absolutely  necessary  to  have  a 
perfect  understanding  of  the  action  of  the  remedy, 
for  numerous  complications  often  arise  during  the 
course  of  the  treatment  which  have  the  greatest 
influence  upon  the  temperature  curve  as  well  as 
upon  the  wound  conditions. 

The  fever  curve  indicates  exactly  whether  or 
not  the  action  of  the  Koch  rerne'dy  is  free  from 
contemporaneous  influence.  When  the  tempera- 
ture rises  rapidly  after  the  injection  and  on  the 
following  day  the  fever  subsides,  we  know  that 
these  fluctuations  of  temperature  are  attributable 
to  the  remedy  alone. 

Patient  Kalow,  age  18,  received  in  Moabit  Hos- 
pital July  12,  1850,  had  resection  for  disease  of 
the  right  hip-joint  on  the  17th  of  July.  The  wound 
was  completely  cicatrized  by  the  beginning  of 
November;  he  first  reacted  in  a  typical  manner 
on  the  25th  of  November,  after  injection  of  4  mg. 
Thenceforth  he  was  treated  with  increasing  doses, 
and  each  time  showed  typical  reaction.  During 
the  treatment  the  cicatrix  showed  intense  redness, 
was  very  painful  but  did  not  break  open.  With 
the  subsidence  of  the  reactions  the  local  disturb- 
ances improved;  the  patient  is  now  entirely  well 
and  goes  about;  he  receives  from  time  to  time,  as 


an  additional  security  against  relapse,  the  larger 
doses  of  1  dg. 

But  there  occur  deviations  from  this  typical  be- 
havior of  the  temperature  curves, and  when , more  es- 
pecially,the  morningremissionsdonot  againreach 
the  normal,  one  can  be  sure  that  this  action  of  the 
temperature  is  conditioned  by  inter-current  com- 
plications. These  comprise,  first  of  all,  the  re- 
tentions, which  are  a  result  of  the  greatly  in- 
creased secretion  following  the  action  of  the 
remedy . 

This  can  be  best  observed  in  operation  wounds 
that  have  not  completely  healed  or  have  left  fis- 
tulas. 

These  retentions  demand  immediate  free  in- 
cision and  drainage  of  the  cavities,  and  if  neces- 
sary, removal  even  of  bones  and  joint-end,  and 
this  is  the  more  necessary  because  there  is,  be- 
sides the  effect  of  the  retentions  themselves,  a  de- 
composition of  the  secreted  material. 

Patient  Hasse,  age  10,  admitted  September  11, 
1890;  coxitis  dextra;  secondary  abscess;  incision 
September  13,  1890.  There  remains  a  wound 
surface  on  the  anterior  aspect  of  the  thigh  which 
secretes  moderately;  joint  changes  are  not  de- 
monstrable under  chloroform  narcosis.  Patient 
was  subjected  to  the  Koch  treatment  November 
22.  After  the  second  injection  already  there  was 
an  irregular  rise  of  the  temperature  to  a  great 
height,  with  deterioration  of  the  general  condi- 
tion. December  5,  the  wound  was  enlarged  un- 
der chloroform  narcosis — as  owing  to  the  increased 
secretion  there  had  occurred  some  retention  of 
pus — and  a  sufficiently  free  drainage  for  the 
secretions  was  established.  The  temperature  now 
returned  to  normal;  general  condition  improved, 
and  the  appetite,  which  had  been  entirely-  lost, 
returned.  (For  result  of  bacteriological  investi- 
gations of  the  wound  secretions — vide  below.) 

After  the  enlargement  and  drainage  of  the 
wound  the  temperature  showed  the  typical  reaction. 

The  patient  now,  the  beginning  of  January,  re- 
ceives at  intervals  injections  of  1  dg.  The  wound 
on  the  anterior  aspect  of  the  thigh  shows  but 
slight  suppuration;  movements  of  the  hip-joint 
painless;  patient  reacts  only  after  large  doses. 

A  quite  similar  condition  appears  in  the  fol- 
lowing: 

Patient  Rueklicke,  age  14,  admitted  in  hospital 


290 


THE  KOCH  TREATMENT. 


[February  28, 


May  8,  1890,  for  coxitis  dextra;  lungs  unaffected. 
October  24,  resection;  caput  femoris  completely 
destroyed;  acetabulum  perforated.  Before  the  re- 
section wound  had  quite  healed  the  injections 
were  begun,  November  22,  but  the  morning  tem- 
perature did  not  fall  to  normal  in  the  typical  man- 
ner.    The  symptoms  after  the  first  two  doses  con- 


cough  and  expectoration  recurred;  tubercle  ba- 
cilli were  present  in  the  sputa  in  considerable 
quanity.  Some  few  bacilli  had  been  found  in  the 
fluid  or  liquid  expectoration  as  early  as  the  24th 
of  November.  Rales  were  found  to  be  increased 
in  the  left  infra- clavicular  fossa.  Injections  had 
been  made  from  the  4th  to  8th  of  December,  when 


sisted  of  slight  sense  of  heat,  some  redness  and  j  they   were    discontinued   that   the   uninfluenced 
sensitiveness  to  touch  about  the  margins  of  the  !  temperature  might  be  observed.      Repeated  haem- 


wound  and  a  little  headache.  Without  injections 
the  high  temperature  persisted  during  the  fol- 
lowing days;  the  wound  became  painful  and  gen- 
eral condition  grew  worse.  Believing  there  was 
again  secretion  retention  in  the  depths  of  the 
wound  it  was  enlarged,  and  it  immediately  gave 
exit  to  considerable  pus.     (Bacteriological  inves- 


optysis  since  December  12.  A  short  time  ago  we 
were  again  enabled  to  resume  the  injections  and 
now  the  dangerous  symptoms  begin  to  disappear. 
Every  retention  of  pus  or  secretion  matters 
must  have  quite  the  same  influence  on  the  tem- 
perature, and  cause  fear,  whether  the  secreted 
matter  accumulates  beneath  the  crusts  of  lupus 


tigations  of  this  pus  showed  staphylococcus  pyo-  j  or  in  the  caverns  of  the  lungs.  This  is  shown 
genes  aureus  in  pure  culture.)  A  large  drain  was  in  the  case  of  the  51-year  old  patient,  Neumann, 
introduced  and  the  general  condition  rapidly  im-    (lupus  faciei  et  scapulae). 

proved,  pains  decreased,  appetite  returned  and  j  In  this  case,  after  the  first  injection,  unusually 
temperature  gradually  subsided  and  reached  nor- 1  copious  exudations,  partly  pus,  appeared,  the 
mal  on  the  third  day  after  the  operation.  Injec-  I  dried  superfices  of  which  formed  crusts;  the  ac- 
tions resumed  December  5.     The  first  two  doses  |  cumulation  of  secretion  thereby  caused  was  evi- 


gave  marked  reactions  and  very  profuse  suppu- 
ration from  the  drained  wound;  then  followed 
larger  doses  without  marked  reactions.  On  the 
days  when  no  reaction  occurred  the  temperature 
remained  perfectly  normal.  The  second  bacteri- 
ological examination  showed  great  quantities  of 
staphylococcus  pyogenes  aureus,  besides  scattered 
forms  of  other  bacteria. 

This  patient  is  now,  at  the  beginning  of  Janu- 
ary, perfectly  cured. 

Another  case  of  the  temperature  being  influ- 
enced by  retentions  is  the  following,  which 
besides  shows  a  number  of  peculiarities. 

The  patient  Hewart,  age  15,  was  admitted  June 
9,  1890,  on  account  of  coxitis  dextra. 

The  patient  comes  of  tuberculous  family;  says 
that  several  years  ago  he  expectorated  blood,  but 
never  suffered  otherwise  from  anything  like  lung 
trouble.  The  coxitis  began  when  two  years  of 
age.  Resection  of  joint  in  1883;  fistulas  formed 
in  the  cicatrix  during  the  next  few  years.  Re-resec- 
tion September  30,  1890,  on  account  of  destruc- 
tion of  acetabulum;  removal  of  sequestra;  drain- 
age. November  22  injections  were  begun  before 
the  wound  was  healed.  Examination  of  lungs  at 
that  time  showed  a  very  slight  change  only  in 
the  left  infra- clavicular  fossa;  no  rales;  no  ex- 
pectoration. 

The  rises  of  temperature  occurring  after  injec- 
tions of  small  doses,  which  seemed  to  call  forth 
general  and  local  reaction,  are  again  owing  to  re- 
tentions. On  December  2  the  wound  was  en- 
larged and  again  drained;  large  quantity  of  pus 
escaped.  (Bacteriological  investigation  of  pus 
shows  staphylococcus  pyogenes  albus.)  After 
this  the  general  condition  improved  and  the  fever 
subsided,  but  very  soon  returned  and  the  cause 
was  found  in   the   lungs.      On  December  7  the 


dently  the  reason  of  slow  temperature  decline 
from  the  25th  to  29th  of  November,  because, 
after  we  had  removed  these  crusts,  by  soaking 
with  compresses  saturated  with  acetate  of  alumi- 
num solution,  typical  reactions  occurred  after  the 
injections ;  that  is  to  say,  there  was  absence  of 
temperature  on  the  very  next  day. 

Now,  it  is  7iot  alone  the  retentions  which  cause 
fever,  but  also  the  decompositions  (mixed  infec- 
tion) resulting  from  secondary  infection.  For  in 
the  increased  secretion  is  provided  for  cocci  a  fa- 
vorable soil  for  growth,  and  if  surgical  interfer- 
ence is  not  soon  employed,  even  septic  conditions 
may  arise. 

In  such  circumstances,  most  likely,  is  to  be 
sought  the  explanation  for  the  "  pyrogenic  fever- 
ish aftereffect"  ("fieberhafte  pyrogene  Nach- 
wirkung")  of  the  remedy,  mentioned  by  some 
authors.  When,  therefore,  for  instance,  consump- 
tive* with  lung  caverns  have  a  fever  persist  after 
injections,  it  is  probably  often  owing  to  stagna- 
tion and  decomposition  of  the  secreted  materials 
within  the  cavities. 

In  the  case  of  the  patient  Hasse  (vide  above), 
after  the  exits  from  the  wound  had  been  enlarged, 
the  examination  of  the  wound  secretion  from  the 
upper  fistula,  leading  to  the  pelvis,  resulted  in  a 
pure  culture  of  staphylococcus  pyogenes  albus, 
from  the  lower  fistula  leading  around  the  trochan- 
ter— a  streptococcus.  At  this  time,  January'  20, 
the  difference  in  the  natures  of  these  two  cocci  is 
clinically  illustrated  by  the  fact  that  the  upper 
(staphylococcus)  fistula  has  healed,  but  the  lower 
(streptococcus)  still  persists,  In  the  case  of  the 
patient  Hewart,  likewise  a  staphylococcus  py- 
ogenes albus ;  in  the  case  of  the  patient  Ruek- 
licke,  above  mentioned — staphylococcus  pyoge- 
nes aureus. 


i89i.] 


THE  KOCH  TREATMENT. 


2y  I 


Quite  the  same  conditions  will  therefore  be  ob- 
served in  other  (serous)  cavities  ;  whenever  reten- 
tions occur  there  is  infection-opportunity  through 
communication  from  without.  In  the  presence  of 
such  complications  the  effect  of  Koch's  remedy 
must  be  prejudiced,  until  the  removal  of  the  dis- 
turbing element  is  accomplished.  In  this  respect 
the  following  case  is  very  instructive  : 

Pauline  Schmidt ;  tuberculosis  of  the  perito- 
neum. I  had  already  performed  laparotomy  on 
October  16,  but  the  operation  was  followed  by  no 
improvement  worth  mentioning.  At  the  time,  8 
litres  of  a  light- colored  serous  fluid  were  removed. 
On  neither  omentum  nor  intestines  were  tubercu- 
lous nodules  then  visible. 

For  diagnostic  purposes,  two  guinea  pigs  were 
inoculated  by  injecting  into  the  peritoneal  cavity 
of  each  i  ccm.  of  the  ascitic  fluid.  The  animals 
appeared  ill  during  the  first  few  days,  but  they 
soon  perfectly  recovered.  Four  weeks  after  they 
had  the  appearance  of  perfectly  sound  animals, 
and  four  weeks  later  the  autopsies  showed  no 
tuberculosis. 

The  effusion  rapidly  reformed  in  the  patient. 
It  was  removed  three  times  by  aspiration.  Oth- 
erwise her  condition  remained  unaltered.  The 
anaemia  and  emaciation  greatly  increased;  the 
abdomen  was  much  distended,  the  temperature 
normal,  pulse  small,  lungs  showed  nothing  ab- 
normal, no  cough. 

On  November  24  the  first  injection  of  1  mg.  of 
Koch's  lymph  was  administered,  but  no  reaction 
followed  :  on  25th,  2  mg. ;  great  sense  of  tension 
in  the  abdomen,  with  a  marked  general  reaction. 
Through  the  last  puncture  wound  escaped  a  con- 
siderable quantity  of  a  light-brown  colored  and 
somewhat  turbid  serous  fluid  (compression  ban- 
dage). 

Also  during  the  following  days,  the  fever  con- 
tinuing, the  exudation  increased  to  such  an  ex- 
tent that  punctures  had  to  be  repeated  several 
times.  Careful  examination  of  the  peritoneal 
fluid  shows :  A  quite  clear  liquid,  which  upon 
standing  deposits  a  very  thin  layer,  resembling 
pus  ;  in  it  are  found  quantities  of  tolerably  wyell 
preserved  leucocytes  and  occasional  endothelia. 
Some  show  greatly  enlarged  neucleoli,  in  others 
there  is  a  yellow,  lumpy  pigment.  Tubercle  ba- 
cilli not  found.  Two  guinea  pigs  were  inoculated 
with  the  exudation  fluid.  The  bacteriological 
investigation  proved  the  existence  of  staplrylo- 
coccus  pyogenes  aureus  (secondary  infection). 

On  December  5  the  patient  was  again  laparot- 
omized.  Operation  was  very-  tedious  and  bloody, 
owing  to  extensive  adhesions  between  omentum 
and  the  old  cicatrix.  The  omentum  had  to  be 
ligated.  Tuberculous  nodules  were  visible  on  the 
mesentery  and  portions  of  the  intestinal  serosa. 
Fibrinous  deposits.  The  right  tube  feels  thick- 
ened. The  wretched  and  extremely  reduced  pa- 
tient  died  soon    after.     Result  of  post-mortem  : 


Old  tuberculosis  of  the  peritoneum,  which  had 
recently  led  to  a  dense  crop  of  nodules,  mainly 
in  the  inferior  portions.  Evidences  of  recent  sup- 
purating peritonitis.  In  addition  there  was  typi- 
cal cirrhosis  of  liver — not  tuberculous  in  origin. 
Lungs  intact.  Thickening  of  right  tube  was 
caused  by  overlying  fibrin  ;  mucous  membrane 
and  tissue  normal. 

Bacteriological  examination  of  the  fluid,  etc.,  re- 
moved at  the  last  operation,  results,  in  one  of  the 
three  tubes  of  agar  inoculated  with  the  liquid,  in 
four  colonies  of  staphylococcus  pyogenes  aureus. 
In  contrast  to  this  fluid,  which  is  almost  free  of 
bacteria,  are  the  two  plates  of  agar,  which  were  in- 
oculated with  the  fibrin  coagula,  showing  staphy- 
lococcus pyogenes  aureus  in  great  quantities  and 
in  pure  culture." 

After  reviewing  what  has  been  so  far  discussed, 
it  is  our  opinion,  that  iu  a  number  of  surgical  tu- 
berculoses which  have  open  wounds  or  fistulse, 
Koch's  remedy,  by  means  of  tissue  necrosis  and 
increased  secretions,  together  with  outward  com- 
munication of  the  wound  cavities,  frequently  calls 
forth  changes  iu  the  diseased  parts  which,  if  sur- 
gical interference  is  not  employed,  may  lead  to 
manifold  complications.  The  action  of  the  rem- 
edy can  be,  thereby,  at  times  completely  nullified. 
Only  by  the  aid  of  surgical  procedure  can  the 
typical  action  and  curative  effect  of  the  remedy 
prevail. 

Recognizing  these  circumstances,  we  have  suc- 
ceeded, up  to  this  time,  in  effecting  perfect  cures 
in  some  of  our  surgical  cases — e.  g. ,  such  was  the 
case  in  the  4- year  old  patient,  Emil  Drateva.  He 
suffered  from  osteitis  tuberculosa  multiplex.  He 
was  under  our  care  since  last  April,  and  repeated 
curettings  and  incisions  had  been  performed.  The 
injections  were  begun  on  November  24. 

The  reactions  in   the  beginning  showed  only 
slight  deviations,  owing  to  new   abscess  forma- 
tion.    On   November  26  occurred  great  swelling 
I  and   marked   sensibility    to    touch,  of  the   right 
ankle-joint,  which  up  to  that  time  had  been  con- 
1  sidered  as  healthy  because  it  had  shown  no  un- 
j  toward  symptoms.     In  this  case  we  were  able  to 
j  increase  the  dose  rapidly.     The  reaction  ceased 
completely   at   15  mg.,  and  now  5  eg.  gives  no 
;  reaction.     The  cicatrices  on  the  hands  and  feet, 
as  well  as  the  right  ankle-joint,  are  entirely  pain- 
less.    The  patient  goes  about  and  feels  very  well. 

In  other  patients  who  had  wounds  or  fistulse, 
and  in  whom  large  doses  caused  no  reaction,  the 
wounds,  fistulse  or  glands  remained  uotwithstand- 
I  ing.  I  should  like  to  remark  here,  that  on  tuber- 
culous glands,  especially,  the  effect  of  the  remedy 
is  comparatively  slow.  The  explanation  is,  prob- 
ably, that  the  remedy  gaius  access  so  gradually 

-  The  guinea  pigs,  intraperitoueally  inoculated  on  December  3, 
appeared  to  be  very  ill  during  the  first  few  days  after  the  injections, 
but  completely  recovered  (corresponding  with  the  fact  that  the  bac- 
teriological examination  of  the  exudated  fluid  showed  that  the  fibrin 
coagula,  not  the  fluid,  contained  the  cocci). 


292 


MECHANICAL  TREATMENT  OF  FRACTURE.  [February  28, 


and  slowly  on  account  of  the  encapsulation  and  I 
the  cheesy  nature  of  these  deposits.  As  a  matter 
of  course  the  surgeon  has  again  to  interfere  in  all ! 
cases  where  the  self-help  of  the  organism  is  insuf- ! 
ficient  to  remove  the  necrotized  tissue. 

Hence,  in  all  cases  in  which  reaction  after  large 
doses  repeatedly  fails,  fistulae,  unhealed  wounds 
and  joints  must  be  most  carefully  and  completely  : 
excised;  we  have  thereby  gained  very  satisfactory 
results.  These  patients,  however,  for  assurance' 
sake,  receive  large  doses  of  the  Koch  remedy  ( 1 
dg.  for  each  adult,  at  intervals  of  from  eight  to  | 
fourteen  days).  This  after-treatment  will  be  con- 
tinued weeks  or  months  according  to  the  case. 

I  can,  therefore,  from  recent  experience,  main- 
tain the  principle  that,  in  surgical  tuberculosis, 
the  practitioner  will  have  more  occasion  now  than 
ever  before  to  resort  to  the  knife,  and  then  only 
will  he  achieve  brilliant  results  from  the  Koch 
treatment.  Here  least  of  all  is  it  permissible  to 
limit  one's  self  to  the  Koch  injection  according 
to  any  prescribed  method,  for  the  highest  demands 
of  the  surgical  art  must  always  be  kept  in  view. 


A    HISTORICAL    RECORD    OF   THE    DE- 
VICES USED    IN  THE   MECHANICAL 
TREATMENT   OF  SIMPLE   FRAC- 
TURE  OF  THE  PATELLA. 

Kead  before  the  Clinical  Society  of  the  Chicago  Policial, 
14,  /8oo. 

BY  CHARLES  F.  STILLMAN,  M.Sc,  M.D., 

PROFESSOR  OF  ORTHOPEDIC  SURGERY  IN  THE  CHICAGO  POLICLINIC. 

In  the  entire  domain  of  surgery  there  is  not  a 
fracture  which  has  interested  more  prominent 
surgical  minds,  or  been  the  subject  of  more  de- 
vices and  inventions  for  its  treatment,  than  this  ; 
and  in  order  to  present  an  accurate  and  compre- 
hensive history,  the  writer  has  been  obliged  to 
extract  freely  from  foreign  authorities,  as  well  as 
those  who  have  written  upon  the  subject  in  our 
own  language. 

Abulcasis1  and  Paul  of  Aegina  were  the  first 
to  mention  fracture  of  the  patella  in  their  writ- 
ings. Their  treatment  wras  most  simple.  The 
former  bound  down  the  upper  fragment  with  a 
bandage ;  the  latter  fastened  the  fragments  to- 
gether with  an  emplastrum,  which  with  a  round 
splint  was  held  in  place  by  a  bandage.  Both 
writers  considered  the  extended  position  of  the 
limb  a  necessity.  It  is  unfortunate  that  no  illus- 
trations can  be  obtained  depicting  their  methods. 

Guido,  TheodorichrGiul.  de  Saliceto  and  Brun- 
schwig  recommended  plasters,  splints  and  band- 
ages, and  even  Pare  considered  the  subject  briefly 
and  with  no  positive  directions  for  treatment  He 
suggested  that  compresses  be  laid  in  the  popliteal 
space,  and  splints  of  straw  used  to  prevent  flexion. 
Pare'  asserted  that  he  had  never  effected  a  cure 
without  deformity,  a  limp  always   remaining   in 


the  patientis  walk.  This  assertion  seems  to  have 
acted  as  a  spur  to  surgical  invention,  and  was  fol- 
lowed by  many  devices  to  overcome  the  difficul- 
ties to  which  he  referred.  Peccetti  (1557)  at- 
tempted to  fasten  the  fragments  together  with  a 
leather  ring  which  wTas  held  in  place  by  a  band- 
age. More  complete  was  the  invention  of  Mus- 
chenbroek,  a  mechanic  of  Leyden. 

This  is  described  by  Solingen3  and  mentioned 
by  Garengeot,*  who  drew  attention  to  the  favor- 
able comment  it  had  occasioned  in  France,  al- 
though it  had  been  claimed  by  Arnaud,  though 
he  neither  invented  it  nor  brought  it  personally 
from  Germany.  Muschenbroek's  apparatus  con- 
sisted of  two  steel  plates  padded,  and  these  were 
screwed  on  to  a  frame  of  the  same  material,  and 
by  means  of  straps  the  fragments  were  kept  in 
approximation  (See  Fig.  1). 

The  next  important  form  of  apparatus  was  de- 
vised by  Purrmann,5  and  consisted  (See  Fig.  2) 
of  an  iron  ring,  covered  with  leather  and  secured 
in  place  by  straps. 

The  first  complete  monograph  upon  the  subject 
of  fracture  of  the  patella  was  written  by  Dr.  H. 
Meibom,;  (1697),  and  in  this  dissertation  he  de- 
scribed the  method  and  splint  invented  and  advo- 
cated by  his  father. 

This  consisted  of  a  padded  cap  that  encircled 
the  fragments,  and  could  in  its  upper  part  be  open- 
ed and  closed  at  will.  The  eighteenth  centurv  was 
very  rich  in  contrivances  to  effect  union. 

Petit  used  a  form  of  gutter  padded  with  Hun- 
garian leather  (Fig.  3),  which  was  provided  with 
side  slots  in  which  the  bandages  were  fastened. 
He  used  two  bandages,  in  the  middle  of  each  of 
which  were  sewed  semicircular  padded  compresses 
which  crossed  above  and  below  the  fragments,  and 
Yerdue7  (1711),  Henckel  (Fig.  4),  Bass8  (Fig.  5), 
Eschenbach*  and  others,  used  compresses  and 
many-tailed  bandages  in  various  forms.  Kalt- 
schrnidt1"  used  a  linen  crown  covered  with  a 
wooden  capsule  with  a  square  opening  at  the  top 
(Fig.  6). 

Valentin"  (1772)  was  the  first  to  draw  atten- 
tion to  the  value  of  placing  the  limb  in  a  satisfac- 
tory position  by  relaxing  the  extensors,  and  ele- 
vating the  foot  so  as  to  approximate  the  fragments. 

Theden12  soon  after  drew  attention  to  the  ineffi- 
cacy  of  the  ring  and  other  forms  of  compressing 
apparatus,  and  strongly  advocated  the  position 
treatment  of  Valentin.  Theden  was  the  first  to 
place  the  limb  in  a  box,  the  lower  end  of  which 
was  elevated  to  maintain  the  extension,  and  the 
fragments  were  held  together  by  circular  loops 
and  bandages. 

Bell"  (Fig.  7)  used  two  heart- shaped  com- 
presses finished  in  leather,  connected  together  by 
two  girths,  one  of  which  passed  around  the  limb 
above  the  knee  and  the  other  below.  These  com- 
presses were  drawn  together  by  other  straps,  the 
fragments  of  the  patella  being  between  them,  and 


i89i.] 


MECHANICAL  TREATMENT  OF  FRACTURE. 


293 


itt;-'-  ~7 ^T~ 


WA///////// 


Ftg.  r.— Muschenbroek's  (1648)  apparatu 


//>///// 


Fig.  4— Henkel.  Fig.  5.—  I 


Fig.  2.  — Purrm  i: 


//r///.u///////-/iC 

Fig.  6.— Kaltsch:i. 


> — ^- 


li3^ 


Fig.  9.— Lampe  (1796)- 


294 


MECHANICAL  TREATMENT  OF  FRACTURE.         [February  28, 


the  upper  compress  was  connected  with  the  end 
of  the  shoe  by  a  long  anterior  strap  which  was 
intended  to  prevent  flexion  and  displacement  of 
the  upper  fragment.  The  leg  was  directed  to  be 
retained  in  position  in  this  apparatus  fourteen 
days. 

Zenker  changed  the  form  of  these  heart-shaped 
compresses  into  that  of  the  horse-shoe,  and  Buck- 


Sir  Astley  Cooper  used  a  hollowed  splint,  al- 
lowed the  patient  to  sit  upright,  the  heel  being 
elevated,  and  waited  until  all  inflammation  had 
subsided.  He  then  bandaged  the  limb  from  the 
foot  to  the  knee,  pressed  the  upper  fragment  down- 
ward, laid  on  each  side  of  the  knee  a  broad  band 
and  fastened  the  same  with  circular  loops  above 
and  below  the  patella.     The  ends  of  the  strips, 


(Fig.    8)  and   Evers   followed   with    slight '  which  had  been  laid  along  the  knee,  were  then 
modifications.  I  turned  over   and  tied  together,  thus  tending  to 


The  next  important  improvement  after  Valen 
tin's  in  the  treatment  of  this  fracture  was  that  of 
Souville.l;'  He  bound  the  thigh  with  bandages 
from  the  hip  downward,  and  from  the  foot  upward 
to  the  knee,  to  control  the  action  of  the  extensors 
and  overcome  the  swelling  of  the  knee-joint.  He 
reports  one  case  treated  by  this  method  in  which 
the  patient  began  to  walk  in  twenty-nine  days. 
Richter10  also  used  this  bandage,  and  asserted  that 
he  never  felt  the  need  of  any  other  instrument  or 
dressing.  Bottcher17  placed  a  compress  and  spoon- 
shaped  splint  posteriorly,  and  fastened  it  so  that 
the  fragments  were  held  by  the  girth  straps  above 
and  below  the  knee,  connected  by  linear  straps 
which  kept  them  in  position.  Lampe!S  (Fig.  9) 
modified  the  apparatus  of  Bucking  (Fig.  8), 
which  was  substantially  that  of  Bell  (except  that 
the  heart-shaped  plates  were  united  by  hinge  rods 
instead  of  straps),  by  substituting  screws  for  the 
hinge  rods,  and  these  screws  were  provided  with 
pivots  where  they  were  attached  to  the  plates,  so 
that  the  latter  could  better  adapt  themselves  to 
the  curves  of  the  limb. 

The  beginning  of  the  nineteenth  century  was 
also  rich  in  inventions.  Desault  and  Richerand19 
were  the  first  to  advance  plans  of  treatment,  but 
the  essential  principles  of  their  methods  were  in- 
corporated in  the  apparatus  of  Boyer™  (Fig.  10). 
This  consisted  of  a  thin  metal  gutter  thorough- 
ly padded,  and  sufficiently  long  to  receive  the  en- 
tire lower  extremity.  To  this  were  fastened  by 
buttons  two  well  padded  straps  of  leather  passing 
above  and  below  the  patella. 

Boyer's  gutter  greatly  resembled  Buirer's  (Fig. 
11),  and  the  suspicion  could  be  entertained  that 
the  latter  had  served  as  a  model  for  Boyer's,  since 
it  was  in  use  prior  to  1801. 

Buirer's'1  apparatus  consisted  of  a  long  gutter 
or  splint,  carved  to  fit  the  posterior  surface  of  the 
limb,  and  in  which,  as  in  Boyer's,  were  two  straps 
fastened  by  means  of  buckles,  holding  between 
them  the  fragments  of  the  patella. 

Assalini"  contrived  a  dressing  (Fig.  12)  in 
which,  in  addition  to  the  rest  of  the  apparatus, 
the  thigh  was  placed  in  a  cylindrical  splint,  and 
four  crossed  straps  were  used  instead  of  two  to 
retain  the  fragments  in  position. 

Sauter  recommended  his  suspension  frame  for 
this  fracture,  and  fastened  the  outstretched  limb 
on  the  same,  but  neglected  to  give  his  suspension 
m  of  an  inclined  plane. 


approximate  the    circular  loops,  and  with  them 
the  fragments  (Fig.  13). 

Another  device  for  which  he  claims  still  more 
excellence,  is  the  employment  of  a  leather  band 
around  the  thigh  above  the  upper  fragment.  This 
is  connected  to  the  sole  of  the  foot  by  straps  pass- 
ing down  each  side  of  the  leg,  which  is  main- 
tained in  an  elevated  and  outstretched  position 
(see  Fig.  14).  This  was  contrived  with  the  evi- 
dent object  of  overcoming  the  contractility  of  the 
muscles  of  the  thigh. 

To  prevent  these  long  side  straps  from  slipping, 
circular  bands  about  the  leg  are  to  be  used  as 
shown  in  Fig.  14. 

He  recommended  the  retention  of  this  position 
for  five  or  six  weeks,  and  after  this  passive 
motion. 

Sir  Chr.  Bell-'  used  a  simple  bandage.  He 
bound  down  the  upper  fragment  first  by  passing 
the  bandage  under  the  knee  in  the  popliteal  space. 
The  lower  fragment  was  treated  in  the  same  man- 
ner, and  he  paid  especial  attention  to  the  direc- 
tions of  his  predecessors  as  to  position. 

Langenbeck,  and  also  Richter,"  bound  up  the 
leg  and  thigh,  the  fragments  being  held  together 
only  by  a  few  circular  turns  of  the  ends  of  the 
bandage.  They  did  not  use  an  inclined  plane, 
but  instead  had  the  patient  sit  in  an  upright  posi- 
tion. Dupuytrem5  used  a  very  simple  bandage 
to  maintain  the  fragments  in  position,  and  placed 
the  limb  on  an  inclined  plane. 

Von  Graefe26  (1824)  was  the  first  to  devise  a 
splint  for  this  fracture,  provided  with  joints  at 
the  side.  (Fig.  15).  It  consisted  of  two  semi- 
circular troughs  made  of  sheet  iron  and  properly 
padded,  united  by  two  lateral  hinge  joints.  The 
splint  is  fastened  to  the  limb  by  means  of  four 
girths,  two  of  which  are  placed  on  the  upper  half 
and  two  on  the  lower  half  of  the  splint.  Union 
of  the  fragments  is  sought  to  be  accomplished 
by  means  of  two  linear  straps  connecting  the 
middle  transverse  ones. 

Amesbury's"  apparatus  consisted  of  two  leather 
cushions,  the  larger  being  placed  over  the  upper 
fragment  of  the  patella,  and  the  smaller  one  the 
lower,  so  that  after  being  buckled  together  they 
hold  the  fragments  between  them.  From  the 
upper  cushion  a  strap  passes  down  along  the  leg 
to  the  sole  of  the  foot,  under  the  same  and  back 
again  up  the  other  side  of  the  leg  to  the  opposite 
side  of  the  same  cushion,   to  which   it  is   then 


i89i.] 


MECHANICAL  TREATMENT  OF  FRACTURE 


I    )aaaaaEJ 


i  Boyer's  apparatus 


Fig.  12.— Assalini's  apparatus. 


296 


MECHANICAL  TREATMENT  OF  FRACTURE.  [February  28, 


buckled.  (Fig.  16).  Before  the  application  of 
the  cushions,  the  limb  is  laid  upon  a  long  carved 
wooden  splint,  extending  from  the  os  ischii  be- 
yond the  heel,  to  which  it  is  fastened  partly  by 
the  straps  attached  to  the  cushions  and  partly  by 
other  bandages  and  straps.     (Fig.  17). 

A  similar  dressing  was  next  invented  by  J.  L. 
Rosseau,  of  Philadelphia,  (1826).     (Fig.  18). 

After  the  outstretched  limb  had  been  placed  at 
an  obtuse  angle  with  the  body,  and  the  fragments 
had  been  approximated,  a  small  stuffed  pillow 
was  placed  against  the  upper  fragment  and 
fastened  there  by  straps  and  girths.  At  a  distance 
of  two  inches  above  and  below  the  patella  were 
placed  two  girths,  the  upper  one  of  which  was 
connected  to  the  foot  by  a  side  strap  as  in  Sir 
Astley  Cooper's  and  Amesbury's  contrivances, 
already  described.  A  splint  eighteen  inches  long 
was  next  placed  under  the  limb,  its  centre  being 
under  the  popliteal  space,  and  on  each  side  of  this 
splint  there  were  narrow  slots  for  the  side  straps 
to  pass  through.  This  splint  was  secured  to  the 
limb  by  roller  bandage  and  the  patella  was  cov- 
ered with  a  compress  which  was  held  in  place  by 
another  girth  encircling  the  limb  and  the  splint. 
F.  W.  Fest23  (1827)  arranged  an  inclined  plane 
for  which  were  claimed  special  advantages. 
(Fig.  19).  It  consisted  of  a  wooden  adjustable 
inclined  surface,  furnished  with  folding  sides,  and 
at  its  lower  end  with  a  sliding  board  to  increase 
or  decrease  its  length. 

Two  longitudinal  slots  were  cut  in  the  board 
opposite  and  under  the  knee  for  the  passage  of 
the  transverse  crossed  straps  which  were  intended 
to  keep  the  fragments  in  apposition. 

To  and  under  the  end  of  each  strap  furnished 
with  buckling  holes,  are  fastened  padded  girths, 
one  of  which  is  laid  against  the  upper,  the  other 
against  the  lower  end  of  the  patella  in  a  hori- 
zontal direction,  which  serve  to  hold  the  frag- 
ments in  position  when  the  straps  are  buckled. 
To  more  firmly  secure  both  girths  in  the  desired 
position,  two  small  straps  are  fastened  at  right 
angles  to  the  upper  edge  of  the  lower  girth  and 
secured  to  the  upper  girth,  and  thus,  in  a  meas- 
ure, prevent  deviation  of  the  fragments  to  one 
side.  To  prevent  the  apparatus  from  falling  over, 
two  large  and  two  small  wings  are  secured  to  the 
side  of  the  lower  end,  and  in  the  middle  of  the 
foot-rest,  these  being  joined  by  hinges  to  allow 
their  folding  together.  Richter  (1828)  observes 
that  what  Valentine  and  Theden  had  sought  to 
attain  through  comfortable  position  had  previ- 
ously been  attempted  by  surgeons  with  machines, 
without  satisfactory  results,  they  not  being  able 
to  prevent  the  contraction  of  the  extensors. 
From  an  historic  study  of  the  subject  he  notes 
how  one  sees  even  in  his  time  a  return  to  simpler 
methods  of  treatment,  and  he  states  that  when 
the  importance  of  this  treatment  is  fully  realized, 
and  the  fact  that  all  new   forms  of  contrivances 


are  constructed  mainly  on  the  same  principles,, 
the  means  to  bring  about  a  perfect  union  are  rec- 
ognized to  be  nearly  analogous  to  those  of  the 
more  ancient  days.  The  indications  which  must 
be  fulfilled,  observes  Richter,  in  the  treatment  of 
fracture  of  the  patella,  are  1,  the  prevention  of 
the  contraction  of  the  extensors,  2,  the  maintain- 
ing in  contact  of  the  fractured  surfaces,  and  3, 
the  prevention  of  the  swelling  of  the  limb.  In 
accordance  with  the  first  indication,  he  advises 
that  the  patient  sit  upright,  the  outstretched  limb 
to  be  placed  on  an  inclined  plane,  and  the  thigh 
bandaged  from  the  hip-joint  downward.  To  pre- 
vent the  foot  from  falling  from  one  side  to  the 
other  he  suggests  that  the  limb  be  placed  in  a 
steel  semi-circular  padded  canal  or  placed  between 
straw  splints  and  compresses  used.  The  second 
indication  he  considers  can  be  accomplished  by 
winding  bow-formed  circular  turns  of  bandage 
above  and  below  the  patella,  these  being  con- 
nected together  in  the  popliteal  space ;  or  again 
by  the  use  of  the  "  Testudo  Inversa,''  of  which 
Kliige  made  especial  mention.  To  obtain  this  a 
sufficiently  long  pasteboard  splint  is  laid  pos- 
teriorly and  it  is  padded  with  linen,  particularly 
on  the  edges,  to  prevent  pressure,  and  leaves  a 
hollow  in  the  middle  so  that  the  circulation  in 
the  vessels  of  the  popliteal  region  cannot  be  dis- 
turbed. This  splint  is  fastened  by  a  few  circular 
turns  above  and  below  the  knee. 

Alcocks"  was  the  first  to  advocate  the  use  of  the 
adhesive  plaster  of  modern  times  in  this  fracture, 
although  Paul  of  -Egina,  centuries  ago  recom- 
mended holding  the  fragments  together  with  an 
emplastrum,  and  was  evidently  actuated  by  the 
same  desire  to  employ  adhesive  material  in  their 
retention. 

A  haemorrhagic  condition  of  the  joint  need  not 
prevent  the  application  of  this  dressing,  but 
Alcock  directs  that  the  knee  must  remain  free  if 
the  swelling  is  inflammatory.  The  treatment 
lasts  several  weeks,  and  its  duration  is  governed 
by  the  individuality  of  the  patient.  He  con- 
siders that  four  weeks  might  suffice  with  a  young 
person,  but  with  older  patients  and  under  un- 
favorable circumstances,  a  longer  time  must  be 
deemed  advisable. 

The  given  time  having  elapsed,  he  states  that 
passive  movements  can  be  allowed,  the  patient 
still  remaining  in  bed,  and  not  until  the  patient 
has  acquired  skill  in  moving  the  knee  must 
crutches  be  used  to  practice  walking.  He  must 
exercise  gradually  until  he  depends  on  a  stick, 
and  only  in  the  end  do  away  with  that.  Richter 
draws  attention  to  a  useful  contrivance  to  prevent 
the  tearing  of  the  newly  formed  ligamentous  tis- 
sue, invented  by  Baillif.31  (Fig.  16).  It  con- 
sists of  four  portions  of  steel  with  leather,  and 
padded  on  the  inside,  of  which  two  are  buckled 
to  the  thigh  and  two  to  the  leg.  By  a  point 
which  only  allows  twenty-four  degrees  of  flexion 


189I-] 


MECHANICAL  TREATMENT  OF  FRACTURE. 


297 


F'g-  25— Fontan's  apparatu 


298 


MECHANICAL  TREATMENT  OF  FRACTURE.  [February  28, 


excessive  motion  of  the  leg  is  prevented,  this 
often  being  a  causation  of  ligamentous  rupture. 
To  prevent  these  splints  from  slipping  downward, 
the  outer  segment  is  joined  by  means  of  a  strap 
to  a  girth  which  surrounds  the  pelvis. 

At  present  the  greater  number  of  forms  of  ap- 
paratus for  pressure  upon  the  fragments  of  the 
patella  are  derived  from  Muschenbroek's,  (Fig.  i 
1),  ahead}'  described,  or  from  the  apparatus  of 
Boyer  (Fig.  10),  which  consisted  of  a  straight 
gutter  with  double  straps,  and  represents  the 
most  simple  model  and  the  best  known  and  the 
most  often  reproduced.  The  great  number  of 
forms  belonging  to  these  two  classes  were  fifty 
years  ago  almost  entirely  abandoned  because  of 
insufficient  action  and  inconvenience,  as  was  well 
shown  by  Malgaigne  in  his  dissertation  upon  the 
subject,  but  during  the  past  half  century  great 
activity  in  invention  has  been  displayed.  In 
Laugier's':  apparatus,  Boyer's  gutter  was  replaced 
by  a  horizontal  plank  covered  with  a  thick 
cushion  and  large  enough  to  enable  the  support- 
ing strap  to  be  maintained  at  a  distance  from  the 
lateral  parts  of  the  limb.  This  plank  is  furnished 
opposite  the  popliteal  space  with  two  pieces  of 
wood,  serving  to  regulate  the  straps.  Instead  of 
the  padded  straps  before  that  time  in  use  to  brace 
the  fragments  of  the  patella  together,  Langier 
applied  to  each  fragment  a  small  piece  of  gutta 
percha  carefully  cast.  Each  one  of  these  is 
solidified  on  the  fragments  and  a  circular  band  of 
caoutchouc  is  utilized  also.  This  is  a  simple  ap- 
paratus, leaves  the  parts  uncovered,  is  easily  ap- 
plied and  looked  after,  is  not  liable  to  accident, 
and  is  possessed  of  sufficient  qualities  to  give 
good  results.  Wood's"  apparatus  is  quite  similar, 
and  consists  of  metallic  blades  placed  behind  the 
limb,  furnished  with  two  hooks  turned  in  the  in- 
verse direction  which  serve  as  points  of  attach- 
ment to  bands  of  India  rubber,  crossing  them- 
selves on  each  fragment. 

Lonsdale's34  apparatus  is  composed  of  two  cov- 
ered metallic  plates,  semi  circular  in  form  and 
slightly  concave  beneath,  thereby  adapting  them- 
selves nearly  to  the  form  of  the  patellae.  These 
two  plates  are  attached  to  iron  supports  which 
slide  laterally  on  transverse  bars  arranged  in  such 
a  manner  as  to  move  from  top  to  bottom  on  two 
vertical  rods,  placed  on  each  side  of  the  knee  and 
riveted  to  the  posterior  blade.  The  supports  and 
horizontal  rods  are  furnished  with  screws  which 
allow  the  parts  to  be  adjusted  in  any  desired  posi- 
tion, horizontal  and  vertical  adjustment  being 
both  permitted  by  the  arrangement. 

Fontan's11  apparatus  is  of  two  forms — one  is 
composed  of  a  board  of  more  length  than  width 
from  the  angles  of  which  rise  rods,  retained  at 
their  position  by  iron  triangles.  These  support 
two  rods,  each  one  receiving  a  strong  wooden 
screw.  These  are  hollowed  two  or  three  thumbs 
length,  and  this  canal  receives  the  free  extremity 


of  a  strong  iron  wire  surmounting  the  two  half 
circles.  The  last  named  are  important  pieces  of 
the  apparatus,  and  press  on  the  superior  and  in- 
ferior parts  of  the  patella.  These  operate  re- 
versely, and  their  pressure  is  augmented  or  di- 
minished as  desired  by  tightening  or  loosening 
the  wooden  screws.  To  prevent  their  sliding  on 
the  fragments,  a  slight  curvation  is  imparted  to 
the  stem  of  the  wire  which  supports  them,  and 
to  still  further  insure  a  good  result,  to  the  ex- 
tremity of  each  piece  is  added  a  strap  which  is 
received  in  buckles  placed  on  the  sides  of  the  board 
that  constitutes  the  foundation  of  the  apparatus. 
The  half  circles  are  movable.  The  foundation  is 
covered  with  a  linen  cushion  thick  enough  to  raise 
the  knee  and  lessen  the  strain  upon  the  popliteal 
region.  The  limb  is  introduced  between  the 
poles,  the  fracture  resting  in  the  centre  of  the 
apparatus.  After  the  rods  and  triangles  are 
properly  adjusted,  the  iron  wire  stem  of  the  half 
circle  is  inserted  in  the  central  canal  of  the  screw, 
and  after  securing  the  half  circles  by  aid  of  straps, 
the  union  of  the  fragments  is  effected  by  tight- 
ening the  screws.  The  second  apparatus  in- 
vented by  Fontan  is  better  known  and  more 
simple  ;  its  action,  however,  is  less  efficacious. 
It  is  a  modification  of  Boyer's  apparatus.  In 
this  second  contrivance  two  circular  bandages  are 
placed  above  and  below  the  patella.  These  are 
introduced  in  the  half  circles  with  which  the 
foundation  is  furnished,  and  approximate  the 
transverse  bandages  to  the  limb  by  means  of 
lateral  girths.  In  spite  of  all  the  care  given  in 
applying  these  forms  of  apparatus,  they  produced 
only  fibrous  union,  and  Bonnet  recommended 
that  whatever  apparatus  was  used  the  heel  should 
not  be  elevated  above  twenty  to  twenty-six  inches, 
thus  to  avoid  producing  a  harmful  tension  in  the 
muscles  of  the  posterior  region  of  the  limb. 

Malgaigne's30  hook  apparatus  was  invented  to 
effect  the  union  of  the  fragments  to  the  necessary 
degree,  to  result  in  the  formation  of  osseous 
union.  Its  employment  was  advocated  when  the 
separation  exceeded  two  inches,  because  then  a 
a  fibrous  union  was  almost  inevitable  if  the  ordinary 
bandage  was  used.  This  instrument  has  its  sup- 
port on  the  bone  itself  without  the  assistance  of 
bandages  or  splints.  It  consists  of  three  inch 
large  steel  plates  so  arranged  as  to  slide  one  upon 
the  other,  and  separated  or  brought  together  by 
means  of  a  horizontal  screw  parallel  with  the 
plates.  This  screw  engages  itself  in  a  hollow  in 
the  centre  of  the  two  riveted  bolts  on  each  of  the 
plates  and  is  turned  by  means  of  a  key.  The 
free  extremity  of  each  plate  is  bifurcated,  ending 
in  two  very  pointed  curved  hooks  resembling 
those  of  a  double  forceps.  The  two  hooks  of  the 
inferior  plate  are  separated  by  one  inch  only,  and 
are  implanted  on  the  summit  of  the  patella  in 
such  a  way  as  to  lodge  their  points  in  the  bone. 
Those  of  the  superior  plate  are  separated  twice 


i89i.J 


MECHANICAL  TREATMENT  OF  FRACTURE. 


299 


Fig.  31. — Hamilton's  apparatus. 

as*much.  The  inside  hook  is  longer,  to  accom- 
modate itself  to  the  obliquity  of  that  part  of  the 
bone.  To  avoid  the  evil  effects  which  were  some- 
times shown  to  be  produced  by  Malgaigne's 
hooks,  Rigaud,  of  Strasburg,  proposed  to  replace 
the  hooks  with  two  metallic  stems,  which  are  to 
be  introduced  not  only  in  the  fibrous  tissue,  but 
in  the  patella  itself.  He  used  two  screws  which 
he  implanted  in  the  fragments  and  afterwards 
brought  together  by  the  aid  of  girths  and  a  me- 
tallic arch. 

Bonnet37  (1851),  of  Lyons,  adopted  the  use  of 
the  screws  implanted  in  the  patella  with  the  pre- 
caution not  to  let  them  penetrate  further  than  4 
to  5  millimeters.  Two  screws  surmounted  each 
fragment  with  a  quadrangular  frame  of  3  milli- 
meters in  height,  and  were  implanted  in  the  in- 
termediary parts  of  the  fragments  to  within  one 
millimeter  of  the  fractured  borders.  Meanwhile, 
as  an  assistant  approximates  the  fragments  as 
much  as  possible,  the  surgeon  fixes   them  in  a 


state  of  coaptation  by  encircling  them  with 
bandages.  He  next  presses  them  together  with 
two  little  steel  branches  united  by  two  screws. 
The  application  of  this  procedure,  more  theo- 
retical than  practical,  was  not  effected  without 
difficulty,  and  inconvenience. 

A.  Cooper's3-  procedure  (of  San  Francisco), 
went  very  much  further,  and  he  proposed  to  unite 
the  fragments  by  metallic  sutures.  A  longi- 
tudinal incision  sufficiently  long  to  uncover  the 
fragments  having  been  made  over  the  patella, 
these  were  pierced  obliquely  with  a  drill  and  the 
surgeon  passed  through  these  perforations  silver 
sutures  whose  extremities  were  to  be  twisted 
until  the  fractured  surfaces  were  brought  into  im- 
mediate contact. 

In  all  the  recent  interesting  papers  upon  the 
feasibility  of  wiring  the  patella,  the  writer  has 
failed  to  find  credit  given  to  this  American  sur- 
geou  who  was  evidently  its  originator. 

Trelat's35  (1S62)  apparatus  consists  of  a  very  in- 


3°° 


MECHANICAL  TREATMENT  OF  FRACTURE.  [February  28, 


genious  combination  of  gutta-percha  and  the 
hooks.  He  uses  the  efficacious  action  of  the  last 
in  bringing  the  fragments  together,  and  evades  by 
the  interposition  of  the  gutta-percha  the  wound- 
ing and  inconvenience  resulting  from  the  im- 
plantation of  the  hooks.  Before  using  this  ap- 
paratus it  is  necessary  to  wait  until  the  inflam- 
matory swelling  has  disappeared,  and  the  surgeon 
then  applies  it  in  the  following  manner :  Two 
plates  of  gutta-percha  are  cut  and  softened  by 
plunging  them  into  hot  water,  and  while  the 
member  is  maintained  in  the  forced  extension  at 
an  angle  of  forty-five  degrees,  the  surgeon  places 
them  on  each  fragment  in  such  a  manner  that 
their  greatest  extremities  face  each  other.  With 
wet  fingers  the  surgeon  models  the  gutta-percha 
to  the  contours  of  the  patella  and  the  neighbor- 
ing points.  It  is  necessary  that  this  modeling 
should  be  done  with  a  great  deal  of  care,  as  the 
efficaciousness  of  the  entire  apparatus  depends 
on  its  exactitude.  Bandages  dipped  in  cold 
water  are  then  applied  on  the  gutta-percha,  and 
as  soon  as  the  plates  are  hardened  enough  to  be 
taken  off  without  alteration,  the  surgeon  plunges 
them  into  a  vessel  filled  with  cold  water,  where  in 
a  few  moments  they  recover  their  normal  con- 
sistency. The  surgeon  then  adapts  them  anew 
to  the  parts,  which  they  fit  without  the  interposi- 
tion of  any  foreign  body.  He  then  fixes  them  to 
the  surface  at  their  pointed  extremities  with  the 
aid  of  a  small  starched  bandage  wound  once  or 
twice  around  the  limb.  Without  this  precaution 
the  moment  the  hook  was  applied  each  plate 
would  tilt  and  the  hooks  would  immediately 
cease  to  operate.  The  surgeon  then  brings  by 
aid  of  the  fingers  each  plate  toward  the  other 
and  implants  strongly  in  each  the  corresponding 
half  of  the  hook.  And  he  need  have  no  fear  of 
piercing  the  guttapercha  and  arriving  as  deep  as 
the  skin,  for  the  gummy  substance  can  only  be 
penetrated  with  difficulty  and  the  point  rarely  at- 
tain half  its  thickness.  There  remains  nothing 
more  but  to  screw  together  the  plates  and  frag- 
ments to  the  degree  desired.  The  surgeon  next 
places  the  limb  in  a  gutter  of  which  the  inferior 
extremity  is  elevated  to  thirty-five  or  forty  de- 
grees. At  the  end  of  several  days  the  soft  parts 
yield,  and  he  must  then  take  the  plates  off  the 
limb  and  re-adjust  the  entire  apparatus.  After  a 
month  this  splint  has  afforded  all  the  results  that 
can  be  expected  and  the  hooks  are  to  be  taken 
off.  But  Trelat  advises  leaving  the  limb  during 
several  days  afterwards  in  the  extension  position. 
He  claims  that  this  apparatus  causes  no  suffering, 
procures  a  uniform  pressure  over  a  large  surface, 
is  not  liable  to  accident,  and  allows  the  examina- 
tion of  the  state  of  the  fracture  through  the 
spaces  between  the  plates. 

Valette's  apparatus  (of  Lyons),  is  composed  of 
an  iron  gutter  well  padded,  supplied  with  four 
straps  and   disposed  in  such  a  manner  as  to  re- 


ceive the  entire  limb.  The  one  here  presented  is 
furnished  with  a  sole  to  support  the  foot,  but  a 
gutter  which  would  embrace  but  a  part  of  the  leg 
and  thigh  could  be  employed.  Opposite  the 
articulation  two  blades  of  iron  arise  connected  by 
an  arch  which  is  perforated  in  its  centre  for  the 
passage  of  forks.  This  arch  can  be  raised  or 
lowered  by  being  placed  in  the  slots  in  the  up- 
rights— the  forks  being  regulated  by  a  key. 
This  apparatus  is  claimed  to  advantageously 
remedy  the  defects  which  Malgaigne's  hooks 
present. 

Prof.  Gross/  of  Philadelphia,  recommended 
the  employment  of  a  padded  tin  case  extending 
from  the  middle  of  the  thigh  to  a  corresponding 
point  in  the  calf  of  the  leg.  A  roller  is  to  be  ap- 
plied upon  the  leg  from  the  toes  upward,  and  an- 
other upon  the  thigh  from  the  groin  downwards, 
the  displaced  fragments  to  be  brought  down  and 
confined  by  numerous  adhesive  straps  carried 
around  the  bone  above  and  below  the  joint,  and 
connected  afterwards  by  vertical  and  transverse 
pieces.  A  long,  thick  and  very  narrow  compress 
should  extend  around  the  upper  border  of  the 
patella  and  confined  by  the  two  rollers,  passed 
around  the  joint  in  the  form  of  the  figure  8. 

Dr.  Sanborn,11  of  Lowell,  Mass.,  suggested  a 
method  by  the  use  of  a  single  adhesive  strip 
twisted  above  the  knee.  He  directs  that  a  strip 
of  ordinary  adhesive  plaster  four  feet  long,  and 
two  and  a  half  inches  wide,  be  applied  to  the 
limb  from  the  upper  portion  of  the  thigh  to  the 
middle  of  the  leg,  leaving  at  the  knee  a  free 
loop.  (Fig.  29.)  A  roller  bandage  is  then  ap- 
plied above  and  below  the  knee  for  the  purpose 
of  securing  the  plaster  and  controlling  the  circu- 
lation and  muscular  contraction.  A  small  stick 
six  or  eight  inches  in  length  then  being  put 
through  the  loop  over  the  knee,  the  plaster  is  to 
be  twisted  until  the  patella  is  brought  near  down 
to  its  proper  situation.  Before  applying  «the 
twist,  a  hard  compress  is  to  be  placed  above  the 
patella  in  such  a  manner  as  to  bring  the  force  to 
bear  directly  upon  the  bone. 

Prof.  Frank  A.  Hamilton  contrived  a  dressing 
consisting  of  an  inclined  plane  of  sufficient 
length  to  support  the  thigh  and  leg,  and  about 
six  inches  wider  than  the  limb  at  the  knee.  (Fig. 
31.)  This  plane  rises  from  a  horizontal  floor  of 
the  same  length. 

Wales  "  draws  particular  attention  to  the  merits 
of  the  forms  of  apparatus  devised  by  two  Ameri- 
can surgeons,  Lausdale  and  Hartshorne.  Of  the 
former  (Fig.  32)  he  terms  a  very  ingenious  and 
efficient  splint — holding  the  fragments  in  exact 
apposition  and  not  constricting  the  limb.  "  It  is 
constructed  with  a  posterior  padded  splint  upon 
which  the  limb  is  secured  with  a  roller  bandage." 
"  Front  a  point  a  short  distance  above  the  knee 
an  iron  loop,  or  arc,  spans  the  limb  obliquely,  and 
when  in  position  its  lop  is  below  the  patella;  a  simi- 


i89i.] 


MECHANICAL  TREATMENT  OF  FRACTURE 


lar  arc  is  fastened  to  the  splint  at  a  correspond- 
ing point  below  the  knee,  and  its  top,  when  in 
position,  is  above  the  knee.  Each  of  these  arcs 
bear  a  screw  at  its  centre  armed  with  a  semi-lunar 
pad.  In  the  application  of  this  apparatus  after 
the  limb  is  secured  to  the  splint,  it  is  simply 
necessary  to  bring  the  upper  fragment  down,  and 
with  the  upper  screw  clamp  the  pad  against  it ; 
in  like  manner  clamp  the  inferior  fragment  with 
the  lower  pad. 

Dr.  Edward  Hartshorne  first  employed  his 
method  in  the  Pennsylvania  Hospital  in  1862, 
and  it  consists  of  a  simple  application  of  the 
Spanish  windlass. 

The  splint,  which  should  be  carefully  padded — aud 
sufficiently  broad — is  furnished  on  its  sides,  at  proper 
distances  above  anil  below  the  knee,  with  notches  or  pro- 
jecting  cleats,  pins  or  hooks  which  are  required  to  hold 
the  bandage.  This  bandage  may  be  the  common  roller 
or  adhesive  strips,  or  even  a  band  or  ring  of  elastic  web- 
bing ;  but  inelastic  webbing,  or  linen,  or  cotton  drilling 
from  one  and  a  half  to  two  inches  wide  in  the  central 
portion  and  narrower  at  its  ends,  answers  better,  especially 
if  the  surfaces  which  we  apply  to  the  integument  above 
and  below  the  fragments  are  thinly  spread  with  old  ad- 
hesive plaster.  The  lower  fragment  is  fixed  in  the 
usual  way,  and  retained  in  position  by  simply  applying 
one  of  the  bandages  by  its  wider  central  portion  in  front 
of  the  knee-joint  directly  to  the  lower  margin  of  this 
fragment,  then  passing  the  two  narrower  ends  obliquelv 
upwards  and  backwards  and  drawing  them  firmly  to- 
gether over  the  upper  cleats,  pins  or  notches,  and  behind 
the  splints,  there  to  be  fastened  in  any  manner  most  con- 
venient. 

The  bandage  or  band  for  the  upper  fragment  requires 
more  careful  application  and  adjustment,  as  it  is  to  ex- 
ert all  the  pressure  aud  traction  force  necessary  to  bring 
the  fragment  down,  and  retain  it  in  apposition  with  the 
fixed  lower  fragment.  Having  been  applied  to  the  in- 
tegument just  above  aud  slightly  over  the  margin  of  this 
upper  fragment,  it  is  then  drawn  firmly  downwards  aud 
forwards  over  the  notches  or  cleats  in  such  an  oblique 
direction  as  may  be  found  the  best  for  efficient  traction 
in  each  particular  case.  The  two  ends  are  firmly  fastened 
together,  and  a  small  stick  (or,  what  is  better,  the  little 
wooden  fork  called  a  clothes-pin),  passed  between  the 
band  and  the  splint,  is  turned  or  twisted  on  its  long  axis 
in  such  a  way  as  to  draw  upon  the  bandage  to  anv  proper 
extent.  This  arrangement  allows  the  whole  knee,  especi- 
ally the  injured  parts  and  the  compressing  bandages,  to 
remain  uncovered,  at  the  same  time  that  it  gives  entire 
control  of  the  joint  and  of  the  separated  fragments,  as 
well  as  of  the  dressing  itself.  Compresses  of  lint  or 
other  material  may  be  employed,  but  they  are  not  often 
needed,  particularly  when  adhesive  plaster  is  spread  upon 
the  central  portion  of  the  bandage.  Tilting  of  the  frag- 
ments may  be  prevented  by  a  transverse  bandage,  or  by 
a  narrow,  well-padded  transverse  splint  pressing  upon 
the  line  of  fracture.  The  ease  and  certainty  with  which 
the  tractiou  may  be  lessened  or  increased  by  the  slightest 
turn  of  the  twisting-stick  or  pin,  at  the  same  time  that 
this  pin  may  be  fastened  beyond  the  reach  or  control  of 
the  patient,  renders  this  contrivance  remarkably  effec- 
tive ;  while  the  simplicity  of  materials  and  arrangement 
bring  it  readily  within  the  reach  of  every  one.  The 
same  care  in  all  essentials,  aud  especially  in  adapting  the 
splint  and  bandage,  as  to  length  and  width  of  the  former, 
and  the  distance  apart  of  the  cleats  or  notches,  and  the 
width  and  obliquity  of  the  latter,  must  be  observed  in 
the  use  of  this  mode  of  dressing,  as  in  other  more  com- 
plex or  different  arrangements. 

From  Erichsen"  whose  remarks  upon  the  treat- 


ment of  this  fracture  twenty  years  ago,  may  be 
taken  as  an  index  of  the  professional  opinion  ex- 
isting at  that  time,  is  extracted  the  following  : 

There  is  rather  severe  inflammatory  action  in  the  knee 
■  with  great  synovial  effusion.  This  requires  to  be  reduced 
by  rest,  and  the  application  of  evaporating  lotions,  U-fore 
anv  other  treatment  can  be  adopted.  When  this  has 
been  effected,  means  must  be  taken  for  the  reunion  of 
the  fragments.  With  this  view  the  principal  point  to  be 
attended  to  is  to  keep  them  in  sufficiently  close  apposi- 
tion for  firm  ligamentous  union  to  take  olace.  With  this 
view  the  upper  fragment,  which  is  movable,  and  has 
been  retracted  by  the  extension  muscles  of  the  thigh, 
must  be  drawn  down  so  as  to  be  approximated  to  the 
lower  one  which  is  fixed  by  the  ligamentous  patella. 
This  approximation  of  the  'fragments  may  be  effected 
either  by  position  aud  relaxation  of  the  muscles  or  by 
mechanical  contrivance.  Simple  position  usually  suffices 
fortius  purpose  and  must  be  attended  to  whatever  me- 
chanical appliances  are  used.  By  placing  the  patient  in 
a  semi-recumbent  position,  and  elevating  the  leg  con- 
siderably so  as  to  relax  the  muscles  of  the  thigh  com- 
pletely, the  upper  fragment  may  be  brought  down  to  the 
lower  one,  and  if  necessary  may  be  retained  there  after 
any  local  inflammation  tha't  results  from  the  accident  has 
been  subdued— by  moulding  a  gutta  percha  cap  accurately 
to  and  fixing  it  firmly  upon  the  knee,  or  by  the  applica'- 
tion  of  pads  of  lint  and  broad  straps  of  plaster.  These 
straps  of  plaster  may  be  applied  above  and  upon  the  up- 
per fragment  in  a  diagonal  direction  from  above  down- 
wards. They  should  be  of  sufficient  length  to  embrace 
the  limb  and  the  back  splint,  to  which  they  are  to  be 
fixed,  or  a  figure  of  S  may  be  applied  around  the  limb 
and  splint  together.  This  position  must  be  maintained 
for  at  least  six  weeks  :  At  the  expiration  of  this  time 
the  patient  may  be  allowed  to  walk  about,  wearing,  how- 
ever, an  elastic  knee  cap,  or  what  is  better,  a  straight 
leather  splint  in  the  ham,  so  as  to  prevent  the  knee  from 
being  bent  for  at  least  three  months. 

In  conclusion  :  this  paper  has  been  prepared 
solely  with  the  idea  of  presenting  to  the  profes- 
sion a  concise  resume  of  the  more  important 
forms  of  apparatus  which  have  been  invented  for 
this  fracture  prior  to  the  last  twenty  years,  and 
as  its  details  are  familiar  to  every  practitioner, 
no  mention  is  made  of  the  present  practice  of  en- 
casing the  limb  in  plaster-of-Paris,  although  this 
must  also  be  considered  a  mechanical  procedure. 

The  writer  in  this  paper,  which  is  intended  to 
be  entirely  historical,  does  not  enter  into  the  con- 
troversy at  present  existing  between  advocates  of 
operative    and   mechanical    treatment,    although 


'Richter.  Berlin  ;;-.  Also  Abulcasis.  De  Chirurgia.  traduction 
latine  par  Channing,  Oxonii  1778 

=  Ars.  Chirurg.  Venetiis  1546,  cap.  xxxix,  fol.  154. 

3  Manuale  operat.  der  Chir.,  Amsterdam,  164--.  part  iv,  chap.  27 
p.  325,  plate  15,  Fig.  26. 

*  Nouveau  traite  des  instrumens  de  Chirurgie  le  plus  utiles.  T. 
11,  p.  301,  Paris,  1723. 

;  Chir.  Lorbeerkranz,  Halberst.  [685,  Chap.  21.  p.  in. 

6De  patella  ejusque  laesionibus  etcuratione,  Kraneq,  1697.  and 
also  in  Haller's  Disput,  Anatora..  Vol.  vi,  p.  ^00.  Gottingen.  1751. 

La  maniere  de  guerer  par  le  moveu  ties  bandages  les  fractures 
et  les  luxations,  Paris.  1712,  p.  168. 

mjlicher  Bericht  von  Bandagen.  Leipzig.  1732,  p.  232. 
Chirurgie  Rostock  u.  Leipzig.  1754.  p.  561. 

'  C.I,  Schma'.z  Seltene  Chir.  und  Med.  Vorfalle.  Leipzig.  1784 
p.  190. 

11  Recherches  critiques  sur  la  Chirurgie  raoderne.  1772. 

'-  Xeue  3emerk  und  Erfahrungen.  Book  11,  p.  219.  (Also  Tbe- 
den,  Progres  ulterieurs  de  la  chirurgie,  trad,  par  Chavron.  Paris 
— 

'3 Lehrbegnff,  Book  iv.  p.  422.     Leipzig 

^Abhandlung  vom  Knies  cheibeubruch.  S'ebst  Beschreibung 
einer  neuen  Maschine  dazu.     Steudal.  17S9.  p.  29. 

'?  Journal  de  Medicine.  Chir.  et  Pharm.,  Pari- 

,c  Richter,  Chir.  Biblioth.,  Book  xl,  p.  513.    Gottingen 


302 


METHYL-VIOLET. 


[February  28, 


this  subject  is  now  attracting  widespread  atten- 
tion in  the  profession.  It  is,  however,  safe  to 
assume,  that  so  long  as  a  surgical  operation  to 
secure  union  of  the  fragments  is  not  unattended 
with  danger,  excepting  under  antiseptic  precau- 
tions, the  details  of  which  render  its  employment 
impossible  for  ninety- five  practitioners  out  of  a 
hundred,  especially  those  residing  in  the  country, 
the  mechanical  treatment  being  devoid  of  danger, 
and  productive  of  a  fairly  good  result  with  but 
little  comparative  inconvenience,  will  interest  and 
continue  to  be  employed  by  far  the  greater  ma- 
jority of  the  profession. 
125  State  St.,  Chicago. 


METHYL-VIOLET. 


.'/;,•  .1//. 


BY  FLAYEL  B.  TIFFANY.   M.D.. 

OF    KANSAS   CITY,   JIO. 

A  few  months  ago  Dr.  J.  Stilling,  of  Stras- 
bourg gave  to  the  world  in  the  Revue  Generate 
a"  Ophthalmologic  his  experience  in  the  use  of 
methyl- violet  in  the  treatment  of  various  affec- 
tious,  more  especially  those  of  the  eye.  When 
the  article  first  appeared,  May,  1890,  I  took  the 
liberty  of  translating  it,  and  subsequently  my 
translation  was  published  in  two  numbers,  (non- 
consecutive)  of  Dr.  Lanphear's  Kansas  City 
Medical  Journal.  I  commenced  the  use  of  methyl- 
violet  from  the  day  I  first  read  Prof.  Stilling' s 
article,  for  at  that  time  I  had  on  hand  a  case  of 
suppurative  iritis  which  had  resisted  all  treat- 
ment, continuing  step  by  step  through  the  sev- 
eral stages  of  inflammation  until  panophthal- 
mitis seemed  inevitable. 


>;  Berlin.  1796. 

•SKohler,  Auleitung  Zum  Verbande.     Leipzig,  1796.  p.  361. 

auslandiscben  I.Ueratur  von  Hufeland.    Schregei 
und  Harlefs.     Jul 

York-sunken  uber  die  Krankheiten  der  Knoeben.  Book  I,  pp. 
529-231. 

.  hiron     Bd   111   p,  64. 
-.1-  Berlin.  iSj\  p.  411,  (also  Manuele di chirurgia,  Milan, 
1S12.) 

A-  1  itive  Surgery,  London.  1807  and  1809. 

Chirurgische  Bibliothek,  Gottiugen,  1772- 
1-96. 

I 


vie  der  Franzosischen  und  Deutschen 
Chirurgie.     l.eii. 

Theoretisch  praktis. .-;■■ 
in  den  Bruchen  und  Verrenkungen  der  Knochen. 
nri::i]  fur  Chin  1         1 

p.  442. 
al  Reporter,  v.  1  p.  279. 

thi    Patellae 

■      Di    Fra<  tm  i 

■  par.G.  i 

E.  Spillm 

Mecuin.    London,  1865,  p.  285. 
Holmes. 

letin  de  Therapeutique,  1 

des  Fractures  et  des  Luxations 

■ 
Kebdom 

illetin  de  Therapeuti     .  1 

eutics,  p  472. 
utics,  Philadelph 

I 

Vol.  i. 


The  patient  was  an  old  man,  72  years  of  age, 
rather  feeble  physique,  upon  whom  I  had  made 
extraction  of  a  nuclear  cataract  some  eight  weeks 
previous  to  the  attack  of  iritis.  He  had  made  a 
good  recovery  from  the  operation  and  with  fair 
results,  viz.,  with  plus  11  D.  \\.  Could  read  No. 
2  with  +  14  D.  There  was  a  slight  amount  of 
cortical  substance  remaining.  The  iritis  did  not 
ensue  for  a  month  after  he  had  gone  from  the  hos- 
pital, when  it  appeared  quite  suddenly  one  day  as  he 
was  sitting  in  the  harvest  field  watching  the  har- 
vesters at  work.  He  says  that  as  he  crossed  the 
lot  from  one  shade  tree  to  another,  in  the  full  blaze 
of  the  bright  August  sun,  he  felt  a  sharp  pain 
dart  through  the  eyes,  and  from  that  time  he 
was  not  fully  free  from  pain,  which  gradually  in- 
creased with  intolerance  of  light  and  diminution 
of  vision.  It  was  several  days  after  the  attack 
before  the  patient  returned  to  the  city.  When 
he  presented  himself  I  found  an  intense  iuflam- 
ination  of  the  iris  with  plastic  exudation  in  the 
front  chambers. 

Mydriatics  and  hot  water  were  scrupulousl y  used 
in  connection  with  other  antiphlogistics,  but  all  to 
no  purpose,  the  inflammation  mounted  higher  and 
higher,  and  the  exudation  was  more  profuse  and 
of  a  suppurative  character;  the  iris  becoming  a 
deeper  red  until  finally  the  whole  chamber  be- 
came blood  red;  the  cornea  began  to  grow  steamy, 
there  was  intense  ciliary  injection;  in  fact  the 
whole  ball  was  aglow,  and  the  lids  swollen. 
There  was  much  pain  and  total  blindness.  I  de- 
spaired of  any  chance  of  saving  the  ball,  much 
less  any  sight. 

It  was  at  this  stage  that  I  read  Dr.  Stilling's 
article  on  methyl-violet.  I  immediately  had  a 
preparation  made,  1  to  1,000,  which  I  had 
dropped  into  the  eye,  one  or  two  drops  at  a  time, 
thrice  a  day.  This  caused  no  irritation,  but  for 
a  few  hours  there  was  little,  if  any,  amelioration 
of  the  inflammation,  although  the  eye  felt  better. 
At  the  end  of  the  second  day  there  was  percep- 
tible abatement  of  congestion,  and  the  pain  was 
nearly  gone.  The  amount  of  medicine  was  in- 
creased. The  conjunctival  sac  was  filled  at  each 
application,  morning,  noon  and  night,  and  the 
inflammation  gradually  subsided. 

The  methyl-violet  was  continued  for  about  three 
weeks,  when  the  eyeball  had  become  clear  and 
free  from  inflammation.  The  shape  and  size  of 
the  ball  had  been  perfectly  conserved,  the  iris  had 
assumed  its  natural  color  and  brilliancy,  although 
the  pupil  was  nearly  occluded  and  there  was  only 
perception  of  sight.  The  patient  returned  to  his 
home  in  Kansas  with  the  hope,  through  the 
means  of  a  subsequent  operation  (to  be  made  in 
few  months )  of  regaining  useful  vision. 

It  has  been  about  six  or  seven  months  since  I 
commenced  the  use  of  methyl-violet  in  affection 
of  the  eye.      I  have  used   it   a   great  many   time, 
and  in   many  patients,  and  have   kept  a   carefu 


i89i.] 


METHYL-YIOLET. 


303 


record  of  several  of  the  cases.   It  has  beeu  mostly 
used  in  phlyctenular  conjunctivitis  and  granular 

conjunctivitis. 

In  cases  of  trachoma,  when  treatment  cannot 
be  continued  by  me  on  account  of  patients  being 
obliged  to  return  to  their  homes,  out  of  the  city, 
it  has  become  my  custom  to  prescribe  a  bottle  of 
methyl- violet  (1  to  1,000)  to  be  used  at  home  three 
times  daily,  and  it  has  beeu  invariably  the  case  that 
these  patients  go  on  to  recovery  without  any  re- 
lapses, and  that  the  medicine  never  acts  as  an 
irritant,  but  is  always  soothing  and  agreeable.  I 
have  used  it  with  excellent  effect  in  dacryocystitis 
by  means  of  the  lachrymal  syringe.  I  have  also 
used  it  in  otitis  media  purulenta  but  not  with  as 
marked  benefit  as  in  affections  of  the  eye,  lachry- 
mal apparatus,  and  nasal  catarrh. 

I  have  employed  this  agent  in  microscopy  as  a 
staining  material,  knowing  its  special  and  thor- 
ough action  as  a  stain  for  different  forms  of  mi- 
crobes, and  especially  for  the  micrococci,  and 
that  it  always  means  death  to  the  bacillus  when 
it  comes  in  contact  with  him;  striking,  as  it  were, 
to  the  heart  or  nucleus  of  all  cells;  paralyzing  all 
vital  action  at  once;  but  it  had  not  occurred  to  me 
to  employ  it  as  a  therapeutic  agent  even  in  those  dis- 
eases which  are  generally  conceded  to  have  their 
etiology  in  the  microbes,  until  my  attention  was 
called  to  it  by  Prof.  Stilling's  able  article  to  which 
I  have  referred. 

Since  I  have  been  using  this  agent  I  have  not 
had  the  opportunity  of  employing  it  in  a  single 
ease  of  gonorrhceal  ophthalmia.  As  yet,  of 
course,  the  remedy  has  not  been  sufficiently  used 
to  establish  it  as  so  valuable  a  remedy  as  Dr. 
Stilling  would  claim  for  it. 

Methyl-violet  may  be  used  as  a  local,  topical 
and  general  systemic  agent,  in  fluid  or  pomade, 
spray  _,',T  to  1  per  cent.  It  remains  to  be  seen  if 
it  shall  prove  a  valuable  remedy  in  pulmonary 
affection,  in  pyaemia,  etc.  If  it  has  a  special  pre- 
dilection for  the  bacillus  and  cocci,  we  shall  look 
for  it  as  a  boon  in  most  diseases. 

Within  the  last  few  days  I  have  had  occasion 
to  use  the  methyl- violet  in  two  cases,  one  of  irido- 
cyclitis and  the  other  choroido-clyclo-iritis,  both 
of  a  most  serious  nature;  that  of  iridocycli- 
tis occurred  in  a  reverend  gentleman,  Mr.  D.,  age 
55,  blue  eyes.  This  patient  consulted  me  Decem- 
ber 9,  complaining  of  quite  a  severe  pain  in  the 
right  eye,  with  dimness  of  vision.  Examination 
revealed  acute  inflammation  of  the  iris  with  in- 
tense deep  red  congestion  of  the  subconjunctival 
vessels  over  the  entire  anterior  scleral  surface.  The 
pupil  was  contracted  and  inactive,  and  would  not 
respond  in  the  least  to  mydriatics.  A  1  per  cent,  solu- 
tion of  sulphate  of  atropia  dropped  into  the  eye  five 
or  six  times  a  day  made  no  impression  whatever, 
not  even  controlling  in  the  least  photophobia  or 
congestion;  in  fact  all  the  symptoms  grew  stead- 
ily worse,  and  on  the  third  day  the  cornea  lost  its 


transparency,  became  steamy,  so  that  the  iris  was 
nearly  hidden  and  the  vision  was  gone;  could  not 
see  to  count  fingers,  and  the  fellow-eye  had  taken 
on  symptoms  of  irritation,  and  its  vision  was  con- 
siderably reduced.  At  this  period,  December  11, 
I  ordered  methyl-violet,  ,'„  per  cent.,  dropped  in 
the  eye  every  hour,  in  connection  with  the  sul- 
phate of  atropia,  and  to  my  great  delight  the  next 
day,  December  12,  I  found  the  pupil  dilated  to 
more  than  twice  its  size  of  the  day  before,  the 
congestion  subsiding,  the  cornea  clearer,  and  the 
vision  sufficient  to  count  fingers.  The  treatment 
was  continued,  and  on  the  following  day  the  pa- 
tient was  able  to  recognize  a  person  across  the  room, 
pain  was  gone,  redness  less  and  pupil  widely 
dilated.  December  15,  pupil  wide  open  and  vis- 
,,  eye  fast  recovering. 
The  methyl-violet  has  quite  a  mydriatic  effect 
and  also  controls  the  power  of  accommodation  to 
a  considerable  extent:  though  it  is  claimed  by 
some  that  it  does  not  affect  the  power  of  accom- 
modation. This  fact  I  have  verified  many  times, 
by  using  it  alone  without  atropia.  In  the  above 
case  I  feel  confident  that  the  methyl-violet,  from 
its  diffusibility  and  germicidic  effect  on  the  pyo- 
genic microbe,  cut  short  the  disease  and  so  saved 
the  eye. 

I  do  not  believe  that  in  this  case  the  mydriatic 
effect  of  the  atropia  could  have  obtained  without 
the  methyl  violet ;  besides,  the  methyl  violet  con- 
trolled the  irritating  effect  of  the  atropia  on  the 
cornea,  and  checked  the  keratitis. 

The  other  case,  choroido-cycloiritis,  occurred  in 
a  young  man  of  25  years,  dark  brown  eyes,  A.  B. 
Patterson,  from  Juniata,  Xeb.,  a  station  agent 
on  the  Missouri  Pacific  railroad.  The  history,  as 
gained  from  the  patient,  was  as  follows  :  While 
walking  down  the  street  October  13,  with  a  pen- 
knife open  in  my  hand,  I  met  a  friend,  who  in 
play  knocked  my  hand  with  the  knife  so  that  the 
open  blade  pierced  my  right  cheek,  going  into  the 
eye,  and  then  the  doctor  put  a  stitch  in  the  eyeball 
and  assured  me  that  the  sight  would  be  all  right 
(a  German  doctor).  For  about  ten  days  the  sight 
was  very  good,  and  then  the  eye  began  to  pain 
and  I  could  not  bear  the  light,  and  the  sight 
gradually  diminished  and  the  pain  grew  worse. 
An  examination  revealed  a  scar  of  the  right 
cheek,  lower  lid  and  eyeball ;  that  of  the  eyeball 
about  10  mm.  long,  about  one-third  of  which  ex- 
tended into  the  cornea  from  the  inner  inferior  re- 
gion, near  the  attachment  of  the  inferior  rectus 
muscle.  The  cut  of  the  cornea  embraced  the  en- 
tire layers  of  the  cornea,  and  evidently  the  blade 
went  through  the  sclera  and  choroidal,  though 
there  was  no  evidence  of  its  cutting  the  iris.  The 
pupil  was  contracted,  and  the  vision  was  not  suf- 
ficient to  count  fingers,  and  photophobia  intense. 
I  ordered  a  1  per  cent,  solution  of  atropia  to  be 
dropped  into  the  eye  every  two  hours,  night  and 
day.    The  second  day  the  patient  was  sent  to  my 


3°4 


MEDICAL  PROGRESS. 


[February  28, 


rooms;  the  mydriatic  had  not  had  the  least  effect. 
The  ophthalmoscope  revealed  a  grayish,  light- col- 
ored body,  with  small,  pale  blood-vessels  mount- 
ing up  over  it,  projecting  from  the  region  of  the 
ciliary  body,  and  the  sclera  immediately  exterior 
was  swollen  or  bulged. 

tached  retina,  with  exudation  beneath  the  retina. 
At  this  date  I  commenced  the  use  of  methyl  vio 
let,  and  had  it  dropped  into  the  eye  every  hour, 
night  and  day 

some  dilation  of  the  pupil,  and  less  pain  and 
soreness.  December  16  I  injected  a  10  per  cent, 
solution,  10  m.,  in  the  eye  through  the  sclera,  by 
means  of  the  hypodermic  syringe.  The  soreness 
has  subsided  and  the  pupil  is  more  open,  although 
the  exudations  are  much  the  same. 

Dr.  Stilling  speaks  of  injecting  the  vitreous  of 
a  rabbit  without  harm  to  the  eye.    My  experience 
so  far  has  been  that  the  good  effect  from  this  agent 
is  especially  to  be  realized  in  inflammation  of  the 
deeper  structures  of  the  eyeball,  owing  probably 
to  the  great  diffusibility  and  penetrability  of  the 
aniline,  traversing  almost  immediately  the  cornea 
and  sclera  to  the  chambers  of  the  eyeball,  and 
having  for  its  predilection  the  bacillus  and  micro- 
cocci.    In  ulceration  of  the  cornea  I  have  used  it 
with  most  excellent  results  in  the  form  of  pomade, 
1  to  200.    For  marginal  blepharitis,  or  tinea  tarsi, 
the  methyl  violet  pomade,  ) '?  per  cent.,  carefully 
worked  into  the  roots  of  the  lashes  by  means  of 
a  spatula,  works   a  speedy  cure.     Prof.  Stilling, 
from  his  bacteriological  experiments,  found  that 
milk  mixed  with  methyl  violet  would  not  sour, 
nor  would  butter  become  rancid  ;  that  urine  even 
could  remain  in  a  thermostat  at  320  C.  for  a  week 
without  putrefaction,  or  presenting  any  bacteria 
whatever.     In  fact,  any  substance   containing  a 
solution  of  methyl  violet  of  even  1  to  32,000,  is 
absolutely  indemnified.     This  agent  acts  as  an 
antiseptic,  killing  the  pyogenic  bacteria,  and  from 
its  diffusibility  and  non-destructiveuess  to  tissues, 
it  is  superior  to  the  other  known  antiseptics,  and 
especially  to  thermo  cautery,  which  is  so  efficient 
a  germicide,  but  can  only  be  used  at  limited  points. 
In  conclusion  I  would  say  that  it  is  most  im- 
portant that  the  drug  (methyl  violet)  be  chemi- 
cally pure,  and  free  from  arsenic.     The  article  I 
have  used  I  obtained  from  H.  W.  Evans  &  Bro., 
proprietors  of  the  Diamond  Drug  Store,  908  Main 
St.,  Kansas  City,  Mo.     An  analysis  made  by  our 
City  Chemist,  Dr.  R.  R.  Hunter,  and  also  by  Dr. 
Claud  C.   Hamilton,  Demonstrator  of  Chemistry 
at  University  Med.  Col.,  shows  no  trace  of  arsenic. 


MEDICAL    PROGRESS. 


Therapeutics  ami  Pharmacology- 

The  Curability  of  Cancerous  Tumors  by 
There  was  evidently  de-   Injections  of  Bichloride  of  Mercury. — Ac- 
cording to  the  Paris  correspondent  of  the  Medical 
Press  and  Circular  tor  September  17,  1890,  Pro- 
fessor Poucel,  surgeon  to  the  Marseilles  Hos- 
On  the  following  day  there  was  pital,  suggested,  in  1884,  that,  in  order  to  explain 
A   the  production  of  cancer,  it  would  be  found  at  no 
distant  date  that  the  microbe  of  cancer  would  be 
discovered  by  the  microscope.     Since  then  efforts 
were  made  to  prove  the  parasitic  origin  of  the 
disease,  and  some  pretended  to  have  discovered 
the  new  microbe,  but  soon  afterward  the  patho- 
genic value  of  the  bacilli,  and  it  was  even  said 
that  the  microorganism  was  not  necessary  to  ex- 
plain the  clinical  phenomena  of  cancer.     Assur- 
edly the  transport  of  living  cancerous  cells  by  the 
veins,  and   above   all  by  the   lymphatics,  would 
produce  homologous  tumors,  wherever  these  cells 
could  find  favorable  conditions  for  germination. 
This  mechanism,  although  explaining  the  gener- 
alization of  the   tumor,  does   not  clear   up    the 
cause.     The  bacilli  of  cancer,  as  in  the   case   of 
tubercles,    exact   certain    conditions   which    are 
transmissible   in  an  hereditary  sense,  and  which 
constitute  the  predisposition  and  the  tendency. 
When  these  exist,  the  rapid  growth  of  these  mi- 
croorganisms becomes  possible,  and  through  their 
contact  the  epithelium  becomes  inflamed,  prolifer- 
ous and  deformed,  characterizing  cancer.     It  was 
with  this  idea  that  he  undertook  a  series  of  re- 
searches at  the  hospital  of  Marseilles.     He  had 
shortly  before  obtained  a  prompt  cure  of  a  malign 
pustule  of  a  very  bad  form  by  injections  of  cor- 
rosive sublimate  around  its  base,  and  these  injec- 
tions proved  to  him,  first,  that  the  bichloride  had 
no  ill  effect  on  the  tissues ;  and  secondly,  that  it 
was  efficacious  against  microbes  absorbed  through 
the  lymphatics.     It  appeared  to  him,  then,  that 
it  was  quite  rational  to   apply  this  treatment  to 
cancer,  or  at  least  to  tumors  of  a  cancerous  aspect 
of  which  the  microbe  (if  there  be  one)  is  trans- 
mitted by  the  same  means.     Seven  patients  have 
already  been  submitted  to  this  treatment,  of  whom 
the  details  are  here  given.    The  first  was  a  woman 
without  any  syphilitic  antecedents,  whom  he  had 
treated  for  a  long  time  with  iodide  of  potassium. 
In  the  month  of  February,  1890,  she  entered  the 
hospital  for  an  ulcerated  cancer  of  the  right  breast, 
which  commenced  ten  months  previously.     The 
tumor  was   hard,  uneven,  and  occupied    all  the 
mammary  glands.    The  nipple  was  retracted,  and 
the    ulceration   occupied  the  under  part,  giving 
exit  to  a  fetid  and  abundant  discharge.     The  ax- 
illary glands  were  as  yet  untouched,  the  tumor 
was  free,  and  the  general  condition  of  the  patient 
good.     On  the  same  day  of  her  entry  six  injec- 
tions (the  half  of  an  ordinary  subcutaneous  syringe 


The  Woman's  Committe  of  the  World's 
Congress  Auxiliary  on  Physicians. — Dr.  Sa- 
rah H.  Stephenson,  Ch'n;  Drs.  Julia  H.  Smith, 
Mary  H.  Thompson,  Mary  Mixer,  Fannie  Dick- 
inson, Elizabeth  Chapin,  Sarah  H.  Brayton,  Ju- 
lia Low,  W.  P.  MacCracken,  Harriet  Heyl  Ca- 
rey, Rachel  Hickey,  all  of  Chicago. 


i89i.] 


MEDICAL  PROGRESS. 


305 


each  time)  of  a  solution  of  bichloride  of  mercury 
(1  in  1,000),  were  made  into  the  most  indurated 
points.  No  salivation  followed,  but  the  breast 
became  a  little  inflamed.  A  month  subsequently 
the  woman  returned,  when  it  was  found  that  the 
tumor  had  diminished  in  volume,  and  another  se- 
ries of  injections  were  made,  which  were  renewed 
four  days  subsequently.  The  decrease  of  the  tu- 
mor was  much  more  marked,  and  the  fetid  dis- 
charge had  ceased.  Unfortunately,  a  few  days 
afterward,  the  patient  was  carried  off  by  an  at- 
tack of  angina  pectoris,  to  which  she  had  been 
for  several  years  subject.  Two  other  patients 
were  treated  without  success,  but  both  of  whom 
were  very  advanced  in  age,  one  of  them  being  81. 
The  fourth  patient  was  a  retired  officer.  M.  Pou- 
cel  was  called  to  him  for  a  large  phlegmon  in  the 
groin.  After  incision,  a  hard  ganglion,  of  the 
size  of  a  nut,  was  discovered,  and  as  the  man  had 
had  some  dozen  of  years  previous^'  an  indurated 
chancre,  he  was  ordered  pills  of  protoiodide  of 
mercury.  The  tumor  increased,  in  spite  of  this, 
rapidly,  and  soon  attained  the  size  of  a  large 
goose-egg.  The  son  of  the  patient,  a  navy  sur- 
geon, was  called  in  in  consultation,  and  the  can- 
cerous nature  of  the  affection  was  fully  recognized. 
The  first  treatment  was  replaced  by  injection  of 
the  sublimate  solution,  a  series  of  six  every  two 
days.  At  the  end  of  three  weeks  all  trace  of  the 
tumor  had  disappeared,  and  no  return  had  taken 
place  up  to  the  present.  Curious  to  say,  the  son 
had  noticed  in  his  own  groin  two  small  ganglions, 
•which  had  dated  three  years  back.  However, 
about  a  year  ago  they  became  much  more  en- 
larged and  harder,  in  spite  of  every  possible  treat- 
ment. Struck  with  the  result  of  injections  in  his 
father's  case,  he  tried  them  on  himself,  and  for 
that  purpose  injected  four  half -syringefuls  daily. 
At  the  end  of  a  week  these  glands  disappeared. 
A  sixth  case  was  that  of  a  man  who  said  that  he 
had  something  wrong  with  his  rectum,  as  he  had 
often  remarked  a  fetid,  bloody  discharge  from  the 
anus.  Examination  revealed  the  existence  of  a 
malignant  tumor.  Four  injections  were  made 
daily,  and  in  twenty  days  the  cancer  had  vanished. 
The  seventh  and  last  case  was  that  of  a  woman, 
aged  58.  She  was  very  emaciated,  and  presented 
in  the  left  breast  a  hardened,  nodulated  tumor, 
about  the  size  of  a  large  walnut.  There  was  no 
retraction  of  the  nipple  nor  any  affection  of  the 
ganglions.  Two  injections  were  made,  and  re- 
newed eight  days  subsequently.  Three  months 
afterward  Dr.  Poucel  revisited  the  patient,  when 
no  trace  of  the  tumor  could  be  found.  Four  more 
patients  are  at  present  undergoing  the  treatment, 
and  a  notable  progress  is  marked  in  each  of  them. 
In  concluding,  the  author  says  that  he  does  not 
pretend  that  the  real  treatment  of  cancer  has  been 
found,  but  what  he  can  affirm  is  that  certain  tu- 
mors of  a  cancerous  appearance  are  susceptible  of 
.being  removed  by  the  injections  in  question,  and 


the  chances,  as  may  be  conceived,  are  much  great- 
er when  practiced  at  the  commencement.  He  used 
the  words  cancerous  appearance  advisedly,  as  in 
some  subjects  tainted  with  hereditary  syphilis  tu- 
mors resembling  cancer  are  observed.  However, 
in  these  cases  iodide  of  potassium  is  the  specific, 
whereas  it  has  no  effect  on  the  true  cancer.  Sev- 
eral of  his  patients  were  treated,  as  stated  above, 
by  that  drug  without  result.  Therefore,  it  may 
be  regarded  as  almost  certain  that  all  the  cases 
mentioned  were  real  cancers. — Pacific  Med.  Record. 

Koch's  Treatment  ;  General  Results, — 
In  a  supplement  to  the  December  number  of  the 
Bristol  Mcdico-Chirurgical  Journal,  Drs.  Mark- 
ham  Skerritt  and  Barclay  Baron  give  an  ac- 
count of  their  observations  of  Koch's  treatment 
during  a  recent  visit  to  Berlin.  They  reached 
the  German  capital  on  Dec.  5,  and  stayed  there 
until  Dec.  13.  They  saw  a  very  large  number  of 
cases  presenting  the  results  of  treatment  under 
the  most  varied  conditions  :  at  the  Charite',  under 
Leyden,  Frantzel,  and  Gerhardt ;  at  the  Lazarus 
Hospital,  under  Langenbuch  ;  and  in  the  clinics 
of  von  Bergmann,  B.  Fraenkel,  Cornet,  and  Levy. 
They  also  had  an  opportunity  of  seeing  Koch's 
original  cases  at  a  demonstration  given  to  the 
Hufeland  Society,  by  Prof.  Paul  Guttmann,  at 
the  Moabit  Hospital.  A  full  description  of  the 
method  of  procedure,  and  of  the  immediate  ef- 
fects of  the  injections  in  different  forms  of  tuber- 
culous disease,  is  given.  The  types  of  reaction 
are  classified  as  follows  :  1.  Typical,  marked  re- 
action to  small  early  dose,  diminishing  reaction 
to  the  same  or  even  to  increasing  doses.  2.  In- 
creased reaction  to  the  same  or  a  diminished  dose. 
3.  Prolonged  or  deferred  reaction.  4.  Effect  of 
reaction  on  hectic  ;  a,  favorable,  when  there  is  a 
tendency  to  the  substitution  of  the  reaction  type 
for  the  hectic  type,  and  b,  negative,  when  the  hec- 
tic persists  unaffected  by  reaction.  5.  Fever  orig- 
inated by  injection.  These  various  types  are  il- 
lustrated by  cases  and  charts,  and  the  cause  of 
the  diversity  of  action  of  the  remedy  in  different 
cases  is  discussed.  With  regard  to  the  results  of 
the  treatment  in  tuberculous  disease  of  bones  and 
joints,  Drs.  Skerritt  and  Baron  say  that  the  sur- 
geons informed  them  that  they  had  never  seen, 
under  any  treatment,  any  approach  to  the  rapid- 
ity with  which  improvement  took  place  under 
the  injections.  They  themselves  saw  cases  where 
sinuses  in  connection  with  the  diseased  bones  and 
joints,  which  had  long  remained  open  in  spite  of 
all  previous  treatment,  rapidly  and  completely 
closed.  With  regard  to  glands,  it  is  pointed  out 
that  the  usual  local  change  is  swelling  and  ten- 
derness during  reaction,  followed  by  gradual 
diminution  in  size.  Suppuration  does  not  com- 
monly occur.  In  the  larynx  the  local  reaction 
may  produce  increase  of  pain  in  swallowing,  in- 
crease of  cough  and  expectoration,  a  feeling  of 


306 


MEDICAL  PROGRESS. 


[February  28, 


dryness  and  constriction,  greater  hoarseness,  per- 
haps aphonia,  and  sometimes  local  pain.  Con- 
trary to  what  the  authors  anticipated,  they  found 
that,  as  a  rule,  no  serious  obstruction  to  breathing 
was  produced,  and  in  many  cases  none  at  all, 
With  regard  to  the  lung,  they  state  that  little  can 
be  said  as  to  improvement  in  physical  signs  ;  '  'in 
some  cases  rales  and  dulness  are  said  to  have  di- 
minished, and  bronchial  breathing  to  have  been 
replaced  by  vesicular,  but  as  yet  time  is  too  short 
to  allow  of  decided  evidence  on  this  point."  They 
add  that  Koch  claims  to  have  completely  cured 
two  phthisical  patients,  with  one  of  whom  they 
had  the  opportunity  of  speaking.  They  also  saw 
a  patient  in  whom,  during  three  weeks'  treat- 
ment, the  disease  markedly  extended  in  both 
lungs,  and  a  cavity  formed  ;  dyspnoea,  absent  be- 
fore, made  its  appearance  ;  bacilli,  previously  few 
in  number,  became  numerous,  and  the  sputum 
was  increased  in  amount.  One  of  the  cases  seen 
by  them,  in  which  there  was  most  marked  lung 
reaction,  had  been  examined  again  and  again 
without  the  detection  of  a  single  suspicious  sign. 
They  also  saw  many  patients  in  whom  the  injec- 
tion revealed  in  very  varied  parts  previously  un- 
suspected tubercle.  In  no  case,  therefore,  even 
the  least  suspicious,  should  an  injection  be  made 
without  the  most  careful  and  thorough  prelimi- 
nary examination,  and  the  greatest  caution  should 
be  observed  as  to  dosage.  In  tuberculosis  of  the 
lungs  and  larynx  the  initial  dose  should  be  one 
milligram,  which  is  gradually  increased,  one  or 
more  "fever  free"  days  being  allowed  between 
the  injections.  For  purposes  of  diagnosis  exact  re- 
liance cannot  be  placed  upon  the  result  of  a  single 
injection.  Skerritt  and  Baron  saw  a  case  of  es- 
tablished phthisis,  with  bacilli,  in  which  no  re- 
action occurred  until  the  dose  had  reached  one 
centigram,  and  they  were  informed  that  this  was 
by  no  means  a  solitary  instance.  On  the  other 
hand,  reaction  occurred  in  patients  who  other- 
wise presented  no  evidence  whatever  of  tubercu- 
losis ;  as,  for  instance,  in  a  girl  with  post-scarla- 
tinal nephritis.  They  sum  up  as  follows  :  "  The 
evidence  at  present  at  our  disposal  warrants  the 
conclusion  that  the  beneficial  effects  of  the  reme- 
dy is  undoubted  in  tuberculosis  of  the  skin,  bones, 
joints,  glands,  and  throat.  With  regard  to  pul- 
monary phthisis,  whilst  there  is  good  reason  to 
hope  that  in  suitable  cases  a  most  satisfactory  re- 
sult may  be  obtained  from  this  treatment,  suffi- 
cient time  has  not  as  yet  elapsed  to  allow  of  the 
formation  of  any  accurate  estimate  of  its  value." 
\tish  Medical  Journal. 

Treatment  of  Erysipelas. — An  elaborate 
■  li  clinical  and  bacteriological,  has  recently 
been  published  by  Professor  Nussbaum's  as 
sistaut.  Dr.  Julius  Fessler,  on  the  treatment  of 
erysipelas  by  ichthyol,  a  plan  which  has  been  for 
some    years    extensively    adopted    in    Munich. 


From  laboratory  experiments  it  was  evident  thatr 
though  ichthyol  has  only  a  slight  effect  in  pre- 
venting the  development  of  staphylococci,  it  has- 
a  very  potent  deterrent  influence  on  the  multipli- 
cation of  streptococci,  and  it  is  well  known  that 
it  is  the  latter  kind  of  bacteria  that  are  the  cause 
of  erysipelas.  The  method  of  treatment  consists 
mainly  of  rubbing  a  strong  ichthyol  ointment  en- 
ergetically, and  for  ten  minutes  at  a  time,  into 
the  affected  surface  and  its  neighborhood  ;  ich- 
thyol in  the  form  of  pills  may  also  be  given  in- 
ternally. Where  there  is  a  wound  it  must  be 
very  carefully  disinfected,  and  an  antiseptic  dress- 
ing applied.  The  results  of  this  treatment  as 
compared  with  ordinary  methods  are  embodied  in 
several  instructive  tables.  From  these  it  appears 
that  while  the  mean  duration  of  the  cases  treated 
by  other  methods  from  1880  to  1888  was  about 
twelve  days,  in  no  single  year  falling  below  nine 
days,  the  cases  treated  by  ichthyol  from  1886  to 
1888  presented  a  mean  duration  of  under  seven 
days,  while  in  the  first  half  of  1889  it  fell  to  5.6 
days. — Lancet. 

Medicine. 

Koch's  Remedy  in  Tuberculosis  of  the 
Larynx. —  Prof.  H,  Krause  contributes  the 
following  interesting  report  to  the  Therapeutischi 
Monatshefte  for  December,  1890.  He  says  it  is 
apparent  that  a  definite  result  cannot  be  affirmed, 
as  at  the  time  of  writing  only  two  and  one-half 
weeks  had  elapsed  since  beginning  treatment,  but 
the  observations  are  of  special  interest  at  this 
time  because  of  the  opportunity  of  observing  the 
direct  effect  of  the  remedy  upon  tubercular  mu- 
cous membranes,  which  can  be  better  seen  than 
the  effect  upon  lupus,  for  there  the  process  is  in 
a  measure  concealed  by  the  thick  crusts  which 
form  on  the  surface.  The  effect  in  the  larynx  is 
not  as  "  stormy  "  as  has  been  reported  by  some 
surgeons.  He  says  nothing  of  the  general  symp- 
toms, fever,  etc.,  though  he  has  noted  consider- 
able variation  from  those  usually  described. 

Unquestionably  a  specific  reaction  is  produced 
in  the  larynx ;  characterized  by  diffuse  redness 
and  swelling,  with  at  first  increase  and  later  com- 
plete loss  of  secretion ;  also  punctiform  and  dif- 
fuse haemorrhages,  superficial  and  deep  exfolia- 
tion. In  ulcers  the  base  was  changed,  and  in 
favorable  cases  was  covered  by  a  dirty  gray  coat 
that  was  thrown  off,  leaving  a  clean  granulating 
surface,  that  showed  a  marked  tendency  to  heal. 
Absorption  of  infiltrated  masses  could  be  deter- 
mined. The  patients  often  experience  a  sense  of 
constriction,  and  in  cases  presenting  marked  in- 
filtration there  is  frequently  some  pain. 

A  cure  cannot  as  yet  be  affirmed,  owing  to  the 
short  time  that  the  remedy  has  been  in  use,  but 
from  its  action  we  may  look  for  favorable  results 
in  those  cases  in  which  the  disease  is  not  too  far 
advanced.     Especial    care  must  be  exercised  in 


I89i.] 


MEDICAL  PROGRESS. 


307 


the  treatment  of  advanced  cases,  as  a  too  rapid 
increase  in  the  dose  may  cause  very  grave  symp- 
toms. 

Krause  mentions  a  case  that  had  been  under 
observation  for  eight  weeks,  in  the  last  two  and 
one- half  of  which  the  treatment  had  been  with 
Koch's  remedy.  A  decided  change  for  the  worse 
was  noticed  in  this  patient,  which  the  writer  is 
inclined  to  attribute  to  the  fact  that  the  limitations 
of  the  remedy  have  not  been  determined,  and  in 
consequence  it  has  not  been  decided  at  what  time 
surgical  interference  is  necessary. 

The  writer  describes  the  following  case :  A 
young  woman,  well  nourished,  presented  herself 
at  the  policlinic.  The  right  lung  was  involved, 
the  mucous  membrane  of  the  larynx  presented  a 
diffuse  swelling,  so  extensive  as  to  interfere  with 
deglutition.  The  epiglottis  was  three  times  its 
normal  size.  Lactic  acid  and  curetting  were  em- 
ployed, and  the  patient  improved  so  that  swal- 
lowing was  easy  and  the  cavity  of  the  larynx 
could  be  seen,  showing  the  gray  ulerations  left 
by  the  caustic.  In  this  stage  Koch's  remedy  was 
employed.  Twenty- four  hours  after  the  injection 
the  secretion  disappeared,  the  infiltrated  liga- 
ments and  epiglottis  decreased.  A  few  days 
later  the  swelling  increased,  but  a  gray  coating 
was  soon  cast  off,  leaving  a  clean  granulating 
surface.  The  later  progress  of  the  case  with  an 
increase  in  the  dose,  showed  similar  results,  ex- 
cepting that  the  action  was  more  vigorous,  and 
left  deep  ulcerating  patches. 

Another  case  was  that  of  a  young  man  who 
had  in  the  posterior  wall  of  the  larynx  a  small 
tumor,  that  after  1  milligram  of  the  remedy  was 
thrown  off  completely,  leaving  a  clean  granula- 
ting surface  that  soon  healed. 

The  writer  contributes  several  similar  cases, 
showing  the  more  or  less  favorable  action  of  the 
remedy. 

Nocturnal  Enuresis  Treated  by  Posture. 
— Dr.  Van  Trenton,  of  La  Hague,  in  a  paper 
read  before  the  Berlin  Congress,  offered  the  sim- 
plest explanation  and  treatment  of  nocturnal  en- 
uresis that  has  lately  been  presented.  His  theory 
is  that  in  some  children  there  is  an  insufficiency 
of  the  sphincter  vesicas,  which  permits  the  urine 
to  come  in  contact  with  the  upper  urethra,  and 
this  in  turn,  by  reflex  action,  causes  the  detrusor 
urinae  to  act.  He  argues  that  it  cannot  be  that 
this  trouble  is  due  to  the  impression  of  distension 
of  the  walls  of  the  bladder,  because  not  a  few 
children  wet  the  bed  within  a  period,  for  example 
two  hours,  after  going  to  bed  that  is  too  brief  to 
have  the  bladder  in  a  distended  condition.  His 
plan  of  treatment  undertakes  to  prevent  the  urine 
from  flowing  into  the  urethra,  by  raising  the  foot 
of  the  bed.  He  has  made  fourteen  cures  by  this 
method,  with  the  two  added  precautions  of  having 
the  child  empty  the  bladder  just  before  getting  j 


I  into  bed,  and  of  allowing  no  drink  to  be  taken 
by  the  patient  for  some  while  before  bedtime. — 
Annals  of  Gynecology. 

Obstetrics  and  Diseases  <>i  Women. 

Laparotomy.  —  M.  C.  Jacobs  (Bulletins  et 
Memoirs  de  la  Sociclc  Obstitricale  et  Gynecologique 
de  Paris,  Seance  du  11  DScembre,  1896)  reports  a 
series  of  fifty  laparotomies  with  only  three  deaths, 
or  a  mortality  of  but  6  per  cent. 

Five  operations  were  for  uterine  fibromas,  in- 
cluding two  hysterectomies,  with  extra-peritoneal 
treatment  of  the  pedicle,  recovery;  one  hysterec- 
tomy, in  which  the  pedicle  was  dropped  with  its 
elastic  ligature;  this  was  followed  by  inflamma- 
tion necessitating  two  consecutive  laparotomies, 
with  ultimate  recovery;  one  double  castration,  cure; 
and  two  ablations  of  pedunculated  fibroids,  at- 
tended with  recovery.  Three  operations  were 
performed  for  tuberculosis  of  the  peritoneum,  with 
three  recoveries  from  the  operation.  The  writer 
justly  observes  that  only  the  lapse  of  considerable 
time  would  permit  one  to  say  that  there  was  com- 
plete recovery.  Twenty-one  operations  were  per- 
formed for  salpingitis,  eighteen  with  castration 
and  ablation  of  the  diseased  tubes.  The  writer 
reports  excellent  results  in  these  cases.  In  uni- 
lateral purulent  salpingitis  the  ablation  of  one 
tube  and  ovary  was  sufficient,  while  in  the 
catarrhal  and  interstitial  forms  the  removal  of 
both  tubes  and  ovaries  is  indicated.  Two  deaths 
are  reported  in  this  group,  one  from  septic  peri- 
tonitis the  other  from  pulmonary  congestion. 

Dr.  Jacobs  reports  five  exploratory  laparotomies, 
but  only  one  of  these  can  be  classed  strictly  under 
this  tentative  procedure, the  abdomen  being  opened 
for  a  phantom  tumor;  another  case  was  one  in 
which  the  abdomen  was  opened  in  consequence 
of  a  septic  accident,  following  a  previous  lapar- 
otomy ;  in  another  case  a  purulent  foyer  was  found 
in  the  upper  portion  of  the  cicatrix.  Eight  ovari- 
otomies with  eight  recoveries  are  reported,  two 
of  them  were  for  cysts  of  the  broad  ligament. 
Five  hysterectomies  were  performed  for  painful 
prolapse  and  retroflexions.  Sufficient  time  has  not 
elapsed  to  permit  a  definite  answer  as  to  results. 

The  Influence  of  Artificial  Respiration 
on  the  Heart  of  the  Newly-Born. — Dr.  W. 
E.  Forest  read  a  paper  in  the  Section  in  Paedi- 
atrics, New  York  Academy  of  Medicine,  Dec.  II, 
1890,  with  this  title,  based  upon  three  interesting 
cases.  In  the  first,  after  prolonged  labor,  the 
child  was  apparently  dead.  No  pulsation  of  the 
heart  could  be  detected  by  the  hand,  but  by  the 
ear  it  was  found  to  be  beating  sixty  a  minute. 
After  artificial  respiration  for  fifteen  minutes  the 
pulsations  increased  to  120,  but  rapidly  decreased 
in  number  when  the  child  was  left  for  a  few  min- 
utes to  itself.  This  was  repeated  many  times 
with  a  similar  result  After  an  hour  and  forty- 
five  minutes  the  heart  continued  to  beat,  but  as 


3o8 


MEDICAL  PROGRESS. 


[February  28, 


no  effort  at  respiration  had  been  made  by  the 
child,  the  case  was  abandoned.  The  second  case 
lived,  the  result  of  artificial  respiration  being  in- 
variably to  increase  the  cardiac  pulsations.  In 
the  third  case  artificial  respiration  was  continued 
an  hour  and  forty  minutes  before  the  child  could 
breathe. 

The  method  employed  is  in  some  respects  en- 
tirely new.  The  child  is  placed  in  a  pail  of  hot 
water  to  maintain  the  vital  heat.  This  the 
author  believes  is  a  point  of  great  importance. 
The  head  is  then  grasped  by  the  hand  and  thrown 
backward  so  as  to  throw  the  vertebrae  of  the  neck 
forward.  The  hands  are  drawn  up  and  pressed 
against  the  chest.  This  compresses  the  oesophagus 
between  the  larynx  and  vertebrae,  and  at  the 
same  time  the  mouth  opens.  The  physician  then 
blows  strongly  into  the  mouth  of  the  child.  The 
oesophagus  thus  compressed  prevents  the  entrance 
of  air  into  the  stomach.  The  head  is  then 
thrown  forward,  and  the  arms  brought  down  to 
the  side  so  as  to  expel  the  air  from  the  lungs. 

The  points  of  especial  importance  are  the  use 
of  the  hot  bath  to  maintain  the  vital  heat  ;  the 
use  of  the  ear  to  detect  the  cardiac  pulsations 
which  could  not  be  felt  by  the  hand  ;  the  neces- 
sity of  long-continued  effort  if  pulsations' can  be 
heard  ;  and  the  peculiar  method  of  compressing 
the  oesophagus. 

Dr.  W.  H.  Thompson,  strongly  advocated  the 
hot  bath.  The  method  of  artificial  respiration 
was  ingenious,  and  certainly  showed  that  the 
lungs  had  been  inflated. 

Sextuple  Pregnancy. — Vasalli  (Rasscgua. 
di  Scienze  Med.)  reports  the  case  of  a  woman  who 
in  the  fourth  month  of  pregnancy  reached  a  size 
equal  to  that  of  term.  She  was  taken  with  pains 
and  in  the  course  of  six  hours  was  delivered  of 
six  foeti.  Their  combined  weight  equalled  1,730 
grams,  the  largest  weighing  305  and  the  smallest 
250  grams.  Their  length  varied  from  22  to  26 
cm.  The  single  placenta  was  large,  adherent, 
and  had  to  be  removed  piecemeal.  It  presented 
six  distinct  foetal  sacks. 

Bacteriology. 

Microbe  of  Epidemic  Cerebro-Spinal  Men- 
ingitis.— At  the  present  time  very  few  opportu- 
nities occur  of  studying  epidemic  cerebro-spinal 
meningitis.  Dr.  Bonome  has  had  such  an  op- 
portunity, and  made  careful  investigations  as  re- 
gards the  anatomy  and  etiology  of  this  disease. 
The  outbreak  occurred  near  Padua.  His  conclu- 
sions, together  with  an  account  of  his  experi- 
ments, are  published  in  Ziegler's  licit), 
pathologische  .  Xnatomie  und  zur  allgemeine  Patho- 
logic Dr.  Bonome  was  able  to  examine  thor- 
oughly the  bodies  of  five  patients  who  had  died 
from  the  disease,  and  the  meningeal  exudation 
from  a  sixth.  In  addition,  in  several  other  cases 
the  blood  and  catarrhal  secretions  from  the  throat 


and  nasal  cavities  were  submitted  to  investiga- 
tion. He  succeeded  in  isolating  from  the  exuda- 
tions of  the  cerebro-spinal  meninges,  and  from 
haemorrhagic  collections  in  the  lungs,  a  strepto- 
coccus, which  did  not,  however,  grow  readily  on 
artificial  media,  and  when  so  cultivated,  or  after 
being  preserved  in  a  dry  state,  soon  lost  its  patho- 
genic characters.  In  white  mice  and  rabbits  the 
microorganism  produced  the  same  effects  as  those 
brought  about  by  injections  of  the  pneumococcus 
or  meningococcus,  fibrinous  inflammations  being 
induced,  whilst  in  guinea  pigs  and  dogs  the  micro- 
organism scarcely  reacted  at  all  to  the  pure  cul- 
tures. This  streptococcus  found  by  Dr.  Bonome 
differs  from  the  pneumococcus  and  meningococcus 
again  in  the  ball-shaped  appearance  of  the  col- 
onies on  agar-agar  plate  cultivations,  in  its  in- 
ability to  grow  on  blood  serum,  and  in  the  diffi- 
culty which  is  experienced  in  carrying  the  cul- 
tures through  five  or  six  generations.  Also  it 
fails  to  produce  true  septicaemia  in  white  mice; 
and  when  rabbits  are  inoculated,  the  micrococci 
obtained  from  the  blood  are  arranged  in  chains 
surrounded  by  a  capsule,  and  the  same  forms  are 
obtained  from  the  gelatinous  transudation  met 
with  in  mice,  guinea  pigs,  and  dogs  which  have 
been  artificially  infected  with  the  disease.  The 
streptococcus,  again,  is  distinguished  from  the 
streptococcus  of  erysipelas  by  its  action  on  ani- 
mals and  by  its  failure  to  grow  on  gelatine  and 
blood- serum,  and  also  by  the  appearance  of  the 
colonies  on  agar-agar  plates.  In  contrast  with 
other  microorganisms  which  are  morphological 
analogues  many  differences  can  be  made  out. 
Thus,  it  differs  from  the  streptococcus  pyogenes 
and  from  the  septic  streptococcus  found  in  earth 
by  Nicolaier  and  Guarnieri;  also  it  can  be 
clearly  distinguished  from  the  streptococcus  found 
by  Loeffler  in  cases  of  diphtheria,  and  from  the 
organism  found  by  Weichselbaum  in  some  cases 
of  pneumonia.  After  careful  consideration  of  all 
the  points  in  connection  with  this  epidemic  at 
Padua,  and  the  results  of  his  bacteriological  ex- 
aminations, Dr.  Bonome  claims  that  he  has  sub- 
stantiated the  existence  of  the  microbe  of  epidemic 
cerebro-spinal  meningitis. — Lancet. 

Pathogenesis  of  Tetanus. —  Faber  {Ber- 
liner Klin.  Wbchensckr.')  has  separated  by  filtra- 
tion, from  pure  cultures  of  virulent  tetanus  bacilli, 
a  substance  that  is  wholly  free  from  germs,  and 
yet  when  it  is  injected  into  animals,  either  in  the 
cellular  tissue  or  blood,  it  produces  the  clinical 
picture  of  tetanus.  There  seems  to  be  a  certain 
latent  period,  before  the  production  of  the  symp- 
toms, that  varies  with  the  virulence  of  the  culture 
fl  0111  which  the  extract  is  prepared.  When  injected 
into  the  blood  it  produces  general  convulsions, 
when  into  the  cellular  tissue  these  are  associated 
with  local  convulsions.  No  specific  immunity 
could  be  determined  as  a  result  of  the  injections. 


i89i.] 


EDITORIAL. 


309 


Journal  of  the  American  Medical  Association 

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Address 

Journal  of  the  American  Medical  Association, 
No.  68  Wabash  Ave., 

Chicago,  Illinois. 
All  members  of  the  Association  shou       send  their  Annual  Dues 
>to  the  Treasurer,  Richard  J.  Dunglison,  M.D.,  Lock  Box  1274,  Phila- 
delphia, Pa. 


London  Office,  57  and  59  Ludgate  Hill. 


SATURDAY,  FEBRUARY  2S,   1891. 


SECTION  MEETINGS  OF  THE  ASSOCIATION. 
The  real  success  of  the  Association  meeting  de- 
pends mainly  upon  the  work  done  in  the  Sections. 
The  general  addresses  van-  widely,  and  although 
they  often  present  very  excellent  discussions  and 
resumes  of  our  present  knowledge,  still  they  are 
not  presumed  to  reflect  the  best  scientific  work, 
but  to  deal  in  a  general  and  popular  way  with 
medical  interests  generally.  The  officers  of  the 
Sections  are,  after  all,  more  influential  in  direct- 
ing medical  progress.  They  should  not  leave  the 
topics  altogether  to  the  chance  of  volunteers  to 
prepare  and  read  papers;  nor  after  inviting  and 
receiving  a  dozen  or  more  papers  on  wideh  differ- 
ing topics,  and  finding  it  impossible  to  group 
them  in  any  natural  order,  should  they  proceed 
to  serve  them  up  on  the  time  plan  in  the  order  of 
their  reception.  The  officers  of  each  Section 
should  select  one  or  more  general  topics  that  have 
a  broad  interest  to  the  whole  profession,  then  in- 
vite several  leading  men  to  discuss  the  different 
phases  of  the  subject.  After  this  voluntary  pa- 
pers may  be  admitted.  In  this  way  the  listener 
could  get  some  general  idea  of  the  views  of  the 
best  authorities,  in  some  of  the  different  fields  of 
medicine. 

More  important  still  is  the  method  of  present- 
ing papers.  Each  reader  should  remember  that 
his  listener  is  a  practical  man,  who  comes  for  a 
practical  purpose  of  enlarging  his  knowledge  of 
science;  also  that  his  medical  position  or  reputation 
is  of  little  moment  to  the  hearer.  The  hearer,  like  the 
Athenian  of  old,  comes  to  hear  something  new; 


or  to  compare  his  knowledge  with  others.  First 
of  all  the  writer  of  a  paper  should  be  convinced 
that  he  has  some  new  fact  to  communicate;  some 
new  view  of  the  etiology,  pathology  or  therapeu- 
tics of  some  disease;  or  some  new  effect  of  a  med- 
cine;  or  some  fact  that  has  not  been  mentioned  be- 
fore. Then  state  this  fact  in  the  briefest  way  possible. 
If  it  be  relating  to  pneumonia,  he  reflects  on  the 
intelligence  of  his  audience  by  giving  the  history 
and  pathology  of  this  disease,  and  the  many 
views  of  different  authors,  when  he  merely  wants 
to  call  attention  to  a  new  remedy  and  method  of 
cure.  If  he  has  made  a  discovery  in  the  pathol- 
ogy of  diphtheria,  the  history  and  views  of  others 
of  the  pathology  is  an  assumption  that  his  audi- 
ence are  first-course  students  in  medicine,  and  can 
not  appreciate  his  views  unless  the  entire  history 
is  given.  If  it  is  on  a  surgical  subject,  or  any 
other  branch  of  the  practice,  it  is  always  in  bad 
taste  to  go  over  in  detail  general  principles  as 
laid  down  in  any  text-book.  It  is  also  very  sus- 
picious for  any  writer  to  load  down  his  topic  with 
references  to  foreign  authorities,  which  the  aver- 
age reader  can  not  verify,  or  even  to  quote  largely 
from  home  writers,  and  close  up  with  a  ponder- 
ous list  of  references.  If  he  is  writing  a  book  or 
prize  essay,  it  may  not  be  noticeable,  but  for  a 
paper  to  be  read  at  the  Association  meeting,  it 
should  not  be.  All  the  listener  wants  are  the 
writer's  conclusions  and  the  facts  upon  which  they 
are  based.  He  will  listen  cheerfully  to  a  full 
elucidation  of  these,  but  turn  away  wearied  when 
the  writer  falls  back  to  describe  well  known  facts. 
A  paper  for  the  Association  should  only  be  ex- 
haustive along  some  new  unknown  range  of  study, 
and  even  then  the  writer  will  be  praised  for  giv- 
ing his  conclusions,  and  refer  the  listener  to  a 
printed  copy  when  it  appears  in  the  Association 
Journal.  The  Journal,  in  not  a  few  instances, 
has  suffered  from  the  space  given  to  long  papers, 
which  were  but  a  mere  repetition  of  what  could  be 
found  in  every  text-book.  These  papers  were 
read  before  some  Section,  and  their  publication 
was  inevitable.  The  writers  were  merely  pub- 
lishing their  own  weakness,  and  The  Journal 
can  not  be  made  responsible.  The  elevation  of 
the  tone  and  character  of  The  Journal  will 
largely  depend  on  the  writers  and  readers  of  pa- 
pers at  the  Association  meetings.  Editors  ma}' 
write  well,  and  make  selections  of  the  best  current 
literature,  but  if  the  best  half  of  The  Journal  is 


3io 


DIET  IN  BRIGHT'S  DISEASE. 


[  February  28, 


filled  with  heavy  padded,  pedantic  and  text-book 
papers,  their  efforts  are  sadly  neutralized. 

Is  it  not  true  that  journalistic  literature  is  un- 
fortunately loaded  down,  in  all  sections  of  the 
country,  with  papers  made  up  from  text-books, 
that  suggest  nothing,  or  teach  nothing,  that  has 
not  been  known  before?  The  Journal  has  the 
same  experience  as  others,  but,  unlike  them,  it 
can  address  its  writers  in  advance.  At  the  com- 
ing meeting  at  Washington  over  a  hundred  pa- 
pers will  be  presented  and  read.  Each  writer  will 
always  represent  himself  more  than  the  topic  he 
discusses.  If  he  has  anything  new  to  communi- 
cate, it  will  not  be  lost  in  faults  of  presentation, 
or  of  style  of  writing.  If  he  has  nothing  new, 
all  the  elegant  flow  of  words,  and  learned  refer- 
ences to  vast  libraries  can  never  give  it  life  or 
vitality.  Each  writer  should  remember  that  he 
can  not  in  any  single  paper  of  any  reasonable 
length  exhaust  his  topic,  or  even  convey  a  com- 
plete general  impression  of  the  entire  subject. 
This  is  very  evident  in  the  attempts  of  really  ex- 
pert men  to  give  reports  of  the  progress  of  science 
in  any  one  department,  which  is  always  imperfect, 
and  becomes  more  so  every  year,  for  the  reason 
that  the  progress  of  medicine  is  so  rapid  and  ex- 
pansive that  no  one  man  can  present  any  com- 
plete picture  of  even  one  department.  Each 
writer  should  remember  that  his  personal  views 
and  opinions  are  only  valuable  when  they  are 
sustained  by  real  or  assumed  facts,  which  his 
audience  would  like  to  hear,  so  as  to  form  an  opin- 
ion for  themselves. 

The  facts  of  medicine  are  like  those  of  astron- 
omy, always  open  to  a  marked  personal  equation 
which  is  a  source  of  error  that  needs  constant  cor- 
rection. A  writer  may  be  very  positive  in  his 
conclusions,  but  a  study  and  comparison  by 
others  of  the  same  topic  fail  to  sustain  him; 
hence  it  is  dangerous  to  urge  the  completeness 
and  accuracy  of  any  facts  beyond  all  others.  Each 
writer  should  never  forget  that  the  Association 
and  its  meeting  represents  the  science  of  medi- 
cine in  this  country.  Papers  which  have  been 
praised  in  his  local  society  come  before  a  different 
audience  in  the  Section  meetings.  Nothing  can 
be  greater  injustice  personally  and  to  the  Society 
than  careless,  confused  egotistical  papers. 

The  Journal  particularly  urges  all  writers 
who  are  to  take  part  in  tin.'  coming  meeting  to 
present  their  best  work,  in  the  best  manner.       It 


would  also  urge  the  officers  of  each  Section  to 
discriminate  and  arrange  papers  that  are  offered, 
and  advise  writers  frankly  as  to  the  merits  of 
their  papers.  Brevity  and  condensation  are  the 
practical  needs  of  the  medical  public.  While  the 
general  character  of  the  papers  read  at  the  Asso- 
ciation meetings  have  been  steadily  improving, 
the  demand  each  year  is  for  broader  more  thor- 
ough scientific  discussions.  The  theories  and 
conclusions  of  last  year  can  not  always  be  trusted 
to-day.  The  progress  of  medical  science  is  rapid 
and  intense,  and  the  aspect  of  many  supposed 
facts  have  changed  materially.  A  repetition  of 
last  year's  papers,  unless  fortified  by  some  new 
evidence  and  new  views,  are  open  to  grave  criti- 
cisms. Extraordinary  results  from  the  applica- 
tion of  remedies  or  methods  of  treatment  bring 
the  writer  into  a  centre  of  suspicious  criticism. 
All  such  papers  need  to  be  grouped  with  great 
care  and  exactness. 

Finally,  The  Journal,  upon  whom  much  of 
the  criticism  falls  for  bringing  to  light  the  varied 
papers  which  are  read  before  the  Association, 
would  remind  all  the  coming  writers,  that  the 
more  accurately  and  scientifically  they  present 
their  papers,  the  greater  the  success  of  the  meet- 
ing. An  ideal  journal  can  only  be  made  by  em- 
bodying the  high  scientific  ideals  of  the  writers 
in  its  pages. 

The  most  practical  fields  of  work  are  observing, 
grouping  and  comparing  real  and  supposed  facts,, 
not  to  discover  their  full  meaning,  but  their  pos- 
sible practical  relation.  This  is  the  spirit  and. 
purpose  of  the  Association,  and  the  responsibil- 
ity and  scientific  success  of  the  coming  meeting 
will  turn  on  the  recognition  of  this  fact. 

The  members  of  the  Association  look  to  the 
officers  of  the  Sections  and  the  writers  to  make 
the  coming  meeting  superior  to  all  others.  This 
will  be  merely  along  the  line  of  all  science  in 
evolutionary  growth. 


DIET  IN  BRIGHT'S  DISEASE. 
L,i:riNK,  in  a  paper  before  the  International 
Medical  Congress,  on  "The  Treatment  of  Blight's 
Disease,"  maintained  that  the  chief  indication 
was  the  prevention  of  uraemia.  With  this  end 
in  view  he  laid  special  stress  upon  the  importance 
of  lessening  nitrogenous  food  to  a  point  where 
tissue  waste  would  be  just  balanced,  which  he 
placed  at  about  80  grams  of  albumen  daily  for 


i89i.] 


HYDROCYANIC  ACID. 


3ii 


the  average  adult.  In  practice  lie  thinks  the 
best  results  will  be  achieved  by  a  milk  diet,  to 
which  a  certain  proportion  of  carbo-hydrates  are 
added,  as  the  nitrogenized  constituents  are  pres- 
ent in  too  great  relative  proportion  in  milk. 

If  we  adopt  the  view  that  "  uraemia  "  is  de- 
pendent upon  an  excess  of  urea  in  the  blood 
(Willis),  or  of  carbonate  of  ammonia  (Frh- 
richs),  or  of  creatin  and  creatinine  (Orn.ER, 
PERLS  and  Zalesky),  it  is  at  once  apparent  that 
a  lessening  of  the  proteids  of  the  diet  would  de- 
crease the  amount  of  these  nitrogen-containing 
su1 (stances,  in  the  blond. 

Unfortunately,  the  process  is  not  quite  as  sim- 
ple as  these  views  would  lead  us  to  think.  In 
Bright's  disease  there  are  profound  changes  in  the 
blood,  and  one  writer,  Rees,  asserts  that  the 
symptoms  of  uraemia  are  caused  by  tenuity  of  the 
blood  and  increased  vascular  pressure.  If  this  is 
true,  it  is  possible  that  a  marked  lessening  in  the 
proteids  of  the  diet  might  aggravate  the  very  con- 
dition it  was  intended  to  relieve. 

Unquestionably  a  proper  regulation  of  the  diet, 
so  as  to  include  only  a  due  proportion  of  nitroge- 
nous food,  is  of  the  utmost  importance,  particu- 
larly in  the  early  stage  of  Bright's  disease,  and 
nephritis  generally.  In  this  stage  the  kidney 
should  be  placed  physiologically  at  rest  as  far  as 
possible.  Whether  in  the  later  stages,  when 
uraemic  S5rmptoms  may  be  looked  for,  and  marked 
•changes  in  the  blood  and  vascular  pressure  are 
present,  much  is  to  be  hoped  for  from  a  mere  les- 
sening of  nitrogenous  food,  is  still  a  matter  of 
grave  doubt,  and  in  the  light  of  the  very  uncer- 
tain pathology  of  uraemia,  perhaps  hardly  justi- 
fiable. 


DIGITAL  SYPHILIS  OF  MEDICAL 
PRACTITIONERS. 
A  correspondent  in  the  Southern  Medical  Rec- 
ord, January,  quotes  Dr.  Fessenden  N.  Otis, 
of  New  York,  in  regard  to  the  occurrence  of  an 
intractable  sore  on  the  finger  of  a  surgeon  or  ac- 
coucheur due  to  syphilis.  Whenever  a  sluggish 
lesion  in  this  situation  presents  itself,  he  always 
suspects  specific  infection,  and  narrates  a  case  il- 
lustrative of  some  of  the  difficulties  that  surround 
a  conclusive  diagnosis.  About  two  years  ago,  he 
chanced  to  be  at  Lakewood,  where  he  saw  a  gen- 
tleman going  about  with  his  fingers  wrapped  up 
in  a  handkerchief.     The  latter  gentleman  was  a 


surgeon  of  large  practice  in  a  Western  city,  and 
having  been  introduced  to  Dr.  Otis,  showed  him 
a  finger  that  had  been  troublesome  for  some 
months,  dating  back  to  the  time  of  a  certain  sur- 
gical operation,  in  the  course  of  which  his  finger 
had  been  cut  with  the  knife.  The  operation  was 
an  ordinary  hare  lip  operation,  on  a  young  Ger- 
man girl,  for  removal  of  a  lesion  that  was  regard- 
ed as  cancer  of  the  lip.  A  sore  soon  after  made 
its  appearance  about  the  nail,  and  became  trouble- 
some. Recognizing  the  possibility  of  causal  re- 
lations between  this  sore  and  the  lip  lesion  of  the 
German  girl,  the  finger  was  laid  open  down  to 
the  bone  and  scraped,  dressed  antisepticallv  and 
put  in  a  plaster  bandage.  He  had  at  the  time  a 
suspicious  eruption,  and  some  of  the  glands  were 
enlarged,  but  not  the  epi trochlear.  He  was  put 
on  mixed  treatment,  and  as  he  was  quite  unable 
to  do  any  professional  work,  was  advised  to  go 
abroad.  He  went  to  England,  and  while  there 
consulted  Sir  Henry  Thompson.  The  latter 
examined  the  patient,  and  his  finger  and  erup- 
tion, carefully,  and  denied  "the  existence  of  syph- 
ilis in  the  case;  he  advised  him  to  throw  away 
his  medicines  and  go  home.  He  returned  to  this 
country  and  related  the  circumstances  of  his  visit 
to  the  London  surgeon  to  Dr.  Otis,  who  strongly 
recommended  him  to  hunt  up  the  German  girl 
upon  whom  he  had  operated.  He  did  so,  and 
subsequently  reported  that  she  had  developed  un- 
mistakable symptoms  of  secondary  syphilis. 

At  the  Hunterian  Society,  recently,  Mk.  C.  J. 
Symonds  stated  that  he  had  known  of  as  many 
as  five  medical  men  with  genuine  Hunterian 
chancre  of  the  finger,  acquired  in  obstetric  prac- 
tice. He  has  known  amputation  of  the  affected 
finger  to  be  performed  where  the  joint  was  much 
endangered;  but  he  had  not  yet  found  this  measure 
needful.  If  the  sore  be  thoroughly  scraped  and 
cauterized  with  acid  nitrate  of  mercury,  the  bone 
and  the  joint  will  most  likely  be  saved. 


HYDROCYANIC  ACID  ANTIDOTAL  TO 
TUBERCULOSIS. 
SchroTTER,  of  the  University  of  Vienna,  has 
announced  to  his  colleagues  of  the  Society  of 
Physicians  that  he  has  made  a  partial  investiga- 
tion regarding  the  alleged  discovery  of  the  im- 
munity of  a  certain  class  of  artisans  in  Austria 
against  tuberculosis,  and  he  has  come  to  the 
conclusion  that  that  disease  is  very  rare  in  those 


312 


EDITORIAL  NOTES. 


[February  28, 


workshops  where  the  eyan-metals,  as  they  are 
called,  cyan-gold  and  cyan-silver,  are  employed. 
He  holds  that  the  hydrocyanic  acid  is  the  effi- 
cient element  in  these  chemicals,  and  that  he  has 
data  sufficient  to  warrant  the  systematic  trial  of 
that  agent  as  a  bactericide  in  tuberculosis.  In- 
cidentally, it  may  be  remarked  that  he  has  found 
that  not  only  is  it  a  very  rare  occurrence,  among 
the  workmen  of  the  class  referred  to,  for  pulmo- 
nary disease  to  attack  one  of  them,  but  also  it  is 
often  remarked  that  those  who  come  from  other 
places  and  other  works  with  incipient  troubles 
have  been  benefited,  and  some  of  them  have  been 
entirely  cured,  at  least  so  far  as  the  testimony  of 
the  workmen  themselves  went. 

There  are  several  large  factories  in  Southern 
Austria  where  fine  metallic  wares  are  made,  and 
in  the  finishing  of  them  the  cyan-metals  dissolved 
in  the  cyanide  of  potassium  are  required  to  be 
used  in  order  to  galvanize  them  in  silver  or  gold, 
and  the  atmosphere  of  these  factories  is  more  or 
less  heavily  charged  with  the  complex  vapors 
given  off  from  the  vats  and  chambers ;  the  as- 
sumption being  made,  however,  that  the  poten- 
tial chemical  is  the  acid,  and  not  the  precious 
metals  that  are  combined  with  it. 


editorial  notes. 
The  Medical  Society  of  the  State  of 
TENNESSEE. — The  annual  meeting  of  this  State 
organization  will  convene  at  Nashville  on  April 
14,  and  will  be  in  session  for  three  days.  The 
officers  of  the  Society  have  made  ample  provi- 
sions for  a  most  successful  meeting.  They  advise 
us  that  an  unusually  full  list  of  valuable  papers 
is  promised  by  men  who  will  not  fail  to  sustain 
their  well  established  reputations  both  as  writers 
and  speakers.  The  home  of  the  President  of  our 
Association  will  not  only  honor  its  State  by  this 
meeting  of  its  representative  men,  but  we  look  to 
Tennessee  for  a  strong  reinforcement  to  the  ranks 
of  the  American  Medical  Association  at  its  next 
annual  meeting. 

Centrax-Zeitung  fur  das  Koch'sche  Heil- 
\  i.Ki  ahren  is  the  title  of  a  new  journal  devoted 
especially  to  progress  in  the  treatment  of  tuber- 
culosis and  other  infectious  diseases.  It  appears 
on  the  first  and  sixteenth  of  each  month.  The 
current  issue,  No.  3,  contains  the  article  of  Prof. 
Virchow  on  the  changes  produced  in  internal  or- 


gans by  injections  of  Koch's  lymph,  a  continued 
article  from  the  pen  of  Dr.  Kammerer  on  the  ex- 
perience with  the  same  remedy  in  Vienna,  also 
von  Gossler's  regulations  to  prevent  the  spread  of 
tuberculosis.  In  addition  there  is  a  resume  of 
other  publications.  It  cannot  be  said  of  modern 
science,  especially  the  German,  that  its  light  is 
under  a  bushel.  The  establishment  of  a  new 
journal  to  exploit  a  discovery  only  a  few  weeks- 
old,  argues  most  praiseworthy  activity. 

Correction. — The  annual  meeting  of  the  Med- 
ical Society  of  the  Missouri  Valley  will  convene 
at  Omaha,  Neb.,  March  19  instead  of  March  17, 
as  previously  announced  in  The  Journal. 

A  Healthful  Subtropical  Climate. — The 
English  journals  evince  a  feeling  of  exultation  in 
speaking  of  the  comparatively  salubrious  sections 
of  the  British  sphere  of  influence,  in  east  Central 
Africa,  some  parts  of  which  lie  directly  under 
the  equator.  In  contrast  with  some  more  south- 
erly points  occupied  bj'  the  Germans,  this  English 
territory,  even  on  the  coast  line,  has  a  climate 
that  is  both  more  endurable  to  white  colonists 
and  more  healthful.  Even  in  the  hot  season  they 
claim  that  it  is  cooler  than  it  is  five  degrees  far- 
ther south. 

Harper  Hospital,  Detroit. — Dr.  Heneage 
Gibbes,  Professor  of  Pathology  at  the  University 
of  Michigan,  has  been  appointed  consulting  pa- 
thologist to  the  Harper  Hospital,  Detroit.  This 
appointment  will  enable  Dr.  Gibbes  to  cooperate 
freely  with  his  colleague,  Dr.  Shurly,  in  their 
joint  researches  concerning  the  nature  and  treat- 
ment of  pulmonary  tuberculosis,  which  are  about 
to  be  carried  out  on  a  larger  scale  than  heretofore. 

Accident  to  von  Bergmann. — An  injury 
sustained  by  Professor  von  Bergmann  in  the 
course  of  professional  duty,  has  compelled  him 
to  take  a  temporary  leave  of  absence  from  all  of- 
ficial work.  The  wound  involved  one  of  the  fin- 
gers of  the  right  hand,  and  at  first  was  not  con- 
sidered to  be  serious,  but  it  has  rendered  repeated 
slight  operations  necessary.  The  professor  has 
been  and  is  still  confined  to  his  room,  and  will 
probably  have  to  carry  his  hand  in  a  sling  for 
some  time  to  come. 

PATIENTS  undergoing  the  "lymph"  treatment 
at  Chicago  Presbyterian  Hospital  showr  no  very 
decided  improvement  up  to  the  present  time. 


i8oi.] 


MEDICAL  ITEMS. 


3i3 


.MEDICAL  ITEMS. 

Accident  to  Prof.  Berg.mann. — It  is  said 
that  Prof.  Bergmann  has  had  the  second  finger  of 
his  right  hand  amputated  on  account  of  threat- 
ened blood  poisoning  from  an  operation  on  a 
lupus  patient  who  was  undergoing  the  Koch 
treatment. 

The  Minnesota  Practice  Act. — The  opera- 
tion of  the  Minnesota  Medical  Practice  Act  has 
reduced  the  ratio  of  physicians,  from  one  to  six 
hundred  and  fifty,  to  one  in  twelve  hundred  and 
fifty.  During  the  past  three  years  two  hundred 
and  five  candidates  presented  themselves  for  ex- 
amination, seventy-seven  of  whom  were  rejected. 

The  Tricks  of  New  Orleans  Milkmen. — 
It  is  said  to  be  a  common  practice  in  New  Or- 
leans for  milkmen  to  renew  the  creamy  appear- 
ance of  skimmed  and  watered  milk  by  the  addi- 
tion of  condensed  milk  from  cans.  If  such  is  the 
case  its  importance  at  once  demands  the  atten- 
tion of  the  health  authorities,  or  else  all  New 
Orleans  infants  should  be  denied  the  preparation. 

Unique  Irish  Decision. — The  Boston  Med- 
ical and  Surgical  Journal  repeats  from  foreign 
sources  as  a  true  story,  a  remarkable  verdict 
rendered  two  or  three  weeks  ago  in  Ireland,  grow- 
ing out  of  the  railroad  calamity  that  took  place 
near  Armagh.  The  plaintiff,  a  woman  who  had 
been  injured,  sued  first  for  damages  to  herself — 
she  had  been  bruised  and  shaken  and  caused  to 
come  to  premature  childbirth,  with  much  risk, 
anxiety  and  suffering — and  the  jury  gave  her 
/'800.  Next  she  sued  on  behalf  of  her  baby, 
which  has  been  from  the  time  of  premature  de- 
livery puny  and  deformed,  and  not  expected  long 
to  survive.  The  jury  awarded  the  infant  nothing, 
for  the  reasons  that  the  company  never  sold  a 
fare  to  include  that  baby,  and  in  fact  the  company 
had  no  knowledge  that  the  baby  was  on  the  train. 
Therefore  according  to  law  no  responsibility  at- 
tached to  the  company  in  respect  of  that  sur- 
reptitious passenger. 

The  American  Electro-Therapeutic  As- 
sociation, was  organized  on  the  22d  of  January, 
1891,  at  the  Academy  of  Medicine,  No.  17  West 
43d  St.,  New  York,  by  the  adoption  of  a  Consti- 
tution and  By-Laws,  and  the  election  of  the 
following  officers  :  President,  G.  Betton  Massey, 
M.D.,  Philadelphia;  Vice-Presidents,  William 
James  Morton,  M.D.,  and  Augustin  H.  Goelet, 


M.D.,  New.  York  ;  Secretary.  William  H. 
Walling,  M.D.,  Philadelphia  ;  Treasurer,  Geo. 
H.  Rohe,  M.D.,  Baltimore. 

Executive  Council. — Horatio  R.  Bigelow,  M.D., 
Philadelphia;  Franklin  H.  Martin,  M.D.,  Chi- 
cago ;  W.  F.  Hutchinson,  M.D.,  Providence,  R. 
I.;  Frederic  Peterson,  M.D  ,  New  York  ;  and 
Chauncey  D.  Palmer,  M.D.,  Cincinnati,  O. 

The  object  of  the  Association,  as  stated  in 
Article  Second  of  the  Constitution  is,  "The 
cultivation  and  promotion  of  knowledge  in  what- 
ever relates  to  the  application  of  electricity  in 
medicine  and  surgery."  The  Association  starts 
with  a  strong  and  vigorous  membership,  and  has 
every  prospect  of  a  most  useful  and  successful 
career.  The  next  meeting  will  be  held  in  Phila- 
delphia, in  September,  of  this  year.  Wm.  H. 
Walling,  M.D.,  Secretary,  2005  Arch  St.,  Phila- 
delphia, Pa. 

Chloral  Hydrate  in  Epileptiform  Con- 
vulsions.— An  Irish  physician,  Dr.  W.  Ashley 
Cummins,  reports  a  'case  of  almost  continuous 
epileptiform  convulsions  opposing  alike  the  in- 
fluence of  nitrite  of  amyl,  hyoscyamine,  potas- 
sium bromide,  chloroform,  nitro-glycerine  and 
bichloride  of  soda,  but  which  finally  succumbed 
to  enemata  of  chloral  hydrate,  gr.  xxx,  every 
three  hours. 

Dr.  N.  H.  Kimball,  a  physician  well  known 
in  Southern  Michigan,  died  at  his  home  at 
Adrian.  Mich.,  recently. 

The  Art  of  Catching  Cold.— The  Provin- 
cial Medical  Journal  has  an  article  in  a  late  issue 
entitled:  "The  Art  of  Catching  Cold  ;  by  a  Pro- 
fessional Failure."  Truly  such  a  heading  should 
not  fail  of  attracting  a  generous  number  of  readers. 

The  Koch  Treatment.  —  General  medical 
literature  (periodical)  still  teems  with  papers, 
lectures,  and  reports  of  the  Koch  treatment  ;  al- 
though it  is  believed  that  the  first  enthusiasm  is 
subsiding  to  a  more  conservative  estimation  of 
the  cases  receiving  attention  in  the  home  hospi 
tals.  The  true  merits  and  proper  application  of 
Prof.  Koch's  discovery,  are  yet  to  be  determined. 

The  Time  to  Record  Daily  Temperature. 
— Prof.  Da  Costa  considers  that  in  important 
cases  the  daily  temperature  should  be  recorded 
close  to  the  hours  of  7  a.m.  and  7  p.m.  Where 
only  one  observation  can  be  taken,  it  should  come 
near  the  evening  hour. 


3H 


TOPICS  OF  THE  WEEK. 


[February  28, 


TOPICS  OF  THE  WEEK. 


THE  MORPHOLOGY.  CULTIVATION  AND   TOXIC  PRODUCTS 
OF  THE  TUBERCLE  BACILLUS. 

At  the  meeting  of  the  Pathological  Society  of  London, 
held  February  3,  1S91,  Dr.  Edgar  M.  Crookshauk  pre- 
sented^ paper]of  remarkable  value  upon  the  above  sub- 
jects. He  gave  a  series  of  demonstrations  of  the  mor- 
phological varieties  of  the  tubercle  bacilli,  comparing 
those  in  the  tuberculosis  of  various  animals,  such  as  the 
horse,  pig  and  cat;  and  of  birds,  such  as  the  fowl,  guinea 
fowl,  pheasant  and  ostrich.  It  is  found  that  in  these, 
minute  morphological  differences  can  be  discerned, 
showing  that,  within  certain  limits,  the  morphology  of 
the  bacillus  varies  with  its  environments,  and  that  certain 
modifications  are  dependent  upon  methods  of  culture. 
He  enters  quite  full}-  into  a  description  of  his  methods, 
and  then  deals  at  length  with  the  toxic  products,  giving 
in  particular  the  results  of  his  own  investigations. 

The  Loudon  Lancet,  commenting  upon  the  paper  of 
Dr.  Crookshank,  gives  a  brief  outline  of  the  conclusions 
to  be  derived  therefrom,  and  from  the  discussions  which 
followed  its  presentation,  in  the  following  words: 

It  is  evident  that,  although  chemists,  bacteriologists, 
and  pathologists  are  working  to  a  common  end,  each 
emphasizes  somewhat  different  points.  On  the  one  hand, 
we  have  the  bacteriologists  taking  up  rather  the  botan- 
ical aspect,  cultivating  the  tubercle  bacillus  in  different 
media,  and  retarding  or  increasing  the  rate  of  growth 
and  development  by  the  addition  of  certain  substances. 
They,  in  fact,  study  the  organism  as  a  saprophyte,  and 
are  contributing  most  remarkable  facts  to  our  knowledge 
of  the  history  of  the  organism  outside  the  bodjr.  When, 
however,  on  the  other  hand,  the  chemist  comes  to  con- 
sider the  action  of  the  organism  as  a  parasite,  the  facts 
obtained  by  the  botanist  are  for  the  moment  of  compara- 
tively little  value,  as  Dr.  Sidney  Martin  indicated.  All  the 
knowledge  that  has  yet  been  obtained  in  connection 
with  the  action  of  the  organism  on  the  animal  economy 
points  to  the  fact  that  they  do  not  act  any  in  way  except 
through  their  poisonous  products.  These  products  are 
derived  entirely  from  the  breaking  down  of  albuminoid 
substances.  It  may  be,  of  course,  that  some  of  them  are 
(inly  one  or  two  removes  from  the  higher  albumens: 
whilst  others  may  be  looked  upon  as  the  later  products 
of  the  decomposition  of  this  same  material  by  special  or- 
ganisms. It  is  evident  therefore  that  the  specific  toxic 
of  a  parasitic  organism  can  only  be  brought 
into  full  play  when  it  is  placed  in  a  medium  th.ii  con 
tains  sufficient  albuminoid  material  on  which  the  organ- 
ism may  act  to  produce  the  specific  material.  Of  course, 
it  may  be  objected  to  Dr.  Martin's  statement  tli.it  alkali 
albumen  1  to  which  lte  would  add  the  special  salts  required 

bly  one  of  the  best  nutrient  media  for  thi 
of  the  tubercle  bacillus  in  all  its  strength,  and  that  alkali 
albumen  does  not  occur  as  such  in  the  body,  jus 

.  but  to  this  may  be  answered  that,  although 
fibrin  docs  not  occur  as  such,  tin-  constant  elements  of 
which  it  is  composed  are  undoubtedly  present,  and  that 
the  organism  has  therefore  only  a  little  more  or  a  little 
less  u  1  1  >btain  the  same  results. 


To  the  physician,  however,  who  has  to  deal  with  dis. 
ease  in  both  its  etiological  and  pathological  aspects, 
something  more  than  either  the  chemist  or  the  bacteri- 
ologist tells  him  is  necessary.  He  has  not  only  to  study 
the  conditions  under  which  the  organism  is  developed 
outside  the  body,  the  method  of  invasion  of  the  tissues 
by  the  tubercle  bacillus,  the  local  changes  to  which  it 
gives  rise,  and  the  general  or  constitutional  symptoms 
that  result,  but  he  has  also,  if  possible,  to  trace  the 
phylogenetic  relations  of  the  organism  to  see  how  its 
specific  activity  may  be  modified,  and  to  apply  the  re- 
sults of  the  experience  already  gained  to  the  improve- 
ments of  methods  of  treatment,  whether  by  inoculation 
or  by  other  means  ;  in  fact,  nothing  must  escape  his 
notice,  and  no  means  of  increasing  his  knowledge  of  any 
phase  of  the  life  of  the  organisms  that  produce  disease 
can  be  neglected  or  cast  aside  as  unimportant.  The 
tubercle  bacillus  within  the  next  year  or  two  will  receive 
more  attention  than  any  other  of  the  microorganisms. 
It  will  be  studied  by  competent  and  incompetent  ob- 
servers ;  the  most  contradictory  results  will  be  obtained  ; 
we  shall  be  told  that  the  tubercle  bacillus  forms  enzymes, 
albumoses,  tox-albumens  and  ptomaines.  It  will  lie 
argued  that  its  growth  takes  place  most  luxuriantly 
under  certain  conditions,  and  that  certain  other  condi- 
tions are  absolutely  inconsistent  with  any  growth  at  all. 
Let  all  such  very  positive  statemeuts  be  taken  with  re- 
serve, for  it  is  becoming  evident  that  if  care  is  taken  to 
make  a  transition  by  sufficiently  easy  stages,  tubercle 
bacilli,  like  many  other  organisms,  may  be  cultivated 
under  very  different  conditions  as  regards  soil,  tempera- 
ture, etc.,  and  that  consequently  the  resulting  products 
are  equally  varied.  Thanks  to  the  younger  workers  in 
physiological  chemistry  in  this  country,  a  new  school  is 
gradually  being  formed,  and  it  is  evident  that  much  more 
accurate  and  valuable  data  than  we  have  hitherto  pos- 
sessed are  being  gradually  accumulated.  We  may,  in 
fact,  look  forward  to  a  comparatively  new  development 
of  bacteriological  science  as  coming  within  the  range  of 
practical  medicine — a  development  that,  in  its  bearings 
on  medical  practice,  must  have  most  far-reaching  results 


FACTA  XOX  VERBA. 

We  have  received  communications  from  several  quar- 
ters pointing  out  what  is,  indeed,  only  too  app 
that  the  scientific  and  public  interest  in  the  remedy  for 
tuberculosis  introduced  by  Dr.  Koch  is  being  utilized 
pretty  extensively  by  many  who  should  know  better,  for 
purposes  and  by  methods  which  cannot  easily  be  differ- 
entiated from  those  of  public  and  personal  advertise- 
ment. This  is  obviously  true,  both  here  and  abroad. 
Sonic  allowance  must,  of  course,  be  made  for  the  excep- 
tional nature  of  the  circumstances,  and  the  intense  pub- 
lic interest  aroused  all  over  the  world  by  the  pronounce- 
ment of  this  distinguished  observer  of  a  probable  cure 
for  a  disease  which  has  so  lout;  been  an  almost  u 

urge  of  the  human   race,  and  the  far-reaching 
vista  which  this  announcement  opened  up  in  many  direc- 
tions.     It  is  more  than  time,  however,  that  means  should 
1    to  ali. ite  the   proceedings    referred  to,  and  the 
good  sense  of  physicians  throughout  the  world  will  lead 


i89i.] 


TOPICS  OF  THE  WEEK. 


315 


them  to  refer  to  the  ordinary  rules  regulating  conduct  in 
the  discussion  of  remedies  sub  judice,  and  the  avoidance 
of  anything  savoring  of  personal  advertisement.  It  is 
sufficiently  clear  that  much  time  must  elapse,  with  rigor- 
ous observation  during  that  lengthened  period,  before 
conclusions  can  be  safely  drawn  either  as  to  the  sphere 
of  utility  or  the  complicated  perils  of  the  process.  Mean- 
time the  professional  tribunals — the  societies,  lecture- 1 
rooms  and  journals — of  the  profession  are  those  which 
should  be  sought,  rather  than  the  public  verdict  on  a 
subject  on  which  only  the  technically  skilled  and  edu- 
cated can  form  a  judgment.  The  excitement  which  so 
momentous  an  issue  could  not  fail  to  raise  has  led  to 
much  premature  proceeding,  and  until  a  mature  judg- 
ment can  be  attained,  silent  work  will  show  to  advantage 
over  hasty  public  utterance. — British  Medical  Journal. 


PROFESSORS  VIRCHOW  AND  HELMHOLTZ. 

Our  Berlin  correspondent  writes:  Professor  Rudolf 
Virchow's  70th  birthday  will  be  celebrated  with  due  hon- 
ors on  October  13  of  this  year.  Professor  Waldeyer,  Drs. 
\V.  Reiss,  Bartels,  Langerhaus,  Ad.  Meyer,  and  Professor 
B.  Fraenkel  have  issued  a  circular  inviting  friends  and 
admirers  of  the  great  pathological  anatomist  to  subscribe 
to  a  gift  of  honor,  which  is  to  take  the  shape  of  a  golden 
portrait  medal  ^bout  19  centimeters  in  diameter'.  We 
understand  that  a  committee  is  in  course  of  formation  in 
London  under  the  presidency  of  Sir  James  Paget,  to  en- 
able his  English  admirers  to  participate  in  the  compli- 
ment. Professor  R.  von  Helmholtz's  70th  birthday  will 
also  fall  this  year  on  August  30.  and  will,  no  doubt,  be 
celebrated  with  the  honors  so  eminently  his  due.  — 
British  Medical  Journal. 


from  their  parents.  With  regard  to  this,  Boinet  states 
that  certain  lepers  whose  resources  permit  them  to  do  so 
send  their  children  from  the  lazaretto  as  soon  as  they  are 
weaned,  to  prevent  their  contracting  leprosy.  The  lep- 
ers of  Hanoi  doubt  the  contagiousness  of  leprosy,  and 
the  chiefs  of  the  village,  who  are  interested  in  denying  it, 
affirm  that  there  has  not  been  a  single  case  of  contagion. 
Boinet,  however,  in  80  observations  made  by  him,  found 
the  possibility  of  contagion  in  51.  and  in  5  of  these  con- 
tagion appeared  clear.  Boinet  gives  particulars  regard- 
ing cultivations  of  the  bacillus  leprse  on  agar-agar.  If 
his  experiments  are  accurate,  it  would  appear  that  the 
bacillus  leprse  develops  in  stagnant  water  and  in  rivers, 
which  he  thinks  would  explain  the  fact  that  there  are 
seen  at  Tonquin  leprous  foci  along  the  course  of  small 
rivulets. — Lancet. 


A  LEPROUS  VILLAGE. 
M.  Boinet  states  that  leprosy  is  rare  in  the  mountain- 
ous parts  of  Tonquin,  but  frequent  in  the  delta,  and  that 
the  lepers  live  in  villages  situated  in  the  environs  of 
some  large  populous  centres.  The  most  curious  of  these 
is  situated  two  kilometres  from  the  French  concession  of 
Hanoi,  the  inhabitants  numbering  400,  almost  one-half 
of  whom  are  affected  with  leprosy,  the  remainder  being 
composed  of  infirm  persons  and  beggars.  According  to 
the  statements  of  the  chiefs  of  the  village,  leprosy  is 
often  transmitted  hereditarily.  Eighty  to  ninety  per 
cent,  of  the  children  of  lepers  contract  the  disease, 
which  usually  appears  for  the  first  time  about  the  eleventh 
year,  and  rarely  develops  after  the  age  of  40,  exception- 
ally before  the  age  of  three  years.  Boinet  traced  heredity 
only  in  15  out  of  So  observations;  but  he  recogni  ,-es  that 
these  figures  are  not  sufficient,  for  lepers  who  come  from 
the  neighboring  villages  do  not  readily  acknowledge  he- 
redity, and  reliable  information  is  impossible.  Anses- 
thetic  leprosy  is  more  often  hereditary  than  tubercular 
leprosy.  Boinet  concludes  that  heredity  is  of  slight  im- 
portance in  the  development  of  leprosy,  many  cases 
called  hereditary  being  only  examples  of  "heredo- 
contagion  "  or  simple  contagion,  the  proof  of  which  lies 
in  the  late  development  of  leprosy  in  the  children  of  lep- 
ers and  in  their  relative  immunitv  when  removed  in  time 


THE  SIEGE  OK  MAYENCE 

The  Archives  of  Military  Medicine  recently  gave  an 
interesting  account  of  the  medical  history  of  this  siege 
in  1793.  The  medical  officer  in  charge  of  the  hospital 
says  :  "On  the  nth  of  April  there  was  a  dreadful  can- 
nonade. Amongst  the  number  brought  us  with  enormous 
womi  is — and  the  number  was  not  inconsiderable  in  less 
than  an  hour,  eight  for  various  amputations  1 — was  a  little 
volunteer  with  great  courage,  although  sufferiug  terribly. 
I  ordered  that  he  should  be  undressed  while  I  went 
round  the  ward  to  glance  at  the  various  operations  which 
the  assistant  surgeons  were  performing.  Returning  to 
him  with  Citizen  Riviere,  who  was  to  perform  the  opera- 
tion, we  perceived  an  enormous  lower  limb,  enormous 
from  the  unusual  amount  of  swelling.  Manipulating  the 
limb,  we  came  across  a  hard  swelling,  which  we  took  to 
be  caused  by  a  grapeshot  ball  lodged  in  the  limb.  Our 
astonishment  was  great  when  we  found  that  an  incision 
of  five  or  six  fingers'  breadth  was  insufficient  to  extract 
this  enormous  foreign  body,  which,  on  being  finally  got 
out.  turned  out  to  be  a  Prussian  ball  weighing  no  less 
than  thirteen  pounds  !  How  could  a  mass  of  this  size 
have  just  the  amount  of  force  necessary  to  lodge  in  a 
thigh  and  not  pass  through  it !  This  problem  I  leave  to 
natural  philosophers,  but  I  admit  it  to  be  almost  neces- 
sary to  have  seen  such  things  to  believe  them.  Of  course 
there  was  nothing  for  it  but  to  operate  on  this  poor 
fellow  or  leave  him  to  certain  death  :  we  therefore  am- 
putated high  up.  When  we  had  finished  he  asked  if  it 
was  done,  and  on  being  told  that  it  was,  he  cried  out 
loudly,  '  Long  live  the  nation  !'  Anassthetics  had  not 
then  seen  the  light,  it  must  be  remembered.  On  an- 
other occasion  the  firing  of  a  mine  caused  a  tremendous 
explosion,  which  shook  the  hospital  building  terribly. 
At  that  moment  I  was  engaged  in  amputating  the  limb  of  a 
soldier.  As  I  was  sawing  the  bone  amidst  the  general 
confusion  caused  by  the  first  shock,  a  second  occurred 
which  brought  down  the  whole  of  a  glass  skylight  over 
the  patient  and  myself.  Xot  knowing  whence  all  the 
glass  came,  I  asked  those  standing  around  what  was  the 
matter.  The  patient  overheard  me,  and  said,  '  Go  on, 
don't  alarm  yourself,  you  will  see  plenty  of  this  kind  of 
thing.'  When  I  had  finished  the  operation  he  cried, 
'Vive  la  Republique  !'  " — Paris  Correspondence.  Lancet. 


3i6 


SOCIETY  PROCEEDINGS. 


[February  28, 


SOCIETY   PROCEEDINGS. 


St.  Louis  Medical  Society. 
Stated  Meeting,  Saturday  Evening,  Feb.  7,  1891. 

The  President,  L.  Bremer,  M.D.,  in  the 

Chair. 

vesicovaginal  fistul.e. 

Dr.  Bond  said:  The  subject  of  vesicovaginal 
fistulse  is  a  subject  that  has  not  lately  received 
much  attention  by  discussion  or  by  the  pen,  and  it  is 
an  affection  which  to  the  sufferer  is  almost  intol- 
erable. The  condition  of  a  woman  with  water 
constantly  escaping  from  the  bladder  through  the 
vagina  occasions  a  degree  of  discomfort  almost 
inexpressible;  considering  the  great  difficulty 
that  in  many  cases  is  encountered  in  relieving 
this  condition,  it  is  important  that  those  gentle- 
men who  attempt  to  operate  for  the  cure  of  vesico- 
vaginal hstulae  should  have  a  clear  appreciation 
of  special  conditions  that  prohibit  or  prevent  the 
best  results. 

During  the  International  Congress  that  met  at 
Washington  City  special  attention  was  directed 
to  the  influence  of  constricting  bands  in  the 
vagina  in  compromising  successful  results,  by  a 
very  elaborate  paper  read  by  Dr.  N.  Bozeman,  of 
New  York  City,  on  this  subject.  In  it  he  em- 
phasized the  necessity  of  dilatation  by  means  of 
sponges  inclosed  in  rubber  bags  and  introduced  into 
the  vagina,  and  also  the  necessity  of  dividing  any 
cicatricial  bands  that  distorted  the  parts  and  pre- 
vented ready  access  to  the  fistula  on  which  he  de- 
sired to  operate;  or  that  might  produce  undue 
tension  upon  the  sutures  after  they  were  placed. 

An  illustration  of  the  value  of  those  instruc- 
tions was  found  in  the  case  of  a  lady  commended 
to  him,  who  for  several  years  had  suffered  from  a 
vesico-vaginal  fistula  resulting  from  a  protracted 
labor.  She  had  already  been  operated  upon,  but 
unsuccessfully.  The  fistula  was  an  inch  and  a 
half  in  length  across  the  vagina,  high  up  in  the 
vagina,  close  to  the  cervix,  and  considerably  re- 
moved from  the  arch  of  the  pubes.  The  finger 
being  introduced  discovered  a  cicatricial  band, 
the  sequel  of  a  posterior  laceration  of  the  cervix. 
In  consequence  of  the  vaginitis,  cellulitis  and 
pelvic  peritonitis  that  occurred  a  firm  union  had 
taken  place  between  the  posterior  portion  of  the 
cervix  and  the  posterior  fornix,  and  by  the  same 
process  the  cervix  was  drawn  high  up  in  the 
vagina,  towards  the  sacrum,  in  which  the  utero- 
sacral  ligaments  were  also  implicated.  It  would 
have  been  utterly  impossible  to  make  a  satisfac- 
tory operation  had  not  the  constricting,  cicatricial 
band  been  first  divided.  On  the  28th  of  Decem- 
ber this  band  was  divided,  the  cervix  thoroughly 
liberated,  and  several  cicatricial  bands  in  the 
lower  portion  of  the  vagina,  that  had  a  tendency 
to  constrict  the  vagina   laterally,  were  divided, 


and  by  that  means  more  space  was  gained.  The 
amount  of  bleeding  was  so  great  that  it  obscured 
the  field  of  operation  and  prevented  the  comple- 
tion of  the  operation  at  the  time;  this  was  post- 
poned only  till  the  bleeding  had  entirely  ceased, 
and  before  the  healing  process  had  been  instituted 
to  any  great  extent,  or  before  a  cicatrix  had 
formed.  Accordingly,  three  days  after  the  pre- 
liminary operation,  the  operation  was  continued, 
the  patient  being  placed  on  her  back.  A  vulsel- 
lum  was  engaged  in  the  anterior  lip  of  the  cervix 
and  the  fistulous  opening  readily  brought  down 
near  the  orifice  of  the  vagina;  in  this  position  of 
the  part  no  trouble  whatever  was  experienced  in 
performing  the  operation — denuding  the  margins 
of  the  fistula  and  passing  the  sutures.  Eight  or 
ten  silk  sutures,  antiseptically  prepared  in  a  2  per 
cent,  solution  of  carbolic  acid,  were  inserted.  The 
patient  was  then  kept  upon  her  back  for  more 
than  twenty  days,  with  a  soft  rubber  catheter 
constantly  in  the  bladder,  but  frequently  changed, 
one  catheter  not  permitted  to  remain  in  the  blad- 
der more  than  four  hours.  Though  the  patient 
was  an  exceedingly  nervous,  sensitive  individual, 
she  yet  bore  the  presence  of  the  catheters  very 
well.  About  a  week  after  the  operation  was  per- 
formed, a  slight  leakage  through  the  vagina  was 
obtained.  The  stitches  were  not  removed,  how- 
ever, until  the  tenth  day,  when  the  union  was 
almost  complete,  so  complete  that  the  point 
through  which  the  water  escaped  could  not  be 
detected;  and  though  assured  that  contraction 
would  continue  and  would  result  in  the  entire 
arrest  of  the  escape  of  water,  prudence  dictated 
the  continuance  of  the  use  of  the  catheters  that 
the  bladder  might  not  be  distended  and  thus  re- 
tard union.  The  result  was  all  that  could  be  de- 
sired, the  woman  recovering  entirely  from  the 
fistula. 

The  secret  of  the  success  of  J.  Marion  Sims, 
one  of  the  pioneers  in  this  department  of  surgery, 
was  attributed  to  the  fact  that  he  used  silver  wire 
sutures.  At  that  time  the  agency  of  sepsis  in 
vitiating  operative  results  was  not  distinctly 
recognized;  nor  was  it  understood  why  success 
seemed  to  follow  the  use  of  silver  wire  sutures, 
while  failures  attended  operations  in  which  the  silk 
or  any  other  form  of  suture  was  employed.  Now 
it  is  well  established  that  when  silk  sutures,  anti- 
septically prepared,  are  used,  the  result  is  just  as 
good  or  1  letter  than  after  the  use  of  silver  wire; 
with  the  additional  advantage  of  being  more 
easily  manipulated. 

The  speaker  stated  he  desired  to  call  especial 
attention  to  the  importance  of  a  thorough  division 
of  the  cicatricial  bands.  In  the  case  under  con- 
sideration it  would  have  been  utterly  impossible 
to  approximate  the  margins  of  the  fistulous  open- 
ing with  security  without  first  dividing  the  cica- 
tricial bands,  because  the  tension  induced  by  the 
operation  would,  of  necessity,  be  thereby  super- 


1891.]  SOCIETY  PROCEEDINGS.  3'7 

added  to  that  already  existing  in  the   anterior  Dr.  Bond:  It  is  a  fact,  sir,  that  to  Dr.  Sims  is 

vaginal  wall.     This  omission  was  unquestionably  due  the  just  credit  for  popularizing  the  operation 

the  reason  of  the  failure  of  the  operation  previ-  for  vesico-vaginal  fistuke.   He  first  operated  upon 

ously  performed,  which  became  apparent  on  the  Negro  women  in  the  South,  and.  after  achieving 

second   day   thereafter,    the  sutures    having  cut  numerous  successes,  he  went  to   New  York  and 

through  the  ti;*sues.  there  taught  the  physicians  his  method  of  curing 

Dr.    A.   H.   Meiskmjach  said  thdt  the  non-  vesicovaginal   fistulse.      He  afterwards  went  to 

union  in  such  cases  as  have  been  referred  to  by  Paris  and  successfully  operated  on   Empress  Eu- 

Dr.  Bond  may  occur  from  the  factors  assigned,  or  genie  after  European  surgeons  had  failed,   and 

it  may  be  due  to  the  fact  that  the  fistula  may  be  thus  acquired  a  world-wide  reputation  in  conse- 

in  such  a  situation  that  it  is  not  readily  accessible  quence  of  his  success. 

through  the  vagina.  The  speaker  said  when  in  As  to  the  position  that  Dr.  Meisenbach  men- 
Baden  he  had  an  opportunity  of  seeing  a  patient  tions  in  regard  to  the  operation  that  he  refers  to, 
upon  whom  Trendelburg  had  operated  for  vesico-  one  insuperable  objection  to  the  method  of  pro- 
vaginal  fistula.  He  placed  the  patient  in  the  cedure  of  Trendelburg  would  be  the  fact  of  the 
position  for  section  of  the  bladder,  the  so  called  impossibility  of  removal  of  the  sutures,  for  these, 
Trendelburg  position,  viz.,  by  elevating  the  hips  if  allowed  to  remain  in  the  bladder,  would  con- 
very  high  and  letting  the  head  hang  down  on  an  stitute  nuclei  for  the  aggregation  of  the  salts  of 
inclined  plane;  by  this  means  the  weight  of  the  the  urine,  and  thus  stones  would  be  generated 
intestines  gravitates  from  the  bladder,  and  thus  unless  the  supra-pubic  opening  was  left  open 
very  materially  enlarges  the  space  bv  reason  of  until  the  sutures  could  with  safety  be  removed, 
the  traction  made  by  the  abdominal  viscera  on  What  is  the  method  of  getting  rid  of  the  sutures  ? 
the  peritoneum.  In  this  position  he  cuts  down  Dr.  Meisenbach  :  The  suggestion  of  leaving 
on  the  bladder  and  has  had  great  success  by  using  the  supra-pubic  opening  until  the  sutures  could 
this  position  in  operations  for  stone.  Having  a  be  removed  would  be  a  procedure  perfectly  feasi- 
patient  suffering  from  vesico-vaginal  fistula,  who  ble.  Only  about  ten  days  are  required  to  secure 
was  in  such  a  state  thas  it  was  impossible  to  a  firm  union  if  the  operation  has  been  successful, 
reach  it  satisfactorily  through  the  vagina,  he  hit  and  as  regards  the  formation  of  calculi,  even 
upon  this  very  novel  position  of  opening  the  blad-  should  they  generate  their  removal  by  modern 
der,  placing  the  sutures  and  reuniting  the  wound  devices  of  surgical  art  is  very  readily  ae- 
on the  vesical  surfaces,  and  then  having  intro-  complished. 
duced  a  catheter  the  operation  was  complete,  and  &  SPECIMEN 
a  perfect  result  obtained,  as  he  saw  the  patient 

ten  or  fourteen  days  after.     Trendelburg  tested  Dr.  Blickhahn  said  :  The  specimen  I  present 

the  bladder  for  continuity  by  injecting  from  four  for  inspection  was  from  a  patient  of  Dr.  Pohlman's 

to  six  ounces  of  water,  and  it  held  the  water  per-  who  was  kind  enough   to  furnish  me  the  clinical 

fectly.     Silk  sutures  were  used  and  tied  in  the  facts.     Dr.  Edward  Evert,  who  made  the  autopsy, 

bladder,  the  supra-pubic  method  being  adopted,  has  kindly  detailed  the  post-mortem  appearances. 

In  operations  where  very  firm  apposition  of  the  This  heart  and  its  aorta  belonged  to  a  man,  aged 

parts  is  desired,  catgut  is  not  always  to  be  trusted  30,  a  blacksmith  by  occupation.     He  had  always 

for  the  reason  that  great  force  must  be  exerted  to  been  in  good   health,   with   the  exception  of  a 

bring  the  parts  together;  and  besides  on  account  cough  which  occurred  several  years  ago,  due  to 

of  its  absorbent  qualities,  one  can  be  sure  that  he  bronchitis,  the  result  supposedly  of  the  inhala- 

has  tied  the  suture  tight  enough,  and  that  in  a  tion  of  dust  and  smoke  while  following  his  occu- 

little  time  the  suture  may  not  absorb  moisture,  pation  ;    the  cough  w-hile  it  continued  was  quite 

and,  in  consequence  of  the  loosening  of  the  knot,  severe,  but  disappeared  completely  under  treat- 

the  suture  becomes  loosened.     It  is  very  difficult  ment  for  the  bronchitis.     On  January  31,  the  pa- 

to  handle  wire  sutures,  from  the  fact  that  correct  tient  worked  as  usual,  and  in  the  evening  went 

apposition  of  the  edges  of  the  wound  can  not  with  to  the  Union  Depot  to  meet  a  relative.     He  drank 

confidence  be  obained  with  it;  the  use  of  a  cer-  several  glasses  of  beer,  appeared  in  good  health 

tain  amount  of  force  in  applying  it  often  produces  and  spirits,  and  retired   n   p.m.     Early  Sunday 

laceration  of  the  tissue;  failures  are,    therefore,  morning,  February   1,  he  awoke  suddenly  with 

often  due,  not  to  the  wire,  but  to  the  lacerated  tis-  great  pain  and  dyspnoea.      Dr.  Pohlman  was  sent 

sue.     It  is  very  hard  to  determine  just  exactly  for  and  on  his  arrival  found  the  patient  cyanosed 

how  tight  to  apply  the  wires.  and  suffering  from  great  dyspnoea,  cold  extrem- 

Dr.  William  Johnston:   Dr.  Bond  says  that  ities  ;    no  radial  or  temporal  pulse,  and  only  a 

Sims  was  the  pioneer  in  operations  on  vesico-  slight  undulation  of  the  carotids.     The  patient's 

vaginal  fistula?.      Dr.  Jobert.  of  Paris,   operated  condition  forbade  much  physical  exploration,  and 

for  this  affection  in    1837;  also  Sir  James  Young  no   acurate  diagnosis   of   the    difficulty  was  at- 

Simpson  later  adopted  it,  and  Dr.  Bozeman  still  tempted,  the  attending  physician  believing  death 

later  operated,  but  not  by  the  same  procedure  as  about  to  ensue  and  so  informed  his  friends.     He, 
Dr.  Sims. 


3i3 


SOCIETY  PROCEEDINGS. 


[February  2S, 


however,  injected  ether  and  whisky  subcutane- 
ously,  remained  with  the  patient  about  an  hour 
and  then  left,  expecting,  on  his  return  some 
hours  later,  to  find  his  patient  a  corpse.  By 
afternoon,  however,  the  condition  of  the  patient 
was  greatly  improved ;  the  pulse  was  percepti- 
ble, the  cyanosis  less,  and  respiration  less  em- 
barrassed, etc.  His  improvement  was  steady, 
and  the  patient  in  a  short  time  insisted  he  was 
well,  and  wanted  to  go  to  work  a  day  or  so  later. 
The  doctor  insisted  he  had  not  satisfactorily  diag- 
nosed his  malady,  the  symptoms  being  still  very 
grave,  and  he  insisted  on  the  patient  remaining 
in  bed,  etc.  The  third  day  the  patient  got  up 
and  walked  about  the  room,  feeling,  as  he  said, 
perfectly  well.  He  awoke  in  the  night,  however, 
of  Tuesday  or  Wednesday,  with  great  dyspncea 
and  cyanosis.  Dr.  Pohlman  was  again  sum- 
moned, but  the  patient  died  before  he  arrived 

The  post-mortem  revealed  nothing  of  special 
import  until  the  pericardium  was  opened.  The 
heart  sac  was  bluish  in  color,  and  when  opened 
it  was  found  filled  by  large  coagula  ;  through 
this  the  heart  was  reached,  and  lifted  out ;  the 
heart  was  replaced  and  examined  from  the  out- 
side. There  was  dilatation  of  the  aorta  ;  and  in- 
side the  sac  just  after  it  leaves  the  heart,  there 
was  observed  an  aneurism  and  a  small  irregular 
opening  of  the  size  of  a  small  pin's  head,  from 
which  the  haemorrhage  had  taken  place.  The 
heart  otherwise  was  found  in  a  healthy  state. 

Dr.  Bond  inquired  :  Can  Dr.  Blickhahn  give 
the  history  of  the  case  as  to  the  possibility  of 
syphilis  on  his  part  or  that  of  his  parents. 

Dr.  Blickhahn  replied :  From  hearsay  I 
learned  there  was  no  syphilitic  history  in  the 
case,  though  the  gentlemen  who  saw  the  case 
earlier,  and  made  the  post-mortem,  were  of  the 
opinion  that  there  might  have  been  syphilis. 

Dr.  Bremer  :  The  question  of  syphilis  is 
always  the  one  that  is  uppermost  in  the  mind  of 
an  inquirer  after  truth  in  such  cases.  He  be- 
lieved that  there  is  almost  no  case  of  diverticulum 
of  the  heart,  as  it  was  formerly  called — or  aneu- 
rism, which  could  not  be  traced  to  syphilis — not 
a  well  authenticated  case.  In  most  cases  syphilis 
certainly  is  the  cause,  either  hereditary  or  ac- 
quired. He  had  known  a  case  of  hereditary 
syphilis  in  which  the  individual  died  from  aneu- 
rism of  the  aorta  ;  that  is  the  only  case  he  had 
met  with  in  his  own  practice. 

Dr.  Broome  said  that  some  cases  of  aneurism 
are  met  with,  which  clearly  are  not  due  to  syph- 
ilis, nor  to  any  known  cause.  He  had  now 
under  observation  a  case  in  which  there  is  posi- 
tively no  history  of  syphilis,  though  the  etiology 
is  obscure.  The  aneurism  is  from  the  arch  of  the 
aorta  and  is  of  enormous  size,  larger  than  any 
heretofore  recorded.  Subjective  symptoms  had 
been  manifest  for  a  year  and  a  half ;  but  a  palpa- 
ble tumor  appeared  only  about  one  year  ago.     Its 


increase  in  size  has  been  so  rapid  and  great,  that 
pressure  on  the  thoracic  walls  has  occasioned  ab- 
sorption of  the  entire  anterior  halves  of  six  ribs, 
a  portion  of  the  sternum  and  also  the  sterno- 
clavicular articulation  ;  the  sternal  extremity  of 
the  clavicje  being  pushed  up  against  the  thyroid 
cartilage.  The  patient  now  complains  but  little 
of  pain,  but  previous  to  the  escape  of  the  tumor 
beyond  the  contour  of  the  ribs,  his  suffering  was 
very  great  in  consequence  of  mechanical  pressure 
of  the  aneurismal  tumor  exerted  within  the 
thoracic  cavity.  The  doctor  endeavored  to  intro- 
duce a  silver  wire  into  the  sac,  but  owing  to  the 
presence  of  septa  within  its  cavity,  the  resistance 
was  greater  than  could  be  overcome  without  ex- 
ercising undue  force.  Ordinary  piano  wire  is 
probably  the  best,  of  which  from  ten  to  twenty 
feet  might  be  introduced  so  large  is  the  sac. 
Macewen  claims  to  have  returned  several  patients 
to  hard  work,  apparently  completely  cured  of 
their  aneurismal  tumors  by  his  method  of  treat- 
ment. This  consists  of  the  introduction  and  re- 
tention of  a  long  needle  into  the  sac  just  deep 
enough  to  strike  the  opposite  wall.  The  needle 
is  thus  practically  suspended  in  the  sac,  and  in 
consequence  of  the  motion  of  the  blood  current 
being  thereby  rendered  b}-  it  tumultuous  and  dis- 
seminated, irritation  is  set  up  in  the  vessel  wall, 
and  leucocytes  is  induced.  This  process  continu- 
ing, superimposed  accretions  of  fibrine  generated, 
and  a  partial  thrombosis  progresses  until  com- 
plete occlusion  of  the  sac  occurs.  The  method 
suggested  is  simple,  besides  devoid  of  danger, 
I  and  appears  to  be  full  of  promise. 

Dr.  Cadwallader  stated  that  he  had  in  his 
possession  a  specimen  taken  from  a  patient  who 
I  gave  a  rheumatic  history  of  several  years'  dura- 
tion, with  a  marked  disturbance  of  the  heart.  He 
discovered,  in  making  a  post-mortem,  an  aneurism 
i  or  diverticulum  on  the  superior  surface  of  the  left 
ventricle  as  large  as  a  walnut.  The  patient  died 
from  some  other  trouble  unconnected  with  it. 

Dr.  Bremer  :  Xo  poison  circulates  in  the  hu- 
'  man  body,  nor  is  there  any  factor  that  tells  to 
I  such  a  degree  and  with  such  an  intensity  upon 
the  vessels,  as  does  syphilis ;  and  next  to  syphilis 
I  comes  alcohol.     The  syphilitic  lesion  is  very  fre- 
|  quently  confined  to  the  muscular  layer  of  the  ves- 
sels.    The  muscular  layer  is   infiltrated  and,  in 
consequence,  there  is  a  shrinkage  of  the  muscle 
fibres  ;  there  being  no  resisting  power,  no  elasti- 
city, the   blood  pressure  will  have   the   effect  of 
pushing   out   and  dilating  the  connective  tissue 
membranes,  which  have  been  formed  in  place  of 
the   muscular   membrane.     In  that  way  miliary 
aneurisms,  when  they  occur  in  the  brain,  prove 
very  frequently  fatal.    In  the  same  way  the  larger 
aneurisms  are  formed.     It  is  true  that    trauma- 
tisms are  sometimes  the  cause  of  aneurisms,  trau- 
matisms which   may  not  be  noticed  ;  but  the  so- 
called  idiopathic  aneurisms  are  probably  all  due 


i89i.] 


FOREIGN  CORRESPONDENCE. 


3i9 


to  syphilitic  infection,  which,  in  a  great  many 
instances,  is  a  matter  unknown  to  the  patients 
themselves. 

Dr.  Bond:  Did  I  undertand  you  to  say  that 
the  retrograde  metamorphosis  incident  to  syphi- 
lis was  represented  by  the  conversion  of  the  mus- 
cular element  into  connective  tissue? 

Dr.  Bremer  :  The  muscular  elements  disap- 
pear at  the  site  of  the  lesion,  and  very  frequently 
in  the  muscular  coat ;  such  is  the  case  in  gum- 
mata,  for  instance.  The  gummata  afterwards 
breaks  down  to  some  extent,  then  connective  tis- 
sue is  formed ;  and  the  blood  current,  the  vis  a 
iergo,  dilates  the  connective  tissue  which  has  been 
formed.  When  the  connective  tissue  is  in  a  fresh 
state — an  embryonic  state — in  a  fibro-plastic  state 
— it  is  very  soft,  and  can  be  pushed  out  and  a 
pouch  very  easily  formed. 


FOREIGN    CORRESPONDENCE. 


LETTER  FROM  LONDON. 

(FROM    OCR    REGULAR    CORRESPONDENT.  I 

Lectures  on  Nursing- — The  Electric  Light  and 
Human  Ailments — The  Treatment  of  Burns — Co- 
operation and  the  Nursing  Profession — Sir  Richard 
Quoin — Diverticulum  of  the  (Esophagus — The 
Mid-wives'  Registration  Bill — Miscellaneous  Items. 

Several  of  the  National  Health  Society's  lec- 
turers are  now  giving  lectures  on  nursing  in  the 
provinces — at  Horstead  for  Lady  Berkbeck,  at 
Dedbury  for  Lady  Henry  Somerset,  and  also  at 
Norwich.  The  lectures  are  attended  by  hundreds 
of  ladies.  The  "homely  talks"  which  follow 
the  set  discourses  are  especially  intended  for  the 
working  women  of  the  districts,  and  many  of  the 
cottage  wives  and  mothers  show  an  earnest  desire 
to  be  better  informed  on  the  important  subject  of 
nursing  their  sick. 

The  electric  light  is  stated  to  exercise  a  most 
soothing  influence  over  human  ailments.  Ac- 
cording to  a  medical  man,  by  reflecting  the  rays 
of  an  incandescent  lamp  upon  the  sufferer,  acute 
pain  is  relieved  in  a  few  moments.  For  example, 
a  headache  will  yield  to  the  treatment  in  from  ten 
to  fifteen  seconds,  a  strong  concentration  of  light 
on  the  seat  of  a  malad}'  in  any  other  part  of  the 
body  will  effect  a  temporary  cure  in  five  minutes, 
and  even  consumptive  patients  find  their  cough 
quieted  and  the  breathing  easier.  The  light  is 
directed  to  the  affected  region  through  a  funnel- 
shaped  apparatus.  The  treatment  is  stated  to 
have  been  tried  in  Moscow. 

In  one  of  the  large  London  hospitals  the  fol- 
lowing method  of  treatment  for  burns  has  been 
tried  with  success :  The  burned  surface  is  first 
carefully  washed  with  a  2  or  3  per  cent,  solution 
of  carbolic  acid;  or  with  a  3  to  1,000  solution  of 


salicylic  acid.  The  blisters  are  then  opened  and 
the  entire  surface  covered  with  subnitrate  of  bis- 
muth finely  powdered,  and  over  this  a  layer  of 
cotton  wool.  This  dressing  is  to  be  renewed  as 
soon  as  it  becomes  at  all  moistened  by  discharges 
from  the  wound.  If  the  burn  is  very  extensive, 
an  ointment  of  bismuth  is  substituted  for  the  dry 
powder.  With  this  dressing  cicatrization  is  found 
to  be  much  more  rapid,  and  the  suffering  of  the 
patient  much  more  quickly  relieved  than  is  the 
case  with  any  other  form  of  treatment.  It  is  found 
that  in  spite  of  the  large  quantities  of  subnitrate 
of  bismuth  which  are  employed  in  this  manner, 
up  to  the  present  no  case  of  ' '  bismuth  poison- 
ing "   following  its  use  has  occurred. 

At  once  pathetic  and  pleasing  was  the  spectacle 
presented  at  King's  College  Hospital,  on  the  oc- 
casion of  the  patients'  annual  Christmas-tree  en- 
tertainment, the  cost  of  which  was  borne  almost 
entirely  by  the  students  attending  the  institution. 
By  the  judicious  use  of  artistic  hangings,  Chinese 
lanterns,  evergreens  and  flowers,  the  wards  were 
made  to  look  exceedingly  bright  and  pretty.  The 
patients  able  to  leave  their  beds  were  accommo- 
dated in  the  area  of  the  great  hall,  while  those 
less  fortunate  were  provided  with  couches  in  the 
three  surrounding  galleries,  so  that  they  might 
share  in  the  enjoyment  derivable  from  an  enter- 
tainment to  which  several  members  of  the  dra- 
matic profession  contributed.  Many  of  the  vis- 
itors inspected  the  wards  containing  patients 
who  had  been  inoculated  with  Koch's  lymph, 
which  in  certain  tubercular  diseases  has  been 
markedly  beneficial. 

Cooperation  is  now  extended  to  the  nursing 
profession.  Some  nurses  have  combined  on  a 
plan  which  will  enable  them  to  receive  their  own 
earnings  in  full,  subject  to  a  slight  deduction  for 
working  expenses.  That  they  are  good  nurses  is 
guaranteed  by  the  fact  that  Miss  Hicks,  the  late 
matron  of  the  Ormond  Street  Hospital,  is  their 
lady  Superintendent.  It  is  said  that  nurses  who 
earn  two  guineas  a  week  sometimes  receive  for 
themselves  no  more  than  £.20  a  year. 

Sir  Richard  Quain,  the  new  medical  baronet, 
is  one  of  the  members  of  the  medical  profession 
who  is  most  popular  outside  his  profession.  For 
many  years  he  has  been  persona  grata  in  literary, 
artistic  and  official  circles,  and  has  numbered 
among  his  friends  or  acquaintances  most  of  the 
great  artists  and  men  of  letters  of  the  last  two 
generations.  For  in  spite  of  his  iron-gray  hair, 
active  habits  and  untiring  energy  in  the  discharge 
both  of  his  professional  and  social  obligations. 
Dr.  Richard  Quain  must  have  already  exceeded 
the  Psalmist's  span.  At  Mallow,  Sir  Richard 
first  saw  the  light,  and  his  first  introduction  to 
medical  practice  took  place  in  Limerick.  He 
soon  found  his  way  to  London  and  quickly  began 
to  make  his  mark,  being  for  some  3'ears  the  right- 
hand  man  of  the  late  Dr.  C.  J.  B.  Williams,  and 


320 


NECROLOGY. 


[February  28, 


then  one  of  the  physicians  appointed  at  the  insti- 
tution of  the  Hospital  for  Consumptives  at  Brotnp- 
ton.  For  many  years  now  he  has  possessed  one 
of  the  leading  consulting  practices  in  London. 
His  magnum  opus  is  the  famous  "  Dictionary  of 
Medicine,"  which  took  some  ten  or  twelve  years 
to  prepare,  and  in  the  production  of  which  he 
obtained  the  assistance  of  most  of  the  best  known 
medical  writers. 

At  the  Pathological  Society's  meeting,  an  in- 
teresting and  rare  specimen  of  diverticulum  of 
the  oesophagus,  taken  from  the  body  of  a  man 
aged  49,  was  shown.  The  patient,  who  was 
much  emaciated,  and  on  whom  gastrostomy  was 
performed  in  July,  1890,  had  given  a  history  of 
dysphagia  extending  over  a  period  of  ten  years. 
Death  occurred  two  days  after  the  completion  of 
the  operation,  from  pneumonia  and  exhaustion. 
The  autopsy  showed  a  diverticulum  of  the  back 
part  of  the  oesophagus  4  inches  in  depth  from  the 
level  of  the  arytenoid  cartilages,  3^  inches  in 
breadth  and  2  '  J  inches  in  thickness,  with  a  mouth 
1  inch  in  diameter  and  a  capacity  of  6  ozs.  The 
walls  of  the  sac  were  lined  throughout  with  mu- 
cous membrane,  and  were  of  the  same  thickness 
as  those  of  the  oesophagus.  When  the  enlarge- 
ment was  filled  with  fluid  the  opening  in  the 
oesophagus  was  firmly  closed  by  the  pressure  of 
the  distended  sac.  There  was  no  malignant 
growth  present.  The  absence  of  muscular  tissue 
except  at  the  mouth  of  the  sac,  supported  the 
contention  that  posterior  diverticula  were  prima- 
rily due  to  effects  of  pressure,  and  not  to  congen- 
ital defect,  as  held  by  some  authorities. 

Dr.  G.  N.  Pitt  has  published  some  notes  on 
the  post-mortem  appearances  in  chronic  alcohol- 
ism. Prima  facie,  the  chronic  dyspepsia  and  ir- 
regular habits  of  these  patients  would  lead  one 
to  expect  that  their  mortality  from  phthisis  would 
be  high.  The  Registrar  General's  Reports,  how- 
ever, showed  that  the  mortality  from  phthisis 
of  publicans  and  others  whose  occupations  ex- 
posed them  to  special  temptations  to  drink,  was 
rather  below  than  above  the  average.  But  acute 
tuberculosis  and  pneumonia  were  very  prone  to 
occur  in  such  patients,  and  the  tuberculous  nature 
of  the  disease  might  often  be  overlooked  during 
life.  Dr.  Pitt  concludes  that  tubercular  lesions 
in  the  lung  in  alcoholic  subjects  generally  assume 
a  fibroid  form,  and  that  tubercular  lesions  are  not 
infrequently  associated  with  alcoholic  neuritis  and 
hepatic  cirrhosis. 

The  Manchester  Medico-Ethical  Association, 
numbering  150  medical  men  practicing  in  Lan- 
cashire and  Cheshire,  have  taken  alarm  at  the 
"Midwifes'  Registration  Bill  "  now  before  Par- 
liament, and  are  organizing  an  opposition  to  that 
measure.  Sir  Walter  Foster,  M.D.,  has  with- 
drawn his  name  from  the  back  of  the  Bill,  and  it 
is  stated  that  others  interested  in  its  promotion 
are  persons   "having  little  experience  of  family 


practice."  It  is  also  alleged  that  the  General 
Medical  Council  has  declined  to  support  the  Bill, 
and  that  the  Royal  College  of  Physicians  has  also 
repudiated  it.  In  the  view  of  the  Association, 
the  measure  is  a  plan  for  avoiding  the  extended 
educational  course  necessary  to  qualify  any  one 
to  treat  the  diseases  of  women  and  children,  and 
that  the  Bill  is  to  be  used  as  a  "back  door  en- 
trance "   for  women  to  the  medical  profession. 

"  The  Coming  Race"  is  the  name  appropriated 
to  a  bazaar  and  fancy  fete  at  the  Royal  Albert 
Hall,  in  aid  of  the  West  End  Hospital  and  School 
of  Massage  and  Electricity.  The  arrangements 
include  a  festival  dinner  to  which  ladies  will  be 
admitted.  The  fete  will  be  opened  on  March  4 
for  four  days. 

The  Swiss  Federal  diploma  which  gives  the 
right  of  practice  has  been  granted  to  Dr.  Holland, 
of  St.  Moritz.  This  act  on  the  part  of  the  Swiss 
authorities  ends  a  long  controversy. 

Sir  George  Humphry,  of  Cambridge,  the  new 
medical  knight,  has  been  invited  to  a  congratu- 
latory dinner  by  the  Cambridge  Medical  Gradu- 
ates' Club,  Among  the  guests  invited  is  the 
Vice  Chancellor  of  the  University  of  Cambridge. 

G.  o.  M. 


NECROLOGY. 


Dr.  William  J.  McClure,  University  of 
Maryland  School  of  Medicine,  Baltimore,  (1866), 
Health  officer  of  York,  Pa.,  and  member  of  the 
Legislature  from  Adams  County  in  1878,  died 
January  24,  aged  52  years. 

Dr.  N.  M.  Bemis,  of  Fairbault,  Minn.,  died 
January  29th,  aged  69  years.  He  was  a  native 
of  Massachusetts,  and  graduated  at  Woodstock, 
48  years  ago.  He  moved  with  his  family  to 
Minnesota  in  1855  where  he  has  been  in  active 
practice  up  to  a  few  weeks  before  his  death.  He 
was  father  of  Dr,  J.  G.  Bemis  of  Chicago. 

Dr.  Pierson  Rector,  President  of  the  Board 
of  Pension  Examiners,  Jersey  City,  N.  J.,  died  in 
that  city,  January  22,  of  pyaemia,  due  to  a  sur- 
gical accident  while  in  attendance  upon  a  charity 
patient.  He  was  born  in  Duanesburg,  N.  Y.,  52 
years  ago  and  was  educated  in  the  Racine  College 
and  the  Albany  Medical  College.  During  the 
war  he  was  Assistant  Surgeon  1 15th  Regiment  N. 
Y.  Volunteer  Infantry,  but  was  transferred  with 
the  same  rank  in  February,  1864,  to  the  127th 
Reg't.  Vol.  Inf't.,  of  the  same  State,  receiving 
his  discharge  December  14,  1864. 

Medical  Director  Jonathan  Dickinson 
MlLLER,  U.  S.  Navy,  (retired)  died  January  29, 
at  his  home,  Mount  Airy,  near  Philadelphia.  He 
was  a  native  of  New  York,  was  commissioned  as- 


i89i.] 


BOOK  REVIEWS. 


321 


•sistant  surgeon  December  6,  1836,  and  assigned 
to  the  North  Carolina,  in  the  Pacific  squadron. 
He  was  passed  in  1841  and  assigned  to  the  Naval 
Hospital,  Brooklyn.  In  1S43  he  was  ordered  to 
the  brig  Perry  of  the  East  India  squadron.  He 
was  again  promoted  in  1S47  and  ordered  to  the 
■Gulf  of  Mexico.  He  served  continuously  till  No- 
vember 6,  1872,  when  he  was  placed  upon  the  re- 
tired list. 

Dr.  Chari.es  C.  Lancaster,  an  alumnus  of 
the  Medical  College  of  Virginia,  class  of 
died  February  3,  at  Knoxville.  Tenn.  He  was 
poisoned  by  a  gangrenous  wound,  which  he  had 
surgically  treated,  through  an  abrasion  under  his 
finger  nail. 

Dr.  Alvin  Talcott,  the  most  distinguished 
although  not  quite  the  oldest  surviving  citizen 
of  Guilford,  Conn.,  died  there  Jan.  17.  He  was 
born  in  Vernon,  Conn.,  Aug.  17,  1804.  He  was 
graduated  at  Yale  in  1824,  and  from  the  Vale 
Medical  School  in  1831.  He  began  to  practice 
in  Vernon  as  successor  to  Dr.  Dow.  Dr.  Talcott 
had  taught  in  Guilford  during  his  college  course, 
and  there  married  Miss  Olive  Chittenden,  on 
March  7,  1831.  He  settled  in  Guilford  about 
1840,  and  became  a  successful  practitioner.  He 
began  early  to  search  out  the  genealogy  of  the 
Guilford  families.  He  wrote  out  in  manuscript 
the  full  family  lists,  as  far  as  obtainable,  of  all 
Guilford's  forty  original  settlers  of  250  years  ago. 
This  notable  genealogical  work  is  embodied  in 
an  imperial  quarto  containing  over  25,000  indi- 
vidual names.  It  is  understood  that  it  is  be- 
queathed to  the  New  Haven  Historical  Society. 
Dr.  Talcott  was  many  years  secretary  and  treas- 
urer of  the  Board  of  Trustees  of  Guilford  Insti- 
tute, himself  an  active  and  ready  classical  scholar. 
For  some  years  he  held  the  office  of  Town  Regis- 
ter. He  had  three  children — one  son  and  two 
daughters — who  died  at  an  early  age,  Mrs.  Tal- 
cott having  passed  away  December  8,  1882. 

Dr.  Nathaxiel  R.  Boutelle,  Jefferson 
Medical  College,  1847,  died  at  his  home  in 
YVaterville,  Me.,  December  21,  of  paralysis.  Be- 
sides being  an  active  practitioner,  he  was  a  bank 
president,  and  an  enthusiastic  stock  breeder. 


BOOK  REVIEWS. 


A  Text-Book  of  Comparative  Physiology 
for  Studexts  axd  Practitioxers  of  Com- 
parative (veterinary)  Medicine.  By  Wes- 
ley Mimms,  M.D.,  DA'S.,  etc.,  Professor  of 
Physiology  McGill  University.  With  476  Il- 
lustrations. New  York:  Appleton  &  Company, 
1890.      Pp.  636.     S3. 00. 

This  compact  and    thoroughly   well  arranged 


volume  will  be  a  desirable  addition  to  any  library. 
Though  written  for  veterinarians  it  is  based  of 
necessity  on  human  physiology,  and  the  recent 
contributions  to  this  department  of  knowledge 
are  clearly  set  forth.  The  author's  style  is  terse 
and  entertaining,  carrying  one  along  agreeably 
over  what  otherwise  would  be  dry,  statistical  and 
unentertaining.  The  illustrations,  though  rarely 
original,  are  well  selected,  and  graphic  demon- 
strative methods  are  emphasized. 

The  Extra  Pharmacopoeia. — With  the  addi- 
tions introduced  into  the  British  Pharmacopoeia, 
18S5.    By  William  Martixdai.k,  F.S.C.,  late 
Examiner  of  the  Pharmaceutical  Society  and  late 
Teacher   of    Pharmacy    and    Demonstrator   of 
Materia  Medica  at  University  College.       Medi- 
cal References  and  a  Therapeutic  Index  of  Dis- 
eases and  Symptoms.   By  W.  Wyxx  WESCOTT, 
M.B.  Lond.,  Deputy  Coroner  for  Central  Mid- 
dlesex.    Sixth     Edition.       London :     H.    K. 
Lewis,  136  Gower  st..  W.  C.      1890. 
This  concise  little  volume  is  familiar  to  Amer- 
ican as  well  as  to  English  physicians,  the  present 
edition    numbering    the    thirty-sixth    thousand 
copies. 

The  necessary  revisions  have  been  made.  The 
derivatives  obtained  from  coal,  tar  and  alcohol, 
which  are  now  so  prominently  presented  as  new 
remedies,  are  incorporated  in  the  text.  The  vol- 
ume is  compact  in  form,  with  flexible  morocco 
cover,  and  can  be  conveniently  carried  in  the 
pocket.  The  posologieal  tables  are  very  com- 
plete, and  the  Therapeutical  Index  at  the  close 
of  the  volume  will  be  found  helpful,  as  suggestive 
of  appropriate  remedies,  especially  in  times  of 
,  emergency. 

I A  Text-book  of  Practical  Therapeutics  ; 
with  Especial  Reference  to  the  Applica- 
tion of  Remedial  Measures  to  Diseases, 
axd  their  Employment  upox  a  Rational 
Basis.      By    Hobart   Emory  Hake.    M.D., 
(Univ.  Pa.),  B.  S.  C,  Clinical  Professor  of  Dis- 
eases of  Children  and  Demonstrator  of  Thera- 
peutics in  the  University  of  Pennsylvania,  etc. 
This  valuable  and   practical  work  of  over  six 
hundred  pages  is  published  by  Lea  Brothers  & 
Co.,  in  their  usual  creditable  style.     The  aim  of 
the  author  has  been  in  a  very  effectual  way  to 
bridge  the  chasm  which  lies  between  the  theory 
and  the  practice  of  medicine.     To  this  end  the 
physiological  actions  of  remedies  are  clearly  set 
forth  so  far  as  they  are  known,  and  the  patholog- 
ical condition  in  which  their  use  is  indicated,  are 
concisely  described.     The  reason  why  in  particu- 
lar stages  of  diseases  particular  remedies  are  re- 
quired is  just  that  which  the  young  physician 
most  needs  to  know,   and   the  ready  reference  to 
the  drug  that  shall   meet  that  requirement,  and 
the  reason  for  its  use,  is  just  the  instruction  which 


322 


SPECIAL  CORRESPONDENCE. 


[February  28, 


raise  one  from  empiricism  to  the  higher  plane  of  work  in  hand  for  the  accommodation  of  the  As- 
rational  practice.  sociation.  The  General  Meetings  will  be  held  in 
We  can  heartily  commend  the  work  for  its  in-  the  auditorium  of  Albaugh's  Opera  House,  the 
telligent  and  reliable  review  of  the  prominent  basement  of  which  having  been  secured  for  the 
therapeutical  agents  in  use,  and  for  its  intelligent  exhibits, 
explanation  of  the  reasons  for  their  administra-  


SPECIAL  CORRESPONDENCE. 


The  Effects  of  Anaesthetics  Modified  by 
Altitudes. 


ASSOCIATION  NEWS. 


tions  in  the  treatment  of  diseases.     The  remedies 

considered  are  arranged  in  alphabetical  order,  as 

are  also  the  diseases  to  which  reference  is  made. 

A  valuable  portion  of  the  work  is  that  devoted  to 

remedial  measures  other  than  drugs  and   to  the 

consideration  of  goods  suitable  for  the  sick.     A 

table  of  doses  of  remedies   and   a   copious  index        To  the  Editor:— The  case  which   I  desire  to  report 

add  to  its  value  and  convenience.      An   examina-    caused  much  unfavorable  comment  in  the  community 

tion  of  the  work    will    ensure    approval,  and  as  a    where  it  occurred,  namely,   one  of  the  high  mountain 
,       _  .       ,    v      ...   sr  r        j  1     1    r  1      cities  of  Colorado — elevation  10,000  leet.     Surgeons  use 

practical  reference  book  it  Will  be  found  helpful.  chloroform  at  these  extreme  elevations  almost  exclu- 
sive!}'. For  some  occult  reason  ether,  or  any  of  the  an- 
aesthetic mixtures  do  not  act  well,  and  are  considered  by 
common  professional  consent  dangerous;  not  because 
they  have  frequently  produced  death,  but  because  of  the 
enormous  quantity  necessary  to  produce  anaesthesia.  For 
this  reason  chloroform,  which  causes  complete  insensi- 
bility very  speedily,  and  in  small  quantity,  is  mostly  used. 
On  January  iS  of  the  preseut  year  a  man  of  37  years  of 
age  was  placed  under  the  influence  of  chloroform  for  op- 
eration for  organic  urethral  stricture  in  the  spongy 
urethra.  The  stricture  was  of  small  calibre  and  the  in- 
dividual had  had  several  attacks  of  retention  following 
debauches.  Iu  the  course  of  the  chloroform  the  sub- 
ject presented  no  symptoms  of  an  alarming  character 
until  efforts  were  made  to  operate  by  the  cutting  method 
when,  suddenly,  the  respirations  stopped,  a  few  convul- 
sive shudders,  a  few  flutters  of  the  heart,  and  the  patient 
was  dead.  Artificial  respiration,  ammonia  by  hypodermic 
injection,  and  the  interrupted  current  failed  to  give  the 
slightest  encouragement,  as  a  means  of  resuscitation. 

These  matters  came  to  my  knowledge  as  coroner's 
medical  adviser,  popular  indignation  demanding  inves- 
tigation and  prosecution  criminally  of  the  unfortunate 
medical  attendant.  The  post-mortem  examination  re- 
vealed heart  dilatation,  enlarged  spleen,  liver — results  of 
chronic  alcoholism.  As  chloroform  is  given  in  this  local- 
ity many  times  each  month,  and  as  this  is  the  first  re- 
corded "death  in  ten  years  from  chloroform,  it  has  at- 
tracted more  than  ordinary  public  attention. 

M.  H.  Sears,  M.D. 
Leadville,  Colorado. 


American  Medical  Association. 

Forty-Second  Annual  Meeting,  at  Washington, 

May  5  to  8,  1891. 

LOCAL  COMMITTEE  OF   ARRANGEMENTS. 

D.  C.  Patterson,  M.D.,  Chairman;  C.  H.  A. 
Kleinschmidt,  M.D.,  Secretary. 

SUB- COMMITTEES. 

Registration. —  Drs.  Bulkley,  J.  O.  Adams, 
Bovee,  Herman  H.  Cook,  Eliot,  J.  D.  Morgan, 
Manning,  J.  D.  McKim,  Mallan,  Osmun,  Ober, 
Radcliff. 

Finance. — Drs.  Stanton,  B.  B.  Adams,  Balloch, 
Crook,  Chamberlin,  Harrison,  Hood,  Magruder, 
Newman,  Sowers,  Toner. 

Entertainment. — Drs. Prentiss, Bromwell,  Deale, 
Fenwick,  Franzoni,  Hyatt,  Johnston,  H.  L.  E. 
Johnson,  Richardson,  Rixey  (U.  S.  N.),  Witmer. 

Transportation. — Drs.  Hawkes,  Acker,  Bur- 
nett, Lee.  Mundell,  Townsheud,  Jas.  T.  Young. 

Hotels  and  Boarding  Houses. — Drs.  Reyburn, 
Bracket,  Friedrich,  Leach,  Lamb,  Murphy, 
Sothoru. 

Reception. — Drs.  Lincoln,  Bryan,  Fry,  A.  He- 
gar,  U.  S.  A.,  J.  T.  Johnson,  Loring,  Mackall, 
Marmion,  Peter,  A.  C.  Patterson,  Rosse,  T.  R. 
Stone,  T.  C.  Smith,  Walsh. 

Place  >•!  Meeting  of  Sections. — Drs.  Lovejoy, 
Beatty,  Bayne,  Callan,  Hill,  D.  H.  Hazen,  H. 
Leach,  McLaughlin,  J.  C.  McGuire,  Neale, 
Spriggs,  J.   T.  Winter. 

Information.  —Drs.  Hickling,  B.  B.  Adams,  S. 
W.  Bogan,  Byrns,  Neale. 


Dislocation  of  Long  Bones. 

To  the  Editor:— In  No.  6,  Vol.  16  of  The  Journal  1 
find  a  communication  from  Dr.  Murdock  to  the  Alle- 
gheny County  Medical  Society  giving  the  details  of 
the  reduction  of  the  dislocation  of  the  head  of 
the  right  femur  upon  the  dorsum  of  the  ilium  by 
extension  and  counter  extension;  which  brings  forcibly 
to  my  mind  two  principles  laid  down  by  two  eminent 
men  iu  regard  to  dislocations  of  long  bones.  One  b_\  the 
late  lamented  Prof.  Moses  Gunn,  of  Rush  Medical  Col- 
lege, Chicago,  tO-wit,  always  make  extension  in  the 
line  of  deformity.  The  other,  by  the  late  lamented  and 
eminent  George  Sutton,  M.D.,  of  Aurora,  Ind.,  which  is: 
In  reduction  of  the  head  of  the  femur  or  humerus,  use  a 
fulcrum  in  tlie  groin  or  axilla  by  which  the  long  arm  of 


—Drs.   Patterson,  S.   A.   H.  McKim,  the  lever]  the  felIllir  „r  humerus,  ;ls  lhe  casc  nlav  i,t.,  can 

Stanton,  Toner.  be  used  efficiently,      in  the  ease  cited  by  Dr.  Murdock 

Printing. — Drs.  Hamilton,  Barker,  Briscoe,  W.  I  oth  oi  these  principles  were  brought  to  bear.    The  foot 

P    C    7Ti-/m    Henderson    Poole  of  the  young  medical  student  in  the  groin  was  the  ful- 

1  .  C.  riazui,  nencierson,  rooie.  crum  and  extension  was  made  in  the  line  of  deformity. 

The  several  Committees,  as  well  as  the  Com-  when  tlu,  this,h  of  the  dislocated  limb  was  brought 
mittees  as  a  whole,  have  met  and  mapped  out  the  i  across  the  thigh  of  the  sound  one  the  pressure  necessary 


i89i.] 


SPECIAL  CORRESPONDENCE. 


323 


to  effect  this  was  sufficient,  acting  on  the  long  arm  of  the 
lever,  the  femur  pressing  on  the  fulcrum,  the  student's 
foot,  to  raise  the  head  of  the  femur  over  the  lip  of  the 
acetabulum,  and  all  extension  then  had  to  do  was  to 
cause  the  head  of  the  femur  to  travel  back  through  the 
rupture  of  the  capsular  ligament  and  drop  into  its  place 
in  the  acetabulum.  The  position  the  dislocated  limb  was 
made  to  take  also  relaxed  the  V  ligament. 

This  case  also  is  a  confirmation  of  the  position  taken 
by  Dr.  McCaun  in  the  discussion,  contrary  to  the  position 
of  Dr.  Murdock,  that  dislocation  does  not  take  place  at 
any  other  point  than  at  the  lower  and  anterior  portion  of 
the  acetabulum.  In  the  case  cited  if  the  capsular  liga- 
ament  had  not  been  ruptured  externally  and  upwardly 
the  means  used  for  reduction  would  not  have  been  suc- 
cessful, but  if  it  had  been  torn  inferiority  and  anteriorily 
it  would  have  been  reduced  by  manipulation  if  a  fulcrum 
had  been  used  in  the  groin.  Jamf.s  Lamb,  M.D. 

Aurora,  Ind.,  Feb.  17,  1891. 


Absence  of  Uterus. 


To  the  Editor: — The  interesting  case  reported  in  No. 
8  of  The  Journal  by  Dr.  McShane,  of  Carmel,  Ind.,  re- 
calls to  mind  a  case  I  had  a  few  years  since.  A  lady,  aged 
24  years,  consulted  me  to  ascertain  why  she  could  not 
have  children.  She  had  been  married  six  years,  was  well 
developed,  not  masculine;  breasts  were  normal,  the  pu- 
dendum normal,  and  well  covered  with  hair. 

I  found  by  digital  examination  a  good- sized  vagina,  but 
no  cervix  uteri;  in  fact,  there  was  nothing  but  a  smooth, 
well  arched  vagina,  about  4  inches  in  depth.  I  introduced 
a  sound  into  the  bladder,  and  with  my  ringer  in  the  rec- 
tum I  could  readily  feel  the  sound,  showing  that  there 
was  complete  absence  of  the  uterus. 

Having  been  a  member  of  the  Association  for  several 
years,  I  think  it  best  to  let  well  enough  alone  and  pub- 
lish The  Journal  at  Chicago. 

H.  W.  Carpenter,  M.D. 

Oneida,  N.  Y. 


•Practical  ^Note." 


To  the  Editor: — I  am  very  glad  to  see  your  "Practical 
Notes."  Keep  it  up  and  enlarge,  and  as  you  have  one 
for  carbuncle  I  will  try  to  help  you  out  with  mine.  In 
1855  Stone  and  Hunt,  of  New  Orleans,  taught  the  -f-  inci- 
sion. I  keep  it  up  under  cocaine.  Now  then  fill  the  carbun- 
cle full  of  dry  salicylic  acid,  it  completely  dissolves  all  the 
hard  white  tissue;  wash  it  away  with  sublimate  soap  and 
hot  water;  fill  cavity  with  peroxide  of  hydrogen;  when 
bubbling  ceases  sponge  out  with  cotton;  dress  with  basil- 
icau  ointment  and  as  soon  as  matter  reforms  repeat  acid, 
etc.     It  makes  a  rapid  and  painless  cure. 

A.  P.  Brown,  M.-D. 

Fort  Worth,  Tex.,  Feb.  19,  1891. 


Shall  The  Journal  be  Removed  to 
Washington  ? 

THE  ACTION  OF  THE   CHICAGO  GYNECOLOGICAL  SOCIETY. 

The  following  resolutions,  formulated  by  a  committee 
appointed  at  a  preceding  meeting,  were  adopted  by  the 
Chicago  Gynecological  Society  February  20,  1891: 

Whereas,  There  is  a  disposition  on  thepartofa  portion  of  the 
Board  of  Trustees  of  The  Journal  of  the  American  Medical 
Association  to  move  The  Journal  from  its  present  place  of  pub- 
lication, Chicago,  to  Washington,  D.  C.  and 

Whereas,  The  Board  of  Trustees  invites  a  free  discussion  in  the 
columns  of  The  Journal,  with  a  free  expression  of  opinion  from 
societies  and  individuals,  be  it  therefore 

Resolved,  That  it  is  the  opinion  of  the  Chicago  Gynecological 
Society,  that  any  change  in  the  place  of  publication  of  The  Jour- 
nal, at  this  time,  will  be  detrimental  to  the  interests  ol  The 
Journal  as  well  as  to  those  of  the  Association,  and  be  it  further 

Resolved,  That  the  delegates  elected  from  this  Society  to  the 


next  meeting  of  the  Association   be  duly  instructed  to  oppose  in 
every  legitimate  manner  such  removal. 

ned)  Bayard  Holmes. 

Hi.skv  T.  byeukd, 
Henry  P.  Newman, 
Franklin  H.  Martin, 

Committee. 


To  the  Editor: — I  have  watched  with  considerable  in- 
terest the  lengthy  and  numerous  discussions  which  have 
been  presented  in  your  columns  in  regard  to  the  pro- 
posed removal  ol  Tup.  Ji  mknai.  to  Washington.  I  can- 
not see  wherein  any  advantage  whatever  would  accrue  to 
The  Journal  by  such  a  change  in  its  location.  The 
American  Medical  Association  is  not  a  sectional  body  ; 
or  if  it  is  open  to  the  charge  of  sectionalism  at  all,  as 
some  may  maintain,  it  certainly  is  not  an  Eastern  organi- 
zation. The  greatest  loyalty  to  its  integrity,  honor  and 
development,  cannot  be  claimed  by  the  medical  profes- 
sion of  the  States  East  of  the  Alleghany  mountains,  as  a 
body.  This  remark  is  not  intended  to  reflect  in  the  least 
upon  the  illustrious  services  of  a  large  mumber  of  East- 
ern physicians  without  whose  cooperation  the  American 
Medical  Association  would  not  be  what  it  is  to-day. 
Nevertheless  the  fact  as  stated  cannot  be  successfully- 
challenged. 

The  Journal  was  born  and  has  been  reared  in  the 
West.  And  while  it  may  not  have  become  all  that  its 
promoters  could  wish  it  to  be,  yet  the  assumption  that  it 
could  have  done  better,  or  even  as  well,  any  place  else  is 
entirely  gratuitous.  Unlike  the  Association  The  Jour- 
nal must  have  a  habitat ;  and.  irrespective  of  an\  other 
consideration,  it  should  be  located  somewhere  near  the 
geographical  centre  of  the  distribution  of  the  member- 
ship of  the  Association.  This  might  be  a  reason  for 
moving  it  farther  West  than  Chicago  if  such  another 
centre  could  be  found  in  that  direction,  but  certainly  is 
an  objection  to  its  removal  Eastward.  It  would  make  a 
difference  of  at  least  one  day  in  its  delivery  to  all  points 
West  of  Chicago  by  removing  it  to  Washington.  So 
much  for  the  geographical  question. 

In  regard  to  the  facilities  for  journalistic  enterprise, 
Washington  is  not  ahead  of  Chicago  in  any  single  point 
except  the  National  Library.  The  Chicago  profession  is 
easily  the  peer  of  that  of  Washington.  The  business  in- 
terests represented  by  Washington  are  scarcely  worth 
mentioning  in  comparison  with  those  of  Chicago.  So- 
that  whatever  advantage  might  be  derived  from  local 
business  interests  by  the  advertising  department,  which 
is  certainly  an  important  feature  in  the  medical  journal 
of  to-day,  would  all  be  in  favor  of  Chicago. 

Those  who  are  inclined  to  criticise  the  status  of  Tut: 
Journal,  and  the  grade  of  its  contributions  should  re- 
member that  as  an  organ  of  an  Association  meeting  once 
a  year  it  is  placed  at  an  enormous  disadvantage.  Papers 
written  ami  read  at  the  annual  meeting  are  scattered 
through  the  fifty-two  weekly  issues  of  The  Journal. 
half  of  them  being  more  than  six  mouths  and  many  of 
them  nearly  one  year  old  before  they  appear.  In  this 
age  of  enormously  rapid  progress  many  papers  and  facts 
grow  stale  or  obsolete  in  much  less  time  than  that.  Be- 
sides this  it  is  impracticable  for  the  officers  of  Sections  to 
exercise  any  discriminating  judgment  in  regard  to  what 
shall  be  placed  upon  the  program.  And  while  the  gen- 
eral standard  may  be.  and  I  believe  is  creditable,  and  in 
many  instances  ranking  very  high  indeed,  there  must 
necessarily  be  an  unfortunately  large  proportion  of  rub- 
bish mixed  with  it.  These  are  difficulties  not  peculiar  to 
Chicago,  but  simply  peculiar  to  this  method  of  conduct- 
ing a  journal  in  the  interests  of  an  organization  which 
meets  only  once  a  year.  It  seems  to  me  that  we  should 
set  ourselves  to  work  in  some  way  to  remedy  the  defects 
of  The  Journal  inherent  not  in  its  location  or  editorial 
management,  both  of  which  are  creditable  in  a  high  de- 
gree, but  rather  dependent  upon  the  peculiar  circum- 
stances under  which  it  is  published. 

G.  W.  McCaskey,  M.D. 

26  W.  Wayne  St.,  Fort  Wayne,  Ind.,  Feb.  16,  1S91. 


324 


MISCELLANY. 


[February  28,  1891. 


To  the  Editor: — As  a  member  of  the  Association,  I 
have  carefully  read  and  compared  the  various  reasons  as- 
signed for  the  removal  of  The  Journal,  or  for  continu- 
ing its  publication  in  Chicago,  wishing,  in  casting  my 
vote,  to  do  so  only  after  mature  consideration. 

It  would  occupy  too  great  space  to  review  the  pros  and 
cons — the  arguments  offered  on  both  sides  of  the  ques- 
tion— those  of  Dr.  Solis-Cohen's  removal  article,  so  ably 
replied  to  by  Harold  N.  Moyer,  M.D.,  and  Harvey  Reed, 
M.D.:  the  spicy  and  patriotic  non-removal  vote  of  E. 
Chenery,  M.D.;  besides  various  other  articles  appearing 
in  The  Journal  under  the  heading:  "  Shall  The  Jour- 
nal, be  Removed  to  Washington?" 

Permit  me,  on  so  appropriate  an  occasion,  to  offer  the 
tribute  of  my  sincere  esteem  to  Dr.  E.  Chenery,  for  the 
display  of  such  unbiased  and  patriotic  sentiments  as  ex- 
pressed in  his  letter  to  The  Journal  of  January  27.  Cer- 
tainly, if  Pope  was  a  contemporary  with  Dr.  Chenery,  he 
would  have  found  an  exception  to  the  doubt  expressed  in 
the  lines: 

"  Where  is  the  man  who  counsel  can  bestow, 
Unbiased  or  by  favor  or  by  spite." 

Please  record  my  vote  against  removing  The  Journal 
from  Chicago,  and  especially  against  removal  to  Wash- 
ington. 

"Come,  your  reason,  Jack,  your  reason." 

While  my  reasons  may  not  be  "as  plenty  as  blackber- 
ries," there  being  no  compulsion,  as  in  Sir  John's  case, 
1  will  simply  urge  the  objection  to  Washington,  on  strict- 
ly sanitary  and  hygienic  reasons. 

I  respectfully  call  the  attent'on  of  the  Trustees  of  the 
Association  to  page  S67,  "Da  Costa's  Medical  Diagno- 
sis," seventh  (last)  edition,  line  17  to  line  39. 

Under  article  "Fevers,"  calling  attention  to  the  effects 
of  malaria  in  simulating  acute  meningitis,  Prof.  Da  Costa 
states  that  the  patient  had  spent  part  of  his  summer  va- 
cation in  the  marshy  neighborhood  of  Washington— the 
cerebral  symptoms  arising  in  which  case  so  simulated 
acute  meningitis,  that  it  was  only  through  the  use  of  the 
quinine  treatment  that  a  differential  diagnosis  could  be 
arrived  at. 

In  this  connection,  one  of  the  most  prominent  scien- 
tific members  of  the  medical  profession  in  the  United 
States,  in  an  address  before  the  British  Medical  Associa- 
tion, not  many  years  ago,  in  speaking  of  the  deleterious 
effects  of  malaria  upon  the  human  system,  declared  that 
malaria  was  antagonistic  to  high  mental  culture,  or  words 
to  that  effect. 

I  think  that  for  the  successful  publication  of  The 
Journal,  it  should  be  kept  as  far  as  possible  from  all 
marshy  or  malarial  centres,  that  the  intellectual  facul- 
ties of  the  editor,  publisher  and  type-setters,  ct  hoc  genus 
omne,  connected  with  it,  may  enjoy  the  full  scope  to  be 
attained  only  in  a  pure  atmosphere,  uncontaminated  bv 
antagonistic  intellectual  influences.  "Stare  decisis,  el 
non  quiela  movere,"  is  a  law  maxim  it  would  be  well  to 
bear  in  mind,  in  considering  the  question  of  the  locus  in 
■quo  for  The  Journal.  C.  D.  Owens,  M.D., 

Pres.  Louisiana  State  Medical  Society. 

Eola,  La.,  February  16,  1891. 


We  of  Galena  are  far  from  the  maddening  and  demor- 
alizing influence  of  political  parties  and  their  intrigues, 
and  when  we  come  home  from  our  muddy  country  rides 
and  hang  up  our  splashed  overcoats,  we  can  give  to  our 
editorial  work  the  full  power  of  our  massive  intellects. 

I  think  Chicago  the  proper  place  for  the  home  of  The 
Journal,  but  as  I  said  before,  if  it  must  be  removed  let  it 
come  to  the  central  city  of  Galena,  and  not  to  the  outer 
edge  of  the  territory  at  Washington. 

Henry  T.  Godfrey,  M.D. 

Galena,  111. 


To  the  Editor: — If  The  Journal  should  be  moved  to 
Washington  City  I  am  fearful  much  of  its  life  and  vigor 
would  be  lost.  Business  activity  is  contagious,  and  in 
Chicago  we  have  the  benefit  of  the  stimulus  of  this 
kind  of  an  epidemic  all  the  time. 

J.  T.  McShane,  M.D. 

Carmel,  Ind.,  Feb.  23,  1891. 


To  the  Editor: — Keep  The  Journal  in  the  great  city 
of  the  enterprising  West.  Chicago  is  the  only  city  that 
presents  so  many  advantages  for  the  publication  of  The 
Journal.  J.  J.  Garver,  M.D. 

Indianapolis,  Ind.,  Feb.  23,  1891. 


To  the  Editor: — Permit  me,  as  a  member  of  the  Amer- 
ican Medical  Association  since  1877,  to  interpose  my  de- 
cided opposition  to  the  removal  of  The  Journal  to 
Washington  or  anywhere  East.  From  my  standpoint  I 
cannot  see  any  good  reasons  for  the  change,  while  to  the 
contrary,  many  sufficient  reasons  have  already  been  sug- 
gested, by  many  members  from  different  points  of  the  com- 
pass, why  it  should  not  be  removed  to  Washington,  but 
should  remain  in  the  great  central  interior  city  of  Chi- 
cago, where  it  first  saw  the  light,  and  where  it  has  served 
us  so  well.  J.  H.  DaviSSON,  M.D. 

Los  Angeles,  Cal.,  Feb.  19,  1891. 


To  the  Editor: — To  some  men  the  arguments  in  favor 
of  Chicago  are  too  obvious  and  too  numerous  to  require 
enunciation.  Insane  or  insincere  men  I  have  neither 
time  nor  inclination  to  labor  with.  Yours  for  Chicago, 
ten  thousand  times  Chicago! 

Donald  Maclean,  M.D. 

Detroit,  Mich.,  Feb.  23,  1891. 


To  the  Editor: — As  a  member  of  the  American  Medical 
Association  I  wish  to  record  my  name  "with  the  crowd" 
and  say:  Let  the  place  of  publication  remain  where  it  is. 
I  think,  with  Dr.  John  M.  Batten,  that  it  should  remain 
in  its  native  habitat.  H.  C.  Fairbank,  M.D. 

Flint,  Mich.,  Feb.  20,  1891. 


To  the  Editor: — If  the  home  of  THE  JOURNAL  must  be 
removed  from  Chicago,  let  it  come  to  Galena,  111.  It 
was  the  home  of  Grant,  Washburn.  Rawlins  and  other- 
great  men.  It  is  far  more  central  than  Washington  and 
has  eight  physicians,  equally  inexperienced  in  editorial 
work  with  their  brethren  of  the  Capital  City,  and  equally 
full  of  enthusiasm  for  the  good  work. 


MISCELLANY. 


Official  List  of  Changes  in  the  Stations  and  Duties  of  Officers  Serving 
in  the  Medical  Department,  U.  S.  Army,  from  February  ;./,  rSoi,  to 
! .  bruary  20,  i8oz. 

I.ieut.  Col.  Charles  C.  Byrne,  Surgeon,  is  relieved  from  duty  at  Ft. 
Sam  Houston,  Tex.,  and  will  report  in  person  to  the  commanding 
General,  Dept.  of  the  Columbia,  for  dutv  as  Medical  Director  of 
that  Dept.,  relieving  Col.  Btynard  J.  D.  Irwin,  Surgeon.  Col.  Ir- 
win, on  being  relieved  by  I.ieut.  Col.  Byrne,  will  proceed,  via  San 
Francisco,  Cal..  to  St.  Louis,  Mo.,  and  report  in  person  to  the  com- 
manding General,  Dept.  of  the  Missouri,  for  duty  as  Medical  Di- 
rector of  that  Dept.,  relieving  Col.  Charles  Page,  Asst.  Surgeon 
General.  Col.  Page,  on  being  relieved  by  Col.  Irwin,  will  report 
in  person  to  the  commanding  General,  Div.  of  the  Atlantic,  fur 
duty  as  Medical  Director  of  that  Division.  By  direction  of  the 
Seeretarv  of  War.  Par.  6,  S.  O.  36,  A.  G.  O.,  Washington,  Fehru- 
■    1  .,  1891. 

Capt     Louis   M,    Mans,  Asst.    Surgeon,  IS  relieved  trom    duty  at    Ft. 

Stanton,  N.  M  ,  and  will  report  in  person  to  the  commanding  offi- 
ce] .  Whipple  Bks.,  An/  ,  for  dutv  at  that  station,  relieving  Capt, 
Richard  W,  [oho  son,  Asst  Surgeon.  Capt.  Johnson,  on  being  re- 
Capt  M.nis  will  report  in  person  to  the  commanding 
mi  Carlos,  Aii/.  Ter.,  for  dutv  at  that  station.  By  direc- 
tion ol  the  Secretary  of  War.  Par.  7,  S.  O.  35,  A.  G.  O.,  Washing- 
ton, February  1,  1891. 


C0RR1GEXDUM. 

in  The  Journal  of  February  .1,  page  286,  next  to  the  last  line 
11  third  paragraph,  for  "Madder"  read  "blades." 


T  1 1  E 


J  ournal  of  the  American  Medical  Association. 

EDITED  UNDER  THE  DIRECTION  OF  THE  BOARD  OF  TRUSTEES. 

PUBLISHED    WEEKLY. 


Vol.  XVI. 


CHICAGO,  MARCH  7,   1891. 


No  10. 


ADDRESSES. 


FORCED  RESPIRATION. 

An  Address  delivered  before  tht    I 

BY  GEO.   E.  FELL.  M.D.,  F.R.M.S., 

OF  BUFFALO.    X.    Y. 

LATE     PRESIDENT   OF   THE   AMERICAN    SOCIETY  OF   MICROSCOPISTS. 

PROFESSOR   OF   PHYSIOLOGY    AND     MICROSCOPY'   MED. 

DEP'T'  NIAGARA    UNIVERSITY,    ETC. 

It  niay  be  well  to  premise  what  I  have  to  say 
by  calling  attention  to  the  difference  in  the  mean- 
ing of  the  terms  used.  We  understand  by  arti- 
ficial respiration,  an  artificial  method  of  breathing 
for  an  individual ;  but  since  forced  respiration 
has  been  used,  with  such  remarkable  results,  it 
seems  to  me  terms  should  be  employed  which 
would  be  distinctive,  and  some  time  ago  I  made 
a  suggestion  to  the  profession  which  seems  to 
have  been  quite  universally  adopted,  to  the  fol- 
lowing effect : 

Auto-respiration:  respiration  by  the  individual 
for  himself. 

Deep  Respiration:  forcible  respiration  by  the 
individual  himself. 

Artificial  Respiration:  this  we  understand  to  be 
that  produced  by  the  methods  which  have  been 
suggested  by  Sylvester.  Howard,  Marshall  Hall 
and  others,  in  which  movements  of  the  limbs  of 
the  patient  and  pressure  are  made  so  as  to  draw 
the  air  into  the  lungs.  In  many  instances  arti- 
ficial respiration  cannot  be  depended  on  to  furnish 
a  sufficient  supply  of  air  to  the  lungs. 

Forced  Respiration:  those  measures  by  which 
air  is  forcibly  passed  into  the  lungs.  (T  do  not 
advocate  forcibly  withdrawing  it,  because  I  think 
it  to  be  an  unphysiological  method.) 

At  the  late  Berlin  Congress  Professor  Horatio 
C.  Wood,  of  the  University  of  Pennsylvania,  the 
only  American,  I  understand,  who  delivered  an 
address  before  the  Congress,  spoke  about  John 
Hunter  and  others  having  devised  an  appara- 
tus for  the  purpose  of  breathing  for  an  individ- 
ual where  it  was  necessary  to  do  so.  I  will 
quote  from  Professor  Wood's  address  on  "  Anaes- 
thesia "  his  remarks  in  this  connection,  which 
will  indicate  that  some  of  the  brightest  lights  of 
medicine  have  considered  the  subject  of  forced 
respiration,  but  have  not  demonstrated  its  value  ; 


but,  through  the   failure  of  their  efforts,    rather 
relegated  it  to  the  field  of  impracticable  methods. 

The  use  of  what  may  be  called  "  forced  "  respiration 
by   the   physiologist   so    nature  I    a   similar 

practice  in  man,  that  the  celebrated  John  Hunter  in- 
vented for  the  purpose  an  apparatus  which  consisted  of 
a  bellows  so  constructed  that  when  it  was  extended  one 
compartment  drew  in  air  from  the  lungs,  whilst  the  other 
drew  air  from  the  atmosphere  ;  and  when  it  was  closed 
the  process  was  reversed,  the  fresh  air  being  thrown  into 
the  lungs,  the  foul  air  into  the  atmosphere.  In  : 
Richardson,  of  London,  invented  an  apparatus  more 
elegant  and  portable,  although  identical  in  principal 
with  that  of  John  Hunter's  ;  but  I  have  not  found  that 
either  Hunter  or  Richardson  treated  by  forced  artificial 
respiration  an  actual  case  of  disease  or  poisoning.  In 
Boston  Medical  Journal,  Vol.  xxi.  1  Dr.  John 
Ellis  Blake  reported  a  successful  case  of  aconite  poison- 
ing, in  which  life  was  apparently  saved,  although  there 
was  no  pulse  for  over  three  hours,  by  artificial  respira- 
tion, with  the  use  of  oxygen.  In  this  case  Marshall 
Hall's  method  was  at  first  used,  but  later  a  small  rubber 
tube  was  connected  directly  with  a  copper  reservoir  of 
condensed  oxygen,  the  other  end  of  the  tube  terminating 
in  a  small  nozzle,  which  was  inserted  in  one  nostril. 
Four  hundred  gallons  of  oxygen  were  thus  used,  but 
how  far  the  force  of  the  compressed  gas  was  employed 
to  dilate  the  lungs  is  not  very  clear  ;  and  it  is  somewhat 
doubtful  whether  this  case  should  be  considered  as  one 
of  forced  respiration.  The  first  physician  to  use  f 61 
respiration  in  actual  human  poisoning,  with  a  clear  idea 
of  its  value  and  power,  so  far  as  my  reading  goe:- 
Dr.  George  E.  Fell  I  International  Medical  Congress. 
Washington.   : 

It  is  plain  that  the  bellows  constructed  by  John  Hunter 
and  by  Richardson  are  unnecessarily  complex  and  faulty 
in  principle.  There  is  no  need  whatever  of  drawing  the 
air  out  of  the  fully  filled  lungs.  Every  physiologist 
knows  that  when  the  muscular  system  is  completely  para- 
lyzed by  woorari  or  even  by  death,  that  the  chest-walls 
have  sufficient  elasticity  to  force  air  out  of  the  lungs, 
and  all  ordinary  laboratory  apparatus  for  artificial 
piration  is  based  upon  this  fact.  For  forced  artificial 
respiration  in  man,  an  ordinary  bellows  of  proper  size  is 
all  that  is  required  for  the  motive  power. 

The  real  difficulty — the  point  to  be  especially  investi- 
gated and  studied — is  as  to  the  connection  between  the 
bellows  and  the  lungs.  Hunter  aud  Richardson  simply 
placed  a  tube  in  one  nostril,  closing  firmly  the  other 
nostril  and  the  mouth  of  the  subject. 

Dr.  Fell  at  first  used  a  tracheal  tube,  the  insertion  of 
which,  of  course  necessitated  the  performance  of  trache- 
otomv.  In  one  case,  however,  a  simple  mask  covering 
the  mouth  and  nostrils  was  a  perfect  success.  I  have 
had  no  opportunity  of  trying  the  apparatus  on  the  living, 
but  have  made  a  series  of  experiments  upon  dead  bodies, 
which  have  demonstrated  that  usually  a  face-mask  is  all 
that  is  necessary  for  the  performance  of  artificial  respira- 
tion. Before  using  the  mask  the  tongue  should  be  well 
drawn  forward,  and  if  necessary  fixed  in  this  position  by 


326 


FORCED  RESPIRATION. 


[March  7, 


an  ordinary  piece  of  suture  silk  run  through  it,  which  upon  a  cadaver,  and  worked  accordingly.  When 
can  be  held  in  the  hand  of  the  operator.  If  in  any  indi-  tj^e  man  gave  evidence  of  life,  I  was  as  much 
vidual  case  the  mask  fails,  an  intubation  tube  may  be  in-  ised  as  any  one  present.  I  rightfully  In- 
troduced into  the  larynx.  I  do  not  believe  that  it  is  ever  '"'l"'^  .  i,  ■  K-  „,  \- 
necessary  to  perform' a  tracheotomy.  came  quite  enthusiastic  over  the  operation. 
Dr.  Fell's  apparatus  consists  of  a  pair  of  foot-bellows  When  some  time  afterward,  I  went  to  Pittsburgh 
(the  bellows  have  always  been  used  by  hand  power),  by  ;  as  Treasurer  and  Custodian  of  the  American  So- 

which  air  is  forced  into  a   receiving  chamber,  which  is       .  f  Microsc0pjsts    to  attend  the  annual  meet- 

connected  with  an   apparatus  for  warming  the  air,  and  a    .        ->  .    f     .   '  .  ■ 

valve  which  can  be  opened  and  shut  by  a  movement  of  mg  of  that  Society,  it  was  suggested  that  I  might 

the  finger.     This  valve  in  turn  leads  to  the  tracheal  tube,    explain    my    methods   to    some  of  the    physicians 

When  the  valve  is  opened  the  air  rushes  through  the  there.  Some  of  Pittsburgh's  ultra-conservative 
chamber  into  the  lungs  and  expands  them  ;    the  finger  is  ,     .       j  j  however,  thought  it  was  just  as  well 

lifted,  the  valve  shuts,   the  lungs  contract;    and  so  the  ■■?    ■>  '  '.  °  ■>  . 

respiration  goes  on.  I  have  no  doubt  that  this  apparatus  |  to  let  me  go  to  Washington,  where  I  was  mtend- 
is  efficient  in  practice,  but  it  is  open  to  the  serious  objec-  ing  to  read  a  paper  on  the  subject,  "  for  fear  there 
tion  of  being  unnecessarily  complex  and  costly.  J  might  be  some  under-hand  business  about  it." 

A  much  simpler,  cheaper  a*d  probably  equally  effici-    Tfa         SQme     f  QUr   Buffalo  physicians  intimated 
ent1  apparatus  may  consist  simply  of  a  pair  of  bellows  01  '  .-i-  1      ,., 

proper  size,  a  few'  feet  of  India  rubber  tubing,  a  face-  that  what  I  had  done  was  nothing  novel ;  the 
mask,  and  two  sizes  of  intubation  tubes.  There  should  operation  was  an  old  one.  said  thejT ;  dogs  had 
also  be  set  in  the  tubing  a  double  metal  tube,  with  open-  been  treated  {killed)  bv  forced  respiration  ever 
jugs  so  placed  that  their  size  can  be  so  regulated  by  turn-      .  vivisection   came  to   be   Utilized  in  the  meet- 

ing the  outer  tube  (similar  to  that  commonly  found  in    .  ,  ,    ,  , 

the  tracheal  canula  of  the  physiological  laboratory),  so  leal  colleges.  I  was  well  aware  of  that,  but  I 
that  it  is  in  the  power  of  the  operator  to  allow  for  the  had  never  been  taught  in  medical  college  that 
escape  of  any  excess  of  air  thrown  by  the  bellows.  I  forced  respiration  would  save  even  a  dog's  life, 
suppose  this  whole  apparatus  could  be  prepared  at  a  very  fa  j        the  Hfe  Qf  a  human  being     And  this  was 

small  cost,  and  it  seems  hardly   necessary  to  point  out  ■ => 

its  probable  value  in  various  narcoting  poisonings,  and  the  teaching  of  the  world  at  that  time.  I  knew 
in  other  accidents  in  which  death  is  produced  by  a  that  my  apparatus  was  original  in  its  conception, 
temporary  paralysis  of  the  respiratory  centres.  The  |  practicability  and  results,  and  took  Steps  which 
proper  use   of  it   could   be  taught  to  persons   without  ;  d   tfai      f     t       As    a   further   fact,    to    show 

special  medical  skill,   so  that  it  ought  to  form  a  part  of  .  ,  •      ,  . 

not  only  the  surgeon's  outfit,  but  might  be  of  great  \  what  even  at  the  present  time  the  teaching  is, 
service  in  life-saving  stations,  about  gas-works,  etc  and  to  indicate  the  necessity  of  repeatedly  pre- 

I  will  comment  on  Prof.  Wood's  article  later  senting  this  subject  to  the  profession,  I  will  merely 
on  state,   that  if  you  will   turn  to  the  last  "  Blakis- 

My  first  operation  of  forced  respiration,  was  ;  ton's "  "Visiting  List,"  you  will  find,  under 
not  made  upon  the  spur  of  the  moment-  I  had  "Marshall  Hall's  ready  method  in  asphyxia," 
thoroughly  considered  it,  for  fully  a  year,  but  t  that  the  directions  are  to  "  avoid  the  immediate 
when  the  opportunity  did  present  it  was  a  re-  removal  of  the  patient,  as  it  involves  a  dangerous 
markable  one,  and  I  took  advantage  of  it.  Shortly  loss  of  time;  also  the  use  of  bellows  or  any 
after  that  first  operation  I  made  a  series  of  notes  forcing  instrument."  This  is  what  the  medical 
upon  what  I  believed  to  be  the  value  of  the  op-  profession  was  taught  to  believe  at  the  time  I 
eration.  These  were  made  in  mv  note-book  in  made  my  first  operation.  I  was  treading  upon 
the  year  1887.  I  then  said  that  I  believed  forced  the  accepted  principles  of  the  profession,  and 
respiration  would  accomplish  more  than  any  liable  to  severe  censure  had  I  failed  in  my  first 
method  of  artificial  respiration,  either  in  cases  of  operation. 

drowning,  or  even  in  cases  of  shock- in  cases  of  Well,  as  stated,  I  went  to  Pittsburgh,  and  the 
asphyxia  of  whatever  nature.  I  am  glad  to  state  conservatism  of  the  profession  showed  itself  there 
now  that  I  am  more  than  ever  satisfied  of  the  by  refusing  to  listen  to  what  I  had  to  say  upon 
truth  of  those  statements,  In  the  last  case  which  |  the  subject.  When  later,  I  went  to  Washington, 
I  will  report  here  to-night,  the  demonstration  will  I  was  not  heralded  by  any  fore-runners,  was  ac- 
bear  this  out.  quainted  with  but  very  few  individuals  at  the  In- 

I  should  like  to  enter  somewhat  into  the  in- ;  ternational  Congress,  and  it  was  with  the  great- 
teresting  experiences  which  I  have  had  since  est  difficulty  that  I  had  an  opportunity  to  read 
making  my  first  operation,  and  the  trials  and  my  paper  at  all ;  and  what  was  the  most  peculiar 
tribulations"  to  which  I  have  been  subjected  in  feature  of  the  whole  circumstance  was,  that,  even 
the  promotion  of  the  measure;  but  I  presume  anion-  a  class  of  men  supposed  to  possess  the 
that  any  one  who  makes  an  operation  possessing  highest  medical  knowledge,  not  any  of  them  saw 
so  far  reach  ins;  an  import  as  does  forced  respira-  the  point  which  presented  in  that  first  case  of 
tion,  will  probably  have  a  like  experience.  I  forced  respiration,  in  which  I  breathed  for  a  man 
made  my  first  operation  in  July,  1887,  and  saved  two  and  one-half  hours  with  a  tube  111  his  neck. 
a  life  which  I  had  thought  there  was  no  possi-  They  did  not  grasp  that  point.  And  I  now  make 
bility  of  saving.  When  I  made  tracheotomy  in  the  statement,  without  fear  of  contradiction,  that 
that  case  I  kit  that  I  was  making  the  operation   there  was  not   a    paper  presented  at  the  Inter- 

- —  I  national   Congress  at   Washington  which   had  a 

I I  do  not  agree  with  Pi    Wood,  reasons  given  further  on.     v. 


r89i.J 


FORCED  RESPIRATION. 


327 


farther  reaching  import,  if  to  save  human  life  is 
desirable,  than  that  little  paper  on  "Opium 
Poisoning,"  which  I  presented — a  paper  embody- 
ing in  it  demonstrations  which  would  alter  and 
advance  one  of  the  greatest  medical  practices  of 
the  day,  a  practice  of  wide  application.  It 
demonstrated  what  was  before  not  practically  ac- 
cepted in  medicine,  that  we  could  force  air  into 
the  lungs  for  an  almost  unlimited  period  without 
danger  to  the  delicate  lung  tissue.  Dr.  Vanden- 
burgh,  of  Columbus,  Ohio,  a  disinterested  ob- 
server, speaks  of  it  as  "  one  of  the  most  interest- 
ing and  valuable  therapeutic  discoveries  of  the 
day." 

When  I  managed,  however,  to  read  my  paper 
at  Washington,  they  did  me  the  kindness  (?)  not 
to  publish  it  in  the  proceedings.  After  I  had 
saved  my  third  life,  however,  by  forced  respira- 
tion, and  the  world  could  not  question  methods 
which  were  so  positive  in  their  demonstrations, 
and  so  undeniably  original,  there  not  being  a 
similar  case  on  record,  I  had  a  discussion  with  the 
Chairman  of  a  Section,  and  also  with  the  Secreta- 
ry-General of  the  International  Congress,  and 
from  that  discussion,  which  can  be  produced  if  it 
should  be  necessary,  it  was  evident  that  my 
paper  either  was  not  carefully  read,  or  the  princi- 
pal point  conveyed  by  it  was  not  grasped  by  the 
members  of  the  committee. 

In  my  first  case,  a  man  had  taken  20  grains  of 
morphia.  After  two  and  a  half  hours  of  forced 
respiration  with  the  apparatus  his  life  was  saved. 
That  is,  after  the  dilatation  of  asphyxia  had 
taken  place,  and  all  known   methods  had  failed. 

In  the  second  case  (not  mine),  a  man  had  taken 
8.24  grains  of  morphia.  This  case  occurred  in 
Vienna,  Austria,  two  months  after  my  first  case. 
After  four  and  a  half  hours  of  forced  respiration, 
that  is,  you  must  note,  after  artificial  respiration 
had  failed  to  do  any  good,  the  patient  was  saved 
by  forced  respiration. 

In  the  third  case  (my  own),  a  man  had  taken 
2  ounces  of  laudanum.  It  had  been  demonstrated 
that  artificial  respiration  would  not  save  him. 
He  was  dying.  Then  we  began  with  forced 
respiration,  and  after  fourteen  and  one  half  hours 
with  the  new  apparatus  which  I  had  devised,  his 
life  was  saved.     That  was  by  tracheotomy 

But  the  fourth  case  came.  A  man  had  taken 
2  ounces  of  laudanum,  had  severed  the  anterior 
jugular  vein,  and  had  lost  a  large  amount  of 
blood.  For  twenty-one  and  one-half  hours  con- 
tinuously applied  forced  respiration  kept  him 
alive  until  he  could  breath  for  himself,  and  then 
in  a  few  hours  he  asked  that  it  be  applied  again. 
He  is  now  living  in  the  southern  part  of  the 
States,  in  good  health.  In  this  case  was  demon- 
strated a  very  interesting  point  which  has  not 
been  brought  out  prominently,  which  is,  that  in 
a  case  of  great  loss  of  blood  from  haemorrhage 
it  does  very  little  good  to  inject  ether  or  brandy 


into  tlu-  peripheral  capillaries,  unless  you  can  in- 
ject it  into,  or  proximally  to  a  large  vein,  where 
you  know  it  will  be  taken  into  the  circulation. 
Tin  patientlaid  in  bed  nearly  two  months  merely 

because  the  ether  and  brandy  which  had  been  in- 
jected into  the  chest  produced  a  gangrenous  con- 
dition of  the  tissue.  The  fluid  was  not  carried  off 
by  the  capillary  circulation,  and  the  muscles  of 
the  chest  sloughed  away,  down  to  the  ribs.  In 
the  thigh,  where  injections  had  also  been  made, 
owing  to  the  same  cause  existing,  a  weak  or  very 
slow  capillary  circulation,  an  abscess  formed,  and 
a  cup  of  pus  was  removed  on  the  first  incision. 
This  demonstrated  very  interestingly  the  neces- 
sity of  care  in  the  employment  of  hypodermic 
medication  where  there  is  excessive  haemorrhage. 

Following  these  interesting  cases,  came  a  series 
in  which  the  results  were  not  so  successful.  An 
old  gentleman,  80  years  of  age,  had  taken  1 
ounce  of  laudanum.  At  the  hospital  artificial 
respration  was  used,  the  hospital  physicians  gave 
him  up.  Then  forced  respiration  kept  him  alive 
for  some  twelve  hours  after  that. 

One  of  my  most  interesting  cases  was  a  little 
child,  18  days  of  age,  of  one  of  our  prominent 
citizens,  which  had  accidentally  been  given  1 
grain  of  morphia  by  a  physician  of  the  homoeo- 
pathic school.  The  little  one  took  the  whole  of 
the  poison,  equivalent  to  about  eighty  doses,  and 
came  under  the  influence  of  it.  It  was  given 
about  a  quarter  to  one.  I  was  called  at  five 
o'clock.  Without  proper  apparatus  I  went  to 
work  and  made  tracheotomy,  a  most  difficult 
undertaking  in  one  so  young  ;  but  I  succeeded  in 
getting  down  to  the  trachea.  I  then  with  a 
small  catheter  inserted  into  the  trachea,  kept  up 
forced  respiration,  with  bellows  and  valve,  with 
the  result  that  the  little  one,  which  was  markedly 
cyanosed,  became  of  a  natural  hue,  the  blood  be- 
came oxygenized,  and  it  breathed  for  itself  a 
short  time.  The  bowels  moved  and  the  evidence 
was  strong  that  the  child  might  live.  But  owing 
to  the  long  time  during  which  the  asphyxiated 
condition  had  lasted  through  the  influence  of  the 
poison,  it  was  too  much  to  expect  that  we  could 
retain  the  vital  condition  of  the  tissue  of  the 
brain  for  a  sufficient  time,  as  was  demonstrated 
by  the  heart  failing  to  act  some  four  hours  after 
the  forced  respiration  was  begun,  when  death 
supervened.  This  was  one  of  the  most  striking 
demonstrations  I  ever  had  of  the  value  of  forced 
respiration. 

Again,  it  is  usually  conceded  that  when  you 
can  obtain  no  pulse  at  the  wrist  and  no  heart  ac- 
tion on  auscultation,  that  an  individual  is  (nearly) 
dead.  This  condition  existed  in  one  instance 
which  occurred.  It  was  a  case  of  opium  poison- 
ing. The  day  before  this  case  presented,  I  was 
about  to  make  tracheotomy  and  earn-  out  my  op- 
eration in  another  case,  when  I  noticed  indica- 
tions that  the  patient  would  probably  live  with- 


328 


FORCED  RESPIRATION. 


[March  7, 


out  it ;  we  waited,  and  he  did  pull  through 
without  the  operation.  The  next  day  I  had  the 
case  referred  to.  I  waited  until  there  was  no  pulsa- 
tion at  the  wrist,  and  could  detect  no  heart  action 
011  listening  over  the  chest-wall.  I  then  made 
tracheotomy.  The  blood  was  markedly  venous, 
but  upon  passing  oxygen  into  the  lungs  it  be- 
came oxygenized  and  red,  and  furthermore,  the 
heart  action  became  distinct,  and  the  pulse  again 
was  present  at  both  wrists.  But  after  an  hour 
the  heart  again  ceased  beating.  I  had  waited  a 
little  too  long  before  beginning  the  forced  respira- 
tion. 

After  this  I  demonstrated  another  method,  by 
which  we  could  perform  forced  respiration  without 
tracheotomy,  and  the  first  application  of  it  oc- 
curred in  trying  to  keep  alive  a  still-born  infant 
by  passing  a  tube  into  the  mouth  and  compressing 
the  nostrils  ;  I  succeeded  in  keeping  it  alive  for  a  , 
number  of  hours.  Owing,  however,  to  compres- ' 
sion  of  the  brain  produced  in  labor  which  ex- 
isted, there  was  evidently  no  chance  for  the  child 
to  live,  and  I  gave  up  the  attempt.  So  long, 
however,  as  the  forced  respiration  was  kept  up, 
the  heart  continued  to  beat. 

Then  came  another  case  which  demonstrated, 
also,  that  life  can  be  kept  up  by  forced  respira- 
tion without  tracheotomy.  A  man  had  taken  2 
ounces  of  laudanum.  One  of  the  physicians" 
present  called  attention  to  the  dilatation  of  the 
pupils  as  an  indication  of  the  very  near  approach 
of  death.  I  had  begun  to  make  the  operation 
for  tracheotomy,  but  found  the  blood  markedly 
venous.  I  stopped,  and  inserted  the  tube  of  the 
apparatus  in  the  mouth,  closed  the  nostrils  and 
forced  air  into  the  lungs  through  the  mouth,  and 
had  the  satisfaction  of  seeing  the  blood  in  the 
neck  turn  from  a  dark  purple  to  bright  scarlet, 
indicating  that  there  was  sufficient  heart  action 
to  carry  the  oxygenized  blood  through  the  sys- 
tem, and  demonstrating  the  valuable  fact  that 
through  the  mouth  and  the  nostrils  sufficient  air 
could  be  made  to  pass  to  the  lungs  for  a  time  to 
retain  life  without  the  necessity  of  tracheotomy. 
This  subject  seemed  to  have  a  mania  for  com- 
mitting suicide  by  taking  laudanum,  and  after- 
ward took  2  ounces  of  laudanum  and  about  5  or 
6  grains  of  morphia  ;  I  repeated  the  operation  of 
tracheotomy,  and  again  saved  him.  Upon  mak- 
ing a  third  attempt  he  was  sent  to  the  asylum, 
and  is  now,  I  believe,  cured  of  his  peculiar  habit. 

Another  case  presented  in  which  a  young 
woman  took  2  ounces  of  laudanum  ;  by  breathing 
for  her  four  hours  with  the  face-mask  alone,  her 
life  was  saved,  i.  c,  without  tracheotomy. 

Now  comes  a  case  which  I  want  particularly 
to  call  your  attention  to,  as  one  in  which  some 
facts  were  demonstrated  which  I  had  been  wait- 
ing for  for  a  long  time.  Dr.  Wood,  while  ad- 
mitting that  I  made  the  first  comprehensive  op- 


•  Dr.  Carltou  C  Fredericks. 


eration  of  forced  respiration,  criticized  the  ap- 
paratus used,  and  in  reply  to  his  objections  I 
desire  to  state  that  when  I  made  my  first  opera- 
tion it  was  with  incomplete  apparatus,  and  it  was 
surprising  on  this  account  that  I  did  not  lose  the 
case.  Had  I  failed  it  would  probably  have 
"settled"  the  question  of  forced  respiration. 
Before,  however,  attempting  to  construct  a  suita- 
ble apparatus,  I  very  carefully  considered  the  de- 
tails and  the  conditions  to  be  met,  and  the  ap- 
paratus as  finally  devised  consists  of  a  trache- 
otomy tube,  a  tube  connected  with  the  air-control 
valve,  and  then  a  tube  connecting  that  with  the 
air-warming  apparatus,  which  in  turn  is  con- 
nected with  the  bellows  by  another  tube.  With 
this  apparatus,  whether  on  board  of  a  ship,  or 
even  on  the  ice,  or  elsewhere  you  can  supply  the 
human  lungs  with  air  at  the  temperature  of  the 
body  within  five  or  ten  minutes  at  the  most  from 
the  time  you  begin,  and  can  keep  it  up  for  an 
unlimited  time.  So  it  will  be  seen  that  while  my 
apparatus  covers  almost  all  the  conditions  for 
every  case  that  may  present,  yet  it  also  answers 
for  the  most  simple  method  possible  in  forced  res- 
piration. That  is,  you  can  use  the  face-mask, 
rubber  connecting  tube  and  bellows  alone,  or  the 
face  mask,  air  control  valve  and  bellows  alone, 
which  I  would  by  all  means  recommend  as  much 
better  than  the  former  combination.  In  this  last 
case,  a  woman  had  taken  an  uncertain  amount  of 
morphia — a  large  amount,  however,  as  was  evi- 
dent from  the  effect  produced  upon  her.  About 
midnight  a  physician  was  called,  but  refused  to 
attend,  so  that  she  was  under  the  influence  of 
the  narcotic  all  through  the  night,  until  about 
10  o'clock  the  next  morning.  I  was  called  at  9 
a.m.,  and  arrived  about  9:30.  I  ascertained  there 
was  no  pulse  at  either  wrist,  but  on  auscultation 
found  the  heart  faintly  acting,  cyanosis  deep.  I 
then  had  her  placed  upon  a  mattress  in  an  adjoin- 
ing room,  and  with  the  face-mask,  air-control 
valve  and  the  bellows,  went  to  work.  I  digress 
again  to  state  that  the  point  of  interest  in  con- 
nection with  this  air- control  valve  is  this,  the 
moment  3'ou  press  the  lever  the  air  passes  into 
the  lungs  ;  release  it,  air  can  pass  out  of  the 
lungs,  or  it  can  pass  into  the  lungs  (though  not 
from  the  bellows),  or  auto-respiration  can  take 
place.  The  moment  the  valve  is  pressed  down, 
though  the  bellows  may  be  ten  or  twenty  feet 
away  for  that  matter,  yet  the  air  is  under  con- 
tinual pressure,  and  enters  the  lungs  from  the 
valve  without  any  loss  of  time.  You  have  abso- 
lute control  of  the  air  passing  to  the  lungs  ;  and 
this  is  the  important  factor  in  the  whole  proceed- 
ing. (Also  in  the  use  of  the  valve,  as  improved 
oxygen  can  be  systematically  administered).  If 
you  had  the  bellows  and  the  face- mask  alone,  the 
air  would  necessarily  have  to  come  clear  from  the 
bellows,  through  the  tube,  to  the  face-mask,  be- 
fore you  could  be  sure  of  its  passing  into  the 


i89i.] 


FORCED  RESPIRATION. 


329 


lungs,  and  consequently  the  respiration  could  not 
be  carried  on  so  satisfactorily.  Dr.  Vandenberg's 
apparatus  operates,  I  believe,  so  that  when  you 
work  the  bellows  air  passes  into  the  lungs  ;  but 
when  you  stop  the  bellows,  the  flow  of  air  ceases  ; 
and  I  do  not  think  there  is  as  quick  control  of  air 
passing  to  the  lungs  as  by  the  method  I  have 
used  so  satisfactorily.  Furthermore,  all  the  phy- 
sician has  to  do  is  to  work  the  air-control  valve, 
and  any  one  can  work  the  bellows,  which  is  the 
work  in  which  physical  exertion  is  expended.  In 
the  case  now  under  consideration,  I  worked  for 
fully  an  hour  and  a  half  before  the  pulse  at  the 
wrist  could  be  detected.  The  woman  then  be- 
came conscious,  sat  up  and  asked  for  a  drink. 

In  the  middle  of  the  afternoon,  Dr.  Porter  came 
in  to  witness  the  operation  and  offered  his  assis 
tauce,  which  was  accepted.  It  ma}'  be  stated  that 
when  a  person  is  very  deeply  narcotized,  with 
forced  respiration  we  may  occasionally  produce  a 
conscious  condition,  but  the  patient  will  again 
pass  under  the  influence  of  the  narcotic,  and  be- 
come utterly  unconscious.  You  may  breathe  for 
him  or  her  for  half  an  hour  at  a  time,  yet  there 
will  be  no  evidence  of  life  except  the  action  of 
the  heart  and  the  fact  that  the  blood  is  supplied 
with  oxygen.  So  this  lady  would  occasionally 
become  conscious.  During  one  of  these  conscious 
periods  Dr.  Porter,  who  had  been  standing  in  one 
corner  of  the  room,  came  forward  and  began  to 
perform  Sylvester's  method  of  artificial  respira- 
tion— with  the  object,  I  presume,  of  demonstra- 
ting that  it  would  accomplish  as  much  as  what  I 
was  doing.  He  understood  how  to  apply  that 
method  from  previous  experience.  All  watched 
the  result  with  interest.  In  a  little  while,  the 
cyanotic  condition  began  to  appear  along  the  face, 
gradually  becoming  deeper  and  deeper.  I  said, 
"Doctor,  you  see  now  just  what  the  result  is." 
"  Yes,"  he  said,  "  there  is  no  question  about  it." 
We  then  renewed  the  forced  respiration  with  the 
face- mask.  In  a  short  time  the  cyanotic  condi- 
tion disappeared,  and  the  woman  again  became 
conscious.  I  regard  it  as  a  very  important  and 
interesting  fact  to  state,  therefore,  that  we  had 
here  a  demonstration  that  forced  respiration  with 
the  face  mask  will  accomplish  more  than  the  best 
of  the  methods  of  artificial  respiration  in  use  in 
the  past  throughout  the  world.  You  can  save 
life  by  forced  respiration  by  this  method  when 
you  cannot  possibly  do  it  by  any  method  of  arti- 
ficial respiration  whatever.  I  kept  up  forced  res- 
piration with  this  woman  until  she  revived  again, 
and  began  to  be  in  quite  a  jovial  condition,  and 
as  I  thought,  was  perfectly  safe.  Then  Dr.  Por- 
ter desired  to  try  the  Faradic  battery,  which  I 
consented  to,  regarding  the  woman's  condition 
such  that,  were  it  necessary,  we  could  at  any 
time  rely  upon  the  forced  respiration  again.  I 
was  anxious,  of  course,  to  report  this  as  another 
case  of  life  saved  by  forced   respiration.     After 


breathing  some  eight  hours  and  carrying  the  case 
through  the  most  critical  period,  we  called  the 
Faradic  battery  into  play.  But  what  is  the  result 
of  faradization  in  a  case  of  that  kind  ?  Merely 
the  stimulation  of  the  heart  at  the  expense  of  its 
energy.  However  weak  the  current  may  be,  if 
you  obtain  any  heart  action,  it  is  of  a  tonic  na- 
ture, and  secured  at  the  expense  of  the  energy  of 
the  heart  muscle.  What  we  need  to  look  out  for 
in  such  a  case  is  to  conserve  the  energy  and  the 
vitality  of  the  heart  muscle.  In  this  case  the 
result  was  that  after  about  three-quarters  of  an 
hour  of  faradization  the  heart  stopped  beating, 
spasmodically.  The  case  was  lost  through  fara- 
dization. 

Now,  a  moment  to  consider  the  relative  value 
of  tracheotomy  and  of  the  face- mask  in  forced 
respiration.  Is  tracheotomy  any  better  than  the 
face  mask?  Prof.  Wood,  of  Philadelphia,  says  he 
does  not  think  it  will  ever  be  necessary  to  resort 
to  tracheotomy.  My  belief  is,  founded  on  this 
last  case,  that  in  a  long- continued  operation  it  is 
possible  to  breathe  for  the  patient  more  easily  and 
thoroughly  by  resorting  to  tracheotomy.  In  re- 
spiring for  a  person  with  the  face-mask,  it  must  be 
remembered  that  the  passage  to  the  stomach  is 
open,  and  the  air  passes  down  the  oesophagus  to 
stomach  and  intestines.  This  presents  the  diffi- 
culty in  working  with  the  face-mask.  If  it  is 
desired  to  eliminate  poisons  the  patient  may  be 
given  anything  without  danger  of  fluids  passing 
into  the  trachea,  by  the  tracheotomy  method;  and 
you  have  better  control  of  the  patient.  If  I  had 
a  case  in  which  I  thought  I  should  have  to  respire 
for  the  patient  for  eight  or  ten  hours  or  more,  I 
would  make  tracheotomy,  feeling  that  I  could 
accomplish  more,  and  have  more  thorough  con- 
trol of  the  patient. 

I  do  not  recommend  as  yet  intubation,  because 
I  think  there  are  many  cases,  in  fact  have  seen 
many,  where  it  was  not  practicable  owing  to  the 
difficulty  of  intubating  the  larynx;  and  if  wTe  can 
pass  air  into  the  larynx  or  trachea  without  intu- 
bation, as  by  the  face-mask,  it  is  of  course  always 
better  to  do  it.  This  is  mj'  opinion,  from  the  ex- 
perience derived  in  operations  on  a  dozen  living 
beings. 

In  these  experiences  I  have  encountered,  I 
think,  quite  a  number  of  facts  bearing  upon  the 
treatment  of  opium  narcosis  which  are  both  new 
and  valuable ;  but  I  will  not  refer  to  that  at  the 
present  time.  I  merely  wish  at  this  time  to  call 
attention  to  the  interesting  fact  that  with  the  face- 
mask  and  forced  respiration  more  can  be  accom- 
plished, as  I  believe,  than  by  any  method  of  artifi- 
cial respiration  ;  and  the  widely  accepted  dictum 
of  Marshall  Hall  that  we  must  use  no  forcible 
measures,  leads  me  to  give  unusual  emphasis  to 
this  statement. 

I  will  merely  add,  in  closing  this  inpromptu 
talk,  that  fifteen  lives  are  so  far  to  be  credited  to 


33Q 


MORVAN'S  DISEASE. 


[March  7, 


the  operation   of  forced  respiration.      When  it :      Originally  Morvan  stated  the  three  characteris- 
comes   into  general   use  in  cases  of  drowning,    tics  of  this  condition  to  be,    1.   Initial  pains  of  a 
shock,   the  tiding  over  of  critical  cases,  in   as 
phyxia  from  whatever  cause,  as  well  as  from  nar- 
cotic poisons,  who  will  not  admit  it  is  one  of  the 
most  important  procedures  at  our  command  ? 
(For  discussion  see  Society  Proceedings.) 


neuralgic  sort  in  the  extremities;  2.  The  appear- 
ance of  paresis  and  analgesia,  mainly  in  the  hands; 
3.  The  appearance  of  successive  painless  and  de- 
structive whitlows.  Subsequently  he  modified  this 
dictum,  as  cases  fell  under  observation  in  which 
sensation  was  not  materially  changed,  or  in  which 
paresis  was  absent,  so  that  the  only  characteristic 
to  be  insisted  upon  is  destructive  and  numerous 
whitlows. 

The  disease  has  numbered  more  men  than  wo- 
men, but  the  few  cases  recorded  do  not  justify 
generalization  in  this  and  many  other  particulars. 
Instances  have  been  noted  at  all  periods  of  life  from 
twelve  to  sixty  years,  and  for  the  most  part  occur 
in  individuals  exposed  by  out-door  avocations. 
As  it  is  the  lower  portion  of  the  cervical  enlarge- 
,  1  tnent  that  is  primarily  and  mainly  affected,  the 
The  first  description  of  the  diseased  state  which  sure  of  the  neck  by  these  pe0ple  to  the   in- 

by  courtesy  and  for  convenience   maybe  called ,  clemencies  of  the  seasons  may  be  worth  noting, 

"  Vtnr\-an'<;  flKpnsp       was  marie  hv     )r    Morvan.  ot  .  .  «•_■■-. 


ORIGINAL  ARTICLES. 

MORVAN'S  DISEASE;  WITH  THE  CLINI 
CAL  REPORT  OF  A  CASE. 

Read  before  the  Chicago  Medical  Society,  March  2, 1891. 
BY  ARCHIBALD  CHURCH,  M.D., 

PROFESSOR  OF  NEUROLOGY  IN  THE  CHICAGO  POLICLINIC,  ETC. 


Morvan's  disease,"  was  made  by  Dr.  Morvan,  of 
Lannelis,  in   Brittany,  and  published  in  the  Ga 


en  passant,  as  a  predisposing  factor. 

The  tangible  clinical  points  of  any  one  case  are 


*  ,    , '  ...         ,      ■,*,-,•■  ,    i     /~i  ■  •     •      I         luc  lautiuic  ■.iiuiccu  uuiiiu-5  ui  any   uuc  case 

ette  hebdomidaire  de  Mcduine  et  de  Chirurgie  in  :  ratber  m        e>  and  owing  to  the  essentially  ch_ 
1883,  under  the  title  of  ■  Paresie  Ana  gesique  avec  ;  fc  and  ssive  course  of  the  malad     the  earl 

Panaris  des  Extremities  Supeneures.  Since  that  j  ,es  are  often  kft  in  doubt  th  h  the  fo  t. 
date  he  has  made  numerous  communications  on  i  fulnesg  of  tfae        ■  F  nUv  there  is  a  his. 

the  same  subject  m  the  same  journal  with  the  re-,  Qf  neura,    ic     ains   of  ,  duration  in  the 

ports  of  eighteen  cases  In  1885  M.  Broca  (Ann  extremities  afterwards  affected,  and  this  is  follow- 
dc  D-rmat  et  de  Syphilog.) published  a  case,  and  |  ed  b  weakness.  Soorjer  or  later  a  feIon  makes 
m    !887   M.    Prouff  {Gazette  Hebdom.\   pother  k  nce  and]  dependi ng  upon  the  condition 

Breton  physician,  recorded  one   followed  by  Ha-  nt  as  to  ana]gesia,  is  painful  or  absolutely 

not  in  the  same  year.  In  1888  d  Oger  de  Speville  |  free  from  discomforti  though  the  swelling,  red- 
collated  in  a  Pans  thesis  nine  cases  from  various  I  and   ulceration  attain 


sources.     In  i88g  Heckel  published  a  clinical  ob- 


grade. 


destructive 
Indeed,  the  tendency  of  these  inflamma- 


servation  (BerlinKhn.  Wochenschnff)  The  same  1 1  disturbances  is  to  produce  more  than  in  or- 
year  (5^.  ^/^.)Gombault  reported  the  autopsy  1  dj  amQunt   of  destruction    and    mutiiation. 

of  ProufFs  case  before  the  Societe  Medicale  des  There  ig  usuaH  exfoliation  of  a  t  or  the  whole 
Hopitauxde  Pans  and  in  1890  Charcot  (P,og.  of  tfae  terminal  phalangeal  bone,  and  the  upper 
Med.)  published  a  clinical  lecture  on  the  subject,    rankg  are  nQt  infrequently  lost.     The  nail  matrix 


to  which  the  writer  is  mainly  indebted  for  the 
following  description  and  for  cuts  1  and  2. 

A  majority   of  the  recorded  cases  have  been 
among  the  Breton  peasantry,  but  the  condition 


is  also  affected,  resulting  in  dwarfed,  claw-like 
nails,  or  only  slight  horny  protuberances  may  be 
left.  When  the  analgesia  is  pronounced,  au  ap- 
parently exquisitel)'  tender   felon    may  give    no 


was  first  observed  in  that  locality,  and  possibly  is,      in  manipulation  and,  as  we  have  seen, 

as  frequently  found  elsewhere,  though  not  recog-  I  nQt  eyen  resent  the  knjfe      In  thig  conditio„  the 
n.zed  under  this  name  or  as  a  disease  of  the  cen-  j    atients  have  frequentiy  themselves  picked  out 


tral  nervous  apparatus.  Morvan's  attention  was 
first  attracted  by  finding  a  painless  whitlow.  In 
his  first  paper  (1883)  he  says  : 

Twenty-five  or  thirty  years  ago  a  man  of  60  presented 
himself,  with  a  whitlow  on  one  of  his  fingers.  We  made 
out  a  necrosed  condition  of  the  ungual  phalanx  and  ]>rn- 
]>c  .-.I  1.0  make  :ui  incision  and  extract  the  bone.  As  the 
patient  gave  his  permission  with  reluctance,  he  was  as- 
sured that  tin-  incision -would  be  made  like  a  Hash,  so 
that  he  would  not  have  time  to  suffer.  The  cut,  which 
was  sufficiently  free,  was  accordingly  made,  but  whal  was 
om  amazement  to  see  tin-  calmness  of  this  man.  Not  a 
complaint!  Had  he  been  of  wood  it  would  have  been 
quite  the-  same.  He  affirmed  that  he  had  not  suffered  it 
all.  .  .  .  Taking  a  pin,  we  thrust  it  into  various  portions 
of  the  hand  and  forearm,  which  were  swollen,  without 
causing  distress. 


the  bony  fragments,  the  slight  discomfort  not 
leading  them  to  seek  surgical  aid.  Such  fingers 
present  a  characteristic  appearance.  They  are 
short  and  thick,  and  if  the  middle  phalanx,  or 
more  emphatically  if  all  the  phalanges  are  lost, 
the  presence  of  the  stunted  nail  at  the  end  of  the 
stump  is  sufficiently  noticeable.  It  appears  as  if 
the  finger  had  been  telescoped.  (Cuts  1  and  4.) 
In  some  cases  other  evidences  of  dystrophy  are 
present.  The  flexures  of  the  fingers  and  the  pal- 
mar folds  are  liable  to  cracks  and  fissures  which 
are  difficult  to  heal,  and  may  present  thickened 
epidermic  margins  about  an  indolent  ulcerated 
centre,   comparable  to  perforating    ulcers    of  the 


i89i.] 


MORVAN'S  DISEASE. 


33i 


feet  due  to  nerve  injury,  and  not  rarely  found  in 
tabes  dorsalis.  While  the  first  felon  may  be  pain- 
ful, and  marked  by  all  the  misery  that  usually 
attends  them,  succeeding  ones  are  not,  and,  as  a 
rule,  both  hands  are  eventually  invaded.  In 
one  of  Morvan's  cases  the  lower  extremity  was 
finally  implicated.  Cases  present  from  two  to  ten 
successive  whitlows,  and  every  digit  ma}-  be  mu- 
tilated by  them.  The  tendency  is  to  their  sym- 
metrical distribution.  The  hands  become  cold, 
dry,  and  subnormal  in  temperature,  or  may  be 
the  seat  of  profuse  sudation  and  chronic  swelling. 
Broca  called  attention  to  the  fact,  confirmed  by 
Morvan,  that  the  spinal  column  in  over  one-half 
the  cases  showed  by  distortions  the  tendency  to 
dystrophy  in  osseous  structure.  The  scoliosis  or 
kyphosis,  however,  is  usually  slight  in  degree, 
and  not  accountable  for  any  injury  to  the  spinal 
cord.  Indeed,  it  is  a  result  of  the  implication  of 
the  cord,  and  another  evidence  of  the  impairment 
of  the  cord's  trophic  functions.  As  a  rule,  the 
convexity  of  the   curvature  is  toward  the  hand 


Hand  in  Morvan's  dis- 
ease.    Hanot's  case.     Af- 
ter Charcot. 

first  involved,  which  is  generally  the  right  in 
men,  the  left  in  women.  The  joints  of  the  hands, 
wrists,  elbows,  and  even  the  shoulders,  are  some- 
times affected  with  a  dry,  painless  arthritis,  and 
a  condition  analogous  to  the  joint  lesions  of  lo- 
comotor ataxia  is  developed.  (Cut.  No.  3.)  In 
several  instances  a  slightly  subnormal  tempera- 
ture has  been  persistently  recorded  even  during 
inflammatory  features  of  the  malady. 

Aside  from  the  analgesia  already  mentioned, 
and  which  seems  primarily  to  affect  the  deeper 
structures,  there  are  usually  well-marked  and  va- 
rious impairments  of  cutaneous  sensation.  Tac- 
tile, pressure  and  thermic  sensations,  severallv 
or  singly,  may  be  diminished  or  obliterated,  or 
intact.  No  mention  is  made  of  hyperesthesia, 
but  the  persistence  of  tactile  sense  with  the  com- 
plete loss  of  thermic  and  painful  impressions,  is 
said  to  be  rarely  or  never  present.  The  extent  of 
these  perverted  areas  of  sensation  seldom  passes 
above   the   upper   extremities,    though    in   some 


cases  the  body  is  invaded  more  or  less  wide- 
ly. The  forearms  and  hands  often  present  con- 
siderable muscular  atrophy,  and  to  the  electric 
current  manifest  changed  reactions  indicative  of 
nerve  degeneration.  Superficial  and  deep  reflexes 
are  not  noticeably  changed,  nor  is  coordination 
materially  modified. 

Gombault's  autopsy  of  Prouffs  case  furnishes 
all  that  is  known  of  the  anatomy  of  the  disease, 
with  the  exception  of  some  minor  observations 
made  upon  the  amputated  extremities  of  the 
fingers,  which  furnished  evidence  of  peripheral 
neuritis.  This,  the  only  case  completed  by  an 
autopsy,  was  a  woman  of  56  years,  who  from  the 
age  of  1 2  had  suffered  from  a  series  of  whitlows 
which  had  caused  considerable  mutilation,  mark- 
ed by  trophic  troubles  of  the  skin  and  muscles 
with  errors  of  sensibility,  all  located  in  the  hands. 
The  spinal  cord  and  peripheral  nerves  of  the  up- 
per extremities  were  particularly  examined.  He 
says  : 

The  nerve  lesions  consisted  in  an  exaggerated  produc- 
tion of  connective  tissue,  with  degeneration  and  disap- 
pearance of  a  large  number  of  the  tubules.  These  le- 
sions presented  the  sort  of  distribution  attributed  to 
ascending  neuritis;  that  is  to  say,  they  were  more  marked 
at  the  periphery  and  gradually  diminished  as  the  body 
was  approached.  In  the  spinal  cord  the  alterations  were 
localized  in  the  cervical  region,  and  only  implicated  the 
posterior  horns,  the  posterior  columns,  and  a  small  por- 
tion of  the  central  gray  substance.  All  these  parts  were 
the  seat  of  an  abnormal  and  diffuse  development  of  in- 
terstitial tissue  with  thickening  of  the  arterial  walls,  and 
frequently  with  obliteration  of  the  lumen  of  the  vessels. 
Nowhere  did  this  sclerosis  assume  the  form  of  an  isolated 
or  separable  tumor.  Owing  to  the  state  in  which  I  found 
the  cord  when  I  was  enabled  to  examine  it,  I  could  not 
decide  whether  there  existed  accidental  cavities  in  the 
middle  of  the  central  gray  substance,  analogous  to  those 
which  characterize  syringomyelia,  or  not.  I  am,  how-ever, 
rather  inclined  to  admit  the  negative.  Nor  can  I  decide 
whether  the  cord  change  had  been  the  cause,  or  only  the 
result,  of  the  lesions  in  the  nerves.  The  single  point  to 
retain  from  this  examination,  it  appears  to  me.  is  the  co- 
existence of  lesions  pertaining  both  to  the  cord  and  to 
the  peripheral  nerves. 

It  was  on  the  same  occasion  pointed  out  by 
Debove  that  these  lesions  bore  a  striking  resem- 
blance to  those  of  tabes.  Charcot  agreed  perfect- 
ly with  Morvan  that  the  trouble  is  primarily  in 
the  cord,  and  that  the  trophic  and  sensory  dis- 
turbances and  the  peripheral  neuritis  are  all  sec- 
ondary to  the  central  change,  while  others  find 
an  explanation  of  the  cord  lesion  in  the  extremi- 
ties and  the  pathological  conditions  found  there. 
It  is  needless  to  say  that  as  yet,  no  microbe  has 
been  brought  forward  as  an  etiological  factor,  and 
the  ultimate  cause  of  the  disease  is  wrapped  in 
the  same  mystery  which  pertains  to  other  scle- 
rotic affections  of  the  cord.  Even  syphilis  has 
not  been  accused  of  the  paternity  of  this  malady. 

The  diagnosis  of  the  disease  in  recent  cases 
must  often  be  difficult,  but  when  the  condition 
has  been  of  long  standing  it  is  probable  that  or- 
dinary attention   and  care,  with  a  knowledge  of 


332 


MORVAN'S  DISEASE. 


[March  8, 


its  existence,  will  be  quite  sufficient  for  its  recog- 
nition. A  somewhat  allied  tropho- neurosis,  lo- 
calized and  symmetrical  scleroderma,  may  at  first 
be  confusing.  When  this  condition  is  limited 
practically  to  the  hands  it  gives  rise  to  paresis, 
distortion  and  changes  of  a  general  nature  in 
sensation,  with  atrophy,  but  there  is  no  tendency 
to  alteration,  to  the  exfoliation  of  bone,  and  the 
peculiar  analgesia  above  described  as  usual  in 
Morvan's  disease  is  wanting.  The  hand  assumes 
a  peculiar  position  with  the  digits  extended,  ex- 
cept at  the  metacarpo-phalangeal  joints,  which 
are  flexed,  and  there  is  a  tendency  to  over-exten- 
sion in  the  middle  joints  of  the  fingers,  particu- 
larly in  the  index.  It  is  the  arrangement  pro- 
duced by  the  action  of  the  interosseous  muscles, 
and  is  sometimes  called  the  interosseous  position. 
The  skin  is  shiny,  adherent  to  the  bones,  and  the 
digits,  atrophied  en  masse,  behave  like  so  many 
tapering  rigid  sticks.  (Cut  No.  2.)  Associated 
with  scleroderma  is  a  peculiar  mask-like  expres- 
sion of  face,  due  to  the  implication  of  the  facial  j 
integument  and  its  adhesion  to  all  bony  promi- 
nences. This  is  so  characteristic  that,  once  rec- 
ognized, it  can  scarcely  be  mistaken. 

Another  form  of  scleroderma,  ainhum,  occur- 
ring almost  invariably  in  hot  climates  and  in  the 
dark-skinned  races,  may  produce  painless  ampu- 
tation of  fingers  and  toes,  but  usually  is  limited 
to  the  feet,  and  it  is  the  outer  toe  that  is  lost,  as 
a  rule.  In  this  condition,  the  history  of  a  slowly 
forming  constriction  by  a  cicatricial- like  encircling 
band  will  prevent  mistake. 

In  the  anaesthetic  forms  of  leprosy  the  nails, 
portions  of  the  fingers  or  entire  digits,  may  be 
lost  without  pain  or  local  suffering.  This  insen- 
sibility is  due  to  a  peripheral  neuritis  set  up  by 
the  bacillary  infection  upon  which  the  disease  de- 
pends. The  condition  is  distinguished  from  Mor 
van's  disease  by  the  history  of  exposure  to  lep- 
rosy, and  the  disseminated  leprous  nodules  and 
patches  on  the  integument  of  the  body.  The 
process,  moreover,  is  the  reverse  of  the  loss  of  a 
finger  from  whitlow.  An  abrasion  of  the  skin 
becomes  an  ulcer,  grows  deeper  and  wider,  encir 
cles  the  finger  or  envelops  it  completely,  and 
finally  causes  its  destruction  or  leads  to  its  ampu 
tation  by  the  surgeon. 

Symmetrical  gangrene  or  Raynaud's  disease,  so 
rare  a  condition  that  Billroth,  a  few  years  back, 
had  never  seen  a  case  in  his  unparalleled  field  of 
observation,  though  sometimes  causing  a  loss  of 
fingers,  presents  a  totally  different  picture  from 
Morvan's  disease.  The  digits  affected,  upon  ex- 
posure to  cold  or  in  the  morning,  or  after  emo- 
tional excitement,  present  a  blanched,  shriveled, 
purplish  or  mottled  appearance,  with  sensations 
of  tingling  and  numbness,  a  loss  of  power  aiu' 
rable  discomfort  This  passes  away  in  a 
short  time  or  may  persist  for  hours,  to  recur  under 
similar  circumstances  for  months  or  years.      Sub- 


sequently, in  destructive  cases,  the  circulation, 
which  is  said  to  be  inhibited  by  vasomotor  spasm, 
does  not  become  even  temporarily  restored,  and 
dry  gangrene  results,  causing  mummification  of 
the  members  and  finally  their  loss.  There  is  no 
whitlow,  no  peculiar  dissociation  of  cutaneous 
sensations,  and  no  evidence  of  organic  cord  dis- 
turbance before  or  after  death. 

Some  writers  and  observers,  with  Debove  in  the 
lead,  assert  that  Morvan's  disease  is  identical  with 
syringomyelia,  but  this  is  most  vigorously  denied 
by  Morvan  himself,  and  he  is  supported  by  Char- 
cot, Hanot  and  others  Nevertheless,  there  are 
many  striking  clinical  resemblances.  The  asserted 
pathognomonic  indication  of  syringomyelia  is  loss 
of  painful  sensations  and  inability  to  distinguish 
the  temperature  of  any  object  brought  into  con- 
tact with  the  affected  areas,  while  the  sense  of 
touch  and  tactile  impressions  remain  essentially 
unimpaired.  It  is  often  associated  with  atrophy 
and  paresis  depending  upon  the  distribution  of 
the  gliomatous  infiltration  about  the  central  canal 
of  the  cord,  which  forms  the  anatomical  basis  of 
the  condition  and  gives  rise  to  the  cavities  within 
the  cord  and  the  dilatation  of  its  central  canal 
upon  which  the  somewhat  unwieldy  name  de- 
pends. Morvan  insists  that  this  particular  disso- 
ciation of  the  cutaneous  sensations  is  never  found 
in  the  malady  bearing  his  name,  and  the  single 
post  mortem  observation  already  quoted  does  not 
correspond  with  the  findings  in  cases  of  syringo- 
myelia now  on  record.  However,  both  Morvan's 
disease  and  syringomyelia  number  but  few  pub- 
lished comolete  instances,  and  it  may  be  prema- 
ture to  insist  upon  their  absolute  differentiation. 
Tc  an  unprejudiced  mind  the  prime  point  of  im- 
portance is  the  fact  that  they  both  depend  upon 
an  irregularly  distributed  sclerosed  condition  of 
the  cord.  The  variations  outside  of  that  seem 
to  be  a  matter  dependent  only  upon  the  position 
of  this  adventitious  and  unsystematized  lesion  as 
it  affects  nutrition,  sensation  and  other  myelic 
functions  in  proportion  to  their  anatomical  impli- 
cation. Besides,  all  gradations  between  typical 
syringomyelia  and  typical  Morvan's  disease  have 
been  encountered.  Both  are  instructive  in  dem- 
onstrating the  location  of  sensory  tracts  in  the 
cross  section  of  the  cord.  The  clinical  and  an- 
atomical features  of  resemblance  between  tabes 
dorsalis  and  Morvan's  disease  have  been  already 
pointed  out. 

The  course  of  the  malady,  as  already  often  in- 
dicated, is  extremely  chronic,  and  as  far  as  now 
known,  practically  beyond  the  influence  of  ther- 
apeutical intervention.  In  any  given  case  it  is 
to  be  expected  that  whitlows  will  occur  from  time 
to  time,  and  of  course  the  resulting  mutilations 
are  irreparable.  In  some  instances,  from  this 
source,  septicaemia  has  resulted  and  terminated 
life.  Such  measures  as  are  directed  against  a  low 
grade  of  inflammation  in  the  cord  are  to  be  tried 


'»9i.] 


MORVAN'S  DISEASE. 


333 


and  persevered  with,  and  of  course  the  general 
health  is  to  be  maintained.  It  would  seem  spe- 
cially advisable  that  the  hands  receive  scrupulous 
care  and  protection,  as  any  traumatism  or  super- 
ficial abrasion  may  cause  serious  results  or  even 
lead  to  the  loss  of  a  finger. 

The  following  case  was  brought  to  the  writer's 
attention  by  Drs.  Patrick  and  Harris,  of  this  city, 
and  of  the  Policlinic  staff,  in  November,  1889, 
for  an  opinion  regarding  the  nature  of  the  joint 
disease  in  the  left  wrist  'Cut  3),  its  similarity  to 
the  joint  lesions  of  locomotor  ataxia  having  given 
rise  to  discussion.  At  that  time  undue  weight 
was  attached  to  the  scoliosis,  which  is  marked 
(Cut  5),  and  implication  of  the  cord  or  nerve  roots 
was  suspected.  Further  consideration  of  the  case 
enables  one  to  classify  it  with  those  recorded  un- 
der the  title  of  "  Morvan's  disease,"  even-  im- 
portant symptom  of  which  it  presents,  besides 
some  additional  features  not  incompatible  with 
such  diagnosis.  Since  that  date  the  man  has 
been  casually  seen  at  intervals,  and  nothing  new 
has  developed.  Recently  (January,  1891)  a  care- 
ful and  thorough  examination  has  been  made  and 
photographs  obtained,  from  which  cuts  3,  4  and 
5  are  reproduced. 


No.  3. — From  a  photograph.      Hand   in 
Morvan's  disease,  snowing  joint  lesion. 

Case. — A.  X.  is  an  unmarried  Swede  of  35 
years,  who  has  been  in  this  country  since  1886. 
He  now  makes  a  fair  living  by  taking  orders 
about  the  city  for  a  tobacco  firm,  in  which  occu- 
pation he  does  much  walking,  and  is  in  the  en- 
joyment of  excellent  physical  health,  confirmed 
by  his  general  appearance.  His  family  history 
presents,  as  far  as  he  is  informed,  absolutely  noth- 
ing in  the  way  of  a  neurotic  trace,  and  his  parents 
both  attained  a  very  advanced  age.     As  a  child, 


youth  and  young  man  he  was  always  in  good 
health,  growing  up  in  the  country.  He  was  en- 
gaged in  farming  until  he  came  to  America.  Ow- 
ing to  the  poverty  of  the  family  and  the  barren- 
ness of  the  land,  his  life  was  one  of  extreme  labor 
and  hardship.  His  habits  have  been  exception- 
ally good  in  all  respects,  and  there  is  neither  his- 
tory nor  trace  of  any  venereal  infection.  He 
states  that  some  ten  years  ago  his  back  became 
crooked.  Previous  to  that  time  he  asserts  that 
he  was  as  straight  as  any  one.  About  the  same 
period  he  had  a  felon  on  the  right  ring  finger, 
near  the  extremity  on  the  palmar  surface,  which 
was  excessively  painful,  kept  him  awake  nights, 
was  marked  by  high  inflammation,  great  swell- 
ing, deep-seated  suppuration,  and  which  has  left 
the  finger  stunted,  with  a  deformed  nail  and  short- 
ened distal  phalanx  as  shown  in  cut  4.  Six  years 
ago,  after  a  bath  in  a  lake  on  a  cold  day,  he  drove 
several  miles  in  a  cold  wind,  and  in  a  day  or  two 
the  left  hand,  wrist  and  arm  became  greatly  swol- 
len and  very  painful.  He  was  sick,  confined  to 
I  his  bed  for  a  month,  and  remembers  having  severe 
chills  and  a  high  fever.  The  swelling  in  his  wrist, 
where  the  main  difficulty  was  located,  never  entire- 
ly subsided,  and  now  presents  the  contour  and  de- 
formity shown  in  Cut  3.  There  is  no  pain,  heat, 
redness  or  tenderness  about  the  greatly  enlarged 
joint,  though  the  carpus  seems  entirely  disinte- 
grated. Upon  passive  motion,  which  is  but  slight, 
there  is  roughness,  grating  and  creaking  in  this 
articulation.  The  thumb  is  shortened  as  is  the 
entire  hand,  and  seems  to  articulate  directly  with 
the  radius.  Its  extremity  does  not  reach  the  first 
phalangeal  joint  of  the  index,  as  it  should  nor- 
mally, by  nearly  an  inch.  There  is  a  subluxation 
of  the  entire  metacarpus  forward,  and  spastic 
flexion  of  the  fingers,  which  cannot  be  straight- 
ened voluntarily,  and  passively  only  by  the  em- 
ployment of  considerable  force.  The  whole  hand 
is  diminished  in  thickness  and  width,  and  the  fin- 
gers present  a  delicate  appearance  out  of  keeping 
with  the  rest  of  the  extremity,  which  is  rather 
muscular.  The  integument  is  somewhat  smooth- 
er than  usual,  but  these  points  may  be  due  to  the 
comparative  disuse  of  the  hand  for  heavy  work. 
The  extensor  tendons  of  the  fingers  are  salient  on 
the  back  of  the  hand,  and  the  intrinsic  muscles 
seem  wasted.  Over  the  thumb  he  has  good  con- 
trol, and  the  thenar  eminence  is  full  and  round. 
Although  the  grasp  of  the  hand  is  very  much  re- 
duced, it  is  a  useful  member,  capable  of  many- 
complicated  and  fine  manoeuvres. 

Three  years  ago  he  lost  the  end  of  the  right 
index  by  what  he  describes  as  exactly  the  same 
process  which  ten  years  ago  attacked  and  muti- 
lated the  right  ring  finger,  with  the  very  extraor- 
dinary exception  that  it  was  absolutely  painless 
and  not  even  marked  by  tenderness.  He  states 
that  the  finger  was  enormously  swollen,  very  red 
and  angry  looking,  finally  discharging  pus,  and 


334 


MORVAN'S  DISEASE. 


[March  7, 


that  he  himself  picked  out  of  it  several  fragments 
of  bone.  As  shown  in  cut  4,  it  now  presents  but 
a  small  portion  of  the  middle  phalanx,  the  distal 
bone  being  completely  absent,  and  the  greatly  de- 
formed, horny,  nipple-shaped  nail  is  seated  upon 
the  end  of  the  stump.  The  scar  marking  the  open- 
ing through  which  the  bones  escaped  is  on  the 
anterior  surface,  running  to  and  involving  the 
nail  matrix. 


No.  4.  — From  a  photograph.  Hand  in  Morvan's  disease,  show 
ing  mutilation  from  whitlows. 

Within  that  same  year  the  middle  finger  of  the 
right  hand  went  through  exactly  the  same  pro 
gramme  and  exhibits  practically  the  same  muti 
lation,  though  even  more  shortening  is  present 
In  both  these  fingers  the  joint  between  the  first 
phalanges  and  the  fragments  of  the  second  is  pre- 
served. The  hands  show  no  other  trophic  dis- 
turbances. The  skin  is  elastic,  soft,  properly 
moist  and  of  a  good  color,  indicating  no  material 
change  in  the  circulation  of  the  parts,  nor  are 
they  unpleasantly  affected  b}'  cold  weather. 

Upon  testing  the  sensibility  of  the  hands  it  is 
found  that  on  all  parts  the  lightest  touch  with  a 
flake  of  cotton  wool  is  instantly  perceived  and  ac 
•curately  located.  Indeed,  he  responds  to  this 
■delicate  test  better  than  some  individuals  in  a 
presumab'y  normal  state  of  health.  The  prick 
of  a  pin  is  equally  well  felt,  but  not  as  a  painful 
sensation.  He  cannot  detect  the  difference  be- 
tween a  pin  point  and  a  blunt  pencil,  and  this  too 
•when  the  pin  is  thrust  sufficiently  into  the  skin 
to  remain  standing  there.  Whey  tested  with  sim- 
ilarly shaped  hot  and  cold  objects  it  is  only  with 
difficulty  that  he  can  properly  make  out  their  re- 
spective temperatures,  and  slight  variations  escape 
him  entirely.  These  peculiar  conditions  are  pres- 
ent in  all  portions  of  both  hands  and  gradually  fade 


out  upwards  toward  the  elbows.  There  is  no  re- 
tardation whatever  in  the  transmission  of  tactile 
impressions,  and  no  subjective  unnatural  sensa- 
tions. Palpation  does  not  detect  any  tenderness 
over  the  nerves  or  thickening  of  their  trunks.  Co- 
ordination in  the  upper  extremities,  as  tested  by 
having  the  patient  make  exact  movements  of  wide 
range  while  his  eyes  are  closed,  is  quite  normal, 
and  electrical  tests  present  no  departure  from  the 
formula  of  health,  even  in  the  left  hand.  The 
muscular  sense  seems  normal. 


His  gait  is  somewhat  shambling  and  difficult 
to  describe,  being  more  of  a  peculiarity  than  any- 
thing else.  There  is  no  limp  or  dragging  of  the 
feet,  and  he  walks  in  a  straight  line  with  great 
precision  and  firmness  with  his  eyes  closed.  His 
body  is  plump,  smooth  and  free  from  blemish  of 
any  sort,  but  the  spinal  column  shows  a  com- 
pound curvature.  The  convexity,  beginning  in 
the  upper  dorsal  vertebrae,  is  backwards  and  to  the 
right,  embracing  most  of  the  dorsal  region,  with 
a  compensatory  curve  in  the  opposite  direction 
in  the  lower  dorsal  and  the  lumbar  spine.  These 
curves  are  practically  very" pronounced  exaggera- 
tions of  the  normal  lateral  deflections,  and  cer- 
tainly not  sufficient  in  themselves  to  implicate  the 
cord,  the  lesion  of  which,  indeed,  cannot  be  below 
the  first  dorsal  segment.  They  may  explain  the 
peculiar  walk.  There  is  no  tenderness  anywhere 
along  the  spine  or  any  marked  prominence  of  the 
spinous  processes,  and  the  column  is  ordinarily 
flexible  throughout.  In  taking  the  photograph 
from  which   Cut  5  is   made,  the   outline   of  these 


l8ui.] 


ABSCESS  OF  THE  LUNG. 


335 


processes  was  indicated  by  roughly  marking  them 
on  the  patient's  back  with  iodine. 

An  examination  of  deep  and  superficial  reflexes 
detects  nothing  abnormal,  though  the  knee  jerk 
is  somewhat  pronounced.  There  has  never  been 
any  loss  of  control  over  the  bladder  and  rectum, 
or  difficulty  of  any  sort  with  these  organs.  There 
is  likewise  nothing  in  the  history  suggestive  of 
the  lightning  pains  and  crises  of  locomotor  ataxia, 
nor  girdle  pains,  nor  hyperaesthesia  of  any  char- 
acter. The  special  senses  and  their  respective  or- 
gans are  quite  normal,  the  mind  unaffected. 

In  summing  up  the  case  the  analgesia  in  the 
hands,  the  dystrophy  of  the  wrist  joint,  the  loss 
of  fingers  by  whitlows,  all  point  to  the  diagnosis 
of  Morvan's  disease  and  furnish  its  most  salient 
characters.  The  retention  of  the  tactile  sense 
with  the  marked  blunting  of  painful  and  thermic 
impressions,  per  contra,  constitute  the  so-called 
pathognomonic  indication  of  syringomyelia.  This 
therefore  is  probably  a  mixed  case.  Such  a  num- 
ber of  speculations  as  to  the  exact  location  of  the 
lesion  in  the  cross  section  of  the  cord  present 
themselves,  that  their  discussion  is  idle.  This 
much  seems  certain,  the  anterior  horns  and  the 
pyramidal  tracts  are  not  implicated.  The  solu- 
tion must  be  left  to  a  post- mortem  examination 
which,  fortunately  for  the  patient,  appears  to  be 
a  distant  contingency. 

167  Dearborn  St.,  Chicago. 


ABSCESS  OF  THE  LUNG. 

Read  before  the  St.  Louis  Medical  Society,  December  14,  iSgo. 
BY  WILLIAM  PORTER,   M.D., 


I  have  not  thought  to  present  an  exhaustive 
essay  upon  this  theme.  The  subject  is  interest- 
ing, its  literature  comparatively  meagre,  and  it  is 
closely  related  to  the  progress  of  that  most  ag- 
gressive department  of  our  science — surgery ;  so 
that  at  least  I  may  offer  a  few  conclusions  regard- 
ing it  for  your  discussion. 

Permit  me  at  the  outset,  by  way  of  definition, 
to  say  that  it  is  not  intended  in  this  paper  that 
the  term  abscess  should  apply  to  those  accumula- 
tions of  pus  secreting  cavities  which  are  so  often 
found  in  the  later  stages  of  phthisis,  but  only  to 
the  circumscribed  suppuration  which  may  arise 
independently  of  tubercular  processes.  The  his- 
tory of  pulmonary  abscess  as  given  by  the  older 
writers  is  not  very  exact.  They  generally  sup- 
posed that  the  condition  was  the  result  of  delayed 
resolution  of  pneumonia,  and  that  if  the  inflam- 
mation did  not  subside  by  the  twenty-first  day 
suppuration  was  sure  to  result.  This  latter  propo- 
sition is  not  in  accord  with  modern  knowledge, 
yet  we  do  find  that  abscess  is  often  preceded  by  a 
pneumonia  more  or  less  severe.  Stokes  places  ab- 
scess as  the  fifth  and  last  stage  of  pneumonia, 


while  Leyden  further  recognizes  a  form  of  chronic 
abscess,  occurring  in  chronic  pneumonia,  resem- 
bling the  vomica  of  phthisis.  While  there  may 
be  many  causes  that  predispose  to  pulmonary  ab- 
scess, the  positive  causes  aside  from  traumatism 
and  foreign  substances  are  easily  placed  in 
three  classes:  1.  Inflammation  within  the  lung; 
2.  Perforation  of  pus  cavities  from  without,  as 
for  instance,  from  the  liver  or  pleural  sac:  3.  Em- 
bolism from  right  endocarditis  or  from  the  sys- 
temic veins.  I  believe  also  that  we  may  some- 
times have  the  first  and  third  conditions  com- 
bined. In  croupous  pneumonia,  for  instance, 
there  is  not  only  the  local  inflammation  within 
the  pulmonary  structures,  but  often  a  marked  de- 
pression of  the  vaso- motor  system  and  of  the  mo- 
tor ganglia  of  the  heart.  As  a  consequence  there 
is  in  addition  to  the  local  pneumonia,  a  distension 
of  the  pulmonary  vessels,  oftentimes  of  the  right 
ventricle  itself,  and  greatly  diminished  circulatory 
force  within  the  lung,  conditions  that  must  favor 
obstructions  in  either  the  bronchial  or  pulmonary 
system  with  destruction  or  infection  of  the  tissues 
beyond  the  occluded  point.  Several  cases  of  cir- 
cumscribed abscess  of  the  lung  that  I  have  ex- 
amined closely  gave  no  evidence  of  preexisting 
pneumonia,  while  everything  pointed  to  the  hy- 
pothesis that  the  local  lesion  was  the  result  of  in- 
farction from  embolism. 

A  few  points  in  the  etiology  of  pulmonary  ab- 
scess may  be  noticed  in  passing.  The  first  is 
the  statement  found  in  most  of  our  books  upon 
the  subject,  that  local  inflammations  in  the  lung 
cause  the  single  abscess,  while  the  results  of  em- 
bolism are  multiple.  Not  always  is  the  latter 
proposition  correct.  There  certainly  may  be  a 
blocking  up  of  a  single  branch  of  a  bronchial 
artery  from  embolism,  sufficient  to  cut  off  all  sup- 
ply from  that  portion  of  the  pulmonary-  structure 
beyond,  causing  gangrene;  so  also  we  may  have 
a  single  branch  of  the  pulmonary  artery  plugged 
by  an  infectious  embolism,  and  consequent  infarc- 
tion and  the  disintegration  of  the  surrounding 
structures. 

A  second  thought  closely  associated  with  the 
etiology  of  pulmonary  abscess  is  the  fact  that 
while  occlusion  of  a  bronchial  artery  is  more 
likely  to  produce  gangrene  than  an  occlusion  of 
a  pulmonary  branch,  yet  the  latter  conditions  may 
also  cause  gangrene  by  the  infarction  and  often 
consequent  apoplexy,  destroying  the  bronchial 
circulation  and  thus  cutting  off  nutrition. 

While  then  we  may  believe  that  an  embolism 
in  either  the  bronchial  or  pulmonary  systems  may 
produce  gangrene,  is  it  not  also  probable  that  an 
embolism  in  a  bronchial  branch  may  produce  an 
abscess  ?  The  fragments  from  this  form  of  endo- 
cardiac  inflammation  are  known  to  have  septic 
properties  and  to  lead  to  suppurative  infarctions. 
Why  not  in  a  small  bronchial  artery  as  well  as 
elsewhere  ? 


336 


ABSCESS  OF  THE  LUNG. 


[March  7, 


Again,  we  may  ask  the  question  as  to  the  rela- 
tion between  a  slowly  resolving  pneumonia  and 
pulmonary  abscess.  Generally  the  influences  of 
the  local  inflammation  may  be  directly  the  cause 
of  the  consequent  suppuration  and  we  nearly 
always  find  the  abscess  at  this  site  of  the  pneu- 
monia. I  believe  it  possible,  however,  for  septic 
material  to  be  carried  from  the  lung  itself,  during 
the  processes  either  of  suppurative  pneumonia  or 
pulmonary  tuberculosis,  to  pass  from  the  pul- 
monary venous  system  through  the  left  heart 
into  the  aortic  and  by  way  of  the  bronchial 
arteries  back  into  the  lung,  and  so  producing  in- 
farction and  infection.  My  reason  for  this  hy- 
pothesis is  the  result  of  an  autopsy  in  a  case  of 
croupous  pneumonia,  which  had  become  suppu- 
rative, and  the  finding  of  a  haemorrhagic  infarct 
and  tissue  degeneration  in  the  opposite  lung,  in 
which  were  no  post-mortem  evidences  of  pneu- 
monia. 

Believing  embolism,  either  of  a  bronchial  or 
pulmonary  arterial  branch,  to  be  a  frequent  cause 
of  abscess  in  the  lung,  I  would  not  underestimate 
the  effect  of  local  inflammation  in  the  lung  as  a 
causative  agent,  for  after  all,  most  of  the  cases  of 
abscess  are  the  result  of  such  conditions.  This 
is  what  we  might  expect  where  restoration  to  the 
normal  is  delayed,  especially  after  pneumonia. 
In  the  croupous  type,  and  indeed,  in  the  catarrhal 
also,  the  epithelial  lining  of  the  vesicle  is  de- 
stroyed, and  if  a  suppurative  process  follows  in- 
complete resolution  it  is  not  hard  to  understand 
how  the  pus-bathed  vesicular  wall,  with  impaired 
blood  and  nerve  supply,  may  break  down  and  the 
vesicles  coalesce  in  abscess  cavities. 

The  close  parallelism  which  exists  in  the  eti- 
ology of  abscess  and  that  of  gangrene  is  also 
found  in  the  study  of  the  pathology.  It  is 
claimed  by  some  that  where  the  abscess  is  the 
result  of  embolism,  that  in  the  obstructed  vessel 
are  found  specific  micrococci  having  pathogenetic 
or  pyogenetic  force.  Ogston  found  microorgan- 
isms present  in  a  large  number  of  cases  of  abscess 
of  the  lung,  and  other  observers  have  made  the 
same  statement.  In  one  case  I  found  large  colonies 
of  the  bacillus  tuberculosis,  the  abscess  being  un- 
doubtedly tubercular,  although  the  rest  of  the 
lung  was  not  infected  so  far  as  could  be  deter- 
mined. After  the  destructive  tendency  has  been 
once  established  the  conditions  of  progress  do  not 
vary  much  from  what  is  known  of  abscesses  in 
any  soft  tissue.  The  main  difficulty  in  the  diag- 
nosis of  pulmonary  abscess  is  its  oftentimes  close 
resemblance  to  gangrene.  It  is  fortunate  for  us 
that  it  is  not  necessary  to  establish  positively  the 
existence  of  one  or  the  other,  in  reference  to 
treatment.  Whether  it  be  a  simple  abscess,  de- 
structive gangrene,  or,  as  often  happens,  gangrene 
with  liquefaction,  the  indications  for  interference 
are  generally  plain  enough. 

I  need  not  long  detain  the    members  of  this 


Society  in  discussing  the  diagnosis  of  abscess  of 
the  lung.  If  in  addition  to  the  physical  symp- 
toms of  localized  dulness  and  absence  of  vesicular 
murmur,  we  have  the  sudden  appearance  of  large 
quantities  of  pus  in  the  expectoration,  an  abscess 
may  be  suspected,  especially  if  we  find  the  pres- 
ence of  the  elastic  fibers  of  the  alveoli,  in  addi- 
tion to  brownish  red  pigment  and  haematoid  crys- 
tals. The  absence  or  presence  of  these  sub- 
stances, as  well  as  the  history,  will  do  much  to- 
ward determining  the  differential  diagnosis  be- 
tween abscess  of  the  lung  and  pus  cavities  pene- 
trating the  lung  from  without. 

Many  writers  have  thought  that  the  main  phy- 
sical symptom  in  making  a  diagnosis  between 
extra- pulmonary  cavities  and  those  within  the 
lung  was  the  pectoral  fremitus.  Fremitus  is  often 
absent  where  the  abscess  is  outside  the  pulmonary 
tissue,  and  increased  over  an  intra-pulmonary 
cavity  communicating  with  a  bronchial  tube,  and 
partly  filled  with  liquid,  but  in  a  paper  by  Feu- 
ger  and  Hollister  in  the  American  Journal  of 
Medical  Sciences  for  1881,  they  concede  the  doc- 
trine so  far  as  consumptive  cavities  are  concerned, 
but  doubt  whether  it  is  true  in  cases  of  abscess 
or  gangrenous  cavities.  In  several  cases  that  I 
have  examined,  where  the  diagnosis  was  after- 
wards confirmed  by  operation,  the  pectoral  frem- 
itus was  greatly  increased.  The  diagnosis  be- 
tween abscess  and  gangrene  is  not  easily  made  so 
far  as  the  physical  symptoms  are  concerned,  but 
the  more  marked  depression,  the  horribly  charac- 
teristic odor,  not  011I3'  of  the  sputum,  but  of  the 
breath,  and  the  greyish  green  expectoration  of 
gangrene  will  not  be  easity  forgotten.  The  lower 
layer  of  the  sputum  from  gangrene,  when  allowed 
to  stand,  contains  peculiar  plug-like  structures 
called  "mycotic  bronchial  plugs"  by  Eichorst, 
from  which  Jaffe  obtained  a  snow-white  substance 
which  turned  blue  when  iodine  was  added,  but 
which  was  neither  albuminoid  nor  saccharine. 
He  and  Leyden  gave  this  fungus  the  name  of 
"leptothrix  pulmonalis,"  resembling  as  it  does 
the  leptothrix  buccalis.  This  cannot  be  estimated 
as  an  unfailing  evidence  of  gangrene,  as  the  same 
fungus  is  found  in  the  sputum  of  other  diseases 
when  allowed  to  putrefy. 

When  an  abscess  of  the  lung  has  been  recog- 
nized, the  manner  of  treatment  is  a  worthy  sub- 
ject for  discussion.  Shall  we,  in  the  words  ap- 
plied to  other  conditions  by  the  venerable  Dr. 
Boisliniere,  "maintain  a  masterful  inactivity"  or 
shall  we  formulate  expectant  measures  for  relief, 
or  shall  we  go  still  further  and  undertake  active 
surgical  interference  ? 

There  are  certain  conditions  which  must  be 
considered  before  these  questions  are  definitely 
answered.  It  must  be  remembered  that  it  is  not 
impossible  that  a  pus  cavity  with  such  free  exit  as 
exists  in  the  lung  may  fully  empty  itself,  and  the 
walls  contract  and  cicatrize.    Much  depends  upon 


.89i.] 


ABSCESS  OF  THE  LUNG. 


337 


the  character  of  the  general  symptoms.  If  there  : 
is  free  expectoration,  little  interference  with  res- 
piration, absence  of  pyrexia,  and  nearly  normal 
pulse  there  may  be  no  great  danger  in  delay.  i 
These  conditions  are  exceptional,  however,  and 
the  temperature  and  the  pulse,  as  well  as  the  | 
quantity  of  pus  expectorated,  point  to  rapid  dis- 
integration which  calls  for  active  treatment.  The 
location  of  the  abscess  may  have  something  to 
do  with  the  question  of  treatment.  Fortunately 
the  direct  danger  from  suppuration  is  not  great. 
The  large  vessels  and  nerves  are  well  to  the  me- 
dian line,  except  in  the  upper  part  of  the  chest, 
and  abscess  in  a  lower  lobe  is  comparatively  easily 
reached.  Just  here  let  me  say  that  contrary 
to  the  statements  of  many  of  our  best  authors,  I 
have  not  found  abscess  of  the  upper  lung  even 
comparatively  frequent,  except  in  tuberculous 
cases.  Nearly  all  of  the  cases  of  which  I  have 
notes  were  found  in  the  lower  lobe,  and  generally 
on  the  left  side.  I  would  not.  however,  place  the 
experience  of  a  single  observer  in  opposition  to 
the  aggregated  result  of  main'. 

The  size  of  the  abscess  cavity  may  be  an  im- 
portant consideration  in  determining  the  treat- 
ment, while  we  might  be  willing  to  wait  the  fur- 
ther development  where  the  lesion  is  small  and 
non-aggressive,  yet  we  would  not  procrastinate  in 
cases  of  opposite  conditions.  I  believe  it  is  a 
recognized  principle  in  surgery  that  when  there 
is  pus  it  should,  if  possible,  be  evacuated.  That 
this  principle  should  apply  to  pus  in  the  lung  as 
well  as  elsewhere  is  a  reasonable  conclusion,  not 
only  theoretically,  but  as  a  deduction  from  prac- 
tice. Even  in  cases  where  the  abscess  is  small, 
where  the  general  symptoms  are  mild  and  the 
local  disintegration  limited,  it  is  a  question  as  to 
whether  the  abscess  should  not  be  treated  as  it 
would  be  did  it  occur  in  any  other  part  of  the  body 
within  reach. 

But  where  there  is  evidence  of  rapid  breaking 
down  of  the  lining  structures,  where  the  general 
symptoms  of  fever,  restlessness  and  great  depres- 
sion are  prominent,  it  seems  to  me  that  there  can 
be  little  doubt  as  to  what  should  be  done,  and 
done  quickly,  lest  there  be  further  infection  from 
the  pus  cavity.  The  indications  for  operation 
may  not,  however,  apply  to  tubercular  cavities  if 
there  be  general  pulmonary  infection. 

Where  there  seems  to  be  a  demand  for  removal 
of  the  pus,  we  may  ask  with  Fenger  and  Hollis- 
ter,  "Is  the  cavity  so  situated  that  we  may  get  at 
it  from  the  outside,  and  is  the  pleural  cavity  cov- 
ering it  obliterated  by  adhesions,  so  that  we  do 
not  run  any  risk  of  causing  a  fetid  pyopneumo- 
thorax by  opening  into  the  abscess  and  allowing 
thedecomposed  matterto  enter  the  pleural  cavity?'' 

The  surgeon  of  to-day  who  removes  ovaries 
from  the  abdomen  and  tumors  from  the  brain, 
would  scarcely  hesitate  to  explore  any  part  of  the 
thorax  did  he  have  a  reasonable  prospect  of  good 


result.  Certainly  the  largest  part  of  the  lung  be- 
low the  mammary  and  axillary  regions  are  within 
reach  of  the  exploring  needle,  and  if  need  be, 
the  knife. 

The  second  question  is  of  serious  import;  for 
surely  we  would  gain  little  did  we  but  transfer 
the  infectious  pus  producing  process  from  the 
lung  to  the  pleural  sac.  There  is  comfort  in 
the  thought  that  if  the  abscess  be  large  and 
near  the  surface,  there  are  often  adhesions  obliter- 
ating the  pleural  cavity  and  removing  the  danger 
in  this  direction.  The  authors  above  referred  to 
assert  that  it  is  quite  possible  to  determine  the 
existence  of  adhesions  by  making  an  incision 
down  to  the  intercostal  muscles  and  passing  a 
needle  through  both  pleural  walls.  If  the  needle 
moves  synchronously  with  the  respirations,  there 
are  adhesions;  if  not  the  pleural  walls  are  not 
adherent  and  the  operation  may  be  abandoned. 

The  above  is  a  valuable  suggestion  but  the  con- 
clusion may  be  modified.  Under  no  circumstances 
would  I  abandon  an  operation  for  pus  so  situated, 
unless  the  life  of  the  patient  were  in  immediate 
peril.  The  fact  of  a  non-adherent  pleura  may 
change  the  character  of  the  operation,  but  the  de- 
sired result  should  be  obtained  in  the  evacuation 
of  the  pus. 

When  the  necessity  for  surgical  treatment  is 
apparent,  there  still  may  be  a  question  as  to  the 
nature  of  the  operation,  Mosler,  some  twenty 
years  ago,  drained  a  superficial  tubercular  cavity 
through  a  silver  tube.  Fenger,  a  decade  later, 
recommends  a  double  soft  rubber  drainage  tube, 
and  both  of  these  avoid  resection  of  the  rib.  I  be- 
lieve that  a  better  operation,  especially  where  the 
abscess  is  large  and  low  down,  is  to  excise  a  large 
piece  of  the  rib  directly  over  the  cavity  and  make 
a  free  opening  into  the  pleural  sac.  This  free  open- 
ing into  the  serous  chamber  not  only  does  away 
with  the  danger  of  subcutaneous  emphysema  but 
enables  us  to  keep  the  pleural  cavity  thoroughly 
aseptic  and  lessens  the  difficulty  spoken  of  by 
Fenger  and  Hollister,  where  there  are  no  adhe- 
sions. If  the  cavity  be  large,  the  excision  of  the 
rib  is  better  for  the  same  reason  that  it  is  almost 
necessary  empyema  in  that  it  permits  a  quicker 
and  better  closure  of  the  abscess  cavity.  This  is 
the  method  advocated  b}-  Ruenberg,  of  Sweden, 
and  adopted  by  some  of  our  best  surgeons,  al- 
though others  object  to  the  excision  of  the  rib  on 
account  of  possible  periostitis  and  necrosis. 

After  the  pleural  sac  has  been  freely  opened  a 
much  smaller  incision  may  be  made  into  the  pul- 
monary tissues.  Within  the  lung,  even  at  the 
base,  are  arteries  and  veins  sufficient  to  cause  con- 
siderable haemorrhage,  which  may  be  difficult  to 
control.  Sutton  warns  against  plunging  the  knife 
into  the  lung,  and  Fenger  suggests  a  small  open- 
ing made  by  a  trocar  gradually  dilated  by  blunt 
instruments  till  large  enough  to  admit  a  good 
sized  soft  rubber  tube. 


338 


CYSTOMA  OF  THE  LARYNX. 


[March  7, 


As  the  patient  will  necessarily  remain  in  bed  for  weak  carbolic  acid  solution  and  in  each  case  com- 
a  considerable  time  the  opening  should  be  made  plete  recovery  ensued.  The  fetid  expectoration 
far  back  on  the  side  to  allow  free  drainage.  The  ceased,  the  temperature  became  less,  and  the  pa- 
tube  may  be  kept  in  place  by  a  safety  pin  passed  |  tients  began  to  improve  immediately  after  the 
through  its  outer  end  and  fastened  to  an  adhesive   evacuation  of  the  pus. 

strip.  An  absorbent  compress  and  bandage  will  These  cases  will  be  more  fully  reported  else- 
not  only  take  up  the  pus  which  will  continue  to  where  from  a  surgical  standpoint,  but  I  have  re- 
come  away  for  some  time,  but  will  prevent  the  j  ferred  to  them  here  to  substantiate  the  position 
exit  and  entrance  of  air  during  respiration.  taken  in  this  paper:    1.  That  abscess  of  the  lung 

That  the  operation  is  justifiable  is  shown  by  the  ]  presents  signs  and  symptoms  which  may  admit 
record.  In  1SS1  Feuger  and  Hollister  reported  of  a  positive  diagnosis.  2.  That  abscess  of  the 
six  cases,  one  of  which,  their  own,  recovered,  and  i  lung  may  be  the  result  of,  or  complicate  gangrene 
Ruenberg  {London  Medical  Record,  1887)  collated  from  occlusion  of  a  bronchial  artery.  3.  That 
eleven  cases  of  abscess.      Two  recovered  and  in   operation  is  often  demanded,  and  that  the  safest 


three  cases  the  diagnosis  was  doubtful.  In  the 
three  fatal  cases  death  could  not  be  attributed  to 
the  surgical  operation.      In    seventeen  cases   of 


operation  is  the  excision  of  a  rib,  giving  free  op- 
portunity to  prevent  accumulation  in  the  pleural 
sac.      4.   That  the  result  of  such  operations  indi- 


2830  Locust  street. 


gangrene  collected  from  medical  literature,  where   cate  the  value  of  this  comparatively  new  field  for 
pneumotomy     was    performed,   seven    recovered  j  surgical  investigation, 
more    or    less    completely    {Annual    of    Medical 
Science,  1888). 

Permit  me  to  offer  an  abstract  of  the  history  of 
two  cases  of  gangrenous  abscess  of  the  lung  seen   CYST0MA  OF  THE  ARYTENOID  REGION 
during  the  last  year. 

Case  1. — Mrs.  G.,  of  North  Eighteenth  street, 
a  young  married  lady  of  good  family  history.  I 
first  saw  her  in  March,  1890,  in  consultation  with 
her  family  physician,  Dr.  A.  S.  Barnes.  The 
statement  was  made  that  she  had  not  been  well 
since  thi  birth  of  her  child  some  months  before, 
and  meanwhile  she  had  had  a  severe  attack  of 
influenza.  She  was  greatly  reduced  in  strength 
and  flesh.  The  symptoms  and  physical  signs  be- 
fore described  as  belonging  to  abscess  of  the  lung 
were  present.     The  odor  was  the  most  offensive 


OF  THE  LARYNX,  WITH  THE  RE- 
PORT OF  A  CASE. 

Read  before  the  Section  of  Laryngology  of  the  Tenth  International 
Congress,  Bet  tin,  ityo. 

BY  W.  E.  CASSELBERRY,  M.D., 


PROFESSOR  OF  MATERIA  ^ 
YNGOLOGY  AND  RHINOLOGV 
LARYNGOLOGIST   TO 


OF  CHICAGO. 

ND  THERAPECTICS,  AXD  OF  LAS- 
I  THE  CHICAGO  MEDICAL  COLLEGE. 
E  WESLEY   HOSPITAL,    ETC. 


Under  this  title  it  is  proper  to  include  only 
cysts,  or  neoplasms  of  predominating  cystic  for- 
mation, which  originate  from  the  immediate  vi- 
I  ever  encountered.     The  lesion  was  in  the  lower  cinity  of  one  or  other  arytenoid  eminence,  inclu 


left  lobe  and  the  diagnosis  was  gangrenous  ab- 
scess of  the  lung. 

Case  2. — The  other  case  is  that  of  Mr.  M.,  of 
St.  Louis,  the  well  known  business  man,  of  mid- 
dle age,  prominent  in  athletic  circles  I  was 
called  in  consultation  with  his  attending  phy- 
sicians, Drs.  Kuhn  and  Ludeking,  in  October  of 
this  year.  The  lesion  was  evidently  not  of  so 
long  standing  as  in  the  former  case,  and  there 
was  no  history  of  a  predisposing  cause.  It  was 
also  in  the  lower  left  lobe.  In  addition  to  the 
usual  symptoms  of  abscess,  there  was  the  phenome- 
non of  marked  tympanitis  at  trie  site  of  the  lesion, 
which  would  be  relieved  by  severe  coughing  and 
leave  an  area  of  dulness  well  marked.  It  was  con- 
cluded that  the  tympanitis  was  the  result  of  the 
cumulation  of  air  in  a  partly  filled  cavity,  where 
by  there  was  distension  until  it  was  forced  out 
by  a  violent  contraction  from  coughing.  There 
was  the  same  kind  of  offensive  odor,  but  not  so 
great,  and  the  same  grayish-green  expectoration. 
The  diagnosis  again  was  abscess  of  the  lung  with 
gangrene.  In  each  case  the  operation  advised 
above  was  done  and  the  diagnosis  verified.  The 
cavities  were  kept  thoroughly  washed  out  with  a 


ding  the  neighboring  part  of  the  inter-arytenoid 
fold  and  of  the  ary-epiglottic  fold. 

Recent  literature  has  contained  numerous  re- 
ports of  cystomata  occurring  elsewhere  in  the 
larynx.  Schwartz,  cited  by  Garel,1  places  the 
proportion  of  cysts  among  laryngeal  neoplasms 
in  general  at  3  per  cent.,  whilst  Garel  himself, 
out  of  a  total  of  sixty  cases,  has  met  with  cysts 
of  the  larynx  sixteen  times — an  unusually  large 
proportion  of  25  per  cent.  Most  of  these  were 
situated  near  the  anterior  third  of  the  vocal  cords, 
and  not  one  was  in  the  arytenoid  region.  Mas- 
sei,'  of  Naples,  found  among  his  200  cases  of 
laryngeal  neoplasms  thirteen  cysts — 6.5  per  cent. 

Cohen,  in  "Sajous'  Annual"  for  1889,  cites  five 
cases  reported  during  the  year;  one  of  the  epi- 
glottis by  Huijsman,  three  of  the  vocal  cord,  re- 
spectively by  G.  Hunter  Mackenzie,  Desvernine 
Hayward  and  Seifert,  and  one  of  the  ventricular 
band  by  Audubert.  None  of  the  arytenoid  re- 
gion.     Other  cases  of  cyst  of  the  vocal  cord  have 


1     Cysts  of  the  Larynx."     Revue  dc  I.aryngologie.  Jul 
■       ■ 
Sui  ueoplasmi  la'ryngei."    Tepografia  del  bagua,  it 

Centralblatt  fiir  I .aryiigologie.  Rhinologie,  etc.,  Zahrgang 
II,  S.  124. 


I89i.] 


CYSTOMA  OF  THE  LARYNX. 


339 


recently  been  reported  by  Major3  and  Fischer;'  of 
cyst  of  the  epiglottis  by  Photiades"  and  Larmuth; 
of  the  ventricular  band  by  Hayward.7  Of  cysto 
ma  of  the  arytenoid  region  we  have  been  able  to 
find  recorded  but  a  single  case — that  of  Fundareno" 
{el  Sigh  Medico,  Madrid,  April  21,  1889),  al- 
though the  monographs  of  Ulrich,"  Mouri"  and 
Cervisato,"  in  the  original,  have  been  inaccessible 
to  us.  Another  case,  however,  probably  of  the 
same  nature,  which  was  operated  upon  by  Garel, 
is  reported  by  Moncage12  under  the  name  of  "  Fi- 
brocystic Tumor  of  the  Ary-epiglottic  Fold." 

The  etiological  factors  in  the  development  of 
cystoma  in  the  arytenoid  region  do  not  differ  from 
those  of  other  laryngeal  cysts,  except  that  they 
seem  capable  of  attaining  a  much  larger  size  and 
of  assuming  more  the  character  of  a  true  neoplasm. 

Pathological  Histology. — Of  cysts  formed  by  the 
accumulation  of  substances  within  the  cavities  of 
preexisting  structures,13  the  first  and  most  promi- 
nent division  is  that  of  "retention  cysts,"  which 
includes,  for  example,  simple  cysts  arising  from 
obstruction  in  the  tubules  of  the  kidney,  the 
ducts  of  the  liver,  the  lacteal  channels,  sebaceous 
cysts  and  mucous  cysts.  Laryngeal  cysts,  when 
simple,  have  all  presented  the  characteristics  of 
"  mucous  retention  cysts,"  and  are  formed  by  the 
retention  of  the  secretions  in  some  one  or  more  of 
the  glands  of  the  mucous  membrane.  The  duct 
of  a  mucous  gland,  perhaps  at  some  period  of 
acute  inflammation  of  the  larynx,  becomes  ob- 
structed by  epithelial  debris  or  inflammatory 
swelling,  and  soon  the  exit  is  obliterated.  This 
doubtless  occurs  with  considerable  frequency,  like 
with  the  sebaceous  glands  of  the  skin,  but  in  most 
instances,  the  glandular  function  being  at  the 
same  time  wholly  suppressed,  the  affected  struc- 
ture subsequently  undergoes  desiccation  or  exfo- 
liation, or,  if  the  function  is  maintained,  the  old 
orifice  may  be  reopened  or  a  new  one  forced,  either 
by  mere  pressure  or  through  the  process  of  sup- 
puration. In  rarer  instances,  however,  the  acci- 
dent of  obstruction  having  happened,  apparently, 
to  a  more  vigorous  gland,  its  secretion  continues, 
is  retained  by  a  less  yielding  wall  which  is  there- 
by distended  to  form  a  thin  sac — a  small  and  sim- 
ple cyst,  which  is  still  devoid  of  any  considerable 
formation  of  neoplastic  matter.  A  case  of  this 
sort,  situated  on  the  ary  epiglottic  fold,  we  ob- 
served in  1882,  under  Prof.  Chiari,  at  Prof. 
Schrotter's  clinic,  and  we  well  remember  the 
genial  but  emphatic  phrase  with  which  Chiari 
corrected  a  mistaken  diagnosis — "  Nein,  Meine 
Herren,  das  ist  eine  Cyste." 


3Jouru.  of  Laryngol.  and  Rhiuol.,  n,  209. 
4  Internationales  Centralblatt  fur  Laryngologie,  etc.,  iv,  104. 
SInternat.  Centrlbl.  fur  Laryugol  ,  etc.,  11.  27S. 
6Internat.  Centrlbl.  fur  I.aryngol..  etc..  vi.,  255. 

7  "  Cyst  of  Ventricular  Baud."     Lancet.  September  15,  1SS8. 

8  The  Journal  of  Laryngologie  and  Rhinologie,  Vol.  iii,  p.  299. 

9  Ueber  Kehlkoffcysten,  Wurzburg.    Becker,  1SS7. 
1    I.a  France  Medicale.  No.  87,  1880. 

"  I.o  Sperimentale,  Heft.  1  and  2,  1SS0. 
■-Inteniat.  Centralbl.  fiir  I.aryngol.,  vi,  608. 
*3  Green,  Pathology  and  Morbid  Anatomy. 


Such  a  simple  cyst  of  limited  growth  may  re- 
main quiescent,  perhaps  unnoticed,  if  favorably 
situated,  for  an  indefinite  period  of  time,  or  it 
may  suddenly  rupture  and  disappear.  But  other- 
wise, with  certain  individuals,  eventually  or  at 
once,  its  presence  excites  an  increased  blood  sup- 
ply to  the  spot,  which  is  utilized  by  perverted 
nature  for  a  further  production  of  endothelium, 
epithelium  and  intermediate  connective  tissue, 
forming  a  thick,  fibrous  wall  sufficiently  strong  to 
resist  the  pressure  of  the  constantly  augmenting 
secretory  contents  There  is  not  now  longer  a 
mere  distension  of  the  structures  of  a  preexisting 
cavity,  and  its  contents  proceed  not  alone  from 
the  original  gland  formation,  but  its  wall  has  a 
vascular  supply  and  a  growth  of  its  own,  the  con- 
tents being  elaborated  by  the  entire  lining  mem- 
brane, which  is  apparently  a  product  of  the  evo- 
lution of  the  original  gland  cells.  Indeed,  the 
transformation  is  into  a  veritable  neoplasm  which 
may  very  properly  be  dignified  by  the  term  cyst- 
oma. 

Desvernine's'*  case  having  died  of  other  causes, 
he  reported  the  pathological  histology  of  the 
"cystoma  of  the  vocal  cord"  as  follows :  "It 
was  found  to  be  a  retention  cyst  of  glandular  ori- 
gin, due  to  inflammation  beginning  in  the  epithe- 
lium of  the  gland  and  progressing  excentrically 
to  the  para- glandular  connective  tissue,  which  has 
become  condensed  layer  by  layer,  with  a  highly 
fused  fibrous  envelope. ' '  The  cavity  of  this  cyst- 
oma measured  only  5  millimetres  transversely, 
and  compared  with  our  immense  cystoma  of  the 
arytenoid  region  presently  to  be  described,  it  was 
minute,  but  showed  nevertheless,  in  its  wall,  evi- 
dence of  independent  growth. 

We  have  tabulated  and  appended  the  records 
of  four  cases,  including  two  of  our  own,  one  of 
which,  presenting  noteworthy  features,  we  will 
relate  in  detail : 

Mrs.  F.  P.,  set.  25  years,  referred  by  Dr.  N.  S. 
Davis,  Jr.,  July  13,  1888,  relates  that  she  has  had 
a  noticeable  habit  since  childhood  of  throwing  her 
head  forward  when  swallowing  as  if  a  slight 
impediment  to  deglutition  existed.  No  other 
symptoms  referable  to  the  throat  were  noticed 
until  May  30,  1888,  "Decoration  Day,"  when  a 
"cold"  from  exposure,  culminated  at  once  in  a 
severe  attack  of  acute  pharyngitis  and  laryngitis. 
Her  voice  became  husky,  and  the  hoarseness  con- 
tinued to  increase  until,  at  the  end  of  two  weeks, 
she  was  completely  aphonic.  Deglutition,  which 
was  at  first  unimpaired,  except  as  indicated  solely 
by  the  habit  above  mentioned,  gradually  became 
more  and  more  difficult  until,  in  less  than  a  month, 
swallowing  was  restricted  to  fluids.  A  sense  of 
discomfort  from  the  "  fulness"  in  her  throat,  but 
no  real  pain,  was  complained  of. 

Status  Preesens. — Emaciation  and  debility  are 
pronounced.      Respiration  is  labored,  and  lividity 


iSajous'  Annual,  tSS9,  G.  17. 


34Q 


CYSTOMA  OF  THE  LARYNX. 


[March  7, 


of  the  lips  and  other  signs  of  impaired  oxygena- 
tion of  the  blood  are  present.  Laryngoscopic  ex- 
amination discloses  an  immense  tumor,  fully  4 
centimetres  in  diameter,  which  occupies  the  en- 
tire top  of  the  larynx,  encroaches  upon  the  oeso- 
phageal orifice  and  forces  the  epiglottis  forward 
upon  the  tongue,  nearly  burying  it  from  sight. 
(Fig.  1.) 


Cystoma  of  the  Laryus 


The  vocal  cords  are  hidden  from  view,  but  by 
drawing  the  tumor  upwards  and  to  the  left,  a 
glimpse  of  a  part  of  the  right  vocal  cord  and  the 
right  arytenoid  eminence  is  obtainable.  The  tu- 
mor is  globular  in  shape,  of  fibrous  appearance, 
hard  and  dense  to  the  touch,  but  suggestive  here 
and  there  of  cystic  contents,  and  presented  on  its 
surface  ramifying  vessels  of  considerable  size. 

The  paroxysms  of  dyspnoea  occasioned  by  the 
examination  were  so  severe  that  one  hesitated  to 
undertake  any  sort  of  operative  treatment,  even 
for  diagnostic  purposes,  without  preliminary  tra- 
cheotomy, which  was  therefore  performed  on  July 
22,  1888.  Present,  assisting,  were  Dr.  W.  W. 
Jaggard,  Dr.  F.  S.  Johnson,  and  Dr.  McCullora. 
Ether  anaesthesia  was  employed,  and  herein  lies 
a  grave  point  of  danger  in  such  cases.  A  respir- 
atory passage  had  been  maintained,  doubtless  by 
aid  of  the  throat  muscles,  serving  to  keep  the 
neoplasm  partly  aside.  With  the  earliest  sus- 
pension of  muscular  action  by  the  ether,  the 
pharyngeal  muscles  collapsed  upon  the  tumor 
and  caused  the  latter  to  act  as  a  complete  stopper 
to  the  larynx,  whereupon  respiration  ceased  and 
the  face  blackened.  In  thjs  condition  of  complete 
asphyxia  the  trachea  was  hastily  opened,  the 
tube  inserted,  and  the  patient  then  resuscitated 
by  artificial  respiration. 

After  a  few  days  I  punctured  the  neoplasm  by 
means  of  a  large  curved  needle  attached  to  a  hy- 
podermic syringe,  and  withdrew  about  8  ccm.  of 
a  light  olive-colored,  viscid  fluid,  which  was  suf- 
ficiently albuminous  t<>  completely  solidify  by 
boiling,  and  which  showed  under  the  microscope 
innumerable  leucocytes.  By  the  following  day 
the  tumor  had  regained  nearly  its  original  size 
through  reaccumulation  of  the  contents.  A  free 
opening  was  now  made  which  permitted  the  es- 


cape of  fluid,  and  also  of  shreddy  material  too 
thick  to  flow  through  the  needle.  The  collapsed 
wall  was  then  drawn  forcibly  upward  b\r  a  curved 
vulsellum,  when  it  could  be  seen  to  be  attached 
by  a  rather  broad  base  over  the  whole  of  the  left 
arytenoid  eminence,  including  the  adjoining  end 
of  the  ventricular  band  and  parts  of  the  inter- 
arytenoid  and  ary-epiglottic  folds.  It  was  sepa- 
rated from  its  attachments  and  removed  in  several 
pieces  by  the  use  of  a  curved  galvano- cautery 
snare,  or  galvano-cautery  knife  electrode,  and 
long  angular  scissors. 

The  wall  of  the  cyst  varied  from  1  to  3  milli- 
metres in  thickness  and  exhibited  a  rather  fibrous 
aspect.  Fragments  of  it  were  submitted  for  mi- 
croscopical examination  to  Dr.  Frank  S.  Johnson, 
Professor  of  Pathology  in  the  Chicago  Medical 
College,  who  reported  the  neoplasm,  from  the 
presence  in  spots  of  closely  aggregated,  small, 
round  cells,  to  be  probably  sarcomatous — a  cystic 
sarcoma.  This  opinion,  somewhat  doubtfully  ex- 
pressed at  the  time,  is  rendered  still  more  doubt- 
ful by  the  subsequent  favorable  history  of  the 
case,  and  from  a  recent  reinspection  of  the  slides, 
jointly,  by  Dr.  Johnson  and  myself,  he  submits 
the  following  report,  with  which  I  concur: 

The  tissue  is  cellular  aud  quite  vascular.  The  stroma 
is  chiefly  fibrous  and  is  dotted  with  small,  round  and 
slightly  angular  cells,  which  in  certain  areas  are  very 
thickly  aggregated  and  present  the  appearance  somewhat 
of  sarcoma,  but  the}-  constitute,  doubtless,  only  a  young 
connective  tissue.  A  few  pavement-like  cells  on  the  edge 
of  the  section  may  possibly  represent  an  endothelium. 

In  view  of  the  possible  sarcomatous  nature  of 
the  cystoma  the  question  of  partial  resection  of 
the  larynx  was  now  considered,  but  after  due 
consideration,  the  patient  expressed  herself  as 
unwilling  to  submit  to  the  operation  without  as- 
surance of  absolute  necessity  greater  than  we 
could  give. 

The  larynx  was  not  located  deeply  in  the 
throat,  and  it  seemed  possible  to  destroy  the  re- 
maining shreds  of  the  growth  and  the  whole  seat 
of  attachment  by  operating  through  the  mouth 
with  vulsellum  forceps,  scissors  and  galvano-cau- 
tery. This  was  the  method  adopted,  but  it  re- 
quired repeated  operations,  at  intervals  of  two  to 
three  weeks,  to  thoroughly  accomplish  the  result, 
for,  notwithstanding  the  use  of  cocaine  in  spray 
and  solution  gradually  advanced  to  the  strength 
of  30  per  cent.,  after  the  first  two  or  three  cauter- 
izations or  clippings,  haemorrhage  aud  gagging 
interfered  with  further  laryngoscopic  observation. 

The  cartilages  of  Wrisberg  and  of  Santorini 
were  removed,  and  the  upper  neighboring  parts 
of  the  ary-epiglottic  fold,  inter  arytenoid  fold, 
and  ventricular  band  were  destroyed.  The  ary- 
tenoid cartilage  remains,  but  it  is  partially  anchy- 
losed,  which  impairs  somewhat  the  mobility  of 
the  left  vocal  cord.  The  cords  are  otherwise  in- 
tact and  the  voice  is  very  good.      (Fig.  2.) 

Two  years  have  passed,  and  there  is  no  sign  of 


i89i.] 


CYSTOMA  OF  THE  LARYNX. 


341 


recurrence.  The  tracheotomy  tube,  having  been 
worn  corked  up  for  a  time,  was  withdrawn  at  the 
end  of  a  year.  Healing  of  the  opening  was  fa- 
cilitated by  occasional  freshening  of  the  edges  by 
the  cautery.     It  is  now  perfectly  closed. 

Annotations  in  Retrospect. — Certain  queries  arise 
cancerning  the  treatment  adopted,  and  first,  Was 
tracheotomy  necessary  ?  Fundareno's15  case  ter- 
minated successfully  without  it.  "A  soft  tumor 
of  the  size  and  shape  of  a  walnut  blocked  up  the 
posterior  half  of  the  laryngeal  cavity.  An  inci- 
sion- was  made  into  the  cyst  with  the  laryngeal 
knife  of  Bruns,  when  a  clear  fluid  mixed  with 
granular  and  fatty  matter  escaped.  Then  it  was 
seen  to  be  attached  over  the  right  arytenoid  car- 
tilage. The  cystic  membrane  was  removed  and 
the  place  of  attachment  cauterized  with  chromic 
acid." 


Fig.  2. — After  operation. 


Should  an  anaesthetic  have  been  administered  ? 
Death  therefrom  was  certainly  averted  only  by 
prompt  albeit  deliberate  action.  But  the  Ameri- 
can surgeon  does  not  contemplate  with  equanim- 
ity the  operation  of  tracheotomy  without  anaesthe- 
sia. No  little  surprise  was  occasioned  by  the 
discussion  which  recently  waged  in  France  re- 
lating to  tracheotomy  with  or  without  an  anaes- 
thetic in  cases  of  membranous  croup,  in  which 
condition,  in  America,  it  is  always  administered, 
notwithstanding  dyspnoea,  unless  the  patient  is 
already  moribund. 

But  these  are  not  wholly  analogous  cases,  and 
another  time,  with  a  tumor  similarly  situated,  re- 
quiring quasi-voluntary  muscular  action  to  main- 
tain patency  of  the  respiratory  passages,  I  would 
make  the  tracheotomy  with  only  local  anaesthesia 
by  ether  spray  to  the  skin  and  cocaine  spray  to 
deeper  layers  as  reached,  aided  perhaps  by  hypo- 
dermics of  cocaine. 

Concerning  the  duration  of  development  of  the 
cystoma,  it  seems  more  reasonable  to  assume  that 
a  small  cyst,  quiescent,  or  of  very  slow  growth, 
had  existed  for  years,  as  indicated  by  the  slight 
disability  in  deglutition,  and  that  this  was  stim- 
ulated to  active  growth  by  the  acute  inflamma- 
tion of  the  surrounding  parts  contracted  on  "Dec- 
oration Day,"  rather  than   to   suppose  that  the 


TABLE 

OF   CASES    OF 

CYST   OF   THE    ARYTENOID   REGION    OF   THE    LARYNX. 

Operator  or  Refer- 

Previous!         Situation  and 

Points  of 

Pathological 

Sex.  '  .  Duration 

Treatment. 

Result. 

fejjlj 

ence. 

gjjof  Symp-               Extent. 

Attachment. 

Nature. 

<      toms. 

I 

Chiari  and 

Male.J30  None  .   . 

Right      ary-  epiglottic  Same 

fold  near  the  aryten- 

Simple re- 

None. 

1882 

ry,  Schrotter  s  Vien- 

tention cyst. 

na     Clinic,      Sec.   in 

oid,   size   of  small 

I.aryn  ,   Tenth    Iut'l 

split  pea. 

Congn 

2 

and    Garel, 

Arv-epiglottic  fold. 

Same       Fibrocystic 

Removal     by    gal-  Presumably 

"Internal,  t  entralb. 

f".    I.arvn  .    Rhlnol.," 
etc.,  Bd.  vi 

tumor. 

vano-caut.  snare                     cured. 

3 

Fundarena  el    Seglo 

Male.  *o 

Right    arytenoid  re- 

Cyst  

Evacuated,     cystic  Presumably 

]--. 

Medico, Apr.  21,  Jour. 
of  I.arvn.  and  Rhin., 

gion,  size  ol   a  wal- 
nut,   covering    two- 

over    right    ary- 
tenoid. 

inemb.  removed.                   cured, 
ba se  cauterized 

Vol.  in 

thirds  oi  larynx. 

with     chromic 

-  -  elberry,  Tenth 

Fe- 

acid. 

1890 

lull  Med.  Congress, 

male. 

weeks. 

Left  arytenoid  region, 

Mucous  and  sub- 

Cystoma. .   . 

Evacuated,  remov-  Cured,  remains 

Sec.  in  Laryngology, 

size  of  large    black 

mucous   tissues 

a  1    b  v    vulsella.      well  after  2% 

Berlin. 

walnut,  covered   all 
but  anterior  angle  oi 
glottis;  seriously  im- 

over left  aryten- 
oid region,    ary- 
epiglottic  fold  8: 

scissors  and  bis-      years, 
toury ;  thorough 
cauterization    of' 

paired  deglutition 

ventricul'r  band.' 

base  by  galvano- 

and  respiration. 

cautery. 

In  our  own  case  the  tumor  was  larger,  firmer, 
the  diagnosis  at  first  uncertain,  whilst  the  dysp- 
noea demanded  immediate  relief  and  rendered 
hazardous  any  attempt  at  operating  per  vias  nat- 
urates  without  an  independent  artificial  opening 
for  respiration.  And  subsequently,  by  reason  of 
the  ready  induction  of  spasm  of  the  glottis,  it 
would  have  been  quite  impossible,  without  tra 
cheotomy,  to  have  effected  that  thorough  destruc- 
tion of  the  seat  of  attachment,  so  desirable  on  ac- 
count of  the  possible  sarcomatous  nature  of  the 
neoplasm. 


neoplasm  had  been  wholly  formed  in  the  short 
period  of  six  weeks,  which  intervened  between 
the  eventful  "  Decoration  Day  "  and  the  time  of 
our  first  examination. 

The  suspicion  first  entertained  of  a  sarcomatous 
element  in  the  case,  we  believe  to  have  been  rea- 
sonably excluded  by  the  subsequent  course  of 
events,  and  that  we  had  to  deal  merely  with  an 
immense  cystoma  which  originated  in  a  simple 
mucous  retention  cyst.      An  analytical  record  of 


cases  is  given. 


342 


MEDICO-LEGAL  NOTES. 


[March  7, 


MEDICOLEGAL   NOTES. 
BY  HENRY  A.  RILEY,  Esq., 

OF   NEW   YORK. 

HYPNOTISM. 

The  subject  of  hypnotism  continues  to  attract 
great  attention,  both  in  the  public  journals  and 
at  the  meetings  of  learned  societies.  At  a  recent 
meeting  of  the  Medico- Legal  Society  of  New 
York  a  committee  made  a  preliminary  report,  and 
this  was,  at  a  later  meeting,  discussed'  by  the 
members. 

Dr.  E.  P.  Thwing  said  :  The  trance  sleep  is 
not  a  disease,  although  neurotic  conditions  pre- 
dispose to  it.  Nor  does  sensitiveness  to  hypnotic 
influence  imply  small  brain  power.  Hypnotism 
is  not  necessarily  productive  of  harm,  and  in 
many  cases  in  medical  practice  has  proved  val- 
uable. 

There  was  a  decided  difference  of  opinion  as  to 
the  value  and  propriety  of  public  exhibitions  of 
hypnotism.  Several  such  exhibitions  have  been 
given  in  this  city,  some  of  which  have  attracted 
attention  from  physicians  as  well  as  from  the  cu- 
rious and  investigating  public. 

Dr.  Paul  Gibier,  the  well-known  head  of  the 
Pasteur  Institute,  approved  of  public  exhibitions 
in  so  far  as  they  served  to  bring  to  light  new 
truths  of  interest  to  science.  It  will  be  of  inter- 
est to  recall  the  fact  that  the  city  authorities  of 
Cincinnati,  at  the  suggestion  of  Dr.  Prendergast, 
the  Health  Officer,  have  prohibited  all  public  ex 
hibitious  in  that  city. 

TAKING  AWAY  THE  CHARTER  OF  A  MEDICAL 
COLLEGE. 

A  bill  is  now  pending  in  the  New  Jersey  Leg- 
islature to  annul  the  charter  of  the  Medical  and 
Surgical  College  of  the  State  of  New  Jersey.  The 
measure  has  already  passed  the  Senate,  and  has 
been  favorably  reported  in  the  house.  It  was  in- 
troduced at  the  request  of  the  Hudson  County 
Medical  Society,  which  recently  adopted  resolu- 
tions to  the  effect  that  "several  members  of  the 
faculty  are  either  incompetent  to  deliver  lectures 
on  the  subjects  assigned  them,  or  are  graduates 
of  disreputable  or  fraudulent  medical  colleges  ; 
that  the  facilities  for  instruction  are  inadequate  ; 
that  the  requirements  of  the  charter  of  the  Col- 
lege are  far  below  the  minimum  requirements  of 
medical  colleges  adopted  and  demanded  by  all 
the  medical  authorities  at  the  present  time." 

The  State  Board  of  Medical  Examiners  is  urg- 
ing the  passage  of  the  bill. 

STATE   REGULATION  OF  VICE. 

The  New  York  Committee  for  the  Prevention 
of  State  Regulation  of  Yice  met  recently  and 
adopted  a  protest  against  the  passage  of  a  bill, 
pending  in  the  New  York  Legislature,  to  lower 
the  age  of  consent  on  the  part  of  young  girls  to 
their  own   ruin   from   sixteen   to   thirteen   years. 


The  committee  also  passed  a  resolution  in  favor  of 
the  appointment  of  women  matrons  at  the  police 
station-houses  in  New  York  City. 

It  is  pleasant  to  state  that  in  all  probability 
both  of  these  recommendations  will  be  effective, 
and  that  the  Legislature  will  hardly  dare  to  lower 
the  age  of  consent,  while  there  seems  to  be  no 
special  opposition  to  the  police  matron  law. 

CREMATION  AND  THE  LAW. 

In  England  very  recentty  three  prominent  men 
have  been  cremated  —  Baron  Huddleston,  Mr. 
Charles  Kinglake,  and  the  Duke  of  Bedford — 
and  some  of  the  papers  are  discussing  the  legale 
of  this  method  of  disposing  of  the  dead.  The  de- 
cisions seem,  however,  to  have  settled  the  point. 
In  a  very  elaborate  decision  some  few  years  ago, 
by  Justice  Stephen,  it  was  held  that  it  was  not  a 
misdemeanor  to  burn  a  body  unless  it  was  so 
done  as  to  create  a  public  nuisance,  or  done  in 
order  to  prevent  the  coroner  holding  an  inquest 
on  the  body. 

In  this  country  there  has  never  been  any  se- 
rious discussion  of  the  question  in  the  courts,  as 
the  legality  of  cremation  seems  to  have  been  con- 
ceded. It  does  not  appear,  however,  that  the 
custom  of  burning  the  dead  is  becoming  very 
much  observed. 

PRACTICING   WITHOUT   A    DIPLOMA. 

The  New  York  County  Medical  Society  fre- 
quently brings  into  court  persons  practicing  med- 
icine who  have  no  legal  right  to  do  so,  not  hav- 
ing diplomas  ;  and  the  convictions  are  quite  nu- 
merous. In  a  recent  case  the  offender  had  been 
before  the  court  once  before,  but  claimed  that  his 
lawyer  had  given  him  a  paper  which  purported 
to  be  a  decision  reversing  the  former  conviction. 
The  lawyer  was  a  shyster,  who  is  now  serving  a 
term  in  the  State  Prison  for  forging  a  divorce  de- 
cree. The  Judge  said  that  it  was  simply  a  case 
of  a  medical  shark  falling  into  the  hands  of  two 
legal  sharks,  and  sentenced  the  bogus  doctor  to 
imprisonment  for  100  days  in  the  penitentiary, 
together  with  a  fine  of  $100. 

BOARDS  OF  HEALTH  MUST    PAY  FOR  MISTAKES. 

In  Massachusetts  it  was  recently  decided  that 
the  law  permitted  Boards  of  Health  to  kill  horses 
infected  with  the  glanders,  but  that  it  did  not  free 
them  from  liability  if  they  killed  animals  which 
did  not,  in  fact,  have  the  disease.  In  such  a  case 
they  would  be  liable  in  damages. 

INFECTED  MEAT  IN  NEW  YORK. 

The  amount  of  bad  meat,  fish  and  vegetables 
seized  each  year  in  New  York  City  by  the  offi- 
cials of  the  Board  of  Health,  would  surprise  al- 
most every  reader.  According  to  the  report  just 
prepared  there  was  confiscated  1,200,000  pounds 
of  tainted  meat  and  fish,  and  1,056,000  pounds  of 
bad   fruit  and  vegetables.     The  milk  inspectors 


i89i.]  MEDICAL  PROGRESS.  343 

examined  97,000  samples  of  milk,  and  caused  299  '  ogy  and  otology.  Pilocarpin  is  of  added  value 
arrests  for  milk  adulteration.  Milk  was  found  from  the  fact  that  we  have  no  remedies  useful  in 
for  sale  in  over  6,000  stores  in  the  citv.  the  chronic  joint  affections  of  rheumatism,  the 

HOW  TO  RUN  A  SLAUGHTER-HOUSE. 

The  following  is  the  direction  given  in  a  Michi- 
gan suit  for  the  proper  management  of  a  slaughter- 


useless  in  these  conditions. 


I'ln  ■iotoffj  . 
house:  "Complainants  are  entitled  to  a  decree  The  Penis  Percussion  Reflex.— We  learn 
requiring  defendant  to  remove  from  his  premises  wjth  each  year  a  few  additional  objective  signs 
every  day  all  manure,  blood,  offal,  hair  and  other  0f  disease,  and  with  these  come  increased  preci- 
refuse  of  his  establishment,  in  covered  garbage  sion  jn  diagnosis.  It  is  but  a  few  years  since  the 
•wagons,  such  as  are  in  use  by  the  Board  of  Pub-  significance  of  absence  or  variation  of  the  patellar 
lie  Works  in  the  city  of  Detroit,  or  in  other  wag-  tendon  reflex  has  been  understood,  though  the 
ons  that  will  effectively  avoid  the  spread  of  of-  phenomenon  of  contraction  of  the  thigh  muscles 
fensive  odors  ;  to  thoroughly  clean,  cleanse  and  wnen  the  tendon  was  struck,  must  have  been 
disinfect  his  premises  daily;  to  provide  sufficient  known  to  the  school  boys  of  ancient  Rome.  Since 
pens  for  the  hogs  in  store  so  that  they  shall  not  the  diagnostic  value  of  alterations  of  this  reflex 
be  crowded  and  rendered  noisy  and  quarrelsome  have  been  learned,  many  others  have  been  found 
by  discomfort  while  in  confinement,  and  to  use  and  studied.  The  last  is  announced  by  Dr.  C. 
such  other  precautions  as  are  necessary  to  render  h.  Hughes  I  Alienist  and  Neurologist,  January, 
his  place  of  business  clean  and  wholesome."  1891),  under  the  term  "virile  reflex,"  because  if 

it  is  impaired  or  lost,  in  a  person  with  a  healthy 

spinal  cord,  it  indicates  a  loss  or  abeyance  of  the 

MPnirM      PRnPPPQQ  sexual    function.      The   reflex    is   produced   bv 

,MnL"LAL     rKUUKCSS.  grasping  the  penis  by  the  foreskin,  between  the 

index  finger  and  thumb,  and  pulling  the  organ 

Therapeutics  and  Pharmacology.  firmly  toward  the  umbilicus,  at  the  same  time  al- 

Treatment  of  Typhoid  Fever  with  Chlo-  lowing  the  ring  and  little  fingers  of  the  same 
roform. — Dr.  Stepp,  of  Xiirnberg,  contributes  hand  to  rest  upon  the  dorsum  of  the  organ.  If, 
to  the  Munchener  Med.  Wochenschr.  an  account  of  while  in  this  condition,  the  organ  is  struck  sharply 
the  excellent  results  he  has  obtained  in  the  treat-  a  distinct  retraction  of  the  bulbo-cavernous  por- 
ment  of  typhoid  fever  with  chloroform.  The  tion  will  be  felt.  Dr.  Hughes  says  that  it  is  of- 
drug  is  given  in  5  minim  doses  thrice  daily.  He  ten,  but  by  no  means  always,  found  in  sympathy 
claims  for  the  medication  a  direct  and  favorable  with  the  other  reflexes  of  the  lumbo-dorsal  spine, 
influence  upon  the  course  of  the  disease  ;  the  He  has  found  it  absent  in  old  men  who  have  ac- 
tongue  becomes  moist,  somnolence  and  delirium  knowledged  complete  virile  incapacity,  and  also 
disappear,  and  immediate  improvement  is  noted  lessened  in  neurasthenia  and  masturbation, 
in  the  general  condition.  The  temperature  is  If  it  shall  appear  upon  further  investigation 
usually  lessened  in  from  eight  to  ten  days,  re-  that  the  claims  made  by  Dr.  Hughes  are  correct, 
lapses  occasionally  occurred,  and  he  notes  the  we  certainly  have  a  valuable  diagnostic  sign  in  a 
death  of  one  patient.  The  fever  stage  averaged,  considerable  number  of  medico  legal  cases.  It  is 
in  severe  cases,  nineteen  days  ;  in  lighter  forms,  a  common  thing  for  men,  especially  those  ad- 
eight  days  vanced  in  years,  if  accused  of  sexual  crimes,  to 
The  writer  thinks  that  the  chloroform  is  ab-  plead  total  impotency.  So  far  as  the  examina- 
sorbed  directly  into  the  blood,  where  it  exerts  a  tion  of  the  medical  jurist  is  concerned,  he  can 
specific  anti-bacterial  effect.  He  has  never  ob-  only  report  as  to  the  conformation  of  the  organs, 
served  unpleasant  consequences  resulting  from  The  virile  power  is  beyond  his  investigation, 
the  medication.  Then.  too.  it  ought  to  prove  of  differential  diag- 
nostic value  in  forms  of  psychical  impotency. 
Pilocarpin  in  Chronic  Rheumatism. — Dr.  We  sincerely  hope  that  the  sign  may  prove  to  be 
Hochholt,  physician  to  the  Pest  Hospital  {Se-  true,  as  it  will  then  prevent  the  somewhat  unfor- 
maine  Medical,  July  2,  1890),  reports  excellent  tunate  contretemps  of  a  man  being  convicted  of 
results  in  chronic  rheumatism,  accompanied  by  bastardy,  and  his  wife  obtaining  a  divorce  on  the 
effusion  into  the  joints  and  some  thickening,  with  ground  of  impotency,  at  the  same  term  of  court, 
pilocarpin.     Coleman  Korda,  a  confrere  of  his. 

had  observed  similar  good  results  ten  years  be-  Results  of  Section  of  the  Corpus  Callo- 
fore.     Korda  attributed   the  favorable  action  of  sum. — Korany:  Arch.,  xlvii.    p. 

the  drug  to  its  power  of  increasing  tissue  change,  in  Golz's  laboratory  in  Strasburg,  has  divided  the 
aiding  elimination  and  thus  favoring  the  absorp-  corpus  callosum  in  a  number  of  dogs,  and  finds 
tion  of  inflammatory  exudates.  It  is  to  this  prop-  that,  provided  other  parts  of  the  brain  be  not  in- 
erty  that  the  drug  owes  its  value  in  ophthalmol-   jured,  especially  the  cerebral  hemispheres,  there 


344 


MEDICAL  PROGRESS. 


[March 


are  no  symptoms  whatever  resulting  from  the  he  is  not  prepared  to  state ;  but  the  experiments 
lesion.  Both  halves  of  the  body  appear  to  retain  that  he  has  recently  made  confirm  those  that 
their  normal  motor  and  sensory  functions,  and  ap-  he  published  in  1879,  in  which  he  found  that 
pear  to  act  in  unison  together.  the   tubercle  bacillus  from  a  mammalian,  when 

injected  into  a  laying  fowl,  caused  the  embryos 

(H)st«lric<i  mid   Kispasps  of  Women.  \r     ,i_  .        j-  ...         n   .1  i_  •    .• 

•p.  ..  T  „      .,  from  the  eggs  to  die  with  all  the  characteristic 

Danger  of .Vaginal  Injections^-Dr   Rou-  features  of\g  marasmus.     He  has  obsen.ed  the 
LIN  (Journal  de  Medeane  de  Pans,  December  14,    £ame  thing   in  the   faens    themselves  when  they 


have  been  inoculated  with  "perlsucht,"  and  even 
with  active  cultivations  of  the  tubercle  bacillus 
from  mammalian  animals ;  whilst,  from  clinical 
observation,  he  is  also  of  opinion  that  the  caseous 
masses  in  tuberculous  individuals  are  the  exciting 
cause  of  the  marasmus  that  is  so  frequently  met 
with  in  patients  affected  with  tuberculous  glands. 
The  abdomen  was  not  sensitive  on  pressure,    bones  0/joints?  and  in  cases  of  tuberculous  phthi- 


1890),  describes  three  cases  where  women  suffered 
from  severe  symptoms  after  the  use  of  vaginal 
injections,  administered  by  themselves  when  in  a 
sitting  position.  The  first  used  the  douche  can, 
fixing  it  rather  high  on  the  wall.  Immediately 
after  the  injection  violent  hypogastric  and  lum- 
bar pains  set  in,  followed  by  vertigo  and  vomit- 
ing 

though  pain  was  intense  Metrorrhagia  followed  sis  He  has  nQW  carried  on  a  serfes  of  experiments 
and  lasted  for  two  or  three  days    but  the  pain  Qn       inea    j      with  cultivations  of  tubercle 

ceased  in  twenty-four  hours.  The  second  case .  bacf1]us  {f^  mammalian  animais)  which  had 
was  almost  precisely  similar,  excepting  that  the   been  allowed  tQ  for  one   t         three  Qr  six 

patient  had  used  a  hand  syringe  and  the  symp-  months  Qn  cons^lidated  blood  serum  t0  which 
torns  were  less  severe.  The  third  case  also  used  lvcerine  had  been  added,  or  on  fluid  bIood  serum 
a  hand  syringe.  She  felt  a  pam  like  a  blow  -  ^  The  culture  was  then  sterllized  at  a  tem. 
across  the  belly  but  continued  the  injection;  ature  of  6s°  t0  o  c  continued  for  one  or 
when  it  was  ended  lumbar  and  abdominal  pains \^Q  fa  0T%    int'ermitteilt  sterilization.     Cul- 

came  on  severely,  with  rigors  and  chattering  of :  tures  of  more  than  six  months>  standing  were 
the  teeth,  but  no  vomiting.  The  symptoms  re- ■  found  tQ  be  already  sterU  and  were  therefore 
curred  on  the  next  day  when  the  patient  got  up,    not  iall     treated.     An     of  tbese   sterilized 

but  on  the  third  day  she  felt  well  and  free  from  .  cultu£s  introduced  into  guinea  pigs  induced,  in 
pam  Dr.  Roulm  employs  laudanum  enemata  from  fourteen  davs  to  six  months,  marked  wast- 
tor  these  cases.     The  cause  of  the  pain  is  obscure 


The  fluid  rushing  into  the  uterine  cavity  may  act 
as  a  foreign  body  and  set  up  conditions  sometimes 
provoked  by  catheterism.  The  admission  of  air 
into  the  uterine  sinuses  has  been,  according  to 
Depaul,  the  cause  of  sudden  death  during  douch- 
ing of  the  cervix  to  produce  abortion.  Dr.  Rou- 
lin  believes  that  water  may  have  entered  in  his 
He 


iug,  but  no  tubercle  bacilli  could  be  found  by 
histological  examination  or  by  cultivation.  There 
was  usually  congestion  of  the  lung  and  of  the 
kidney,  the  splenic  follicles  were  wasted,  the  pulp 
was  also  atrophied,  but  was  usually  somewhat 
congested,  and  considerable  quantities  of  pigment 
might  be  observed  in  the  pulp  cells,  and  even  ly- 
ing free  outside  them.  The  atrophv,  however,  was 
cases  Me  insists  that  patients  must  be  taught  al°ost  invariablv  well-marked,  and  the  liver  cells 
how  to  administer  vaginal  injections  to  them-  were  usual]y  considerabIv  wasted.  He  concludes 
selves.  The  patient  must  he  on  her  back  and  ^  ^  tQxic  substance  is  not  destroved  in  the 
only  introduce  the  nozzle  for  a  short  distance  ;  bod  of  an  anima]  wWch  dieg  from  marasmus> 
nor  must  she  play  too  strong  a  jet  of  fluid  into  and  fae  hol(Js  that  these  observations  must  have 
the  vagina.  -British  Medical  Journal.  a  yery  important  bearing  on  the  ultimate  SUCcess 

Bacteriology.  j  or  failure  of  Koch's  treatment. — British  Medical 

Virulence  of  Tubercle  Bacillus. — Pro-  Journal. 
FESSOR  A.  Maffucci,  in  a  preliminary  commu- 
nication {Centra/hi.  Ji/r  allgemeinc  Pathologic  it.  Bacteria  in  the  Air. — Prof.  Roster  of  the 
pathologische  Anatomic,  Band  i,  No.  26,  Decern-  Intituto  degli  Studii  Superiori,  of  Florence,  has 
ber  15,  1890)  concludes  that  all  Hammerschlag's  recently  examined  the  air  of  the  island  of  Elba, 
experiments  with  the  alcoholic  extracts  of  pure  and  comes  to  the  following  important  and  prac- 
cultivations  of  tubercle  bacillus  cannot,  in  face  of  tical  conclusions:  1.  The  air  of  an  island,  eve-n 
the  clinical  nature  of  tuberculous  disease  in  the  when  of  considerable  size,  contains  fewer  bacteria 
human  subject,  be  looked  upon  as  conclusive,  than  the  mainland.  2.  When  the  wind  is  off  the 
There  is,  however,  he  considers,  some  poison  de- 1  sea  the  number  of  bacteria  is  enormously  de- 
veloped by  the  tubercle  bacillus,  especially  in  creased.  3.  A  comparatively  narrow  arm  of  the 
older  growths,  which  bj  its  action  produces  ma-  sea  is  sufficient  to  purify  the  air  blowing  over  it. 
rasmus,  apparently  by  interfering  with  the  nutri-  4.  Atmospheric  bacteria  increase  in  proportion  to 
tion  of  the  cellular  elements  of  the  body.  What  tin-  velocity  of  the  wind.  5.  Rain  is  the  most 
relation  the  bacilli  and  their  products  bear  to  in-  important  factor  in  purifying  air  of  its  contained 
flammation,   fever,   marasmus   and  degeneration,    germs. 


i8oi.] 


EDITORIAL. 


345 


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Address 

Journal  of  the  American  Medical  Association, 

No.  68  Wabash  Ave., 

Chicago,  Illinois. 
All  members  of  the  Association  shou       send  their  Annual  Dues 
to  the  T>tasurer,  Richard  J.  Dunglison,  M.D.,  Lock  Box  1274,  Phila- 
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London  Office,  57  and  59  Ludgate  Hill. 


SATURDAY,  MARCH   7,    1891. 


THE  LESSON  OF  THE  FILARIA  SANGUINIS 
HOMINIS. 

The  greatest  achievements  of  medicine  in  the 
past  have  been  in  clinical  observation,  those  of 
the  present  are  in  biological  investigation.  The 
uncertain  methods  of  the  former  are  reinforced 
by  the  verdict  of  a  jury  of  the  profession  at  large; 
the  positive  decisions  of  the  latter  must  be  con- 
firmed by  the  same  method  after  they  are  handed 
down  by  the  expert.  Xo  more  brilliant  study  of 
parasitism  is  to  be  found  in  the  annals  of  biology 
than  that  which  this  little  hcematozoan  furnished. 

Dr.  Rudolph  Matas  in  the  January  number 
of  the  New  Orleans  Medical  and  Surg  ical  Journal, 
cites  a  case  of  parasitic  chylocele,  which  illus- 
trates the  rational  treatment  of  this  disease,  fol- 
lowing a  positive  diagnosis  and  relative  indica- 
tions dependant  on  an  exact  knowledge  of  the  life 
history  of  the  filaria.  This  article  is  a  model  of  med- 
ical literature,  and  it  should  be  carefully  studied 
by  every  physician  on  the  Gulf  coast.  It  is  an- 
other witness  to  the  richness  of  the  New  Orleans 
clinic  in  tropical  and  sub-tropical  diseases,  and 
promises  for  that  city  an  opportunity  for  medical 
study  and  clinical  investigation  of  these  diseases, 
without  the  dangers  which  attend  a  residence  in 
the  tropics. 

The  relation  of  the  filaria  to  chyluria  was  first 
noticed  by  Wacherer  in  Bahia  in  1866,  but 
Demarguay  had  found  and  described  the  same 
wormlike  form  in  the  chylous  fluid  from  a  hydro- 
cele in  1863.  This  little  worm,  however,  did 
not  escape  the  penetrating  eye  of  Dr.  J.  H. 
Salisbury,    who,   in    1868,  named  it    "trichina 


cystica."  Lewis,  <>f  Calcutta,  first  found  the 
embryonic  worm  in  the  circulating  blood,  and  the 
mature  and  living  male  and  female  in  a  piece  of 
scrotum  amputated  for  elephantiasis.  The  most 
interesting  and  brilliant  chapter  in  the  history  of 
our  little  animal  is  associated  with  the  name  of 
Patrick  Manson.  It  was  long  known  that  the 
embryonic  and  a  sexual  filaria  lived  equally  well 
in  the  blood  and  lymph,  and  that  their  presence 
there  depended  upon  a  mature  and  sexual  female 
of  comparatively  prodigious  size  confined  in 
some  lymph  space,  usually  in  the  scrotum.  None 
of  the  myriads  of  embryos  ever  became  sexual 
while  in  the  original  host.  The  sexual  liberator 
was  supposed  to  lie  in  some  intermediary  host. 
It  remained  for  Bancroft,  of  Australia,  to  sug- 
gest (1877),  and  Manson,  of  China,  to  prove 
(1881),  that  the  mosquito  is  the  sexual  liherator 
of  the  filaria  sanguinis  hominis. 

The  adult  sexual  filaria  has  never  been  found 
outside  the  lymph  glands  or  lymph  sacs.  There 
the  female  is  coiled  up  and  her  uteri  and  vagina 
are  crowded  with  embryos  in  various  stages  of  de- 
velopment. During  the  night  the  free  embryos  are 
found  in  enormous  numbers  in  the  blood  of  the 
patient;  but  during  the  day  the  blood  is  free  from 
them,  as  Manson  first  proved.  This  periodicity 
points  to  a  remarkable  adaptation  when  we  learn 
that  the  nocturnal  mosquito  dips  her  proboscis 
into  the  circulating  blood  and  fills  her  stomach 
with  a  drop  of  blood  containing  sometimes  one 
hundied  and  twenty  embryo  filariae.  Some  of 
these  are  carried,  directly  or  indirectly,  to  a 
second  host  to  become  sexually  mature  worms, 
and  give  rise  to  all  the  symptoms  of  invasion 
with  the  embryos.  We  can  not  recount  all  the 
interesting  and  astonishing  features  of  this  rare 
parasite.  It  may  be  compared  with  the  filaria  of 
the  dog,  which  does  become  sexually  mature 
in  the  primary  host,  and  with  the  plasmodium 
malariae,  which  shows  a  parallel  periodicity. 

In  the  United  States,  the  appearance  of  the 
filaria  has  been  studied  by  three  careful  inves- 
tigators, Guiteras,'  Mastin,"  and  Dr.  Sals- 
sure,"  and  although  the  climate  of  Southern 
United  States  is  barely  subtropical,  a  very  aston- 
ishing number  of  native  cases  have  been  presented, 
mostly  from  Charleston.  The  pathology  and 
clinical   history    of  the  chylocele  of  the  tunica 

■  Medical  News,  April 
*  Annals  of  Surgery,  188S. 
Mi  dical  News,  1890. 


346 


VENESECTION. 


[March  7, 


vaginalis  testis  has  been  first  fully  demonstrated 
by  Mastin,  and  we  are  proud  to  say  his  demon- 
stration has  borne  fruit  in  the  successful  treatment 
of  a  case  by  Dr.  Mat  as,  to  whom  we  are  indebted 
for  the  opportunity  of  calling  attention  to  this 
subject  again.  We  predict  that  imported  cases 
will  be  found  in  the  Northern  States, and  trust  that 
every  case  of  chyluria,  chylocele,  elephantiasis, 
suppurating  multiple  lymphadenitis,  chylo- thorax 
and  chylous  ascites  will  receive  careful  clinical 
examination  for  this  parasite. 

This  is  a  typical  obligate  parasite  and,  as 
might  be  predicted,  it  is  not  destructive  to  its 
host.  Patients  live  for  many  years  under  proper 
conditions,  and  their  chief  source  of  danger  is 
from  infection  with  more  destructive  parasites, 
such  as  the  erysipelas  coccus  and  the  pyogenic 
bacteria.  Recovery  from  the  uncomplicated  dis- 
ease is  the  rule  when  the  patient  emigrates  to  a 
cold  climate,  or,  otherwise,  when  the  parent  worm 
is  removed  by  operation  or  dies  from  natural  or 
accidental  causes.  The  prognosis  without  emi- 
gration depends  largely  on  the  number  of  sexual 
females  in  the  host  and  the  risk  of  wound  dis- 
eases. 

The  remarkable  effect  of  a  cold  climate  on  this 
parasite,  resulting  in  the  death  of  the  pregnant 
female  and  consequent  disappearance  of  the  dis- 
ease, furnishes  an  analogy  which  should  be  re- 
membered, not  only  in  its  narrow  application  to 
malaria,  but  to  all  parasitic  diseases.  For,  how- 
ever uniform  the  conditions  of  human  vitality 
seem  to  us  to  be  at  all  times  and  in  all  places,  we 
have  indubitable  evidence  here  of  such  vital 
changes  as  result  in  the  death  of  an  otherwise 
permanent  parasite.  In  these  times  of  vigorous 
therapy,  let  not  so  important  a  suggestion  go  un- 
noticed, but  let  it  furnish  a  theme  for  meditation, 
for  hypothesis,  for  investigation,  and  for  scientific 
deduction. 


FUNERAL  REFORM.     DANGERS  OK  DECORA- 
TION  DAY. 

The  Lancet  inveighs  against  the  practice  of  so 
conducting  funerals  as  to  endanger  human  lives. 
The  past  winter  has  been  unusually  chilly  and 
cold  in  England,  and  the  editor  of  the  Lancet  has 
had  occasion  to  notice  not  a  few  distressful  conse- 
quences  due  to  the  standing  of  participants  at 
funeral  exercises  with  their  heads  bared.  In  fine 
weather   this   mark   of  respect  may  very  well  be 


observed,  but  in  the  winter  time  it  is  too  liable 
to  be  attended  with  grave  risks  to  be  looked  upon 
with  favor  by  medical  men.  The  editor  com- 
mends the  shortening  of  the  out-door  services  in 
cold  and  stormy  weather,  as  has  been  voluntarily 
undertaken  by  some  of  the  clergy,  and  the  keep- 
ing of  the  hat  on  the  head  except  for  a  moment 
or  more  at  a  time  when  the  word  "Amen  "  after 
prayer,  or  some  like  passage,  is  pronounced  by 
the  clergyman.  Standing  with  the  head  bared  is 
indeed  a  seemly  token  of  respect  to  the  dead,  but 
a  due  regard  for  the  living  teaches  us  that  a  re- 
form in  this  particular  may  properly  be  expected 
before  this  century  closes.  The  dangers  of  Deco- 
ration Day  deserve  consideration  here.  We  hold 
that  it  is  unfortunate  that  that  holiday  has  been 
located  so  early  in  the  year,  while  yet  the  soil  of 
our  cemeteries  is  saturated  with  damp  and  un- 
oxidized  deposits  of  a  winter's  harvest  of  snow 
and  frost,  and  mould  and  vegetable  decay.  We 
have  seen  too  many  instances  of  injury  to  health 
and  of  death  even,  caused  by  that  kind  of  filial- 
ity  and  loyalty  which  leads  the  families  of  depart- 
ed patriots  and  others  to  decorate  the  last  resting- 
places  of  their  loved  ones,  to  be  admirers  of  the 
practice  from  the  standpoint  of  health  preserva- 
tion. This  act  of  respect  has,  in  not  a  few  in- 
stances, been  the  occasion  of  a  second  visit,  soon 
after,  to  the  cemetery,  for  the  purpose  of  closing 
up  a  newly  made  grave  due  to  Decoration  Day 
exposures. 


VENESECTION. 
It  is  quite  a  noteworthy  coincidence  that  the 
subject  of  venesection  has  been  the  theme  of  ex- 
tended and  favorable  comment,  within  the  past 
fortnight  or  so,  in  London,  Edinburgh,  and  in 
this  country.  Were  it  not  for  the  very  evident 
modification  of  the  remarks  put  forth  the  critic 
of  to-day  would  fain  be  tempted  to  regard  the 
flight  of  the  past  half  century  as  a  dream — that 
the  heroic  times  of  blood-letting  were  but  as 
yesterday.  And  yet  progress  in  medicine  is  but 
an  awakening — after  a  variable  lapse  of  time — to 
a  due  appreciation  and  proper  regard  of  means. 
If,  in  a  particular  measure,  it  requires  fifty  years 
of  slumber  or  ostracism  to  insure  in  it  that  which 
is  truly  good  and  for  the  public  weal,  we  had  best 
view  it  through  our  optimistic  glasses,  and  com- 
placently await  the  advent  of  the  next  time-tried 
expedient.      Experience    teaches    us — and    very 


i89i.] 


A  LESSON  IN  LONGEVITY. 


347 


plainly  in  this  case  of  venesection — that  it  is  use-  to  a  patient  previous  to  the  opening  of  a  mam- 
less  to  look  for  any  one  means  by  which  to  com-  mary  abscess.     Death  came  quickly,  and  before 
bat  the  whole  diversified  army  of  disease.     This  the  operation  was  commenced, 
has  been  clearly  illustrated  by  history,  notably  of       The  Indian,  i   Medical  Journal  editorially  criti- 
the  last  one   hundred  years.     Enthusiasm — pro-  cises  the  case,  with  the  following  concluM' 

1  enthusiasm— in  the  direction  of  meteoric  «■  That  the  administration  of  an  anaesthetic  by  a  phy- 

ne,  if  we  may  be  allowed   the  expression,  :  sician  for  a,1-v  purpose  whatever,  except  in  obstetrics  and 

,    ,  ,     .          .               ,     .        .   .     .         -.I.  cases   of  emergency,   without   the   presence  of  another 

is  commendable  to  a  degree,  but  yet  is  inevitably  ...                        ,            .                  .    .     .     . 

.  physician,   when   such   can   be  procured,  is  to   be   con- 

disastrous.     This  was  certainly  the  result  with  , iemne,i. 


venesection.     It  was  relegated   to  such  oblivion 
that  the  student  of  medicine  during  the  past  two 
decades  at  least,  has  scarce  heard  it  mentioned, 
and  never  observed  its  use. 
— with    few   exceptions — throughout   the  entire 


2.  In  a  large  city  like  Indianapolis,  where  the  services 

of  an  expert  in  anaesthesia  can  always  be  procured,  the 

physician  who  does   not   avail    himself  of  such   services 

,  should  be  held  to  a  strict  accountability  for  any  disas- 

And  so  it  has  been  ,     .,  - 

trous  results  that  may  occur. 

3.  The  administration  of  a  general  anaesthetic,  for  the 


justifiable. 

4.  In  view  of  the  above  unassailable  propositions,  the 
death  of  the  above  patient  should  not  be  attributed  to  an 
unavoidable  accident,  from  the  necessary  and  skilful  ad- 
ministration of  chloroform. 


A  LESSON  IN  LONGEVITY. 


field  of  medical  research.     History  repeats  itself  purpose  of  opening  a  mammary  abscess,  is  wholly  un- 
almost  daily  upon  this  point. 

When  Dr.  Pye-Smith  read  his  paper,  entitled: 
"The  Therapeutical  Value  of  Venesection  :  its 
Indications  and  its  Limits,"  before  the  Royal 
Medical  and  Chirurgical  Society,  it  is  interest- 
ing to  note  how  conservative,  not  only  the  title 
and  contents  of  Dr.  Pye-Smith's  contribution,  The  Medical  Age  draws  a  lesson  in  longevity 
but  its  reception  by  the  Society  and  the  discussion  from  the  life  of  the  late  George  Bancroft,  in 
which  followed  the  paper.  Some  of  the  foremost  which  while  it  admits  that  there  is  no  system  of 
medical  men  of  England  came  forward  with  their  living  which  wiu  insure  longevity,  yet,  withal, 
opinions— well-washed  by  the  ever-lapping  waves  there  are  certain  considerations  tending  that 
of  Time— and  humbly  laid  them  down  at  the  feet  of  way  and  wnich  if  carefully  lived  up  to,  offers 
Record.  O  Shades  of  fifty  years  agone !  O  probably  the  best  chance  of  reaching  close  to, 
Whilom  Hero  of  the  Lance,  pray  heed  e'en  this  |  if  not  quite    the  hundred  year  period.     The  fol- 


faint  justification  !  Contumely  hides  her  scrawny 
lines  and  a  newer  light — and  brighter — bids  fair 
to  shine  ! 

Physicians  and  Surgeons  alike,  at  this  meeting, 
expressed  themselves  in  favor  of  venesection  in 
those  cases  wherein  depletion  was  clearly  indi- 
cated, viz.,  and  more  particularly,  first,  in  cyano- 
sis with  distention  of  the  right  side  of  the  heart, 
whether  from  pulmonary  or  some  other  obstacle 
to  the  circulation  ;  secondly,  the  intense  pain  of 
aortic  aneurism  ;  and  thirdly,  uraetnic  and  pro- 
longed epileptic  convulsions. 


lowing  pertinent  advice  is  given  : 

Live  as  much  as  possible  out  of  doors,  never  letting  a 
day  pass  without  spending  at  least  three  or  four  hours  in 
the  open  air. 

Keep  all  the  powers  of  mind  and  body  occupied  in  con- 
genial work.  The  muscles  should  be  developed  and  the 
mind  kept  active. 

Avoid  excesses  of  all  kinds,  whether  of  food,  drink,  or 
of  whatever  nature  they  may  be.  Be  moderate  in  all 
things. 

Never  despair.  Be  cheerful  at  all  times.  Never  give 
way  to  anger.  Never  let  the  trials  of  one  day  pass  over 
to  the  next. 

The  period  from  fifty  to  seventy-five  years  should   not 


Dr.  Pye-Smith  justifies  himself  fully — which    be  passed  in  idleness,  or  abandonment  of  all  work.  Here 


the  discussion  bears  out — by  the  statement  that 
he  felt  the  time  had  come  when  it  could  be  shown 
that,  if  rightly  used,  venesection  was  a  valuable 
remedy. 


ANOTHER  DEATH  FROM  CHLOROFORM. 
Another  death  under  chloroform  recently  oc- 
curred   at    Indianapolis.     A    physician,   without 
professional  assistance,  exhibited  the  anaesthetic 


is  where  a  great  many  men  fail — they  resign  all  care  or 
interest  iu  worldly  affairs,  and  rest  of  body  and  mind  be- 
gins. They  throw  up  their  business  and  retire  to  private 
life,  which  in  too  many  cases  proves  to  be  a  suicidal 
policy. 

Duriug  the  next  period — the  period  from  seventy-five 
years  to  one  hundred  years,  while  the  powers  of  life  are 
at  their  lowest  ebb,  one  cannot  be  too  careful  about 
"catching  cold."  Bronchitis  is  a  most  prolific  cause  of 
death  in  the  aged.  During  this  last  period  rest  should 
be  in  abundance. 


348 


EDITORIAL  NOTES. 


[March  7, 


editorial  notes. 
Railroad  Ticket  Arrangements  for  the 
Annual  Meeting. — The  Railroad  Associations 
have  agreed  to  sell  tickets  on  the  certificate  plan, 
as  last  year,  for  one  full  fare  going,  one-third  fare 
returning.  All  must  obtain  a  certificate  on  pur- 
chasing ticket  to  Washington,  or  they  can  not 
have  the  reduction  in  returning. 

American  Medical  College  Association. 
— The  next  meeting  of  the  American  Medical 
College  Association  will  convene  at  the  Arlington 
Hotel,  Washington,  D.  C,  at  8  o'clock  p.m.,  May 
4,  1 89 1.  The  indications  point  to  a  very  inter- 
esting session  and  a  representation  from  a  large 
majority  of  the  Colleges  of  the  United  States. 
The  special  committee  on  permanent  organization 
is  at  work,  and  will  be  ready  to  report  at  this 
meeting. 

A  Good  Record. — The  report  of  the  Medical 
Department  of  Harvard  College  gives  the  total 
number  of  students  enrolled  during  the  year 
iSSq-'qo  as  304;  and  of  these  156  had  literary  or 
scientific  degrees — an  excellent  record  in  a  ver}' 
commendable  direction.  The  force  of  a  higher 
teaching  and  of  sterner  requirements  is  also 
shown  by  the  fact  that  out  of  seventy- five  appli- 
cants for  the  degree  of  Doctor  of  Medicine  in  the 
three-years'  course,  twenty-two  were  rejected; 
while  out  of  fifteen  applicants  for  the  same  de- 
gree in  the  four-years'  course,  two  were  rejected, 
and  four  received  the  degree  cum  laude.  There 
is  food  for  thought,  as  well  as  a  decided  plea,  in 
these  figures. 

Social  Evil  Act. — The  Legislature  of  Mis- 
souri has  listened  to  the  second  reading  of  an  Act 
for  the  regulation  of  prostitution.  The  funda- 
mental points  of  the  bill  are  patterned  after  the 
German  laws,  which  have  proved  to  be  ineffective. 

Leprosy  in  Minnesota. — The  State  Board  of 
Health  of  Minnesota  report  sixteen  cases  of 
leprosy  within  its  jurisdiction.  It  is  quite  en- 
tiri.lv  among  emmigrants. 

Aids  to  Military  Field  Service. — The 
French  have  adopted  a  very  simple  yet  servicea- 
ble plan  of  supplying  each  soldier  with  a  packet  of 
surgical  dressings  suitable  for  immediate  use,  and 
always  present.  The  packet  consists  of  antisep- 
tic gauze,  absorbent  cotton,  and  bandage,  together 
with  two   safety   pins.     All  this  is  folded  com- 


pactly, surrounded  by  oiled  silk,  stitched  within 
another  covering  of  durable  material,  which  ren- 
ders it  waterproof,  and  sewed  upon  the  inside  of 
the  clothing  over  the  left  breast. 

New  College  Building. — Plans  are  out, 
furnished  by  S.  S.  Beman,  architect,  for  a  new 
four  story  building  for  the  Chicago  Medical  Col- 
lege. It  is  to  cost  one  hundred  thousand  dol- 
lars, and  is  to  be  located  on  Dearborn  St.,  near 
Twenty-  fourth. 

College  Societies. — That  medicine  is  gradu- 
ally acquiring  that  recognition  to  which  its 
nobleness  and  scientific  character  entitles  it,  is 
indicated — to  a  degree — by  the  establishment 
and  progress  of  fraternal,  Greek-letter  chapters 
at  the  larger  and  more  progressive  centres  of 
medical  learning.  The  Nu  Sigma  Nu  confra- 
ternity (Medical)  held  its  ninth  annual  meeting  at 
Detroit  recently,  there  being  a  representation 
from  chapters  located  at  Ann  Arbor,  Detroit, 
Pittsburg,  Philadelphia,  and  Minneapolis. 

Harvard  Alumni  in  New  York  City. — 
The  graduates  of  the  Medical  department  of 
Harvard,  now  residing  in  New  York  City,  have 
of  late  organized  into  an  association.  Monthly 
meetings  will  be  held. 

Practical  Lectures  in  Practical  Fields. 
— A  free  course  of  practical  lectures  is  announced 
for  mothers  and  nurses,  at  the  New  York  Post- 
Graduate  Medical  School.  Among  the  subjects 
to  be  treated  are  the  following  :  ' '  The  Care  of 
the  Eye;"  "The  Most  Frequent  Surgical  In- 
cidents in  Infancy  and  Early  Childhood;"  "The 
Care  of  the  Skin  in  Health  and  Disease;" 
"Practical  Points  in  the  Nursing  at  the  Babies' 
Wards  as  Employed  in  Lung  Diseases,  Fevers, 
Intestinal  Diseases,  etc.;"  and  "Infant  Feeding 
and  the  General  Care  of  Young  Children." 

The  wav  tiikv  do  at  YiEXNA. — Late  corre- 
spondence to  the  Medical  Record  rehearses  the  de- 
tails of  a  sudden  death  upon  the  operating  table 
— from  the  occurrence  of  an  air-thrombus,  as 
was  shown  by  the  autopsy — and  following  the 
operation  for  the  removal  of  a  goitre.  It  was  at 
Billroth's  public  clinic,  and  the  absence  ot 
measures  which  aid  recuscitation  was  notable, 
however  impossible  of  success  their  application 
might  have  been.  Yet  it  was  the  events  follow- 
ing, more  than  the  "shadows  before,"  which  are 


i8yi.] 


MEDICAL  rTEMS. 


349 


unique,  as  will  be  illustrated  by  the  following 
quotation  :  "A  most  unpleasant  impression  was 
made  on  all  the  foreigners  present  by  this  tragic 
spectacle,  and  one  could  not  but  be  struck  by  the 
unshaken  coolness  with  which  the  surgeon,  after 
the  dead  body  of  his  patient  had  been  carried 
out,  proceeded  immediately  to  perform  a  goitre 
extirpation  on  a  second  case — this  time  with  a 
happier  result." 

Medical  Legislation. — A  bill  to  regulate  the 
practice  of  medicine  in  California  has  been  intro- 
duced before  the  legislative  assembly  at  present 
in  session.  The  bill  provides  for  the  establish- 
ment of  a  State  Board  of  Medical  Examiners 
consisting  of  seven  members,  appointed  by  the 
Governor,  one  from  each  of  the  well-established 
medical  schools,  and  the  others  at  large. 

Bromoform,  which  has  recently  received  wider 
endorsement  in  the  treatment  of  whooping  cough, 
was  first  brought  forward  as  a  remedy  in  this  dis- 
ease by  Dr.  Stepp,  of  Niirnberg,  in  1889,  who  spoke 
of  its  value  by  both  inhalation  and  internal  ad- 
ministration. According  to  Phar.  Zeitsch.  fur 
Russland,  Stepp  administered  it  in  the  following 
manner  :  bromoform  10  drops,  alcohol  3  to  5  c.c, 
aqua  dest.  100  c.  c,  syrupus  10  c.  c.  A  cure  is 
claimed  in  from  five  to  ten  days. 

Foreign  Body  in  the  Male  Bladder. — Dr. 
Geo.  H.  Monks,  of  Boston,  mentions  in  the 
Boston  Medical  and  Surgical  Journal,  the  removal 
by  perineal  section,  of  a  piece  of  lead  pencil  over 
two  inches  long  from  the  male  bladder.  The 
substance  had  been  introduced  by  the  patient 
with  a  view  of  overcoming  a  stricture  of  the 
urethra. 

MEDICAL  ITEMS. 

Medical  Legislation  in  Missouri. — There 
is  now  pending  in  the  Missouri  legislature  a  bill 
to  compel  all  medical  colleges  in  the  State  to 
adopt  three  courses  of  lectures  as  a  condition  for 
graduation.  All  of  the  medical  colleges  in  the 
State,  excepting  one,  are  favorable  to  the  bill. 

The  Illinois  State  Board  of  Health  has 
decided  that  hereafter  it  will  recognize  no  foreign 
diploma  that  does  not  confer  upon  its  holder  the 
right  to  practice  medicine  in  the  country  in  which 
it  was  granted.  The  holder  of  an  Austrian,  a  Ger- 
man, Russian,  or  Swiss  diploma,  wishing  to  prac- 
tice in  Illinois,  must  hereafter  pass  an  examination 


before  the  Board,  unless  he  have  a  pass  certificate 
from  a  government  examining  commission.  The 
holder  of  a  Canadian  diploma,  unless  a  licentiate 
of  the  College  of  Physicians  and  Surgeons  of 
Ontario  and  Quebec,  must  pass  an  examination 
in  order  to  be  licensed  in  Illinois, 

The  Prevention  of  Narcotic  Inebriety. 
— At  a  meeting  of  the  American  Association  for 
the  Cure  of  Inebriety,  held  February  18,  at  the 
Academy  of  Medicine,  New  York,  Dr.  J.  B. 
Mattison,  of  Brookhm,  offered  the  following 
preamble  and  resolutions  : 

Whereas,  a  leading  cause  of  morphinism, 
chloralism  and  cocainism  is  the  facility  with 
which  morphine,  chloral  and  cocaine  can  be  pro- 
cured from  pharmacists  :  and, 

Whereas,  the  refilling  of  prescriptions  con- 
taining these  drugs  is  a  potent  factor  in  the  rise 
and  growth  of  these  diseases  : 

Therefore,  be  it  resolved,  as  the  sense  of  this 
Association,  that  no  retail  druggist  should  sell 
morphine,  chloral  or  cocaine,  except  on  a  physi- 
cian's prescription. 

That  no  prescription  containing  morphine, 
chloral  or  cocaine  should  be  refilled  except  on 
the  written  order  of  a  physician. 

These  were  unanimously  adopted,  and  a  com- 
mittee consisting  of  Drs.  Mattison,  Crothers  and 
Wright,  was  appointed  to  secure  legislation  along 
the  line  of  the  resolutions. 

In  future  all  candidates  for  medical  degrees  in 
France  must  produce  a  certificate  of  re-vaccina- 
tion according  to  the  regulations,  otherwise  they 
will  be  debarred  from  registration. 

The  State  Board  of  Health  of  Maine 
has  introduced  a  bill  into  the  legislature  to  pro- 
vide for  the  registration  of  vital  statistics.  The 
bill  was  prepared  by  the  State  Board  of  Health 
after  an  extended  examination  of  the  existing 
laws  of  other  States,  and  an  effort  is  now  being 
made  to  secure  its  passage.  It  seems  almost 
needless  to  point  out  the  value  of  such  a  bill.  An 
official  registration  of  births,  marriages  and 
deaths,  in  such  a,  form  as  to  make  it  furnish  facts 
available  and  valuable  for  various  purposes,  is 
considered  so  important  a  work  that  most  civil- 
ized States  and  nations  have  not  omitted  to  pro- 
vide for  it.  Vital  statistics,  when  properly  col- 
lected and  recorded,  are  invaluable  for  a  variety 
of  purposes  which  will  readily  suggest  themselves, 
and  it  is,  therefore,  somewhat  remarkable  that 
the  State  of  Maine  should  have  thus  far  neglected 
'to  provide  for  their  registration. — Sanitary 


5° 


TOPICS  OF  THE  WEEK. 


[March  7. 


TOPICS  OF  THE  WEEK. 


THE  LONDON  LANCET. 

For  years  this  valuable  journal  has  occupied  a  fore- 
most position  iu  the  field  of  medical  literature. 

It  has  achieved  a  success  of  which  any  Briton  may 
justly  be  proud,  and  we,  as  Americans,  are  none  the  less 
ready  to  accord  to  it  the  preeminence  which  by  the  her- 
culean labors  of  its  founder  it  finally  came  to  command. 
The  difficulties  which  it  encountered  were  simply  im- 
mense; but  by  reason  of  these  its  triumphs  were  the 
more  conspicuous.  Medical  journalism  has  everywhere 
its  obstacles — hindrances,  criticisms  and  discouragements 
— and  those  who  become  familiar  with  the  earlier  history 
of  The  Lancet  will  discover  that  such  besetmeuts  are  by  no 
means  peculiar  to  medical  journalism  in  America. 

We  are  confident  that  American  readers  will  be  deeply 
interested  in  a  brief  recital  of  some  of  the  earlier  experi- 
ences of  The  Lancet  as  given  recently  by  one  of  its  cor- 
respondents, and  we  quote  from  his  article  as  follows. 
He  says: 

I  have  recently  had  the  curiosity  to  go  through 
the  files  of  The  Lancet  with  the  object  of  discovering  and 
recording  if  possible  the  tone  and  aims  of  that  journal 
from  its  inception,  and  the  enormous  labor  has  been  am- 
ply repaid  by  the  discovery  of  the  rich  mine  of  wealth 
which  the  volumes  contain.  I  believe  I  have  discovered 
the  secret  of  the  unparalleled  success  and  the  high  repu- 
tation of  the  chief  organ  of  the  medical  profession.  In 
one  of  the  volumes  I  came  across  what  may  be  called 
The  Lancet's  confession  of  faith.  "The  Lancet  will  per- 
petuate the  memory  of  Thomas  Wakley — the  founder  of 
this  journal — by  cherishing  after  his  death  the  principles 
to  which  he  consecrated  his  life."  The  solemnity  of  ex- 
pression in  the  passage  on  the  occasion  of  the  death  of 
the  founder  led  me  to  further  inquire  by  what  motives 
he  had  been  actuated,  what  such  a  memory  and  example 
required  of  his  successors,  and  how  far  the  solemn  prom- 
ise had  been  fulfilled  by  them.  What  had  he  to  gain  in 
requiring  that  medical  men  should  be  adequately  re- 
warded for  their  labors?  "I  have,"  said  Mr.  Wakley  in 
a  public  speech — "I  have  foresworn  medical  practice.  I 
use  only  the  lancet,  and  that  in  the  form  of  a  quill." 
From  that  time  he  became  the  champion  of  medical  re- 
form of  all  kinds.  If  we  turn  to  The  Times  of  1827  we 
find  that  at  that  early  period  The  Lancet  gave  the  first 
blow  to  "cupidity  and  corruption,  by  establishing  a  free 
medical  press,  and  rousing  the  profession  to  a  sense  of 
its  injuries  and  indignities,  and  to  a  spirit  of  resistance." 
Mr.  Wakley's  great  aim  was  always  to  uphold  the  rights 
of  the  profession  as  a  whole  by  the  adoption  of  straight- 
forward courses  of  action.  What  has  he  gained  for  med- 
ical men?  Iu  former  days,  when  scarcely  a  week  passed 
without  furnishing  instances  of  imbecility  and  ignorance 
on  the  part  of  coroners,  and  the  reports  of  insults  borne 
bv  medical  men  who  were,  without  fee  or  reward,  com 
pelled  to  attend  these  "worthless,  expensive,  and  perni- 
cious exhibitions,"  he  raised  hi--  voice  with  no  uncertain 
sound  against  such  palpable  abuses,  and  earned  for  him- 
self no  small  share  of  obloquy  from  those  who  considered 


themselves  injured  by  his  fearless  exposure  of  base  prin- 
ciples. Unmistakable  deaths  from  poisoning  were  re- 
corded by  coroner's  juries  from  time  to  time  as  "Deaths, 
by  the  visitation  of  God."  Abuses  so  apparent  soon 
roused  him  to  most  energetic  action,  resulting  in  his 
candidature  and  election  for  the  office  of  Coroner  for  the 
Western  Division  of  Middlesex  at  the  enormous  cost  to. 
himself  of  many  thousands  of  pounds.  From  that  time 
The  Lancet  has  consistently  supported  the  appointment 
of  medical  coroners,  and  now  scores  of  medical  men  occupy 
that  position.  The  Coroners  Act,  allowing  the  appoint^ 
mem  of  a  permanent  deputy  coroner,  and  the  Medical 
Witnesses  Bill  were  introduced  to  parliament  on  his  in- 
stigation and  passed  in  consequence  of  his  exertions. 

As  a  direct  result  of  his  personal  patience,  an  inquiry 
iuto  the  flogging  to  death  of  a  soldier  at  Hounslow  Bar- 
racks led  to  the  abolition  of  flogging  in  the  army.  His. 
keenest  shafts,  however,  were  aimed  at  empiricism  and 
cant,  "  the  prima  materia  of  the  devil,"  asCarlyle  called 
it.  He  hated  shams,  and  loathed  the  feebleness  which 
succumbs  to  mere  authority.  He  succeeded  to  a  great 
extent  in  rescuing  the  very  institutions  which  were  es- 
tablished to  prevent  quackery  from  the  quagmire  of  em- 
piricism into  which  they  themselves  had  fallen.  His  at- 
tack on  the  faults  and  absurdities  connected  with  medical 
education  should  render  the  medical  student  of  to-day, 
perhaps  more  than  anyone  else,  grateful  to  the  founder 
of  The  Lancet,  for  it  is  through  his  instrumentality  that 
every  student  has  now  secured  to  him  able  and  earnest 
teachers,  and  the  right  of  using  freely  the  opportunities 
which  public  hospitals  afford  him  for  his  improvements 
The  first  great  battle  by  which  the  rights  of  a  free  medi- 
cal press  were  established  was  won  by  Mr.  Wakley  on 
their  behalf.  Up  to  the  year  1825,  no  clinical  lectures, 
were  delivered  in  the  hospitals,  and  no  reports  of  the 
cases  which  occurred  in  them  were  published.  The  fa- 
mous action  of  Abernethy  v.  Wakley  established  the 
right  of  the  medical  journals  to  print  public  lectures,, 
and  was  a  triumph  for  the  press,  the  influence  of  which 
has  been  great  and  lasting.  With  regard  to  the  decision 
in  the  case  of  Bransby  Cooper  v.  Wakley,  Sir  James  Scar- 
lett, the  opposing  counsel,  admitted  "  that  the  example 
of  this  proceeding  has  given  to  the  periodical  press  a 
triumph  and  an  influence  which  it  never  had  before." 

Mr.  Wakley  was  one  of  the  first  to  urge  upon  his  med- 
ical brethren  the  necessity  for  their  being  represented  im 
Parliament  by  members  of  their  own  profession;  and, 
ever  read}-  to  practice  what  he  preached,  he  submitted! 
himself  as  Parliamentary  candidate  for  Finsburv.  T\\  ice- 
he  went  to  the  poll,  and  twice  was  he  defeated.  Un- 
daunted, he  went  again  to  the  poll  at  the  next  election  . 
and  was  returned  by  an  overwhelming  majority.  Before 
he  had  been  many  weeks  in  the  House  he  began  to  man- 
ifest his  care  for  the  interests  of  the  profession  by  asking; 
questions  of  the  greatest  importance  to  its  members,  audi 
throughout  the  whole  of  his  Parliamentary  career  of 
twenty-four  years  was  he  the  staunch  champion  of  med- 
ical men,  influencing  the  House  to  appoint  select  com- 
mittees to  inquire  into  abuses,  introducing  Bills,  moving 
amendments,  and  in  many  other  ways  acting  in  their  i«- 
terests.    He  established  a  life  assurance  office  for  the  pur- 


i89i.] 


TOPICS  OF  THK  WEEK. 


35i 


now  attained  in  public  esteem,  where  some  of  the  labors 
of  a  life  remarkable  at  once  for  uprightness  and  disin- 
terestedness of  purpose. 

•  :ird  of  hearts  unkind, 
Kind  deeds  with  cold  returning. 

t  lie  gratitude  ol  men 
Hath  oftener  left  me  mourning." 

The  memory  of  Thomas  Wakley  should  be  written  in 
letters  of  gold  on  the  mind  of  every  medical  man.  Ex- 
amples and  principles  such  as  these  are  surely  those 
which  all  should  be  proud  to  follow  and  adopt,  for  even 
now  necessity  for  further  reform  in  each  and  all  of  the 
directions  I  have  indicated  is  not  wanting.  I  earnestly 
hope  and  believe  that  you,  the  successors  of  so  worthy 
an  ancestor,  will  persist  in  the  noble  endeavor  to  carry 
out  the  promise  made  at  the  time  when  he  ceased  to 
labor  among  us,  and  in  so  doing — though  you  may  easily 
fall  short  of  the  rare  excellence  which  he  at  all  times  dis- 
course 
which  shall  be  honorable  alike  to  yourselves  and  of  the 
highest  utility  to  the  noble  profession  you  have  the 
honor  to  represent. 


pose  of  enforcing  the  payment  by  the  various  offices  of 
the  fees   for   the   medical  examination  of  their  clients, 
urging  that,  as  medical   reports  were  given  in  the  inter- 
ests of  the  offices,  payment  of  the  fees  should  therefore 
be  made  by  them.    What  is  the  direct  result  of  this  action 
at  the  present  day?     Every  office   now  pays  the    medical 
fees,  and  I  observed  in  a  recent  issue  of  The  Lancet  that 
during  the   past  year   one    office   had   paid  as    much    as 
^"50,000  in  recognition  of  the  services  of  medical  officers. 
In   his   threefold   capacity  of  Member  of  Parliament  for 
Finsbury,  Coroner   for  West  Middlesex,  and  Editor  of 
The  Lancet,  he  wielded  a  power  unequalled  by  any  other 
man  in  the  profession,  and  was  not  slow  to  use  it  for  the 
advancement  of  its  interests  and  welfare.     Perhaps  one 
of  the  most  important  public  functions  performed  on  be- 
half of  the   poor   by  Mr.  Wakley  was  the   establishment 
of  an  Analytical  Commission  which  exposed  the  adulter- 
ation of  food,  and  converted  the  press  into  an  instrument 
c       ,•      ,         .  ...  ..       .,„,,.  ...  ,  r'plaved — nevertheless   vou  will   have   adopted 

of  police  by  establishing  m  J  he  Lancet  the  precedent  01    •_  f  ■  *  » 

publishing,  fearless  of  all  legal  consequences,  the  name 
and  address  of  the  establishment  where  adulteration  was 
carried  on.  In  many  cases  he  would  add:  "This  is  the 
third  article  which  we  have  found  adulterated — the  pub- 
lic should  avoid  the  shop."  As  a  result,  legal  actions 
bristled  around  him,  but  such  was  the  genuineness  of  his 
work  that  in  not  a  single  instance  was  an  unfavorable 
verdict  recorded  against  him.  Some  years  after  the  es- 
tablishment of  his  Analytical  Commission,  an  Act  of  Par- 
liament was  passed  requiring  the  appointment  of  public 
analysts  throughout  ever)'  district  of  the  country.  The 
public  benefits  resulting  from  this  work  cannot,  indeed, 
be  overrated. 

What  did  he  gain  by  the  exertion  of  his  indomitable 
courage  on  behalf  of  his  professional  brethren  ?  Either 
as  plaintiff  or  as  defendant  in  the  law-courts  Mr.  Wakley 
must  have  fought  some  twenty-five  or  thirty  actions,  con- 
testing in  his  own  person  with  some  of  the  leading  bar- 
risters of  that  day  over  matters  connected  with  the  ad- 
vancement of  the  profession  at  so  great  a  personal 
expense  that  on  several  occasions  the  very  existence  of 
The  Lancet  was  imperilled.  He  lent  his  aid  in  reforming 
the  Lunacy  Laws,  and  was  always  the  defender  of  the 
rights  and  privileges  of  the  medical  officers  of  the  united 
services  and  of  the  Poor-law  administration.  He  was  the 
champion  of  the  Fellows  and  Members  of'  the  Royal 
College  of  Surgeons,  who  were  unfairly  treated  by  a 
Council  then  wholly  irresponsible  and  self-elective.  In 
regard  to  this  body  he  maintained  that  when  a  few  indi- 
viduals were  appointed  to  watch  over  the  interests  of  a 


THE  ELEVENTH  ANNUAL  REPORT  OF  THE  NEW  YORK 
STATE  BOARD  OF  HEALTH. 

Doubtless  the  most  interesting  point  in  the  report  of 
the  State  Board  of  Health  for  last  year  is  the  statement 
concerning  the  effects  of  the  influenza  which  prevailed  a 
year  ago.  According  to  the  report,  the  number  of  deaths 
in  January,  1S90,  was  13,000 — larger  than  ever  before  and 
5,000  in  excess  of  the  average  for  that  month  for  five 
years.  This  increase  is  considered  to  have  been  undoubt- 
edly due  to  the  epidemic.  There  were  3.51  deaths  per 
1,000  population  from  zymotic  diseases  during  1890, 
against  3.90  in  1SS9.  Typhoid  fever  had  a  lower  mortal- 
ity. Diphtheria  also  seems  steadily  to  have  declined  in 
prevalence.  Small-pox  caused  only  four  deaths  during 
the  year,  two  of  which  were  reported  from  New  York 
Citv,  the  others  occurring  in  Cohoes  and  Dansville.  Con- 
sumption caused  about  12  per  cent,  of  all  deaths. 


PROGRESS  IN  THE  RIGHT  DIRECTION. 

A  comparison  of  the  Seventh  Report  of  the  Illinois 
State  Board  of  Health,  on  Medical  Education,  with  the 
one  for  1S90,  shows  that  some  marked  changes  have 
taken  place  in  the  past  year,  and  when  a  review  is  made 
of  the  changes  for  the  better  since  the  session  of  1SS2- 
18S3,  there  is  much  cause  for  congratulation  and  en- 
large body  of  men,  it  was  quite  necessary,  in  order  to  se-  I  couragement.  There  are  now  14S  medical  colleges  of  all 
cure  upright  conduct  on  their  part,  that  the  interests  of   kinds   in    existence   in    the    United   States  and   Canada, 


those  few  should  be  identified  with  those  of  the  many. 
To  this  end  he  labored,  exposing  and  denouncing  the 
procedure  of  the  "  minacious  oligarchy  of  our  mis- 
managed temple,"  as  he  called  the  Council,  and  charac- 
terizing  certain  of  the  By-Laws  then  in  force  as  "  instru- 
ments of  corporate  iniquity."  To  attack  abuses  un- 
compromisingly wherever  they  existed,  to  spare  no 
effort,  toil,  or  trouble  to  effect  reforms  wherever  they 
were  required,  to  raise  the  profession  as  a  whole  from  the 
lowly  position  it  then  occupied  to  such  a  level  as  it  has 


there  being  135  in  this  country  and  13  in  Canada. 
In  1SS2  the  number  of  colleges  requiring  certain  edu- 
cational qualifications  for  matriculation  was  45  ;  in  ibb6. 
114;  in  1SS9,  117:  in  1S90,  124;  and  in  this  report  129. 

In  1882  the  number  of  colleges  that  required  attend- 
ance on  three  or  more  courses  of  lectures  before  gradua- 
tion was  22  ;  1886,  41  ;  in  1889,  47  ;  in  1890,  64;  in  this 
Report,  85.  Of  the  14S  colleges  all  have  chairs  of  hygiene 
except  14.  making  123  that  teach  this  branch,  while  119 
now  have  chairs  of  medical  jurisprudence. 


352 


PRACTICAL  NOTES. 


[March  7, 


PRACTICAL   NOTES. 


FOR  NASAL  CATARRH. 

A  writer  in  L'  Union  Med.  states  that  the  fol- 
lowing prescription  is  much  used  in  London  hos- 
pitals : 

ft.     Amruouii  chlorid.,  30.0. 

Sodii  chlorat.,  75.00.      tt);. 
Sig.     A  teaspoonful  to  a  glass  of  water,  to  be  used  twice 
daily  as  a  nasal  douche  in  post-nasal  catarrh  combined 
with  deafness. 

—  The  College  and  Clinical  Record. 


TO  RELIEVE  NAUSEA  AND  VOMITING. 

A  writer  in  the  Therap.  Gazette  states  that  a 
mixture  of  1  part  of  menthol,  20  parts  of  alcohol 
and  30  parts  of  simple  syrup,  will  relieve  nausea 
and  vomiting — sometimes  even  the  obstinate  vom- 
iting of  pregnancy — if  given  in  teaspoonful  doses 
everv  hour. 


TO  PRODUCE  ANAESTHESIA  OF  THE  SKIN. 

A  spray  of  chloroform,  10  parts;  ether,  15; 
menthol,  1  part,  produces  complete  anaesthesia  of 
the  skin,  lasting  for  from  two  to  six  minutes. — 
Pittsburg  Med.  Review. 

AN  OINTMENT  FOR  PRURITUS  OF  THE   ANUS    AND 
VULVA. 

Balfour  reports  that  he  has  almost  never  failed 
to  obtain  relief,  in  cases  of  pruritus  of  the  anus 
and  vulva,  from  an  ointment  containing  80  grs. 
of  calomel  to  the  oz.  of  vaseline  or  other  unguent. 


FOR    FURUNCULAR    AFFECTIONS. 
R.     Mentholis.  gr.  x. 

Cocainas  hydroehlorat,  gr.  v. 
Ung.  resinse,  5J.     ttjj. 

— Shoemaker. 

MIGRAINE. 

The  following  powder  is  recommended  in   I. a 
Mid.  Moderne  for  migraine: 
ft.     Citrate  of  caffeine,  i)i  gr. 

Phenacetin,  2  grs. 

Sugar  of  milk,  4  grs.      trjj. 
To  be  repeated,  if  necessary,  in  two  hours. 


WHEN  SHOULD  MEDICINE  BE  TAKEN? 

The  editor  of  the  Medical  Summary  for  No- 
vember thus  discourses  on  this  topic  :  The  proper 
time  for  the  administration  of  medicines  is  of 
equal  importance,  in  many  instances,  with  the 
selection  of  the  medicine  itself.  The  sooner  phy- 
sicians realize  this  fact  the  better  for  the  pa- 
tients. A  large  number  of  medicines  are  used  in 
a  routine  way,  after  meals;  but  too  often,  when 
so  employed,  they  are  not  properly  absorbed,  or 
they  hinder  digestion,  and  thus  undermine  the 
foundations  of  nutrition.  For  example,  if  the 
bromides  be  given  aftei    meals  their  absorption  is 


hindered,  and  their  presence  in  the  stomach  in- 
terferes with  the  peptic  ferment ;  so  that,  in  addi- 
tion to  the  depression  caused  by  the  bromide 
treatment,  we  have  superadded  that  which  fol- 
lows derangements  of  digestion.  Some  medicines 
can  be  taken  at  any  time,  because  of  their  diffu- 
sibility  ;  other  medicaments,  in  order  to  produce 
good  results,  should  be  exhibited  after  meals;  and 
others  again  should  be  used  only  between  meals, 
when  the  stomach  is  presumed  to  be  empty.  The 
administration  of  pepsin  and  pancreatin  furnish 
excellent  illustrations  of  these  principles.  When 
the  secretions  of  the  stomach  are  sufficiently  acid, 
pepsin  alone  can  be  used  in  the  course  of  half  an 
hour  after  food ;  but  if  there  be  a  lack  of  acidity, 
it  will  be  advisable  to  combine  the  pepsin  with 
an  acid,  preferably  hydrochloric  acid,  which  is 
the  normal  acid  of  the  stomach.  Should  gastric 
digestion  be  slow  or  imperfect,  a  little  more  acid 
can  be  added  from  time  to  time,  although  there 
will  be  no  need  of  increasing  the  amount  of  pep- 
sin provided  the  peptones  are  taken  up.  In  the 
use  of  pancreatin,  on  the  other  hand,  the  acid 
condition  of  the  stomach  will  destroy  its  activity. 
This  will  not  take  place,  however,  if  the  pancre- 
atin be  taken  with  food  just  after  the  first  mouth- 
ful is  swallowed,  or  if  the  preparation  be  taken 
about  two  or  two  and  a  half  hours  after,  when 
the  contents  of  the  stomach  are  supposed  to  be 
neutral  in  reaction. — Medical  Age. 


THE  SPEEDY  CURE   OF  TONSILLITIS. 

The  Loudon  Medical  Recorder,  October,  con- 
tains the  following  prescription  for  the  rapid  re- 
lief of  tonsillitis : 

R.     Tinct.  of  yeratrum  viride,  30  minims. 
Sulphate  of  morphia,  l}4  gr. 
Distilled  water,  6  drachms. 
ttjj.      Dose,    one   teaspoonful,    given   twice,    with    one 
hour's  interval,  at  the  outset  of  the  treatment,  and  then 
at  interyals  of  two  or  three  hours,  as  may  be  required. 

The  author  of  the  treatment  holds  that  there 
is  some  kind  of  therapeutical  agreement  or  har- 
mony between  the  drugs,  when  used  together, 
which  gives  them  an  efficiency  not  possessed  by 
either  of  them  when  used  separately.  For  ex- 
ample, the  liability  to  nausea  from  either  of  them 
alone  is  greatly  modified  by  the  combination.  He 
refers  to  a  number  of  cases  in  which  this  treat- 
ment has  seemed  to  produce  unusually  prompt 
relief,  and  he  asserts  that  lie  knows  of  no  drug  or 
drugs  which  have  the  power  to  control  tonsillar 
inflammation  with  the  certainty  and  celerity  of 
those  agents  when  used  jointly. 


PRESCRIPTION    FOR   A  COKYZA  POWDER. 

The  Lyon  Midical offers  the  following  powder 
for  inhalation  in  coryza  :  Menthol,  1  part,  mixed 
with  roughly  powdered  roasted  coffee,  50  parts. 
Another  contains  menthol,  2  parts;  hydrochlo- 
rate  of  cocaine,  1  part  ;  and  boric  acid.  100  pints. 


i89i.] 


SOCIETY  PROCEEDINGS. 


353 


SOCIETY   PROCEEDINGS. 


Buffalo    Medical  and    Surgical   Association. 

Meeting  of January  5,  1891. 

The  President,  Dr.  A.  A.  Hubbei.l,  in  the 
Chair. 
Dr.  Geo.  E.  Fell  read  a  paper  on 

FORCED    RESPIRATION. 

(See  page  325.) 

Dr.  Hartwig  said  he  regarded  Dr.  Fell's  ac- 
complishments as  being  of  lasting  value  to  the 
profession.  He  considered  the  use  of  the  face- 
mask  preferable  in  average  cases  of  forced  respir- 
ation, because  it  dispensed  with  the  tracheotomy, 
which,  of  course,  was  not  so  readily  carried  out. 

He  alluded  to  Schultz's  method  of  artificial 
respiration  by  swinging  the  patient.  He  was  con- 
vinced, from  his  own  observation  and  experience, 
that  infants  who  were  not  too  heavy  to  handle, 
could  be  revived  in  every  instance  where  there 
was  heart  beat  remaining,  by  that  method  ;  and 
reported  a  case  in  which  he  had,  after  working 
half  an  hour  at  a  stretch  before  obtaining  the 
first  gasp,  revived  a  child  ;  though  it  died  some 
thirty-six  hours  later  from  pneumonia  induced 
by  fluids  entering  the  lungs.  For  larger  persons 
there  was  no  method  comparable  with  forced  res 
piration. 

Dr.  Phelps  reported  a  case  of  forced  respira- 
tion performed  by  himself  and  Dr.  Mann,  some 
eight  or  ten  years  ago,  by  introducing  a  catheter 
into  the  larynx  of  an  infant  still  born  after  a  very 
troublesome  breech  presentation.  They  took 
turns,  one  blowing  air  from  his  lungs  through 
the  catheter,  while  the  other  applied  pressure  to 
the  chest  to  force  the  air  out.  After  two  hours' 
continuous  work  the  child  breathed  all  right,  and 
lived  for  several  hours. 

Dr.  Eli  H.  Long  :  I  want  to  thank  Dr.  Fell 
for  his  address  this  evening.  I  do  not  know  but 
that  I  have  done  the  Doctor  the  injustice  of  in- 
difference to  the  claims  of  his  method.  I  have 
refrained  from  criticism,  but  I  must  confess  that 
I  have  not  given  it  the  attention  which  I  proba- 
bly ought  to  have  done  ;  and  therefore  I  am  all 
the  more  surprised  and  pleased  at  his  explanation 
of  it  this  evening.  I  believe  very  firmly  in  forced 
respiration,  and  with  my  experience  with  asphyx- 
iated infants  I  am  convinced  that  such  cases  can 
be  saved  by  it  that  cannot  be  saved  in  any  other 
way. 

Dr.  Long  reported  a  case  of  severe  asphyxia 
following  a  breech  presentation,  in  which,  after 
the  use  of  the  catheter  in  the  larynx  and  supply- 
ing air  from  his  own  lungs,  he  had  the  child 
breathing  after  three  fourths  of  an  hour's  work. 
The  child  lived  twelve  days.  He  had  also  had 
the  pleasure  of  seeing  infants  live  and  thrive  in 


several  other  cases  in  which  he  had  resorted  to 
the  method  of  blowing  the  air  directly  from  his 
mouth  into  that  of  the  child,  without  the  catheter. 

Dr.  \V.  H.  Bkki.told  :  A  remarkable  case 
occurred  in  the  experience  of  some  friends  of 
mine,  which  I  think  I  can  with  propriety  say  a 
few  words  upon.  It  was  the  case  of  a  boy  who 
was  brought  into  the  hospital  having  every  sign 
and  symptom  of  tubercular  meningitis.  He  was 
taken  one  afternoon,  about  one  o'clock,  with  en- 
tire stoppage  of  respiration,  suddenly,  and  with 
no  premonitory  symptoms  whatever.  The  heart 
continued  beating,  firm,  strong  and  regular.  The 
house  staff  performed  artificial  respiration  on  him 
by  Sylvester's  method  for  four  hours.  The  heart 
continued  to  beat  during  this  time.  When  the 
house  staff  became  pretty  well  tired  out,  the 
trachea  was  incised  and  a  tube  put  in,  with  a  sort 
of  bellows  arrangement.  I  do  not  know  how 
nearly  it  compares  with  Dr.  Fell's,  because  I 
have  never  examined  his,  and  know  nothing 
about  its  construction.  Altogether  this  boy  was 
kept  alive  twelve  hours  from  the  time  his  respira- 
tion first  stopped.  At  the  post-mortem,  which  I 
made  the  day  after,  it  was  found  he  had  the  most 
marked  tubercular  meningitis.  The  ventricles 
were  enormously  dilated,  and  there  was  only 
about  three- fourths  of  an  inch  of  cerebral  tissue 
left  from  the  cortex  down  into  the  ventricles.  All 
of  the  contiguous  tissue  was  absolutely  diffluent. 
It  was  not  softened,  but  it  was  almost  like  pus. 
and  the  medulla  was  also  involved  in  this  pro- 
cess. This  case,  of  course,  was  absolutely  hope- 
less because  of  the  involvement  of  the  respiratory 
centre  in  this  process  of  sloughing.  But  it  illus- 
trates very  beautifully  what  forced  respiration 
will  do,  and  it  shows  that  Dr.  Fell  certainly  did 
us  a  very  great  service  in  showing  us  how  much 
can  be  accomplished  by  it. 

Dr.  Bartlett  objected  to  the  practice  often 
resorted  to  and  advised,  of  keeping  patients  in 
motion  when  suffering  from  an  over-dose  of  mor- 
phia. He  strongly  recommended  flagellation, 
which  he  had  used  for  many  years  with  good  re- 
sults, and  for  other  than  severe  cases  he  consid- 
ered it  one  of  the  best  of  methods.  In  severe 
cases  there  was  probably  no  method  which  would 
compare  with  forced  respiration. 

Dr.  Hartwig  :  I  would  like  to  ask  Dr.  Fell 
whether  he  would  not  be  afraid  of  injecting  al- 
cohol or  ether  into  a  large  vein  on  account  of  the 
possibility  of  thrombosis? 

Dr.  Fell:  If  such  a  procedure  were  attempt- 
ed at  all,  it  should  be  done  with  the  greatest  pre- 
caution, and  very  slowly  injected.  In  the  case  of 
J.  B.  we  injected  8  ozs.  of  a  normal  salt  solution. 
and  I  believe  it  would  be  safe  to  inject  the  smaller 
amount  of  brandy  and  ether  which  would  be  in- 
jected by  the  hypodermic  method. 

Regarding  these  other  methods  of  artificial  res- 
piration, one  significant  point  I  wish  to  mention 


354 


SOCIETY  PROCEEDINGS. 


[March  7, 


is  that  forced  respiration  is  more  easily  applied 
than  any  of  them,  even  in  infants,  if  you  have 
the  simple  apparatus.  Then  again,  in  blowing 
air  from  the  lungs  of  an  attendant  by  the  way  of 
the  tracheal  tube,  it  must  be  recognized  that  the 
air  passes  to  the  lungs  of  the  patient  contaminated 
with  carbon  dioxide;  we  do  not  pass  pure  air  into 
the  lungs,  and  cannot  expect  as  good  results. 
It  seems  to  me  that  Schultz'  method  would  be 
pretty  hard  on  the  child,  and  harder  on  the  prac- 
titioner— and  that  is  the  great  objection  to  artifi- 
ficial  respiration  generally.  Furthermore,  regard- 
ing these  vigorous  methods,  I  believe  that  a  great 
many  cases  are  lost  through  them.  In  cases,  for 
instance,  where  the  asphyxia  has  been  long  con- 
tinued, the  bare  fact  of  moving  the  patient  about 
might  in  many  cases  produce  just  the  condition 
which  would  cause  death,  through  the  loss  of 
energy  to  the  muscular  tissues  of  the  body;  and 
the  heart  tissue  also. 

In  narcotized  subjects,  I  believe  that  means 
should  be  used  in  conjunction  with  the  forced 
respiration,  for  combating  the  poison — atropia, 
digitalis,  and  every  other  means  applicable.  I 
think  it  of  very  great  importance  to  keep  up  the 
energy  of  the  system,  even  with  the  use  of  nutri- 
ent material,  which  will  sometimes  help  greatly. 

As  to  forced  respiration  being  necessary  in  des- 
perate cases  only,  if  you  have  the  apparatus,  it 
should  always  be  used  in  preference  to  artificial 
respiration  because  it  accomplishes  more,  and  is 
not  conducted  at  the  loss  of  the  patient's  energy, 
and  is  also  less  tiresome  and  easier  to  apply.  As 
to  flagellation,  I  do  not  know  how  valuable  it  is, 
but  it  seems  to  me  that  there  are  cases  in  which 
it  would  be  of  no  value  whatever,  where  forced 
respiration  would  be  of  great  value.  Only  those 
who  have  witnessed  the  effects  of  forced  respira- 
tion in  a  serious  case  can  fully  appreciate  the  full 
extent  of  its  influence  upon  the  system. 

Another  point  that  needs  to  be  considered  is, 
that  it  is  not  always  the  quality  or  the  quantity 
of  the  narcotic  poison  taken  that  is  of  the  first 
importance;  but  how  long  has  the  poisonous  in- 
fluence existed?  For  instance,  a  grain  of  mor- 
phia interferes  with  respiration  and  produces  a 
cyanotic  condition,  with  the  heart  tissue  and  the 
muscular  tissue  of  the  body  losing  energy  through 
the  asphyxiated  condition.  There  you  have  an 
influence  entirely  outside  of  the  influence  of  the 
poison,  which  indeed  may  be  the  controlling  fac- 
tor in  the  question  as  to  whether  the  patient  will 
live  or  not. 

Dr.  Bartlett:  Will  Dr.  Fell  kindly  express 
his  opinion  as  to  the  advisability  of  keeping  the 
patient  in  motion  ? 

Dr.  Fell  :  I  think  it  unadvisable.  After 
forced  respiration  is  instituted  the  entire  energy 
of  the  patient  should  be  saved  as  far  as  possible, 
in  my  opinion.  All  that  is  required  is  to  elimi- 
nate   the   poison   and   to   supply    the   blood    with 


oxygen.  Do  that  in  the  easiest  way  possible, 
and  you  are  doing  all  that  can  be  done,  except 
the  using  of  antidotes  advisedly.  In  opium 
poisoning  it  is  always  very  important  to  catheter- 
ize  the  patient.  Opium  and  morphia  being 
eliminated  mostly  by  the  kidneys,  this  should 
never  be  forgotten,  nor  the  injection  of  water  into 
the  rectum,  and  the  administration  of  water  to 
drink.  As  the  poison  is  also  eliminated  by  the 
stomach  it  may  be  advisable  in  some  cases  to 
carefully  wash  it  out,  but  do  not  let  any  fluids 
pass  to  the  lungs.  In  this  way  the  patient  will 
probably  be  enabled  to  eliminate  the  poison  more 
quickly  than  by  any  other  means. 

Dr.  Dorr  :  Do  you  from  your  experience,  and 
from  the  case  of  this  patient  mentioned,  think 
that  those  abscesses  were  caused  by  the  brandy 
and  ether  or  by  a  bad  needle  and  infected  in- 
strument ? 

Dr.  Fell  :  I  believe  that  the  abscesses  were 
caused  by  the  brandy  and  ether,  merely  because 
after  a  few  days  there  were  circumscribed  areas 
all  over  the  region  where  the  injections  had  been 
deposited. 

Dr.  Dorr  :  Merely  because  the  capillary 
circulation  was  weak  ? 

Dr.  Fell  :  Very  weak,  almost  inert,  owing  to 
small  quantity  of  blood  in  the  system.  I  thought 
at  first  from  rapid  breathing  it  was  pneumonia. 
Another  fact  worthy  of  mention  is,  that  in  none 
of  these  cases  has  pneumonia  or  any  bronchitis 
been  produced,  not  even  in  B's  case,  the  indica- 
tions were  caused  by  pain  over  the  region  of 
hypodermic  medication. 

Dr.  Dorr  :  Have  you  ever  seen  in  any  other 
case  brand}'  and  ether  produce  abscess  ? 

Dr.  Fell  :  I  never  have. 

Dr.  Dorr:  It  is  peculiar  if  it  does  in  just  this 
condition,  because  I  have  never  seen  it  in  any 
other  condition.    • 

Dr.  Fell  :  I  believe  it  was  entirely  owing  to 
the  fact  that  the  patient  had  lost  so  large  an 
amount  of  blood.  The  capillary  circulation 
must  have  been  insufficient  to  carry  off  the  brandy 
and  ether. 

Dr.  Dorr  :  That  is  quite  a  physiological  point. 

Dr.  Fell  ;  Another  point  I  wish  to  emphasize 
is  the  adaptability  of  forced  respiration  in  drown- 
ing and  cases  of  asphyxia  from  whatever  cause. 
The  drift  of  this  discusssion  may  give  the  im- 
pression that  it  is  more  useful  in  cases  of  opium 
poisoning  than  other  cases  of  asphyxia. 

The  President,  Dr.  A.  A.  Hubbell:  I  am 
sure  we  are  satisfied  of  one  thing,  gentlemen, 
and  that  is  that  Dr.  Fell  can  give  us  a  good  deal 
of  light  on  the  subject  of  opium  poisoning  and 
all  cases  of  asphyxia,  and  his  remedy  certainly 
deserves  a  great  deal  of  commendation,  as  it  has 
in  fact  received  it  by  so  eminent  an  authority  as 
Dr.  11.  C.  Wood,  of  Philadelphia,  and  in  such  a 
public  way. 


i89k] 


FOREIGN  CORRESPONDENCE. 


355 


FOREIGN    CORRESPONDENCE. 


LETTEB    PROM     PARIS. 

CPROM    OCR   OWN   CORRESPONDENT.) 

Koch's  I.vmph  in  tlic  Hospitals  and  Laboratories 
of  Paris — The  Library  of  a  French  Doctor  in  rdop 
—  Compulsory  Revacdnation  of  Medical  and  Phar- 
maceutical Students  —  Post-Guillotine  Phenomena 
Observed  in  the  Body  of  Eyraud — Portal.. 
Dressings  for  French  Soldiers — Hygiene  at  the 
Hair- Dressers. 

The  latest  j  udgment  passed  by  our  leading  medi- 
cal authorities  on  this  new  treatment  of  tuberculo- 
sis are  not  of  a  favorable  nature.  The  most  sweep- 
ing condemnation  of  the  method  emanates  from 
Professor  Verneuil,  the  veteran  surgeon  of  the 
Hotel  Dieu,  (formerly  of  La  Pitie).  At  a  clinical 
lecture  recently  delivered,  the  Professor  summar- 
izes the  results  yielded  by  Koch's  treatment  as 
follows- 


1.  Genuine    and   lasting:  cure 

still  unknown. 

2.  Temporary    improvement  - 

few  instances. 

3.  Improvement  of  any 

able  duration— much  rarer.      | 

4.  Condition    stationary    after  1 

weeks     of    treatment  —  very 
common. 

5.  Temporary,  but  more  or  less 

serious  local  aggravation — or- 
dinary result. 

6.  Persistent  local  aggravation- 


Serious  complications  set  up 
in  normal  or  non-tuberculous 
organs— frequent. 

Early  fatal  complications  from 
local  aggravation  or  the  set- 
ting  up  of  lesions  of  hitherto 
healthy  viscera— already  very 
numerous,  Virchow  having 
made  28  autopsies. 

Remote  complications  ending 
fatally-several  already  noted . 


As  regards  the  diagnostic  value  of  the  lymph, 
he  disparages  it  on  the  ground  of  its  uncertainty, 
and  the  danger  inseparable  from  the  inoculatory 
process.  He  asserts  that,  in  the  immense  major- 
ity of  cases,  ordinary  clinical  and  bacteriological 
examination  suffice  amply  to  elucidate  the  true 
nature  of  tuberculous  affections,  and  he  opines 
that,  even  when  these  diagnostic  means  fail,  it  is 
wise  to  abstain  from  the  employment  of  the 
lymph. 

We  still  await  the  collective  report  of  the  com- 
mittee appointed  at  St.  Louis  Hospital  to  study 
the  clinical  effects  of  the  lymph.  M.  Vidal,  one 
of  its  members,  has  made  (Soc.  de  Dermatologie 
et  de  Syphiligraphie,  January  15)  an  anticipatory 
report  which  reveals  no  new  facts,  excepting  the 
supervention  in  the  course  of  the  treatment  of 
myocarditis  and  endocarditis.  Great  caution  has 
been  observed  in  the  dosage,  each  patient  receiv- 
ing only  one-half  milligram,  and  the  dose  being  in- 
creased by  the  same  quantity  till  the  temperature 
reaches  102.20  F.,  an  interval  of  from  four  to  eight 
days  being  allowed  between  each  inoculation. 

•  At  the  Academie  de  Medecine  (February  10) 
Professor  Jaccoud  reported  the  results  obtained 
from  the  inoculation  of  guinea  pigs  with  Koch's 
lymph.  A  robust  Angora  guinea  pig,  weighing 
580  grams,  received  in  two  series  of  inoculations 
(separated  by  an  interval  of  a  week),  and  extend- 
ing over  ten  and  eight  days  respectively,  a  quan 


tity  of  pure  lymph  equal  to  50  centigrams.  The 
only  effect  observed  was  a  loss  of  weight  of  26 
grams.  The  day  following  the  last  inoculation 
the  animal  was  inoculated  over  the  right  shoulder 
with  one-half  of  a  tuberculous  gland  furnished  by 
another  guinea  pig.  A  month  later  the  animal 
died,  weighing  only  450  grams.  The  autopsy  re- 
vealed the  presence  of  tuberculous  glands  in  both 
axillte,  confluent  grey  tubercles  in  both  lungs, 
hepatization  of  right  apex,  and  caseous  masses  in 
the  liver  and  spleen.  The  experiment  was  con- 
trolled by  the  simultaneous  inoculation  of  a  test 
guinea  pig  with  the  other  half  of  the  tuberculous 
gland.  This  animal  has  lost  88  grams  in  weight 
and  has  developed  tuberculous  glands  in  the  ax- 
illae, but  he  has  already  survived  his  Kochined 
comrade  by  six  days.  Dr.  Dujardin-Beaumetz 
has  likewise  treated  tuberculous  guinea  pigs  with 
the  lymph,  but  this  treatment  did  not  prevent  the 
animals  dying,  as  usual,  when  they  had  lost  one- 
third  of  their  weight.  The  same  fatal  result  en- 
sued in  the  case  of  Kochined  guinea  pigs  inocu- 
lated subsequently  with  tuberculous  virus. 

The  following  inventory  of  the  somewhat  mea- 
gre library  of  a  whilom  practitioner,  one  Richard 
Hunot,  "en  sou  vivant  midecin  et  bourgeois  de 
Saifit-Ouen  de  Caen,"  may  interest  your  readers. 
As  a  rendering  into  modern  English  of  this  curious 
document  would  deprive  the  Rabelaisian  phrase- 
ology of  its  author  of  its  native  piquancy,  I  tran- 
scribe it  in  extenso: 

Le  27  Janvier  1609,  Guillaume  Le  Bailly,  sergent  roval 
"fit  enventaire  par  repertoire  des  lettres,  pieces  d'escrip- 
tures,  ensemble  de  quelques  livres  demeurez  du  decez  de 
deffunct  M.  Richard  Hunot,  d'aultant  que  j 'en  ay  trouv£ 
tant  dens  l'une  des  armares,  ung  buffet  que  dens  ung 
petit  coffret."  L'inventaire  etablit  de  nouveau  l'excel- 
lente  situation  du  defunt:  quant  a  la  bibliotheque,  elle 
est  bien  peu  volumiueuse: 

Item  ung  grand  livre  couvert  de  blanc,  intitule^  Les- 
pourtraictz  anatomiques  de  toutes  les  parties  du  corps 
humain,  graves  en  tailles  douces; 

Item  ung  autre  grand  livre  couvert  de  rouge,  intituled 
Les  ceuvres  de  Anbroise  Pard,  conseiller  et  premier  chir- 
urgien  du  Roy; 

Autre  livre  couvert  de  parchemin  intitule  Les  voyages 
du  s'  de  Vilarnont; 

Autre  livre  couvert  de  rouge  intitule  Les  institutions- 
chirurgies  de  Jean  Trigault,  docteur  en  medecine; 

Autre  vieil  livre  sans  intitullacion  comtuancant;  puis- 
que  j'auray  rendu  graces  a  Dieu  qui  donne  vie,  etc.; 

Autre  petit  livre  intitulle  Traicte  de  la  nature  et  cura- 
tion  des  plaies  de  pistolle  et  arquebouses; 

Autre  livre  intitulle:  La  chirurgie  mise  en  teorique  et 
pratieque; 

Autre  livre  en  latin  intitulle^  Petit  pontamy  cecy  bur- 
gensis  [sic),  etc.; 

Item  autre  petit  livre  couvert  de  blanc  intitule  Le 
guidon  des  apoticqveres; 

Autre  vie]  petit  livre  intitulle  Le  grand  Albert. 

According  to  the  terms  of  a  ministerial  decree, 
dated  January  1,  1891,  all  students  of  medicine 
and  pharmacy  throughout  France  are  compelled, 
before  their  names  are  allowed  to  be  entered  on 
the  rolls  of  their  several  faculties  or  schools,  to- 
produce  a  certificate  of  revacdnation  performed 


356 


NECROLOGY. 


[March  7, 


under  the  control  of  the  faculty  or  school 
at  which  the  aspirant  desires  to  prosecute  his 
studies.  This  prophylactic  measure  is,  moreover, 
rendered  incumbent  on  students  already  on  the 
books  before  they  can  take  out  further  inscriptions 
(sixteen  inscriptions  are  necessary  for  the  doc- 
torate). Apropos  of  this  excellent  regulation,  I 
may  mention  that  a  strong  current  is  setting  in 
among  French  hygienists  in  favor  of  compulsory 
vaccination  and  even  revaccination  for  all  classes 
of  society.  The  subject  has  been  hotly  discussed 
for  the  last  few  weeks  at  the  Academie  de  Medi- 
cine in  connection  with  the  "depopulation"  so- 
called  of  France.  It  is  strange  to  hear  such  an 
enlightened  personage  as  Professor  Le  Fort  re- 
jecting such  a  wise  precaution  as  an  infringement 
of  the  liberty  of  the  citizen.  On  the  other  hand, 
Brouardel,  Proust,  Colin,  Hervieux  are  all  in 
favor  of  the  primary  and  the  secondary  operations 
being  rendered  more  vigorous  in  their  application, 
rightly  regarding  the  forcible  isolation  of  vari- 
olous patients  advocated  by  M.  Le  Fort  as  a 
greater  violation  of  individual  liberty  than  the 
innocuous  and  much  more  effective  practice  of 
vaccination. 

The  late  Paul  Loye  maintained  that  decapita- 
tion put  an  immediate  stop  to  all  vital  phenomena. 
M.  Laborde  had  the  opportunity  of  noting  in  the 
case  of  the  notorious  assassin  of  the  process-server 
Gouffe,  the  occurrence  of  the  following  phe- 
nomena, the  presence  of  which  disproves  the 
above  assertion.  Immediately  aft^r  the  execu- 
tion there  was  noted  marked  corrugation  of  the 
forehead  extending  to  the  vertex;  associated  ocu- 
lar movements;  opening  and  shutting  movement 
of  the  mouth  of  a  respiratory  type.  The  palbe- 
bral  reflex  could  be  plainly  evoked  for  from  fif- 
teen to  twenty  minutes  after  decapitation,  during 
which  time  the  iris  remained  sensible  to  the  stim- 
ulus of  light.  Simultaneously  with  the  deposit 
of  the  trunk  in  the  basket  there  were  noticed  up 
and  down  movements  of  the  arms,  plainly  visible 
despite  the  fact  that  they  were  firmly  ligatured  to 
the  sides.  This  phenomena  is,  it  appears,  well 
known  to  Deibler's  assistants,  who,  in  their  figu- 
rative language  denominate  it  "the  flapping  of 
the  wings."  The  feet  were  strongly  retracted, 
and  when  M.  Laborde  pinched  the  arm,  the  trunk 
being  in  the  basket,  a  reflex  movement  was  very 
apparent.  As  M.  Laborde  remarks,  these  reflex 
movements  are  strictly  analagous  to  those  per- 
ceived in  the  abattoirs,  where  the  stimulation  of 
a  member  immediately  after  felling  produces  a 
violent  kick. 

The  Minister  of  War  has  decreed  that  each 
officer  and  private  shall  receive,  in  the  event  of 
mobilization,  a  field  dressing  to  be  carried  in  the 
inside  pocket  of  his  dolman,  waistcoat  or  hood. 
The  small  packet,  shaped  like  a  flat  pocket-book, 
is  composed  of:  1,  An  outer  covering  of  cotton 
stuff;    2.    An   inner  envelope  of  macintosh;    3.   A 


cake  of  cotton  wool  rendered  antiseptic  by  a  pre- 
vious steeping  in  a  1  per  1,000  solution  of  «cor- 
rosive  sublimate.  This  cake  is  wrapped  up  in 
gauze  and  can,  if  need  be,  be  divided  into  two  layers 
for  a  double  dressing  (entrance  and  exit  wounds  Ky 
bullets);  4.  A  small  compress  of  silk  gauze,  also 
asepticised  by  sublimate;  5.  A  fragment  of  mac- 
intosh to  prevent  the  drying  of  the  dressings  when 
applied;  6.  A  gauze  bandage,  also  sublimated,  six 
centimetres  broad  by  7  metres  long;  7.  Some 
safety-pins  wrapped  in  paper  and  deposited  be- 
tween the  two  envelopes  so  as  to  prevent  the  metal 
being  attacked  by  the  sublimate. 

While  on  the  subject  of  antiseptics,  let  me  re- 
cord the  first  instance  known  in  this  country,  so 
renowned  for  its  coiffeurs,  of  a  barber  applying 
the  principles  of  surgical  cleanliness  to  the  puri- 
fying of  the  weapons  with  which  he  assails  the 
faces  and  scalps  of  hirsute  humanity.  The  name 
of  this  perfumed  emulator  of  Lister  is  not  stated, 
but  he  applies  his  aseptic  scissors,  razors  and 
brushes  at  Lyons.  His  razors  are  mounted  in 
aluminium,  the  scissors  are  nickeled,  the  brushes 
being  provided  with  bristles  which  are  screwed 
on  to  the  wood,  thus  avoiding  the  necessity  for 
the  employment  of  glue  or  stitches.  After  use, 
these  instruments  are  well  washed  and  then  sub- 
jected to  a  temperature  of  120°  C.  in  an  oven  en- 
closed in  a  layer  of  glycerine  heated  b3T  a  range 
of  gas  jets. 

Some  time  ago,  the  Board  of  Health  of  the 
Seine  adopted,  at  the  instance  of  M.  Lancereaux, 
a  resolution  recommending  similar  precautions 
(the  purifying  of  instruments  used  by  hair-dress- 
ers by  means  of  the  flame  of  a  spirit-lamp,  and 
antiseptic  solutions).  This  resolution  has,  I  be- 
lieve, remained  a  dead  letter,  and  the  public  con- 
tinues to  run  the  risk  of  contracting  various  par- 
asitic cutaneous  diseases,  not  to  mention  syphilis, 
at  the  hands  of  "capillary'  artists"  unacquainted 
with,  or  careless  of,  these  dangers.  All  honor, 
then,  to  the  pioneer  of  fin  de  siecle  shearing  who 
is  the  subject  of  this  article  !  j.  h.  b. 


NECROLOGY. 


Dr.  Hosmer  Allen  Johnson. 

Dr.  Hosmer  Allen  Johnson  was  born  not  far 
from  Buffalo,  N.  Y.,  in  a  town  called  Wales. 
Here  he  lived  until  about  10  years  of  age,  enjoy- 
ing those  advantages  for  early  boy  life  which 
spring  from  a  home  filled  witli  elevating  influen- 
ce! .  and  from  contact  with  the  phenomena  of 
rural  nature.  It  was  interesting  to  note  how  this 
early  study  of  the  beautiful  in  nature  acted  like 
a  lofty  education,  and  impressed  itself  on  the 
whole  tone  of  his  mind.  Near  his  early  home 
there  is  a  hill  range  of  considerable  height.      Its 


i89i.] 


NECROLOGY. 


357 


rocks  are  carved  by  streams  into  gorges,  decorated 
with  mosses  and  wild  flowers  and  crowned  with 
woods.  Here  the  boy,  Hosmer  Johnson,  used  to 
wander  and  climb,  studying  the  beauty  of  the 
views,  and  tilling  his  memory  with  pictures  which 
tinted  all  his  after  life  and  were  never  effaced  by 
the  larger  views  of  other  regions.  Here  he  learned 
to  love  nature,  and  to  realize  how  its  magnificence 
typifies  the  glory  of  its  Creator. 

These  sentiments  never  died  out.  On  the  con- 
trary, they  strengthened  with  his  growth,  and 
helped  to  form  in  him  that  pure  and  elevated 
taste  which  gave  such  a  charm  to  his  whole 
career. 

It  was  this  which  caused  him  to  select  a  scien- 
tific profession,  as  well  as  to  study  nature  for  a 
recreation.  He  traversed  wild  rivers  in  a  canoe, 
sleeping  in  the  forests;  he  climbed  the  White 
Mountains  on  foot,  and  rolling  himself  in  a  blan- 
ket, slept  under  the  stars  with  a  friend  or  two  at 
his  side.  The  same  feeling  led  him  to  explore 
Switzerland,  California,  Colorado,  and  the  moun- 
tains about  Puget's  Sound. 

These  memories  prompted  him  when  he  assist- 
ed to  found  the  Chicago  Academy  of  Sciences  and 
the  Astronomical  Society,  and  led  him  to  say  and 
do  all  he  could  to  encourage  the  stud}'  of  natural 
objects.  Such  results  are  worthy  of  thought  at 
a  period  when  the  growth  of  cities  is  more  and 
more  shutting  men  out  of  nature.  Perhaps  if  we 
could  bring  more  children  under  the  influences 
which  molded  the  youth  of  Johnson,  we  would 
have  more  such  men  in  after  life. 

At  the  age  of  about  ten  years  he  removed  to 
Almont,  Mich.,  and  helped  cut  a  farm  out  of  the 
woods,  at  a  time  when  wolves  and  Indians  were 
far  more  abundant  than  civilized  beings.  During 
this  period  an  attack  of  sickness  left  him  with  an 
irritation  of  the  bronchial  tubes  which  never  fully 
left  him,  and  caused  many  of  his  acquaintances 
to  suppose  for  fifty  years  that  he  was  on  the  verge 
of  consumption.  There  was,  however,  not  the 
slightest  tendency  to  tuberculosis  in  any  part  of 
his  bodjr,  but  the  pulmonary  irritation  subjected 
him  to  repeated  attacks  of  pneumonia;  and  it  was 
one  of  these  which  at  last  caused  his  death  at  the 
age  of  sixty-eight  years.  In  his  early  manhood 
he  expected  only  a  short  life,  and  scarcely  dreamed 
of  attaining  the  age  which  he  finally  reached. 

In  the  year  1841  he  entered  an  academy  at 
Romeo,  Mich.,  where  he  prepared  for  college,  and 
then  entered  the  University  of  Michigan,  from 
which  he  graduated  in  1849. 

His  educational  career  showed  a  remarkable 
talent  for  the  acquisition  of  languages,  both  an- 
cient and  modern,  and  he  studied  Latin,  Greek, 
Hebrew,  French,  German,  Italian,  and  to  some 
extent,  Spanish.  In  his  boyhood  he  also  picked 
up,  from  the  surrounding  Indians,  a  considerable 
practical  knowledge  of  the  Ojibway  tongue. 
Three  years  after  taking  his  A.B.  he  received  the 


degree  of  A.M.,  and  at  a  later  period  that  of  LL.D. 

After  graduation  he  went  to  Chicago  and  com- 
menced the  study  of  medicine  under  the  supervi- 
sion of  Prof.  Herrick.  In  1851  he  became  the 
first  interne  of  Mercy  Hospital,  and  in  1852  grad- 
uated in  Rush  Medical  College.  In  1853  ne  he- 
came  a  member  of  the  Faculty,  and  continued 
with  it  until  1858,  when  he  resigned,  Xot  long 
after  his  resignation  he  united  with  a  few  others 
in  founding  the  Chicago  Medical  College,  in 
which  he  was  a  professor  and  trustee  from  the  be- 
ginning to  the  day  of  his  death,  and  was  the  first 
president  of  the  faculty. 

His  zeal  for  the  study  of  nature  led  him  to  be- 
come one  of  the  founders  of  the  Chicago  Acade- 
my of  Sciences,  as  well  as  of  the  Historical  So- 
ciety, and  of  the  Astronomical  Society. 

He  was  for  some  years  editor  of  the  Northwest- 
ern Medical  Journal,  and  afterwards  a  member  of 
the  City,  State  and  National  Boards  of  Health. 
During  the  war  of  the  rebellion  he  was  commis- 
sioned by  the  Governor,  with  the  rank  of  Major, 
as  one  of  the  Board  for  examining  surgeons  and 
assistant  surgeons  for  the  Illinois  regiments,  and 
such  was  the  faithfulness  of  the  Board  that  the 
medical  officers  of  Illinois  were  conspicuous  in 
the  whole  army  for  their  thorough  knowledge, 
and  their  humane  and  skilful  conduct  on  the  field 
of  battle.  In  examining  assistant  surgeons  for 
promotion,  he  had  to  traverse  the  field  of  war, 
and  his  duties  brought  him  occasionally  under 
fire,  at  which  times  he  showed  his  skill  as  an  op- 
erator and  as  a  manager  of  field  ambulance  service. 

After  the  great  Chicago  fire,  Dr.  Johnson  was 
one  of  the  chief  managers  of  the  Relief  and  Aid 
Society,  which  distributed  millions  of  dollars  of 
property  among  the  sufferers. 

He  married  Miss  Margaret  Seward,  a  relative 
of  the  New  York  statesman,  William  H.  Seward. 
He  had  two  children,  of  whom  only  one  survived 
him,  Dr.  Frank  S.  Johnson,  Professor  of  Pathol- 
ogy in  Chicago  Medical  College. 

Dr.  Johnson  was  much  more  than  simply  an 
eminent  physician.  He  was  a  magnificent  man, 
possessing  a  clear,  trenchant  intellect,  and  a 
great  and  noble  heart.  His  reputation  is  with- 
out spot,  and  his  honor  without  stain. 


HOSMER    A.  JOHNSON. 
OBIIT  FEB.  26,  1S9I. 

We  mourn  for  him  whose  life  has  flown 
Out  from  its  fragile  shell  of  clay. 
Into  the  nightless.  perfect  day. 

To  reap  the  fruit  that  here  was  sown. 

Xot  all  the  good  of  earth  die  young: 

Of  him  no  truthful  tougue  spoke  ill; 
And  praises  to  his  gentle  skill 

By  twice  ten  thousand  hearts  are  sung. 

For  him  no  banners  drape  the  air, 

No  half-mast  flags  droop  in  the  blue; 
But  tears  shall  fall  as  evening  dew, 

And  science  garb  of  mourning  wear. 


No  need  of  shaft  to  mark  the  bed 

Wherein  his  dust  dissolves  in  dust — 
Fair  Science  keeps  her  own  in  trust, 

If  they  but  walked  where  Nature  led. 


353 


SPECIAL  CORRESPONDENCE. 


[March  7, 


1  nation  honors  those  that  stand 
And  battle  with  the  living  death— 


i-edged  sword 
ay  he  fought ; 


'Twixt  Death  and  human  kind  he  stood  : — 
Let  fame  on  such  no  longer  frown, 
For  deeds  of  blood  award  no  crown, 

But  rather  for  the  doing  good. 

Man's  friend  he  was  ;  foes  had  he  none 
In  fruitful  youth  or  ripened  age— 
His  life  a  clear  and  blotless  page 

Of  noble  deeds  more  nobly  done. 

No  bias  warped  his  balanced  mind 
To  superstition  ne'er  a  slave; 
Let  this  be  written  o'er  his  grave: 

"He gave  his  life  to  all  Mankind." 

Such  men  kind  Nature  ever  needs 
To  reason  from  effect  to  cause; 
Yet  shows  them  on  ly  half  her  laws, 

To  spur  them  on  to  nobler  deeds. 

For  these  the  stonv  paths  she  smooths, 
And  guides  her  children  in  the  night, 
While  far  beyond  she  hangs  the  light 

That  lures  them  on  to  greater  truths. 

What  need  his  virtues  to  portray  ? 

What  need  his  memory  to  defend? 

As  patriot,  healer,  sage  and  friend 
He  walked  in  his  Great  Master's  way. 


Springfield,  111.,  Feb. 


William  G.  Eggleston. 


SPECIAL  CORRESPONDENCE. 


An  Act  Pending  in  Congress  of  Interest  to 
the  Medical  Profession. 

To  the  Editor:— The  chief  provision  and  object  of  a 
measure  now  pending  in  Congress,  and  subject  to  action 
at  an  early  date,  is  that  requiring  all  articles  publicly 
sold  for  consumption  or  use  to  show  upon  the  container 
the  nature,  or  name  of  the  contents. 

The  Bill,  having  a  strong  and  influential  commercial 
backing,  came  near  passing  when  first  presented,  and 
early  in  the  session,  but  was  made,  with  all  other  legisla- 
tion, to  give  way  for  tariff  politics,  but  not  until  it  had 
aroused  a  furore  of  alarm  among  a  class  against  whom  it 
was  not  aimed,  but  were  in  its  line  of  effect.  These  were 
proprietary,  and  the  whole  swarm  of  patent  medicine 
frauds. 

Is  not  this  the  time  to  see  that  these  evils,  enemies  of 
the  public— infinitely  worse  than  an  oleomargarine  op- 
erator—do not  escape  the  just  application  of  so  reasona- 
ble and  unassailable  regulation.  Floods  of  the  most  po- 
tent and  poisonous  articles  whose  effects  every  practi- 
tioner is  called  to  relieve,  are  sold  with  no  evidence  or 
means  of  judging  its  character,  thus  obliging  us  blindly 
to  prescribe,  or  select  an  antidote. 

The  deadly  results  from  the  use  of  substances  for  food 
and  medical  purposes  are  becoming  of  alarming  and 
increasing  frequency. 

No  exceptions  should  be  made  in  this  Act  now  before 
Congress,  and  medical  men  are  already  discerning  the 
penalties  which  torpor  and  inattention  upon  the  part  of  the 
profession  has  incurred.  The  public  robbed,  swindled,  and 
injured  in  health— not  to  say  fatally  imposed  upon  by  the 
unrestricted  and  unchallenged  purveyors  of  death  and 
disi  1  in  the  guise  referred  to.  Medical  men  are  held 
responsible  for  their  dispensing  by  the  files  of  thi  drug 
gists,  whose  convenience  in  rases  of  carelessness  ,,,  ,,  ,  , 
dent  is  often  proven,  while  the  veriest  ignoramus  may, 
nndei  copyrighl  protection,  sell  the  most  potenl  drug 
and  disguise  its  character  by  any  term  he  may  chose  to 
adopt.  H.  C.  Markham,  .M.l). 

Independence,  Iowa,  Feb.  19,  1891. 


The  Association  of  Military  Surgeons  of 
the  Wisconsin  National  Guard. 

To  the  Editor: — In  response  to  a  call  from  the  Sur- 
geon-General, N.  Senn,  for  February  26,  1891,  the  sur- 
geons of  the  Wisconsin  National  Guard  met  in  Milwau- 
kee for  the  purpose  of  organizing  an  association  for  the 
advancement  of  military  and  accidental  surgery  and  to 
be  called  "The  Association  of  Military  Surgeons  of  the 
Wisconsin  National  Guard."  The  work  of  the  Associa- 
tion will  be  clinical,  experimental,  original,  etc.,  per- 
taining to  military  surgery.  Surgeon- General  Nicholas 
Senn  was  elected  President;  Major  F.J.  Wilkes,  2nd  Reg. 
W.  N.  G.,  Vice-President;  lieutenant  Ralph  Chandler, 
1st  Light  Battery  W.  N.  G.,  Secretary  and  Treasurer. 

The  surgeons  responded  to  a  man.  The  Association 
has  a  membership  of  fifteen  and  will  meet  once  every 
four  months. 

The  day  was  spent  very  profitably  in  clinical  work  at 
the  Milwaukee  Hospital,  Soldier's  Home  Hospital,  and 
in  demonstrative  and  experimental  work  in  intestinal 
surgery  and  gun-shot  wounds  of  the  abdomen,  on  dogs, 
at  the  Milwaukee  County  Hospital.  Each  member  was 
given  an  opportunity  to  exercise  his  skill  in  suturing  in- 
testinal wounds.  At  S  p.m.  the  surgeons  assembled  at 
the  Republican  House,  where  an  elaborate  banquet  was 
tendered  by  Surgeon-General  N.  Senn.  Toasts  were 
given  and  the  wee  small  hours  were  long  on  their  way 
ere  the  surgeons  had  fully  vanquished  the  enemy. 

All  await  with  pleasure  the  announcement  of  the  next 
meeting.  It  is  hoped  that  this  will  be  a  stimulus  to  sur- 
geons of  other  States  to  form  similar  organizations  with 
a  view  of  eventually  calling  a  National  one. 

Efforts  will  be  made  to  fill  vacancies  in  the  medical 
department  of  the  W.  N.  G.  as  they  occur,  by  a  competi- 
tive examination.  Ralph  Chandler, 

Lieut,  and  Asst.  Surg.  1st  Lt.  Battery,  W.  N.  G.» 
Sec'y  and  Treas. 

Milwaukee,  Feb.  28,  1891. 


Shall  The  Journal  he  Removed  to 
Washington  ? 

To  the  Editor: — The  arguments  for  removal  are:  1. 
Our  Journal  has  a  name  distinctive  of  its  nationality, 
and  inasmuch  as  it  represents,  or  is  intended  to  represent 
the  status  of  the  medical  profession  of  this  country,  it 
would  seem  as  if  its  seat  ought  to  be  at  the  Capital, 
which,  though  not  the  geographical  centre,  is  really  the 
centre  from  which  our  whole  system  of  National  econ- 
omy radiates.  2.  The  Library  of  the  Association  and  the 
ever  increasing  National  Library,  and  the  Army  Medical 
Museum  are  there,  and  always  at  hand  for  the  use  of  the 
editorial  department.  3.  The  Army,  Navy  and  Marine- 
Hospital  medical  and  surgical  news  are  there  and  easily- 
available.  4.  National  pride  may  say  to  many:  "Place  the 
National  Journal  in  the  National  Capital." 

Against  removal :  1.  Thi;  Journal,  although  born  in 
Cleveland,  O.,  was  immediately  taken  to  Chicago,  where 
it  was  carefully  nurtured  during  its  infancy,  and  where  it 
rapidly  grew  into  its  present  state  of  vigorous  adolescence. 
It  has  become  acclimated  to  the  soil  of  Illinois,  and  will 
for  the  present,  other  tilings  being  equal,  no  doubt  do> 
better  there,  and  reach  a  vigorous  manhood  much  earlier 
than  if  stunted  by  transplantation;  no  matter  how  well 
the  new  soil  may  Ik-  adapted  to  its  reception.  2.  The 
personnel  of  The  JOURNAL  may  be  equally  as  good  and 
efficient  in  Chicago  as  in  Washington,  and  the  removal 
of  the  material  would  be  attended  with  a  loss  that  cannot 
is  well  1"'  afforded  at'  present  as  in  the  future,  especially 
if  the  management  of  its  financial  relations  continues  ass 
iucce  sful  in  the  future  as  in  the  past.  3.  Chicago  is 
much  nearer  the  centre  of  our  population  than  any  East- 
ern city,  and  will  continue  for  some  years  to  become  more 

so,  and  will  annually  get  a  larger  increase  to  the  subscrip- 
tion list  of  The  Journal  from  the  West,  in  proportion 
to  present  population,  than  from  the  East. 


1891.] 


SPECIAL  CORRESPONDENCE. 


359 


My  conclusions  are,  after  weighing  carefully  the  argu- 
ments for  ami  against,  that  as  The  JOURNAL  has  made  a 
phenomenally  rapid  growth  in  Chicago  it  should  remain 
there.  One  of  the  fathers  of  the  American  Medical  Asso- 
ciation and  the  first  editor  of  The  JOURNAL  lives  in 
Chicago.  He  is  robed  in  honor;  THE  JOURNAL  was  his 
pet.     Let  it  remain  there,  at  least,  while  he  1: 

E.  GR1SWOLD,  M.I). 

Sharon,  Pa.,  Feb.  23,  1S91. 


JOURNAL  from  its  home  in  Chicago  to  Washington  City." 

k.  11  \kvj:v  Reed,  m.d. 

Mansfield,  O.,  February  24,  1891. 


To  the  Editor: — Relative  to  the  removal  of  The  JOUR- 
NAL to  Washington,  D.  C,  I  would  say  I  can  see  no  rea- 
son why  it  should  not  remain  where  it  is,  and  think  there 
art-  several  valid  reasons  why  it  should. 

Wh,  Caston,  m.d. 
Spokane  Falls,  Wash.,  Feb.  25,  1S81. 


To  the  Editor: — I  can  see  nothing  to  be  gained  by  re- 
moving The  Journal  to  Washington,  D.  C.;  while,  on 
the  other  hand,  by  so  doing  you  leave  one  of  the  best 
medical  centres  in  the  world,  and  take  THE  JOURNAL  to 
the  extreme  border  of  its  circulation,  thereby  depriving 
many  of  its  readers  of  its  reading  for  many  days  after 
publication.  If  there  is  any  necessity  for  moving  Tin-. 
Ji  II  RNAL  from  Chicago,  I  would  be  in  favor  of  St.  Louis, 
or  some  equally  good  city  located  mid-Continent,  and  if 
I  consult  my  selfish  choice,  Chicago  is  preeminently  that 
choice.  A.  F.  HuNTOON,  M.D. 

W.  Duluth,  Minn.,  February  21,  1891. 


To  the  Editor: — You  may  add  my  vote  to  the  Chicago 
column,  relative  to  the  site  of  vour  publication. 

E.  C.  Spitzka,  M.D. 
712  Lexington  ave.,  New  York. 


To  the  Editor: — I  have  within  the  last  week  or  ten 
days  received  two  or  three  letters  suggesting  that  the 
question  of  removing  The  Journal  should  be  referred 
back  to  the  Trustees,  who  have  the  power  to  act.  And 
now  comes  the  deponent,  the  St.  Louis  Clinique  of  Feb- 
ruary, 1S91,  who  deposes  and  says,  that  "  we  hope  a  mo- 
tion will  prevail  to  refer  the  question  back  to  the  trus- 
But  he  preludes  that  assertion  by  saying  that 
"the  Board  was  given  full  power  to  act:  by  its  act  The 
JOURNAL  was  located  in  Chicago,  and  by  its  authority  it 
could  remain  or  be  removed."  Very  good.  But  will  the 
said  deponent  tell  the  Court,  who  gave  said  Board  this 
authority?  And  tell  us  whether  the  same  body  which 
extended  the  power  in  the  first  place,  cannot  rescind  that 
power,  or  take  up  any  subject  referred  to  the  Board  of 
Trustees,  and  modify  it  to  suit  their  liking? 

It  is  simply  the  old  story  of  whether  the  dog  shall  wag 
his  own  tail  or  whether  the  tail  shall  wag  its  own  dog? 
and  that  question  was  overwhelmingly  settled  at  New  Or- 
leans a  few  years  ago,  on  the  question  of  adopting  the 
report  of  the  Committee  on  organizing  the  Ninth  Inter- 
national Congress,  which  at  that  time  tried  to  convince 
this  same  Association  that  they  had  been  given  power  to 
act,  and  the  dog  must  be  wagged  by  the  tail;  but  the  dog 
protested  against  this,  and  the  result  was  the  tail  was 
wagged  instead  of  the  dog. 

Si  1  "  ith  this  or  any  other  committee  of  a  representative 
body:  that  body  has  the  power  to  take  up  any  question 
it  has  referred  to  any  subcommittee,  and  settle  it  to  suit 
the  majority,  and  the  Trustees  acted  wisely,  and  in  ac- 
cordance with  parliamentary  law  and  common  usage,  and 
former  precedents,  when  they  referred  the  matter  of  re- 
moving The  Journal  from  Chicago  to  Washington, 
back  to  the  Association. 

Each  Permanent  Member  of  the  Association  and  sub- 
scriber is  an  interested  stockholder  in  The  Journal,  to 
the  amount  of  five  dollars  a  year,  and  has  a  perfect  right 
to  give  an  expression  as  to  where  he  wants  The  Journal 
he  supports  published,  and  this  expression  should  be  a 
guide-board  to  the  coming  delegates  of  the  next  meeting, 
to  direct  them  in  their  deliberations,  who  alone  have  a 
right  to  speak  officially  on  all  questions  that  pertaiu  to 
the  interests  of  the  Association. 

Again,  permit  us  to  correct  the  statement  of  the  Clin- 
ique which  says  that  the  Trustees  "  have  recommended 
that  the  change  be  made."  The  Trustees  as  a  body  have 
not  made  any  such  recommendation.  That  is  what  a  cer- 
tain faction  of  the  Trustees  wanted  them  to  vote,  but 
failed  to  secure  such  recommendation,  and  hence  the 
"  great  controversy  "  which,  the  Clinique  says,  "  is  now 
being  carried  on  regarding  the  proposed  removal  of  The 


To  the  Editor:— -Why  should  The  Journal  go  to 
Washington?  The  question  is  full  of  suggestion.  Why 
should  it  have  been  established  at  Chicago  ?  Clearly  be- 
cause it  was  a  convenient  centre,  with  no  East  and  no 
West,  whence  it  could  most  speedily  communicate  w  ith 
all  points. 

Has  it  ceased  to  be  our  great  central  metropolis  ?  Then 
Congress  made  a  mistake  in  locating  the  world's  greatest 
exposition. 

Are  paper,  and  ink,  and  printing  presses  no  longer  at 
its  command,  or  are  mailing  facilities  unequal  to  its  de- 
mands, or  have  all  the  brains  of  the  Nation  gravitated 
to  its  Eastern  slope  ? 

We  grant  "the  sun  rises  in  the  East  to  open  and 
illume  the  dav,"  but  she  travels  westward,  and  at  high 
noon  is  its  beauty  and  glory. 

Whilst  Chicago  will  long'  remain  the  central  metrop- 
olis of  America  and  the  most  convenient  home  for  its 
great  medical  journal,  no  one  section,  no  one  man,  will 
absorb  all  majesty  or  power. 

Why  should  The  Journal  go  to  Washington  ? 

W.  L.  SCHENCK,  M.D. 

Topeka,  Kan.,  Feb.  2S.  1S91. 


To  the  Editor: — Leave  The  Journal  where  it  prop- 
erly belongs,  in  the  business  and  population  centre  of  the 
country— Chicago,  111.  G.  L.  Pritchett.  M.D. 

Fairbury,  Neb.,  February  27,  1S91. 


To  the  Editor: — I  have  heard  and  read  many  con- 
vincing reasons  why  The  Journal  may  with  advantage 
to  the  whole  profession  be  edited  and  published  in  Chi- 
cago: but  have  so  far  failed,  in  answer  to  my  enquiries, 
to  discover  any  justification  for  its  taking  up  house  at 
the  Capital. 

It  appears  to  me  that  the  very  advance  guard  of  the 
Washington  attack  has  not  yet  appeared  in  sight.  In  the 
meantime  I  suppose  it  is  proper  for  us  to  know  that  when 
it  does  come  to  a  comparison  between  the  two  cities  as 
teaching  centres,  as  sources  of  subscription,  as  sources  of 
advertising  patronage  and  as  centres  of  medical  popula- 
lation,  most  of  them  who  cannot  be  accused  of  partizan- 
ship,  and  who  are  quite  as  much  interested  as  we  are, 
will  decide  at  once  in  favor  of  Chicago. 

In  the  meantime,  will  some  promoter  of  the  Washing- 
ton scheme  kindly  give  us  a  resume  of  the  superior  ad- 
vantages, temporal  and  spiritual,  which  The  Journal  is 
to  enjoy  after  its  advent  in  Washington  ? 

But  perhaps  these  are  to  be  held  back  until  the  well- 
known  hospitality  and  patriotic  associations  of  the  Fed- 
eral city  shall  have  had  an  opportunity  to  work  their 
charms. 

Still,  in  spite  of  these  seductions,  I  expect,  in  common 
with  the  majoritv,  to  cast  a  vote  for  Chicago. 

Casey  A  Wood,  M.D. 

Chicago,  111.,  Feb.  25,  1891. 


360 


MISCELLANY. 


[March  7,  1891. 


To  the  Editor:— As  an  humble  member  in  the  rural 
ranks.  I  wish  to  enter  my  solemn  protest  against  the  re- 
moval of  The  Journal.  Such  an  experiment  would  be 
child's  play.      '  W.  M.  Lewis,  M.D. 

Greeusburg,  Ky.,  Feb.  28,  1S91. 


MISCELLANY. 


The  Philadelphia  Polyclinic— At  the  annual 
meeting  of  the  corporators  of  the  Philadelphia  Poly- 
clinic held  on  January  12,  1891,  the  following  new  mem- 
bers were  elected  :  John  L.  Wilson,  James  Hay,  James 
P  Scott,  Mrs.  Thomas  A.  Scott,  Mrs.  Wm.  Waldorf 
Astor,  Roland  B.  Whitridge,  M.  D.,  Mrs  Matthew  Baird, 
Mrs.  Elizabeth  H.  Farnum,  Dr.  Thomas  S.  K.  Morton, 
George  W.  Childs,  Mrs.  Moses  Brown,  H.  H.  Houston, 
Mrs.  Isaac  B.  Thorn,  and  Rev.  Wm.  Neilson  McVickar. 

At  the  same  meeting  the  Board  of  Trustees  for  1891 
was  elected  as  follows  :  Charles  K.  Mills,  John  B. 
Roberts,  Charles  B.  Baeder,  Rev.  G.  Woolsey  Hodge, 
H  H.  Wilson,  Rev.  Wm.  Neilson  McVickar,  Henry 
Leffmann,  J.  Henrv  C.  Simes,  Caleb  C.  Roberts,  Hon. 
Wm.  N.  Ashman,  'Thos.  S.  K.  Morton,  H.  Augustus 
Wilson. 


Meetings  of  Medical  Societies  for  1891.— We  are 
indebted  to  the  New  York  Medical  Journal  for  the  fol- 
lowing list  of  National  and  State  Medical  Societies,  and 
the  places  and  dates  of  their  meetings  for  the  current 
year.  . 

For  the  convenience  of  those  who  may  desire  to  con- 
sult it,  we  reproduce  the  list  entire  : 

Florida  Medical  Association,  Pensacola,  April  14 
and  15. 

Medical  Society  of  the  State  of  Tennessee,  Nashville, 
April  r4,  15  and  16. 

Medical  Association  of  the  State  of  Alabama,  Hunts- 
ville,  April  14,  15,  16  and  17. 

Medical  Asssociation  of  Georgia,  Augusta,  April  15, 
16  and  17. 


Delaware   State   Medical   Society,   Rehoboth,  June   91 

and  10. 

Maine  Medical  Association,  Portland,  June  9,  10  and  11. 
Massachusetts  Medical  Society,  Boston,  June  9  and  10. 
South   Dakota    State    Medical    Society,    Chamberlin, 
June  10,  11  and  12. 

Rhode   Island   Medical  Society,   Providence,  June   11 
and  12. 

Michigan   State   Medical   Society,    Saginaw,   June    11 
and  12. 

New  Hampshire  Medical  Society  (centennial)  Concord,. 
June  15  and  16. 

Colorado    State    Medical    Society,    Denver,    June    16 
and  17. 

Ohio  State  Medical   Society,   Put-in  Bay,  June  17.  iS 
and  19. 

Minnesota  State  Medical  Society,  Minneapolis,  June 
18,  19  and  20. 

Medical  Society  of  New  Jersey,  Long  Branch,  June  23, 
and  24. 

Vermont  State  Medical  Society,  Burlington,  October 
15  and  16.  . 

Mississippi  Valley  Medical  Association,  St.  Louis,  Oc- 
tober 14,  15  and  16. 

Tri  State  Medical  Association  of  Tennessee,  Alabama 
and  Georgia,  Chattanooga,  October  (date  to  be  fixedV 

Medical  Society  of  Virginia,  Lynchburg,  October  27, 
28  and  29  (subject  to  change). 

New  York  State  Medical  Association,  New  York,  Oc- 
tober 28,  29  and  30. 

Louisiana  State  Medical  Society  (place  and  date  to  be 
determined). 

NATIONAL    ASSOCIATIONS. 

American  Academy  of  Medicine,  Washington,  May  2 
and  4. 

American  Medical  Association,  Washington,  May  5,  o, 
7  and  S. 

National   Association  of   Railway  Surgeons, 
N.  V.,  April  30  and  May  1. 

American   Gynecological   Society,    Washington,    Sep- 
tember 15,  16  and  17. 

American  Orthopaedic  Association,  Washington,  Sep- 
tember 15,  16  and  17. 

American  Association  of  Andrology  and  Syphilology, 


Buffalo, 


April  21,  22  and  23. 

Medical   Association   of  Montana,    Helena,    April   24 

Medical  and  Chirurgical  Faculty  of  Maryland,  Balti- 
more, April  28,  29  and  30. 

Texas  State  Medical  Association,  Waco,  April  28,  29 
and  30,  and  May  1. 

State  Medical  Society  of  Arkansas,  Hot  Springs,  April 
29  and  }o  and  Mav  I. 

Medical  Society  of  the  State  of  Washington,  Seattle, 
Mav  6,  7  and  S.  .  . 

Missouri  State  Medical  Association,  Excelsior  Springs, 
May  12,  13  and  14. 

Indiana  State  Medical  Society,  Indianapolis,  May  13, 
14  and  15. 

Kansas    Medical    Society,   Wichita,     May    13,    14,    15 

an<l  Iu-  ,-  ,  ,    ,, 

Illinois  State   Medical   Society,   Springfield,   May   19, 

20  and  21. 

West  Virginia  State  Medical  Society,  Fairmount,  May 
20,  21  and  22. 

North  Carolina  State  Medical  Society,  Asheville,  May 
26,  27  and  28. 

Connecticut  Medical  Society,  Hartford,  May  27,  28 
and  29. 

Pennsylvania  State  Medical  Society,  Reading,  June  2, 
3,  4  and   v 

State  Medical  Society  of  Wisconsin,  Madison,  June  ;„ 
4  and  5. 


this  congress  ' 

Climatological  Association,  American  Ophthalmologieal 
Society,  American  Otological  Society  and  American 
Neurogical  Association. 

American    Dermatological    Association,    Washington, 
September  22,  23,  24  and  25. 

American  Surgical  Association,  Washington,  Septem- 
ber 22,  23,  24  and  25.  _     _ 

American    Laryngological    Association,    Washington, 
September  23,  24  and  25. 

Southeru    Surgical    and    Gynecological    Association, 
Richmond,  November  10,  II  and  12. 


Officio!  1 


the  Stations  a„,i  Duties  of  Officers  Serving 

the  Medical  Depa  ■  Intent,  1 '.  S.  .  I 1  my,  from  >•  hi  nary ii,  1891,  to 

Februai  ,    ;,  1891. 

C  ml    AI...1Z.1  R.  Chapin.  Asst.  Surgeon,  leave  of  absence  granted  in 

£0   [7,  Dept.  of  l>ak     [■"■■■  is  extended  one  month. 

By  direction  of  the  Secretary  of  War.     S  >>    |i,  A.  G.  O.,  February 


Blencowe  E.  Fryei    Asst.  Medical  Purveyoi    havim 
found  incapacitated  by  Irmy  Retiring  Hoard,  on  account  o 


:,,  active  servi<  e  this  date, 
1  ■  ,i    Revised  Statutes,     Pai     1  i, 


been 
disa- 
,1  the  President,  re- 
in*  pn«  isions  pi  Section 


O.,  February  24. 
Hi.  following  named  offii  era,  having  been  found  by  Army  Retiring 

ll^rdsim-o^citMcd    t.,t    active   Si   !        1         l"l      ""I    Of  disability  m- 


Board    Incapacitated  foi  active 

riaenl  to  the  servto     an     bj   direction  ofthe  President, 

from  activ.   service  at  this  date.undei  the  provisions  oi  section 

,-t   Revised  statute-     Capl     [ohn  de  B    W.  Gardiner,  Asst.  Sur- 

tpl    Robert  W  shufeldt,  Asst.  Surgeon. 
\   1.   o.,  Washington,  February  35, 1891. 


Par. 


etired 


O.  43. 


3£' 


T  1  i  E 


Journal  of  the  American  Medical  Association 

EDITED  UNDER  THE  DIRECTION  OF  THE  BOARD  OF  TRUSTEES. 

PUB]   1  Ml  I   D    WEEKLY. 


Vol.  XVI. 


CHICAGO,   MARCH   14,    1891. 


No  11. 


ADDRESSES. 


PHTHISrS  PULMONALIS. 

t  Address  delivered  before  the  King     County   \fedical  Association 
BY  WM.    McCOLI.OM,   M.D., 


OF   BROOKLYN,  I 

1111      11    I  1RINO     PRE 


I  have  chosen  as  a  subject  for  the  address  which 
I  offer  you  this  evening,  the  very  old  and  deeply 
interesting  one  of  "phthisis  pulmonalis,"  a  sub- 
ject which  has,  perhaps,  occupied  the  attention 
of  the  profession  and  called  forth  more  earnest, 
active  effort  for  its  solution  for  centuries,  than 
any  other  subject  in  medicine;  and  yet  its  ravages 
have  not  been  checked  to  any  considerable  extent, 
for  it  destroys  more  life  in  almost  all  countries 
than  any  other  disease.  The  deaths  from  con- 
sumption in  the  United  States  of  America  are  not 
less  than  100,000  annually. 

It  is  not  that  I  have  anything  specially  new  to 
offer  in  etiology,  prophylaxis  or  therapeutics  that 
I  select  this  as  a  subject  of  discourse,  but  a  con- 
densed review  of  what  is  more  modern  and  prac- 
tical, with  suggestions  based  upon  personal  obser- 
vation and  experience  as  it  relates  to  the  general 
management  of  the  disease,  may  be  of  interest  to 
some  of  the  members  of  this  Association. 

It  is  not  my  purpose  to  examine  the  various 
theories  bearing  on  the  pathology  of  consumption. 
That  organization,  anatomical  and  physiological 
peculiarities  and  inherited  constitutional  predis- 
position, are  factors  in  favoring  the  development 
of  tuberculosis,  is  evident  beyond  question.  The 
dyserasia  of  the  scrofulous  diathesis,  inherited  or 
acquired,  with  tendency  to  cheesy  deposits,  fits  a 
soil  for  the  growth  of  bacteria.  In  deference  to 
popular  opinion,  we  accept  the  teaching  of  Koch 
and  other  bacteriologists,  that  tuberculosis  is  the 
result  of  the  life  and  growth  of  a  microorganism 
in  a  soil  favorable  to  its  development.  It  is  not 
proven,  however,  that  phthisis  pulmonalis  is  al- 
ways tuberculosis.  Clinical  and  pathological  in- 
vestigation seem  to  show  that  phthisic  pulmonalis 
is  sometimes  tuberculous,  and  sometimes  non-tu- 
berculous. 

I  think  most  physicians  who  have  had  long 
clinical  experience  have,  from  time  to  time,  ob- 
served cases  of  good  family  and  personal  history, 


without   predisposition  inherited  or   acquired  to 

scrofulous  or  tuberculous  disease,  come  suddenly 
down,  with  cause  apparent,  from  broncho-  or 
croupous  pneumonia,  and  pass  rapidly  into  con- 
solidation, caseation,  disintegration  and  formation 
of  cavities,  general  emaciation,  progressive  debil- 
ity and  death.  Then  we  have  the  more  chronic 
fibroid  phthisis,  the  prime  cause  sometimes  being 
from  inflammatory  pneumonic  consolidation,  and 
at  other  times  from  the  daily  inhalation  of  irri- 
tating particles  of  matter,  metallic  or  earthy. 
This  cause  of  phthisis  has  been  productive  of 
fearful  mortality  in  certain  employments. 

While  it  is  shown  that  numerous  bacilli  are 
present  in  the  forms  of  phthisis  which  appear  to 
have  a  specific  cause  independent  of  true  tubercle, 
it  is  not  proven  that  the  bacilli  found  are  the  tu- 
bercle bacilli  of  Koch.  Drs.  Gibbes  and  Shurly, 
who  have  been  doing  good  bacteriological  work, 
tested  the  matter  by  feeding  several  guinea  pigs 
with  the  sputum  filled  with  bacilli  from  a  case 
diagnosed  as  phthisis  during  life,  but  which  an 
autopsy  showed  to  have  been  a  case  of  bron- 
cho-pneumonia, with  disintegration  of,  and  large 
cavities  in  lungs.  The  guinea  pigs  inoculated 
with  matter  swarming  with  bacteria,  suffered  from 
abscesses  at  point  of  inoculation,  but  none  suf- 
fered from  tubeculosis. 

We  are  not  yet  ready  to  accept  the  doctrine  of 
the  positive  minds  who  have  attempted  to  settle 
the  question  for  all. 

Germain  See  says:  "The  unity  of  phthisis 
comprises  all  acute  and  chronic  manifestations. 
There  exists  no  dualism  between  tubercle  and 
caseous  pneumonia ;  no  distinction  between  tu- 
berculous phthisis  and  inflammatory  phthisis." 
We  believe  that  this  is  still  an  open  question. 

If  we  grant  that  all  pulmonary  tuberculosis  is 
the  result  of  the  action  of  the  bacillus  of  Koch 
upon  anatomical  structure  rendered  vulnerable  by 
reason  of  inherited  tendency,  the  scrofulous  dia- 
thesis, caseous  pneumonia  with  cheesy  deposits, 
lessened  vitality  with  enfeebled  circulation  and 
respiration,  we  shall  feel  the  importance  of  care- 
fully studying  preventive  measures.  Prophylaxis 
is  all-important. 

If  we  accept  the  teaching  of  Virchow  and  Xie- 
meyer,  that  caseous  pneumonia  and  miliary  tuber- 
culosis are  distinctive  diseases,  and  remember  the 


362 


PHTHISIS  PULMONALIS. 


[March  14, 


great  liability  to  tuberculosis  in  the  metamorpho- 
ses of  tissue  from  caseous  pneumonia,  our  course 
of  action  will  be  little  influenced  by  the  technical 
question. 

Whatever  the  pathogenesis  of  tuberculosis  may 
be,  it  is  evident  that  the  strumous  diathesis  is 
frequently  the  predisposing  cause.  The  relation 
of  the  two  conditions  is  too  evident  to  be  ques- 
tioned, and  as  struma  manifests  itself,  many  times, 
in  the  earlier  periods  of  life,  and  is  often  due  to 
faulty  dietetic  and  hygienic  management,  we  can- 
not too  much  feel  the  vital  importance  of  correct- 
ing a  condition  which  warns  of  approaching  dan- 
ger ;  for  when  the  specific  microorganisms  enter 
the  blood,  the  corpuscles  or  leucocytes  are  de- 
stroyed in  the  unequal  warfare  of  such  enfeebled 
constitutional  conditions. 

Noxious  microorganisms  may,  and  do,  enter 
the  body  without  producing  disease.  Man  is  con- 
tinually exposed  to  infection  by  the  bacillus  tu- 
berculosis. Heller,  from  microscopical  prepara- 
tions, estimates  that  in  a  single  expectoration,  on 
an  average,  3,000,000  bacilli  are  discharged. 
Sputa,  swarming  wiih  bacteria,  is  deposited  on 
walks,  floors  of  cars,  boats,  school-rooms  and 
public  halls.  Such  sputa  soon  dries,  forms  a 
floating  dust  full  of  poisonous  microbes  to  which 
all  are  exposed,  but  only  a  few  of  the  many  are 
susceptible  to  their  influence.  Microbes,  when 
introduced  into  the  system,  may  or  ma3r  not  result 
in  structural  change  or  disease  ;  the  soil  may  be 
favorable  or  unfavorable.  It  is  not  yet  determined 
what  the  chemical  conditions  of  the  solids  and 
fluids  of  the  body  are  in,  when  the  tuberculous 
cachexia  is  developed.  The  child  may  inherit 
the  diathesis  or  predisposition  to  susceptibility  to 
tubercular  disease  ;  yet,  under  most  favorable  en- 
vironment, never  contract  tuberculosis.  Cancer 
and  syphilis  are  transmitted  from  parent  to  child. 
Children  are  born  with  these  diseases  well  devel- 
oped, but  there  is  little  evidence  that  tuberculosis 
is  inherited — the  diathesis  is  inherited,  not  the 
specific  disease. 

We  do  not  fully  understand  what  the  condition 
of  the  system  is,  which  we  call  the  tubercular 
cachexia.  It  is  probably  something  more  than 
debility,  lowered  vitality,  or  anatomical  defect, 
but  a  peculiar  change  in  the  fluids  or  secretions 
of  the  body  which  favors  the  development  and 
destructive  work  of  the  tubercle  bacillus  when  it 
finds  entrance  into  the  system.  It  has  been  ob- 
served in  laboratory  experiments  that  certain 
conditions  are  essential  in  cultivating  bacteria. 

Pasteur  relates  that  when  he  used  agar-agar 
with  4  per  cent,  of  glycerine  as  a  culture  medium, 
the  tubercular  bacilli  developed  rapidly,  but  when 
he  added  8  per  cent,  instead  of  4  percent  of  glycer- 
ine to  the  medium,  the  growth  of  germs  ceased. 
'1'h'  11  may  we  not  hope  that,  in  the  progress  of  sci- 
entific investigation  and  experiment,  the  definite 
cause  of  susceptibility  to  tuberculosis  may  be  made 


out,  and  means  devised  to  destroy  such  susceptibil- 
ity, and  to  render  the  tissues  of  the  body  unfit  for 
the  life  and  growth  of  these  microorganisms  ? 

It  is  probable  that  tuberculosis  is  sometimes 
acquired  from  the  flesh  and  milk  of  tuberculous 
animals.  The  weight  of  opinion  seems  to  favor 
this  belief.  It  is  the  duty  of  physicians,  individ- 
ually and  collectively,  to  influence,  so  far  as 
possible,  the  Department  of  State  Medicine,  to 
create  and  enforce  strict  regulations  against  the 
spread  of  tuberculosis,  so  far  as  it  can  be  done. 
I  will  not  particularize  how  this  should  be  done. 
The  measures  to  be  taken  are  important  and  va- 
ried, and  suggest  themselves  to  the  physician  and 
sanitarian. 

Our  duty  as  physicians,  is  the  important  one  of 
guarding  and  guiding,  so  far  as  we  can,  the  child, 
the  youth  and  the  man,  against  inherited  predis- 
position to  phthisis,  as  well  as  to  correct,  so  far 
as  possible,  constitutional  defects,  and  conditions 
of  health  leading  to  a  susceptibility  of  danger  al- 
most ever-present.  It  becomes  us  to  inquire  what 
are  the  conditions  which  precede  the  infection, 
and  the  causes  which  produce  the  condition. 

It  is  not  my  purpose  to  examine  the  various 
theories  and  alleged  causes  which  precede  tuber- 
culosis, such  as  abnormalities  of  organization  with 
faulty  development  of  chest  and  lungs,  and  lack 
of  anatomical  and  physiological  balance  in  the 
vital  organs,  but  to  causes  which  are  susceptible 
to  influence  by  hygienic,  dietetic  and  medicinal 
means. 

The  child  and  the  youth  with  low  vital  force, 
with  cardiac  power  below  the  average  normal, 
with  relatively  small  volume  of  lung  and  feeble 
respiratory  system,  will  necessarily  suffer  from 
adynamic  catarrhs,  glandular  congestions  and  in- 
flammations, defective  assimilation  and  nutrition, 
and  this  condition  strongly  predisposes  to  phthisis. 
The  importance  of  nutrition  as  a  preventive  of 
consumption  cannot  be  exaggerated ;  but  with 
faulty  organization  and  feeble  respiratory  func- 
tion, how  can  good  nutrition  be  maintained? 

Physical  training  for  the  purpose  of  developing 
the  chest  walls  and  respiratory  muscles,  enlarging 
the  volume  of  the  lungs,  thereby  stimulating  and 
developing  the  circulation  of  blood  throughout 
the  system,  blood  which  has  been  more  complete- 
ly arterialized  in  the  lungs,  will  do  more  than 
anything  else  to  favor  digestion,  assimilation  and 
nutrition.  Training,  systematically  and  perse- 
veringly  practiced,  will  often  change  the  flat, 
narrow-chested,  poorly  nourished,  feeble  youth 
into  the  large-chested,  ruddy,  vigorous  man. 

The  physiological-therapeutical  effects  of  in- 
creased chest  development  with  lung  expansion 
and  volume,  thereby  increasing  the  activity  of  in- 
tra-pulmonary  circulation  and  oxidizing  a  larger 
number  of  blood  corpuscles,  renders  active  the 
nutrition  of  pulmonary  tissue — not  alone  of  pul- 
monary tissue,  but  a  general  tonic  effect  is  pro- 


I89I.] 


PHTHISIS  PULMOXAI.IS. 


3*3 


duced  upon  the  nervous  system  ;  digestion  and 
cellular  nutrition  are  improved;  the  vital  power 
is  raised,  and  alimentation,  the  most  important 
element  in  the  prevention  and  cure  of  phthisis,  is 
increased. 

All  ohservers  know  that  faulty  nutrition  and 
wasting  usually  precede  phthisis.  Dr.  Horace 
Dobell,  in  his  work  on  the  "True  First  Stage  of 
Consumption,"  gives  expression  to  the  belief  that 
the  wasting  or  inanition  preceding  tuberculosis 
should  lie  considered  as  belonging  to  the  first 
stage  of  the  disease. 

Next  in  importance  to  nutrition  is  vigorous 
circulation  of  blood,  pure  air  and  sunlight. 

It  was  an  interesting  and  instructive  experi 
ment  made  by  a  physician  a  little  time  ago — I 
cannot  give  his  name  or  the  date  of  the  article 
— showing  the  influence  of  favorable  conditions 
in  preventing  the  development  of  tuberculosis. 
He  inoculated,  I  think  it  was  two  dozen  rabbits 
with  the  tubercle  bacillus.  One-half  the  number 
were  confined  in  pens  with  not  good  chance  for  sun- 
light nor  active  exercise,  nor  with  supply  of  food 
exactly  suited  to  their  wants.  All  died  from  tuber- 
cular disease.  The  other  half  were  turned  into  a 
field,  favored  with  fresh  green  grass,  strong  light, 
and  opportunity  for  the  freest  exercise,  with  the 
result  of  only  one  falling  a  victim  to  tuberculosis; 
all  the  others  remained  healthy,  notwithstanding 
the  true  tubercle  bacillus  had  been  introduced 
into  their  bodies.  We  should  not  forget  this  les- 
son, for  it  is  in  harmony  with  what  has  so  often 
been  observed  in  man.  The  vigorous  and  well 
nourished,  with  favorable  environment,  rarely  fall 
victims  to  tuberculosis  from  infection  when  closely 
exposed,  sometimes  for  years.  Then  let  us  re- 
member that  preventive  measures  must  be  in  the : 
keeping  of  the  general  health  above  the  grade  of 
susceptibility  to  the  microbic  influence ;  keep  the 
soil  unfavorable  to  the  development  and  growth  of 
bacilli. 

The  scope  of  this  paper  will  not  allow  me  to 
attempt  to  note  all  or  many  of  the  various  die- 
tetic and  hygienic  measures  to  be  observed  as  con-  j 
tributing  to  the  raising  of  the  standard  of  health 
and  creating  an  immunity  from  the  disease. 

Climatic  influences  are  efficient  aids  in  prophy- 
laxis of  phthisis.  When,  from  hereditary-  pre- 
disposition, fault}'  anatomical  and  physiological 
condition,  the  thoracic  cavity  small,  and  respira- 
tory power  feeble,  a  change  of  climate  should  be 
made  from  the  lower  sea  level  to  high  altitudes. 

An  elevated,  cool,  dry  region  should  be  select- , 
ed  for  such  cases.  In  high  altitudes,  respiratory 
activity  is  much  increased,  and  portions  of  the  i 
lung  tissue-  little  used  on  low  levels,  are  brought  I 
into  activity.  Both  children  and  adults  who  live 
in  high  mountainous  regions  have  proportionately  ' 
larger  chests  and  lungs  than  those  who  live  in 
low  altitudes;  this  has  been  shown  from  repeated 
observation.     Dr.   Francis,  of  the  Bengal  Army,  i 


states,  after  extended  observation,  that  the  lungs 
are  smaller  in  Europeans  in  India  than  the  Euro- 
pean standard.  The  lesson  from  this  is  practical 
and  should  be  kept  in  mind.  Low  temperature 
in  high  altitudes,  with  dry  atmosphere,  is  most 
favorable.  Cold  stimulates  to  more  active  exer- 
cise, with  increased  respiration  and  blood  circu- 
lation. The  appetite  for  fatty,  nitrogenous  food 
is  increased,  foods  specially  adapted  to  the  pre- 
vention as  well  as  to  the  arrest  of  consumption. 
The  spores  of  tubercular  bacteria  are  tenacious  of 
life,  resist  almost  all  influences  for  their  destruc- 
tion, maintain  life  for  hours  in  water  at  the  boil- 
ing point.  Extreme  cold  and  perfect  dryness  are 
without  influence,  then  it  cannot  be  claimed  that 
high  altitude  has  germicidal  influence,  but  im- 
munity, if  it  comes,  is  from  improved  physiolog- 
ical conditions. 

Dryness  and  purity  of  the  air  are  important, 
perhaps  the  most  important,  factors  in  prophy- 
laxis. Air  tested  in  the  higher  mountains  of 
Switzerland  showed  no  bacteria,  while  the  same 
volume  of  air  in  Paris  contained  7,000. 

The  atmosphere  of  high  elevations  is  both  drier 
and  purer  than  that  of  low  levels,  and  when  free 
from  microbes,  it  must  greatly  favor  prophylaxis, 
and  efficiently  aid  in  the  recovery  from  incipient 
phthisis.  The  air  by  the  sea  side,  or  in  the  val- 
leys when  sparsely  settled,  may  be  as  pure  and 
as  clear,  may  be  as  favorable  to  the  consumptive 
in  the  advanced  stage  of  the  disease  as  the  rare- 
fied air  of  high  alticudes.  though  it  is  probable 
that  the  dry,  rarefied  air  of  the  mountains  is  in- 
imical, in  some  degree,  to  the  development  and 
growth  of  microorganisms. 

Altitude  in  advanced  consumption  often  acts 
unfavorably,  particularly  as  it  relates  to  the  con- 
gestive, the  hsemoptoic,  and  the  irritable  condi- 
tions. 

We  have  been  too  much  inclined  to  send  all 
cases  of  confirmed  phthisis  to  certain  localities 
according  to  the  prevailing  fashion,  without  care- 
fully scrutinizing  even,-  condition  likely  to  be  in- 
fluenced by  denser  or  rarefied  air,  by  temperature, 
by  physical  comfort  and  mental  and  emotional 
happiness. 

It  is  all- important  that  the  consumptive  shall 
live  an  outdoor  life,  and  the  climate  and  condi- 
tions of  the  locality  must  be  such  that  a  life  much 
in  the  open  air  can  be  enjoyed.  While  altitude 
has  an  important  influence,  the  most  recent  study 
of  the  subject  seems  to  show  that  the  mortality 
from  pulmonary  phthisis  is  not  exactly  graded  by 
elevation,  though  largely  influenced  by  it. 

Dr.  Schroeter,  carefully  studying  the  exact 
official  statistics  of  Switzerland  bearing  upon  the 
mortality  of  consumption  for  eleven  years,  states: 
"  The  annual  mean  of  deaths  caused  by  pulmo- 
nary tuberculosis  is  2.31  to  1,000  living  inhab- 
itants." In  an  altitude  of  200  to  400  metres, 
there  were  112  deaths  from  tuberculosis  in  1,000; 


364 


PHTHISIS  PULMONAUS 


[March  14, 


from  400  to  700  metres,  105  deaths;  from  700  to 
900  metres,  106  deaths;  from  900  to  1,200  metres, 
.92  deaths;  above  1,200  metres,  71  deaths.  The 
death-rate  in  great  altitudes  falls  low,  71  in  1,000; 
but  there  are  other  influences  than  altitude  of 
which  we  should  not  lose  sight.  Density  of  pop 
ulation,  and  industrial  occupations  indoors,  great 
ly  increase  mortality.  The  higher  elevations  are 
more  sparsely  settled,  and  the  people  live  an  active 
outdoor  life ;  this,  perhaps,  in  itself  would  ac- 
count largely  for  the  difference  in  the  rate  of  mor- 
tality in  different  altitudes. 

The  contagiousness  of  tuberculosis  is  now  so 
well  established,  and  the  more  common  method 
of  infection  made  so  apparent  from  a  careful 
study  of  the  subject,  that  it  requires  little  argu- 
ment to  sustain  the  statistical  facts  bearing  on  the 
question  of  prophylaxis,  and  as  the  methods  of 
prophylaxis  are  the  methods  for  the  arrest  of  the 
disease  in  its  early  stage,  they  can  not  be  too 
carefully  studied. 

Cornet,  whose  investigations  have  been  exten- 
sive, and  apparently  carefully  and  scientifically 
made,  concludes,  that  tuberculous  consumption 
is  very  largely  communicable  by  dried  sputum, 
in  the  form  of  dust  floating  in  the  air,  and  taken 
into  the  air  passages  by  inhalation.  He  accounts 
for  the  greater  prevalence  of  pulmonary  tuber- 
culosis over  other  forms  of  the  disease  in  this 
way,  and  questions  whether  the  lungs  have  any 
especial  predilection  for  tubercular  infection. 

Remembering  how  tubercular  bacilli  are  most 
likely  to  gain  access  to  the  body,  we  should  ever 
keep  in  mind  the  importance  of  avoiding  the  or- 
dinary sources  of  danger. 

Dr.  Bowditch,  of  Boston,  more  than  thirty 
years  ago,  in  studying  the  predisposing  and,  as 
he  believed,  the  exciting  causes  of  consumption, 
showed  clearly  that  the  most  common  predispos- 
ing cause  as  it  relates  to  climate  and  locality,  is 
low  temperature  and  humidity,  with  soil  satura- 
tion; the  most  marked  predisposing  and  exciting 
causes,  other  than  cold  and  dampness,  bad  air  from 
overcrowding  and  faulty  nutrition.  All  subse- 
quent study  has  confirmed  the  wisdom  of  this 
earlier  teaching. 

In  the  knowledge  of  the  contagiousness  of  tu- 
berculosis we  more  clearly  understand  that  den 
sity  of  population  and  industrial  occupations  so 
largely  increase  mortality  from  phthisis.  Then  it 
would  seem  vitally  important  in  the  management 
of  consumption,  particularly  in  its  earlier  stage, 
when  any  hope  exists  for  arresting  its  progress  oi 
effecting  its  cure,  to  radically  change,  so  far  as 
possible,  all  unfavorable  environments  so  as  it 
relates  to  climate,  to  habits  of  life  and  sanitai  v  in 
fluences.  Individuals  living  mar  the  sea  level 
should  change  to  mountain  regions  and  live  an 
active  out- door  life  if  strength  will  permit.  A 
larger  portion  of  cases  of  advanced  phthisis  will 
do  better  in   high  altitudes,  with  cold,  clear,  dry 


atmosphere  than  in  warmer  lower  levels;  but 
there  are  many  exceptions  to  this  rule. 

The  high,  cold  mountain  region  of  winter  can- 
not be  favorable  to  the  nervous,  sensitive  man  or 
woman,  who  has  led  a  life  largely  in  doors,  debil- 
itated from  disease,  In  those  suffering  from  car- 
diac weakness,  functional  or  organic,  and  of  those 
of  haemorrhagic  diathesis,  such  winter  climate 
should  be  avoided. 

In  advanced  phthisis  with  high  and  marked 
change  in  pyrexia,  and  much  destruction  of  lung 
tissue,  and  in  laryngeal  phthisis,  as  well  as  in  the 
old  and  the  very  young,  a  milder  climate  in  win- 
ter must  be  advised. 

Cases  specially  unfavorably  influenced  by  the 
cold  of  high  altitudes  are  those  of  defective  heart 
power  and  specially  sensitive  to  cold,  and  not  of 
sufficient  vitality  to  take  active  exercise  out  of 
doors;  such  cases  are  not  likely  to  do  well  any- 
where, but  they  are  more  comfortable,  and  per- 
haps live  as  long  or  longer  in  a  warmer,  denser 
atmosphere,  particularly  as  it  relates  to  the  colder 
seasons.  Too  much  stress  cannot  be  put  upon 
the  importance  of  a  life  out  of  doors.  I  have  re- 
peatedly seen  the  most  remarkable  recoveries  in 
unpromising  cases  from  a  life  on  the  road  by 
horseback  or  carriage. 

A  large  proportion  of  cases  of  phthisis  in  the 
adult  male  feel  the  stern  necessity  of  doing  some- 
thing for  their  support  as  long  as  it  is  possible  for 
them  to  do  so.  Persuade  the  worker  indoors  to 
lead  the  life  of  a  country  peddler,  or  to  go  to  the 
country,  buy  produce  to  ship  to  market,  or  do 
anything  which  will  contribute  to  his  support  and 
keep  the  mind  employed,  and  give  him  pure  air 
and  strong  sunlight.  Such  a  life,  with  frequent 
change  in  diet,  gives  appetite  for  better  food  and 
greatly  favors  digestion  and  nutrition.  The  skin 
grows  brown  and  the  blood  redder,  the  mind  hap- 
pier in  the  sense  of  self-support,  and  hope  and 
courage  grow  accordingly.  The  law  of  necessity 
often  favors  recovery.  I  have  seen  more  cases  do 
well  when  leading  such  a  life  for  a  livelihood 
than  I  have  seen  where  fortune  allowed  a  life  of 
luxurious  invalidism.  It  is  folly,  worse  than 
folly  to  advise  the  sufferer  to  go  to  a  popular  re- 
sort for  the  consumptive  when  he  has  not,  and 
cannot  obtain  the  means  for  his  support.  It  is 
cruel  to  allow  him  to  feel  that  his  life  depends 
•npon  what  he  cannot  have.  It  is  not  only  irn- 
portant  that  respiration  shall  be  carried  on  in  free 
pure  air  all  day,  but  all  night  as  well;  the  day 
exposure  favors  freedom  of  air  circulation  at 
night. 

It  is  not  my  purpose  in  this  brief  address  to  say 
much  of  the  general  management  of  phthisis,  or 
to  collate  what  has  been  said  by  masterminds  re- 
garding it,  l)ii t  only  to  emphasize  what  seems  to 
me  most  important. 

In  therapeutics  we  have  made  little  advance- 
ment in  the  last  thirty  years,  though  pharmacy 


I89i.] 


PHTHISIS   1TLM0NALIS. 


365 


Ins  given  us  tonic  combinations  like  the  com- 
pound hypophosphites,  more  elegant  and  less  ob- 
jectionable to  the  taste  ami  the  stomach  than  the 
remedies  and  mixtures  of  earlier  times.  Arsenic 
is  now  more  used  than  formerly  and  is  an  impor- 
tant aid  in  increasing  assimilation  and  nutrition 
when  judiciously  used.  Cod  liver  oil  and  fatty 
pods  justly  hold  full  favor  when  they  can  1"  as 
similated.  Medicinal  inhalations,  after  much 
trial,  have  proved  of  little  value 

Each  case  is  a  study  in  itself  and  treatment  <>l 
individual  cases  must  often  widely  differ.  We 
have  no  specifics,  and  bearing  in  mind  scientific 
experiment  as  it  relates  to  the  destruction  of  ba- 
cilli outside  the  body,  we  can  dismiss  as  useless 
microbicidal  treatment.  All  effort  in  that  direc- 
tion has  proved  futile  and  is  more  than  likely  to 
in  the  future. 

Progress  has  been  made  in  dietetics.  The  im- 
portance given  to  food  more  largely  animal,  and 
the  methods  of  its  preparation,  like  depriving 
beef  wholly  of  its  water  and  reducing  the  same 
to  a  powder  so  that  it  can  be  taken  freely  when 
meat  will  not  be  eaten,  is  a  step  in  advance. 

Predigested  beef  and  milk  and  pancreatic  pre- 
parations of  fatty  foods,  so  essential  in  wasting 
disease,  greatly  aid  nutrition  when  digestion  is 
impaired. 

It  is  a  noteworthy  fact  that  tuberculosis  is  sel- 
dom found  in  carnivora  living  in  their  natural 
state;  though  wild  beasts  confined  in  cages  and 
fed  upon  the  flesh  of  domestic  animals  liable  to 
be  tuberculous  contract  the  disease.  Herbivorous 
animals  are  easily  inoculated  with  the  tubercle 
bacillus.  Reasoning  from  analogy,  we  should 
expect  to  see  less  tuberculosis  in  classes  living 
principally  upon  animal  food,  and  this  holds  true. 

In  Iceland  and  the  Faroe  Islands,  where  the 
inhabitants  live  almost  exclusively  upon  ani- 
mal diet,  consumption  is  almost  unknown.  Ex- 
perience, I  think,  has  shown  that  consumptives 
who  can  live  largely  upon  animal  food,  meats, 
animal  oils  and  fats,  milk  and  eggs,  do  best.  In 
the  advanced  stage  of  phthisis  with  high  pyrexia, 
lessened  volume  of  lung  from  destruction  of  tis- 
sue interfering  with  oxidization  of  heavy  nitro- 
genous food,  a  simple  diet  of  milk,  soups,  ku- 
myss,  malt   extract,  glycerine,   etc.,  is  indicated. 

The  dietetic  management  of  phthisis  is  more 
important  than  the  therapeutic,  and  should  re- 
ceive more  careful  supervision  from  the  physician; 
he  should  supervise  the  feeding,  the  methods  of 
nutrition,  as  fully  as  the  medicinal  treatment, 
and  not  leave  the  more  important  to  the  badly- 
educated  appetite  of  the  patient,  nor  to  the  ignor- 
ance of  friends  and  nurses.  Feeding  must  be 
prescribed  and  nutrition  enforced.  A  paper  on 
"Food  in  the  Treatment  of  Pulmonary  Con- 
sumption," by  Dr.  Solis-Cohen,  of  Philadelphia, 
published  in  The  Journal,  February  8,  18S9,  is 
full  of  pertinent  suggestions,  clearly  and  forcibly- 
stated. 


Jaccoud's  teaching,  than  which  little  is  better, 
as  it  relates  to  therapeutical  management,  should 
be  studied  by  the  inexperienced  practitioner,  par- 
ticularly the  advice  to  avoid  the  use  of  cough 
syrups,  opiates  and  palliatives,  which  lessen  ap- 
petite, impair  digestion  and  nutrition.  His  < 
recommendation  to  use  persistent  counter-irrita- 
tion over  diseased  parts,  to  lessen  cough  instead 
of  giving  anodyne  cough  mixtures,  is  to  be  com- 
mended. 

Something  can  be  done  to  relieve  harrassing 
cough  and  not  disturb  nutrition  by  the  inhalation 
from  respirators  charged  with  volatile  anaesthetic 
and  antiseptic  agents,  like  creosote,  iodized  car- 
bolic acid,  bromine,  menthol  and  camphor  mix- 
tures. 

There  is  diversity  of  opinion  as  to  the  use  of 
alcoholic  drinks  in  phthisis.  Sometimes  they  are 
indicated  and  are  efficient  in  creating  appetite  and 
promoting  digestion  and  nutrition.  Many  will 
take  a  glass  of  good  ale  or  porter  with  real  relish 
and  marked  benefit.  Others,  females  in  particular, 
can  take  whisky  in  milk,  or  good,  sound  red 
wine  at  times  with  good  effect,  while  in  other 
cases  stimulants  are  contraindicated;  the  appetite 
is  lessened  and  digestion  impaired  from  their  use. 

It  will  not  be  profitable  to  review  what  has 
been  written  relative  to  the  method  of  treating 
tuberculosis  by  Prof.  Koch.  The  literature  upon 
the  subject  is  now  voluminous,  but  most  of  it  is 
of  little  value.  Sufficient  time  has  not  elapsed 
to  determine  whether  or  not  it  will  be  the  method 
of  the  future  for  the  treatment  of  pulmonary  tuber- 
culosis. 

The  later  reports  from  the  more  competent  ex- 
perimenters are  not  specially  promising. 

If  the  creating  of  the  so-called  lymph  is  so  dif- 
ficult, and  its  use  so  dangerous  that  it  cannot  be 
entrusted  to  scientific  physicians  of  all  countries, 
it  will  be  a  long  time  before  the  value  of  the  dis- 
covery will  be  determined. 

It  is  now  six  months  since  the  announcement 
of  an  important  discovery  was  made,  and  why 
should  so  much  secrecy  surround  it  ?  We  cannot 
believe,  as  has  been  asserted,  that  it  is  for  pur- 
poses of  money-making  by  a  great  and  progressive- 
government,  or  that  scientific  physicians  of  world- 
wide reputation  would  join  government  officials 
in  financial  speculation  in  material  only  used  in 
the  relieving  of  physical  and  mental  anguish,  and 
in  the  saving  of  human  life. 

It  is  important  that  great  care  should  be  taken 
to  have  the  matter  tested  by  careful,  competent 
men,  but  the  production  of  the  material  and  its 
use  can  be  safely  entrusted  to  other  than  German 
physicians. 

In  the  giving  out  of  the  lyrnph  for  experimental 
purposes,  the  supply  being  limited,  it  was  proper- 
ly restricted  to  hospital  use.  The  dishonest 
acquisition  and  use  of  it  for  personal  advertise- 
ment in  public  print  cannot  be  too  severely  con- 


366 


EPIDEMIC  INFLUENZA. 


[March  14. 


detnned.  No  physician  with  sufficient  self  re- 
spect to  regard  the  good  opinion  of  the  profession 
at  large  will  allow  himself  to  be  advertised  for 
personal  gain  in  such  a  way. 

The  advertising  physician  is  found  in  the  hos- 
pital as  well  as  in  private  practice,  and  "some  of 
them  are  making  good  and  ingenious  use  of  the 
popular  interest  in  the  subject  to  bring  their 
names  into  daily  notice  and  prominence."  Such 
practice,  whenever  it  occurs,  should  be  frowned 
upon. 


ORIGINAL  ARTICLES. 


AN  ANALYSIS    OF   THE  STATISTICS  OF 
FORTY-ONE    THOUSAND    FIVE 
HUNDRED  CASES  OF  EPI- 
DEMIC  INFLUENZA. 

Read  before  the  American  Academy  of  Medicine,  Philadelphia, 
December  4,  1890. 

BY  BENJAMIN  LEE,  A.M.,  M.D.,   Ph.D., 

SECRETARY  OF  THE  STATE  BOARD   OF   HEALTH   OF   PENNSYLVANIA. 

It  is  not  difficult  to  understand  why,  in  the 
extreme  south  eastern  portion  of  Europe,  doubts 
should  have  been  entertained  as  to  the  diagnosis 
of  the  disease,  which  during  the  past  year  has 
not  only  overspread  that  continent,  but  crossing 
the  ocean,  has  swept  over  this  country  so  gener- 
ally and  attacked  the  population  so  universally- 
that  we  are  justified  in  calling  it  a.  pandemic. 

It  is  evidently  due  to  the  fact  that  one  of  the 
prominent  symptoms,  which  is,  however,  by  no 
means  an  essential  symptom,  namely  :  coughing 
and  sneezing,  indicating  catarrh  of  the  air  pass- 
ages, has  been  mistaken  in  the  minds  of  the 
people,  and  to  some  extent  also  of  the  medical 
profession,  for  the  disease  itself.  To  such  an  ex- 
tent is  this  true,  that  one  medical  author  of  con- 
siderable reputation  has  designated  it  Epidemic 
Acute  Bronchitis. 

The  first  intimation  which  we  had  of  its  pres-. 
ence  in  Europe  was  that  all  St.  Petersburg  was 
coughing  and  sneezing.  And  so,  for  many  weeks, 
almost  the  only  references  to  the  spread  of  the 
disease  on  that  continent  contained  allusions, 
usually  of  a  jocular  character,  to  this  peculiar 
feature  of  a  certain  proportion  of  the  cases. 
People  appeared  to  look  forward  to  its  appear- 
ance on  this  side  the  ocean  as  an  experience, 
which,  on  the  whole,  would  constitute  a  mild 
amusement,  rather  than  an  occasion  of  suffering, 
distress,  terror  and  death.  A  very  few  weeks, 
however,  sufficed  to  convince  both  the  public  and 
the  profession  that  influenza  meant  a  good  deal 
more  than  a  bad  cold  in  the  head. 

Discovering  this  fact,  and  observing  the  seri- 
ous involvement  of  the  nervous  system  in  a  large 
percentage  of  the  cases,   the   inquiry  suggested 


itself  to  those  who  were  looking  for  nothing  more 
than  a  bronchial  catarrh,  "  Is  this  influenza  after 
all,  or  is  it  some  other  epidemic  disease,  and  if 
some  other,  is  it  not  dengue  ?"  It  is  true  that  this 
misconception  prevailed  to  a  much  greater  extent 
in  Europe  than  here,  and  especialfy  was  this  true 
of  the  extreme  East,  Turkey,  Greece  and  Austria. 
It  ma)-  not  be  out  of  place,  however,  to  outline 
the  distinctive  features  of  the  two  affections,  not 
so  much  to  enable  the  most  of  us  who  are  pres- 
ent to  make  the  diagnosis  iu  our  practice,  since 
dengue  is  almost  exclusively  confined  to  hot 
countries,  but  in  order  that,  hearing  of  the 
prevalence  in  Europe  or  Asia  of  an  epidemic  dis- 
ease having  a  similarity  to  either  affection,  we 
may  be  able  to  determine  its  character  in  our  own 
minds,  and  hence,  the  necessity  for  expecting  its 
advent  in  this  country  and  for  forewarning  the 
people,— or  the  absence  of  any  such  necessity. 
Certainly  if  our  health  authorities  had  possessed 
the  knowledge  of  the  character  of  the  disease,  and 
its  rate  of  progression  geographically,  in  the 
Autumn  of  1S89,  which  they  now  possess,  they 
would  have  been  enabled  to  issue — and  it  would 
have  been  their  duty  to  issue — precautionary 
circulars,  notifying  the  people  that,  at  about  such 
a  time,  it  might  be  expected  that  from  one-fourth 
to  one- sixth  of  the  population  would  be  so  pros- 
trated, that  they  would  be  more  or  less  inca- 
pacitated from  attention  to  business,  and  that  it 
would  be  the  part  of  wisdom  for  those  who  found 
themselves  attacked  with  the  disease  to  give  up 
work  at  once  and  secure  medical  advice.  People 
could  then  have  arranged  their  affairs  in  advance 
to  meet  the  emergency,  and  many  lives  of  those 
who  kept  at  business  after  they  ought  to  have 
been  in  bed,  or  returned  to  business  when  they 
ought  to  have  stayed  in  bed,  might  have  been 
saved. 

The  first  point  of  distinction  that  we  may 
make  is  in  regard  to  the  mode  of  extension  of  the 
two  affections.  Influenza,  as  we  have  had  recent 
demonstration,  spreads  like  a  flood,  inundating 
whole  sections  in  an  hour,  while  dengue  works 
along  gradually,  establishing  centres  of  infection 
here  and  there,  enabling  its  course  to  be  easily 
traced.  In  their  sudden  onset,  intense  headache, 
pain  in  the  back  and  limbs  and  excessive  lassi- 
tude they  have  much  in  common,  but.  while  the 
fever  in  dengue  is  invariably  of  a  high  grade,  in 
influenza  it  is  often  slight  or  absent  altogether. 
tarrhal  and  pneumonitic  complications  of 
influenza,  the  dyspnoea,  the  feeble  piping  voice, 
an-  very  rare  in  dengue,  while  on  the  other  hand, 
the  latter  is  characterized  by  violent  and  per- 
sistent gastric  disturban 

An  erythematous  eruption  followed  by  desqua- 
mation, beginning  in  the  face  and  descending,  is 
rarely  absent  in  dengue,  and  ;is  rarely  seen  in  in- 
Dengue  very  rarely  terminates  fatally, 
influenza,    as  we  know   to  our  cost,  often  does. 


iSgi.J  EPIDEMIC  INFLUENZA. 

While,  therefore,    there  are  points  of  similarity       It  is  probable  that  not  a  single  individual  en- 

between   the  two  affections,  especially  in  regard  tirely   escaped    its    pernicious  effects.     Its  raani- 

to  their  nervous  phenomena,  the  distinctions  are  festations  were  so   various,  affecting  in   one  the 

Sufficiently  marked  to  prevent  any  misconception,  bronchial  tubes,  in  another  the  nei 

when    large    numbers   of  cases    are    under   con-  now  the  brain  and  now  the   bowels,  here  perito- 

sideration.  nitis  and   there    pneumonia,  that   it   was   a  long 

To  refer  now  to  the  history   of  the  disease  in  time,     comparatively,    before    physicians,    even, 


our  own  country: — sporadic  cases  appear  in  our 
Wiring  the  month  of  November.      One  ac- 
curate observer  in   Philadelphia  reports  a  case  in 


recognized  it  in  its  protean  forms.  It  is  scarcely 
conceivable  that  a  disease  which  spreads  with 
such  astonishing  rapidity,  goes  through  the  pro- 


July.  Without  discrediting  his  diagnosis  we  can  cess  of  re-development  in  each  person  infected, 
scarcely  consider  this  case  as  due  to  the  epidemic  and  is  only  communicated  from  person  to  person 
influence.  What  we  are  accustomed  to  call  in-  or  by  infected  articles.  And  yet  this  theory  has 
fluenza  colds,  we  may  meet  with  at  any  time,  and  '  been  maintained  by  a  few  authorities  who  claim 
we  are  all  familiar  with  circumscribed  epidemics  |  that  it  is  always  more  prevalent  along  lines  of 
of  influenza  of  a  mild  type.  Other  physicians  !  travel,  and  that  it  did  not  progress  more  rapidly 
report  cases  probably  to  be  classed  in  the  same  than  modern  means  of  communication  would  en- 
category  in  September  and  October      About  the   able  it  to  do. 

tenth  of  December  it  began  to  exist  epidemically  Whatever  theory  we  may  adopt  of  its  means  of 
on  our  seaboard.  It  was  prevailing  sufficiently  propagation,  it  was  felt  by  the  writer  that  an 
to  attract  general  attention  in  Philadelphia,  by  j  affection  so  fatal  in  its  results  and  so  widespread 
the  20th  of  that  month.  The  disease  began  to  in  its  domain  possessed  an  importance  which  en- 
appear  as  an  acknowledged  factor  in  the  mortality  titled  it  to  especial  study.  He  therefore  prepared 
tables  of  the  city  on  the  4th  day  of  January,  the  following  circular,  cyclostyle  copies  of  which, 
when  one  death  is  recorded  from  the  disease.  An  to  the  number  of  more  than  seven  thousand  were 
increase  in  the  number  of  deaths  from  inflamrna  ■  distributed  to  the  members  of  the  medical  pro- 
tion  of  the  lungs,  however,  from  thirty-three  in  fession  throughout  the  State  of  Pennsylvania  : 
the  week  previous  to  seventy  one  in  the  first  week  Dear  /;„,/,,,  ..  1  am  desirous  to  obtain  reliable  sta- 
in January,  sufficiently  indicates  that  the  epidemic  tirtics  in  regard  to  the  recent  pandemic  of  influenza  as 
had  become  fairlv  seated.  It  spread  with  a  observed  in  this  State.  Will  you,  therefore,  kindly 
rapiditv  Which  is  scarcely  conceivable,  and  gained  £™»,»  \h%  information  called  for  below  by  filling  up 
.    r.       -      .  ,  J    .  c    .  .     .°  the  blanks  from  the  data  111  vour  visiting  list  or  note  book 

in   intensity    as    the    numbers   of    Its  victims   ill-    and  returning  the  sheet  to  me  as  early  as  practicable? 
creased.      By   the   23d  of  December,  it  was  esti-  Vours  very  respectfully, 

mated  that   there  were    2,000  cases  in  the  citv.       (Signed)  Benjamin  Lke,  M.D.. 

On  the  9th  of  January,  6,000  of  the  pupils  of  the  Superintendent  of  Vital  Statistics. 

public  schools  were  reported   as  prostrated  with  „Re?idencfe Connty.T~^Date  °L,^r.!lCase~^7 

',         ,.  _,  v,  ,     ,  *\ ,        .  ,  Number    of    cases Adults Children Pre- 

the   disease.      The  number    of    deaths    increased  dominant  type  (nervous) (Catarrhal  1 (Inflam- 

the  first  week  in  January,  from  404  in  the  week  maton  — - — Number  of  deaths  1  Directly  caused  

previous,  to   492.      In   two  weeks  it   reached  the  (Indirectly  caused) . 

startling  figure  of  770,  more  than  twice  as  sjreat       Irradiate  ^u*e  of  death  :  .?^"*^£S '. 

0      °  ,.  .'.'    '  ,.  ,      °    ,        Children ;     Pneumonia,    Adults Children ; 

as  the  mortality  of  tne  corresponding  week  of  the    Pnthisis,    Adults Children ;     Nervous    affec- 

year    1888.      The   overworked   physicians  were  j  tions,  Adults Children . 

prostrated  both  by  fatigue  and  by  the  disease'  Up  to  the  1st  of  May,  4,500  of  these  letters  had 
itself,  and  many  succumbed  finally.  been  sent  out. 

Business  was  now  almost  at   a  standstill.       In        fhe  following  is  an  analysis  of  the  results  ob- 
several   instances   places  of    business   or   manu-  <  tained  at  that  date  : 
fucture  were  compelled  to  close  for  want  of  hands.  Number  of  physicians  reporting  .    .        265 

Whole  families  were  confined  to  the  bed  at  once,  Number  of  cases 37 

so  that  neighbors  were  obliged   to  provide  them  Adults 26,302 

with  food  and  nursing  care.     This  week,  ending  Children      10.973 

T                     „             ,      ,   °,       ,  .    ,     ..,         c  ..               .?  Number  of  cases  nervous 0,913 

January  18,  marked  the  high  tide  of  the  pesti-  Number  of  cases  catarrhal  ....    16,434 

lence  in  Philadelphia  so  fai  as  mortality  was  con  Number  of  cases  inflammatory  .    .      5,829 

cerned,  the   citv  death-rate   having  fallen  to   its  No.  of  deaths  directly  caused.      56 1       ,6l 

norm    by    the   end   of  Februarv.       In   the   mean-  J*o.  »*"  deaths  indirectly  caused.                 - 

.,           .,       .     .    a              ,     -,               ,  ...          .,  ,  Immediate  cause  of  death,  bronchitis,            b 

time  the  epidemic  influence  had  spread  like  wild-  ..            ..                  pneumonia,      117 

fire,    literally    "on    the    wings    of   the    wind"  ■■              ••     phthisis.     .        42 

throughout    the    entire   State.     On    the    27th  of  "                                  nervous.     .        21 

December  the  disease  was  rife  in  Lancaster,  and  Supposing,  which  there  is  no  reason  to  doubt, 

genuine  cases  had  appeared  in  Pittsburgh  on  the  that  the  265  physicians  who  replied,  represent  a 

.extreme  western  border,  and  Wilkesbarre  on  the  fair  average  of  the  practitioners  of  the  State,  this 

northern  border  of  the  State.  I  would  give  us  1,120000  persons  as  having  been 


368 


EPIDEMIC  INFLUENZA. 


[March  14, 


sufficiently  ill  with  the  disease  to  demand  med- 
ical aid  or  come  beneath  the  observation  of  a 
medical  man,  and  7,879  deaths  directly  or  in- 
directly caused  by  the  epidemic  influence  in  the 
State  of  Pennsylvania  alone.  We  know  that 
there  were  many  who  suffered  mild  attacks  who 
never  sought  advice,  and  many  more  whom  phy- 
sicians, in  their  excessive  haste,  failed  to  enter  on 
their  visiting  lists  although  they  may  have  pre- 
scribed for  them. 

In  fact  this  is  exactly  the  return  that  was  made 
in  some  instances  : 

"Treated  an  immense  number  of  cases  but 
kept  no  record." 

Nearly  one- half  of  the  cases  reported  were  in 
the  city  of  Philadelphia  As  the  Philadelphia 
physicians  reporting  constituted  only  about  one- 
third  of  the  whole  number,  the  disease  must 
therefore  have  been  more  prevalent  iu  large  cities 
tban  in  the  country.  To  be  exact,  the  average 
of  cases  to  each  physician  reporting  was  140; 
while  the  average  to  each  Philadelphia  physician 
reporting,  was  193. 

The  disease  seems  to  have  been  especially 
prevalent  in  mining  towns.  Two  physicians  in 
Shamokin,  a  place  of  about  12,000  inhabitants, 
report  950  cases  between  them.  In  Greens 
burg,  a  place  of  about  6,000  inhabitants,  two 
physicians  report  737  cases.  In  the  little  village 
of  Portage,  Cambria  County,  numbering  650  in- 
habitants, one  physician  reports  400  cases.  Ill- 
fated  Plymouth  suffered  seriously  as  did  the  most 
of  the  other  mining  towns  and  villages  of  Lu- 
zerne County.  Scranton  was  also  severely 
visited. 

One  curious  fact  developed  by  the  investiga- 
tion is  that  the  disease  was  observed  quite  as 
early  in  the  extreme  western  portion  of  the  State 
as  in  Philadelphia  on  the  eastern  border.  In- 
deed more  observers  in  proportion  to  the  popula- 
tion report  having  observed  cases  in  November  in 
Allegheny  County  than  iu  Philadelphia  County: 
as  though  a  disease  bearing  air  current  had 
passed  over  the  eastern  border  at  a  great  altitude 
and  dipped  down  in  the  western  portion  of  the 
State. 

Of  the  265  physicians  reporting  206  made  the 
distinction  as  to  the  predominant  type  of  the  dis- 
ease. While  it  is  to  be  regretted  that  all  did  not, 
still  this  number,  representing  more  than  29,000 
•cases,  is  ample  for  purposes  of  deduction. 

Nearly  7,000  of  these  are  recorded  as  belong- 
ing to  the  nervous  type.  This  is  very  nearly  25 
per  cent,  and  does  not,  of  course,  preclude 
the  presence  of  nervous  symptoms  in  a  large  pro- 
portion of  those  set  down  as  catarrhal  or  inflam- 
matory. And  this  takes  us  back  to  the  point 
from  which  we  started,  namely  the  marked  pre- 
dominance of  the  nervous  element  and  the  pro- 
tean character  of  the  manifestations  in  this 
singular  affection.        How   shall    we   account    for 


the  production  of  such  varied  morbid  phenomena 
by  a  single  morbific  agent. 

Some  writers,  among  whom  may  be  mentioned 
Dr.  Dixon,  of  the  University  of  Pennsylvania, 
attempt  to  explain  it  by  saying  that  the  disease 
lowered  the  vitality  of  the  cells  of  the  various 
tissues  so  that  they  were  no  longer  able  to  resist 
the  onslaughts  of  the  microbes  of  the  various  dis- 
eases, and  that  any  that  happened  to  be  present 
found  an  entrance  and  developed  their  peculiar 
affection.  Others,  as  Dr.  Baker,  Secretary  of  the 
State  Board  of  Health  of  Michigan,  consider 
that  the  atmospheric  condition  affected  the  lining 
membrane  of  the  air  passages  in  such  a  way  as  to 
make  it  easy  for  the  ever  present  germs  to  find 
an  entrance  into  the  blood  ;  and,  as  in  the  first 
mentioned  theory,  that  each  produced  its  charac- 
teristic chain  of  symptoms 

One  great  obstacle  to  the  acceptance  of  these 
theories  is  the  fact,  that  they  require  the  ex- 
istence of  a  great  number  of  microbes  of  which 
we  have  no  knowledge. 

To  the  writer  it  seems  more  rational  to  suppose 
that  the  morbific  influence,  whether  germ, 
microbe  or  occult  meteorological  departure  from 
the  normal  condition,  spent  itself  directly  upon 
the  nervous  system,  and  more  particularly  on  the 
vegetative  portion  of  that  system,  or  to  particu- 
larize, still  further,  upon  the  pneumogastric 
nerve  and  its  associated  ganglia  with  partial  im- 
plication of  the  spinal  cord.  Nearly  all  phe- 
nomena which  distinguish  influenza  from  other 
similar  affections  can  be  readily  accounted  for  by 
this  theory  ;  the  excessive  nervous  prostration, 
so  entirely  out  of  proportion  to  the  catarrhal  dis- 
turbance, the  emotional  depression,  causing  the 
victim  to  weep  incessantly  without  consciousness 
of  any  reason  for  so  doing,  the  sense  of  constric- 
tion about  the  larynx,  the  strident  cough,  piping 
voice  and  occasional  aphonia,  the  sudden  con- 
gestions of  the  lungs,  the  pain  and  stiffness  in 
the  dorsal  muscles,  especially  along  the  nucha, 
the  gastric  and  intestinal  disturbances,  the  in- 
tense headache,  and  transient  manias,  all  can  be 
accounted  for  by  the  supposition  that  the  great 
balance  wheel  of  organic  life  has  become  de- 
ranged— and  on  no  other  theory  so  simply. 

The  fact  that  all  the  remedies  which  were 
found  most  beneficial  in  the  treatment  of  this 
affection  are  nervines,  such  as  phenacetine, 
morphia  and  mix  vomica  may  also  be  adduced 
as  strongly  confirmatory  of  this  theory. 
1532  Pine  St.,  Philadelphia. 


A  vkkdict  of  $100  damages  has  been  given 
against  a  London  chemist  who  supplied  ammonia 
when  sal  volatile  was  asked  for.  The  plaintiff, 
an  actress,  was  said  to  have  been  prevented  from 
following  her  engagements  for  nine  days  as  a  re- 
sult of  the  mistake. 


is.,..; 


BATH  TREATMENT  OF  TYPHOID  FEVER 


369 


NOTE  OX  THE    BATH    TREATMENT    OF 

TYPHOID  FEVER. 

BY  SIMON  BARUCH,  M.D., 

.     YORK. 
rBYSICIAK     TO     llll:     MANHATTAN    GENERAL    HOSPITAL 
YORK  JDVENILE   ASYLUM. 

In  the  article  "Has  progress  been  made  in  the 
Medicinal  Treatment  of  Typhoid  Fever?"'  Dr. 
T.  J.  Happel,  after  reviewing  the  various  methods 
of  medicinal  treatment,  goes  out  of  his  way  to  at- , 
tack  the  Brand  Treatment  I  which  certainly  is  not 
a  "medicinal"  treatment  . 

I  feel  called  upon  to  say  a  word  in  defence  of 
the  bath  treatment  which  he  dismisses  so  sum- 
marily. "The  bathing  must  be  begun  early," 
says  the  author  (p.  811)  in  quoting  the  directions 
I  gave  in  a  review  before  the  Academy  of  Medi- 
cine, "even  before  a  diagnosis  can  possibly  be 
made.  I  would  suggest  that  the  longer  before  a 
diagnosis  can  be  made,  the  bathing  is  begun,  the 
greater  the  per  cent,  mejudice,  of  cures,  because 
the  greater  the  number  of  febriculae  and  simple 
continued  fever  cases  you  are  apt  to  have  to  treat." 

It  does  not  seem  to  have  occurred  to  this  gen- 
tleman that  men  like  Ziemssen,  Juergeusen,  Yogi, 
Brand,  Tripier.aud  other  eminent  clinical  teachers 
are  as  capable  of  making  a  diagnosis  of  febriculae 
from  typhoid  as  he  is,  and  that  they  do  not  re- 
gard a  case  as  typhoid  unless  it  runs  its  charac- 
teristic course. 

Again,  this  author  says  (p.  Su  i:  "If  we  wait 
until  we  are  fully  satisfied  that  we  have  a  case  of 
typhoid  fever,  we  will  find  that  Brand's  method 
will  offer  no  advantage  over  former  methods  of 
treatment."  This  positive  dictum  of  the  author 
would  presuppose  that  he  has  given  these  meth- 
ods a  fair  trial,  which  I  greatly  doubt,  on  account 
of  the  horror  he  expresses  of  the  Brand  method. 
Moreover,  I  deny  that  "its  advocates  must  admit 
that  it  is  as  yet  subjtidice." 

In  discussing  this  question  I  have  been  careful 
not  to  obtrude  my  own  personal  experience,  al- 
though it  extends  over  twenty-eight  years  in  mil- 
itary and  civil,  private  and  hospital,  village, 
country  and  city  practice,  North  and  South.  The 
experience  of  one  individual  is  valuable  only  as 
a  part  of  the  aggregate,  unless  it  be  very  large. 
Such  an  experience  we  have  obtained  from  Yogi, 
the  chief  of  the  garrison  hospitals  of  Munich.  As 
this  is  only  confirmatory  of  Brand,  Ziemssen, 
Juergensen,  Struempell  and  others,  and  as  he  is 
not  the  originator  of  the  method,  we  may  in  all 
fairness  accept  his  statements  as  positively  free 
from  bias,  and  incontrovertible.  Vogl  #telis  us 
that  he  was  led  to  abandon  all  other  treatment 
of  typhoid  fever,  in  favor  of  the  cold  bath,  by 
studying  the  records  of  the  institutions  under  his 
charge  for  forty-seven  years.  During  this  period 
every  method  in  vogue  had  been  applied  in  8,325 

1  In  the  Journal  of  the  American  Medical  Association,  Decem- 


cases  of  typhoid  fever.  The  various  types  of 
disease  are  clearly  pictured  in  his  work,  giv- 
ing symptoms,  complications  and  pathological 
From  venesection  to  nihilism,  and, 
later,  antipyretics  and  baths;  the  gamut  was  run 
as  was  the  fashion  at  different  times.  Since  1868 
the  bath  treatment  has  been  used  in  889  cases; 
alone  in  one  station  and  combined  with  antipy- 
retics in  another,  with  the  following  results: 

Combined  Pure  Bath 

nent.  Treatment. 

Mortality 6.7  per  cent  2.7  per  cent. 

Average  hospital  iys.      47-3 

Per  cent. complications  102  65.2 

Average  number  diar- 
rhoeas per  person  per 
day 1-9  °-7 

The  mortality  under  the  old  treatment  ranged 
from  40.3  per  cent,  down  to  7.6  per  cent.  These 
figures  will,  I  trust,  convince  your  readers  that 
Dr.  Yogi  did  not  mistake  febriculae  for  typhoid 
fever,  and  as  they  only  sustain  the  verdict  of  a 
large  number  of  equally  capable  and  honest  hos- 
pital physicians,  they  demonstiate  that  the  supe- 
riority of  the  bath  treatment  is  not,  as  your  au- 
thor supposes,  "still  sub  judice."  Medical  sta- 
tistics are  proverbially  unsatisfactory,  but  if  ever 
they  approach  exactness,  these  of  Dr.  Yogi  are 
an  instance;  for  here  we  have  a  military  hospital, 
under  various  administrations  during  forty  seven 
years,  treating  exactly  the  same  class  of  patients, 
soldiers  of  about  the  same  age.  previously  in  good 
health,  having  the  same  employment,  the  same 
food  etc.  Surely  no  better  data  for  a  compara- 
tive estimate  of  a  question  in  medicine  can  be 
imagined.  And  yet  the  author  has  the  temerity 
to  tell  your  readers,  "I  enter  a  protest  that  the 
mortality  of  typhoid  fever  cannot  be  reduced  to 
3  per  cent,  by  any  such  procedure,  but  that  the 
errors  in  diagnosis  account  for  the  vast  discrep- 
ancy!" 

Upon  another  point  I  must  take  issue  with  the 
author  when  he  says:  "Antifebrin  given  in  such 
doses  as  the  patient  is  found  to  bear,  will  accom- 
plish in  one  hour  what  is  effected  by  the  Brand 
system  in  three  times  that  length  of  time."  If 
the  author  had  ever  tried  a  genuine  Brand  bath 
he  would  have  discovered  several  errors  in  this 
proposition,  the  principal  one  being  that  the  effect 
of  the  bath  upon  the  temperature  and  pulse  is  ob- 
tained, not  in  "three  hours"  after  the  bath,  but 
in  fifteen  minutes.  If  the  author  had  studied 
recent  developments  in  experimental  therapeutics, 
he  would  also  have  known  that  Lepine  demon- 
strated in  the  Paris  Congress  of  Therapeutics  in 
1888  that  antipyrin  and  antifebrin  lower  the 
vitality  of  the  protoplasm,  that  they  convert 
the  haemoglobin  and  attack  the  cell  structure  and 
destroy  the  red  blood  corpuscles.  It  was  gener- 
ally accepted  that  they  undermine  every  organic 
function,  hence  they  are  dangerous  in  a  disease 
recovery  from  which   depends  upon  their  integ- 


37o 


KOCH  TREATMENT  OF  TUBERCULOSIS. 


[March  14, 


rity.  Vinay  also  shows  that  they  diminish  the 
excretion  of  urea  and  nitrogen.  That  this  is  not 
mere  theory  is  proved  by  the  almost  unanimous 
verdict  against  the  use  of  antipyretics  in  typhoid 
fever,  given  by  the  American  Association  of  Phy- 
sicians in  1887,  and  in  favor  of  the  bath  treat- 
ment by  the  Wiesbaden  Congress  of  1885. 

I  agree  with  the  author  upon  one  point,  viz., 
the  Brand  bath  requires  a  considerable  outlay 
of  trouble.  But  when  we  consider  that  it  saves 
the  involuntary  soiling  of  beds,  the  muttering 
and  wild  delirium,  the  frequent  diarrhoeas,  and, 
above  all,  that  it  saves  enormously  in  mortality, 
that  it  abbreviates  convalescence  and  cheers  the 
family  and  friends,  the  latter,  even  in  the  country, 
will  not  be  averse  to  the  additional  trouble  for 
fifteen  minutes  every  three  to  six  hours.  The 
water  need  be  changed  only  once  in  twenty-four 
hours,  unless  the  patient  soils  it.  If  it  cannot  be 
executed  with  precision,  the  nearest  approach 
must  be  made,  just  as  we,  who  have  practiced  in 
the  country,  were  so  often  called  upon  to  do. 

My  friend,  the  late  Dr.  Trantham,  of  South 
Carolina,  once  did  a  craniotomy  with  a  jack  knife, 
and  did  it  well.  In  my  experience,  country  phy- 
sicians, many  of  whom  I  have  in  former  times 
met  in  consultation,  are  the  readiest  men,  most 
full  of  resources,  whom  I  have  ever  met.  They 
will  not  fail  to  invent  some  means  by  which  they 
will  nearly  substitute  the  Brand  "method.  If 
the>-  can  accomplish  it,  those  living  in  towns  and 
cities  will  not  fail  to  do  so.  ,In  Gaillard's  Medi 
cal  Journal Tor  January,  1891,  such  methods  are 
fully  given,  as  I  have  found  useful  in  the  past. 
The  principles  of  the  bath  should  always  be  borne 
in  mind.  A  temperature  of  the  water  not  below  65° 
nor  above  jo°,  duration  te?i  to  fifteen  minutes,  con- 
stant friction  of  the  surface. 

There  are  many  points  in  the  paper  of  Dr. 
Happel  which  tempt  me  into  criticism,  but  I 
have  referred  only  to  the  most  salient  point  of 
his  argument,  which  seems  to  be  a  denial  of  the 
mortality  reducing  value  of  the  bath-treatment 
upon  the  ground  that  "errors  of  diagnosis  account 
for  the  discrepancy."  The  untenability  of  the 
argument  (?)  is  proven  by  Vogl's  plain  statement 
of  the  duration  and  complication  of  his  cases,  and 
the  results. 

Sixtieth  >t  .  December  11,  1890. 


KOCH  TREATMENT  OF  TUBERCULOSIS. 
BY  SOLOMON  SOLIS-COHEN,  M.D., 


DELPHTA. 


In  the  Polyclinic  evening  lecture  course,  Feb- 
ruary 17,  Professoi  Solomon Solis-Cohen reviewed 
ublished    records   of  cases   treated    by   the 
He  stated    his   continued    dis- 
belief in  the  etiological  rule  ascribed  by  the  ma- 


d  foi  The    lournal 


jority  of  cotemporary  writers  to  Koch's  bacillus. 
The  work  of  Dr.  Heneage  Gibbes  was  highly 
commended,  and  close  attention  asked  for  the 
facts  brought  out.  The  close  association  of 
Koch's  bacillus  with  certain  forms  of  the  diseases 
called  tuberculous,  and  its  possible  determining 
influence  in  the  destructive  outcome  of  the  lesions, 
were  admitted  by  the  lecturer.  But  the  actual 
disease  in  the  preponderence  of  cases  he  found  in 
that  condition  of  system  or  cells  which  permits 
tlie  bacillus  to  find  pabulum  in  the  tissues.  Given 
this  condition,  the  reaction  between  the  tissues 
and  the  bacillus  gives  rise  to  some  product  which 
destroys  tissue.  If  we  produce  this  substance  out- 
side the  body  and  inject  it,  we  destroy  tissue  more 
quickly.  This  is  what  Koch's  method  does.  The 
poison  or  poisons  —  ferment,  toxine  or  whatever 
it  or  they  may  be — generated  by  the  mutual  re- 
action of  the  bacillus  and  the  tissue,  being  dis- 
solved in  glycerine  is  called  "Koch's  remedy," 
and  is  injected.  In  subjects  of  tuberculous  dis- 
ease it  causes  the  process  to  become  more  rapid. 
The  affected  tissues  dying,  the  microbes  are  de- 
prived of  food  and  starve  to  death.  If  the  lesions 
are  external  the  dead  tissues  are  cast  off  and  tem- 
porary recovery  takes  place.  But  the  condition 
of  the  remaining  tissues  permitting  them  to  suc- 
cumb is  not  cured  unless  this  is  accomplished  by 
other  means,  and  relapse,  that  is  to  say  reinfec- 
tion, may  occur  at  any  time. 

When  the  affected  tissues  are  not  external, 
even  if  only  slight  lesions  exist,  the  inflamma- 
tion, ulceration  and  haemorrhages  produced  may 
be  fatal,  as  in  the  cases  reported  by  Chiari,  Virchow, 
Fraenkel  and  others.  In  other  words,  a  case  that 
might  last  months,  or  even  years,  completes  its 
destructive  course  in  a  few  days  or  weeks.  Even 
in  external  cases  in  highly  susceptible  patients, 
rapid  spread  of  the  disease  may  result,  as  in 
Fraenkel's  case  of  tuberculosis  of  the  tongue. 
Cases  have  been  reported  also  in  which  after  the 
injection  bacilli  were  found  in  the  blood.  In  the 
meninges  or  the  brain  the  local  reaction  is  almost 
sure  to  have  fatal  results  by  compromising  impor- 
tant structures.  In  the  larynx  occlusion  from 
local  reaction  may  necessitate  prompt  tracheot- 
omy. In  cases  with  extensive  pulmonary  cavities 
further  destruction  means  immediate  death.  It 
is  only  fair  to  Koch  to  recall  that  the  counter  in- 
dications in  cerebral,  laryngeal  and  extensive  pul- 
monary tuberculosis,  were  pointed  out  by  him. 

It  is  claimed  that  reaction  occurs  only  in  sub- 
jects already  tuberculous. 

Dr.  Cohen  doubts  this.  He  points  out  that 
human  beings  may  clinically  be  divided  into  three 
groups:  1,  Those  highly  susceptible  to  tuber- 
culosis.  -\  Those  moderately  susceptible.  3. 
Those  insusceptible.  The  first  and  second  groups 
an-  subject  to  many  subdivisions  which  need  not 
be  considered  in  detail  in  this  connection,  and 
individuals  of  the  third  group  might  under  pecu- 


i89i.] 


A  CLINICAL  LECTURE  ON  INSANITY. 


37i 


liarly  depressing  environment  acquire  temporary 
susceptibility.  If  Koch's  virus  be  injected  in 
moderate  quantity  in  a  nonsusceptible  person,  no 
harm  might  result.  If  injected  in  a  highly  suscep- 
tible person, even  if  he  had  not  already  acquired  the 
disease,  the  injection  would  probably  give  it  to 
him.  The  reaction  proved  not  the  previous  pres- 
ence of  the  disease,  but  the  susceptibility  of  the 
patient,  and  possibly  the  acquirement  of  disease 
from  the  injection.  Its  diagnostic  use  is  like  set- 
ting fire  to  a  house  in  order  to  find  out  if  the 
house  is  fireproof.  It  might  be  fireproof— in 
which  case  no  harm  would  be  done— but  then 
again,  it  might  not.  One  further  danger,  the 
speaker  said,  had  been  illustrated  in  a  case  not 
yet  reported,  of  which  he  had  personal  knowl- 
edge. The  patient  had  both  laryngeal  and  pul- 
monary disease,  and  most  probably  would  have 
perished  in  the  natural  course  of  events,  after  a 
somewhat  more  prolonged  illness.  The  point  to 
be  made,  however,  was  independent  of  the  actual 
condition  of  this  patient.  Death  occurred  after 
profuse  haemorrhage.  Old  and  unsuspected  cica-  j 
trices  had  broken  down  in  the  lung,  and  while 
recent  lesions  had  been  apparently  favorably  in- 1 
fluenced,  death  had  occurred  from  extensive  de- 1 
struction  of  the  salutary  work  formerly  accom- 
plished by  nature,  unaided.  This  seemed  to 
indicate  that  in  subjects  of  a  certain  degree  of 
susceptibility,  tubercular  formation  might  go  on  ! 
to  fibroid  change,  the  bacillus  being  unable  to 
bring  about  necrosis  ;  but  by  injection  of  the  ne- 
crosis-poison the  fibroid  tissues,  being  still  weak- 
er than  normal,  might  succumb,  and  a  patient 
whom  nature  was  curing,  be  slain  by  art. 

Moderate  susceptibility  was  proved  by  the  ex- 
istence of  lupus  for  many  years,  or  of  certain  joint 
lesions,  or  glandular  lesions  for  many  years, 
without  fatal  involvement  of  important  organs. 
The  fire  was  there  but  it  only  smouldered.  The 
house  then  was  partially  fireproof.  In  these 
cases  it  might  be  very  good  practice,  where  it 
was  impossible  to  thoroughly  cut  away  the 
smouldering  portions,  and  where  they  were  fa- 
vorably situated  for  this  purpose,  to  cause  them 
to  burn  out  quickly  and  thus  limit  danger  of 
further  spread.  Hence  Dr.  Cohen  believed  the 
Koch  treatment  justifiable  in  chronic  lupus  and 
chronic  joint  tuberculosis  of  long  standing,  with- 
out serious  visceral  involvement.  The  chronicity 
of  the  disease  proved  that  the  patient  was  only 
moderately  susceptible.  It  might,  and  did,  in 
joint  cases,  at  least,  require  surgical  aid  to  re- 
move the  debris. 

In  lupus  or  joint  lesions  of  short  standing, 
however,  other  measures  should  be  used  at  first, 
and  only  after  these  had  failed  and  time  had 
proved  comparative  insusceptibility  of  viscera 
should  the  Koch  remedy  be  used.  A  case  recently 
reported  of  death  in  a  girl  of  17,  with  lupus,  after 
one  injection  of  two  milligrams,  was  cited  in  sup- 
port of  this  position. 


Dr.  Cohen  said  in  conclusion  that  in  incipient 
phthisis  the  remedy  was  not  needed.  Food  and 
air,  with  exercise  and  rest  appropriately  alter- 
nated— in  other  words  nutrition,  with  the  aid  of 
creosote,  iodoform  and  a  few  other  drugs  at  suit- 
able times  limited  the  spread  of  the  disease  and 
brought  about  recovery  in  all  cases  where  recov- 
ery was  possible.  Those  highly  susceptible  did 
not  recover,  but  had  their  lives  greatly  prolonged. 
Injection  of  iodine  or  other  medicaments,  as  re- 
commended by  Dr.  Shurly,  might  prove  to  be  of 
assistance.  The  speaker  was  now  making  some 
observations  with  Shurly's  method.  In  acute 
miliary  tuberculosis,  or  in  chronic  phthisis  with 
large  cavities,  Koch  himself  had  said  that  his 
remedy  was  counter-indicated. 

Dr.  Cohen  therefore  limited  its  use  to  appro- 
priate cases  of  lupus  and  joint-disease,  or  other 
external  lesions  whose  course  and  duration 
proved  the  patient  to  be  only  moderately  suscep- 
tible. It  had  been  said  that  the  death-rate  was  only 
1  per  cent.,  85  cases  in  8,500,  but  what  physician 
would  dare  to  prescribe  opium,  arsenic,  or  even 
quinine  indiscriminately,  if  it  killed  one  patient 
out  of  every  hundred?  Furthermore,  if  the  pro- 
portion of  deaths  to  injections  in  phthisis  alone 
were  considered,  it  would  be  found  to  reach  a  far 
more  alarming  percentage.  For  the  present,  at 
least,  he  did  not  hesitate  to  declare  the  use  of 
Koch's  remedy  in  phthisis  a  practice  full  of  dan- 
ger. 


THE  CLINIC. 


A   CLINICAL   LECTURE    ON    INSANITY. 

Delivered  at  the  Insane  Hospital.  Dunning,  III.,  to  the  Students  of  the 
Woman's  Medical  College  of  Chicago. 

BY  DANIEL  R.  BROWER,  M.D., 

PROFESSOR  OF  DISEASES   OF  THE   NERVOUS   SYSTEM    DIDACTIC  «D 
CLINICAL.  IN   THE   WOMAN'S   MEDICAL   COLLEGE;   PROFESSOR  OF 
MENTAL  DISEASES  IN  RUSH    MEDICAL  COLLEGE;   PROFESSOR 
OF  DISEASES   OF  THE   NERVOUS   SYSTEM  IN  POST-GRADU- 
ATE  SCHOOL,   CHICAGO,   ILL. 

[Reported  by  Elizabeth  H.  Trout.  M  d    Assistant  to  the  Chair  of 
Nervous  Diseases,  Woman's  Medical  College,  Chicago.] 

Case  1.  Melancholia. — The  delusions  of  melan- 
cholia, as  we  have  told  you,  are  of  a  very  depress- 
ing character.  This  woman,  you  will  see  at  a 
glance,  is  perfectly  miserable.  Her  delusions  are 
of  the  religious  type,  as  they  frequently  are.  All 
varieties  of  this  disease  have  the  fundamental 
character  of  melancholia,  viz. :  the  depressed  emo- 
tional state,  as  their  essential  feature. 

The  temperature  in  this  case  is  normal,  which 
is  unusual.  In  acute  melancholia  the  tempera- 
ture is  generally  below  normal. 

Case  2. — Here  is  a  case  showing  the  character- 
istic position  that  these  patients  assume  in  the 
early  stage.  The  head  is  bowed  upon  the  chest, 
the  eyes  drooped,  the  expression  thoughtful.  She 
is  apparently  in  deep  meditation,  she  evidently 


372 


A  CLINICAL  LECTURE  ON  INSANITY. 


[March  14. 


has  some  weighty  matters  on  her  mind.  She  never 
speaks.  Her  temperature  is  depressed,  as  is  usual 
in  these  cases.  After  the  melancholia  has  existed 
for  some  time,  if  the  patient  becomes  excited  the 
temperature  will  not  be  subnormal.  An  interest 
ing  feature  of  this  case  is,  that  it  is  the  outgrowth 
of  lactation.  We  have  connected  with  the  life  of 
woman  the  insanity  of  pregnancy,  of  the  puerpe- 
ral state,  and  of  lactation.  The  insanity  of  lacta 
tion  usually  manifests  itself  as  is  illustrated  here. 
The  delusions  are  of  a  depressing  character.  The 
insanity  of  pregnancy  is  usually  of  this  type  also, 
while  that  arising  out  of  the  puerperal  period  is 
generally  maniacal. 

The  depressing  influences  surrounding  the  preg 
nant  state,  and  the  physical  exhaustion  resulting 
from  lactation,  have  doubtless  a  great  deal  to  do 
with  these  cases  assuming  this  type  of  insanity. 
Women  in  these  conditions  suffer  from  insomnia, 
impaired  appetite,  disturbances  of  digestion,  etc. 
There  are  many  important  etiological  factors. 
The  prognosis  is  less  favorable  than  that  of  mania. 

Cases 3  and  /.  Mania. — Here  are  two  cases  of 
puerperal  insanity ,  usually  so  called  if  it  occurs  dur- 
ing thefirst  six  weeks  of  parturition.  It  is  a  form 
of  mania.  Note  the  difference  in  expression  and 
attitude  from  the  cases  we  showed  you  a  moment 
ago.  The  head  here  is  held  up ;  see  the  constant 
play  of  the  facial  muscles  and  the  activity  of  the 
entire  body.  The  delusions  of  these  cases  are  of 
the  happier  type  :  expansive  delusions.  The  cir- 
culation is  quickened,  the  pulse  is  1 20.  Note  the 
contrast  to  the  absolute  rest  and  quiet  of  the  cases 
of  melancholia  just  shown  you.  The  insanity  of 
the  puerperal  period  is  the  most  fortunate  form  of 
insanity  to  encounter.  The  proportion  of  recov- 
eries is  about  80  per  cent.  They  are  to  be  treated 
by  such  remedies  as  will  control  the  violence  of 
their  activities,  and  depress  their  nerve  centres, 
and  by  nutrients  and  eliminants.  These  patients 
must  have  a  large  amount  of  food  and  rest.  Eight 
or  nine  hours  of  the  twenty-four  should  be  spent 
in  sleep,  and  to  produce  this,  some  form  of  nar- 
cotic should  be  given  :  chloral  or  sulfonal.  The 
latter  acts  well  in  many  cases.  You  must  give 
some  sleep-producing  agent  that  will  accomplish 
the  result  without  too  much  depression  of  the  cir- 
1  ulation.  Sulfonal  is  not  commonly  a  cardiac  de- 
pressant, and  does  not  usually  interfere  with  the 
nutritive  processes.  The  deodorized  tincture  of 
opium  is  often  beneficial..  Preparations  of  mor- 
phia are  sometimes  very  valuable  in  these  cases. 
Some  of  the  opiates  will  produce  sleep  better  than 
such  depressants  as  bromides  or  chloral.  Tonics 
are  to  be  administered  judiciously  :  preparations 
of  malt,  iron,  strychnia,  quinine  and  the  hypo 
phosphites.  The  food  should  be  of  a  very  nutri- 
tious character  and  easily  digested — milk,  eggs, 
beef  extract,  etc.  You  must  bear  in  mind  the 
fart  that  the  exciting  cause  may  be  in  the  uterus 
or  its  appendages;  as  subinvolution  or  partial  in 


version.  In  fact,  you  should  examine  carefully 
every  organ  in  the  body  and  correct,  if  possible, 
any  departure  from  the  physiological  standard. 

In  melancholia  we  find  a  sluggishness  of  the 
alimentary  tract.  These  patients  need  laxatives 
much  more  than  do  the  manias.  The  aloetic 
purgatives  are  the  most  useful  here.  The  food 
also  in  melancholia  should  be  easily  assimilable, 
and  if  the  patients  refuse  to  eat,  as  they  frequent- 
ly do,  no  time  should  be  lost  in  resorting  to  arti- 
ficial feeding.  The  nutritive  processes  are  very 
much  disturbed,  and  to  allow  these  patients  to  go 
without  food  would  be  very  injurious.  The  prompt 
use  of  forced  feeding,  in  some  cases,  hastens  the 
return  of  the  physiological  habit.  The  medicine 
can  be  administered  at  the  same  time.  The  proper 
treatment  of  lithaemia  and  allied  conditions,  if 
present,  should  be  prompt,  and  may  be  remedial. 
Patients  whose  temperature  is  subnormal  should 
bs  kept  in  warmer  apartments  than  those  of  the 
sthenic  type.  These  patients  need  cardiac  and 
general  stimulants  also. 

Case  5. — Here  is  a  case  of  acute  mania  of  three 
or  four  months'  duration.  The  facial  expression 
is  one  of  pleasure.  The  activity  of  the  muscles 
of  the  face  and  body  is  very  great.  The  circula- 
tion is  quickened.  The  delusions  are  of  the  ex- 
pansive type,  as  with  the  puerperal  cases. 

Case  6. — This  is  also  a  case  of  mania.  She  has 
been  in  this  condition  a  long  time,  she  is  a  klep- 
tomaniac. The  tongue  is  coated,  digestion  dis- 
ordered, the  pulse  quickened,  but  not  to  the  same 
extent  as  in  the  case  just  shown  you.  You  will 
also  notice  that  the  activity  of  the  muscles  is  not 
so  great. 

Case  7.  Chronic  Melancholia. — I  will  call  your 
attention  in  this  case,  to  the  peculiar  appearance 
of  the  finger-nails.  Fothergill  calls  it  the  "  gouty 
finger-nail."  It  is  well  shown  here;  it  consists 
of  rough,  somewhat  irregular,  whitish  ridges, 
running  longitudinally.  You  will  also  notice  in 
this  case  the  discoloration  of  the  hands  and  feet, 
due  to  some  error  of  the  circulation.  The  hy- 
peraemia  is  probably  due  to  degeneration  of  the 
blood-vessels.  These  defects  accompanying  in- 
sanity are  very  interesting.  They  serve  to  teach 
us  an  important  fact,  viz.:  that  insanity  is  a  dis- 
ease of  the  whole  organism ;  no  person  can  be 
insane  without  having  more  or  less  disturbance 
of  the  whole  organization.  "A  person  who  is 
insane  is  insane  to  his  finger  ends."  Such  is  the 
intimate  connection  between  the  brain  and  the 
periphery,  that  it  is  impossible  to  have  an  amount 
of  disturbance  of  the  brain  sufficient  to  produce 
insanity  without  great  physical  or  constitutional 
disturbance,  and  more  or  less  want  of  nutrition 
all  over  the  body.  To  find  a  person  of  insane 
mind  with  a  perfectly  healthy  organism  would  he 
an  impossibility.  The  "  Fothergill  fingernails" 
show  disturbed  nutrition  and  a  defective  circula- 
tion.     The  temperature  is  subnormal,  and  her  de- 


i89i.] 


A  CLINICAL  LECTURE  ON  INSANITY. 


373 


lusiuns  are  of  'Ik-  most  depressing  character.    The 
peculiarity  "I  the  mental  disturbance  in  this  case 
is  that  the  woman  does  not  talk  at  all.     It  is  a; 
case  of  chronic  melancholia  of  manyyears 
Big.      There  is  considerable   malformation  of  the 
head  here,  excess  of  development  of  the  left  side  J 
Compared  with  the  right.     These  defects  arc  very 
common,  especially  in  monomania.     Take  a  pic 
tore   of  first    <  ■  n i ■   side   of  the  head  and  then   the 
other,    and   you  have  really   pictures  of  two  in 
dividuals. 

Cases  8  and  p. — Here  are  two  excellent  cases 
of  chronic  melancholia.  You  see  that  they  as- 
sume the  characteristic  attitude:  the  head  bowed 
upon  the  chest,  the  hands  resting  upon  the  knees. 
They  also  show  the  disordered  circulation,  the 
peculiar  disturbance  so  common  in  these  cases; 
a  congestion  of  the  capillary  system.  I  presume 
that  for  a  pathological  basis  in  many  of  these 
cases  there  is  a  similar  condition  of  malnutrition 
of  the  brain,  such  as  you  see  so  well  marked  in 
the  hands  of  these  men 

Melancholia  remains  as  such  for  man}'  years. 
All  cases  both  of  mania  and  melancholia  are 
tending  either  towards  recover}'  or  towards  that 
other  form  of  insanity  to  which  we  called  your 
attention  a  few  days  ago,  dementia.  Both  these 
cases  are  nearing  the  latter  type.  This  condition 
is  recognized  by  the  loss  of  memory,  the  untidy 
habits,  etc.  These  patients  become  more  and 
more  slovenly  until  finally  they  cease  to  pay  any 
attention  to  their  personal  appearance,  and  be- 
come exceedingly  negligent  and  dirty  in  their 
habits.  During  the  active  stage  they  are  simply 
depressed,  they  have  the  same  mental  capacity 
that  they  ever  had,  only  they  are  under  the  influ- 
ence of  their  delusions.  What  is  simply  func- 
tional in  the  beginning  becomes  organic.  The 
brain  cells  are  slowly  destroyed,  they  atrophy, 
and  these  people  literally  lose  their  minds  and 
become  demented.  This  we  call  secondary  or 
terminal  dementia.  These  cases  are  all  more  or 
less  hopeful  until  the  memory  begins  to  fail;  when 
this  occurs  and  dementia  is  established  there  is 
no  possibility  of  recovery. 

Case  10.  Monomania. — Here  is  a  case  with  a 
fixed  and  limited  delusion.  This  woman  is  under 
the  impression  that  she  is  engaged  and  is  to  be 
married.  She  prepared  her  trousseau.  There  is 
no  rational  basis  for  her  delusion.  The  man  she 
expected  to  marry  was  ignorant  of  the  whole  af- 
fair. Along  with  this  form  of  insanity  that  takes 
the  neurotic  character,  there  are  certain  physical 
defects.  These  cases  have  been  recently  termed 
"paranoias."  They  come  into  the  world  physi- 
cally defective,  but  their  mental  derangement  is 
not  usually  manifest  until  puberty.  The  mind  is 
enfeebled,  but  they  are  not  imbeciles ;  they  may 
possess  considerable  influence.  Their  delusions 
are  systematized  and  are  often  of  the  exalted  type, 
in  the  way  of  pride   or  grandeur.      In   this  case 


no  physical  defect  apparent,  and  outside 
of  this  one  delusion,  she  seems  to  he  all  right. 
These  cases  form  a  large  percentage  of  insanities. 
It  is  an  embarrassing  class,  as  it  is  difficult  to  ap- 
ply the  tests  of  insane  delusions.  Von  will  often 
tie  perplexed  as  to  these  cases  of  monomania. 
t  was  one,  Peter  the  Hermit,  who  led  the 
Crusades,  was  probably  another,  Guiteau  another. 
The  man  who  shot  at  Edwin  Booth  was  probably 
one  also.  His  delusion  was  that  Booth  was  his 
father  and  was  neglectir.g  him  ;  acting  upon  this, 
his  whole  life  was  shaped  at  redress.  He  followed 
him  about  from  place  to  place,  annoying  him 
greatly,  and  finally  shot  at  him  in  McYicker'.s 
Theatre,  in  this  city.  Outside  of  this  particular 
line  of  mental  derangement,  he  seemed  to  be  per- 
fectly rational.  He  imagined  he  possessed  great 
dramatic  ability,  and  endeavored  to  secure  an  en- 
gagement with  one  theatre  company  or  another. 
These  people  frequently  have  the  power  of  hiding 
their  delusions  ;  you  may  study  them  for  weeks 
without  finding  them  out. 

Cases  ii,  12  and  /?.  Epileptic  Insanity. — Here 
are  three  epileptic  cases.  Epilepsy  is  a  disease  of 
the  brain.  All  epileptics  are  drifting  towards  in- 
sanity. It  is  a  possibility  with  any  of  them,  al- 
though it  occurs  much  more  frequently  with  the 
petit  mal  type  than  it  does  with  that  of  grand 
mal.  Petit  mal  attacks  are  just  as  serious,  if  not 
more  so,  than  grand  mal,  on  account  of  the  fre- 
quency of  their  occurrence.  A  patient  will  have 
several  of  these  attacks  of  petit  mal  in  one  day, 
thus  keeping  the  brain  in  a  state  of  commotion. 
Insanity  that  grows  out  of  epilepsy  is  most  per- 
plexing. All  these  insane  epileptics  have  defec- 
tive inhibition.  They  are  impulsive,  liable  to 
sudden  outbursts.  In  the  interval  between  their 
attacks  they  are  often  the  most  useful  people  in 
the  hospital — kind  and  industrious.  During  their 
paroxysms  they  are  often  very  dangerous.  These 
epileptic  manifestations  are  usually  preceded  and 
followed  by  a  state  of  excitement.  Irritability 
and  epilepsy  go  hand  in  hand  ;  almost  all  these 
cases  are  irritable  above  the  average  person,  they 
are  also  vacillating.  They  are  the  most  unsatis- 
factory patients  the  physician  has  to  deal  with. 
They  will  be  under  your  treatment  for  awhile, 
then  get  discouraged,  and  travel  from  one  doctor 
to  another.  They  lack  fixedness  of  purpose,  are 
irritable  always,  and  may  be  exceedingly  violent 
during  their  paroxysms.  This  case  shows  well 
■  the  asymmetry  of  the  face,  and  also  a  deformity 
of  the  chest. 

Case  14. — Here  is  an  interesting  case  of  epilep- 
tiform insanity  showing  discoloration  of  the  face 
— "argerism."  This  is  caused  by  a  persistent 
use  of  the  nitrate  of  silver.  He  took  the  drug  for 
j  five  or  six  years.  In  using  this  drug  it  should 
never  be  administered  for  more  than  three  months 
at  a  time,  and  the  amount  given  should  not  ex- 
ceed 90  grs.,  1  gr.  per  diem.     This  will  produce 


374 


A  CLINICAL  LECTURE  ON  INSANITY. 


[March  14, 


whatever  benefit  is  to  be  derived  from  the  drug. 
After  a  long  interval  you  can  repeat  the  treat- 
ment. In  this  case  no  benefit  was  derived  from 
its  use,  nor  is  there  any  to  be  expected  except  in 
those  cases  that  are  stomachic  in  their  origin. 

Case  15.  Hemiplegia. — This  case  you  see  has 
lost  the  power  of  the  arm.  There  is  some  con- 
traction of  the  fingers  and  also  of  the  foot.  There 
is  also  exaggerated  patellar  tendon  reflex,  and 
aphasia.  She  understands  perfectly  well  what 
she  wants  to  say,  but  she  cannot  say  it.  It  is  a 
case  of  amnesic  aphasia ;  the  power  of  speech  is 
lost  because  of  the  loss  of  memory  of  words.  Ar- 
ticulation is  not  lost.  The  doctor  tells  us  that 
there  was  a  blocking  of  the  internal  saphenous 
\rein.  The  case  may  be  one  of  embolism,  but  be- 
cause she  has  lost  the  power  of  expressing  her 
ideas  she  was  supposed  to  be  insane.  There  is 
no  other  evidence  of  insanity.  In  right-sided 
hemiplegia  there  is  always  some  aphasia,  and 
when  the  lesion  is  pronounced  it  cuts  off  the 
speech  centre  from  the  parts  below.  Such  a  con- 
dition as  this  might  serve  to  impress  some  people 
with  the  idea  of  insanity.  The  case  is  of  interest 
to  us  only  as  one  of  mistaken  diagnosis.  She  is 
not  insane,  but  it  serves  to  show  us  the  necessity 
of  making  a  careful  examination. 

I  will  now  call  your  attention  to  another  type 
of  insanity  :  Paretic  Dementia — General  Paralysis 
of  the  Insane.  This  disease  usually  occurs  in  the 
prime  of  life,  and  is  much  more  frequent  among 
males  than  females.  In  females  the  disease  runs 
a  slower  and  more  even  course ;  the  delusions  are 
not,  as  a  rule,  so  expansive,  nor  the  remissions 
so  abrupt  as  in  the  male.  We  have  two  varieties: 
the  ascending  type,  beginning  in  the  spinal  cord, 
and  the  descending  type,  beginning  in  the  cere- 
brum. The  average  duration  of  the  disease  is 
about  three  years,  although  it  may  terminate 
much  sooner  or  extend  over  a  period  of  many 
years.  All  cases  of  paretic  dementia  have  many 
symptoms  in  common :  the  peculiar  thickness  of 
speech,  the  inequality  of  the  pupils  and  their  im- 
mobility to  light,  the  clumsy  walk,  and  their  un- 
systematized delusions,  usually  of  the  expansive 
type,  of  wealth  or  grandeur. 

Case  16.  Female. — This  woman,  you  see,  has 
the  depressive  form  of  delusion.  She  imagines 
that  she  has  been  greatly  wronged.  It  is  very 
uncommon  to  find  the  delusions  as  depressive  as 
they  are  in  this  case,  even  among  women.  Von 
will  notice  here  the  peculiar  defect  in 
Later  along  this  defect  becomes  aggravated  by 
the  increasing  amnesia  of  the  patient,  causing  the 
frequent  use  of  the  wrong  consonant.  A  char- 
acteristic feature  of  the  later  stages  is  the  unnec- 
essary movements  of  the  lips  and  tongue,  associ- 
ated with  those  of  other  muscles,  upon  efforts  at 
speaking:  the  nostrils  dilate  and  contract  alter- 
nately, the  corrugation  of  the  occipito- frontal  is 
muscle  increases,  and  after  all  these  spasmodic 


and  exaggerated  movements,  the  word  is  thrown 
out  as  though  it  had  to  force  its  way  through 
some  impediment.  This  case  shows  some  ine- 
quality of  the  pupils,  and  has  exaggerated  patel- 
lar tendon  reflexes,  showing  that  the  spinal  cord, 
as  well  as  the  brain,  is  involved  in  the  degeneracy. 

Case  i".  Male. — Here  is  another  case  of  pa- 
retic dementia.  This  man  says  there  is  nothing 
the  matter  with  him.  He  feels  first-rate.  He 
tells  us  he  is  worth  $30,000;  he  is  happy,  satis- 
fied with  himself  and  his  surroundings.  Note 
the  similarity  in  speech  in  this  case  and  the  pre- 
ceding one.  We  have  here,  also,  inequality  of 
the  pupils — contracted,  in  this  case;  they  are  also 
immobile.  The  delusions  of  this  man  are  of  the 
character  usual  in  this  disease :  the  expansive, 
happy  type.  These  people  simply  assert  their 
wealth,  or  grandeur,  or  whatever  it  may  be;  they 
do  not  reason  about  it ;  their  delusions  are  all 
unsystematized.  Compare  the  appearance  of  this 
man  to  that  of  the  woman.  The  mental  deterio- 
ration is  just  as  serious  in  one  case  as  the  other. 
The  man,  you  see,  has  a  satisfied,  happy  look, 
while  the  woman  is  perfectly  miserable. 

Case  18.  Male. — Here  is  another  typical  case. 
He  says  he  is  not  so  well  as  he  expects  to  be,  but 
he  imagines  he  can  jump,  box  and  spar.  He  also 
thinks  he  is  a  graduate  of  Yale,  and  valedictorian 
of  the  class.  You  see  he  is  self-satisfied  and 
happy.  Notice  here  the  same  disturbance  of 
speech,  the  same  pupillary  phenomena,  and  the 
same  exalted  character  of  the  delusions. 

Case  ip.  Male. — This  man  imagines  he  owns 
all  the  real  estate  in  the  world,  all  the  horses,  and 
every  stick  of  wood.  He  has  the  same  air  of 
satisfaction  and  content,  and  all  the  symptoms 
enumerated  in  the  two  preceding  cases. 

Case  20.  Male. — This  man  tells  us  he  is 
wealthy ;  he  imagines  he  can  sing  and  dance. 
You  see,  he  is  happy  and  contented.  He  has  the 
unequally  dilated  pupils,  the  clumsy  walk,  and 
the  same  defective  speech. 

Case  21.  Male. — Here  is  another  wealthy  (?) 
paretic.  He  owns  the  State  of  California.  He 
has  the  same  characteristic  symptoms  shown  you 
in  these  other  cases.  The  tremor  of  the  tongue 
is  present,  in  a  greater  or  less  degree,  in  most  of 
these  cases. 

Case  22.     Male. — This  is  a  recent  case. 

(To  patient):      "How  is  your  health?" 
Patient:     "  Perfect,  doctor — I'm  first-rate, 
Prof.  B.:     "How  long  have  you  been  1 
Patient:      "  Throe  or  four  weeks." 

Prof.  B.:     "  Why  did  yon  come  here?  " 

Patient:  "I  ran  for  Senator  .it  the  election.  I  had  no 
ime  around  for  some  'stuff.1  I  had 
none,  and  they  attacked  the  house  and  broke  the  win- 
dows. Some  one  came  to  protect  me,  and  took  me  to 
the  Town  Hall;  next  day  my  house  was  set  afire  and 
burned.  That  disturbed  me,  powerful.  Some  of  my 
children  came  down  to  tell  me  about  it.  and  were  run 

■  i\  ei   by  a  train." 

Prof   I'..:     "How  nn  :ii\  were  von  elected 

by?" 


iSyl.] 


MEDICAL  PROGRESS. 


375 


Patient:        I  don't  know,  exactly,    lit  was  pretty  fair." 
Prof.  B   (to  class).     "This  is  all  a  delusion." 
Patient:     I  ill  no,  it  is  not." 

Prof.  I'..:     "Will,  your  assistance  in  the 

Legislat  a 
Patient:     "  Vov  shall  ba  .     it,  v,  ith  pie 

During  the  early  stage  of  this  disease,  depres- 
sive  delusions  may  occur,  as  in  this  case.  The 
detect  in  speech  is  noticeable  in  this  case,  and 
there  is  some  inequality  of  the  pupils. 

The  prognosis  of  this  disease,  while  ii". 
lutely  hopeless,  is  bad.  Treatment  is  of  service 
only  in  the  early  stage.  If  the  condition  is  rec- 
ognized during  the  prodromal  period,  you  may 
possibly  be  of  some  service  to  them.  In  the  cere- 
bral form,  this  stage  presents  as  its  most  notable 
sign,  a  change  of  character.  The  heretofore  care 
ful  business  man  becomes  negligent,  the  kind 
husband  and  father,  indifferent  or  irritable.  The 
memory  is  early  affected  and,  at  first,  relates  to 
trifles.  As  this  period  progresses,  more  serious 
omissions  and  errors  occur.  He  becomes  irregu- 
lar in  his  habits,  forgets  his  appointments,  and 
along  with  these  symptoms  the  morals  begin  to 
totter.  The  patient  forgets  his  moral  obligations 
to  himself  and  to  his  family.  His  walk  becomes 
less  steady  and  regular.  The  legs  are  thrown 
wider  apart  in  order  to  widen  the  base  of  support. 
During  this  stage  the  patient  may  be  more  or  less 
depressed.  At  the  close  of  this  period  the  depres- 
sion, if  it  existed,  disappears,  and  delusions  of 
grandeur  take  its  place,  often  coupled  with  ex- 
travagant expenditures.  There  is  also  an  in- 
crease of  all  the  physical  signs.  This  excited 
condition  may  last  a  few  hours,  days  or  weeks, 
when  a  remission  occurs  and  the  patient  appar- 
ently recovers.  In  the  majority  of  cases,  tremor 
of  the  hands,  inequality  of  the  pupils  and  a  slight 
speech  defect  are  more  or  less  prominent  during 
the  remissions,  which  may  last  from  three  or  four 
months,  to  years.  With  every  exacerbation,  the 
physical  signs  increase,  and  the  mental  deteriora- 
tion becomes  more  manifest.  When  the  disease 
is  recognized,  the  patient  should  at  once  be  put 
to  rest,  physically  and  mentally.  Mild  alteratives 
combined  with  tonics  may  be  of  some  service. 
The  blood  supply  to  the  brain  should  be  regu- 
lated, by  such  remedies  as  bromides,  ergot,  etc. 
Narcotics  of  a  non-depressing  character  should 
be  used  if  necessary,  and  the  diet  should  be  care- 
fully attended  to.  Nutritious  and  easily  digested 
food  should  be  freely  administered.  Massage  and 
the  constant  galvanic  current  are  also  of  great 
value. 


Small- Pox. — Authentic  reports  indicate  quite 
a  widespread  existence  of  this  disease  in  Texas 
— that  is,  that  it  has  appeared  at  a  considerable 
number  of  points  throughout  the  State.  Two 
cases  are  also  reported  to  have  been  found  in 
New  York  City. 


MEDICAL    PROGRESS. 


Therapeutics  nnd  Pharmacolog-y. 

Inhalations  of  Pekoxidk<>i   Hydrog 
Gabrii.0  rnides,    1891),  has 

tried  the  inhalation  of  peroxide  of  hydrogen  in  a 
large  number  of  cases  of  affections  of  the  larynx 
and  trachea.  He  begins  ordinarily  with  a  one 
per  cent,  solution  which  is  gradually  incn 
strength  ;  in  tuberculosis  he  recommends  a  be- 
ginning strength  of  five  per  cent.  He  has  em- 
ployed the  remedy  in  a  large  number  of  condi- 
tions affecting  the  respiratory  organs,  acute  and 
chronic  laryngitis,  trachitis  and  bronchitis. 

The    Treatment    of    Addison's   D: 
with  Koch's  Remedy. — Dr.   Hermann   Len- 
hartz  (Sonderheft  der  Therap.  Monatske/te,  Janu- 
ary, 1891),  contributes  an  exceedingly  interest- 
ing case  of  this  disease  that  was  apparently  cured. 

The  writer  thinks  that  the  most  frequent 
change  in  the  adrenals  in  Addison's  disease  con- 
sists of  a  caseous  tubercular  degeneration.  In 
the  152  cases  collected  by  Greenhow  changes 
were  confined  to  the  supra- renals  in  10 1,  the 
bulk  of  these  cases  presented  the  typical  picture 
of  tubercular  caseous  degeneration.  It  is  appar- 
ent that  in  any  case  of  morbus  Adisonii  a  local- 
ized tubercular  process  may  be  present  in  the 
adrenals,  and  therefore  in  the  writer's  judgment 
the  use  of  Koch's  lymph  in  these  cases  is  at  least 
justifiable. 

The  patient,  23  years  of  age,  came  from  a 
healthy  family  of  eight  children.  On  December 
24,  was  taken  ill,  with  marked  debility,  loss  of 
appetite,  headache  and  fever  (?),  was  confined  to 
the  bed  until  the  16th  of  January.  One  of  the  most 
prominent  symptoms  was  frequent  vomiting;  diar- 
rhoea was  occasionally  present,  alternating  with 
constipation.  From  the  middle  of  January  un- 
til the  beginning  of  May  the  patient  was  com- 
paratively well  though  he  complained  of  weak- 
ness and  had  occasional  vomiting.  A  Carlsbad 
cure  was  ordered,  but  only  increased  the  weak- 
ness of  the  patient  and  the  frequent  vomiting; 
at  this  time  he  was  in  bed  more  or  less,  had  daily 
vomiting  with  alarming  and  frequent  attacks  of 
sudden  weakness.  The  writer  saw  the  patient 
first  on  the  22d  of  October  last,  when  he  was 
emaciated  and  greatly  reduced  in  strength.  The 
most  noticeable  appearance  at  this  time  was  the 
intense  bronzing  of  the  skin  especially  marked 
over  the  shoulders,  along  the  dorsal  spines  and 
on  the  trochanters  ;  in  marked  contrast  to  the 
dirty  vellow  color  of  the  face  was  the  bright 
glistening  white  of  the  sclera,  of  the  eye-ball. 
Punctiform  and  linear  grey  and  bluish-black  pig- 
mentation was  found  on  the  lips,  inner  side  of 
the  cheeks  and  on  the  tongue.  The  lungs  and 
heart   were  normal,   the   pulse  small,   and   often 


376 


MEDICAL  PROGRESS. 


[March  14, 


uneven  ;  with  some  tenderness  in  the  epigastric 
region  constituted  the  clinical  picture  ;  no  other 
abnormalities,  such  as  glandular  enlargements, 
etc.,  could  be  made  out.  At  first  a  strict  dietetic 
cure  was  employed,  under  which  the  patient  im- 1 
proved  in  weight  and  the  vomiting  ceased.  On  | 
November  16,  the  first  injection  was  given,  which 
was  followed  by  a  typical  reaction.  On  Novem- 
ber 20,  a  second  injection  was  given,  followed  by 
reaction  eighteen  hours  later.  On  November  24, 
an  injection  of  two  milligrams  was  used  that 
wyas  followed  by  marked  reaction  eight  hours 
later.  The  fifth  injection,  of  three  milligrams 
produced  the  most  marked  reaction,  the  tempera- 
ture reaching  400  C,  and  such  a  degree  of  pros- 
tration as  to  cause  much  anxiety,  but  as  the 
author  remarks  "  it  was  the  only  possible  method 
of  saving  the  patient"  so  he  continued  the  treat- 
ment. On  December  5,  the  sixth  injection  of 
3.5  milligrams  was  given,  the  temperature  rose 
to  39.  i°  C,  but  the  appetite  and  sleep  were  not 
disturbed,  while  vomiting  did  not  occur  as  it  had 
previously  with  some  of  the  larger  doses.  The 
seventh  injection  was  given  on  December  9,  four 
milligrams  were  used,  but  it  did  not  cause  dis- 
turbance of  the  general  condition,  and  only  the 
slightest  rise  in  temperature  from  38°,  to  38.  1°  C. 
December  11,  15  and  20  injections  were  employed 
consisting  of  5,  8  and  1 1 . 5  milligrams  respectively. 
These  did  not  cause  the  slightest  local  or  gpneral 
reaction.  From  day  to  day  the  general  condition 
improved,  within  the  last  fourteen  days  an  in- 
crease in  weight  of  five  pounds.  The  appetite 
is  good,  no  vomiting,  voice  strong,  in  short  he 
presents  the  appearance  of  one  convalescent  from 
an  acute  infectious  disease.  The  pigmentation 
remained  unchanged. 

The  author  closes  with  a  brief  resume  of  his 
conclusions,  which  are  that  this  method  is  of 
great  diagnostic  value,  especially  in  obscure  con- 
ditions such  as  these.  He  is  of  course,  doubtful 
of  the  permanency  of  the  cure,  and  insists  that 
from  time  to  time  the  lymph  should  be  injected 
in  large  doses.  He  especially  calls  attention  to 
the  fact  that  the  pulse  of  this  patient  did  not 
rise  with  the  temperature  as  it  usually  does. 
This  he  attributes  to  a  direct  inhibitory  action 
upon  the  vagus,  through  the  local  action  in  the 
adrenals. 

Koch's  Treatment. — Dr.  Alessandro 
Borghkkini  gives  an  account  (Lo  Sperimentale, 

January  15,  1891),  of  the  results  of  Koch's  treat- 
ment in  fourteen  cases  of  tuberculosis  of  the  in- 
ternal organs  and  two  cases  of  lupus  in  the 
Medical  Clinic  at  Padua.  Of  the  former,  five 
were  affected  with  pulmonary  phthisis,  seven 
with  both  pulmonary  and  laryngeal  tubercle, 
while  two  suffered  from  tuberculous  disease  ol 
the  intestines  and  bones  as  well  as  of  the  lungs 
and  larynx.      In  all  the  cases,  careful  observations 


were  made  of  the  patient's  general  condition  be- 
fore, during  and  after  the  treatment.  Every  day 
the  sputum,  the  urine,  and  the  blood  were  care- 
fully examined.  The  injections  were,  as  a  rule, 
made  every  second  day,  the  initial  dose  being 
from  0.00 1  to  o.oo2g.,  and  the  amount  being 
graduall}'  increased  by  1  or  2  milligrams  at  a 
time.  The  largest  dose  given  was  o.oogg.  The 
reaction  had  the  same  general  characters  which 
are  now  familiar,  but  in  two  cases  in  which 
pyrexia  had  not  previously  been  present,  the 
fever,  which  was  of  intermittent  type,  still  per- 
sisted at  the  date  of  the  report  (eight  days  after 
the  last  injection).  In  two  cases  the  urine  showed 
traces  of  albumen,  which  soon  disappeared.  In 
the  larynx  the  local  process  became  more  acute 
after  the  first  injections,  this  effect  gradually 
diminishing  till  it  ceased  altogether  ;  the  local 
condition  was  very  considerably  modified,  while 
the  subjective  symptoms  were  greatly  relieved, 
and  in  some  cases  entirely  removed.  In  the  lung, 
the  reaction  consisted  in  a  series  of  symptoms  at 
the  seat  of  the  primary  focus  of  disease,  recalling 
pneumonic  hepatization.  The  resolution  of  the 
hepatized  tissue  was  sometimes  speedy,  sometimes 
slow.  When  it  took  place  rapidly,  resonance, 
which  was  before  diminished,  became  exagger- 
ated, but  there  always  remained  certain  local 
signs,  such  as  rales,  harsh  breathing,  prolonged 
expiration.  In  only  one  case  did  the  physical 
signs  entirely  disappear.  With  the  modification 
in  the  physical  signs,  the  symptoms  were  corre- 
spondingly mitigated  ;  the  cough  became  easier, 
the  expectoration  scantier,  and  the  appetite 
keener.  In  some  cases  it  was  noticed  that  the 
local  reaction  in  the  lung  was  accompanied  by 
vaso  motor  disturbance  in  the  cheek  of  the  same 
side.  In  nearly  all  cases  diminution  of  the 
haemoglobin  in  the  blood  was  noted  in  the  early 
part  of  the  treatment,  but  this  loss  was  speedily 
made  good,  and  in  three  cases  there  was  after  a 
time  increase  of  haemoglobin.  The  injections 
caused  slight  haemoptysis  in  patients  who  had 
previously  had  attacks  of  bleeding  from  the 
lung.  As  a  rule,  the  bacilli  did  not  diminish  in 
number,  but  changes  in  form  were  sometimes  ob- 
served. Borgherini  sums  up  his  results  as  fol- 
lows: In  four  cases  in  which  the  disease  was  very 
mild  there  was  "some  slight  favorable  change  in 
the  physical  conditions  of  the  lung  and  in  the 
general  condition."  Other  factors,  such  as  careful 
hygiene,  good  nourishment,  etc.,  may,  however, 
have  contributed  to  this.  In  the  other  cases  the 
morbid  process  was  not  modified  in  any  way  by 
the  treatment.  With  regard  to  the  lupus  cases, 
in  one  (a  girl,  aged  8),  after  treatment  for  about 
a  month,  the  local  condition  was  somewhat  im- 
proved, but  the  nodules  could  still  be  seen  as 
numerous  as  they  were  before  the  injections  were 
begun,  only  a  little  paler.  In  the  other  1  a  wo- 
man  in  whom    the  disease  was  of  fifteen  years' 


i89i.] 


MEDICAL  PROGRESS. 


377 


standing),  the  injections  did  some  good,  but  the 
reactions  were  so  severe  that  the  treatment  could 
not  be  carried  out  to  the  extent  necessary  to  pro 
duce  any  marked  effect.  In  Borgherini's  hands, 
so  far,  the  injections  have  not  been  attended  with 
any  untoward  result. — British  Med.  Journal. 

Koch's   Remedy  and  its   Results. — This 

theme  still  occupies  the  attention  of  several  for- 
eign societies,  notably  the  Berliner  Medicinische 
Gesellschaft  (International  Klinische  Rundschau, 


groups  it  among  the  drugs  and  preparations  used 
for  all  sorts  of  purposes,  but  now  mostly  "anti- 
quated or  obsolete."  Phillips,  however,  in  his 
well  known  work  on  the  "  Vegetable  Kingdom," 
recognizes  that  the  drug  has  a  decided  purgative 
action.  Dr.  Murrell  had  his  attention  drawn  to 
the  subject  a  lew  year-,  ago  by  casually  prescrib- 
ing for  a  man  suffering  from  rheumatism  some 
lozenges  of  guaiac  made  up  with  the  ordinary 
i  black  currants.  The  patient  continued 
to    take    the   lozenges  long    after  the  pains  had 


February  8,  1891).  Prof.  Virchow  (meeting  of  ceased,  and  in  explanation  said  that  they  did  him 
January  28,  1891)  claimed  that  there  was  but  lit-  good  by  acting  on  the  liver  and  bowels.  One  or 
tie  to  add  to  his  report  of  the  last  session  describ- :  two  lozenges  taken  in  the  morning  before  break- 
ing the  action  of  the  remedy  upon   the  internal   fast  acted  as  a  prompt  and  convenient  laxative. 


organs.  He  presented  additional  specimens,  from 
two  patients  who  had  died  in  the  course  of  the 
treatment,  that  showed  fresh  tubercle  in  different 
organs,  in  so  far  confirming  his  earlier  expressed 
opinions. 

Dr.  Lassar  presented  a  young  girl  that,  follow- 
ing a  tubercular  inflammation  of  the  hip,  devel- 
oped a  large  ulcer  on  the  thigh.  After  a  few  in- 
jections with  a  small  dose,  the  sore  cleared  up, 
and  healed,  its  place  being  marked  by  a  smooth 
cicatrix. 

Flatau  reported  a  case  of  laryngeal  tuberculosis 
that  at  first  improved,  but  later  developed  addi 
tional  tubercles  upon  the  vocal  cords. 

Fiirbringer,  out  of  one  hundred  patients,  reports 
forty- six  who  have  been  more  than  two  months 
under  treatment,  of  these  three  no  longer  present 
the  characteristic  symptoms,  fifteen  have  been 
distinctly  improved,  nine  unimproved,  and  five 
have  become  worse,  and  seven  have  died.  Fiir- 
bringer is  of  the  opinion  that  in  florid  phthisis, 
or  those  presenting  marked  hectic,  or  great  weak- 
ness, should  not  be  treated. 

Prof.  Pribram  (  Verein  deutscher  Aerzte  in  Prag.) 
reports  that  sixty  cases  have  been  under  treat 


Following  up  this  clue,  other  patients  suffering 
from  constipation  and  that  train  of  symptoms 
that  are  summed  up  under  "biliousness,"  were 
treated  by  the  same  drug,  and  a  result  equally 
satisfactory  followed  in  many  cases.  For  hospi- 
tal purposes,  the  author  had  a  confection  pre- 
pared containing  10  grs.  of  guaiac  resin  to  a 
drachm  of  honey,  and  this  became  a  popular 
purgative  in  the  hospital,  besides  being  used  with 
other  remedies  in  rheumatism,  sciatica,  tonsillitis 
and  dysmenorrhcea.  The  dose  was  increased  in 
some  cases  to  1  and  even  2  drachms  thrice  daily. 
Taken  in  this  manner,  the  plirgative  and  "anti- 
bilious"  effects  are  very  pronounced  ;  in  one  case 
the  patient  had  fifty  evacuations  in  the  week.  In 
one  case  an  eruption  was  produced,  covering  the 
arms  and  legs,  not  unlike  the  rash  of  copaiba. 
That  this  kind  of  resultant  rash  is  most  uncom- 
mon may  be  gathered  from  the  fact  that  Dr.  Til- 
bury Fox  did  not  remember  to  have  seen  more 
than  one  case  like  it  previously.  Intense  itching 
accompanied  it,  and  it  ceased  soon  after  the  drug 
was  discontinued.  The  guaiac  sometimes  gave 
rise  to  a  sensation  of  burning  in  the  throat:  to 
obviate  this  Dr.  Murrell  frequently  made  use  of  a 


ment    during   the   past   two   months.     Of  these ,  half- ounce  of  malt  extract  as  a  vehicle  for  each 


three,  he  thinks,  may  be  considered  as  cured. 
He  also  notes  several  unfavorable  results  :  in  one 
case   dangerous   haemoptysis,  and   in   another  a 


10  gr.  dose  of  the  drug.  This  worked  well,  and 
may  be  regarded  as  a  kind  of  renaissance  of  the 
old-time  Chelsea  Pensioner,  which  was  compound- 


rapid  extension  of  the  tubercular  process  that  was   ed  of  guaiacum,   rhubarb,  ginger,  sulphur,   and 

some  other  less  active  ingredients,  but  they  both 
have  an  attractiveness  to  those  veteran  cases  of 
the  hospital  and  dispensary  that  complain  of  tor- 
pid liver  and  bilious  attacks.  The  author  believes 
that  the  drug  will  prove  itself  a  very  satisfactory 
laxative  or  purgative,  according  to  the  dose  em- 
ployed. It  is  "possible,  also,  that  if  the  drug 
were  triturated  with  cream  of  tartar,  with  sugar 
the  thirst  after  novelties  in  therapeutics,  there  is  a  I  of  milk,  or  other  inert  substance,  its  activity  may 
danger  that  some  of  our  good  old-fashioned  drugs  |  be  enhanced  and  the  size  of  the  dose  reduced. 


fatal  in  eighteen  days. 

Medicine. 

Guaiacum  and  Biliousness. — Dr.  W.  Mir 
rell,  of  London,  revives  the  interest  of  old  prac 
titioners  in  guaiac,  and  invites  the  younger  ones 
to  make  trial  of  the  almost  discarded  favorite. 
In  the  Press  and  Circular  he  points   out  how,  in 


may  get  the  go-by.     This  is  partly  the   fault  of 
the  text  books  on  materia  medica,  for  the  reason 


Disinfection  of  TrBERCULors  Sputum.  —  In 


that  they  mistakenly  described  the  properties  of  1  the   Centralblatt  fur  fiaktcriologic."No*.   1  and  2 
the  old  drugs  in  some  instances.     For  example,    1891,  Dr.  Martin  Kirchner  points  out  that  the 
many  books  speak  of  guaiac  as  diaphoretic  and   general  consensus  of  opinion  has  come  to  regard 
diuretic,    while    Schmiedelberg,    of   Strasbourg,  |  the  sputum  of  tuberculous  patients  as  the  ordi- 


378 


MEDICAL  PROGRESS. 


[March  14 


nan-  means  by  whicc.  tuberculous  disease  spreads 
from  one  individual  to  another.  In  many  of  the 
large  military  establishments  in  Germany  it  has 
been  shown  that  tuberculous  disease  has  been  very 
widespread  amongst  the  nurses  and  attendants 
upon  the  sick,  and  stringent  rules  are  already  in 
force  in  many  such  places  to  prevent  the  indiscrim- 
inate disposal  of  sputum.  Tubercle  bacilli  are  more 
resistant  than  some  other  microorganisms  to  the 
action  of  some  antiseptic  fluids,  but  are  very  easily 
destroyed  by  others.  Four  per  cent,  carbolic  acid, 
with  the  addition  of  2  per  cent,  of  hydrochloric 
acid ;  2  per  cent,  and  5  per  cent,  of  sulpho  car- 
bolic acid,  or  10  per  cent,  of  creolin,  will  suffice 
to  render  tubercle  bacilli  innocuous  in  a  very 
short  time.  Caustic  soda  and  potash,  on  the 
other  hand,  and  5  per  cent,  of  permanganate  of 
potash,  have  no  effect,  nor  is  a  solution  of  1  in 
1,000  of  corrosive  sublimate  sufficient,  owing  to 
the  highly  albuminous  character  of  the  sputum 
in  which  the  bacilli  are  contained.  It  has  now 
been  proved  that  tuberculous  sputum  may  retain 
its  infective  properties  for  ten  months  even  after 
decomposition  or  drying  up.  It  must,  therefore, 
be  equally  active  as  it  lies  in  the  various  recepta- 
cles which  have  been  devised  for  its  reception. 
The  methods  by  which  these  vessels  are  cleaned 
becomes  a  matter  6Y  considerable  importance. 
Boiling  water  is  used  in  some  places,  but  it  is 
open  to  the  chance  of  the  water  becoming  cool 
before  it  can  be  used,  and  does  not  do  away  with 
the  necessity  for  the  wiping  of  the  adherent  spu- 
tum from  the  sides  of  the  vessel  by  the  hands  of 
the  attendant.  A  temperature  of  700  C.  has  been 
shown  to  be  insufficient  to  render  tuberculous 
sputum  innocuous,  and  the  author  of  the  paper 
believes  that  absolute  disinfection  is  to  be  obtain- 
ed only  by  means  of  steam.  This  plan  was  ad- 
vocated by  Grancher  and  De  Gennes  in  1888,  but 
the  apparatus  devised  for  the  purpose  was  cum- 
brous and  costly.  Now  that  there  is  a  general 
disposition  tc  treat  tuberculous  cases  on  much  the 
same  lines  as  leprosy  cases,  by  collecting  them 
together,  it  should  be  an  absolute  law  that  all  the 
sputum  proceeding  from  such  cases  should  be  ren 
dered  harmless  before  it  is  disposed  of  in  the  com- 
mon drains.  With  this  object,  Dr.  Kirchner  has 
caused  a  form  of  disinfecting  kettle  to  be  con- 
structed, consisting  of  a  round  metal  box  about 
10  inches  high  and  16  inches  in  diameter,  its  floor 
forming  a  shallow  tank  to  hold  the  water  to  be 
vaporized,  the  whole  being  covered  with  a  lid  per- 
forated at  one  point  for  the  passage  of  a  thermom- 
eter. In  this  box  are  placed  two  or  more  trays, 
perforated  to  permit  of  the  free  circulation  of 
steam,  and  so  arranged  as  to  carry  five  spitting- 
cups  of  the  special  pattern  which  he  uses.  These 
cups  are  placed  for  half  an  hour  within  this  ap- 
paratus, heat  being  maintained  so  that  the  tem- 
perature of  the  steam  never  falls  below  ioo°  C. 
A  strong  protest  is  made  against  the  use  of  the 


ordinary  spittoon,  whether  filled  with  sawdust  or 
some  antiseptic  fluid.  The  spittoon  is  of  neces- 
sity too  far  removed  from  the  patient's  mouth  to 
ensure  that  all  the  expectorated  matters  are  col- 
lected by  it.  The  state  of  the  floor  round  and 
about  any  spittoon  in  a  public  place  is  appealed 
to  as  sufficient  evidence  of  the  truth  of  this  state- 
ment. Small  cups  made  of  glass,  with  wide  lips 
and  easily  cleaned,  should  be  used  in  preference 
to  the  spittoon,  but  must  be  placed  within  reach 
of  the  patient's  hand,  and  be  clearly  labelled. 
These  cups  must  be  placed  in  the  disinfecting  box 
for  half  an  hour  before  they  are  emptied,  and 
their  contents  may  then  with  safety  be  treated  by 
simple  washing. — British  Medical  Journal. 
Surgery. 

Stomach  Resection. — February  6Dr.Porges 
presented  to  the  Aerztliches  Veremsleben,in  Wien, 
a  middle  aged  man  in  whom  Prof.  Maydl,  the 
previous  August,  had  resected  at  least  half  of 
the  stomach.  The  carcinomatous  mass  was  ad- 
herent to  the  pancreas,  necessitating  a  removal 
of  a  portion  of  that  gland,  as  well  as  a  part  of  the 
greater  and  lesser  omentum.  The  patient  ap- 
parently fully  recovered  and  up  to  the  present 
has  shown  no  signs  of  a  return  of  the  disease.  In 
discussing  the  case  Kahler  contended  that  the 
entire  removal  of  the  stomach  was  practicable,  as 
the  small  intestine  was  amply  sufficient  to  pro- 
vide nourishment. 

Bacteriology. 

Action  of  Koch's  Lymph  on  Healthy  Ani- 
mals.— M.Jaccoud  has  recently  communicated  to 
the  Academie  de  Medecine,  Seance  du  10  Fevrier, 
1891  (Le  Bulletin  Medicate)  the  history  of  a  guinea 
pig  that  was  inoculated  with  Koch's  lymph,  and 
subsequently  with  the  tubercle  bacillus.  The  pig, 
exceptionally  robust  and  strong,  weighing  580 
grams,  received  two  series  of  daily  injections  sep- 
arated by  an  interval  of  eight  days,  the  one  ex- 
tending from  the  8th  to  the  18th  of  December, 
and  the  second  from  December  27  to  the  4th  of 
January;  in  all  50  centigrams  of  the  liquid  were 
used,  or  25  in  each  series.  On  the  5th  of  Janu- 
ary the  animal  was  inoculated  upon  the  shoulder 
with  tubercle  taken  from  a  tuberculous  guinea 
pig.  It  succumbed  one  month  later  with  all  the 
typical  signs  of  tuberculosis,- — grey  confluent 
granulations  in  both  lungs,  a  heemorrhagic  hepa- 
tization in  the  upper  part  of  the  right  lung,  and 
caseous  tubercle  in  masses  in  the  spleen  and 
liver.  This  species  of  guinea  pig  (angora  1  usu- 
ally survives  longer  than  one  month,  therefore 
the  particular  animal  presented  the  minimum  of 
resistance  and  the  maximum  of  pathological 
change  common  to  its  species,  proving  that 
Koch's  remedy  does  not  act  as  a  preventive. 
Another  and  smaller  guinea  pig  was  inoculated 
at  the  same  time  with  a  portion  of  the  same 
tuberculous  matter;  at  the  time  of  the  report  this 
animal  was  still  alive. 


'89I-] 


EDITORIAL. 


379 


Journal  of  the  American  Medical  Association 

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Address 

Journal  of  the  American   Medical  Association, 

No.  6S  Wabash  Ave., 

Chicago,  Illinois. 
All  members  of  the  Association  shou       send  their  Annual  Dues 
to  the  Treasurer,  Richard  J.  Dunglison,  M.D.,  Lock  Box  1274,  Phila- 
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London  Office,  57  and  59  Ludgate  Hill. 
SATURDAY,   MARCH    14,    1S91. 


best  of  foreign  literature  can  be  secured,  and  tbe 
proceedings  of  medical  societies  and  organizations 
can  be  tersely  and  impartially  abstracted,  and 
The  Journal  itself  remain  absolutely  divorced 
from  political  and  partizau  purposes,  tben,  if  we 
rightly  estimate,  will  it  be  prepared  to  render 
strong  and  legitimate  assistance  in  the  uplifting 
of  journalism  in  this  country.  This  is  our  hope 
and  our  anticipation  as  the  future  achievement  of 
The  Journal. 

We  wish  to  be  in  utmost  harmony  with  all  le- 
gitimate journalistic  work  and  workers  in  the  ful- 
fillment of  possibilities  as  set  forth  in  another 
article  in  this  issue,  in  which  reference  is  made 
to  the  coming  meeting  of  the  Medical  Editors' 
Association. 


THE  PURPOSE  OF  "THE  JOURNAL." 
Our  views  with  reference  to  the  preparation  of 
papers  for  presentation  and  discussion  in  the  sev- 
eral Sections  at  the  annual  meetings  of  the  Asso- 
ciation, as  presented  in  the  last  number  of  The 
Journal,  we  trust  will  not  be  considered  as  stric- 
tures upon  legitimate  work.  If  the  humblest 
member  of  our  profession  has  a  single  unknown 
fact,  an  observation  of  value  not  hitherto  recorded, 
a  special  method  of  operation,  or  a  practical  sug- 
gestion with  reference  to  the  action  of  a  remedy 
or  the  method  of  administration  of  which  the  pro- 
fession should  be  advised,  he  certainly  will  not 
be  deterred  by  what  was  written  from  the  fulfill- 
ment of  an  obvious  duty.  But  if,  on  the  other 
hand,  one  shall  be  simply  ambitious  to  place  him- 
self on  record  and  propose  to  bring  as  his  contri- 
bution the  cerebrations  of  other  brains  better  re- 
corded elsewhere,  if  from  our  suggestions  he 
shall  deem  it  wiser  to  accord  the  field  to  those 
who  write  of  what  they  themselves  have  wrought, 
then  the  purpose  of  our  writing  will  not  have 
been  in  vain.  If  more  and  more,  in  the  future, 
the  "Original"  department  of  The  Journal  can 
be  made  to  represent  original  thought  and  original 
researches  of  our  foremost  medical  men — whose 
articles  it  were  a  credit  to  publish,  and  a  pleasure 
to  peruse,  one  of  the  grandest  purposes  of  The 
Journal  will  be  attained. 

If,  in  this  connection,  the  concurrent  labors  of 
an  able  corps  of  editorial  writers  can  be  assured; 
if  the  current  literature  of  the  day  can  have  ample 
and   judicious  representative  expression;  if  the 


THE  MEDICAL  EDITORS'  ASSOCIATION. 

This  Society,  although  only  a  few  years  old, 
is  practically  the  most  influential  and  important 
in  the  country.  Everywhere  it  is  apparent  that 
medical  journals  are  taking  the  place  of  volumes 
and  text-books.  Medical  readers  want  the  latest 
facts  concerning  every  movement  of  science,  in 
the  laboratory,  bedside  and  hospital  practice. 

The  value  of  such  facts  are  recognized,  not  only 
by  the  isolated  country  physician,  but  medical 
teachers  in  crowded  cities,  and  busy  physicians, 
who  have  little  time  for  reading  volumes.  While 
medical  journalism  is  yet  in  its  infancy  compared 
with  what  it  will  be  in  the  coming  century,  its 
educational  power  and  value  is  felt  in  every  circle 
of  science.  It  is  fatal  to  egotism  and  dogmatic 
conceptions  of  theories  in  science,  and  points  out 
the  fact  that  no  one.  however  eminent,  can  fully 
master  all  the  facts,  or  apply  them  in  the  practice 
of  healing.  The  formative  power  of  the  press  is 
really  greater  than  medical  colleges,  for  it  not 
only  shapes  the  action  of  educational  forces,  but 
it  continues  through  all  the  after  professional  life 
of  the  student.  It  is  literally  a  teacher  that  is 
always  present.  The  majority  of  the  editors  of 
the  medical  press  realize  this  power,  and  use  it 
to  promote  the  higher  interests  of  science. 

A  small  and  ever  decreasing  minority  still  cling 
to  the  idea  that  medical  journals  are  only  valua- 
ble in  proportion  as  they  serve  some  personal, 
selfish  ends,  or  become  the  organ  of  a  faction  or 
a  party.  They  form  their  conceptions  from  the 
secular  press  and  politics,  and  it  is  needless  to 


38o 


TREATMENT  OF  PHTHISIS. 


[March  14, 


say  that  in  the  long  run  the}-  foster  conditions 
which  will  result  in  their  own  destruction.  All 
medical  journals  have  a  local  personality,  and 
quite  naturally  give  prominence  to  some  college, 
or  teachers,  or  even  a  publishing  house.  But  this 
localism  is  generally  subordinate,  and  rarely  ever 
assumes  the  superiority  over  all  others,  of  its  col- 
lege, teachers  or  publishing  house. 

The  great  art  of  good  journalism  is  to  have  a 
distinct  personality,  that  is  broad,  clear  and  gen- 
erous, above  all  low  levels  of  impulse  and  feeling; 
also  to  discriminate  the  value  of  facts  and  theo- 
ries above  the  authors,  or  sources;  and  be  able  to 
determine  their  place  and  meaning  in  science. 
This  is  an  art  that  must  be  natural,  as  well  as 
cultivated,  and  requires  as  distinct  talents  as  in 
surgery,  or  in  other  fields  of  medicine.  Among 
medical  journals  in  this  country  there  are  notable 
examples  of  great  ability  in  this  direction. 

The  number  of  journals  is  steadily  increasing, 
and  the  process  of  the  "survival  of  the  fittest" 
is  going  on  with  unerring  certainty.  The  stand- 
ard and  editorial  tone  is  rising  constantly ;  a 
broader  generosity  and  feeling  prevails,  and  sci- 
entific kinship  is  springing  up.  As  the  medical 
press  rises  in  scientific  conceptions  of  medicine, 
the  old  rivalry  dies  away,  and  the  great  ocean  of 
undiscovered  truth  looms  up,  where  each  can  sail 
alone,  without  crossing  his  neighbor's  track,  and 
beyond  all  contest  and  rivalry. 

The  coming  meeting  of  medical  editors  should 
include  every  medical  editor  in  the  country.  A 
personal  exchange  of  opinions,  and  personal  ac- 
quaintance, are  large  factors  in  developing  the 
best  interests  of  each.  The  day  for  fulsome  ad- 
miration, bitter  personalities,  and  hilarious  eat- 
ing and  drinking  has  gone  by.  The  time  has 
come  for  united  work,  and  every  medical  editor 
should  join  his  influence  and  power  to  make  the 
Association  a  true  exponent  of  American  medi- 
cine. With  a  united  medical  press,  many  of  the 
existing  abuses  in  medical  education  and  chari- 
ties would  be  corrected.  The  low  estimate  of  the 
profession  by  public  opinion  would  be  a  thing  of 
the  past.  While  the  Medical  College  Association 
and  Societies  can  do  much  to  advance  the  stand- 
ard of  medicine,  a  united  medical  press  can  do 
more;  this  is  apparent  in  the  increased  quotations 
of  opinions  of  journals  on  points  of  interest. 

The  profession  will  watch  with  increasing  in- 
terest the  coming  meeting  of  the  medical  editors, 


not  that  they  will  cause  any  great  revolutions 
of  science,  but  the  more  united  they  become  in 
both  personality  and  scientific  interest,  the  better 
their  work.  While  science  is  truly  cosmopolitan, 
every  journal  and  medical  man  ought  to  cultivate 
a  National  pride  and  ambition  to  distinguish  facts 
and  principles  of  medicine  as  clearly  and  quickly 
as  foreigners. 

Journalism  ought  to  lead  and  direct  the  obser- 
ver to  fields  of  discovery  that  are  as  accessible 
from  this  country  as  elsewhere.  Concentrate  the 
medical  press  in  work  and  interest,  and  the  road 
is  open  for  brilliant  discovery. 


TREATMENT  OF  PHTHISIS. 
The  treatment  of  disease  of  the  respiratory 
tract  by  the  inhalation  of  gases  or  medicated  air 
attracted  attention  in  the  childhood  of  medicine. 
The  bringing  of  the  curative  agent  in  direct  con- 
tact with  the  diseased  surface  was  apparently  so 
rational  a  procedure  that  few  could  doubt  its  util- 
ity, and  yet  of  all  the  fantastic  methods  that  have 
been  devised,  and  the  various  inhalants  that  have 
been  introduced  with  such  eclat,  none  of  them 
attained  permanent  popularity.  This  inhalation 
treatment  of  phthisis  has  ever  proved  an  ignis 
fatuus,  leading  men  into  all  sorts  of  pathological 
sloughs  and  etiological  pitfalls.  The  discovery 
of  the  tubercle  bacillus  has  but  added  an  impetus 
to  the  mad  race  for  something  that  would  kill  the 
parasite  and  not  harm  the  host.  Can  we  hope  to 
kill  the  tubercle  bacillus  in  the  lung  by  inhala- 
tion? Certainly  not,  because  the  remedy  does 
not  come  in  contact  with  the  bacillus.  The  most 
powerful  disinfectant  known,  unless  brought  in 
direct  contact  with  the  germ,  will  not  destroy  it — 
if  the  most  infinitesimal  part  of  an  inch  intervene 
its  action  will  be  prevented.  Now  if  the  tubercle 
bacillus  were  swimming  around  in  the  bronchial 
secretion  on  the  surface  of  the  epithelial  cells  we 
could  accomplish  something  with  our  disinfecting 
gas,  but  unfortunately  it  is  situated  deeply  in  the 
tissue  of  the  lung,  in  the  giant  cell,  and  often  en- 
capsulated in  connective  tissue.  It  is  apparent 
that  any  direct  effect  that  the  inhaled  gas  may 
have  upon  the  bacilli  is  due  to  its  absorption,  and 
action  through  the  blood.  We  do  not  wish  to  be 
misunderstood;  it  is  not  claimed  that  inhalations 
may  not  be  useful  in  phthisis,  the  catarrhal  con- 
ditions and  mixed  infections  that  accompany  the 


I89I.J 


ANTI-TUBERCULOSIS  INOCULATION. 


38i 


disease  may  be  greatly  benefited,  but  tbey  can 
not  kill  the  bacilli  directly. 

It  would  seem  that  many  of  our  professional 
friends  bad  lost  sight  of  the  etiological  factor  in 
phthisis.  Are  the  broad-chested,  healthy  and 
robust  especially  prone  to  this  disease,  or  is  it 
one  that  is  liable  to  attack  the  pun}',  ill-nourished 
and  narrow  chested  ?  And  are  not  these  condi- 
tions favored  by  over-crowding,  ill  ventilated 
school-rooms,  long  hours  of  study  and  cramped 
positions,  with  the  attendant  imperfect  expansion 
and  passive  congestions  of  the  lungs?  Too  much 
analogy  has  been  assumed  in  the  various  micro 
bic  disorders.  Take,  for  example,  small  pox, 
how  different  are  its  etiological  relations;  attack- 
ing indifferently  the  strong  and  the  weak,  self- 
limited  in  its  nature  and  one  attack  conferring 
immunity.  If  these  things  were  true  of  phthisis 
how  much  more  might  be  hoped  for  from  medi- 
cinal treatment  ?  Is  it  not  time  that  scarlet  fever 
should  be  brought  under  control,  and  its  ravages 
limited,  as  have  been  those  of  small- pox? 

We  submit  our  view,  and  not  without  trepida- 
tion, that  the  tubercle  bacillus  will  hold  its  own 
against  all  the  sulphuretted  hydrogen,  chloride 
of  gold,  pneumatic  cabinets,  hot  air  or  lymph 
that  can  be  brought  against  it.  Many  of  these 
remedies  may  prove  to  be  most  useful  in  the 
treatment  of  phthisis,  but  the  danger  now  is  that 
their  too  enthusiastic  advocates  will  forget  the 
predisposing  and  exciting  causes  of  this  disease 
and  with  the  inevitable  resultant  failure  will 
come  a  therapeutic  nihilism,  that  will  work  to 
the  discredit  of  scientific  medicine.  In  conclu- 
sion we  cannot  refrain  from  calling  attention  to 
the  words  of  Koch,  to  show  how  clearly  he 
recognized  these  limitations  when  he  said:  "How 
far  the  present  methods  of  cure,  mountain  climate, 
open  air  treatment,  etc.,  may  be  combined  with 
the  new  measure  is  not  yet  determined,  but  I  be- 
lieve that  these  curative  factors  may  be  usefully 
employed  in  many  cases,  especially  in  neglected 
and  severe  forms  as  well  as  in  the  convalescent 
stage. ' ' 


THE    ANTITUBERCULOSIS    INOCULATION 
TREATMENT  OF  RICHET. 

During  the  past  two  years,  a  series  of  communi- 
cations has  been  made  to  the  Society  of  Biology 
at    Paris,   by  Richet    and    Hericourt,   giving 


their  results  obtained  by  intravenous  injections 
and  inoculations  for  the  relief  of  tuberculosis, 
ive  not  been  limited  to  any  one  inocula- 
tion-material, but  since  April,  1890,  their  atten- 
tion has  been  especially  directed  to  the  blood  of 
animals  refractory  to  tuberculosis,  as  the  dog, 
although  they  have  also  used  non-bad  liar  pro- 
ducts from  old  tubercular  cultures.  They  have 
lately  reported  that  dog's  blood  has  been  demon- 
strated to  have  a  retarding  effect  in  the  case  of 
rabbits  where  tuberculosis  has  been  artificially 
produced,  without,  however,  arresting  the  dis- 
ease altogether.  They  next  undertook  to  in- 
tensify, if  possible,  these  partially  protective 
properties  of  canine  blood,  by  inoculating  a  dog 
with  unmistakably  active  tuberculous  matter,  in 
large  doses,  and  one  month  later,  the  animal 
having  meanwhile  lost  flesh  and  given  manifest 
signs  of  ill-condition,  injected  into  the  peritoneal 
cavit)^  of  three  rabbits  about  2.4  fluid  ounces  of 
this  dog's  blood.  One  week  later,  these  rabbits, 
were  with  three  other  test  rabbits  injected  with 
strong  tubercular  virus,  with  this  result  that  in 
twenty- five  days  two  of  the  latter  were  dead, 
while  the  others  survived.  Their  next  step  was 
to  extend  the  application  of  their  method  to 
tuberculous  human  beings,  using  the  blood- 
serum  only  and  injecting  it  subcutaneously  in 
the  interscapular  region.  This  was  done  early  in 
last  December  upon  four  males.  Richet  re- 
ported, January  24,  to  the  Society  of  Biology, 
that  the  treatment  has  appeared  to  counteract 
the  progress  of  the  disease  to  some  extent,  at 
least,  in  all  four  cases ;  two  of  whom  are  affected 
with  pulmonary  phthisis,  while  the  other  two 
have  both  the  larynx  and  lungs  involved. 
Eighteen  days  after  the  treatment  was  begun 
the  physical  signs  were  markedly  reduced,  night- 
sweats  had  been  suppressed,  and  the  appetite  of 
the  patients  had  improved,  as  well  as  their 
weight  and  strength,  one  of  them  had  gained  in 
weight  fully  nine  pounds  in  that  period ;  that  of 
the  others  in  a  less  degree.  The  laryngeal  pa- 
tients had  been  relieved  of  that  distressing  agony 
formerly  experienced  on  deglutition,  the  epiglottis 
which  had  been  very  swollen  and  motionless  had 
become  reduced  in  volume  and  regained  its  mo- 
bility. In  all  the  cases,  the  interscapular  region 
became  the  seat  of  itching,  some  time  after  the 
injections,  and  attained  its  maximum  twenty- four 
hours  later.      The  size  of  the  dose  of   injected 


382 


EDITORIAL  NOTES. 


[March  14, 


serum  was  stated  at  about  fifteen  minims  to  a 
fluid  drachm,  which  was  administered  in  from 
three  to  six  days.  No  constitutional  reaction 
occurred,  and  the  local  disturbance  was  very 
slight ;  pain  was  complained  of  after  two  treat- 
ments only. 


THE  SPHERE  OF  WOMEN  MEDICAL  PRAC- 
TITIONERS IN  CHINA. 

The  Edinburg  Medical  Missionary  Society  pub- 
lishes, in  its  quarterly  paper  for  February,  189 1, 
some  facts  regarding  the  sphere  for  female  medi- 
cal attendance  among  the  women  of  China.  Not 
only  is  medical  skill  lacking  and  of  most  indiffer- 
ent quality  among  the  Chinese,  but  even  such  as 
it  is  it  can  hardly  be  obtained  by  the  women,  be- 
cause the  native  practitioners  are  males  and  it  is 
not  considered  proper  for  them  to  treat  female 
patients.  Under  some  conditions  an  old  woman 
of  experience  in  obstetrical  and  children's  com- 
plications may  attain  to  some  consequence  in  a 
limited  locality.  But  there  is  a  vast  female  pop- 
ulation that  has  practically  no  medical  attend- 
ance whatever  ;  and  if  the  children  are  included 
with  the  women,  as  they  must  be  to  the  extent 
of  many  millions,  the  needs  of  China  for  female 
medical  attendance  will  be  found  to  be  in  the 
thousands.  The  number  of  practitioners  who 
can  satisfy  these  demands  can  never  be  supplied 
from  Western  lands.  The  constant  aim  of  all 
well-wishers  of  China  must  be  to  raise  up  a  sup- 
ply from  among  the  natives  themselves  ;  and  for- 
tunately it  has  already  been  proved  that  there  is 
no  want  of  capacity  in  the  Chinese  female  mind 
in  this  direction.  Certain  difficulties  have  been, 
and  will  continue  to  be,  met  in  Oriental  life  and 
habits  of  thought,  as  to  women  taking  a  promi 
nent  or  professional  position,  especially  during 
young  and  middle  life,  but  these  can  be  overcome 
by  wise  fathers  and  husbands  and  by  senior  fe- 
male counsellors  who  have  broken  away  from 
their  old  superstitions.  In  many  respects  the 
Chinese  are  intensely  practical,  and  are  not  slow 
to  see  if  a  new  proposition  will  pay.  This  is  all 
that  is  needed  to  insure  the  progress  of  the  move- 
ment. The  economic  wisdom  of  the  people  will 
soon  teach  them  that  it  is  wasteful  not  t<>  take 
better  care  of  their  women  and  children,  if  for  no 
other  reason,  at  least  for  that  which  prompts  to 
the  care  of  cattle.  The  family  is  much  stronger 
among    them    than    is  generally  supposed,   and 


China  is  the  land  of  the  family,  in  an  eminent 
degree.  The  pride  of  country  is,  also,  intense, 
and  leads  them  to  no  little  exultation  when  one 
of  their  countrywomen  has  shown  herself  to  be  a 
skilled  physician.  Western  healing  has  a  strong 
popular  hold  already.  Its  results  often  appear  to 
be  almost  miraculous  ;  so  that  by  the  time  a  good 
medical  training  can  be  supplied  to  native  wo- 
men and  acquired  by  them,  the  demand  for  them 
will  be  sure  to  be  far  in  excess  of  the  supply. 


EDITORIAL  NOTES. 

Special  Notice  to  the  Officers  of  Sec- 
tions.— It  is  not  only  desirable,  but  necessary, 
that  those  who  have  in  hand  the  work  of  secur- 
ing papers  for  presentation  in  the  several  Sections 
at  the  coming  meeting  of  the  Association,  shall 
complete  their  work  at  an  early  date.  The  pro- 
grammes for  the  Sections  should  be  in  type  as 
early  as  April  10,  and  revisions  secured  at  once. 
The  entire  programme,  thus  completed,  will  be 
copyrighted  and  published  in  a  single  issue  of 
The  Journal,  and  also  in  pamphlet  form  for 
general  distribution.  The  appropriation  of  this 
programme,  in  whole  or  in  part,  by  scheming 
publishers  or  advertisers,  as  in  times  past,  we 
trust  will  not  be  attempted. 

Officers  of  the  Sections  !  An  important  responsi- 
bility is  upon  you.  The  value  of  the  papers  which 
you  solicit  must  largely  determine  the  value  of 
the  Original  Department  of  The  Journal  for 
the  coming  year.  Let  your  selections  be  well 
made.     Let  your  work  be  completed  promptly. 

Special  Notice. — In  consequence  of  the  con- 
flict of  dates  of  the  American  Medical  Association 
and  the  Indiana  State  Medical  Society,  the  date 
of  the  meeting  of  the  Indiana  State  Medical  Soci- 
ety has  been  fixed  for  June  10,  1891,  the  second 
Wednesday. 

Change  of  Time  of  Holding  the  Meeting 
of  the  National  Association  of  Railway 
Surgeons. — On  account  of  the  meeting  of  the 
American  Medical  Association  at  Washington, 
D.  C,  on  May  the  5th,  and  continuing  to  the 
8th,  it  has  been  thought  best  by  the  officers  of 
the  National  Association  of  Railway  Surgeons  to 
change  the  time  of  meeting  from  May  7  to  April 
30.  The  meeting  will  he  held  at  Buffalo,  New 
\\>rk,  beginning  at  10  o'clock  a.m.,  and  continu- 
ing t.>  May   3.      This  change  will   give   the   sur- 


i89i.] 


EDITORIAL  NOTES. 


383 


geons  who  have  a  long  distance  to  travel  an  op- 
portunity of  attending  both  meetings  on  one  trip. 
Remember  the  change  from  .May  7  to  April  30.  Any 
further  information  desired  can  be  had  by  address- 
ing Dr.  E.  R.  Lewis,  Kansas  City,  Mo.,  or  Dr. 
A.  G.  Gumaer,  Buffalo,  New  York.  The  meet- 
ing promises  to  be  well  attended  by  surgeons 
from  all  parts  of  the  country. 

Notice  to  Military  Surgeons  of  the 
National  Guard. — Dr.  N.  Senn,  of  Milwaukee, 
Surgeon  General  of  Wisconsin,  is  desirous  of  ob- 
taining the  name  and  address  of  every  surgeon 
of  the  National  Guard  in  the  United  States  for 
the  purpose  of  taking  the  necessary  preliminary 
steps  towards  the  formation  of  a  permanent 
National  Association. 

The  Hasseki  Hospital  for  Women  at 
Constantinople. —  Hospitals  are  an  index  of 
the  progress  of  civilization,  their  establishment 
and  support  always  means  progress  in  science  and 
art.  We  note  an  excellent  description  by  Peche- 
dimaldji  in  the  Revue  Medico- Pharmacaitique  on 
the  Hasseki  Hospital  for  Women,  situated  in  one 
of  the  most  populous  quarters  of  Constantinople. 
The  sun  of  humanity  is  rising  upon  the  women 
of  the  East, 

Koch's  Remedy  and  its  Results. — Under 
the  head  of  "  Progress  "  in  this  issue  appears  an 
abstract  of  the  proceedings  of  the  Berlin  Medical 
Society,  in  which  Prof.  Furbringer  reports  forty- 
six  cases  of  pulmonary  tuberculosis  that  had 
been  under  treatment  for  more  than  two  months. 
The  results  are  certainly  not  what  we  had  hoped 
for — three  cures  and  seven  deaths.  The  death- 
rate  in  this  treatment  is  proving  exceptionally 
high,  and  the  statistics  so  far  as  they  are  at  hand 
show  more  fatalities  than  recoveries. 

Important  Notice. — An  announcement  was 
recently  made  that  an  Army  Medical  Board  would 
be  in  session  in  New  York  City  during  April  next 
for  the  examination  of  candidates  for  appointment 
in  the  Medical  Corps  of  the  United  States  Army, 
to  fill  existing  vacancies.  At  the  time  of  that 
announcement  there  were  only  five  vacancies  to 
be  filled.  Recent  Congressional  legislation  has, 
however,  permitted  the  retirement  of  certain  offi- 
cers, so  that  there  are  now  fourteen  vacancies  in 
the  grade  of  assistant  surgeon,  with  the  proba- 
bility that  the  number  will  be  increased  to  seven- 


teen by  the  time  the  examining  board  begins  its 
labors.  As  ahead}-  stated,  persons  desiring  to  pre- 
sent themselves  for  examination  by  the  Board 
t  will  make  application  to  the  Secretary  of  War, 
before  April  1,  1891,  for  the  necessary  invitation, 
stating  the  date  and  place  of  birth,  the  place  and 
State  of  permanent  residence,  the  fact  of  Ameri- 
can citizenship,  the  name  of  the  medical  college 
from  which  they  graduated,  and  a  record  of  ser- 
vice in  hospital,  if  any,  from  the  authorities  there- 
of. The  application  should  be  accompanied  hy 
certificates  based  on  personal  knowledge,  from  at 
least  two  physicians  of  repute,  as  to  professional 
standing,  character,  and  moral  habits.  The  can- 
didate must  be  between  21  and  28  years  of  age, 
and  a  graduate  from  a  Regular  Medical  College, 
as  evidence  of  which  his  diploma  must  be  submit- 
ted to  the  Board.  Further  information  regard- 
ing the  examinations  may  be  obtained  by  ad- 
dressing C.  Sutherland,  Surgeon  General  U.  S. 
Army,  Washington,  D.  C. 

The  Medical  Society  of  the  Missouri 
Valley  will  meet  at  Omaha,  Neb.,  March  19 
and  20.  Papers  will  be  read  by  Drs.  A.  F.  Jonas, 
Omaha ;  J.  M.  Emmert,  Atlantic ;  Flavel  B,  Tif- 
fany, Kansas  City;  Donald  Macrae,  Council  Bluffs; 
S.  Stewart,  Council  Bluffs;  J.  E.  Summers,  Jr., 
Omaha  ;  J.  F.  White,  Council  Bluffs  ;  S.  G.  Gant, 
Kansas  City;  H.  Gifford,  Omaha;  Rebecca  Hanna, 
Red  Oak  ;  and  J.  P.  Lord,  Omaha. 

Recent  Status  of  Koch's  Method. — The 
French  and  German  medical  press  have  devoted 
a  very  considerable  part  of  their  space  for  the 
past  two  months  to  accounts  of  trials  and  results 
obtained  by  the  use  of  the  lymph.  We  have 
from  time  to  time  presented  our  readers  with  ab- 
stracts of  the  more  important  and  typical  contri- 
butions. Their  number  has  now  become  so  large 
that  to  abstract  even  a  part  of  the  mass  would 
require  vastly  more  space  than  the  editor  has  at 
his  disposal.  At  the  same  time  owing  to  the 
wide  range  of  cases  in  which  the  remedy  has 
been  employed,  the  great  variation  in  results  and 
the  want  of  uniformity  in  method  of  reporting 
would  make  any  statistical  compilation  at  this 
time  not  only  useless,  but  positively  misleading. 
French  writers  have  been  skeptical  from  the 
start,  but  some  of  them  report  favorable  results 
in  isolated  cases.  This  is  shown  in  the  abstract, 
given    in    "progress"   of   this   week,   of  thirty- 


3§4 


MEDICAL  ITEMS. 


[March  14, 


eight  cases  of  lupus  treated  in  the  French  hos- 
pitals. The  German  medical  press  has  become 
more  conservative  in  their  claims,  and  they  re- 
port many  unfavorable  effects  of  the  remedy.  A 
careful  examination  of  the  communications  to 
date  would  seem  to  show  that  the  method  has  a 
substantial  range  of  usefulness,  though  it  comes 
far  short  of  the  too  sanguine  earlier  expectations. 
medical  items. 
The  Michigan  State  Board  of  Health. — 
The  recently  inaugurated  Governor  of  Michigan 
is  understood  to  advise  the  abolition  of  the  State 
Board  of  Health,  and  it  is  feared  by  many  that 
the  Legislature  will  act  accordingly.  It  is  to  be 
regretted  that  such  an  important  element  in  the 
general  welfare  of  a  commonwealth  is  liable  to  be 
sacrificed.  The  Michigan  State  Board  of  Health 
has  for  years  performed  an  excellent  sendee  to 
the  people  of  that  State,  and  certainly  deserves 
better  recognition  than  threats  of  extinction.  It 
is  to  be  hoped — for  it  assuredly  is  to  be  expected 
— that  the  intelligence  of  a  State  Legislature  will 
not  be  so  myopic  and  unmanifested  as  to  permit 
the  value  of  State  Medicine  to  remain  unheeded 
and  uncared  for. 

How  to  Dispose  of  a  Hopeless  Invalid. — 
A  writer  in  the  lay  press  has  lately  advanced  a 
somewhat  singular  method  of  relieving  the  in- 
curable. The  plan  has  certainly  the  merit  of 
permanency  if  not  that  of  practicability,  or  any 
other  winning  virtue.  Endeavoring  to  argue  from 
a  humane  point  of  view,  not  only  as  to  the  pa- 
tient himself,  but  as  well  those  surrounding  and 
intimately  connected  with  the  pains  and  sorrows 
of  the  invalid,  the  writer  creates  his  plea  of  kill- 
ing those  so  afflicted.  Really,  this  plan  is  not 
new,  it  has  been  advocated  before,  and  actually 
— in  earlier  ages — put  into  practice.  It  is  merely 
noticed  here  as  an  example  of  the  ingenuity  of 
the  human  brain  in  its  effort  to  meet  all  condi- 
tions of  environment,  and  the  extreme  views  to 
which  those  dwelling  upon  euthanasia  may  arrive. 

Hygiene  in  Philadelphia. — Mr.  Henry  C. 
Lea,  of  Philadelphia,  has  given  a  sum  of  $50,000 
to  the  University  of  Pennsylvania  for  the  erection 
of  a  hygienic  laboratory.  The  plans  have  been 
revised  by  Dr.  John  S.  Billings,  who  has  em- 
bodied in  them  the  results  of  his  observations 
during  a  scientific  tour  in  Europe.  The  institu- 
tion will,  it  is  stated,  be  the  finest  of  the  kind  in 


the  world — till  some  other  American  millionaire 
builds  a  grander,  or  at  least  a  higger,  Temple  of 
Hygiene  somewhere  else.  It  is  to  be  provided 
with  lecture  rooms,  museums,  bacteriological  and 
photographic  rooms,  a  crematory,  a  separate 
building  for  the  rabbits,  guinea  pigs,  and  other 
animals  used  for  experiments. — British  Medical 
Journal. 

Drs.  Shurlv  and  Gibbes. — These  gentlemen 
appeared  before  the  Medical  Society  of  the  State 
of  New  York,  at  its  fifty-fifth  annual  meeting 
held  in  Albany,  on  February  3,  4,  and  5,  and 
gave  a  resume  of  consumption,  as  it  is  considered 
by  them,  both  pathologically  and  therapeutically. 

The  Harvard  Medical  Society  of  New- 
York  City,  of  which  mention  was  made  in  the 
last  issue,  .has  perfected  its  organization  by  the 
election  of  the  following  officers  :  President, 
Dr.  Rufus  P.  Lincoln  ;  Vice-President,  Dr.  Paul 
F.  Munde  ;  Secretary,  Dr.  Dillon  Brown  ;  and 
with  an  Executive  Committee  consisting  of  the 
President,  Secretary,  Dr.  Frederick  R.  Sturgis, 
William  J.  Morton  and  Henry  C.  Coe.  Meetings 
are  to  be  held  on  the  first  Saturday  of  each 
month,  except  June,  July,  August  and  September. 

A  New  Scientific  Society  has  just  been 
started  at  Philadelphia,  the  main  object  of  which 
is  to  examine  critically  the  brains  of  distinguished 
decedents.  It  is  said  the  operations  of  the  soci- 
ety will  be  limited  to  persons  holding  diplomas 
from  the  University  of  Pennsylvania.  We  trust 
this  is  not  a  masked  effort  to  "boom"  a  worthy 
institution  of  learning. 

Decrease  of  Lunacy. — The  report  of  the 
Commission  in  Lunacy  of  the  State  of  New  York 
slums,  through  the  means  of  improved  methods 
of  registration  and  returns  which  have  been 
adopted,  that  there  is  a  material  decline  in  the 
proportion  of  lunatics  to  population.  Not  alone 
are  the  improved  records  responsible  for  the  more 
gratifying  figures;  but  the  advanced  ways  of 
treatment  have  had  no  inconsiderable  part  in  the 
observed  result.  The  term  "chronic"  with  refer- 
ence to  the  insane  is  having  a  more  modified  ap- 
plication. Better  housing  and  attention,  together 
with  broader  views  generally,  are  working  factors. 

Dr.  \V.  W.  DALE,  a  leading  physician  of  South- 
ern Pennsylvania,  died  at  Carlisle,  Februan  ;6, 
of  pneumonia,  aged  74  years. 


>!■] 


TOPICS  OF  THE  WEEK. 


385 


TOPICS  OF  THE  WEEK. 


THE  DEBATE  ON  Kucii  S  REMEDY  AT    nil:  BERLIN 
MEDICAL  SOCIETY. 

The  subject  of  Koch's  remedy  still  continues  to  be  dis- 
cussed at  the  Berlin  Medical  Society  every  week,  the 
proceedings  on  February  7  being  as  follows: 

Professor  Virchow  exhibited  the  lungs  from  a  case 
treated  at  the  Augusta  Hospital  with  twelve 
from  December  4  to  January  12.  In  each  lung,  especially 
the  left,  were  circumscribed  areas  of  dense  pigmented 
eariiification,  intersected  by  whitish  bands  of  "dissecting 
pneumonia"  or  spaces  filled  with  pus  and  caseous  mate- 
rial. Hut  there  was  no  true  caseous  hepatization. 
Another  specimen,  from  a  patient  who  had  received 
thirty  injections,  illustrated  the  passage  into  gangrene 
of  acute  "smooth''  hepatization.  There  were  large  apical 
cavities,  and  recent  as  well  as  old  pleurisy,  whilst  the 
lower  lobes  showed  areas  of  recent  catarrhal  pneumonia 
already  breaking  down.  There  were  numerous  healing 
ulcers  in  the  colon.  A  third  case  was  one  of  phthisis 
complicated  with  syphilis  and  amyloid  disease;  only  two 
injections  had  been  given.  The  phthisis  was  acute,  and 
there  was  extensive  cicatrization  of  laryngeal  ulceration. 
Lastly,  he  exhibited  specimens  from  a  case  of  hip  dis- 
ease in  a  child  aged  three  years  and  three  quarters.  The 
head  of  the  femur  had  been  recently  excised,  and  prior 
to  that  the  child  had  had  five  injections.  Death  occurred 
from  acute  miliary  tuberculosis,  tubercles  being  well  seen 
in  the  bone  marrow.  They  also  occurred  in  the  lung, 
and  the  rare  (in  child)  complication  of  arytenoid  peri- 
chronditis  was  present.  Professor  Virchow  deprecated 
very  strongly  the  statement  that  in  many  cases  (espe- 
cially the  fatal  ones)  the  injections  had  been  made  on 
experimental  grounds  and  with  no  therapeutic  aim. 

Dr.  P.  Guttmann  showed  a  case  of  inoculated  tubercle 
on  the  ring  finger,  in  which  the  diagnostic  reaction  of 
Koch's  fluid  had  been  confirmed  by  microscopical  exam- 
ination of  excised  portions.  The  "warts"  were  attributed 
to  inoculation  of  an  abraded  surface  from  a  corpse  which 
the  man  (a  hospital  porter)  was  engaged  in  carrying. 
Under  the  treatment  they  much  diminished. 

Dr.  Grabower  had  no  doubt  as  to  the  supervention  of 
fresh  miliary  nodules  in  laryngeal  cases  under  treatment, 
but  he  did  not  think  this  serious;  it  rather  showed  that 
the  treatment  should  be  continued.  In  two  cases,  which 
he  exhibited,  such  nodules  appeared  without  anv  pre- 
existing disease  of  the  larynx.  He  gave  the  details  of 
these  cases,  both  early  pulmonary  phthisis  with  bacillary 
expectoration.  In  the  one  laryngeal  symptoms  arose 
after  the  twenty-fourth  injection,  and  examination 
showed  swelling  of  the  false  cords  and  a  profuse  erup- 
tion of  grey  miliary  tubercle.  These  nodules  soon  be- 
came confluent,  but  entirely  disappeared  during  the  con- 
tinuance of  the  injections.  The  other  case  was  very  sim- 
ilar, except  that  the  nodules  had  not  been  vet  wholly  re- 
moved. He  had  often  noticed  this  rapid  subsidence  of 
laryngeal  tubercle  after  a  few  injections,  and  without 
denying  the  possibility  of  infection  by  contiguity,  he  re- 
garded their  appearance  as  a  direct  indication  for  perse- 
vering with  the  treatment. 


Dr.  Jolly,  who  resumed  the  debate  on  Prof 
Fraenkel's  paper,  directed  attention  specially  to  the 
mental  disturbance  excited  by  the  fever 
injections  in  some  cases,  analogous  to  othei 
He  mentioned  two  case:,  in  I 
Leyden's  wards,  one  a  man  who  had  pleurisy  with  effu- 
sion, and  who  had  become  depressed  mentally  by  his 
long  illness.  The  injections  (2  to  7.5  mgr.  I  produced 
very  notable  febrile  reaction  (38. 30  to  40°),  during  which 
he  always  became  dull  and  confused.  After  five  injec- 
tions they  were  discontinued,  and  two  days  later  lie  be- 
gan to  have  delusions  and  was  transferred  to  the 
ward,  where  his  delirium  continued  to  increase.  How- 
ever, these  mental  symptoms  disappeared  in  a  fortnight: 
they  were  compared  by  Dr.  Jolly  to  the  delirium  of 
defervescence  or  post-febrile  delirium,  not  infrequentlv 
seen.  The  man  was  predisposed  by  his  former  depres- 
sion, and  by  the  excitement  attending  the  hopes  of  cure 
by  the  new  remedy.  The  other  patient  was  in  an  early 
stage  of  phthisis  but  very  wasted,  and  much  enfeebled 
mentally  as  well  as  physically.  Although  verv  little 
fever  followed  the  injections  there  was  severe  headache 
on  each  occasion,  so  that  after  four  had  been  given  they 
were  remitted  for  a  time.  Then  they  were  again  used, 
and  he  received  fifteen  more,  always  suffering  severely 
from  pains  in  the  head.  He  also  lost  weight.  He  then 
lapsed  into  a  state  of  melancholia  with  marked  delusions. 
Mention  was  also  made  of  a  hysterical  subject  who  be- 
came markedly  delirious  after  each  of  three  injections 
she  received  ;  she  had  been  very  delirious  previously  dur- 
ing the  hectic  fever  of  the  phthisis  from  which  she 
suffered.  Although  such  symptoms  might  arise  only  in 
a  minority  and  were  seldom  permanent,  yet  occasionally 
(in  predisposed  subjects)  they  initiated  an  incurable  dis- 
order. Hence  the  need  to  proceed  very  carefully  with 
injections  in  such  subjects. 

Dr.  Henoch  spoke  unfavorably  of  the  treatment  in 
pulmonary  tuberculosis  of  children,  of  whom  he  had 
treated  twenty  by  this  method.  Three  of  these  were  in 
the  "advanced"  stage,  but  without  fever;  they  were  all 
made  much  worse,  the  fever  induced  by  the  injectious 
persisting  as  hectic.  Yet  only  %  mgr.  lat  first  he  only 
gave  1-10  mgr.)  was  given  at  the  commencement  of 
treatment,  and  the  largest  dose  was  3  mgr.  In  one  case 
there  was  temporary  improvement,  dulness  disappearing; 
only,  however,  to  return  with  increase  of  other  signs  on 
continuance  of  the  injectious.  Another  case  illustrated 
Professor  Yirchow's  statements.  A  girl  n  years  old, 
whose  mother  had  recently  died  from  phthisis,  had  suf- 
fered from  a  cough  for  a  year;  but  there  were  hardlv  any- 
physical  signs,  except  slight  dulness  near  spine  of  scap- 
ula, prolonged  expiration,  and  some  rhonchus  at  apices. 
An  injection  of  ',  mgr.  gave  no  reaction.  One  of  1  mgr. 
produced  next  day  a  rise  of  temperature  to  3S.6°,  and 
some  rales  appeared  at  the  left  base.  Five  injections  in 
all  were  given,  and  a  few  days  after  the  last,  signs  of  ex- 
tensive consolidation  of  the  left  lung  appeared;  and  even 
after  a  month's  interval  they  had  very  slightlv  decreased. 
Obviously  it  was  not  a  mere  transitory  bvperremia,  but 
whether  caseous  or  catarrhal  hepatization  conld  not  be 
determined.     There  was  some  suspicion  of  commencing 


•386 


TOPICS  OF  THE  WEEK. 


[March  14, 


excavation,  for  the  breathing,  which  was  intensely  bron- 
chial, had  an  occasional  amphoric  tone,  and  the  rales 
were  metallic.  Prof.  Henoch  attributed  this  change  with- 
out doubt  to  the  injections.  He  said  not  one  of  his  cases 
had  been  "cured,"  not  one  "  improved  "  except  the  one 
which  subsequently  relapsed  to  a  worse  state;  and  he  was 
embarrassed  to  decide  if  he  should  continue  the  treat- 
ment in  children  any  longer.  It  would  be  ludicrous  in 
the  case  of  a  child  to  follow  the  practice  of  some  physi- 
cians who  do  not  use  the  injections  except  at  the  patient's 
o\\  11  wish.  Bearing  in  mind  the  tendency  for  tubercle  in 
children  to  be  dispersed  in  many  foci  throughout  the 
body,  he  felt  one  would  be  justified  in  only  using  it  with 
itest  reserve,  and  perhaps  at  no  distant  date  in 
discontinuing  the  practice  altogether. —  The  Lam;/. 


SOME  MILK  STATISTICS. 

The  American  Analyst  says  that  there  are  $2, 000,500,- 
000  invested  in  the  dairy  business  in  this  country.  That 
amount  is  almost  double  the  money  invested  in  banking 
and  commercial  industries.  It  is  estimated  that  it  re- 
quires 15,000,000  cows  to  supply  the  demand  for  milk 
and  its  products  in  the  United  States.  To  feed  these 
cows  60,000,000  acres  of  land  are  under  cultivation.  The 
agricultural  and  dairy  machinery  and  implements  are 
worth  $200,000,000.  The  men  employed  in  the  business 
number  750,000,  and  the  horses  over  1,000,000.  There 
are  over  12,000,000  horses  all  told.  The  cows  and  horses 
consume  annually  30,000,000  tons  of  hay  and  nearly  90,- 
000,000  bushels  of  cornmeal,  about  the  same  amount  of 
oatmeal,  275,000,000  bushels  of  oats,  2,000,000  bushels  of 
bran,  and  30,000,000  bushels  of  corn,  to  say  nothing  of 
the  brewery  grains,  sprouts,  and  other  questionable  feeds 
of  various  kinds  that  are  used  to  a  great  extent.  It  cost 
$450,000,000  to  feed  these  cows  and  horses.  The  average 
price  paid  to  the  labor  necessary  in  the  dairy  business  is 
probably  $20  per  month,  amounting  to  $iSo,ooo,ooo  a 
year.  The  average  cow  yields  about  450  gallons  of  milk 
a  year,  which  gives  a  total  product  of  6,750,000,000. 
Twelve  cents  a  gallon  is  a  fair  price  to  estimate  the  value 
of  the  milk,  at  a  total  return  to  the  dairy  farmers  of 
$810,000,000,  if  they  sold  all  their  milk  as  milk.  But  50 
per  cent,  of  the  milk  is  made  into  cheese  and  butter.  It 
takes  27  pounds  of  milk  to  make  1  pound  of  butter,  and 
about  10  pounds  to  make  1  pound  of  cheese.  There  is 
the  same 

of  milk  that  mere   is   111    1   pou 

furnishes  50  per  cent,  of  boneless  beef,  but  it  would  re- 
quire 24,000,000  steers,  weighing  1,500  pounds  each,  to 
produce  the  same  amount  of  nutrition  as  the  annual  milk 
product  does. — Dietetic  Gazette. 


in  fact  to  any  one  physician,  their  rule  being  to  change 
doctors  two  or  three  times  a  day  if  they  can  afford  it. 
Again,  there  have  been  but  small  hospital  facilities  for 
studying  fevers,  and  there  is  an  impossibility  of  obtain- 
ing post-mortem  examinations.  Dr.  Coltman  considers 
that  small-pox  is  the  most  common  disease,  nearly  even- 
person  suffering  from  it  at  some  period  of  his  or  her  life. 
Vaccination,  although  practiced,  is  done  very  carelesslv. 
Measles  appear  to  be  common,  but  is  somewhat  milder 
than  in  Europe.  Scarlet  fever,  althought  it  undoubtedly 
occurs  among  the  natives,  is  far  less  common  than 
amongst  Europeans.  Erysipelas  is  rare.  Typhoid  fever 
is  very  difficult  to  diagnose  in  the  short  time  that  a  for- 
eign medical  man  is  allowed  to  attend  a  case;  but  Dr. 
Coltman  thinks  that  when  more  accurate  reports  are 
possible,  this  disease  will  be  found  to  be  more  common 
among  the  natives  than  is  now  supposed.  Typhus  fever 
is  met  with  all  over  North  China,  and  as  far  south  as 
Shanghai.  Relapsing  fever  is  found  constantly  associated 
with  typhus.  Dengue  does  not  seem  to  be  known  amongst 
natives.  Cholera  occurs  as  an  epidemic  every  few  years 
and  is  very  fatal.  Diphtheria  is  severe  and  frequently 
fatal  amongst  the  natives.  Whooping-cough  has  occa- 
sionally been  met  with.  Rheumatic  fever  is  very  preva- 
lent in  some  parts.  Chronic  muscular  rheumatism  is 
common  all  over  China,  but  is  unattended  by  fever.  Ma- 
larial fevers  appear  to  be  common  everywhere,  though 
the  prevailing  type  varies;  thus,  tertian  is  most  common 
in  Pekin,  quartan  in  Foochow,  Swatow,  Shanghai  and 
Hangchow,  and  remittent  in  Cheefoo  and  Tientsin.  In 
Chinanfu  Dr.  Coltman  has  never  seen  a  case  of  quar- 
tan ague;  it  is  all  intermittent  of  the  tertian  or  quotidian 
type.  The  treatment,  of  course,  of  all  malarial  fever  is 
by  quinine  or  some  other  cinchona  bark  alkaloid.  In 
Hangchow  the  carbolic  acid  and  iodine  treatment  has 
been  used  successfully  as  a  prophylactic;  arsenic  is  rec- 
ognized as  valuable  in  the  chronic  form. — Lancet. 


THE  BARRING  OUT  OF  FOREIGN  DIPLOMAS  BY  THE 
ILLINOIS  STATE  BOARD  OF  HEALTH. 

This  action  was  taken  because:  1.  The  diplomas  of 
medical  schools  and  universities  do  not  entitle  the  holders 
to  practice  in  these  countries;  2.  As  may  be  seen  from  p. 
viii  of  the  "Report  on  Medical  Education"  of  the  Illinois 
State  Board  of  Health  for  1S91,  the  Prussian  Staats-Ex- 

amount  of  nutritive  albuminoids"inS'<  pounds    amer  Coml»issi°u  rejected  in  1890  more  than  40  per  cent. 

bat  there  is  in    x  pound  of  beef.     A  fat  steer   of  the  Sraduates  of  the  University  of  Berlin,  more  than 

17  per  cent,  of  the  Breslau  graduates,  more  than  31  per 
cent,  of  the  Griefswald  and  Halle  graduates— and  in  fact 
more  than  29  per  cent,  of  the  university  graduates  that 
came  before  the  commission;  3.  Many  of  the  rejected  can- 
didates come  to  this  country;  |.  .Many  such  graduates, 
fearful  of  failing  in  the  government  examinations  in 
then  own  countries,  come  to  this  country  to  enjoy  a 
privilege  denied  them  at  home  of  practicing  medicine 
simply  on  their  diplomas;  5.  The  Illinois  State  Board  of 
Health  feels  that  it  should  not  place  upon  such  diplomas 
lluation  than  is  given  to  them  in  the  countries 
in  which  they  are  granted. 


iiii;  FEVERS  of  china. 
Dr.  Coltman,  writing  in  the  China  medical  missionary 
journal  npon  the  fevers  of  China,  remarks  that  hut  little 
i<  on  the  subject  has  been  made  up  to 
the  present  time,  owing  to  the  comparatively  recent  ad- 
vent of  foreign  medical  men,  and  to  the  want  of  confi- 
dence on  the  part  of  natives  to  submit  for  any  length- 
ened period  to  the  treatment  of  a  foreign   phi 


i89i.] 


PRACTICAL   NOTES. 


387 


•    PRACTICAL   NOTES 


rotter's  antiseptic. 

R.    Zinc  chloride. 

Zinc  sulpho-carbolate,  aa  3.00  grams  (45  grains). 
Boracic  acid,  1.80 

lium  chloride.  0.15  grain  [2.%  grains). 
Salicylic  acid,  0.33  gram  16  grai 
Citric  acid. 

Thymol,  aa  0.06  gram  11  grain  V 
Water.  473.12  c.cm.  11  pint).     tJC- 

This  solution  is  used  for  compresses,  irrigation 
of  wounds,  etc.,  in  surgery. — Merck' '  s  Bulletin. 


IODIDE    OF    POTASSIUM    IN    GONORRHEAL     RHEU- 
MATISM. 

Rubinstein  strongly  recommends  (in  the  Thera- 
peutische  Monatshefte  I  the  treatment  of  arthrites 
and  inflammations  of  the  mucous  bursa;  with 
potassium  iodide  after  the  following  formula  : 

R.     Potassium  iodide.  3  iv. 
Distilled  water,  gv. 

Mix  and  dir-  fablespootiful  every  hour  for 

two  or  three 

Amelioration     usually    begins    after    three   or 
four  dose*.      Rubinstein   reports   fifteen  cases  of 
acute    and     subacute     gouorrhceal    rheumatism 
treated  in  this  manner  with  the  happiest  results 
— National  Druggist. 


their  dislodgtnent  was  likely  to  prove  valueless. 
He  held  that  operation  should  be  early  resorted 
to  in  a  well  defined  case,  and  an  explorat 
cisiou  should  be  made  where  doubt  existed  The 
mortality,  where  the  operation  was  undertaken 
before  complications  had  arisen,  was  but  small, 
and  it  should  be  remembered  that  a  post-mortem 
diagnosis  was  of  no  use  to  the  patient  and  of 
very  little  consolation  to  the  friends. — A* 
Medical  Journal. 

THE      TREATMENT     OF     SYPHILIS      DURING 
PREGNANCY. 

Besnier  {Journal '  de  Midecine,  November,  1890), 
has  obtained  good  results  in  the  treatment  of 
syphilis,  during  pregnancy,  by  the  administration 
of  cinchona  wine  and  syrup  of  the  iodide  of  iron 
as  tonics,  together  with  nourishing  food.  The 
patient  also  took  daily  a  pill  containing  one  sixth 
of  a  grain  of  bichloride  of  mercury,  combined 
with  one  twelfth  of  a,  grain  of  extract  of  opium 
and  one  twelfth  of  a  grain  of  extract  of  gentian, 
the  whole  rubbed  up  with  glycerine.  Iodide  of 
potassium  was  also  advised  in  amounts  of  from 
seven  and  a  half  to  fifteen  grains  daily. — Amer- 
ican Journal  Medical  Sciences. 


TO  REMOVE  THE  PIGMENTATIONS  OF  PREGNANCY. 

In  the  Journal  de  Medeciw  de  Paris.  January 
4,  1 89 1,  the  following  ointment  is  recommended 
to  be  rubbed  into  the  affected  parts  twice  daily  to 
remove  the  pigmentations  which  so  often  disfigure 
pregnant  women : 
R.    Cocoa  butter. 

Castor  oil,  aa  ,^ij  \  . 

Oxide  of  zinc,  gr.  v. 

Yellow  oxide  of  mercury,  gr.  ij. 

Essence  of  roses,  enough  to  perfume. 


A    MIXTURE    FOR    SIMPLE    COLIC. 

Dujardin  Beaumetz,  it  is  stated,  recommends  the 
following  mixture  in  the  treatment  of  colic  : 
R.     Strong  chloroform-water,  4  ounces. 
Decoction  of  orange-flowers,  4  ounces. 
Tincture  of  capsicum.  2  drachms. 

A  dessertspoonful  of  this  mixture  may  be  given 
every  fifteen  minutes  until  the  pain  is  relieved. 


TREATMENT    OF    INGROWN    NAIL. 

Dr.  Ptirckhauer  moistens  the  surface  of  the 
diseased  nail  with  a  luke  warm  forty  per  cent, 
solution  of  caustic  potash,  and  then  scrapes  off 
the  softened  upper  layers  with  a  sharp-edged 
piece  of  glass.  After  a  second  application  of  the 
potash  solution  the  scraping  is  continued  until 
the  nail  is  as  thin  as  a  sheet  of  paper.  It  is  then 
lifted  up  from  the  soft  parts  with  forceps,  and  the 
diseased  parts  are  excised. —  Therapeutic  > 


PREPARATION    OF   SACCHARIN. 
R      saccharin,  150  grains. 

Bicarbonate  of  soda,  75  grains. 
Distilled  water.  Oij. 

One  part  of  this  solution  is  equivalent  to  two 
and  one- half  times  as  much  sugar. — ATou:eaux 
Reniedes. 


THE    TREATMENT    OF    GALL-STONES. 

Dr.  W.  W.  Seymour,  of  Troy,  in  a  paper  on 
this  subject,  after  reviewing  all  the  theories  as  to 
the  possibility  of  successfully  dislodging,  dissolv- 
ing, or  otherwise  effecting  the  removal  of  gall- 
stones by  medicinal  agents,  concluded  with  the 
emphatic  opinion  that  these  accretions  could  not 
>lved.  and  that  all  medical  treatment  for 


DNNA'S  TREATMENT  FOR  RED  NOSE. 

When  red  nose  is  due  to  acne  rosacea  Unna 
gives  ichthyol  internally  in  doses  of  5  grains, 
and  prescribes  at  the  same  time  lotions  of  the 
same  substance  in  aqueous  solution.  At  night, 
the  following  paste  is  applied  to  .  the  affected 
organ  : 

R.    Sulphur   3  -  - 

Rice  powder.  3  iv- 
Ointment  of  zinc  oxide,  5  v. 
Mix,  and  make  a  pomade. 

If  the  patient  is  scrofulous  or  debilitated,  he 
also  orders  cod-liver  oil,  syrup  of  iodide  of  iron, 
etc. — Bacteriological   World. 


SOCIETY  PROCEEDINGS 


[March  14, 


SOCIETY    PROCEEDINGS. 

Gynecological  Society  of  Chicago.1 

Regular  Meeting  of  Nov.  21,  1890. 

The  President,  Dr.  W.  W.  Jaggard,  in  the 

Chair. 

exhibition  of  specimens. — extra-uterine 

pregnancy. 

Dr.  C.  T.  Parkes  presented  a  specimen  taken 
from  a  case  of  ruptured  Fallopian  pregnancy 
where  the  history  extended  back  three  months, 
and  the  symptoms  of  rupture  to  three  weeks. 
But  three  days  had  elapsed  since  the  operation, 
and  therefore  the  outcome  could  not  be  told. 

The  second  specimen  was  of  a  fibroid  uterus, 
removed  through  the  vagina  in  August  last. 
Electricity  had  previously  been  thoroughly  tried, 
but  without  effect.  Upon  incising  the  specimen 
a  small  intra-uterine  fibroid  was  found  projecting 
internally,  and  which  could  not  be  cauterized  by 
the  intra-uterine  electrode. 

Dr.  Karl  Sandberg  first  offered  a  specimen 
of  large  sized  ovarian  abscess. 

Next  was  a  supposed  papilloma  of  the  ovary, 
removed  from  a  girl  sixteen  years  old,  where 
there  had  been  a  history  of  much  pain  with 
marked  enlargement  of  the  ovary — since  an  at- 
tack of  scarlet  fever  four  years  previously. 

The  third  specimen  was  a  tube  and  ovary  ap- 
parently normal,  but  which,  from  an  incomplete 
history,  was  evidently  the  source  of  the  debility 
and  retardation  of  convalescence  from  parturition 
ten  months  before. 

A  fourth  specimen  showed  pyo-salpinx,  re- 
moved three  weeks  previously.  This  also  fol- 
lowed the  puerperal  state,  and  was  evidently  pro- 
ducing an  altered  condition  of  the  mind.  Since 
operation,  .however,  all  appearances  of  insanity 
had  disappeared. 

Dr.  Henry  P.  Newman  read  a  paper  entitled 

the    remote    results    of    shortening  the 
round  ligaments  for  uterine   dis- 
placements by  the  newer 
direct  method. 
After  reviewing  a  few  of  the  technical  points  of 
Alexander's  operation,  particularly  with  reference 
to  the   initiative   steps  of  finding   the  chord   by 
deepening  the   wound  to  the  aponeurosis  of  the 
external  oblique,  and  referring  to  the  acceptance 
of  a  new  method  first  suggested  by  Dr.  J.  Frank, 
of  Chicago,  the  claim  of  calling  this  the  "direct 
treatment"  was  defended  by  the  following  distinc- 
tive   advantages,   viz.:    1.  The  single   sweep  or 
two  with  which  we  cut  down  upon   the   inguinal 
canal  or  the  glistening  aponeurosis  of  the  trans- 
versalis  muscle,  directly  over  the  internal   ring, 
or  canal  of  Nuck.     2.  Through  a  single  nick   in 

icted  forThe  Journal. 


the  course  of  the  reflected  fibres  of  this  aponeuro- 
sis the  blunt  hook  may  often  be  passed  into  the 
canal  and  the  round  ligament  pulled  out  in  less 
time  than  it  takes  to  tell  it;  or,  by  lengthening 
the  incision,  it  may  be  exposed  along  the  canal 
in  its  entirety.  3.  There  can  be  no  doubt  here 
of  the  identity  of  the  ligament,  as  a  duplication 
of  the  peritoneum  is  seen  surrounding  it  at  its 
abdominal  extremity.  4.  The  force  used  in  pul- 
ling out  the  ligament  is  both  brought  to  bear 
upon  it  at  its  strongest  portion  and  is  in  a  direct 
line  with  its  intra-abdominal  course.  This  is  in 
strong  contrast  to  the  old  mode  of  pulling  upon 
its  frayed- out  terminal  fibres  at  an  acute  angle 
with  its  inner  and  stronger  portion  and  over  the 
sharp,  resisting  surface  of  the  ring.  5.  Aided  by 
the  sense  of  sight,  and  seizing  the  ligament  above 
the  inguinal  canal,  we  can  feel  assured  that  we 
are  drawing  upon  the  abdominal  portion  of  the 
ligament,  and  not  merely  stretching  its  inguinal 
section.  6.  As  there  are  few  or  no  adhesions  at 
this  portion,  there  should  be  absolutely  no  tear- 
ing of  the  tissues.  Consequently,  where  aseptic 
methods  are  used,  there  should  always  be  healing 
by  first  intention,  and  drainage  and  after  treat- 
ment be  relatively  simplified.  7.  Where  the  lig- 
ament is  strong  and  fully  developed,  as  it  is  in  its 
upper  portion,  it  can  be  more  securely  anchored 
or  made  fast  to  the  surrounding  tissues.  8.  Hernia 
is  guarded  against  by  deep  sutures  constricting 
the  canal  about  the  internal  ring,  insuring  firm 
union  where  most  needed.  9.  The  intercolumnar 
fibres  and  tissues  about  the  internal  ring  are  not 
interfered  with  or  irritated  in  any  way. 

The  histories  of  seven  cases  were  given  where- 
in the  operation  of  abbreviating  the  round  liga- 
ments had  been  performed.  In  all  the  cases  two 
3'ears  or  more  had  passed  since  the  operation,  and 
the  results  were  shown  to  be  highly  successful. 
In  three  cases  there  was  retroversion  with  pro- 
lapsus of  both  uterus  and  ovaries;  in  one  proci- 
dentia with  enlarged,  tender  ovaries;  and  the  re- 
maining number  "presented  the  usual  menstrual 
disorders  indicative  of  the  severer  types  of  uterine 
and  ovarian  displacements,  and  were  upward  of 
ten  years'  standing." 

Dr.  A.  W.  Abbott,  of  Minneapolis,  Minn., 
reported  nineteen  cases  in  which  he  had  clone  the 
operation  up  to  November,  1888.  All  of  them 
were  for  retroflexion,  and  not  for  prolapsus.  The 
Alexander  method  was  closely  followed,  and  with- 
out the  difficulty  described  by  some.  He  be- 
lieved that  if  Dr.  Alexander's  directions  were 
followed  implicitly  the  operation  would  be  found 
simple  and  easy;  at  the  same  time  he  would  not 
disparage  Dr.  Newman's  ideas.  Of  his  nineteen 
cases  in  thirteen  the  normal  position  of  the  uterus 
is  maintained,  and  of  these  eleven  stand  improved, 
and  two  unimproved.  Of  those  in  which  the  pos- 
ition is  not  improved,  six;  in  three  the  symptoms 
are  improved.     Of  the  total  number  of  operations, 


I89i.] 


SOCIETY  PROCEEDINGS. 


389 


the  sj  mptoms  have  entirely  disappeared  in  ten, 
in  four  they  are  improved,  and  in  five  not  im- 
proved at  all.  Dr.  Abbott  believed  that  the  re- 
sults were  far  better  in  the  parous  state;  and 
that  manifest  adhesions,  or  the  slightest  history 
of  a  former  peritonitis  should  preclude  operative 
measures. 

Dr.  F.  H.  Martin  reported  the  same  number 
of  cases  as  Dr.  Abbott,  and  contended  strongly 
for  a  proper  and  thoroughly  cautious  selection  of 
cases.  In  cases  that  were  well  selected  the  jus- 
tifiableness  of  the  operation  had  been  well  demon- 
strated. Dr.  Martin  believed  the  operation  was 
well  indicated  in  those  cases  in  which  the  uterus 
allowed  of  replacement  and  retention  by  a  well- 
fitting  pessary,  and  that  it  is  only  in  such  cases 
that  it  should  be  doue. 

Dr.  T.  J.  Watkins  had  performed  the  opera- 
tion a  limited  number  of  times,  and  had  had  an 
opportunity  of  observing  its  results  in  a  large 
number  of  cases.  "None  of  these,"  he  says, 
"were  called  therapeutically  cured,  but  in  many 
of  them  an  alleged  anatomical  cure  resulted.  The 
suffering  in  these  so-called  anatomical  cases  is 
caused,  in  my  opinion,  either  by  adhesions,  by 
mal-  location  of  the  uterus,  or  by  continuous  strain 
upon  the  shortened  ligaments,  that  is,  muscular 
strain." 

Dr.  H.  P.  Newman,  in  closing  the  discussion, 
said  :  "  There  will  always  be  failures  in  this  op- 
eration where  it  is  done  for  indications  that  Al- 
exander's operation  is  not  claimed  to  cure.  Where 
done  as  a  conservative  operation  for  restoring 
ovaries,  their  condition  not  being  definitely  known, 
there  is  always  an  element  of  uncertainty  and  al- 
ways a  possibility  of  failure ;  but  the  failure 
should  not  be  referred  to  the  operation,  but  to  the 
judgment  of  the  physician.  In  regard  to  the 
method  I  have  brought  forward,  the  points  that 
I  have  stated,  I  think,  are  well  taken,  and,  if  put 
in  practical  use,  will  perhaps  be  better  realized 
than  thej-  can  be  by  simply  hearing  them  tabu- 
lated here." 

Dr.  Bayard  Holmes  read  a  paper  having  the 
title 

THE  TREATMENT  OF  ACUTE  AX.EMIA  BY 
INFUSION. 

After  barely  touching  the  history  and  uses  of 
transfusion,  Dr.  Holmes  struck  out  with  the  state- 
ment: "  Death  from  haemorrhage  is  due  to  anae- 
mia of  the  brain:"  and  "fatal  anaemia  maybe 
either  quantitative  or  qualitative."  The  author 
then  dwelt  upon  the  physiological  state  and  qual- 
ity of  the  blood,  and  the  loss,  both  in  volume  and 
constituency,  which  could  be  sustained  before 
reaching  the  fatal  point.  And  in  considering  the 
loss  of  blood  as  the  cause  of  death  in  obstetrical 
and  surgical  cases,  as  well  as  in  accidents,  and  as 
a  factor  in  protracted  convalescence,  he  felt  that 
its  best  mode  of  treatment  should  be  well  recog- 


nized. If  one-half  the  volume  of  the  blood  was 
to  be  found  in  the  collapsible  veins,  it  was  quite 
evident  that  they  would  be  first  emptied  in  pro- 
fuse bleeding.  If  an  anaemic  patient  be  placed 
in  a  vertical  position,  with  the  head  down,  the 
vessels  throughout  the  three  vital  parts,  viz..  the 
brain,  heart,  and  lungs,  will  be  freely  distended 
with  the  least  amount  of  blood,  and  therefore 
the  first  indication  in  severe  acute  anaemia  is  to 
procure  and  maintain  this  decubitus.  Bandaging 
the  extremities  would  have  quite  the  same  effect. 
When  these  measures  fail  to  meet  the  require- 
ments of  the  case,  the  recourse  to  the  infusion  of 
a  neutral  salt  solution  will  be  found  necessary. 
The  amount  of  salt  solution,  as  well  as  its  con- 
centration, was  of  some  moment.  Yet  it  is  not 
unlikely  that  the  establishment  of  a  quantitative 
equilibrium  will  prove  but  temporarily  a  relief, 
inasmuch  as  the  oxygen- carrying  and  nutritive 
needs  of  the  circulation  are  not  thereby  met.  It 
is  then  the  desired  result  may  be  won  by  the 
transfusion  of  defibrinated  blood. 

The  paper  concluded  with  the  following  apho- 
risms :  1 .  In  dangerous  acute  anaemia  auto  trans- 
fusion should  first  be  practiced.  2.  When  the 
lymph  spaces  are  drained,  as  is  indicated  by  the 
sunken  and  drawn  appearance  of  the  face,  or  by 
the  time  auto  transfusion  has  been  tried  and  the 
symptoms  of  anaemia  persist,  infusion  of  a  large 
amount  of  0.6  per  cent,  salt  solution  should  be 
practiced.  The  necessary  apparatus  is  so  simple 
and  the  danger  so  remote  that  this  measure  should 
not  be  neglected.  3.  The  immediate  intra  vas- 
cular injection  of  salt  solution  or  blood  for  acute 
anaemia  cannot  be  countenanced  in  the  present 
state  of  our  experience  and  knowledge.  4.  The 
value  of  secondary  subcutaneous  or  intraperito- 
neal injection  of  blood  in  cases  of  so  extensive 
haemorrhage  that  a  qualitative  anaemia  is  pres- 
ent after  the  mechanical  needs  of  the  circulation 
are  satisfied,  is  still  conjecture,  but  certainly 
such  injection  of  blood  should  not  be  practiced 
until  reaction  is  well  restored.  5.  The  immedi- 
ate subcutaneous  injection  of  blood  diluted  with 
a  large  amount  of  salt  solution  is  not  contra-in- 
dicated .  but  its  value  is  still  problematical.  6.  The 
rotary  surgical  pump  is  the  most  perfect  and  man- 
ageable apparatus  yet  proposed  for  subcutaneous 
infusions  and  injections  of  large  amounts,  and 
for  direct  intravascular  transfusion. 

Dr.  Parkes  desired  to  ask  the  author  what 
local  effect  the  introduction  of  a  quart  of  the  so- 
lution had.  He  referred  to  two  instances  where 
a  large  quantity  of  the  salt  solution  was  injected 
to  exsanguinated  patients,  in  both  of  which  good 
results  followed. 

Dr.  F.  H.  Martin  commended  the  apparatus 
exhibited  by  the  author  of  the  paper.  He  also 
spoke  of  the  very  favorable  results  in  a  case  un- 
der his  care. 

The  President  mentioned  the  effect  of  a  pro- 


390 


SOCIETY  PROCEEDINGS. 


[March  14 


fuse  haemorrhage,  and  spoke  also  of  the  subcu- 
taneous use  of  the  salt  solution  in  a  case  of  pro- 
found collapse,  and  where  an  almost  magical  ef- 
fect was  produced. 


Philadelphia  Electro-Therapeutic  Society. 

Wm.  H.  Walling,  M.D.,  Secretary. 

.  The  February  meeting  of  this  society  was  held 
at  36  N.  Nineteenth  St.,  February  8,  President 
G.  Betton  Massey,  M.D.,  in  the  Chair.  The 
minutes  of  the  last  meeting  having  been  read  and 
approved,  and  the  Treasurer's  report  having  been 
received  and  accepted,  the  society  went  into  the 
election  of  officers  for  the  ensuing  year,  with  the 
following  result : 

President,  Dr.  Matthew  W.  Grier  ;  Vice-Presi- 
dents. Drs.  I.  P.  Willits  and  Horatio  R.  Bigelow; 
Secretary  and  Treasurer,  Dr.  Wm.  H.  Walling  ; 
Executive  Council,  Drs.  G.  Betton  Massey,  J.  J. 
Taylor,  and  W.  H.  Walling. 

Dr.  Massey  then  read  the  following  paper  : 

electro-puncture  of  a  cystic  goitre  ;  disap- 
pearance OF   BOTH  CYST  AND  GOITRE. 

A  maiden  lady,  aged  41  years,  was  brought  to 
me  by  Dr.  Emily  W.  Wyeth,  Oct.  1,  1889,  with 
an  irregularly  shaped  goitre,  about  the  size  of  a 
small  orange.  The  left  lobe  was  much  the  larger 
and  was  the  seat  of  a  monocyst  of  considerable 
proportions,  which  had  increased  very  much  dur- 
ing the  last  year,  the  growth  having  been  no- 
ticed about  seventeen  years.  The  circumference 
of  the  neck  at  this  point  was  sixteen  and  three- 
eighths  inches.  Treatment  was  begun  by  a  neg- 
ative puncture  of  the  cyst  with  a  solid  needle,  35 
milliamperes  being  used  for  fifteen  minutes.  This 
was  followed  by  a  considerable  oozing  of  a  straw- 
colored  liquid.  Four  days  later  the  cyst  was 
evacuated  of  its  contents,  measuring  an  ounce 
and  a  half,  and  40  ma.  negative  applied  to  the 
cyst  walls  for  ten  minutes,  by  means  of  the  cau- 
ula  acting  as  an  electrode,  the  latter  being  insu- 
lated as  far  as  the  cavity.  This  procedure  was 
repeated  five  times  subsequently,  with  current 
strengths  rising  to  100  ma.,  the  cavity  being  per- 
mitted to  refill  after  each  puncture.  Careful 
measurements  showed  that  the  cyst  was  refilling 
more  slowly  after  each  application,  but  on  Dec 
9  it  was  decided  by  Dr.  Wyeth  and  myself  to 
make  a  free  opening  and  apply  the  positive  pole, 
by  means  of  a  gold  bulb  electrode,  to  all  sides  of 
the  cavity  at  stated  intervals,  maintaining  free 
■  in  the  meantime.  This  procedure  was 
required  but  twice,  with  currents  of  100  and  of 
50  ma.,  the  drainage-tube,  which  was  most  assid- 
uously looked  after  by  I  >r  Wyeth,  bein] 
ually  shortened  and  removed  (in  the  seventh  day. 
During  this  time  the  patient  suffered  a  slight  rise 
pi  ratine,  due  to  a  temporary  obstruction  of 


the  discharge  by  accidental  removal  of  the  tube. 
By  February  21  nothing  remained  of  the  growth 
but  a  cicatricial  lump  about  the  size  of  a  peach 
stone,  and  two  months  later  this  had  also  disap- 
peared without  further  treatment. 

Dr.  Grier  :  Has  never  treated  the  cystic  vari- 
ety, but  has  used  outward  applications  on 
true  goitre  with  currents  of  not  over  twenty-five 
ma.  He  used  tin  electrodes  covered  with  muslin, 
placing  the  positive  pole  on  the  inferior  cervical 
ganglion,  and  two  negative  plates  upon  the  tu- 
mor, one  on  each  side.  The  sittings  lasted  for 
five  minutes  each,  being  repeated  three  times  a 
week,  for  from  two  to  three  months.  Some 
preparation  of  the  iodides  was  also  used.  Favor- 
able results  were  obtained  in  about  fifty  per  cent, 
of  the  cases. 

Dr.  Peterson  spoke  of  a  case  in  which  the 
fluid  extract  of  ergot  was  used,  with  good  effect, 
being  applied  to  the  tumor  upon  the  positive  pole. 

Dr.  Bigelow:  There  is  a  canton  in  Switzerland 
in  which  you  cannot  walk  out  without  meeting 
a  goitre.  The  disease  is  not  confined  to  those 
who  drink  the  waters,  neither  to  those  who  carry 
heavy  burdens  on  their  heads. 

Dr.  Bigelow  could  not  see  why  the  same  treat- 
ment should  not  be  followed  in  a  fibroid  in  the 
neck,  as  well  as  in  any  other  part  of  the  body. 

In  a  cystic  tumor  the  action  of  the  current  was: 
1.  Electrolysis.  2.  The  arresting  of  secretion, 
and  3.  To  compel  absorption.  He  also  thought 
that  constriction  should  act  well  in  such  cases. 
Neggaroth  uses  the  faradic  current  in  overcom- 
ing ovarian  cysts.  He  applies  the  negative  pole ' 
to  the  ovaries,  per  vagina,  and  the  positive  on  the 
abdomen,  using  swelling  currents  for  an  hour  at 
a  sitting,  obtaining  good  results  in  six  weeks.  It 
must  be  the  heavy  voltage  that  acts  so  favorably, 
and  if  in  one  case,  why  not  another? 

Dr.  Grier  had  used  faradism  in  goitre,  but 
abandoned  it  on  account  of  its  unpleasant  effects. 

Dr.  Walling  :  Dr.  Massey  says  that  he 
emptied  the  cyst  before  applying  the  galvanic 
current.  We  must  be  guided  by  experience,  as 
well  as  by  theory.  Why  was  the  positive  used  ? 
Was  not  the  negative  pole  the  one  indicated  ?  In 
the  treatment  of  hydrocele,  Dr.  Walling  does  not 
drain  the  sac,  unless  it  is  extremely  distended, 
and  then  but  little.  Use  the  negative  needle  in 
the  tumor,  and  the  positive  on  the  thigh,  with  a 
current  strength  of  fifteen  ma.  for  fiftten  or 
twenty  minutes.  He  had  excellent  results  in 
such  cases.  Scarcely  any  inflammation  followed, 
and  the  contents  of  the  cysts  were  rapidly  ab- 
sorbed, with  obliteration  of  the  sacs, 

He  had  used  the  strong  faradic  current,  but 
saw  no  benefit  from  it,  although  it  caused  strong 
contractions  of  the'  muscles  Win  not  tieat  other 
cysts  in  the  same  way  5  You  cannot  reach  all 
parts  of  tlie  surface  of  the  sac,  after  emptying  it, 
while  some  parts   would   be  unduly  acted  upon, 


iSgi.] 


FOREIGN  CORRESPONDENCE. 


39i 


tending  to  set  up  too  much  inflammation.  What 
better  electrolytic  than  the  fluid  in  the  sac,  thus 
reaching  every  portion  alike. 

Dk.  MASSEY  said  he  was  disposed  to  regard  the 
faradic  current  as  of  no  value  in  cystic  tumors ; 
hut  in  one  case,  where  a  cyst  developed  in  a 
fibroid,  he  used  a  strong  faradic  current  with 
great  advantage.  He  regarded  aseptic  aspiration, 
followed  by  electrolytic  puncture,  as  the  best  pro- 
cedure in  cystic  conditions. 


FOREIGN    CORRESPONDENCE. 


LETTER  FROM  LONDON. 

Cfrom  our  regular  correspondent.) 

The  Physical  Advantages  of  Abstinence — The 
New  Fashion  of  Naming  Bazaars — What  a  Spell 
oj  Severe  Weather  Cost  the  Metropolis  —  Low 
Death- Rate  in  the  British  Army — The  Gull  Stu- 
dentship in  Pathology — Ether  Drinking  in  Ireland 
The  Barber-Surgeons  of  London — Female  Nursing 
in  India — Dr.  Koch  has  a  Rival  at  Edin- 
burgh. 

At  a  meeting  recently  held  for  the  consideration 
of  the  physical  advantages  of  abstinence,  the 
chair  was  occupied  by  Dr.  B.  W.  Richardson,  who 
in  opening  the  proceedings  detailed  some  of  the 
researches  which  he  had  made  at  the  instance  of 
the  British  Association  in  1863, -when  he  was  re- 
quested to  continue  his  inquiries  into  the  action 
of  various  chemical  substances  on  animal  bodies. 
His  observations  led  him  to  the  conclusion  that  the 
effect,  even  in  strict  moderation,  of  alcohol  was  in- 
variably to  reduce  the  temperature  of  the  body, 
whilst  it  neither  tended  to  promote  its  muscular 
development  nor  strengthen  its  vital  power.  Dr 
Norman  Kerr  directed  his  remarks  chiefly  to 
young  men,  and  he  pointed  out  that  the  habitual 
use  of  alcohol  led  to  the  augmentation  of  the 
non-reasoning  connective  tissue  of  the  brain,  with 
the  consequences  that  there  was  found  to  be  a 
perceptible  dwindling  of  and  alteration  in  the 
shape  and  power  of  the  reasoning  cells  of  the 
mind,  and  he  thought  that  the  best  physical  con- 
dition was  only  to  be  attained  by  uncompromising 
total  abstinence  from  all  intoxicating  liquors. 

In  accordance  with  the  newr  fashion  of  naming 
bazaars  like  dramas,  or  tales,  or  other  works  of 
art,  the  title  "  A  Dream  of  Health  for  Sick  Chil- 
dren," has  been  hit  upon  for  one  at  which  all  of 
the  stalls  will  represent  scenes  from  the  works  of 
Charles  Dickens.  The  bazaar  is  to  be  held  under 
royal  patronage  at  Kensington  Town  Hall,  in  aid 
of  the  fund  for  furnishing  the  Convalescent  Home 
for  the  Victoria  Hospital  for  Children  at  Broad- 
stairs,  Kent.  A  special  feature  will  be  a  stall  de- 
voted to  dressed  dolls.    Any  dolls  not  disposed  of 


at  the  bazaar  will  be  distributed  among  the  chil- 
dren of  the  Victoria  Hospital,  Chelsea. 

They  are  now  able  to  tell  approximately  what 
the  late  spell  of  severe  weather  has  cost  the  me- 
tropolis in  lives  lost.  The  first  distinct  increase 
of  mortality  due  to  the  cold  was  shown  in  the 
record  for  the  week  ending  December  20,  when 
the  death-rate  had  jumped  from  21.1  to  26  per 
1,000.  It  reached  its  maximum,  29.7,  on  Janu- 
ary 3,  and  the  last  week  of  the  frost  it  fell  to  25.7. 
For  the  six  weeks  the  average  rate  was  nearly 
27.7,  an  increase  over  that  hitherto  prevailing  of 
rather  over  1.5  per  i, 000  per  annum.  What  this 
means  applied  to  the  3,815,704  inhabitants  of  Lon- 
don embraced  in  the  returns  is  that  frost,  snow 
and  fog  have  carried  off"  about  2,860  victims  in 
the  six  weeks.  It  was  a  curious  circumstance  that 
during  the  same  period  zymotic  diseases  were  less 
fatal  than  usual. 

The  death  rate  in  the  British  Army,  as  com- 
pared with  those  of  Germany,  France,  Austro- 
Hungary  and  Belgium,  is  extremely  low.  For 
last  year  the  death  rate  of  the  British  Army  was 
.86  per  cent,  of  the  whole,  whilst  Dr.  Corput,  who 
has  been  charged  by  the  Belgian  Government  to 
examine  the  sanitary  institutions  of  Germany, 
states  in  his  report  that  the  annual  army  death-rate 
of  Germany  is  3.97,  of  Belgium  4.07,  of  France  5, 
and  of  Austro-Hungary  5.95  per  cent. 

Sir  William  Cameron  Gull  has  founded  a  Gull 
studentship  at  the  Medical  School  of  Guy's  Hospi- 
tal, with  which  his  father,  Sir  William  Gull,  was 
so  long  and  so  honorably  connected.  The  student- 
ship will  be  of  the  yearly  value  of  ^125,  with  a 
further  allowance  of  ^25  for  apparatus.  The  ap- 
pointment will  be  tenable  for  three  years,  and  may 
be  renewed  for  two  years  more.  The  student  will 
not  be  selected  by  examination  and  the  appoint- 
ment will  be  open,  though  preference  will  be 
given  to  a  suitable  candidate  from  Guy's  Hospi- 
tal. The  foundation  will  worthily  commemorate 
the  late  Sir  William  Gull's  love  for  pathological 
studies,  as  well  as  his  long  tenure  of  office  as  phy- 
sician to  Guy's  Hospital. 

Never,  perhaps,  has  the  direct  relation  between 
death  and  overcrowding  been  more  strikingly  pre- 
sented than  in  a  little  table  compiled  by  Mr.  C. 
Roberts,  and  included  in  an  article  by  him  in  the 
new  paper  entitled  Physique.  It  relates  to  the 
sanitary  districts  of  London,  and  shows,  among 
other  suggestive  facts,  that  whereas  in  Hamp- 
stead,  where  the  allowance  of  space  is  180  square 
i  yards  to  every  inhabitant,  the  death-rate  is  only 
I  10.5  per  thousand  per  annum,  in  the  Bethnal 
Green  condemned  district,  where  the  allowance  is 
13  square  yards  only  per  person,  the  death-rate  is 
just  40  per  thousand. 

Ether  drinking  is  practiced  largely  throughout 
many  districts  of  Northern  Ireland,  notably  in 
Derry  and  Tyrone.  According  to  a  Government 
report,  some   100,000  Irish  consume   17,000  gal- 


392 


SPECIAL  CORRESPONDENCE. 


[March  14, 


Ions  of  impure  ether  annually,  and  it  is  proposed 
to  counteract  the  baneful  habit  by  introducing 
naphtha  into  all  ether  sold  otherwise  than  medi- 
cinally, or  else  to  limit  the  sale  to  chemists. 

In  these  days  of  higher  development  of  the 
medical  art,  the  idea  of  associating  surgeons  with 
barbers  is  apt  to  raise  a  smile.  But  however  wide- 
ly the  ways  of  doctors  and  barbers  may  now  dif- 
fer, there  was  a  time  when  the  wielders  of  the 
lancet  were  allied  by  the  most  solemn  ties  to  the 
manipulators  of  soap  and  razor.  The  records  of 
the  ancient  city  guilds  show  how  jealously  the 
privileges  of  these  members  of  society  were  for- 
merly guarded,  and  in  perusing  the  volume  <>t 
"  Annals  of  the  Barber-Surgeons  of  Eondon," 
compiled  by  Mr.  Sidney  Young,  one  may  gain  a 
more  particular  knowledge  of  the  history  of  a 
venerable  yet  utilitarian  craft.  The  author  points 
out  that  the  barber-surgeons  were  a  professional 
rather  than  a  trade  guild,  and  their  company 
stood  alone  as  the  pioneer  of  technical  education. 
As  long  ago  as  the  middle  of  the  fifteenth  century 
the  company  provided  surgical  lectures  and  sys- 
tematic instruction  for  its  members.  Museums, 
libraries  and  anatomical  theatres  were  established, 
and  a  valuable  amount  of  lasting  work  was  done 
which  benefited  the  Kingdom  at  large.  Mr. 
Young  holds  that  the  barbers  were  banded  to- 
gether as  early  as  the  thirteenth  century.  The 
first  record  of  the  company's  existence  as  a  trade 
society  bears  the  date  of  1308.  The  barbers  per- 
formed many  of  the  minor  operations  of  surgery, 
such  as  bleeding,  tooth  drawing  and  cauteriza- 
tion. Up  to  the  twelfth  century  the  only  reliable 
surgeons  were  the  clergy,  but  the  Council  of  Tours 
held  that  blood-letting  was  incompatible  with  the 
office  of  priesthood.  At  the  present  time  the 
chief  treasure  belonging  to  the  Company  of  the 
Barber-Surgeons  is  the  well-known  famous  paint- 
ing by  Holbein,  10  ft.  2  in.  long  by  5  ft.  11  in. 
high,  which  represents  either  the  granting  of  the 
charter  by  Henry  VIII  or  the  Royal  assent  to  an 
Act  of  Parliament  uniting  the  Barbers'  Company 
with  the  Guild  of  Surgeons.  The  picture  is 
painted  on  oak  panel,  and  contains  nineteen  fig- 
ures. Mr.  Young  has  much  that  is  interesting  to 
say  concerning  the  property,  charities,  plate,  pict- 
ures and  general  features  of  the  Company  as  it 
exists  to  day. 

Through  the  instrumentality  of  Sir  Frederick 
Roberts,  the  Government  of  India  has  organized 
a  "  female  nursing  service  "  for  the  army  hospi 
tals  of  that  country.  The  nurses  to  be  employed 
are,  it  is  said,  ladies  who  will  he  required  to  show 
that  tluv  have  undergone  training  for  at  least 
twelve  months  in  a  civil  hospital  in  England  in 
which  in  ile  patients  receive  medical  and  surgical 
treatment.  The  scheme  constitutes  a  modifica- 
tion oi  that  inaugurated  by  Lady  Roberts.  The 
number  of  nurses  to  he  employed  will  be  fixed  by 
the    Government.      For    administrative  purposes 


the  service  will  be  divided  into  four  circles,  each 
under  a  superintendent,  with  their  headquarters 
at  Meerut,  Rawal  Pindi,  Bangalore  and  Poona. 

Dr.  Koch  has  just  reached  the  age  of  42.  His 
father  was  a  mine  manager,  and  young  Koch  had 
a  hard  struggle  in  his  profession.  Having  passed 
through  the  university,  he  finished  his  medical 
education  in  Hamburg  Hospital,  and  then  started 
as  a  country  doctor  in  Hanover.  He  was  restless 
in  the  provinces,  however,  and  changed  several 
times  before  he  landed  in  Berlin. 

Dr.  Koch  has  a  rival  in  Dr.  Russell,  of  Edin- 
burgh, and  Dr.  Russell  in  his  turn  has  a  rival  in 
Dr.  Stills.  A  Scotch  paper  says  that  consider- 
able discussion  has  been  aroused  through  a  rumor 
having  gained  currency  to  the  effect  that  Dr.  H. 
I.  Stills  had  arrived  at  the  same  conclusions  as  Dr. 
Russell  concerning  the  extermination  of  cancer 
some  time  ago,  and  was  only  awaiting  further 
confirmation  before  announcing  it. 


ASSOCIATION  NEWS. 


American  Medical  Association. 

Members  who  intend  to  read  papers  before  the 
Section  on  Practice  and  Physiology  are  requested 
to  send  titles  to  the  secretary  at  their  earliest  con- 
venience, so  that  by  grouping  allied  subjects  and 
giving  timely  notice  of  the  programme  the  work 
of  the  Section  may  be  facilitated  and  the  interest 
of  the  meeting  increased.  By  request  of  the  chair- 
man. George  Dock,  M.D.,  Sec'y, 

Galveston,  Texas. 


SPECIAL  CORRESPONDENCE. 


L,egal  View  of  Insanity  Commitments. 

To  the  Editor:— -In  reference  to  your  editorial  citation 
of  David  McAdam's  1  at  present  Judge  of  the  Superior 
C.mrt  of  New  \  '  View  of  Insanity  Commit- 

ments,"  permit    me    to  state   that   they   have    bei 
laughing-stock  among  all  judges,  lawyers  and  ph 
who  have  any  knowledge  of  the  subject-matter,  01  1.1  mil 
iarity  with  the   daih  and  hourly  emergencies  to  which 
the  physician  railed  upon  to  deal  with  the  problems  of 
insanity  is  exposed.     His  loud  and  positive  declarations 
were  the  outcome  of  an  agitation  of  the  subj<  ct,  proi  oked 
l,\  ih,   publicity  given  to  the  commitment  oi  on< 
private   patients.     The  learned  judge  has  construed  for 
,    remarkable  dilemma,     on  the   one  hand  he 
states  ih.it  Ids  judicial  action  added  no  force  to  the  com- 
mitment, and  that  he  had  indulged  in  this  action 
cases,  oil  t in    othei  he    or  at  all  event-,  the  Court  pye* 

1        1 the  medium  to  give  publicity 

to  what  a  certain  sensi  oi  propriety  which  has  thus  far 
1  to  guide  our  judges,  regards  as  a  private,  family 
judgi  am  no  responsibilii 
,,  ct;  u  is  (In  ]ih\  sicians  who  are  responsible,  and  whom 
the  law  registers  the  responsibility  of  bj  compelling  them 
to    comply   with   the    existing    legal    forms.      It   is   to    be 


I89i.] 


SPECIAL,  CORRESPONDENCE. 


393 


hoped  that — not  further  hampering  legislation,  as  a  few 
lies  in  "in  State  Senate  are  attempting  to  impose 
— hut  some  measure  l>c  adopted  to  protect  physicians 
again- 1  such  out)  ageous  anil  libellous  publications  as  the 
indiscretions  of  the  legal  officers  exposed  them  to,  in  the 
very  case  which  led  to  Judge  McAdam's  gratuii 
i  igo  E.  C.  Spitzka,  M.D. 

New  York,  February  26,  1891. 


The  Treatment  of  Carbuncle. 

To  the  Editor : — Under  the  head  of  "  Practical  Notes" 
in  a  recent  issue,  we  will  all  agree  with  Dr.  A.  P.  Brown 
in  his  treatment  of  carbuncle,  as  far  as  crucial  incision, 
use  of  cocaine,  and  packing  with  salicylic  acid  are  con- 
cerned ;  but  as  for  applying  a  dirty  ointment  to  an  open 
wound  the  modern  surgeon  will  most  decidedly  disap- 
prove of.  A  better  procedure  would  be.  first  scrub  with 
soap  and  Hg.CL  1-1,000,  anaesthetize  with  cocaine,  incise, 
cunttc,  swab  with  tr.  iodine,  pack  with  iodoform 
gauze  and  apply  a  moist  dressing  of  Hg.CL,  1-5,000  or  car- 
bolic acid  1  percent.;  the  latter  will  lessen  pain.  Re- 
move dressing  once  in  a  day  or  so,  and  reapply  tr.  iodine 
if  necessary  and  proceed  as  before. 

Ralph  Chandler,  M.D. 

135  Grand  Ave.,  Milwaukee,  Wis.,  Feb.  27,  1S91. 


Shall  The  Journal  be  Removed  to 
Washington  ? 

THE  ACTION  OF  THE  MCLEAN  COUNTY   MEDICAL  SOCIETY. 
BLOOMINGTON,  ILL. 

To  the  Editor: — The  following  resolutions  were  unani- 
mously adopted  at  the  regular  monthly  meeting  of  the 
McLean  County  Medical  Society,  Thursday,  March  5, 
t89i: 

Whereas,  There  is  an  effort  being  made  to  remoye  The  Jour- 
nal of  the  American  Medical  Association  from  Chicago  to 
Washington,  D,  C. 

WHEREAS,  The  American  Medical  Association  is  no  sectional 
1>,  hIv,  and  when  we  consider  Chicago  from  its  geographical  location, 
so  readily  accessible  from  all  parts  of  our  country,  it  being  the 
greatest  railroad  centre  in  the  world,  its  unsurpassed  mail  facilities, 
and  destined  to  become  the  greatest  medical  centre  of  our  country-, 
also  in  wealth  and  population, 

That  the  Members  of  the  McLean  County  Medical  Soci- 
ety cannot  set-  what  advantageTHE  Journal  could  possibly  gain  by 
its  removal  to  Washington,  but  believe  that  such  removal  would  be 
detrimental  to  The  Journal  and  interests  of  the  Association,  and. 
lie  it  further 

.     That  the  delegates  elected  to  attend  the  next  meeting 
of  the  Association  do  all  in  their  power  to  oppose  the  removal  of 

1  in      i'U-RNAL. 

G.  M.  Smith, 

Rhoda  Galloway 

F.  J.  Parkhurst,  Committee. 


To  the  Editor: — I  have  always  felt  the  deepest  interest 
in  the  creation  of  a  journal  that  would  represent  the 
medical  living  age  :  around  which  would  be  rallied  the 
most  cultured  minds  and  ardent  efforts  of  the  medical 
profession  iu  this  nation,  and  which  should  n 
besides,  the  ttmst  advanced  thinkers  and  workers  in  all 
the  world.  When,  therefore,  the  proposition  was  brought 
forward  to  create  The  JOURNAL,  OF  THE  A  B 
Medical  Association,  I  became  its  enthusiastic  sup 
porter  and  predicted,  confidently,  its  future  triumph  as 
the  representative  of  the  medical  interests  throughout 
the  country  ;  and  now  my  judgment  is,  that  it  has  done 
well — reflecting  great  honor  upon  its  editors,  the  Hoard  of 
Trustees  and  Chicago,  where  it  has  been  so  well  carried 
on.  Nevertheless,  I  am  bound  to  say  that.  111  my  belief. 
the  managers  have  been  so  conservative,  so  determined 
to  take  no  risks  that  involved  a  prospect  of  pecuniary 
embarrassment,  that  The  Journal  has  been  kept  too 
much  in  the  rear  of  the  Hue  of  a  contest  for  the  due 
rank  of  medicine  in  communities  and  in  the  State.  It 
has  not,   I   think,   been   full   enough   of  an   aggressive 


spirit  ;  nor  has  it  presented  early,  and  in  a  compact  form, 

il  progress  at  home  and  abroad.     The  great 

Otis,  I  am  sure,  has  been  that  the  managers 

have   never    felt   willing,  or,  I  might  say,  able — to  select 

a  highly  competent  editor,  who  should  direct  its  way  and 

:  responsible  for  a  high  character  of  work. 

No  one  doubts  the  editorial  capacity  of  I)r.  X.  S. 
Davis,  or  Dr.  Hollister,  but  these  gentlemen,  both  are 
large  practitioners  and  could  not  have  afforded  to  give 
their  entire  time  to  so  exacting  a  situation.  Hei 
JOURNAL,  excellent  and  able  as  il  is,  has  not  attained  to 
the  exalted  position  of  the  leading  journal  of  this  country. 

Now,  this  is  what  The  Journal  must  become  to  be 
commensurate  with  the  spirit  and  demands  of  our  pro- 
fession here.  Thus  far  The  JOURNAL  has  stood  only  as 
the  child  of  the  Association — nursed  by  it — not 
pendent,  but  sustained  by  the  funds  remaining  in  the 
treasury  after  all  other  claims  had  been  satisfied.  But 
now  a  new  state  of  things  should  be  inaugurated.  The 
fOURNAL  must  lead  and  sustain  the  Association  ;  it  must 
earn  the  necessary  sums  to  give  to  it  the  broadest  charac- 
ter and  mos^elevated  rank  in  the  promotion  of  scientific 
medicine,  and  its  due  social  and  political  influence  in  the 
State.  It  must  be  able,  by  its  great  strength  and  activity, 
to  fuse  into  one  mass  the  intelligence,  feeling  and  force 
of  our  vast  faculty.  Our  obligations  to  society  are  con- 
tinually increasing  ;  the  elevation  of  the  social  and  po- 
litical State  requires,  in  a  great  degree,  our  cooperation. 

The  time  has  come  for  medicine  to  demand  a  place  iu 
the  administration  of  the  most  important  affairs.  We 
must  insist  on  the  creation  of  a  secretaryship  of  Public 
Health,  as  fully  empowered  with  responsible  duties  as 
any  other  in  the  Presidential  Cabinet. 

I  suppose  that  this  proposition  will  be  met  by  derisive 
jests  and  supercilious  exclamations  ;  nevertheless,  the 
fact  remains  that  there  is  no  other  profession  that  excels 
ours  in  positive  efficiency  to  sustain  public  order,  com- 
fort and  virtue.  We  have  vast  capacities  for  the  direc- 
tion of  society  and  the  promotion  of  human  happiness. 
At  this  time  I  cannot  dwell  but  in  a  general  way  upon 
this  topic.  Give  us  the  power  to  direct  all  that  which 
constitutes  hygienic  laws — the  control  of  the  mode  of 
living  of  the  people  :  e.g.,  to  secure  unadulterated  food, 
pure  water,  ample  light  and  air  space  in  their  dwellings, 
drainage,  disposal  of  excrement,  garbage  and  offal  of 
ever}-  description,  regulation  of  the  hours  of  labor,  the 
protection  of  childhood  from  severe  toil,  quarantine 
against  pestilence,  isolation  of  infectuous  diseases,  the 
disinfection  of  certain  localities,  the  overcrowding  of 
school  rooms,  the  abuse  of  the  brain  in  teaching,  the 
prevention  of  marriage  in  hereditary  diseased  types  of 
constitution  and  in  cases  of  near  consanguinity,  the  care 
of  the  sick,  and  of  the  insane  in  special  and  general 
hospitals,  and  the  regulation  of  those  two  giant  evils  of 
civilization,  intemperance  and  prostitution. 

At  this  moment  the  profession  is  manifest"  . 
higher  spirit  than  ever  before,  the  purpose  of  suppressing 
contagious  and  infective  diseases.  This  work  was  begun 
by  Jenner,  a  century  ago,  and  the  awful  scourge  of  small- 
pox has  been  nearly  stamped  out,  wherever  vaccination 
is  compulsory.  We  have  now  assumed  the  stupendous 
task  of  suppressing  all  the  terrible  diseases  that  deso- 
late the  world.  To  accomplish  all  this  we  ask  for  the 
facilities  of  the  government  and  the  power  of  law.  We 
must  assist,  also,  iu  the  formulation  of  appropriate  laws 
and  in  their  effective  application. 

I  affirm  that  the  medical  profession  is  worthy  of  full 
recognition  by  the  State  in  its  Councils  and  by  its  re- 
sources  to  carry  forward  its  beneficent  work.  Moreover, 
our  profession  lives  closer  to  the  heart  of  humanity  than 
any  other.  We  are  bound  to  lavish  our  consolatory  art 
upon  all  races  and  ranks  of  society,  alike.  We  cannot 
abandon  the  lowest,  most  degraded,  the  poorest  and  most 
criminal  of  our  fellow  beings.  We  cannot  shrink  from 
impact  with  the  pestilence,  or  the  terrible  ordeal  of  bat- 
tle.     It  is  not  the  bugle  note  of  "  forward,"  the  advance 


394 


SPECIAL  CORRESPONDENCE. 


[March  14. 


of  the  standards,  or  the  roar  of  the  conflict,  that  excites 
our  enthusiasm  ;  it  is  the  cries  of  the  wounded  and 
dying,  the  fearful  ruin  of  the  field  that  sustains  our 
energies  in  the  smoke  and  flame  of  battle. 

During  all  the  dread  scenes  through  which  we  have  so 
lately  passed,  the  physicians  on  both  sides  gave  their  best 
services  to  friend  and  foe  alike;  and,  when  the  conflict 
was  over,  they  were  the  first  to  extend  the  fraternal  hand 
across  the  red  field  of  war.  It  is  my  opinion  that,  to-day, 
the  strongest  bond  of  union  in  these  L'nited  States  is  the 
medical  profession,  founded  upon  their  high  order  of  cul- 
ture  in  the  "  humanities,"  in  science,  and  that  deep  sense 
of  sympathy  and  good-will  to  men,  which  makes  war 
abhorrent. 

We  are  often  discouraged  by  seeing  our  advice  disre- 
garded, and  feel  that  our  profession  does  not  command 
properly  public  confidence.  Our  opinions,  it  is  said,  are 
unreliable  in  comparison  with  other  learned  professions. 
We  declare  this  to  be  unjust.  We  do  not  claim  that  med- 
icine is  perfect;  we  feel  its  deficiencies;  yet  we  know  that 
a  steady  and  brilliant  growth  exists,  and  that,  in  every 
respect/ we  are  abreast  with  other  professions.  When  we 
compare  our  opinions  with  those  of  lawyers,  theologians, 
statesmen,  merchants,  manufacturers,  civil  engineers, 
etc.,  we  find  that  all  these  are  tainted  with  as  much  un- 
certainly as  our  own.  Why  should  not  scientific  medi- 
cine be  of  equal  certainty?  We  employ  the  same  logical 
processes  in  solving  the  problems  of  disease  as  those  ma  le 
use  of  by  all  investigators  in  serious  questions.  We  em- 
ploy the  methods  of  the  calculus  in  clinical  investiga- 
tions, like  those  followed  by  astronomers  in  solving  the 
problems  in  celestial  mechanics. 

Hence,  it  seems  to  me  a  duty  on  the  part  of  the  medical 
profession  to  strive  for  a  substantial  representation  in  the 
Cabinet,  in  the  Senate  and  House  of  Representatives,  in 
Congress,  by  men  who  shall  be  distinguished  for  profes- 
sional ability  and  general  knowledge  of  affairs.  We  know 
the  exalted  position  held  by  Rush  in  the  Continental  Con- 
gress. Since  his  day  a  number  of  distinguished  medical 
men  have  sat  in  the  Senate  and  in  the  House,  but  their 
number  has  decreased  since  the  rancor  of  partisan  poli- 
tics has  become  so  bitter  and  the  glut  of  wealth  has  push- 
ed aside  the  most  capable  men,  because  they  have  not  a 
money  power  to  back  them. 

In  the  British  Parliament  we  see  a  steady  increase  in 
the  medical  representation.  Trousseau,  Paul  Bett  and 
Nelaton  were  Senators  of  France.  Virchow  has  served 
in  German,  and  Semmola  in  Italian  Parliaments.  Who 
that  recalls  all  the  qualities  of  Gross,  Eve,  Flint  and  H 
(  ampbell,  can  doubt  the  high  rank  they  would  have  held 
in  our  Senate.  The  influence  of  our  Associatioi 
plished  the  elevation  of  the  surgeons  of  the  Army,  Navy 
and  the  Marine  Corps  to  increased  rank  and  pay. 

In  regard  to  the  local i mi  of  The  Journal. 

We  are  all  proud  of  the  greatness  and  splendor  of  Chi- 
cago: she  is  a  wonder  of  the  world;  for  cerlainh  ,  no  citi 
in  the  world's  history  has  had  as  rapid  a  growth  and  has 
so  fully  developed  and  maintained  as  massive  a  trade  in 
manufacturing  and  mercantile  pursuits.  Moreover,  it  is 
plain  that  in  the  aits  and  is  making  rapid 

progress — aiming  to  make  the  place  a  seat  of  learning  as 
tnmero  ro  one  can  visit  that  wondrous 
city  and  become  involved  in  the  ebb  and  flow  of  her  busy 
streets,  travel  through  her  great  avenues  and  parks,  with- 
out seeing  the  most  convincing  proofs  that  her  stupen 

ill's  are  being  directed   l'\    minds  of  V  I!  ' 

:  ivity. 
Nevertheless,  the  con  not  eqt 

Nation — whi  1 
is  Washington.     The  correspondencies  of  the   i 
illimitab  I  to  the  Capital:  th, 

father's  house,  and  there  we  are  all  at  home. 
The   assumption    of  our   higher    claim 

pi  litii  ,d  recognition    musl  I  !  there,  in 

I  The  Jour 


Association  shall  become  our  potent  advocate.  Nowhere 
else  can  it  exert  so  great  an  influence — neither  at  Chica- 
go, New  York  nor  Philadelphia.  I  pray  our  brothers  of 
the  Northwest — of  which  Chicago  is  conceded  to  be  the 
capital — to  give  their  good-will  to  this  new  movement; 
not  forgetting,  though,  the  honor  which  Chicago  has 
given  to  the  foundation  of  the  Organ  of  the  Association. 

No  one  of  a  generous  nature,  I  hope,  will  asperse  this 
movement  towards  Washington  as  one  that  will  lower 
our  noble  profession  to  the  plane  of  common  politics. 
No,  we  despise  the  intimation:  the  politics  we  shall 
struggle  to  develop  will  be  the  elevation  of  medical  ad- 
ministration to  its  proper  place  as  an  integral  part  of 
public  affairs  for  the  promotion  of  public  well-being. 

If  a  general  and  heart}-  consent  to  the  removal  of  The 
Journal  from  Chicago  to  Washington  shall  have  been 
agreed  to.  then  the  general  business  management  of  the 
Organ  and  its  editorial  work  will  become  most  important 
subjects  of  consideration. 

The  business  management  is  of  the  first  importance; 
not  second,  I  think,  to  the  purely  editorial;  but  both 
must  be  made  the  strongest  possible  and  cooperative: 
and  the  gentlemen  who  obtain  these  places  must  be  paid 
sufficiently  to  give  The  JOURNAL  their  entire  time.  I 
mean  that  they  shall  have  no  other  employment — Gov- 
ernmental or  otherwise.  In  fact,  as  I  see  it,  their  duties 
shall  absorb  all  their  capabilities;  and  in  the  editorial 
work,  more  especially,  large  assistance  will  be  required. 

In  order  to  secure  the  best  talent  for  the  editorial  de- 
partment, more  funds  than  are  now  at  the  disposal  of  the 
managers,  must  be  provided.  I  propose,  for  this  pur- 
pose, that  an  appeal  be  made  to  the  members,  at  large, 
for  a  loan  of  $  10,000,  in  sums  of  $50  and  f  100,  to  be  re- 
turned in  due  time  with  interest  at  3  per  cent.  If  one 
hundred  persons  can  be  found  who  will  thus  loan  $  100 
each,  it  will  meet  the  appeal.  Professional  hope  and 
pride  will  surely  answer  such  a  call,  promptly.  Iu  this 
way  the  whole  present  income  could  be  devoted  to  the 
enlargement  of  the  paper. 

The  profession  in  this  country  needs  a  journal  as  great 
in  size  and  in  capacity  as  that  of  the  British  Association. 
We  have  the  men,  the  money,  and  certainly  the  patriot- 
ism. It  must  and  can  be  made  so  strong  as  to  become 
indispensable  to  the  practitioners  in  our  land. 

It  will  become,  in  nowise,  the  overpowering  rival  of 
our  present  capable  and  ably  conducted  local  journals; 
it  will  not  deprive  them  of  their  patronage,  profession- 
ally or  in  a  business  way;  and  I  hope  that  gradually,  it 
would  be  able  to  drop  the  greater  part  of  its  advertise- 
ments. 

Every  practitioner  knows  that  his  greatest  suc<  ess  de 
pends  upon  his  standing  in  his  own  community;  so  his 
best  productions  must  be  made  known  to  his  professional 
brothers  at  home.  But  there  are  subjects  about  which 
he  may  desire  to  address  the  profession  at  large;    in    that 

ease  The  Journal  of  the  Association  would  be  his  vehi- 
cle and  give  him  an  audience  commensurate  with  the 
nation.  Proceedings  of  the  leading  medical  and  scientific 
societies,  and  reports  of  the  great  general  hospitals, 
-.hould  l>e  promptlj  displayed  in  its  columns;  and  the 
subscribers  would,  in  this  way,  become  furnished  with 
the  work  of  eminent  men,  here  and  abroad.     Careful  re- 

new  books  should  also  be  produced.   It 
me  that  not  only  local  journals  will  be  bettei  patronized, 
but  the  proceedings  of  State  and  local  societies  will  be- 
come nun  h  more  valuable. 

In  short,  when  THE  JOURNAL  shall  have  been  fully 
equipped,  the  subscribers  shall  be  kept  mi  courant  with 

the  pro,"''  '      1        and    cities  at 

home  and  abl  i 

We  have,  in  the  famous  journal  of  the  British  Medical 

I     'III     |8S  I    to    [867 

on  tlie  same  plane,  :  but,   when   in    [867 

mi  eliii  t'  and  Francis  Fow  ke 

d     business    m  1     was    quickly 

printed  mattl 


I89i.] 


SPECIAL  CORRESPONDENCE. 


395 


d  and  has  been  more  than  doubled,  50  that,  now 
it  prints  3,000  pages  a  year,  and  its  contents  include  the 
whole  progress  <>i  medu  al  scii  0.1  1  Its  subscription  list 
is  abonl  seventeen  thousand,  ami  its  annual  income,  in- 
cluding advertisements,  is  over  $\  jo.ooo.  its  surplus  in- 
come has  accumulated,  I   understand,  to  somi    - 

rest  of  which  is  employed  in  many  ways,  to  en- 
large medical  culture  and  take  care  of  pro 
estS  in  the  government.  The  influence  of  sue: 
cal  organ,  and  its  power  for  doing  good  is  incal- 
culable. When,  during  the  past  year,  the  General  of 
the  Army,  Lord  Wolseley,  issued  a  general  order,  the  op- 
eration of  which  was  sure  to  lower  the  status  of  the  med- 
ical corps,  The  Journal  promptly  but  respectfully  pro- 
tested against  its  execution  and  secured  its  modification. 

(  mr  great  Association,  many  are  saying,  has  been  grad- 
ually losing  influence  in  the  profession  at  large.  A  slow 
and  somewhat  insidious  disintegration  has  been  mani- 
fested for  some  time  past.  I  have  heard  it  said  that,  with 
the  death  of  its  eminent  founder,  there  is  great  possibil- 
ity of  it  ceasing  to  exist.  Everybody  knows  that  his  in- 
defatigable labors  have  done  vastly  much  to  keep  it  alive. 
The  indications  of  decay,  it  is  said,  are  more  especiallv 
seen  in  the  formation  of  so  many  new  societies,  semi- 
national  in  character,  and  in  the  fact  that  large  numbers 
of  distinguished  phvsiciansand  surgeons  stand  aloof,  and 
do  not  participate  in  its  annual  meetings  as  in  the  past 
years, 

In  short,  they  assume  that  the  Association  is  not  re- 
garded, nowadays,  as  indispensable  for  the  unification  of 
medical  interests  as  formerly.  Its  associations  are  agree- 
able enough,  it  is  said,  but  that  it  is  no  longer  the  centre 
of  centripetal  and  centrifugal  forces  for  the  maintenance 
of  our  medical  system;  that  were  it  not  for  the  opportu- 
nities it  affords  for  cheap  travel  to  our  great  cities,  the 
recreation,  and  the  entertainments,  which  give  variety  to 
pleasurable  journeys,  it  would  soon  go  to  pieces. 

There  is  no  thoughtful  man,  I  think,  who  could  regard 
the  suspension  of  these  annual  meetings  in  any  other 
light  than  as  a  public  and  professional  calamity.  What 
the  Association  has  done  for  the  elevation  and  unifica- 
tion of  the  profession,  I  have  no  space  to  recount;  more- 
over, I  believe  that  its  power  to  do  good  could  never  have 
been  exerted  to  a  greater  purpose  than  at  this  time.  It 
has  required  many  years  to  formulate  all  the  methods  for 
its  government  and  higher  work.  It  can  and  must  be 
made  so  powerful  in  promoting  a  broader  and  more 
scientific  scholarship,  that  the  fraternity  shall,  at  length, 
gain  the  public  estimation  as  the  most  highly  educated 
and  trustworthy  class  of  citizens  of  the  Republic.  It  must 
command  so  much  professional  regard  that  everv  mem- 
ber of  the  fraternity  shall  give  it  his  profound  reverence, 
and  consider  it  one  of  his  highest  titles  to  distinction  to 
be  a  corporate  fellow. 

With  higher  culture  of  professional  esprit  de  corps,  and 
sustained  by  a  powerful  organ,  there  can  be  no  aspersion 
by,  nor  combination  of  sectarian  or  irregular  practice, 
nor  any  display  of  self-importance  by  individuals,  or 
groups  of  regular  physicians  who  hold  themselves  apart 
in  haughty  satiety,  that  can  restrain  the  fulfillment  of 
the  beneficent  aims  of  the  American  Medical  Associa- 
tion. 

If  its  great  purpose  can  be  accomplished  in  Chicago, 
let  it  remain;  but  I  repeat,  the  consciousness  of  Chicago 
is  so  immensely  inferior  to  that  of  our  political  capital, 
that  I  hope  that  all  of  us  may  see  that  the  great  destiny 
of  the  Association  niav  more"  surelv  be  accomplished  at 
Washington.  '  Cornelius  G.   Comegvs,  M.D. 

Cincinnati,  Feb.  20,  1S91. 


matter  that  deserves  to  be  read  by  every  progressive  phy- 
sician. The  editorials  compare  well  with  those  of  any 
medical  journal  published  in  the  East. 

I  am  satisfied  that  if  the  future  location  of  THE  J"'  R> 
xai,  would  be  left  to  a  vote  of  every  member  of  the 
American  Medical  Association  as  it  should  be,  nine  out 
of  every  ten  votes  would  be  cast  for  Chicago. 

If  our  brethren  in  the  East  wish  to  make  Tin-;  J<,ir- 
nal  what  every  member  and  the  Supervising  Editor 
wants  it  to  be,  let  them  contribute  scientific  articles  for 
its  columns,  which  will  be  eagerly  read  and  thoroughly 
appreciated  by  every  member  of  the  Association,  instead 
of  wasting  rime  and  talent  in  criticising  the  present 
management.  ,\.  Sexn. 

Milwaukee,  March  4,  1S91. 


To  the  Editor: — It  was  resolved,  at  a  recent  meeting 
of  this  Board,  that  it  is  the  desire  of  this  College  that  the 
place  of  publication  of  T11K  Journal  remain  in  Chicago. 
W.  F.  Milroy, 

Secretary  Board  Trustees, 
Omaha  Medical  College. 
Omaha,  Neb.,  March  4,  1891. 


To  the  Editor: — I  think  that  Chicago  is  much  the 
better  place  for  the  publication  of  The  Journal,  it  being 
the  most  central  and  most  convenient  place.  I  have 
written  to  the  different  members  of  the  Board  of  Trustees, 
expressing  my-  views  on  the  subject. 

The  membership  of  the  American  Medical  Association 
is  made  up  largely  of  physicians  who  live  in  the  West 
and  South  ;  the  most  active  work  in  the  Association  is 
done  by  members  who  live  in  the  territory  tributarv  to 
Chicago,  and  I  am  quite  certain  it  will  be  found  that  a 
vast  majority  of  the  members  of  the  American  Medical 
Association  wish  to  have  The  Journal  published  in  the 
future,  as  it  has  been  in  the  past,  in  the  city  of  Chicago, 
and  would  look  with  jealous  eyes  upon  any  attempt  to 
remove  it  elsewhere.  They  will  certainly  most  bitterly 
oppose  any  attempt  to  remove  it  farther  East. 

St.  Paul,  Minn..  March  2,   1891. 

John  F.  Fulton,  M.D. 


To  the  Editor  :— The  Journal,  has  the  most  favora- 
ble geographical  and  business  location  that  could  be 
found  in  the  United  States.  The  Journal  has  been  a 
success  from  the  very  beginning,  and  has  a  history  of 
which  its  friends  may" well  be  proud.  It  has  appeared 
regularly,  and  its  pages  have  always  been  filled  with 


To  the  Editor: — The  American  Medical  Association 
may  now  be  considered  a  success.  The  Journal,  pub- 
lished where  it  has  been,  in  Chicago,  and  edited  as  it  has 
been,  has  contributed  more  to  accomplish  this  end  than 
any  other  and  all  other  influences  combined.  Believing 
this  as  strongly  as  I  do,  I  say  let  it  alone  !  All  things 
that  are  doing  well  should  be  let  alone.  Chicago  is  nearer 
the  home  of  the  great  number  who  contribute  to  the 
make-up  and  support  of  the  Association  than  New  York, 
Philadelphia,  or  Washington  City  would  be.  Men  will 
support  home  matters  better  than  they  will  more  distant 
ones. 

Dr.  N.  S.  Davis,  of  Chicago,  has  done  more  to  make 
the  Association  a  success  than  any  other  man.  Why- 
should  he  be  thus  insulted  and  his  home  despised  ?  I  for 
one  am  opposed  to  this  high-hauded  outrage. 

Robert  Crawford,  M.D. 
Cooperstown,  Pa.,  March  3,  1S91. 


To  the  Editor: — Deeply  interested  in  every  move  like- 
ly to  contribute  to  the  enhancement  of  material  and  sci- 
entific interests  of  The  Journal  we  regard  as  the  ex- 
ponent of  the  best  literary  and  scientific  culture  of  the 
first,  best  and  largest  medical  organization  of  our  country, 
I  cannot  but  enter  my  personal  protest  against  the  re- 
moval of  the  "plant"  and  editorial  management  of  The 
Journal  from  Chicago  to  Washington,  D.  C.  Certainly 
no  man  of  broad  scholarship,  literary  and  scientific  cul- 
ture, can  find  one  incontrovertible  argument  in  favor  of 
the  contemplated  change.     In  every  element  of  material 


39& 


MISCELLANY. 


[March  14,  1891. 


advantage,  and  facilities  for  ready  and  quick  distribution, 
no  city  in  our  country,  when  we  regard  The  Journal's 

constituency,  is  comparable  to  Chicago.  And  I  feel 
assured  no  man  will  have  the  temerity  to  deny  us  such  a 
measure  of  classical,  special  and  general  scholarship  as 
render  secure  the  best  educational  interests  of  this  repre- 
sentative journal  ?  Central,  ambitious,  progressive,  our 
city  furnishes  all  the  splendid  environments  calculated 
to  "inspire  the  best  editorial  management.  I  vote  for 
Chicago!  WILLIAM  T.  Akixs,  M.D. 

Chicago,  March  7,  1891. 


To  the  Editor:— It  is  my  opinion  to  the  best  interests 
of  The  Journal  to  have  it  remain  in  Chicago.  The 
geographical  location  of  Chicago  is  superior  to  Washing- 
ton or  any  other  city.  It  being  the  great  commercial 
centre  of  the  Northwest,  and  a  centre  for  medical  educa- 
tion. Hence  it  would  not  be  advantageous  to  the  inter- 
ests of  the  Association,  and  a  detriment  to  the  financial 
interest  of  The  Journal,  depriving  it  from  a  large  legit- 
imate advertising  patronage,  a  factor  in  support  of  The 
Journal. 

The  editorial  department  has  been  well  managed  and 
gives,  I  believe,  general  satisfaction  to  the  majority  of 
the  members  of  "the  Association.  It  would  be  wise  to 
let  well  enough  alone.  Thos.  W.  Forshee,  M.D. 

Madison,  Ind.,  February  26,  1S91. 


To  the  Editor:—!  am  in  favor  of  keeping  The  JOUR- 
NAL where  it  now  is.  B.  F.  Rolfe,  M.D. 
Staceyville,  la.,  March  6,  1S91. 


MISCELLANY. 


Greensburg,  Pa.:  Dr.J.  C.  Keffer. 
Grove  Citv.  111.:  Dr.  R.  S.  Anderson. 
Harold,  Neb.:    Willie  Calkins- 
Hartford.  Conn.:  Plimpton  Mfg.  Co. 
Hartland,  Vt.:  Dr.  D.  F.  Rugg. 
Judson.  Ind.:  Dr.  J.  T.  Ball. 
Kansas  City,  Mo.:  Dr.  M.  A.  Bogie. 
LaCrosse.  Wis.:  Dr.  Chas.  Ottilie. 
Lebanon.  O.:  Dr.  C.  A.  Hough. 

Lincoln,  Neb.:  Clasen  &  Fletcher.  Dr.  G.  H.  Simmons. 
Louisville.  Kv  :  J    A.  Flexuer.  Paul  Kratz,  Dr.  W.  Walling. 
Loveland.'o.:  Dr.  H.  H.  Peachy. 
Maroa,  111.:  Dr.  E.  A.  Morgan. 
Marshall,  Mich.:  Dr.  <"..  H.  Greene. 
Mendota,  Wis.:  S.  J.  M.  Putnam. 

Miamisburg,  O.:  Clarke,  Forbes  &  Co. 
Milwaukee,  Wis.:  Dr.  E.  W.  Bartlett. 

Mt.  Lebanon.  La.;  Dr.  T.  J.  Fonts. 

Mt.  Pleasant,  Iowa:  Dr.  F.  P.  Peck. 

Newmarket.  Ens;.:  Dr.  G.  O.  Mead. 

New  Orleans:  Dr.  M.  J.  Magruder. 

New  York  Citv:  Robinson-Baker  Advertising  Bureau,  Reed  & 
Carnrick  New  York  and  Chicago  Chemical  Co..  J.  H.  Bates.  Dr.  E. 
SteioJitz.  J.  Movius  &  Son,  W.  P.  Clearv.  Dauchy  &  Co..  The  U.  S. 
Mail  Geo.  P.  Rowell  &  Co..  Boehringer  ,v  Soehne,  B.  Westermann 
&  i        N    Y.  Post-Graduate  Medical  School.  J.  F.  Madden. 

Omaha,  Neb.:  Dr.  R.  C.  Moore. 

Ottawa.  O.:  Dr.  C.  E.  Beardsley. 

Paris.  France:  Rigaud  &  Chapoteaut. 

Peninsula.  O.:  Dr.  W.  N.  Boerstler. 

Phila..  Pa.:  Dr.  R.  J.  Dunglison,  Dr.  Edward  Jackson. 

Pikesville,  Pa.:  Dr.  W.  D.  DeLang.  _ 

Pittsburg   Pa  :  Remington  Bros,  Western  Pa.  Medical  CoLege, 

Quiucv.  Mich.:  Bennett's Newspape-  "■ 

Rock  "Rapids,  la.:  A.  M.  Vail. 

St.  Louis,   Mo.:    Dr.   Wm.   Dickinsoi 
bers  &Co    A.  L.  Pope.  Dios  Chemical  Co. 

Salem,  Mass.:  Dr.  Wm.  M.  Tarker. 

Spokane  Falls.  Wash.:  Dr.  R.  S.  Thomson. 

Stanford,  Kv.:  Dr.  J.  G.  Carpenter. 

Tecumseh.  "Mich.:  Dr.  Geo.  Howell. 

Titusville,  Pa.:  Dr.  T.  J.  Y/oung. 

Warrensburg,  O.:  Dr.  Wm.  Mclntyre. 

Washington,  D. 

Zanesviile,  O.: 


Dr.  Hosmer  Allen  Johnson.— At  a  recent  meeting 
of  the  Council  of  the  Northwestern  University  it  was 

Resolved  That  bv  the  death  of  Hosmer  Allen  Johnson.  A  M 
M  D  II.  D.,  the  Northwestern  University  has  lost  one  of  the  most 
active  and  efficient  founders  and  supporters  of  Us  medical  depart- 
ment an  active  and  wise  member  of  its  Board  of  Trustees  and 
Council,  and  an  influential  patron  and  friend  of  all  its  interests  ; 
the  medical  profession  one  of  its  most  learned,  skilful  am 
ble  members  the  citv  and  State  one  of  its  most  enlightened  pa- 
triotic and  useful  citizens  .  the  cause  of  education  and  sanitary  sci- 
ence one  of  their  most  earnest  supporters :  and  his  family  one  ol 
the  most  unselfish  and  affectionate  of  husbands  and  fathers. 

rhat  the  foregoing  be  entered  upon  the  records  of  this 

ind  a  copy  ol  the  same  transmitted  by  the  Secretary  to  the 

ind  a  copy  furnished  for  publication  in  the 


LETTERS  RECEIVED. 


Antonius,  111.:  Dr.  A.  Moll. 
Arcadi  '>'.  Hidershide; 

udmore,  Pa.:  Dr.  J.  S.  Gerhard. 
Auburn.  N.  Y.:  Dr.  J.  P.  Creveling. 
Baltimore.  Md.:  James  u  Connor. 

a,  Mass  :  lir.  A.  C.  Garrett 

lyn,  N.  Y.:  in     H  M.  Wyckoff. 

[o,  x   v.:  Ross,  Daniels  ,v  Co. 
Burlington.  la.:   Dr.  M.  B.  Tu 

•  w     A    T    Mansfield. 

Charleston,  S.  C:  Dr.  C.  W.  K 
Chicago:  Dr    '•■  viola  M.  French 

W.  Whitford,  Dr.  J.  I     Ho  >g    Di    r.  G 
Cfucinn  nnati  Public  I. 

1  onti  til 

lie   Kail..   111.:    Dl 

Mich      Parki 
Edisto,  S.  C:  Dr.  I.  C.  Woodruff. 

n    \  1     Dr.J,  A.  Reyburn. 
:  nomas. 
1! .:  Dr.  C.  W    '■ 
Fort  Dodge.  la.:  Anton  Rank. 

Fulton  1         Bacon. 

Rapids,  Mich.:  Dr.  Reuben  Peterson. 
Greelv,  Colo:   Dr    1.  P   Wallace. 


■  Agency,  Dr.  M.  F.  Bassett. 
Battle  &  Co..  J.  H.  Cham- 


.  Washii 

relieved  from  furtht 
eport  in  person 


Official  List  of  Chances  in  the  Stations  and  Duties  of  Offic, 

in  the  Medical  Department.   U.  S.  Army,  from  March  /,  1891,10 
March  6,  1891. 

Major   Samuel  Horton,  Surgeon,  is  granted  leave  ot  absence  for 
two  months,  on  surgeon's  certificate  of  disability.     By  direct'" 
of  the  Secretary  of  War.     Par.  7.  S.   O.  49.  A 
February  4,  1891. 

Capt.  William  O.  Owen.  Jr.,  Asst.  Surge 
dutv  in  the  Dept.  of  the  Missouri,  an 

the  commanding  officer.  Jefferson  Bks..  Mo.,  for  duty  at  that 
tion.  and  by  letter  to  the  Superintendent  of  the  recruitm- 
By  direction  of  the  Secretary  of  War.     Par.  2   S.  O.  14-  A.  G.  O., 
Washington,  February  26.  1891. 

The  following  named  officers,  having  been  found  by  Army  Retiring 
Boards  incapacitated  for  active  service  on  account  of  disability  in- 
cident to  the  service,  are.  bv  direction  of  the  President,  reared 
from  active  service  at  this  date,  under  the  prov. 
1251,  Revised  Statutes:  Capt  J.  Victor  De  Haune,  Asst.  Surgeon, 
and  Capt.  William  R.  Steinmetz.  Asst.  Surgeon.  Par.:-  - 
A.  G.  O..  February  26 

Major  Henrv  M.  Cronkhite,  Surgeon,  will  report  in  pers;  n  to  tne 
commanding  officer.  Ft.  Adams,  R  1  for  temporary  duty  at  that 
post  until  tile  arrival  of  a  successor  to  Major  Samuel  M.  Horton, 
Surgeon,  when  he  will  return  to  his  proper  station.  By  direction 
of  the  Secretar;.  '■    "-  Washington, 

February  27,  , 

Capt.    Frederick  W.  Elbrev,  Asst     Surgeon,  having  been  examined 
by  a  board  of  officers  and  found  physicallj  disqu 
surgeon  with  the  rank  oi    Mr  ir,  bv  1. 
incident  1  -     bv   direction  of  the   PreSlden 

ice  with  the  rank  of  Major,  under  the  p 
of  the  AC 

date  from  which  he  would  have  been  promoted 
seniority,  if  found  qualified.     Par.  I.  5. 

Thefollowii  1  found  by  Army  Retiring 

Boards  incapacitated  for  active  service,  on  account  ol 
incident  I  direction  of  the  President,  retired 

from  active  service  this  date,  under  the  : 

Revised  ""■  Major 

\\  astiing- 

,,  „r„K 

Capt    Willi 
sence  granted  in  S.  O.  22,  D 

further  ■  ection   ot  the  Secretary  ■  •< 

\   G.  'i  ,  Washington   February  .- 
■     Surgeon,  1-  relii  red   from   duty  at  Ft. 
in  the  final  abandonment  of  that 

Ft.    Adams.  R      I       and 

person  to  the  command  :   <"•   duty  as  Post 


S.o 

1S91. 


T  1 1  E 


Journal  of  the  American  Medical  Association. 

EDITED  UNDER  THE  DIRECTION  OF  THE  BOARD  OF  TRUSTEES. 

KLY. 


Vol.  XVI. 


CHICAGO,  MARCH  21,   1891. 


No  12. 


ORIGINAL  ARTICLES. 


ECTOPIC  PREGNANCY  ;    WITH  PRESEN- 
TATION OF  SPECIMEN. 

Read  before  the  St.  Lout's  Medical  Society,  Ja 

BY  YOUNG  H.  BOND.  M.D., 

OF  ST.    LOUIS.    MO. 

PROFESSOR  OF  GYNECOLOGY.  MARION-SIMS  COLLEGE  OF   MEDICINE  : 

ATTENDING  GYNECOLOGIST  TO  THE  GRAND  AVENUE  FREE 

dispensary:  consulting  gynecologist  ro  the 

ST.  LOUIS  FEMALE  HOSPITAL  AND   ST  LOUIS 
CITY"   HOSPITAL. 

I  do  not  wish  to  report  a  case  of  mere  ectopic 
pregnancy,  since  I  did  not  see  the  patient  from 
whom  this  specimen  was  obtained.  She  bled  to 
death  and  presented  the  usual  symptoms  incident 
to  a  lesion  of  this  character  ;  the  diagnosis  was 
not  made. 

On  post-mortem  the  abdominal  cavity  was 
found  filled  with  clotted  blood,  which  had  pro- 
ceeded from  a  rupture  of  the  right  Fallopian  tube. 

With  great  confidence,  I  pronounce  this  a  case 
of  ruptured  tubal  pregnancy  ;  for  whilst  no  foetus 
was  found  (none  being  sought  for),  the  gross  ap- 
pearance of  the  parts  justifies  the  exclusion  of  all 
other  lesions  to  which  the  tubes  are  liable.  Noth- 
ing is  found  to  sustain  the  belief  that  the  inflam- 
matory disturbances  to  which  the  tubes  are  liable, 
or  the  neoplasms  which,  in  rare  instances,  attack 
them,  produced  the  pathological  appearances 
present.  Extravasation  of  blood  into  the  tubes, 
with  subsequent  rupture  into  the  abdominal  cav- 
ity, in  consequence  of  distension,  unassociated 
with  extensive  inflammatory  alterations  of  the 
walls  of  the  tube,  rarely,  if  ever,  occur ;  there- 
fore, there  is  no  question  but  that  the  specimen 
is  that  of  a  ruptured  tubal  pregnancy.  It  will  be 
submitted  to  Prof.  Summa  for  microscopic  exam- 
ination, and  there  is  no  doubt  that  histological 
appearances  will  be  found  that  will  demonstrate 
the  existence  of  placental  tissue  at  the  point  of 
rupture,  and  that  the  uterine  cavity  is  lined  with 
a  membrane  approaching  in  character  decidua 
vera.  We  have  here  the  uterus,  together  with 
both  broad  ligaments  and  ovaries.  The  uterus  is 
three  times  as  large  as  the  normal  unimpregnated 
uterus,  and  from  its  size  we  may  predict  there 
will  be  found  evidences  of  chronic  metritis,  asso- 
ciated with  an  increased  development  of  the  mus- 


cular element,  the  latter  being  incident  to  the 
innervation  of  pregnancy. 

The  uterus  is  much  larger  than  is  usually  the 
case  at  the  stage  of  extrauterine  pregnancy 
reached  in  this  instance,  which  is  perhaps  six 
weeks.  The  ovaries,  too,  are  quite  large.  No 
evidences  of  a  corpus  luteum  of  pregnane}-  can 
be  detected.  Small  cicatrices  can  be  seen,  the  se- 
quelae, perhaps,  of  ruptured  follicles,  but  nothing 
pathognomonic  of  a  corpus  luteum  of  pregnane}'. 

In  1 88 1  Mr.  Tait  stated  that  evidence  was  rap- 
idly accumulating  in  his  hands  that  "corpora 
lutea  are  not  a  necessary  result  of  the  maturation 
and  shedding  of  true  ova;"  and  in  1889  he  reit- 
erates the  same  assertion.  The  determination  of 
the  truth  in  this  regard  may  possess  an  important 
medico-legal  bearing,  and  no  case  that  may  come 
before  us  that  can  throw  light  upon  this  subject 
should  escape  scrutiny.  Perusal  of  nine-tenths 
of  all  that  has  been  written  upon  the  subject  of 
ectopic  pregnancy  will  impress  one  with  the  be- 
lief that  ectopic  gestation  is  a  veritable  curiosity 
— a  case  of  nature  let  loose,  without  restraining 
or  guiding  influences,  that  should  act  with  any 
degree  of  uniformity  in  determining  the  steps  of 
her  aberrant  course.  And  as  a  consequence,  it 
was  for  a  long  time  thought  to  be  idle  to  attempt 
to  establish  anything  like  a  defined  line  of  action, 
in  dealing  with  a  process  so  eccentric.  Thus  is 
explained  the  fact  that  century  after  century 
rolled  on,  and  no  intelligent  method  of  combat- 
ting the  deadly  agency  of  this  process  was  dis- 
covered. Countless  thousands  of  women  have 
gone  to  their  graves  prematurely,  because  no  Tait 
had  arisen  to  unravel  the  mysteries  of  ectopic 
gestation,  and  point  out  a  sure  and  reliable  meth- 
od of  dealing  with  the  same. 

Although  the  propriety  of  performing  laparot- 
omy, tieing  off  the  vessels,  and  removing  the 
gestation- sac,  had  been  by  many  suggested,  it 
was  r.ot  until  1883  that  one  appeared  who  had 
sufficient  courage  and  conviction  upon  the  sub- 
ject to  put  his  conceptions  into  actual  practice. 
In  1873  Tait  formulated  certain  conclusions  re- 
specting ectopic  pregnancy,  and  so  far  as  has  come 
to  my  knowledge,  all  carefully  conducted  obser- 
vations upon  the  subject  since  then  have  served 
to  establish  their  correctness. 

He  claims  that  all  ectopic  pregnancies  are  pri- 


398 


ECTOPIC  PREGNANCY. 


[March  21, 


marily  tubal,  unless,  perchance,  there  should  be 
an  ovarian  variety,  which,  as  yet,  has  not  been 
proved.  Clinically,  two  kinds  of  tubal  pregnancy 
are  met  with,  viz.:  the  one  occurring  in  the  free 
portion  of  the  tube,  and  the  other  in  that  portion 
of  the  tube  embraced  in  uterine  tissue,  the  old 
interstitial  form. 

In  explaining  the  cause  of  Fallopian  pregnan- 
cy, he  refers  to  the  similar  states  found  in  the 
mucous  surface  of  the  uterus  after  menstruation, 
and  that  of  the  tubes  in  desquamative  salpingitis. 
Menstruation  is  regarded  as  a  nidation  process, 
a  state  in  which  the  epithelial  layer  of  the  mu- 
cous membrane  of  the  uterus  has  been  thrown  off, 
thus  fitting  the  cavity  for  the  retention  and  nu- 
trition of  the  fecundated  ovum  during  the  period 
of  its  earl}-  existence,  and  for  the  formation  of 
the  placenta  subsequently. 

The  cilia  of  the  healthy  tube,  acting  toward 
the  uterus,  assist  in  conducting  the  ovum  to  the 
uterine  cavity,  and  at  the  same  time  hinder  the 
ingress  of  spermatazoa. 

A  result  of  desquamative  salpingitis  is  to  re- 
move the  cilia  and  place  the  mucous  surface  in 
a  vascular  state  similar  to  that  of  the  uterus  after 
menstruation,  as  regards  its  power  to  furnish  nu- 
trition to  the  ovum  in  its  early  life.  Parentheti- 
cally I  will  state  that  the  conditions  for  the  forma- 
tion of  the  placenta  are  not  limited  to  uterine 
tissue,  even  though  the  Fallopian  tubes  be  re- 
garded as  a  part  of  the  uterus. 

When  we  reflect  that  the  placenta  is  a  product 
of  the  chorion,  and  that  the  latter  is  the  property 
of  the  ovum,  we  can  understand  how  the  inherent 
forces  of  the  fecundated  ovum  will  take  on  activ- 
ity, if  the  requisite  warmth,  moisture,  and  nutri- 
tive elements  are  at  hand,  as  has  been  evidenced 
by  the  implantation  and  growth  of  fertilized  ova 
along  fistulous  tracts  following  hysterectomy. 

In  confirmation  of  the  desquamative  theory, 
Parry  says  "women  who  have  become  pregnant 
outside  of  the  uterine  cavity  often  show  a  pre- 
vious inaptitude  for  conception,  the  interval  be- 
tween marriage  and  the  first  impregnation  being 
frequently  very  long. 

If  the  woman  has  borne  children,  a  period  of 
sterility  frequently  precedes  the  extra-uterine 
pregnancy.  The  fact  that  the  woman  has  been 
sterile  points  to  the  conclusion  that  there  has 
been  Fallopian  trouble.  The  recent  observa- 
tions of  Formas,  read  at  the  meeting  of  the  Amer- 
ican Association  of  Obstetricians  and  Gynecolo- 
gists, serve  to  confirm  the  theory  of  Tait  as  to 
the  influence  of  desquamative  salpingitis  in  oc- 
casioning extra-uterine  pregnancy. 

If  it  be  conceded  that  impregnation  usually 
takes  place  in  the  tube,  we  thence  derive  an  ar- 
gument against  the  theory  that  desquamative  sal- 
pingitis plays  an  important  n*>lc  in  causing  Fal- 
lopian pregnancy.  It  will  be  remembered  that 
in  the  latter  part  of  the  last  century  and  the  early 


part  of  this,  it  was  believed  that  the  spermatozoa 
passed  along  the  Fallopian  tube,  reached  the 
ovum  and  conception  took  place  at  the  ovary, 
and  that  the  impregnated  ovum  retraced  its  steps 
and  entered  the  cavity  of  the  uterus. 

Experiments  on  lower  mammals  show  that  the 
spermatozoa  are  usually  found  high  up  in  the 
cornua  of  the  bi-partite  uteri  (the  cornua  erro- 
neously supposed  to  be  Fallopian  tubes).  Fallo- 
pian tubes  only  exist  in  the  higher  order  of  ani- 
mals, those  that  have  assumed  the  upright  pos- 
ture. That  is  the  position  advanced  by  Mr.  Tait. 
The  observations  of  Parry  and  Formas  as  re- 
gards the  association  of  sterility  and  extra-uterine 
pregnancy,  will  find  general  confirmation.  The 
very  first  case  of  extra-uterine  pregnancy  of 
which  we  have  any  history  was  furnished  in  1594, 
when  a  Dr.  Primrose  operated  successfully.  That 
case  was  preceded  by  the  occurrence  of  extra- 
uterine pregnancy,  a  dead  child  having  been  re- 
moved several  years  before  through  a  large  aper- 
ture in  the  abdominal  parietes  in  consequence  of 
necrosis  of  the  part. 

An  ovarian  pregnancy  may  possibly  occur,  but 
it  has  not  been  conclusively  shown.  In  conso- 
nance with  the  view  that  pregnancy  occurred  at 
the  ovary,  it  was  formerly  believed  that  most 
cases  of  extra-uterine  pregnancy  were  really  cases 
of  ovarian  pregnancy. 

Many  pathological  specimens  are  found  in  mu- 
seums labeled  "ovarian  pregnancies,"  and  the 
appearances  furnished  by  a  Fallopian  pregnancy 
when  the  gestation- sac  has  not  been  ruptured,  are 
very  suggestive  of  an  ovarian  form.  But  a  close 
examination  of  these  specimens  serves  to  demon- 
strate that  very  few,  if  any,  are  ovarian  pregnan- 
cies. Possibly  some  of  them  are  ovarian  in  part, 
and  that  we  might  expect ;  we  have  cysts  involv- 
ing the  fimbriated  portion  of  the  Fallopian  tube 
and  the  ovary;  both  structures  playing  a  part  in 
their  formation  ;  and  it  is  reasonable  to  suppose 
that  in  certain  instances  the  fimbriated  extremity 
of  the  Fallopian  tube,  in  consequence  of  inflam- 
matory action,  would  become  adherent  to  the 
ovary,  and  the  spermatozoa  be  carried  down  to 
the  ovary,  and  impregnation  there  take  place.  In 
that  case  we  would  have  a  combined  form  of  ova- 
rian and  Fallopian  pregnancy.  In  one  portion 
of  the  gestation  sac  we  would  have  ovarian  tissue 
and  in  the  other  the  tissue  of  the  Fallopian  tube. 
In  order  to  prove  that  any  case  is  strictly  one  of 
ovarian  pregnancy,  it  would  be  necessary  that 
the  Fallopian  tube  should  be  intact  (normal),  the 
uterus  should  be  intact,  and  at  least  one  ovary 
thoroughly  intact ;  and  whilst  the  other  ovary 
might  not  be  present,  to  demonstrate  conclusively 
that  it  was  an  ovarian  pregnane}',  ovarian  stroma 
should  be  found  throughout  the  cyst  wall  of  the 
pregnancy.  I  do  not  know  a  single  case  recorded 
in  which  ovarian  tissue  had  been  found  through- 
out the  cyst  wall. 


i89i.] 


ECTOPIC  PREGNANCY, 


399 


Tubal  Form  of  Pregnancy. — Mr.  Tait  claims 
that  all  ectopic  pregnancies  are  primarily  tubal, 
taking  place  in  the  free  or  interstitial  portion  of 
the  tube.  It  is  only  exceptionally  the  case  that 
impregnation  takes  place  in  the  uterine  portion  of 
the  tube.  When,  however,  tubal  pregnancy 
occurs  the  fecundated  ovum  will  be  accommo- 
dated in  the  Fallopian  tube  only  for  a  short  time; 
the  tube  will  be  ruptured  at  some  time  before  the 
expiration  of  the  fourteenth  week.  If  the  rup- 
ture occurs  at  the  upper  portion  of  the  tube  where 
the  layers  of  the  broad  ligament  fall  over  it  as  a 
curtain,  the  opening  will  be  into  the  peritoneal 
cavity;  and  we  will  have  as  a  result  death  from 
hemorrhage  or  septic  peritonitis.  In  the  vast 
majority  of  cases  death  very  promptly  ensues, 
usually  in  time  ranging  from  a  few  hours  to  a 
few  days.  The  patient  may  die  from  haemor- 
rhage  in  its  primary  stage — there  being  no  inter- 
ruption to  the  haeinonhage  from  the  first  to  the 
last.  It  may  be  stayed  for  a  time  by  a  clot,  and 
then  recur.  As  a  rule,  death  ensues  from  primary 
haemorrhage,  since  there  are  no  influences  to  ar- 
rest it.  The  parts  being  exceedingly  vascular  at 
the  point  where  the  haemorrhage  occurs  a  large 
quantity  of  blood  is  poured  into  the  peritoneal 
cavity.  By  its  presence  peristalsis  is  excited;  the 
patient  in  consequence  of  her  suffering  is  restless; 
cannot  be  kept  still;  therefore,  the  conditions 
requisite  to  the  coagulation  of  the  blood  cannot 
be  complied  with. 

When  rupture  occurs  at  the  lower  portion  of 
the  tube,  we  have  a  sub- peritoneal  pregnancy, 
and  there  ensues  one  of  five  results: 

i.  The  fcetus  may  live  and  reach  a  viable  pe- 
riod. 

2.  It  may  be  converted  into  a  lithopaedian. 

3.  It  may  perish  and  be  absorbed  as  a  hsema- 
toma. 

4.  It  may  undergo  suppuration  and  may  be 
discharged  through  the  bowel,  vagina,  the  blad- 
der or  abdominal  wall  at  or  near  the  umbilicus. 

5.  It  may  develop  up  to  a  certain  point  and  then 
rupture  into  the  peritoneal  cavity, constituting  what 
is  known  and  designated  as  a  secondary  rupture. 
This  secondary  rupture  may  cause  death,  or  the  foe- 
tus may  be  extruded  into  the  abdominal  cavity 
without  amnion,  chorion  or  decidua  to  invest  it. 
Cases  are  reported  in  which  the  fcetus  has  been 
found  in  the  abdominal  cavity,  surrounded  by  the 
intestines,  with  no  proper  covering  at  all;  but  in 
such  instances  the  placenta  was  found  in  general 
attached  sub-peritoneally,  and  the  presumption  is 
strong  that  the  pregnane}-  had  proceeded  up  to 
perhaps  the  seventh  or  eighth  month,  and  then  a 
portion  of  the  broad  ligament  had  given  way,  and 
the  fcetus  was  emptied  into  the  free  peritoneal 
cavity.  This  assumption  is  supported  by  the 
fact  that  the  peritoneal  secretion  exercises  a  de- 
cided digestive  influence  upon  soft  structures 
such  as  obtain  during  the  early  life  of  the  embryo. 


Nor  is  the  rupture  of  the  Fallopian  tube  due 
to  distension.  At  the  point  where  the  placenta 
happens  to  grow,  if  from  the  upper  wall  of  the 
tube,  it  will  penetrate  the  true  tissue  of  the  tube 
in  the  form  of  venous  channels,  the  tubal  tissue 
becoming  constantly  thinner;  a  rupture  will 
finally  take  place  as  a  consequence,  and  then,  of 
necessity,  an  alarming  haemorrhage  occurs. 

If  the  placenta  should  be  developed  at  the 
lower  portion  of  the  tube,  in  the  direction  of  the 
space  between  the  broad  ligament,  a  rupture  will 
take  place  by  the  same  processes,  in  that  direc- 
tion, and  then  are  presented  either  of  the  five 
conditions  enumerated. 

Diag?iosis, — It  surely  is  a  decided  desideratum 
to  be  able  to  diagnose  extra-uterine  pregnancy — 
tubal  pregnancy  before  rupture.  Were  we  thus 
endowed,  and  the  proper  course  pursued,  main- 
lives  would  be  saved.  Should  the  patient  con- 
sult us  about  her  condition  previous  to  the  time 
of  rupture,  and  we  be  induced  to  make  a  physical 
examination,  I  should  think  the  testimony  of 
physical  signs  considered  in  connection  with  the 
subjective  symptoms,  in  the  vast  majority  of  cases, 
would  amply  justify  the  presumption  of  extra-uter- 
ine pregnancy;  in  fact,  a  presumption  so  strong 
that  the  neglect  to  make  an  exploratory  laparotomy 
would  be  inexcusable.  Suppose  a  case:  A  wo- 
man gives  the  history  of  sterility,  a  condition  not 
the  consequence  of  her  choice;  has  been  regular 
in  her  menstruation,  and  yet  a  few  weeks  previ- 
ously she  had  missed  a  menstrual  period;  had 
passed  a  week,  ten  days  or  two  weeks  or  more; 
then  menstruation  returned,  profuse  and  irregular; 
she  had  paiu  in  the  region  of  the  Fallopian  tube; 
her  attention  is  directed  to  that  region  by  the 
sense  of  discomfort,  and  recurring  attacks  of  pain; 
her  breasts  are  enlarged;  suffers  from  nausea; 
and  may  or  may  not  present  those  subjective 
indications  of  pregnancy  that  exist  when  the 
pregnane}-  occurs  in  the  uterus. 

The  cervix  is  soft,  and  the  uterus  continues  to 
develop  up  to  about  the  first  or  second  month; 
and  in  addition,  we  have  in  the  region  of  the 
Fallopian  tube,  upon  the  side  of  the  uterus  or 
posteriorily  to  it,  a  mass  of  appropriate  size  and 
form  to  that  of  a  pregnancy  at  the  particular  pe- 
riod. This  combination  of  symptoms  would  fur- 
nish strong  presumptive  evidence  of  pregnancy; 
if,  however,  after  one  examination  had  been  made 
and  the  size  of  the  mass  definitely  ascertained,  a 
subsequent  examination  should  reveal  a  proper 
increase  in  size,  then  the  conclusion  would  be 
almost  inevitable.  In  a  case  of  hydro-salpinx  the 
outline  of  the  tumor,  in  a  case  of  pyo-  salpinx,  the 
increased  sensibility  will  assist  in  reaching  a  sat- 
isfactory conclusion.  Diagnosis  of  tubal  preg- 
nancy, before  rupture,  have  been  made,  and  ap- 
propriate operations  performed;  and  when  this  se- 
quence of  symptoms  is  present  our  minds  should 
be  ou  the  qui  five  for  the  possibility  of  such  a 


400 


ECTOPIC  PREGNANCY. 


[March  21, 


condition  of  things.  The  diagnosis  of  tubal 
pregnancy  at  the  time  of  rupture  is  almost  un 
equivocal;  no  excuse  could  hardly  ever  be  claimed 
for  failing  to  diagnose  it,  and  to  invoke  promptly 
the  one  only  surgical  interposition  that  can  res 
cue  from  impending  death.  The  woman,  as  a 
rule,  is  taken  suddenly  ill;  complains  of  pain  in 
the  pelvic  region;  at  once  becomes  collapsed;  is 
faint;  is  almost  pulseless;  cries  for  water,  the  de- 
mand being  like  that  of  the  wounded  soldier  when 
profusely  bleeding;  her  anaemic  state  indicates 
conclusively  that  she  is  suffering  from  loss  of 
blood,  and  if  there  is  no  palpable  explanation  for 
it  elsewhere,  it  is  imperative  that  her  surgeon 
open  the  abdomen  and  ascertain  that  she  is  not 
bleeding  from  a  ruptured  Fallopian  tube. 

In  respect  to  a  diagnosis  of  a  rupture  of  the 
tube  into  the  broad  ligament,  the  subjective  symp- 
toms render  less  assistance  than  in  the  case  of 
rupture  into  the  abdominal  cavity,  but  the  phy- 
sical indications  are  more  positive.  The  woman 
suffers  from  collapse  to  a  degree  corresponding 
to  the  amount  of  blood  effused.  In  some  it  is 
very  great;  even  to  the  separation  of  the  broad 
ligament  and  the  formation  of  a  virtual  stricture 
around  the  rectum,  and  thus  obstructing  the 
passage  of  the  fseces.  In  such  cases  the  degree 
of  systemic  disturbance  is  very  pronounced.  If 
the  symptomatic  history  of  extra-uterine  preg- 
nancy be  present  together  with  the  sudden  occur- 
rence of  collapse,  and  the  finger  introduced  into 
the  vagina  detects  a  haematoma,  of  concave  form 
below,  and  sufficiently  large  to  reach  the  pelvic 
inlet,  being  convex  above,  the  conclusion  is  al- 
most absolute  that  the  case  is  one  of  tubal  preg- 
nancy ruptured  into  the  broad  ligament.  If  the 
rupture  has  thus  taken  place,  and  the  child  con- 
tinues to  live,  it  will  be  impossible  to  diagnose 
the  existence  of  a  living  child  until  after  the  ex- 
piration of  the  fourth  month.  After  this  period 
the  heart  sound  and  souffle  will  afford  sufficient 
data  to  determine  the  existence  of  a  living  child. 
In  case  of  the  death  of  the  child,  at  or  near  full 
term,  there  usually  precedes  a  process  of  spurious 
labor.  Women  sometimes  are  in  labor  for  sev- 
eral days,  exhibit  symptoms  that  simulate  those  | 
of  true  labor,  but  the  cervix  is  not  drawn  out  as  ; 
it  is  in  normal  pregnancy  at  the  full  period.  After 
the  cessation  of  labor  pains  the  mass  promptly 
becomes  reduced  in  size,  the  amniotic  fluid  un- 
dergoes absorption,  the  amnion  closely  invests 
the  child,  and  the  process  of  digestion  rapidly 
goes  on.  Prompt  reduction  in  the  size  of  the  ab- 
domen in  connection  with  the  absence  of  motion 
is  one  of  the  strongest  evidences  that  an  extra- 
uterine foetus  has  perished. 

Interstitial  Pregnancy. — It  is  impossible  to  di- 
agnose this  condition  either  by  physical  or  sub- 
jective symptoms  on   account  of  the   many  and 
conflicting  conditions  that   exist.      These  cases  i 
usually  rupture  into  the  peritoneal   cavity   at  a| 


time  varying  from  three  to  twenty  weeks.  If  it 
were  possible  to  diagnosticate  a  case  of  interstitial 
pregnane}-,  one  mode  of  treatment  only  would  be 
indicated,  viz.,  Porro's  operation,  removal  of 
uterus  and  child. 

Treat me  /it. — Primary  rupture  into  the  abdom- 
inal cavity  demands  laparotomy  promptly;  that 
portion  of  the  broad  ligament  in  which  the  sac  is 
situated  must  be  ligated  and  removed.  The  re- 
sult in  such  cases  is  usually  a  very  happy  one.  Mr. 
Tait  reports  thirty- eight  cases  with  only  one 
death;  Martin  reports  eleven  cases  with  three 
deaths;  others  report  favorable  results;  therefore, 
in  view  of  the  fearful  mortality  that  obtained  pre- 
vious to  the  institution  of  this  method  of  treat- 
ment, there  no  longer  exists  an)'  question  as  to 
the  propriety  of  this  procedure. 

hi  Case  of  Rupture  into  the  Blood  Ligature. — 
If  the  foetus  perishes  at  the  time  of  rupture,  a 
haematoma  is  formed  ;  if  the  haematoma  be  mod- 
erate in  size  the  question  arises,  shall  it  be  re- 
moved surgically  or  shall  it  be  left  with  the  hope 
that  it  will  disappear  by  absorption.  Some  con- 
tend that  an  operation  is  the  proper  thing  ;  others 
deny  that  laparotomy  and  the  opening  of  the 
broad  ligament  and  cleaning  out  the  collection  of 
blood  is  the  best  course.  If  the  condition  of  the 
patient  seems  not  to  be  serious,  and  the  collec- 
tion of  blood  not  unduly  large,  I  would  be  dis- 
posed to  leave  it  to  be  absorbed  ;  for  haematomata 
are  not  of  very  uncommon  occurrence,  and  it  is 
known  that  they  generally  undergo  absorption. 

As  a  rule,  therefore,  no  operative  measure  is 
called  for,  as  this  mass  of  blood  will  be  absorbed. 
It  has  been  contended,  however,  that  in  all  cases 
of  haematoma  complicated  with  extra-uterine 
pregnancy,  that  removal  by  abdominal  section  or 
an  operation  on  the  broad  ligament  through  the 
vagina  should  be  practiced  for  the  reason  that  in 
such  cases  sepsis  sooner  or  later  attacks  the 
effused  blood,  upon  the  assumption  that  the  des- 
quamative salpingitis  was  due  to  a  septic  condi- 
tion, and  that  the  septic  germs  still  existing  in 
the  Fallopian  tube  would,  in  the  course  of  six 
month  or  more,  infect  the  blood  poured  out  into 
the  broad  ligament.  As  a  matter  of  course,  if 
the  discharge  of  blood  into  the  broad  ligament 
was  of  such  extent  as  to  endanger  the  life  of  the 
patient  or  render  it  almost  certain  that  suppura- 
tion would  ensue,  the  wise  course  would  be  to 
perform  laparotomy,  open  the  broad  ligament. 
cleanse  it  thoroughly,  and  if  necessary  use  --rune 
styptic  application  and  stitch  the  divided  portion 
of  the  broad  ligament  to  the  abdominal  opening, 
and  if  necessary  insert  a  drainage  tube. 

What  line  of  action  shall  be  adopted  when 
extra-uterine  pregnancy  is  diagnosed  at  the  fourth 
month  or  thereafter,  the  foetus  being  alive  but 
not  viable  ?  Shall  efforts  be  made  to  destroy  the 
child  by  electricity,  by  the  injection  of  morphine 
or  by  other  means,  or  shall   we  by  a  laparotomy 


i89i.] 


SOME  COMMON  ERRORS  IX  DIAGNOSIS 


401 


remove  it  at  once,  or  wait  till  it  reaches  a  viable- 
period  and  then  attempt  to  save  both  mother  and 
child  ? 

When  such  a  case  is  diagnosed  as  early  as  the 
fourth  month,  or  soon  thereafter,  an  attempt  at 
its  removal  should  be  made,  otherwise  the  in- 
terests of  the  mother  will  be  compromised  in  a 
idegree  commensurate  with  the  delay  up  to  the 
viable  period  or  beyond,  for  the  smaller  the  pla- 
centa the  less  the  danger  :  the  greater  also  the 
possibility  of  tieing  off  the  vessels  and  greater 
likelihood  of  saving  the  mother.  But  if  the 
child  be  near  the  viable-  period  I  should  wait 
until  it  reached  the  full  period. 

Martin,  of  Chicago,  has  recently  experimented 
with  the  view  of  determining  the  comparative 
potency  of  the  faradie  current  and  galvanic  cur- 
rent in  destroying  eggs  in  the  process  of  incuba- 
tion, and  has  awarded  it  to  the  latter. 

In  regard  to  the  destruction  of  the  child,  statis- 
tics show  that  iii  iSSS  and  1889  eleven  cases  were 
operated  on  in  which  the  children  were  viable ; 
four  mothers  died,  and  four  children  were  saved, 
making  a  mortality  of  36  per  cent.  In  operations 
performed  from  six  to  eight  weeks  after  the  death 
of  the-  fcetus,  of  forty-four  cases  reported  in  1888 
and  1889,  there  were  nine  deaths,  a  mortality  of 
20  per  cent. 

These  are  vastly  more  favorable  results  than 
were  obtained  in  the  time  of  Parry,  who  says  in 
1873,  "of  nine  women  operated  on  during  foetal 
life,  or  soon  after  its  extinction,  they  all  died." 
Then  the  clamp  was  in  use,  and  no  antiseptic 
precautions  were  employed.  Consequently,  causes 
of  mortality  prevailed  that  do  not  exist  at  the 
present  day. 

Operation  of  Laparotomy,  Removal  of  the  Living 
Child.  —  Mr.  Tait  recommends  that  the  umbilical 
cord  lie  tied  close  to  the  placenta  and  that  the 
latter  be  left  intact.  The  abdominal  incision 
should  be  made  not  in  the  median  line,  the  con- 
ception being  below  the  broad  ligament,  as  the 
gestation  sac  increases  in  size  the  broad  ligament 
is  carried  up ;  consequently,  the  incision  is  made 
to  the  right  or  to  the  left  of  the  median  line,  as 
the  case  may  require ;  if  the  child  is  upon  the 
right  side  the  incision  should  be  to  the  right  of 
the  median  line,  and  vice  versa.  By  that  means 
it  is  sought  to  avoid  entering  the  peritoneal  cav- 
ity at  all.  The  sac,  after  thorough  ablution,  at- 
mospheric air  being  displaced  by  hot  water  forci- 
bly injected  and  gradually  abstracted,  is  sewed  to 
the  opening  in  the  abdominal  wall,  hermetic  clo- 
sure being  attempted. 

Efforts  have  been  made  to  remove  the  viable 
child  through  the  vagina,  but  the  results  have 
been  unfortunate.  I  am  acquainted  with  but  one 
case  in  which  a  living  child  has  been  thus  re- 
moved. The  circulation  under  such  circumstan- 
ces is  so  seriously  interfered  -with  that  the  child 
perishes   before  delivery   is  accomplished ;  lapa- 


rotomy, therefore,  furnishes  a  much  more  prom- 
ising mode  of  operation,  in  these  cases,  than  ex- 
traction per  vaginam, 

If  the  child,  however,  has  developed  in  the 
broad  ligament,  and  a  rupture,  with  haemorrhage, 
has  taken  place  secondarily  from  the  broad  liga- 
ment into  the  peritoneal  cavity,  and  the  symp- 
toms are  sufficiently  grave,  then  it  will  be  imper- 
ative that  we  open  the  abdomen,  ligate  the  vessels 
below  the  placenta,  if  possible,  and  remove  the 
extraneous  parts. 

In  case  of  suppurating  ovum,  the  mass  not 
being  large,  and  it  being  possible  to  reach  it  read- 
ily from  the  vagina,  its  removal  in  that  direction 
is  advised ;  but  if  the  mass  be  large  and  there  be 
complicating  conditions  resulting  from  inflamma- 
tory states,  laparotomy  and  removal  of  the  sup- 
purating contents  is  the  proper  procedure.  The 
cyst  wall  should  be  sewed  to  the  opening  in  the 
abdominal  parietes  and  drainage  practiced.  Ten 
cases  have  been  reported  in  which,  after  recovery 
from  one  extra- uterine  pregnancy,  a  like  preg- 
nancy  occurred  upon  the  other  side.  *~~£ 

The  question  very  naturally  presents  itself 
whether  or  not,  in  such  cases,  the  removal  of  the 
appendages  of  both  sides  is  indicated.  Salpingitis 
is  bilateral  in  nearly  one-half  of  the  cases,  a  sig- 
nificant fact  in  this  connection. 

Grand  and  Page  Aves. 


SOME    COMMON    ERRORS    IN    DIAGNOS- 
ING DISEASES  OF  THE  SKIN. 

.'  before  the  Chicago  Medical  Society,  February  2,  1891. 
BY  JOSEPH  ZEISLER,  M.D., 

FROFESSOR    OF   SKIN    AND    VENEREAL    DISEASES   IN     THE     CHICAGO 
MEDICAL  COLLEGE,  WOMEN'S  MEDICAL  COLLEGE.  POST-GRAD- 
UATE   MEDICAL    SCHOOL,    DERMATOLOGIST   TO    COOK 
COUNTY    HOSPITAL.    MEMBER   OF   THE    AMER- 
ICAN DERMATOLOGICAL  ASSOCIATION, 
ETC.,  ETC. 

There  is  surely  no  other  class  of  diseases  in 
which  the  chief  symptoms  are  more  tangible  and 
conspicuous,  more  read}'  for  close  inspection 
and  touch,  more  easy  of  examination  by  the  eye, 
be  it  unaided  or  armed  with  loupe  and  micro- 
scope, than  in  affections  of  the  skin.  And  vet 
perhaps  in  no  other  branch  of  medicine  are  diag- 
nostical  errors  committed  with  equal  frequency. 
The  cause  for  this  peculiar  discrepancy  lies  partly  in 
the  fact  that  real  difficulties  are  indeed  but  too  often 
encountered,  inasmuch  as  diseases  of  essentially 
different  etiology  and  nature  may  assume  similar 
pictures.  Under  such  circumstances  only  large 
experience  and  often  only  a  continued  observa- 
tion of  the  course  of  the  disease  will  help  in 
arriving  at  a  correct  understanding  of  the  case. 
In  a  large  number  of  instances,  however,  the  symp- 
toms are  so  clear  and  unmistakable  that  a  misin- 
terpretation of  the  same,  by  the  majority  of  gen- 
eral practitioners,  appears  in  an  entirely  different 
light;  and  without  wishing  to  do  anyone  particu- 


402 


SOME  COMMON  ERRORS  IN  DIAGNOSIS. 


[March  21, 


lar  injustice,  I  may  state  it  as  my  experience  that 
many  physicians,  who  in  every  other  direction 
are  splendidly  equipped,  look  upon  dermatology 
as  a  terra  incognita,  and  are  usually  free  in  admit- 
ting their  inability  of  recognizing  even  common 
forms  of  cutaneous  disorders.  This  may  well  be 
excused,  if  we  consider  the  entire  lack  of  facili- 
ties, at  least  in  our  city,  for  the  study  of  this  im- 
portant branch  of  medicine,  and  more  especially 
the  curious  fact  that,  with  the  many  and  well- 
appointed  hospitals  in  our  city,  there  is  not  one 
single  ward  set  aside  for  the  treatment  and  me- 
thodical study  of  skin  and  venereal  diseases.  To 
show  how  different  the  opportunities  in  other 
cities  are,  I  may  mention  that  Vienna,  with  no 
more  inhabitants  than  Chicago,  has  in  the  Gen- 
eral Hospital  three  distinct  services  for  cutaneous 
and  syphilitic  affections,  with  an  aggregate  of 
about  300  beds,  besides  largely  attended  out  door 
departments,  and  that  four  other  military  and 
civil  hospitals  have  each  a  special  dermatological 
service,  with  several  wards,  a  chief  and  his 
assistants.  This  subject  has  been  dwelt  upon 
with  great  emphasis  by  Dr.  P.  A.  Morrow,  in  an 
address  recently  delivered  before  the  American 
Dermatological  Association. 

Returning,  after  this  deviation,  to  my  theme, 
let  me  say  first,  that  a  frequent  source  of  error  in 
diagnosing  skin  diseases  is  too  great  a  reliance 
upon  the  statements  of  most  patients.  Time  and 
again  I  have  learned  to  appreciate  the  golden  rule 
of  my  teacher,  Kaposi,  never  to  ask  any  questions 
of  the  patient,  but  to  examine  his  skin  objective- 
ly and  uninfluenced,  and,  so  to  say,  to  read  on 
his  skin  all  the  aiiamnestical  data.  Duration  of 
the  trouble,  presence  or  absence  of  itching,  pre- 
vious treatment  and  other  valuable  points  will 
thus  be  often  easily  learned  without  the  aid  of 
the  patient,  which  will  greatly  contribute  to  make 
him  feel  that  his  case  is  well  understood.  How 
easily  patients  may  intentionally  or  involuntarily 
mislead  the  physician  I  experienced  in  a  very 
striking  manner  only  a  few  days  ago.  A  young 
man  came  to  see^  me  for  what  he  believed  to  be 
quinsy  sore  throat,  of  which  he  had  suffered 
for  the  past  two  weeks.  Looking  into  his  mouth 
and  throat,  I  immediately  informed  the  patient 
that  he  had  syphilis  and  asked  him  how  long  ago 
he  had  had  a  chancre.  He  vigorously  denied 
any  such  accident  and  thought  it  impossible  that 
he  could  have  been  infected.  I  demonstrated  to 
him  the  presence  of  numerous  mucous  patches  on 
his  tongue  and  tonsils,  the  corners  of  his  mouth, 
and  even  the  depressed  cicatrix  on  the  left  border 
of  the  tongue,  in  all  probability  the  seat  of  the 
primary  lesion,  but  all  this  did  not  seem  to 
him  convincing  enough.  I  then  made  him  un- 
dress and  discovered  on  his  chest  and  back  and 
the  upper  arms,  a  classical  roseola,  and  found  all 
the  superficial  lymphatic  glands  distinctly  en- 
larged.    This    at    least    settled    the    diagnosis, 


although  it  did  not  clear  up  the  mode  of  infection. 
However,  we  cannot  be  expected  to  play  the  part 
of  detective  always. 

This  case  of  an  unconscious  infection  by  the 
syphilitic  poison  is  by  no  means  a  unique  one, 
and  I  could  cite  from  my  own  observations  a 
number  of  similar  occurrences.  We  can  learn 
another  lesson  from  it,  namely,  to  examine, 
whenever  practical,  the  whole  integument,  and 
not  only  the  place  which  is  offered  for  inspection. 
I  have  still  under  treatment  a  young  druggist, 
who  some  time  ago  was  treated  by  one  of  his 
medical  friends  for  what  appeared  to  be  a  very 
rebellious  acne  of  the  face.  When  he  first  con- 
sulted me  I  noticed,  besides  the  eruption  on  his 
face,  a  well  developed  iritis  of  the  left  eye.  Sus- 
pecting the  specific  nature  and  causal  connection 
of  both  affections,  I  examined  his  body,  which  I 
found  literally  covered  with  a  large  papular  syph- 
ilide.  The  young  man,  who  evidently  had  not 
paid  much  attention  to  his  extensive  eruption, 
was  perfectly  alarmed  to  learn  the  nature  of  his 
trouble  and,  protesting  his  innocence,  assured 
me  that  for  the  past  year  he  had  not  indulged  in 
sexual  intercourse,  as  he  expected  to  get  married 
to  a  young  lady.  A  thorough  search  revealed 
the  cicatrix  of  the  former  initial  lesion  near  the  tip 
of  the  tongue,  and  I  learned  that  this  place  had  for 
some  time  been  the  seat  of  a  stubborn  sore.  The  j 
young  lady  in  turn  proved  also  perfectly  innocent, 
for  an  examination  showed  her  to  be  a  virgo  intacta, 
adorned,  however,  by  some  condylomata  lata  and 
mucous  patches  in  the  mouth,  for  which  she  had 
to  thank  her  own  father,  who  in  an  intoxicated 
condition  had  attempted  to  abuse  her. 

This  acquisition  of  syphilis  as  a  non-venereal 
disease,  when  no  history  of  infection  can  be 
gained,  is  too  often  overlooked.  I  shall  never 
forget  the  case  of  a  busy  fellow  practitioner  in 
this  city,  who  for  some  time  had  noticed  an  erup- 
tion on  his  body  and  the  palms  of  his  hands,  which 
he  showed  to  several  professional  friends,  who 
in  the  absence  of  any  anamnestical  data,  never 
suspected  syphilis;  while  one  of  them  considered 
the  case  as  eczema  and  prescribed  diachylon  oint- 
ment, the  next  pronounced  the  eruption  as 
psoriasis  and  recommended  chrysarobin,  until 
the  persistence  of  the  symptoms  and  the  compli- 
cation by  iritis  at  last  put  him  on  his  guard. 

While  we  thus  see  how  grave  errors  may  some- 
times be  committed  by  overlooking  the  syphilitic 
nature  of  cutaneous  manifestations,  the  opposite 
mistake  of  pronouncing  as  specific  an  eruption  of 
entirely  different  nature  is  probably  made  just  as 
frequently.  Once  a  prominent  lawyer  visited  me 
with  his  wife,  and  desired  my  opinion  about  a 
breaking  out  on  the  lady's  body,  which,  by  the 
family  physician,  had  been  declared  as  syphilitic. 
I  found  a  large  number  of  pea-sized  pale  red 
papules,  covered  with  glistening,  silverish  white 
seaks,  which  could  easily   be  removed,  when  a 


i89i.J 


SOME  COMMON  ERRORS  IN  DIAGNOSIS. 


403 


minute  bleeding  point  would  be  noticed;  very  cases  of  prurigo,  showing  that  this  disease  is  by 
little  itching,  no  glandular  infiltration,  no  no  means  very  rare  here,  and  R.  W.  Taylor  and 
alopecia,  no  sore  throat,  in  short  a  case  of  psoria-  James  C.  White  have  since  confirmed  my  views, 
sis,  which  by  its  somewhat  acute  development,  that  prurigo  is  often  overlooked  and  taken  for 
deviated  from  the  ordinary  type.  But  even  eczema,  urticaria,  lichen,  etc. 
chronic,  typical  cases  of  psoriasis,  with  large,  Another  disease  with  a  rather  typical  distribu- 
characteristic  scaly  patches  are  often  taken  as  tion  of  its  lesions  and  which  is  frequently  con- 
signs of  syphilis,  treated  by  mercury  and  the  founded  with  psoriasis,  is  eczema  seborrhoieum, 
iodides,  and  sent  to  the  Hot  .Springs.  a  very  common  type  of  eczema,  as  described  in  a 

Lastyearlwascalledtooneofthehospitalstosee  classical  manner  by  Unna.  It  occurs  principally 
a  young  girl  with  extensive  ulcerations  and  haern-  on  the  scalp,  usually  extending  over  the  hair 
orrhagic  bullae  of  the  skin,  which  the  house  physi-  border  towards  the  forehead  and  neck,  on  the 
cian  had  treated  for  some  time  with  antispecific  rem-  eyebrows,  external  auditory  channel,  around  the 
edies.  I  called  the  attention  of  the  young  JEseulap  corners  of  the  nose,  on  the  sternal  and  interscap- 
to  the  bleeding  of  the  gums  and  nostrils,  to  the  ular  surfaces  and  occasionally  affects  the  axillary, 
irregular  shape,  the  soft  edges,  the  haemorrhagic  ;  suprapubic  and  genito  crural  regions.  The  scales 
base  of  the  ulcers,  and  still  further  referred  him  differ  from  those  in  psoriasis  in  that  they  are 
to  the  hospital  record,  which  showed  that  the  more  fatty,  scanty  and  never  imbricated.  I  have 
patient  had  previously  been  treated  there  for  a  '  no  doubt  that  in  many  instances  of  claimed  cures 
similar    attack,    which    then    was   diagnosed  by   of  psoriasis  the  real  nature  of  the  trouble   has 


me  as  purpura  haemorrhagica,  or  Werlhoft's  dis- 
ease. The  child  was  then,  partly  on  account  of 
the  improper  treatment,  in  a  very  miserable  con- 
dition, and  died  soon  afterwards. 

Acne  varioliformis,   that  peculiar  pustular  af- 
fection, which  has  been  described  under  various 
itions  as   acne   frontalis,    a.    necrotica,   a 
atrophica  (Bulkley),molluscum  sebaceum  (Bazin) 


been  that  of  a  seborrhoical  eczema,  which  by  the 
gyrate  outlines  of  some  of  the  patches  and  its 
other  features  will  sometimes  simulate  a  light 
case  of  psorii 

The  idea  that  most  skin  diseases  are  caused  by 
systemic  derangements,  not  to  say  by  impurities 
of  the  blood,  seems  still  to  be  quite  prevalent, 
even  among  modern  physicians,  and  thus  some- 


also  occasionally  regarded  as  a  specific  trouble,  times  near  lying  local  causes  will  be  overlooked, 
perhaps  because  cicatrization  terminates  the  pro-  ]  whose  removal  would  easily  accomplish  a  cure, 
cess.  This  disease  is  somewhat  rare,  but  the  An  interesting  illustration  of  this  fact  was  seen 
peculiar  localization,  mostly  on  the  forehead  and  !  by  me  in  a  very  respectable  young  lady  from  Cal- 
anterior  part  of  the  scalp,  occasionally  on  the  ifornia,  who  spent  some  time  with  relatives  in 
nose  and  in  the  bearded  face,  less  often  on  the  j  Chicago,  and  soon  after  her  arrival  began  to 
hack,  the  formation  of  thick  crusts  after  the  pus-  notice  an  urticarial  rash  on  her  body.  The  fam- 
tules  have  dessicated,  the  resulting  depressed '.  ily  doctor  very  promptly  diagnosed  hives  and 
scar,  the  recurrence  of  the  eruption  in  irregular  prescribed  cathartics  and  alteratives,  but  new 
intervals  will  help  to  strengthen  the  diagnosis.      j  crops  of  wheals  continued  to  appear.  After  being 

As  just  indicated,  a  frequent  source  of  error  in  troubled  some  four  weeks  she  came  to  consult 
recognizing  skin  diseases  is  indeed  a  lack  of  ac-  me,  and  I  modestly  inquired  about  the  young 
quaintance  with  their  peculiar  localization,  which  lady  having  noticed  in  her  bed  some  six-legged 
is  sometimes  the  only  important  factor  in  deter-  companions.  This  was  blushingly  confirmed, 
mining  the  diagnosis.  Scabies  f.  i.  is  always  after  which  the  treatment  was  suggested  very 
found  on  certain  well  defined  places  of  predilec-  easily.  In  another  case  a  young  man  who  had 
tion  and  leaves  the  face,  with  rare  exceptions,  recently  arrived  here  from  New  York,  noticed  an 
free.  And  yet.  incredible  as  it  may  sound,  I  extensive  eruption  on  the  body,  which  had  unsuc- 
receutly  had  a  patient,  who  for  five  months  had  cessfully  been  treated  under  the  supposition, 
been  treated  for  that  trouble  under  differing  diag-  '  that  it  was  an  acute  papular  eczema.  Diligently 
nosis,  as  urticaria,  eczema,  and  even  lichen,  al-  j  examining  his  body,  which  was  covered  with  a 
though  the  penis  and  buttocks,  and  interdigital  luxuriant  growth  of  hair,  I  succeeded  to  pick  up 
were  almost  labeled  with  the  characteristic  with  my  tweezers  from  the  base  of  a  hair  on  the 
burrows.  lower  limb   what  appeared  to  be  a  little  black 

Prurigo,  also,  can  only  be  recognized  by  exam-  point,  but  soon  moved  along  slowly,  as  pediculi 
ining  the  whole  integument,  when  the  extensor  pubis  will  do. 

surfaces  will  be  found  principally  involved,  but  During  the  late  fall  I  see  even-  year  a  number 
the  cubital,  inguinal  and  popliteal  spaces  per-  of  cases  of  that  well-defined  disease,  pruritus 
fectly  smooth.  The  existence  of  this  disease  in  hiemalis  (winter  itch),  which  was  first  described 
the  United  States  was  for  a  long-  time  denied  by   by  Duhring.     This  trouble  does  not  seem  to  be 


dermatologists.  But  at  the  meeting  of  the  Amer 
ican  Dermatological  Association  in  September, 
1889,  I  was  enabled  to  report  a  series  of  twelve 


universally  appreciated  and  is  frequently  con- 
founded with  eczema.  This  word  eczema  is,  by 
the  way,  of  all  dermatological  terms,  perhaps  the 


4o4 


MEDICO-LEGAL  RELATIONS  OF  LAPAROTOMIES. 


[March  21, 


most  abused,  and  there  is  hardly  a  skin  affection  new  ulcerations  appeared,  and  the  continued  suf- 
to  which  I  have  not,  on  and  off,  found  that  name  fering  almost  made  her  a  physical  wreck.  When 
being  given.  All  forms  of  pruritus,  sycosis,  finally  her  remarkable  confidence  and  power  of 
lichen,  prurigo  and  many  parasitical  dermatoses  endurance  had  given  out,  she  consulted  Dr.  I.  X. 
are  occasionally  baptized  with  the  always  ready  Danforth,  of  this  city,  who  kindly  referred  her  to 
name,  eczema.  me.     I  found  on  her  face  about  half  a  dozen 

The  term  lupus,  too,  is  often  used  in  a  very  smaller  and  larger  ulcers,  which  showed  the  very 
loose  manner.  First  there  is  rarely  a  distinction  characteristic  horse-shoe  form.  The  greater  part 
made  between  lupus  vulgaris,  that  one  form  of  of  the  upper  lip  was  missing,  having  been  ex- 
local  tuberculosis  of  the  skin  and  lupus  erythe-  cised,  which  made  the  closing  of  the  mouth  al- 
inatosus,  which  has  nothing  to  do  with  the  other  most  impossible,  and  the  whole  ala  nasi  of  the 
and  ought  better  to  be  called  according  to  Hebra  right  side  had  also  been  sacrificed  at  one  of  those 
sen.  seborrhcea  congestiva.  Then,  the  natural  "surgical"  procedures.  Xumerous  disfiguring 
history  of  lupus  vulgaris  is  often  ignored.  Thus  scars,  moreover,  gave  the  face  a  very  pitiable  as- 
I  saw  a  short  time  ago  that  diagnosis  made  in  a  pect.  The  fact  could  easily  be  ascertained  that 
man  near  the  fortieth  year,  who  had  a  pea-sized  the  lad}*  had,  some  years  ago,  been  infected  by 
follicular  infiltration  on  his  nose,  while  it  is  the  her  husband,  which  was  followed  by  various  erup- 
rule  for  lupus  never  to  appear  after  puberty.  In  tions  on  the  body,  and  also  by  iritis.  How,  with 
another  case  a  young  man,  over  30  years  old,  had  such  an  anamnesis  and  with  the  unmistakable, 
an  indurated  and  superficially  ulcerated  sore  on  objective  signs,  syphilis  could  be  overlooked,  and 
his  lower  lip  of  the  size  of  a  hazel-nut.  He  came  in  entire  defiance  of  all  that  is  known  about  lu- 
to  me  pretty  well  scared,  for  during  six  weeks  of  pus,  this  diagnosis  made,  is  beyond  my  cornpre- 
previous  treatment  two  prominent  physicians  had  hension.  The  lady  made  a  splendid  recovery  as 
pronounced  it  as  epithelioma,  while  another  took  far  as  the  ulcers  then  present  were  concerned, 
it  for  lupus.  My  first  question  of  this  patient,  which  healed  in  two  weeks  and  never  again  ap- 
after  examining  the  trouble  was,  "When  have  peared  in  a  year  ;  but  whether  a  plastic  operation, 
3-011  had  a  chancre,"  to  which  the  prompt  reply  which  she  now  contemplates,  will  be  able  to  re- 
was  given,  "Ten  years  ago."  The  presence  of  a  store  the  shape  of  the  nose  and  the  mouth,  when 
large  scar  on  the  chin,  the  absence  of  any  cartilag-  no  flexible  skin  is  available  in  the  adjoining 
inous  induration  on  the  borders  of  the  ulcer  and  parts,  I  doubt  very  much.  I  have  no  further 
the  considerable  pain  further  pointed  to  the  diag-  comment  to  make  upon  this  case,  except  that  I 
nosis  of  an  ulcerating  gumma,  which  was  suffi-  succeeded  in  preventing  the  lady  from  beginning 
ciently  proven  to  be  correct  by  the  result  of  treat-   a  suit  for  malpractice. 

ment,  which  in  the  course  of  ten  days  caused  the        Let  me  finally  assure  you   that  the   foregoing 
ulcer  to  heal  up.                                                             paper  is  presented  with  no  ill  spirit,  but  with  the 
I  could  easily  mention,  from  my  own  experi-   sincere  wish  to  awake  a  little  more  interest  in  the 
ence,   any  number  of  further  cases,  illustrating  somewhat  neglected  study  of  dermatology, 
various  diagnostical  errors,  but  this  would  go  far 
beyond  the  scope  of  this  merely  suggestive  essay.  


MEDICO-LEGAL    RELATIONS    OF 
LAPAROTOMIES. 

I      Med      Legal  S  Dec.  6, 1S90. 

BY  J.   II.   ETHKRIDGK.  M.D., 

TROFESSOR   Or   G  -H    MEDICAL   >. 

CHXCA.G 

Abdominal    Surgery    is    comparatively    new, 


We  all  know  that  mistakes  will  sometimes  be  un- 
avoidable, not  only  in  dermatology,  but  in  all 
other  departments  of  medicine  ;  as  long,  howev- 
er, as  the  patient  gets  well,  all  is  well.  To  show, 
on  the  other  hand,  how  treatment  based  upon  a 
false  diagnosis  maj  '■'■■  followed  by  almost  disas- 
trous consequences,  let  me  give  vou,  in  conclu- 
sion, a  few  notes  about  a  case,  which  impressed 

specially  strongly  upon  my  mind.   A  young  there  is  nothing  settled  concerning  the  method  of 

widow  from  Boston  came  to  Chicago,  upon  the  performing  abdominal  surgery,  that  is,  abi 

solicitation  of  her  sister,  to  place   herself  under  and  diy'hi itely  as  compared  with  what  may  be  said 

the  care  of  a  phvsician  who  stands  at  the  front  to  be  settled  about  the  treatment  of  fractures  and 

of  the    homoeopathic    fraternity.       She   suffered  dislocations.     Whenever  a  case  of  medico-lega| 

from  extensive-   ulcerations  in   her  face,  particu-  interest  finds  its  way  into  the  courts  concerning 

larly  the  nose,  cheeks  and  lips.     The  doctor  and  the  treatment  of  fracture  or  dislocation,  there  is 

his  assistant,  ding  up  the  case,  decided  very  little  difference  of  opinion  in  the   minds  of 

i,  lupus,  and  finding  in  their  surgeons  concerning  the  treatment  of  these  cases 

:ommended  as  one  of  the  meth-  —ami  they  constitute  nine-tenths  of  malpractice 

ods  of  treatment,  thorough  scraping  ami  exci-  suits — for  the  reason  that  the  treatment  of  frac* 

sion.pi  this  line  of  action.    Dur-  lures  and   dislocations    is    nearly  as  old  as   the 

ing  a  year  the  patient  submitted  to  twelve  different  human  family.      Abdominal  surgery  cannot  boast 

surgical  operations  under  chloroform  narcosis,  but  of  this  ancient  lineage,  but  is  so  recent  and  new. 


I89i.] 


MEDICO  LEGAL  RELATIONS  OF  LAPAROTOMIES. 


405 


and  so  many  innovations  are  coming  in   every   puerperal  fever  was  owing  to  the  uncleanness  of 
day  that  it  seems  to  me  one  might,  after  looking   the  attending  physician. 

overall  the  would-be  settled  points  concerning  Next,  as  to  the  time  of  operating,  whether  be- 
the  technique  of  the  operation,  conclude  that  fore  or  after  supervention  of  reaction.  In  all 
there  is  nothing  very  definitely  settled.  And  ordinary  cases  of  gunshot  injuries  and  the  like 
when  the  President  of  the  Medico-Legal  Society,  about  the  limbs,  surgeons,  generally  speaking, 
in  the  seductive  way  he  has.  asks  a  man  to  handle  desire  to  await  reaction  before  operating,  but  in 
;i>jeet  in  ten  minutes,  before  an  audience  of  cases  of  abdominal  wounds,  where  intestines  are 
this  kind,  I  think  he  has  thrust  a  herculean  task  perforated  and  fixed  organs  injured,  we  know 
upon  that  man.     I   cannot  thoroughly   go  over   that  collapse  almost  always  follows  at  once,  and 


the  wide  ground  covered  by  this  subject  in  ten 
minutes,  but  I  will  touch  briefly  upon  the  most 
important  points. 

First,  it  seems  to  me  we  are  attackable  in  many 
ways  concerning  the  subject  of  positive  knowl- 
edge in  diagnosis.  There  is  nothing  that  is 
more  easy  to  be  deceived  in  than  the  diagnosis  in 
abdominal  troubles.  One  can  operate  a  hundred 
times  in  succession  upon  the  various  cases  that 
come  along  in  abdominal  surgery,    and  make 


to  await  for  reaction  here  would  seem  to  me  to 
be  waiting  for  peritonitis  to  invade  the  premises 
and  make  short  shrift  of  the  patient.  I  think 
any  one  giving  testimony  and  saying  we  ought 
to  wait  for  reaction  in  such  cases,  is  a  dangerous 
person. 

We  all  know  that  it  is  only  a  few  years  since 
gunshot  wounds  of  the  abdomen  were  first  oper- 
ated upon,  but  dogs  have  been  shot,  under  anaes- 
thesia, and  the  intestinal  preparations  closed  up 


correct  diagnosis  in  perhaps  sixty  percent,  and  in  ,  and  the  dogs  have  recovered  and  lived  good  long 
the  others  "he  may  not,  but  when  a  man  has  oper- 1  lives  afterwards.  In  this  investigation  the  in- 
ated  ten,  fifteen— twenty  times,  and  has  not  made  ,  testines  were  distended  by  hydrogen  gas  for  the 
a  correct  diagnosis,  he  begins  to  feel  like  the  \  purpose  of  locating  the  holes  in  the  intestines 
surgeon  who  said,  he  who  makes  a  diagnosis  that  could  not  be  located  by  ordinary  digital  ex- 
after  he  opens  the  abdomen  is  the  man  who  is  I  animation.  To-day  there  are  some  meuln  the 
most  cautious  and  correct.  So  I  think  if  a  doctor  j  country  who  believe  that  we  are  as  bound  to  op- 
should  be  brought  up  before  the  courts  to  answer  i  erate  upon  a  man  who  is  shot  in  the  abdomen  as 
for  a  faulty  diagnosis— for  the  doctor,  legally,  is  [  we  are  to  operate  in  almost  any  plain  case  in 
responsible  for  his   diagnosis — and  is  made  re- j  ordinary  surgery.     Statistics  are  hard  things  to 


sponsible  on  that  account,  that  he  is  possessed  of 
a  very  large  loophole  of  escape,  in  that  so  many 
doctors  ar-e  unable  to  make  a  diagnosis  before 
operating. 

So  many  things  are  involved  in  abdominal 
surgery  that  have  to  be  gone  over  clinically,  that 
I  cannot  pause  longer  than  to  make  the  barest 
mention  of  these  points  : 

First  is  the  condition  of  the  hands  and  sponges; 
the  hands  of  the  operator,  the  hands  of  the  nurse, 
of  the  internes,  and  everybody  implicated  in  the 
operation.       It  is   a  settled   fact   that   complete 


combat  :  The  old-fashioned  treatment  was  to 
put  the  patient  at  rest,  giving  opium,  and  letting 
him  run  along  in  that  way  until  the  intestinal 
wounds  healed  and  he  escaped  the  possibility  of 
fatal  peritonitis  ;  if  he  got  well — well  ;  if  he 
didn't— ill ;  that  was  about  all.  Statistics  in  the 
State  of  New  York,  for  the  last  ten  years,  com- 
piled by  skillful  surgeons,  show  eighty-four  cases 
of  intestinal  perforation  by  gunshot  wound  op- 
erated upon  with  a  mortality  of  eighty-three  per 
cent.  In  the  preceding  ten  years  the  number 
of  cases  treated,  not  by   operation,  resulted  in  a 


cleanliness  is  the  only  thing  permitted,  any  doubt  [  mortality  of  only  thirty -five  per  cent.  Therefore 
as  to  this  makes  the  doctor  reprehensible.  The  1 1  think  the  man  who  goes  on  the  witness  stand 
most  perfect  means  of  cleansing  the  hands  and  1  and  says  this  patient  with  an  intestinal  gunshot 
sponges  should  be  required  of  the  physician.  uid  should  have  been  operated  upon  by  the 

A  point  was  made  in  a  recent  case  brought  up  surgeon  in  attendance,  that  he  should  not  have 
in  the  East,  concerning  the  length  of  time  of  an  \  waited  to  take  the  old  course,  is  very  ■dangerous, 
operation.  It  was  claimed  that  the  doctor  was  Now  a  few  words  concerning  the  incision  :  As 
too  long,  and  the  astounding  evidence  was  given  j  a  rule  the  incision  should  be  as  short  as  possible, 
by  one  laparotomist,  that  resection  of  the  in-  still  there  are  cases  where  the  incision  should  be 
testine  ought  not  to  occupy  more  than  twenty  made  from  the  pubes  to  the  ensiform  cartilage. 
Ainutes.  That  evidence  was  very  material  with  So  when  a  man  says  there  is  any  cast  iron  rule  in 
the  jury,  since  the  physician  had  been  some  three  regard  to  the  operation  he  doesn't  know  what  he 
and  a  half  hours  getting  through  with  the  opera  ;  is  talking  about,  and  is  giving  misleading  testi- 
tion.     I  think  it  is  safe  to  say  that  no  man  can   mony 


do  that  operation  successfully  and  safely  under 
two  hours,  and  a  man  who  goes  upon  the  witness 
stand  and  gives  such  evidence  as  that  quoted 
above  is  exceedingly  dangerous,  almost  as  danger- 
ous as   the  man   who    testified   that   a   case   of 


Another  point  is  concerning  the  pedicle, 
whether  it  be  ovarian  cyst  or  uterine  fibroid.  In 
years  gone  by,  but  not  so  very  remote,  the  pedicle 
used  to  be  treated  with  a  clamp  outside  of  the 
abdomen.     Twenty  years  ago  that  was  classical 


406 


MEDICO-LEGAL  RELATIONS  OF  LAPAROTOMIES.  [March  21 , 


treatment;  to-day  it  is  not.  It  seems  to  be  j  on  that  point.  Next,  in  regard  to  drainage,  shall 
pretty  well  settled  in  the  matter  of  ovarian  tumors  I  we  drain  or  not  ?  I  believe  there  are  cases  ap- 
that  the  treatment  of  the  pedicle  should  be  by  ,  propriate  for  draining,  and  cases  that  do  not  call 
ligature,  and  accordingly  we  will  find  that  all  I  for  it,  but  we  will  find  that  a  drainage  advocate 
cases  treated  by  ligature  will  be  good  surgery,  will  claim  that  all  cases  should  be  drained.  But 
and  the  man  who  attempts  to  treat  by  the  clamp  j  the  man  who  is  best  posted  on  this  question  will 
outside  would  not  be  judged  a  good  surgeon  by  |  on  general  principles  usually  have  as  little  foreign 
the  medical  profession,  and  on  the  witness  stand  j  substances  in  the  abdomen  as  possible,  and  for 
would  be  handled  pretty  badly  ;  there  is  but  one  this  reason  :  The  pressure  of  the  organs  against 
opinion  in  regard  to  the  treatment  of  the  ordinary  !  the  drainage  tube  permits  the  formation  of  a 
ovarian  pedicle  in  laparotomy.  But  there  is  a  j  fistula,  and  in  that  way  we  have  intestinal  fistulas 
variation   of  opinion  concerning   the  ligatures  ;   opening  into  the  abdomen  followed  by  peritonitis. 


some  use  Japanese  silk,  some  Chinese  silk ;  some 
plain  and  some  braided  silk.  Some  operators  are 
so  strenuous  that  the}7  will  operate  only  with  one 
kind  of  silk,  while  others  will  only  operate  with 
catgut.  I  saw  a  gentlemen  in  the  East  a  short 
time  ago,  who  believes  that  all  the  ovarian 
pedicles  should  be  treated  by  catgut  ligatures  and 
nothing  else,  for  the  reason  that  suppuration  may 
follow  the  use  of  silk  whereas  catgut  is  absorbed. 
That  man  going  on  the  witness  stand  with  this 
kink  in  his  mind  would  testify  very  strongly 
against  any  one  who  used  silk  ligatures. 

In  regard  to  the  treatment  of  the  pedicle  of 
uterirfe  tumors,  in  cases  of  myomectomy  there 
are  two  ways,  one  is  to  treat  the  stump  in  the 
intra-peritoneal  way,  and  the  other  is  the  extra- 
peritoneal way.  One  making  a  covering  of  the 
peritoneum  over  the  stump,  stitching  it  tightly 
and  dropping  it  back ;  the  other  is  to  bring  it 
forward,  anchoring  it  to  the  abdomen  and  letting 
it  slough  off.  These  two  methods  are  very  satis- 
factory, but  they  both  have  their  defects.  We  are 
in  a  stage  of  transition  concerning  all  these  things. 
Concerning  ligatures :  Not  only  in  the  ab- 
domen, but  for  the  treatment  of  the  wound  silk 
is  used  a  very  great  deal,  and  so  is  catgut  ex- 
ternally ;  the  majority  of  the  profession  I  think 
use  nothing  but  silk,  and  they  use  the  silk  with 
one  sweep  through  the  mural  tissues  on  both 
sides  of  the  incision  in  that  way  including  in  the 
loop  the  skin  and  all  tissues  to  the  abdominal 
cavity.  Another  way  to  close  the  abdomen  is  to 
make  three  banks  of  stitches,  first  sewing  the 
peritoneum  down,  then  running  the  same  liga- 
ture back  again  taking  the  connective  tissue  and 
the  muscles  through  up  to  the  upper  angle  of  the 
wound,  and  then,  with  silk,  bringing  the  skin  to- 
gether in  three  banks  of  stitches.  I  saw  a  gentle- 
man who  had  done  this  operation  a  hundred 
times  and  never  had  had  a  hernia,  and  he  believes 
that  is  the  classical  way  of  doing  it 
should  go  on  the  witness  stand  and  give  evidence 
he  might  hurt  those  of  us  very  much,  whose 
method,  varying  from  his,  chances  to  be  followed 
by  a  ventral  hernia. 

The  toilet  of  the  peritoneum  is  another  poinl 
we   will   consider.     In  abdominal   surgi 
lute  cleanliness   is  required,  any  uncleanness  is 
reprehensible;    I  think  there  is  but  one  opinion 


So  you  see  there  is  something  to  be  said  against 
the  drainage  tube.  I  think  in  some  cases  a  good 
method  of  drainage  is  through  the  vagina. 

In  regard  to  the  after-treatment  a  great  deal 
can  be  said.  I  can  scarcely  stop  to  go  into  the 
details,  but  on  the  first  day  after  a  laparotomy 
the  fear  of  haemorrhage  is  entertained,  and  on 
the  second  day  the  well-marked  symptoms  of 
peritonitis  may  come  on,  and  if  the  physician  is 
ignorant  of  this  he  may  not  employ  the  usual 
means  of  treatment.  On  the  third  day  we  are 
likely  to  get  sepsis,  and  the  man  who  does  not 
know  about  this  fails  to  recognize  the  condition, 
and  in  that  way  the  patient  may  die,  and  this 
may  lead  to  a  malpractice  suit. 

All  that  can  be  said  about  these  cases  is  that 
very  little  comparatively  is  well  settled  in  regard 
to  them. 


Dr.  C.  T.  Parkes:  It  is  hardly  necessary  for 
me  to  occupy  your  time  on  a  subject  which  has 
been  handled  so  perfectly  by  Dr.  Etheridge.  He 
has  opened  so  many  questions  for  discussion  that 
it  would  be  impossible  to  go  over  them  all  if  we 
talked  a  month.  I  agree  with  him  entirely  in 
the  rather  positive  assertion  he  makes  that  doc- 
tors are  dangerous  men,  and  they  are  more  dan- 
gerous to  themselves  than  to  most  other  people. 
Especially  is  a  doctor  a  dangerous  man  when  he 
gets  to  be  a  very  positive  man,  when  he  has  had 
so  much  experience  as  to  get  into  a  rut;  has  had 
so  many  successful  cases  that  he  knows  he  is  go- 
ing to  have  a  good  result — and  perhaps  does  gen- 
erally get  good  results  whatever  the  case.  And  that 
brings  to  us  the  thought  that  the  method  of  doing 
things  is  of  immense  advantage.  It  does  not  make 
any  difference  whose  method  it  is,  the  thing  for  the 
individual  to  do  is  to  make  it  his  method,  and  if 
he  knows  all  about  it — all  about  its  peculiarities 
— that  method  is  going  to  succeed.  Medical  men 
if  that  man  who  get  into  the  habit  of  being  dependent  upon 
themselves  as  to  their  methods  will,  I  am  sure, 
get  better  results  by  that  means  than  by  any 
other,  but  when  they  do  that,  they  should  always 
feel  that  it  is  owing  to  the  fact  tli.it  they  have 
practiced  in  this  way  that  they  have  become  suc- 
cessful, and  should  believe  that  their  friends  and 
associates  with  other  plans  are  doing  as  well  as 
themselves. 


'»9i.] 


A  REMARKABLE  CASE 


407 


I  am  interested  a  little  bit  in  the  subject  of 
gun-shot  wounds  of  the  abdomen.  I  do  not  be- 
lieve in  statistics;  you  can  prove  anything  by 
statistics,  even  a  fact.  I  am  quite  sure  that  Dr. 
Etheridge  in  his  quotation  of  statistics  has  taken 
them  from  the  monograph  of  friends  of  mine  in 
New  York,  Drs.  Stimpson  and  Manley.  Appar- 
ently they  have  collected  all  the  bad  cases,  and, 
just  so  as  to  not  make  it  too  bad,  they  have  put 
in  a  few  good  cases.  People  would  not  believe 
them  if  they  said  all  the  cases  were  fatal.  That 
is  all  right.  Doctors  are  apt  to  make  their  side 
of  the  question  the  most  reasonable  side  if  they 
can;  that  is  all  right  too.  There  is  no  question 
but  that  the  doctor  is  responsible  always  when  he 
takes  human  life  in  his  hands,  but  there  should  lie 
a  little  liberality  shown  him  when  he  lakes  a  case 
of  this  kind,  in  which  the  life  of  the  individual  is 
absolutely  gone,  as  in  the  vast  majority  of  cases  of 
gun- shot  wounds  of  the  abdomen;  certainly  if  it  is  a 
fatal  wound,  he  should  not  be  blamed  if  occa- 
sionally he  happens  to  lose  a  case  of  gun-shot 
wound  of  the  abdomen. 

The  profession  is  apt  to  be  elated  about  every 
thing  a  little  new,  and  go  wild  over  it,  and  the 
same  is  true  with  reference  to  operations  for  gun- 
shot wounds  of  the  abdomen.  When  laparotomy 
for  this  injury  was  first  advocated  by  myself, 
everybody  began  to  operate  upon  individuals  who 
had  received  gun  shot  wounds  without  remem- 
bering that  he  who  advised  this  method  of  open- 
ing the  abdomen  to  treat  these  injuries  had 
asserted  positively  that  in  his  belief  the  majority 
of  gun-shot  wounds  of  the  abdomen  were  fatal. 
The  fatal  injuries  were  not  the  ones  we  were 
after,  but  cases  like  the  ones  we  often  met  with 
in  hospital  experience,  in  which  the  patient  dies, 
and  upon  a  post-mortem  examination  it  was 
found  that  there  was  only  a  small  wound,  or  two 
or  three  holes  in  the  intestines  which  caused 
death,  and  they  were  separated  from  security 
only  by  the  thickness  of  the  abdominal  walls. 
No  man  can  tell  what  is  done  in  the  peritoneal  cav- 
ity when  a  bullet  has  penetrated  it  until  it  has  been 
opened;  and  while  we  must  ask  our  legal  friends 
to  be  a  little  liberal  with  us  in  these  cases,  I  cer- 
tainly agree  with  the  author  of  the  paper,  that 
the  item  of  abdominal  surgery  is  entitled  to  more 
support  from  the  general  profession  than  perhaps 
that  in  connection  with  any  other  part  of  the 
body.  It  is  the  terra  incognito  of  surgical  prac- 
tice. All  general  surgeons  know  how  impossible 
it  is  for  us  frequently  to  tell  the  character  of  a 
simple  tumor  beneath  the  skin,  and  how  are  we 
going  what  is  the  character  of  a  mass  in  a  per- 
son's abdomen  that  fills  it  to  such  distension  that 
we  can  find  no  signs  of  the  existence  of  the  ordin- 
ary organs  in  it?  And  how  is  a  man  to  tell  of 
those  conditions  which  produce  death  many 
times,  and  yet  are  so  simple  in  their  specific  devel- 
opment that  they  cannot   be  discovered  without 


opening  the  abdominal  cavity?  A  doctor  always 
takes  a  risk,  and  that  is  part  of  the  nobility  of 
the  profession. 

Dr.    W.    ]•:.   CLARKE:    At    this   late  hour  the 
only  thing  that  I  wish  to  refer   to   in   the  matter 
of  abdominal  surgery  is  the  size  of  the   im 
In  my  opinion,  more  injury  can  de  done  thi 
a  small  one,  in  consequence  of  the  shock  pi  1 
by   the  traction    and  the    abscesses   that  might 
result  from  the  bruising  of  the  parts,  than  would 
follow    if  the  opening   were  sufficiently  large  to 
enable  the  surgeon  to  operate  readily   and   with 
less  violence. 

Dr.  Etheridge,  in  closing  the  discussion  said: 
I  have  nothing  additional  to  say  beyond  men- 
tioning a  characteristic  case  that  recentlv  came 
up  in  the  courts.  One  man  shot  another  and 
was  taken  and  held  until  the  result  to  his  victim 
could  be  ascertained.  The  wounded  man  was 
taken  to  the  hospital  and  had  the  holes  in  his  ab- 
domen sewed  upand  promptly  died.  Thecasecame 
to  trial  and  the  defence  was  that  the  man  came 
to  his  death  at  the  hands  of  the  surgeons.  Thus 
we  see  that  matters  may  assume  a  most  grave  as- 
pect in  abdominal  surgery,  and  which  at  once  put 
medical  men  upon  their  metal  to  defend  them- 
selves. I  mention  this  circumstance  to  show  the 
indirect  possible  bearing  of  legal  responsibility  in 
laparotomy. 


A    REMARKABLE    CASE. 
BY  W.  J.  GALBRAITH,  M.D., 

PROFESSOR   CLINICAL   SURGERY,   OMAHA    MEDICAL  COLLEGE  -    VICE- 
PRESIDENT    NATIONAL    ASSOCIATION    RAILWAY    SURGEONS ' 
VISITING  SURGEON  ST.  JOSEPH'S  HOSPITAL,  AND 
CONSULTING   SURGEON  IMMANUEL  HOS- 
PITAL, OMAHA,  NEB. 

Incredible  as  it  may  seem,  I  trust  the  readers 
of  The  Journal,  will  not  consider  me  a  fit  sub- 
ject for  an  insane  asylum  in  reporting  what  I  sin- 
cerely believe  to  be  a  fact.  I  most  cordially  in- 
vite any  member  of  the  profession  to  examine 
this  unique  pathological  freak  with  me  and  trust 
you  will  avail  yourself  of  the  invitation.  I  fully 
appreciate  the  amount  of  criticism  I  will  receive 
in  reporting  this  case,  and  I  realize  that  you  will 
take  the  same  version  of  the  case  that  I  did  before 
I  examined  her.  Notwithstanding  I  had  good  au- 
thority regarding  her  malady,  I  could  not  for  an  in- 
stant entertain  the  statements  in  any  other  light 
than  those  applied  to  a  case  of  pure  and  adulterated 
deception;  but  since  my  examination  and  two 
months  constant  caie  I  have  changed  my  views, 
and  feel  that  I  am  fully  prepared  to  substantiate 
my  statement  by  submitting  the  patient  to  any 
examination  or  test  you  may  choose  to  make,  and, 
moreover,  I  trust  that  many  of  you  will  feel'suffi- 
ciently  interested  in  this  case  to  make  a  personal 
examination. 

Mrs.   M.,  aged  26,  married  five  years,  mother 
of  one  child  two  years  old,  medium  height,  light 


408 


A  REMARKABLE  CASE. 


[March  21, 


complexion  and  of  rather  a  nervous  temperament, 
has  attended  one  course  of  lectures  in  the  Wo- 
man's Medical  College  at  Chicago  in  the  fall  of 
On  or  about  the  first  of  December,  1 


liar  circumstances  were  explained  to  Dr.  Hoover, 
by  his  partner,  they  immediately  proceeded  to 
try  the  new  thermometers, — placing  one  in  the 
axilla  and  one  under  the  tongue.     This  resulted 


she  was  taken  sick  with   peritonitis  and  was  re-   in  a  repetition  of  Dr.    Duckworth's  experience. 
moved  to  the  Woman's  and  Children's  Hospital,    Repeatedly  the  temperature  was  taken  and  with 


where  she  remained  several  weeks 

Her  statement  as  regards  her  temperature  at 
that  time  corresponds  with  one  received  from 
some  of  the  attending  physicians  in  Chicago. 

I  will  give  only  a  brief  history  of  her  case  be- 
fore coming  under  my  charge.  After  her  recov- 
ery from  the  attack  of  peritonitis  while  in  Chi- 
cago, she  returned  to  her  home  in  Kearney,  Neb. 
On  or  about  the  12th  of  April,  1890,  she  was 
again  taken  down  with  a  severe  attack  of  gen- 
eral peritonitis.  Her  family  physician,  Dr. 
Duckworth,  was  called,  and  after  making  a  care- 
ful examination  satisfied  himself  that  there  was 
an  abdominal  or  tubal  pregnane}-.  A  tumor  the 
size  of  a  foetal  head  could  be  mapped  out  over  the 
region  of  the  left  tubes  and  ovary.  The  treat- 
ment following  his  first  visit  consisted  of  hot 
fomentations  applied  over  the  abdomen  and  the 
hypodermic  injection  of  morphia.      The  follow- 


the  same  results. 

The  doctors  wired  Chas.  Truax  &  Co. ,  of  Chi- 
cago, to  forward  them  a  fever  thermometer  that 
would  register  1250  F. ;  after  some  delay  the  new 
thermometer  arrived  and  they  commenced  to 
keep  an  hourly  record  of  her  temperature.  On 
the  first  trial  the  thermometer  was  found  to  regis- 
ter 3°  below  normal;  the  same  evening  it  rose  to 
1070  F.  The  peritoneal  inflammation  had  by 
this  time  almost  subsided,  but  the  removal  of 
bones  continued  the  same.  On  the  following 
day,  after  a  chill,  her  temperature  was  taken,  and 
to  their  horror  they  found  the  mercury  had  risen 
to  the  top  of  the  thermometer,  which  registered 
1250  F.,  in  less  than  one  minute.  Satisfying 
themselves  that  they  must  have  a  thermometer 
that  would  register  higher,  they  again  wired 
Chas.  Truax  &  Co.,  of  Chicago,  to  have  a  ther- 
mometer made  that  would  register   1500  F.     On 


ing  morning  the  Doctor  was  again  called  to  see  |  the  arrival  of  the  new  thermometer,  or  within  a 


the  patient  who  complained  of  pains  similar  to 
those  of  labor.  After  a  vaginal  examination  had 
been  made,  the  Doctor  was  somewhat  surprised 
to  find  a  foreign  body  engaged  in  the  cervical 
canal  near  the  external  os.  He  procured  a  pair 
of  long  and  narrow-jawed  forceps  and  removed 
the  body,  which  proved  to  be  a  scapula  of  a  four 
mouths  old  foetus.  The  pains  increased  in  sever- 
ity after  its  delivery.  A  half  a  grain  of  morphia 
had  been  given  hypodermically  when  several 
more  bones  were  delivered  in  the  same  manner. 
The  patient  became  somewhat  exhausted  and 
complained  of  being  very  feverish;  after  an  ex- 
amination of  the  radial  pulse  the  Doctor  assured 
her  she  had  no  fever  as  her  pulse  was  only  62, 
and  in  order  to  satisfy  her  attempted  to  take  her 
temperature.  The  thermometer  was  placed  un- 
der her  tongue  and  left  there  about  two  minutes 
when,  upon  its  removal,  the  mercury  was  found 
to  be  at  the  top  of  the  thermometer,  which  regis- 
tered 1120  F,  Believing  he  had  not  properly 
shaken  the  mercury  down,  he  took  particular 
pains  in  doing  so,  and  again  placed  the  ther- 
mometer under  her  tongue,  holding  the  end  with 
one  hand;  in  a  short  time  he  removed  it,  and  to 
his  surprise  found  it  registered  the  same  as  before. 
Again  shaking  it  down  he  placed  it  under  the 
tongue  and  watched  the  mercury  rise  to  the  top 
almost  instantly. 

This  was  too  much  for  the  Doctor  to  stand,  and 
as  he  expressed  himself,  "I  believe  I  or  tie  ther- 
mometer is  crazy."  He  immediately  dispatched 
a  messenger  for  his  partner,  Dr.  M.  A.  Hoover, 
to  come  at  once  and  bring  two  or  three  Hick's 
thermometers  along  with  him.      After  the  pecu- 


few  days,  her  temperature  was  found  to  register 

I  was  invited  to  see  the  case  by  letter,  but 
made  no  reply  to  the  same;  the  case  continued 
on  its  peculiar  career  for  several  days,  when  Dr. 
Hoover  made  a  visit  to  Omaha  to  consult  me  in 
regard  to  same.  I  assure  you  I  felt  sorry  for  him, 
as  I  supposed  he  had  "slipped  a  cog"  and  his 
mental  equilibrium  was  somewhat  impaired.  I 
advised  him  to  return  home  and  explained  to  him 
that  he  certainly  had  been  deceived  by  a  shrewd  and 
hysterical  woman;  also  advising  him  to  say  noth- 
ing to  any  one  else.  In  a  measure  he  accepted 
my  advice  and  returned  home,  but  continued 
writing  me  about  the  wonderful  case  and  insist- 
ing that  I  should  see  her. 

On  November  6,  I  was  telegraphed  to  come  at 
once'  to  see  this  case  and,  in  order  to  satisfy  the 
doctors,  I  determined  to  go,  but  believing  that  I 
was  going  on  a  "wild  goose  chase." 

I  equipped  myself  with  a  chemical  thermome- 
ter, borrowed  from  Mr.  Hodges,  Chief  Chemist 
of  the  Union  Pacific  Railway  Co.,  which  I  had 
standardized,  and  obtained  a  certificate  of  its  cor- 
rectness, then  inviting  one  of  my  colleagues,  Dr. 
J.  H.  Peabody,  of  Omaha,  to  accompany  me, 
proceeded  to  see  this  wonderful  case. 

On  our  arrival  the  temperature  was  found  to  be 
two  and  two-fifth  degrees  below  normal;  this,  of 
course,  somewhat  surprised  us,  but  in  less  two 
hours  we  were  more  surprised  to  find  the  ther- 
mometer had  reached  1170  F.,  and  at  midnight, 
following  a  chill,  the  mercury  registered  in  the 
axilla  1450  F.,  and  at  the  same  time  registering 
125°  F.  under  the  tongue.     In  less  than   thirty 


i89i.] 


MEDICAL  PROGRESS. 


409 


minutes  the  temperature  in  the  same  localities 
had  fallen  to  three-fifths  of  a  degree  below  nor- 
mal, followed  by  sweating  and  a  slight  deliii  nn 
You  can  imagine  that  I  was  somewhat  puzzled 
and  immediately  apologized  to  the  doctors.  I 
could  not  believe  my  own  eyes,  and  I  assure  you 
that  Dr.  Peabody  was  in  the  same  condition.  I 
thought  that  some  form  of  heat  must  have  been 
used  or  that  she,  in  some  manner,  had  tipped  the 
thermometers  upside  down,  unbeknown  to  me,  or 
that,  possibly  it  might  be  accomplished  by  some 
muscular  action  with  which  I  was  not  familiar. 
The  following  morning  the  patient  was  placed 
in  a  chair,  all  clothing  removed  and  a  careful 
examination  was  made  of  her  mouth  and  axillary 
region,  every  possible  precaution  taken  in  order 
to  prevent  any  deception,  and  holding  the  end  of 
the  thermometer  so  that  it  could,  not  be  tipped 
in  any  way,  we  again  proceeded  to  take  her  tem- 
perature; but,  gentlemen,  the  result  was  the 
same,  the  thermometer  under  the  axilla  register- 
ing 137°  F.  while  that  under  tongue  registered 
131°  F. 

Another  peculiar  condition  is  that  when  her 
temperature  reaches  1400  F.  or  more  her  pulse  is 
slow,  60  or  70  a  minute;  when  her  temperature  is 
normal,  or  below  normal,  her  pulse  runs  from  100 
to  120. 

The  axilla  and  mouth  are  the  two  points  on 
her  body  that  register  the  highest.  I  have  seen 
the  axillary  temperature  1310  F.,  while  under  the 
flexure  of  the  knee  her  temperature  was  below 
normal.  Again,  I  have  seen  the  temperature 
under  the  tongue  register  6°  F.  below  normal. 

The  case  has  now  been  under  my  charge  for 
nearly  three  months.  The  highest  I  have  ever 
seen  her  temperature  was  1510  F.,  while  the 
nurse's  record  in  the  hospital  shows '  it  to  have 
reached  1710   F. 

She  has  been  delivered  of  over  1,000  pieces  of 
bone;  very  few,  however,  are  perfect,  the  most 
of  them  being  deformed.  Her  general  health 
seems  to  be  quite  good,  considering  her  Jong  and 
tedious  sickness,  and  when  she  is  free  from  peri- 
toneal inflammation,  is  able  to  be  up  and  about 
the  house.  At  this  writing,  February  2,  she  is 
confined  to  her  bed  with  one  of  her  attacks  of 
peritonitis. 

There  is  no  special  time  for  her  temperature  to 
rise;  it  is  usually  preceded  by  a  chill. 

I  have  no  theory  further  than  I  believe  it  to  be 
some  chemical  change  or  combustion  that  takes 
place  in  the  lymphatics,  as  its  elimination  is  very 
speedy. 

I  deem  it  unnecessary  to  fill  a  dozen  pages  with 
a  record  of  her  temperature,  as  it  is  almost  con- 
stantly changing. 


MEDICAL   PROGRESS. 


Dr.  Henry  Bacon,  of  Jacksonville,  Fla.,  has 
been  appointed  Surgeon-General  of  that  State. 


Therapeutics  :nul  Pharmacology. 

Koch's  Treatment  of  Tuberculosis  :  Gen- 
eral Results.— Dr.  J.  Amann,  of  Davos,  says 
{Centralbl.  f.  Bakteriologie  u.  Parasitenk.,  No  "1 

Band  ix,  January,  1S91),  that  since  November 
17,  there  have  been  in  Davos  400  cases  of  phthisis 
treated  by  Koch's  method.  Of  288  patients 
whose  sputum  he  examined,  198  have  been  so 
treated,  lie  examined  the  sputum  of  these  lat- 
ter sometimes  once  a  day.  sometimes  once  every 
two,  three,  or  six  days.  He  comes  to  the  conclu- 
sion that  the  treatment  has  a  most  marked  effect 
on  the  tuberculous  tissues  of  the  lung,  and  gives 
the  following  points  of  evidence  in  favor  of  this 
statement :  The  quantity  of  expectoration  after 
the  inoculation  reaction  is,  as  a  rule,  increased 
in  one  case  from  30  cubic  centimetres  to  140  cubic 
centimetres  per  diem.  The  number  of  tubercle 
bacilli  in  thejsputuni  is  also  increased,  in  some 
cases  the  bacilli  becoming  very  numerous  where 
before  it  had  been  almost  impossible  to  find 
them.  In  about  70  per  cent.  (134  out  of  198) 
this  increase  was  observed.  There  was  only 
slight  diminution  in  a  very  small  number  of 
cases.  He  also  considers  that  the  bacilli  are 
considerably  altered  in  form,  the  rods  are  broken 
down  into  micrococci,  and  abnormal  forms  are 
pretty  frequently  met  with  ;  the  tubercle  bacilli 
under  these  conditions  lose,  to  a  certain  extent 
their  power  of  retaining  the  staining  fluid  in  the 
presence  of  acids.  The  quantity  of  elastic  tissue 
found  in  the  sputum  was  considerably  increased 
in  about  40  per  cent,  of  the  inoculated  cases 
All  these  changes  he  attributes  to  the  action  of 
the  tuberculin  on  the  young  tuberculous  tissue 
which  leads  to  its  rapid  breaking  down. 

At  the  fourth  general  meeting  of  Russian  med- 
ical men  at  Moscow,  Dr.  Nikolai  S.  Kishkin 
{Vratch,  No.  2,  1891,  p.  49),  read  a  report  of 
seven  cases  of  pulmonary  phthisis  treated  after 
Koch's  method  in  Professor  M.  P.  Tcherinoffs 
clinic,  in  Moscow.  The  observations  lasted  in 
four  cases  five  weeks  ;  in  two,  four  weeks  ■  and 
in  one,  three  weeks.  In  all  the  cases  the  symp- 
toms were  "quite  distinct,  but  not  very  severe  " 
the  general  state  being  more  or  less  satisfactory 
In  five  no  fever  existed,  while  in  two  there  was 
slight  pyrexia.  The  effects  of  the  injections 
were  as  follows  :  1.  The  percussion  phenomena 
remained  unaltered.  2.  The  auscultatory  signs 
m  two  did  not  undergo  any  changes ;  in  two  the 
rales  somewhat  diminished  ;  in  one  they  disap- 
peared almost  completely  ;  in  one  they  disap- 
peared entirely  ;  and  in  one  they  disappeared 
from  their  former  situation,  to  appear  in  another. 
3-  Cough,  expectoration,  and  the  number  of 
bacilli  in  the  sputum  showed  no  alterations  in 
two  cases,  while  in  the  remaining  five  they  de- 


410 


MEDICAL  PROGRESS. 


[March  21, 


creased.  4.  The  weight  in  four  cases  increased, 
but  in  three  fell  somewhat.  On  the  whole,  of 
the  seven  cases,  four  slightly  improved,  the 
amelioration  being  both  local  and  general,  and 
apparently  due  to  the  injections  alone.  The  re 
action,  though  invariably  present,  varied  greatly 
both  in  the  time  of  its  appearance  (developing  in 
some  cases  in  five,  and  in  others  in  twenty- four 
hours  after  the  injection),  and  in  its  intensity  (os- 
cillating between  a  very  slight  elevation  of  the 
temperature  with  trifling  general  weakness,  and 
severe  prostration  accompanied  by  a  rise  of 
temperature  to  410  C).  The  local  reaction  was 
different  in  different  cases.  Dr.  Kishkiu  feels 
sure  that  such  differences  were  dependent  solely 
upon  individual  peculiarities,  having  no  relation 
whatever  to  the  dose  of  the  lymph  or  the  exten- 
sion of  the  tuberculous  process. 

Dr.  Fedor  I.  Lominsky,  of  Kieff  {Vratch, 
No.  1,  1891,  p.  23),  reports  ten  cases  of  phthisis 
in  which  he  tried  Koch's  treatment,  injecting 
from  0.001  to  0.006  gram  every  ojher  day.  In 
one  of  the  cases,  large  cavities  were  present  in 
the  lungs,  the  remainder  presenting  either  in- 
cipient symptoms  or  only  slight  destruction  of 
the  pulmonary  tissue.  The  lungs,  respiration, 
pulse,  and  temperature,  were  carefully  examined 
every  three  hours.  The  following  are  the  princi- 
pal results  of  the  observations  :  1.  After  0.001 
g.  doses,  the  reaction  was,  as  a  rule  (nine  cases), 
either  absent  altogether,  or  limited  to  a  trifling 
rise  of  temperature  (which,  after  all,  might  have 
occurred  quite  independently  of  the  lymph).  A 
considerable  rise  was  observed  only  in  the  pa- 
tients with  large  excavations.  2.  In  incipient 
cases  no  reaction  could  be  noticed  even  after 
0.002  g.  or  0.003  g.  doses  (in  one  even  after 
0.006  g.).  In  more  advanced  cases,  however, 
these  doses  were  followed  by  a  slow  febrile  rise. 
The  latter  began  from  four  to  twelve  hours  after 
the  injection,  and  reached  its  maximum  in  from 
six  to  fourteen  hours,  keeping  at  the  level  for 
three  hours,  after  which  it  gradually  fell'  to 
normal.  In  all  but  one  case,  on  the  following 
day  the  temperature  either  remained  normal  or 
rose  but  slightly.  In  the  severe  case,  however, 
a  secondary  elevation  occurred,  which  was  still 
more  considerable  than  the  primary  one.  3.  In 
some  of  the  febrile  patients  the  injections  modi- 
fied the  type  of  the  fever.  4.  The  reaction,  when 
present,  was  accompanied  by  oppression  about 
the  chest,  increased  dyspnoea  and  cough,  and 
sometimes  haemoptysis,  the  symptoms  being  in 
some  so  intense  that  the  patients  declined  further 
treatment.  Simultaneously,  the  expectoration 
became  more  abundant,  and  the  sputa  thinner, 
the  number  of  bacilli  sometimes  decreasing.  In 
one  patient  albuminuria  also  supervened.  Dr. 
Eominsky  describes  a  case  of  faucial,  laryngeal, 
and  pulmonary  tuberculosis,  in  which  the  follow- 
ing  "interesting  reaction"   was  observed.     Be- 


fore the  treatment  the  faucial  changes  were 
limited  to  considerable  congestion  of  the  pillars, 
with  two  white  patches  on  the  left  one.  Four 
injections  were  given  in  the  course  of  a  week, 
the  dose  being  on  the  first  occasion  0.001  g.,  and 
on  the  subsequent  three  o  002  g.  Shortly  after 
the  first  injection  the  congestion  increased  and 
the  tissues  became  infiltrated,  while  there  gradu- 
ally' appeared  numberless  greyish  nodules  which 
rapidly  coalesced,  broke  down,  and  formed  ulcers, 
until  the  whole  fauces  and  sides  of  the  pharynx 
were  transformed  into  a  single  extensive  ulcer- 
ated surface,  covered  with  a  yellowish  grey  coat. 
At  the  same  time,  the  faucial  and  laryngeal  pain 
became  aggravated  to  such  a  degree  that  the  pa- 
tient "almost  ceased  to  take  food,"  while  his 
subjective  state  grew  worse.  Though  no  rise  of 
the  temperature  occurred,  the  patient  lost  3 
pounds  during  the  treatment. — British  Medical 
Journal. 

Mixture  for  Venereal  Warts. — M.  Ciro 
Urriola  {La  Semaine  Midicale)  recommends  a 
mixture  of  salicylic  acid  two  parts  and  acetic 
acid  thirty  parts  in  the  treatment  of  venereal 
vegetations.  The  mixture  is  applied  with  a  fine 
camels-hair  pencil  once  or  twice  daily.  Usually 
but  two  or  three  treatments  are  required  to  cause 
the  greater  portion  of  the  vegetations  to  disap- 
pear. The  writer  claims  that  the  application 
causes  but  slight  and  transitory  pain,  and  that  it 
is  preferable  to  all  other  modes  of  treatment. 

Zyzigium  Jambolanum. — This  drug,  after  a 
latent  period  of  some  years,  seems  destined  to 
again  be  put  upon  trial,  notwithstanding  its  in- 
efficiency, as  was  shown  some  years  ago.  Rosen- 
blatt in  Vratch  (Nouveaux  Remedes,  Feb.  8, 
1 891),  reports  a  case  of  diabetes  in  which  there 
was  marked  ameloriation  of  the  symptoms,  and 
a  diminution  of  the  amount  of  sugar  in  the 
urine.  The  drug  was  administered  in  the  form 
of  powder,  three  to  fifteen  grams  in  twenty-four 
hours,  and  the  fluid  extract  three  to  twenty-two 
grams  daily. 

Rfedicine. 

Practical  Communications  Regarding 
the  Tubercle  Bacillus.  —  Dr.  Bliesener 
{Dent.  Med.  Zeit.)  recommends  the  following  as 
a  good  method  of  staining  the  bacilli:  Prepare  a 
solution  containing,  fuchsin  1  part,  absolute  alco- 
hol 10  parts,  carbolic  acid  5  parts,  distilled  water 
95  parts.  The  sputum  to  be  examined  is  spread 
thinly  upon  a  cover-glass,  passed  rapidly  through 
the  flame  of  a  spirit  lamp  and  then  laid  upon  a  small 
piece  of  tin  with  the  prepared  side  up.  A  few 
drops  of  the  above  solution  are  placed  upon  the 
glass  and  the  tin  placed  over  a  spirit  lamp  until 
bubbles  are  given  off.  Remove  the  flame  and 
allow  the  glass  to  cool,  but  not  to  dry,  if  neces- 
sary add  a  drop  of  the  solution.  The  cover  should 


iS9i.] 


MHDICAL  PROGRESS. 


411 


then  be  washed  and  floated  upon  the  surface  of 
the  following  solution  contained  in  a  watch  glass: 
Methyl  blue  1.5  par^,  distilled  water  100  parts, 
sulphuric  acid  25  parts.  Allow  it  to  remain  upon 
this  solution  for  about  one  minute,  then  wash 
and  mount.  With  this  method  the  tubercle  ba- 
cilli are  stained  a  bright  red  upon  a  light  blue 
ground. 

The  Munchener Med.  Wbckenschr.,  No.  1.  1891, 
gives  the  following  account  of  Biedert's  method 
of  finding  the  tubercle  bacillus  in  suspected  fluids: 
One  drachm  of  the  fluid  is  mixed  with  an  equal 
part  of  water  and  7  or  8  drops  liq.  natr.  caust. 
(Ger.  phar.).  The  mixture  is  then  boiled,  four 
drachms  of  water  added  and  again  boiled  until 
the  fluid  is  of  equal  consistence.  If  the  fluid  is 
not  perfecth-  thinned  by  this  procedure,  more 
water  can  be  added.  The  liquid  should  then  be 
placed  in  a  conical  glass  and  set  aside  for  two  or 
three  days,  when  the  bacilli  will  collect  in  the 
lower  portion  of  the  glass,  which  is  examined  in 
the  usual  way.  By  this  method  it  is  often  pos- 
sible to  detect  the  bacilli  when  the  ordinary  ex- 
amination gives  a  negative  result. 

It  is  apparent  that  a  negative  answer  to  the 
question,  "Is  the  tubercle  bacillus  present  in  a 
given  specimen  ?  "  is  much  more  difficult  than  a 
positive  one.  If  they  are  looked  for  and  found, 
that  settles  the  matter,  but  if  they  are  not  found, 
have  we  simply  overlooked  them  ?  The  method 
of  Biedert,  as  given  above,  unquestionably  adds 
to  the  certainty  with  which  we  can  find  the  ba- 
cilli, and  thus  is  an  additional  precision  in  diag- 
nosis. The  present  active  therapy  of  tuberculosis 
lends  additional  interest  to  these  observations. 

Dr.  Berxhard  Meyer  (Centrcdblattfur  klin. 
Med.  Feb.  7,  1891)  has  contributed  an  excellent 
study  of  the  methods  of  examining  various  secre- 
tions and  excretions  for  the  presence  of  the  tu- 
bercle bacillus.  He  especially  recommends  Bie- 
dert's method  in  examining  the  sputum.  In  his 
hands  it  has  often  shown  the  presence  of  the  ba- 
cilli when  the  repeated  examinations  with  the 
ordinary  methods  failed  to  show  them.  If  the 
bacilli  are  not  found  with  this  method  we  cannot 
absolutely  affirm  that  they  are  not  present,  as 
was  shown  in  a  case  of  Prof.  Fraenkel's,  in  which 
the  symptoms,  cough,  expectoration,  fever  and 
emaciation,  pointed  to  a  phthisical  condition, 
while  repeated  examinations  of  the  sputum,  ex- 
tending over  a  period  of  six  months,  failed  to  re- 
veal the  bacilli,  and  yet  the  patient  died  with 
the  typical  symptoms  of  florid  phthisis.  The 
writer  claims  that  while  the  method  of  Biedert  is 
not  absolute,  yet  where  it  is  employed  in  investi- 
gating the  sputum,  and  no  bacilli  are  found, 
we  may  affirm  with  reasonable  certainty  that  there 
is  no  tubercular  process  in  the  lungs.  He  thinks 
that  inoculation  is  the  only  method  of  absolutely 
determining  the  presence  or  absence  of  the  ba- 
cillus. 


In  eleven  cases  of  pleuritis  the  exudate  was  ex- 
amined for  the  bacilli,  and  in  one  case  of  empy- 
ema the  bacilli  were  found  in  great  number--.  In 
no  case  of  either  primary  or  secondary  serous 
pleuritis  was  the  bacillus  found. 

Two  peritoneal  exudates  were  examined,  one 
with  negative  and  the  other  with  positive  results. 
The  former  was  a  serous  exudate  from  a  case  of 
pulmonary  tuberculosis,  with  abdominal  symp- 
toms.    The  second  was  a  purulent  exudate. 

The  writer  has  determined  the  presence  of  the 
tubercle  bacillus  in  urine  that  was  perfectly  clear 
and  free  from  albumen.  In  examining  this  ex- 
cretion Biedert's  method,  or  one  devised  by  the 
author,  may  be  employed.  The  latter  consists  in 
mixing  the  urine  with  thymol  and  so  arranging 
a  small  filter  that  the  urine  shall  fall  drop  by 
drop  uoon  the  centre.  The  surface  of  this  small 
area  is  then  examined  in  the  usual  manner. 

The  presence  of  the  bacillus  in  faeces  is  even 
easier  to  determine  than  in  sputum,  therefore  the 
writer  has  not  had  occasion  to  use  the  method  of 
Biedert.  Out  of  eight  cases  examined  that  came 
to  autopsy  six  were  found  to  have  a  tubercular 
process  in  the  digestive  tract.  The  two  other 
cases  were  those  of  advanced  pulmonary  tuber- 
culosis, and  the  presence  of  the  bacilli  is  accounted 
for  under  the  theory  that  some  of  the  bronchial 
secretion  had  been  swallowed. 

A  case  is  described  in  which  secretion  from  the 
middle  ear  was  examined  and  the  bacilli  found. 
Under  the  influence  of  Koch's  remedy  the  bacilli 
increased,  and  then  diminished,  finally  disappear- 
ing with  the  secretion,  and  the  closing  of  the 
opening  in  the  drum.  The  concurrent  pulmonary 
tuberculosis  of  this  patient  was  not  in  any  way 
affected  by  the  injections. 

Tubercular  Affections  of  the  Sktx  Treat- 
ed by  Koch's  Lymph. — La  Semaine  Medicale  of 
February  14  contains  a  table  of  thirty-eight  cases 
treated  in  the  Paris  hospitals  and  by  various  sur- 
geons, as  follows  :  E.  Yidal  2,  Vidal  and  Bes- 
nier  5,  E.  Besuier  9,  Founder  2,  Hallopeau  14, 
Tenneson  5,  Quinquaud  1. 

Of  course,  the  number  of  the  injections  varied, 
as  well  as  the  dose.  In  twenty  cases  there  was 
a  violent  reaction  with  high  fever  and  great  pros- 
tration ;  in  fifteen  cases  the  reaction  was  moder- 
ate, in  two  variable,  that  is,  differing  from  the 
usual  type,  and  in  one,  weak. 

Local  reaction  in  the  affected  part  was  described 
as  very  intense,  erysipelatoid  in  character  in  eight 
cases,  and  in  one  other  case  as  leading  to  a  vast 
phlegm  requiring  surgical  interference.  In  nine 
cases  the  reaction  is  spoken  of  as  lively,  in  six- 
teen as  moderate,  in  two  as  slight,  and  one  in 
which  it  was  absent. 

The  results  in  these  thirty-eight  cases  were  : 
Much  improved,  1  ;  improved,  12  ;  slight  ameli- 
oration, 1 1  ;  negative  in  fourteen. 


412 


MEDICAL  PROGRESS. 


[March  21, 


Treatment  of  Leprosy  with  Koch's  Lymph. 
— Dr.  Goldschmidt  (Berliner  Klin.  Wochensch., 
No.  2,  1891)  has  treated  five  cases  of  leprosy, 
four  of  the  tubercular  form,  and  one  of  ansesthetic- 
paralytic  type.  At  the  close  of  his  article  he  ad- 
vances the  following  conclusions : 

1.  Doses  of  less  than  one  mg,  have  little  or  no 
effect. 

2.  One  mg.  in  the  first  three  cases  produced  a 
general  reaction  after  twenty-four  hours  ;  in  two 
cases  there  was  local  reaction. 

3.  Larger  doses,  under  0.01,  produced  a  high 
temperature  (excepting  case  5),  and  in  another 
(case  1)  a  very  remarkable  local  reaction,  that  is 
still  under  observation. 

•     4.  The  remedy  gives  a  reaction  with  lepra  as 
well  as  tuberculosis. 

5.  He  cannot  exclude  the  possible  presence  of 
a  tubercular  foyer  in  the  first  four  cases. 

6.  The  immediate  contact  of  the  remedy  with 
leprous  skin  seems  to  cause  more  irritation  than 
with  healthy  integument. 

7.  The  leprous  mucous  membrane  showed  no 
reaction. 

8.  Nervous  lepra  showed  general  and  slight 
local  reaction. 

Sui'K'ery. 

Removal  of  the  Left  Lobe  of  the  Liver. 
— The  number  of  operations  upon  the  liver  in 
which  a  portion  of  the  organ  has  been  removed 
are  not  so  great  but  that  special  interest  attaches 
to  any  case. 

Lucke  of  Strasburg,  (Cent ralblatt fur  Chirurgic 
Feb.  7,  1 891)  reports  the  case  of  a  woman  who 
presented  a  small,  firm  tumor  in  the  epigastrium. 
There  was  pain,  vomiting  and  considerable  dis- 
turbance of  the  general  health.  A  careful  exam- 
ination of  the  stomach  and  its  contents  showed 
an  apparently  healthy  organ.  A  diagnosis  of 
cancer  of  the  left  lobe  of  the  liver  was  made  and 
an  operation  determined  upon.  On  opening  the 
abdomen  the  tumor  presented  and  was  readily 
brought  through  the  wound  and  transfixed.  It 
was  then  encircled  with  an  elastic  ligature,  the 
wound  closed  as  far  as  possible  and  a  dressing  ap- 
plied. Three  times  the  dressing  was  changed 
and  each  time  the  ligature  was  tightened,  finally 
the  tumor  was  separated  and  the  constricted  sur- 
face of  attachment  was  thoroughly  cauterized. 
The  abdominal  wound  healed  slowly.  There  has 
been  no  return  of  the  disease. 

Resection  ofthk  Spleen. — Bakphnheuer 
(Deutsche  med.     \\  ff)  describes   an  ex- 

ceedingly interesting  case.  The  patient,  47  years, 
had  complained  of  some  indistinct  uterine  and 
stomach  disturbance.  Upon  examination  a  small 
•  tumor  could  be  felt  in  the  true  pelvis,  it  was  not 
readily  movable  and  the  writer  concluded  that  he 
had  a  small  ovarian  cyst  with  adhesions.  The 
incision  was  made  with  possible  reference   to  an 


intra-ligarneutous  cyst,  but  as  a  diagnosis  was  not 
possible  by  the  extra-peritoneal  method,  that 
membrane  was  opened,  when  much  to  the  opera- 
tor's surprise  he  found  that  the  tumor  was  a  small 
cyst  of  the  spleen,  The  organ  was  grasped  by 
an  assistant  and  the  tumor  cut  away.  But  little 
hfemorrhage  followed  which  was  easily  controlled 
bjf  the  actual  cautery.  The  organ  was  then 
replaced,  and  the  wound  closed.  Seven  weeks 
later  the  patient  was  discharged.  An  examina- 
tion of  the  cyst  showed  that  it  was  of  parasitic 
origin. 

Obstetrics  :iml  l>iseases  of  Women. 

Inflammation  of  the  Clitoris. — Philip- 
peau  (Gazette  Gynicologie,  February  1,  1891)  re- 
ports the  case  of  a  woman  who  consulted  him 
about  one  week  after  menstruation  for  an  itching 
of  the  upper  part  of  the  vulva.  On  examination 
the  vulva  was  found  to  be  normal  in  color;  no 
discharge  from  the  urethra  or  vagina.  Uterus 
healthy.  The  clitoris  was  enlarged,  reddened 
and  excoriated,  the  vulvo-vaginal  glands  were 
normal.  The  writer  could  not  refer  the  condition 
to  any  exciting  cause.  The  patient  had  had  two 
other  attacks  within  six  years,  from  which  fact 
he  refers  the  peculiar  inflammation  to  a  rheumatic 
origin.  Under  soothing  lotions  and  the  applica- 
tion of  cocaine  the  inflammation  rapidly  subsided. 
The  case  is  certainly  deserving  of  notice  as  pri- 
mary inflammation  of  the  clitoris  is  a  very  rare 
occurrence. 

Vomiting  of  Pregnancy. — The  Journal  de 
Medicine  recommends  the  following  for  vomiting 
of  pregnancy:  Tr.  iodine  and  chloroform,  equal 
parts,  five  drops  to  be  taken  morning  and  even- 
ing, in  a  little  water,  with  the  repast. 


Hygiene  in  France. — Recently  the  French 
Chamber  of  Deputies  have  considered  a  general 
law  governing  workers  in  factories,  child  labor, 
etc.  M.  de  Mun  proposed  an  amendment  pro- 
viding that  women  should  not  be  allowed  to ' 
work  the  first  four  weeks  after  confinement.  The 
proposition  created  a  lively  discussion,  the  gen- 
eral tenor  of  which  was  to  the  effect  that  the  pri- 
vate life  of  citizens  should  not  be  interfered  with 
t"  tin-  extent  proposed,  and  that  the  fixing  of  an 
arbitrary  limit  of  four  weeks  was  not  wise,  as 
in  any  would  be  able  to  be  at  work  long  before 
that  time,  while  others  would  be  incapacitated 
far  beyond  the  limit.  One  member  proposed  that 
compensation  by  the  State  be  given  to  the  extent 
of  one  franc  per  day.  The  amendment  was 
finally  tabled  by  a  decisive  vote. — Le  Bulletin 
Midicale. 


i89i.] 


EDITORIAL. 


413 


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Address 

Journal  of  the  American  Medical  Association, 

No.  68  Wabash  Ave., 

Chicago,  Illinois. 
All  members  of  the  Association  shou      send  their  Annual  Duel 
to  the  Treasurer,  Richard  J.  Dunglison,  M.D.,  Lock  Box  1274,  Phila- 
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SATURDAY,  MARCH   21,   1891. 


THE  GRADUATING  AGE  IN  MEDICINE. 

Ill  the  Seventh  Report  on  Medical  Education 
just  issued  by  the  Illinois  State  Board  of  Health 
is  a  paragraph  that  reads  as  follows : 

Under  the  schedule  of  two-year  courses  aud  three  years' 
study  the  earliest  age  at  which  a  student  can  be  gradu- 
ated is  21  years.  The  addition  of  one  year  each  to  the 
time  of  study  aud  the  college  term  would  seem  to  justify 
the  limitation  of  the  minimum  age  of  graduation  to  22 
years.  This  is  a  matter  that  the  boards  of  examiners  and 
the  colleges  would  do  well  to  take  under  consideration. 

Following  this  paragraph  is  a  table  showing 
the  ages  of  graduation  of  5,719  graduates— 5,497 
of  American  colleges,  82  of  Canadian,  32  of  Eng- 
lish, 98  of  German  and  10  of  Swiss  colleges.  Of 
the  5,497  American  graduates  5,214  were  males 
and  283  females.  The  number  from  the  Swiss 
colleges  is  so  small  that  it  may  be  eliminated. 
The  following  shows  the  numbers  up  to  40  years 
of  age,  the  males  and  females  being  given  separ- 
ately for  the  United  States  : 

Age.        United  States.        Canada.        England.        Germany. 

19  9        O  O  O  O 

20  79        2  O  O  O 

21  233  5  12  4  9 

22  431  11  8  6  6 

23  506  10  9  4  15 

24  507  14  12  5  13 

25  496  15  10  2  12 

26  409  15  6  2  10 

27  37S  11  7  2  7 
2S  322  18  4  2  2 

29  255  21  2                 2                 2 

30  21S  15  125 

31  17S  16  2                 o'               4 

32  175  4001 

33  161  9  4                  o                  3 

34  12S  18  o                  o                  2 

35  12S  12  4                  o                  3 

36  94       12  O  O  2 

37  Si  9  1  1  o 

38  67  4  o  o  1 

39  44  7  °  °  ° 

40  47  10  o  o  o 


From  these  figures  it  is  seen  that  the  greatest 
number  for  any  age  was  551  for  24  years, 
and  that  the  two  next  highest  numbers  are  544 
for  23  and  535  for  25  years.  After  these  came 
462  for  22  and  442  for  26  years.  The  number  of 
graduates  at  21  years  is  lower  than  at  any  subse- 
quent age  until  30  years.  Omitting  the  numbers 
of  graduates  at  19  and  20  years,  the  total  from  21 
to  30  inclusive  is  4,073,  out  of  a  grand  total  of 
5,719.  Of  the  total  graduates  from  21  to  30, 
then,  the  percentages  at  different  ages  are:  21 
years,  6.43;  22  years,  11.34;  23  years,  13.35;  24 
years,  13.52;  25  years,  13. 11;  26  years,  10.85;  27 
years,  9.94;  28  years,  8.54;  29  years,  6.92;  30 
years,  5.91.  It  will  probably  never  occur  again 
in  this  country  that  so  large  a  proportion  of  med- 
ical men  will  graduate  after  the  age  of  30. 

The  question  is,  Is  it  best  to  raise  the  minimum 
age  for  graduation  to  22  years?  The  figures 
above  are  given  merely  as  a  part  of  the  data  upon 
which  to  discuss  the  question.  All  that  they  show 
is  that  of  the  known  ages  of  graduation  of  5,719 
graduates,  fewer  graduated  at  the  present  mini- 
mum age  than  at  any  later  age  up  to  29,  inclu- 
sive. The  reason  for  this  may  help  answer  the 
question  at  issue.  In  order  to  graduate  at  21 
years  after  two  courses  one  must  enter  college  at 
19,  which,  we  believe,  is  below  the  mean  age  of 
the  seniors  in  the  better  class  of  academic  insti- 
tutions. This  leaves  no  time  for  the  one  year  of 
medical  study  (or  reading)  before  entering  a  med- 
ical college.  On  the  two-course  and  three  years' 
study  schedule,  then,  the  average  student  cannot 
be  graduated  until  after  he  is  22  years  old,  even 
if  he  enter  upon  the  study  of  medicine  as  soon  as 
he  leaves  the  academic  college.  There  are  some 
that  do  not  graduate,  however,  but  begin  the 
study  of  medicine  before  the  time  at  which  they 
would  complete  their  academic  course.  On  the 
other  hand,  a  considerable  number  of  academic 
graduates  do  not  begin  the  study  of  medicine  im- 
mediately after  leaving  college — often  for  finan- 
cial reasons.  It  is  not  improbable  that  young 
men  having  no  more  than  a  common  or  high 
school  education  enter  upon  the  study  of  medi- 
cine a  little  later  than  do  college  graduates.  The 
foregoing  remarks  apply  to  this  country  only.  In 
other  countries  young  men  go  into  business — in- 
cluding the  practicing  of  professions — later  than 
in  this  country.  They  may,  on  an  average,  be- 
gin the  study  of  medicine  about  the  same  age, 


414 


A  MASTER'S  INFLUENCE. 


[March  21, 


but  the  term  of  study  is  much  longer.  Yet  it  is  py  at  least  three  years.  It  is  doubtful,  however, 
probable,  almost  certain,  that  the  foreign  student  |  if  it  should  be  begun  before  the  age  of  15.  Noth- 
begins  the  study  of  medicine  later  than  the  Amer-  ing  is  to  be  gained  by  forcing  a  mind.  As  be- 
ican,  and  in  addition  to  his  maturer  years  and  tween  a  hot-house  mind  and  one  of  more  natural 
mind  he  has  a  better  education.  Asa  rulemedi-  growth,  the  latter  will  have  the  better  develop- 
cine  has  been  the  life-aim  of  the  foreign  medical   ment  at  the  age  of  30  years. 

student  since  his  youth.  In  America  the  study  I  Taking  all  things  into  consideration  it  seems 
of  medicine  is  often  the  result  of  a  sudden  deter-  that  the  minimum  age  for  graduation  should  be 
initiation,  a  reverse  of  fortune,  or  is  decided  upon   placed  nearer  the  normal,  at  22  years.     The  pub- 


lic and  the  profession  would  be  the  gainers  by 
this,  and  the  public  more  than  the  profession. 


in  early  manhood. 

It  is  now  agreed,   however,   that  the   term  of 
medical  study  in  this  country  shall  be  four  years, 

including  three  courses  of  lectures,   and   a  few  A  .MASTER'S  INFLUENCE. 

colleges  have  adopted  four  courses  of  lectures.  In  Such  it  is  which  moves  our  feelings  and 
order  to  comply  with  these  requirements  the  stu-  prompts  the  springs  of  eulogj-  to  flow;  and  such 
dent  must  begin  to  study  medicine  at  17  in  order  it  is  which  turns  the  eyes  of  a  medical  world 
to  graduate  at  21.  Very  rare  is  the  young  man  towards  a  memory  indelibly  blended  with  the  his- 
of  sufficiently  mature  mind  to  begin  the  study  of  tory  of  medicine  and  allied  sciences.  February 
medicine  at  17  years;  so  rare,  indeed,  that  he  may  14th,  the  Hunterian  Oration  was  given  in  the 
be  left  out  of  consideration.  The  study  of  medi-  theatre  of  the  Royal  College  of  Surgeons,  London, 
cine,  properly  carried  on,  demands  a  well-devel-  :  by  Jonathan  Hutchinson;  and  quite  coinci- 
oped  reasoning  faculty  rather  than  the  exercise  of  dently  there  wras  delivered  at  the  London  Insti- 
the  faculty  of  memory.  Up  to  the  age  of  18  or  tution  the  oration  of  the  Hunterian  Society  for 
19  years,  often  until  later,  the  whole  system  of  1891,  by  Fletcher  Beach,  and  entitled: 
education,  as  at  present  applied,  is  chiefly  re- "  Psychological  Medicine  in  John  Hunter's  Time 
stricted  to  certain  dogmatic  facts,  rules,  laws  and  '  and  the  Progress  it  has  Since  Made." 
axioms.  From  early  youth  the  pupil  has  learned  Jonathan  Hutchinson  compared  the  mind  of 
grammatical  rules  only  to  find  that  they  have  ex-  j  Hunter  with  that  of  Aristotle  of  ages  gone,  and 
ceptions,  which  are  sometimes  so  numerous  that  erected  a  tower  of  mental  strength  into  which  no 
the  rule  itself  seems  an  exception.  So  thoroughly  third  mind  could  enter.  The  tireless  industry , 
is  he  saturated  with  this  sort  of  knowledge  that   the  keen  perception,  the  courage  of  conviction, 


he  pictures  a  law  of  science — nature — as  some- 
thing that  has  exceptions;  and  he  is  quite  ready 
to  believe  that  the  law  of  gravity  has  ex- 
ceptions. The  methods  of  inductive  and  deduc- 
tive reasoning  are  unknown  to  him.  and  what- 
ever logical  faculty  he  may  have  is  always 
silenced  by  the  voice  of  what  he  considers 
authority." 

Such  a  young  man  is  not  yet  even  in  the  low- 
lands of  medicine,  but  in  the  vast  swamp  of  un- 
reason, from  which  he  can  be  rescued  by  nothing 
but  a  scientific  course,  and  preferably  one  prepar- 
atory to  the  study  of  medicine — such  as  is  now 
offered  by  some  of  the  larger  universities.  It  is. 
of  course,  better  that  such  a  course  be  substituted 
for  a  part  of  the  regular  academic  college  course, 
since  in  the  latter  much  time  is  spent  on  subjects 
the  study  of  which  is  of  no  assistance  to  the  stu- 
dent of  medicine  or  to  the  physician.  The  scien- 
tific course  preparatory  to  medicine  should  occu- 


the  wonderful  self-reliance  and  originality,  the 
mental  hardihood — all  leading  to,  and  being  part 
of,  that  insatiable  thirst  for  knowledge  which  so 
intensely  characterized  the  man,  left  their  mark- 
ings upon  the  times  after  him,  and  we  have  to- 
day magnificent  examples  of  the  effects  of  this 
an    teaching. 

It  is  the  influence  of  master  minds  which  stim- 
ulates the  thinking  world  to-day — as,  indeed,  it 
always  has  done — and  notwithstanding  that  those 
minds  may  have  long  since  lapsed  to  dust  again, 
yet  the  song  of  their  glory  and  mighty  achieve- 
ments still  echoes  to  our  ears,  and  awakens  that 
bright  glow  of  a  generous  pride,  and  the  warm 
impulse  of  emulation.  Like  in  that  spectral  re- 
view of  Napoleon,  the  medical  learner  of  now 
may  stand  where  the  sifted  utterances  of  the  past 
u'h  him,  and  be  directed  thereby  to  goals 
which  Patient  Toil  and  Genius  command.  It  is 
the   noble  examples    of    yesterday    and    to-day 


i89i.] 


SHOULD  PHYSICIANS  STUDY  LATIN? 


415 


whose  influence  thrill  throughout  the  great  med-  reasoning,  acute  rheumatism  is  caused  by  the 
ical  body,  carrying  it  onward  in  its  march  of  presence  of  uric  acid,  primarily,  in  the  blood  and 
progress,  and  in  its  earnest  seekings  to  alleviate  that  being  driven  thence  by  a  high  acidity,  it  is 
the  afflictions,  and  prolong  the  lives  of  brotlier  precipitated  in  the  joints,  and  that  this  precipita- 
mortals.  lion  of  the  acid,  together  with  the  fact  of  the  non- 

Well  may  we  listen  a  moment  to  the  echoes  of1  destruction  of  the  acid  furnish  us  with  the  most 
a  Hunter's  teaching,  the  observations  of  a  Jenner,  manageable  theory  as  to  the  inflammatory  pro- 
or  the  analysis  of  a  Cavendish;  and  yet  all  blend-   cesses  and  pyrexia  of  the  malady.     The  rise  of 


ed  into  the  great  stream  of  enlightenment  which 
flows  to  us,  and  which  we.  in  turn,  are  striving 
to  enlarge. 


LOSS  OF  LIFE  BY  FIREARMS. 
The  Lancet  offers  editorially  some  considera- 
tions as  to  the  much-needed  legislation  against  an 
easily  preventable  cause  of  death,  the  promiscu- 
ous handling  of  loaded  pistols.  Even  in  this 
country  where  many  men,  and  some  boys,  habit- 
ually "earn-  a  gun"  the  legislation  needed  to  ".  ". 
circumscribe  the  habit  and  thereby  save  life,  is 
extremely  defective.  The  suggestions  of  The 
Lancet  are  in  the  main  twofold,  first,  the  regis- 
tration of  sales,  including  a  prohibition  to  sell  to 
minors;  second,  an  exceedingly  heavy  tax  to  be 
assessed  upon  everyone  who  indulges  in  the  lux- 
ury of  habitually  carrying  the  means  of  ready 
homicide.  The  American  practice  of  giving  a 
man  a  permit  to  carry  a  pistol,  a  right  which  in 
some  of  our  cities  is  seemingly  vested  by  law  in 
the  department  of  police,  is  a  practice  of  very 
doubtful  humanity,  expediency  or  equity. 


temperature  adds  to  the  acidity  and  the  precipi- 
tation of  acid  in  the  joints  is  more  complete  than 
in  gout.  There  may  be  other  causes  besides  py- 
rexia that  will  increase  the  acidity,  such  as  sup- 
pressed perspiration  and  chilling,  tonsillitis  and 
other  local  inflammations,  and  the  ingestion  of 
acids  and  acid-forming  foods,  all  of  which  are 
predisposing  causes  for  rheumatic  attacks.  He 
also  holds  that  the  high  arterial  tension  at  the 
end  of  an  attack  is  an  indication  of  an  excessive 
of  uric  acid  in  the  blood,  and  that, 
therefore,  any  cause  that  increases  the  acidity  at 
that  time  tends  to  bring  on  a  reprecipitation  of 
the  acid  and  a  relapse. 


SHOULD  PHYSICIANS  STUDY  LATIN? 
In  the  day  when  medicine  was  held  to  be  one 
of  the  learned  professions,  and  Latin  an  essential 
part  of  a  gentleman's  education,  this  would  have 
seemed    a    superfluous   question.      Times   have 
changed  since  then.     The  physician  of  the  pres- 
ent time  knows  many  things  of  which  his  prede- 
cessor of  a  century  or  two  ago  was  ignorant,  that 
are  of  more  importance  to  his  patients  than  a 
'ARISON   BETWEEN   SALICIN  AND   THE  dead   language,   but   even   when   liberally   edu- 
SALICYLATE  OF  SODIUM.  cated  it  is  apt  to  be  the  case  that  he  is  less  of 

Dr.  Alexander  Haig  has  recently  read  a  pa-  what  is  called  a  scholarly  man  than  those  of  cor- 
per  before  the  Medical  and  Chirurgical  Society  of'  responding  standing  in  times  when  the  require- 
London  on  the  comparative  merits  of  these  two  |  ments  of  strictly  professional  education  were  less 
drugs  in  the  treatment  of  acute  articular  rheuma-  :  exacting.  That  the  gain  has  been,  on  the  whole 
tism.  He  bases  his  comparison  on  the  relative  \  greater  than  the  loss,  there  can  be  no  doubt,  and 
power  of  the  two  drugs  to  excrete,  or  to  stimulate  j  the  question  becomes  more  and  more  a  serious 
the  excretion  of,  uric  acid.  He  has  found  .that  \  one,  which,  among  the  ever  increasing  multitude 
the  salicylate  of  sodium  has  about  thirteen  times  of  things  that  it  is  desirable  for  a  physician  to 
the  excretory  potency  of  the  other  drug,  and  he '  know,  are  essential,  and  which  more  or  less 
thinks  he  has  seen  that  their  power  to  interfere  superfluous. 


with  the  course  of  the  disease  has  been  approxi- 
mately identical  with  their  liberation  of  uric  acid. 


No  one  who  reads  the  medical  periodicals,  and 
understands  Latin,  can  fail  to  be  aware  that  a 


His  contention  is  that  all  those  plans  of  treatment  knowledge  of  it  is  not  essential  either  to  a  marked 
of  acute  rheumatism  that  have  proved  beneficial  degree  of  competence  or  to  high  professional 
have  been  so  in  an  exact  proportion  to  their  uric  standing.  Whether  a  classical  education  would 
acid  secerning  power.     According  to  Dr.  Haig's  [have  been  a  help,  in  all  cases,  to  those  who  have 


416 


EDITORIAL  NOTES. 


[March  21, 


succeeded  without  it,  will  probably  never  be 
known.  The  question  of  the  comparative  dis- 
ciplinary value  of  such  studies  and  others  of 
more  immediate  practical  application  is  one  into 
which  we  do  not  propose,  at  present,  to  enter, 
but  there  is  at  least  one  drawback  connected  with 
ignorance  of  the  language  which  is  indisputable, 
and  somewhat  serious. 

The  technical  nomenclature  of  medicine  is  a 
relic  of  the  time  when  every  educated  man  was 
expected  to  be  familiar  with  Latin,  not  only  as  a 
written  but  a  spoken  language,  and  would  incur 
more  discredit  by  using  it  incorrectly  than  by 
mistakes  in  his  own  language.  It  is  impossible 
for  an>'  one  who  is  not  acquainted  with  Latin  to 
use  such  terms  grammatically,  and,  although  cor- 
rect grammar  may  be  classed  rather  among  the 
luxuries  than  the  necessities  of  life,  it  is  some- 
thing which,  like  clean  linen,  is  rather  expected 
of  men  in  certain  positions.  When  medical  men 
in  countries  in  which  a  classical  education  is  an 
essential  prerequisite  to  the  study  of  medicine 
find  that  professors  in  our  medical  schools,  and 
men  otherwise  of  high  standing  in  the  profession, 
are  unable  to  use  the  terms  of  their  profession 
correctly,  they  are  apt  to  draw  unfavorable,  and 
often  unjust  inferences  as  to  their  competency  in 
other  respects. 

It  is  unnecessary  to  multiply  instances  ;  every 
one  who  understands  Latin  has  met  with  plenty 
of  them,  and  those  who  do  not  would  be  none 
the  wiser.  It  may  be  enough  to  say,  by  way  of 
example,  that  to  speak  of  a  woman's  right  labia 
majora  is  a  mistake  of  the  same  kind  as  to  speak 
of  her  right  feet. 

What  is  the  remedy  ?  Shall  the  doctors  learn 
Latin,  or  shall  they  be  provided  with  English 
equivalents  for  those  terms  to  which  they  are 
now  lacking,  and  compelled  to  use  them  ?  Either 
course  would  have  its  difficulties.  With  respect 
to  the  latter,  a  glance  at  the  experience  of  an- 
other country  may  be  instructive.  In  Germany, 
although  physicians  in  general  are  acquainted 
with  Latin,  tin.-  patriotic  feeling  of  some  of  them 
impels  them  to  find  or  invent  German  words  for 
those  of  foreign  origin.  In  a  large  proportion  of 
cases  the  substituted  terms  are  literal  translations 
of  the  Latin  words.  The  essential  absurdity  of 
the  present  nomenclature  is  thus  held  up  to  view 
in  all  its  naked  deformity.  "Egg-stem"  for 
ovary  is  not  so  bad,  and  "  thin-gut  "  and  "  thick- 


gut"  for  the  two  divisions  of  the  intestines  are 
descriptive,  if  not  elegant,  but  it  is  difficult  to 
see.  the  merit  of  "see-hills"  for  optic  thalami, 
"  knee-humps "  for  corpora  geniculata,  and 
"brain-leg-hood"  and  " brain-leg- foot "  for  the 
two  divisions  of  the  cerebral  peduncles.  If  our 
medical  terminology  is  to  be  reformed,  it  is  to  be 
hoped  that  it  will  fall  into  the  hands  of  some  one 
who  will  "  reform  it  altogether." 


EDITORIAL  NOTES. 

A  Distinguishing  Mark. — A  British  doctor 
has  lately  contended  in  favor  of  a  particular  style 
of  hat  for  physician's  use.  His  argument  is  not 
made  for  advertising  purposes  ;  but  to  facilitate 
a  proper  recognition  between  men  of  the  same 
class — as  largely  obtains  in  England  between 
clergymen,  and  between  barristers,  from  distinct- 
ive features  of  their  costume.  Other  points  are 
also  advanced,  such  as  a  saving  of  time  to  the 
physician,  and  the  prompt  assistance  which  may 
be  afforded  in  accidents  by  being  quickly  recog- 
nized among  a  mass  of  people. 

We  remember  that  these,  and  other  arguments, 
were  put  forth  some  time  ago  by  a  physician  in 
this  country,  who  favored  the  wearing  of  an 
olive- colored  button  by  all  members  of  the  med- 
ical profession. 

It  is  feared,  however,  that  plans  of  this  char- 
acter will  beg  adoption,  for  reasons  which  all  will 
appreciate. 

Apropos  to  this  may  be  mentioned  the  uniform 
allowed  the  French  doctor  on  State  occasions. 
By  a  clause  in  a  law  of  1803,  it  was  enacted  that 
a  plain  Doctor  of  Medicine  could  wear  at  public 
ceremonies,  or  when  giving  evidence  before  a 
court  of  justice,  a  costume  as  follows:  A  black 
gown  of  bolting  cloth  (etaniine),  the  back  and 
front  of  which  are  of  crimson  silk  bordered  with 
ermine  ;  a  black  coat  a  la  Francaise ;  cambric 
bands,  and  a  cap  of  crimson  silk  with  a  border  of 
gold  lace. 

Aseptic  Urine  from  Salol. — M.  Lacroix  re- 
ports to  the  Paris  Societe  de  Pharmacie,  that  his 
experiments  have  demonstrated  that  the  pyogenic 
bacillus  cannot  develop  in  the  urine  of  those  tak- 
ing salol  internally. 

State  Care  of  Inebriates. — The  Legislature 
of  the  State  of  North  Carolina  has  set  aside  a 
portion  of  the  Western  North  Carolina  Hospital 


i89i.] 


MEDICAL  ITEMS. 


4'7 


for  the  care  and  treatment  of  inebriates.  This  is 
looked  upon  as  only  a  beginning  of  what  will  ul- 
timately be  a  duly-appointed  and  properly- 
equipped  asylum. 

A  Comrade  of  Tyrotoxicon. — Prof.  Victor 
C.  Vaughan  announces  that  a  new  toxic  element 
has  been  discovered  in  cheese,  differing  from 
tyrotoxicon.  As  yet  it  has  not  been  isolated,  but 
has  been  found  to  be  intensely  poisonous. 

Honors  to  Helmholtz. — The  70th  birthday  of 
Professor  von  Helmholtz  occurs  on  Aug.  30, 
1 89 1,  and  it  is  proposed  to  commemorate  the 
event  by  presenting  him  with  a  marble  bust,  and 
the  striking  of  a  special  medal  to  be  bestowed 
upon  physicists  of  eminence.  It  is  desired  to 
form  an  international  committee  for  carrying  out 
the  scheme. 

The  Reputed  Cause  of  Influenza. — Dr. 
Tezzier,  of  Lyons,  France,  claims  that  influenza 
is  produced  by  a  microbe,  which  he  styles  the 
strepto  bacillus,  whose  habitat  is  putrid  mud. 
That  Russia  is  its  home  is,  in  his  opinion,  due  to 
the  fact  that  bad  drainage,  filthy  streets  and  neg- 
lected barnyards  are  the  rule,  a  condition  particu- 
larly aggravated  by  swollen  rivers  and  generally 
wide  plains. 

Cremation  in  Liverpool. — The  following 
resolution  was  passed  by  an  overwhelming  ma- 
jority at  a  late  meeting  of  the  Medical  Institution 
of  Liverpool  : 

Resolved,  That  this  society  recognizes  the  advantages 
of  cremation  as  a  means  of  disposal  of  the  dead,  and 
considers  the  establishment  of  a  crematorium  in  Liver- 
pool, under  suitable  regulations,  as  free  from  objection. 

It  is  stated  that  there  are  now  about  forty-two 
crematoria  in  existence  throughout  the  world  ; 
and  that  the  first  crematorium  of  modem  times 
was  erected  at  Milan,  Italy,  in  1880.  The  prac- 
tice of  cremation  will,  therefore,  be  seen  to  have 
had  a  large  and  rapid  growth. 


MEDICAL  ITEMS. 
Testimonial  to  Virchow. — The  friends  and 
admirers  of  Dr.  Rudolf  Virchow  in  Great  Britain 
have,  according  to  The  Lancet,  February  7,  un- 
dertaken the  formation  of  a  testimonial  fund  to 
enable  them  to  unite  with  others  of  other  nations 
in  the  celebration  of  the  seventieth  birthday  of 
"the  great  exponent  of  cellular  pathology." 
This  event  will  take  place  October  13,  1891.    Sir 


James  Paget  was  unanimously  agreed  upon,  \>y 
the  committee  organizing  the  Fund,  to  be  invited 
to  take  the  chairmanship  of  the  English  branch 
of  the  movement.  The  editor  of  The  Lancet  adds: 
"The  movement  set  on  foot  in  Germany  will 
doubtless  spread  to  every  country  in  the  world, 
and  we  are  glad  to  find  that  Great  Britain  will  be 
represented."  The  nature  of  the  proposed  testi- 
monial will  include  the  presentation  of  a  large 
gold  portrait  medal  to  Virchow  himself,  and  bronze 
replicas  of  the  same  to  members  of  his  family  and 
to  some  scientific  institutions. 

The  Hunter  McGuire  Prize  Essay. — The 
announcement  is  made  that  the  subject  of  Dr. 
Hunter  McGuire's  Prize  Essa}'  for  189 1  will  be 
"Pyelo-Xephritis."  The  prize  offered  is  $100.00 
and  is  to  be  awarded  during  the  session  of  the  Med- 
ical Society  of  Virginia  at  Lynchburg,  Va.  The 
prize  is  only  open  to  members  of  the  Medical  So- 
cieties of  the  States  of  West  Virginia  and  North 
Carolina. 

Congress  of  German  Surgeons. — The  20th 
Congress  of  the  German  Surgical  Society  is  to  be 
held  in  Berlin  from  April  1st  to  4th,  under  the 
presidency  of  Professor' Thiersch.  It  is  proposed 
to  give  the  first  day  of  the  meeting  to  Koch's 
treatment  of  tuberculosis,  and  the  introductory 
address  on  this  topic  will  be  delivered  by  Professor 
von  Bergmann.  Patients  and  specimens  illustrat- 
ing the  effects  of  the  new  mode  of  treatment  will 
be  shown  in  the  University  Clinic  on  the  morning 
of  Thursday,  April  2nd. 

Mortality  effects  of  the  Late  Cold 
Weather  in  Paris. — Vital  returns  of  Paris 
plainly  indicate  the  effects  of  the  cold  weather  of 
the  season  just  passed.  Frost  is  reported  to  have 
j  set  in  on  November  26th,  and  lasted  without  in- 
termission until  January  21st.  Deaths  from  res- 
piratory diseases  were  much  increased,  though 
the  effect  was  not  noticeable  until  some  three 
weeks  or  more  after  the  setting  in  of  the  cold 
spell;  and  the  general  thaw  was  followed  by  an 
almost  immediate  lowering  of  the  death-rate. 

The  Colonization  of  Epileptics. — A  bill 
has  been  introduced  before  the  Legislature  of  the 
State  of  New  York  providing  for  the  creation  of 
a  Board  of  Commissioners  which  shall  have 
charge  of  the  housing,  and  grouping  under  care, 
of  epileptics. 


4i8 


TOPICS  OF  THE  WEEK. 


[March  21, 


TOPICS  OF  THE  WEEK. 


THE  ETIOLOGY    OF  TETANUS. 

In  the  last  number  of  the  Annates  de  I'Institut  Pasteur 
there  appears  (from  the  Bacteriological  Laboratory  of 
Val-de-Grace)a  most  interesting  paper  on  tetanus  by  Drs. 
Vaillard  and  Vincent,  which  appears  to  throw  very  con- 
siderable light  on  the  subject  of  tetanus,  and  to  clear  up 
a  number  of  points  and  observations  that  have  hitherto 
been  enshrouded  iu  obscurity.  After  describing  the  or- 
ganism, and  identifying  it  with  that  already  made  famil- 
iar through  the  papers  of  recent  writers,  the  authors  give 
it  as  their  firm  opinion  that  in  cases  of  artificial  inocula- 
tion of  pure  cultures  it  is  always  the  poison  introduced 
along  with  the  bacillus,  and  not  the  organism  itself,  that 
acts  upon  the  animal.  This  indeed  seems  to  be  probable, 
as  they  are  able  to  prove  that  almost  inconceivably  mi- 
nute doses  of  this  poison,  which  they  compare  with  snake 
poison,  are  quite  sufficient  to  produce  all  the  svmptoms 
of  most  acute  tetanus;  in  fact,  it  was  almost  impossible, 
from  some  of  the  cultures  that  they  obtained,  to  admin- 
ister a  dose  that  was  not  lethal. 

An  exceedingly  interesting  feature  brought  out  in  the 
course  of  their  work  is  that  iu  no  case  was  the  poison  devel- 
oped as  soon  as  the  organism  began  to  grow;  in  fact,  gel- 
atine cultures  of  the  tetanus  bacillus  were  never  capable 
of  producing  toxic  symptoms  until  liquefaction  of  the 
gelatine  had  commenced,  when  spores  were  demonstrated 
to  have  been  formed,  and  when  the  peculiar  disagreeable 
odor  so  characteristic  of  tetanus  cultures  had  become 
perceptible.  They  associate  both  the  odor  and  the  pep- 
tonizing power  with  the  formation  of  the  poison  in  the 
cultures.  That  it  was  due  merely  to  the  presence  of  the 
spores  that  the  material  was  poisonous  they  demonstrat- 
ed by  heating  their  cultures  to  a  temperature  of62°C. 
for  a  short  time  (a  temperature  which  is  quite  incapable 
of  interfering  with  the  vitality  of  the  spores),  when  it  was 
found  that  cultures  so  heated  and  introduced  by  inocula- 
tion into  a  rabbit  or  a  guinea-pig  failed  to  produce  any 
tetanus,  thus  proving  that  although  the  spores  are  not 
killed  the  poison  has  been  destroyed  bv  the  heat.  The 
spores  were  proved  to  be  living  bv  making  fresh  cultures 
from  them  in  artificial  media;  after  a  time  they  grew 
luxuriantly,  and  if  left  togrow  eight  or  ten  days  produced 
another  crop  of  the  poison.  By  simply  washing  auav  the 
poison  from  the  spores  with  distilled  water  thev  also  ob- 
tained similar  results,  for,  although  the  spores  could  still 
develop  and  form  the  specific  poison  iu  artificial  media, 
they  were,  when  inoculated,  incapable  of  giving  rise  to 
any  symptoms  of  tetanus.  From  tin-  reaction  to  heat  of 
a  substance  they  were  able  to  separate,  and  from  its  re- 
semblance to  the  diastases  in  other  respects,  thev  con- 
clude that  they  have  obtained  from  tetanus  cultures  the 
true  tetanus  poison,  a  poison,  however,  that  cannot  be 
Formed  by  the  tetanus  bacillus  in  healthy  tissues.  The 
microorganisms  are  here  so  rapidly  attacked  bv  the  leu- 
cocytes that  they  an-  rendered  horsde  combat  before  they 
have- time  to  form  their  poison. 

It   has  for  long  been  well   known    that    the   tetanus 


bacillus  could  not  develop  in  the  tissues  except, 
apparently,  iu  the  presence  of  other  organisms,  and  the 
suggestion  is  offered  that  these  other  organisms  act  in 
one  of  two  ways;  they  either  paralyze  the  activity  of  the 
leucocytes,  or  they  draw  off,  as  it  were,  their  attention 
and  activity  from  the  tetanus  bacillus,  thus  allowing  it 
sufficient  time  to  develop  its  characteristic  products.  It 
is  interesting  to  note  that  Drs.  Vaillard  and  Vincent  con- 
sider that  in  many  respects  the  tetanus  bacillus  is  ex- 
tremely like  the  diphtheria  bacillus,  the  method  of  action 
on  and  in  the  organism  being  essentially  the  same  in  the 
two  cases,  the  above  factors  in  all  probability  playing  a 
part  in  diphtheria  much  as  in  the  case  of  tetanus;  and  it 
is  evident  that  in  studying  the  one  poison  mnch  light 
may  be  thrown  on  the  other.  Behriug  and  Kitasato  ap- 
preciated this  fact,  and  combined  their  forces  to  work 
out  the  question  of  immunity  in  these  two  diseases.  It 
is  obvious,  however,  from  a  consideration  of  some  of  the 
points  that  are  indicated  in  this  paper,  that  there  are 
main' sources  of  fallacy  that  will  have  to  be  eliminated 
before  the  ultimate  explanation  of  the  condition  of  im- 
munity in  protected  animals  can  be  given.  The  facts 
that  this  poison  is  active  in  such  extraordinarily  minute 
quantities,  and  that  the  microorganisms  are  able  to  grow 
with  such  difficulty  in  the  human  tissues,  allow  us  to 
hope  that  extremely  minute  changes  in  the  blood  may 
be  quite  sufficient  to  secure  the  alteration  or  breaking- 
down  of  the  virulent  poison,  even  when  it  has  become 
diffused  throughout  the  system.  So  long  as  the  organism 
is  localized  to  the  wound,  there  is,  of  course,  more  chance 
of  coping  successfully  with  the  disease,  although  here, 
as  in  other  diseases,  there  always  appears  to  be  a  possi- 
bility of  the  poison  exerting  such  a  paralyzing  influence 
on  the  cells  that  usually  take  up  foreign  substances,  that 
secondary  septic  conditions  may  be  liable  to  occur  even 
when  the  action  of  the  tetanic  poison  can  be  antagonized 
so  far  as  its  primary  effects  on  the  cells  are  concerned. 
One  question  appears  to  be  set  at  rest,  and  that  is,  as  re- 
gards tetanus  and  diphtheria,  the  ptomaines  have  had 
their  day.  whatever  may  become  of  the  products  of  other 
organisms.  It  may  be  accepted  that  here,  at  any  rate, 
we  have  some  subtle  poison  which,  although  it  has  not 
yet  been  actually  separated,  has  become  so  far  isolated 
that  it  may  be  taken  as  proved  that  it  is  not  an  alkaloid 
or  basic  poison.  A  most  remarkable  feature  is  that,  in 
peptonizing  gelatine  with  the  filtrate  from  a  meat-broth 
culture  of  the  tetanus  bacillus,  the  poisonous  properties 
are  lost  to  a  certain  degree  in  direct  proportion  to  the 
amount  of  gelatine  that  is  peptonized;  this,  taken  in 
conjunction  with  the  fact  that  the  properties  are  not  de- 
veloped until  the  gelatine  begins  to  liquefy,  has  led  Drs. 
Vaillard  and  Vincent  to  suppose  that  the  same  agent 
that  peptonizes  the  gelatine  is  the  active  agent  in  bring- 
ing about  the  development  of  the  toxic  symptoms  of 
tetanus.  —  The  Lancet. 


THE   INV1SSTIGATION  OF  HYPNOTISM 

The  action  taken  by  the  British  Medical  Association  at 
the  last  annual  meeting  with  regard  to  hypnotism,  which 
resulted  in  the  appointment  of  a  Committee  of  Inquiry, 


i89i.]  TOPICS  OF  THE  WEEK.  4i9 

will  be  strengthened  by  the  report  of  the  Standing  Com-  and  where  they  have  caused  changes  to  take  place  ;  and 
mittee  on  Hypotisni  appointed  by  the  Medico- Legal  So-  that  this  influence  consists  in  a  corrosive  action  with 
ciety  of  New  York,  which  had  just  been  submitted.  The  supervening  necrosis.  Thus  I  uphold  my  opinion  that 
report  is  not  lengthy,  but  it  is  very  much  to  the  point,  tuberculin  is  a  specific  for  tuberculosis.  If  this  be  so. 
It  states  that  "  the  number  of  reputable  investigators  in-  whence  comes  it  that  its  therapeutic  action  is  so  much 
creases,  and  that  taken  out  of  the  hauds  of  those  whose  called  in  question  ?  I  think  the  answer  i  s:  because  tuber- 
aims  and  methods  cast  discredit  on  it,  hypnotism  is  culin  (i)  does  not  affect  the  tubercle  bacilli,  and 
studied  by  members  of  the  learned  professions,  vitally  cause  it  has  some  untoward  by-effects."  He  carefully 
related  as  it  is  to  the  interests  of  which  they  are  the  na-  weighed  the  pros  and  cons  of  the  tuberculin  treatment. 
tural  custodians."  Whilst  we  hold  to  the  opinion  that  such  as  his  own  experience  had  made  known  to  him.  and 
hypotism  should  only  be  practiced  by  qualified  medical  said  that  though  fully  alive  to  the  possible  dangtr 
men,  we  cannot  deny  there  are  medico-legal  questions  injections,  he  had  found  the  curative  effect  in  man  v  cases 
connected  with  the  study  of  the  subject  which,  on  further  so  marked,  so  much  greater  than  he  had  yet  observed  to 
investigation,  may  be  found  worthy  of  attention.  Before,  follow  any  other  therapeutic  method,  that  in  his  opinion 
however,  going  so  far  as  the  Committee  of  the  Medico-  the  physician,  after  having  carefully  and  conscientiously 
Legal  Society  of  New  York,  and  countenancing  the  study  selected  suitable  cases,  must  calmly  face  the  danger,  in 
of  this  subject  by  "  members  of  each  of  the  learned  pro-  the  same  way  as  the  surgeon  does  day  after  dav 
fessions,"  we  should  be  satisfied  that  the  medico-psycho-  close  of  his  remarks  Professor  Fraenkel  referred  to  Pro- 
logical  aspect  of  hypnosis  is  clearly  defined  and  under-  fessor  Liebreich's  new  remedy,  with  which  he  had  ob- 
stood.  The  moral  and  legal  relationships  of  hypnosis,  tained  surprisingly  successful  results  in  cases  of  tuber- 
which  the  medical  profession  has  now  begun  to  regard  as    culosis  of  the  larynx. 

a  physiological  and  not  a  pathological  state,  can  only  be  The  Yerein  fur  innere  Medizin  has  opened  a  discussion. 
studied  with  advantage  by  the  learned  professions  after  on  Koch's  tuberculin.  The  introductory  address  fell  to 
it  has  been  thoroughly  investigated  and  given  the  place  Dr.  Thorner.  who  reported  most  favorable  experiences 
to  which  it  may  be  found  to  be  entitled  by  those  compe-  with  the  lymph,  adding  that,  in  his  experience,  the 
tent  to  undertake  such  a  purely  medical  inquiry.  dangerous  by-effects  had  been  quite  exceptional. 

Briefly,  the  conclusions  which  the  Standing  Committee  '•  The  official  regulations  as  to  the  sale  of  tuberculin  have 
arrive  at  are  :  That  hypnosis,  or  artificial  trance  sleep,  j  appeared.  The  chemists  are  to  obtain  their  supply  from 
is  a  subjective  phenomenon,  that  it  is  not  in  itself  a  dis-  ,  Dr.  Libbertz,  who  will  continue  to  prepare  the  lymph 
ease.  Neurotic  conditions  predispose  to  the  trance  sleep,  j  under  the  supervision  of  Professor  Koch.  It  will  be  sold 
but  the  strongest  minds  have  been  enthralled.  Hypnosis  in  sealed  bottles  containing  from  I  to  5  cubic  centimetres, 
is  recognized  in  three  stages — lethargy,  somnambulism,  and  marked  with  the  date  of  preparation.  The  chemists 
catalepsy.  It  has  been  serviceable  in  medical  and  surgi-  are  to  use  the  same  precautions  as  with  poison,  and  onlv 
cal  practice  as  a  therapeutic  agent,  and  in  some  cases  as  ,  to  sell  it  in  the  original  bottles  and  upon  the  written  pre- 
a  safe  anaesthetic.  The  last  proposition,  that  ' '  the  j  scriptibn  of  medical  men.  A  special  book  is  to  be  kept 
illusory  impressions  created  by  hypnosis  may  be  made  to  for  the  entry  of  sales,  etc.,  and  in  each  case  the  quantitv 
dominate  and  tyrannize  the  subsequent  actions  of  the  sold,  the  date  of  preparation,  of  purchase,  and  of  sale, 
subject  "  is  far  from  being  established,  We  have  not  yet '  and  the  name  of  the  physician  prescribing  it  must  be 
sufficient  proof  that  post-hypnotic  suggestion  has  led  to  noted.  Six  months  after  preparation  the  lvmph  mav  no 
actual  crime,  or  that  "  illusory  impressions  "  (hallucina-  '  longer  be  sold.  Bottles  six  months  old  should  be  re- 
tion?)  have  been  either  lasting  or  post-hypnotic.  The  turned  to  Dr.  Libbertz,  who  will  exchange  them  for  new- 
more  medical  men  study  this,  interesting  and  possibly  ones  without  extra  charge.  The  price  has  been  fixed  at 
valuable  agent  as  a  means  of  combating  disease,  the  6  marks  (6s.)  for  a  cubic  centimetre,  and  25  marks 
stronger  will  the  desire  of  the  profession  become  to  see  £1  ."s. )  for  5  cubic  centimetres. — Correspondence 
it  taken  out  of  the  hands  of  showmen.     Nothing  can  be  '  British  Medical  Journal. 

more  degrading  to  the  medical  profession  than  to  see  

these  would-be  doctors  posing  in  public  and  filling  their 
pockets  by  exhibitions  of  the  power  of  hypnotism  before 
lay  audiences,  and  to  see  them  supported  and  patronized  In  the  Glasgow  Medical  Journal  for  October  appears 
by  medical  men  as  stated  by  one  of  our  correspondents  '  an  account  of  an  epidemic  of  erysipelas  and  sore  throat, 
in  last  week's  \ssun.— British  Medical  Journal.  occurring  among  families  supplied  with  milk  from  a  cer- 

tain farm.     The  most  striking  symptom  was  an  intense 
inflammation  of  the  fauces,  resembling  erysipelas  of  the 
FROM  BERLIN  mucous  membrane,  with  swelling  of  the  glands  of  the 

At  last  Wednesday's  meeting  of  the  Berliner  Medi-  neck,  and  in  some  cases  suppuration.  In  some,  true  ery- 
zinische  Gesellschaft,  the  discussion  on  Fraenkel's  ad-  sipelas  of  the  skin  developed.  The  temperatures  ranged 
dress,  the  longest  and  perhaps  the  most  important  from  1020  to  1050  during  the  first  few  days  of  an  attack, 
discussion  on  record  in  the  annals  of  the  society,  came  Convalescence  was  attended  by  extreme  prostration.  No 
to  an  end.  Professor  Fraenkel.  in  replying,  said:  "I  bacterial  examination  was  made,  but  a  clear  connection 
am  of  opinion  that  tuberculin  exercises  a  direct  influence  was  traced  between  the  milk  and  the  epidemic. 
on  those  parts  of  the  body  where  tubercle  bacilli  exist. 


INFECTION  FROM    MILK. 


420 


PRACTICAL  NOTES. 


[March  21, 


PRACTICAL  NOTES. 


CONVULSIONS  OF  TEETHING. 

ft     Chloral  hydrat.  gr.  xv. 

Potass,  bromid.,  3j. 

Svrup  simplic,  f  3 ;  v. 

Aq.  destillat.,  f,^  lj.     n)? 
S.     Teaspoonful  every  three  hours. — Kinder-*  Irzt. 


PRURIGO. 


The   following  prescription    is  useful   in   the 
treatment  _of  prurigo : 
ft.     Resorcin,  gr.  xxxv. 

Sulphur  prsecipitat.,  3  v. 

Acid,  carbolic. 

Acid,  salicylic,  aa  gr.  vij. 

Chloral,  gr.  xx. 

Vaseline,  5  iss.     njj 
Sig.     Use  externally. 

— La  Semaine  Medicate. 


OINTMENT    FOR    HEMORRHOIDS. 

Audhoui  recommends,  in  L'  Union  Afcdica/e.the 
following  ointment  for  haemorrhoids  : 
ft.     Extract  of  belladonna,  15  grains. 

Extract  of  thebaia,  15  grains. 

Antipyriue,  45  grains. 

Mercury  ointment,  2  U  drachms. 

Simple  cerate,  1  ounce. 
--  This  is  to  be  made  into  an  ointment  and  ap- 
plied to  the  inflamed  haemorrhoids.       Rectal  in- 
jections of  warm  water  are  to  be  employed  if  con- 
stipation is  present. — Medical  News. 


journal,  that  he  has  found  iodide  of  iron,  in  the 
form  of  pills,  as  prescribed  in  the  French  Codex, 
very  efficacious  in  treating  the  lead  poisoning 
which  occurs  amongst  workmen  employed  in 
white-lead  manufactories.  Sometimes  he  gives 
the  iodide  of  iron  by  itself,  at  others  he  combines 
with  it  phosphide  of  zinc.  Under  this  treatment 
workmen  who  had  already  commenced  to  show 
signs  of  lead  poisoning  were  enabled  to  continue 
their  occupation  ;  their  general  health  also  im- 
proved, and  the  amount  of  haemoglobin  increased. 


GONORRHOEA. 


INHALATIONS    FOR    OZ.ENA. 

Moire  recommends  the  following  to  be  used  as 
a  fumigation  in  the  treatment  of  fetid  nasal 
catarrh  : 

ft.     Camphor,  1  }i  drachms. 

Tincture  of  iodine,  3  drachms. 
Iodide  of  potassium,  30  grains. 
Tar,  3>2  drachms. 
Ninety-per-cent.  alcohol,  3  ounces. 
Water,  6  ounces. 

Place  this  solution  on  a  water-bath  and  inhale 
the  fumes  for  two  or  three  minutes,  after  which 
the  nasal  chambers  should  be  washed  out  with  a 
spray  of  i-to-100  of  carbolized  water. — Medical 
News. 


Thomas  R.  Neilson  states  that  the  plan  of  in- 
ternal treatment  which  he  has  pursued  for  so 
many  years  past,  consists,  first,  during  the  earlier 
stages  of  the  disease  in  the  administration  of  an 
alkaline  sedative  mixture,  with  the  purpose  of 
alleviating  the  scalding  caused  by  urination,  the 
tendency  to  frequent  micturition  and  to  chordee. 
The  standard  formula  in  his  dispensary  practice 
has  been  : 

ft.     Potass,  acetat.,  Siij-gss. 
Potass,  bromid.,  3jss. 
Acid,  boric,  3ij  9ij. 
Tinct.  belladon.,  rrixxx. 
Liq-  potass,  citrat.,  gviij.     "JJ. 
Sig. — A  teaspoonful  in  water  ever}'  three  or  four  hours. 

Secondly,  as  soon  as  the  symptoms  are  in  a 
measure  relieved,  the  administration  of  either 
oleoresin  of  cubebs  and  balsam  copaiba  in  capsule, 
or  of  cubebs  alone  in  powder,  in  teaspoonful 
doses,  or  finally,  where  chordee  is  troublesome,  a 
combination  of  two  parts  by  weight  of  powdered 
cubebs  and  one  part  of  bromide  of  potassium, 
given  in  the  same  doses,  and  from  three  to  four 
times  daily.  —  Univ.  Med.  Magazine. 


CONSTIPATION    IN    WOMEN. 

ft.     Citrate  of  irou  and  ammonium,  grs.  31. 
11.  est.  cascara  sagrada,  m  32. 
Saccharin,  grs.  S. 
Water,  5  ijss. 
M.     Sig.     A  half  teaspoonful  three  times  daily  before 
meals. 

— Medical  News. 


IODIDE  OF    IRON  IN  LEAD    POISONING. 

It  is  stated  by  M.  Lavrand,  in  a  Lille  medical 


TREATMENT  OF  SYPHILITIC  ULCERATIONS. 

Plumert  gives  the  following  applications  for 
ulcers  of  syphilitic  origin  : 

ft.     Mercury  salicylate,  gr.  xv. 
Potassium  carbonate,  gr.  xv. 
Distilled  water,  3  vj.     itJJ. 
Dissolve.      Sig. — Wet   compresses  with   this  solution 
and  apply  to  the  ulcerations. 

If  an  ointment  is  preferred,  recurrence  may  be 
had  to  the  following  : 

ft.      Mercury  salicylate,  gr.  xvj. 

Vaseline,  5  j. 
tljj.  and  make  a  pomade. 

— Bacteriological  World. 


IRRITABLE    BLADDER. 

H.     Potassium  citrate,  3  iv. 
Fluid  ext.  triticum  repens. 
Tinct,  of  hyoscyamus,  aa  .,j. 
Fluid  ext.  ofbuchu,  5  ss. 
Water,  sufficient  to  make  ,5iij. 
M.     Sig.     One  teaspoonful  in  a  wineglassful  of  water, 
three  or  four  times  daily. 

— Med.  Summary. 


I89i.] 


SOCIETY  PROCEEDINGS. 


421 


SOCIETY   PROCEEDINGS. 


Gynecological  Society  of  Boston. 

216th  Regular  Meeting. 

The  Gynecological  Society  of  Boston  met  at 
No.  19  Boylston  Place  on  Thursday,  Nov.  13, 
1890,  at  4  o'clock  p.m.,  with  the  President,  \V. 
Symington  Brown,  M.D.,  in  the  Chair. 

Dr.  Frank  L.  Burt  read  a  paper  entitled 

INTRA-UTERINF.  DISEASES — THEIR  DIAGNOSIS 
AND  TREATMENT. 

The  reader  placed  the  diseases  to  be  considered 
under  three  groups,  viz. : 

First,  the  benign. 

Second,  the  intermediate. 

Third,  the  malignant. 

The  benign  growths  mentioned  were,  endome- 
tritis, erosions,  areolar  hyperplasia,  submucous 
fibroids,  uterine  polypi,  cystic  degenerations  and 
retained  secundiues.  The  intermediate  were  ad- 
enoma. The  malignant  were  carcinoma  and  sar- 
coma. 

Endometritis  was  treated  at  greater  length  be- 
cause of  its  being  a  complication  of  the  other  dis- 
eases and  a  disease  of  itself.  In  case  we  find 
some  tenderness  about  the  uterus,  likely  also 
some  enlargement,  and  we  notice  sticky  mucus 
or  a  purulent  discharge  coming  from  the  os,  we 
can  make  the  diagnosis  of  endometritis  ;  provided 
we  can  prove  that  pus,  if  present,  does  not  come 
from  the  tube.  Division  is  made  into  cervical 
and  corporeal  endometritis,  and  it  is  generally 
believed  that  the  cervical  variety  is  much  more 
common  than  the  corporeal,  although  the  causes 
are  the  same.  Of  all  the  cases  which  the  reader 
has  been  called  upon  to  operate,  he  has  found 
that  whatever  the  symptoms  and  whatever  the 
kind  of  discharge,  the  whole  portion  of  the  endo- 
metrium has  been  more  or  less  diseased. 

For  treatment  he  advises  local  applications  of 
caustics,  or  the  use  of  galvanism  or  thorough  cu- 
retting. Local  congestion  should  be  relieved  and 
proper  constitutional  treatment  adopted.  The 
method  used  would  depend  upon  the  complica- 
tions in  the  case. 

Polypi,  or  retained  secundines,  should  be  re- 
moved entire,  and  a  local  application  of  some- 
thing like  iodized  phenol  made  to  the  surface.  If 
we  have  uterine  haemorrhage,  whether  it  be  from 
the  presence  of  fibroid  or  other  causes,  a  thor- 
ough curetting  is  usually  of  great  service.  In 
many  of  these  cases  galvanism  also  is  of  decided 
advantage,  many  statements  to  the  contrary  not- 
withstanding. 

Laparotomy  should  be  advised  in  many  of 
these  cases  of  fibroids  with  severe  haemorrhage, 
and  in  some  cases  for  severe  pain,  but  the  reader 
does  not  feel  like  condemning  all  these  patients 
to  abdominal  surgery,  because  many  of  those  who 


have  objected  to  surgery  have  been  entirely  re- 
lieved by  local  treatment ;  and  he  has  also  records 
of  a  large  number  of  patients  who  have  been 
urged  to  have  the  organs  removed  for  tumor  or 
haemorrhage,  who  had  been  completely  cured  by 
galvanism  alone. 

If  there  was  subinvolution  or  areolar  hyperpla- 
sia, a  course  of  chlorides  was  recommended  for 
internal  medication,  while  locally  curetting  and 
galvanism  were  advised.  An  old  view  that  are- 
olar hyperplasia  is  incurable  must  be  revised  to- 
day: for  those  cases  are  to  be  considered  as  per- 
fectly curable  by  modern  surgery. 

In  speaking  of  adenoma,  a  growth  which  may 
be  benign  for  a  long  period,  but  which  has  a  ten- 
dency to  take  on  malignancy,  the  reader  advised 
curetting  with  suitable  applications  as  long  as 
they  might  be  considered  serviceable,  or  as  long 
as  no  malignancy  showed  itself.  When  such  a 
change  became  apparent,  the  proper  method  to 
pursue  was  vaginal  hysterectomy.  This  class  of 
cases  would,  without  doubt,  furnish  the  greatest 
number  of  cures  following  this  operation. 

In  the  consideration  of  malignant  diseases  of 
the  uterus  the  subject  of  diagnosis  was  recognized 
as  of  great  importance,  and  it  was  thought  that 
too  much  care  cannot  be  given  to  all  cases  in 
which  there  is  any  possibility  of  malignant  dis- 
ease, because  so  man}'  cases,  unrecognized  at  first 
when  curable,  are  allowed  to  go  on  without  suit- 
able operative  treatment,  till  they  were  past  all 
hope  of  an5'thing  more  than  temporary  relief. 
Many  such  cases  come  to  every  surgeon. 

It  is  perfectly  evident  that  the  disease  must  be 
discovered  while  it  is  yet  confined  entirely  to  the 
uterus,  or  else  no  treatment  can  cure.  All  inter- 
nal medication  and  local  application  have  failed 
in  the  hands  of  the  reader.  If  the  disease  is  con- 
fined to  the  cervix,  where  it  originated,  an  ampu- 
tation of  the  cervix  will  be  sufficient  to  cure  some 
cases,  as  shown  by  records  of  some  years  stand- 
ing. If  the  disease  is  located  at  the  fundus,  no 
method  will  be  of  sen-ice  except  the  entire  re- 
moval by  vaginal  hysterectomy.  This  operation 
should  not  be  performed  in  case  the  disease  passes 
beyond  the  uterus.  When  we  find  a  patient  suf- 
fering from  pain  or  haemorrhage,  and  find  that 
the  disease  has  progressed  so  far  that  removal  is 
impossible,  we  should  still  subject  the  patient  to 
a  thorough  curetting  for  a  complete  removal  of 
the  sloughing  tissue,  after  which  caustic  or  cau- 
tery should  be  thoroughly  applied.  This  treat- 
ment is  often  extremely  satisfactory.  The  pa- 
tient for  the  time  recovers  entirely  from  the  foul 
discharges,  haemorrhage  and  pain.  The  relief  at 
times  is  very  great,  and  life,  besides  being  made 
more  comfortable,  may  be  greatly  prolonged. 

Dr.  C.  W.  Stevens  said  that  he  is  very  much 
interested  in  this  subject.  In  regard  to  the  man- 
ner of  applying  liquid  medicament  to  the  endo- 
metrium, he  is  accustomed  to  use  a  hard  rubber 


422 


SOCIETY  PROCEEDINGS. 


[March  21, 


Eustachian  catheter,  to  which  a  small  rubber  ball 
is  attached,  by  means  of  which  an  injection  of 
five  to  ten  minims  may  be  made.  In  a  few  cases 
there  may  be  slight  pain  for  five  to  ten  minutes 
after  the  injection  is  thus  made.  This  probably 
is  a  mild  uterine  colic.  Dr.  S.  takes  pains  to  be 
sure  that  the  injected  fluid  flows  out  again,  and 
hence  he  prepares  a  pad  in  the  vagina  to  receive 
it.  He  places  his  best  reliance,  however,  in  cu- 
retting to  cure  discharge  of  purulent  or  even  mu- 
cus character  when  in  excessive  quantity.  After 
he  has  curetted  he  applies  the  instrument  devised 
by  Dr.  Outerbridge  for  the  cure  of  sterility,  which 
was  originally  made  one  and  one-half  inches  long. 
It  is  self-retaining,  and  permits  free  drainage. 
When  he  makes  an  iutra-uterine  application  of 
galvanism,  he  uses  externally  a  large  pad  of 
spongio-piline,  protected  with  gauze,  which  takes 
the  place  of  the  water  apparatus  and  is  especially 
useful  when  high  currents  are  employed. 

Dr.  C.  E.  Prior  said  that  he  rarely  sees  a  case 
of  endometritis  which  does  not  yield  to  the  ap- 
plication of  Squibbs'  crude  carbolic  acid,  and  he 
believes  if  this  does  not  produce  the  desired  ef- 
fect, that  something  else  is  at  fault,  after  removal 
of  which  the  endometrium  gets  well.  He  once 
had  an  unfortunate  experience  with  creolin.  Dr. 
Church  mentioned  that  patients  taste  iodoform 
who  have  had  it  applied  locally  in  the  uterus  and 
vagina. 

Dr.  Mary  E.  Bates  suggested  that  she  should 
never  think  of  curing  endometritis  without  the 
use  of  hot  water  at  a  temperature  of  11 8°  to  1200 
F.,  in  addition  to  other  treatment. 

Dr.  Prior  agrees  with  this  statement,  and  if 
only  one  method  of  treatment  could  be  adopted, 
he  would  use  the  hot  water. 

Dr.  Thomas  P.  Jefferson  stated  that  he  be- 
lieved in  the  importance  of  drainage  after  the  op- 
eration of  curetting,  and  he  thinks  that  something 
should  be  left  in  the  os  Jhat  will  allow  the  debris 
to  come  out  easily.  He  also  has  used  the  Outer- 
bridge  instrument  with  success,  and  has  also  had 
good  results  by  the  insertion  of  gauze,  which 
may  be  left  for  a  day  or  two.  Care  should  be 
taken  lest  the  os  closes  and  shuts  the  gauze  in. 
He  thinks  there  is  more  reason  to  be  afraid  of 
the  intra-uterine  application  of  caustics,  etc.,  than 
of  electricity. 

Dr.  C.  A.  Eastman  said  that  in  cases  of 
corporeal  endometritis  he  finds  the  disease  in 
patches,  and  he  is  accustomed  to  use  the  sharp 
curette,  which  should  be  used  until  the  grating 
sound  is  heard. 

I)k.  Henry  O.  Marcy  said  that  this  is  an  old 
subject  but  it  is  one  which  is  always  interesting. 
What  is  endometritis?  A  name  merely.  Our 
opinions  have  lately  changed  in  regard  to  all  in- 
flammations. What  makes  the  inflammation  in 
this  case?  The  glandular  apparatus  is  diseased 
bj  means  of  foreign  material,   viz.:  microorgan- 


isms, and  all  of  the  medicines  which  have  been 
recommended  in  the  line  of  treatment  are  anti- 
septics of  greater  or  less  value.  The  vagina  af- 
fords most  excellent  conditions  for  the  growth  of 
microorganisms.  In  these  cases  the  circulation 
and  hence  nutrition  is  also  at  fault.  The  cause 
should  first  be  sought  before  attempting  a  cure. 
Strong  applications  are  too  often  introduced  in- 
to the  uterus,  when  such  are  used  at  all  it  should 
only  be  with  extreme  care.  The  operation  of 
curetting  should  not  be  thought  lightly  of.  It 
should  be  done  thoroughly  if  at  all  and  with  all 
the  care  of  any  surgical  operation.  Even  after  a 
thorough  curetting  all  of  the  glands  are  not  de- 
stroyed. Ordinary  menstruation  may  be  said  to 
be  nature's  effort  to  clean  house  each  month.  The 
glands  are  removed  and  they  grow  again.  Dr. 
Marcy  protests  against  doing  the  operation  of 
curetting  with  cocaine  for  an  anaesthetic  since 
when  so  done  it  can  never  be  sure  or  safe.  He 
does  not  generally  use  anything  for  drainage 
after  curetting,  but  if  for  any  reason  he  wishes  it, 
he  prefers  a  small  rubber  tube.  He  does  not  as  a 
rule  make  applications  to  the  interior  of  the  uterus, 
and  prefers  iodoform  when  he  needs  anything. 
He  has  never  had  occasion  to  regret  the  use  of 
iodoform  although  the  patients  sometimes  have 
the  taste  of  the  drug  after  it  has  been  applied. 
He  believes  that  the  poisoning,  when  it  occurs, 
is  due  to  iodine  and  not  iodoform. 


St.  Louis  Medical  Society. 

Stated  Meeting  February  21,  1891. 

The  President,  L.  Bremer,  M.D.,  in  the 
Chair. 

[Abstracted  for  The  Journal], 
TYPHOID    BACILLUS. 

Dr.  A.  Green  read  a  quotation  from  Koch 
relative  to  the  difficulty  of  determining  the 
species  of  bacilli — and  particularly  the  typhoid 
bacilli — inasmuch  as  there  are  as  yet  no  dis- 
tinguishing or  constant  marks  which  positively 
indicate  the  specific  typhoid  germ. 

Dr.  Bremer  spoke  of  the  method  of  separating 
and  differentiating  various  bacilli  in  Koch's 
laboratory,  and  also  referred  to  the  way  in  which 
the  cultivations  were  made. 

Dr.  Green  believed  that  the  bacillus  of  typhoid 
fever  was  not  present  during  the  earlier  stages  of 
the  disease,  not  being  shown  in  the  feces  under  a 
week  or  ten  days. 

Dr.  Bremer  referred  to  the  difficulty  of  diag- 
nosing typhoid  in  its  early  stages,  and  even 
throughout  the  entire  course  of  its  manifestation. 
He  also  spoke  of  the  difficulty  of  the  compara- 
tive study  of  contagious  diseases  on  the  lower 
animals,  inasmuch  as  the  disease,  in  a  character- 
istic form,  cannot  there  be  produced. 


i89i.] 


SOCIETY  PROCEEDINGS. 


423 


ENCYSTED    HYDROCELE    OF    THE    CORD. 

Dr.  Brokaw  presented  a  specimen  which  was 
of  interest  more  directly  from  the  mistake  in  diag- 
nosis which  it  had  caused.  It  had  been  taken 
for  a  hernia,  and  had  been  treated  as  such  hero- 
ically, and  for  a  considerable  time. 

TUBO  OVARIAN    DISEASE. 

Another  specimen  having  much  interest  was 
also  presented  by  Dr.  Brokaw.  The  patient,  36 
years  of  age,  had  suffered  greatly  for  a  long  time. 
Childbirth  occurred  seven  years  previously,  and 
for  the  last  fourteen  months  the  patient  had  been 
bedridden.  The  case  had  been  variously  diag- 
nosed, and  treated  accordingly.  At  the  operation 
very  extensive  adhesions  were  found,  and  a  large, 
far-reaching  abscess,  involving  and  surrounding 
the  larger  blood-vessels  of  the  region.  The  pa- 
tient was  extremely  emaciated,  and  died  on  the 
fifth  day  after  the  operation. 

MVXO  SARCOMA    OF    THE    KIDNEY. 

A  third  case  was  that  occurring  in  a  child  3 
years  and  8  months  of  age.  This  is  the  second 
youngest  child  operated  upon  for  this  peculiar 
disease.  Altogether  twenty-nine  previous  cases 
have  been  reported  in  young  children.  In  this 
case  the  tumor  had  developed  very  rapidly.  Op- 
eration took  place  in  November,  but  the  child 
had  a  metastasis  involving  the  liver  and  suc- 
cumbed two  months  ago. 

INTRACRANIAL     TUMOR. 

Dr.  N.  S.  Carson  rehearsed  the  history  of  a 
well-marked  case  of  cerebral  tumor  involving  the 
arm- centre  first,  but  afterwards  extending.  The 
operation  of  trephining  was  performed,  and  pa- 
tient made  a  good  recovery  until  the  eighth  day 
when  death  occurred,  the  immediate  cause  of 
which  was  unknown.  The  case  progressed  very 
favorably  in  every  way  until  the  sudden  onset  of 
a  state  of  alarm  in  the  patient,  which  preceded 
the  fatal  termination  but  a  short  time. 

Dr.  Atwood  gave  a  word  picture  of  two  cases 
occurring  in  asylum  practice,  where  the  autopsy 
revealed  the  presence  of  cerebral  tumors.  In 
neither  case  could  the  diagnosis  be  positives- 
made  during  life,  nor  a  correct  localization  offered. 

Dr.  Bremer  believed  that  death  happened,  in 
the  case  reported  by  Dr.  Carson,  from  the  sudden 
relief  of  the  pressure  which  had  maintained  from 
the  tumor.  This  result  obtained,  whatever  the 
operative  dexterity  had  been  on  the  part  of  the 
surgeon,  and  therefore  reflected  nothing  against 
the  surgeon's  skill.  In  this  case  the  tumor  was 
large,  and  its  removal  was  attended  with  con- 
siderable haemorrhage.  Subsequent  capillary 
haemorrhage  took  place,  notwithstanding  the 
presence  of  the  gauze,  and  the  general  evidences 
of  favorable  progress,  and  finally  death  came 
from  an  cedema  of  the  cerebral  structures. 


A  general  discussion  followed  touching  the  in- 
fluences of  coarse  cerebral  lesions,  and  the  effects 
of  brain  pressure. 


New  York  Academy  of  Medicine. 

S'ctio7i  on  Orthopedic  Surgery. 
Samuel  Ketch,  M.D.,  Chairman. 

-tracted  for  The  JorK-. 

CONGENITAL    (DOUBLE)  equino-yarus. 

Dr.  Charles  X.  Dixon  Jones  reported  a  case 

in  which  ordinary,  and  other,  methods  had  failed, 

necessitating,  finally,  the  removal  of  both  tarsi, 

with  good  results. 

aggravated  flat-foot. 

Dr.  Jones  reported  a  case  where  the  inner 
side  of  the  right  foot  rested,  in  its  whole  length, 
on  the  ground.  Resection  of  the  astragalo-scaphoid 
articulation  was  made  with  good  result. 

tubercular  ostitis   of  the  hip-joint. 

Two  cases  of  this  disease  were  also  offered  by  Dr. 
Jones.  In  the  first  case  there  was  high  tempera- 
ture, and  the  operation  of  resection  liberated 
several  cunces  of  pus.  The  temperature  at  once 
dropped,  and  there  was  a  good  recovery,  not  re- 
quiring apparatus,  and  with  but  one  inch  of 
shortening.  In  the  second  case  the  child  was 
three  years  old  and  had  never  walked.  There 
was  a  fluctuating  swelling  over  the  joint,  together 
with  the  other  symptoms  of  tubercular  coxitis.  A 
similar  operation  to  that  on  the  first  case  was 
done,  and  the  recovery  was  rapid  and  uninter- 
rupted. 

Dr.  V.  P.  Gibney,  in  discussing  the  cases, 
said  that  in  the  first  case  the  result  was  probably 
due  to  poliomyelitis,  the  anterior  and  posterior 
tibial  muscles  being  mostly  affected;  and  that  in 
the  effort  to  bring  down  the  heel  the  flatness  had 
been  produced.  He  thought  that  a  still  further 
improvement  could  be  produced  by  division  of  the 
tendo  Achillis. 

Dr.  Royal  Whitman  considered  the  result 
obtained  in  the  case  of  the  flat-foot  a  good  one, 
but  he  withheld  his  approval  from  this  class  of 
operations.  He  felt  that  as  good  a  result  could 
be  obtained  by  over-correction  under  ether,  to- 
gether with  subsequent  attention  and  exercise. 

Dr.   A.  B.  Judson    remarked  that  the  occur- 
rence of  flat-foot  as  a  result  of  infantile  par:, 
was  rather  unusual. 

Dr.  R.  H.  Sayre  did  not  agree  with  Dr. 
Judson  that  equino-valgus  was  rare  after  polio- 
myelitis when  the  anterior  tibial  muscle  happened 
to  be  the  chief  one  involved.  As  to  other  points 
he  did  not  believe  there  was  any  such  thing  as  a 
relapsed  club-foot;  such  cases  were  simply  in- 
stances of  imperfect  cures,  in  which  the  patients 
i  had  been  unable  to  voluntarily  retain  the  foot  in 


424 


SOCIETY  PROCEEDINGS. 


[March  21, 


its  normal  position.  He  considered  that  Dr. 
Jones'  exsection  of  the  hip-joint  a  very  excellent 
piece  of  work,  and  believed  it  was  much  better 
than  attempting  to  produce  anchylosis. 

HYDRARTHROSIS. 

The  Chairman  presented  a  case  that  he 
had  first  seen  in  1S87.  Patient  fifteen  years  of 
age.  No  history  of  rheumatism  or  joint  dis- 
ease, but  there  is  phthisis  011  the  maternal 
side.  Two  years  before  the  right  knee  be- 
came swollen,  and  later  the  ankles  and  the  left 
knee.  General  health  is  good,  and  there  is  no 
known  cause  for  the  trouble.  Examination 
showed  a  large,  dough}-  swelling  of  the  knee;  no 
pain;  movements  of  the  joint  only  limited  by  the 
effusion,  and  then  only  in  extreme  flexion.  No 
elevation  of  the  temperature.  An  exploratory 
puncture  showed  a  clear,  syrupy  fluid.  Treat- 
ment was  first  by  plaster  bandages,  and  after- 
wards by  elastic  compression,  counter-irritation, 
and  systematic  massage  of  the  joints.  The  prog- 
ress of  the  case  was  at  first  slow,  but  afterwards 
became  more  rapid,  until  now  there  is  very  decided 
improvement. 

Dr.  Gibxey  remarked  that  the  case  was  inter- 
esting, both  on  account  of  its  comparative  rarity, 
and  the  excellent  result  which  had  been  obtained. 

Dr.  A.  M.  PnELrs  had  been  accustomed  in 
these  cases  of  effusion  into  the  joints,  to  open  the 
joint  and  wash  it  out  with  a  1-1200  solution  of 
bichloride.  He  believed  it  shortened  the  period 
of  treatment;  was  a  safe  practice;  and  gave 
equally  good  results  with  the  more  common 
method.  In  dispensary  practice  his  cases  had 
been  discharged  in  three  months.  Tubercular 
joints  were  not  necessarily  purulent.  He  had  ex- 
amined many  microscopically,  and  while  fre- 
quently finding  the  tubercle  bacilli,  yet  there  was 
no  suppuration. 

The  Chairman  in  closing  the  discussion,  said 
that  in  private  practice  the  consent  to  an  opera- 
tion, when  there  was  such  slight  disability,  could 
not  easily  be  obtained;  and  furthermore  he 
thought  the  operation  somewhat  dangerous  in 
itself  and  liable  to  result,  in  a  tuberculous  case, 
in  a  general  infection  of  the  system. 

RHEUMATOID    ARTHRITIS. 

The  Chairman  also  presented  a  man,  thirty- 
six  years  of  age,  and  with  good  family  history. 
Had  rheumatism  when  ten  and  fourteen  years  of 
age,  and  a  third  severe  attack  about  ten  years 
inch  involved  only  the  right  ankle.  Two- 
and-a-half  years  ago  was  exposed  to  damp  and 
cold  for  a  number  of  hours  at  night,  which  was 
followed  by  pain  in  the  left  hip,  thence  to  the 
side  of  the  leg  and  knee,  and  across  the  back  to 
the  right  hip.  After  that  the  joints  became  stiff, 
though  with  only  a  feeling  of  soreness  on  motion. 
Now  there  was  but  little  motion  in  both  hips,  yet 
the  arms  and  hands  were  quite  free.     Has  been 


examined  under  ether,  when  the  movements  were 
somewhat  increased. 

Dr.  R.  H.  Sayre  said  that  the  appropriate 
treatment  was  indicated  by  the  movements  made. 
Slight  daily  movements  of  the  joints  should  be 
undertaken  while  the  patient  was  immersed  in  a 
bath  having  a  temperature  of  no- 115  degrees. 
Massage  was  more  successful  in  this  way.  When 
the  joints  are  inflamed  and  tender  massage  may 
intensify  the  inflammation  so  as  to  cause  anchy- 
losis, but  in  this  case  there  had  been  absence  of 
pain  for  a  long  time. 

Dr.  Gibney   approved  of  these  suggestions. 

The  Chairman,  in  closing  the  discussion, 
said  that  he  had  seen  a  number  of  these  cases, 
and  his  experience  had  been  unfortunate.  The 
case  should  be  classified  as  rheumatoid  arthritis, 
which  disease  terminates  in  anchylosis.  There 
might  be  temporary  amelioration.  He  believed 
that  massage  and  baths  at  the  Hot  Springs  the 
best  treatment. 

THE    IMPORTANCE    OE    THOROUGH    EXAMINATION 
IN  SUSPECTED    POTTS'  DISEASE. 

Dr.  R.  H.  Sayre  read  a  paper  having  this  title. 
He  said  that  although  in  childhood  the  signs  of 
Potts'  disease  are  usually  so  marked  as  not  to  be 
confounded  with  other  troubles,  in  adults,  espe- 
cially in  females,  there  are  times  when  the  diag- 
nosis is  not  clear.  In  some  cases  of  uterine  dis- 
placement and  ovarian  disease,  the  reflex  pains, 
the  position  and  gait,  may  simulate  Pott's  disease 
so  closely  as  to  be  mistaken  for  it  by  competent 
observers. 

A  number  of  cases  were  cited  illustrating  the 
similarity  of  symptoms,  and  the  errors  made  in 
treating  the  cases  as  Pott's  disease;  and  where 
uterine  replacement  by  a  pessary  or  Alexander's 
operation,  together  with  faradism  and  general 
treatment,  produced  a  cure. 

In  conclusion  the  writer  said  that  the  descrip- 
tion of  these  cases  showed  that  the  mistakes  in  diag- 
nosis had  been  made  by  men  of  large  experience, 
and  he  therefore  thought  it  worth  while  to  call 
attention  to  the  fact  that  reflex  pains  from  pelvic 
irritation  might  easily  lead  one  astray  in  consider- 
ing cases  of  supposed  Pott's  disease. 

PATHOLOGICAL    DISLOCATION    OF    THE    HIP. 

Dr.  W.  R.  TOWNSEND   presented  a    specimen 

of  this  condition  which  had  been  removed  from  an 
Italian  girl.  The  head  of  the  femur  was  deeply 
eroded  and  was  dislocated  onto  the  dorsum  ilii. 
There  was  a  marked  erosion  of  the  pelvic  bones, 
but  no  perforation  of  the  pelvis, 

ACUTE    INFANTILE    ARTHRITIS. 

Dr.  Townsend  also  presented  a  specimen  show- 
ite  arthritis  in  an  infant  11  months  old. 

Dr.  Judson  said  that  the  specimen  illustrating 
pathological  dislocation  of  the  hip  recalled  a  dis- 
cussion which  took  place  a  few  years  ago  on  the 


i89i.] 


Dl  >MKSTIC  CORRESPONDENCE. 


425 


question  of  the  possibility  of  this  dislocation. 
Dr.  March,  of  Albany,  argued  that  Dupuytren, 
Astley  Cooper,  C.  Bell,  Brodie,  Lis  ton,  Fergus- 
son,  Milk-r.  Gibson,  Carnochan,  and  a  host  oi 
other  authorities  were  wrong  in  considering 
spontaneous  dislocation  in  hip  disease  as  a  fre- 
quent occurrence.  He  declared  that,  as  purely 
tfa  result  of  morbid  action  unaided  by  superficial 
violence,  it  seldom,  or  never,  took  place.  He 
visited  forty  pathological  museums  in  all  parts  of 
the  world,  and  failed  to  find  evidences  of  this 
lesion.  His  forcible  article  in  the  "  Transactions 
of  the  American  Medical  Association,  1S53,"  ex- 
cited great  opposition,  and  Dr.  Hayward,  of 
Boston,  in  his  Surgical  Reports,  1855,  said  it 
would  require  more  specimens  than  would  fill 
forty,  or  forty  thousand  museums  to  convince 
him  that  a  certain  specimen,  which  he  described, 
■was  not  the  result  of  spontaneous  dislocation. 

Before  this  discussion,  spontaneous  dislocation 
■was  supposed  to  be  a  very  common  incident  of 
hip  disease,  in  spite  of  the  doubts  expressed  by 
Baron  Larry,  and  the  statement  by  Wickham,  in 
1833,  that  it  is  of  very  rare  occurrence.  That 
dislocation  is  very  often  simulated  when  not 
really  present,  is  not  generally  conceded. 

Dr.  Gibxey  showed  a  specimen  to  the  Patho- 
logical Society  in  1S77,  in  which  dislocation  was 
simulated  by  an  appearance  due  to  the  altered 
direction  of  the  neck  of  the  femur.  But  that  it 
sometimes  does  occur,  is  clear  enough  from  the 
fine  specimen  in  Dr.  Townsend's  hands.  There 
is  another  pathological  dislocation  of  the  hip  that 
is  worth  considering  from  an  orthopaedic  stand- 
point, i.  <-.,  that  thought  to  be  produced  by  dis- 
tention of  the  capsule  in  the  synovitis  following 
continued  fevers,  as  set  forth  by  Dr.  Keen,  in  the 
fifth  Toner  Lecture  in  1877.  He  had  recently 
examined  a  convalescent  from  typhoid  fever  in 
whom  there  was  great  impairment  of  motion,  and 
a  distended  capsule.  Ostitis  was  eliminated  by 
the  history  of  the  case,  and  hy  the  absence  of 
atrophy  and  natal  asymetry.  The  patient  was 
warned  against  undue  disturbance  of  the  joint, 
and  recovered  without  dislocation,  and  without 
any  special  treatment.  The  subject  is  practically 
important  because  it  is  generally  believed  that 
serious  joint  diseases  not  infrequently  have  their 
origin  in  fevers. 

Dr.  Gibuey  said  that  he  would  like  to  know 
whether  Dr.  Townsend  thought  the  child  might 
have  been  saved  if  the  head  of  the  bone  had  been 
excised.  A  number  of  years  ago  Dr.  Yale  read 
a  paper  on  excision  of  the  hip,  before  the  Surgical 
Society,  and  among  other  conclusions  he  stated, 
that  the  best  antipyretic  for  septicaemia  was  ex- 
cision of  the  hip. 

Dr.  Townsend  replied  that  there  was  marked 
septicaemia  preseut  at  the  time  he  had  operated 
and  drained  the  abscess,  so  that  he  doubted  if  the 
result  would  have  been  different  had  he  excised 


the  head  of  the  bone.  He  thought,  however, 
that  an  earlier  operation  might  have  saved  the 
child's  life.  He  had  recently  seen  in  Bellevue 
Hospital  a  man  suffering  from  aggravated  sep- 
ticaemia due  to  absorption  cellulitis  of  the  leg, 
-  so  ill  that  it  was  feared  he  would  die  on 
the  table  during  the  amputation  of  the  thigh  ; 
yet,  instead  of  this,  the  amputation  was  followed 
by  a  very  rapid  improvement  in  his  general 
condition. 


DOMESTIC  CORRESPONDENCE. 


LETTER  FROM    NEW  YORK. 

(FROM  OI'R  own  correspondent.) 

York  County  Medical  Association — A  Koch 
Institute  for  Consumptives — Dr.  Simon  Baruch  on 
the  Koch  Lymph  Treatment — Dr.  J.  Blake  White's 
Treatment  for  Tuberculosis — Sanitary  Condition  of 
the  Public  Schools. 

At  the  February  meeting  of  the  Xew  York 
County  Medical  Association  the  retiring  Presi- 
dent, Dr.  George  T.  Harrison,  on  vacating  the 
chair,  delivered  an  eloquent  address,  in  which  he 
dwelt  upon  the  value  and  the  desirability  of  a 
more  general  study  of  the  medical  literature  of 
the  past.  In  his  admirable  inaugural  address  the 
President  elect,  Dr.  S.  B.  Wylie  McLeod,  alluded 
to  the  great  success  of  the  Association  during- the 
past  year,  whether  viewed  from  the  standpoint  of 
an  increased  membership  and  a  well  filled  treas- 
ury, or  from  that  of  the  value  and  amount  of  sci- 
entific work  performed.  In  speaking  of  the  future 
he  urged  the  cultivation  of  the  closest  possible 
relations  with  the  State  and  National  Associa- 
tions. "We  are  their  representative,"  he  said, 
"  in  this  County  of  New  York,  and  they  are  ours 
in  that  unity  of  effort  and  purpose  which  gives 
strength  to  our  cause.  If  we  should  be  feeders 
to  them  in  membership,  and  the\-  in  certain  cases 
should  exercise  a  supervision  over  us,  it  would  be 
a  relation  at  once  natural  and  calculated  to  secure 
the  great  ends  of  our  respective  formations.  A 
desire  for  cooperation  and  a  willingness  on  the 
part  of  a  distinct  majority  to  thus  organize, 
should  precede  the  plan,  and  until  these  are  first 
secured,  it  is  a  dictate  of  wisdom  to  wait ;  for  it 
often  happens  that  we  should  not  take  the  course 
which  is  ideally  most  effective,  but  that  one  which 
commands  cooperation  and  assent." 

At  this  meeting  sixteen  new  members  were  re- 
ceived;  thus  bringing  up  the  total  membership 
of  the  County  Association  to  about  600. 

A  "Koch  Institute  for  Consumptives"  has 
been  opened  in  the  lower  part  of  the  city,  on  the 
East  Side,  and  it  will  doubtless  serve  the  purpose 
of  affording  considerable  free  advertising  for  the 
physicians  having  the  project  in  charge,  and,  for 


426 


DOMESTIC  CORRESPONDENCE. 


[March  21, 


the  time  at  least,  bring  in  handsome  financial  re- 
turns.    It  would  not  at  all  do  for   some  of  the 
profession  here,  however,  to  cry  out  against  such 
gratuitous  advertising,  as  quite  a  number  of  the 
shining  lights  in  it  received  a  good  deal  of  this 
in  the  newspapers  at  the  time  of  the  introduction 
of  and  first  experiments  with  the  Koch  lymph.  : 
Aside  from  any  such  considerations,  however,  the  ! 
wisdom  of  establishing  an  institution  for  the  spe- 
cial purpose  of  employing  the  Koch  treatment 
would  seem  to  be  extremely  problematical  at  the 
present  time,  when  grave  doubts  are  felt  by  many 
of  the  best  observers  as  to  whether  the  treatment 
may  not,  after  all,  be  more  injurious  than  benefi- 
cial.    That  it  has  not  accomplished  as  much  as 
was  at  first  hoped  for  from  it  there  can   be  no 
question,  and  the  unsatisfactory  results  that  have 
thus  far  been  met  with  led  Professor  Francis  Del- 
afield  lately  to  make  the  remark  that  we  seemed 
to  be  still  as  much  in  the  tentative  stage  of  the 
treatment  of  phthisis  as  ever.     The  present  feel- 
ing in  Berlin  in  regard  to  the  matter  is  shown  by 
the  letter  of  Dr.  Ingals  recently  published  in  The 
Journal. 

It  is  now  some  time  since  Frankel,  observing 
the  fact  that  the  tolerance  of  the  Koch  remedy 
disappeared  if  no  injection  were  made  for  ten 
days,  and  that  the  patient  then  became  as  easily 
affected  as  by  the  original  dose,  drew  the  conclu- 
sion that  in  phthisis  tolerance  is  established  as 
soon  as  all  tubercle  is  acted  upon,  and  was  led  to 
explain  the  return  of  the  original  susceptibility 
by  the  hypothesis  that  the  patient  had  again 
infected  himself  with  tubercle  from  the  necrosed 
tissue  lying  in  the  lung,  and  that  the  reaction 
again  appeared  from  a  minimum  dose  because  the 
case  was  once  more  a  tuberculous  one.  If  this 
explanation  is  correct — and  the  autopsies  made  1 
by  Yirchow  would  seem  to  afford  some  corrobora- 
tion of  this,  or  at  least  to  indicate  that  in  certain  I 
instances  the  effect  of  the  lymph  treatment  is  ap- 
parently to  disseminate  the  tubercle  bacilli  in  the 
system— the  difficulties  in  the  way  of  success  with 
the  method  would  seem  to  be  very  great,  if  not 
altogether  insurmountable. 

In  this  city  there  have,  of  course,  occurred 
some  deaths  in  the  patients  treated  with  the  Koch 
lymph,  and  it  would  certainly  have  been  very  re- 
markable if,  among  so  many  cases  of  phthisis, 
this  had  d  ie  case.     In  commenting  on 

these  deaths  Dr.  Simon  Baruch.  who  at  an  early 
date  began  experimenting  with  the  new  treatment 
at  the  Montefiore  Home  for  Chronic  Invalids, 
writes  as  follows:  "The  public  may  easily  be 
deceived  by  reports  of  death  from  lymph,  b< 
these  cases  happened  to  die  while  under  the  lymph 
treatment ;  but  the  experienced  physician  1 
but  too  well  how  fallacious  such  a  conclusion  is 
in  a  disease  which  furnishes  so  large  a  percentage 
of  the  world's  death-rate.  From  an  experience 
with  over  thirty  cases  of  lymph  treatment   the 


writer  is  led  to  the  conclusion  that,  although 
the  lymph  has  an  undoubted  elective  affinity  for 
tuberculous  tissue,  and  produces  decided  local  re- 
actions, as  Koch  has  stated,  not  one  case  has, 
after  six  weeks'  experience,  offered  him  ^the 
slightest  evidence  of  a  curative  tendency.  Nev- 
ertheless, he  does  not  despair,  because  much  time 
is  required  for  the  processes  which  Koch  has  de- 
lineated as  probable  in  throwing  off  the  diseased 
structures."  On  the  whole,  therefore,  the  estab- 
lishment of  a  special  "  Koch  Institute "  at  the 
present  time  would  seem  to  be  somewhat  prema- 

The  most  recent  treatment  for  tuberculosis  that 
has  been  advanced  is  that  advocated  by  Dr.  J. 
Blake  White  in  a  paper  read  before  the  Section 
on  Practice  of  the  New  York  Academy  of  Medi- 
cine.    In  addition  to  such  general  measures  as 
are  generally  agreed  upon  by  the  profession,  he 
employs  hypodermically  the  chloride  of  gold  and 
the  iodide  of  manganese,  given  in  a  1  per  cent 
solution  of  carbolic  acid.     The  preparations   of 
gold,  he  claims,  have  been  too  long  neglected  by 
the  profession,  though  their  value  has  been  rec- 
ognized from  time  to  time  by  some  of  the  high- 
est authorities.     Thus,  Roberts  Bartholow  extols 
their   efficacy  in   cancer,  scrofula,  syphilis   and 
chronic  Bright' s  disease,  and  at  the  same  time  he 
advances  the  important  observation  that  they  are 
singularly  apt  to  undergo  decomposition  in  the 
alimentary  canal ;  a  fact  which  may  explain  the 
inefficacv'of  the  remedy  when  used  internally, 
and  which  also  offers  the  strongest  reason  for  its 
hypodermic  use.    Under  any  circumstances,  how- 
ever, Dr.  White  believes  that  in  phthisis  the  hy- 
podermic method  is  the  only  proper  one  to  use 
for  medication,  as  the  overtaxed  digestive  system 
has  already  more  than  it  can  attend  to  in  dispos- 
ing of  the  food  taken  into  the  body.     He  coin- 
1  bines  manganese  with  the  gold  for  the  reason  that 
this  drug  has  been  found  to  have  so  excellent  an 
effect  in  improving  the  character  of  the  blood  and 
increasing  the  tone  of  the  general  condition. 

The  minimum  dose  of  the  fluid  employed  is 
one  drop,  and  this  should  always  be  given  as  the 
initial  injection.  The  remedy  appears  to  produce 
a  reaction  in  the  system  very  closely  resembling 
that  caused  by  the  Koch  lymph.  Afterwards,  it  is 
claimed,  there  is  increase  in  the  appetite,  followed 
In-  a  marked  improvement  in  the  general  nutri- 
and  later  by  an  amelioration  of  the  charac- 
teristic phthisical  signs.  In  three  illustrative 
cases  narrated  by  Dr.  White,  which  have  been 
under  treatment  since  December,  the  results,  as 
far  as  they  have  gone,  are  certainly  very  encour- 
aging. In  one  i'\  them  the  body  weight  has  m- 
uearlv  eight  pounds,  and  in  another  the 
amount  of  expectoration  has  diminished  from 
fourti  en  to  two  ounces  in  the  twenty-four  hours. 
These  patients  are  in  the  wards  of  Charity  Hos- 
pital   Blackwell's  Island,  and  have  been  seen  by 


i89i.] 


DOMESTIC  CORRESPONDENCE. 


427 


quite  a  number  of  other  physicians.  As  to 
whether  any  permanent  beneficial  results  will  en- 
siK-  it  is,  of  course,  entirely  too  soon  to  form  any 
opinion.  In  addition  to  phthisis.  Dr.  White 
states  that  he  has  found  the  hypodermic  use  of 
these  salts  of  gold  and  manganese  very  efficacious 
in  the  chronic  glandular  enlargements  and  sinu- 
ous abscesses  of  scrofula,  in  obstinate  chronic 
skin  affections,  especially  of  a  leprous  character, 
in  chronic  Bright's  disease,  and  in  persistent 
anaemia  and  the  cachexias  due  to  syphilis  and 
scrofula. 

The  sanitary  condition  of  our  public  schools 
has  of  late  received  a  good  deal  of  attention  on 
the  part  of  the  medical  profession.  To  this  sub- 
ject was  devoted  the  piincipal  part  of  the  report 
of  the  Committee  on  Hygiene  of  the  Medical 
Society  of  the  County  of  Xew  York  at  the  last 
annual  meeting  of  the  Society,  and  at  a  recent 
meeting  of  the  Section  on  Public  Health  of  the 
Xew  York  Academy  of  Medicine,  Dr.  Henry  D. 
Chapin,  who  industriously  collected  ;he  data  on 
which  that  report  was  based,  read  an  additional 
paper  on  the  same  subject.  He  said  that  of  the 
thirty-eight  separate  primary  schools  and  eighty- 
one  primary-  departments  in  grammar  schools  he 
had  investigated  eighteen  of  those  which  were 
known  to  be  most  defective,  and  that  in  ten  of 
these  he  had  found  a  condition  of  affairs  that 
was  simply  disgraceful.  His  description  of  one 
of  the  schools  on  Chrystie  street,  in  the  midst  of 
a  crowded  tenement-house  population,  which  may 
be  taken  as  an  example,  was  as  follows: 

"In  it  there  are  over  one  thousand  children  in 
the  primary  department,  which  is  housed  in  three 
buildings  occupying  the  lower  part  of  the  gram- 
mar school  building  at  Xo.  60,  an  old  rookery, 
formerly  a  tenement  house,  and  a  factory  on  Hes- 
ter street  that  has  lately  been  patched  up  for  this 
sen-ice.  The  children  attending  this  school  come 
from  the  poorest  families  in  this  densely  popu- 
lated neighborhood,  and  it  is  evidently  regarded 
in  consonance  with  the  fitness  of  things  to  give 
them  the  poorest  and  scantiest  of  accommodations. 
Although  the  school  was  visited  on  an  excep- 
tionally' bright  and  sunny  da}-,  eleven  of  the 
crowded,  stuffy  rooms  were  lit  by  gas,  which, 
with  the  poor  ventilation,  made  the  atmosphere 
almost  unbearable.  Even  the  main  room  was 
partially  lighted  by  gas,  the  windows  on  the 
right  opening  into  a  narrow  well,  at  the  bottom 
of  which  are  boys'  water-closets.  The  class- 
rooms in  the  tenement-house  and  factory  have  low 
ceilings,  are  generally  poorly  lighted,  and  are 
very  badly  ventilated.  It  is  difficult  to  compre- 
hend how  teachers  and  scholars  can  remain  for 
hours  in  the  polluted  air  of  these  rooms,  and  not 
become  ill.  In  the  latter  two  buildings  the  stair- 
w-ays  and  passages  are  narrow  and  tortuous,  and 
they  might  both  prove  a  veritable  fire-trap,  espe- 
cially as  thin  woodeu  partitions  are  used  to  sep- 


arate many  of  the  rooms.  It  would  be  absolutely 
impossible  to  empty  these  buildings  speedily  and 
safely  in  case  of  alarm.  Several  of  the  class-rooms 
have  no  desks.  There  is  a  small,  dark  play- 
ground in  the  basement.  Altogether,  this  school 
contains  a  combination  of  unhygienic  conditions 
that  has  probably  been  rarely  equalled  in  a  build- 
ing devoted  to  such  a  purpose." 

In  speaking  in  general  Dr.  Chapin  said:  "The 
ventilation  of  the  primary  schools  is  dangerously 
defective,  and  the  cubic  air  space  allowed  to  each 
pupil  is  insufficient.  In  the  three  lower  classes 
the  prescribed  allowance  of  space  to  each  pupil  is 
70  cubic  feet,  and  in  the  three  higher  grades,  80 
feet;  while  in  the  four  lower  grades  of  the  gram- 
mar classes  the  allowance  is  90  feet,  and  in  the 
four  higher  grades,  100  feet.  The  Board  of 
Health  requires  that  in  tenement- houses  the 
allowance  shall  be  at  least  400  cubic  feet,  and  in 
some  cases  6co  cubic  feet,  to  each  person.  400 
cubic  feet  are  required  for  each  lodger  in  the  lodg- 
ing-houses of  this  city.  There  is  not  a  city  in 
the  country  that  requires  such  a  small  num- 
ber of  square  feet  and  cubic  feet  per  pupil  as 

Xew  York  in  its  public  schools The  life 

conditions  of  thousands  of  poor  children  in  tene- 
ment-houses are  hard  enough.  It  is  the  duty  of 
the  city  to  see  to  it  that  their  bad  environment  is 
not  continued  in  the  schools.  As  children  grow 
older,  and  growth  is  not  so  active,  the  system 
loses  this  susceptibility  to  noxious  influences.  In 
young  children,  however,  where  unhygienic  con- 
ditions prevail,  the  constitution  will  surely  be 
weakened  and  the  effects  particularly  disastrous." 

The  Superintendent  of  School  Buildings,  who 
was  present  on  this  occasion,  explained  that  the 
unfortunate  condition  of  affairs  referred  to  was 
due  principally  to  the  fact  that  the  Board  of  Edu- 
cation was  able  to  obtain  from  the  city  but  a 
small  proportion  of  the  funds  which  were  neces- 
sary to  carry  out  its  work  properly.  During  the 
past  four  years,  however,  no  less  than  twenty- 
seven  new  school  buildings  had  been  erected,  in 
whose  accommodations  '  and  appointments  the 
medical  profession  would  find  nothing  to  criti- 
cise. In  reply,  Dr.  Alexander,  the  Secretary  of 
the  Section,  said  that  to  the  physicians  of  Xew 
York  it  made  but  little  difference  who  was  re- 
sponsible for  the  evils  existing  in  the  schools,  and 
that  it  was  simply  their  duty  to  demonstrate  these 
evils  scientifically  and  iucontrovertibly  until  pub- 
lic sentiment  should  demand  their  abolition. 

It  would  appear,  however,  that  Xew  York  is 
not  the  only  place  where  school- houses  are  not 
all  models  of  hygienic  perfection.  The  Hudson 
County  I  X.  J.)  Board  of  Health  recently  declared 
one  of  the  public  schools  of  Jersey  City  to  be  in 
such  a  bad  sanitary  condition  as  to  require  the 
immediate  attention  of  the  city  school  authorities. 
A  reasonable  time  having  been  allowed  to  pass, 
I  and  nothing  whatever  having  been  done  to  im- 


428 


SPECIAL  CORRESPONDENCE. 


[March  21. 


prove  the  premises,  the  Board  of  Health,  at  its 
last  meeting,  very  properly  ordered  the  school  to 
be  at  once  closed.  p.   b.  p. 


NECROLOGY. 


Dr.  Stephens  G.  Cowdry,  Surgeon  U.  S.  A., 
died  in  New  York  City  Feb.  22,  aged  52  years. 
He  was  a  native  of  New  Hampshire,  and  ap- 
pointed from  New  York  in  1868.  He  had  been 
on  sick  furlough  since  last  December,  having  left 
his  post  at  Santa  Fe  at  that  time  in  order  to  con- 
sult with  friends,  medical  and  others,  in  the  East, 
in  the  interests  of  his  health.  The  cause  of  his 
death  is  assigned  to  heart-failure. 

Dr.  John  A.  Mead,  of  Pearlington,  Miss.,  died 
at  the  Hospital  Hotel  Dieu,  New  Orleans,  La.,  on 
January  30,  1891.  He  was  born  in  Portland, 
Me.,  July  16,  1842,  educated  at  Harvard  Medical 
School,  Boston,  and  graduated  June  30,  1869. 
He  had  been  a  sufferer  from  abscess  of  the  liver, 
but  finally  succumbed  to  an  attack  of  bronchial 
pneumonia.  He  was  a  member  of  the  American 
Medical  Association  since  1885, 

Dr.  Forrest  W.  Brayton. — The  sad  news  is 
announced  of  the  sudden  death,  in  Cincinnati,  of 
Dr.  Forrest  W.  Brayton.  In  January,  1890,  Dr. 
Brayton  went  to  Toledo  and  associated  himself 
with  Dr.  W.  W.  Jones,  in  the  practice  of  medi- 
cine, and  at  once  became  a  favorite  with  all  with 
whom  he  came  in  contact.  He  was  successful 
from  the  beginning,  and  had  an  extremely  bright 
future  before  him.  But  sickness  came,  and  some 
months  ago  he  was  obliged  to  give  up  his  work. 
Since  then  he  has  been  traveling,  trying  to  regain 
his  lost  health,  but  without  avail ;  death  came 
and  ended  his  career,  so  auspiciously  begun. 

Dr.  Brayton  was  only  34  years  of  age,  his  home 
being  in  Carey,  Ohio.  He  was  a  member  of  the 
Northwestern  Ohio  Medical  Association,  of  which 
he  was  at  one  time  Vice-President,  and  later  Sec- 
retary. He  was  also  a  member  of  the  Ohio  State 
Medical  Society,  of  the  American  Medical  Asso- 
ciation, of  the  American  Microscopical  Society, 
and  of  the  Toledo  Medical  Association. 

John  S.  Messersmith,  Medical  Director  U.  S. 
N.,  retired,  died  at  Lancaster,  Pa.,  Feb.  16,  aged 
81  years.  He  was  commissioned  by  President 
Andrew  Jackson  in  1837,  and  served  in  Commo- 
dore Perry's  first  expedition  to  Japan,  as  well  as 
during  the  Mexican  and  Civil  wars.  He  was  re- 
tired in  1872. 

Dr.  Marius  Duvall,  Medical  Director  of  the 
U.  S.  Navy,  with  rank  of  Commodore,  retired, 
died  suddenly  on  Februar}'  21  at  his  home  in  Bal- 
timore.    He  was  nearly  73  years  of  age. 


SPECIAL  CORRESPONDENCE. 


To  the  Editor: — It  affords  me  much  pleasure  to  inform 
vim  that  our  bill  repealing  the  charter  of  the  Medical 
and  Surgical  College  of  this  State  has  been  passed  by  the 
Legislature  anil  approved  by  Governor  Abbett.  It  is 
hardly  necessary  for  me  to  say  that  this  Board  feels  that 
it  lias,  in  the  first  year  of  its  existence,  done  something 
towards  the  purification  of  the  medical  profession,  not 
only  in  the  State  of  New  Jersey,  but  in  its  sister  States. 
Wm.  Terry  Watson, 
Sec'y  State  Board  of  Medical  Examiners. 

Jersey  City,  X.  J.,  March  II,  1S91. 


Shall  The  Journal  he  Removed  to 
Washington  ? 

THE  ACTION  OF  THE  CHATTANOOGA  MEDICAL  SOCIETY. 

At  a  regular  meeting  of  the  Chattanooga  (Tenn.)  Med- 
ical Society,  March  6,  1S91,  the  following  resolution  was. 
passed,  viz. : 

Whereas,  An  effort  will  be  made  at  the  next  meeting  of  the 
American  Medical  Association  to  move  The  Journal  from  Chicago 
to  Washington,  and 

Whereas,  We  believe  it  to  be  for  the  best  interestsjfof  The 
Journal  to  remain  where  it  is  :  Therefore, 

Be  it  Resolved,  That  we  urge  all  Tennessee  delegates  to  vote  for 
110  change  to  be  made  in  the  home  of  The  Journal. 

Fred.  B.  Stopp,  M.D.,  Secy. 


Till     ACTION  OK  Tin:  WAYNE  COUNTY  MEDICAL   SOCIETY. 

At  a  regular  meeting  of  the  Wayne  County  (Ind.)  Med- 
ical Society,  held  on  the  12th  iust.,  Dr.  L.  C.  Johnson 
moved  : 

That  it  is  the  sense  of  this  Society  that  the  office  of  The  Journal 
of  the  American  Medical  Association  ought  not  to  be  removed 
froxn  Chicago  to  Washington  at  this  time,  and  that  the  delegates, 
frmi  this  Society  to  the  next  meetingoft"e  American  Medici1.  Asso- 
ciation are  hereby  instructed  to  vote  against  such  removal.^ 

After  full  interchange  of  views  of  members  on  the  sub- 
ject the  motion  was  unanimously  adopted. 

G.'H.  Grant,  M.D., 
Sec'y  Wayne  Co.  Med.  Society. 

Richmond,  Intl.,  March  13,  1S91. 


To  the  Editor: — I  am  most  unalterably  opposed  to  the- 
proposed  change. 

It  is  very  evident  that  the  movement  for  the  changer 
from  Chicago  to  Washington  has  had  its  origin  in  the 
minds  of  some,  who  are  very  reluctant  to  admit  the  fact 
which  should  be  plainly  apparent  to  all,  that  not  only 
the  centre  of  population  but  the  financial  and  intellectual 
centres  are  surely  moving  westward.  Nothing  worthy 
the  name  of  argument  has  as  yet  been  advanced  in  favor 
of  it,  neither  can  there  be,  for  there  is  none  to  offer. 

Some  of  the  reflections  which  have  recently  been  cast 
upon  the  management  of  The  Journal,  and  upon  the 
character  of  its  contents,  have  been,  to  say  the  very- 
least,  uncalled  for  and  out  of  place.  The  profession  as  a 
whole  is  not  only  well  pleased  with  The  Journal,  but 
is  proud  of  it,  and  in  my  judgment  with  the  best  of  rea- 
sons. I  turn  to  my  old  volumes  of  the  London  Lancet* 
the  American  Journal  of  Medical  Sciences,  and  others. 
ami  search  in  vain  for  anything  so  nearly  representing; 
and  embodying  advanced  thought  and  progress  in  all  de- 
partments of  the  profession. 

No  !  Leave  it  where  it  is,  in  Chicago,  the  eighth  won- 
del  of  tin-  world,  destined  to  be,  within  the  lifetime  of 
thousands  now  living,  the  greatest  city  upon  the  Con~ 
threat.  I  would  leave  it  in  Chicago  also  because  itsj 
great  and  growing  success  has  already  been  achieved! 
there,  and  that  city  is  the  home  of  many  of  its  best  ami 
earliest  friends,  one  ill  particular,  whose  name  I  need  m-.t 
mention.     There  are  no  end  of  arguments  that  could  r>e 


iS9i.] 


SPECIAL  CORRESPONDENCE. 


429 


advanced  against  the  change,  but  the  facts  have  been  so 
ably  and  unanswerably  set  forth  by  recent  writers  that  I 
will  not  enlarge  upon  the  theme. 

There  seems  good  reason  to  believe  that,  in  many  re- 
spects, the  welfare  of  The  Journal  would  he  jeopardized 

by  the  consummation  of  the  proposed  change,  and  I  have 
little  fear  that  the  small  and  obscure  band  of  "kickers" 
can  succeed  in  the  consummation  of  this  folly. 

Luther  Brown,  M.D. 

Rockford,  Iowa,  March  3,  1S91. 


To  the  Editor:— \n  my  opinion  Tin-:  JOURNAL  should 
remain  where  it  is.  It  is  centrally  located  and  prosper- 
ous. Chicago  bids  fair  to  become  one  of  the  great  cen- 
tres of  learning,  generally  and  specially.  Sooner  or 
later,  its  great  clinical  advantages  will  go  far  toward 
helping  to  make  it  one  of  the,  if  not  the  centre  of  medi- 
cal learning.  J.  B.  Walker,  M.D. 

Effingham.  111.,  February  26,  1S91. 


there  cannot  be  a  doubt  of  the  future  success  of  The 
JOURNAL,  for  its  financial  condition  is  01  a  sound  and 
enduring  basis,  while  its  editorial   management  has  al- 

n  of  the  highest  order.  Its  editorials  are  ' 
progressive,  broad  and  cosmopolitan.  While  its  attitude 
has  been  conservative  and  judicious,  it  has  assumed  a 
high  position  for  the  advancement  of  the  whole  domain 
of  medicine.  The  aim  of  The  Journal  has  been  of  a 
high  and  lofty  character  in  the  exposition  of  thi 
principles  of  the  Code  of  Medical  Ethics.  It  has  also 
been  a  most  potent  factor  in  the  effort  to  raise  and  ele- 
vate the  standard  of  medical  education.  TheJouRNAL 
has  been  loyal  to  the  masses  of  our  noble  profession,  and 
in  this  it  has  been  as  free  from  the  manifestation  of  a  par- 
tisan spirit  as  the  most  liberal-minded  person  could  ex- 
pect, and  the  profession  will  give  their  loyalty  and  sup- 
port in  return.  By  all  means  leave  The  JOURNAL  in 
Chicago.  H.  H.  Middelkamp,  M.D. 

Warrenton,  Mo..  March.  5,  1S91. 


To  the  Editor: — Being  a  reader  of  The  JOURNAL,  and 

interested  in   the   question   of  its    removal  from  the  old 
stand,  I  was  curious  enough  to  figure  out  the  number  of 

r>  (members)  in  the  principal  Eastern 
compared  with  those   in   the  West,  and  I  find  Chicago 
leads,  them  all. 

The  number  of  subscribers  (members)  in  the  Eastern 
•  as  follows:  Philadelphia  109.  Washington  S2, 
New  York  77,  Baltimore  35,  Brooklyn  25,  and  Bi 
making  a  total  of  361  copies  distributed  in  six  cities  with 
a  population  of  nearly  five  millions.  In  the  Western 
171.  Cincinnati  S3,  St.  Louis  79,  Louis- 
ville 24,  Detroit  2S,  and  Cleveland  20,  making  a  total  of 
scribers  (members)  in  six  cities  of  a  population 
of  about  two  and  a  half  million.  The  Eastern  Males 
make  the  following  showing:  Pennsylvania  397,  New 
York  234,  Massachusetts  121.  New  Jersey  55.  and  Mary- 
land 44,  a  total  of  S51  in  a  population  of  nearly  sixteen 
millions.  In  the  West:  Illinois  406.  Ohio  372.  Indiana 
275.  Iowa  220,  and  Missouri  213.  being  a  total  of  L4S6 
subscribers  (members)  in  a  population  of  about  fourteen 
millions.  I  take  these  from  the  list  of  members  pub- 
lished in  Tin:  Journal  at  the  conclusion  of  the  last 
volume. 

So  far  as  the  advertisement  department  is  concerned, 
New  York  and  Chicago  seem  to  be  about  equally  divided. 
Washington,  however,  has  only  three  advertisements, 
viz. :  the  Medical  Department  of  the  University  of  George- 
town, J.  E.  Ruehsam,  and  that  of  the  Librarian  of  the 
Association.  I  have  simply  for  curiosity  found  these  6g- 
nres,  and  they  can  be  used  by  either  party  accordingly  as 
they  look  at  them.  Reader. 

Washington.  D.  C,  March  6,  1891. 


To  the  Editor: — Allow  me,  as  a  member  of  the  Amer- 
ical  Association  since  1S77,  to  enter  my  protest 
against  the  removal  of  The  JOURNAL  to  Washington.     I 
fail  to  see  any  good  reason  for  its  removal. 

H.  I-  M.I)..  L.R.C.P.E. 

1  iS  Grant  Ave.,  San  Francisco,  Cal.,  March  7,  1S91. 


To  the  Editor:— No!  Geo.  A.  Zei.i.er,  M.D. 

Peoria,  111.,  March  9,  1S91. 


To  the  Editor: — You  may  record  my  vote  iu  favor  of 
Chicago  as  the  home  of  The  JOURNAL. 

j.  D.  Cole,  m.d. 
Newborn.  Tenn.,  March  9,  1S91. 


To  the  Editor: — I  have  read  the  arguments  pro  and 
con,  anent  the  removal  of  The  Journal.  My  vote  is 
with  Chicago,  believing  it  to  be  to  the  best  interests  of 
The  Journal  to  remain  where  it  is.  Would  it  not  be 
well  to  request  every  member  of  the  Association  to  send 
a  postal  card  with  his  vote,  not  later  than  April  4.  I  be- 
lieve we  are  all  interested  enough  to  do  this,  and  iu  this 
way  it  will  not  cost  The  Journal  much  to  find  out  which 
side  has  the  majority.  Philip  Dickes,  M.D. 

Boundary,  Ind.,  March  7,  1891. 


To  the  Editor: — It  is  a  matter  of  no  urgent  import- 
ance to  the  readers  of  The  Journal  whether  it  be  pub- 
lished in  Chicago  or  in  Washington,  unless  it  can  be 
proven  that  it  can  be  made  a  better  journal  iu  Washing- 
ton than  it  can  in  Chicago.  The  members  of  the  Asso- 
ciation estimate  The  Journal  by  its  merits  and  hold  the 
Editors  and  Publishers  responsible  for  its  character.  It 
should  be  left  with  them  to  determine  where  it  would  be 
most  convenient  for  them  to  do  the  work  and  do  it  best. 
When  the  National  Government  makes  liberal  appropri- 
ations for  the  establishing  of  a  National  Medical  Institute, 
and  makes  provisions  for  professorships  by  which  exper- 
imental research  can  be  conducted;  where  hospitals, 
libraries,  museums  and  other  necessary  helps  are  pro- 
vided by  the  government,  as  is  done  in  some  other  coun- 
tries; then  I  sav  move  to  Washington. 

J.  W.  Harvey,  M.D. 

Indianapolis,  Ind.,  March  10,  1S91. 


To  the  Editor: — Please  allow  me  to  record  my  vote  in 
favor  of  The  Journal  remaining  in  Chicago.  "  Let  well 
enough  alone!"  A  thousand  reasons  and  arguments 
might  be  offered  why  it  should  remain  iu  Chicago,  while 
as  many  could  be  given  against  its  removal.  "  Westward 
the  star  of  Empire  takes  its  course."  Chicago  is  cer- 
tainly a  great  medical  centre,  and  perhaps  the  greatest 
railroad  centre  iu  the  Union;  her  future  is  great,  so  that 


To  the  Editor: — Record  my  name  in  favor  of  removing 
The  Journal  to  Washington.  The  official  representa- 
tive of  the  profession  should  keep  as  closely  to  the  gov- 
ernment as  possible.  E.  T.  B.  Godfrey,  M.D. 

Camden,  N.  J..  March  10,  1S91. 


To  the  Editor: — The  location  is  of  much  less  interest 
than  the  character  of  The  Journal.  The  members  of 
Congress  are  very  careful  about  their  journal.  It  is  a 
record  of  their  doings.  It  is  a  photograph,  so  to  speak, 
of  each  individual  as  well  as  the  whole.  A  journal  goes, 
into  history  as  the  exponent  of  this  or  that  body  of  men. 
Now,  Sir,  I  submit  that  all  this  squabble  about  location, 
will  not  appear  upon  the  page  of  history  as  reflecting  a 
very  bright  halo  of  glory  from  the  A.  M.  A.  Therefore, 
I  move  the  previous  question.  Let  us  have  no  more  of  it. 
S.  E.  Hampton,  M.D. 

Milton,  Ky.,  March  12,  1S91. 


430 


SPECIAL  CORRESPONDENCE. 


[March  21, 


To  the  Editor: — I  cast  rny  vote  in  favor  of  The  Jour- 
nal remaining  in  Chicago,  the  best  place  for  it. 

L.  L.  Leeds,  M.D. 
Lincoln,  111.,  March  13,  1891. 


To  the  Editor: — In  reference  to  the  removal  of  The 
Journal  to  Washington,  I  have  a  high  appreciation  of 
the  Eastern  brethren  and  their  journals,  and  their  ability 
to  conduct  them.  I  have  just  as  high  an  appreciation  of 
the  profession  in  the  West,  as  I  have  of  those  in  the  East, 
and  regard  them  equally  competent  to  conduct  The 
Journal  as  the  former,  and  therefore  object  to  the  re- 
moval of  The  Journal  from  Chicago  to  Washington,  as 
a  useless  and  needless  expense,  besides  the  accompany- 
ing loss  of  talent  which  would  follow. 

J.  W.  Craig,  M.D. 

Mansfield,  O.,  March  12,  1891. 


To  the  Editor:— Dr.  Comegys'  letter  in  last  week's 
Journal  was  a  most  agreeable  surprise  to  me.  I  feel 
that  he  has  given  a  new  interest  to  the  subject,  and  made 
in  realitj'  a  most  convincing  plea  to  have  The  Journal 
remain  where  it  is.  One  or  two  more  letters  of  this  char- 
acter would  practically  fix  The  Journal  at  Chicago  for 
at  least  a  generation  to  come. 

While  the  text  of  his  letter  seems  to  favor  a  removal  to 
Washington,  the  reasons  he  urges  are  the  very  strongest 
which  have  been  published,  showing  the  necessity  of 
leaving  The  Journal  where  it  is. 

The  charge  of  conservatism  and  want  of  aggressive 
spirit  is  the"highest  compliment  he  could  pay  to  the  pres- 
ent management.  The  unwillingness  of  the  managers  to 
select  a  highly  competent  editor  to  direct  things,  is 
equally  flattering;  the  history  of  medical  journalism 
shows*  that  only  through  prudent  conservatism,  and 
with  a  non-aggressive  spirit,  can  any  journal  hope  to  sur- 
vive the  perils  of  childhood.  The  sagacity  of  the  man- 
agers is  commendable  who  early  recognized  that  highly 
competent  editors  were  not  on  the  market,  but  were  pro- 
ducts that  had  to  be  grown;  also  that  the  very  laudable 
ambition  to  attain  an  exalted  position,  and  become  the 
leading  journal  in  the  country,  was  also  a  matter  of 
growth  hardly  attainable  in  eight  years— especially  in 
view  of  the  historical  fact  that  for  nearly  half  a  century 
journals  in  Boston,  New  York,  and  Philadelphia  have 
sought  to  attain  this  position,  sustained  by  capital,  enter- 
prise, and  very  superior  iutelligence.  Yet  it  is  by  no 
means  clear  that  any  one  of  these  journals  lead  all  the 
others,  or  have  attained  the  exalted  position  of  the  great 
journal  of  the  country. 

It  would  appear  to  be  of  the  nature  of  a  miracle  to  ex- 
pect a  journal  depending  entirely  on  the  good  will  of  an 
association,  and  in  the  face  of  over  a  hundred  rival  jour- 
nals, to  become  independent,  and  attain  a  degree  of  solid- 
ity and  leadership  that  would  command  the  Association, 
in  eight  years.  It  took  over  a  quarter  of  a  century  of  ex- 
perience for  the  British  Medical  Journal  to  attain  this, 
and  many  journals  of  longer  experience  sustained  by 
large  capital  and  shrewd  management  have  not  yet  ac- 
complished it. 

It  will  be  new  to  practical  business  men,  that  the  con- 
sciousness of  the  National  Capital  is  of  so  much  impor- 
tance in  the  life  of  a  strugglingjournal.  While  this  power 
in  Chicago  may  not  equal  that  of  Washington,  the  value 
of  this  spirit  entity  would  rank  very  low  amongst  business 
men.      The  same  may  be  said  of  the  social   and   political 
at  Washington.    Experiments  in  the 
tion  of  journals  have  been  going  on  for  over  half  a 
Publishing    houses,    colleges,     societies,    men 
with  Capital,    and    ambitious   physicians   of    all     grades, 
eivable  p I  in  to  grow  and    build    up 
a  National  journal.       Change  of  location,    consolidation, 
;s  of  rates,  frantic  appeals  to  the  readers,  selling 
,,ut  to  advt  rtisers,  and  yet  all  failed. 


The  same  experiment  is  repeated  to  day,  and  if  Wash- 
ington offered  the  slightest  possible  advantage  over  Phil- 
adelphia or  New  York  or  Baltimore,  shrewd  men  would 
occupy  the  field  at  once.  If  Washington  could  infuse 
new  life  in  any  journal,  or  make  its  success  any  more 
certain  in  the  future, many  well  established  journals  would 
move  into  this  field  in  a  week.  Over  thirty  journals  are 
published  within  a  day's  ride  of  Washington,  and  not 
one  of  them  have  yet  discovered  that  this  city  offers  any- 
possible  inducement,  or  promise  of  success  for  the  publi- 
cation of  a  medical  journal. 

To  practical  men  who  know  what  medical  journalism 
is, there  is  only  one  road  to  success,  and  that  is  along  the 
line  of  prudent  conservative  management,  with  the  least 
possible  risk  in  any  direction.  The  change  to  Washing- 
ton is  a  risk,  it  is  leaving  a  certainty  for  an  uncertainty, 
and  the  hunt  for  an  ideal  editor  will  go  on  while  the 
world  lasts. 

Dr.  Comegys'  letter  comes  like  a  flash  light  along  the 
shore,  telling  us  of  the  danger  of  a  change  to  Washington 
and  warning  the  members  to  look  out  for  breakers. 

A  wild  rocky  beach  strewn  with  wrecks  of  journals  is 
in  sight,  and  I  ask  in  the  light  of  the  history  of  journal- 
ism 111  this  country,  what  reasons  have  we  to  expect  that 
the  change  of  location  and  change  of  management  will 
not  end  in  a  wreck  on  the  same  shore?  Will  The  Jour- 
nal escape  the  same  fate  which  has  befallen  others? 

There  can  be  no  doubt  that  Dr.  Comegys  was  obscure 
as  to  names,  and  that  the  central  idea  of  his  letter  was  to 
have  a  good  practical  journal  grow  up  where  it  is  at  pres- 
ent, and  be  an  honor  to  the  Association.  If  this  is  not 
clear  another  letter  from  Dr.  Comegys  will  settle  the 
difficulty  at  once.  T.  D.  Crothers,  M.D. 

Hartford,  Conn.,  March  16,  1891. 


To  the  Editor: — I  am  not  in  favor  of  the  removal  of 
The  Journal  from  Chicago  to  Washington,  because  I 
feel  confident  that  such  a  measure,  if  carried  out,  would 
be  a  rash  one,  and  would  prove  to  be  a  serious  detriment 
to  the  future  prosperity  of  The  Journal.  The  perma- 
nent establishment  of  The  Journal  at  Chicago,  and  the 
selection  of  Dr.  Davis  as  its  editor-in-chief,  gave  indica- 
tions of  a  grand  success  in  the  development  of  medical 
knowledge  and  practice,  and  in  the  evolution  of  a  journal 
that  should  be  second  to  none  in  this  country,  if  not  in  the 
whole  civilized  world,  and  of  a  journal  that  all  fair-minded 
persons  would  regard  as  worthy  of  its  distinguishing  title, 
"Our  National  Medical  Journal."  That  these  anticipa- 
tions have  been  largely  met  there  can  be  no  question.  We 
have  ample  proof  that  The  Journal  has  been  extensive- 
ly read,  and  the  reports  of  cases  have  been  gleaned,  in- 
corporated in  other  papers  published  not  only  in  our  own 
language,  but  also  in  the  languages  of  other  couutries. 

Some  fault  has  been  found  because  all  the  papers  pub- 
lished have  not  been  up  to  certain  individual  standards. 
In  answer  to  this  I  need  only  say  that  the  appearance  of 
such  articles  in  our  journals  is  not  so  much  the  fault  of 
the  editorial  staff  as  it  is  from  the  crudeuess  of  many  of 
the  theories  of  the  medical  profession  generally.  The 
profession  was  not  made  for  The  Journal;  The  Jour- 
nal is  but  a  mere  reflection  of  the  methods  of  practice 
of  the  individual  members  composing  the  Association. 
Since  the  American  Medical  Association  was  founded, 
and  more  especially  within  the  last  decade,  there  have 
been  organized  many  different  associations  composed  of 
specialists.  The  peculiar  standards  of  many  of  these 
have  directed  the  attention  of  their  members  toward  the 
preDaration  of  papers  in  accordance  with  their  own  re- 
quirements, to  be  included  in  volumes  of  their  own  pub- 
lication. Notwithstanding  all  these  drawbacks,  the  Am- 
erican Medical  Association  has  had  the  good  fortune  to 
be  able  to  publish  some  as  c aiclulh  prepared  papers  as 
were  «  ver  offi  red  as  contributions  to  associations  of  such 
special  class. 

Should  we  change  our  location  of  publishing  to  Wash- 


I89i.] 


MISCELLANY. 


43i 


ington,  what  guaranty  would  there  be  that  our  journal, 
which  was  not  established,  of  course,  for  a  clique,  class, 
or  for  any  special  hospital  staff,  or  for  political  incum- 
bents, but  rather  to  be  a  National  journal,  would  be  bet- 
ter enabled  to  eradicate  the  evils  that  have  been  charged 
against  it,  to  say  nothing  of  inclining  the  risk  of  sinking 
below  the  standard  to  which  it  has  already  attained?  We 
cannot  afford  to  try  the  experiment.  The  profession  of 
Washington,  though  counting  among  its  members  sev- 
eral worthy  and  distinguished  lights,  is  not  specially  fa- 
mous for  organizing  and  maintaining  medical  journal- 
ism. The  city  itself  is  not  a  great  centre;  it  is  too  far 
east.  It  is  true  that  Washington  is  our  National  Capital; 
it  is  also  true  that  it  is  the  rendezvous  of  a  large  class  of 
politicians  and  office-holders  who  can  only  thrive  by  hav- 
ing their  hands  in  range  of  the  public  purse.  From  such 
we  should  be  forever  divorced. 

Something  has  been  said  relative  to  the  Medical  Libra- 
ry and  the  Museum  at  Washington.  In  regard  to  that 
argument,  I  fancy  that  the  supposed  advantages  of  such 
helps  are  more  theoretical  than  practical.  Their  collec- 
tions, for  authors  of  larger  works  and  for  students  of  spe- 
cial study,  will  always  prove,  no  doubt,  to  be  of  priceless 
value.  For  editors  who  are  to  keep  abreast  of  the  times, 
and  who  are  to  inspect  and  supervise  papers  for  a  weekly- 
journal,  I  fail  to  see  how  these  great  collections  can  be  of 
all-important  service. 

That  Chicago  is  a  good  field  and  is  abundantly  able  and 
ready  to  sustain  a  first-class  journal,  no  one  can  deny. 
The  city  is  of  sufficient  distance  from  Boston,  New  York, 
Philadelphia,  etc.,  as  not  to  interfere  with  those  local 
centres.  The  location  of  Chicago  has  given  the  city  a 
strong,  healthy  and  marvellous  growth.  The  medical 
profession  of  Chicago  stands  high.  I  have  only  to  in- 
stance the  reports  and  proceedings  of  her  Gynecological 
Society  to  corroborate  this  statement.  Its  Transactions 
are  the  very  models  of  what  such  a  Society  should  pre- 
sent. Let  us,  then,  retain  our  old  base  of  operations, 
ever  seeking  to  uphold  the  standard  of  our  Journal,  for 
in  so  doing  we  are  confident  that  we  have  a  rich  and  bril- 
liant future  before  us. 

Augustus  P.  Clarke,  M.D. 

Cambridge,  Mass.,  March  8,  1S91. 


To  the  Editor: — It  would  seem  from  the  number  of 
opposing  voices  that  the  proposition  to  remove  The 
Journal  from  Chicago  to  Washington  is  overwhelm- 
ingly snowed  under.  This,  however,  does  not  prove  that 
the  minority  who  favor  the  change  is  in  the  wrong.  Be- 
tween the  lines  of  all  these  staunch  advocates  of  Chicago 
a  strong  sectional  bias  is  plainly  visible.  Whenever  sec- 
tional prejudices  are  permitted  to  rule,  then  all  hope  of 
a  judicial  frame  of  mind  is  gone. 

The  geographical  or  population  argument,  which  has 
been  so  strongly  emphasized  by  nearly  all  who  oppose 
the  change,  really  has  no  place  in  this  question. 

The  question  is  not  a  commercial  or  a  financial  one, 
much  less  is  it  a  question  of  noses.  All  these  would  have 
great  weight  were  a  bank,  a  manufacturing  or  a  pork- 
packing  establishment  to  be  located,  but  in  the  selection 
of  a  suitable  place  for  publishing  a  scientific  journal  they, 
in  my  opinion,  ought  not  to  enter. 

It  is  simply  a  question  of  "the  eternal  fitness  of  things." 
The  Journal  is  a  representative  sheet,  the  mouthpiece 
of  the  medical  profession  of  the  United  States,  and  as 
such,  it  ought  to  have  its  home  at  the  Capital  of  the  Na- 
tion. It  should  not  be  associated  or  identified  with  the 
name  of  any  town,  city  or  section,  however  mighty  it 
may  be,  save  only,  the  Capital  City  of  the  whole  country. 

Of  course,  there  are  many  other  good  reasons,  why  the 
The  Journal  should  be  issued  here.  The  fact  might  be 
cited,  that  Washington  is  fast  becoming  a  centre  of  liter- 
ary  and  scientific  culture.  Every  year,  men  and  women 
possessing  attainments  in  these  directions  come  from  all 
parts  of  our  land,  and  either  settle  here  permanently,  or 


for  a  portion  of  the  year.  They  find  in  the  great  Con- 
gressional Library,  in  the  Smithsonian  Institution,  in  the 
National  Museum,  and  in  the  different  departments,  are 
untold  wealth  ol  materials  suitable  for  their  study  and 
investigation.  Men  of  all  shades  of  political  or  religious 
opinions,  inventors,  people  with  various  literary  scientific 
bents  are  wont  to  visit  the  National  Capital  for  an  ex- 
change of  views  or  for  recreation.  While  everything  of 
this  sort  is  centering  and  crystallizing  in  Washington, 
would  you  have  the  medical  profession  make  for  herself 
a  capital  elsewhere?  London,  Paris,  and  Berlin  and  other 
cities  of  Europe,  is  each  the  literary,  scientific  and  medi- 
cal, as  well  as,  the  political  capital  of  its  respective  coun- 
try; why  should  Washington  be  an  exception  in  this 
respect? 

I  am  fully  aware  that  some  men  are  so  provincially  in- 
clined as  to  lose  their  appetite  when  away  from  home  or 
from  their  accustomed  place  at  table,  or  fail  to  relish  the 
news  of  the  day,  unless  dished  up  by  their  favorite  news- 
paper, but  it  is"  to  be  hoped  that  these  little  peculiarities 
and  prejudices  will  not  be  permitted  to  sway  the  judg- 
ment in  selecting  a  permanent  and  suitable  home  for 
The  Journal.    "  J.  W.  Shivelv,  M.D. 

Washington,  D.  C,  March  16,  1891. 


To  the  Editor:  -Having  looked  the  ground  all  over 
fairlv  and  carefully  I  have  come  to  the  conclusion  that 
there  is  no  place  better  fitted  for  its  publication  than 
Chicago.  There  are  many  reasons  why,  but  as  they  are 
familiar  to  all  I  will  not  rehearse  any. 

E.J.  Tidd,  M.D. 

Clark,  Pa.,  March  12,  1891. 


To  the  Editor:— I  vote  to  have  The  Journal  remain 
at  Chicago.  I  appreciate  its  weekly  visits,  and  hope  its 
era  of  prosperity  will  constantly  increase. 

J.  A.  Hines,  M.D. 

Van  Wert,  O.,  March  13,  1S91. 


To  the  Editor:— -Why  should  we  move  The  Journal 
to  Washington?  It  is  a  great  political  centre  and  noth- 
ing more.  We  do  not  want  The  Journal  entangled  in  the 
wire-pulling  of  medical  politicians.  The  Journal  is  the 
expression  of  the  American  Medical  Association,  and  not 
of  self  seekers  in  politics.  Certainly  the  "  original  work" 
could  not  be  improved  by  locating  it  at  Washington.  I 
do  not  know  of  much  lasting  original  research  coming 
from  a  political  centre.  The  men  in  such  places  are  usu- 
ally too  busy  in  self  seeking  to  work  very  hard.  By  all 
means  keepTHE  Journal  in  Chicago. 

James  T.  Jelks,  M.D. 

Hot  Springs,  Ark.,  March  13,  1891. 


MISCELLANY. 


Dr.  Hosmer  Allen  Johnson.— The  following  resolu- 
tions were  adopted  by  the  Faculty  of  the  Chicago  Medi- 
cal College  at  a  meeting  held  on  February  28,  1891: 

Resolved,  That  in  the  deatli  of  Hosmer  Allen  Johnson.  M.D., 
LL.D.,  the  Chicago  Medical  College  has  lost  the  services  of  one  of  its 
founders  and  most  active,  able  and  eloquent  teachers;  the  North- 
western University  one  of  its  wisest  Trustees  and  Councillors:  the 
medical  profession  one  of  its  most  learned,  honorable  and  influen- 
tial members;  and  the  community  one  who  for  nearly  forty  years 
has  been  an  active,  skilful  and  untiring  benefactor  to  the  suffering, 
alike  in  peace,  in  war,  and  in  the  midst  of  the  direst  of  conflagra- 
tions. 

..'.  That  to  his  bereaved  family  and  friends  we  tender  our 
most  sincere  and  abiding  sympathy,  and  the  assurance  that  their 
temporal  loss  is  his  eternal  gain. 

Resohed,  That  the  Secretary  of  the  Faculty  furnish  a  copy  of  the 
foregoing  resolutions  to  the  family  of  the  deceased,  and  to  the  med- 
ical and  other  periodicals  of  this  citv. 

N    S.  Davis.  M.D..  LL.D., 
Edmund  Andrews,  M.D..  LL.D., 
Ralph  N   Isham   A.M..  M.D. 

Committee. 


432 


MISCELLANY. 


[March  21,  1891. 


letters  Received. 

Allison.  la..  Bank  of  Allison. 

Alma,  Mich.,  Dr.  L,  J.  Belknap. 

Alma  Center,  Wis.,  Dr.  J.  R.  Breakey. 

Ansonia,  Conn.,  McArthur  Hvpophosphite  Co. 

Asheville.  N.  C,  Dr.  Carl  von'Ruck. 

Athens,  Ga.,  Dr.  J.  H.  Goss. 

Austin,  Texas,  Dr.  Q.  C.  Smith. 

Bakersfield.  Cal.,  Dr.  C.  A.  Rogers. 

Baltimore.  Md..  Baltimore  Medical  College,  Dr.  R.  D.  Cole. 

Bedford,  Pa.,  First  National  Bank. 

Bertrand,  Neb.,  Dr.  H.  E.  Harrington. 

Binghampton,  X   V     Dr.  J.  M.  Farrington. 

Birmingham,  Ala.,  Dr.  W.  E.  B.  Davis,  First  National  Bank. 

Birmingham,  Conn.,  Dr.  C.  H.  Piuney. 

Boston,  The  Press  Clipping  Bureau. 

Brainerd,  Minn.,  Dr.  J.  H.  Hunt. 

Brookline,  Mass.,  Dr.  Walter  Channing.  Dr.  H.  A.  Martin  &  Son. 

Brooklyn,  N.  Y.,  Dr.  A.  Boyee  Marion.  Dr.  J.  B.  Mattison.  Dr. 
Wm.  McCo'llom,  Dr.  N.  B.  Page,  Dr.  H.  D.  Schenck,  Dr.  X.  B.  Sizer, 
The  Wm.  C.  Warner  Med.  Mfg.  Co.,  E.  D.  Homoeopathy  Pharmacy. 

Buffalo,  N.  Y..  Dr.  G.  E.  Fell,  Dr.  M.  B.  Folwell. 

Bryan,  O.,  Dr.  S.  B.  Crover. 

Carv,  O.,  Dr.  Asa  Brayton. 

Casileton,  111.,  Dr.  J.  R.  Holgate. 

Catskill.  N.  Y.,  P.  C.  Lewis. 

Chattanooga.  Tenn.,  Dr.  C.  F.  McGahan. 

Chicago,  III.,  C.  S.  Baker  &  Co.,  Dr.  F.  Billings,  Dr.  P.  F.  Chase. 
Dr.  Archibald  Church.  Dr.  E.  H.  Pratt,  Lord  &  Thomas,  Proofread- 
ing Bureau,  Physicians'  National  Supply  Co.,  Dr.  Joseph  Zeisler, 
Dr.  F.  E.  Waxharn. 

Coldwater,  Mich.,  Dr.  J.  M.  Bennett. 

Columbus.  O..  Siebert  '&  Lilly 

Cumberland.  Md.,  Dr.  F.  T.  McKaig. 

Denver,  Colo.,  Dr.  J.  B.  Devlin,  Dr.  Robert  Levy. 

Detroit,  Mich..  Dr.  C.  W.  Hitchcock,  Dr.  G.  W.  Stoner,  Parke, 
Davis  &  Co. 

Duluth.  Minn..  Dr.  S.  C.  McCormick. 

East  Greenville,  Pa.,  Perkiomer  National  Bank. 

Elkhart,  Ind.,  Dr.  F.  Eck<-lman. 

Ellsworth,  O.,  Dr.  R.  C.  Fausett. 

Eureka,  111.,  Dr.  C.  F.  Banta. 

Flippen,  Ky.,  Dr.  C.  E.  Reeves. 

Ft.  Atkinson,  Wis..  Dr.  N   P.  Stair. 

Ft.  Madison,  la.,  Dr.  W.  T.  Ecklev. 

Fort  Wavne,  Ind.,  Dr.  C.  B.  Stemen. 

Fort  Worth.  Texas,  Dr.  A   P.  Brown. 

Frenchtown.  X.  J.,  Iir.  E    K.  Deemy. 

Fremont,  O..  Dr.  C.  R.  Pontius. 

Galesburg,  111.,  First  Xational  Bank. 

Galveston.  Dr.  Geo.  Dock. 

Gavlord,  Minn.,  Dr.  D.  N.  Jones. 

Hampton,  la.,  Dr.  J.  H.  Hutchins. 

Hoboken,  X.  J..  Dr.  A.  W.  Herzog. 

Indianapolis,  Ind..  Dr.  O.  W.  Pfaff. 

Ipswich.  Mass.,  Dr.  W.  H.  Russell. 

Jacksonville,  111..  Ward  Bros. 

Kansas  City,  Mo.,  Dr.  J.  H.  Van  Eman. 

Laketown,"lnd  ,  I >r.  H.  C.  Moonev. 

Lancaster,  Pa.,  Dr.  C.  M.  Franklin. 

Lansing,  Mich.    Dr.  Henry  B.  Baker. 

Lebanon.  Pa.,  Dr.  J.  Steiner. 

Le  Mars.  Iowa,  Dr.  P.  L.  Brick. 

Louisville,  Kv  ,  Hinzen  &  Rosen.  R.  E.  Queen,  In  S  M. 
Renshaw.  Dr.  F.  W.  Samuel. 

Miamisburg,  O.   Clark.  Forbes  &  Cm. 

Manchester.  N.  H.:  Dr.  H.  B.  Burnham. 

McCredie.  Mo.:  Dr.  J.  M,  Tate. 

Medina,  X.  Y.:  Excelsior  Agency. 

Michigan  City,  Ind..  First  National  Bank. 

Milton  Grove",  Pa.,  Dr.  J.  G.  Kreider. 

Milwaukee,  Wis.,  The  R.  Hyde  Co.,  August  Spankers. 

Minneapolis,  Minn  ,  Union  National  Bank. 

Naples.  Italy.  La  Riforma  Medica 

Nashua.  N.  II..  Londonderry  Lithia  Spring  Water  Co. 

New  Haven,  Conn.,  J.  E.  Heaton. 

New  Orleans,  Dr.  M.  J.  Magruder,  Dr.  Geo.  N.  Monette. 

New  York  City,  J.  H.  Bates,  Eisner  &  Mendelson  Co.,  Meyrowitz 

Dr.]     H.  M.  Sell,  Henry  A.  Riley,  W.  A.  Towns 

end.  Dr.  J.  D.  McConnell,  Dr.  W,  A.  Hawes,  W.  P.  Clearv.  Dr.  E.  W. 

Iir    C.  B     Meding,  Dr     F.  Halves,    Dr.    L.   L.    Danforth, 

■     In    F    King,  I.  Haldenstein, Dr.  C   F    Korner,  B 

in  \  Co.    1  "   A   I..  Root,  Dr.  Aronson,  G.  E.  Stechert,  M. 

Volkmann,  Scott  ,\:  Bowne,  Dr.  a    h.  Goelet,  Dr.  C.   H.   Wi  is  b<  I 

G.    X.    Hanker,    Dr.   T.   J.    Currie,    Merchants     : 

:  rank. 

Norri-i  Dr.  1     X   Johnston. 

I  ind,  Md.,  Dr.  J.  L.  McComas. 

Omaha,  Neb.,  Dr.  j   E.  Clauss 

1  Ixfi  Cook. 

1'aris,   France,   Dr.   1    11    Barnard.  Dr.  1.  Astier,  Anno  Marie 

Philadelphia,  Dr.  Dwight,  Dr.  A.  L-  Hummell,  Dr  w  Peppei 
Di     H     V    Hare    Di     R    |    Dunglison,   University  of  Pa.  Press,  P 

Pilol  Point    !"•  \  .-    1 1'    I.  u    Smith. 

Quincy,  III.,  First  National  Hank,  Dr.  C.  W.  Rook. 

Richmond.  Ind,.  Dr,  F.  F,  Wells. 

Rochester     \     V  ,  Dr     B.   V,   Hovev. 

Rock  Rapids    [a  .  Dr     \.  M.  Vail   " 

Rutland,  III.,  Dr    Urn    (I.  Ensign, 


St.  Joseph,  Mo.,  Dr.  C.  E.  Fearl. 

St.  Louis.  Mo.,  A.  M.  Leslie  Surgical  Instrument  Co..  Lambert 
Pharmacal  Co.,  Henry'  Bernd  &  Co.,  J.  H.  Chambers  &  Co.,  Dr. "J. 
Steer. 

Scranton,  Pa.,  Dr.  T.M.  Kav. 

South  Bend,  Ind.,  Dr.  Wm.  C.  Winkler. 

Spokane  Falls,  Wash..  Dr.  D.  C.  Neumau. 

Springfield,  111..  Dr.  Wm.  G.  Eggleston. 

Tionesta,  Pa.,  Dr.  J.  W.  Morrow. 

Union  City,  Mich.,  Farmers'  National  Bank. 

Urbana.  Ind..  Dr.  W.  H.  Martin. 

Warrensburg,  O.,  Dr.  Wm    Mclntire. 

Washington,  D.  C,  Dr.  S.  C.  Busev,  Dr.  I.  C.  Rosse,  Dr.  L.  L 
Loomis,  Dr.  L.  Eliot,  Dr.  F.  L.  Magruder.  Dr.  McKim, 

Wessington,  Dak.,  Dr.  J.  Chancellor  Gilbert. 

\-onkers,  X.  Y.,  Dr.  G.  X.  Banker. 


Official  List  of  Changes  in  the  Stations  and  Duties  of  Officers  Serving 
in  the  Medical  Department,  U.  S.  Army,  from  March  ~,  1891,  to 
March  /j,  1801. 

RETIREMENT. 

Lieut.  Col.  Blencowe  E.  Fryer,  Asst.  Medical  Purveyor,  February 

PROMOTIONS. 

Major  Charles  R.  Greenleaf,  to  be  Lieut.  Col.  and  Asst.  Medical  Pur- 
veyor, February-  2 

Capt.  Charles  K.  Winne.  Asst.  Surgeon,  to  be  Major  and  Surgeon, 
February  22,  1S91. 

Capt.  Timothy  E.  Wilcox.  Asst.  Surgeon,  to  be  Major  and  Surgeon, 
February  24,  1S91. 

Capt.  Fred.  C.  Airisworth,  Asst.  Surgeon,  to  be  Major  and  Surgeon, 
February  27,  1891. 

Capt.  ValeVy  Havard,  Asst.  Surgeon,  to  be  Major  and  Surgeon,  Feb- 

Bv  direction  of  the  Secretary  of  War,  a  board  of  medical  officers,  to 
consist  of  Col.  Edward  P.  Vollum,  Chief  Medical  Purveyor;  Lieut. 
Col.  Dallas  Bache,  Surgeon:  Major  Alfred  C.  Girard,  Surgeon;  am! 
Capt.  Charles  M.  Gaudy.  Asst.  Surgeon,  is  constituted  to  meet  in 
New  Y'ork  City,  on  March  16.  1S91.  or  as  soon  thereafter  as  practi- 
cable, for  the  examination  of  candidates  for  admission  into  the 
Medical  Corps  of  the  Army,  and  such  other  business  as  the  Sur- 
geon-General may  desire  to  bring  before  it.  Par.  iS,  S.  n.  52,  A 
G.  O.,  Washington,  March  7,  1S91. 

Capt.  James  A.  Finley.  Asst.  Surgeon,  having  been  found  by  an 
Army  Retiring  Board  incapacitated  for  active  service,  on  account 
of  disability  which  is  not  the  result  of  any  incident  of  service,  is, 
by  direction  of  the  President,  wholly  retired  from  the  service  this 
date,  under  the  provisions  of  Sections  1252 and  1275,  Revised  Stat- 
utes, and  his  name  will  be  henceforward  omitted  Irom  the  Armv 
Register.     Par.  2,  S.  0.  54.  A.  G.  O.,  Washington,  Man  b 

Capt.  Henry  I.  Raymond,  Asst,  Surgeon,  is  relieved  from  duty  at 
Xewport  Bks..  Ky..  and  assigned  to  duty  at  Ft.  Thomas  Ky  re- 
porting in  person  to  the  commanding  officer,  Ft.  Thomas,  and  by 
letter  to  the  commanding  General,  Div.  of  the  Atlantic  By  li- 
rection  of  the  Acting  Secretary  of  War.  Par.  18,  S.  O.  54,  A  G.  1 1, 
Washington,  March  10,  1891. 

Official  List  of  Changes  in  the  Medical  Corps  of  11 
the  Two  Weeks  Ending  March  l.f.  1891. 

Surgeon  M.  L.  Ruth,  granted  one  month's  sick  leave. 

Asst.  Surgeon  S.  G.  Evans,  detached  from  Xaval  Academy,  and  to 
the  "  Monongahela." 

Surgeon  A.  F.  Price,  ordered  to  the  0.  S.  s.  "  Monongahela." 

Asst.  Surgeon  H.  X.  T.  Harris,  ordered  for  examination  prelimi- 
nary to  promotion. 

Asst.  Surgeon  George McC  Bicknell.  ordered  for  examination  pre- 
liminary to  promotion. 

P.  A.  Surgeon  Ernest  W.  Auzal.  ordered  to  the  l".  S,  S  "  Lancaster." 

Asst.  Surgeon  Jas.  H.  North,  Jr.,  ordered  to  the  U.  S.  S. 
ter," 

Surgeon   James  H.   Gaines,  ordered  before    the    Relirim 
March  12. 

P.  A.  Surgeon  G.  W.  Kite,  from  New  York  Hospital  and  to  the 
"  Lancaster   ' 

t\sst.  Surgeon  J.  H.  North,  Jr., detached  from  the 
wait  orders. 

Asst.  Surgeon  G.  T.  Smith,  from  the  "Independence"  and  to  the 
Mohican." 

Asst.  Surgeon  George  A    Lung,  from  the  "  Mohican"  an 
ingtou,  D.  C,  in  charge  of  insane  pair 

Stations  and  Duties  of  Medical 
v   Marine-Hospital  Service, for  the  Three  lie. 
February 
r.  A.  Surgeon  w.  J.  Pettus,  relieved  torn  special  dutj  as  *    ■ 

of  Immig!  Ordered  to  Marine  Hos- 

pital. Boston,  Mass      1  ,  ' 

of  absence  for  thirty  days. 

[\  relievi  I  from  duty  at  Cincinnati,  o. 

to  Marini    n  ispital,  New  York  City.     February 

Cofet    detailed  foi   special  duty  as  Inspector  of 
Immigrants,  Port  ol  Boston,  M.tss      February    0 
A-r    Surgeon  I    M    Eager,  assigned  to  temporary  duty  at  Cincin- 
nati. 0.     February  20,  1891. 

AITOIN  ]  Mr    M 

rhn  M.,  of  Pennsylvania,  commissioned  as  Asst.  Surgeon 
by  the  President    February  16,  loot. 


T  1 1  E 


Journal  of  the  American  Medical  Association. 

EDITED  UNDER  THE  DIRECTION  OF  THE  BOARD  OF  TRUSTEES. 
PUBLISHED    WEEKLY. 


Vol.  XVI. 


CHICAGO,  MARCH  28,    1891. 


No  13. 


ORIGINAL  ARTICLES. 


THE  INFLUENCE  OF  THE  POSITION  OF 
THE   PATIENT   IN  LABOR  IN  CAUS- 
ING UTERINE  INERTIA  AND 
PELVIC  DISTURBANCES. 

Read  before  the  Gynecological  Society  of  Boston,  December  u,  1800. 
BY  AUGUSTUS  P.  CLARKE,  A.M.,  M.D., 

OF  CAMBRIDGE,  MASS. 

It  has  been  generally  taught  that  during  the 
first  stage  of  labor  the  patient  may  be  allowed  to 
assume  that  position  which  she  considers  the  eas- 
iest for  herself.  Some  accoucheurs  encourage  the 
patient  not  to  take  to  the  bed  at  the  beginning  of 
labor,  but  for  the  influence  of  the  pressure  of  her 
own  hands  and  the  weight  of  the  fcetus  in  aiding 
flexion  of  the  head  and  in  promoting  dilatation 
of  the  cervix,  to  maintain  the  sitting  or  upright 
posture.  In  the  early  stage,  the  dorsal  position 
is  often  assumed ;  later,  for  convenience  in  mak- 
ing frequent  inspection  of  the  perineum,  in  as- 
sisting to  carry  out  certain  manipulative  proce- 
dures, and  in  giving  the  necessary  attention  to 
uterine  and  rectal  discharges,  the  left  lateral  pos- 
ture is  often  advised.  Some  place  the  patient 
on  the  side  to  which  the  occipital  presentation  is 
inclined.  Some  reverse  the  position  by  placing 
,  the  patient  on  the  side  toward  which  the  sinciput 
or  the  vertex  is  descending.  Women  of  the  lower 
classes  of  some  countries,  while  in  labor,  place 
themselves  on  their  hands  and  knees.  .  Other  po- 
sitions are  sometimes  assumed,  such  as  half-sitting 
or  partially  reclining  postures.  Some  women  per- 
sist in  standing  or  in  getting  on  their  knees. 
Formerly,  the  French  women  were  delivered 
while  in  the  dorsal  position,  with  knees  drawn 
up.  In  other  countries,  especially  among  the 
Aborigines,  or  among  the  half-civilized  orders, 
many  strange  and  singular  positions  have  been 
assumed  by  women  when  in  labor.  -Inquiry  into 
the  purpose  for  which  any  of  the  various  positions 
which  women  have  from  time  to  time  assumed 
while  in  labor,  will  show  that  the  choice  has  been 
made  more  from  the  force  of  custom,  from  caprice, 
ignorance,  and  from  a  blind  submission  to  author- 
ity— exercised  by  those  who  make  unwarrantable 
pretensions   to    skill    in    midwifery,    than   from 


knowledge  deduced  from  facts  gained  by  careful 
study  and  close  observation. 

The  left  lateral  posture,  with  thighs  drawn  up 
and  legs  flexed  upon  the  thighs,  the  shoulders 
projecting  forward  and  the  spine  curved,  has  been 
thought  to  be  more  favorable  for  relaxation  of  the 
psoac  and  other  muscles  traversing  the  brim  of 
the  pelvis.  This  position  has  also  been  thought 
to  be  more  favorable,  as  the  axis  of  the  en- 
trance of  the  pelvis  and  that  of  the  trunk 
would  be  on  the  same  line,  or  be  nearly  parallel. 
Those  who  place  their  patients  in  such  posture 
look  upon  the  phenomena  of  parturition  as  de- 
pendent on  mechanical  forces,  and  not  on  the 
physiological  function  of  the  uterus  and  the  pow- 
ers of  the  system  generally.  The  effectiveness  of 
the  uterine  pains  has  been  increased  by  change 
of  posture,  especially  after  the  patient  has  main- 
tained for  a  long  time  a  constrained  position. 
Under  such  circumstances,  a  mere  temporary  re- 
lief from  a  too  irksome  restraint  has  been  followed 
by  an  increase  in  the  general  character  of  the 
pains  which  has  more  than  counterbalanced  any 
deficiency  in  the  advantage  of  a  better  mechani- 
cal position.  Women  who  are  of  a  nervous  tem- 
perament often  find  it  exceedingly  difficult,  in  the 
second,  as  also  in  the  first,  stage  of  labor,  to  u  ndergo 
the  fatigue  of  any  one  position  for  a  considerable 
length  of  time.  The  vital  forces  of  the  system  gen- 
erally are  often  the  first  to  suffer,  and  this  fatigue 
quickly  extends  to  the  nervous  force  resident  with- 
in the  uterine  and  adjacent  muscular  tissue.  The 
exhausting  effects  of  a  constrained  position  cannot 
be  wholly  overcome  by  the  employment  of  anaes- 
thetics, for  often  the  only  manifestation  of  an  ex- 
pression of  the  baleful  effects  of  too  long  con- 
strained position  is  in  the  failure  of  the  power  of 
the  uterine  pains.  The  patient  then  begins  to 
complain  of  weakness,  she  appears  unable,  or  at 
least  is  unwilling,  to  move  or  to  alter  her  position 
in  bed.  She  may  call  for  ether;  if  she  is  indulged 
by  its  employment  the  beneficial  effects  which  fol- 
low are  the  result  of  its  stimulating  properties, 
and  from  change  of  position  for  its  administration. 
If,  unfortunately,  the  position  is  not  ruaterially 
altered,  and  the  second  stage  of  labor  is  not  near 
its  termination,  the  increased  power  in  the  pains 
derived  by  its  administration  will  soon  cease,  and 
the  patient  will  lapse  into  a  state  worse  than  the 


434 


INFLUENCE  OF  POSITION  IN  LABOR. 


[March  28, 


one  before  its  attempted  administration.  Fortu- 
nately, on  the  other  hand,  in  such  cases,  in  which 
ether  is  given  with  only  temporary  benefit,  early 
in  the  second  stage  of  labor,  it  is  often  deemed 
advisable  to  withhold  it  until  the  patient  regains 
more  or  less  consciousness.  The  outcries  of  the 
patient  then  for  more  ether,  and  the  changes  of 
position  in  bed  she  frequently  makes,  notwith- 
standing the  severe  restraint  imposed  upon  her 
by  the  attendants,  serve  to  increase  the  power  of 
the  pains  and  to  bring  to  happy  termination  the 
second  stage  of  labor. 

Besides  the  occurrence  of  uterine  inertia  from 
long-continued  position  of  the  patient  in  labor, 
other  disturbances  are  liable  to  arise.  The  effects 
of  the  blood  pressure,  and  the  gravitating  of  flu- 
ids toward  the  left  uterine  appendages  and  the 
peri-uterine  structures,  when  the  patient  occupies 
for  a  long  time  the  left  lateral  posture,  should  not 
be  overlooked.  Such  untoward  effects  are  par- 
ticularly apt  to  follow  in  cases  of  those  who  suffer 
from  cardiac  affections,  from  .disease  of  the  lungs, 
bronchial  tubes,  kidneys,  from  general  or  partial 
oedema,  and  from  deficient  circulation.  As  al- 
ready stated,  parturition  is  not  a  mechanical  but 
a  physiological  function,  dependent  upon  a  force 
having  its  origin  in  the  nerves  distributed  to  the 
uterine  tissue  and  to  the  system  generally.  What- 
ever, therefore,  tends  to  exhaust  the  general  sys- 
tem, interferes  with  the  normal  action  of  the 
parts,  and  disturbs  the  proper  function  of  the 
uterine  tissue.  When  such  disturbances  are  im- 
parted to  structures  outside  of  the  uterine  walls, 
they  are  not  easily  overcome,  but  leave  their  im- 
press more  or  less  indefinitely  on  the  parts  in- 
volved. The  great  impressibility — as  well  as 
sensibility — which  women  acquire  even  in  the 
early  stage  of  pregnancy,  is  well  shown  by  the 
development  of  that  peculiar  appearance  denom- 
inated mother's  marks  which  sometimes  occur  on 
the  cutaneous  surface  of  the  child.  It  is  not  only 
in  the  early  stages  of  pregnancy,  but  in  every  stage 
of  that  condition,  and  even  for  some  time  after 
delivery,  that  this  highly  sensitive  condition  ob- 
tains, leaving  its  impressibility  more  or  less  per- 
manently not  only  on  the  foetus,  but  also  on  her 
own  tissues  adjacent  to  the  uterine  structures. 

Among  the  puerperal  lesions  which  may  result 
from  the  lateral  posture  too  long  retained  are 
affections  of  the  bladder.  The  prolonged  pressure 
of  some  portion  of  the  foetus  on  the  sensitive 
bladder  arrests  to  a  considerable  degree  the  nor- 
mal action  of  that  viscus.  It  thus  weakens  its 
integrity — causes  inflammation  of  the  mucous 
surface.  The  inflammation  in  the  bladder  is 
prone  to  extend  backward  into  the  ureter.  The 
ureter  itself,  on  one  or  both  sides,  taking  on  in- 
flammatory processes  becomes  distended  with  un- 
healthy urine.  This  may  lead  to  rupture  into 
the  pelvic  tissue,  and  thus  give  rise  to  sloughing 
or  to  the  formation  of  abscess.      I   have  notes  of 


the  autopsy  in  the  case  of  Mrs.  E. ,  who  died  dur- 
ing the  third  week  after  delivery.  The  death  oc- 
curred after  second  confinement.  The  bladder 
throughout  its  entire  surface  was  tumefied,  red, 
and  covered  with  dark,  purulent  fluid.  The  pel- 
vis contained  a  quantity  of  semi-purulent  exuda- 
tion having  the  odor  of  urine.  The  left  ureter 
was  abnormally  distended,  it  was  inflamed  and 
was  found  to  have  undergone  rupture  at  a  point 
three  and  one-quarter  inches  from  the  base  of  the 
bladder.  The  ureter  on  the  right  side,  though 
somewhat  inflamed  from  the  contact  with  morbid 
urine,  was  not  greatly  distended.  The  history  of 
the  case  showed  that  the  patient  was  in  labor 
some  thirty-six  hours,  and  that  during  the  last 
twenty-three  hours  she  had  occupied  for  the  most 
part  the  left  lateral  posture.  The  pelvis  was  well 
formed  and  of  normal  dimensions.  The  child 
was  not  large.  It  was  born  alive  and  did  well. 
The  cause  of  the  delay  in  the  delivery  appeared  to 
be  owing  to  inertia  into  which  the  uterus  had  par- 
tially lapsed  quite  early  in  the  second  stage  of  labor. 
The  patient  had  suffered  from  chronic  cystitis  and 
from  marked  anteversion  of  the  uterus.  Recto- 
vaginal and  vesico-vaginal  fistulae  are  lesions 
which  now  and  then  occur  and  which  are  largely 
the  result  of  childbirth.  Emmet  mentions  two 
hundred  and  two  cases  that  were  admitted  to  the 
Women's  Hospital.  One  hundred  and  seventy- 
one  of  the  cases  were  caused  by  child-birth.  He 
says  the  average  duration  of  the  labor  completed 
from  rupture  of  the  membranes  was  58.69  hours. 
On  another  table  he  says  46.19  per  cent,  of  the 
cases  were  delivered  by  forceps,  and  that  the  aver- 
age duration  of  labor  was  68.55  hours.  Emmet 
does  not  coincide  in  the  popular  belief  that  in- 
strumental delivery  is  the  cause  of  fistulas.  He 
rather  attributes  their  occurrence  to  retardation 
in  the  progress  of  labor,  induced  by  negligence 
to  empty  the  bladder.  Though  he  recognizes 
over-distension  of  the  bladder  as  a  factor  in  the 
production  of  fistulae,  he  does  not  appear  to  be 
wholly  certain  as  to  that  condition  of  the  patient 
being  the  final  cause,  for  he  says  it  is  not  improb- 
able, since  the  averaged  time  is  so  long  before  the 
separation  of  the  sloughs  that  the  additional  force 
in  many  cases  necessary  to  effect  the  delivery  may 
be  the  exciting  cause  of  the  inflammation.  In 
six  cases  of  vesico-vaginal  fistulae  whose  histor- 
ies I  obtained,  the  additional  factor  could  not  be 
attributed  to  force  necessary  to  effect  delivery'. 
It  was  clearly  due  to  the  position  of  the  patient 
too  long  retained.  In  three  of  the  cases  the  pos- 
ition was  the  left  lateral,  in  two  the  dorsal;  in 
one  was  the  right  lateral  which  the  patient  per- 
sisted in  retaining  for  some  forty-four  hours. 

Among  the  other  inflammatory  conditions 
which  follow  confinement  are  those  of  the  uterine 
appendages.  Sometimes  we  have  salpingitis  on 
one  or  both  sides,  but  often  more  severe  on  one 
side.     Sometimes  the  morbid  process  comes  from 


i*9i.J 


MIGRAINE  FROM    EYE-STRAIN. 


435 


the  escape  of  blood  through  the  fimbriated  ex- 
tremity of  the  tube  into  the  pelvic  cavity.  Some 
times  we  have  following  confinement  an  haematic 
tumor  hi  cyst,  and  occasionally,  if  not  often, 
hsematosalpinx.  All  these  lesions  or  morbid  pro- 
Cesses,  whatever  be  their  predisposing  causes,  are 
influenced  more  or  less  by  posture  of  the  patient. 

Haemorrhage  from  the  lungs  and  fr.om  other 
organs,  and  from  the  vascular  tissues,  is  greatly 
influenced  by  position.  In  the  treatment  and  in  the 
prevention  of  such  symptoms  position  of  the  patient 
and  of  the  parts  must  always  he  a  factor  for  consid- 
eration. In  the  management  of  haemorrhage  and  ac- 
cidents peculiar  to  the  puerperal  state  position  of 
the  patient  becomes  of  still  more  consequence.  This 
is  rendered  so  not  only  on  account  of  the  extreme 
sensitiveness  of  the  organs  and  the  system  gen- 
erally but  also  on  account  of  the  development  of 
that  nervous  function  and  the  exhausting  exer- 
cise of  it  necessary  for  production  and  accomplish- 
ment of  parturition.  Another  condition  some- 
times following  labor  is  subinvolution  of  the 
uterus.  The  cause  of  this  condition  has  often 
been  ascribed  to  laceration  of  the  cervix.  Cases 
of  subinvolution  now  and  then  occur  in  which 
no  appreciable  laceration  can  be  found  to  have 
taken  place.  In  such  cases  in  the  absence  of  a 
history  of  an  injur)'  having  been  received  it  is 
usual  to  consider  the  cause  to  be  want  of  tone 
in  the  pelvic  venous  circulation. 

I  have  the  history  of  two  cases  of  subinvolution 
of  the  uterus,  in  which  there  was  no  laceratiouof 
the  cervix  nor  of  the  perineum.  Nor  was  there' 
any  reason  to  suspect  that  there  existed  in  either 
case  a  perverted  condition  of  the  system  gener- 
ally. Neither  patient  had  sustained  injury  im- 
mediately __ preceding  or  during  parturition.  In 
one  case  uterine  dyskinesia  was  also  a  trouble- 
some symptom.  In  the  other  case,  though  the 
subinvolution  was  not  so  pronounced,  there 
was  for  a  long  time  inability  to  walk  (uter- 
ine lameness).  There  was  an  increase  of  the 
tendon  reflex,  and  there  were  areas  of  much  sen- 
sitiveness in  the  vicinity  of  the  dorsal  and  lum- 
bar vertebrae.  The  first  patient  was  in  labor 
forty-nine  hours,  but  was  delivered  without  in- 
struments. She  occupied  for  the  most  part  the 
l^ft  lateral  posture.  The  second  patient  was  in 
labor  fifty  three  hours.  She  was  delivered  also 
without  instrumental  interference.  She  occupied 
almost  continuously  during  labor  the  dorsal  pos- 
ture. 

In  conclusion  I  would  say  that  I  have  chosen 
this  subject  for  consideration  not  because  I  am 
now  prepared  to  offer  any  special  rules  for  guid- 
ance as  to  the  position  of  the  patient  in  labor,  but 
from  a  conviction,  deepening  more  and  more  by 
experience,  that  posture  in  some,  if  not  in  a  large 
class  of  cases,  is  an  important  factor  in  the  pro- 
duction of  derangement  of  uterine  force  and  also 
in  that  of  pelvic  disturbance.     Such  perversion  in 


the  function  of  the  uterine  tissue  and  adjacent 
structures  is  li  I  upon  as  being  the 

result  of  some  possible  defect  in  the  particular 
treatment  in  which  all  due  and  proper  care  may 
have  been  exercised,  and  not  as  the  result  of  some 
other  element  in  the  management  of  the  case  for 
the  reason  of  which  it  has  not  occurred  to  the 
medical  attendant  to  make  inquiries. 

(For  discussion  see  Society  Proceedings.) 


MIGRAINE  AND  FUNCTIONAL  HEAD- 
ACHES FROM  EVE  STRAIN. 
BY  PETER  A.  CAI.LAX,   M.D., 

SURGEON    NEW   VOUK    EYE   AND   EAR    INFIRMARY. 

Writers  on  nervous  diseases,  as  a  rule,  devote 
considerable  attention  to  migraine,  its  etiology 
and  clinical  phases.  It  is  generally  conceded 
that  it  is  due  to  some  special  sources  of  irritation, 
whether  in  the  stomach,  uterus,  eye  or  elsewhere 
in  the  system.  The  eye  is  often  honored  as  a 
causative  factor  with  the  appropriate  heading  of 
"  Ophthalmic  Migraine."  Physicians  and  scien- 
tists have  recorded  minutely  and  accurately, 
attacks  occuring  in  their  own  persons.  Among 
these,  Wollaston  stands  preeminent  as  the  first 
who  drew  general  attention  to  one  phase  of  this 
functional  disturbance,  viz. :  temporary  hemian- 
opsia. A  dissertation  on  the  "Semi-Decussation 
of  the  Optic  Nerves"  was  published  by  him  in 
the  "Philosophical  Transactions"  a  few  years 
prior  to  his  death,  which  took  place  in  iSo6,  from 
organic  disease  of  the  brain.  In  this  paper  he 
stoutly  affirmed  his  belief  in  the  semi-decussation 
of  the  nerves  at  the  optic  chiasm.  He  arrived  at 
this  conclusion  by  a  study  of  his  seizures  of  tem- 
porary homonymous  hemianopsia.  His  experi- 
ence led  him  to  regard  temporary  hemianopsia,  as 
common  in  migraine  seizures.  Sir  John  Herschel, 
Sir  Charles  Wheatstone  and  Dr.  Herbert  Airy 
have  recorded  their  special  phases  of  the  disease. 

Parry,  to  whom  credit  is  due  for  first  having 
drawn  attention  to  that  complex  disarrangement 
of  several  organs,  wThich  we  now  designate  as 
Basedow's  or  Graves'  disease.  He  described  the 
eye  symptoms  occuring  in  his  own  person  during 
migraine  attacks  as  incomplete  scotomata,  lasting 
from  twenty  to  thirty  minutes.  We  find  various 
names  used  to  designate  these  attacks:  migraine, 
megrim,  sick  or  bilious  headaches,  hemicrania. 

The  influence  of  heredity  is  marked,  and  we  find 
a  neurotic  element  in  many  of  the  cases.  Women 
are  supposed  to  suffer  much  more  frequently  than 
men.  Eulenburg  states  that  the  proportion  is 
five  to  one.  Three  to  two  would  be  more  in  keep- 
ing with  my  record  of  cases.  We  find  that  mi- 
graine is  likely  to  last  from  the  fifteenth  to  the 
fiftieth  year — the  active  period  of  life;  that  young 
children  and  quite  old  may  suffer  with  it.  In  the 
majority  of  these  attacks  the  pain  is  apt  to  begin 


436 


MIGRAINE  FROM  EYESTRAIN. 


[March  28, 


on  one  side  of  the  forehead  or  temple,  more  often 
the  left,  involving  the  ophthalmic  division  of  the 
fifth  nerve  with  its  branches,  and  at  times  the 
occipital  and  its  branches,  but  in  the  severe  seiz- 
ures the  pain  is  not  confined  to  one  side  but  in- 
cludes both.  In  some  the  first  manifestation  is 
dizziness;  in  others  the  eye  symptoms  precede 
the  head  and  stomach.  After  a  variable  interval 
of  pain,  the  eyes  become  affected — perhaps  a  tem- 
porary blindness,  half  blindness  or  blur  of  objects, 
scotomata,  light  phenomena,  which  assumes  in 
some  cases  fantastic  shapes,  great  intolerance  of 
light  and  noise;  eyes  become  bloodshot  and  pain- 
ful, especially  when  the  eyes  move  in  their  sock- 
ets. This  lasts  from  fifteen  minutes  to  half  an 
hour;  then  the  stomach  manifestations  are  in 
order;  this  varies  from  mere  nausea  to  the  most 
violent  retchings  and  vomiting.  This  is  usually 
the  turning  point  of  the  attack,  and  if  the  patient 
can  only  get  asleep,  he  awakens  free  from  pain, 
but  weak.  The  duration  of  an  attack  may  be 
from  a  few  hours  to  two  days. 

The  subdivision  of  migraine  into  anaemic  and 
congestive  types  as  a  classification  has  something 
to  recommend  it,  but  in  practice  the  exceptions 
outnumber  those  that  follow  the  rule.  Even  in 
the  same  individual  the  attacks  vary  in  duration 
and  severity,  sometimes  being  so  slight  that  all 
ordinary  routine  work  is  done  without  much  dis- 
turbance, while  again  the  head,  eye  and  stomach 
symptoms  are  so  severe  that  life  is  not  worth  liv- 
ing. The  patient  lies  in  bed  utterly  prostrated, 
pale,  drawn  countenance,  racked  with  pain  and 
vomiting,  unable  to  bear  the  slightest  noise, 
while  light  is  simply  intolerable — a  picture  of 
misery.  Liveing's  appellation,  "  nerve  storm," 
becomes  very  appropriate. 

These  nerve  storms  vary  in  frequency  from 
only  a  few  in  the  course  of  a  year  to  one  or  two 
in  a  week.  This  difference  we  attribute  to  the 
health  of  the  patient,  and  in  the  main  we  are  cor- 
rect. At  the  same  time,  if  we  question  closely 
such  a  patient,  we  find  that  headaches  are  of  very 
frequent  occurrence,  oft-times  daily;  they  have 
become  so  common  that  they  accept  them  philo- 
sophically. The  pains  extend  across  the  brows, 
temples,  back  of  head  and  even  descending  down 
the  cervical  vertebrae.  Close  work  is  certain  to 
produce  a  headache;  so  is  shopping,  watching  a 
play  at  the  theatre,  or  looking  out  of  a  car  win- 
dow while  traveling,  and  if  the  headache  is  not 
an  immediate  sequence  it  is  likely  to  come  on  the 
next  morning.  I  have  known  patients  who  could 
not  look  at  a  floor  of  square  marble  tiles  or  pat- 
terns of  wall  paper  without  a  headache,  even  at 
times  amounting  to  migraine. 

Many  of  these  sufferers  are  nervous  and  irrita- 
ble, especially  if  the  health  is  below  par.  Trifles 
upset  them,  and  not  a  few  pass  into  an  neuras- 
thenic condition.  Stevens,  in  his  book  on  "Func- 
tional Nervous  Diseases,"  gives  it  as  his  experi- 


ence that  the  eyes  are  the  most  prolific  source  of 
nervous  disturbances,  and  more  frequently  than 
any  other  conditions  contribute  a  neuropathic 
tendency. 

As  to  the  pathology — the  views  are  as  numer- 
ous as  the  observers. 

Du  Bois  Reymond,  in  i860,  arguing  from  his 
own  personal  manifestations  of  migraine,  held 
that  there  is  a  tetanic  condition  of  the  vessels  of 
the  affected  side,  with  involvement  of  the  cervi- 
cal sympathetic.  Mollendorf  maintains  that  there 
is  a  dilatation  of  the  vessels  due  to  paralysis. 
Liveing,  that  there  is  a  nerve  storm  passing 
through  the  centres  at  certain  intervals  constitut- 
ing an  attack  of  migraine.  Latham,  that  owing 
to  a  spasm  of  the  vaso-motor  nerves  there  is  pri- 
marily a  condition  of  anaemia  of  the  parts  of  the 
brain  affected. 

In  all  probability  each  of  the  views  expressed 
describes  one  stage  and  only  so  much:  that  the 
hemianopsia  scotomata  and  other  ocular  phe- 
nomena result  from  anaemia  of  the  controlling 
cerebral  centres,  and  are  due  to  the  contraction  of 
the  capillaries,  brought  about  by  irritation  of  the 
sympathetic  vaso-motor  nerves.  This  stage  is 
but  temporary,  not  exceeding  an  hour  at  most, 
and  is  followed  by  a  stasis  or  congestion,  causing 
the  pain  within  the  brain,  followed  by  stomach 
and  other  disturbances.  There  are  no  two  eyes 
exactly  alike — we  unconsciously  use  the  better 
eye  more  than  its  fellow,  hence  the  one-sided  pain 
in  mild  attacks. 

Binocular  vision  is  a  very  complex  perform- 
ance, demanding  for  its  accomplishment  the  har- 
monious cooperation  of  several  cerebral  centers — 
cranial  nerves  and  the  sympathetic  system.  The 
2d,  3d,  4th,  and  6th,  and  perhaps  in.  a  measure 
the  5th  cranial  nerves,  as  well  as  the  sympathetic, 
are  called  into  play.  One  or  more  parts  of  this 
system  may  be  defective,  thereby  throwing  extra 
strain  on  the  others.  The  refraction  of  the  eyes 
is  usually  at  fault,  with  secondary  involvement 
of  the  muscles — ciliary  and  external  ocular 
muscles.  A  common  illustration  of  this  is  seen 
in  convergent  squint,  owing  to  a  deficient  refrac- 
tion of  the  eyes — it  becomes  easier  to  sacrifice 
binocular  vision  and  work  with  one  eye.  The 
result  is  that  the  external  rectus  of  squinting  eye 
becomes  weak,  while  the  contracted  interuus  is 
over  developed. 

To  the  memory  of  Donders  mankind  owes  an 
undying  debt  for  his  classic  work.  He  placed 
the  refractive  errors  of  the  human  eye  on  a  scien- 
tific basis.  To  give  some  idea  of  the  misconcep- 
tions that  were  extant  with  regard  to  the  refrac- 
tive errors  I  will  quote  Mackenzie,  a  great 
authority  in  his  day  and  that  not  fifty  years  ago, 
while  writing  about  presbyopia,  or  farsight.  He 
states  when  it  came  on  suddenly  much  under  the 
age  of  forty  it  was  dm;  to  some  disease  within  or 
behind  the  eyes.     It  was  even  observed  in  chil- 


IS9I-J  MIGRAIXK  FROM  EYE  STRAIN. 


437 


dren:  in  all  such  cases  evacuating  remedies  were  the  defect  and  mention  the  fact,  but  this  does  not 
found  useful.     Leeches  to  the  temples;  blisters   necessarily  follow. 

behind  the  ears  and  the  use  of  purgatives.  These.  The  difficulty  is  with  the  masked  cases  of  re- 
he  naively  remarks,  generally  cured.  He  quotes  fractive  error,  when  the  vision  is  excellent  and  a 
the  case  of  a  boy  under  Mr.  Ware's  care,  whom  fair  amount  of  work  done  without  much  apparent 
the  master  at  school  frequently  whipped  on  discomfort.  The  majority  of  patients  claim  that 
account  of  defective  sight.  Mr.  Ware  supple-  their  vision  is  excellent,  when,  in  fact,  ofttimes  it 
mented  the  school  master's  counter-irritation   by    is   quite    iudifferer.  ns  as    to  the    eye 

evacuating  remedies,  and  effected  a  cure.  I  have  strains  are  stoutly  denied:  not  through  any  wrong 
no  hesitation  in  saying  that  refraction  errors  of  motive,  but  they  have  such  abiding  faith  in  the 
high  degree  have  great  influence  on  the  forma-  excellence  of  their  eyes;  and  further,  few  persons 
tion  of  the  character.  The  young  myope  seeks  study  themselves  carefully.  Any  headaches  or 
companionship  in  his  books — grows  introspec-  migraine  attacks  are  promptly  attributed  to  some 
tive- lives  in  an  ideal  or  unreal  world  of  his  own  cause,  dyspepsia,  liver,  or  neuralgia,  and  then 
creation;  becomes  bashful,  diffident,  and  takes  no  they  have  always  suffered,  at  least  for  many- 
part  in  the  sports  of  his  companions,  so  that  his  years,  that  one  or  the  other  of  the  parents,  suffer- 
physique  suffers.  The  hyperope  with  high  de-  ed  in  a  similar  way,  and  how  can  they  expect  to 
gree  of  error  learns  but  slowly  on  account  of  the  escape. 

great  strain  to  see — books  are  to  him  distasteful —  I  well  remember  the  case  of  a  lady  ten  years 
may  be  classed  as  a  dullard  by  his  parents  and  ago  who  had  long  and  frequently  suffered  from 
teachers — often  censured  unjustly,  when  really  he  migraine,  who  was  cured  by  wearino-  o-iasses 
has  entered  the  race  heavily  handicapped.  When  I  first  suggested  to  her' that  her*eyes  were 

Donders,  in  his  classic  work,  states  distinctly  ,  at  fault  she  remarked  that  it  was  impossible,  for 
that  the  emmetropic,  or  normal  eye,  is  one  with  a  her  vision  was  excellent  and  none  of  the  many 
small  amount  of  error,  which  must  not  exceed  physicians  whom  she  had  consulted,  both  at  home 
Vit  of  hyperopia;  while  under  astigmatism  he  and  abroad,  never  even  mentioned  such  a  thino-. 
writes,  "so  long  as  astigmatism  does  not  essen- '  In  very  many  of  these  cases  distant  vision  ts 
pally  diminish  the  acuteness  of  vision,  we  call  it  good  and  if  they  could  be  ranchmen,  sailors,  or 
normal,  and  if  it  amounts  to  T's  or  more  it  is  ab  lead  a  pastoral  life,  there  would  be  but  little  trou- 
normal."  ble  worth  mentioning. 

Donders  published  his  book  over  twenty -seven  In  examining  patients  who  suffer  from  func- 
years  ago  and  his  observations  were  made  in  Hoi-  tional  headache  and  migraine  we  should  resort 
land.  With  regard  to  our  country,  at  the  pres-  always,  when  it  is  possible,  to  mydriatics,  so  as 
eut  time,  the  errors  which  he  accepted  and  called  to  put  the  ciliary  muscle  at  complete  rest.  There 
normal  are  too  great  to  pass  uncorrected,  espe-  are  quite  a  number  to  select  from — sulph.  atropise 
cially  if  the  patient  suffers  from  headache  or  is  most  generally  used,  but  where  time  is  of  im- 
other  nervous  disturbance.  The  hurry  and  ex-  portance  we  can  get  satisfactory  results  from  a 
citement  incidental  to  life,  in  a  large  city,  com-  combination  of  homatropine  and  cocaine —  two 
bined  with  our  stimulating  climate,  tend  to  ex-  per  cent,  to  four  per  cent,  solution;  the  effects 
haust  the  system  much  sooner  than  abroad.  pass  off  in  about  twenty-four  hours.     Xo  one  is 

Even-  organ  has  its  limitations  of  work  and  justified  in  excluding  the  eyes,  as  a  cause,  until  a 
endurance,  and  the  human  eye  is  no  exception  to  thorough  examination  is  made,  as  to  refractive 
this  rule.  Further,  a  normal  eye  is  the  exception,  errors,  under  complete  ciliary  paralysis.  I  have 
and  when  we  impose  or  exact  of  our  eyes  an  frequently  found  that  correcting  0.25  D.  ofastig- 
amount  of  work  that  calls  for  very  great  strain  to  matism  has  given  complete  relief, 
accomplish,  pain  and  nervous  disturbances  are  !  In  testing  eyes  the  accepted  standard  of  fg  vis- 
most  likely  to  develop.  I  do  not  advocate  that  ion  is  only  a  guide,  for  with  young  patients  ff- 
all  refractive  errors  of  the  human  eye  should  be  ;  fg  is  not  very  exceptional.  So  that  a  glass  in 
corrected,  but  if  we  have  reason  to  suppose  that  such  a  case,  that  gives  a  vision  of  only  |f,  is  not 
such  errors  are  prejudicial  to  the  comfort  and  the  correction  and  we  should  look  further.  If  we 
health  of  a  patient,  it  becomes  our  duty  to  have  find  that  a  convex  glass  appears  to  correct — try  and 
that  strain  removed  by  suitable  glasses.  When  see  if  a  combination  of  a  weaker  convex  with  a 
vision  is  poor  and  the  daily  avocation  demands  weaker  cylinder  does  not  do  equally  as  well,  if  not 
good  sight,  correction  is  in  order  as  a  matter  of  better.  To  any  one  who  has  much  experience  in 
course.  With  the  aid  furnished  satisfactory  work  this  line,  it  is  often  surprising  to  note  the  various 
can  be  accomplished,  and  the  eyes  used  within  combinations  which  appear  to  give  equally  good 
the  ordinary  physical  limitations,  which  we  must  vision,  viz.:  i'l  in  a  given  case,  and  often  consid- 
all  learn  for  ourselves.  As  a  rule  it  is  not  such  erable  care  must  be  exercised  in  deciding  which 
cases  that  perplex  a  physician,  for  if  there  is  any  gives  the  best  results  on  the  astigmatic  chart  and 
oblivious  defect  of  sight,  with  pain  and  blur  foi-  test  type  card, 
lowing  the  use  of  eyes,  the  patient  may  know  of,      Always  fully  correct  the  astigmatic  error,  but 


43» 


INFLUENCE  OF  GERMAN  UNIVERSITIES. 


[March  28, 


in  respect  to  the  ametropia  which  may  exist,  too 
main-  factors  have  to  be  considered  to  discuss  the 
subject  in  this  paper.  Test  ocular  muscles  be- 
fore and  during  the  accommodative  paralysis.  It 
will  be  found  that  the  results  vary  very  much  at 
different  examinations.  I  am  of  the  opinion  that 
the  eye  strain  makes  faulty  ocular  muscles  and 
generally,  the  ametropia  satisfactorily  corrected, 
the  muscles  will  not  be  a  disturbing  factor. 
Hypermetropic  astigmatism  furnishes  the  great- 
est number  of  cases  for  the  simple  reason  that 
n^-opia  is  rare,  comparatively  speaking,  when  we 
consider  the  whole  population. 

Correct  for  distance  and  near  work;  insist  on 
the  continuous  wearing  of  the  glasses,  but  here 
we  strike  a  snag,  for  many,  especially  women, 
will  not  wear  glasses  out  of  doors.  They  would 
rather  take  antipyrin,  or  some  similar  drug,  when 
they  have  migraine. 

In  conclusion — from  an  extended  experience  of 
years,  with  hundreds  of  cases,  I  am  forced  by 
experience  to  regard  eye  strain  as  the  cause  in 
over  seventy-five  per  cent,  of  all  the  cases  of  func- 
tional headache  and  misrraine. 


THE  INFLUENCE  OF  GERMAN  UNIVER- 
SITIES UPON  OUR  PROFESSION. 

Read  before  the  American  Academy   of  Medicine,  at   its  Fourteenth 
Annual  Meetiyig  at  Philadelphia.  December  j.  iSgo. 

BY  HEXRV  E.   DWIGHT,   A.M.,    M.D.,   D.D., 

OF  PHILADELPHIA,  TA. 

From  the  minutes  of  the  Council,  I  extract  the 
following  authority  for  the  selection  of  my  sub- 
ject, and  its  presentation  at  this  meeting  of  the 
Academy  : 

In  accordance  with  the  leading  objects  of  our  organi- 
zation, the  education  of  the  physician,  both  preliminary 
and  technical,  the  relations  of  the  profession  in  this  coun- 
try to  that  of  other  countries,  and  the  elevation  of  the 
literary,  scientific  and  social  standing  of  the  Profession, 
are  especially  appropriate  subjects. 

In  view  of  the  fact  that  the  constitution  was 
altered  at  the  last  annual  meeting  so  as  "  to  ad- 
mit, in  addition  to  those  possessing  the  degrees 
of  A.B.  and  A.M.,  those  who  can  present  evi- 
dences of  preparatory  liberal  education  equivalent 
to  the  same  " — the  subject  proposed  in  the  follow- 
ing paper  is  of  vital  importance  at  this  meeting 
of  the  Academy. 

INFLUENCE  OF  GERMAN    UNIVERSITIES  UPON 
THE  MEDICAL  PROFESSION. 

/.    What  is  a  University? 

It  is  one  thing  in  America,  another  in  England, 
and  something  else  in  Germany.  Hence  the  im- 
portance of  a  clear  definition.  The  University  of 
London  has  no  teachers,  no  scholars,  no  buildings, 
except  a  room  in  Burlington  House,  no  libraries, 
no  laboratories,  and  yet  it  has  a  brilliant  staff  of 
Professors  in  the  Scientific  and  Medical  Depart- 


ment. It  is  simply  the  Napoleonic  University  of 
France  without  the  principle  of  teaching.  Why 
not,  therefore,  have  a  University  without  teach- 
ers, in  this  age  of  printing,  of  many  books  on 
every  subject?  Because,  the  mind,  the  voice,  the 
eye  of  the  living  instructor  is  as  necessary  to-day 
as  in  the  days  of  the  Athenian  Agora  or  Acade- 
mia,  with  Plato,  Aristotle,  Socrates  and  their  pu- 
pils In  Germain'  by  these  means  Hegel  in  phi- 
losophy,  Dorner  in  theology,  Hoffman  in  ehemistry 
and  von  Virchow  in  physiology,  have  been  equal- 
ly successful. 

Hence  a  University  is  a  body  of  instructors, 
teaching  the  highest  knowledge,  of  the  most 
worth  to  men,  dealing  with  their  dearest  inter- 
ests, appealing  to  their  finest  powers  and  noblest 
feelings.  To  aid  them  in  this  blessed  work  let 
the  University  prescribe  certain  courses  and  what 
rewards  shall  follow  a  complete  and  thorough 
training ;  and  not  for  these  alone,  but  let  them 
arrange  for  those  who  thirst  for  knowledge,  and 
earnestly  desire  the  best  sources,  who  should  be 
welcomed  to  lectures  suited  to  their  needs,  just 
as  hungry  souls  pass  through  church  doors  al- 
ways open  to  satisfy  their  wants.  Therefore  Uni- 
versities must  teach,  must  vivify  knowledge,  by 
appeals  to  the  discursive  reason  and  the  creative 
imagination.  But  they  must  do  more.  Among 
the  services  thej-  render  when  rightly  conducted, 
is  the  prosecution  of  scientific  research  into  facts 
imperfectly  examined.  True  teachers  are  always 
progressive  and  not  content  with  imparting  the 
conclusions  of  others.  The}-  are  investigators  for 
testing  the  observations  of  their  predecessors,  while 
reaching  their  own  conclusions.  In  the  natural 
sciences,  they  will  observe  phenomena,  collect 
and  classify  observations,  draw  inferences  and 
force  nature  to  give  up  her  secrets  by  experi- 
ments. Among  the  greatest  teachers  in  science  a 
large  number  have  been  and  are  now,  discoverers. 

In  such  an  institution,  famed  for  its  teachers 
and  its  original  researches,  a  young  student  in 
medicine  escapes  exclusiveness,  because  the  meth- 
ods of  one  science  are  corrected  by  those  of  an- 
other. In  such  an  atmosphere,  theologians  and 
mathematicians  are  not  intolerant  of  the  votaries 
of  natural  science.  The  student  sees  a  host  of 
men,  eminent  in  genius  and  industry,  who  enlarge 
his  horizon  by  bearing  her  torch  into  abstruse 
paths  of  knowledge,  to  masterpieces  of  thought 
and  feeling  which  bear  fruit  in  his  own  mind 
through  life.  Hence  the  Catholicity  of  his  views, 
the  elevation  of  his  feelings  and  the  success  of 
his  pursuits. 

2.  But  what  claims  have  ike  German  Universv. 
ties  on  our  peculiar  attention  to-day  .' 

Montesquieu,  in  his  "Spirit  of  the  Laws,"  de 
clared  that  the  English  Constitution  is  found  in 
the  forests  of  Germany,  which  is  abundantly  con- 
firmed by  Tacitus,  and  in  later  days  by  Palgrave 
Kemble  and  Sir"  Henry  Maine.     English  customs 


: 


I89i.] 


INFLUENCE  OF  GERMAN  UNIVERSITIES. 


439 


and  laws  migrated  with  the  Pilgrims  to  America. 
The  Germanic  System  of  common  fields  was  re 
vived  as  Commons  or  Town  Lands  in  New  En- 
gland. The  Saxou  Hege,  Warden  of  the  Hedge, 
was  the  pound  keeper  of  the  United  States.  In 
the  Mayflower's  cabin  was  representative  govern- 
ment, and  in  the  Pilgrim's  soul  there  was  rever- 
ence for  law,  to  be  maintained  in  a  legalized,  organ- 
ized town,  with  a  church  for  God's  worship  and  a 
seminary  of  learning  for  man's  welfare,  on  which 
rested  the  institutions  of  a  new  world.  Hence 
Harvard  and  Yale  are  the  legitimate  offspring  of 
Teutonic  ideas  and  German  ideals— the  "Alma 
Mater"   of  a  numerous  family. 

German  Universities  ate  controlled  by  the  ideas 
that  national  unity  depends  on  national  culture, 
that  the  powers  that  be  are  ordained  of  God,  and 
that  rulers  arc  to  be  obeyed,  if  they  consecrate  their 
power  to  the  welfare  of  the  -whole  people.  The  in- 
struction is  by  means  of  lectures,  and  the  discus 
sions  are  conducted  by  the  professors.  With  the 
highest  instruction  in  theory  are  combined  labo- 
ratories, clinics,  and  the  best  apparatus  for  obser- 
vation and  experiment,  to  secure  practical  in- 
struction. Diligence  and  scholarship  are  rewarded 
by  degrees  which  the  student  must  have  before 
Re  can  graduate  or  enter  a  profession.  Our  col- 
leges are  stepping-stones,  like  their  gymnasia,  to 
a  university.  We  have  no  institution  which  the 
Germans  will  recognize  as  a  university,  and  they 
have  none  which  an  intelligent  American  would 
recognize  as  a  college.  Their  high  schools,  with 
a  .-ix  years'  course,  furnish  a  general  education, 
not  a  liberal  one,  and  are  designed  to  prepare  stu- 
dents for  business  life.  The  school  for  liberal 
education  is  the  Gymnasium,  with  a  nine  years' 
course,  which  pupils  begin  at  nine  years  of  age. 
Linguistic  and  historical  studies  are  the  peculiar 
principle  of  the  gymnasium,  and  as  the  Minister 
of  Education,  von  Gosler,  officially  declared  in 
18S2,  "are  designed  to  prepare  for  independent 
study  at  the  University." 

The  Real  Schools,  the  rivals  of  the  gymnasia, 
have  received  their  inspiration  from  the  people, 
and  were  promoted  by  progress  in  natural  science, 
industrial  pursuits,  and  in  realism,  instead  of 
idealism.  They  emphasized  modern  languages, 
history,  mathematics  and  natural  science.  The 
real  was  to  be  secured  by  the  Real  Schools.  But 
Geynan  scholars  are  not  prepared  to  sever  schol- 
arship from  the  ancient  classics,  to  take  in  their 
place  the  modern  languages,  or  translations  of 
the  ancient — and  the  German  Government  prefers 
the  gymnasium,  for  every  position  in  its  gift  is 
accessible  to  its  graduates.  German  physicians 
are  not  ready  for  such  a  change,  for  out  of  163 
Medical  Societies  only  three  gave  their  unquali- 
fied consent  for  the  admission  of  students  in  the 
Real  School  to  the  University  Medical  Depart- 
ment. There  are  serious  complaints  by  the  Ger- 
man Government  respecting  the  efficiency  of  their 


medical  students,  and  fear  lest  the  change  in  the 
standard  of  admission  to  the  University  Medical 
Department  might  lower  the  standard  of  scholar- 
ship. They  favor  an  increase  of  the  study  of 
medicine  from  four  to  five  years,  to  secure  better 
preparation  for  the  faculty. 

The  testimony  of  that  eminent  chemist,  Prof. 
A.  W.  Hoffmann,  rector  of  the  University  of  Ber- 
lin, is  very  important  to  all  liberally  educated 
physicians.  He  is  certainly  one  of  the  ablest  in- 
structors in  that  great  University,  and  means 
what  he  says,  viz.:  "  That  all  efforts  to  find  a  sub- 
stitute for  the  study  of  the  ancient  classics,  wheth- 
er in  the  modern  languages,  mathematics,  or  nat- 
ural sciences,  have  thus  far  proved  a  failure.  How 
often  have  I  heard  young  men  prepared  in  Real 
Schools  deeply  regret  that  they  had  not  enjoyed 
the  training  of  a  gymnasium.  The  ideality  of 
academical  study,  the  unselfish  devotion  to  sci- 
ence as  science,  the  free  exercise  of  thought, 
the  condition  and  result  of  this  devotion  recede 
in  proportion  as  the  classic  basis,  as  training  for 
the  university,  is  withdrawn.  I  have  had  much 
occasion  to  speak  of  this  matter  with  friends  de- 
voted to  physics  and  mathematics,  and  with 
scarcely  an  exception  I  found  they  had  the  same 
conviction."  These  are  strong  words,  and  merit 
careful  consideration.  Similar  testimony,  as  to 
the  value  of  a  classical  education,  has  been  given 
by  Liebig,  the  father  of  agricultural  chemistry, 
Wolff,  Henneberg.Knap,  Nobbe,  Stohmann,  Kiihn 
and  others,  all  of  whom  are  well-known  chemists 
and  discoverers  in  Germany. 

3.  Does  the  History  of  Medicine  confirm  these 
Claims/ 

Are  we  members  of  a  learned  profession? 
Should  we  rank  with  lawyers  and  theologians  on 
University  Catalogues2  Have  we  a  scientific  pro- 
fession? 

These  are  important  questions  in  America  as 
well  as  in  Germany.  Let  us  see.  Homer  men- 
tions two  physicians.  Machaon  and  Podalims, 
skilful  in  stanching  wounds  and  relieving  pain. 
The  storv  of  .Lseulapius  proves  that  as  far  back 
as  legendary  history,  men  made  disease  and  the 
healing  art  a  special  study,  and  lived  by  the  prac- 
tice of  their  craft ;  but  their  observations  and  the- 
ories were  worth  little,  because  their  philosophy 
was  so  crude.  The  labors  of  Hippocrates  are 
constantly  marred  by  his  identification  of  effect 
with  cause,  restrictions  placed  on  the  dissections 
and  undeveloped  collateral  science,  still  hi 
is  a  monument  of  uuwearied  industry  and  won- 
derful fidelity  to  nature.  The  signs  of  fa< 
the  facts  themselves,  or  effects  taken  for 
ruined  every  system  of  nosology  from  Hippocrates 
to  Cullen. 

There  was  no  sound  anatomy  or  physiology 
to  solve  the  problems  of  the  diseased  system,  and 
not  until  the  analytical  method  of  the  Alex- 
andrine  School    pointed    to    dissection    ar.c.    un- 


44Q 


INFLUENCE  OF  GERMAN  UNIVERSITIES. 


[March  28, 


locked  the  human  frame,  that  true  light  revealed 
the  phenomena  of  disease.  Herophilus,  their 
most  celebrated  teacher,  made  six  hundred  dis- 
sections, and  acquired  such  distinction  that  the 
proverb  remains  to  this  day,  ' '  To  contradict  Her- 
ophilus is  to  contradict  the  Gospel."  But  the 
famous  fire  at  Alexandria  destroyed  his  researches 
with  the  Library,  but  not  the  principles  which 
they  discovered,  for  Philinus,  his  disciple,  left  the 
most  important  system  of  early  medicine.  Phili- 
nus urged  a  return  to  observation  and  clinical 
studies,  and  was  surrounded  by  a  host  of  obser- 
vers, among  whom  was  the  celebrated  Heraclides 
of  Tarentum,  who  first  introduced  opium  into 
practice. 

So  far,  scientific  medicine  is  confined  to  a  I  nivet 
sity,  Alexandria,  with  its  literary  treasures  and 
learned  men.  Let  us  pass  from  the  East  to  the 
West,  from  Egypt  to  Italy.  Pliny  assures  us  that 
the  Roman  people  had  been  without  a  physician 
for  six  hundred  years.  In  some  things  the  world 
is  not  wiser  now  than  at  that  period.  Then  peo 
pie  resorted  to  certain  temples,  even  in  the  se- 
verest epidemics,  as  now  to  the  shrine  of  St. 
Vitus,  where  the  "Faith  Cure"  had  its  most 
numerous  disciples  as  well  as  victims.  St.  Ossi- 
fy ga  cared  for  the  growth  of  bones  at  Rome,  just 
as  St.  Ursula  now  cares  for  them  when  dead  in 
the  Church  of  the  11,000  Virgins  at  Cologne. 
In  Rome,  and  at  this  epoch,  appeared  the  elder 
Pliny,  who  collected  in  his  "  Historia  Mundi,"  all 
the  systems  from  Hippocrates  to  his  own,  and  has 
left  in  his  history  many  original  views  and  reflec- 
tions, as  evidence  of  the  profound  mind  of  a  great 
naturalist.  From  Pliny  to  Galen,  the  inquiries 
multiplied  exceedingly,  because  Galen  revived 
the  principles  of  the  great  physician  of  Coos,  and 
held  undisputed  sway  in  medical  matters  till  the 
sixteenth  century.  Devoted  to  anatomy  and  phy- 
siology, especially  the  former,  his  authority  be- 
came as  infallible  in  medicine  as  that  of  Aristotle 
in  philosophy.  With  Galen,  early  medicine  lost 
its  greatness,  and  with  the  downfall  of  the  Roman 
Empire  it  retrograded  likewise,  but  during  the 
history  of  that  Empire,  so  far  as  progress  was 
made  in  the  principles  and  practice  of  our  art,  it 
was  on  a  scientific  basis.  .Esculapius  was  en- 
throned at  Rome,  and  not  at  Canossa. 

The  age  of  Dante  was  the  period  of  the  renais- 
sance, when  science  was  divorced  from  supersti- 
tion and  charlatanism.  The  first  modern  dissec- 
tion of  the  human  subject  was  made  by  Mondini  <li 
Luzzi,  towards  the  close  of  the  sixteenth  century, 
when  the  tone  of  the  European  mind  influenced  art 
:i>  u  ill  as  medicine,  but  tile  public  authorities  cen- 
sured Mondini,  and  dissections  ceased.  Inthesix- 
teenth  century,  Vesalius  resumed  them,  and  laid 
the  foundation  of  modern  anatomy.  The  purity 
of  his  intentions  and  his  noble  views  removed 
popular  prejudice,  which  enabled  Ambrose  Pare, 
litst    lii  turn  to  practical   use   the    labors    of  his 


predecessors,  and  as  surgeon  to  several  European 
sovereigns,  by  systematizing  the  researches  of  his 
predecessors,  to  lay  foundations  for  the  structure 
reared  by  John  Hunter,  Dupuytren,  Abernethy 
and  Sir  Astley  Cooper.  During  the  eighteenth 
and  nineteenth  centuries  such  stars  of  the  first 
magnitude  as  Morgagni  and  Scarpa  in  Italy ; 
Haller,  Boerhaave,  Heister  and  Soemmering  in 
Germany ;  Dupuytren  and  the  illustrious  Bichat 
in  France ;  Cullen  and  the  Hunters  in  England 
— all  eminent  physicians  and  surgeons,  continue 
the  work  of  scientific  research  in  medicine,  and 
science  based  on  facts  and  not  on  theoretic  prin- 
ciples, in  a  field  of  enquiry  commensurate  with  the 
three  physical  kingdoms  of  nature. 

Surely,  the  Germans  have  not  erred  in  their  es- 
timate of  a  classical  and  scientific  training  for  a 
physician  up  to  the  nineteenth  century,  if  the 
history  of  our  profession  means  anything  in  the 
development  of  the  race. 

What  shall  I  say  of  our  century,  now  drawing 
to  a  close?  How  the  labors  of  our  predecessors 
pale  before  the  wonders  of  the  nineteenth  century ! 
Physical  examinations,  chemical  tests,  microscop- 
ical histology,  anaesthetics  in  surgery,  have  cer- 
tainly elevated  medicine  to  a  science,  and  its 
practitioners  to  the  front  rank  of  her  votaries, 
entitled  to  the  respect  and  gratitude  of  all  en- 
lightened men.  Every  tissue  of  the  body  is  under 
the  microscope,  all  living  organisms  are  the 
products  of  elementary  cells,  so  that  every  dif- 
ference of  structure  implies  a  difference  of  func- 
tion. Thus  we  mount  from  the  simple  cells  to 
the  marvelous  structure,  man,  the  paragon  of 
animals,  the  beauty  of  the  world.  Under  the 
careful  studies  of  the  German,  Kolliker,  the  liver 
is  revealed  as  a  complex  and  beautiful  structure, 
symmetrical  in  design,  with  an  arrangement  of 
lobules,  cells,  nerves  and  blood-vessels,  worthy  of 
the  warmest  admiration,  not  simply  to  make  bile, 
but  to  repair  the  waste  of  nerve  tissue.  No  less 
the  eye,  when  under  the  microscope,  bears  the 
happiest  results.  The  discovery  of  the  retinal 
expansion  of  the  optic  nerve  or  Jacob's  mem- 
brane, has  wonderfully  elucidated  the  phenomena 
of  vision.  Those  nerve  fibres  are  specially  fitted 
to  the  undulations  of  light.  What  a  change  in 
our  theories  of  color  vision  !  Anaesthetics  h  ive 
robbed  surgery  of  all  its  cruelty  and  half  its  dan- 
ger, extended  its  sphere  of  action,  increased  the 
proportion  of  recoveries  after  severe  wounds  nnd 
mutilations,  and  insured  the  safety  of  obstetrics. 
Within  fifty  years  the  operation  for  stone  will 
become  obsolete.  Small  pox  is  no  longer  a  pos- 
sible danger  to  life.  Typhoid  fever  is  rarely  fatal 
and  typhus  is  almost  unknown,  except  in  the 
wake  of  armies  or  famine.  Madness  is  now  a 
curable  disease,  and  the  drugs  employed  are  less 
loathsome  than  the  disease.  Fluid  extracts  and 
active  principles  take  the  place  of  nauseating 
powders   and    tinctures.      The    causes   of  disease 


I89i.] 


AMERICAN   MEDICAL  ASSOCIATION. 


44i 


are  more  thoroughly  studied  and  better  under- 
stood. From  a  cold  in  the  head  to  pulmonary 
phthisis,  from  lupus  to  cancer,  Bacillus  is  the 
password,  no  matter  what  may  be  the  "Grippe,'' 
Query.  Is  the  Bacillus  the  cause  or  a  consequence 
of  the  disease?  Let  that  star  of  the  first  magni- 
tude now  in  the  zenith  at  Berlin  so  guide  our  wise 
men,  now  about  to  visit  him  from  the  East,  that 
we  may  all  have  a  quick  deliverance  from  the 
scourge  of  mankind. 

Mr.  President  and  Fellows  of  the  Academy,  I 
thank  you  for  your  patient  attention.  May  I  ask 
for  your  careful  consideration  ? 

BIBLIOGRAPHY. 

"The  Value  of  a  Classical  Education,"  by  Rev.  Jona- 
than Edwards,  Sr..  A.M..  on  accepting  the  Presidency  of 
Princeton  College.  "  Life  and  Works  of  Pres't  Jonathan 
Edwards,  A.M.."  by  Rev.  Pres't  Sereno  Edwards  Dwight, 
D.D.,  Pres't  Hamilton  College,  Cliutou,  X.  V. 

"The  Nature  and  Advantages  of  the  Exact  Sciences 
and  of  the  Classics  in  Collegiate  Education,"  by  Rev. 
Jonathan  Edwards,  Jr.,  D.D.,  Pres't  Union  College,  New 
York.     Life  by  Dr.  Tryon  Edwards. 

"The  Culture  Derived  from  the  Mathematics  and  Clas- 
sics," by  Rev.  Pres't  Timothy  Dwight,  D.D.,  LL.D.  See 
'  Pres't  Dwight's  Decisions  on  Debates  by  the  Senior 
Class."     Yale  University,  1796-1816. 

"  The  Stud v  of  the  Classics  and  Comparative  Philology, 
their  Influence  on  Mind  and  Character,"  see  "Value 
of  the  Higher  Education  and  Modern  Philology,"  by 
Rev.  B.  W.  Dwight,  LI.  D.     New  York. 

"Germany  and  its  Universities,"  by  Henry  E.  Dwight, 
A.M.    US29)" 

"The  German  Universities  Compared  with  those  of 
England  and  America."  Oration  before  the  Yale  Alum- 
ni i  [844),  by  Rev.  \V.  T.  Dwight.  D.D.,  Portland,  Me. 

"  Universities,  their  Rights  and  Privileges,  their  Rela- 
tions to  Trustees,  Visitors,  and  Governing  Boards."  be- 
fore the  Supreme  Judicial  Court  of  Massachusetts,  by 
Hon.  Judge  Theodore  W.  Dwight,  LL.D.,  Prof.  Munici 
pal  Law  in  Columbia  College.  New  York. 

"An  American  University" — Its  Constitution.  Scope 
and  Design.  Inaugural  Address,  as  President  of  Yale, 
by  Rev.  Pres't  Timothy  Dwight,  D.D.,  LL.D. 

'•'University  Education  (University  of  Pennsylvania!, 
as  seen  in  the  Life  and  Writings  of  Hon.  V.  L.  Brad- 
ford, D.C.L.,  LL.D.,"  by  Henry  E.  Dwight,  A.M.,  MI), 
D.D.     Large  8vo. 

"  High  School  Education,"  its  effects  and  their  conse- 
quences in  Girard  College  and  Heriot's  Hospital.  Edin 
burgh,  portrayed  in  "  Fifty  Years'  Work  in  the  Spread 
of  the  Gospel,  Relief  of  the  Worthy  Poor  and  Care  of 
Destitute  Children."  (Prize  Essav "in  Philadelphia),  by 
Henry  E.  Dwight,  A.M.,  M.D.,  D.D. 

"University  Education,"  its  power  in  moulding  the 
life  and  character  of  Hon.  E.  G.  Booth  (University  of 
North  Carolina),  Revisor  of  the  Code  of  Virginia,  bv 
Henrv  E.  Dwight,  A.M.,  M.D.,  D.D.     Large  Svo. 

The  Works  of  Prof.  P.  Schaff,  D.D.,  LL.D.;  Prof.  J. 
Thorold  Rogers;  Prof.  Palmer,  Harvard;  Prof.  Ladd, 
Yale;  Prof.   Hoffman,  Berlin. 


AMERICAN   MEDICAL  ASSOCIATION. 


Educational  Position  of  Berlin. — There 
are  5,527  students  in  attendance  upon  the  differ- 
ent faculties  of  the  University  of  Berlin,  which 
places  it  at  the  head  of  all  the  German  uni- 
versities. Throughout  Germany  there  are  nearly 
30,000  students  in  attendance  at  twenty  uni- 
versities. 


Plan  of  Organization  for  a   National   Medical 
Association. 

Whereas,  The  Medical  Convention,  held  in 
the  city  of  New  York,  in  May.  1846,  have  declared 
it  expedient  "for  the  medical  profession  of  the 
United  States  to  institute  a  National  Medical  As- 
sociation ;"   and. 

Inasmuch  as  an  institution  so  conducted  as  to 
give  frequent,  united  and  emphatic  expression  to 
the  views  and  aims  of  the  medical  profession  in 
this  country,  must  at  all  times  have  a  beneficial 
influence,  and  supply  more  efficient  means  than 
have  hitherto  been  available  here  for  cultivating 
and  advancing  medical  knowledge  ;  for  elevating 
the  standard  of  medical  education  ;  for  promoting 
the  usefulness,  honor,  and  interests  of  the  med- 
ical profession  ;  for  enlightening  and  directing 
public  opinion  in  regard  to  the  duties,  responsi- 
bilities, and  requirements  of  medical  men  ;  for  ex- 
citing and  encouraging  emulation  and  concert  of 
action  in  the  profession,  and  for  facilitating  and 
fostering  friendly  intercourse  between  those  who 
are  engaged  in  it :  therefore,  be  it 

Resolved,  In  behalf  of  the  medical  profession 
of  the  United  States,  that  the  members  of  the 
Medical  Convention,  held  in  Philadelphia,  in 
May,  1847,  an<*  al1  others  who,  in  pursuit  of  the 
objects  above  mentioned,  are  to  unite  with  or 
succeed  them,  constitute  a  National  Medical  As- 
sociation ;  and  that  for  the  organization  and 
management  of  the  same,  they  adopt  the  follow- 
ing Regulations: — ' 

I. — TITLE    OF    THE    ASSOCIATION. 

This  institution  shall  be  known  and  dis- 
tinguished by  the  name  and  title  of  "The  Ameri- 
can Medical  Association." 

II. — MEMBERS. 

The  members  of  this  institution  shall  col- 
lectively represent  and  have  cognizance  of  the 
common  interests  of  the  medical  profession  in 
every  part  of  the  United  States  ;  and  shall  hold 
their  appointment  to  membership  either  as  dele- 
gates from  local  institutions,  as  members  by  in- 
vitation, as  permanent  members,  or  members  by 
application. 

The  Delegates  shall  receive  their  appointment 
from  permanently  organized  State  medical  so- 
cieties, and  such  county  and  district  medical  so- 
cieties as  are  recognized  by  representation  in 
their  respective  State  societies,  and  from  the  med- 
ical department  of  the  Army  and  Navy  of  the 
United  States,  and  the  Marine  Hospital  Sen-ice 
of  the  United  States. 

Each  delegate  shall  hold  his  appointment  for 
one  year,  and  until  another  is  appointed  to  suc- 
ceed him,  and  shall  participate  in  all  the  business 
and  affairs  of  the  Association. 

■  Revised  to  date. 


442 


AMERICAN  MEDICAL  ASSOCIATION. 


[March  28, 


Each  State,  county  and  district  medical  so- 
ciety, entitled  to  representation,  shall  have  the 
privilege  of  sending  to  the  Association  one  dele- 
gate for  every  ten  of  its  regular  resident  members, 
and  one  for  every  additional  fraction  of  more  than 
half  that  number  ;  Provided,  however,  that  the 
number  of  delegates  from  any  particular  State, 
Territory,  county,  city,  or  town  shall  not  exceed 
the  ratio  of  one  in  ten  of  the  resident  physicians 
who  may  have  signed  the  Code  of  Ethics  of  this 
Association.  The  Medical  Staffs  of  the  Army 
and  Navy  shall  be  entitled  to  four  delegates  each. 
The  Marine  Hospital  Service  of  the  United  States 
shall  be  entitled  to  one  delegate. 

No  individual  who  shall  be  under  sentence  of 
expulsion  or  suspension  from  any  State  or  local 
medical  society  of  which  he  may  have  been  a 
member,  or  whose  name  shall  have  been,  for  non- 
payment of  dues,  dropped  from  the  rolls  of  the 
same,  shall  be  received  as  a  delegate  to  this  As- 
sociation, or  be  allowed  any  of  the  privileges  of 
a  member,  until  he  shall  have  been  relieved  from 
the  said  sentence  or  disability  by  such  State  or 
local  society,  or  shall  have  paid  up  all  arrears  of 
membership  ;  nor  shall  any  person  not  a  member 
and  supporter  of  a  local  medical  society,  where 
such  a  one  exists,  be  eligible  to  membership  in 
the  American  Medical  Association. 

No  one  expelled  from  this  Association  shall  at 
any  time  thereafter  be  received  as  a  delegate  or 
member,  unless  by  a  three-fourths  vote  of  the 
members  present  at  the  meeting  to  which  he  is 
sent,  or  at  which  he  is  proposed. 

Members  by  Invitation  shall  consist  of  practi- 
tioners of  reputable  standing  from  sections  of  the 
United  States  not  otherwise  represented  at  the 
meeting.  They  shall  receive  their  appointment 
by  invitation  of  the  meeting,  after  an  introduc- 
tion from,  and  being  vouched  for  by,  at  least 
three  of  the  members  present,  or  three  of  the  ab- 
sent permanent  members.  They  shall  hold  their 
connection  with  the  Association  until  the  close  of 
the  annual  session  at  which  they  are  received  ; 
and  shall  be  entitled  to  participate  in  all  its 
affairs,  as  in  the  case  of  delegates,  except  the 
right  to  vote. 

The    Permanent  Members  shall  consist  of   all 

crved  in   the  capacity   of  dele 

.ml  of  such  other  members  as  rnay  receive 

tli:-  appointment    by    unanimous   vote,  and  shall 

continue  such   so   long  as   they   remain  in  good 

standing  in  tin-  body  from  which  the)*  were  sent 

and  comply  with  the  requirements 

of  the  By-laws   of   the  Association.      Permanent 

members  shall  at  all  times   be  entitled   to  attend 

the  meetings,  ami  participate  in  the  affairs  of  the 

ition,   so   long   as  they   shall  continue  to 

conform  to  its  regulations,  but  without  the  right 

of  voting  ;    and,   when   not    in    attendance,    they 

shall  be  authorized  to  granl  letters  of  introduc 

tion  to  reputable  practitioners  of  medicine  resid 


ing  in  their  vicinity,  who  may  wish  to  partici- 
pate in  the  business  of  the  meeting,  as  provided 
for  members  by  invitation. 

Members  by  Application  shall  consist  of  such 
members  of  the  State,  County  and  District  Med- 
ical Societies  entitled  to  representation  in  this 
Association  as  shall  make  application  for  admis- 
sion, in  writing,  to  the  Treasurer,  and  accompany 
said  application  with  a  certificate  of  good  stand- 
ing, signed  by  the  President  and  Secretary  of  the 
Society  of  which  they  are  members,  and  the 
amount  of  the  annual  fee,  five  dollars.  They 
shall  have  their  names  upon  the  roll,  and  have 
all  the  rights  and  privileges  accorded  to  permanent 
members,  and  shall  retain  their  membership  on 
the  same  terms. 

Every  member  elect,  prior  to  the  permanent 
organization  of  the  annual  meeting,  or  before 
voting  on  any  question  after  the  meeting  has 
been  organized,  must  exhibit  his  credentials  to 
the  proper  committee,  and  sign  these  regulations, 
inscribing  his  name  and  address  in  full,  specifying 
in  what  capacity  he  attends,  and,  if  a  delegate, 
the  title  of  the  institution  from  which  he  has  re- 
ceived his  appointment. 

III. — MEETINGS. 

The  regular  meetings  of  the  Association  shall 
be  held  annually.  The  place  of  meeting  shall  be 
determined,  with  the  time  of  meeting  for  each 
next  successive  year,  by  vote  of  the  Association. 

IV. — OFFICERS. 

The  officers  of  the  Association  shall  be  a  Presi- 
dent, four  Vice-Presidents,  one  Permanent  and 
one  Assistant  Secretary,  a  Treasurer,  and  Li- 
brarian. They  shall  be  nominated  by  a  special 
committee  of  one  member  from  each  State  repre- 
sented at  the  meeting,  and  shall  be  elected  by 
vote  on  a  general  ticket. 

Each  officer  except  the  Permanent  Secretary, 
shall  hold  his  appointment  for  one  year,  ami  un- 
til another  is  elected  to  succeed  him.  The 
Permanent  Secretary  shall  hold  his  appointment 
until  removed  by  death,  resignation,  or  a  vote  of 
two- thirds  of  the  members  present  at  a  regular 
annual  meeting. 

The  President  and  Vice-Presidents  shall  as- 
sume the  functions  of  their  respective  offices  at 
the  beginning  of  the  annual  meeting  next  suc- 
their  election;  all  other  officers  shall 
enter  upon  their  duties  immediately  after  their 
election, 

The  Pri  sident  shall  preside  at  the  meetings,  pre- 
serve order  and  decorum  in  debate,  give  a  casting 
vote  when  necessary,  and  perform  all  the  other 
duties  that  custom  ami  parliamentary  usage  may 
require. 

The  Vice-Presidents,  when  called  upon,  shall 
assist  the  President  in  the  performance  of  his 
duties,  ami  during  tin-  absence,  o;    it  the  request 


iSoi.J 


AMERICAN   MEDICAL  ASSOCIATION. 


443 


of  the  President,  one  of  them  shall  officiate  in 
his  place. 

The  Permanent  Secretary  shall  record  the  min- 
utes and  authenticate  the  proceedings  :  give  due 
notice  of  the  time  and  place  of  each  next  ensuing 
annual  meeting;  notify  all  members  of  com- 
mittees of  their  appointment,  and  of  the  duties 
assigned  to  them;  hold  correspondence  with 
other  permanently  organized  medical  societies, 
both  domestic  and  foreign  ;  and  carefully  pre- 
serve the  archives  and  unpublished  transactions 
of  the  Association. 

The  Assistant  Secretary  shall  aid  the  Permanent 
Secretary  in  recording  and  authenticating  the 
proceedings  of  the  Association  ;  serve  as  a  mem- 
ber of  the  Committee  of  Arrangements,  and  per- 
form all  the  duties  of  Permanent  Secretary 
temporarily  whenever  that  office  shall  be  vacant, 
either  by  death,  resignation,  or  removal. 

The  Treasurer  shall  have  the  immediate  charge 
and  management  of  the  funds  and  property  of 
the  Association.  He  shall  give  to  the  Board  of 
Trustees  bonds  for  the  safe  keeping  and  proper 
use  and  disposal  of  his  trust.  And  through  the 
same  Board  he  shall  present  his  accounts,  duly 
authenticated,  at  every  regular  meeting. 

The  Librarian  shall  receive  and  preserve  all 
the  property  in  books,  pamphlets,  journals,  and 
manuscripts  presented  to  or  acquired  by  the  As- 
sociation, record  their  titles  in  a  book  prepared 
for  the  purpose  and  acknowledge  the  receipt  of 
the  same. 

V. — STANDING    COMMITTEES. 

The  Committee  of  Arrangements  shall,  if  no 
sufficient  reasons  prevent,  be  mainly  composed  of 
seven  members,  of  whom  the  Assistant  Secretary 
shall  be  one,  residing  in  the  place  at  which  the 
Association  is  to  hold  its  next  annual  meeting ; 
and  shall  be  required  to  provide  suitable  accom- 
modations for  the  meeting,  to  verif}'  and  report 
upon  the  credentials  of  membership,  to  receive 
and  announce  all  essays  and  memoirs  voluntarily 
communicated,  either  by  members  of  the  Associa- 
tion, or  by  others  through  them,  and  to  determine 
the  order  in  which  such  papers  are  to  be  read  and 
considered. 

The  Board  of  Trustees  shall  consist  of  nine  mem- 
bers, three  of  whom  shall  be  elected  annually,  on 
the  nomination  of  the  Nominating  Committee,  and 
shall  serve  for  three  years.  It  shall  be  the  duty 
of  this  Board  to  provide  for  and  superintend  the 
publication  and  distribution  of  all  such  proceed- 
ings, transactions,  and  memoirs  of  the  Associa- 
tion as  may  be  ordered  to  be  published,  in  such 
manner  as  the  Association  may  direct,  and  in 
doing  this  it  shall  have  authority  to  appoint  an 
editor  and  such  assistants,  and  determine  their 
salaries,  and  procure  and  control  such  materials 
as  may  be  necessary  for  the  accomplishment  of 
the  work  assigned  to  it.     To  further  facilitate  its 


work,  it  shall  be  the  duty  of  the  Secretaries  of 
the  Association,  and  of  the  several  sections  dur- 
i  annual  meeting,  or  as  soon  thereafter  as 
practicable,  to  deliver  to  the  Board,  or  such  edi- 
tor or  agent  as  it  shall  appoint,  all  such  records 
of  proceedings,  reports,  addresses,  papers  and 
other  documents  as  may  have  been  ordered  for 
publication  either  in  the  general  sessions  or  in 
the  sections.  All  moneys  received  by  the  Board 
of  Trustees,  or  its  agents,  resulting  from  the  dis- 
charge of  the  duties  assigned  them,  must  be  paid 
to  the  Treasurer  of  the  Association,  and  all 
orders  on  the  Treasurer  for  disbursements  of 
money  in  any  way  connected  with  the  work  of 
publication,  must  be  endorsed  by  the  President  of 
the  Board  of  Trustees.  It  shall  be  the  further 
duty  of  the  said  Board  of  Trustees  to  hold  the 
official  bond  of  the  Treasurer  for  the  faithful  ex- 
ecution of  his  office,  to  annually  audit  and  au- 
thenticate his  accounts,  and  present  a  statement 
of  the  same  in  its  annual  report  to  the  Associa- 
tion, which  report  shall  also  specify  the  character 
and  cost  of  all  the  publications  for  the  Associa- 
tion during  the  year,  the  number  of  copies  still 
on  hand,  and  the  amount  of  all  other  property 
belonging  to  the  Association,  under  its  control, 
with  such  suggestions  as  it  may  deem  necessary. 

VI.  —  FUNDS  AND  APPROPRIATIONS. 

Funds  shall  be  raised  by  the  Association  for 
meeting  its  current  expenses  and  awards  from 
year  to  year,  but  never  with  the  view  of  creating 
a  permanent  income  from  investments.  Funds 
may  be  obtained  by  an  equal  assessment  of  not 
more  than  ten  dollars  annually,  on  each  of  the 
delegates  and  permanent  members;  by  volun- 
tas contributions  for  specific  objects;  and  by  the 
sale  and  disposal  of  publications,  or  of  works  pre- 
pared for  publication. 

The  funds  may  be  appropriated  for  defraying 
the  expenses  of  the  annual  meetings,  including 
the  necessary  expenses  of  the  Permanent  Secre- 
tary in  maintaining  the  necessary  correspondence 
of  the  Association;  for  publication;  for  enabling 
the  Standing  Committees  to  fulfill  their  respective 
duties,  conduct  their  correspondence,  and  pro- 
cure the  materials  necessary  for  the  completion 
of  their  stated  annual  reports;  for  the  encourage- 
ment of  scientific  investigation  by  prizes  and 
awards  of  merit;  and  for  defraying  the  expenses 
incidental  to  specific  investigations  under  the  in- 
struction of  the  Association,  where  such  investi- 
gations have  been  accompanied  with  an  order  on 
the  Treasurer  to  supply  the  funds  necessary  for 
carrying  them  into  effect. 

VII. — PROVISION  FOR  AMENDMENT. 

No  amendment  or  alteration  shall  be  made  in 
any  of  these  articles,  except  at  the  annual  meet- 
ing next  subsequent  to  that  at  which  such  amend- 
ment or  alteration  may  have  been  proposed;  and 


444 


AMERICAN  MEDICAL  ASSOCIATION. 


[March  28, 


then  only  by  the  voice  of  three- fourths  of  all  the 
delegates  in  attendance. 

Provided,  however,  that  when  an  amendment 
is  properly  under  consideration,  and  an  amend- 
ment is  offered  thereto,  germane  to  the  subject,  it 
shall  be  in  order,  and  if  adopted,  shall  have  the 
same  standing  and  force  as  if  proposed  at  the  pre- 
ceding meeting  of  the  Association. 

BY-LAWS. 

I. — ORDER  OF  BUSINESS. 

The  order  of  business  at  the  annual  meetings 
of  the  American  Medical  Association  shall  at  all 
times  be  subject  to  the  vote  of  three- fourths  of  all 
the  members  in  attendance;  and,  until  permanent- 
ly altered,  except  when  for  a  time  suspended,  it 
shall  be  as  follows,  namely : 

1st.  The  calling  of  the  meeting  to  order  by  the 
President  elected  the  preceding  year,  or,  in  his 
absence,  by  one  of  the  Vice-Presidents. 

2nd.  The  report  of  the  Committee  of  Arrange- 
ments on  the  credentials  of  members,  after  the 
latter  have  registered  their  names  and  addresses, 
and  the  titles  of  the  institutions  which  they  repre- 
sent. 

3d.  The  reception  of  members  by  invitation. 

4th.  The  election  of  permanent  members. 

5th.  The  reading  of  notes  from  absentees. 

6th.  The  hearing  of  the  annual  address  of  the 
President. 

7th.  The  reception  of  the  reports  of  all  special 
committees  and  voluntary  communications,  and 
their  reference  to  the  appropriate  Sections. 

8th.  The  appointment  of  the  committee  of  one 
from  each  State  represented,  to  nominate  officers 
of  the  Association,  and  to  fill  the  standing  com- 
mittees. 

9th.  The  reading  and  consideration  of  the  re- 
ports of  the  Standing  Committees,  of  Publication, 
on  Prize  Essays,  and  of  Chairmen  of  Sections. 

10th.  Resolutions  introducing  new  business, 
and  instructions  to  the  permanent  committees. 

nth.  The  selection  of  the  next  place  of  meet- 
ing. 

12th.  The  report  of  the  Nominating  Commit- 
tee, and  the  election  of  officers  of  the  Association. 

13th.  Reports  from  the  several  Sections. 

14th.   Reading  of  the  minutes  by  the  Secretary. 

15th.   Unfinished  and  miscellaneous  business. 

16th.  Adjournment. 

II. — SECTIONS. 

The  general  meetings  of  the  Association  shall 
be  restricted  to  the  morning  sessions;  and  the 
afternoon  sessions,  commencing  at  three  o'clock, 
shall  be  devoted  to  the  hearing  of  reports  and 
papers  and  their  consideration,  in  the  following 
Sections. — 

1.  Practical  Medicine  and  Physiology. 

2.  Obstetrics  and  Diseases  of  Women. 


3.  Surgery  and  Anatomy. 

4.  State  Medicine. 

5.  Ophthalmology. 

6.  Diseases  of  Children. 

7.  Dental  and  Oral  Surgery. 

8.  Medical  Jurisprudence  and  Neurology. 

9.  Dermatology  and  Syphilis. 

10.  Laryngology  and  Otology. 

11.  Materia  Medica  and  Pharmacy. 

On  the  second  day  of  each  annual  meeting  each 
Section  shall  nominate  its  own  officers  to  serve 
for  the  next  ensuing  year,  their  duties  to  com- 
mence with  the  close  of  the  annual  meeting  at 
which  they  are  nominated  and  to  continue  until 
their  successors  are  appointed. 

The  Section  on  State  Medicine  shall  be  com- 
posed of  one  member  from  each  State,  one  from 
the  army  and  one  from  the  navy  of  the  United 
States,  representing,  as  far  as  practicable,  the 
State  Boards  of  Health.  The  officers  of  this  Sec- 
tion to  be  also  designated  by  the  Committee  on 
Nominations. 

The  Chairman  of  each  Section  shall  prepare  an 
address  on  the  recent  advances  in  the  branches 
belonging  to  his  Section,  including  such  sug- 
gestions in  regard  to  improvements  or  methods 
of  work  as  he  may  regard  important,  and  present 
on  the  first  day  of  its  annual  session  the  same  to 
the  Section  over  which  he  presides.  The  reading 
of  such  address  not  to  occupy  more  than  forty 
minutes. 

It  shall  be  the  duty  of  every  member  of  the 
Association  who  proposes  to  present  a  paper  or 
report  to  any  one  of  the  Sections,  to  forward 
either  the  paper,  or  a  title  indicative  of  its  con- 
tents, and  its  length,  to  the  Chairman  of  the  Com- 
mittee of  Arrangements  at  least  one  month  be- 
fore the  annual  meeting  at  which  the  paper  or 
report  is  to  be  read.  It  shall  also  be  the  duty  of 
the  Chairman  and  Secretary  of  each  Section  to 
communicate  the  same  information  to  the  Chair- 
man of  the  Committee  of  Arrangements  concern- 
ing such  papers  and  reports  as  may  come  into 
their  possession  or  knowledge,  for  their  respective 
Sections,  the  same  length  of  time  before  the  an- 
nual meeting.  And  the  Committee  of  Arrange- 
ments shall  determine  the  order  of  reading  or 
presentation  of  all  such  papers,  and  announce  the 
same  in  the  form  of  a  programme  for  the  use 
of  all  members  attending  the  annual  meeting. 
Such  programme  shall  also  contain  the  rules  speci- 
fied in  the  By-laws  and  Ordinances  concerning  the 
consideration  and  disposal  of  all  papers  in  the 
Sections. 

No  paper  shall  be  read  before  either  of  the  Sec- 
tions, the  reading  of  which  occupies  more  than 
twenty  minutes.  Such  papers  shall  be  referred 
by  the  Section  to  sub  committees  specially  ap- 
pointed for  their  examination.  The  sub-commit- 
tees shall  be  allowed  thirty  days  for  such  exam- 
ination; at  the  end  of  which  time  they  shall  for- 


-gi.] 


AMERICAN   MEDICAL  ASSOCIATION. 


445 


ward  the  papers  to  the  Board  of  Trustees,  with 
such  recommendation  as  they  may  deem  proper. 
The  author  of  such  papers,  however,  may  read 
ts  before  the  Section  within  the  allotted 
twenty  minutes.  No  member  shall  address  the 
Section  more  than  once  upon  the  same  subject, 
nor  speak  longer  than  fifteen  minutes  without 
unanimous  consent. 

All  papers  presented  directly  to  the  Association, 
and  other  matters,  may,  at  the  discretion  of  the 
Association,  be  referred  to  the  various  Sections 
for  their  consideration  and  report. 

III. — STANDING  COMMITTEES. 

The  following  are  the  Standing  Committees  of 
the  Association,  to  be  filled  by  the  Committee  on 
Nominations,  and  to  report  at  the  next  annual 
meeting  subsequent  to  their  appointment,  namely, 
Committee  of  Arrangements,  Board  of  Trustees, 
and  Committee  on  American  Medical  Necrology. 

The  Board  of  Trustees  shall  append  to  each 
volume  of  the  Transactions  hereafter  published,  a 
copy  of  the  Constitution,  By-laws  and  Code  of 
Ethics  of  the  Association.  It  shall  print  con- 
spicuously, at  the  beginning  of  each  volume  of 
the  Transactions  the  following  disclaimer,  namely, 
The  American  Medical  Association,  although 
formally  accepting  and  publishing  the  reports  of 
the  various  standing  committees,  holds  itself 
wholly  irresponsible  for  the  opinions,  theories  or 
criticisms  therein  contained,  except  when  other- 
wise decided  by  special  resolution. 

The  Committee  on  American  Medical  Necrology 
shall  consist  of  one  member  for  each  State  and 
Territory  represented  in  the  Association,  whose 
duty  it  shall  be  to  procure  memorials  of  the  emi- 
nent and  worthy  dead  among  the  distinguished 
phvsicians  of  their  respective  States  and  Terri- 
tories, and  transmit  them  to  the  chairman  of  this 
committee  on  or  before  the  ist  of  April  of  each 
and  every  year. 

IV. — THE  PUBLICATION  OF  PAPERS  AND  REPORTS. 

No  report  or  other  paper  shall  be  entitle?!  to 
publication  in  the  volume  for  the  year  in  which 
it  shall  be  presented  to  the  Association,  unless  it 
be  placed  in  the  hands  of  the  Board  of  Trustees 
on  or  before  the  first  day  of  July.  It  must  also 
be  so  prepared  as  to  require  no  material  alteration 
or  addition  at  the  hands  of  its  author. 

Authors  of  papers  are  required  to  return  their 
proofs  within  two  weeks  after  their  reception; 
otherwise  they  will  be  passed  over  and  omitted 
from  the  volume. 

Every  paper  received  by  this  Association  and 
ordered  to  be  published,  and  all  plates  or  other 
means  of  illustration,  shall  be  considered  the  ex- 
clusive property  of  the  Association,  and  shall  be 
published  and  sold  for  the  exclusive  benefit  of 
the  Association. 

The  Board  of  Trustees  shall  have  full  discre- 
tionary power  to  omit  from  the  published  Trans-  \ 


in  part  or  in  whole,  any  paper  that  may 
be  referred  to  it  by  the  Association,  or  either  of 
the  Sections,  unless  specially  instructed  to  the 
contrary  by  vote  of  the  Association. 
V. — ASSESSMENTS, 
sum  of  five  dollars  shall  be  assessed  an- 
nually, upon  each  delegate  to  the  sessions  of  the 
Association,  as  well  as  upon  each  of  its  permanent 
members,  whether  attending  or  not,  for  the  pur- 
pose of  raising  a  fund  to  defray  necessary  ex- 
penses. The  payment  of  this  sum  shall  be  re- 
quired of  the  delegates  and  members  in  attend- 
ance upon  the  sessions  of  the  Association  previ- 
ously to  their  taking  their  seats  and  participating 
in  the  business  of  the  sessions.  Permanent  mem- 
bers, not  in  attendance,  shall  transmit  their  dues 
to  the  Treasurer. 

Any  permanent  member  who  shall  fail  to  pay 
his  annual  dues  for  three  successive  years,  unless 
absent  from  the  country,  shall  be  dropped  from 
the  roll  of  permanent  members,  after  having  been 
notified  by  the  Secretary  of  the  forfeiture  of  his 
membership. 

VI. — DELEGATES  FROM  THE  MEDICAL   STAFFS    OF 

THE  ARMY,    NAVY,   AND  MARINE-HOSPITAL 

SERVICE. 

Delegates  representing  the  medical  staffs  of  the 
United  States  Army  and  Navy,  shall  be  ap- 
pointed by  the  Chief  of  the  Army  and  Navy  Med- 
ical Bureaus,  and  the  U.  S.  Marine- Hospital  Ser- 
vice. The  number  of  delegates  so  appointed  shall 
be  four  from  the  army  medical  officers,  and  an 
equal  number  from  the  navy  medical  officers,  and 
one  from  the  Marine-Hospital  Service. 

VII. — DELEGATES  TO  FOREIGN  MEDICAL 
SOCIETIES. 

The  President  shall  be  authorized  annually  to 
appoint  delegates  to  represent  this  Association  at 
the  meetings  of  the  British  Medical  Association, 
the  American  Medical  Society  at  Paris,  and  such 
other  scientific  bodies  in  Europe  or  other  foreign 
countries  as  may  be  affiliated  with  us. 

VIII. — DUTIES  OF  MEMBERS. 

No  one  shall  be  permitted  to  address  the  Asso- 
ciation, except  he  shall  have  first  given  his  name 
and  residence,  which  shall  be  distinctly  an-  . 
nounced  from  the  chair,  and  the  member  may  be 
required  to  go  forward  and  speak  from  the  stand, 
but  not  more  than  ten  minutes  at  one  time. 

No  one  appointed  on  a  special  committee,  who 
fails  to  report  at  the  meeting  next  succeeding  the 
one  at  which  he  is  appointed,  shall  be  continued 
on  such  committee,  or  appointed  on  any  other, 
unless  a  satisfactory  excuse  is  offered. 

IX. — CONDITION  EXCLUDING  REPRESENTATION. 

No  State  or  Local  Medical  Society,  or  other 
organized  institution,  shall  be  entitled  to  repre- 
sentation in  this  Association  that  has  not  adopted 
its  Code  of  Ethics;  or  that  has  intentionally  vio- 


446 


AMERICAN  MEDICAL  ASSOCIATION. 


[March  28, 


lated  or  disregarded  any  article  or  clause  of  the 
same. 

X. — OF  THE  PREVIOUS  QUESTION. 

When  the  previous  question  is  demanded,  it 
shall  take  at  least  twenty  members  to  second  it; 
and  when  the  main  question  is  put  under  force  of 
the  previous  question  and  negatived,  the 
question  shall  remain  under  consideration  the 
same  as  if  the  previous  question  had  not  been 
enforced. 

XI. — JUDICIAL  COUNCIL. 

A  council,  consisting  of  twenty- one  members, 
shall  be  appointed  by  the  Nominating  Committee, 
whose  duty  it  shall  be  to  take  cognizance  of,  and 
decide,  all  questions  of  an  ethical  or  j  udicial  charac- 
ter that  may  arise  in  connection  with  the  Associ- 
ation. Of  the  twenty-one  members  of  the  council 
first  appointed  the  seven  first  named  on  the  list 
shall  hold  office  one  year,  and  the  second  seven 
named  shall  hold  office  for  two  years. 

With  these  exceptions  the  term  of  office  of 
members  of  the  council  shall  be  three  years, 
seven  being  appointed  by  the  Nominating  Com 
mittee  annually. 

The  said  council  shall  organize  by  choosing  a 
President  and  Secretary,  and  shall  keep  a  per- 
manent record  of  its  proceedings.  The  decisions 
of  said  council  on  all  matters  referred  to  it  by  the 
Association  shall  be  final,  and  shall  be  reported 
to  the  Association  at  the  earliest  practical  mo- 
ment. 

All  questions  of  a  personal  character,  including 
complaints  and  protests,  and  all  questions  on 
credentials,  shall  be  referred  at  once,  after  the  re- 
port of  the  Committee  of  Arrangements  or  other 
presentation,  to  the  Judicial  Council,  and  without 
discussion. 

XII. —NEW   BUSINESS. 

No  new  business,  resolutions  by  members,  etc. , 
shall  be  introduced  at  the  general  session  of  the 
Association  except  on  the  first  and  fourth  days 
of  meetings. 

XIII, — OFFICERS  AND   COMMITTEES. 

In  the  election  of  officers  and  appointment  of 
committees  by  this  Association  and  its  President, 
they  shall  be  confined  to  members  and  delegates 
present  at  the  meeting,  except  in  the  Committee 
of  Arrangements. 

XIV. — ADDRESSES. 

The  Association  shall  annually  elect,  on  the 
nomination  of  the  Nominating  Committee,  three 
members  of  the  profession,  eminent  in  some  of  its 
departments,  to  deliver  addresses  in  the  general 
□  of  the  next  ensuing  annual  meeting — one 
on  some  topic  or  topics  relating  to  general  med- 
icine, another  relating  to  general  surgery,  and 
the  third  relating  to  public  medicine,  including 
under  that  bead,  hygiene,  sanitation,  prophylaxis, 
education  and   medical  legislation,  each  of  such 


addresses  not  to  exceed  one  hour  it  its  delivery. 

The  following  resolution  was  adopted  at  the  ses- 
sion of  1888  : 

That  in  future,  each  delegate  or  permanent 
member,  shall,  when  he  registers,  also  record  the 
name  of  the  Section,  if  any,  that  he  will  attend, 
and  in  which  he  will  cast  his  vote  for  Section  offi- 
cers. 

Also,  that  the  Permanent  Secretary  may  be  en- 
abled to  erase  from  the  roll  the  names  of  those  who 
have  forfeited  their  membership,  the  Secretaries 
are,  by  special  resolution,  requested  to  send  to  him 
annually,  a  corrected  list  of  the  membership  of 
their  respective  Societies. 

ORDINANCES. 

Resolved,  That  the  several  Sections  of  this  Asso- 
ciation be  requested,  in  the  future,  to  refer  no  pa- 
pers or  reports  to  the  Board  of  Trustees,  except 
such  as  can  be  fairly  classed  under  one  of  the  three 
following  heads,  namely:  1.  Such  as  may  contain 
and  establish  positively  new  facts,  modes  of  prac- 
tice or  principles  of  real  value.  2.  Such  as  may 
contain  the  results  of  well  devised  original  ex- 
perimental researches.  3.  Such  as  present  so 
complete  a  review  of  the  facts  on  any  particular 
subject  as  to  enable  the  writer  to  deduce  there- 
from legitimate  conclusions  of  importance. 

Resolved,  That  the  several  Sections  be  re- 
quested, in  the  future,  to  refer  all  such  papers  as 
may  be  presented  to  them  for  examination  by 
this  Association,  that  contain  matter  of  more  or 
less  value,  and  yet  cannot  be  fairly  ranked  under 
either  of  the  heads  mentioned  in  the  foregoing 
resolution,  back  to  their  authors  with  the  recom- 
mendation that  they  be  published  in  such  regular 
medical  periodicals  as  said  authors  may  select, 
with  the  privilege  of  placing  at  the  head  of  such 
papers,  "Read  to  the  Section  of  the 

American  Medical  Association  on    the  day 

of  iS     ."     (Vide  Transactions,  Vol.  xvi, 

p.  40.) 

Resolved,  That,  instead  of  yearly  reprinting  the 
list  of  members  of  the  American  Medical  Associ- 
ation, the  Board  of  Trustees  be  instructed  to  pre- 
pare and  print  in  the  Transactions  an  alphabeti- 
cal catalogue  triennially,  containing  a  complete 
list  of  the  Permanent  Members,  with  their  names 
in  full,  designating  their  residences,  the  year  of 
their  admission,  the  offices  they  have  held  in  the 
Association,  and,  in  case  of  death  or  rejection, 
the  date  thereof.       (Vide  Transactions,  Vol.  xvii, 

P-  33) 

Resolved,  That  no  report  or  other  paper  shall 
be  presented  to  this  Association  unless  it  be  so 
prepared  that  it  can  be  put  at  once  into  the  hands 
of  the  Permanent  Secretary,  to  be  transmitted  to 
the  Board  of  Trustees.  (Vide  'Transactions,  Vol. 
xvii,  p.  27.) 

ed,  That  the  Permanent  Secretary  here- 
after  and  from  this  date  be  authorized  to  draw  a 


I89i.] 


AMERICAN  MEDICAL  ASSOCIATION. 


447 


warrant  upon  the  Treasurer  for  the  expenses  in- 
curred in  bis  attendance  upon  each  session  of  the 
Association,  and  that  the  Treasurer  is  hereby 
instructed  to  pay  the  same.  (Vide  Transactions, 
Vol.  xviii,  p.  42.) 

<e<t,  That  the  faculties  of  the  several  med- 
ical colleges  of  the  United  States  lie  recommended 
to  announce  explicitly  in  their  annual  announce- 
ments, circulars  and  advertisements  that  they  will 
not  receive  certificates  of  time  of  study  from  irreg- 
ular practitioners,  and  that  they  will  not  confer ' 
the  degree  upon  any  one  who  may  acknowledge 
his  intention  to  practice  in  accordance  with  any 
exclusive  system.     (Vide  Transactions,  Vol.  xix,  ' 

P-  3I-) 

Resolved,  That  those  gentlemen  who  desire  to 
report  on  special  subjects  and  will  pledge  them- 
selves to  report  at  the  next  meeting,  be  requested 
to  send  their  names,  and  the  subjects  on  which 
they  desire  to  report  to  the  Permanent  Secretary. 
(Vide  Transactions,  Vol.  xix,  p.  42.) 

Resolved,  That  hereafter  the  necessary  expenses 
for  rent  of  hall  for  general  meetings  and  rooms 
for  Sections  to  accommodate  the  annual  meetings, 
and  the  necessary  expenses  for  cards  of  member- 
ship, be  paid  out  of  the  treasury  of  the  Association. 
(Vide  Transactions,  Vol.  xix,  p.  42.) 

Resolved,  That  each  State  Medical  Society  be 
requested  to  prepare  an  annual  register  of  all  the 
regular  practitioners  of  medicine  in  their  respec- 
tive States,  giving  the  names  of  the  college  in 
which  they  may  have  graduated,  and  date  of  di 
ploma  or  license.  (Vide  Transactions,  Vol.  xx, 
p.  20.) 

Resolved,  That  this  Association  recognizes  spe- 
cialties as  proper  and  legitimate  fields  of  labor. 

Resolved,  That  specialists  shall  be  governed  by 
the  same  rules  of  professional  etiquette  as  have 
been  laid  down  for  general  practitioners. 

Resolved,  That  it  shall  not  be  proper  for  spe- 
cialists publicly  to  advertise  themselves  such,  or 
to  assume  any  title  not  specially  granted  by  a 
regularly  chartered  college. 

Resolved,  That  private  handbills  addressed  to 
members  of  the  medical  profession,  or  by  cards  in 
medical  journals,  calling  the  attention  of  profes- 
sional brethren  to  themselves  as  specialists,  be 
declared  in  violation  of  the  Code  of  Ethics  of  the 
American  Medical  Association.  (Vide  Transac- 
tions, Vol.  xx,  p.  28.) 

red,  That  a  committee  of  one  be  appointed 

residing  at  Washington,  to  render  the  Librarian 

of  Congress  such  assistance  as  the  interests  of  the 

ition   may   require.       (Vide    Transactions, 

Vol.  xx,  p.  29. 1 

WHEREAS,  The  proper  construction  of  Art. 
IV,  Sec.  1,  Code  of  Ethics,  A.  M.  A.,  having 
been  called  for,  relative  to  consultation  with  irreg- 
ular practitioners  who  are  graduates  of  regular 
schools. 

Resolved,  That  said    Art.   IV,  Sec.  1,  Code  of 


Ethics,  excludes  all  such  practitioners  from  recog- 
nition by  the  regular  profession.  (Vide  Trans- 
actions, Vol.  xx,  p.  30.) 

Resolved,  That  if  any  member  fail  to  reply  for 
more  than  one  year  to  the  circular  sent  to  him  by 
the  Board  of  Trustees  he  shall  forfeit  his  right  to 
tfie  volume,  and  it  shall  revert  to  the  Association, 
to  be  sold  to  any  applicant  at  the  current  rates. 
(Vide  Transactions,  Vol.  xxi,  p.  30.) 

Resolved,  That  the  Committee  of  Arrangements 
for  the  next  ensuing  meeting  of  this  Association, 
and  for  all  meetings  thereafter,  be  directed  to  pre- 
pare a  list  of  members  present  on  a  separate  roll, 
for  convenience  and  accuracy  in  calling  the  ayes 
and  nays  when  the  same  shall  be  demanded. 
(Vide  Transactions,  Vol.  xxi,  p.  60.) 

Resolved,  That  each  year,  until  otherwise 
ordered,  the  President-elect  and  the  Permanent 
Secretary  be  directed  to  appeal  in  the  name  of 
the  Association  to  the  authorities  of  each  State 
where  no  State  Board  of  Health  exists,  urging 
them  to  establish  such  boards.  (Vide  Transac- 
tions. Vol.  xxvi,  p.  50.) 

Resolved,  That  the  Permanent  Secretary  is 
hereby  directed  annually  to  report  the  names  of 
States  where  boards  of  health  exist,  and  also  of 
those  which  decline  to  establish  them;  said  re- 
port to  form  a  part  of  the  annual  proceedings  of 
the  Association.     (Vide  Transactions,  Vol.  xxvi, 

P-  SO.) 

Resolved,  That  members  of  the  medical  profes- 
sion who  in  any  way  aid  or  abet  the  graduation 
of  medical  students  in  irregular  or  exclusive  sys- 
tems of  medicine,  are  deemed  thereby  to  violate 
the  spirit  of  the  ethics  of  the  American  Medical 
Association.  (Vide  Transactions,  Vol.  xxvii,  p. 
48.) 

:vd.  i.  That  the  American  Medical  Asso- 
ciation adopts  the  International  Metric  System, 
and  will  use  it  in  its  Transactions,  (Vide  Trans- 
actions, Vol,  xxx,  p.  44.  ) 

2.  Requests  that  those  who  present  papers  at 
its  future  meetings  employ  this  system  in  their 
communications, or  reprints  thereof.  (Vide  'Trans- 
actions, Vol.  xxx,  p.  44.) 

3.  Requests  the  medical  boards  of  the  hospitals 
and  dispensaries  to  adopt  the  Metric  System  in 
prescribing  and  recording  cases  ;  and  that  the 
Faculties  of  the  medical  aud  pharmaceutic 
schools  adopt  it  in  their  didactic,  clinical,  or 
dispensing  departments.  (Vide  Transactions,  Vol. 
xxx,  p.  44.^ 

ed,  That  the  President  and  Secretary  of 
this  Association  are  directed  to  annually  petition 
Congress  to  enact  a  law  which  shall  permit  every 
person  engaged  in  a  scientific  pursuit  to  import 
for  his  own  use,  free  of  duty,  any  one  book  or  in- 
strument appertaining  to  his  special  pursuit. 
(Vide  Transadio   .-.  Vol.  xxx,  p.   ; 

,<d.  That  the  above-named  officers  are 
further  directed  to  urge  the  State  Medical  Socie- 


448 


MEDICAL  PROGRESS. 


[March  28 


ties  and  their  auxiliary  branches  to  aid  this  As- 
sociation in  accomplishing  this  purpose,  by  peti- 
tions to  Congress,  and  by  otherwise  influencing 
Congressmen.       (Vide   Tra?isactions,   Vol.    xxx, 

Decision  by  Judicial  Council:  A  gentleman  who 
is  not  in  affiliation  with  a  Count}',  District,  or 
State  Medical  Society,  where  such  organizations 
exist,  is  not  entitled  to  be  registered  as  a  perma- 
nent member  upon  the  claim  of  having  been  a 
delegate  from  a  body  not  now  entitled  to  repre- 
sentation in  this  body.  (Vide  Transactions,  Vol. 
xxx,  p.  57.) 

Resolved:  First.  That  a  committee  of  five  be 
appointed  by  the  President  of  the  Association,  to 
be  called  the  Standing  Committee  on  "  Atmos- 
pheric Conditions,  and  their  relations  to  the  pre- 
valence of  Diseases." 

Second.  That  that  committee  be  authorized  to 
select  such  places  as  will  best  indicate  atmos- 
pheric conditions  in  the  more  important  climatic 
and  sanitary  districts  of  the  United  States — not 
less  than  six,  nor  more  than  twelve — and  estab- 
lish therein  a  means  for  continuous  observation 
and  record  of  all  appreciable  conditions  of  atmos- 
phere, according  to  the  most  approved  methods, 
and  of  the  origin  and  prevalence  of  all  acute  dis- 
eases. 

Third.  That  the  Committee,  through  their 
chairman,  be  authorized  to  draw  upon  the  Treas- 
urer of  this  Association  for  such  sums  as  may  be 
found  necessary  for  the  proper  execution  of  the 
work  assigned  to  it,  the  aggregate  amount  not  to 
exceed  $500,  during  the  ensuing  year,  and  that  a 
detailed  report  of  all  sums  drawn  and  expendi- 
tures made  must  be  presented  at  the  next  annual 
meeting  of  the  Association.  (Vide  Transactions, 
Vol.  xxxii,  p.  35.) 

Resolved,  That  the  regular  graduates  of  such 
dental  and  oral  schools  and  colleges  as  require  of 
their  students  a  standard  of  preliminary  or  gener- 
al education,  and  a  term  of  professional  study 
equal  to  the  best  class  of  medical  colleges  of  this 
country,  and  embrace  in  this  curriculum  all  the 
fundamental  branches  of  medicine,  differing  chief- 
ly by  substituting  practical  and  clinical  instruc- 
tion in  dental  and  oral  medicine  and  surgery,  in 
place  of  practical  and  clinical  instruction  "in  gen- 
eral medicine  and  surgery,  be  recognized  as  mem- 
bers of  the  regular  profession  of  medicine,  and 
eligible  to  membership  in  this  Association  on  the 
same  conditions  and  subject  to  the  same  regula- 
tions as  otlur  members.  (See  Journal  of  the 
Amer.  Med.  Assoc'n,  Vol.  viii,  p.  722.) 

Whereas,    It  has  been  the  unswerving  policy  of 

the  Trustees  for  the  publication  of  The  Journal, 

to  enlarge  and  increase  tiie   value  of  The  Jour- 

the  income  of  the  Association  will 

permit,  therefore,   ' 

Resolved,  That  said  Hoard  of  Trustees  be  a 
Standing  Committee   on    Finance  to   which   all 


propositions  for  the  appropriation  of  money,  made 
hereafter,  shall  be  referred  and  reported  upon  be- 
fore final  action  on  the  same  by  the  Association. 
(See  Journal  *of  the  Amer.  Med.  Assoc'n, 
Vol.  viii,  p.  722,  1887.) 


MEDICAL   PROGRESS. 


Therapeutics  an«l  Pharmacology. 

Professor  Liebreich's  Remedy  for  Tuber- 
culosis.— Liebreich  has  given  to  the  Berlin 
Medical  Society  an  account  of  his  newly  proposed 
remedy  which  consists  of  cantharidate  of  potash 
— being  0.2  gram  of  pure  cantharidin  and  0.4 
gram  of  potassic  hydrate — in  20  cubic  centimetres 
of  water.  He  uses  the  remedy  by  subcutaneous 
injections,  beginning  with  not  more  than  one- 
fiftieth  part  of  a  decimilligram  of  the  solution. 
The  dose  is  gradually  increased  until  one  or  two 
decimilligrams  have  been  attained  ;  it  is  likely 
that  six  decimilligrams  will  be  found  to  be  the 
maximum  dose.  The  drug  appears  to  affect  dis- 
eased tissues  only,  and  it  may  be  applicable  to 
other  affections  besides  tuberculosis.  Drs.  Hey- 
mann  and  B.  Fraenkel  have  made  the  clinical  ex- 
periments thus  far  reported.  They  have  no  cures 
to  report,  but  they  have  been  agreeably  impressed 
by  the  measure  of  amelioration  in  some  of  their 
cases  and  the  absence  of  any  untoward  conse- 
quences. It  has  been  found  that  expectoration 
has  been  increased,  an  effect  which,  as  Liebreich 
infers,  is  due  to  the  specific  property  of  cantharidin 
to  excite  serous  exiidation  from  capillar}'  vessels, 
especially  in  those  that  have  already  been  the 
subject  of  morbid  irritation. 

Medicine. 

Arthritis  Blennorrhoica. — Deutschmann 
(Archivfur  Ophthalmologic')  has  observed  a  child 
three  weeks  old,  with  ophthalmia  neonatorum, 
that  later  presented  redness  and  swelling  of  the 
knee-joint.  Gonococci  were  found  in  the  secre- 
tion of  the  conjunctival  sack  in  large  numbers, 
and  also  in  smaller  proportion  in  a  portion  of  the 
joint  secretion  obtained  by  exploratory  puncture. 
The  writer  is  of  the  opinion  that  the  cocci  were 
carried  directly  by  the  blood  or  lymphatics,  from 
the  conjunctival  sack  to  the  joint. 

Lead  Poisoning  Treated  by  Iodide  of 
Iron. — The  following  practical  suggestion  in 
, .-.  for  February  14,  is  quoted  from  a 
medical  journal  of  Lille,  full  title  not  given,  re- 
garding the  treatment  of  workmen  in  white  lead 
who  suffer  from  lead-poisoning.  It  is 
stated  b}  M.  Lavrand  that  he  lias  found  the 
iodide  of  iron,  in  the  form  of  pills  as  prescribed 
in  the  French  Codex,  very  efficious  in  the  above 
named  condition.     Sometimes  he  gives  these  pills 


i89i.] 


MEDICAL  PROGRESS. 


449 


alone,  at  other  times  he  combines  the  iron  with 
the  phosphide  of  zinc.  Under  this  treatment, 
workmen  who  have  already  begun  to  show  signs 
of  plumbism  were  enabled  to  continue  their  oc- 
cupation ;  their  general  health  also  improved, 
and  the  amount  of  haemoglobin  was  increased. 

Obstetrics  ami  Diseases  of  Women. 

Ovariotomy  During  Pregnancy. — The 
British  Medical  Journal  contains  an  editorial  com- 
ment on  the  report  of  Engstro.m.  of  Helsiugfors, 
concerning  seven  cases  of  the  above  named  oper- 
ation, published  in  the  Annates  de  Gynecologie  for 
November,  1890.  In  two  of  these  casts  the 
ovariotomy  was  performed  during  the  second 
month,  while  the  other  five  ranged  between  the 
third  and  seventh  months  of  gestation.  All 
seven  patients  survived  the  operation,  and  with  a 
single  exception  all  went  on  their  time  of  ac- 
couchment,  giving  birth  to  living  children.  In 
the  exceptional  case  abortion  occurred  at  the  third 
month,  and  it  is  stated  that  she  had  aborted  three 
times  previously,  early  in  gestation.  In  the 
course  of  the  operation  in  this  case  the  uterus 
was  wounded,  as  the  tumor  was  sessile.  For 
some  years  past,  pregnancy  has  not  been  held  by 
ovariotomists  to  be  a  contra- indication  to  abdom- 
inal operations,  since  it  has  been  found  that  such 
operations  are  not  only  not  necessarily  fatal,  and 
that  they  do  not  of  necessity  result  in  abortion. 
In  some  cases  there  have  been  removed  success- 
fully cysts  of  large  size  or  large  solid  tumors,  the 
very  gravity  of  the  ovarian  disease  having  been 
the  incentive  to  the  surgeon  to  undertake  the  op- 
eration, in  order  that  by  so  doing  the  pregnant 
uterus  might  be  liberated  from  its  ovarian  com- 
plication. On  the  other  hand,  a  small  tumor  has 
been  regarded  as  an  indication  to  operation,  since 
the  progress  of  uterine  evolution  in  pregnancy 
may  involve  a  torsion  of  the  ovarian  pedicle  and 
all  its  perilous  sequels. 

As  to  the  method  of  operation  in  these  cases, 
it  is  advised  that  the  incision  should  be  made 
high,  and  begin  near  the  umbilicus,  especially  if 
the  tumor  lies  high,  so  as  to  avoid  as  far  as  pos- 
sible any  excessive  traction  on  the  pedicle  of  the 
tumor.  The  uterus  should  be  exposed  as  little 
as  possible  during  the  operation,  since  atmospheric 
contact  is  often  an  excitant  to  uterine  contrac- 
tion. A  warm  sponge  should  be  made  to  cover 
the  exposed  surface  during  the  time  of  the 
tumor's  extraction.  After  the  operation,  a  care- 
fully adjusted  bandage  will  ordinarily  secure  the 
healing  abdominal  wound  against  damage  during 
the  subsequent  stages  of  gestation.  Engstrom 
favors  the  removal  of  an  ovarian  complication  of 
pregnancy  whenever  the  diagnosis  becomes  clear, 
and  he  quotes  the  experience  of  Jetter  to  the 
effect  that  the  tumor,  if"  left  alone,  is  liable  to  be- 
come a  serious  source  of  danger.  Some  of  the 
worst  casts  of  torsion  of   the  pedicle  have  oc- 


curred during  pregnancy,  and  the  foetus  is  in 
especial  danger,  not  less  than  48  per  cent,  perish- 
ing, either  by  a  premature  arrest  of  pregnancy  or 
by  accident  during  parturition.  The  statistics 
obtained  by  Engstrom  in  regard  to  the  results  of 
operation  in  these  cases  appear  to  show  that  not 
more  than  20  per  cent,  was  attended  by  prema- 
ture delivery  ;  and  in  some  of  these  cases  there 
was  a  wounding  of  the  uterus  in  the  course  of 
the  operation — and  where  this  complication  arises 
the  presumption  that  the  uterus  will  be  evacuated 
is  almost  inevitable.  It  is  not,  of  course,  claimed 
that  ovariotomy  can  be  practiced  in  all  these 
cases,  as  for  example,  in  those  patients  where 
the  tumor  is  large  and  lies  low,  occupying  the 
pelvic  cavity,  and  the  uterus  has  already  de- 
veloped to  a  considerable  size.  In  one  such  case, 
Engstrom  induced  labor  at  the  seventh  month, 
and  afterwards  removed  the  tumor. 
Pathologrs . 

Scarlatinal  Cirrhosis.— Dr.  Saundby,  of 
Birmingham,  in  the  British  Medical  Journal,  De- 
cember 27,  treats  of  some  of  the  rarer  forms  of 
hepatic  cirrhosis,  such  as  the  diabetic,  rachitic 
and  scarlatinal  varieties.  In  regard  to  the  last 
named  variety,  he  thinks  that  a  decidedly  practi- 
cal interest  may  be  involved  in  it  as  a  possible 
cause  of  those  not  very  uncommon  cases  of  cir- 
rhosis met  with  at  the  post-mortem  table  in  young 
children.  Scarlatinal  cirrhosis  may  be  said  to  be 
known  only  to  the  pathologists,  who  have  found 
it  in  the  bodies  of  persons  dead  from  the  sequelae, 
of  scarlet  fever.  The  liver,  in  these  cases,  pre- 
sents no  abnormal  change  that  can  be  recognized 
by  the  naked  eye,  but  the  microscope  shows  com- 
mencing new  formation  of  fibrous  tissue  in  the 
portal  canals,  fissures  and  spaces. 

Ophthalmology. 

•  Panophthalmitis. — Dr.  Vknidks,  of  Smyr- 
na, (Journal  de  Midecine  de  Paris),  Feb.i,  1891), 
claims  that  early  operative  interference  should  be 
insisted  upon  in  all  these  cases.  He  reports  one 
case  of  evisceration  in  a  child  a  few  weeks  old, 
that  was  followed  by  recovery  in  a  case  apparently 
hopeless. 

In  adults  he  regards  enucleation  as  the  prefera- 
ble procedure,  while  in  children  he  thinks  eviscer- 
ation should  be  employed.  He  altogether  rejects 
sections  of  the  optic  nerve  as  it  leaves  a  foyer  of 
infection,  that  may  lead  to  meningitis. 

Cortical  Blindness.— Forster  (Archivfur 
Ophthalmologic,  xxvi,  1)  offers  the  following  con- 
clusions from  his  observations :  1 .  The  deviation 
of  the  line  of  demarkation  toward  the  defective 
side,  so  often  met  with  in  homonymous  hemian- 
opsia, does  not  depend  upon  a  mingling  of  the 
elements  of  both  optic  tracts  in  the  retina,  but 
upon  the  favorable  vascular  conditions  of  the 
point  of  sharpest  perception  in  the  occipital  cor- 


45° 


MEDICAL  PROGRESS. 


[March  28, 


tex.  2.  Bilateral  hemianopsia  is  not  necessarily 
connected  with  complete  loss  of  function  in  both 
halves  of  the  visual  fields  of  both  eyes.  3.  The 
cortex  of  the  occipital  lobe  governs  the  topograph- 
ical ideas  or  conceptions,  whether  acquired  by  the 
sense  of  sight  or  the  sense  of  touch,  or  by  the 
consciousness  of  effected  muscular  movements,  or 
by  descriptions.  If  these  portions  of  the  brain 
become  diseased,  the  power  to  grasp  or  to  repro 
duce  topographical  conceptions  is  lost.  4.  For 
color  distinction,  it  is  not  enough  that,  with  com- 
plete integrity  of  the  retina,  a  small  portion  of 
the  cortical  region  should  be  intact  in  its  func- 
tions. The  power  to  distinguish  color  is  much 
more  readily  lost  than  the  power  to  distinguish 
the  shape  of  small  letters,  when  the  nutrition  of 
the  cortical  elements  is  disturbed.  5.  Destruction 
of  the  cortex  in  the  occipital  lobes  does  not  pro- 
duce atrophy  of  the  optic  nerves. — N.  Y.  Medical 
Journal. 

Determination  of  Refraction. — Schweig 
ger  uses  the  phrase  "illumination  test"  to  de- 
scribe the  process  of  retinoscopy,  or  keratoscopy, 
or  coreoscopy,  because  its  essential  purpose  is  to 
determine  the  optical  value  of  the  displacement  of 
the  illuminated  field  in  the  fundus  of  the  eye,  by 
revolving  the  mirror  upon  its  axis.  The  test  is  of 
special  value  in  the  determination  of  strabismus. 

Bacteriology . 

Typhoid  and  Pseudo-Typhoid  Bacilli  in  Riv- 
er Water. — Dr.Cassedebat  (Annates  deVInsti- 
tut  Pasteur,  No.  10,  October,  1890),  following  up 
Rietsch's  work  on  the  river  waters  of  Marseilles, 
gives  the  result  of  an  examination  of  seventy 
specimens  of  water  from  which  250  cultivations 
were  made,  with  a  view  of  determining  whether 
the  Eberth  bacillus  is  to  be  found  in  the  waters 
of  the  Durance  which  supply  a  part  of  the  city 
where  typhoid  fever  is  endemic  and  often  epi- 
demic. In  no  case  was  he  successful  in  finding 
the  Eberth  bacillus,  but  he  was  able  to  separate 
three  bacilli-- "pseudo-typhoid bacilli"— which  re- 
semble the  typhoid  bacillus  in  many  respects; 
like  it,  they  can  all  withstand  the  action  of  pretty 
strong  carbolic  acid.  They  all  present  clear 
or  deeply  stained  masses,  which  might 
readily  be  taken  for  spores:  but  they  and  the  true 
typhoid  bacillus  containing  these  bodies  are  all 
killed  at  a  temperature  of  a  little  over  450  C. 
They  stain  equally  badly  by  Grain's  method. 
They  have  a  lateral  and  oscillatory  motion  as 
well  as  the  forward  motion.  The  plate  cultiva 
tions  are  so  much  alike  that  unless  all  four  can 
a  together  it  is  difficult  to  distinguish  one 
from  the  other.  On  potatoes,  in  broth,  and  in 
milk,  they  are  alike,  except  that  they  develop 
with  different  degrees  ol  rapidity  and  vai 
what  as  regards  the  alkalinity  and  acidity  of  theii 
prodm  ibout  thirty  days,  and  also 

as  to  the  degree  and   i; .  ■. 


turbidity  produced  in  broth.  There  are  differ- 
ences, however,  to  be  observed  in  these  organ- 
isms grown  in  broth  or  milk  to  which  small 
quantities  of  the  various  aniline  staining  rea- 
gents have  been  added.  The  ordinary  cultiva- 
tion methods  are  sufficient  to  distinguish  these 
four  forms  from  ten  others  (a  list  of  which  is 
given  in  the  paper)  for  which  the  typhoid  bacib 
lus  has  at  times  been  mistaken.  None  of  the 
pseudo  forms  are  quite  so  toxic  to  white  mice  as 
the  true  form,  and  one  of  them  is  quite  innocu- 
ous. Although  Cassedebat  was  not  able  to  find 
the  true  form  in  water  taken  from  the  water  sup- 
ply which  was  most  open  to  contamination,  he 
found  that  this  was  not  because  bacilli  could  not 
live  in  water,  as  in  distilled  water,  to  which  a 
cultivation  had  been  purposely  added,  he  could 
easily  distinguish  its  presence  at  the  end  of  forty- 
four  days,  and  when  added  along  with  half-a- 
dozen  other  forms  he  could  find  them  at  the  end  of 
seventeen  days.  He  comes  to  the  conclusion, 
therefore,  that  the  true  typhoid  bacillus  does  not 
occur  in  water  so  frequently  as  is  sometimes  repre- 
sented, and  that  one  or  other  of  the  forms  of 
pseudo-typhoid  bacilli  has  in  certain  cases  been 
mistaken  for  it. — British  Medical  Journal. 

Media  for  Cultivation  of  Tubercle  Ba- 
cillus.— Sir  Hugh  Beevor,  at  a  recent  meeting 
of  the  Pathological  Society  of  Loudon,  read  a 
note  on  "Media  for  Cultivation  of  the  Tubercle 
Bacillus."  The  results  he  had  obtained  showed 
how  diverse  might  be  the  media  that  could  be 
employed,  and  how  wide  the  variations  of  tem- 
perature in  which  the  bacilli  would  grow.  His 
observations  on  potato  cultivations  agreed  with 
those  of  other  observers — that  the  growth  was 
very  slow,  there  being  from  twenty  days  to  a 
mouth  before  the  first  sign  of  growth  appeared. 
It  was  stated  that  cultivations  on  the  potato  for 
three  generations  did  not  diminish  the  virulence 
of  the  organism.  He  found  that  the  bacilli  grew 
in  broth  to  which  glycerine  had  been  added  at  a 
temperature  lower  than  they  did  on  potato  or  in 
glycerine  agar-agar,  and  he  showed  tubes  which 
had  been  kept  at  a  temperature  not  exceding  6o° 
F.  Bacilli  cultivated  in  glycerine  agar- agar  to 
which  corrosive  sublimate  in  the  proportion  of  1 
in  200,000  had  been  added  were  hindered  slightly 
in  their  growth.  This  proportion  of  perchloride 
when  compared  with  the  average  body  weight  of 
a  man  equalled  from  five  to  six  grains.  The  de- 
monstration of  the  wide  range  of  temperature  at 
which  the  organisms  would  grow  was  interesting 
in  suggesting  that  their  habitat  was  probably 
wider  than  had  been  supposed.  Dr.  Crookshank 
said  that  the  paper  had  involved  a  very  great 
auu  ant  of  labor,  the  grow  ths  being  very  slow  and 
requiring  constant  watching.  The  results  of  in- 
oculation of  animals  with  these  subcultures  when 
mid    1]  ;real  mien  st, 


i89i.] 


EDITORIAL. 


45i 


Journal  of  the  American  Medical  Association 

PUBLISHED  WEEKLY. 


turn  the  outer  edge  of  the  sole  downward,  their 
feet  being  better  adapted  to  climbing.  In  the 
untrammeled  foot  of  the  youth  the  hallux  is  quite 
opposible,  and  the  whole  foot  is  muscular  and  ex- 
pressive. This  expressiveness  and  sympathy  with 
the  ground,  we  sometimes  see  in  bathers  and  in 


kiption  Price,  Including  Postage. 

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Address 

Journal  of  the  American  Medical  Association, 

No.  68  Wabash  Ave., 

Chicago,  Illinois. 
All  members  of  the  Association  should  send  their  Annual  Dues 
to  the  Treasurer,  Richard  J.  Dunglison.  M.D.,  Lock  Box  U74.  Phila- 
delphia, Pa. 


London  Office,  57  and  59  Ludgate  Hlll. 


SATURDAY,  MARCH   28,    1S91. 


It  is  manifested  in  a  coordination  of  muscular 
action,  which,  beginning  in  the  contact  of  the 
feet  with  the  earth,  is  reflected  up  through  all  the 
muscles  of  the  body  to  the  face. 

Unfortunately,  our  civilization  is  in  the  prohib- 
itive stage.  The  feet  of  our  children  are  encased 
at  an  early  age  in  unyielding  boxes.  The  mus- 
cles of  the  sole  are  arrested  in  their  development, 
and  the  subtle  foot  is  made  into  an  unyielding 
stump.  The  circulation  in  the  extremity  is  im- 
peded during  half  the  day,  and  during  the  time 
when  it  is  called  into  greatest  use.  The  ligaments 


THK  ABUSE  OF  THE  FOOT. 
This  humble  member  may  be  likened,  mechani- 
cally, to  an  arch  of  five  single  boulders  of  unequal  and  bones  fail  to  develop  symmetrically  from  re- 
size. The  abutments  are  the  calcaneus  on  one  side  j  strained  function  and  inadequate  nutrition.  As  a 
and  the  metatarsi  on  the  other,  and  the  thrust '  result,  when  the  burdens  and  emergencies  of  life 
which  the  load  on  the  astragalus  exerts  on  these  fall  upon  the  unfortunate  victim  of  civilization, 
two  points  is  equalized  by  the  plantar  muscles  and  j  sprains  and  dislocations  are  of  frequent  occur- 
fascia.  As  a  matter  of  fact,  like  the  triangular  rence.  Nor  is  the  arrest  of  development  noticed 
bridge  at  Croyland,  the  foot  has  more  than  two  ,  in  the  plantar  muscles  only;  it  is,  on  the  contrary, 
points  of  support.  The  posterior  haunch  of  the  felt  in  all  those  muscles  of  locomotion  which  are 
arch  of  the  foot  is  the  calcaneus  alone,  but  the  called  into  play  in  graceful  walking,  and  are  un- 
auterior  haunch  divides  first  into  two,  then  into   used  in  stumping  about  on  the  si     s  fashion  pre- 


four,  and  then  into  five  branches.  Xot  only  does 
the  load  on  this  arch  vary  from  moment  to  mo- 
ment, but  almost  even-  voussoir  is  subject  to 
strains  in  many  directions  from  tendons  or  mus- 
cles attached  to  it.  The  resultant  of  these  vary- 
ing factors  is  a  living  equilibrated  polygon,  a  liv- 
ing arch. 

In  every  movement  of  the  knee  there  is  a  cor- 


scribes.  Especially  is  the  tibialis  porticus  unde- 
veloped, and  as  the  load  on  the  astragalus  in- 
creases with  the  weight  of  the  body,  the  result- 
ant of  all  the  forces  on  the  bones  of  the  foot  de- 
termines "a  joint  of  rupture."  This  is  more 
often  brought  about  by  the  coincident  stretching 
of  the  plantar  fasciae,  supporting  the  arch,  by  the 
use  of  shoes  which  bring  them  in  contact  with 


responding  change  in  this  subtle  arch,  as  may  be  the  soffit,  or  under  surface  of  the  arch.  As  soon 
demonstrated  by  the  reader  by  crossing  one  leg  as  the  shoes  grow  old,  or  when  they  are  exchanged 
over  his  knee.  To  go  a  little  further,  changes  in  for  loose,  flexible  slippers,  the  plantar  fasciae  drop 
the  position  of  the  body  in  any  direction  are  fol-  to  a  straight  line  again,  and  the  abutments  of  the 
lowed  by  related  changes  in  the  form  of  the  foot,  arch  separate  so  far  that  a  joint  of  fracture  ap- 
It  is  not  only  modified  in  its  form  by  momentary  i  pears,  usually  at  the  top  of  the  arch.  Thus  re- 
exercise,  but  its  growth  and  development  follow  suits  that  most  serious  and  refractory  condition 
the  needs  of  the  body  which  it  supports.     To  re-   called  flat  foot. 

verse  the  comparison,  the  supple,  graceful  foot  It  must  not  be  supposed  that  flat  foot  is  to  be 
makes  healthful  exercise  and  graceful  activity  applied  to  those  conditions  only  in  which  the 
a  possibility.  The  undeveloped  or  unhealthy  plantar  arch  is  wholly  collapsed.  Almost  as  pain- 
foot  is  a  cause  of  bodily  and  mental  disease,  as  we  ml  conditions  are  to  be  observed  where  the  plantar 
shall  attempt  to  show.  fasciae  have  been  stretched  only  enough  to  allow 

The  anthropomorpha  and  children,  in  walking,    all  or  most  of  the  strain  to  come  on  the  ligaments 


452 


IS  CANCER  A  PARASITIC  DISEASE? 


[March  28, 


of  the  joints.  This  strain  gives  rise  to  a  traumatic 
inflammatory  process,  which  has  been  termed  by 
Gosselin  "tarsalgia"  of  the  young  adults.  It 
results  in  a  muscular  immobilization  of  the  foot 
on  account  of  the  pain.  Then  follows,  as  a  con- 
sequence of  the  vascularization  of  the  bones,  a 
melting  together  of  the  joint  surfaces,  and,  at  last, 
bony  union  in  the  segments  of  the  arch.  This 
process  requires  years  of  suffering. 

The  method  which  prevails  in  foot-wear  is  re- 
sponsible for  this  fearful  condition,  and  it  is  ag- 
gravated by  the  habit  which  prevails  in  schools 
of  having  children  stand  in  classes  for  a  long  time. 
Shopkeepers,  and  bookkeepers,  and  mechanics 
who  have  to  stand  long  in  tight  shoes,  are  apt  to 
acquire  the  condition.  Among  dentists  it  is  easily 
noticed  in  one  foot  more  than  the  other.  The  di- 
agnosis is  made  by  the  symptoms,  by  the  form  of 
the  foot,  and  by  the  track  which  the  bare  foot 
makes  on  paper. 

The  treatment  is  mechanical  and  preventive. 
The  former  may  be  read  in  the  literature,  but  we 
should  like  to  call  attention  to  the  latter  for  the 
benefit  of  posterity.  Children  should  not  wear 
our  box  shoes,  but  a  flexible,  loose,  moccasin-like 
slipper  with  no  heel.  The  shoes  of  young  people 
should  have  added  a  stiff  heel  and  a  stiff  half- 
sole,  nothing  more.  The  constriction  of  the  ankle 
and  instep  should  be  avoided,  because  it  results 
in  interference  with  the  nutrition  of  the  foot. 

So  small  a  matter  can  hardly  receive  too  much 
attention  when  we  see  how  necessary  are  sound 
feet  to  exercise,  health  and  happiness.  In  the 
fierce  struggle  for  existence  which  is  now  upon 
our  race,  survival  will  depend  on  the  application 
of  intelligent  attention  to  little  matters.  The 
prejudice  of  custom  and  fashion  ought  not  to 
taboo  the  scientific  discussion  of  any  subject,  not 
the  least  important  of  which,  is  the  normal  devel- 
opment of  the  foot. 


IS  CANCER  A  PARASITIC  DISEASE? 
The  analogy,  in  many  respects,  of  the  malig- 
nant tumors  to  those  infective  diseases,  such  as 
tuberculosis  and  leprosy,  which  have  been  shown 
to  be  due  to  the  presence  of  microorganisms,  has 
naturally  suggested  to  pathologists  the  possibility 
of  a  similar  canst-,  and  in  1S87  SCHEUKRI.KN, 
published  an  account  of  a  bacillus  which  he  had 
found  in  cancers,   and   which  he  believed  to  be 


the  materies  morbi.  Similar  observations  have 
since  been  published  by  others,  but  his  views  do 
not  seem  to  have  met  with  very  wide  acceptance. 
More  recently,  attention  has  been  called  to  other 
bodies  occurring  in  cancerous  tumors,  which 
have  been  thought  to  belong  to  the  lowest  order 
of  animal  life.  Uarier,  in  1889,  described  a 
parasite  occurring  in  Paget's  disease  of  the  nip- 
ple, which  he  believed  to  be  a  coccidium — a  mem- 
ber of  the  order  of  sporozoa.  Albarran, 
Thoma,  Wickham  and  Sjobring  have  since 
then  reported  observations  of  the  same  kind, 
although  Thoma  does  not  commit  himself  as  to 
the  nature  of  the  organism.  Finally,  Russell 
has  published  in  the  British  Medical  Journal, 
an  account  of  what  seem  to  have  been  very 
painstaking  investigations  on  what  he  con- 
siders a  characteristic  organism  of  cancer.  He 
demonstrates  it  by  staining  the  sections  with 
fuchsine,  decolorizing  in  water  and  alcohol,  and 
then  staining  with  iodine  green  for  contrast. 
The  bodies  in  question  retain  the  fuchsine  stain, 
which  is  removed  from  the  other  tissues.  They 
are  minute,  spherical  bodies,  surrounded  in  many 
cases,  by  a  transparent  capsule,  and  apparently 
propogating  both  by  spores  and  buds.  Russell, 
although  he  believes  them  to  be  identical  with 
some,  at  least,  of  the  organisms  described  by 
previous  observers,  is  disposed  to  think  them  of 
vegetable  nature,  belonging  to  the  sprouting 
fungi,  of  which  the  yeast  plant  is  the  most  fa- 
miliar example. 

They  were  found  in  forty- three  out  of  forty- 
five  cases  of  cancer  of  different  organs,  often  in 
great  numbers.  In  non-cancerous  tissues  they 
were  found  five  times  in  over  fifty  cases.  In 
three  of  these,  owing  to  the  presence  of  ulcerat- 
ing surfaces,  the  author  thinks  there  was  a  proba- 
bility of  infection,  which  might  ultimately  have 
developed  the  cancerous  character.  Of  the  other 
two,  one  was  an  adenoma  of  the  breast,  the  other 
a  gumma  of  the  meninges. 

Dr.  Russell's  conclusions  have  been  called  in 
question  in  various  quarters.  EDINGTON  consid- 
ers the  bodies  described  to  be  cells  in  a  condition 
of  hyaline  degeneration,  and  gives  drawings 
which  seem  to  tend  to  confirm  this  view.  Cat- 
tle fmds  that  bodies  presenting  much  1. 
pearance  of  those  described  and  figured  by  Krs- 
ski.i.  may  be  produced  by  the  presence  in  the 
staining   solution  of  minute  drops  of  the  aniline 


i89i.] 


EDITORIAL  N< 


453 


used  in  its  preparation.  Ou  the  whole,  at  the 
present  time,  the  probabilities  seem  rather  against 
the  parasitic  nature  of  the  bodies  in  question.  A 
theoretical  objection  to  any  parasitic  hypothesis 
might  be  raised  from  the  fact  that,  although  car- 
cinomata  usually  resemble,  in  their  histological 
structure,  the  epithelium  of  the  tissue  in  which 
they  originate,  metastatic  deposits  develop  with 
the  same  structure  as  the  original  tumor.  This 
would  appear  to  favor  the  view  that  the  infecting 
elements  are  the  cells  of  the  tumor  rather  than 
a  foreign  organism.  In  view  of  the  doubt  as  to 
the  interpretation  to  be  put  on  the  appearances, 
cultivation  experiments  seem  desirable. 


SURGERY  OF  THi:  GALL  BLADDER. 
Sir  Spexckr  Wells,  in  his  Bradshaw  lecture, 
recently  published,  presents  a  review  of  the 
status  of  modern  abdominal  surgery,  in  the  course 
of  which  he  refers  to  the  operations  that  are  now 
done  on  the  liver  and  gall  bladder.  He  admits 
that  many  successful  cases  are  on  record  of  re- 
moval of  gall  stones  and  subsequent  closure  of  the 
gall  bladder  by  sutures,  as  well  as  of  fixing  it  to 
the  abdominal  wall  and  forming  a  fistulous  open- 
ing, but  he  is  strong  in  his  opinion,  expressed 
first  about  five  years  ago,  that  an  excision  of  the 
gall  bladder,  or  cholecystectomy,  is  the  prefer- 
able practice.  He  says  that  he  can  almost  for- 
see  that  the  general  rule  for  future  surgeons  will 
be  to  expose  the  gall  bladder,  empty  it  with  a 
syringe,  raise  the  liver,  protect  the  stomach  and 
intestines  by  sponges,  tie  the  cystic  duct,  with 
two  ligatures,  divide  it  between  them,  separate 
the  gall  bladder  from  the  liver  by  knife  or  scis- 
sors, aud  then  close  the  abdominal  wound. 


professional  triumph  as  the  saving  of  life  by  ovari- 
otomy, by  Caesarian  section,  or  by  the  operation 
for  appendicitis,"  it  becomes  the  bounden  duty 
of  the  profession  to  turn  for  a  moment  to  a  due 
consideration  of  the  statement,  and  a  thought — 
or  more  than  thought — of  the  real  possibilities  of 
reducing  the  number  of  still- births.  We  can 
scarcely  agree  with  the  author  in  believing  that 
the  resuscitation  of  the  still-born  is  to  be  regarded 
as  an  achievement  of  equal  greatness  as  the  con- 
serving of  a  developed  life  by  the  surgical  pro- 
cedures above  named ;  yet  the  importance  ot 
rescuing  an  infant  life — where  two  lives  are  not 
in  immediate  peril — is  not  to  be  determined  by  a 
comparison.  It  is  clear  that  if  well-directed  and 
patiently-continued  efforts  will  restore  life  in  a 
goodly  number  of  still-births,  then  the  pro- 
fessional course  to  pursue  admits  of  no  discus- 
sion, but  does  call  for  more  elucidation,  a  wider 
and  deeper  interest,  and  a  continued  investiga- 
tion with  a  view  of  both  limiting  the  known 
causes  of  still-births,  and  the  perfection  of  those 
methods  will  the  more  readily  insure  the  return 
of  viability  to  the  one  whose  spark  of  life  was 
supposed  to  have  departed. 


RESUSCITATIVE  EFFORTS  IN"  THE  NEW-BORN. 
When  it  is  stated  by  an  authority  of  eminence 
that,  "  I  believe  the  attitude  of  the  profession,  in 
general,  is  one  of  incredulity,  as  regards  the 
efficacy  of  the  means  at  our  disposal  to  restore 
the  life  of  children  in  the  more  desperate  cases  of 
asphyxia.  In  my  experience  it  is  the  usual  pro- 
cedure to  spank  the  child,  to  immerse  it  in  hot 
and  cold  water,  and  then  to  wrap  it  in  warm 
'  clothes  and  place  it  by  the  fire  to  die.  Yet  the 
object  of  medical  practice  is  to  save  life,  and  for 
my  part  I  regard  the  rescuing  of  a  new-born  in- 
fant from  impending  death  to  be  as  distinctly  a 


EDITORIAL  NOTES. 
Curious  Spelling. — The  Albany  Medical 
Annals  prints  a  list,  received  from  one  of  the  gov- 
ernmental departments  at  Washington,  showing 
169  ways  in  which  the  word  "pterygium"  was 
spelled — 157  attempts  in  the  singular,  and  12  at- 
tempts in  the  plural  form  of  the  word — in  reports 
to  the  department  from  "boards"  consisting  of 
three  graduates  in  medicine. 

Extreme  Antiseptic  Views  of  Leopold. — 
At  Prof.  Leopold's  obstetrical  klinik  but  one  vag- 
inal examination  is  made — except  in  pathological 
cases — and  the  examiner  must  first  pass  through 
a  veritable  antiseptic  mill.  First,  the  operator 
must  have  a  general  bath  and  fresh  clothing,  then 
a  cleansing,  rubbing  and  scrubbing,  with  brush, 
soap  and  water,  of  the  hands  and  arms  for  a 
period  of  five  minutes — being  accurately  timed 
during  the  operation.  The  follows  a  brushing 
for  three  minutes  with  a  sublimate  solution 
1:2,000.  Everything  is  then  removed  and  the 
process  of  brushing  and  cleansing  is  again  re- 
peated, this  time  with  a  1:1,000  sublimate  solu- 
tion.    After  this  the  hands  are  to  be  kept  im- 


45  + 


MEDICAL  ITEMS. 


[March  28, 


ruersed  in  the  antiseptic  solution  until  the  patient 
is  ready,  when  one  finger  may  be  quickly  passed 
into  the  vagina.  Prof.  Leopold  really  deprecates 
any  vaginal  examination  in  normal  labor,  giving 
it  out  that,  "The  ideal  childbeds  are  those  in 
which  no  vaginal  examinations  have  been  made." 

Typhoid  Fever  Germs  in  Milk  and  Water 
Supply. — Two  very  interesting  and  professionally 
instructive  examples  of  the  communication  of 
typhoid  fever  through  contaminated  milk  and 
water  have  lately  been  added  to  the  record  we  al- 
ready have  along  this  line  of  research.  In  both 
instances  the  outbreak  was  quite  widespread 
throughout  the  given  district,  and  careful  inves- 
tigation clearly  brought  out  the  exact  source  of 
the  contagion,  and  the  means  of  its  dissemina- 
tion. One  point  appears  to  be  quite  certainly  in- 
dicated by  these  recurring  examples  of  the  spread 
of  this  fever,  viz.,  that  in  typhoid  fever  the  ques- 
tion of  a  physical  resistence  to  the  influence  of 
the  poison  does  not  play  so  important  a  part  as 
may  be  the  case  with  other  affections.  In  other 
words,  the  essential  principle  of  typhoid  does  not 
seem  to  be  a  more  or  less  constant  factor  of  our 
environment;  therefore,  when  it  is  forced  within 
the  circle  of  extrinsical  influences  any  resisting 
power  is  insufficient  to  its  overthrow. 

Birth-List  of  Chicago. — The  completed  re- 
turns for  1890  place  the  total  number  of  births  at 
20,878;  number  of  males  born  9,813;  number  of 
females  9,452;  number  of  twins  221;  and  one 
case  of  triplets.  This  proportion  of  twin  and 
triplet  births  does  not  agree  with  that  observed 
in  foreign  countries.  It  is  stated  that  the  pro- 
portion of  triplet  births  in  Saxon}'  is  as  1:1,000, 
in  Russia  as  1:4,054,  in  Ireland  as  1:4,995,  au<i 
in  England  as  1:6,720. 

A  New  Use  for  Old  Barracks. — Applica- 
tion has  been  made  to  President  Harrison  for  the 
appointment  of  a  commission  to  visit  the  aban- 
doned army  posts  of  Southern  Colorado  and 
Northern  New  Mexico  with  the  view  of  selecting 
the  best  site  for  a  National  Retreat  for  Consump- 
tives. It  is  claimed  that  the  climate  of  the  sec- 
tions mentioned  is  probably  the  most  favorable 
we  have  for  those  afflicted  with  serious  lung 
troubles. 

Gold  and  Manganese  in  Tuberculosis. — 

Dr.  John  Blake  White  read  a  paper  upon  the   use 


of  gold  and  manganese,  subcutaneously,  before 
the  Medical  Section  of  the  N.  Y.  Academy  of 
Medicine,  February  17th.  While  the  writer  does 
not  claim  any  specific  action  for  this  method  of 
treatment,  yet — as  with  Drs.  Shurly  and  Gibbes — 
the  results  have  been  very  promising  in  a  num- 
ber of  cases.  Marked  improvement  has  occurred 
in  cases  having  detailed  histories  of  phthisis.  A 
number  of  physicians  spoke  upon  this  occasion  of 
having  observed  the  good  effects  mentioned  by 
the  author,  and  upheld  the  moderate  claims  put 
forth.     A  further  outcome  is  awaited. 

Results  of  Intubation  of  the  Larynx. — 
Dr.  J.  Mount  Bleyer,  of  New  York  City,  gives  in 
the  Archives  of  Pediatrics  an  analysis  of  five  hun- 
dred and  twelve  cases  of  intubation  with  the  fol- 
lowing results:  "Out  of  251  cases  of  children 
under  three  years  of  age,  there  were  73  recover- 
ies, and  in  260  cases  three  years  of  age  and  over, 
there  were  115  recoveries;  total,  189  cases  out  of 
512  operated  on."  The  causes  of  death  are  given 
throughout.  The  greatest  number  died  from 
sepsis  (39),  broncho  pneumonia  (40),  pneumonia 
(41),  diphtheritic  bronchitis  (67),  bronchitis  (45), 
heart  failure  (21),  exhaustion  (20),  double  pneu- 
monia (16),  and  membranous  croup  (12). 

MEDICAL  ITEMS. 
Progress  of  State  Medicine. — A  Bacterio- 
logical Laboratory   has  been  established  in  con- 
nection with  the  Ontario  Board  of  Health,  with 
Dr.  McKenzie  in  charge. 

A  Poor  Field. — Scott  County,  Kansas,  has 
but  one  physician,  and  he  is  now  compelled  to 
leave  because  of  the  following  conditions  :  but 
one  natural  death  has  occurred  during  the  past 
year  ;  obstetrical  cases  and  accidents  happen  but 
infrequently  ;  and  the  atmosphere  is  so  pure,  and 
the  people  so  generally  healthy,  that  even  an 
ordinary  living  cannot  be  made  by  one  practicing 
the  healing  art.  The  population  of  the  county 
is  given  at  1,260. 

Handy  Surgical  Dressings.— Dr.  Clinton 
B.  Herrick  (JV.  }".  Med.  Jour.'),  in  a  paper  on 
"Railroad  Surgery"  advises  that  each  "caboose" 

fgage  car  carry  a  packet  containing  splints 
and  antiseptic  dressings  of  a  simple  nature,  and 
so  labeled  that  any  man  of  ordinary  intelligence 
would  be  able  to  apply  them  in  case  of  accident. 

lies  that  it  would  rentier   the    condition    of 


I8yl.] 


MEDICAL  ITEMS. 


455 


the  injured  more  comfortable,  and  his  wounds  less  |  pathologist  to  the  Presbyterian  Hospital,  and  one 
liable  to  become  septic,  until  the  aid  of  a  sur-  of  the  surgeons  at  St.  Mary's  Hospital.  He  is  a 
geon  could  be  had.  fellow  of  the  College  of  Physicians,   and  of  the 

Reports  of  the  Illinois  State  Board  OF  Philadelphia  Academy  of  Surgery,  member  of 
n.-The  medical  press  generally  appear  the  Philadelphia  County  Medical  Society,  and 
to  appreciate  the  leading  position  taken  by  the  H'e  Medical  Society  of  the  State  of  Pennsylvania. 
Illinois  State  Board  of  Health  in  the  matter  of  a  Women  Pharmacists  in  Xew  York.— It  is 
higher  standard  of  medical  education.  The  Bos-  stated  that  there  are  over  one  hundred  women 
ton  Medical  and  Surgical  Journal  says  :  "  These  pharmacists  in  Xew  York  City,  not  one  of  whom, 
publications  of  the  Illinois  State  Board  are  an  however,  maintains  an  independent  busi:: 
important    factor   in    the    gradual    improvement 

which  is  taking  place  in  the  medical  colleges."  Tl"bes   for  Kochixk.-Ah    order    has   been 

placed  with  a  German  firm  of  glass  manufacturers 

The  VlRCHOW  TESTIMONIAL  is  assuming  large  ;  for  one  million  tubes  of  particular  form  and  extra 
proportions.      The     seventieth     birthday    anni-   quality  of  glass,   to  be  used  for  the  general  dis- 


varsary  of  this  great  man  occurs  on  October  13, 
189 1.  The  form  the  testimonial  is  taking  seems 
to  be  wise  and  enduring,  viz..  a  large  gold  por- 
trait medal  to  be  presented  to  Professor  Yirchow 
himself,  while  bronze  replicas  of  the  same  will 
be  given  to  members  of  his  family,  and  to  a  cer- 
tain number  of  scientific  institutions. 

The  Constant  Bacteria  of  Milk. — Over 
forty  different  varieties  of  bacteria  have  been  iso- 
lated from  a  specimen  of  normal  milk.  They  are 
grouped  into  classes,  and  their  varied  actions  pro- 
duce the  changes  ordinarily  taking  place  in  milk, 


tribution  of  the  now  famous  "  lymph." 

St.  Louis  Medical  Schools. — About  280 
diplomas  will  be  given  out  in  St.  Louis  this 
month. 

A  Woman's  Hospital  for  Memphis. — A 
Woman's  Hospital  Association  has  been  organ- 
ized under  the  laws  of  the  State  of  Tennessee,  the 
object  of  which  is  the  erection  of  a  properly- 
equipped  hospital  at  Memphis  for  the  treatment 
of  deserving  poor  women  and  children. 

Medical    Training    for    Women. — Official 


as  well  as  the  extraordinary  chemical  effects  pro-  notice  has  been  given  of  the  admission  of  women 
duced  under  peculiar  and  unusual  circumstances,  to  the  Edinburgh  Roj'al  Infirmary,  under  certain 
It  is  not  gainsaid,  however,  that  "foreign"  conditions  which  are  embraced  under  six  different 
bacteria    are    not    concerned    in   the   uncommon '  headings. 


chemical  changes. 

Summer  School  of  Medicine. 


-The   Medi- 


International  Congress  of  Hygiene  and 
Demography. — The  seventh  meeting  under  this 


cal  Department  of  the  University  of  Yirginia  has   title  will  be  held  in  London  on  August   10-17, 


decided  upon  the  establishment  of  a  summer  ses- 
sion, beginning  July  13,  and  continuing  two 
months. 


with  the  Prince  of  Wales  as  president. 


Tenth  German  Congress  for  Internal 
Medicine  is  to  be  held  in  Berlin  immediately 
Jefferson  College's  New  Surgeon.— At  a  following  the  Surgical  Congress,  or  from  April 
meeting  of  the  faculty  of  Jefferson  Medical  Col-  6-9.  Professor  Leyden,  of  Berlin,  will  be  presi- 
lege  on  March  9,  H.  Augustus  Wilson,  M.D.,  dent.  Very  interesting  discussions  will  take 
was  elected  Lecturer  on  Orthopedics  in  the  piace)  prominent  among  which,  of  course,  will  be 
Jefferson  Medical  College,  and  surgeon  in  charge  the  Koch  treatment, 
of  the  Orthopedic  Department  of  Jefferson  Med- 
ical College  Hospital,   vice  O.    H.    Allis,   M.D. 


resigned.       Dr.    Wilson    is  professor  of  General 


Spring  is  with  us. — March  2,   the  Medical 
Department  of  the  University  of  Louisville  con- 


and   Orthopedic    Surgery    in    the    Philadelphia   Jrred  the  degree  of  M.D.  upon  one  hundred  and 
Polyclinic  and  College  for  Graduates  in  Medicine, 
surgeon  and  medical  director  to  the  Polyclinic 


Hospital,  lecturer  on  Orthopedic  Surgery  in  the 
Woman's    Medical    College,    and   was   formerly 


fifty  candidates. 

The  Library  of  the  Xew  York  State 
Medical  Association  now  contains  about  8,000 
volumes,  and  5,000  pamphlets. 


456 


TOPICS  OF  THE  WEEK. 


[March  28 


TOPICS  OF  THE  WEEK. 


CANTHARIDINATB  OF  POTASH    IN  TUBERCULOSIS. 

Last  week's  meeting  of  the  Berliner  Medizinische  Ges- 
ellschaft  was  of  exceptional  interest.  Everyplace  in  the 
hall  was  filled  in  expectation  of  Professor  Liebreich's 
address  on  his  new  remedy  for  tuberculosis.  The  follow- 
ing is  an  abstract  of  the  address,  some  of  the  principal 
points  being  given  in  the  Professor's  own  words.  He  be- 
gan by  saying  that,  though  it  was  not  his  custom  to  pub- 
lish a  research  the  results  of  which  he  had  not  investiga- 
ted in  detail,  he  felt  obliged,  by  the  special  circumstauces 
of  the  case,  to  do  so  in  this  instance. 

He  gave  an  account  of  the  principles  that  had  guided 
him  in  this  and  similar  researches.  Years  ago,  in  his 
first  address  on  chloral  hydrate,  he  had  already  pointed 
out  that,  in  considering  a  substance,  it  is  of  the  greatest 
importance  to  form  a  notion  of  the  atomic  grouping  in 
the  molecule.  The  observation  of  this  principle  led  to 
the  discovery  of  a  number  of  efficacious  remedies — for 
instance,  salicylic  acid  and  salicylate  of  soda.  "How 
long  substances  can  remain  unemployed  is  shown  by  the 
example  of  chloral  hydrate,  the  therapeutic  qualities  of 
which  were  unknown  for  thirty- seven  years  after  its  dis- 
cover}- by  Justus  von  Liebig." 

But  it  would  be  onesided  to  be  led  only  by  the  above 
principle  in  research.  An  illustration  of  a  different 
method  is  the  discovery  of  lanolin,  by  which  ointment 
therapeutics,  which  had  sunk  almost  into  contempt,  were 
raised  to  a  scientific  basis.  ' '  Theu  again — and  this  we 
owe  to  Koch — disinfectants  were  made  the  objects  of  in- 
quiry. From  the  beginning  I  expressed  my  opinion  that 
all  those  substances  that  exercise  a  deleterious  influence 
on  the  lowest  organisms  outside  the  body  must  be  ineffi- 
cacious when  introduced  into  living  tissue.  In  continua- 
tion of  my  former  chloral  researches,  I  was  able  to  show, 
in  connection  with  the  'dead  spaces'  in  chemical  reac- 
tions that  the  reaction  that  takes  place  in  the  cell  is  very 
different  from  that  which  takes  place  outside  of  it." 

Then,  again,  Pasteur's  theory  that  bacteria  are  destroy- 
ed by  their  own  products  of  metabolism  was  followed  up; 
but  the  extremely  toxic  quality  of  these  products  has 
hitherto  formed  a  hindrance  to  their  efficacious  therapeu- 
tic action.  It  is  to  be  hoped,  however,  that  the  attempts 
to  extract  efficacious  bactericidal  substances  from  the 
products  of  metabolism  of  the  bacteria  may  yet  be  at- 
tended with  success.  At  present,  treatment  by  attenua- 
ted bacterial  cultivations  is  forming  the  subject  of  main' 
experiments,  but  this  has  no  direct  relation  to  pharina- 
co-dynamie  investigations. 

Professor  Liebreich  then  turned  to  his  experiments 
■with  local  anaesthetics,  named  by  him  anaesthesia  dolor- 
osa, because  though  they  produce  local  anaesthesia,  the 
injection  itself  is  painful.  In  the  course  of  investigations 
with  these  bodies,  it  became  clear  that  their  effect  was 
not  due  to  chemical  action,  as  in  the  case  of  chloral  hy- 
drate, but  to  purely  physical  causes.  It  was  while  in- 
gaged  in  these  researches  that  Professor  Liebreich  first 
saw  lupus  oases  which  were  being  treated  by  tuberculin, 
and  at  once  formed  the  opinion  that  the  local  action  must 


be  due  to  a  substauce,  whatever  its  origin,  similar  in  ac- 
tion to  those  known  under  the  name  of  "acria."  Upon 
this  the  speaker's  experiments  with  cantharidin  (the 
active  principle  of  the  Spanish  fly)  were  begun.  The 
Spanish  fly  has  been  used  occasionally  iu  therapeutics 
since  the  time  of  Hippocrates;  Pliny  mentions  it.  In 
later  times  it  occurs  in  France  and  Italy  under  the  names 
of  "pastilles  galautes"  and  "  diabolini,"  but  its  effect 
has  always  been  uncertain,  often  dangerous,  owing  to  the 
impossibility  of  dosing  the  active  principle  with  any  ac- 
curacy. 

It  was  Robiquet  who  first  extracted  the  active  princi- 
ple, cantharidin,  as  a  chemically  pure  crystalline  sub- 
stance, which  can  be  weighed  and  dosed  with  exquisite 
accuracy.  Its  toxic  qualities,  and  especially  its  irritating 
action  on  the  kidneys  and  urino-genital  apparatus  are 
well  knowm,  and  have  been  described  by  Coruil,  Ida 
Eliaschoff,  and  others.  When  cantharidin  is  taken  in- 
ternally serum  is  exuded  from  the  capillaries,  not  only 
of  the  kidneys,  but  also  of  the  lungs  and  of  other  organs, 
as  has  been  proved  by  the  experiments  of  the  speaker. 
This  is  the  characteristic  action  of  cantharidin.  Accord- 
ing to  the  speaker's  theory,  the  irritability  of  the 
capillaries  varies  iu  the  different  parts  of  the  organism. 
He  assumes  that  an  irritated  condition  of  the  capillaries 
favors  the  process  of  exudation.  Thus  a  dose  of  can- 
tharidin, too  small  to  exercise  a  toxic  action  on  healthy 
capillaries,  will  produce  exudation  iu  inflamed  capillaries. 
The  exudation  of  serum  in  tissue  may  act  in  two  ways, 
1,  by  nourishing  the  cells  and  bringing  back  to  their 
normal  condition  badly  nourished  cells  ;  and  2,  by  the 
disinfecting  action  of  the  serum  the  affected  spot. 

Iu  his  experiments,  wdiich  he  began  at  the  Augusta 
Hospital,  the  speaker  made  use  of  a  solution  containing 
cantharidinate  of  potash.  The  maximum  dose  was  6 
decimilligrams,  the  usual  dose  being  from  i  to  2  deci- 
milligrams.  "  If  it  can  be  proved  that  in  cantharidin  we 
possess  a  means  of  producing  an  increased  secretion  of 
serum  at  any  one  spot,  we  may  succeed  in  concentrating 
at  this  spot  efficacious  substances,  which,  under  ordi- 
nary circumstances,  do  not  easily  find  their  way  there. 
We  know  substances  that  circulate  in,  and  are  decom- 
posed by  the  blood,  but  which  only  with  difficulty  pass 
through  the  capillaries.  But  if  we  know  that  at  an 
affected  spot  the  exudation  from  the  capillaries  is  fa- 
cilitated, we  can  imagine  that  a  larger  quantity  of  an 
efficacious  substance  may  find  its  way  to  this  spot,  thus 
strengthening  the  otherwise  feeble  disinfecting  power  of 
the  serum.  It  seems  to  me  not  unlikely  that  such  a 
combination  of  two  remedies  might  possibly  lead  to  a 
new  therapeutic  method.  As  regards  practical  applica- 
tion, special  attention  should  be  paid  to  the  kidneys.  It 
is  clear  that  this  treatment  should  not  be  applied  where 
there  is  disease  of  the  kidneys.  I  should  advise  doses  of 
1  decimilligram  to  begin  with,  followed  by  an  experi- 
mental increase  to  2  decimilligrams.  It  is  as  well  to  let 
a  daj  elapse  between  the  injections." 

On  the  conclusion  of  the  address  Dr.  Heymann  and 
Professor  11.  Fracnkel  exhibited  cases  treated  by  can- 
tharidinate of  potash,  which  showed  marked  and  in 
some  cases  surprising  improvement.  Berlin  Corre- 
spi  indent.  —  British  Medical  Journal. 


I89i.] 


TOPICS  OF  THK  WEEK. 


457 


TEMPERANCE  MEDICAL   MEN   IN  ENGLAND 

Whatevi  i  may  be  said  of  total  abstainei 

ever  lie  alleged  truthfully  against  them  that  their 
peculiar  habil  inti  i  R  res  with  their  indust: 
or  tlu-ir  perseverance.  When  an  aspiring  member  of  Par- 
liament is  about  to  contest  a  district,  one  of  the  first 
things  he  considers  is  the  strength  of  the  teetotal  ele- 
ment. If  there  be  many  teetotal  organizations,  he  is 
sure  from  the  first  that  he  must  reckon  with  them;  they 
will  have  their  own  ideas,  they  are  likely  to  combine  in 
manv  ideas,  and  perfectly  certain  it  is  that,  should  they 
set  to  work,  their  physical  powers  will  fully  con 
I'm  any  shortcomings  of  an  argumentative  kind.    They 

will  be  aggressive,  patient,  vigilant,  and  of  long  endur- 
ance. Last  week  there  was  an  illustration  of  some  of 
these  faculties  in  those  abstaining  members  of  the  pro- 
fession of  medicine  who  are  the  representatives  of  the 
British  Medical  Temperance  Association,  a  medical  body 
now  numbering  close  upon  500,  and.  we  believe,  over- 
numbering  that  figure  if  they  who  are  learning  their 
"rudimaus,"  as  Dr.  Cophagus  called  it,  may  be  consid- 
ered medical.  This  Society,  like  its  fellows,  meets  ordi- 
narily iff  its  own  central  rooms  in  the  west  end  of  Lon- 
don, or  in  the  central  rooms  of  its  branches  in  other 
parts  of  the  Kingdom,  and  there  carries  on  its  work  of 
papers  and  discussions.  But  now,  on  the  suggestion  of 
its  indefatigable  honorary  secretary,  Dr.  Ridge,  the  mem- 
bers of  the  Society,  with  characteristic  pertinacity,  are 
moving  into  new  pastures  and  holding  meetings  in  dif- 
ferent districts,  in  order  to  invite  the  busy  practitioners 
of  the  district  visited  to  meet  them  in  the  most  conven- 
ient way,  and  discuss  with  them  the  great  argument  for 
and  against  alcohol.  On  Wednesday  week  last,  Febru- 
ary 25,  the  first  meeting  of  this  kind  was  held  at  North- 
ampton House,  St.  Paul's-road,  Highbury,  and  for  num- 
bers present,  as  well  as  for  the  matter  of  debate,  it  must 
be  accepted  as  a  most  successful  first  attempt.  Dr.  B. 
W.  Richardson,  the  President  of  the  Association,  occu- 
pied the  chair,  and  in  an  opening  address  led  the  way 
simply  towards  discussion.  Every  word  that  was  extreme 
was  avoided  as  unnecessary.  The  apathy  of  the  profes- 
sion as  compared  with  the  energy  of  the  clergy  was  first 
touched  upon,  and  then  the  sanitary  side  of  the  matter 
was  made  a  special  point  for  consideration.  Alcohol  pro- 
duces a  certain  large  and  calculable  mortality;  the  mor- 
tality means  a  large  bill  of  sickness,  and  the  sickness 
means  an  enormous  loss  of  labor  and  the  rewards  of 
labor.  But  we,  as  a  profession  of  health,  said  the  chair- 
man, are  the  custodians  of  health,  and  ought,  therefore, 
specially  to  concern  ourselves  in  the  wholesale  removal 
of  the  preventable  cause  of  so  much  disease  and  misery. 
If  an  epidemic  from  some  more  obscure  cause  destroyed 
a  tithe  of  people  so  systematically  and  regularly  as  alco- 
hol does,  we  should  be  ambitious  to  vie  with  each  other 
in  discovering  the  mode  of  reaching  and  removing  the 
root  of  the  evil.  It  is  our  duty  to  do  the  same  thing  in 
regard  to  this  great  plague  which  is  always  before  our 
eyes.  Another  point  dwelt  upon  was  the  recognizable 
pathology  of  alcohol,  and  the  lesson  it  supplies,  in  respect 
to  the  employment  of  it  as  a  medicinal  remedy.  Touch- 
ing this  last  subject,  the  speaker  repeated  his  often  stated 


opinion  that  alcohol,  whenever  it  is  prescribed  iu  disease, 

should  i„  :  of  precision  " — that 

diluted  with  water  in  measured  doses,  without 

complication.      This    plan,    be  urged,   answers 

.  and  after  fifteen  years'  employment  of  it  he 
had  found  it  equal  to  every  requirement.  Finally,  the 
requirement  itself  was,  he  thought,  in  truth,  very  much 
curtailed  when  all  the  facts  of  the  necessity  were  fully 
disclosed.  The  masters  of  physic  who  recognized  the 
force  of  the  expert entiafallax  were  most  sound  when 
they  exposed  that  kind  of  experience,  and  never  more 
was  that  soundness  verified  than  in  the  practice  of  alco- 
hol administration.  Let  a  practitioner,  said  the  speaker, 
who  has  been  accustomed  to  use  alcohol,  once  have  the 
courage  to  look  at  the  other  side  of  the  shield,  aud  see 
what  remarkable  results  follow  treatment  without  it — as, 
for  example,  in  cases  of  haemorrhage,  pneumonia  and 
asthenia,  and  the  rapidity  with  which  the  mode  of  treat- 
ment without  alcohol  would  advance  would  lead  to  quite 
a  revolution  in  the  practice  of  using  alcohol  as  a  reme- 
dial instrument.  Dr.  Ridge,  Dr.  Norman  Kerr  and  Mr. 
Moir  followed  on  the  same  side.  The  most  trenchant 
opponent  was  Dr.  King,  who  dwelt  more  particularly  on 
the  social  influence  of  alcohol  for  good  when  perfect 
moderation  tempered  appetite.  He  was  of  opinion  that 
wine,  judiciously  taken,  aided  the  worker  and  sustained 
the  enfeebled.  Altogether,  this  new  experiment  of  local 
discussion  on  the  alcohol  topic  from  its  medical  aspects, 
by  medical  men  amongst  themselves,  was  so  friendly, 
hopeful  and  instructive  that  we  trust  it  will  be  repeated. 
It  is  good  for  brethren  to  dwell  together  iu  unity. — Edi- 
torial, Lancet. 


CHOLERA  INTELLIGENCE. 

According  to  intelligence  up  to  the  eud  of  January- 
last,  cholera  had  undergone  a  great  diminution  in  Syria, 
no  new  cases  having  been  recorded  for  several  weeks  in  the 
villayets  of  Aleppo,  Adana,  and  Damascus.  On  the  other 
hand  it  was  reported  that  two  cholera  deaths  had 
occurred  in  the  villayet  of  Diarbekir  and  five  in  that  of 
Beyrout.  The  total  cholera  mortality  in  Syria  up  to  the 
week  ending  January  24,  had  been  4,170.  Of  these,  the 
villayet  of  Aleppo  was  responsible  for  2,361,  that  of  Da- 
mascus for  1,189,  of  Beyrout  for  421,  of  Adana  for  97,  of 
Memouret-ul-Aziz  for  85,  aud  of  Diarbekir  for  15.  Later 
intelligence  is  to  the  effect  that  cholera  had  ceased  in 
Syria  by  January  22,  and  we  have  information  from  a 
correspondent  who  is  able  to  speak  with  considerable  au- 
thority, to  the  effect  that  so  far  as  the  towns,  at  least,  of 
Beyrout  aud  Damascus  are  concerned,  no  new  case  of 
cholera  has  as  yet  appeared.  It  may  also  be  added  that 
quarantine  restrictions  imposed  at  Constantinople  on 
arrivals  from  Syriau  ports  between  Alexandretta  aud 
Beyrout  have  been  removed,  and  that  the  Syriau  ports 
generally  are  regarded  as  free  from  the  disease.  There 
is,  however,  reason  to  believe  that,  as  regards  Tripoli 
cases  are  being  hushed  up,  and  that  the  disease  has  not 
yet  quite  ceased  there.  The  serious  epidemic  in  Japan, 
to  wdrich  we  have  from  time  to  time  adverted,  also  seems 
to  have  come  to  an  eud. —  The  Lancet. 


458 


PRACTICAL  NOTES. 


[March  28, 


PRACTICAL  NOTES. 


TAENIA. 


Thomson  speaks  highly  of  the  following : 

B.    Cbloroformi,  fjj. 

Syrup  simp.,  fgj.     n\,xl.     "J. 
S.    Take  in  three  equal  closes  at  7  A.M.,  9  A.M.,  and  11 
a.m.     At  midday  give  fgj  of  castor  oil. 

— Le  Courier  Medical,  March  15,  1890. 
Another  combination  is : 

B.     Flor.  Koosso,  3iis-3iv. 

Ext.  filie.  mar.  aeth.,  f^iss— 3y. 

Aquae  destillat.,  fgiij-     nX- 
S.  Take  in  three  portions  half  hourly. 

— Kinder-Arzt,  April,  1890. 

After  a  light  diet  the  evening  before,  give  the 
following  on  an  empty  stomach  : 

ft.    01.  tiglii,  gtt.j. 

Chloroform,  purif.,  fjy. 

Glycerin..  fgj,  fgij.     ")>. 
S.  Take  in  two  doses,  half  an  hour  apart. 

— Pharniaz.  Zeit.  45,  1890. 


SUMMER    DIARRHOEA. 

The  following  is  recommended  : 

ft.    Resorcin,  gr.  iss-gr.  iij. 

Iufus.  chamomil,  fgij. 

Tr.  opii..  gtt.  ij. 

Tr.  cascarill.,  gtt.  xv.     Ttjj. 
S.  Teaspoon  ful  every  two  hours. 

— Kinder-Arst,  April,  1890. 
Critzmann  employs  the  following  : 

ft.    Bismuth,  salicylat.,  gr.  xv-^ss. 
Tine,  opii.,  gtt.  j-v. 
Iufus.  These.,  fgij. 
Syrup  rubi,  fjjv. 
Rum,  fjjiv-v.     njj. 


K 


ASTHMA 
Tinct.  stramonii,  31J. 
Tiuct.  lobelia  aether. 
Potass,  nit.,  Jj. 
Sp.  aether  nit.,  gss. 
Tinct.  aurant  recent. 
Aq.  chlorof.,  gvi.     «^. 
S.  Take  two  tablespoonfuls  at  bedtime,  and  one  table- 
spoonful  if  difficulty  of  breathing  comes  on. 


3J- 


,,?s. 


and  uncertain,  but  Sir  Morell  tells  us  that  by  set- 
ting up  a  rival  reflex,  the  laryngeal  spasm,  itself 
a  reflex,  usually  due  to  peripheral  irritation,  ma> 
be  overcome  instanter.  All  one  has  to  do  is  to 
get  the  sufferer  to  take  a  pinch  of  snuff  or  pep- 
per, or,  failing  either  condiment,  to  excite  sneez- 
ing by  tickling  the  mucous  membrane  of  the 
nares.  The  immediate  result  is  a  paroxysm  of 
sneezing,  after  which  the  patient  sinks  quietly 
back  to  sleep,  breathing  like  a  newborn  infant. 
The  treatment  is  logical  as  well  as  practical,  and 
as  it  is  now  made  public  for  the  first  time,  it  is 
well  worth  a  trial. — Ex. 


ACUTE    ECZEMA    AND  IRRITABLE    CONDITIONS    OF 
THE  SKIN. 

Dr.   J.   V.   Shoemaker    {Times  and  Register) , 
advises : 

B.     Cocaiu.  hydrochlorat.,  gr.  iij. 
Atropinae  sulphat.,  gr.  j. 
Morphinae  sulphat.,  gr.  ij. 
Unguent,  acidi  earboliei,  gj.     ng. 


<n\. 


PIGMENTATION  OF  PREGNANCY. 

Cacao  butter,  gijss. 

Castor  oil,  gijss. 

Zinc  oxide,  grs.  45. 

Oil  of  rose,  q.  s. 

Sig.,  to  be  applied  morning  and  evening. 


ANAESTHETIC   MIXTURES. 


The  following  formulae  for  the  preparation  of 
the  anaesthetic  mixtures,  are  given  in  the  Medicin- 
ische-chirurgische  Rundschau.  The  A.  C.  E.  mix- 
ture, according  to  this  journal,  is  made  by  taking: 

B.     Alcohol,   1  part, 

Chloroform,  2  parts. 
Ether,  3  parts. 

Another  method  of  making  it  is  to  use : 
B.     Alcohol  and  ether,  1  part. 
Chloroform,  3  parts. 

With  some  the  anaesthetic  mixture  is  made  by 
adding  4  parts  of  chloroform  to  1  part  of  alcohol. 

— Medical  News. 


TREATMENT  OF  SPASM  OF  THE  GLOTTIS. 

Sir  Morell  Mackenzie,  an  acknowledged  au- 
thority in  laryngeal  cancer,  recently  imparted  to 
his  brethren  of  the  Laryngological  and  Rhino- 
logical  Association  an  item  of  practical  informa- 
tion, which  we  communicate  to  our  readers  in  the 
hope  that  it  may  come  in  handy  just  when  some 
thing  handy  is  a  desideratum.  The  successful 
treatment  of  that  alarming  and  dangerou 
tion,  spasm  of  the  glottis,  is  oftentimes  difficult 


ARISTOL  FOR    FISSURED  NIPPLES. 

Vinay,  in  Lyon  Medical,  has  recommended  the 
employment  of  aristol  in  the  treatment  of  fissured 
nipples  occurring  during  lactation.  He  uses  it  in 
cases  in  which  there  is  much  ulceration  and  pain. 
The  mixture  is  as  follows  : 

B.     Aristol,  1  drachm. 

Liquid  vaseline,  5  drachms. 

This  is  to  be  applied  to  the  breast  and  carefully 
wiped  off  before  the  child  nurses.  After  its  em- 
ployment the  pain  diminishes  and  cicatrization 
goes  cm  rapidly.  In  casts  in  which  the  glands 
become  much  involved,  this  preparation  of  aristol 
may  be  rubbed  into  the  enlargements  with  advan- 
tage.— Medical  X,  . 


I89i.] 


SOCIETY  PROCEEDINGS. 


459 


SOCIETY   PROCEEDINGS. 

Gynecological    Society  of  Boston. 
217th  Regular  Meeting. 

The  Gynecological  Society  of  Boston  held  its 
217th  regular  meeting  at  No.  19  Boylston  Place, 
Boston,  on  Thursday  December  11,  1890,  at  4 
o'clock  p.m.,  with  the  President.  W.  Symington 
Brown,  M.D..  in  the  chair. 

Dr.  Augustus  P.  Clarke  read  a  paper  entitled 

THE     INFLUENCE    OF    THE    POSITION  OF    THE    PA- 
TIENT IN  LABOR  IN  CAUSING    UTERINE  INER- 
TIA AND    PELVIC    DISTURBANCES. 

(See  page  432.) 

Dr.  Wm.  G.  Wheeler  said  that  common  cus- 
tom influences  the  position  of  the  patient  or  the 
time  of  labor,  but  each  case  should  be  treated  ac- 
cording to  its  own  merits.  The  Irish  physicians 
use  the  knee  elbow  position.  He  prefers  the  left 
lateral  position  but  does  not  feel  like  recommend- 
ing any  particular  position  exclusively. 

Dr.  C.  E.  Prior  stated  that  most  women  select 
their  own  position  and  in  his  own  practice  he  al- 
lows the  patient  to  do  so.  He  doubts  whether 
the  long  continued  position  is  responsible  for  the 
many  results  alleged.  He  feels  that  the  sooner 
the  patient  is  delivered  the  better,  and  he  would 
rather  use  the  forceps  early  than  allow  trouble- 
some delay.  He  said  the  reader  did  not  touch 
upon  the  subject  of  position  to  rectify  presentation. 
On  this  subject  he  is  not  as  enthusiastic  as  a  cer- 
tain writer  whose  article  appeared  about  a  year 
ago. 

Dr.  D.  Waldo  Stearns  said  that  he  had  the 
same  opinion  as  the  last  speaker  and  he  believes 
that  too  long  labor  is  responsible  for  mam-  evils. 
The  patient  should  walk  about  during  the  first 
stage  in  order  to  keep  up  the  pains  which  stop  if  the 
patient  lies  down.  In  the  second  stage  he  prefers 
the  left  lateral  position.  If  there  is  inertia  he 
gives  15  grains  quinine  according  to  the  teach- 
ings of  Fordyee  Barker:  this  is  usually  very 
effective.  Friction  over  the  abdomen  may  also 
be  applied.  If  there  is  still  no  progress  he  then 
uses  the  forceps.  The  urine  should  be  drawn  and 
the  bowels  evacuated  unless  there  has  been  an 
operation  within  a  short  time.  He  gives  an 
enema  in  the  first  stage.  He  prefers  the  use 
offorceos  to  turning.  Can  the  physician  prevent 
rupture  of  the  perineum?  Some  authorities  say 
that  ten  per  cent,  are  unavoidable.  He  does  not 
have  as  many  cases  of  rupture  as  formerly.  He 
forces  up  the  head  when  necessary.  He  has  re 
cently  read  an  article  which  advised  the  occurrence 
of  a  rupture  if  n<r^  save  the  child  from 

too  long  delay. 

Dr.  Brown  could  recall  no  case  he  had  seen 
in  which  the  position  of  the  patient  made  any 
difference.     He  prefers  the  left  side.     The  patient 


should  walk  about  during  the  first  stage  but  not 
enough  to  get  tired.  To  relieve  tiresome  aggra- 
vating pains  he  administers  an  opiate  and  thinks 
it  preferable.  He  would  not  use  forceps  until 
absolutely  certain  that  labor  would  be  too  long 
delayed  if  they  were  not  used.  He  has  seen  the 
perineum  torn  several  times,  but  believes  that  it 
can  frequently  be  saved  by  the  method  explained 
by  Dr.  Stearns,  which  he  also  has  used.  Changes 
in  position  are  recommended.  He  does  not  like 
to  give  much  ether  and  would  use  it  only  just  as 
the  head  is  coming  out.  He  fears  post-partum 
haemorrhage  after  the  use  of  ether. 

Dr.  Williams  has  had  the  same  experience  as 
Dr.  Stearns.  He  thinks  the  position  should  be 
changed.  Some  of  the  effects  may  be  due  to 
something  of  which  we  do  not  know.  He  has 
used  chloral  with  much  benefit. 

Dr.  Jefferson  has  experienced  no  trouble 
from  any  one  position  long  continued,  and  he 
fears  too  speedy  delivery  more  than  this. 

Dr.  Elliot"  prefers  'the  left  position  and  he 
changes  if  necessary.  He  remembered  one  pa- 
tient who  would  not  lie  down,  and  the  head  of 
the  child  was  found  to  be  blocked.  He  has  used 
chloral  and  opium,  but  would  rather  feed  the  pa- 
tient, which  he  thinks  prevents  tardy  labor.  He 
stretches  the  perineum  and  holds  back  the  head 
and  thus  rarely  gets  a  rupture.  Sometimes  gives 
stimulants. 

Dr.  Cook  treats  the  bowels  before  labor 
but  he  finds  it  difficult  to  get  his  orders  carried 
out.  He  prefers  the  action  of  chloral  to  opium. 
He  has  seen  good  results  from  the  use  of  hot 
water  douches  by  rectum  or  vagina.  He  prefers 
the  position  on  the  left  side  because  manipulation 
to  save  the  perineum  by  the  fingers  in  the  rectum 
is  easier  thus.  He  would  not  allow  one  position 
too  long  in  the  second  stage.  If  the  os  remains 
rigid  after  three  or  four  hours  he  would  not  allow 
labor  to  go  on  without  treatment. 

Dr.  Irish  said  he  never  saw  any  mischief  arise 
from  the  use  of  one  position,  yet  he  feels  that  too 
long  delay  in  one  position  may  cause  trouble. 
He  would"  use  instruments  if  after  three  hours 
there  was  no  advance  and  there  were  sufficient 
pains.  He  prefers  chloroform  to  ether.  He 
never  had  any  post-partum  haemorrhage  result 
I  from  the  use  of  anaesthetics.  He  does  not  con- 
tinue the  administration  until  there  is  complete 
anaesthesia.  He  thinks  it  acts  as  a  stimulant  to 
I  pains. 

Dr.  Wheeler  narrated  a  case  of  complication 
;  which  he  had  not  seen  for  forty  years  before.  It 
1  is  unique  in  his  experience.  He  has  seen  one 
case  complicated  with  measles  which  did  well  and 
another  with  scarlet  fever  from  which  the  patient 
died.  The  peculiar  case  was  one  of  cerebro- 
spinal meningitis.  The  woman  was  28  or  30 
years  old.  First  labor.  She  had  the  disease  for 
tweh-e  hours  before  labor.     Dr.  W.   saw  it  with 


460 


SOCIETY  PROCEEDINGS. 


[March  28, 


another  physician,  who  said  he  had  a  patient 
with  rheumatism.  There  were  pains  in  various 
parts  of  the  body  but  no  labor  pains — no  increase 
of  temperature — no  heat  or  swelling.  The  uterus 
was  quiet — eight  hours  later  there  was  more  pain 
— no  vomiting.  The  os  uteri  seemed  to  be  a  lit- 
tle more  patulous  and  dilatable.  Thought  the 
pains  to  be  neuralgic  and  gave  an  opiate.  Then 
noticed  some  spots  on  the  abdomen  which  did  not 
disappear  on  pressure.  The  whole  skin  was  sen- 
sitive. He  urged  dilatation  as  he  felt  that  some- 
thing was  coming.  He  ruptured  the  membranes 
and  the  pains  subsided.  The  labor  was  termina- 
ted in  about  eight  hours.  When  the  uterus  be- 
gan to  act  the  other  pains  ceased  for  about  twenty- 
four  hours,  when  the}'  came  on  again  and  the 
spots  became  more  pronounced.  There  was  some 
rigidity  of  the  muscles  of  the  neck.  Both  typhoid 
and  meningeal  disease  were  thought  of.  Next 
day  the  head  drew  back  and  the  patient  died  in 
seventy- two  hours.  He  had  never  met  with  such 
a  case  before. 

Dr.  Prior  stated  that  he  uses  the  forceps  to 
deliver  a  difficult  case  if  the  head  is  low  down, 
but  he  turns  it  if  it  is  high  up. 

The  President,  Dr.  W.  S.  Brown,  said  that  he 
prefers  the  position  on  the  left  side.  He  does  not 
allow  too  long  a  delay  in  labor,  but  advises  and 
uses  forceps  or  some  other  method  of  interfer- 
ence. 

Dr.  Clarke,  in  closing  the  discussion,  said 
that  he  has  felt  like  giving  food  during  labor  but 
he  found  he  had  been  criticised  for  such  advice. 
He  has  had  cases  of  labor  which  came  to  a  speedy 
termination  after  a  change  of  position. 


Philadelphia  County  Medical  Society. 
Meeting  of  February  11,  i8gi. 

(Abstracted  for  The  Journal). 
THE    TREATMENT    OF    CORNEAL    ULCERS    BY    THE 
ACTUAL   CAUTERY. 

Dr.  G.  E.  DeSchweinitz,  read  a  paper  hav- 
ing the  above  title.  After  rehearsing  the  history 
of  the  use  of  the  actual  cautery  in  cases  of  cor- 
neal troubles  the  writer  brought  his  own  cases, 
in  which  this  method  of  treatment  had  been 
used,  together  under  the  following  several  heads  : 
1.  Small  central  ulcers  in  children  of  bad  nutri- 
tion, which  either  through  neglect  or  imperfect 
treatment  have  tended  to  form  an  abscess.  2. 
Shallow  central  ulcers  in  scrofulous  patients,  the 
ulcer  having  a  slightly  turbid  base,  very  chronic 
in  its  course,  and  declining  to  heal  under  ordi- 
nary remedies;  in  all  of  the  cases  of  this  char- 
acter there  were  the  appearances  of  former  granu- 
lar lids,  and  in  one  active  trachoma.  3.  Phlyc- 
tenular ulcers,  beginning  in  the  form  of  small 
pustules  at  the  conical  border,  speedily  ulcerating 


and  surrounding  themselves  by  a  yellow  area  of 
infiltration,  and  with  a  strong  tendency  to  per- 
forate. 4.  Infecting  or  sloughing  ulcers  associ- 
ated with  pus  in  the  anterior  chamber,  or,  in 
other  words,  hypopyon  keratitis.  5.  Marginal 
ring  ulcer,  or  that  form  which  is  sometimes  seen 
in  purulent  ophthalmia,  occurring  just  at  the 
circumference  of  the  cornea,  often  covered  up  by 
the  chemotic  conjunctiva,  and  very  likely  to  per- 
forate, because  it  is  hidden  by  the  swollen  tissues 
and  not  observed.  6.  Herpes  of  the  cornea,  one 
being  an  example  of  an  ulcer  associated  with 
herpes  zoster  ophthalmicus,  and  the  other  true 
herpes  of  the  cornea  in  which  a  vesicular  erup- 
tion occurs,  breaks  down,  and  leaves  an  ulcer ; 
that  form  which  has  been  seen  under  the  same 
circumstances,  as  when  herpes  occurs  around  the 
lips  and  nose. 

In  all  cases  the  cautery  had  only  been  used 
after  other  methods  of  treatment  had  been  tried, 
and  the  author  says  that  he  has  not  one  single 
bad  result  to  record.  In  three  out  of  thirty  cases 
perforation  of  the  cornea  took  place,  "  with  evacu- 
ation of  the  aqueous  humor,  twice  as  an  accident 
during  the  application  of  the  cautery,  and  once 
when  the  ulcer  had  nearly  perforated,  and  Desce- 
met's  membrane  had  bulged  forwards,  forming 
its  floor,  then  I  deliberately  burned  through  the 
tissue." 

As  to  the  method  of  application,  a  small 
Paquelin  therrno- cautery,  a  galvano  caustic  loop, 
or,  as  in  the  writer's  experience,  a  platinum  probe 
heated  to  redness  in  a  Bunsen  burner,  ma}-  be 
used. 

The  pupil  is  atropinized  or  eserinized — accord- 
ing to  the  indications  present — and  a  few  drops 
of  cocaine  are  instilled  shortly  before  the  opera- 
tion. The  lids  are  then  separated  by  the  opera- 
tor, and  the  cautery  applied  gently  to  all  of  the 
sloughing  material.  Usually  but  one  application 
is  required,  yet  subsequent  touching  may  be  de- 
manded. The  after-treatment  does  not  differ 
from  that  given  to  an  ordinary  corneal  ulcer  ;  and 
as  to  the  cicatrix,  or  leucoma,  resulting  it  is  no 
more  extensive — the  author  holding  that  it  is 
even  less  so — than  happens  when  healing  from 
other  means.  There  are  some  contra  indications 
to  this  use  of  the  actual  cautery,  among  which 
are  "extensive  ulceration,  involving  a  large  area 
of  the  cornea,"  and  yet  in  "just  such  cases  very 
good  results  have  been  obtained."  It  should 
not  be  used  in  an  ulcer  which  has  already  perfor- 
ated, and  where  anterior  synechia  has  occurred. 
And  it  does  not  seem  to  the  writer  to  be  indi- 
cated in  cases  of  hypopyon  keratitis  where  "  there 
is  a  large  ulcer  associated  with  a  hypopyon  that 
nearly  tills  the  anterior  chamber,  and  in  which  it 
can  be  demonstrated  that  the  collection  is  exceed- 
ing' y  tenacious,  having  assumed  the  character  of 
a  slough." 

In  the  discussion  which  followed,  Dr.  Edward 


iSqi.] 


DOMESTIC  CORRESPONDENCE 


461 


Jackson  said  he  had  but  a  comparatively  small 
experience  in  the  use  of  this  method.  He  felt 
convinced  that  heat  was  the  only  antiseptic  which 
would  penetrate  as  far  as  the  tissue  was  involved, 
yet  while  it  does  so,  and  destroys  the  suppurative 
process,  it  also  destroys  the  corneal  tissue  leading 
to  a  corresponding  opacity.  In  his  experience 
scraping  of  the  surface  of  the  ulcer,  together 
with  the  use  of  eserine,  had  beeu  sufficient. 

Dr.  Charles  H.  Thomas  had  not  used  the 
cautery,  having  found  that  a  thorough  wiping  of 
the  ulcers,  and  touching  with  the  solid  stick  of 
nitrate  of  silver,  to  have  answered  very  well. 

Dr.  Samuel  D.  Risley,  also,  had  not  used  the 
cautery,  although  aware  of  its  merits.     He  had 


Dr.  Reynolds  Wilson  said  he  simply  wished 
to  refer  to  the  use  of  morphia  in  the  treatment  of 
puerperal  convulsions.  He  had  recently  seen  its 
clinical  use  by  Professor  Winckle,  who  advocated 
its  administration  hypodermieally  in  doses  of  one- 
half  grain,  repeated  in  from  four  to  seven  hours, 
and  continued  until  three  grains  in  all  had  been 
given. 

Dr.  William  S.  Stewart  had  seen  a  num- 
ber of  cases  of  puerperal  convulsions,  and  never 
found  any  difficulty  in  controlling  them  by  the 
use  of  chloral,  which  he  found  acted  decidedly 
within  a  specific  length  of  time.  "One  drachm 
of  chloral  injected  into  the  rectum  will  control 
the  convulsions  for  about  one  hour  and  a  half, 


found  other  measures  to  do,  excepting  in  some   almost  to  the  minute."     It  may  then  be  repeated, 
cases  in  which  failure  had  been  met.     In  such  I  The  effect  is  profound  sleep,  and  the  action   of 


cases,  hereafter,  he  felt  that  he  would  resort  to 
the  cautery  treatment. 

In  closing  the  discussion,  Dr.  DeSchweinitz 
said  :  "The  actual  cautery  should  not  be  used,  as 
a  rule,  until  the  ordiua^  and  milder  methods 
have  been  employed.  If  the  cautery  is  applied 
carefully,  and  not,  as  recommended  in  some  text 
books,  beyond  the  edge  of  the  ulcer  and  into  the 
healthy  tissue,  and  only  that  portion  of  the 
structure  burnt  which  would  be  destroyed  by  the 
process  of  disease,  there  will  be  no  more  opacity 
of  the  cornea  thau  if  it  had  not  been  applied. 
In  certain  types  of  infecting  ulcers,  with  a  creep- 
ing tendency,  it  seems  to  me  there  should  be  no 
delay  in  the  employment  of  this  most  potent 
remedv." 


the  drug  will   be  manifest,   it  is  stated,    in  ten 
seconds. 

Dr.  William  H.  Welch  mentioned  a  case  in 
which  chloral  had  been  freely  used,  yet  the  pa- 
tient was  not  saved. 


DOMESTIC  CORRESPONDENCE. 


Results  with  Koch's  Remedy. 

To  the  Editor: — I  desire  to  give  my  results 
with  Dr.  Koch's  remedy  in  a  short  communica- 
tion. I  may  say  that  the  same  has  been  used  in 
my  private  institution  for  diseases  of  the  lungs 
and  throat  since  December  23,  1890,  in  twenty- 
two  cases  of  pulmonary  tuberculosis,  some  of 
them  having  also  laryngeal  tuberculosis,  and  in 
one  case  of  lupus  vulgaris  of  the  face.  These 
cases  were  reported  and  shown  to  the  Buncombe 


severe  puerperal  eclampsia;    the    immedi 
ate  induction   of   labor ;    recovery. 
A  few  remarks,  together  with  a  very  complete 
history  of  a  case,   were  offered  by  Dr.  William 

H.  Morrison.  The  medicinal  measures,  wHiAloonntylifcSSSodrty.'lfcurch'a. 
had  been  found  of  value,  were  rehearsed,  and  the!  FrorB  tbe  beginning  I  determined  to  avoid 
unsettled  etiology  of  the  disease  was  reviewed.  :  CTeneral  reactions°  and  we  kept  the  temperature 
The  primary  indication  in  puerperal  convulsions   records  to  preserve  us  from  overdosage   rather 

than  to  assure  us  that  the  patient  is  showing 
therapeutic  effects  in  the  symptoms  produced.  I 
find  that   local  reactions  can  frequently   be   ob 


happening  previous  to  delivery,  viz.,  the  speedy 
termination  of  the  pregnancy,  was  emphasized  ; 
and  meantime  the  convulsions  should  be  con- 
trolled by  the  use  of  ether,  chloroform,  chloral 
and  other  similar  substances.  Also  was  relief  to 
the  kidneys  to  be  afforded  by  free  catharsis  and 
diaphoresis.  The  writer  felt  that  in  the  more 
severe  cases,  where  uterine  contractions  were 
tardy,  and  a  rapid  termination  of  the  pregnancy, 
in  consequence,  impossible,  that  the  question  of 
the  removal  of  the  foetus  by  abdominal  section 
should  be  seriously  considered.  "Such  a  course 
would  in  a  few  minutes  remove  an  important 
causative  factor  in  the  production  of  the  disease, 
afford  a  better  opportunity  for  the  action  of 
remedies  intended  to  control  the  paroxysms,  to 


served  with  the  stethoscope  by  examinations  in 
from  two  to  thirty-six  hours  after  an  injection. 
and  that  local  reactions  occur  in  the  larynx  and 
in  the  lupus  case,  as  well  as  in  the  lungs,  without 
material  rise  of  temperature,  or  the  production  of 
general  symptoms. 

I  find  further  that  all  the  cases  which  I  have 
selected  for  the  Koch  method,  in  both  early  and 
advanced  stages,  but  particularly  in  the  former, 
show  an  unmistakable  general  improvement,  con- 
sisting in  gain  of  flesh,  from  three  to  fifteen 
pounds  (one  advanced  case  gained  ten  and  one- 
half  pounds  in  three  weeks),  there  is  an  increase 


stimulate  the  action  of  the  kidneys  and  to  favor  in  strength  a  better  color,  less  cough  and  better 
the  excretion  of  poisonous  matters,  and  probably  :  sl  thg  patients  are  thoroughly  conscious  of 
give,  both  to  the  mother  and  to  the  child,  the  |  their  improvement.  Also  that  in  the  majoritv  of 
best  chance  for  life." 


462 


DOMESTIC  CORRESPONDENCE. 


[March  28, 


cases  local  changes  have  occurred  in  the  affected 
parts,  which,  without  Koch's  method,  we  have 
always  recognized  to  be  for  the  better.  These 
local  changes  consist  in  the  disappearance  of 
moist  sounds,  gurgles,  rales  and  crepitations,  and 
the  reappearance  in  their  stead  of  a  better  charac- 
ter of  respirations;  in  the  larynx  of  diminution  of 
swellings  and  infiltrations,  cleaning  off  and  gran- 
ulation of  ulcerations;  in  the  lupus  case,  of  pro- 
gressive healing  and  repair,  and  with  these  im- 
provements we  have  less  cough  and  expectora- 
tion. 

In  four  cases  the  symptoms  have  entirely  dis- 
appeared, and  microscopically,  the  bacilli  fail  of 
demonstration,  or  are  comparatively  few  and 
gradually  diminishing  in  number  where  we  still 
get  sputum  for  examination. 

In  my  local  examinations  I  find  that  all  tuber- 
cular deposits  do  not  react  to  the  remedy  at  the 
same  time.  Virchow  and  others  have  shown 
anatomically  that  the  very  young  tubercle,  the 
miliary  eruptions,  and  the  old  deposits  located  in 
fibroid  and  cicatricial  surroundings  are  frequently 
unaffected,  and  I  explain  these  evidences  by  the 
vascularity  of  the  tissue  surrounding  the  tubercle, 
being  least,  or  entirely  non-vascular,  where  we 
find  a  given  dose  of  the  remedy  inoperative. 
Eater  local  reactions  occur  in  recent  deposits  to 
even  smaller  doses  than  formerly  were  borne  with- 
out local  reaction,  because  by  the  natural  changes 
these  tubercles  have  undergone  in  the  intervening 
time,  vascular  and  granulation  tissue  has  been 
produced,  and  the  tubercle  is  now  accessible. 
Older  deposits  react  locally  only  after  reaching 
large  doses,  because  of  the  slight  and  feeble  cir- 
culation through  cicatrizing  connective  tissue, 
not  enough  of  the  remedy  could  previously  reach 
them  to  produce  an  effect.  The  local  reaction  of 
accessible  tubercular  tissue  is  in  proportion  to  the 
dose,  and  if  excessive,  causes  not  only  necrosis  of 
the  tissue,  but  so  rapidly  that  I  have  seen  the  ex- 
cavation and  an  almost  entire  upper  lobe  in  less 
than  a  week,  at  one  of  the  Hospitals  in  Berlin. 
Such  rapid  processes  bring  with  them  the  dan- 
gers of  general  infection. 

In  considering  our  results,  we  have  of  course  to 
remember  that  some  improvements  would  have 
occurred,  the  same  as  we  have  witnessed  hereto- 
fore, due  to  climatic  and  other  influences,  and 
particularly  due  to  the  strict  and  correct  manage- 
ment of  cases  in  a  well  conducted  institution.  We 
had,  a  year  ago  at  this  writing,  not  a  single  case 
in  our  establishment  that  was  not  showing  some 
improvement,  but  1  believe  I  am  not  mistaken  in 
my  belief  that  under  Koch's  method  we  have  had 
a  more  uniform  and  more  rapid  favorable  inllu- 
ence  to  record  than  heretofore,  and  in  some  cases, 
so  much  so  that  we  cannot  hut  attribute  it,  at 
least  to  a  considerable  degree,  to  the  action  oi 
the  remedy. 

Our  dosage  begins  with  half  a  milligram,  and 


an  increase  by  half  milligrams  every  second  or 
third  daj-,  and  only  then  when  we  are  entirely 
satisfied  that  to  the  last  two  doses  no  general  or 
local  reaction  has  occurred.  Any  rise  in  temper- 
ature at  all  attributable  to  the  remedy  is  a  signal 
for  a  delay  of  an  additional  day  in  repeating  now 
a  smaller  dose.  After  ten  milligrams  have  been 
reached  we  increase  by  two  or  two  and  a  half 
milligrams,  and  we  have  now,  in  some  cases, 
arrived  at  forty  milligrams  without  ever  having 
disturbed  the  subjective  feelings  of  the  patient, 
and  with  the  happiest  results. 

Seeing  these  results  so  satisfactory,  and  know- 
ing that  nowhere  in  this  country  or  in  Europe  a 
similar  method  of  administration  has  been  adopted, 
I  believe  it  my  duty  to  call  attention  to  what  I 
believe  to  have  been  a  system  of  over-dosage  with 
production  of  poisonous  and  dangerous  symptoms 
in  the  use  of  the  remedy. 

Carl  von  Ruck,  M.D. 

Asheville,  N.  C,  Marches,  1891. 


The  Philosophy  of  Consumption. 

To  the  Editor: — A  proclamation  by  an  eminent 
physician  that  he  has  discovered  a  specific  cure 
for  consumption  in  its  most  prevalent  and  insidu- 
ous  form,  known  as  tuberculosis,  might  well 
create  a  deep  and  universal  interest,  since  there 
are  comparatively  few  of  us  that  do  not  have  this 
deadly  enemy  within  the  limits  of  our  cousin  kin- 
ship. And  if  German  slaughter-house  statistics 
are  to  be  taken  as  representative,  no  less  than  ten 
per  cent,  of  our  domesticated- horned  cattle,  are  a 
prey  to  the  same  disease,  though  seldom  discov- 
ered during  life.  This  fact  would  suggest  that 
tubercular  consumption  is  still  more  prevalent  in 
the  human  family  than  has  yet  been  supposed, 
and  that  many  carry  it  under  the  cover  of  other 
maladies. 

But  unfortunately  for  any  hope  for  a  specific 
remedy,  the  preponderance  of  evidence  points  to 
the  fact  that  consumption  is  much  more  a  pro- 
duct of  individual  habits  and  social  and  climatical 
conditions,  than  a  resultant  of  any  one  agency. 
Indeed,  the  positive  evils  may  vary  not  only  in 
their  degree,  but  also  in  their  number  and  order 
of  action  in  the  period  of  its  evolution. 

If  it  were  hereditary  in  the  sense  that  it  is 
transmitted  by  the  blood,  as  a  specific  germ  or 
virus,  then  the  offspring  of  consumptives  would 
have  an  attenuated  form  of  the  disease  which,  by 
reasoning  from  analogy,  ought  to  secure  them 
exemption  from  any  further  danger  along  that 
line.  Such,  however,  is  not  the  case.  But  if  we 
say  a  special  fitness  is  inherited,  then  we  can  un- 
derstand how  the  offspring  of  consumptives  are 
prone  to  develop  it,  since  they  are  not  only  horn 
with  hereditary  qualifications,  but  not  infrequent- 
ly  thej    are   cradled    amidst  the    very    agencies 


i8qi.] 


DOMESTIC  CORRESPONDENCE. 


which  fostered  the  evil  in  their  parents,  if  indeed. 
they  were  not  primarily  causative. 

That  the  contribution  of  heredity  to  consump- 
tion is  great  is  undoubtedly  the  case,  and  more 
than  any  other  factor  it  would  seem  to  have  a  di- 
recting power  in  the  army  of  inducing  evils.  But 
the  fact  that  the  greater  number  of  the  offspring 
of  consumptives  escape  the  disease,  even  where 
the  general  family  resemblance  is  quite  pro- 
nounced, is  readily  explained  by  the  difference  in 
personal  habits,  the  circumstances  of  different 
periods  or  the  domestic  regulations  instituted  by 
medical  counsel.  Also  the  fact  that  consump- 
tives so  frequently  spring  from  neurotic  paren- 
tage and  the  victims  of  dissipation,  especially  al- 
coholic, still  further  goes  to  show  that  the  heredi- 
tary element  is  essentially  a  reduced  power  of  re- 
sistance to  formative  evils,  and  that  as  a  negative 
condition,  it  may  hold  the  balance  of  power  in 
focusing  the  forces.  Thus,  heredity  in  disease 
can  be  understood  as  in  no  sense  implying  a  spe- 
cific force,  but  rather,  as  an  atonic  or  susceptible 
condition,  varying  in  its  precise  character  and 
producing  a  pars  minoris  risistentus,  or  a  special 
weakness  in  a  special  way. 

That  the  germ  bacillus  does  not  originate  con- 
sumption, there  can  be  no  doubt,  unless  consump- 
tion is  not  to  be  regarded  as  a  disease  until  it  is 
full  fledged,  for  otherwise,  the  germ  would  be 
present  in  the  earlier  formations,  as  well  as  the 
later,  which,  according  to  good  authority,  is  not 
the  case.  But  that  this  parasite  has  a  special  af- 
finity for  consumptive  tissue,  there  is  no  question, 
and  that  it  thrives  therein  with  great  rapidity, 
hastening  retrogressive  changes,  is  also  to  be 
granted.  But  as  yet,  this  is  all  we  are  entitled 
to  believe. 

We  thus  see  that  the  lines  of  successful  treat- 
ment must  be  both  constitutional  and  local,  that 
the  constitutional  cannot  be  specific  and  the  strict- 
ly local  cannot  be  curative.  The  constitutional 
must  be  of  a  negative  and  positive  character, 
having  regard  to  the  support  of  the  healthy  rem- 
nant, and  which  will  require  correction  of  any 
deficiency  whatsoever  in  order  to  remove  the 
morbid  constitutional  habit.  The  local  will  be 
cleansing  of  the  affected  organs  from  the  germs 
and  morbid  products. 

The  evident  selective  affinity  of  Koch's  lymph 
for  tuberculous  tissue  may  enable  it,  in  certain 
cases,  to  effectually  seal  the  arterial  capillaries 
about  the  affected  organs,  owing  to  the  intense 
vaso-motor  disturbance  produced.  This  would 
starve  the  germs,  which  with  the  tubercular  mat- 
ter, may  be  expectorated  through  the  moisture 
and  motion  of  the  lungs.  In  incipient  cases  the 
tubercles  might  be  as  readily  absorbed  as  catgut 
ligature,  and  the  germs,  if  any,  fall  to  phagocitic 
prey.  The  Koch  lymph  is  evidently  not  a  poison 
to  the  germs,  and  probably  has  no  other  action 
on  the  affected  organs  than  that   of  an  irritant, 


having  a  selective  affinity  by  virtue  of  the  kinship 
with  its  contents.  This  theory  of  its  action  is 
supported  by  our  common  knowledge 
power  of  pyogenic  agents  to  awaken  old  or  slum- 
bering inflammations,  and  the  fact  that 
fevers,  such  as  small-pox,  have  been  known  to 
leave  the  consumptives  in  the  last  stages  free 
from  every  svmptom. 

J.  S.  Christian,  M.D. 

;,-}s  Washington  Boul.,  Chicago. 


Cases  of  Typhoid  Fever  in  Infants. 

To  the  Editor: — It  is  commonly  thought  that 
typhoid  fever  is  rare  in  young  children.  Perhaps 
.  yet  so  far  as  I  have  observed,  it  is  not 
much  of  a  respecter  of  persons,  for  in  mj-  experi- 
ence it  has  ranged  through  all  ages.  The  follow- 
ing cases  it  may  be  proper  to  state  : 

Some  years  ago  ray  wife  took  this  fever  while 
nursing  a  child  6  months  old.  This  child  became 
sick  with  the  disease  the  same  day  and,  though 
separated  from  her  parent,  ran  a  course  pari  passu 
with  her  mother.  When  one  bad  a  good  day  the 
other  did,  and  when  one  had  a  bad  day  the  other 
followed  suit.  It  was  not  till  the  end  of  three 
weeks  that  there  began  to  be  signs  of  improve- 
ment. But  both  began  to  improve  the  same  day, 
and  so  went  on.  For  two  years  afterwards  both 
were  alike  subject  to  occasional  attacks  of  stom- 
atitis. When  nearh-  3  years  old,  the  child  died 
of  diphtheria.  Its  mother  then  took  the  diphthe- 
ria, but  had  it  lightly. 

The  second  case  was  9  months  old,  and  was 
also  a  nursing  child.  In  this  family  there  were 
nine  children  from  14  years  down,  and  all  had  the 
fever.  The  mother  also  had  the  fever  and  was  in 
the  family  way  with  her  tenth  child.  I  did  not 
discover  that  she  was  any  the  worse  for  being 
pregnant,  though  she  was  well  worn  down  by 
care  before  she  took  the  fever.  They  all  recov- 
ered. In  due  time  the  mother  was  confined.  The 
child,  however,  was  smaller  than  any  of  the  oth- 
ers. I  had  an  interest  to  know  whether  this  child 
had  the  fever  in  utero,  and  so  rendered  insus- 
ceptible to  the  fever  afterwards  ;  but  at  the  age  of 
3  years  it  died  of  croupous  diphtheria,  and  so  closed 
my  interest  in  the  case.  The  father,  who  had  had 
the  fever  in  the  army,  escaped.  It  was  plain  that 
they  were  all  exposed  to  the  same  cause— filthy 
water  from  a  tank  filled  by  wash  in  which  were 
dead  rats. 

In  another  family  of  six  children,  they  and 
their  mother  had  the  fever,  except  the  youngest, 
then  1)2  year  old.     It  was  not  nursing. 

These  examples  rather  hint  that  it  ma}-  not  be 
so  much  due  to  difference  in  constitution  of  young 
children  that  they  should  be  measurably  exempt 
from  typhoid,  as  to  their  less  exposure  to  the  or- 
dinary sources  of  the   cause.     As   a   rule,  they 


464 


SPECIAL  CORRESPONDENCE. 


[March  28, 


move  in  narrower  spheres  than  older  children, 
and  so  are  less  exposed  and  less  liable  to  be  af- 
fected ;  while,  if  they  are  nursing  mothers  who 
come  down  with  the  fever,  they  are  exposed  and 
take  the  poison  point  blank,  and  do  not  escape. 

Is  there  any  record  of  the  case  of  an  infant  who 
was  nursing  its  mother  when  she  came  down  with 
the  typhoid  fever,  that  did  not  also  take  the  dis- 
ease? If  not,  this  shows  the  great  danger  to  fam- 
ilies, if  cows  from  whom  they  receive  their  milk 
happen  to  be  affected  with  the  fever,  examples  of 
which  have  been  reported. 

E.  Chenery,  M.D. 

Boston,  Mass. 


BOOK  REVIEWS. 


A  Treatise  on  Rheumatism  and  Rheumatoid 
Arthritis.  By  Archibald  E.  Garrod, 
M.A.,  M.D.  (Oxon.),  M.R.C.P.,  etc.  With 
charts  and  illustrations.  Philadelphia:  P. 
Blakiston,  Son  &  Co.  1890.  Chicago:  A.  C. 
McClurg  &  Company.     Pp.  342.     $6.00. 

To  the  student  of  medicine — be  he  either  upon 
the  threshold  of  the  great  science,  or  treading 
faithfully  along  those  sacred  grounds  which  a 
life  time's  toil  has  gained  him  access — -this  classi- 
cal treatise  will  find  a  warm  interest.  And  he 
who  has  the  "love  of  learning"  in  his  heart  will 
but  bewail  the  interruptions  of  professional  duty 
which  call  him  away  ere  "finis"  proclaims  that 
all  has  been  said.  It  is  really  unfortunate  that 
professional  exactions  prohibit  the  resolve  — 
which  comes  when  such  a  lucid  delineation  of  a 
disease  process  so  widely  observed  as  rheumatism 
is  placed  before  us — to  closet  one's  self  for  a  day, 
or  a  night,  that  the  mind  may  arise  to  a  full  con- 
ception of  quite  all  there  is  to  know  upon  the 
subject  in  hand.  Few  there  are  thus  blessed. 
Yet  for  those  who  run,  the  moment's  halt  they 
must  needs  have  will  find  refreshment  between 
the  covers  of  this  volume. 

Starting  out  with  a  clearly  written  history  we 
have,  following  a  review  of  the  theories  hereto- 
fore advanced  with  relation  to  the  pathology  of 
rheumatism,  which  the  author  concludes  with 
this  statement : 

Time  alone  can  show  whether  or  no  any  of  the  above- 
mentioned  observers  have  succeeded  in  discovering  a 
microorganism  which  is  the  actual  specific  cause  of  the 
phenomena  of  rheumatism.  Until  then,  we  can  only  rely 
safely  upon  the  results  of  clinical  study,  which  seem  to 
indicate  that,  in  spite  of  the  difficulties  presented  by  the 
apparently  constitutional  nature  of  the  malady,  no  theory 
of  the  pathologv  of  rheumatism  which  has  as  yet  been 
advanced  makes  so  good  .1  show  of  explaining  the  pecu 
liarities  and  variations  in  the  prevalence  and  type  of 
rheumatic  attacks,  or  accounts  so  satisfactorily  for  tin- 
peculiar  distribution  of  the  local  lesions  of  the  disease, 
as  does  that  which  attributes  them  to  an  infection  from 
without. 


Then  appear  clear,  terse  chapters  upon  the  eti- 
ology of  rheumatism,  and  the  association  main- 
tained with  other  bodily  affections,  going  into  the 
subject  quite  to  the  uttermost, and  yet  without  that 
redundancy  of  expression  which  so  often  mars  a 
study  of  this  nature. 

The  first  part  of  the  treatise  ends  with  a  re- 
sume of  the  treatment  of  rheumatism  as  it  stands 
to-day,  and  shows  the  strong  position  held  by 
the  salicylates. 

Part  II  (Book  II)  treats  of  rheumatoid  arthritis, 
and  is  a  comprehensive  exposition  of  the  leading 
thought  of  the  times. 

A  voluminous  bibliography,  and  a  very  com- 
plete general  index,  closes  the  volume. 

The  reviewer  cannot  well  take  leave  of  this 
book  without  also  noticing  the  publisher's  work, 
which  is,  in  few  words,  much  superior  to  that 
usually  observed. 


ASSOCIATION  NEWS. 


Notice  to  Secretaries  of  Sections. 

To  the  undersigned  Secretaries  of  Sections  are 
urgently  requested  to  send  the  list  of  Papers  to  be 
read  before  their  respective  Sections,  as  soon  as 
completed,  in  order  that  there  may  be  no  delay  in 
the  printing  of  the  Programme  of  the  Meeting. 
C.  H.  A.  Kleinschmidt,  M.D., 

Local  Secretar}'. 
3045  N  St.,  Washington,  D.  C. 


SPECIAL  CORRESPONDENCE. 


Shall  The  Journal  be  Removed  to 
Washington  ? 

THE    ACTION    OF    THE    MEDICAL   SOCIETY     OF     THE    MIS- 
SOURI   VALLEY. 

The  following  resolution  was  unanimously  passed  by 
the  Medical  Society  of  the  Missouri  Valley,  in  session  at 
Omaha,  Neb  ,  March  20 : 

Whereas,  It  having  come  to  the  knowledge  of  this  Society  that 
an  effort  is  being  made  to  remove  the  headquarters  of  The  JOURNAL 
OF  the  ami  khan  Medical  Association-  from  its  present  location 
in  Chicago  to  Washington,  D.  C;  Therefore,  he  it 

Resolved.  That  we,  the  Medical  Society  of  the  Missouri  Valley,  in- 
struct our  delegates  to  the  coming  meeting  of  the  American  Medical 
Asso,  i.,ti  -ii  to  use  all  honorable  means  to  retain  the  headquarters 
of  said  Journal  in  its  present  location. 

F.  S.  Thomas,  m.d.,  Sec. 
Council  Bluffs,  Iowa,  March  21,  1891. 


To  the  /Cditor: — I  have  been  waiting  patiently  to  hear 
the  arguments  that  our  Eastern  friends  rely  on  to  effect 
the  removal  of  The  Journal  to  Washington.  I  have 
been  impressed  with  most  of  them  as  applying  with  in- 
creased force  to  Chicago. 

Leaving  out  the  question  of  politics,  there  appears  to  be 
nothing  in  this  agitation.  But  the  fact  that  the  next 
meeting  of  the  Association  will  occur  in  the  city  that  is 
.1  candidate  for  the  location  of  Tin;  Journal  renders  it 


i89i.] 


SOCIETY  PROCEEDINGS. 


465 


.  to  thoroughly  canvass  the  merits  of  the  case 
s  ote  is  taken. 

There  is  always  a  large  attendance  of  the  local  mem- 
bers of  the  profession  wherever  the  meetings  are  held. 
Washington,  Baltimore,  Pittsburgh,  Philadelphia,  New 
York  and  other  Eastern  and  Southern  cities  will  be  more 
largely  represented  than  they  would  be  if  the  meeting 
were  to  be  held  iu  some  other  section  of  the  country. 
Ought  the  vote  of  the  members  who  chance  to  be  pres- 
ent at  the  Washington  meeting  to  decide  this  question, 
instead  of  a  vote  of  the  whole  membership? 

Should  any  meeting  held  in  Washington  or  Chicago 
settle  a  dispute  between  these  two  cities  :  Undoubtedly 
the  modesty  and  sense  of  fairness  of  our  Washington 
brethren  would  forbid  their  participation  iu  such  a 
scheme. 

There  are  the  best  of  reasons  to  bslieve  that  the  re- 
moval of  The  Jul -rn ,\  1.  would  deprive  it  of  a  large  share 
of  those  requisites  to  success  that  have  contributed  to 
make  it  the  peer  of  any  American  medical  journal. 

When  the  loss  of  advertising  patronage  is  mentioned, 
some  of  the  advocates  of  moving  for  the  sake  of  a  chauge 
reply  that  The  Journal  should  get  along  without  adver- 
tisements. Very  well.  When  Grant  proposed  to  take 
Richmond  did  he  tell  his  soldiers  that  they  should  get 
along  without  biscuit  and  bacon,  or  coffee  ?  Have  these 
gentlemen  ever  tried  the  novel  experiment  of  publishing 
a  journal  without  advertisements?  Which  one  is  so 
philanthropic  as  to  give  bond  to  indemnify  from  the  loss? 

A  good  certainty  is  better  than  an  unreasonable,  senti- 
mental uncertainty. 

It  is  not  surprising,  since  The  Journal  has  passed  the 
experimental  stage  and  is  an  assured  success,  that  a 
clever  neighbor  should  covet  the  promising  prodigy,  but 
it  is  too  late,  gentlemen,  to  ignore  the  labors  of  those 
who  made  it  what  it  is. 

Who  is  there  in  Washington  who  would  have  done 
better,  under  the  same  experimental  circumstances, 
than  have  Drs.  Davis,  Hollister  and  Eggleston  in  an  edi- 
torial capacity,  and  Mr.  White  in  his  able  and  courteous 
management  of  the  important  business  aud  mechanical 
department  of  the  enterprise  ? 

Can  we  afford  to  repudiate  those  who  have  built  up, 
and  are  improving  our  plant,  sacrifice  our  best-paying 
advertisers,  and  move  out  of  this  great  centre  of  popula- 
tion, commerce  and  wealth,  with  its  vast  accumulating 
libraries,  universities  aud  nine  medical  schools,  with  its 
army  of  about  2,000  under-graduate  and  post-graduate 
medical  students? 

Is  it  expected  that  the  mere  fact  of  publishing  The 
JOURNAL  within  the  city  limits  of  our  Capital,  is  to  ex- 
ercise great  influence  over  our  representatives  who  go 
there  periodically  to  make  laws?  In  other  words,  has  it 
become  necessary  to  have  editors  and  publishers  perform- 
ing the  role  of  lobbyists  to  accomplish  the  ends  of  our 
great  Association  ? 

If  a  change  must  be  had,  for  the  sake  of  a  change,  St. 
Louis  would  be  a  better  location  for  The  Journal  than 
Washington.  S.  S.  Bishop,  M.I  1. 

Chicago,  March  14,  1891. 


To  the  Editor: — I  have  read  most  of  the  letters  to  The 
Journal,  pro  and  con,  in  relation  to  the  moving  of  the 
same  to  Washington.  D.  C,  and  I  have  not  seen  any 
opinion,  as  yet,  coming  from  the  profession  in  the  old 
Granite  State.  But  I  am  sure,  that  as  I  have  consulted 
with  my  confreres  thus  far,  a  united  voice  will  come  from 
her  hills  and  valleys:  "Let  The  Journal  remain  where 
it  is,  unless  you  wish  to  asphyxiate  its  present  life 
powers ! ' ' 

My  reasons  are  the  following:  As  far  as  I  can  judge, 
there  are  three  to  one  of  the  members  of  the  Association, 
regardless  of  location,  who  are  opposed  to  its  removal. 
It  is  much  better  and  safer  policy  to  let  the  majority  rule 
in  the  make-up  of  all  organized  bodies.      If  for  no  other 


reason,  organic  law  will  decide:  "Let  it  remain   in   Chi- 
cago." 

That  city  affords  the  best  location  for  it  of  any  city 
upon  this  Continent,  at  the  present  time.  I  spent  some 
four  mouths  there  during  the  last  season,  and  1  know- 
whereof  I  write.  I  took  some  little  pains,  while  there, 
to  investigate  the  past  and  present  condition  of  the  city: 
and  I  wrote  several  letters,  which  were  printed  in  one  of 
our  local  county  papers,  in  regard  to  the  city's  develop- 
ment during  the  past  fifty  years.  It  is  the  most  wonder- 
ful city  upon  this  Continent.  It  puts  all  other  cities  iu 
the  shade  as  a  business  centre,  when  you  combine  its 
commercial  and  railroad  facilities,  even  New  York  itself. 
While  the  latter  city  has  25  main  lines,  Washington  has 
3,  Chicago  has  38  through  lines,  running  to  all  sections 
of  the  great  West,  upon  which  1,500  to  2.000  trains  run 
iu  and  out  of  the  city  every  day.  Then  its  population  of 
1,200,000  makes  it  the  second  city  in  this  Nation  in  num- 
bers. In  every  form  of  mechanical,  industrial  and  mer- 
cantile growth  it  is  most  wonderful.  She  to-day  possesses 
30,000  industrial  shops  and  factories,  has  an  area  of 
almost  400  square  miles,  aud  if  it  increases  in  population 
for  twenty  years  to  come  as  it  has  in  the  last  decade,  it 
will  become  the  Queen  City  of  the  World,  larger  than 
Ancient  Babylon,  Modern  Paris,  or  British  London. 

It  is  argued  that  Washington  is  the  best  location  on  ac- 
count of  its  superior  advantages  in  medical  men  and  litera- 
ture, and  this  will  serve  to  make  the  personnel  of  The 
Journal  of  a  higher  order.  But  I  say  Chicago  leads  all 
other  cities  in  this  country  (save  New  York )  in  advan- 
tages for  medical  instruction.  She  has  five  chartered 
medical  colleges,  all  in  a  most  healthy  and  prosperous 
condition,  keeping  pace  with  all  the  wonderful  and 
amazing  developments  of  the  other  departments  of  the 
city. 

I  am  not  aware  that  our  profession  has  any  more  lofty 
mountain  peaks  in  medical  erudition,  or  scholastic  qual- 
ification, in  Washington  than  in  other  medical  centres. 

Another  plea  for  its  removal — that  because  our  Asso-  • 
ciation  is  a  National  body  it  ought  to  be  in  Washington, 
as  that  is  the  National  Capital.  This  may  seem  patriotic 
and  theoretical,  but  who  shall  say  how  long  Washington 
may  remain  the  Capital  of  this  Nation  ?  The  West  is 
making  great  strides  in  population  and  increase  of  States, 
aud  soon  the  voice  of  this  Republic  may  be  heard  in  its 
vote  to  chauge  the  location  of  its  Capital,  and  put  it  in  a 
more  central  position.  The  vote  of  the  people  will  rule 
this  country,  and  that  portion  east  of  Washington.  D.  C, 
is  but  a  fragment,  in  point  of  territory  and  population, 
compared  with  Northwest,  West  and  South  of  this  fast 
growing  Republic. 

It  is  for  the  very  reason  that  Washington  is  the  Capi- 
tal, and  the  great  centre  of  political  demagogueism  and  * 
partisan  strife  that  it  should  be  the  very  last  place  to 
select  for  the  home  c/The  Journal.  It  is  the  medium 
through  which  the  sentiments  of  all  medical  writers  are 
voiced  from  all  sections  of  the  Union,  and  it  should  not 
be  placed  where  there  is  danger  of  its  becoming  colored 
in  the  least  with  political  proclivities. 

Let  our  noble,  aud  ancient  profession,  stand  upon  its 
own  broad,  scientific  character,  aud  its  intrinsic  worth,  to 
the  best  good  of  humanity.  Keep  it  sacredly  free  from 
all  foreign  influences  that  can  belittle  its  value  in  the 
estimation  of  the  world. 

For  these  reasons,  and  I  could  cite  more  if  time  and 
space  would  permit,  I  shall  vote  not  to  change  the   pres- 
ent home  of  our  popular  and  well  managed  Journal. 
w.  b.  Porter,  m  d. 

Walpole,  N.  H..  March  14, 


To  the  Editor:  —  I  am  opposed  to  the  movement 
to  chauge  the  place  of  publication  of  our  Nation- 
al Journal  from  Chicago  to  the  City  of  Washington. 
I  think  there  is  no  valid  reason  for  it:  The  Journal  is 
ably  conducted,  centrally  located  geographically,  and  a 


466 


SPECIAL  CORRESPONDENCE. 


[March  28, 


large  business  city  like  Chicago  is  much  more  conducive 
to  the  support  and  advancement  of  a  medical  journal  than 
apolitical  rookery  like  the  city  of  Washington.  I  think 
our  western  members  would  have  just  cause  for  complaint 
if  it  were  removed  farther  East.  S.  LaughTon,  M.D. 
Bangor,  Me..  March  15,  1891. 


To  the  Editor:— As  several  good  reasons  have  been  and 
can  easily  be  advanced  why  Tin:  Journal  should  not  be 
removed"  and  no  good  reason  has  yet  been  given  why  it 
should  be  removed,  and  since  no  medical  journal  has  ever 
yet  flourished  at  the  Capital,  I  cast  my  vote  ia  favor  of 
The  Journal  remaining  at  Chicago. 

E.  H.  M.  Sell,  M.D. 

44  West  49th  St.,  New  York,  March  17,  1S91. 


To  the  Editor:— My  best  wishes  for  the  continued 
prosperity  of  The  JOURNAL.  I  hope  it  may  long  remain  in 
the  great  City  of  the  Lakes.         W.  W.  Reeves,  M.D., 

Supt.  State  Lunatic  Asylum. 

Austin,  Tex.,  March  17,  1891. 


To  the  Editor:— I  can  see  no  reason  why  the  location 
of  The  Journal  should  be  changed  from  where  it  now 
is  and  has  been  so  long  published,  and  as  1  believe,  to  the 
best  interests  of  the  Medical  profession.  Chicago  is  near- 
er the  centre  of  the  United  States,  and  why  remove  The 
Journal?  I  think  it  far  better  for  the  Medical  profession 
to  advocate  less  change  in  our  associations,  rules,  and 
regulations,  and  stand  firmly  together  as  a  band  of  broth- 
ers and  frown  upon  all  movements  to  create  "  isms"  and 
"cisms"  that  tend  to  weaken  and  destroy  the  old  land- 
marks of  the  profession.  C.  R.  EARLEY,  M.D. 

Ridgway,  Pa.,  March  17,  1891. 


To  the  Editor: — I  notice  one  of  the  reasons  given  by  a 
subscriber  for  moving  Tin:  Journal  to  Washington,  is, 
that  "We  the  official  representatives  of  the  profession 
should  keep  as  closely  to  the  Government  as  possible." 

The  people  is  the  Government,  and  as  Chicago  is  the 
centre  of  the  people  let  The  Journal  remain  in  Chicago 
and  move  the  Capital  near  to  The  Journal— that  the 
centre  be  less  lop-sided.  E.  F.  Clapp,  M.D. 

Iowa  Cilv,  la.,  March  21,  1S91. 


To  the  Editor:— Please  put  me  dowu  as  in  favor  of  re- 
taining The  Journal  at  Chicago. 

A.  B.  Judson,  M.D. 
New  York  City,  March  21,   1S91. 


To  the  Editor:— It  is  sound  doctrine  in  medicine,  as  in 
other  pursuits  in  life,  to  let  well  enough  alone.  The 
Journal  has  passed  its  minority,  and  is  now  full  grown 
and  is  second  to  no  journal  published.  Its  financial  suc- 
cess has  grown  with  its  years  and  it  is  now  on  a  sound 
basis;  its  editorials  are  concise  and  to  the  point;  its  selec- 
tions good  and  of  the  latest  published.  The  Journal 
is  in  a  healthy  condition.  It  requires  no  medication  or 
change  of  climate,  to  sustain  its  vigor  and  usefulness. 

Let  it  remain  in  Chicago.  B.  L.  IIovev,  M.D. 

Rochester,  N.  V.,  March  21,  1891. 


A    REPLY   TO    DOCTOR   COMEGYS'    LETTER. 
To  the  Editor:—!  see  by  the  last  issue  of  Tin:  JOUR- 
NAL, that  my  erudite  friend  of  Cincinnati,  Or.  Cornelius 
G.  Comegvs,  has  evidently  made   an    Herculean   effort  to 

convince  the  members  of  the  American  Medical 
tion,    that  their   journal    should    be   transplanted    from 
Chicago   to  Washington,    D.    C.       But    like  many    other 
persons,  who  have  unfortunately  got  on  the  wrong  side 


of  great  National  problems,  it  has  required  a  prolonged 
aud  gigantic  effort  on  the  part  of  the  doctor,  to  convince 
even  the  most  unsophisticated  member  of  our  Association 
that  his  position  was  right,  or  that  his  arguments  were 
well  founded  and  his  logic  unassailable. 

The  doctor  seems  to  have  forgotten  that  when  The 
JOURNAL  was  born,  some  seven  years  ago,  that  there  was 
only  1,000  members  of  the  Association,  which  limited  its 
income  to  not  over  £5,000  a  year,  plus  the  scanty  returns  it 
received  from  its  advertising  patronage,  which  at  that  time 
was  less  than  $1,000  a  year,  thus  limiting  the  entire  in- 
come (provided  every  member  aud  patron  paid  up  his 
subscription  and  advertisements  promptly,  which  is  sel- 
dom the  case),  not  to  exceed  $6,000,  whilst  the  expense 
of  publishing  alone,  not  including  any  pa}-  for  editorial 
work,  was  over  $8,000  a  year  or  $2,000  in  excess  of  the 
annual  iucome. 

But  by  being  "so  conservative,  so  determined,  to  take 
no  risks"  that  involved  a  prospect  of  pecuniary  embar- 
rassment" the  management  has  increased  the  member- 
ship of  the  Association  from  1,000  or  less  to  over  5,000 
members  and  subscribers,  which  guarantees  an  annual 
income  of  at  least  $25,000  a  year  besides  the  annual  re- 
ceipts from  its  advertising  patronage  of  about  $10,000,  or 
a  total  of  about  $35,000  a  year.  The  management  has. 
bought  aud  paid  for  their  own  plant  aud  equipment  for 
publishing,  binding  and  mailing  The  Journal,  and  has 
done  all  this  within  the  short  space  of  seven  years  ;  and 
yet  by  this  extreme  care  of  the  financial  aud  business  in- 
terests of  The  Journal,  which  Dr.  Comegys  condemns, 
and  by  which  he  says  it  "has  been  kept  too  much  in  the 
rear  of  the  line  of  a  contest  for  the  due  rank  of  medicine 
in  communities  and  in  the  State  ;"  yet,  notwithstanding 
all  this,  it  has  risen  from  the  cradle  of  journalism  in  this 
short  time  to  a  place  second  to  none  among  the  medical 
journals  of  the  United  States  and  Canada  ;  and  publishes 
more  pages  of  reading  matter  each  issue  than  any  jour- 
nal in  our  country,  and  over  400  more  pages  annually 
than  any  medical  journal  on  the  Continent. 

From'  The  Journal  and  its  management  proper  he 
next  turns  his  "  old  smooth  bore"  on  the  editoria 
fications  of  the  organ  of  our  Association,  and  says.  "  no 
one  doubts  the  editorial  capacity  of  Dr.  N.  S.  Davis  or 
Dr.  Hollister,  but  these  gentlemen,  both  are  large  prac- 
titioners," and  because  they  are  both  industrious  prac- 
tical men,  who  are  familiar  with  the  every  da}-  work  of 
the  profession,  and  in  sympathy  with  the  ups  and  downs 
of  the  daily  routine  of  the  physician's  life,  and  from  ex- 
perience know  what  he  needs,  he  claims  they  are  dis- 
qualified to  edit  a  practical  journal,  for  the  practical  doc- 
tors of  the  United  States.  Did  mortal  man  ever  hear  of 
such  an  inuocuous  untenable  argument  ?  Does  Dr. 
Comegvs  flatter  himself,  for  a  moment,  that  there  is  one 
out  of  every  ten  members  of  our  Association  who  would 
or  could  be  induced  to  believe  that  because  a  doctor  is  in 
the  actual  practice,  and  really  a  practical  physician  or 
surgeon,  that  he  is  therefore  disqualified  for  the  position 
of  "Supervising  Editor"  of  a  practical  journal  for 
practical  doctors  ? 

Does  any  person  suppose  for  a  moment  that  if  Dr. 
Comegvs  was  seriously  ill,  or  any  member  of  his  family, 
that  he  would  employ  such  a  physician  as  he  would 
recommend  for  "Supervising  Editor"  of  our  journal  to 
treat  him  or  his  family?  "Not  by  a  jug  full."  He 
would  obtain  the  very  best  practical  physician  or  surgeon 
lie  could  get,  because  he  was  a  practical  man  and  not  an 
unpractical  theorist.  For  the  same  reason  the  members 
of  our  Association  want  a  practical  physician  at  the 
helm  of  the  Editorial  Department,  as  well  as  a  practical 
man  at  the  head  of  the  Business  Department  of  Thb 
Journal,  because  they  are  practical  and  know  by  ex- 
perience, what  they  are  doing  and  talking  about. 

isociation  has  no  use  for  high-flying  theorists  at 
the  head  of  the  Editorial  Department  of  The  Journal, 
who  would  fain  weave  gauzy  editorials  out  of  fine  spun 
theoretical  yarn,  which  to  the  innocent  student,  or  unso- 


i89i.] 


SPECIAL  CORRESPONDENCE. 


467 


phisticated,  might  appear  like  a  brilliant  mental  effort, 
but  which  to  the  everyday  practical  physician  would  be 
about  as  useful  as  sounding  brass  or  a  tinkling  cymbal, 
as  compared  with  food,  in  a  time  of  famine. 

In  the  preface  of  the  first  volume  of  Prof.  Agnew's  "Sur- 
gery" you  will  find  this  eminent  surgeon  saying:  "Most 
of  the  pages  have  been  written  not  in  what  may  be  termed 
moments  of  leisure,  but  during  the  hours  of  the  night —  ' 
hours  stolen  from  the  time  usually  allotted  to  the  repose 
of  body  and  mind,  and  after  the  daily  labors  of  an  exact- 
ing public  and  private  practice."  This  sentence  alone  I 
explains  why  the  best  physicians  and  surgeons  of  our 
country  as  well  as  of  foreign  lands  so  eagerly  sought  this 
most  valuable  work.  Because  it  was  written  by  a.  practi- 
cal surgeon  and  not  by  a  theoretical  tyro  in  the  medical 
profession;  and  yet  in  the  face  of  all  this  our  erudite 
friend  would  advise  chaugiug  the  practical  physician  and 
surgeon  we  now  have  for  "supervising  editor,"  for  one 
who  was  not  in  the  active  practice,  and  who  would 
"promise  and  swear"  that  he  would  never  enter  the 
practice  of  medicine  while  he  swings  the  editorial  pen  of 
our  popular  Journal.  Now,  Doctor,  how  long  would  such 
an  editor  retain  the  confidence  and  respect  of  the  mem- 
bers of  our  Association?  The  hollow  echo  answers: 
"  How  long?" 

The  absurd  idea  that  The  Journal  must  be  moved  to 
Washington  to  obtain  a  place  in  the  Cabinet  is  ridiculous. 
The  farmers  were  but  recently  represented  in  our  cabinet, 
but  I  have  no  knowledge  that  a.  single  one  of  them  left 
his  farm  and  moved  to  the  miasmatic  flats  of  the  Potomac 
in  order  to  secure  this  recognition  recently  granted  by 
the  federal  government.  Then  why  should  we  remove 
our  Journal  there  to  obtain  the  same  recognition? 

In  speaking  of  the  consciousness  of  Chicago  as  com- 
pared with  the  perception  of  Washington  we  desire  to 
ask  the  Doctor  if  he  was  conscious  of  the  fact,  that  Wash- 
ington only  had  three  railroads,  which  it  is  absurd  to 
compare  with  Chicago  with  more  railroads  than  any 
other  city  in  the  world?  We  will  ask  the  Doctor  if  he  is 
conscious  of  the  fact  that  notwithstanding  the  extreme 
consciousness  of  Washington,  that  there  is  not  a  journal 
— either  medical,  religious,  scientific,  agricultural  or  of 
any  other  nature — that  has  prospered  or  attained  a  na- 
tional reputation  that  was  or  is  edited  and  published  in 
Washington?  Doctor,  are  you  conscious  of  the  fact  that 
there  is  not  a  daily  paper  published  at  present,  or  that 
ever  was  published  in  Washington  that  has,  or  ever  had 
a  real  good  local  reputation,  saying  nothing  of  a  national 
reputation?  Are  you  conscious  of  the  fact,  Doctor,  that 
even  the  Index  Medicus  of  which  so  much  has  been  said, 
is  published  in  Detroit,  and  that  the  Annals  of  Surgery 
is  published  in  St.  Louis,  and  even  the  Therapeutic  Ga- 
zette, although  edited  in  "The  City  of  Brotherly  Love," 
is  also  published  in  Detroit?  But  these  are  private  bus- 
iness enterprises  and  are  run  on  business  principles,  yet 
they  don't  seek  the  National  Capital  to  insure  their  suc- 
cess. How  strange!  How  passing  strange,  that  you 
should  insist  on  The  Journal  of  our  Association  to  as- 
sume business  risks  which  not  a  prosperous  journal  of  the 
country  will  dare  to  assume. 

Again,  the  Doctor  says:  "If  a  general  and  hearty  con- 
sent to  the  removal  of  The  Journal  from  Chicago  to 
Washington  should  have  been  agreed  to,  then  the  gener- 
al business  management  of  the  organ,  and  its  editorial 
work  will  become  most  important  subjects  of  considera- 
tion." 

Why  not  tell  the  truth  Doctor,  although  you  should 
shame  the  Devil,  and  say  that  already  the  editorial  and 
business  management,  (should  The  Journal  be  removed 
to  Washington)  has  been  bargained  for,  and  instead  of 
the  horse  pulling  the  cart,  in  this  apparent  scramble  "  for 
the  loaves  and  fishes"  the  cart,  poor  thing,  is  trying  to 
pull  the  horse.  In  fact  it  really  thought  at  one  time  it 
had  pulled  the  horse! 

Just  think  of  it,  a  "club  building,"  in  the  National 
Capital  with  its  three  railroads,  leading  to  "our  father's 


house"  where  we  will  all  be  at  home!  (when  we  gel 
there),  many  of  us,  however,  only  once  in  from  one  to 
five  years,  but  for  which  we  are  all  expected  to  pay  our 
hard  earned  money  just  the  same;  to  accommodate  the 
erudite  editor  without  practice  or  experience,  who  with 
his  friends  and  followers  are  to  occupy  "our  fathers" 
mansion  from  day  to  day,  and  issue  out  editorial  instruc- 
tions from  week  to  week  to  the  practical  hard  working 
Doctors  of  our  National  Association.  What  a  sublime 
idea!     What  a  brilliant  conception! 

Nor  is  this  all.  The  Doctor  wants  us  to  raise  an  extra 
$10,000  to  carry  out  this  pet  scheme  of  removing  The 
JOURNAL  to  Washington.  Surely  he  has  never  suffered, 
or  at  least,  is  not  suffering  now  from  a  severe  attack  of 
conservatism  regarding  any  prospective  financial  embar- 
rassment of  the  Association  or  its  Journal.  These  facts 
alone  are  sufficient  reasons  for  keeping  The  Journal  at 
Chicago  where  it  has  grown  from  a  dependent  child,  to  a 
strong,  robust  self-supporting  man;  and  which  never  has 
and  does  not  now  seek  to  incumber  the  Association  with 
any  "  Club  Houses,"  or  $10,000  loans  with  which  to  en- 
tertain, and  pay  for  an  unpractical  "  supervising  editor," 
who  is  expected  to  live  in  "  our  father's  house"  and  fare 
sumptuously,  everyday,  but  who  must  not  practice  any 
for  fear  he  loses  some  of  his  theoretical  brain  power, 
which  must  be  kept  in  reserve  to  elevate  the  editorial 
standard  of  The  Journal.  Why,  Doctor,  don't  you 
know  that  the  very  moment  the  American  Medical  Asso- 
ciation decides  to  hold  its  annual  meetings  in  any  one 
city,  I  care  not  whether  it  be  the  "  Queen  City  of  the 
West" — Chicago,  Washington,  or  San  Francisco,  just 
that  moment  the  Association  will  commence  to  lose  its 
membership,  and  will  gradually  succumb  to  the  slow  but 
fatal  disease  of  inanition? 

The  sad  fate  of  the  National  Board  of  Health  should 
be  a  warning  for  us  to  steer  clear  of  Washington  with 
both  the  Association  and  its  journal  if  we  desire  them  to 
live  out  their  natural  expectancy  of  life.  Are  you  not 
conscious  of  the  fact  that  that  august  body  was  not  only 
conceived,  but  born  in  the  National  Capital  ?  Yet  it 
soon  came  to  an  untimely  end  from  a  severe  attack  of 
federal  marasmus.  The  political  atmosphere  of  "our 
National  Capital  "  soon  withered  this  oace  promising 
offspring,  which  has  long  since  passed  the  way  of  all  the 
world.  And  yet,  you  would  drag  our  now  prosperous 
journal  into  these  same  death-dealing  political  fumes 
and  hazard  its  chances  for  a  long  life  and  prosperity  by 
so  doing. 

How  unreasonable,  how  absurd  it  is  to  expect  our 
National  Journal  to  obtain  a  subscription  list  or  an  ad- 
vertising patronage  such  as  the  British  Medical  fournal 
has  now,  in  only  seven  years,  when  the  latter  journal  has 
been  thirty-seven  years  obtaining  15.000  members  and 
subscribers,  with  an  annual  income  of  $130,000,  whilst 
we  have  only  been  seven  years  securing  one-third  the 
membership  and  one-fourth  of  the  annual  income.  At 
this  same  rate  the  American  Medical  Association  will 
only  require  twenty-one  years  to  obtain  a  membership  of 
15,000,  and  less  than  twenty-eight  years,  the  same  annual 
income  the  British  Medical fournal iiow  has  !  or  sixteen 
years  less  time  than  it  required  for  the  British  Medical 
Association  to  obtain  the  same  membership,  and  nine 
years  less  than  it  took  the  British  Medical  fournal  to  ob- 
tain the  same  annual  income,  and  yst you  have  the  auda- 
city and  gall  to  stand  up  before  our  Association  and  de- 
nounce the  management  of  our  Journal  and  condemn  the 
place  of  its  publication  with  all  these  cold  facts  staring  you 
boldly  in  the  face.  Indeed,  I  am  surprised  and  astounded 
at  vou,  and  the  more  I  think  of  it  the  more  maniacal  it 
appears,  until  I  am  compelled  to  exclaim  with  Felix  of 
old:  Cornelius,  "thou  art  surelv  beside  thyself !" 

R.  Harvey  Reed,  M.D. 

Mansfield,  O.,  March  19,  1S91. 


468 


MISCELLANY. 


[March  28,  1891. 


MISCELLANY. 


State  Medical  Society  Meetings  in  1S91. — We 
give  below  a  corrected  list  of  State  Medical  Societies, 
with  the  name  of  the  Secretary,  and  the  place  and  date 
of  meeting : 

Ala.,  T.  A.  Means,  Mongomery;  Huntsville,  April  14. 

Ark.,  L.  P.  Gibson,  Little  Rock;  Hot  Springs,  April  29. 

Cal.,  W.  W.  Kerr,  San  Francisco;  Sacramento,  April  21. 

Colo.,  H.  W.  McLanthlin,  Denver;  Denver,  June  16. 

Conn.,  N.  E-  Wordin,  Bridgeport;  Hartford,  May  27. 

Del.,  W.  C.  Pierce,  Wilmington;  Rehoboth,  June  q. 

Fla.,  J.  D.  Fernandez,  Jacksonville;  Pensacola,  April  14. 

Ga.,  King  P.  Moore,  Macon,  Augusta,  April  is. 

111.,  D.  W.  Graham,  Chicago;  Springfield,  May  19. 

Ind.,  E.  S.  Elder,  Indianapolis;  Indianapolis, "June  10. 

Iowa,  C.  F.  Darnall,  West  Union;  Waterloo,  April  15. 

Kan.,  W.  S.  Lindsav.  Topeka:  Wichita,  Mav  12. 

Ky„  Steele  Bailev,  Stanford;  Lexington,  Mav  4. 

La.,  P.  B.  McCutchon,  New  Orleans;  New  Orleans.  May  13. 

Me.,  C.  D.  Smith,  Portland;  Portland,  June  9. 

Md.,  G.  Lane  Taneyhill,  Baltimore;  Baltimore,  April  28. 

Mass..  F.  W.  Goss.  Boston;  Boston,  June  9. 

Mich.,  C.  W.  Hitchcock,  Detroit;  Saginaw,  June  n. 

Minn..  C.  B.  Witherle,  St.  Paul;  Minneapolis,  June  IS. 

Miss..  W.  E.  Todd,  Jackson;  Meridian,  April  15. 

Mo.,  L  C.  Mulhall,  St.  Louis;  Excelsior  Springs,  Mav  12. 

Mont.,  J.  W.  Gunn,  Butte  City;  Helena.  April  24. 

Neb.,  M.  L.  Hildreth,  Lyons:  Lincoln,  May  — . 

N.  H.,  G.  P.  Conn,  Concord;  Concord,  June  15. 

N.  J.,  Wm.  Pierson,  Orange;  Long  Branch,  June  23. 

N.  Y.,  E.  D.  Ferguson,  Troy;  New  York,  Oct.  2S. 

N.  C,  J.  M.  Havs,  Oxford;  Asheville,  Mav  26. 

Ohio,  G.  A.  Coliamore,  Toledo;  Put-in-Ba"y,  June  17. 

Ore.,  C.  C.  Strong,  Portland. 

Pa..  Wm.  B.  Atkinson,  Philadelphia;  Reading,  June  2. 

R.  I.,  W.  R.  White,  Providence;  Providence,  June  11. 

S.  C,  W.  Pevre  Porcher.  Charleston;  Anderson,  June  9. 

S.  Dak..  R.  C.  Warne,  Mitchell;  Chamberlain,  June  10. 

Tenu.,  D.  E.  Nelson,  Chattanooga;  Nashville,  April  4. 

Texas,  F.  E.  Daniel.  Austin;  Waco,  April  28. 

Vt.,  D.  C.  Hawley,  Burlington;  Burlington,  Oct.  15. 

Va.,  L.  B.  Edwards.  Richmond;  Lynchburg,  Oct.  27. 

Wash.,  C.  L.  Flannigan,  Olympia;  Seattle,  May  6. 

W.  Va..   F.  L-  Fullerton,  Charlestown;  Fairmont,  May  20. 

Wis.,  J.  R.  McDill,  Milwaukee,  Madison,  June  3. 


Police  Surveillance  of  Railroad  Street  Cross- 
ings.— Anent  the  fact  that  in  Chicago  105  persons  were 
killed  last  year  at  railroad  crossings  of  streets,  The  Jour- 
nal of  the  National  Association  of  Railway  Surgeons 
editorially  recommends  police  regulation  of  such  cross- 
ings as  are  the  most  important,  i.  e. ,  such  as  have  been 
found  to  be  particularly  hazardous  from  the  activity  of 
human  traffic.  Shut  gates  at  railway  crossings  may  pre- 
vent the  passage  of  vehicles,  but  they  do  not  stop  many- 
people  from  dodging  around  them  and  hurrying  across 
the  tracks  in  front  of  approaching  trains. 


State  Regulation  of  Professional  Conduct. — An 
Act  has  been  passed  and  approved  by  the  legislative  au- 
thorities of  Arkansas  entitled:  "An  Act  to  Prevent  Un- 
professional Conduct  in  the  Practice  of  Medicine."  Sec. 
9,  of  this  Act  reads  as  follows:  "Unprofessional  conduct 
for  the  purposes  of  this  Act  shall  be  held  to  be:  First, 
The  procuring,  or  aiding,  or  abetting  in  the  procuring  of 
criminal  abortion.  Second,  Employing  or  using  what 
are  known  as  cappers,  steerers  or  drummers,  or  the  sub- 
sidizing of  hotels  or  boarding-houses  to  procure  practice. 
Third,  The  obtaining  of  any  fee  on  the  assurance  that  a 
manifestly  incurable  disease  can  be  permanently  cured. 
Fourth,  The  wilfully  betraying  a  professional  secret  to 
the  detriment  of  a  patron.  Fifth,  All  advertising  of 
medical  business  in  which  untruthful  and  improbable 
statements  are  made.  Sixth,  All  advertisement  of  any 
medicine  or  means  whereby  the  monthly  periods  of  wo- 
men can  be  regulated  or  the  menses  reestablished. 
Seventh,  Conviction  of  any  offence  involving  moral  tur- 
pitude.    Eighth,   Habitual  drunkenness. 


LETTERS  RECEIVED. 

Allegheny,  Pa.,  Dr.  J.  S.  Phillips. 

Ann  Arbor,  Mich.,  Dr.  W.  A.Campbell. 

Ausonia,  Conn.,  McArthur  Hypophosphite  Co. 

Artesia,  Miss.,  Dr.  N.  D.  Guefi^-. 

Baltimore,  Md..,  National  Bank  of  Commerce,  Dr.  Geo.  J.  Pres- 
ton. 

Bedford  Springs,  Mass..  N.  Y.  Pharmaceutical  Co. 

Boston.  Mass.,  Dr.  F.  Irwin. 

Brainerd,  Minn.,  First  National  Bank. 
Catskill.  N.  Y.,  P.  C.  Lewis. 

Chattanooga,  Tenn..  First  National  Bank. 

Chicago,  111.,  Dr.  W.  F.  Coleman.  Dr.  H.  ;M.  Smith,  Lord  & 
Thomas. 

Cincinnati,  O.,  Dr.  Coffinan,  Ohio  Valley  National  Bank. 

Cumberland,  Md.,  Dr    F.  T.  McKaig. 

Dallas,  Tex.,  American  National  Bank. 

Denison.  Tex.,  First  National  Bank. 

Detroit,  Mich.,  Geo.  M.  Savage,  Parke,  Davis  &  Co. 

Eola,  La.,  Dr.  P.  B.  McCritchon. 

F.vanston,  111.,  The  Evanston  Bank. 

Fort  Dodge,  la.,  Fort  Dodge  National  Bank, 

Fort  Madison,  la.,  German  American  Bank. 

Fort  Worth,  Tex.,  Dr.  A.  P.  Brown. 

Grand  Rapids.  Mich..  The  U.  S.  Post  Office. 

Indianapolis,  Ind.,  Dr.  G.  C.  Fisher,  Dr.  E.  S.  Elder. 

Joliet,  111.,  Nemeck  Bros. 

Lacey,  la..  Dr.  J.  W.  Green. 

Las  Animas,  Col.,  Dr.  G.  E.  Brown. 

Miamisburg,  O.,  Clark,  Forbes  &  Co. 

Milwaukee,  Wis.,  Dr.  N.  Senn. 

Mireral  Point,  Wis.,  First  National  Bank. 

Mount  Vernon,  Mo.,  Mount  Vernon  Bank. 

Newmarket,  Eng.,  Dr.  Geo.  O.  Mead. 

New  Orleans,  La..  Geo.  F.  Wharton. 

New  York  Citv,  L.  H.  Crall,  J.  F.  Madden,  Dr.  P.  A.  Callan,  R. 
A.  Ward. 

Philadelphia,  Pa.,  Dr.  R  J.  Dunglison,  Dr.  A.  L.  Hummel,  Uni- 
versitv  of  Pennsylvania  Press,  J.  B.  Lippincott  Co.,  Dr.  J.  W.  Hol- 
land, Dr.  W.  B.  Atkinson.     • 

Princeton,  Ind..  Dr.  S.  E.  Munford. 

Ravenna,  O.,  O.  D.  Haven. 

Red  Jacket,  Mich.,  First  National  Bank  of  Calumet. 

St.  Louis,  Mo.,  Dios  Chemical  Co.,  A.  M.  Leslie  Surgical  Instru- 
ment Co..  Battle  &  Co. 

San  Antonio,  Texas,  Texas  National  Bank. 

San  Francisco,  Cal.,  J.  N.  Patton. 

Southmayd.  Texas,  Dr.  G.  V.  Hale. 

Stockton*  Cat,  First  National  Bank. 

Walpole,  N.  H..  Dr.  W.  B.  Porter. 

Waterloo,  la..  Dr.  D.  W.  Crouse. 

Wessington,  Dak.,  Dr.  J.  Chancellor  Gilbert. 

Wilkesbarre,  Pa.,  Dr.  Maris  Gibson. 

Winslow,  111..  Dr.  J.  B.  Goddard. 

Yorkers,  N.  Y  ,  Dr.  Jas.  A.  Steuart,  Dr.  E.  Schopen. 

Yoiingstown,  O..  Dr.  M.  S.  Clark. 


A  COURSE  in  HyGIENB.— A  practical  course  in  hy- 
giene will  be  given  this  spring  at  Johns  Hopkins  Univer- 
sity, under  the  charge  of  Dr.  John  S.  Billings. 


Official  List  of  Changes  in  the  Stations  and  Duties  of  Officers  Serving 
in  the  Medical  Department.  U.  S.  Army,  from  March  14,  r&ol,  to 
March  20,  rSoi. 

Capt.  William  C.  Shannon,  Asst.  Surgeon,  now  on  duty  at  Ft.  Apa- 
che, Ariz.,  will  repair  to  this  city  and  report  in  person  to  the  Ad- 
jutant General  of  the  Armv  for  further  orders.  Bv  direction  of 
the  Acting  Secretary  of  War.  Par.  5,  S.  O.  55,  A.  G.  O.,  Washing- 
tun.  March  11,  1891. 

Capt.  Henry  P.  Birmingham.  Asst.  Surgeon,  is  granted  leave  of  ab- 
sence for  one  month,  with  permission  to  apply  for  an  extension 
of  one  month,  to  take  effect  upon  arrival  at  Boise  Bks.  of  First 
Lieut.  Robert  R.  Ball,  Asst.  Surgeon  U.  S.  A.  Par.  2,  S.  O.  39,  Dept. 
of  the  Columbia,  March  13,  1891. 

Official  List  of  Changes  in  the  Medical  Corps  of  the  ('.  S.  .Y::.i.  for 
the  Week  Ending  March  21,  1891. 

Medical  Director  C.  J.  Cleborne,  detached  from  Naval  Hospital,  Nor- 
folk, Va.,  and  to  Naval  Hospital,  Chelsea,  Mass. 

Medical  Inspector  T.  N.  Penrose,  ordered  in  charge  of  Naval  Hos- 
pital. Norfolk. 

P.  A  Surgeon  fohn  M  Steele,  detached  from  Coast  Survey  Str. 
"  Bache,     and  granted  three  months'  leave  of  absence. 

Surgeon  James  H.  Gaines,  placed  on  Retired  List,  March  IS,  1891. 

id     I..  Ruth,  granted  a  month's  leave  from  April  2  next, 
with  permission  to  leave  the  United  States. 

of  Changes  of  Stations  and  Duties  of  Medical  Officers  of 
the  ('.  S.  Marine-Hospital  Service,  for  the  Tuo   H'eeks  Ending 
March  14,  iSot. 
Surgeon   \v.   H,  Long,   granted  leave  of  absence  for  seven  days. 
March 

--ui 11   M    \V    Austin,  to  proceed  to  Baltimore,  Md.,  for  special 

duty.     March  14. 

11  John  Godl     . 

linaton  of  officer  of  Revenue  Marine  Servii 
P.  A    Surgeon  C.  E.  Banks,  to  proceed  to  Boston,  Mass.,  on  special 

duty.     March  7,  1S91. 
Asst.  Surgeon  T.  B.  Perry,  leave  of  absence  extended  thirty  days. 

March  1,1,  1891. 
Asst.  Surgeon  B.  K.  Houghton,  detailed  as  recorder  of  Board 
sical  examination  of  officers  of  Revenue  Marine  Service       Match 


T  1 1  E 


J  ournal  of  the  American  Medical  Association. 

EDITED  UNDER  THE  DIRECTION  OF  THE  BOARD  OF  TRUSTEES. 

PUBLISHED    WEEKLY. 


Vol.  XVI. 


CHICAGO,  APRIL  4.   1891. 


No  14. 


ORIGINAL  ARTICLES. 


ETIOLOGY  AND  TREATMENT  OF 

TYPHOID. 

BY  A.  L.  WAGXER,  M.D., 

OF   SOUTH    BENT'.  IND. 

Some  of  the  matter  contained  in  this  discourse 
may  seem  irrelevant,  but  it  was  impossible,  with- 
out some  prelude,  to  make  my  meaning  clear.  It 
strikes  me  that  physicians  do  not  stop  often 
enough  to  consider  the  significance  and  cause  of 
symptoms  in  disease.  Why  does  not  one  in  sick- 
ness go  on  to  recovery  or  to  death  without  any 
such  manifestation  as  a  symptom  ?  As  compared 
to  the  time  since  the  creation  of  man  the  short 
period  that  our  profession  has  been  able  to  ren- 
der any  service  to  mankind  is  but  a  day.  These 
same  symptoms  were  manifest  in  the  systems  of 
the  preglacial  man  and  long  before  they  could  be 
interpreted  or  associated  as  they  now  are.  Are 
they  then,  as  now  so  generally  accepted,  simply  the 
signs  of  disease,  the  perverted  and  morbid  condi- 
tions signaling  to  the  physician  to  annihilate 
them  and  thus  cure  the  disease  which  the)-,  in 
the  aggregate,  are  supposed  to  represent?  Nature 
is,  undoubtedly,  always  conservative.  She  will 
never  kill  one  of  her  own  creatures,  and  if  disease 
attack  the  system  of  one  of  them  she  is  up  in 
arms  at  once  to  protect  him.  What  are  common- 
ly called  symptoms  are  Nature's  remedies  for  the 
disease  in  which  they  are  seen,  or  they  are  con- 
ditions, or  collections  of  conditions  following  her 
remedies. 

Now  I  wish  to  show  that  in  a  given  disorder 
there  are  symptoms  and  sets  of  symptoms  or 
si;;ns,  which  are  essentially  different,  and  though 
speaking  in  the  same  tongue  are  dwelling  upon 
a  different  topic.  For  example,  and  a  more  thor- 
ough study  of  disease,  it  seems  rational  to  divide 
symptoms  as  follows: 

1.  Those  symptoms  that  are  due  to  01  really 
pre  the  morbid  materials,  e.  g. ,  the  haematozoa 
malariae  of  Laveran,  in  ague,  or  the  alkaloidal 
ptomaines  in  the  diseases  due  to  germs. 

2.  Those  that  are  Nature's  remedies  and  which 
are  directed  toward 'the  destruction,  removal  or 
the  modification  of  any  foreign  substance  w'hich 


is  incompatable  with  natural  function.  Nature's 
remedies  are  her  only  resources,  and  the}-  differ 
to  a  great  extent  from  those  the  physician  can 
exhibit;  but  if  the  cause  of  the  disease  is  to  be 
removed  and  recovery  to  take  place  the  physician 
must  follow  in  Nature's  lead  or  else  leave  her  un- 
trammelled in  her  efforts  to  relieve  the  sufferer. 
In  typhoid  fever  this  set  of  symptoms  comprises 
elevation  of  temperature  to  burn  out  or  oxidize 
the  typhoid  poison,  and  an  antiseptic  diarrhoea 
to  prevent  the  growth  of  the  B.  typhosus  and  to 
remove  the  germs  from  the  bowels.  In  tuber- 
culosis these  symptoms  are  fever  for  oxidation, 
expectoration  to  rid  the  economy  of  the  poisoning 
material  and  profuse  perspiration  to  wash  out  the 
oxidized  products  from  the  system. 

3.  The  symptoms  of  this  class  might  properly 
be  called  concomitant,  as  they  occur  as  a  sequel, 
not  following  in  the  wake  of,  but  rather  accom- 
panying, the  symptoms  above.  These  represent 
the  effect  of  Nature's  remedies  or  the  cardinal 
symptoms,  and  the}'  are  not  directly  curative.  In 
phthisis  we  have  wasting  of  tissue  from  the  hec- 
tic fever,  haemorrhage  from  ulceration  through 
the  vessel  wall  in  the  lung.  Here  haemorrhage 
and  wasting  are  symptoms  but  they  are  not  of 
any  utility  to  the  patient;  they  represent  the 
effect  of  the  remedy  that  Nature  applies  in  the 
one  instance,  and  the  effect  of  the  presence  of  the 
first  class  of  symptoms,  in  the  other.  In  typhoid 
this  class  is  represented  by  the  peculiar  smell  of 
the  dejections,  muscular  debility,  haemorrhage, 
borborygmus,  coated  tongue,  etc. 

4.  This  class  is  due  to  the  remedies  the  phy- 
sician applies,  and  are  very  much  more  variable 
than  those  preceding,  for  the  reason  that  the  phy- 
sician is  more  inconstant  than  Nature  in  pre- 
scribing. These  symptoms  are  the  physiological 
actions  of  the  drugs  administered.  The  first  class 
given  is  no  doubt  not  symptoms  in  reality  but 
pathological  indications,  and  represent  the  cause 
of  disease. 

Therefore,  from  the  foregoing,  a  symptom  is  a 
modified  physiological  function  brought  about  for 
the  better  adaptation  of  the  system  to  rid  itself  of 
a  foreign  and  irritating  substance. 

I  here  introduce  this  definition  to  accentuate 
the  fact  that  what  is  commonly  called  a  symptom 
is  a  modified  physiological  function,  and  that  this 


47° 


ETIOLOGY  AND  TREATMENT  OF  TYPHOID. 


[April  4, 


modification  is  brought  about  to  meet  the  condi- 
tions arising  from  a  morbid  substance  in  the  econ- 
omy. If  this  is  brought  about  to  meet  such  con- 
dition, and  it  manifestly  is,  then  we  must  accept 
the  fact  that  what  we  speak  of  as  symptoms  are  ap- 
parent (1.  e.,  easily  seen)  conditions  or  safeguards 
thrown  out  by  the  system,  actuated  by  its  "cell 
sense,"  to  do  battle  against  the  foe. 

My  purpose  in  thus  classifying  symptoms  is  to 
show  those  symptoms  that  it  is  safe  to  combat; 
those  that  it  is  safe  to-augment,  and  those  that  it 
is  safe  and  wise  to  ameliorate.  In  all  cases  we 
know  that  it  is  safe  to  remove  or  combat  the 
cause.  In  typhoid  the  germ  must  be  removed, 
and  Nature  is  trying  to  do  this  by  a  diarrhoea  of 
a  peculiar  kind.  Then  combat  the  cause  by  aug- 
menting the  remedy,  diarrhoea.  Look  to  it  that 
this  is  not  hampered  by  what  I  have  denominated 
concomitant  symptoms,  tympanites,  coated  ton- 
gue, haemorrhage,  debility,  etc.,  by  correcting  or 
assuaging  them.  My  purpose  in  considering  the 
fourth  class  as  symptoms  in  an}-  given  disease,  is 
for  the  better  illustration  of  the  preceding  classes 
and  to  elucidate  what  I  consider  the  true  defini- 
tion of  a  symptom. 

For  example,  a  lethal  dose  of  morphia  is  ad- 
ministered; this  is  the  disease.  Deep  sleep,  in- 
sensibilit}',  heart  failure,  failure  of  respiration, 
clammy  skin,  vomiting  at  the  outset,  great  irri- 
tation of  the  skin  (itching),  especially  of  the  nose 
and  lips.  These  are  concomitant  symptoms.  Now, 
this  is  a  lethal  dose,  and  strikes  down  with  over- 
whelming force  the  centres  and  lines  held  in  the 
hand  of  Nature  as  surely  as  a  pistol  ball  would;  but, 
notwithstanding,  Nature  reveals  the  line  to  be 
followed.  The  indications  are  but  short  lived, 
and  are  only  to  be  noticed  for  a  limited  time  after 
the  dose  is  administered  and  are  known  collective- 
ly as  the  stage  of  stimulation,  in  which  the  tem- 
perature is  elevated,  arterial  pressure  increased, 
renal  elimination  hurried,  respiration  accelerated 
and,  frequently,  emesis.  These  are  Nature's 
remedies,  but  they  are  not  strong  enough  to  ward 
off  the  trouble  and  the  system  sinks;  but  if  a  pa- 
tient recover  from  a  poisonous  dose  of  morphia 
this  sequence  of  symptoms  must  be  prolonged. 

In  typhoid  fever  the  germ  B.  typhosus  is  the 
cause;  the  alkaloid  typhotoxine  is  the  disease; 
fever,  diarrhoea,  anorexia  and  lassitude  are  the 
cardinal  symptoms  of  Nature's  remedies,  and 
furred  tongue,  debility,  tremors,  etc.,  the  concom- 
itant symptoms,  or  the  results  of  the  vis  medica- 
trix  natures. 

Etiology. — Geographical  location,  climate,  sea- 
son, age  and  diet  are  predisposing  causes.  It  is 
with  the  last  only  that  I  wish  to  deal  in  conjunc- 
tion with  the  direct  exciting  cause,  the  Koch- 
Eberth  germ  B,  typhosus.  After  a  case  of  ty- 
phoid in  1S82  I  began  the  investigation  of  the 
disease  and  its  causes.  This  case  was  that  of  a 
Polish  youth,  and  I  did  as  many  a  more  learned 


physician  has  done  before  me,  made  a  mistake  in 
the  diagnosis.  Being  fresh  from  college,  and  full 
of  J.  Milner  Fothergill's  "Indigestion  and  Bil- 
iousness, ' '  the  trouble  was  pronounced  subacute 
biliousness  and  was  treated  accordingly;  but  the 
fever  continued,  and  though  better,  my  patient 
did  not  recover  as  he  should  had  it  been  a  simple 
bilious  attack.  On  the  tenth  day,  in  company  with 
another  physician,  the  diagnosis  of  typhoid  was  pro- 
nounced. From  the  fact  that  my  patient  had 
grown  no  worse  the  cholygogue  treatment  was 
continued,  and  on  the  sixteenth  day  we  were 
pleased  to  see  the  temperature  normal,  and  after 
this  convalescence  supervened  rapidly.  My  next 
cases  were  treated  on  the  same  line  and  inquiry 
into  the  cause  was  instituted.  It  will  be  ob- 
served that  the  stools  in  enteric  fever  are  dark 
greenish-brown,  which  I  attribute  to  the  presence 
of  bile,  and  knowing  that  occlusion  of  the  bile 
ducts  permits  a  peculiar  decomposition  of  the  in- 
testinal contents,  I  arrived  at  the  conclusion  that 
the  presence  of  bile  in  the  gut  destroyed  the  ty- 
phoid germ  in  some  manner,  and  consequently 
the  absence  of  bile  would  favor  the  growth  of  the 
bacillus.  Careful  inquiry  has  been  made  in  all 
my  subsequent  cases  and  symptoms  of  profound 
biliousness  have  been  uniformly  noted.  If  we 
but  compare  the  symptoms  of  hepatic  congestion 
and  the  prodromes  of  typhoid,  we  cannot  but 
note  their  similarity.  In  both  we  have,  in  the 
language  of  Loomis,  in  his  "Practical  Medicine," 
"a  grumbling  headache,  more  or  less  aching  of  the 
limbs,  a  tired  feeling  all  over,  chilly  sensations, 
1  flashes  of  heat  and  anorexia;"  then  we  may  have 
a  slight  diarrhoea,  and  always  in  the  beginning  a 
yellowish-white  coat  on  the  tongue.  Listen  for 
a  moment  to  Murchison:  "The  symptoms  of  de- 
ficient excretion  of  bile  are  irregular  bowels,  col- 
orless stools,  loss  of  appetite,  yellowish  fur  on 
the  tongue,  bitter  taste  in  the  mouth  flatulence, 
languor,  disinclination  to  exertion,  great  depres- 
sion, frontal  headache  and  heaviness."  Fotber- 
gill  adds:  "I  am  so  tired  and  sore  all  the  time; 
as  tired  on  awaking  as  retiring." 

There  is  no  doubt  from  the  experiments  of 
Charrin  and  Roger  that  bile  is  an  antiseptic  of  no 
mean  magnitude.  They  have  shown  that  some 
of  the  components  of  bile  are  more  energetic  than 
others,  especially  were  the  tauro-cholates  shown 
to  be  effective  antiseptics.  The  bile  salts  as  above 
were  more  powerful  than  bilirubin.  Bufallin 
gives  us  the  same  results.  Fothergill  says,  "the 
bile  coloring  matter  and  the  bile  acids  go  together, 
where  the  one  is  the  other  is  not  far  away." 
Taurocholic  acid  (C.  H.  NO  S)  contains  sulphur 
and  is  more  profuse  in  the  presence  of  bilirubin. 
When  the  fur  on  the  tongue  is  most  brown  from 
the  staining  of  its  epithelium  with  the  bilirubin, 
the  taste  is  the  most  bitter  from  the  presence  of  the 
taurocholate  of  soda.  This  shows  that  when  the 
tongue  is  thus  coated  the  liver  is  not  acting  and 


i*9I.] 


ETIOLOGY  AND  TREATMENT  OF  TYPHOID. 


47i 


that  there  is  no  bile  being  poured  out  into  the  in- 
testine. 

Desiring  to  ascertain  whether  bile  has  any  an- 
tiseptic action  on  the  typhoid  germ  I  obtained  a 
pure  culture  from  one  of  my  cases.  From  this  I 
inoculated  twelve  halves  of  boiled  potatoes.  After 
twenty  four  hours  a  few  drops  of  carefully 
prepared  ox  bile  were  applied  to  the  cul- 
tures. This  was  repeated  for  three  days  at  in- 
tervals of  six  hours  and  the  cultures  made  no 
further  material  progress,  and  on  the  seventh 
day  were  about  as  much  developed  as  the  untreated 
cultures  were  on  the  third  day.  Four  others  were 
treated  with  the  bile  after  fifty- six  hours,  at  which 
time  the  cultures  had  made  considerable  progress, 
and  although  the  cultures  continued  to  grow  the 
growth  was  very  slow,  and  on  allowing  the  bile 
to  drain  off  and  dry,  the  germ  growth  did  not 
continue.  All  the  cultures  emitted,  in  a  very 
marked  manner,  the  characteristic  odor  of  the  ty- 
phoid stool. 

My  second  and  third  experiments  were  on  six 
potatoes  and  six  test  tubes  of  nutrient  gelatin  on 
which  were  used  fresh  specimens  of  ox  bile.  These 
served  to  confirm  the  first  experiments,  but  in  a 
more  positive  manner.  The  cultures  that  were 
treated  within  the  first  twenty-four  hours  exhib- 
ited no  growth  whatever  for  many  days. 

The  conclusions  to  be  drawn  from  the  above 
are:  1.  Bile  destroys  or  at  least  retards  the 
growth  of  the  B.  typhosus,  and  apparently  does 
so  by  retarding  sporification  ;  2.  It  is  reasonable 
to  suppose  that  bile  is  excreted  in  larger  quanti- 
ties, coloring  the  stools  and  aiding  peristalsis  to 
rid  the  bowels  of  the  germ  ;  3.  If  the  above  are 
true,  then  in  the  absence  of  bile  in  the  bowel  the 
germ  would  find  no  restriction  to  its  growth  and 
multiplication,  and  the  diet  that  would  produce 
biliousness  would  be  a  predisposing  cause  of 
typhoid  ;  4.  If  bile  destroys  the  germ  it  must  be 
one  of  Nature's  remedies  and  should  be  en- 
couraged to  flow.  It  is  generally  stated  that  the 
most  dangerous  cases  of  typhoid  are  those  in 
which  the  bowels  refuse  to  act.  In  those  cases 
where  there  is  a  profuse  diarrhoea  which  is  indi- 
cative of  great  irritation  of  the  mucous  lining  of 
the  bowel  from  the  presence  of  the  germs,  the 
diarrhoea  can  be  most  easily  checked,  when  in 
the  early  stage,  and  there  is  no  reason  to  suspect 
much  glandular  necrosis,  by  a  gentle  cholagogue 
cathartic.     Bile,  then,  is  one  of  Nature's  remedies. 

The  Cause  ami  i'se  of  Febrile  Movements. — 
Before  there  can  be  a  rise  of  temperature  there 
must  be  a  derangement  of  the  thermotaxic  func- 
tion of  the  system.  That  is,  the  avenues  for  the 
escape  of  heat  must  be  unstable  and  heat  loss  be 
less  than  heat  production.  Now  if  this  alone 
constituted  the  phenomena  of  pyrexia  the  sub- 
ject would  be  a  simple  one  indeed,  and  all  that 
would  be  required  would  be  to  aid  radiation  and 
conduction  of  the  heat.     But  Wood  and  Reichert  | 


have  shown  that  the  matter  does  not  end  here, 
for  a  high  temperature  may  be  present  with  a 
great  amount  of  heat-loss  going  on,  and  by  their 
calorimetric  researches  they  have,  with  Donald 
Macalister,  shown  that  the  thermogenic  function 
may  be  actively  excited,  and  the  sublingual 
temperature  be  little  more  than  normal,  or  there 
may  be  little  excitation  of  the  thermogenic  centre 
and  a  very  high  sublingual  or  rectal  temperature, 
provided  the  conduction  and  radiation  of  heat  be 
abolished  or  hindered.  The  significance  of  this 
is  stated  by  Macalister  {British  A/edical  Journal, 
Vol.  1,  1887,  page  566),  as  follows  ;  "  The  pro- 
cesses which  issue  in  motion  on  the  one  hand  and 
thermogeuesis  on  the  other  are  associated  with 
chemical  movements  in  the  muscle,  with  metab- 
olisms, whose  terminal  steps  are  accretion  of 
oxygen  and  excretion  of  carbonic  acid  and  water. 
Both  the  contractile  and  the  thermogenic  stuffs 
are  stored  in  the  muscles  but  are  not  the  same, 
but  as  far  as  function  goes  they  are  the  muscle. 
Each  can  be  exhausted,  the  thermogenic  some- 
times sooner  than  the  contractile.  Both  are  up- 
built by  the  circulating  blood,  but  in  some  cases 
the  contractile  stuff  sooner  than  the  thermogenic. 
Both  are  affected  by  cold,  but  the  thermogenic 
much  sooner  and  more  intensely  then  the  con- 
tractile. We  know  but  little  of  the  chemistry  of 
these  metabolisms.  Oxygen  is  taken' up  in  each, 
and  carbonic  acid  is  eliminated,  but  the  pro- 
cesses passed  through  between  these  terminal 
stages  are  more  complex  than  simple  oxidation. 
This  in  health  ;  but  if  tlie  reconstructive  part  of 
the  process  is  inadequate  or  absent,  the  balance  of 
accounts  wiUgive  evidence  of  a  nitrogenous  residuum 
which  is  marked.  The  muscle  substance  will  ap- 
pear itself  to  be  consumed ;  it  will  no  longer  be 
iv hat  I  might  call  the  circulating  medium  of  con- 
sumption. The  cast- out  muscle  molecules  are 
not  exeretionary  in  the  same  sense  that  carbonic 
acid  is  exeretionary.  In  fever  the  nitrogen 
substance  of  the  system  have  been  consumed,  and 
for  some  reason.''  Will  we  say  that  this  sub- 
stance has  been  consumed  by  the  fever,  or  will 
we  say  that  the  fever  has  been  fed  by  this  com- 
bustible substance  ?  Macalister  again  says  (ibid.) : 
"Some  of  the  figures  show  that  as  the  course  of 
the  temperature  varies,  the  rate  of  heat  produc- 
tion may  actually  be  highest  when  the  tempera- 
ture is  lowest,  an  excessive  rate  of  heat-loss 
overbear,  and  thus  disguise  a  simultaneous  ex- 
cessive rate  of  heat  production  ;  and  conversely, 
the  time  when  the  temperature  is  high  may  coin- 
cide with  a  time  when  the  heat  production  is  low." 
If  this  tissue  metabolism  goes  on  regardless  of 
the  height  of  body  temperature,  then  there  is 
some  other  reason  beside  elimination,  or  rather 
the  lack  of  elimination,  for  this  heat  being  pres- 
ent. It  is  reasonably  demonstrated  by  physi- 
ologists (Wood,  Foster,  Hale- White,  Reichert), 
that  there  is  a  nervous  centre  which  regulates  the 


472 


ETIOLOGY  AND  TREATMENT  OF  TYPHOID. 


[April  4, 


production  of  heat  in  the  animal  body,  which 
they  call  the  thermotaxic  centre.  If  this  be  ex- 
cited, or  rather  stimulated,  heat  production  is  in 
excess ;  if  it  be  depressed  the  usual  thermogenesis 
does  not  occur.  Now  if  this  be  true,  is  it,  or  is 
it  not  similar  to  the  centre  governing  respiration, 
and  when  its  function  is  most  needed  is  it  not 
called  into  the  field  of  action  there  to  do  its 
duty?  When  the  tissues  need  rebuilding  they 
send  out  a  dispatch  over  their  telegraph  lines  to 
the  central  office,  the  brain,  for  food,  and  the 
central  office  again  wires  the  commissariat,  the 
stomach  ;  and  if  there  be  no  stores  on  hand  it  is 
here  that  the  desire  for  food  is  felt.  The  tissues 
feel  a  need  of  oxygen.  The  message  is  flashed 
to  the  brain  and  thence  onto  its  switch-board, 
from  whence  the  message  is  conveyed  to  the 
respiratory  centre  which  notifies  the  lungs  to 
rapidly  fill  and  empty  themselves.  Why  do 
these  dispatches  have  to  be  sent  out  ?  Because 
there  is  some  obstruction  to  physiological  func- 
tion, and  this  substance  must  be  something  use- 
less to  the  economy.  Where  there  is  a  demand 
on  the  respiratory  centre  the  offending  material 
is  carbonic  acid  gas.  In  the  case  of  hunger  the 
presence  of  the  materials  of  retrograde  meta- 
morphosis is  in  excess  of  the  building  materials, 
or  perhaps  more  accurate^,  there  is  felt  the  de- 
sire for  more  strength  through  more  protoplasm, 
blood,  chyle,  food.  If  there  is  any  offending 
material  in  the  system  which  it  is  Nature's  in- 
tent to  burn  out  or  oxidize,  the  alarm  is  sent  to 
the  centre  governing  the  heat  production.  The 
thermogenic  stuff  is  there  in  the  system ;  and 
then  comes  the  call  for  more  oxygen.  The  con- 
flagration goes  on  and  the  material  is  oxidized, 
and  perhaps  thus  rendered  wholly  inert.  What 
benefit  then  is  to  be  derived  from  measures 
directed  toward  aiding  evaporation,  or  radiation 
or  conduction  of  the  heat  away  from  the  body 
through  the  skin  ?  It  is  true  that  some  of  the 
offending  matter  may  be  thus  washed  out  of  the 
system  through  the  pores,  or  the  immediately 
contiguous  atom  to  the  one  being  oxidized  may 
be  cooled  off  to  await  combustion  on  another 
day  ;  but  the  material  is  there  to  be  consumed 
and  the  tissue  must  be  sacrificed  to  do  it,  for  it 
matters  not  whether  there  be  a  high  sublingual 
temperature  or  not,  the  consumption  of  the  thermo- 
genic and  the  contractile  stuffs  is  progressing. 
It  would  be  far  more  rational  to  prevent  the 
irritating  substance  from  entering  the  system,  or 
where  this  is  impossible  from  lack  of  accurate, 
scientific  knowledge,  to  conserve  the  tissues,  as 
we  can  do  by  furnishing  something  to  the  system 
easily  oxidizable  which  would  be  burned  in 
preference  to  the  tissues. 

By  experimenting  with  bacteria  it  is  ascer- 
tained that  there  are  particular  temperatures  at 
which  they  thrive  and  grow,  at  which  they  cease 
to  seggregate  and  sporify,  and  at  which  they  die. 


The  temperature  at  which  they  grow  most  lux- 
uriantly is  between  96-990  F.,  that  at  which  they 
cease  to  seggregate  and  sporify  is  m-1140  F. 
The  most  of  them  die  outright  at  a  temperature 
of  1500  and  the  spore  dies  at  212-2200  F.  You 
say  then  that  the  temperature  has  nothing  to  do 
with  the  germ  in  fevers,  and  only  apparently 
makes  it  grow  more  rapidly,  Granted  that  you 
may  be  right,  but,  let  us  inquire. 

When  the  sublingual  temperature  is  98.6°  F. 
the  temperature  in  the  hepatic  vein  is  103-1070 
F.,  and  if  the  sublingual  rise  to  1050  we  would 
have  the  hepatic  temperature  of  114°  F.  This  of 
course  will  not  kill  the  germ,  but  it  is  very  effec- 
tive in  preventing  multiplication  by  fission  and 
sporification.  Pasteur,  Koch,  Breger,  Eberth  and 
others  tell  us  that  the  B.  anthracis  is  not  in  the 
circulating  blood  but  one  or  two  hours  before 
death  ensues  from  its  presence.  Breger  tells  us 
the  same  thing  also  regarding  the  B.  typhosus, 
when  it  is  then  also  in  the  spleen.  When  the 
germs  once  enter  the  blood  there  is  nothing  to 
prevent  their  rapid  multiplication  except  high 
temperature,  which  being  interferred  with,  per- 
mits death  to  quickly  ensue.  Nature  makes  one 
final  effort ;  the  outlets  for  the  escape  of  heat  are 
closed,  and  an  intense  conflagration  is  lighted  up 
in  the  body  furnace,  but  it  is  then  perhaps  too 
late  and  the  patient  is  said  to  have  died  of  hyper- 
pyrexia. 

Again,  the  disease  is  not  the  germ  but  the 
ptomaine  manufactured  by  the  germ,  and  at  cer- 
tain temperatures  it  is  rendered  inert  (Breger),  or 
is  formed  into  a  less  harmful  product,  which  is 
perhaps  excreted  as  a  leucomaine,  or  else  it  is 
not  formed  at  all.  For  instance,  if  in  nutrient 
peptone  broth  cultures  of  B.  typhosus  remain  at 
a  temperature  of  102.2°  F.  for  twenty-four  hours 
there  will  be  no  ptomaine,  typhotoxine,  formed, 
but  in  its  stead  there  will  appear  creatine,  a  leu- 
comaine of  less  harmful  tendencies.  Now  how 
can  we,  in  the  face  of  the  fact  that  the  tempera- 
ture of  the  liver  is  almost  constantly  105°  and 
the  temperature  requisite  to  convert  typhotoxine 
into  creatine  is  only  102. 2°,  say  that  pyrexia  is 
not  a  remedy  instead  of  a  symptom,  and  that  it 
ought  to  be  interferred  with  ?  But  hyperpyrexia? 
It  will  not  occur  if  nature  be  aided  in  other 
quarters. 

For  two  thousand  years  physicians  have  been 
engaged  in  a  wild,  hurried  and  anxious  rage  to 
discover  some  new  remedy  to  combat  fever. 
They  have  had  tartar  emetic,  digitalis,  aconite, 
veratrum,  quinine,  salycilic  acid,  antipyrin  and 
acetanilid  and  still  the  fever  goes  on.  We  are 
told  that  the  fever  must  be  lowered  or  the  patient 
will  die.  I  do  not  believe  that  high  temperature 
ever  killed  anyone.  But  we  are  told  that  the  pa- 
tient cannot  live  long  with  a  temperature  of  106° 
or  107°  F.  Of  course  they  cannot ;  but  this  is 
no  proof   that  they  expire  from   hyperpyrexia. 


..Sol.] 


LESIONS  INDUCED  BY  TYPHOID  FEVER 


473 


When  the  fever  suddenly  flashes  up  to  such 
dangerous  height  it  indicates  that  the  system's 
bulwarks  have  been  overthrown,  and  that  the 
germs  are  invading  the  blood  and  tissues  gener- 
ally, or  more  frequently  it  denotes  a  great  influx 
of  the  alkaloids  or  the  albumoses  into  the  sys- 
tem, which  immediately  begins  to  burn  them  out, 
because  they  are  there  in  large  enough  quantities 
to  stimulate  excessively  the  thermogenic  centre. 
The  larger  the  dose  of  typhotoxine  injected 
under  the  skin  the  higher  the  temperature  will 
run  till  a  certain  limit  is  reached,  when  the  irrita- 
bility of  the  thermogenic  centre  becomes  ex- 
hausted and  the  temperature  falls  below  the 
normal.  If  the  above  be  true  why  do  we  ever 
give  an  antipyretic  in  typhoid  that  we  have  had 
under  our  care  from  the  first  ?  And  above  all, 
why  is  it  ever  necessary  to  give  a  cold  bath  ? 
Cold  bathing  and  a  milk  diet  is  the  present  treat- 
ment. Do  we  expect  to  depress  the  temperature 
below  the  growing  point  of  the  germs  or  the 
forming  point  of  the  ptomaine?  The  remedy  is 
a  good  one  in  its  place  for  it  acts  as  a  tonic  to 
the  system,  and  by  contracting  the  surface 
arterioles  it  flushes  the  capillaries  of  the  internal 
organs,  and  thus  retards  the  absorption  of  the 
poison  which  is  being  manufactured  in  the 
bowels.  It  also  possibly  aids  the  elimination 
of  the  ptomaine  already  in  the  system.  But  all 
the  previous  methods  of  treating  typhoid  have 
required  from  four  to  six  weeks  for  recovery. 
Now  if  a  treatment  that  allows  of  a  normal  tem- 
perature in  from  ten  to  sixteen  days  be  advanced, 
why  still  advocate  an  unnatural  method  of  treat- 
ment that  loses  two  or  three  weeks  of  the  pa- 
tient's time? 

We  do  not  now  expect  to  cure  ague  with 
quinine  by  depressing  the  temperature,  but  by 
killing  the  haematozoa  malariae  of  Laveran. 
Quinine  is  absorbed  and  circulates  along  side  of 
the  organism  and  destroys  it  by  attacking  its 
protoplasm.  The  B.  typhosus  is  not  in  the  blood 
till  late  in  the  disease,  but  exists  by  the  million 
in  the  bowels  and  faecal  matter.  By  actual  ex- 
periment it  has  been  demonstrated  that  bile  kills 
or  stunts  them  ;  shall  ice  baths  and  milk  diet  be 
ordered,  or  shall  a  cholagogue  be  exhibited? 

Since  mercurials  are  not  cholagogues  in  reality, 
but  serve  to  stimulate  the  liver  and  thus  eliminate 
bile  more  rapidly  than  any  other  means  at  our 
command,  it  is  preferable,  since  bile  is  in  excess 
in  the  system  and  only  needs  to  be  eliminated, 
to  begin  with  some  mild  preparation  of  mercury, 
such  as  calomel.  This  is  administered  for  the 
first  two  or  three  doses  in  two-  or  three-grain 
powders,  then  the  next  six  or  eight  doses  in  one- 
half  or  one- fourth  grain  doses,  and  then  for  six 
to  ten  days  one- tenth  of  a  grain  at  a  dose  even- 
three  or  four  hours.  About  the  fifth  or  sixth 
day  the  salicylates,  turpentine  or  salol  which 
really  cause  a  greater  formation  of  bile,  will  be 


of  service  in  combination  with  the  calomel,  to 
the  case.  If  the  case  is  seen  late  and  there  is  a 
very  high  temperature  to  combat,  with  great  de- 
pression and  wasting,  conserve  the  tissues  with 
alcohol.  It  is  possible  that  the  calomel  may  act 
directly  as  an  antiseptic  on  the  germs,  but  I  have 
had  quite  the  same  results  with  the  administra- 
tion of  podophyllin.  Out  of  fifty-two  cases  that 
I  have  thus  treated  I  have  not  observed  one 
instance  in  which  there  appeared  salivation. 
Of  the  fifty-two  cases  there  were  none  that  were 
not  free  from  fever  on  the  seventeenth  day,  and 
only  one  that  ever  had  a  temperature  of  103. 50 
F.,  and  he  called  me  on  the  fifth  day  that  he  was 
confined  to  his  bed. 

Apropos  of  the  action  of  bile  on  the  intestinal 
contents  and  the  utility  of  the  cholagogue  treat- 
ment set  forth  above,  it  might  not  be  untimely 
here  to  say  that  the  same  comparative  results  ob- 
tain in  treating  summer  diarrhoea  of  children  in 
the  same  manner.  Podophyllin,  calomel,  salol 
and  turpentine  continued,  with  an  occasional 
dose  of  coto,  have  produced  most  brilliant  re- 
sults, and  I  apprehend  that  Dr.  Boardman  Reed's 
experience  (Practitioner)  in  checking  diarrhoea 
with  podophyllin  is  a  like  result. 

102  So.  Michigan  St. 


SOME  OF  THE  LESIONS  INDUCED  BY 
TYPHOID  FEVER. 


Read  before  the  Cambridge  Society  fm 
February  23,  /8a 


Medical  Improvement, 


BY  AUGUSTUS  P.  CLARKE,  A.M.,   M.D.. 

OF  CAMBRIDGE.  MASS. 

Perhaps  no  disease  whose  records  have  been 
embodied  in  medical  literature  is  attended  or  fol- 
lowed by  a  greater  variety  of  lesions  than  is  that 
of  typhoid  fever.  The  functions  of  the  great 
nerve  centres,  including  the  brain  and  spinal  cord, 
as  also  those  of  the  nervous  system  generally,  are 
liable  to  be  seriously  influenced,  weakened  or  in- 
terrupted, for  periods  of  uncertain  duration,  by 
the  occurrence  of  an  attack  of  typhoid  fever. 

Among  the  sequels  or  complications  that  have 
been  observed  is  dementia,  insanity,  loss  of  sight, 
aphasia,  paraplegia  and  other  forms  of  paralysis. 
Sometimes  only  one  limb,  as  a  leg  or  an  arm ; 
rarely,  only  an  arm  and  a  leg  at  the  same  time. 
At  other  times  disturbances  are  limited  to  the 
functions  of  speech.  Cases  now  and  then  occur, 
in  which  we  have  paralysis  without  appreciable 
anaesthesia.  The  more  common  forms  are  those 
in  which  both  the  motor  and  the  sensory  por- 
tions of  the  nerve  are  involved.  Neuritis  begin- 
ning at  the  peripheral  portions  of  the  nerve  is 
not  an  uncommon  sequel  of  typhoid  fever.  An- 
other complication  of  typhoid  fever  is  pneumonia. 
This  is  often  of  a  limited  extent,  but  occasionally 
it  is  more  or  less  diffused.    Perhaps  the  particular 


474 


LESIONS  INDUCED  BY  TYPHOID  FEVER. 


[April  4. 


position  which  the  patient  assumes  during  the 
first  illness  in  the  fever  may  have  a  controlling 
influence  in  the  extent  and  severity  toward  that 
sequel  of  the  disease.  Formerly  much  was  said 
in  reference  to  pneumonia  as  a  complication  of 
disease.  Such  attacks  of  pneumonia  were  called 
"  hydrostatic,"  from  the  supposed  influence  posi- 
tion of  the  patient  exercised  in  favoring  the  grav- 
itation of  the  blood  and  other  fluids  to  the  more 
dependent  portions  of  the  parenchyma  of  the 
lungs. 

In  my  own  practice  I  have  met  with  three  well 
marked  cases  of  aphasia  occurring  in  typhoid 
fever.  The  patients  were  young;  their  ages  being 
12,  14  and  17  years.  The  aphasia  in  each  case 
occurred  after  the  second  week  of  the  fever.  The 
temperature  had  been  unusually  high,  and  much 
exhaustion  had  ensued.  No  paralysis,  nor  other 
morbid  process  of  the  nerves  occurred.  The  pa- 
tients at  length  fully  recovered. 

The  record  of  the  following  case  presents  an 
affection  of  the  eye :  Mrs.  B.,  aged  31  years  and 
mother  of  three  children,  had  the  characteristic  i 
symptoms  of  typhoid  fever,  such  as  epistaxis,  rose 
spots  appeanng  on  the  seventh  day  following  the 
initial  chill.  The  patient  had  been  very  delirious, 
and  had  become  much  exhausted.  After  the  fifth 
week  she  complained  of  pain  in  the  eyes,  more  es- 
pecially in  the  left  one.  Ophthalmoscopic  exam- 
ination revealed  neuritis  extending  to  both  discs. 
After  the  temperature  became  normal  she  suffered 
from  perversion  of  the  senses,  and  at  length  be- 
came partially  insane.  There  was  no  history  of 
renal  trouble,  the  urine  at  that  time  contained 
only  traces  of  albumen.  The  patient  finally  re- 
covered without  sustaining  permanent  loss  of 
vision. 

Disease  of  the  optic  discs  following  typhoid 
fever  is  mentioned  by  Dr.  Oglesby,1  of  Leeds. 
That  author  says  that  he  has  never  met  with  a 
case  without  a  distinct  history  of  meningitis. 
"The  majority  of  those  patients,"  he  says,  "pre- 
sent objective  symptoms  indicative  of  acute  kid- 
ney mischief,  having  a  decided  appearance  of 
cellular  dropsy  of  the  face,  with  the  usual  pallor 
of  such  cases.  It  is  very  exceptional  that  albu- 
men is  found  in  the  urine." 

I  have  records  of  a  case  of  severe  laryn- 
geal inflammation,  following  typhoid  fever.  The 
case  occurred  six  years  ago,  in  a  man  aged  42 
years.  The  typhoid  symptoms  were  quite  char- 
acteristic. The  morning  decline,  and  the  even- 
ing increase  of  temperature  prevailed  through- 
out the  attack.  From  the  onset  there  had 
been  much  delirium,  also  tympanites  and  a  pro- 
fuse diarrhoea.  After  the  fourth  week  the  pa- 
tient showed  Redded  improvement.  On  the  for- 
tieth day  a  dyspnoea  ensued,  though  there  was 
but  little  cough  and  no  cardiac  disturbance.  For 
the  next  two  weeks  the  symptoms  were  more  se- 

1  Boston  Med.  and  Surg.  Journal,  Vol.  cviii,  p.  476. 


rious.  The  respiration  became  more  and  more 
difficult,  and  at  length  the  patient  appeared  in 
imminent  danger  of  suffocation.  The  late  Dr.  A. 
F.  Holt  saw  with  me  for  several  times  the  case  in 
consultation.  It  being  evident  that  there  was  an 
abscess  which  was  extending  into  the  laryngeal 
perichondrium.  On  the  sixty-first  day  operative 
measures  were  decided  upon.  By  the  use  of 
cocaine  we  were  enabled  to  reach  the  abscess 
without  the  necessity  of  resorting  to  laryngotomy. 
The  patient  ultimately  recovered,  though  there 
remained  a  laryngeal  stenosis  Two  years  later 
the  patient  died  of  acute  pneumonia,  hastened, 
no  doubt,  by  the  laryngeal  constriction. 

I  have  notes  of  four  cases  of  pneumonia  occur- 
ring as  sequel  or  complication  of  typhoid  fever. 
In  one  case  in  which  the  typhoid  symptoms  were 
well  pronounced,  pneumonia  developed  in  the 
third  week  and  led  to  a  fatal  termination.  This 
occurred  in  a  female  aged  18  years.  For  some 
two  3-ears  previous  to  the  occurrence  of  her  last 
sickness  she  had  suffered  from  impaired  health. 
In  three  cases  the  patients  were  aged  respectively 
17,  20  and  29  years.  In  two  of  the  cases  the 
area  of  dulness  was  limited.  In  the  third  case 
the  whole  of  the  right  lung  was  involved.  The 
patient  did  not  recover  until  the  fourth  week 
after  the  onset  of  the  pneumonic  symptoms. 

In  a  case  of  typhoid  fever  occurring  in  a  woman 
aged  34  years,  the  mother  of  two  children,  acute 
pleurisy  developed  in  the  sixth  week.  There  was 
marked  dulness  on  percussion  over  the  right  side, 
also  egophony  and  absence  of  vocal  fremitus  of 
that  side  except  at  the  upper  third.  The  effusion 
was  moderate  in  amount.  She  recovered  with 
slight  retraction  of  the  chest  of  that  side.  Two 
years  later  phthisis  supervened,  from  which  she 
died  within  eighteen  months. 

In  one  case  of  typhoid  fever  occurring  in  a  man 
aged  41  years,  facial  erysipelas  made  its  appear- 
ance on  the  forty-first  day  after  the  beginning  of 
the  febrile  symptoms.  This  complication  ran  into 
the  ninth  week,  causing  an  abscess  of  the  scalp 
just  back  of  the  forehead. 

Another  complication  I  have  met  with  is  that 
of  parotiditis.  This  occurred  in  the  case  of  a  man 
aged  37  years.  The  attack  of  typhoid  in  the  pa- 
tient was  of  a  severe  type.  Inflammation  of  the 
right  parotid  began  on  the  tenth  day  after  the 
initial  symptoms  of  the  fever.  Hope  in  the  pa- 
tient's recovery  was  entertained  until  the  twenty- 
fourth  day.  Soon  after  that  the  patient  rapidly 
I  sank,  and  died  three  days  later.  Suppuration  of 
the  parotid  did  not  take  place.  The  inflamma- 
tion, however,  extended  into  the  cervical  and  ax- 
illary glands.  This  was  the  most  marked  case  I 
have  ever  met  with,  in  civil  practice. 

I  recall  cases  occurring  in  the  Spring  and  Sum- 
mer of  1862,  during  the  Peninsular  campaign. 
At  that  time  the  occurrence  of  an  affection  of  the 
parotid  in  a  typhoid  case  was  regarded  as  an  ex- 


IS9I.J 


LESIONS  INDUCED  BY  TYPHOID  FEVER. 


475 


treraely  dangerous  complication.  Some  forms  of 
paralysis  after  typhoid  fever  have  been  reported 
by  Dr.  Ross.2  Dr.  Ross  mentions  two  cases ;  in 
one  case  there  was  severe  paraplegia  attended 
with  much  pain,  rigidity,  and  wasting  of  the 
limbs,  but  with  no  anaesthesia.  In  the  other  the 
paralysis  was  unusually  extensive,  involving  all 
the  limbs,  also  the  muscles  of  the  palate.  Both 
cases  ended  in  recovery. 

A  case  of  paraplegia  after  typhoid  fever  occur- 
ring in  my  own  practice  was  that  of  Mr.  S 
29  years,  a  teacher  in  a  Boston  school.  The  fever 
had  not  been  unusually  severe,  though  the  symp- 
toms were  well  pronounced.  After  the  fourth 
week  the  temperature  became  normal.  The  pa- 
tient in  other  respects  was  also  much  improved, 
except  that  there  was  pain  in  the  limbs  and  an 
inability  to  use  them.  The  patient  at  first  was 
unable  to  stand.  Ten  days  later  he  was  able  to 
get  about  his  room,  with  a  sort  of  shuffling  gait. 
Some  weeks  later  he  fully  recovered  and  was  able 
to  resume  the  duties  of  his  school. 

Two  cases  affecting  the  muscles  supplied  by 
the  circumflex  nerve  I  have  met  with.  One,  a  case 
of  a  child  aged  6  years,  occurred  in  my  own  prac- 
tice. The  other,  a  case  of  a  man  aged  21  years, 
occurred  in  the  practice  of  the  late  Dr.  Church. 
This  case  I  saw  in  consultation.  Each  patient 
finally  made  a  good  recovery. 

Two  years  ago  I  was  called  to  attend  a  child 
aged  7  years,  who  had  recently  recovered  from  an 
attack  of  typhoid  fever,  and  who  was  suffering 
from  partial  loss  of  speech.  The  palatal  muscles 
were  affected.  The  paresis  resembled  that  super- 
vening after  diphtheria.  The  history  of  the  symp- 
toms clearly  showed  that  her  condition  was  the 
result  of  typhoid  fever.  She  afterward  greatly 
improved.  I  am  now  unable  to  state  whether  she 
ever  fully  recovered. 

Two  cases  of  periostitis  occurring  in  typhoid 
fever  have  come  under  my  treatment.  The  first 
patient,  J.  O.,  a  girl  aged  9  years.  She  suffered 
from  typhoid  fever  upwards  of  three  weeks.  She 
was  then  able  to  be  up  and  about  her  room.  Six 
days  later  she  was  seized  with  a  relapse  which 
lasted  nearly  four  weeks.  The  evening  tempera- 
ture was  unusually  high,  there  was  much  deliri- 
um. The  patient  refused  all  kinds  of  nourish- 
ment except  milk  and  the  stronger  stimulants. 
The  latter  she  took  in  abundance.  After  the 
fourth  week  of  the  relapse,  her  left  elbow-joint 
became  greatly  inflamed  and  was  much  swollen. 
Suppuration  of  the  elbow-joint  ensued,  necessi- 
tating a  deep  incision  into  the  joint  and  a  large 
amount  of  pus  was  evacuated.  Several  places  in 
the  periosteum  of  the  ulna  from  elbow  to  wrist 
were  the  foci  of  suppuration  ;  indeed,  the  whole 
shaft  of  the  ulna  was  involved.  The  first  abscess 
appeared  in  the  periosteum  near  the  left  olecranon, 
and  involved  the  elbow-joint.     An  abscess  also 


-  Braithwaite,  part  97,  p. 


appeared  on  the  opposite  side  of  the  joint.  Both 
these  abscesses  communicated  with  each  other. 
An  inch  below  and  more  to  the  inside  was  a  third 
abscess.  On  the  same  line  and  an  inch  below  the 
first  was  a  fourth  abscess.  Another  formed  mid- 
way between  the  other  two.  Another  occurred 
in  the  middle  third  of  the  ulna.  Another,  the 
seventh,  opened  near  the  wrist,  but  fortunately 
did  not  involve  the  joint.  From  time  to  time 
several  pieces  of  necrosed  bone  were  discharged 
through  the  open  sinuses  formed  by  the  suppura- 
tive processes.  This  patient  finally  recovered 
!  with  a  stiff  elbow-joint.  Dr.  H.  O.  Marcy,  and 
I  also  Dr.  Geo.  H.  Lyman,  of  Boston,  saw  the  pa- 
tient while  she  was  suffering  from  the  effects  of 
the  periosteal  inflammation. 

There  was  a  peculiar  interest  attached  to  this 
case,  as  a  suit  by  the  parents  was  brought  to  re- 
cover compensation  for  the  child's  sickness  and 
also  for  the  loss  of  use  of  the  arm.  It  appears 
that  the  mother,  a  short  time  immediately  pre- 
ceding the  attack  of  the  typhoid  fever,  was  em- 
ployed to  do  special  work  in  a  family  in  which 
there  occurred  a  fatal  case  of  typhoid  fever.  With- 
out being  informed  of  the  dangers  incident  to  such 
service,  the  mother  returned  to  her  own  home, 
carrying  from  the  sick-room  a  piece  or  pieces  of 
bedding  to  be  washed.  Not  long  after  this  her 
own  daughter,  J.  O.,  was  seized  with  typhoid 
fever  with  results  as  above  stated.  Had  the  case 
not  come  to  a  settlement  without  a  trial,  some  of 
the  most  important  points  relating  to  the  respon- 
sibility of  families  to  domestics  would  have  been 
urged  in  the  prosecution  for  judicial  considera- 
tion. 

The  other  case  occurred  in  a  lad,  H.  M.,  aged 
13  years.  The  history'  of  the  case  shows  that  he 
had  studied  hard  at  school ;  that  often  he  had 
been  out  late  at  night  to  fulfil  engagements  as 
cornetist.  When  I  was  called,  February  7,  the 
patient  showed  the  characteristic  symptoms  of 
typhoid  fever.  He  had  epistaxis,  tympanites, 
headache,  delirium  ;  later  rose  spots,  evening 
temperature  higher  than  the  morning.  After  the 
third  week  the  typhoid  symptoms  abated ;  the 
patient  was  able  to  leave  his  bed.  His  recover}' 
was  soon  interrupted  by  repeated  chills,  each  chill 
being  followed  by  a  greatly  increased  temperature 
and  an  exacerbation  of  the  other  constitutional 
symptoms.  In  the  right  thigh,  just  above  the 
knee,  there  was  a  most  intense  pain.  Soon  much 
swelling  at  that  point  developed.  March  14,  with 
Dr.  H.  O.  Marcy's  concurrence,  I  made  a  deep 
incision  into  the  swelling  and  obtained  a  free  dis- 
charge of  pus.  By  liberal  use  of  antiseptics  and 
the  drainage  tube,  the  patient  at  length  fully  re- 
covered without  appreciable  injury  to  the  knee- 
joint. 

On  reviewing  the  history  and  symptoms  of  this 
case  it  might  appear  at  first  that  the  constitu- 
tional symptoms  were  wholly  due  to  inflammation 


476 


EMPYEMA. 


[April  4, 


of  the  periosteum,  as  there  was  a  history  of  a  fall 
upon  the  knee.  The  initial  symptoms,  however, 
from  which  the  patient  suffered  were  typical  of 
typhoid  fever ;  beside,  after  the  third  week  there 
was  for  awhile  an  intermission,  or  rather  cessa- 
tion of  the  constitutional  disturbance. 

J.  O.  Affleck,3  M.D.,  reports  three  cases  of  peri- 
ostitis in  typhoid  fever.  These  cases  appeared  in 
a  total  of  117  cases  which  were  under  treatment 
in  1884  (in  the  typhoid  wards  of  the  Fever  Hos 
pital  of  the  Edinburgh  Royal  Infirmary).  Two 
of  them  occurred  in  young  men,  aged  each  21 
years.  One  of  them  had  periostitis  commencing 
in  the  right  tibia  in  the  third  week  of  the  fever. 
This  produced  a  recrudescence  of  the  fever,  and 
prolonged  the  case  for  four  weeks,  but  the  patient 
made  a  good  recovery.  The  other  showed  symp- 
toms of  marked  periostitis  in  the  right  humerus 
in  the  third  week,  and  this  was  followed  by  a 
similar  condition  of  the  right  tibia.  Convales- 
cence was  slow,  and  after  the  periostitis  had  ap- 
parently departed,  it  reappeared  in  the  right 
humerus,  and  an  abscess  formed.  The  patient 
ultimately  recovered.  The  third  case  was  that 
of  a  girl,  aged  9  years.  The  attack  reduced  her 
to  such  a  degree  of  exhaustion  that,  for  a  time, 
it  seemed  scarcely  possible  she  could  survive.  In 
the  fifth  week,  and  just  as  the  temperature  had 
begun  to  subside,  she  was  attacked  with  perios- 
titis of  the  right  humerus,  which  set  up  fever 
again  and  caused  her  intense  suffering.  Con- 
trary to  expectation,  she  recovered.  No  abscess 
formed,  but  the  painful  swelling  of  the  shaft 
of  the  humerus  continued  for  full  six  weeks 
from  its  appearance.  Dr.  Affleck  refers  to  Sir 
James  Paget' s  observations  that  periostitis  with 
or  without  necrosis  may  be  enumerated  as  one  of 
the  sequels  of  typhoid  fever.  Sir  James  had  seen 
such  cases  when  they  occur  only  at  advanced 
stages  of  convalescence,  and  when  the  patient 
was  regarded  as  free  from  fever.  Dr.  Affleck  says 
that  periostitis  may  occur  at  the  height  of  the 
fever,  or  when  convalescence  has  no  more  than 
begun  ;  that  such  a  morbid  condition  may  be  re- 
garded as  a  complication  no  less  than  as  a  sequel 
of  typhoid  fever. 

Among  a  few  of  the  more  serious  sequels  which 
are  liable  to  arise  in  typhoid  fever  is  softening 
and  degeneration  of  the  tissues  and  organs  be- 
longing to  the  circulator}'  system.  Cardiac  throm- 
bosis, emboli  of  the  larger,  and  embolic  occlusion 
of  the  smaller  branches  of  that  system,  are  not 
very  uncommon  occurrences  of  the  typhoid  state. 
Affections  of  the  heart  from  such  a  cause  were 
long  since  described  by  M.  Louis,  and  also  by 
earlier  observers.  Variation  from  the  typical  di- 
urnal temperature  is  another  peculiarity  which  is 
sometimes  observed.  Quite  recently,  in  a  case  of 
typhoid  fever  occurring  in  a  man  aged  31  years, 


there  was  a  morning  increase,  and  an  evening 
decline  in  the  temperature.  The  patient  had  been 
greatly  exhausted  from  overwork,  and  from  a  di- 
arrhoea which  supervened  at  an  early  stage  of  the 
fever.  The  diarrhoea,  however,  was  readily  over- 
come. Delirium  from  the  first  stage  was  unusu- 
ally marked.  Though  the  patient  was  able  to 
take  a  liberal  amount  of  nourishment,  including 
milk,  broth  and  even  stimulants,  he  had  but  a 
feeble  and  compressible  pulse.  He  gradually 
lapsed  into  a  cyanotic  state,  and  died  apparently 
of  cardiac  failure  (if  such  a  failure  from  such  a 
cause  ever  occurs),  in  the  fourth  week  of  the  fever. 
In  regard  to  the  etiology  of  the  sequels  and 
complications  of  typhoid  fever,  it  may  be  remark- 
ed that  the  typhoid  bacilli  and  their  ptomaines 
produce  such  changes  in  the  tissues  as  to  dimin- 
ish their  resisting  power.  The  osseous  tissues, 
as  also  the  parenchyma  of  the  lungs  and  of  the 
other  parts  of  the  organism,  being  subjected  to 
such  influences,  are  thereby  more  easily  invaded 
by  the  pyogenic  and  septic  cocci.  These  invading 
elements,  under  such  conditions,  induce  sooner  or 
later,  in  one  or  more  of  the  various  tissues,  an 
irritation,  inflammation  or  suppuration.  The  se- 
vere and  prolonged  pyrexia  also  interferes  with 
the  nutrition  of  the  nerves.  This  undoubtedly 
leads,  occasionally,  to  dementia,  insanity,  and  to 
cerebral  affections  generally;  also  to  disturbances 
of  nerves,  sometimes  at  their  origin,  sometimes 
along  their  branches,  and  sometimes  only  at  their 
periphery.  The  presence  of  such  lesions  and 
their  extent  will  depend,  no  doubt,  largely  upon 
the  susceptibility  of  the  patient,  the  degree  of 
exhaustion  of  the  nutritive  functions,  and  upon 
the  nature,  potency,  and  perhaps  quantity  of  the 
invading  cocci. 


3  Braithwaite 
nal,  1885). 


Retrospect,  part  92,  p.  27  (British  Medical    ]< 


LECTURES. 


EMPYEMA. 

A  Lecture  delivered  at  the  Post-Graduate  Medical  School,  Chicago, 
January  34,  1891. 

BY  BAYARD  HOLMES,    M.D., 

OF   CHICAGO,  ILL. 

No  surgical  procedure  is  so  little  studied  and 
so  often  overlooked  with  such  deplorable  conse- 
quences as  empyema. 

One  of  my  neighbors,  who  is  quite  deaf,  recog- 
nized a  case  of  right-sided  empyema  in  a  man  36 
years  old,  and  sent  him  immediately  to  one  of 
our  large  hospitals.  He  remained  in  the  hospital 
three  weeks  and  was  discharged  to  die  of  phthisis. 
My  deaf  neighbor  was  surprised  that  the  true  con- 
dition was  not  recognized,  and  fearing  he  had 
made  a  mistake,  he  drew  out  a  syringeful  of  pus 
with  his  hypodermic.  Thus  satisfied  as  to  his 
own  diagnostic  acumen  he  took  care  of  the  pa- 
tient and  "promoted  euthanasia." 


I89i.] 


EMPYEMA. 


477 


Numerous  instances  have  come  to  my  knowl- 
edge when  cases  have  not  been  recognized;  others 
where,  though  recognized,  proper  and  adequate 
treatment  has  not  been  instituted  and  others, 
though  recognized  and  properly  treated  at  first, 
the  same  degree  of  logic  and  skill  has  not  been 
followed  out  in  the  subsequent  treatment. 

As  an  instance  of  the  first  kind  I  will  mention 
a  case  which  was  observed  in  a  man  who  was 
discharged  from  the  Kankakee  Insane  Asylum  to 
die  from  phthisis.  This  man  recovered  with- 
out any  inhalations  or  injections  in  a  remarkably 
short  time,  both  of  his  insanity  and  of  his  phthi- 
sis, upon  the  evacuations  and  drainage  of 
the  right  pleural  cavity.  Numbers  of  similar 
cases  have  come  in  the  experience  of  almost  every 
physician.  Some  of  the  cases  even  more  mourn- 
ful in  their  results. 

My  only  excuse  for  calling  attention  to  this 
disease  is  to  enforce  the  teachings  of  modern  my- 
cological  pathology  in  an  instance  which  presents 
many  peculiar  difficulties  and  modifying  ele- 
ments. 

There  can  certainly  be  no  progressive  suppura- 
tion without  the  presence  of  pyogenic  bacteria. 
Every  other  form  of  inflammation  (non-suppur- 
ative)  in  the  pleural  cavity  is  due  to  the  infec- 
tion of  that  cavity  with  non-pyogenic  but  patho- 
genic bacteria  or  other  microorganisms.  It  follows 
from  the  anatomy  of  the  pleura  that  except  in 
penetrating  wounds,  its  infection  must  always  be 
secondary,  and  pleuritis  and  empyema  must  be 
looked  upon  as  secondary  and  complicating  dis- 
eases. 

Pentzcld  observes  that  empj-ema  is  a  frequent 
sequence  of  fibrinous  pneumonia,  and  he  looks 
upon  it  as  a  secondary  infection  of  the  pleurae 
with  pus  microbes.  The  manner  of  this  secon- 
dary infection  I  shall  try  to  explain. 

The  normal  physiological  resistance  of  the  per- 
itoneum to  infection  is  known  from  clinical  expe- 
rience and  experiment  to  be  very  great.  (Rinne.) 
This,  as  I  have  repeatedly  asserted,  is  due  to  the 
evolution  of  a  tolerance  to  infection  from  the 
great  proximity  of  infective  material  in  the  intes- 
tinal canal.  The  same  tolerance  to  infection  has 
not  been  evolved  in  the  pleural  surfaces,  for  they 
are  farther  removed  from  sources  of  contamina- 
tion. 

The  pleurse  are  most  likely  to  be  infected  from 
the  invasion  of  micrc organisms  from 
cells  or  bronchioles.     These  small  air  spaces  are  al- 
most as  impervious  to  germs  as  the  wad  of  cotton 
with  which  we  stop  our  test-tubes. 

Vinay  describes  a  case  of  pneumo-thorax  which 
originated  in  the  rupture  of  the  respiratory  tract 
into  a  pleura  upon  the  patient's  rising  from  his 
bed.  It  healed  without  any  inflammation  or 
effusion  and  the  temporary  loss  of  function  was 
removed  in  about  two  months.  This  case  shows 
how  perfectly    the  healthy    lung  filters  the  air, 


which  passes  through  it.  Similar  results  in  pneu- 
mo-thorax are  noticed  when  they  result  from  stabs 
and  gunshot  wounds  of  the  lung.  So  the  pleurae 
are  much  less  liable  than  the  peritoneum  to  in- 
fection, and,  therefore,  natural  selection  has  not 
guaranteed  the  same  germicidal  power  in  the 
pleural  surfaces  which  we  find  in  the  peritoneum. 
For  the  same  reason  the  pericardium  being  still 
farther  removed  from  the  possibility  of  infection, 
it  is,  therefore,  still  less  tolerant  when  infected. 

One  of  the  causes  which  determines  the  locali- 
zation of  infection  anywhere  is  an  antecedent  in- 
fection and  coincident  saturation  of  the  germici- 
dal power  of  the  part  and  of  the  blood  nourish- 
ing it. 

Too  little  attention  has  been  paid  to  the  destruc- 
tive power  of  the  blood  upon  microoganisms.  Al- 
low me  to  recount  in  the  briefest  manner  the  ex- 
periments of  Buchner  and  Netter,  as  well  as  those 
of  Prudden.  These  investigators  found  that 
blood  drawn  from  the  living  animal  was  able  in 
two  hours  to  destroy  as  many  as  4.950  anthrax 
bacilli  out  of  5000  mixed  with  each  cubic  centi- 
meter of  blood.  It  seems  still  stranger  that  the 
germicidal  action  was  manifested  in  almost  as 
great  a  degree  in  the  defibrinated  blood  and  in  the 
serum  alone.  This  germicidal  action  rapidly  dis- 
appeared until  after  five  hours  the  remaining 
germs  began  to  multiply  and  the  blood  or  blood 
serum  then  furnished  the  best  possible  culture 
material. 

One  of  the  causes,  then,  which  undermines  the 
localization  of  infection  is  an  antecedent  infec- 
tion and  a  coincident  saturation  of,  or  exhaus- 
tion of  this  germicidal  power  of  the  blood.  In  the 
infection  of  the  pleura  with  pus  microbes,  this  is 
a  prime  essential.  Suppurative  disease  rarely 
takes  place  in  the  pleura  without  a  previous  gen- 
eral septicaemia  with  some  such  parasite  as  the 
pneumo-coccus,  the  malarial  plasmodeum,  the 
parasite  of  influenza,  or  one  of  the  other  infectious 
diseases.  This  coincident  septicaemia  and  conse- 
quent saturation  of  the  germicidal  power  of  the 
blood,  account  for  a  diminished  physiological  re- 
sistance, always  small  in  the  pleura  (as  we  have 
already  seen\  It  is  still  necessary  to  account  for 
the  presence  of  the  pyogenic  bacteria.  Because 
this  subject  has  not  been  adequately  studied  ex- 
perimentally, it  is  possible  only  to  conjecture  the 
source  of  infection  from  analogous  cases.  In 
man}-  cases  of  pleuritis,  there  is  an  extensive  or 
limited  pneumonia.  In  this  pneumonic  area,  as 
time  goes  on,  the  bronchioles  become  infected  to 
a  greater  or  less  depth,  with  the  pyogenic  bacteria 
which  are  always  present  in  the  air  we  breathe, 
and  therefore  in  the  larger  bronchi.  The  oedema 
surrounding  the  bronchioles  in  the  pneumonic 
area  block  the  normal  course  of  the  lymphatics 
toward  the  hylus  of  the  lung,  and  the  current  from 
active  congestion  turns  in  the  direction  of  the 
periphery  of  the  lung  and  the  pleural  cavity.   For 


478 


EMPYEMA. 


[April  4, 


a  time  the  effused  fluid  is  germ-free  and  is  ab- 
sorbed by  the  still  healthy  pleura  over  the  unaf- 
fected portion  of  the  lung  and  the  parietes.  In  a 
series  of  experiments  upon  rabbits,  undertaken 
by  Fleiner,  it  is  shown  that  fluids  (blood  and 
fluids  holding  coloring  matter  in  suspension)  in- 
jected into  the  pleural  cavities  are  readily  ab- 
sorbed, and  that  the  corpuscular  elements  or  color 
granules  are  easily  recognized  in  the  mediastinal 
lymph  glands.  It  seems  that  normal  respiratory 
movements  are  necessary  for  this  transfer  of  mat- 
ter. This  absorption,  however,  reaches  a  limit 
when  the  effused  serum  carries  with  it  also  so 
large  a  quantity  of  infectious  germs  that  corre- 
sponding pathological  changes  take  place  in  the 
absorbing  pleura.  Its  epithelium  becomes  swollen, 
and  multiplies  imperfectly.  Its  normal  physio- 
logical action  is  suspended;  the  whole  pleural 
surface  becomes  the  seat  of  suppuration.  A  true 
empyema  supervenes.  It  is  not  to  be  supposed 
that  under  conditions  of  health  the  pleura  is  un- 
able to  resist  a  moderate  amount  of  pyogenic  in- 
fection for  a  moderately  long  time.  When  the 
lung  and  the  whole  circulation  is  suffering  from 
malarial,  pneumo- coccus,  or  other  forms  of  infec- 
tion, the  first  serum  effused  contains  one  of  these 
pathogenic  germs.  This,  many  bacteriological 
experiments  have  demonstrated.  The  antecedent 
infection  is  responsible  for  the  low  vitality  of  the 
pleural  surfaces  and  for  the  want  of  germicidal 
power  in  the  effused  serum  itself. 

From  the  investigations  of  Kracht  it  would  ap- 
pear that  microorganisms  are  absent  in  simple 
serous  effusions.  Those  found  in  purulent  or 
fibrino  purulent  pleuritis  are  not  specific  for  the 
empyema,  but  point  to  a  whole  series  of  concom- 
itant inflammations.  Empyema  only  appears 
when  the  pleura  is  so  injured  or  its  cavity  con- 
tains such  a  fluid  that  a  suitable  soil  is  present 
for  the  multiplication  of  pus  cocci.  Kracht  ex- 
perimented upon  rabbits  with  a  view  of  demon- 
strating the  origin  of  empyema.  He  injected  pus 
bacteria  into  the  pleural  cavity,  and  saw  no  in- 
jury result,  but,  when  mixed  with  a  large  quan- 
tity of  water  or  ptomaines  pleuritis  resulted. 

In  the  same  manner,  tubercular  effusions  in  the 
pleural  cavities  become  infected  from  suppurative 
bronchitis  with  the  pus  microbes  and  a  true  em- 
pyema follows  a  tubercular  effusion. 

In  these  cases  some  of  the  most  mournful  errors 
have  been  made  in  the  diagnosis.  The  phyt-ical 
signs  and  even  the  examination  of  the  sputa 
have  confirmed  the  diagnosis  of  tuberculosis.  The 
patient  has  been  pursuing  a  quiet  and  fairly  satis- 
factory existence  when,  suddenly,  chills,  pain, 
fever  and  hectic  appears.  The  examination  of 
the  chest  cloes  not  discover  more  than  increased 
lidation  but  as  time  passes  on,  a  considera- 
mount  of  pus  may  be  discharged  by  the 
month,  as  a  post-mortem  examination  may  dis- 
close a  circumscribed  empyema. 


There  are  instances  in  which  coagulation  takes 
place  in  the  effused  serum,  and  larger  or  smaller 
clots  resembling  white  thrombi  fill  the  space  be- 
tween the  pleurae.  If  the  effusion  takes  place 
very  rapidly,  it  may  contain  red  blood  corpuscles, 
and  these  again  rna}-  be  found  in  the  clots.  The 
cavity  may  be  so  filled  with  these  fibrinous  masses 
as  to  resemble  a  sponge.  After  the  absorption  of 
the  serum,  the  solid  portions  of  the  effusion  may 
be  left  behind  and  give  rise  to  anomalous  physi- 
cal signs.  When  such  a  pleuritis  becomes  sup- 
purative it  is  difficult  to  drain  and  it  is  wholly 
insusceptible  to  treatment  by  aspiration. 

The  indications  for  operating  in  cases  of  empy- 
ema depend  very  largely  on  the  character  of  the 
infection.  It  may  be  stated  in  general  terms  that 
the  serous  pleuritic  effusion  is  from  the  nature  of 
the  origin  of  effusions  charged  with  the  primary 
infective  material;  thus;  in  specific  pneumonia, 
with  the  pneumo-coccus;  in  malaria,  measles  and 
influenza,  with  the  organism  which  gives  rise  to 
the  pneumonias  of  these  diseases.  These  infec- 
tive materials  are  incapable  of  producing  suppur- 
ation under  any  circumstances,  and  their  infec- 
tive powers  are  limited  in  destructiveness  and  in 
time.  Such  serous  effusions  are  ultimately  com- 
pletely absorbed  without  any  loss  of  function  in 
the  parts  concerned. 

Suppurative  empyema  is  due,  as  a  rule,  to  the 
pyogenic  staphylococci  or  streptococcus.  A  great 
number  of  investigators  have  found  these  alone  or 
mixed  with  the  infective  parasite  of  the  primary 
disease.  It  matters  little  which  one  of  the  pyo- 
genic bacteria  is  the  originator  of  the  suppura- 
tion. It  is  in  any  case  essentially  progressive  and 
destructive;  there  is  only  the  remotest  hope  of 
the  absorption  of  the  pus.  Two  methods  of  ter- 
mination have  been  observed.  The  pus  has 
either  been  discharged  through  the  thoracic  walls 
or  into  the  respiratory  passages. 

Beside  the  non- destructive  pleuritic  infection 
and  suppurative  pleuritis  or  true  pyothorax,  there 
remains  one  other  important  pathological  and 
clinical  manifestation  of  pleuritis,  that  is  tubercu- 
lar pleuritis. 

Tubercular  empyema  may  follow  the  perfora- 
tion into  the  pleural  cavity  of  a  tubercular  peri- 
pleuritic  abscess  going  out  from  a  tubercular 
osteitis  in  one  of  the  ribs  or  vertebrae,  or  from  a 
tubercular  mediastinal  lymph  gland,  and  pyo- 
genic empyema  may  arise  from  true  pus  cavities 
in  the  same  localities. 

Many  authors  have  held  that  the  presence  of 
pleuritis  without  traumatism,  is pritnae  facie  evi- 
dence of  tuberculosis,  but  this  Dr.  A.  A.  Smith1 
has  shown  from  careful  clinical  observation  fol- 
lowed in  many  cases  by  post-mortem  examina- 
tion, is  not  supported  by  the  carefully  considered 
fails.  Pyaemic  pleuritis  occurs  in  the  course  of 
osteo- myelitis,  carbuncle  and  other  suppurative 


Medical  News.  July  9.  1S90. 


1891.J 


EMPYEMA. 


479 


diseases,  and  usually  has  the  staphylococcus  pyo- 
genes aureus  in  the  exudate.  The  streptococcus 
pyogenes  is  usually  found  in  those  cases  which 
occur  in  puerperal  sepsis  or  wound  diseases.  In 
tubercular  pleuritis  the  tubercle  bacillus  is  found 
only  with  difficulty.  Tubercular  pleuritis  origi- 
nates from  infection  of  the  pleura  from  neighbor- 
ing tubercular  organs,  and  principally  from  tuber- 
cular foci  in  the  lungs.  While  it  has  been  ob- 
served without  other  antecedent  forms  of  pneu- 
monia it  is  prone  to  follow  non-tubercular  and 
non-suppurative  disease. 

True  or  pyogenic  empyema  may  arise  from  the 
puncture  of  the  pleural  cavity  with  an  infected 
instrument.  It  was  occasionally  declared  before 
the  antiseptic  period,  and  even  well  into  it,  that 
thoracentesis  was  followed,  as  a  rule,  by  suppur- 
ation. This  is  denied  by  the  methods  and  prac- 
tice of  modern  operators.  It  does,  however,  oc- 
casionally occur.  Gunshot  wounds  and  stabs 
with  sharp  instruments  without  perforation  of 
the  lung  and  without  pneumo-thorax  is  occasion- 
ally, if  not  as  a  rule,  followed  by  suppurative 
pleuritis.  That  the  perforation  of  the  lung  and 
consequent  pneumo- thorax  is  not  invariably  fol- 
lowed by  infection  of  the  cavity  is  due  to  the 
germ-free  condition  of  the  air  which  has  traversed 
for  some  distance  through  the  moist  bronchioles. 

It  must  be  remembered  that  in  cases  of  pyaemia, 
pyothorax  may  arise  and  is  to  be  accounted  for  in 
the  same  manner  as  in  other  forms  of  sepsis. 

Marfau  reduces  the  forms  of  empyema  etiologi- 
cally  into  three  categories:  i.  Those  that  follow 
pneumonia  and  are  characterized  by  the  presence 
of  the  pneumococcus  in  the  exudate;  2.  Those 
that  occur  in  the  course  of  pyaemia  and  contain 
the  staphylococcus  or  the  streptococcus;  3.  Those 
that  follow  tuberculosis  and  contain  the  tubercle 
bacillus.  The  indications  for  operation,  depend- 
ing on  the  quantity  of  effusion,  differ  in  respect 
to  urgency  the  same  in  all  kinds  of  empyema. 
Thus  the  effusion  may  be  so  great  that  it  dimin- 
ishes the  lung  capacity  beyond  the  limit  of  exist- 
ence. l,ife  ma}'  thus  be  threatened  in  a  one-sided 
effusion  of  such  extent  that  it  encroaches  upon 
the  cavity  of  the  other  lung,  or  when  the  oppo- 
site lung  is  already  useless  from  pneumonia  or 
other  causes.  In  such  cases  the  effusion  must  be 
immediately  removed  on  account  of  its  mechan- 
ical danger  to  life.  The  same  may  be  said  of  such 
cases  as  are  complicated  by  great  interference 
with  the  circulation  of  the  blood.  Effusions,  of 
even  small  extent,  in  both  pleural  cavities  be- 
come dangerous,  especially  when  complicated 
with  pneumonia  or  bronchitis. 

I  will  attempt  here  to  demonstrate  the  action 
of  a  considerable  effusion  in  one  of  the  pleural 
cavities  of  a  dog.  In  order  that  the  circulatory 
complications  may  be  at  a  minimum,  I  will  use 
the  right  cavity.  This  I  will  fill  by  inserting  this 
canula  between  the  fourth  and  fifth  rib  and  mid- 


way between  the  sternum  and  spine.  A  consid- 
erable quantity  of  warm  water  flows  into  the  cav- 
ity with  great  rapidity,  and  by  raising  the  perco- 
lator a  still  larger  quantity  flows  into  the  thorax, 
compressing  the  lung  and  pressing  the  mediasti- 
num over  the  left  side,  diminishing  the  capacity 
of  the  left  lung.  This  is  manifest  in  the  rapid 
breathing  and  the  rapid  and  irregular  pulse. 

Such  an  interference  with  the  function  of  the 
lung  calls  for  immediate  evacuation  of  the  fluid 
without  regard  to  the  nature  of  the  fluid  or  the 
character  of  the  coincident  inflammation. 

There  is  another  less  urgent,  but  not  less  pos- 
itive, indication  for  operation  in  those  cases  of 
effusion  which  are  infected  with  pyogenic  bacteria. 
It  matters  not  what  the  original  effusion  may  have 
been,  or  what  the  condition  of  the  patient  may 
be  in  other  respects,  the  presence  of  a  suppura- 
tive disease  in  the  pleural  cavity,  or  in  both  of 
them,  is  a  positive  indication  for  immediate  and 
permanent  removal.  The  suppurative  disease  is 
progressive  and  destructive,  and  never  terminates 
favorably  except  in  drainage  and  cicatrization  of 
the  suppurating  surfaces,  and  closure  of  the  cav- 
ity. The  temporary  or  interrupted  drainage  of 
the  pleura  is  not  adequate  in  such  cases,  and  can- 
not meet  the  positive  indication. 

The  treatment  of  tubercular  effusions  into  the 
pleural  cavity  may  be  stated  in  almost  as  positive 
terms.  It  is  assumed  that  the  tubercular  infec- 
tion is  unmixed  with  suppurative  disease.  The 
locus  of  tubercular  disease  is  assumed  to  be  in  the 
lung  and  beyond  the  power  of  the  operator  to  re- 
move. The  effusion  is  not  usually  large,  and  is 
apt  to  be  circumscribed  by  adhesions.  The  wall 
of"  the  cavity^  is  covered  by  tubercular  granula- 
tion tissue  and  is  sometimes  found  little  more 
than  a  tortuous  tubercular  channel.  Drainage 
by  free  incision  is  followed  sooner  or  later  (and  in 
spite  of  the  most  careful  antiseptic  treatment),  by 
pyogenic  infection  of  the  tubercular  tract,  and, 
when  the  opening  begins  to  close,  by  symptoms 
of  sepsis.  Neither  simple  incision  and  antiseptic 
irrigation  nor  the  excision  of  a  portion  of  a  rib 
and  evidement  of  the  cavity  is  followed  by  a 
speedy  recovery.  The  tubercular  disease  in  the 
other  part  of  the  thorax  is  apt  to  speedily  carry 
off  the  patient.  It  may  be  said  that  there  is  no 
positive  contra-indication  to  operation  on  tuber- 
cular empyemas,  and  that  they  may  be  operated 
on  when  there  is  any  special  indication.  This 
special  indication  may  be  found  in  the  size  of  the 
cavity,  in  the  accessibility  of  the  original  focus, 
or  in  the  otherwise  healthy  condition  of  the  pa- 
tient. That  the  drainage  of  tubercular  pleuras 
should  not  be  undertaken  with  any  favorable 
prognosis,  except  in  the  young,  and  when  these 
follow  tubercular  disease  in  an  accessible  bone  or 
other  part  and  is  not  accompanied  by  an  exten- 
sive disease  in  other  parts  of  the  thorax,  passes 
without  saying. 


480 


EMPYEMA. 


[April  4, 


In  removing  pleuritic  effusions  a  great  obstacle 
is  met  in  the  contactility  of  the  lung  and  its 
tendency  to  immediately  collapse  and  retract  to 
the  upper  and  posterior  part  of  the  thorax  under 
the  pressure  of  the  atmosphere.  This  is  a  diffi- 
culty nowhere  else  met  with,  and  one  which  has 
long  been  looked  upon  as  sufficient  to  interdict 
the  opening  of  the  pleural  cavity  under  any  cir- 
cumstance. This  is  termed  the  elasticity  of  the 
lung,  and  it  has  been  estimated  by  Hutchinson  to 
be  equal  to  one-half  pound  to  the  square  inch. 
The  pleural  cavity  may  be  opened  into  a  partial 
vacuum  and  the  collapse  thus  avoided,  or  the 
function  of  a  single  lung  may  be  dispensed  with. 
Thus  we  have  two  principal  methods  of  draining 
the  pleurae — the  one  into  a  vacuum,  and  the  other 
against  a  full  atmospheric  pressure. 

I  shall  attempt  to  show  3rou  with  the  animal 
before  us  just  how  great  is  the  contractile  power 
of  the  lung  of  the  living  dog.  Taking  the  per- 
colator down  and  placing  it  some  inches  below 
the  canula,  the  fluid  flows  rapidly  from  the 
thorax  into  the  percolator  as  is  indicated  by  the 
height  of  the  water  in  that  vessel  and  by  the 
greater  ease  in  respiration  which  the  dog  mani- 
fests. Fourteen  inches  is  -fa  of  348  inches  or  -^  of 
an  atmosphere,  which  corresponds  very  well  with 
the  estimation  of  Hutchinson  for  the  human  lung. 

Of  all  the  methods  of  removing  a  pleuritic 
liquid  effusion,  that  originally  proposed  by  Stan- 
ski  is  the  simplest  and  attended  with  the  fewest 
dangers.  This  is  the  aspiration  with  a  small  tro- 
car which  has  come  so  much  in  vogue  since  the 
perfection  of  the  apparatus.  For  effusions  which 
are  infected  with  microorganisms  of  a  non-  de- 
structive character,  and  for  those  effusions  which 
are  removed  solely  on  account  of  their  extent,  it 
is  the  most  serviceable  and  desirable  method.  It 
is  not  to  be  used  in  cases  of  pyogenic  infection 
with  the  hope  of  effecting  an  arrest  of  the  destruc- 
tive disease.  However,  when  so  modified  as  to 
be  used  continuously  it  may  be  of  the  greatest 
advantage  to  those  adults  who  can  have  the 
necessary  attention  from  skilled  nurses  or  physi- 
cians, and  when  it  is  instituted  early  enough  to 
preserve  the  elasticity  of  the  lung.  When  ad- 
vantage is  taken  of  the  weight  of  a  column  of  anti- 
septic solution  for  the  aspirator  this  becomes  the 
recently  much  lauded  method  of  Buelau. 
Whether  it  can  be  depended  upon  for  the  com- 
plete removal  of  the  products  of  suppurative  pleu- 
ritis,  experience  has  not  yet  adequately  demon- 
strated. It  seems  to  promise  the  most  favorable 
results  when  instituted  early  and  so  vigorously  as 
£0  remove  nearly  all  the  effusion,  and,  at  the 
same  time,  bring  the  granulating  pulmonary  and 
parietal  pleural  surfaces  together  and  secure  a 
rapid  obliteration  of  the  cavity.  It  would  accom- 
plish enough  if  it  would  do  this  and  limit  the 
effusion  to  a  small  cavity,  which  could  be  after- 
wards drained  by  incision.     It  is  the  only  method 


which  can  be  used  in  bilateral  pleurisies  of  great 
extent.  It  commends  itself  to  the  patient  as  a 
less  formidable  operation  than  incision  or  rib-re- 
section, and  would,  therefore,  be  likely  to  be  un- 
dertaken early.  With  a  proper  apparatus  to  be 
made  from  any  exploring  aspirator  and  a  long 
rubber  tube,  it  is  within  the  reach  of  every  physi- 
cian, and  the  difficulties  and  dangers  of  thoracen- 
tesis with  constant  aspiration  are  not  great.  The 
feeding  of  the  siphon  with  an  antiseptic  solution 
on  the  principle  of  a  Sprengel  pump,  as  here  pro- 
posed, may  be  found  to  be  a  safeguard  in  filling 
the  tube  which  might  become  clogged  or  full  of 
gases. 

The  following  method  is  employed  by  Fiirbin- 
ger  in  such  cases  of  pleuritic  exudations  as  are  of 
long  standing,  and  with  little  pressure.  He  takes 
advantage  of  the  sucking  power  of  the  mouth  to 
remove  the  fluid.  A  glass  tube  entering  the  bot- 
tom of  an  irrigator  bottle  is  connected  with  the 
trocar  by  means  of  a  rubber  tube.  Another  tube 
from  the  top  of  the  bottle  is  used  as  an  exhaust- 
ing tube. 

I  will  try  to  evacuate  the  air  which  has  pur- 
posely been  allowed  to  enter  this  dog's  pleura. 
The  percolator  is  hung  up  three  or  four  feet 
above  the  dog's  body.  An  aspirator  needle 
having  a  calibre  of  about  a  millimetre  is  now 
put  on  the  end  of  the  delivery  tube.  This  nee- 
dle is  thrust  into  the  rubber  tube  which  con- 
nects the  canula  in  the  thorax  with  the  basin  be- 
low, and  it  is  pointed  downwards.  As  soon  as 
the  fluid  is  allowed  to  flow  from  the  percolator  it 
fills  the  waste  tube,  and  the  weight  of  this  column 
of  water  aspirates  the  air  from  the  thorax  and 
may  be  seen  escaping  in  bubbles  from  the  end  of 
the  tube.  Percussion  over  the  lung  now  demon- 
strates the  absence  of  air  in  the  thorax  and  the 
presence  of  the  expanded  lung.  The  only  re- 
maining method  of  treatment  consists  in  free  in- 
cision and  drainage.  This  is  accomplished  in  a 
number  of  ways. 

An  incision  is  made  in  the  axillary  line  and 
at  the  upper  border  of  a  rib  into  the  centre  of  the 
effusion.  The  finger  is  passed  into  the  incision 
and  any  information  gained  which  the  palpation 
affords.  A  rubber  or  other  drainage  tube  is 
passed  on  the  finger  or  forceps  into  the  cavity  and 
placed  in  the  most  advantageous  position  for  drain- 
age. The  cavity  may  ormay  not  now  be  washed  out 
with  a  warm  antiseptic  solution  and  carefully 
dressed.  This  antiseptic  irrigation  and  dressing 
are  to  be  repeated  every  day  with  the  most  con- 
scientious care  and  scrupulous  antiseptic  precau- 
tions. At  the  end  of  a  week  or  two  the  discharge 
of  pus  will  be  found  to  have  disappeared.  Then 
if  the  method  of  Professor  Quiue  and  Bouvert  is 
to  be  followed  a  still  more  careful  antiseptic  irri- 
gation is  to  be  employed,  and  the  tube  removed 
entirely,  and  the  hole  in  the  side  stopped  with  a 
stick  of  iodoform.     The  dressing    is  left   on   for 


.891.] 


EMPYEMA. 


481 


two  weeks  or  more,  and  the  air  and  other  con- 
tents of  the  cavity  left  to  be  absorbed  by  the  now 
clean  and  healthy  pleura.  There  is  no  reason  why 
this  should  not  fill  all  the  indications  of  any  op- 
eration, viz.:  First,  to  evacuate  the  pus.  Second, 
to  prevent  the  production  of  more  purulent  matter, 
and  third,  to  restore  the  respiratory  apparatus  to 
its  normal  condition.  I  must  admit  that  while 
there  is  no  reason  to  think  that  the  pleural  cavity 
may  not  thus  be  sterilized,  our  experience  has 
been  so  unfortunate  that  until  Professor  Quine 
reported  his  cases  it  had  not  been  regularly  prac- 
ticed. 

At  the  German  Congress  for  Internal  Medicine 
referred  to,  Mosler  alone  advocated  simple  incis- 
ion and  drainage.  The  treatment  most  favorably 
received  there  was  Buelau's  method  and  the  sub- 
periosteal excision  of  a  rib  and  drainage  without 
antiseptic  irrigation. 

As  to  the  site  of  operation,  it  must  be  admitted 
that  a  great  many  mistakes  have  been  made  both 
by  writers  and  operators,  and  Godlee  alone  has 
put  the  matter  exactly.  The  retraction  of  the 
diaphragm  is  more  rapid  than  the  retraction  of 
the  lung,  and  the  opening  into  the  thorax  should 
be  at  least  as  high  as  the  centre  of  the  effusion  in 
all  cases  in  which  drainage  is  made  against  the 
atmosphere.  In  case  drainage  is  made  into  a 
vacuum  after  the  manner  of  Buelau,  the  locality 
of  the  fissure  between  the  lobes  of  the  lung  pre- 
sents some  obvious  advantages.  Dr.  Marshall's 
muscle- free  spot  is  certainly  too  far  forward. 
The  drainage  can  be  better  accomplished  in  the 
axillar}-  line  notwithstanding  the  amount  of  mus- 
cle and  fascia. 

The  second  method  of  drainage  against  the 
full  atmospheric  pressure  is  incision,  counter-in- 
cision and  through  and  through  drainage.  This 
method  certainly  secures  better  drainage  and 
gives  an  opportunity  for  irrigation  without  dan- 
ger of  distending  the  cavity  and  interfering  with 
the  retraction  of  the  lung.  It  hardly  offers  the 
best  means  of  restoring  the  respiratory  organs  to 
the:r  normal  condition.  It  is  the  method  which 
would  be  least  likely  to  be  received'  by  the  pa- 
tient, and  it  has  few  advocates  except  in  Eng- 
land. 

The  subperiosteal  excision  of  a  large  portion  of 
a  rib  and  the  drainage  of  the  cavity  by  one  or 
more  tubes  through  the  defect  thus  established. 
This  is  the  method  to  be  used  in  all  cases  which 
cannot  have  the  care  of  a  skilled  nurse  and  the 
care  of  a  careful  and  scrupulous  physician.  The 
drainage  is  established  in  the  most  comprehensive 
manner  and  is  accompanied  by  the  fewest  dan- 
gers. It  is  the  method  best  adapted  to  those 
cases  that  must  take  care  of  themselves. 

Through  and  through  drainage  and  insufflation 
of  dry  air.  This  method  offers  the  same  advan- 
tages as  perrigation,  with  the  advantage  of  scab 
formation  and  destruction  of  the  infection  by  des- 
iccation. 


The  perflation  of  air  has  also  (1866J  been  prac- 
ticed by  Roser,  and  later,  combined  with  antisep- 
tic liquid  irrigation,  by  Quincke,  and  by  Ewart 
and  Fitzroy. 

When  pyogenic  and  non- tubercular  empyemas 
are  treated  by  any  one  of  the  preceding  methods 
early  in  their  formation,  there  is  the  greatest  hope 
of  a  restoration  of  the  functions  of  the  respiratory 
apparatus  to  its  integrity.  When  treatment  is  in- 
adequate to  meet  the  indications,  or  when  it  is 
delayed,  such  serious  changes  take  place  in  the 
thorax  that  new  indications  arise.  Thus  sponta- 
neous discharge  of  the  pus  may  take  place  through 
the  bronchi,  and  the  cavity  formerly  filled  with 
pus  will  come  to  be  occupied  with  pus  and  air. 
If  the  cavity  is  small,  or  favorably  situated,  it 
may  drain  sufficiently  into  the  bronchus  to  close, 
and  recovery  will  be  nearly  perfect.  Again,  if 
drainage  is  not  instituted  early  in  the  course  of 
the  disease,  the  lung  will  be  pressed  back  and  up 
and  adhesions  will  be  formed  between  the  walls 
of  the  thorax,  and  the  collapsed  and  shrunken 
lung,  which  will  prevent  its  ever  being  able  to 
fill  the  pleural  cavity  again.  This  compression, 
with  coincident  infection,  may  result  in  gangrene 
of  the  lung  and  in  the  invasion  of  the  empyemic 
fluid  and  the  dead  tissues  by  saprophytic  bacteria 
and  other  organisms,  and  the  production  of  a 
complicating  sepsis  of  a  grave  nature.  This  in- 
vasion takes  place  from  the  bronchial  tubes,  which 
are  always  filled  with  saprophytic  bacteria  and 
other  putrefactive  organisms. 

When  such  adhesions  or  such  destruction  has 
taken  place  before  the  case  comes  to  treat- 
ment, or  when  the  methods  instituted  have  been 
inadequate  to  close  the  cavity  entirely,  it  may  be 
necessary  to  depress  the  thoracic  wall  so  that  it 
will  come  in  contact  with  the  surface  of  the  col- 
lapsed lung.  This  is  done  by  the  excision  of  a 
sufficient  number  and  extent  of  ribs  to  meet  the 
indication.      (Estlander.) 

This  review  of  the  etiology  of  pyothorax  makes 
it  possible  to  formulate  the  following  positive  in- 
dications for  operation  : 

1.  Serous  effusions  must  be  removed  whenever 
they  interfere  with  respiration  or  circulation  by 
their  extent,  or  when  they  show  a  tendency  to 
remain  after  recover}-  from  the  primary  disease 
which  gave  rise  to  their  presence.  The  aspirator 
may  be  found  sufficient  in  these  cases,  but  when 
inadequate  after  repeated  trials,  one  of  the  more 
radical  and  permanent  methods  of  drainage  must 
be  resorted  to. 

2.  Pyi  I  tubercular  effusions  of  large 
size  or  of  small  size  must  be  immediately  and 
permanently  drained. 

3.  Drainage  into  a  vacuum  must  be  practiced 
in  all  cases  of  bilateral  effusion  without  adhesive 
limitation,  and  in  those  cases  of  unilateral  effu- 
sion in  which  the  opposite  lung  is  so  incapacitated 
as  to  be  inadequate  for  respiration.     It  may  be 


482 


PROPOSED  MEDICAL  LEGISLATION. 


[April  4, 


practiced  in  all  cases  in  which  the  expansibility 
of  the  lung  is  intact  and  the  patient  can  have 
skilled  attention.  It  will  be  found  of  the  great- 
est value  in  limiting  the  extent  of  the  empyemic 
cavity,  which  may  be  afterward  drained  against 
the  atmosphere. 

4.  Intercostal  incision  and  antiseptic  irrigation 
of  the  cavity  to  a  point  reaching  a  practically 
aseptic  condition  of  the  same,  and  permanent 
closure  of  the  incision,  is  indicated  when  the  ex- 
pansibility of  the  lung  is  intact  and  the  skill  of 
the  operator  is  sufficient. 

5.  Rib  resection  and  thorough  drainage  should 
be  practiced  in  all  cases  of  tubercular  effusion, 
and  pyogenic  effusions  which  are  not  treated 
early,  or  those  occurring  in  patients  who  cannot 
have  the  best  of  care. 

6.  Operation  must  never  be  delayed  on  account 
of  the  extreme  condition  of  the  patient,  nor  on 
account  of  the  presence  of  tuberculosis  in  one  or 
both  lungs,  nor  on  account  of  the  presence  of 
pneumonia  on  the  same  side.  All  of  these  con- 
ditions are  additional  indications  for  radical  oper- 
ation. 


PROPOSED  MEDICAL  LEGISLATION. 

BY   HENRY  A.    RILEY,  ESQ., 

OF    NEW    YORK. 

The  Legislatures  of  man)-  of  the  States  are  now 
in  session,  and  in  most  of  them  measures  have 
been  proposed,  of  more  or  less  importance,  affect- 
ing medical  practice  or  public  health.  It  is  dif- 
ficult to  present  a  full  statement  of  all  these  bills, 
but  the  substance  of  many  of  them  has  been  pub- 
lished in  the  daily  papers  and  will  be  of  interest. 

In  New  York  the  principal  bills  are  the  follow- 
ing :  One  removing  the  pauper  insane  from  the 
county  poorhouses  and  transferring  them  to  the 
State  Asylums.  This  involves  the  expenditure 
of  about  $500,000  for  a  new  building  to  accom- 
modate the  new  patients,  and  has  been  actively 
opposed  by  local  officials  who  have  found  some 
pecuniary  or  other  advantage  in  keeping  the  in- 
sane in  the  poorhouses,  which  are  badly  adapted 
for  the  care  of  such  patients.  The  general  sen- 
timent of  the  profession  and  of  humane  persons 
is  strongly  in  favor  of  the  bill,  and  it  has  within 
the  last  few  days  received  the  Governor's  signa- 
ture and  become  a  law.  Another  measure  of 
great,  though  local,  importance  requires  the  ap- 
pointment of  matrons  at  the  police  stations  in 
New  York  City,  to  care  for  women  who  ma)'  be 
arrested  or  apply  for  shelter.  This  bill,  appeal- 
ing as  it  does  to  the  sentiments  of  humanity  and 
decency,  has  also  just  become  a  law.  Another 
measure  of  general  importance  provides  for  a 
Park  in  the  Adirondacks  for  the  purpose  of  pre- 
serving the  forests  from  destruction,  and  conser- 
ving the  water  supply  at  the  sources  of  the  Hud- 


son. The  plans  proposed  involve  the  expenditure 
of  not  far  from  $3,000,000,  and  while  the  Legis- 
lature will  not  appropriate  so  large  a  sum,  it  is 
probable  that  a  beginning  will  be  made,  and  the 
State  committed  to  the  sound  policy  of  preserving 
its  forest  area. 

In  Connecticut  a  bill  has  been  prepared  to  reg- 
ulate the  practice  of  medicine,  and  this  provides 
for  education  at  reputable  institutions  and  the 
possession  of  diplomas  by  all  practitioners  resid- 
ing in  the  State.  Examinations  by  medical  boards 
will  also  be  required. 

In  Pennsylvania  there  are  two  measures  pro- 
viding for  the  regulation  of  medical  practice  — 
one  emanating  from  the  Allopathic  school  and 
one  from  the  Homoeopathic.  The  first  provides 
for  a  Board  of  Examiners  consisting  of  nine  mem- 
bers, who  shall  have  been  in  active  practice  for 
not  less  than  ten  years.  The  term  of  office  is  for 
three  years.  Not  more  than  one  shall  be  appoint- 
ed from  the  same  county,  and  none  shall  be  a 
member  of  the  faculty  or  staff  of  any  medical 
school  or  college.  The  applicants  shall  be  exam- 
ined in  anatomy,  physiology,  chemistry,  toxicol- 
ogy, pathology,  hygiene,  materia  medica  and  ther- 
apeutics, principles  of  medicine,  surgery  and  ob- 
stetrics. Any  candidate  for  examination  may 
choose  the  system  of  materia  medica  and  thera- 
peutics in  which  he  or  she  shall  be  examined,  and 
no  one  shall  be  rejected  on  account  of  adherence 
to  any  school  of  practice.  The  bill  proposed  by 
the  Homoeopathic  Medical  Society  is  similar  in 
some  points,  but  quite  different  in  others.  The 
Board  of  Examiners  is  to  consist  of  nine  mem- 
bers, who  must  have  been  in  practice  for  five 
years,  and  the  term  of  office  is  six  years.  The 
Board  shall  have  power  to  fix  the  grade  of  pre- 
liminary education  required  of  all  students  enter- 
ing a  medical  college,  and  shall  also  establish  the 
minimum  curriculum  in  medical  schools,  and  the 
length  of  the  course  of  studies  requisite  to  gradu- 
ation. The  course  of  instruction  shall  not  be  less 
than  four  years.  The  Board  shall  inquire  into 
the  fitness  to  practice  of  graduates  of  any  college 
having  a  lower  standard  than  that  required  by  the 
Board  of  State  institutions.  The  main  point  of 
difference  in  the  two  bills  is  that  the  one  proposed 
by  the  Allopathic  school  vests  the  appointment  of 
the  members  of  the  Board  in  the  Governor  with- 
out prescribing  the  school  to  which  they  shall  be- 
long, and  one  of  the  State  medical  journals  says 
that  the  different  schools  ought  to  be  represented 
according  to  their  relative  numbers  in  the  State. 
The  bill  of  the  Homoeopathic  school  requires  the 
Governor  to  appoint  equally  from  lists  presented 
to  him  by  the  Allopathic,  Homoeopathic  and  Ec- 
lectic Societies  of  the  State. 

In  Michigan  no  special  legislation  regarding 
medical  practice  is  reported,  but  it  is  said  that  the 
Governor  advises  the  abolition  of  the  State  Board 
of  Health  and  that  the  Legislature  may  adopt  the 


i89i.] 


MEDICAL  PROGRESS. 


483 


suggestion.  This  would  certainly  be  a  retrograde 
step,  and  would  no  doubt  be  .1  cause  for  subsequent 
regret. 

In  Maine  the  State  Health  Board  has  introduced 
a  bill  providing  for  the  registration  of  vital  statis- 
tics. It  is  rather  strange  that  so  important  a 
matter  as  this  should  not  have  been  already 
under  legal  sanction.  The  official  record  of 
births,  marriages  and  deaths,  arranged  in  such  a 
manner  as  to  be  thoroughly  reliable  and  readily 
accessible,  is  held  by  most  civilized  communities 
to  be  a  prime  necessity,  and  no  doubt  the  lack  of 
such  a  record  has  caused  already  great  inconve- 
nience in  Maine. 

In  Missouri  there  is  a  bill  requiring  all  medical 
colleges  in  the  State  to  adopt  three  courses  of 
lectures  as  a  condition  for  graduation.  Most  of 
the  colleges  are  said  to  favor  the  measure,  and 
certainly  the  requirement  is  small  enough  if  other 
States  are  considering  the  matter  of  requiring  four 
years  of  study,  before  granting  a  diploma.  An- 
other measure  pending  in  the  Missouri  Legisla 
ture  touches  on  the  regulation  of  prostitution. 
The  provisions  are  modeled  after  the  German 
laws  on  the  subject. 

In  Illinois  the  State  Board  of  Health,  by  virtue 
of  legislation  already  enacted,  has  decided  that  it 
will  not  recognize  a  foreign  diploma  which  does 
not  confer  upon  its  holder  the  right  to  practice 
medicine  in  the  country  in  which  it  was  granted. 
The  holder  of  an  Austrian,  a  German,  Russian 
or  Swiss  diploma  wishing  to  practice  in  Illi- 
nois, must  hereafter  pass  an  examination  before ! 
the  Board,  unless  he  have  a  pass  certi6cate  from 
a  Government  examiningcommission.  The  holder 
of  a  Canadian  diploma,  unless  a  licentiate  of  the 
College  of  Physicians  and  Surgeons  of  Ontario 
and  Quebec,  must  pass  an  examination  in  order 
to  be  licensed  in  Illinois. 

In  Oregon  a  bill  has  been  introduced  regulating 
medical  practice,  and  part  of  it  touches  on  medi- 
cal ethics,  and  provides  for  the  revocation  of  li- 
censes in  case  of  unprofessional  conduct.  The 
acts  which  will  cause  a  revocation  are  as  follows: 
First,  the  procuring,  or  aiding  and  abetting  in 
procuring  a  criminal  abortion.  Second,  The  em- 
ploying of  what  are  known  as  cappers  or  steerers. 
Third,  the  obtaining  of  any  fee  on  the  assurance 
that  a  manifestly  incurable  disease  can  be  perma- 
nently cured.  Fourth,  the  wilful  betraying  of  a 
professional  secret.  Fifth,  all  advertising  of  med- 
ical business  in  which  untruthful  and  improbable 
statements  are  made.  Sixth,  all  advertising  of 
any  medicine  or  of  any  means  whereby  the  month- 
ly periods  of  women  can  be  regulated,  or  the  men- 
ses reestablished  if  suppressed.  Seventh,  convic- 
tion of  any  offense  involving  moral  turpitude. 
Eighth,  habitual  intemperance. 

In  California  there  is  a  proposed  measure  for 
regulating  the  practice  of  medicine.  It  estab- 
lishes a  State  Board  of  Medical  Examiners,  con- 


sisting of  seven  members,  who  are  to  be  appointed 
by  the  Governor.  One  member  is  to  be  appointed 
from  each  of  the  well-established  medical  schools, 
and  the  others  are  at  large. 

Probably  a  number  of  other  States  are  contem- 
plating legislation  somewhat  along  the  lines  of 
the  bills  mentioned  above,  but  no  statement  of 
such  legislation  has  been  noticed  in  the  public 
journals. 

A  statement  will  be  made  in  these  columns, 
after  the  adjournment  of  the  Legislatures,  of  the 
measures  which  actually  became  laws. 


MEDICAL    PROGRESS. 


Therapeutic*  ami  Pharmacology. 

Treatment  of  Icterus  with  Turpentine. 
— Carreau  {La  Semaine  Medicate,  March  11, 
1891)  recommends  the  use  of  large  doses  of  ozon- 
ized turpentine  in  the  treatment  of  grave  forms  of 
jaundice.  It  is  administered  in  the  form  of  cap- 
sules, as  many  as  sixty  being  given  in  the  first 
thirty- six  hours.  In  case  of  obstinate  vomiting 
in  which  the  stomach  rejects  the  capsules,  the 
drug  ma}*  be  administered  hypodermically,  the 
following  mixture  being  employed:  Essence  of 
ozonized  turpentine  {Codex  Francaise)  10  grams, 
liquid  vaseline  50  grams.  In  one  case  of  grave 
icterus,  attended  with  fever,  the  writer  employed 
twenty- three  injections  in  thirty-six  hours.  The 
symptoms  rapidly  improved,  and  at  the  end  of  a 
few  days  the  patient  was  convalescent. 

Treatment  of  Erysipelas  with  Glycer- 
ole  of  Salicylate  of  Sodium. — Dr.  S.  C. 
Inglessis  {La  Semaine  Medieale.  March  4,  1891) 
has  employed  a  solution  of  salicylate  of  sodium, 
in  glycerine,  in  the  treatment  of  erysipelas.  The 
solution  should  have  a  strength  of  from  4  to  6 
per  centum  and  be  used  each  four  or  six  hours, 
the  affected  part  being  protected  with  a  layer  of 
cotton.  At  the  same  time,  in  the  absence  of  heart 
weakness,  or  albuminuria,  salicylate  of  sodium  is 
given  internally,  about  two  grams  in  each  twenty- 
four  hours. 

The  writer  has  treated  thirty-six  cases  by  this 
method,  and  notes  favorable  results.  The  appli- 
cation immediately  lessens  the  pain  and  discharge, 
and  shortens  the  disease. 

Medicine. 

Additional  Observations  upon  Canthar- 
IDIN — .\t  the  meeting  of  the  Berlin  Medical 
Society,  held  March  4  I  La  Semaine  Medicate), 
Saalfeld  presented  a  patient  suffering  from  lu- 
pus who  had  been  treated  by  injections  of  the  alka- 
line solution  of  cantharidin.  The  ulcerating  lu- 
pus had  become  flat,  pale,  and  was  apparently 
disappearing.      The  Landgraf  had  injected  the 


484 


MEDICAL  PROGRESS. 


[April  4, 


solution  in  a  series  of  eases  affected  with  acute 
laryngeal  troubles,  but  had  not  noted  any 
results.  In  nine  patients  with  chronic  trouble  he 
had  come  to  the  following  conclusions:  That  the 
remedy  caused  an  oedema  of  the  mucous  mem- 
brane, expectoration  was  facilitated,  the  redness 
of  the  vocal  cords  diminished.  He  absolutely  ig- 
nored the  question  of  the  remedy  producing  a 
cure.  Lublinski  had  observed  after  the  injections 
pain  and  strangury,  but  neither  albuminuria  nor 
hematuria.  Expectoration  was  facilitated  and 
ulcerations  contracted  and  healed.  A  patient 
affected  with  laryngeal  and  pulmonary  phthisis, 
and  presenting  a  lupus  on  the  back  of  the  hand, 
was  markedly  relieved  by  the  injections.  Frankel 
had  not  observed  a  case  of  perfect  recovery  from 
the  injections.  Since  his  last  communication  he 
had  seen  several  cases  of  albuminuria,  so  that  he 
now  examined  the  urine  after  each  injection. 


Surgical  Treatment  of  Pulmonary  Cavi- 
ties.— The  bold  endeavor  to  radically  attack 
phthisical  cavities  and  drain  them,  although  in- 
troduced some  years  ago,  has  been  lately  receiv- 
ing fresh  advocacy,  especially  in  relation  to  the 
treatment  of  phthisis  by  Koch's  "tuberculin." 
Many  of  the  dangers  of  this  remedy  in  advanced 
cases  of  phthisis  rest  upon  the  retention  of  ne- 
crotic material  within  the  lung,  and  the  liability 
to  its  being  inhaled  into  previously  unaffected 
areas.  Dr.  Sounenberg  recently  operated  upon 
four  cases  undergoing  this  treatment,  and  Dr.  E. 
Leser  of  Halle  reports  two  more.  One  of  these 
was  a  female  aged  43,  who  had  had  symptoms  for 
four  years,  and  presented  physical  signs  of  exca- 
vation at  the  left  apex.  The  operation  consisted 
in  making  an  incision  in  the  first  intercostal  space, 
7  centimetres  long,  and,  after  dividing  the  mus- 
cles and  securing  blood-vessels,  introducing  a  tro 
car  in  the  direction  of  the  cavity.  Although  no 
fluid  could  be  obtained,  it  was  evident  that  the 
point  of  the  trocar  was  in  the  cavity,  and  the 
pleurae  being  firmly  adherent,  an  aperture  was 
bored  through  the  layer  of  tissue  overlying  the 
cavity  by  means  of  a  Paquelin's  cautery,  the  tro- 
car being  taken  as  a  guide.  The  cavity  was  the 
size  of  an  apple,  had  somewhat  irregular  walls, 
and  was  coated  with  flakes  of  inspissated  pus  and 
caseous  matter;  these  were  removed,  and  the  cav- 
ity stuffed  with  antiseptic  gauze.  Subsequently 
the  patient  was  injected  with  Koch's  "tubercu- 
lin," which  always  caused  increased  discharge 
from  the  cavity  ;  and  later  still  some  of  the  fluid 
was  directly  introduced  into  the  cavity  itself.  At 
the  last  report  the  patient  had  improved  much  in 
general  health,  and  the  cavity  had  dwindled  to 
one-half  its  former. size.  The  second  case,  a  man 
aged  42,  was  similar,  except  that  in  him  the  cav- 
ity was  no  larger  than  a  chestnut,  and  was  situ- 
ated at  the  right  apex.     Here,  too,  the  use  of  tu- 


berculin produced  increased  discharge,  and  on 
one  occasion  its  injection  into  the  cavity  was  fol- 
lowed by  severe  vomiting,  dyspnoea,  and  other 
alarming  symptoms.  Dr.  Leser,  however,  thinks 
this  mode  of  treatment  has  a  future  before  it.  At 
present  he  would  make  it  a  sine  qua  non  that  the 
costal  and  pulmonary  pleurae  should  be  firmly 
united,  as  they  usually  are  when  cavities  are  of 
some  standing,  and  he  enters  fully  into  the  tech- 
nique of  the  operation,  laying  stress  upon  having 
a  fairly  large  incision  through  the  thoracic  wall, 
but  not  a  very  large  aperture  made  in  the  lung, 
since  this  will  be  sure  to  increase  by  sloughing. 
The  notable  feature  of  these  cases  seems  to  be  the 
immediate  relief  to  cough  and  expectoration 
given  by  the  external  opening,  although,  when 
the  injections  are  resorted  to,  the  secretion  be- 
comes so  much  more  abundant.  —  The  Lancet. 

Experiments  to  Determine  the  Centre  of 
Respiration. — Dr.  Laborde  communicates  to 
the  Comptes  Rendus  de  la  Societe  de  Biologie  the 
results  of  experiments  made  by  him  to  ascertain 
the  nerve  centre  for  respiration,  promising  a 
larger  work  at  some  future  time.  He  found  that 
superficial  mechanical  injury  to  the  region  of  the 
alse  cinerae  does  not  accelerate  respiration;  a  deep 
puncture  decreases,  or  even  temporarily  arrests, 
respiration ;  if  the  injury  penetrates  at  least  to 
the  middle  of  the  substance,  respiration  may  cease 
altogether.  This  result  is  always  obtained  if  a 
certain  circumscribed  portion  of  the  substance  is 
cauterized  with  the  hot  iron.  This  portion  need 
in  the  rabbit  be  only  half  a  millimetre  in  diameter, 
in  the  dog  from  one  to  two  millimetres.  The  iron 
must,  however,  enter  immediately  above  the  apex 
calami,  and  must  penetrate  at  least  half  the  sub- 
stance from  the  raphe.  If  the  injury  is  unilateral, 
respiration  may  continue  for  some  little  time  on 
the  opposite  side.  Total  separation  of  the  me- 
dulla below  the  apex  calami  alwa3Ts  arrests  respi- 
ration of  the  trunk,  while  that  of  the  head  con- 
tinues for  some  time.  Spinal  reflexes  continue, 
and  even  increase ;  irregular  superficial  contrac- 
tions of  the  respiratory  muscles,  leading  to  no 
results,  may  be  observed.  The  increase  of  the 
reflex  action  is  especially  remarkable  in  newborn 
animals.  No  parts  of  the  brain  above  the  me- 
dulla oblongata,  including  the  cortex,  the  corpora 
quadrigemina,  and  thalama  optici,  have  any  spe- 
cific influence  whatever  on  the  respiratory  mus- 
cles.—  The  Lancet. 

Bacteriology. 

Etiology  of  Grouse  Disease. — Professor 
E.  Ki.kin  (Cent.  f.  Dak.  Parasitenk.)  finds  that 
the  bacillus  of  the  grouse  disease  as  it  occurs  in 
autumn  is  not  nearly  so  virulent  as  that  obtained 
from  the  disease  during  the  spring  months,  the 
bacilli  being  obtained  from  the  heart  blood  in  the 
autumn  and  from  the  lungs  in  the  spring. 


I89i.] 


EDITORIAL. 


485 


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SATURDAY,  APRIL  4,    1S91. 


KOCH'S    TUBERCULIN    IX    PULMONARY 
TUBERCULOSIS. 

As  we  continue  to  receive  letters  from  phy- 
sicians in  different  parts  of  the  country  anxiously 
inquiring;  how  and  where  they  can  obtain  Koch's 
Lymph  or  Tuberculin  with  which  to  treat  some 
of  their  consumptive  patients,  we  think  it  proper 
to  call  the  attention  of  all  general  practitioners  to 
the  present  status  of  the  Koch  treatment,  par- 
ticularly in  relation  to  pulmonary  tuberculosis. 
And  we  would  remind  all  inquirers  that  we  know 
of  no  mode  of  obtaining  a  supply  of  the  Tuber- 
culin, except  by  application  to  Koch's  laboratory 
iu  Berlin,  Prussia.  There  is  none  in  the  drug 
market  of  this  or  any  other  country,  and  no  one 
outside  of  Koch's  laboratory  knows  how  it  is 
made,  or  precisely  what  its  active  ingredients  are. 
The  authorities  at  Berlin  sitnply  authorized  the 
remedy  to  be  furnished  in  limited  quantities  to  be 
used  in  hospitals  where  the  patients  could  be  kept 
under  constant  observation,  and  reliable  record 
made  of  the  results.  Under  this  regulation  it  has 
Been  obtained  and  used  with  the  utmost  care  in 
many  of  the  hospitals  in  the  different  countries  of 
Europe,  and  in  the  chief  cities  of  this  couutry 
during  the  last  three  or  four  months.  The  re- 
sults have  been  faithfully  reported  from  week  to 
week  in  the  leading  medical  journals  of  this  and 
other  countries. 

It  has  been  used  chiefly  in  cases  of  lupus  and 
tuberculous  affections  of  the  external  lymphatic 
glands,  bones  and  joints,  and  in  a  large  number 
of  cases  of  pulmonary  tuberculosis.  It  has  also 
been  used  in  a  limited  number  of  cases  of  cancer 


and  lepra,  but  generally  with  negative  results. 
A  careful  review  of  all  these  reports  seems  to  justify 
the  following  summary  of  results  at  this  stage  of 
the  investigation: 

First,  The  remedy  when  used  in  the  manner 
and  in  the  doses  advised  by  Dr.  Koch,  has  in 
most  instances  affected  the  human  system  in  the 
manner  claimed  by  him;  although  the  febrile  re- 
actions have  varied  very  much  in  different  cases 
and  sometimes  at  different  times  in  the 
same  patient,  both  in  regard  to  intensity 
and  duration.  The  effect  of  the  remedy  on  tuber- 
cular tissue  has  also  been  adundantly  demon- 
strated, especially  iu  lupus  and  such  tubercular 
cases  as  admitted  of  free  external  drainage; 
while  the  numerous  post-mortem  examinations 
by  ViRCHOW  and  others  show,  not  only  the  same 
necrotic  effect  upon  the  tubercular  tissue  of  the 
lungs  and  other  internal  tissues,  but  also  the  rapid 
diffusion  of  the  bacilli  in  the  blood  and  tissues 
previously  unaffected. 

Second,  In  perhaps  two- thirds  of  the  cases  of 
lupus  and  such  tuberculous  joints  and  glands  as 
have  free  external  openings,  the  injections  of 
Tuberculin  have  been  followed  by  marked  im- 
provement and  in  from  three  to  six  weeks  some 
of  them  have  appeared  nearly  well,  while  in 
man}'  cases  tolerance  to  the  remedy  was  soon  ac- 
quired and  improvement  ceased.  In  the  remain- 
ing third  of  this  class  of  cases  no  improvement 
was  obtained  and  some  of  them  were  made  worse . 
One  girl,  17  years  of  age,  with  lupus  of  the  face, 
received  a  single  injection  of  two  milligrams, 
which  was  followed  by  violent  febrile  reaction 
and  death  in  about  thirty-six  hours. 

In  some  of  the  early  cases  that  were  reported 
as  nearly  or  quite  well,  the  disease  has  since  re- 
turned with  as  much  activity  as  before,  thus  show- 
ing that  even  in  the  most  favorable  cases  the  cur- 
ative effects  of  the  remedy  may  prove  only  tem- 
porary. 

Third,  The  number  of  cases  of  pulmonary  tu- 
berculosis that  have  now  been  treated  with  Tuber- 
culin aggregates  many  hundreds.  A  large  ma- 
jority of  them  have  been  described  as  in  the  early 
stage  of  the  disease,  i.  e.,  before  the  softening  or 
disintegration  of  tubercular  masses,  or  the 
formation  of  cavities  in  the  lungs.  A  much 
smaller  number  presented  the  physical  signs 
of  some  suppuration  or  small  cavities;  while 
a  still  smaller  number  were  plainly  in  the  advanced 


486 


TRACHEAL  TUGGING." 


[April  4, 


stage  of  the  disease.  In  the  two  groups  of  cases 
last  mentioned,  the  Tuberculin  treatment  has 
pretty  uniformly  accelerated  the  progress  towards 
a  fatal  result, 

In  the  first  group  named,  supposed  to  contain 
only  cases  in  the  early  stage  of  pulmonary  tuber- 
cular disease,  the  first  effect  of  the  Tuberculin  in- 
jections has  pretty  uniformly  been  more  or  less 
temporary  febrile  reaction  followed  by  increased 
cough  with  marked  increase  of  expectoration  con- 
taining a  greater  number  of  bacilli.  In  a  consider- 
able number  of  these  cases  a  continuance  of  the 
treatment  was  attended  by  diminished  febrile  re- 
actions and  decidedly  less  expectoration  with 
moderate  general  improvement  until  apparent  im- 
munity or  tolerance  to  the  further  action  of  the 
remedy  was  acquired  by  the  patient.  But  in  no 
case  did  the  physical  signs  of  the  tubercular  disease 
in  the  lungs  disappear,  and  after  an  intermission 
of  ten  days  or  more  in  the  treatment,  some  of  the 
patients  were  again  found  susceptible  to  the  action 
of  the  remedy.  Consequently  we  have  not  yet 
found  a  single  case  of  pulmonary  tuberculosis  in 
which  the  remedy  could  be  regarded  as  having 
effected  a  complete  cure.  In  a  large  proportion 
of  the  cases  treated  in  the  early  stage  of  the  dis- 
ease, instead  of  even  temporary  improvement, 
the  progress  of  the  disease  has  been  accelerated, 
accompanied,  in  some,  by  haemorrhage,  in  others 
by  rapid  formation  of  cavities,  and  in  a  few  by 
the  appearance  of  albumen  in  the  urine. 

Fourth,  The  foregoing  results  sufficiently  de- 
monstrate that  the  Tuberculin  manufactured  in 
Berlin  is  an  exceedingly  active  poison,  possessing 
a  special  affinit}'  for  tissues  affected  with  tuber- 
culosis, and  capable  of  causing  necrosis  or  rapid 
disintegration  of  such  tissue  in  every  part  of  the 
living  body,  and  consequently  its  use  as  an  in- 
ternal remedy  will  always  involve  more  or  less 
danger  to  the  welfare  of  the  patient. 

If  the  foregoing  summary  of  results  thus  far 
obtained  is  correct,  it  is  obvious  that  the  use  of 
the  Tuberculin  should  be  restricted  to  such  cases 
of  tubercular  disease  as  are  on  the  surface  or  have 
free  communication  therewith;  and  the  general 
practitioner  should  abandon  all  idea  of  using  it 
in  cases  of  tuberculosis  of  the  lungs  or  any  of  the 
internal  viscera. 


ON  THE  SIGN  CALLED  "TRACHEAL  TUGGING," 
IN  THORACIC  ANEURISM. 

Dr.  R.  L.  Macdonnell,  of  the  Montreal  Gen- 
eral Hospital,  relates  in  The  Lancet,  March  7,  the 
clinical  aspects  of  seventeen  cases  of  thoracic  dis- 
ease where  "tracheal  tugging"  was  recorded. 
This  sign  was  first  brought  forward  in  1878,  by 
Surgeon-Major  W.  S.  Oliver,  in  7'he  Lancet, 
and  his  account  of  it  has  since  been  republished  in 
only  two  text-books,  so  far  as  is  at  present  known. 
In  the  original  publication,  the  writer  suggested 
the  following  procedure  in  the  diagnosis  of  thor- 
acic aneurism:  "As  the  diagnosis  of  thoracic 
aneurism  of  the  aorta  is  often  difficult  and  ob- 
scure, notwithstanding  the  various  means  we  have 
at  our  disposal  for  detecting  it,  I  am  desirous  ot 
mentioning  a  method  of  examination  which  has 
afforded  me  material  assistance  in  diagnosing 
this  disease — or  even  simple  dilatation  of  the  ves- 
sel— when  it  occurs,  as  is  most  generally  the  case, 
either  in  the  ascending  or  first  part  of  the  trans- 
verse portion  of  the  arch;  the  process  is  as  follows: 
Place  the  patient  in  the  erect  position,  and  direct 
him  to  close  his  mouth  and  elevate  his  chin  to  the 
fullest  extent,  then  grasp  the  cricoid  cartilage  be- 
tween the  thumb  and  finger,  and  use  gentle  up- 
ward pressure  on  it,  when,  if  dilatation  or  aneur- 
ism exist,  the  pulsation  of  the  aorta  will  be  dis- 
tinctly felt  transmitted  through  the  trachea  to  the 
hand.  The  act  of  examination  will  increase 
laryngeal  distress  should  this  accompany  the  dis- 
ease. 

The  application  of  this  method  of  examination 
has  been  in  vogue  in  the  wards  of  Montreal  Hos- 
pital for  twelve  years,  and  the  sign  has  come  to 
be  known  as  "tracheal  tugging."  Its  great  im- 
portance was  early  recognized  by  Dr.  George 
Ross,  who  in  his  clinical  teaching  and  published 
reports  of  aneurismal  cases  has  been  careful  to 
note  the  presence  or  absence  of  tracheal  tug.  It 
has  always  been  found  to  be  a  reliable  sign  oi 
aneurism  of  the  transverse  arch,  and  in  one  case, 
at  least,  it  was  the  only  positive  sign  present  of 
an  aneurism,  whose  existence  was  made  manifest 
subsequently  by  other  signs  and  symptoms. 
Where  the  aneurism  is  deep-seated  and  is  in  con- 
tact at  all  with  either  the  trachea  or  one  of  its 
principal  subdivisions  there  will  be  a  very  dis- 
tinct and  unmistakable  tugging  downward  of  the 
cricoid  cartilage  with  each  cardiac  systole.  In 
some  cases  the  movements  of  the  box  of  the  larynx 


iS9i.] 


POISONING  BY  EXALGINE. 


•    " 


have  been  so  well-marked  that  the  pulse  could  be 
counted  by  simply  placing  the  tip  of  the  fore- 
:pon  the  pomum  Adami,  and  making  a 
slight  pressure  upwards.  One  other  condition  may 
possibly  be  mistaken  for  that  under  consideration, 
but  a  little  care  will  exclude  the  chance  of  error: 
this  is  when  the  heart  is  acting  strongly,  or  when 
aortic  incompetence  is  present,  and  so  acting  as 
to  convey  to  the  fingers,  from  the  adjacent  caro- 
tids, a  considerable  amount  of  rhythmical  pulsa- 
tion. But  this  will  be  noted  as  something  differ- 
ent from  the  downward  tugging  of  the  aneurismal 
sign.  Dr.  Macdoxxell  formulates  two  propo- 
sitions from  his  clinical  experience,  and  that  of 
his  colleagues  at  the  Montreal  Hospital:  i. 
Tracheal  tugging  is  never  present  except  in  an- 
eurism. 2.  When  tracheal  tugging  is  present  the 
aneurism  is  so  situated  as  to  press  from  above 
downwards  on  the  left  bronchus,  or  on  that  por- 
tion of  the  trachea  that  is  immediately  adjacent 
to  it.  Of  the  twenty-five  cases  in  which  this 
phenomenon  was  examined  for  and  recorded  as 
present  or  absent,  twenty-three  were  from  the  hos- 
pital, and  two  were  from  private  practice.  In 
seventeen  cases  the  sign  was  found.  In  eight  an 
autopsy  was  obtained. 


SANITARY  UNDERTAKING. 

The  State  Board  of  Health  of  Pennsylvania 
has  recently  issued  its  Circular  No.  31,  contain- 
ing instructions  to  sextons  and  undertakers  re- 
garding the  handling  of  the  bodies  of  those  who 
have  died  by  contagious  diseases.  It  bears  date 
of  December  1,  1890,  and  comprises  in  a  dozen 
pages  a  very  full  digest  of  rules  and  suggestions 
as  to  "when,  how  and  where  undertakers  can 
and  should  be  sanitarians."  One  point  of  prime 
importance,  the  avoidance  of  public  funerals  after 
death  by  infectious  disease,  is  made  especially 
prominent,  and  it  is  urged  upon  all  intelligent  un- 
dertakers that  their  influence  and  counsel  should 
always  be  exerted  against  publicity  and  delay  in 
the  disposal  of  the  dead  in  such  cases.  The  un- 
dertaker not  only  owes  it  to  his  personal  - 
manage  such  cases  with  despatch,  but  the  inter- 
ests of  the  commonwealth,  in  checking  the  dan- 
>m  communicable  disease,  point  in  the 
same  direction. 

The  importance  of  a  free  use  of  potent  disin- 
fectants is  emphasized,  and  suggestions  are  offered 


tending  to  the  employment  of  simple,  efficient  and 
non-hazardous  means  for  embalming  the  conta- 
gious dead.  The  circular  advises,  however,  that 
no  process  of  cadaveric  preservation  by  arsenical 
preparations,  and  the  like,  shall  be  used  unless  it 
shall  be  known  to  the  undertaker  that  a  written 
certificate  of  the  cause  of  death  has  been  given 
by  the  attendant  physician  :  and  that  embalming 
should  never  be  attempted  in  the  face  of  circum- 
stances of  a  suspicious  nature.  This  advice  is 
valid  chiefly  from  the  medico  legal  standpoint, 
since  death  from  poison  may  be  covered  up  by  an 
unduly  hasty  use  of  certain  embalming  methods. 
The  use  of  the  ice-box  is  particularly  named  as 
an  objectionable  procedure  in  the  case  of  conta- 
gious deaths.  The  superficial  action  of  the  ice 
used  in  the  refrigerant  process  can  have  little  to 
do  towards  removing  the  contagious  dangers  in 
these  cases,  while  the  process  itself  is  unsafe  as 
regards  the  undertaker  and  his  assistants,  since  it 
.involves  considerable  unnecessary  manipulation 
of  the  bodies  so  treated.  The  circular  adds,  in 
this  connection,  that  instances  of  wanton  reck- 
lessness have  been  reported  to  the  Board,  in  which 
the  ice  after  use  in  the  box  has  been  thrown  in 
the  public  street,  and  the  box  has  been  taken  the 
same  day  into  an  uninfected  house  without  hav- 
ing been  disinfected. 


POISONING  BY  EXALGINE. 
A  case  of  poisonous  overdosing  with  exalgine 
is  given  in  a  recent  issue  of  the  British  Medical 
Journal,  by  E.  E.  Dyer,  M.D.  The  patient,  a 
man  of  twenty  years,  applied  for  treatment  for 
rheumatism.  Exalgine  was  ordered  in  doses  of 
grains  ijss,  in  tincture  of  orange  and  water,  at 
six  hour  intervals.  Dr.  Dyer  was  prevented  from 
seeing  the  man  until  over  forty  hours  had  elapsed, 
during  which  time  he  was  told  that  six  doses  had 
been  taken.  The  patient  presented  the  symptoms 
of  carbolic  acid  poisoning ;  had  been  sleeping  al- 
most continuously  for  twelve  hours,  frequently 
starting  in  his  sleep,  and  was  very  dull  and  heavy 
when  aroused  ;  complained  of  pain  in  the  lumbar 
region.  Urine  had  been  passed  only  twice  in 
twenty- four  hours  and  was  of  an  olive-green  color; 
its  specific  gravity  was  high  ;  there  was  no  albu- 
men or  blood;  deposits  of  the  urates,  and  not  phos- 
phates, were  observed.  He  complained  greatly  of 
the  skin  was  hot  and  dry,  but  the  highest 


EDITORIAL  NOTES. 


[April  4, 


temperature  obtained  was  980  F. ;  the  pulse  count- 
ed 102,  and  was  full  and  strong.  Salivation  was 
a  marked  symptom  for  several  days ;  this  was 
treated  by  occasional  doses  of  chlorate  of  potash 
and  subsided  soon  after  the  cerebral  and  renal 
conditions  improved.  Otherwise  the  only  treat- 
ment mentioned  was  a  diaphoretic  and  diuretic 
mixture.  The  rheumatic  and  myalgic  symptoms 
appeared  to  be  relieved  by  the  exalgine. 


A  FORM  OF  FAITH  CURE  FOR  SNAKE-BITE. 
In  Southern  India,  where  the  natives  suffer  so 
much  from  snake-bite,  especially  that  of  the  ven- 
omous cobra,  it  is  strange  that  these  reptiles  are 
for  the  most  part  left  in  peace,  on  account  of  the 
influences  of  tradition,  superstition  and  worship 
of  all  forms  of  animal  life  which  forbid  their  de- 
struction Even  special  days  are  set  apart  for  the 
adoration  of  the  cobra,  when  offerings  of  sugar, 
milk  and  other  articles  of  food  are  made  to  it. 
And  this  is  done  despite  the  fact  that,  in  the  prov- 
ince of  Mysore  at  least,  the  Government  offers  to 
pay  a  reward  for  ever}-  snake  that  is  killed  and 
brought  in,  and  thus  a  superstitious  dread  of  con- 
sequences prevents  the  extermination  of  these 
reptiles.  The  natives  believe  that  their  best  pro- 
tection against  snake-bites  lies  in  their  devotions 
and  offerings,  and  that  if  they  do  not  secure  im- 
munity against  the  venom  of  the  reptiles,  the 
fault  has  been  their  own,  by  reason  of  their  in- 
adequate devotions  and  offerings ;  which  is  much 
the  same  line  of  reasoning  as  that  adopted  by  the 
unfortunate  faith-healers  of  our  own  country,  who, 
starting  with  the  proposition  that  all  disease  is 
sin  and  want  of  faith,  find  it  easy  to  charge  the 
latter  upon  every  poor  invalid  who  does  not  at 
once  declare  that  he  has  been  healed  under  the 
ministrations  of  the  "healers." 


EDITORIAL  NOTES. 
The  Benefits  of  a  Satisfied  Stomach. — 
Aside  from  the  well-known  aphorism  touching 
the  importance  of  a  well- filled  stomach  upon  the 
joy  of  the  individual,  there  now  comes  a  confir- 
mation of  an  opinion  which  has  long  been  held 
among  physicians,  viz.,  that  a  full  stomach  acts 
as  a  force  against  the  invasion  into  the  system  of 
the  peculiar  poisons  of  many  diseases.  Experi- 
ments have  recently  been  made  which  go  to  show 


quite  conclusively  that  hunger  lessens  the  ability 
of  the  body  to  defend  itself  against  disease  germs. 
This  comes  not  alone  from  the  fact  that  the 
stomach,  and  sympathizing  organs,  are  actively 
engaged  in  that  work  which  they  are  physiologi- 
cally destined  to  perform,  but  as  well  from  the 
general  effect  this  may  have  upon  those  guiding 
and  governing  centres  of  the  central  nervous  or- 
ganization, and,  also,  probably,  other  factors  of 
which  we  have  but  little  knowledge. 

A  New  Interpretation. — An  English  quack 
was  recently  brought  before  the  police  court  for 
practicing  without  due  qualification,  who,  in  de- 
fending the  use  of  the  characters  M.D.  and  F.  R. 
S.  after  his  name,  said  they  meant  "money 
down"  and  "  Fosterer  of  Real  Science."  The 
individual's  genius,  however,  did  not  save  him 
for  he  was  fined  twenty  pounds  M.D. 

Harper  Hospital,  Detroit. — Staff  positions 
at  this  institution  are  hereafter  to  be  had  only 
through  the  avenue  of  a  competitive  examination, 
and  such  examination  has  been  thrown  open  to 
the  graduates  of  all  medical  schools.  Formerly 
the  positions  were  accessible  but  to  those  holding 
credentials  from  the  Detroit  College  of  Medicine. 

The  Wisdom  of  Galen. — Even  upon  the 
subject  of  lead-poisoning  that  great  medical  wri- 
ter of  early  ages — Galen — had  a  clear  conception. 
Thomas  Oliver,  M.A.,  M.D.,  {Brit.  Med.  Jour.) 
refers  to  him  as  condemning  the  use  of  leaden 
pipes,  stating  that  the  water  which  was  conveyed 
through  them  took  on  a  muddiness  from  the  lead, 
and  produced  a  kind  of  dysentery  in  those  who 
drank  it. 

Further  Precautions  Against  Poisoning 
from  Preserved  Meats.— A  timely  suggestion 
has  been  offered  by  a  German  physician  that  the 
date  of  original  preservation  be  stamped  upon  each 
and  every  can  or  package  containing  meat  foods. 
It  is  held  that  preserved  meats,  hermetically 
sealed,  may  remain  wholesome  for  a  year  or  so, 
but  that  there  is  danger  in  the  use  of  such  foods 
after  this  period. 

Paget's  New  Book  of  Cases. — Sir  James 
Paget  has  issued  a  new  book,  Longman's  pub- 
lishers, entitled  "  Studies  of  Old  Case  books,"  in 
which  he  discloses  somewhat  of  his  literary 
methods.  He  began  to  take  notes  with  the  very 
first  case  he  ever  saw,  while  he  was  yet  an  appren- 


'89I-] 


EDITORIAL  NOTES. 


489 


tice  to  a  medical  practitioner  of  Yarmouth,  and 
he  has  continued  during  his  forty  years  of  prac- 
tice the  systematic  recording  of  his  cases.  It  is 
from  his  numerous  volumes  of  notes  that  some  of 
his  former  writings  and  these  newly  published 
"Studies"  have  been  drawn.  In  the  latter,  as 
in  earlier  books,  is  displayed  the  same  graceful 
diction  and  charm  of  polished  style  that  have 
won  for  him  friends  among  American  readers  who 
never  saw  him.  In  one  of  his  essays  he  writes  in 
autobiographic  way  of  "  An  irregular  pulse 
own.  which  record  he  closes  with  the  sententious 
saying:  "  Few  things  are  more  inconceivable  than 
are  many  things  which  are  certainly  true  "  And 
on  another  page  when  treating  of  spines  that  are 
suspected  of  being  deformed  he  gives  expression 
to  this  pithy  precept :  ' '  Bad  postures,  long  main- 
tained, will  bring  on  bad  shapes,  and  even  good 
postures,  maintained  with  weariness  are  hardly 
To  those  who  may  never  hope 
to  see  this  great  surgeon  in  person  this  book  gives 
an  opportunity  to  view  that  winning  mental  part 
of  him  which  can  be  reflected  upon  the  printed 
page. 

"When  Doctors  Disagree." — The  follow- 
ing resolution  was  passed  at  a  late  meeting  of  the 
British  Gynecological  Society:  "That  the  Ob- 
stetrical Society  be  invited  to  appoint  a  sub- com- 
mittee to  act  with  the  sub-committee  of  this  Socie- 
ty to  inquire  into  the  cases  in  dispute  between 
Sir  Spencer  Wells  and  Mr.  Lawson  Tait." 

Ornamented  Skeletons. — M.  Vasselovski 
has  recently  discovered  two  caves  in  the  Crimea 
which  contain  prehistoric  remains.  These  in- 
clude parts  of  human  skeletons  of  which  some 
of  the  bones  give  evidence  of  having  been  painted. 
It  is  probable  that  these  relics  come  down  from 
the  time  of  the  Cimmerians,  of  whom  Herodotus 
wrote,  regarding  their  strange  rites  of  sepulture: 
it  was  their  practice  to  expose  the  bodies  of  the 
dead  at  the  top  of  some  hill  or  promontory  and 
there  leave  them  until  the  bones  had  been  picked 
clean  by  birds  of  prey:  then  the  skeletons  were 
collected  and  when  completely  dried  were  painted 
over  with  some  mineral  pigment. 

Dangers  and  Damages  due  to  Factory 
Whistles. — Dr.  J.  H.  Albee  has  won  a  suit  for 
damages,  amounting  to  S6,ooo,  for  a  broken  leg, 
which  the  jury  at  White  Plains,  X.  Y.,  decided 
was  chargeable  to  the  blowing  of  a  steam- whistle, 


belonging  to  the  shoe-factory  at  Chappaqua.  Dr. 
Albee  is  a  Rhode  Island  physician  who  had  been 
summering  at  Chappaqua,  in  the  summer  of  1888; 
one  day  in  July  he  with  a  friend  was  driving  near 
the  shoe-factory,  when  the  whistle,  know:, 
"seven-mile  whistle."  was  blown;  the  horse  they 
were  driving  became  affrighted  and  ran  away. 
The  riders  were  thrown  out  of  the  wagon,  and 
one  of  them,  the  physician,  received  a  serious 
fracture  of  the  leg.  The  injured  physician,  in 
nee,  may  or  may  not  have  been  engaged 
in  professional  duty  when  the  whistle  shrieked, 
but  he  has  our  sympathy  in  either  case, 
hope  that  his  cause  is  well  and  finally  won.  And 
for  this  reason:  we  thoroughly  detest  and  rep- 
robate the  use  of  these  life-endangerinj 
whistles,  which  disrupt  the  atmosphere  for  miles 
around.  These  seven-mile  whistles  serve  no  use- 
ful purpose  that  is  imperatively  demanded  by  trade 
or  industrial  pursuits,  while  they  are  in  many 
places  a  daily  menace  to  property  on  wheels,  to 
limb  and  life  of  animals  and  men.  and  of  the  gen- 
eral practitioner,  in  an  especial  degree.  These 
frightsome  noises  have  no  right  to  e 

Scabies  Among  the  Chinese. — The  I 
Medica'.  I  rbruary,  in  some  remarks  on 

the  low  state  of  medical  practice  among  the  Cki- 

:es  that  whatever  else  may  be  lacking  in 
-tern,  they  do  not  stand  in  need  of  medical 
aphorisms.  These  have  come  down  to  them  from 
numberless  generations  and  are  a  large  part  of 
their  stock  in  trade.  One  of  these  aphorisms, 
taken   at   hazard  by  the   J\d  -  Out  of 

a  men'  eleven  have  the  itch."  While 
there  is  abundant  testimony  from  other  sources 
that  the  itch  is  very  prevalent  in  China,  we  are 
forced  to  the  conclusion  that  as  a  statistical  state- 
ment the  above  aphorism  is  a  failure.  There  is 
evidently  no  need  for  any  parliamentarily  ii 
individual  to  rise  up  and  "  move  to  mak-. 
animous  :  "   the  unanimity  is  there  already. 

Dr.  Koch  in  Egypt. — The  overworked  Pro- 
<och  has  gone  on  a  trip  up  the  X:'.-_ 
will  consume  a  fortnight  or  more.    It  is 
that  he  will  be   back  again   in   Berlin 
after  Easter  to  take  up  his  new  duties.     The  Lan- 
cet correspondent  at  Cairo  wr  -Coch  ar- 
rived there  on  February  12.  looking  very  thin  and 
ill  after  five  days*  sea-sickness  and  all  its  attend- 
i  ant  evils,  and  that  he  avoided  all  social  entertain- 


490 


MEDICAL  ITEMS. 


[April  4, 


ment,  proffered  dinners,  visits  and  the  like  so  far 
as  it  was  possible.  Before  leaving  the  city  on  the 
14th,  however,  Koch  found  time  to  visit  the  Kasr- 
el-Aini  Hospital  and  the  German  Hospital  and  to 
inspect  the  cases  under  treatment,  at  both  of  them, 
by  tuberculin.  At  the  former  institution  he  found 
not  less  than  twenty  cases  of  phthisis,  lupus  and 
tuberculous  joints  on  which  to  lecture  briefly  as 
to  the  time  and  method,  and  quantity  for  the  in- 
jection. He  inclined  to  criticise  here,  as  else- 
where, those  operators  who  use  the  remedy  with 
too  much  caution.  He  thought  the  doses  were 
not  infrequently  too  small  and  at  too  long  inter- 
vals to  procure, the  desired  result. 

Regarding  the  tourist-season  on  the  Nile,  the 
writer  adds  that  despite  the  opening  of  new  hotels 
and  a  new  line  of  Nile  boats,  Cairo  has  never 
been  so  overcrowded  before  as  it  has  been  during 
the  past  winter ;  during  four  days  of  the  week 
when  Koch  passed  through  not  less  than  500  trav- 
elers left  the  capital— 250  to  go  up  the  Nile  and 
as  many  more  going  in  the  other  direction  to  the 
Holy  Land,  Athens,  Rome  and  other  points. 

A  Striking  Definition.— Dr.  Holmes  in  his 
"  Over  the  Teacups  "  defines  a  crank,  "  as  a  man 
who  does  his  own  thinking."  They  are  called 
cranks  because  they  ' '  make  all  the  wheels  in  all 
the  machinery  of  the  world  go  round." 

American  Academy  of  Medicine. — The  six- 
teenth annual  meeting  of  the  American  Academy 
of  Medicine  will  be  held  at  Washington,  D.  C, 
May  2  and  4,  opening  at  3  p.m.  May  2.  As  it 
will  be  just  previous  to  the  sessions  of  the  Amer- 
ican Medical  Association,  members  will  be  able 
to  attend  both  meetings. 

MEDICAL  ITEMS. 

Idiosyncrasy  Towards  Fruit.— Dr.  S.  V. 
Clevenger,  of  Chicago,  mentions  a  case  (Times 
and  Register)  of  marked  aversion  towards  all 
varieties  of  fruit.  The  person  is  a  young  lady, 
now  twenty  years  of  age,  and  has  always  suffered 
from  this  peculiarity.  She  is  sickened  at  once 
upon  the  sight  or  odor  of  apples,  peaches,  pears, 
etc.,  and  she  abhors  sweets  of  all  kinds.  Dr. 
Clevenger  desires  that  physicians  having  cases 
ol  a  similar  character  should  make  them  known 
to  the  medical  world. 

Iowa  Statu  Medical  Society.— The  fortieth 
annual  session  of  this  Society  will  be  held  at 


Waterloo,  Iowa,  Wednesday ,  Thursday  and  Friday , 
April  15,  16,  17.  A  cordial  invitation  is  extended 
to  the  profession.  An  excellent  programme  has 
been  prepared.  Let  every  county  or  district  soci- 
ety send  a  full  representation  of  new  delegates, 
and  let  the  permanent  members  be  in  full  force. 
The  Chairmen  of  the  different  Sections  and  all 
officers  of  the  Society  are  requested  to  meet  in 
Waterloo  on  Tuesday  preceding  the  annual  meet- 
ing, to  confer  with  the  President,  Dr.  W.  D.  Mid- 
dleton,  and  the  Chairman  of  the  Committee  on 
Arrangements,  Dr.  D.  W.  Crouse,  at  such  place 
as  the  latter  may  designate,  for  the  purpose  of 
arranging  the  programme  and  attending  to  other 
business  matters.  Reduced  rates  have  been 
granted  on  all  roads  in  Iowa.  When  you  buy 
your  tickets  be  sure  to  ask  the  agents  for  certifi- 
cates that  you  have  paid  full  fare  one  way.  Pre- 
sent these  early  in  the  session  for  Secretary's  sig- 
nature. Any  further  information  will  be  cheer- 
fully given  by  C.  F.  Darnall,  West  Union,  Sec- 
retary; W,  D.  Middleton,  Davenport,  President, 
or  D.  W.  Crouse,  Waterloo,  Chairman  of  Com- 
mittee on  Arrangements. 

Decrease  in  Candy  Poisoning. — Owing  to 
the  increasing  and  constant  warfare  by  the 
National  Confectioners'  Association,  there  has 
been  a  very  marked  decline  in  the  number  of  in- 
stances of  untoward  effects  from  candy  eating. 

The  National  Association  of  Railway 
Surgeons  will  convene  at  Buffalo,  N.  Y.,  Thurs- 
day, April  30,  1891.  This  is  a  change  of  one 
week  from  the  time  previously  announced,  the 
change  having  been  made  so  as  not  to  conflict 
with  the  dates  covered  by  the  meeting  of  the 
American  Medical  Association. 

An  Evidence  of  Faith. — That  faith  as  to  the 
ultimate  outcome  of  the  Koch  treatment  strongly 
abides  in  the  breasts  of  those  constituting  the 
municipal  authority  of  Berlin  is  indicated  by  the 
movement  now  being  made  to  found  a  home  for 
convalescents  who  have  undergone  the  new  pro- 
cess of  cure. 

A  New  Medical  Library  Building. — In 
connection  with  the  Boston  City  Hospital  a  build- 
ing was  recently  opened  and  occupied  for  library 
purposes.  The  general  arrangement  is  quite  con- 
venient, and  the  event  of  the  opening  was  made 
the  occasion  of  a  hearty  reciprocity  of  good  feel- 
ing  between  the  members  of  the  various  hospital 
staffs  in  the  city. 


i«9i-J 


TOPICS  OF  THE  WEEK. 


49' 


TOPICS  OF  THE  WEEK. 


PROFESSOR    KOCH'S  TREATMENT  OF  TTJBERCl 

Professor  Virchow,  at  the  meeting  of  the  Berlin  Med- 
ina] Society  on  February  25,  again  referred  to  Koch's 
treatment,  and  showed  some  specimens  in  illustration  of 
his  remarks.  He  doubted  whether  the  statement  by  Dr. 
B.  Fraenkel,  as  to  the  duration  of  miliary  tubercle, 
based  on  inoculation  experiments,  was  correct — namely, 
that  a  period  of  three  weeks  is  required  for  its  develop- 
ment. The  question  was  one  to  be  decided  by  clinical 
observers,  for  it  could  not  be  determined  by  pathologists. 
If  one  were  to  admit  that  in  all  those  cases  in  which 
miliary  tubercle  is  found  this  has  been  present  before 
the  injections  were  practiced,  then  a  much  longer  ex- 
tension must  be  given  to  the  duration  of  miliary  tubercle 
than  has  hitherto  been  assigned  to  it.  A  distinction  in 
this  respect  must  be  made  between  local  tuberculosis  and 
the  general  acute  disease  which  creates  such  marked 
constitutional  disturbance.  He  detailed  a  case  of 
pleuritic  effusion  under  the  care  of  Professor  Leyden,  in 
which  phthisical  signs,  with  laryngitis  and  fever,  devel- 
oped whilst  under  treatment  by  Koch's  injections,  death 
supervening  four  weeks  after  the  first  injection.  In  this 
case  there  was  very  marked  general  miliary  tuberculosis, 
submiliarv  granulations  occurring  in  liver,  kidneys. 
thyroid,  larynx,  and  in  parts  of  the  peritoneum,  includ- 
ing the  recto-vesical  pouch,  as  well  as  in  the  lungs, 
which  were  also  the  seats  of  old  apical  mischief.  Here 
was  a  case  which  certainly  did  not  come  under  the  class 
referred  to  by  Dr.  Fraenkel,  for  it  had  beeu  long  under 
observation  and  had  beeu  injected  before  the  superven- 
tion of  the  acute  tuberculosis.  Professor  Virchow  also 
showed  a  lung  from  a  patient  who  had  received  eight  in- 
jections, which  presented  a  large  caseous  mass  in  process 
of  separation,  and  an  intestine  exhibiting  a  very  marked 
eruption  of  tubercles  and  implication  of  the  lacteals  in 
the  vicinity  of  ulcers. 

Professor  Cantani,  of  Naples,  in  giving  the  results  of 
his  experience  with  Koch's  remedy  (Berl.  Klin.  Woe/;., 
No.  9),  points  out  that  the  important  part  of  the  method 
is  the  production  of  local  reaction,  which  in  some  cases 
occurs  without  any  general  febrile  disturbance.  This 
local  reaction,  he  said,  is  nothing  else  than  a  quickening 
of  the  natural  processes  whereby  the  organism  seeks  to 
get  rid  of  the  materies  morbi.  He  found  more  marked 
improvement  in  cases  where  there  was  no  fever  and  only 
slight  local  reaction — cases  in  which  the  commencing 
doses  were  very  small,  and  their  repetition  with  slight 
increase  in  quautity  made  at  some  intervals.  He  further 
explained  that  many  of  the  alleged  dangerous  results  of 
the  treatment  are  prone  to  occur  in  the  spontaneous 
course  of  tubercular  disease,  but  may  occur  more  readily 
and  rapidly  from  the  hastening  of  the  necrotic  process 
by  the  injections.  Nor  should  the  result  of  every  case 
that  is  fatal  whilst  undergoing  this  treatment  be  assigned 
to  the  latter  ;  and  he  did  not  doubt  that  when  the  time 
came  for  a  full  survey  it  would  be  found  that  the  favora- 
ble results  would  counterbalance  the  unfavorable.  As 
to  the  prospect  of  Koch's  fluid  curing  tuberculosis,  Pro- 


fessor Cantani  remarked  that  the  changes  observe' 1  in 
lupus  were  very  hopeful.  In  the  lungs  the  physical 
signs  denote  the  occurrence  of  similar  changes  to  those 
observed  in  lupus,  and  the  increased  bacillary  ea 
ation  was  evidence  of  the  focus  being  destroyed.  But 
the  impediment  to  the  free  removal  of  the  necrosed  area 
in  the  case  of  the  lungs  was  against  marked  progress, 
although  this  was  noted  in  some  cases.  The  laryngeal 
cases  showed  more  obviously  the  local  improvement. 
Professor  Cantani  points  out  that  phthisis  embraces  not 
only  tuberculosis,  but  other  septic  processes  due  to  the 
presence  of  pyogenic  organisms ;  so  that  in  advanced 
cases  little  can  be  expected  from  the  treatment,  which  in 
such  must  be  followed  with  the  greatest  caution,  if  at  all. 
He  did  not  think  the  time  had  arrived  for  a  definite  con- 
clusion to  be  formed  as  to  the  efficacy  of  the  method  in 
phthisis,  and  deprecated  too  great  enthusiasm  on  the  one 
hand  and  depreciation  on  the  other  as  contra: 
interests  of  truth.  The  remedy  was  new  and  its 
striking,  but  it  must  be  further  studied  before  its  prac- 
tical value  is  appraised.  At  any  rate,  Koch  had  shown 
the  path  to  be  taken  by  bacteriology  in  the  future,  and 
the  progress  of  knowledge  would  cause  its  further  ex- 
tension.—  The  Lancet. 


MEDICAL  MEN  AND   LITERATURE. 

Literary  production  in  other  than  professional  fields 
has  in  all  ages  divided  with  more  purely  technical  studies 
the  power  of  attracting  the  mental  energies  of  medical 
men.  Such  names  as  those  of  Roger  Bacon,  Sir  Thomas 
Browne,  Locke.  Garth,  and  others  have  indeed  so  shone 
in  the  fame  of  letters  that  in  their  case  an  original  con- 
nection with  medicine  has  almost  been  forgotten.  In 
these  days  the  zeal  for  learning  follows  a  more  exclusive- 
ly practical  and  scientific  tendency.  As  if  in  harmony 
with  the  laws  of  the  circulation,  the  cravings  of  the  med- 
ical mind  commonly  find  satisfaction  within  the  round  of 
its  most  familiar  occupations.  There  are,  however,  not 
a  few  exceptions  to  this  rule.  We  have  not  yet  lost  the 
medical  poet  or  philosopher,  nor  have  the  efforts  of 
romance  in  prose  been  unassisted  by  practitioners  of  our 
art.  To  employ  thus  the  precarious  leisure  of  routine  in 
practice  cannot  but  refresh  the  mind  of  those  most  near- 
ly interested,  while  recent  experience  might  also  be 
shown  to  prove  that  efforts  thus  applied  have  not  been 
fruitless  in  refreshing  the  intellect  of  the  reading  com- 
munity. Some  faults  might  naturally  be  expected  in 
the  productions  of  a  medical  writer.  Among  the  chief 
obstacles  to  his  success  may  be  numbered  a  too  didactic 
style,  a  philosophic  heaviness,  above  all,  a  tendency  to  ex- 
cess in  realism,  particularly  if  engaged  upon  that  now  all- 
popular  and  most  profitable  form  of  composition, the  novel. 
An  error  of  discretion,  indeed,  may  sometimes  lead  to 
serious  embarassment.  Take,  for  example,  the  case  of 
a  medical  novelist  in  France,  who  was  lately  called  upon 
to  answer  the  allegations  of  an  indignant  husband  that 
his  wife's  morbid  state  was  exactly  reproduced  in  the 
heroine  described  by  her  doctor,  who  was  therefore  lia- 
ble for  a  breach  of  professional  secrecy.  The  case  might 
well  have  been  one  in  which  the  cap  of  the  proverb  was 
found  to  fit  a  head  for  which  it  was  not  made,  but  it  may 


492 


TOPICS  OF  THE  WEEK. 


[April  4, 


serve,  nevertheless,  to  accentuate  the  dislike  to  an  exact 
description  of  morbid  states  and  symptoms  in  which  we 
must  admit  a  share  with  many  general  readers.  A  high 
professional  standard  alike  in  literary  taste  and  in  true 
medical  propriety  is,  we  take  it,  best  maintained  by 
those  who  can  discreetly  separate  what  are  in  them  re- 
lated faculties,  and  be  medical  in  their  medicine  but 
scholarly  in  letters. — The  Lancet. 


OFFICIAL  REGULATIONS  AS  TO  TUBERCULIN  IN  GERMANY 
AND  ITALY. 

The  Prussian  Miuister  of  the  Interior  has  given  per- 
mission for  the  use  of  Koch's  remedy  for  tuberculosis  in 
prisons,  under  the  following  conditions  :  (1)  A  special 
department  must  be  established  for  the  purpose.  (2)  The 
medical  officer  in  charge  of  these  cases  must  reside  in  the 
institution.  (3)  In  the  case  of  patients  with  pulmonary 
phthisis,  only  those  in  whom  the  disease  is  recent,  or 
who  seem  in  other  respects  particularly  suitable  subjects, 
must  be  subjected  to  the  treatment;  and  (4)  the  remedy 
must  in  110  case  be  used  against  the  patient's  will.  Sur- 
geon-General von  Coler  has  issued  an  order  regulating 
the  use  of  Koch's  remedy  for  tuberculosis  in  the  Prussian 
army.  Each  garrison  hospital  is  to  be  provided  with  a 
special  department  in  which  the  treatment  can  be  carried 
out,  and  to  this  all  cases  of  tuberculosis  in  soldiers  be- 
longing to  the  corresponding  district  corps  which  appear 
suitable  are  to  be  sent.  The  tuberculosis  department  is 
to  be  isolated  from  the  others,  and  must  be  provided  with 
all  the  necessary  equipment  for  scientific  observation. 
At  a  recent  meeting  of  the  Italian  Superior  Council  of 
Health,  the  President,  Professor  Baccelli,  presented  a  re- 
port on  the  Koch  treatment,  which  was  referred  to  a  Spe- 
cial Committee.  This  committee  has  now  submitted  the 
conclusions  at  which  it  has  arrived  to  the  Council.  The 
following  is  a  summary  of  the  committee's  report:  (1) 
The  instruction  issued  by  the  sanitary  authorities  on  De- 
cember 14th,  provisionally  restricting  the  use  of  Koch's 
fluid  to  university  and  hospital  clinics,  is  approved  of. 
(2)  Circumstances  arc  now  changed.  The  numerous  ex- 
periments made  in  Italy  and  in  other  countries,  and  par- 
ticularly those  of  Professor  Baccelli  himself,  have  better 
i  R  led  the  true  value  of  the  remedy,  and  shown  the  in- 
dications for  its  use,  and  the  possible  dangers  attending 
it.  The  committee  therefore  has  no  hesitation  in  propos- 
ing that  the  remedy  be  entrusted  to  the  hauds  of  individ- 
ual members  of  the  medical  profession,  just  as  they  are 
[to  use  other  remedies  not  less  useful  and  at  the 
same  time  not  less  dangerous.  (3)  Compared  with  other 
in  the  pharmacopoeias,  however,  Koch's  fluid 
lice  while  the  purity  and  quality  of 
1  always  he  kept  nailer  strict  control,  in  the  case 
of  the  latter  there  is  no  other  guarantee  than  the  fact  of 
ig  from  the  institute  in  which  it  was  originally 
discovered.  The  committee  therefore  considers  it  indis- 
the  fluid  should  be  introduced  into  Italy 
central  authority,  by  which  also  it  should 
I  under  such  conditions  and  with  . 
guards  as  may  be  thought  ad  i.astly,  the  com- 

1.  I  i.  it  in  distributing  the  fluii 

tiority  should  at  the  same  time  issue  the  a 


instructions  for  its  use,  and  should  request  the  medical 
practitioners  to  whom  it  is  supplied  to  report  all  the 
cases  in  which  they  employ  it,  and  the  results  obtained. 
The  committee's  report  was  unanimously  adopted  by  the 
Superior  Council  of  Health. — Brit.  Med.  Journal. 


THE  BEQUESTS    UNDER    THE    FAYERWEATHER    WILL    TO 
HOSPITALS. 

The  will  of  Daniel  B.  Fayerweather,  late  of  New  York 
City,  by  arrangement  with  counsel  for  the  contestants 
has  at  length  been  admitted  to  probate.  The  error  of  the 
devisor  was  the  having  made  too  low  an  estimate  for  the 
adequate  support  of  his  widow.  The  exact  terms  of  the 
settlement  are  not  known  to  the  public  beyond  the  in- 
crease of  income  and  a  cash  payment,  both  in  favor  of 
the  widow.  The  estate  is  supposed  to  be  worth  five  and 
a  half  millions  of  dollars,  which  after  certain  gifts  and 
bequests  leaves  a  remainder  to  be  divided  into  ten  parts: 
one  to  Yale,  one  to  Harvard,  one  to  Princeton,  one  to 
Columbia,  one  to  the  Presbyterian  Hospital  and  five  to 
the  Woman's  Hospital.  As  now  arranged  St.  Luke's, 
the  Presbyterian  and  the  Manhattan  Eye  and  Ear  Hos- 
pitals receive  each  $ 50,000;  the  Woman's  $210,000;  the 
New  York  Eye  and  Ear  Dispensary,  the  Manhattan  Dis- 
pensary, the  Moutefiore  Home  for  Chronic  Iuvalids,  the 
Mount  Sinai,  the  Methodist  (Brooklyn)  and  the  New 
York  Cancer  Hospitals  receive  each  $25,000,  while  the 
Society  of  St.  Vincent  de  Paul  receives  $50,000.  It  is 
shown  by  the  tabulated  statements  as  given  by  the  secu- 
lar press  that  the  $25,000  bequests  are  gains  to  the  insti- 
tutions named  by  absolute  deed  of  gift.  So  also  the  So- 
ciety of  St.  Vincent  de  Paul  gains  its  full  amount,  while 
St.  Luke's,  the  Presbyterian,  the  Manhattan  Eye  and  Ear 
Hospitals  gain  severally  $25,000  apiece,  the  Woman's 
Hospital  $200,000  and  Mouul  Sinai  $15,000.  While,  on 
the  whole,  this  estate  so  far  has  made  the  greatest  gifts 
in  this  country  for  benevolence  and  education,  we  cannot 
but  deplore  the  ignoring  of  a  profession  which  has  ren- 
dered all  such  charities  possible.  Truly  there  are  many 
libraries  in  and  about  the  cities  and  towns  which  might 
have  been  medically  reinforced  with  profit  to  not  over- 
wealthy  physicians.  Still,  we  are  not  inclined  to  jeal- 
ousies. 


LIVING  MICRO-ORGANISMS  IN   TUBERCULIN. 

The  Russian  commission  for  the  study  of  Koch's 
method,  headed  by  Prof.  Wissotsky.  received  two  pack- 
ages of  tuberculin,  one  from  Libberts  and  the  other  from 
Guttmanu.  Both  were  found  to  contain  living  microor- 
ganisms. From  this  the  commission  concluded  that  it 
would  he  wise  to  confine  their  researches  to  experiments 
mals  ami  to  bacteriological  studies.  Three  pack- 
ages secured  later  contained  living  microorganisms  and, 
like  those  earlier  received,  were  strongly  alkaline  in  re- 
action.— La  Semaine  Mtdicale. 


IN   PARIS. 

um   1  1  of  medical  prai  i      Parii  is  stated 

1  1  be     . As  the  population  of  the    1  rench  capital  is 

2,300,000.  this  gives  a  proportion  of  one  medical  man  to 
0  inhabitants. 


I89i.] 


PRACTICAL  NOTES. 


493 


PRACTICAL  NOTES 


ACUTE    CYSTITIS. 

Dr.  A.  W.  Marsh,  iu  the  Therapeutic  Gazette, 
strongly  recommends  the  use  of  the  following 
formula,  requiring  that  distilled  or  rain  water  be 
used  in  its  preparation  to  prevent  the  formation 
of  oxalate  of  lime.  The  relief  from  pain  is  prompt 
and  the  results  exceedingly  satisfactory  : 

R.      Acid  oxalic,  gr.  xyj. 
Syr.  aurantii  cor.,  J5J. 
Aquae  pluv.,  q.  s.  giv.     "X. 
Teaspoonful  every  four  hours. 


FOR  THE  GRIPPE. 

Dr.  E.  R.  Palmer,  <>(  Louisville,  says  that  with 
the  recurring  prevalence  of  the  so  called  grippe, 
he  suggests  the  following  as  a  specific  for  adults 
in  such  cases  : 
Salol,  Jiij. 
Phenacetin,  9ij. 
Quinise  salicylate,  Jj. 
M.,  ft.  cap.  xx.     Sig.     Two  every  three  hours. 

— American  Practitioner  and  News. 


WARTS. 


ft. 


Hydrarg.  chlor.  corros.,  I  part. 
Collodion,  30  parts,     ttjj. 
S.     Apply  once  daily  about  the  base  of  the  wart. 

— Cin  cin  nati  Lancet-  Clin  ic. 

AN    INJECTION    FOR    GONORRHOEA. 

Prof.  Keen  gave  the  following  formula  to  be 
used  as  an  injection  in  gonorrhoea  : 
R.     Zinci  sulphat,  gr.  xviij. 
Catechu. 

Matico,  aa  f  3  jss. 
Glycerini. 

Aquae,  aa  q.  s.  ad.  f  5  yj. 
S. — Inject  f^ss,   retaining  each  injection   for   at 


M. 


least  five  minutes. 


■  Times  and  Register. 


CREOLIN  IN    ACUTE    GASTROENTERITIS. 

Schwiuz  has  employed  this  drug  with  success 
in  the  following  formulae  . 
ft.     Creolin,  n\_iij. 

Syrup  althaea,  f-Jv. 
Aq.   ciiinamonii,  q.  s.  ad.,  f 5 i ij .      t)J. 
S.  To  a  very  young  child  a  small  teaspoonful  hourly. 
To  older  children  the  drug  may  be  given  in  a  powder. 
R.     Creolin,  n\,xv. 

Sacchari  alb.,  gr.  lxxv.     nj;. 
Divide  in  Chart  No.  X. 
S.     One  or  two  powders  daily. 

—  Wiener  Medizinische  Wochenschrift, 


FOR  ASTHMA. 


Dr.  W.  T.  Plant,  of  Syracuse,  N.  Y.,  says  that 
an  asthmatic  neighbor  of  his  gets  so  much  relief 


from  inhaling  the  smoke  of  a  teaspoonful  of  the 
following  combination   that  he  wants  all   other 
chronic  asthmatics  to  know  about  it  : 
ft.     Stramonium  leaves,  Bfi  §iv. 
Green  tea  dust,  aa  §iv. 
Lobelia,  §iss. 
Mix  together  and  wet  up  with  a  saturated  solution   01 
nitrate  of  potassium.       Dry   thoroughly    and  keep   in    a 
close  can  or  well  stoppered  bottle. 

— American  Practitioner  and  News. 


FOR  ECZEMA,  ETC. 

In  the  case  of  a  child  7  months  old  presenting 
the  following  symptoms  :  The  food  taken  passed 
by  the  bowels  undigested  ;  there  was  obstinate 
constipation  ;  the  patient  also  had  an  eczematous 
rash  upon  the  face.  Dr.  Rex  prescribed  the  fol- 
lowing treatment : 

ft.     Resinae  podophylli,  gr.  j. 
Alcoholis,  Qjj. 

Aquae,  f^iij. 
viR.  S.     In  drop  closes. 

For  the  eczema  of  the  face : 
ft.     Acid,  salicyli,  gr.  x. 

Adipis,  fgj". 
"K.   S.     Apply  locally. 

For  a  case  of  pharyngitis  complicated  with  bron- 
chitis, Dr.  Brintou  gave  the  following  formula  : 

R.     Ammonii  chloridi.gr.  v. 

Vini  antimonii,  gtt.  x. 

Vini  ipecuacuanhae,  gtt.  x. 

Mist,  glycyrrhizae  coinp.,  fjj. 
«K.  S.     Every  three  or  four  hours. 

—  Times  and  Register. 


CROUP. 


Dr.  J.  B.  Johnson  uses  the  following : 

ft.     Aquae  destillat,  fgj. 
Potass,  chlorat. 
Potass,  iodid.,  aa  3j. 
Emuls.  arabicae,  §ij. 
Mucilag.  acaciae. 
Ext.  ipecac,  fl. 
Olei  copaiba;,  aa  Sjj.     "K. 
S.     Shake  well.     Dose,  a  teaspoonful  every  ten   min- 
utes, to  an  infant  of  S  months,  till  free  vomiting  ensues; 
and  then  continue  the  same  dose  every  half  hour  or  hour 
until  the  disease  is  cured.     The  dose  must  be  giveu  ac- 
cording to  the  age  of  the  child. 

— New  England  Med.  Monthly. 

CYSTITIS. 

This  remedy  is  highly  spoken  of  by  a  number 
of  practitioners  in  genito  urinary  diseases,  and 
more  especially  in  cases  of  cystitis,  following  op- 
erations, or  from  other  causes.  One  of  the  best 
formulas  is  that  of  Dr.  Hal.  C.  Wyman,  which  is 
as  follows : 

R.     Fl.  ext.  pichi,  sj. 

Potass,  nitr.,  3j. 

Simple  elixir,  giij. 
"JJ.    Sig.,  teaspoonful  once  in  two  hours. 

— St.  Louis  Med.  and  Surg.  Journal. 


494 


SOCIETY  PROCEEDINGS. 


[April  4, 


SOCIETY    PROCEEDINGS. 

The  Clinical  Society  of  Louisville. 

Stated  Meeting  January  ij,  iSpi. 

Thos.  P.  Satterwhite,  M.D.,  President,  in 

the  Chair. 

Dr.  L.  S.  McMurtry  presented  a  specimen 
from 

A    CASE    OF    EXTRA-UTERINE     PREGNANCY 

with  the  following  history  : 

Mrs.  S.  E.  M.,  age  twenty  seven  years,  mar- 
ried nine  years.  Eight  years  ago  she  suffered  an 
abortion  at  three  months,  has  had  uterine  disease 
ever  since,  and  has  been  sterile.  She  missed  the 
menstrual  period  in  November,  and  on  December 
7th  called  to  see  her  physician,  Dr.  George  W. 
Griffiths.  Her  complaints  were  of  general  abdom- 
inal pain  and  discomfort.  She  again  called  on 
Dr.  Griffiths  on  December  nth.  On  the  13th, 
two  days  later,  she  had  a  violent  paroxysm  of 
pelvic  pain  localized  on  the  right  side.  Dr. 
Griffiths  saw  her  soon  afterward  and  administered 
a  dose  of  morphia.  She  was  relieved  for  the 
time.  On  the  evening  of  the  18th  Dr.  Griffiths 
summoned  me  to  meet  him  in  consultation,  and 
expressed  the  belief  that  abdominal  section  was 
indicated.  The  abdomen  was  swollen  and  tender 
with  increasing  peritonitis.  There  was  a  bloody 
flow  from  the  uterus.  The  patient  was  pallid  as 
from  postpartum  haemorrhage.  Vaginal  exami- 
nation showed  the  uterus  pushed  to  the  left  side 
and  the  pelvis  choked  with  effusion.  The  pulse 
was  134,  small,  the  pulse  of  haemorrhage.  The 
bowels  had  not  acted  for  four  days.  We  gave  an 
energetic  purgative,  and  arranged  for  operation 
the  following  morning. 

Early  on  the  morning  of  the  19th  I  opened  the 
abdomen.  Dr.  J.  W.  Guest  gave  ether  and  Dr. 
Griffiths  assisting.  On  opening  the  peritoneum 
a  large  quantity  of  blood  flowed  out  over  the 
table.  More  than  a  gallon  of  blood-clot  was  re- 
moved. The  foetal  ball  was  on  the  right  side. 
The  right  appendage  was  tied  off  close  to  the  uter- 
us, the  cavity  irrigated  with  warm  distilled  water, 
a  glass  drainage-tube  placed,  and  the  abdomen 
closed.  When  put  on  the  table  the  pulse  was 
140  and  quite  feeble.  The  appendage  on  the  op- 
posite side  was  not  removed,  as  I  feared  to  pro- 
long the  operation.  The  operation  was  conclud- 
ed in  thirty  minutes. 

The  specimen  is  of  great  interest.  You  will 
recognize  here  the  ovary,  and  here  the  ruptured 
Fallopian  tube  and  the  foetal  envelopes.  From 
this  poured  the  fearful  haemorrhage,  which  invar- 
iably ends  in  death  if  not  arrested  by  surgical  in- 
terference. 

This  is  the  first  case  of  extra-uterine  pregnancy, 
so  far  as  I  can  learn,  operated  upon  in  Louisville 
by  abdominal  section  at  the  time  of  rupture.  The 


success  of  the  case  is  due  to  Dr.  Griffiths'  recog- 
nition of  the  gravity  of  the  situation,  and  advice 
for  immediate  operation. 

Ectopic  gestation  is  a  very  common  accident. 
Hundreds  of  women  perish  annually  from  this 
cause  because  it  is  not  recognized.  Dr.  Formad, 
the  well-known  pathologist  of  the  University  of 
Pennsylvania,  as  coroner's  physician  for  Phila- 
delphia, states  that  in  one  year  he  found  post- 
mortem nineteen  cases  of  ruptured  ectopic  preg- 
nancy unrecognized.  The  symptoms  are  those 
of  shock,  internal  haemorrhage  and  peritonitis. 
The  patients  exhibit  a  history  of  sterility  and 
peri-uterine  inflammation.  The  fertilization  of 
the  ovum  in  the  Fallopian  tube  is  due  to  a  des- 
quamated salpingitis  by  which  the  lining  of  the 
tube  is  deprived  of  its  ciliary  epithelium.  Extra- 
uterine pregnancy  is  almost  invariably  tubal.  The 
tube  ruptures  about  the  twelfth  week.  It  may 
rupture  through  the  free  surface  of  the  periphery 
of  the  tube  directly  into  the  peritoneum,  as  in 
the  specimen  here  presented.  This  is  a  deadly 
accident,  if  the  haemorrhage  is  not  arrested  by 
surgical  means.  The  rupture  may  occur  in  the 
portion  of  the  tube  included  between  the  folds  of 
the  broad  ligament,  allowing  the  foetal  structures 
to  escape  into  the  cavity  of  the  broad  liga- 
ment. These  latter  are  the  cases  of  extra- 
uterine pregnancy  which  go  on  to  a  viable 
period.  Extra-uterine  pregnancy  until  very  re- 
cently was  not  understood  in  its  pathology,  and 
was  classified  and  treated  as  accidental  haemor- 
rhage, haematocele,  etc.  It  is  now  well  known 
that  most  cases  of  haematocele  so-called,  are  in 
reality  cases  of  ectopic  pregnancy.  The  treat- 
ment in  all  cases  should  be  immediate  abdominal 
section.  The  uterine  appendages  of  both  sides 
should  be  removed,  inasmuch  as  the  predisposing 
salpingitis  is  symmetrical.  I  have  now  operated 
in  three  cases  within  the  last  two  years  for  rup- 
tured tubal  pregnancy,  and  all  have  recovered. 
The  only  safety  in  such  a  condition  is  immediate 
operation.  The  diagnosis  before  rupture  is  prac- 
tically impossible.  When  rupture  occurs  the  in- 
dications for  surgical  interference  are  as  positive 
as  in  treating  a  wround  of  the  brachial"  artery. 

Dr.  George  W.  Griffiths  :  I  can  add  very 
little  to  the  history  as  already  detailed.  As  soon 
as  the  symptoms  of  shock  and  haemorrhage  ap- 
peared I  advised  operation.  I  have  witnessed  a 
great  many  bloody  operations,  and  in  my  work 
as  railroad  surgeon  have  seen  many  severe  acci- 
dents, but  I  must  say  that  when  the  abdomen 
was  opened  in  this  case  and  the  blood  gushed 
out  it  was  the  most  formidable  operation  I  have 
ever  seen.  I  saw  the  patient  to  day  and  she  is 
entirely  healed  and  well,  though  she  is  pale  from 
the  severe  loss  of  blood.  She  went  out  to  the 
ta'ile  and  ate  with  the  family  to-day  for  the  first 
time,  three  weeks  after  the  operation. 

Dr.    I.    N.   Bloom  :  Had  the  symptoms  been 


i89i.] 


SOCIETY  PROCEEDINGS. 


495 


more   pronounced  the   night  you   first   saw  her 
would  you  not  have  operated  immediately5 

Dk.  McMiktry:  Operation  would  have  been 
immediately  done  had  the  diagnosis  been  abso- 
lutely positive.  That  is,  of  course,  impossible  be- 
fore the  abdomen  is  opened. 

Dr.  J.  A.  OrcHTERi.ONY  :  I  do  not  know  when 
I  have  seen  a  specimen  and  heard  a  repo; -1 
teresting  and  of  such  great  practical  importance 
as  this.  It  brings  vividly  to  my  mind  a  number 
of  cases  I  have  seen  during  the  past  thirty  years, 
which  were  diagnosticated  by  myself  and  others 
with  whom  I  was  a-sociated  as  pelvic  hsem- 
atocele,  and  at  the  same  time  there  was  always 
something  inadequate  in  the  diagnosis,  and  it 
seemed  incomprehensible  why  there  should  be 
such  terrific  haemorrhage  and  such  profound 
shock.  It  is  a  great  satisfaction  to  know  that 
light  has  been  shed  upon  this  important  and  peril- 
ous condition,  and  that  we  can  predicate  accur- 
ately the  pathological  condition.  Cases  that  for- 
merly were  considered  to  be  cases  of  haematocele 
are  now  known  to  be  ruptured  ectopic  pregnancy. 
A  most  pleasant  reflection  is  the  fact  that  these 
cases  can  be  so  successfully  managed  by  prompt 
surgical  interference.  It  gives  confidence  and 
hope  to  the  medical  attendant,  and  it  is  a  warn- 
ing, and  a  solemn  one,  to  lose  no  time  in  adopt- 
ing the  prompt  course  of  procedure  taken  in  the 
case  just  reported. 

Dr.  F.  Leber  :  Many  cases  of  haematocele  re- 
cover by  absorption,  without  operative  inter- 
ference. 

Dr.  McMurtry:  When  rupture  occurs  through 
the  free  surface  of  the  tube  it  is  a  deadly  acci- 
dent from  haemorrhage  unless  treated  by  surgical 
means.  If  the  rupture,  however,  takes  place 
into  the  folds  of  the  broad  ligament  the  effusion 
may  become  absorbed,  or  the  foetus  may  develop 
there,  forming  abdominal  pregnancy  and  going 
on  to  and  beyond  full  term.  The  foetal  mass  may 
break  down  and  suppurate,  discharging  through 
the  rectum  or  the  bladder.  In  any  contingency 
the  safest  result  is  secured  by  abdominal  section. 
There  is  less  danger  in  abdominal  section  accord- 
ing to  modern  methods  than  by  taking  the  risk 
of  these  several  terminations. 

Dr.  T.  P.  Satterwhite  :  It  is  the  first  speci- 
men of  the  kind  I  have  ever  seen.  I  agree  with 
the  essayist  that  it  is  an  exceedingly  difficult  mat- 
ter to  diagnose  absolutely  that  condition  of  things. 
In  several  cases,  which  I  have  seen  with  Dr.  Mc- 
Murtry. I  considered  his  advice  to  open  the  ab- 
domen unwise,  but  in  every  instance  have  been 
convinced  that  it  was  the  correct  course  to  pursue. 

Dr.  F.  Leber  :  I  was  asked  to  see  a  young 
man  who  was  injured  out  West.      It  was 

A  CASE  OF  CRUSHED    FOOT. 

When  he  arrived  at  his  home  in  Louisville  he 
had  been  treated  for  three  weeks.     The  foot  was 


in  a  very  bad  condition,  and  I  advised  amputa- 
tion above  the  ankle  joint.  This  was  refused, 
and  the  case  was  treated  by  another  physician. 
I  was  again  asked  to  see  him,  and  again  suggest- 
ed amputation,  which  was  refused.  I  report  this 
case  to  say  that  in  my  opinion  in  all  such  cases 
amputation  should  be  done  above  the  ankle-joint. 
In  my  opinion  Chopart's  amputation  has  never 
been  satisfactory.  I  recall  to  mind  a  case  left  in 
my  care  by  the  late  Dr.  Cowling,  in  which  Cho- 
part's amputation  was  done.  It  left  a  miserable 
pointed  stump.  I  treated  it  for  months  with  va- 
rious devices,  but  never  succeeded  in  getting  a 
good  stump.  I  was  compelled  finally  to  ampu- 
tate. My  experience  during  the  war  convinced 
me  that  none  of  these  operations  below  the  ankle 
gave  such  good  results  as  amputating  above  the 
ankle. 

Dr.  J.  W.  Guest  (by  invitation)  :  I  had  two 
cases  of  this  description  in  the  hospital.  Both 
healed  by  primary  union  and  were  discharged  at 
the  end  of  one  month.  It  seems  to  me  that  in 
doing  Chopart's  amputation  you  save  the  ankle- 
joint  as  a  natural  joint,  which  is  better  than  an 
artificial  one.  At  each  of  these  operations  tenot- 
omy was  performed  to  prevent  the  stump  from 
pointing.  My  experience  with  Chopart's  opera- 
tion has  confirmed  that  operation  in  my  confi- 
j  dence.  It  gives  a  good  solid  base  for  a  foot  in- 
dependent of  any  artificial  foot. 

Dr.  I.  N.  Bloom  :  I  wish  to  make  a  report  ot 
a  case,  although  one  case  can  not  determine  the 
method  of  treatment  for  a  given  disease.  I  re- 
cently had 

A  CASE  OF  SWEATING  OF  THE  FEET. 

The  means  I  employed  in  this  case  were  very 
simple.  I  had  the  patient  bathe  the  feet  in  a  so- 
lution of  bichloride  of  mercury,  i  to  i.ooo,  morn- 
ing and  evening.  After  rubbing  the  surface  care- 
fully so  as  to  remove  the  dead  epidermis  macera- 
ted by  the  sweat,  I  directed  the  following  course, 
which  is  partly  though  not  wholly  original.  I 
had  a  plaster  sole,  partly  soaked  in  a  bichloride 
solution,  put  in  the  shoe,  the  solution  being  i  to 
1,000.  After  drying  the  sole  and  placing  it  in 
the  shoe,  I  sprinkled  it  with  powdered  boric  acid. 
As  regards  the  advantage  of  this  method  of  treat- 
ment, there  is  much  diversity  of  opinion.  In  this 
case  the  result  was  quite  satisfactory.  If  this 
treatment  were  uniformly  successful  it  would  point 
to  a  microorganismic  origin  for  the  disease  rather 
than  a  neurological.  My  experience  has  been 
too  short  to  determine,  but  this  I  know,  that  in 
many  cases,  especially  of  the  lighter  forms,  it  is 
of  nervous  origin.  I  have  always  found  it  much 
easier  to  cure  simple  hyperidrosis  of  the  feet  than 
of  the  hands,  and  have  found  that  Hebra's  method 
with  diachylon  ointment  is  the  only  one  promis- 
ing any  hopes  of  success.  I  have  tried  many 
other  means  recommended  by  worthy  men,  but 


496 


DOMESTIC  CORRESPONDENCE. 


[April  4, 


always  had  to  return  to  the  diachylon.  The  in- 
convenience of  this  latter  method  is  great,  but 
patients  bear  it,  or  will  bear  any  treatment  that 
will  help  to  get  rid  of  the  disagreeable  disease. 
This  is  especially  true  of  women. 

Dr.  Wm.  Cheatham  :  I  have  seen  recently 
three  cases  of  congenital  pharyngeal  fistula.  They 
all  opened  on  the  left  side  of  the  larynx.  Col- 
ored fluid,  such  as  the  methyl-violet  solution,  in- 
jected into  the  fistula,  passes  into  the  pharynx  ; 
a  peculiar  viscid  fluid,  with  air  bubbles,  escapes 
when  pressure  is  made  on  the  tract.  These  cases 
are  very  difficult  to  heal,  as  the  course  of  the  fis 
tula  is  so  sinuous,  and  the  healing  must  com- 
mence at  the  pharyngeal  end  ;  the  best  method 
to  close  them  is  by  the  galvano-cautery  wire. 


DOMESTIC  CORRESPONDENCE. 


LETTER  FROM  BALTIMORE. 


REGULAR 


The  Winter  Course  of  Lectures  at  Johns  Hopkins 
Hospital — Professor  Welch  on  the  Etiological  Rela- 
tionship of  the  Klebs-Lwjjter  Bacillus  to  Diphtheria 
— Professor  Osier's  Researches  upon  the  Amccba 
Coli — The  District  Club — Miscellaneous  Items. 

Among  the  special  courses  given  this  winter  at 
the  Johns  Hopkins  Hospital  are  the  following : 
"  Valvular  Diseases  of  the  Heart  "  and  "  Practi- 
cal Aspects  of  Cerebral  Localization,"  by  Prof. 
Osier ;  "  The  Pathology  of  Bright's  Disease,"  by 
Prof.  Councilman;  "The  Historical  Development 
of  Bacteriology  "  and  "The  Development  of  Mod- 
ern Views  on  Immunity,"  by  Dr.  Abbott;  "Spe- 
cial Subjects  in  Bacteriology,"  including  "The 
Relation  of  Bacteria  to  the  Infection  of  Wounds," 
by  Prof.  Welch,  and  special  subjects  connected 
with  mental  disease,  gynecology  and  surgery,  by 
Professors  Hurd,  Kelly  and  Halstead. 

Contrary  to  the  views  of  J.  Lewis  Smith,  that 
"the  Klebs-Lceffler  bacillus  has  no  more  signifi- 
cance as  a  cause  of  diphtheria  than  the  micrococ- 
cus of  Oertel,"  and  of  Oertel,  who  "admits  that 
the  theory  that  diphtheria  is  due  to  bacteria, 
though  plausible,  is  not  proved  "  (Keating's  Cy- 
clopaedia of  Diseases  of  Children,  Vol.  i,  p.  587, 
etc.),  Professor  Welch  considers  the  evidence  of 
the  etiological  relationship  of  this  microorganism 
to  diphtheria  as  now  complete.  He  finds  it  al- 
ways present  in  examination  of  the  pseudo-mem- 
brane, and  he  has  isolated,  cultivated  and  success- 
fully inoculated  it  upon  animals.  To  all  appear- 
ances, the  membrane  to  which  it  gives  rise  is 
identical  with  that  from  which  the  infecting  ma- 
terial was  obtained.  The  bacillus  in  question,  a 
rod-shaped  organism,  of  about  the  same  length 
as  the  bacillus  tuberculosis  but  twice  its  thick- 
ness, is  motionless,  does  not  form  spores,  is  nota- 


ble for  variety  of  shape,  being  sometimes  clubbed 
or  pear-shaped,  sometimes  of  a  dumb-bell  form, 
and  sometimes  swollen  in  the  middle.  Often  it 
is  dotted,  suggesting  spores,  but  the  effect  ot 
moderate  heat  upon  these  dots  shows  that  they 
have  not  the  vitality  of  spores.  The  fact  that  the 
bacillus  has  been  discovered  in  other  affections, 
as  measles  and  scarlet  fever,  and  even  very  ex- 
ceptionally in  the  mouth  in  health,  upon  which 
so  much  stress  has  been  laid,  offers  no  obstacle, 
in  Prof.  Welch's  view,  to  its  acceptance,  for  ruany 
facts  show  that  something  more  is  required  than 
the  bacillus,  viz.:  an  abrasion  or  a  catarrhal 
condition  of  the  mucous  membrane.  Without 
some  such  favoring  condition,  the  bacillus  will 
not  gain  an  entrance  and  find  a  nidus  for  its  lodg- 
ment and  development.  Prof.  Welch  gave  mi- 
nute directions  for  taking  the  membrane  from  the 
throat  for  examination  and  for  the  cultivation  of 
the  organism.  He  laid  great  stress  upon  the  value 
of  such  examination  for  diagnosis,  considering  it 
to  be  the  duty  of  every  physician  to  fit  himself 
for  making  it  whenever  the  occasion  requires. 

Prof.  Osier  continues  his  researches  upon  the 
amoeba  coli,  and  a  short  time  ago  exhibited  mi- 
croscopic specimens  from  his  tenth  case.  Hun- 
dreds of  these  giant  amoebae,  which  are  nine  or 
ten  times  as  large  as  the  white  blood  corpuscles, 
were  seen  upon  the  slide,  undergoing  continual 
change  of  shape.  The  last  nine  cases  were  in- 
digenous. In  more  than  one  he  was  able  to  make 
the  diagnosis  of  abscess  of  the  liver  with  perfora- 
tion into  the  lung,  merely  from  finding  the  or- 
ganism in  the  sputa.  Such  sputa  present  a  very 
characteristic  appearance,  he  says. 

The  Historical  Club  at  the  Hopkins  continues 
to  be  well  attended  and  to  present  interesting  pro- 
grammes. Many  outside  physicians  interested 
in  such  subjects  attend  its  meetings.  In  a  sketch 
of  John  Archer,  M.B.,  by  Dr.  J.  M.  T.  Finney, 
the  following  interesting  account  of  the  circum- 
stances attending  the  awarding  of  the  first  medi- 
cal diploma  in  America  is  given:  "In  June, 
1768,  at  the  Commencement  of  the  College  of 
Philadelphia,  afterwards  the  University  of  Penn- 
sylvania, medical  degrees  were  conferred  for  the 
first  time  in  the  New  World.  On  that  occasion 
there  were  ten  candidates  for  degrees,  their  names 
being  Archer,  Carroll,  Duffield,  Potts,  Elmer, 
Fullerton,  Jackson,  Lawrence,  Tilton  and  Way. 
At  that  time,  seven  years  before  the  War  of  In- 
dependence, the  feeling  among  many  of  the  col- 
onists was  still  strongly  in  favor  of  the  mother 
country  on  all  occasions.  Among  their  number 
were  the  faculty  of  Philadelphia  College,  all  of 
whom  had  received  their  medical  education  in 
England.  Immediately  a  controversy  arose  as  to 
who  should  receive  the  first  medical  diploma  on 
this  side  of  the  ocean.  The  faculty,  animated 
by  the  feelings  alluded  to,  declared  their  inten- 
tion of  conferring  it  upon  the  only  Englishman 


189I-] 


DOMESTIC  CORRESPONDENCE. 


497 


among  the  candidates—  Potts  by  name.  The 
other  candidates  protested  ;  still  the  faculty  would 
not  yield.  But  the  former,  who  had  already 
passed  their  examination,  demanded  unanimous- 
ly, with  the  single  exception  of  the  Englishman, 
certificates  of  their  having  so  passed,  at  the  same 
time  expressing  their  determination  to  repair  at 
once  to  Princeton,  present  their  certificates  to  the 
faculty  there  and  request  diplomas  from  them. 
The  idea  of  losing  nine  out  of  ten  members  of 
this,  their  first  graduating  class,  was  a  little  more 
than  the  faculty  could  stand,  so  they  agreed  finally 
to  let  the  young  rebels  arrange  the  matter  among 
themselves,  whereupon  they  agreed  to  receive 
their  diplomas  in  alphabetical  order,  except  that 
the}'  generously  allowed  the  Englishman  to  come 
fourth  in  order,  whereas  a  strictly  alphabetical 
arrangement  would  have  placed  him  eighth  in  the 
list.  As  Dr.  A.'s  name  headed  the  list,  he  was 
the  first  of  the  candidates  to  receive  his  diploma. 
In  the  published  history  of  the  University,  the 
list  of  graduates  is  printed  in  the  order  given 
above.  The  Princeton  College  and  Philadelphia 
Medical  College  diplomas  of  this  quite  remark- 
able man  are  to  be  seen  at  the  Medical  Library 
room  in  this  city,  also  his  old  mortar,  medical 
ledgers  and  a  pocket-case  of  silver-mounted  sur- 
gical instruments  which  he  used  in  his  practice, 
as  well  as  the  proceedings  in  manuscript  of  the 
Hartford  Count}'  Medical  Society,  held  in  his  of- 
fice in  old  Medical  Hall  over  a  hundred  years 
ago." 

Dr.  Osier  spoke  of  the  first  American  surgery, 
published  in  1776,  and  of  its  author,  Dr.  John 
Jones,  who  died  in  1791  in  Philadelphia.  It  was 
used  as  a  manual  by  the  medical  officers  during 
the  Revolution.  Dr.  Hoch  gave  extracts  from  the 
•'  Ebers  Papyrus,"  the  oldest  medical  writing  ex- 
tant. It  was  written  in  the  Coptic  language,  aud 
was  discovered  in  Egypt.  It  is  preserved  in  the 
library  at  the  University  of  Leipzig,  stretching 
through  two  rooms,  and  is  covered  with  glass  for 
protection.  It  is  still  neat  and  clean.  Its  only 
medical  value  appears  to  be  its  antiquity.  Dr. 
Kelly  drew  attention  to  a  trial  for  witchcraft  for 
deformed  genitals,  which  took  place  in  Virginia 
in  1705,  aud  is  given  in  "Howe's  History  of 
Virginia  ;  "  he  believed  it  to  be  the  only  case  of 
the  sort  reported  in  the  Southern  States. 

Dr.  John  N.  Mackenzie  reported  recently  a  case 
of  tuberculosis  of  the  lip  in  a  negro,  aged  35. 
The  man  first  noticed  an  ulcer  on  the  centre  of 
the  lower  lip  four  months  before  he  cafne  under 
notice,  having  previously  suffered  from  symptoms 
of  pulmonary  and  laryngeal  trouble.  One  month 
later  he  had  noticed  another  ulcer  at  the  right 
angle  of  the  mouth,  extending  slowly  and  in- 
vading the  inner  surface  of  the  cheek.  When  he 
came  under  notice  (he  was  seen  at  the  dispensary 
only  twice,  as  he  died  shortly  after),  the  central 
ulcer  was  slightly  less  in  size  than  a  silver  quar- 


ter, it  was  granular,  oval,  on  one  side  shading  off 
into  the  surrounding  tissues,  and  on  the  other 
presenting  a  more  or  less  clearly  marked  beveled 
border  ;  its  base  consisted  of  flabby  granulations, 
some  resembling  small  tubercles,  was  covered 
with  muco-pus,  and  had  a  worm-eaten  appear- 
ance. The  other  ulcer  presented  similar  appear- 
ances. The  lip  was  swollen  to  three  or  four  tunes 
its  normal  size.  The  tuberculous  nature  ol  the 
ulcer  was  confirmed  by  microscopic  examination. 
The  larynx  showed  the  usual  signs  of  tubercu- 
lous disease.  The  great  variety  of  these  case-  was 
pointed  out:  of  114  cases  of  buccal  tuberculosis 
collected  by  Delavan,  in  1886.  only  two  were 
seated  on  the  lip.  H.  Mackenzie,  of  Edinburgh, 
refers  to  a  third,  a  fourth  was  seen  in  Vienna. 
but  not  reported,  and  Prof.  Welch  had  met  with 
a  fifth.  As  pointed  out  by  Prof.  Welch,  it  is  pos- 
sible that  some  of  the  cases  reported  as  epitheli- 
oma of  the  mouth  were  of  this  nature. 

Dr.  Charles  E.  Simon,  Assistant  Physician  at 
the  Hopkins  Hospttal,  having  tested  the  urine  in 
almost  even-  case  occurring  in  that  institution, 
and  also  cases  in  health,  has  not  obtained  Ehr- 
lich's  test  (the  so  called  diazo-reaction)  in  any 
cases  except  phthisis  and  typhoid  fever.  Conta- 
gious diseases  were  not  included  in  his  researches. 

A  department  for  teaching  the  science  and 
practice  of  invalid  cooking  has  been  organized  in 
the  Johns  Hopkins  Hospital  Training  School  for 
Nurses,  under  Miss  Hampton,  the  Superintend- 
ent. A  competent  teacher  was  secured  from  the 
Boston  Cooking  School.  Two  pupils  are  sent 
to  her  for  a  month  at  a  time  and  their  hours 
of  duty  are  from  7:30  a.m.  to  5.30  p.m.  The 
chief  portion  of  the  instruction  is  given  in  the 
cooking  school  kitchen  which  is  in  a  room  con- 
venient to  the  wards.  The  method  of  preparing 
about  1 50  different  articles  of  sick  diet  is  taught 
during  the  month,  and  all  the  beef  tea,  chicken- 
broth  and  mutton-broth  for  the  use  of  the  hospital 
are  made  each  morning  by  the  pupils.  Theoreti- 
cal instruction  by  lectures  is  given  in  the  after- 
noon. Each  pupil  is  required  to  give  a  practical 
test  of  her  proficiency  at  the  end  of  her  month  by 
preparing  as  large  a  number  of  dishes  without  aid 
from  her  teacher  or  notes  as  possible.  There  are 
also  oral  and  written  examinations.  The  approx- 
imate cost  of  establishing  and  providing  such  a 
school  for  the  first  year  is  $600,  after  that  $500  or 
less.  Itemised,  the  expenses  are  :  complete  out- 
fit of  utensils,  $70;  range,  $20;  tables  $8;  dresser, 
$3;  china  closets,  $3;  sink,  S15;  other  details.  $5; 
teacher's  salary,  S30  per  month;  cost  of  teaching 
material  per  month.  So  to  SS:  fuel,  51.50.  The 
school  has  been  working  for  six  months  and  its 
value  has  been  demonstrated. 

The  University  of  Maryland  Training  School 
for  nurses  is  in  a  flourishing  condition,  under  the 
able  direction  of  Miss  Parsons,  Superintendent, 
an  English  nurse  trained  at  St.  Thomas'  Hospital, 


498 


DOMESTIC  CORRESPONDENCE. 


[April  4, 


London,  and  in  the  Egyptian  campaign  under 
General  Wolseley.  She  was  decorated  by  the 
Queen  with  the  royal  red  cross.  It  was  estab- 
lished primarily  to  supply  nurses  to  take  the 
place  of  the  Sisters  of  Mercy,  who  left  the  Uni- 
versity Hospital  two  years  ago,  and  the  present 
class  (the  second)  consists  of  twenty  students.  A 
concert  and  tea  were  tendered  to  the  nurses  on 
the  25th  ult.  by  the  wives  of  the  members  of  the 
medical  faculty.  Notwithstanding  the  unfavora- 
ble weather,  a  large  and  distinguished  company 
assembled,  comprising  many  of  the  elite  of  the 
city.  The  interior  of  the  hospital  was  beautifully 
decorated  with  potted  plants,  and  the  whole 
building  with  its  bright  and  cheerful  rooms,  and 
its  spotlessly  clean  corridors  was  thrown  open  for 
inspection.  In  the  nurses'  sitting-room  a  table 
was  spread  with  good  things,  lit  up  by  wax  candles 
in  shining  candelabra  and  under  yellow  shades. 
After  addresses  by  Prof.  Chew  and  Miss  Parsons, 
outlining  the  work  and  methods  of  the  hospital 
and  training  school,  a  delightful  musical  pro- 
gramme was  rendered  by  several  of  our  best  vo- 
calists, including  two  of  the  alumni  of  the  Uni- 
versity, Drs.  Hopkinson  and  Sanchez.  The  es- 
tablishment and  success  of  this  school  have  been 
most  gratifying  to  the  authorities  of  the  Univer- 
sity; it  not  only  supplies  the  nursing  service  of 
the  hospital  in  the  most  effective  manner,  but 
promises  likewise  to  supply  a  much-felt  want  in 
the  community.  The  nurses  have  a  thorough 
training  both  in  the  general  and  in  the  Free- 
Lying-In  Hospital  of  the  University  near  by. 

On  Thursday,  January  15th,  in  the  presence  of 
a  number  of  city  officials  and  several  members  of 
the  medical  profession,  the  new  morgue  was  turn- 
ed over  to  the  Health  Commissioner  by  the  In- 
spector of  buildings.  Dr.  Rohe,  Health  Com- 
missioner, made  an  address  in  which  he  stated 
that  the  small  amount  which  had  been  appropri- 
ated ($4000)  had  been  judiciously  spent,  after  due 
examination  of  similar  structures  elsewhere,  and 
he  did  not  believe  there  was  a  building  in  the 
country  better  adapted  for  the  purpose  of  a 
morgue  than  this  one.  It  has  an  office,  an  in- 
quest room,  a  cold  storage-room  containing  a 
refrigerator  capable  of  accommodating  five  bodies, 
an  autopsy  room,  a  room  for  surgeon's  instru- 
ments, a  cabinet  room  for  the  effects  of  the  de- 
ceased, an  elevator,  closets,  etc.  A  lunch  was 
served  at  the  close  of  the  exercises.  The  cause 
of  the  medical  education  of  women,  which  re- 
ceived such  an  impulse  by  the  action  of  the  Johns 
Hopkins  Hospital  authorities,  has  been  further 
strengthened  by  the  able  advocacy  of  Cardinal 
Gibbons,  the  Roman  Catholic  Archbishop  of 
Baltimore.  In  a  letter  recently  published,  he 
-ays  there  is  no  obstacle  in  ecclesiastical  or  cation 
law  to  the  study  and  practice  of  medicine  by 
women.  "I  do  not  hesitate  to  say,"  he  says, 
"  with  due  deference  to  the  judgment   of  others! 


that  in  my  opinion  it  is  important  to  the  well-be- 
ing of  society  that  the  study  of  medicine  by 
Christian  women  should  be  continued  and  ex- 
tended. The  difficulties  that  are  said  to  attend 
their  pursuing  the  necessary  studies  in  the  same 
schools  with  men  may  be  obviated  by  judicious 
precautions,  and  these  difficulties  should  not  de- 
bar women  from  the  profession  of  medicine.  The 
prejudice  that  allows  women  to  enter  the  profes- 
sion of  nursing  and  excludes  them  from  the  pro- 
fession of  medicine  cannot  be  too  strongly  cen- 
sured. ' ' 

The  annual  reports  for  1890  of  our  two  special 
Eye  and  Ear  Hospitals— the  Presbyterian,  and 
the  Baltimore  Eye,  Ear  and  Throat  Charity  Hos- 
pitals, were  published  in  January.  In  the  former, 
which  is  much  the  larger,  being  supported  with 
zeal  and  liberality  by  the  large  and  wealthy  Pres- 
byterian denomination  of  this  city,  there  were 
9096  entries,  with  an  average  work-day  attend- 
ance of  115;  1,517  operations  were  performed  and 
586  patients  were  treated  in  the  wards  averaging 
9  days  for  each.  In  the  other  institution,  now 
in  its  9th  year,  2,620  patients  were  treated;  971  of 
these  were  colored  and  1,649  white;  1,632  were 
eye  cases,  414  ear,  and  599  throat  cases;  226  op- 
erations were  performed.  The  dispensary  recorded 
8,329  visits. 

A  course  in  hygiene  is  being  conducted  and 
will  continue  through  the  spring  at  the  Johns 
Hopkins  Hospital,  under  the  direction  of  Drs 
John  S.  Billings  and  Alex.  C.  Abbott,  the  latter 
assistant  in  bacteriology  and  hygiene;  it  consists 
of  lectures  and  laboratory  work,  and  embraces 
studies  and  investigations  in  the  hygiene  of  atmos- 
phere, water,  ground,  milk,  meat,  heating,  venti- 
lation, disinfection,  building  material  and  cloth- 
ing. It  is  announced  that  Dr.  Abbott  has  re- 
ceived and  will  accept  a  call  to  the  hygienic  labor- 
atory of  the  University  of  Pennsylvania. 

The  Academy  of  Medicine  of  Baltimore  is  de- 
funct. Instituted  in  May,  1877,  by  a  number  of 
the  older  physicians  of  the  city,  it  began  an  un- 
popular career  by  requiring  that  candidates  for 
membership  should  have  been  ten  years  in  prac- 
tice. Later  it  relaxed  so  far  as  to  "permit  those 
excluded,  to  enter  upon  the  presentation  of  an 
acceptable  thesis.  A  few  availed  themselves  of 
this  privilege  to  become  members,  but  the  society 
never  was  vigorous,  and  ultimately  perished  for 
the  want  of  that  young  and  working  element  of 
which  it  had  voluntarily  deprived  itself.  There 
were  those  who  thought  that  had  it  begun  by  re- 
quiring of  all  its  candidates  without  regard  to  age, 
theses,  the  result  would  have  been  different. 

At  recent  elections  held  in  our  several  societies, 
the  following  were  chosen  presidents:  Gvneco- 
logicaJ  and  Obstetrical,  Dr.  Henry  M.  Wilson; 
Medical  Association,  Dr.  J.  Edwin  Michael;  Med- 
ical  and  Surgical  Society,  Dr.  David  Street. 
A  change  in  the  editoral  management  of  the 


iSyl.J 


BOOK  REVIEWS. 


499 


Maryland  Medical  Journal  places  Prof.  J.  Edwin  j  States,  the  Report  shows  the  marked  changes  for 


Michael  in  charge  of  that  journal,  whilst  the  re- 
tiring editor,  Dr.  Wm.  B.  Canfield,  assumes 
charge  of  our  new  journal,  the  Baltimori  Medical 
and  Surgical  Record.      Dr.    Michael  is  one  of  our 


the  better  that  have  taken  place  in  the  past  ten 
years,  and  it  is  seen  that  more  progress  will  be 
made  within  the  next  two  years.  Most  of  the 
changes  for  the  better  that  have  been  made  in 


best  writers  and  speakers,  and  is  energetic,  cou-  this  century  have  occurred  since  1881,  when  the 
rageous  and  talented.  His  appointment  promises  first  number  of  this  Report  was  published,  and 
well  for  the  future  of  the  journal.  since   1882-83,  when  the  schedule  of  minimum 

To  the  Alumni  of  the  University  of  Maryland,  requirements  of  the  Illinois  State  Board  of  Health 
scattered  far  and  wide,  it  will  be  of  interest  to!  went  into  effect.  In  18S2  only  45  colleges  in  the 
learn  that  the  present  class  of  the  old  school  have1  United  States  and  Canada  required  educational 
adopted  maroon  and  black  as  the  University  col-  qualifications  for  matriculation  ;  now  the  number 
ors,  and  a  yell — "Rah!  Rah!  Ree  !  U-ni-V  of  is  129.  Of  the  148  medical  colleges  123  now 
M.D.  Rah!"  teach  hygiene  and   119  teach   medical  jurispru- 

Although  the  Koch  lymph  has  been  used  in  I  dence.  In  1882  these  branches  were  taught  in 
our  four  principal  hospitals,  no  results  have  been !  52  and  61  colleges,  respectively.  In  1882-83  tne 
made  known  as  far  as  I  have  seen  except  those  at  j  average    length   of  the    lecture   terms    was  23.5 


the  Hopkins.  Whilst  the  expressions  of  the  Hop- 
kins staff  are  reserved,  they  are  decidedly  favora- 
ble.    More  time  is  evidently  required  to  know 


weeks;  the  average  is  now  26.3  weeks.  There 
are  now  1 1 1  colleges  that  have  lecture  terms  of  6 
months  or  more,  while  in  1882-83   tne  number 


the  true  value  of  the  method,  and  the  cautious  was  42.  A  table  shows  the  results  of  the  exam- 
utterances  of  Dr.  Osier  and  his  associates  cannot  j  inations  before  the  State  Boards  of  Medical  Ex- 
but  elicit  our  commendation.  Prof.  Osier  met  j  aminers  of  Alabama,  Minnesota,  Xew  Jer-ey, 
with  one  case,  where,  although  there  were  bacilli  North  Carolina,  South  Carolina  and  Virginia, 
in  the  sputa,  and  other  evidences  of  phthisis,  there  since  the  dates  of  their  organization.  Another 
was  no  reaction  after  injections  of  0.003  mS-  of' table  shows  the  results  of  the  Prussian  State  Ex- 
the  fluid.  aminations  in  1890. 

According  to  the  figures  of  the  Federal  Census  :  Special  attention  is  called  to  the  fact  that  in 
taken  last  June,  Baltimore  then  had  434,439  in- j  some  of  the  largest  universities  in  this  country- 
habitants;  the  police  census  taken  in  November  courses  preliminary  to  the  study  of  medicine  are 
made  it  455,427.  the  increase  in  ten  years  was  now  offered — the  University  of  Pennsylvania, 
101,838  or  30.34  per  cent.;  about  one  fourth  of  Cornell.  Yale,  Princeton,  Lake  Forest  and  North- 
this  increase  was  derived  from  annexing  two  miles  western  Universities,  Johns  Hopkins  and  the  Uni- 
of  territory  on  the  north  and  west  of  the  city,  versity  of  Wisconsin,  while  Harvard  has  made 
During  the  same  period  the  per  cent,  of  increase  j  arrangements  by  which  those  intending  to  study 
in  the  State  at  large  was  only  11.28.  The  city  medicine  can  take  a  special  A.  B.  course  in  three 
has  been  steadily  gaining  on  the  State  ever  years.  The  course  offered  by  the  University  of 
since  the  first  census  in   1790;  at  that  time,   it   Wisconsin   is   fully  outlined,  as  is  the   one  that 


had  only  4.22  of  the  State's  population,  whereas 
in  1890  it  had  41.73  per  cent.  e.  f.  c. 


BOOK  REVIEWS. 


was  proposed  by  the  Medical  Department  of  the 
University  of  Michigan,  but  was  rejected  by  the 
joint  faculties.  The  Report  shows  a  marked  in- 
crease in  requirements  as  to  preliminary  educa- 
tion during  the  year  1890.  It  shows  also  that 
the  movement  for  four  years'  study  and  three 
courses  of  lectures  is  an  assured  success,  and  a 
I  list  is  given  of  the  colleges  that  have  adopted  or 
Illinois  State  Board^  of  Health.     Seventh   will  soon  adopt  the  requirements  of  longer  terms 


Report  on  Medical  Education,  Medical  Col- 
leges, and  the  Regulation  of  the  Practice  of 
Medicine  in  the  United  States  and  Canada, 
1765-1891.     Medical  Education  and  the  Regu- 


of  study. 

Several  State  Boards,  having  authority  similar 

to  the  Illinois  Board,  have  already  adopted  the 

requirement  in  this  respect,  and  those  that  have 

lation   of  the  Practice  in    Foreign   Countries.    not  aireadv  done  so,  will  in  a  short  time  cooperate 

By  John-  H.  Ratjch,  M.D.,  Secretary.  1S91.        in  the  movement.     The  potency  of  this  factor  will 

For  the  first  time  in  its  history  the  Report  on !  be  appreciated  when  it  is  considered  that  these 

Medical   Education,  issued  by  the   Illinois  State  j  boards  directly  control  the  recognition  of  diplo- 

Board   of  Health,  embraces  the   medical  institu- 1  mas  in  an  area  embracing  about  41,000,000  peo- 

tions  of  the  whole  world.     This  is  a  feature  that ,  pie,  and  indirectly  in  almost  the  entire  area   of 

will  be  an  assistance  to  medical  boards  that  have   the  United  States ;  and  that  a  number  of  them 

to  determine  the  value  and  validity  of  a  medical   exercise  jurisdiction  in  the  new  States  and  Terri- 

diploma.  tories. 

As  regards  medical   education   in  the   United  j      It  is  suggested  in  the  Report  that,  with  four 


500 


ASSOCIATION  NEWS. 


[April  4. 


years'  study  and  three  courses  of  lectures  assured, 
the  boards  of  medical  examiners  and  the  colleges 
should  cooperate  in  establishing  a  system  of  reg- 
istration of  medical  students  before  they  enter 
college,  in  order  that  the  requirement  of  one  year 
of  study  outside  a  college  may  not  be  a  mere  form. 

A  correct  resume  of  the  Medical  Practice  Acts 
in  the  different  States  and  Territories  is  a  valua- 
ble addition  to  the  Report.  Comprehensive  tables 
show  the  progress  made  towards  higher  medical 
education  in  the  past  ten  years,  with  the  numbers 
of  matriculates  and  graduates  for  each  year,  and 
the  percentage  of  graduates  to  matriculates.  These 
tables  show  the  effect  of  the  schedule  of  minimum 
requirements  of  the  Illinois  Board  after  the  ses- 
sion of  1882-83.  In  1882-83  the  total  number 
of  medical  students  in  the  United  States  was  12,- 
274,  while  in  1884-85  it  was  10,987;  and  the 
12,000  mark  was  not  reached  again  until  1887- 
88.  The  percentage  of  graduates  to  matriculates 
in  the  United  States  has  fallen  from  35.8  in  188 1 
-82  to  30.1  in  1890.  The  percentage  in  Canada 
has  not  reached  24  in  ten  years. 

That  portion  of  the  Report  devoted  to  institu- 
tions and  regulations  in  foreign  countries  contains 
in  full  the  requirements  of  the  examining  boards 
in  Great  Britain,  with  the  names  of  all  the  medi- 
cal schools  and  of  all  the  hospitals  in  which  in- 
struction is  given.  The  requirements  as  to  pre- 
liminary education  in  foreign  countries  are  given 
for  purposes  of  comparison,  as  well  as  the  require- 
ments for  graduation  and  for  the  license  to  prac- 
tice. The  course  of  study  and  the  semesters  in 
which  the  various  subjects  should  be  taken  up, 
as  advised  in  the  German  universities,  as  well  as 
a  description  of  the  German  method  of  examining 
for  the  license  to  practice,  are  given  in  full.  In 
addition,  the  correct  names  and  locations  of  for- 
eign medical  institutions  are  given. 

A  Compend  of  Diseases  of  Children.  Espe- 
cially adapted  for  the  use  of  medical  students. 
By  Marcus  P.  Hatfield,  A.M.,  M.D.,  etc. 
With  a  colored  plate.  Philadelphia:  P.  Blak- 
iston,  Son  &  Co.  1890.  Pp.  185.  $1.00. 
(Quiz-Compends  No.  14.) 

We  have  no  hesitancy  in  saying  that  the  neat 
little  volume  before  us  is  a  succinct  presentation, 
in  a  pleasant  form,  of  many  of  the  diseases  of 
children.  To  say  that  it  is  a  complete  compend 
would  require  the  critic  to  ignore  almost  wholly 
the  existence  of  such  an  important  feature  of  the 
human  economy  as  the  respiratory  system. 

Of  all  the  diseases  of  early  life  a  very  large 
number  belong  to  either  the  digestive  or  respira 
tory  tracts;  yet,  whereas  upwards  of  forty  pages 
are  devoted  to  diseases  of  the  digestive  apparatus, 
it  is  impossible  to  find  spape  given  to  respiratory 
affections — aside  from  two  or  three  pages  upon 
atelectasis  pulmonum  and  asphyxia  neonatorum. 
The  author  must  certainly  have  a  due  apprecia- 


tion of  such  diseases  as  catarrhal  laryngitis, 
pseudo-membranous  laryngitis,  bronchitis,  pneu- 
monitis, pleuritis,  etc.,  and  the  importance  of 
their  intelligent  treatment  at  the  bedside  of  the 
child. 

The  subject  of  intestinal  worms,  also,  remains 
untouched. 


NECROLOGY. 


Professor  Charles  T.  Parkes. 

Charles  T.  Parkes,  Professor  of  Surgery  in  Rush 
Medical  College,  one  of  the  leading  and  most 
popular  surgeons  in  the  United  States,  died  at 
his  home,  No.  51  Lincoln  avenue,  Chicago,  111., 
March  28,  at  3:30  a.m.  Death  resulted  from 
pneumonia  produced  by  an  attack  of  the  "grip," 
the  illness  dating  from  Monday,  March  16. 

Dr.  Parkes  was  born  in  Troy,  N.  Y.,  in  1847. 
He  served  during  the  war  in  an  Illinois  Volunteer 
Regiment,  and  was  mustered  out  as  Captain  in 
1865. 

Entering  upon  the  study  of  medicine  he  at  once 
assumed  a  foremost  position  in  his  classes,  and 
from  i868until  1875  was  Demonstrator  of  Anatomy 
in  Rush  Medical  College.  He  was  then  advanced 
to  the  Chair  of  Anatomy,  which  professorship  he 
held  until  his  appointment  to  the  Chair  of  Sur- 
gery in  the  same  institution,  made  vacant  by  the 
death  of  Prof.  Moses  Gunn.  His  advancement 
in  his  profession  was  phenomenal,  and  this  sud- 
den termination  to  his  brilliant  career  will  bring 
grief  to  the  hearts  of  all  who  knew  him. 

The  family  of  Dr.  Parkes  is  sojourning  in  Eu- 
rope; his  wife  and  only  daughter  being  in  Italy, 
and  his  only  son  in  Paris,  to  whom  the  sad 
news  has  been  cabled.  His  remains  have  been 
placed  in  a  receiving  vault  to  await  their  return. 
This  signal  loss  to  his  city,  to  his  State,  and  to 
the  country  will  be  more  fully  referred  to  when 
by  the  faculty  of  his  college  and  by  the  various 
medical  organizations,  in  which  he  rendered  such 
conspicuous  services,  appropriate  action  shall 
have  been  taken. 


ASSOCIATION  NEWS. 


American  Metlieal  Association. 

The  Forty-second  Session  of  the  American 
Medical  Association  will  be  held  in  Washington, 
D.  C,  on  Tuesday,  Wednesday,  Thursday,  and 
Friday,  May  5th,  6th,  7th,  and  8th,  commencing 
on  Tuesday  at  11  o'clock,  a.  m. 

Section  of  Oral  and  Dental  Surgery. 

The  following  is  a  list  of  Essayists  (with  sub- 
jects), who  have  promised  to  prepare  papers  for 
the  Section  of  Oral  and  Dental  Surgery  : 


i89i.] 


SPECIAL  CORRESPONDENCE. 


501 


Address  of  the  Chairman  of  Section,  Dr.  Eugene  S. 
Talbot. 

"Adenoid  Growth,"  Dr.  \V.  H.  Atkinson. 

"  Treatment  of  Fractures  of  the  Maxilla,"  Dr.  Win. 
Carr. 

"Genesis  of  Contour  Fillings,"  Illustrated.  Dr. 
Geo.  S.  Allan. 

"The  Teeth  of  Invertebrate  Animals,"  Dr.  A.  H. 
Thompson. 

"Some  practical  points  on  the  care  of  Instruments." 
Dr.  Win.  H.  Potter. 

W"  Rheumatic  and  Gouty  Diathesis  as  Manifested  in 
Diseases  of  the  Paridental  Membrane,"  Dr.  John  S.  Mar- 
shall. 

'•  Dental  Infirmary  Patients, — The  Use  and  Abuse  of 
Dental  Charity,"  Dr.  Richard  Grady. 

"  Growth  of  the  Cementum,"  Dr.  R.  R.  Andrews. 

"  Remarks  on  Incipient  Necrosis  and  Caries,"  Dr.  J. 
Williams. 

"Choice  of  Therapeutic  Filling  Materials."  Dr.  W.  A.  ' 
Allport. 

"Thorough  Dentistry  vs.  Partial  Dental  Surgery,"  Dr. 
J.  Y.  Crawford. 

"  Pathological  Conditions  produced  by  Galvanic  action 
between  dissimilar  Metals  in  the  Mouth,"  Dr.  George 
W.  Whitefield. 

Other  members  who  desire  to  read  papers  before 
this  Section,  should  as  required  by  the  By-Laws, 
forward  the  paper  or  its  title  and  length,  to  the 
Chairman,  Dr.  Eugene  S.  Talbot,  125  State  St., 
Chicago,  111.,  one  month  before  the  meeting. 

Henry  \V.  Morgan,  Sec'y. 

Nashville,  March  25,  1S91. 


"The  Prevention  of  Opium  Inebriety,"  by  J.  R.   Matti- 
son,  Brooklyn,  N.  Y. 

"The   Treatment  of  Opium    Neuroses,"    by  Stephen 
Lett,  Guelph,  Canada. 

T.  D.  Crothers,  M.D.,  Chairman, 
HAROLD  N.  MOVER,  M.D.,  Secy,  Hartford,  Conn. 

434  W.  Adams  street,  Chicago. 


SPECIAL  CORRESPONDENCE. 


Preliminary  Announcement  of  Programme  of  the 

Section  of  Neurology  and  Medical  furis- 

prudence. 

"Psychological  Social  Problems,"  by  Daniel  Clark, 
Toronto,  Canada. 

"Status  Epilepticus,"  by  Gros  R.  Trowbridge,  and 
Chas.  B.  Mayberry,  Danville,  Pa. 

"The  Neuroses  from  a  Demographic  Point  of  Yiew," 
by  Irving  C.  Rosse,  Washington.  D.  C. 

"The  Functional  Degeneracy  of  the  Brain,"  by  J.  T. 
Searcy,  Tuscaloosa,  Ala. 

"Diagnosis  of  Traumatic  Lesions  in  the  Cerebro-Spinal 
Axis  and  the  Detection  of  Malingering  Referred  to  this 
Centre,"  by  B.  A.  Watson,  Jersey  City.  N.  J. 

"A  Consideration  of  Traumatic  Lesions  of  the  Spine 
Resulting  from  Railroad  and  Other  Injuries;  Their  Im- 
mediate and  Remote  Results,  Etiology,  Pathology  and 
Diagnosis,"  by  Thos.  H.  Manley.  New  York,  N.  Y. 

General  discussion  of  '  'The  Traumatic  Neuroses  with 
Especial  Reference  to  Railway  Injuries,"  to  be  opened 
by  R.  Harvey  Reed,  Mansfield,  Ohio. 

"Rib-Fracture  in  Insane  Hospitals  in  its  Medico-Legal 
Aspects,"  by  Jas.  G.  Kiernan,  Chicago,  111. 

"Medico- Legal  Investigation  of  Death  by  Yiolence  in 
the  State  of  Massachusetts,"  by  Silas  B.  Presbery.  Taun- 
ton. Mass. 

"A  Medico-Legal  Study  of  Blood  Corpuscles  in  Syph- 
ilis and  Other  Diseases,"  bv  Ephraim  Cutter,  New  York, 
N.  Y. 

"On  What  Constitutes  Reliable  Evidence  in  Trials  of 
Criminal  Poisoning,"  by  John  Reese,  Philadelphia,  Pa. 

"Hallucinations  of  the  Sane,"  by  David  Inglis,  De- 
troit. Mich. 

"Personality  as  it  Effects  Inebriety,"  by  T.  L.  Wright, 
Bellefontaine,  O. 

"Opium  Inebriety,  its  Legal  Recognition  and  Treat- 
ment." by  W.  S    Watson,  Matteawau,  N.  Y. 

"Ether  Inebriety,"  by  Norman  Kerr,  London,  Eng. 


shall  The  Journal  be  Hemoveil  to 
Washington  ? 

ACTION    OK    THE    NORTH     CENTRAL    OHIO    MEDICAL 
SOCIETY. 

The  following  preamble  and  resolution  was  unanimous- 
ly adopted  and  ordered  published  in  The  Journal  at 
the  forty-first  quarterly  meeting  of  the  North  Central 
Ohio  Medical  Society,  held  at  Mansfield,  Ohio,  March 
27,  1S91: 

Whereas,  An  effort  is  being  made  to  remove  The  Jocrnal  of 
the  American  Medical  Association  from  Chicago,  111.,  to  Wash- 
ington, D.  C:  and. 

Whereas.  The  Journal  which  was  born  in  Cleveland.  Ohio, 
has  been  so  well  nurtured  in  Chicago  that  it  has  gTown  from  a  de- 
pendent, unsupporting  infant,  to  an  independent  self-supporting 
adult,  which  commands  the  respect  and  support  of  the  profession 
throughout  the  Continent,  and  now  stands  among  the  first  of  any 
of  its  colleagues  in  America,  and. 

Whereas,  It  has  accomplished  all  this  in  the  short  space  of  seven 
years  through  the  judicious  management  and  untiring  energies  of  its 
Trustees,  Supervising  Editors  and  Business  Manager. 

Therefore,  Be  it  resolved  that  it  is  the  sense  of  the  North  Cen- 
tral Ohio  Medical  Society  in  convention  assembled  this  2-th  day  of 
March.  1S91.  at  Mansfield,  Ohio,  that  it  is  against  the  best  interests 
of  The  Journal  and  the  Association  to  have  it  removed  from  Chi- 
cago to  Washington,  and  hereby  instruct  our  delegates  to  oppose 
such  removal. 

R.  Harvev  Reed.  J.  W.  Craig,  M.  J.  Finlev.  A.  V.  Patterson,  J. 
Harvey  Craig,  W.  H.  Race.  W.  H.  Svkes.  A.  H.  McCullough.  R.  D. 
Sykes,  F.  C.  I.arrimore.  W.  S.  Meeklem.  W.  M.  Miller.  W.  E. 
Loughridge.  Geo.  Mitchell.  Josiah  S.  Hedges. 

Yery  respectfully  submitted, 

R.  Harvey  Reed,  Prest.  J.  S.  Hedges,  Sec'y. 


To  the  Editor: — I  protest  against  using  any  more  of 
the  space  of  The  Journal  discussing  its  removal,  and 
with  S.  E.  Hampton,  M.D.,  of  Kentucky,  move  the  pre- 
vious question.  Am  willing  that  it  should  remain  at 
Chicago,  only  make  a  good  Journal  of  it.  Am  happy  to 
note  improvement.  L.  M.  Gates.  M.D. 

Scrantoa,  Pa.,  March  23,  1S91. 


To  the  Editor: — As  many  of  the  letters  in  The  Jour- 
nal opposed  to  its  removal  to  Washington  are  from  the 
West,  I  write,  as  originally  from  New  England  and  liv- 
ing East,  to  express  my  opinion  and  firm  belief  that  the 
best  interests  of  The  Journal  will  be  served  by  keeping 
it  in  Chicago, 

The  fact  that  full  delegations  of  the  profession  in  and 
near  Washington  will  be  at  the  meeting  to  vote  for  re- 
moval should  induce  delegates  of  the  North.  South  and 
West  to  attend  the  meeting  and  vote  against  removal,  so 
that  the  small  percentage  of  membership  favoring  re- 
moval mav  not  out-vote  the  vast  majority  opposed  to  re- 
moval from  the  remoteness  of  one  party  and  nearness  of 
the  other  partv  to  the  place  of  meeting. 

F.  B.  Davison,  M.D. 

Fleetville,  Lackawanna  Co.,  Pa. 


To  the  Editor: — It  is  a  poor  plan  to  swap  horses  while 
crossing  a  stream.  The  Journal  is  successful  and  grows 
steadily  more  so,  and  I  see  no  valid  reason  for  making 
any  change  in  its  present  location. 

John  P.  Gray-,  M.D. 

Utica.  N.  Y..  March  2S,  1S91. 


502 


SPECIAL  CORRESPONDENCE. 


[April  4, 


To  the  Editor: — Had  1  a  dozen  votes  on  the  location  of 
The  Journal  not  one  of  them  would  be  cast  for  Wash- 
ington; it  should,  in  my  opinion,  be  published  at  some 
central  point:  Chicago,  Cincinnati,  or  St.  Louis;  but  if 
it  is  to  go  East,  let  it  be  to  Philadelphia,  New  York,  or 
Boston. 

Washington  is  the  place  for  many  things  of  National 
importance; — a  quiet  place  for  legislators  to  meet — it  is  a 
National  burying  ground  full  of  monuments;  there  can 
be  found  the  remains  of  many  men,  things,  and  enter- 
prises; in  fact  hundreds  of  clever,  live  men  are  buried 
there  in  the  various  departments  yearly,  but  Washington 
is  not  the  place  for  the  headquarters  of  the  American 
Medical  Association  or  its  organ.  Keep  the  one  on 
wheels,  the  other  in  Chicago.      J.  W.  Holiday,  M.D. 

Burlington,  la.,  March  28,  1891. 


To  the  Editor: — It  seems  strange  that  the  whole  mem- 
bership of  the  American  Medical  Association  should  be 
so  aroused  over  the  question  of  the  removal  of  the  home 
of  The  Journal,  if  it  is  to  be  such  a  gain  as  some  would 
make  it  appear. 

Is  it  possible  that  Washington  City  can  furnish  us  so 
much  better  editorial  material  and  the  Association  not 
find  it  out  until  it  has  been  told  to  us  by  themselves  or 
their  allies  in  intrigant:' 

When  a  question  of  so  much  moment  as  the  resigning 
of  so  important  a  journal  to  an  ignominious  death  to  fur- 
nish a  stepping-stone  for  somebody  to  raise  themselves 
into  greater  prominence  is  to  be  met,  it  seems  as  if  the 
whole  membership  ought  to  be  questioned,  and  each  al- 
lowed himself  to  answer. 

A  selfish  motive,  cloaked  as  this  was  at  birth,  cannot 
expect  to  meet  with  any  other  answer  from  them  against 
whom  the  scheme  was  laid,  and  noiv  an  answer  should  be 
given  that  would  henceforth  doom  such  actions  to  -infa- 
mous obloquy.  The  suddenness  and  untimely  hour  of 
springing  the  subject  does  not  show  honesty  of  purpose, 
and  since  the  question  is  being  agitated,  how  few  cham- 
pions are  showing  in  the  list  for  the  unseemly  act,  and 
when  one  does  he  is  unkind  enough  to  make  charges  of 
incompetency  against  the  editorial  management,  and  the 
manner  in  which  the  Trustees  are  conducting  the  publi- 
cation. Men  who  stoop  to  vilify  their  compeers  do  not, 
at  least,  show  a  generous  nature,  into  whose  hands  one 
would  desire  to  place  a  trust  of  so  much  importance  as 
the  control  of  The  Journai,  of  the  American  Medical 
Association. 

If  there  be  not  "method  in  their  madness,"  why  did 
they  so  secretly  secure  the  promise  of  furtherance  of 
their  scheme  by  a  member  before  he  was  promised  the 
nomination  to  fill  a  vacancy  on  the  Board  of  Trustees  last 
spring?  It  is  such  Washingtonian  acts  that  have  so 
aroused  the  members  in  all  parts  of  this  great  country  to 
answer  against  the  removal.  This  is  not  the  work  or 
wish,  seemingly,  of  a  North  or  South,  an  East  or  West, 
but  that  of  a  few  with  wild  dreams  of  imaginary  honor, 
who  live  to  thrive  on  "such  stuff  as  dreams  are  made 
of."  Were  they  to  be  deprived  of  the  National  pap,  and 
left  to  their  own  ability  and  natural  resources,  they 
would  dwindle  into  less  than  nature  had  ordained  them. 
Men  and  their  works  do  not  become  great  because  of 
the  opportunities  offered,  but  because  of  opportunities 
accepted  and  made  use  of. 

Chicago  may  yet  lead  Washington  in  extensive  libra- 
ries and  institutions  of  learning,  because  of  its  inherent 
energy  and  push  to  the  front.  If  there  be  any  stored  up 
energy  in  Washington  otherwise  than  that  which  bub- 
bles and  seethes  in  the  political  caldron,  would  it  not  be 
well  to  take  it  to  Chicago,  where  it  can  find  a  wholesome 
atmosphere  to  thrive  upon  and  freedom  of  association  of 
its  kind?  The  home  of  The  Journal  undoubtedly  was 
at  first  well  chosen,  at  least  it  has  proven  well;  and  it  is 
but  fair  to  keep  it  where  it  has  prospered  so  well. 

A.  M.  Vail,  M.D. 

Rock  Rapids,  la.,  March  25,  1891. 


Editorial  Opinions  of  the  Medical  Press. 

In  another  column  will  appear  the  proceedings  of  a 
recent  meeting  of  the  Board  of  Trustees  of  the  American 
Medical  Association  Journal  at  Washington.  As  will  ap- 
pear, the  Board  has  announced  as  its  belief,  that  Wash- 
ington City  is  the  proper  place  for  the  home  of  The  Jour- 
nal. The  editor  of  the  Mirror,  as  a  member  of  the  Board 
of  Trustees,  has  favored  and  does  favor,  not  only  as  a 
member  of  the  Board,  but  as  an  individual,  the  removal 
of  the  Association  Journal  to  Washington.  He  believes 
that  the  action  of  the  Board  in  deferring  the  final  deci- 
sion until  the  meeting  in  May  and  inviting  an  expression 
of  opinion  from  the  profession  at  large  upon  the  subject, 
was  appropriate.  A  number  of  members  of  the  Associa- 
tion in  the  West,  near  and  dear  friends  of  the  writer, 
have  expressed  the  thought  that  The  Journal  ought  not 
to  go  East;  that  it  was  now  in  the  West  and  that  we 
ought  to  keep  it  here.  Were  the  effort  being  made  to  re- 
move The  Journal  to  New  York,  Philadelphia,  Boston, 
or  any  other  commercial  Eastern  city,  we  believe  that 
the  argument  would  hold;  that  it  would  be  removing  it 
to  the  Eastern  line  and  away  from  the  centre.  The  same 
argument  might  be  brought  against  its  removal  to  any  of 
the  other  cities  of  the  West.  As  a  matter  of  fact,  Chica- 
go is  not  a  Western  city.  Chicago  is,  more  properly 
speaking,  a  branch  of  New  York  City,  although  it  is 
supposed  to  be  a  representative  Western  city,  it  is  not  at 
all  so.  Were  geographical  considerations  to  have  weight, 
St.  Louis  would  be  more  properly  the  centre.  Unques- 
tionably it  is  the  hub  of  the  Continental  wheel,  toward 
which  all  the  spokes  point. 

It  is  the  distributor  of  supplies  to  a  greater  territory 
than  any  other  city  in  America.  But  in  spite  of  these 
arguments,  we  are  not  in  favor  of  the  removal  of  The 
Journal  to  St.  Louis;  nor  would  we  favor  its  removal  to 
Cincinnati,  Louisville,  or  any  point  South.  In  truth,  any 
commercial  city  in  America,  suggested,  would  be  a  sec- 
tional suggestion.  The  removal  of  The  Journal  to  Wash- 
ington, however,  the  home  of  the  National  Government, 
is  appropriate.  A  representative  of  the  American  medi- 
cal profession,  a  National  medical  journal,  should  un- 
questionably be  located  in  the  Nation's  Capital,  the  only 
unsectional  point  in  America.  We  are  strong  in  the  con- 
viction that  this  is  not  only  the  patriotic  view  to  take  of 
the  question,  but  it  is  the  view  that  is  in  the  direction  of 
the  best  good  to  the  American  Medical  Association.  A 
by-law,  which  was  adopted  some  years  ago  by  the  Asso- 
ciation, provided  for  every  alternate  meeting  of  the  As- 
sociation to  be  held  in  Washington  City,  looking  toward 
Washington  City  as  being  eventually,  in  fact  even  now, 
the  home  of  the  National  Association.  If  appropriate 
efforts  were  made,  unquestionably  a  very  large  fund  could 
be  secured  and  a  permanent  building  erected  for  the  ac- 
commodation of  the  Association  and  its  Journal  in  Wash- 
ington. The  various  International  Congresses  are  held 
the  world  over  in  the  capitals  of  the  various  nations. 
The  home  of  the  British  Medical  Journal  is  in  Loudon; 
in  fact,  we  are  strong  in  the  belief  that  all  the  arguments 
are  in  favor  of  the  permanent  home  of  the  American 
Medical  Association  and  its  official  organ,  being  located 
in  the  Capital  of  the  Nation.  If  the  time  ever  comes, 
that  the  Capital  should  be  moved  to  a  more  central  point, 
geographically  speaking,  then  let  the  Association  follow 
the  Capital.  In  the  meantime,  we  hope  that  there  will 
be  a  full  and  free  discussion  in  every  medical  journal  of 
the  United  States.  The  Board  of  Trustees  of  The  Journal 
have  invited  the  freest  discussion  on  the  part  of  the  mem- 
bers of  the  profession.  The  Medical  Mirror  will  be  glad 
to  hear  from  those  of  the  profession  who  are  interested 
in  the  question. 

In  the  meantime,  we  are  on  record  as  being  in  favor  of 
the  National  Capital  as  the  home  of  The  Journal;  but  we 
are  open  to  conviction,  and  shall  remain  in  a  receptive 
state  of  mind,  ready  for  the  suggestions  and  arguments 
of  all  friends  of  the  Association. — Medical  Mirror,  Dec, 
1890. 


I89i.] 


SPECIAL  CORRESPONDENCE. 


503 


According  to  an  official  report  of  a  meeting  of  the 
Board  of  Trustees  of  The  Journal,  held  in  Washinton,  D. 
Ci  Nov.  13th,  1890,  three  things  were  done  : 

1.  The  Board  called  upon  the  President  of  the  United 
States. 

2.  It  resolved  that  the  home  of  The  Journal  should  be 
in  Washington,  and  that  the  Association  should  be  so  in- 
formed. 

3.  The  Trustees  recommend  that  the  members  of  the 
Association,   and    the  various   Stale  and   local    societies, 
contribute  funds  for  the  erection  of  a  permanent  building 
as  an  office,  library,  etc.,  of  the  American  Bffedii 
ciation. 

Aside  from  some  criticism  of  the  Secretary's  mode  of 
keeping  his  book,  this  is  all  the  Board  report  having 
done  at  this  meeting;  and  yet  a  fair  estimate  of  the  actu- 
al expenses  of  the  members  in  attendance  will  make  it 
cost  not  less  than  three  hundred  dollars — probably  four 
hundred  would  be  nearer  correct.  Is  the  Association  so 
rich  that  it  can  afford  to  pay  its  Trustees  three  or  four 
hundred  dollars  to  make  a  trip  to  Washington,  in  order 
that  the  Board  may  visit  the  President  of  the  United 
States,  and  announce  gravely  to  the  Association  that  it 
should  permanently  locate  The  Journal  in  Washington, 
and  call  upon  individuals  and  societies  in  the  profession 
for  funds  to  erect  a  building? 

The  members  of  the  Association  would  like  to  learn 
why  the  Board  of  Trustees,  or  any  portion  of  it,  deemed 
it  fitting  to  gravely  announce  its  opinion  upon  the  sub- 
ject or  subjects,  and  why  Washington  is  better  than  Chi- 
cago ?  This  is  a  question  for  the  Trustees  to  answer  ! 
Further,  what  reason  is  there  for  making  this  question 
prominent  just  now  ?  We  desire  to  vote  and  act  intelli- 
gently upon  this  question,  hence  seek  for  information. 

We  do  know  that  several  years  ago  the  Trustees  care- 
fully secured  bids  from  publishing  houses,  printers,  etc., 
in  all  principal  cities  of  the  United  States,  with  the  uni- 
form result  of  ascertaining  that  Washington  was  the  most 
expensive,  and  Chicago  the  cheapest,  place  of  publica- 
tion. Have  the  Trustees  made  full  and  complete  inves- 
tigations, with  the  result  of  finding  a  cheaper  place  of 
publication  than  Chicago?  If  so  they  should  have  an- 
nounced the  fact,  and  the  grounds  upon  which  it  rested. 

Do  the  Trustees  desire  to  move  The  Journal  to  Wash- 
ington because  hitherto  every  medical  journal  issued 
there  came  to  an  untimely  end  ?  Can  it  be  that  thev  de- 
sire to  plant  The  Journal  in  a  spot  hitherto  noted  for  its 
failures  in  medical  journalism  ?  Have  they  a  hope  that 
under  the  special  influence  for  which  Washington  is 
noted.  The  Journal  of  the  Association  will  die  an  easy 
and  painless  death  ?  Or  is  it  because  the  Trustees  have 
a  grudge  against  eastern  medical  journals  in  general,  and 
the  medical  weeklies  in  particular,  that  they  desire  to 
transfer  The  Journal  to  an  eastern  locality.  Naturally  it 
would  seem  as  if  the  strip  of  country  along  the  Atlantic 
coast  had  medical  journals  in  abundance,  and  that  the 
removal  thither  of  another  would  act  more  or  less  disad- 
vantageous^-. On  this  view  of  the  fact,  it  would  appear 
that  the  Trustees  of  The  Journal  either  resolved  thought- 
lessly, or  were  acting  in  disregard  of  the  interests  of 
other  journals. 

Can  a  better  or  more  reliable  business  manager  be  se- 
cured in  AVashiugtou  ?  Can  better  or  more  effective  edi- 
torial work  be  secured  ?  In  short,  is  there  a  single  rea- 
son for  fixing  The  Journal  permanently  in  Washington  ? 
We  have  not  heard  of  a  single  reason  that  counts  in  favor 
of  The  Journal  or  of  the  Association.  We  are  informed 
that  such  location  is  desirable  because  Washington  is  the 
Nation's  Capital:  but  the  publication  of  The  Journal  is  a 
business  to  be  conducted  upon  business  principles,  for 
the  attainment  of  business  ends.  If  there  are  good  bus- 
iness reasons  for  locating  The  Journal  in  Washington, 
we  have  yet  to  learn  of  them.  The  fact  that  Washington 
is  the  Capital  affords  the  strongest  of  reasons  whv  such  a 
lusi.iess  as  the  conduct  of  a  great  medical  journal  should 
not  be  located  there;  a  great  commercial  centre  is  the 


place  for  a  business  that   is  National  in  its  scope,  and 
Washington  is  not  such  a  centre.     More  anon. 

N.  B. — If  we  hear  any  reasons  for  removing  The 
Journal  to  Washington,  we  shall  lay  them  before  our 
readers,  that  all  may  be  prepared  to  vote  intelligently 
upon  the  question. —  The  American  Lancet,  Jan 


Tin-  minutes  of  the  Board  of  Trustees  of  The  Journal, 
published  in  a  late  edition,  show  that  an  attempt  has 
been  made  to  move  the  plant  to  Washington.  There  is 
some  question  as  to  the  advisability  of  such  a  proceeding 
at  this  time,  when  in  the  course  of  the  next  two  years  so 
many  medical  men  from  all  over  the  world  will  visit  Chi- 
cago, the  place  where  The  Journal  was  born  and  nur- 
tured. Admitting  that  it  is  in  some  respects  a  Chicago 
journal,  the  question  arises  as  towhetherit  would  be  any 
better,  or  have  a  greater  influence  or  larger  circulation  if 
it  were  a  Washington  journal  instead  of  what  it  is  at  the 
present  time  ?  With  all  due  respect  to  Dr.  Hamilton,  it 
is  suggested  that  his  official  position  should  prevent  him 
from  entering  into  any  political  schemes  by  which  he 
will  reward  his  friends  and  punish  his  enemies. 

The  time  has  not  yet  arrived  when  the  members  of  the 
Association  can  afford  to  trust  the  welfare  of  The  Journal 
in  the  hands  of  those  who  are  not  directly  and  person- 
ally interested  in  its  progress  and  permanent  success. 
Attempts  have  been  previously  made  to  corral  the  mem- 
bers of  the  Board,  with  a  view  to  manage  the  paper  to 
the  personal  advantage  of  those  who  desired  to  "run  it 
for  the  monev  there  was  in  it,"  but,  fortunately,  all  such 
efforts  have  heretofore  failed,  and  it  is  hoped  a  like  fate 
will  attend  this  last  attempt,  although  it  may  have  been 
considered  with  the  best  intentions.  Let  it  be  under- 
stood, once  and  for  all  time,  that  The  Journal  cannot  be 
bought,  merged  or  hypothecated. — Philadelphia  Medical 
Summary,  Jan.,  1891. 


The  question  of  the  removal  of  The  Journal  from  Chi- 
cago to  Washington  City  is  being  agitated.  A  meeting 
of  the  Board  of  Trustees  has  already  been  held  to  that 
effect.  The  final  decision  has  been  deferred  until  the 
meeting  in  May,  when  an  expression  of  opinion  from  the 
profession  at  large  upon  the  subject  will  be  had.  We 
think  it  folly  to  ask  its  removal  to  Washington,  simply 
because  it  is  the  home  of  the  National  Government,  in 
order  that  it  may  be  designated  a  National  Medical 
Journal.  Washington  is  not,  never  has  been  and  prob- 
ably never  will  be  a  medical  centre,  and  neither  its  loca- 
tion nor  railroad  facilities  recommend  it. — Kansas  Med- 
ical Journal,  Jan.,  1S91. 


Shall  the  A.  M.  A.  Journal  go  to  Washington  ?  This 
is  the  question  which  the  Association  will  be  called  upon 
to  answer  at  its  next  meeting.  The  Board  of  Trustees, 
at  a  recent  session  in  Washington,  adopted  a  resolution 
favoring  the  change,  but  not  a  single  "Whereas"  pre- 
cedes the  "Resolution."  What  are  the  reasons  for  want- 
ing the  change  made  ?  Surely  they  exist  in  the  minds 
of  the  Trustees,  and  as  officers"  of  the  Association  having 
at  heart  the  best  interest  of  this  organization,  those  rea- 
sons should  be  made  public.  Can  The  Journal  be  pub- 
lished cheaper  in  Washington  ?  That  can  hardly  be,  for 
Chicago  is  a  great  publishing  centre.  Are  the  mailing 
facilities  at  Washington  better?  Mr.  Wanamaker  would 
hardly  admit  that  thev  are.  Can  it  be  better  edited  at 
Washington?  That's"  a  "sure  enough"  question.  The 
Associatiou  will  be  very  certain  to  know  something 
about  a  prospective  editor  before  it  votes  upon  this  mat- 
ter. In  the  far  Eastern  country  the  Islam  prophet  of  old 
failed  in  an  attempt  to  make  the  mountains  skip  at  his 
command  as  kids  at  plav,  but  perhaps  "a  greater  than 
he  is  here."  It  does  look  as  though  the  mountain  were 
seriously  contemplating  a  journey  in  a  Pullman  palace 
car  to  aMaliomet  who  has  bid  it  come.     In  all  soberness, 


5<M 


MISCELLANY. 


[April  4,  1891. 


Messrs.  Trustees,  let  the  Association  know  why  \-our  as- 
sembled wisdom  deems  it  best  to  transfer  The  Journal 
to  Washington.  Let  it  stay  where  it  now  is  unless  cer- 
tainly shown  that  the  interests  of  both  the  Association 
and  its  Journal  will  be  conserved  by  its  removal. — Med- 
ical Herald,  Feb.,  1891. 


A  great  controversy  is  now  being  carried  on  regarding 
the  proposed  removal  of  The  Journal  from  its  home  in 
Chicago  to  Washington  City.  The  control  of  The  Jour- 
nal is  in  the  hands  of  a  Board  of  Trustees,  which  has 
recommended  that  the  change  be  made.  The  question 
will  come  up  at  the  nest  meeting  in  Washington,  and 
there  will  be  a  warm  discussion,  and  possibly  indefinite 
results. 

The  time  for  an  opinion  upon  this  proposition  is  not 
arrived,  for  we  are  sure  that  the  best  arguments  for  the 
removal  have  not  as  yet  been  advanced.  We  fear  that 
the  action  of  the  Trustees  in  referring  the  matter  to  the 
Association  is  wrong;  and  will  result  in  harm.  The  Board 
was  given  full  power  to  act;  by  its  act  The  Journal  was 
located  in  Chicago,  and  by  its  authority  it  could  remain 
or  be  removed. 

As  it  is  now,  there  is  a  pretty  war  on  hand,  and  it  will 
grow  fiercer  and  hotter  as  the  time  for  the  meeeting 
draws  nigh.  Even  if  a  conclusion  be  reached  at  the  next 
meeting,  it  may  be  undone  at  any  succeeding  one.  We 
hope  a  motion  will  prevail  to  refer  the  question  back  to 
the  Trustees.  They  are  abundantly  able  to  settle  the 
matter — in  fact,  are  elected  to  carry  just  such  responsi- 
bility. We  will  have  something  to  say  about  the  argu- 
ments for  and  against  removal  further  along. — St.  Louis 
Cliniquc,   Feb.,  1891. 


faster  mailing  facilities  or  more  brilliant  intellects  in 
Washington  than  in  Chicago?  The  Capital  is  merely  a 
political  center  and  as  such  is  inimical  to  the  highest  de- 
velopment of  science  or  literature.  We  do  not  want  the 
politics  of  the  Capital  engrafted  upon  the  journalistic  in- 
terests of  the  American  Medical  Association 

Gentlemen  of  the  West  and  South,  be  at  Washington 
on  May  the  5th  and  vote  upon  this  question. — Cincinnati 
Medical  Journal,  Feb.  15,  1S91. 


MISCELLANY. 


At  the  last  meeting  of  the  Trustees  of  The  Journal  of 
the  American  Medical  Association,  it  was  resolved  to 
move  The  Journal  from  Chicago  to  Washington.  By 
subsequent  resolution,  however,  it  was  determined  to 
leave  the  matter  open  until  a  vote  could  be  had  by  the 
members  at  the  Ma}-  meeting.  The  question  is  therefore 
a  proper  one  for  agitation  and  it  is  well  enough  to  con- 
sider the  pros  and  cons  relative  to  a  matter  of  so  much 
importance  to  so  large  a  number  of  the  medical  profes- 
sion. 

The  Journal  when  established  was  located  in  Chicago, 
largely  because  Chicago  influence  was  dominant  in  the 
Association,  but  chiefly  because  it  was  a  central  point 
from  which  proofs  could  be  readily  sent  to  writers  and  as 
readily  returned.  This  convenience  has  been  experi- 
enced by  contributors  to  The  Journal,  the  vast  majority 
of  whom  reside  in  the  great  interior  valley  of  our  broad 
country.  Since  the  location  of  the  official  organ  of  the 
Association  at  Chicago,  type  and  other  fixtures  have  been 
purchased,  and  the  periodical  under  conservative  manage- 
ment has  become  one  of  the  most  influential  in  the  coun- 
try. But  now  right  on  the  heels  of  this  success  comes  an 
effort  to  take  The  Journal  from  its  central  and  convenient 
location  and  publish  it  in  a  provincial  city  on  one  side 
of  the  continent. 

The  question  is  at  once  asked  why  ?  Is  it  because  there 
are  no  longer  printing  presses  in  Chicago  ?  Is  it  because 
the  paper  market  in  that  city  has  become  exhausted  ?  Is 
it  because  the  mailing  facilities  in  that  metroplis  are  in- 
adequate ?  Is  it  because  there  are  no  men  of  brains  to  be 
found  either  in  that  great  anil  growing  medical  center,  or 
who  can  be  induced  to  take  up  their  residence  there  to 
assume  editorial  charg<  of  one  of  the  leading  medical 
journals  of  the  country5  These  are  the  only  reasons  that 
are  entitled  to  consideration  relative  to  changing  the  lo- 
cation of  a  great  journal  and  yet  a  knowledge  of  the  facts 
in  the  present  instance  condemn  them  as  absurd  In  the 
verge  of  idiocy. 

Tile  only  reason  so  far  given  by  the  promotl  rs  ol  thl 
move  is  that  Washington  is  the  Capital  of  the  country. 
Well  what  of  it?     Arc  there   better   presses,    more   paper, 


The  Big  Four  and  the  Annual  Meeting  of  the 
Association. — To  members  of  the  American  Medical 
Association  who  contemplate  attending  the  annual  Meet- 
ing at  Washington,  D.  C,  May  5th  to  Sth,  a  few  words  in 
regard  to  the  best  means  of  reaching  Washington  will  no 
doubt  prove  acceptable.  The  recognized  line  from  Chi- 
cago is  the  Popular  Big  Four  Route  in  connection  with 
the  Scenic  Chesapeake  &  Ohio  Ry.,  from  Cincinnati 
running  via  White  Sulphur  Springs,  through  the  beauti- 
ful mountain  regions  of  the  Virginias,  over  its  own  tracks 
into  the  City  of  Washington. 

Passengers  via  this  popular  line  have  the  choice  of  two 
elegant  traius,  starting  from  Lake  Street  Depot,  Chicago, 
— the  morning  train  equipped  with  elegant  parlor  cars, 
cafe  dining  car  and  luxurious  coaches,  makes  connection 
at  Cincinnati  with  the  Famous  "  Fast  Flying  Virginian" 
via  the  C.  &  O.  Route,  assuring  passengers  of  first  class 
service,  including  Dining  Cars,  for  the  entire  trip.  The 
evening  train  from  Chicago  is  equipped  with  private 
compartment  buffet  sleeping  car,  standard  Wagner  palace 
sleeping  car  and  elegant  reclining  chair  car  and  makes 
connection  with  the  "Washington  Fast  Line"  via  the 
Chesapeake  &  Ohio  Ry.,  affording  a  day-light  ride 
through  the  beautiful  Ohio  Valley,  and  across  the  scenic 
Blue  Ridge  Mountains  into  the  Capital. 

These  trains  are  vestibuled  throughout,  provided  with 
an  unequaled  dining  car  service  and  afford  every  comfort 
and  convenience  of  modern  railroading.  For  tickets  and 
full  information  call  on  or  address  J.  C.  Tucker,  General 
Northern  Agent  121  Randolph  St.,  Chicago,  III.,  D.  B. 
Martin  General  Pass.  Agent  Big  Four  Route  Cincin- 
nati, t  1. 


Official  List  of  Changes  in  the  Stations  and  Duties  of  Officers  Serving 
in  the  Medical  Department,  U.  S.  Army,  from  March  21,  1S01,  to 
Match  17,1891. 

Major  Henry  R.  Tilton,  Surgeon  U.  S  .  A.,  is  hereby  granted  leave 
of  absence  for  one  month,  on  surgeon's  certificate  of  disability. 
Par.  5,  S    O.  56,  Hdqrs.  Div.  Atlantic,  March  21,  iSqi. 

Major  Passmore  Middleton.  Surgeon,  is  relieved  from  duty  at  St. 
Francis  Bks.,  Fla.,  and  will  proceed  to  Newport  Bks  .  K\\.  and 
await  further  orders.  The  travel  enjoined  is  necessary  for  the 
public  service.  By  direction  of  the  Acting  Secretary  of  War.  Par. 
8,  S.  O.  62,  A.  G.  O.,  Washington,  March  1  1,  [89] 

Major  John  H.  Bartholf.  Surgeon,  now  on  duty  at  Pittsburgh  Bks.. 
N  v.,  will  proceed  to  Fort  Wayne,  Mich.,  and  report  in  person  to 
the  commanding-  officer  of  that  post  for  temporary  duty.  By  di- 
rection of  the  Acting  Secretary  of  War.  Par.  7,  S.  O.  64,  A.  G.  O.. 
Washington,  March  2,  1891. 

Capt,  l!<  nrv  Johnson,  Medical  Storekeeper,  retirement  from  active 
service  this  date,  under  the  provisions  of  the  Act  of  Congress  ap- 
proved June  to,  1SS2,  is  announced.  By  direction  of  the  Acting 
Secretary  ol  w  11  Pal  S  0  66  A  G.  O.,  Hdqrs.  of  the  Army, 
Washington,  March  24 

Capt.  Robert  J.  Gibson,  Asst  Surgeon,  leave  of  absence  granted  in 
S.  O.  232,  A   G.  0     Ocl  From  this  office,  is  extended  one 

month.     By  direction  ol  the  Acting  Secretary  of  War.     Par.  10.  S. 
O.65,  A.  G.O.,  Washington,  Marcn  2.-,,  1891.  " 

First   Lieut.   Eugene    I..    Swilt,  Asst.   Surgeon,  now  on  duly  at    It 
Thomas,  Ariz.,  will  report  hy  leth     to  th<    commandin 
Ft.  Grant,  Ariz.,  for  duty  at  that   station  or   Ft.  Thomas,  Ariz.,  as 
the  commanding  officer  may  direct.     By  direction  o(  the  Acting 
Secretary   oi  War.     Par.  7,  S.  O  66   A.  G    O.,  Washington,  March 

Lieut     Col     Charles    B     Greenleaf,    Asst     Medical    Purveyor,   will 
proceed  to  New  York  city  on  public  business,  and  them 
i    11     Mass.,  to   represent   thl     Inny  Medical   Department  ,-.t  the 

ciation  for  Physical  Education:  and  upon 
pletion  oi  theduties  contemplated,  will  return  to  his  station  in 
this  city,    liv  direction  of  the  Act  ins   Secretary  oi  War.     Pai    3, 
11         A.  6.O.,  Washington    Man  h  25,  1891. 


Tin-; 


J  otirna!  of  the  American  Medical  Association. 

EDITED  UNDER  THE  DIRECTION  OF  THE  BOARD  OF  TRUSTEES. 

PUBLISHED    WEEKLY. 


Vol.  XVI. 


CHICAGO,  APRIL  n,   1891. 


Xo  15. 


ADDRESSES. 


THE    RELATIOX    OF    BACTERIA    TO 
PRACTICAL  SURGERY. 

The  Address  in  Surgery  of  the  Medical  Society  of  the  State  of 
Pennsylvania,  Pittsburgh,  June  II,  1890. 

BY  JOHX  B.  ROBERTS,  M.D., 


POLYCLINIC. 


The  revolution  which  has  occurred  in  practical 
surgery  since  the  discovery  of  the  relation  of 
microorganisms  to  the  complications  occurring  in 
wounds  has  caused  me  to  take  up  this  subject  for 
discussion.  Although  main-  of  my  hearers  are 
familiar  with  the  germ  theory  of  disease,  it  is 
possible  that  it  may  interest  some  to  have  put  be- 
fore them,  in  a  short  address,  a  few  points  in  bac- 
teriology, which  are  of  value  to  the  practical  sur- 
geon. 

It  must  be  remembered  that  groups  of  symp- 
toms which  were  formerly  classed  under  the  heads 
of  "inflammatory  fever,"  "symptomatic  fever," 
"traumatic  fever,"  "hectic  fever,"  and  similar 
terms,  varying  in  name  with  the  surgeon  using 
them,  or  with  the  location  of  the  disease,  are  now- 
known  to  be  due  to  the  invasion  of  the  wound  by 
microscopie  plants.  These  bacteria,  after  enter- 
ing the  blood  current  at  the  wound,  multiply  with 
such  prodigious  rapidity  that  the  whole  system 
gives  evidence  of  their  existence.  Suppuration 
of  wounds  is  undoubtedly  due  to  these  organisms, 
as  is  tubercular  disease,  whether  of  a  surgical  or 
medical  character.  Tetanus,  erysipelas  and 
many  other  surgical  conditions  have  been  almost 
proved  to  be  the  result  of  infection  by  similar 
microscopic  plants,  which,  though  acting  in  the 
same  way,  have  various  forms  and  life- histories. 

A  distinction  must  be  made  between  the  "yeast 
plants,"  one  of  which  produces  thrush,  and  the 
"mould  plants,"  the  existence  of  which  as  para- 
sites in  the  skin  gives  rise  to  certain  cutaneous 
diseases.  These  two  classes  of  vegetable  parasites 
are  foreign  to  the  present  topic,  which  is  surgery; 
and  I  shall,  therefore,  confine  my  remarks  to  that 
group  of  vegetable  parasites  to  which  the  term 
bacteria  has  been  given.  Tbese  are  the  micro- 
organisms whose  actions  and  methods  of  grow-th 
particularly  concern  the  surgeon.  The  individual 


plants  are  so  minute  that  it  takes  in  the  neigh- 
borhood of  ten  or  fifteen  hundred  of  them  grouped 
together  to  cover  a  spot  as  large  as  the  full  stop 
or  period  used  in  punctuating  an  ordinary  news- 
paper. This  rough  estimate  applies  to  the  glo- 
bular or  egg-shaped  bacteria  to  which  is  given 
the  name  "coccus"  (plural  cocci).  The  cane,  or 
rod-shaped  bacteria  are  rather  larger  plants.  Fif- 
teen hundred  of  these  placed  end  to  end  would 
reach  across  the  head  of  a  pin.  Because  of  the 
resemblance  of  these  latter  to  a  walking  stick 
the}-  have  been  termed  bacillus  (plural  bacilli). 

The  bacteria  most  interesting  to  the  surgeon 
belong  to  the  cocci  and  the  bacilli.  There  are 
other  forms  which  bacteriologists  have  dubbed 
with  similar  descriptive  names,  but  they  are  more 
interesting  to  the  physician  than  to  the  surgeon. 
Many  microorganisms,  whether  cocci,  bacilli,  or 
of  other  shapes,  are  harmless;  hence  they  are 
called  non-pathogenic,  to  distinguish  them  from 
the  disease-producing,  or  pathogenic  germs. 

As  many  trees  have  the  same  shape  and  a  sim- 
ilar method  of  growing,  but  bear  different  fruit: 
— in  the  one  case  edible,  and  in  the  other  poison- 
ous— so,  too,  bacteria  may  look  alike  to  the  mi- 
croscopist's  eye,  and  grow  much  in  the  same  way. 
but  one  will  cause  no  disease,  while  the  other 
will  produce  serious  disease,  such,  perhaps,  as 
tuberculosis  of  the  lungs  or  brain. 

Many  scores  of  bacteria  have  been,  by  patient 
study,  differentiated  from  their  fellows  and  given 
distinctive  names.  Their  nomenclature  corres- 
ponds in  classification  and  arrangement  with 
the  nomenclature  adopted  in  different  depart- 
ments of  botany.  Thus,  we  have  the  pus- 
causing  chain  coccus  (streptococcus  pyogenes\ 
so  called  because  it  is  globular  in  shape;  because 
it  grows  with  the  individual  plants  attached  lo 
each  other,  or  arranged  in  a  row  like  a  chain  of 
beads  upon  a  string;  and  because  it  produces  pus. 
In  a  similar  way  we  have  the  pus-causing  grape- 
coccus  of  a  golden  color  (staphylococcus  pyogenes 
aureus).  Itproduces pus. grow-s with theindividual 
plants  arranged  somew-hat  after  the  manner  of  a 
bunch  of  grapes,  and  when  millions  of  them  are 
collected  together  the  mass  has  a  golden  yellow- 
hue.  Again,  we  have  the  bacillus  tuberculosis; 
the  rod-shaped  plant  which  is  known  to  cause 
tuberculosis  of  the  lungs,  joints,  brain,  etc. 


506 


BACTERIA  AND  PRACTICAL  SURGERY. 


[April  ii, 


It  is  hardly  astonishing  that  these  fruitful 
sources  of  disease  have  so  long  remained  unde- 
tected, when  their  microscopic  size  is  borne  in 
mind.  That  some  of  them  do  cause  disease  is 
indisputable,  since  bacteriologists  have,  by  their 
watchful  and  careful  methods,  separated  a  single 
plant  from  its  surroundings  and  congeners, 
planted  it  free  from  all  contamination  and  ob- 
served it  produce  an  infinitesimal  brood  of  its 
own  kind.  Animals  and  patients  inoculated  with 
the  plants  thus  cultivated  have  rapidly  become 
subjects  of  the  special  disease  which  the  particu- 
lar plant  was  supposed  to  produce. 

The  difficulty  of  such  investigations  becomes 
apparent  when  it  is  remembered  that  under  the 
microscope  many  of  these  forms  of  vegetable  life 
are  identical  in  appearance,  and  it  is  only  by 
observing  their  growth,  when  in  proper  soil,  that 
they  can  be  distinguished  from  each  other.  In 
certain  cases  it  is  quite  difficult  to  distinguish 
them  by  their  ph3rsical  appearances  produced 
during  their  growth.  In  such  instances  it  is  only 
after  an  animal  has  been  inoculated  with  them 
that  the  individual  parasite  can  be  accurately 
recognized  and  called  by  name.  It  is  known  by 
the  results  it  is  capable  of  producing. 

The  various  forms  of  bacteria  are  recognized,  as  I 
have  said,  by  their  method  of  growth,  and  by  their 
shape.  Another  meansof  recognition  is  their  indi- 
vidual peculiarity  of  taking  certain  dyes  so  that  spe- 
cial plants  can  be  recognized,  under  the  microscope, 
by  the  color  given  to  them,  which  they  refuse  to 
give  up  when  treated  with  chemical  substances 
which  remove  the  stains  from,  or  bleach,  all  the 
other  tissues  which  at  first  have  been  similarly 
stained. 

The  similarity  between  bacteria  and  the  ordin- 
ary plants  with  which  florists  are  familiar  is  in- 
deed remarkable.  Bacteria  grow  in  animal  and  other 
albuminous  fluids,  as  a  soil,  but  it  is  just  as  essen- 
tial for  them  to  have  a  suitable  soil  as  it  is  for  the 
corn  or  wheat  that  the  farmer  plants  in  his  field. 
By  altering  the  character  of  the  albuminous  fluid 
in  which  the  microorganism  finds  its  subsistence, 
these  small  plants  can  be  given  a  vigorous 
growth  or  may  be  actually  starved  to  death.  The 
farmer  knows  that  it  is  impossible  for  him  to 
grow  the  same  crop  year  after  year  in  the  same 
field,  and  he  is,  therefore,  compelled  to  rotate  his 
crops.  So  it  is  with  these  microscopic  plants 
which  we  are  considering.  After  a  time  the  cul- 
ture fluid  or  soil  becomes  so  exhausted  of  its 
needed  constituents  by  the  immense  number  of 
plants  living  in  it  that  it  is  unfit  for  their  life  and 
development.  Then  this  particular  plant  will  no 
longer  thrive,  but  some  other  form  of  bacterium 
may  find  in  it  the  properties  required  for  func- 
tional activity,  and  grow  vigorously.  It  is  prob- 
able that  exhaustion  or  absence  of  proper  soil  is 
an  important  agent  in  protecting  man  from  sick- 
11  ss  due  to  infection  from  bacteria.       The  ever 


present  bacteria  often  gains  access  toman's  blood 
through  external  wounds,  or  through  the  lungs 
and  digestive  tracts;  but  unless  a  soil  suited  for 
their  development  is  found  in  his  fluids,  the 
plants  will  not  grow.  If  they  do  not  grow  and 
increase  in  numbers  they  can  do  little  harm. 

Again,  there  are  certain  bacteria  which  are  so 
antagonistic  to  each  other  that  it  is  impossible  to 
make  them  grow  in  company,  or  to  co-exist  in 
the  blood  of  the  same  individual.  For  example, 
an  animal  inoculated  with  erysipelas  germs  can- 
not be  successfully  inoculated  immediately  after- 
ward with  the  germs  of  malignant  pustule.  Such 
antagonism  is  illustrated  by  the  impossibility  of 
having  a  good  crop  of  grain  in  a  field  overrun 
with  daisies.  On  the  other  hand,  however,  there 
are  some  microorganisms  which  flourish  luxuri- 
antly when  planted  together  in  the  same  fluid, 
somewhat  after  the  manner  of  pumpkins  and  In- 
dian corn  growing  between  the"  same  fence  rails. 
Others  seem  unwilling  to  grow  alone,  and  only 
flourish  when  planted  along  with  some  other 
germs.  It  is  very  evident,  therefore,  that  bac- 
teriology is  a  branch  of  botany,  and  that  Nature 
shows  the  same  tendencies  in  these  minute  plants 
as  it  does  in  the  larger  vegetable  world  visible  to 
our  unaided  eyes. 

As  the  horticulturist  is  able  to  alter  the  charac- 
ter of  his  plants  by  changing  the  circumstances 
under  which  they  live,  so  can  the  bacteriologist 
change  the  vital  processes  and  activities  of  bac- 
teria by  chemical  and  other  manipulations  of  the 
culture  substances  in  which  these  organisms  grow. 
The  power  of  bacteria  to  cause  pathological 
changes  thus  may  be  weakened  and  attenuated; 
in  other  words,  their  functional  power  for  evil  is 
taken  from  them  by  alterations  in  the  soil.  The 
pathogenic,  or  disease-producing  power,  may  be 
increased  by  similar,  though  not  identical,  alter- 
ations. The  rapidity  of  their  multiplication  may 
be  accelerated,  or  they  may  be  compelled  to  lie 
dormant  and  inactive  for  a  time;  and  on  the  other 
hand,  by  exhausting  the  constituents  of  the  soil 
upon  which  they  depend  for  life,  they  may  be  killed. 

It  is  a  most  curious  fact  also  that  it  is  possible, 
by  selecting  and  cultivating  only  the  lighter  .col- 
ored specimens  of  a  certain  purple  bacterium,  for 
the  bacteriologist  to  finally  obtain  a  plant  which 
is  nearly  white,  but  which  has  the  essential  char- 
acteristics of  the  original  purple  fungus.  In 
this  we  see  the  same  power  which  the  florist  has 
to  alter  the  color  of  the  petals  of  his  flowers  by 
various  methods  of  selective  breeding. 

The  destruction  of  bacteria  by  means  of  heat 
and  antiseptics  is  the  essence  of  modern  surgery. 
It  is,  then,  by  preventing  access  of  these  parasitic 
plants  to  the  human  organism  (aseptic  surgery), 
or  the  destruction  of  them  by  chemical  agents 
and  heat  (antiseptic  surgery),  that  we  are  en- 
abled to  invade,  by  operative  attacks,  regions  of 
the  body  which  a  few  years  ago  were  sacred. 


t89i.J 


BACTERIA  AND  PRACTICAL  SURGERY. 


507 


When  the  disease-producing  bacteria  gain  ac- 
cess to  the  tissues  and  blood  of  human  ami  other 
animals  by  means  of  wounds,  or  through  an  in- 
flamed pulmonary  or  alimentary  mucous  mem- 
brane, they  produce  pathological  effects  provided 
there  is  not  sufficient  resistence  and  health  power 
in  the  animal's  tissues  to  successfully  antagonize 
the  deleterious  influence  of  the  invading  parasitic 
fungus.  It  is  the  rapid  multiplication  of  the 
germs,  which  furnishes  a  continuous  irritation, 
that  enables  them  to  have  such  a  disastrous  effect 
upon  the  tissues  of  the  animal.  If  the  tissues 
had  only  the  original  dose  of  microbes  to  deal 
with,  the  warfare  between  health  and  disease 
would  be  less  uncertain  in  outcome.  Victory 
would  usually  be  on  the  side  of  the  tissues  and 
health. 

The  immediate  cause  of  the  pathogenic  influ- 
ence is  probably  the  chemical  excretions  which 
are  given  out  by  these  microscopic  germs.  All 
plants  and  animals  require  a  certain  number  of 
substances  to  be  taken  into  their  organisms  for 
preservation  of  their  vital  activities.  After  these 
substances  have  been  utilized  there  occurs  an  ex- 
cretion of  other  chemical  products.  It  is  prob- 
ably the  excretions  from  the  many  millions  of 
bacteria  circulating  in  the  blood  which  give  rise 
to  the  disease  characteristic  of  the  fungus  with 
which  the  animal  has  been  infected.  The  con- 
dition called  sapraernia,  or  septic  intoxication,  for 
example,  is  undoubtedly  due  to  the  entrance  of 
the  excretory  products  (ptomaines)  of  putrefac- 
tion-bacteria into  the  circulation.  This  can  be 
proved  by  injecting  into  an  animal  a  small  por- 
tion of  these  products  obtained  from  cultures  of 
the  germs  of  putrefaction.  Characteristic  symp- 
toms will  at  once  be  exhibited. 

Septicaemia  is  a  similar  condition  due  to  the 
presence  of  the  putrefactive  organisms  themselves, 
and  hence  of  their  products  or  ptomaines  also  in 
the  blood.  The  rapidity  of  their  multiplication 
in  this  albuminous  soil,  and  the  great  amount 
of  excretion  from  the  numerous  fungi,  makes  the 
condition  more  serious  than  sapraernia.  Clinic- 
ally, the  two  conditions  occur  together. 

The  rapidity  with  which  symptoms  may  arise 
after  inoculation  of  small  wounds  with  a  very  few 
germs  will  be  apparent  when  it  is  stated  that  one 
parasitic  plant  of  this  kind  may,  by  its  rapidity 
of  multiplication,  give  rise  to  fifteen  or  sixteen 
million  individuals  within  twenty-four  hours. 
The  enormous  increase  which  takes  place  within 
three  or  four  days  is  almost  incalculable.  It  has 
been  estimated  that  a  certain  bacillus  only  about 
1- 1000  of  an  inch  in  length  could,  under  favor- 
able conditions,  develop  a  brood  of  progeny  in  less 
than  four  days  which  would  make  a  mass  of 
fungi  sufficient  to  fill  all  the  oceans  of  the  world 
if  they  all  had  a  depth  of  one  mile. 

Bacteria  are  present  everywhere.  They  exist 
in  the  water,  earth,  air,  and  within  our  respira- 


tory and  digestive  tracts.  Our  skin  is  covered 
with  millions  of  them,  as  is  every  article  about 
us.  They  can  circulate  in  the  lymph  and  blood, 
and  reach  every  tissue  and  part  of  our  organisms 
by  passing  through  the  walls  of  the  capillaries. 
Fortunately,  they  require  certain  conditions  of 
temperature,  moisture,  air  and  organic  food  for 
existence,  and  for  the  preservation  of  their  vital 
activities. 

If  their  surroundings  are  too  hot,  too  cold,  or 
too  dry,  or  if  they  are  not  supplied  with  a  proper 
quantity  and  quality  of  food  from  the  soil  in  which 
they  are  living,  the  bacterium  becomes  inactive, 
until  the  surrounding  circumstances  change,  or 
die  absolutely.  The  spores  which  finally 
become  full-fledged  bacteria,  are  able  to  stand  a 
more  unfavorable  environment  than  the  adult 
bacteria.  Many  spores  and  adults,  however,  per- 
ish. Each  kind  of  bacterium  requires  its  own 
special  environment  to  permit  it  to  grow  and 
flourish.  The  frequency  with  which  an  unfavor- 
able combination  of  circumstances  occurs  limits 
greatly  the  disease-producing  power  of  the  patho- 
genic bacteria. 

Many  bacteria,  moreover,  are  harmless  and  do 
not  produce  disease  even  when  present  in  the 
blood  and  tissues.  Besides  this  the  white  blood 
cells  are  perpetually  waging  war  against  the  bac- 
teria in  our  bodies.  They  take  the  bacteria  into 
their  interiors  and  render  them  harmless  by  eat- 
ing them  up,  so  to  speak;  and  they  crowd  to- 
gether and  form  a  wall  of  white  blood  cells  around 
the  place  where  the  bacteria  entered  the  tissues, 
thus  forming  a  barrier  to  cut  off  the  blood  sup- 
ply to  the  germs  and  perhaps  to  prevent  them 
from  entering  the  general  blood  current. 

The  war  between  the  white  blood  cells  and  bac- 
teria is  a  bitter  one.  Many  bacteria  are  killed; 
but,  on  the  other  hand,  the  life  of  many  blood 
cells  is  sacrificed  by  the  bacteria  poisoning  them 
with  ptomaines.  The  tissue  cells,  if  healthy. 
offer  great  resistance  to  the  attacks  of  the  army  of 
bacteria.  Hence,  if  the  white  cells  are  vigorous 
and  abundant  at  the  site  of  the  battle,  defeat  may 
come  to  the  bacteria,  and  the  patient  suffers  noth- 
ing from  the  attempt  of  these  vegetable  parasites 
to  harm  him.  If,  on  the  other  hand,  the  tissues  have 
a  low  resistive  power,  because  of  the  general  debil- 
ity of  the  patient,  or  of  a  local  debility  of  the  tissues 
themselves,  and  the  white  cells  be  weakened  and 
not  abundant,  the  bacteria  will  gain  the  victory, 
get  access  to  the  general  blood  current  and  invade 
every  portion  of  the  animal's  body.  Thus,  a  gen- 
eral, or  a  local,  disease,  will  be  caused;  varying 
with  the  species  of  bacteria  with  which  the  pa- 
tient has  been  infected,  and  the  degree  of  resist- 
ance on  the  part  of  the  tissues. 

From  what  has  been  stated,  it  must  be  evident 
that  the  bacterial  origin  of  disease  depends  upon 
the  presence  of  a  disease-producing  fungus  and  a 
diminution  of   the  normal   or  healthy  tissue-re- 


5o8 


BACTERIA  AND  PRACTICAL  SURGERY. 


[April  ii, 


sistance  to  bacterial  invasion.     If  there  is  no  fun- 
gus present,  the  disease  caused  by  such  fungus 


Having  occupied  a  portion  of  the  time  allotted 
to  me  in  giving  a  crude  and  hurried    account  of 


cannot  develop.  If  the  fungus  be  present,  and  I  the  characteristics  of  bacteria,  let  me  discuss  the 
the  normal  or  health  tissue- resistance  be  undi- !  relations  of  bacteria  to  the  diseases  most  frequent- 
minished,  it  is  probable  that  disease  will  not  oc  !  ly  met  with  by  the  surgeon. 

cur.  As  soon,  however,  as  over-work,  injury  of,  Mechanical  irritations  produce  a  very  ternpor- 
a  mechanical  kind,  or  any  other  cause  diminishes  i  ary  and  slight  inflammation,  which  rapidly  sub- 
the  local  or  the  general  resistance  of  the  tissues  sides;  because  of  the  tendency  of  nature  to  restore 
and  individual,  the  bacteria  have  the  upper  hand,  j  the  parts  to  health.  Even  severe  injuries,  there- 
and  are  able  to  produce  their  malign  effect.  fore,  will  soon  become   healed  and  cured,  if  no 

Many    conditions  favor  the  bacterial    attack.  |  germs  enter  the  wound. 


Suppuration  of  operative  and  accidental  wounds 
was,  until  recently,  supposed  to  be  essential.  We 
now  know,  however,  that  wounds  will  not  sup- 
purate if  kept  perfectly  free  from  one  of  the  dozen 
forms  of  bacteria  that  are  known  to  give  rise  to 
the  formation  of  pus. 

The  doctrine  of  present  surgical  pathology  is 
bacteria  may  multiply;  the  blood  "may  have  un- 1  that  suppuration  will  not  take  place,  if  pus-form- 
dergone  certain  chemical  changes  which  render  j  ing  bacteria  are  kept  out  of  the  wound,  which 
it  better  soil  than  usual  for  the  rapid  growth  of  i  will  then  heal  by  first  intention  without  inflarnma- 
these  parasitic  plants.  tion  and  without  "  inflammatory"  fever. 

The    number   of    bacteria    originally  present  j      In  making  this  statement  I  am    not  unaware 
makes  a  difference  also.     It  is  readily  understood   that  there  is  a  certain  amount  of  fever  following 


The  patient's  tissues  may  have  an  inherited  pe- 
culiarity, which  renders  it  easy  for  the  bacteria 
to  find  a  good  soil  for  development;  an  old  injury 
or  inflammation  may  render  the  tissues  less  re- 
sistant than  usual;  the  point  at  which  inocula- 
tion has  occurred  may  have  certain  anatomical 
peculiarities  which  make  it  a  good  place  in  which 


that  the  tissues  and  white  blood  cells  would  find 
it  more  difficult  to  repel  the  invasion  of  an 
army  of  a  million  microbes,  than  the  attack  of  a 
squad  of  ten  similar  fungi.  I  have  said  that  the 
experimenter  can  weaken  and  augment  the  viru- 
lence of  bacteria  by  manipulating  their  surround- 
ings in  the  laboratory.  It  is  probable  that  such 
a  change  occurs  in  nature.  If  so,  some  bacteria 
are  more  virulent  than  others  of  the  same  species; 
some  less  virulent.  A  few,  of  the  less  virulent 
disposition,  would  be  more  readily  killed  by  the 
white  cells  and  tissues  than  would  a  larger  num- 
ber of  more  virulent  ones.  At  other  times 
times  the  danger  from  microbic  infection  is  great- 
er because  there  are  two  species  introduced  at  the 
same  time;  and  these  two  multiply  more  vigor- 
ously when  together  than  when  separated.  They 
are,  in  fact,  two  allied  hosts  trying  to  destroy  the 
blood  cells  and  tissues.  This  occurs,  for  instance, 
when  the  bacteria  of  putrefaction  and  the  bacteria 
of  suppuration  are  introduced  into  the  tissues  at 
the  same  time.  The  former  causes  sapraemia  and 
septicaemia,  the  latter  cause  suppuration.  The 
bacteria  of  tuberculosis  are  said  to  act  more  vi- 
ciously if  accompanied  by  the  bacteria  of  putre- 
faction. Osteomyelitis  is  of  greater  severity,  it 
is  believed,  if  due  to  a  mixed  infection  with  both 
the  white  and  the  golden  grape-coccus  of  suppur- 
ation. 

I  have  previously  mentioned  that  the  bacteria 
of  malignant  pustule  are  powerless  to  do  harm 
when  the  germs  of  erysipelas  are  present  in  the 
tissues  and  blood.  This  is  an  example  of  the  way 
in  which  one  species  of  bacteria  may  actually  aid 
the  white  cells,  or  leucocytes,  and  the  tissues  in 
repelling  an  invasion  of  disease-producing  mi- 
crobes. 


various  severe  wounds  within  twenty- four  hours, 
even  when  no  suppuration  occurs.  This  wound- 
fever,  however,  is  transitory,  not  high,  and  en- 
tirely different  from  the  prolonged  condition  of 
high  temperature  formerly  observed  nearly  always 
after  operations  and  injuries.  The  occurrence  of 
this  inflammatory,  traumatic,  surgical,  or  symp- 
tomatic fever,  as  it  was  formerly  called,  means 
that  the  patient  has  been  subjected  to  the  poison- 
ous influence  of  putrefactive  or  suppurative 
germs. 

We  now  know  why  it  is  that  certain  cases  of 
suppuration  are  not  circumscribed  but  diffused, 
so  that  the  pus  dissects  up  the  fascias  and  mus- 
cles and  destroys  with  great  rapidity  the  cellular 
tissue.  This  form  of  suppuration  is  due  to  a 
particular  form  of  bacteria  called  the  pus  forming 
"chain-coccus."  Circumscribed  abscesses,  how- 
ever, are  due  to  one  or  more  of  the  other  pus- 
causing  microorganisms. 

How  much  more  intelligent  is  this  explanation 
than  the  old  one  that  diffuse  abscesses  depended 
upon  some  curious  characteristic  of  the  patient.  It 
is  a  satisfaction  to  know  that  the  two  forms  of  ab- 
scess differ  because  they  are  the  result  of  inocu- 
lation with  different  germs.  It  is  practically  a 
fact  that  wherever  there  is  found  a  diffuse  abscess 
there  will  be  discovered  the  streptococcus  pyo- 
genes, which  is  the  name  of  the  chain-coccus 
above  mentioned. 

So  also  is  it  easy  now  to  understand  the  forma- 
tion of  what  the  old  surgeons  called  "cold  ab- 
scess," and  to  account  for  the  difference  in  ap- 
pearance of  its  puriform  secretion  from  the  pus  of 
acute  abscess.  Careful  search  in  the  fluid  com- 
ing from  such  cold  abscesses  reveals  the  presence 
of  the  bacillus  of  tuberculosis  and  proves  that  a 


t89i.] 


BACTERIA  AND  PRACTICAL  SURGERY. 


509 


cold  abscess  is  not  a  true  abscess,  but  a  local 
lesion  of  tubercular  infection.  Easy  is  it  now  to 
understand  the  similarity  between  the  "cold  ab- 
cess"  of  the  cervical  region  and  the  "cold  abscess" 
of  the  lung  in  a  phthisical  patient.  ISoth  of  them 
are,  in  fact,  simply  the  result  of  invasion  of  the 
tissues  with  the  ubiquitous  tubercle  bacillus:  and 
are  not  due  to  pus- forming  bacteria. 

Formerly  it  was  common  to  speak  of  the  scrof- 
ulous diathesis,  and  attempts  were  made  to  de- 
scribe the  characteristic  appearance  of  the  skin 
and  hair  pertaining  to  persons  supposed  to  be  of 
scrofulous  tendencies.  The  attempt  was  unsuc- 
cessful and  unsatisfactory.  The  reason  is  now 
clear  because  it  is  known  that  the  brunette  or 
blonde,  old  or  young,  may  become  infected  with 
the  tubercle  bacillus.  Since  the  condition  de- 
pends upon  whether  one  or  other  becomes  infected 
with  the  ever  present  bacillus  of  tubercle,  it  is 
evident  that  there  can  be  no  distinctive  diathesis. 
It  is  more  than  probable  that  the  cutaneous 
disease  so  long  described  as  lupus  vulgaris  is  sim- 
ply a  tubercular  condition  of  the  skin,  and  not  a 
special  disease  of  unknown  causation. 

The  metastatic  abscesses  of  pyaemia  are  clearly 
explained  when  the  surgeon  remembers  that  they 
are  simply  due  to  a  softened  blood  clot,  contain- 
ing pus-forming  germs,  being  carried  through  the 
circulation  and  lodged  in  some  of  the  small  capil- 
laries. 

A  patient  suffering  with  numerous  boils  upon 
his  skin  has  often  been  a  puzzle  to  his  physician, 
who  has  in  vain  attempted  to  find  some  cause  for 
the  trouble  in  his  general  health  alone.  Had  he 
known  that  every  boil  owed  its  origin  to  pus  bac- 
teria which  had  infected  a  sweat  gland  or  hair 
follicle,  the  treatment  would  probably  have  been 
more  efficacious.  The  suppuration  is  due  to  pus- 
germs,  either  lodged  upon  the  surface  of  the  skin 
from  the  exterior,  or  deposited  from  the  current 
of  blood  by  which  they  have  been  carried  to  the 
spot. 

I  have  not  taken  time  to  go  into  a  discussion  of 
the  methods  by  which  the  relationship  of  micro 
organisms  to  surgical  affections  has  been  estab- 
lished; but  the  absolute  necessity  for  every  sur- 
geon to  be  fully  alive  to  the  inestimable  value  of 
aseptic  and  antiseptic  surgery  had  led  me  to  make 
the  foregoing  statements  as  a  sort  of  resume  of 
the  relation  of  the  germ  theory  of  disease  to  sur- 
gical practice.  It  is  clearly  the  duty  of  every 
man  who  attempts  to  practice  surgery  to  prevent, 
by  every  means  in  his  power,  the  access  of  germs, 
whether  of  suppuration,  putrefaction,  erysipelas, 
tubercle,  tetanus  or  any  other  disease  to  the 
wounds  or  body  of  a  patient.  This  as  we  all 
know,  can  be  done  by  absolute  bacteriological 
cleanliness.  It  is  best,  however,  not  to  rely  sole- 
ly upon  absolute  cleanliness,  which  is  almost  un- 
attainable; but  to  secure  further  protection  by  the 
use  of  antiseptic  solutions.  I  am  fully  of  the  opin- 


ion that  chemical  antiseptics  would  be  needless, 
if  absolute  freedom  from  germs  was  easily  ob- 
tained. When  I  know  that  even  such  an  enthu- 
siast as  I,  myself,  is  continually  liable  to  forget 
or  neglect  some  step  in  this  direction,  I  feel  that 
i  tional  security  of  chemical  antiseptics  is 
of  great  value.  It  is  difficult  to  convince  the  ma- 
jority of  physicians,  and  even  ourselves,  that  to 
touch  during  an  operation  a  finger  to  a  door 
knob,  to  an  assistant's  clothing,  or  to  one's  own 
body  may  be  to  vitiate  the  entire  operation  by  in- 
troducing one  or  two  microbic  germs  into  the 
wound. 

An  illustration  of  how  carefully  the  various 
steps  of  an  operation  should  be  guarded  is  afford- 
ed by  the  appended  rules,  which  I  have  adopted 
at  the  Woman's  Hospital  of  Philadelphia  for  the 
guidance  of  assistants  and  nurses.  If  such  rules 
were  taught  every  medical  student  and  every 
physician  entering  practice  as  earnestly  as  the 
paragraphs  of  the  catechism  are  taught  the  Sun- 
day School  pupil  (aud  they  certaiuly  ought  to  be 
so  taught)  the  occurrence  of  suppuration,  hectic 
fever,  septicaemia,  pyaemia  and  surgical  erysipelas 
would  be  practically  unknown.  Death  then 
would  seldom  occur  after  surgical  operations  ex- 
cept from  haemorrhage,  shock  or  exhaustion. 

With  this  feeble  plea,  Mr.  President  and  Mem- 
bers of  the  Society,  I  hope  to  create  a  realization 
of  the  necessity  for  knowledge  and  interest  in  the 
direction  of  bacteriology,  for  this  is  the  founda- 
tion of  Modern  Surgery.  There  is,  unfortunate- 
ly, a  good  deal  of  abdominal  work  done  under 
the  name  of  antiseptic  and  aseptic  surgery,  be- 
cause the  simplest  facts  of  bacteriology  are  un- 
known to  the  operator.  I  have  taken  the  liberty 
of  bringing  here  a  number  of  culture  tubes  con- 
taining beautiful  specimens  of  some  of  the  more 
common  and  interesting  bacteria.  The  slimy 
masses  seen  on  the  surface  of  the  jelly,  contained 
in  the  tubes,  are  man)-  millions  of  individual 
plants,  which  have  aggregated  themselves  in  vari- 
ous forms,  as  they  have  been  developed  as  the 
progeny  of  the  parent  cells  planted  in  the  jelly  as 
a  nutrient  medium  or  soil. 

RULES  TO  BE    OBSERVED   IN    OPERATIONS    IN    DR. 

ROBERTS'  SURGICAL  CLINIC  OF  THE  WOMAN'S 

HOSPITAL   OF   PHILADELPHIA. 

After  wounds  or  operations,  high  temperature  usually, 
and  suppuratiou  always,  is  due  to  blood  poisoning, 
which  is  caused  by  infection  with  vegetable  parasites 
called  bacteria.  These  parasites  ordinarily  gain  access 
to  the  wound  from  the  skin  of  the  patient,  the  finger 
nails  or  hand  of  the  operator  or  his  assistants,  the  liga- 
tures, sutures  or  dressings. 

Suppuratiou  and  high  temperature  should  not  occur  af- 
ter operation  wounds,  if  suppuration  has  not  existed  previ- 
ously. Bacteria  exists  almost  everywhere  as  invisible  par- 
ticles in  the  dust;  hence,  everything  that  touches  or  comes 
into  even  momentary  contact  with  the  wound  must  be 
germ- free;  technically  called  "sterile."  A  sterilized 
condition  of  the  operator,  the  assistant,  the  wound,  in- 
struments, etc.,  is  obtained  by  removing  all  bacteria  by 


5io 


PREVENTION  OF  SHORT  LEG  OF  HIP  DISEASE. 


[April  ii, 


means  of  absolute  surgical  cleauliness  (asepsis, )  and  by 
the  use  of  those  chemical  agents  which  destroy  the  bac- 
teria not  removed  by  cleanliness  itself  (antisepsis).  Surr 
gical  cleanliness  differs  from  the  housewife's  idea  of 
cleanliness  in  that  its  details  seem  frivolous,  because  it 
aims  at  the  removal  of  microscopic  particles.  Stains 
such  as  housewives  abhor,  if  germ-free,  are  not  objected 
to  in  surgery.  The  hands  and  arms,  and  especially  the 
finger  nails  of  the  surgeon  and  assistants  and  nurses, 
should  be  well  scrubbed  with  hot  water  and  soap  by 
means  of  a  nail  brush  immediately  before  the  operation. 
The  patient's  body  about  the  site  of  the  operation  should 
be  similarly  scrubbed  with  a  brush  and  cleanly  shaven. 
Subsequently  the  hands  of  the  operator,  assistants  and 
nurses,  and  the  field  of  operation,  should  be  immersed  in, 
or  thoroughly  washed  with,  corrosive  sublimate  solution 
(iiooo,  or  1-2000).  Finger  rings,  bracelets,  bangles, 
cuffs  worn  by  the  surgeon,  assistants  or  nurses,  must  be 
removed  before  the  cleansing  is  begun,  and  the  clothing 
covered  by  a  clean  white  apron  large  enough  to  extend 
from  neck  to  ankles  and  provided  with  sleeves. 

The  instruments  should  be  similarly  scrubbed  with  hot- 
water  and  soap  and  all  particles  of  blood  and  pus  from 
any  previous  operation  removed  from  the  joints.  After 
this  they  should  be  immersed  for  at  least  fifteen  minutes 
in  a  solution  of  betanaphthol  (1-2500),  which  must  be 
sufficiently  deep  to  cover  every  portion  of  the  instru- 
ments. After  cleansing  the  instruments  with  soap  and 
water,  baking  in  a  temperature  a  little  above  the  boiling 
point  is  the  best  sterilizer.  During  the  operation  the 
sterilized  instruments  should  be  kept  in  a  betanaphthol 
solution  and  returned  to  it  when  the  operator  is  not  using 
them. 

Sponges  should  be  kept  in  a  betanaphthol  solution 
(or  a  corrosive  sublimate  solution)  during  the  operation. 
After  the  blood  from  the  wound  has  been  sponged  away, 
they  should  be  put  in  another  basin  containing  an  anti- 
septic solution  and  must  be  thoroughly  cleansed  and 
sterilized  anew  before  being  used  again.  The  antiseptic 
sutures  and  ligatures  should  be  similarly  soaked  in 
betanaphthol  solution  during  the  progress  of  the  opera- 
tion. 

No  one  should  touch  the  wound  but  the  operator  and 
his  first  assistant.  No  one  should  touch  the  sponges  but 
the  operator,  his  first  assistant,  and  the  nurse  having 
charge  of  them.  No  one  should  touch  the  already  pre- 
pared ligatures  or  instruments  except  the  surgeon  and 
his  first  and  second  assistant.  None  but  those  assigned 
to  the  work  are  expected  to  handle  instruments,  sponges, 
dressings,  etc.,  during  the  operation. 

When  any  one  taking  part  in  the  operation  touches  an 
object  not  sterilized,  such  as  a  table,  a  tray,  or  the  ether 
towel,  he  should  not  be  allowed  to  touch  the  instruments, 
the  dressings,  or  the  ligatures  until  his  hands  have  been 
again  sterilized.  It  is  important  that  the  hands  of  the 
surgeon,  his  assistants  and  nurses  should  not  touch  any 
part  of  his  own  or  the  patient's  body,  because  infection 
may  be  carried  to  the  wound.  Rubbing  the  beard  or 
head,  or  wiping  the  nose,  requires  immediate  disinfec- 
tion of  the  hands  to  be  practiced. 

The  trailing  ends  of  ligatures  and  sutures  should  never 
be  allowed  to  touch  an  assistant's  or  surgeon's  dress,  or 
to  drag  upon  the  operating  table  because  contact  may 
occasionally,  though  not  always,  pick  up  bacteria,  which 
may  cause  suppuration  in  the  wound. 

Instruments  that  fall  upon  the  floor  should  not  be  again 
used  until  thoroughly  disinfected.  The  clothing  of  the 
patieni  in  the  vicinity  of  the  part  to  be  operated  upon, 
and  the  blankets  and  sheets  used  to  keep  him  warm 
should  be  covered  with  dry  sublimate  towels,  and  all 
dressings  should  be  kept  safe  from  infection  by  being 
stored  in  glass  jars  or  wrapped  in  dry  sublimate  towels. 


ORIGINAL  ARTICLES. 


THE  PREVENTION  OF  THE  SHORT  EEG 
OF   HIP  DISEASE. 


Read  be/ore  the  Ar, 


an  Orthopaedic  Association 
September  rS,  iSSq. 

BY  A.  B.  JUDSON,  M.D.: 


at  Boston.  Mas 


iKTfiur.r.nic  mkgkon  to  ti 


A  short  leg  is  what  is  commonly  dreaded  as  the 
result  of  hip  disease.  The  shortening  is  not, 
however,  as  a  rule,  due  to  the  shortening  of  the 
bones.  What  produces  the  short  leg  of  hip  dis- 
ease is  an  immobilization  of  the  joint  which  pre- 
vents the  reduction  of  flexion  of  the  thigh,  or  ad- 
duction of  the  thigh;  or  which,  as  too  often  hap- 
pens, prevents  the  reduction  of  both  flexion  and 
adduction.  If,  for  instance,  the  patient  stands 
with  the  thigh  considerably  adducted,  we  will 
say  22.5  degrees,  and  fixed  at  that  angle,  the 
limb  cannot  be  made  vertical  without  elevation 
of  that  side  of  the  pelvis,  with  of  course  a  draw- 
ing upward  of  the  heel  and  an  inevitable  appear- 
ance of  shortening;  and  if  the  thigh  is  flexed,  for 
example  45  degrees,  and  fixed  at  that  angle,  the 
limb  cannot  be  made  vertical  without  an  inclina- 
tion forward,  which  gives  an  appearance  of  short- 
ening to  the  whole  figure.  Thus  we  see,  that 
when  the  patient  stands,  adduction  means  "ap- 
parent shortening."  The  same  is  true  of  flexion. 
And  when  we  direct  our  attention  to  the  deform- 
ity which  attends  the  patient  when  he  walks,  we 
see  that  the  affected  side  dips  at  every  step,  and 
that  when  the  limb  comes  into  a  vertical  position, 
as  it  does  at  the  critical  moment  when  it  is  called 
upon  to  support  the  weight  of  the  body,  the  pel- 
vis rocks  forward  or  laterally,  or  it  may  be  in  both 
directions  at  ever}'  step;  and  we  have  the  charac- 
teristic gait  of  hip  disease. 

If,  on  the  other  hand,  the  thigh  is  immovable 
on  the  pelvis  in  a  good  position,  neither  adducted 
nor  flexed,  when  the  patient  stands,  the  limb  is 
vertical  and  the  pelvis  is  level  in  all  directions; 
and  when  the  patient  walks,  the  pelvis  without 
any  lateral  tilting,  rocks  to  and  fro  with  a  moder- 
ate motion,  enough  to  allow  the  limb  'to  swing 
backward  and  forward,  by  virtue  of  the  mobility 
of  the  vertebral  joints  and  the  hip  joint  of  the  un- 
affected side,  in  the  arc  appropriate  for  locomo- 
tion in  a  comparatively  easy  and  graceful  way. 
Walking  thus  performed,  is  attended  by  no  dip- 
ping of  the  affected  side,  and  with  no  shortening 
except  what  may  come  from  shortening  of  the 
bones  or  "  real  shortening." 

How  to  secure  this  good  position  of  the  limb  in 
a  hip  joint  anchylosed  by  disease,  is  a  question  of 
great  importance,   second  only  to  the  question. 


■  In  abdominal  operations  it  is  usually  not  necessary,  and  may 
be  mi  wise,  to  use  tbe  ordinary  cliemical  antiseptic solutli 
oftheii  irritant  qualities,     when  used  in   the  abdominal  and  pelvic 

cavities  such  solutions  must  be  very  weak;  ordinarily,   water  ren- 


dered sterile  by  boiling  just  before  the  operation,  is  the  proper  fluid 
for  sponges,  irrigation  and  Instruments.  The  precautions  as  to 
cleansing  the  area  of  operations  externally,  and  as  to  instrumental 

must  be  the  same  as  in  other  operative  procedures. 


iS9i.] 


PREVENTION  OF  SHORT  LEG  OF  HIP  DISEASE. 


5" 


How  can  we  promote  resolution  of  the  inflamma- 
tion? I  believe  a  good  ultimate  position  of  the 
limb  can  be  obtained  by  inducing  the  patient 
to  use  the  affected  limb  as  much  as  possible  in 
walking,  of  course  protected  from  concussion  by 
the  hip  crutch. 

I  do  not  mean  to  say  that  traction  is  usi 
an  agent  for  overcoming  deformity;  it  will  di- 
minish extreme  deformity  with  absolute  certainty 
whether  applied  with  the  weight  and  pulley  or 
rack  and  pinion;  but  it  is  less  effective  when  the 
dty  is  only  moderate  or  slight.  Applied,  for 
instance,  to  an  extreme  case  i  if  flexion,  it  will  pro- 
duce extension.  Indeed,  traction,  a  few  years 
ago,  was  universally  called  extension.  But  in 
proportion  as  the  flexiou  is  reduced,  the  power  of 
traction  to  further  reduce  the  deformity  rapidly 
diminishes,  because  it  is  evident  that  a  given 
power  loses  its  ability  to  overcome  resistance  at 
the  angle,  as  the  angle  becomes  more  obtuse.  If, 
for  instance,  we  would  straighten  a  crooked  nail 
we  may,  if  the  nail  is  very  much  bent,  say  at  an 
angle  of  900,  reduce  the  angle  by  traction:  but  as 
the  angle  becomes  more  and  more  obtuse,  the 
power  of  traction  to  accomplish  our  object  les- 
sens, and  finally  disappears. 

This  consideration  is  one  of  those  which  lead 
rue  to  discredit  traction  as  a  means  of  reducing 
deformity.  Another,  is  the  fact,  that  although 
traction  may  in  skilful  hands  overcome  even 
slight  degrees  of  deformity,  it  is  only  by  assidu- 
ous attention  and  a  nice  adjustment  of  the  direc- 
tii  in  in  which  the  force  is  applied  that  this  may  be 
done.  The  correct  position  of  the  limb,  thus 
brought  about,  is  maintained  while  the  patient  is 
under  special  supervision  and  restraint;  but  when 
they  are  relaxed,  the  causes,  whatever  they  may 
be,  which  produce  the  deviation,  resume  their  in- 
fluence. And  this  leads  to  the  inquiry.  What  are 
the  causes  which  produce  the  customary  deform- 
ity of  hip  disease;  what  flexes  and  adducts  the 
limb? 

This  question  is  quite  distinct  from  the  ques- 
tion, What  prevents  motion?  We  know  that  mo- 
tion is  prevented,  first,  by  reflex  contraction  of  the 
muscles,  and  afterward  by  anchylosis:  but  what 
determiues  the  position  of  the  limb  through  the 
months  and  years  when  muscular  action  holds  it 
fixed;  what  forbids  a  good  position  and  inclines 
toward  adduction  and  flexion?  If  we  can  discover 
the  forces  which  cause  the  limb  to  err,  we  may 
perhaps  remove  or  thwart  them.  It  has  been  said 
that  effusion  determines  the  direction  of  the  limb, 
which  takes  that  position  in  which  the  capsule 
can  best  accommodate  the  volume  of  fluid.  Mi- 
gration of  the  acetabulum  and  dislocation  of  the 
femoral  head,  have  also  been  cited  as  controlling 
forces.  Abduction  has  been  thought  to  depend  on 
spasm  of  the  gluteal  muscles  followed  by  their 
paralysis,  whipb  allows  their  opposing  muscles  to 
produce  adduction.     Atrophy  and  attrition  of  the 


head  and  acetabulum  have  been  thought  to  have 
some  effect  in  deciding  the  character  of  the  de- 
formity. It  has  also  been  said  that  the  limb 
takes  that  position  in  which  an  imaginary  pain- 
ful spot  or  area  on  the  head  of  the  femur  is  furthest 
removed  from  the  depth  of  the  acetabulum,  where 
it  would  receive  pressure  from  muscular  action. 

In  some  stages,  and  in  certain  cases,  each  of 
these  modes  of  accounting  for  the  chosen  position 
of  the  limb  may,  or  may  not,  be  correct;  but 
what  we  want,  is  to  recognize  some  cause,  gen- 
eral in  its  application,  and  independent  of  such 
pathological  conditions  as  have  been  cited,  which 
are  more  or  less  transient  and  difficult  to  demon- 
strate in  bone,  muscle,  nerve,  or  effused  fluid.  A 
more  widely  applicable  theory  is  that  which  says 
the  position  is  generally  the  attitude  of  minimum 
suffering;  but  pain  is  not  always  present,  indeed, 
as  a  rule,  it  is  present  but  a  small  portion  of  the 
time  during  which  the  limb  is  held  in  its  select- 
ed position.  Can  we  not  find  a  cause  which  is 
in  force  in  all  the  periods  of  the  affection,  the 
paiuless  as  well  as  the  painful  ? 

It  has  been  said,  and  wisely,  that  the  position 
is  due  to  efforts  made  by  the  child  and  nature  to 
secure  fixation,  and  that  the  position  assumed  is 
that  in  which  immobilization  by  nature  reaches 
its  maximum.  This  is  a  good  explanation,  and 
applicable  to  every  case  in  all  of  its  stages;  but  I 
do  not  think  these  words  quite  cover  the  whole 
ground.  I  would  add  to  them  a  line  recognizing 
the  influence  exerted  on  the  direction  of  the  limb 
by  the  patient's  habitual  attitudes  and  positions. 

Before  accepting  this  addition,  however,  it  will 
be  necessary  for  us  to  accustom  ourselves  to  recog- 
nize the  fact  that  the  fixation  or  immobilization 
by  reflex  muscular  action  is  very  far  from 
being  absolute  immobility.  This  view  is  in 
with  the  ordinary  events  of  practice.  Cases 
in  which  fixedness  is  inconstant  are  matteis  of 
daily  observation.  For  instance,  a  joint  at  the 
first  moment  of  examination  is  without  motion, 
but  a  few  moments  of  delay  and  skilful  manipu- 
lation reveal  slight  motion.  Or,  at  one  examin- 
ation, the  limb  is  in  a  position,  adducted  we  will 
say,  at  a  certain  angle,  which  is  made  a  matter 
of  record,  and  at  the  next  examination,  a  few 
hours  or  days  later,  the  angle  is  widely  increased 
or  diminished.  Or  a  patient  with  marked  de- 
formity is  put  to  bed  with  a  weight  and  pulley, 
or  is  treated  by  traction  with  the  hip-splint,  and 
the  deformity  is  greatly  mitigated  in  a  few  hours. 
In  all  these  cases,  reflex  muscular  action  is  in 
force,  and  yet  it  does  not  prohibit  changes  in  the 
direction  of  the  limb.  The  condition  resembles 
that  found  in  patients  affected  with  a  certain 
kind  of  paralysis,  whose  joints  have  been  com- 
pared to  a  leaden  pipe  which  retains  its  shape 
with  a  very  positive  degree  of  fixedness,  but 
which  can  be  bent  by  the  application  of 
able  degree  of  force. 


512 


PREVENTION  OF  SHORT  LEG  OF  HIP  DISEASE. 


[April  ii, 


In  view  of  this  mobility  of  the  joint,  fixed  by 
reflex  muscular  action,  I  believe  that  the  position 
assumed  by  the  limb  is  determined  by  the  pa- 
tient's efforts,  both  voluntary  and  reflex,  to  place 
the  limb  where  its  fixation  will  be  liable  to  the 
least  disturbance,  and  where  it  will  afford  him 
the  most  convenience  in  his  ordinary  attitudes 
and  movements. 

Before  considering  how  to  avert  deformity  it  is 
in  order  to  review  the  typical  positions  of  the 
limb  in  hip  disease.  They  seem  to  be  three  in 
number,  and  arranged  chronologically  as  follows: 
i.  Abduction,  which  is  produced  early  in  the 
disease,  when  the  patient  seeks  to  favor  the  limb 
when  he  stands  by  putting  his  weight  on  the 
sound  limb.  He  assumes  the  attitude  which  fol- 
lows the  military  order,  "at  rest,"  in  which  the 
limb  is  abducted  with  a  descent  of  the  pelvis  on 
that  side  and  apparent  lengthening.  Eater  in  the 
progress  of  the  disease,  we  have,  2.  Adduction 
and  flexion,  caused  by  the  patient's  efforts  to 
withdraw  the  affected  limb  from  undue  contact 
with  the  ground,  and  to  make  the  disabled  mem- 
ber as  little  an  impediment  as  possible,  while  the 
chief  work  of  progression  is  done  by  the  sound 
limb.  The  natural  rhythm  of  the  gait  is  broken, 
the  sound  foot  being  on  the  ground  longer  than 
the  other,  and  the  affected  limb  is  drawn  up  out 
of  the  way,  when  the  foot  is  raised  from  the 
ground,  by  an  elevation  of  the  pelvis  on  that  side, 
with  of  course,  adduction  and  flexion  of  the  thigh 
and  apparent  shortening.  Finally,  in  the  neg- 
lected and  bed-ridden  patient,  we  have,  3.  Ex- 
treme flexion  of  the  knee  and  thigh,  and  extreme 
adduction  of  the  thigh,  obviously  the  position  in 
which  the  patient  is  most  comfortable,  and  the 
joint  most  free  from  disturbance. 

These  changes,  taking  place  in  a  typical  and 
uninterrupted  case,  but  illustrate  the  mobility  of 
the  immobilization,  so  to  speak,  which  charac- 
terizes hip  disease.  In  passing,  would  it  not  be 
well  to  agree  to  call  this  form  of  immobilization, 
"fixation,"  a  term  the  status  of  which  is  not  well 
established,  leaving  the  longer  word  to  be  ap- 
plied to  absolute  immobility,  such  as  accompanies 
anchylosis  or  bony  union  after  fracture  ?  We 
could  also  use  the  term  fixation  to  indicate  what 
we  produce  in  the  hip-joint  by  traction,  which  is 
not  absolute  immobility,  but  enough  immobiliza- 
tion to  aid  the  natural  efforts  to  keep  the  joint 
still  and  promote  resolution,  and  yet  not  enough 
to  stand  in  the  way  of  desirable  changes  in  the 
position  of  the  limb. 

To  return  to  methods  of  averting  deformity, 
the  first  position,  that  of  abduction,  seldom  calls 
for  attention  in  practice.  It  would,  in  some  cases, 
be  fortunate  if  slight  abduction  could  be  main- 
tained as  the  ultimate  position,  because  the  ap- 
parent lengthening  thus  secured  might  happily 
compensate  for  whatever  real  shortening  is  en- 
tailed by  the   destruction  or  retarded  growth  of 


the  bone.  The  third  position,  extreme  flexion 
and  adduction,  cannot  occur  with  the  use  of 
the  hip-splint;  and  as  we  all,  I  presume,  adhere 
to  treatment  by  this  apparatus,  the  practical  ques- 
tion before  us  concerns  only  the  prevention  of  the 
second  position,  that  in  which  the  thigh  is  seri- 
ously but  not  extremely  flexed  and  adducted. 
How  can  we  then,  by  the  use  of  the  hip  splint, 
keep  the  limb  slightly  flexed  and  free  from  adduc- 
tion during  the  man)'  months  which  usually  in- 
tervene between  the  first  appearance  of  deformity 
and  the  occurrence  of  anchylosis  ? 

To  recall  what  we  have  said  about  the  cause  of 
this  deformity,  it  is  the  result  of  the  patient's  ef- 
forts to  keep  the  affected  limb  off  the  ground  while 
the  well  limb  does  most  of  the  work  of  progres- 
sion. If  then,  we  can  induce  the  patient  to  adopt 
a  gait  in  which  the  two  limbs  are  used  equally, 
the  cause  of  the  deformity  would  vanish.  The 
affected  limb  would  then  reach  for  the  ground  at 
every  step  when  its  turn  came,  and  that  would 
mean  a  descent  of  the  pelvis  and  the  abolition  of 
adduction,  and  this  would  be  unattended  with 
violence  to  the  affected  joint,  because  the  weight 
of  the  body  comes  on  the  ischiatic  tuberosity 
resting  on  the  perineal  strap,  and  not  on  the  heel. 
The  first,  or  an  occasional  effort  of  this  kind, 
would  not  be  likely  to  produce  any  effect,  but  if 
the  effort  is  made  habitual  or  a  matter  of  system- 
atic drill,  the  adduction  of  the  limb  will  be  gen- 
tly and  gradually  corrected,  becanse  the  patient, 
consciously  or  otherwise,  will  incline  the  limb 
towards  abduction,  so  that  he  can  more  readily 
conform  to  the  mode  of  walking  prescribed  for 
him.  Undue  flexion  is  subject  to  similar  correc- 
tive procedures.  And  if  the  naturally  rhythmical 
action  of  the  limbs  is  restored  and  becomes 
habitual,  the  limb  fixed  in  a  good  position  by  re- 
flex muscular  action,  becomes  immobilized  by 
anchylosis,  and  the  patient  recovers  with  the 
minimum  of  deformity  and  locomotor  disability. 

It  may  be  said,  by  the  way,  that  the  rhythm 
of  the  human  gait  is  a  subject  which  has  not 
received  the  attention  to  which  it  is  entitled. 
When  natural,  it  is  very  simple,  the  time  being 
divided  equally  between  the  two  feet;  but  its  very 
simplicity  makes  a  slight  deviation  very  notice- 
able, as  in  the  lameness  of  incipient  hip  disease 
in  a  child,  in  whom  the  ordinary  motions  of  the 
joint  are  as  yet  unlimited,  and  whose  lameness  is 
entirely  due  to  the  fact  that  he  violates  rhythm 
by  spending  more  time  on  the  sound  than  on 
the  affected  limb.  He  accents  the  blow  given  to 
the  ground  by  the  well  foot,  which  hastens  to  re- 
lieve the  affected  limb  of  the  weight  of  the  body. 
It  is  a  point  of  practical  importance  that  many 
people  who  are  lame,  add  to  their  lameness  by 
neglecting  to  keep  correct  time  with  their  et. 
Any  of  us  can  appear  lame  by  simply  giving  more 
time  to  one  foot  than  to  the  other,  a  matter  of 
easy  and  immediate  demonstration;   and  one  who 


I89I.] 


PREVENTION  OF  SHORT  LEG  OF  HIP  DISEASE. 


5'3 


is  really  lame  can  lessen  the  appearance  of  being 
so  by  simply  giving  natural  rhythm  to  the  action 
of  the  feet. 

I  have  been  led  to  the  opinions1  presented  in 
this  paper  by  pondering  the  question,  Why  do 
patients  similarly  affected,  and  treated  exactly 
alike,  recover  with  such  different  degrees  of  de- 
formity? A  young  girl,  for  instance,  was  in  the 
third  stage,  in  which  she  nearly  lost  her  life,  be- 
fore treatment  was  begun.  She  has  recovered 
with  no  adduction,  and  almost  no  flexion  ;  so 
that  although  there  is  real  shortening  of  nearly 
two  inches,  there  is  very  little  lameness.  I  at- 
tribute this  good  position  to  the  fact  that  her 
mother  was  very  anxious  about  her  only  daugh- 
ter, and  was  always  with  her,  so  that  every  step 
the  child  took  with  the  hip  splint  was  taken  un- 
der the  necessity  of  appearing  as  well  as  she 
could.  Her  steps  were  equally  timed,  and  the 
affected  limb  became  anchylosed  in  a  useful  posi- 
tion because  it. had  to  do,  so  far  as  was  possible, 
half  the  work  of  locomotion.  I  also  treated  a 
boy  who  recovered  from  the  disease,  in  a  more 
moderate  although  purulent  form  ;  but  he  iimps 
about  most  awkwardly  with  20  degrees  of  ad- 
duction, and  50  degrees  of  flexion.  I  explain 
his  bad  position  by  the  fact  that  the  mother,  one 
of  the  best  of  women,  was  busy  out  of  the  house, 
every  day,  and  nearly  all  day,  necessarily  leaving 
at  home  and  very  much  to  their  own  devices,  her 
family  of  four  boys.  As  the  patient  was  most  of 
the  time  in  excellent  general  health  and  very  am- 
bitious, he  vied  with  his  brothers  in  all  their 
games,  and  developed  his  well  limb  enormously 
at  the  expense  of  the  affected  one,  which  was 
elevated  and  adducted  to  keep  it  out  of  the  way. 
In  another  case  the  patient,  who  recovered  after 
long-continued  purulent  discharges,  was  a  girl 
endowed  with  uncommon  beauty  ;  and  although 
she  was  by  no  means  docile,  and  under  very  lit- 
tle restraint  at  home,  her  vanity  led  her  to  try 
always  to  appear  at  the  best  advantage,  and 
thanks  to  her  careful  gait  and  studied  attempts 
to  be  graceful,  she  now  walks  with  very  little 
lameness,  with  flexion  not  more  than  10  degrees, 
adduction  nil,  and  more  than  two  inches  of  real 
shortening. 

Another  child,  whose  treatment  as  a  hospital 
out-patient  was  finally  suspended  for  neglect,  will 
probably  recover  with  the  limb  adducted  forty- 
five  degrees.  A  year  before  her  final  discharge 
she  was  made  an  in-patient  and  the  deformity 
was  entirely  reduced  by  recumbency  and  the 
weight  and  pulley  for  seven  weeks ;  but  soon 
after  returning  to  her  unfortunate  home,  where  a 
large  family  and  poverty  make  even  ordinary  pa- 
rental care  impossible,  the  deformity  recurred  and 
will  doubtless  be  permanent. 

These  are  the  more  striking  examples  selected 


1  Medical  Record.  May 
ne.  May.  if  Si.  p.  372. 


St.  Louis  Courier  of  Med- 


from  many  cases,  the  study  of  which  has  led  me 
to  the  practical  conclusions  above  expressed.  I 
believe  that  for  years  I  made  a  mistake  by  en- 
couraging patients,  protected  by  the  hip  splint, 
to  take  part  in  the  rough  occupations  of  healthy 
children.  One  result  was  frequent  chafing  by  the 
perineal  straps,  which  at  orrce  destroys  correct 
rhythm,  because  it  is  impossible  for  the  patient 
to  divide  his  weight  equally  between  the  well  foot 
on  the  one  side,  and  the  excoriated  perineum  on 
the  other.  It  is  my  practice  rrow  to  advise  mod- 
eration in  exercise,  and  especial  attention  to  the 
manner  of  walking.  I  insist  on  the  patient's 
keeping  time  in  his  steps  so  far  as  practicable, 
and  lead  him  to  adopt  and  maintain  a  proud  bear- 
ing, keeping  his  head  high  and  behind  the  verti- 
cal of  the  centre  of  gravity.  A  girl  is  told  to 
practice  deportment  before  the  looking  glass,  and 
a  boy  is  advised  to  organize  a  juvenile  military 
company,  and  to  take  command  of  it  himself. 
The  parents  are  informed  of  the  importance  of 
encouraging  the  child  to  adopt  deliberate  and 
graceful  movements  on  all  occasions.  Since  I 
have  changed  my  practice  in  this  regard,  there 
has  been  an  improvement  in  results,  and  I  no 
longer  am  anxious  as  to  the  ultimate  position 
except  in  those  cases  in  which  the  patient  is  in- 
tractable, and  the  domestic  management  at  fault. 

It  may  be  well  to  mention  that,  as  in  this  meth- 
od of  regulating  the  position  of  the  limb  no  ac- 
count is  made  of  the  abductive  power  of  the 
traction  by  the  hip  splint,  the  perineal  strap  on 
the  sound  side  is  dispensed  with.  A  single  strap 
is  more  convenient,  and  has  proved  sufficient  both 
as  an  ischiatic  crutch  and  an  agent  for  making 
counter  traction  when  the  rack  and  pinion  are 
used. 

Summai jr.—  The  deformities  of  hip  disease  are 
caused  by  the  patient's  efforts  to  so  place  the 
limb  that  it  shall  be  the  least  disturbed  by.  and 
afford  him  the  most  convenience  in,  his  customary- 
attitudes  and  movements.  They  are,  i.  Abduc- 
tion ;  2,  Adduction  and  flexion  :  and  3.  Extreme 
adduction  and  flexion.  The  second  position  is 
practically  by  far  the  most  important,  and  is  the 
only  one  considered  in  this  paper.  It  is  caused 
by  the  patient's  elevating  that  side  of  the  pelvis 
in  order  to  take  the  limb  off  the  ground,  and  to 
keep  the  affected  limb  out  of  the  way  of  the  well 
one.  which  is  on  the  ground  a  longer  time  than 
the  affected  limb,  and  does  most  of  the  work  of 
progression.  The  limb  is  maintained  in  the  chosen 
position  by  reflex  muscular  contraction,  which 
does  not  immobilize  the  joint,  but  fixes  it  in  such 
a  manner  that  changes  in  its  position  are  readily- 
made  by  the  application  of  gentle  but  persistent 
force.  It  is  proposed  therefore,  to  induce  the  pa- 
tient, wearing  the  hip  splint,  which  protects  the 
joint  from  the  violence  of  walking,  to  divide  the 
time  on  the  ground  equally  between  the  two  feet, 
or  rather  between  the  foot  of  the  sound  side  and 


514 


MALIGNANT  SMALL-POX. 


[April  ii, 


the  ischiatic  crutch  on  the  affected  side,  with  the 
expectation  that  adduction  and  flexion  will  be 
wholly  or  in  part  reduced,  when  the  affected  limb 
makes  repeated  efforts  to  reach  the  ground  and 
do  its  share  in  locomotion.  It  is  believed  that 
the  patient  can  be  induced  by  precept  and  drill  to 
adopt  this  manner  of  locomotion  with  the  result 
indicated,  a  belief  which  is  sustained  by  the  ob- 
servation that  patients  led  by  accident  to  walk  in 
this  way,  have  recovered  with  a  good  position  of 
the  limb,  and  by  the  results  of  the  adoption  in 
practice  of  this  method  of  preventing  deformity. 

4  East  25th  St.,  Madison  Square.  New  York  City. 


MALIGNANT   SMALL- POX;    A  FORM 
HITHERTO   FATAL. 
BY    H.    RUSSELL,   M.D., 

OF  SUPERIOR,   WIS. 
FORMERLY    FIRST   ASS'T   SURGEON    38TH     WISCONSIN    VOLUNTREF 

I  take  the  liberty  of  sending  you  a  report  of 
some  cases  of  above  form  of  small- pox  for  pub- 
lication in  your  valuable  journal,  in  order  to  ex- 
pose to  the  notice  of  the  medical  profession  a 
pretty  accurate  description  thereof  and  its  treat- 
ment, so  that  the  disease  may  be  diagnosed,  if 
possible,-  at  time  of  physician's  first  visit  and 
thereby  not  permitted  to  spread,  which  state  of 
matters  occurred  after  the -first  case  of  it,  which 
I  saw  in  vicinity  of  Westfield,  Marquette  Co., 
Wisconsin,  in  the  winter  of  1872-73,  as,  although 
prior  thereto,  I  had  seen  many  cases  of  variola 
and  varioloid,  I  totally  failed  to  discern  the  least 
resemblance  to  last  diseases. 

My  first  case  was  that  of  a  young  man,  named 
James  Brown,  whom  I  first  visited  on  the 
18th  of  January,  1873,  and  found  in  the  usual 
febrile  state,  precursory  to  an  eruptive  disease, 
with  an  eruption  just  appearing  on  the  forehead, 
which  I  considered  as  having  been  that  of  scarla- 
tina and  announced  it  as  such  to  his  parents,  but 
on  the  following  day  the  patches  were  larger  than 
those  of  scarlatina,  and,  after  having  looked  over 
the  various  exanthema  in  Aitken's  "Practice," 
I  concluded  that  it  was  a  case  of  hybrid,  de- 
scribed therein,  and  watched  its  progress  carefully 
for  a  few  days,  when  I  told  them  that  I  did  not 
know  the  name  of  the  disease  that  affected  their 
son  and  advised  counsel,  which  was  not  obtained, 
ami  cm  the  following  Monday  another  physician 
took  charge  of  the  case  and  diagnosed  it  as  black 
measles,  and  as  no  one  was  afraid  of  measles, 
many  visited  the  patient;  hence,  in  about  two 
weeks  thereafter  there  were  many  affected  by 
variola,  varioloid,  and  referred  to  malignant  form, 
and.  knowing  that  the  treatment  of  the  first  two 
is  simple,  and  that  the  character  of  the  pustules, 
etc.,  attending  them  is  easily  detectible  and  rec- 
ognizable by  physicians  and  others  who  have, 
previously,  seen  such  cases,  I  shall,  in  the  follow- 


ing, try  to  describe  the  appearance  of  the  pus- 
tules in  said  form,  its  history  and  the  treatment 
which  I  found  to  be  of  service  in  my  last  case, 
aud  the  only  one  in  which  I  tried  it  to  any 
amount. 

The  pustules,  if  such  they  may  be  termed,  in 
this  almost  hitherto,  nondescript,  are  not  cone- 
shaped  as  in  variola,  and  varioloid,  but  are  um- 
bilicated  in  the  centres,  of  about  the  size  of  an 
ordinary  cowpoek,  are  red  around  the  bases  and 
marginally  contain  a  clear  fluid  which  scarcely 
ever  becomes  opaque  in  the  least,  are  mostly  con- 
fined to  the  face  and  extremities,  whilst  the 
whole  trunk,  as  far  down  as  the  umbilicus,  is  of 
a  bright  red  color,  and  in  no  case  need  the  at- 
tending physician  expect  such  a  patient  to  live 
more  than  ten  or  ten  and  one-half  days  after  the 
first  appearance  of  the  eruption  by  using  ordinary 
treatment ;  such,  at  least,  having  been  my  ex- 
perience ;  but  in  my  last  case,  that  of  a  child 
named  Hannah  Smith,  aged  9  years,  I  used  tinc- 
ture of  iodine,  of  which  I  gave  her  eight  drops 
in  syrup  every  three  hours,  and  am  happy  to 
state  that  she  recovered  as  readily  as  if  she  had 
merely  been  affected  with  measles,  whereas  her 
brother  and  sister  had  succumbed  to  the  same 
fatal  form,  the  former  not  having  taken  any 
iodine  and  been  treated  by  another  physician, 
and  the  latter  only  having  used  it  for  the  period 
of  three  or  four  days  prior  to  death. 

In  regard  to  the  use  of  iodine  in  this  form  of 
small-pox.  I  would  say  that  I  got  the  idea  from 
having  seen  Prof.  Daniel  Brainard,  of  Chicago, 
successfully  use  it,  hypodermically,  on  chickens, 
in  the  presence  of  his  class  for  the  bite  of  the 
rattlesnake,  and  having  used  in  my  former  cases, 
of  which  I  had  thirteen  during  said  winter,  the 
different  acids,  etc.,  and  hydrate  of  chloral  (said 
to  have  been  used  beneficiall}'  in  the  German 
army  for  small  pox),  without  the  least  success,  I 
happened  to  think  of  the  iodine,  and  presumed 
that,  as  it  had  acted  so  well  against  rattlesnake 
poison,  it  might,  possibly,  have  a  good  effect  on 
small  pox  poison,  and  hence,  used  it  with  the 
above  happy  result,  and  it  is  my  opinion,  that  if 
I  had  used  it  in  my  former  cases  I  would  have 
saved  all  of  their  lives  except  those  of  two,  who, 
during  the  continuance  of  the  disease,  were 
affected  by  severe  intestinal  haemorrhage. 

In  regard  to  the  terrible  affection  being  a  new 
one.  I  have  very  good  reason  to  believe  that  it 
was  in  the  north  of  Ireland  about  seventy-nine 
years  since,  and  in  other  parts  of  Europe  about 
one  hundred  and  sixty-nine  years  ago,  and 
wonder  why  a  very  accurate  description  of  it  is 
not  to  be  found  to  day  in  every  standard  work  on 
the  practice  of  medicine,  whereas  it  is  not  in  any 
of  them  unless  in  one  lately  published  by  that 
cc'  titi  '1,  time-honored  veteran,  Prof.  N.  S.  Davis, 
of  Chicago,  ami  is  by  all  odds,  more  fatal  than 
any  and   all.  of  the  pustular  or  exanthematous 


i»9i.] 


ACUTE  INTESTINAL  OBSTRUCTION. 


5'5 


diseases.  The  only  cases  of  it  of  which  I  have 
read  a  description,  were  those  of  two  published 
by  him  in  an  issue  of  The  Journal  in  1872  ;  his 
description  was  very  fine,  and  he  described  them 
under  the  heading  of  "  new  diseases,"  and  stated 
that  the  first  terminated  fatally  from  intestinal 
hsemorrhage  and  that  he  sent  the  second  to  the 
pest-house  and  did  not  know  the  result  thereof. 
The  New  York  Sun,  in  1S73,  published  a  his- 
tory of  the  disease  as  having  been  known  in  the 
countries  referred  to  above,  and  at  said  periods, 
and  I  also  obtained  from  an  old  reliable  gentle- 
man, named  James  Hamilton,  formerly  of  County 
Down,  Ireland,  a  verbal  statement  in  which  he 
said  that  he  recollected,  when  a  ".wee  boy"  that 
such  a  form  of  small-pox  was  in  the  north  of  Ire- 
land at  the  same  time  as  stated  by  the  Sun,  and 
that  all  cases  of  it  were  invariably  fatal.  I  might 
also  say  that  in  all  of  my  fourteen  cases  none  had 
been  successfully  vaccinated  and  would,  there- 
fore, respectfully  suggest  that  stringent,  general, 
State  and  local  enactments  be  immediately  passed 
for  the  very  charitable  and  life-saving  purpose  of 
carrying  out  the  entire  vaccination  of  all  parties 
not  vaccinated  as.  owing  to  the  small  number 
that  were  exposed  to  my  first  case  of  malignant 
small-pox  with  the  result  of  thirteen  having  con- 
tracted same  fatal  form  and  sixty-four  been  af- 
fected with  variola  and  varioloid  during  the  con- 
tinuance of  the  disease  in  said  winter,  it  is  my 
humble  opinion  that  to-day  there  are  not  less  than 
ten  millions  of  people  in  the  United  States  who 
are  liable  at  any  time  to  contract  said  fatal  form. 
I  might,  also,  say  that  in  a  newspaper  in  1873.  I 
read  an  account  of  a  case  of  it  having  occurred  in 
Indiana  with  the  same  result  as  in  my  first  case  but 
whether  it  was  published  in  a  medical  journal  or 
not  I  do  not  know.  That  said  disease  might, 
with  propriety,  be  called  black  small-pox,  espe- 
cially in  the  fatal  cases,  as  in  each  and  all  of  those 
which  I  treated,  about  the  second  day  prior  to 
death  the  face  and  surface  generally  began  to  as- 
sume a  dark  color,  which  continued  to  become 
more  so  gradually  until  the  patient  for  hours  be- 
fore death  appeared  almost  as  black  as  a  negro, 
and  that  in  each  of  my  fatal  cases  each  doomed 
patient  several  hours  before  death,  realized  that 
he  or  she  was  about  to  die  and  told  relatives  the 
manner  in  which  the}7  desired  their  property  to  be 
divided,  whilst  at  the  same  time  I  could  not  yet 
infer  from  the  character  of  the  pulse  nor  respira- 
tion that  my  patient  was  commencing  to  fail. 


Not  a  Bad  Idea.— A.  Oakey  Hall,  one  of  the 
ex  mayors  of  New  York,  in  one  of  his  London 
contributions  to  the  N,  }".  Press,  suggests  a 
statue  of  Dr.  Valentine  Mott,  to  be  erected  in 
the  Central  Park.  In  the  metropolitan  city,  how- 
ever, all  memorials  are  of  rather  tardy  growth. 


A  CASE  OF  ACUTE  INTESTINAL 
OBSTRUCTION. 

Read  before  the  Kings  County  Medical  Association,  March  w,  /So/. 
BY  R   C.   RAVXOR.   M.D., 

OF    BROOKLYN.  N.  V. 

The  following  history  of  a  case,  which  I  pre- 
sent for  discussion,  is  of  interest,  first,  from  the 
'difficulty  in  making  a  diagnosis;  secondly,  from 
the  manner  in  which  the  obstruction  was  pro- 
duced ;  thirdly,  from  the  amount  of  intestine  oc- 
cluded. 

The  patient,  a  colored  woman,  aged  57,  weigh- 
ing about  175  lbs  ,  single,  and  a  cook  by  occupa- 
tion, was  taken,  two  days  before  I  was  called, 
with  a  sudden  and  severe  pain  while  ascending 
\  the  stairs,  and  it  was  some  little  time  before  she 
j  was  able  to  proceed,  and  then  with  much  difficul- 
ty she  reached  her  room.  Later  she  had  occa- 
!  sional  colicky  pains,  and  vomited  some  biliary 
matter.  As  the  bowels  had  not  moved  for  sev- 
eral days,  she  was  given  an  enema,  which  only 
j  brought  away  a  few  hard  faecal  masses.  For  her 
pain  she  had  been  using  hot  applications.  These 
symptoms  continuing,  I  was  sent  for.  On  ray 
first  visit,  May  21,  1889,  I  found  her  complaining 
as  above,  with  a  normal  temperarure.  and  a  fairly- 
strong  pulse  of  70.  The  abdomen  was  slightly 
distended,  and  she  had  some  general  soreness, 
but  there  was  no  marked  tenderness,  and  on  firm 
pressure  I  could  detect  no  sensitive  spot.  There 
was  no  local  tumefaction  that  I  could  detect,  and 
the  external  abdominal  rings  were  normal.  A 
careful  vaginal  and  rectal  examination  was  made 
with  a  negative  result.  As  she  had  been  subject 
to  what  she  called  ' '  bilious  attacks, ' '  and  further, 
being  under  the  impression  that  she  had  worms, 
had  taken  at  intervals  for  years  past  about  all  the 
different  vermifuges  on  the  market,  it  was  my 
opinion  she  was  suffering  from  some  digestive 
derangement  due  to  improper  eating  and  over- 
medication.  Accordingly,  I  prescribed  a  seda- 
tive and  a  diet  of  milk  and  Yiehy.  On  the  22d 
the  temperature  was  normal,  pulse  74.  The 
stomach  rejected  all  food  taken,  and  she  fre- 
quently vomited  biliary  matter.  I  continued  the 
sedative  and  prescribed  a  cathartic.  23d,  No  ef- 
fect from  the  cathartic,  vomiting  continues,  some 
hiccough,  temperature  97°,  pulse  104  and  weak. 
Continued  sedative  and  ordered  beef  peptonoids 
and  brandy,  per  rectum.  24th,  Patient  weaker, 
vomiting  persists,  and  for  the  first  time  is  sterco- 
raceous ;  has  passed  flatus  twice.  I  then  knew  I 
had  some  form  of  intestinal  obstruction  to  deal 
with,  but  what?  At  this  visit  the  temperature 
was  980,  pulse  108.  Treatment  continued.  25th 
Has  not  vomited  in  twenty-four  hours,  and  bow- 
els moved  freely,  passing  formed  and  semi- liquid 
stools  with  considerable  flatus,  slept  well  during 
the  night,  has  no  pain,  and  feeling  stronger. 
Temperature  990.  pulse  ico.     I  then  was  of  the 


5i6 


OVARIOTOMY  A  CURE  FOR  INSANITY. 


[April  ii, 


opinion  that  the  obstruction  was  a  volvulus,  and 
that  it  had  been  spontaneously  relieved,  and  I 
felt  more  hopeful  of  the  case.  26th,  General 
condition  somewhat  improved ;  retains  food  and 
stimulants.  27th,  Still  retains  food  and  stimu- 
lants, but  is  weaker.  At  my  evening  visit  I  found 
her  in  collapse ;  she  was  suffering  no  pain,  was 
somewhat  restless,  but  her  mind  was  clear.  She 
did  not  respond  to  treatment  and  died  at  5  o'clock 
a.m.  on  the  28th.  A  partial  autopsy  was  permit- 
ted, and  revealed  the  following  :  The  abdominal 
walls  were  two  inches  thick ;  no  fluid  in  the  peri- 
toneal cavity;  peritoneum  normal;  omentum  con- 
taining a  large  amount  of  fat.  On  the  right  side 
was  an  incipient  hernia,  which  barely  entered  the 
inguinal  canal.  The  gut  at  a  point  opposite  to 
the  mesentery  was  so  firmly  adherent  to  the  mar- 
gin of  the  internal  ring  that  it  could  not  be  sepa- 
rated. It  was  twisted  on  itself,  and  gangrenous 
where  twisted  to  the  extent  of  about  one  square 
inch.  It  was  not  constricted  in  the  ring,  and 
when  untwisted,  the  canal  was  pervious.  The 
mesentery  of  the  adherent  gut  formed  a  constrict- 
ing band  which,  extending  across  to  the  last  lum- 
bar vertebra,  passed  one  inch  to  the  left  side  of 
the  caput  coli,  and  occluded  eleven  feet  of  ileum. 
The  lower  half  of  the  large  intestine  was  empty; 
the  upper  contained  solid  faeces ;  stomach  and 
small  intestine  above  the  constriction  contained 
fluid;  other  organs  not  examined. 

Let  us  review  briefly,  on  the  authority  of  Erich- 
sen,  the  more  usual  causes  of  acute  intestinal  ob- 
struction with  their  diagnostic  symptoms.  1. 
We  may  have  internal  strangulation  from  a  por- 
tion of  the  gut  slipping  through  an  aperture  in 
the  mesentery  or  omentum,  forming  the  so-called 
internal  hernia  ;  or  a  portion  of  the  intestine  may 
be  constricted  by  becoming  entangled  round  a 
band  passing  from  one  part  of  the  abdominal  cav- 
ity to  another ;  these  bands  may  be  from  old  peri- 
tonitic  adhesions,  from  the  vermiform  appendix, 
or  a  diverticulum  from  the  ileum,  the  free  end  of 
which  has  become  attached  to  some  part  of  the 
abdominal  wall.  2.  Volvulus.  3.  Stricture  which, 
gradually  closing,  becomes  suddenly  obstructed. 
4.  Foreign  bodies.  5.  Inflammatory  affections. 
6.  Intussusception.  As  there  was  no  history  to 
suggest  the  third,  fourth  and  fifth  causes,  we  can 
exclude  them  and  confine  ourselves  to  the  first, 
second  and  sixth.  The  symptoms  common  to  all 
are,  severe  pain  coming  on  suddenly,  followed  by 
early  collapse ;  the  pulse  is  quickened,  tempera- 
ture at  first  slightly  elevated,  but  soon  becoming 
subnormal ;  acute  abdominal  pain  fixed  in  one 
spot  with  paroxysmal  exacerbations;  early  severe 
vomiting,  becoming  stercoraceous  speedily,  if  the 
obstruction  is  in  the  small  intestine,  or  after  sev- 
eral days  if  the  large  intestine  is  occluded ;  com- 
plete constipation;  marked  abdominal  distension. 

In  thin  subjects  coils  of  intestine  and  peristalsis 
may  be  observed  through  the  abdominal  walls. 


In  volvulus  the  twist  is  generally  in  the  sigmoid 
flexure,  or  the  descending  colon,  and  the  pain  will 
be  referred  to  that  region.  Peristalsis  is  said  to  be 
greatest  in  this  variety  of  obstruction.  In  intus- 
susception, in  addition  to  the  foregoing  there  is, 
at  the  seat  of  the  obstruction,  a  sausage-shaped 
tumor,  dough}'  to  the  feel,  which  becomes  tense 
on  manipulation,  owing  to  the  peristaltic  contrac- 
tion of  the  gut,  which  is  thereby  excited.  It  is 
tender,  and  the  contractions  are  accompanied  by 
griping  pains.  There  may  be  also  tenesmus,  and 
a  discharge  of  bloody  mucus.  The  other  author- 
ities that  I  have  consulted  agree  substantial- 
ly with  the  above.  Comparing  this  description 
with  my  case,  which  was  both  a  volvulus  of 
the  small  intestine  and  a  constricting  band — for 
I  do  not  regard  the  hernia  per  se,  a  cause  of  the 
obstruction — we  note  an  absence  of  any  fixed 
pain,  great  abdominal  distension,  or  any  local  tu- 
mefaction or  point  of  tenderness,  and  although 
the  obstruction  was  high  up  in  the  ileum,  sterco- 
raceous vomiting  did  not  occur  until  the  fifth  day. 
The  pulse  and  temperature  were  also  at  variance 
with  the  description  given.  But  the  most  mis- 
leading symptoms  were  the  passing  of  faeces  and 
flatus,  in  considerable  quantities,  on  the  sixth  day, 
together  with  an  improvement  in  the  general  con- 
dition, making  it  appear  that  the  obstruction  had 
been  removed.  I  can  only  account  for  it  by  as- 
suming that  the  discharge  came  entirely  from  the 
large  intestine,  and  was  occasioned  by  a  local 
peristalsis. 

On  reviewing  the  case  I  am  of  the  opinion  that 
the  hernia  had  been  a  long  time  adherent,  and 
occasioned  the  symptoms  which  she  attributed  to 
worms,  and  the  obstruction  was  caused  by  the  in- 
testine becoming  entangled  around  the  mesenteric 
band,  and  which,  twisting  the  gut  on  itself,  pro- 
duced the  volvulus.  In  regard  to  the  propriety 
of  surgical  interference  in  the  treatment  of  the 
case,  it  seems  to  me  that  the  symptoms  at  first 
did  not  warrant  an  explorative  laparotomy,  and 
when  dangerous  symptoms  did  appear  they  were 
apparently  relieved  spontaneously  within  twenty- 
four  hours,  and  from  the  conditions  found  at  the 
autopsy,  it  is  questionable  if  an  operation  could 
have  been  successfully  performed. 


OVARIOTOMY  AS  A  PROPHYLAXIS  AND 
•  CURE  FOR  INSANITY. 
BY  ROBERT  A.  KITTO,   M.D., 

OF  RACINE,  WIS. 

I  desire  to  present  to  the  readers  of  The  Jour- 
nal a  very  interesting  case  of  pseudo  insanity 
which  I  recently  cured  by  removing  both  ovaries 
with  their  tubes,  bringing  about  a  complete  resto- 
ration of  a  mind  which  had  been  under  a  cloud  for 
thirteen  years,  and  whiph  had  been  pronounced 
incurable  insanitv. 


"891.] 


OVARIOTOMY  A  CURE  FOR  INSANITY. 


5"7 


Miss  Ada  M.,  Racine,  Wis.,  age  25,  brunette, 
full  habit,  fair  health.  When  she  was  thirteen 
years  old  she  had  a  severe  attack  of  scarlet  fever 
which  left  her  in  a  very  unsound  condition  of 
mind.  From  the  age  of  14  she  began  to  show 
Blgns  of  unsoundness  of  mind,  which  grew  rap 
idly  worse  until  she  was  18,  when  she  became 
so  violent  and  unmanageable  that  her  parents 
were  obliged  to  apply  for  a  medical  commission 
to  examine  into  her  mental  condition  with  a  view 
of  sending  her  to  an  asylum,  which  was  accord- 
ingly done.  She  was  committed  to  Oshkosh 
(Wis.)  Asylum  in  1887.  There  she  remained 
under  regular  treatment  for  a  period  of  eight 
months,  when  she  was  discharged  and  sent  home. 
She  was,  however,  by  no  means  cured,  as  she  al- 
most immediately  began  to  show  signs  of  a  return 
of  her  former  trouble,  and  after  a  space  of  two 
years  she  was  again  committed  to  the  same  asy- 
lum for  treatment,  where  she  remained  for  a  space 
of  one  year ;  she  was  again  returned  home,  but 
remained  in  a  semi-sane  condition,  being  not  vio- 
lent, but  so  much  deranged  that  it  was  found  neces- 
sary to  confine  her  to  the  house.  She  would  often 
escape  into  the  street  in  almost  a  nude  condition; 
she  would  scream,  dance,  laugh  and  cry  just  as 
the  fancy  took  her.  She  complained  constantly 
of  a  pain  in  the  groin  and  region  of  the  womb, 
she  had  had  a  constant  discharge  of  acrid  pus  per 
vaginam.  Her  menses  were  irregular  from  the 
first  of  their  appearance,  which  was  at  the  age  of 
14.  She  would  often  ask  her  attendants  if  there 
was  no  help  for  her.  She  was  treated  by  various 
local  physicians  with  but  little  benefit  for  several 
years.  She  had  grown  old-looking  and  very  idi- 
otic, she  had  lost  all  self-control  and  was  decid- 
edly childish. 

She  came  under  my  care  in  September,  1890. 
I  made  a  careful  examination  and  diagnosed  the 
case  as  hysterical  insanity  and  advised  ovariot- 
omy, believing  that  her  ovaries  and  tubes  were  dis- 
eased from  the  symptoms.  I  was  met  by  stern  op- 
position from  members  of  the  family,  also  from  va- 
rious counseling  doctors.  I  finally  sent  her  to  a 
prominent  specialist  in  Chicago,  who  decided  it 
was  a  hopeless  case  of  brain  disease.  The  unfor- 
tunate girl  heard  the  eminent  specialist  pronounce 
her  doom,  and  came  home  much  depressed  and 
grew  violent  and  wholly  uncontrollable. 

It  was  January  4  of  the  present  year  that,  after 
such  good  counsel,  her  parents  decided  to  send 
her  again,  for  life,  to  the  insane  asylum.  I  re- 
monstrated with  them,  and  finally  persuaded 
them  to  allow  me  to  operate  and  remove  her  ova- 
ries, which  they  did.  Accordingly,  on  February 
4,  I  performed  the  operation  with  the  above  re- 
sult, for  which  both  the  patient  and  myself  have 
much  reason  to  feel  gratified,  for  she  is  now  en- 
tirely well,  mentally  and  physically. 

The  usual  steps  of  the  operation  being  familiar 
to  all,  I  shall  not  take  time  nor   space  to  dwell 


upon.  The  usual  incision  was  made  and  the  or- 
gans accordingly  removed  with  the  tubes.  I  found, 
as  I  had  predicted,  that  both  ovaries  were  in  a 
state  of  chronic  inflammation,  also  the  tubes  were 
in  a  state  of  pyosalpinx.  A  thimbleful  of  acrid 
pus  escaped  from  each  ovary  in  removing  them, 
they  having  grown  extensively  on  the  bowels  and 
surrounding  pelvic  tissues,  which  necessitated 
considerable  tearing  in  order  to  remove  them.  An 
accident  which  is  much  dreaded  by  surgeons,  and 
a  most  formidable  one  too,  occurred  in  trying  to 
tear  the  ovaries  from  the  intestines.  I  acciden- 
tally tore  the  gut,  which  was  followed  by  an  es- 
cape of  faecal  matter  and  gas.  Being  prepared 
for  such  an  accident,  I  at  once  proceeded  to  close 
the  lacerated  gut,  which  was  done  by  simply 
excising  the  lacerated  edges  and  putting  in  the 
Czerny  and  Lembert  suture  of  silk.  The  wound 
closed,  I  proceeded  to  complete  the  operation  by 
removing  the  other  ovary  with  its  tube,  which 
was  done  without  a  similar  accident.  When  I 
closed  the  wound  and  applied  the  usual  dressing, 
I  put  the  patient  to  bed,  applied  hot  bottles  and 
gave  a  full  hypodermic  injection  of  morphia.  '.; 
gr.  She  emerged  from  the  chloroform  in  due 
time,  and  upon  fully  awaking  she  looked  about 
her,  but  not  with  the  former  idiotic  gaze,  but  a 
serene  calmness  which  was  remarked  by  the  at- 
tending physicians.  She  said,  "Dr.  Kitto,  have 
you  succeeded  in  removing  the  offending  appen- 
dages?" Being  answered  in  the  affirmative,  she 
smiled  and  said,  '  I  am  so  happy,  and  I  feel  so 
different  that  I  know  I  shall  now  remain  well." 
While  this  will  be  read  with  much  doubt  by  some, 
yet  I  must  insist  upon  the  fact  that  it  was  none 
the  less  true.  She  continued  to  improve  from 
that  day  on,  which  is  now  four  weeks.  She  has 
been  discharged  from  the  hospital  cured  mentally 
and  physically. 

I  believe  this  case  will  do  much  to  establish  my 
theory,  that  hundreds  of  unfortunate  women  are 
to  day  languishing  in  insane  asylums,  who  might 
be  cured  by  a  similar  operation. 

This  goes  to  show  that  this  and  man)'  hundreds 
of  such  cases  are  not  insane,  in  the  usual  accepta- 
tion of  the  term,  but  are  subjects  of  reflex  irri- 
tations. 

I  have  not  further  time  to-day  to  dwell  upon 
this  important  case,  but  will  write  again  on  this 
subject,  touching  upon  diagnosis  and  proper  se- 
lection of  cases  for  the  knife. 
March  2,  1S91. 


German  Opposition  to  Women  in  the 
Practice  of  Medicine. — A  discussion  occurred 
in  the  German  Reichstag  on  March  11,  touching 
the  admission  of  women  to  the  liberal  professions, 
during  which  Herr  Schroder  urged  that  the  gov- 
ernment should  open  the  way,  and  offer  oppor- 
tunities, for  women  in  the  practice  of  medicine. 
The  House  declared  itself  against  the  petition. 


518 


MEDICAL  PROGRESS. 


[April  ii, 


MEDICAL    PROGRESS. 


Therapeutics  and  Pharmacology. 

Trichloracetic  Acid. — Ehrmann  (/.'  I  Tnion 
Medicale,  Feb.  28,  1891)  has  employed  this  agent  j 
in  the   treatment  of   diseases  of   the  nose    and  | 
throat.  Touching  the  affected  parts  with  a  crystal 
produces  a  white  eschar,  strictly  localized,  rapid 
ly  detached,  and  free  from  secondary  irritation  or 
inflammation.     Of  140  cases,  87  required  cauteriz- 
ing but  once,  30  were  treated  twice,  and   a   few  1 
resisting  cases  from  three  to  five  times.      A  per- ! 
manent  cure  was  effected  in  122  cases.    Ehrmann 
is  of  the  opinion  that  this  substance  is  of  the  first 
rank  in  the  treatment  of  diseases  of  the  throat 
and  nose. 

Trichloracetic  acid  may  also  be  employed  as  an 
astringent,  according  to  the  following  formula: 
Iodine  15  grams,  iodide  of  potassium  20  grams, 
trichloracetic  acid  15  to  30  grams,  glycerine  30 
grams,  to  be  applied  to  the  affected  part  upon 
pledgets  of  cotton. 

The  Open  Treatment  of  Pulmonary  Cav- 
ities.—  Professor  Sonnenburg  reports  five 
cases  in  which  he  opened  pulmonary  cavities 
from  the  outside  as  a  preliminary  to  treatment  by 
injections  of  tuberculin  {Die  Wirksamkeit  des 
Koch' schcn  Heilmittels  gegen  Tuberculose.  Amt- 
liche  Berichle,  etc.,  p.  837,  et  scq.*).  His  method 
of  procedure  and  the  immediate  results  of  the  op- 
eration in  the  first  four  cases  have  already  been 
described  (Supplement,  January  17,  1891,  p.  21). 
As  soon  as  the  slight  reaction  following  the  in- 
cision has  subsided  the  injections  are  begun,  and 
Sonnenburg  says  their  effect  can  be  followed  as 
readily  as  on  the  skin  and  mucous  membrane. 
The  action  of  the  remedy  was  well  displayed  in 
the  case  last  operated  on  in  which  a  cavity  in  the 
right  apex  was  laid  open.  For  a  fortnight  after 
the  operation  Koch's  treatment  was  not  employed. 
In  strong  contrast  to  what  occurred  in  the  other 
cases,  the  cavit}7  remained  greasy  and  discolored, 
did  not  become  clean,  and  showed  no  tendency  to 
heal.  As  soon  as  the  injections  were  begun  the 
cavity  was  transformed  into  a  healthy  granulat- 
ing wound.  In  all  the  cases  a  considerable 
amount  of  necrotic  lung  tissue  was  expelled,  after 
which  the  cavities  began  to  shrink;  and,  with 
regard  to  three  of  the  patients,  "one  can  already 
speak  of  almost  complete  cure."  The  result  of 
the  combinations  of  the  injections  with  incision 
of  pulmonary  cavities  has  been  to  convince  Son- 
nenburg  that  the  treatment  presents  no  danger, 
and  offers  good  hopes  of  cure.  In  the  three  sue- 
eneral  condition  has  improved; 
there  are  Fewer  tubercle  bacilli  in  the  sputum, 
and  the  patients  have  gained  weight:  Sonnenburg 
adds  that  further  experience  is  required  before 
trustworthy  rules  can  be  laid  down  for  the  guid- 


ance of  the  practitioner  in  the  selection  of  suit- 
able cases  for  the  surgical  treatment  of  pulmon- 
ary cavities.  Much  also  has  still  to  be  learnt  as 
to  the  right  method  of  using  tuberculin,  par- 
ticularly as  to  individualizing  the  treatment. 
— British  1  Medical  Journal. 

Surgery. 

The  Pathology  and  Surgery  of  the  Ap- 
pendix C.ECi. — Although  the  Clinical  Society 
departed  from  its  usual  course  and  devoted  a 
meeting  recently  to  an  adjourned  discussion  on 
the  above  subject,  yet  it  must  have  been  felt  at 
its  close  that  the  question  had  been  by  no  means 
exhausted.  It  is  one  that  has  of  late  years  come 
prominently  to  the  front — one,  too,  in  which  both 
physicians  and  surgeons  have  an  interest.  It 
deals,  moreover,  with  a  class  of  disease  of  singu- 
lar frequency,  and  of  varying  fatality.  To  dis- 
cuss it  adequately  would  require  a  debate  much 
more  prolonged  than  that  which  has  just  been  as- 
signed to  it.  We  will  therefore  content  ourselves 
here  with  noting  some  of  the  points  raised  in  the 
course  of  that  discussion.  In  the  first  place  is  to 
i  be  remarked  the  want  of  unanimity  upon  the  true 
nature  of  so-called  typhlitis — a  term  which  is,  in 
I  the  opinion  of  some,  misapplied  to  the  larger  pro- 
portion of  cases  that  are  at  present  included  under  : 
it.  Although  Mr.  Treves  has  apparently  gone 
back  from  his  former  belief  as  to  the  frequency 
with  which  the  appendix  shares  in  the  produc- 
tion of  the  symptoms  of  typhlitis,  and  although, 
as  Mr.  Pearce  Gould  showed,  the  diagnosis  of 
"  appendicitis  "  had  in  some  quarters  been  often 
very  erroneously  made,  still  there  is  no  question 
that  the  pathological  evidence  of  an  independent 
inflammation  of  the  body  of  the  caecum  is  as  rare 
as  the  verification  of  an  inflamed  and  ulcerated 
appendix  in  cases  of  "typhlitis"  is  common. 
Drs.  Coupland  and  Kingston  Fowler  expressed 
this  view  strongly,  the  latter  dealing  with  defi- 
nite post-mortem  facts.  Mr.  Treves  laid  some 
stress  upon  the  palpation  of  an  enlarged  appen- 
dix through  the  rectum  as  serving  to  distinguish 
the' cases;  but  he  did  not  state  whether  this  plan 
had  been  adopted  in  the  ordinary  cases,  which 
recover  under  the  guiding  principles  of  "  rest ;  I 
and  it  is  certain  that  "relapsing"  cases  form  no 
very'  large  proportion  of  all  those  in  which  there 
is  appendix  mischief,  nor,  indeed,  that  there  is 
more  danger  in  a  relapse  than  in  a  primary  attack. 
On  the  whole,  it  will  conduce  to  lucidity  if  we 
regard  the  appendix  as  the  seat  of  the  trouble  in 
all  classes  of  cases — those  which  resolve  and  those 
which  lead  to  more  or  less  extensive  perityphlic 
suppuration.  Mr.  Bland  Sutton's  comparison  of 
the  appendix  to  the  tonsil  was  suggestive,  but 
hardly  essential  to  the  argument.  For  although, 
as  he  showed,  this  structure  is  richly  provided 
with  lymphatic  tissue,  yet  it  is  by  no  mean 
tain  that  its  inflammatory  lesions  are   primarilj 


i89i.] 


MEDICAL  PROGRESS. 


519 


evolved  and  not  excited  by  faecal  or  other  im- 
pacted contents.  As  to  the  results  of  inflamma- 
tion and  ulceration  of  this  structure,  the  cases 
may  be  grouped  under  the  following  heads  :  1. 
Cases  where  perforation  occurs  suddenly,  leading 
to  general  peritonitis.  2.  Cases  where  the  sur- 
rounding inflammation  is  limited,  owing  to  the 
formation  of  adhesions.  This  class  may  he  fur- 
ther subdivided  into  (a)  those  where  there  is  res- 
olution of  the  inflamed  products,  with  or  without 
a  liability  to  relapse;  and  (b)  those  where  suppu- 
ration takes  place,  the  ultimate  issue  being  un- 
certain, the  pus  sometimes  burrowing  into  the 
tissues  outside  the  peritoneum  in  various  direc- 
tions, sometimes  being  more  or  less  confined 
within  a  peritoneal  abscess,  the  existence  of 
which  is  a  constant  element  of  danger  to  life. 
There  can  be  no  hesitation  as  to  the  propriety  of 
surgical  intervention  in  these  latter  cases;  but  the 
fact  that  the  progress  of  the  suppurative  inflam- 
mation is  often  very  insidious  emphasizes  the 
need  for  a  prompt  recourse  to  surgery  whenever 
possible.  A  highly  interesting  point  was  raised 
by  Mr.  Pearce  Gould — namely  :  whether  the  dis- 
eased appendix  should  be  removed  or  not.  He 
advocated  the  latter  course,  trusting  to  free  inci- 
sion and  drainage,  and  he  was  supported  by  Mr. 
Charters  Symonds;  whilst  Mr.  Sutton,  in  his  able 
reply,  contended  that  this  would  hardly  be  an 
advance  upon  the  old  practice,  and  that  it  would 
be  wrong  to  leave  behind  the  source  of  irritation. 
The  final  decision  in  this  matter  must  be  left  to 
the  teachings  of  experience.  One  thing  at  any 
rate  may  be  hoped  for  as  the  result  of  this  debate. 
and  that  is  a  prompter  resort  to  surgical  interfer- 
ence when  the  indications  point  to  extension  of 
the  inflammatory  process  to  the  general  perito- 
neum or  the  supervention  of  suppuration. —  The 
Lancet. 

Results  of  Operations  upon  Tuberculous 
Lymphatic  Glands. — Noorden  {Beit rage  Zur 
Klin.  Chirnrgie)  gives  the  results  in  149  cases 
that  were  operated  in  the  clinic  of  Tubingen. 
Only  those  cases  were  tabulated  in  which  three 
years  or  more  had  elapsed  since  operation — 93 
cases  were  free  from  any  return  of  the  disease  at 
periods  varying  from  three  to  fourteen  years.  In 
30  cases  the  disease  returned,  with  local  manifes- 
tations; 31  cases  died  within  sixteen  years  of  op- 
eration. In  no  case  was  there  a  return  of  the  dis 
ease  later  than  six  years  after  operation.  The 
writer  reckons  that  28  per  cent,  of  all  patients 
suffering  from  lymph  adenoma  die  of  other  forms 
of  tuberculosis.  The  most  usual  form  of  which  is 
phthisis  pulmonalis,  and  the  writer  recommends 
the  early  extirpation  of  enlarged  glands,  to  pro- 
tect the  patient  from  a  general  systemic  infection. 

Physiology. 

Recent  Experiments  on  the  Cervical  Sym- 
pathetic and    Sympathetic    Ganglia. — The 


existence  of  vasomotor  fibres  for  the  iris,  and  cer- 
tain secretory  fibres  for  the  salivary  glands  in  the 
cervical  sympathetic  nerve  is  well  known.  Luch- 
singer  several  years  ago  found  that  the  cervical 
sympathetic  also  contains  secretory  fibres  for  the 
glands  in  the  muzzle  of  the  ox.  Arloing  {Archives 
de  Phvsio/ogie,  ii,  1890,  p.  1)  confirms  the  exist- 
ence of  these  fibres:  but  he  finds  that  inhibitory 
secretory  fibres  are  also  present  in  the  same  nerves. 
Ten  minutes  or  so  after  section  of  the  vago-sym- 
pathetic  nerve  in  the  ox  the  muzzle  of  that  side 
becomes  dry.  Twenty  to  forty  days  after  sec- 
tion of  the  cervical  sympathetic,  or  rather  the 
vago-sympathetic,  nerve,  stimulation  of  it  is 
without  effect;  but  if  pilocarpin  be  injected  there  is 
active  secretion  in  the  glands  in  both  sides  of  the 
muzzle,  but  the  secretion  is  more  pronounced  on  the 
side  on  which  the  nerve  is  divided.  According  to 
Arloing,  the  result  is  not  due  to  vasomotor  effects, 
but  is  to  be  explained  by  the  inhibitory  influences 
of  the  inhibitory  secretory  fibres  disappearing 
with  the  degeneration  of  the  inhibitory  nerve 
fibres.  An  increased  secretion  of  tears  and  also 
of  the  secretion  of  the  Meibomian  glands  occurs 
after  section  of  the  cervical  sj'mpathetic,  and  the 
secretion  is  further  increased  by  pilocarpin.  Ar- 
loing regards  these  glands  as  receiving  more  in- 
hibitory than  secretion-exciting  fibres.  Hirsch- 
mann  some  years  ago  showed  that  after  nicotine 
was  given  to  an  animal  the  cervical  sympathetic 
lost  its  effect  on  the  pupil.  Laugley  and  Dickin- 
son (On  the  Local  Paralysis  of  Peripheral  Gang- 
lia, etc.,  Proc.  Roy.  Soc,  vol.  xlvi,  p.423)  find, 
however,  that  in  the  rabbit  stimulation  of  the 
nerve  above  the  superior  cervical  ganglia  causes 
dilatation  of  the  pupil.  What,  however,  consti- 
tutes the  chief  interest  in  their  observations  is  the 
local  action  of  nicotine  If  a  1  per  cent,  solution 
of  this  drug  be  pencilled  on  the  superior  cervical 
ganglion,  stimulation  of  the  nerve  below  the 
gauglion  or  of  the  ganglion  is  without  effect  on 
the  iris.  Nicotine,  however,  when  applied  local- 
ly to  the  nerve  above  the  ganglion,  has  no  effect 
on  the  nerve.  Nicotine  applied  locally  to  the 
ganglion  prevents  stimulation  below  the  gang- 
liou  from  having  its  usual  vasamotor  effect  on  the 
blood  vessels  of  the  ear,  and  in  addition  the  se- 
cretory action  on  the  salivary  gland  is  also  arres- 
ted. The  authors  conclude  that  the  sympathetic 
fibres  for  the  blood  vessels  of  the  ear,  the  fibres 
for  the  iris,  aud  the  secretory  fibres  for  the  saliv- 
ary glands,  end  in  the  nerve  cells  of  the  superior 
cervical  ganglion,  and  from  these  nerve  cells  fibres 
proceed  to  their  regions  of  distribution.  Similar 
results  were  obtained  by  experiments  on  the  solar 
plexus,  that  is,  the  local  application  of  nicotine 
prevented  the  inhibitory  effect  of  the  splanchnic 
nerve  on  the  movements  of  the  intestine  and 
stomach.  Beyond  the  ganglion  the  fibres  were 
active.  The  authors  conclude  that  the  inhibitory 
fibres  of  the  splanchnic  for  the  stomach  end   in 


520 


MEDICAL  PROGRESS. 


[April  ii. 


the  nerve  cells  of  the  coeliac  ganglion,  and  those 
for  the  intestine  in  the  superior  mesenteric  gang- 
lion. Even  when  both  plexuses  are  eliminated 
by  the  local  action  of  nicotine,  stimulation  of  the 
vagus  still  causes  movements  of  the  stomach  and 
intestine,  so  that  it  is  concluded  that  the  vagus 
does  not  form  connections  with  the  nerve  cells  of 
these  two  plexuses.  The  vasomotor  fibres,  how- 
ever, appear  to  end  in  or  form  connections  with 
the  nerve  cells  in  these  plexuses.  In  a  later  re- 
search {Archives  de Physiol.,  No.  i,  January,  1891, 
p.  160)  Arloing  gives  an  account  of  continuation 
of  his  researches  on  the  cervical  sympathetic 
nerve,  and  in  this  paper  he  cites  experiments 
which  lead  him  to  believe  that  trophic  nerve 
fibres  are  also  present  in  this  nerve.  The  experi- 
ments were  made  on  the  ox  and  dog.  In  the 
muzzle  of  the  ox  marked  histological  changes  in 
the  papillae  and  stratum  granulosum  follow  upon 
section  of  this  nerve.  In  the  dog  after  section  of 
the  vago-  sympathetic  nerve,  the  humidity  on  the 
muzzle  is  not  altered,  nor  does  galvanic  stimula- 
tion of  the  nerve  or  injection  of  pilocarpin  in- 
crease the  moisture,  these  results  being  due  to  the 
absence  of  glands  in  the  more  hairy  part  of  the 
dog's  nose,  while  such  glands  are  abundant  in  the 
muzzle  of  the  ox.  After  two  months  or  so,  how- 
ever, there  are  marked  changes  in  the  nose  of  the 
dog,  the  skin  becomes  papillated  and  dry,  while 
there  is  great  hypertrophy  of  the  corneous  layer. 
Arloing  concludes  from  his  experiments  that  the 
cervical  sympathetic  nerve  in  the  ox  and  dog  con- 
tains tropic  fibres  for  the  glands  and  epithelium 
in  the  former,  and  for  the  epithelium  in  the  latter; 
and  that  their  action  is  independent  of  the  vaso 
motor  and  glandular  nerve  fibres. — Brit.  Med. 
Journal. 

Powers  of  Perception  of  Children. — Bi- 
NET  {Revue  Philosophique,  December,  1890)  has 
made  a  series  of  very  interesting  observations  on 
the  powers  of  perception  of  children.  He  exper- 
imented upon  two  little  sisters,  and  found  that 
the  first  color  to  be  recognized  was  invariably 
red.  When  between  1  and  2  years  old  they  could 
easily  recognize  the  entire  figure  drawn  on  paper 
in  outline  of  some  common  object,  as  a  man,  but 
it  was  several  years  before  they  could  with  cer- 
tainty recognize  an  outline  drawing  of  some  in- 
dividual part — as  an  ear  or  a  finger.  Binet  also 
investigated  how  far  the  ideas  of  children  are 
spontaneous,  and  how  far  they  are  recollections 
of  dreams,  but  he  found  it  difficult  to  come  to 
any  conclusion.  He  points  out  that  at  first  child- 
ren always  regard  themselves  in  the  third  person, 
and  he  gives  several  interesting  conversations 
which  show  that  their  ideas  about  all  objects  are 
utilitarian  ;  for  example,  they  look  upon  a  knife 
as  a  thing  to  cut  with,  bread  as  something  to  be 
eaten,  and  so  on. 


Pathology. 

The  Microorganisms  of  Cancer.  —  Dr. 
Schutz  {Centralbl.f.  Chir.,  January  24th,  1891), 
whilst  fully  recognizing  the  appearances  which 
have  been  described  by  several  authors  as  occurring 
in  cancer,  does  not,  however,  regard  the  bodies 
in  question  as  living  organisms,  but  thinks  it  far 
more  probable  that  they  are  formed  (in  part,  at 
least)  of  red  blood  corpuscles  which,  both  in  car- 
cinoma and  sarcoma,  find  their  way  freely  into 
the  tissues  and  assume  various  disguises,  so  that 
their  origin  is  not  easily  determined.  Another 
source  of  the  so-called  organisms  depends,  he  as- 
serts, on  the  alteration  of  the  cells  of  the  various 
tissues  which  take  upon  themselves  amoeboid 
movement,  and  congregate  oftentimes  in  masses; 
and  it  is  by  the  alteration  of  these  masses  that 
the  so-called  sporocysts  are  formed.  So  far,  he  is 
of  opinion  we  are  as  far  as  ever  from  finding  the 
true  organism  which  produces  cancer,  even  sup- 
posing that  it  exists. — Brit.  Med.  Journal. 

The  Blood  in  Pneumonia. — Dr.  Kikodze 
has  published  in  the  Bolnichnaya  Gazeta  of  Dr. 
Botkin,  some  interesting  observations  on  the  blood 
during  pneumonia.  He  found  that  during  the 
course  of  this  disease  the  white  corpuscles  increase 
in  number  to  as  much  as  double,  or  even  treble, 
what  they  are  in  healthy  persons.  The  increase 
is  observed  in  the  fully  mature  and  over-mature 
corpuscles  rather  than  in  the  young  ones.  It  is 
worthy  of  note  that  in  fatal  and  very  severe  cases 
no  increase  in  the  white  corpuscles  is  found.  As 
a  rule,  however,  the  increase  begins  even  before 
the  physical  signs  of  pneumonia  are  detected. 
It  persists  from  that  time  onward  without  any 
great  variations  to  the  crisis,  immediatel}r  after 
which  it  suddenly  falls. — Lancet. 

If.vsi<"i»^- 

Typhoid  Bacillus  in  Drinking  Water. 
Dr.  Finkelnburg  {Ccntralblatt  fur  Baktcriologie 
und  Parasitenkunde,  March  7,  1891)  mentions  an 
instance  in  which  he  examined  a  suspected  water 
and  found  no  bacilli  by  the  ordinary  method — ■ 
mixing  a  cubic-centimetre  of  the  water  with  nutri- 
ent gelatine  and  spreading  out  upon  plates.  By 
the  use  of  his  settling  apparatus  (described  in  the 
Corresp-blatt  des  niederrhein.  Vereins  fur  iff.  Ges, 
Pflege,  Band  //)  there  developed  in  the  cultures 
colonies  of  bacteria,  that  appeared  to  be  identical 
with  Eberth's  typhoid  bacillus.  Within  a  few 
years  the  writer  has  examined  fifteen  samples  of 
water  thought  to  contain  the  typhoid  bacillus  in 
which  the  ordinary  method  of  examination  gave 
negative  results,  but  the  application  of  the  set- 
tling method  demonstrated  on  the  first  trial  the 
presence  of  the  bacillus.  He  thinks  the  use  of 
this  method  would  in  many  instances  demon- 
strate pathogenic  organisms  in  waters,  which  are 
now  pronounced  free  from  contamination. 


'89I-] 


EDITORIAL. 


521 


Journal  of  the  American  Medical  Association 

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Address 

Journal  of  the  American  Medical  Association. 

No.  68  Wabash  Ave  , 

Chicago,  Illlnois. 
All  members  of  the  Association  should  send  their  Annual  Dues 
to  the  Treasurer,  Richard  J.  Dunglison.  M.D..  Lock  Box  1274,  Phila- 
delphia, Pa. 


London  Office,  57  and  59  Ludgate  Hill. 


SATURDAY,  APRIL   II,    1891. 


THE  FURTHER  DEVELOPMENT  OF  THE 
SECTION'S. 

It  seems  to  us  that  the  time  has  arrived  when 
the  question  should  be  carefully  considered  by 
the  members  of  the  Association,  as  to  the  best 
method  of  developing  the  work  of  the  Sections, 
of  presenting  that  work  at  the  annual  meetings, 
and  of  preparing  the  same  for  publication. 

Faithful  as  its  officers  have  been,  and  lib- 
eral in  the  expenditure  of  money  as  some  of  the 
officers  of  Sections  are,  in  the  effort  to  secure  a 
proper  reporting  of  their  proceedings,  still  we 
doubt  if  in  any  instance  they  have  been  fully  sat- 
isfied with  the  results  they  sought  to  accomplish. 
The  fault  was  certainly  not  with  them,  but  in  so 
far  as  there  was  failure  it  was  inherent  to  our 
present  method  of  securing  and  presenting,  dis- 
cussing and  publishing  our  papers. 

It  was  with  no  ordinary  effort  that  the  Sections, 
now  eleven  in  number,  were  inaugurated  and 
brought  into  their  present  working  order.  Thus 
far,  probably,  the  present  methods  were  the  best 
that  we  could  hope  to  secure.  But  now  that  the 
Sections  are  firmly  and  permauentl}'  established, 
it  seems  desirable  to  carefully  consider  to  what  ex- 
tent and  in  what  respects  modifications  may  be 
made  which  may  remedy  existing  evils,  and  en- 
hance the  general  good.  With  this  in  view,  and 
with  no  purpose  to  undo  what  has  already  been 
so  well  done,  we  desire  to  offer  for  the  considera- 
tion of  our  members  the  following  suggestions : 

1.   With  reference  to  the  preparation  and  pre- 


sentation of  papers.  Practically,  at  the  annual 
meetings  there  are  three  working  sessions  of  the 
Sections,  extra  sessions  not  included,  of  about 
three  hours  each,  giving  at  the  most  from  ten  to 
twelve  hours  for  the  presentation  of  papers.  If 
the  length  of  these  papers  be  limited  to  twenty 
minutes  each,  and  the  discussion  of  each  paper  to 
the  same  length  of  time,  not  more  than  fifteen 
papers  can  be  profitably  presented  in  any  one 
Section.  This  would  give  an  aggregate  of  at 
least  one  hundred  and  fifty  papers  for  publication, 
which,  with  the  discussions  properly  reported, 
would  fully  occupy  the  pages  devoted  to  the  pub- 
lication of  "Original"  matter  in  The  Journal 
for  the  entire  year. 

Of  a  given  fifteen  papers  in  a  Section  at  least 
ten  could  be  assigned  to  men  of  known  ability 
in  token  of  honorable  recognition.  It  should  be 
accounted  a  matter  of  honor — also,  if  a  man  be 
assigned  to  the  discussion  of  a  given  paper,  and 
if  each  fulfill  his  engagement,  even.-  paper  would 
secure  appropriate  consideration.  Five  volunteer 
papers  could  also  be  presented,  thus  giving  abun- 
dant opportunity  for  individuals  desiring  to  pre- 
sent special  subjects  to  come  before  the  Sections, 
such  volunteer  papers  or  full  abstracts  of  the  same 
being  first  submitted  to  a  constituted  board  for 
their  approval.  Xo  papers  should  be  read  simply 
by  title  and  referred  to  the  publishing  committee, 
nor  should  papers  be  announced  in  the  programme 
unless  there  is  reasonable  assurance  that  they  will 
be  read  in  the  Sections.  Thus  the  officers  will 
have  measurable  control  of  the  material  to  be 
submitted  both  as  to  its  amount  and  quality. 

2.  With  reference  to  the  reporting  of  the  pro- 
ceedings. We  deem  this  an  important  matter.  Xo 
just  estimate  can  be  made  of  the  work  done  in 
any  given  Section  unless  it  is  properly  reported. 
We  have  reached  the  point  now  when  such  re- 
porting is  perfectly  feasible.  The  present  re- 
ceipts of  the  treasury  will  safely  permit  the  neces- 
sarv  expenditure.  We  have  carefully  considered 
the  cost  and  find  that  expert  medical  reporters 
can  be  secured  by  a  single  contract  for  the  full  re- 
porting of  the  eleven  Sections,  in  typewritten 
copy,  for  from  eight  hundred  to  one  thousand 
dollars  per  year. 

An  annual  appropriation  of  one  thousand  dol- 
lars, which  the  present  income  of  the  treasury 
will  fully  warrant,  will  secure  the  full  and  satis- 
factory reporting  of  our  entire  proceedings. 


522 


SPLENIC  LEUCOCYTHEMIA. 


[April  ii, 


3.  The  publication  of  the  papers  presented  in 
the  Sections.  These  should  be  referred  to  the  care- 
ful supervision  of  men  specially  qualified  for  their 
work  by  reason  of  their  familiarity  with  the  sub- 
jects to  be  considered.  We  believe  the  best  interests 
of  the  Association  will  be  promoted  by  the  selec- 
tion of  one  member  from  each  Section  who  shall 
be  charged  with  the  duty  of  preparing  the  papers 
and  discussions  of  his  Section  for  publication, 
and  that  suitable  recognition  for  such  services 
should  be  made,  in  such  manner  as  the  Associa- 
tion may  deem  advisable. 

No  editor-in-chief,  nor  supervising  editor,  is 
alone  competent  to  this  work,  and  once  the  super- 
vision is  given  into  the  hands  of  those  who  are 
experts  in  their  specialties,  the  "Original"  de- 
partment may  become  the  crowning  feature  of  our 
Journal. 

In  the  next  issue  we  purpose  to  consider  the 
question  of  the  increase  of  our  membership, 
and  in  that  connection  to  suggest  the  propriety 
of  appointing,  at  a  suitable  time,  an  able  com- 
mittee which  shall  consider  these  various  subjects, 
and  at  a  subsequent  meeting,  recommend  to  the 
Association  such  modifications  of  our  present 
plans  as  may  be  deemed  desirable. 


LAST  WINTER'S  EMERGENCY  IN  PARIS. 

The  efficient  measures  adopted  in  Paris  for  the 
relief  of  the  poor  and  starving,  during  the  terrible 
cold  of  last  January,  command  our  highest  ad- 
miration. The  statistics,  showing  the  number  of 
lodgings  and  meals  provided,  have  been  cited 
with  wonderment  throughout  Europe.  For  cel- 
erity of  action  and  unstinted  relief  to  the  suffer- 
ing the  Municipal  Council  have  left  a  record  that 
must  prove  most  stimulating  to  other  cities  when 
they  shall  have  been  brought  face  to  face  'with  a 
like  trying  emergency  of  cold  and  want. 

Much  want  occurred  in  unexpected  quarters 
because  so  many  people  were  thrown  out  of  em- 
ployment by  the  extreme  cold  and  they  could  not 
get  the  money  wherewith  to  pay  their  rent. 
Many  such  were  compelled  to  leave  their  homes 
and  live  in  the  streets,  for  a  time  at  least.  This 
strange  emergency  was  met  by  the  prompt  estab- 
lishment of  eighty  or  more  "  brasseros"  or  great 
Open  fires  in  grates  in  the  public  places,  so  that 
many  were  there  cheered  and  revived  when  weak- 
ened by  the  cold.  Temporary  refuges  and  special 


shelters  for  women  were  organized  in  art  galler- 
ies and  gymnasia  so  as  to  accommodate  many 
hundreds,  giving  both  food  and  sleeping  places. 
All  this  was  done  by  the  authorities  without  hes- 
itation or  red-tape.  The  maximum  of  these  lodg- 
ings taken  up  on  any  one  day  was  4,500.  The 
beds  consisted  of  a  mattrass  of  straw  and  a  mili- 
tary rug,  or  robe,  provided  by  the  War  Depart- 
ment. Soup  was  served  out  morning,  noon  and 
night.  As  man}'  as  24,000  soup-portions  were 
prepared  in  a  single  day.  It  is  calculated  that 
the  soup  cost  about  three  cents  per  plate.  It  was 
made  of  beans,  peas,  lentils,  salt  and  lard,  bones 
and  fresh  vegetables  being  exorbitantly  high 
priced  during  the  "cold  snap."  The  lard  was 
found  to  make  a  fair  substitute  for  soup-meat. 
Soup  of  this  kind  was  still  being  given  out  at  the 
Paris  refuges  after  the  month  of  March  had 
opened.  The  heartiness,  catholicity  of  charity, 
and  even  hospitable  spirit  with  which  this  proffer 
of  relief  was  extended  made  it  easy  for  those  in 
want  to  accept  of  it.  At  first  no  inquiry  was 
made  of  any  applicant,  but  subsequently,  when 
the  rigor  of  the  cold  had  moderated,  the  personal 
descriptive  papers  were  required  to  be  shown. 
Perhaps  the  most  active  man  in  all  this  charitable 
work  was  Dr.  Paul  Brousse,  a  vice-president  of 
the  Municipal  Council,  and  physician.  It  was  in 
part,  at  least,  due  to  his  personal  representations 
to  the  authorities  that  some  of  the  measures  of 
relief  were  so  rapidly  undertaken  ;  and  he  thus 
became  the  willing  means  by  which  much  suffer- 
ing, sickness,  starvation  and  mortality  were  pre- 
vented. Not  the  least  remarkable  feature  in 
strange  situations  was  the  celerity  of  action  on 
the  part  of  public  officials,  who  for  the  time  being 
became  a  unit  in  the  disregard  of  precedent,  red- 
tape  and  every  other  ordinary  occasion  for  delay. 
If  the  poor  famishing  Brules  and  Ogallalas,  in 
the  West,  could  for  a  short  time  only  have  the 
services  of  Dr.  Paul  Brousse,  it  would  be  a  god- 
send to  the  country. 


SPLENIC  LEUCOCYTHEMIA. 
Dr.  H.  Toulmin  has  described  in  the  Johns 
Hopkins  Hospital  Bulletin  a  well-marked  case  of 
this  disease,  in  which  the  microscopic  blood-con- 
ditions were  examined  with  more  than  usual  min- 
uteness. The  patient  was  a  colored  waiter  twenty- 
three  years  old.       He  gave  a  history  of  malarial 


:89i.] 


EDITORIAL  NOTES. 


523 


infection,  dating  back  about  two  years;  and  had 
been  suffering  from  swelling  of  the  abdomen  and 
legs  from  six  to  nine  months.  Among  other 
symptoms  he  had  had  were  epistaxis,  a  slight 
diarrhoea  and  incontinence  of  urine;  priapism, 
so  often  observed  in  leucocythetnia,  was  denied  as 
having  existed.  The  splenic  "lump  in  his  stom- 
ach" was  first  noticed  by  the  patient  about  nine 
months  before,  when  it  would  seem  to  have  at- 
tained it  present  enormous  size  quite  rapidly.  It 
was  prominent  in  the  left  hypochondrium  and 
epigastrium,  and  occasioned  a  girth  of  36  inches 
at  umbilicus.  The  lump  was  a  firm,  solid  and 
movable  mass,  occupying  the  left  zone,  reaching 
to  the  level  of  the  anterior  superior  spine,  to 
nearly  three  inches  from  the  pubic  bone  and  to 
three  and  a  half  inches  to  the  right  of  the  median 
line  at  the  umbilicus.  The  edge  of  the  swollen 
spleen  could  best  be  palpated  in  the  right  in- 
guinal region.  Xo  notch  could  be  felt.  Posterior 
dulness  on  percussion  extended  from  the  lower 
border  of  the  seventh  rib  for  sixteen  inches.  I 
There  was  no  pulsation;  no  murmur  could  be  I 
heard;  the  superficial  veins  showed  no  enlarge- 1 
ment;  no  engorgement  of  the  lymph-glands,  and 
no  tenderness  over  the  bones  or  enlargement  of 
their  extremities  were  found.  The  examination  1 
of  the  blood  showed  the  proportion  of  white  cor- 
puscles to  be  as  one  to  four,  to  the  reds;  reds 
were  2,008,000;  haemaglobin  30  per  cent.  Two 
weeks  later,  there  were  reds  2,700.000;  propor- 
tion of  whites  to  reds  1  to  4.48;  total  of  Fowler's 
solution  taken  minims  cc;  haemoglobin  not 
stated.  One  month  after  last  entry,  there  were 
reds  3,430,000;  proportion  of  whites  to  reds  1  to 
iS.S:  total  of  Fowler's  solution  minims  dccxx; 
haemoglobin  51  per  cent.  As  indicated  in  the 
above,  the  patient  was  put  on  Fowler's  solu- 
tion, beginning  with  three  minims  thrice  daily, 
and  increased  to  six  minims.  Under  this  treat- 
ment the  cedema  was  reduced,  and  some  of  the 
other  symptoms  were  mollified;  but  the  splenic 
enlargement  remained  and  was  practically  un- 
changed. The  general  condition  of  the  patient 
is  otherwise  favorable,  and  the  man  reports  to  be 
feeling  well.  An  examination  of  the  cell-ele- 
ments, made  according  to  Ehrlich's  method,  show 
the  blood  to  contain  some  in  deficient  quantity, 
such  as  lymphocytes  4  per  cent.;  polyiiuclear 
neutrophiles  50  per  cent. ;  mononuclear  transition 
forms   5   per  cent.;    while  others  are  in  excess, 


such  as  eosinophiles  5  per  cent.,  and  myelocytes 
(mononuclear  neutrophiles)  30  per  cent  Not 
the  least  remarkable  feature  in  the  case  is  the  ex- 
cellent general  condition  that  has  been  sustained; 
he  states  that  he  has  never  before  weighed  more 
than  165  pounds,  while  at  present  his  weight  is 
ten  pounds  above  that  record. 


editorial  notes. 
The  Preliminary  Training  of  Railway 
Employes. — In  view  of  the  very  large  number 
of  accidents,  resulting  either  fatally,  or  in  the 
maiming  of  the  unfortunate  ones  for  life,  it  is 
proposed  to  establish  schools  of  training  at  favor- 
able railway  points.  In  the  aggregate  the  num- 
ber— 2,000  killed,  and  20,000  injured  in  1890 — 
of  sufferers  is  great,  and  the  utmost  means  of 
prevention  should  be  taken.  It  is  true  that  care- 
lessness is  responsible  for  a  goodly  proportion  of 
the  accidents,  and  it  is  this  very  factor  which  will 
be  largely  overcome  by  a  proper  drilling,  and  a 
due  presentation  of  consequences. 

A  New  Disease. — Two  English  physicians — 
Dr.  Hale  White  and  Mr.  Golding-Bird— have  re- 
cently described  an  affection  to  which  they  give 
the  name  "  Idioglossia."  It  appears  that  the  pa- 
tients hear  well,  and  express  themselves  in  arti- 
culate sounds,  but  such  sounds  are  unlike  those 
of  any  known  language.  The  patients  really 
have  a  language  entirely  of  their  own,  in  which 
there  does  not  seem  to  be  any  confusion,  i.  e.,  the 
sounds  given  forth  have  an  intelligent  application, 
and  the  same  sound  always  has  the  same  mean- 
ing. The  discussion  before  the  Royal  Medical 
and  Chirurgical  Society  was  varied,  some  of  the 
members  contending  that  the  so-called  language 
of  those  affected  was  but  a  modification  of  the 
English  tongue,  and  was  to  be  accounted  for  by 
a  lack  of  development  in  that  particular  direction. 

A  Literary  Physician.  —  Notwithstanding 
the  almost  constant  application  required  of  a  phy- 
sician in  the  active  pursuit  of  his  profession,  yet 
there  are  men — we  have  them  in  this  country — 
who  find,  or  make,  the  opportunity  of  adding  lit- 
erary laurels  to  the  honors  achieved  in  medicine. 

Dr.  William  Strieker,  of  Frankfort  on-the-Main, 
has  recently  passed  away,  leaving  behind  endur- 
ing works,  of  which  the  following  is  a  partial 
list :  "  History  of  Medicine  in  Frankfort ;"  "  The 
Lives  of  Soemmering,  Neff  and  Stiebel ;  "    "  Ett- 


524 


EDITORIAL  NOTES. 


[April  ii, 


ner's  Medical  Novels;  "  "The  Cure  of  the  Sick  in 
the  Wars  of  the  Past ;  "  "  Taylor,  Ludwig  Hoer- 
nigk,  Burggrave,  Haller,  Zimmerman;"  "The 
Mortality  of  Children  ;  "  "  Suicide  ;  "  "  Marri- 
ages between  Blood  Relations ;  "  "  Medical  Sta- 
tistics ;  ' '  Hermaphroditism  ;  "  "  Hairy  Men  ; ' ' 
"Small-pox;"  "Vaccination;"  "  Labial  Can- 
cer; "  "The  Effects  of  Lightning  on  the  Human 
Organism;"  "  Histor)'  of  Frankfort ;  "  "  Life  of 
Goethe,"  etc. 

A  Case  of  Acromegaly. — Dr.  Joseph  Red- 
mond has  recently  reported  to  the  Irish  Royal 
Academy  of  Medicine  a  case  of  acromegaly,  be- 
lieved to  have  been  the  first  hitherto  reported 
from  Ireland.  According  to  the  British  Medical 
Journal  the  attack  dates  from  December,  1889, 
during  the  prevalence  of  the  influenza.  The  pa- 
tient, a  female  of  19  years,  was  admitted  to  the 
hospital  in  July  last.  The  first  symptoms  that 
attracted  her  attention  were  the  changes  in  her 
hands  and  feet,  which  became  swollen,  sore  and 
tender  to  the  touch.  The  hands  were  large,  fin- 
gers thick  and  bulbous,  with  nails  somewhat  con- 
vex ;  the  back  of  hands  became  oedematous,  but 
did  not  pit  on  pressure.  There  was  marked  in- 
crease in  the  size  of  the  carpal  ends  of  both  radi- 
us and  ulna.  The  knees  were  enlarged,  as  well 
as  the  legs  and  ankles.  The  ankle-joints  con- 
tained some  effusion.  The  feet  were  larger  and 
thicker  than  normal ;  the  toes  were  thicker  and 
bulbous.  The  dorsum  of  the  feet  was  oedema- 
tous. Urine  normal.  The  thyroid  gland  ap- 
peared to  be  absent,  and  no  evidence  of  the  per- 
sistence of  the  thymus  could  be  obtained.  Pulse 
average  was  100;  temperature  101.60;  respira- 
tions 24.  The  patient  has  at  times  complained 
of  lumbar  pains,  and  has  had  occasional  attacks 
of  diarrhoea. 

Depopulation  from  Disease. — Official  re- 
ports go  to  show  that  the  native  population  of 
Alaska  is  fast  disappearing,  mainly  from  the  se- 
vere ravages  of  syphilis,  tuberculosis  and  small- 
pox. Medical  measures  are  unknown,  yet  if 
there  was  some  appreciation  of  the  advantages  of 
prevention  and  treatment  there  appears  to  be  no 
opportunity  by  which  aid  could  be  given.  The 
plight  of  these  unfortunates  is  certainly  a  sorry 
one,  and  the  possibilities  for  the  medical  mission- 
ary are  great.  Some  attention,  whether  govern- 
mental, or  through  the  operation  of  the  organ- 


ized charitable  associations,  should  be  directed  to 
this  state  of  things  prevailing  upon  American 
soil. 

A  Very  Commendable  Fashion. — Occasion- 
ally Fashion — so-called — has  the  credit  of  leading 
the  susceptible  mind  into  channels  where  Health 
and  Vigor  follow.  This  is  the  case — this  is  the  lead- 
ing— at  present  in  regard  to  hot  milk  as  a  popu- 
lar beverage.  If  only  the  temperance  disciples 
could  fully  awake  to  the  golden  opportunity  this 
"  fad"  opens  ! 

Hot  milk  is  a  wonderful  food  and  stimulant. 
It  combines  these  two  virtues  most  happily,  more 
so,  probably,  than  any  other  one  substance,  or 
combination  of  substances.  National  degeneracy 
need  hardly  be  feared  from  the  universal  con- 
sumption of  hot  milk  as  a  constant  drink.  We 
can  see  but  one  danger  in  this  direction,  and 
that  we  believe  will  be  fully  overcome  by  having 
the  temperature  of  the  milk,  in  all  cases,  carried 
to  the  boiling  point. 

Epidemic  Influenza  in  Africa  and  Asia.— 
Letters  from  the  Congo  Free  State  mention  the 
occurrence,  in  October  last,  of  an  extension  to 
those  parts  of  an  epidemic  sickness  that  bears  a 
very  close  resemblance  to  the  "  Russian  influ- 
enza." Nearly  everybody  has  had  "a  cold," 
while  some  have  been  very  ill.  The  season  there 
has  been  unusually  cold  in  the  upland  regions, 
two  and  three  hundred  miles  back  from  the  coast. 

A  letter  in  The  Lancet,  also,  states  that  at  Gil- 
git,  Kashmir,  in  December,  there  had  been  an 
epidemic,  supposed  to  have  been  taken  there  by 
a  party  of  Moslem  priests  from  a  place  200  miles 
farther  west,  where  the  influenza  had  already 
been  prevalent.  These  mountain  valleys,  about 
5000  feet  above  the  sea,  called  the  Hindu  Khush 
valleys,  have  hitherto  been  exempt  from  the  in- 
fluenza, although  it  had  existed  in  India  earlier 
in  the  year  1890.  The  invasion  seemed  to  ap- 
proach from  the  west  rather  than  from  the  south, 
although  the  avenues  of  communication,  in  the 
latter  direction,  were  much  more  accessible. 

The  Interviewer  in  Medicine. — Some  of 
our  New  York  brethren  in  open  rebellion  against 
the  American  Medical  Association,  held  an  expe- 
rience meeting  a  few  weeks  ago,  to  which  some 
how  the  ubiquitous  reporter  also  came,  presuma- 
bly for  the  benefit  of  those  who  do  not  take  the 
journals.     There  was    a  debate  upon  the  inter- 


i89i.] 


MEDICAL  ITEMS. 


525 


views  as  conducted  by  the  secular  press,  faintly 
apologetic  but  mainly  mock-heroic  in  tone  with 
which  nearly  all  (lay  and  professional)  regaled 
themselves  at  their  morning  breakfast.  With  a 
single  exception,  the  speakers  who  were  sticklers 
for  the  dignity  of  the  profession  were  either  silent 
or  un-reported.  We  need  not  remind  our  breth- 
ren of  goodly  Gotham,  who  are  so  strenuous 
about  enlightening  the  public,  that  there  is  an 
oft  quoted  phrase  about  barking  with  hounds  and 
running  with  the  hare.  There  also  comes  to  us 
the  story  of  the  vain-glorious  veteran,  of  whom 
some  little  Wilhelmina,  "  with  wonder-waiting 
eyes"  asked,  "  Grand- pa  didn't  you  have  anybody 
to  help  you." 

MEDICAL  ITEMS. 

Dissection  Material  in  New  York. — A 
bill  to  meet  the  wants  of  postgraduate  instruc- 
tion in  surgical  anatomy  at  the  two  schools  in 
New  York  City  has  been  put  upon  its  passage. 
The  under  graduates'  schools  have  hitherto  been 
able  to  absorb  all  the  material  allowed  by  law  to 
be  distributed  to  the  colleges.  The  new  arrange- 
ment will,  if  it  passes  the  legislature,  enable  the 
post-graduates  to  come  in  for  a  pro  rata  share. 

Cruelty  of  a  Nurse  Punished.— A  recent 
conviction  in  New  York  has  resulted  in  sending 
up  to  Sing  Sing  Prison  a  former  Bellevue  Hospital 
nurse,  who  struck  a  blow  at  a  delirium  tremens 
patient,  who  spat  upon  the  nurse;  the  patient 
was  in  a  strait  jacket  at  the  time.  The  convic- 
tion was  for  assault  in  the  second  degree  and  the 
term  of  imprisonment  will  be  two  years  and  eight 
months. 

A  Tornado  Memorial  Hospital.  —  The 
citizens  of  Louisville,  On  March  27,  commemor- 
ated the  cyclone  of  last  year  by  meeting  and  by 
taking  up  collections  for  the  establishment  of  a 
Children's  Hospital,  to  be  a  memorial  of  the  de- 
structive tornado.  It  is  reported  that  S^o.ooo 
have  already  been  promised  for  this  unusual  pro- 
ject to  link  a  great  public  calamity  with  an  endur- 
during  monument  of  charity,  and  thus  convert  it 
into  a  blessing  in  disguise. 

Influenza  in  Central  Africa. — A  recent 
number  of  the  Lancet  publishes  a  letter,  dated 
October  11,  1890,  from  the  neighborhood  of  Lake 
Nyasa,  Central  Africa,  by  which  it  appears  that 
epidemic  influenza  had  just  reached  that  distant 


point.  It  had  been  very  severe  and  a  number  of 
deaths  among  the  natives  had  resulted  from  it  or 
its  consequences;  most  of  the  Europeans  at  Blan- 
tyre,  a  Scottish  mission  station  near  the  Shire 
River,  had  been  attacked  by  it  in  a  more  or  less 
severe  form. 

Tobacco  and  Organic  Lesion  of  the 
Heart. — In  connection  with  the  discussion  which 
occurred  at  the  New  York  Academy  of  Medicine 
at  its  stated  meeting  of  Dec.  18,  1890,  (as 
chronicled  in  the  Medical  Record  of  Jan  17,  1891), 
relative  to  the  influence  of  tobacco  upon  the  sys- 
tem, the  President,  Dr.  A.  L.  Loomis,  thought 
that  when  tobacco  poisoning  reached  a  point 
where  it  produced  disturbance  of  the  heart  there 
was  something  more  than  functional  disturbance; 
there  was  a  change  either  in  the  connective  tis- 
sue or  of  the  muscular  fibres  of  the  heart.  Such 
hearts  did  not  bear  ether  nor  cocaine.  He  im- 
pressed the  fact  that  the  heart  condition  was  not 
functional ;  it  was  organic. 

Dr.  A.  Jacobi  having  elicited  from  the  Presi- 
dent the  opinion  that  in  such  cases  there  was 
never,  as  far  as  his  observation  had  gone,  entire 
recovery  from  the  heart  trouble,  said  that  he 
could  not  agree  with  him.  He  knew  persens 
who  had  had  functional  disturbance  of  the  heart 
from  tobacco- poisoning  recover  entirely  after  the 
use  of  tobacco  had  been  discontinued.  That  was 
a  hope  which  he  thought  we  should  hold  out  to 
our  patients,  unless  it  could  be  shown  that  the 
lesion  causing  the  disturbance  was  of  a  nature 
which  did  not  admit  of  entire  recovery. 

The  President  thought  Dr.  Jacobi  had  in  mind 
cases  of  disturbance  of  the  stomach  from  use  of 
tobacco,  which  caused  reflex  irritability  of  the 
heart. 

Dr.  Jacobi  remarked  that  the  President  seemed 
to  know  his  mistakes  better  than  he  knew  them 
himself.  He  did  not  believe  that  he  had  made  a 
mistake,  although  he  thought  there  was  room  for 
diversity  of  opinion.  He  would  be  very  sorry  to 
have  patients  get  the  idea  that  their  condition 
was  an  organic  change  in  the  heart  which  could 
not  be  remedied. 

Dr.  Andrews  mentioned  a  case  in  which  the 
man  was  obliged,  twenty-five  years  ago,  to  give 
up  tobacco  on  account  of  disturbance  of  the 
heart,  and  he  remained  well  to-day  at  76. 


526 


TOPICS  OF  THE  WEEK. 


[April  ii, 


TOPICS  OF  THE  WEEK. 


OFFICIAL  REPORT  ON  THE  RESULTS  OF  KOCH'S  TREAT- 
MENT IN  PRUSSIA. 

We  surrender  the  space  usually  assigned  to  the  con- 
sideration of  current  medical  topics,  this  week,  that  we 
may  present  to  the  readers  of  The  Journal  a  very  com- 
plete resume  of  the  results  thus  far  obtained  in  Prussia, 
in  connection  with  the  use  of  tuberculin  in  the  treatment 
of  tuberculous  diseases.  From  the  voluminous  report 
published  as  a  supplement  to  the  Klitiisches  Jahrbuch 
the  British  Medical  Journal  of  March  14,  presents  the 
following  valuable  abstract,  which  we  publish  entire: 

The  official  report  of  the  results  of  Koch's  treatment  of 
tuberculosis,  as  observed  in  the  University  clinics  and 
"polikliniks,"  and  other  public  institutions  of  Prussia, 
has  just  been  issued  in  the  form  of  a  supplement  to  the 
Klinisches  Jahrbuch,  a  publication  which  owes  its  ex- 
istence to  Cultus  Minister  von  Gossler.  The  editor  of 
the  volume  is  Professor  Albert  Guttstadt,  Lecturer  on 
Medical  Statistics  in  the  University  of  Berlin.  It  includes 
55  reports,  of  which  43  are  from  the  University  clinics 
and  "polikliniks,"  2  from  non-clinical  departments  of 
the  Charite  Hospital,  2  from  the  Moabit  City  Hospital, 
and  8  from  pathologicoanatomical  institutes  of  univer- 
sities. The  period  to  which  the  reports  refer  comprises, 
as  a  rule,  the  eight  weeks  from  the  beginning  of  Novem- 
ber to  the  end  of  December,  1890;  in  some  few  cases, 
however,  it  goes  down  to  the  middle  of  January,  1891. 
The  reports  of  Professor  Frantzel  and  Dr.  R.  Kohler  be- 
gin from  September  12  and  October  11  respectively.  The 
total  number  of  patients  injected  during  the  period  cov- 
en <1  by  the  reports  was  2,172,  the  total  number  of  injec- 
tions being  more  than  17,500.  The  greatest  number  of 
injections  in  any  one  case  was  54.  This  patient  was  un- 
der the  care  of  Dr.  Paul  Guttmann,  suffering  from  very  ad- 
vanced pulmonary  phthisis,  and  he  received  in  all  3.345 
grams  of  the  mother  liquor.  He  is  now  in  a  relatively 
favorable  condition,  but  there  is  no  appreciable  change 
in  the  objective  symptoms.  The  largest  quantity  of  tu- 
berculin administered  in  any  one  case  was  3.826  grams. 
This  patient  (a  man  with  pulmonary  phthisis,  under  the 
care  of  Professor  Frantzel)  received  in  all  43  injections. 
In  this  case  remarkable  improvement  in  the  physical 
signs  and  in  the  general  bodily  condition  followed  the 
treatment,  and  was  maintained  when  last  heard  of  (in 
February), 

The  volume  contains  reports  from  Professors  Leyden, 
Gerhardt,  Senator,  Frantzel,  Bardelebeu  (with  Dr.  A. 
1  ),  Olshausen,  Jolly,  Henoch  (with  Dr.  Goerue), 
Lewin,  Schweninger,  Schweigger,  Lucae,  E.  von  Berg- 
mann,  B.  Frankel,  and  R.  Virchow,  and  Drs.  R.  Kohler 
and  Westphal,  of  the  University  of  Berlin;  Professors  P. 
Schultze,  Trendelenburg,  Doutrelepont,  Walb,  Fiukler, 
and  Koester,  of  Bonn;  Professors  Biermer,  Mikulicz, 
Fritsch,  Neisser,  and  Ponfick,  of  Breslau;  Professors  Eb- 
stein,  Konig  (with  Dr.  Hildebrand),  and  Orth,  of  Gott- 
ingen;  Professors  Mosler  and  Striibing  (with  Dr.  Peiper), 
and  Helferich,  of  Griefswald;  Professors  Weber,  von 
Brain. mn.  Schwartze,  and   Ackermanu,  of  Halle;   Profes- 


sors Quincke,  Edlefsen,  von  Esmarch,  and  F.  Petersen, 
of  Kiel;  Professors  Lichtheim,  J.  Schreiber,  Braun,  von 
Hippel,  and  Neumann,  of  Konigsberg;  Professors  Mann- 
kopff,  Ruinpf,  Kuster,  Barth  and  Marchand,  of  Marburg; 
besides  supplementary  reports  from  Professor  Julius 
Wolff,  of  the  Berlin  Orthopaedic  Poliklinik,  Professor  A. 
Heller,  of  the  Pathological  Institute  at  Kiel,  and  Dr. 
Paul  Guttmann  and  Professor  Sonneuburg,  of  the  Moa- 
bit Hospital,  Berlin.  Professor  Koch's  two  papers  on 
his  remedy  are  published  in  an  appendix.  Finally,  there 
is  an  elaborate  analysis  of  the  reports  with  tabular  state- 
ment of  the  clinical  details,  number  and  doses  of  injec- 
tions, and  results  in  most  of  the  cases,  by  Professor  Gutt- 
stadt. 

DIAGNOSTIC  VALUE  OF  TUBERCULIN. 

Internal  Tuberculosis. — Leyden  looks  upon  tuberculin 
as  of  essential  service  in  confirming  the  diagnosis  of  tu- 
berculous disease,  but  in  ttie  absence  of  definite  symp- 
toms would  not  rely  on  it  alone  for  that  purpose  Ger- 
hardt thinks  it  is  not  absolutely  to  be  depended  on,  inas- 
much as  cases  have  occurred  in  which,  though  tubercle 
bacilli  were  undoubtedly  present,  the  injection  caused 
no  reaction.  It  may,  however,  be  useful  for  the  differ- 
entiation of  tubercle  from  syphilis  in  the  larynx  and 
lung.  Schultze  thinks  it,  within  certain  limits,  a  reagent 
for  the  detection  of  tubercle.  Biermer  expresses  him- 
self with  some  reserve,  as  he  has  met  with  two  cases  of 
certain  tuberculosis  with  bacilli  in  the  sputum  in  which 
continued  injections  produced  neither  general  nor  local 
reaction.  Ebstein  thinks  the  detective  action  of  the 
fluid  uncertain;  This  opinion  is  shared  by  Mosler,  Striib- 
ing  and  Peiper,  who,  nevertheless,  think  tuberculin  may 
help  to  show  whether  previously  existing  tubercle  is 
cured  or  not.  Weber  says  it  is  not  a  sure  diagnostic 
agent  for  internal  tuberculosis,  aud  does  not  give  certain 
results  in  doubtful  cases;  it  is  more  useful  in  external 
disease.  Quincke  is  at  present  unable  to  conclude  that 
in  all  cases  in  which  the  fluid  causes  reaction  there  are 
latent  foci  of  tuberculosis.  Finkler  and  Schreiber  place 
more  reliance  upon  it,  and  Rumpf  thinks  it  of  service  in 
doubtful  cases.  P.  Guttmann  speaks  in  the  tone  of  an 
ardent  believer.  In  pregnant  women  Olshausen  says  tu- 
berculin has  failed  to  produce  any  reaction  when  the  ex- 
istence of  phthisis  was  certain.  Fritsch  thinks  the  fluid 
is  of  high  diagnostic  value  in  the  differentiation  of  tuber- 
cle from  cancer. 

External  Tuberculosis. —  Bardeleben  aud  A.  Kohler 
admit  that  tuberculin  occasionally  fails  to  produce  reac- 
tion in  cases  of  external  tuberculosis;  they  think  this 
may  possibly  be  accounted  for  by  individual  idiosyncrasy 
or  by  slight  differences  in  the  fluid  itself.  Von  Berg- 
mann  thinks  it  is  a  valuable  means  of  differentiating  tu- 
bercle from  syphilis  aud  cancer;  Trendelenberg  consid- 
ers it  reliable  except  in  tubercle  of  the  testis;  Mikulicz 
places  confidence  in  it;  Konig  and  Hildebrand  do  not 
value  it  highly;  Helferich  thinks  it  an  important  aid  to 
diagnosis;  von  Bramann  says  it  is  "apparently"  a  sure 
reagent  for  tubercle;  von  Esmarch  also  thinks  highly  of 
it  in  lupus  and  in  bone  and  joint  disease;  von  Braun  and 
Kuster  think  it  extremely  useful,  though  not  infallible; 
R.  Kohler  and  Westphal  look  upon  it  as   superior  to   all 


l89I.] 


TOPICS  OF  THE  WEEK. 


known  aids  to  differential  diagnosis;  Lewin  considers  it 
useful;  Dnutrelepont  and  Neisser  think  it  of  high  diag- 
nostic value;  von  Hippel  has  found  it  of  service  in  two 
cases  of  doubtful  eye  disease. 

THERAPEUTIC  RESULTS. 
Commencing  Pulmonary  Phthisis. — Leyden  treated  9 
cases  of  commencing  pulmonary  phthisis,  but  no  statis- 
tics are  given  as  to  results.  Gerhardt  treated  15  cases,  of 
which  4  were  discharged  improved  and  11  are  still  under 
treatment;  of  the  latter  3  are  said  to  be  materially  im- 
proved, 1  is  improved,  while  in  7  there  is  no  change. 
Senator  reports  39  cases,  of  which  10  have  been  dis- 
charged and  29  are  still  under  treatment;  of  those  be- 
longing to  the  former  category,  3  were  materially  im- 
proved, 3  were  improved,  and  4  were  in  statu  quo.  Of 
those  still  under  treatment,  2  are  greatly  improved.  3  im- 
proved, 20  are  unchanged,  and  4  have  been  made  worse. 
Schultze  has  treated  9.  of  which  1  has  been  discharged 
unrelieved,  while  of  the  S  still  remaining  under  treat- 
ment, 2  are  materially  improved,  2  improved,  and  4  un- 
relieved. Biermer  has  had  12  cases,  of  which  2  have 
been  discharged  unrelieved,  while  of  the  remaining  io, 
improvement  is  recorded  in  6  and  no  improvement  in  4. 
Ebstein  reports  3  cases,  of  which  1  was  discharged  unre- 
lieved, while  of  the  2  others,  1  is  not  improved  and  1  is 
described  as  worse  than  before  the  injections  were  begun. 
Of  7  cases  treated  by  Mosler,  2  have  been  discharged  ma- 
terially improved,  1  improved,  and  2  unrelieved;  of  the  2 
still  under  treatment,  both  are  improved.  Of  9  cases  still 
under  treatment  by  Weber,  3  are  materially  improved  and 
6  are  improved.  Quincke  reports  10  cases,  of  which  2 
haue  been  discharged  improved,  while  the  8  still  under 
treatment  show  no  change.  Lichtheim  has  9  cases  under 
treatment,  of  which  2  are  greatly  improved,  4  are  im- 
proved, and  3  are  unchanged.  Mannkopff  has  9  cases 
under  treatment,  of  which  1  is  greatly  improved,  2  are 
improved,  and  6  are  unrelieved.  Finkler  has  had  10 
cases,  of  which  4  were  discharged  cured  and  3  greatly 
improved;  the  3  remaining  under  treatment  were  all 
improved.  Edlefsen  has  2  cases  under  treatment,  both 
of  which  are  materially  improved.  Schreiber  reports  12 
cases,  1  of  which  was  discharged  cured  and  2  unrelieved; 
of  the  9  still  under  treatment,  2  are  greatly  improved,  1 
is  improved,  and  6  are  unchanged.  Of  19  cases  under 
Rumpf's  treatment,  13  are  greatly  improved,  5  are  im- 
proved, and  I  shows  no  change.  Of  3  cases  under  Frant- 
zel's  care,  1  is  greatly  improved  and  the  other  2  show  no 
change.  -Of  54  cases  treated  by  P.  Guttmann,  4  have 
been  discharged  cured,  S  greatly  improved,  1  improved, 
and  1  in  statu  quo.  Of  the  40  cases  still  under  treatment, 
21  are  greatly  improved,  10  are  improved,  and  9  are  un- 
changed. Neisser  reports  2  cases,  both  improved.  Hen- 
och has  5  still  under  treatment,  of  which  1  is  improved 
and  4  unchanged.  B.  Frankel  has  4,  all  of  which  show 
great  improvement. 

Moderately  Advanced  Pulmonary  Phthisis.  — Leyden 
has  had  23  cases,  of  which  no  particulars  are  forthcom- 
ing. Gerhardt  has  had  34,  of  which  2  have  been  dis- 
charged unrelieved,  2  have  died,  and  of  the  30  still  under 
treatment  3  are  materially  improved,  4  improved,  and  23 
unchanged.     Senator  has   had   32   cases,  of  which  1  has 


been  discharged  greatly  improved,  6  improved,  and  14 
unrelieved,  while  1  has  died;  of  the  10  cases  still  under 
treatment  1  is  greatly  improved,  3  are  improved,  and  6 
show  no  change  or  have  been  made  worse.  Schultze  has 
26  under  his  care,  of  which  2  are  greatly  improved,  4 
improved,  and  20  unrelieved.  Biermer  reports  17  cases, 
of  which  1  was  discharged  unrelieved,  1  died,  and  of  the 
remaining  15,  5  are  improved,  and  10  show  no  change. 
Ebstein  records  18  cases,  of  which  6  have  been  discharged 
unrelieved,  and  12  are  still  under  treatment  without  show- 
ing any  improvement.  Mosler  has  had  25  cases,  of  which 
4  have  been  discharged  much  improved,  4  improved,  and 
14  unrelieved;  of  the  3  still  under  treatment  all  are  much 
improved.  Of  13  cases  under  Weber's  care.  2  are  much 
improved,  4  improved,  and  7  unrelieved.  Of  21  under 
Quincke  not  one  shows  any  improvement.  Of  16  under 
Lichtheim,  1  has  died;  and  of  the  15  still  under  treatment, 
9  are  improved  and  6  unchanged.  Of  13  under  Mann- 
kopff, 1  is  greatly  improved,  5  are  improved,  and  7  are 
unchanged.  Of  27  cases  reported  by  Finkler,  2  have  been 
discharged  materially  improved,  5  improved,  and  13  un- 
relieved; of  the  7  still  under  treatment,  2  are  improved, 
and  5  show  no  change.  Of  4  cases  under  Edlefsen.  1  has 
been  discharged  much  improved,  and  1  has  died;  of  the 
2  still  under  treatment,  1  is  improved,  the  other  not.  Of 
1 1  cases  treated  by  Schreiber,  1  has  been  discharged  im- 
proved, and  4  unrelieved;  of  the  remaining  6,  there  is 
material  improvement  in  1,  while  5  show  no  change.  Of 
20  cases  treated  by  Rumpf,  3  have  been  discharged  unre- 
lieved, and  1  has  died;  of  the  16  still  under  treatment,  6 
are  much  improved,  and  10  in  statu  quo.  Of  16  under 
Frantzel,  3  have  been  discharged  improved,  and  1  has 
died;  of  the  remainder,  4  are  greatly  improved,  2  are  im- 
proved, and  7  are  unchanged.  Of  112  cases  under  P. 
Guttmann,  16  have  been  discharged  much  improved,  4 
improved,  and  5  unchanged;  of  the  S7  still  under  treat- 
ment, 14  are  greatly  improved,  and  3  unchanged.  Hen- 
och has  had  1  case,  which  was  discharged  unrelieved  or 
rather  worse  than  before.  B.  Frankel  has  had  14,  of 
which  1  has  been  discharged  cured;  the  13  still  under 
treatment  are  all  greatly  improved.  Lewin  has  had  one 
case,  which  was  discharged  unrelieved. 

Very  Advanced  Pulmonary  Phthisis. — Leyden  has  had 
20  cases,  of  which  4  have  died;  as  to  the  remaining  16  no 
details  are  furnished.  Gerhardt  has  had  S,  of  which  1 
has  died,  and  7  are  still  under  treatment  without  show- 
ing any  improvement.  Senator  has  had  8,  with  5  deaths, 
the  remaining  3  being  unrelieved.  Schultze  reports  14, 
in  none  of  which  has  there  been  any  improvement;  Bier- 
mer 7.  with  1  death  and  6  unrelieved;  Ebstein  6,  of  which 
2  have  been  discharged  unrelieved,  while  4.  which  are  still 
under  treatment,  show  no  improvement;  Moslei 
which  3  have  been  discharged  greatly  benefited,  7  im- 
proved, and  14  unrelieved,  while  of  the  5  still  under 
treatment  1  is  improved  and  4? unchanged:  Weber  22.  oi 
which  2  have  died,  2  are  improved,  and  iS  unchanged; 
Quincke  5,  of  which  1  is  improved  and  4  not:  Lichtheim 
9,  with  one  death,  4  improved,  and  4  uurelieved;  Mann- 
kopff 8,  of  which  1  is  improved  and  7  unchanged:  Finkler 
32,  of  which  3  have  been  discharged  improved,  and  II  un- 
relieved, and  2  have  died,  while  of  the  remaining  16,  2 


528 


TOPICS  OF  THE  WEEK. 


[April  ii. 


are  improved  aud  14  in  statu  quo;  Edlefsen  3,  all  un- 
changed; Schreiber  6,  of  which  1  has  been  discharged 
improved,  3  unrelieved,  and  1  has  died,  while  the  1  still 
under  treatment  shows  no  improvement;  Rumpf  7,  of 
which  1  has  been  discharged  unrelieved,  while  of  the  6 
still  under  treatment  2  are  improved  and  4  in  statu  quo; 
Frantzel  17,  of  which  1  has  been  discharged  improved,  1 
unrelieved.  4  have  died,  whilst  of  the  11  still  under  treat- 
ment, 1  is  greatly  improved,  3  are  improved,  and  7  are 
unchanged;  P.  Guttmann  30,  of  which  5  have  been  dis- 
charged unrelieved  and  8  have  died,  while  of  the  17  still 
under  treatment  none  show  any  improvement ;  Sonnen- 
burg  7,  of  which  3  are  greatly  improved,  3  are  improved, 
and  1  is  unrelieved ;  Olshausen  3,  of  which  2  have  been 
discharged  unrelieved,  while  1  is  in  statu  quo;  Henoch 
1,  discharged  unrelieved ;  and  B.  Frankel  5,  with  : 
death,  1  improved,  and  3  unrelieved. 

On  the  whole  Leyden  is  fairly  satisfied  with  the  results 
so  far,  while  Senator  thinks  them  better  than  could  have 
been  produced  by  any  other  treatment ;  Schultze  is  not 
enthusiastic ;  Ebstein  is  inclined  to  be  pessimistic ; 
Biermer  states  that  in  3  cases  the  tuberculous  process 
made  distinct  headway  during  treatment  ;  Hosier,  Striib- 
ing,  Peiper,  Weber,  Finkler,  and  Schreiber  all  speak 
with  reserve ;  P.  Guttmann  claims  decided  "improve 
meut  "  in  38  per  cent,  of  all  his  cases  (i64\  and  in  81 
per  cent,  of  the  "incipient''  cases  taken  alone. 

Effect  of  Treatment  on  Symptoms  in  Phthisis. — 1. 
Body  weight :  Of  61  cases  under  Gerhardt,  22  have 
gained  weight,  17  remain  as  before,  and  22  have  lost. 
The  gain  ranged  from  >2  to  5  kilos.,  the  loss  from  }i  to 
Sj-2  kilos.  In  one  of  the  Senator's  cases  4.4  kilos,  were 
gained  in  a  week,  and  on  several  occasions  there  was  an 
increase  from  1^  to  2  kilos,  in  the  same  space  of  time. 
Eight  patients  in  a  very  advanced  stage  of  phthisis,  with 
cavities,  chronic  diarrhcea,  etc.,  gained  weight,  in  some 
cases  as  much  as  2  Vz  kilos.  Biermer  found  increase  in 
11  cases,  the  average  gained  being  from  2  lbs.  to  3  lbs., 
and  in  one  case  as  much  as  10  lbs.  In  17  cases  there 
was  progressive  loss  of  weight  to  the  extent  of  1  lb.  to 
6  lbs.;  in  the  other  cases  there  was  neither  loss  nor  gain. 
Weber  noted  increase  in  16,  and  loss  in  2S,  while  in  12  it 
remains  stationary.  P.  Guttmann  says  the  weight  in- 
creased in  a  large  number  of  cases  under  his  care,  the 
maximum  gain  being  7^  kilos.  2.  Expectoration  : 
Gerhardt  says  expectoration  mostly  increased  at  first,  in 
5  cases  it  became  bloodstained.  Afterwards  it  gradually 
decreased,  and  became  more  mucous.  Iu  several  cases 
the  bacilli  seemed  to  diminish  at  first ;  in  particularly 
favorable  cases  they  disappeared  from  the  sputum. 
Senator  found  that  the  bacilli  diminished  in  favorable 
cases,  but  in  no  instance  disappeared  altogether.  Eb- 
stein has  seen  no  improvement  either  in  the  quantity  or 
the  quality  of  the  sputum,  and  no  diminution  of  bacilli. 
Mosler  on  several  occasions  noticed  that  the  expec- 
toration was  bloodstained,  but  he  did  not  see  actual 
hemoptysis.  Weber  says  cough  was  improved  in  14 
cases,  increased  in  15,  and  remained  in  statu  quo  in  the 
rest.  The  expectoration  was  diminished  in  18,  increased 
in  12,  and  unchanged  in  the  remainder.  L,iclrtheim  says 
that  in  almost  all  cases  after  the  subsidence  of  the  reac- 


TablE  I. — Statistical  Statement  of  the  Action  of  Koch's 
Fluid  in  Tuberculosis  of  Internal  Organs. 


-Pulmonary  Tuberculosis  : 

1.  Early  pulmonary  phthisis  .    .    . 

(a)  With  laryngeal  tuberculosis 

(b)  With  tuberculosis  of  other  ii 

ternal  organs 

(c)  With  other  diseases 

2.  Moderately  advanced  pulmonary 

phthisis'. 

(aj  With  laryngeal  tuberculosis 
(/»)  With  tuberculosis  of  other  in- 
ternal organs 

[c]  With  other  diseases  .... 

3.  Very  advanced  pulmonary  phthi- 

sis (cavities) 

(a)  With  laryngeal  tuberculosis 

[b)  With  tuberculosis  of  other  ; 

ternal  organs 

\>  1  With  other  diseases 


—Pulmonary    Tuberculosis  (all    grades 
taken  together) 

(a)  With  laryngeal  tuberculosis 

(b)  With  tuberculosis  of  other  i 

ternal  organs 

(<  1  With  other  diseases 

.—Laryngeal  Tuberculosis 

with  Pulmonary  tuberculosis.  . 

I.— Pleurisy 

r.—Pemictous  Anosmia 

—  Tuberculous  Meningitis 

[. — Peritoneal  Tuberculosis 

[I.— Intestinal  Tuberculosis 

[II. — Renal  Tuberculosis 

L.— Urethral  and  Vesical  Tuber 

—  Testicular  Tuberculosis 

I.  — Double  Tuberculous   Pyosalp 

with  incipient  pulmonary  phthisis 


■t/<  >  \  is 


Totals 


mber  of  cases  and  the 
given  is  due  to  the  fact 


*  The  difference  between  the  total  1 
number  iu  which  the  result  of  treatment 
that  a  few  reporters  give  no  information  as  to  the  result 

Table  II. — Statistical  Statement  of  the  Action  of  Koch's 
Fluid  in  External  Tuberculosis. 


';"(•" 


With  tuberculosis  of  internal  organs 

I I.  —  Tuberculosis    of  Single   Bones  and 

Joints 

With  tuberculosis  of  internal  organ 

III.  —  Tuberculosis  of  Several  Bones  and 

Joints 

With  tuberculosis  of  internal  organs 
IV. —  Tuberculosis  of  Lym^h  Glands.  .   . 

With  tuberculosis  of  internal  organs 
V.— Tuberculosis  of  Soft  Parts 
VI.— Tuberculosis  of  Scars  .  . 

VII. — Scrofuloderma 

VIII 


Rodent  I 'leer 

X. —  Tuberculous  Anal  fistula.   .    .    . 
XI.—  Tuberculosis  of  Sheaths  of  Tendons 

XII. — Scrofulous  Eczema 

XIII.—  Scrofulous   h'oatitisof  Both  Eyes 

XIV—  Eat  Diseases 

With  pulmonary  tuberculosis.  . 


Totals 708       15    148   237   298 


tion  both  cough  and  expectoration  were  lessened.  In 
one  case  expectoration  and  the  appearance  of  bacilli 
followed  the  commencement  of  the  injection,  and  ceased 
on  their  discontinuance.     Mannkopff  noticed  little  or  no 


I89I.] 


SOCIETY  PROCEEDINGS. 


529 


change  in  the  quantity  or  quality  of  the  expectoration 
3.  Respiration  :  Gerhardt  says  that  vital  capacity  in 
creased  in  5  out  of  10  cases.  4.  Physical  signs:  Ger 
hardt  says  that  in  many  cases  there  was  diminution  of 
dulness  and  rales.  Senator  noticed  in  some  favorable 
cases  a  complete  disappearance  of  catarrhal  signs  and 
rules.  Neither  Ebstein  nor  Mannkopff  observed  any  par- 
ticular change  in  the  physical  signs.  Frantzel  says  that 
after  treatment  had  been  continued* for  a  certain  time 
the  r&les  almost  disappeared  in  some  cases.  5.  Night 
sweats:  Senator  records  the  cessation  of  night  sweats 
even  in  cases  where  before  the  treatment  they  had  been 
considerable  in  amount.  Weber  says  that  in  11  cases  the 
night-sweats  diminished,  while  in  3  they  increased. 
Lichtheim,  Mannkopff,  and  Frantzel  also  say  the  injec- 
tions had  a  good  effect  on  night-sweats.  6.  General  con- 
dition: Gerhardt  says  that  three  patients  felt  so  well 
that  they  insisted  on  leaving  the  hospital,  though  the 
physical  signs  showed  that  they  were  not  cured.  In  10 
cases  the  treatment  had  to  be  discontinued  by  reason  of 
weakness,  persistent  fever,  or  progressive  loss  of  weight. 
Senator  says  the  treatment  had  a  favorable  effect  on  the 
subjective  feelings  of  a  large  number  of  patients ;  they 
looked  better,  and  were  stronger  and  more  cheerful. 
Biermer,  on  the  other  hand,  found  that  many  patients 
complained  that  the  treatment  made  them  feel  weaker 
and  lower.  Mosler  notes  an  improvement  in  the  ap- 
pearance of  patients.  Weber  says  that  the  general  con- 
dition became  worse  in  22  cases,  while  33  patients  ex- 
pressed themselves  as  satisfied  with  the  effects  of  the 
remedy. 

Other  Tuberculous  Diseases. — The  general  results  of 
the  treatment  in  laryngeal  phthisis,  lupus,  and  other 
forms  of  tuberculous  diseases  will  be  seen  in  the  table 
here  appended,  which  is  literally  translated  from  pages 
9°4,  9°5- 


SOCIETY    PROCEEDINGS. 


St.  Louis  Medical  Society. 

Stated  Meeting,  Saturday,  February  28,  1891. 

The  President,  L.  Bremer,  M.D.,  in  the 
Chair. 

[Abstracted  for  The  Journal]. 
TUBERCULOSIS  (?)  OF  THE  LIVER. 

Dr.  Gale  presented  an  abscised  portion  of  a 
liver  taken  from  a  boy  1 1  years  old.  An  abscess 
had  formed  over  the  liver  two  years  ago,  and  lat- 
terly a  tumor  had  developed  in  the  same  situation. 
Syphiloma  was  excluded.  Upon  operating  a  tu- 
mor involving  one-third  of  the  right  lobe  was 
found,  and  which  was  removed.  The  tempera- 
ture, which  had  previously  been  1010  constantly, 
regained  the  normal  point  after  the  operation, 
and  the  case  (twelve  days  after)  promised  a  good 
recovery. 

Discussion  was  postponed  pending  a  microscop- 
ical examination  of  the  specimen. 


ACUTE   OTITIS  MEDIA. 

Dr.  Barclay  reported  a  case  of  this  disease 
where  quinine  had  been  ordered  in  large  doses, 
with  the  effect  of  greatly  increasing  the  patient's 
distress,  and  where  relief  was  found  by  the  almost 
constant  application  of  cold  water  to  the  ear.  The 
patient  had  himself  applied  the  cold  water  from  a 
well  for  two  nights  and  one  day. 

Dk.  Brkmer  mentioned  a  case  of  death  from 
probable  meningo  encephalitis  as  the  outcome  of 
a  too  severe  syringing  of  the  ear;  and  a  case, 
also,  of  the  same  inflammation  from  a  too  severe 
syringing  of  the  nose.  He  did  not  believe  it  a 
good  or  safe  practice  to  inject  a  forcible  stream 
into  these  cavities. 

Dr.  Williams  thought  the  President  accused 
the  syringe  unjustly.  He  believed  the  ear  syringe 
had  been  made  to  answer  for  a  great  many  results 
it  was  in  no  wise  accountable  for.  He  had  cer- 
tainly used  the  syringe  a  great  deal,  yet  had  never 
seen  encephalitis  induced. 

Dr.  F.  J.  Lutz  agreed  with  Dr.  Williams,  still 
an  observation  of  two  recent  cases  wherein  men- 
ingitis followed  closely  upon  the  use  of  ear  and 
nasal  syringes,  led  him  to  believe  that  there  might 
at  times  be  danger  in  the  unskilful  and  untimely 
use  of  these  measures. 

Dr.  Loeb  did  not  think  harm  followed  the 
reasonable  use  of  the  douche.  Exaggerated  cases, 
doubtless,  there  were.  He  advocated  the  spray 
instead  of  the  douche. 

Dr.  Funkhouser  reported  an  interesting  case 
of  inflammation  of  the  ear,  extending  to  the  men- 
inges and  finally  resulting  in  death,  and  in  which 
the  syringe  was  not  used. 

Dr.  Glasgow  reported  a  case  very  similar  to 
that  of  Dr.  Funkhouser,  and  in  which  a  syringe 
had  not  been  used. 

Dr.  Barclay  remarked  that  the  ear  syringe, 
like  almost  all  other  instruments  of  value  in  the 
physician's  hands,  might  be  used  in  such  man- 
ner, and  at  such  times,  as  to  cause  harm.  Dis- 
cretion and  judgment  were  highly  necessary.  He 
mentioned  a  case  where  syringing  had  been  re- 
sorted to  three  times  daily  for  three  months,  for 
an  abscess,  yet  when  it  was  discontinued  the  ab- 
scess healed  completely  in  three  days.  He  be- 
lieved that  authorities  discarded  the  syringe  more 
and  more  as  their  experience  became  extended. 

Dr.  Bremer  said  that  he  recognized  the  differ- 
ent results  which  would  occur  from  the  use  of  the 
instrument  in  the  hands  of  the  intelligent  expe- 
rienced, and  the  thoughtless  inexperienced. 


Hypnotizing  a  Medical  Procedure. — In  a 
recent  discussion  of  the  question :  Should  a 
person,  who,  not  being  a  member  of  the  medical 
profession,  performs  hypnotic  experiments  on  an- 
other, be  prosecuted  for  illegal  practice  of  medi- 
cine? The  Conference  of  Paris  Advocates  de- 
cided in  the  affirmative. 


53Q 


FOREIGN  CORRESPONDENCE. 


[April  ii, 


FOREIGN    CORRESPONDENCE. 


LETTER  FROM  LONDON. 

(FROM   OUR   OWN   CORRESPONDENT.) 

Sir  James  Crichton  Brown  on  ''Brain  Rest" — 
B  Naphthol  and  Salicylate  of  Bismuth  as  a  Dis- 
infectant in  the  Internal  Treatment  of  Typhoid 
Fever — Results  of  Treatment  with  Dr.  Koch's 
"■Tuberculin''' — The  Consumption  of  Ether  by  the 
Irish — Miscellaneous  Gleanings. 

Sir  James  Crichton  Brown,  in  his  course  of  lec- 
tures recently  delivered  upon  the  subject  of  "Brain 
Rest,"  said  that  ordinary  sleep  grows  deeper  for 
the  first  hour  and  a  half  and  then  steadilydiminishes 
until  the  slumberer  awakens.  Dr.  Brown  pleaded 
for  eight  hours  for  actively  working  brains, 
though  ascetic  notions  have  led  many  people  to 
shorten  the  time,  with  the  result  that  in  certain 
cases  it  has  been  proved  that  the  amount  of  sleep 
may  be  considerably  reduced  without  injury. 
Literary  men  were  apt  to  starve  the  brain  in  the 
matter  of  sleep,  but  some,  nevertheless,  had  got 
on  pretty  well  in  spite  of  insomnia.  Cartyle  and 
Rossetti  furnished  instances.  Dr.  Brown  quoted 
a  letter  from  his  friend  Dr.  Tyndall,  who  said: 
"For  four  weeks  I  have  never  had  a  single  second 
of  sleep,  and  during  those  nights  I  walked  thou- 
sands of  times  round  my  room  to  no  purpose. 
What  astonishes  me  above  all"  (he  adds)  "is  not- 
withstanding my  nights'  weariness  my  brain 
power  does  not  appear  to  be  sensibly  impaired. 
After  two  or  three  hours'  sleep  I  feel  my  brain  as 
strong  and  clear  as  it  ever  was  at  any  period  of  my 
life."  It  is,  in  Sir  J.  Crichton  Brown's  opinion, 
impossible  to  doubt  that  nutrition  and  repair 
must  have  gone  on  in  the  brain  during  periods  of 
sleeplessness.  The  brain  in  short  must,  as  he  ex- 
pressed it,  "have  learnt  the  trick  of  the  heart  and 
gone  to  sleep  during  the  beats,  or  it  must  have 
slept  in  centres  which  were  not  active  at  the 
same  time." 

During  the  recent  prevalence  of  typhoid  fever 
various  agents  have  been  brought  forward  as  dis- 
infectants in  the  internal  treatment  of  the  disease. 
Several  physicians  consider  naphthol  to  be  supe- 
rior to  any  other.  There  appears  to  be  two  kinds 
of  naphthol,  one  which  is  more  soluble  and  less 
toxic,  but  more  irritant,  is  called  A  napthol,  the 
other  less  soluble,  more  toxic,  but  less  irritant,  is 
called  B  naphthol.  It  is  to  the  latter  that  prefer- 
ence is  given,  it  being  associated  with  salicylate 
of  bismuth,  both  being  given  in  the  form  of  pow- 
ders or  granules,  in  such  a  manner  that  the  pa 
tient  takes  daily  from  fifteen  to  thirty  grains  of 
naphthol. 

The  news  has  arrived  that  the  official  repents 
from  all  the  Prussian  clinics  and  pathological  in- 
stitutes on  the  results  of  treatment  with  Dr. 
Koch's  "tuberculin"  have  been  published  by  the 
Ministry  for  Public  Instruction.     It  appi 


the  results  were  much  better  than  was  believed. 
From  the  middle  of  November  to  the  end  of  De- 
cember 2,172  persons  received  injections,  the 
number  of  injections  being  more  than  17,500.  Of 
these  patients  932  had  tuberculosis  of  the  lungs, 
120  tuberculosis  of  other  internal  organs,  and  700 
external  tuberculosis.  Of  those  suffering  from 
tuberculosis  of  the  internal  organs  13  were  cured, 
171  considerabl}'  improved,  194  improved,  and  46 
died.  Of  708  patients  suffering  with  external  tu- 
berculosis 15  were  cured,  148  were  considerably 
better,  237  better,  and  nine  died. 

There  has  lately  been  a  great  outcry  concern- 
ing the  consumption  of  ether  by  the  Irish  who 
have  chosen  it  as  an  intoxicant,  and  in  the  House 
of  Commons,  in  answer  to  a  question  by  Dr.  Tan- 
ner, Mr.  Balfour  said:  "As  stated  by  my  right  hon- 
orable friend  the  Chancellor  of  the  Exchequer,  in 
reply  to  a  question  addressed  to  him  on  Decem- 
ber 1st, ether  has  been  scheduledand  it  can  now  only 
be  sold  by  qualified  chemists  or  druggists  as  a  poi- 
son." The  statement  laid  before  the  executive 
government  by  Mr.  Thomas  Ledlie  affords  some 
idea  as  to  the  alarming  proportions  the  habit  had 
assumed.  Mr.  Ledlie  calculates  that  seventeen 
thousand  gallons  of  impure  ether  of  the  vilest 
form  is  annually  consumed  by  the  people  in  the 
districts  situated  in  the  counties  of  Derry  and  Ty- 
rone, as  well  as  parts  of  Armagh,  Monaghan  and 
Fermanagh,  no  fewer  than  100,000  people  spread 
over  an  infected  area  of  190,000  acres  in- 
dulge in  this  baneful  habit.  He  suggests  six  ways 
of  getting  rid  of  what  he  considers  a  baneful  prac- 
tice, the  chief  of  which  may  be  summarized  as  fol- 
lows: The  introduction  of  naphtha  into  the  pre- 
paration of  all  ether,  save  that  used  purely  for 
medicinal  purposes,  which  would  give  it  nauseat- 
ing odor  and  taste,  the  reimposition  of  a  pro- 
hibitive tax,  and  the  making  of  the  practice  ille- 
gal and  placing  it  upon  the  criminal  code,  as  well 
as  making  the  sale  of  ether  illegal  by  all  persons 
save  chemists,  and  by  this  class  of  persons  only 
for  bona  fide  medicinal  or  commercial  purposes. 

At  the  Westminster  Hospital  there  has  recently 
been  a  death  by  asphyxia  caused  by  exophthal- 
mic goitre.  The  patient,  a  girl  aged  20,  had 
been  under  medical  care  for  twelve  months.  In 
spite  of  treatment  the  goitre  slowly  increased  un- 
til there  were  attacks  of  dyspnoea.  Upon  admis- 
sion to  the  hospital  asphyxia  became  imminent, 
and  Mr.  Spencer  opened  the  trachea  through  the 
upper  part  of  the  tumor.  The  gland  substance 
bulged  greatly  when  the  capsule  was  divided, 
and  there  was  a  large  amount  of  haemorrhage. 
Upon  opening  the  trachea  no  improvement  in  the 
breathing  took  place,  nor  was  there  upon  the  in- 
troduction of  an  ordinary  tracheotomy  tube.  A 
vulcanite  tube  was  then  passed  for  four  inches 
down  the  trachea,  when  air  entered  freely.  For 
a  time  the  dyspnoea  was  entirely  relieved,  but 
during  the  evening  mucus    collected  below    the 


tS9i.]  DOMESTIC  CORRESPONDEN 

tube,  this  the  patient  was  unable  to  cough   up,    lish  man  of  science  f.o  have  discovered 

and  she  died  asphyxiated.  The  operator  con-  at  Berlin  a  "cure"  for  anthrax,  had  a  very  bril- 
sidered  that  this  termination  of  such  a  case  was  liant  career  as  a  student  at  St.  Bartholomew's 
extremely  rare.  Mr.  Spencer  thinks  that  some  Hospital,  where  his  singular  aptitude  for  micros- 
recent  operations  by  which  a  cure  had  resulted  copical  work  and  his  general  power  for  work  made 
after  the  removal  of  a  great  portion  of  the  gland  him  one  of  the  favorite  pupils  of  Dr.  K1 
connected  the  pathology  of  the  disease  closely  celebrated  bacteriologist. 
with  the  thyroid  gland. 

The  Senate  of  the  University  of  London  has 
received  communications  from  the  Royal  College        DOMESTIC    CORRESPONDENCE, 
of  Physicians  and  Royal  College  of  Surgeons  to 
the  effect  that  both  these  institutions  had  given 

their  complete  adherence  to  the  scheme  proposed         Dp.   -Tolm   P.  Gray's   Experience  with 
for  granting  a  medical  degree  to  London  students  ruberculln. 

after  going  through  a  presented  course  of  educa-  i  To  the  Editor: — I  have  read  with  much  in- 
tion  and  passing  the  required  examination  by  a  terest  the  communication  of  Dr.  von  Ruck  in 
competent  board,  formed  by  representatives  from  a  recent  issue  of  The  Journal,  and  desire  to 
the  University  and  the  two  Royal  Colleges.  This  add  my  experience  to  his,  as  to  the  favorable 
will  be  an  immense  boon  to  the  students  of  the  results  to  be  obtained  from  the  proper  use  of 
London  medical  schools,  who  have  hitherto  been  "tuberculin."  Returning  from  Berlin  in  the 
obliged  to  go  in  search  of  degrees  bestowed  by  early  part  of  January,  I  at  once  began  the  use  of 
foreign  or  provincial  universities.  the  lymph  in  the  hospital  here,  and  have  had 

At  the  recent  meeting  of  the  Pathological  So-  under  treatment  up  to  date  twenty  cases — of 
ciety  Dr.  Rolleston  showed  a  patella  from  a  joint  which  three  were  lupus  and  the  remainder 
which  had  been  for  some  years  partially  dislocated  pulmonary  tuberculosis  in  the  first  and  second 
outwards.  To  the  articular  surface  of  the  bone  stages.  It  is  not  my  purpose  in  this  art 
was  apoarentlv  attached  the  internal  semilunar  go  into  a  full  report  of  these  cases,  reserving  that 
cartilage.  The  internal  semilunar  cartilage  being  for  a  later  date,  but  to  simply  jgive  the  general 
from  its  proper  position.  The  cartilage  at-  results.  In  those  patients  suffering  from  lupus 
tached  to  the  patella  was  adherent  to  its  periph  a  steady  improvement  has  been  noticea' 
ery  just  in  the  way  that  the  semilunar  cartilages  diseased  tissue  has  gradually  sloughed  off,  leav- 
are  to  the  tibia,  there  was  the  same  space  between  ing  a  healthy  cicatrix  behind,  so  that  in  all  three 
the  articular  surface  of  the  patella  and  what  ap-  there  seems  to  be  a  reasonable  hope  of  permanent 
peared  to  be  the  tibial  surface  of  the  internal   recovery. 

semilunar  cartilage  as  there  is  normally  between  Of  the  seventeen  cases  of  phthisis  two  have 
:i!unar  cartilages  and  the  tibia.  In  the  recovered,  or  at  least  are  well  to  the  extent  that 
present  case  the  cartilage  was  adherent  for  its  they  are  up  to'  their  normal  weight,  have  no 
whole  depth  to  the  patella  at  the  upper  part,  cough,  or  expectoration,  and  the  physical  signs 
The  two  extremities  of  what  was  apparently  th.->  in  the  lungs  are  daily  improving.  Eight  have 
internal  semilunar  cartilage  were  firmly  united  by  improved  markedly  in  that  they  have  good  appe- 
a  plate  of  cartilage  the  size  of  a  shilling.  This  tites.  have  gained  in  flesh,  and  general  strength, 
portion  was  underhung  by  a  synovial  pouch,  as  and  thecough  and  expectoration  have  been  greatly 
was  the  greater  part  of  the  body.  This  additional  diminished.  Three  have  improved  slight 
piece  of  cartilage  lay  to  the  inner  side  of  the  that  the  disease  appears  to  have  been  checked, 
patella,  consequently  the  supposed  internal  semi-  The  remaining  four  have  only  been  under  treat- 
lunar  cartilage  must  have  turned  round  before  ment  a  short  time,  but  two  of  these  I  hope  will 
becoming  adherent  to  the  patella.  The  surface  of  recover,  or  they  are  favorable  cases  and  are  im- 
the  external  condyle  was  eburnated  and  devoid  of  proving  rapidly. 

cartilage:  the  external  semilunar   cartilage  was       As  to  the  doctor's  statement  that  "  nov. 
partially  eroded.       The  internal  condyle  of  the  this  country  or  in  Europe"  a  similar  method  of 
femur  was  covered  with  cartilage.  administrating  the  lymph  has  been  adopted,  I 

A  special  meeting  of  the  Ophthalmological  So-  can  only  say  that  from  the  first  I  have  followed 
ciety  has  brought  forward  a  motion  in  the  follow-  exactly  the  same  course,  begining  with  a  quarter 
ing  terms:  "That  in  view  of  the  course  of  medical  or  half  a  milligram,  and  gradually  increasing  the 
study  extending  over  a  period  of  five  years,  it  is  dose — never  bringing  on  any  violent  general  re- 
expedient  that  the  Ophthalmological  Society  of  the  actions,  and  never  raising  the  amount  while  there 
United  Kingdom  urge  upon  the  General  Medical  was  any  effect  to  be  observed  from  the  injections. 
Council  the  desirability  for  making  the  study  of  I  also  see  from  the  Wochenschrift  that  the  method 
ophthalmic  medicine  and  surgery  a  compulsory  has  been  adopted  in  some  of  the  German  hospitals, 
part  of  the  ordinary  curricu'.  Of   course  we  have  not  had  the  climatic  ad- 

Mr.  Ernest  Stanburv  Haukin,  the  young  Eng-   vantages  that  Asheville  affords,  and  it  has  struck 


532 


DOMESTIC  CORRESPONDENCE. 


[April  ii. 


me  forcibly  while  observing  the  effects  of  the 
lymph  treatment  that  if  such  good  results  could 
be  obtained  in  the  two  worst  months  of  the  year, 
when  the  patients  are  more  or  less  confined  to 
the  house,  how  much  more  might  we  hope  for 
under  favorable  surroundings.  Dr.  Jacobi,  in  a 
recent  article,  hints  that  the  future  treatment  for 
consumption  will  be  a  proper  combination  of 
climate  and  lymph,  and  feeling  stronger  that  this 
is  the  case,  I  propose  if  possible  to  arrange  for 
the  treatment  of  a  number  of  cases  in  the  Adi- 
rondac  region,  where  I  am  sure  the  percentage  of 
cures  can  be  greatly  increased. 

John  P.  Gray,  M.D. 

Utica,  N.  Y.,  March  29,  1891. 


An  American  Medical  Temperance 
Society. 

To  the  Editor: — Several  months  since  the  un- 
dersigned received  a  communication  from  the 
Secretary  of  the  British  Medical  Temperance  As- 
sociation, suggesting  the  formation  of  a  similar 
organization  in  this  country  and  the  establish- 
ment of  fraternal  relations  between  them.  The 
British  Medical  Temperance  Association  was  or- 
ganized in  1876,  in  London,  with  thirt}'  members 
and  Dr.  Edmunds  as  President.  It  now  embraces 
about  five  hundred  members,  with  Dr.  B.  W. 
Richardson  as  President,  and  Dr.  J.  J.  Ridge, 
Secretary.  Among  its  members  are  many  of  the 
more  eminent  members  of  the  profession  in  that 
country,  and  it  has  exerted  a  wide  and  most  ben- 
eficial influence.  The  objects  of  the  Association 
are  declared  to  be  "  to  advance  the  practice  of 
total  abstinence  in  and  through  .the  medical  pro- 
fession, to  promote  investigation  as  to  the  action  of 
alcohol  in  health  and  disease,  and  to  constitute  a 
bond  of  union  among  medical  abstainers  scattered 
all  over  the  country."  .  .  .  "  It  admits  as  mem- 
bers, registrable  medical  practitioners  who  are 
practical  abstainers  from  all  alcoholic  liquors  as 
beverages.  It  admits  as  associates,  medical  stu- 
dents who  also  practice  total  abstinence.  Neither 
members  nor  associates  are  required, to  sign  any 
pledge,  but  if  such,  for  any  reason,  cease  to  be 
total  abstainers,  it  is  expected  that  notice  of  with- 
drawal from  the  Association  will  forthwith  be 
sent  to  the  Secretary."  The  liberty  of  members 
in  prescribing  alcohol  as  a  medicine  is  entirely 
uncontrolled.  The  formation  and  active  maiute 
nance  of  such  an  Association  in  this  country 
would  accomplish  an  amount  of  good  not  easily 
estimated;  and  if  those  members  of  the  profession 
who  would  favor  such  a  step,  will  send  me  their 
address  on  postal  card,  I  will  provide  a  time  and 
place  for  a  meeting  in  Washington  during  the 
week  of  the  next  annual  meeting  of  the  American 
Medical  Association  in  that  citj 

N.  S.  Davis,  M.D. 
65  Randolph  St  ,  1/1 


Medical  Legislation  in  the  State  of 
Missouri. 

To  the  Editor . — In  The  Journal  of  March  7 
appears  an  item  relative  to  medical  legislation  in 
the  State  of  Missouri,  to  the  effect  that  a  bill  was 
pending  to  compel  all  medical  colleges  in  the 
State  to  adopt  three  courses  of  lectures  as  a  con- 
dition for  graduation.  The  bill  was  unanimously 
recommended  for  passage  by  the  committees  of 
both  House  and  Senate.  The  House  passed  it 
by  the  gratifying  vote  of  85  ayes  to  22  noes.  The 
Senate  voted  against  the  bill.  As  the  session 
closes  in  two  days  there  is  no  time  to  work  for 
reconsideration,  hence  this  most  necessary  reform 
is  defeated,  to  the  shame  of  Missouri.  What 
makes  the  fact  all  the  more  mortifying  is  the  con- 
temptible nature  of  the  opposition,  all  of  the  col- 
leges in  the  State  (14  in  number)  but  one — lo- 
cated in  St.  Louis — appearing  in  favor  of  the  bill. 
The  medical  profession  of  the  State,  so  far  as  ev- 
idence shows,  being  overwhelmingly  favorable. 
Powerful  outside  pressure  was  brought  to  bear  to 
influence  the  Senate  unfavorably. 

The  history  of  the  bill  is  most  interesting  and 
extremely  instructive,  now  that  the  profession 
all  over  our  Nation  is  so  busy  in  medical  reform. 
The  Missouri  State  Board  of  Health  last  year 
promised,  through  its  Secretary,  to  foirow  the 
grand  example  of  the  Illinois  Board,  and  in  the 
due  exercise  of  its  proper  authority  defines  a  col- 
lege "  in  good  standing"  to  be  such  a  one  only, 
as  among  other  conditions,  required  three  years 
attendance  upon  lectures  and  clinics.  For  rea- 
sons that  would  take  too  long  to  explain  here, 
the  Board  this  year  declined  to  take  this  step,  but 
formally  referred  the  whole  matter  to  the  Legis- 
lature, then  in  session.  The  Medico-  Chirurgical 
Society  of  St.  Louis  applauded  the  bill,  on  reso- 
lution, and  appointed  a  committee  of  three  to 
assist  in  securing  its  passage  This  committee 
waited  on  both  House  and  Senate  committee. 
Only  in  the  Senate  committee  was  any  opposition 
made,  the  Dean  of  the  objecting  St.  Louis  college 
appearing.  The  ostensible  basis  of  the  opposi- 
tion consisted  in  these  two  arguments,  which  will 
probably  have  to  be  confronted  in  every  State 
where  substantial  medical  reform  in  education  is 
attempted  :  First,  to  require  three  years'  attend- 
ance would  work  a  hardship  on  the  "poor  boy;" 
secondly,  to  discriminate  among  the  colleges  would 
be  "class  legislation,"  and  therefore  "unconsti- 
tutional." The  "poor  boy"  argument  was  vig- 
orously worked  and  ingeniously  applied.  Among 
well-informed  people  these  arguments  may  excite 
a  smile,  but  that  they  should  seriously  be  ad- 
vanced and  be  ostensibly  accepted  by  the  Senate 
of  a  great  State  as  sufficient  ground  to  defeat  so 
important  a  measure — what  shall  be  said  !  Cer- 
tainly, here  is  no  smiling  matter  ;  particularly  as 
thi'-  defeat  will  affect  great  interests  outside  Mis- 
souri.    The  Medico  Chirurgical  Society  regarded 


i89i.] 


DOMESTIC  CORRESPONDENCE. 


533 


the  adoption  of  the  reform  as  likely  to  strengthen 
the  noble  work  of  Illinois  in  that  direction.  Also, 
many  of  the  Southern  States  and  South-western 
might  be  led  by  this  example  to  enact  similar  de- 
sirable laws ;  and  thus  the  grand  advance  in  med- 
ical education  so  imperatively  demanded  and  so 
long  agitated  all  over  the  Union,  would  be  ac- 
complished. 

It  is  a  fact  that  there  is  an  element  in  Missouri 
sympathizing  with  the  malcontents  in  Illinois, 
that  openly  declares  that  the  Illinois  State  Board 
of  Health  will  be  broken  down  in  its  reform 
measures.  Our  neighbors  need  to  be  on  guard 
so  long  as  its  Legislature  sits,  lest  some  hostile 
bill  be  slipped  through  in  disguise,  or  in  the  ruck 
of  measures  blindly  rushed  along  in  the  last  days 
of  the  session. 

I  should  state  that  great  efforts  were  made  to 
carry  our  bill.  Members  of  the  Legislature  were 
written  to  by  doctors  from  all  over  the  State. 
One  Senator  assured  me  that  his  pockets  were 
full  of  such  letters,  but  that  he  did  not  always 
vote  as  his  constituents  desired  ;  that,  in  fact,  he 
thought  people  ought  to  be  at  liberty  to  employ 
just  such  service  as  they  wanted,  that  he  had  ob- 
tained a  license  to  practice  law  simply  because  an 
oppressive  statute  compelled  him  to  do  so,  not 
that  he  thought  such  restrictions  necessary.  An- 
other solon  with  considerable  violence  declared 
that  for  his  part  he  would  rather  employ  a  doctor 
w'ho  had  never  been  inside  a  medical  college  ;  I 
judged  this  contemner  of  mundane  illumination 
believed  with  the  immortal  Dogberry,  that  read- 
ing and  writing  came  by  nature.  Still  another 
of  the  Patres  Conscripti  thought  the  bill  favored 
caste  in  society,  and  having  been  born  under  the 
British  monarchy,  like  a  sound  convert  to  repub- 
licanism, the  very  sniff  of  such  servitude  was 
abomination  of  abominations. 

But  enough  of  such  experiences,  so  mortifying 
to  a  native  Missourian  ;  it  is  a  comfort  to  know 
that  the  prime  mischief  worker  is  not  even  a 
Westerner  by  birth.  I  will  close  by  saying  that 
the  friends  of  the  bill  summed  up  their  argument 
in  this:  A  jury  of  intelligent  physicians  from 
any  part  of  the  civilized  world  will  not  hesitate 
to  declare  that  it  is  impossible  to  give  the  most 
capable  student  an  education  fitting  him  to  prac- 
tice medicine,  under  three  years'  attendance  upon 
lectures  and  clinics. 

In  the  Senate  committee  it  was  protested  that 
it  was  wTith  a  sense  of  shame  that  we  set  the  limit 
at  three  years.  In  Europe,  even  in  Mexico, 
which  country  requires  six  years,  no  period  less 
than  four  years  is  recognized.  No  wonder  Amer- 
can  diplomas — that  is  an  injustice  to  South  Amer- 
ica and  Canada — no  wonder  diplomas  from  the 
United  States  are  regarded  as  contemptible  in 
Europe. 

I  sincerely  trust  that  The  Journal  will  make 
these  facts  known  all  over  the  Union.     The  Leg- 


islature  has  not  fairly  dealt  with   its  people,  so 
that  Missouri  need  not  bear  the  burden  of  shame; 
the  near  future  will  put  that  where  it  shall  stick. 
Chas.  A.  Todd,  M.D., 
Of  the  Committee  of  the  St.  Louis  Med.-Chir.  Si 


Thai  "Remarkable  Case." 

To  the  Editor: — I  cannot  help  thinking  that 
there  must  be  an  element  of  deception  in  the  very 
remarkable  case  reported  by  Dr.  Galbraith  in  your 
last  issue.  Apart  from  the  inherent  improba- 
bility of  the  extremely  high  temperatures  noted, 
it  seems  to  me  a  physical  impossibility,  so  long 
as  the  circulation  of  the  blood  is  maintained,  that 
the  temperature  in  the  axilla  should  be  20  degrees 
higher  "than  in  the  mouth.  A  temperature  of 
171,  or  even  1510  F.,  can  only  be  borne  by  the 
finger  for  a  very  brief  time  without  severe  pain, 
and  I  think  it  may  be  set  down  as  certain,  that 
with  a  temperature  approaching  even  the  lower 
of  these  points,  the  vapor  of  the  breath  would 
form  a  cloud,  in  a  room  at  the  ordinary  tempera- 
ture, as  that  of  a  healthy  person  does  on  a  cold 
day.  I  would  suggest,  in  case  of  opportunity 
for  further  observations  of  the  sort,  that  the  tem- 
perature be  taken  in  the  rectum,  under  close 
observation.  If  the  case  were  my  own  I  should 
be  satisfied  that  if  the  thermometer  registered 
higher  either  in  the  mouth  or  axilla  than  in  the 
rectum,  there  was  fraud  somewhere,  whether  I 
could  detect  the  manner  of  it  or  not. 

In  The  Lancet  (January,  1882,  p.  35,  American 
ed.),  Dr.  Mahomed  reports  a  case,  apparently  some- 
what similar,  that  came  under  his  observation  at 
Guy's  Hospital.  The  patient,  a  woman,  aged  22, 
suffering  from  phthisis,  was  repeatedly  found  to 
give  readings  of  the  thermometer  ranging  ftom  112 
to  120°,  and,  in  one  instance,  as  high  as  128°  F. 
Although,  with  careful  observation,  he  was  never 
able  to  detect  the  way  in  which  they  were  pro- 
duced, he  was  satisfied  that  they  were  fraudulent, 
for  the  following  reasons.  When  observations 
were  made  on  several  different  parts  at  once, 
there  were  great  differences  in  the  temperatures 
recorded  by  the  different  thermometers.  Surface 
thermometers  gave  only  ordinary  temperatures  ; 
neither  the  skin  of  the  axilla  nor  the  bulb  of  the 
thermometer  on  removal  felt  extraordinarily  hot 
at  times  when  high  readings  were  obtained.  Xo 
unusual  temperatures  were  ever  obtained  by  non- 
registering  thermometers,  although  they  were 
often  used. 

In  the  same  volume  of  the  The  Lancet,  p.  78, 
is  an  account  by  Dr.  Stephen  Mackenzie  of  the 
case  of  a  woman  who  was  under  his  care  for  an 
inflamed  condition  of  the  stump  of  an  amputated 
thigh,  who  gave  abnormally  high  temperatures 
on  repeated  occasions,  the  highest  being  133. 6°. 
This  never  occurred  while  she  was  closely 
watched,  and  she  afterwards  admitted   that  she 


534 


BOOK  REVIEWS. 


[April  ii, 


had  produced  the  high  temperatures  by  means  of 
poultices,  hot  bottles,  etc.  Such  means  can,  of 
course,  be  excluded  in  Dr.  Galbraith's  case,  of 
which,  I  hope  that  he  will  let  us  know  the  final 
outcome. 

W.  L.  Worcester,  M.D. 

State  Lunatic  Asylum,  Little  Rock,  Ark.,  Mar.  23,  1891. 


Has  Omaha   Found  Munchausen's  Mantle  ? 

To  the  Editor: — The  extraordinary  case  re- 
ported by  Dr.  Galbraith,  of  Omaha,  in  which  the 
temperature  of  a  lady  with  a  slow  pulse  rose  at 
times  to  1510  F.,  requiring  the  construction  of  new 
thermometers  to  register  the  phenomenon,  scores 
another  point  for  science.  The  average  layman 
would  doubtless  flout  such  a  story  as  ridiculous. 
He'd  vow  the  doctor  had  conjured  up  this  "whop- 
per" only  to  see  how  great  fools  we  mortals  be, 
who  should  believe  it.  But  in  scientific  matters 
of  a  medical  nature,  laymen  don't  know.  In  the 
presence  of  a  wonder  like  this,  they'd  do  like  the 
old  Dutch  emigrant  who  chanced  to  go  to  a  hot 
spring  for  water  as  he  was  about  to  camp  for  the 
night.  When  the  hot  water  splashed  up  on  his 
hands,  he  dropped  the  bucket  in  great  fright  and 
cried  out  to  his  sou:  "Trive  on,  Hans.  Hell  ish 
not  far  from  dish  blace  !"  But  it  is  the  province 
of  science  to  account  for  the  wonderful. 

No  doubt  this  case,  if  properly  handled — and 
the  doctor  seems  to  be  the  man  to  do  it — will  yet 
reach  the  boiling  point.  We  have  heard  of  peo- 
ple's blood  boiling,  and  if  voiding  1,000  dead 
bones  would  not  make  one's  blood  boil,  why  pray 
what  could?  Of  course  it  requires  the  mental 
breadth  of  high  professional  achievement  to  take 
such  marvels  in. 

The  case  is  the  reverse  of  Longfellow's  "Excel- 
sior." Dr.  Holland  said  of  it  that  it  sounded 
like  the  truth  but  it  was  a  lie.  This,  on  the  other 
hand,  sounds  like  a  lie,  but  it's  the  truth;  not  a 
bit  of  doubt  about  it.  Perhaps  some  doubting  med- 
ical Thomases  will  even  ridicule  this  humble  at- 
tempt at  the  Doctor's  defense.  No  matter.  Let  the 
heathen  rage  and  the  women  siss.  Science  will 
be  vindicated  in  the  end.  A  medical  book  agent 
once  approached  a  neighbor  of  mine  to  sell  him 
the  latest  thing  out  in  surgery.  "No,"  said  the 
Doctor,  "I've  no  time  to  read  it.  I  already  have 
10,000  volumes  in  my  medical  librarj-,  and  be- 
sides I  have  to  ride  twelve  miles  every  day  to 
catheterize  a  lady  from  whose  bladder  I  draw  ten 
gallons  of  water  every  twenty-four  hours."  The 
agent  was  a  layman.  He  couldn't  understand  it. 
He  was  dumbfounded  at  the  Doctor's  solemn  as- 
severation of  a  scientific  fact,  and  pronounced 
him  "the  monumental  liar  of  America."  The 
Doctor  not  having  a  string  of  titles  to  bis  name, 
the  agent  thought  he  had  no  license  to  lie  like- 
that.  But  the  ignorant  fellow  simply  didn't 
know.      That's  one  great  advantage  the  trained 


physician  has.     He  can  take  in  the  most  aston- 
ishing revelations  of  science  without  wincing. 
James  L.  Taylor,  M.D. 

Wheelersburg,  Ohio. 


ASSOCIATION  NEWS. 


American.  Medical  Association. 

The  Copyrighting  of  The  Programme. 
The  attention  of  the  Committees  having  charge 
of  the  compiling  and  printing  of  the  Official  Pro- 
gramme is  called  to  the  following  resolutions 
unanimously  adopted  at  the  Nashville  meeting: 

Whereas,  Certain  parties  without  authority  are  pre- 
suming to  make  use  of  this  Association  for  the  further- 
ance of  advertising  interests,  therefore 

Resolved,  That  at  all  future  meetings  of  the  Associa- 
tion such  publications  be  excluded  from  the  place  of 
meeting  either  of  the  General  Sessions  or  of  its  Sections. 

Resolved,  That  in  the  future  each  Chairman  of  the 
Committee  of  Arrangements  be  directed  to  procure  a 
copyright  of  the  Official  Programme,  to  the  end  that  the 
financial  rights  of  the  Association  may  be  protected  by 
due  process  of  law. 


Railroad  Arrangements. — Full  particulars 
of  the  Railroad  Arrangements  for  the  Annual 
Meeting  at  Washington  will  be  published  in  our 
next  issue. 


Notice  to  Secretaries  of  Sections. — The 
programme  should  be  in  hand  one  week  before 
the  meeting  of  the  Association.  It  will  be  im- 
possible to  print  correctly  a  list  of  addresses  and 
papers  received  after  that  date.  Secretaries  of 
Sections  will  insure  accuracy  in  the  programme, 
and  greatly  facilitate  the  work  of  the  Committee 
by  sending  their  lists  in  time. 

C.  H.  A.  Kleinschmidt,  M.D. 
Secretary  Com.  Arrangements. 

We  desire  to  emphasize  the  request  of  Secre- 
tary Kleinschmidt  for  the  early  completion  of  the 
programmes  of  the  various  Sections,  and  hope  to 
present  the  Preliminary  Programme  in  The 
Journal  before  the  meeting.  The  Official  Pro- 
gramme will  be  issued  promptly  by  the  Com- 
mittee of  Arrangements.  We  are  grateful  to 
know  that  such  efficient  action  has  been  taken 
by  the  officers  of  the  Sections,  and  the  prospect 
now  is  that  the  next  annual  meeting  will  exceed 
in  interest  any  that  have  preceded  it. — Ed. 


BOOK  REVIEWS. 


Auscultation  and  Percussion.     By  Freder- 
ick C.  Shattuck,  M.D.,  etc.     Detroit,  Mich.: 
Geo.  S.  Davis.     1890.     Pp.  121. 
This  is  the  concluding  number  of  Series  IV  of 

the  Physician's  Leisure  Library. 


I89i.] 


SPECIAL  CORRESPONDENCE. 


535 


The  work  opens  with  seven  diagramatic  plates 
which,  were  it  not  for  the  confusing  numbers  and 
letters  with  long  "  fingers"  to  denote  their  inten- 
tion, would  enhance  the  value  of  the  text  in  no 
slight  degree.  A  physician's  life  is  generally 
made  up  of  too  few  hours,  and  he  can  therefore 
ill-afford  the  struggle  of  deciphering  no  less  than 
seventeen  tracings  or  references  on  a  single  plate 
of  small  size.  It  will  be  seen  that  the  placing  of 
such  requirement  in  a  "  Leisure"  library  is  smil- 
ingly significant. 

The  text  is  orthodox,  dealing  first  with  the 
lungs,  where  56  pages  are  devoted  to  a.  clear  and 
concise  statement  of  the  physical  signs  in  health 
and  disease.  Then  follows  Part  II — heart  and 
aorta — the  concluding  chapter  of  which,  however, 
touches  upon  physical  exploration  of  the  liver, 
spleen,  stomach,  and  pancreas.  Altogether  this 
little  manual  will  find  a  place  of  some  value. 

A  Guide  to  the  Practical  Examination  of 
Urine.     For  the  use  of  physicians  and  students. 
By  James  Tyson,  M.D.,etc.     Seventh  edition. 
Revised  and  corrected.     With   a  colored  plate 
and  wood  engravings.     Philadelphia,  P.  Blak- 
iston,  Son  &  Co.     189 1.     Pp.   255. 
No  important  change  has  been  made  in  issuing 
a  new  edition  of  this  handy  little  volume.     The 
general  arrangement  and  plan  of  the  work  makes 
it  a  ready  guide  for  the  student,  as  well  as  enab- 
ling a  quick  reference  for  the  busy  practitioner. 

Prof.  Tyson  still  holds — and  we  do  not  know 
but  wisely- — to  the  superior  reliability  of  the  time- 
honored  "heat"  test  for  albumen.  In  the  light 
of  claims — which  are  not  without  well- accepted 
authority — put  forth  from  time  to  time  of  late 
years,  we  were  prepared  to  see  their  advocacy  or 
adoption;  but  in  language  not  to  be  misunder- 
stood the  author  treats  the  claims  honestly,  and 
as  honestly  expresses  his  thorough  satisfaction 
with  those  tests  which  in  his  hands  have  left  but 
little  more  to  be  desired. 


SPECIAL  CORRESPONDENCE. 


shall  The  Journal  be  Removed  to 
Washington  ? 

WHAT   OUR  ADVERTISING  PATRONS  HAVE  TO  SAY  ON  THE 
REMOVAL    SUESTION. 

To  the  Editor: — Permit  me  to  request  the  insertion  in 
The  Journal  of  the  accompanying  circular  and  blank 
sent  out  to  our  advertising  patrons,  with  their  replies 
thereto  in  tabulated  form.  My  reason  for  seeking  space 
in  your  columns  is  the  desire  that  the  members  of  the 
Association  may  be  fully  informed  as  to  how  business 
men,  who  contribute  nearly  one-half  the  income  of  The 
Journal,  look  upon  the  proposition  to  remove  it  to 
Washington.  Though  the  majority  of  our  advertisers 
are  not  members  of  the  Association,  still  their  opinion, 
coming  as  it  does  from  practical  business  men  having  a 
financial  interest  in  its  success,  should  have  weight  in 
the  settlement  of  this  question. 


Some  members  may  look  with  disfavor  upon  this 
method  of  gauging  the  business  future  of  The  JOURNAL, 
to  such  I  would  say,  most  respectfully,  that  when  the  ad- 
vertising interests  of  Tin;  Journal  were  confided  to  my 
can-  1  found  them  very  low,  but  by  persistent  a 
tematic  work  have  increased  the  receipts  from  that 
source  three  hundred  per  cent.  This  statement  is  made 
to  bring  out  the  point  that  the  bulk  of  this  increase  is 
due  to  having  proved  to  the  satisfaction  of  advertisers 
that  Tin:  Journal  is  the  profitable  medical  advertising 
medium  of  the  West. 

It  was  therefore  desirable  to  obtain  their  views  in  the 
premises,  and  after  obtaining  them  to  submit  them  to 
the  members  of  the  Association  as  detailed  in  the  table 
on  pages  536-7,  which  shows  that  15  voted  for  Washing- 
ton, representing  13  per  cent,  of  the  cash  receipts  from 
advertising  for  the  financial  year  just  closed  ;  45  for  Chi- 
cago, and  a  few  not  voting.  J.  Harrison  WHITE, 

Office  of  The  Journal.  Business  Manager. 

6S  Wabash  ave.,  Chicago. 

Dear  Sir: — Some  members  of  the  Association  are  des 
making  Washington  the  permanent  home  of  The  Journal,  and 
the  question  is  to  come  before  the  members  at  their  annual  meet- 
ing next  May.  Being  of  the  opinion  that  the  advertising  patrons, 
who  contribute  so  largely  towards  its  financial  success,  should  have 
an  opportunity  of  expressing  their  views  on  the  matter  : 
to  consider  the  question  in  all  its  bearings,  and  give  me  vour  reply 
at  an  early  date.     Very  truly  yours,  J.  HARRISON  WHITE, 

Business  Manager. 

Chicago,  January  2,  1S91. 

PLEASE  FILL  OCT  BLANKS  AND  RETURN  IN  ENCLOSED 
ENVELOPE. 

Do  you  favor  the  removal  of  the  Journal  of  the  American  Medical" 

Association  from  Chicago  to  Washington  ? 

Would  you  consider  the  Journal  of  the  same  value  to  you  as  an  ad- 
vertising medium  if  located  in  Washington  ?  .   .   .* 

Remarks  ....  

Signed 


To  the  Editor: — The  question  of  the  removal  of  The 
Journal  from  Chicago  to  Washington,  which  is  now 
being  discussed  by  many  physicians  in  every  part  of  the 
United  States,  is,  to  my-  mind,  clearly  opposed  by  a  large 
majority  of  the  members  of  the  Association — and  I,  for 
one,  say.  Let  it  remain  where  it  is,  a  place  which  is  ap- 
proved of  by  the  great  majority,  as  I  firmly  believe. 

B  S.  WoodworTh,  A.M.,  M.D. 

Fort  Wayne,  Ind.,  March  2S,  1S91. 


To  the  Editor: — Except  as  I  desire  to  see  The  Jour- 
nal represent  the  best  thought  and  the  highest  standard 
of  the  American  medical  profession,  I  am  in  no  way  in- 
terested in  its  place  of  publication  nor  in  who  edits  it. 

I  do  not  know  the  origin  of  the  agitation  to  take  The 
Journal  to  Washington,  but  I  surmise  that  it  ai 
of  a  feeling  that  some  change  was  desirable. 

I  do  not  know  how  much  editing  the  present  editors 
feel  justified  in  performing,  nor  exactly  what  is  meant  by 
the  term  "supervising  editor"  employed  by  Dr.  Reed  in 
his  communication  in  The  Journal  of  March  2S,  but 
certainly  the  "supervision"  has  been  somewhat  lax. 
Doctors  are  not  always  good  writers,  I  have  no  reference 
to  the  old  illegible  prescription  story,  I  mean  that  they 
do  not  always  pay  much  attention  to  the  rules  of  grammar 
or  composition.  And  even  those  who  have  a  message  of 
importance  to  communicate,  are  not  by  any  means  direct 
and  certain  in  their  statements. 

My  impression  of  editorial  duty  extends  beyond  writing 
leaders,  and  making  up  the  contents  of  a  number  of  The 
Journal,  and  until  the  editors  feel  warranted  in  rigidly 
enforcing  the  ordinary  and  reasonable  rules  of  composi- 
tion, and  either  editing  or  rejecting  all  communications 
which  make  both  writer  and  Journal  ridiculous,  there 
will  continue  to  be  dissatisfaction,  whether  The  Journal 
is  published  in  Chicago  or  Washington. 

Dr.  Reed's  comparisons  are  very  lame.  Applv  his  re- 
mark about  employing  a  practical  physician  or  surgeon. 
Does  any  one  for  a  moment  suppose  that  if  Dr.  Reed 


536 


SPECIAL  CORRESPONDENCE. 


[April  ii, 


WHAT   THE   ADVERTISERS   SAY   ABOUT    IT. 


nia  Chemical  Co.,  St.  Louis,  Mo 


Armour  &  Co.,  Chicago 

Baker,  Charles  S.  &  Co.,  Chicago 

Baltimore  College  Physicians  and  Surg. 

Baltimore,   Md 

Battle  &  Co.,  St.  Louis.  Mo 

Bernd,  Henry  &  Co.,  St.  Louis,  Mo.  .   .   . 


Blakelv,  C.  H.  &  Co.,  Chicago  .... 
Brown"  Drs.  Geo.  &  Geo.  A.,  Barre,  Mass 

Caldwell,  Frank  H.,  Sanford,  Fla 

Canton   Surgical  and   Dental   Chair  Co. 

Canton,   O 

Chaim,  Adolph,  Chicago 

Chanuing,  Dr.  Walter,  Brookline,  Mass. 
Chicago  Medical  College,  Chicago.  .  .  , 
College  of  Phys.  and  Surgeons,  Chicago 


Cooke,  George  F.,  M.D.,  Oxford,  O. 
Crittenton,  C.  N.,  New  York  City  . 


Cincinnati  Sanitarium,  College  Hill,  O 


i  &  ShurtlefF,  Boston,  Mass. 


Dauchy  &  Co.  (Liebig  Ext.  of  Beef),  New 
York  City 


Detroit  Coll.  of  Medicine,  Detroit,  Mich, 
Drevet  Manufg  Co.,  New  York  City.  .   . 

Fredigke,  Dr.  Charles,  Chicago 

Garden  City  Bindery,  Chicago 

Gardner,  R.  W.,  New  York  City 

Gray,  J.  Lucius,  M.D.,  Chicago 


Gorges,  Mrs.  J.  A.,  Rogers  Park,  III  . 
Hance   Bros.  &  White,  Philadelphia. 
Haldenstein,   I.   (Apolliuaris    Co.),    New 
York  City 


Horlick's  Food  Co.,  Racine,  Wis.  .   . 
Imperial  Granum  Co.,  New  Haven,  Conn 


Keener.  W.  T.,  Chicago 

Kirkley,  C.  A.,  M.D.,   Toledo,  O  . 

Lagorio,  Dr.  A.,  Chicago 

Lambert  Pharmacal  Co.,  St.  Louii 


vn   Un 


Levytype    Co.,   Chicago 

Mad'son,  William,  Chicago.   .   . 
Magruder,  G.  L.,  Dean  Georgeto 

versity,   Washington,  D.  C.  .   .   . 
Marcy,  Henry  O.,  M.D.,  Boston,  Mass. 
Mattison,  J    is.,  M  D.,  New  York  City  . 


Maury  &  Mitchell,  Memphis,  Tenn  .    .    . 
versity,  Wash 


Med.  Dep't  Columbian  l'n 
ington,  D.  C 


Med.  Dep't  University  of  Michigan,  Aim 

Arbor,  Mich 

Millard,  P.  II.,  M.D.,  Minneapolis,  Minn, 

Movius,  J    &  Son,  New  York  City  .   .   .   . 

Mcintosh  Battery  and  Opt.  Co.,  Chicago. 


New  Table  Co.,  St.  LOUIS,  Mich. 


Parrish,  Win.  ('..,  M.D.,  Burlington,  N.  J 


for  removing  the  Jour- 
Washington  as  its  per- 


In  our  opinion  a  journal  located  in  an  active  business  centre  is  more  in  touch  with  bus- 
iness necessities,  and  quicker  to  respond  to  new  ideas,  than  others  even  though 
they  may  be  nwr^-  esthetically  located  under  the  aegis  of  the  Capitol. 

We  are  not  deeply  interested  in  the  question. 

wish  the  Journal  continued  and  increased  success. 

Washington  is  a  political  centre  and  not  a  business  centre. 

To  any  other  Western  city,  "  Yes."  We  du  not  favor  anything  that  will  take  prestige 
away  from  the  West.  We  do  not  see  why  Washington  is  any  better  than  any 
other  city.     From  a  commercial  standpoint  it  is  the  poorest  city  in  the  U.  S. 

No.     Would  not  be  of  same  value  to  us. 

We  consider  Chicago  the  most  desirable  place  in  the  U.  S. 

Yes. 

Dr.  John  E-  Owens,  Chairman  of  Adv.  Com.,  objects  to  the  removal. 

Dr.  D.  A.  K.  Steele,  Secretary,  writes  :  In  reply  to  your  note  of  inquiry  regarding  the 
desire  of  some  members  of  the  Association  to  make  Washington  the  permanent 
home  of  the  Journal,  I  would  state  that  it  is  my  opiuion,  as  one  of  the  advertis- 
ing patrons  of  the  Journal,  that  its  removal  to  Washington  from  Chicago  would 
be  a  mistake.  I  am  decidedly  in  favor  of  its  continuation  here. 
Would  nut  be  of  same  value  to  me  as  an  advertising  medium. 

We  deem  it  quite  unadvisable  for  your  publication  to  remove  to  Washington,  D.  C,  as 
it  would,  in  our  judgment,  lose  its  prestige,  owing  to  the  competition  it  would  be 
obliged  to  meet  from  other  medical  jo 

Dr.  Orpheus  Everts,  Supt.,  writes:  I  see 
nal  from  Chicago,  and  if  it  is  to  be  mo 
manent  home. 

Decidedly  No  !  We  think  it  much  better  that  the  Jo 
as  we  value  it  for  its  present  large  circulation,  ^ 
ened  if  the  proposed  removal  were  effected. 

Our  opinion  is  decidedly  adverse  to  the  removal  of  your  paper  from  a  great  business 
centre  like  Chicago  to  the  city  of  Washington.     We  do  not  see  how  it  is  possible 
for  the  paper,  if  published  from   the  latter  point,  to  exert  as  immediate  an  in- 
fluence on  business  men  as  if  it  issued  from  Chicago. 
Would  not  be  of  same  value  as  an  advertising  medium. 

Your  Journal  has  been  giving  us  satisfactory  returns,  and  we  feel  confident  that  its 
removal  to  Washington  may  increase  the  number  of  your  subscribers. 

No  value  to  us  if  removed. 
Yes. 

The  present  headquarters  of  the  Journal  on  geographical,  scientific  and  editorial 
grounds  cannot  be  improved  upon,  in  my  judgment. 

Yes. 

From  the  point  of  view  of  my  customers,  the  Journal  would  not  derive  any  advantage 
from  being  located  in  Washington  that  it  does  not  possess  in  Chicago,  while  Chi- 
cago in  a  business  way  offers  greater  facilities  than  Washington. 

NO  !  in  letters  almost  an  inch  in  depth. 

We  can  see  no  objection  to  Chicago,  but  if  a  change  seems  necessary,  why  Washing- 
ton is  neutral  ground,  and  should  satisfy  everybody.  However,  the  present  ten- 
dency seems  to  be  for  all  roads  to  lead  to  Chicago. 

I  am  quite  confident  that  the  business  interests  of  the  Journal  would  suffer  loss  by  the 
proposed  change. 

Yes. 

New  York,  Philadelphia^  St.  Louis,  Boston,  Baltimore  and  Cincinnati  support  weekly 
medical  journals.     Evidently  the  Association  Journal  must  answer  the  purpose  of 


weekly  for 
cellent  opportt 
ness  enterprisi 
with  the  great 
by  the  change. 


nd  largest  city.  In  giving  up  this  perquisite  you  offer  a 
nity  for  the  establishment  of  a  weekly  medical  journal  as  a  busi- 
,  and  force  the  Association  Journal  into  more  direct  competition 
nedical  weeklies  of  the  East.    In  our  opinion  it  will  suffer  severely 


i<  mbei   in  the  Journal  of  Tanuary  31.) 

the  change.     It  is  a  National  journal,  and  should  be  pub- 


;ie  value   to  us  ; 


advertising  medii 


).     (See  his  letter  as  : 
:s.     Most  heartily  j  iv 

lished  at  the  Nation 
>.    Would  not  consider  it  of  the 

moved  to  Washington. 
1  the  first  question,  yes.     To  the  second,  not   necessarily  the  same,  but 

perhaps  better.     The  Journal  should   be  central,   N   " 

local  interests 

Sec'y,  writes:  From  the  standpo: 
,ur  use,  [considei  Chicago  the  besl  location  for  the  Jo 
-.  P.  H.  Millard,  Dean  Med.  Dep't  Univ.  of  Minnesota 

Journal  will  forfeit  our  entire  patronage. 


nt  of  an  advertiser,  and  for 

irnal. 

writes  :    The  removal  of  the 


if  the 


>.    Dr.  Mcintosh  verballj   stated  that  they  would  stop  their  advertis 

journal  is  removed  From  Chii  .ik-> 
Chicago        thi      econd   grral   business  centre  of  the  U.  S.,  and  in  twenty  years 

will  be  the  first  in  importance.   Washington  will  not  be  anything  but  the  political 

quasi  centre. 
appears  to  me  that   the  Journal  would  have  the  same  circulation  through  the  West, 

where  it  is  well  known,  if  at  Washington  as  a  headquarters,  and  woujd  gain  still 

more  East  and  South  by  the  change,  in  subscribers  and  advertisers. 


iSgi.J 


SPECIAL  CORRESPONDKXCi;. 


537 


What  the  Advertisers  Say  About  It. 


roit.  Mich. 


I  hemical  Co    SI 


Phillips  (C.  H.)  Chemical  Co.,   New  York 

City 

G     duate  Med.  School,  Chicago. 


RiM  Chemical  Co..  St.  Louis,  Mo  .   . 
Robinson-Pettit  Co.,  Louisville.   Ky 


Ruebsam,  John  K.,  Washington,  D.  C  . 

Rush  Medical  College,  Chicago 


Sander  &  Son,  Dillon,  Iowa 

Schieffelin,  W.  H.  &  Co.,  New  York  City 


Scott  &  Bowne,  New  York  City. 


Sharp  &  Dohme,  Baltimore,  Md.    .    .    . 

Sharp  &  Smith,  Chicago 

Smith,  Bradner&  Co.,  Chicago 

St.  Louis  Med.  College,  St.  Louis,  Mo  . 


Sultan  Drug  Co.,  St.  Louis,  Mo. 


Tarrant  &  Co.,  New  York  City 

Tyndale  Eucalyptus  Co.,  Chicago  .  .  .  . 
Walnut  Lodge 'Hospital,  Hartford.  Couu 
Warner,  Wm.  K.  &  Co.,  Philadelphia  .    . 


Woodruff,  I.  D.  &  Co..  New  Y-ork  City. 


management  of  the  Journal  of  the  A.  M.  A.,  as  located 
in  Chicago,  is  convenient  t"  us  at  I >eir- -it,  and  it  being  assumed  that  the  Journal 
large  local  circulation  in  the  West  incidental  to  its  publication  in  that  sec- 
tion of  the  country,  we  believe  that  it  exe:  !  isfactory  influence  for 
Western  advertisers  than  would  be  the  case  if  locate: 

eve  the  Journal  would  wield  the  same  influence  from  either  point,  but  consider 
the  present  location  and  management  hard  to  improve  upon. 
Do  not  favor  removal.     Would  ii"t  be  so  valuable  to  us  as  an  advertising  medium. 

Dr.  W.  Franklin  Coleman,  the  Secretary,  writes  :    The  Bast  is  well  supplied  alreadv 

with  wei  kly  Journals.     The  P.-C.  Med   School  desires  to  come  in  contact,  through 

advertising,  with  Western  physicians.     The  removal  of  the  Journal  to  Washing- 

ssen  our  interest, 'and  I  think  that  of  the  Western  physicians,  in  it. 

t  think  the  removal  of  the  Journal  to  Washington  would  make  any  material 

difference. 

We  would  say  that  in  our  opinion  Chicago  is  a  better  point  for  issuing  the  Journal 
i  ihington  would  be,  on  account  of  its  central  location. 

I  favor  the  removal.    The  Association  will  grow  with  the  Nation's  Capital. 

Dr.  J.  H.  Etheridge,  Sec'y.  writes:     Am  indifferent.     It  would  be  very  interesting  to 
enquire  what  criticism  of  the  local  directory  of  the  Journal  has  led  up  to  this  move. 
Perhaps  there  is  something  written  between  the  lines  that  would  be  interesting. 
such  a  move  as  the  right  step  at  the  time  in  the  right  direction. 

We  believe  the  Journal  to  be  a  good  medium  for  advertising,  and  can  express  no  pref- 
erence as  to  the  location  of  its  office  of  publication. 

We  desire  to  say  that  the  location  of  your  Journal  in  Chicago  is  very  much  more  to 
our  interest  and  advantage  than  it  would  be  located  in  Washington.  As  we  are 
well  represented  in  Eastern  Journals,  we  do  not  think  we  would  care  to  advertise 
in  it  if  you  changed  to  that  city. 

We  are  in  favor  of  transferring  the  permanent  home  of  the  Journal  to  Washington. 

No.     We  would  not  advertise  in  the  Journal  if  same  was  located  in  the  East. 

Dr.  H.  H.  Mudd,  Dean,  opposes  removal  and  considers  the  Journal  would  not  be  of 

the  same  value  as  an  advertising  medium. 
Since  the  Journal  is  a  National  affair,  it  should  be  located  centrally.    Next  to  St. 

Louis,  we  prefer  Chicago.     If  we  have  a  voice  in  the  matter  we  must  proclaim  for 

the  West. 
Yes. 

(See  Dr.  Crothers'  letters  in  the  Journal  of  January  31  and  March  21.) 
The  circulation  and  the  quality  of  a  medical  journal  are  the  questions  of  most  impor- 
tance to  the  advertiser.  Your  Association  being  a  National  one,  it  is  quite  proper, 
we  should  venture  to  say.  that  its  Journal  should  be  published  in  Washington. 
Every  advertiser  will  admit  that  there  are  too  many  medical  journals.  About  three- 
fourths  of  them  are  located  East  of  Indiana  and  North  of  Washington.  Do  not 
aggravate  matters.  Stay  where  you  are.  There  you  are  the  leading  weekly  med- 
ical journal.    Here  you  will  have  to  take  fourth  or  fifth  place. 


wanted  a  journal  of  real  literary  and  scientific  merit  pub- 
lished he  would  employ  as  editor  any  one  merely  because 
he  was  a  practical  physician,  if  he  were  not  satisfied  that 
his  practical  physician  knew  when  a  sentence  had  a  pred- 
icate and  had  the  courage  to  put  one  in  when  it  was  nec- 
essary in  Dr.  Blank's  very  good  "practical"  article  on 
pneumonia,  or  to  take  out  the  double  negative  from  Dr. 
J.  Doe's  otherwise   readable  article  on  fractured  patella? 

I  am  not  questioning  for  a  moment  the  ability  of  the 
present  editorial  staff,  but  I  have  often,  in  reading  THE 
Journal,  queried  whether  the  "intelligent  compositor" 
or  "vigilant  proof-reader."  or  the — shall  I  say  timid — 
editor  was  responsible  for  some  of  the  assaults  upon  our 
mother  tongue  which  so  often  appear  in  the  pages  of  The 
Journal. 

As  the  voters  who  have  voted  through  The  Journal 
appear  to  be  nearly  all  of  one  mind,  let  us  hear  from  them 
and  others  as  to  how  much  editorial  cutting  and  mending 
they  are  willing  their  manuscripts,  correspondence  as  well 
as  contributions  to  the  scientific  papers,  shall  undergo 
before  being  sent  to  the  printer. 

If  the  Association  will  sustain  the  editors  and  the  edi- 
tors will  fearlessly  edit  the  articles  before  sending  them 
to  the  printer,  I  think  there  will  be  a  steady  increase  in 
the  value  and  reputation  of  The  Journal. 

We  may  not,  like  one  of  our  law-makers,  '  'care  much 
for  abroad,"  but  I  have  reason  to  know  that  The  Jour- 
nal, through  some  of  its  articles,  has  not  reflected  much 
credit  upon  the  literarv  ability  of  the  profession. 

E.  N.  Brush,  M.D. 

Philadelphia,  March  30,  1891. 


me  on  time  and  is  chock  full  of  the  very  best  medical 
literature.     I  prefer  to  let  well  enough  alone. 

D.  A.  Walker,  M.D. 
Friendship,  Tenji.,  March  31,  1S91. 


To  the  Editor: — I  know  of  no  reason  why  The  Jour- 
nal should  be  moved  from  Chicago.     It  always  reaches 


To  the  Editor: — It  is  immaterial  to  me  where  The 
Journal  is  published,  provided  it  is  conducted  exclu- 
sively in  the  interests  of  scientific  medicine  and  the  great- 
est good  of  the  profession.  That  it  does  not  fully  meet 
the  requirements  of  either  now  is  a  source  of  dissatisfac- 
tion, and  creates  a  desire  for  change  in  the  minds  of 
many  members  of  the  Association.  But,  if  these  defi- 
ciencies can  be  corrected  without  removal,  it  is  better  to 
allow  it  to  remain  in  Chicago,  for  the  present  at  least,  to 
try.  Believing  that  it  can  be  thus  improved  and  brought 
up  to  the  ideal  standard  where  it  is,  and  disclaiming  all 
carping  criticism,  I  offer  suggestively  the  following  to 
that  desirable  end. 

1.  In  the  first  place,  then,  The  Journal  should  be 
printed  on  plain  and  not  on  glazed  paper,  which  from  its 
reflection,  dazzles  the  eye,  irritates  the  optic  nerves,  mus- 
cles and  lobes,  brain  and  mind,  and  sympathetically 
other  parts  of  the  system,  thus  impairing  the  sight,  caus- 
ing eye-strain  with  spasm  and  twitching  of  muscles,  ocular 
aud  cerebral  hyperaernia.  dizziness,  headache,  neuralgia, 
melancholy,  petulance,  irascibility,  and  other  disorders  of 
the  physical,  mental  and  moral  nature,  more  or  less  seri- 
ous, ft  is  thus  a  serious  obstruction  to  the  acquisition  of 
knowledge  and  preservation  of  health  of  the  whole  being, 
body  and  soul,  which  should  be  discarded  as  dangerously 
insanitary  and  wholly  unscientific,  especially  discredit- 
able in  a  publication  under  the  auspices  of  physicians, 
the  special  exponents  thereof.  Besides,  it  is  not  only  an- 
tagonistic to  the  well-being  of  mankind,  but  also  to  com- 
mercial success, for  no  sensitive,  or  enlightened  person  will 


533 


SPECIAL  CORRESPONDENCE. 


[April  ii, 


even  willingly  read,  except  occasionally  and  for  brief 
periods,  much  less  subscribe  for  such  a  glaring  sight  and 
health-destroying  publication,  no  matter  how  cheap  or 
meritorious  it  nay  be.  This  evil  can  and  should  be 
speedily  rectified  by  substituting  plain  for  glazed  paper, 
not  only  in  The  Journal,  but  all  other  publicatious,  and 
people  should  protect  themselves  by  tabooing  all  printed 
matter  on  glazed  paper  in  the  interests  of  good  sight, 
good  health,  of  body  and  mind,  good  temper  and  morals, 
education,  enlightenment,  development  and  civilization. 

2.  While  The  Journal  should  stimulate  original 
research,  and  uphold  American  medicine  especially, 
it  should  not  be  provincial  or  subservient  to  for- 
eign ideas,  but  as  cosmopolitan  as  medicine  itself, 
truth  being  universal,  teaching,  developing  and  cull- 
ing it  from  all  sources,  with  a  due  regard  to  the 
philosophy  as  well  as  the  art  of  medicine,  for  the  highest 
educational  purposes,  and  to  enlighten  the  concrete  with 
the  abstract  knowledge  of  truth,  so  that  principles  and 
practice,  science  and  art  shall  go  together,  as  they  are 
mutually  essential  to  the  perfect  development  of  medi- 
cine. The  prevention  and  treatment  of  every  disease  is 
a  problem  to  be  solved  in  accordance  with  mathematical, 
logical  and  scientific  principles,  as  a  guide  to  insure  the 
greatest  certainty  ami  success  in  both.  Hence  empiricism 
can  only  be  employed  with  advantage  in  so  far  as  it  is 
necessary  for  disclosing,  testing  and  determining  the 
truth.  Thus  enlightened  empiricism  or  rational  experi- 
ment inductively  leads  to  the  advance  of  the  science,  and 
deductively  promotes  the  philosophy  of  medicine  (which, 
by  the  way,  should  be  the  crowning  part  of  the  cur- 
riculum of  every  medical  college),  while  blind  empiricism 
is  merely  chance  experiment  and  arrant  quackery. 
Secresy  and  assertion  with  wild,  haphazard  or  irrational 
experimentation  are  unscientific, and  involve  in  confusion, 
doubt,  disappointment,  disaster  and  death.1  Thus  accurate 
observation,  experiment  and  experience,  guided  by  rea- 
son, aided  by  judgment,  leads  directly  to  a  knowledge  of 
the  truth  in  medicine  as  in  everything  else,  and  it  is  the 
mission  of  The  Journal  to  present  this  in  the  most 
definite,  condensed  and  available  form  with  as  little  er- 
roneous or  extraneous  matter  as  possible,  so  as  to  edu 
cate  and  enlighten  the  profession  to  the  fullest  extent. 

3.  The  department  of  notes  and  news  should  be  as  brief, 
impersonal,  professional  and  general*  as  possible,  notic- 
ing only  subjects  of  immediate  practical  interest  to  phy- 
sicians everywhere,  and  omitting  as  "fiat,  stale  and  un- 
profitable" all  tending  to  promote  personal,  local,,  or  ex- 
traneous interests  of  any  kind,  for  it  is  merely  gratui- 
tously advertising  them,  and  concerns  few  beyond  those 
mentioned.  The  space  thus  occupied  and  wasted  should 
be  utilized  with  useful  medical  ideas  of  import  to  prac- 
titioners in  general  as  contributing  to  the  relief  of  the 
afflicted  and  suffering,  and  desirable  to  those  trying  to 
solve  the  problems  of  health  and  disease,  life  and  death, 
everywhere  throughout  the  world. 

4.'  As  the  representative  of  the  American  Medical  Asso- 
ciation and  scientific  medicine  The  Journal  should 
avoid  any  encouragement  to  empiricism  or  quackery, 
domestic  or  foreign,  and  rigidly  exclude  from  its  adver- 
tising as  well  as  reading  pages  all  articles  relating  thereto 
in  every  shape  and  form,  especially  secret  and  proprie- 
tary agents  of  polypharmacal  ami  physiologically  incom- 
parable admixtures  or  hodge  podge  of  drugs,  under  fan- 
ciful and  misleading  names,  or  some  ingredient  thereof 
without  the  full  formula,  or  otherwise  concealed  so  that 
physicians  cannot  fully  know  their  constituents  and  de- 
termine accurately  their  doses  and  uses,  independent  of 
the  prejudiced  and  often  erroneous  statements  of  their 
makers  and  vendors.  Thk  Journal  is  not  the  organ  of 
any  one  person,  institution,  clique,  trade,  local  or  ex- 
traneous interest  whatsoever,  but  of  the  Association  or 
profession  in  general,  and  it  should  not  be  the   medium 


follows  a  criticism  of  the  "Koch  occult  lymph"  which  0 
account  of  its  length,  and  being  foreign  to  the  subject  under  di 
is  omitted. 


of  advertising  nostrums,  or  secret,  disguised,  and  quack 
preparations  of  any  kind.  "We  rightly  denounce  the 
religious  and  secular  press  therefore,  yet  inconsistently 
allow  our  own  professional  organ  to  be  used  for  the  same 
base  purpose  for  a  little  pelf,  thus  degrading  it,  ourselves, 
our  profession,  and  medical  science.  Of  course,  all  per- 
sons, physicians  included,  are  justly  entitled  to  a  due 
recompense  for  their  discoveries  in  medicine  as  in  every- 
thing else  whenever  made  known,  but  secresy  and  decep- 
tion therein  is  opposed  to  progress  and  should  not  be  tol- 
erated, by  physicians  at  least,  as  they  prevent  those  who 
are  induced  to  use  them  from  comprehending  their  na- 
ture, acquiring  correct  knowledge,  and  intelligently  per- 
forming their  duties  to  their  patients,  while  giving  false 
ideas  and  experience  detrimental  instead  of  beneficial  to 
those  most  concerned.  Hence  the  evils  therefrom  are 
manifold  in  being  fraudulent  and  injurious  throughout, 
for  besides  the  immediate  pecuniary  loss,  there  is  often 
direct  harm  or  failure  to  promote  the  welfare  of  the  sick 
and  suffering  with  humanity  in  general,  as  well  as  detri- 
mental to  medical  science.  While  life  is  based  upon 
reciprocity,  it  is  only  in  the  domestic  circle  that  it  is  of  a 
more  purely  personal  nature,  for  outside  of  that  it  must 
necessarily  be  more  exclusively  of  a  commercial  charac- 
ter, though  insensibly  it  merges  throughout  into  free 
efforts  for  the  relief  of  the  helpless  aud  unfortunate,  yet 
it  is  only  those  favored  with  a  surplus  of  health  and 
wealth  who  can  afford  to  work  gratuitously  for  the  good 
of  mankind.  But  many  are  so  selfish  as  to  have  no  feel- 
ing for  their  fellows,  as  they  will  work  and  starve  them 
to  death,  and  even  rob  the  sick  and  afflicted  for  self- 
aggrandizement.  Such  are  like  sponges  that  absorb 
everything  they  can,  and  give  out  nothing  but  what  they 
cannot  hold  and  w-hat  is  squeezed  out  of  them.  These 
greedy  sharks  would  monopolize  everything  and  leave 
others  to  suffer  and  perish,  they  must,  therefore,  be  act- 
ively antagonized  to  restrain  their  cruel  propensities, 
especially  in  the  case  of  empirics,  nostrum-makers  and 
quacks  of  every  kind,  to  oppose  and  afford  them  as  little 
opportunity  as  possible  to  rob  the  sick  aud  thrive  on  the 
ignorance,  suffering,  aud  misfortunes  of  others,  particu- 
larly by  refusing  to  aid  them  in  their  nefarious  schemes 
to  disseminate  a  knowledge  aud  promote  the  use  of  their 
empirical  preparations  under  the  sanction  of  medical 
journals  and  physicians,  who  thus  become  accessories  to 
all  the  evils  therefrom.  Besides,  the  tendency  of  this 
pernicious  practice  and  support  of  charlatanry  is  to  de- 
grade the  profession  itself  and  reduce  physiciaus  to  mere 
medical  mechanics,  not  to  be  thinkers  and  leaders,  but 
dependents  and  servants,  to  follow  the  directions  of  em- 
pirics, nostrum-makers  aud  traders.  Hence  The  Journal 
should  be  kept  free  from  all  such  objectionable  matter 
aud  cease  to  be  an  agent  of  evil,  for  which  the  members 
of  the  Association  are  responsible,  and  should  it  not  be 
so  improved  where  it  is,  then  it  would  be  better  to  re- 
move it  to  Washington  or  some  other  place  where  it 
could  attain  the  ideal  National,  professional  and  repre- 
sentative character,  exempt  from  all  such  obnoxious  busi- 
ness, quackish,  and  other  degrading  influences. 

5.  Finally,  The  Journal  should  be  under  stricter 
medical  supervision  throughout  all  its  pages  of  reading 
aial  advertising  alike,  inculcating  therein  most  fully  and! 
purely  the  principles  and  practice  of  scientific  medicine, 
both  preventative  aud  curative,  refusing  to  paudertoein- 
pirical,  personal,  clique,  local,  trade,  nostrum,  quack  or 
extraneous  interests  of  any  kind,  so  as  to  insure  the 
greatest  progress  aud  highest  development  of  rational 
medicine.  It  would  thus  become  a  shining  exponent  of 
the  science  and  philosophy  of  medicine  and  leader 
of  professional  knowledge,  not  only  a  creditable  organ  of 
the  American  Medical  Association,  and  a  source  of  en- 
lightenment and  pride  to  each  member  thereof,  but  to 
1  j  sician  of  this  country  and  abroad,  as  its  benef- 
icent influence  would  extend  indefinitely  throughout 
tii'   world.  Geo.  J.  ZlKGLER,  M.D. 

Philadelphia,  April  2,  1S91. 


I89i.] 


SPECIAL  CORRESPONDENCE 


539 


Editorial  Opinions  Of  the  Medical  Press.         Il  mav  be  urged  that  a  permanent  home  and  the  removal 

A  question  at  present  agitating  the  American  Medical    f^Z  }^f  n  Wa*hin^on  ,ficf s  not  imP'-v  tl,at  mee 
-ier  Thf  lounial  shall  he  —mJS  -v  .       "'^  bha!1  J*  h?U1  ln  tha*  cll-v'  but  we  "-J?"*  lC 


Association  is  whether  The  Journal  shall  be  removed  from 
Chicago,  its  present  place  of  publication,  to  Washington, 
1).  C.    The  subject  has  just  now  been  brought  into  prom- 


as  an  en- 
tering wedge  that  should  certainly  be  withdrawn. 

As  for  the  question  of  the  removal  of  The  Journal,  the 


Hooper,  of  Little  Rock.  Ark.,  upon  a  requisition  signed  ^^^  W"T  lu.c  lcs.llmony  ap'"sl  u  ls  overwhelming. 
by  a  majority  of  the  Board,  for  the  special  purpose  of  The  Present  location  is  central:  Chicago  as  a  great  c.ty 
Considering  the  question,  upon  which  a  special  commit-  .  and  ^^  ""  ?  °^erS  faC.ll,tleS  for  Publication  that  are 
tee  had  been  appointed.  The  following  report  was  then  "  surPasse']  °v  other  cities ;  as  a  great  railroad  centre 
received  aad  adopted:  B      P  j lts  0PP°rtu"ltlef  for  distribution  and  mail  service  are  une- 

qualled.    This  latter  fact  chieflv  concerns  us  in  the  West, 
Resolved  That  the  sense  of  the  Committee  be  that  the  home  of   as  The  Journal  now  reaches  us"  on   Mondav,  two  davs  in 
The  Journal  ot  the  Association  should  be  permanently  at  Wash-     „  !,.,„„      „r  .,_  _f  »l.  u...  i  %•  j   .,  -, 

i,  c  H  -        "•■>"     advance  of  any  of  the  Eastern  weeklies,  and  three  davs 

■'.  That  the  Trus                        u  the  foregoing  resolu-  ahead  of  all  but  one.    It  has  been  stated  that  S5  per  cent. 

lion  in  their  report  to  be  presented  at  the  next  meeting  of  the  of  its  advertisers  have  expressed  a  preference  for  Chicago 

S^fmi°!V      .               .     .                 ,  he  place  of  publication.    While  we  do  not  accept  these 

The  following  resolution  was  also  adopted.  figures  at  their  face  value,  we  still  believe  that  a  journal 

That  the  Trustees  rec  mmend  the  members  of  the  As-  published  in  Chicago  is  much  more  likelv  to  have  a  large 

£733  ■                       ^o^ntribSe  orlLbieri£eeSsnfof  Ihe  amount  of  advertising  than  the  same  journal  in  Washing- 

ntbuil                            of  meeting,  as  well  as  tou-     Outside  of  these  facts  there  are  no  propositions  for 

The  Journal  is  not  what  its  best  friends  de- 


The  immediate  .result  of  this  action,  audits  subsequent 
^publication  in  The  Journal,  has  been  a  very  ani: 
cus>ion,  into  which   considerable  heat  and  not  a  little 
personal  feeling  seems  to  have  been  injected.     This 


discussion. 

sire  it  to  be.  On  the  other  hand,  it  is  questionable 
whether  under  existing  circumstances  it  could  have  been 
made  better,  and  certainly  its  present  location  has  had 
nothing  to  do  with  the  matter.  There  are  two  factors 
xceediugly  unfortunate.  The  question  is  not  in  thVYeast  neecIed  to  make  The  Journal  what  we  desire  it  to  be — the 
a  sectional' one,  and  should  have  no  possible  personality  American  medical  journal:  1.  A  large  and  increasing 
involved,  but  must  be  considered  0:1  the  broader  basis  of  income-  2-  An  able  and  competent  editor,  who  shall  be 
the  welfare  of  The  Journal,  and,  therefore,  of  the  Asso-  :  aIlowecl  to  «#'  The  Journal  untrammeled  by  the  direction 
ciation,  and  it  is  from  this  standpoint  that  we  shall  discuss  °.r  supervision  of  any  authority  save  that  of  the  Associa- 
it.  We  shall  assume,  as  we  believe,  that  the  committee  tion  in  gene.ral-  These  factors  can  be  attained  as  well  in 
making  the  recommendation  did  so  under  the  conviction    Chicago  as  in  a  and  a  careful  study  of  the 

that  it  was  'for  the  best  interests  of  all  concerned, "  and  (luesUon  shows  that  there  are  nnmentioned  conditions 
in  seeking  a  reason  for  this  action  find  the  second  reso-  Si"nS  ner  superior  advantages.  The  question  is  to  be 
lution,  that  really  seems  to  be  the  kev  to  the  situation.  voted  uPon  at  tfle  next  meeting—;',  e.,  the  question  of  re- 
The  proposition  to  establish  a  home  for  the  Association  is  moval  to.  Washington  is  to  be  voted  upon  at  Washington 
not  new;  it  emanates  from  the  same  sentiment  that  would  j  ~a  manifestly  unfair  proceeding,  giving,  as  it  does,  a 
hold  every  second  meeting  at  the  National  Capital.  The  PrePonderauce  to  the  local  vote.  Arrangements  should 
^establishment  of  a  permanent  home  in  Washington,  with  be  made. ,or  an  early  canvass  of  the  entire  Association, 
annual  meetings  in  that  citv.  logically  carries  with  it  the  tllus  SJvl'nS  ever>'  member  the  opportunity  of  e\ 
removal  of  The  Journal  to  headquarters.  We  do  not  be-  an.  opinion,  though  not  of  voting. — Occidental  Medical 
lieve  for  a  moment  that  this  scheme  will  ever  be  carried  7*mes>  March,  1S91. 
out.  or  that  the  Association  will  deliberately  adopt  a 
cidal  policy.     The  American   Medical  Association   : 


be   of  the  whole  United  States;  it  must  be   thoroughly 
National;  with  its  loose  and  defective  organization,  a  ten- 


For  years  there  has  been  a  move  on  foot  by  certain 
self-constituted  custodians,  who  flatter  themselves  that 


■dency  to  centraliz-ation  would  be  fatal'to  its  existence,  they  possess  all  the  brains  and  refinement  of  the  Ameri- 
The  Association  should  meet  each  year  in  a  different  citv,  can  Medical  Association,  to  remove  The  Journal  of  the 
and,  as  far  as  practicable,  in  localities  widely  apart.  At  Association  to  Washington.  These  "wise  mei 
every  meeting  there  is  a  fresh  accession  to  the  member- !  east  "  whose  habitation  is  circumscribed  bv  the  Alle- 
ship,  drawn  largely  from  the  surrounding  country,  and  a  ghanies  on  the  West,  the  Potomac  on  the  South,  the  St. 
fair  proportion  of  these  accessions  become  permanent  Lawrence  on  the  North  and  the  pine  clad  hills  of  Maine 
members.  Does  any  one  suppose  that  similar  additions  on  the  East,  would  take  to  themselves  the  sole  preroga- 
would  take  place  if  the  annual  meetings  were  held  vear  '  tive  of  dictating  the  editorial  utterances  of  The  Journal. 
after  year  in  Washington,  or  any  other  city?  It  needs  This  clique  has  its  head  at  WasUington.  D.  C.  Not  satis- 
the  immediate  influence,  the  presence  of  a  large  meeting  ne.i  with  the  honor  the  capital  can  confer  upon  them, 
and  the  enthusiasm  evoked  to  compel  this  annual  incre-  this  admiration  society,  composed  of  medical  politicians. 
ment.  To  a  large  number  of  the  profession,  the  American  would  take  to  themselves  the  complete  control  of  our 
Medical  Association  is  only  a  name,  and  this  mavbe  em-  National  Journal  and  crack  its  fingers  in  the  face  of  the 
phasized  by  the  comparatively  small  number  who  have   great  South  and  West.     Is  ft  [sit just?     Will 

-embraced  the  privilege  of  joining  ■•  by  application."    To    it  be  tolerated  ? 

•one  who  has  attended  a  meeting,  the  Association  is  a  liv-  The  reason  given,  ostensibly,  for  removing  The  Journal 
ing  reality,  and  incidents  happening  twenty  or  twenty-  to  Washington,  is  that  it,  being  a  national  organ,  should 
five  years  ago  have,  as  we  know,  been  cherished  and  oft  be  published  at  the  capita!  of  the  nation.  T. 
repeated  by  those  who  in  that  period  may  have  met  the  merest  nonsense.  The  truth  is,  a  few  of  those  would-be 
Association  at  most  but  twice.  The  centre  of  population  censors  desire  to  get  control  of  The  Journal  for  no  other 
is  rapidly  moving  westward,  and  with  this  increase  of  reason  thad  self  glorification.  Let  every  member  of  the 
population  the  number  of  physicians  located  in  the  West  Association  from  the  South  and  West,  who  attend  the 
has  proportionately  increased.  The  increase  has  been  next  session,  see  to  it  that  this  move  to  rob  them  of  their 
greatest  in  the  Pacific  Coast  States  and  Territories;  vet  just  dues  be  unceremoniously  decapitated, 
how  many  physicians  of  this  vast  region  could  afford  to  I  The  great  West  has  about  ceased  to  bow  its  knee  to  the 
attend  a  meeting  held  in  Washington,  and  to  take  an  ex- !  sweet  scented,  velvet  fii  1st.     Washing- 

pensive  trip,  involving  an  absence  of  at  least  three  weeks,    ton  City  is  scarcely  large  enough  to  make  a  respectable 


54° 


MISCELLANY. 


[April  ii,  1891. 


suburb  to  Chicago,  yet  they — the  medical  politicians  and 
presto  pass  quick  manipulators — have  the  immaculate 
gall  to  attempt  to  gobble  up  and  control  our  National 
Journal.     Can  they  do  it  ? 

In  our  next  issue  we  shall  give  some  facts  and  figures 
demonstrating  the  absurdity  and  injustice  of  the  selfish 
move. — The  Texas  Health' Journal,  March,  1891. 


MISCELLANY. 


Convention  of  Medical  Licensing  Boards. — At 
the  suggestion  of  Dr.  William  Perry  Watson,  Secretary 
of  the  State  Board  of  Medical  Examiners  of  New  Jersey, 
Dr.  Rauch  has  called  a  meeting  of  one  or  more  repre 
sentatives  of  the  various  medical  licensing  boards  in  the 
United  States,  to  be  held  in  Washington,  D.  C,  on  May 
6,  during  the  meeting  of  the  American  Medical  Associa- 
tion, in  order  to  effect  a  permanent  organization  and  to 
make  rules  and  examinations  as  nearly  uniform  as  pos- 
sible. Licensing  boards  now  control  medical  practice  in 
21  States.  It  is  expected  that  much  good  will  come  of 
this  meeting. 


Nashville,  Tenn.,  Dr.  H.  W.  Morgan,  Dr.  Chas.  Mitchell,  Dr.  J. 
B.  Warren. 

New  Orleans.  La.,  Dr.  G.  N.  Monette. 

New  York  City,  Robinson-Baker  Advertising  Bureau,  J.  F- 
Madden,  W.  P.  Clearv,  The  Drevet  Mfg.  Co.,  Dr.  M.  E.  Van  Fleet. 

Notasulga,  Ala.,  Dr.  C.  L.  C.  Atkeson. 

Paris,  Texas.,  Dr.  W.  M.  Moore, 

Parkersburg,  W.  Va..  Dr.  \V.  H.  Sharp. 

Philadelphia.  Dr.  R.  J.  Dunglison,  Dr  A.  L.  Hummel.  Uni- 
versity of  Pa.  Press,  Dr.  Thos.  Hav,  Dr.  W.  B.  Atkinson.  Dr.  S- 
Solis-Cohen,  Dr.  G.  B.  Massey,  Dr.  John  Aulde. 

Port  Bvron.  111.,  Dr.  Wm.  H.  Lvford. 

Racine,  Wis.,  Dr.  R.  A.  Kitto. 

Ravenna,  O.,  Dr.  O.  D.  Haven. 

Richland  Centre,  Wis.,  Dr.  Hugh  Morrow. 

Rockford.  111..  Dr.  D.  Lichtv. 

St.  Mary's,  Pa.,  Dr.  J.  H.  Hoffmann. 

St.  Louis.  Mo.,  Rio  Chemical  Co.,  Dios  Chemical  Co. 

Ventura,  Cal.,  Bank  of  Ventura. 

Westport,  Conn.,  Dr.  L.  T.  Dav. 

Wilkes-Barre,  Pa..  Dr.  Maris  Gibson. 

Williamsburg,  Ky..  Dr.  W.  Murphy. 

Winslow,  111..  Dr.  J.  B.  Goddard. 

Xenia,  O.,  Dr.  T.  Van  Dupuy. 


The  Big  Four  and  the  Annual  Meeting  of  the 
Association. — To  members  of  the  American  Medical 
Association  who  contemplate  attending  the  annual  Meet- 
ing at  Washington,  D.  C,  Ma}'  5th  to  Sth,  a  few  words  in 
regard  to  the  best  means  of  reaching  Washington  will  no 
doubt  prove  acceptable.  The  recognized  line  from  Chi- 
cago is  the  Popular  Big  Four  Route  in  connection  with 
the  Scenic  Chesapeake  &  Ohio  Ry. ,  from  Cincinnati 
running  via  White  Sulphur  Springs,  through  the  beauti 
ful  mountain  regions  of  the  Virginias,  over  its  own  tracks 
into  the  City  of  Washington. 

Passengers  via  this  popular  line  have  the  choice  of  two 
elegant  trains,  starting  from  Lake  Street  Depot,  Chicago. 
— the  morning  train  equipped  with  elegant  parlor  cars, 
cafe  dining  car  and  luxurious  coaches,  makes  connection 
at  Cincinnati  with  the  Famous  "  Fast  Flying  Virginian" 
via  the  C.  &  O.  Route,  assuring  passengers  of  first  class 
service,  including  Dining  Cars,  for  the  entire  trip.  The 
evening  train  from  Chicago  is  equipped  with  private 
compartment  buffet  sleeping  car,  standard  Wagner  palace 
sleeping  car  and  elegant  reclining  chair  car  and  makes 
connection  with  the  "  Washington  Fast  Line"  via  the 
Chesapeake  &  Ohio  Ry.,  affording  a  day-light  ride 
through  the  beautiful  Ohio  Valley,  and  across  the  scenic 
Blue  Ridge  Mountains  into  the  Capital. 

These  trains  are  vestibuled  throughout,  provided  with 
an  unequaled  dining  car  service  and  afford  every  comfort 
and  convenience  of  modern  railroading.  For  tickets  and 
ful!  information  call  on  or  address  J.  C.  Tucker,  General 
Northern  Agent  121  Randolph  St..  Chicago,  III.,  D.  P.. 
Martin  General  Pass.  Agent  Big  Four  Route  Cincin- 
nati, O. 

LETTERS  RECEIVE!' 
Ansonia,  Conn..  McArthur  Hypophosphite  Co. 
Baltimore.  Md.,  James  O'Gor'man. 
Beaver  City,  Neb.,  First  National  Bank 

Boston,  Dr.  Fairfax  Irwin,  Dr.  J    I..  Williams. 
Brooklvn.  N.  Y..  Dr.  Wm.  McCollOm. 
Buffalo.  N.  \".,  Dr.  Geo.  E.  Fell,  Koss,  Daniels  ti  Co. 
Burlington.  R.  J.,  Dr.  Wm    G 
•:<>,  111.,  Dr.  R.  L.  Mintie 
Jones.  Dr.  H.  N.  Mover,  Dr.  M.  R-  Brown. 
Cincinnati.  O..  Dr.  C.  G.  Com 
Cumberland,  Md  ,  Dr.  F.  T.  Mi 
1  ■ 

Fleetville,  Pa.,  Dr.  F.  B.  Davis  in. 
Hooper.  Neb..  Dr.  M.  T.  Zell 

R   I..  Dr.  Geo.  Keene. 
Intlianap  lis.  Did     Dr    E   S.  Elder. 
iville,  111..  Ward 
\!.i  ,  1 11   1 .   Caldwi  ;i 
Kansas  City,  Mo.,  Dr.  T    1     Bennett. 
Rock,  Ark.,  Dr.  T.  E   Murrell. 
Marion    Ind  .  In    Wm 
Milwaukee,  Wis.,  Dr.  II    Y    \\  1. 1'' 111  urn    In    N    Stun. 


Official  List  of  Changes  in  the  Stations  and  Duties  of  Officers  Serving; 
in  the  Medical  Department,  £/.  S.  Army,  from  March  28,  iSqi,  to- 
Aprils,  1891. 

By  direction  of  the  President,  the  following  named  officers  are  de- 
tailed for  duty  under  the  Intercontinental  Railway  Commission  ,ap- 
pointedunde'raprovisiou  in  the  Act  of  Congress  approved  July  14, 
1890,  for  the  purpose  of  making  "  a  preliminary  survey  forinfor- 
niation  in  respect  of  a  continental  railway  recommended  by  the 
International  American  Conference,"  and  they  will  report  in  per- 
son to  the  Commission  in  thiscitv  accordingly:  Capt.  Edgar  L.  Ste- 
vens, Third  Cavalry;  First  Lieut".  Stephen  M.  Foster.  Fourth  Ar- 
tillery; First  Lieut".  Lyman  W.  V.  Kennon,  Sixth  Cavalry;  First 
Lieut.  Andrew-  S.  Rowan,  Ninth  Infantry:  Second  Lieut.  Samuel 
Reber,  Fourth  Cavalry;  Second  Lieut.  Charles  A.  Kitchen,  Third 
Cavalry.  Capt.  William  C.  Shannon,  Asst.  Surgeon  U.  S.  A.,  for 
duty  as  medical  officer  of  the  party  to  which  he  may  be  attached. 
Par.  9,  S.  O.  73,  A.  G.  O.,  Hdqrs.  of'the  Army.  Washington.  April 
I,  1S91. 

Major  David  L.  Huntington.  Surgeon,  on  being  relieved  by  Capt. 
Henry  G.  Burton,  Asst.  Surgeon,  from  duty  at  San  Diego  Bks.,  Cal., 
will  report  in  person  to  the  commanding  officer,  St.  Francis  Bks., 
St.  Augustine.  Fla.,  for  duty  at  that  post,  reporting  by  letter  to  the 
commandingGeneral,  Divofthe  Atlantic.  Par.  5,  S.  6.  71,  A.  G.  0.r 
Hdqrs.  of  the  Army.  March  30,  1891. 

Capt.  Henry  G.  Burton,  Asst.  Surgeon,  now  at  San  Diego,  Cal..  on 
sick  leave  of  absence,  is  relieved  from  further  duty  at  Vancouver 
Bks.,  Washington,  and  will  report  in  person  to  the  commanding 
officer,  San  Diego  Bks.,  Cal,,  for  duty  at  that  post,  relieving  Major 
David  L.  Huntington.  Surgeon,  and  reporting  by  letter  to  the 
commanding  General,  Dept.  of  Ariz.  Par.  5,  S.  O.  71,  A.  G  O., 
Hdqrs  of  the  Army,  March  30,  1S91. 

Capt.  Van  R.  Hoff,  Asst.  Surgeon,  leave  of  absence  granted  in  Order 
61,  c.  s..  Ft. Riley,  Kan.,  is  extended  twenty-three  days.    Par 
O,  36,  Dept.  of  the  Missouri,  March  27,  1891. 

Major  Joseph  B.  Girard,  Surgeon  is  relieved  from  duty  at  Ft.  Low- 
ell, Ariz.,  to  take  effect  upon  the  withdrawal  of  the"  troops  from 
that  post,  and  will  report  in  person  to  the  commanding  officer, 
Alcatraz  Islaud,  Cal..  for  duty  at  that  station,  reporting  by  letter 
to  the  commanding  General,  Dept.  of  Cal.  By  direction  o!  the 
Acting  Secretary  of  War.  Par.  5,  S.  O.  70,  A.  G.  O.,  Hdqrs.  of  the 
Ariny.  Washington.  March  28,  1891. 

Official  List  of  Changes  in  the  Medical  Corps  of  the  V.   S.  .Xa;  v.  for 

a  Weeks  Ending  April  1 
P.  A.  Surgeon  Howard  E.  Ames    promoted  to  Surgeon   March  19,. 

1891. 
P.  A.  Surgeon  Stephen  S.  White,  ordered  to  the  U.S.  S.  "  Baltimore.'' 
Asst     Surgeon   Geo.   McC.   Pickerell,  promoted  to  P.  A.  Surgeon 
March  25,  1891. 

;    Wm.  Martin,  ordered  to  Naval  Rendezvous,  San   :  1 
1 
Medical  Inspector  C.  H.   White,  appointed  Fleet  Surgeon,  Pacific 

Asst.  Surgeon   H.  N.  T.  Harris,  ordered  to  the  U.  S.  receiving  ship* 

"St.  Louis. 
P.   A    Surgeon  George  McC.  rickei  ell,  ordered  to  Naval  Hospital, 

New    Y 
I'.   A    Surgeon  C.  W.  Rush,  ordered    for  duty  with  Intercontinental 

:i  iSSl   Ml. 

:; F.  N.  Ogden,  ordered  for  duty  with  the  Interconti 

1 

on  James  H.  North,  !r.,  ordered  to  the  Navy  Y'ard,  New 

F.  B.  Stephenson    ordered  to  the  U.  S  S."Marion." 

1  S.S.  '   Marion." 

ispector  C.  H   v.  .                                1  Baltimore." 

ispectorj.  H.  '  '                             tbi   I  S.  S.  '  San  Frau- 

spector  A.  A.  Hoehliug,  detached  from  President  ol  Na- 
mining  Board. 

ndP  Crandall,  promoted  to  be  P.  A.  Surg   1 
■  1891. 

uiinissioned  an  Asst.  Sui 
g<  0,1  in  tlu  Navy  April  1. 


T  1 1  E 


J  ournal  of  the  American  Medical  Association. 

EDITED  UNDER  THE  DIRECTION  OF  THE  BOARD  OF  TRUSTEES. 

PUBLISHED    WEEKLY. 


Vol.  XVI. 


CHICAGO,  APRIL  18,   1891. 


No.   16. 


ORIGINAL  ARTICLES. 


SPONTANEOUS    UMBILICAL   HEMOR- 
RHAGE IN  NEWLY-BORN  INFANTS. 

Read  before  the  Medical  Society  of  the  Distrtt  t  / 
February  /, 

BY  J.  WESLEY  BOYEE,  M.D., 

VISITING  PHYSICIAN    TO  WASHINGTON  ASYLUM    HOSPITAL:    ATTEND- 
ING PHYSICIAN  TO   ST.  ANN'S    INFANT    ASYLUM;   AND   OBSTETRI- 
CIAN   TO    COLUMBIA    HOSPITAL    FOR    WOMEN    AND    LYING-IN- 
ASYLUM. 

The  subject  of  haemorrhage  from  the  umbili- 
cus and  umbilical  cord  of  infants  during  the  first 
few  days  after  birth  has  received  very  little  atten- 
tion from  the  profession.  Audi  amled  to  think  this 
condition  has  not  received  the  amount  of  consid- 
eration it  deserves.  It  is  fortunate^  of  infre- 
quent occurrence,  and  having  seen  four  cases,  I 
have  ventured  to  prepare  this  paper  upon  that 
subject. 

Any  malad5'  having  a  mortality  rate  of  76  per 
cent.,  occurring  ever  so  seldom,  should  command 
more  earnest  attention  from  the  medical  profes- 
sion than  is  shown  by  the  literature  upon  this 
grave  condition  of  the  newly-born.  It  should 
not  be  cast  aside  with  but  superficial  considera- 
tion; it  should  be  carefully  studied.  In  this  paper 
I  have  considered  only  the  variety  of  omphalor- 
rhagia in  which  there  are  usually  manifestations 
of  a  general  condition. 

The  seventeenth  century  brought  us  the  first 
allusion  to  this  subject,  since  which  time  various 
writers  have  occasionally  written  upon  it.  Prob- 
ably the  first  case  of  this  trouble  ever  recorded  in 
medical  annals  was  that  published  in  the  work  of 
Philipp  Hoechstetter,  of  Augsburg,  in  1635.  The 
victim,  a  boy,  was  thought  to  be  suffering  from 
haemophilia.  According  to  my  researches  the  next 
was  the  fatal  case  of  Mauriceau,  in  1668.  Next 
following  this  was  the  case  of  Watts,  in  1752,  so 
frequently  quoted  by  recent  writers  as  the  first 
recorded  case,  and  following  it,  Degland's  case. 
These  reported  cases  comprise  nearly  all  the  lit- 
erature on  the  subject  to  1800.  Cheyne  begins 
the  work  for  this  centum  by  reporting  a  case  in 
1801,  and  four  years  later  Sedillot's  excellent  ar- 
ticle appeared.  In  1822  Pout  reported  three 
cases,  and  since  that  date  over  500  cases  have 
been  reported.     A  number  of  valuable  contribu- 


tions to  this  subject  have  been  furnished  by  Marc 
Buchner,  Rittershain,  Ribemont,  Grandidier,  Jen- 
kins and  others,  and  to  these  writers  I  have  to  ac- 
knowledge my  indebtedness  for  much  information 
received  from  their  papers.  I  have  also  to  thank 
the  officers  of  the  U.  S.  Army  Medical  Library 
for  their  kind  assistance. 

Frequency. — If  by  considering  the  number  of 
reported  cases  an  opinion  as  to  its  frequency  can 
be  formed,  surely  it  is  a  very  rare  occurrence,  for 
since  the  memorable  first  case  published  by  Ho- 
echstetter in  1635,  but  518  cases  of  this  kind  of 
haemorrhage  from  the  umbilicus  of  the  newly- 
born  child  have  been  published.  Previous  to 
1850  this  subject  was  scarcely  mentioned  by  text- 
books on  diseases  of  children  and  obstetrics.  Since 
that  date  those  that  mention  it  pass  it  over  as  of 
little  moment  because  of  its  rarity.  During  the 
years  185 1  and  1852  nearly  10,000  children  were 
admitted  to  the  Foundling  Hospital  in  Paris, 
there  being  but  one  case  among  this  large  num- 
ber of  children.  Vogel  says  it  occurs  once  in 
10,000  cases,  he,  in  a  large  experience,  having 
seen  but  one  case ;  and  according  to  Dr.  Stephen 
Smith,  there  were  among  6,654  births  in  the  Dub- 
lin Lying-in  Hospital,  no  cases  of  this  trouble. 

Minot  says:  "It  is  not  a  little  remarkable 
that  men  of  such  large  experience  as  Churchill 
and  West  should  barely  allude  to  this  subject." 
West's  work  on  Diseases  of  Infancy  and  Child- 
hood, contains  the  results  of  640  observations, 
chiefly  made  among  16,276  children  who  came 
under  his  observation.  He  never  met  with  a 
case.  Other  writers,  however,  claim  for  it  a  much 
greater  frequency.  Cox  reported  two  cases  among 
2,000  births  at  the  Emigrants'  Refuge,  Ward's  Is- 
land, New  York,  and  Dr.  E.  L.  Partridge  says 
that  among  1, 166  infants  born  in  the  Nursery  and 
Child's  Hospital  in  New  York,  eleven  cases  of 
haemorrhage  from  the  umbilicus  occurred,  with  a 
mortality  of  75  per  cent.,  and  that  in  the  Sloane 
Maternity  Hospital  fourteen  cases,  with  a  mortal- 
ity of  over  60  per  cent.,  occurred  among  850  in- 
fants. He  has  seen  over  thirty  cases,  but  writes 
me  he  has  no  notes  of  them.  Whitall,  writing 
ion  this  subject  in  1877,  said  that  during  the  last 
preceding  twelve  years  2  per  cent,  of  the  infants 
,  born  in  the  Colored  Hospital  in  New  York  had 
I  suffered  from  this  malady.    Dr  Julia  Ingram  had 


542 


SPONTANEOUS  UMBILICAL  HEMORRHAGE. 


[April  18, 


three  fatal  cases  at  the  same  time  in  one  ward  of 
the  New  England  Hospital.  The  greatest  num- 
ber of  cases  seen  by  one  practitioner  were  the 
132  cases  of  Rittershain.  If  its  occurrence  be 
rare,  what  must  have  been  the  experience  of  a 
man  who  has  seen  132  genuine  cases.  I  cannot 
believe  it  is  so  rare.  On  the  contrary,  my  expe- 
rience is  that  it  is  much  more  frequent  than  sup- 
posed, probably  occurring  as  often  as  once  in  500 
cases,  and  I  believe  it  figures  largely  as  a  cause 
of  death  among  infants.  The  health  office  re- 
ports of  the  large  cities  should  show  valuable  fig- 
ures on  this  subject. 

Causes, — The  causes  of  this  form  of  bleeding 
are  numerous  and  varied.  If  the  cord  has  been 
short,  considerable  traction  may  have  been  made 
upon  it  during  labor,  and  slight  solution  of  con- 
tinuity of  the  tissues  about  the  umbilicus  may 
have  been  produced,  though  perhaps  escaping 
notice  for  some  time.  It  ma3r  also  be  commenced 
by  injury,  as  cited  by  Willis,1  causing  alarming- 
haemorrhage,  but  usually  arises  spontaneously. 
Another  frequent  exciting  cause  is  the  formation 
of  granulations  at  the  umbilicus  following  the 
dropping  of  the  cord,  as  in  Read's2  case,  which 
readily  yielded  to  the  application  of  benzoated 
oxide  of  zinc  ointment.  Deformities  of  the  vis- 
cera have  been  considered  in  this  connection,  in- 
asmuch as  they  have  been  frequently  found  in 
patients  that  have  died  from  this  cause. 

Some  writers  have  thought  climatic  conditions 
of  various  kinds  have  been  influential  as  a  cause, 
but  I  think  without  tangible  reasons. 

Sex  was  pointed  out  by  Ray,3  in  1849,  as  being 
important  in  this  connection,  as  two-thirds  the 
infants  affected  were  males. 

The  most  prolific  causes'  are  hereditary  diseases, 
such  as  syphilis,  haemophilia,  etc.,  and  dyscrasia 
either  local  or  constitutional.  Grandidier4  states 
that  out  of  576  bleeders,  spontaneous  haemorrhage 
from  the  umbilicus  occurred  in  but  twelve  cases, 
but  some  of  these  twelve  cases  were  not  newly- 
born.  In  fact,  fatal  bleeding  in  this  class  of  peo- 
ple does  not  usually  occur  until  after  the  first  or 
second  year,  and  the  blood  is  usually  coagulable, 
in  contradistinction  to  the  condition  of  the  blood 
in  the  malady  under  consideration. 

There  can  be  no  doubt  that  syphilis  is  a  fre- 
quent cause.  Campbell's5  case,  the  mother  of 
which  did  not  know  who  was  the  child's  father, 
and  who  had  previously  been  under  treatment  for 
syphilis  by  Dr.  Campbell,  is  a  striking  case.  The 
child  seemed  at  two  months  to  thrive  upon  large 
doses,  5  to  8  grs.,  of  iodide  of  potash  four  times 
daily.  In  cases  one  and  three  of  the  author's, 
syphilis  also  seemed  to  have  acted  as  a  cause. 
In  Ingram's  cases  the  cord  was  not  ligated  just 


after  birth,  as  is  customary,  which  possibly  may 
have  acted  as  an  exciting  cause,  inasmuch  as 
three  of  them  occurred  at  the  same  time  in  the 
same  hospital  ward. 

Dr.  Minot0  published  cases  which  bear  very 
strong  evidence  of  heredity.  He  quotes  Dr.  A. 
Hoover,  of  East  Cambridge,  who  says:  "I  at- 
tended a  woman  to  all  appearances  health}',  and 
who  has  good  labors.  She  has  lost  four  children 
from  umbilical  haemorrhage.  She  has  since  had 
a  child  which  presented  a  slightly  jaundiced  look, 
but  no  haemorrhage  took  place  and  it  did  well." 
Minot  has  also  had  cases  in  which  the  first,  a 
female,  and  fourth,  a  male  child,  had  died  from 
this  cause,  and  the  second  and  third  children 
were  healthy  and  escaped  umbilical  haemorrhage. 
He  found  that  in  n  out  of  12  cases,  or  912.;  per 
cent.,  the  mothers  were  healthy;  that  in  26  out 
of  32  cases,  or  81  per  cent.,  the  children  were  born 
healthy;  that  in  22  out  of  32  cases,  or  68^4  per 
cent.,  the  children  were  males;  and  that  in  14  out 
of  15  cases,  or  93 yi  per  cent.,  the  labors  were  nat- 
ural. It  could  readily  be  understood  if  haemor- 
rhages of  this  character  would  be  most  frequent 
in  poorly  developed  and  feeble  children,  but  most 
cases  have  been  reported  as  being  in  good  condi- 
tion and  of  good  weight. 

Another  cause  that  is  worth  noticing  is  the 
mental  condition  of  the  mother  during  pregnan- 
cy. This  may  be  bordering  upon  the  subject  of 
maternal  impressions,  but  the  two  have  actually 
been  merged.  In  one  of  Minot' s  cases  the  mother 
had  worried  continually  during  pregnancy  lest  the 
child  should  be  a  victim  of  haemorrhage  from  the 
cord,  and  this  after  having  a  number  of  children 
none  of  which  was  so  afflicted.  If  the  mother 
has  been  subjected  during  pregnancy  to  uncom- 
fortable and  improper  hygienic  surroundings,  and 
is  in  bad  general  health  from  any  cause,  the  in- 
fant will  be  more  liable  to  this  unfortunate  con- 
dition. 

Symptoms. — Bleeding  about  the  navel  usually 
appears  without  warning,  though  in  occasional 
cases  it  is  preceded  by  more  or  less  marked  jaun- 
dice, purpuric  spots,  as  in  one  of  McCarty's7 
cases,  ecchymoses,  petechiae,  and  perhaps  bleed- 
ing from  other  parts,  as  observed  by  Dr.  Julia  In- 
gram.8 Granulations  at  umbilicus  should  cause 
us  to  fear  this  malady.  Although  nearly  all  the 
children  that  have  been  afflicted  with  this  trouble 
have  been  in  good  condition,  yet  it  is  believed 
that  premature  birth,  as  in  two  of  the  author's 
cases,  may  predispose  to  it.  The  various  eviden- 
ces of  syphilis,  and  of  purpura  and  kindred  affec- 
tions, when  present  should  give  us  alarm.  One 
of  Ingram's  cases  was  noticed  to  have  a  peculiar 
whining  cry  accompanied  by  paralysis  of  left  side 
of  face.     In  Gibbs'0  case  the   mother  stated  she 


>  Med.  and  Surf;.  Reporter,  Philadelphia,  1889,  lx,  709. 
-■  Ibid.,  t88i!  xliv,  342. 
3Ray,  r.ond   Med   Gaa  ,  1849,  \liii,  423. 
4Grandidier.  "  Die  Haemophilia,  "  i*S5,  Schmidt's  Ja 
1863,  Bd.  cs 

5  Arch.  Paediatrics,  Philadelphia,  1890,  vii,  449-445. 


'  Amer.  Jour.  Med.  Sci.,  iSs2.  xxiv,  310. 

m   I    uly,  Southern  California  Pract.,  1887,  ii,  - 
H  T.oc.  cit. 
9  Philadelphia   Med.  Times.  18B3-84,  xiv,  616-621 


'89i.] 


SPONTANEOUS  UMBILICAL  HEMORRHAGE. 


543 


always  bled  easily  and  at  the  slightest  provoca- 
tion. She  had  severe  post-partal  haemorrhages. 
These  two  facts  should  have  aroused  anxiety  con- 
cerning the  child.  Very  frequently  the  only  symp- 
tom noticed  previous  to  the  haemorrhage  from  the 
umbilicus  is  jaundice,  which  is  often  quite  mark- 
ed, but  clayey  stools  usually  accompany  it.  Usu- 
ally the  first  indication  of  this  form  of  haemor- 
rhage is  the  bloody  appearance  of  the  dressings 
over  the  umbilicus,  which,  according  to  the 
amount  of  blood  lost,  is  more  or  less  marked. 
This  may  occur  at  any  time.  In  fact,  one  case 
was  reported  in  a  young  lady  who  had  frequent 
attacks  of  bleeding  from  the  umbilicus  since  in- 
fancy, but  Minot  found  in  47  cases  that  the  aver- 
age age  at  which  it  began  was  eight  days.  It 
may  be  a  very  slow  oozing,  continuing  several 
days  and  yielding  to  treatment,  or  ending  in 
death.  Or  it  may  be  sudden  and  severe,  like 
Young's10  case,  which  ended  in  death  in  twenty 
minutes,  and  that  of  Stephen  Smith,"  which  died 
in  one  hour. 

Some  cases  have  been  reported  where  the  haem- 
orrhage was  slight  and  of  brief  duration,  recovery 
soon  following.  Unfortunately,  these  cases  are  but 
a  small  part.  The  bleeding  may  occur  previous 
to  separation  of  the  cord,  and  in  that  case  is  usu- 
ally severe,  and  generally  fatal.  Of  the  last  37 
cases  reported  19  began  bleeding  before  the  cord 
separated.  Of  these  14,  or  74  per  cent.,  died. 
And  of  18  in  which  haemorrhage  occurred  subse- 
quent to  that  event  only  7,  or  39  per  cent.,  suc- 
cumbed. It  would  appear  that  most  cases  occur 
at  the  time  of  or  subsequent  to  separation,  as  the 
cord  usually  separates  from  the  fourth  to  the  sixth 
day,  and  Minot's  average  for  the  beginning  is  the 
eighth  day. 

There  seems  to  be  some  relation  between  jaun- 
dice and  this  malady,  and  Dr.  Brooks,12  of  Texas, 
reports  a  case  of  profuse  escape  of  bile,  itself,  from 
the  umbilicus.  In  some  cases  there  is  diarrhoea, 
and  in  others  constipation.  Yen'  frequently,  after 
the  loss  of  blood  has  gone  on  one  or  two  days, 
haemorrhage  from  the  bowels,  eyes,  skin  abra- 
sions, roof  of  mouth,  gums,  etc.,  occur.  Part- 
ridge13 has  found,  also,  blood  in  the  vagina,  and 
by  post-mortem  examinations,  blood  in  the  ute- 
rus. One  of  Ingram's  cases  vomited  blood.  Vom- 
iting, however,  very  seldom  occurs,  and  pain  was 
noted  in  but  four  cases.  In  these  cases  it  was  at- 
tributed to  extending  the  legs.  Petechiae  and  ec- 
chymotic  spots  on  different  portions  of  the  body 
occur  frequently  during  the  progress  of  the  mal- 
ady. They  are  most  frequent  on  the  back,  fore- 
head, roof  of  mouth,  knees  and  elbows.  Minot 
found  these  conditions  in  twelve  out  of  thirty- 
nine  cases.  In  Campbell's  case,  wThich  was  much 
emaciated,  there  were  bullous  syphilides.     The 


Young,  Med.  and  Surg.  Reporter,  Philadelphia,  1SS5,  liii,  162. 


haemorrhage,  when  rapid  or  profuse,  comes  usu- 
ally from  the  arteries  and  is  lighter  in  color  than 
when  it  merely  oozes  from  about  the  umbilical 
pit.  In  Young's  case  which  died  so  quickly,  the 
haemorrhage  was  from  the  left  side  of  the  base  of 
the  cord,  and  Claudy's  was  of  the  same  character. 
Quite  a  number  of  patients  have  died  in  convul- 
sions. After  the  bleeding  has  progressed  in  spite 
of  treatment,  one  or  two  days,  the  infant  shows 
marked  lowering  of  vitality,  nurses  feebly,  moans, 
appears  pallid  and  emaciated,  and  perhaps  dies 
though  the  haemorrhage  be  arrested.  Bulging  of 
the  fontanelles  is  frequently  present,  and  the  pres- 
ence of  fluctuating  tumors  about  the  head  has 
been  observed.  The  blood  is  usually  thin  and 
watery,  and  varying  in  color  from  very  pale  to 
very  dark,  when  it  is  thought  to  contain  bile,  as 
it  stains  the  clothing  the  same  as  bile  would  if 
brought  in  contact  with  them.  It  usually  oozes 
from  the  umbilical  depression  and  is  non-coagu- 
lable.  The  average  duration  of  this  form  of 
bleeding  cannot  be  definitely  determined,  as  the 
length  of  time  bleeding  continues  is  not  usually 
reported  in  the  successful  cases.  Rouse  says  the 
average  length  of  haemorrhage  in  fatal  cases  is 
three  and  a  half  days.  The  fortunate  cases  prob- 
ably bleed  considerably  less  and   a  shorter  time. 

It  has  been  my  misfortune  to  meet  with  four 
cases  of  this  fatal  condition,  and  but  one  of  them 
recovered.  I  give  them  in  detail  below.  Two 
cases  were  seen  by  my  friend,  Dr.  H.  M.  New- 
man, of  this  city,  who  has  kindly  furnished  me 
notes  of  them  which  are  appended  to  my  own 
cases. 

Case  1. — Carrie  C,  colored,  single,  age  16  years, 
an  inmate  of  the  female  workhouse  in  this  city, 
was  seized  with  pains  in  lower  abdomen,  with 
haemorrhage  from  uterus,  during  the  month  of 
March,  1890.  In  this  institution  there  is  a  daily 
average  number  of  about  120  women — the  refuse 
of  the  District  of  Columbia.  The  patient,  Car- 
rie C,  though  better  than  the  greater  portion  of 
her  associates,  was  not  a  brilliant  in  the  moral 
world,  and  upon  inquiry  it  was  revealed  that  she 
had  not  menstruated  during  the  past  six  months. 
She  was  transferred  to  the  Washington  Asylum 
Hospital,  where  upon  examination  she  was  found 
to  be  pregnant  about  six  months,  and  was  kept 
in  bed  five  days,  taking  opium  to  the  extent  of 
narcosis  for  the  first  two  or  three  days.  After 
being  about  the  ward  she  complained  of  pains 
and  lost  a  little  blood.  She  was  treated  nearly 
the  same  as  during  the  first  attack.  After  this 
she  felt  very  well  for  a  few  weeks,  wdien  another 
attack  occurred  similar  to  but  not  as  severe  as  the 
former  attacks.  I  suspicioned  she  was  attempt- 
ing to  relieve  herself  of  the  foetus  and  had  her 
constantly  watched.  She  was  tided  along  until 
the  night  of  June  4,  when  labor  began  in  earnest, 
and  she  was  delivered  at  8  A.m.,  the  5th,  of  a 
health}-  male  child  weighing  8  lbs.,  nothing  un- 


544 


SPONTANEOUS  UMBILICAL  HEMORRHAGE. 


[April  18, 


usual  occurring.  During  this  and  the  following 
days  the  child  voided  urine  and  its  bowels  moved, 
nothing  unusual  being  noted  by  nurse  concerning 
either  act.  At  4  p.m.  the  6th  the  nurse  reported 
bleeding  from  the  cord.  A  second  ligature  was 
placed  around  the  cord  near  the  abdominal  wall 
and  the  bleeding  ceased.  At  11  p.m.  bleeding 
was  again  observed  and  a  third  ligature  was  ap- 
plied, still  lower  than  the  second  one.  The  flow 
ceased,  but  in  a  short  time  oozing  from  about  the 
junction  of  cord  and  abdomen  was  noticed.  A 
concentrated  solution  of  tannin  was  applied  and 
again  the  haemorrhage  ceased,  to  reappear  in  a 
few  minutes.  Collodion  was  now  used,  which 
checked  the  oozing  for  about  fifteen  minutes,  but 
the  respiratory  movements  of  the  child  cracked  it 
and  the  flow  resumed.  Monsel's  solution  was 
freely  applied,  but  with  little  avail,  the  child  dy- 
ing at  12:30  a.m.  the  7th.  There  were  no  symp- 
toms other  than  bleeding. 

Autopsy  at  9  a.m.  June  7.  Rigor  mortis  not 
well  marked,  muscles  pale  and  soft,  heart  con- 
tracted ;  umbilical  vein  large,  as  were  the  hypo- 
gastric arteries.  A  clot  about  3  inches  long  and 
1  inch  broad  was  found  on  right  side  of  abdomen, 
with  deep  staining  of  peritoneum  beneath  and 
around  it.  Other  extravasations  of  blood  were 
found  in  both  the  visceral  and  parietal  layers  of 
the  peritoneum.  All  the  visceral  organs  pale  and 
soft.  The  next  three  cases  occurred  in  the  Col- 
umbia Hospital  for  Women  and  Lying-in  Asy- 
lum during  my  services  there,  and  through  the 
kindness  of  Drs.  Scott  and  Kelly  I  am  able  to 
give  them  in  detail.     They  are  as  follows : 

Case  2. — Mary  L-  C,  colored,  age  20  years,  was 
admitted  to  hospital  December  16,  1885,  pregnant 
the  first  time.  Her  general  appearance  was  ex- 
cellent, and  she  could  remember  no  symptoms  of 
pregnancy  other  than  morning  sickness  during 
the  early  months.  Urine  contained  no  albumen. 
Foetal  heart  sounds,  140  per  minute,  heard  to  the 
left  of  median  line.  Labor  began  December  18 
at  6  a.m.,  and  progressed  slowly  and  normally 
until  the  19th  at  10  p.m.,  when  she  was  delivered 
of  a  colored  living,  female  child  weighing  5 '4 
lbs.,  and  healthy  to  all  appearances.  The  pla- 
centa appeared  normal  and  was  expelled  intact, 
weight  1 J 4  lb.  On  the  second  day  after  birth 
a  slight  haemorrhage  occurred  from  the  cord, 
which  yielded  to  a  compress  and  a  second  liga- 
ture. On  the  fourth  day  another  attack  occurred 
that  was  also  treated  successfully  by  the  same 
method  for  a  time,  but  at  2  a.m.  the  23d,  a  fresh 
fatal  haemorrhage  began  and  lasted  but  a  few 
minutes.  The  haemorrhage  was  always  sudden 
and  without  warning. 

Case^. — P.  A.,  a  prostitute,  was  admitted  about 
1  p.m.  January  29,  1887,  in  labor.  She  was  white, 
thin  in  flesh,  anaemic  and  of  a  nervous  tempera- 
ment. About  two  months  previously  I  had  at- 
tended  her  for   threatened    miscarriage,  she  de- 


claring it  her  first  pregnancy.  She  was  put  in 
bed,  and  an  examination  revealed  a  footling 
presentation,  the  sacrum  to  the  right  and  front. 
The  labor  was  rapid  and  easy,  and  at  3 :  20 
p.m.  she  was  delivered  of  a  male,  white  child, 
weighing  4^3  lbs.,  in  good  condition  but  probably 
premature.  Milk  was  secreted  sixty- three  hours 
after  delivery,  but  she  refused  to  nurse  child  and 
secretion  was  arrested  in  a  few  days  by  applica- 
tion of  spirits  of  turpentine.  The  child  was  wet 
nursed.  Considerable  haemorrhage  occurred  from 
the  umbilicus  on  the  seventh  day,  February  5, 
which  could  not  be  arrested  by  pressure  and  per- 
sulphate of  iron.  It  was  transfixed  with  hare-lip 
pins,  ligated  and  covered  with  plaster  of  Paris. 
This  permanently  checked  the  oozing  of  blood. 
Three  days  later  the  pins  were  removed.  After 
the  haemorrhage  was  arrested  the  child  improved 
rapidly,  and  was  in  an  excellent  condition  when 
it  left  the  hospital  with  its  mother  about  two- 
weeks  later.  It  was  farmed  out  that  summer, 
and  was  buried  before  the  hot  weather  ended. 
The  mother  is  yet  a  thin,  nervous  woman,  bear- 
ing evidence  of  syphilis. 

Case  4.. — Eleanor  M.,  black,  21  years  old,  was 
admitted  to  hospital  in  labor  December  13,  1887. 
This  was  her  first  child.  She  menstruated  last 
April  i,  and  felt  life  in  July.  She  had  suffered 
almost  continually  from  vomiting  since  concep- 
tion occurred,  and  headaches  during  her  preg- 
nancy were  severe  and  frequent.  Labor  pains 
were  feeble  and  cervix  uteri  was  not  dilated  until 
3  p.m.  The  second  stage  was  very  rapid.  The 
head  had  just  begun  to  bulge  the  perineum 
slightly  when  a  hard  pain  came  on.  The  pa- 
tient now  became  unmanageable  through  fright 
and,  bearing  down  hard,  drove  the  child  through 
the  perineum  into  the  world.  The  placenta,  weigh- 
ing 1^  lb.,  immediately  followed  without  another 
pain.  Part  of  the  membranes  were,  however, 
firmly  adherent,  and  had  to  be  peeled  off  manu- 
ally. Severe  post-partal  haemorrhage  occurred. 
Notwithstanding  this  the  perineum  was  closed  by 
sutures  and  union  procured.  The  child,  a  male, 
was  very  light- colored  as  a  negro  child,  and  from 
its  appearance  was  thought  to  be  three  or  four 
weeks  premature.  Slight  oedema  of  left  eyelids 
appeared  December  20,  which  was  attributed  to 
child  frequently  rubbing  them  with  fists ;  hands 
were  tied;  mild  sol.  alum  and  zinc  dropped  in  eye 
every  two  hours  and  lids  smeared  with  vaseline. 
Eye  recovered  in  three  days.  December  27.  Baby 
nurses  regularly,  but  seems  to  be  suffering  from 
malnutrition.  Bowels  loose  and  faeces  of  grayish 
color.  Ordered  beef  peptonoids  and  hydrarg. 
cum  creta  gr.  T'?,  with  bism.  subnitr.  gr.  ij.,  di- 
orrhcea  ceased  entirely  December  28,  after  taking 
twelve  powders.  December  30  diarrhoea  began 
again;  urine  very  high-colored,  powders  renewed; 
spts.  aeth.  nit.,  gtts.  v.  every  two  hours.  There 
appeared  considerable  oozing  of  blood  from  um- 


i89i.] 


SPONTANEOUS  UMBILICAL,  HEMORRHAGE. 


545 


bilicus,  which  was  touched  with  liq.  ferri  sub- 
sulph.  and  a  compress  applied.  Haemorrhage 
persisting,  styptic  cotton  was  used  and  the  stump 
touched  several  times  with  the  iron  solution. 
The  blood  persistently  oozed  under  the  compress, 
being  very  dark,  as  thin  as  water  and  noncoag- 
ulable.  Several  times  during  the  night  bleeding 
was  very  profuse,  but  would  entirely  cease  for  a 
few  minutes  whenever  the  dressing  was  renewed. 
The  skin  was  extremely  yellow,  jaundice  being 
well  marked.  Gums  bled  upon  the  slightest 
touch.  Patient  grew  weaker  as  haemorrhage  con- 
tinued, until,  about  9  a.m.  December  31,  it  died 
of  exhaustion. 

The  next  two  cases  occurred  in  the  practice  of 
Dr.  H.  M.  Newman  of  this  city,  who  communica- 
ted them  to  me.  He  was  called  during  the  year, 
1885,  to  see  a  fairly  plump  female  child  that  had 
been  delivered  by  a  midwife  and  had  progressed 
well  until  the  fourth  day  when  haemorrhage  from 
the  umbilicus  began.  The  oozing  continued,  and 
on  the  third  day,  being  the  seventh  since  birth  of 
the  child,  he  was  first  called  to  see  it.  He  found 
the  cord  had  sloughed  off  and  blood  welling  up 
from  the  umbilicus.  He  applied  persulphate  of 
iron  under  a  compress  and  later  nitric  acid. 
These  failing,  he  ligated  en  masse  which  checked 
the  flow  for  a  short  time  only,  and  the  child  died 
the  following  night.  The  other  case  he  saw  dur- 
ing the  month  of  September,  1890.  A  healthy 
male  child  ten  days  old  was  attacked  by  a  sharp 
haemorrhage  from  the  umbilicus  which  yielded  to 
one  application  of  a  styptic  covered  by  a  com- 
press. No  recurrence  of  the  accident  was  noticed 
and  the  child  is  now  well. 

Prognosis. — The  gravity  of  this  malady  is  un- 
der the  most  favorable  circumstances  very  great. 
The  result  seems  to  be  most  favorable  when  the 
infant  is  of  the  female  sex,  born  of  good  parents, 
the  mother  being  in  good  health  during  the  term 
of  pregnane}' ;  when  the  general  condition  of  the 
child  is  at  or  above  par,  the  bleeding  slight  and 
occurring  at  an  advanced  age  of  the  child.  Of 
course  any  malformation  of  the  viscera  would 
tend  to  a  fatal  termination.  But  marked  jaun- 
dice with  persistent  oozing  of  blood  from  about 
the  umbilicus  are  very  alarming  phenomena,  and 
if  haemorrhages  from  other  parts  set  in,  purpuric 
spots  appearing,  the  result  will  be  fatal  in  nearly 
every  C3se.  Occasionally  a  slight,  short  haemor- 
rhage from  the  umbilicus,  even  in  vigorous  chil- 
dren, will  cause  such  a  depression  that  reaction 
never  occurs  and  the  child  dies.  I  think,  how- 
ever, that  in  infants  suffering  from  marasmus  and 
kindred  affections  in  which  their  vitality  is  low, 
that  an  attack  of  even  slight  omphalorrhagia 
proves  fatal.  Altogether  the  mortalit)'  rate  in 
this  malady  is  gradually  decreasing.  As  given 
by  Jenkins  in  178  cases  it  was  84  per  cent.  Hen- 
nig1*  says  it  was  83  per  cent,  in  230  cases,  includ- 


i  Handbuch  <Ur  Kiuderkrankheiu  i 


ing  Jenkin's  table,  and  Keiller'5,  adding  six  < 
Hennig's  list,  says  it  is  68  per  cent,   while  the 
author  finds  in  518  cases  it  is  76  per  cent.     Hen- 
nig  says  one- half  die  on  the  fourth  day  and   83 
per  cent,  do  not  live  beyond  the.  second  week. 

A  few,  however,  live  longer  before  death  over- 
takes them.  Olliffe's15  case  died  at  the  end  of 
seven  weeks,  being  the  longest  case  yet  recorded^ 
His  patient  was  small  and  delicate  and  on  the 
sixth  day  the  cord  separated.  Five  days  later 
omphalorrhagia  began,  accompanied  by  icterus, 
purpuric  spots  on  tongue  and  palate  and  bloody- 
dejections.  The  oozing  was  soon  controlled  by 
ligature  en  masse  but  great  debility  continued  un- 
til death  occurred.  Of  the  518  cases  reported  393 
cases  died  and  123  recovered, — a  mortality  of  76 
per  cent.  Of  these  cases  the  sex  is  given  in  but 
347  cases,  224  of  which  were  males  of  which  174 
died,  78  per  cent.,  and  123  were  females,  95  of 
which  died,  77  per  cent.  Of  the  1C9  cases  in 
which  the  sex  was  not  given  124  died,  a  mortali- 
ty rate  of  73  per  cent.  The  male  sex  is  afflicted 
about  twice  as  often  as  the  female. 

Pathology. — The  pathological  conditions  exist- 
ing in  umbilical  haemorrhage  in  the  newly- born 
has  received  very  little  attention  and  so  far  the 
microscope  has  had  very  little  acquaintance  with 
this  subject,  although  Vancott,  of  Brooklyn,  did 
some  careful  work  on  the  subject.  The  diseased 
conditions  found  have  been  variable,  and  again 
cases  have  occurred  in  which  no  lesion  was  found. 
In  a  number  of  autopsies  on  infants  that  have 
died  from  this  trouble  the  umbilical  vessels  have 
been  found  closed  and  in  others  patulous,  which 
in  early  cases  is  not  necessarily  pathological. 

M.  Lorain,  according  to  M.  Henri  Roger,'7 
while  a  student  at  Enfans  Trouve,  investigated 
extensively  the  process  of  obliteration  of  the  um- 
bilical arteries  and  arrived  at  the  following  con- 
clusions. There  are  two  modes  of  obliteration; 
in  the  first  the  obliteration  is  provisional;  it  suf- 
fices for  the  present  necessities  of  the  new- bom 
child  and  guards  against  early  accidents;  it  con- 
sists in  a  clot  which  forms  a  few  hours  after  birth. 
This  coagulum  is  found  in  children  who  have  not 
lived  more  than  four  or  five  hours;  it  commences 
sometimes  in  the  arteries  of  the  cord,  and  some- 
times at  the  junction  of  these  vessels  with  those  of 
the  abdomen;  it  is  black,  of  mediocre  consistence, 
adhering  but  slightly  to  the  walls  of  the  artery, 
and  is  at  first  very  short;  subsequently  it  is  elon- 
gated by  the  successive  deposition  of  new  mole- 
cules, until,  at  the  end  of  the  second  day  it  oc- 
cupies two- thirds  or  half  the  length  of  the  artery, 
commencing  at  the  umbilicus.  It  is  then  firmer, 
denser  and  more  adherent  to  the  walls  of  the  ves- 
sel. During  the  succeeding  days  this  coagulum 
acquires  greater  consistence  and  loses  at  the  same 
time,  its  black  color  and  assumes  a  fibrinous  aspect; 


I.  Union  Med.  1853,   138   u; 


546 


SPONTANEOUS  UMBILICAL  HEMORRHAGE. 


[April  18, 


becomes  more  and  more  regularly  cylindrical.  In 
proportion  as  the  coagulum  contracts  the  artery 
narrows.  This  may  be  called  the  provisional 
mode  of  obliteration.  The  other  consists  in  the 
complete  occlusion  of  the  artery  at  its  umbilical 
extremity,  and  occlusion  which  occurs  in  the  fol- 
lowing manner:  The  extremity  of  the  artery  is 
retracted  from  the  navel,  contracts,  and  presents 
a  conical  extremity;  this  hardly  takes  place  be- 
fore the  twenty-fifth  or  thirtieth  day;  at  this  date 
the  calibre  of  the  artery  is  very  small,  and  is  oc- 
cupied by  a  fibrinous  clot,  white,  dense,  regularly 
cylindrical  and  closely  adherent  to  the  arterial 
coats.     This  is  the  true  obliteration. 

Keiller  found  in  a  case  that  began  bleeding  on 
the  eleventh  da}'  and  died  on  the  fourteenth,  that 
the  umbilical  vein  and  left  hypogastric  artery 
were  empty  and  firmly  contracted,  while  the  right 
hypogastric  artery  was  open  and  contained  traces 
of  blood.  A  very  plausible  cause  of  this  trouble 
and  a  condition  usually  present  in  it  is  inflamma- 
tion of  the  umbilical  blood  vessels.  By  thicken- 
ing and  stiffening  the  walls  of  these  vessels  it 
prevents  contraction  of  them  and  consequently 
encourages  bleeding.  There  seems  to  be,  how- 
ever, no  constant  condition  of  the  blood  vessels 
of  the  navel  in  this  malady.  In  one  case  in  which 
the  arteries  and  vein  were  both  found  pervious 
and  pus  and  blood  clots  were  adhered  to  the 
tunica  of  the  veins.  It  is  reasonable  to  think 
these  vessels  should  close  shortly  after  birth  as  in 
the  lower  animals  where  the  cord  is  not  tied  and 
haemorrhage  does  not  occur.  I  believe  that  when 
these  vessels  are  found  pervious  after  a  week  it  is 
due  to  a  non-coagulable  state  of  the  blood  and 
is  pathological.  In  cases  of  bleeding  after  separ- 
ation of  the  cord  there  are  usually  found  ulcers 
at  the  site  of  detachment. 

The  most  constant  condition  found  is  some 
functional  trouble  with  the  liver — some  derange- 
ment with  the  formation  and  elimination  of  bile. 
Jaundice  and  clayey  stools  would  naturally  indi- 
cate obstruction  to  the  passage  of  bile  into  the 
alimentary  canal  and  this  really  is  true  is  many 
cases.  Thayer"  found  in  a  case  an  empty  gall- 
bladder and  an  impervious  condition  of  the  lower 
half  of  the  bile  duct  and  the  whole  of  the  ductus 
communis  choledochus.  In  about  half  the  au- 
topsies the  bile  duct  was  found  occluded.  Many 
different  phrases  have  been  used  to  express  the 
but  little  altered  condition  of  the  liver  in  this 
malady.  Van  Cott19  found  by  the  microscope  that 
in  a  case  examined  by  him  the  cells  of  the  paren- 
chyma of  the  liver  were  quite  uniformly  swollen, 
granular,  contained  bile  pigment  and  their  nuclei 
quite  indistinct  or  invisible.  The  connective  tis- 
sue of  the  portal  canals  was  everywhere  increased 
and  densely  infiltrated  with  small  round  cells. 
This  indicated  hepatitis  which  no  doubt  caused 

■»  N.  Y.  Med.  Jour,  1885,  xlii.  434. 

'9  Brooklyn  Med.  Jour.  1888,  i,  219-229. 


the  jaundice  and  secondarily  the  haemorrhage  on 
the  6th  day  which  ended  fatally  on  the  nth  day. 

The  condition  of  the  blood,  no  doubt,  plays  an 
important  part  in  umbilical  haemorrhage.  If 
over-loaded  with  bile  it  is  rendered  non  coagula- 
ble  by  its  extreme  alkalinity  and  the  red  blood 
corpuscles  are  to  some  extent  destroyed.  The 
walls  of  the  vessels  are  consequently  weakened 
and  the  fluid  blood  escapes  more  easily  than  usual. 
The  extreme  fluidity  of  the  blood  of  infants  suf- 
fering from  bleeding  from  the  umbilicus  has  been 
considered  due,  by  some  writers,  to  the  mothers 
drinking  large  quantities  of  water  during  preg- 
nancy thus  diluting  their  own  blood  and  of  course 
that  of  the  child.  The  changes  in  the  circulation 
of  the  blood  at  birth  are  not  always  perfect  and 
these  imperfections  tend  to  nonaeration  of  the 
blood.  In  consequence  venous  blood  is  carried 
back  through  the  arterial  system  to  the  tissues  of 
the  body  and  vitiation  ensues.  With  that  comes, 
also,  weakening  of  the  blood  vessels  and  probably 
loosening  of  the  provisional  clots  in  the  umbilical 
vessels.  This  loosening  permits  bleeding  from 
these  vessels  varying  in  amount  according  to  the 
extent  of  loosening  and  if  the  blood  be  much 
thinned  by  loss  of  red  blood  globules  and  by  di- 
lution with  bile  the  tendency  of  the  flow  is  to  con- 
tinue. Various  malformations  have  beer,  found 
in  the  circulatory  system  in  these  cases.  Ingram 
found  a  very  small  right  ventricle  of  the  heart 
and  no  septum  between  its  auricles.  This  child 
lived  fourteen  days,  four  days  after  the  haemor- 
rhage began,  which  continued  until  death  ensued. 
There  was  bleeding  at  other  points,  vomiting  of 
blood  occurring  twice  and  the  post-mortem  exam- 
ination revealed  two  stomachs,  both  filled  with 
deorganized  blood. 

Keiller  found  the  ductus  venosus,  ductus  ar- 
teriosus and  foramen  ovale,  all  open  in  a  child 
that  died  on  the  fourteenth  da}'  after  four  days  of 
uncontrollable  haemorrhage.  In  many  cases  a 
tendency  to  bleeding  is  shown  by  constant  drib- 
bling of  thin  non-coagulating  blood  from  very 
slight  scratches  on  various  parts  of  the  body. 
These  anatomical  defects  must  seriously  interfere 
with  the  proper  circulation  of  the  blood  and  de- 
crease its  oxygenation.  It  can  be  readilv  under- 
stood how  the  venous  system  would  become  en- 
gorged and  blood  back  up  into  the  umbilical  vein, 
dilating  it  where  it  had  nearly  closed  and  escap- 
ing at  its  delicately  closed  extremity.  Again 
some  inherited  disease  may  have  effected  the  wall 
of  the  blood  vessels.  This  was  noticed  in  a  num- 
ber of  cases  where  such  condition  was  almost  cer- 
tain to  have  existed  and  the  blood  being  very 
fluid  and  deficient  in  fibrinogen  the  flow  was  free. 
I  tsemorrhages  also  occurred  from  the  gums,  eyes, 
bowels,  stomach  and  other  parts. 

In  the  author's  first  case  there  were  numerous 
extravasations  of  blood  in  the  peritoneum  and  a 
large  clot  was  found    in  the  abdominal  cavity. 


I89i.] 


INFLAMMATION  OF  THE  MIDDLE  MAR 


547 


Effusions  of  blood  have  also  been  found  in  the 
lateral  ventricles  and  under  the  arachnoid.  Other 
organs  have  been  found  at  fault  in  these  cases. 
Hennig  states  that  in  every  case  there  are  uric 
acid  infarcts  in  the  kidneys.  Melsena  is  a  very 
frequent  complication  of  the  form  of  haemorrhage 
under  consideration,  probably  due  to  the  same 
cause.  Zeigler*'  says  backing  up  of  blood  into 
veins,  the  walls  of  which  are  diseased,  is  usually 
the  cause  of  this  condition,  and  Klebs1'  and  Ep- 
pinger"  have  described  a  micrococcus  found  in 
this  malady  which  they-  called  monas  haemorrhag- 
icum. 

i  To  be  concluded.} 


REMARKS    ON    THE   TREATMENT   OF 

PROLIFEROUS  INFLAMMATION 

OF  THE  MIDDLE  EAR. 


BY  H.  V.  WURDEMANN,   M.D., 

OF  MILWAUKEE.  WIS. 

Chronic  non-suppurative  inflammation  of  the 
middle  ear  has  been  well  divided  by  one  of  our 
American  writers  into  two  great  classes  (St.  John 
Roosa): — 

CATARRHAL  AND  PROLIFEROUS. 

Politzer  and  Gruber  accept  the  same  classifica- 
tion but  under  different  names.'  Others  subdi- 
vide these  terms,  giving  each  a  local  habitation 
according  to  its  most  conspicuous  lesion. 

By  proliferous  disease  is  meant  that  form  of 
chronic  non-suppurative  catarrh  in  which  there 
are  marked  changes  in  increase  or  hypertrophy 
of  tissue,2  attended  by  little  or  no  fluid  secretion, 
i.  e.,  a  dry  catarrh  (Roosa.)  This  disease  is 
characterized  chiefly  by  its  insiduous  course,  hav- 
ing little  or  no  symptoms  beyond  gradually  in- 
creasing deafness  and  tinnitus  aurium.  It  event- 
uates in  entire  sclerosis  (hence  the  name  given 
to  it,  by  some  writers,  of  "sclerosis  of  the  middle 
ear")  and  profound  deafness.  The  tinnitus  may 
indeed  be  the  only  symptom  of  which  the  patient 
may  complain.  He  may  indignantly  refute  the 
idea  that  he  is  at  all  deaf  and  only  seeks  the  re- 
moval of  the  obnoxious  subjective  sounds.  The 
pathology  of  this  affection  has  been  well  displayed 
in  several  well  known  text-books.  I  wish  to 
make  a  few  remarks  on  the  methods  of  treatment 
that  in  my  experience  have  been  found  to  afford 
the  most  relief. 

Proliferous  inflammation  having  acquired  a 
foothold  in  the  ear.  as  it  were,  is  in  some  cases 


-  Textbook  on  Pathology-.  English  Translation,  Wood  &  Co. 
1887,  p.  54. 

"  Ibid,  p.  J03. 

=a  Ibid. 

1  Politzer,  "Ohrenheilkunde,"  p.  210.  Gruber,  "Ohrenheil- 
kunde,"  p.  409. 

;  In  some  instances  secondary  atrophv  of  the  drum.  etc..  mav 
occur.    (Figs.  3  and  4.) 


practically  incurable,  and  the  patient  should  be 
satisfied  if  the  disease  is  but  kept  in  check  by  the 
treatment.  Without  proper  care  the  affection 
is  invariably  progressive,  going  from  bad  to 
worse  and  lasting  the  lifetime  of  the  patient. 
Thus  the  prognosis  should  be  always  a  guarded 
one.  and  the  patient  should  be  acquainted  with 
the  course  and  nature  of  the  disease  in  order  that 
his  cooperation  may  be  secured  and  that  he  may 
not  become  disappointed  with  the  length  of  the 
treatment.  One  or  two,  or  a  half  dozen  sittings, 
in  some  cases,  accomplishes  little  or  nothing. 
The  amount  of  good  that  can  be  done  may  only 
be  determined  by  a  week  or  ten  days'  trial.  There 
are  some  cases  in  which,  within  certain  restric- 
tions, an  absolute  cure  may  be  promised.  After 
a  course  of  treatment  by  which  the  hearing  has 
been  restored  and  the  distressing  tinnitus  removed, 
the  patient  should  be  warned  that  a  point  of  less 
resistance  has  been  formed  which  will  again  give 
way  before  a  succession  of  colds  and  induce  a  re- 
turn of  the  trouble.  Those  patients  who  are  so 
fortunate  as  to  recover  must  observe  the  strictest 
rules  of  hygiene,  and  should  return  under  the 
care  of  their  medical  adviser  at  the  slightest  ear 
symptom.  As  a  general  rule  they  should  be 
counseled  to  return  in  the  spring  and  fall  of  the 
year  for  examination,  and  if  necessary',  for  a 
course  of  treatment. 

Do  not  think  this  a  too  gloomy  view  of  the 
matter,  others  have  given  worse.3 

Although  we  cannot  in  all  cases  guarantee  a 
cure,  yet  we  may  lift  many  up  from  the  slough  of 
despond  into  which  they  have  been  plunged  by 
their  deafness  and  the  agonizing  annoyances  of 
the  accompanying  tinnitus.  Yea.  we  may.  it  it 
is  allowed,  save  some  from  the  madhouse.  Many 
persons  have  been  reckoned  insane  by  reason  of 
hallucinations  of  hearing  caused  by  tinnitus,  and 
some  have  even  been  cured  of  '  "brain  disease' '  by 
treatment  of  the  ears.* 

The  deaf,  with  the  exception  of  deaf  mutes,, 
are  proverbially  sullen  and  morose.  By  lifting 
however  so  little  their  load  of  affliction  we  may 
restore  those  to  the  world  who  have  retired  with- 
in themselves,  and  render  them  agreeable  neigh- 
bors and  thankful  patients. 

The  therapeutic  measures  at  our  disposal  are 
the  following : 

I.  Local  treatment  of  the  middle  ear  and 
Eustachian  tube : 

1.  Inflation  by  Politzer's  method :  a,  with  air; 
b,  with  vapors. 

2.  Inflation  by  catheter  :  a,  with  air;  b,  with 
steam:  <-.  with  medicinal  vapors. 

3.  Injection  of  fluids  through  catheter. 

4.  Eustachian  bougies. 

5.  Electricity. 

3  Roosa,  "Diseases  of  the  Ear,"  pp 

J  Roosa.  "Diseases  of  the  Ear."  p.  344-5.  Gower.  Diseases  ol 
the  Nervous  System."  p.  6".     'Troltsch  on  the  Ear."  p.  531  et  al. 


548 


INFLAMMATION  OF  THE  MIDDLE  EAR 


[April  18, 


6.  Methodical  use  of  ear  trumpet  and  Siegel's 
otoscope. 

7.  Operative  treatment. 

8.  Symptomatic  treatment  of  tinnitus  and  ver- 
tigo. 

II.  Local  treatment  of  nose  and  fauces. 

III.  Constitutional  treatment. 

The  local  treatment  of  the  middle  ear  and 
Eustachian  tube  is  of  course  the  most  essential. 
Often  the  disease  is  circumscribed  and  it  is  this 
■class  of  cases  that  yield  most  readily  to  the  local 
applications.  Although  the  topical  applications 
are  used  through  the  Eustachian  tube  they  are 
not.  as  some  writers  would  have  it,  entirely 
directed  to  that  appendix.  The  vapors  and  fluids 
used  do  undeniably  reach  the  cavity  of  the  tym- 
panum, as  is  evinced  by  an  inspection  of  the  drum 
after  using  them. 

Atmospheric  air  is  of  great  importance,  as  the 
simple  use  of  it,  either  by  Politzerization  or  by 
the  catheter,  restores  the  equilibrium  of  the  air 
pressure  on  either  side  of  the  drum,  and  the  force 
of  its  entrance  breaks  up  adhesions  and  drives  out 
accumulations  of  mucous,  and  besides  all  this,  is 
a  valuable  means  of  diagnosis.  The  gain  in  hear- 
ing distance  (H.  D.)  after  the  first  inflation,  while 
not  so  marked  as  in  the  strictly  catarrhal  forms  of 
middle  ear  disease,  is  frequently  so  great  as  to 
give  the  patient  undoubted  confidence  in  the 
physician. 

Chloroform,  ether,  bromethyl  or  iodine  crystals 
may  be  used  in  the  Roosa  bulb  inhaler.  The 
first  named  is  of  value  in  determining,  in  doubt- 
ful cases,  whether  the  tympanum  has  been  reached 
by  the  inflation.  This  point  is  shown  by  an  in- 
jection of  the  blood-vessels  at  the  handle 
of  the  mallus,  caused  by  the  irritation  of 
the  vapor,  and  an  enlargement  of  the  light  spot. 

Where  sclerosis  exists  a  sensation  of  heat 
will  be  felt  by  the  patient  in  the  ear  after  the  in- 
flation of  the  same  by  any  of  the  three  first 
named,  while  in  a  healthy  ear  the  sensation  is 
that  of  coldness.  This  may  be  considered  a  valu- 
able aid  in  both  diagnosis  and  prognosis.6 

Where  decided  retraction  of  the  drum  is  pres- 
ent (Figs.  1  and  2),  or  where  spots  of  atrophy 
occur,  a  great  change  will  be  seen  after  inflation. 
(Figs.  3  and  4.) 

Treatment  through  the  catheter  is  our  main- 
stay in  proliferous  inflammation.  The  vapors 
which  have  been  advocated  have  resolved  them 
selves  into  three.  The  vapor  of  water  (steam), 
although  an  old  remedy,  is  sometimes  useful 
where  deficient  secretion  exists." 

For  the  exhibition  of  this  remedy  I  use  an  or- 
dinary steam  atomizer  to  which  is  attached  a 
bottle  with  three  glass  tubes  in  the  cork  for  the 


in     Uiwenberg,  of  Paris,   "Deutsche   Med.  Wochenschrift  ' 
July  10.  1890. 

1     Pardee,  Transact.   American    Otological  Society.    1870 
Roosa,  "Diseases  of  the  Kar,"  p.  396. 


purpose  of  catching  the  water  of  condensation 
and  to  connect  the  propulsive  power.     (Fig.  5.) 


Fig.  1. — Great  retraction  of  drum  with  chalk  iu  membrane. 

A  rubber  catheter  must  be  used  as  metal  be- 
comes too  hot.  One  must  be  certain  that  the 
end  of  the  catheter  is  in  the  tuba  Eustachii,  or 
damage  may  be  done.  To  that  end  steam  should 
be  used  only  when  a  well-developed  sound  is 
heard  through  the  otoscope  on  auscultation  when 


Fig.  2.— Same  after  inflation  with  chloroform. 

the  ear  is  inflated  with  air.  The  steam  should 
be  conducted  to  the  ear  by  successive  puffs  per- 
mitting the  catheter  to  cool  between  each  inter- 
val. The  sitting  should  last  from  five  to  ten 
minutes  three  to  four  times  a  week. 

The  vapor  of  camphor  and  tincture  of  iodine  is 
a  more  convenient  remedy  and  accomplishes  the 
purpose  of  steam,  that  of  local  stimulation,  and  is 
applicable  to  the  great  majority  of  cases.  It  is 
employed  in  the  apparatus  shown  in  Fig.  6.  This 
remedy  was  suggested  by  Roosa.7 


Fig.  3.— Partial  atrophy  of  membrana  tympani, 

The  sitting  should  last  from  two  to  five  min- 
utes daily.  Where  considerable  effect  is  desired 
this  treatment  may  be  preceded  by  steaming. 


I  Vt  Res.  Camphoric,  S.oo;  Tr.  Iodin.,  60.00. 


t*9i.] 


INFLAMMATION  OF  THE  MIDDLE  FAR 


549 


Nascent  muriate  of  ammonium  (first  suggested 
by  Moos,  of  Heidelburg),  is  of  high  value  where 
irritatioii  is  required,  in  those  cases  that  do  not 
respond  to  other  treatment.' 


Fig.  4. — Same  after  inflation  with  atmospheric  air. 

The  apparatus  that  I  use  for  the  purpose 
of  conveying  this  vapor  to  the  ear  is  shown  in 
Fig.  7.  It  consists  of  a  test  tube  holding  a  small 
quantity  of  muriatic  acid  enclosed  in  a  bottle 
half-filled  with  water,  to  which  has  been  added  a 
few  drops  of  strong  aqua  ammonia.  The  two  are 
connected  as  per  illustration. 

The  sitting  should  last  from  two  to  five  min- 
utes daily,  the  patient  taking  care  to  breathe 
none  of  the  irritating  vapor. 


The  German  authors  are  firm  believers  in  the 
efficacy  of  fluid  injections  through  the  Eustachian 
tube  into  the  tympanum.  This  treatment,  in  my 
opinion,  is  useful  in  some  cases  in  conjunction 
with  other  methods.  The  ordinary  way  is  to  in- 
ject a  few  drops  of  the  desired  fluid  (warrnedj  into 
a  catheter  after  insertion,  and  then  to  forcibly 
blow  into  the  same  by  the  air  bag.  Doubts  have 
been  expressed  as  to  whether  the  medicine  ever 
gets  farther  than  the  mouth  of  the  tube.  If  the 
patient  is  instructed  to  swallow  during  this  pro- 
cedure, the  fluid  usually  gains  the  tympanic  cav- 
ity. The  elastic  catheter  of  Weber  may  be  used 
and  the  fluid  pushed  forcibly  beyond  the  isthmus 
tubse  and  into  the  tympanum.  This  method, 
however,  is  dangerous,  and  should  be,  if  at  all, 
carefully  done.      Evidences   of  success  may   be 


Eustachian  tube  and 

In  using  each  of  these  apparatus  the  catheter 
is  either  held  in  place  by  the  left  hand  of  the  sur- 
geon or  by  the  patient,  or  a  pair  of  nose-nippers 
may  be  employed.  The  best  of  these  is  composed 
of  a  strip  of  whalebone  folded  upon  itself ;  this 
was  first  used  by  Delstanche.     (Fig.  8.) 

All  apparatus  figured  in  the  foregoing  is  easily 
made  by  the  physician  himself. 


Fig.  7. — Apparatus  for  generating  uasceut  ammonium  muriate. 

noticed  by  the  patient  feeling  a  slight  pain,  which 
passes  away  in  a  few  moments,  and  a  feeling  of 
fullness  and  deafness,  which  exists  for  some  hours, 
when  some  benefit  from  the  procedure  may  be 
expected.  This  treatment  attains  its  best  results 
when  used  about  three  times  a  week. 

Numerous  ingenious  and  complicated  instru- 
ments have  been  devised  for  making  these  injec- 
tions, but  in  my  opinion,  simply  the  catheteriza- 
tion and  swallowing  are  essential.'' 

-ft 


Fig.  S— Catheter  holder. 

It  is  advisable  to  treat  patients  by  either  of  the 
previously  described  methods  not  longer  than  two 
months  at  a  time,  when  an  interval  of  at  least  a 


phor  and 


Politzer,  Lehrbuch,  p.  92.     Troltsch  on  the  Ear,  p.  22S 


9  \mong  the  numberless  recipes  advocated  I  select  the  follow  - 

1  ing  as  the  most  efficient :  ft.  Sod.  bicarb.  .50;  glycerin,  pur.  2.00; 
aq  dest  ado  s  1000.  M.  S.  One  half  a  medicine  dropperful  to 
be  warmed  and  injected  into  the  middle  ear  through  the  catheter 
three  times  a  week  bv  the  surgeon.    R.    Tr.  iodin.  .25;  aq.  dest. 

I  ad  q  s  10.00.  M.  S."  As  the  foregoing.  K.  Potass,  caust.,  .05; 
aq  dest.  ad  q.  s.,  10.00.    M.     S.     When  syphilis  is  known,  or  is  sus- 

I  pected  to  be  present,  the  following  is  useful:     K.     Potass.  iod., 

1  .10-. 50;  aq.  dest.  ad  q.  s.,  10.00.    M.     S. 


55° 


INFLAMMATION  OF  THE  MIDDLE  EAR. 


[April  18, 


month  should  intervene  before  treatment  is  again 
renewed  fey  the  physician.  During  this  time  a 
Politzer  bag  with  the  inhaler  may  be  used  by  the 
patient,  who  should  be  instructed  to  blow  up  the 
ears  once  or  twice  a  day  according  to  the  indica 
tions.  Iodine  crystals  or  ether  and  chloroform 
may  be  used  in  the  inhaler. 

The  following  procedures  are  of  occasional  use 
in  special  cases.  Eustachian  bougies  are  indi- 
cated where  an  insufficient  current  of  air  on  infla- 
tion by  the  catheter  reaches  the  tympanum. 
(This  can  only  be  determined  by  the  use  of  the 
auscultation  tube  or  otoscope.)  They  are  strongly 
advocated  by  Urbantschitsch,  of  Vienna,  who 
lays  down  a  number  of  indications  for  their  use. 
It  is  but  seldom  that  we  must  have  recourse  to 
them.  The  catheter  is  first  passed  and  then  the 
bougie  is  pushed  up  as  far  as  the  isthmus  (24 
mm.).  It  is  allowed  to  remain  in  situ  four  to 
five  minutes  and  then  is  withdrawn.  The  end  of 
the  bougie  which  had  rested  in  the  tube  after  with- 
drawal should  present  the  shape  of  a  lengthened 
letter  S.  Afterwards  the  ear  should  be  gently 
inflated  by  the  air  bag.    If  the  bougie  has  caused 


Fig-.  9. 


ot  the  posterior  fold. 


pain  or  if  upon  withdrawal  it  should  be  smeared 
with  blood,  on  no  account  should  inflation  be 
practiced.  Emphysema  and  other  grave  accidents 
have  occurred  from  neglect  of  this  precaution, 
even  in  the  hands  of  the  most  earnest  advocates 
of  this  method.10 

The  good  of  electricity  is  doubtful,  still  judg- 
ing from  the  effects  of  the  galvanic  current  in 
other  parts  of  the  body,  it  may  aid  in  the  absorb- 
tion  of  exudative  masses.  A  recent  writer"  ad- 
vocates its  use  in  proliferous  disease  as  follows  : 
"An  electrode  consisting  of  an  insulated  rubber 
speculum  with  a  handle,  through  which  speculum 
runs  a  conducting  wire"  is  attached  to  the  nega- 
tive pole  of  the  battery  and  used  in  the  meatus, 
the  latter  being  filled  with  warm  salt  water.  "  If 
the  tube  is  pervious  the  positive  pole  is  attached 
to  an  ordinary  sponge  electrode  and  pressed  under 
the  angle  of  the  jaw  of  the  opposite  side.  If  the 
tube  is  not  freely  open  the  positive  pole  is  attach- 
ed to  an  electrode  consisting  of  a  hard   rubber 


Eustachian  catheter  with  a  copper  wire  running 
through  it.  The  catheter  with  the  wire  drawn 
inside  is  introduced  in  the  usual  way  and  the 
wire  being  held  firmly  the  catheter  is  withdrawn 
one  half  inch  leaving  wire  in  the  tube.  The  cur- 
rent is  now  turned  on  until  the  burning  feeling 
is  as  great  as  the  patient  can  comfortably  bear 
and  continued  from  five  to  ten  minutes."  My 
experience  with  this  method  has  led  me  to  attri- 
bute any  apparent  increase  in  hearing  distance 
during  the  use  of  this  agent  rather  to  the  effect 
of  suggestion  than  as  the  result  of  the  current. 

Systematic  use  of  the  hearing  trumpet  is  in  the 
profoundly  deaf  not  alone  an  aid  to  hearing  but 
may  even  prevent  the  extension  of  the  deafness, 
and  in  some  instances  an  improvement  may  be 
noticed  under  its  use.1'- 

Siegel's  otoscope  is  not  only  a  valuable  aid  in 
diagnosis,  in  the  differentiation  of  atrophic  spots 
and  scars  from  perforations  and  iu  the  determina- 
tion of  rigidity  and  adhesions,  but  is  also  of  ther- 
apeutic value  in  breaking  up  the  latter.  By  a 
course  of  local  gymnastics  with  this  instrument 
sometimes  the  hearing  is  improved. 

Operative  treatment  is  sometimes  indicated  al- 


Fig.  10. -In 


for  tenotomy. 


1  Clinical  Lectures,  Prof  Urbantschitsch,  Vienna,  1SS9.  "Dis- 
eases of  the  Ear,'"  Roosa,  p.  403. 

"B.  L.  Jones,  of  Florence,  Ala..  "  Suggestion  on  the  Use  of 
Electricity  in  Ear  Diseases,"  The  Journal,  July  12,  1890. 


though  it  seems  that  in  this  country  at  least  it 
has  fallen  into  disrepute.13 

It  is  advisable  in  the  following  instances:  An 
artificial  opening  may  be  made  in  the  drum  when 
the  membrane  is  very  thick  or  has  much  chalk 
deposit  (Figs,  i  and  2),  or  where  there  is  fixation 
of  the  ossicles,  when  an  undilatable  stricture  of 
the  tube  exists,  and  finally  when  excessive  tinni- 
tus has  not  been  controlled  by  previous  treat- 
ment. 

It  is  almost  impossible  to  keep  up  an  artificial 
opening  for  any  length  of  time,  as  it  soon  closes 
over.  The  puncture  of  the  galvano-cautery 
needle  gives  the  best  results.  The  application 
of  chromic  acid  on  the  end  of  a  silver  probe,  al- 
though a  painful  procedure,  is  sometimes  success- 
ful in  keeping  up  a  permanent  opening.  Polit- 
zer puts  a  very  small  piece  of  hard  gum  tubing 
into  the  wound  made  by  a  paracentesis  needle." 

Division  of  the  posterior  fold  of  the  drum  is  in- 


'-'  Lawrence  Turnbull,  "  Aids  to  Defective  Hearing,  etc.,"  Med. 
Register,  March  3d,   1888. 

1    Transact.  American  Otological  Society.  1S81,  p.  45S  et  seq. 
'4  I.ehrbuch,  p.  257. 


(89I.J 


THE  VOICE  IX  FEMALE  SINGERS. 


55i 


dicated  in  excessive  retraction  of  the  same  when 
inflation  does  not  restore  the  natural  position.  It 
is  done  by  the  paracentesis  needle  in  the  position 
shown  in  Fig.  9. 

Tenotomy  of  the  tensor  tympani  muscle  is  done 
by  a  sickle  shaped  knife  or  the  one  that  is  com- 
monly used  for  scarification.  It  is  indicated  in 
those  cases  where  strong  retraction  exists,  where 
the  drum  is  restored  to  its  normal  contour  and 
the  hearing  distance  is  markedly  increased  by 
inflation,  but  where  a  few  moments  later  it  is 
found  that  the  original  condition  has  returned. 
In  some  cases  of  the  "  telephone  ear,"  (spasmodic 
contraction  of  the  M.  tensor  tympani  I,  which  are 
not  mitigated  by  rest  and  other  treatment,  it  may 
be  allowable  to  divide  the  tendon. " 

This  operation  is  again  becoming  fashionable 
and  it  is  even  being  advocated  by  the  continental 
authors  as  applicable  to  all  "cases  of  sclerosis  of 
the  tympanum  with  relatively  good  bone  conduc- 
tion." ' 

I  have  noted  two  cases  this  year  in  which  im 
provement  was  seen  after  this  operation  which 
was  done  on  account  of  the  first  indication  men- 
tioned. The  knife  is  entered  one  mm.  behind  the 
malleus  between  it  and  the  stapes  (Fig.  10),  the 
blade  being  pressed  upwards  upon  withdrawal. 

In  cases  where  anchylosis  of  the  stapes  exists, 
which  have  not  yielded  to  previous  treatment  and 
where  warranted  by  profound  deafness  and  exces 
sive  tinnitus,  the  entire  drum  with  the  ossicles 
has  been  excised,  or  in  other  cases  simply  the  os- 
sicles. '7 

Where  there  has  been  adhesion  of  the  mem- 
brane and  malleus  to  the  inner  wall  of  the  tym 
panum  Burnett  has  excised  the  malleus  and  the 
membrane  with  good  results  in  a  case  where  this 
condition  was  accompanied  by  distressing  tinni- 
tus and  vertigo.  u 

Trephining  the  mastoid,  although  practiced  in 
previous  years  for  this  disease,  is  of  course  unwar- 
rantable. '■' 

The  tinnitus  and  vertigo  accompanying  this  af- 
fection is  not  always  due  to  this  disease  alone. 
The  deafness  may  also  be  greatly  heightened  by 
affections  of  other  parts  of  the  auditory  apparatus, 
as  for  instance,  disease  of  the  labyrinth,  of  the 
nerve  or  even  of  the  brain  center.  These  struc- 
tures are  invariably  affected  after  the  disease 
has  existed  a  length  of  time.  The  nerve  and 
labyrinthine  structures  atrophy  from  disuse.10 

The  treatment  of  the  tinnitus  and  vertigo 
should  be  pursued  on  general  principles  and  all 
sources  of  irritation  should  if  possible  be  re- 
moved. Bromides  may  be  exhibited,  the  effect 
being  heightened  by  the  addition  of  Tr.  Cannabis 


15  Clinical  Lecture.  Prof.  Politzi 

16  Cholewa  of  Berlin  and  Kessel  of  Prague,  Archives  of  Otology. 
April- Julj 

»"  Pohtzer,  Lehrbuch,  p.  262. 

1  Charles  II.  Burnett.  "Permanently  Good  Results  ol  Ex- 
cision nf  the  M.  T.  and  Malleus  in  a  Caseof  Chonic  Aural  Vertigo 
etc..''  Transact.  Aim  t  - 

•     *9  Roosa.  'Diseases  nf  the  E 


Indicae.  '"  Morphine  may  be  given  when  noises 
are  paroxysmal. 

No  other  sedatives  have  been  found  useful. 
Counter- irritation  by  a  blister  behind  the  ear  will 
be  occasionally  of  avail.  Quinine  has  also  been 
recommended  in  small  doses.   (Gowers). 

The  nose  and  pharynx,  although  usually  in 
better  condition  than  in  that  which  obtains  in  the 
purely  catarrhal  form  of  inflammation,  generally 
need  attention,  and  the  disease  may  not  be  deem- 
ed cured  until  these  parts  are  in  good  order.  I 
would  especially  refer  to  the  removal  of  hyper- 
trophied  lingual  or  pharyngeal  tonsils. 

Of  course  constitutional  treatment  is  here,  as 
well  as  in  other  special  affections,  of  prime  im- 
portance. As  is  recommended  by  Sexton52  it  has 
been  my  practice  to  administer  minute  doses  of 
mercury  for  lengthened  periods.  The  exhibition 
of  strychnine  is  at  times  of  value  but  upon  its 
discontinuance  the  acuteuess  of  hearing  is  again 
diminished.  The  disease  is  essentially  a  local 
complaint,  beiug  due  to  a  combination  of  causes, 
arising  as  a  rule  from  diseased  conditions  of  the 
11:1-11  pharynx.  After  it  has  existed  for  a  length 
of  time  a  change  of  climate  does  but  little  good 
except  in  the  way  of  prophylaxis  from  colds. 

The  treatment  through  the  catheter  try  medi- 
cinal vapors,  especially  the  vapor  of  camphor  and 
iodine,  combined  with  the  use  of  Politzer's  method 
of  inflation,  seems  to  afford  the  most  relief,  and 
should  be  first  tried.  Some  cases  are  helped  by 
the  fluid  injections  and  in  others  a  mixed  treat- 
ment must  be  pursued.  Of  the  operations  advo- 
cated those  of  tenotomy  and  of  division  of  the  pos- 
terior fold  prove  the  most  useful.  Operative 
treatment  is,  in  the  majority  of  instances,  only  a 
last  resort. 

'  '.rand  Ave. 


VOICE  IN  FEMALE  SINGERS  AFFECTED 

BY  GYNECOLOGICAL  DISORDERS. 

BY  CARL  H    VON  KLEIN,  A.M.,  M.D.. 

OF    DAYTON,    O. 

I  am  requested  by  a  well  known  ovariotomist 
to  state  my  observation  of  the  voices  of  female 
singers  when  affected  by  gynecological  disorders, 
hence  the  following  is  a  brief  statement  of  my 
observation. 

The  most  difficult  cases  the  laryngologist  has 
to  contend  with  are  diseases  of  the  throat  caused 
by  disturbance  of  the  ovaries.  It  is  a  common 
thing  to  meet  with  cases  of  acute  inflammation  of 
the  tonsils,  larynx,  pharynx  aud  fauces  in  females 
during  their  menstrual  period.  I  have  observed 
the  voice  in  many  professional  choir  singers  who 
have   applied  to    me   for   treatment   during   the 


:.  Lehrbuch,  p.  47s.   Weher-Liel.   "Leber  das  AVesen  und 
die  Heilbarkeit  der  haufigsten  Form  progressive  Schwerh 
Berlin 

sease  ol  the  Nervous  System 

- 


552 


MEDICAL  PROGRESS. 


[April  18, 


menstrual  period,  defective  in  gravity,  force,  and 
timbre,  producing  in  many  cases  a  husky  sound, 
as  of  a  low,  masculine  order. 

A  laryngologist  of  acute  hearing  who  will  train 
his  ear  to  the  recognition  of  sounds  and  acquaint 
himself  with  a  known  voice,  can  detect  a  menstru 


casionally  there  was  slight  diarrhoea,  which 
ceased  of  itself.  In  some  cases  smarting  in  pass- 
ing water  was  complained  of,  and  one  patient 
said  he  noticed  blood  in  his  urine  after  an  injec- 
tion of  4  decimilligrams.  The  following  were 
the  results  of  the  treatment   (which  was  in  no 


ate  nine  times  out  of  ten.     It  is  a  known  fact  that  j  iustarice   supplemented    by    any    other):     After 
all  prima  donnas  try  to  avoid  engagements  dur-  J  three   or    four    injections    the    voice    improved 


ing  their  expected  period.  It  is  a  recognized  fact 
from  time  immemorial  that  extirpation  of  the  tes- 
ticles will  greatly  change  the  voice  in  males. 
Unto  this  day  the  operation  is  practiced  in  some 
parts  of  the  civilized  world. 

The  finest  male  chorus  I  ever  heard  was  by  a 
band  of  eunuchs  at  the  Alexandre  Nefsky  Church 
at  St.  Petersburg,  Russia,  who  were  prepared  for 
that  purpose.  Born  eunuchs,  or  hermaphrodites, 
generally  have  voices  of  feminine  order,  but  do 
not  make  good  singers  on  account  of  their  slug- 
gishness and  want  of  animal  propensities.  It  is 
said  in  order  to  make  a  good  singer  one  must  be 
in  love.  It  is  undisputable  that  impediment  in 
the  male  organs  influences  the  male  voice,  so,  too, 
impediment  in  female  organs  influences  the  fe- 
male voice. 

In  many  cases  of  ovarian  disturbance,  enlarge- 
ment and  hypertrophy  of  the  tonsils  and  of  the  soft 
palate  are  observed,  hence  the  laryngologist  often- 
times can  accomplish  but  very  little  without  the 
assistance  of  a  competent  gynecologist. 


MEDICAL    PROGRESS. 


Therapeutics  and  Pharmacology. 

Cantharidinate  of  Potash  in  Tubercu 
LOSiS.— At  the  meeting  of  the  Berlin  Medica 
Society,   on  February  25,   after  Professor  Oscar  j  laryngitis,  and  was  treated  by  Liebreich's  method. 


steadily,  till  hoarseness  almost  entirely  disap- 
peared. The  patients  felt  much  better.  The 
bacilli,  however,  showed  no  change.  In  the 
chest  the  physical  signs  cleared  up,  and  even 
disappeared  in  some  cases  ;  the  expectoration  be- 
came smaller  in  quantity,  more  mucus  and  less 
frequent ;  cough  subsided,  and  in  4  cases  ceased 
altogether ;  night  sweats  diminished,  and  in 
some  cases  disappeared.  In  one  case  hectic  fever 
ceased  after  the  fourth  injection,  but  this  result 
was  unique.  In  tuberculous  disease  of  the 
tongue  the  granulations  became  flatter  and  paler, 
and  the  ulcers  became  cleaner  and  began  to  heal, 
as  is  seen  in  syphilitic  affections  under  the  use  of 
iodide  of  potassium.  In  one  patient,  who  was 
almost  voiceless  and  who  was  the  subject  of 
tuberculous  ulceration  of  the  larynx,  after  nine 
injections  the  ulcer  had  disappeared,  and  after 
three  more  the  only  abnormality  in  the  larynx 
was  a  scarcely  visible  infiltration  of  the  left  vocal 
cord,  whilst  the  physical  signs  in  the  chest  had 
entirely  cleared  up.  Another  patient  with  catar- 
rhal ulcers  in  the  larynx  was  cured  after  ten  in- 
jections; in  three  others  suffering  from  similar 
conditions  the  infiltration  and  redness  of  the  cords 
began  to  diminish  as  soon  as  the  injections  were 
commenced.  Dr.  G.  Guttmann  related  the  case 
of  a  patient  whom  he  had  been  treating  for 
typical  trachoma  in  the  right,  and  recent  granu- 
lation   of   the    left,    eye.      The    man   developed 


Liebreich  had  presented  his  communication  on 
his  new  remedy  for  tuberculosis,  reports  on  cases 
treated  by  the  method  were  submitted  by  Drs. 
Paul  Heymann  and  G.  Guttmann,  and  Pro- 
fessor B.  Fraenkel  (Berlin  klin.  Wochenschr., 
March  2,  1891).  Dr.  Paul  Heymann  has  used 
cantharidinate  of  potash  in  27  cases,  in  10  of 
which  the  treatment  had  only  just  been  begun  at 
the  date  of  the  report.  Of  the  remaining  17,  1 1 
were  suffering  from  tuberculous  lesions  of  the 
larynx  of  a  more  or  less  serious  nature.  In  all 
these  cases  the  lungs  were  also  affected,  and  in 
all  except  one  there  were  bacilli  in  the  sputum. 
They  were  all  treated  at  the  Poliklinik  as  out- 
patients, and  made  no  change  in  their  ordinary 
mode  of  life.  The  dose  injected  was  from  1  to 
4  decimilligrams  :  only  once  did  the  injection 
cause  redness,  but  never  suppuration.     The  ii 


When  Guttmann  saw  him  again  there  was  no 
trace  of  inflammation  in  the  left  eye,  while  there 
was  only  a  trifling  swelling  in  the  right.  Pro- 
fessor Fraenkel  said  he  had  treated  15  patients 
suffering  from  laryngeal  tuberculosis  by  the  new 
method  ;  5  of  these  he  presented  to  the  Society. 
Under  the  treatment  the  redness  and  infiltration 
of  the  cords  had  steadily  diminished,  pain  in 
swallowing  had  disappeared,  cedenia  of  the  epi- 
glottis and  ary- epiglottic  folds  had  subsided, 
while  ulcers  had  gradually  become  smaller,  and 
in  some  places  had  entirely  healed.  In  one  pa- 
tient there  was  no  longer  any  trace  of  ulceration. 
In  the  cases  in  which  the  voice  had  been  lost, 
it  had  been  restored.  In  one  patient  Dr.  Fraenkel 
had  noticed  the  appearance  of  submiliary  nodules 
which  became  yellow,  broke  down,  and  finally 
disappeared,  leaving  a  scar  in   their  place.     In 


jections  were,  as  a  rule,  given  in  the  back,  but  in  j  another  patient  there  was  at  the  date  of  the  re- 
two  cases  the  patients  were  so  thin  that  the  nates  i  port  a  serious  exudation  at  the  level  of  the 
were  chosen.  Sometimes  the  injections  were  I  larynx,  a  fact  which  seemed  to  him  to  confirm 
followed    by    headache   and    giddiness,    and    oc- 1  Liebreich's  explanation  of  the  mode  of  action  of 


t89i.] 


MEDICAL  PROGRESS. 


553 


his  remedy.  When  this  patient  coughed  he 
brought  up  serous  fluid  from  his  larynx.  The 
pain  of  the  injection  lasts  some  time,  and  in  one 
case  there  was  some  difficulty  in  micturition  after 
an  injection  of  I  decirnilligrarn.  Fraenkel  thinks 
he  has  noticed  a  slight  diminution  in  the  number 
of  bacilli,  and  the  microbes  seemed  to  have  lost 
their  reaction  to  coloring  matters  ;  they  had  to 
be  kept  in  the  staining  solution  for  twenty  four 
hours  before  they  were  sufficiently  stained.  The 
rapid  improvement  seen  in  patients  submitted  to 
the  treatment  was  due  to  a  direct  action  of  the 
remedy  on  the  bacilli.  None  of  the  cases  could 
be  said  to  be  cured,  but  Fraenkel  thinks  that  the 
mu^t  brilliant  results  may  be  hoped  for  from  the 
method. — British  Medical  Journal. 

S.VLOL    IN    THE   TREATMENT    OF    DISEASES  OF 

the  Urinary  Passages. — The  drug  has  been 
recommended  in  the  treatment  of  diseases  of  the 
urinary  passages  by  Lejune,  Neucki,  Dreyfus  and 
Sahli,  in  place  of  the  balsams.  De  Smet  of 
the  hospital  St.  Pierre  of  Brussels  {La  Clinique), 
has  treated  forty-seven  patients  with  salol. 
Three  of  these  patients  presented  arthritis  with 
urethritis,  the  others  were  simple  cases  of  ure- 
thritis, simple  gonorrhceal  cystitis  with  or  with- 
out urethritis.  A  cure  was  noted  in  two  of  the 
cases  with  joint  complications.  Salol  produced 
excellent  effects  but  did  not  cause  much  change 
in  the  urethritis,  when  associated  with  injections 
it  seemed  to  shorten  the  malady.  It  renders  the 
urine  antiseptic,  as  he  was  always  able  to  find 
free  salicylic  acid  in  the  urine.  The  patients 
ordinarily  take  the  drug  in  quite  large  doses 
without  any  special  derangement  of  the  stomach 
or  appetite.  The  dose  should  range  from  three 
to  five  grams  daily. 

Medicine. 

Suspension  in  the  Treatment  of  Nervous 
Diseases.— Rault  {Le  Progres  A/edieale,  Feb. 
28,  1 891)  contributes  a  critical  review  of  the  liter- 
ature of  this  subject.  He  has  constructed  a  table 
of  reported  cases,  in  which  the  results  in  210  are 
given.  Of  these  162  were  improved,  and  48  unim- 
proved. Notwithstanding  the  contradictory  opin- 
ions that  have  been  emitted  by  high  authority  the 
method  seems  destined  to  win  a  place  in  the  ac- 
cepted methods  of  treating  certain  nervous  dis- 
eases. It  is  probable  that  further  observations  will 
limit  its  application  to  cases  more  likely  to  be 
benefited;  its  too  indiscriminate  use  may  bring  a 
really  good  method  into  disfavor. 

Injections  of  Dog's  Serum  in  Tubercu- 
losis.— Hericourt,  Langlois  and  Saint-Hil- 
AIRE  {Gazette  Medicale  de  Paris,  Feb.  7  and  14, 
1 891)  have  presented  to  the  Societe  de  Biologie 
the  results  obtained  by  them  with  injections  of 
dog's  serum  in  the  treatment  of  tuberculosis.  The 
first  case,  by  M.  Hericourt,  was  one  of  well  ad- 


vanced pulmonary  tuberculosis,  with  caseous 
pneumonia  and  cavities  in  both  apices.  On  De- 
cember 6th  last  the  patient  received  one  cubic 
centimetre  of  dog's  serum  which  the  writer  calls 
"hemocyne,"  as  being  a  short  and  convenient 
term.  After  receiving  19  cubic  centimetres  there 
was  a  marked  improvement  in  the  general  and 
local  conditions,  the  cough  lessened,  expectora- 
tion diminished,  and  a  gain  of  eight  pounds  was 
noted  in  weight, 

Langlois  describes  a  case  with  cavities  and 
abundant  expectoration  that  was  markedly  im- 
proved by  four  injections  extending  over  a  period 
of  ten  days.  The  cough  and  bronchial  secretion 
lessened  and  the  patient  gained  two  pounds  in 
weight. 

The  case  of  Saint- Hilaire  was  one  presenting 
marked  pulmonary  involvement  with  invasion  of 
the  larynx,  night-sweats,  hectic,  etc.  Seven  in- 
jections were  given  extending  over  a  period  of 
nineteen  days,  the  quantity  of  each  injection  vary- 
ing from  1  to  3  ccm  There  was  appreciable  in- 
crease in  the  patient's  strength,  the  night  sweats 
disappeared,  the  laryngeal  symptoms  improved, 
and  there  was  a  gain  of  six  pounds  in  weight. 

A  second  was  in  the  early  stage  with  rough 
crepitant  rales  at  the  apex,  some  consolidation 
with  involvement  of  the  larynx.  After  eight  in- 
jections the  physical  signs  disappeared  and  the 
laryngeal  symptoms  improved.  In  this  last  case 
the  sputum  was  examined  and  found  to  contain 
abundant  bacilli.  The  writer  does  not  say 
whether  they  were  looked  for  after  the  treatment 
began. 

The  injection  of  hemocyne  does  not  cause  any 
or  but  slight  local  reaction  and  no  general  dis- 
turbance of  the  system.  The  first  case  mentioned 
by  Saint-Hilaire  had  proved  refractory  to  other 
treatment,  such  as  creosote,  etc. 

Suryre  ry. 

Test  of  Complete  Chloroform  Narcosis. — 
Guelliot  (Journal  de  Midecine  de  Paris)  claims 
that  the  absence  of  the  cremasteric  reflex,  is  one 
of  the  best  and  readiest  means  of  determining 
complete  chloroform  narcosis.  The  quickness 
and  force  with  which  the  reaction  is  produced  is 
some  index  of  the  degree  of  narcosis.  The  point 
seems  to  be  one  well  worthy  of  consideration  by 
the  practical  surgeon. 

Obstetrics  ami  Diseases  of  Women. 

Partial  Inversion  of  the  Uterus  from 
Trifling  Causes. — Dr.  S.  Remv  {Archives  de 
Tocol.  et  de  Gynec,  February,  1891),  describes 
two  cases  of  inversion,  the  one  from  slight  force 
in  extracting  the  placenta,  the  second  from  a 
more  passive  cause.  A  woman,  aged  32,  aborted 
early  in  her  first  pregnancy.  Hypogastric  pains 
followed,  and  she  soon  became  pregnant  again. 
Labor  occurred  at  term  :  it  was  rather  lingering, 
but  was  left  to  nature.     Ten   minutes  after  the 


554 


MEDICAL  PROGRESS. 


[April  18 


birth  of  a  rather  heavy  female  child,  the  midwife 
placed  her  hand  on  the  fundus  and  pulled  gently 
on  the  cord ;  the  placenta  came  away.  Then  the  I 
midwife  found  that  the  uterus  could  no  longer  be 
felt  above  the  pubes.  A  large  tumor  filled  the 
vagina.  Dr.  Remy  was  summoned,  and  came  a 
few  minutes  after  the  accident.  The  patient  felt 
queer,  but  there  was  no  shock  and  little  haemor- 
rhage.  He  could  feel  apart  of  the  uterus,  deeply 
cupped,  above  the  pubes.  By  steadying  this  part 
with  one  hand  and  pressing  with  the  back  of  the 
fingers  with  the  other  on  the  vaginal  tumor,  he 
succeeded  in  reducing  the  inversion,  which  did 
not  recur.  Inertia  or  weakness  of  the  muscular 
tissue  at  the  placental  site  had  caused  failure  of 
retraction  when  the  placenta  separated,  and  in- 
tra-abdominal pressure  forced  that  part  of  the 
uterus  downwards  into  the  space  left  by  the  re- 
treating placenta.  In  uterine  inertia  clots  caused 
by  haemorrhage  no  doubt  check  the  tendency  to 
inversion  in  many  cases.  In  the  second  case  the 
patient  was  an  anaemic  young  lady.  Several 
floodings  followed  her  first  labor.  At  the  end  of 
a  month,  after  free  dosing  with  ergotine,  very  se- 
vere haemorrhage  took  place.  The  abdomen  was 
flat,  the  uterus  could  not  be  felt  above  the  pubes. 
The  os  was  patulous  and  blocked  by  a  soft  pre- 
senting body  covered  with  fetid  blood.  Careful 
bimanual  palpation  proved  that  there  was  partial 
inversion  with  retained  fragments  of  placenta. 
The  inverted  surface  was  dressed  with  antisep- 
tics. Two  plugs  of  wool,  covered  with  iodoform 
gauze,  were  placed  against  it  to  control  the  haem- 
orrhage. This  dressing  was  renewed  daily.  Two 
days  later  two  pieces  of  placental  tissue  came 
away.  No  more  bleeding  occurred.  On  the  sev- 
enth day  the  patient  was  much  better,  the  cervix 
was  closed,  the  inversion  had  reduced  itself.  Four- 
teen months  later  the  patient  was  in  stronger  health 
than  she  had  ever  enjoyed  before  in  her  life.  Leu- 
corrhcea,  constant  down  to  the  end  of  the  preg- 
nancy, had  ceased  altogether.  The  period  was 
regular  but  very  scanty.  The  retained  placental 
fragments  had  caused  great  congestion  of  the  re- 
gion of  the  uterus  to  wThich  they  were  attached. 
.  Hence  there  was  softening  of  that  part  of  the 
uterine  wall,  the  contractions  causing  it  to  be 
gradually  drawn  downwards.  Such  is  Dr.  Remy's 
explanation. — B>  itisli  Medical  Journal. 

II>  ui<'ii«'. 

Disinfecting  Power  of  Sulphur  Fumiga- 
tions.— One  of  our  prominent  surgeons  once 
told  the  writer  that  the  only  value  of  sulphur 
fumigations  was  to  destroy  such  unfortunate 
ntativesofcimex  lectularius  as  came  within 
:  its  influence.  Notwithstanding  this  pes- 
simistic view,  many  physicians  rely  upon  sulphur 
fumigations,  and  in  main'  of  our  hospitals  it  still 
forms  one  of  the    ip  ceremonials  at  the 

altar  of  antisepsis.     Undoubtedly   much   of  the 


disfavor  that  has  met  this  method  of  late  years 
has  been  caused  by  experimental  work,  in  which 
the  bacillus  anthrax  has  been  the  test  organism 
employed.  The  researches  of  Thoinot  {Annates 
de  V Institute  Pasteur}  show  that  while  the  spore 
forming  bacilli,  anthrax,  malignant  oedema,  etc., 
resist  the  bacilli  of  tuberculosis,  glanders,  typhoid, 
cholera,  and  diphtheria  are  destroyed  by  the 
action  of  the  sulphur.  The  writer  thinks  that 
absolute  security  is  assured  if  60  grams  are  burned 
to  each  cubic  meter  of  space  with  the  room  care- 
fully sealed. 

Bacteriology. 

Koch's  Treatment:  Experiments  on  Cat- 
tle.— The  experiments  recorded  in  the  British 
Medical  Journal  of  January  24th  afford  subject 
matter  for  very  careful  consideration.  In  three 
cews  in  which  tuberculosis  was  undoubtedly 
piessnt,  as  determined  by  physical  examination 
and  by  the  presence  of  bacilli  in  the  bronchial 
mucus  and  in  the  milk  and  by  the  changes  in  the 
lympathic  glands,  "reaction"  was  obtained  in 
proportion  to  the  amount  of  fluid  injected,  whilst 
in  healthy  control  animals  no  rise  of  temperature 
was  noticed.  It  is  evident  from  this  that  what- 
ever may  be  the  ultimate  result  of  treatment  by- 
Koch's  fluid  we  have  in  it  an  agent  that  may 
prove  of  the  greatest  value  in  helping  to  form  a 
diagnosis  of  tuberculous  disease  in  cattle,  and  we 
have  here  an  indication  of  the  lines  on  which,  for 
a  time  at  any  rate,  much  of  the  experimentation 
with  Koch's  lymph  must  be  carried  on.  Some 
physicians  and  surgeons  have  been  so  unfortunate 
in  the  selection  of  their  cases  that  they  have 
already  resolved  that  until  more  is  known  of  the 
action  of  the  remedy  on  the  human  subject  they 
will  be  very  chary  indeed  of  using  it  as  a  thera- 
peutic agent.  The  veterinary  surgeons,  however, 
will  scarcely  be  deterred  by  such  considerations. 
It  is  often  an  exceedingly  difficult  matter  to  de- 
termine whether  a  cow  is  tuberculous  or  not,  and 
if  these  experiments  are  to  be  relied  on,  all  that 
is  necessary  to  obtain  confirmation  of  the  diagno- 
sis is  to  inject  some  of  the  fluid.  We  can  scarcely 
look  forward  to  this  being  used  as  a  method  of 
treatment  for  the  disease  in  cattle  (except  in  the 
case  of  pedigree  animals),  but  in  the  hands  of 
veterinary  surgeons  it  will  prove  an  instrument 
of  precision  of  the  very  highest  value.  It  will 
enable  them  to  state  in  all  doubtful  cases  what 
animals  should  be  condemned  as  tuberculous  and 
which  should  be  allowed  to  remain  in  the  cow- 
house without  danger  of  infection  to  the  other 
cattle.  These  experiments  certainly  open  up  a 
most  important  and  fruitful  branch  of  research  to 
the  veterinary  profession.  And  it  will  at  once 
suggest  itself  that  the  consideration  of  this  ques- 
tion might  with  advantage  occupy  the  attention 
of  the  Royal  Commission  on  Tuberculosis  now 
sitting. 


189I-] 


EDITORIAL. 


555 


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Address 

Journal  OF  THE    AMERICAN   MEDICAL  ASSOCIATION, 
No.  68  Wabash  Ave., 

Chicago.  Illinois. 
All  members  of  the  Association  should  send  their  Annual  Dues 
to  the  Treasurer,  Richard  J.  Dunglison,  M.D.,  Lock  Box  1274,  Phila- 
delphia, Pa. 


London  Office,  57  and  59  Ludgate  Hill. 


SATURDAY,  APRIL   18,    1891. 


NOTICE  TO  THE  BOARD  OF  TRUSTEES. 

Office  of  the  Board  of  Trustees  of  the! 
American  Medical  Association, 

Little  Rock,  Ark.,  April  5,  1891.  J 

The  Annual  Meeting  of  the  Board  of  Trustees 
of  the  American  Medical  Association  will  be  con- 
vened in  the  parlors  of  the  Arlington  Hotel,  at 
Washington,  D.  C,  on  Saturday,  May  2,  at  10 
o'clock  a.m.  P.  O.  Hooper, 

Jno.  B.  Hamilton,  Prest.  of  the  Board. 

Secretary. 


THE  TURKISH  BATH  AS  A   REMEDY. 

For  over  a  thousand  years  the  hot  air,  or  Turk- 
ish bath,  has  been  used  both  as  a  luxury  and 
therapeutic  measure.  Thirty  years  ago  Mr.  Ur- 
quhart,  Dr.  Erasmus  Wilson,  of  London,  and 
others,  described  and  urged  the  bath  as  a  reme- 
dy for  many  diseases;  and  since  that  time  it  has 
been  slowly  coming  into  practical  use,  and  is  now 
recognized  as  a  remedy  of  positive  value. 

While  it  has  been  very  largely  in  the  hands  of 
irregulars,  who  have  claimed  the  most  extrava- 
gant therapeutic  powers,  whenever  it  has  been 
used  in  scientific  medicine  it  has  been  retained 
and  adopted  as  invaluable.  In  Europe  many 
government  asylums  and  hospitals  have  the  most 
elaborate  baths,  and  sanitariums  and  private  hos- 
pitals for  chronic  diseases  depend  on  the  bath  as 
a  remedy.  In  this  country  much  indifference 
prevails.  Except  in  a  few  sanitariums  and  pub- 
lic baths  in  the  large  cities,  it  is  almost  unknown; 
yet  writers  and  men  of  practical  experience  are 
always  warm  defenders  of  its  powers  and  virtues. 


The  number  of  persons  who  use  the  bath  as  a 
preventive  of  disease  among  the  laity  are  in- 
creasing constantly.  The  scientific  reason  is  no 
doubt  to  be  found  in  the  fact  that  copious  per- 
spiration in  the  high,  dry  temperature  of  the  hot 
room  is  a  powerful  eliminator  of  effete  and  poison- 
ous matters  from  the  system.  The  excess've 
stimulation  of  the  cutaneous  circulation  is  also  of 
great  value  in  relieving  obstructions  and  con- 
gestions in  both  the  glandular  and  circulatory 
systems.  The  marked  change  and  relief  which 
follows  the  use  of  this  form  of  bath  is  due  to  the 
profound  diversion  and  equalization  of  the  fluids 
of  the  body. 

The  massage  which  follows  the  excessive  forced 
perspiration  is  a  muscular  tonic  of  equal  value. 
Experience  proves  most  conclusively  that  free, 
artificially  produced  perspiration  is  not  followed 
by  exhaustion,  and  also  that  the  three  stages  of 
the  bath — the  sweating,  shampooing  and  the 
final  cooling,  are  all  true  physiological  processes. 
Thus  the  combined  impetus  of  the  shampooing 
and  the  heat  stimulates  powerfully  the  nervous, 
vascular  and  absorbent  systems.  To  supply  the 
waste  of  fluids  eliminated  by  the  skin,  the  cutane- 
ous system  of  blood-vessels  draw  upon  the  in- 
ternal trunks,  thoracic,  abdominal  and  cerebral. 
The  exalted  condition  of  the  circulating,  nervous 
and  glandular  systems,  induced  by  friction,  aug- 
ments the  vital  force,  restores  the  balance  in  ob- 
structive disorders,  and  promotes  secretion  and 
absorption.  With  each  muscle,  nerve  and  blood- 
vessel, thus  stimulated,  the  results  are  greater 
tone  and  vigor. 

The  class  of  cases  from  which  the  most  benefit 
will  be  obtained  by  the  baths  are  the  rheumatics, 
the  neuralgics,  and  those  suffering  from  malaria, 
blood  poisoning  and  general  plethora.  Another 
large  class  who  are  frequently  under  the  physi- 
cian's care,  are  those  who  are  over-fed,  and  who 
do  not  exercise  properly,  or  are  underworked. 

Often  they  are  brain  and  office  workers  who  do 
not  go  out  in  the  open  air  much,  and  rarely  have 
any  muscular  exercise,  but  eat  heartily.  Another 
class  of  cases  become  exhausted  and  suffer  from 
mental  anxiety,  overstraining  the  nervous  sys- 
tem ;  continuous  care,  worry  and  excitement 
bringing  on  all  forms  of  functional  nerve  disturb- 
ances. 

All  these  cases  are  chiefly  prominent  in  defec- 
tive secretions  and  irregularities   of  the  bowels 


556 


THE  INCREASE  OF  OUR  MEMBERSHIP. 


[April  18 


and  skin.  Digestive  disturbances  and  temporary 
congestions  of  all  sorts  come  and  go.  The  heart 
is  irregular  in  its  action;  murmurs  and  sounds 
are  heard,  which,  although  formidable  at  the 
time,  disappear  in  a  few  days.  Both  albumen 
and  sugar  appear  in  the  urine,  and  disappear  in 
a  few  days.  Often  these  cases  furnish  symptoms 
at  different  times  of  very  serious  diseases,  and 
the  recent  graduate,  or  the  unthinking  specialists, 
are  surprised  to  find  their  most  positive  diagnosis 
fail,  while  some  elderly  practitioner,  supposed  to 
be  far  behind  the  front  line  of  exact  science,  will 
step  in  with  a  strong  cathartic,  and,  perhaps,  an 
old  fashioned  hemlock  sweat,  and  all  the  grave 
symptoms  pass  away.  These  cases  go  from  one 
physician  to  another,  and  are  the  object  of  much 
anxiety  and  professional  unpleasantness  both  in 
and  out  of  the  regular  profession.  They  are  sup- 
posed to  be  incurable  and  finally  go  to  a  sanitar- 
ium where  the  Turkish  bath  is  the  chief  remedy, 
or  to  some  city  public  bath,  and  rapidly  recover; 
frequently  giving  credit  for  the  cure  to  some  pro- 
prietary medicine,  which  was  accidentally  used  at 
the  last  moment.  If  the  family  physician  had 
understood  the  value  of  the  bath,  and  prescribed 
it,  his  reputation  would  have  been  unimpaired. 

Where  the  baths  are  not  accessible  away  from 
large  cities,  sanitariums  must  supply  the  want. 
Country  and  village  physicians  who  have  large 
houses  could,  at  a  trifling  expense,  have  a  bath, 
which  would  not  only  bring  substantial  returns 
financially,  but  would  increase  their  power,  and 
enable  them  to  cure  many  cases  now  thought  in- 
curable. There  can  be  no  doubt  that  the  Turk- 
ish bath  will  be  largely  used  in  every  town  and 
village  of  the  country  by  physicians  in  the  near 
future.  Simply  because  it  is  a  great  natural 
means  of  restoration,  and  along  the  line  of  physi- 
ological processes. 

The  Turkish  bath  belongs  to  rational  therapeu- 
tics and  should  be  rescued  from  the  realm  of 
quackery  and  studied  and  used  on  scientific  prin- 
ciples. It  is  also  evident  that  hot  air,  high  heat, 
water  and  massage  are  most  powerful  agents  in 
disease,  and  should  not  be  confined  to  hospitals 
and  large  establishments,  but  should  be  made 
available  for  every  physician,  in  some  form  or 
other.  In  Europe  the  Turkish  bath  is  attracting 
increased  attention,  and  a  number  of  excellent 
papers  on  the  value  of  the  baths  in  certain  dis- 
eases have  appeared. 


Practically  the  Turkish  bath  has  been  used  in 
principle,  in  the  various  sweats  common  in 
domestic  medicine.  If  to  this  had  been  added 
expert  rubbing  and  shampooing,  and  careful  after 
treatment,  the  result  would  have  made  this  means 
very  prominent  as  a  method  of  treatment. 

The  public  seem  to  more  fully  appreciate  the 
use  of  the  bath  than  medical  men,  and  this  is  a 
most  serious  mistake.  They  should  be  the  ad- 
visers and  authority  on  this  remedy.  They  should 
know  what  class  of  cases  would  receive  the 
most  benefit  from  these  baths,  and  advise 
them.  The  baths  in  large  cities  should  be  under 
the  care  of  scientific  men,  who  would  give  a  thor- 
ough study  of  the  cases  and  the  effects  of  the 
baths.  In  smaller  towns  the  family  physician 
could  do  this.  If  this  was  done  the  present  con- 
fusion of  theory  and  experience  would  give  way 
to  established  facts,  and  the  Turkish  bath  as  a 
remedy  would  take  its  place  among  the  great 
therapeutic  agents,  of  priceless  value  in  the  pre- 
vention and  cure  of  disease. 


THE  INCREASE  OF  OUR  MEMBERSHIP. 
The  permanent  enlargement  of  our  Association 
must  depend  upon  the  value  of  the  returns  which 
it  will  be  able  to  make  to  its  individual  members. 
It  must  be  made  able  to  so  compensate  men,  that 
once  they  become  members  they  will  remain  such, 
else,  when  convenient,  they  will  maintain  their 
membership,  but  when  at  all  inconvenient  they 
will  forfeit  it.  This  has  been  the  history  of  the 
Association  for  the  last  forty  years.  It  is  at  this 
point,  it  is  to  be  hoped,  that  The  Journal  is 
coming  to  our  help,  and  will  hold  many  to  a 
permanency  which  might  not  be  otherwise  se- 
cured. When  it  comes  to  be  an  everywhere  ac- 
knowledged fact  that  The  Journal  is  worth,  to 
the  masses  of  the  profession,  much  more  than  its 
cost,  there  will  be  a  two-fold  reason  for  one's 
maintaining  his  membership.  Just  in  proportion 
as  men  come  to  appreciate  the  advantages  to  be 
derived  from  attendance  at  its  annual  meetings, 
and  to  value  its  accredited  organ  as  a  medical 
journal,  to  that  extent  may  we  look  for  perma- 
nency in  the  membership  of  the  Association.  That 
The  Journal  is  thus  asserting  for  itself  a  place 
is  evident  from  the  fact,  that  nearly  one  thousand 
men  are  receiving  it  upon  subscription,  although 
they  have  no  relation  whatever  with  the  Associa- 


i89i.] 


IMPORTANT  QUESTIONS  ANSWERED. 


tion.  There  is  no  reason  why  its  value  may  not 
be  more  and  more  developed  until  The  Journal 
shall  become  the  great  centralizing  and  unifying 
power  in  our  medical  profession. 

The  permanent  attractive  influence,  which  more 
than  all  others  shall  draw  men  year  by  year  to 
our  annual  meetings,  must  centre  in  our  Sections. 
We  shall  stand  or  fall,  as  these  shall  or  shall  not 
give  to  the  profession  such  returns  as  shall  well 
repay,  for  the  labor  and  expense  incident  to  at- 
tendance at  the  annual  meetings.  It  is  absolutely 
essential  to  our  permanent  growth  that  the  Sec- 
tions be  made  as  nearly  perfect  as  possible  in 
their  organization,  and  that  they  command  the 
best  of  talent,  not  only  to  interest  those  present 
but,  through  the  medium  of  The  Journal,  to 
profit  the  thousands  who  must  necessarily  be  ab- 
sent. Give  to  the  medical  profession  of  America 
value  received  and  they  will  come  to  be  enrolled 
in  the  membership  just  as  fast  as  they  come  to 
know  the  worth  of  the  Association  to  medical  men. 

The  next  question  to  be  considered  is  that  of 
more  fully  acquainting  physicians  with  the  Asso- 
ciation and  bringing  them  into  such  relation,  that 
they  shall  rightly  appreciate  its  value  It  need 
not  be  a  matter  of  material  expense,  according  to 
the  present  rule,  for  any  regular  physician  to  be- 
come a  member  of  the  American  Medical  Associ- 
ation by  application.  It  is  a  first  essential  that  he 
be  an  accredited  member  of  some  local  medical 
organization  which  is  in  affiliation  with  the  As- 
sociation. It  is  competent  for  the  president  and 
secretary  of  that  local  society  to  so  certify,  and 
with  their  certificate  of  his  standing  he  has  sim- 
ply to  inclose  with  his  application  for  membership 
a  fee  of  five  dollars,  and  he  will  be  duly  enrolled 
and  will  receive  The  Journal  without  additional 
expense,  so  long  as  he  shall  continue  in  good 
standing  with  his  local  society-  and  shall  pay  his 
annual  dues.  Thus  it  is  possible  for  physicians 
all  over  this  broad  land  to  become  members  by 
application,  and  to  receive  The  Journal  regu- 
larly, upon  the  payment  of  this  small  fee,  with- 
out ever  incurring  the  expense,  unless  they  shall 
so  choose,  of  an  attendance  upon  an  annual  meet- 
ing: and  yet  we  are  confident  that  the  influence 
of  The  Journal  will  bring  the  great  majority  of 
these  into  active  membership  as  time  goes  on. 

Again,  we  trust  the  time  is  not  far  distant  when 
in  some  desirable  way  there  may  be  such  a  unison 
of  the  State  Societies  with  the  Association  that 


each  member  of  a  State  Society,  by  reason  of  that 
relation,  will  also  be  a  member  of  our  National 
Organization.  We  believe  this  to  be  feasible;  we 
believe  it  to  be  eminently  desirable.  We  hope, 
therefore,  that  the  resolution  offered  at  the  last 
session  by  Dr.  Culbertson.  of  Cincinnati,  and 
which  will  be  called  from  the  table  at  the  coming 
meeting,  will  receive,  on  the  part  of  our  members, 
the  serious  consideration  which  we  believe  the 
subject  deserves,  and  that  it  will  be  referred  to  an 
able  committee  who  shall  give  it  full  consideration, 
the  results  to  be  embodied  and  submitted,  in  the 
form  of  a  report,  to  the  Association  at  a  subse- 
quent session. 

Is  it  too  much  to  anticipate  the  time  when  this 
National  Association  shall  represent  the  entire 
membership  of  all  our  State  organizations?  We 
are  building  for  the  future  needs  of  a  mighty 
Empire.     Let  us  build  largely,  wisely  and  well. 

It  is  surely  safe  for  the  Association  to  refer  this 
subject  and  that  of  the  development  of  the  Sec- 
tions, to  which  we  alluded  last  week,  to  an  able 
and  representative  committee,  who  shall  consider 
most  carefully  the  subjects  so  referred,  and  with 
instructions  to  submit  such  report  at  the  next  an- 
nual meeting. 


QUESTIONS     OF     IMPORTANCE    TO    THE    MEM- 
BERS ANSWERED. 

We  have  received  the  following  letter  from  Dr. 
Fred.  J.  Parkhurst,  of  Danvers,  111.: 

Editor: — There  is  a  great  amount  of  ignorance 
prevailing  in  our  section  of  the  country  in  regard  to  the 
present  Editorial  management  of  The  Journal.  This 
will  be  a  subject  of  great  importance  to  the  members  of 
the  Association  when  they  come  to  prepare  their  ballots 
on  the  question  of  moving  The  Journal  to  Washington. 
By  answering  the  following  questions  I  am  sure  you  will 
confer  a  favor  on  a  large  number  of  the  members  of  the 
Association  who  are  at  present  ignorant  of  the  facts: 

i.  Who  is  the  present  Editor  of  The  Journal  and  how 
long  has  he  occupied  the  position  ? 

2.  Has  Dr.  N.  S.  Dans  at  present  any  official  connec- 
tion, either  editorial  or  otherwise,  with  the  management 
of  The  Journax  ? 

3.  What  is  the  date  of  Dr.  Davis'  resignation  as  Editor- 
in-Chief  of  The  Journal  ? 

4.  Was  Dr.  John  B.  Hamilton  Editor  of  The  Journal 
at  one  time  ?     If  so,  for  how 

Fred.  J.  Parkhurst.  M.D. 

Dr.  N.  S.  Davis  was  Editor-in-Chief  of  The 
Journal  until  Jan.  1,  1SS9.  Dr.  John  B.  Ham- 
ilton,   Sursreon- General  of   the  Marine-Hospital 


558 


EDITORIAL  NOTES. 


[April  18, 


Service,  was  Editor-in-Chief,  from  January  i,  to 
February  i,  1889.  Dr.  N.  S.  Davis,  at  the  re- 
quest of  the  Board  of  Trustees  conducted  The 
Journal  from  February  1,  1889,  to  May  1,  1889. 
The  Secretary  of  the  Board  of  Trustees,  Dr. 
John  H.  Hollister,  was  then  made  Supervising 
Editor,  and  has  acted  in  that  capacity  up  to  the 
present  date. 


editorial  notes. 

Treatment  of  Tuberculosis  with  Vaccine 
Lymph. — As  a  further  indication  of  the  stimulus 
given  to  the  experimental  medical  world  by 
Koch  it  may  be  mentioned  that  a  New  York  phy- 
sician, Dr.  J.  Hilgard  Tyndale,  has  announced, 
before  the  New  York  County  Medical  Association, 
March  16,  1891,  the  results  obtained  upon  twenty- 
three  patients  from  the  hypodermic  use  of  bovine 
vaccine  lymph.  Dr.  Tyndale  divides  his  tuber- 
culous cases  into  four  classes,  viz.:  1.  Those  in 
whom  the  general  condition  is  good,  the  local 
lesion  limited  and  just  beginning  to  be  active.  2. 
Those  in  whom  the  general  condition  is  below 
par  and  the  local  lesion  not  great.  3.  Those  in 
whom  constitutional  impairment  is  grave  and  the 
local  destruction  advanced  and  disposed  to  be 
active.  4.  Those  in  whom  the  local  lesion  is  ex- 
tensive but  not  active,  and  the  general  condition 
reasonably  good. 

The  writer  believed  that  investigators  were  on 
the  right  track  in  seeking  to  overcome  this  dis 
ease  by  hypodermic  inoculations  of  animal  virus 
or  chemical  substances  of  marked  toxical  effect. 
In  using  the  vaccine  lymph  he  had  made  one  in- 
jection every  six  or  seven  days.  There  was  no 
active  reaction.  Benefit  had  shown  upon  all 
the  symptoms,  both  subjective  and  objective. 

Other  measures  of  relief,  such  as  tonics,  lung 
gymnastics,  etc.,  were  not  discarded,  but  were 
withheld  until  benefit  from  the  lymph  was  well 
established. 

The  author  believed  that  more  than  one  ani- 
mal lymph,  or  chemical  intoxicant,  would  be 
found  to  have  an  abortive  influence  upon  the 
tuberculous  process,  and  that  his  experiments 
thus  far  with  vaccine  lymph  demonstrated  the 
correctness  of  the  assertion.  Nine  of  the  patients 
upon  whom  this  method  of  treatment  had  been 
tried,  were  presented  before  the  meeting. 

In  this  connection  we  are  led  to  say  that 
scarcely    a  day   passes  without  new  knowledge 


coming  to  us  of  patient  and  conscientious  re- 
search along  this  new  path,  and  the  world  at 
large  is  waiting  to  place  the  very  highest  honors 
upon  those  results  which  break  the  force  and  de- 
stroy the  power,  not  alone  of  this  mighty  disease 
— tuberculosis,  but  those  of  like  nature  as  well. 
No  one  can  fight,  in  this  manner,  with  success, 
against  disease  as  a  unit,  but  in  specific  direc- 
tions, and  with  that  stern  singleness  of  purpose 
which  so  marks  our  discoverers,  the  possibilities 
of  future  medicine  are  scarcely  to  be  measured. 

Influenza  in  New  York  City. — The  med- 
ical press  now  chronicles  the  occurrence  of  influ- 
enza in  the  metropolis,  though  in  not  as  severe 
or  general  a  form  as  maintained  a  year  ago. 
Chicago's  Health  Commissioner  is  quoted  as 
claiming  that  it  is  not  so  much  the  influenza 
which  that  city  has  of  late  been  afflicted  with,  as 
a  lack  of  the  disease- opposing  virtue  of  bright, 
clear  sunshine.  The  month  of  March  was  par- 
ticularly gloomy  and  cloudy,  and  the  uncleansed 
atmosphere  therefrom  tended  to  rapidly  pre- 
cipitate untoward  conditions  in  existing  diseases 
of  the  respiratory  system,  as  well  as  to  predispose 
the  onset  of  such  affections. 

Appendicitis. — This  subject  is  still  a  favorite 
one  among  surgeons,  really  occupying  quite  the 
first  position  in  the  great  field  of  surgical  discus- 
sion. The  appendix  is  but  a  small  portion  of 
the  human  anatomy,  and  yet  it  appears  that  it 
has  a  wonderful  significance  which  in  the  past 
did  not  receive  that  degree  of  attention  it,  in  the 
light  of  our  present  knowledge,  merited.  In  a 
very  short  time  a  great  advance  has  been  made 
by  surgeons  along  this  line.  In  the  last  number 
of  the  Annals  of  Surgery  almost  sixty  pages  are 
devoted  to  this  subject  of  appendicitis,  consisting 
of  five  papers  by  as  many  authorities  in  this 
branch. 

Parkin  Prize,  Royal  College  of  Physi- 
cians of  Edinburgh. — The  late  Dr.  John  Par- 
kin, Fellow  of  the  Royal  College  of  Physicians, 
Edinburgh,  left  a  bequest  of  one  hundred  pounds 
sterling  for  the  best  essay,  "On  the  Curative 
Effects  of  Carbonic  Acid  Gas  or  other  forms  of 
Carbon  in  Cholera,  the  different  Forms  of  Fever, 
and  other  Diseases."  The  prize  is  open  to  com- 
petitors of  all  nations.  Essays  intended  for  com- 
petition must  be  written  in  the  English  language, 
and  must  be  received  by  the  Secretary,  Dr.  G.  A. 


-S9I-] 


MEDICAL  ITEMS. 


559 


Gibson,  not  later  than  December  31st,  1892. 
Each  essay  must  bear  a  motto,  and  be  accompa- 
nied by  a  sealed  envelope  bearing  the  same  motto 
outside  and  the  author's  name  inside.  The  suc- 
cessful candidate  must  publish  his  essay  at  his 
own  expense,  and  present  a  printed  copy  of  it  to 
the  College  within  three  months  after  the  adjudi- 
cation of  the  prize. 

New  York  Academy  of  Medicine. — The 
property  of  this  great  and  representative  medical 
body  is  now  valued  at  S4oo,ooo,  with  a  debt  of 
only  $30,000. 

Colorado  For  Consumptives. — Notwith- 
standing the  possibilities  which  have  been  looked 
for,  and  hoped  for,  from  tuberculin,  there  con- 
tinues even  an  increased  interest  in  the  beneficial 
influences  of  the  Colorado  climate.  Much  infor- 
mation is  advanced  to  show  that  factors  undenia- 
bly dwell  in  that  region  which  exert  a  wholesome, 
and  many  times  curative,  effect  upon  wasting 
diseases,  notably  phthisis. 

The  Ophthalmoscope  in  Nervous  Dis- 
eases.— Dr.  G.  Sterling  Ryerson,  Professor  of 
Ophthalmology  in  Trinity  Medical  College,  Can- 
ada, arrives  at  the  following  conclusions  under 
the  above  heading:  1.  That  diseases  of  the  brain 
and  spinal  cord  are  frequently  associated  with 
ocular  disturbances.  2.  That  serious  eye  trouble 
may  be  present  without  subjective  symptoms. 
3.  That  eye  troubles  often  precede  and  give  warn- 
ing of  impending  nerve  disease.  4.  That  dis- 
ease of  the  optic  nerve  and  retina  are  of  great 
diagnostic  value  in  nervous  diseases.  5.  That  it 
is  the  duty  of  the  physician  to  examine  the  eye 
and  its  muscles  in  all  cases  of  nervous  diseases. 

The  Result  of  Medical  Legislation  in 
New  York. — In  the  State  of  New  York  there  is 
now  a  compulsory  three  years  course  of  study, 
prefaced  by  a  compulsory  preliminary  examina- 
tion, and  ending  by  an  independent  examination 
for  a  license  to  practice  before  a  Board  of  Medical 
Examiners  appointed  by  the  State. 

A  Full  Meeting  Anticipated. — By  reason 
of  its  location  the  next  meeting  will  be  largely 
attended  by  gentlemen  resident  in  the  East.  By 
no  means  let  the  West,  the  South-west,  or  the 
South,  fail  of  their  full  quota  of  delegates  and 
members.  We  anticipate  that  the  coming  meet- 
ing will  be  the  largest  one  in  the  history  of  the 


Association.  Questions  of  unusual  interest  are 
to  be  considered  and  it  is  important  that  every 
portion  of  the  country  should  be  fully  repre- 
sented.    What  we  say  to  one  we  say  to  all,  go! 

Small- Pox  in  St.  Louis. — A  slight  epidemic 
of  this  disease  is  reported  to  have  been  in  progress 
in  St.  Louis  during  last  month.  Every  precau- 
tion was  taken,  however,  and  a  prompt  limitation 
was  enforced.  As  so  often  occurs,  the  exact 
origin  cannot  be  clearly  ascertained. 

Congress  of  American  Physicians  and 
Surgeons. — The  meetings  of  the  Congress  of 
American  Physicians  and  Surgeons  will  be  held 
in  Washington  from  3  to  6  p.m.,  September  22d 
to  25th,  1891.  William  Pepper,  of  Philadelphia, 
is  Chairman  of  the  Executive  Committee. 

The  National  Association  of  Railway 
Surgeons. — The  Annual  Meeting  of  this  Asso- 
ciation will  convene  at  Buffalo,  April  30,  and  be 
in  session  for  four  days.  This  important  organi- 
zation is  assuming  immense  proportions,  and  the 
meeting  at  Buffalo  bids  fair  to  be  one  of  excep- 
tional interest.  The  date  of  the  meeting  is  so  ar- 
ranged that  large  numbers  of  its  members  are 
preparing  to  go  from  there  to  the  meeting  of 
the  American  Medical  Association  at  Washing- 
ton. Why  not  go  bodily,  and  give  the  Associa- 
tion such  an  accession  as  it  never  received  before. 
First  to  Buffalo,  gentlemen  ;  then  on  to  Wash- 
ington. 

The  Tenth  Congress  for  Internal 
Medicine  was  held  in  Wiesbaden  from  April  6 
to  9.  Among  the  more  important  subjects  dis- 
cussed was  Koch's  method  of  treating  tubercu- 
losis of  the  lungs  and  other  internal  organs. 

Dr.  Eugen  Jendrassik,  professor  of  physiology 
in  the  University  of  Buda-pest,  is  dead.  He  was 
widely  known  as  a  contributor  of  scientific  mon- 
ographs. He  invented  a  myograph  of  practical 
utility  and  also  describes  a  method  of  reinforcing 
the  reflexes  of  the  lower  limbs,  that  is  generally 
known  by  his  name. 

MEDICAL  ITEMS. 

A  Parisian  Medical  Library. — The  library 
of  the  Paris  Ecole  de  Medecine,  which  contains 
some  40,000  volumes,  will  shortly  be  transferred 
to  its  new  quarters  overlooking  the  Boulevard 
Saint  Germain.  The  new  building  contains  a 
large  room  with  places  for  150  readers,  and  other 


560 


MEDICAL  ITEMS. 


[April  18 


smaller  rooms  where  anatomical  models,  etc.,  will 
be  open  for  the  use  of  students.  A  special  section 
will  be  reserved  for  a  collection  of  autographs  of 
the  Deans  of  the  Faculty  from  1324  to  1789. 

A  Large  Brain. — Wilson  (Edin.  Med.  Jour,,  ! 
January,  1891)  reports  the  removal  of  a  brain 
which  weighed  64  ozs.,  in  the  postmortem  room 
of  the  Royal  Edinburgh  Asylum,  from  a  man  75 
years  of  age,  5  feet  10  inches  in  height.  The 
circumference  of  the  head  was  24  inches.  The 
brain  was  very  anaemic,  contained  hardly  any 
fluid,  and  was  put  on  the  scales  immediately  after 
removal.  It  was  described  as  "  large  vertically, 
well- shaped  all  over,  with  convolutions  if  any- 
thing larger  than  normal,  and  sulci  wide  over  the 
vertex,  except  the  occipital." 

The  man's  intelligence  seemed  to  have  been 
above  the  level  required  for  his  work  as  a  sawyer, 
but  was  never  of  a  high  grade. — N.  Y.  Medical 
Journal. 

The  New  Polyclinic. — The  handsome  new 
building  of  the  Philadelphia  Polyclinic,  on  Lom- 
bard Street,  west  of  Eighteenth,  was  formally 
opened  April  2  by  Lieutenant-Governor  Watres 
as  a  charitable  institution  of  the  State.  In  mak- 
ing the  formal  transfer  of  the  building  to  the 
trustees,  Dr.  Thomas  S.  K.  Morton,  chairman  of 
the  Building  Committee,  said:  "The  importance 
of  this  occasion  to  the  city  and  State  cannot  be 
overestimated,  for  it  is  the  establishment  of  a 
unique  medical  school,  and  all  the  undergraduate 
medical  colleges  send  their  representatives  with 
greetings  to  the  successful  launching  of  this  in- 
stitution." 

Dr.  SiEBERThas  resigned  the  editorship  of  the 
New  Yorker Deutschen  Medicinischen  Monatssckrift, 
and  Dr.  Heppenheimer  has  been  appointed  to  fill 
the  vacancy. 

The  Fattest  Man  in  the  World  is  said,  by 
the  St.  Petersburger  Med.  Wochensch.,  to  live  in 
Danville,  U.  S.  A.  His  name  is  Mr.  John  Han- 
sen Craig,  is  35  years  of  age,  and  weighs  907 
American  or  925  Russian  pounds. 

Hernia  among  Russian  Army  Recruits. — 
It  is  stated  that  in  Russia  among  the  Jewish  youth, 
who  are  subject  to  conscription  for  military  duty, 
they  have  a  secret  plan  for  the  self-production  of 
inguinal  hernia,  in  order  to  bring  about  rejection 
by  the  medical    examiners.     An  instrument  re- 


sembling the  ordinary  glove-stretcher  is  used  as 
a  means  for  the  gradual  dilatation  of  the  inguinal 
canal. 

Analysis  of  "  Antikamnia." — Professor  C. 
M.  Ford,  of  Denver,  has  reported  that  the  above 
is  a  mechanical  mixture  of  acetanilid  85  parts  and 
carbonate  of  soda  15  parts.  The  presence  of  the 
latter  will  explain  the  effervescence  complained  of 
by  several  pharmacists  when  acid  preparations, 
such  as  wine  of  pepsin,  have  been  added  to  the 
antikamnia. 

Two  Chinese  physicians,  Drs.  Chon-yuan-yeh 
and  Cheng-bhi  piao,  have  been  sent  by  their  Gov- 
ernment to  Berlin,  for  the  purpose  of  studying  the 
results  obtained  in  the  use  of  Koch's  lymph. 

Photographing  in  Colors. — The  recent  an- 
nouncement, which  is  producing  such  interest  in 
the  general  scientific  field,  may  well  receive  the 
attention  of  the  great  medical  body.  The  value 
of  this  discovery  will  be  felt,  in  no  small  degree, 
by  those  engaged  in  medical  research;  and  to  the 
surgeon,  pathologist,  microscopist,  physiologist, 
et  a/.,  the  force  of  demonstrations  will  be  in- 
creased by  the  application  of  this  means. 

Medical  and  Surgical  College  of  New 
Jersey. — The  above  was  the  title  assumed  by  a 
so  called  institution  of  medical  learning  which 
had  its  local  habitation  on  Montgomery  street,  in 
Jersey  City.  The  last  edition  of  "Polk's  Med- 
ical Directory"  contains  a  card  setting  forth  some 
of  its  claims  and  a  list  of  its  faculty  in  1890.  The 
said  college  no  longer  exists.  The  New  Jersey 
State  Board  of  Medical  Examiners  has  caused  the 
introduction  of  a  bill  repealing  the  charter  of  the 
school  before  the  legislature  now  in  session,  and 
the  bill  has  been  passed  and  signed  by  the  Gov- 
ernor. Dr.  W.  P.  Watson,  Secretary  of  the  State 
Board,  has  been  influential  in  bringing  about  the 
desired  result,  and  he  with  other  members  of  that 
Board  are  to  be  congratulated  upon  their  success 
in  ridding  their  State  of  a  concern  having  strung 
points  of  resemblance  to  one  of  the  old-time  Bu- 
chanan diploma  mills. 

A  Proper  Recognition. — Dr.  Edith  Pechy- 
Phipson,  appointed  a  member  of  the  senate  of 
Bombay  university  for  her  public  spirit  in  speak- 
ing against  child  marriage  in  India,  was  one  of 
tin  first  women  to  take  the  medical  course  of 
Edinburgh  university,  which  she  entered  in  1869. 


i89i.] 


TOPICS  OF  THE  WEEK. 


56i 


TOPICS  OF  THE  WEEK. 


HYPNI 

An  interesting  article  appears  in  the  British  Medical 
Journal  of  March  28,  from  the  pen  of  Mr.  Krnest  Hart. 
He  sums  up  ill  the  following  words  his  general  conclu- 
sions :  To  sum  up  then  in  a  few  words  the  actual  state  of 
iIk  question,  an  impartial  observe r  might,  in  my  opinion, 
conclude  that  hypnotism  is  a  pathological  modification 
of  the  nervous  system,  which  always  indicates  that  tin- 
subject  belongs  to  a  neuropathic  class.  The  complete 
and  typical  form  of  hypnotism  described  by  Charcot  is 
rare.  Suggestion  plays  a  considerable  part  in  hypnotic 
phenomena,  but  there  are  somatic  phenomena  which  are 
independent  of  it.  Hypnotism  may  frequently  be  dan- 
gerous, and  very  rarely  useful.  It  may  be  the  cause  of 
crime,  or  of  mental  disorder;  it  can  really  cure  no  disease 
not  more  easily  curable  by  simpler  and  less  dangerous 
methods.  A  considerable  number  of  facts  attributed  to 
it  which  have  most  impressed  the  public  imagination, 
such  as  the  actions  of  medicines  at  a  distance,  the  so 
called  telepathic  communications  or  communications 
made  without  speech,  and  the  clairvoyant  phenomena 
sometimes  described,  are  mere  errors  of  experiment 
arising  from  insufficient  precautions  and  a  too  vivid  im- 
agination. Precisely  those  phenomena  which  have  been 
most  publicly  talked  about  and  excited  most  interest  in 
"psychical  circles"  so-called,  are  the  least  real.  The 
hopes  which  the  therapeutic  hypnotist  aroused  have  not 
been  realized,  and  any  expectations  of  producing  by  hyp- 
notic methods  any  desirable  moral  or  mental  effect  rest 
upon  a  totally  inadequate  basis  of  fact,  and  are  far  from 
being  promising. 


tion  of  a  few  milligrams  of  the  protein  of  bacillus 
pyocyaneus  caused  an  inflammation  which,  though  non- 
infectious and  free  from  bacilli,  and  almost  deserving  the 
name  of  chemical  inflammation,  presented  all  the  clini- 
cal symptoms  of  erysipelas  with  lymphangitis;  the  course 
of  this  inflammation  is,  however,  more  rapid  and  more  be- 
nign, and  the  general  state  of  health  is  little  disturbed. 
The  author  considers  that  the  proteins  can  exercise  their 
activity  onlv  when  they  have  been  secreted  from  the  bac- 
terial cell,  and  that  this  secretion  takes  place  exclusively 
when  the  cell  is  in  "  involution"— that  is,  dying,  or  at 
any  rate  morbidly  affected.  This  also  explains  why  in 
anthrax  of  rodents,  when  virulent  bacilli  are  indefinitely 
increased  in  the  blood  and  never  die,  there  is  no  sign  of 
inflammatory  leucocytosis,  while  a  hypodermic  injection 
of  very  weak  or  even  completely  sterilized  anthrax  cul- 
ture has  a  strong  pyogenic  effect  in  the  same  rodents. 
Of  seven  different  bacilli  which  the  author  has  been  able 
to  experiment  upon  the  proteins  of  the  typhus  bacillus 
seem  particularly  effective.  It  is  very  easy  to  obtain  the 
protein  of  Friedlander's  pneumonia  bacillus,  and  still 
more  so  that  of  the  bacillus  pyocyaneus.  The  protein 
has  the  same  chemical  reaction  as  all  albuminoids,  and 
most  nearly  approaches  in  that  respect  vegetable  caseins. 
The  author  subsequently  experimented  on  vegetable 
caseins,  especially  on  the  gluten  casein  of  wheat,  and  the 
result  was  remarkably  similar  to  that  of  experiments  with 
bacilli. — Lancet. 


BACTERIA  PROTEINS" AXD  THEIR  RELATION  TO   INFLAM- 
MATION AND  PTJS  I'i  IRMA.TION. 

Dr.  II.  Buchner  gave  last  year  three  lectures  on  the  re- 
lation of  bacteria  proteins  to  the  inflammatory  and  pyo- 
genic process,  in  which  he  said  that  it  is  generally  sup- 
posed the  proximate  chemical  cause  of  inflammation  and 
formation  of  pus  is  the  presence  of  decomposing  sub- 
stances, the  chemical  produce  of  bacterial  cells;  but  that 
ptomaines  and  toxins,  and  even  toxalbumens,  are  pre- 
eminently nerve  poisons,  and  in  only  a  few  of  them,  as 
in  cadaverin  and  putrescin,  can  a  pyogenic  effect  be 
traced  as  well.  These  substances  do  not,  therefore,  ex- 
plain the  inflammatory  and  pyrexial  character  of  most 
infectious  processes,  including  suppuration,  especially  as 
Lange  and  Roemer  have  proved  by  their  experiments 
that  no  decomposing  substances  have  any  considerable 
affinity  for  leucocytes.  Substances  having  such  affinity, 
however,  do  exist,  according  to  the  author,  and  he 
has  already  referred  to  them  in  a  previous  publication. 
They  are  parts  of  the  bacillary  body,  that  is,  of  its  plas- 
ma— namely,  the  so-called  bacteria  proteins,  which  Xen- 
cki  had  already  studied  in  1SS0  without  imagining  their 
great  pathological  importance.  Dr.  Buchner  has  shown 
bv  his  experiments  that  bacteria  proteins  have  the  strong- 
est affinity  for  leucocytes,  and  that  in  man  they  also  have 
an  intensely  inflammatory  effect.     A  hypodermic  injec- 


DOCTORS  AND  POLITICS. 

It  is  not  generally  known,  says  the  San  Francisco 
Chioniclc,  that  Marat,  the  Revolutionist  dispatched  by- 
Charlotte  Corday,  was  a  physician,  and  that  he  had  a 
certain  success  in  treatiug  consumption.  It  is  recorded 
of  him  that  he  cured  a  titled  lady  of  this  disease  in  its  ad- 
vanced stages,  and  that  her  gratitude  to  him  knew  no 
bounds.  Unfortunately  he  was  enticed  into  politics  and 
prevented  from  pursuing  his  studies  further  in  a  direc- 
tion that  might  have  made  his  memory  revered  instead 
of  detested. 

For  some  reason  doctors  seem  to  drift  naturally  toward 
politics  and  radicalism,  perhaps  because  their  profession 
tends  to  render  them  skeptical.  In  Brazil  and  the  Ar- 
gentine Republic  they  have  shown  themselves  decidedly- 
ambitious.  The  celebrated  Dr.  Charcot  is  a  radical 
whose  principles  verge  on  the  revolutionary.  Clemen- 
ceau  gave  up  his  medical  practice  years  ago  to  devote 
himself  to  politics,  and  though  he  is  a  man  of  great  tal- 
ent and  a  brilliant  orator,  his  political  efforts  have  not 
contributed  to  his  personal  advancement  or  been  of  great 
benefit  to  his  country.  Besides  Clemenceau  there  are 
from  forty  to  fifty  physicians  in  the  French  Chamber  of 
Deputies. 


ASSOCIATION  OF  AMERICAN  PHYSICIANS  IN  BERLIN. 

There  has  been  formed  in  Berlin  an  association  under 
the  above  title.  Dr.  Judson  Dolland,  of  Philadelphia, 
was  elected  President:  Dr.  F.  Weber,  of  Milwaukee, 
Secretary;  Prof.  Miller,  of  Philadelphia,  Dr.  Amos,  of 
Iowa,  Dr.  H.  Douglas,  of  New  York,  together  with  the 
President  and  Secretary,  were  elected  as  a  Committee  on 


562 


TOPICS  OF  THE  WEEK. 


[April  18 


Constitution.  Dr.  H.  R.  Brooks,  of  New  York  City,  Dr. 
Louis  Frank,  of  Louisville,  Dr.  Crystal,  of  Baltimore,  Dr. 
Neal  Mitchell,  of  Florida,  Dr.  Marple,  of  New  York,  and 
Dr.  Kennedy,  of  Montreal,  were  appointed  a  Committee 
on  Information  to  New-Comers  and  on  Organization  of 
Special  Private  Courses. 

The  principal  objects  of  this  association  are  :  1.  The 
arrangement  of  medical  work  and  the  formation  of 
special  private  courses,  so  that  any  desired  instruction 
may  henceforth  be  obtainable  at  this  University.  2. 
The  giving  of  advice  to  new-comers  regarding  instruc- 
tion, lodging,  books,  instruments,  etc.  3.  The  reading 
and  discussion  of  papers  of  general  interest,  exhibition  of 
patients  and  demonstration  of  specimens  in  all  lines  of 
work  taken  up  by  members.  4.  The  furthering  of  mu- 
tual ends  by  a  more  extended  acquaintance  of  the  phy- 
sicians here. 

We  doubt  not  that  this  organization  of  American  phy- 
sicians sojourning  for  a  period  in  Berlin  will  be  found  to 
be  helpful  as  well  as  pleasant. 


THE  NEW  PATHOLOGICAL  DRAMA. 

The  modern  novel  has  accustomed  us  to  the  interweav- 
ing of  physiology  and  pathology  with  romance.  The 
introduction  of  these  sciences  into  the  drama  is  quite  a 
new  and  wholly  unwelcome  departure.  A  week  or  two 
ago,  at  the  Royalty  Theatre,  the  elect  who  hail  Heinrich 
Ibsen,  the  Norwegian  dramatist,  as  the  new  Shakspeare, 
contrived,  by  means  of  a  "subscription  representation," 
to  elude  the  authority  of  the  Lord  Chamberlain,  and  pro- 
duced to  a  crowded  house  Ibsen's  much  talked-of  play, 
Ghosts.  The  theme  is  heredity.  After  an  instructive 
discussion  between  his  mother  and  a  clergyman  on"  free 
sexual  relations,  Oswald  Alving,  the  hero,  is  overheard  in 
an  adjoining  room  making  advances  to  her  pretty  servant 
in  a  manner  more  suggestive  than  decorous.  The  maid 
in  question  turns  out  to  be  his  own  half-sister,  and  Os- 
wald at  once  proceeds  to  discuss  the  rectitude  of  that  re- 
lationship countenanced  by  the  Pharaohs,  but  is  happily 
cut  short  by  brain  disease,  the  result  of  inherited  syphi- 
lis, in  a  manner  which  may  be  deemed  natural  by  the 
playwright,  but  which  is  wholly  unknown  to  the  physi 
cian.  The  question  of  the  desirability  of  shortening  his 
days  by  poison  is  under  consideration  when  the  curtain 
falls.  To  take  all  the  disintegrating  views  of  viewy  peo- 
ple, to  make  them  become  self-conscious  in  plain  John 
and  Betsey,  and  operative  on  their  lives,  to  adorn  this 
"  psychological  study  "  with  a  quasi-scientific  exactitude, 
as  absurd  and  untrue  as  it  is  pretentious,  is  the  rdle  of  the 
new  great  realist.  There  is  some  stagecraft,  but  the  dra- 
matic pamphleteer  is  much  more  apparent  than  the  artist. 
It  is  sadly  to  be  feared  that  the  sanity  of  true  genius  has 
not  appeared  in  this  latest  fad  of  staging  grotesque  pa- 
thology and  ethical  Nihilism.  To  the  strict  scientist  such 
a  play  is  an  amusing  travesty;  to  the  moralist  it  is  por- 
tentously significant.  From  the  purely  literary  point  of 
view,  it  would  be  well  if  admirers  of  novel  genius  should 
adopt  Matthew  Arnold's  advice,  and  carry  about  with 
them  a  gem  or  two  of  the  true  masters  to  serve  as  touch- 
stones in  distinguishing  the  spurious  and  ephemeral  from 
the  enduring  and  truly  greal.— British  Medical  Journal. 


PATHOLOGY  OF  GRIEF. 

That  severe  mental  distress  or  fright  sometimes  pro- 
duces physical  disease,  and  occasionally  even  death,  is 
an  admitted  fact,  although  the  way  in  which  it  acts  has 
hitherto  been  but  little  studied.  In  order  in  some 
measure  to  supply  the  deficiency  in  our  knowledge  re- 
garding this  matter,  Dr.  G.  Bassi  has  recently  made  a 
number  of  observations  on  animals  which  apparently 
died  in  consequence  of  capture.  Birds,  moles,  and  a 
dog  which  had  succumbed  to  conditions  believed  by  Dr. 
Bassi  to  resemble  those  known  amongst  human  beings 
as  acute  nostalgia  and  "a  broken  heart  "  were  examined 
post-mortem.  Generally  there  was  hyperemia,  some- 
times associated  with  capillary  hemorrhages  of  the  ab- 
dominal organs,  more  especially  of  the  liver,  also  fatty 
and  granular  degeneration  of  their  elements,  and  some- 
times bile  was  found  in  the  stomach  with  or  without  a 
catarrhal  condition.  The  clinical  symptoms  were  at 
first  those  of  excitement,  especially  in  the  birds,  these 
being  followed  by  depression  and  persistent  anorexia. 
The  theory  suggested  by  Dr.  Bassi  is  that  the  nervous 
disturbance  interferes  with  the  due  nutrition  of  the  tis- 
sues in  such  a  way  as  to  give  rise  to  the  formation  of 
toxic  substances — probably  ptomaines — which  then  set 
up  acute  degeneration  of  the  parenchymatous  elements 
similar  to  that  which  occurs  in  consequence  of  the  action 
of  certain  poisonous  substances  such  as  phosphorus,  or 
to  that  met  with  in  some  infectious  diseases.  In  support 
of  this  view,  he  points  out  that  Schule  has  found  parenchy- 
matous degeneration  in  persons  dead  from  acute  de- 
lirium, and  that  Zenker  found  hsemorrhages  in  the  pan- 
creas in  persons  who  had  died  suddenly  ;  he  refers  also 
to  some  well-known  facts  concerning  negroes  in  a  state 
of  slavery  and  to  the  occasional  occurrence  of  jaundice 
after  fright.  He  hopes  that  these  hints  may  induce  med- 
ical officers  of  prisons  and  others  to  stud}-  both  clinically 
and  anatomically  this  by  no  means  uninteresting  or  un- 
important subject.  —  The  Lancet. 


BIOLOGICAL  ACTION  OF  IRON  AND  MANGANESE. 

Dr.  Fausto  Faggioli  has  published  in  a  recent  issue  of 
La  Riforma  Medica,  some  notes  of  a  research  upon  the 
physiological  behavior  of  iron  which  he  has  carried  out, 
with  Professor  Pellacani's  assistance,  in  the  Bologna 
laboratory  of  Forensic  Medicine.  From  these  it  would 
appear  that  iron  enjoys  the  property  of  setting  up  mitosis 
or  nuclear  change  and  cellular  increase,  especially  in 
cultures  of  unicellular  organisms  such  as  protococci. 
Under  some  circumstances  manganese  will  act  in  the 
same  way,  but  Dr.  Faggioli  was  unable  to  find  that  any 
other  metal  could  do  so. 


AMERICAN  DENTAL  ASSOCIATION. 

The  executive  committee  have  decided  on  Saratoga 
Springs  as  the  next  place  of  meeting  of  the  American 
Dental  Association,  commencing  first  Tuesday  in  August, 
1891.  It  is  hoped  by  the  committee  that  each  society 
will  send  delegates,  that  there  may  be  a  full  representa- 
tion from  all  parts  of  the  country.  J.  N.  Crouse,  2231 
Prairie  Ave.,  Chicago,  111.,  is  Chairman  of  the  Executive 
Committee. 


.89i.] 


PRACTICAL  NOTES. 


563 


PRACTICAL   NOTES 


PRESCRIPTION  OF  CHLOR»ALAMin. 

Galiana  recommends  the  following  prescription 
when  using  chloralamid  : 
K.     Chloralamid,  45  grains. 

Dilute  hydrochloric  acid,  5  drops. 

Distilled  water,  2  ounces. 

Syrup  of  raspberry,  2'2  drachms. 

One-half  of  this  amouut  may  be  given.  This 
may  be  divided  into  four  doses,  one  of  which  may 
be  given  every  four  hours.  For  rectal  injection 
he  recommends  : 

R.     Chloralamid,  30  grains. 

Dilute  hydrochloric  acid,  3  drops. 
Distilled  water,  3  ounces. 

Or  the  chloralamid  may  be  dissolved  in  an  infu- 
sion of  tea  to  which  should  be  added  a  consider- 
able quantity  of  sugar. — Medical  News. 


tion  by  increasing  its  fluid  element,  which  is  the 
principal  indication  in  the  expulsion  of  gall- 
stones. 

The  cholagogue  property  of  salicylate  of  soda 
was  made  known  by  Rutherford,  but  has  not  re- 
ceived much  attention;  with  the  additional  recom- 
mendation of  Prof.  See,  supported  by  his  vast 
clinical  experience,  the  remedy  should  be  con- 
sidered worthy  of  trial.  —  New  Remedies. 


;alicylate  of  mercury. 


For  hypodermic  injections  Yacher  uses  the  fol- 
lowing solution  : 

R.     Hydrarg.  chloridi  corrosiv.,  1  part. 
Sodii  salicylici,  2  parts. 
Aqua.- destil.,  100  parts.     Trj>. 

In  this  solution  each  cubic  centimeter  contains 
one  centigram  of  salicylate  of  mercury.  For  use 
by  the  mouth  a  1-1000  to  1-5000  solution  should 
be  used. — Deutsche  Med.    Wocli. 


pilocarpine  in  glaucoma. 

Drs.    Saint-Germain     and    Valude    [L' Union 
Med.)  recommend  the  following: 
R.     Pilocarpine,  4  ' :  grs. 
A<j.  destil  , 
"I"  ft.  collyrium. 

This  collyrium  is  employed  alone,  or  in  alter- 
nation with  a  solution  of  eserine,  in  glaucomatous 
conditions  of  children,  when  eserine  does  not 
agree  with  the  patient. —  The  Prescription . 


PRURITUS  HIEMALIS. 

Corlett  recommends  the  following  topical  ap- 
plications in  "winter  itch": 
R.     Resorcin,  3j. 

Glycerin.  3  ij. 

Aquae,  ad.  .5  iv.     nR. 
Sig.     Apply. 
R.     Menthol,  3  iijss. 

Glycerin,  5  ij. 

Aquse,  ad.  51  v.     HJJ. 
Sig.     Apply. 
R.     Ichthyol.  amnion,  sulph.,  3j.  to  iij. 

Glycerin,  jjij. 

Alcohol,  aa  q.  s.  ad.  ,3  iv. 

Aquae,  aa  q.  s.  ad.  .3  iv.     'iR. 
Sig.     Apply. 

— Boston  Med.  Journal. 


TREATMENT    OF    TINEA    TONSURANS. 

Simpson  {Med.  Analectic)  has  had  excellent 
success  with  the  following  treatment  for  ring- 
worm of  the  scalp  and  body  :  Cut  the  hair  short 
and  wash  the  scalp  well  with  tincture  of  green 
soap,  and  apply  the  following  solution  with  a 
camel's  hair  brush  : 

R.     Hydrargyri  chlorid.  corrosiv.,  gr.  j. 
Collodii.  ,3j.     nj;. 

This  treatment  may  be  recommended  for  three 
reasons  : 

1.  The  corrosive  sublimate  destroys  the  fungi. 

2.  The  ether  of  the  collodion  penetrates  to  the 
root  of  the  hair,  conveying  the  corrosive  subli- 
mate to  the  seat  of  the  disease. 

3.  The  film  formed  bj'  the  collodion  shuts  off 
the  supply  of  oxygen  to  the  fungi  and  thus  helps 
to  destroy  them. — Pittsburgh  Medical  Review. 


RINGWORM. 


SALICYLATE    OF    SODA    AS    A    CHOLAGOGUE. 

Prof.  Germain  See  in  an  article  on  hepatic 
colic,  published  in  the  London  Lancet,  calls  special 
attention  to  the  use  of  salicylate  of  soda,  which 
he  has  found  to  be  the  most  efficient  of  all  chola- 
gogues  in  promoting  the  expulsion  of  gall-stones. 
The  well-known  cholagogues  were  found  worth- 
less in  this  ailment,  for  they  stimulate  the  biliary 
secretion  by  increasing  the  solid  elements,  which 
is  not  desirable. 

Salicylate  of  soda  stimulates  the  biliary  seere- 


Ringworm  of  the  body  is  generally  very  amena- 
ble to  treatment,  judging  from  the  numerous 
domestic  remedies  which  act  so  successfully. 
Sometimes,  however,  an  obstinate  case  is  en- 
countered and  recourse  is  had  to  the  ph\siciau. 
In  such  cases  a  rapid  cure  is  desirable,  and  the 
application  of  the  following,  once  daily,  for  two 
or  three  consecutive  days,  will  generall}-  prove 
successful  : 

R.     Hydrarg.  bichloridi,  gr.  ij. 

Tinct.  benzoin  CO.,  5J.     nj. 
Paint  over  affected  parts. 

Care  should  be  exercised  not  to  paint  too  large 

a  surface,  as  the  above  mixture   is  toxic.      If  an 

excoriation  exists  it  should  not  be  applied,  as  it 

is  irritating  to  the  wounded  integument.- — Medical 

\  Chips. 


564 


SOCIETY  PROCEEDINGS. 


[April  18, 


SOCIETY   PROCEEDINGS. 

Gynecological  Society  of  Chicago. 

Regular  Meeting,  December  19th,  1890. 

The  President,  W.  W.  Jaggard,  M.D.,  in  the 
Chair. 

[Abstracted  for  The  Journal.] 
EXHIBITION    OF    SPECIMENS. 

a.  Polypoid  Myoma.  Dr.  C  T.  Parkes  pre- 
sented a  moderate-sized  tumor  removed  from  the 
vagina  of  a  patient  about  50  years  old.  Upon 
examination  the  pelvis  was  found  blocked  with  a 
tumor,  which  showed  signs  of  decomposition. 
There  was  no  history  of  the  discharge  of  the  tumor 
from  uterus  into  the  vagina,  and  no  history  of 
severe  bleeding.  On  further  examination  under 
anaesthetics  a  long  pedicle  was  found  attached  to 
anterior  uterine  wall.  Upon  severing  the  attach- 
ment the  mass  was  delivered. 

b.  PregnantUterus  with  Fibroid  Tumor.  Spec- 
imen presented  of  pregnant  fibroid  uterus  at  four- 
and  a-half  or  five  months.  At  time  of  operation 
mass  filled  the  abdomen  as  completely  as  preg-  ! 
nancy  at  full  term.  Saw  patient  after  she  had 
suffered  severely  for  two  weeks  with  pain,  high 
temperature,  considerable  peritonitis,  etc.,  indi 
eating  that  interference  was  necessary.  Preg- 
nancy had  been  diagnosed  previously.  Two  dis- 
tinct tumors  were  evident  on  palpation.  Exam- 
ination showed  pregnancy,  and  an  operation  was 
deemed  best,  which  was  done,  pedicle  being 
treated  by  extra  peritoneal  method.  Patient  re 
covered  entirely  in  four  weeks. 

Dr  Jaggard  inquired  the  nature  of  the 
first  tumor,  and  whether  it  was  thought  to  origi- 
nate in  uterus  or  vagina. 

Dr.  Parkes  said  it  was  diagnosed  before 
the  operation  as  a  submucous  fibroid  of  the  uterus. 
Pedicle  could  yet  be  felt  coming  out  of  cervix, 
and  at  time  of  operation  it  was  found  attached 
high  up  on  anterior  wall. 

TUBAL  PREGNANCY  WITH  TWO  OVA  IN  SAME  FAL- 
LOPIAN TUBE. 

Dr.  Christian  Fenger  offered  specimen  of 
tubal  pregnancy  in  second  month.  Rupture  of 
sac  caused  much  bleeding  in  peritoneal  cavity. 
Rupture  occurred  at  4  a.m.,  and  operation  was 
done  at  11  a.m.  Patient  was  almost  pulseless, 
and  had  all  signs  of  dangerous  haemorrhage.  It 
was  the  left  tube,  and  on  opening  abdomen  large 
clots  and  much  liquid  was  found.  Upon  explor- 
ing the  tubal  pregnancy  was  found  to  be  hanging 
out  of  ovum,  and  another  oval  body  was  also  dis 
covered.  Patient  made  a  good  recovery.  The 
principal  point  in  case  was  the  two  ova,  one  de- 
-.iH  rated,  both  in  same  tube.  Degenerated  ovum 
was  cystic,  one  and  one- quarter  by  one  inch  in 
diameter.     Second  ovum  was  ruptured  and  con- 


tained fcetus  attached  by  umbilical  cord  to  inside 
of  ovum.  The  cystic  ovum  was  on  uterine  side 
of  ruptured  one. 

YELAMENTCfUS  INSERTION  OF  THE  CORD. 

Dr.  A  H.  Foster  reported  case  of  a  woman, 
aged  26,  confined  in  October.  Tedious  and  pain- 
ful delivery;  considerable  haemorrhage  at  and  im- 
mediately following  accouchement ;  child  normal. 
Placenta  was  easily  expelled.  Cord  entered  mem- 
branes opposite  placenta,  and  dividing  and  spread- 
ing passed  to  one  margin  of  placenta,  where  it 
divided  into  still  more  branches  running  across 
its  surface.     One  large  vein  was  ruptured. 

HEMICEPHALUS    WITH    HYDRAMNION. 

Dr.  Foster  also  presented  the  following: — 
Patient  having  passed  through  a  number  of  con- 
finements became  depressed  and  melanchul}',  and 
was  found  to  have  sharp  anteflexion  with  cervical 
catarrh,  which  upon  correction  improved  her  con- 
dition, though  not  restoring  her  fully.  Preg- 
nancy was  advised  and  sought.  Upon  conceiving 
she  at  once  became  greatly  benefited.  Towards 
end  of  term  her  large  size  caused  discomfort  and 
some  anxiety.  At  time  of  ruptnre  of  membranes 
a  profuse  discharge  of  water  took  place,  and  a  few 
strong  pains  expelled  a  hemicephalus  dead  foetus 
of  about  seven  months.  Shoulders  presented. 
Patient  made  a  good  recovery,  and  is  in  better 
condition  than  for  two  years  previously. 

Dr.  W.  W.  Jaggard  remarked  that  the  cases 
were  of  interest.  The  hemicephalus  case  is  a 
typical  example  of  cranio  rhachischisis.  These 
creatures  are  not  viable,  and  commonly  present 
by  the  head.  The  second  specimen  is  most 
typical. 

LAPAROTOMY    FOR    EXTRA- UTERINE    PREGNANCY 

TWO  MONTHS  AFTER  DEATH  OF  FCETUS 

AT    TERM. 

Dr.  C.  T.  Parkes  presented  specimen  of  entire 
sac  and  foetus  removed  from  a  case  of  extra-uter- 
ine pregnancy  two  months  after  child's  death  at 
term.  When  removed  child  was  macerated,  and 
showed  evidence  of  'decomposition.  Sac  easily 
broke  down,  especially  at  upper  part.  A  portion 
of  sac  was  within  pelvis.  Thickness  of  sac  in 
places  was  remarkable;  at  some  points  it  could  be 
divided  into  several  layers.  The  uterus  was  car- 
ried to  left  side  and  out  of  pelvis,  where  it  could 
easily  be  felt  before  operation.  The  accidental 
rupture  of  upper,  decomposed  portion  of  sac  at 
time  of  operation  necessitated  its  entire  removal. 
Clinical  history  of  case  is  somewhat  as  follows: 
Age  j  1,  married,  no  children,  sterile  seven  years, 
last  normal  menstruation  June  20th,  1889.  In 
August  had  nausea  and  vomiting,  and  diagnosis 
.it  1  unliable  pregnancy  was  given.  In  October 
had  seven-  pain  and  haemorrhage.  Recovered, 
but  had  occasional  attacks  thereafter.  Abdomen 
enlarged  and  foetal  movements  were  detected.  On 


i89i.] 


SOCIETY  PROCEEDINGS. 


565 


March  1st,  and  for  several  days  after,  had  unusual 
pains  which  subsided,  and  an  examination  devel- 
oped death  of  foetus.  After  this,  and  until  last 
■week  in  April,  there  was  gradual  diminution  in 
size  of  abdomen,  and  apparent  improvement  in 
patient's  health.  At  this  time — last  week  in 
April — a  decided  change  came  on.  Severe  pains, 
fever,  rapid  pulse,  etc.,  evidences  of  septic  infec- 
tion. March  28th  decidual  membrane  was  passed 
entire.  On  examination  two  abdominal  enlarge- 
ments could  be  distinguished,  one  the  fcetal  tu- 
mor, and  the  other  the  enlarged  and  displaced 
uterus.  Previous  to  March  1st  the  fcetal  head 
could  readily  be  made  out  occupying  the  Douglas 
cul-de-sac,  but  after  that  date,  through  some 
change  in  the  position  of  the  foetus,  nothing  but 
fluctuation  could  be  felt.  Digital  examination 
per  rectum  permitted  the  fcetal  bones  to  be  plain- 
ly felt,  and  showed  but  very  little  tissue  between 
the  rectum  and  the  child.  In  summing  up  the 
diagnostic  points  in  this  case  we  have  :  1.  The 
ordinary  signs  and  symptoms  of  pregnancy.  2. 
Haemorrhage  at  irregular  intervals  during  the  en- 
tire period  of  pregnancy.  3.  Pain,  collapse  and 
haemorrhage  at  about  the  end  of  the  fourth  month. 
4.  Irregular  abdominal,  cramp-like  pains,  more 
severe  and  continuous  than  would  be  expected  in 
a  condition  of  normal  pregnancy.  5.  Death  of 
foetus  at  term,  followed  by  diminution  in  size  of 
abdominal  protuberance  and  of  breasts,  and  by 
cessation  of  lacteal  secretions.  6.  Irregularity  of 
the  abdominal  enlargement.  7.  Passage  of  de- 
cidual membrane.  8.  Position  of  os  uteri,  for- 
ward and  behind  symphysis,  and  obliteration  of 
cervix.  9.  Very  dilatable  os.  10.  Empty  uter- 
ine cavity.  1 1 .  Pressure  of  the  foetal  head  in  the 
cul-de-sac  of  Douglas. 

The  immediate  reason  for  operation  was  the 
evidences  of  general  septic  infection.  A  free  ab- 
dominal incision  was  made  and  tumor  exposed, 
which  was  of  a  dirty,  sphacelated  appearance, 
soft  and  easily  broken  down.  An  offensive,  thick 
fluid  discharged  upon  incising.  Child  was  at 
once  seen,  breach  upward,  and  was  easily  extrac- 
ted, but  in  so  doing  the  thin  upper  portion  of  sac 
was  broken,  allowing  small  intestines  to  protrude 
into  sac,  and  fluid  from  sac  to  get  into  abdominal 
cavity.  It  was  now  thought  best  to  remove  en- 
tire sac,  if  it  could  be  done.  Sac  was  free  all 
around,  and  down  as  far  as  brim  of  pelvis:  but 
this  cavity  was  entirely  filled  by  development  of 
sac.  Tumor  seemed  to  be  covered  by  the  peri- 
toneum, the  caecum  on  the  right  and  the  sigmoid 
flexure  on  the  left  were  intimately  adherent  to  its 
walls.  An  incision  was  made  through  covering 
posteriorly,  fingers  introduced  and  covering  peel- 
ed away  and  secured  in  sections  by  forceps.  At 
this  point  of  operation  darkness  supervened  from 
a  passing  storm,  and  nothing  could  be  seen  in  ab- 
dominal cavity,  being  compelled  to  depend  alone 
on  the  sense  of  touch.     This  misfortune  led  to  a  , 


separation  of  portion  of  sigmoid  flexure  too  close 
to  its  walls,  interfering  with  its  vitality  and  caus- 
ing it  to  slough  away  on  the  sixtii  day.  The 
right  ureter  failed  also  to  be  recognized,  and  was 
included  in  the  grasp  of  one  of  the  forceps,  and 
divided.  Neither  of  these  accidents  would  have 
happened  had  the  light'  been  even  fair.  As  soon 
as  coverings  were  lifted  off  all  around,  the  sac 
was  easily  pealed  from  and  lifted  out  of  the  pel- 
vis. Bleeding  was  slight  and  cavity  of  abdomen 
was  thoroughh-  cleansed.  Patient  was  much  ex- 
hausted, but  soon  rallied  and  progressed  nicely 
until  sixth  day.  Urine  was  secreted  daily,  and 
by  patient's  own  efforts.  On  removing  dressings 
and  gauze  packing  on  sixth  day  faecal  matter 
was  found.  Thorough  irrigation  was  made.  Fe- 
cal fistula  continued  until  eleventh  day;  other 
progress  good.  Signs  then  of  bowel  obstruction 
came  on,  and  patient  sank  rapidly,  dying  on  the 
twelfth  day  after  operation.  Autopsy  showed 
opening  size  of  half-a-dollar  in  lowest  part  of  sig- 
moid flexure.  Kidney  on  right  side  atrophied. 
No  evidence  of  peritonitis.  Similar  cases  have 
been  recorded  by  a  number  of  operators. 

EXHIBITION  OF  NEW  UTERINE  DILATOR. 

Dr.  E.  C.  Dudley  presented  an  instrument 
similar  in  appearance  to  a  Fritsch  dilator.  One- 
half  was  hollow  from  the  handle  to  the  blade,  the 
hollow  part  being  convex  on  its  inner  side  and 
fitting  into  the  opposite  concave  blade.  After 
the  uterus  has  been  dilated  by  other  instruments. 
this  instrument  ma}-  be  introduced,  the  blades 
separated,  and  water  poured  through  the  hollow 
blade  from  a  fountain  S3'ringe  connected  with  it. 
The  fluid  passes  into  the  uterus  through  several 
small  openings  at  the  end  of  the  hollow  blade, 
and  out  of  the  uterus  between  the  two  diverging 
blades.  The  instrument  has  been  used  with  con- 
siderable satisfaction  for  eight  months. 

EXHIBITION'    OF    PERIXEAL  SHIELD. 

Dr.  T.  J.  Watkins  showed  a  device  to  be 
used  to  protect  the  recently  injured  or  repaired 
perineum  from  urine.  It  is  inserted  just  below 
the  urethra,  and  covers  and  protects  the  peri- 
neum. It  is  made  of  hard  rubber,  and  easily  kept 
clean.  It  renders  catheterization  and  douching 
after  urination  unnecessary. 

A  CASE  OF  HYPOSPADIAS.      (SPURIOUS    HERMAPH- 
RODITISM. 

Dr.  L.  A.  Frost  of  the  Illinois  Central  Hospi- 
tal for  the  Insane,  presented,  by  invitation,  the 
following:  E.  P..  age  43,  native  of  Germany, 
married  to  a  man,  mentally  a  mild  dement. 
Development  and  general  appearance  masculine. 
Beard  about  six  inches  long;  no  hair  on  breast  or 
limbs.  Mammae  slightly  developed.  Sexual  or- 
gans imperfect.  Mons  veneris  more  prominent 
than  general  in  men.  Clitoris,  or  penis,  about 
one  and  a-half  inches  long,    with   well- developed 


566 


FOREIGN  CORRESPONDENCE. 


[April  18, 


glans;  movable  foreskin  which  does  not  cover 
glans.  Under  side  of  penis  covered  with  mucous 
membrane.  «Penis  is  situated  between  two  folds 
of  skin  resembling  labia  majora;  left  labium  con- 
tains a  testicle  which  is  firm  and  freely  movable, 
having  a  small  epididymis.  Right  labium  is 
smaller  and  has  no  testicle.  The  external  appear 
ance  of  the  hypospadias  is  much  like  that  of  a 
vagina,  is  one-and-a-half  inches  deep,  and  urethra 
opens  into  this  about  one  inch  above  external 
opening.  No  spermatozoa  can  be  found  in  ureth- 
ral secretion.  When  the  subject  was  a  child  the 
parents  were  unable  to  tell  what  the  sex  was,  but 
noticing  particularly  that  urination  was  like  that  of 
a  female  the  child  was  dressed  accordingly,  given 
a  girl's  name,  and  subsequently  married  to  a  man. 
Dr.  W.  W.  Jaggard  had  seen  this  individual 
in  consultation  with  Dr.  Frost.  The  disposition 
of  the  patient  was  a  practical  difficulty.  In  the 
asylum  was  he  to  be  placed  among  the  males  or 
females  ?  He  had  been  placed  by  the  hospital 
authorities  in  the  female  department,  feeling  that 
less  harm  would  thus  result.  This  case  is  evi- 
dently one  of  pseudo-hermaphroditism.  An  au- 
topsy ouly  can  fully  determine  the  question. 
True  hermaphroditismus  does  occur,  general  pro- 
fessional conviction  to  the  contrary  notwithstand- 
ing. 


:OREIGN    CORRESPONDENCE. 


LETTER  FROM   l'.I  RMINGHAM. 


The  Meeting  of  the  Pathological  and  Clinical 
Section  of  the  British  Medical  Association — A  Case 
of  Obstetrical  Paralysis — .-/  successful  Case  ofChole- 
i — Mr.  Lawson  'fait — Intestinal  Perfora- 
tions and  Disturbances — The  Effect  of  Abdominal 
Section  on  the  Action  of  the  Kidneys. 

The  British  Medical  Association  met  in  this 
city  January  30.  with  Mr.  Priestly  Smith  in  the 
chair.  This  meeting  was  the  Pathological  and 
Clinical  Section.  It  was  a  discussion  of  rare  in- 
terest, especially  to  the  gynecologist  and  abdom- 
inal surgeon. 

The  first  case  (with  patient)  presented  was  thai 
of  an  infant  4  months  old,  afflicted  with  what  is 
called  "obstetrical  paralysis."  At  the  birth  of 
the  child  great  difficulty  arose  in  delivering  the 
shoulders,  and  after  the  birth  the  child's  right 
arm  was  almost  completely  paralyzed.  The  mus- 
cles of  the  arm  were  nearly  all  atrophied  and  the 
arm  was  rotated  in  a  prone  position.  The  deltoid 
biceps,  coroco-brachialis,  brachialis  auticus  and 
tors  were  severely  affected. 

Dr.  Suckling,  who  presented  the  case,  consid- 
ered the  path  to  be  situated  at  the 
root  of  the   fifth  cervical   nerve,  and  was  due  to 


mechanical  injury  during  delivery — traction  on 
the  arm.  Three  months'  application  of  galvanic 
electricity,  twice  a  week,  had  induced  improve- 
ment. The  prognosis,  Dr.  Suckling  stated,  was 
unfavorable. 

Mr.  J.  W.  Taylor  presented  a  successful  case  of 
cholecystotomy,  with  especial  reference  to  the 
differential  diagnosis  between  enlarged  gall  blad- 
der and  kidney  tumors.  This  elicited  warm  dis- 
cussion from  such  good  observers  as  Drs.  Foxwell, 
May,  Tait  and  Marsh.  Dr.  Taylor  claimed  that 
kidney  and  gall  bladder  enlarged  must  be  best 
distinguished  by  the  movements  induced  by  the 
hand  of  the  examiner  and  position  of  the  patient. 
Dr.  Taylor  claimed  that  when  a  patient  turned 
on  the  side,  the  kidney  tumor  was  as  plain  to  feel 
or  plainer  to  feel  than  when  the  patient  was  on 
the  back.  But  in  an  enlarged  gall  bladder  it  was 
different,  that  one  could  feel  or  palpate  an  enlarged 
gall  bladder  better  in  the  horizontal  or  vertical 
position  than  when  the  patient  turned  on  the  side, 
and  that  the  enlarged  gall  bladder  was  lost  very- 
much  to  palpation  when  the  patient  turned  on 
the  side. 

Mr.  Lawson  Tait  illustrated  by  a  sketch  on  the 
blackboard  that  Dr.  Taylor's  rules  were  entirely 
fallacious.  Mr.  Tait  said  that  one  could  diagnose 
an  enlarged  gall  bladder  from  kidney  tumor  (right) 
only  when  he  could  be  sure  that  the  changed  po- 
sition of  the  patient  only  changed  the  axis  of  the 
swollen  gall  cyst.  Otherwise,  said  Mr.  Tait,  "I 
defy  any  one  to  make  a  differential  diagnosis  be- 
tween enlarged  gall  bladder  and  kidney  tumor." 
Mr.  Tait  said  that  he  examined  his  patients  both 
in  the  standing  and  lying  posture,  and  so  far  he 
was  unable  to  observe  any  movement  communi- 
cated to  the  gall  bladder  by  respirations.  Mr. 
Tait  talks  on  the  subject  of  cholecystotomy  with 
an  authoritative  assurance  born  of  well  and  hard 
earned  experience.  He  is  an  interesting  speaker 
in  this  new  field,  as  he  has  such  a  special  indi- 
viduality in  all  his  work.  One  feels  in  listening 
to  him  that  he  makes  every  one  of  his  statements 
in  a  fighting  attitude,  and  every  statement  con- 
tains a  challenge.  But  his  assertions  and  the 
truth  seem  to  agree  so  closely  that  he  absolutely 
forces  men  into  thinking  and  investigating.  His 
mastery  in  his  own  fields  makes  him  the  most  fas- 
cinating of  talkers,  as  he  speaks  apparently  with- 
out any  possible  fear  of  contradiction.  His  meth- 
ods of  talk  and  work  fire  men  with  zeal  to  progress. 
Mr.  Tait  has  operated  about  seventy  times  for 
cholecystotomy  with  four  deaths,  but  I  under- 
stand that  three  of  these  could  not  be  chargeable 
ion.  One  of  the  cases  died  of  suffo- 
cative catarrh  three  weeks  after  the  operation, 
and  two  died  of  cancer.  Such  could  not  be  di- 
rectly referred  to  the  operation. 

\)r.  Foxwell  claimed  that  the  large  gall  bladder 
and  the  kidney  tumor  had  distinct  and  positive 
connection  with  respiration.      He  said:    "  I  have 


i89i] 


FOREIGN  CORRESPONDENCE 


567 


carefully  measured  the  distance  these  tumors 
move  during  respiration,  and  have  found  that  the 
enlarged  gall  bladder  will  move  three-quarters  of 
an  inch  more  or  less,  and  the  kidney  tumor  one- 
half  inch  more  or  less."  A  claimed,  disputed 
and  undecided  question  arose  that  the  enlarged 
gallbladder  rested  on  the  right  kidney,  and  there- 
fore it  would  be  impossible  to  differentially  diag- 
nose them.  Normal  anatomy  and  pathology  differ 
so  much  that  only  the  conditions  found  in  actual 
pathological  cases  were  acceptable  in  forming  con- 
clusions. However,  concrete  cases  demand  each 
their  own  special  observation,  as  this  gall  bladder 
may  contain  half  a  dozen  parts  and  reach  to  the 
pubes. 

The  next  subject  brought  up,  and  presented  in 
an  able  and  interesting  lecture,  was  that  of  intes- 
tinal perforations  and  disturbances.  This  made 
your  correspondent  feel  that  he  was  again  at  home 
in  his  own  green  pastures,  lying  under  his  own 
shamrocks  among  his  own  dog  kennels,  where  he 
had  quieted  about  two  hundred  of  the  barking 
curs  in  order  to  find  out  some  useful  knowledge 
in  intestinal  surgery.  Mr.  Langley  Browne  first 
brought  forward  a  case  of  death  by  ulcerative  per- 
foration of  the  duodenum.  The  man  was  brought 
to  the  hospital  writhing  in  agony.  His  pain  came 
on  suddenly  after  a  healthy  life.  Mr.  Browne  saw 
him  some  ten  hours  after  the  accident  and  consid- 
ered him  in  such  a  condition  of  collapse  that  he 
was  an  unfit  subject  for  operation.  Some  hours 
after  the  man  died.  At  the  post-mortem  the  ab- 
dominal cavity  was  found  to  contain  fluid  and 
material  from  the  alimentary  canal.  Dr.  Browne 
said,  five  physicians  were  present  at  this  au 
topsy,  and  noted  that  the  perforation  could  not 
be  found  at  all  while  the  alimentary  tract  was 
in  the  abdomen,  and  that  it  could  not  be  dis- 
covered until  the  whole  canal  was  removed  from 
the  belly  and  water  forced  inch  by  inch  along 
the  canal  from  the  rectum  toward  the  stomach. 
When  the  water  neared  the  pyloris  it  was  ob- 
served to  trickle  out  of  a  small  perforation  close 
to  the  pyloric  valve,  in  the  duodenum.  Mr. 
Browne  observed  that  it  was  so  difficult  to  find 
that  he  defied  any  operator  to  have  discovered  it 
and  saved  his  patient.  (Mr.  Tait  amusingly  re- 
marked that  Mr.  Browne  did  not  know  the  skill 
of  all  operators,  which  created  some  merriment.) 

It  surprised  us  that  some  of  these  able  men  and 
skilful  surgeons  did  not  even  allude  to  such  a 
wonderful  aid  to  diagnosing  intestinal  perforations 
as  the  simple  use  of  simple  113-drogen  gas.  Your 
correspondent,  with  fifteen  minutes  to  generate  a 
few  gallons  of  hydrogen,  and  five  minutes  to  find 
the  perforation  after  the  abdomen  was  open, 
could  locate  this  insurmountable  difficulty  for 
Mr.  Langley  Browne  and  tell  him  with  a  scientific  j 
certainty,  "there  is  the  hole."  These  keen  sur- 
geons and  observers  are  not  yet  familiar  with  this 
wonderful  aid  to  intestinal  diagnosis.       In  an  in- 


teresting and  wide  discussion  of  intestinal  diag- 
nosis it  was  not  even  referred  to  or  mentioned, 
but  I  am  informed  that  vivisection,  as  it  is 
wrongly  denominated,  is  not  allowed  in  this 
country.  One  might  as  well  call  Koch's  inocu- 
lation of  animals  vivisection,  or  breaking  a  young 
ox  or  colt,  vivisection,  as  to  call  experiments 
on  dogs  systematically  carried  out  under  anaes- 
thetics, vivisection.  But  intestinal  surgery  rests 
for  its  progress  on  experiments,  and  in  justice  to 
humanity  these  experiments  should  be  performed 
first  on  the  lower  animals  and  not  on  our  fellows. 

Mr.  Browne  mentioned  another  case  of  a  bar- 
maid suddenly  taken  ill,  and  he  was  called  and 
found  her  in  a  condition  of  collapse,  unfit  for  op- 
eration, dying  some  eight  hours  after.  The  au- 
topsy showed  intestinal  perforation  with  extrava- 
sation. Now,  it  is  my  firm  belief  that  if  these 
cases  have  laparotomy  performed  on  them  and 
the  abdomen  washed  out  with  a  few  gallons 
of  hot  water  it  will  rouse  them  from  the  shock, 
then  with  the  hydrogen  gas  find  the  perforation 
and  close  it.  The}-  have  no  chance  for  life  with- 
out operation  and  there  certainly  is  some  chance 
with  operation. 

Again,  Mr.  Browne  stated  in  his  lecture  that 
whenever  a  person  suddenly  taken  sick  in  the  ab- 
domen, and  died  shortly,  that  it  was  due  to  two 
causes,  viz.,  perforation  or  hemorrhage.  This 
statement  is  very  good  as  far  as  it  goes.  But  it 
must  be  remembered  that  the  shock  to  the  nerv- 
ous system  by  crushing  violence  on  the  periph- 
pheral  nerve  apparatus  of  the  peritoneum  and  gut 
wall  is  sufficient  to  kill  in  a  very  short  time  from 
invagination,  volvulus,  or  strangulation  by  bands 
and  through  apertures.  I  have  seen  invagination 
cause  gangrene  in  ten  hours  or  less.  The  gan- 
grene is  caused  by  the  obstruction  cutting  off  the 
return  of  venous  blood  while  the  artery  continues 
to  carry  its  blood  to  the  parts,  increasing  the 
oedema.  So  it  thus  appears  that  death  can 
occur  very  shortly,  and  as  equally  short  from 
other  forms  of  interstitial  disturbances  as  from 
perforation  and  bleeding.  I  had,  h6wever,  one 
young  woman  die  in  five  hours  from  rupture  of  a 
pelvic  abscess  into  the  peritoneum. 

The  old  idea  that  duodenal  perforations  were 
likeh-  to  occur  after  severe  burns  was  confirmed 
by  reported  observation  at  this  meeting.  The 
question  was  asked  why  the  ulcers  occurred  in 
the  duodenum  and  not  in  other  parts  of  the  canal 
after  burns.  No  direct  answer  arose,  but  it  was 
intimated  that  ulcers  really  occurred  in  the  stom- 
ach also,  and  simply  extended  over  into  the  duo- 
denum. Mr.  Tait  gave  evidence  that  one  of  his 
cases  of  burns  confirmed  the  theory  that  duodenal 
perforations  followed  severe  burns,  and  also  in 
cases  of  diabetes. 

A  very  interesting  talk  followed  on  operations 
on  the  kidney  and  bladder,  and  also  the  effect 
that  abdominal  section  had  on  the  kidney.   Nearly 


568 


DOMESTIC  CORRESPONDENCE. 


[April  18. 


ever3r  surgeon  favored  supra-pubic  cystotomy 
rather  than  the  perineal  operation  for  stone  in 
the  bladder.  The  only  objection  raised  against 
supra-pubic  cystotomy  was  the  difficulty  of  drain- 
age. The  objections  against  the  perineal  opera- 
tion for  stone  in  the  bladder  are  shock  to  the  sys- 
tem from  cutting  the  bladder  where  the  nerve 
supply  is  the  greatest,  of  danger  of  cutting  im- 
portant structures,  and  of  dangerous  immediate 
and  subsequent  haemorrhage. 

The  effect  of  abdominal  section  on  the  action 
of  the  kidney  was  freely  discussed.  I  can  remem- 
ber that,  years  ago,  the  celebrated  Fothergill 
called  the  attention  of  the  profession  to  the  fact 
that  men  should  be  careful  to  observe  the  real 
function  of  the  kidney  before  surgical  procedures 
were  applied,  and  he  noted  cases  in  which  the 
kidneys  were  not  working  right  in  which  he  ad- 
vised that  no  operation  should  be  performed,  but 
in  those  ver}T  cases  his  advice  was  neglected  and 
operation  occurred,  followed  by  death.  As  gyne- 
cologists we  have  learned  to  day  that  Fothergill 
was  right,  but  also  we  think  that  operations  on 
the  peritoneum  have  special  dangers  in  relation  to 
the  kidney.  I  am  thoroughly  convinced  that  sur- 
gical procedures  on  the  peritoneum  are  more  effi- 
catious  in  morbidly  disturbing  the  kidney  secre- 
tion than  on  almost  any  other  bodily  organ. 
Whether  the  effect  lies  in  the  wounding  of  the 
rich  and  even  luxuriant  peripheral  nerve  appar- 
atus which  lies  thickly  scattered  in  the  wall  of 
the  peritoneum,  I  am  not  prepared  to  say. 

Dr.  Foxwell  said  that  he  had  studied  the 
matter  from  two  points.  He  said  that  he  had 
finally  satisfied  himself  that  albumen  was  not  a 
very  reliable  standard  to  go  by,  and  especially  a 
single  examination  of  the  urine  was  useless  to  in- 
dicate when  the  operations  could  be  performed 
safety.  He  thought  that  the  best  standard  to  in- 
dicate whether  abdominal  section  should  be  per- 
formed was  the  amount  of  urea  secreted  daily. 
He  said  that  abdominal  section  should  not  be 
performed  with  less  urea  secreted  than  200  to  160 
grains  daily. 

Mr.  Bennett  May  observed  that  it  was  espe- 
cially necessary  to  observe  the  rules  of  the  secre- 
tion of  urea  in  kidney  extirpation,  as  one  might 
remove  the  very  kidney  which  contained  about 
all  the  secreting  substance  that  the  patient  pos- 
sessed. 

Mr.  Tait  thought  that  the  rules  relative  to 
albumen  and  urea  were  more  important  in  kid- 
ney extirpation  than  other  abdominal  sections, 
but  he  was  quite  anxious  to  secure  definite  laws 
with  regard  to  the  amount  of  substances  secreted 
by  the  kidney  that  would  indicate  abdominal  sec- 
tions with  safety. 

Mr.  Langley  Browne  showed  several  large 
stones  removed  by  perineal  operation  from  the 
bladder,  and  some  kidneys  which  were  largely 
filled  in  the  pelvis  with  numerous  and  large 
calculi. 


Dr.  Christopher  Martin,  assistant  to  Mr.  Law- 
son  Tait,  demonstrated  some  specimens  of  ab- 
dominal tumors  which  had  been  rotated  on  their 
pedicle.  Dr.  Martin  showed  one  that  was  gan- 
grenous'from  the  twist  in  the  pedicle,  and  which 
was  successfully  removed  by  Mr.  Tait.  He  showed 
another  tumor  which  had  a  pedicle  twisted  like 
an  umbilical  cord,  but  which  was  not  strangula- 
ted. The  rotation  had  not  progressed  far  enough 
to  mechanically  occlude  the  vein  or  artery.  This 
tumor  was  also  successfully  removed  by  Mr.  Tait. 
The  tumor  which  was  strangulated  had  occurred 
in  Dr.  Martin's  practice.  Dr.  Martin  examined 
the  woman  and  found  a  tumor  in  the  abdomen, 
and  he  was  called  to  see  her  three  days  after, 
when  he  found  the  tumor  had  increased  to  double 
the  size.  She  was  then  very  sick.  The  sudden 
increase  of  the  tumor  induced  the  diagnosis  of 
axial  rotation  of  a  tumor  with  haemorrhage  into 
it.  Mr.  Tait  was  called  in  consultation  with  Dr. 
Martin,  when  it  was  decided  to  remove  the  tumor. 
The  above  named  gentlemen  operated,  and  found 
the  tumor  twisted  on  its  pedicle  and  gangrenous. 
The  woman  made  an  easy  recovery. 

Birmingham,  Eng.,  Feb.  2.  1891. 


DOMESTIC  CORRESPONDENCE. 


Did  a  Majority  of  the  Board  of  Trustees  Vote 

for  the  Removal  of   the  Journal  to 

Washington? 

To  the  Editor: — The  general  impression  seems 
to  have  gone  abroad  that  the  majority  of  the 
Board  of  Trustees  were  in  favor  of  the  removal  of 
The  Journal  to  Washington.  If  I  am  not  mis- 
taken this  is  not  in  accordance  with  the  facts.  If 
I  am  mistaken  I  desire  to  be  corrected. 

As  I  understand,  Dr.  Garcelon,  of  Maine,  was 
not  present  at  the  Washington  meeting  of  the 
Trustees,  and  was  not  represented  by  proxy.  Dr. 
Moore  was  represented  by  proxy  directed  to  Dr. 
Hooper,  the  President  of  the  Board,  but  without 
an  expression  of  preference.  The  same  of  Dr. 
Dawson,  of  Ohio.  Of  the  six  members  present  I 
understand  that  Dr.  Hamilton,  of  D.C.,  Dr.  Love, 
of  Missouri,  and  Dr.  Shoemaker,  of  Pennsylvania, 
were  in  favor  of  immediate  removal ;  that  Dr.  Hol- 
lister  of  Illinois,  was  opposed  to  removal  ;  that 
Dr.  Nelson,  of  Tennessee,  was  in  favor  of  sub- 
mitting the  question  to  the  Association,  and  that 
the  President,  Dr.  Hooper,  of  Arkansas,  would 
favor  the  removal  to  Washington  provided  it  was 
the  expressed  wish  of  the  majority  of  the  mem- 
bers of  the  Association. 

If  my  information  is  correct  it  certainly  cannot 
be  affirmed  that  a  majority  of  the  Board  are  in 
favor  of  removal! 

H.  MartynScudder,  M.D. 

Chicago,  111. 


■'.] 


DOMESTIC  CORRESPONDENCE. 


569 


a  Pan-American  Medical  Congress. 

7ii  the  Editor: — I  beg  leave  to  announce  to  the 
members  that  it  is  my  intention  to  move  at  the 
Washington  meeting,  1.  That  the  American  Med- 
ical Association  extend  to  the  profession  of  the 
Republics  and  Colonies  of  the  Western  Continent 
an  invitation  to  assemble  in  this  country  in  an 
Into  national  American  Medical  Congress  ;  and,  if 
this  resolution  be  adopted,  then,  2.  That  the 
Nominating  Committee  be  instructed  to  report  a 
committee  of  one  from  each  State  and  territory, 
and  one  each  from  the  Army,  Navy,  and  Marine 
Hospital  Service,  to  whom  shall  be  referred  the  time, 
place,  and  permanent  organization  of  the  pro- 
posed Congress. 

There  is  substantial  reason  why  this  step 
should  be  taken  and  why  the  proposed  Congress 
should  be  held.  Polite  learning  has  always  fol- 
lowed  in  the  wake  of  commerce.  The  recently 
established  and  rapidly  developing  politico  com- 
mercial relations  between  the  United  States  and 
the  other  countries  of  the  two  Americas  must,  in 
the  nature  of  things,  bring  about  an  interchange 
of  the  sciences  and  arts.  Among  these  latter, 
medicine  in  its  broad  sense  will  be  the  first  to  be 
forced  into  the  foreground.  The  restrictions 
which  are  placed  upon  commerce  in  the  interest 
of  health  make  it  imperative  that  problems  of  na- 
val hygiene  and  international  sanitarian  be  dis- 
cussed and  definitely  settled.  The  question  of 
epidemics,  their  causation,  propagation  and  hab- 
itat, becomes,  as  never  before,  one  fraught  with 
imminent  commercial  and  vital  importance. 
Pressing  hard  upon  both  these  broad  and  com- 
prehensive themes,  indeed  forming  integral  parts 
of  them,  is  the  great  and  developing  department 
of  bacteriology.  Through  the  medium  of  this 
newest  of  medical  departments  all  branches  of 
medicine  and  surgery  have  become  intimately 
correlated.  Thus  we  discover  at  once  that,  be- 
tween the  United  States  and  the  other  countries 
of  the  Western  Continent  there  exists  a  commer- 
cial interest  in  all  topics  which  can  engage  the 
attention  of  a  Medical  Congress. 

The  medical  schools  of  Latin  America  are  gen- 
erally endowed  and  enjoin  a  curriculum  which 
insures  the  scholarship  of  their  alumni.  The 
recent  graduates,  however,  go  to  the  European 
schools  for  advanced  study.  If  the  profession  of 
the  Southern  Republics  could  be  induced  to  visit 
the  United  States  and  thus  become  familiar  with 
the  clinical  and  educational  resources  of  our  great 
cities  the  result  would  doubtless  be  an  increased 
enrollment  from  these  countries  in  both  our  under- 
and  post-graduate  schools.  On  the  other  hand 
our  own  students  desirous  of  prosecuting  their 
studies  in  a  language  which  shall  have  a  commer- 
cial as  well  as  a  classical  importance  may  find  it 
profitable  to  spend  a  season  among  the  hospitals 
and  laboratories  of  Havana,  Rio  Janeiro  and 
Buenos  Ayres. 


I  beg  to  state  that  early  last  winter  I  opened  a 
personal  correspondence  with  distinguished  med- 
ical gentlemen  of  Mexico,  Central  America  and 
South  America,  requesting  their  individual  views 
as  to  the  exediency  of  such  a  Congress  and  that 
the  replies  so  far  received  are  uniformly  favorable. 

My  apology  for  bringing  this  matter  up  before 
the  assembling  of  the  Association  must  be 
found  in  the  importance  of  the  contemplated  ac- 
tion and  in  the  further  importance  of  having  the 
delegates  come  to  the  meeting  able  to  reflect  in 
some  measure  the  sentiments  of  the  profession 
whom  they  represent. 

Charles  A.  L.  Reed,  M.D. 

Cincinnati,  April  6,  1891. 


Phymosls. 

To  the  Editor.— Page  271  in  No.  8  of  The 
Journal  contains  an  article  on  "  Painless  Circum- 
cision" by  Dr.  G.  W.  Overall,  with  which  I  was 
much  pleased.  It  is  a  great  step  in  advance  of 
the  old  method  of  giving  chloroform,  which  sev- 
eral times  in  my  practice  endangered  the  life  of 
the  little  patient.  Since  then  I  have  to  a  certain 
extent  followed  the  method  of  Dr.  Overall.  That 
is,  I  have  used  a  20  or  30  per  cent,  solution  of 
cocaine  and  injected  10  or  15  drops  with  a  blunt 
pointed  glass  syringe  into  the  preputial  orifice, 
pressing  the  prepuce  tightly  around  the  end  so  as 
to  retain  the  fluid,  after  removing  the  syringe.  I 
churned  the  fluid  cocaine  so  as  to  come  in  con- 
tact with  the  entire  mucous  membrane  for  ten  or 
fifteen  minutes.  I  at  the  same  time  sprayed  over 
the  entire  integument  where  the  circumcision  was 
to  take  place  an  anaesthetic  solution  consisting  of 
R.     Chloroform.  ftiiss. 

^Ether  sulphuric,  3iv. 

Menthol,  grs.  xv.     rtg. 

until  I  felt  satisfied  that  complete  anaesthesia  of 
the  part  was  produced.  I  now  begin  the  now 
painless  operation  and  so  far  I  have  not  been  dis- 
appointed in  that  respect.  A  fine  catgut  inter- 
rupted suture  will  soon  unite  the  edges.  Dress 
with  iodoform  gauze  and  bi-chlorinated  cotton,  and 
you  will  have  ever}-  reason  to  feel  satisfied  with 
the  best  method  of  operating  for  phymosis.  Tepid 
water  sprays  and  dressings  will  keep  down  all 
local  inflammation  should  there  be  much. 

If  the  operation  now  required  for  enuresis  of 
long  standing  a  little  medication  may  be  necessary 
for  a  week  or  two  after  the  operation,  in  that  case 
I  have  found  excellent  results  from  the  following: 

B.     Atropiae  sulph.,  gr.  ij. 
Aquas  distil,  sj.     nR. 

Sig.  One  drop  for  each  year  of  age  of  the  child,  at  4 
and  7  p.m.  Increase  the  dose  if  no  effect  is  produced  in 
one  week. 

All  nervous  irritation,  spasms,  convulsions  in 
the  little  sufferer  will  generally  rapidly  subside. 

I  will  close  by  saying  that  all  male  children 
troubled  with  enuresis  and  all  other  nervous  dis- 


57o 


SPECIAL  CORRESPONDENCE. 


[April  18 


eases  of  a  reflex  nature  should  never  be  prescribed 
for  unless  the  physician  is  satisfied  from  actual 
observatioti  that  no  condition  of  phymosis  exists. 
If  there  is,  circumcision  is  the  only  radical  cure. 
B.  Storch,  M.D. 
Alta,   Iowa. 


SPECIAL  CORRESPONDENCE. 


Shall  Tlie  Journal  be  Removed  to 
AVashiiigton  ? 

THE    VOICE    OF   OUR     MEMBERS    AS    SHOWN   BY   A 

VOTE    OF  THE  SAME   ON   THE  QUESTION   OF 

THE  REMOVAL  OF  THE  JOURNAL  FROM 

CHICAGO  TO  WASHINGTON. 

As  straws  show  which  way  the  gentle  zephyrs  blow; 
Thus  Votes,  the  will  of  our  Association  show  ! 

The  agitation  on  the  part  of  some  of  the  Trus- 
tees, which  contemplates  a  removal  of  The  Jour- 
nal of  the  Association  from  Chicago  to  Washing- 
ton, was  scarcely  announced,  before  a  general 
feeling  of  opposition  was  clearfy  evident  in  a 
large  majority  of  the  more  active  members  of  the 
entire  Association— North,  South,  East  and 
West.  But  how  to  obtain  an  expression  from 
the  members  regarding  such  a  movement,  and,  at 
the  same  time,  put  in  force  the  will  of  the  major- 
ity of  the  same  under  all  the  circumstances,  was  a 
perplexing  question.  The  Association  being  made 
up  of  permanent  members  and  delegates,  the  for- 
mer having  no  vote  and  the  latter  having  become 
extinct  by  virtue  of  their  adjourning  sine  die, 
there  was  no  official  way  by  which  an  expression 
of  the  will  of  the  members  could  be  obtained  prior 
to  the  coming  meeting.  In  other  words,  our  As- 
sociation is  like  a  chrysalis,  so  far  as  any  official 
action  of  its  members  is  concerned  between  each 
annual  meeting.  This  being  the  case  it  was  pa- 
tent to  every  one  that  no  official  action  could  be 
taken  on  this  vital  question  by  the  members  be- 
fore the  meeting  at  Washington.  Yet  this  did 
not  prevent  any  permanent  member  from  canvas- 
sing the  field  and  ascertaining  as  nearly  as  possi- 
ble the  feelings  of  the  members  regarding  the 
proposed  removal  of  The  Journal  to  Washing- 
ton. The  result  was  that  after  several  consulta- 
tions with  numerous  friends  of  The  Journal 
who  were  simply  high  privates  in  the  rear  ranks 
of  our  membership,  I  decided  to  conduct  a  com- 
plete canvass  of  the  members  and  ascertain  their 
individual  opinions  on  this  most  important  ques- 
tion. Consequently  I  prepared  and  mailed,  or 
had  mailed,  to  each  permanent  member  of  the 
Association,  the  following  circular  letter  with 
which  I  enclosed  a  postal  card  addressed  to  my- 
self, or  such  others  as  were  assisting  me,  on  which 
the  following  blank  was  printed: 

My  Dear  Doctor: — You  are  no  doubt  aware  long  ere 


this  that  an  effort  is  being  made  to  remove  The  Jour- 
nal of  the  American  Medical  Association  from  Chicago, 
111.,  to  Washington,  D.  C.  As  I  am  desirous  of  obtaining 
a  free  expression  from  the  leading  members  of  the  Asso- 
ciation, of  their  candid  opinion  in  regard  to  this  all  im- 
portant question,  I  herewith  enclose  you  a  blank  postal 
card  on  which  I  will  ask  you  to  kindly  inform  me  wheth- 
er you  are  in  favor  or  opposed  to  this  movement  to  change 
the  place  of  publication  of  our  National  Journal  from  the 
Western  Metropolis  to  the  National  Capital;  to  which  we 
will  be  pleased  to  have  you  add  the  principal  reason  "for 
the  faith  that  is  within  you." 

Trusting  that  I  may  have  the  honor  to  receive  an  early 
reply  through  your  courtesy,  I  remain, 

Sincerely  and  Fraternally  Yours, 

R.  Harvey  Reed. 

Mansfield,  O. 

1891. 

Dear  Doctor: — In  answer  to  your  inquiry  of  ...  . 
1S91,  regarding  the  removal  of  "The  Jourual"of  the  Amer- 
ican Medical  Association  from  Chicago  to  Washington,  it 
is,  in  my  opinion,  to  the  best  interests  of  the  "Journal" 

to  have  it 

Briefly  my  reasons   for  the  above  opinion  are 

(Signed) M.D. 

In  this  work  I  was  ably  assisted  by  Dr.  T.  D. 
Crothers,  of  Hartford,  Conn.,  who  sent  out  the 
same  circular  to  the  members  in  the  Eastern 
States,  and  received  and  recorded  their  views. 
Likewise  I  was  assisted  by  Dr.  C.  E.  Beardsley, 
of  Ottawa,  O. ,  who  looked  after  the  votes  in 
Ohio,  and  Dr.  JohnF.  Fulton,  of  St.  Paul,  Minn., 
who  canvassed  Minnesota,  and  Dr.  T.  M.  Hood 
of  Weston,  W.  Va.,  who  secured  the  votes  for  his 
State;  all  of  which  votes  have  been  carefully  re- 
corded on  tally  sheets  prepared  for  that  purpose, 
of  which  the  following  is  &fac  simile,  giving  the 
name,  his  postoffice  address,  together  with  his 
vote,  all  of  which  is  backed  by  his  reply  on  the 
postal  card  or  letter  he  returned,  which  has  been 
carefully  filed  away  for  future  reference. 

Tally  Sheet. — Showing  the  Record  of  the  Returns 
of  the  Votes  taken,  with  Reference  to  the  removal  of 
"The  Journal"  of  the  American  Medical  Association 
from  Chicago,  111. ,  to  Washington,  D.  C. 

Returned  to  Dr.  R.  Harvey  Reed,  Mansfield.  O.,  by 

Dr of St. 

Post  Office,   State  of 

Division. 


Vote  for  Vte  foi 
Chicago  Wash. 


After  recording  the  votes  on  these  tally  sheets 
we  journalized  them,  so  to  speak,  into  States, 
giving  the  total  number  of  members  in  each 
State,  to  each  of  whom  a  circular  had  been  sent; 
the  total  number  of  votes  received  from  each 
State  ;  the  total  number  for  Chicago  ;  the  total 
number  for  Washington,  and  the  total  number 
for  other  places,  or  those  who  were  undecided  or 
had  no  preference,  all  of  which  is  clearly  shown 
by  the  following  tabulated  report.  This  report 
was  closed  on  the  8th  of  April,  notwithstanding 
we  were  receiving  quite  a  number  of  votes  daily, 
and  have  continued   to  receive  them  ever  since  it 


i89i.] 


SPECIAL  CORRESPONDENCE. 


571 


was  closed,  these  unrecorded  votes  being  largely 
in  favor  of  Chicago. 


Name  of  State. 


Alabama 

Arizona 

Arkansas 

California  .... 

Colorado 

Connecticut  .  .  . 
Cherokee  Nation. 
Dist.  of  Columbia 



Delaware 

Florida 

Georgia 



Illinois 

Indiana 

Iowa 

Kansas. 

Kentucky  .... 
Louisiana  .... 

Maine 

Maryland  .... 
Massachusetts .  . 

Michigan 

Minnesota.  .   .    . 

Missouri 

Mississippi.  .   .   . 

Montana 

N.  Carolina.  .  .  . 
N.  Mexico  .... 

Nebraska 

N.  Hampshire .   . 

N.  Jersey 

N.  York 

Ohio 

Oregon 

Pennsylvania  .  . 
Rhode  Island.  .  . 
S.  Carolina.  .  .  . 
Tennessee  .... 

Texas  

Utah 

Vermont 

Virginia 

W.  Virginia  .  .  . 
Washington  .  .  . 
Wisconsin  .... 
Wyoming  .... 
Votes  with  no  address 

Totals  .... 


Hi 

0  £"£ 


rt-o-- 

III 


Number  not  reported,  1,692. 

It  will  be  observed,  by  studying  this  table,  that 
there  are  eight  States  which  have  a  membership 
of  over  200  each,  and  they  stand  in  the  following 
numerical  order  : 


Name  of  State. 

No.  of 

No.  Votes 

Chica- 

Wash- 

Scat- 

Members. 

Returned. 

go- 

ington. 

ter'g. 

435 

271 

271 

1 

2 

Pennsylvania  .... 

422 

184 

139 

26 

19 

Ohio 

299 

244 

210 

21 

13 

277 

169 

164 

4 

275 

127 

M 

32 

14 

232 

104 

90 

11 

226 

149 

H5 

3 

I 

Missouri 

217 

115 

99 

II 

5 

Totals 

2,383 

1,366 

M99 

109 

58 

In  these  eight  States  you  will  observe  there  is 
a  total  membership  of  2,383,  and  out  of  this 
number  1,366  voted  :  1, 199  of  which  are  in  favor 
of  Chicago,  whilst  only  109  are  in  favor  of  Wash- 
ington, and  58  are  undecided.  But,  were  all 
those  voting  for  Washington  and  scattering  to 
join  together  with  those  who  did  not  vote  at  all, 


to  vote  for  the  Capital  City,  Chicago  would  still 
have  a  majority  of  the  whole. 

By  a  further  study  of  this  table  it  will  be  ob- 
served that  Illinois  stands  first  numerically  in  the 
replies  to  our  circular,  Ohio  second,  Pennsylvania 
third,  Indiana  fourth,  Iowa  fifth,  New  York 
sixth,   Missouri  seventh,   and  Tennessee  eighth. 

In  regard  to  the  vote  for  Chicago,  Illinois  also 
stands  first,  Ohio  second,  Indiana  third,  Iowa 
fourth,  Pennsylvania  fifth,  Missouri  sixth,  Ten- 
nessee seventh,  and  New  York  last. 

In  the  vote  for  Washington  this  is  reversed, 
and  New  York  stands  first,  Pennsylvania  second, 
Ohio  third,  Missouri  and  Tennessee  equal  for 
fourth  place,  Indiana  sixth,  Iowa  seventh,  and 
Illinois  last,  with  only  one  vote  for  the  National 
Capital. 

As  to  the  scattering  and  undecided  vote  Penn- 
sylvania ranks  first,  New  York  second,  Ohio 
third,  Missouri  fourth,  Tennessee  fifth,  Illinois 
sixth,  with  Iowa  and  Indiana  on  an  equal  foot- 
ing for  seventh  place. 

Again,  you  will  observe  that  88  per  cent,  ot 
the  entire  vote  in  these  eight  States  is  for  Chi- 
cago, and  only  8  per  cent,  for  Washington,  with 
4  per   cent,    undecided   or  for   some  other  city. 

But  when  you  consider  that  out  of  3,911  mem- 
bers all  but  1,692  voted  on  this  question,  and 
that  out  of  the  2,219  votes  cast  1,892  were  for 
Chicago,  and  only  209  for  Washington,  and  but 
118  scattering  and  undecided,  or,  in  other  words, 
over  85  per  cent,  of  all  the  votes  cast  are  in 
favor  of  The  Journal  remaining  at  Chicago, 
and  only  9  per  cent,  are  in  favor  of  it  being  re- 
moved to  Washington,  whilst  only  a  fraction 
over  5  per  cent,  are  either  undecided  or  voted  for 
some  other  city,  it  shows  that  the  evidence  is 
overwhelmingly  in  favor  of  Chicago,  and  against 
the  removal  of  The  Journal  to  Washington. 

It  does  not  seem  possible  that  any  Board  of 
Trustees  would  dare  to  attempt  such  a  hazardous 
undertaking  against  the  wishes  of  such  a  large 
percentage  of  their  constituents,  and  especially 
so  when  we  remember  that  45  of  the  heaviest  ad- 
vertising patrons  of  The  Journal  are  decidedly 
in  favor  of  it  remaining  in  Chicago  against  15  of 
the  lighter  advertising  patrons  who  favor  the 
National  Capital,  as  reported  in  last  week's 
Journal. 

The  marked  indifference  manifested  by  the  pro- 
fession in  the  District  of  Columbia  is  worthy  of 
some  attention.  Out  of  a  total  membership  of 
84,  only  36  voted  on  this  question  at  all,  or  in 
other  words,  six  less  than  half  of  the  total  mem- 
bership expressed  any  opinion  whatever,  and  ten 
of  these  were  in  favor  of  The  Journal  remain- 
ing at  Chicago,  whilst  five  were  indifferent,  and 
but  21  out  of  84,  or  to  be  more  explicit,  only  25 
per  cent,  of  the  entire  membership  living  in 
Washington  and  the  District  of  Columbia  ex- 
pressed themselves  in  favor  of  this  change  ;    this 


572 


SPECIAL  CORRESPONDENCE. 


[April  18, 


fact  alone  should  cause  us  to  pause  a  moment 
at  least,  and  ask  why  all  this  indifference  regard- 
ing the  removal  of  The  Journal  on  the  part  of 
the  profession  of  our  Capital  City,  if  they  favored 
such  a  change  and  thought  it  for  the  best  inter- 
ests of  The  Journal  ? 

We  trust  that  the  facts  we  have  presented  to 
you  in  the  above  table,  which  have  been  procured 
at  no  small  amount  of  labor  and  expense,  will 
serve  to  satisfy  everj'  reader  of  The  Journal 
as  to  what  the  popular  feeling  of  the  members  of 
our  Association  is,  regarding  this  proposed  re- 
moval, which  has  been  so  thorough!}7  discussed, 
both  pro  and  con,  in  The  Journal,  that  no  reader 
of  the  same  could  have  voted  other  than  intelli- 
gently on  this  question. 

We  trust  that  every  State,  district  and  local 
medical  society  in  our  country,  will  see  to  it  that 
a  full  representation  of  their  delegates  are  present 
at  the  coming  meeting  at  Washington  to  vote 
their  convictions  on  this  question,  and  also  to 
see  to  it  that  the  member  of  your  nominating 
committee  in  each  State  is  true  to  your  interests, 
and  a  man  who  will  favor  the  election  of  new 
members  on  the  Board  of  Trustees  who  are  in 
full  accord  with  the  wishes  of  their  constituents, 
on  this  important  issue,  and  thus  forever  settle 
this  needless  and  unprofitable  controversy  which 
has  evidently  been  sprung  on  the  members  by  a 
clique  of  medical  politicians. 

Very  respectfully  submitted. 
R.  Harvey  Reed. 

"Mansfield,  O.,  April  13,  1891. 


ACTION    OF   THE     GOLDEN     BELT     DISTRICT    MED- 
ICAL SOCIETY   OF   KANSAS. 

At  a  regular  meeting  of  the  Golden  Belt  Dis- 
trict Medical  Society  of  Kansas,  held  at  Topeka, 
Kansas,  on  April  9,  1891,  Dr.  William  B.  De- 
wees,  of  Salina,  moved  the  following  resolution 
which  passed  unanimously,  viz.: 

Whereas,  The  Board  of  Trustees  of  The  Journal 
of  the  American  MedIcal  Association,  at  a  receut 
special  session  in  Washington,  D.  C,  adopted  a  resolu- 
tion favoring  the  change  of  the  home  of  The  Journal 
from  Chicago  to  Washington,  and 

Whereas,  This  is  a  question  which  the  Association 
will  be  called  upon  to  answer  at  its  next  meeting  at 
Washington,  D.  C,  in  May,  1891,  and 

Whereas,  We  believe  it  to  be  for  the  best  interests  of 
The  Journal  and  the  Association,  that  the  office  and 
place  of  publication  of  The  Journal  should  not  be  re- 
moved.    Therefore,  be  it 

Resolved,  That  the  delegates  from  this  Society  to  the 
next  meeting  of  the  American  Medical  Association  are 
hereby  instructed  to  vote  Cor  no  change  to  be  made  in 
the  location  of  The  Journal,  and  further,  be  it 

Resolved,  That  we  urge  all  Kansas  delegates  to  vote 
against  its  removal. 

F.  B.  Browne,  M.D.,  Secretary. 


To  the  Editor. — While  in  favor  of  Chicago,  as 
the  publishing  centre  for  The  Journal,  I  think 


the  better  plan,  in  view  of  the  present  contro- 
versy, would  be  to  abolish  The  Journal  altogether. 
It  has  never  supplied  a  want  in  medical  journal- 
ism, and  it  can  never  be  a  universal  success,  be- 
cause it  cannot  unite  and  harmonize  the  varied 
and  various  interests  of  this  immense  breadth  of 
country.  Comparisons  with  the  British  Medical 
Journal,  so  often  made  in  these  columns,  are  en- 
tirely illogical  when  we  take  in  consideration  the 
small  area  of  England,  and  the  difference  in  the 
character  of  the  medical  profession  in  the  two 
countries.  There  are  plenty  of  medical  journals 
in  this  country  to-day  which  would  publish  the 
papers  that  ar&  read  at  our  meetings  to  much 
greater  advantage  to  their  authors,  and  much 
sooner,  than  The  Journal  can  or  has  done. 

I  am  in  favor  of  abolishing  The  Journal, 
which  is  in  most  cases  but  a  late  edition  of  the 
Association  proceedings.  In  its  stead  I  am  in 
favor  of  having  the  Transactions  of  each  Section 
published  separately  in  good  shape,  as  soon  after 
the  meetings  as  possible,  and  sent  to  the  mem- 
bers, each  member  designating  the  Section  whose 
Transactions  he  wishes.  In  this  way  each  mem- 
ber would  have  in  a  complete  and  compact  form 
the  proceedings  of  the  Section  he  is  most  inter- 
ested in,  always  ready  for  reference,  and  a  useful 
addition  to  his  library.  Increase  the  membership 
by  reducing  the  annual  dues,  and  abolishing  The 
Journal.  Publish  the  Transactions  of  each  Sec- 
tion separately.  Neither  Chicago,  nor  Washing- 
ton, but  union  forever. 

Eric  E.  Sattler,  M.D. 

117  Garfield  Place,  Cincinnati,  O. 


To  the  Editor: — Remove  The  Journal  to 
Washington  ?  No !  Remove  Washington  to 
The  Journal.  E.  D.  Moffett,  M.D. 

Indianapolis,  April  9,  1891. 


To    the   Editor: — Eet  The  Journal  remain 
where  it  is — at  least  for  the  present. 

John  C.  Sundberg,  M.D. 

San  Francisco,  Cal. 


To  the  Editor: — I  have  been  interested  in  the 
correspondence  pro  and  con  on  the  proposed  re- 
moval of  The  Journal  from  Chicago  to  Wash- 
ington. Unless  some  very  important  personal  in- 
terests are  to  be  served,  no  tangible  reason  appears 
why  the  change  should  be  made. 

One  might  have  a  certain  National  pride  in  the 
location  of  The  Journal  in  Washington  because 
it  is  the  Capital  of  the  Nation  ;  but  sentiment  in 
such  an  enterprise  should  give  way  to  utility. 
There  are  decided  practical  advantages  in  a  great 
medical  centre,  which  Washington  can  never 
have.  It  is  a  question  whether  the  quality  of  The; 
Journal  would  be  satisfactory  to  the  whole  pro- 
fession if  it  were  made  subject  to  the  political  and 
bureaucratic  influences  of  the  Capital. 


n.) 


SPECIAL  CORRESPONDENCE. 


573 


As  a  permanent  home  for  Tiih  Journal  Chi- 
cago would  improve  ;  Washington  would  not. 
Of  all  the  great  medical  centres  in  the  country 
Chicago  has  the  minimum  average  distance  from 
subscribers  and  contributors, —an  advantage  which 
will  increase  with  time. 

The  political  and  commercial  centres  of  gravity 
of  the  United  States  are  moving  westward  with  a 
force  which  is  irresistible.  The  question  is  wheth- 
er The  Journal  would  profit  by  going  against 
such  a  force.  E.  C.  Dudley,  M.D. 

-<>  Monroe  St.,  Chicago,  April  2,  1891. 


To  the  Editor: — Let  The  Journal  remain  in 
Chicago. 

Geo.  R.  Highsmith,  M.D. 

Carrollton,  Mo. 


This  is  certainly  a  case  of  "  pure  cussedness," 
and  having  diagnosed  it  correctly  we  are  certainly 
competent  to  treat  it  with  success,  and  I  would 
recommend  heroic  dosage  that  would  at  once 
eliminate  or  suppress  it — "  sit  dozen  on  it" — and 
ifeffectually  suppressed  in  that  way  it  will  not  soon 
manifest  itself  again. 

But  there  has  already  been  too  much  time 
spent  and  too  much  space  in  The  Journal  wasted 
in  discussing  the  removal  inasmuch  as  not  one  in 
every  twenty  members  really  desire  it  ;  while  no 
one  urging  its  removal  ever  has  offered,  or  prob- 
ably ever  will,  or  can  offer,  a  single  reason  justify- 
ing its  removal  to  Washington,  while  the  reasons 
j  assigned  for  its  remaining  where  it  is  have  been 
:  both  abundant  and  overwhelming  in  force. 

A.  J.  Scott,  A.M., M.D. 
Loudon ville,  Ohio.  April  7,  1891. 


To  the  Editor : — Please  enter  me  as  a  voter  to 
let  The  Journal  remain  at  Chicago.  There  have 
been  many  valid  reasons  assigned  by  your  cor- 
respondents why  it  should  not  be  removed,  but  I 
have  seen  none  so  far  to  the  contrary. 

T.  B.  Greenley,  M.D. 

West  Point,  Kv.,  April  6,  1S91. 


To  the  Editor : — The  American  Medical  Asso- 
ciation acted  wisely  when  it  exchanged  the  an- 
nual volume  of  Transactions  for  the  wTeekly  Jour- 
nal ;  and  displayed  equal  wisdom  in  locating  the 
plant  for  its  publication  in  Chicago. 

The  growth  of  The  Journal  has  been  in  keep- 
ing with  the  growth  of  its  home,  and  both  bid 
fair,  in  the  near  future,  to  stand  without  rivals, 
the  pride  of  the  American  people  and  the  admira- 
tion of  the  world. 

Each  member  of  the  Association,  may  with  the 
writer  feel  proud  that  his  vote  helped  to  create 
the  journal  and  gave  it  a  home  in  the  grandest 
city,  for  its  age,  that  the  world  has  ever  seen  ; 
while  to  all.  it  should  be  a  source  of  regret, 
amounting  almost  to  sorrow  and  shame,  that  so 
small  a  personal  matter,  a  mere  whim  of  a  vain 
and  over  selfish  brain,  should  be  permitted  to 
cause  such  a  commotion  and  menace  the  prosper- 
ity and  very  life  of  The  Journal.  The  Journal 
belongs  to  the  Association,  and  to  the  ordinary 
mind,  it  looks  preposterous  that  any  measure  so 
potent  for  evil,  so  uncalled  for,  as  the  removal  of 
The  Journal  to  Washington  City,  should  for  one 
moment  be  seriously  considered,  or  much  less  be 
carried  into  effect  or  attempted  to  be,  without  the 
consent  of  a  clear  majority  of  its  members. 

While  trickery  may  be  permitted  in  politics,  it 
is  certainly  too  contemptible  to  be  allowed  a  place 
in  the  deliberations  of  so  august  and  honorable  a 
body,  as  the  American  Medical  Association,  or  to 
figure  conspicuously  in  its  transactions  ;  striking 
as  it  does,  in  this  case,  at  the  prosperity  and  wel 
fare,  yes  at  the  very  vitality  of  the  Organ  of  the 
Association;  and  all  for  mere  selfish  ends. 


Editorial  Opinions  oi'tlic  Medical   Press. 

The  arguments  used  in  favor  of  the  removal  of  The 
Journal  of  the  American  Medical  Association  to  Wash- 
ington, are  somewhat  peculiar.  The  arguments,  that  the 
personal  influence  of  Dr.  X.  S.  Davis  is  too  marked,  and 
that  the  Chicago  profession  have  a  monopoly  of  its  con- 
tents, or  that  it  is  conducted  in  the  interest  of  a  clique, 
are  not  very  well  substantiated.  If  The  Journal  were  li- 
able to  fall  into  the  hands  of  a  select  coterie,  nowhere 
would  it  be  more  possible  than  in  Washington. — Physi- 
cian and  Surgeon,  March,  1S91. 


Shall  The  Journal  be  removed  to  Washington?  The 
call  for  a  general  expression  of  opinion  on  the  above 
question,  was  prompted  by  the  knowledge  that  the  inem- 
|  bers  of  the  profession  are  very  largely  interested  in  The 
I  Jourual,  and  as  integral  parts  of  the  American  Medical 
I  Association  they  should  have  a  voice  in  the  debate.  The 
arguments  for  and  against  the  removal  have  been  more 
I  numerous  thau  convincing,  and  in  many  instances  have 
degenerated  into  mere  partisan  exhortations.  It  should 
be  remembered  that  this  publication  represents  the  Na- 
tional Association,  and  that  sectionalism  has  no  right  to 
be  heard.  Any  argument,  therefore,  based  on  the  prior 
claims  of  the  medical  men  of  any  location  or  district,  is 
out  of  place. 

Of  all  the  reasons  given  as  to  why  The  Journal  should 
remain  in  Chicago  (aside  from  the  fact  that  Chicago  is 
its  present  home),  one  only  appears  to  have  weight. 
This  is  the  geographical  situation  of  that  city,  which 
is  nearer  the  population  centre  of  the  country  than 
most  other  eligible  places.  But  The  Journal  is  the  offi- 
cial organ  of  an  Association  that  meets  only  once  a  year; 
it  is  the  means  of  publication  of  the  transactions  of  these 
yearly  meetings,  and  half  of  the  articles  presented  are  six 
months  old  or  more  before  they  can  appear  in  print.  The 
sole  advantage  of  a  central  location  is  the  delivery  of  The 
Journal  a  few  hours  earlier  to  most  of  its  subscribers,  an 
advantage  that  under  the  circumstances  of  its  publica- 
tion does  not  seem  to  be  of  very  great  importance 

The  arguments  in  favor  of  Washington  as  the  seat  of 
publication  are  two:  First,  that  as  the  Capital  City  of 
the  United  States,  as  the  centre  of  government,  Wash- 
ington is  a  peculiarly  appropriate  home  for  the  publica- 
tion of  a  National  journal.  This  is  mere  sentimentalism. 
Washington  is  the  political  centre  of  the  coir: 
nothing  more.  It  is  not  the  art  centre,  nor  the  scientific 
centre,  nor  the  educational  centre,  and  it  certainly  :s  not 
the  medical  centre  of  the  United  States.  The  second  ar- 
gument, that  the  National  Library  and  Museum  at  Wash- 
ington offer  advantages  lacking  in  other  places,  is  worthy 


574 


SPECIAL  CORRESPONDENCE. 


[April  18, 


of  more  consideration,  but  it  is  not  clear  that  some  other 
localities  may  not  equal  or  even  excel  Washington  in  this 
particular;  moreover,  the  history  of  The  Journal  does  not 
show  any  need  of  such  facilities;  it  is  not  of  that  ultra- 
scientific  character  that  demands  resources  of  this  kind. 
It  seems  to  us  there  are  but  two  deciding  factors  to  be 
considered  in  this  question.  One  is  the  facilities  offered 
by  a  large  city  for  the  mechanical  part  of  the  publica- 
tion.  This  demand  may  be  satisfied  in  any  locality  that 
provides  a  sufficient  printing  establishment,  and  where 
the  postal  service  is  good.  The  other  and  most  impor- 
tant consideration  regards  the  editorial  equipment.  The 
success  or  failure  of  The  Journal  depends  directly  upon 
the  editor,  and  The  Journal  should  be  published  in  the 
locality  where  it  can  command  the  very  best  editorial 
talent  be  it  Chicago  or  Washington,  Boston  or  New  Or- 
leans, New  York  or  St.  Louis,  or  Arcot,  Tennessee. — 
Pittsburgh  Medical  Review,  March,  1891. 


This  subject  has  been  pretty  thoroughly  discussed  from 
one  point  of  view,  namely,  whether  the  interests  of  The 
Journal  and  the  needs  of  its  readers  will  be  subserved  by 
the  proposed  change.  The  argument  stands  about  as 
follows:  Drs.  A.,  B.  and  C.  believe  The  Journal  should 
be  removed  to  Washington,  because  they  wish  it;  whereas 
Drs.  X.,  Y.  and  Z.  desire  it  to  remain  in  Chicago,  be- 
cause their  interests  demand  it.  Which  of  these  parties 
succeeds  in  fortifying  this  principal  argument  by  the 
strongest  accessories  in  the  shape  of  votes,  will  be  shown 
at  the  coming  meeting  of  the  Association. 

But  there  is  auother  aspect  of  the  case,  which  has  not, 
we  believe,  received  any  attention.  How  will  the  re- 
moval affect  the  interests  of  Chicago? 

To  the  present  resident  staff  of  The  Journal  this  would 
seem  a  matter  of  course,  as  it  would  seriously  incom- 
mode them  to  be  compelled  to  remove  to  Washington. 
They  form  but  a  small  element  in  the  Chicago  profes- 
sion, however,  and  when  we  eliminate  the  question  of 
personal  interest,  we  cannot  come  to  any  other  conclu 
sion  but  that  the  removal  would  be  a  good  thing  for 
Chicago. 

The  Journal  is  not,  and  must  not  be,  in  any  sense  a 
local  journal.  It  is  national ;  and  any  attempt  to  make 
it  a  representative  of  Chicago  medicine  would  be  met 
with  a  howd  of  reprobation  from  all  quarters.  And  yet, 
as  the  only  professional  journal  published  in  that  city,  it 
blocks  the  way  for  what  Chicago  needs,  a  strong  and 
well-supported  weekly  medical  journal.  Chicago  is  now 
the  second  city  in  this  continent.  Its  business  interests 
are  even  greater  than  its  population,  proportionately. 
Its  physicians  number  over  2.000;  active,  progressive 
and  cultured  men.  But  in  medical  journalism  it  is  repre- 
sented by  three  monthlies,  published  by  two  manufactur- 
ing drug  firms  and  one  surgical  instrument  house.  Very 
good  journals  they  are,  and  very  well  edited  ;  but  is  it 
not  a  disgrace  that  the  medical  profession  of  that  city 
has  no  journal  of  its  own,  but  is  contented  to  take  its 
literature  from  such  sources  ? 

If  The  Journal  were  to  remove  to  Washington,  there 
would  be  an  opportunity  for  Chicago's  warring  cliques 
to  unite  in  the  production  of  a  good  medical  weekly  that 
would  worthily  represent  the  profession  of  that  city. — 
Tunes  and  Register,  March  21,  1S91. 


Our  readers  all  know  that  the  American  Medical  As- 
sociation has  a  journal,  a  real  live  publication,  of  its  own, 
and  that  The  Journal  is  managed  by  a  Board  of  Trustees, 
and  that  the  Trustees  have  just  more  than  stirred  up 
matters  by  openly  proposing  to  move  the  place  of  its 
publication  from  Chicago  to  Washington.  Praises  and 
denunciations  of  the  Trustees  and  The  Journal  have  been 
as  general  as  the  rustling  of  the  leaves  in  Autumn. 
Every  member  of  the  Association  is  a  stock-holder,  and 
realizes   fully  the   grave  responsibility  that  rests   upon 


him  in  that  capacity,  and  away  down  deep  in  the  inner- 
most recesses  of  his  consciousness  he  believes  he  knows 
more  about  the  creation  and  running  of  a  weekly  med- 
ical journal  than  that  whole  Board  of  Trustees  put  to- 
gether, and  any  number  have  gone  so  far  as  to  argue 
that  The  Journal  ought  to  remain  in  Chicago  because  of 
its  superior  mail  facilities,  or  that  it  ought  to  go  to  Wash- 
ington because  that  city  isn't  a  medical  centre  and  hasn't 
got  a  medical  journal  of  any  kind,  and  would,  on  that 
account,  be  free  from  influences.  Such  arguments  are 
downright  heavy-weights  in  the  minds  of  the  doctors 
who  live  at  crossroad  villages  and  receive  a  mail  but 
once  or  twice  a  week,  and  who  hesitate  about  sending 
their  sons  to  a  large  city  for  fear  of  their  contact  with 
the  sin  and  wickedness  that  stalks  all  around,  or  lies  in 
ambush  for  just  such  sons  as  theirs. 

As  for  mail  facilities  in  these  days  of  wonderful  works, 
the  Journal  of  the  American  Medical  Association  can  be 
just  as  rapidly  distributed  to  its  subscribers  if  mailed  at 
Kokomo,  Lebanon  or  Kankakee,  as  if  mailed  in  Chicago; 
and  as  for  influences,  why  bless  the  innocent  souls  of  the 
Oskkosh  and  Podunk  members,  Washington  is  full  of 
them.  There  is  the  Columbia  Medical  College,  that  is 
just  as  much  a  medical  college  as  the  Chicago  Medical 
College  ;  aud  the  Columbia  Hospital ;  the  Surgeon- 
Generals  of  the  Army,  Navy  and  Marine-Hospital  Service, 
three  of  them,  and  all  influences  of  the  most  potent 
kind.  A  National  Medical  Library  is  there  also,  one  that 
belongs  to  the  United  States,  although  its  manipulator 
sometimes  has  spells  in  which  he  don't  think  so,  and  just 
placards  it  "  closed  for  repairs."  Why  there  are  actually 
more  influences  in  Washington  than  there  is  wind  in 
Chicago.  Another  argument,  aud  the  one  most  leaned 
upon  by  those  favoring  Washington  is,  that  it  is  the 
Capital  of  our  Nation.  This  is  true,  aud  it  means  much, 
but  Washington  is  in  no  sense  a  metropolis,  nor  is  it 
near  the  centre  of  population.  We  think  the  latter  a 
factor  of  the  very  greatest  importance.  We  regard  the 
centralization  of  goodly  numbers  in  active  medical  so- 
ciety work  as  a  barometer  that  never  fails  to  tell  of  the 
quality  and  character  of  the  men  who  support  medical 
journals. 

The  New  England  profession  has  its  Boston  Journal, 
the  New  York  profession,  their  Record  and  Journal,  and 
in  Philadelphia,  the  Reporter,  News,  Times  and  Register, 
not  counting  the  monthlies.  These  are  all  well  and  ably 
sustained;  and  not  one  of  the  proprietors  of  those  journals 
wants  the  Association  Journal  one  mile  nearer  to  them 
than  it  now  is.  This  journalistic  lukewarrnness  has  ex- 
tended to  the  subscribers  and  supporters  of  those  publi- 
cations. The  local  medical  profession  of  Washington,  to 
their  credit  and  honor,  it  must  be  said,  have  as  a  body 
been  103'al  sustainers  of  the  American  Medical  Associa- 
tion. Furthermore,  it  caunot  be  charged  against  them 
that  they  have  engaged  in  any  intrigues  to  secure  the 
transfer  of  the  journal  publication  office  to  their  city. 
While  the  question  has  been  of  the  most  vital  interest  to 
the  Chicago  profession.  The  discussion  seems  to  have 
done  great  good  in  stimulating  them  to  activity  in  good 
works  that  was  not  before  manifest;  in  fact  there  is  an 
awakening  to  a  realizing  sense  of  the  good  thing  they 
have  enjoyed  in  the  location  of  the  Association  Journal 
in  their  city. — Cincinnati  Lancet-Clinic,  March  21,  1891. 


Dr.  J.  L.  Fullerton,  Secretary  of  the  Medi- 
cal Society  of  the  State  of  West  Virginia,  died 
March  3,  near  Charleston,  W.  Va. 

Surgeon  Abel  F.  Price,  U.  S.  N.,  formerly 
of  the  Naval  Dispensary,  Washington,  D.  C. ,  has 
been  ordered  to  the  Monongahela,  as  also  Assist. 
Surgeon  S.  G.  Evans,  from  the  Naval  Academy. 


I89i.] 


ASSOCIATION  NEWS 


575 


ASSOCIATION  NEWS. 


American  Medical  Association. 

RAILROAD     ARRANGEMENTS. 

We  are  able  to  announce  that  arrangements 
have  been  made  with  the  Pennsylvania  Central, 
the  Baltimore  and  Ohio,  and  the  "  Big  /■'our," 
the  three  great  through  lines  from  Chicago  to 
Washington,  by  which  Physicians  and  their  fam- 
ilies can  obtain  transportation  with  return  tickets 
at  one  and  one  third  rates. 

Dr.  Atkinson,  the  Secretary  of  the  Association, 
informs  us  that  the  Western  Passenger  Associa- 
tion has  refused  to  grant  commutation  upon  the 
following  roads:  the  Atchison,  Topeka  &  Santa 
Fe,  Burlington,  Cedar  Rapids  &  Northern,  Bur- 
lington &  Missouri,  Chicago  &  Alton,  Chicago  & 
Northwestern,  Chicago,  Burlington  &  Northern, 
Chicago,  Burlington  &  Quincy,  Chicago,  Mil- 
waukee &  St.  Paul,  Chicago,  Rock  Island  6c  Pa- 
cific, Chicago,  "St.  Paul,  Minneapolis  6c  Omaha, 
Chicago,  St.  Paul  6c  Kansas.  Hannibal  ..V  St. 
Joseph,  Kansas  City,  St.  Joseph  &  Council  Bluff, 
Illinois  Central,  Iowa  Central,  Milwaukee  & 
Northern,  Milwaukee,  Lake  Shore  &  Western, 
Minneapolis  &  St.  Louis,  Missouri  Pacific,  Rock 
Island  &  Peoria,  Sioux  City  &  Pacihc,  St.  Louis, 
Keokuk  &  North  Western,  St.  Joseph  &  Grand 
Island,  Union  Pacific,  W abash.  Wisconsin  Cen- 
tral. It  may  therefore  be  desirable  for  those  who 
propose  to  go  to  Washington  to  secure  tickets  to 
Chicago,  St.  Louis  or  Cincinnati,  and  from  thence 
avail  themselves  of  the  special  rates. 

We  have  received  a  further  communication 
from  Dr.  Atkinson  in  which  he  states  that  all  who 
buy  tickets  over  the  roads  which  have  agreed  to 
the  certificate  plan  must  obtain  a  certificate  of  the 
agent  at  the  time  of  purchase.  "This  signed  by 
me  at  Washington  enables  him  to  obtain  a  return 
ticket  at  one-third  full  rate."  No  rebate  will  be 
allowed  otherwise.  The  following  roads  are  all 
that  agree  to  any  reduction: 

Trunk  Line  Association,  comprising  the  Grand 
Trunk,  New  York  Central  &  Hudson  River, 
West  Shore,  N.  Y.  Central  &  Western,  New 
York,  Lake  Erie  &  Western,  Delaware,  Lacka- 
wanna &  Western,  Lehigh  Valley,  New  Jersey 
Central,  Phila.  &  Reading,  Pennsylvania,  Balti- 
more &  Ohio,  Chesapeake  &  Ohio. 

York  &  Boston  Lines  Passenger  Commit- 
tee, comprising  the  New  York,  New  Haven  & 
Hartford,  Old  Colony,  Old  Colony  Steamship  Co., 
New  York,  Providence  &  Boston,  Providence  & 
Stonington  S.  S.  Co.,  New  York  &  New  Eng- 
land, Norwich  &  New  York  Transportation   Co. 

Southern  Passenger  Association,  comprising  the 
Atlantic  Coast  Line,  Atlanta  &  West  Point, 
Brunswick  &  Western,  Charleston  &  Savannah, 
Central  of  Georgia,  East  Tennessee,    Virginia  & 


Georgia,  Georgia  Pacific,  Georgia  Southern  & 
Florida,  Jacksonville,  Tampa  .S:  Keywest,  Nor- 
folk Western,  l'enua.  south  of  Washington, 
Port  Royal  &  Augusta,  Raleigh  &  Gaston,  Rich- 
i  Danville,  Richmond,  Fredericks  &  Poto- 
mac, Savannah,  Florida  6c  Western,  Sea  Board  & 
Roanoke,  Shenandoah  Valley,  South  Carolina, 
Western  6c  Atlantic. 

Central  Traffic  Association,  comprising  the  ter- 
ritory bounded  on  the  East  by  Pittsburg 
manca,  Buffalo  6c  Toronto:  on  the  North  by  the 
line  of  the  States  of  Ohio,  Indiana  &  Illinois  to 
the  north  line  of  Cook  County;  on  the  West  by 
the  west  line  of  Cook  County  and  the  Illinois  & 
Mississippi  Rivers  to  Cairo,  including  Burlington, 
Quincy,  Hannibal  and  St.  Louis;  and  on  the 
South  by  the  Ohio  River,  but  including  points  on 
either  side  of  that  river. 

INSTRUCTIONS  TO  DELEGATES. 

1.  Each  person  must  purchase  (not  more  than  three 
davs  prior  to  the  date  of  the  meeting  nor  Liter  than  three 
days  after  the  commencement  of  the  meeting  i  a  first- 
class  ticket  i  either  unlimited  or  limited  i  to  the  place  of 
meeting,  for  which  he  will  pay  the  regular  tariff  fare, 
and  upon  request  the  ticket  agent  will  issue  to  him  a  cer- 
tificate of  such  purchasi  properly  filled  upand 
signed  by  said  ticket  agent. 

2.  If  through  tickets  cannot  be  procured  at  the  starting 
point,  the  person  will  purchase  to  the  nearest  point 
where  such  through  tickets  can  be  obtained,  and  there 
repurchase  through  to  place  of  meeting,  requesting  a 
certificate  properly  filled  out  by  the  agent  at  the  point 
where  repurchase  is  made. 

3.  Tickets  for  the  return  journey  will  be  sold  by  the 
ticket  agents  at  the  place  of  meeting  at  one-third  the 
highest  limited  fare,  onlv  to  those  holding  certificates 
(Form  2),  signed  bv  the  ticket  agent  at  point  where 
through  ticket  to  the  place  of  meeting  was  purchased, 
and  countersigned  by  the  secretary  or  clerk  of  the  con- 
vention, certifying  that  the  holder  has  been  in  attend- 
ance upon  the  convention. 

4.  It  is  absolutelv  necessary  that  a  certificate  be  pro- 
cured, as  it  indicates  that  full  fare  has  been  paid  for  the 
going  journev.  ami  that  the  person  is  therefore  entitled 
to  the  excursion  fare  returning.  It  will  also  determine 
the  route  via  which  the  ticket  for  return  journey  should 
be  sold,  and  without  it  no  reduction  will  be  made,  as  the 
rule  of  the  association  is  that  "  Xo  refund  of  fare  can  be 
expected  because  of  failure  of  the  parties  to  obtain  certi- 
ficates." 

5.  Tickets  for  return  journey  will  befuruisued  only  on 
certificates  procured  not  more  than  three  days  before  the 
meeting  assembles,  nor  later  than  three  days  alter  the 
commencement  of  the  meeting,  and  will  be  available  for 
continuous  passage  onlv:  no  stop  over  privileges  being 
allowed  on  tickets  sold  at  less  than  full  fares.  Certificates 
will  not  be  honored  unless  presented  within  three  days 
after  the  date  of  the  adjournment  of  the  convention. 

6.  Ticket  agents  will  be  instructed  that  excursion  fares 
will  not  be  available  unless  the  holders  of  certificates  are 
properlv  identified,  as  above  described,  by  the  secretary 
or  clerk,  on  the  certificate,  which  identification  includes 
the  statement  that  one  hundred  or  more  persons,  who 
have  purchased  full  fare  tickets  for  the  going  passage, 

I  and  hold  properly  receipted  certificates,  have  been  in  at- 
,  tendance  at  the  meeting. 

j  The  certificates  are  not  transferable,  and  the  signature 
1  affixed  at  the  starting  point,  compared  with  the  signature 
j  to  the  receipt,  will  enable  the  ticket  agent  to  detect  any 
I  attempted  transfer. 


576 


MISCELLANY. 


[April  18,  1891. 


Section  on  Materia  Medica  and  Pharmacy. 

The  Section  on  Materia  Medica  and  Pharmacy 
will  meet  for  organization  at  2:30  p.m.,  on  Tues- 
day, May  5,  at  a  place  to  be  named  by  the  Com- 
mittee on  Arrangements  of  the  American  Medical 
Association. 

In  conformity  with  the  report  of  the  Committee 
on  Conference,  adopted  at  the  last  session,  the 
American  Pharmaceutical  Association,  by  inyta- 
tion,  has  appointed  a  Committee  of  twenty-five 
of  its  leading  members,  representing  all  sections 
of  the  United  States,  to  attend  this  Section  and 
contribute  to  its  scientific  proceedings.  The  after- 
noon of  the  second  day  will  be  devoted  to  the 
consideration  of  the  United  States  Pharmacopoeia, 
the  discussion  to  be  opened  by  Professors  H.  C. 
Wood,  M.D.,  and  Joseph  P.  Remington,  Ph.G. 
As  a  number  of  members  of  the  Committee  on 
Revision  of  the  U.  S.  Pharmacopoeia  will  be  pres- 
ent, such  discussion  cannot  fail  to  be  interesting 
and  valuable. 

Members  of  the  American  Medical  Association 
engaged  in  teaching  pharmacolog5'  are  especially 
requested  to  manifest  their  interest  in  this  new 
Section  by  registering  their  names  as  members 
and  by  contributing  to  its  proceedings. 

Titles  of  papers,  with  brief  abstracts  of  con- 
tents, should  be  sent  at  once  to  the  office  of  the 
Chairman,  No.  218  S.  Sixteenth  St.,  Philadel- 
phia, in  order  that  they  may  be  published  in  the 
official  programme.  Papers  should  not  occupy 
more  than  fifteen  minutes  in  delivery, 

Frank  Woodbury,  Chairman. 
W.  G.  Ewing,  Secretary. 


inoculation  treatment  was  yet  in  progress  when 
the  ill-fated  young  pathologist  was  confined  to 
his  house  by  symptoms  of  peripheral  neuritis. 
His  sufferings  were  intense  and  were  succeeded 
by  paralytic  symptoms,  which  were  progressive 
and  extended  finally  to  the  muscles  of  respiration, 
to  remedy  which  resort  was  had  to  artificial  res- 
piration, maintained  for  over  sixteen  hours  b}r 
the  young  man's  medical  friends  and  students 
from  the  New  York  Hospital.  Consciousness 
persisted  until  a  few  minutes  before  the  end.  His 
loss  is  one  not  lightly  to  be  measured,  for  he 
united  to  high  native  ability,  a  well  trained  judg- 
ment, as  well  as  industry,  courage  and  fidelity 
to  dutv. 


MISCELLANY. 


NECROLOGY. 


Dr.  Henry  William  Stephens  of  Brooklyn, 
N.  Y.,  died  February  22,  in  consequence,  as  is  be- 
lieved of  an  autopsical  injury  or  infection.  He 
was  only  thirty-three  years  of  age  and  had  been 
only  eight  years  in  the  profession.  He  was  a 
native  of  Saratoga  Springs,  a  graduate  of  Will- 
iams College  and  of  the  College  of  Physicians  and 
Surgeons,  New  York.  After  graduating  he  spent 
two  years  as  interne  in  the  New  York  Hospital, 
whence  he  went  to  Cheyenne  and  there  remained 
in  practice  until  last  October.  He  then  came 
East  and,  having  made  his  residence  in  Brooklyn, 
was  soon  thereafter  chosen  assistant  pathologist 
to  the  hospital  above  named.  In  the  latter  part 
of  January,  he  had  oecasion,  in  the  performance 
of  his  round  of  duty,  to  participate  in  an  autopsy 
in  a  hydrophobic  case,  although  at  that  very  time 
having  an  unhealed  dissection-wound  and  some 
inflammation  of  the  left  arm  resulting  therefrom. 
The  old  sore  was  broken  in  upon  in  the  course  of 
the  hydrophobic  autopsy,  and  Dr.  Stephens 
deemed  it  wise  to  put  himself  under  the  treat- 
ment of  Dr.  Gibier  of  the  Pasteur  Institute.     The 


LETTERS  RECEIVED. 

Albany,  N.  Y..  J.  F.  Madden. 

Ansonia.  Conn.,  McArthur  Kvpophosphite  Co. 

Baltimore.  Md..  Dr.  H.  Freideuwald,  Dr.  H.  A.  Kellv. 

Birmingham.  Ala..  Dr.  W.  E.  B.  Davis. 

Boston,  Dr.  Henry  O.  Marcy,  R.  Hodgson. 

Buffalo  Lithia  Springs.  Va.,  Thos.  F.  Good*. 

Chicago,  111.,  Dr.  J.  H.  Chew,  Dr  D.  A.  Dobie,  Dr.  E.  S.  Talbot. 
Rush  Medical  College. 

Cincinnati,  O.,  Dr.  Chas.  A.  L.  Reed. 

Cleveland  O.,  Mrs.  F.  J.  Weed. 

Detroit,  Mich.,  Dr.  A.  L.  Worden,  Dr.  I,.  S.  Trowbridge. 

East  Pasedeua,  Cal.,  Dr.  G.  S.  Gore. 

Galveston.  Texas,  Dr.  Geo.  Dock. 

Jacksonville,  111.,  Ward  Bros. 

Jersey  Citv,  N.  J.,  Dr.  Wm  P.  Watson. 

Kansas  City,  Mo.,  Dr.  T.  L-  Bennett,  Dr.  F.  B.  Tiffany. 

Long  Beach,  Cal.,  Dr.  E.  A.  Dial. 

Louisville.  Ky.,  Dr.  D.  Reynolds,  Robinson-Pettit  Co. 

Middlesborough,  Kw,  Dr.  J.  K.  Kutnewskv. 

Mt.  Sterling.  111.,  Dr.  W.  M.  Cox. 

New  York  Citv,  Drevet  Mfg.  Co.,  American  and  Continental 
Sanitas  Co.,  Woman's  Medical  College.  W.  P.  Cleary,  Dr.  P.  A.  Lal- 
lan, Robinson-Baker  Advertising  Bureau. 

Paris,  France,  J.  Astier. 

I'arkersburg,  W.  Va     Dr.   W.   H.   Sharp. 

Philadelphia,  Pa.,  Dr.  W.  B.  Atkinson,  Dr.  R.  J.  Duuglison,  Dr. 
H.  A.  Hare.  Wm.  R.  Warner  &  Co.,  Dr.  Benjamin  Lee,  Dr.  Frank 
Woodbury,  Lea  Bros.  &  Co. 

Pouglikeepsie,  N.  Y. .  Dr.  Wm.  Cramer. 

Racfne,  Wis.,  Horlick's  Food  Co. 

Sacramento,  Cal.,  Dr.  G.  D.  Sunmores. 

St.  Louis,  Mo.,  Dr.  R.  M.  Jordan,  Dr.  C.  A,  Todd. 

Toledo,  O.,  Dr.  N.  A.  Hollister. 

Wilkesbarre,  Pa.,  Dr.  Maris  Gibson, 


Official  List  of  Changes  in  Ike  Stations  and  Duties  of  Officers  Serving 
in  the  Medical  Department,    l\  S    Army,  from  April  4,  /.<<>/.  to 
to,  /Sqi. 
Capt.  Jno.  Van  R.  Hoff,  Asst.  Surgeon,  now  in  New  York  City,  on 
leave  of  absence,  is  assigned  to  duty  as  an  additional  member  of 
the  board  of  medical  officers  constituted  by  par.  is.  S.  O.  52,  March 
7,  1801,  from  this  office.  to  meet  111  New  York  City,  for  the  exam- 
ination of  candidates  for  admission  to  the  Medical  Corps  of  the 
Armv,  etc.     Bv  direction  of  the  Acting  Secretary  of  War.     I'ar.  6, 
A.  <'. ."().,  Washington,  April  ■ 
Official  List  of  Changes  of  Stations  and  Duties  of  Medical  Officers  of 
the  V.  S.  Maiiue-Hospital  Seince,  foi  the  Three  Weeks  Ending 
April 
Sui 11  Walter  Wyman,  to  inspect  Delaware  Breakwatei  Quaran- 
tine station.     March  27,  189] 
i  Surgeon  George  Purviance,  detailed  as  Chairman,  Board  of  Exam- 
inns.    April  3,  1891, 
SuiKoon   H.   W     SawUllc    In   ptnc dl  to    Rockland,  Me.,  on    special 

duty.     March  75.  1891. 
Surgeon    1     M.   Gassawav,  giant- 1  ence  for    five  davs. 

April  2,1891. 

G   dlrey,  detailed  a<  member  Board  of  Examiners 
April 

nrtax  Irwin,  del    ill  ard  ol  Examiners. 

April  3,  1891. 

1   in  C.  T.  Feckham,  grauti  bsence  for  ten  days. 

A1    0  I    I 

P.  A.  Surgeon  Eugeni    Ws  ■  abseuce  for  thirty 

!.i\  .      Man  11 
Asst.  Surgeon  \\    <■   -.inn;  to]  t  to  Charleston,  S  C.,foi 

J  duty.     March 


THE 


J  ournal  of  the  American  Medical  Association. 

EDITED  UNDER  THE  DIRECTION  OF  THE  BOARD  OF  TRUSTEES. 
PUBLISHED    WEEKLY. 


Vol.  XVI. 


CHICAGO,  APRIL  25,   1891. 


No.   17. 


ORIGINAL  ARTICLES. 


SPONTANEOUS    UMBILICAL   HEMOR- 
RHAGE IN  NEWLY-BORN  INFANTS. 

■rote  the  Medical  Society  of  the  District  of  Columbia, 
Febi 

BY  J.  WESLEY  BOVEE.   M.D., 

VTSITTNG  PHYSICIAN   TO  WASHINGTON  ASYLUM   HOSPITAL:   ATTEND- 
ING PHYSICIAN  TO   ST.  ANNS   INFANT   ASYLUM;    AND    OBSTETRI- 
CIAN   TO    COLUMBIA    HOSPITAL    FOR   WOHXH   AND    LYING-IN- 
ASYLUM. 

(Concluded  from  page  54  ~ 

Diagnosis. — The  diagnosis  of  this  condition  is 
usually  not  difficult.  The  appearance  of  blood  on 
the  dressings  about  the  navel  usually  leads  to  ex- 
amination of  it  and  of  the  cord  if  still  attached. 
The  bleeding  will  be  noticed  in  nearly  even'  case. 
When  it  occurs  from  the  end  of  the  cord  it  may 
be  mistaken  for  bleeding  due  to  defective  liga- 
tion. It  may  occur  at  various  intervals  and  in 
small  quantities,  thus  escaping  detection.  Espe- 
cially will  this  be  the  case  if  the  blood  be  very 
hydraemic  or  if  containing  much  bile.  If  the 
bleeding  of  this  nature  be  from  the  end  of  the 
cord  successive  ligation  will  probably  prove  futile 
and  the  true  nature  of  the  malady  will  be  recog- 
nized. There  will  be  evidences  of  a  constitutional 
affection,  denoted  by  purpuric  spots,  haemorrhage 
from  other  parts  of  the  body,  jaundice  and  other 
unmistakable  symptoms. 

Treatment. — The  treatment  of  umbilical  haem- 
orrhage in  newly-born  infants  is  of  great  impor- 
tance, as  about  three -fourths  of  the  cases  succumb 
to  it  and  those  that  withstand  it  usually  are  much 
weakened  for  some  time  afterward. 

Occasionally  cases  have  recovered  with  very 
little  treatment,  and  others  have  resisted  all  forms 
of  treatment  for  weeks  and  ended  fatally.  These 
slow  persistent  cases  have  allowed  sufficient  time 
for  all  the  different  remedies  that  could  possiblj- 
be  suggested,  each  and  all  failing  to  permanent- 
ly check  the  haemorrhage,  or  at  least,  not  avert- 
ing death.  Successive  ligation,  applications  of 
astringents  of  even-  kind,  caustics,  the  actual 
cautery,  collodion,  plaster  of  Paris,  acu-pressure, 
transfixion  with  double  ligature,  ligation  en  masse. 
ligation  by  the  puckering  string  method,  ligation 
of  the  hypogastric  arteries  and  umbilical  vein  by 


Dakin's*3  method  and  dissection  about  umbilicus 
with  ligation  of  cord  before  its  exit  from  the  ab- 
dominal wall,  have  all  been  used  in  attempts  to 
arrest  omphalic  bleeding  in  infants.  Caustics  and 
the  actual  cautery  have  done  more  harm  than 
good,  the  bleeding  usually  beginning  afresh  as 
the  slough  comes  away.  The  application  of 
liquid  plaster  of  Paris  with  proper  ligation  as  first 
recommended  by  Churchill**  is  highly  praised  by 
Robinson'-'  and  others  and  was  sufficient  in  one  of 
the  author's  cases. 

The  ligature  en  masse  is  one  of  the  most  effi- 
cient topical  remedies  in  use,  but  I  think  its  bene- 
fit will  be  enhanced  by  the  application  over  it  of 
styptics  and  compression,  or  of  plaster  of  Paris. 
Radford"  recommended  cutting  down  and  ligat- 
ing  the  umbilical  vein,  and  Dakin  ligates  the  um- 
bilical vein  or  arteries,  first  passing  on  a  level 
with  the  lower  edge  of  the  umbilicus.  He  uses  a 
hare-lip  pin,  passing  it  through  the  abdominal 
wall,  under  the  arteries,  and  back  through  the  ab- 
dominal wall.  This  pin  he  finds  sufficient  to  control 
arterial  haemorrhage  and  for  venous  haemorrhage 
he  applies  a  figure  8  ligature  over  the  ends  of  the 
pin  including  the  umbilicus  in  it.  This  treat- 
ment is  very  ingenious  and  I  think  easily  per- 
formed.    It  desen~es  further  trial. 

Dr.  L.  Eliot, !:  of  Washington,  was.  I  think,  the 
first  to  adopt  the  suggestion  of  Radford  and  ligate 
the  cord  in  the  abdominal  wall.  He  did  not  save 
his  patient,  but  had  the  operation  been  done  ear- 
lier, before  the  child  was  exhausted  from  loss  of 
blood,  and  without  anaesthesia.  I  believe  the  re- 
sult would  have  been  better.  Pout*.  1822,  report- 
ed a  case  in  which  death  occurred  from  bleeding 
from  the  left  hypogastric  artery  and  stated  that 
in  a  similar  case  he  would  cut  down  upon  the  ar- 
teries and  tie  them.  He,  probably,  desen-es  as 
much  credit  as  does  Radford  for  the  early  sugges- 
tion of  the  operation  performed  by  Dr.  Eliot.  In 
nearly  every  case  the  treatment  has  been  entirely 
local,  with,  perhaps,  the  addition  of  some  chola- 
gogue  cathartic  as  calomel  or  sulphate  of  soda, 
when  marked  jaundice  was  present. 

The  profession  has  been  slow  to  believe  that 

p.  296. 

.:-gh  Med.  Jour 
Mcdico-Chir.  Transact..  London 


573 


SPONTANEOUS  UMBILICAL  HEMORRHAGE. 


[April  25, 


this  form  of  haemorrhage  was  but  a  symptom  of 
a  general  condition  and  have  treated  it  locally  in- 
stead of  generally.  The  local  treatment  cannot 
be  dispensed  with  but  the  internal  administration 
of  remedies  to  improve  the  condition  of  the  blood 
and  tissues  in  general  is  of  great  importance.  The 
mineral  acids,  the  muriated  tincture  of  iron  and 
tonics  should  be  given.  Brandy  should  be  given 
to  keep  up  the  strength  and  in  some  cases  ergot 
is  admissible.  The  food  should  be  the  best,  con- 
sisting principally  of  milk,  and  a  building-up 
course  instituted.  If  syphilis  is  present  it  must 
not  be  forgotten  in  the  treatment.  The  general 
hygiene  of  the  patient  must  be  the  very  best. 
Prophylaxis  might  in  a  measure  be  carried  out  in 
the  treatment  of  this  trouble. 

Dr.  M.  S.  Perry=,J  has  treated  mothers  who  have 
had  children  with  hemorrhagic  diathesis  in  this 
way.  He  noticed  women  who  were  accustomed 
to  take  alkalies  during  pregnancy  for  dyspeptic 
or  other  symptoms  were  peculiarly  liable  to  haem- 
orrhages after  parturition.  He  accordingly  gave 
mineral  acids,  instead,  with  good  results. 

It  would  be  well  to  put  mothers,  during  preg- 
nancy, whose  former  children  have  had  haemor- 
rhages shortly  afterbirth,  upon  this  treatment. 

BIBLIOGRAPHY. 

Porak,  C,  Ann.  de  gyn£c,  Paris,  1S7S,  x,  189,  200,  291, 
306;  also  Arch,  de  Tocol.,  Paris,  1879,  vi,  30-39. 

Maasmann,  St.  Petersb.  Med.  Wchnsch.,  1SS9,  iv,  9S. 
Hyrntschak,  Centr.  Ztg.  f.  Kiuderk.,  Berlin,  1S7S-9,  ii, 

355- 

Weiss,  M.,  Prag,  Med.  Wchnsch,  1879,  iv,  301-4. 

Weiss,  M.,  Prag,  Med.  Wchnsch.,  1S79,  *v.  2S9-295. 

Depaul,  J.,  d.  Sages-fem.,  Paris,  1SS9,  viii,  17. 

Ribernont,  A.,  Des  hemorrhagies  chez  le  nouveau-ne, 
Paris,  1SS0,  4to. 

Lenoel,  Soc.  Med.  d' Amiens  Bull.,  (1878-9)  1SS0,  xviii 
and  xix,  98. 

Dieterlen,  Bull.  Soc.  Chir.  de  Par.,  (1881)  1SS2,  v,  101- 
105. 

Abbe,  X.  Y.  Med.  Jour.,  1SS3,  xxxviii.   193. 

Hirigoyen,  J.,  de  Med.  de  Bordeaux,  1SS2-3,  xii,  565. 

Lemere,  Gaz.  Med.  de  Picardie,  Amiens,  1883,  1,  117- 
119. 

Furth,  L.,  Arch.  f.  Kinderk.  Stuttg.,  1SS3-4,  v,  s°5-i3- 

Silverskiold,  Eira,  Goteberg,  1SS5,  ix,  485-8. 

Borelius,  J.,  Upsala,  Lakaref.,  Forh.,  18S6,  xxii,  40-44. 

Tross,  O.,  Berl.  Klin.  Woch.,  iSSS,  xxv,  833-835. 

Ashby  and  Wright,  Dis.  of  Children,  Med.  and  Surg., 
London,  1S89,  700  pp,  Svo,  p  30. 

Smith,  Eustace,  Dis.  of  Children,  London,  1SS9,  2d  ed., 
p.  764. 

Keatmg's  Cvclopaed.  Dis.  of  Children,  Philadelphia, 
1890,  iii,  p.  6 

M  aniens,  Jahrb.  f.  Kinderk.  u.  phys.  Erzieluug,  1SS9, 
Bil.  22,  H.  and  C,  p.  452. 

Lamare,  A..  De  la  tenacite  et  de  la  rupture  du  cordon 
ombilical,  Par.,  [888,  143  p..  4to.,  X".  259. 

Goebel,  Der  Frauenarzt,  H.  ix,  iSSS,  iii,  469-522. 

Ritchie,  R.  P.,  Edinb.  Med.  Jour,  iSi,s,  xiii.  1072,  10S6. 

Margueritte,  I...  Bull,  de  Therap.,  Paris,  1868,  Ixxiv, 
271. 

r.  R.  M.,  De  Omphalorrhagia,  idiopathica,  Leip- 
sic,  1859,  8vo. 

Richard,  Bull.  Soc.  Chir.,  Paris,  1856,  vii,  1  ; 

Blatter  f.  gericht.   Anthropol.,  Numbers,    t86l,    j6l-8. 


'See  Mill.' 


Tourelle,  J.,  Ueber  blutungen  aus  der  nabelschnur  und 
dem  nabel,  Inaug.  Dissert.,  1S54,  Giessen,  Druck,  29  p., 
Svo. 

Schauenberg,  Carl.  H.,  zu  der  Lehre  von  den  Verblut- 
ungen  aus  dem  Nabel  Mit  Siichsicht  auf,  sec.  201,  des 
Preussischen  Strafgesetzbuches,  24  p.,  Svo.,  Neuwied  and 
Leipzig,  J.  H.  Heuser,  1S70. 

Whitall,  S. ,  Umbilical  Haemorrhage,  Hosp.  Gaz..  New 
York,  1S77,  1,  62,  63. 

Marcailhou  d'Agmeric.  Un  cas  d'h£mophilie  par  le 
cordon  ombilical.,  Alger.  Med.,  1873,  1,  30-37. 

Shepherd,  J.,  Umbilical  Haemorrhage,  Lancet,  Lon- 
don, 1861,  ii,  n.  s.j  360. 

Duplain,  Note  sur  l'h£morrhagie  du  cordon  ombilical, 
Svo,  St.  Etienne,  1S72. 

O'Connor,  T.,  Haemorrhage  from  Navel  seventeen  days 
after  Birth,  Brit.  Med.  Jour.,  i860,  ii,  61S,  619. 

Hewitt,  G.,  A  Case  of  fatal  Umbilical  Haemorrhage  in 
an   Infant,  Trans.  Obst.  Soc,  Lond.,  1854,  vi,  65,  66. 

Duhois.  E.,  Hemorrhagic  ombilicale  chez  les  enfants 
nouveau-nes,  Gaz.  Hebd.  de  med.  et  de  chir.,  Paris,  1859, 
vi,  729-30. 

Vormann,  Die  Todesart  durch  Verblutuug  aus  der  Na- 
belschnur bei  Neugeborneu  Kindern,  Vierteljahrsch.  f. 
gericht.  Hoff,  Med.  Berl.,  1850,  ix,  77. 

Marsh,  E.  J.,  A  Case  of  Haemorrhage  from  the  Umbil- 
icus, N.J.  Med.  Rep.,  Burlington,  1848,  i,  1S1. 

McGraw,  T.  A.,  Detroit,  Rev.  Med.  et  Pharm.,  1S67,  ii, 
444-446,  p-  I3J-2- 

Jeuniu,  B.,  Jour,  des  Connais.,  Med.  Chir.,  Paris,  1S47; 
Bull.  Gen.  de  Therap.  Med.,  et  Chir.,  Paris,  1S49,  xxxvii, 

308-3I3- 

Sedillot,  Jour.  ge'n.  de  med.  de  chir.  de  Pharm.,  etc., 
1S05,  xxii,  153-160. 

Dubois,  P.,  Jour,  des  Comd.  Med.-Chir.,  Paris,  1S47, 
97.  9S- 

Degland,  Recueil  Periodique  de  la  soc.  de  mdd.  de 
Paiis,  1798-9.  iv,  345. 

Rittershain,  G.  Ritter  von,  Oesterr.  Jahrb.  f.  Paediat., 
Wien.,  1S70,  i,  15;  Med.  Circ,  etc.,  London,  1S64,  xxiv, 
P-  339- 

Walker,  J.  E.,  South.  Med.  and  Surg.  Jour.,  1S52,  viii, 
606-60S. 

Townsend,  W.  E.,  Boston  Med.  and  Surg.  Jour.,  1S61, 
lxiv,  210,  211. 

Gage,  W.,   Western  Lancet,  Cincinnati,  1S53,  x'v-  552- 

Mauley,  J.,  Lond.  Med.  Gaz.  n.  s.  1850,  xlv,  755-763. 

Pepper,  Am.  Jour.  Obstet.,  New  York,  1870.  iii,  327, 
328. 

H.  D.  R.,  Bost.  Med.  and  Surg.  Jour.,  1S51,  xliv,  521-2. 

Homaus,  J.,  Ibid.,  1S49,  xl,  449-452. 

Anderson,  W.  C,  Ibid.,  1S50,  xli,  440-442. 

Stark,  W.,  Cincin.  Lane,  and  Obs. ,  1871,  xiv,  n.  s.  72-81. 

Bridge,  N.,  Chicago  M.  J.,  1873,  xxx,  595,  596. 

Cabot,  Bost.  M.  and  S.  Jour.,  185S-59,  lix,  121. 

Bierbaum,  Med.  Zeitung,  Berlin,  1851,  pp.  50;  55-56; 
58-59;  64-65. 

Marc.  Ann.  d'Hygiene  Pub.,  Paris,  1831.  vi,  12S-159. 

Dardel,  Lyon  M^dicale,  1S70,  v,  98-101;  also  mem. 
soc.  de  Sci.  Mdd.,  Lyons.  1S71,  x,  4S-51. 

Ray,  E.,  Arch.  gen.  de  Med.,  Paris,  1S49,  iii,  177-191; 
also  London  Med.  Gaz..  1849.  xliii,  423. 

Sinclair,  Boston  Med.  and  Surg.  Jour.,  1S73,  x,  65  n.  s. 

Talley,  A.  N.,  Charleston  M.  J.,  1S60,  xv,  750-753 

Werber,  Jour.  f.   Kinderk..  Erlangen,  1S66,  xlvi,  191-6. 

Roth,  Th.,  Ibid..  1S6S,  li,  1-29. 

Buchner.  C.  C.  E.,  De  Omphalainorrhagia  Commeu- 
tatio  Academics,  4to.  Moaachii,  [843. 

Dessau,  (',.  EL,  X.  Y.  Med.  Rec,  1S73,  viii,  254. 

Blatter  f.  gericht.  Anthrop.,  Niirnberg.  [858,  Hft.  3.  p. 
2040. 

Kleinwachter,  Viertelj.  f.  d.  prakt.  Heilk..  Leipzig,  etc., 
[876,  OKXxi,  1 21-30. 

Albert,  Zeitschr.  f.  d.  Staatsarzneik.  Erlangen.  1831, 
x\i,  183-219. 

Chedevergne,  Bull.  gen.  de  Thcr.  Med.  et  Chir.,  Paris, 
1S66,  lxxi,  405-409. 


i»9i.] 


SPONTANEOUS  UMBILICAL  H.EMORRIIAGE. 


57 


TABLE  OF    RECORDED   CASH-  <>[-'    OMPHALORRHAGIA 

M    INATORUM    SPONTANEA,   CHRONOLOGI- 

CALI.Y   ARRANGED 


TABLE  OF  CASES.   OOMTIHUKD, 


Bv   whom 
Reported 


Place  of  Record. 


a  Mauriceau 

3  Watts,  G  . 

4  Deglaud    . 

5Cheyne,  J. 
6  Sedillot . 
-  Pout 


10  Elsaesser . 

1 1  Muhrbeck. 
i2Stoltz  .  .  . 
13  Cams  .  .   . 


i ; 


5  Seibold  . 

16  Albert.  . 

17  Radford. 

-• 


23 

24  Schneider. 

2^  Burdach.  . 
26  Aubinais  . 


s. 


Virchow's  Arch.  Med  .  1S63,  xxviii,  426;  M. 
also  Ziemssen's  Cyc  Mel,  '78,  xvii,  7. 

Traite  des   Mai.  des   Femmcs  Grosses, 
2d  ed. 

Gentlemau's  Mag..  I.ond.,  1752.  xxii,  172. 

Recueil  Periodique  de  la  Soc.  de  Med.de 
Paris.  179S-9.  v.  345. 

1   Diseases  of  Children,  Edin- 
burgh 

Jour.  Gen.  de  Med.  de  Chir.  de  Pharm.. 
etc.    18  5.  xxii.  153-60. 

Med.  Chir.  Trans.,  London,  1822.  xii.  1S3. 


Hufeland's  Jour,  de   Prakt.   Heilk  and  M. 

Med.  Rev..  Phila.,  1S24.  p.  279.     . 

Rust  Magazine    1825,  B^-  ».   . F. 

(Seibold's  Jour.  f.  Geb.,  1S27,  Bd  -    - 
Gemeins  Deutsche  Zeits.  f.  Geb.  Hemdv..    .    . 
lid.  3.  S.  144. 

Ibid.,  S.  145 

Jour.   f.   Geb.    Frauenz.   und    Kinderk,  F. 

Frankfort.  1829,  am.  ix.  31-33. 
Zeitschr.  f.  d.  Staatsarzneik.  Erlangen,   . 

1831 .  xxi    -.--3-219. 
Edinburgh  Med.  and  Surg.  Jour.,    1S32, 


Ibid 


J- 


Hufeland's  Jour..  I--33.  72  B  .   . 
Med -Chir.  Rev.,  1834,  xxv.  232 

Ibid 

Ibid 


Ibid 

Siebold's  Jour.  f.  Geb.  Frauenz.  und  K..  M.    D. 

Bd,  15,  H,  3, 
Mediz  Yereiuzeituiig.  1836,  N.  34  .   . 
Jour,  de  la  Sect,  de  Med.  de  la  Soc.  Acad, 
du  Depart,  de  la  Loire  Infant  -.- 


27  Tiemann  . 


30  Richard . 

31  Costes.   . 

32  Klose .    . 


:u 

.  Ges.  Med.,  Hamburg, 


33  Quadrat .  . 

34  Jecker.  -   . 
Jf  Churchill  . 


-.- 

39  Londsberg. 

40  Riefenstahl 

41  Campbell  . 
42 

43 

44  Clsamer.  . 

45  Dubois.  .  . 

46Jeunin.  . 
Lifle.  .   . 


4S  Simpson. 


52  Keiller 

53  Marsh. 


k .  .   .   . 
neuve. 

re  .    .    . 
50  Dubois.  .   . 
60  Wachsmuth 
6: 
62 

63  Walker 

64  Rav  -   • 


Hufeland's 
Zeitschr.  f. 

- 
Traite  Prat,  des  Mai.  des  Enfants.  Paris 

1830. 
[Aubinais)  Jour,  de  la  Sect,  de  Med..  &c. 

1852,  xxviii,  121. 
Deutsche    Zeits.  f.  d.  Staatsarz.  Erlan 

gen.  1S40.  xx,  105. 
Oester.  Mediz.  Woch..   1841,  N.  S3-  - 
Fricke  &  Oppenheim's  Z 
Op.  Midwifery-.  Dublin.  1S41,  p.  296  . 
Ibid. 


Prov.  Med.  and  Surg.  Jour.  St  - 

Gaz.  Med.  de  Paris  

Hufeland's  Jour.,  Mar.  1^42 

Mediz.  Yeremszeit,  1^4;.   S.  :;>  .... 
North.  Jour,  of  Med  .Edinb..  [84 

Ibid 

Ibid 

Neue  Zeitsch.  f.  Geb..  1*45,  rvii 
IJour.  des  Com.  Med.-Chir.,  Paris.  1847, 
;    97-S. 

Rev.  MM..  Pari?    Sept..  1847,  xcix.  87.  . 
1  Dubois'  Arch.  Gen.  de  Med..  Oct.,  1S49, 

Edinburgh  Jour,  of  Med.  Sci..  Julv.  1847 
Ibid 

IV.id 


Ranking's  Abstract.  Am   I 
New  Tersev  Med.  Rep.. 
I  Ibid  . 


'Dublin  Med.  Press 

New  York  An •■       -  ---190..    . 

Gaz   MM.  de  Paris.  March  n.  1S4S,  191 

Ibid 

Arch   Gen.  de  Med..  Oc- 

Die  Bluterkrankheit.  1849 

Ibid ' 

'Ibid 

South.  M.  &  S.  Jour..  1852,  riii,  n.s..6o6-S 
London  Med.  Gaz..  i?40,  xliii.  423 
:ibid  . 


Ibid 

Ibid 

,rbid 

!Ibid 

Ibid 

Boston  M.  &  S.  Jour., 


i  7 


Place  of  Record. 


223  Hagen.  .  .   . 

224  Berolinensis. 

nnor.   . 
226  Tallev.  .    .    . 


23c  Aueshansel . 

237  Zober  .... 

23s  Yerrier  .    .    . 
239  \Yerber  .   . 
240 

241  Griffith  .   . 

242  Lehnerdt  . 

243  Pooley.  .   . 

244  Du  plain  .  . 

24:  Keiller  .  . 

246  Linton.  .  . 

:  -raw.  . 


.   .   .   F 

Ibid 

M 

M. 

Ibid '.! 

Ibid 

Am.  Jour.  Med.  Sci.,  1850,  xix,  6-, 

Ibid .   .   .   M 

- 

Boston  M         -  :• 

Ibid  .   . 

London  Med.  Gaz  '■: 

Med.  Zeitung,  Br: 

Deutsche  :  t,N.  49  M. 

21 

Am.  Jour.  Med.  Sci.  Apr:: 


Am.  J.  Med.  Sci..  Oct..  1852.  310.     Cases  . 

90  to  1  to.  inclusive  ;  9  males.  7  females; 

19  deaths,  2  recoveries- 
Western  Lancet.  Sept..  1SS3,  552.  .   . 
Yirginia  M    .V  s 
L'Union  Med..  March  24.  is-,.   .   .   . 


Ceber  blutengen    aus  der  nabelschnur 

und  d.  Nabel.  1S54.  (In3ug   I 
Zeit    z    Path.  Anat.    der    Neuborenen, 

Med.  Times  and  Gaz..  March.  :- 
Boston  M.  &  S  Jour..  1855,  liii.  No.  6  .  . 

New  York  Jour,  of  Med.  July 


3d  ed.,  p.  636, 

Trans.  Am.  Med.  Ass'n,  1555.  viii.  45:.  . 

Casper's  Yierteljsch.  f.  Ger.  Mi 

Jahrb.  d   gesavunt  in  end  Ausland  Med- 

3:3- 
Note  sur  l'hasmorrhagie  du  cord  ombil., 
St    Etienne 

Med.  Korrespondensblatt  des  Wurtemb. 

Arztl.  Yer..  1S36.  N.  3. 
Gaz.  des  Hopitaux,  Paris.  Oct 
Yirginia  M.  and  S.  Jour.,  Marc" 
Behrend's  Jour.   f.    Kinderk. 

xxviii.  H.  1  and  2. 

Ijour.  f.  Kinderk..  Sept.  u.  Oct 
Fricke  &  Oppenheim  s  Zeits 
Boston  M.  and  S.  Jour..  1858,  :ix.  12:  .   . 
Trans.  Am.  Med  .-.  300-307. 

Cases   144  to  222.  inc'.    - 

16  females  ;  6c  deaths.  17  recoveries. 
Bottger.  De  Omphalorrhagia  idiopathi- 

ca,  Leipsig.  iSsS-<i.  p.  23. 

Ibid 

Brit.  Med.  Jour..  1S60,  ii.  p.  6i5 

Charleston  Med.  Jour..  1S60.  xv 


Lancet,  London.  1S61,  ii.  n.  s.  360  .  .  . 

Ibid.,  p.  529 

Boston  M.'and  S.  Jour.,  iS6r,  lxiv,  210. 
Edinburgh   V 

- 
Med.  Circular.  London 
Deutsche   Zeitschr.  f.  d.  Staatsarz"  Er 

langen.  1S65.  xxiii.  399. 
Yerhandl.  d  Gesell.  f.  Geb..  Berlin.  1S66 


D        244  Bleynie  . 


:plaim  Gaz.  de  Hop..  1S66.  . 
[Jour.  f.   Kinderk.  Erlangen,   1S66,  xlvi, 
(6. 
:  ed.  Press  and  Circ.  1866 
I  Yerhandl.  d.  Gesell.  f.  Geb..  Ber.  • 

x:x 
Am.  Jour.  Med.  Sci..  1S66,  li,  560-561.  .   . 
I  Note  sur  l'haemorrhagie  du  cordon  omb. 

Edinburgh  Med.  Jour..  [567.  i.  467.  .   .   . 
Ibid.,  ii.  44>  -   - 

Rev.  Med. and  Phar..  :• 

Rev.  Med.  de  Limoges.  1S67.  i.  6S  .  .   .  . 


58o 


SPONTANEOUS  UMBILICAL  HEMORRHAGE. 


[April  25, 


TABLE  OF  CASES,  Continued. 


Bv  whom 
Reported. 


Konig.  .  .  . 
Margueritte. 
Ritchie  .   .   . 

Hamilton  .  . 
Syme  .... 
Moir 


Place  of  Record. 


Vide  Duplain 

Jour.  f.  Kinderk.,  Erlangen,  iS68,li,  1-29 


Burn. . 
Wilson 
Adams. 


27s  Dardel.  .   .    . 
276  Schauenberg 


Paasch   .   .    . 
Rittershain  . 


Stark  .  .  .  . 
Dessau  .  .  . 
Bridge.  .  .  . 
Marcailhou  , 
Sinclair .  .  . 
Piukham  .  . 
Laity  .  .  .  . 
Whitall  .  .  . 
Petit 


Downs.  .  .  . 
Caro  .... 
Hyrntschak . 
Lieven. .  .  . 
Maasmann  . 
Jellinek.   .  . 


43S 


Junikowski. 


Depaul 


Dull,  de  Therap.,  Paris,  1S68,  lxxiv,  271  . 
Edinburgh  lied.  Jour.,  1S6S,  xiii,  1072-S6. 


Ibid 

Ibid,  (also  Ibid.  1S67,  ii,  949). 
Ibid 


These  de  Sahut,   1869,  Strasburg.     (S> 
,0  Ribemont.) 

Lyon  Medieale,  1S70,  v,  98-101 

Zu  der  Lehre  von  dem  Verblutungeu 
aus  dem  Nabel,  &c.  Neurvied  and 
Leipzig,  8vo,  24  pp. 

Beitrage  z.  Geb.  u.  Gynak.,  Berlin,  1S70 
872,  i,  136-140. 

Oesterr.  Jahrb.  f.  Psediat.,  Wien,  1870,  i 
15.  Cases  27S  to  409,  inclusive ;  59  fe- 
males, 73  males  ;  96  deaths,  36  recov- 
eries. 

Cincin.  Lan.  and  Obs.,  1871,  xiv,  n.s.  72-8] 

Med.  Record,  N.  Y.,  1S73,  viii,  254.  .   .   . 

Chicago  Med.  Jour.,  1S73,  xxx,  595.  .   .   . 

Alger.  Med.,  1873,  i,  30-37.  .   .   . 

Boston  M.  and  S.  Jour.,  1S73,  x 

Med.  Record,  N.  Y.,  1S75,  x,  165 

Brit.  Med.  Journal,  1876,  ii,  166 

Hospital  Gazette,  New  York,  1877,  i,  62 

South.  Med.  Rec,  Atlanta,  1877,  xvii,  31 


1,  29: 


.65 


3^ 


Centr.  Ztg.  f.  Kinder.,  Berl.,  187S-9, 

(See  Maasmann.) 

St.  Petersb.  Med.  Wochensch.,  1879,  iv,  9* 
Mitth.  de  Ver.  e.  Aerzte,  in  Med.  Oest. 

Wien,  1S79,  v,  39. 
Prag.  Med.  Woch.,   1S79,  289-295  ;  301-304 


Dwatvgodnik  Med.  Pub.  Krakow,  1S79, 

i'i.  73-75- 
Med.  Cor.  Bl.  d.  Wiirtemb.  Ver.  Stuttg., 

1S79,  xlix,  217. 
Lancet,  London,  1S79,  i,  293. 
De   Bloeding  mit  de  Navelstring,   Svo 

Utrecht,  1879. 

Des  Hemorrhagies  cheg  le  Nouveau-ne 
Paris,  18S0,  4to.  Cases  439  to  450,  inclu- 
sive ;  11  cases,  5  males,  2  females;  10 
deaths,  1  recovery. 

See  Ribemont,  p.  200 


TABLE  OF  CASES,  CONTINUED. 


Charrier.  .  . 
Dubois  .  .  . 
Baumgartel. 


By  whom 
Reported. 


Morel  . 

Prewitt 
Barrett 
Rouse . 
Reed.  . 

Keiller. 
Dauyan 

Lemere 

Abbe  . 
Ingram 


473 

Gibb 

475  Plant  .... 
476Sibcrt  .  . 
4  77  Hirigoyen.  . 
478  Raven.  .  .  . 
.179  Silverskidld. 
480 

4S1  Thayer  .  .  . 
482Claudy  .  .  . 
4S3  Young  .  .  . 
"  Borelius.  .  . 
McCarty.  .   . 


Gilroy. 


ncott . 

490  White.    . 

491  Manicus. 


Laycock .  . 
Partridge  . 
Vogel .    .    . 


Campbell .    . 
Smith,  J.  L  . 


Place  of  Record. 


See  Ribemont,  p.  188 

Ibid.,  p.  169 

Zeitschr.  f.  Wundaszte  u.  Geb.  Winnen- 
den,  iSSo,  xxxi,  358. 


(Lenoel)  Soc.  Med.  d' Amiens  Bulletin, 

(1S78-9),  18S0,  xviii  and  xix,  98 

St.  Lou's  Cour.-Med.,  1S80,  iv,  69 

Ibid 


Mich.  Med.  News,  1SS1, 
ind  S.  Rep..  Phila., 


Edinb.  Med.  Jour.,  1880-S1,  xxvi,  309-393 
(Otis)  Va.  M.  and  S.  J.,  Oct.,  1853,  p.  957 


Gaz.  Med.  de  Picardie,  Amiens,  18 


Phila.  Med.  Times,  iSS^-S4,  xiv,  616-621 

Arch.  Pediat.,  1S84,  i,  376 

Ibid.,  p.  307 

Jour,  de  Med.  de  Bordeaux,  1SS2-3,  xii;  565 

Brit.  Med.  Jour,  i884.  ii,  907 

Eira,  Gbteberg,  1SS5,  ix,  458 


X.  Y.  Med.  Jour.,  18.85,  xiii,  4^4  ..    . 
Med.  and  Surg.  Rep.,  Phil  ,  1SS5,  liii,  331 

Ibid.,  P.  162 

Upsala,  Liikaref.  Forh.,  18S6,  xxii,  40-44 
South.  California  Practit'r,  18S7,  ii,  211  . 


Lancet,  London,  iSSS,  i,  621 

Berlin  Klin.  Woch.,  1S88,  xxv,  833-835.  . 
Brooklyn  Med.  Jour.,  1S88,  i,  219-229.  .   . 

Am.  Jour.  Obst.  i8S8,  xxi,  48-54 

Jahrb.  f.   Kinderh.  u.  Phys.  Erzielung 
"89,  Bd.  27,  452. 
ns.  Am.  Ass'n  Obstet'ns  and  Gyn. 


Med.  and  S.  Rep.,  Phil.,  1S89,  lx,  70S-71. 
Lancet,  London,  1S89,  i,  626 


Eustace  Smith,  Dis.  of  Children,  2d  ed. 
p.  764. 

d.  World,  1890,  viii,  73 

Med.  Record,  N.  Y.,  1890,  xxxviii,  202.   . 
is.   of  Children,  Appleton's   Med.   Li 
brary,  1890,  p.  65. 
Cvclop.  Dis.  of  Children,  Phila.,  Lippin- 
cott  &  Co.,  1S90,  iii,  6S8. 


,  441-459. 


Not  previously  reported. 


Downs,  Med.  Rec,  New  York,  1X78,  xiii,  298. 

Hill,  F.,  Dublin  Med.  Press,  1S4S,  xix,  358-9. 

Hofmann,  E.,  Mitth.  de  Ver.  d.  Aerzte  in  Nied.  Oester. 
Wien.,  1878,  iv,  1-4;  also  Oester.  Jahrb.  f.  Psed.,  Wien., 
1S78,  ii,  187-202. 

Hohnbaum,  Zeitseh.  f.  d.  Startsarz.,  Erlangen,  1834, 
20th  Ergzgshft.,  310-316. 

Lawrence,  H.  C,  Obst.  Jour.,  Lond.,  1876,  iv,  520-24. 

Udell,  J.  A.,  N.  Y.  Med.  Jour.,  1867,  v,  387,  388. 

Paasch,  Beitrage,  z.  Geburts.  u.  Gynak.,  Berlin,  1870- 
i,  136-140. 

Petit,  A.,  South.  Med.  Rec,  Atlanta,  1877,  vii,  p.  31,  32 
1  New  Orleans  M.  J.). 

Reimanu,  Arch.  Med.  Erfahrung  (etc.),  Berlin,  1834, 
i>  5^o-523. 


Sadler,  Zeitschr.  f.  d.  ges.  Med.,  Hamburg,  1839,  xi, 
236.  237. 

Schneider,  Jour.  f.  Geburtsh,  Frauenz,  u.  Kinderk., 
Leipzig,  1835,  xv,  641-657. 

Blatter  f.  gericht,  Authropol,  Niirnberg,  1S61,  xii,  461- 
468. 

Steinthal,  Ueberdieidiopathische  Nabelblutungneuge- 
borenen  Kinder,  Svo,  Erlangen,  1857  (reprint). 

McCarthy,  T.  J.,  South.  California  Pract.,  Los  An- 
geles, 1S87,  ii,  211-255. 

Vezin,  II.,  Vierteljahrs.  f.  gericht.  u.  off  Med.,  Berlin, 
1*55,  vii,  330-341. 

Baumgartel,  G.,  Zeitschr.  f.  Wundaszte  u.  Geburtsh., 
Winnenden,  18S0,  xxxi,  45S-370. 

Keiller,  A.,  Edinburg,  M.  J.,  18S0-1,  xxvi,  389-393. 


'»9i.] 


SPONTANEOUS  UMBILICAL  HEMORRHAGE. 


58i 


Rivet,  G.,  Arch,  de  Tocol.,  Paris,  1S83,  x,  513-521. 

Claudy,  J.  C,  Med.  aud  Surg.  Rep.  Phila.,  1885,  liii, 
331- 

Thayer,  W.  H.,  N.  V.  Med.  Jour.,  18S5,  xlii,  454. 

Weiss,  M.  Vtjlschr.  f.  d.  prakt.  Heilk.,  Prague,  1879, 
n.  f.  iii.  47-74- 

Degen.  E.,  Med.  Cor.  Bl.  d.  Wiirtemb.  Ver.  Stuttg., 
1879,  xl'x.  217-219. 

Junikowski.  Dwutygodnik  Med.  pub.  Krakow,  1879, 
iii,  73-75. 

Lehnerdt,  Verhandl.  d.  Gesell,  f.  Geburtsh,  in  Beriin, 
1.S67,  xix,  12-14. 

Zober,  Ibid,  1866,  xviii,  215-221. 

Bowditch,  H.  P.,  Am.  J.  Med.  Sci.,  1850,  xix,  65-71. 

Church,  J..  Va.  Med.  Jour.,  1S57,  195-196. 

Hecker,  T'riedrich's  Blatter  f.  ger.  med.  Xiirnberg, 
1871,  sxii,  215-219. 

Cock,  T.  F..  The  Annalist,  X.  V..  1848,  ii,  1S9-190. 

Glaister,  Lancet,  Lond.,  1S79,  i,  293. 

White,  J.  B.,  Am.  J.  Obstet.,  X.  Y.,  1888,  xxi,  48-54. 

Immermann,  Ziemssen's  Cyclop.  Med.,  xvii,  7,  1S7S. 

Virc'now,  Archiv.  Med.,  1S65,  xxviii.  426. 

Siebold,  E.  C.  G.  v.,  Jour.  f.  Geb.  Frauenz.  und  Kin- 
derk,  Frankfort,  1S29,  ix,  31-33. 

Stieuthal,  Jour,   of  Kinderk.,   Erlangen,   1S57,  xxviii, 

33-52- 

Aubinais,  P.,  Jour,  de  la  sect,  de  med,  de  la  soc.  acad. 
du  Depart,  de  la  Loire  Infaneure,  1S52,  xxviii,  n.s.,  121- 
133, 

Riecke,  Jour.  f.  Kinderk.,  Erlangen,  1852,  xviii,  192-194 

Roger,  H.,  Ibid,  1S55.  xxi,  14-52,  also  l' Union  Medi- 
cale,  1S53,  vii,  ^S-g,  142-7. 

Lattey,  W.,  Brit.  M.  Jour.,  Lond..  1S76,  ii,  166. 

Aueshansel,  Deutsche  Zeitschr.  f.  d.  Staatsarz,  Erlan- 
gen. 1S65,  n.f.,  xxiii,  399-404. 

Griffith,  de  G.,  M.  Press  and  Circ,  Dublin,  1S66,  ii, 
5S7-S. 

Kloss,  C.  L.,  Deutsche  Zeitschr.  f.  d.  Staatsarz,  Erlan- 
gen, 1S40,  xx,  105-125. 

Thore,  M.  C,  Gaz.  Med.  de  Paris,  1S4S,  3  c.  sen.,  191-2. 

Allaire,  Gaz.  des.  Hop.,  Paris,  1S56,  478-9. 

Minot,  F.,  Am.  J.  M.  Sci.,  Phila.,  1S52,  xxiv,  n.s.. 
310  20. 

Bailev,  W.  C,  Ibid,  1S52,  xxiii,  n.s.,  432-435. 

Radford,  T.,  Edinburgh,  M.  and  S.  J.,  1S32,  xxxviii, 
1-6. 

Roth,  Jour.f.  Kinderk..  Erlangen,  1S69,  liii,  S7-96. 

Pooley,  J.  H.,  Am.  J.  M.  Sci*.,  1S66  (Apr.  1,  560-561. 

Grandidier,  J.  f.  Kinderk.,  Erlangen,  1S59,  xxxii.  5S0- 
408. 

Jenkins,  J.  T.,  Trans.  Am.  Med.  Assoc,  1S5S,  xi,  203- 
318. 

Pout,  G.,  Med.-Chir.  Trans.,  London,  1823,  xii,  1S3-5. 

Smith,  S.,  X.  Y.  Jour.  Med,  1S55,  xv,  n.s.,  73-84. 

Watts,  G.,  Gentlemen's  Mag.  aud  Hist.  Chron.,  Svo, 
1752.  xxii,  172-175. 

Otis,  G.  A.,  Va.  M.  and  S.  J.,  Richmond,  1S54,  ii,  49-64. 

Dubois,  Emile  Amable,  De  l'hemorrhagie  ombilicale 
Apres  la  chute  cordon,  These  Xo.  241,  Paris,  1S4S,  p.  35- 
40,  Paris  Theses  v,  469. 

Belkv,  J.,  Pest  Med.-Chir.  Presse.  Budapest,  1SS1, 
xvii,  545-549;  565-567- 

Gibb.  J.  S.,  M.  and  S.  Rep.,  Phila.,  1SS4,  1,524;  also 
Phila.  Med.  Times,  1SS3-4.  xiv,  616-621. 

Hirigoyen,  L.,  J.  de  Med.  de  Bordeaux,  1SS2-3,  xii,  565; 
also  mem.  et.  Bull.  soc.  de  m£d.  et  chir.  de  Bordeaux, 
1883  4,  392"395- 

Ingram,  J..  M.  and  S.  Rep.,  1S84,  li,  345-348;  also  Lou- 
isville M.  Xews,  1SS4,  xviii.  151-133. 

Jellinek,  H..  Mitth.  d.  Yer.  d.  Aerzte  in  Xied.  Oest., 
Wieu.,  1S79,  v,  39-41. 

Pinkham,  J.  G.,  The  M.'Rec,  Xew  York,  1S75.  x,  165. 

Rouse,  W.  H.,  Mich.  M.  Xews.  Detroit.  1SS1,  iv,  ;S  40. 

Yan  Cott.  J.  M..  Jr..  Brooklyn  M.  J.,  iSSS.  i.  219-229. 

Homolle,  M..  Lancet,  London.  1S61,  ii.  n.  s.  329. 

Smith,  J.  L.,  Dis.  of  Children,  7th  ed.,  1890,  12S. 


Yan  Loon,  W.  M.,  De  bloeding  niit  de  navelstring  bij 
hetparsegeborin  kind,  gerechtelijkkgeneeskundig  bes- 
choinud.  Svo,  Utrecht.  1879. 

Owen,  Ed.,  Surgical  Dis.  of  Child.,  Phila.,  1SS5.  260. 
Raven,  T.  P.,  Brit.   Med.  Jour.. 
Bleynie.  Rev.  med.  de  Limoges,  1S67,  i,  6S. 
Vogel.  Diseases  of  Children,  Appleton's  Med.  Library, 
1S90,  p.65. 
Dakin,  W.  R., Lancet,  London,  18S9,  i,  626. 
Willis,  II.  P.,  Med.   and  S.    Rep.,  Phila.,  1879,  ix,  708- 
710. 

Sibert,  D.   E..  Arch.   Paediat..  Jersev  Citv,  1884,1,307. 
Hennig.  Handbuch  der  Kinderk.  (Gerhardt) 
Plant,  W.  T.,  Arch.  Paediat..  1S84.  i.  376. 
Laycock,  L.  C.  Medical  World.  1890,  viii,  73. 
Partridge.  E.  I...  Med.   Rec.  Xew  York,  1S90,  xxxviii, 
202. 

Eliot.  L..  Trans.  Am.  Assoc.  Obset.  and  Gvn.,  1889, 
ii,  202. 

Bicking,  Hufeland's  Jour.,  1S57,  H.  4. 
Quadrat,  Oester.  Med.  Woch.,  1S41.  X.  33. 
Burdach,  Mediz.  Yereinszeitung.  1S36.  x.  -_j. 
Elsasser.  Hufeland's  Jour.,  1S33,  72  B. 
Stoltz  (In  Strassburgi,  SieboMt's  Jour,   f.   Geb.    1S17 
Bd.  7.  S.  975- 
Richard.  Traite  prat,  des  Mai.  des  enfants,  Paris.  1S39. 
Landsberg,  Hufeland's  Jour.  Marz.  1S42. 
Carus,  Gemeins.  deutsche  zeits.   f.  Geb.   Hemd..   1S28, 
Bd.  3.  s.  144. 

Riefenstahl.  Mediz.  Yereinz..  1843,  s.    135. 
Weber,   Beitrage  zur  path.  Anat.   der  neuborenen.  3, 
Lieferung,  Kiel,  1S54. 

Muhrbeck.  Rust.  Mag.  1S25,  Bd.  20. 
Elsasser,  Med.  Korrespondensblatt  des  Wurtemb.  arztl, 
Yereines,  1S56.  n.  3. 

Storres,  Prov.  M.  and  S.  J.,  Sept..  1S42. 
Wachsmuth,  Die  Bluterkrankheit 
Bartels,  Deutsche  Kliuik,  von  Goschen,  1S51,  n.  49. 
Gaz.  Med.  de  Paris,  1S42  1  anonymous  1. 
Cheyne,  J..  Essay  on  Dis.  of  Children,  Edinburg,  1S01, 
essay  ii. 

Elssaesser,  Hufeland's  J.  der  prakt.  Heilk.  and  Med. 
Rev..  Phila.,  1S24,  279. 

Med-Chir.  Rev.,  xxv,  232,  from  Jour,  der  prakt.  Heilk- 
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sur  l'art  des  Accouchments,  ou  recherches  sur,  etc.,  Paris, 
79- 

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West.  Diseases  of  Infancv  and  Childhood.  2nd  ed..  pv 
417- 


5»s 


EXTRA-UTERINE  PREGNANCY. 


[April  25, 


A    CASE    OF    EXTRA-UTERINE    RETRO- 
PERITONEAL PREGNANCY  IN  THE 
SEVENTH  MONTH. 

Read  before  the  Chicago  Gynecological  Society,  December  10,  1S00. 
BY  W.  W.  JAGGARD,   M.D., 

PROFESSOR   OF  OBSTETRICS,   CHICAGO    MEDICAL  COLLEGE,   AND   OB- 
STETRICIAN  TO   MERCY   HOSPITAL.      OF   CHICAGO. 

As  my  contribution  to  this  evening's  discus- 
sion, I  beg  to  report  a  case  of  extra-uterine,  retro- 
peritoneal pregnancy  that  is  especially  noteworthy 
on  account  of  its  clinical  course,  anatomy,  diag- 
nosis, and  treatment. 

History  (Dr.  Fitch  C.  E.  Mattison).— Mrs.  L- 
S.,  36  years  6  months  old,  born  in  Altenberg, 
Saxony,  coachman's  wife ;  5  feet  3  inches  in 
height,  130  pounds  in  weight.  Family  history 
good  ;  mother  living,  father  died  from  septicsemia 
following  injury  to  the  hand. 

Married  two  years  ago  (September  23,  1888). 
Date  of  commencement  of  last  menstruation, 
April  15,  1890;  first  pregnancy.  Course  of  early 
pregnancy  distinctly  abnormal ;  patient  said  she 
was  in  bed  at  least  three  days  out  of  the  seven 
from  pain  and  weakness. 

Dr.  Fitch  first  saw  the  patient  September  23, 
9:30  a.m.,  when  he  found  a  woman,  with  a  large 
abdominal  tumor,  in  a  condition  closely  bordering 
on  collapse.  She  was  cold,  pallid,  nearly  pulse- 1 
less,  and  vomited  incessantly.  Pulse  150,  tern-, 
perature  970  F. ;  relative  suppression  of  urine  (3 
ounces  non- albuminous  urine  by  catheter).  Mind 
clear ;  patient  complained  of  difficulty  in  breath- 
ing rather  than  of  positive  pain.  The  patient 
and  her  friends  informed  Dr.  Fitch  that  the 
alarming  condition  had  developed  gradually  dur- 
ing the  past  three  days,  apparently  in  consequence 
of  a  day's  washing.  Dr.  Fitch  concluded  that 
the  abdominal  tumor  was  the  pregnant  uterus. 
Upon  vaginal  examination  he  found  the  vaginal 
portion  of  the  cervix  uteri  unchanged,  and  per- 
ceived no  bleeding  from  the  os.  Upon  the  appli- 
cation of  the  usual  remedies — dry  heat  and  diffusi- 
ble stimulants— the  patient  did  not  react. 

At  4  p.m.,  I  saw  the  case  in  consultation  with 
Drs.  F.  E.  Waxham,  Bayard  Holmes,  and  Fitch 
C.  E.  Mattison.  The  woman  showed  such 
ominous  signs  of  considerable  internal  haemor- 
rhage and  of  severe  shock  that  I  thought  death 
certain.  Her  mind,  however,  was  clear,  and  Dr. 
Fitch  informed  us  that  her  general  condition 
was  not  more  unfavorable  than  in  the  morning. 
The  fact  of  pregnancy  was  evident  from  the 
appearances  of  the  mammse  alone,  without 
reference  to  the  changes  in  the  pelvic  genitalia, 
or  to  the  history  of  amenorrhcea  in  a  woman 
previously  healthy  and  perfectly  regular.  But 
the  nature  of  the  pregnancy  and  the  cause  of  the 
bleeding  were  obscure. 

Inspection  revealed  a  single,  symmetrical  ab- 
dominal tumor  as  large  as  the  gravid  uterus  at 


the  seventh  month,  with  an  arcuate  fundus. 
Each  horn  extended  upward  to  the  lower  border 
of  the  false  ribs,  while  the  median  furrow  dipped 
downward  to  a  point  four  centimetres  above  the 
umbilicus.  The  size  and  shape  of  the  tumor 
were  suggestive  of  twin  pregnane}-,  On  palpa- 
tion the  walls  of  the  tumor  were  so  tense  and  un- 
yielding that  it  was  impossible  to  outline  any 
contained  object  or  to  practice  ballottement. 
Alternations  in  density — that  is,  intermittent 
uterine  contractions — were  notably  absent.  The 
tumor  was  absolutely  flat  on  percussion.  Ma- 
ternal heart  tones  and  pulsations  of  the  aorta 
were  transmitted  with  uncommon  clearness  and 
distinctness  over  all  areas,  but  fetal  heartbeats 
and  uterine  souffle  could  not  be  detected.  Upon 
examination  per  vaginam  it  was  evident,  from 
the  conical  shape  of  the  vaginal  portion  of  the 
cervix  uteri  and  from  the  persistent  hymen,  that 
the  woman  was  a  primipara.  The  vaginal  por- 
tion of  the  cervix,  three  centimetres  in  length 
and  unchanged,  seemed  relatively  hard  for  such 
an  advanced  pregnancy  ;  it  was  displaced  to  the 
right  of  the  median  line,  and  the  os  externum 
was  closed.  The  vaginal  vault,  symmetrically 
convex  downward,  and  apparently  filled  out  by 
the  head  well  engaged  within  the  pelvic  cavity, 
was  directly  continuous  with  the  vaginal  portion, 
and  presented  the  sensation  of  equal  resistance 
in  all  directions.  Upon  withdrawal  of  the  finger 
it  was  found  to  be  stained  with  blood,  although 
there  was  no  external  haemorrhage.  The  blad- 
der contained  one  ounce  of  non-albuminous  urine. 

The  diagnosis  seemed  to  me  to  lie  between 
intra  uterine  haemorrhage  from  premature  detach- 
ment of  the  normally  implanted  placenta,  and 
haemorrhage  into  the  placenta  of  an  extra- 
uterine pregnancy,  with  the  weight  of  evidence 
in  favor  of  the  former  view.  Rupture  of  the 
normal  uterus,  or  of  the  adventitious  uterus  of 
1  ectopic  gestation,  could  be  definitely  excluded  by 
reason  of  the  single,  symmetrical,  perfectly  cir- 
cumscribed character  of  the  tumor,  and  on  ac- 
count of  the  absence  within  the  peritoneal  cavity 
of  fluid  or  unusual  solid  objects.  In  this  opinion 
the  other  consultants  concurred. 

Any  operative  interference  at  this  time  was 
clearly  coutraindicated — first,  because  the  woman 
appeared  to  be  in  artieulo  mortis,  ;  and,  second, 
since  the  tumor  had  persisted  of  the  same  size  at 
least  since  morning.  There  was  nothing  to  be 
gained  and  very  much  to  be  lost  by  the  immedi- 
ate removal  of  such  a  mass  of  blood  already  ex- 
travasated.  Accordingly,  at  Dr.  Holmes'  sug- 
gestion, we  determined  to  transfuse  and  to  await 
developments.  Twenty  ounces  of  the  physio- 
logical salt  solution  (0.6  per  cent.)  were  injected 
by  means  of  Allen's  surgical  pump  into  the  sub- 
cutaneous connective  tissue  about  the  inferior 
angles  of  the  scapulae  and  over  the  lumbar 
reg-ion.     The  insertion  of  the  needle  caused  little 


i89i.] 


EXTRAUTERINE  PREGNANCY. 


583 


pain,  and  the  injection  of  the  solution  and  its 
dispersion  by  rubbing  only  slight  discomfort. 
About  one-half  hour  was  occupied  in  the  act  of 
transfusion,  and  at  the  end  of  this  period  no  ap- 
parent effect  on  the  circulation  was  observed. 
Dr.  Holmes  thought  there  was  an  increase  in  the 
volume  of  the  pulse,  but  I  was  unable  to  per- 
ceive any  change.  Dry  heat  to  the  body  was 
continued,  and  rectal  alimentation  (six  ounces  of 
peptonized  milk  every  eight  hours)  was  recom- 
mended. 

Then  we  left  the  patient  iu  the  care  of  Dr. 
Fitch,  with  the  understanding  that  in  the  event 
of  death  we  should  be  summoned  to  the  autopsy, 
or,  in  case  of  sufficient  reaction,  to  the  woman's 
active  relief.      10:30  PM.:   Pulse  150,  temperature 

97°  F- 

Second  day,  September  24,  7  a.m.:  Pulse  130, 
temperature  ioof°  F. ;  2  ounces  of  urine  by 
catheter  that  contained  neither  sugar  nor  al- 
bumen. The  woman  rose  from  her  bed  without 
aid  and  walked  across  the  floor.  10:30  a.m.: 
Consultation.  Improvement  was  marked,  in  con- 
sequence of,  or  independent  of,  the  transfusion 
and  rectal  enemata.  No  apparent  change  in  the 
abdominal  tumor  nor  in  the  vaginal  portion  of 
the  cervix  uteri ;  slight  oozing  of  blood  from  the 
os  externum.  Upon  careful  and  prolonged 
physical  examination  of  the  abdomen  no  addi- 
tional facts  were  discovered.  The  woman  was 
still  too  feeble  to  bear  a  severe  operation  ;  she 
had  plainly  gained  during  the  night  ;  moreover, 
the  case  looked  more  and  more  like  an  example 
of  accidental  haemorrhage,  so  we  determined  to 
wait.  Enemata  of  peptonized  milk,  and  am- 
monium carbonate  per  os,  since  the  vomiting  had 
ceased,  were  recommended. 

10  p.m.:  Pulse  120,  temperature  99°  F.  Pa- 
tient complained  of  paiu  in  the  region  of  the  ab- 
dominal tumor,  but  no  contractions  were  percepti- 
ble and  no  effect  upon  the  vaginal  portion  of  the 
cervix  was  apparent.  Morphine  hypoderma- 
tically. 

Third  day,  September  25,  7  A.M.  Pulse  100, 
temperature  99!°  F. ;  2  ounces  of  urine  by  cathe- 
ter that  contained  neither  sugar  nor  albumen. 
10:30  A.M.,  consultation.  General  condition  much 
better  than  at  any  time  since  we  saw  the  case. 
No  change  in  the  abdominal  tumor  nor  in  the 
vaginal  portion.  Again,  for  the  third  time,  we 
discussed  at  length  the  propriety  of  exploratory 
dilatation  of  the  cervix  and  of  exploratory  lapa- 
rotomy, but,  in  view  of  the  apparent  nature  of  the 
case  and  of  the  distinct  and  progressive  gain,  we 
decided  to  wait.  We  left  the  case  in  Dr.  Fitch's 
care,  with  the  understanding  that  we  should  be 
called  in  the  event  of  any  change  for  the  worse. 
9:30  p.m.:  Pulse  98,  temperature  99!°  F.  Void- 
ed voluntarily  6  ounces  urine  since  previous  night. 

Fourth  day,  September  26  :  Pulse  100,  tem- 
perature 990.     Voided  8  ounces  urine,  passed  a 


comfortable  night,  moved  about  in  bed,  and  sat 
up  in  a  chair  while  the  mother  made  the  bed. 
Drank  with  relish  large  quantities  of  peptonized 
milk.  No  change  in  the  abdominal  tumor  nor 
in  the  vaginal  portion  of  the  cervix. 

9  P.M.:  Pulse  100,  temperature  normal ;  urine, 
10  ounces  since  morning. 

Fifth  day,  September  27,  8  a.m.:  Pulse  9'"..  tem- 
perature normal ;  20  ounces  of  urine.  Patient 
passed  a  comfortable  night,  but  complained  of 
some  pain  in  the  back  and  in  the  region  of  the 
lower  abdomen.  No  change  in  the  abdominal  tu- 
mor nor  in  the  vaginal  portiou  of  the  cervix. 

9  p.m.:  Pulse  100,  temperature  normal;  36 
ounces  of  urine. 

Sixth  day,  September  28,  8  a.m.:  Pulse  96, 
temperature  99!°  F. ;  26  ounces  of  urine.  Patient 
passed  an  uneasy  night,  restless,  and  complained 
of  pain.  Slight  bowel  movement.  One  teaspoon- 
ful  and  one  half  of  compound  licorice  powder  was 
followed  by  five  free  discharges  of  fluid  faeces ; 
complained  of  considerable  abdominal  pain.  No 
local  change.  9  P.M.:  Pulse  120,  temperature 
1010  F. ;  40  ounces  of  urine  ;  slight  discharge  of 
blood  per  vaginam. 

Seventh  day,  September  29,  8  a.m.:  Pulse  112, 
temperature  1010  F. ;  20  ounces  of  urine.  Bowels 
moved  four  times  during  the  night,  with  pain, 
and  the  discharge  of  large  quantities  of  faecal 
matter.     No  local  change. 

9  p.m.:  Pulse  120,  temperature  1020  F. ;  bowels 
moved  four  times  since  morning,  but  pain  slight. 

Eighth  day,  September  30,  8  a.m.:  Pulse  104, 
temperature  ioi;;+°  F. ;  great  pain. 

9  p.m.:    Pulse  114,  temp.  103 1°  F.;  great  pain. 

Ninth  day,  October  1,  8  a.m.:  Pulse  116,  tem- 
perature io2§°  F.  Passed  a  comfortable  night. 
Rigor  at  7:30  a.m. 

10:30  A.M.:  Consultation.  I  saw  the  case  for 
the  fourth  time  with  Drs.  Waxham,  Holmes  and 
Fitch.  Marked  changes  had  occurred  in  the  ab- 
dominal tumor.  It  had  increased  slightly  in  size 
and  was  notably  emphysematous  ;  on  percussion 
the  sound,  while  not  absolutely  flat,  was  still  not 
resonant,  as  in  physometra.  Even  on  this  occa- 
sion it  was  impossible  to  outline  the  body  of  the 
foetus.  Vaginal  portion  of  the  cervix  uteri  ab- 
solutely unchanged  ;  slight  oozing  of  blood  from 
the  os  externum. 

Plainly  the  woman  was  the  subject  of  septic 
infection  that  had  its  origin  iu  the  abdominal  tu- 
mor, and  the  indication  for  active  treatment 
seemed  absolute.  We  discussed  exploratory  ab- 
dominal section  and  exploratory  dilatation  of  the 
cervix,  and  decided  in  favor  of  the  latter.  The 
patient's  critical  condition  was  fully  recognized, 
and  her  friends  were  informed  of  the  possibility 
of  death  during  the  operation. 

Operation  11  a.m.  Ether  narcosis.  Patient 
placed  on  a  table,  and  with  all  antiseptic  precau- 
tions, I  dilated  what  I  supposed  to  be  the  cervix 


5§4 


EXTRA-UTERINE  PREGNANCY. 


[April  25, 


uteri  tn  means  of  Hegar's  bougies  and  Robert 
Barnes'  water  bags.  Upon  the  introduction,  with- 
out violence,  of  a  Hegar  bougie  No.  6  through 
the  os  externum,  a  free  discharge  of  liquor  am- 
nii  stained  with  blood  occurred.  Uncommon  dif- 
ficulty was  encountered  in  the  use  of  Barnes' 
"bags.  Finally,  however,  with  Dr.  Waxham's  aid, 
I  succeeded  in  passing  two  fingers  into  what  I 
thought  was  the  cavum  uteri,  recognized  the  foe- 
tal head,  with  the  occiput  to  the  right  and  pos- 
terior, O.  D.  P.  Failing  to  turn  by  the  method 
of  Braxton  Hicks,  the  canal  was  further  dilated, 
the  right  hand  introduced,  and  version  by  the 
feet  with  immediate  extraction  easily  accom- 
plished. The  child,  male,  was  dead  and  macer- 
ated, its  tissues  emphysematous.  The  placenta, 
detached  for  one-half,  was  found  to  be  firmly  ad- 
herent for  the  rest  of  its  area  to  the  site  over  the 
right  anterolateral  wall  of  the  cavity.  Several 
bands  of  dense  connective  tissue  were  sawed 
through  by  the  hand,  and  the  after-birth  deliv- 
ered. During  version  I  felt  the  promontory  of 
the  sacrum  and  the  pulsation  of  the  aorta  with 
alarming  distinctness  ;  but  it  was  only  after  de- 
livery of  the  placenta  that  I  recognized  the  fact 
of  extra-uterine  pregnancy.  At  this  time  I  felt 
the  posterior  surface  of  the  normal  uterus,  here- 
tofore covered  in  part  by  the  placenta. 

The  woman  was  put  to  bed  and  dry  heat  ap- 
plied ;  death  followed  in  a  few  moments  The 
duration  of  the  operation  was  one  and  one- fourth 
hours  ;  the  total  quantity  of  blood  lost  slight.  I 
attribute  death  immediately  to  the  combined  ef- 
fect of  trauma  and  ether. 

Autopsy. — A  limited  post-mortem  examination 
was  permitted  and  at  once  performed.  Peritoneal 
cavity  dry,  free  from  blood  ;  a  few  adhesion  bands, 
evidently  old,  stretched  between  adjacent  coils  of 
small  intestine,  but  the  structures  were  not  mat- 
ted together  in  any  important  degree.  The  mesen- 
tery, unfolded,  and  the  small  intestines  greatly 
separated  by  the  unfolding  of  the  mesentery,  to- 
gether with  the  unfolded  right  broad  ligament 
and  the  normal  uterus,  constituted  the  anterior 
covering  or  wall  of  a  large  sac  that  extended 
from  the  pelvic  floor  below  to  the  transverse  meso- 
colon above.  The  thickness  of  this  anterior  wall 
was  not  much  greater  than  that  of  the  mesentery 
and  flattened-out  small  intestine,  except  in  the 
region  of  the  placental  site — the  under  surface  of 
the  right  broad  ligament  and  the  upper  posterior 
surface  of  the  uterus.  Here  the  wall  was  one 
centimetre  in  thickness,  and  contained  a  broad 
stratum  of  non-striated  muscular  fibre,  the  only 
visible  sign  of  an  adventitious  uterus.  Upon  the 
removal  of  the  anterior  covering  the  posterior 
wall  was  found  to  be  the  usual  undifferentiated 
subperitoneal  connective  tissue. 

The  cavity  thus  bounded  was  chiefly  abdomi- 
nal, to  a  lesser  degree  pelvic.  It  was  extra-uter- 
ine and  retro-peritoneal.    In  addition  to  old  blood 


clots  and  fragments  of  the  foetal  envelopes,  the 
cavity  contained  several  lumps  of  maternal  faeces; 
two  perforations  through  the  inferior  border  of 
the  smallintestine  were  discovered,  probably  due 
to  pressure  atrophy. 

The  uterus,  slightly  deflected  to  the  right  of 
the  median  line,  enlarged  to  a  degree  correspond- 
ing to  the  tenth  week  of  pregnancy,  presented 
the  following  measurements  :  Length,  equally 
distributed  between  corpus  and  cervix,  10  cm.; 
thickness  of  the  wall  of  the  corpus,  2.5  cm.;  of 
vaginal  cervix,  1  cm.  The  uterus  was  situated 
directly  in  front  of  the  child's  head.  Examina- 
tion showed  that  the  lower  mouth  of  the  canal, 
through  which  the  foetus  had  been  delivered,  con- 
sisted in  the  os  externum,  while  the  mouth  com- 
municating with  the  sac  was  a  rupture  through 
the  posterior  wall  of  the  lower  uterine  segment, 
at  a  point  where  the  tissue  was  as  thin  as  blot- 
ting paper.  In  other  words,  I  had  passed  the 
bougie  per  os  externum  through  the  posterior 
wall  of  the  supravaginal  portion,  thinned  out 
from  pressure  atrophy.  The  decidua  vera,  partly 
detached,  had  not  been  extruded  from  the  cavum 
uteri. 

The  left  ovary  and  Fallopian  tube  were  appar- 
ently normal ;  the  tube  was  pervious  ;  no  corpus 
luteum.  The  right  ovary  and  tube  were  com- 
pletely lost  in  the  gestation  sac. 

The  placenta,  pretty  well  disintegrated  by  the 
force  of  the  original  haemorrhage  and  by  subse- 
quent changes,  showed  a  few  white  infarcts  and 
several  bands  of  tough  connective  tissue  that 
firmly  bound  the  organ  to  its  site  over  a  consider- 
able area.  The  after-birth  was  also  studded  with 
old  coagula.  Fragments  of  chorion  and  amnion 
were  visible,  attached  to  the  placental  edges.  The 
foetus,  male,  well  developed,  macerated,  1,165  Sm- 
in  weight,  40  cm.  in  length,  corresponded  to  the 
seventh  month  of  pregnancy. 

The  items  in  the  history  of  this  melancholy 
case  that  I  beg  to  call  particular  attention  to  are: 

1.  This  case  presents  a  typical  example  of  the 
classical  picture  of  extra-uterine  pregnancy,  in 
that  the  anomaly  occurred  in  the  person  of  an 
old  primipara  that  had  been  married  for  some 
time  before  the  event  of  pregnancy.  It  is  true, 
the  right  tube  and  ovary  were  involved,  instead  of 
the  same  organs  on  the  left  side  ;  but  then  the 
dissection  of  specimens  collected  within  recent 
years  shows  that  the  election  of  the  left  side  is  not 
of  such  relatively  frequent  occurrence  as  was  for- 
merly believed  to  be  the  case. 

2.  The  anatomical  findings  indicate  that  the 
pregnancy,  originally  tubal  or  ovarian,  developed 
in  the  cavity  of  the  right  broad  ligament.  Later 
the  ovum  passed  up  into  the  abdomen,  lifting  up 
the  peritoneum  and  unfolding  the  mesentery,  still 
maintaining  its  extraperitoneal  character.  Death 
of  the  foetus,  from  haemorrhage  into  the  placenta, 
probably  occurred  about  the  time  and  in  conse- 


189I.] 


EXTRA-UTERINE  PREGNANCY. 


585 


quence  of  the  day's  washing,  already  mentioned. 
The  bleeding,  however,  took  place  within  a  closed 
sac,  and  the  haemorrhage  ceased  when  the  pres- 
sure of  the  extravasated  blood  became  equal  to 
the  general  blood  tension  of  the  mother.  Infec- 
tion doubtless  resulted  from  perforation  of  the 
small  intestine,  although,  of  course,  other  modal- 
ities are  possible. 

It  is  of  interest  to  note  that  the  cervix  persisted 
in  its  original  virginal  length.  That  is  to  say, 
the  anatomical  os  internum  was  situated  midway 
between  os  externum  and  fundus,  in  a  uterus  hy- 
pertrophied  under  the  influence  of  extra-uterine 
pregnancy  to  a  degree  corresponding  to  the  tenth 
week.  In  pregnant  uteri  of  the  same  date,  the 
cervix  is  both  relatively  and  absolutely  shorter. 
(Compare  Braum,  "Der  mannlich  und  weibliche 
Kbrper  in  Sagittalschnitt,"  Leipzig,  1872  ;  Benc- 
kiser,  '"  Beitrage  zur  Anatomie  des  schwangeren 
Uterus,"  Stuttgart,  1887,  Taf.  L).  Does  not  this 
fact  seem  to  indicate  that  during  pregnancy  the 
supravaginal  portion  of  the  cervix  uteri  is  dilated 
from  above  downward,  or,  in  other  words,  that 
the  lower  uterine  segment  is  derived,  in  part  at 
least,  from  the  cervix? 

3.  As  regards  diag?iosis,  all  the  medical  men 
connected  with  the  case  must  feel  some  degree  of 
chagrin  over  the  failure  to  locate  exactly  the 
pregnancy. 

Still,  the  fact  that  four  medical  men,  not  with- 
out experience  in  this  class  of  cases,  and  presum- 
ably qualified,  deliberately,  and  independently  of 
each  other,  formed  the  same  opinion,  though  an 
erroneous  one — this  fact  indicates  that  the  case 
presented  extraordinary  difficult}-.  Possibly, 
also,  this  fact  may  add  to  the  instructive  value  of 
this  communication.  Furthermore,  the  circum- 
stances under  which  we  saw  the  case  were  unfa- 
vorable to  an  accurate  diagnosis.  We  first  saw  the 
woman  in  a  state  closely  borderingon  collapse,  and 
her  precarious  condition  at  a  later  period  seemed 
to  contra-indicate  the  exposure  and  fatigue  inci- 
dent to  a  more  thorough  examination.  Then, 
too,  an  account  of  the  character  of  the  abdomi- 
nal tumor  already  mentioned,  we  were  utterly  un- 
able to  elicit,  by  the  usual  method  of  physical 
exploration,  sufficient  signs  to  constitute  a  posi- 
tive diagnosis.  During  the  course  of  the  case, 
however,  there  were  presented  certain  significant 
signs  that  deserved  clearer  recognition  and  more 
exact  valuation.  Some  of  these  significant  signs 
were: 

1  The  abdominal  tumor  was  absolutely  quies- 
cent  throughout  the  period  of  observation.  The 
woman,  indeed,  at  times  complained  greatly  of 
abdominal  pain,  but  this  symptom  was  not  at- 
tended by  rhythmical  contractions,  with  their 
characteristic  changes  in  the  contour  and  consist- 
ence of  the  tumor.  In  the  severest  cases  of  "ac- 
cidental haemorrhage"  some  sign  of  uterine  con- 
tractions is    almost    alwavs    manifested    within 


twenty-four  or  forty-eight  hours  after  the  occur- 
rence of  the  accident. 

2.  The  maternal  heart  tones  were  transmitted 
uncommonly  clearly  and  distinctly  over  all  areas 
of  the  tumor,  and  the  uterine  souffle  was  absent. 

3.  The  vaginal  portion  of  the  cervix  uteri  per- 
sisted relatively  hard  and  unchanged  in  length 
throughout  the  eight  days  of  observation.  Every 
one  is  familiar  with  Goodell's  off-hand  rule: 
"When  the  cervix  is  as  soft  as  one's  lips,  the 
woman  is  probably  pregnant ;  when  it  is  as  hard 
as  the  tip  of  one's  nose,  the  womb  is  most  likely 
empty.''  In  this  case  the  vaginal  portion  was 
softened,  yet  not  to  the  degree  commonly  observed 
at  the  seventh  month.  The  persistence  in  the 
length  of  the  vaginal  portion— absence  of  efface- 
ment  and  dilatation — was  still  more  significant. 
In  all  these  cases  of  "accidental  haemorrhage" 
that  I  have  observed,  marked  changes  in  the 
vaginal  portion  appeared  and  progressed  within 
the  first  twenty-four  hours  after  the  accident. 

4.  The  vaginal  portion  of  the  cervix  was  dis- 
tinctly deflected  to  the  right  of  the  median  line. 

The  evidence  accumulated  from  these  four 
signs,  although  negative  in  character,  was  still  of 
a  degree  to  overbalance  the  evidence  in  fa%-or  of 
"  accidental  haemorrhage,"  which,  as  before  re- 
marked, consisted  in  the  fact  of  advanced  preg- 
nancy, of  the  single,  symmetrical  form  of  the  tu- 
mor, of  the  apparent  direct  continuity  of  the  ab- 
dominal and  pelvic  tumor,  of  the  vault  of  the 
vagina  convex  downward  and  filled  out  by  the 
head.  At  least  the  negative  evidence  ought  to 
have  deterred  from  a  therapy  based  upon  an  ab- 
solutely positive  and  exclusive  diagnosis. 

The  fact  that  the  haemorrhage  through  the  os 
externum  was  an  insignificant  oozing  might  be 
interpreted  as  equally  in  favor  of  both  "  acciden- 
tal haemorrhage"  and  extra-uterine  pregnancy. 
I  have  encountered  examples  of  the  former 
anomaly  in  which  scarcely  a  drop  of  blood  escaped 
into  the  vagina. 

Finally,  an  exploration  per  rectum  was  not 
made.  Such  an  examination,  I  believe,  might 
have  revealed  the  real  nature  of  the  case. 

4.  Under  the  topic  of  treatment  I  wish  to  men- 
tion :  1 .  The  apparently  important  effect  of  the 
subcutaneous  injection  of  the  physiological  salt 
solution.  The  total  quantity  injected— twenty 
ounces — was  absorbed  without  local  reaction 
within  twelve  hours  after  the  operation.  At  the 
same  time,  however,  peptonized  milk  was  ex- 
hibited per  rectum.  2.  Two  procedures  were  dis- 
cussed when  we  first  saw  the  woman  and  at  each 
subsequent  meeting.  These  were,  in  view  of  the 
uncertain  diagnosis,  exploratory  abdominal  sec- 
tion and  exploratory  dilatation  of  the  cervix 
uteri.  In  the  light  of  the  autopsy,  laparotomy 
would  have  accomplished  nothing  except  to  re- 
veal the  nature  of  the  case,  because  the  small  in- 
testine was  so   generally  distributed  over  the  an- 


586 


TREATMENT  OF  GALL-STONES. 


[April  25 


terior  wall  of  the  sac,  because  the  product  of 
conception  was  retroperitoneal,  and  because  the 
retroperitoneal  connective  tissue  had  been  ex- 
tensively dissected  up  in  all  directions.  It  would 
not  have  been  possible  even  to  ligature,  on  the 
peritoneal  side,  the  uterine,  ovarian,  and  sper- 
matic arteries  before  their  distribution  to  the  pla- 
centa, for  the  reason  that  the  relations  of  these 
vessels  were  so  distorted  that  the}'  were  not  found 
after  prolonged  search  during  the  autopsy.  Ex- 
ploration through  the  cervix,  therefore,  was  in- 
dicated, and  it  was  only  unskilful  or  unfortunate 
use  of  the  sound  that  led  to  the  serious  mistake 
in  the  operation.  Under  the  conditions  of  the 
case,  the  vaginal  operation  for  advanced  extra- 
uterine pregnancy  would  have  been  the  operation 
of  election,  even  in  the  presence  of  the  risk  of 
bleeding  from  the  placental  site. 

It  may  be  urged,  in  criticism  of  the  manage- 
ment of  this  case,  that  the  golden  opportunity 
for  operation  was  presented  and  lost,  when  the 
patient  had  recovered  in  some  degree  from  shock 
and  haemorrhage,  but  had  not  yet  become  in- 
fected. In  reply  to  this,  I  desire  to  say  that 
while  the  actual  time  of  the  operation  was  un- 
favorable, still  it  was  the  only  time  we  were 
summoned  to  the  case  when  the  indication  for  in- 
terference was  absolute.  As  a  matter  of  fact,  I 
believed  the  woman  received  a  necessarily  fatal 
injury  when  the  original  haemorrhage  into  the 
placenta  occurred,  and  when  the  retroperitoneal 
connective  tissue  was  so  extensively  destroyed. 

2330  Indiana  Ave.,  December  19,  1890. 


TREATMENT  OF  GALLSTONES. 

Read  before  the  New  York  State  Medical  Society,  February,  1S01. 

BY   WILLIAM   WOTKYNS    SEYMOUR,  A.B.    (Yale), 

M.D.  (Harvard); 

OF  TROY,  N.  Y. 

FORMERLY  HOUSE-SURGEON  OF   THE   BOSTON  CITY   HOSPITAL  ,    MEM 

BER   OF  THE   AMERICAN  AND   BRITISH   MEDICAL  ASSOCIATIONS; 

FELLOW  OF  THE  N.   Y.  STATE  MEDICAL  ASSOCIATION  AND  OF 

THE   AMERICAN    ASSOCIATION  OF  OBSTETRICIANS   AND 

GYNECOLOGISTS  ;  PROFESSOR  OF    THE  SURGICAL 

DISEASES  OF  WOMEN  IN  THE  UNIVERSITY 

OF   VERMONT. 

In  considering  the  treatment  of  gallstones  we 
have  to  consider  the  treatment  during  the  par- 
oxysm, during  the  intervals  between  the  par- 
oxysms, medical  and  surgical  measures  for  their 
radical  relief  and  the  constitutional  vice  leading 
to  their  formation.  During  the  paroxysms  I  do 
not  think  anything  superior  to  hypodermatic  in- 
jections of  morphine  and  atropine.  They  are 
capable  of  very  accurate  dosage,  but  must  be 
very  carefully  employed,  for  some  patients  are 
extremely  susceptible  to  these  drugs  and  one  who 
has  long  had  the  drugs  only  with  benefit  may 
suddenly  be  thrown  into  a  very  alarming  condi- 
tion by  the  usual  dose.  I  should  in  an  adult  pre- 
fer to  administer  repeated  doses  of  a  '+  grain  of 
morphine  and  a  1-150  grain  of  atropine,  than  to 


give  as  some  do  at  the  very  outset ) '? ,  3-4.  or 
even  a  grain  of  morphine.  To  the  hypodermics, 
chloroform  or  ether  by  inhalation  are  the  only 
possible  rivals,  with  the  added  disadvantage  that 
in  employing  the  anaesthetics,  we  expose  the 
patient  to  the  dangers  of  anaesthetization. 

My  friend  Dr.  James  Hutchison,  of  Troy,  not 
infrequently  has  employed  chloroform  hypoder- 
matically  as  an  adjuvant  to  the  administration 
of  morphine  and  atropine,  and  has  found  it  of 
excellent  service.  He  first  injects  a  half  drachm 
of  pure  chloroform,  and  follows  it  by  an  injection 
of  morphine  and  atropine.  The  chloroform  acts 
almost  instantly  in  relieving  the  pain  and  its  in- 
fluence persists  until  the  morphine  and  atropine 
begin  to  exert  their  influence. 

With  morphine  alone  I  have  never  had  such 
prompt  results  as  with  a  combination  of  it  and 
atropine.  The  atropine,  by  relaxing  the  muscu- 
lar fibers  of  the  gall-bladder,  and  of  the  abdominal 
muscles,  puts  in  abeyance  one  of  the  most  potent 
factors  of  gallstone  colic.  The  present  formula 
I  use  is  Magendie's  solution  with  half  grain  of 
sulphate  of  atropia  to  the  ounce.  Formerly  I 
used  a  grain  of  atropine,  but  I  found  the  amount 
of  atropine  altogether  too  large  ;  giving  rise,  in 
some  cases,  to  paresis  of  bladder  lasting  for  several 
days,  hallucinations  of  sight,  together  with  dry- 
ness of  the  throat  that  was  most  tormenting.  If 
the  agonies  did  not  yield  promptly  to  hypoder- 
matics of  morphine  and  atropine  I  would  certainly 
have  recourse  to  chloroform  or  ether  by  inhala- 
tion, personalty  I  would  prefer  chloroform,  es- 
pecially if  it  be  administered,  as  it  ought,  by  the 
physician.  Not  merely  do  morphine  and  atropine, 
as  well  as  the  anaesthetics,  relieve  the  pain,  but 
they  produce  such  relaxation  of  the  tissues  in- 
volved that  the  expulsion  of  calculi  is  greatly 
favored.  Whether  prolonged  anaesthetization 
and  the  consequent  saturation  of  the  tissues  with 
them  can  have  any  actual  solvent  power  on  cal- 
culi, I  think  very  improbable,  although  some 
practitioners  are  inclined  so  to  believe,  as  a  result 
of  their  trials  in  some  severe  cases.  If  from  any 
reason  we  can  not  employ  drugs  hypodermatic- 
ally,  they  may  be  administered  by  the  rectum  in 
shape  of  enemata  or  suppository,  by  the  mouth, 
or  has  very  recently  been  suggested,  in  the  case 
of  morphine,  by  insufflation  into  the  nose.  As  a 
rule,  vomiting  precludes  giving  medicines  by  the 
mouth,  and  we  are  consequently  limited  to  the 
rectal,  nasal  or  epidermal  methods,  and  for  these 
methods,  morphine  and  atropine  or  the  various 
preparations  of  opium  and  belladonna  are  the 
main  stays.  Hot  baths  during  the  paroxysms 
are  of  great  service. 

From  the  fluid  extract  of  wild  yam  (Dioscorea 
Villosa)  I  have  had  very  good  results  in  some 
cases.  The  relief  from  pain  has  been  very  prompt 
at  times,  but  it  has  the  disadvantage  of  being 
only  administered  by  the  mouth  and  its  vile  taste 


i89i. J                                       TREATMENT  OF  GALLSTONES  587 

is  very  difficult  to  conceal.  As  to  chloroform,  elements  and  the  precipitation  of  the  cholesterine 
ether  and  turpentine  by  the  mouth,  alone  or  in  held  in  solution.  A  dietary  rich  in  facts,  a 
their  various  much  lauded  combinations,  I  have  sedentary  life  with  full  diet,  and  paludal  poison- 
met  with  few  stomachs  which  could  bear  them,  ing  seem  to  favor  the  formation  of  gallstones, 
and  where  they  were  borne,  I  ha\*e  seen  no  benefit  Hence  we  should  interdict  fats  and  sugar,  en- 
which  could  not  be  sooner  attained  by  morphia  courage  exercise  and  combat  even-  malarial 
and  atropine.     As  to  their  solvent  action,  more  taint. 

will  be  said  anon.     Large  doses  of  olive  oil  have '      Although  ether,    turpentine,    and   chloroform 

some  effect,  as  has  been  shown  in  recent  experi-  have  long  had  a  reputation  in  gallstone  cases  and 

ments  in  increasing  the  flow  of  bile,  but  its  repu-  many  have  claimed  for  them,  especially  in  the 

tation  for  expelling  enormous  numbers  of  calculi  well    known    Durande    Mixture,   a    true  solvent 

depends  upon  masses  of  saponified  oil  being  mis-  action  on  the  stones,   the   evidence  is    that    not 

taken    for    gallstones.     Harley,   however,    is   in-  only  do  they  have  no  such  action,  but  that  even 

clined  to  believe  that  oil  removes  what  he  terms  if  the  stomach  can  bear  them  they  do  not  in  my 

sleatomatous  concretions.  experience  and  that  of  my   friends  of  whom  I 

In  the  case  of  a  person  who  is  subject  to  these  have  inquired,  relieved  the  pain.  Backlei 
attacks  it  is,  I  think,  desirable  to  advise  their  ton  Med.  and  Surg.  Journal,  October,  1879  >. 
always  having  about  them  some  preparation  of  claimed  that  oss  doses  of  chloroform  even-  four 
opium  in  case  they  are  attacked  on  a  railway  hours  combined  with  the  saccharated  succinate 
journey  or  anywhere  where  immediate  assistance  of  iron  0  t.d.  would  actually  dissolve  calculi  in 
is  uncertain.  Any  one  who  has  endured  the  the  gallbladder.  But  while  benefit  has  undoubt- 
tortures  of  an  attack  when  assistance  was  not  to  edly  followed  the  administration  of  these  dru^s, 
be  had  will  appreciate  the  sense  of  security  thus  especially  of  the  succinate  of  iron,  I  think  it  is 
given.  The  vomiting  is  often  one  of  the  most  unproven  as  yet  that  they  have  actually  dis- 
harassing  features  of  these  cases  and  the  twisting  solved  or  eroded  stones.  Even  in  a  test  tube  con- 
contractions  of  the  empty  stomach,  multiply  taining  several  volumes  of  chloroform  I  have 
many  fold  the  agonies  of  the  extrusion  of  the  failed  to  dissolve  cholestion  stones  of  less  than 
stone.  In  such  circumstances  it  is  good  practice  6  grains  in  five  hours.  The  cholate  of  soda 
to  keep  filling  the  stomach  with  warm  water  so  recommended  by  Schiff  and  Dabnev  occupies  a 
that  it  may  have  something  to  contract  upon,  somewhat  different  position,  although  its  solvent 
The  relief  from  this  simple  procedure  is  most  action  is  not  proved,  yet  it  supplies  to  the  blood 
welcome,  as  any  who  have  been  "  through  the  a  salt  in  such  form  as  to  be  very  favorable  to  the 
mill"  can  testify.  maintenance  of  the  alkalinity  of  the  bile  and  the 

After  the  termination  of  a  paroxysm  we  are  retention  in  solution  of  the  cholestrine.  How- 
confronted  with  the  question  of  treatment  to  ever,  it  is  from  the  salts  of  soda  or  to  the  vegeta- 
eradicate  the  disease.  For  an  understanding  of  ble  acids  that  by  common  consent  we  are  to  ex- 
the  indications  we  must  bear  clearly  in  mind  the  pect  the  best  results,  if  not  in  dissolving,  at  least 
constitution  of  the  calculi,  the  location  in  which  in  preventing  the  formation  of  calculi.  Although 
they  are  formed  and  the  conditions  favoring  their  Harley  thinks  that  with  the  alkalies  one  can  as 
formation.  The  calculi  consist  almost  entirely  of  surely  dissolve  calculi  as  when  in  a  test  tube,  it 
chlolestione  in  combination  with  salts  and  biliary  does  not  seem  rational,  and  proof  is  certainly 
coloring  matter  in  various  proportions.  They  wanting  of  their  solvent  action.  However  there 
occur  at  even-  period  of  life,  although  more  com-  can  be  but  little  doubt  that  they  are  very  efficient 
mon  after  thirty  years,  and  have  even  been  found  in  removing  the  catarrhal  conditions  of  the  biliary 
in  the  fcetus,  and  have  been  found  every  where  in  canals  and  in  maintaining  the  solubility  of  the 
the  biliary  canals,  from  the  liver  to  the  duodenum,  cholestrine. 

That  gallstones  are  not  formed  in  the  gall-bladder  Harley  prefers  the  sulphate  and  bicarbonate  of 

alone  seems  to  be  very  generally  overlooked,  and  soda.     Bartholow  the  phosphate  of  soda.     In  my 

hence  has  arisen  the  illogical  advocacy  of  some  own  cases  I  have  especially  used  phosphate  and 

surgical  procedures  as  methods  of  election.     Xor-  salicylate  of  soda  with  excellent  results:  not.  I 

mal  bile  is  thin  and  alkaline  or  neutral  in  its  re-  am    free  to  admit,  with  any  hope  of  dissolving 

action,  and  whatever  favors  its  becoming  thicker  stones  already  formed,  but  with  the  hope  of  cor- 

or  acid  favors  the  precipitation  from  out  of  it  the  recting  the  conditions  favoring  their  formation, 

cholesterine    nominally  present.     Probably    the  With  these  salts  I  have  not  infrequently  employed 

most  common  cause  is  catarrhal  affections  of  the  the  wild  yarn  and   Carlsbad  salts  and  iron,  and 

bile  ducts  and  gall-bladder  which  are  in  two  ways  have  frequently  been  pleased  with  the  long  im- 

favorable  to  the  formation  of  calculi,  the  first  by  munity  from  attacks  and  the  improved  condition 

the  formation  of  mucus  which  splits  up  the  un-  of  health.     From  what   I  have    already  said  it 

stable  bile  salts,  and,  second,  by  the  obstruction  may  easily  seem  that  I  do  not  believe  gallstones 

arising  from  catarrhal  swelling  checking  the  flow  are  ever  dissolved  in  the  body.     Patients  may 

of  bile,    favoring  the  reabsorption  of  its  watery  remain    years    without   an    attack    in    apparent 


538 


TREATMENT  OF  GALLSTONES. 


[April  25. 


health  and  like  the  late  Dr.  Sabin,  of  West  Troy, 
may  credit  daily  doses  of  bicarbonate  of  soda  with 
removing  the  stones  and  curing  the  disease,  and 
yet  years  later  have  sudden  fatal  attacks,  as  in  Dr. 
Sabin's  own  case,  and  a  gall  bladder  filled  with 
stones.  For  some  years  I  have  inquired  of  my 
professional  acquaintances  how  many  fatal  cases 
of  gallstones  they  have  seen,  and  very  large 
though  the  number  has  been,  it  does  not  in  my 
opinion  represent  a  third  of  the  direct  mortality, 
and  when  the  secondary  effects  are  considered, 
chronic  diseases  of  the  liver,  cancer,  etc.,  recur- 
rent gallstone  attacks  must  answer  for  a  very 
large  mortality. 

My  belief  is  that  in  all  cases  where  the  attacks 
recur  with  frequency  and  severity  in  spite  of  a 
moderately  prolonged  treatment  with  the  alkalies, 
iron  and  wild  yam,  operation  is  the  only  wise 
course  to  pursue.  But  I  mean  operation  not  as  a 
forlorn  hope, but  before  the  powers  are  broken  by  in- 
cessant,agonizing  pain, impaired  digestion,  or  chol- 
semia.  In  ordinary  cases  operation  will  not  be 
difficult,  but  in  neglected  cases,  cases  with  re- 
peated attacks  of  local  peritonitis,  with  prolonged 
jaundice  and  large  impacted  stone,  the  operation 
may  try  severely  the  most  accomplished  surgeon, 
and  the  mortality  instead  of  being  5  per  cent. 
may  amount  to  25  or  30  per  cent. 

It  is  not  fair  to  decry  the  results  of  surgery  in 
these  cases  when  months  have  been  allowed  to 
pass  by  during  which  the  patient  has  been  racked 
with  pain,  weakened  by  impaired  digestion,  or  so 
poisoned  by  prolonged  retention  of  bile  that  all  the 
vital  organs,  especially  the  heart,  are  at  their 
lowest.  What  the  profession  at  large  must  learn 
and  must  teach,  is  that  in  early  operation  in  the 
hands  of  expert  abdominal  surgeons,  the  mortal- 
ity is  as  low  as,  or  even  lower,  than  in  ovari- 
otomy. The  sentiment  of  the  profession  ought 
soon  to  become  such  that  the  man  who  in  a  case 
of  intense  jaundice  from  impacted  stone  or  re- 
peated attacks  of  colic  allows  a  patient  to  go 
months  without  surgical  relief  will  be  regarded 
as  culpable  as  he  who  waits  until  stercoraceous 
vomiting  has  occurred  in  strangulated  hernia  be- 
fore advocating  operation.  It  has  been  my  for- 
tune to  see  several  cases  in  which  even  eminent 
medical  men  have  "monkeyed"  week  after  week 
with  such  cases,  and  have  decried  operation  as 
unjustifiable  because  of  the  presence  of  a  suppos- 
ititious cancer,  until  after  months  of  suffering  the 
patients  have  either  temporarily  recovered  or 
died  from  gallstone  accident,  and  no  cancer  has 
been  found.  Certainly  a  careful  exploratory  in- 
-cision,  even  in  such  cases,  can  do  no  harm,  and 
the  patient  ought  to  be  given  an  early  opportu- 
nity to  have  the  doubt  settled,  when,  if  ever,  op- 
eration will  avail. 

Now  as  to  the  methods  of  operation,  we  can 
limit  ourselves  to  two,  both  of  which  are  now  not 
rarely  done;  cholocystotomy  or  incision  of  the  gall- 


bladder, and  cholecystectomy  or  excision  of  the 
gall-bladder.  Although  favored  by  such  brilliant 
surgeons  as  Sir  Spencer  Wells  (Bradshaw  Lecture, 
1890),  by  Kocher,  of  Bern,  and  others,  I  can  but 
regard  excision  of  the  gall-bladder  as  a  thorough- 
ly irrational  procedure  when  done  as  an  operation 
of  election.  It  starts  with  the  unwarranted  as- 
sumption that  the  gall-bladder  is  the  only  organ 
in  which  gallstones  are  formed  and  that  with  its  re- 
moval the  fans  et  origo  Maliis  removed.  Were  gall- 
stones formed  in  the  gall-bladder  alone  there  would 
be  little  justification  for  the  removal  of  the  organ; 
save  if  it  could  be  shown  that  the  mortality  of 
excision  was  better  than  that  of  cholocystotomy. 
But  in  addition  to  the  fact  that  the  gall-bladder 
probably  has  some  physiological  office  besides  be- 
ing a  receptacle  for  bile  the  results  had  from  ex- 
cision are  very  much  worse  than  from  incision, 
drainage  and  suture  of  the  organ  to  the  abdom- 
inal walls.  In  cases  of  haemorrhage,  contracted 
gall-bladder,  or  where  all  the  tissues  are  matted 
together,  we  may  be  driven  to  removing  the  or- 
gan, but  as  an  operation  of  election  it  ought 
never  to  be  entertained.  On  the  other  hand, 
cholocystotomy  with  suture  of  the  gall-bladder  to 
the  abdominal  wall  after  opening  and  evacuating 
the  gall-bladder,  permits  the  excision  or  crushing 
of  stones  in  the  common  duct  and  affords  an  out- 
let to  the  bile,  until  any  inflammatory  or  trauma- 
tic swelling  of  the  ducts  has  subsided.  Further- 
more, if  a  stone  in  the  common  duct  has  been 
overlooked,  by  establishing  a  biliary  fistula  the 
cholcemia  is  relieved  and  one  can  later  attack  the 
impacted  stone.  If,  however,  a  stone  impacted 
in  the  common  duct  is  overlooked  when  the  gall- 
bladder is  removed,  one  of  two  things  must 
speedily  ensue,  either  a  forcing  of  the  ligatured 
cystic  duct  by  the  retained  bile  and  consequent 
fatal  peritonitis,  or  fatal  cholaemia. 

The  objections  to  suturing  the  gall-bladder  and 
dropping  it  back  into  the  belly  are,  that  it  ex- 
poses the  patient  to  the  risk  of  the  sutures  being 
forced  by  retained  bile,  especially  if  a  stone  in 
the  common  duct  has  been  overlooked,  and  the 
mortality  of  this  operation  has  justified  the  the- 
oretical objections.  To  doing  the  operation  in 
two  stages,  first  suturing  the  gall-bladder  to  the 
abdominal  wound  and  opening  it  later  when  ad- 
hesions have  formed,  the  objection  is  that  imme- 
diate incision  with  suture  to  the  wound  has  proved 
reliable  and  consequently  the  double- timed  op- 
eration is  unnecessary. 

The  objection  to  cholocystotomy  that  a  fistula 
sometimes  remains  is  of  little  consequence  in  view 
of  the  enormous  advantage  it  offers  over  the  sev- 
eral operations,  and  obstinate  fistula  occur  most 
commonly  where  stones  in  the  common  duct  have 
been  overlooked.  But  even  this  rare  sequence 
has  been  cured  by  both  Grieg  Smith  and  Wini- 
warter through  cholocysto-enterostomy  ;  that  is 
in  uniting  the  gall-bladder  to  the  intestine  and 


)89I.] 


TENTH  INTERNATIONAL  CONGRESS 


589 


subsequently  closing  the  external  opening.  The 
attachment  of  the  gallbladder  to  the  abdominal 
wall  gives  rise  to  no  discomfort  after  a  few  weeks, 
and  during  the  first  few  weeks  it  is  very  slight. 
In  my  own  case  I  have  fenced,  sparred,  swum 
and  rowed  without  the  slightest  discomfort  and 
without  harm. 

In  a  paper  read  before  the  American  Associa- 
tion of  Obstetricians  and  Gynecologists,  in  Sep- 
tember, 1890  (New  York  Medical  Record'),  I  ad- 
vocated as  a  result  of  an  observation  in  one  of  my 
own  cases,  the  attempt,  in  cases  of  contracted  or 
friable  gall  bladder,  instead  of  extirpation  of  the 
organ,  to  make  out  of  the  omentum  an  artificial 
sac  and  to  stitch  it  into  the  abdominal  walls,  with 
drainage.  Very  pleased  was  I  subsequently  to 
learn  that  this  had  already  been  successfully  put 
in  operation  by  Mayo  Robson. 

My  conclusions  are : 

1.  That  it  is  as  hopeless  to  expect  to  dissolve 
gallstones  as  to  dissolve  stone  in  the  bladder. 

2.  Protracted  medical  treatment  should  give 
way  to  operative  measures  in  face  of  increasing 
frequency  and  severity  of  attacks. 

3.  Operation  should  be  done  early  and  not  de- 
layed until  a  forlorn  hope. 

4.  Better  a  late  operation  than  ncne  at  all  where 
death  is  otherwise  inevitable. 

5.  Cholocystotomy  should  be  the  operation  of 
election,  cholecystectomy  never. 

6.  The  mortality  in  the  hands  of  expert  ab- 
dominal surgeons  is  very  small,  probably  less 
than  5  per  cent. 

7.  In  doubtful  cases  exploratory  incision  ought 
to  be  much  more  frequent,  especially  as  the  risk 
is  infinitely  less  than  the  probable  benefit. 

8.  A  post-mortem  diagnosis  is  no  help  to  the 
patient,  and  but  little  satisfaction  to  the  friends. 

My  views  may  seem  dogmatic  to  many,  but 
they  are  the  result  of  the  observation  of  many 
cases,  of  the  disasters  of  dawdling,  and  of  much 
reflection  over  my  own  operations,  and  especially 
the  daily  weighing  of  the  merits  of  operative 
measures  when  my  own  life  was  in  the  balance, 
and  the  ever  present  apprehension  and  unutter- 
able torture  led  me  to  accept  for  myself  the  oper- 
ation which  has  given  me  the  health  and  strength 
which  I  now  enjoy. 


THE  TENTH    INTERNATIONAL  CON- 
GRESS AT  BERLIN,  AS  I  SAW  IT. 

Read  before  the-  /Tings  County  Medical  Association,  March  to,  1891. 
BY  E.  J.  CHAPIN    M1XARD,   II. D., 

OF  BROOKLYN.  N.  V. 

I  saw  the  capital  city  of  Imperial  Germany  in 
the  early  morning  from  an  elevated  railroad  depot, 
on  Friedrich-Strasse.  After  having  washed  the 
dust  from  my  eyes,  and  given  twenty- five  cents 
for  so  doing,  I  took  a  look  at  my  strange  sur- 
roundings. 


To  see  this  city  had  been  a  dream  of  childhood. 
The  roofs  decorated  with  statuary  and  symbols, 
the  clean  asphalt  pavement,  the  peculiar  architec- 
ture of  the  buildings,  the  silent  way  of  doing  the 
city  work,  and  the  subdued,  even  tread  of  com 
panies  of  soldiers  going  to  morning  parade,  keen- 
ly excited  my  curiosity.  I  was  satisfied  even  to 
look  over  the  city  which  held  the  greatest  ruler 
and  the  grandest  man — Virchow — the  father  of 
cellular  pathology. 

The  unexpected  greetings  of  long  ago  friends, 
known  as  college  chums,  and  the  reminiscences 
of  college  life,  made  me  feel  kindly  towards  the 
whole  German  nation  and  at  home  at  once.  The 
friendly  reception  of  the  Secretary,  Dr.  Lassar, 
the  acceptance  of  credentials  as  delegate,  the  pre- 
sentation of  the  queer  little  badge,  the  assignment 
to  the  Gynecological  Section,  without  fuss  or 
blunder,  were  very  agreeable. 

The  building  in  the  Ausstellungs  Park  was  the 
place  assigned  to  the  Sections  of  the  Congress. 
It  was  noisy  and  close,  there  being  no  corridors, 
and  much  glass  and  skylight.  The  three  general 
sessions  of  the  Congress  were  held  in  the  Circus- 
ring.  It  reminded  me  of  the  descriptions  of  a 
Roman  amphitheatre,  when  Rome  was  in  her 
glory.  It  was  bright  and  gay  with  light  and 
color.  Its  magnificence  was  enhanced  by  the 
presence  of  army'  officers  and  surgeons,  who  wore 
imperial  decorations  upon  their  gay  uniforms, 
which  were  marks  of  fidelity  in  the  service  of  a 
worshiped  Emperor.  Others  wore  badges  spark- 
ling with  jewels,  for  work  done  in  laboratories 
and  societies.  These  gay  trappings  seemed  a  fit- 
ting framework  for  the  eight  or  ten  thousand  sci- 
entists and  scholars  from  all  parts  of  the  globe, 
who  had  come  to  submit  to  a  tribunal  of  the  no- 
blest criticism,  the  results  of  their  truest  thoughts 
and  most  patient  labors.  It  was  an  event  to  en- 
rich a  lifetime. 

To  hear  and  see  Virchow,  who,  crowned  with 
the  knowledge  of  three-quarters  of  a  century  of 
research,  has  lived  to  verify  and  rectify  his  own 
investigations,  and  whom  his  countrymen  have 
honored,  idolized  and  outgrown,  but  who  to-day, 
in  his  waning  life,  is  the  one  scientist  who  can 
measure  arms  with  the  younger  giant,  Koch  ;  to 
touch  the  hand  of  Apostoli,  and  hear  him  defend 
"galvanism"  as  only  a  master  can;  to  return 
the  smile  of  recognition  on  the  broad,  good-na- 
tured face  of  Martin  ;  to  look  with  reverence  ap- 
proaching awe  upon  the  faces  of  Koch,  Pasteur, 
Lister,  Esmarch.  Tait,  Billroth,  Oppingheim,  Sir 
Spencer  Wells,  and  a  host  of  others,  with  more 
or  less  unpronounceable  names;  to  find  Lusk, 
Parvin,  Senn,  Wood,  Billings  and  many  others 
of  my  countrymen  in  their  midst ;  to  hear  ten 
tongues  and  twice  as  many  dialects  spoken,  yet 
to  understand  the  universal  language  of  science, 
and  to  be  an  accepted  member  of  this  great  body 
of  investigators  and  thinkers — is  an  honor  to  be 


59° 


TENTH  INTERNATIONAL  CONGRESS. 


[April  25, 


worn  with  fidelity  that  only  those  who  wear  the 
motto,    "Guard  the  Faith,'"  can  fully  understand. 

Mexico  met  Russia;  Great  Britain  met  Italy; 
Spain  met  Japan  ;  Holland  and  Sweden  met  Asia 
and  the  Islands  of  the  Sea ;  France,  shy  and  sul- 
len, met  Germany,  and  grew  cheerful  under  the 
kindly  greetings ;  and  America,  with  her  657 
delegates,  had  no  favors  to  ask,  nor  had  she  need 
to  blush  for  lack  of  talent. 

But  the  extreme  modesty  which  marked  the 
demeanor  of  Americans  was  not  pleasing.  Per- 
haps our  national  nervousness  develops  self-con- 
sciousness— or  is  it  a  lack  of  university  training? 

Our  papers  were  fine,  and  some  led  in  the  de- 
partments to  which  they  were  assigned.  Brook- 
lyn had  her  place.  Dr.  French  led  in  his  spe- 
cialty— the  throat.  His  paper  was  sui  generis,  as 
you  all  know.  Dr.  Parvin's  paper  equalled  any- 
thing in  its  line;  and  Dr.  Wood's  address  on 
' '  Anaesthetics ' '  was  a  State  paper,  and  was  as- 
signed a  place  of  honor — that  of  the  closing  ses- 
sion. 


nic  excursion,"  were  things  undescribable  to  an 
American.  How  from  ten  to  fifteen  thousand 
people  were  fed  and  wined  without  fee,  and  how 
each  coterie  and  table  mixed  without  mingling, 
is  incomprehensible. 

Some  one  has  said,  "  To  learn  at  the  fountain 
head  of  the  masters,  and  to  love  historic  Ger- 
many, is  only  scholarly." 

We  have  all  the  facilities  in  our  great  cities  for 
scientific  investigations,  except,  perhaps,  the  de- 
plorable class  to  practice  upon — and  may  that 
never  exist ! — but  we  work  too  fast  and  are  not 
yet  painstaking  enough.  Few  of  us  so  far  have 
had  the  patience  to  work  up  clinical  material. 

But  the  woman's  side  of  this  tidal  wave  of 
medical  science  may  not  be  ignored.  The  furore 
with  which  Germany  has  received  Koch's  inves- 
tigations, compared  with  the  reception  of  Jeuner's 
mighty  discovery,  points  to  the  growth  that  has 
taken  place  in  this  great  Empire  in  ten  decades, 
and  is  suggestive. 

When  the  Congress  was  younger  and  smaller 


To  give  an  idea  of  the  subject-matter  of  even  I  than  it  is  to  day,  it  met  in  Amsterdam.    A  woman 
a  few  papers  is  impossible.     The  most  advanced  ]  physician  of  unusual  ability  was  put  upon  the 


ideas  were  treated  respectfully  and  discussed  fair 
ly.  Apostoli  was  hissed  a  little  ;  but  as  it  came 
from  the  French,  we  all  smiled  and  applauded 
louder. 

The  whole  line  of  antiseptic  treatment  culmi- 
nated in  one  word — "cleanliness."  There  were 
new  instruments,  which  Americans  bought  to 
bring  home  and  improve  upon.  We  are  ahead 
in  the  use  of  the  drugs  (the  new  remedies)  which 
bear  the  German  trademark. 

While  listening  to  the  papers  of  these  intellec- 
tual giants,  one  could  divine  that  a  great  tidal 
wave  in  science  was  imminent — and  that  it  cen- 
tred upon  the  discovery  of  Koch. 

Every  delegate  will  remember  so  long  as  reason 
remains,  the  scene  when  Koch  stepped  forward 
to  read  his  "  Researches."  His  deep-set  eyes,  so 
true  and  steady ;  his  gentle,  yet  decided  bearing, 
said  so  plainly  that  he  was  giving  us  the  "  truth  " 
as  he  had  found  it;  and  scientists  accepted  it  with- 
out question.  When  the  greetings  had  subsided,  it 
was  far  more  interesting  to  watch  the  faces  of  the 
listeners  than  to  follow  his  reading  with  the  dull 
ear  of  my  American  German.  The  lines  and  shad- 
ows on  the  faces  of  those  listeners  from  the  ends  of 
civilization  quivered  like  the  needle  of  the  milliam- 
peremetre,  when  the  current  is  near.  I  have  heard 
from  forum  and  pulpit  passionate  orations,  which 
have  made  my  countrymen  famous  throughout 
the  world  ;  but  this  man  who  stood  here  giving 
to  dying  humanity  a  respite,  would  have  been 
made  a  god  in  the  days  of  Greece. 

The  social  resources  for  festivities  which  a  gay 
capital  city  has  at  its  command  were  called  into 
play,  and  the  delegates  were  wined  and  dined  and 
amused  to  satiety.  The  banquet  at  Kroll's  Gar- 
den— "  the  good-bye  feast  " — "a  hotel  on  a  pic- 


programme  with  a  paper  on  pathological  stud- 
ies made  in  Syria.  Objections  were  made  to  her 
and  her  paper;  but  parliamentary  rules  were 
stronger  than  German  barbaric  usages,  and  she 
read.  In  august  executive  session  this  Congress 
voted  that  no  woman  should  be  admitted  into  its 
ranks  so  long  as  Germans  held  control.  The 
Congress  grew  in  knowledge  and  in  numbers, 
and  met  now  in  one  country,  now  in  another,  till 
it  reached  London.  Titled  and  diplomaed  ladies 
sought  admission  to  it,  now  that  Germans  did  not 
control.  Surely  their  Queen  would  decide  in  their 
favor !  but  the  Empress  of  India  said,  No  !  Amer- 
ican women  smiled,  "  for  are  we  not  all  princesses 
in  America  ?' '  — and  turned  their  attention  to  work , 
fully  believing  in  the  "survival  of  the  fittest." 

The  Congress  grew,  till  it  covered  the  whole 
earth,  and  came  to  Washington.  Americans  sur- 
prised it  and  taught  it  to  respect  Western  medi- 
cal work.  Women  physicians  had  become  so  ab- 
sorbed in  the  work  of  "surviving"  that  it  was 
entirely  forgotten.  A  few  captured  the  giants 
from  abroad,  taking  them  to  our  hospitals  to 
show  them  our  working  material. 

The  re-instatement  of  woman  in  medicine  has 
not  yet  exceeded  a  half  century.  This  re-instate- 
ment began  in  New  York,  and  was  re-inforced  by- 
Berlin.  England  and  Germany  have  the  honor 
of  the  nationality  of  the  first  two  regularly  di- 
plomaed women  doctors  in  the  world.  One  grad- 
uated from  the  College  of  Geneva,  N.  Y.,  the 
other  from  Cleveland,  O.  But  only  in  America 
could  this  have  been  done  ;  and  only  women  from 
the  Old  World,  well  grounded  in  literature  and 
midwifery,  could  have  laid  such  a  foundation  as 
to-day  underlies  the  structure  of  woman's  educa- 
tion in  medicine. 


i89i.] 


RUSH  MEDICAL  COLLEGE. 


591 


The  result  of  her  work  has  been  to  increase 
our  number  from  eight  to  thousands  within  the 
past  twenty- five  years;  to  build  two  medical  col- 
leges equal  to  the  best  male  colleges;  and  to  grad- 
uate doctors  with  as  high  a  degree  of  scholarship 
and  preparation  for  work  as  male  colleges  have 
•done,  with  a  hundred  years  of  experience,  and  a 
thousand  of  culture.  There  are  now  forty-seven 
colleges  to  which  women  are  admitted  in  the 
United  States  and  Canada,  fifteen  of  which  have 
been  built  for  her  alone. 

Women  doctors  in  America  had  now  become 
sure  of  surviving,  and  when  at  last  the  Congress 
decided  to  hold  its  tenth  triennial  meeting  in  Ber- 
lin, they  were  reasonably  sure  of  being  fellow- 
shipped.  One  thing  an  American  will  not  brook 
without  resenting  —  that  is  being  snubbed — so 
great  caution  was  observed  among  a  few,  and 
quietly  every  line  sent  out  from  the  executive 
committee  at  Berlin  was  scanned  with  great  care. 
When  a  male  delegate  was  asked  how  he  thought 
Americans  would  be  received  he  said,  ' '  They  will 
be  snubbed,  of  course  ;  the  German  knows  he  has 
it  all  his  own  way."  The  result  proved  other- 
wise. Americans  were  honored  as  much  as  they 
•deserved.  If  there  were  individual  heart-burns 
it  must  have  been  from  lack  of  knowledge  of 
local  customs,  or  of  the  language.  As  for  woman 
— without  premeditated  effort  there  were  more 
than  twenty  women  in  these  sessions.  There 
were  chemists,  biologists,  physiologists,  botanists, 
■dentists,  and  among  these  were  fourteen  women 
physicians,  one  being  an  honored  delegate  from 
the  New  York  State  Medical  Association,  and  ad- 
mitted as  such. 

Germany  is  now  the  only  civilized  Government 
where  women  are  not  allowed  to  practice  medi- 
cine as  physicians.  Women  here  obtain  their  di- 
plomas, usually,  from  Ziirich,  and  are  admitted 
to  all  the  rights  of  midwives  (which  are  many), 
but  are  not  allowed  to  use  the  forceps,  write  a 
death  certificate,  or  one  of  vaccination 

The  admission  of  women  delegates  to  this  Con- 
gress in  the  face  of  the  decisions  of  former  ses- 
sions, was  hailed  with  enthusiasm  by  the  women 
of  Berlin.  "  How  did  you  do  it?  You  do  more 
in  America  in  twenty  years  than  we  do  here  in  a 
hundred,"  was  the  greeting.  "  Meet  us  in  Rome 
in  '93,  where  coeducation  has  existed  since  Agnes 
of  Coronna  captivated  with  her  mathematics  and 
her  beauty,"   was  the  parting  word. 

Right  upon  the  heels  of  this  innovation  comes 
the  Johns  Hopkins  College,  where  post  graduate 
medical  education  of  the  highest  order  is  assured 
woman  ;  but  she  will  have  to  do  it  herself.  Then 
the  Brooklyn  Board  of  Health,  through  its  suc- 
cessful health  officer,  has  appointed  from  its  civil 
service  list,  two  of  our  number  upon  its  sanitary 
work.     Surely  1890  has  been  propitious! 

There  will  never  be  more  women  in  medicine 
than  will  be  needed.     The  great  advance  made 


in  gynecology  owes  more  to  her  entrance  into 
medicine  than  will  ever  be  told.  None  of  you 
would  be  willing  to  return  to  the  time  of  the  un- 
trained nurse,  with  her  snuftbox,  catnip  tea  and 
gin. 

The  first  intelligent  nurse  at  Bellevue  was  a 
medical  woman  student,  who  entered  as  a  nurse 
to  obtain  the  knowledge  otherwise  inaccessible  to 
her.  The  cruel  neglect  and  want  of  delicacy  found 
in  this  institution,  where  help  was  taken  from  the 
workhouse  paupers,  suggested  the  necessity  for 
reforms,  which  have  culminated  in  the  enlight- 
ened system  for  the  education  and  training  of 
nurses,  which  is  one  of  the  blessings  of  the  age. 

We  might  say  that  the  work  in  this  line  in 
Germany  is  done  by  the  Lutheran  Sisterhood,  who 
do  through  religious  duty  what  our  trained  nurses 
do  for  the  large  remunerations  which  we  pay 
them .  And  the  success  of  surgery  is  due  to  the 
cleanliness  and  care  given  by  this  class,  whether 
from  duty-  or  fee. 

The  woman  physician  stands  to-day,  side  by 
side,  not  as  a  rival,  but  as  a  helper,  to  her  broth- 
ers in  the  profession.  Then  open  wide  every  ave- 
nue of  learning  to  her  !  Only  the  best  will  satisfy 
her  now.  It  is  such  a  pity  that  so  much  vital 
force  should  be  expended  in  hewing  out  new 
roads  for  learning.  I  returned  from  that  great 
gathering  at  Berlin,  fully  believing  that  only 
upon  the  foundation  of  a  university  training,  with 
ancient  and  modern  languages,  may  the  Western 
student  hope  to  cope  in  knowledge  with  the  schol- 
ars of  the  Old  World,  in  scientific  and  medical 
researches  in  the  future,  without  regard  to  sex. 


THE  CHAIR  OF  SURGERY  IX  RUSH 
MEDICAL  COLLEGE. 

/„/,„,:  he  Class,  April 11. 1891. 

BY  N.  SENN,  M.D.,  Ph.D., 

OF  CHICAGO. 

PROFESSOR  OF   SURGERY   IN    RUSH  MEDICAL   CCH-LEGE  .    ATTENDING 

SURGEON  PRESBYTERIAN    HOSPITAL. 

Within  the  short  space  of  four  years  ruthless 
death  has  twice  vacated  the  Chair  of  Surgery  in 
this  college.  On  both  of  these  sad  occasions  the 
faculty,  students  and  alumnae  felt  that  an  irrepar- 
able loss  had  been  sustained.  To  fill  the  Chair 
of  Surgerv  made  vacant  by  the  death  of  men  who 
have  distinguished  themselves  in  their  profession 
by  honest  scientific  work,  and  have  endeared 
themselves  to  their  colleagues  and  students  as 
exemplary  and  masterly  teachers  is  by  no  means 
an  easy  task,  hence  the  anxious  inquiries  from  all 
sides  and  everywhere :  Who  shall  be  the  suc- 
cessor? Who  shall  continue  the  work  left  unfin- 
ished? Rush  Medical  College  has  always  been 
justly  proud  of  its  Chair  of  Surgery.  Its  founder 
was  a  surgeon  of  world-wide  repute,  and  there 
can  be  no  doubt  that  from  its  very  beginning  the 


592 


RUSH  MEDICAL  COLLEGE. 


[April  25 


men  who  have  occupied  this  chair  have  been  the 
great  magnet  which  has  attracted  an  increasing 
number  of  students  from  year  to  year.  I  am  not 
saying  too  much,  if  I  make  the  claim,  that  the 
Chair  of  Surgery  in  this  school,  with  the  immense 
clinics  attached  to  it,  stand  to-day,  in  the  estima- 
tion of  the  profession  and  the  people,  second  to 
none  in  this  country. 

The  faculty  of  this  college  has  entrusted  me 
with  the  work  commenced  by  the  immortal  Brain- 
ard,  the  work  so  faithfully  and  ably  conducted  by 
the  genial  and  scholarly  Gunn,  the  work  brought 
up  to  the  present  immense  proportions  and  impor- 
tance through  the  heroic  labors  of  Parkes,  whose 
untimely  death  is  now  the  cause  of  universal  sor- 
row. To  be  chosen  as  successor  of  such  men  should 
satisfy  the  goal  of  ambition  of  any  man.  To  be 
the  fourth  in  a  genealogy  of  a  group  of  such  sur- 
geons in  the  oldest  and  most  famous  institution  for 
medical  education  in  the  great  Northwest  is  a  mark 
of  distinction  which  I  fully  appreciate,  and  which  I 
shall  make  a  faithful  endeavor  to  merit  by  earnest 
devotion  to  the  duties  imposed,  and  by  contribut- 
ing my  humble  share  towards  making  this  great 
city  what  it  surely  will  be  in  less  than  twenty- 
five  years — the  most  important  medical  centre  in 
the  United  States. 

Brainard,  the  founder  of  this  institution  and 
the  first  occupant  of  the  Chair  of  Surgery,  was  a 
great  surgeon,  a  gifted  teacher,  and  an  original 
investigator.  His  giant  intellect  was  not  content 
in  acquiring,  practicing  and  teaching  what  was 
known  at  his  time,  but  sought  new  fields  for  ex- 
ploration, and  the  knowledge  thus  gained  was 
freely  infused  into  his  students.  Brainard's  work 
in  the  field  of  experimental  surgery  brought  him 
an  international  fame,  and  his  name  will  be 
quoted  as  long  as  books  on  surgery  will  be  printed. 
His  work  has  not  only  left  numerous  permanent 
impressions  in  surgical  literature,  but  it  created 
a  stimulus  which  took  possession  of  his  students 
and  the  progressive  surgeons  throughout  the  civ- 
ilized world,  leading  them  away  from  the  old 
well-beaten  paths  into  new,  unexplored  territories 
awaiting  the  advance  column  of  original  explorers. 
It  is  difficult  to  estimate  the  importance  and  mag- 
nitude of  his  work  in  this  direction,  but  hundreds 
of  his  students  scattered  all  over  this  country  still 
remain  living  witnesses  of  his  zeal,  industry  and 
ability  as  a  surgeon,  teacher  and  scientist.  They 
are  to  be  envied  for  having  received  their  first  sur- 
gical knowledge  from  one  of  the  greatest,  and 
certainly  from  the  most  original  surgeon  that 
America  has  yet  produced. 

Professor  Gunn  assumed  a  responsible  position 
when  he  succeeded  Brainard.  That  the  faculty 
acted  wisely  in  securing  his  services  has  been 
abundantly  shown  by  his  marvellous  success  as  a 
teacher  and  the  ever-increasing  prosperity  of  the 
college  under  his  watchful  eye  and  judicious 
guidance.      Gunn  loved    this    institution  dearly 


and  jealousfy  watched  its  interests.  He  was  more 
than  a  friend  of  every  one  of  its  graduates.     He 
was  not  only  familiar  with  the  current  surgical 
literature  but  also  added  his  share  of  original  sci- 
entific  work.     His   love    for    original    research 
seemed  to  increase  as  he  grew  older.     His  contri- 
butions to  our  knowledge   of  the  mechanism  of 
dislocations  were  the  outcome  of  patient  experi- 
mental work  and    philosophical  reasoning,    and 
mark  a  decided  advance  in  this  important  depart- 
ment of  surgery.     His  last  paper  on  this  subject 
is  a  masterly  product  and  should  be  in  the  hands 
of  every  student, as  it  is  a  genuine  multum  inparvo, 
containing  all  essential   facts  pertaining  to   this 
difficult  chapter  in  surgery  in  a  nutshell.  Athough 
the  faculty,  the  students,  and  every  graduate  felt 
keenly  the  great  loss  sustained  by   the  death  of 
Professor  Gunn   the  action   of  the  faculty  was 
plain  in  the  selection  of  his  successor.     Professor 
Gunn   made  ample  provision    to  meet  such   an 
emergency  during  the  whole  time  he  was  con- 
nected with  the  college.     He  selected  and  trained 
his  own  successor.     The  late   Professor  Parkes 
was  well  aware  of  this  fact  and  made  the  best  of 
his  excellent  opportunities.     For  fifteen  years  he 
taught  anatomy  with   an   enthusiam  and  ability 
unsurpassed  in  this  or  any  other  country.   Under 
his  tuition  thousands  of  students  learned  to  re- 
gard   the  study  of  anatomy  as   a  pleasant  and 
profitable  pastime   instead    of  an    uninteresting 
drudgery,  as  is  so  often  the  case  when  taught  by 
one  less  skilled  and  conversant  with  his  subject; 
and  left  the  college  perfectly  familiar  with  the 
essential  basis  of  a  thorough  knowledge  of  sur- 
gery.   During  all  this  time  Parkes  was  the  right- 
hand  of  his  teacher  of  surgery,  master  and  stu- 
dent assisting  and  stimulating  each  other  in  their 
respective    work.     How   well   he   had    prepared 
himself  for  his  life  work  is  shown  by  his  short, 
but  brilliant  career  as  professor  of  surgery.     His 
accurate  knowledge  of  anatomy  combined  with 
his  familiarity  with  modern  surgery  made  him  a 
brilliant  and  successful  operator.     His  skill  as  a 
surgeon  was  soon   recognized  and  was   eagerly 
sought  for  far  and  near.      His  success  as  a  sur- 
geon has  made  this  clinic  what  it  is  to  day,  one 
of  the  largest  and  most  profitable  on  the  contin- 
ent.    As  a  teacher  few  equalled,  none  surpassed 
him.     Like  his  predecessors,  Parkes  was  not  only 
a  distinguished  surgeon  and  great   teacher,  but 
also  an  enthusiastic,  faithful  worker  in  the  field 
of  original  research.     His  valuable  experimental 
investigations  on  the  surgical  treatment  of  pene- 
trating  gunshot  wounds   of   the  abdomen  have 
laid  the  foundation  for  the  rational  treatment  of 
these  injuries  for  all  time  to  come.       His  experi- 
mental and  clinical  contributions  in  this  depart- 
ment of  surgery  have  erected  a  monument  to  his 
memory   more  enduring  than   marble  and  more 
precious  than  bronze. 

His  untimely  death  is  surrounded  by  halos  of 


i89i.] 


MEDICAL  PROGRESS. 


593 


peculiarly  sad  and  distressing  circumstances.  The 
cold  hand  of  death  touched  him  in  the  prime  of  life. 
The  final  message  reached  him  at  a  time  when  he 
was  just  beginning  to  reap  a  well-earned  abun- 
dant harvest,  and  when  in  full  view  of  a  profes- 
sional career  unparalleled  in  usefulness  and  pros- 
perity. His  pen  dropped  from  his  busy  hand 
after  he  had  nearly  completed  what  promised  to 
be  a  most  interesting  and  valuable  work  on  ab- 
dominal surgery.  His  work  as  a  teacher  came 
to  a  sudden  end  near  the  close  of  the  session  and 
just  before  the  Commencement  exercises  at  which 
one  of  the  largest  and  best  classes  left  the  portals 
of  Rush  Medical  College  in  deep  mourning  over 
the  loss  of  their  favorite  and  most  esteemed 
teacher.  His  restless  soul  departed  from  this 
world  in  the  absence  of  his  family,  and  the  last 
moments  of  his  life  were  not  cheered  by  words  of 
love  and  parting  kisses  from  those  nearest  and 
dearest  to  him. 

The  life  of  Professor  Parkes  furnishes  a  strik- 
ing illustration  of  what  can  be  accomplished  in  a 
little  more  than  half  a  life  time  by  well-directed, 
hard  study;  close  application  to  professional 
duties  and  unremitting  work  in  search  of  new 
facts.  In  appearing  before  you  as  his  successor, 
I  am  free  to  confess  that  it  is  with  a  keen  appre- 
ciation of  my  many  shortcomings.  In  resuming 
the  work  as  a  teacher  of  surgery  in  this  institu- 
tion, I  am  encouraged  by  the  prospects  that  I 
shall,  in  the  near  future,  be  joined  in  my  work  by 
an  associate,  a  surgeon  of  more  than  National 
reputation.  If  the  combined  work  of  both  of  us 
shall  accomplish  for  the  college  and  students 
what  was  done  by  Brainard,  Gunn  and  Parkes 
my  ambition  and  expectation  will  hare  been  re- 
alized. I  have  left  a  lucrative  practice,  a  pleas- 
ant home,  a  large  circle  of  professional  and 
social  relations,  a  prospering,  wide-awake  State, 
and  a  beautiful  city,  and  have  come  here  to  de- 
vote the  balance  of  my  life  to  the  interests  and 
welfare  of  this  college  and  its  students.  I  am 
fully  conscious  of  the  fact  that  I  am  coming  at 
a  time  when  the  methods  of  teaching  are  under- 
going a  radical  change.  In  the  future  recitations 
will  largely  take  the  place  of  didactic  lectures. 
Text- books  will  be  written  with  this  special  end 
in  view.  This  comparatively  new7  method  of 
teaching  surgery  will  be  made  a  prominent  fea- 
ture during  the  next  and  all  subsequent  sessions. 
This  new  departure  will  necessarily  change  some- 
what the  plan  and  scope  of  clinical  teaching.  It 
is  my  intention  to  carefully  arrange  and  classify 
the  available  clinical  material  in  my  department 
which  will  enable  me  to  combine  didactic  with 
clinical  instruction.  Thischange  will  result  in  a  re- 
duction of  the  number  of  cases  brought  before  the 
class,  but  will  prevent  unnecessary  repetition,  and 
thus  save  more  time  for  the  study  and  examination 
of  pathological  lesions,  which  will  be  a  sufficient 
inducement  for  the  students  to  attend  every  clinic. 


take  full  notes  of  what  they  see  and  hear  and 
to  remain  from  beginning  to  end.  May  God 
grant  that  the  work  entrusted  to  me  and  my  ab- 
sent colleague  may  be  worthy  of  our  predecessors, 
and  equally  efficient  in  relieving  suffering  human- 
ity, in  advancing  the  interests  and  increasing  the 
sphere  of  usefulness  of  this  college,  and  finally, 
in  giving  to  its  students  a  thorough  knowledge 
of  the  science  and  art  of  surgery. 


MEDICAL    PROGRESS. 


Therapeutics  ami  Pharmacology. 

Resorcin  in  Rodent  Ulcer.— Bock  (Monats. 
f.  prakt.  Derm.,  No.  4,  February,  1891)  has  ob- 
tained unusually  good  results  by  treating  rodent 
ulcer  with  Unna's  resorcin  plaster,  and  selects 
two  cases  as  examples.  In  one  there  was  an  ulcer 
an  inch  and  a  half  square,  which  had  lasted  ten 
years.  The  surface  was  everywhere  open,  moist, 
and  suppurating.  The  resorcin  plaster  was  ap- 
plied and  changed  daily.  After  a  few  days  con- 
siderable improvement  was  observed,  and  after 
two  months  the  whole  ulcerating  surface  was 
healed  over,  only  here  and  there  being  a  minute 
oozing  point.  In  the  second  case  the  ulcer  had 
lasted  for  six  months,  and  was  about  a  centi- 
metre square,  with  raised  infiltrated  borders.  Ex- 
cision was  declined  (the  patient  was  about  82 
years  old),  and  resorcin  plaster  was  applied.  In 
seven  weeks,  when  the  patient  was  accidentally 
met,  the  ulcer  was  found  to  have  been  long 
healed,  and  treatment  given  up.  A  shallow, 
slightly  reddened  cicatrix  remained.  Unna  (ibid.) 
reports  a  similar  case. 

Hydrocele  Treated  by  Injections  of 
Chloral  Hydrate. — Dr.  Marc  See  has  made 
use  of  hydrate  of  chloral  in  the  treatment  of  two 
hundred  cases  of  hydrocele.  According  to  him 
chloral  has  the  property  of  coagulating  the  blood 
and  serous  fluids,  and  thus  obtains  a  limited 
range  of  usefulness  in  surgery.  It  may  be 
made  to  take  the  place  of  the  iodine  solution 
very  generally  injected  into  hydroceles.  He  has 
used  chloral  in  this  way  repeatedly  and  without 
any  untoward  results.  For  this  purpose  he  has 
employed  a  ten  per  ceat.  solution  of  the  drug, 
which  he  has  injected,  either  slowly  or  all  at  once, 
into  the  sac.  He  has  used  one  ounce  to  each  in- 
jection. Two  or  three  days  afterwards  a  large 
effusion  of  fluid  occurs,  which  is  soon  entirely  re- 
absorbed. When  the  walls  of  the  hydrocele  are 
very  much  thickened,  neither  the  injections  of 
chloral  nor  any  other  substance  are  of  much  avail, 
and  the  use  of  the  knife  becomes  the  best  treat- 
ment. From  an  abstract  in  the  Lancet,  which 
has  supplied  us  with  the  above  data,  it  further 
appears  that  some  success  has  followed  the  use 


594 


MEDICAL  PROGRESS. 


[April  25, 


of  chloral  injections  in  the  neighborhood  of  vari- 
cose veins,  as  they  cause  a  gradual  coagulation 
of  the  contained  blood,  and  a  contraction  of  the 

veins  themselves. 

Novel  Treatment  of  Ingrown  Toenail. — 
Dr.  Puerckhatjer  recommends  a  novel,  simple, 
and  at  the  same  time  competent  treatment  for  in- 
grown toenail:  A  40  per  cent,  solution  of  potassa 
is  applied  warm  to  the  portion  of  the  nail  to  be 
removed.  After  a  few  seconds  the  uppermost 
layer  of  the  nail  will  be  so  soft  that  it  can  be 
scraped  off  with  apiece  of  sharp- edged  glass;  the 
next  layer  is  then  moistened  with  the  same  solu- 
tion and  scraped  off ;  this  must  be  repeated  until 
the  remaining  portion  is  as  thin  as  a  sheet  of  pa- 
per, when  it  is  seized  with  a  pincette  and  lifted 
from  the  underlying  soft  parts  and  severed  from 
the  other  half.  The  operation  does  not  require 
more  than  half  an  hour's  time,  is  painless  and 
bloodless,  while  the  patient  is  delivered  from  his 
suffering  without  being  disabled  even  for  an  hour. 
—  The  Pittsburgh  Medical  Review. 

A  Simple  Treatment  of  Corneal  Ulcers. 
— M.  Valude,  one  of  the  ophthalmic  surgeons 
of  the  Quinze-Vingts  Eye  Hospital,  communi- 
cated to  the  Academie  de  Medecine  on  February 
10,  a  new  method  of  treating  those  troublesome 
cases — ulcers  of  the  cornea—  so  simple  in  its  ap- 
plication, and,  according  to  its  inventor,  so  suc- 
cessful in  its  results  that  it  cannot  fail  to  be  gen- 
erally adopted.  Hitherto  corneal  ulcers  compli- 
cated with  hypopion  have  been  treated  by 
puncture  either  by  the  knife  or  thermo-cautery, 
this  operation  having  frequently  to  be  repeated, 
and  too  often  leaving  behind  it  opacities,  if  not 
actual  staphyloma.  For  this  unsatisfactory 
method  M.  Valude  substitutes  a  simple  dressing, 
consisting  of  a  pad  of  salol  gauze,  which,  with 
a  moistened  gauze  bandage,  effectually  seals  the 
eye  and  maintains  a  certain  amount  of  compres- 
sion. Before  being  applied  the  eye  is  carefully 
disinfected.  The  dressing  is  not  renewed  until 
after  three  or  four  days  have  elapsed,  when  the 
ulcer  is  found  to  be  already  healing,  and  the  col- 
lection of  pus  in  the  anterior  chamber  much  di- 
minished. M.  Valude  states  that  the  cornea 
tends  to  regain  its  original  transparency  without 
any  opacities.  In  corneal  ulcers  uncomplicated 
by  hypopion  M.  Valude,  relying  on  his  experi- 
ence of  fifteen  successful  cases,  asserts  that  this 
new  treatment  is  the  treatment  par  excellence. 

Cocaine  Incompatibles. — Cocaine  is  used  in 
manifold  mixtures,  and  often  brought  in  contact 
witb  substances  with  which  it  is  entirely  incom- 
patible. A.  Brunner  states  that  it  is  frequently 
prescribed  with  silver  nitrate  in  ointments,  when, 
as  is  probably  not  known  to  the  prescriber,  de- 
composition of    the  hydrochloride   ensues   with 


formation  of  insoluble  chloride  of  silver,  and  a 
corresponding  change  in  the  cocaine.  E.  Schell, 
in  the  Els-lothr  Jcicrn.  d.  Pharm.,  reports  that  if 
calomel  and  cocaine  hydrochlorate  are  rubbed  to- 
gether chemical  reaction  sets  in.  Mercuric  oxide, 
too,  if  dispensed  in  form  of  ointment  containing 
cocaine  hydrochlorate  changes,  so  that  the  oint- 
ment, instead  of  producing  an  anaesthetic  effect 
upon  the  eyes,  produces  an  exceedingly  irritating 
one.  This  is  due  to  the  formation  of  oxy-chlor- 
ide  of  mercury,  the  quantity  of  which  depends  on 
the  amount  of  cocaine  used,  the  intimacy  of  its 
mixture  with  the  oxide,  and  the  age  of  the  oint- 
ment.— Apoth.  Ztg. 

Treatment  of  Diphtheria. — Dr.  Guntz,  of 
Dresden,  has  had  great  success  in  the  treatment 
of  diphtheria  with  bichromate  of  potash  in  water 
containing  carbonic  acid,  which  he  has  found  by 
numerous  experiments  on  animals,  as  well  as  in 
the  course  of  extensive  clinical  observations,  to 
be  entirely  harmless.  For  an  adult  600  grams 
(about  a  pint)  are  ordered  per  diem,  in  which  are 
dissolved  3  centigrams  (about  12  gr.)  of  potas- 
sium bichromate.  The  whole  quantity  is  directed 
to  be  taken  in  about  half  a  dozen  doses,  regarding 
which  it  is  important  to  observe  that  the}-  must 
not  be  taken  on  an  empty  stomach  ;  a  little  milk 
or  gruel  should  therefore  be  swallowed  before 
each  dose.  Children,  of  course,  take  smaller 
quantities,  according  to  age.  They  can  be  given 
the  medicine  in  a  tumbler  mixed  with  some  fruit 
syrup,  and  they  do  not  generally  object  to  it. 
At  the  commencement  of  the  disease  Dr.  Guntz 
washes  the  mouth  out  with  a  1  per  cent,  solution 
of  permanganate  of  potash  containing  o.  1  per 
cent,  of  thymol,  or  with  a  corrosive  sublimate 
solution  of  the  strength  of  1  in  3,000,  taking 
care,  in  the  latter  case,  that  none  is  swallowed, 
and  that  the  mouth  is  well  rinsed  with  water  af- 
terwards. In  the  case  of  young  children  the 
pharynx  must  be  brushed  out  with  the  solution. 
Sometimes  iodoform  is  employed,  being  applied 
on  the  tip  of  the  finger  to  the  affected  spots.  Dr. 
Guntz  specially  remarks  that  potassium  bichro- 
mate, though  harmless  in  the  way  described,  is 
by  no  means  so  when  in  pills,  powders,  or  in  so- 
lution in  non  carbonated  water. — -The  Lancet. 

Simple  Treatment  for  Cholera.  —  Dr. 
Harkin  has  proved  the  following  method  by  ac- 
tual experience  :  Blistering,  collodion  or  any 
epispastre,  is  applied  behind  each  ear  and  along 
the  course  of  the  pneumogastric  nerve  as  far  as 
the  angle  of  the  lower  jaw.  The  object  is  to 
cause  inhibition  of  the  sympathetic  in  the  abdo- 
men by  stimulating  the  vagus.  The  result  is  at 
once  apparent  ;  the  purging  and  other  character- 
istic symptoms  cease,  and  the  patients  fall  asleep 
long  before  vesication  takes  place,  and  awake 
cured,  or  at  least   tided  over  the  dangerous  pe- 


i89i.] 


MEDICAL  PROGRESS. 


595 


riod.  Counter-irritation  with  mustard  or  spice 
leaves  might  be  useful  in  a  similar  way  in  the 
treatment  of  cholera  infantum. — India  Med.  Gas. 

OI»«.t€>tri<-s. 

CAFFEIN     IX      PUERPERAL      HEMORRHAGE. — 

Misrachi  (Centralblatt  fur  Gyncecologie)  recom- 
mends the  hypodermic  injection  of  caffein  in  pu- 
erperal haemorrhage.  He  says  that  it  produces 
quicker  results  than  ergot,  and  it  is  at  the  same 
time  a  powerful  stimulant.  He  begins  with  a 
dose  of  20  centigrams,  which  is  repeated  until  a 
desirable  reaction  is  established.  The  insolubil- 
ity of  caffein  may  be  met  by  mixing  it  with  ben- 
zoate  of  sodium,  the  two  substances  readily  dis- 
solving in  hot  water. 

Medicine. 

Salol  in  the  Gastrointestinal  Diseases 
of  Children. — Salol,  administered  by  the  mouth, 
does  not  undergo  any  change  until  it  reaches  the 
intestine,  where  it  is  acted  upon  by  pancreatic 
secretion  and  decomposed  into  carbolic  acid  and 
salicylic  acid.  Its  use  as  an  antiseptic  is  modified 
by  the  action  of  the  pancreatic  secretion,  and  it 
has  been  employed  for  different  diseases  of  the 
stomach  and  intestines  in  children.  Barr  has  re- 
ported thirty-five  cases  of  gastrointestinal  in- 
flammation in  which  salol  was  administered. 
When  the  symptoms  were  those  of  acute  gastro- 
enteritis, with  vomiting  of  the  food  and  copious 
stools  of  disagreeable  odor,  the  use  of  salol,  either 
pure  or  combined  with  an  inert  powder,  was 
found  efficacious.  If  the  stools  were  lumpy  and 
the  vomited  material  mixed  with  bile,  calomel 
alone  gave  better  results  than  when  combined 
with  salol.  When  the  stools  are  serious,  in 
dysentery  and  in  colic,  salol  should  be  mixed  with 
a  little  opium  to  allay  the  tenesmus,  or  it  may  be 
combined  with  codeine  or  narceine.  In  the  first 
period  of  acute  gastro- enteritis,  and  in  the  chronic 
forms  of  entero-colitis,  salol  acts  most  efficiently. 
Barr  gave  salol  in  doses  of  three  centigrams  to 
children  under  six  months  of  age,  and  from  three 
to  nine  centigrams  to  those  from .  sixteen  to 
eighteen  months,  from  nine  to  twelve  centigrams 
to  those  who  have  reached  two  years.  Salol  is  a 
remedy  which  is  easily  administered,  and  it  is 
without  toxic  action.  It  is  to  be  ranked  among 
the  approved  intestinal  antiseptics,  which  also  in- 
clude naphthol  naphthaline, sulphide  of  carbon,  and 
Belloe's  charcoal.  The  author  used  it  in  the 
summer  of  1889,  combined  with  oleo-saccharate 
of  canella,  in  four  cases  of  infantile  cholera,  and 
•with  very  encouraging  results.  Lowenthal  has 
used  salol  to  prevent  the  proliferation  of  the 
bacillus  of  cholera  and  the  formation  of  toxine, 
which  is  produced  by  contact  of  the  bacillus  with 
the  pancreatic  secretion,  in  the  midst  of  pepton- 
ized albuminous  matter.  In  his  experiments  he 
used  tubes  containing  an  infected  paste,  introducing 
salol  into  some  of  the  tubes,  and  leaving  it  out  of 


others.  Some  of  the  latter  was  introduced  into 
mice.  Some  of  the  mice  died  and  the  others  be- 
came very  sick.  Other  mice  were  inoculated 
with  material  which  contained  salol.  Xo  effect 
was  produced  because  the  toxic  secretion  of  the 
bacilli  could  not  act  upon  the  pancreatine  con- 
tained in  the  material  of  inoculation,  while  the 
salol  was  decomposed  by  the  pancreatine  into 
carbolic  and  salicylic  acid. —  Archives  of  Ped- 
iatrics. 

Surt-ery. 

The  Operative  Treatment  of  Perityph- 
litis.— Professor  Sonnenberg,  of  Berlin, 
closes  an  interesting  article  which  is  quoted  by 
the  International  Journal  of  Surgery  from  the 
Berliner  Klinische  Wochenschrift  as  follows: 

1.  We  must  strive  by  all  possible  means  to 
differentiate  clinically  between  the  simple  inflam- 
matory and  the  purulent  forms  of  perityphlitis. 
The  serofibrinous  exudations,  which  usually  re- 
sult from  faecal  obstruction  in  the  caecum  and 
colon,  are  generally  reabsorbed  in  healthy  per- 
sons, even  if  the}-  are  extensive,  and  do  not  re- 
quire surgical  interference.  It  is  only  in  patients 
suffering  from  tuberculosis  or  acute  or  chronic 
intestinal  diseases  that  these  exudations  may  be- 
come purulent  in  consequence  of  perforation, 
and  the>'  then  require  very  simple  surgical  pro- 
cedures, as  general  peritonitis  is  extremely  rare 
in  these  cases. 

2.  Purulent  exudations,  originating  in  the 
vermiform  appendix,  cannot  be  absorbed.  In 
these  cases  the  disease  has  been  preceded,  at 
greater  or  less  intervals,  by  attacks  of  colicky 
pains  in  the  ileo-cascal  region.  The  exudation, 
which  is  circumscribed  and  small  at  the  begin- 
ning, is  the  result  of  gangrene  and  perforation 
of  the  appendix,  and  is  of  purulent  or  sero- puru- 
lent character.  The  experienced  and  careful 
physician  will  usually  be  able  to  recognize  these 
forms  of  purulent  perityphlitis  with  certainty. 

3.  The  more  superficial  a  purulent  perityph- 
litic  exudation  is  situated,  the  earlier  an  opera- 
tion is  indicated,  that  is.  within  the  first  few  days 
after  the  occurrence  of  the  initial  symptoms.  A 
simple  incision  is  sufficient  in  most  cases,  owing 
to  the  presence  of  adhesions. 

4.  If.  however,  the  exudation  is  small,  indis- 
tinct and  deeply-situated,  we  should  perform  the 
operation  in  two  sittings,  as  early  as  possible 
after  the  beginning  of  the  disease,  especially  if 
the  resistance  and  dulness  disappear  on  account 
of  the  increasing  meteorism ;  for  experience 
teaches  that  by  proceeding  in  this  manner  we  are 
able  to  discover  again  the  purulent  deposits,  and 
lay  them  open  without  injury  to  the  peritoneum 

I  and  risk  to  the  patient. 

By  this  treatment,  the  operation  is  deprived  of 
its  dangers,  and  even  in  doubtful  cases  this  pro- 
!  cedure  is  a  rational  one.  The  surgical  methods 
i  described  above  will  enable  us  to  avoid  the  un- 


596 


MEDICAL  PROGRESS. 


[April  25, 


certain  results  of  a  spontaneous  cure,  the  danger- 
ous recurrences,  and  the  occurrence  of  fatal 
general  peritonitis  in  apparently  mild  cases. 


Cholera  Nostras. — In  a  paper  read  before 
the  Societe  Medicale  des  Hopitaux  on  February 
6th,  Drs.  Gilbert  and  Girode  describe  the  re- 
searches they  have  made  in  regard  to  some  cases 
of  cholera  nostras.  The  chief  interest  lies  in  the 
bacteriological  work.  The  stools  in  some  of  the 
cases  yielded  almost  pure  cultivations  of  Esche- 
rich's  bacillus.  Cultivations  were  also  made 
from  the  faeces  on  different  media,  and  numerous 
colonies  were  also  obtained  from  the  cerebro- 
spinal fluid,  but  not  so  many  were  yielded  by  the 
blood  of  the  liver  and  spleen.  The  fluid  squeezed 
from  the  lungs  produced,  in  addition  to  the  patho- 
genic bacteria,  organisms  morphologically  similar 
to  the  pneumococcus.  Although  certain  organic 
disturbances,  such  as  high  temperature,  favored 
the  development  of  the  bacillus,  as  shown  by  the 
fact  that  when  such  occurred  pure  cultivations 
could  be  easily  obtained  from  the  stools,  the 
authors  would  not  imply  the  reverse  order  of 
things — that  the  high  temperature,  etc.,  was 
caused  by  rapid  multiplication  of  the  organism  ; 
they  considered  that  cholera  nostras  is  not  always 
a  symptom  of  a  local  lesion  of  the  intestine,  and 
that  the  germs  were  able  to  pass  through  the 
walls  of  the  intestine,  invading  the  body,  and  so 
bringing  about  a  new  morbid  type — the  infectious 
form  of  the  disease.  The)"  were  also  of  opinion 
that  the  bacillus  of  Escherich  was  not  the  only 
choleraic  microbe  in  this  climate.  Finkler  and 
Prior  have  also  found  a  bacillus  in  the  alvine 
evacuations  of  patients  suffering  from  cholera 
nostras,  very  similar  to  the  cholera  bacillus  of 
Koch.  There  are  two  suppositions  which  may 
be  considered  as  regards  the  connexion  of  Esche- 
rich's  bacillus  with  cholera  nostras.  In  one  the 
microbe  may  be  concluded  to  be  harmless  before  it 
enters  the  body,  and  may  there  develop  its  special 
pathogenic  properties.  The  second  idea  supposes 
that  the  germs  are  widely  distributed,  and  ac- 
quire their  poisoning  properties  before  entering 
the  body,  most  probably  doing  so  by  means  of 
drinking  water.  In  the  guinea-pig,  if  a  pure  cul- 
ture of  this  bacillus  be  injected,  it  is  followed  by 
all  the  symptoms  of  a  typical  attack  of  cholera 
nostras.—  Lancet. 

Can  Simple  Vaginitis  be  Distinguished 
from  that  of  Gonorrheal  Origin  ? — If  the 
confident  assertions  of  various  writers  in  the  med- 
ical journals  are  to  be  believed,  it  is  a  matter  at- 
tended with  little  or  no  difficulty  to  distinguish 
between  a  case  of  simple  vaginitis  and  one  of 
specific  origin.  Within  the  month  we  read  the 
following  from  a  well-known  professor  of  gyne- 
cology:     "It  is  very  difficult  to  distinguish  be- 


tween specific  and  non-specific  vaginitis,  unless 
the  microscope  is  used  to  demonstrate  the  pres- 
ence or  absence  of  the  specific  microorganisms 
characteristic  of  the  disease." 

The  following,  which  we  copy  from  the  Medi- 
cal and  Surgical  Reporter,  seems  to  us  to  express 
the  truth  of  the  matter:  "When  in  adults,  the 
discharge  has  appeared  suddenly,  is  purulent  in 
character,  and  in  its  earl)'  stages  has  been  asso- 
ciated with  scalding  pain  on  micturition,  a  hot 
and  tender  vagina  with  bright  red  points  cover- 
ing the  mucous  membrane,  and  with  a  red,  vel- 
vety or  granular  os  uteri,  the  probabilities  are 
altogether  in  favor  of  gonorrhoea.  And  yet  it  is 
doubtful  whether  many  men  could  be  found  will- 
ing to  take  the  witness  stand  and  declare  posi- 
tively, from  the  symptoms  and  appearances  we 
have  described,  that  the  disease  is  gonorrhoea. 
The  difficulty  becomes  still  greater  when  the  pa- 
tient is  not  an  adult  but  a  child.  Fortunately 
the  cases  of  gonorrhoea  in  little  girls  are  much 
less  frequent  in  this  country  than  they  appear  to 
be  on  the  continent  of  Europe. 

The  discovery  of  the  so  called  "  gonococcus" 
by  Neisser  was  hailed  by  many  with  enthusiasm. 
But  it  was  scarcely  discovered  before  assertions 
were  made  that  it  could  be  found  in  non-specific 
discharges,  and  that  it  could  not  be  distinguished 
under  the  microscope  from  other  bacteria,  par- 
ticularly diplococci.  The  latter  conclusion  is  the 
one  to  which  Vibert  and  Bordas  have  come. 
These  writers  have  investigated,  from  a  medico- 
legal point  of  view,  the  discharge  present  in  the 
vulvitis  of  little  girls,  and  declare  that  micro- 
scopic examination  of  such  discharge  never  ena- 
bles an  expert  to  affirm  that  a  particular  vulvitis 
is  or  is  not  gonorrhceal.  They  find  the  gonococ- 
cus practically  indistinguishable  from  the  diplo- 
coccus — both  bacteria,  they  say,  have  the  same 
form  and  dimensions,  the  same  arrangement  in 
masses  and  heaps,  and  not  in  chains,  and  they 
stain  alike  and  are  alike  deprived  of  their  stain 
by  alcohol. 

It  not  infrequently  happens  that  men  are  ac- 
cused of  having  committed  rape  upon  little  girls, 
and  sometimes  vulvitis  is  adduced  as  one  of  the 
evidences  of  the  violation.  A  vulvitis,  however, 
has  been  found  in  a  violated  child  although  the 
person  guilty  of  the  rape  was  free  from  any  evi- 
dences of  urethral  disease.  It  would  seem  to  be 
impossible,  therefore,  in  the  present  state  of  our 
knowledge  of  the  bacteriology  of  gonorrhoea,  to 
base  upon  it  a  diagnosis  sufficiently  positive  to 
warrant  a  judgment  by  the  court  in  a  criminal 
suit.  No  doubt  this  difficulty  will  be  overcome 
by-and-by,  and  perhaps  by  cultivation  the  gono- 
coccus can  be  distinguished  from  the  diplococcus. 
But  just  now  the  conclusion  seems  to  be  that  our 
methods  of  detecting  the  gonococcus  are  not  pre- 
cise enough  for  medico-legal  purposes. — Editorial, 
Massachusetts  Medical  Journal. 


I89i.] 


EDITORIAL. 


597 


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Address 

Journal  of  tut.  American  Medical  Association, 

No.  68  Wabash  Ave  , 

Chicago,  Illinois. 
All  members  of  the  Association  should  send  their  Annual  Dues 
to  the  Treasurer,  Richard  J.  Dunglison,  M.D.,  Lock  Box  1274,  Phila- 
delphia, Pa. 


London  Office,  57  and  59  Ltjdgate  Hill. 


SATURDAY,  APRIL  25,    1891. 


THE  VALUE  OF  KOCH^S  TUBERCULIN. 
Never  has  a  medical  discovery  led  within  so 
short  a  time  to  such  an  amount  of  observations, 
as  have  been  recorded  since  Koch  first  announced 
his  discovery  of  a  remedy  against  tuberculosis. 
Now  that  five  months  have  elapsed  since  Koch's 
first  paper  and  many  observers  can  speak  of  three 
months  experience,  a  survey  of  the  applicability 
of  "tuberculin"  seems  proper. 

1.  Its  Diagnostic  Value. — Koch  stated  origin- 
ally that  no  effects  had  been  observed  by  him  in 
healthy  people  from  doses  under  about  i  centi- 
gram. He  therefore  considered  a  reaction  of  the 
system  to  a  smaller  dose,  by  fever,  lassitude, 
diffuse  pains,  etc.,  absolutely  characteristic 
of  tuberculosis.  The  subsequent  experience  of 
others  has  shown  that  this  rule  is  not  without  ex- 
ceptions, hence  it  is  at  present  only  safe  to  say 
that  "a  systemic  reaction  on  injection  of  less  than 
1  eg.  of  tuberculin  in  an  adult  is  a  very  probable 
but  not  absolutely  decisive  indication  of  tuberculosis. ' ' 
Numerous  observers  have  injected  the  sub- 
stance for  diagnostic  or  experimental  purposes  in 
non-tubercular  patients  or  healthy  subjects.  No 
very  large  statistics  are  as  yet  reported,  but  while 
some  never  obtained  any  reaction,  others  found  a 
a  variable  proportion  of  non  tubercular  people 
reacting  to  doses  under  one  centigram.  Peiper 
tested  twenty- two  non- tubercular  patients  under 
careful  observation.  Of  nineteen  receiving  2 
mg.,  four  reacted  ;  of  twenty-one  subjects  eight 
responded  to  5  mg. ,  while  of  sixteen  who  were 
tested  with  10  mg.,  twelve  suffered  with  fever. 
Miculicz  reports  that  of  ten  healthy  young  men, 


five  reacted  to  0.01  lymph,  and  five  did  not. 
Amongst  twenty- five  surgical,  but  non-tubercular 
patients,  twenty-two  showed  no  result  on  injecting 
quantities  varying  from  1  to  15  mg.,  while  in 
three  reaction  was  obtained.  Many  reporters 
state  that  in  numerous  instances  reaction  occurred 
in  people  who  at  the  time  were  considered  free 
from  tuberculosis,  but  in  whom  the  tuberculin 
made  manifest  a  latent  tubercular  focus,  as  the 
subsequent  history  showed.  Of  great  interest 
are  the  researches  of  Schreiber  on  forty  new  born 
children,  who  beginning  with  the  utmost  caution, 
found  that  he  could  increase  up  to  50  mg.  with- 
out ever  getting  any  reaction  whatever. 

While  it  has  thus  been  learned  that  occasion- 
ally a  non-tubercular  human  organism  may 
respond  by  a  general  disturbance  to  a  dose  less 
than  the  average  usually  requisite,  all  observers 
agree  that  a  local  reaction  indicates  infallibly  a  tu- 
bercular lesion,  as  it  has  never  been  observed  un- 
der other  conditions.  The  local  reaction  shows 
itself  by  increased  redness  and  swelling  on  the 
diseased  skin  or  visible  mucous  surfaces,  and  b3' 
pain  and  tenderness  in  diseased  bones  and  joints, 
often  with  increased  secretion  if  fistulae  exist,  and 
redness  and  swelling  of  the  fistulous  tract.  The 
reaction  of  the  internal  organs  is  sometimes,  but 
not  always,  indicated  by  pain,  while  in  the  lungs 
an  increase  in  the  area  of  dulness  and  an  aug- 
mentation of  rhonchi  often  indicate  the  local  dis- 
turbance induced  by  tuberculin.  The  local  re- 
action is  not  invariably  accompanied  by  fever, 
especially  if  it  be  slight.  It  is  generally  stated 
that  it  precedes  the  fever  in  its  first  beginning, 
the  febrile  disturbance  being  evidently  dependent 
upon  it.  In  leprosy  Goldschmidt  and  Babes 
and  Kalendero  have  observed  a  very  gradual 
and  rather  persistent,  though  temporary,  change 
in  the  affected  parts  (viz.,  increased  swelling  and 
tenderness),  which  might  be  termed  a  delayed 
and  protracted  local  reaction  quite  different  from 
that  in  tubercular  lesions. 

While  the  typical  febrile  reaction  begins  gener- 
ally between  the  fifth  and  twelfth  hour  after  the 
injection,  reaching  its  acme  in  about  two  hours, 
and  lasts  altogether  from  six  to  twelve  hours  if 
at  all  marked,  various  deviations  from  this  type 
have  been  observed.  Occasionally  the  whole 
febrile  paroxysm  is  postponed  some  twenty-four 
hours.  A  few  times  a  slight  second  rise  of  tem- 
perature has  been  observed  on  the  second  day.  A 


598 


IS  INSANITY  A  CRIME? 


[April  25. 


continuous  febrile  disturbance  succeeding  the 
acute  rise  of  temperature  has  been  shown  by  Son- 
nenburg  to  be  due  to  the  retention  of  increased 
secretion  in  surgical  patients,  and  was  relieved 
by  him  by  free  drainage.  It  indicated  in  his 
cases  that  the  lesions  were  not  merely  tubercular, 
but  due  to  mixed  infection.  Since  this  is  the 
case  also  in  advanced  phthisis  a  pyogenic  after- 
effect can  be  accounted  for  by  retention  of  pus  in 
the  pulmonary  as  well  as  in  the  surgical  cases. 
Mikulicz,  however,  a  competent  surgeon,  as 
well  as  others,  have  seen  lasting  febrile  disturb- 
ance following  the  use  of  tuberculin,  which  could 
not  be  attributed  to  retention  of  secretions.  It  is 
generally  admitted  that  in  the  latter  instances 
tuberculin  is  of  doubtful  service,  sometimes  posi- 
tively harmful. 

It  cannot  be  predicted  from  the  weight  or  the 
condition  of  the  patient,  or  the  extent  of  the  tu- 
berculosis, how  intense  the  reaction  to  a  given 
dose  of  tuberculin  will  be.  It  can  only  be  said 
that  any  increase  of  dose  beyond  the  quantity 
necessary  to  produce  a  febrile  reaction  will  ren- 
der the  reaction  more  intense. 

The  diagnostic  value  of  the  substance  depends 
of  course  upon  the  certainty  with  which  the  tu- 
bercular organism  will  respond  to  it.  It  seems 
that  a  marked  febrile  disturbance  can  be  avoided 
by  beginning  with  small  doses  and  increasing 
them  cautiously.  Some  of  the  instances  in  which 
manifestly  tubercular  patients  did  not  react  by 
fever  were  evidently  due  to  this  mode  of  proced- 
ure. The  Berlin  observers,  who  have  perhaps 
the  largest  experience  (especially  Guttmann  and 
Ehrlich),  have  pointed  out  that  if  it  is  desired 
to  get  a  reaction  for  diagnostic  purposes  1  mg. 
should  be  given  to  test  the  patient's  susceptibil- 
ity. If  no  reaction  follows,  5  mg.  should  be  in- 
jected after  waiting  four  or  five  days,  and  if  still 
doubtful,  10  mg.  after  another  lapse  of  five  days. 
If  these  procedures  yield  no  reaction,  the  over- 
whelming probability  is  that  the  patient  is  free 
from  tuberculosis.  It  must  not  be  forgotten, 
however,  that  such  rapid  increase  in  the  dose  is 
justifiable  only  when  it  is  very  important  to 
arrive  at  a  diagnosis  and  other  means  of  differ- 
entiation fail.  Yet  amongst  the  thousands  of 
cases  now  on  record  there  have  been  a  few  tuber- 
culous patients  who  did  not  respond  at  all.  But 
since  these  were  almost  invariably  advanced 
lesions,  the  diagnostic  value  of  tuberculin  in  de- 


tecting the  earliest  localization  of  tuberculosis 
must  be  considered  as  very  great,  although  not 
infallible. 


IS  INSANITY  A  CRIME? 

There  is  an  evident  disposition  in  many  quar- 
ters at  the  present  time  to  assimilate  the  law  of 
insanity  to  the  criminal  law.  As  is  well  known, 
for  some  years  the  State  of  Illinois  has  made  trial 
by  jury  an  essential  prerequisite  to  admission  to 
the  asylums  for  the  insane,  and  a  similar  provis- 
ion is  contained  in  a  bill  for  the  codification  of 
the  New  York  lunacy  laws,  recently  introduced 
into  the  legislature  of  that  State.  We  cannot 
but  think  legislation  of  this  sort  most  unfortu- 
nate in  every  aspect  in  which  it  can  be  regarded. 
It  is  detrimental  to  the  best  interests  of  the  in- 
sane ;  it  is  a  needless  affliction  to  their  friends  ;  it 
is  an  insult  to  the  medical  profession  ;  it  is  a  use- 
less tax  on  the  community,  and  there  is  no  reason 
to  suppose  that  it  affords  any  protection  against 
improper  commitments  that  could  not  be  secured 
in  a  more  humane,  expeditious  and  economical 
way. 

The  interests  of  an  insane  person  require  that 
he  should  be  placed,  as  speedily  as  possible,  and 
in  such  a  manner  as  will  be  least  likely  to  ag- 
gravate his  symptoms,  under  the  influences  best 
calculated  to  promote  his  recovery.  In  a  large 
proportion  of  cases — not  all,  by  any  means — this 
implies  a  restriction  of  the  patient's  liberty.  In 
such  cases,  admission  to  a  hospital  specially  or- 
ganized and  conducted  for  their  treatment,  may 
be  the  most  valuable  of  privileges  for  its  benefi- 
ciaries— none  the  less  so  for  the  fact  that  their 
mental  condition  prevents  them,  for  the  time 
being,  from  appreciating  their  needs.  The  ques- 
tions involved  are  strictly  medical,  as  much  so  as 
the  diagnosis  and  treatment  of  a  case  of  small- 
pox, or  yellow  fever.  The  law,  in  some  cases, 
requires  that  persons  suffering  from  these  diseases 
should  be  restrained  of  their  liberty  and  treated 
in  special  hospitals,  but  we  do  not  remember  ever 
to  have  seen  it  proposed  that  they  should  have 
the  benefit  of  a  jury  trial,  nor  do  we  think  that 
there  is  likely  to  be  a  very  loud  call  for  it  on  the 
part  of  those  members  of  the  legal  profession 
who  are  so  fearful  that  some  one  may  be  de- 
prived of  liberty  without  due  process  of  law.  In 
the  one  case  as  in  the  other,  everything  that 
throws  needless  delays  or  obstacles  in  the  way  of 


ISQI.] 


IS  INSANITY  A  CRIME? 


599 


the  prompt  application  of  proper  treatment  is  a 
wrong  to  the  patient.  That  such  is  the  natural 
result  of  a  jury  trial,  no  one  will  be  likely  to  ques- 


Probably  no  one  would  maintain  that  a  jury- 
trial  is  a  benefit  to  those  who  are  actually  insane, 
or  that  it  is  of  material  benefit  to  the   public    in 


tion.  The  publicity  that  it  involves  makes  the  ,  general.  The  ground  on  which  it  is  advocated  is 
relatives  of  patients  reluctant  to  take  the  ne-  the  alleged  danger  that  sane  persons  may  be  con- 
cessary  steps,  the  proceedings  themselves  involve  fined  in  hospitals  for  the  insane,  and  that  a  pro- 
delay,  and  there  is  always   the   possibility    that   cedure  like  that  in  criminal   cases  is  a  security 


the  incompetence  of  jurymen  to  decide  difficult 
questions  of  diagnosis  may  result  in  the  failure 
of  the  patient  to  receive  the  treatment  that  is  re- 
quired for  the  best  interests  of  all  concerned. 
The  very  circumstances  of  being  taken  into  court 
and  put  on  trial,  like  a  criminal,  is  calculated  to 
exert  an  unfavorable  influence  on  the  minds  of 
many  of  the  insane,  endangering  their  prospects 
of  recovery. 

The  natural  desire  of  any  right- feeling   person 


against  such  a  misfortune.  Two  questions  are 
raised  here,  as  to  the  reality  and  extent  of  the 
danger,  and  of  the  value  of  the  protection. 

As  to  the  former  point,  it  may  be  admitted  at 
once  that  physicians  are  not  infallible,  and  that, 
now  and  then,  a  person  is  improperly  committed 
to  a  hospital  for  the  insane.  In  the  great  major- 
ity of  such  cases,  no  serious  hardship  is  inflicted. 
Some  persons  are  temporarily  crazy  from  drink  ; 
some  are  idiots  and   epileptics,  in    need    of  care, 


who  has  a  friend  or  relative  suffering  from  mental   but  not  insane  in  the  ordinary  acceptation  of  the 
derangement  is  to  keep  everything  concerning  it 
as  private  as  possible.     To  require  the  friends  of 
the  insane  to  do  violence  to  all  their  best  feelings 


term  ;  a  few  are  delirious  or  stupid  from  fever  or 
uraemia.     In   a  very  large  proportion  of  cases, 


in  such  a  case- 


they  are  admitted  with  their  own  consent,  as  an 
-to  make  the  extravagances,  the  j  alternative  to  confinement  in  a  penal  institution. 


follies,  the  indecencies  of  their  dear  ones  a  specta- 
cle to  the  loafers  of  a  court- room — is  a  hardship 
which  nothing  but  the  most  imperious  necessity 
can  justify,  and  if  useless,  can  only  be  character- 
ized as  an  abominable  cruelty. 

Considered  with  reference  to  its  bearing  on  the 


either  with  or  without  criminal  prosecution.  Not 
a  few  of  them  have  had  the  benefit  of  a  trial  by 
jury,  and  been  improperly  acquitted  on  the  ground 
of  insanity.  The  number  of  persons  who,  with- 
out having  conducted  themselves  in  such  a  man- 
ner as  to  throw  reasonable  doubt  on  their  mental 


medical  profession,  legislation  of  this  sort  can !  soundness,  have  been  confined  in  institutions  for 
only  mean  one  of  two  things  ;  either  that  physi- ;  the  insane  from  improper  motives  is,  we  believe, 
cians  are  less  competent  in  their  own  business !  extremely  small.  Compared  with  the  numbers 
than  the  average  juryman,  or  that  the}-  are  more  j  who  are  unjustly  convicted  of  crime  by  juries,  it 
likely  to  be  swayed  by  improper  motives  in  cases  would  be  ridiculously  small.  There  is  probably, 
of  this  kind.  We  deny  that  reason  or  experience  !  for  the  average  man,  at  least  a  hundred  times  the 
shows  either  to  be  the  fact,  and  we  have  no  doubt  probability  that  he  will  be  deprived  of  his  liberty 
that,  on  this  point,  at  least,  our  readers  will  by  the  verdict  of  a  jury,  in  a  malicious  criminal 
agree  with  us  that  such  a  law  is  an  unwarranted  1  prosecution,  than  by  physicians  on  a  groundless 
imputation  on  the  intelligence  and  the  integrity   charge  of  insanity,  and  the  consequences  in  the 


of  an  honorable  body  of  men. 

Legal  proceedings  of  all  sorts  are  known  to  be 
a  rather  expensive  luxury,  and  one  for  which 
some   one  has  to   pay.     The   amount    that    has 


former  case  are  much  the  more  serious. 

But,  taking  the  danger  for  what  it  amounts  to, 
how  much  protection  would  a  jury  trial  afford? 
In  all  cases  presenting  any  difficult}'  the  jurors 


been  expended    in   trials  for  insanity  in   Illinois  j  would,  in  most  cases,  be  entirely  incompetent  to 
would,  if  devoted  to  increasing  or  improving  the  judge  of  the  value  of  the  evidence.      They  must 


accommodations  for  the  insane,  have  made  no 
contemptible  addition  to  the  funds  for  those  pur- 
poses. But  this  is  by  no  means  the  total  cost  of 
such  legislation.  The  public  must  pay  for  the 
maintenance  of  those  who,  for  want  of  timely 
treatment,  become  incurably  insane,  and  for  the 
damage  that  they  may  do  while  at  large. 


accept  or  reject  the  opinions  of  the  physicians, 
and  in  so  doing,  they  must  be  governed,  not  by 
an  independent  judgment  of  the  facts,  but  by  their 
impressions  as  to  the  competence  and  honesty  of 
the  witnesses.  If  they  accepted  the  medical  tes- 
timony, they  would  be  useless;  if  they  rejected  it 
they  would  probably  go  wrong.      Any  one  who 


6oo 


WHO  OWNS  THE  PRESCRIPTION? 


[April  25. 


thinks  that  it  would  be  impossible  for  any  one  to 
be  unjustly  decided  insane  by  a  jury,  or  even  that 
such  an  event  would  be  improbable  if  interested 
parties  should  go  to  work  and  get  up  a  case,  must 
have  a  faith  in  the  jury  system  that  is  very  little 
affected  b3'  observation  of  its  practical  workings. 
We  protest,  then,  against  all  such  legislation, 
as  detrimental  to  the  interests  of  all  concerned. 
More  particularly  we  protest  against  it  as  calcu- 
lated to  foster  the  feeling,  already  too  prevalent, 
that  insanity  is  a  crime  instead  of  a  symptom  of 
disease — a  disgrace  instead  of  a  most  pitiable  mis- 
fortune. In  the  name  alike  of  common  sense  and 
of  humanity,  we  urge  that  an  end  be  put  to  such 
foolish  cruelty. 


WHO  OWNS  THE  PRESCRIPTION? 
The  Philadelphia  Medical  and  Surgical  Reporter, 
quoting  from  the  American  Journal  of Pharmacy, 
embodies  a  legal  opinion,  the  gist  of  the  argu- 
ment of  which  appears  to  be  that  the  apothecary 
needs  the  filled  prescription  as  evidence  for  his 
own  or  other  protection  and  therefore  retains  the 
paper  on  the  ground  of  convenience,  ' '  to  warrant 
himself  if  a  question  shall  arise  as  to  correctness 
of  conduct."  "  Evidently  the  only  dispute  can 
exist  in  a  case  in  which  the  physician  and  pa- 
tient have  parted  with  the  possession  of  the  pa- 
per and  it  has  lawfully  come  into  the  hands  of 
the  apothecary  at  the  instance  of  the  patient." 
The  delivery  to  the  apothecary  is  not  virtually  a 
transfer,  nor  is  a  new  prescription  requisite  every 
time  the  order  is  sought  to  be  filled.  Says  Mr. 
McMurtrie,  the  utterer  of  the  opinion,  "there 
ought  to  be  no  doubt  that  the  apothecary  may,  if 
he  sees  fit  and  is  foolish  enough  to  run  the  risk, 
put  the  paper  in  the  fire.  There  can  be  no  duty 
to  produce  it  for  inspection  or  to  give  copies, 
while  it  would  be  silly  to  refuse  to  do  so,  when 
reasonably  demanded." 

Notwithstanding  the  ad  captandum  vein,  there 
is  much  logic  in  the  opinion,  albeit  the  profession 
too  may  have  certain  interests  akin  to  those  in- 
volved by  the  copyright.  These  self-same  pre- 
emptions are  figments  of  the  brain,  made  by  this 
custom  of  repeating  a  menace  to  the  future  emol- 
uments of  the  physician,  but  this  is  equally  true 
of  every  other  vocation  in  all  civilized  countries 
and  cannot  be  made  the  subject  of  special  legisla- 
tion.    To  ourselves  it  has  always  seemed  that  the 


patient  did  own  the  written  order  upon  the  apoth- 
ecary— the  former  rather  than  the  latter — and 
last  of  all  the  physician,  who,  being  exempt  from 
responsibility  for  the  unauthorized  use  of  what 
was  once  his  commodity,  is  not  required  to  give 
any  warning  in  order  to  purge  himself  of  the 
charge  of  being  a  particeps  criminis.  The  risk  as 
against  public  policy  is  mainly  with  the  apothe- 
cary, especially  in  the  matter  of  opiates,  which 
may  or  may  not  call  forth  a  coroner's  jury  cen- 
sure. But  this  censure  is  only  an  inoperative 
substitute  for  a  penalty,  which  at  the  utmost  only 
entails  a  certain  amount  of  notoriety,  conjoined 
with  a  probable  loss  of  business.  The  store- keep- 
er who  has  sold  a  murderous  pistol  may  have  his 
regrets,  but  readily  consoles  himself  with  the  re- 
flection that  he  might  as  well  have  his  price  as 
any  of  his  rivals.  Criminal  intent  being  absent, 
the  law  cannot  well  take  cognizance  of  results. 
Besides  the  spirit  of  trade  has  so  ordained,  and 
every  individual  is  interested  in  the  principle  of 
discretion  in  one  way  or  another. 

The  whole  question  has  been  discussed  in  many 
medical  societies  from  one  session  to  another;  ar- 
gument has  been  pitted  against  intuition  and  sim- 
plicity has  all  but  been  evolved  out  of  the  com- 
plexities, and  to  what  profit?  The  counter  of  the 
apothecary  has  settled  it  all  with  the  package  de- 
livered without  numerous  questions  There  may 
be  nice  points  deserving  of  notice,  but  they  can 
only  be  presented  as  lawyers'  quibbles,  not  as 
Supreme  Court  decisions.  We  scarcely  think 
that  the  apothecary  deliberately  intends  to  de- 
fraud his  patron,  the  physician,  of  a  fee,  for  he 
knows  that  the  patient  does  not  intend  to  return 
to  him  for  medical  advice  and  that  he  probably 
only  gratifies  a  whim  or  mood,  There  are  griev- 
ances to  be  sure,  and  notwithstanding  the  alleged 
blood-relationship  between  law  and  justice,  they 
very  frequently  do  not  speak  as  they  pass  by. 


THF  PROPOSED  PAN-AMERICAN  MEDICAL 
CONGRESS. 

We  are  advised  that  a  resolution  will  be  brought 
forward  at  the  coming  meeting  of  the  Association 
recommending  that  appropriate  action  be  taken 
to  assemble  in  this  country  an  International 
American  Medical  Congress.  Our  people  are 
probably  aware  that  among  the  Eatin-Arnerican 
schools  on  this  Continent  a  standard  of  medical 


I89i.] 


EDITORIAL  NOTES. 


601 


education  obtains  which  insures  a  high  standard 
of  attainment  on  the  part  of  their  alumni. 

An  American  Medical  Congress  would  serve  to 
bring  into  closer,  and  as  we  believe  mutually  ben- 
eficial relations  with  North  American  institutions, 
the  valuable  laboratories,  hospitals  and  other  med- 
ical institutions  of  Havana,  Rio  Janeiro  and  Bra- 
zil. These  Governments  are  fast  becoming  our 
Continental  allies,  in  all  commercial  relations, 
and  there  is  abundant  reason  for  us  to  cultivate 
the  utmost  of  friendly  relations  with  the  medical 
profession  in  each  of  the  Governments  on  the 
Continent.  We  favor  the  holding  of  such  a  Con- 
gress, and  hope  that  favorable  consideration  will 
be  given  to  such  resolution  when  it  shall  be  pre- 
sented. 


EDITORIAL  NOTES. 
Don't  fail  to  Send  Delegates  to  the  meet- 
ing at  Washington.  Every  local  medical  society 
in  the  United  States,  which  is  in  affiliation  with 
the  Association  is  entitled  to  representation  in  that 
body  and  to  a  voice  in  its  proceedings.  Simply 
see  to  it  that  delegates  are  elected  ;  that  they  are 
furnished  with  credentials,  and  that  they  attend 
and  represent  their  constituencies  in  the  coming 
meeting.  Let  the  Permanent  Members  go  as 
Delegates  also.  The  advantage  of  a  delegate  is 
this  :  When  the  discussion  of  a  question  is 
ended  the  Delegate  can  vote,  the  Permanent  Mem- 
ber can  not.  In  the  decision  of  the  important 
questions  now  pending,  votes  alone  will  tell ! 
Let  every  section  of  the  Union  send  its  full 
quota  of  Delegates. 

How  to  Secure  Return  Tickets.— Persons 
desirous  of  securing  commutation  rates  upon  re- 
turn tickets  from  Washington,  must  note  the  fol- 
lowing requirements : 

i.  A  certificate  must  be  obtained  at  the  office  where 
the  ticket  is  purchased  stating  that  you  have  paid  full 
fare  for  your  ticket  to  Washington. 

2.  At  Washington  a  certificate  must  be  secured  from 
the  General  Secretary  of  the  Association  certifying  your 
attendance. 

3.  That  certificate  must  be  presented  with  the  one 
which  you  received  when  you  purchased  your  ticket  at 
the  railroad  office  where  tickets  over  your  road  are  for 
sale,  and  with  that  certificate  iu  hand  you  will  be  able  to 
obtain  return  tickets  over  the  roads  elsewhere  designated 
at  one-third  rates. 


In  this  connection  we  desire  to  bespeak  your 
kind  consideration  of  the  needs  and  comfort  of 
our  always  genial  and  obliging  General  Secretary, 
Dr.  Atkinson.  He  will  devote  abundant  time  and 
designate  the  place  and  hours  for  obtaining  his 
signature,  and  during  these  hours  the  members 
should  be  in  prompt  attendance.  We  protest 
against  a  custom  which  more  and  more  obtains, 
of  waylaying  him  in  his  dressing-room,  in  public 
halls,  at  the  banquets,  and  in  the  midst  of  general 
discussions,  for  the  purpose  of  gaining  that  cov- 
eted signature.  He  is  burdened  with  many  duties 
quite  as  important,  and  in  order  that  he  may  give 
due  attention  to  this  it  is  essential  that  you  ob- 
tain your  certificates  at  the  appointed  time. 

American  Association  for  the  Advance- 
ment of  Physical  Education.  —The  sixth  an- 
nual meeting  of  this  association  was  held  at 
Boston,  April  3  and  4,  Dr.  D.  A.  Sargent  presid- 
ing. An  array  of  papers  dealing  with  the  phys- 
ical education  and  elevation  of  the  race  were 
presented,  many  of  the  contributors  being  mem- 
bers of  the  medical  profession.  ' '  The  Delsarte 
System;"  "  Phj-sical  Education  in  Colleges;" 
"The  Growth  of  Children  ;"  "  Physical  Educa- 
tion in  the  Y.  M.  C.  A.;"  "  Physical  Training  iu 
the  Regular  Army;"  "  Some  of  Galton's  Tests;" 
"The  Muscular  Strength  of  Growing  Girls," 
etc.,  are  among  the  subjects  considered.  One 
hundred  and  sixty  new  members  were  elected. 
The  next  annual  meeting  is  to  be  held  at  Balti- 
more. A  committee  was  appointed  to  petition 
Congress  for  the  creation  of  a  chair  of  physi- 
ology, hygiene  and  physical  training  at  the  U. 
S.  Military  Academy  at  West  Point. 

On  Indefinite  Titles. — Indefinite  captions 
to  articles  in  scientific  periodicals  are  a  delusion 
and  torment,  the  very  bane  of  indexers.  Dr. 
Billings  and  others  have  repeatedly  indicated  to 
medical  writers  how  good  work  may  be  partially 
nullified  by  the  use  of  meaningless  titles,  such  as 
"An  Important  Case,"  "An  Improved  Opera- 
tion," "Ethical  Question,"  "Useful  Sugges- 
tion," "  A  Measure  of  Reform  "  and  a  thousand 
others  that  might  be  mentioned.  When  a  writer 
has  a  valuable  communication  to  make  to  the 
medical  profession,  he  should  so  prepare  it  that 
it  shall  arrest  the  attention  of  the  reader  in  pur- 
suit of  that  particular  kind  of  information,  and 
be  comprehended  without  unnecessary  delav  or 


602 


MEDICAL  ITEMS. 


[April  25 


search.  To  do  these  two  things,  a  great  help  is 
a  precise  and  descriptive  title,  an  outline  in  a 
very  few  words  of  the  chief  point  contained  in 
the  contribution.  If  a  writer  finds  that  it  is  diffi- 
cult to  concisely  state  the  object  of  his  article, 
there  is  a  strong  presumption  that  he  has  noth- 
ing of  importance  to  say  to  his  medical  brethren. 
Every  pithy  and  instructive  paper  is  worthy  of  a 
pertinent  caption,  and  in  ninety- nine  cases  out  of 
a  hundred  such  a  caption  can  be  formed  with  less 
than  six  to  eight  words. 

Faulty  Construction  of  a  Government 
Hospital. — A  conflagration  at  the  Naval  Hos- 
pital, Brooklyn,  narrowly  escaped  effecting  the 
complete  destruction  of  that  institution.  It  is 
reported  that  the  fire  was  occasioned  by  a  faultily 
constructed  shute  for  the  disposal  of  sweepings 
and  refuse  from  the  wards.  The  members  of  the 
medical  corps  have  repeatedly  called  the  atten- 
tion of  the  authorities  at  Washington  to  this 
inflammable  wooden  flue  running  from  one  story 
to  another;  but  too  much  'Ted  tape,"  or  too 
little  attention  to  duty,  or  both,  resulted  in  its 
non-removal  until  the  day  of  the  fire,  April  8, 
when  the  flames  effectually  destroyed  it.  Con- 
siderable damage  was  done  to  the  hospital,  but 
no  lives  were  lost.  The  fire  occurred  in  the  day- 
time and  was  extinguished,  by  the  aid  of  the  fire 
department  of  the  city,  without  much  delay. 
The  first  principles  of  hospital  construction  would 
seem  to  interdict  the  construction  or  maintenance 
of  combustible  shafts  or  sbutes  such  as  that 
alleged  to  exist  in  this  instance. 

MEDICAL  ITEMS. 

Influenza  at  Hong  Kong. — A  very  sharp 
epidemic  of  influenza  has  of  late  prevailed  at 
Hong  Kong,  taking  on  all  the  characteristics  of 
the  same  affection  as  observed  in  this  country. 

Diphtheria  in  Iowa. — Reports  go  to  prove 
that  this  disease,  which  has  prevailed  quite  freely 
for  several  months,  has  now  greatly  declined. 

Piperazine  is  a  new  uric  acid  solvent  which 
promises  to  be  a  valuable  addition  to  our  list  of 
remedies. 

A  Falling-off  in  California. — According 
to  the  last  issue  of  the  Register  of  Physicians  in 
the  State  of  California  there  is  a  notable  decline 
in  the  number  of  physicians  seeking  to  locate  in 
that  land  of  fruit  and  flowers. 


Diphtheria  in  Newfoundland.  —  That  a 
scourge  of  this  kind  has  been  existing  in  New- 
foundland can  be  gathered  from  the  following : 
Within  the  past  two  years  2,499  cases  have  oc- 
curred at  St  Johns,  and  as  the  population  of  the 
city  is  given  as  30,000,  it  will  be  seen  that  the 
pioportion  of  persons  suffering  was  one  in  twelve. 
The  rate  of  mortality  has  been  one  in  five. 

A  Late  View  Touching  Tuberculin. — In 
an  official  report  from  P.  A.  Surgeon  J.  J.  Kin- 
youn,  detailed  from  the  U.  S.  Marine- Hospital' 
Bureau  to  stud}7  the  methods  of  Professor  Koch 
in  the  Hygienic  Institute  of  the  Berlin  Univer- 
sity, occurs  the  following:  "I  am  more  con- 
vinced that  the  remedy  has  but  a  limited  range 
of  usefulness,  and  should  only  be  administered 
in  the  first  stage  of  the  disease." 

Transactions  of  the  Berlin  Interna- 
tional Congress.  —  The  Transactions  of  the 
Tenth  International  Medical  Congress  are  now 
ready  for  distribution  among  members.  Foreign 
members  must  make  application  and  forward 
postage.  Copies  have  been  placed  on  sale  in 
London. 

Typhus  Fever  in  New  York  City. — A  case 
of  this  disease  recently  occurred  at  Bellevue 
Hospital,  ending  fatally.  Until  just  before  death 
it  was  quite  impossible  for  the  physicians  in  at- 
tendance to  arrive  at  a  diagnosis.  Active  pre- 
cautions have  been  taken  against  the  disease 
spreading  abroad. 

Yellow  Fever  on  Steamship  from  Bra- 
zilian Ports. — The  steamship  Dryden,  from  Rio 
and  other  Brazilian  ports,  arrived  in  New  York 
Harbor,  April  9,  infected  with  yellow  fever. 
Three  deaths  from  the  fever  occurred  among  the 
crew  during  the  passage  northward.  All  three 
cases  began  and  terminated  between  March  1 1 
and  22;  and  no  other  cases  arose  after  the  latter 
date.  The  ship  was  detained  at  Quarantine  for 
disinfection  and  was  ordered  to  be  kept  there  un- 
der observation  for  a  period  of  five  days. 

Influenza. — Dr.  Benjamin  Lee,  of  Philadel- 
phia, has  made  a  report  based  upon  a  considera- 
tion of  upwards  of  4 1 ,  500  cases  of  influenza.  We 
merely  desire  to  say  in  this  connection  that  if 
numbers  are  sought  upon  which  to  rest  conclu- 
sions Dr.  Lee  will  do  well  to  place  himself  in 
communication  with  Chicago  physicians. 


l89I.j 


TOPICS  OF  THE  WEEK. 


603 


TOPICS  OF  THE  WEEK. 


Till-:  POSSIBILITIES  OF  MEDICINE. 

At  the  recent  commencement  exercises  of  Long  Island 
College  Hospital  Professor  T.  Gailliard  Thomas,  in  giv- 
ing the  concluding  address,  spoke  as  follows: 

Even  in  these  unsentimental  days  many  men  chose 
their  occupations  more  because  of  attending  dangers  and 
chances  of  heroism  than  from  any  less  romantic  notion 
of  their  usefulness.  Thus  the  youth  of  a  smiling  country- 
are  persuaded  to  risk  their  lives  on  the  sea,  and  the 
painter  in  the  hope  of  fame  starves  at  his  work  in  the 
attic.  Young  men  would  willingly  lav  down  their  lives 
for  the  glory  of  a  Sheridan  or  a  Farragut.  Arms,  litera- 
ture, art,  law,  divinity,  all  had  bright  and  glorious  re- 
wards for  those  who  had  the  courage  to  aspire  to  them 
and  patience  to  suffer  for  them,  the  industry  to  work  for 
them  and  the  genius  to  obtain  them.  Think  you,  con- 
tinued the  speaker,  that  the  science  of  medicine,  founded 
400  years  before  the  birth  of  Christ;  the  chosen  work  of 
our  Saviour  himself;  the  most  far  reaching  and  benign 
of  all  modern  pursuits,  stands  alone  in  its  inability  to  re- 
ward its  votaries?  Far  from  it.  Look  back  with  me 
into  history,  and  I  shall  not  be  called  upon  to  take  you 
into  the  fields  of  ancient  history,  even,  and  it  will  go 
hard  but  I  shall  make  you  agree  with  me  that  of  all  call- 
ings, all  pursuits,  all  professions,  the  rewards  of  medicine 
are  greater,  more  lofty,  more  desirable  and  more  endur- 
ing than  those  of  any  other  in  existence.  His  hearers 
would  agree  that  he  who  had  done  the  greatest  good  for 
his  fellowman  had,  in  the  doing  of,  won  the  greatest  re- 
wards in  earth's  possessions,  even  if  no  mortal  man 
knew  of  the  deed  but  him.  The  forces  of  civilization 
work  hand  in  hand  for  the  common  good.  All  the  forces 
of  intelligence,  law,  the  fine  arts,  religion  and  medicine 
were  all  contributing  their  quota.  Hygiene — the  science 
of  cleanliness— as  taught  by  medicine,  had  wiped  off  the 
globe  the  terrible  scourges  which  made  the  dark  ages  so 
terrible.  Cholera,  the  dread  monster.had  been  almost  total- 
ly shut  up  in  its  birthplace  in  Asia  and  checked  in  its  wan- 
derings over  the  world.  Quarantine  had  transferred  yel- 
low fever  from  a  universal  menace  into  a  local  distemper. 
Small-pox  had  been  lashed  to  hell  by  the  agent  vaccina- 
tion, and  like  a  whimpering  hound  was  held  securely  in 
leash.  The  work  of  medicine  had  far  more  numerous 
conquests  than  even  those  enumerated.  So  wonderful, 
so  startling,  so  extraordinary  were  those  results  that  he 
feared  his  non-medical  hearers  would  suspect  him  of 
boasting  if  he  read  the  full  record  of  the  proud  achieve- 
ments of  medicine  during  the  past  hundred  years.  But 
conquests  in  the  past  in  no  wise  curtailed  the  possible 
achievements  in  the  future.  One  great  initial  discoverv 
ever  opened  the  way  for  numberless  others  equally  as 
great  to  be  made.  This  was  illustrated  by  the  micro- 
scope, by  the  telescope,  by  the  circulation  of  the  blood, 
by  steam  and  electricity.  The  discovery  of  the  transmis- 
sion of  disease  by  bacilli  had  brought  the  students  of  to- 
day upon  a  plane  far  more  elevated  than  that  which  even 
the  youngest  of  their  teachers  occupied  upon  his  gradu- 
ation.     The  present  students'   possibilities  in  medicine 


were  proportionately  greater  than  his  were,  and  it   was 
their  function  to  profit  by  their  good  fortune. 

The  speaker  declared  if  he  had  the  power  to  accomplish 
one  wish  in  his  life  he  thought  he  would  select  the  de- 
struction of  the  process  by  which  alcohol  was  created. 
If  that  were  denied  him,  the  power  of  stampiug  out  for- 
ever those  contagious  diseases  which  fill  our  graves  with 
curly  heads  and  dimpled  cheeks  and  our  homes  with 
sorrow  that  knows  no  comforting.  He  would  destroy  those 
terrors  of  the  household,  scarlatina,  diphtheria 
host  of  contagious  maladies  which  went  hand  in  hand 
with  them.  The  first  of  these  wishes  was  impossible  of 
attainment.  Hut  not  so  of  the  second.  The  way  of  its 
accomplishment  was  open  to  every  man  with  willing 
hand,  determined  mind  and  intelligent  brain.  Surely  it 
was  not  too  sanguine  a  prediction  that  the  next  century 
might  see  the  extinction  of  contagious  disease.  Elabor- 
ating this  point,  the  speaker  pointed  that  since  1799,  the 
date  of  Jenner's  discovery  of  vaccination  for  small-pox 
— and  unless  the  claims  of  Pasteur  and  Koch  should 
prove  valid — no  other  contagious  disease  has  been  pre- 
vented by  the  elaboration  of  the  brilliant  idea  of  inocu- 
lation. Diseases  were  also  checked  by  certain  drugs 
which  seemed  to  have  the  power  of  destroying  their  ba- 
cilli cause  :  but  with  these  but  two  diseases  had  been 
checked  iu  the  history  of  medicine.  Here  was  the  field 
and  it  remained  but  for  the  student  of  to-day  to  work  iu 
it.  There  was  everything  to  accomplish  and  the  road 
was  made  clear  before  him.  After  formulating  his  sug- 
gestions in  detail  and  giving  illustrations  of  how  genius 
had  labored  long  to  solve  some  of  the  simplest  problems 
of  life  the  speaker  said  in  conclusion  : 

The  motto  of  the  New  York  Academy  of  Medicine, 
coming  down  from  mythological  times,  is  this:  "Hom- 
ines deos  accedunt  hominibus  dando  salutem."  "Men 
most  nearly  resemble  the  gods  when  they  afford  health 
to  their  fellow-men."  If,  as  seems  now  highly  probable, 
Robert  Koch  should  succeed  in  curing  and  preventing 
tubercular  disease  in  its  various  manifestations,  what 
greater  reward  could  he  possibly  ask  for  than  the  pleas- 
ure which  he  must  feel  when  the  reflection  to  which  this 
motto  gives  rise  comes  to  his  mind.  The  reward  of  the 
phvsiciau  whose  happy  discovery  stamps  out  a 
which  before  his  day  slew  its  thousands,  comes  from  the 
hand  of  no  Emperor;  his  glory  from  the  appreciation  of 
no  applauding  multitude;  his  renown  from  the  pen  of  no 
fulsome  historian.  For  him  the  victor's  crown  comes 
from  the  hand  of  the  immortal  God;  his  glory  from  the 
satisfaction  of  doing  a  great  and  glorious  work;  his  re- 
nown from  the  gratitude  of  his  fellow-men!  The  "  great 
awakening  light "  which  blessed  the  eyes  of  Abou  Ben 
Adhem,  not  the  imperial  purple  which  decked  the  shoul- 
ders of  the  mighty  Julius,  constitutes  his  diadem  and 
causes  a  halo  to  shine  around  his  head!  In  the  golden 
days  of  chivalry,  when  a  young  knight  was  to  receive 
the  accolade  and  become  the  defender  of  the  weak  and 
the  redresser  of  wrong,  he  was  required  to  spend  an  en- 
tire night  iu  cathedral  or  other  solemn  place,  reflecting 
upon  the  purity,  the  beneficence  and  the  grandeur  of  his 
new  office,  and  in  forming  the  noble  resolve  to  make  of 
it  no  trade,  but  to  administer  his  duties  with  the  love  of 


604 


TOPICS  OF  THE  WEEK. 


[April  25 


rnan  in  his  heart  and  the  glory  of  God  in  his  soul.  Let 
this  night  and  these  exercises  bear  to  you  the  relation  of 
that  vigil  night  of  old!  Medicine  is  the  noblest  of  pro- 
fessions; the  meanest  of  trades.  Unless  you  can  live 
lives  of  purity,  of  virtue,  of  honor  and  of  honesty,  seek 
a  livelihood  elsewhere  and  insult  not  the  gods  by  striving 
through  base  methods  and  ignoble  ambitions  to  resemble 
them!  Will  you  not  now  fully  agree  with  me  when  in 
closing  this  address  I  ask  you  whether  the  possibilities  of 
medicine  are  not  really  greater  than  those  of  her  sister 
sciences  and  arts?  Will  you  not  accord  in  my  postulate 
that  arms,  arts,  literature,  science,  all  have  their  rewards, 
but  that  not  one  of  them  surpasses  in  the  magnificence  of 
its  gifts  those  of  which  the  godlike  science,  medicine,  is 
capable?  When,  a  quarter  of  a  century  hence,  I  meet 
with  one  of  you,  as  we  both  wend  our  ways  along  the 
highway  of  life,  my  locks  as  white  as  the  driven  snow 
and  yours  as  white  as  mine  are  now,  come  up  to  me,  re- 
port yourself  as  a  member  of  the  graduating  class  of  the 
Long  Island  College  Hospital  of  1S91,  and  tell  me  which 
one  of  the  beneficent  discoveries  which  the  next  twenty- 
five  years  are  sure  to  bring  forth  has  been  the  means  of 
causing  you  to  resemble  the  gods  and  enrolled  your  name 
"among  the  few,  the  immortal  names  that  were  not  born 
to  die;"  and  I,  recalling  at  once  to  mind  you  and  this 
pleasant  evening  which  has  made  us  acquainted,  will  bid 
you  God-speed,  even  as  I  do  to-night. 


THE  PHONOGRAPH  IN  MEDICINE. 

The  applicability  of  the  phonograph  to  the  record  and 
demonstration  of  defects  in  speech  has  been  well  illustra- 
ted during  the  past  week  at  the  Royal  Medical  and 
Chirurgical  Society  and  at  the  Hunterian  Society.  At 
the  first-named  Dr.  Hale  White  and  Mr.  Golding-Bird 
were  enabled  by  means  of  this  instrument  to  allow  the 
Fellows  present  to  hear  the  curiously  defective  speech  of 
two  children,  and  to  contrast  this  with  the  improvement 
•effected  by  treatment,  for  the  subjects  were  present,  and 
after  the  phonograph  had  given  their  past  utterances, 
their  present  speech  was  demonstrated  viva  voce.  The 
papers  read  by  the  above  gentlemen  and  that  by  Dr.  F. 
Taylor  led  to  an  instructive  debate,  which  was  further 
illustrated  by  some  marked  cases  introduced  hy  Dr.  Had- 
den.  The  outcome  seemed  to  be  that  these  defects  in 
articulation  are  probably  of  central  origin,  and  not  due 
to  any  mechanical  interference  with  the  organs  of  speech. 
Whether,  as  suggested  by  Dr.  Langdon  Down  and  Mr. 
Spencer  Watson,  the  defect  was  primarily  one  of  audition 
is  a  question  certainly  worthy  of  consideration.  Another 
point  raised  w.is  whether  the  defect  should  be  considered 
one  of  speech  or  language,  and  some  exception  was  taken 
by  Drs.  Taylor,  Pye-Smith,  and  others,  to  the  use  of  the 
term  "  idioglossia,"  which,  however,  was  ably  defended 
by  Dr.  Hale  White.  The  other  phonographic  demonstra- 
tion at  the  Hunterian  Society  was  by  Dr.  Hughlings 
Jackson,  who  thus  reproduced  the  characteristic  speech 
of  a  subject  of  cerebro  spinal  sclerosis.  There  can  be 
little  question  that  the  phonograph  will  ultimately  prove 
very  useful,  especially  in  the  preservation  of  certain  an- 
omalies of  articulation,  and  its  further  extension  toother 
sound  phenomena  in  the  range  of  clinical  medicine  may 
be  justifiably  hoped  for. —  'Ike  Lancet. 


WORD-BLINDNESS  WITH  UNUSUAL  FEATURES. 

The  following  case  was  reported  by  Professor  Mierze- 
jewski  at  a  recent  meeting  of  the  St.  Petersburg  Society  of 
Psychiatry,  and  is  given  in  the  Neurologisches  Central- 
blatt  for  December  15,  1890.  A  physician,  fifty-six  years 
old,  had  had  syphilis  in  his  youth,  and  for  several  years 
had  suffered  from  chronic  nephritis.  In  January,  iSgo, 
he  had  an  attack  of  ursemic  coma,  which  listed  four  or 
five  days.  He  had  since  had  two  other  attacks  of  shorter 
duration.  Some  time  after  the  third  attack,  which  oc- 
curred last  spring,  the  patient  noticed  that  he  had  lost 
the  power  of  reading,  although  he  could  distinguish  the 
letters  easily,  and  his  sight  in  general  was  unchanged. 
Mierzejewski  found  the  following,  on  examination:  The 
patient  sees  each  individual  letter  clearly,  but  is  unable 
to  join  the  letters  into  syllables  or  words.  He  writes 
without  difficulty  and  correctly  whatever  is  dictated  to 
him,  but  can  not  read  what  he  has  written.  He  can  write 
prescriptions  in  due  form,  but  cannot  read  them  after- 
ward. He  can  make  correct  copies  without  understand- 
ing the  meaning  of  the  words  copied.  Numbers,  how- 
ever, he  can  read  and  pronounce  correctly.  The  patient's 
sight  is  perfect,  and  the  fundus  of  the  eye  is  normal. 
There  is  no  disturbance  of  speech,  and  the  intelligence  is 
unaffected.  There  is  no  change  in  sensation,  motion,  or 
the  reflexes.  After  looking  through  the  literature  of  the 
subject,  Mierzejewski  concludes  that  this  is  the  first  case 
of  word-blindness  as  yet  reported  in  which  the  ability  to 
distinguish  the  single  letters  was  retained,  and  he  calls  it 
ccecitas  syllabaris  et  verbqlis,  sed  turn  lateralis. — .Y.  )'. 
Med.  Jour. 


THE  NAVAL  MEDICAL  SERVICE. 

Mr.  Tracv.  Secretary  of  the  Navy,  is  evidently  no  friend 
of  the  medical  profession,  nor  is  he  very  keen  for  the  im- 
provement of  the  personnel  of  the  service,  if  one  may 
judge  from  the  following  Washington  despatch  printed 
in  the  New  York  Times.     The  writer  says  : 

"The  medical  corps  of  the  Navy  is  still  experiencing 
considerable  difficulty  in  filling  vacancies  in  the  grade  of 
assistant  surgeon.  Several  candidates  have  recently  been 
examined  by  the  New  York  Board,  but  none  was  success- 
ful. The  San  Francisco  Board  has  been  dissolved  be- 
cause no  candidates  presented  themselves.  The  medical 
colleges  are  now  being  canvassed  by  tempting  circulars 
sent  out  by  the  Navy  Department.  The  reluctance  felt 
bv  students. toward  entering  this  branch  of  the  Govern- 
ment service  is  obvious.  Until  Congress  has  increased 
the  pav  and  conditions  aboard  ship  of  assistant  surgeons, 
medical  officers  say  that  it  will  be  impossible  to  keep  the 
corps  recruited  to  its  full  quota  unless  the  standard  of 
examination  is  reduced.  This  Secretary  Tracy  has  abso- 
lutely refused  to  do." 

The  Naval  Department  is  expending  enormous  sums 
in  the  building  of  ships  ;  but,  after  all.  these  new  iuku- 
sters  of  the  sea  cannot  be  efficiently  utilized  without  a 
high  class  of  officers  and  men.  Money  expended  in  pro- 
moting this  end  would  be  wisely  spent,  and  it  is  difficult 
to  understand  why,  when  millions  are  spent  on  experi- 
mtntal  ships  and  guns,  a  few  thousands  cannot  be  used 
for  raising  tile  standard  of  the  medical  service  to  that  of 
tin-  army.  As  it  is  now,  it  looks  as  though  it  was  in- 
voluntarily boycotted.— Medical  Record. 


i89i.] 


PRACTICAL  NOTES. 


605 


PRACTICAL  NOTES 


PAINLESS  CIRCUMCISION. 

The  suggestion  of  Dr.  Overall,  strongly  en- 
dorsed by  Dr.  Storch,  for  producing  anaesthesia 
of  the  parts  to  be  operated  upon,  is  as  follows: 
Of  a  twenty  to  thirty  per  cent,  solution  of  co- 
caine let  ten  or  fifteen  drops  be  pressed  into  the 
preputial  opening  with  a  blunt-pointed  syringe 
and  retained  by  pressure  as  the  syringe  is  with- 
drawn. Let  the  parts  be  so  manipulated  that  the 
entire  preputial  mucous  membrane  shall  be  in 
contact  with  the  fluid  ten  or  fifteen  minutes.  At 
the  same  time  the  integument  where  circumcision 
is  to  take  place  should  be  sprayed  with  the  fol- 
lowing mixture: 

R.     Chloroform,  3  ijss. 

Ethei  sulphuris.  3  iv. 

Menthol,  grs.  xv.     nj. 

Continue  the  spraying  of  the  parts  until  com- 
plete anaesthesia  is  produced.  Following  this 
procedure  the  operation  is  painless. 

If  the  operation  be  performed  for  enuresis  of 
long  standing,  the  following  medication  is  recom- 
mended ■ 

R.     Atropiae  sulph.,  grs.  ij. 
Aquae  distillatae  sj.     tijj. 

Sig.  One  drop  for  each  year  of  the  age  of  the  child 
at  4  o'clock  and  at  7  o'clock,  increasing  the  dose  if  no 
effect  is  produced  after  one  week. 


gestion  to  the  mucous  membrane;  it  is  often  fol- 
lowed by  a  profuse  flow  of  nasal  mucous  with  lit- 
tle sneezing.  Breathing  through  the  nose  and 
mouth  the  steam  of  hot  camphor  water,  and  the 
internal  use  of  carbonate  of  ammonia,  are  also 
recommended,  and  there  is  often  utility  in  the 
production  of  active  diaphoresis.  Many  of  late 
years  have  claimed  decided  benefit  from  full  doses 
of  antipyrin.  acetanilid,  phenacetin,  in  the  on- 
set of  colds;  and,  doubtless,  these  new  remedies 
are  more  and  more  taking  the  place  of  the  depres- 
sant diaphoretics. — Boston  Medical  and  Surgical 
Journal. 

PREVENTION  OF  PITTING  IN  SMALL-POX. 

The  pitting  of  small-pox  has  been  entirely  pre- 
vented by  Dr.  Lewintaner,  of  Constantinople,  by 
antiseptic  treatment,  as  follows:  The  entire  head 
and  face,  except  eyes,  and  the  neck,  are  covered 
with  plaster  consisting  of  three  parts  carbolic 
acid  and  fifty  parts  each  of  olive  oil  and  starch. 
The  body  is  covered  over  with  a  mixture  of  three 
!  parts  salicylic  acid,  thirty  parts  starch,  and  seven- 
ty parts  olive  oil.  The  internal  treatment  con- 
sists in  giving  quinine  in  acid  solution. —  Witn. 
Klin.   Woch. 


WHAT   SHALL    BE    DONE    FOR    A    COLD    IN   THE 
HEAD. 

It  may  not  be  always  possible  to  break  up  a 
cold.  Sometimes  during  the  congestive  stage, 
anything  which  will  allay  irritation  will  suffice. 
The  person  who  feels  a  cold  coming  on  should 
instantly  betake  himself  to  bed,  drink  a  cup  of 
hot  ginger-tea,  and  make  use  of  a  snuff  like  that 
which  was  proposed  several  years  ago  by  Dr. 
Ferrier : 

R.      Morph.  sulph..  gr.  j. 

Bismuth  subnit.,  3  iij. 

Pulv.  acaciae..  -Jj.     "£. 

The  insufflation  of  a  little  morphine  at  the  com- 
mencement of  a  cold  in  the  head  is  sometimes  at- 
tended with  very  happy  results.  Quinine  as  an 
abortant  in  commencing  cold  is  much  in  use;  the 
dose  should  be  somewhat  large;  Dr.  T.  J.  Mac- 
lagan  says  ten  grains.  Its  efficiency  is.  however, 
rather  problematical.  Doubless,  menthol  is  one 
of  the  best  local  applications  in  the  early  stages 
of  coryza.  It  may  be  used  in  the  form  of  an  oint- 
ment (menthol  one  part,  vaseline  thirty  parts),  or 
as  a  spray  with  liquid  albolene.  A  formula 
which  may  do  good  service  is  the  following:  Men- 
thol, one  part,  liquid  albolene,  thirty  parts.  A 
special  spray  atomizer,  such  as  sold  by  all  the  in- 
strument makers,  is  needed  for  the  effective  use 
of  this  combination.   Menthol  seems  to  limit  con- 


THE  DEODORIZATION  OF  IODOFORM    BY    CREOLIN. 

Dr.  Ludwig  Vaczi,  a  practitioner  in  Xagy- 
Karoly,  communicates  to  the  Medicinischchirur.- 
gische  Rundschazi  his  discovery  of  the  power  ol 
creolin  to  deodorize  iodoform.  He  had  prescribed 
an  ointment  consisting  of  one  part  of  creolin,  two 
of  iodoform,  and  twenty-five  parts  of  vaseline.  On 
the  following  day  he  was  surprised  that  not  only 
was  the  usual  color  of  iodoform  ointment  changed, 
but  that  there  was  no  smell  of  iodoform  and  only 
a  slight  smell  of  creolin.  He  points  out  how  im- 
portant it  is  in  many  cases  that  the  presence  of 
iodoform  should  not  be  known  by  its  odor,  and 
considers  creolin  the  very  best  of  all  deodorizing 
drugs  for  the  same.  It  not  only  does  not  irritate, 
but  it  is  also  itself  a  good  disinfectant. — Lancet. 


A    POWDER    FOR    DYSPEPSIA. 

Dujardin-Beaumetz  {U  Union  .Vedicale)  uses 
the  following  powder  for  painful  dyspepsia  and 
gastralgia  : 

R.    Bismuth  subnit., 
Magnesiae, 
Cretae  prep.. 

Calcii  phosphatis  aa  3  ijss.     "J. 
Divide  in  pulv.  No.  XL.     Sig.  One  powder  before  each 
meal. 


FOR    ENURESIS. 
R.    Tinct.  cantharidis.  gtt.  xvj- 
acaciae,  3ij. 
Pepsin  cordial,  P.  D.  &  Co.,  3XJV-     *%■ 
S.  3j  ter  in  die. 

—  The  Country  Doctor 


6o6 


AMERICAN  MEDICAL  ASSOCIATION. 


[April  25, 


ASSOCIATION  NEWS. 


American  Medical  Association. 

Preliminary  Programme  of  the   Forty-second  Annual 

Meeting,  to  be  held  at  Washington,   D.   C., 

May  5  to  8,   1891. 

President's  Address,  by  Win.  T.  Briggs,  Nash- 
ville, Term. 

On  General  Medicine,  by  E.  L.  Shurly,  De- 
troit. Mich. 

On  General  Surgery,  by  Jos.  M.  Mathews, 
Louisville,  Ky. 

On  State  Medicine,  by  W.  L-  Schenck,  To- 
peka,  Kan. 

Committee  on  Arrangements  :  Dr.  D.  C.  Pat- 
terson, Chairman,  919  I  Street,  N.  W.,  Wash- 
ington, D.  C. 

Section  of  Practice  of  Medicine  and  Physiology. 

"The  Growing  Importance  of  Chemical  Studies  in 
Medical  Education  and  in  Medical  Research,"  by  the 
Chairman. 

Title  not  received,  Win.  Osier,  Baltimore. 

"A  Contribution  to  the  Clinical  Study  of  Protracted 
Pyrexia,"  by  Wm.  Pepper,  Philadelphia. 

"The  Report  of  a  Case  of  Fatty  Urine  accompanying 
an  Abscess  in  the  Right  Iliac  Fossa,"  by  J.  P.  Connelly, 
Williamsport,  Pa. 

"  The  presence  and  significance  of  Albuminuria  in  Per- 
sons Apparently  Healthy, "  by  W.   B.  Davis,  Cincinnati. 

"The  Diagnosis  of  Renal  Calculus,"  by  I.  N.  Dan  forth, 
Chicago. 

Title  not  received,  J.  C.  Wilson,  Philadelphia. 

"A  Pathological  Condition  of  the  Lungs  hitherto  un- 
described  in  this  countrv,  but  which  is  not  infrequent,"  by 
F.  Peyre  Porcher,  Charleston,  S.  C. 

Title  not  received,  J.  H.  Musser,  Philadelphia. 

Title  not  received,  W.  J.  Herdman,  Ann  Arbor,  Mich. 

"Some  of  the  Remote  Effects  of  Injury  to  the  Brain 
in  Delivery,"   by  F.  W.  Goodell,  Bennington,  Vt. 

"  Physiological  Properties  of  Living  Tissue  and  their 
Relations  to  Practical  Medicine,"  by  N.  S.  Davis,  Chica- 
go, 111. 

"  Recent  Contributions  to  the  Knowledge  of  Diphthe- 
ria," by  J.  Lewis  Smith,  New  York. 

"Koch's  Treatment  of  Tuberculosis, "  by  John  B.  Ham- 
ilton, Washington. 

"  Prof.  Koch's  Method  for  the  Cure  of  Tuberculosis  and 
its  Results  in  Pulmonary  and  Laryngeal  Cases,"  by  Karl 
von  Ruck,  Asheville,  N.  C. 

"Tuberculin  in  the  Treatment  of  Tuberculosis,  with  a 
Report  of  Cases  treated  at  the  Good  Samaritan  Hospital 
of  Cincinnati,"  by  S.  P.  Kramer,  Cincinnati,  O. 

"On  the  Treatment  of  Chronic  Phthisis,"  by  Asa  F. 
Pattee,  Boston,  Mass. 

"  Strychnine  as  a  Cardiac  Supporter  in  Acute  Febrile 
Diseases,"  by  S.  Solis-Cohen,  Philadelphia. 

"Antiseptic  Treatment  and  Liquid  Diet  in  Tvphoid 
Fever,"  by  B.  M.  Griffith,  Springfield,  111. 

"  Naphthulin  in  Typhoid  Fever,  based  on  One  Hun- 
dred Cases,"  by  L.  Wolf,  Philadelphia. 

"The  Present  Status  of  Antiseptic  Medication,"  by 
F.J.  Groner,  Grand  Rapids,  Midi. 

"Some  Clinical  Experiences  with  Eucalyptol,"  byj. 
X.  Brainerd,  Alma,  Mich. 

•  The  Atmospheric  Causative  Relations  of  Intermittent 
Fever,"  by  H.  P..  Hemenway,  Evanston,  111. 

"  Further  Studies  in  Malarial  Disease,"  by  George 
Dock,  Galveston,  Texas. 

Title  not  received,  Chas.  G.  Stockton,  Buffalo,  N.  Y. 


Title  not  received,  C.  W.  Dulles,  Philadelphia. 

"Some  Accidental  Cardiac  Murmurs,"  by  N.  S.  Davis, 
Jr.,  Chicago. 

"  The  Pulse,"  by  Starling  Loving,  Columbus,  O. 

"Slow  and  Rapid  Pulse,  Causation  and  Treatment," 
by  D.  Webster  Prentiss,  Washington. 

"  Have  we  a  Science  of  Medicine?  "  by  H.  J.  Herrick, 
Cleveland,  O. 

f  itle  not  received,  W.  F.  Waugh,  Philadelphia. 

"  Digitalis  in  the  First  and  Second  Stages  of  Pneumo- 
nia," D3-J.  W.  Carhart,  Lampasas,  Tex. 

"  Treatment  of  Spasmodic  Asthma,"  by  J.  F.Jenkins, 
Tecumseh,  Mich. 

"Antiseptic  Midwifery,"  by  Hiram  Corson,  Plymouth 
Meeting,  Pa. 

"Epidemic  Cerebro-Spinal  Meningitis,"  by  J.  S.  Now- 
lin,  Shelbyville.  Tenn. 

"The  Action  of  the  Turkish  Bath  in  Disease,"  by  Chas. 
H.  Shepard.  Brooklyn.  X.  Y. 

Victor  C.  Vaughan,  Chairman, 

Ann  Arbor,  Mich. 
Geo.  Dock,  Secretary, 

Galveston,  Tex. 

Section  of  Obstetrics  and  Diseases  of  Women. 

"Joint  Reflexes  Consecutive  to  Pelvic  Inflammation." 
by  W.  W.  Potter.  Buffalo. 

"Removal  of  the  Appendages  for  Relief  of  Nervous 
and  Mental  Disturbances,"  by  Geo.  J.  Engelman.  St. 
Louis. 

"Relation  of  Gynecology  to  Neurology,"  by  Wm.  B. 
Delbers,  Saliua,  Kan. 

"A  Report  of  Ten  Selected  Cases  of  Laparotomy  with 
Remarks,"  by  Jno.  A.  Mclntyre,  St.  Louis. 

"Some  Comparative  Data  on  the  Treatment  of  U/terine 
Tumors,"  by  Marie  B.  Werner,  Philadelphia. 

"A  Peculiar  Forceps  Complication."  by  Dan.  Millikin. 
Hamilton.  O. 

"Treatment  of  Posterior  Face  Presentations,"  by  E.  T. 
Bernardy.  Philadelphia. 

"The  Practical  Treatment  of  Accidental  Abortion."  by 
Bedford  Brown,  Alexandria.  Ya. 

"Exhibition  of  35  Specimens  of  Ectopic  Gestation  Re- 
moved Post-mortem,"  by  Henry  F.  Formad,  Philadel- 
phia. 

"Ectopic  Pregnancy,"  by  Donnel  Hughes.  Philadel- 
phia. 

"Report  of  Cases  of  Ectopic  Gestation."  by  C.  S.  and 
W.  D.  Hamilton,  Columbus,  O. 

"  Hysterectomy  Without  a  Pedicle,"  by  S.  C.  Gordon, 
Portland,  Maine. 

"  Present  Status  of  Minor  Gvnecological  Surgery,"  by 
J.  M.  Baldy,  Philadelphia,  Pa. 

"  Pyoktanin  as  an  Antiseptic,"  bv  H.  J.  Boldt,  New- 
York  ,'  N.  Y. 

"A  Triplet  Birth,"  by  A.  A.  Barton,  Plains,  Pa. 

"  Practical  Remarks  with  Reference  to  the  Technique 
of  Intraperitoneal  Operations,"  by  R.  Stansbury  Sutton, 
Pittsburgh,  Pa. 

"  Rapid  Dilatation  and  Curetting,"  by  J.  G.  Carpenter, 
Stanford,  Ky. 

"Pathological  Anteflexion  of  the  Uterus,"  by  Eliza  J." 
C.  Minard,  Brooklyn,  N.  Y. 

'  The  Technique  of  Successful  Abdominal  and  Pelvic 
Surgery,"  by  Wm.  H.  Wathen,  Louisville.  Ky. 

"The  Clinical  Teaching  of  Obstetrics  in  America."  by 
E.  S.  McKee,  Cincinnati,  0. 

"The  Restoration  of  the  Tclvic  Structures  after  In- 
jury," by  Henry  O.  Marcv,   Boston,  Mass. 

"  When  is  Antisepsis  a  Failure?"  by  George  Erety 
Shoemaker,  Philadelphia,   Pa. 

1  My  Experience  with  the  Surgical  Treatment  of  Re- 
troflexion and  Prolapsus  Uteri;"  Outline  of  Paper:  1. 
Comparison  between  Alexander's  Operation  and  Hyster- 
orrhaphy  as  applied  to  Retro-displacements  and  Prolap- 
sus, Respectively.     2.  Vaginal  Operations  for  the  Cure  of 


is.,,.; 


AMERICAN  MEDICAL  ASS0C1ATK  >X. 


607 


Above  Displacements.     3.   Permanency  of  Results   from 
each,  by  Paul  F.  Mund6,  New  York,  N,  V. 

"  Short  or  Coiled  Funis."  by  A.  1.  A.  King.  Washing- 
ton, D.  C. 

What   Cases   Should    be    Drained   After    Abdominal 
Section,"  by  Rufus  B.  Hall,  Cincinnati,  O. 

"  Treatment,  Medical,  Surgical  and  Electrical,  of 
Uterine  Fibroids,"  by  Franklin  H.  Martin,  Chii 

"Papillomatous  Cystoma  of  the  Ovary  with  Report  of 
a  Case."  by  A.  R  Walker.  Canton,  Ohio. 

" Supra- Vaginal    Extra-Peritoneal   Hysterectomy,    In- 
cluding the  Porro  Operation,  With  Report  of  C 
Joseph  Price,   Philadelphia,  l'a. 

ward    Displacements    of   the    I'terus."  by    I,.    S. 
McMurtry,  Louisville.  Ky. 

"  Pathology  and  Treatment  of  Chronic  Ovaritis."  bv 
A.  J,  C.  Skene.  Brooklyn.  X.  V. 

Drainage  After  Laparotomy — When  in  Doubt  do  not 
Drain,"  by  P..  I".  Baer,  Philadelphia.  Pa. 

"  Report  of  a  Case  of  Double  Vagina  and  I'terus,"  by 
N.  Gunman,  St.  Louis,  Mo. 

"  Hydrorrhea  Following  Pregnancy,"  by  J.  H.  Brad- 
shaw,  1  )range,  X.  J. 

"  Prevention  of  Puerperal  Convulsions  by  the  Induc- 
tion of  Premature  Labor."  bv  II.  I).  Fry,  Washington, 
D.  C. 

•'  Abdominal  Drainage.  Presentation  of  a  Simple  Drain- 
age Apparatus,"  by  Robert  T.  Morns.  Xew  York.  X.  Y. 

"  Currents  of  Induction."  by  Horatio  R.  Bigelow, 
Philadelphia.  Pa. 

"  Fibroid  Tumors  of  the  I'terus  Growing  after  the 
Menopause."  by  J.  Taber  Johnson,   Washington,  D.  C. 

"A  Xew  Forceps."  by  L.  F..  Xeale,  Baltimore.  Md. 

"The  Protection  of  the  Perineum."  by  W.  S.  Gardner, 
Baltimore,  Md. 

"Two  Suggestions  Regarding  the  Surgical  Treatment 
of  Imperforate  Hymen  With  Retained  Menses."  by  Jas. 
F.  W.  Ross.  Toronto.  Canada. 

-modic  Stricture  of  the  L'rethra  Following  Labor," 
by  Llewelyn    ?:iiot.  Washington.  D.  C. 

"  Metrorrhagia  of  Tubal  Origin."  by  T.  A.  Ashby,  Bal- 
timore. Md. 

"A  certain  Class  of  Obstetric  Cases  in  which  the  use  of 
F'orceps  is  Imperatively  Demanded."  by  Augustus  P. 
Clarke,  Cambridge,  Mass. 

"  Adenoma  Uteri,"  vWith  Specimens)  by  H.  C.  Coe, 
Xew  York,  X.  Y. 

"  Can  the  Gynecologist  Aid  the  Alienist  in  Institutions 
for  the  Insane?"  by  I.  S.  Stone,   Washington,  D.  C. 

"  The  Management  of  Cases  of  Abdominal  Section 
After  Operation,"  by  C.  P.  Xoble,  Philadelphia,  Pa. 

"  Laparo-hysterorrbaphy,"  by  W.  J.  Asdale,  Pitts- 
burgh, Pa. 

"The  Surgical  Treatment  of  Retroflexion  of  the  Uter- 
us." by  Young  H.  Boud,  St.  Louis,  Mo. 

"  Hysterorrhaphy,"  by  William  Pawson  Chunn,  Balti- 
more. Md. 

"  The  Management  of  the  Drainage  Tube,"  by  Hunter 
Robb,  Baltimore.  Md. 

"  The  Histology  and  Pathology  of  the  F'allopian  Tube," 
by  J.  Whitridge  Williams.  Baltimore,  Md. 

"A  Xew  Plastic  Operation  for  Complete  Descent  of 
the  Uterus."  by  E.  C.  Dudley.  Chicago.  111. 

"  Post  Operative  Peritonitis, "by  Benjamin  T.  Shimwell, 
Philadelphia,  Pa. 

"Laparotomy  with  Report  of  Cases."  by  J.  H.  Branham, 
Baltimore.  Md. 

"Twelve  Hundred  Cases  of  Labor  and  Results,"  by 
George  R.  Dean.  Spartanburgh,  S.  C, 

"  Is  the  Removal  of  the  Uterine  Appendages  for  the 
Relief  of  Epilepsv  Justifiable?"  bv  A.  YanderYeer.  Al- 
bany. X    Y. 

"  Diagnosis  of  Pregnancy  in  the  Early  Months,"  by 
Charles  Jewett.  Brooklyn,  X.  Y. 

"The  Electrical  Treatment  of  Fibroid  Tumors."  by  G. 
Betton    Massey.  Philadelphia.  Pa. 


"Treatment  of  Ectopic  Gestation,"  by  E.  E.  Mont- 
gomery. Philadelphia,  Pa. 

"The  Use  of  Vaginal  Tampons,"  by  W.  A.  B.  Sell- 
man.  Baltimore.   Md. 

"The  Retroflexed  Uterus  and  its  Treatment,"  bv  W. 
Hampton  Caldwell,  Lexington,  Ky. 

"Diagnosis  and  Treatment  of  Peritonitis,"  by  W.  H. 
Myers.  Fort  Wayne.  Indiana. 

"  The  Management  of  the  Omentum  after  Abdominal 
Section."  by  Andrew  F.  Currier.  Xew  York.  X.  Y. 

"The  Relation  of  D6sdquilibr(5s  of  the  Abdominal  Vis- 
cera to  Pelvic  Diseases  in  Women,"  bv  J.  H.  Kellogg, 
Battle  Creek.   Mich. 

"Treatment  of  Occipito-posterior  Positions,"  by  A. 
Worcester.  Waltham.   Mass. 

"  My  Fourth  Conservative  Caesarean  Section,"  bv 
Howard  A.  Kelly,  Baltimore.  Md. 

"  Conservatism  in  Dealing  with  the  Appendages,"  bv 
W.  M.  Polk.   Xew  York. 

Title  not  received.  E.  L.  Duer,  Philadelphia,  Pa. 

Title  not  received,  Thos.  Opie.  Baltimore.  Md. 

Cha.s.   A.  L.  Rked,  Chairman, 

311  Elm  St.,  Cincinnati,  O. 
Howard  A.  Kki.lv.  Secretary, 
Johns  Hopkins  Hospital,  Baltimore.  Md. 

Section  of  Surgery  and  Anatomy. 

Address  of  the  Chairman:  "  Use  of  the  Elastic  Liga- 
ture in  the  Surgerv  of  the  Intestines,"  by  T.  A.  McGraw. 
Detroit,  Mich. 

"The  Pathologv  and  Treatment  of  Peri-Caecal  Inflam- 
mation, with  the  Report  of  Cases  Illustrating  Diagnosis." 
by  Thos.  L.  Morton.  Philadelphia.  Pa. 

"Removal  of  the  Appendix  for  Recurring  Attacks  of 
Appendicitis."  by  Jos.  Price,  Philadelphia,  Pa. 

Three  Unusual  Cases:  1.  Large  Fatty  Tumor  of  Scro- 
tum. 2.  Complete  Removal  of  the  External  Organs  of 
Generation.  3.  Removal  of  a  Foreign  Body  from  the 
Right  Bronchus."  by  A.  Vander  Veer,  Albany,  X.  Y. 

"The  Scientific  Rationale  of  Modern  Wound  Treat- 
ment." by  Henry  O.  Marcy,  Boston,  Mass.  . 

"  The  Relation  of  Concussion  of  the  Brain  and  Spinal 
Cord  to  Inflammatorv  and  other  Morbid  Changes  in  these 
Organs,"  by  B.  A.  Watson.  Jersey  City.  X.  J." 

"Linear  Craniotomy  for  Defective  Mental  Develop- 
ment." by  W.  W.  Keen.  Philadelphia.  Pa. 

"  Peritonitis  from  a  Surgical  Standpoint,"  by  Morde- 
cai  Price,  Philadelphia,  Pa. 

"  A  Xew  Operation  for  Harelip,"  by  Chr.  Fenger,  Chi- 
cago. 111. 

■•A  Report  of  Epicystotomies."  by  Chas.  S.  Hamilton. 
Columbus.  1  ' 

-Report  of  a  Lumbar  Xephrectomy."  by  William  D. 
Hamilton,  Columbus.  O. 

Some  Points  in  the  Surgical  Treatment  for  the  Radi- 
cal Cure  of  Hernia."  by  Augustus  P.  Clarke,  Cambridge. 
Mass. 

"Series  of  One  Hundred  Abdominal  Sections."  by  Jo- 
seph Taber  Johnson.  Washington,  D.  C. 

"Traumatism  of  the  Chest,"  by  J.  McF.  Gaston,  At- 
lanta. 1  '.a. 

"  The   Removal  of  X'ecrotic   Bone  with  Hydrochloric 
Acid  and  Pepsin,"  by  Robt.  J.  Morris,  Xew  York.  X.  Y. 
itomy  for  Rupture  of  the  Uterus  during  Labor," 
by  H.   C.   Coe'.  Xew  York.  X.  Y. 

"A  Practical  Technique  in  Intestinal  Surgerv."  bv  A. 
V.  L.  Brokaw.  St.  Louis    M 

"  riatinum  Xeedles  for  Electrolysis,"  by  Robert  Xew- 
nian.  Xew  York.  X.  Y. 

"The  Pathology  and  Treatment  of  Stricture  of  the 
Male  Urethra."  by  Thos.  J.  Druth.  Harrisburg.  Pa. 

"Another  Modified  Spinal  Jacket,  with  a  new  Jurv 
Mast."  by  S.  L.  McCurdy.  Dennison,  O. 

"  On  the  Deaths  from  Chloroform  and  Ether,  since  the 
Hyderabad  Commission,  with  Conclusions  drawn  from 
them."  by  Laurence  Turnbull.  Philadelphia,  Pa. 


6o8 


AMERICAN  MEDICAL  ASSOCIATION. 


[April  25, 


"  Exploratory  Incisions  in  Cases  of  Fracture  of  Bones 
where  Doubt  Exists  as  to  their  Character,  with  Report  of 
Observations  in  the  Lower  Animals."  by  B.  Merrill  Riek- 
etts.  Cincinnati.  O. 

"Dislocations  upward  and  backward  of  the  Scapular 
and  of  the  Clavicle,"  by  Win.  H.  Doughty,  Augusta.  Ga. 

"A  New  and  Novel  Procedure  in  Skin-Grafting,"  by 
C.  B.  Kibler.  Corry,  Fa. 

"Sprains  of  the  Ankle,"  by  W.  R.  Townsend,  New 
York,  N.  Y. 

"The  Relation  of  Calculi  to  Malignant  Disease  of  Liver 
and  Kidneys,"  by  I.  S.  Stone,  Washington,  D.  C. 

"The  Relations  of  Syphilis  to  the  Healing  of  Wounds 
and  Surgical  Diseases,"  by  G.  Frank  Lydston,  Chicago, 
111. 

••  Combined  Internal  and  External  Urethrotomy  with 
Perineal  Drainage,"  by  F.  W.  McRae,  Atlanta,  Ga. 

"  Treatment  of  Umbilical  Hernia  in  Children,"  byjno. 
T.  Chapman,  Bessemer.  Ala. 

"The  Management  of  the  Epicystic  Fistula,-'  by  J.  D. 
S.  Davis.  Birmingham,  Ala. 

Title  not  received.  Wm.  D.  Hamilton,  Columbus,  O. 

"Two  Cases  of  Intestinal  Obstruction;  Laparotomy; 
Results."  bv  David  Barrow.  Lexington,  Ky. 

"Is  Early  Resection  or  Conservative  Treatment  Ad- 
visable in   Coxitis,"   by  Herman   Mynter,  Buffalo,  N.  Y. 

"Infra-Pubic  Cvstotomv,"  by  John  A.  Wyeth.  New 
York,  N.  Y. 

"Electricity  as  a  Therapeutic  Agent;  What  is  Needed 
to  Determine  its  Merits?"  by  W.J.  Herdman.  Ann  Arbor. 
Mich. 

Thko.  A.  McGraw,  Chairman. 

Detroit,  Mich. 
W.  E.  B.  Davis,  Secretary, 

Birmingham,  Ala. 

Section  of  State  Medicine. 
First   Day. 

Registration  of  the  names  of  members  present. 

Reading  of  the  Minutes  of  the  last  meeting. 

Annual  Address  by  the  Chairman,  J.  D.  Plunket. 

Report  of  the  Committee  on  School  Hygiene ;  D.  T. 
Lincoln,  Chairman. 

Original  Investigations  on  the  Heating  and  Yentilation 
of  School  Buildings,  by  R.  Harvey  Reed,  offered  as  a 
portion  of  the  Report  of  the  above-named  Committee. 

SYNOPSIS   OF    REPORT. 

1.  Date  and  time  of  day  of  inspection. 

2.  Name  of  building  and  room. 

3.  Number  of  cubic  feet  of  air  in  room. 

4.  Number  of  pupils  present. 

5.  Outside  temperature. 

6.  Temperature  of  room,  at  level  of  feet,  head  and  ceiling. 

7.  Humidity  outside. 

6    Humidity  in  room,  at  level  of  feet,  head  and  ceiling. 
u    Kind  of  heating  apparatus  in  use. 
10.  System  of  ventilation  employed. 

ii  Number  of  cubic  feet  of  fresh  air  supplied  and  of  foul  air  dis- 
charged per  hour. 

12.  Estimation  of  amount  of  carbon-monoxide  present  in  the  air 
of  the  room. 

13.  Estimation  of  amount  of  carbon-dioxide. 

14.  Consideration  of  amount  of  organic  matter  present  in  the  air 
of  the  room. 

1  5.  Bacteriological  examination  of  the  air. 

Miscellaneous  remarks  and  suggestions. 
17.  Conclusions. 

The  discussion  on  this  subject  will  be  opened  by 
Octavius  A.  White,  New  York,  N.  Y.  The  subject  being 
one  of  great  importance,  the  remainder  of  this  session 
will  be  devoted  to  its  discussion. 

Second   Day. 

Report  of  the  "Committee  on  Meteorological  Condi- 
tions of  the  Atmosphere  and  their  Relations  to  coincident 
prevalence  of  Diseases,"  by  X.  S.  Davis,  Chairman. 

■■  Sickness  and  Mortality  in  the  Army  of  the  United 
St. il<s."  by  Joseph  R.  Smith.  Col.  ami  Surgeon  I".  S.  A. 
Medical  Director,  Department  of  Arizona. 


"  The  Beneficence  of  Disease, "  bv  A.  N.  Bell,  Brooklvn, 
N.  Y. 

Election  of  officers  for  the  ensuing  year. 

Third   Day. 

"  The  Disinfection  of  Excreta,"  by  George  M.  Stern- 
berg, Lieut.  Col.  and  Surgeon  U.  S.  A. 

"Simple  Methods  of  Sewage  Disposal,  by  C.  W. 
Chancellor,  Secretary  of  the  State  Board  of  Health  of 
Maryland,  Baltimore,  Md.  Discussion  on  the  above 
papers  opened  bv  Dr.  Robert  C.  Davis,  Member  of  New 
York  City  Board' of  Health.  N.  Y. 

"The  Coroner  System  in  the  United  States."  by  Henrv 
0.  Marcy.  Boston. 

"Hygiene  in  the  Rural  Districts."  By  G.  W.  Jenkins. 
Kilbourn  City,  Wis. 

"The  Duty  of  the  Government  in  the  Prevention  of 
Tuberculosis."  by  Lawrence  E.  Flick,  Philadelphia. 

Papers  are  also  expected  from  Walter  Wyman,  United 
States  Marine- Hospital  Service;  James  F.  Harrison, 
Gainesville,  Yirginia ;  and  Peter  H.  Bryce,  Secretary  of 
the  Provincial  Board  of  Health  of  Ontario. 

J.  D.  Plunket.  Chairman. 

145  N.  Spruce  St.,  Nashville,  Tenu. 
Benjamin  Lee.  Secretary. 
1532  Pine  St.,  Philadelphia,  Pa. 

Section  of  Ophthalmology, 

First  Day — May*  5TH.    At  3  p.m. 

Remarks  by  the  Chairman. 

"The  Causation  and  Management  of  Incipient  Cata- 
ract," by  Samuel  D.  Risley,  Philadelphia,  Pa. 

•"  Treatment  of  Incipient  Cataract  by  Electricitv  and 
other  Measures,"  by  J.  Elliott  Colburn.'Chicago,  111. 

"Treatment  of  Immature  Cataract,  including  (<j1  Re- 
port of  Twenty-five  Extractions  of  Immature  Cataract ; 
((•>)  Review  of  Yarious  Modes  of  Artificially  Maturing 
the  Slowly  Forming  Cataract,"  by  John  F.  Fulton,  St. 
Paul,  Minn. 

"The  Method  of  Performing  Cataract  Extraction," 
by  J.  J.  Chisolm,  Baltimore,  Md. 

"  My  Personal  Experience  in  Cataract  Extraction,"  by 
A.  W. "Calhoun,  Atlanta,  Ga. 

"  Practical  Observations  in  the  Treatment  of  Cataract,'' 
by  Flemming  Carrow,  Ann  Arbor,  Mich. 

"  Pressure  on  Eyeball  after  Cataract  Extraction,"  by 
Edward  Jackson,  Philadelphia,  Pa. 

"To  what  Extent  are  Personal  Restraints  Essential 
During  the  Healing  of  Corneal  Wounds,"  bv  T.  E.  Mur- 
rell,  Little  Rock,  Ark. 

"An  Improved  Apparatus  for  the  More  Efficient  Pro- 
tection of  the  Eye  after  Cataract  Extraction,"  by  Geo. 
E.  Frothingham,  Detroit,  Mich. 

Discussion  upon  these  papers,  opened  by  H.  Knapp 
and  Karl  Roller,  New  York  ;  F.  C.  Hotz,  Chicago,  111.; 
J.  L.  Thompson,  Indianapolis,  Ind.;  S,  O.  Richey,  Wash- 
ington, D.  C.;  P.  D.  Keyser.  Philadelphia,  Pa. 

Yoluntary  Communications.  Exhibition  of  Patients, 
Instruments  or  Pathological  Specimens,  etc. 

Miscellaneous  Business. 

Second  Day— May  6th. 

Election  of  Officers  (Time  fixed  by  the  By-Laws  . 

' '  Tlie  Centrad  in  the  Reformed  Numeration  of  Prisms,'* 
by  B.  Alexander  Randall.  Philadelphia.  Pa. 

Discussion  opened  bv  Swan  M.  Burnett,  Washington, 
I).  C;  W.  S.  Dennett'  New  York;  Edward  Jackson, 
Philadelphia,  Pa. 

"  Further  Contributions  to  Keratometrv,"  bv  Swan  M. 
Burnett,  Washington,  D.  C. 

Discussion  opened  by  Geo.  de  Schweinitz,  Phila- 
delphia, Pa. 

"  Full  Correction  of  Ametropia,"  by  Edward  Jackson, 
Philadelphia,  Pa. 

Discussion  opened  by  G.  C.  Savage,  Nashville,  Tenn. 


i89i.] 


AMERICAN  MEDICAL  ASSOCIATION. 


609 


\n  Analysis  of  One  Hundred  Cases  of  Astigmatism 
— Contrary  to  Rule  and  the  Associated  Symptoms,"  by 
Geo.  de  Schweinitz,  Philadelphia,  Pa. 

Discussion  opened  by  Wm.  Cheatham,  Louisville,  Ky. 

■•  The  Value  of  Weak  Cylinders  for  the  Relief  of  Eye 
Muscle  Strain,"  by  J.  J.  Chisolm,  Baltimore,  Md.  The 
points  made  by  this  paper  are — (a)  Is  it  necessary  to 
recognize  the  very  small  degrees  of  corneal  irregularity  ? 
[8)  Is  it  possible  to  work  eyes  comfortably  with  these 
slight  errors?  (c)  Is  the  Eye  Surgeon  warranted  in  pre- 
scribing glasses  as  feeble  as  0.25  cylinders?  [d \  What 
can  such  weak  cylinders  accomplish  ? 

Discussion  opened  by  Geo.  T.  Stevens,  New  York. 

"  Paper  on  Myopia  Based  upon  Recent  Original  Ob- 
servations," by  Francis  Dowling,  Cincinnati,  O. 

Discussion  opened  by  A.  W.  Calhoun,  Atlanta,  Ga.; 
B.  A.  Randall,  Philadelphia,  Pa.;  J.  M.  Ray,  Louisville, 
Kv.;  C.  H.  Hughes,  St.  Louis. 

"  Double  Monocular  Diplopia  Dependent  upon  Cere- 
bral Lesion,"  by  J.  H.  Thompson,  Kansas  City,  Mo. 

Discussion  opened  by  Charles  A.  Oliver,  Philadel- 
phia, Pa. 

"  A  Study  of  Fifteen  Hundred  Cases  of  Ametropia," 
by  A.  R.  Ba'ker,  Cleveland.  O. 

"  Lessons  of  Fifteen  Hundred  Consecutive  Refractive 
Cases  in  Private  Practice,"  by  George  M.  Gould,  Phila- 
delphia, Pa. 

Discussion  upon  these  two  papers  opened  by  J.  A. 
Lippincott,  Pittsburgh,  Pa. 

"An  Examination  of  von  Graefe's  Doctrine  of  Antip- 
athv  to  Single  Vision,"  by  George  T.  Stevens,  New 
Yofk. 

Discussion  opened  bv  J.  H.  Thompson,  Kansas 
City,  Mo. 

Voluntary  Communications,   Exhibition  of   Patients, 
Instruments  or  Pathological  Specimens,  etc. 
Third  Day — May  ;th. 

"  Hemorrhagic  Glaucoma,"  by  R.  L.  Randolph,  Balti- 
more, Md. 

Discussion  opened  by  F.  C.  Hotz,  Chicago,  111. 

"  Perimetric  Observations  on  the  Influence  of  Eserine 
and  Iridectomy  in  Chronic  Glaucoma,"  by  Geo.  de 
Schweinitz,  Philadelphia,  Pa. 

Discussion  opened  by  Karl  Roller,  New  York,  and 
Lewis  H.  Taylor,  Wilkesbarre,  Pa. 

"  An  Experimental  Study  of  the  Comparative  Mydri- 
atic Effect  of  Atropia  and  Homatropia,"  by  Horace  M. 
Starkey,  Chicago,  111. 

Discussion  opened  bv  Chas  J.  Kipp,  Newark,  N.  J. 

"Modern  Ophthalmic  Therapeutics,"  by  W.  T.  Mit- 
tendorf,  New  York. 

Discussion  opened  by  R.  L.  Randolph,  Baltimore,  Md. 

"Jequirity  in  the  Treatment  of  Granular  Lids,"  by  J.  G. 
Carpenter,  Stanford,  Ky. 

Discussion  opened  by  J.  W.  Wright.  Columbus,  O. 

"  Papilloma  of  the  Cornea,  with  Specime-us, "  by  S.  C. 
Ayres,  Cincinnati,  O. 

Discussion  opened  by  H.  Knapp,  New  York. 

"  Prognosis  in  Treatment  of  Injuries  of  the  Eye,"  by 
C.  M.  Hobby,  Iowa  City,  Iowa. 

Discussion  opened  by  X.  C.  Scott,  Cleveland,  O. 
"Excision  of  Diseased  Eyeball,  Followed  by  Relief  of 
Cerebral  Derangements,"   bv  H.  Moulton,  Fort  Smith, 
Ark. 

Discussion  opened  by  J.  E.  Coburn,  Chicago,  111. 
"Independent  Relation  of  Tracoma  and  Blepharitis 
Papillaris,"  by  Dudley  S.  Reynolds,  Louisville,  Ky. 

Discussion  opened  by  W.  T.  Montgomery,  Chicago,  111. 
"The  Pathogenv  of  Sympathetic  Ophthalmia,"  by   F. 
C.  Heath,  Lafayette,  Ind. 

Discussion  opened  by  George  H.  Goode,  Cincinnati,  O. 
"  Choroidal   and   Retinal  Haemorrhages,   their   Many- 
Causes,  etc.,  Including  Some  Hitherto  Unrecognized," 
by  William  H.  Cheatham,  Louisville,  Ky. 

"Discussion  opened  by  W.  V.  Marmion,  Washing- 
ton, D.  C. 


"A  Case  of  Fibro-Sarcoma  of  the  Neck  attended  by 
Temporary  Paresis  of  the  Third  Nerve,  Illustrated  by 
Photographs  and  Miorophotographs,"  by  A.  V.  Wiede- 
mann. Milwaukee,  Wis. 

"  An  Analysis  of  the  Sensory  Changes  and  Conditions 
of  the  Ocular  Apparatus  as  found  in  Imbecilitv,  Epi- 
lepsy and  General  Paralysis  of  the  Insane,"  by  Charles 
A.  Oliver,  Philadelphia,  Pa. 

Discussion  opened  bv  E.  J.  Gardiner,  Chicago,  111  - 
and  D.  H.  Smith,  Cleveland,  O, 

"  Treatment  of  Irido-dialysis  from  Contusion.  Partial 
Iridencleisis  with  or  without  Suture,"  by  Eugene  Smith 
Detroit,  Mich. 

Voluntary  Communications,  Exhibition  of  Patients, 
Instruments,  Pathological  Specimens,  etc. 

Chairman,  Leartus  Conxor,  Detroit,  Mich. 
Secretary,  T.  E.  Mirrei.i..   Little  Rock,  Ark. 

Section  of  Laryngology  and  Otology. 

President's  Address,  by  Carl  Seiler.  Philadelphia. 

"Surgery  of  Hard  Palate  Perforations,"  bv  \  G 
Hobbs,  Atlanta,  Ga. 

"Treatment  of  Enlarged  Tonsils,"  by  Chas.  H.  Knight, 
New  York. 

"Treatment  of  Follicular  Tonsillitis,"  by  A.  B.  Farn- 
ham,  Milwaukee,  Wis. 

"  Pharyngeal  Tuberculosis,  with  Report  of  Cases,"  by 
T.  V.  Fitzpatrick,  Cincinnati. 

"An  Effective  Remedy  in  Diphtheria."  bv  Jonathan 
Wright,  Brooklyn.  N.  Y. 

"Chronic  Catarrhal  Laryngitis,"  by  M.  Thrasher.  San 
Francisco. 

"Excision  of  Metnbrana  Tympani,"  by  C.  H.  Burnett, 
Philadelphia. 

"Remarks  on  Excision  of  the  Drumhead,  Malleus  and 
Incus,  specially  with  reference  to  the  method  of  employ- 
ing his  Instruments  for  the  same,"  by  Samuel  Sexton, 
New  York. 

"Tinnitus  Aurium,"  by  Laurence  Turnbull,  Philadel- 
phia. 

"  Myringoplasty,"  by  C.  W.  Tangeman,  Cincinnati,  O. 

"  Nasal  Cystoma  with  Specimen,"  by  C.  W.  Richard- 
son. Washington. 

' '  Exostosis  of  Septum  and  Congenital  Malformations, ' ' 
by  Allen  DeVilbiss,  Toledo,  O. 

"  Epistaxis:  Its  Etiology  and  Treatment,"  by  S.  J.  Rad- 
cliffe,  Washington,  D.  C. 

"Report  of  Two  Cases  of  Paralysis  of  Vocal  Cords, 
and  a  Case  of  Lupus  of  the  Nasal  Mucosa,"  bv  E.  E. 
Sattler,  Cincinnati,  O. 

"  Nun-Topical  Treatment  of  Throat  and  Ear  Diseases. " 
by  E.  Cutter,  New  York. 

"  Laryngismus  due  to  a  Congenital  Valvular  Formation 
of  the  Upper  Orifice  of  the  Larynx,"  bv  J.  H.  Brvan, 
Washington,  D.  C. 

"Suppuration  Occurring  in  Chronic  Catarrh  of  the 
Middle  Ear."   by  J.  M.  Ray,  Louisville.  Ky. 

"Treatment  of  Ear  Disease  Following  the  Grippe."  by 
Joseph  V.   Ricketts,  Cincinnati.  O. 

"  Some  Results  from  Early  Paracentesis  in  Middle  Ear 
Catarrh,"  by  J.  E.  Boylan,  Cincinnati,  O. 

"  Mouth  Breathing  not  the  Cause  of  Contracted  Jaws 
and  High  Vaults,"  by  Eugene  S.  Talbot,  Chicago.  111. 

"  The  Relation  of  Tonsillitis  to  Rheumatism."  bv  Hal 
Foster,  Kansas  City.  Mo. 

"The  Influence  of  Nasal  Obstruction  on  Phonation," 
bv  Max  Thorner,  Ci»cinnati,  O. 

(Papers,  titles  not  yet  announced,  promised  by  A.  W. 
McCoy,  Philadelphia^  and  Frank  H.  Potter,  Buffalo.  I 
Carl  Seiler,  Chairman. 

Philadelphia.  Pa. 
A.  B.  Thrasher,  Secretary. 

Cincinnati.  1  1. 
Section  of  Diseases  of  Children. 

"  Lithaemia  in  Children,"  by  William  Pepper,  Phila- 
delphia. 


6io 


AMERICAN  MEDICAL  ASSOCIATION. 


[April  25, 


"  Prevention  of  Pulmonary  Phthisis  in  the  Adult  by 
the  Proper  Treatment  of  the  Lung  Lesions  of  Child- 
hood,'' by  W.  J.  Stickler,  Orange,  X.  J. 

"  The  Pathological  Aspect  of  Phimosis  in  Children," 
by  C.  N.  Dixon-Jones,  Brooklyn. 

"  Tetanus  Neonatorum,"  bv  B.  A.  Waddington,  Salem, 
X.J. 

"The  Prophylaxis  and  Treatment  of  Diphtheria,"  by 
J.  Lewis  Smith,  New  York. 

"The  Present  Status  of  our  Knowledge  (including 
bacterial  demonstrations)  upon  the  Subject  of  Sterilized 
Milk."  by  Henry  Koplik,  Xew  York. 

"  Cervical  Adenitis."  by  B.  T.  Shimwell.  Philadelphia. 

"  Sympathetic  Convulsions  in  Children,"  by  S.J.  Rad- 
clitTe.  Washington.  D.  C. 

' '  Report  of  30  cases  of  Diphtheria  Treated  by  Sub- 
membranous  Injections,  with  Demonstration  of  Instru- 
ments," by  A.  Seibert,  New  York. 

"  Xecrosis  of  the  Maxillae,  with  a  Report  of  three 
Cases,"  by  Walter  B.  Johnson,  Paterson,  N.  J. 

"Annus  Pediatricus  MDCCCXC,"  by  Wm.  Perry 
Watson,  Jersey  City,  N.  J. 

"Remarks  on  the  Child's  Ear"  by  Samuel  Sexton, 
Xew  York. 

"The  Chemistry  and  Clinical  Yalue  of  Sterilized 
Milk."  by  Professor  A.  R.  Leeds  and  E.  P.  Davis,  Phila- 
delphia, Pa. 

W.  PERRY  WaTSOX,  Chairman,  Jersey  City  N.  J. 
HobarT  A.  Hare,  Secretary,  Philadelphia,  Pa. 

Section  of  Dental  and  Oral  Surgery. 

Address  of  the  Chairman  of  Section,  bv  Eugene  S. 
Talbot. 

"  Adenoid  Growth,"  by  W.  H.  Atkinson. 

•Treatment  of  Fractures  of  the  Maxillae,"  bv  Wm. 
Carr. 

"Genesis  of  Contour  Fillings,"  Illustrated  bv 
Geo.  S.  Allan. 

"The  Teeth  of  Invertebrate  Animals."  by  A.  H. 
Thompson. 

"Some  practical  points  on  the  care  of  Instruments," 
Wm.  H.  Potter. 

"  Rheumatic  and  Gouty  Diathesis  as  Manifested  in 
Diseases  of  the  Peridental  Membrane,"  bv  John  S.  Mar- 
shall. 

"Dental  Infirmary  Patients, — The  Use  and  Abuse  of 
Dental  Charity,"  by  Richard  Grady. 

"  Growth  of  the  Cementum,"  by  R.  R.  Andrews. 

"Remarks  on  Incipient  Necrosis  and  Caries,"  by  J. 
Williams. 

"Choice  of  Therapeutic  Pilling  Materials,"  by  W.  W. 
Allport. 

"Thorough  Dentistry  vs.  Partial  Dental  Surgery,"  by 
J.  Y.   Crawford. 

"  Pathological  Conditions  produced  by  Galvanic  action 
between  dissimilar  Metals  iu  the  Mouth,"  bv  George 
W.   Whitefield. 

"  Care  of  the  Teeth,"  by  J.  Taft. 

E.  S.  Talbot,  Chairman,  Chicago,  111. 

HENRY W.  MORGAN,  Secretary,  Nashville,  Tenn. 

Section  0/  Neurology  and  Medical  Jurisprudence. 

Address  by  the  Chairman  of  the  Section:  "Early  Psy- 
chical Symptoms  of  Traumatic  Brain  Injuries,"  by  T.  D. 
Crothers,  Hartford.  Conn. 

('Psychological  Social  Problems,"  by  Daniel  Clark, 
Toronto,  Can 

"Status  Epilepticus,"  by  Gros  R.  Trowbridge,  and 
Chas.  B.  Mayberry,  Danville,   Pa. 

"The  Neuroses  from  a  Demographic  Point  of  View," 
bv  Irving  C.  Rosse,  Washington.  D.  C. 

"The  Functional  Degeneracy  of  the  Brain."  by  J.  T. 
Searcy,  Tuscaloosa,  Ala. 

"Diagnosis  of  Traumatic  Lesions  in  the  Cerebro-Spinal 
Axis  and  the  Detection  of  Malingering  Referred  to  this 
Centre,"  by  B.  A.  Watson,  Jersey  City,  N.  J. 


"A  Consideration  of  Traumatic  Lesions  of  the  Spine 
Resulting  from  Railroad  and  Other  Injuries;  Their  Im- 
mediate and  Remote  Results,  Etiology,  Pathology  and 
Diagnosis,"  by  Thos.  H.  Manley,  New  York,  N.  Y. 

General  discussion  of  "The  Traumatic  Neuroses  with 
Especial  Reference  to  Railway  Injuries,"  to  be  opened 
by  R.  Harvey  Reed,  Mansfield,  Ohio. 

"Medico-Legal  Investigation  of  Deaths  by  Yiolence  in 
the  State  of  Massachusetts,"  by  Silas  B.  Presbery,  Taun- 
ton, Mass. 

"A  Medico-Legal  Study  of  Blood  Corpuscles  in  Syph- 
ilis and  Other  Diseases,"  bv  Ephraim  Cutter,  New  York, 
N.  Y. 

"On  What  Constitutes  Reliable  Evidence  in  Trials  of 
Criminal  Poisoning,"  by  John  Reese,  Philadelphia,  Pa. 

"Hallucinations  of  the  Sane,"  by  David  Inglis,  De- 
troit, Mich. 

"Personality  as  it  Effects  Inebriety,"  by  T.  L.  Wright, 
Bellefoutaine,  O. 

"Opium  Inebriety,  its  Legal  Recognition  and  Treat- 
ment," by  W.  S.  Watson,  Matteawan,  N.  Y. 

"Ether  Inebriety,"  by  Norman  Kerr,  London,  Eng. 

"The  Prevention  of  Opium  Inebriety,"  by  J.  B.  Matti- 
son,  Brooklyn,  N.  Y. 

"The  Treatment  of  Opium  Neuroses,"  by  Stephen 
Lett,  Guelpb,  Canada. 

"Suggestions  in  the  Treatment  of  Spinal  Scleroses," 
by  D.  R.  Brower,  Chicago.  111. 

"A  Description  of  the  Newly  Discovered  Virile  (penilei 
Reflex,"  by  C.  H.  Hughes,  St'.  Louis.  Mo. 

"The  Pathogeny  of  Chorea  and  Hysteria,"  by  J.  F. 
Barbour,  Louisville.  Ky. 

"The  Relation  Between  Occipital  Cortical  Disturbance 
and  Amblyopia,"  by  L.  Bremer,  St.  Louis,  Mo. 

"Electro- Diagnosis  in  Brain  and  Nerve  Injuries."  bv 
W.  H.  Willing,  Philadelphia,  Pa. 

"Private  Treatment  of  Insanity,"  by  N.  Roe  Bradner, 
Philadelphia. 

"Mental  Treatment  of  Women  in  Child  Birth,"  bv  J. 
A.  Axtel.  Hartford,  Conn. 

"Paretic  Dementia  and  Life  Insurance,"  by  James  G. 
Kiernan,  Chicago,  111. 

"Studies  of  Cranial  Degeneracy  and  Aberrant  Maxil- 
larv  Development  in  the  Criminal  Class,"  by  G.  Frank 
Lydston  and  E.  S.  Talbot.  Chicago,  111. 

"On  Neurotic  Heredity  in  Disease  and  Injurv."  by  f. 
O.  Flaherty.  Hartford,  Conn. 

"Description  of  a  Tumor  of  the  Pons,  with  Microscopic 
Specimens,"  by  L.  Hektoen.  Chicago.  111. 

"Absence  of  Motive  in  the  So-called  Criminal  Acts  of 
the  Inebriate,"  by   Lewis  D.  Mason.   Brooklyn,  X  Y. 

"What  Can  be  Done  for  Over-Taxed  Brain  Workers  to 
Prevent  Inebriety?"  by  John  Morris,' Baltimore.  Md. 

"lints  Modern  Science  Justify  the  Use  of  Alcohol  in 
Therapeutics?  If  so  in  What  Cases  and  When  ?"  by  E. 
Chenery,  Boston,  Mass. 

"Therapeutic  Action  of  Alcohol,"  by  I.  N.  Quimby, 
Jersey  City.  X.  J. 

"Brain  Disease  from  Opium,"  b\-  R.  Burkart.  Bonn, 
Germanv. 

T.  D.  Crothers,  M.D.,  Chairman, 
Harold  N.  Mover.  M.D..  Secy,  Hartford,  Conn. 

434  W.  Adams  street.  Chicago. 

Section  of  Dermatology  and  Syphilography. 
(Copy  not  received.) 

L.  D.  Bur.KLEY,  Chairman. 

Xew  York,  X.  Y. 
W.  T.  Corlett,  Secretarv, 

Cleveland,  O. 
Section  of  Materia  Medica  and  Pharmacy. 
(Copy  not  received.  1 

Ik  ink  WOODBURY,  Chairman, 

Philadelphia,  Pa. 
W.  G.   EWING,  Secretary. 

Xashville.  Tenn. 


i89i.] 


SPECIAL  CORRESPONDENCE. 


611 


OF    MEETING    OF    THE    ASSOCIATION    AND 
SECTIONS. 

The  following  is  a  list  of  places  of  meeting  of 

ssociation  and  Sections: 
General  Sessions.  Albaugh's  Opera  House. 
Practice  of  Medicine    and    Phvsiologv,   Grand  Armv 
Hall. 

::cs  and  Disease-  of  Women,  Masonic  Temple. 
gery  and  Anatomy.  National  Rifles'  Armorv. 
State  Medicine.  Columbian  Uui- 

Ophthalmology.  Medical  Department  University  of 
Georgetown 

Laryngology  and  Otology,  Medical  Department  Uni- 
versity of  Georgetown. 

Diseases  of  Children.  Masonic  Temple. 
Oral  and  Dental  Surgery.  Medical  Department  Colum- 
bian University. 

Medical  Jurisprudence  and  Neurologv,  Grand  Armv 
Hall. 

Dermatology  and  Syphilography,  Grand  Am: 
Materia  Medica  and  Pharmacy.  Grand  Army  Hall. 

HOTELS. 

The  following  named  hotels  have  liberally  con- 
tributed to  the  funds  collected  by  the  Committee 
of  Arrangements,  and  deserve  the  patronage  of 
our  members  :  Arlington  Hotel,  Ebbitt  House, 
Welcker's  Hotel,  Willard's  Hotel.  La  Normandie. 
The  Arno,  The  Shoreham.  The  Randall,  Metro- 
politan, Hamilton  House,  Hotel  Johnson.  Made's 
Hotel. 

RAILROAD    ARRANGEMENTS. 

For  railroad  arrangements,  etc..  see  advertis- 
ing pages  S.  ii.  12  and  13. 


sociation,  now  published  in  Chicago,  from  the 
latter  city  to  Washington,  as  eastern  physicians 
now  contemplate  and  urge  The  secretary  was 
instructed  to  send  a  copy  of  the  resolutions  to 
The  Journal  of  the  Association  in  Chicago. 


SPECIAL  CORRESPONDENCE. 


Shall  The  Journal  be  Removed  to 
w  asbJLnsrton  ? 

THE  ACTION  OF  THE  WAYNE  CO..   N.   Y. ,   MEDICAL 
SOCIETY. 

To  the  Editor: — I  send  you  a  copy  of  the  reso- 
lution passed,  unanimously,  by  the  Wayne  Co. 
Medical  Society  at  its  quarterly  meeting  held  to- 
dav. 

D.  Colyin.  M.D. 
Palmyra.  Wayne  Co..  X.  Y..  April  14 
Resolved.  That  we  deplore  the  agitation  now  going  on 
relative  to  the  removal  of  the  office  of  publication  of  The 
Journal  of  the  American  Medical  Associa: 
we   earnestly  protest  against   any  and  every  attempt  to 
change  the  present  localitv  of  its  publication. 
A.  A.  Young,  M.D. 
J.  M.  Tcrnee.  M.D..  Sec  y 


SOCIETY   PROCEEDINGS. 


Omaha  Medical  Society. 

The  annual  meeting  of  the  Omaha  Medical 
Society  was  held  in  the  cafe  of  the  Paxtou  hotel 
on  the  14th  inst.  Officers  were  elected  for  the  en- 
suing year  as  follows:  President,  Dr.  B.  F.  Cram- 
mer :  vice-president.  Dr.  D.  C.  Bryant :  second 
vice-president,  Dr.  Harrold  Gifford :  secretary, 
Dr.  J.  P.  Lord;   treasurer,  Dr.  S.  K.  Spalding. 

Dr.  Charles  Rosewater,  who  has  acted  as  secre- 
tary the  past  year,  asked  to  be  relieved  of  the 
office,  as  the  duties  thereof  had  demanded  more 
of  his  time  than  he  could  spare. 

After  the  election  the  society  listened  to  the 
reading  of  a  paper  on 

SARCOMA  OF  THE  CHOROID  WITH  TWO  CASES, 

by  Dr.  D.  C.  Bryant.  The  paper  was  discussed 
briefly  by  the  other  members  of  the  society. 

On  motion  of  Dr.  Gapen  the  delegates  to  the 
meeting  of  the  American  Medical  Association,  to 
be  held  at  Washington,  D.C.,  were  instructed  to 
invite  the  Association  to  meet  in  Omaha  in  1S92. 

The  Society  also  passed  a  resolution,  offered  by 
Dr.  Gapen,  protesting  against  the  removal  of 
The  Journal  of  the  American  Medical  As- 


THE   ACTION  OF  THE    OMAHA    MEDICAL   SOCIETY. 

To  the  Editor:  At  the  meeting  of  the  Omaha 
Medical  Society  held  last  Tuesday  (April  14), 
the  following  resolution  was  passed  unanimously: 
Resolved,  That  the  delegates  from  this  Society  to  the 
American  Medical  Association  be  instructed  to  oppose  the 
change  of  location  of  The  Journal  of  the  Association, 
and  that  a  copv  of  this  resolution  be  sent  to  The  Journal. 
C.  Rosewater.  M.D..  Sec  y. 


THE  ACTION  OF  THE  TENNESSEE  STATE  MEDICAL 
SOCIETY. 

At  the  annual  meeting  of  the  Tennessee  State 
Medical  Society  held  at  Nashville.  Tenn.,  April 
14,  the  following  resolutions  were  una>:: 
adopted : 

Whereas.  There  is  now  an  effort  being  made  in  some 
quarters  to  remove  The  Journal  of  the  American 
Medical  Association  from  its  present  commodious, 
comfortable,  and  successful  location  at  Chicago  to  an  un- 
tried field  at  Washington:  and 

Whereas.  We  consider  the  matter  an  unwarranted 
venture,  as  we  can  neither  see  nor  conceive  of  any  valid 
reason  for  such  a  change;  therefore  be  it 

•d,  That  we.  the  Tennessee  State  Medical  Soci- 
ety, do  hereby  enter  our  most  hearty  protest  against  the 
proposed  change,  and  respectfully  request  the  delegates 
who  may  be  appointed  from  this  body  to  use  their  every 
endeavor  to  prevent  the  consummation  of  so  hazardous 
an  experiment. 

-  .  That  the  Secretary  of  this  Society  be 
requested  to  forward  to  the  Editor  of  The  Journal  the 
foregoing  preamble  and  resolution. 

W.  K.  Shedpan.  M.D. 
T.  W.  Penn.  M.D..  Pres. 
D.  E.  Nelson.  M.D..  Sec'y. 


6l2 


MISCELLANY. 


[April  25,  1S91. 


THE  ACTION  OF  THE    HUNTINGDON   COUNTY,   PA., 
MEDICAL  SOCIETY. 

At  the  annual  meeting  of  the  Huntingdon 
Count}'  Medical  Society,  held  at  Huntingdon,  Pa., 
on  April  14,  1891,  the  following  resolution  was 
unanimously  adopted  : 

Resolved.  That  it  is  the  opinion  of  the  Huntingdon 
County  Medical  Society  that  the  office  of  publication  of 
The  Journal  ok  the  American  Medical  Association 
should  not  be  removed  from  Chicago.  Illinois,  and  that 
the  delegates  to  the  American  Medical  Association  from 
the  Huntingdon  County  Medical  Society,  of  the  State  of 
Pennsylvania,  are  hereby  instructed  to  vote  against  the 
removal  of  the  office  of  publication.     Attest. 

Geo.  C.  Borst,  Sec. 


To  the  Editor. — By  all  means  let  The  Journal 
remain  at  Chicago.  It  is  a  more  central  city. 
Washington  is  not  the  place  for  it. 

Frank  D.  Green,  M.D. 

Dallas,  Tex. 


NECROLOGY. 


MISCELLANY. 


Rocky  Mountain  Medical  Association. — The  twen- 
tieth meeting  of  the  Rocky  Mountain  Medical  Associa- 
tion will  be  held  iu  the  parlors  of  the  Arlington  Hotel, 
Washington.  D.  C  on  Wednesday  evening.  May  6.  at  7:30 
p.m.  John  Morris.  M.D. . 

Secretary. 


LETTERS  RECEIVED. 


Dr.  Joseph  H.  Warren,  of  Boston,  died  March 
26,  aged  sixty,.  His  father  was  the  seventh  son 
of  General  Warren,  of  Revolutionary  fame.  He 
was  a  medical  director  in  General  Casey's  division, 
and  of  provisional  troops  during  the  last  war  as 
well  as  President  Lincoln's  medical  attendant. 
He  saw  active  service  in  the  field  before  York- 
town,  Va.,  and  soon  after  was  disabled  while 
bearing  special  dispatches  to  Washington,  and 
was  obliged  to  resign.  He  was  quite  a  traveler, 
traveled  for  health  and  pleasure,  more  than  once 
serving  as  a  delegate  from  the  American  Medical 
Association,  of  which  he  was  vice-president  in 
1889  and  1890.  He  read  papers  before  the 
British  Medical  Association  and  the  French 
Academy  of  Medicine.  He  published  in  Loudon 
a  "Practical  Treatise  on  Hernia,"  a  second  edi- 
tion of  which  was  issued  in  1882  in  America.  He 
operated  in  Guy's  Hospital,  in  London,  and  else- 
where, to  demonstrate  the  method.  He  later 
published  "  A  Plea  for  the  Cure  of  Rupture,"  and 
has  written  very  many  monographs  and  medical 
papers,  as  well  as  general  articles. 

Dr.  Luther  Halsey  Gulick,  for  nearly  forty 
years  a  medical  missionary  to  the  islands  of  the 
Pacific,  died  at  Springfield,  Mass.,  on  the  8th 
inst.  His  father  was  a  missionary  before  him 
and  brought  up  a  family  of  seven,  all  of  whom 
gave  themselves  to  lives  of  self-denial  in  foreign 
lands.  He  was  a  graduate  in  medicine  at  the 
University  of  New  York  in  1850,  and  the  follow- 
ing year  went  to  Micronesia,  with  a  pioneer  party, 
destined  there  to  spend  twenty  years.  He  was 
afterwards  for  many  years  a  resident  at  Madrid, 
Spain.  Nearly  forty  years  of  his  life  were  passed 
in  foreign  lands. 


Anaiuosa,  la.,  Dr.  E.  Blakeslee. 

Ann  Arbor,  Mich.,  Dr.  W.  J.  Herdman,  Dr.  Heneage  Gibbes,  H. 
Soule. 

Augusta.  Me.,  Dr.  A.  G.  Young. 

Baltimore,  Md.,  Dr.  H.  T.  Revnolds. 

Barrv,  111.,  Dr.  G.  O.  Cromwell. 

Birmingham,  Ala.,  Dr.  W.  E.  B.  Davis. 

Boston.  Mass.,  Richard  Hodgson,  Dr.  Roeth. 

Chicago,  111.,  C.  S.  Baker  &  Co.,  Dr.  C.  F.  Stillman,  Sharp  & 
Smith.  Dr.  H.  N.  Mover.  Dr.  N.  Senn. 

Cincinnati.  O..  J.'R.  Hawley,  Dr.  C.  A.  L-  Reed. 

Detroit.  Mich.,  Dr.  L.  Connor,  Dr.  T.  A.  McGraw. 

Dversville,  la..  Dr.  A.  A.  Mathews. 

Ft.  Smith,  Ark.,  Dr.  J.  W.  Breedlove. 

Goldsboro,  N.  C,  Dr.  R.  A.  Smith. 

Jackson,  La.,  Dr.  Irvine  Robins. 

Jacksonville,  111..  Ward  Bros. 

Kevsville,  Ga.,  Dr.  T.  A.  Buxton. 

Lincoln.  Neb.,  Dr.  Alice  Huff  Crandall. 

Louisville.  Kv.,  Dr.  J.  M.  Mathews. 

Lowell,  Mass".,  Dr.  M.  G.  Parker. 

Marshalltown.Ia.,  Dr.  II.  L.  Cetz. 

Mulberry,  N.  C,  Dr.  C.  E.  Warren. 

Nashville,  Temi.,  Dr.  S.  P.  Deahofe. 

New  Haven,  Pa.,  Dr.  G.  W.  Gallagher. 

New  YorkCity,  L.  H.  Crall,  Dr.  B.  W.  McLeod,  Maltine  Mfg.  Co. 

Philadelphia,  J.  B.  Lippincott  Co..  Dr.  Benjamin  Lee. 

Rochester,  N.  Y.,  Dr.  E.  H.  Wolcott. 

Rosbv'sRock,  W.  Va.,  Dr.  W.  S.  Howard. 

St.  Louis,  Mo.,  Peacock  Chemical  Co.,  Battle  &  Co..  Henry 
Bernd  &  Co.,  The  Antikamuia  Chemical  Co.,  College  of  Physicians. 
and  Surgeons. 

San  Francisco,  Cal.,  Dr.  John  C.  Sundberg. 

Trov.  N.  Y.,  Dr.  William  Wotkyns  Seymour. 

Wheelersburg,  O.,  Dr.  J.  L.  Taylor. 


ths'  leave  of 
direction  of 
3.,  Hdqrs.  of 


Official  List  of  Changes  in  the  Stations  ami  Duties  of  Officers  Serving 
in  the  Medical  Department,  V.  S.  Army,  from  April  ji,  1S91,  tt> 
April  ij,  1891. 

Major  Passmore  Middleton.  Surgeon,  granted  sia 
absence  on  surgeon's  certificate  of  disabilitv 
the  Acting  Secretary  of  War.  Par.  4.  S.  O.  81,  A 
the  Army,  April  II,  1891. 

Capt.  Henry  I'.  Birmingham,  Assistant  Surgeon,  leave  of  absence 
granted  in  S.  O.  39,  March  13,  1891,  Dept.  of  the  Columbia,  is  ex- 
tended one  month.  By  direction  of  the  Acting  Secretary  of  War. 
Par.  2,  S.  O.Si,  A.G.  6.,  Hdqrs.  of  the  Army, "Washington,  April 

By  direction  of  the  Secretary  of  War,  the  following  changes  in  the 
"stations  of  medical  officers  are  ordered:  Capt.  Marshall  W,  Wood, 
Asst.  Surgeon,  is  relieved  from  duty  at  Ft.  Meade,  S.  Dak.,  ami 
will  report  in  person  to  commanding  officer.  Ft.  Preble,  Me.,  for 
duty  at  that  post,  relieving  Capt.  William  B.  Davis.  Asst.  Surgeon. 
Capt.  Davis,  on  being  relieved  by  Capt.  Wood,  will  report  in  per- 
son to  the  commanding  officer.Ft.  Clark,  Tex.,  for  duty  at  that 
station.     Par.  11,  S.  O.  S5,  A.  G.  O.,  Washington.  April  1=.,  1891. 

By  direction  of  the  Secretary  of  "War,  a  board  of  medical  officers, 
to  consist  of  Major  Henry  McElderry,  Surgeon;  Capt.  James  C. 
Merrill,  Asst.  Surgeon;  Capt.  W  Fitzhugh Cartel,  Issl 
is  appointed  to  meet  at  W<  st  Poiul  x.  v.,  May  1,  1891,  or  as  soon 
thereafter  as  practicable,  to  examine  such  cadets  nfihe  U.  S.  Mili- 
tary Academy  as  have  been  granted  leave  of  absence  until  that 
■  lite  i>n  account  <>f  physical  disability,  and  to  report  upon  their 
physical  Btness  to  continue  with  the  Corps  of  Cadets.  Pai  -.  S 
0      1,  A.G   O.,  Washington,  April  13, 1891. 

• .  oj  the  U.  S.  Navy,  for 

Beard  appointed  a  delegate  to  repre- 

it  Mi  dical  Dept.  oi  thi  ■  an  Medical 

Ass<  ciation  at  Washington,  D  ^'     May  5. 

1  ,uies  M.  Flint,  appointed  a  delegate  to  represent  Medi- 
.1   meeting  of  American   Medical  Associa- 
tion at  Washington,  D.  C,  May  5. 
P.  A.  Surgeon  S   H   Griffith  m  the  U.  S.  S.  *'  Dolphin, 

ucclone  month's  have  of  absence  from  date  of  detach- 


T  1 1  E 


Journal  of  the  American  Medical  Association. 

EDITED  UNDER  THE  DIRECTION  OF  THE  BOARD  OF  TRUSTEES. 

PI    B]   [SHI    D    WEEKLY. 


Vol.  XVI. 


CHICAGO,   MAY  2,    1891. 


No.   18. 


LECTURES. 

THE  CHEMICAL  FACTORS  IX  THE 
CAUSATION  OF  DISEASE. 

A  Course  of  Three  Lectures  delivered  at  the  Post-Graduate  Medical 
School  of  Chin; 

BY  VICTOR  C.   VAUGHAN,   .M.I)..    Ph.D., 

OF   ANN   ARIIOR,  MICH. 
PROFESSOR    OF    HYGIENE    AND  PHYSIOLOGICAL   CHEMISTRY  AND  DI- 
RECTOR OF  THE  HYGIENIC  LABORATORY  IN  MICHIGAN 

UNIVERSITY. 

LECTURE  I.       GENERAL    CONSIDERATIONS  OF  THE 

RELATION  OF  BACTERIAL  POISONS  TO  THE 

INFECTIOUS   DISEASES. 

The  majority  of  diseases  may  be  grouped,  from 
an  etiological  standpoint,  into  the  following  class- 
es: 1.  Traumatic;  2.  Infectious;  3.  Autogenous, 
and  4.  Neurotic.  It  must  be  understood,  how- 
ever, that  in  many  diseases  the  cause  is  not  single, 
but  multiple,  and  for  this  reason  sharp  lines  of 
classification  cannot  be  drawn.  For  instance,  the 
greatest  danger  in  those  traumatic  affections  in 
which  the  traumatism  itself  does  not  cause  death, 
lies  in  infection.  The  wound  has  simply  provided 
a  suitable  point  of  entrance  for  the  infecting  agent. 
Indeed,  the  break  in  the  continuity  of  tissue  may 
be  so  slight  that  it  is  of  import  and  danger  only 
on  account  of  the  coincident  infection.  This  is 
true  in  many  cases  of  tetanus.  Furthermore,  an 
infectious  disease,  wThether  it  originates  in  a  trau- 
matism or  not,  is  markedly  influenced  by  what 
we  are  pleased  to  call  the  idiosyncrasy  of  the  pa- 
tient, and  by  which  we  mean  the  peculiarities  of 
tissue  metabolism  taking  place  in  the  individual 
at  the  time.  A  dozen  men  may  be  exposed  alike 
to  the  same  infection,  and  the  infecting  agent 
may  find  a  suitable  soil  for  its  growth  and  devel- 
opment in  two  of  these,  while  in  the  other  ten 
this  same  agent  meets  with  such  adverse  influ- 
ences that  it  dies  without  producing  any  appre- 
ciable effect;  or  all  may  be  infected,  but  with 
differences  in  degree,  as  is  evidenced  by  varia- 
tions in  symptoms,  in  the  length  of  time  that  the 
infecting  agent  continues  to  grow  and  develop  in 
the  body,  and  in  the  ultimate  result.  Every 
physician  who  has  had  experience  in  the  treat- 
ment of  typhoid  fever,  diphtheria,  scarlet  fever — 
or,  in  short,  of  any  of  the  infectious  diseases,  will 
appreciate  the  importance  of  the  personal  equation 


in  his  patients.  That  some  neurotic  affections 
originate  in  traumatism  we  know.  That  others 
of  this  class  are  largely  due  to  malnutrition  ac- 
companied by  improper  metabolism  or  insufficient 
elimination ;  or,  in  other  words,  are  to  some  ex- 
tent autogenous,  all  believe.  Understanding,  then, 
that  the  above  classification  does  not  attempt  a 
sharp  and  marked  differentiation  of  the  causes  of 
disease,  I  wish  to  devote  the  first  two  of  the  three 
lectures,  which  you  have  kindly  asked  me  to  give, 
to  a  consideration  of  the  chemical  factors  in  the 
causation  of  the  infectious,  and  of  the  traumatic, 
autogenous  and  neurotic  diseases  in  so  far  as  these 
are  influenced  by  infection. 

The  science  of  bacteriology  is  now  entering 
upon  a  new  and  promising  era  in  its  development. 
Heretofore,  this  science  has  been  largely  founded 
upon  morphological  studies.  Bacteriologists  have 
given  their  time  and  attention  to  the  discovery  of 
bacterial  forms  in  the  diseased  organism,  and  to 
the  observation  of  characteristics  in  structure  and 
growth  of  different  species  of  bacterial  life.  The 
question,  do  certain  germs  have  a  causal  relation 
to  certain  diseases?  having  been  settled  in  the  af- 
firmative, the  next  question  which  naturally  arises 
is,  In  what  way  is  this  causal  eflect  accomplished? 
How  do  germs  prove  harmful?  To  this  question, 
a  number  of  answers  have  been  proposed.  But  as 
I  have  elsewhere1  discussed  these  theories,  I  will 
not  repeat  them  here.  Suffice  it  to  say  that  it  is 
now  generally  admitted  that  the  deleterious  effects 
wrought  by  germs  are  due  to  chemical  poisons 
elaborated  by  them  during  their  growth.  Grant- 
ing this,  it  will  be  at  once  seen  that  the  morpho- 
logical study  of  germs,  important  as  it  is,  becomes 
wholly  inadequate  in  ascertaining  their  true  rela- 
tionship to  the  diseases  with  which  the}'  are  asso- 
ciated. We  must  now  study  the  physiology  and 
the  chemistry  of  germs,  and  until  this  is  done  we 
must  remain  ignorant  of  the  true  cause  of  disease, 
and  so  long  as  we  remain  ignorant  of  the  cause, 
it  cannot  be  expected  that  we  shall  discover  sci- 
entific and  successful  methods  of  treatment.  Sup- 
pose that  our  knowledge  of  the  yeast  plant  was 
limited  to  its  form  and  method  of  growth,  of  how 
little  practical  importance  this  knowledge  would 
be.  That  the  yeast  plant  requires  a  saccharine 
soil  before  it  can  grow,  and  that  given  such  a  soil 

I  "  Ptomaines  and  Leucomaines. 


614 


CHEMICAL  FACTORS  IN  CAUSATION  OF  DISEASE. 


[May  2, 


it  produces  carbonic  acid  gas  and  alcohol,  are  the 
most  important  and  practical  facts  which  have  been 
ascertained  in  its  study.  Likewise,  the  conditions 
under  which  pathogenic  germs  multiply  and  the 
products  which  they  elaborate  in  their  multiplica- 
tion must  be  ascertained  before  their  true  relation- 
ship to  disease  can  be  understood. 

In  saying  that  the  morphological  work  upon 
which  the  science  of  bacteriology  rests  almost 
wholly  is  inadequate,  I  wish  that  it  may  be  plainly 
understood  that  I  am  not  offering  any  hostile  criti- 
cism upon  the  great  men  who  have  done  this  work 
and  who  have  formulated  conclusions  therefrom. 
The  development  of  bacteriology  has  been  in  ac- 
cordance with  the  natural  laws  governing  the 
growth  of  all  the  biological  sciences.  The  study 
of  form  naturally  and  necessarily  precedes  the 
study  of  function.  The  ornithologist  finds  a  new 
species  of  bird.  He  first  studies  its  shape  and 
size,  the  color  of  its  plumage,  the  form  of  its 
beak,  the  number  and  arrangement  of  the  feath- 
ers, of  the  tail  and  wing,  the  color  of  the  eyes, 
etc.  All  this  he  can  do  with  a  single  specimen, 
recognizing  the  fact,  however,  that  variations, 
more  or  less  marked,  are  likely  to  be  found  in 
other  individuals.  More  time  and  wider  oppor- 
tunities of  observation  will  be  needed  before  he 
can  tell  where  and  when  this  bird  is  accustomed 
to  build  its  nest,  upon  what  insects,  grains  and 
berries,  it  feeds,  with  what  other  species  of  birds 
it  lives  in  peace  and  with  what  it  is  at  war.  A 
much  greater  range  of  observation  and  stud}'  is 
necessary  before  the  naturalist  can  tell  how  his 
newly  discovered  species  would  thrive  if  carried 
to  a  new  climate,  where  it  would  be  compelled  to 
live  upon  unaccustomed  food,  to  build  its  nest  of 
strange  material  and  to  encounter  new  foes.  I 
repeat  that  it  is  no  discredit  to  the  science  nor  to 
the  men  who  have  developed  it,  to  say  that  the 
study  of  bacteriology  has  hitherto  been  almost 
wholly  morphological;  without  the  morphologist, 
the  physiologist  and  the  physiological  chemist 
would  not  exist.  The  science  having  had  for  its 
support  only  morphological  studies,  the  deduc- 
tions and  formulated  statements  arrived  at  by  its 
students  have  been  reached  in  accordance  with 
the  knowledge  obtained  from  this  source.  But 
now,  it  being  admitted  that  the  causal  relation 
between  a  given  germ  and  a  certain  disease  is  de- 
pendent upon  the  chemical  products  of  the  growth 
of  the  germ,  the  fundamental  lines  of  work  must 
be  altered  in  order  to  correspond  with  this  new 
knowledge.  Let  us  inquire  into  the  changes, 
which  the  introduction  of  this  new  factor  must 
make  in  our  fundamental  conceptions  of  the  causal 
relation  between  germs  and  disease. 

The  four  rules  of  Koch  have  been  generally 
conceded  to  be  sufficient  to  show  that  a  given 
germ  is  the  sole  and  sufficient  cause  of  the  disease 
with  which  that  germ  is  associated.  Briefly  these 
rules  are  as  follows : 


i.  The  germ  must  be  found  in  all  cases  of  this 
disease. 

2.  The  germ  must  be  separated  from  other  or- 
ganisms and  from  all  other  matter  found  with  it 
in  the  diseased  animal. 

3.  The  special  bacterium  thus  freed  from  all 
foreign  matter  must,  when  properly  introduced, 
produce  the  disease  in  healthy  animals. 

4.  The  microorganism  must  be  found  properly 
distributed  in  the  animal  in  which  the  disease  has 
been  induced. 

Let  us  give  our  special  attention  to  the  first  of 
these  rules  for  a  few  moments.  What  is  meant 
by  the  statement  that  the  special  germ  must  be 
found  in  every  case  of  the  disease ?  How  will  A, 
pursuing  his  studies  on  the  bacteriology  of  a  given 
disease  in  America,  decide  whether  or  not  a  ba- 
cillus, which  he  finds,  is  identical  with  one  which 
has  been  reported  as  invariably  present  in  the 
same  disease,  by  B,  who  has  investigated  an  epi- 
demic in  Germany  ?  What  means  are  relied  upon 
to  prove  the  identity  of  these  two  organisms? 
The  means  which  have  been  relied  upon  wholly 
are  the  form,  size,  reaction  with  staining  reagents, 
manner  of  growth  on  the  various  nutrient  media, 
and,  in  exceptional  instances,  correspondence  in 
their  effects  upon  the  lower  animals.  In  other 
words,  with  the  exception  of  those  instances  in 
which  the  effects  upon  animals  are  tried,  the  char- 
acteristic, by  which  the  germ  causes  the  disease, 
is  left  wholly  out  of  consideration. 

Indeed,  some  of  the  most  eminent  bacteriolo- 
gists have  taught  that  in  the  identification  of 
germs  the  reactions  with  staining  agents  and  the 
appearances  of  the  growths  on  the  various  nutri- 
tive media  are  of  more  importance  than  the  obser- 
vation of  the  effects  upon  animals.  Thus,  Fliigge 
says: 

"Inoculation  experiments  with  both  typhoid  dejections 
and  pure  cultures  of  the  Eberth  bacillus  have  universally 
been  without  success.  The  few  experiments  in  which  a 
typhoid  disease  has  followed  inoculation  or  feeding  have 
been  made  with  impure  material  containing  other  active 
bacteria.  It  is  known  that  a  group  of  widely  distributed 
organisms,  which,  however,  are  wholly  different  from  the 
typhoid  bacillus,  have  the  power  when  injected  subcuta- 
neously  or  intravenously,  of  producing  in  animals  death 
with  marked  swelling  and  ulceration  of  Fever's  patches. 
To  these  organisms  undoubtedly  are  due  the  apparently 
positive  results  which  some  authors  have  supposed  to  be 
due  to  inoculation  with  the  typhoid  bacillus." 

In  other  words,  this  eminent  author  teaches 
that  although  other  germs  may  cause  the  essen- 
tial symptoms  and  lesions  of  typhoid  fever  in  the 
lower  animals,  they  are  not  related  to  the  germ 
found  in  the  spleen  of  man  after  death  from  ty- 
phoid fever,  because  they  do  not  react  in  the 
same  manner  with  the  aniline  stains. 

Bacteria  cannot  be  classified  so  far  as  their 
causal  relationship  to  diseases  is  concerned  (and 
this  is  the  most  important  knowledge  to  be  gain- 
ed from  them)  until  we  know  the  nature  of  the 
chemical   poisons  which  they  elaborate,  for  it  is 


I89I.] 


CIIKMICAL  FACTORS  IN  CAUSATION  OF   DISEASE 


615 


by  virtue  of  these  poisons  that  they  have   any 
causal  relationship  to  disease. 

It  is  possible  that  two  germs  may  be  unlike  in 
form,  and  yet  they  may  produce  poisons  which 
are  identical  or  those  which  are  very  similar  in 
their  effects  upon  man.  One  germ  may  be  stained 
by  Oram's  method  and  another  fail  to  bi 
Upon  when  so  treated,  but  this  does  not  prove 
that  their  chemical  products  are   totally  unlike. 

We  will  suppose  that  in  an  epidemic  of  diph- 
theria A  examines  the  membrane  from  a  hundred, 
or  we  might  as  well  suppose,  a  thousand  children 
and  finds  a  characteristic,  well-marked,  easily  rec- 
ognized bacillus  in  all.  He  isolates  this  organ- 
ism and  obtains  it  in  pure  culture.  He  inocu- 
lates animals  and  these  manifest  all  the  signs 
together  with  the  appearance  of  the  characteristic 
membrane  of  diphtheria,  and  in  these  animals  he 
finds  his  bacillus  growing  as  in  the  throats  of  the 
children.  All  of  the  rules  of  Koch  have  been 
complied  with.  Has  A  demonstrated  that  his 
bacillus  is  the  sole  cause  of  diphtheria?  No. 
He  has  shown  that  his  bacillus  is  a  cause  of 
diphtheria,  but  he  has  not  proven  that  there  may 
not  be  other  germs,  wholly  different  from  his  in 
form  and  size,  which  may  also  cause  diphtheria. 
The  most  which  can  be  proven  by  Koch's  rules 
is  that  a  given  germ  is  a  cause  of  the  disease. 
They  do  not  show,  as  most  bacteriologists  would 
have  us  believe,  that  this  germ  is  the  sole  cause 
of  the  disease. 

To  illustrate,  we  will  suppose  that  a  botanist 
in  visiting  Arabia  should  find  a  tree  producing  a 
berry,  the  coffee  berry,  which  when  properly  pre- 
pared and  taken  into  the  system  produces  certain 
effects.  These  effects  are  due  to  the  alkaloid  caf- 
fein,  and  our  supposed  discoverer  finds  that  they 
invariably  follow  the  drinking  of  a  decoction  of 
these  berries.  Would  he  be  justified  in  conclu- 
ding that  the  coffee-tree  is  the  only  plant  in  the 
world  capable  of  producing  these  supposed  char- 
acteristic effects?  Should  he  reach  such  a  conclu- 
sion, the  fact  that  it  is  not  warranted  would  be 
shown  by  a  study  of  the  tea-plant  in  China  and 
the  guarana  of  South  America. 

What  is  meant  in  the  first  of  Koch's  rules  by 
the  statement  that  the  germ  must  be  present  in 
all  cases  of  the  disease?  In  answering  this  ques- 
tion I  will  give  two  specific  illustrations  showing 
the  manner  in  which  eminent  bacteriologists  have 
applied  this  rule.  This  is  well  shown  in  the  bac 
teriological  literature  of  typhoid  fever  and  diph- 
theria. 

Eberth  found  the  bacillus,  which  is  now  gener- 
ally considered  by  bacteriologists  as  the  sole  cause 
of  typhoid  fever,  in  eighteen  out  of  forty  cases. 
In  the  examination  of  twenty-eight  bodies  dead 
from  typhoid  fever  Gaflky  found  the  Eberth  germ 
in  twenty-six  ;  Fninkel  and  Simmonds  reported 
in  twenty-five  out  of  twenty-nine  cases ;  Seitz  in 
twenty- two  out  of  twenty-four ;  Rietsch  in  thirty- 


five  out  of  thirty  six  :  and  Kowalskski  found  it 
present  in  each  of  twenty-nine  cases.  From  these 
and  similar  reports  bacteriologists  have  concluded 
that  this  germ  is  not  only  a  cause,  but  the  sole 
cause  of  typhoid  fever.  Are  they  justified  scien- 
tifically in  this  conclusion?  Have  they  any  right 
.  that  there  is  no  other  germ  in  existence 
which  may  cause  typhoid  fever?  The  speaker 
has  shown  that  there  are  at  least  two  other  germs 
which  induce  the  same  symptoms  in  a  more  in- 
tensified form  in  the  lower  animals,  and  has  iso- 
lated and  studied  the  chemical  poisons  of  these 
germs,  and  recently  Babes  has  shown  that  in  the 
examination  of  twelve  persons  who  died  at  Bu- 
charest of  typhoid  the  Eberth  germ  was  not  pres- 
ent, and  that  an  organism  giving  quite  different 
reactions  was  present. 

Lbffler  and  other  German  investigators  have 
shown  the  presence  of  a  bacillus  in  the  majority, 
not  in  all,  of  the  cases  of  diphtheria  which  they 
have  studied,  and  they  again  conclude  that  this 
bacillus  is  not  only  a  cause,  but  the  sole  cause  of 
the  disease  In  a  large  number  of  cases  in  New 
York,  Prudden  failed  to  find  the  Lbffler  bacillus, 
but  did  find  a  wholly  different  organism.  Xo  one 
acquainted  with  Prudden's  work  will  question  the 
accuracy  and  care  with  which  it  was  done.  It  is 
true  that  the  chemical  poisons  of  the  Lbffler  ba- 
cillus have  been  studied,  and  no  one  can  doubt 
that  it  is  a  cause  of  diphtheria,  but  it  may  be 
found  that  the  streptococcus  of  Prudden  is  capa- 
ble of  elaborating  a  similar  poison. 

The  moment  that  it  is  granted  that  the  real 
poison  of  the  disease  is  chemical  in  character, 
it  becomes  evident  that  no  one  is  justified  in  say- 
ing that  one  germ  is  the  sole  source  of  such  a 
poison.  Such  a  statement  would  be  as  much  un- 
warranted as  one  that  the  coffee-tree  is  the  sole 
source  of  caffein,  or  that  the  strychnos  ignatii  is 
the  only  species  of  the  natural  order  logayiiacecz 
which  produces  a  convulsive  poison.  In  other 
words,  the  specific  cause  of  a  given  disease  is  not 
to  be  determined  wholly  by  the  morphology  of 
the  germ  found  associated  with  that  disease  in  a 
given  epidemic,  but  by  the  character  of  the  chem- 
ical poison  which  is  the  true  materies  morbi. 

I  think  that  we  are  justified  in  concluding  that 
in  those  diseases  in  which  the  four  rules  of  Koch 
have  been  complied  with,  the  germ  is  a  cause  of 
the  disease,  but  our  range  of  observation  must  be 
much  wider  than  it  now  is.  before  we  can  say  that 
the  given  germ  is  the  only  cause  of  the  disease. 
ft  may  be  found,  and  f  think  this  highly  probable, 
that  those  few  infectious  diseases,  such  as  anthrax 
and  tuberculosis,  which  have  such  a  ell- marked  typi- 
cal clinical  histories,  are  due  to  equally  well-marked 
and  morphologically  distinct  microorganisms  which 
can  be  recognised  by  microscopical  study  alone:  but 
I  do  not  expect  that  this  w ill prove  to  be  true  in  dis- 
eases showing  such  wide  variations  in  symptoms  as 
is  done  by  typhoid  fever  and  cholera  infantum.     In. 


6i6 


CHEMICAL  FACTORS  IN  CAUSATION  OF  DISEASE. 


[May  2, 


fact  I  am  convinced  that  these  last  mentioned  dis- 
eases may  and  do  result  from  any  one  of  a  number 
of  bacteria  which  are  in  form,  size,  methods  of 
growth  and  reactions  towards  staining  reagents, 
quite  distinct  one  from  the  other,  but  which  pro- 
duce poisons  similar  in  their  effects. 

That  you  may  be  convinced  of  the  truth  of  the 
foregoing  statements  I  give  a  few  specific  instances 
which  will  confirm  them,  and  demonstrate  that  in 
their  causal  relation  to  disease,  germs  cannot  be 
classified  from  a  study  of  the  form,  size,  methods 
of  growth  and  reactions  wdth  staining  reagents. 

Typhoid  Fever.  — Eberth  lays  special  stress  upon 
the  fact  that  his  germ  does  not  take  the  ordinary 
stains  readily,  and  says  that  it  is  not  colored  by 
Bismark- brown  and  hasmotoxylin,  and  only 
slightly  by  the  other  ordinary  stains ;  but  what 
is  the  verdict  of  others  on  this  point?  In  the 
paper  in  which  he  calls  attention  to  the  fact  that 
he"  has  photographed  the  short  bacillus  before 
Eberth  had  published  his  discovery,  Koch  says : 
"  Eberth  states  that  these  short  bacilli  have  but 
slight  tendency  to  take  stains.  The  photograph 
here  given  shows,  to  the  contrary,  that  in  taking 
stains  these  bacilli  are  but  slightly  inferior  to 
other  bacteria."  Gaffky  states  that  the  best  col- 
oring agent  is  methylen-blue,  but  that  the  bacilli 
are  stained  very  well  with  methyl- violet,  gentian- 
violet,  Bismark-brown  and  fuchsin,  and  less  well 
by  hsemotoxylin.  Coats  had  no  difficulty  in  stain- 
ing with  Bismark-brown.  Meyer  had  the  same 
difficulty  as  Eberth  in  staining;  but  Friedlander 
found  that  the  bacilli  in  sections  from  the  spleen 
stained  intensely.  In  view  of  this  variety  of 
statement,  can  any  one  claim  that  these  men  were 
working  with  a  germ  which  can  be  distinguished 
from  others  by  its  tinctorial  properties  ? 

Tetanus. — The  tetanus  germ  of  Kitasato  and 
that  of  Tizzoni  and  Cattani  are  known  to  be 
quite  distinct.  Cultures  of  the  former  in  bouillon 
are  virulent,  while  those  of  the  latter  in  the  same 
medium  are  inert.  Not  only  are  these  two  organ- 
isms morphologically  and  biologically  different, 
but  their  poisons  are  chemically  unlike.  Brieger 
and  Friinkel  precipitated  the  poisonous  albumin 
of  the  germ  of  Kitasato  with  alcohol,  but  this  re- 
agent renders  the  poison  of  the  Italian  germ  inert. 
Notwithstanding  this  difference,  however,  both 
microorganisms  and  their  chemical  products  pro- 
duce tetanic  convulsions  and  death  in  the  lower 
animals.  We  must,  therefore,  admit  that  there 
are  at  least  two  distinct  germs,  each  of  which  is 
capable  of  causing  tetanus,  and  how  many  other 
bacteria  with  like  properties  there  may  be  no  one 
can  tell. 

The  Summer  Diarrhoeas  of  Infancy. — In  this 
class  of  diseases  all  attempts  to  find  a  morpholog- 
ically specific  germ  have  failed.  Tin  I 
Booker  in  this  country,  and  of  EscHerich  in  Ger- 
many, have  shown  that  no  one  species  or  variety 
is   constantly  present.     No  less   than  thirty  dis- 


tinct germs  have  been  obtained  from  the  bowels 
and  faeces  of  children  suffering  from  the  summer 
diarrhoeas.  A  germ  which  is  frequently  present 
one  season  will  not  be  found  at  all  the  next.  Are 
we  to  conclude  from  this  failure  to  comply  with 
the  first  of  Koch's  rules  that  the  summer  diar- 
rhoeas of  infancy  are  not  due  to  microorganisms? 
Certainly  not ;  especially  in  view  of  the  fact  that 
Baginsky  and  Stadthagen  have  shown  that  the 
bacillus  discovered  by  Baginsky  produces  a  chem- 
ical poison  which  induces  diarrhoea  in  the  lower 
animals,  and  I  have  shown  that  at  least  three 
of  Booker's  bacteria  produce  poisons  which  have 
similar  effects.  To  the  contrary,  we  are  jus- 
tified in  concluding  that  the  diarrhoea  may  be 
due  to  any  oue  or  more  of  a  number  of  germs 
which  differ  from  one  another  sufficiently  mor- 
phologically to  be  classified  as  distinct  species. 
The  similarity  among  these  bacteria  will  not  be 
discovered  by  a  study  of  their  size,  form  and  re- 
actions with  staining  reagents,  but  by  a  study  of 
their  chemical  poisons,  the  agents  by  virtue  of 
which  they  cause  the  disease.  At  the  meeting  of 
the  American  Medical  Association  at  Newport, 
in  1889,  I  proposed,  in  a  paper  on  the  etiology  of 
typhoid  fever,  that  in  those  cases  in  which  the 
lower  animals  are  not  available  on  account  of 
their  insusceptibility,  before  a  given  germ  can  be 
considered  a  cause  of  a  disease,  it  must  be  shown 
that  that  germ  can  produce  chemical  poisons 
which  will  induce  in  the  lower  animals  in  an 
acute  form  the  characteristic  symptoms  of  the 
disease.  That  this  rule  would  be  a  wise  one  I 
have  become,  even  more  stronglj'  than  I  was  at 
that  time,  convinced. 

In  the  little  volume  on  "Ptomaines  and  Leu- 
comaines, ' '  written  by  Novy  and  myself  and  pub- 
lished in  1888,  I  gave  the  following  definition  of 
an  infectious  disease:  "An  infectious  disease 
arises  when  a  specific,  pathogenic  microorganism, 
having  gained  admittance  to  the  body  and  having 
found  the  conditions  favorable,  grows  and  multi- 
plies, and  in  so  doing  elaborates  a  chemical  poison 
which  induces  its  characteristic  effects." 

It  should  be  remembered  that  this  definition 
was  written  at  a  time  when  the  importance  of  the 
chemical  products  of  bacterial  growth  was  not 
generally  recognized.  Indeed,  at  that  time  bac- 
teriologists quite  universally  held  to  the  mechan- 
ical interference  theory,  and  more  than  a  year 
later  so  good  an  authority  as  Welch,  of  Balti- 
more, stated  that  a  knowledge  of  the  chemical 
products  of  bacteria  was  interesting  but  not  es- 
sential to  a  belief  in  the  causative  agency  of  a 
microorganism,  and  he  went  still  further,  inas- 
|  much  as  he  claimed  that  the  successful  inocula- 
tion of  animals  is  not  necessary  in  order  to  prove 
lb  causal  relationship  of  a  certain  germ  to  a 
given  disease.  Now,  it  is  generally  conceded 
that  a  successful  inoculation  is  a  proof  of  the  for- 
mation  of  deleterious  chemical  products,  and  in 


i89i.] 


CHEMICAL  FACTORS  IN  CAUSATION  OF  DISEASE. 


617 


case  successful  inoculation  cannot  be  obtained  on 
account  of  the  insusceptibility  of  the  lower  ani- 
mals, the   demonstration  of  the   elaboration   of 

chemical  poisons  is  deemed  not  only  interesting 

but  important.  For  instance,  the  strongest  proof 
that  the  cholera  bacillus  of  Koch  has  a  causal  re- 
lation to  Asiatic  cholera  has  been  furnished  by 
the  study  of  its  chemical  products,  and  similar 
studies  of  many  of  the  other  infectious  diseases 
have  yielded  results  which  are  of  both  interest 
and  importance,  as  I  shall  endeavor  to  show  in 
the  next  lecture. 

The  only  modification  which  I  desire  to  make 
in  the  above  definition  of  an  infectious  disease 
consists  of  an  elaboration  of  what  is  meant  by  a 
"specific"  microorganism.  The  specific  nature 
of  a  germ  is  to  be  determined  not  by  its  size,  form, 
growth  on  nutritive  media  and  reactions  with 
staining  reagents,  all  of  which  properties  are 
more  or  less  variable  with  the  conditions  under 
which  the  germ  has  been  grown,  but  upon  its 
capability  of  producing  within  the  body  delete- 
rious substances. 

The  study  of  the  chemical  factors  in  the  causa- 
tion of  the  infectious  diseases  opens  up  for  us  a 
field  in  which  much  work  must  be  done.  Let  us 
attempt  a  statement  of  the  nature  of  some  of  the 
researches  that  must  be  carried  out  along  this 
line. 

In  the  first  place  we  must  ascertain  what  germs 
are  toxicogenic.  This  would  necessitate  a  chem- 
ical study  of  all  kinds  of  bacteria,  both  the  pa- 
thogenic and  the  non- pathogenic.  Every  fact 
learned  in  this  investigation  will  not  have  its 
practical  application  in  medicine,  but  will  have 
its  scientific  value,  and  many  will  most  probably 
be  of  more  or  less  direct  service  to  man.  There 
is  a  vast  field  here  for  careful  scientific  work,  and 
I  should  be  glad  to  see  these  researches  carried 
out  largely  in  our  own  country. 

Secondly,  it  must  be  determined  under  what 
conditions  these  germs  are  toxicogenic.  It  is  not 
at  all  probable  that  all  those  bacteria  which  are 
capable  of  producing  poisons  when  grown  on 
dead  material  outside  of  the  body  are  also  capa- 
ble of  multiplication  and  the  production  of  the 
same  substances  when  under  the  influence  of  the 
various  secretions  of  the  body.  Some  bacteria 
are  destroyed  by  a  normal  gastric  juice  within  a 
short  time,  while  others  are  not.  The  conditions 
of  life  and  growth  are  different  when  the  infecting 
agent  is  introduced  into  the  blood  from  what  they 
are  when  infection  occurs  by  the  way  of  the  ali- 
mentary canal.  This  is  well  recognized  in  the 
two  forms  of  anthrax,  one  of  which  arises  from 
inoculation  through  a  wound  and  the  other  by 
way  of  the  intestines.  A  preventive  treatment 
which  is  efficient  in  the  one  is  of  no  service  in  the 
other.  Then  again,  we  are  to  study  those  condi- 
tions of  the  blood  and  other  fluids  of  the  bod}', 
which  are  especially  unfavorable  to  the  successful 


implantation  or  the  continued  existence  of  an  in- 
fectious disease. 

Thirdly,  the  chemical  properties  and  the  phy- 
siological action  of  these  poisons  will  demand 
careful  attention.  Some  are  especially  depre-^ing 
in  their  action  upon  the  heart,  others  seem  to 
manifest  their  energy  upon  the  central  nervous 
system,  while  others  still  act  like  true  gastroin- 
testinal irritants.  In  the  study  of  the  toxicological 
effects  of  these  bacterial  poisons  every  method  of 
investigation  known  in  the  most  advanced  physi- 
ological work  must  be  employed.  The  action  of 
these  agents  on  the  heart,  the  brain,  the  spinal 
cord,  etc.,  must  be  thoroughly  studied. 

After  all  this  has  been  done  we  shall  certainly 
advance  in  our  knowledge  of  the  treatment  of  the 
infectious  diseases.  The  morphological  study  of 
bacteriology  has  been  of  inestimable  value  to  us 
in  the  prevention  of  the  infectious  diseases.  It 
has  rendered  the  investigation  of  disinfectants 
both  possible  and  imperative,  and  by  the  knowl- 
edge thus  gained  yellow  fever  has  repeatedly,  and 
Asiatic  cholera  in  one  instance  at  least,  been  kept 
from  our  shores.  Epidemics  of  small-pox,  diph- 
theria and  scarlet  fever  have  been  arrested.  In 
this  way  scientific  medicine  has  been  advanced, 
and  such  an  advance  is  never  made  without  great 
benefit  to  mankind  in  general.  Moreover,  anti- 
septic surgery,  which  had  already  been  inaugu- 
rated by  the  genius  of  Lister,  has  received  the 
scientific  support  which  was  necessary  to  its  con- 
stant, universal  and  correct  employment.  All  of 
these  benefits,  and  possibly  more,  which  do  not 
occur  to  me  at  this  time,  have  been  accomplished, 
and  to  Pasteur,  Koch  and  the  host  of  others  who 
have  rendered  this  possible,  we  should  be  and  are 
grateful.  But  what  can  those  of  us  who  are  en- 
gaged in  the  treatment  of  the  infectious  diseases 
say  of  the  present  condition  of  the  practice  of 
medicine?  As  one  of  this  number  I  am  forced  to 
admit  that  my  successes  are  few  and  my  failures 
many.  Are  we  satisfied  with  the  treatment  which 
we  now  employ  for  tuberculosis,  diphtheria,  scar- 
let fever,  typhoid  fever  and  the  other  internal  in- 
fectious diseases?  Do  we  treat  these  diseases 
with  much  more  success  than  our  fathers  did? 
The}-  prescribed  for  their  consumptive  patient  lib- 
eral food,  cod-liver  oil  and  all  the  open  air  exer- 
cise possible.  They  never  carried  a  Bergeron 
hydrogen- sulphide  bag,  used  a  Weigert  hot  air 
oven,  or  injected  Koch's  lymph  ;  but  can  we  say 
that  our  successes  are  markedly  more  numerous 
than  theirs  ?  Has  the  knowledge  of  germs  aided 
us  in  the  treatment  of  these  diseases?  Do  we  to- 
day possess  one  germicidal  agent  which  will  de- 
stroy the  bacilli  of  typhoid  fever  in  the  spleen  of 
our  patient  and  at  the  same  time  do  no  injury  to 
the  patient  himself? 

For  myself  I  am  perfectly  willing  to  acknowl- 
edge that  I  am  not  satisfied  with  my  success  in 
the  treatment  of  the  infectious  diseases,   and  it 


6i8 


ARTERIO-SCLEROSIS. 


[May  2, 


seems  to  me  that  careful  scientific  study  along  the 
lines  which  we  have  been  following  to-night  holds 
out  sufficient  encouragement  to  lead  us  to  further 
stud}-.  Could  we  treat  morphine  poisoning  before 
we  knew  anything  of  the  chemical  properties  or 
the  physiological  and  toxicological  effects  of  this 
alkaloid?  Can  we  counteract  or  antidote  the  ty- 
phoid poison,  before  we  know  anything  of  its  na- 
ture or  its  manner  of  action?  I  do  not  mean  to 
imply  that  it  is  the  duty  of  each  of  us  to  become 
a  chemist  or  to  undertake  physiological  research. 
We  need  as  much  as  anything  else  a  closer  study 
of  these  subjects  at  the  bedside.  The  scientific 
methods  of  the  laboratory  should  be  carried  into 
the  wards  of  the  hospital.  The  physiologist  keeps 
the  dog  upon  which  he  is  making  some  important 
study  under  his  own  trained  eye  and  trusts  no  one 
else  with  the  observations.  The  patient  with  ty- 
phoid fever  in  the  hospital  ward  is  seen  by  his 
medical  attendant  once  or  twice  during  the  day. 
The  remainder  of  the  time  all  observations  must 
be  made  and  records  taken  by  a  nurse,  who  is  not 
only  devoid  of  scientific  training,  but  has  so  much 
work  to  do  that  but  little  time  can  be  given  to  the 
individual  patient.  There  is  work  enough  in  the 
study  of  the  poisons  of  disease  to  employ  the 
chemist,  physiologist  and  clinician,  and  the  great- 
est good  can  be  secured  only  by  the  combined  la- 
bors of  all. 

You  may  think  it  strange  that,  enthusiastic  as 
I  am  about  the  importance  of  the  study  of  the 
bacterial  poisons,  I  have  said  nothing  about  the 
therapeutical  uses  to  which  some  of  them  may  be 
put,  as  evidenced  by  the  introduction  by  Koch  of 
his  so-called  lymph  or  tuberculin  as  a  cure  for 
tuberculosis.  There  may  be  valuable  curative 
agents  discovered  among  the  products  of  bacterial 
activity,  but  I  have  never  believed  that  a  disease 
will  be  cured  by  the  administration  of  the  very 
poison  which  is  causing  the  disease.  I  say  I  have 
never  believed  this,  but  I  am  open  to  conviction 
on  this  point,  and  take  much  interest  in  a  study 
of  the  results  now  being  reported  from  all  parts 
of  the  world,  as  well  as  in  my  own  observation 
of  the  effects  of  the  proposed  cure.  So  far,  how- 
ever, I  have  seen  no  sufficient  reason  for  any 
change  in  my  belief  on  this  point. 
I  To  be  continued.) 


ORIGINAL  ARTICLES. 


A  Portrait  of  Virchow. — The  famous  por- 
trait painter  Franz  Lenbach  of  Munich  is  paint- 
ing a  portrait  of  Virchow  for  the  Berlin  Medical 
Society.  It  will  be  unveiled  at  a  festal  meeting 
of  the  Society,  and  presented  to  the  Langenbeck 
House.  There  it  will  hang  beside  a  portrait  of 
Langenbeck  in  the  hall  destined  for  the  meetings 
of  the  medical  societies  of  Berlin,  for  congress  as- 
semblies, festal  ceremonies,  etc. 


THE    EFFECT    OF   ARTERIO-SCLEROSIS 

UPON  THE   CENTRAL  NERVOUS 

SYSTEM. 

Read  before  the  Clini  at  Society  of  Maryland,  January  16,  rSor. 
BY  GEORGE  J.  PRESTON,  M.D.. 


I'ROKISmiK 


BALTIMORE 


In  order  to  appreciate  fully  the  significance  of 
disease  of  the  blood  vessels  of  the  central  nervous 
system,  it  is  necessary  to  keep  in  mind  the  gen- 
eral plan  of  the  blood  supply  of  the  brain  and 
cord.  If  we  disregard  a  few  meningeal  branches 
from  other  arteries,  the  brain  is  supplied  by  four 
trunks :  the  two  internal  carotids  and  the  two 
vertebrals.  It  is  not  necessary  to  mention  the 
well  known  arrangement  of  these  arteries  at  the 
base  of  the  brain  into  the  circle  of  Willis.  The 
blood-vessels  that  supply  the  brain  are  peculiar 
for  their  long  and  tortuous  course  through  bony 
canals,  and  the  fact  that  they  are  unaccompanied 
by  veins.  After  having  formed  the  circle  of  Wil- 
lis they  send  branches  to  supply  the  different  re- 
gions of  the  cortex,  and  other  branches  which 
penetrate  the  substance  of  the  brain  and  supply 
internal  parts.  These  latter  branches  while  they 
are  small  are  very  important,  because  they  sup- 
ply the  basal  ganglia  and  internal  capsule.  They 
do  not  communicate  with  each  other  or  with  the 
cortical  system  of  vessels  and  hence  are  known  as 
end  arteries,  or  what  is  a  better  designation,  as 
terminal  arteries.  The  term,  end  artery,  is  not  a 
very  good  one,  as  confusion  may  sometimes  arise 
between  this  and  the  pathological  term,  endar- 
teritis. 

The  branches  which  supply  the  cortex  are  per- 
haps to  a  certain  extent  terminal  arteries,  though 
anastomoses  of  the  larger  branches  take  place  in 
the pia  mater.  From  these  branches  ramifying 
in  the  pia  mater,  arterioles  pass  into  the  cortex 
perpendicularly  to  the  convolutions.  These  ar- 
terioles may  be  divided  into  two  groups.  The 
short  or  nutrient  arterioles  which  form  a  network 
in  the  gray  matter  of  the  cortex,  and  the  long  or 
medullary  arterioles  which  pass  deep  down  into  the 
white  matter  with  little  or  no  communication 
with  each  other,  with  the  short  arteries  or  the 
basal  branches. 

The  significance  of  this  peculiar  mode  of  dis- 
tribution of  the  arteries  of  the  brain  becomes  at 
once  apparent  when  we  consider  the  effects  of 
plugging  by  thrombus  or  embolus  of  a  vessel 
which  has  no  free  anastomosis. 

The  spinal  cord  derives  its  blood  supply  from 
the  vertebral,  intercostal,  lumbar  and  sacral  ar- 
teries. Each  vertebral  gives  off  a  branch,  which 
branches  unite  and  form  the  anterior  spinal  artery 
which    runs  in  the  anterior   median  fissure    the 


I89i.] 


ARTKRIO-SCLKROSIS. 


619 


■whole  length  of  the  cord.  From  this  artery 
branches  pass  deeply  into  the  fissure  and  along 
the  anterior  nerve  roots.  The  branches  which 
penetrate  the  fissure  pass  on  into  the  gray  mat- 
ter of  the  anterior  horns,  where  they  form  a  rich 
network.  The  vertebrals  also  give  off  posterior 
spinal  arteries  which  do  not  unite  as  do  the  an- 
terior vessels,  but  pass  down  the  posterior  as- 
pect of  the  cord,  one  on  either  side,  near  the  at- 
tachments of  the  posterior  nerve  roots;  these 
branches  are  united  however,  by  numerous  anas- 
tomoses, and  send  small  twigs  towards  the  poste- 
rior median  fissure.  From  the  periphery  of  the 
cord  numerous  branches  pass  into  its  substance, 
some  of  them  reaching  the  gray  matter.  James 
Ross  has  shown  that  the  arteries  which  supply 
the  different  areas  of  the  cord  are  fairly  constant 
and  regular  in  their  distribution. 

The  minute  anatomy  of  the  blood  vessels  of  the 
central  nervous  system  presents  certain  import- 
ant peculiarities.  The  vessels  are  not  as  closely 
applied  to  the  tissue  in  which  they  ramify  as  are 
the  vessels  in  many  other  parts  of  the  body,  but 
lie  in  little  canals  known  as  the  peri- vascular 
spaces.  Most  histologists  agree<that  these  spaces 
are  lined  by  a  delicate  membrane,  and  communi- 
cate with  the  spaces  in  which  lie  the  cells.  They 
are  undoubtedly  lymph  spaces,  containing  lymph 
corpuscles,  and  form  the  only  lymphatic  system 
really  that  the  central  nervous  system  possesses. 
If  we  examine  a  fresh  or  carefully  prepared  sec- 
tion of  the  brain  we  find  that  the  structure  of  the 
arteries  differs  somewhat  from  the  structure  of 
the  arteries  elsewhere  in  the  body.  The  coats  are 
in  the  main  the  same,  but  between  the  muscularis 
and  adventitia  we  find  a  space  known  as  the  ad- 
ventitial space.  The  two  coats  are  not  in  actual 
contact.  This  space  may  be  regarded  as  a  lymph 
channel.  The  veins  possess  a  somewhat  similar 
arrangement. 

It  was  formerly  supposed  that  arterio  sclerosis, 
and  particularly  its  later  stage,  atheroma  was  not 
of  common  occurrence  in  the  arteries  of  the  cen- 
tral nervous  system.  More  recent  investigation, 
however,  has  shown  that  this  condition  is  fre- 
quently met  with.  It  is  to  be  noted,  however, 
that  one  may  fail  to  find  any  marked  changes  in 
the  blood  vessels  of  the  brain  and  cord  of  subjects 
in  whom  there  existed  marked  sclerosis  elsewhere, 
and  the  contrary  is  perhaps  sometimes  seen, 
namely'  artheroma  occurring  in  the  vessels  of  the 
brain  and  cord  while  it  is  absent  or  not  well 
marked  in  the  general  arterial  system.  The  alter- 
ation in  structure  of  the  vessels  of  the  brain 
and  cord,  affected  with  sclerosis  does  not  dif- 
fer materially  from  that  found  in  the  vessels 
elsewhere,  and  which  was  so  clearly  described  by 
Dr.  Welch  at  a  former  meeting  of  this  Society. 
The  fact  that  the  vessels  of  the  central  nervous 
system  lie  in  lymph  spaces  and  are  not  supported 
by  the  surrounding  tissue,  and  also   the   fact  of 


the  space  which  exists  between  the  media  and  ad- 
ventitia, the  adventitial  space  to  which  attention 
has  been  directed,  offers  special  facilities  for  these 
vessels  to  alter  their  shape  and  become  tortuous 
under  high  pressure,  and  greatly  favors  the  for- 
mation of  aneurism.  The  basal  arteries  and  the 
large  branches  derived  from  them  present  thick- 
enings,  tortuosities,  dilatations,  aneurisms,  and 
the  microscopic  changes  which  are  familiar.  If 
a  section  of  the  brain  be  made,  the  small  arteries 
can  be  seen  sticking  up  like  bristles,  with  gaping 
mouths.  If  the  small  sized  twigs  be  gently  pull- 
ed out  they  will  often  show  the  most  remarkable 
tortuosities.  Irregularities  in  the  size  of  the 
vessels,  dilatations  and  constrictions  occurring  at 
frequent  intervals  in  the  course  of  the  same  vessel 
are  commonly  met  with.  Where  the  branches  are 
given  off  there  is  often  a  marked  dilatation. 
Small  aneurisms,  both  fusiform  and  sacular  are 
frequent  and  characteristic.  The  mode  of  forma- 
tion of  these  miliary  aneurisms,  and  their  bear- 
ing upon  intracranial  haemorrhage,  has  given 
rise  to  some  difference  of  opinion.  Charcot  and 
Bouchard,  who  first  drew  attention  to  this  curi- 
ous and  important  phenomenon,  thought  that 
the  aneurisms  were  the  result  of  an  arteriosclero- 
sis, which  began  as  a  peri  arteritis.  That  is  to 
say  that  the  inflammatory  process  began  outside 
the  artery.  Cornil  and  Ranvier  held  that  the  an- 
eurisms were  the  results  of  an  endarteritis  and  a 
peri  arteritis  combined.  In  all  probability  the 
disease  begins  in  the  cerebral  arteries  as  elsewhere 
by  a  degeneration  of  the  middle  coat,  as  has  been 
shown  by  Thoma  and  others. 

This  condition  of  miliary  aneurism  is  rarely- 
met  with  in  the  spinal  cord.  Most  authorities 
agree  with  Charcot  in  saying  that  this  peculiar 
formation  of  small  aneurisms  in  the  vessels  of  the 
brain,  is  the  underlying  cause  of  most  if  not  all 
cases  of  ordinary  intracranial  haemorrhage.  It 
might  perhaps  seem  to  be  stating  the  case  too 
strongly  to  say  that  miliary  aneurism  is  always 
to  be  found  in  apoplexy,  but  it  certainly  is  the 
rule,  though  exceptions  do  occur.  Whenever 
they  have  been  systematically  sought  for  in  per- 
sons dying  from  haemorrhage  of  the  brain,  they 
have  been  found,  in  nearly  all  cases.  It  requires 
some  care  and  a  good  deal  of  patient  work  to  de- 
tect their  presence  at  times,  for  while  they  may 
exist  in  one  case  in  great  numbers,  another  case 
will  show  perhaps  only  three  or  four  after  the 
most  careful  search.  Then,  as  has  been  noted, 
we  may  have  numerous  miliary  aneurisms,  with- 
out marked  atheroma  of  the  vessels  elsewhere. 
Twenty- five  per  cent,  of  Charcot's  cases  in  which 
miliary  aneurism  was  marked  in  the  cerebral  ves- 
sels showed  no  condition  of  atheroma  of  the  ar- 
teries generally.  It  is  very  possible,  then,  that 
observers,  not  noting  any  atheroma  in  other  ves- 
sels, have  not  been  led  to  look  for  it  in  the  brain, 
and  so  the  frequency  of  aneurism,  and  consequent- 


620 


ARTERIO-SCLEROSIS 


[May 


ly  of  arterio-sclerosis,  has  been  underestimated  by 
some  authorities.  On  the  other  hand,  there  rnay 
be  marked  atheroma  of  other  arteries  and  no 
miliary  aneurisms  found  in  the  brain.  This  was 
illustrated  in  a  case  recently  examined,  in  which 
the  aorta  showed  large  plaques  of  atheroma,  and 
yet  the  most  careful  investigation  failed  to  reveal 
a  single  miliary  aneurism. 

Next  in  importance  to  the  fqrmation  of  aneu- 
rism comes  the  great  tendency  to  the  formation, 
in  the  diseased  vessels,  of  thrombi  and  resulting 
emboli.  The  roughened,  diseased  intima  offers 
the  most  favorable  conditions  for  thrombus,  and 
this  liability  is  enhanced  by  the  fact  that  we  may 
have  local  disturbances  of  the  circulation,  as 
slowing  of  the  blood  stream  by  a  constricted  ves- 
sel. The  significance  of  thrombosis  of  the  cere- 
bral vessels  becomes  at  once  apparent  when  we 
consider  the  fact  already  alluded  to,  that  the  arte- 
ries passing  up  from  the  large  trunks  at  the  base 
of  the  brain  to  the  basal  ganglia  and  internal  cap- 
sule, as  well  as  the  cortical  system,  are  for  the 
most  part  terminal  arteries,  and  hence  plugging 
of  these  vessels  means  softening  of  the  area  of 
the  brain  to  which  they  are  distributed,  since  no 
provision  exists  for  collateral  circulation. 

Another  pathological  condition  which  is  met 
with  in  sclerosis  of  the  arteries  of  the  brain,  and 
which  has  perhaps  some  clinical  significance,  is 
the  great  tortuosity  and  unequal  calibre  of  the 
vessels.  In  following  the  course  of  the  smaller 
arteries,  under  the  microscope,  observing  now  a 
marked  dilatation,  now  a  narrowing  almost  to 
obliteration,  and  everywhere  tortuosity,  one  can- 
not help  thinking  that  these  marked  changes  in 
the  lumen  and  direction  of  the  vessel  must  pro- 
duce decided  irregularity  in  the  blood  supply  of 
the  area  to  which  it  is  distributed.  It  must  be 
borne  in  mind  that  many  of  the  brain  centres  are 
in  constant  activity,  and  hence  must  have  a  reg- 
ular and  uninterrupted  supply  of  blood. 

When  we  come  to  consider  the  effect  of  arterio- 
sclerosis upon  the  spinal  cord,  we  have  far  fewer 
data  from  which  to  draw  conclusions  than  in  the 
case  of  the  brain.  Miliary  aneurisms  of  the  ves- 
sels of  the  cord,  while  they  have  been  found,  are 
rare.  Thrombosis  and  embolism  sometimes  oc- 
cur, and  haemorrhage  is  now  and  then  met  with 
which  would  seem  to  have  been  dependent  upon 
disease  of  the  vessels.  It  seems  to  me  that  we 
might  with  some  show  of  plausibility  attribute 
certain  degenerative  cord  lesions  to  arterio-sclero- 
sis: We  have  seen  that  the  arteries  of  the  cord 
are  distributed  with  a  certain  degree  of  regular- 
ity to  the  different  columns  of  fibres.  Now  in 
conditions  of  sclerosis  of  the  columns  of  the  cord 
we  commonly  meet  with  a  very  decided  increase 
of  the  neuroglia  or  connective  tissue  element. 
vSuch  outgrowth  produces  compression  and  sub- 
sequent degeneration  of  the  nerve  elements.  Now 
it  seems  to  me  that  we   might  suppose,  without 


forcing  the  facts  too  much,  that  the  hyperplasia 
of  connective  tissue  in  the  sclerosed  vessels,  ex- 
tending into,  or  beginning  in  the  adventitial 
might  encroach  upon  and  compress  the  nerve  ele- 
ments, or  set  up  a  connective  tissue  outgrowth 
around  the  blood-vessel,  which  would  extend  into 
the  substance  of  the  cord.  Again,  it  is  supposable 
that  in  conditions  of  arterio-sclerosis  the  blood 
supply  to  the  connective  tissue  elements  of  the 
cord,  the  neuroglia,  being  irregular  or  even  mark- 
edly deficient,  an  irritation  might  be  produced 
which  might  lead  to  outgrowth  of  connective  tis- 
sue and  consequent  damage  to  the  nerve  elements 
proper.  The  causes  usually  assigned  as  the  most 
important  in  the  production  of  sclerosis  of  the 
columns  of  the  cord,  such  as  alcoholism,  syphilis. 
exposure  to  cold  and  wet,  over-exertion,  great 
mental  excitement  and  the  like,  are  many  of  them 
just  the  factors  which  are  the  most  potent  in  the 
production  of  arterio-  fibrosis.  There  been  no  ob- 
servations that  I  am  aware  of  bearing  upon  this 
point,  either  for  or  against  the  theory  proposed. 
It  must  be  borne  in  mind  that  we  may  have  a 
condition  in  the  veins  similar  to  that  found  in  the 
arteries.  This  point  has  been  clearly  brought  out 
by  Spillmann,  of  Nancy,  quoting  Thiebaut,  Tho- 
ma,  Huchard,  Borel  and  others.  Of  course  this 
fact  has  not  as  much  significance  in  considering 
the  effect  of  atheroma  in  the  central  nervous  sys- 
tem as  in  other  parts  of  the  body,  owing  to  the  pe- 
culiar arrangement  of  the  veins  in  the  former  case. 
One  fact  strikes  us  with  peculiar  force  when  we 
consider  the  clinical  bearing  of  arterio-sclerosis 
and  atheroma,  and  that  is  that  we  must  distin- 
guish between  the  condition  occurring  in  the 
young  and  in  those  in  early  middle  life,  and  the 
same  condition  occurring  in  the  old.  In  aged 
people  it  would  seem  to  be  a  part  of  the  general 
decay  of  the  tissues.  Add  to  the  general  tendency 
to  fatty  degeneration,  an  enfeebled  circulation, 
and  we  have  the  conditions  most  favorable  to  the 
deposit  of  the  lime  salts.  And  yet  the  system 
seems  to  adapt  itself  so  perfectly  to  the  gradual 
change  that  we  may  have  the  most  marked  con- 
ditions of  atheroma  with  no  attending  symptoms 
other  than  those  incident  upon  old  age.  How 
far  the  general  symptoms  of  senility  may  be  due 
to  this  change  in  the  blood-vessels  it  is  not  easy 
to  say.  That  this  condition  of  the  blood-vessels, 
causing  irregularities  of  the  circulation  and  im- 
pairment of  nutrition,  is  an  important  factor  in 
the  production  of  many  of  the  symptoms  of  senil- 
ity, is  almost  certain. 

It  is  not  in  the  aged,  however,  but  in  the  indi- 
vidual in  middle  life  who  has  grown  old  before 
his  time,  old  in  all  but  years,  that  we  see  most 
clearly  the  evil  effects  of  atheroma.  The  tissues 
of  this  latter  individual  have  not  become  accus- 
tomed to  the  changed  condition  of  the  blood  ves- 
sels, and  have  not  adapted  themselves  to  the 
irregular  or  deficient  blood  supply. 


I89i.] 


ARTERIOSCLEROSIS. 


621 


The  study  of  the  effects  of  arteriosclerosis  on 
the  central  nervous  system  resolves  itself  into  the 
Study  of,  first,  senility  or  physiological  decay,  a 
subject  of  great  interest  and  wide  range,  and 
which  can  be  touched  upon  only  very  lightly  in 
this  paper  :  secondly,  the  effects  of  atheroma  in 
the  middle-aged  ;  the  study  of  premature  old  age, 
of  age  as  a  disease,  and  finally  the  predisposition 
to  haemorrhage  in  the  brain  and  cord  of  athero- 
matous subjects,  and  the  possible  effect  of  the 
condition  upon  certain  chronic  degenerations  of 
the  cord. 

I  have  noted  the  symptoms  in  about  fifty  indi- 
viduals at  Bay  View  Asylum,  in  whom  athe- 
roma was  more  or  less  well-marked,  and  have 
been  surprised  to  find  what  a  very  high  degree  of 
arterial  deformity  may  exist  without  producing 
any  very  marked  symptoms.  The  following  sum- 
mary from  the  careful  tables  which  wen 
prepared  for  rue  by  Dr.  Sanger  will  illustrate  this 
point. 

p.  c. 

Total  number  of  persons  examined 50 

youngest  person  examined 43 

camined 92 

Average  age  of  persons  examined 68.5 

Number  of  males  examined 30  60 

Number  uf  females  examined 20  40 

Number  of  blacks  examined 17  34 

Number  of  whites  examined -33  66 

Number  showing  specific  history 

Number  showing  non-specific  history                   23  46 

Number  showing  uncertain  history 20  40 

Number  of  intemperate  persons 25  50 

Number  of  temperate  persons 25  50 

Number  whose  "arteries  present  no  sclerosis  at  wrists      .  14  2S 

Number  whose  arteries  present  slight  sclerosis  at  wrists  .  21  42 

Number  whosearteriespresent  markedsclerosisat  wrists  .  15  30 

Number  whose  temporal  arteries  are  not  marked 13  26 

Number  whose  temporal  arteries  are  slightly  marked  .    .  25  50 

Number  whose  temporal  arteries  are  marked" 12  24 

Number  in  which  heart  lesions  were  found 10  20 

Number  in  which  albumen  was  found  in  urine 6  12 

Number  showing  mental  impairment 16  32 

Number  of  hemiplegias 12  24 

Of  course  it  is  not  intended  to  draw  any  very 
definite  conclusions  from  such  a  comparatively 
small  number  of  cases,  but  they  are  simply  used 
by  way  of  illustration.  The  atrophy  and  actual 
loss  of  brain  weight  in  old  persons  is  perhaps  due 
in  part  to  the  faulty  blood  supply,  which  is  con- 
sequent upon  atheroma.  While  one  would  hardly 
like  to  say  that  atheroma  of  the  arteries  is  always 
present  in  old  persons,  still  the  great  frequency 
with  which  it  occurs,  makes  it  a  physiological 
rather  than  a  pathological  degeneration.  It  is  to 
this  decay,  this  alteration  of  the  blood  supply  to 
the  central  nervous  system,  this  lack  of  nutrition 
to  the  centers,  that  we  must  attribute  the  ordi- 
nary mental  changes  of  old  age.  The  blood  sup- 
ply to  the  centres  is  imperfect,  causing  perhaps 
alteration  in  the  cells,  innervation  is  enfeebled 
and  all  the  mental  processes  are  slow.  Often  we 
see  something  more  than  a  mild  decay  of  the 
mental  faculties.  The  various  forms  of  senile 
dementia,  present  pictures  in  which  the  physio- 
logical process  of  decay  has  been  in  part  replaced 
by  a  more  decided  degeneration,  a  pathological 
process.  We  may  have  conditions  of  dementia 
with  hypochondriacal   delusions,  with  total   loss 


of  memory,  with  almost  entire  abolition  of  the  in- 
tellectual faculties,  dependent  largely  if  not  en- 
tirely upon  an  atheromatous  condition  of  the  ves- 
sels and  the  changes  in  the  brain  incident  upon 
such  condition.  It  is  not  this  state  of  gradual 
senile  decay,  dependent  though  it  is  upon  athero- 
ma that  especially  engages  our  attention;  it  is 
ie  condition  of  atheroma  which  has  over- 
stepped the  physiological  bounds.  That  is  to 
say  a  condition  of  atheroma  in  persons  whose  age 
does  not  warrant  such  a  change,  or  as  noted  above. 
symptoms  other  than  those  of  mere  senility,  oc- 
curring in  elderly  people.  In  persons  who  are 
not  yet  old.  but  whose  arteries  are  atheromatous, 
we  often  see  very  marked  mental  changes.  The 
general  disposition  of  the  individual  often  under- 
lie decided  change:  he  becomes  irritable, 
excitable, hysterical,  or  a  condition  of  hypochondria 
with  apathy  supervenes.  The  mental  symptoms 
peculiar  to  old  age  are  intensified.  The  picture 
is  not  unlike  that  of  beginning  general  paralysis 
before  the  advent  of  delusions.  There  is  an  in- 
aptitude for  any  kind  of  mental  exertion,  and  the 
memory  becomes  very'  bad.  Such  symptoms  as 
these  are  frequently  met  with  and  are  commonly 
ascribed  to  the  effect  of  the  diseased  condition  of 
other  organs  than  the  brain,  notably  to  the  effect 
of  the  lesion  which  often  coexists  in  the  kidney. 

Bearing  in  mind  the  condition  of  the  arterie>  in 
the  brain,  and  the  consequent  derangement  of 
the  circulation,  it  is  easy  to  conceive  how  such 
symptoms  as  these  detailed  are  produced.  The 
small  arteries  are  often  narrowed  almost  to  the 
point  of  obliteration,  and  any  increased  vaso  con- 
strictor action  will  temporarily  close  them. 

One  of  the  most  pathognomonic  symptoms  of 
arterio- sclerosis  of  the  vessels  of  the  brain  is  tran- 
sient paralysis.  These  attacks  aie  sometimes 
very  frequent  and  well  marked.  They  come  on 
with  the  suddenness  of  embolism,  or  again  grad- 
ually like  the  formation  of  a  thrombus,  last  from 
a  few  minutes  to  a  few  hours  and  are  entirely  re- 
covered from.  Such  a  person  nearly  always  dies 
from  haemorrhage  or  softening  as  the  result  of  the 
rupture  or  permanent  closure  of  the  vessel.  Due 
to  the  same  cause,  narrowing  or  temporary  closure 
of  the  small  arteries  are  severe  headache  and  ver- 
tigo. This  last  symptom  has  been  carefully  in- 
vestigated recently  by  Grasset  who  finds  in  addi- 
tion to  simple  vertigo,  epileptiform  vertigo  and 
attacks  of  syncope.  The  most  important  change, 
however,  in  the  vessels  is  the  formation  of  miliary 
aneurisms,  which  has  been  described,  for  it  is  to 
this  condition  that  most  cases  of  simple  apoplexy 
are  due.  Given  this  condition  of  miliary  aneur- 
ism, it  is  easy  to  see  how  with  high  arterial  ten- 
sion present  the  conditions  for  haemorrhage  are 
most  favorable.  The  fact  that  arterio- sclerosis  is 
undoubtedly  as  has  been  shown,  the  underlying 
cause  of  miliary  aneurism,  and  also  that  the  same 
condition  favors  the  production  of  thrombosis  and 


622 


ARTERIOSCLEROSIS. 


[May  2, 


embolism,   gives   the  subject   great   importance. 

The  limits  of  this  paper  do  not  permit  any  dis- 
cussion of  the  subjects  of  intracranial  haemor- 
rhage and  thrombosis  and  embolism.  Miliary 
aneurism,  as  has  been  noted,  is  very  infrequent 
in  the  vessels  of  the  cord,  and  as  non-traumatic 
haemorrhage  into  the  cord  is  a  comparatively  rare 
event,  this  fact  might  be  adduced  to  strengthen 
the  position  taken,  that  these  small  aneurisms  are 
always,  practically,  the  precursors  of  haemorrhage 
in  the  brain.  Of  course  there  are  other  reasons 
why  haemorrhages  into  the  cord  are  infrequent, 
as  the  length,  size  and  mode  of  distribution  of  the 
spinal  vessels.  It  is  doubtful  whether  any  symp- 
toms can  be  ascribed  to  changes  in  the  blood- 
vessels of  the  cord,  unless  we  include  anaemia  and 
hyperaemia,  which  can  hardly  be  said  to  be  con- 
ditions which  can  be  recognized  clinically. 

The  purely  theoretical  suggestion  mentioned 
in  the  first  part  of  this  paper,  that  perhaps  athe- 
roma of  the  vessels  of  the  cord  may^  be  a  factor 
in  the  production  of  sclerotic  degeneration  of  the 
fibres  in  the  manner  indicated,  may,  if  confirmed 
by  any  facts,  prove  useful  in  clearing  up  our  some- 
what indistinct  ideas  of  the  production  of  these 
lesions. 

There  are,  as  we  have  seen,  no  very  pathogno- 
monic symptoms  of  arterio  sclerosis  of  the  vessels 
of  the  central  nervous  system.  The  diagnosis 
must  rest  upon  the  general  symptoms  that  have 
been  outlined.  When  a  patient  presents  certain 
of  these  symptoms,  and  shows  sclerosis  of  the 
vessels  that  can  be  examined,  we  can  pronounce 
with  some  degree  of  certainty  upon  the  probable 
condition  of  the  arteries  of  the  brain.  The  oph- 
thalmoscope sometimes,  though  by  no  means  al- 
ways, shows  us  a  condition  of  sclerosis  in  athero- 
ma of  the  vessels  of  the  retina,  Raehlmann  found 
changes  in  the  vessels  in  forty-four  out  of  ninety 
cases  examined,  or  nearly  fifty  per  cent.  He  de- 
scribes a  certain  hazy  appearance  of  the  vessels, 
looking  as  if  a  thin  veil  were  stretched  over  them. 
He  noted  dilatations  and  constrictions  in  the  ves- 
sels and  in  two  cases  aneurism,  and  found  the 
veins  affected  also,  in  twenty  six  per  cent,  of  the 
cases. 

One  can  say  little  as  to  treatment,  other  than 
the  general  rules  that  are  laid  down  for  the  treat- 
ment of  the  general  condition.  It  is  necessary 
for  patients  who  have  a  high  degree  of  arterio- 
sclerosis to  avoid  violent  sudden  exertion  for  ob- 
vious reasons.  At  the  same  time  systematic, 
regular  exercise  in  the  open  air,  with  hill  climb- 
ing in  suitable  cases,  is  of  great  value.  Avoid- 
ance of  excessive  amounts  of  liquids  is  certainly 
an  important  point.  Large  quantities  of  water 
cannot  but  be  injurious,  by  overfilling,  or  at  least 
greatly  increasing  the  total  quantity  of  fluid  in 
vessels  that  are  already  embarrassed.  The  diet 
>uld  be  light  and  nutritious.  An  occasional 
.saline  purge   is  beneficial,  such    as    concentrated 


magnesia  sulph.  The  bromides  are  often  of  de- 
cided value  in  quieting  the  cerebral  circulation, 
as  are  also  warm  baths.  Nitro  glycerine  is  fre- 
quently of  value  in  these  cases,  especially  when 
we  have  a  sudden  raising  of  arterial  tension  and 
the  danger  of  intracranial  haemorrhage  imminent. 
In  these  acute  conditions  an  ice  cap  to  the  head 
is  valuable. 

The  above  imperfect  sketch  of  arterio-sclerosis 
of  the  central  nervous  system  will.  I  trust,  aid  in 
directing  attention  to  the  importance  of  the  sub- 
ject, and  show  the  necessity  of  more  careful  clin- 
ical work  to  make  the  picture  complete. 

9  E.  Townsend  St. 


REPORT    ON    THE    OPHTHALMOSCOPIC 

EXAMINATION  OF  DR.   PRESTON'S 

CASES  OF  ARTERIO-SCLEROSIS. 

BY  HARRY  FRIEDEXWALD,   M.D., 


>  '1      r;.w    [  IM    »RL 


As  a  preface  to  the  short  report  of  the  result  of 
the  ophthalmoscopic  examination  of  Dr.  Pres- 
ton's cases,  I  should  like  to  state  that  it  is  but 
recently  that  attention  has  been  attracted  to  those 
changes  of  the  retinal  arteries  as  are  found  in 
general  arterio-sclerosis.  A  few  years  ago  Ole 
Bull1  described  several  cases  of  disease  in  the 
retinal  arteries,  and  showed  how  this  was  the 
cause  of  symptoms  frequently  ascribed  to  embol- 
ism. Raehlmann2  made  an  exceedingly  careful 
study  of  the  relation  between  general  and  retinal 
arterio  sclerosis,  besides  collecting  a  few  scattered 
cases  in  literature.  He  examined  ninety  cases  of 
general  arterio  sclerosis  and  found  that  in  most 
cases  the  retinal  arteries  were  narrow  and  tortu- 
ous, that  19  per  cent,  showed  whitish  margins 
along  the  retinal  arteries,  that  21  per  cent,  pre- 
sented localized  narrowings  in  their  course,  but 
that  retinal  aneurisms  are  very  rare.  Confining 
ourselves  to  these  signs  of  arterial  disease  with- 
out considering  the  changes  in  the  veins  which 
he  likewise  frequently  found,  we  must  admit  that 
the  results  are  very  remarkable.  They  are,  in- 
deed, surprising,  if  you  remember  that  in  all 
works  on  ophthalmoscopy  such  changes  are 
not  considered  throughout  :  6  per  cent,  referred 
to:  that  in  the  very  latest,  that  of  Gowers.  we  find 
the  statement  referring  to  general  atheroma,  that 
"  in  cases  in  which  it  is  well  marked  elsewhere" 
In-  has  "  often  looked  for  appearances  in  the  retina 
suggesting  it>  existence  but  without  success." 
Prof.  Hirschberg  recently  published  the  results 
of  very  careful  ophthalmoscopic  examinations  ot 
-011s  between  the  ages  of  60  and  So  years. 
Besides  the  many  other  "senile  changi 
finds  that  4''  if  the   persons  examined 

iges   in   the   retinal   arteries;    44    per 


iorts   Washington, 
Vol  III,  p 

<    it    XVI. 


iSqi.J 


MEDICAL  LEGISLATION. 


623 


cent,  of  the  persons  examined  showed  variations 
in  the  caliber  of  the  arteries  at  different  points  in 
their  course  ;  2  per  cent,  showed  whitish  lines 
on  their  margins. 

Btfore  going  further,  it  would  be  well  to  ex- 
plain more  definitely  what  is  meant  by  these 
terms.  The  healthy  retinal  artery  is  perfectly 
transparent.  What  we  see  is  the  blood  column 
within  it.  When  the  walls  of  the  arteries  thicken 
at  the  expense  of  their  inner  caliber  and  the 
thickened  portion  remains  as  transparent  as  the 
healthy  vessel — and  this  is  commonly  the  case — 
we  detect  the  change  in  the  narrowing  of  the 
column  of  blood.  This  thickening  may  take 
place  at  localized  points,  causing  the  localized 
variations  in  the  thickness  of  the  blood  column 
or  throughout  the  course  of  the  vessel.  In  the 
cases  mentioned  above,  we  must,  therefore,  re- 
member that  the  terms  refer  only  to  the  blood 
column,  and  that  we  infer  from  these  the  condi- 
tion of  the  vessel,  for  instance,  when  Raehlmann 
describes  "localized  narrowings  of  the  arteries," 
there  are  only  localized  narrowings  of  the  blood 
column,  and  we  infer  from  these  that  there  are 
localized  thickenings  of  the  walk  of  the  vessel.  In 
those  cases  where  "white  lines  are  seen  along 
the  margins  of  the  vessels, ' '  the  wall  of  the  ves- 
sel has  lost  part  of  its  transparency,  and  reflects 
some  light  which  is  seen  as  the  white  lines. 
This  depends  upon  a  change  in  the  substance  of 
the  vessel,  or  a  deposit  within  it  different  from 
that  in  the  transparent  thickening  mentioned 
above,  and  is  much  rarer. 

My  attention  was  first  drawn  to  the  localized 
narrowings  (apparent !)  of  the  retinal  arteries  in 
cases  of  optic  nerve  atrophy,  and  especially  in 
those  due  to  embolism  of  the  central  retinal 
artery,  in  which  conditions  they  are  much  less 
uncommon  than  is  ordinarily  supposed.  But 
their  importance  struck  me  when  I  saw  them  in 
a  case  of  beginning  retinitis  albuminurica  where 
the  signs  of  inflammation  were  almost  limited  to 
but  one  eye,  while  the  localized  narrowings 
could  be  seen  in  the  retinal  arteries  of  both  eyes." 
Since  then  I  have  paid  more  attention  to  this 
point  and  have  found  the  changes  not  infrequently. 

It  was  with  great  pleasure,  therefore,  that  I 
undertook  to  examine  the  retinal  arteries  of  Dr. 
Preston's  cases.  I  must  mention  that  some  of 
the  cases  were  in  bed  when  I  was  at  the  asylum, 
and  could  not  be  examined  sufficiently  carefully 
with  the  ophthalmoscope  to  look  for  these  minute 
changes.  For  this  reason  only  twenty-nine  cases 
were  examined,  or  fifty- eight  eyes.  In  eighteen 
of  these  eyes  un  twelve  patients)  an  ophthalmo- 
scopic examination  was  rendered  impossible  by- 
such  impediments  as  cataract,  corneal  opacities, 
etc.,  and  this  reduced  the  number  of  retinae  ex- 
amined  to  forty  (in  twenty-three  patients). 

=  Prof.  Hirschberg  published  this  case  in  detail.  Centralblatt  f. 
Augenh.  1890,  p.  206. 


Of  these  forty  retinae,  nineteen  presented  de- 
cided local  or  general  narrowing  of  the  arteries 
with  frequent  tortuosity  I  twelve  patients  ;  ten 
presented  moderate  or  slight  changes  of  the  same 
kind  (seven  patients);  four  presented  whitish 
margins  along  the  arteries  (two  patients);  one 
presented  a  haemorrhage  on  the  papillae  ;  seven 
appeared  thoroughly  normal  (five  patient- 
appeared  thoroughly  normal,  while  there  were 
other  extensive  retinal  changes.  Besides  these  I 
noted  in  several  cases  senile  retinal  changes,  in 
the  characteristic  little  yellowish  spots  due  to 
colloid  degeneration  of  the  lamina  vitrea  of  the 
choroid. 

The  proportion  of  cases  in  which  decided 
changes  were  found  is  so  great  that  I  am  led  to 
thoroughly  accord  with  Raehlmann  as  to  the  fre- 
quency of  these  changes  and  their  importance  in 
diagnosis. 


A  KNOWLEDGE    OR   A    TIME  REQUIRE- 
MENT.     A  PLEA  FOR  A  MORE  RA- 
TIONAL SYSTEM  OF  MEDICAL 
LEGISLATION. 
BY  YOUNG  H.  BOXD,  M.D., 

DEAN   OF  THE 


The  very  general  move  in  the  direction  of  med- 
ical legislation-,  during  the  past  year  or  so,  indi- 
cates the  urgent  demand  on  the  part  of  the  pro- 
fession, for  the  just  and  proper  regulation  of  the 
practice  of  medicine.  In  addition  it  is  significant 
of  the  increase  in  competition  and  of  the  grow- 
ing metamorphosis  of  the  art  of  medicine  into  the 
science  of  medicine,  of  which  the  precepts  and 
teachings  follow  such  fixed  laws,  that  he  who 
studies  may  learn. 

THE    NINETEENTH    CENTURY. 

Our  nineteenth  century  is  a  wonderful  one — 
the  like  of  which  has  never  been  seen  in  the 
whole  compass  of  earthly  years.  Born  during 
the  great  struggle  of  freedom  against  tyranny 
and  oppression,  living  through  the  downfall  of 
the  ancient  superstition  of  the  divine  right  of 
Kings,  it  is  about  to  make  its  exit  from  a  world 
whose  democracy  is  stamped  in  every  act,  and 
whose  parting  requiem  to  the  hoary  century  will 
be  "Vox  populi,  vox  Dei."  The  people — the 
Demos  rule.  Throughout  this  whole  century  an 
equalizing  power  has  been  exerted  which  has 
been  so  thoroughly  engrafted  upon  the  lives  and 
actions  of  men,  that  it  has  become  the  spirit  and 
temper  of  the  age. 

Such  a  condition  must  have  a  positive  bearing 
upon  our  civilization  and  its  effects  may  be  con- 
centrated in  the  one  expression,  competition. 
Fair,  open  competition  is  the  life  of  our  institu- 
tions, but  when  it  begets  exclusion,  it  becomes 
the  very  bane  of  their  existence. 


624 


MEDICAL  LEGISLATION. 


[May  2 


MECHANICS    AND    DOCTORS. 

"Too  many  mechanics"  is  the  cry,  and  forth- 
with in  not  a  few  branches  of  labor  an  elaborate 
system  of  restriction  is  practiced,  and  the  number 
of  artisans  is  maintained  small  by  control  of  ap- 
prenticeship vested  in  the  workers  of  that  special 
line.  As  a  consequence  we  find  an  undue  limita- 
tion of  the  number  of  apprentices,  and  an  equally 
undue  extension  of  the  time  of  apprenticeship, 
all  because  those  within  the  inner  circle  fear  hon- 
est competition. 

What  a  decided  similarity  certain  misdirected 
members  of  the  medical  profession  would  en- 
courage between  their  high-aiming  profession 
and  these  restricted  divisions  of  labor.  Do  we 
not  hear  on  all  hands  the  cry,  "  Too  many  doc- 
tors, too  many  medical  colleges,  let  both  be 
limited."  Again,  like  the  apprentice-restricting 
mechanic,  they  say,  "Make  them  study  longer; 
make  the  restrictions  greater"  in  face  of  the  fact 
that  they  who  rant  and  cry  "  reform  "  underwent 
the  application  of  no  such  law,  nor  would.  They 
cry,  "The  wolf!  the  wolf !"  but  fail  to  protect 
their  charge  by  just  and  equable  safeguards,  pre- 
ferring, it  appears,  to  resort  to  artificialities 

MEDICAL    LEGISLATION. 

It  is  a  sad  feature  for  our  vaunted,  fraternal 
and  unselfish  feeling  for  one  another,  that  such 
an  affair  as  medical  legislation  is  necessary-  Its 
origin,  coeval  with  that  of  medicine,  dates  back 
to  the  time  of  Hippocrates,  whose  stringent  oath 
formed  at  once  an  obligation  and  a  text  for  future 
laws.  Throughout  the  middle  ages  medical  laws 
prevailed,  though  more  or  less  crude.  In  these 
more  modern  times  medical  legislation  is  an  ele- 
ment in  every  civilized  set  of  laws,  some  natural 
and  just,  others  artificial  and  presumptuous. 

Our  own  country  is  at  present  in  the  throes  of 
the  subject  and  each  State  is  prodded  here  and 
there,  with  persuasive  prayers  or  emphatic  de- 
mands, emanating  not  from  the  people  but  from 
the  doctors.  The  consequence  is  that  many 
legislators  and  the  public  look  upon  the  medical 
profession  as  a  band  of  sycophants,  always  boast- 
ing of  their  professional  regard  for  one  another, 
yet  ever  anxious  to  outdo  each  other,  ever  seek- 
ing protection,  yet  becoming  the  most  violent 
and  persistent  of  persecutors. 

Is  it  strange,  therefore,  that  sarcasm  should 
now  and  then  creep  into  our  legislatures,  such  as, 
for  instance,  the  bill  introduced  by  a  Missouri  leg- 
islator, fixing  the  uniform  rate  of  $1.00  for  visits 
and  fifty  cents  for  office  consultations?  Other 
bills  of  a  like  strain  have  been  presented,  a 
recent  one  being  an  act  to  compel  each  physician 
to  advertise  in  the  local  papers  his  name,  age, 
years  of  practice  and  source  of  medical  diploma. 
All  this  is  medical  legislation. 

Every  time  a  State  legislature  meets  there  is  a 
pilgrimage  of  doctors  to  the  State  Capitol,  asking 


that  certain  laws  be  enacted,  the  sum  and  sub- 
stance of  all  being  the  lessening  of  competition 
and  the  exaltation  of  the  few. 

Some  years  ago  the  animus  appeared  directed 
towards  the  annihilation  of  quacks  and  impostors. 
Much  good  was  accomplished,  but  the  more  the 
charlatans  were  persecuted,  the  more  they  pros- 
pered. And  to-day,  according  to  the  provisions 
of  the  courts,  the  only  restriction  is  "  Thou  shalt 
not  lie."  They  may  advertise  what  they  will,  so 
long  as  falsehood  does  not  appear. 

The  people  did  not  eventually  look  so  kindly 
upon  the  efforts  of  the  profession  to  efface  quack- 
ery, not  as  has  been  so  often  represented,  because 
of  their  desire  to  be  humbugged,  but  because 
they  knew  there  were  two  sides  to  every  question, 
and  because  they  felt  certain  that  so  notable  an 
effect  must  have  some  deep-seated  cause.  Add- 
ing to  this  the  great  stampede  of  doctors  for  med- 
ical legislation,  they  arrived  at  the  conclusion 
that  doctors  were  perhaps  actuated  by  selfish 
motives,  just  as  much  as  by  their  interest  in  hu- 
manity, and  thej-  decided  that  opponents  and 
prosecutors  should  not  be  made  judges  and  exe- 
cutors. What  was  the  result  ?  We  hear  of  the 
Board  of  Health  being  refused  support  year  after 
year ;  in  more  than  one  case  the  board  has  been 
compelled  to  cease  its  prosecutions  as  a  condition 
of  its  existence,  and  in  one  notable  instance,  the 
official  member  was  compelled  to  resign  in  order 
J  that  an  appropriation  might  be  made. 

THE  THREE  COURSE  REQUIREMENT. 

The  contest  for  a  three-course  qualification  is 
I  far  more  in  opposition  to  democratic  principles 
than  what  has  just  been  mentioned.  The  raison 
I  d'etre  of  its  advocacy  by  the  profession  is  evi- 
dent. Shuddering  at  the  laxness  of  its  condi- 
I  tions  it  seeks  to  improve  itself.  Commendable 
indeed,  for  there  are  many  doctors  who  do  not 
deserve  the  title  and  whose  knowledge  of  medi- 
cine is  confined  to  exceedingly  narrow  limits. 
Many  are  graduates  who  attended  two  courses, 
some  three  courses,  others  perhaps  still  more.  I, 
too,  agree  that  this  is  due  to  the  fact  that 
two  years  of  attendance  at  a  medical  college  has 
been  the  standard  of  license.  But,  believe  me,  I 
consider  this  the  fault  of  the  whole  system  and 
not  of  the  lack  of  a  three-term  requirement. 

If  these  doctors,  if  all  doctors  would  have  been 
examined  by  a  Board,  the  number  of  ignoramuses 
would  have  been  immeasurably  less,  in  fact,  it 
would  be  nil.  What  assurance  have  we  that  the 
adoption  of  a  three-years  course  will  change  the  ex- 
isting order  of  things?  Will  the  fact  that  three 
years  are  required  make  the  professors  any  better  as 
teachers  or  the  students  any  more  faithful  ?  Will 
it  not  encourage  laxness  on  the  part  of  the  teach- 
ers and  idleness  on  the  part  of  students  ?  It  is 
indeed  plausible  to  consider  that  many  students 
will  spend  their  time  after  the  fashion  of  so  many 


t89i.] 


MEDICAL  LEGISLATION. 


625 


of  their  continental  co-workers,  whose  time  and 
money  wax  so  heavy  on  their  hands  that  they 
spend  the  half  in  riotous  life  and  dissipation. 

Of  course  if  the  instruction  is  improved  coinci- 
dently,  and  the  examinations  made  more  rigid  and 
effective,  in  so  far  good  will  be  accomplished. 
This  is,  however,  by  no  means  due  to  the  length- 
ened course,  but  to  the  knowledge  requirement 
which  has  been  added. 

THE  KNOWLEDGE  REQUIREMENT. 

And  here  is  just  where  I  rest  my  oars,  in  the 
calm  and  righteous  waters  of  knowledge.  Knowl- 
edge the  basis,  knowledge  the  foundation,  and 
knowledge  the  standard  of  qualification  and  ex- 
cellence. 

Make  the  two  or  three-course  student  pass  a 
satisfactory  examination  before  a  competent 
board  and  you  settle  the  question  at  once  upon  a 
basis  both  rational  and  just.  No  school's  ipse 
dixit  is  taken;  all  submit  to  a  fair  and  impartial 
test.  Under  this  system  a  student  who  is  a  good 
chemist,  on  account  of  his  academic  education, 
needs  not  worry  through  two  or  three  years  of 
reiteration  of  what  he  already  knows,  and  the  ca- 
pable druggist  would  be  saved  much  time  that 
otherwise  he  would  squander  in  listening  to  lec- 
tures, useless  to  him.  Equally  would  there  be 
given  to  a  nurse  of  experience  or  to  one  who  has 
had  much  to  do  with  invalids,  the  opportunity  of 
deriving  whatever  benefits  he  deserves,  and  not 
be  hampered  by  a  time  requirement,  the  same  for 
tyros  and  for  more  experienced  students. 

With  three  courses  a  compulsory  condition  to 
graduation,  a  competent  graduate  of  a  good  two- 
years  school,  whose  professors  have  been  conscien- 
tious, would  be  denied  the  right  to  practice  and  to  ; 
exercise  his  hard-earned  knowledge  as  he  should, 
while  the  incompetent  graduate  of  a  three-term 
college  of  the  most  questionable  reputation,  would 
at  once  by  the  power  and  might  of  an  unjust  act, 
enterinto  thejoysof  the  professional  kingdom.  Ob- 
serve the  whole  system  which  should  be  an  en- 
couragement to  industry  and  knowledge,  by  rea- 
son of  the  unnatural  restriction  of  time,  simmers 
down  to  an  impalpable  and  foolish  mixture  of 
sentiment  which  is  both  unreal  and  ridiculous. 
Unreal  because  its  basis  is  artificial  and  inefficient, 
and  ridiculous  because  its  application  accom- 
plishes but  slight  improvement  at  best,  and  that 
at  the  expense  and  hardship  of  injustice  to  the 
very  men  whose  entrance  into  the  profession  is  so 
desirable. 

It  is  evident  then  that  the  three- term  qualifica- 
tion places  us  no  nearer  the  goal  of  our  efforts 
than  we  are  at  present,  for  unde:  its  action,  as 
now,  the  whole  matter  of  licensing  practitioners 
would  rest  in  the  hands  of  the  professors  of  med- 
ical colleges — interested  parties, — and  not  vested, 
as  it  should  be,  in  the  divine  right  of  the  people, 
in  a  board  whose  standard  is  knowledge  and  fair- 
ness to  all. 


Yet  so  long  have  doctors  advocated  the  deifica- 
tion of  time  in  this  particular  that  what  should 
be  the  foundation  of  medical  legislation  is  over- 
looked, yea  ignored,  in  the  fetich  worship  of  the 
time  god. 

This  appears  the  more  astonishing  from  the  fact 
that  the  knowledge  requirement  is  such  a  taking 
argument  with  legislators  and  men  whose  work  and 
study  is  law-making.  In  the  recent  considera- 
tion, before  the  Missouri  legislature,  of  the  three- 
course  measure,  the  bill  was  lost  not,  as  has  been 
falsely  represented,  by  personal  influence,  but  be- 
cause the  senators  saw  the  fallacy  of  considering 
time  and  not  knowledge  as  the  proper  require- 
ment. 

To  say  that  every  medical  student  shall  attend 
for  three  years  a  medical  college  is  to  minimize 
the  difference  which  exists  between  intellects  and 
to  deprive  many  a  competent  man  from  enjoying 
on  account  of  a  few  paltry  dollars,  the  fruits  of 
his  industry  and  knowledge,  thus  defeating  the 
!  purpose  and  sense  of  all  law. 

I  believe  in  trusts  of  no  kind,  and  I  most  de- 
cidedly enter  a  protest  against  what  is  nilly-willy 
a  medical  students'  trust.  Any  combination  hav- 
ing for  its  avowed  purpose  a  limitation  based 
upon  a  standard  which  is  unjust,  which  dictates 
unfairly  and  summarily,  and  which  excludes  de- 
serving individuals  from  the  enjoyment  of  such 
rights  which  by  virtue  of  their  knowledge  they 
should  have — when  such  a  combination  exists  by 
agreement  it  must  answer  to  the  name  of  trust. 
As  such  it  is  detrimental  to  our  country's  interests 
and  is  in  direct  opposition  to  the  old  sterling 
principles  of  our  government,  that  each  man 
should  receive  fair  treatment  by  the  laws  and 
that  justice  be  given  in  accordance  with  each 
man's  deserts. 

FOREIGN    DOCTORS. 

Much  has  been  said  of  the  superiority  of  the 
European  doctors  over  the  American  production, 
a  statement  whose  deprecation  is  accompanied  by 
the  information  that  the  fault  is  in  the  two-years' 
course.  Again  I  beg  to  take  issue  for  the  palpa- 
ble reason  that  the  rigid  examinations  to  which 
each  student  is  subjected  furnish  proof  which  no 
argument  as  to  time  can  belittle. 

In  Germany  two  examinations  are  held,  the 
University  and  the  State,  each  being  independ- 
ent of  the  other.  It  might  be  interesting  to  men- 
tion the  number  of  rejections  by  the  Prussian 
State  Examiners  of  those  who  had  already  passed 
the  University  Examiners.  In  the  year  1S90  out 
of 563  applicants,  231,  or  29.09,  percent,  failed. 
Forty  per  cent,  of  the  applying  graduates  of  the 
University  of  Berlin  were  rejected.  Where  is  the 
efficiency  of  the  long  term  school  compared  with 
a  good  examining  board  ?  Certainly  there  is 
much  valid  argument  in  this  little  statement  of 
the  Prussian  examinations. 


626 


MEDICAL  LEGISLATION. 


[May  2, 


In  France  the  whole  matter  is  left  to  the  six 
Medical  Faculties  who  constitute  virtually  six 
examining  boards  and  who  alone  are  authorized 
to  issue  diplomas  to  students  of  all  the  French 
schools. 

In  England,  while  the  diploma  issued  by  the 
University  Faculties  (in  themselves  almost  equiv- 
alent to  an  impartial  examining  board)  carries 
with  it  a  licensing  power,  the  various  royal  col- 
leges make  examinations  granting  to  the  success- 
ful applicant  what  is  distinctive  evidence  of  the 
knowledge  he  has  acquired. 

Austria  and  Russia  have  laws  similar  to  Ger- 
many and  hence  present  a  proper  solution  to  the 
question. 


forcement  just  as  well  as  now  and  they  would  be 
equally  well  patronized. 

ADVANTAGES   OF   THE    EXAMINING    BOARD. 

1.  It  possesses  a  just  and  rational  basis,  that 
of  knowledge. 

2.  Every  student  would  perforce  depend  upon 
his  own  efforts  and  zeal,  and  would  not  he  indif- 
ferent of  his  studies  unless  he  was  not  anxious  to 
practice. 

3.  It  is  impartial — the  rich  have  no  advantage 
over  the  poor. 

4.  The  licensing  power  being  taken  away  from 
the  medical  colleges,  their  instruction,  by  the 
sheer  force  of  competition,  would  be  the  drawing 


These   illustrations  are  given    to  indicate  as  card   for  students    would  go   where  they  could 
clearly  as  possible  that  the  circumstance  of  the   m0st  easily  graduate. 

high  intellectual  standing  of  European  physicians  I      5.  Second  class  colleges  (and  by  this  I  mean 
depends  upon  the  constitution  of  what  is  equiva- ;  those   characterized   by    loose   management  and 


lent  to  examining  boards,  and  upon  the  strictness 
of  the  examinations,  rather  than  upon  the  number 
of  days,  hours  and  minutes  devoted  to  medical 
study. 

It  is  a  very  serious  question  whether  or  not  the 
unamerican  legislation  based  upon  a  time  require- 
ment and  excluding  all  who  do  not  comply  with 
its  provisions  is  constitutional.  Certain  it  is  that 
the  recent  resolutions  of  the  various  boards  of 
health  which  define  the  term  "  College  in  good 
standing"  to  signify  a  three- term  school  will  not 
hold  in  any  Court  in  the  land.     Efforts  on  the 


incompetent  instruction)  would  be  forced  out  of 
existence,  because  so  many  of  their  graduates 
would  be  rejected  by  the  various  Mate  boards. 

In  conclusion  let  me  restate  a  remark  that  I 
have  already  made,  to  the  effect  that  it  will  be 
easy  to  convince  the  legislators  of  the  wisdom  of 
this  measure;  it  is  so  thoroughly  in  keeping  with 
fairness  and  right  that  to  the  law-makers  it  so 
smacks  of  the  very  essence  of  all  law,  that  they 
advocate  it  in  preference  to  all  other  measures. 

Then  let  the  right  prevail;  relieve  the  boards 
of  health  of  the  annoying  duty  as  censors  of  the 


part  of  boards  of  health,  such  as  has  just  been  in-  medical  profession,  and  dictators  of  medical  col 
dicated,  are  valueless  as  they  are  misdirected,  j  leges;  let  the  State's  money  be  expended  not  for 
Any  college  which  fulfils  the  significance  of  the  the  compilation  of  statistics,  their  publication  and 
term  "College  in  good  standing"  at  the  time  of  j  circulation,  of  value  to  the  doctors  alone,  but  for 
the  passage  of  the  Act,  can  by.  mandamus  com-  j  the  prime  object  of  such  a  board — the  hygiene  of 
pel    the  board  to  grant  licenses  to  its  graduates,  j  the  State;  let  the  impartial  board  of  examiners 


A  more  rational  definition  of  the  term,  the 
boards  might  adopt,  to-wit:  Such  colleges,  all  of 
whose  students  are  able  to  pass  a  satisfactory  ex- 
amination before  the  boards  of  health.  It  does 
seem  to  me  that  this  would  be  equally  as  legal 
and  far  more  satisfactory  and  just. 

OBJECTIONS  TO    A  THREE- COURSE  REQUIREMENT. 

i.  It  possesses  an  erroneous  basis,  viz.:  the 
standard  of  time  and  not  of  knowledge. 

2.  It  is  unfair  in  that  it  takes  no  cognizance  of 
the  superior  intellectuality  and  industry  of  stu- 
dents. 

3.  It  allows  no  credit  for  previous  work  and 
study,  no  matter  how  extensive,  unless  pursued 
reguiarly  in  a  recognized  medical  school. 

4.  It  is  unjust  because  it  works  hardship  upon 
deserving  young  men  who  happen  to  be  poor  in 
worldly  goods;  the  rich  are  thus  given  the  ad- 
vantage and  preference. 

5.  It  perhaps  would  encourage  laxness  of 
teachers  and  indifference  of  students. 

6.  The  ends  would  not  be  accomplished  because 
second  class  colleges  would  exist  under  its  en- 


pass  on  every  new  graduate  who  seeks  the  privil- 
ege of  practicing  in  the  State. 

In  such  a  commonwealth,  the  law  of  medicine 
be  the  law  of  fairness,  democracy  and  right,  and 
the  licensed  doctor  will  lie  more  comfortably  on 
the  bed  of  roses,  nurtured  by  his  own  industry, 
and  the  incompetent  one  will  seek  some  more 
congenial  occupation. 

Three  results  will  obtain: 

1.  An  ever  increasing  number  of  good,  compe- 
tent and  worthy  doctors. 

2.  An  ever  decreasing  number  of  unworthy,  un- 
professional and  incompetent  physicians. 

3.  Medical  colleges  upon  a  higher,  better  and 
more  intelligent  plane. 

Grand  and  Page  Ave. 


Increase  in  the  Use  of  Alcoholics  in 
France. — From  late  returns  it  is  found  that  the 
consumption  of  alcohol  in  France  is  largely  in- 
creasing, and  this  despite  the  fact  of  the  decrease 
in  population.  Can  it  be  shown  that  there  is  a 
relation  between  these  two  processes  ? 


i89i.] 


ETIOLOGY  OF  ALCOHOLIC  INEBRIETY. 


627 


ETIOLOGY  OF  ALCOHOLIC    INEBRIETY. 

A'f-ad  before  the  American  Association  for  "the  Study  and  Cure  of 
Inrbritty,  April  II,  1891. 

BY   I..  1).    MASON,  M.D., 

CONSULTING    PHYSICIAN    INEBRIATES'  HOME,  FORT   HAMILTON,  I.,   I. 

The  causes  of  alcoholic  inebriety  may  be  di- 
vided into  predisposing  and  exciting,  and  the  lat- 
ter into  two  forms,  direct  and  indirect.  Inebriety 
from  either  of  these  latter  subdivisions  may  be 
comprehended  under  one  term,  "acquired"  ine- 
briety— in  contradistinction  to  those  forms  of  in- 
ebriety directly  traceable  to  heredity.  This  term 
"acquired"  we  shall  apply  to  the  form  of  inebri- 
ety due  to  "accidental"  causes. 

In  the  great  majority  of  cases  inebriety  is  not 
voluntarily  acquired  in  the  same  sense  that  a  per- 
son deliberately  and  as  a  matter  of  choice  "makes 
himself  an  inebriate"  so  to  speak,  we  use  the 
term  acquired,  therefore,  as  we  would  apply  it  to 
other  diseased  conditions,  not  necessarily  by  its 
use  implying  a  "moral  delinquency."  The  pre- 
disposing cause  of  inebriety  is  latent  and  has  to 
be  called  out  by  some  exciting  cause,  either  di- 
rect or  indirect,  usually  of  a  slighter  nature  than 
would  develop  an  "acquired  inebriety." 

Heredity  is  the  great  underlying  or  predispos- 
ing cause  of  alcoholic  inebriety,  in  the  same  sense 
that  heredity  is  the  predisposing  cause  to  many- 
diseased  conditions — as  insanity,  phthisis,  gout, 
etc.,  constituting  a  diathesis  or  tendency  to  spe- 
cial diseases.  We  can  with  perfect  propriety  use 
the  term  "inebriate  diathesis."  We  can  trace 
"the  pedigree  of  disease,"  as  Jonathan  Hutchin- 
son calls  it,  in  inebriety  as  in  other  forms  of  dis- 
ease. Dr.  Elam  affirms  that  the  offspring  of  the 
drunkard  will  inherit  either  the  original  vice  or 
some  of  its  countless  protean  forms.  Plutarch, 
in  his  essay  on  "Delays  of  Divine  Justice,"  asserts 
this  fact;  likewise  Aristotle  and  Plato.  "The 
fathers  have  eaten  sour  grapes,  and  the  children's 
teeth  are  set  on  edge,"  writes  the  Hebrew 
prophet,  and  amid  the  thunders  of  Mount  Sinai 
the  finger  of  God  wrote  on  tables  of  stone,  "the 
sins  of  the  father  shall  lie  visited  upon  the  chil- 
dren." 

Dr.  Norman  Kerr  regards  maternal  inebriety  as 
the  chief  hereditary  cause  of  inebriety.  Statistics 
show  that  female  inebriates  are  much  more  com- 
mon in  Great  Britain  than  with  us — in  Wales 
convicted  inebriate  females  to  convicted  inebriate 
males  stood  as  3  to  1,  while  in  the  upper  classes 
of  English  society  it  is  well  known  that  inebri- 
ety among  females  is  greater  than  in  America. 
My  own  observations  trace  the  hereditary  cause 
in  the  majority  of  our  cases  to  an  inebriate  father. 

Heredite  croisS,  or  cross  heredity,  has  been 
noticed  in  inherited  inebriety — that  is  inebriate 
mothers  gave  rise  to  inebriate  sons;  inebriate 
fathers  to  inebriate  daughters.  Giron  states 
that  the  hunters  have  a  proverb,  "chienne  ct 
chien — chienne    ct  chicn" — the  mother's  qualities 


in  the  son,  the  father's  in  the  daughter.  Buffon 
recognizes  that  fact,  also;  personally  I  have  not 
any  observations  to  give  on  this  point 

■  in  has  been  observed;  that  is,  where  the 
inebriate  tendency  or  diathesis  escaped  the  second 
generation  and  appeared  in  the  third — the  grand- 
parents being  the  transgressors.  We  notice  this 
fact  in  other  diseases,  as  consumption,  etc. 

This  is  the  sequence  that  is  established  should 
an  inebriate  mother  conceive  : 

1.  The  foetus  may  die  in  utero.  Miscarriage  is 
I  a  common  condition    in    chronic  alcoholism  in 

pregnant  women. 

2.  Should  the  foetus  survive,  pass  to  full  term. 
and  a  living  child  be  deli%rered,  it  may  be  an 
idiot  or  congenital  imbecile. 

3.  Kscaping  from  these  conditions,  and  mani- 
festing a  fair  amount  of  intelligence,  the  child,  at 
or  about  pubert3'  or  earlier,  may  develop  one  of 
the  various  neuroses — chorea,  paralysis,  epilepsy, 
etc. 

4.  Passing  from  youth  to  manhood  without 
any  of  these  manifestations,  then  suddenly,  often- 
times from  slight  exciting  causes,  inebriety,  or 
insanity,  stand  out  in  bold  relief,  and  the  hand  of 
fate,  shall  we  call  it?  draws  the  curtain  on  a  life 
that  has  struggled  from  birth  with  an  "inebriate 
diathesis." 

Surely  no  class  of  persons  in  this  wide  world 
have  a  more  marked  claim  on  our  aid  and  sym- 
pathy than  these  "  miserables."  Impotent  to 
help  themselves;  lacking  entirely  that  necessary 
self-restraint  and  control  that  belongs  to  a 
healthy,  normal  constitution.  The  so-called 
moderate  drinker — we  define  such  a  one  as  a 
person  who  drinks  habitually  every  day,  so  as  to 
keep  himself  moderately  stimulated,  and  his 
blood  and  fluids  moderately  alcoholized,  but  is 
never  drunk,  never  loses  his  self-control,  and  is 
eminently  respectable  in  the  general  sense  of  that 
term.  Such  a  man  we  assert  may  be  the  origin- 
ator of  a  long  line  of  inebriates,  insane  or  neurotic 
individuals.  It  is  a  common  impression  that  the 
bloated  drunkard  and  the  debauchee  alone  gave 
being  to  such  a  progeny,  yet  so  potent,  so  far- 
reaching  are  the  effects  of  alcohol  if  continuously 
used  with  so-called  moderation,  that  who  shall 
say  in  what  quantity  it  may  be  used  safely,  hab- 
itually, so  as  not  to  affect  cell  growth  in  our  own 
organism,  and  dwarf  and  degenerate  it  tenfold  in 
the  being  whom  we  may  beget.  The  modified 
cell  in  our  own  organism  being  much  more  mod- 
ified in  our  progeny. 

Dr.  Baer,  of  Berlin,  says  : 

"The  extremely  delicately  organized,  very  sensitive  and 
easily  destroyed  construction  of  the  nerye  and  ganglion 
-apposes  for  the  normal  physiological  function 
of  this  structure  the  cornpletcst  integrity  of  this  appara- 
tus, not  only  anatomically,  hut  also  physio-chemically. 
Every,even  the  smallest,  inroadon  the  nutritive  and  form- 
ative processes  produces  here  a  reaction  of  incomparably 
grayer  significance  and  weightier  results  than  on  any 
bodily  tissue." 


628 


ETIOLOGY  OF  ALCOHOLIC  INEBRIETY. 


[May  2, 


Dr.  Baer  refers  to  the  brain  particularly,  for  upon 
the  brain  and  nervous  system  alcohol  produces 
its  most  marked  (probably  functional)  changes, 
and  slight  changes  in  cerebral  or  nerve  tissue 
mean  a  great  deal  more  than  similar  changes  in 
other  tissues  or  organs.  We  do  not  feel  that  we 
are  making  an  extravagant  statement  when  we 
say  that  these  slight  cerebral  and  nerve  changes 
may  occur  in  the  progeny  of  so-called  moderate 
habitual  users  of  alcoholic  liquors.  If  so,  here  is 
the  "initial  lesion,"  the  starting  point  of  the  long 
line  of  inebriates  and  insane  with  which  this 
world  is  cursed. 

"Total  abstinence"  is  the  safest  remedy  for  this 
evil,  and  until  it  is  universally  practiced  the  pro- 
duction of  idiots,  imbeciles,  insane,  and  neurotic 
individuals  will  not  cease.  But,  it  may  be  asserted 
that  the  so-called  moderate  habitual  user  of  alco- 
holic liquors  will  not  be  answerable  for  "this  train 
of  consequences"  if  he  does  not  exceed  his  "phy- 
siological quantity."  Will  any  one  state  what  is 
that  safe  or  "physiological  quantity?"  We  shall 
certainly  lay  this  waif  of  hereditary  inebriety,  in- 
sanity, and  kindred  evils  at  the  door  of  the  so- 
called  moderate  habitual  user  of  alcoholic  liquors. 
But  it  may  be  added  there  are  cerebral  changes 
produced  by  causes  other  than  alcoholic;  very 
well,  eliminate  from  the  etiology  of  cerebral  dis- 
ease one  of  the  most  potent  of  these  causes — the 
habitual  use  of  alcohol  in  any  quantity.  Not 
only  inebriety  or  insanity  in  ancestry,  but  all 
hereditary  diseases  that  tend  to  weaken  the  nerv- 
ous system  or  give  rise  to  a  so-called  "congenital 
neurasthenia"  are  the  fertile  soil  from  which  ine- 
briety may  spring.  How  many  persons  born 
with  "a  tendency  to  diseased  cravings  and  par- 
alyzed control,"  as  Dr.  Clouston  aptly  styles 
it,  cannot  resist  the  ordinary  shocks  of  life, 
readily  yield  to  the  seductive  influence  of  some 
narcotic,  alcohol,  opium,  chloral,  cocaine,  and  be- 
come veritable  narco- maniacs  !  What  a  birth- 
right ! 

The  question  naturally  arises,  must  all  born 
with  such  a  diathesis  succumb  eventually  to  ine- 
briety or  insanity  in  some  form  ?  We  are  not 
prepared  fully  to  answer  this  question.  There 
are  in  every  community  those  who  are  aware  of 
theirbeing  possessors  of  this  unfortunate  tendency. 
There  are  also  those  who  inherit  a  consumptive 
diathesis.  Instances  are  on  record  in  which 
those  having  a  consumptive  diathesis  have,  by 
selecting  .their  environments,  as  to  climate,  occu- 
pation and  habits  of  life,  successfully  warded  off 
the  inroads  of  special  disease.  May  it  not  be 
that  a  person  who  inherits  the  inebriate  diathesis 
may  also  escape  the  usual  results  of  the  same  in 
his  own  person  by  observing  certain  rules,  regula- 
tions and  habits  of  life  ?  Children  born  of 
parents  who  have  not  yet  become  inebriates  es 
cape,  while  children  born  after  parents  have  be 
come  inebriates  inherit  the  inebriate  tendency 


Children  who  inherit  the  mental  or  physical 
traits  of  either  inebriate  parent  are  apt  to  inherit 
the  inebriate  tendency,  while  other  children  in 
the  same  family  escape  it. 

Moral  causes  are  written  down  as  the  chief  prev- 
alent causes  of  insanity  proper,  second  only,  in 
productiveness,  to  alcoholism.  How  often,  as  we 
have  stated,  do  these  congenital  neurasthenics, 
these  unfortunates  born  with  a  diathesis  either 
inebriate  or  insane,  yield  to  grief,  strong  mental 
emotions,  loss  of  friends  or  estate,  and  become 
either  inebriates  or  insane,  when  such  causes 
would  have  produced  neither  result  in  a  healthy, 
nervous  organization.  There  are  other  causes, 
to  which  we  think  the  term  accidental  might  also 
be  properly  applied,  and  where  we  generally  use 
the  term  "acquired  inebriety,"  with  which  pre- 
disposing causes  have  nothing  to  do,  and  where 
we  might  with  propriety  say:  "Neither  did  this 
man  sin  nor  his  parents."  Whether  inherited  or 
acquired  ;  inebriety  is  produced  by  certain  excit- 
ing causes  which  may  act  directly  or  indirectly 
upon  the  nervous  system. 

Direct  causes  are  those  that  operate  directly 
upon  the  cerebro-spinal  axis,  more  especially  the 
cerebrum,  viz.,  sunstroke,  head  injuries,  including 
concussion  and  fractures  of  the  skull,  cerebral 
syphilis,  and  brain  tumors. 

Moral  causes  producing  more  or  less  mental  shock 
act  through  the  different  nerves  on  the  great  nerve 
centres,  leaving  behind  them  a  profound  cerebral 
disturbance  that  has  as  its  outward  manifestation 
insanity,  or  inebriety,  or  some  other  form  of  narco- 
mania. Other  causes  act  indirectly  by  peripheral 
irritation  through  the  afferent  nerves  on  the 
central  nervous  system.  Such  are  painful  ulcers, 
dysmenorrhoea,  urethral  stricture,  chronic  neural- 
gias, chronic  painful  diseases  of  any  nature; 
taenia  solium  has  been  known  to  cause  inebriety, 
when  relieved  of  the  cause  the  patient  recovered. 

Any  cachexia  that  debilitates  the  nervous  sys- 
tem, or  that  may  result  in  neurotic  changes,  must 
be  classed  among  the  causes  of  "acquired  inebri- 
ety." Chronic  malarial  poisoning,  syphilis,  etc., 
are  among  these. 

Neurasthenia,  or  nerve  exhaustion  from  under- 
feeding and  over-work,  especially  if  combined 
with  mental  anxiety,  is  a  fertile  source  of  inebri- 
ety or  insanity.  Moral  causes  produce  this  con- 
dition usually  before  plunging  the  patient  into  one 
or  the  other  of  these  conditions.  Certain  employ- 
ments, by  their  unsanitary  surroundings,  may 
produce  the  tendencies  that  lead  to  inebriety. 
The  explanation  for  the  reason  that  any  condition 
producing  unrest,  insomnia,  pain,  mental  worry, 
or  mental  and  physical  exhaustion,  causing  the 
subject  of  these  conditions  to  turn  to  alcohol  for 
relief  from  exhaustion,  insomnia,  or  pain  is  found 
in  the  fact  that  alcohol 'is  a  stimulant,  an  hypnotic, 
an  aneesthetic,  a  triple  capacity;  hence  the  neuras- 
thenic from  any  causes  flies  to  it  for  relief.     The 


i89i.] 


MEDICAL  CASES  IN  THE  COURTS. 


629 


victim   of   dyspepsia    and    mal-assimilation,    for  I  ling,  and  the  arrivals  from  countries  where  the 
faintness,  and  sinking  sensations,  etc.  immigrants  are  of  the  most  undesirable  classes 

The  one  who  cannot  sleep  finds,  especially  if  show  the  largest  totals, 
the  cause  of  insomnia  is  mental  worry,  that  alco-  The  countries  of  Southern  Europe  are  now  out- 
hol  is  to  him  a  true  hypnotic.  As  an  anesthetic,  stripping  Great  Britain  and  Germany  in  the  num- 
alcohol  is  very  pronounced,  and  in  degree  will  re-  ber  of  arrivals.  During  1890,  40.883  persons  ar- 
lievepain  as  much  as  opium,  chloroform,  or  ether,  rived  from  Russia,  29,994  from  Hungary,  62,492 
The  older  surgeons  recognized  this  fact,  and  be-  from  Italy,  and  19,737  fr°m  Poland.  It  would  be 
fore  the  days  of  modern  anaesthesia  alcohol  was   one  of  the  alleviating  circumstances  of  the  dis- 


used for  this  purpose.  The  laity  have  found  out 
\o\\%  since  this  peculiar  quality  of  alcohol,  and 
many  victims  of  pain  have  sought  relief  in  its 
anaesthetic  effects. 


graceful  massacre  at  New  Orleans  if  it  checked 
in  whole  or  in  part  the  present  inundation  of  Ital- 
ian immigrants.  There  is  hardly  any  problem 
connected  with  the  duties  of  Health  Boards  which 


The  great  lesson  that  all  those  who  attempt  to  is  so  serious  and  so  perplexing  as  how  to  deal  with 
cure  the  inebriate  is  that  his  inebriety  has  a  cause,  the  insane  and  sick  foreigners  who  crowd  the 
that  the  inebriety  itself  is  only  a  symptom  of  a  steerages  of  the  ocean  steamships.  It  seems  dif- 
nascent  condition — assomeone  has  said  "neuralgia  ficult  to  devise  a  practicable  scheme  for  inspection 
is  the  cry  of  a  diseased  nerve."  so  inebriety  is  the  in  foreign  ports,  and  it  will  perhaps  only  be  a 
cry  of  a  diseased  nervous  system,  produced   by   heavy  pecuniary  loss  which  will  teach  the  steam- 


causes  acting  directly  or  indirectly  upon  it.  ' '  ToUe 
Causam,"  the  motto  of  every-  practitioner  in  deal- 
ing with  all  forms  of  disease,  should  also  be  the 
motto  of  every  specialist  on  inebriety.  A  care- 
ful analysis  of  the  cases  of  inebriety  presented  to 
us  would  show  that  there  are  many  cases  directly 
traceable  to  causes  or  diseased  conditions  that 
can  be  removed,  and  upon  which  the  inebriety 
depends.  It  is  the  duty  of  every  specialist  on  in- 
ebriety, every  physician  who  would  deal  success- 
fully with  such  cases,  to  trace  out  and  eradicate 
the  cause  of  the  disorder.  We  cannot  remove  the 
cause  in  all  cases;  we  cannot  eradicate  hereditary 
tendencies  or  certain  lesions  of  tissue  resulting 


ship  companies  to  exercise  some  supervision  them- 
selves. It  is  proposed,  among  other  things,  to 
photograph  all  rejected  immigrants,  so  as  to  see 
that  they  do  not  slip  in  at  some  later  time. 

COSMETICS  AND  SPECTACLES  IN  COURT. 

There  have  been  various  attempts  in  New  York 
to  convict  of  illegally  practicing  medicine  a  famous 
dealer  in  cosmetics,  face  washes,  etc. ,  whose  ad- 
vertisements, consisting  mainly  of  his  own  face. 
are  to  be  found  in  journals  all  over  the  country, 
but  his  business  seems  to  go  on  thrivingly.  It 
is  somewhat  difficult  to  distinguish  clearly  where 


from  disease  or  injury;  but.  in  many  instances,  '  the  line  between  business  and  professional  dealings 


we  can  relieve  the  patient  of  a  painful  or  exhaust 
ing  disease  and  thus  cure  his  inebriety  or  other 
form  of  narco- mania. 


MEDICAL  CASES  IN  THE  COURTS. 
BY   HENRY  A.    RILEY,   ESQ.. 

OF  NEV   YORK. 

THE  DANGERS  OF    FOREIGN  IMMIGRATION. 


The  steamship  companies  are  making  a  hard 
fight  to  avoid  the  penalties  imposed  for  violations 
of  the  recent  law  passed  by  Congress  against  un- 
desirable immigration.  The  United  States  offi- 
cials have  refused  to  allow  a  considerable  number  I  in  the  eye  of  the  law? 
of  pauper  and  vicious  immigrants  to  land,  and  the  recentlv  held  to  the  narrow,  technical  theory,  and 


lies  in  such  cases,  but  we  think  it  would  be  a  wise 
stroke  of  policy  if  the  aforesaid  face  washer  were 
to  become  the  bona  fide  holder  of  a  medical  di- 
ploma by  a  conscientious  course  of  study  at  some 
reputable  medical  school. 

In  this  connection  it  may  be  noted  that  the  op- 
tician holds  a  somewhat  doubtful  position  in  re- 
gard to  the  practice  of  medicine.  If  he  furnishes 
a  customer  glasses  to  cure  errors  in  sight,  does  he 
practice  medicine  so  as  to  run  counter  to  the  law 
requiring  the  possession  of  a  license  ?  If  he  in- 
vestigates the  troubles  of  the  eye,  determines  the 
errors  in  refraction  and  prescribes  a  combination 
of  lenses  such  as  will  remedy  the  affection,  has 
he  crossed  the  line  which  makes  him  an  offender 
The  French  courts  have 


agents  of  the  steamship  companies  claim  that  it  is 
a  hardship  to  be  obliged  to  care  for  them  until  they 
can  be  sent  back.  The  conclusive  answer  of  the 
Government  is  that  the  law  is  clear  on  the  sub- 


have  decided  that  it  is  illegal  for  an  optician  to 
give  pathological  information  on  the  state  of  the 
eyesight  and  to  prescribe  for  any  visual  trouble  a 
combination  of  lenses.     The  optician  ma}-  be  a 


ject,  and  the  companies  should  not  have  brought   physiologist,  but  cannot  do  anything  to  remedy 
the  unhealthy,  insane,  vicious  and  pauper  immi-  j  the  troubles  he  discovers.     It  is  not  unlikely  that 


grants  whom  it  is  desired  to  shut  out.  If  they 
are  brought,  any  expense  connected  with  their 
return  must  be  paid  by  the  steamship  companies. 


The  figures  of  immigration  are  somewhat  start- 1  ticians. 


a  broader  principle  of  legal  construction  would  be 
adopted  in  this  country-  if  the  question  arises,  as 
it  may  at  any  time,  concerning  the  status  of  op- 


630 


MEDICAL  PROGRESS. 


[May  2, 


steamboats  and  cemetery  vaults  are  not  i  and  followed  up  by  a  linseed  poultice  every  two 

buildings.  hours,  or  a  hot  fermentation  or  spongiopilin  if  the 

A  New  York  court  holds  that  where  the  Civil  poultice  be  too  heavy.     A  few  drops  of  brandy 

Damage  Law  forbids  the  selling  of  liquor  under  or  other  spirit  sprinkled  on  the  flannel  on  the 

certain   circumstances  in   a   "building  or  prem-  side  which  will  touch  the  skin  often  takes  away 

ises,"  it  does    not  apply  to   a   steamboat  where  pain  successfully.   It  is  well  in  two  or  three  days' 

liquor  is   sold.     The  learned  judge  likened  the  time  to  administer  a  fair-sized  enema  of  soap  and 

steamboat  to  a  vault  in  a  cemetery,  which  he  said  water,  and  unless  the  bowels  are  moved  of  them- 

was  not  a  "building  "  in  the  sense  meant  by  the  selves,  this  had  better  be  repeated  daily.      With 

statute    against  burglarv,  although   it   might  be  ordinary  care   it  is  quite  harmless;    it  removes 


above  ground. 

PIGEON    SHOOTING    IS     NOT    CRUEL    IN 
PENNSYLVANIA. 

A  Pennsylvania  statute  provides  that  any  per- 
son who  shall  wantonly  or  cruelly  ill-treat,  over- 
load, beat  or  otherwise  abuse  any  animal  shall  be 


whatever  may  be  in  the  sigmoid  flexure,  and  it 
stimulates  the  colon  to  get  rid  of  its  contents, 
thus  probably  helping  to  empty  the  caecum  and 
withdrawing  the  cause  of  the  inflammation.  If 
the  vomiting  is  troublesome,  an  effervescing  mix- 
ture with  hydrocyanic  acid  or  small  doses  of 
lime-water,    will   be   useful.     For   diet,    a    little 


deemed  guilty  of  a  misdemeanor,  but  the  Supreme  brothj  or  beef.teSi  or  arrow.r0ot,  or  Benger'sfood, 
Court  has  just  held  that  this  does  not  apply  to  a  -n  every  tw0  hours  in  two  or  three  ounce  doses 
member  of  a  gun  club  who,  at  a  pigeon  shooting  wil]  sljffice  Mi]k  j  regard  as  not  very  good  food 
match,  shoots  at  and  wounds  a  pigeon  set  loose  in  these  cases;  unless  u  be  fredy  diluted  with 
from  a  trap,  if  it  is  immediately  killed  when  its  soda.water  0r  lime-water,  it  is  too  apt  to  become  a 


wounded  condition  is  made  known.     The  Court 
said: 

From  tbe  facts  found  by  the  jury,  the  defendant  has 
merely  been  punished  for  want  of  skill.  It  is  doubtless 
true  that  much  pain  and  suffering  is  often  caused  to  dif- 
ferent kinds  of  game  by  the  unskilfulness  of  sportsmen 


mass  of  hard  curds  in  the  stomach,  which  may 
prove  very  irritating  to  the  inflamed  bowel.  With 
the  cessation  of  pain,  the  lessening  of  the  lump 
in  the  groin,  and  the  general  improvement 
in  the  patient,  of  course  an  improved  diet  and 
A  squirrel  badly  wounded,  may  yet  crawl  to  its  hole  and  1  some  changes  in  the  medicine  become  needful, 
suffer  for  many  hours  or  days  and  die.    So  with  birds.  |  Bismuth,  I  have  generally  found   to  be  service- 

Thev  are   often  badly  wounded   and  vet  manage  to  get      ,  ,     .       J      ,  °        _   .    _         .     _i__ ,„„„ 

away  only  to  suffer.  '  It  was  not  pretended  that  the  Act  able  in  the  later  stage  going  on  to  convalescence, 
applied  to  such  cases.  The  sportsman  in  the  woods  is  With  the  surgical  varieties  into  which  typhlitis 
not  responsible  for  the  accuracy  of  his  aim  under  the  may  stray,  I  will  not  deal  here,  as  I  have  no  per- 
Act  of  1869.  At  the  same  time  it  is  manifest  that  much  I  SQnal  experience  of  them,  nor  will  I  touch  on 
suffering  would  be  spared  wild  game  if  sportsmen  were 
better  trained.  Skill  in  shooting  upon  the  wing  can  only 
be  gained  by  practice.  It  is  not  so  with  inanimate  ob- 
jects. There  accuracy  of  aim  can  be  acquired  by  shoot- 
ing at  a  mark.  It  is  conceded  that  the  sportsman  in  the 
woods  may  test  his  skill  by  shooting  at  wild  birds.  Win- 
then  may  he  not  do  the  same  with  a  bird  confined  in 


that  debated  question,  removal  of  the  appendix. 
— Archives  of  Pediatrics. 

The   Effect  of   Certain   Drugs  on  the 
Renal  Circulation. — Dr.  Albanese  has  pub- 


the  woods?     Both  were  placed  here  by  the  Almighty  for 
the  use  of  man 


In  accordance  with  this  reasoning 
in  the  trial  court  was  set  aside. 


a  conviction 


cage  and  let  out  for  that  purpose?   Is  the  bird  in  the  cage  |  lished  in  an   Italian  journal   some   important  re- 
any  better  or  has  it  any  higher  rights  than  the   bird  in    searches    Oil    the    effects    of   Caffeine,  chloral,  and 

curare  on  the  circulation  in  the  kidney,  by  which 
he  has  been  led  to  the  conclusion  that  the  amount 
of  urine  secreted  is  not  directly  proportional  to 
the  quantity  of  blood  passing  through  the  organ. 
When  chloral  alone  was  given  there  was  a  very 
marked  increase  in  the  volume  of  the  kidney, 
though,  as  is  well  known,  this  drug  has  an  ex- 
ceedingly slight  diuretic  actioii ;  while  curare, 
which  has  a  marked  diuretic  action,  was  shown 
to  cause  no  perceptible  increase  in  the  volume. 
the   When    caffeine    was  introduced  into   an    animal 


MEDICAL    PROGRESS. 


Therapeutics  ami  Pharmacology. 

The    Treatment    of    Typhlitis. —  In 

earliest  stage,  absolute  rest  in  bed,  entirely  liquid  already  under  the  influence  of  either  chloral  or 

food,  and  a  sedative  mixture  are   necessities.     I  curare,  it  immediately  caused  a  decided  increase 

have  generally  used  the  liquor  opii  sedativus  (B.  in  the  size  of  the  kidney,  and  at  the  same  time 

P   1,  and  occasionally  joined  with  it  some  tincture  induced  marked  diuresis.      Nevertheless,  the  in- 

of  belladonna;  nepenthe  has  also  proved  very  val-  crease   in    size   produced  under  these  conditions 

liable  on  two  or  three  occasions.      If  the  pain  be  was  not  enough  to  account  for  the  large  quantity 

wry  severe,  a  hypodermic  injection  of  morphine  of  urine  secreted.     Dr.  Albanese  does  not  agree 

will  relieve  it  for  a  time,  and  I  have  found  it  dis-  with  Schroeder  that  caffeine  contracts  the  renal 

appear  "for  good"  after  one   injection.     A  mus-  vessels,  but  finds  that  its  action  is  first  to  increase 

tard-leaf  may  be  applied  to  the  seat  of  the  pain,  slightly    the   volume  of  the  organ  and  then   to 


l89i.] 


MEDICAL  PROGRESS. 


631 


cause  a  slight  dilatation  of  the  vessels.  As  there 
appears  to  be  no  indication  that  the  diuretic 
action  of  drugs  is  due  to  increase  in  circulation  or 
in  volume,  he  is  inclined  to  refer  it  to  some 
change  effected  in  the  renal  epithelium. 

The  Treatment  oe  Irritable  Bladder. — 
The  best  internal  medication  is  iodide  of  potas- 
sium in  from  ten  to  thirty  grain  doses  every  few- 
hours  with  large  quantities  of  hot,  soft  water. 
This  often  in  the  incipient  stage  will  effect  a  cure 
in  a  few  days  and  will  give  relief  in  a  few  min- 
utes. The  decoction  of  the  triticum  repens  which 
has  been  so  highly  praised  by  some,  I  have  been 
much  disappointed  in,  as  it  has  appeared  to  me 
todo  nothing  more  than  act  as  a  diuretic.  Tincture 
of  belladonna  in  some  cases  is  of  benefit  but  can- 
not be  relied  upon.  Keep  the  body  warm;  warm 
baths  with  shampooing  is  of  great  benefit.  Some 
cases  that  in  the  early  stages  were  particularly  in- 
tractable have  been  cured  by  a  few  weeks'  resi- 
dence at  Excelsior  Springs,  with  a  liberal  use  of 
those  iron-manganese  waters.  Probably  they 
change  the  nutritive  processes  that  are  always  at 
fault,  and  at  the  same  time  wash  out  the  bladder 
thoroughly  by  their  diuretic  action.  Relapses 
are  liable  to  occur,  hence  great  care  should  be 
used  both  as  to  diet  and  hygiene,  and  the  first 
symptoms  of  relapse  promptly  treated. — Halley, 
Kansas  City  Medical  Record. 

Pomade  for  Alopecia. — Monin  (Z.'  Union 
Medicate,  March  3,  1891),  recommends  a  pomade 
composed  of  gallic  acid  3  grams,  castor  oil  20 
grams,  white  vaseline  40  grams,  spirits  of  lavender 
15  drops.  To  be  thoroughly  rubbed  into  the 
scalp  night  and  morning. 

Chorea. — The  physician  is  often  at  his  wits' 
end  to  find  some  efficient  remedy  for  chorea. 
Tilden  claimed  to  have  obtained  great  benefit  by 
throwing  a  spray  of  ether  for  five  or  ten  minutes 
along  the  spine,  at  the  same  time  keeping  up 
nerve  nutrition  by  appropriate  food  and  exercise. 
Clark,  surgeon- in-chief  of  the  police  department 
in  Newark,  N.  J.,  reported  some  time  since  in  the 
Times  an  exceedingly  aggravated  case  of  chorea 
treated  with  entire  success  by  antipyrin.  Acting 
upon  the  hint,  we  have  recently  controlled  in 
children  from  5  to  10  years  of  age  serious  forms 
of  chorea  with  5-gr.  doses  of  antipyrin,  at  first 
every  four  hours,  and,  as  the  condition  improved, 
three  times  a  day.  Very  likely  there  are  condi- 
tions of  the  system  which  would  prevent  the  cu- 
rative action  of  the  drug,  but  in  these  cases  it  was 
certainly  very  effective,  acting  as  a  positive  cura- 
tive agent.  That  this  drug  is  something  more 
.  than  an  antipyretic  and  antispasmodic  is  seen  in 
its  action  in  renal  spasm,  the  result  of  calculi,  in 
which  it  not  only  controls  the  spasms  but,  con- 
tinued in  5-gr.  doses  for  several  days,  causes  the 


uric   acid   and  the   sand  to   disappear  from   the 
urine. — N.   Y.  A  fed.  Times. 


Ehrlich's  Test  in  Typhoid  Fever. — C.  E. 
Simon  {Johns  Hopkins  JIosp.  Bull.,  1890,  93)  re- 
fers to  the  nature  of  the  diazo  compounds,  and 
their  tendency  to  enter  into  combination  with 
aromatic  bodies,  and  cites  the  first  experiments 
of  Ehrlich  while  endeavoring  to  discover  some  of 
these  aromatic  bodies  in  the  urine.  Owing  to  the 
controversy  which  arose  regarding  the  diazo  reac- 
tion, especially  as  to  its  diagnostic  import  in  ty- 
phoid fever,  the  test  has  come  to  be  regarded  by 
many  as  a  medical  curiosity  of  110  clinical  value- 
whatever.  The  author,  however,  is  convinced  by 
his  experience  that  the  original  work  done  by 
Ehrlich  is  not  appreciated,  since  his  own  results 
fully  coincide  with  those  which  Ehrlich  obtained. 
After  explaining  the  chemical  nature  of  the  reac- 
tion as  far  as  it  is  understood,  and  the  methods 
which  Ehrlich  advocated,  he  details  the  modifica- 
tion which  he  has  found  most  convenient  as  well 
as  most  delicate.  Two  solutions  are  made,  one  of 
50  cc.  of  hydrochloric  acid  in  9,950  cc.  of  water, 
and  this  saturated  with  sulphauilic  acid;  the  other 
of  a  '  _-  per  cent,  solution  of  sodium  nitrite.  To 
make  the  test,  40  cc.  of  the  first  solution  is  thor- 
oughly agitated  with  1  cc.  of  the  second.  A  few 
cc.  of  this  is  next  thoroughly  shaken  in  a  test- 
tube  with  an  equal  quantity  of  urine.  One  cc.  of 
ammonia  is  now  allowed  to  run  down  the  side  of 
the  test-tube,  forming  a  colorless  zone  above  the 
mixture,  and  at  the  juncture  of  the  two  a  more  or 
less  deeply  colored  ring  will  be  seen,  the  slightest 
carmine  tint — the  characteristic  of  the  diazo  reac- 
tion— being  made  out  by  contrast  with  the  color- 
less layer  above  and  the  yellow  urine  below.  Vari- 
ous plays  of  color  may  appear  in  different  urines, 
but  in  that  of  typhoid  fever  there  is  produced  a 
red  coloration,  which  may  van-  from  an  eosin  to 
a  deep  garnet.  Simon  has  examined  the  urine  of 
almost  every  disease  which  has  occurred  in  the 
wards  of  Johns  Hopkins  Hospital,  but  has  ob- 
served the  reaction  only  in  cases  of  typhoid  fever 
and  phthisis  pulmonalis.  He  has  had  no  oppor- 
tunity of  searching  for  it  in  cases  of  contagious 
fevers,  in  which  Ehrlich  has  occasionally  found 
it  present. 

The  report  now  made  is  based  upon  observa- 
tions in  thirty-six  cases  of  typhoid  fever,  and  the 
details  of  the  examinations  of  these  are  given. 
The  results  which  he  obtained  lead  him  to  con- 
clude that,  with  the  methods  of  examination  given 
by  Ehrlich,  the  reaction  may  be  obtained  without 
difficulty  in  typhoid  fever  from  the  fifth  to  the 
thirteenth  day  of  the  disease,  and  that  with  his 
1  own  modification  it  may  still  be  seen  as  late  as 
j  the  twenty-second  day.  Its  absence  from  the  fifth 
to  the  ninth  day  indicates  a  very  mild  case,  ex- 
!  cepting  in  children,  although  this   rule  is  prob- 


632 


MEDICAL  PROGRESS. 


[May  2, 


ably  not  an  absolute  one.  As  it  occurs  previously 
to  the  appearance  of  the  rash,  it  is  a  very  useful 
aid  in  the  diagnosis  in  typhoid  fever. — American 
Journal  Med.  Sciences. 

Catarrh  treated  by  Peroxide  of  Hydro- 
gen AND  Aristol. — The  Pharmaceutical  Era, 
March,  has  a  note  by  the  editor  to  the  effect  that 
aristol,  dissolved  in  the  lighter  petrolatum  prod- 
ucts, has  helped  him  in  a  considerable  number  of 
difficult  cases  of  naso  pharyngeal  catarrh.  The 
proportion  of  the  aristol  used  has  not  exceeded 
10  grs.  to  the  ounce.  He  begins  the  treatment 
by  using  hydrogen  peroxide,  in  a  weak  solution, 
by  means  of  an  atomizer.  This  as  a  preliminary 
cleansing  measure  is  beneficial.  It  is  to  be  fol- 
lowed with  the  aristol  solution  as  a  spray,  by 
which  the  affected  parts  are  protected  as  by  an 
antiseptic  oily  covering.  Aristol  is  harmless  in 
the  strength  above  indicated,  and  it  may  safely 
be  prescribed  to  the  patient  for  home  use.  The 
results  of  this  treatment  have  been  the  re-estab- 
lishment of  a  healthy  mucous  membrane  and  a 
reduction  of  the  catarrhal  flow.  The  cleansing 
power  of  the  peroxide  is  admitted  on  every  hand, 
and  favors  the  more  thorough  action  of  drugs 
than  if  they  are  immediately  applied. 


Indications  for  Trephining  the  Mastoid 
Process. — Dr.  Schwarze  {Deutsche  militararztl. 
Zeitschrijt,  Heft  vii,  1890)  gives  the  following  in- 
dications for  opening  up  the  cells  of  the  mastoid 
process:  1.  In  recent  inflammation  of  this  pro- 
cess with  retention  of  pus  in  its  cells,  when  the 
local  application  of  ice  and  superficial  incision 
have  failed  to  reduce  the  swelling,  pain  and  fever. 
2.  In  cases  of  secondary  inflammation  of  the  mas- 
toid process,  the  external  meatus  should  in  the 
first  place  be  emptied  of  any  retained  pus  If  in 
adult  patients  this  treatment,  together  with  the 
application  of  ice,  fail  after  a  week's  trial,  re- 
course should  be  taken  to  operative  treatment.  3. 
The  mastoid  process  should  be  trephined  in  cases 
of  chronic  suppuration  with  repeated  swelling, 
superficial  abscess,  or  fistula,  and  spreading  of 
the  pus  to  the  neck,  external  meatus,  or  pharynx, 
even  when  there  are  no  apparent  symptoms  in- 
dicative of  immediate  danger.  4.  The  mastoid 
process,  even  when  healthy  at  its  surface,  should 
be  opened  up  in  cases  of  retained  pus  and  choles- 
teatoma, on  the  first  appearance  of  symptoms 
pointing  to  dangerous  complications  in  the  mid- 
dle ear.  5.  The  operation  should  be  performed 
for  the  prevention  of  fatal  consequences  in  cases 
of  incurable  foul  suppuration  in  the  middle  ear, 
although  no  other  symptom  may  present  itself 
save  a  persistent  ill  odor. — Brit.  Med.  Journal. 

Bacteriology^ 

The  Alkaloid  Obtained  from  the  Tuber- 


cle Bacillus. — Great  interest  is  naturally  attach- 
ed to  the  various  experiments  which  have  been 
made  in  regard  to  the  pathological  chemistry  of  the 
tubercle  bacillus.  Although  we  are  now  in  pos- 
session of  a  pretty  full  knowledge  of  the  mode  of 
action  of  the  products  of  the  tubercle  bacilli  as 
exhibited  by  the  recent  experiments  made  in  all 
parts  of  the  world  with  tuberculin,  we  as  yet 
know  comparatively  little  of  the  chemistry  of  this 
substance.  An  alkaloid  was  obtained  from  the 
products  of  the  anthrax  bacilli  by  Dr.  Sidney 
Martin,  and  Professor  Zuelzer  has  succeeded 
in  obtaining  a  similar  bod}'  from  the  bacillus  of 
tuberculosis.  A  short  account  of  Zuelzer's  mode 
of  isolating  the  alkaloid  is  given  in  the  Wiener 
Medicinishe  Wbchensckrift,  No.  10,  1891.  The 
entire  contents  of  the  tubes  in  which  the  pure  cul- 
tures were  made  were  repeatedly  treated  with  hot 
water  acidulated  with  hydrochloric  acid.  The 
solution  was  filtered,  evaporated,  and  then  sever- 
al times  precipitated  with  platinum  chloride;  the 
double  salt  decomposed  by  sulphuretted  hydrogen, 
and  the  liquid  again  filtered  and  evaporated  to 
dryness.  In  this  way  an  almost  white  crystalline 
salt  was  obtained,  which  was  easily  soluble  in 
hot  water,  but  with  great  difficulty  in  cold.  Its 
solution  was  light  yellow  in  color.  Ater  keep- 
ing it  for  some  time  the  dry  salt  assumed 
a  light  brown  color.  The  chloride  when 
injected  into  rabbits  and  guinea  pigs  exhib- 
ited a  characteristic  toxic  action;  about  one 
centigram  injected  subcutaneously  produced  af- 
ter from  three  to  five  minutes  an  increase  in  the 
frequency  of  respiration,  the  movements  reaching 
180  per  minute.  This  continued  for  about  a 
quarter  of  an  hour,  when  the  rate  gradually  be- 
came slower.  The  temperature  rose  in  two  out 
of  the  ten  observations  from  normal  to  102. 2°  F. 
Another  constant  symptom  was  well-marked 
protrusion  of  the  eyes,  which  also  appeared 
bright  and  shining,  with  somewhat  dilated  pu- 
pils. The  sclerotic  was  considerably  injected.  It 
was  remarkable  that  the  protrusion  of  the  eye  was 
more  marked  on  the  side  on  which  the  injection 
had  been  made  than  on  the  other.  All  these  ap- 
pearances disappeared  in  from  fifteen  to  twenty 
minutes.  Toxic  symptoms  only  showed  them- 
selves in  three  rabbits,  and  these  had  received 
somewhat  larger  doses,  between  two  and  three 
centigrams  having  been  administered.  Death 
usually  occurred  somewhere  between  the  second 
and  fourth  days.  At  the  site  of  injections  there 
was  considerable  redness,  and  small  hemorrhages 
were  found  in  the  muscles  immediately  beneath. 
Small  effusions  of  blood  were  also  found  in  the 
mucous  membrane  of  the  stomach  and  small  in- 
testine. In  two  cases  effusion  occurred  into  the 
abdominal  cavity.  The  brain  was,  as  a  rule,  soft 
and  congested.  Almost  precisely  similar  results 
followed  the  injection  of  the  alkaloid  into  the 
conjunctiva. — The  Lancet. 


i89l.] 


EDITORIAL. 


633 


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SATURDAY,   MAY   2,    1891. 


MEDICAL  LITERATURE  AND  PHILOSOPHY. 

If  there  is  one  need  in  American  medicine 
above  another,  it  is  literature — words  that  live. 
All  our  physicians  are  comparatively  rich  and 
they  occupy  a  position  in  the  society  of  the  com- 
munities in  which  they  live,  which  is  far  above 
that  occupied  by  the  same  class  of  men  in  Euro- 
pean countries.  We_  have  not  only  a  larger 
number  of  readers,  but  a  larger  number  of  men 
who  may  become  writers.  We  are  astonished, 
then,  that  so  few  examples  of  the  philosopher  are 
produced  by  our  guild. 

Certainly  there  is  nothing  inherent  in  medicine 
which  tends  to  dwarf  this  manifestation  of  the 
human  mind.  The  medical  man  has  an  oppor- 
tunity to  gain  a  deep  insight  into  the  soul,  and 
to  follow  the  trend  of  life  in  rare  and  hidden  de- 
clivities and  acclivities.  His  intelligent  sym- 
pathy is  called  into  constant  and  varied  activity. 
He  knows  the  pinch  of  poverty  and  the  load  of 
luxury.  But  the  inexorable  laws  of  nature  are 
not  less  familiar  to  him,  and  he  is  trained  to 
follow  effect  back  to  adequate  cause.  To  him 
vice  and  crime  are  expressions  of  conduct  which 
are  analogous  to  the  errors  or  ignorance  for  the 
effects  of  which  his  services  are  required.  His 
experience  is  wide  and  his  touch  with  man  acute. 
Certainly  such  a  training  might  well  be  coveted 
by  a  philosopher. 

The  occupation  of  the  physician  gives,  then, 
the  pabulum  for  thought.  Does  it  furnish  the 
motive  ?  Of  all  pursuits,  medicine  is  the  most 
humane  and  benevolent.  In  the  true  physician's 
life  there  is  a  constant  character-building.     More 


than  any  other  man  he  knows  and  feels  the 
moral,  mental  and  physical  needs  of  his  people, 
and  he  plans  for  their  practical  betterment.  The 
betterment  of  his  people  is  the  betterment  of  all, 
philanthropy — the  motive  of  philosophy. 

But  does  the  busy  life  of  the  doctor  furnish  op- 
portunity for  thought?  That  is  as  you  choose. 
There  are  those  who,  for  gain  or  ambition,  fill  their 
lives  with  petty  cares  and  nothingnesses,  who 
think  of  naught  but  the  engagements  of  the  mo- 
ment from  the  time  they  are  rung  out  of  their  beds 
in  the  morning,  until,  after  dragging  themselves 
home  at  midnight,  they  throw  themselves  un- 
dressed on  anything  that  will  serve  as  a  couch, 
stupid,  tired.  There  are  those  who  fill  their  work- 
ing hours  with  work  to  gain  means  to  vie,  in  dress. 
in  equipage  and  in  display,  with  brokers,  mer- 
chants and  manufacturers.  There  are  those  who 
make  their  office  and  their  profession  an  excuse 
for  doing  nothing  else,  and  they  follow  their  oc- 
cupation in  a  perfunctory  manner,  as  men  in  their 
dotage  aimlessly  sit  at  the  desk  where  they  once 
transacted  business.  For  these  there  is  no  oppor- 
tunity, as  there  is  motive  for  thought.  But  the 
great  majority  of  physicians,  both  in  country 
and  city,  have  leisure,  and  they  should  dedicate 
that  leisure  to  philosophy.  The  amount  of  leis- 
ure may  be  increased  by  directing  some  calls  and 
some  cares  to  j-ounger  men. 

If  our  profession  furnishes  character  as  well  as 
motive  and  opportunity  for  thought,  why  are 
there  so  few  thinkers  in  our  ranks?  It  is  because 
method  is  neglected.  Logic  and  rhetoric  are  dis- 
placed by  novelty  or  blazonry.  It  is  because  there 
is  a  sentiment,  borrowed  from  the  commercial 
world,  that  facts  are  more  than  thoughts.  Hence 
our  magazines  and  journals  are  full  of  experi- 
ments and  clinical  histories,  the  former  often  un- 
dertaken without  logical  limitation,  and  the  latter 
recorded  without  rational  deductions;  both  are  un- 
garnished  by  rhetoric  and  unseasoned  with  wit. 

In  our  medical  schools  no  attention  is  given  to 
the  motive  and  method  of  medical  philosophy. 
Our  colleges  are  loosely  connected  with  the  uni- 
versity, where  philosophy  itself  is  taught,  and 
the  lyceum,  even  in  this  country,  forms  no  part 
of  medical  education.  However  completely  the 
j  class  room  instruction  is  given  or  the  technique 
of  the  laboratory  acquired,  that  is  a  poor  equip- 
ment which  the  student  carries  away,  that  does 
not  provide  for  subsequent  medical  culture. 


634 


THE  DANGERS  OF  TUBERCULIN. 


[May  2, 


The  multiplicity  of  medical  journals  must  not 
be  looked  upon  as  an  unmitigated  curse  if  their 
unvaried  mediocrity  enforces  attention  to  the  lack 
of  medical  philosophy.  In  the  writer's  opinion, 
there  is  not  a  medical  author  in  the  United  States 
who  has  produced  anything  in  the  past  five  years 
which  will  last  a  lifetime.  We  have  careful  ex- 
perimenters, brilliant  operators,  astute  observers, 
accurate  diagnosticians  and  successful  therapeu- 
tists, but  where  are  our  teachers?  The  material 
of  our  clinics  is  only  partially  utilized.  Our 
laboratories,  surpassing  in  equipment  those  of 
Europe,  are  not  heard  from,  and  our  monographs 
and  compilations  are  dull,  crude  tokens  of  the 
literal  taste  and  criticism  of  our  profession. 

The  remedy  is  not  far  to  seek.  The  student 
should  be  admitted  to  the  study  of  medicine  only 
after  adequate  preliminary  training.  The  study 
of  medical  literature  and  philosophy  should  be 
made  a  part  of  every  graduating  course,  and 
should  occupy  a  large  place  in  post-graduate 
education.  Special  attention  should  be  given 
authors  who  write  worthy  papers,  and  a  few 
words  of  encouragement  and  thanks  should  be 
sent  by  every  reader  to  the  author  of  a  paper 
which  has  afforded  him  pleasure  and  instruction. 
Those  journals  only  should  be  patronized  that 
maintain  in  their  columns  a  respectable  standard 
of  literary  excellence.  In  our  State  and  National 
gatherings  those  papers  should  be  presented  that, 
other  things  equal,  are  clothed  in  the  most  be- 
coming garb. 


THE  DANGERS  OF  TUBERCULIN. 
These  have  been  overstated  by  some  with  the 
same  precipitous  spirit  which  others  have  dis- 
played in  their  anticipation  of  its  power  for  good. 
In  the  many  control  observations  tuberculin  has 
not  been  found  to  injure  any  non-tubercular  per- 
son beyond  the  inconvenience  of  the  febrile  reac- 
tion. In  tubercular  subjects,  however,  the  reac- 
tion may  be  alarming  in  severity  and  lead  to  de- 
lirium, coma,  angina  pectoris  (Jacobi)  collapse 
and  even  death.  At  least  one  death  (Janisch  of 
Innsbruck)  has  thus  been  caused  by  acute  tuber- 
culin-poisoning. This  danger  is  more  or  less  in 
proportion  to  the  intensity  of  the  reaction  and  it 
is  now  universally  conceded,  that  by  sufficient 
caution  in  beginning  with  minute  quantities  and 
increasing  only  slowly  in  dose,  such  acute  dan- 
gers can  be  avoided  with  certainty.     But  apart 


from  the  possibility  of  acute  poisoning,  other  ac- 
cidents have  been  observed.  The  local  reaction 
consists  in  intense  congestion  around  the  tubercu- 
lar focus,  effusion  of  serum  and  more  or  less  mi- 
gration of  leucocytes,  in  short  a  disturbance  verg- 
ing towards  or  even  identical  with  severe  inflam- 
matory swelling.  Under  certain  conditions  such 
a  reaction  may  prove  dangerous,  if  too  intense. 
The  fear  that  too  much  reaction  in  the  larynx 
may  necessitate  tracheotomy  in  laryngeal  tuber- 
culosis has  not  been  realized,  since  observers  have 
learned  to  avoid  the  rash  use  of  large  doses. 
Virchow  has  stated  that  at  the  autopsy  of  a 
child  dead  of  tubercular  meningitis  he  saw  the 
most  intense  congestion  of  the  meninges  in  con- 
sequence of  the  tuberculin  treatment,  that  he  had 
ever  observed.  Yet  the  few  cases  of  tubercular 
meningitis  in  which  the  treatment  was  tried  did 
not  seem  to  suffer  clinically  and  although  none 
were  saved  they  did  not  seem  to  run  a  more  acute 
course  than  ordinarily.  In  the  lungs,  however, 
damage  has  evidently  been  done  by  tuberculin  a 
number  of  times.  Virchow,  his  assistant  Hanse- 
mann,  and  various  others  (Nauwerk)  report 
the  frequency  of  catarrhal  pneumonia  and  of 
caseous  pneumonia  with  rapid  disintegration  of 
lung  tissue  and  even  exceptionally  phlegmonous 
infiltration  of  the  lungs  in  subjects  dying  while 
under  treatment  with  tuberculin.  In  fact,  clinic- 
ally an  increased  area  of  dulness  and  of  crepita- 
tion can  certainly  be  recognized  in  some  phthis- 
ical patients  undergoing  treatment.  Such  occur- 
rences evidently  mean  danger,  especially  to  pa- 
tients weakened  by  their  previous  disease.  No 
doubt  some  deaths  have  been  hastened  by  the 
use  of  the  remedy,  and  in  other  instances,  like 
that  of  Grasset,  life  has  even  been  destroyed, 
where  without  tuberculin  it  might  have  been 
maintained  for  a  long  period.  But  these  unfor- 
tunate accidents  are  getting  to  be  less  numerous 
in  the  more  recent  reports,  as  observers  gradually 
learn  to  use  the  substance  with  more  discretion  in 
the  selection  of  the  patients,  and  greater  caution 
in  the  administration.  Various  specimens  have 
also  been  exhibited  in  Berlin,  especially  by  Vir- 
chow, which  show  that  intestinal  tubercular  ul- 
cers may  perforate  into  the  peritoneal  cavity,  of 
course  with  fatal  result. 

Perhaps  the  gravest  question  raised  by  VIR- 
CHOW and  since  discussed  by  many  reporters,  is 
the  query:  Can  tuberculin  cause  a  dissemination 


I89I-] 


THE  DANGERS  OF  TUBERCULIN. 


635 


of  the  pre-existing  bacilli  throughout  the  body 
and  thus  lead  to  fresh  tubercular  disease,  or  even 
miliary  tuberculosis  ?  Numerous  clinical  obser- 
vations and  autopsies  have  shown  that  miliary 
tuberculosis  can  occur  in  patients  while  undergo- 
ing the  specific  treatment.  Of  course  attention  is 
at  present  called  to  every  such  case,  but  testi- 
mony is  yet  wanting  to  prove  that  miliary  tuber- 
culosis is  a  more  frequent  complication  in  patients 
submitted  to  treatment  with  tuberculin  than  it 
used  to  be  formerly.  Hence  it  cannot  be  stated 
with  certainty  that  a  dissemination  of  the  bacilli 
is  produced  by  tuberculin.  But  on  the  other 
hand  the  possibility  of  such  an  occurrence  can  al- 
so not  be  denied.  It  sounds  like  a  warning  to 
hear  HANSHMANN  declare  that  within  a  few 
months  he  had  dissected  three  subjects  with  erup- 
tion of  miliary  tubercles  on  the  epicardial  surface, 
when  the  records  of  the  Berlin  Pathological  In- 
stitute showed  this  localization  to  have  been  seen 
only  six  times  in  the  last  ten  years. 

Liebmann  claims  to  have  found  free  tubercle 
bacilli  in  the  blood  of  patients  during  the  period 
of  reaction  to  tuberculin  in  nine  cases.  Some  of 
his  specimens  examined  in  Berlin  by  Kossel 
showed  that  this  was  due  to  a  deception.  The 
cover-glasses  showed  that  they  had  been  used  for 
the  examination  of  sputum  and  had  been  insuffi- 
ciently cleansed.  Various  other  experts  confirmed 
this  opinion.  Liebmanx  indeed  admitted  its 
possibility,  but  claimed  that  in  other  instances  he 
had  also  found  the  bacilli  in  the  blood  when  no 
such  error  could  have  occurred.  Ewald  corrob- 
orated this  so  far  as  he  could  tell  from  the  slides 
submitted  to  him.  On  the  other  hand,  however. 
Ewald  himself,  Ehrlich,  Guttmann,  Kossel, 
Prior  and  others  have  examined  the  blood  of 
numerous  patients  during  the  reaction  with  entire- 
ly negative  results. 

It  has  also  been  stated  by  Wissoki,  of  Kasan, 
that  the  lymph  itself  contains  occasionally  tuber- 
cle bacilli.  In  answer  to  this  allegation  Libbertz, 
the  manufacturer  of  tuberculin,  has  replied  that 
while  a  few  bacilli  ma}-  occasionally  be  found  in 
the  lymph,  they  are  absolutely  harmless  because 
they  are  dead,  since  the  mode  of  production 
guarantees  the  destruction  of  all  living  germs 
with  infallible  certainty,  and  the  amount  of  gly- 
cerine in  the  lymph  prevents  the  growth  of  any 
germs  which  might  accidentally  get  into  the 
flasks  from  the  air. 


Can  the  dangers  be  avoided  by  any  precautions 
in  the  administration  of  tuberculin  .'  The  agent 
in  question  cannot  be  compared  in  its  therapeutic 
effect  with  any  other  known  remedy,  and  the 
rules  guiding  its  administration  have  to  be  learned 
by  empirical  experience.  It  is  not  a  substance 
which,  if  inefficacious,  is  at  least  harmless.  An 
agent  exercising  such  remarkable  specific  influ- 
ence on  the  tubercular  process,  even  in  infinites- 
imal quantities,  yet  without  directly  killing  the 
bacilli,  is  capable  of  doing  harm  in  unsuitable 
1  cases.  Its  indications  and  technique  require  pre- 
cision like  those  of  any  responsible  operation. 

It  has  been  learned  that  tuberculin  has  hitherto 
been  at  least  useless,  if  not  harmful,  in  very  ex- 
tensive infiltration  of  the  lungs,  in  pulmonary 
cavities  (except  when  combined  with  surgical 
measures),  and  particularly  in  acute  and  progres- 
sive tuberculosis  of  the  lungs  (or  any  other  in- 
ternal organs)  with  continuous  fever.  Great  re- 
duction of  strength  is  likewise  an  unfavorable 
condition  for  its  action,  since  the  tuberculin  re- 
action, if  at  all  marked,  runs  down  the  patient 
still  further.  Advanced  cases  of  phthisis  have  not 
given  sufficiently  encouraging  results  to  warrant 
its  use  as  now  employed,  in  view  of  the  possible 
dangers. 

All  observers  agree  that  intense  reaction  is  not 
of  sufficiently  greater  advantage  to  the  patient 
than  a  milder  influence  of  tuberculin  to  warrant 
the  large  doses  with  which  many  of  the  earlier 
observations  were  begun.  Many  authors  state 
that  they  have  found  it  best  to  reduce  the  quan- 
tity of  the  initial  dose  and  the  ratio  of  increase, 
as  their  experience  became  wider.  The  most  ex- 
treme advice  as  to  the  dosage  has  just  been 
given  by  Guttmann  and  Ehrlich,  who  have 
charge  of  the  Berlin  wards  under  Koch's  per- 
sonal supervision.  In  pulmonary  or  laryngeal 
disease  they  begin  with  one-tenth  milligram  in- 
creasing daily  by  one-tenth  milligram  more  until 
the  dose  of  one  milligram  is  reached.  Every  sec- 
ond day  an  injection  is  now  given  two- tenths  milli- 
grams larger  than  the  preceding  one.  After  two  to 
three  milligrams  have  been  tolerated  the  dose  is 
augmented  one-half  milligram  each  time.  Later 
on  the  quantity  is  more  rapidly  increased.  Some 
patients  showed  thus  favorable  local  reaction 
without  any  rise  of  temperature,  except  perhaps 
a  few  tenths  of  one  degree,  and  without  anv  dis- 
comfort.  If  any  dose  (sometimes  less  than  1  mg.) 


636 


THE  QUESTION  OF  REMOVAL. 


[May  2, 


causes  a  normal  transient  febrile  reaction,  the 
same  dose  is  repeated  every  second  day  until  it 
has  lost  its  pyrogenic  influence,  whereupon  an  in- 
creased quantity  is  used.  If  a  continued  febrile 
state  is  produced,  no  injection  is  given  until  the 
temperature  has  become  normal,  whereupon  a 
smaller  quantity,  one  or  even  the  initial  one  tenth 
milligram  may  be  made  use  of.  Any  continuous 
fever  the  observers  regard  as  a  contraindication 
to  tubercuHn.  The  therapeutic  results  obtained 
have  not  yet  been  published  by  Guttmann  and 
Ehrlich.  Until  this  is  done  by  these  authors  or 
others  following  the  same  plan,  the  question 
whether  tuberculin  can  cure  tubercular  disease 
without  febrile  reaction,  cannot  be  answered 
definitely.  Various  accidental  observations,  espe- 
cially one  case  by  Senator,  have  taught  that 
some  patients  who  did  not  respond  to  the  usual 
doses  by  general  reaction,  still  were  unmistak- 
ably benefited.  Ljchtheim  has  attempted  to 
solve  this  problem  by  treating  several  cases  of  lu- 
pus with  the  precaution  to  avoid  fever  altogether 
by  the  use  of  minimal  initial  and  very  cautiously 
increased  doses.  He  states  that  while  the  usual 
local  reaction  tending  towards  a  cure  of  the  easily 
observed  patches  of  lupus  was  manifested,  the 
patients  did  neither  improve  as  fast,  nor  to  the 
same  extent  as  those  treated  with  fewer  but 
larger  doses,  and  that  the  tolerance  to  tuberculin 
and  consequent  loss  of  its  specific  influence 
occurred  before  the  lupus  had  healed  entirely. 
He  therefore  considered  a  moderate  general  re- 
action as  an  advantage.  Other  observers  have 
found  that  after  tuberculin  had  ceased  to  produce 
any  further  local  improvement,  on  account  of  the 
tolerance  established,  an  interval  of  some  days  or 
weeks  permitted  the  organism  to  react  again.  By 
adopting  this  plan  Renvers  reports  the  cure  of  a 
case  of  extensive  tuberculosis  of  the  larynx. 


THE  FINANCES  OF  THE  JOURNAL. 
From  what  was  recently  suggested  by  us  with 
reference  to  the  propriety  of  making  an  appropri- 
ation for  payment  of  the  expenses  for  reporting 
the  proceedings  of  the  Sections,  we  find  that  some 
of  our  members  anticipate  that  such  an  appropri- 
ation will  at  once  be  made,  and  that  the  Sections 
will  be  thus  provided  for  at  the  coming  session. 
Much  as  it  may  be  desirable,  such  a  provision 
cannot  be  made  at  once. 


Experience  has  taught  us  over  and  over  again 
that  reporting  by  other  than  medical  experts  is 
totally  unsatisfactory.  Such  experts  can  be  ob- 
tained, but  it  will  require  time  to  organize  such 
a  corps  and  to  adjust  them  to  their  Sections. 
And  when  the  time  for  such  reporting  arrives 
each  Section  should  be  provided  for  and  all 
should  share  alike. 

It  will  be  borne  in  mind  that  though  the  Asso- 
ciation may  desire  to  make  appropriations,  the 
decision  of  all  such  questions  is  vested  in  your 
Board  of  Trustees.  This  Board  has  always  been 
eminently  conservative  in  the  handling  of  your 
funds,  and  it  has  always  labored  under  the  em- 
barrassment of  not  knowing  in  any  given  year 
how  much  money  it  could  safely  appropriate. 
And  this  arises  from  the  fact  that  they  could 
never  ascertain  until  near  the  close  of  the  finan- 
cial year  how  much  would  be  paid  in  by  the 
members  as  annual  dues,  and  how  much  could  be 
earned  by  The  Journal.  For  this  reason  they 
have  been  extremely  prudent,  both  with  reference 
to  the  expenses  of  the  publishing  department  and 
for  editorial  work  as  well.  Under  the  working 
of  this  general  policy  The  Journal  has  never 
owed  a  debt  which  it  could  not  pay,  and,  having 
money  in  its  treasury,  is  able  to  avail  itself  of 
the  advantages  in  the  market  accorded  to  cash 
customers.  We  have  learned  from  critical  obser- 
vation just  what  our  publishing  expenses  will 
approximate  from  year  to  year,  and  as  there  is  a 
steady  increase  in  our  annual  receipts,  we  believe 
the  time  has  come  when  by  recommendation  of  a 
special  committee  to  our  Trustees,  and  with  their 
approval,  some  special  appropriations  may  safely 
be  made  which  will  greatly  enhance  the  value 
and  usefulness  of  The  Journal.  But  it  is  idle 
to  suppose  that  such  appropriations  will  be  made 
without  due  consideration  or  that  they  can  be 
available  for  use  at  the  coming  session. 


THE  QUESTION  OF  REMOVAL. 
To  those  who  have  so  strenuously  urged,  that 
the  discussion  of  the  question  of  removing  The 
Journal  to  Washington  be  terminated,  and  that 
its  pages  be  devoted  to  the  promotion  of  medical 
interests  instead,  we  have  simply  this  to  say : 
By  a  vote  of  the  Trustees,  under  whose  direction 
The  Journal  is  published,  the  members  of  the 
Association  were  invited  to  express  their  views 


I89i.] 


EDITORIAL  NOTES. 


637 


upon  the  subject  of  removal.  In  answer  to  that 
request  communications  have  come  to  us  from 
every  section  of  the  Union.  We  have  felt  it  our 
duty  to  obey  instructions,  and  just  in  the  order 
in  which  they  have  been  received  these  commu- 
nications have  been  published.  We  write  to  say 
that  with  this  issue  of  The  Journal  that  discus- 
sion will  be  closed.  It  now  remains  for  the 
Association  to  determine  for  itself,  through  its 
Trustees,  where  The  Journal  shall  be  pub- 
lished, and  under  what  supervision. 

The  Journal  has  occupied  no  partisan  ground 
in  this  discussion,  though  it  has  had  occasion  to 
suggest  the  modification  of  some  articles  which 
would  have  been  deemed  personal  by  those  who 
strongly  favor  the  removal.  Such  suggestions 
have  been  kindly  received,  and  what  might  oth- 
erwise have  led  to  unpleasant  results  has  thus 
been  averted.  In  no  other  way,  and  never  except 
as  stated,  has  The  Journal  sought  in  any  man- 
ner to  influence  the  writers  who  have  engaged 
in  this  discussion. 


EDITORIAL  NOTES. 
An  Amazing  Charitable  Expenditure. — 
According  to  the  Secretary  of  the  Charity  Organ- 
ization Societ}'  of  New  York,  300  societies  and 
agencies  in  that  city  spend  54,000,000  annually 
in  charitable  work. 

The  New  Langenbeck- Haus. — The  founda- 
tion stone  of  the  projected  Eangenbeck-Haus 
was  laid  in  Berlin,  by  Professor  Tirsch,  on  April 
4th.  This  memorial  to  von  Langenbeck  is  of  the 
most  enduring  and  highly  practical  kind.  As  its 
name  might  indicate  it  is  not  to  be  a  hospital  or 
invalid  home,  but  rather  a  medical  club  house— 
a  general  meeting  place  containing  lecture-room, 
library,  reading-rooms,  refreshment-rooms,  etc. 
It  appears  that  the  idea  originated  with  the  late 
Empress  Augusta,  who  gave  much  interest  and 
attention  to  medical  matters,  and  whose  wisdom 
in  this  connection  of  von  Langenbeck' s  memorial 
certainty  is  not  to  be  gainsaid.  The  last  day  of 
the  recent  German  Surgical  Congress  was  set 
aside  for  the  ceremonies  attendant  upon  the  cor- 
ner stone  placing,  and  the  members  of  that  body, 
together  with  State  dignitaries  and  representa- 
tives of  royalty,  were  present. 

A  Suggestion  Bearing  upon  Tuberulosis. 
— Dr.    James    Braithwaite,    of    Leeds,    mentions 


{Brit  Med.  Jour.,  April  11,  1891)  the  possibility 
of  curing  tuberculosis  by  the  destructive  powers 
of  other  bacilli  than  those  belonging  to  the  tuber- 
culous class.  He  believes  the  converse  to  this  is 
true,  viz.,  that  a  system  thoroughly  infected  with 
the  tubercle  bacilli  renders  the  action  of  other  or- 
ganisms more  or  less  inert,  and  in  favor  of  this 
view  he  gives  the  statement  of  a  gravedigger, 
that  those  who  have  died  of  consumption  and 
been  accidentally  exhumed  two  or  three  years 
after  burial  have  an  undecomposed  appearance — 
are  "like  wax,"  while  it  is  not  so  when  death 
has  resulted  from  other  diseases. 

"Drumming"  Doctors. — The  Journal  oj  the 
Arkansas  State  Medical  Society  cries  out  fiercely 
— and  very  justly,  indeed — -against  the  unprin- 
cipled doctors  who  prey  upon  the  unfortunate  in- 
valids at  the  Hot  Springs.  It  is  hoped  the  action 
of  the  last  legislature  will  avail  something  in  the 
way  of  renovation. 

Transmissibility  of  Influenza. — In  oppo- 
sition to  the  theory  that  influenza  is  a  disease  not 
dependent  upon  personal  contact  of  individuals 
for  its  progression,  that  it  is  not  evolved  by  the 
intrinsical  operations  of  a  specific  poison  and 
propagated  through  and  by  means  of  the  ordinary 
channels  of  human  intercourse,  maybe  mentioned 
that  during  the  late  epidemic  observers  have 
found  that  the  course  of  influenza  was  independ- 
ent of,  and  quite  opposed  to,  the  prevailing  winds. 
It  travelled  slow  in  Siberia  and  Russia,  but  rap- 
idly as  soon  as  it  reached  the  network  of  railways 
in  Central  and  Western  Europe  Its  course  was 
changed  by  the  mountain  ranges  of  Scandinavia, 
and  it  invaded  Norway,  not  from  Sweden,  but 
from  Holland  and  England.  Again,  it  was  de- 
flected by  the  Carpathians,  turning  its  course  in 
the  channels  of  travel  down  the  valley  of  the 
Danube,  and  ultimately  following,  in  direction 
and  time,  the  ocean  routes  to  Africa,  India,  Aus- 
tralia, and  this  country.  In  India  it  has  shown 
the  same  peculiarities  in  following  the  railway 
lines  as  has  been  observed  with  us. 

Venesection  Again. — J.  G.  Swayne,  M.  D., 
has  a  contribution  in  the  last  number  of  the  Bris- 
tol  Medico-Chirurgical  Journal  entitled  "Puerperal 
Eclampsia,"  and  in  which  he  seeks  to  show  the 
great  value  of  timely  venesection.  After  review- 
ing a  case,  he  says:  "This  case  is  only  one  of 
many  others  which  I  have  published  from  time  to 


638 


MEDICAL  ITEMS. 


[May  2, 


time,  in  order  to  prove  the  efficacy  of  venesec- 
tion in  puerperal  convulsions,  and  thus  to  rescue, 
if  possible,  from  unmerited  oblivion  a  most  valu- 
able but,  in  the  present  day,  most  unaccountably 
neglected  remedy."  Further  on,  in  a  note  ap- 
pended to  his  paper,  the  author,  having  late  cog- 
nizance of  Dr.  Pye-Smith's  defense  of  venesection 
before  the  Royal  Medical  and  Surgical  Society  of 
London — noticed  editorially  in  this  Journal  not 
long  since — continues  as  follows:  "It  is,  there- 
fore, very  gratifying  to  find  that  I  am  not  alone 
in  my  attempts  to  rescue  so  important  a  remedy 
from  oblivion." 

Diseases  of  the  Tropics. — An  authoritative 
consideration  of  those  diseases  which  give  to  the 
tropics  their  greatest  stigma  brings  out  the  con- 
clusion— based  largely  upon  military  returns — 
that  although  malaria  is  the  most  widely  diffused 
and  the  most  commonly  talked  of  and  dreaded 
affection,  yet  dysentery  is  without  question  the 
most  fatal. 

Faulty  Construction  of  Hospitals. — In  an 
Editorial  Note  in  the  last  number  of  The  Jour- 
nal, in  making  reference  to  the  recent  fire  in  the 
Brooklyn  Naval  Hospital,  while  censuring  such 
construction  of  Hospitals  as  will  permit  by 
means  of  wooden  elevator  shafts  and  dust  shutes 
the  rapid  communication  of  fire  to  the  entire  build- 
ing, we  were  led  to  infer  that  the  Naval  Depart- 
ment had  been  remiss  in  its  duty  in  replying  to 
solicitations  from  its  medical  officers. 

The  following  note  from  one  well  known  to  the 
profession,  and  so  related  as  to  be  an  authority 
upon  this  subject,  so  entirely  exonerates  the  Na- 
val Department  from  such  criticism  that  we 
cheerfully  give  place  to  it : 

To  the  Editor „■— I  regret  that  The  Journal  has  been 
misled  in  its  account  of  a  fire  at  this  Hospital  by  a  ma- 
licious sensational  report  in  a  daily  paper.  The  reflec- 
tions on  the  Washington  authorities  are  unauthorized, 
uncalled  for,  unfounded  and  untrue.  I  have  never  made 
any  request  that  has  not  been  generously  granted  and 
without  stint.  The  trifling  damage  was  promptly  re- 
paired at  slight  expense.  Albert  L.  Gihon. 

Medical  Director  in  charge. 

Brooklyn,  X.  Y.,  April  26,  1891. 

medical  items. 
The  Medical  Society   of  the   State  of 
North  Carolina  will  hold  its  annual  meeting 
at  Asheville,  May  26,  27  and  28,  1891.     The  ef- 
fort will  be  made  to  make  the  meeting  one  of  un- 


usual interest  and  pleasure.  The  scientific  and 
the  social  features  offer  special  attractions.  The 
railroads  and  hotels  are  granting  special  rates. 
North  Carolina  ought  to  be  more  fully  represented 
in  our  National  Organization,  and  we  trust  that 
her  leading  medical  men  will  give  their  influence 
in  this  direction. 

Illinois  State  Medical  Society,  John  P. 
Mathews,  Carlinville,  President;  D.  W.  Graham,. 
Chicago,  Secretary.  This  old  and  able  Society- 
will  convene  this  year  at  Springfield  on  May  19. 
Its  sessions  are  always  interesting,  and  the  pro- 
gramme before  us  gives  assurance  that  the  com- 
ing meeting  will  well  maintain  the  standard  of 
excellence  so  long  established. 

Dr.  F.  S.  Billings,  who  formerly  held  that  po- 
sition, is  again  appointed  Director  of  the  Patho- 
Biological  Laboratory  of  the  State  University  of 
Nebraska. 

Japanese  Centenarians.  — The  authorized 
report  of  the  census  returns  of  Japan,  completed 
December  1,  1889,  shows  a  total  population  of 
upwards  of  40,700,000.  Sixty-five  persons  were 
found  who  had  reached  their  one  hundredth  year 
of  life,  45  were  one  hundred  and  one,  13  were 
one  hundred  and  two,  4  were  one  hundred  and 
three,  1  was  one  hundred  and  four,  9  were  one 
hundred  and  five,  3  were  one  hundred  and  six, 
1  was  one  hundred  and  seven,  and  1  had  reached 
his  one  hundred  and  ninth  year. 

The  Luxury  (?)  of  Tuberculosis. — Now 
that  cod- liver  oil  has  advanced  about  400  per 
cent,  in  price,  and  with  tuberculin  at  no  incon- 
siderable figure,  there  may  be  some  measure  of 
satisfaction  to  the  proud  consumptive  in  the  re- 
flection that  he  is  certainly  not  having  "  cheap  ,v 
dosage. 

An  Unfortunate  Occurrence. — A  late  ex- 
change comments  under  the  heading  :  "  Arsenic 
in  the  Massachusetts  Legislature."  This  cer- 
tainly awakens  our  deep  sympathy  that  so  pois- 
onous a  drug  should  get  into  an  assembly  of  law- 
makers. We  have  often  heard  of  whisky  getting 
into  such  distinguished  bodies — it  has  even  been 
hinted  that  our  National  Legislature  occasionally 
suffers  in  this  way — but  this  is  quite  the  first  time 
we  have  ever  heard  of  an  arsenious  legislature. 
We  would  recommend  the  hydrated  peroxide  of 
iron  at  once. 


i89i.] 


TOPICS  OF  THK  WEEK. 


639 


TOPICS  OF  THE  WEEK. 


GOOD  POINTS  FOR  STUDENTS  AND  DOCTORS 

Dr.  \V.  H.  Steele,  in  /tons  of  Interest,  says  : 

Oar  colleges  will  turn  out  an  unusually  large  number 
of  graduates  in  the  spring,  who  undoubtedly  expect  to 
locate  in  some  Canaan  of  promise  and  build  up  a  prac- 
tice. It  shows  push  and  pluck  for  a  young  man  to  strike 
out  for  himself,  much  more  so  than  to  buy  out  a  practice 
or  partnership.  We  all,  who  have  tried  it,  know  it  re- 
quires many  things  besides  a  sheep-skin  to  successfully 
conduct  a  practice  I  will  give  a  few  points,  many  of 
which  I  have  learned  from  sad  experience,  so  that  others 
may  profit  by  my  errors  and  losses. 

Don't  neglect  your  busil 

Don't  misrepresent  anything  to  get  business. 

Don't  try  to  economize  by  using  cheap  material  or  poor 
instruments. 

Don't  make  any  promises,  either  financial  or  pro- 
fessional, that  you  cannot  fulfill. 

Don't  lock  your  office  daring  office  hours  to  go  off  on 
a  frolic,  or  to  attend  to  any  side  show,  or  for  any  other 
purpose  that  can  be  avoided. 

Don't  try  to  tear  down  a  competitor's  reputation  on 
which  to  build  your  own  ;    it  makes  a  rotten  foundation. 

Don't  forget  that  the  poor  have  feeling,  as  well  as  the 
rich,  and  are  just  as  deserving  of  respect  and  your  best 
services. 

Don't  be  cross  to  the  little  ones;  some  day  they  will 
be  men  and  women,  and  they  will  remember  you  for 
good  or  for  bad. 

Don't  fail  to  take  several  good  journals,  and  to  keep 
yourself  posted  on  all  new-  instruments  and  improve- 
ments. 

Don't  buy  a  bill  of  goods  because  they  are  cheap  or 
you  can  get  time  on  them.  Do  a  cash  business,  and  be 
a  cash  customer  to  every  one.  It  will  wonderfully  en- 
hance your  reputation  in  the  community. 

Don't  repeat  some  slanderous  story  that  may  have  been 
told  you  by  talkative  patients  while  operating  for  them. 

Don't  let  a  "good  enough  job  "  go  out  of  your  office  ; 
do  your  very  best  every  time  for  your  patient.  By  this 
means  you  will  improve  your  work ,  improve  your  patron- 
age, and  improve  your  bank  account. 

Don't  fail  to  be  prompt  in  collecting  and  paying  your 
from  any  cause  you  feel  obliged  to  give  or  re- 
ceive credit.  By  so  doing  you  will  gain  and  keep  the 
confidence  of  all. 

Don't  use  tobacco  in  any  form  ;  it  is  certainly  of  no 
benefit  to  you,  and,  to  say  the  least,  will  work  you  harm 
physically,  morally  and  financially 

Don't  use  intoxicating  liquors,  for  intemperance  is  the 
rock  on  which  many  a  good  practice  has  been  stranded, 
and  any  indulgence  leads  to  excess. 

Don't  forget  there  will  come  a  time  when  your  eyes 
will  grow  dim,  and  your  hand  lose  its  cunning.  It  is 
when  you  are  young,  healthy  and  prosperous  that  you 
should  lay  aside  something  to  fall  back  on  in  sickness 
and  old  age,  and  when  you  will  be  glad  to  be  able  to  re- 
flect that   you  are  leaving  a  busy,  bustling  world  better 


for  the  part  you  have  played  in   it.     A   serene,  satisfied 

well    provided    for.    must   be   delightful. — Cin- 
cinnati Medical  Ni  ,. 


CLINICAL  ART. 

Visitor:-  to  th  familiar  with  a 

certain  phase  of  Impressionist  art,  which  depicts  medical 
men  carrying  on  their  every -flay  work,  and  even  follows 
the  hand  of  the  surgeon  into  a  variety  of  practical  details 
ranging  from  vaccination  to  ovariotomy.  -Our  own  Eng- 
lish school  does  not  lend  itself  so  readily  to  this  unpleas- 
ant realism,  but  every  now  and  then  we  find  a  peep  taken 
into  the  hospital  ward  or  the  sick  room,  and  some  little 
idyl  of  domestic  medicine  worked  out  with  a  quiet  pa- 
thos which  is  apt  to  call  into  sudden  activity  the  func- 
tions of  the  lachrymal  gland.  Many  of  us  remember 
John  Faed's  "  From  Dawn  to  Sunset,"  and  "Tired  Out;" 
and  Fildes's  stalwart  navvy  gazing  with  speechless  misery 
at  his  dead  child  can  hardly  be  forgotten  by  those  who 
have  seen  the  impressive  work  which  now  finds  a  some- 
what inappropriate  resting-place  at  the  Holloway  Col- 
lege. This  year  the  brilliant  painter  of  bright  scenes 
returns  to  his  early  love,  and  gives  us  another  touching 
little  domestic  drama  on  the  stage  of  humble  real  life.  A 
sick  child  lies  on  a  hastily  improvised  bed  in  the  middle 
of  a  poorly-furnished  room,  and  the  doctor,  before  he  dis- 
turbs its  half-comatose  sleep  for  further  examination, 
takes  a  long  and  keen  diagnostic  glance  at  the  pale  face 
and  limp  lying  arms.  There  are  obviously  difficulties  in 
the  case,  and  he  is  evidently  puzzled,  whilst  the  uncer- 
tainty of  the  situation  is  reflected  by  the  fathi 
standing  in  the  background  beside  his  despairing  wife, 
eyes  the  arbiter  of  his  child's  destiny  with  an  anxious 
look,  and  waits  patiently  for  the  verdict.  The  lamp-light 
throws  a  ruddy  glow  over  principal  actor  in  the  scene, 
and  through  the  eastward  window  we  see  the  chill  light 
of  the  early  morning  just  beginning  to  make  itself  felt. 
When  visiting  the  studio  our  representative  met  several 
physicians  who  were  speculating  with  keen  professional 
interest  as  to  the  intentions  of  the  artist.  What  is  the 
matter  with  patient  ?  Is  the  prognosis  hopeful  or  hope- 
less?— and  ou  these  points  a  wholesome  difference  of 
opinion  existed.  One  pronounced  for  tuberculous  men- 
ingitis, and  a  necessary  fatal  result.  Another,  relying  on 
the  absence  of  certain  diagnostic  symptoms,  decided  in 
favor  of  fever,  and  a  favorable  prognosis.  Mr.  Fildes, 
on  being  appealed  to.  •  ^ive  any  opin- 

ion of  his  own.  The  picture  is  simply  called  :  "The  Doc- 
tor, "  and  he  leaves  those  who  look  at  it  to  puzzle  out  its 
meaning  for  themselves;  and  if  one  object  of  art  is  to 
stimulate  thought  and  encourage  mental  speculation, 
is  been  perfectly  attained,  and  the  pathetic 
force  of  this  masterly  work  will  combine  with  the  rich 
and  harmonious  coloring  and  the  perfection  of  complete 
yet  unobtrusive  detail  to  render  it  one  of  the  most  attrac- 
tive pictures  of  the  coming  Academy.  It  will  be  good 
news  for  the  art-loving  world  to  hear  that  it  has  been 
bought  bv  Mr.  Tate,  and  that  we  may  therefore  hope  to 
find  it  included  in  the  fine  collection  which  he  has  so 
generouslv  presented  to  the  nation.  By  a  curious  coin- 
cidence Mr.  Dicksee  has  this  year  worked  on  very  much 


640 


TOPICS  OF  THE  WEEK. 


[May  2, 


the  same  lines  as  Mr.  Fildes.  Under  the  name  of  "  The 
Crisis,"  he  represents  a  sick  girl  sleeping  that  slumber 
which  may  end  in  the  more  permanent  sleep  of  death,  or 
lead  on  to  the  joyful  awakening  into  convalescence.  Worn 
out  by  long  watching  the  anxious  father  fixes  his  eyes  on 
his  daughter's  face,  and  waits  for  Nature  to  say  the 
word  which  will  fill  him  with  joy  or  sorrow.  There  is 
something  very  fine  about  the  blended  look  of  half-puz- 
zled expectation  mixed  with  a  kind  of  hopeful  resigna- 
tion, which  fills  the  eyes  and  shades  the  brow  of  the  im- 
pressive father's  head,  which  rests  on  and  is  partly  hid- 
den by  the  thin  hand.  And  again  we  begin  to  try  and 
look  into  future.  But  it  is  very  difficultto  say  how  things 
are  to  go  in  this  case.  The  patient  is  thin  and  worn  and 
thoroughly  exhausted,  but  sleep  may  do  much  for  her, 
and  "  the  crisis"  may  be  past  when  she  wakes.  As  the 
visitor  turns  away  from  the  canvas  he  cannot  help  recall- 
ing a  well-worn  quotation  from  Hood  : 

We  thought  her  dying  when  she  slept 

And  sleeping  when  she  died. 

— Brit.  Med.  Journal. 


OLD  AGE  AS  A  FACTOR  IN  SURGERY. 

Dr.  N.  F.  Graham,  of  Washington  [Medical  News, 
February  7,  1891),  reports  eight  cases  observed  by  him- 
self, and  refers  to  others  published  in  this  country,  which 
show  wonderful  recuperative  powers  in  very  old  men  and 
women.  With  regard  to  advanced  age  being  a  contra- 
indication to  surgical  operation,  it  is  held  that  if  the  pa- 
tient be  in  fair  general  health,  with  au  hereditary  tendency 
to  lpng  life,  mere  old  age  is  not  a  good  reason  for  with- 
holding treatment,  either  with  the  view  of  prolonging 
life,  or  for  the  relief  of  acute  suffering.  As  a  rule,  old 
people,  Dr.  Graham  states,  tolerate  pain  better  than  the 
young,  but  with  them  shock  is  more  severe  and  not  so 
quickly  rallied  from.  In  shock  lies  the  greatest  danger 
to  the  aged,  and  if  the  patient  rallies,  the  prognosis,  so 
far  as  repair  is  concerned,  may  be  considered  good.  They 
endure  operations  for  pathological  conditions,  such  as 
new  growths,  remarkably  well.  Their  recovery  from  ac- 
cidental wounds  is  not  so  rapid. 


apothecaries,  none  of  whom,  however,  have  passed  the 
final  examination;  indeed,  since  1884  no  lady  has  applied 
for  admission.  In  Russia  ladies  have,  since  the  beginning 
of  last  year,  been  entitled  to  become  pharmacists,  and 
nine,  having  completed  the  requisite  preparatory  studies 
at  Zurich,  have  passed  the  Russian  examination.  Courses 
of  instruction  in  pharmacy  for  women  have  already,  as 
we  stated  a  week  or  two  ago,  been  established  in  one  of 
the  St.  Petersburg  hospitals,  from  the  dispensary  of 
which  the  fair  pillmakers  have  already  succeeded  in 
ousting  the  rival  sex.  The  facts  which  we  have  men- 
tioned seem  to  show  that  the  strong-minded  sisterhood 
have  not  the  devouring  enthusiasm  for  pharmacy  which 
they  display  for  medicine,  though  it  is  an  occupation  for 
which  they  are  in  some  respects  especially  well  fitted. 
This  indifference  may  perhaps  be  due,  at  least  in  some 
measure,  to  the  comparatively  little  opposition  they  have 
met  with  in  the  attack  on  that  particular  male  citadel.— 
British  Medica  I  Journal. 


TUBERCULIN. 
The  following  charade  was  written  by  a  patient  recently 
under  treatment  by  Koch's  method  at  Banff,  Scotland, 
and  sent  to  the  Lancet  by  Dr.  William  Fergusson  : 

My  first  lies  at  the  root  of  things, 

With  homely  earth  is  soiled, 
Yet  at  the  festive  board  of  kings 

Is  always  welcome — boiled. 

My  second  o'er  the  level  green 

Impels  the  polished  ball  ; 
Where  "cannons"  rattle  it  is  seen, 

Yet  loves  the  peaceful  "  stall." 

My  third  around  the  green  earth  lies, 

No  angel  ever  saw  it ; 
'  Twas  never  viewed  by  mortal  eyes, 

Yet  men  must  somewhere  draw  it. 

When  wasting  sickness  crowns  the  ills 

Bv  hapless  men  endured, 
TAy' whole  fresh  strength  and  hope  instils, 

And  whispers  "  Be  thou  cured  !" 

— Boston  Medical  and  Surgical  Journal. 


LADY  APOTHECARIES. 
The  tyrant,  man,  is  slowly  but  surely  being  driven  be- 
hind the  last  breastworks  of  his  professional  monopolies, 
and  woman  is  everywhere  more  or  less  triumphantly  as- 
serting her  "rights."  Not  content  with  prescribing 
drugs  she  now  insists  on  compounding  them.  A  projet 
de  loi  lias  just  passed  the  French  Chamber  of  Deputies 
admitting  properly  qualified  women  to  the  practice  of 
pharmacy.  Frenchmen  are  nothing  if  not  chivalrous, 
and  it  is  therefore  somewhat  surprising  to  find  them  con- 
siderably behind  other  nations  in  this  respect.  In  Nor- 
way women  have  for  the  last  six  years  been  allow.. It.. 
stu.lv  pharmacy  and  to  manage  and  own  drug  shops. 
About  ten  women  are  at  present  employed  in  pharma- 
ceutical establishments  either  as  pupils  or  assistants,  but 
not  ..no  of  them  has  presented  herself  for  the  final  ex- 
amination, in  Denmark  only  two  women  have,  in  tin- 
course  of  many  years,  taken  Up  pharmacy,  and  neither  of 
them  lias  "qualified."    In  Finland  there  are  seven  female 


THE  MONKEY  SOLVES  THE  PROBLEM. 

Monkeys  have  a  keen  sense  of  imitation  and  are  always 
prone  to  copy  their  master's  movements  whenever  fancy 
strikes  them.  Seldom,  however,  is  it  that  a  moukey  has 
proved  itself  useful  by  such  an  undesirable  propensity. 
Yet  one  of  these  inquisitive  creatures  has,  we  understand, 
recently  performed  a  feat  in  the  matter  of  medicine-tak- 
ing, and  by  so  doing  has  earned  for  itself  a  reputation 
which  deserves  recognition.  This  is  how  it  was:  A  prac- 
titioner recently  received  a  box  of  Count  Mattel's  medi- 
cines, and  one  of  his  children  getting  hold  of  the  box 
gave  it  to  a  tame  monkey  in  the  house.  The  animal 
very  soon  broke  open  the  box.  and  taking  a  vial  of  anti- 
cauceroso,  which  is  used  as  a  cure  for  leprosy,  swallow...! 
750  globules,  besides  some  other  fever  medicines.  The 
proper  method  of  taking  the  anti-canceroso  is  to  dissolve 
one  of  the  globules  in  a  quart  of  water,  and  the  dose  is  a 
teaspoonful  at  a  time.  The  monkey,  however,  is  not 
only  quite  well,  but  as  lively  as  ever,  and  must  now  be 
impervious  to  leprosy.  Clearly,  il  the  monke)  had  been 
able  to  read  he  would  have  been  more  discreet  with 
Count   Mattel's  remedies,  but  as  no  harm  happened  to 

him.  the  presumption  is  that  the    remedies    are   harmless 

howevei  they  au-  taken.— Medical  Press. 


i89i.] 


PRACTICAL  NOTES. 


641 


PRACTICAL  NOTES 


-CAR  LET  l'EYER. 

Itching  in  scarlet  fevers  is  not  always  agree- 
able, and  it  has  never  been  supposed  to  be  a 
favorable  sign,  but  St.  Phillippe  [Rev.  .Urns,  des 
Maldel'Enf.,  February,  1890),  according  to  A. 
F.  C.  in  Archiv.  Ped.,  in  a  paper  presents  the 
following  conclusions,  viz.: 

1.  Scarlatina  is  often  a  disease  which  is  accom- 
panied by  itching. 

2.  This  variety  usually  has  a  favorable  prog- 
nosis. 

3.  The  itching  is" due  to  the  fact  that  the  erup- 
tion is  not  intense  and  the  cutaneous  lesion  not 
very  profound. 

The  best  application  for  the  relief  of  this  itch- 
ing, or  almost  any  other  for  that  matter,  is  the 
following  ■ 

ft.     Campbo-phenique,  .^  ss. 
Abolene  unguent    . 

nj>.     Sig.     Apply  night  and  morning. 

Another  advantage  is  that  it  is  in  the  direction 
of  personal  disinfection. — Medical  Mirror. 


DENTAL  CARIES. 

The  following  prescription  has  been  suggested: 

ft.     Acid,  tannic,  gr.  lxxv. 
Tinct.  iodinii. 
Tiuct.  myrrhae,  aa  f  3  j- 
Potassii  iodidi,  gr.  xv. 
Aqua;  rosse,  f  5  vj.      nj>. 

Add  a  teaspoonful  to  a  small  glass  of  water  and 
use  daily  as  a  mouth  wash. — Pharm.  Record, 
March  5,   1891. 

CHRYSAROBIN  IN  PSORIASIS. 

Dr.  Unna  recommends 
R.     Chrysarobin,  5  parts. 

Salicylic  acid,  2  parts. 

Ichthyol,  5  parts. 

Vaseline.  SS  parts. 

Made  into  an  ointment  and  to  be  rubbed  into 
the  affected  parts. — Nouveaux  Remedes. 


FOR  ANGINA  PECTORIS. 

The  indications  for  treatment  during  the  par- 
oxvsms  are  the  following  (Dr.  W.  R.  Jackson, 
Va.  Med.  Monthly,  Feb.,  1891): 

1.  To  relieve  pain,  by  hypodermic  injections  of 
morphia  or  inhalation  of  ether  or  chloroform. 

2.  To  stimulate  the  heart  to  action — by  use  of 
brandy,  whisky  or  sulphuric  ether  by  hypoder- 
mic injections  or  by  the  mouth. 

3.  To  keep  or  maintain  the  continued  rhyth- 
mical action  of  the  heart,  and  to  diminish  the 
arterial  tension,  which  is  best  done  by  nitrogly- 
cerine, nitrite  of  amyl,  or  electricity  or  galvan- 


ism. The  casi  -  most  amenable  to  treatment  are 
the  purely  cardiac  kind,  without  any  cardiac  le- 
sions. 

Dr.   Anstie  nic  as  a  tonic  and  pre- 

ventive, it  is  well  to  put  your  patient  on  a 
tonic  of  iron  and  arsenic,  or  quinia  with 
aromatic.  If  there  is  a  gouty  or  rheumatic  dia- 
aopriate  treatment, 
and  a  suspicion  of  syphilis  should  liken 
suggestive.  Sea-baths  and  travel  are  to  be  recom- 
mended. The  patient  should  avoid  all  commo- 
tion— moral  and  physical;  he  should  lead  a  quiet, 
cheerful  life,  and  should  religiously  abstain  from 
tea,  alcohol,  and  tobacco. — College  and  Clinical 
Record. 


APPLICATION  FOR  ACNE  ROSACEA. 

Dr.  Unna,  of  Hamburg,  has  produced  what  he 
believes  to  be  an  ideal  preparation  of  ichthyol  for 
application  in  cases  of  acne  rosacea.  It  is  pre- 
pared by  combining  it  with  starch  in  the  follow- 
ing manner:  Forty  parts  of  starch  are  moistened 
with  twenty  parts  of  water,  and  this  is  well 
rubbed  up  with  forty  parts  of  ichthyol,  and  final- 
ly, one  or  one  and  a  half  parts  of  a  strong  solu- 
tion of  albumen  intermixed  with  it.  This  is  ap- 
plied to  the  skin  at  night;  it  dries  in  about  two 
minutes,  and  can  be  easily  washed  off  in  the 
morning.  As  there  is  no  fatty  matter  iu  this 
varnish  it  is  eminently  suited  as  an  application 
in  lupus  erythematosus,  or,  as  Unna  calls  it, 
"ulerythema  centrifugum,"  in  which  fatty  mat- 
ter is  to  be  avoided. 


FOR    ERYSIPELAS. 

ft.    Ichthvol,  3ij. 

Ether,  3ij. 

Collodion,  Jiv.     "T.. 
S.  Paint  over  and  around  infected  area. 

— Prov.  Med.  Journ. 


ACETANILID  AS  AN  ANTISEPTIC. 

Early  in  the  days  when  acetanilid  was  first  in- 
troduced, some  prominence  was  given  to  its  anti- 
septic properties,  but  in  the  crowd  of  substances 
specially  introduced  as  members  of  the  "antisep- 
tica,"  this  field  of  usefulness  for  it  was  forgotten. 
Quite  recently  its  virtues  in  this  direction  have 
been  accentuated  by  the  descriptions  of  its  use 
instead  of  iodoform  in  the  treatment  of  hard  and 
soft  venereal  sores.  The  chancre  is  simply 
dusted  with  the  powdered  compound,  and  the  re- 
sult is  said  to  be  a  rapid  and  complete  healing. 
The  advantages  of  the  odorless  and  non-toxic 
acetanilid  over  iodoform  need  no  emphasis:  while 
for  hospitals  and  dispensaries  its  cheapness  would 
further  recommend  it  if  increased  observation 
confirm  these  statements. — Provincial  Med.  Jour. 


642 


SOCIETY  PROCEEDINGS. 


[May  2, 


SOCIETY   PROCEEDINGS. 

Tennessee  State  Medical  Society. 

Fifty-Eighth  Annual  Meeting  held  in  Nashville, 

April  i+,   75,  and  16,   1891. 

First  Day — Morning  Session. 

The  Society  met  in  Watkins  Hall,  and  was 
called  to  order  by  The  President,  Dr.  Geo.  A. 
Baxter,  of  Chattanooga,  at  10:30  a.m. 

Prayer  was  offered  by  Rev.  C.  D.  Elliot,  of 
Nashville. 

The  first  paper  read  was  by  Dr.  T.  J.  Hap- 
pel,  of  Trenton,  on 

ABSCESSES. 

He  said  this  fiejd  was  a  profitable  one  for 
thought  and  investigation,  especially  in  the 
direction  of  diagnosis.  So  far  as  the  treatment 
goes,  the  Latin  expression  ubi  pus,  ibi  inrisio, 
gives  us  the  therapy  of  such  cases  in  a  few  words, 
so  far  as  their  last  stages  are  concerned.  The 
prophylactic  treatment  is  a  different  matter. 
Everything  that  can  be  done  to  prevent  pus,  to 
prevent  the  development  of  an  abscess,  must  be 
resorted  to,  but  when  pus  is  present  the  knife  is 
the  instrument  for  relief.  An  aspirator  can  re- 
move the  pus  itself,  but  the  cause  of  it,  the 
pyogenetic  something,  is  left  behind.  A  free 
outlet  must  be  given  to  the  pus,  the  cavity  care- 
fully cleaned,  perfect  drainage  secured,  arrange- 
ments made  for  thoroughly  flushing  the  diseased 
organ  with  antiseptic  fluids,  the  strength  of  the 
patient  maintained  by  a  generous  diet,  and  nature 
aided  by  an  abundance  of  pure  fresh  air  to  re- 
pair the  broken-down  constitution. 

Dr.  Happel  reported  a  case  of  abscess  of  the 
spleen.  He  said  this  was  a  rare  trouble,  many 
of  our  best  authorities  never  having  met  with  a 
single  case.  He  had  in  the  course  of  seventeen 
years  practice  found  two  cases ;  one  due  to 
pressure  upon  the  organ  ;  and  the  other  to  chronic 
malarial  poisoning.  He  also  reported  a  case  of 
abscess  of  the  cornea  forming  hypopyon,  and  one 
of  the  liver,  which  came  under  his  observation. 
In  closing  he  called  attention  to  the  peroxide  of 
hydrogen  as  one  of  the  best,  if  not  the  best,  of 
all  agents,  used  to  cleanse  and  restore  to  a  normal 
state  all  pyogenic  membranes,  surfaces  and  cav- 
ities. As  one  writer  expressed  it:  "It  hunts 
out  pus  in  all  its  ramifications  as  a  ferret  does 
a  rat." 

A I'TKIi xoc  >n   S ESSION . 

Dr.  George  R.  West,  of  Chattanooga,  read 
a  paper  on 

ovulation  and  menstruation. 

He  said  that  individual  opinions  and  theories 
are  as  those  who  love  darkness  rather  than  light, 
and  insist  upon  remaining  in  darkness  rathe]  than 
to  be  disturbed  by   the  entrance  of  facts  which 


might  bring  light.  The  subject  of  ovulation  and 
menstruation,  their  dependence  or  independence, 
is  one  of  these  benighted  fields  where  individual 
opinions  and  theories  run  riot,  and  where  the 
light  of  facts  gained  from  research  and  experi- 
ence is  so  perverted  as  to  render  uncertain  the 
supposed  certainty  that  has  previously  existed. 

After  giving  a  resume  of  the  literature  on  the 
subject,  Dr.  West  drew  the  following  conclusions: 

1.  That  the  increased  familiarity  with  the 
pelvic  organs,  the  result  of  modern  surgery,  has 
not  materially  added  to  our  knowledge  of  their 
functions. 

2.  That  though  the  ovular  theory  of  menstru- 
ation has  not  been  overthrown,  yet  the  weight  of 
accumulating  evidence  seems  against  it. 

3.  That  the  most  recent  observations  point  to 
a  common  nervous  origin  for  both  ovulation  and 
menstruation,  and  yet  an  individual  inde- 
pendence. 

Dr.  Thomas  M.  Woodson,  of  Gallatin,  con- 
tributed a  paper  entitled 

TREATMENT  OF  PNEUMONIA;  THE  PAST  AND 

PRESENT  METHODS  ;  HAS  THE  RATE  OF 

MORTALITY  BEEN  CHANGED  ? 

He  briefly  reviewed  the  literature  on  pneumonia 
to  illustrate  the  opinions  of  medical  teachers  and 
writers.  He  was  glad  that  Hare,  of  Philadelphia, 
in  his  work  on  "Practical  Therapeutics,"  re- 
vived the  old  lines  of  treatment.  He  extolled 
veratrum  veride,  and  said  that  in  the  first  stage 
of  the  disease  it  is  very  useful  as  a  medicant. 
Its  two  alkaloids  possess  different  influences  and 
that  between  them  they  fulfill  every  object  that 
is  sought  for.  Jervine,  a  powerful  vaso-motor 
depressant,  relaxes  the  walls  of  the  blood-vessels 
everywhere,  at  the  same  time  it  quiets  the  action 
of  the  heart  by  an  action  over  its  muscle  or 
ganglia  as  to  reduce  its  force,  thus  preventing 
engorgement  of  the  lung;  while  veratraidine,  by 
stimulating  the  inhibitory  nerves  of  the  heart, 
also  slows  its  beat,  fills  the  ventricles  and  allays 
excitement.  The  advantages  of  veratrum  veride 
are  its  completeness  and  rapidity  of  action  ;  the 
fact  that  it  preserves  in  healthy  blood-vessels  the 
blood  which  may  be  needed  in  the  crisis,  if  the 
disease  is  not  aborted,  and  its  safety,  is  a  point 
largely  in  its  favor.  In  the  second  stage  to  pre- 
vent heart  failure  by  engorgement  from  over-dis- 
tension, Dr.  Hare  gives  digitalis  with  strychnine 
to  stimulate  the  respiratory  centres;  that  he 
thinks  alcohol  in  the  second  stage  is  inferior  to 
digitalis  ;  carbonate  and  muriate  of  ammonia  are 
valuable  adjuncts  m  the  second  and  third  - 
He  uses  opium  sparingly  for  troublesome  cough 
in  the  later  stages,  ami  not  in  the  first  stage. 

In  the  first  stage  of  croupous  pneumonia  the 
indications,  said  the  speaker,  are  clear:  1.  To 
control  the  circulation  and  diminish  the  de- 
termination of  blood  to  the  lungs  ;   2.   To  reduce 


t89i.] 


SOCIETY  PROCEEDINGS. 


643 


the  temperature  if  high  ;  3.  Allay  pain  by  both 
physical  and  physiological  rest ;  4.  Support  the 
vital  powers. 

The  first  two  indications  are  met  by  veratrum 
viride  better  and  with  more  certainty  than  any 
other.  The  third,  to  allay  pain,  we  have  but  one 
remedy — opium  or  its  salts,  which  stands  without 
a  rival.  Fourth,  to  support  the  patient  with 
especial  reference  to  failing  heart  and  respiratory 
centres  ;  digitalis,  strychnine  and  alcohol  for  the 
later  stages. 

More  than  twenty  years  ago  the  speaker  ex- 
pressed the  opinion  that  in  inflammatory  affec- 
tions veratrum  viride  was  a  sedative  of  the  great- 
est value,  controlling  the  action  of  the  heart  as 
effectually  as  blood-letting,  without  the  exhaus- 
tion incident  to  the  latter.  Arterial  excitement 
is  reduced  by  it.  while  the  vital  forces  are  econo- 
mized. It  is  especially  adapted  in  pneumonia  in 
.the  stage  of  engorgement  in  which  it  appears  to 
bring  about  prompt  resolution.  It  may  be  used 
in  the  treatment  of  children  with  safety.  Its 
constitutional  effects  having  been  secured,  there 
is  a  reduced  force  and  frequency  of  the  circula- 
tion, reduction  of  temperature  and  respiration, 
and  an  amelioration  of  all  the  symptoms  of  the 
disease.  While  extolling  the  virtue  of  veratrum 
viride,  he  would  not  rely  on  it  alone  in  pneu- 
monia, as  opium  was  unquestionably  entitled  to 
a  prominent  place,  palliative  and  curative  in  its 
action,  allaying  pain,  cough  and  nervous  irrita- 
tion, available  in  the  latter  as  well  as  the  early 
stages. 

PHTHISIS    PfLMONALIS.    WITH    ESPECIAL    REFER- 
ENCE  TO   PROPHYLAXIS, 

was  the  title  of  a  paper  contributed  by  Dr.  J.  R. 
Buist,  of  Nashville. 

As  physicians,  impressed  with  the  claims  of 
suffering  humanity,  we  should  never  relax  our 
efforts  as  long  as  consumption,  with  its  multiplied 
ills,  afflicts  our  race,  with  its  sickness,  pain,  and 
death.  Nor  have  we  any  right,  as  scientists,  to 
despair  of  the  ultimate  triumphs  of  knowledge 
and  the  practical  results  of  scientific  research. 
The  acknowledged  failure  of  all  the  proposed 
plans  for  the  cure  of  phthisis,  based  upon  thera- 
peutical agents,  should  lead  us  upon  other  lines 
of  effort  for  its  destruction.  The  impossibility  of 
procuring  for  the  mass  af  consumptives  the  bene- 
fits of  climate  and  altitude,  even  if  these  benefits 
approximated  the  value  some  assign  them,  should 
admonish  us  to  look  to  the  higher  plane  of  pre- 
ventive medicine  in  dealing  with  this  disease. 

Regarding  Koch's  paratoloid  as  a  remedy  for 
consumption,  Dr.  Buist  said  the  high  expecta- 
tions so  recently  excited  in  these  inoculations  do 
not  seem  to  be  verified.  Certainly  for  advanced 
stages  of  phthisis,  and  many  other  conditions  of 
tuberculosis  it  is  unsuited  and  positively  danger- 
ous; and  it  is  not  settled  whether  any  benefit  can 


attend  its  use  in  the  incipient  cases.  In  making 
this  statement,  he  would  not  detract  anything 
from  the  real  value  and  merit  of  the  discovery, 
and  meant  no  disparagement  of  the  genius  of 
Koch. 

Preventive  medicine  is  after  all  the  acknowl- 
edged aim  and  end  of  scientific  research.  Though 
still  in  its  infancy,  it  has  accomplished  wonders 
for  humanity.  And  it  is  obvious  that  its  first  and 
highest  triumphs  are  to  be  won  among  the  class 
of  zymotic  and  infectious  maladies.  The  power 
of  prevention  is  incalculably  more  precious  than 
any  therapeutical  measures.  It  is  therefore  high- 
ly incumbent  upon  us  individually  and  collective- 
ly to  assure  ourselves  of  the  modern  theory  of 
consumption,  and  so  convinced,  we  should  direct 
our  attention  and  efforts  to  a  rational  prophylaxis 
of  this  fatal  disease. 

It  may  be  said  that  the  true  difficulty  is  to  get 
the  public  to  realize  its  danger  from  various 
sources,  and  still  more  to  have  wise  prophylactic 
measures  adopted.  This  is  in  the  main  true:  yet 
education  can  perform  wonders.  The  benefits  of 
sanitary  reform  are  now  acknowledged  and  trust- 
ed, although  fifteen  years  ago  it  met  with  indiffer- 
ence and  opposition. 

The  speaker  closed  with  the  words  of  Dr.  E. 
O.  Shakespeare,  of  Philadelphia:  "  What  use  was 
it  for  Koch  to  have  made  his  discovery  of  the  in- 
fectious nature  of  the  bacillus  tuberculosis,  if  the 
practitioners  of  medicine,  those  who  come  in  di- 
rect contact  with  the  people,  who  are  the  natural 
agents  for  arousing  such  a  public  sentiment  and 
enforcement  of  laws  for  the  protection  of  public 
health,  utterly  neglect  to  act  upon  the  ample  and 
exact  knowledge  which  we  possess  concerning 
the  etiology  and  prophylaxis  of  tuberculosis." 
Evening  Session. 

The  public  were  invited  to  attend  this  session. 
Addresses  were  delivered  by  Hon.  William  Lit- 
terer.  Mayor  of  Nashville,  Hon.  H.  H.  Norman, 
and  Judge  J.  M.  Dickinson.  Dr.  Geo  A.  Baxter 
also  delivered  at  this  session  the  Presidential  Ad- 
dress, his  subject  being  Topics  of  Import  to  the 
Profession  and  Public.  The  address  was  scholar- 
ly, very  instructive,  and  was  listened  to  with 
marked  attention. 

Second  Day — Morning  Session. 

Dr.  J.  S.  Cain,  of  Nashville,  read  a  paper  on 

chronic  endometritis, 

in  which  he  said  the  question  as  to  the  localiza- 
tion of  the  chronic  form  of  endometritis  is  render- 
ed more  prominent  than  that  of  the  acute  form  on 
account  of  the  conflicting  opinions,  entertained  by 
distinguished  authors  and  teachers.  None,  he  be- 
lieved, questioned  the  very  frequent  occurrence  of 
chonic  cervical  endometritis,  but  Drs.  Emmet, 
Bennett,  and  other  very  distinguished  authorities, 
almost  absolutely  ignored  the  existence  of  chronic 


644 


DOMESTIC  CORRESPONDENCE. 


[May  2, 


corporeal  endometritis  as  a  special  disease,  and 
consequently  except  for  the  relief  of  haemorrhages, 
and  to  meet  temporary  emergencies,  discounte- 
nance all  intra-uterine  medication,  relying  entirely 
upon  treatment  directed  to  the  urerine  os  and  vault 
of  the  vagina.  But  the  great  preponderance  of 
medical  authority  is  averse  to  the  opinions  enter- 
tained by  these  gentlemen,  and  with  the  latter 
class  he  was  entirely  in  accord. 

Chronic  endometritis  and  the  conditions  neces- 
sarily allied  therewith  are  the  most  common  as 
well  as  the  most  important  diseases  with  which 
the  gynecologist  has  to  deal.  This  condition  is 
often  a  sequel  to  the  acute  form  of  the  disease, 
and  grows  out  of  repeated  acute  attacks.  It  mat- 
ters not  how  or  from  what  source  the  acute  out- 
breaks originate,  whetherfrom  catarrhal,  specific, 
traumatic  or  internal  constitutional  causes,  they 
are  often,  but  not  always,  the  starting-point  from 
which  not  only  the  endometrium  but  the  entire 
uterine  and  periuterine  parenchymatous  struc- 
tures become  involved.  He  would  here  venture 
the  assertion,  that  while  the  change  in  structure 
and  function  of  the  lining  membrane  of  the  uter- 
us often  seem  to  be  the  most  prominent  conditions, 
and  those  which  demand  our  first  and  most  care- 
ful attention,  this  tissue  is  probably  never  chron- 
ically diseased  without  a  corresponding  involve- 
ment of  the  entire  uterine  structures. 

Treatment. — While  the  curette,  as  has  been 
said,  is  a  blind  instrument  and  capable  of  doing 
harm  in  careless  and  incompetent  hands,  yet  for 
the  removal  of  fungoid  vegetations  and  adenoid 
degenerations  from  the  endometrium,  it  affords 
the  surest,  speediest  and  safest  means  as  yet  devis- 
ed. Dr.  Cain  is  accustomed  to  following  the  cur- 
etting by  an  application  of  Churchill's  tincture 
of  iodine  or  diluted  carbolic  acid,  as  is  the  usual 
practice,  and  always  precedes  the  treatment  by  a 
careful  washing  out  of  the  vagina  and  uterus  with 
a  disinfectant  of  one  to  two  thousand  corrosive 
sublimate. 

In  cases  where  this  treatment  is  not  admissi 
ble,  or  where  it  has  failed  to  afford  relief,  his  next 
reliance  is  on  the  electro-chemical  action  of  nega- 
tive galvanism,  in  removing  the  vegetations  after 
the  method  of  Apostoli.  This  is  accomplished 
by  introducing  an  electrode,  insulated  to  near  the 
point,  into  the  uterine  cavity,  and  connecting 
with  the  negative  pole  of  the  battery,  connecting 
the  other  pole  with  a  large  pad  of  moistened  pot- 
ter's clay,  sponge  or  prepared  cotton,  placed  over 
the  abdomen.  The  time  for  employment  of  the 
galvanism  at  each  treatment  should  be  from  ten 
to  fifteen  minutes,  and  the  treatment  should  be 
repeated  about  twice  a  week. 

The  strength  of  the  current  to  be  employed 
will  depend  much  upon  the  acuteness  of  the  par- 
ticular case,  and  the  susceptibility  of  the  patient 
to  electrical  treatment.  The  chronic  cases  al- 
ways require  the  stronger  current.     The  dosage 


may  be  fixed  at  from  ten  to  three  hundred  milli- 
amperes;  the  minimum  is,  in  his  judgment,  too 
small  to  accomplish  any  good  results,  and  yet 
physicians  with  much  larger  experience  have  had 
to  employ  it. 

This  line  of  treatment  he  considers  free  from 
many  of  the  objections  to  others;  it  is  cleanly, 
free  from  pain,  and  exempt  from  danger.  Un- 
like cauteries  and  escharotics  it  can  be  limited  in 
its  influence  and  produces  no  deleterious  effects 
upon  the  sound  tissues,  nor  does  it  leave  a  raw 
and  exposed  surface  like  the  curette  to  absorb 
poisons  and  septic  agencies,  and  while  it  removes 
the  vegetations  it  imparts  renewed  tone  and  vi- 
tality to  the  diseased  organ. 

(To  be  concluded.) 


DOMESTIC  CORRESPONDENCE. 

LETTER  FROM    NEW  YOItK. 

(FROM   OUR   OWN   CORF 


The  Treatment  of  Phthisis  by  Inoculation  with 
Vaccine  Lymph  —  Bellevue  Hospital  Training 
School  for  Male  Nurses — Hospital  Saturday  and 
Sunday  Association — The  Establishment  of  Public 
Hospitals — Care  of  the  Insane  Poor — Miscellaneous 
Items. 

It  will  perhaps  be  remembered  that  some  time 
ago  reference  was  made  in  this  correspondence  to 
the  treatment  of  phthisis  by  inoculation  with  vac- 
cine lymph,  as  practiced  by  Dr.  J.  Hilgard  Tyn- 
dale.  At  the  last  meeting  of  the  New  York 
County  Medical  Association,  Dr.  Tyndale,  in 
reading  a  paper  on  this  subject,  presented  nine 
patients  who  had  all  shown  the  presence  of  the 
tubercle  bacillus  in  their  sputa,  and  most  of 
whom  had  cavities  in  their  lungs,  who,  he  claim- 
ed, had  all  either  recovered  or  were  in  a  fair  way 
to  recovery  from  their  tuberculous  trouble.  Al- 
together he  has  treated  twenty-three  carefully 
selected  cases  by  this  method,  and  he  stated  on 
this  occasion  that  in  the  other  fourteen  the  same 
favorable  results  had  been  noted  as  in  the  nine 
that  he  exhibited.  He  lays  great  stress  on  exact 
and  localized  diagnosis,  and  would  select  for  in- 
oculation cases  in  which  are  found  more  or  less 
active  cavities  and  infiltrations,  with  suppurative 
expectoration,  coupled  to  a  not  entirely  hopeless 
general  condition.  No  cases  of  pure  connective 
tissue  proliferation,  nor  of  general  or  localized 
cirrhosis  of  the  lung  (in  other  words,  peri-bron- 
chitis I,  and  no  cases  of  purely  mechanical  dis- 
turbances of  respiration  caused  by  the  binding 
down  'it'  lung  tissue  by  pleuritic  adhesions,  nor 
cases  in  which  diffused  dry,  sibilant  rales,  heard 
all  over  the  chest,  distinctly  point  to  obstruction 
in  the  upper  air  passages,  are  regarded  as  suitable 
for    this    method   of  treatment.      Cases  in  which 


i89i.] 


DOMESTIC  CORRESPONDENCE. 


645 


the  bacilli  are  no  longer  localized,  but  have  he- 
come  disseminated  throughout  the  lungs, 
mitted  by  Dr.  Tyndale  to  be  incurable  by  his  own 
or  any  other  treatment  that  has  as  yet  b 
vised. 

For  each  injection  he  usually  employs  the  con- 
tents of  one  capillary  tube,  about  2  drops,  of  pure 
vaccine  lymph,  and  he  mixes  with  it  15  drops  of 
distilled  water  and  1  drop  of  glycerine.  The 
Quid  is  injected  subcutaneously  near  the  seat  of 
trouble  by  means  of  an  ordinary  hypodermic 
syringe.  At  first  the  injections  are  made  at  in- 
tervals of  from  six  to  eight  days,  but  after  the 
bacilli  have  disappeared  and  the  expectoration 
has  become  sparse  and  of  a  mucus  character, 
they  are  made  only  once  in  every  two,  three  or  four 
weeks.  At  the  third  and  fourth  injections  the 
contents  of  two  tubes  are  often  used.  No  violent 
reaction  follows  the  injection,  but  the  temperature 
usually  rises  from  one  to  two  degrees  in  the  course 
of  from  eight  to  twenty  hours,  and  more  or  less 
frontal  headache  is  apt  to  be  experienced.  As 
long  as  the  signs  of  active  tuberculosis  remain, 
no  supporting  treatment  is  adopted,  but  as  soon 
as  these  have  disappeared,  means  for  the  promo- 
tion of  blood  and  fat  formation,  varied  according 
to  the  circumstances  of  the  special  case,  are  at 
once  inaugurated.  Lung  gymnastics,  consisting 
of  five  deep  inspirations  every  twenty  minutes 
throughout  the  day,  also  constitute  an  important 
part  of  Dr.  Tyndale's  treatment. 

So  far  as  known,  the  twenty  three  cases  men- 
tioned are  all  that  have  as  yet  been  treated  by  the 
vaccine  lymph  inoculations,  but  the  impression 
made  by  the  paper  and  by  the  nine  patients  ex- 
hibited was  such  that  it  is  probable  that  before 
long  the  method  will  be  tested  by  a  series  of  in- 
vestigations sufficiently  extended  to  showwheth 
er  it  is  really  of  permanent  value  or  not.  In  regard 
to  the  treatment  of  tuberculosis  in  general,  Dr. 
Tyndale's  idea  is  that  more  than  one  animal  and 
chemical  virus  will  be  found  to  accomplish  the 
same  object,  and  that  the  secret  of  the  whole  mat- 
ter lies  to  a  great  extent  in  a  correct  diagnosis 
and  the  adaptation  of  the  remedy  to  each  indi- 
vidual case. 

Since  the  meeting  at  which  his  paper  was  read 
it  has  been  suggested  that  a  commission  should 
be  appointed  by  the  County  Association  to  make 
a  thorough  investigation  and  report  upon  Dr. 
Tyndale's  method,  and  it  is  probable  that  this 
will  be  done. 

A  very  interesting  occasion  was  that  of  the 
graduation  of  the  first  class  of  pupils  from  the  Bel- 
levue  Hospital  Training  School  for  Male  Xurses, 
which  was  established  two  3-ears  ago  through  the 
liberality  of  Mr.  D.  O.  Mills,  and  was  probably 
the  first  institution  of  its  kind  in  the  world. 
There  w7ere  seventeen  graduates,  and  a  remark- 
able feature  in  regard  to  the  class  was  the  di 
versity  of  the  localities  from  which  its  members 


hailed.  One  was  from  New  York  City,  two  from 
other  parts  of  the  State  of  New  York,  two  from 
New  Jersey,  two  from  Pennsylvania,  one  from 
Connecticut,  one  from  Massachusetts,  one  from 
Michigan,  ami  one  each  from  London,  Berlin,  Co- 
penhagen, Edinburgh,  Paisley,  Scotland,  Wale--. 
and  Clare,  Ireland.  The  diplomas  were  presented 
by  the  founder.  Mr.  Mills,  himself,  and  addresses 
were  delivered  by  ex-Mayor  Abram  S.  Hewitt 
and  the  Hon.  Chauncey  M.  Depew.  Since  the 
school  was  established  there  have  been  in  all  115 
pupils,  and  there  are  at  present  43  in  attendance. 
The  Hospital  Saturday  and  Sunday  Associa- 
tion's distributing  committee  recently  met  at  the 
Mayor's  office,  and  made  the  annual  apportion- 
ment of  the  money  resulting  from  the  annual 
public  collection  for  the  hospitals.  The  amount 
collected  this  year  was  558,297,  and  of  this 
000  was  distributed  to  the  various  institutions 
represented  in  the  Association  in  accordance  with 
the  number  of  free  days  of  treatment  furnished 
by  each  during  the  year  1890.  The  hospitals  re- 
ceiving the  largest  amounts  are  the  following : 
Mount  Sinai  Hospital.  56,789;  St.  Luke's  Hospi- 
30;  Montefiore  Home  for  Chronic  Inva- 
lids, 55.020;  German  Hospital,  54.890;  and  the 
Hospital  for  Ruptured  and  Crippled,  54,^77.  '  >n 
Easter  Sunday  the  Rapid  Transit  Electric  Rail- 
road Conjpany,  of  Newark,  N.  J.,  generously 
gave  all  its  receipts  to  the  three  hospitals  of  that 
city  which  are  supported  by  charity — St.  Mi- 
chael's, St.  Barnabas  and  the  German.  The  traf- 
fic was  unusually  heavy,  and  as  many  of  the  pas- 
sengers paid  bills  instead  of  nickels  for  their  fares, 
the  amount  realized  was  the  handsome  sum  of 
$902. 

The  noted  Fayerweather  will  contest  having 
been  brought  at  last  to  an  end,  many  of  our  hos- 
pitals will  receive  substantial  additions  to  their 
endowments.  Thus  the  Woman's  Hospital  is  to 
get  from  the  estate  S2 10.000,  St.  Luke's  Hospital, 

[  the  Presbyterian  Hospital  and  the  Manhattan  Eye 
and  Ear  Hospital  each  Sso.ooo,  and  Mount  Sinai 
Hospital,  the  New  York  Eye  and  Ear  Infirmary, 
the  Manhattan  Hospital  and  Dispensary,  the  New 

I  York  Cancer  Hospital  and  the  Montefiore  Home 

j  for  Chronic  Invalids,  each  S25,ooo 

A  gratifying  mark  of  progress  in  this  close  of 

I  the  nineteenth   century  is  the   establishment  of 

!  public  hospitals  in  so  many  of  the  smaller  cities 
and  towns  of  the  country.     In  the  village  of  Sing 

ISing.  on  the  Hudson,  there  has  just  been  opened 

I  the  Ossiming  Hospital,  a  substantial  building  con- 
taining thirty  rooms  and  fitted  up  with  all  need- 

I  ful  appliances.  It  stands  on  a  two-acre  lot  in  a 
healthful  location,  and  is  lighted  with  gas  and 
supplied  with  water  from  the  village  system. 

The  bill  appropriating  5454.000  for  carrying 
out  the  provisions  of  the  law  establishing  State 
care  of  the  insane  poor,  which  was  enacted  a  year 
ago,  has  happily  passed  the  Legislature  and  re- 


646 


DOMESTIC  CORRESPONDENCE. 


[May  2, 


ceived  the  Governor's  signature.  The  State  pol- 
icy in  regard  to  this  matter  having  been  once  set- 
tled, good  faith  required  that  the  appropriation 
should  be  made,  to  give  full  effect  to  the  benefi- 
cent measure  which  was  the  result  of  so  many 
years  of  agitation  and  effort.  Yet  it  had  to  en- 
counter the  same  opposition  that  this  grand  re- 
form movement  has  always  met  with,  and  at  one 
time  Albany  fairly  swarmed  with  county  super- 
visors and  with  lobbyists  who  spared  no  effort  to 
defeat  it.  While  the  bill  was  pending  the  Medi- 
cal Society  of  the  State  of  New  York  was  in 
session,  and  it  adopted  resolutions  strongly  urg- 
ing its  passage.  The  annual  report  of  the  State 
Commission  in  Lunacy  for  1890  shows  that  the 
money  thus  appropriated  will  be  sufficient  to  pro- 
vide for  all  of  the  insane  poor  now  unprovided 
for  by  the  State,  when  used  in  conjunction  with 
appropriations  which  have  been  already  made 
and  with  other  provisions  which  have  been  se- 
cured. The  claim  which  had  been  put  forth  by 
the  enemies  of  this  movement,  that  the  State  hos- 
pitals for  the  insane  are  all  badly  overcrowded,  is 
shown  by  the  report  to  be  almost  entirely  without 
foundation.  Moreover,  the  Commission  shows  in 
its  estimate  that  it  has  left  a  liberal  margin  for 
the  annual  increase  in  the  number  of  the  insane 
in  the  State.  While  the  report  clearly  indicates 
that  the  Commissioners  do  not  favor  overcrowd- 
ing in  the  State  hospitals,  it  is  undoubtedly  their 
opinion  that  even  if  this  should  exist  to  some 
little  extent,  it  would  be  much  better  for  the  pa- 
tients than  to  be  crowded  together  in  the  wretched 
quarters  and  with  the  inadequate  care  provided 
by  the  county  poor-houses. 

Until  within  a  comparatively  recent  period  in- 
sanity was  believed  to  be  increasing  with  great 
rapidity  relatively  to  the  increase  of  population. 
The  report  of  the  State  Commission  in  Lunacy 
shows,  however,  that  at  present  insanity  is  ap- 
parently decreasing,  rather  than  increasing,  rela- 
tively to  the  general  population.  Notwithstand- 
ing the  incalculable  harm  that  has  resulted  from 
the  legal  division  of  the  insane  into  two  classes, 
the  acute  and  chronic,  or  so-called  incurable  (one 
of  the  great  evils  against  which  the  long  agita- 
tion in  this  State  has  been  directed),  there  is  rea- 
son to  believe  that  this  favorable  result  has  been 
chiefly  brought  about  by  the  improved  methods 
that  have  been  more  or  less  generally  adopted  in 
the  treatment  of  the  insane.  Consequently,  there 
can  be  little  question  that  when  all  the  insane 
poor  of  the  various  countries  shall  have  been 
brought  under  the  beneficent  influences  which 
prevail  at  the  State  Hospitals  under  their  present 
enlightened  management,  the  results  will  be  even 
more  satisfactory.  The  statistics  presented  in 
the  report  of  the  Commission  show  that  in  the 
State  Hospital  at  Utica  the  percentage  of  recov- 
nuong  the  patients  has  been  19.53,  in  the 
Buffalo   hospital   29.19,  in  the   Middletown  hos- 


pital 16.16,  in  the  Poughkeepsie  hospital  18,  and 
in  the  Asylum  for  Insane  Criminals  3.96.  The 
report  outlines  the  history  of  the  State's  system 
of  caring  for  its  insane  dependents,  and  shows 
that  the  present  plan  of  management  is  in  accord 
with  the  policy  that  has  been  adopted  for  the 
prisons  and  other  large  interests  that  require  ap- 
propriations by  the  Legislature. 

Like  liberty,  however,  reform  in  the  care  of  the 
insane  by  the  State  must  depend  on  eternal  vigi- 
lance for  its  maintenance,  requiring  constant  ef- 
forts on  the  part  of  its  friends.  The  State  Com- 
mission in  Lunacy,  which  has  been  so  prominent 
in  the  movement,  has  naturally  made  enemies 
not  only  of  a  host  of  county  officers,  but  of  all  the 
corrupt  elements  of  the  managing  boards  of  the 
State  Asylums,  which  have  been  practically  su- 
perceded by  it.  The  unchecked  expenditure  of 
from  two  to  three  million  dollars  yearly  has  been 
taken  from  them,  and,  as  has  been  pointed  out, 
the  expenditure  of  large  sums  of  money  derived 
I  from  State  and  other  nonlocal  sources  by  local 
'.  boards  can  hardly  be  otherwise  than  extravagant 
J  and  corrupt.  The  prize  of  the  two  or  three  mill- 
]  ions  annually  required  for  the  State  hospitals  for 
I  the  insane  is  a  tempting  one,  and  there  is  consid- 
!  erable  danger  that  a  ring  of  public  plunderersy 
j  now  drawn  from  the  hospital  boards,  or  held  in 
!  check  by  the  Commission  in  Lunacy,  may  suc- 
ceed in  abolishing  that  bod)',  and  re-establishing 
their  rights  to  these  institutions  as  a  local  fran- 
I  chise  and  to  the  function  of  investigating  them- 
selves and  their  agents. 

Since  the  appropriations  required  for  the  pres- 
ent needs  of  the  State  hospitals  were  made  by 
the  Legislature,  a  bill  has  been  passed  by  the 
Senate  which  materially  modifies  the  law  for  the 
State  care  of  the  insane  so  far  as  it  applies  to  the 
State  hospital  at  Middletown,  which  is  in  charge 
of  a  staff  of  homoepathic  physicians  ;  and  the 
State  Commission  in  Lunacy,  the  State  Charities 
Aid  Association,  and  all  those  who  worked  to  se- 
cure the  enactment  of  the  existing  law,  are  nat- 
urally strongly  opposed  to  the  adoption  of  this 
measure.  Under  the  present  law's,  all  the  State 
hospitals  are  authorized  to  receive  paying  pa- 
tients from  all  parts  of  the  State,  provided  that 
there  is  room  for  such  patients  not  required  by 
the  pauper  and  indigent  insane  for  whose  benefit 
these  institutions  are  established.  The  proposed 
legislation  (adopted  by  the  Senate,  but  not  yet 
by  the  Assembly),  seeks  to  free  the  Middletown 
Asylum  from  this  condition,  leaving  it  optional 
with  this  hospital  to  fill  its  wards  entirely  with 
paying  patients  should  it  so  desire,  without  re- 
striction of  any  kind.  The  second  part  of  the 
bill  is  designed  to  allow  the  Middletown  State 
Hospital  to  receive  indjgent  and  pauper  patients 
without  restriction  from  all  parts  of  the  State, 
and  to  fix  the  charge  to  the  counties  for  their 
maintenance. 


i89i.] 


DOMESTIC  CORRESPONDENCE. 


This  legislation,  as  pointed  out  by  Prof.  Chas. 
F.  Chandler,  President  of  the  State  Charities  Aid 
Association,  with  which  the  State  Care  Act  orig- 
inated, would  nullify  two  important  features  of 
the  latter  act.  "That  an  effort,"  he  says,  in  a 
letter  addressed  to  the  Chairman  of  the  Commit- 
tee on  Public  Health,  "  should  be  made  to  break 
up  the  State  Care  system,  as  provided  by  this 
law — a  law  which  for  three  years  has  been  under 
discussion  by  the  entire  press  of  the  State,  by 
three  successive  Legislatures,  and  has  received 
the  verdict  of  popular  approval — before  the  law 
has  had  time  to  go  into  full  operation,  is  much 
to  be  deplored.  On  October  ist,  1890,  the  State 
was  divided  into  State  asylum  districts.  .  .  .  I 
This  provision  of  the  law  causes  no  injustice,  and 
is  working  satisfactorily,  and  therefore  I  wish  to 
express  my  dissent  from  that  portion  of  the  bill 
which  gives  the  Middletown  hospital  the  right 
to  receive  pauper  and  indigent  insane  patients 
from  any  part  of  the  State,  as  tending  to  break 
down  the  State  districting  of  the  State  Care  act. 
Should  the  same  privilege  be  extended  to  all  the 
State  asylums  the  valuable  State  districting  fea- 
tures of  the  State  Care  Act  would  cease  to  ex- 
ist. The  other  importaut  feature  of  the  State 
Care  Act  which  will  be  nullified,  should  the 
Legislature  grant  special  privileges  to  the  Mid- 
dletown State  Hospital,  is  that  which  provides 
that  after  the  State  has  been  divided  into 
asylum  disiricts,  the  charge  to  the  counties  for 
their  pauper  and  indigent  insane  in  State  asylums 
shall  be  the  same  for  all  the  counties  of  the  State. 
It  seems  to  me  right  and  just  that  the  charges  to 
the  counties  for  the  care  of  their  pauper  and  indi- 
gent patients  in  State  asylums  should  be  thesame 
for  all  the  counties  of  the  State,  and  therefore  I 
am  obliged  again  to  express  my  dissent  to  that 
portion  of  the  bill  which  exempts  the  Middletown 
asylum  from  this  provision  of  the  act.  As  Pres- 
ident of  the  State  Charities  Aid  Association  I  re- 
spectfully protest  against  the  enactment  of  this 
special  legislation,  which  I  believe  to  be  opposed 
to  the  best  interests  of  the  pauper  and  indigent 
insane  of  this  State." 

The  University  Medical  School,  which  has  just 
celebrated  its  50th  anniversary,  had  a  very  large 
graduating  class  this  year,  203.  The  Bellevue 
graduates  numbered  152,  and  those  of  the  Long 
Island  College  Hospital,  Brooklyn,  82.  At  a 
meeting  of  friends  of  the  University  called  for  the 
purpose  of  aiding  in  raising  a  fund  of  5500, 000  for 
the  needs  of  this  institution  Prof.  Alfred  L. 
Loomis  recently  stated  that  the  medical  depart- 
ment of  the  University  on  its  present  basis  had 
reached  its  utmost  possible  limit  of  success.  This 
year  there  was  a  matriculating  class  of  694,  so 
that  all  the  professors  received  salaries  sufficient 
to  compensate  them.  Without  an  endowment, 
however,  it  would  not  do  to  raise  the  standard  of 
the  school,  since  maintenance  was  dependent  on 


the  tuition  fees  of  the  students,  and  to  do  this 
would  cause  a  falling  off  of  about  30  per  cent,  in 
the  attendance.  Dr.  Loomis  said  furthermore  on 
this  occasion  that  rich  New  Yorkers  were  pour- 
ing out  their  money  for  hospitals,  while  they  al- 
lowed educational  interests  to  suffer.  He  be- 
lieved that  at  least  $500,000  had  been  spent  for 
hospitals  in  this  city  which  ought  to  have  been 
devoted  to  the  latter.  Consequently,  New  York 
had  more  hospitals  to-day  than  the  needs  of  the 
sick  and  indigent  required,  and  nearly  one-third 
of  the  patients  in  these  hospitals  who  are  able  to 
be  taken  care  of  elsewhere.  p.  b.  p. 


To  the  Editor: — In  your  issue  of  October  11 
there  appears  a  paper  by  Dr.  Wm.  H.  Daly,  a 
nose  and  throat  specialist  of  this  city,  on  ' '  The 
Medical  Treatment  of  Diphtheria,"  containing 
statements  that  call  for  correction.  The  paper 
was  read  at  the  forty-first  annual  meeting  of  the 
American  Medical  Association  at  Nashville,  June, 
1890,  and  strange  to  relate,  its  claims  for  origi- 
nality were  not  contradicted.  The  special  treat- 
ment for  diphtheria  to  which  Dr.  Daly  refers,  and 
which  he  claims  as  his  own,  is  that  by  large  doses 
of  calomel.  He  says  :  "  You  will  pardon  me  if 
I  undertake  to  draw  your  attention  again  to  a 
well-tried  plan  of  treatment  which  I  had  the 
honor  of  bringing  to  the  notice  of  the  profession 
in  a  paper  entitled,  '  The  Simplest  and  most  Effi- 
cient Treatment  of  Diphtheria,'  which  I  read  be- 
fore the  Congress  of  the  American  Laryngological 
Association  in  Philadelphia  in  1886."  I  propose 
to  prove  to  you  that  the  writer  of  both  of  these 
papers  shows  a  lack  of  justice  toward  his  profes- 
sional brethren  that  is  truly  marvelous.  The 
treatment  of  diphtheria  by  large  doses  of  mercury 
was  first  practiced  by  Bretonneau  in  182 1,  and 
his  method  of  administering  the  drug,  and  his 
history  of  cases  appear  in  the  Transactions  of  the 
Sydenham  Society.  Dr.  Daly  may  be  ignorant 
of  the  work  of  Bretonneau,  but  he  cannot  enter 
such  a  plea  as  regards  the  work  of  the  late  Dr. 
Wm.  C.  Reiter,  of  this  city.  Dr.  Daly  and  Dr. 
Reiter  were  fellow-townsmen  and  cotemporaries, 
and  Dr.  Daly,  like  the  rest  of  Dr.  Reiter's  friends, 
cannot  forget  the  earnest  enthusiasm  with  which 
the  calomel  treatment  was  urged.  Dr.  Reiter's 
sole  aim  during  his  later  years  was  to  impress  the 
value  of  the  calomel  treatment  on  the  profession, 
and  in  pursuance  of  this  effort  he  published  in 
1S7S.  through  the  Lippincotts,  of  Philadelphia, 
a  monograph  entitled.  "The  Treatment  of  Diph- 
theria Based  upon  a  New  Etiology  and  Pathol- 
ogy." It  is  to  this  little  book  that  Dr.  Daly  is 
indebted,  not  only  for  his  ideas,  but  in  many  in- 
stances/!"- his  very  words.  Finally,  Dr.  J.  Chris. 
Lange  read  a  paper  on  the  calomel  treatment  be- 
fore the  Mott  Club,  of  Pittsburgh,  of  which  Dr. 
Daly  was    a   member,  in  1SS2,  and  published  it, 


648 


MISCELLANY. 


[May  2,  1891. 


together  with  the  discussion  which  it  provoked, 
in  the  Philadelphia  Medical  Times  of  January 
8,  1883. 

It  may  seem  a  gratuitous  labor  on  my  part  to 
make  this  correction,  but  I  am  convinced  of  the 
need  of  it  by  the  citation,  in  Keating's  Cyclopae- 
dia of  the  Diseases  of  Children,  of  Dr.  Daly  as 
the  sponsor  for  the  calomel  treatment.  A  proper 
regard  for  the  memory  of  Dr.  Reiter  prompts  me 
to  speak.  Adolph  Kcenig,  M.D. 

v\  Ninth  St.,  Pittsburgh. 


SPECIAL  CORRESPONDENCE. 


To  the  Editor: — Those  doctors  at  Washington 
who  have  endeavored  to  transfer  The  Journal, 
had  better  come  to  Chicago ;  they  will  find  much 
to  their  own  advantage.  At  least  the  good  of 
The  Journal  and  Association  can  be  best  served 
at  the  geographical  centre,  Chicago.  Decidedly 
no  !  Do  not  remove  The  Journal  to  Washing- 
ton.    "  Do  not  put  it  under  a  bushel." 

J.  Ch.  Dodds,  M.D. 

Denver,  Col. 


Shall  The  Journal  be  Removed  to 
Washington  ? 

action   of   the   aurora  (ill.),  medical 

SOCIETY. 

At  the  regular  meeting  of  this  Society,  held 
April  7,  the  following  preamble  and  resolution 
was  read,  and  unanimously  adopted  : 

Whereas,  we  as  members  of  the  Medical  Profession, 
feel  a  deep  interest  in  the  prosperity  and  welfare  of 
The  Journal  of  the  American  Medical  Associa- 
tion, situated  as  it  is  near  the  geographical  centre  of  its 
numerous  subscribers  and  contributors,  with  facilities  for 
its  earh-  and  rapid  distribution  unsurpassed  in  the 
United  States,  and  believing  that  its  removal  to  the  City 
of  Washington,  in  place  of  being  an  advantage,  would 
certainlv  be  a  detriment  to  its  usefulness.  Therefore, 
be  it, 

Resolved,  that  we  cast  our  unanimous  vote  to  have  it 
remain  in  its  present  location  and  under  its  present  able 
management. 


To  the  Editor : — I  have  been  a  member  of  the 
American  Medical  Association  for  a  number  of 
years,  and  have  taken  The  Journal  ever  since 
its  first  publication,  and  live  900  miles  from  Chi- 
cago, and  always  receive  it  on  the  day  of  its 
issue,  and  find  it  increasing  in  value  and  interest; 
therefore,  cannot  see  what  advantage  could  be 
derived  from  changing  the  place  of  its  publi- 
cation from  Chicago  to  Washington.  Under  such 
circumstances  I  say,  let  it  remain  in  Chicago. 
A.  M.  Miller,  M.D. 

Bird-in-Hand,  Pa.,  April  20,  1891. 


MISCELLANY. 


Missouri  State  Medical  Association. — The  an- 
nual meeting  of  this  Association  will  be  held  at  Excelsior 
Springs,  May  19th,  20th,  and  21st. 


To  the  Editor : — The  publication  of  The  Jour 
nal  is  preeminently  a  business  enterprise.  If 
the  place  of  publication  is  to  be  changed,  good 
and  sufficient  reason  must  be  shown  for  such 
change  ;  no  argument  being  necessary  to  main- 
tain a  location  when  it  has  prospered.  No  argu- 
ment has  been  brought  forward  which  a  business 
man  would  consider  for  a  moment  as  a  reason  for 
changing  his  place  of  business.  Therefore,  do 
not  change, 

Horace  M.  Starkey,  M.D. 

Chicago,  111.,  April  23,  1891. 


Official  List  of  Changes  in  the  Stations  and  Duties  of  Officers  Serving 
in  the  Medical  Department,  V.  S.  Army,  from  April  iS,  iSoj,  to- 
April  21,  1891, 

Major  Alfred  A.  Woodhull,  Surgeon,  is  detailed  to  represent  the 
Medical  Dept.  of  the  Army  at  the  International  Congress  of  Hy- 
giene and  Demography,  at  its  meeting  in  London,  Eng.,  from 
August  10  to  17,  1S9L  He  will  leave  his  present  station  not  later 
than  June  i,  1S91,  and  will  proceed  to  London.  After  the  adjourn- 
ment of  the  Congress  he  will  return  to  his  proper  station.  While 
abroad  under  this  order,  and  before  returning  to  the  United  States. 
he  will  visit  on  official  business  such  points  in  Great  Britain  as 
may  be  deemed  necessary  by  the  Surgeon  General  of  the  Array. 
Bv  direction  of  the  Acting  Secretary  of  War.  Par.  17,  S.  O.  91,  A. 
G".  O.,  Washington,  April  22,  1891. 

Capt.  William  F.  Kuudler,  Asst.  Surgeon,  is  relieved  from  duty  at 
Tackson  Bks.,  La.,  and  will  report  in  person  to  the  commanding 
officer,  Ft.  Logan,  Col.,  for  duty  at  that  post,  reporting  also  by 
letter  to  the  commanding  General,  Dept.  of  the  Miss,  1. 
rection  of  the  Acting  Secretary  of  War.  Par.  2.  S.  O.  SS,  A.  G'.  O., 
Hdqrs.  of  the  Army,  Washington,  April  is,  1S91. 

Official  List  of  Changes  in  the  Medical  Corps  of  the  U.  S.  Navy,  for 
the  Week  Ending  April  2$,  1891. 

Medical  Inspector  D.  McMurtrie.  detached  from  Navy  Yard,  New 
Y..rk.  and  to  the  U.  S.  S.  "  Lancaster." 

Medical  Inspector  Edward  Kershner,  detached  from  Marine  Ren- 
dezvous and  to  Naw  Y'ard,  New  York. 

Surgeon  C  G.  Herudon,  from  Naval  Hospital,  New  Y'ork.  and  to 
the  Marine  Rendezvous. 

P.  A.  Surgeon  Tames  E.  Gardner,  ordered  to  Naval  Hospital,  New 
\-ork. 

Official  List  of  Changes  of  Stations  and  Duties  of  Medical  Officers  of 
the  U.  S.  Marine-Hospital  Service,  for  the  T:,o   Weeks  Ending 

April  IS,  1891. 
Surgeon  P.  A.  Bailhache.  to  represent  the  Service  at  the  annual 

meeting  of  the  California   State  Medical  Society.     April  8,  1891. 

Detailed  as  chairman  of  Board  for  the  physical  examination  ol 

officers,  Revenue  Marine  Service.     April  14,  i^qi. 
Surgeon  John  Vansant,  detailed  as  chairman  of  Board  for  physical 

examination  of  officers,  Revenue  Marine  Service.     April  14,  1891. 
Surgeon  H.  VV.  Austin,  detailed  as  chairman  of  Boards  for  physical 

examination  of  officers  and  candidates,  Revenue  Marine  Service. 

April  14  and  15,  1S91. 
Surgeon  J.  M.  Gassawav,  leave  of  absence  extended  five  davs.   April 

15,  1S91. 
Surgeon  G.  W.  Stoner,  to  proceed  to  Alpena,  Mich.,  on  special  duty. 

April  12,  1891. 
P.   A.  Surgeon  W.  P.  Mcintosh,  detailed  as  recorder  of  Board  for 

physical  examination  of  officers,  Revenue  Marine  Service.    April 

P.  A.  Surgeon  G.  M.  Magruder,  detailed  as  recorder  of  Board  for 
physical  examination  of  officers,  Revenue  Marine  Service.    April 

Asst.  Surgeon  T.  B.  Perry,  ordered  to  examination  for  promotion. 
April  6,  1891. 

Asst  Surgeon  R.  M.  Woodward,  ordered  to  examination  for  promo- 
tion.   April  6,  1891. 

Asst.  Surgeon  H.  T.  Goodwin,  ordered  to  examination  for  promo- 
tion.   April  6,  1891. 

Asst.  Surgeon  G.  T.  Vaughan,  ordered  to  examination  for  promo- 
tion.    April  6,  1891. 

Asst.  Surgeon  H.  D.  Geddings,  detailed  as  recorder  of  Board  for 
physical  examination  of  officers  and  candidates,  Revenue  Marine 
Service.    April  14,  1891. 

.»  --t.  Surgeon  J.  C.  Perry,  detailed  as  recorder  of  Board  for  physical 
examination  of  officers.  Revenue  Marine  Service.     April  14,  1891. 

Assl    Surgeon  J.  F.  Groenevelt.  to  rejoin  station  1  New  York).   April 

1.  Sur.. 

iv  duty.     Aprif  13,  1891 


T  1 1  E 


J  ournal  of  the  American  Medical  Association. 

EDITED  UNDER  THE  DIRECTION  OF  THE  BOARD  OF  TRUSTEES. 

IT  li  LI  SHED    WEEKLY. 


Vol.  XVI. 


CHICAGO,   MAY  g,    1891. 


No.   19. 


ADDRESSES. 


THE  PRESIDENT'S   ADDRESS. 


Delivered  at  the  Forty~sccond  Annual  Meeting  of  tht-  American  Medi- 
cal Association,  at    Washing'  ,1891. 

BY  WM.  T.  BRIGGS,  M.D., 

OF     NASHVILLE,     TENN. 
PRESIDENT    OF   THE   ASSOCIATION. 

Ladies  and  Gentlemen:  My  heart  swells  with 
pride  when  I  look  over  this  vast  assembly  of  the 
representatives  of  a  profession,  distinguished  alike 
for  its  antiquity,  its  scientific  attainments,  and  its 
usefulness  ;  a  profession  which  forms  the  true 
link  between  science  and  philanthropy. 

You,  gentlemen,  as  members  of  this  Associa- 
tion, have  been  delegated  by  your  local  Associa- 
tions, from  every  part  of  this  Grand  Republic, 
from  the  Kennebec  to  the  Rio  Grande,  from 
orange  groves  and  golden  sands,  from  mountains 
clad  in  eternal  snows,  and  valleys  smiling  iu  per- 
petual verdure,  to  represent  them  on  this  occasiou. 

You  are  here  with  no  selfish  motives,  nor  pur- 
poses of  self-aggrandizement,  nor  to  excite  or 
perpetuate  sectional  antipathies. 

Indeed,  as  physicians  you  should  recognize  no 
section  ;  with  you  there  should  be  no  East,  no 
West,  no  North,  no  South.  You  are  here  solely 
for  the  promotion  of  science  and  for  the  good  of 
the  human  race.  You  are  here  to  maintain  the 
honor  and  dignity  ot  the  profession  and  to  hold 
aloft  the  flag  of  honorable  medicine.  You  are 
here  to  lay  your  contributions, — the  accumula- 
tions of  your  study  and  observation, — upon  a 
common  altar  for  the  common  good  ;  to  worship 
at  the  sacred  shrine  of  medicine  and  to  renew 
your  fealty  to  the  noble  profession  to  which  you 
have  devoted  your  lives  and  linked  your  fortunes. 
You  are  here  to  exchange  experiences  with  each 
other,  to  separate  by  discussion  the  grains  of 
truth  from  the  wordy  chaff  in  which  they  may  be 
hidden,  to  renew  friendships  and  to  weave  more 
closely  the  bonds  of  professional  brotherhood. 

As  physicians  you  have  an  almost  superhuman 
mission  to  fill.  Life,  the  greatest  of  human  bless- 
ings, and  health,  the  greatest  stimulant  to 
earthly  enjoyment,  are  the  issues  with  which  you 
are  called  to  deal. 

The  chief  objects  of  your  professional  work  are 


to  preserve  the  one,  and  to  procure  the  other. 
The  goal  of  your  ambition  and  desire  is  almost 
at  the  end  of  human  capacity.  It  is  your  prov- 
ince as  well  as  your  earnest  desire  to  know  all 
the  secrets  of  organization.  You  would  have  the 
formative  crystal  and  germinal  spot  made  trans- 
parent. You  would  enter  the  microscopic  world 
and  witness  the  wonders  therein  revealed.  In- 
deed, you  would,  if  it  were  possible,  search  into 
and  unravel  the  very  mysteries  of  the  vital 
principle. 

To  this  perfect  knowledge  you  aspire. 

It  is  doubtful  if  man's  intellect,  great  as  it  is, 
can  ever  compass  all  that  he  so  earnestly  desires, 
yet  by  constant  and  faithful  work  he  may  ap- 
proach nearer  and  nearer  to  its  consummation. 

He  has  before  him  rich  and  boundless  fields  for 
research,  from  which  the  eager  and  enthusiastic 
explorer  may  gather  the  richest  prizes.  To  these 
fields  the  future  generation  of  physicians  will  be 
attracted  in  the  hope  and  belief  that  as  man  ad- 
vances in  knowledge  and  approaches  nearer  to 
the  understanding  of  the  perfect  wisdom,  which 
designed  his  physical  organization  and  by  which 
he  is  brought  in  relation  with  the  world  around 
him,  he  will  be  enabled  to  solve  more  and  more  of 
the  difficult  problems  which  have,  for  ages,  baf- 
fled, and  perplexed  him,  and  to  elevate  the  profes- 
sion of  medicine  to  a  position  more  nearly  akin 
to  that  accorded  to  the  exact  sciences. 

We  live  in  an  age  of  progress,  and  all  the  arts 
and  sciences  are  advancing  with  gigantic  strides. 
With  the  aid  of  steam  and  electricity  time  and 
space  have  been  almost  obliterated.  The  most 
distant  parts  of  the  world  have  been  made  neigh- 
bors. A  fact  developed  or  an  important  discovery 
made,  is  flashed  in  the  shortest  conceivable  time 
to  the  most  remote  parts  of  the  globe  and  given  to 
the  public  without  money  and  without  price. 

The  science  of  medicine  has  kept  pace  with,  if 
it  has  not  outstripped  all  other  sciences. 

It  has  been  completely  revolutionized  within 
our  day.  The  microscope,  chemical  analysis, 
clinical  observation  and  vivisection  are  carrying 
the  medical  mind  with  wonderful  velocity  in  pur- 
suit of  knowledge,  far  beyond,  indeed,  the  most 
sanguine  conceptions  of  even  a  third  of  a  century 
ago. 

In  every  part   of  the  habitable   world   blessed 


650 


THE  PRESIDENT'S  ADDRESS. 


[May  9, 


with  the  light  of  civilization,  active,  busy  members 
of  our  profession  endowed  with  high  culture  and 
incited  by  the  noblest  resolves  are  enthusiastic- 
ally engaged  in  unravelling  the  mysteries  of  dis- 
ease and  seeking  the  means  and  methods  of  treat- 
ment for  the  mitigation  and  relief  of  suffering 
and  the  prolongation  of  life. 

That  the  full  benefit  of  the  labors  of  American 
physicians  might  be  attained  and  utilized,  it  was 
essential  that  the  members  of  the  profession  scat- 
tered over  an  area  of  country  of  almost  inconceiv- 
able extent,  should  be  brought  into  associated  ac- 
tion,— should  be  organized  into  a  body  by  whose 
annual  discussion  an  exciting,  vivifying  and 
healthful  influence  might  be  exerted  over  the 
length  and  breadth  of  the  land,  until  a  correct 
and  noble  sentiment  had  been  engendered  in  the 
bosom  of  every  member  of  the  profession. 

Through  the  brilliant  genius  and  indomitable 
energy  of  one  who  is  known  as  the  "  Father  of  the 
Association,1'  this  grand  body  was  formed  and 
has  ever  been  sustained  and  fostered  by  his  pa- 
rental solicitude,  in  which  he  has  been  nobly  as- 
sisted by  the  cordial  cooperation  of  his  brethren. 
More  than  a  generation  has  passed  since  its  organ- 
ization, and  many  of  the  master  spirits  which 
were  present  and  assisted  in  the  inauguration  of 
the  enterprise  have  joined  the  silent  majority, 
leaving  it  as  a  precious  heritage  to  their  succes- 
sors, who  should  be  actuated  by  the  same  spirit 
which  inspired  those  who  had  preceded  them,  and 
with  the  same  energy  and  zeal  endeavor  to 
manage  the  high  trust  with  an  eye  single  to  the 
honor  and  glory  of  the  profession. 

A  few  of  those  who  assisted  in  its  organization 
in  1847,  weighed  down  with  honors  and  years, 
still  make  annual  pilgrimages  to  this  Medical 
Mecca  and  by  their  presence  and  counsel  add  in- 
creased interest  to  its  meetings. 

Chiefest  among  these  is  Nathan  Smith  Davis, 
to  whom,  more  than  any  other,  is  due  the  credit 
of  establishing  and  perpetuating  this  National 
Association — venerable,  distinguished,  renowned, 
may  he  be  long  spared  to  counsel  and  assist  in 
the  deliberations  of  the  body  ! 

The  purposes  of  those  who  organized  the  Asso- 
ciation were  to  protect  and  promote  the  interests 
of  the  American  Medical  profession,  to  maintain 
its  honor  and  respectability,  to  advance  its  knowl- 
edge and  to  extend  its  usefulness. 

That  these  desirable  objects  have  been  accom- 
plished to  a  very  gre?t  extent  is  a  matter  of 
history. 

Through  its  moral  influence  it  has  united  the 
great  mass  of  physicians  from  Maine  to  Texas, 
and  from  the  Atlantic  to  the  Pacific  in  the  bonds 
of  fellowship,  many  of  whom  at  great  sacrifice  of 
personal  comfort  and  pecuniary  interest,  come  to 
the  annual  meetings  with  hearty  fraternal  ;■ 
ingforeach    other,  and   who,  becoming   touched 


as  with  a  living  coal  of  fire,  renew  their  vows  of 
faithfulness  and  loyalt}'  to  the  cause  in  which 
they  are  engaged,  and  form  the  high  and  noble 
resolve  to  devote  their  time,  talent  and  lives  with 
still  greater  assiduity  to  their  chosen  profession. 
If  the  Association  had  done  nothing  more  than 
to  have  accomplished  this  unification  of  the  Med- 
ical profession,  it  would  have  performed  a  service 
entitling  it  to  an  imperishable  name.  It  has, 
however,  been  an  active  and  powerful  agent  in 
the  promotion  of  medical  science  and  in  the  dis- 
semination of  useful  knowledge.  It  has  excited 
a  spirit  of  improvement  among  the  masses  of  the 
profession  which  nothing  can  stay. 

Another  great  benefit  conferred  by  the  Associa- 
tion was  the  establishment  of  an  esprit  de  corps  in 
the  profession,  by  the  preparation  and  adoption 
of  a  Code  of  Ethics  which  comprises  the  great 
principles  of  truth,  honor  and  justice,  in  regulat- 
ing the  relations  of  physicians  to  each  other,  to 
their  patients  and  to  the  public.  It  should  be 
and  is  the  written  law  clearly  defined  and  of  ac- 
knowledged force  and  effect  that  prevails  from  one 
end  of  the  country  to  the  other.  It  forms  an  im- 
passable barrier  between  the  sheep  and  the  goats, 
the  clean  and  the  unclean,  the  physician  and  the 
charlatan. 

The  strict  observance  of  the  Code  has  done 
more  than  anything  else  to  maintain  harmony  in 
the  profession  and  to  elevate  it  in  the  public  esti- 
mation. It  embodies  the  true  spirit  of  the  Golden 
Rule, — "  Do  unto  others  as  you  would  have  others 
do  unto  you." 

Every  one  who  enters  the  profession  should  be 
provided  with  a  copy  of  the  Code  and  should 
make  it  the  guide  of  his  medical  life.  It  will  serve 
as  a  talisman  to  the  young  physician,  and  will  be 
the  best  safe- guard  against  the  snares  and  pitfalls 
which  environ  his  pathway  in  his  early  profession- 
al life. 

It  would  seem  that  every  honorable  and  high 
minded  member  of  the  profession  would  be  will- 
ing to  endorse  and  be  controlled  in  his  intercourse 
with  his  medical  brethren  and  the  public  by 
every  article  of  the  Code. 

It  is,  however,  to  be  regretted  that  there  are 
some,  who  undoubtedly  possess  high  order  of 
talents,  and  are  justly  distinguished,  who  have 
an  utter  repugnance  to  the  observance  of  certain 
parts  of  the  Code  and  hold  themselves  aloof  from 
the  Association  in  consequence. 

They,  probably  are  as  proud  of  our  noble  pro- 
lev,  ion  as  we,  and  are  equally  as  anxious  for  the 
advancement  of  its  interests,  but  can  they  con- 
scientiously affirm  that  the  motives  by  which  they 
are  influenced  are  pure  and  unselfish?  And  should 
1  small  minority,  put  their  opinion  against 
tin  unbiased  and  unselfish  judgment  of  the  wisest 
and  most  experienced  in  the  profession?  And 
when,  too,  nine  tenths  of  that  profession  endorse 


I89i.] 


THE  PRESIDENT'S  ADDRESS. 


651 


and  are  guided  in  their  actions  bv  the  spirit  and 
letter  of  the  Code? 

The  chief  object — indeed  the  fundamental  idea 
of  those  who  originated  the  Association  was  the 
improvement  of  the  American  system  of  medical 
education  and  the  elevation  of  the  standard  of  re- 
quirements for  the  professional  degree.  Never 
was  there  a  greater  expenditure  of  effort,  illumi- 
nated with  genius  and  learning,  to  accomplish 
these  two  great  objects.  Never  was  there  more 
eloquent  and  philosophical  reports  to  any  organ- 
ization than  those  presented  by  the  committees 
appointed  year  after  year,  to  this  body  ;  yet  it 
seemed,  after  all  efforts  in  that  direction,  as  far 
from  fruition  as  at  its  initial  meeting.  The  resolu- 
tions proposed  and  adopted  from  time  to  time, 
were  sufficiently  pointed  and  admirably  adapted 
to  the  end  in  view,  but,  unfortunately  the 
tion  had  no  legislative  authority  or  power  to  en- 
force its  enactments,  and  its  moral  suasion  and 
influence  was  not  great  enough  to  move  the  col- 
lege to  accept  their  counsel. 

In  1850  the  medical  colleges  were  invoked  to 
meet  and  correct  the  great  evils  of  the  prevalent 
plan  of  teaching  in  this  country,  but  they  did 
not  respond  to  the  appeal.  Since  then,  on 
various  occasions,  delegates  from  the  medical 
colleges  have  met  and  discussed  plans  for  the  ad- 
vancement of  medical  education  but  have  failed, 
from  want  of  cooperation  and  united  action,  to 
make  the  desired  changes. 

The  idea  of  making  such  changes  in  the  med- 
ical education  of  our  youths  in  a  country  so  di- 
versified and  of  such  extent,  in  a  few  years,  was 
probably  Utopian.  Such  radical  and  lasting 
changes  can  only  be  effected  by  the  slow  work  of 
time.  There  has,  however,  been  a  gradual  eleva- 
tion in  the  standard  of  education,  fully  equal  to 
the  progress  of  the  country  in  every  other  depart- 
ment of  human  learning. 

To  those  of  us  who  entered  upon  our  medical 
studies  twenty,  thirty,  or  forty  years  ago  it  will 
be  gratifying  to  visit  any  well  organized  medical 
college  and  witness  the  many  improvements  and 
the  increased  facilities  for  the  instruction  of  its 
pupils.  The  extended  curriculum  of  instruction, 
both  in  the  didactic  and  clinical  departments,  the 
patient  and  painstaking  work  in  the  laboratories 
of  Chemistry,  Physiology,  Pathology  and  experi- 
mental Therapeutics  :  the  special  instruction  in 
the  department  of  Surgery,  Obstetrics  and  Gyne- 
cology and  Ophthalmology;  the  resources  afforded 
by  hospitals  and  dispensaries,  and  the  admirable 
arrangement  for  the  prosecution  of  Practical 
Anatomy  in  the  dissecting  room,  all  attest  the 
wonderful  progress  and  advancement  made  in 
medical  teaching  since  our  pupilage. 

I  am  ready  to  maintain  that  the  advantages  and 
facilities  for  medical  instruction  in  our  country 
even  at  the  present  time  are  quite  equal  to  those 


of  any  other,  and  that  our  medical  colleges  have 
produced  as  able,  learned  and  successful  practi- 
tioners as  ever  graduated  from  other  institutions, 
and  while  I  am  willing  to  admit  that  our  trans- 
atlantic bi others  have  excelled  us  in  experimen- 
tal work,  we  excel  in  all  practical  department-  of 
medicine.  Chassaignac,  the  eminent  Parisian 
surgeon, exclaimed  a  few  years  since,  that  America 
held  the  scepter  of  the  Surgical  world  ;  and  more 
recently  Yirchow,  President  of  the  late  Inter- 
national Medical  Congress,  said,  "The  American 
Medical  world  to-day  excels  in  Surgery,  Mid- 
wifery and  Dentistry.'' 

What  American  physician  is  not  overwhelmed 
with  thankfulness  when  be  remembers  the  pain 
and  anguish  which  has  been  prevented  thro 
the  great  boon  of  anaesthesia,  which  in  the  pi 
dence  of  God  was  given  to  our  country  ;  who 
will  ever  tire  of  hearing  of  the  great  blessing 
conferred  on  suffering  women  by  the  genius  and 
skill  of  McDowell,  or  of  the  marvellous  changes 
made  in  Gynecological  Surgery  by  the  prolific 
brain  and  cunning  hand  of  Sims. 

Had  America  done  nothing  else  than  contrib- 
ute these  gifts  to  the  world  it  would  have  been 
made  famous  for  all  time  to  come. 

The  great  advance  made  in  our  medical  educa- 

I  tion  has  been  undoubtedly  due  to  the  frequent 
and  very  able  discussions  which  have  been  held 
on  the  subject  in  this  Association,  and  to  the  elo- 
quent and  philosophical  reports  of  committees  of 
education  which  have  been  so  often  appointed, 
and  apparently  with  so  little  effect, — but  the  -eed 
so  wisely  sown  in  the  organization  of  this  body 
have  germinated  and  are  now  of  hardy  growth, 

(  and  it  is  hoped  in  the  near  future  will  attain  ma- 
turity and  yield  a  harvest  of  abundant  and  per- 

'•  feet  fruit. 

The  professional  public  have  been  aroused  on 

1  the  subject  of  a  higher  and  better  education  than 
has  been  furnished  by  the  old  system,  even,  as 
improved  by  modern  advancement.  This  pro- 
fessional sentiment  has  extended  to  medical 
teachers,  and  I  believe  that  a  majority  of  Ameri- 
can medical  colleges  are  now  ready  to  acquiesce 
in  the  demands  of  the  profession  for  a  higher  edu- 
cation, and  that  they  will  execute  to  the  fullest 
extent  the  wishes  of  the  Medical  College  Associ- 
ation as  expressed  at  the  meeting  in  Nashville 
last  year.  And  when  the  medical  colleges  shall 
have  entered  upon  the  higher  education  which 
they  have  determined  to  do,  the  American  Medical 
Association  will  have  cause  to  congratulate  itself 
in  the  accomplishment  of  the  chief  object  of  its 

organization. 

The  success  of  the  Association  in  these  and 
other  purposes  has  been  very  great,  even  bevond 
the  expectations  of  its  most  sanguine  friends.  '  'As 
asocial  and  professional  reunion  of  kindred  spirits 
and  great  minds,  its  memories   afford   perennial 


652 


THE  PRESIDENT'S  ADDRESS. 


[May  9, 


delight.  It  has  given  impetus  to  the  progress  of 
polity  and  science,  it  exercises  moral  suasion 
rather  than  authority,  it  has  brought  together  a 
bright  constellation  of  intellect,  cemented  the 
bonds  of  friendship  among  good  men  and  true, 
and  has  formed  a  luminous  track  of  light  in  the 
firmament  of  the  ^Esculapian  heavens  throughout 
the  length  and  breadth  of  the  land. "  It  has  passed 
safely  through  the  perils  of  infancy,  avoided  the 
errors  of  youth,  has  entered  upon  the  full  estate 
of  manhood,  and  now  occupies  an  advanced  posi- 
tion in  the  deliberative  assemblies  of  the  world. 
Constituted  of  delegates  coming  from  every  part 
of  the  country  and  representing  every  interest  of 
the  profession,  it  is  really  a  great  National  Con- 
gress ;  it  is  the  only  legislative  body  of  the  pro- 
fession which  can  regulate  the  action  of  its  mem- 
bers and  harmonize  their  conflicting  interests ; 
and  it  is  full  time  that  it  should  assume  the  power 
of  legislating  for  the  whole  American  profession 
and  demand  that  its  enactments  be  observed. 
That  this  power  may  be  attained  and  exerted 
beneficiall}r,  greater  efforts  should  be  made  to 
bring  into  the  Association  ever}-  prominent  and 
influential  member  of  the  medical  profession,  es- 
pecially those  who  have  thought  proper  to  alien- 
ate themselves  from  its  deliberations.  Let  us 
ask  them  in  the  true  spirit  of  conciliation  to 
throw  aside  their  narrow  prejudices  and  renew 
their  allegiance  to  the  Association.  Let  us  rele- 
gate all  the  asperities  of  the  past  to  oblivion  and 
remove  the  unpleasant  feelings  which  have  ex- 
isted for  the  past  four  or  five  years,  to  the  end 
that  the  medical  profession  of  America  may  be, 
' '  Though  distinct  like  the  billows, yet  one  like  the 
sea  ;"  that  it  may  be  truthfully  exclaimed,  "Be- 
hold how  good  and  how  pleasant  for  brethren  to 
dwell  together  in  unity."  Then,  encouraged  by 
the  knowledge  of  the  moral  power  of  the  Associa- 
tion, let  us  not  be  satisfied  with  what  has  been 
done  in  the  past,  but  press  on  in  the  good  work 
we  have  undertaken,  toward  perfection,  securing 
as  much  beauty  and  finish  for  the  body  as  is 
compatible  with  the  imperfections  of  the  human 
understanding. 

Now  that  the  College  Association  has  adopted 
all  the  requirements  for  improved  medical  educa- 
tion, which  the  Association  has  been  so  long 
urging,  and  for  which,  in  fact,  it  was  established, 
it  is  eminently  proper,  and  I  would  urgently  press 
its  importance  on  the  members,  to  pass  a  resolu- 
tion, that  after  the  changes  contemplated  have 
gone  into  effect,  no  medical  man  who  has  re- 
ceived a  degree  from  a  college  which  has  not 
adopted  the  improved  method  of  teaching,  and 
no  professor  nor  attache  of  such  college  shall  be 
eligible  as  delegates  or  members  of  this  As- 
sociation. 

This  great  moral  support  is  due  those  colleges 
which  so  heartily  took  up  the  burden  that  the 
Association  has  carried  for  nearly  half  a  centiiiv. 


and  I  hope  it  will  be  cheerfully  accorded  them. 

It  is  a  well  known  fact  that  a  very  large  pro- 
portion of  the  members  of  this  body  at  each  ses- 
sion, come  from  the  vicinity  of  the  place  of  meet- 
ing, many  of  whom  have  never  been  present  at 
the  sessions  before,  and  are  ignorant  of  the  parlia- 
mentary usages  of  the  body,  or  entirely  indifferent 
what  business  is  before  it,  or  how  it  is  disposed 
of.  So  that  a  few  only  of  its  members  shape  and 
conduct  the  entire  business.  Indeed,  the  trans- 
action of  routine  business  of  the  Association  is 
uninteresting  and  irksome.  Sometimes  in  the 
discussion  unpleasant  feelings  are  engendered  and 
animosities  formed  which  interfere  materially 
with  the  harmony  necessary  for  the  welfare  and 
usefulness  of  the  Association.  I  would  therefore 
respectfully  suggest,  that  all  business  matters  of 
the  Association,  should  be  referred  without  dis- 
cussion or  comment,  to  an  executive  commit- 
tee composed  of  two  members  to  be  appointed 
by  every  State  Society  in  affiliation  with  this 
body,  who,  after  mature  deliberation,  shall  re- 
port them  back  to  be  adopted  or  rejected,  as 
the  Association  may  determine ;  and  that  the 
morning  session,  which  has  been  heretofore  con- 
sumed in  the  transaction  of  ordinary  business, 
shall  be  occupied  in  the  discussion  of  living, 
burning  questions  selected  by  the  business  or  the 
nominating  committee,  and  that  members  especi- 
ally qualified  to  discuss  the  questions  chosen, 
shall  be  selected  a  year  in  advance,  that  they 
may  be  thoroughlj'  prepared  for  the  duties  as- 
signed them.  Such  discussion  will  be  greatly 
conducive  to  the  advancement  of  medical  science 
and  will  attract  a  great  number  of  the  best  med- 
ical men  who  are  not  interested  in  the  routine 
business  of  the  Association,  and  who  are  conse- 
quently never  present  at  the  meetings. 

To  still  further  promote  science  and  add  to  the 
interest  of  this  body,  I  would  suggest  that  prize 
essays  provided  for  in  the  organization,  and  for 
so  long  a  time  ignored,  shall  again  receive  the 
attention  they  deserve.  I  feel  sure  that  it  is  the 
sincere  desire  of  every  member  of  the  Association 
that  it  progressively  improves  in  the  quality  of 
the  work  it  presents  to  the  profession  from  year 
to  year.  There  is,  in  mj-  opinion,  no  exercise 
which  will  add  more  to  the  interest  of  the  Associ- 
ation, or  do  more  to  promote  science,  than  the  pre- 
sentation of  essays  which  will  be  offered  in  com- 
petition for  suitable  prizes. 

In  this  connection  it  may  be  well  to  call  the 
attention  of  the  Association  to  the  fact,  that 
original  research  and  experimental  investigation 
have  nut  received  the  attention  from  American 
physicians,  which  their  importance  demands. 
Living  as  we  do,  in  a  comparatively  new  country, 
our  energies  have  been  directed  to  the  promotion 


i89i.] 


THE  PRESIDENT'S  ADDRESS. 


653 


of  the  practical,  and  more  directly,  useful  depart- 
ments of  the  profession  than  to  the  minute  in- 
vestigation of  scientific  subjects;  and  our  govern- 
ment, while  the  most  liberal  and  best  under  the 
sun,  has  never  seemed  to  comprehend  that  the 
cause  of  science,  especially  medical  science,  would 
be  greatly  advanced,  and  its  own  honor  propor- 
tionately increased,  by  the  establishment  of  schools 
for  original  investigation  and  experimental  re 
search.  It  has  not  kept  pace  with  the  other  en- 
lightened governments  in  scientific  enterprises. 
It  is  hardly  to  be  expected,  however,  that  in  the 
rapidly  changing  political  dynasties,  the  atten 
tion  of  our  legislators  could  in  the  near  future 
be  directed  to  the  advancement  of  pure  science. 
This  must,  for  the  present,  at  least,  be  left  to  the 
progressive  spirit  which  animates  our  univers 
and  to  private  laboratories  which  are  being  6 
lished  in  different  sections  of  the  country. 
Would  it  not  be  advisable  for  the  Association  to 
establish  a  Section  of  Experimental  Research,  to 
which  young  and  enthusiastic  devotees  might  be 
encouraged  to  make  and  repeat  experiments  in 
all  the  departments  of  medicine?  It  would 
certainly  form  a  very  interesting  and  useful  Sec 
tion,  and  would  tend  to  advance  science  and  add 
greatly  to  the  interest  of  the  Association. 

It  was  a  happy  conception  of  one  of  our  most 
distinguished  presidents  to  make  the  establish- 
ment of  an  Association  Journal  the  burden  of  his 
iuaugural  address,  and  so  powerfully  did  he  im- 
press its  importance  upon  the  minds  of  the  mem- 
bers of  the  Association,  that  a  committee  was  at 
once  appointed  to  take  into  consideration  his  sug- 
gestion, with  the  result  that  a  weekly  Journal 
was  established  to  take  the  place  of  the  annual 
volume  of  Transactions.  That  the  change  has 
been  a  valuable  one  none  will  deny.  It  has  as- 
serted and  maintained  the  honor,  dignity  and 
power  of  the  medical  profession  as  a  factor  in 
civil  life ;  it  has  tended  to  enlighten  and 
strengthen  the  profession,  and  to  lead  it  in  the 
proper  direction.  Its  design  has  been  to  repre- 
sent in  the  broadest  sense  the  true  status  and  pro- 
gress made  in  this  country  and  to  give  expression 
to  the  thoughts,  purposes,  and  will  of  American 
physicians.  It  has  in  the  short  period  of  its  ex- 
istence given  evidence  of  its  power  in  the  ad- 
vancement of  its  purposes.  Yet  it  must  be  ac- 
knowledged, notwithstanding  the  great  learn- 
ing and  untiring  energy  of  its  editors,  together 
with  the  faithful  cooperation  of  its  trustees, 
that  it  has  never  attained  the  ideal  excellence 
which  should  characterize  the  organ  of  this  great 
body  of  physicians.  It  may  require  years  to 
bring  it  to  the  desired  standard,  and  it  should 
be  determined  here  to-day,  that  every  effort  shall 
be  made  to  advance  it  to  the  highest  standard. 
To  effect  so  desirable  an  object  it  is  necessary  to 
make  provision  for   an    ample   annual    income. 


Nothing  less  than  from  seventy- five  to  one 
hundred  thousand  dollars  should  be  considered 
ample.  To  many,  this  sum  may  seem  chimerical, 
but  it  is  not.  If  every  member  of  this  body 
would  constitute  himself  a  live,  active  agent  to 
solicit  subscriptions  from  his  brother  physicians 
living  in  his  vicinity,  and  to  assure  himself  that 
Thb  Journal  is  on  the  table  of  every-  doctor 
within  his  reach  ;  and  if  to  this  is  added  the  in- 
come which  may  be  derived  from  legitimate  and 
properly  selected  advertisements,  the  neeessary 
fund  will  be  assured. 

Next  in  importance  to  finance,  is  the  selection  of 
an  editor,  able,  learned,  highly  educated,  with 
ample  editorial  tact  and  business  qualifications, 
who  will  devote  all  of  his  time  and  talent  to  his 
editorial  duties.  He  should  be  empowered  to 
spend  money  liberally  in  obtaining  scientific  ma- 
terial, original  communications,  translations  and 
reviews  from  every  part  of  the  world.  He  should 
have  absolute  control  in  the  selection  of  matter 
The  Journal;  he  should  manage  The 
Journal  boldly,  vigorously  and  with  an  eye  sin- 
gle to  the  honor  and  glory  of  the  profession. 

To  such  an  editor  a  salary  should  be  given 
which  would  make  him  independent  in  a  pecun- 
iary point  of  view.  Not  less.  I  would  suggest, 
than  ten  or  fifteen  thousand  dollars  should  be 
paid  to  him  annually.  Then,  with  elegant  paper, 
perfect  typography  and  attractive  binding.  The 
Journal  will  add  lustre  to  the  Association  and 
honor  to  the  profession. 

The  necessary  fund,  which  can  be  easily  raised 
by  proper  exertion,  will  not  only  sustain  The 
Journal  in  the  best  style,  but  will  afford  a  sum 
in  addition  which  can  be  used  in  many  ways  to 
the  advantage  of  the  Association. 

The  future  location  of  The  Journal  is  a  mat- 
ter of  such  importance  as  to  require  our  careful 
consideration  and  mature  deliberation.  Its  weal 
or  woe  may  depend  on  the  action  of  this  meeting. 

At  an  extraordinary  session  of  the  Board  of 
Trustees  of  The  Journal  called  to  meet  in  Wash- 
ington city  last  November,  it  was  determined  to 
submit  the  question  of  its  removal  from  Chicago 
to  Washington,  to  the  action  of  the  members  of 
this  session. 

I  would  beg  the  delegates  and  members  of  the 
Association  to  consider  well  every  side  of  this 
question  before  they  commit  themseh-es  to  a  vote, 
and  not  act  too  hastily  in  the  matter.  The  Jour- 
nal has  now  had  its  home  in  Chicago  for  eight 
years.  Its  development  and  growth  has  been 
wonderfully  rapid.  It  has  already  become  the  peer 
of  any  of  the  great  weeklies  of  the  country  and  if 
properly  sustained  by  the  profession  and  wisely 
and  energetically  conducted  by  its  managers,  it 
will  become  the  recipient  of  the  best  thought  of 
our  own  country  and  be  the  worthy  exponent  of 
the  American  profession.     It  is   free  from   debt 


654 


THE  ADDRESS  IN  SURGERY. 


[May  9. 


and  has  funds  sufficient  to  close  the  financial 
year  and  still  leave  a  satisfactory  balance  in  the 
treasury.  It  has  been  proven  that  it  can  be  more 
economically  published  in  Chicago  than  in  Wash- 
ington. The  Board  of  Trustees  several  years 
since  solicited  and  obtained  estimates  from  two  or 
more  publishing  houses  in  Philadelphia,  Wash- 
ington, New  York  and  Chicago.  These  estimates 
were  uniformly  highest  in  Washington  and  low- 
est in  Chicago. 

Chicago  is  a  geographical  and  railroad  centre 
not  excelled  in  facilities  for  rapid  mail  distri- 
bution. It  is  also  a  great  medical  and  surgical 
centre  and  can  place  at  the  disposal  of  The  Jour- 
nal a  wealth  of  resource,  second  to  no  other  city 
in  the  Union.  It  is  the  best  place  for  advertisers 
to  reach  the  profession  in  the  Mississippi  Valley 
and  the  great  North-west,  and  if  The  Journal 
should  be  removed  to  Washington,  it  will  lose 
many  very  lucrative  advertisements  and  will  he- 
brought  into  direct  and  sharp  competition  with 
six  important  weekly  journals,  several  sus- 
tained by  large  and  influential  book  houses, 
which  occupy  the  field  between  Washington  and 
Boston, 

Washington  is  in  no  sense  an  important  scien- 
tific, educational  or  professional  centre;  but  it  is 
the  great  centre  of  American  politics,  to  which 
everything  is  made  subordinate;  and  it  would  be 
impossible  if  The  Journal  should  be  published 
here,  to  prevent  its  becoming  contaminated  by 
the  political  air,  with  which  it  would  be  surround- 
ed. Washington  has  never  been  a  healthy  local- 
ity for  medical  journals,  for  every  journal  which 
has  been  published  within  its  boundaries,  has  died 
early  from  inanition.  I  do  not  think  that  it  is  a 
better  locality  than  Chicago  that  is  wanting,  but 
a  better  Journal  than  we  have. 

Let  us  then  as  members  of  a  profession  engaged 
in  the  most  beneficent  and  humane  calling  known 
to  man,  in  the  language  of  the  immortal  Jackson, 
swear  "by  the  Eternal"  that  The  Journal  of 
the  American  Medical  Association,  wher 
ever  it  may  be  located,  shall  be  made  and  kept 
equal  in  excellence  with  any  journal  published 
in  the  world. 

It  is  now  time  to  enter  upon  the  duties  which 
have  called  us  together.  Let  us  endeavor  to  dis- 
charge them  in  a  spirit  of  conciliation  and  justice. 
Let  us  art  with  such  prudence  and  judgment  in 
this  meeting  as  will  tend  to  unite  more  closely 
the  members  of  this  great  National  family.  Let 
us  not  forget  how  rich  an  heritage  has  been  be- 
queathed to  us  by  our  predecessors  which  we 
should  make  more  valuable  and  transmit  to  pos- 
terity. Let  us  indulge  the  hope  that  our  labors 
during  the  present  session  will  not  only  sustain 
the  advance  already  made  in  medical  science,  but 
will  carry  us  still  further  onward  in  the  great  road 
of  progress. 


THE  ADDRESS  ON  SURGERY. 

Delivered  tit  the  Forty-second  Annual  Meeting  oj  the  American  Medi- 
cal Association,  held  at  II  'ashington,  D.C..  Ma  1 

BY  JOSEPH    M.   MATHEWS. 

OF     LOUISVILLE.    KY 

I  am  familiar  with  the  fact  that  it  is  expected 
that  the  general  address  on  surgery  read  to  this 
Association  shall  be  a  rSsumSol the  advances  made 
in  each  and  every  department  of  the  science  and 
art  of  surgery,  since  the  previous  meeting.  To 
have  gone  over  this  entire  field  would  have  con- 
sumed more  of  your  valuable  time  than  you  would 
like  to  grant,  and  involved  a  task  too  burdensome 
for  me  to  undertake.  I,  therefore,  determined  to 
select  some  single  subject  for  my  address.  I  was 
then  confronted  by  the  fact  that  every  single  sub- 
ject of  importance  would  be  fully  discussed  in  the 
section  on  surgery  ;  hence  I  was  embarassed  in 
selecting  one,  for  the  reason  that  I  w-ished  to 
edify  rather  than  fatigue  you.  This,  then,  was 
the  rub.  Having  confined  myself  for  fifteen 
years  to  a  special  line  of  practice,  it  occurred  to 
me  that  it  would  be  best  to  select  some  subject 
relating  thereto,  and  give  my  individual  opinion 
and  experience  in  regard  to  it.  Then,  too,  I  had 
the  consolation  of  believing  that  no  paper  of  a 
similar  topic  would  be  read  before  the  Associa- 
tion. I  have,  therefore,  selected  as  my  subject, 
stricture  of  the  rectum — its  etiology,  pa- 
thology, SYMPTOMOLOGY,  DIAGNOSIS  AND 
TREATMENT. 

I  realize,  in  discussing  this  subject,  I  shall  take 
positions  contrary  to  the  accepted  teachings  of  the 
day,  "out  I  shall  not  beg  for  pardon  for  so  doing. 
I  take  it  that  the  one  great  object  of  the  meetings 
of  this  Association  is  to  elucidate  and  discuss  sub- 
jects that  are  in  doubt,  those  that  are  mooted, 
not  admitted.  The  caption  of  my  address  may 
sound  homely,  but  the  importance  of  it  as  a  sur- 
gical subject  should  commend  the  respect  and 
attention  of  every  surgeon  here.  Its  frequency, 
its  terrors,  and  its  dangers,  appeal  to  us  for  relief. 

Etiology. — The  following  classification  of  the 
varieties  of  stricture  of  the  rectum  is  given  by  Dr. 
Kelsey.  I  believe  that  for  my  purpose  it  is  the 
best  classification,  as  it  embraces  the  varieties  as 
given  and  agreed  to  by  many  different  authors. 
<_  'ongenital: 

1.  Complete, 

2.  Partial. 
Acquired: 

1.  Spasm.     (?.    Dysenteric. 

2.  Pressure  from  without,     b.   Tubercular. 

3.  Non-venereal,     c.   Inflammatory,     d.  Traumatic. 

1  Venereal,  a.  Ulceration  (either  chancroidal,  secon- 
dary or  tertiary.) 

5.  Cancer,  b.  I>ue  to  unnatural  vice.  c.  Neoplastic 
(gummata,  anorectal  syphiloma.) 

The  first  great  division,  it  will  be  noticed,  is 
congenital  and  acquired  stricture.  In  writing  of, 
or  dealing  with  stricture,  the  idea  intended  to  be 
conveyed  is  of  a  pathological  change  in  tissues, 


I89i.] 


THE  ADDRESS  IN  SURGERY. 


655 


etc.,  a  deviation  from  the  natural  brought  about 
by  disease  ;  hence  I  object  to  the  consideration 
of  congenital  malformations  of  the  rectum,  or  to 
define  them  under  the  head  of  strictures  of  the 
same,  for  the  reason  that  it  is  misleading  to  do  so. 
It  will  be  more  to  the  point  to  caH  these,  atresias 
of  the  gut.  Therefore,  I  shall  dismiss  this  part 
of  the  division  that  he  has  made.  Indeed,  excep- 
tion could  also  be  made  to  the  second  division  of 
this  grand  classification,  namely,  acquired.  I 
am  aware  of  the  fact  that  the  term  is  often  used 
in  the  sense  herein  applied,  but  to  my  mind  a 
better  term  or  classification  could  be  used.  It  is 
very  easy  to  understand  how  cne  can  acquire  a 
stricture,  the  result  of  venery,  but  it  will  be  diffi- 
cult to  understauel  how  one  could  acquire  a  spas- 
modic or  cancerous  stricture.  But  I  will  adopt, 
for  the  sake  of  discussion,  the  above  classifica- 
tion, leaving  out  the  congenital  variety . 

1.  Spasm. — To  this  form  of  stricture  I  shall 
prefer  two  objections.  First,  if  it  be  true  that 
such  condition  ever  exists,  which  I  doubt,  then 
it  should  not  be  classed  as  stricture  at  all,  for  the 
reason  that  no  pathological  change  is  manifest  to 
constitute  a  stricture,  and  no  treatment  could  be 
given  it  per  se.  In  other  words,  it  would  be  a 
symptom  of  some  lesion  or  trouble  outside  of  the 
one  called  stricture.  Second,  I  believe  that  from 
the  anatomical  construction  of  the  rectum,  it 
would  be  utterly  impossible  for  its  lumen  to  be 
so  constricted  as  to  be  perceptible  as  an  obstruc- 
tion, by  spasmodic  contraction  of  its  muscular 
fibres.  I  might  add  as  a  third  reason,  that  in  all 
my  examinations  of  this  part  of  the  gut,  I  have 
never  seen  a  spasmodic  contraction  that  could  be 
called  a  stricture. 

2.  Dysenteric. — Although  it  is  frequently  stated 
that  dysentery  is  a  common  cause  of  stricture  of 
the  rectum,  I  have  never  seen  cases  sufficient  to 
convince  me  of  the  truth  of  the  statement,  indeed 
that  it  was  a  cause  at  all.  I  have  many  times 
seen  patients  who  gave  me  a  historv  of  having 
had  dysentery  and  were  treated  for  a  long  time 
for  the  affection,  but  a  close  scrutiny  of  the  case 
revealed  the  fact  that  the  so  called  dysentery  was 
caused  by  an  already  existing  stricture  and  ulcera- 
tion, the  rule  here  being  reversed.  —  that  dysentery 
was  the  result,  not  the  cause.  If  dysentery  really 
be  a  cause  of  stricture  of  the  rectum,  how  very 
often  we  would  expect  to  meet  with  it  in  our 
practice,  considering  the  great  number  of  people 
who  have  dysentery,  especially  in  the  warmer 
climates.  Again,  practitioners  of  medicine  know 
that  ulceration  proper  very  seldom  exists  in  the 
rectum  during  or  after  attacks  of  dysentery.  The 
sloughing  in  these  cases  occurs  from  the  gut  above 
the  rectum.  I  do  not  deny,  but  I  am  not  con 
vinced,  that  ulceration  may  sometimes  be  caused 
by  repeated  dysenteries  or  diarrhoea,  but  my  ex- 
perience has  not  taught  me  that  they  are  frequent. 
by  any  means.     If  a  long  continued  irritation  is 


kept  up  in  the  rectum,  from  any  cause,  the  result 
would  be,  of  course,  an  inflammatory  exudate, 
resulting  perhaps  in  ulceration  and  stricture  ;  but 
I  must  confess  that  in  searching  for  this  as  a  cause, 
the  road  to  a  conclusion  has  not  been  plain  enough 
for  me  to  put  dysentery'  in  the  list  as  a  cause  at 
all  for  stricture  of  the  rectum.  If  this  disease  is 
a  common  cause  of  stricture,  as  asserted  by  so 
many,  it  occurs  to  me  that  the  trouble  would  be 
often  found  in  the  veterans  of  war.  Indeed,  I 
could  not  imagine  a  more  ideal  case  for  a  pen-ion 
than  the  existence  of  stricture  of  the  rectum,  the 
result  of  a  dysentery  contracted  while  in  the  ser- 
vice. Yet  the  pension  records  are  singularly 
silent  on  this  point.  At  a  late  meeting  of  the 
Louisville  Clinical  Society,  Prof.  John  A.  Ouch- 
terlony,  a  distinguished  pathologist  and  teacher, 
in  discussing  the  subject  of  stricture  of  the  rec- 
tum, said: 

I  call  to  mind  a  dead  house  experience  extending  over 
many  years.  During  the  war  I  made  post  mortem  exam- 
inations upon  hundreds  of  cases  who  died  of  dysentery, 
the  most  malignant  forms  of  the  disease,  as  all  will  at- 
test whose  observations  extend  back  to  war  times,  and  I 
cannot  remember  to  have  ever  seen  a  stricture  of  the  rec- 
tum as  a  result  of  dysentery.  In  the  two  hospitals,  to 
which  I  was  pathologist,  there  were  eleven  hundred  and 
fifty  beds,  and  we  sometimes  made  as  many  as  five  or  six 
post-mortems  a  day.  After  the  close  of  the  war,  I  was 
for  many  years  pathologist  to  the  City  Hospital,  but  in 
all  mv  dead  house  experience.  I  never  saw  a  stricture  of 
the  rectum  caused  by  dysentery. 

These  are  the  remarks  of  a  very  close  observer, 
and  mv  experience  certainly  coincides   with   his. 

3.  Tubercular. — Since  the  discovery  of  the  tu- 
bercle bacilli,  and  the  demonstrations  that  con- 
vince us  of  the  effect  on  the  tissues,  etc.,  it  is  self 
evident  that  tuberculosis  is  often  met  with  in  the 
mucous  membrane  and  the  structures  of  the  rec- 
tum. If  stricture  and  ulceration  is  the  term  used. 
I  could  make  no  objection  to  the  classification  of 
tuberculosis  as  a  cause  of  ulceration.  That  ul- 
ceration frequently  results  from  this  diathesis 
or  dvscrasia  no  one  could  doubt,  but  that  the 
coincident  stricture  follows,  as  from  other  well 
known  causes,  notably  syphilis,  I  cannot  agree. 
The  disposition  of  tuberculous  tissue  everywhere 
is  to  break  down.  Before  the  capacious  rec- 
tum is  filled  with  tubercular  deposit  sufficient 
to  stricture  it.  it  will  have  broken  down  from 
ulceration,  etc.,  and  it  must  be  by  deposition 
only  that  we  can  conceive  of  stricture  from  this 
cause;  because  cicatrization  is  so  seldom,  and  so 
feeble,  in  these  parts  that  it  would  be  the  rarest 
accident  to  find  it.  In  no  instance  have  I  ever 
seen  a  stricture  of  the  bronchi  as  the  result  of  tu- 
berculosis. There  would  be  just  as  much  rea- 
son to  expect  it  here,  or  indeed  more  so,  than  in 
the  rectum. 

4.  Inflammatory. — This  term  is  so  broad  and 
comprehensive  that  we  must  perforce  of  reason 
admit  it  as  a  cau:.e  of  stricture  of  the  gut,  indeed 
as  the  one  grand  and  common  cause;  for  if  stric- 


656 


THE  ADDRESS  IN  SURGERY. 


[May  9, 


tures  exist  from  whatever  cause,  be  it  trauma, 
pressure,  venery,  dysentery,  cancer,  tubercle, 
syphilis,  ulceration,  or  what  not,  it  is  inevitably 
due  to  the  processes  and  products  of  inflamma- 
tion— in  no  other  way  can  a  stricture  be  formed. 
It  might  be  argued  that  a  lesion  or  wound  exist- , 
ing  in  the  bowel  by  the  reparative  process  heals 
and  leaves  cicatricial  tissue,  and  that  stricture 
was  the  result  of  the  cicatrix,  and  not  to  plastic 
infiltration  of  the  tissue.  In  answer,  I  would  say 
that  there  could  have  been  no  cicatrization  if 
there  had  been  no  inflammatory  process.  Hence, 
inflammation  being  the  cause  of  the  cicatrix,  was 
in  truth  the  cause  of  the  stricture.  It  is  said,  i 
"  Any  severe  form  of  proctitis  resulting  in  ulcer- 
ation may  be  a  cause  of  stricture."  To  this  I 
freely  assent,  but  the  most  difficult  part  of  the 
whole  matter  is  to  tell  the  cause  of  the  proctitis, 
which  is  inflammation.  It  is  not  to  the  proposition 
that  I  object,  but  to  the  supposed  cause.  For 
instance,  in  naming  several,  the  following  is  given 
as  a  cause  of  stricture:  'Erosion  and  ulceration 
of  haernorrhoidal  tumors."  Now,  in  the  nature 
of  things,  how  can  this  be  true?  A  hsemorrhoid 
is,  in  fact,  a  tumor,  and  by  friction  the  mucous 
membrane  on  the  tumor  can  become  ulcerated.  \ 
Suppose  it  does,  how  can  that  ulceration  produce 
a  stricture  of  the  rectum?  As  we  have  intimated, 
strictures  may  result  from  two  pathological  condi- 
tions. First,  from  a  deposition  of  plasma,  causing 
an  obstruction,  or  second,  by  cicatrization,  caus- 
ing a  stricture.  Can  either  of  these  conditions 
result  from  haernorrhoidal  tumors  being  ulcera- 
ted? Certainly  not.  The  inflammatory  deposit 
would  only  involve  the  tumor,  and  a  cicatrix  on 
top  of  a  pile  would  not  amount  to  a  stricture. 

5.  Traumatism. — Under  this  head  the  authors 
include  ulceration  following  operations  or  wounds 
of  the  rectum,  and  cite  the  surgical  operation 
done  for  haemorrhoids  and  fistula  in  ano.  In  all 
my  practice,  I  have  never  seen  such  result  follow 
either  operation.  I  can  understand  how  the  cica- 
trix resulting  from  the  removal  of  too  much  skin 
from  the  anal  region  might  cause  a  stricture  of 
the  anus.  My  friend  Dr.  W.  O.  Roberts,  of  Louis- 
ville, has  told  me  recently,  of  operating  upon  a 
patient  of  this  kind,  the  original  operation  for 
haemorrhoids  having  been  done  by  an  inexpe- 
rienced hand.  I  cannot  understand  how  a  sur- 
geon used  to  operating  in  this  region,  would  do 
an  operation  that  would  result  in  a  stricture.  But 
traumatic  strictures  are,  in  fact,  inflammatory 
strictures.  Inflammation  is  the  result  of  trauma. 
so  one  class  would  include  both.  For  brevity, 
this  would  be  best. 

6.  Venereal. — "  Without  admitting  too  much," 
says  one  author,  "  it  may  be  safely  said  that,  be- 
yond dispute,  there  are  three  forms  of  well  recog- 
nized venerea]  diseases  in  the  rectum,  which  may 
result  in  stricture.  These  are  chancroidal,  secon 
'1  ii'   and  tertiary  ulcerations,  either  simple,  trau- 


matic, or  the  result  of  direct  inoculation,  and  an 
unusual  form  of  tertiary  disease  of  the  general 
nature  of  gummatous  deposit  variously  described 
by  different  authors,  and  by  Fournier  as  ano-rectal 
syphiloma."  This  author  leads  us  to  infer  that 
these  three  venereal  causes,  namely  chancroidal, 
secondary  and  tertiary  ulcerations,  are  the  most 
infrequent  way  that  stricture  of  the  rectum  can  be 
produced  by  venery.  Allingham  reports  that  out 
of  seventy  patients  suffering  with  stricture  of  the 
rectum,  thirty- five  of  them  had  a  history  of  syph- 
ilis. I  have  frequently  said  that  I  believe  that 
more  than  one- half  of  the  strictures  met  with  in 
the  rectum  were  the  result  of  syphilis.  I  have 
often  asserted  that  in  no  single  instance  have  I 
ever  seen  a  stricture  of  the  rectum  caused  by  the 
healing  of  a  soft  sore.  I  do  not  believe  that  it 
can  occur.  In  this  opinion  I  am  partially  sus- 
tained by  Allingham,  James  R.  Lane,  Alfred 
Cooper,  Coulson,  Christopher  Heath  and  others. 
These  three  causes  are  alleged  by  many  to  pro- 
duce their  effect  by  simple  trauma  or  direct  inocu- 
lation. Neither  of  these  can  be  true.  If  so,  cer- 
tainly not  one  in  ten  thousand  cases.  Granting 
that  the  soft  sore  could  produce  an  ulceration 
J  that  might  end  in  stricture,  how,  I  would  ask, 
j  can  the  aforesaid  pus  get  into  the  rectum?  It  may 
have  occurred,  it  is  not  impossible,  but  granting 
that  it  did  by  direct  contact,  I  do  not  believe 
that  it  would  result  in  a  stricture.  Instead  of 
secondary  syphilis  being  an  unusual  cause  of 
stricture  of  the  rectum,  I  assert  that  it  is  the 
usual  and  only  form  that  we  find  this  disease  pro- 
ducing or  causing  stricture  of  the  rectum.  Ricord, 
Fournier,  Heath  and  others  believe  this,  and  Mr. 
Bryant,  in  his  excellent  practice  on  surgery,  as- 
cribes these  ulcerations  and  strictures  of  the  rec- 
tum as  "  mainly  syphilitic,"  and  says:  "Foreign 
authors  describe  chancroidal  diseases  of  the  rec- 
tum, venereal  but  not  syphilitic.  In  this  coun- 
try it  is  hardly  recognized."  I  certainly  agree 
with  this  author.  To  conclude,  if  I  were  asked, 
what  is  the  prime  cause  of  stricture  of  the  rectum, 
I  would  answer  inflammation.  But  what  causes 
the  inflammation?  In  many  cases  I  do  not  know, 
.but  ordinarily  syphilis,  cancer  and  trauma — if  by 
trauma  can  be  meant  a  wound  or  lesion  from  any 
or  many  causes.  Outside  of  the  two  first  named, 
cancer  and  syphilis,  I  am  satisfied  that  no  one 
can  tell  the  cause  that  originates  the  stricture.  I 
wish  to  reiterate,  that  outside  of  these  two  well 
recognized  causes  for  stricture  of  the  rectum,  I 
am  not  prepared  to  admit  any  othe»  as  a  well 
known,  recognized,  indisputable  cause. 

Pathology. — In  delivering  the  Bradshawe  lec- 
ture before  the  Royal  College  of  Surgeons,  Lon- 
don, Mi.  Thomas  Bryant  selected  as  his  subject, 
"  Colotomy."      He  said  : 

But  as.-i  means  for  ^ivin.t;  reliel  to  patients  from  chronic 
intestinal  organic  ulcerations  or  obstruction  from  what- 
ever cause,  COlotomy    was   generally,    and    indeed  I  may 


i8oi.] 


THI-:  ADDRESS  IX  SURGERY. 


657 


say  is  still,  too  much  regarded  as  a  dernier  ressort,  and  \ 
as  a  consequence,  it  was.  as  a  rule,  only  carried  out  when 
all  other  measures  had  been  tried  and   proved  to  be  use- 1 
less.     This  position  I,  in  common  with  some   few  other 
surgeons,  have,  however,  never  accepted.       We  have  re- 
garded it  as  the  best  means  the  surgeon  has  at  his  dispo- 
sition  for   the  relief  of  rectal   obstruction   from   cancers 
and  everj  disease  which  is  not  otherwise  removable,  and  . 
experience  has  proved  that  life  may  by  it  be  saved,  when 
the  disease  is   not  cancerous,   and  prolonged  even   for  1 
years  when  it  is  so. 

Turning  to  page  605  in  Wyeth's  Text  Book 
on  Surgery,  we  read :  "'In  stricture  of  the 
rectum,  when  all  other  measures  fail,  colotomy  is 
the  last  resort."  "Here  are  two  diverse  views,  by- 
two  very  distinguished  authors.  Which  is  cor- 
rect? I  am  decidedly  inclined  to  Dr.  Wyeth's 
opinion  (if  colotomy  is  performed  at  all),  and  j 
although  he  has  been  content  with  the  bare  state- 
ment, without  argument,  I  shall  in  a  few  words 
give  you  my  reasons  for  differing  from  Mr.  Bry- 
ant, in  his  statement  and  proposition.  I  quite 
agree  with  him  in  the  preference  given  to  lumbar 
over  inguinal  colotomy,  but  I  beg  to  differ  as  to 
the  need  for  the  operation,  and  base  my  belief  on 
the  pathology  of  the  disease.  Instead  of  ad- 
mitting his  premise  that  colotomy  is  called  for 
the  relief  of  rectal  inflammation  by  cancer  and : 
other  diseases,  and  should  be  performed  early  in 
the  disease,  I  shall  contend  that  such  a  procedure 
is  warranted  only  in  the  rarest  cases,  and  then  as 
a  dernier  ressort  only,  which  he  denies.  My  con- 
clusions are  based  upon  an  observation  of  several 
hundred  cases  of  so-called  obstruction  of  the  j 
rectum.  I  shall  not  found  my  objections  upon 
the  dangers  that  attend  the  operation,  although 
every  surgeon  will  admit  that  some  danger  at- 
tends it.  I  recognize  the  fact  that,  under  anti- 
septic surgery,  the  mortality  attending  these, 
as  well  as  all  other  surgical  operations,  is  re- 
duced. However,  this  admission  plays  no  part 
in  rebutting  other  arguments  that  are  urged ; 
for  the  operation.  I  will  be  permitted  to  remark 
that,  in  my  opinion,  it  has  become  too  much  the 
custom,  or  fad,  to  do  this  operation  in  cases  where 
there  is  no  possible  chance  of  doing  the  patient 
any  good.  Indeed  it  has  become  so  common,  , 
that  the  moment  cancer  of  the  rectum  is  diag- 
nosed,  colotomy  is  resorted  to.  Mr.  Bryant  states 
two  distinct  propositions,  namely,  "First,  the! 
immediate  success  or  failure  of  the  operation 
turns  but  little  upon  the  operation  itself,  if  well 
performed,  but  upon  two  main  points,  the  first 
being  the  local  condition  of  the  bowel  above  the 
seat  of  obstruction,  and  the  second,  upon  the 
general  condition  and  age  of  the  patient." 

Some  surgeon  once  said,  that  the  reason  lapa- 
rotomies for  gunshot  wounds  showed  such  a  low  j 
per  cent,  of  recoveries,  was  that  too  many  wtre  1 
attempting  the  operation.  Mr.  Bryant  can  very- 
well  say  that  the  immediate  success  or  failure  of 
colotomy  turns  but  little  upon  the  operation,  if 
it  is  well  performed.     The  trouble  is  that  if  his  j 


premise  be  true,  that  this  operation  should  not  be 
considered  as  a  dernier  ressort  in  stricture  of  the 
rectum,  but  that  it  should  be  resorted  to  early  in 
the  disease,  and  is  the  best  of  all  procedures,  too 
many  men,  accepting  his  dictum  as  true,  will  lie 
doing  the  operation,  when  less  dangerous  meth- 
ods might  accomplish  the  same  results.  As  to 
his  two  main  points  to  be  considered  before  doing 
the  operation,  first  the  local  condition  of  the 
bowel  above-  the  seat  of  obstruction,  I  take  it 
that  he  means  whether  or  not  the  bowel  above 
the  seat  of  obstruction  is  invaded  by  the  disease, 
or  if,  in  consequence  of  the  disease  below,  has 
suffered.  In  my  opinion  it  would  have  been 
more  to  the  point  to  have  said,  the  local  condi- 
tion of  the  bowel  both  above  and  below  the  seat 
of  obstruction.  He  says:  "  If  from  procrasti- 
nation, serious  intestinal  changes  have  taken 
place  before  relief  is  present,  recovery  is  hardly 
to  be  expected."  Now  I  suppose  that  the  dis- 
tinguished author  refers  here  to  cancer  or  syphilis 
as  the  serious  causes  of  intestinal  changes.  It  is 
quite  agreed  that  these  two  diseases  account  for 
fully  two  thirds  of  the  obstructions  or  strictures 
of  the  rectum,  which,  as  Mr.  Bryant  and  others 
would  say,  would  call  for  colotomy.  Suppose 
the  gut  above  the  stricture  was  not  invaded  or 
changed  at  all,  but  that  below  the  stricture,  in- 
cipient it  may  be,  there  is  a  slight  infiltration  by- 
cancerous  deposit,  is  the  operation  justifiable?  I 
certainly  cannot  agree  that  it  is.  It  is  admitted 
that  a  colotomy  is  a  loathing  and  disgusting 
thing.  Patients  with  cancer  of  the  rectum  live 
from  three  to  six  years.  Many  in  my  practice 
have  lived  five  years  after  the  disease  was  first 
observed.  Why  subject  these  people  to  such  an 
operation  during  the  incipiency  of  the  disease, 
when  it  does  not  stop  it?  Again,  are  we  quite 
certain  that  there  is  an  infallible  sign  of  cancer  ? 
In  quite  a  number  of  cases  I  have  taken  speci- 
mens from  rectal  growths,  had  them  examined  by 
microscopists,  and  pronounced  cancer,  whose 
subsequent  history  revealed  the  fact  that  it  was 
not  cancer  at  all.  Then,  too,  in  the  early  stages 
of  cancer,  there  is  not  sufficient  clinical  evidence 
to  base  an  opinion  upon.  Certainly  for  a  benign 
and  incipient  stricture,  or  obstruction,  if  you 
please,  in  this  locality,  colotomy  would  not  be 
advised. 

Again,  if  the  disease  be  cancerous,  in  its  in- 
cipiency^, or  otherwise,  can  the  operation  of 
colotomy  cure  it  ?  It  might  be,  as  Mr,  Bryant 
suggests,  the  operation  could  be  done  much  more 
successfully-  while  the  general  health  is  in  good 
condition,  but  it  is  not  whether  one  can  perform 
colotomy  successfully  or  not,  the  prime  question 
is,  what  good  will  it  do  ?  A  surgeon  may  do  a 
beautiful  operation  for  stone  in  the  bladder  and 
get  the  stone,  but  the  patient  dies.  How  then, 
I  would  ask.  can  the  establishing  of  an  artificial 
anus  in  the  side,  in  any  way  cure  or  arrest  the  in- 


658 


THE  ADDRESS  IN  SURGERY. 


[May  9, 


roads  of  cancer  in  the  rectum.  If,  then,  it  is 
granted  that  the  disease  being  constitutional  will 
go  on  regardless  of  the  opening  in  the  side,  I 
would  ask  can  the  colotoruy  prolong  life  of  the 
cancerous  patient?  In  no  wa)T  possible  can  it  do 
so,  but  one,  that  is  by  preventing  one  source  of) 
irritation,  namely,  the  passage  of  faeces  over  the  j 
cancerous  mass.  The  argument  would  be,  the 
more  irritation,  the  more  deposit. 

In  my  opinion,  this  is  of  very  little  importance, 
or  consideration  in  cancer  of  the  rectum.  Ma- 
lignant growths  increase  by  an  inherent  power, 
a  deposition,  infiltration,  etc.,  intrinsic,  not  ex- 
trinsic. They  will  exist  in  the  rectum  a  long 
time,  acquiring  a  great  size,  involving,  perhaps, 
the  whole  circumference  of  the  gut  before  the 
mucous  membrane  is  ulcerated,  notwithstanding 
this  "great  irritation  "  is  constantly  kept  up.  I 
dare  say  if  a  cancer  of  the  same  kind  and  pro- 
portion, in  the  same  character  of  subject,  could 
be  watched  each  day,  in  one  colotomy  had  been 
performed,  the  other  without,  that  no  difference 
could  be  observed  in  the  rate  of  progress  that 
was  being  made.  I  am  forced  to  this  belief  after 
an  observation  of  many  years,  covering  many 
cases.  As  I  have  before  stated,  my  patients 
have  generally  lived  from  four  to  six  years  with 
cancer  of  the  rectum,  without  colotomy.  Do 
they  live  any  longer  with  colotomy  ?  In  other 
words,  can  any  one  say,  because,  colotomy  being 
performed,  a  patient  lives  four  or  six  years,  that 
the  colotomy  was  the  cause  of  prolonging  his  life  ? 
Again,  it  is  claimed  that  by  colotomy  much  of 
the  pain  is  the  rectum  is  relieved,  in  that  the 
faeces  having  been  directed  from  their  natural 
course.  In  some  instances  this  may  be  true,  but 
the  rule  will  not  hold  good  in  all.  I  have  known 
patients  to  suffer  equally  as  much  with  pain 
after,  as  before  the  operation,  nor  is  it  always 
true  that  the  faeces  are  diverted  from  the  natural 
channel.  Much  discomfort  is  often  complained 
of  by  the  patient,  after  a  colotomy,  from  the 
lodging  in  the  mass,  or  strictured  surface. 
In  a  paper  read  by  Mr.  Jessop,  on  the  treat- 
ment of  cancer  of  the  rectum,  at  the  Leeds  meet- 
ing of  the  British  Medical  Association,  he  said  : 
In  cancer  of  the  rectum,  the  constriction  in  the 
majority  of  cases  can  be  got  over  for  a  time,  by 
injections,  the  introduction  of  the  finder,  or 
bougies,  the  use  of  laxatives  and  the  like." 
This  lias  certainly  been  my  observation.  In- 
deed I  have  seen  many  cases  where  the  patient 
never  complained  of  even  constipation  or  ob- 
struction. Add  to  this  that  many  patients  of  the 
kind  complain  of  but  little,  if  any  pain,  especi 
ally  if  the  growth  is  situated  above  the  sphincter 
muscle,  it  lessens  the  cases  materially  which 
would  call  for  colotomy. 

1  cannol  agree  with  Mr.  Bryant  in  his  state 
ment  that  the  operation  is  demanded  for  the  pur- 
pose of  relieving  the  local  distress,  admitting,  as 


he  does,  that  when  the  disease  is  in  the  lower 
part  of  the  rectum  that  obstruction  seldotns  occurs. 
I  have  seven  cases  of  cancer  of  the  rectum  now 
under  observation,  and  in  but  one  is  pain  a  factor 
at  all.  Admitting  that  pain  is  a  prominent  symp- 
tom, colotomy  does  not  bring  that  radical  relief 
which  would  justify  its  being  done.  We  have 
in  opium  a  remedy  which  will  quiet  pain  effectu- 
ally, and  if  the  argument  be  used  that  we  would 
make  an  habitue  of  the  patient,  I  would  remark, 
what  is  the  difference  if  he  is  to  die  so  soon? 
As  I  have  observed,  pain  in  cancer  is  inherent, 
caused  by  the  local  affection  of  the  nerves,  and  is 
not  controlled  by  extraneous  circumstances. 
Hence,  of  what  account  is  opening  the  gut  at  a 
distant  point,  if  pain  is  not  a  great  factor  in  the 
disease?  If,  in  answer,  it  is  said  that  it  prevents 
the  irritation  and  pain  caused  by  the  passage  of 
the  feces,  I  would  answer  that  in  many  cases 
this  does  not  increase  the  pain,  and  if  it  does, 
dilatation  will  materially  prevent  it.  I  saw,  this 
day,  in  consultation,  a  lady  whose  lower  rectum, 
including  buttocks,  labia,  etc.,  were  involved,  the 
gut  for  six  inches  tightly  strictured,  and  when 
asked  how  much  pain  she  suffered,  answered, 
"Oh,  very  little,"  and  said  that  the  fecal  dis- 
charges caused  her  no  trouble. 

If,  as  some  would  have  us  believe,  colotomy 
would  prevent  the  extension  of  the  disease,  and 
its  consequences,  such  as  involvement  of  the  blad- 
der, vagina,  etc.,  I  would  ask  how  is  colotomy 
to  prevent  it?  It  is  not  the  passage  of  fecal  mat- 
ter over  the  affected  parts  that  causes  this  result, 
but  rather  the  nature  of  the  disease  to  infiltrate, 
and  break  down  the  tissue.  If  a  cancerous  growth 
is  situated  above  the  sphincter  muscle,  its  ten- 
dency is  to  extend  upwards,  and  in  this  event 
pain  is  not  great,  unless  some  other  organs  are 
affected.  It  is  not  uncommon  that  patients  come 
to  my  office  to  consult  me  for  some  trivial  rectal 
affection  and  I  find,  upon  examination,  a  cancer- 
ous mass,  extending  all  around  the  rectum,  pain 
being  scarcely  a  symptom  in  these  cases.  Of 
what  value  would  colotomy  be  here?  Hence  I 
am  forced  to  the  conclusions  that  the  operation 
is  not  warrantable  simply  because  cancer  is  found 
in  the  rectum,  either  in  an  incipient  or  confirmed 
state  ;  nor  for  the  relief  of  pain  simply,  unless 
other  complications  exist,  for  we  have  medicines 
that  will  relieve  pain  :  nor  to  prevent  invasions 
by  the  disease,  because  it  would  fail  of  its  pur- 
pose. Infiltration  and  pathological  change  can- 
not be  overcome  by  colotomy.  Nor  for  obstruc- 
tion or  fear  of  obstruction  in  the  lower  rectum, 
because,  as  Mr.  Jessop  says,  this  obstruction  sel- 
dom takes  place,  and  if  it  does,  it  can  be  relieved 
b^  dilatation  and  other  methods.  Lastly,  I  do 
not  believe  that  colotomy  should  ever  be  done  for 
the  obstruction  of  the  rectum  by  cancer,  save, 
perhaps,  in  a  few  exceptional  cases,  and  then  only 
a->  a  dernier  ressort.     Vet  in  every  instance  before 


iSoi.J 


THE  ADDRESS  IN  SURGERY. 


659 


the  operation  is  done,  the  nature  of  it  and  its  eon- 
sequence  should  be  fully  explained  to  the  patient, 
with  the  assurance  that  it  cannot  possibK  effeci 
a  cure.  It  is  a  well  recognized  fact  that  colotomy 
is  advised  and  practiced  by  man}',  for  other  ulcer- 
ations and  constrictions  of  the  rectum,  beside 
those  of  a  cancerous  nature  Except  under  cer- 
tain conditions,  I  shall  object  to  this  procedure 
with  just  as  much  emphasis  as  to  the  operation 
in  malignant  stricture. 

I  have  stated,  in  this  article,  that  I  do  not 
hold  to  the  theory  of  chancroidal  ulceration,  as 
so  vehemently  advocated  by  Zeigler,  Mason,  Kel- 
sey,  Gosselin  and  others.  My  reasons  have 
already  been  given,  but  I  do  hold  that  syphilis  is 
responsible  for  more  than  one-half  the  cases  of 
stricture  of  the  rectum,  and  in  the  manner  I  have 
described.  But  to  do  a  colotomy  simply  because 
a  patient  has  a  syphilitic  stricture  of  the  rectum, 
is,  I  believe,  unjustifiable.  As  a  proposition, 
then,  I  shall  maintain  that  where  a  syphilitic 
stricture  or  strictures  exist  in  the  rectum,  located 
within  four"  inches  of  the  external  sphincter  mus- 
cle, colotomy  should  not  be  done.  In  supporting 
this  statement,  I  desire  to  say  that  in  my  opinion, 
a  stricture  located  within  the  distance  named, 
can  be  treated  more  successfully  by  other  methods. 

Before  leaving  the  subject  of  colotomy,  as  one 
of,  if  not  the  most  important  of  all  methods  of 
treatment  for  stricture  of  the  rectum,  from  what- 
ever cause,  I  beg  to  call  to  mind  that  the  statis- 
tics of  Erckelen  carefully  compiled  in  1884,  and 
shown  by  Treves  that  38  in  every  100  cases  of 
lumbar,  and  46  in  every  100  cases  of  iliac  colot- 
omy died  within  twenty- one  days  after  the  opera- 
tion. This  statement  speaks  for  itself.  Stricture 
from  benign  causes  located  within  the  distance 
that  I  have  named,  should  be  dealt  with  in  a 
similar  way. 

Symptoms. — The  early  symptoms  of  stricture 
in  the  rectum  are  very  obscure  and  confusing. 
Indeed  no  stricture  exists  at  all  in  the  pathologi- 
cal changes  going  on  in  the  gut  which  conduce 
to  this  state.  The  great  trouble  is  that  the  early 
symptoms  are  so  masked  or  entirely  nil,  that  no 
attention  is  paid  to  them  by  the  patient,  that 
when  he  is  forced  to  consult  a  phj'sician  a  very  de- 
cided stricture  may  exist.  The  changes  made 
manifest  in  the  rectum  are  those  of  inflammation 
and,  if  from  cancer,  the  condition  of  the  blood 
vessels,  and  the  gradual  deposit  of  the  morbid 
material,  together  with  infiltration  of  the  tissue, 
goes  on  so  slowly  and  iusiduously,  that  for  a  long 
time  there  are  really  no  symptoms.  I  have  seen 
many  cases  where  the  first  symptom  noticed  was 
a  so-called  constipation,  obstipation  would  be  a 
better  word,  and  upon  the  introduction  of  the 
finger  a  tight  constriction  could  be  felt.  This 
may  apply  to  any  form  of  stricture.  I  have 
under  observation  now  three  cases  of  this  kind. 
The  first  symptoms  of  stricture  then  are  not  the 


discharge  of  bloody  pus,  etc.,  indicative  of  ulcer- 
ation, that  some  describe.  Therefore,  I  must 
differ  from  those  who  place  the  symptoms  of  ulcer- 
ation first,  and  those  of  constriction  afterward. 
Ulceration  cannot  take  place,  together  with  the 
symptoms  incident  thereto,  a  discharge  of  blood, 
pus  or  miico  purulent,  until  the  changes  of  in- 
flammation have  been  such  that  the  mucous 
membrane  and  sub  •mucous  tissues  have  under- 
gone that  change  which  constitutes  ulceration. 
When  this  latter  condition  is  established,  we  have 
the  characteristic  discharges — diarrhoea,  flatus, 
the  muco-purulent  discharge,  or  rather  a  muco- 
bloody  discharge  first,  succeeded  eventually  by  a 
purulent  discharge,  and  alternating  diarrhoea  and 
constipation.  The  bearing  down  sensation,  to- 
gether with  tenesmus,  a  reflected  pain  to  the 
back  and  down  the  thighs,  an  irritation  of  the 
kidneys  and  bladder,  and  uncomfortable  feeling 
always  about  the  rectum.  A  passage  of  small 
bits,  or  tape-like  actions,  are  all  indications  of  the 
disease.  I  am  persuaded  that  oftentimes  stric- 
ture is  diagnosed  from  this  characteristic  tape- 
like action,  when  in  reality  the  moulding  is  done 
by  the  sphincter  muscle  in  an  irritable  state,  and 
that  no  stricture  in  reality  exists.  I  am  satis- 
fied, too,  that  many  cases  of  so  called  chronic  con- 
stipation are  due  to  a  narrowing  of  the  lumen  of  the 
gut  from  this  cause.  This  has  occurred  so  often 
in  my  practice  that  I  am  now  in  the  habit  of  ex- 
amining the  rectum  in  every  case  of  chronic  con- 
stipation. This  same  rule  holds  good  in  cases 
of  supposed  dysentery,  for,  as  I  have  observed, 
dysentery  is  but  one  of  the  symptoms  of  stricture, 
and  caused  by  it. 

I  have  had  but  two  cases  of  acute  obstruction 
caused  by  the  chronic  condition  of  the  stricture. 
-  One  in  the  case  of  a  young  lady  who  failed  to  re- 
port to  me  as  often  as  necessary  for  a  dilatation  of 
the  stricture  (she  would  not  consent  to  an  opera- 
tion)  and  during  a  summer  outing  took  sick  and 
died  from  an  acute  obstruction.  The  other  was  a 
young  married  woman,  in  the  practice  of  one  of  our 
local  ph3"sicians.  An  operation  with  the  knife 
relieved  her.  Acute  obstruction,  as  the  first  symp- 
tom of  stricture,  I  have  never  seen,  although  I 
have  examined  a  number  of  patients  who  com- 
plained of  constipation  only,  who  upon  being  ex- 
amined, showed  a  decided  stricture  that  the 
smallest  finger  could  not  pass.  In  one  instance  I 
found  a  close  stricture  at  the  entrance  of  the  sig- 
moid flexure.  It  is  truly  wonderful  to  see  patients 
who  have  strictures  of  the  smallest  calibre,  who 
seem  to  enjoy  perfect  health,  and  whose  physical 
proportions  and  development  are  not  hurt  in  the 
least.  It  must  not  be  forgotten,  however,  that 
these  are  dangerous  conditions  and  constantly  im- 
peril the  life  of  the  patient. 

Diagnosis. — When  the  stricture  is  within  four 
inches  of  the  sphincter  muscle,  it  is  easily  diag- 
nosed, be  it  malignant,  benign  or  syphilitic — the 


66o 


THE  ADDRESS  IN  SURGERY. 


[May  9. 


finger  will  detect  it.  It  is  a  very  different  mat- 
ter, however,  to  determine  its  character,  and  yet, 
to  a  certain  extent,  the  treatment  depends  upon 
it.  I  desire  to  quote  from  Kelsey  the  following 
statement: 

There  is  an  old  and  deeply  rooted  idea  in  the  minds  of 
the  profession,  that  a  stricture  of  the  rectum  must  be 
either  cancerous  or  syphilitic — au  idea  founded  on  error 
and  capable  of  doing  much  harm  and  injustice  to  inno- 
cent people.  Again  and  again  I  have  been  able  to  give 
great  comfort  to  women  suffering  from  this  disease  by 
denying  the  correctness  of  this  idea,  and  in  my  own 
practice,  the  fact  that  a  stricture  is  not  cancerous  adds 
little  weight  to  the  idea  that  it  may  be  syphilitic. 

This  is  so  diametrically  opposed  to  my  views 
and  observations  that  I  desire  to  say  that,  in  my 
opinion,  fully  sixty  per  cent,  of  the  strictures  of 
the  rectum  are  due  to  syphilis.  Not  venereal  in 
the  sense  that  many  would  have  us  believe, 
namely:  by  the  infection  of  the  rectum  by  can- 
chrous  pus,  or  by  direct  contact,  but  as  a  second- 
ary deposit,  the  result  of  constitutional  disease. 
There  are  but  few  authors  to-day  that  deny  this 
fact,  but  in  admitting  it,  class  these  as  exception- 
al cases.  By  a  late  estimate  it  is  calculated  that 
five  million  people  in  the  United  States  are  sub- 
jects of  constitutional  syphilis.  If  it  is  admitted 
that  one  single  case  of  stricture  of  the  rectum  can 
result  from  this  constitutional  disease,  it  admits 
the  argument.  Then  taking  into  consideration 
the  great  number  affected  with  it,  is  it  any  won- 
der that  we  should  have  the  per  cent,  named  as 
suffering  from  this  manifestation  in  the  rectum  ? 
Mr.  Allingham,  in  tabulating  his  cases  of  stric- 
ture, says:  "  Thus  out  of  the  total  number  of  99 
patients,  52  or  more  were  syphilitic." 

As  a  means  of  diagnosis,  the  clinical  history 
and  observation  of  the  case  has  much  to  do  with 
forming  a  correct  opinion.  If  it  is  ascertained  that 
the  patient  has  constitutional  syphilis,  I  would  con- 
sider that  it  was  a  strong  point  gained.  I  do 
not  wish  to  be  understood  as  saying  that  in  every 
case  where  both  syphilis  and  stricture  exist,  that 
the  latter  was  caused  by  the  former,  but  undoubt- 
edly in  the  vast  majority  of  cases  this  is  true. 
Indeed,  so  firm  am  I  in  this  belief,  that  if  it  is  a 
question  between  cancer  or  no  cancer,  and  it  i  s 
decided  that  it  is  not  malignant,  99  out  of  every 
100  cases  will  prove  to  be  syphilitic;  for  the  rea- 
son that  stricture,  the  result  of  benign  ulceration, 
does  not  resemble  in  the  least  stricture  from  ma- 
lignant deposition.  To  the  contrary,  syphilitic 
stricture  does,  to  a  degree,  in  its  pathology,  re- 
semble malignant  growths.  To  be  plainer,  ma- 
lignant disease,  and  syphilitic  disease,  invade  the 
rectum  as  a  deposit,  infiltration  of  the  sub- mucous 
tissues,  etc.  Ulceration  here  is  secondary  to  the 
deposit  caused  by  the  friction  of  the  passage  of 
faeces,  or  the  breaking  down  of  the  tissue,  the  re- 
sult of  the  disease  per  se.  Benign  ulceration  be- 
gins with  the  damage  done  to  the  mucous  mem- 
brane, and  the  plastic  infiltration  is  secondary  to 


it,  the  reverse  of  both  the  malignant  and  specific 
disease. 

Again,  as  a  diagnostic  symptom,  the  touch  re- 
veals a  great  deal.  Allingham  says:  "There  is 
something  peculiar  about  the  feeling  of  cancer, 
which  the  operator's  finger  rarely  mistakes  even 
for  simple  indurated  ulceration."  This  is  the 
fact,  yet  if  I  was  called  on  to  describe  it,  I  could 
not.  It  is  said  by  many  authors  that  the  pecu- 
liar smell  or  odor  of  cancer  is  pathognomonic.  I 
am  certain  that  I  have  seen  many  cancers  that  did 
not  evidence  this  peculiar  odor.  Great  stress  is 
also  laid  on  the  disposition  of  malignant  growths 
to  bleed,  especially  when  touched  or  handled.  I 
am  just  as  sure  that  1  have  seen  many  cases  of 
cancer  that  had  no  such  disposition.  The  swol- 
len or  enlarged  glands  in  the  inguinal  region  can- 
not be  taken  as  a  postive  sign  or  indication  of 
cancer  in  the  rectum,  from  the  fact  that  they  are 
swollen  in  many  cases  of  benign  ulceration  and 
inflammation.  I  will  again  state  that  pain,  in 
my  opinion,  is  made  too  great  a  symptom  of  can- 
cer. It  depends  altogether  upon  circumstances 
whether  it  exists  to  any  degree  or  not.  In  cancer 
the  nodular  form  of  the  mass  is  more  apparent 
than  in  any  other  trouble.  In  syphilis,  the  in- 
duration is  more  even  and  extends  with  more  reg- 
ularity, and  after  a  time  is  of  a  fibrous  character 
and  is  so  indicated  to  the  touch.  In  simple  ul- 
ceration, the  stricture  is  apt  to  be  annular. 

As  a  method  of  diagnosis,  I  object  to  the  use 
of  rectal  bougies,  either  metal,  soft,  or  hard  rub- 
ber, to  which  so  many  authors  call  attention. 
They  are  exceedingly  dangerous,  and  accomplish 
no  earthly  good.  I  have  known  two  patients 
killed  by  the  attempt  to  introduce  the  common 
hard  rubber  English  bougie  within  a  stricture  of 
the  rectum.  The  common  seat  of  stricture  is 
within  reach  of  the  finger.  It  is  the  rarest  thing 
that  one  is  ever  found  in  the  movable  gut.  Grant- 
ing that  one  exists  there,  if  there  is  not  a  total 
obstruction,  what  is  the  use  of  an  exploration 
with  a  dangerous  instrument,  when  the  finding 
of  the  stricture,  or  the  supposed  finding  of  it 
would  result  in  no  good.  A  stricture  located  in 
the  movable  gut  cannot  be  dilated.  If  it  be  total 
occlusion  or  obstruction,  it  calls  for  very  differ- 
ent treatment  from  this. 

Treatment. — In  considering  the  treatment  of 
this  very  formidable  disease,  I  shall  adhere  in 
the  strictest  sense  to  the  pathological  condition, 
namely,  a  stricture.  This  entirely  rules  out  the 
treatment  of  proctitis,  or  the  subsequent  ulcera- 
tion, which  is  one  cause  of  stricture,  and  brings 
us  directly  to  the  means  of  treating  that  which  is 
the  result  of  said  causes.  It  must  be  granted 
that  many  times  ulcerations,  which  would  even- 
tuate in  stricture,  are  cured  before  that  condition 
results.  This  cannot  hold  good  in  cancer.  Can 
it  in  syphilis?  I  doubt  it.  In  the  great  majority 
of  cases,  we  are  confronted  at  the  onset  with  stric- 


I89i.] 


THE  ADDRESS  IX  SURGERY. 


66 1 


ture,  not  with  the  ulceration,  so  insidious  is  the 
disease.     The  methods  practiced  to-day  for  treat- 
ing stricture  of  the  rectum  are: 
i.   Dilatation. 

2.  Incision 

3.  Electrolysis,  and  raclage. 

4.  Excision. 

5.  Colotomy. 

Of  course,  under  the  division  I  have  made,  we 
rule  out  general  treatment. 

Dilatation. — Kelsey  in  speaking  of  dilatation, 
says. 

"  By  dilatation  I  mean  gradual  stretching,  not 
forcible  divulsion,"  and  adds  that  the  latter  is 
seldom  applicable.  I  must  dissent  to  these  views. 
The  gradual  dilatation  of  stricture  is  objectiona- 
ble, for  the  reason  that  by  this  form  of  repeated 
irritation,  more  plasma  is  thrown  out  and  the 
strictured  surface  increases.  It  may  be  true  that 
some  temporary  relief  is  afforded,  but  upon  the 
contraction  of  the  tissue,  which  is  sure  to  take 
place,  we  have  lost  more  than  we  have  gained.  I 
do  not  hold  to  the  view  that  by  the  passing  of 
bougies  through  the  strictured  surface  absorption 
of  the  tissue  is  caused,  I  believe  that  the  converse 
is  true.  Why  forcible  divulsion  is  seldom  appli 
cable  in  these  cases,  I  cannot  understand.  If  a 
fibrous  stricture  exists,  I  am  sure  that  forcible  di- 
vulsion is  the  best  method.  In  other  words,  we  do, 
in  a  few  minutes,  by  immediate  dilatation,  what 
it  would  take  weeks  to  accomplish  by  gradual 
dilatation.  The  fear,  in  the  past,  has  been  haem- 
orrhage in  this  operation.  To-day  we  do  not  fear 
it,  because  we  understand  howT  to  control  it. 
Therefore,  I  would  put  but  little  stress,  or  no 
stress  at  all,  upon  treating  stricture,  of  whatever 
kind,  by  bougies.  In  fibrous  stricture  it  would 
do  no  good;  in  the  malignant  one,  it  would  be 
dangerous.   I  have  abandoned  their  use  altogether. 

In  1878  I  read  a  paper  before  the  Kentucky 
State  Medical  Society,  in  which  I  reported  a  case 
of  close  stricture  at  the  entrance  of  the  sigmoid 
flexure.  The  plan  adopted  was  to  break  the 
sphincter  muscle,  introduce  the  hand  and  arm  into 
the  rectum,  and  reaching  the  stricture,  which  bare- 
ly admitted  my  index  finger,  I  made  a  cone  of 
my  four  fingers  and  forcibly  pushed  them  through 
the  stricture.  It  gave  way  before  them,  and  al- 
though great  shock  supervened,  the  recovery 
from  immediate  danger  was  effectual.  I  am  sat 
isfied  that  a  more  perfect  and  radical  relief  was 
obtained  than  if  I  had  done  colotom}-.  Gradual 
dilatation  here  was  out  of  the  question.  I  am 
very  positive  then  in  saying  that  if  dilatation  of 
a  stricture  of  the  rectum  is  decided  upon,  let  it 
be  a  forcible  and  radical  one. 

Incision. — I  am  very  partial  to  incision,  or  in- 
cisions, for  the  relief  of  stricture  of  the  rectum. 
Of  the  two  operations  recommended,  internal  and 
external  posterior  linear  proctotomy.  I  much 
prefer  the  internal.     It  is  urged  for  the  external, 


which  consists  of  not  only  going  through  the 
strictured  surface,  but  also  in  dividing  the  sphinc- 
ter muscle,  that  it  is  all  important  to  get  the  ne- 
cessary drainage.  I  do  not  think  so,  and  if  I  did, 
I  believe  the  ill-effects  of  dividing  the  sphincters 
outweigh  the  matter  of  drainage.  I  cannot  be- 
lieve that  the  internal  incision  is  as  dangerous  as 
it  is  represented  to  be  by  some  authors.  My  plan 
is  to  introduce  a  three  or  four  valve  speculum, 
and.  after  dilating  sufficiently  for  the  purpose,  a 
long  sharp  knife  is  used  to  divide  the  constrictions 
of  fibrous  tissue,  down  to  a  health}-  base — not 
only  in  the  median  line,  but  in  several  places 
around  the  circumference  of  the  gut.  I  then  place 
a  tampon,  through  which  I  have  inserted  a  metallic 
tube  for  drainage,  and  the  escape  of  gases.  This 
tampon  is  aseptic,  and  usually  dusted  with 
powdered  persulphate  of  iron.  On  the  fourth 
day  it  is  removed  and  the  rectum  irrigated  with  a 
mercuric  solution.  If  the  operation  is  done  effec- 
tually, I  have  never  seen  the  necessity  of  employ- 
ing the  bougies  afterward,  for  the  purpose  of  dil- 
atation. Patients  are  averse  to  their  use,  and 
they  do  not  accomplish  the  good  claimed  for 
them.  My  objection  to  the  external  operation,  al- 
though I  have  practiced  it  often,  is  that  to  divide 
the  sphincters  when  all  the  tissues  are  in  a  dis- 
eased condition  invites  non-union,  and  incontin- 
ence is  nearly  certain  to  follow.  The  sugges- 
tion of  Weir,  to  confine  the  incision  to  the  stric- 
ture and  then  to  drain  the  incision  by  a  tube 
brought  out  through  the  skin,  at  the  tip  of  the 
coccyx,  I  do  not  think  will  accomplish  the  pur- 
pose in  many  cases;  besides,  it  leaves  a  channel 
which  may  not  heal.  To  divide  the  sphincters 
and  then  employ  three  or  four  deep  provisional 
wire  sutures  between  the  anus  and  the  strictures, 
leaving  them  loose  and  stuffing  the  incision  with 
charpie,  after  the  manner  of  Kelsey,  I  think  un- 
wise and  unsurgical.  It  is  said  that  one  great 
danger  of  the  operation  is  septic  peri-proctitis, 
but  under  antiseptic  precautions,  the  danger,  in 
my  opinion,  is  reduced  to  a  minimum.  In  one 
case  of  malignant  disease,  in  which  I  did  the  ex- 
ternal operation,  rapid  sepsis  took  place,  and  the 
patient  died  in  twenty-four  hours.  I  do  not 
think  either  the  internal  or  external  operation 
should  be  done  for  malignant  growths,  unless  to- 
tal, or  nearly  total,  occlusion  has  taken  place.  In 
all  cases  of  non-malignant  stricture,  syphilitic  or 
simple,  either  the  internal  linear  proctotomy  of 
the  French  surgeons,  or  the  external  operation  as 
practiced  by  many,  is  far  more  preferable  to  ex- 
cision, or  colotomy. 

Electrolysis  — It  does  appear  that  where  we  can 
so  effectually  go  through  a  stricture  by  linear 
proctotomy  atone  sitting,  that  it  would  be  useless 
to  attempt  so  slow  a  process  as  electrolysis.  Af- 
ter a  careful  review  of  the  subject,  I  cannot  be- 
lieve that  any  benefit  obtained  is  brought  about 
by  the  dilatation  from    the  electrodes   used,    as 


662 


THE  ADDRESS  IN  SURGERY. 


[May  9 


suggested  by  some.  If  there  be  a  benefit,  in  fact, 
it  must  be  attributed  rather  to  what  is  claimed 
for  it — partial  destruction  of  tissue  by  cauteriza- 
tion. To  claim  radical  cures  by  this  method,  I 
must  admit,  seems  untheoretical,  if  not  unsurgi- 
cal,  and  yet  Dr.  Newman  and  others  report  many 
cases  of  stricture  cured  by  this  method.  In  a 
paper  read  before  this  Association  and  published 
in  The  Journal,  he  makes  the  following  con 
elusion: 

I.  Electrolysis  in  the  treatment  of  stricture  of  the  rec- 
tum is  not  a  panacea;  on  the  contrary  failures  may  hap- 
pen, and  probably  will.ifthe  stricture  is  due  to  carcinoma. 
2.  Electrolysis  will  give  improvement  to  the  stricture 
when  all  other  methods  have  failed.  3.  Electrolysis  will 
cure  a  certain  percentage  of  cases,  without  relapse,  and  1 
without  the  necessity  of  an  after  treatment  or  using  bou- 
gies. 4.  The  best  agents  for  a  cure  are  through  the 
fibrous  inflammatory  stricture. 

Having  no  personal  experience  with  this 
method  of  treating  a  stricture  of  the  rectum,  I  am 
not  prepared  either  to  advocate  it  or  disprove  the 
statements  made. 

Excision. — I  think  a  better  term  to  employ 
here  would  be  extirpation.  Excision  of  a  stric- 
ture of  the  rectum  conveys  but  a  little  idea  of  the 
operation.  I  cannot  appreciate  the  idea  of  excis- 
ing a  benign  stricture,  not  from  any  serious 
doubts  as  to  whether  it  could  be  done  or  not,  or 
any  dangers  attending  the  operation,  but  there 
are  methods  so  much  simpler  in  their  nature  for 
the  relief  of  benign  strictures,  that  I  cannot  con- 
ceive of  a  surgeon  attempting  its  excision. 

Extirpation  of  the  rectum  for  malignant  disease 
I  believe  to  be  an  ideal  operation.  Between  the 
plan  of  the  German  surgeons  of  removing  the  en- 
tire rectum  up  to  the  sigmoid  flexure,  and  the 
English  surgeons  of  restricting  the  operation  to  a 
very  limited  extent,  I  believe  that  a  middle 
ground  can  be  established  and  practiced,  based 
upon  a  true  pathology.  It  is  an  axiom  in  sur- 
gery that  in  operating  for  cancer,  the  whole 
growth  must  be  removed,  together  with  the 
glands  that  are  involved.  Let  us  take  this  axiom 
as  our  guide  in  rectal  surgery.  If  the  growth  ex 
tends  beyond  the  point  where  it  is  prudent  to  op- 
erate, it  is  best  not  to  attempt  its  removal,  except, 
perhaps,  for  total  obstruction,  not  with  any  idea 
of  cure.  Cripps  makes  the  point  that  the  opera 
tion  is  of  doubtful  propriety  when  the  disease  in- 
volves the  upper  part  of  the  recto-vaginal  section, 
where  it  is  covered  with  peritoneum.  I  do  not 
consider  this  injunction  as  meaning  that  it  is  so 
dangerous  to  open  the  peritoneum,  but  that  this 
membrane  being  involved  in  the  disease,  renders 
the  operation  useless.  If,  however,  there  is  no 
fear  of  the  invasion  of  the  peritoneum,  an  admir- 
able operation  is  afforded  us  by  Kraske's  sugges- 
tion, enabling  us  to  remove  much  of  the  length 
of  the  rectum.  The  chief  argument  in  favor  of 
his  operation  is  that  the  entire  length  of  the  rec- 
tum can   be   removed,    without    disturbing   the 


sphincter  muscles.  In  continence  of  faeces,  the 
result  of  injury  to  these  muscles,  is  the  one  great 
objection  to  any  other  mode  of  operating. 

Kraske's  operation  is  admirably  suited  to  can- 
cerous stricture.  It  consists  in  resecting  the  dis- 
eased part,  through  an  opening  made  at  the  left 
side  of  the  sacrum.  This  operation,  of  course, 
is  only  applicable  in  a  certain  class  of  cases.  For 
instance,  if  the  sigmoid  flexure  is  involved,  it 
would  be  of  no  use.  If  the  stricture  is  low  down, 
it  can  be  divided  with  a  knife.  According  to  his 
method,  the  soft  paits  are  divided  in  the  median 
line  from  the  second  sacral  vertebra  to  the  anus. 
The  muscular  attachments  to  the  sacrum  are  di- 
vided as  far  as  the  edge  of  the  opening  on  the  left 
side.  The  coccyx  is  removed,  the  attachments 
of  the  two  sacro-sciatic  ligaments  to  the  sacrum 
are  cut,  and  the  soft  parts  drawn  to  the  left  side. 
If  still  more  room  is  necessary,  it  may  be  gained 
by  removing  a  part  of  the  lower  left  side  of  the 
sacrum.  If  the  bone  be  divided  on  a  line,  begin- 
ing  on  the  left  edge,  at  the  level  of  the  three  pos- 
terior sacral  foramen,  and  running  in  a  curve 
concave  to  the  left,  through  the  lower  border  of 
the  three  posterior  sacral  foramen  and  through 
the  fourth  to  the  left  lower  border  of  the  sacrum, 
the  more  important  nerves  are  not  injured  and 
the  sacral  canal  is  not  opened.  In  this  way,  the 
lower  part  of  the  rectum,  as  far  as  the  sigmoid 
flexure,  may  be  removed.  It  will  be  found  in 
this  operation,  that  the  dissection  is  a  very  diffi- 
cult one. 

Alexander  modified  this  operation,  the  chief 
points  being  that  he  exsected  the  coccyx  and  all 
of  the  sacrum  necessary  to  a  certain  limit.  Ex- 
perimenting with  the  two,  I  much  prefer  Kraske's 
original  operation.  I  have  removed  as  much  as 
five  inches  of  the  rectum,  by  simply  removing 
the  coccyx,  making  a  deep  and  long  dorsal  incis- 
ion, and  then  practicing  a  thorough  dissection  of 
the  gut.  The  one  great  object  of  both  of  these 
operations  is  to  keep  the  sphincter  muscles  and 
anus  intact.  It  is  true,  however,  that  in  some 
cases  the  cicatrization  is  sufficient  to  establish 
partial  control  at  least  of  the  actions  after  the  re- 
moval of  the  muscles.  This  was  beautifully  illus- 
strated  in  a  case  of  extirpation  which  I  recently 
did  for  cancer.  The  patient  was  a  man  about  60 
years  of  age.  The  growth  extended  completely 
around  the  gut,  beginning  at  the  anus  and  ex- 
tending up  the  rectum  for  fully  five  inches.  The 
tissues  surrounding  the  rectum  were  involved  to 
the  extent  of  three  inches.  Both  sphincters  were 
embraced  in  the  disease.  A  deep  dorsal  incision 
was  made  through  the  sphincters  and  tissues  to 
the  sacrum,  and  brought  out  over  the  coccyx. 
The  incision  was  then  made  completely  around 
the  whole  diseased  structure,  extending  from  the 
j  coccyx,  around  through  the  perineum.  The  gut 
and  sphincters  were  then  carefully  dissected  out. 
The  vessels  were  tied  as  the}'  were  net,  drainage 


i89i.] 


THE  ADDRESS  IN  SURGERY. 


663 


tubes  placed,  and  the  wound  dressed  antiseptieal- 
ly.  I  did  not  do  as  the  German  surgeons  sug- 
gest, draw  down  the  end  of  the  rectum  to  the 
skin,  attach  it  by  a  row  of  sutures,  nor  did  I  do 
as  Allingham  and  Kripps  advise,  stitch  the  gut 
lightly  to  the  skin,  and  leave  the  wound  to  close 
by  granulation.  In  lieu  of  both,  I  left  the  wound 
just  as  I  made  it,  and  made  no  attempt  to  either 
bring  the  mucous  membrane  down  or  to  stitch  it. 
When  the  wound  had  filled  up  and  healed,  the 
cicatrization  afforded  him  protection  against  any 
sudden  evacuation  of  the  bowels.  I  am  more 
and  more  persuaded  that  where  there  is  a  possi- 
bility of  removing  the  entire  malignant  growth 
from  the  rectum,  excision  is  far  more  preferable 
to  colotomy.  Excision  would  remove  the  dis- 
ease, thereby  having  some  grounds  to  hope  that 
it  will  not  reappear.  By  colotomy  we  simply 
palliate  the  symptoms,  leaving  the  disease  in  its 
rava..   - 

Colotomy. — In  a  paper  read  before  the  Ninth 
International  Medical  Congress,  which  convened 
in  this  city  in  1S87.  I  took  exception  to  colotomy 
as  a  means  of  treating  cancer  of  the  rectum.  In 
that  paper  I  said : 

It  is  after  a  careful  survey  of  all  the  reasons  advanced 
by  those  who  advocate  colotomy.  in  cases  of  cancer  of  the 
rectum,  that  I  am  constrained  to  differ  from  them  and  to 
sav  that  I  do  not  believe  that  the  operation  is  justified  in 
these  cases,  except  under  the  rarest  circumstances,  if  at 
all. 

I  am  still  of  the  same  opinion.  Too  many  peo- 
ple are  being  subjected  to  this  horrible  and  dis- 
g  operation,  that  could  be  benefited  equal- 
ly as  much,  by  simpler  means.    The  operation  in 
I  romises  but  little.     Kelsey  - 

e  common  doctrine  taught,  that  it  is  to  prolong 
life  by  the  relief  of  pain,  the  prevention  of  obstruction, 
and  in  retarding  the  growth  of  cancerous  disease. 

To  these  statements  I  cannot  give  my  full  ap- 
proval. First,  that  to  prolong  life  by  the  relief 
of  pain  I  answer,  in  the  majority  of  esses  that 

me  under  my  observation,  and  they  have 
been  many,  there  has  not  been  much  pain  com- 
plained of.  Indeed,  it  has  not  been  a  factor.  A 
young  lady  just  sent  to  me  from  the  South,  with 
a  pronounced  cancer  of  the  rectum,  says  she  has 
never  suffered  any  pain.  This  is  simply  repeat- 
ing what  many  have  said  to  me.  If  this.  then. 
be  the  reason  assigned  for  the  operatic: 

ould  be  ruled  out,  and  they  constitute  the 
majority.     But    suppose  that  pain    exists,    does 
colotomy  relieve  it?     It  may  in  some  ca- 
I  am  certain  that  in  many  it  does  not.   As  I  have 
said  in  this  article,  pain  is  within  the  growth  it 
self,  by  the  involvement  of  the  nerves.     Surely 
colotomy   could  not  relieve  it.     It  is  likely  true 
that  the  faeces  passing  over  the  growth  may  irri 
tate  it  to  a  certain  extent,  but  my  experience  has 
taught  me  that  if   the  sphincter  muscles  are  not 
i  nvolved,  there  is  but  little  pain,   and  if  they  are 


involved,  scraping  the  mass  out,  according  to  the 
Germans,  will  relieve  it,  equally  as  well  as  colot- 
omy would.  Again,  it  must  be  admitted  that 
after  colotomy  is  done,  there  is  no  abso1.-' 
tainty  that  some  of  the  faeces  will  not  pass  down 
into  the  rectum. 

Second,  that  it  prevents  obstruction.  It  will  be 
admitted  that  the  greater  number  of  cancers  are 
located  in  the  lower  or  fixed  part  of  the  rectum. 
It  is  a  recognized  fact,  too,  that  total  obstruction 
from  faecal  impaction  rarely  takes  place;  because 
it  is  the  disposition  of  malignant  tissue  to  break 
down  after  a  certain  stage.  But  suppose  it  does 
not,  and  a  stricture,  total,  if  you  please,  results. 
to  cut  through  it,  divulse  it.  or  resect  it.  would 
be  better  than  to  do  colotomy.  The  L:  - 
will  promise  equally  as  much,  and  the  last  much 
more.  I  have  never  seen  a  total  obstruction  by 
faeces  in  a  cancerous  stricture.  I  have  known 
total  obstruction  to  occur  by  the  closure  of  a  stric- 
ture. We  have  means  of  eradicating  this  by  the 
three  methods  mentioned.  They  are  much  sim- 
pler than  colotomy,  why  not  do  them? 

Third,  that  it  retards  the  growth  of  cancerous 
disease.  Neither  can  I  subscribe  to  this  proposi- 
tion. How  the  establishing  of  an  artificial  open- 
ing in  the  loin  or  groin  materially  retards  the 
growth  in  the  rectum.  I  cannot  understand.  I 
know  that  it  is  used  as  an  argument  that  the 
stoppage  of  the  faeces  over  the  growth  would,  to 
a  degree,  stop  the  growth.  This  is  utter  falla- 
cious. The  cancer  persists  in  its  progressive 
course  of  infiltration,  ulceration,  etc..  with  as 
much  rapidity  after  colotomy  is  performed.     Cor- 

.-.isties   of  the   condition  will  ver 
statement.     Admitting  that  there  was   truth  in 
the  assertion,  patients  who  suffer  with  cancer  to 
that  degree,  or  extent,  requiring  colotomy,   are 
not  anxious  to  have  their  lives  prolonged, 
last  argument,  it  is  said  that  colotomy  substitutes 
a  painless  death  for  one  of  great  agony 
statement  cannot  be  borne  out  by  facts.     Patients 
who  have  malignant  disease  of  the  rectum  usual- 
ly die  of  a  low  and  gradual  form  of  peritonitis.  I 
have  witnessed  a  number  of  such  deaths,  and  they 
are  usually  painless.     In  what  way  colotomy  can 
substitute  a  painless  death,  granting  that  such  a 
conditi'  ;annot  understand.      It  would 

appear  that  they  would  die  very  much  the  same 
way,  whether  colotomy  is  done  or  not.  So  I  am 
forced  to  conclude  that  neither  one  nor  all  of  the 
so-called  arguments  in  favor  of  doing  colotomy. 
rf  other  methods,  for  cancerous  stricture, 
can  be  substantiated  in  fact.  If  I  were  asked. 
when  is  colotomy  justified  in  cancer  of  the  rectum. 
I  would  ansv.  if  at  all.     But  if  there  be 

total  obstruction  of  the  xure  from  a 

cancerous  mass,  and  if  for  any  special  reason  we 
wish  to  prolong  life  a  few  days,  then  I  believe 
colotomy  would  be  justifiable.  I  kuow  that  this 
I  is  a  radical  view  to  take  of  the  case,   and  I  also 


664 


CHEMICAL  FACTORS  IN  CAUSATION  OF  DISEASE. 


[May  9, 


recognize  that  the  great  majority  of  surgeons 
will  differ  from  me,  but  my  conclusions  have 
been  formed  after  a  care  ful  investigation  of  the 
subject. 

But  to  proceed.  Is  colotomy  to  be  recommend- 
ed as  a  procedure  in  the  treatment  of  stricture  of 
the  rectum  ?  I  unhesitatingly  answer,  yes. 
Whenever  a  stricture  other  than  malignant,  espe- 
cially when  caused  by  syphilis,  is  located  in  the 
movable  part  of  the  gut,  or  in  the  sigmoid  flex- 
ure, either  carsing  total  obstruction  or  about  to 
cause  it,  colot<  my  should  be  done.  If  I  am  asked 
why,  in  this  in  tance,  and  not  in  cancerous  stric- 
ture, I  would  answer,  in  this  we  prolong  life  in- 
definitely. I  see  no  reason  why  one  should  not 
live  many  years  after  the  operation  done  for  this 
condition.  A  fibrous  stricture  in  the  locality 
named  would  likely  cause  death  by  occlusion,  if 
let  alone.  It  is  beyond  reach  for  dilatation,  divis- 
ion or  excision.  There  is  nothing  in  the  stric- 
ture per  se  to  cause  death,  only  in  the  manner 
mentioned.  It  acts  as  a  foreign  body,  causing 
obstruction.  It  can  never  be  reabsorbed.  It  can- 
not cause  death  by  infection  of  the  body.  Hav- 
ing blocked  the  channel,  we  open  a  gate-way 
above  for  the  escape  of  faeces,  and  life  is  pro- 
longed indefinitely.  To  do  the  operation  for  can- 
cerous stricture,  the  disease  is  neither  stayed  nor 
cured.  The  patient  dies  and  the  friends  ask,  why 
you  did  so  formidable  and  disgusting  an  opera- 
tion, when  you  knew  that  death  would  so  soon 
ensue.  To  the  contrary,  in  benign  or  syphilitic 
strictures,  the  patient  will  live  to  thank  you  for 
doing  the  colotomy.  If,  then,  it  is  decided  to  do 
colotomy,  which  of  the  two  operations  is  prefera- 
ble, the  lumbar  or  extra-peritoneal,  or  iliac,  or 
intra-peritoneal  ?  I  think  the  anatomical  phrase 
used  in  designating  the  two  should  decide  it.  An 
operation  extra-peritoneal  is  certain  to  be  prefer- 
red to  one  that  is  intra  peritoneal. 

I  am  cognizant  of  all  that  is  said  in  regard  to 
the  perfect  safety  of  opening  the  peritoneum  under 
aseptic  precautions.  Nevertheless,  it  cannot  be 
gainsaid  that  it  is  more  dangerous  to  open  the  per- 
itoneum than  not  to  open  it.  I  know,  too,  it  is 
asserted  that  in  doing  a  lumbar  operation,  the 
peritoneum  is  often  opened.  This  has  not  been 
the  case  in  my  experience,  and  in  Mr.  Bryant's 
170  cases  of  lumbar  colotomy.  the  peritoneal  cav- 
ity was  opened  but  twice.  This  disproves  the 
assertion.  It  is  urged  in  favor  of  the  iliac  opera- 
tion, that  by  it  there  can  be  no  possibility  of  the 
surgeon  mistaking  the  small  intestines,  duodenum, 
or  stomach,  for  the  large  intestine.  Just  as  well 
say  that  it  is  dangerous  to  attempt  to  ligate  inter- 
nal haemorrhoids,  because  there  is  a  possibility  of 
including  the  prostate  gland.  A  surgeon  that 
could  not  recognize  the  stomach  from  the  colon, 
ought  not  to  attempt  a  colotomy.  If  the  opera- 
tion is  done  for  the  condition  that  I  have  named, 
namely  cancerous  stricture  or  obstruction  in  the 


sigmoid  flexure,  the  lumbar  operation  is  also 
preferable  for  the  reason  that  it  is  a  greater  dis- 
tance from  the  diseased  part  and  not  so  apt  to  be 
embraced  by  it. 

I  have  not  the  time  or  disposition  to  argue  the 
pros  and  cons  of  this  much  mooted  question.  I 
think  Mr.  Bryant  has  met  all  the  objections  against 
the  lumbar  operation,  and  I  quite  agree  with 
him  when  he  says:  "Iliac  colotomy  is  not  yet 
proved  to  be  superior  to  the  lumbar  operation." 


LECTURES. 

THE  CHEMICAL  FACTORS  IN  THE 
CAUSATION  OF  DISEASE. 

Course  0/  Three  Lectures  delivered  at  the  Post-Graduate  Medical 
School  of  Chicago,  March  26,  27  and  28,  I&ol. 

BY  VICTOR  C.  VAUGHAN,  M.D.,   Ph.D., 

OF   ANN  ARBOR,  MICH. 


PROFESSOR    OF    HYGIENE    AND  PHYSIOLOGICAL  CHEMISTRY"  AND  DI- 
RECTOR OF  THE  HYGIENIC  LABORATORY'  IN  M1CHIGAN 
UNIVERSITY. 

{Continued from  page  61S.) 

LECTURE  II.       THE    BACTERIAL  POISONS    OF  SOME 
OF  THE  INFECTIOUS  DISEASES. 

An  exact  classification  of  the  chemical  factors 
in  the  causation  of  the  infectious  diseases  cau 
probabl3-  not  be  made  at  present.  We  know  of 
two  chemically  distinct  classes,  one  of  which  con- 
tains substances  which  combine  with  acids,  form- 
ing chemical  salts,  and  which  in  this  respect  at 
least  correspond  with  the  inorganic  and  vegetable 
bases.  The  members  of  this  class  are  designated 
as  ptomaines,  a  name  suggested  by  the  Italian 
toxicologist,  Salmi,  and  derived  from  the  Greek 
word  rfToojxa,  meaning  a  cadaver.  A  ptomaine  may 
be  defined  as  a  chemical  compound  which  is  basic 
in  character  and  which  is  formed  by  the  action  oi 
bacteria  on  organic  matter.  On  account  of  the 
basic  properties,  in  which  they  resemble  the  veg- 
etable alkaloids,  ptomaines  may  be  called  putre- 
factive alkaloids.  They  have  also  been  called 
animal  alkaloids,  but  this  is  a  misnomer,  because 
in  the  first  place  some  of  them  are  formed  in  the 
putrefaction  of  vegetable  matter ;  and  in  the  sec- 
ond place,  the  term  "animal  alkaloid"  is  more 
properly  restricted  to  the  leucomaines,  those  basic 
substances  which  result  from  tissue  metabolism 
in  the  body.  While  some  of  the  ptomaines  are 
highly  poisonous,  this  is  not  an  essential  prop- 
erty, and  others  are  wholly  inert.  Indeed,  the 
greater  number  of  those  which  have  been  isolated 
up  to  the  present  time  do  not,  when  employed  in 
single  doses,  produce  any  apparently  harmful  ef- 
fects. Brieger  restricts  the  term  ptomaine  to 
the  iiin-poisonous  basic  products,  and  desig- 
nates the  poisonous  ones  as  "toxines."  This  is 
a  classification,  however,  which  seems  to  be  of 
questionable  utility.     It  is  not  always  easy  to  say 


•39i.] 


CHEMICAL  FACTORS  IX  CAUSATION  OF  DISEASE 


665 


just  what  substances  are  poisonous  and  what  are 
not.  The  poisonous  action  of  a  substance  de- 
pends upon  the  conditions  under  which,  and  the 
time  during  which,  it  is  administered.  Thirty 
grains  of  quinine  may  be  taken  by  a  healthy  man 
during  twenty-four  hours  without  any  appreciable 
ill  effect,  yet  few  of  us  would  be  willing  to  admit 
that  the  administration  of  this  amount  of  quinine 
daily  for  three  months  would  be  wise  or  altogether 
free  from  injury.  In  the  same  manner  the  ad- 
ministration of  a  given  quantity  of  a  putrefactive 
alkaloid  to  a  dog  or  guinea-pig  in  a  single  dose 
may  do  no  harm,  while  the  daily  production  of 
the  same  substance  in  the  intestine  of  a  man  and 
its  absorption  continued  through  weeks  and  pos- 
sibly months,  may  be  of  marked  detriment  to  the 
health.  We  do  not  as  yet  know  enough  about 
the  physiological  or  toxicological  action  of  the 
putrefactive  alkaloids  to  render  the  classification 
proposed  by  Brieger  worthy  of  general  adoption. 

All  ptomaines  contain  nitrogen  as  an  essential 
part  of  their  basic  character.  In  this  they  re- 
semble the  vegetable  alkaloids.  Some  of  them 
contain  oxygen,  while  others  do  not.  The  latter 
correspond  to  the  volatile  vegetable  alkaloids, 
nicotine  and  coniine,  and  the  former  correspond 
to  the  fixed  alkaloids. 

Since  all  putrefaction  is  due  to  the  action  of  bac- 
teria, it  follows  that  all  ptomaines  result  from  the 
growth  of  these  microorganisms.  The  kind  of 
ptomaine  formed  will  depend  upon  the  individual 
bacterium  engaged  in  its  production,  the  nature 
of  the  material  being  acted  upon,  and  the  condi- 
tion under  which  the  putrefaction  goes  on,  such 
as  the  temperature,  amount  of  oxygen  present, 
and  the  duration  of  the  process. 

A  second  class  of  the  chemical  factors  in  the 
causation  of  the  infectious  diseases  embraces  the 
so-called  poisonous  albumins.  In  1S86,  Mitchell 
and  Reichert  published  the  results  of  their  inves- 
tigations into  the  nature  of  the  venom  of  serpents, 
from  which  they  concluded  that  the  poisonous 
constituents  are  peptones  and  globulins.  Of  the 
latter  they  reported  the  presence  of  three  varie- 
ties, each  of  which  is  toxical  in  its  action.  Al- 
though it  had  been  known  before  this  that  the 
injection  of  any  considerable  amount  of  artifi- 
cially prepared  peptone  directly  into  the  blood 
is  followed  by  markedly  deleterious  effects,  this 
was  the  first  demonstration  of  the  possession  of 
characteristic  toxicity  by  any  of  the  proteids,  and 
from  the  report  of  Mitchell  and  Reichert  we  may- 
date  all  modern  studies,  at  least,  of  the  poisonous 
albumins. 

In  1887,  Sewall  found  that  tolerance  to  the 
venom  of  the  rattle- snake  could  be  established  in 
pigeons  by  the  inoculation  of  a  very  small  quan 
tity  and  gradually  increasing  the  amount.  In 
this  manner  a  pigeon  was  found  to  bear  without 
ill  effect  seven  times  the  amount  ordinarily  fatal 
to  the  same    animals.     The  immunity  thus  ob- 


tained was  observed  to  gradually  diminish  after 
the  discontinuance  of  the  inoculation.  However, 
after  five  months,  while  the  larger  amounts  reach- 
ed in  the  last  injections  proved  fatal,  the  ordina- 
rily fatal  dose  was  without  effect. 

Salmon  and  Smith  protected  pigeons  against 
the  germ  of  hog  cholera  by  previous  injections 
with  cultures  of  the  same  organism  which  had 
been  sterilized  by  exposure  to  a  temperature  of 
from  580  to  6o°  C.  for  one  hour.  However,  since 
these  cultures  contained  one  or  more  ptomaines 
as  well  as  the  poisonous  albumins,  it  could  not 
be,  at  that  time  at  least,  said  to  which  of  these 
constituents  the  immunity  was  due. 

To  Christmas,  I  believe,  is  due  the  credit  of 
first  showing  the  presence  of  active  proteids  in 
bacterial  cultures.  In  1888,  this  investigator  ob- 
tained from  cultures  of  the  staphylococcus  pyo- 
genes aureus  a  proteid  body  which,  when  injected 
into  the  anterior  chamber  of  the  eye  or  under  the 
skin,  caused  suppuration. 

We  will  now  give  our  attention  to  the  chemical 
poisons,  both  the  ptomaines  and  the  albumins,  of 
some  of  the  infectious  diseases,  and  in  doing  this 
we  will  illustrate  and  substantiate  the  statements 
made  in  the  preceding  lecture. 

Anthrax. — The  definition  of  an  infectious  dis- 
ease, as  we  have  given  it,  is  well  illustrated  by 
the  facts  which  have  been  learned  concerning  the 
causation  of  anthrax,  which  has,  probably,  been 
more  thoroughly  studied  than  any  other  infec- 
tious disease.  Kausch  taught  that  this  disease 
has  its  origin  in  paralysis  of  the  nerves  of  respi- 
ration. Upon  the  cause  of  this  paralysis  he  gave 
us  no  information.  Delafond  thought  that  an- 
thrax has  its  origin  in  the  influence  of  the  chem- 
ical composition  of  the  soil,  affecting  the  food  of 
animals  and  leading  to  abnormal  nutrition.  The 
investigations  of  Gerlach,  in  1845,  demonstrated 
the  contagious  nature  of  the  disease,  which  was 
emphasized  by  Heusinger  in  1850  and  accepted 
by  Virchow  in  1855.  However,  as  early  as  1849, 
Pollender  found  numerous  rod-like  microorgan- 
isms in  the  blood  of  animals  with  the  disease. 
This  observation  was  confirmed  by  Brauel,  who 
produced  the  disease  in  healthy  animals  by  inoc- 
ulations with  matter  taken  from  a  pustule  on  a 
sick  horse.  Attempts  were  made  to  ridicule  the 
idea  that  these  germs  might  be  the  cause  of  the 
disease,  and  it  was  said  that  the  bodies  seen  were 
only  fine  shreds  of  fibrin  or  blood  crystals.  Some 
claimed  that  the  rod-like  organisms  reported  were 
due  to  defects  in  the  glass,  while  others  claimed 
that  the  defects  existed  in  the  eye  of  the  observer, 
and  others  still  suggested  that  the  defects  might 
be  found  back  of  the  eye  and  in  the  brain.  But 
in  1863,  Davaine  showed  that  these  little  bodies 
must  have  some  causal  relation  to  the  disease, 
inasmuch  as  his  experiments  proved  that  inocu- 
lation of  healthy  animals  with  the  blood  of  those 
sick  with  anthrax  produced  the  disease  only  when 


666 


CHEMICAL  FACTORS  IN  CAUSATION  OF  DISEASE. 


[May  9, 


taken  at  a  time  when  the  blood  contained  these 
organisms.  He  also  demonstrated  beyond  any 
question  that  these  rod- like  bodies  are  bacteria, 
capable  of  growth  and  multiplication.  The  con- 
clusions of  this  investigator  were  combated  by 
many ;  but  Pasteur,  Koch,  Bollinger,  De  Barry 
and  others  studied  the  morphology  and  life  his- 
tory of  these  organisms,  and  then  came  the  bril 
liant  results  of  Pasteur  and  Koch  in  securing 
protection  against  inoculation  anthrax  by  the 
vaccination  of  healthy  animals  with  the  modified 
germ  and  subsequent  inoculation  with  the  viru- 
lent form.  Now,  the  bacillus  anthracis  is  known 
in  every  bacteriological  laboratory,  and  by  inoc- 
ulation with  it  the  disease  is  communicated  at 
will  to  susceptible  animals.  But  here  the  ques- 
tion arose,  How  do  these  bacilli  produce  anthrax? 
and  in  answer  to  this  question  the  various  theories 
which  we  have  mentioned  were  proposed. 

The  first  successful  attempt  to  study  the  chem- 
ical poisons  of  anthrax  was  made  by  Hoffa,  who 
obtained  from  pure  cultures  of  the  bacillus  small 
quantities  of  a  ptomaine  which,  when  injected 
under  the  skin  of  animals  produces  the  symptoms 
of  the  disease  and  death.  This  substance  causes 
at  first  increased  respiration  and  action  of  the 
heart,  then  the  respirations  become  deep,  slow 
and  irregular.  The  temperature  falls  below  the 
normal;  the  pupils  are  dilated,  and  a  bloody 
diarrhoea  sets  in.  On  section  the  heart  is  found 
contracted,  the  blood  dark,  and  ecchymoses  are 
observed  on  the  pericardium  and  peritoneum. 
Hoffa  names  his  poison  anthracin. 

It  has  been  said  that  Hoffa's  work  was  the  first 
successful  attempt  to  study  the  chemical  poisons 
of  anthrax.  However,  his  results  cannot  be  con- 
sidered altogethersatisfactory.  The  small  amount 
of  the  basic  substance  which  he  obtained  rendered 
it  highly  probable  that  in  the  case  of  a  germ  so 
virulent  as  that  of  anthrax  there  must  be  other 
chemical  poisons  produced.  This  supposition  has 
been  confirmed  by  the  labors  of  Hankin  who,  in 
1889,  while  at  work  in  Koch's  laboratory,  pre- 
pared from  cultures  of  the  bacillus  anthracis  an 
albumose  which  when  employed  in  comparatively 
large  amount  proved  fatal  to  animals,  but  when 
used  in  very  small  quantity  gave  immunity 
against  subsequent  inoculations  with  the  living 
germ.  Unfortunately  Hankin  does  not  mention 
the  symptoms  induced  by  toxical  doses  of  this 
substance.  Whether  or  not  the  albumose  of 
Hankin  contains  in  stain  nascendi  the  base  of 
Hoffa,  and  owes  it  poisonous  properties  to  the 
same,  has  not  been  determined.  There  is  yet  a 
promising  field  for  research  in  the  chemistry  of 
this  di  -. 

Asiatic  Cholera. — There  are  good  reasons,  apart 
from  experimental  evidence,  for  believing  that 
the  comma  bacillus  of  Koch  produces  its  ill  effects 
by  the  elaboration  of  chemical  poisons.  This 
germ  is  not  a  blood  parasite.      It  grows  only  in 


the  intestine,  and  the  symptoms  of  the  disease 
and  death  must  result  from  the  absorption  of  its 
poisonous  products.  In  confirmation  of  this  state- 
ment, experiment  has  shown  that  this  is  one  of 
the  most  active,  chemically,  of  all  known  pathog- 
enic germs. 

In  the  first  place,  Bitter  has  shown  that  the 
comma  bacillus  produces  in  meat-peptone  cul- 
tures a  peptonizing  ferment,  which  remains  active 
after  the  organism  has  been  destroyed.  Like 
similar  chemical  ferments  it  converts  an  indefinite 
amount  of  coagulated  albumin  into  peptone.  It 
is  more  active  in  alkaline,  than  in  acid  solutions, 
thus  resembling  pancreatin  more  than  pepsin. 
This  resemblance  to  pancreatin  is  further  demon- 
strated by  the  fact  that  its  activity  is  increased  by 
the  presence  of  certain  chemicals,  such  as  sodium 
carbonate  and  sodium  salicylate.  That  adiastatic 
ferment  is  also  produced  by  the  growth  of  the 
bacillus  was  indicated,  in  the  experiments  of  Bit- 
ter, by  the  development  of  an  acid  in  nutrient 
solutions  containing  starch  paste.  However,  all 
attempts  to  isolate  the  diastatic  ferment  were  un- 
successful. A  temperature  of  6o°  C.  destroys  or 
greatly  decreases  the  activity  of  ptyalin,  and  this 
seems  to  be  true  also  of  the  diastatic  ferment  pro- 
duced by  the  comma  bacillus.  But  the  formation 
of  an  acid  from  the  starch  presupposes  that  the 
starch  is  first  converted  into  a  soluble  form. 

Rietsch  believes  that  the  destructive  changes 
observed  in  the  intestines  in  cholera  are  due  to 
the  action  of  the  peptonizing  ferment. 

Cantani  injected  sterilized  cultures  of  the  com- 
ma bacillus  into  the  peritoneal  cavities  of  small 
dogs  and  observed  after  from  one- quarter  to  one- 
half  hour  the  following  symptoms:  Great  weak- 
ness, tremor  of  the  muscles,  drooping  of  the  head, 
prostration,  convulsive  contractions  of  the  pos- 
j  terior  extremities,  repeated  vomiting  and  cold 
head  and  extremities.  After  two  hours  these 
>\  inptoms  began  to  abate,  and  after  twenty- four 
hours  recovery  seemed  complete.  Control  ex- 
periments with  the  same  amounts  of  uninfected 
I  beef- tea  were  made  with  negative  results.  The 
cultures  used  were  three  days  old  when  sterilized. 
Older  cultures  seemed  less  poisonous  and  a  high 
or  prolonged  heat  in  sterilization  decreased  the 
toxicity  of  the  fluid.  From  these  facts  Cantani 
concluded  that  the  poisonous  principle  is  volatile, 
but  the  effect  of  high  or  prolonged  heat  in  dimin- 
ishing the  toxicity  was  more  probably  due  to  its 
destructive  effect  on  the  poisonous  proteids. 

Brieger  succeeded  in  isolating  from  cultures  of 
the  comma  bacillus  in  meat  broth  two  basic  sub- 
stances which  he  considers  the  specific  poisons  of 
cholera.  One  of  these,  found  in  the  mercuric 
chloride  precipitate,  is  a  diamine,  resembling  tri- 
methylenediamine.  It  produces  muscular  tremor 
and  heavy  cramps.  In  the  mercury  filtrate  was 
found  another  poison,  which,  in  mice,  produced  a 
lethargic  condition;  the  respiration  and   heart's 


i89i.J 


CHEMICAL  FACTORS  IN  CAUSATION  OF  DISEASE. 


667 


action  became  slow,  and  the  temperature  sank, 
so  that  the  animal  felt  cold.  In  some  instances 
there    was  a  bloody  diarrhoea. 

Later  Brieger  and  Friinkel  have  obtained  a 
cholera-albumin  which  proves  fatal  to  guinea- 
pigs  after  two  or  three  days,  but  is  without  effect 
upon  rabbits. 

More  recently  Winter  and  Lesage  treat  a  bouil- 
lon culture  of  the  cholera  germ  with  sulphuric 
acid,  dissolve  the  precipitate  in  an  alkaline  me- 
dium, reprecipitate  with  acid,  and  redissolve  in 
ether,  which  on  evaporation  leaves  oily  drops 
which,  on  cooling,  form  a  yellow  mass  of  the  ap- 
pearance of  a  fat.  This  substance  is  insoluble 
in  water  and  acids,  soluble  in  alkalies  and  ether. 
It  melts  at  500  C,  and  does  not  lose  its  virulence 
on  being  boiled  with  alcohol  rendered  feebly  al- 
kaline. The  virulence  of  a  culture  and  the  amount 
of  this  substance  contained  therein  are  in  direct 
proportion  to  each  other. 

Small  doses  of  this  substance  (one  milligram 
to  100  grams  of  body  weight  of  the  animal)  in 
feebly  alkaline  solution  introduced  into  the  stom- 
achs of  guinea-pigs  cause,  as  a  rule,  within  from 
four  to  six  hours,  a  chill,  and  death  after  twenty- 
four  hours.  With  larger  doses  the  temperature 
falls  after  from  one-half  to  one  hour,  and  death 
results  within  from  twelve  to  twenty  hours. 
Smaller  doses  cause  a  less  marked  reaction  and 
the  animal  recovers  within  twenty- four  hours.  If 
killed  within  this  time  the  animal  shows  a  chol- 
eraic condition.  Rabbits  succumb  only  after  re- 
peated subcutaneous  injections.  The  substance 
can  be  extracted  from  the  muscles,  liver,  kidneys 
and  urine  of  the  poisoned  animals.  This  substance 
can  also  be  obtained  from  cultures  of  a  cholera 
infantum  germ.  The  fact  that  this  poison  be- 
longs neither  to  the  ptomaines  or  albumins  is  of 
interest. 

Cholera  Infantum. — The  fact  that  Booker,  Es- 
cherich  and  other  investigators  have  failed  to  find 
any  one  germ  constantly  present  in  the  bowels  or 
stools  of  children  suffering  from  summer  diarrhoea 
was  mentioned  in  the  preceding  lecture.  Notwith- 
standing this,  the  fact  that  chemical  poisons  are 
concerned  in  the  production  of  these  diarrhoeas 
has  been  abundantly  demonstrated.  In  the  first 
place  the  symptoms  of  the  choleraic  form  of  these 
diarrhoeas  are  so  very  similar  to  those  induced  by 
a  number  of  gastro-intestinal  irritants,  which  at 
the  same  time  depress  the  nerve  centres,  that  the 
suggestion  that  the  disease  might  be  due  to 
chemical  poisons  has  been  fa\  orabl\-  received  by 
the  profession.  The  poisonous  substance  first 
found  by  the  writer  in  cheese  and  afterwards  in 
ice-cream,  milk  and  various  milk  preparations, 
and  which  is  known  as  tyrotoxicon,  induces 
symptoms  which  cannot  be  distinguished  from 
those  of  choleriform  diarrhoea  in  infants.  More- 
over, the  post-mortem  appearances  are  very  much 
alike,  if  not  identical,  and  the  poison   has  been 


found  in  a  sample  of  milk,  a  part  of  which  had 
been  given  to  a  child  not  more  than  two  hours 
before  the  first  symptoms  of  a  violent  attack  of 
the  disease  manifested  themselves. 

Tyrotoxicon  however,  is  only  one  of  the  poi- 
sons which  may  appear  in  milk  and  milk  pro- 
ducts, or  may  be  formed  in  the  intestines  of  the 
infant  and  cause  an  exhausting  diarrhoea.  I  have 
recently  isolated  from  samples  of  poisonous 
cheese,  in  which  tyrotoxicon  could  not  be  de- 
tected, a  poisonous  albumin. 

I  have  also  isolated  from  pure  cultures  of  the 
germs,  x,  a,  and  A  of  Booker's  list  of  summer  diar- 
rhcea  microorganisms,  three  poisonous  bodies. 
small  quantities  of  which  injected  under  the  skin 
of  kittens  and  puppies  cause  retching,  vomiting, 
purging,  collapse  and  death.  Ten  milligrams  of 
the  dried  proteid  from  "a"  killed  a  large  guinea- 
pig  within  twelve  hours,  and  a  smaller  amount 
proved  fatal,  in  other  experiments,  after  a  ionger 
time.  These  poisons  differ  from  one  another,  more 
or  less,  in  their  physical  and  chemical  properties, 
but  all  produce  the  above  mentioned  symptoms. 
It  may  be  that  a  more  exact  study  of  the  effects 
induced  will  enable  us  to  distinguish,  in  this  way. 
one  from  the  other.  Evidently,  here  are  three 
germs  differing  from  one  another  morphologically 
sufficiently  to  be  classified  as  different  species, 
but  belonging  chemically  and  toxicologically  to 
the  same  group.  How  many  more  of  the  long 
list  of  bacteria  found  by  Booker,  Escherich  and 
others  in  the  study  of  these  diseases  remains  to 
be  ascertained.  There  is  no  reason,  however,  for 
supposing  that  in  taking  three  of  these  at  random, 
I  have  hit  upon  the  only  toxicogenic  ones. 

The  fact  that  Baginsky's  cholera  infantum 
germ  produces  a  poisonous  albumin  was  referred 
to  in  the  first  lecture;  also  the  formation  of  a 
choleraic  poison  by  the  germ  of  Lesage  has  been 
mentioned  in  discussing  the  chemical  poisons  of 
Asiatic  cholera. 

The  prevention  of  the  summer  diarrhoeas  of 
infancy  becomes  a  more  difficult  task  than  those 
who  believe  that  a  single  microorganism  is  con- 
cerned in  their  causation  admit.  All  bacteria  which 
are  capable  of  growth  and  reproduction  within 
the  intestines  of  the  infant,  and  of  the  production 
of  chemical  poisons  during  their  development, 
must  be  excluded.  The  treatment  of  the  same 
diseases  will  not  be  wholly  successful  until  we 
know  how  to  antidote  these  poisons.  To  accom- 
plish these  ends  will  probably  require  many  years 
of  research  and  observation  by  our  profession. 
However,  if  this  be  the  right  line,  let  us  follow  it, 
realizing  that  our  successors  will  profit  by  our 
mistakes,  and  render  our  partial  successes  more 
successful. 

Diphtheria. — Roux  and  Tersin  rendered  cul- 
tures of  Loffler's  bacillus  of  diphtheria  sterile  by 
,  filtration  through  porcelain,  and  injected  thirty- 
1  five  cubic  centimeters  of  the  filtrate  into  the   ab- 


668 


CHEMICAL  FACTORS  IN  CAUSATION  OF  DISEASE. 


[May  9. 


dominal  cavity  of  guinea-pigs.  No  immediate 
effects  were  observed,  but  after  two  or  three  days, 
the  animals  refused  to  eat,  passed  bloody  urine, 
showed  muscular  weakness  in  the  posterior  ex- 
tremities, manifested  marked  irregularity  in 
respiration  and  died  after  from  five  to  six  days. 
Section  showed  marked  renal  hyperaemia  and  a 
serous  exudatiou  in  the  pleura.  In  cases  of  less 
acute  intoxication,  paralysis  of  certain  groups  of 
muscles  become  apparent. 

The  cultures  first  employed  were  seven  days 
old.  Older  cultures  (six  weeks)  contain  more  of 
the  poison,  and  the  symptoms  appear  within  a 
few  hours  after  the  injection.  In  cultures  especially 
rich  in  the  poison,  a  small  amount  (from  0.2  to 
2.0  cc.)  injected  under  the  skin  suffice  to  induce 
the  symptoms.  The  place  of  injection  becomes 
cedematous,  the  respiration  rapid,  and  death  re- 
sults as  quickly  as  after  inoculation  with  the 
germ.  Mice  and  rats  are  markedly  insusceptible, 
but  succumb  to  large  doses. 

The  action  of  this  poison  was  found  to  be  much 
lessened  by  continued  exposure  to  a  temperature 
of  only  580.  These  investigators  believed  that 
this  poison  belonged  to  the  group  of  enzymes. 

Brieger  and  Frankel  have  continued  the  study 
of  the  chemical  poison  of  the  Eoffler  bacillus. 
These  investigators  find  that  this  poison  can  be 
heated  to  500  in  the  presence  of  an  excess  of 
hydrochloric  acid  without  being  destroyed,  and 
they  conclude  from  this  that  the  substance  can- 
not be  an  enzyme  or  ferment.  The  poison  is  pre- 
cipitated from  the  culture,  after  sterilization  by 
filtration  through  porcelain,  by  absolute  alcohol, 
slightly  acidified  with  acetic  acid.  It  forms  a 
snow-white,  amorphous  mass.  It  stands  verj' 
closely  related  to  serum- albumin.  It  may  also 
be  precipitated  by  saturation  with  ammonium 
sulphate,  and  can  be  purified  by  removing  the 
sulphate  by  dialysis.  This  reaction  distinguishes 
it  from  the  peptones.  In  small  doses  (two  and 
one  half  milligrams  per  kilogram  body  weight), 
injected  into  the  blood-vessels,  it  causes  death, 
not  like  other  poisons,  immediately,  but  after 
days,  weeks  or  months,  with  the  formation  of 
abscesses  and  necrotic  tissue  at  the  point  of  in- 
jection, with  progressive  emaciation  and  paralysis. 
Brieger  and  Frankel  propose  for  this  and  similar 
bodies  the  name  "  toxaibumin."  As  was  stated 
in  the  first  lecture,  these  studies  leave  no  room 
for  us  to  doubt  that  the  Loffler  bacillus  is  a  cause 
of  diphtheria.  The  chemical  poisons  of  Prud- 
den's  streptococcus  and  of  the  germ  found  by 
Klein  in  the  diptheria  of  some  of  the  lower  ani- 
mals, have  not  been  investigated. 

Suppuration. — The  fact  that  a  pus- producing 
chemical  poison  was  found  in  cultures  of  the 
staphylococcus  pyogenes  aureus  has  been  already 
noted.  In  addition  much  interesting  work  on  the 
poisons  of  suppuration  has  been  done.  Thai  tin- 
ptomaines,  cadaverine  and  putrescine,  of  Brieger, 


when  injected  under  the  skin  in  sterile  solutions, 
cause  abscesses,  has  been  known  for  some  years. 
It  has  been  shown  that  sterilized  cultures  of  a 
number  of  different  germs  produce  suppuration. 
Thus,  Biichner  showed  that  sterilized  cultures  of 
the  bacillus  of  Friedlander  contains  pyogenetic 
substances,  and  when  injected  into  man  in  very 
dilute  solution  produce  an  elevation  of  tempera- 
ture. In  view  of  the  fact  that  so  much  has  been 
said  about  the  wonderful  effect  of  small  doses  of 
the  so-called  cure  for  tuberculosis  proposed  by 
Koch,  the  following  account  of  an  experiment 
made  upon  himself  and  reported  by  Biichner  early 
in  1890,  may  be  of  interest :  Five  tenths  of  a 
cubic  centimeter  of  a  sterilized  very  dilute  emul- 
sion of  Friedlander's  bacillus  was  injected  under 
the  skin  of  the  forearm,  after  it  had  been  found 
that  500  times  this  quantity,  reckoned  per  kilo- 
gram of  body  weight,  caused  no  local  irritation 
or  suppuration  in  a  rabbit.  One  and  one-half 
hour  after  the  injection  sharp  pain  extended 
along  the  arm  to  the  axilla.  One-half  hour  later 
there  was  a  chill  followed  by  a  fever  which 
reached  a  maximum  of  36. 6°  in  the  axilla  five 
hours  after  the  injection.  At  the  same  time  the 
pulse  arose  to  108.  On  the  following  day  there 
were  well  marked  erysipelatous  swelling  and  red- 
ness extending  over  an  area  larger  than  a  saucer 
about  the  place  of  inoculation,  and  there  was 
marked  redness  along  the  lymphatics  of  the  arm. 
On  the  third  day  all  these  symptoms  disappeared. 

Biichner  has  shown  that  the  cells  of  seventeen 
different  species  of  bacteriacontain  pyogenetic  sub- 
stances. The  cells  may  be  boiled  for  hours,  their 
substance  dissolved  in  dilute  alkali  and  precipi- 
tated by  acid  without  losing  its  pyogenetic  prop- 
erties. It  should  be  understood,  however,  in 
this  case  that  the  active  substance  is  contained 
within  the  bacterial  cell,  and  this  leads  us  to  dis- 
tinguish between  the  chemical  poisons  which 
arise  from  bacterial  activity  and  are  found  in  solu- 
tion in  cultures,  and  those  which  reside  within 
the  cell  and  form  an  integral  part  of  the  same. 
Biichner  finds  this  active  substance  within  the 
cell  to  be  proteid  in  character.  It  gives  the  biuret, 
Millon's  and  xanthoprotein  reactions.  Before  the 
substance  can  cause  suppuration  within  the  body 
it  is  most  likely  necessary  for  the  bacterial  cells 
to  suffer  disintegration.  It  is  hardly  necessary  to 
add  that  the  pus  formed  by  this  bacterial  proteid 
is  germ- free. 

Typhoid  Fever.  — The  poisons  of  this  disease  are 
both  basic  and  proteid,  though  those  belonging 
to  the  latter  group  seem  to  be  the  more  virulent. 

In  1885  Brieger  obtained  from  pure  cultures  of 
the  Eberth  bacillus  a  ptomaine,  which  produced 
in  guinea-pigs  a  slight  flow  of  the  saliva,  increased 
frequency  of  respiration,  dilatation  of  the  pupils, 
profuse  diarrhoea,  paralysis  and  death  within 
twenty-four  to  forty-eight  hours.  Post-mortem 
examination   showed    the    heart  in  systole,   the 


i89i.] 


CHEMICAL  FACTORS  IN  CAUSATION  OF  DISEASE 


669 


lungs  hypercernic  and  the  intestines  contracted 
and  pale.  Brieger  was  at  first  inclined  to  regard 
this  as  the  specific  poison  of  typhoid  fever  and 
named  it  "typhotoxine."  However,  he  obtained 
with  this  substance  no  elevation  of  temperature. 

In  1887  Novy  and  the  writer  obtained  from 
cultures  of  a  germ  found  in  drinking  water  which 
had  been  the  supply  of  many  persons  who  had 
typhoid  fever,  an  extract  which,  when  injected 
under  the  skin  of  cats,  caused  an  elevation  in  the 
temperature  of  from  two  to  four  and  one- half  de- 
grees. 

In  1889  the  writer  obtained,  from  mixed  cul- 
tures made  from  typhoid  stools,  a  small  amount 
of  a  basic  substance  which  caused,  in  the  lower 
animals,  an  elevation  of  temperature  accompa- 
nied by  profuse  diarrhoea. 

Brieger  and  Frankel  obtained,  from  cultures  of 
the  Eberth  bacillus,  a  poisonous  albumin,  but 
have  reported  no  particulars  concerning  its  action. 
The  writer  has  two  germs,  obtained  from  drink- 
ing water  supposed  to  have  caused  typhoid  fever, 
and  which,  after  having  been  kept  for  some  days 
at  a  fever  temperature,  give  all  the  reactions 
which  have  hitherto  been  supposed  to  be  charac- 
teristic of  the  Eberth  bacillus.  From  pure  cul- 
tures of  each  of  these  he  has  isolated  highly  poi- 
sonous proteids,  which,  in  dogs,  cause  a  chill, 
followed  by  marked  elevation  of  temperature. 
These  poisons  are  soluble  in  water,  from  which 
they  are  not  precipitated  by  heat  or  nitric  acid, 
singly  or  combined.  They  are  precipitated  by 
saturating  the  aqueous  solution  with  ammonium 
sulphate,  and  are  not,  therefore,  peptones.  They 
are  not  precipitated  by  carbonic  acid  gas,  or  by- 
sodium  sulphate  to  saturation,  and  this  excludes 
them  from  the  class  of  globulins.  The  aqueous 
solutions  respond  to  the  xanthroprotein  and  biu- 
ret reactions.  Chemically  I  can  so  far  distinguish 
no  difference  between  the  poisonous  albumins 
produced  by  the  two  germs,  but  physiologically 
there  is  a  marked  difference.  That  from  bacillus 
A  produces  paralysis  of  the  voluntary  muscles, 
which  is  preceded  in  some  animals  by  most  vio- 
lent convulsive  movements.  With  the  proteid 
of  bacillus  B  neither  the  convulsions  nor  the  mus- 
cular paralysis  has  been  observed.  The  animal 
seems  to  die  from  gradual  failure  of  the  heart. 
However,  these  poisons  demand  a  much  more  ex- 
tensive and  exhaustive  study  than  has  yet  been 
made.  It  will  be  seen  from  what  has  been  said, 
that  the  chemistry  of  typhoid  fever  promises  to 
be  both  fertile  and  interesting  in  results. 

Tetanus. — Brieger  has  obtained  from  the  mixed 
cultures  of  the  germs  of  Nicolaier  and  Rosen- 
bach,  four  poisonous  substances.  The  first,  tet- 
anine.  which  rapidly  decomposes  in  acid  solu- 
tions, but  is  stable  in  the  presence  of  free  alkali, 
produces  tetanus  in  mice  when  injected  in  quan- 
tities of  only  a  few  milligrams.  The  second,  tet- 
anotoxine,   produces  tremor,  followed  by  severe 


convulsions.  The  third,  to  which  no  name  has 
been  given,  causes  tetanus,  accompanied  by  a 
free  flow  of  the  saliva  and  tears.  The  fourth, 
spasmotoxine,  produces  heavy  convulsions. 

Later,  the  same  investigator  extracted  tetanine 
from  an  amputated  arm  of  a  man  with  tetanus. 
This  is  of  special  importance,  since  it  answers 
the  assertion  made  by  Baumgarten,  that  there  is 
no  proof  that  the  poisons  which  have  been  ob- 
tained from  artificial  cultures,  are  formed  within 
the  body  of  man. 

From  pure  cultures  of  the  tetanus  bacillus  of 
Kitasato,  Brieger  and  Frankel  have  isolated  a 
poisonous  proteid,  and  with  cultures  of  another 
bacillus,  Tizzoni  and  Cantani  have  been  equally 
successful.  These  investigations  leave  us  with- 
out cause  to  doubt  that  the  convulsions  of  traum- 
atic tetanus  are  due  to  one  or  more  spinal  poi- 
sons, and  the  causal  relation  of  a  given  bacillus 
is  determined  not  by  its  morphological  character- 
istics, but  by  its  capability  of  producing  a  chem- 
ical substance  which  has  a  definite  toxicological 
effect. 

Tuberculosis. — Whatever  may  be  the  ultimate 
verdict  concerning  the  curative  properties  of 
Koch's  tuberculin,  its  employment  has  made  us 
familiar  with  the  action  of  the  chemical  products 
of  the  bacillus  tuberculosis  on  man.  LTnfortu- 
nately,  Koch  has  given  us  but  little  information 
concerning  the  nature  of  his  tuberculin,  and  the 
little  which  he  has  given  us  has  been  to  some 
extent  misleading.  I  would  not  imply  that  he 
has  intentionally  been  misleading.  Indeed,  I 
believe  that  such  was  not  his  intention.  He 
speaks  of  the  agent  as  an  extract  of  a  pure  cul- 
ture of  the  bacillus  tuberculosis  with  50  per  cent. 
glycerine.  Now,  chemists  who  have  been  at  work 
with  bacterial  poisous,  distinguish  between  bacte- 
rial products  and  the  contents  of  the  bacterial 
cells.  One  would  infer  from  Koch's  statements 
that  tuberculin  is  prepared  by  extracting  the  bac- 
terial cells  with  50  per  cent,  glycerine,  and  that 
the  bacterial  products  are  not  present.  But.  as 
has  been  shown  by  Hueppe  and  Schall,  the  pro- 
teids of  the  cells  of  the  bacillus  tuberculosis 
cannot  be  extracted  with  50  per  cent,  glycerine. 
Moreover,  the  same  investigators  have  prepared 
a  fluid  identical  in  physical  properties,  in  chemi- 
cal reactions,  and  in  its  effects  on  animals,  with 
Koch's  fluid,  by  each  of  the  three  following 
methods : 

1.  Cultures  of  the  bacillus  are  filtered,  steril- 
ized by  heat  and  concentrated. 

2.  The  supernatant,  fluid  portion  of  the  cul- 
ture is  decanted  from  the  mass  of  germs  at  the 
bottom  of  the  flask,  and  then  concentrated. 

3.  The  culture  is  freed  from  germs  by  filtration 
through  a  Chamberland  filter  and  concentrated. 

These  fluids  contain,  1,  the  constituents  of  the 
nutritive  medium  which  have  not  been  altered  by 
the  growth  of  the  germ,  such  as  glycerine,  albu- 


670 


MEDICAL  PROGRESS. 


[May  9, 


mius,  albumoses  and  peptones ;  2,  the  bacterial 
products,  which  may  possibly  belong  to  the  pto- 
maines, the  bacterial  albumins  or  albumoses  and 
bacterial  ferments ;  and  3,  any  constituents  of 
dead,  broken-down  bacilli  which  may  have  passed 
into  solution.  To  which  of  these  constituents  the 
action  of  the  fluid  is  due  has  not  been  positively 
determined.  However,  from  the  similarity  in  the 
action  of  this  fluid  with  that  of  the  bacterial  prod- 
ucts of  other  germs,  we  seem  justified  in  assuming 
that  these  constitute  the  active  principle. 

As  early  as  1888,  Hammerschlag  found  a  poi- 
sonous proteid  among  the  products  of  the  growth 
of  this  germ. 

Recently  Zuelzer  has  reported  the  isolation  of 
a  poisonous  ptomaine  from  agar  cultures  of  the 
bacillus  tuberculosis.  He  says  that  the  injection 
of  1  centigram  or  less  of  this  substance  subcu- 
taneously  in  rabbits  or  guinea  pigs  causes,  after 
from  three  to  five  minutes,  increased  frequency 
of  respiration  (to  180  per  minute?)  and  an  ele- 
vation of  temperature  of  from  0.50  to  i°.  He 
also  reports  marked  protrusio  bulbi  as  a  constant 
symptom ;  the  eyes  become  very  bright  and  the 
pupils  are  dilated.  From  two  to  three  centigrams 
suffice  to  kill  rabbits,  death  occurring  in  from  two 
to  four  days.  The  place  of  injection  is  reddened 
and  hasmorrhagic  spots  are  formed  in  the  mucous 
membrane  of  the  stomach  and  small  intestines. 
In  two  instances  from  15  to  20  cc.  of  clear  fluid 
were  found  in  the  peritoneal  cavity. 
( To  be  concluded. ) 


MEDICAL    PROGRESS. 


Therapeutics  ami  Pharmacology. 

Treatment  of  Bed-Sore. — Billroth  recom- 
mends that  the  part  should  be  bathed  with  vine- 
gar or  lemon  juice  as  soon  as  erythema  appears,  i 
Excoriations  should  be  touched  with  nitrate  of 
silver  and  the  part  dressed  with  simple  cerate,  or 
soap  plaster  spread  upon  linen  or  soft  leather 
When  gangrene  occurs  the  surface  should  be 
covered  with  a  disinfectant,  such  as  chlorinated 
water.  Carbolic  acid  should  be  avoided,  because 
of  its  liability  to  cause  poisoning.  Energetic  in- 
ternal measures  should  be  employed,  to  strengthen 
and  build  up  the  system,  such  as  wine,  acid 
drinks,   quinine  and  musk. — L?  Union  Medicate. 


Determination  of  the  Lower  Border  of 
the  Liver, — Verstrai/tbn  {Centralblatt  fur 
Klin.  Mid.)  points  out  how  difficult  it  is  in  many 
cases  to  outline  the  surface,  and  particularly  to 
determine  the  exact  position  of  its  lower  bonier. 
This  he  thinks  is  easier  by  auscultation  than  by 
any  other  method;  taking  advantage  of  the  ex- 


cellent conducting  power  of  the  liver,  the  stetho- 
scope is  placed  over  the  heart  and  then  gradually 
moved  downward  and  to  the  right.  The  point  at 
which  the  heart  sounds  are  no  longer  heard  marks 
the  lower  border  of  the  organ.  A  source  of  error 
is  contracted  abdominal  walls  ;  they  should  be  re- 
laxed as  far  as  possible,  if  necessary,  by  placing 
the  patient  in  a  sitting  posture. 


Ten  Years'  Experience  of  Gastric  Sur- 
gery.— Dr.   Torras  has  made  a  study  of  the 
statistics  of  the  resection   of  the  pylorus  during 
the  years  from  1S80  to   1S90.      From   this  it  ap- 
pears that  in  1880  there  was  one  extirpation  fol- 
lowed by  death.     In  1881,  out  of  20  in  whom  the 
section  of  the  pylorus  was  performed,  there  were 
15  deaths  and   5  cures.      In   1882,  the  numbers 
stood,  as  out  of  16  cases:   13  deaths  and  3  cures; 
in  1883,  13  cases,  7  deaths  and  6  cures;  in  1884, 
5  deaths  and  3  cures;  in  1885,  5  cases,  3  deaths 
i  and    2  cures;  in    1886,   3  cases,    1    death   and   2 
j  cures;  in   1887,  2  cases,  2  cures;  in  1888,  1  case, 
1  1  cure;  in  1889,  1  case,  1  cure;  in  1890,  2   cases, 
2  cures. 

In  reviewing  these  statistics  Dr.  Torras  ob- 
serves that  the  surgical  enthusiasm  which  led  a 
man  so  eminent  as  Billroth  to  sanction  this  oper- 
ation has  evidently  decreased,  till,  in  1889,  only 
one  operation  of  the  kind  was  performed,  and  two 
in  1890.  This  proves  that  the  results  have  not 
corresponded  to  the  hopes  conceived,  and  that 
such  an  operation  is  very  rarely  indicated  in  can- 
cer of  the  stomach.  Dr.  Torras  details  a  case  of 
exploratory  laparotomy  performed  by  Dr.  Fargas 
in  a  woman  of  52,  who  had  for  several  months 
suffered  from  vomiting  and  pain  in  the  gastric 
region.  In  this  situation  a  moveable  tumor  could 
be  felt,  about  the  size  of  an  orange,  which  was 
supposed  to  be  malignant,  and  to  be  attached  to 
the  gastro-colic  epiploon.  On  opening  the  ab- 
dominal wall,  it  was  found  to  be  a  carcinoma  of 
the  head  of  the  pancreas,  adhering  to  the  duo- 
denum and  pylorus.  Under  these  conditions,  Dr. 
Fargas  did  not  venture  to  attempt  removal,  but 
confined  himself  to  cauterize  with  the  thermo- 
cautery some  points  of  the  bleeding  surface  of  the 
tumor,  and  to  close  the  iticision  with  sutures. 
The  outer  wound  healed  in  ten  days,  and  the  pa- 
tient felt  better  for  a  month  after,  when  she  died 
in  a  cachetic  condition. 

Though  most  of  those  stated  to  be  cured  by 
the  operation  have  survived  above  five  years,  yet 
none  of  them  can  be  regarded  as  really  out  of 
danger  from  the  disease.  Dr.  Torras  would  con- 
fine the  operation  of  gastrotomy  to  cases  in  which 
digital  or  instrumental  dilatation  might  be  prac 
ticed  for  simple  stenosis  of  the  pylorus,  or  for 
contraction  of  the  orifice  from  cicatrices  or  fibrous 
tumors,  or  for  the  extraction  of  foreign  bodies 
from  the  stomach. 


[89I.] 


EDITORIAL. 


671 


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SATURDAY,   .MAY   9,    1891. 


SURGICAL    TREATMENT    OF    GENERAL 

PARALYSIS. 

The  possibility  of  curing  general  paralysis  by 
trephining  the  skull  is  again  coming  into  prom- 
inence. Two  years  ago  Dr.  Shaw,  of  London, 
performed  the  first  operation  of  this  kind,  which 
was  practically  a  success.  He  reasoned  that  all 
the  symptoms  in  general  paralysis  seemed  to  in- 
dicate an  irritative  inflammatory  process  in  the 
upper  layers  of  the  convolutions.  An  operation 
would  produce  an  alteration  in  the  morbid  pro- 
cess; on  the  theory  of  nerve  stretching  he  pro 
posed  to  give  the  brain  at  this  point  more  space 
to  expand,  and  relieve  itself  of  the  increased 
arterial  pressure,  which  the  sphygmograph  indi- 
cated as  one  of  the  early  conditions  of  this  dis- 
ease. He  hoped  by  relieving  the  fluid  pressure 
to  stimulate  some  new  nutritive  processes. 

The  patient  upon  whom  the  operation  was  per- 
formed was  in  the  second  stage  of  the  disease. 
He  had  delusions  of  grandeur,  affection  of  speech, 
exaggerated  reflexes,  unsteady  gait  and  retention 
of  urine.  Convulsive  attacks  followed,  with 
periods  of  loss  of  sensation,  difficulty  in  swallow- 
ing and  talking,  and  rapidly  approaching  demen- 
tia. The  trephine  was  applied  on  the  right  side 
of  the  skull,  over  the  central  sulcus,  two  inches 
outside  of  the  longitudinal  fissure.  The  patient 
improved  to  such  an  extent  that  he  was  dis- 
charged as  recovered. 

From  post-mortem  appearances  in  such  cases 
both  atrophy  of  the  brain  and  increase  of  brain 
fluids  are  found.  It  is  not  known  whether  this 
condition  comes  from  pressure  of  brain  fluid  or 


whether  the  fluid  collects  on  account  of  brain 
shrinking.  The  extreme  bulging  of  the  dura  in 
this  case  seemed  to  show  that  the  first  theory  was 
correct.  By  removing  a  portion  of  the  bone,  and 
corresponding  meninges  of  the  brain,  not  only 
would  the  existing  fluid  be  let  out,  but  a  perma- 
nent contact  would  be  established  between  the 
secreted  fluid  and  the  under  surface  of  the  scalp- 
flap,  to  the  absorbent  of  which  was  entrusted  its 
future  removal. 

The  second  case  was  operated  on  by  Dr.  Batty 
Tuke.  It  was  farther  advanced  and  more  hope- 
less. A  large  button  of  bone  was  taken  out,  and 
the  patient  was  more  sane  and  improved  in  every 
way  for  some  time ;  finally  the  old  symptoms  re- 
turned, and  he  was  taken  to  Dr.  Clocston's 
asylum  at  Edinburgh,  and  at  present  he  is  hope- 
lessly demented.  Drs.  Tuke  and  Cloustox  both 
considered  that  the  operation  was  fully  justified, 
and  that  the  modifications  and  improvements  in 
the  symptoms  were  hopeful  signs  of  what  might 
be  expected  in  more  recent  cases. 

Several  criticisms  have  been  made  on  the  theo- 
ries of  this  operation.  It  is  asserted  that  the 
paralysis,  loss  of  power  of  talking,  attacks  of 
stupidity,  etc.,  are  not  due  to  fluid  pressure,  and 
that  the  excess  of  fluid  is  only  a  secondary  and 
compensating  process.  Also  that  holes  in  the 
skull  cannot  relieve  the  pressure  on  the  convolu- 
tions. Tcke  asserts  that  obstructed  lymph  makes 
its  way  very  imperfectly  by  natural  channels  to  the 
pia-matral  space  and  becomes  diffused  through 
the  tissues,  injuring  and  displacing  cell  and  fibre, 
and  impairing  their  functional  activity,  while  the 
operation,  by  permitting  a  healthy  action  of  the 
lymphatics  and  blood-vessels,  stays  the  process  of 
sclerosis. 

The  criticism  of  this  view  is  that  only  in  the 
second  stage  of  this  disease  is  there  any  extraor- 
dinary development  of  the  lymph  connective  sys- 
tem of  the  brain,  with  degeneration  and  disap- 
pearance of  nerve  elements,  the  axis  cylinders 
of  which  are  denuded  ;  that  the  first  stage  is  one 
of  true  degeneration  due  to  acute  interstitial 
changes,  that  are  similar  to  senile  atrophy.  That 
the  excess  of  fluid  in  the  second  stage  is  of  secon- 
dary importance,  and  is  the  only  stage  when  an 
operation  can  be  expected  to  be  of  any  value  on 
this  theory,  while  in  fact  the  case  has  passed  all 
possibility  of  cure  in  this  stage.  The  first  stage 
is  the  only  period  that  any  operation  can  be  justi- 


672 


THE  VALUE  OF  KOCH'S  TUBERCULIN. 


[May  9, 


fied,  but  at  this  time  no  lymph  has  been  formed, 
and  no  benefit  can  be  expected  on  the  pressure 
theory.  The  critics  affirm  that  any  change  which 
may  follow  this  operation  is  due  to  a  natural  re- 
mission in  the  disease. 

From  these  theories  and  criticisms  there  are 
many  reasons  for  expecting  some  startling  devel- 
opments along  this  new  line  of  brain  surgery. 
The  general  hopelessness  of  these  cases,  and  in- 
ability of  remedies  to  even  stay  the  progress  of 
the  disease,  would  seem  to  justify  the  surgeon  in 
experiments,  which  cannot  alter  the  final  issue  of 
the  case,  under  any  circumstances.  The  reckless 
use  of  powerful  remedies  experimental!}'  and  the- 
oretically is  common  in  nearly  all  cases,  and  the 
surgeon  is  equally  justified  in  attempting  means 
that  give  promise  of  relief.  These  two  cases  will 
arouse  new  interest  in  this  disease,  and  suggest 
theories  of  pathology  and  treatment  that  would 
have  been  impossible  a  few  years  ago. 


THE  VALUE   OF  KOCH'S  TUBERCULIN. 

The  therapeutical  results  obtained  by  tuberculin 
may  be  summarized  in  two  statements  :  1.  With 
the  exception  »of  certain  forms  to  be  specified 
hereafter,  the  agent  exerts  a  specific  effect  on  all 
tubercular  lesions,  by  starting  an  inflammatory 
process  in  and  around  the  tubercular  tissue,  which 
tends  to  cure  the  disease.  2.  This  reparative  change 
has  NOT  proceeded  tip  to  the  actual  aire  hi  the  ma- 
jority of  cases  hitherto  treated.  The  exceptions 
not  influenced  by  tuberculin  are  old  lesions  in  a 
state  of  caseation,  a  fact  already  pointed  out  by 
Koch  in  his  first  communication,  but  also  fresh 
miliary  eruptions,  attention  to  which  latter  im- 
portant observation  has  been  called  by  Virchow 
and  other  pathologists.  The  inability  of  tuber- 
culin to  affect  fresh  miliary  tubercles  or  to  prevent 
their  dissemination,  and  the  frequent  cessation  of 
its  curative  influence  before  the  infiltration  has 
completely  disappeared,  are  at  present  the  main 
obstacles  to  success  with  this  treatment.  Hut  in 
order  to  review  what  the  agent  can  do  and  has 
done,  it  is  necessary  to  consider  the  various  tu 
bercular  localizations  separately. 

In  lupin,  with  scarcely  an  exception,  the  agent 
has  produced  an  improvement  which,  competent 
observers  claim,  cannot  be  obtained  by  any  other 
means  within  the  same  time.    This  improvement 


can  proceed  up  to  absolute  cure  of  the  disease, 
at  least  for  the  time  being.  Thus,  of  the  later 
authors,  Doutrelepont  states  that  of  thirty-one 
cases  of  lupus  four  were  completely  cured,  and 
all  the  others  were  in  a  state  of  marked  improve- 
ment. But  in  the  majority  of  cases  the  improve- 
ment ceases  before  the  entire  patch  is  healed, 
while  in  others  where  a  smooth  cicatrix  has  re- 
sulted, nodules  can  still  be  felt  under  the  skin  and 
— on  the  cessation  of  the  treatment — these  give  rise 
to  fresh  manifestations  of  the  disease.  Yet  most 
of  the  writers  admit  that  they  could  not  have 
benefited  their  patients  to  the  same  extent  within 
the  same  time  by  any  other  means. 

In  tuberculosis  of  the  mucous  membranes  and  oj 
the  larynx  especially,  perhaps  the  most  brilliant 
results  have  been  accomplished  with  tuberculin. 
Numerous  cases  have  been  placed  on  record,  in 
which  the  ulcers  healed  completely  under  the 
eyes  of  the  observer,  even  when  the  accompany- 
ing pulmonary  lesion  was  not  benefited  to  the 
same  extent.  It  has  often  been  noticed  that  on 
mucous  surfaces,  and  especially  in  the  larynx, 
fresh  nodules  and  even  minute  ulcers  appear  in 
the  vicinity  of  the  preexisting  lesion  under  tu- 
berculin treatment.  In  one  of  such  instances 
Flatau  has  proven  by  histological  examination 
(presence  of  bacilli)  that  the  nodule  was  a  true 
tubercle.  It  is  an  open  question  whether  these 
"new"  lesions  are  the  result  of  preexisting  ba- 
cilli, the  presence  of  which  is  made  manifest  by 
the  tuberculin  influence,  or  whether  they  indicate 
really  a  dissemination  of  the  virus.  At  any  rate, 
they  disappear  readily  under  the  continuance 
of  the  treatment,  differing  in  this  respect  from 
fresh  eruptions  in  internal  organs.  A  few  in- 
stances of  laryngeal  tuberculosis  (and  also  dis- 
eases of  other  mucous  surfaces)  have  been  re- 
ported without  benefit  from  tuberculin,  but  as  a 
rule  this  agent  has  cured  the  tubercular  localiza- 
tion in  these  parts  with  a  rapidity  not  equaled  by 
any  other  means  at  our  command.  It  is  not  possi- 
ble to  prove  its  relative  efficacy  by  statistics  as  yet. 
In  the  official  report  to  the  German  Government 
on  the  efficacy  of  Koch's  remedy  10S  cases  of 
laryngeal  tuberculosis  are  mentioned,  of  which 
seventy  oik- had  been  more  or  less  improved.  But 
this  report  includes  only  experiences  of  from  two 
to  six  weeks,  and  that  during  the  time  when 
most  observers  were  only  learning  the  mode  of 
employment    of   the    substance.      More   definite 


i89i.] 


THE  VALUE  OF   KOCH'S  TUBERCULIN. 


673 


statements   can    be   obtained    from  the   separate   ment  produced  by  tuberculin  can  be  considered  a 
publications  in  periodic   literature,   but  in  most   contraindication  against  its  further  use. 
cases  the  number  of  cases  is  not  fully  stated.  The  more  advanced  the  phthisis  the  less  can  be 

In  phthisis  satisfactory  results  have  been  ob-  expected  of  Koch's  remedy.  Cases  of  diffuse  in- 
tained,  as  a  rule,  only  in  incipient  cases,  i.  e.,  of  filtration,  extensive  cavities,  or  rapid  course  to- 
short  duration,  weeks  or  months,  infiltration  lim-  wards  the  worse  have  but  rarely  been  arrested  in 
ited  in  extent,  no  cavities  and  no  continuous  their  progress,  and  occasionally  been  injured  by 
fever.  Koch  himself  cured  his  first  two  patients,  tuberculin.  Still,  with  some  discretion  in  their 
and  repeated  examination  has  confirmed  their  selection,  and  the  cautious  use  of  minute  initial 
continued  good  health  during  the  last  three  to  doses,  they  need  not  all  be  excluded  absolutely 
four  mouths.  The  majority  of  incipient  consump  from  the  treatment,  for  in  a  fair  number  of  in- 
tives  are  reported  as  improved,  at  least  subjective  stances  at  least  subjective  amelioration  has  been 
lv,  by  most  of  the  authors.  Gain  in  strength,  noted.  As  Koch  suggested  in  his  first  note,  the 
cessation  of  night-sweats  and  of  evening  rise  of  influence  of  tuberculin  should  be  aided  by  all 
temperature,  and  diminution  of  cough,  indicate  measures  known  to  benefit  such  patients.  The 
a  favorable  change  which,  under  the  observation  most  promising  results  have  been  obtained  by 
of  Glttmann,  is  said  to  have  occurred  in  41  of  51  Sonxenburg  in  Koch's  hospital  wards  by  the 
cases  of  incipient  phthisis.  The  improving  pa-  surgical  treatment  of  cavities  combined  with  tu- 
tients  do  not  always  gain  in  weight,  although  berculin  injections.  Onby  those  cases  were 
this  often  occurs.  Evidently  the  reparative  in-  selected  in  which  the  cavities  were  limited  to  the 
fluence  is  counterbalanced  by  the  increased  tissue  upper  lobe  of  one  lung;  the  patients  being  vet  in 
consumption  during  the  febrile  reaction,  especially  a  state  of  moderate  vigor.  After  cutting  down 
if  the  latter  be  intense.  But  a  consumptive  can-  to  the  fascia  with  the  resection  of  a  piece  of  the 
not  be  said  to  be  cured  until  all  cough  has  first  rib,  a  trocar  was  plunged  into  the  cavitv, 
ceased,  and  no  sputum  containing  bacilli  can  be  the  wound  enlarged  with  the  thermo  cautery 
obtained.  A  perfect  cure  does  not  necessarily  and  a  strip  of  iodoform  gauze  inserted.  Sonnen- 
imply  that  all  abnormal  percussion  and  ausculta-  burg  considers  the  operation  easy  and  compara- 
tory  sounds  have  disappeared.  For  where  there  tively  safe  when  there  are  adhesions  between  the 
was  any  extensive  consolidation  of  lung  tissue  two  layers  of  pleura,  and  but  little  more  serious 
we  can  neither  expect  normal  breathing  sound  when  the  pleural  space  still  exists  over  the  region 
nor  resonance  of  normal  lung  tissue.  There  will  of  the  cavity.  He  reported  five  cases,  one  of 
always  remain  a  shrinkage  of  the  involved  part  which  was  cured  inside  of  four  weeks  while  two 
of  the  lung.  But  applying  all  reasonable  criticism,  more  were  on  the  road  to  recovery.  One  died, 
we  can  still  say  that  not  a  few  cases  of  complete-  but  from  the  disease,  and  not  in  consequence  of 
ly  cured  incipient  phthisis  are  now  on  record,  the  operation,  while  the  fifth  had  but  been  oper- 
Perhaps  the  most  favorable  figures  are  claimed  by  ated  upon  just  before  publication.  Others  have 
Stricker,  who  speaks  of  eight  absolute  cures  since  repeated  the  operation,  but  their  results  are 
among  nine  young  soldiers  with  incipient  phthisis,    not  yet  known. 

whilst  amongst  forty-seven  soldiers,  whose  pul  In  pleurisy  0/  tubercular  origin  a  rapid  absorp- 
monary  trouble  was  more  advanced,  four  could  tion  of  the  effusion  has  been  observed  in  most  in- 
be  considered  completely  well  at  the  end  of  treat- !  stances,  but  the  pulmonary  lesion  itself  has  not 
ment.     While   many  observers  speak   nearly  as   been  invariably  benefited,  its  course  being  influ- 


enced in  about  the  same  manner  and  with  the 
variable  results  as  observed  in  similar  instances 


highly  as  Stricker  of  their  experience  in  incip- 
ient phthisis,  especially  in   private   and  in  sani- 
tarium practice,  others  like  Schl'LTze  report  but   without  pleural  complication. 
little  success,  but  such  pessimistic  reports  are  de- 
cidedly in  the  minority.   Yet  it  must  be  admitted 

that  a  few  instances  even  of  beginning  phthisis  Multiple  Births.  —  An  English  physician 
get  worse  under  the  treatment,  whether  in  conse-  writes  to  the  British  Medical  Journal  of  a  woman 
quence  of  or  notwithstanding  tuberculin,  is  an  who  had  twins  five  times,  triplets  once,  and  sin- 
open  question.      Any  continuous  febrile  move-  .  gle  children  four  times. 


674 


"IN  SIMPUCI  SALUS." 


[May  9, 


"IN  SIMPUCI  SALUS.'' 

Hippocrates  proclaimed  that  "accurate  ob- 
servation of  facts,  and  correct  generalization  from 
them,  forms  the  only  rational  basis  of  medicine," 
and  so  we  are  taught  to-day.  To  discover  truth 
in  science,  the  most  learned  will  admit,  is  very 
often  difficult,  but  in  no  science  is  it  more  difficult 
than  in  medicine.  Independent  of  the  common 
defects  of  medical  evidence,  our  self-interest,  our 
self-esteem,  our  prejudices,  our  likes  and  dislikes. 
and  not  infrequently  our  ignorance,  only  too 
often  hide  the  truth  from  our  view,  and  we 
ascribe  too  much  to  art,  and  too  little  to  the  op- 
erations of  nature.  Thus  the  mass  of  testimony 
is  most  with  art,  and,  although  we  believe  we 
are  right  in  our  reasoning,  we  only  pursue  the 
old,  time-honored  course  that  has  been  instilled 
into  our  minds  through  training  and  education. 
The  best  and  safest  practitioner  is  he  who  knows 
when  to  abstain  from  acting  as  well  as  when  to 
act  ;  in  other  words,  who  has  learned  when  and 
to  what  extent  the  case  can  be  left  to  the  salutary 
processes  of  nature.  The  tendency  to  recovery 
which  manifests  itself  under  different  modes  of 
treatment,  and  even  in  spite  of  opposite  modes, 
has  induced  in  some  minds  a  degree  of  skepticism 
as  to  the  utility  of  any  remedies.  That  the  op- 
posite error  to  that  of  mischievous  or  meddle- 
some activity  may  likewise  be  easily  carried  far  is 
at  once  apparent.  It  does  not  follow  because  the 
majority  of  diseases,  such  as  continued  fevers  and 
acute  affections  generally  get  well,  with  or  with- 
out the  administration  of  medicine,  that  therefore 
the  disease  should  be  abandoned  to  what  Cullen 
calls  the  "  vis  medicatrix  natures." 

A  knowledge  of  the  circumstances  upon  which 
health  depends  is  one  of  the  most  important 
parts  of  the  moral  and  intellectual  education  of 
the  true  physician.  The  essentials  necessary  to 
the  attainment  of  health  are: 

i.  The  inheritance  of  a  healthy  constitution. 

2.  Pure  atmosphere  and  water. 

3.  Wholesome  food  in  quantity  and  quality. 

4.  Freedom  from  contagious  and  infectious 
diseases. 

Either  of  these  primitive  essentials  of  health  is 
controlled  but  little,  if  any,  by  the  individual 
efforts  of  man.  To  medical  science  solely  must 
mankind  look  for  the  foundation  rock  from 
whence  the  principles  governing  these  essentials 
of  nature's  law  are  to  be  revealed  by  virtue  of  in- 


telligent, progressive,  active,  zealous,  and  truly 
conscientious  physicians,  who  will,  sooner  or 
later,  succeed  in  educating  the  legislator  to  under- 
stand and  realize  the  fact  paramount,  that  only 
through  the  State  or  municipal  government  can 
we  ever  hope  to  see  mankind  enjoy  these  bless- 
ings. Nature  puts  into  our  hands  the  means  of 
preserving  health,  and  this  gift  involves  responsi- 
bility. Health  will  be  counted  among  those 
talents  for  the  use  of  which  we  are  to  answrer  to 
our  Creator,  and  it  is  our  duty  to  become  fully 
acquainted  with  the  laws  which  regulate  and 
govern  it. 

Experience  teaches  that  disease,  as  well  as 
health,  is  controlled  by  nature,  that  her  laws 
must  be  consulted  if  we  would  practice  success- 
fully. But  alas!  how  often  do  we  find — even  in 
this  most  eniightened  age  of  science — the  truth 
as  expressed  by  the  late  Prof.  Chapman,  "That 
many  physicians  are  given  to  profound  thought, 
and  possess  extensive  knowledge,  united  with 
sterling  honesty,  being  by  nature  endowed  with 
the  highest  order  of  talents,  and  yet  be  wanting 
in  good  common  sense."  The  most  experienced, 
close  observing,  earnest  searchers  after  truth  in 
nature's  operations,  most  skillful  and  best  phy- 
sicians, hesitate  above  all  things  to  give  large 
quantities  of  medicine,  and  proclaim  the  best 
way  to  help  the  invalid  to  health  is  simply  to 
"  assist  nature."  The  writings  of  Drs.  Benjamin 
Rush,  Shippen,  Chapman,  Radcliffe,  Bostwich, 
Dumoulin,  and  Oliver  Wendell  Holmes,  Sir 
Astley  Cooper,  Sir  Wm.  Gull,  and  numerous  other 
shining  lights  are  too  well  known  to  need  reitera- 
tion, but  are  simply  called  to  mind  as  evidence 
that  the  more  matured  minds  in  the  profession 
are  guided  by  the  light  of  nature's  in  simplici 
salus. 


EDITORIAL  NOTES. 


Endocarditis  during  Measles. —Mr.  J.  H. 
Hutchinson  submitted  a  contribution  to  the  Royal 
Medical  and  Chirurgical  Society  of  London,  at 
its  meeting  of  April  14,  1891,  in  which  a  connec- 
tion was  held  to  subsist  between  measles  and  en- 
docarditis, four  cases  being  cited  in  which  the 
heart  affection  developed  during  the  course  of 
tlv  acute  exanthematous  disease.  The  opinions 
of  the  medical  gentlemen  present  were  divided 
on  the  subject,  some   declaring  that  heretofore 


i89i.] 


EDITORIAL  NOTES. 


675 


unexplainable  cases  might  find  solution  through  investigation  into  the  previous  medical  history  of 
the  possible  influence  of  the  specific  poisons  pro-  the  prisoner.  There  should  also  be  an  inquiry 
ducing  the  acute  febrile  diseases  of  childhood,  into  the  family  history,  so  as  to  elucidate  the 
The  cases  presented  by  N.  W.  Hutchinson,  heredity  with  special  reference  to  inebriety,  in- 
though  few,  were  yet  sustained,  in  a  measure,  sanity,  and  other  neurotic  affections,  syphilis  and 
by  the  post-mortem   appearances  of  other  cases   gout.     This  twofold  inquiry  should  be  entrusted 


with  like  characteristics. 

This  connection — or,  as  we  should  more  readily 
believe,  coincidence — has  been  noted  before.  We 
quote  Garrod,  as  follows:  "Dr.  Sansom  is  of 
opinion  that  the  importance  of  measles  as  a  pre- 
disposing cause  of  endocarditis  has  not  been 
sufficiently  taken  into  account,  and  he  is  inclined 
to  assign  to  that  fever  a  share  in  the  production 
of  articular  rheumatism  also.  He  has,  moreover, 
recorded  a  case  in  which  chorea,  associated  with 
pericarditis  and  endocarditis,  developed  during 
convalescence  from  an  attack  of  measles." 

Second  Childhood. — This  is  often  spoken  of 
as  a  condition  into  which  those  of  advanced  life 
enter.  The  mind,  disposition,  and  actions  be- 
come child-like,  until  finally  the  evening  of  ex- 
istence becomes  no   less   lightsome  and  blank  to 


either  to  a  medical  expert,  or  to  a  mixed  com- 
mittee composed  of  a  legal  and  medical  expert 
acting  conjointly.  The  object  of  this  investi- 
gation is  to  ascertain  how  far  the  accused  has 
been  cognizant  of  his  alleged  criminal  offence,  as 
to  whether  he  was  competent  to  discern  its  con- 
sequences, and  as  to  whether,  if  so  cognizant  and 
competent,  he  was  able  to  resist  the  criminal  im- 
pulse. Such  an  expert  inquiry  should  be  pro- 
vided for  the  accused,  whatever  their  circum- 
stances, as  a  judicial  provision  to  ensure  a  fair 
and  just  trial. 

2.  The  appointment  of  a  mixed  commission  of 
judges,  counsel,  solicitors,  and  medical  experts 
for  the  consideration  of  the  question  of  dealing 
with  inebriates  who  have  been  convicted  of  a 
criminal    offence.       This    inquiry    should    have 


.  ,■,•       ,,  ■    .    ■      ,     .  ,u     1  c  special  reference  to  the  best  procedure  to  be  pur- 

sterner  realities   than   maintained  at  the  dawn  of  I    F  \  -  ... 

I  sued  ;  whether,  1,  if  penal,  by  cumulative  punish- 
ment or  otherwise;  or,  2,  if  curative,  by  medical 
treatment  for  a  diseased  condition,  with  due  pro- 


life.  However  that  may  be,  we  have  in  medicine 
occasional  evidences  which,  if  they  do  not  point  | 
to  a  secondary  physical  childhood — so  to  speak — 
yet  are  sufficiently  interesting  to  have  note. 
Among  these  points  of  interest  may  be  mentioned 
a  case  of  scarlet  fever  occurring  recently  in  a 
woman  59  years  of  age,  and  a  case  of  whooping- 
cough  in  a  man  aged  84. 


visions    for   classification,    occupation,    hygienic 
measures,  and  elevating  influences." 

Another  Danger  in  the  Profession — 
Charged  with  Kissing.  — An  Irish  physician 
was  recently  tried  under  the  charge  of  attempting 


A  Praiseworthy  Relief  Organization.-  to  kiss  a  >oun£  raarried  woman  while  in  his  con- 
The  Society  for  Relief  of  Widows  and  Orphans  j  sulting  room-     Five  thousand  dolla^  represented 

the  amount  claimed  for  damages.  The  woman's 
story  proved  to  be  exceedingly  incredible,  and 
there  was  little  doubt  of  its  being  the  creation  of 
an  hysterical  mind.     The  jury  promptly  found  a 


of  Medical  Men  (British),  of  which  Sir  James 
Paget  is  President,  is  active  in  the  work  towards 
which  its  title  points.  Examples  of  signal  bene- 
fit, in  the  operations  of  such  societies,  are  not  at 

all    few,    and,    like  all  such    acts   of    honorable ,  verdict  for  the  Ph>"sician' 
charity,  the  result  is  of  a  two- fold  nature.  Treatment  of  Influenza. — Based  upon  his 

Inebriatism  a  Disease.-As  emphasizing  the   observations  during  the  epidemic  of  one  year  ago, 
trend  of  professional  opinion  in  the  direction  of  Dr-  John  William  W 
the  morbiditv  of  inebriatism   mav   be  mentioned 


the  proposals  embodied  in  the  President's  Address 
before  the  Society  for  the  Study  of  Inebriety,  of 
London,  as  follows  : 

1.  "In  all  criminal  trials  in  which  the  alleged 
criminal  act  has  been  committed  by  the  accused 
when  under  the  influence  of  liquor,  or  has  been 
committed  bv  an  inebriate,   there  should   be  an 


as  follows,  touching  treatment :  "The  treatment 
of  the  affection  turns  upon  common-sense  princi- 
ples. It  is  expectant,  palliative,  and  symptom- 
atic. There  is  no  specific  for  influenza  ;  but  the 
most  useful  drugs  to  employ  in  its  treatment  are, 
1,  quinine;  2,  autipyrin  (except  in  young  chil- 
dren, and  the  weakly)  ;  3,  salicylate  of  sodium, 
especially  in  effervescence  ;  4,  phenacetin  ;  and 
5,  effervescing  citrate  of  caffein." 


676 


MEDICAL  ITEMS. 


[May  9 


MEDICAL  ITEMS. 
Missouri  Medical  Association. — The  date 
of  meeting  of  this  Association  is  given  as  May 
19,  20  and  21 — instead  of  May  12,  as  formerly 
announced — and  the  place  of  meeting  is  to  be 
Excelsior  Springs. 

Ether  Drinking  in  Michigan. — A  corre- 
spondent communicates  to  The  Medical  Age  the 
prevalence  of  one  sort  of  ether  drinking — the 
compound  spirits  of  ether  — in  the  northern 
counties  of  the  State  of  Michigan,  principally 
among  the  Finns,  Swedes,  and  Poles.  It  is  gen- 
erally consumed  with  alcohol  or  whisky. 

A  Rare  Case.— Dr.  Thomas  D.  Dunn  of  West- 
chester, Pa.,  reports  (U?iiversity  Medical  Maga- 
zine, May,  1891)  a  case  of  ligation  of  the  com- 
mon carotid  artery,  in  a  child  three  and  one-half 
years  of  age,  for  haemorrhage  following  peri- ton- 
sillar abscess,  and  with  the  result  of  recovery  of 
the  patient.  The  case  is  remarkable,  both  from 
the  disease,  and  the  operation  in  one  so  young. 

The  Chair  of  Therapeutics  in  Jefferson 
Medical  College.— Dr.  Hobart  Armory  Hare 
was  elected,  April  22,  1891,  by  the  Trustees  of 
Jefferson  Medical  College,  to  fill  the  Chair  of 
Materia  Medica  and  Therapeutics.  Dr.  Hare  is 
a  young  man,  yet  has  already  distinguished  him- 
self as  an  investigator  and  medical  author,  and 
will  no  doubt  find  scope  for  continued  and  added 
renown  in  the  field  of  his  new  relationship. 

Stimulus  for  Medical  Workers. — Dr.  Bail- 
larger,  the  late  eminent  French  alienist,  has  be- 
queathed to  the  French  Academy  of  Medicine  a 
sum  sufficient  to  produce  a  biennial  revenue  of 
$400.00,  which  will  be  offered  as  a  prize  for  the 
best  work  appearing — during  the  intervals  be- 
tween which  it  becomes  available — on  the  subject 
of  mental  diseases. 

A  Resignation. — It  is  announced  that  Prof. 
J.  M.  DaCosta  has  resigned  the  Chair  of  Practice 
of  Medicine  at  Jefferson  Medical  College  which  he 
has  occupied  with  such  honor  for  upwards  of 
nineteen  years. 

Cases  in  Obstetrics. — An  interesting  tabula- 
tion of  the  first  i.ococases  of  obstetrics  in  the 
Sloan  Maternity  Hospital,  New  York  City,  ap- 
pears  in  the  pages  of  the  last  issue  of  the  Ameri- 
can Journal  of  1  Obstetrics,     The  oldest  patient  con- 


fined was  46,  while  the  youngest  was  12  years  and 
10  months  of  age.  The  largest  number  (659)  were 
between  20  and  30  years  old.  Also  in  the  largest 
number  (547)  it  was  the  first  pregnancy,  while  in 
one  case  occurring  in  the  table  it  was  the  patient's 
seventeenth  confinement.  Of  the  presentations 
936  were  vertex,  and  of  these  610  occupied  the 
L-  O.  A.  position.  As  to  operative  interference, 
there  were  112  in  which  it  was  required,  as  fol- 
lows: induction  of  labor,  12;  forceps,  83;  version, 
14;  craniotomy,  3.  Of  twin  cases  there  were  131 
about  one  in  seventy-seven  of  the  whole  number 
of  women  delivered.  In  the  forceps  cases  the  re- 
turns are  certainly  noteworthy.  Out  of  the  83 
cases  none  of  the  mothers  died.  Of  the  84  chil- 
dren 75  were  living,  9  still-born,  including  pre- 
mature twins.  In  nearly  all  the  cases  the  long 
curved  forceps  (McLane's)  were  used,  both  in 
high  and  low  operations.  Of  the  fatal  cases  in 
this  report  we  have  as  causes  chronic  Bright's  dis- 
ease, 1  ;  rupture  of  uterus,  1 ;  placenta  praevia,  1 ; 
placenta  praevia  with  contracted  pelvis,  1;  eclamp- 
sia, 1  ;  septicaemia,  1 ;  total,  6.  On  analyzing 
these  deaths  it  is  seen  that  one  was  from  chronic 
organic  disease  and  not  labor ;  in  another  the  pa- 
tient was  moribund  when  taken  from  the  ambu- 
lance; in  a  third— placenta  praevia — there  was 
much  delay  and  great  bleeding  before  assistance 
could  be  given.  The  septicaelnia  case  was  ad- 
mitted while  in  the  second  stage  of  labor,  and 
was  in  a  very  filthy  condition.  The  showing, 
therefore,  is  highly  creditable. 

Ether  Drinking  in  Ireland. — The  state- 
ment lately  put  forth  of  the  prevalence  of  ether 
drinking  among  certain  classes  in  Ireland,  has 
had  confirmation  before  a  British  committee.  The 
Rev.  Dr.  Carter,  Rector  of  Cookstown,  gave  evi- 
dence that  ether  drinking  was  not  a  rarity,  but 
quite  a  common  practice.  Children,  even,  were 
given  to  the  habit,  obtaining  the  intoxicant  from 
beggar-women  who  tramped  the  country.  On 
market  days  particularly  a  great  number  of  peo- 
ple would  keep  themselves  drunk  at  small  ex- 
pense, taking  a  given  quantity  of  ether  at  certain 
intervals.  Some  Government  action  will  prob- 
ably be  taken  at  an  early  date. 

Fund  for  a  Biological  Laboratory. — The 
trustees  of  Columbia  College  have  determined  to 
devote  the  late  Mr.  Charles  M.  DaCosta's  bequest 
of  $100,000  towards  a  laboratory  of  biology. 


I89i.] 


TOPICS  OF  THK  WEEK. 


677 


TOPICS  OF  THE  WEEK. 


THE  C8NTENAX.Y  OF  THE   MICROSCOPE. 

It  is  generally  thought  that  the  invention  of  the  micro- 
scope goes  back  to  the  close  of  the  fifteenth  century,  or. 
to  be  more  precise,  to  the  year  1591.  when,  in  the  city  of 
Middleburg,  in  Holland,  two  spectacle-makers,  named 
invented  both  the  telescope  and  the  microscope. 
This  date  for  the  invention,  according  to  which  its  third 
centenary  would  arrive  in  1^90,  does  not  rest  on  authentic 
documents,  but  is  based  on  assertions  published  in  1665 
by  the  physician,  Peter  Borel.  He  denied  that  Galileo, 
Drebbel  and  others  deserved  the  credit  of  having  invent- 
ed the  telescope;  and  in  order  to  demonstrate  that  the 
invention  of  that  instrument,  as  well  as  of  the  micro- 
scope, was  due  to  the  Jaussens,  produced  some  docu- 
ments which  showed  that  the  two  spectacle  makers, 
having  invented  the  telescope  in  1590,  presented  a  speci- 
men of  it  to  Prince  Maurice.  Stadtholder  of  the  Nether- 
lauds,  and  to  the  Archduke  Albert.  Later  on,  however, 
the  telescope  of  Prince  Maurice  became  a  microscope,  in 
a  letter  of  William  Borelli,  who  declared  that  he  had  al- 
ways heard  in  Middleburg,  his  native  city,  that  the  Jans- 
sens  had  invented  these  optical  instruments,  and  further 
that,  when  he  was  ambassador  at  London,  in  1619,  he  had 
seen  in  the  hands  of  Drebbel  the  identical  microscope 
that  the  Jansseus  had  presented  to  Prince  Maurice. 

Professor  Govi,  however,  in  a  work  v.  hich  demonstrates 
the  excellence  of  his  judgment  and  his  vast  erudition, 
has  collected  a  series  of  documents,  which  not  only  seem 
to  restore  the  merit  of  the  invention  of  the  microscope 
to  Galileo,  but  show  the  various  vicissitudes  of  the  dis- 
covery itself.  The  first  hint  of  the  transformation  of  the 
Holland  telescope  into  a  microscope  is  found  in  a  little 
book  published  in  1610  by  Wodderborn,  a  pupil  of  Gali- 
leo. Speaking  of  the  wonderful  qualities  of  the  tele- 
scope,  Wodderborn  adds,  in  praise  of  Galileo,  that  "  with 
the  instrument  could  be  perfectly  distinguished  the  or- 
gans of  motion  and  sensibility  in  the  smallest  animal- 
cule. "  so  that  the  particular  formation  of  multiplied  eyes 
in  very  small  animals  could  be  perceived.  This  new  ap- 
plication of  the  telescope  by  himself  Galileo  did  not  deny, 
though  he  never  directly  affirmed  it.  In  the  National 
Library  at  Paris  is  preserved  a  letter  by  Canon  Tarde,  in 
which  he  speaks  of  visiting  Galileo  in  Florence,  in  1614. 
when  the  latter  was  sick  in  bed.  Notwithstanding,  to 
Tarde  Galileo  gave  ample  explanation  of  a  microscope 
then  in  his  possession. 

Whether  the  invention  of  the  simple  microscope  be 
due  to  Janssen  or  Galileo,  to  Drebbel  is  due  the  merit  of 
having  produced  at  Rome,  in  1624,  the  compound  micro- 
scope. The  difference  between  the  two  hardly  needs  ex- 
planation. The  simple  microscope  magnifies  with  a  single 
lens,  or  with  several  lenses  so  close  together  that  they 
act  like  a  single  lens.  The  compound  microscope  has 
two  or  more  lenses,  separated  by  a  convenient  distance 
from  each  other,  and  which  act  separately.  In  1669, 
Eustachio  Divini  constructed  a  colossal  microscope  which 
magnified  140  times.  A  little  after,  Bonannus  invented  a 
horizontal  microscope  which  magnified  300  times. 


In  the  seventeenth  century  were   laid  the   fouB 
of  micrography,  a   science  which,  by  the  study  of  the 
minute   anatomical   elements   and  their   functions,    has 
made  such  great  progress  under  the  name  of  histology, 
and  been  such  a  fertile  cause  of  important  disc 
With  the  microscope,  Malpighi,  by  the  minute  examina- 
tion of  the  tissues,  confirmed  the  theories  about  them  he 
had  previously  formed;  Leuwenhcek  discovered '.': 
ules  of  the  blood  and  the  structure  of  the  nervous  fibres; 
and  Swaminerdam  dissected  insects,  of  the  most  minute 
organs   of  which   he  gave  descriptions   still   considered 
perfect. 

In  the  eighteenth  century,  observes  Henocque.  but 
few  modifications  were  made  in  the  microscope.  To 
mention  all  the  improvements  made  in  the  instrument 
during  our  century  would  be  tedious.  During  the  last 
forty  years  enormous  advances  have  been  made  in  science 
by  the  aid  of  the  microscope,  of  which  the  usefulness  has 
been  greatly  increased  by  the  skill  with  which  the  mat- 
ter to  be  examined  is  prepared,  and  by  the  aid  of  pho- 
tography. Micro-photography  dates  from  1S40  only;  but 
since  that  date  it  has  had  an  uninterrupted  series  of 
noteworthy  improvements. 

Besides  histology,  created  by  the  microscope,  by  which 
our  acquaintance  with  the  most  hidden  structure  of  or- 
ganisms is  constantly  increasing,  bacteriology,  with  its 
rapid  succession  of  discoveries  of  the  highest  importance, 
owes  its  existence  to  the  microscope.  Those  little  be- 
ings, those  microorganisms,  which,  by  the  change 
of  the  medium  in  which  their  evolution  is  effected, 
can  produce  so  much  good  or  so  much  evil,  and 
of  which  it  takes  several  millions  to  occupy  the  tenth 
part  of  half  an  inch  in  space,  can  now  be  identified 
according  to  their  species,  notwithstanding  their  change- 
able aspect.  We  can  estimate  the  rapidity  of  multiplica- 
tion, the  number,  the  dimensions,  and  the  singular  man- 
ner in  which  by  dividing  themselves,  or  by  means  of  a 
sort  of  buds  or  spores,  the  microorganisms  reproduce 
themselves. 

In  the  examination  of  the  inorganic  world  the  micro- 
scope has  had  results  not  less  precious.  The  wonderlul 
phenomena  of  crystallization,  the  exact  form  of  the  crys- 
tals, the  more  precise  in  proportion  to  their  minuteness, 
the  modifying  properties  of  the  light  called  forth  by  the 
thinnest  layer  of  a  mineral,  the  interior  texture  of  rocks, 
all  these  can  be  studied  with  a  precision  impossible  be- 
fore the  invention  of  the  improved  microscope.  And. 
finally,  not  to  mention  all  the  triumphs  achieved  by  the 
instrument,  it  has  had  an  application  which  formerly 
would  have  seemed  paradoxical,  since  the  microscope 
has  been  employed  to  show  the  particulars  of  the  nature 
of  the  surface  of  the  planets,  particulars  which  have 
been  made  clear  by  microscopic  observations  of  instan- 
taneous photographs. — Ernesto  Manciui.  Nuova  Antolo- 
gia,  Literary  Digest. 

MEASURING  THE  PERCEPTION   OF    ODOR. 

At  a  recent  meeting  of  the  French  Academy.  Secretary 
Berthelot  exhibited  a  new  instrument  called  the  "  olfac- 
tometer." The  inventor  is  M.  Charles  Henry.  The  ob- 
ject of  the  apparatus  is  to  determine  the  minimum  rate 


6y8 


TOPICS  OF  THE  WEEK. 


[May  9 


of  odoriferous  vapor  per  cubic  centimetre  of  atmospheric 
air  perceptible  to  the  human  olfactory  nerves.  The  ol- 
factometer consists  principally  of  a  graduated  glass  tube 
which  moves  within  a  paper  envelope.  The  tube  is  held 
to  the  nose  and  the  paper  gradually  withdrawn.  As  soon 
as  the  subject  of  the  experiment  perceives  the  odor  of 
the  material  contained  within  the  glass  tube,  the  latter  is 
withdrawn,  and  the  quantity  of  vapor  which  has  escaped 
is  calculated  from  the  known  capacity  of  the  tube,  and 
the  degree  marked  by  the  paper  envelope.  The  cubic 
space  affected  by  the  odorous  vapor  is  simultaneously 
determined  by  means  of  a  small  areometer.  The  inven- 
tor of  the  instrument  shows  that  the  perceptibility  of 
different  odors  by  different  subjects  varied  enormously, 
the  two  limits  of  his  experiments  falling  between  2 
milligrams  of  ether  per  cubic  centimetre,  and  one- 
thousandth  of  a  milligram  of  oil  of  wintergreen  per 
cubic  centimetre. 


FRIEDLANDKR'S  PNEUMOCOCCUS  AS  A   FERMENT. 

It  has  been  known  for  some  time  that  Friedljinder's 
pueumococcus  is  capable  of  inducing  fermentative 
changes  in  suitable  solutions  of  glucose  and  cane  sugar, 
this  having  been  first  discovered  by  Brieger.  His  ob- 
servations have  quite  recently  been  confirmed  by  Dr. 
Percy  Frankland,  Mr.  Arthur  Stanley,  and  Mr.  William 
Frew,  who  have  just  communicated  a  paper  on  the  sub- 
ject to  the  Chemical  Society  of  London.  They  further 
found  that  the  organism  ferments  maltose,  milk  sugar, 
raffinose,  dextrin,  and  mannitol,  but  that,  like  the 
bacillus  ethaceticus,  it  does  not  attack  dulcitol.  They 
made  a  special  study  of  the  fermentations  of  glucose  and 
mannitol,  determining  quantitatively  the  proportions  in 
which  the  several  products  are  formed.  These  products 
are  in  each  case  ethyl,  alcohol,  acetic  acid — generally  ac- 
companied by  a  little  formic  acid  and  a  trace  of  succinic 
acid — carbon  dioxide,  and  hydrogen.  Both  the  glucose 
and  mannitol  were  in  all  cases  only  partially  fermented, 
and  the  decomposition  of  the  glucose  was  especially  in- 
complete, glucose  being  apparently  less  readily  attacked 
by  the  organism  than  mannitol  and  cane  sugar.  The 
fermentation  was  not  rendered  more  complete  by  furnish- 
ing the  organism  with  a  more  abuudaut  supply  of  nitrog- 
enous food.  The  products  of  the  mannitol  fermenta- 
tions were  not  only  qualitatively  similar  to  those  obtained 
in  the  fermentation  of  the  same  substance  by  the  bacillus 
ethaceticus,  but  the  relative  proportions  in  which  they 
were  formed  were  almost  identical,  the  ratio  correspond- 
ing closely  to  the  molecular  proportions  2  C...IJ  .  OH: 
■  IOH.—  The  Lancet. 


Till-;  POPULATION  QUESTION  IN"  FRANCE. 

This  subject  naturally  continues  to  exercise  the  minds 
of  French  statisticians  and  scientists.  Dr.  Jomileff  dis- 
cusses it  in  the  February  number  of  the  Archives  de 
Tocologic.  The  true  cause  of  the  stationary  population 
appears  undiscovered — perhaps  the  theory  that  the  race 
is  naturally  not  prolific,  or  thai  climate  and  1 
against  fertilin  i      orrecl       L,i       seui    Di     [om 

ntly  shown  that  the  question   of  professions  and 
socio-religious  ideas  has  little  direct  influence  on  fertility. 


Thus  statistics  make  members  of  the  liberal  professions 
less  prolific  than  farmers  and  business  men,  but  the  lib- 
eral professions  best  allow  celibacy,  or  often  enforce  it, 
and  late  marriages  are  common.  Social  and  religious 
ideas  seem  to  have  little  influence,  contrary  to  what 
might  have  been  supposed.  In  strictly  religious  com- 
munities— Protestant  as  well  as  Catholic — a  large  family 
is  held  to  be  an  honor,  if  not  a  blessing,  and  checks  to 
impregnation  are  deprecated.  Yet  statistics  show  that 
the  fertility  of  such  communities  is  not  higher  than  that 
of  large  bodies  of  men  and  women,  chiefly  laborers, 
I  where  the  religious  element  is  weak  and  where  checks 
are  openly  tolerated.  Britanuy,  the  Maritime  Alps,  and 
Corsica  are  fertile  in  children,  and  the  populition  are 
strict  in  religious  observances  and  almost  free  from  cor- 
rupting influences  ;  yet  the  inhabitants  of  the  valley  of 
the  Garonne,  also  a  strict  and  pious  folk  taken  as  a 
whole,  have  very  few  children.  Lastly,  some  districts 
where  the  peasauts  are  comfortably  off.  have  a  low  fer- 
tility, others  show  an  increasing  population,  whilst  the 
same  irregularity  is  seen  in  different  departments,  where 
the  country  people  are  poor  and  ill-fed. — British  Med- 
ical Journal. 

THE  INFLUENCE  OF  EXERCISE  ON  DIGESTION. 

Dr.  Streng,  in  a  lecture  before  the  Medical  Society  of 
Giessen  on  the  Influence  of  Exercise  on  the  Digestion, 
which  has  been  published  in  the  Deutsche  Medicinische 
Wochenschrift,  states  that  he  concludes  from  his  own  ex- 
periments that  this  influence  is  of  a  retarding  nature. 
His  experiments,  however,  suffer  from  the  fact  that  he 
always  injected  300  cubic  centimetres  of  water  before  ob- 
taining the  contents  of  the  stomach,  so  that  the  propor- 
tion between  gastric  juice  and  water  continually  varied. 
The  first  experiments  in  the  clinic  at  Giessen  were  made 
on  two  dogs.  Twenty-five  grams  of  meat,  suspended  in 
300  cubic  centimetres  of  warm  water,  were  twice  injected 
into  the  fasting  stomach,  and  after  one  feeding  the  dogs 
were  compelled  to  remain  for  three  hours  in  absolute 
bodily  rest,  while  after  the  other  feeding  they  were  made 
to  take  active  exercise.  After  the  three  hours  the  con- 
tents of  the  stomach  were  obtained  and  analyzed.  The 
quantity  did  not  essentially  differ  in  the  two  cases;  the 
experiments  consequently  tended  to  prove   that  exercise 

!  does  not  influence  the  time  required  for  digestion.  The 
chemical  analysis  also  detected  no  difference.  The  same 
results  were  obtained  by  substituting  the  white  of  an  egg 
for  the  meat.  The  experiments  were  then  repeated twenty- 

j  five  times  on  three  men  with  healthy  stomachs.  Two  of 
these  suffered  From  sycosis,  and  the  third  from  incipient 
muscular  atrophy.  They  were  fed  each  time  with  200  grams 
of  minced  meat,  a  bun.  a  plate  of  bouillon,  and  three 
spoonfuls  of  mashed  potatoes,  and  the  contents  of  their 
wire  obtained  tour  hours  ami  a  half  afterwards. 
The  exercise  after  meals  consisted  partly  in  gymnastics, 
partly  ill  walking;  absolute  rest  was  obtained  in  bed 
rimen      ;ave  the  same  results  as  those  on  the 

dogs,  the  difference  resulting  from  the  chemical  analysis 
being    especially    imperceptible.      The    author   therefore 
■    that   the   gastric    function  is   in    no  way  influ- 
enced either    by  muscular  action   or  by   absolute   rest. 
i  The  Lancet. 


•89I-] 


PRACTICAL  NOTES. 


679 


PRACTICAL  NOTES. 


INFANTILE  DIARRIKKA. 
i.  Withdraw  all  milk  for  from  twenty-four  to 
thirty-six  hours.  2.  Regulate  the  quantity  and 
quality  of  the  food  and  the  frequency  of  giving 
it.  3.  Give  plenty  of  cool  water.  4.  Reduce  the 
temperature  with  the  hath.  5.  Give  medicines 
of  an  antiseptic  and  astringent  character  and  stim- 
ulants as  needed.  6.  Wash  out  the  colon  two  or 
three  times  a  day.  —Archives  of  Pediatrics. 


IODOFORM  AND  ARISTOL. 

Dr.  Richtmann  recommends  (Nouveaux  Rem.) 

that  aristol  he  used  to  replace  iodoform,  since  it 
presents  all  the  advantages  of  iodine  and  thymol 
without  any  of  their  disadvantages.    Aristol  does 
not  cause  irritation  :  its  absorption  is  not  followed 
by  any  phenomena  of  intoxication,  and  its  odor 
is  not  disagree. ible     Being  less  volatile  than  thy- 
mol, its  use   is  especially  indicated  in   extensive 
burns.      It  may  be  prescribed  as  a  powder,  or  an 
ointment,  or  given  in  solution.    The  preparations 
used  by  Richtmann  are  as  follows : 
R.      Aristol  pure.  gm.   lo. 
S.      For  external  use. 
K.      Aristol.  gm.    I. 
Ether,  gui.  i<>. 
S.     For  external  use. 
ft.     Aristol. 

Ol  ricini  aa,  gm 
Collodion,  gm.  S. 
S.      As  a  paint  for  the  region  affected. 
ft.      Aristol,  gm.  1. 

Paraffin  ointment,  gm.  lS. 
S.     For  local  application. 
11.      Aristol,  I  to  5  cgtn. 

Cocoa  butter.  <j.  s. 
S.      For  urethral  or  vaginal  bougies. 

— Medical  Standard. 


many  cases,  however,  which  do  not  respond  to  it 
very  markedly.  Doubtless,  too,  there  are  man}' 
cases  of  sciatica  neuritis,  rheumatism,  gout,  etc., 
in  which  a  diagnosis  of  sciatica  is  erroneouslv 
but  perhaps  more  frequently  sciatica  is 
mistaken  for  one  of  these  affections. — Practice. 

BISMUTH  FOR  ECZEMA   OF  INFANTS. 

The  following  formulae  are  given  in  Nouveaux 
Reniedes: 

R.     Bismuth,  subnit.,  3v. 

Zinci  oxidi.  ,~i>s. 
Acidi  carbolici,  m.  x. 
Vaseline,  §j.     nj>. 
To  make  an  ointment. 

In  case  there  is  much   irritation  paint  on   the 

following  with  a  soft  brush  : 

R.     Bismuth,  subnit.,  gr.  xl. 

Glycerine,  " 

Acidi  carbol.,  gtts.  vj. 

Aquae  rosae,  ~,\\.     ^J. 

To  be  well  shaken. 


RESORCIX  IX  ACXE. 

Isaak  recommends  the  following  : 

R.      Resorciu,  3j  to  ijss. 

Zinci  oxidi  pulv. .  aa  31'jss. 
Amyli  pulv.,  aa  gijss. 
Liquid  vaseline.  3v.     "J. 

Rub  on  the  part  affected  morning  and  night, 
or  it  may  be  used  at  night  only,  and  removed  in 
the  morning  with  sweet  oil. 


SEDATIVE  FOR    BABIES. 

Dr.  Van  Goidtsnoven,  of  Atlanta,  gives  a  for- 
mula with  which  he  has  had  most  gratifying  re- 
sults in  restlessness,  spasms,  deliri.a,  and  in  all 
cases  requiring  a  sedative,  anodyne,  anti-spas- 
modic or  somnifacient. 

ft.     Camphor,  monobromat..  gr.  xvi. 
Ext.  hyoscyami  fl.,  gtt.  xvi-xxx. 
Syrup  lactucarii  I Aubergier's)   f 5 viij.     nj. 
S.     A  tablespoonful  every  hour  till  relieved. 

— Dixie  Doctor. 


ACUTE    BRONCHITIS. 

The  citrate  of  potassium  is  a  favorite  remedy 
of  Dr.  H.  C.  Wood  in  acute  bronchitis;  his  for- 
mula is,  he  says,  the  most  reliable  and  efficient 
sedative  cough  mixture  that  he  has  ever  used  : 

R.      Potass,  citrat. .  j§j. 
Sue.  limonis,  15 ij. 
Syr.  ipecac,  fgss. 
Syr.  q.  s.  ad.,  f^vj.     itjj. 
Sig.     A  tablespoonful  four  to  six  times  a  dav. 
Another  favorite  expectorant  with  this  writer 
is  oil  of  eucalyptus,  which  may  be   given  in  rive 
minim  capsules  every  three  hours.      It  is  only  of 
use  after  expectoration  is  established. 


PHENACETIN  IX  SCIATICA. 

Sciatica  is  not  only  one  of  those  affections 
which  are  extremely  annoying  and  painful  to  the 
patient,  but  on  account  of  its  persistency  often 
greatly  tries  the  patience  of  the  physician.  At 
the  clinic  of  Prof.  Landon  Carter  Gray  most  ben- 
efit has  perhaps  been  obtained  from  phenacetin, 
given,  say,  in  tablets  of  four  to  eight  grains 
every  three  or  four  hours.       There   are  a  good 


MOUTH  WASH. 

David  uses  the  following  mixture  as   a  tonic 
and  antiseptic  mouthwash   {Medical  News,  Feb- 
ruary 21,  1 891)  : 
ft.     Thymol,  7  grs. 
Borax,  15  grs. 
Water.  1  '2  ozs.     nj. 

A  few  drops  of  this  are  to  be  placed  in  a  wine- 
glassful   of  warm  water,   and  the  mouth  rinsed 
with  it.    In  cases  in  which  the  breath  is  fetid,  ow- 
ing to  deposits  about  the  tonsils  and  gums,  the 
following  wash  is  said  to  be  serviceable : 
ft.     Borate  of  sodium,  15  grs. 
Alcohol.   '2  drachm. 
Water,  1  pint. 
Thymol,  7  grs.     W)J. 


68o 


SOCIETY  PROCEEDINGS. 


[May  9 


SOCIETY    PROCEEDINGS. 

Gynecological  Society  of  Boston. 

Annual  {218th  Regular)  Meeting. 

The  Gynecological  Society  of  Boston  held  its 
218th  regular  meeting  at  the  Medical  Library  on 
January  8,  1891,  with  the  President,  W.  Sym- 
ington Brown,  M.D.,  in  the  chair. 

THE  ANNUAL  ADDRESS  ON  GYNECOLOGICAL 
PROGRESS 

was  delivered  by  the  President,  who  said:  Our 
third  by-law  requires  that  the  retiring  President 
shall  deliver  an  Address  upon  the  previous  year's 
progress  in  gynecology, — a  law,  by  the  way, 
which,  since  my  connection  with  the  Society,  has 
been  rarely  attended  to.  On  the  present  occasion 
I  propose  to  discuss  very  briefly  a  few  recent  sug- 
gestions by  prominent  gynecologists,  principally 
relating  to  menstruation. 

Dr.  E.  C.  Gehrung,  of  St  Louis,  read  a  paper 
before  the  American  Gynecological  Society  at  its 
meeting  in  Boston,  in  September,  1889,  on  arrest 
of  menstruation.  He  thinks  that  sanguineous 
menstruation  is  an  abnormal  process,  an  inherited 
disease,  eventually  to  be  got  rid  of  through  the 
Darwinian  process  of  evolution.  He  says  that 
"menstruation  is  not  necessarily  sanguineous." 
The  practical  part  of  the  paper  consists  in  a  pro- 
posal to  arrest  menstruation  in  all  cases  where 
the  loss  of  blood  would  be  injurious  to  the  pa- 
tient. He  asserts  "that  bloody  menstruation, 
whether  profuse  or  scanty,  may  be  safely  re- 
pressed (preferably  by  the  vaginal  tampon)  when- 
ever the  individual  cannot  or  should  not  spare 
the  blood  thus  wasted,  and  that  great  benefits 
may  be  derived  from  this  restriction  in  otherwise 
incurable  or  partly  curable  cases."  Dr.  Gehrung 
has  practiced  this  method  successfully  for  several 
years.  The  vagina  is  thoroughly  tamponed,  a 
iievv  tampon  being  inserted  every  48  or  60  hours. 
Another  member  said  that  he  also  had  employed 
this  method  with  great  success. 

Dr.  Johnstone,  of  Danville,  Ky.,  strenuously  ob- 
jected  both  to  the  theory  and  to  the  treatment. 
He  believes  that  menstruation  results  from  the 
erect  posture,  as  proved  by  the  fact  that  men 
struation  occurs  in  the  higher  apes,  who  stand 
erect,  or  nearly  so,  most  of  the  time.  Quadrupeds 
possess  a  rich  plexus  of  lymph  vessels  connected 
with  the  womb;  whereas  the  human  uterus  is 
almost  destitute  of  such  vessels.  The  proposed 
treatment  did  not  seem  to  meet  with  much  favor 
by  those  present  at  the  meeting. 

Dr.    A.    W.    Parsons,   of  Northampton,  Mass., 
■  ,.,.;„, ,<s  tu  do  away  with  napkins  during  menstru 
ation   and   substitute   an   antiseptic    tampon,   in- 
through  a  glass  speculum,  as  soon  as  the 
nitory  symptoms  appear.     This  is  removed 
aturated   and  another  roll  inserted.     Dr. 


P.  claims  that  the  tampon  supports  the  con- 
gested uterus  and  is  more  cleanly.  I  have  not 
learned  that  this  suggestion  has  been  generally- 
adopted  by  women  and  scarcely  expect  that  it 
will  be  practiced.  One  serious  objection  is  that 
it  necessarily  keeps  the  vaginal  walls  apart, 
which  naturally  are  in  contact;  and,  judging 
from  my  own  experience,  it  is  a  very  difficult 
thing  to  induce  patients  to  insert  a  cotton  or  wool 
tampon,  even  when  it  is  needed  to  counteract 
prolapsus.  They  prefer  to  wear  a  pessary,  which 
does  not  need  to  be  removed  for  weeks  or  months. 
If  used  as  a  substitute  for  napkins,  the  tampon 
should  consist  of  wool,  with  a  covering  of  cotton, 
and  a  string  attached  to  facilitate  removal. 

Dr.  H.  P.  C.  Wilson,  of  Baltimore,  recommends 
the  performance  of  laparotomy  during  menstrua- 
tion. He  refers  to  the  paper  of  our  Dr.  H.  R. 
Storer,  read  at  the  first  meeting  of  the  American 
Gynecological  Soeiet\-  in  1876,1  in  which  Dr.  S. 
concludes  "that  for  pelvic  operations,  all  things 
being  equal,  it  is  better  to  select  the  week  imme- 
diately following  the  cessation  of  the  catamenia 
for  all  such  operations."  Dr.  Wilson  differs  from 
this  conclusion.  He  says,  "for  laparotomies  in- 
volving the  pelvic  organs,  my  experience  teaches 
me  to  select  the  uterine  flood  rather  than  the 
uterine  ebb."  This  is  the  opinion  of  a  surgeon 
who  has  had  abundant  opportunities  to  test  it, 
and  who  is  well  known  for  conservative  tenden- 
cies; and  I  think  that  the  majority  of  gynecolo- 
gists are  now  of  the  same  opinion. 

The  question  so  frequently  discussed  during 
the  last  ten  years,  whether  menstruation  depends 
on  ovulation  or  is  independent  of  that  process, 
has  had  some  light  thrown  on  it  by  a  case  recent- 
ly reported  in  the  British  Medical  Journal  (Sept. 
27,  1890).  Dr.  J.  A.  Robertson  reports  the  case. 
The  woman  was  23  years  of  age.  She  commenced 
to  menstruate  before  she  was  14  years  old,  and 
continued  to  do  so  regularly  for  six  years.  Dur- 
ing the  following  three  years  the  quantity  became 
ks>  and  less  and  the  periods  irregular,  until  Sept., 
1SS7,  when  the  flow  stopped  entirely.  Pain,  from 
the  ovaries,  extending  to  the  top  of  the  sacrum, 
ktpt  constantly  increasing;  lately  she  spat  up 
blood  every  day.  Both  ovaries  were  removed  on 
Jan.  29,  1889,  and  the  patient  made  a  good  re- 
covery. She  began  to  menstruate  the  following 
April,  and  continued  to  do  so  regularly  until 
October.  In  June  she  was  married,  and  was  de- 
livered nt  a  boy  August  13,  1890,  which  weighed 
about  to  pounds.  The  labor  was  protracted,  for- 
ceps were  used,  and  the  child  was  still-born. 

I  think  it  is  evident  that  a  portion  of  one  ovary 
must  have  been  left,  or  supplementary  ovarian 
tissue  existed;  and  the  fact  that  impregnation  re- 
sulted weakens  the  Tait  argument  that  menstrua- 
tion  is   independent   of  ovulation.      Dr.  R.  says: 

'Dr.  Storer's  paper  does  doI  appear  in  the  Society  rransac 
lions,    n  was  afterwards  published  iu  the  Edinburgh  Med.  Journal. 


i89i.] 


SOCIETY  PROCEEDINGS. 


68 1 


"I  was  not  aware  of  leaving  any  ovarian  tissue. 
Indeed,  my  aim  was  to  extirpate  the  ovaries 
thoroughly,  and  I  thought  I  had  done  so.  I  sus- 
pect, however,  that  a  small  portion  of  healthy 
ovarian  tissue  had  reached  up  to  or  beyond  the 
hilus  of  the  right  ovary,  and  that  this  may  have 
taken  on  regular  ovarian  functions.  This,  of 
course,  is  merely  conjecture." 

Dr.  L.  C.  Coe  has  an  excellent  paper  in  the 
Medical  Record  for  August  9,  1890,  on  "The 
Dangers  attendant  upon  Artificial  Prolapsus  Ute- 
ri." These  are  :  overstretching  of  the  ligaments; 
tearing  of  adhesions;  starting  inflammations;  and 
causing  an  abscess  to  burst  internally.  I  have 
no  doubt  that  the  rude  way  in  which  the  uterus 
is  often  brought  down  to  the  vulvar  orifice  occa- 
sionally causes  one  or  more  of  these  mishaps. 
We  are  too  much  disposed  to  copy  the  doings  of 
German  hospital  surgeons,  who  operate  on  a  class 
of  women  widely  different  in  constitution  from 
the  bulk  of  our  American  women.  And  while  I 
do  not  say  that  artificial  prolapsus  should  never 
be  produced,  I  think  that  the  seldomer  it  is  had 
recourse  to  the  better  it  will  be  for  our  patients. 

The  uterus  normally  is  the  most  movable  organ 
in  the  body.  Practitioners  sometimes  forget  this 
fact,  and  try  to  fix  an  organ  by  a  pessary  or  oth- 
erwise, which  nature  intended  should  be  allowed 
a  great  deal  of  freedom.  Aud  the  practice  of 
gynecology  seems  to  change  its  position  about  as 
freely  as  the  uterus  itself  does.  No  specialty  I 
am  acquainted  with  is  so  much  subject  to  fashion- 
able changes  as  ours  is,  keeping  pace  with  the 
multiform  revolutions  which  fashionable  clothing 
inaugurates.  But  I  need  not  waste  your  time  by 
proving  an  assertion  which  I  scarcely  expect  will 
be  disputed. 

Before  closing  allow  me  to  call  your  attention 
to  a  few  personal  items.  I  believe  that  a  greater 
inclination  to  look  after  constitutional  measures 
than  formerly  has  arisen  in  the  profession.  Dr. 
Field  and  the  late  Dr.  Warner  did  more  than  the 
rest  of  us  to  bring  about  this  result.  I  hope  to 
see  some  of  the  younger  members  follow  in  their 
footsteps ;  for  the  constitutional  field  is  not  yet 
thoroughly  gleaned. 

Some  progress  has  also  been  made  in  recording 
the  after  effects  of  surgical  operations.  Sir  Spen- 
cer Wells  inaugurated  this  reform,  and  has  spent 
more  time  in  perfecting  it  than  any  other  surgeon. 
One  of  the  most  recent  discoveries  in  this  field  is 
that  a  mild  melancholia,  generally  of  brief  dura- 
tion, is  apt  to  follow  surgical  operation  on  the 
genital  organs.  I  have  seen  one  case  recently, 
and  several  others  have  been  reported  to  me. 

So  far  as  I  am  aware  there  has  been  only  one 
death  of  an  active  member  during  the  past  year. 
Several  members  have  resigned,  but  at  least  an 
equal  number  have  joined  our  Society  in  1890. 
I  am  pleased  to  see  that  a  considerable  number 
of  the  new  members  are  young  men,  full  of  en- 


ergy, believers  in  the  virtue  of  cleanliness,  some 
of  whom  will  probably  leave  names  behind  them 
which  the  medical  world  will  "  not  willingly  let 
die." 

If  I  might  be  allowed  to  give  a  hint  to  men 
much  better  qualified  than  myself,  it  would  be 
this  :  Cultivate  an  esprit  du  corps.  We  are  mem- 
bers of  the  oldest  Gynecological  Society  in  the 
world — not  in  itself  a  slight  honor.  Let  us  make 
up  our  minds  to  stand  by  one  another,  to  take  an 
interest  in  one  another's  success  in  consultation 
and  otherwise  ;  subject,  of  course,  to  the  welfare 
of  the  patient,  which  is  the  first  dogma  in  every 
good  surgeon's  creed.  And  I  have  no  doubt, 
when  the  time  comes  for  each  of  us  to  render  an 
account  of  our  stewardship,  he  or  she  will  not  be 
embarrassed  by  the  reflection  that  "it  is  more 
blessed  to  give  than  to  receive." 


Tennessee  State  Medical  Society. 

Fifty-Eighth  Annual  Meeting  held  in  Nashville, 

April  /j,    /j,   and  16,   iSgr. 
(Concluded  from   page 
Second  Day — Afternoon  Session. 

Dr.  A.  J.  Swaney,  of  Gallatin,  contributed  a 
paper  on 

RETAINED      PLACENTA     IN      MISCARRIAGE;      HOW- 
SHALL    WE    TREAT    SICH    CASES? 

He  said  the  dangers  from  retained  placenta  in 
miscarriage  were  haemorrhage  and  septicaemia. 
When  the  delivery  of  the  placenta  is  prolonged 
ought  we  still  to  abstain;  ought  we  to  wait  or 
ought  we  to  interfere  actively  in  order  to  forestall 
these  dangers  which  almost  certainly  will  result 
and  further  interfere  at  a  time  when  it  is  far  eas- 
ier than  later  to  remove  the  placenta  ?  Those  who 
favor  active  interference  are  Tyler  Smith,  Murray, 
Simpson,  Leishman,  Munde,  Grandin,  and  mam- 
others.  The  reasons  given  for  active  interference 
are  the  frequency  of  these  dangers  in  prolonged 
delivery  of  the  placenta.  Simpson  directs  that  if 
the  cervix  is  dilated  or  patent  to  act  at  once;  if  it 
is  not  dilated  he  dilates  it  at  once.  The  woman 
is  then  anaesthetized,  the  uterus  depressed  as  much 
as  possible  by  the  external  hand  and  with  the  in- 
dex finger  of  the  other  hand  he  removes  the  pla- 
centa and  membrane.  If  he  cannot  sufficiently 
depress  the  uterus  with  the  baud  he  does  not  hes- 
itate to  forcibh-  drag  it  down  by  a  double  tenacu- 
lum fixed  in  the  cervix.  Munde  and  Grandin  go 
still  further  and  curette  the  cavity  of  the  uterus 
with  special  instruments  made  for  the  loosening 
of  adherent  placenta  and  its  removal  from  the 
uterus. 

The  authorities  who  counsel  waiting  for  seri- 
ous complications  before  interfering  are  just  as 
many.      We  mention  Ramsbotham,  Davis,  Burns, 


682 


SOCIETY  PROCEEDINGS. 


[May  9, 


Fleetwood  Churchill,  Graile}'  Hewitt,  and  many 
others.  Active  intervention  does  not  mean  un- 
necessary interference.  Nature  is  ever  to  be 
given  a  chance,  but  when  we  see  that  her  efforts 
are  futile  certainly  it  is  but  rational  to  assist  her, 
and  this  should  be  done  as  directed  by  Munde, 
by  placing  the  woman  in  the  left  lateral  position 
and  with  a  dull  wire  curette  remove  the  placenta 
or  any  part  of  the  secundines  that  may  remain 
through  a  Sims  speculum.  This  is  far  better  and 
easier  than  the  method  advised  by  Simpson,  of 
dragging  or  pressing  down  the  uterus  and  intro- 
ducing the  finger  into  the  uterine  cavity.  The 
uterine  cavity  should  then  be  washed  out  with 
hot  water,  slightly  carbolized,  through  a  Jame- 
son's uterine  douche,  and  this  should  be  repeated 
every  six  or  eight  hours  until  all  fetor  disappears 
from  the  lochial  discharge. 

Haemorrhage  after  miscarriage,  even  when  we 
believe  the  placenta  and  secundines  have  been  re- 
moved, invariably  means  retention  of  a  part  of 
the  placenta  or  secundines,  said  the  speaker. 
Profuse  haemorrhage  may  occur  for  weeks  from 
this  cause,  and  in  such  cases  we  should  boldly 
explore  the  uterine  cavity  and  remove  any  offend- 
ing matter  that  may  be  present.  In  the  first 
twelve  weeks  of  pregnancy  the  dangers  from 
haemorrhage  and  septicaemia  are  not  so  great  and 
the  expectant  plan  is  more  justifiable.  After  the 
third  month  it  is  criminal  negligence  to  wait  and 
subject  a  woman  to  the  dangers  arising  from  re- 
tained placenta  when  she  can  be  relieved  by  an 
operation,  which,  if  properly  done,  can  do  no 
harm,  and  spare  her  the  risk  of  haemorrhage  and 
septic  poisoning.  In  short,  the  author  believes 
the  early  removal  of  the  secundines  is  easy  and 
safe,  and  forthwith  guarantees  the  woman  against 
the  dangers  of  haemorrhage  and  sepsis. 

Dr.  J.  L.  Jones,  of  Bells,  read  a  paper  entitled 

INDIGO  AS  AN   EMMENAGOGUE, 

in  which  he  said  his  attention  was  first  directed 
to  this  drug  as  an  emmenagogue  in  July,  1887, 
from  an  essay  published  in  the  Medical  and  Sur- 
gical Reporter,  of  Philadelphia,  by  Dr.  S.  L. 
Gount,  of  Lafayette,  Ind.  Acting  on  the  sug- 
gestions offered  by  Dr.  Gount,  he  had  used  it  in 
many  and  various  cases. 

His  first  case  was  a  young  lady,  20  years  of 
age,  who  had  not  menstruated  in  five  months. 
He  had  been  treating  her  for  three  months  with 
the  usual  remedies  without  any  effect,  so  he  made 
up  his  mind  to  give  indigo  a  trial,  which  he  did. 
He  ordered  indigo  5ij,  subnitrate  of  bismuth  ,^ss, 
well  mixed.  Of  this  the  patient  took  one-half 
teaspoonful  in  one-third  of  a  glass  of  water,  three 
times  daily,  for  nearly  four  weeks,  when  one  day 
he  was  sent  for  in  great  haste.  On  his  arrival 
he  found  the  patient  in  bed,  and  comfortable. 
He  was  then  told  by  the  mother  that  her  daughter, 
while  walking  in  the  garden,   without  pain  or 


warning  of  any  kind,  began  to  flow.  The  gush 
was  followed  by  a  gentle  flow  which  lasted  only 
for  a  short  time.  In  five  days  she  was  well, 
and  has  not  suffered  from  amenorrhcea  since. 
Dr.  Jones  has  since  used  indigo  in  thirteen  cases 
with  but  one  failure,  and  this  case  proved  to  be 
pregnant. 

During  the  administration  of  the  drug  the  os 
uteri  becomes  soft  and  patulous,  admitting  the 
end  of  the  index  finger.  There  is  often  a  serous 
discharge  from  the  vagina.  The  urine  becomes 
brownish  green  in  color,  and  its  odor  is  offensive. 
The  stools  are  watery  and  offensive. 

Third  Day— Morning  Session. 

Dr.  J.  A.  Witherspoon,  of  Columbia,  read  a 
paper  on 

diabetes, 
in  which  he  confined  his  remarks  principally  to 
diabetes  mellitus.  He  said  the  term  diabetes 
mellitus  is  a  symptomatic  one,  being  a  deviation 
from  health  in  which  the  processes  of  nutrition 
are  seriously  deranged,  and  presenting  a  group 
of  complex  symptoms,  the  most  conspicuous  of 
which  are,  first,  frequent  micturition,  passing 
large  amounts  of  pale,  saccharine  urine.  Coin- 
cident with  this  is  an  insatiable  thirst  and  dry- 
ness of  the  mouth  and  fauces,  which  is  by  far 
the  most  annoying  symptom,  the  freest  draughts 
of  water  giving  but  little  or  no  satisfaction.  The 
skin  becomes  dry  and  harsh,  with  complete  ab- 
sence of  perspiration,  and  followed  by  a  general 
pruritus,  sometimes  impossible  to  relieve.  These 
were  some  of  the  many  symptoms  of  the  disease. 

The  etiology  of  the  disease  is  yet  an  unsolved 
problem.  It  is  an  affection  of  adult  life,  but  few 
cases  being  reported  in  children,  and  those  al- 
ways fatal.  The  only  recovery  reported,  so  far 
as  the  speaker  was  aware,  was  a  girl  12  years  of 
age. 

The  treatment  is  conveniently  divided  into 
dietetic,  medicinal,  and  the  hygienic.  The  die- 
tetic is  by  far  the  most  important.  We  must  ex- 
clude from  the  bill  of  fare  all  food  stuffs  contain- 
ing starch  or  sugar,  for  two  reasons:  1.  The 
normal  action  of  the  liver  in  its  glycogenic  func- 
tion is  seriously  deranged  and  incapable  of  oxi- 
dizing the  maltose  sent  to  it  by  the  digestion  of 
carbo-hj-drates,  and  they  are  therefore  useless  ali- 
ments. 2.  They  seem  to  aggravate  and  increase 
the  glycosuria.  A  strict  meat  and  green  vegeta- 
ble diet  agrees  better  than  any  other.  Some  give 
milk,  others  forbid  it  entirely.  He  had  found  in 
the  few  cases  he  had  treated  that  it  was  impossi- 
ble to  continue  for  long  periods  any  one  diet. 
The  pure  skim-milk  diet  is  meeting  with  much 
favor.  Alcohol,  and  all  spirits,  except  small 
quantities  of  light  wine  or  beer,  must  be  forbid- 
aen.  This  regimen  alone  will  lessen  the  quantity 
of  sugar  eliminated,  but  it  is  necessary  to  use  in 
connection  certain  medical  treatment.    The  drugs 


i89i.] 


DOMESTIC  CORRESPONDENCE. 


683 


giving  the  best  satisfaction  are  opium,  or  its  al- 
kaloids, morphia  or  codeia  ;  ergot,  arsenic,  and 
many  others.  Of  all  the  drugs  mentioned,  codeia 
has  been  by  far  the  most  satisfactory  in  Dr.  With- 
erspoon's  hands.  It  was  first  suggested  by  Dr. 
Pavy,  of  London,  and  has  the  great  advantage 
over  its  sister  alkaloid,  morphia,  in  not  producing 
sleep.  It  is  more  efficient,  less  dangerous,  and 
does  not  produce  the  troublesome  constipation 
caused  by  morphia  or  opium.  Next  to  it.  the 
speaker  would  place  ergot,  for  its  physiological 
effect  upon  the  blood-vessel  walls.  Recently  sul- 
phonal  and  antipyrin  have  been  used  with  re- 
ported good  results.  He  had  never  used  antipy- 
rin in  this  disease,  for  the  reason  that  it  is  recom- 
mended in  from  30  to  60  grain  doses.  He  did 
try  sulphonal  in  10-grain  doses,  three  times  a 
day,  and  in  two  days  it  produced  so  much  giddi- 
ness and  sleepiness  that  he  quit  giving  it.  He 
had  only  used  arsenic  as  an  alterative  tonic  after 
the  sugar  had  disappeared  from  the  urine.  With 
this  treatment  the  patient  should  be  advised  to 
take  light  exercise,  always  short  of  fatigue,  and 
their  surroundings  should  be  good  and  well  ven- 
tilated. Alkaline  carbonated  waters  are  often 
of  great  utility. 


TREATMENT  OF  STRICTURES  OF  THE  MALE 
URETHRA. 

This  was  the  title  of  a  paper  read  by  Dr.  J.  W. 
Handlv,  of  Nashville. 

He  said  strictures  of  large  calibre,  if  they  be 
recent,  but  poorly  organized  and  of  the  linear 
variety,  may  be  treated  by  dilatation,  which  must 
be  continued  for  months.  But  should  the  stric- 
ture be  densely  fibrous,  and  not  easily  dilatable, 
the  cutting  operation  becomes  necessary,  for 
which  purpose  he  prefers  the  Otis  improved  dilat- 
ing urethratome  with  which  the  surgeon  can  ac- 
curately divide  any  stricture  to  any  size  desired. 

Strictures  of  small  calibre,  situated  in  advance 
of  the  bulbo-membranous  junction,  unless  seen 
very  early  and  found  to  be  unusually  soft  and 
dilatable,  furnish  a  typical  condition  for  internal 
urethrotomy,  that  in  which  it  is  attended  with 
the  least  possible  danger  and  greatest  prospect 
for  a  permanent  cure.  Should  the  contractions 
be  so  great  that  the  Otis  urethratome  cannot  be 
used,  he  had  found  Bank's  whalebone  dilators, 
which  are  made  in  four  sizes,  of  great  advantage 
in  opening  the  canal  so  as  to  admit  of  the  ure- 
thratome, and  considered  them  very  useful. 

Strictures  of  small  calibre  posterior  to  the 
bulbo-membranous  junction  require  a  very  differ- 
ent course  of  treatment,  since  internal  urethrotomv 
at  this  point  is  often  attended  with  profuse  haem- 
orrhages, fever,  rigors,  or  other  disturbances 
equally  as  disagreeable.  Strictures  of  this  va- 
riety permeable  only  to  filiform  bougies,  may  be 
treated  in  one  of  the  four  following  ways  : 

1.    After  the  filiform  has  been  introduced   it 


may  be  allowed  to  remain  in  silii  for  two  or  three 
days  and  another  passed  alongside  of  it  to  serve 
as  a  guide  for  the  introduction  of  a  tunnelled 
sound,  later  to  be  followed  by  the  ordinary  soft 
or  steel  bougies.  This  is  good  and  safe  surgery 
in  the  absence  of  retention. 

2  The  surgeon  may  attempt  to  conduct  a 
tunnelled  sound  over  it  at  once,  to  be  followed  by 
gradual  dilatation. 

3.  He  may  conduct  over  it  a  grooved  staff  and 
then  proceed  to  the  performance  of  external 
urethrotomy,  or, 

4.  He  may   use   the  staff  as  a  guide   for  the 

ineuve  urethratome  and  may  immediately 
perform  internal  urethrotomy. 

OFFICERS    FOR    l802. 

The  following  officers  were  elected  for  the  en- 
suing year  : 

lent — Dr.  J.  \V.  Perm.  Humboldt. 

Vice-President  for  Middle  Tennessee — Dr.  J.  A. 
Witherspoon,  Columbia. 

/  'ice-President  for  East  Tennessee — Dr.  C.  E. 
Ristine,  Knoxville. 

Vice-President  for  West  Tennessee — Dr.  C.  H. 
Lovelace,  Dukedom. 

Secretary — Dr.  D.  E.  Nelson,  Chattanooga. 

Treasure) — Dr.  J.  P.  C.  Walker,    Dyersburgh. 

Next  place  of  meeting,  Knoxville,  second 
Tuesday  in  April.  1892. 


DOMESTIC  CORRESPONDENCE. 


Forced   Respiration. 

To  the  Editor : — In  a  recent  number  of  The 
Journal  I  find  an  address  by  Dr.  G.  E.  Fell,  on 
"  Forced  Respiration."  Allow  me  to  draw  your 
attention  to  an  article  which  appeared  in  the  year 
1822,  and  wThich  may  possibly  be  of  interest  to 
the  medical  fraternity. 

I  am  in  possession  of  the  London  fournal  of 
Arts  and  Sciences,  Vol.  3,  London,  1822,  page  93  : 
"Account  of  an  apparatus  for  restoring  the  lost 
action  of  the  lungs,  in  consequence  of  suspended 
animation  from  drowning,  etc.;  invented  and 
communicated  by  John  Murray,  Esq." 

There  is,  perhaps,  no  subject  which  ought  to  excite  a 
deeper  interest,  than  that  of  suspended  animation.  The 
number  of  human  beings  who  are  hurried  suddenly  out 
of  existence,  by  being  deprived  of  that  necessary  pabu- 
lum, atmospheric  air.  form  annually  a  lamentable  cata- 
logue ;  and,  although  a  Goodwill,  a  Hawes,  a  Cogau,  and 
many  others  of  the  benevolent  of  our  species,  have  done 
much  in  exciting  attention  to  this  interesting  subject, 
yet  it  is  to  be  lamented,  that  the  scientific  world  has  not 
paid  so  much  attention  to  it.  as  its  importance  most  un- 
questionably and  imperiously  demands. 

FORSAN    SCINTILLA    I.ATEAT. 

Plate  4,  figs.  5.  4.  ami  5,  exhibits  drawings  of  an  ap- 
paratus, which  I  have  invented  for  restoring  the  lost  ac- 
tion of  the  lungs.  It  consists  of  two  cylinders  con- 
centric with  each  other  ;  the  inner  one  is  three  inches  in 


684 


MISCELLANY. 


[May  9,  1891. 


diameter,  the  exterior  one  four  inches,  forming  a  space 
of  half  an  inch  round  the  cylinder,  which  is  to  be  occu- 
pied with  water,  heated  to  9S  degrees,  the  animal 
temperature  to  elevate  the  air  contained  in  the  interior 
cylinder  to  that  degree. 

The  piston  is  solid,  and  moves  horizontally  ;  the  piston 
rod  is  perforated,  to  receive  a  metallic  pin,  which,  being 
introduced,  shortens  the  stroke,  checked,  by  the  plate 
covering  the  end  of  the  cylinder,  and  gives  the  means  of 
apportioning  the  volume  of  air  to  the  capacity  of  the 
lungs,  which  is  to  be  determined  by  the  -victim  of  experi- 
ment being  of  tender  age,  or  adult.  This  will  obviate 
the  danger  of  rupturing  the  lungs.     To  the  pipe  pro- 


flexible  tube  should  be  formed  of  caoutchouc,  and  be  per- 
fectly elastic  and  pliant  like  the  bougies. 

In  this  improved  apparatus,  the  heated  water — which 
will  be  better  at  some  degrees  above  98  to  compensate 
for  the  loss  of  temperature  sustained  by  the  conducting 
of  the  metal  and  the  transit  of  the  air  through  the 
pipe  into  the  receptacles  of  the  lungs — is  supplied  ex- 
terior to  the  cylinders  and  above  ;  thus  affording  every 
facility  of  ascertaining  the  temperature  by  a  ther- 
mometer. There  is  also  an  exit  pipe,  with  a  stopcock  to 
permit  the  water  when  cooled,  to  flow,  so  that  without 
altering  the  position  of  the  apparatus  in  the  least,  it  may 
be  supplied  with  heated  water  anew.     The  valve  which 


ceeding  from  this  cylinder,   is  affixed   a  cell  and  cock,    communicates  with  the  lungs,  is  Mr.  Trevithick's  conical 


with  an  elastic  tube  terminating  in  a  mouth-piece  and 
plate  of  leather. 

The  stopcock  is  so  constructed,  that,  when  the  handle 
is  parallel  with  the  pipe,  as  in  the  figure,  there  is  a  free 
communication  established  between  the  lungs  and  the 
cylinder,  to  the  exclusion  of  external  air.  When  on  the 
other  hand  the  cock  is  turned  the  quadrant  of  a  circle, 
the  communication  with  the  lungs  is  cut  off,  and  there  is 
a  free  channel  opened  between  the  cylinder  and  the  ex- 
ternal atmospheric  air. 

The  lateral  cell,  appended  to  the  cock,  will  be  found 
of  varied  use  and  importance.  Should  the  subject  of  ex- 
periment have  been  the  victim  of  carbonic  acid  gas  (choak 
damp),  a  drop  or  two  of  ammonia  may  be  mingled  with 
the  air  in  the  cylinder,  and  when  thrown  into  the  lungs 
will  condense  the  mephitic  gas.  If  a  septic  poison — as 
sulphuretted  or  arsenicated  hydrogen — have  occasioned 
the  asphyxia,  a  few  drops  of  solution  of  chlorine  or  nitro- 
muriatic  acid  will  destroy  the  septic  virus.  Should  the 
atmosphere  be  too  dry,  a  small  portion  of  water  put  into 
the  cell,  will  mix  with  the  air,  and  impart  additional 
elasticity ;  and  if  we  desire  an  additional  stimulus,  a 
drop  or  two  of  ether  posited  here,  will  expand  in  the  air 
of  the  cylinder,  aud  this  mixed  atmosphere  will  act  with 
all  the  consequence  of  nitrous  oxide.  These  provisions 
for  various  reasons,  are  valuable  auxiliaries  in  returning 
respiration. 

When  the  machine  is  to  be  used,  the  victim  of  sus- 
pended animation  is  to  be  raised  in  a  gently  inclined  pos- 
ition opposite  to  the  operator;  the  nostrils  are  to  be 
plugged  up,  and  the  plate  of  leather  fixed  on  the  mouth, 
as  nearly  air-tight,  by  means  of  white  of  egg,  etc.,  as 
possible;  this  must  be  kept  in  its  position  by  means  of  a 
ribbon  tied  round  the  head.  The  operator'over  against 
the  victim,  manages  uniformly  and  equally  the  piston. 
The  apparatus  being  adjusted  in  the  manner  described, 
the  air  is  first  withdrawn  from  the  lungs,  and  then  ejected 
laterally;  and  the  piston  rod  being  drawn  to  the  ex- 
tremity of  the  cylinder — if  an  adult — the  pure  atmos- 
pheric air  fills  the  instrument;  the  communication  with 
the  lungs  being  restored  by  turning  the  stopcock  parallel 
with  the  pipe,  the  operator  begins.  About  twenty 
plunges  of  the  piston  a  minute  may  be  the  proper  num- 
ber. It  will  not  be  necessary  to  change  the  included  air 
until  natural  respiration  is  restored;  because,  until  this 
does  take  place,  the  blood  cannot  eject  its  excess  of 
carbon,  the  consequence  of  the  circulation  of  that  fluid; 
but  when  this  is  required,  it  is  instantly  accomplished  in 
the  manner  already  described. 

This  invention  has  met  with  the  most  unequivocal  tes- 
timony of  approbation  from  several  eminent  physicians 
and  surgeons,  and  gentlemen  of  distinguished  mechani- 
cal genius. 

The  apparatus,  with  my  latest  improvements  on  it,  .if 
which  a  drawing  accompanies  this  paper,  is  formed  of 
Britannia  metal,  and  has  been  presented  by  me  to  the 
Royal  Humane  Society.  It  is  made  to  rest  in  a  groove, 
which  may  lie  easily  fixed  to  a  table  by  means  of  a  clamp. 
It  possesses  an  attached  pin,  which  being  fixed  int..  tin 
perforated  piston  rod,  readily  apportions  the  injected  air 
tn  tin-  capacity  of  the  lungs,  whether  of  an  adult  or  child. 
Hence  there  can  be  no  danger  of  injuring  the  lungs.  The 


one,  used  in  the  steam  engine.  The  internal  cylinder, 
being  one  foot  long  and  three  inches  in  diameter,  will 
contain  S.4S2  cubic  inches  of  air ;  about  half  this  extent 
will  be  sufficient  for  an  ordinary  inspiration. 

A.  W.  Herzog,  M.D. 
Hoboken,  N.  J. 


MISCELLANY. 


LETTERS  RECEIVED. 

Aberdeen,  S.  Dak.,  Aberdeen  Daily  Ne 
Albuquerque,  N.  M.,  Dr.  J.  P.  Raster. 


iCo. 


Bellefontaine,  O.,  Dr.  W.'W. 

Boston,  E.  L.  Damrell. 

Brooklyn.  N.  Y.,  Dr.  R.  M.  W'vckoff,  Dr.  Albert  Gihon,  Dr.  L. 
Q.  Mason,  Dr.  F.  C.  Raynor. 

Chambersburg,  Pa.,  Dr.  R.  W.  Ramsey. 

Chicago,  Dr.  L.  L.  McArthur,  Dr.  L.  H.  Mettler. 

Chilhowee,  Mo.,  Dr.  C.  T.  Sweeney. 

Cincinnati,  O.,  J.  Taft. 

Coquille  City,  Ore.,  Dr.  W.  C.  Owen. 

Corinna,  Me.,  Dr.  O.  H.  Merrill. 

Dallas,  Tex.,  Dr.  D.  Green. 

Denver,  Col.,  Dr.  C.  R.  Crandall. 

Detroit,  Mich.,  Citizens'  Savings  Bank,  Dr.  E.  L.  Shurly. 

Eagle  Grove,  la.,  Dr.  C.  H.  Morse. 

Klmore,  Wis.,  Dr.  William  Hausmann. 

Florence,  Ala.,  Dr.  E.  L.  Jones. 

Galveston,  Tex.,  Dr.  Geo.  Dock. 

Indianapolis,  Ind.,  Dr.  E.  S.  Elder. 

Jersey  City,  N.  J.,  Dr.  E.  Vockvoth. 

Leigh,  Neb.,  Dr.  j.  C.  McKinley. 

Lincoln,  Neb.,  Dr.  F.  S.  Billings. 

Livingston,  Mont.,  Dr.  W.  H.  Campbell. 

Lodi,  Cal.,  Mrs.  J.  L.  Sargent. 

London,  Eng.,  Kegan  Paul,  Trench,  Triibner  &  Co. 

Montgomery,  Vt„  Dr.  B.  W.  Davis. 

Nashua,  N.  H.,  Londonderry  Lithia  Spring  Water  Co. 

New  York  Citv,  Reed  &  Carhrick,  A.  L.  Chatterton  &  Co.,  Chas. 
H.  Phillips  Chemical  Co.,  The  Drevet  Mfg.  Co.,  J.  Walter  Thomp- 
son, J.  H.  Bates,  Dr.  Jas.  Moran,  W.  P.  Cleary,  Geo.  P.  Rowell  & 
Co.,  P.  H.  Drake  &  Co. 

Panora,  111.,  Dr.  C.  O.  Sones. 

Paris,  Tex.,  Dr.  Wm.-M.  Moore. 

Philadelphia,  Dr.  R.  J.  Dunglison,  Dr.  J.  H.  C.  Simes,  Dr.  A  L. 
Hummel,  N.  W.  Aver  &  Son. 

Robertsdale,  Pa.,  Dr.  W.  H,  Johnson. 


2nd  Duties  of  Officers  Serving 
Army,  from  April  23,  iSyl,  to 


Official  List  of  Changes  in  the  S 
in  the  Medical  Department, 
Ma  1'  /,  1891. 

Capt.  George  E.  Bushnell,  Asst.  Surgeon  U.  S.  A.  (Camp  Pilot  Butte, 
Wvo.),  is  granted  leave  of  absence  for  twenty-one  davs,  to  take 
effect  on  or  about  May  1  next.  Par.  9,  S.  O.  49,  Dept.  Platte,  Oma- 
ha, Neb.,  April  20.  1S91, 

Lieut. -Col.  James  C.  McKee,  Surgeon,  having  been  found  incapaci- 
tated for  active  service  by  an  Army  Retiring  Board,  is  relieved 
from  further  duty  as  attending  surgeon  and  examiner  of  recruits 
.it  Philadelphia.  Pa.,  and  will  proceed  to  his  home  and  report  by 
letter  to  the  Adjutant  General  of  the  Armv.  Bv  direction  of  the 
Secretary  of  War.  Par.  3,  S.  O.  96,  A.  G.  O.,  Washington,  April 
2S,  1891. 

'  of  Changes  in  the  Medical  Corps  of  the  U.  S.  Navy,  fur 
tin-  Week  Ending  May  2,  i8qs. 
Asst.  Surgeon  George  A.   Long,  granted  two  months'  leave  of  ab- 

Medical  Inspector  A.  A.  Hoehling,  detached  from  Navy  Yard, 
League  Island,  and  waiting  orders. 

W   11   Jones,  ordered  to  Navy  Yard,  League  Island. 
P.  A.  Surgeon  0.  1>    Norton,  detached  from  Naval  Hospital,  Chel- 

11    Mass,  and  waiting  orders. 
P.  A.  Surgeon  f    I    B  Cordelro,  ordered  to  Naval  Hospital,  Chelsea, 

M:tSS 


the 


Journal  of  the  American  Medical  Association. 

EDITED  UNDER  THE  DIRECTION  OF  THE  BOARD  OF  TRUSTEES. 
PUBLISHED    WEEKLY. 


Vol.  XVI. 


CHICAGO,  MAY  16,   1891. 


No.  20. 


ADDRESSES. 

UPON  THE  USE   OF  THE   ELASTIC  LIG- 
ATURE IX  THE  SURGERY  OF  THE 
IXTESTIXES. 

The  Chairman's  Address,  delivered  before  the  Section  of  Surgery  and 

A  natomy  at  the  Forty-second  A  nnual  Meeting  of  the  American 

Medical  Association,  held  at  Washington,  D.  C,  A£ayt  iSqi. 

BY  THEO.  A.  McGRAW,  M.D.. 

OF    DETROIT. 

Gentlemen: — Under  the  regulations  now  in  force 
in  the  American  Medical  Association,  provision 
is  made  for  two  addresses  on  Surgery,  one  by  a 
gentleman  appointed  for  the  purpose,  before  the 
general  body  of  the  Association,  and  the  other 
for  delivery  before  the  Surgical  Section  by  its 
chairman. 

It  was  evidently  the  design  of  the  Association 
in  adopting  this  order  of  exercises,  to  have  the 
morning  address  devoted  to  the  general  subject  of 
Surgery — its  history,  its  progress,  its  present  con- 
dition and  its  relations  to  general  medicine.  The 
reason  of  the  second  address  is  not  so  obvious, 
but  it  is  natural  to  suppose  that,  as  provision  has 
been  made  for  a  general  address  before  the  entire 
Association,  it  was  meant  that  the  one  held  before 
the  Surgical  Section  should  be  more  special  and 
technical  in  character.  Indeed,  it  would  hardly 
seem  proper  or  advisable  to  consume  the  time  of 
this  body  of  experienced  and  learned  surgeons,  in 
rehearsing  what  every  one  is  familiar  with,  the 
changes  which  have  taken  place  in  our  art  during 
the  past  year,  nor  in  discussing  themes  of  general 
interest  which  have  been  worn  threadbare  in  the 
countless  meetings  of  this  and  other  societies. 
For  these  reasons,  I  have  on  this  occasion  chosen, 
for  the  topic  of  my  address,  a  subject  that  is  lim- 
ited in  scope,  technical  in  cbaracter,  and  of  par- 
ticular interest  only  to  operating  surgeons. 

In  common  with  many  American  surgeons,  I 
have  been  intensely  interested  in  the  surgery  of  the 
intestines.  It  is  well  known  to  you  all  that  the  im- 
pulse which  turned  the  attention  of  the  profession 
in  the  United  States  in  this  direction  was  given  by 
the  now  famous  labors  of  Dr.  Senn,  the  impor- 
tance of  which  is  to  be  measured,  not  alone  by 
the  value  of  the  operative  measures  which  he  in- 


troduced, but  also  and  even  more  b}-  their  influ- 
ence on  the  professional  mind,  not  only  in  Amer- 
ica, but  all  over  the  world.  For  his  experiments 
in  a  field  at  that  time  very  little  cultivated,  served 
to  place  procedures,  which  had  previously  been 
regarded  as  odd  and  experimental,  on  a  sound 
pathological  basis,  and  we  began  to  perceive  a 
real  therapeutical  value  in  operations  which  most 
surgeons  had  regarded  as  of  doubtful  propriety. 
The  operation  for  intestinal  anastomosis  intro- 
duced by  Wolfler  and  practiced  to  a  limited  extent 
by  German  surgeons,  had  not,  in  this  country  and 
England  at  least,  become  recognized  by  the  pro- 
fession, until  Senn  had  simplified  its  methods  and 
demonstrated  its  usefulness.  Since  the  publica- 
tion of  his  papers  on  that  subject,  great  activity  has 
been  manifested  by  American  surgeons  both  in 
operating  and  in  improving  the  technique  of  the 
operation.  In  fact,  I  fear  that  some  in  the  pro- 
fession have  become  a  little  weary  of  the  constant 
recurrence  in  our  periodical  literature  of  papers 
on  modifications  of  Senn's  operation  for  intestinal 
anastomosis.  I  shall  nevertheless,  at  the  risk  of  ad- 
ding to  this  weariness,  ask  your  attention  to-day  to 
a  new  operation,  which  I  have  devised  for  this  pur- 
pose, and  which  I  believe  will  prove  of  superlative 
value,  in  a  limited  class  of  cases.  The  reasons  for 
endeavoring  to  modify  the  established  operations 
will  be  apparent  to  even*  surgeon  experienced  in 
this  kind  of  work.  The  operation  for  intestinal 
anastomosis  is  indicated  :  1.  Wherever  there  is  a 
chronic  stenosis  of  the  gut,  such  as  we  find  in 
cancer  of  the  pylorus,  or  small  or  large  intestine, 
or  in  cicatricial  contraction  from  injury  or  ulcer- 
ation, which  cannot  be  otherwise  radically  cured. 
2.  Whenever  there  is  acute  obstruction  that  can- 
not be  relieved  by  any  other  procedure,  such  as 
sometimes  occurs  in  volvulus  or  in  entanglement 
of  the  gut  with  Meckel's  diverticulum,  or  in  that 
kind  of  obstruction  recently  described  by  Prof. 
Kundrat,1  of  Vienna,  in  which  the  duodenum  is 
compressed  by  the  mesentery  of  the  small  intes- 
tines: and  3.  In  some  cases  of  gangrenous  hernia, 
false  anus  and  intestinal  fistula. 

In  the  vast  majority  of  all  these  cases,  the  pa- 
tient comes  to  the  operation  already  exhausted, 
with  a  vitality  so  low  that  even  a  long  continu- 
ance of  the  anaesthesia  becomes  a  source  of  dan- 

1  Wiener  Med.  Wochenschrift.  Xo.  S,  1S91. 


686 


ON  THE  USE  OF  THE  ELASTIC  LIGATURE. 


[May  i  6, 


ger.  For  that  reason  the  operation  for  intestinal ;  if  some  method  could  be  invented  by  which  the 
anastomosis  is  one  that  demands  all  possible  junction  of  the  intestines  could  be  effected  before 
speed.  It  may  be  truly  said  that  its  danger  is  in  the  formation  of  the  opening  of  communication 
direct  proportion  to  the  time  occupied  in  its  per-   between  the  two  coils,  two  of  the  especial  dan- 


formance.  The  longer  the  patient  is  under  the 
anaesthetic  the  greater  the  danger  from  vomiting 
and  exhaustion.     The  longer  the  intestines  are 


gers,  viz.:  that  of  haemorrhage  and  that  of  faecal 
extravasation,  might  be  altogether  eliminated, 
and  that  possibly  the  duration  of  the  operation 


exposed  to  the  air  the  greater  the  danger  from  ,  might  also  be  much  lessened.  My  first  thought 
shock  and  the  greater  the  liability  to  bacterial  in- 1  was  of  a  metal  clamp  with  two  thin  arms  con- 
fection. It  becomes  important,  then,  to  devise  !  nected  with  a  hinge  and  furnished  with  a  strong 
plans  of  operation  which  will  occupy  the  very  least  I  spring.  The  two  arms  were  to  be  thrust  through 
possible  time.  Whatever  plan  may  be  adopted  the  opposing  intestines  and  then  brought  sharply 
the  rapidity  of  its  execution  will  depend,  of !  together  with  the  spring.  In  this  way  I  thought 
course,  largely  upon  the  personal  equation  of  the  !  a  force  could  be  brought  to  bear  upon  the  intes- 
operator.  I  have  experimented  with  various  i  tinal  wall  which  would  gradually  cut  its  way 
methods,  and  find  that  the  time  occupied  in  mak-  J  through,  while  adhesive  inflammation  was  bind- 
ing an  anastomosis  after  the  intestines  have  been  ing  the  outer  surfaces  together.  I  believe,  still, 
exposed  and  brought  out  on  to  the  abdomen,  by  that  this  could  be  done  to  advantage,  but  some 
the  old  method  of  incising  the  intestines  and  practical  difficulties  in  procuring  the  desired  in- 
uniting  their  cut  edges  by  a  double  row  of  su-  strument,  led  me  to  abandon  it  temporarily  for 
tures,  is  from  twenty-five  to  thirty  minutes,  and  ,  another  and  more  simple  contrivance,  which  thus 
by  Senn's  method  from  fifteen  to  twenty-five  min-  far  has  acted  admirably  in  my  hands,  and  that  is 
utes,  according  to  the  good  fortune  of  the  oper-  the  elastic  ligature— and  this  is  the  theme  of  my 
ator  in  keeping  the  many  needles  and  threads  !  paper  to-day,  "  The  use  of  the  elastic  ligature  in 
from  becoming  entangled.  I  believe  that  these  ,  the  surgery  of  the  intestines."  The  value  of  the 
figures  will  represent  pretty  accurately  the  time  ]  elastic  ligature  in  cutting  through  inclosed  tissues 
consumed  in  the  process  by  the  average  operator,  [  has  long  been  known  to  the  profession  in  connec- 
if  he  have  any  experience  whatever  in  this  par-  j  tion  with  the  treatment  of  fistula  in  ano,  of  piles, 
ticular  kind  of  work.  Operators  of  exceptional  I  and  small  polypoid  tumors  of  the  rectum  and  skin, 
skill  might  accomplish  it  in  muchless  time,  while  In  18S4  Dr.  J.  McF.  Gaston,  of  Atlanta,  Ga,,  used 
those  who  had  not  previously  qualified  them- :  it  and  other  forms  of  ligatures  in  experiments  on 
selves  by  practicing  on  the  lower  animals  would  |  dogs  which  had  for  their  purpose  the  establish- 
require  a  much  more  generous  allowance  of  time.  '  ment  of  a  fistulous  opening  between  the  gall  blad- 
There  can  be  no  doubt  that  the  reduction  of  this  '  der  and  duodenum.  Later  still  Liicke  had  used 
time  by  ten  or  fifteen  minutes  would  in  many  |  it  successfully  for  the  removal  of  a  pedunculated 
cases   make   all  the  difference  between  life  and  j  cancer  of  the  liver. 

death — success  and  failure.  I    learned   very    recently    from    Professor   Dr. 

Besides  the  dangers  which  result  from  the  time  '  Helfenrich,  of  Greifswald,  that  some  experiments 

consumed  in  the  operation,  there  are  others  which    had  been    made   by  Dr.  Franz   Bardenheuer,   at 

are  caused  by  the  operation  itself.     One  of  these  [  present  an  assistant  in  Professor  von  Bergmann's 


is  the  escape  of  the  contents  of  the  intestine  into 
the  abdominal  cavity,  either  at  the  time  of  oper- 
ation or  afterwards  from  defects  in  healing;.    How 


clinic  in  Berlin,  which  had  for  their  object  the 
production  of  intestinal  anastomosis  by  the  use 
of  an  elastic  ligature,  and  through  his  great  kind- 


serious  this  danger  is  the  history  of  operations  on  1  ness  have  been  enabled  to  secure  a  copy  of  Dr. 
the  intestines  will  show.  This  source  of  danger  |  Bardenheuer's  paper  from  the  author  himself, 
is  common  to  all  those  methods  of  operating  in  '  The  paper  is  entitled  "  Experimentelle  Beitriige 
which  the  junction  of  the  intestines  is  preceded  fur  Abdominal  Chirurgie,"  J.  Dietz  and  Baum- 
by  incision  into  their  cavities.  Still  another  sche  Druckerei,  18S8,  and  states  the  results  of 
danger  is  that  of  haemorrhage  from  the  cut  walls  ,  many  experiments  similar  to  my  own.  His  meth- 
of  tiie  gut.  While  this  danger  is  not  great  if  the  od,  however,  was  materially  different  from  mine, 
operator  cut  in  the  middle  line  of  the  convex  bor- '  and  consisted  in  connecting  the  intestines  together 
der  of  the  intestines,  as  far  away  as  possible  from  i  by  three  or  four  rubber  ligatures,  which  were 
the  mesentery,  yet  there  are  cases  of  unusual  vas-  joined  together  in  loops  like  a  chain,  each  loop 
cularity  in  which  the  bleeding  may  be  serious,  not  containing  about  i1.-  centimetre  of  tissue.  He, 
so  much  from  the  difficulty  of  its  control  as  from  .also,  evidently  ignorant  of  Dr.  Gaston's  previous 
the  expenditure  of  time  required  in  accomplish-  experiments,  operated  once  successfully  on  a  dog 
ing  it.  To  perfect  this  operation,  then,  we  must  by  the  same  method,  for  the  production  of  an 
devise  some  means  by  which  the  difficulties  and  anastomosis  between  the  gall  bladder  and  duode- 
dangers  of  our  present  methods  may  be  lessened  I  num.  These  experiments  of  Dr.  Bardenheuer  do 
or  avoided.  not  seem,  thus  far,  to  have  borne  any  practical 

On  considering  the  matter  it  seemed  to  me  that  I  fruit.      Without   knowing  of  any  previous  ex- 


i89i.] 


ON  THE  USE  OF  THE  ELASTIC  LIGATURE. 


687 


periments  with  the  elastic  ligature,  I  began 
myself  to  experiment  with  it  (.luring  the  early 
part  of  the  summer  of  1890,  hoping  in  this 
way  to  find  a  means  of  accomplishing  the  de 
sired  end  of  producing  an  anastomosis  with 
previous  adhesion  of  the  intestinal  surfaces. 
In  my  experiments,  I  tried  three  kinds  of  liga- 
tures. One,  a  large,  round  rubber  cord  4  milli 
metres  in  diameter,  was  speedily  discarded.  It 
was  too  large,  was  clumsy  to  tie  ;  when  tied  it 
took  up  too  much  room  and  tore  too  big  a  hole 
through  the  intestinal  wall.  A  second  consisted 
of  a  flat  rubber  band  3  millimetres  in  width.  This 
proved  to  be  serviceable  and  can  be  advanta- 
geously used  if  the  third  variety  cannot  be  ob- 
tained. The  third  kind,  a  rubber  cord  2  millime- 
tres in  diameter,  is  that  ordinarily  used  for  the 
ligature  of  piles.  It  could  not,  for  some  reason,  be 
obtained  for  my  first  experiments,  but  is  to  be  pre 
ferred  to  all  others  on  account  of  its  smoothness, 
elasticity  and  great  tenacity.  By  shaving  the  end 
of  the  rubber  thin  it  may  be  drawn  through  the 
eye  of  a  so-called  worsted  needle  (a  needle  with 
a  long  eye)  smaller  than  itself.  This  is  a  decided 
advantage  for  the  reason  that  it  is  important  to 
make  as  small  a  hole  as  possible  through  the  in- 
testinal wall,  and  also  to  have  the  ligature  not 
only  completely  fill,  but  r>ven  to  distend  the  hole 
so  as  to  prevent  any  extravasation  of  faeculent 
fluid.  Now,  by  stretching  the  rubber  during  its 
passage  and  rendering  it  thin  and  small,  it  may 
easily  be  drawn  after  the  needle,  and  its  subse- 
quent contraction  will  then  largely  increase  its 
size  and  cause  it  to  more  than  fill  the  orifice.  The 
ligature  in  the  most  cases  was  passed  through  the 
gut  in  the  direction  of  its  long  axis  and  at  points 
most  distant  from  the  mesenteric  attachment. 
Before  passing  it  the  bowels  were  stitched  to- 
gether by  from  three  to  six  Lembert  stitches,  and 
afterwards  similar  stitches  above  the  ligature 
served  not  only  to  give  additional  protection  but 
also  to  bury  the  rubber  in  the  intestinal  folds. 
Usually  an  inch  or  more  in  length  was  included 
in  the  ligature.  After  the  cord  had  been  drawn 
through  both  coils  of  intestine  it  was  tied  as 
tightly  as  possible  in  a  square  knot.  Although 
this  knot  will  ordinarily  hold  without  further 
fastening,  yet  as  I  wished  to  cut  the  ends  very 
short  in  order  to  cause  as  little  peritoneal  irrita- 
tion as  possible,  I  always  secured  the  ends  so  as 
to  make  slipping  impossible.  At  first  I  ^id  this 
by  runniug  a  fine  needle  threaded  with  silk 
through  the  ends  and  thus  tying  them  together. 
but  as  this  procedure  was  awkward  and  consumed 
much  time,  I  later  on  adopted  a  suggestion  of  my 
student,  Mr.  Hickey,  and  secured  the  knot  by  ty- 
ing a  silk  thread,  which  wTas  laid  under  it,  first 
over  the  first  turn  of  the  knot  and  afterwards  over 
the  completed  knot.  This  consumed  almost  no 
time  and  fastened  the  rubber  securely  against  the 
possibility  of  accident.     In  making  the  knot,  the 


ture  should  be  drawn    as  tightly  as  possible 
without  breaking. 

The  first  effect  of  the  ligation  was  to  draw  the 
intestines  together  into  folds,  and  I  was  not  a  lit- 
tle apprehensive  at  first,  lest  these  folds,  aggluti- 
nated together,  might  be  fixed  in  a  permanent 
corrugation.  In  this  I  was  agreeably  disappoint- 
ed. Examination  of  the  intestines,  even  after  so 
short  a  time  as  twenty-four  hours,  and  before  the 
ligature  had  made  any  perceptible  progress  in 
cutting  through,  would  find  these  folds  in  process 
of  obliteration.  In  some  way  the  intestine  ac- 
commodated itself  to  its  new  conditions  and  be- 
came speedily  smooth  and  shapely.  In  some 
respects  the  early  disappearance  of  these  corruga- 
tions has  been  quite  a  puzzle,  as  I  should  have 
expected  them  to  remain  until  the  intestine  was 
released  from  the  binding  cord.  I  feared,  too, 
lest  the  ligation  and  folding  of  the  intestinal  wall 
might  cause  irritation  or  even  obstruction  of  the 
:  gut.  When  we  consider,  indeed,  the  severity  of 
j  the  symptoms  produced  by  the  pinching  of  even 
a  small  segment  of  a  gut  in  strangulated  hernia, 
we  might  reasonably  expect  the  occurrence  of 
j  similar  phenomena,  with  the  extreme  pinching  of 
two  adjacent  intestines  held  together  by  a  tightly 
drawn  rubber  ligature.  This,  however,  never 
happened.  Obstruction  occurred  in  one  or  two 
cases  from  a  too  acute  bending  of  an  intestine, 
but  the  ligation  itself  seemed  in  no  case  to  pro- 
duce distress — even  in  gastroenterostomy,  where 
the  involvement  of  the  stomach  in  the  ligature 
might  warrant  fears  of  an  uncontrollable  gastric 
irritability,  this  did  not  occur.  The  man  upon 
whom  I  operated  by  forming  a  gastro-intestinal 
enterostomy  for  the  relief  of  a  pyloric  cancer, 
vomited  only  once  after  the  operation,  namely, 
on  the  third  day. 

It  is  evident  that  the  mere  pinching  or  con- 
striction of  a  portion  of  the  intestinal  wall  is  not 
in  itself  a  cause  of  great  irritation,  provided  the 
nutrition  of  the  gut  is  not  seriously  interfered 
with.  In  fact,  the  symptoms  which  followed  the 
operation  seemed  in  no  case  to  depend  merely 
upon  the  injury  done  to  the  intestine.  If  the 
wound  ran  a  perfectly  aseptic  course,  the  animals 
would  show  no  distress  whatever.  If  it  became 
septic  they  would  suffer  accordingly.  Every  one 
who  has  operated  on  dogs,  knows  the  difficulty  of 
making  and  keeping  them  aseptic,  especially  in 
confined  quarters.  From  lack  of  proper  facilities 
I  lost  several  animals  from  septic  peritonitis.  It 
was  noteworthy,  that  the  origin  of  trouble  was 
rarely  to  be  found  at  the  seat  of  ligature  or  con- 
necting with  the  cavity  of  the  intestine,  for  the 
ligature,  in  fatal  cases,  was  almost  always  found 
buried  in  the  intestinal  fold  aud  progressing  its 
usual  course,  while  the  distant  peritoneal  surfaces 
were  covered  with  lymph  or  pus.  In  no  case  was 
there  found  any  escape  of  faeces  or  intestinal  con- 
tents into  the  peritoneal  cavity. 


f".SS 


ON  THE  USE  OF  THE  ELASTIC  LIGATURE. 


[May  i  6, 


The  normal  course  of  the  ligature  and  inclosed 
tissues,  was  about  as  follows  : 

Animal  killed  after  twenty  four  hours,  showed 
no  change  in  the  condition  of  the  intestines  op- 
erated on,  except  a  partial  obliteration  of  the 
folds  caused  by  the  ligature,  and  an  adhesion  of 
the  adjacent  peritoneal  surfaces.  No  opening 
became  as  yet  apparent  at  the  seat  of  ligation. 
After  forty- eight  hours  the  intestines  resumed 
their  normal  shape,  all  folds  had  disappeared, 
the  adhesions  had  become  firmer,  and  the  rubber 
was  seen  to  have  slightly  cut  through  the  in- 
closed structures.  At  the  end  of  seventy-two 
hours  a  free  space  usually  appeared  on  each  side 
of  the  ligature,  through  which  water  could  be 
made  to  pass  from  one  intestine  into  the  other. 
The  ligature  still  hung  in  the  middle  on  uncut 
tissue.  At  the  end  of  the  fourth  day,  the  open- 
ing became  complete,  the  ligature  disappeared 
and  the  anastomosis  was  accomplished.  As  the 
ligature  cut  through,  the  edges  of  the  mucous 
membranes  of  each  gut  became  glued  together 
and  united,  and  the  result  was  a  smoothed, 
healed  edge  all  around  the  opening.  The  irrita- 
tion caused  by  a  rubber  ligature  in  the  peritoneum 


well  until  three  years  ago,  when  he  had  begun  to 
suffer  from  indigestion  and  occasional  attacks  of 
vomiting.  The  trouble  gradually  increased  un- 
til he  found  himself  during  the  last  three  months 
unable  to  retain  any  food  whatsoever.  He  became 
gradually  very  weak,  and  at  the  time  he  entered 
the  hospital  was  much  emaciated.  His  breath 
was  foul,  and  his  food  was  vomited  regularly  a 
few  hours  after  its  ingestion.  Examination  re- 
vealed a  tumor  as  large  as  a  hen's  egg,  four  centi- 
meters above  and  four  centimeters  to  the  right  of 
the  navel.  This  tumor  was  immoveable,  and  was 
evidently  adherent  to  the  adjacent  structures. 

January  9.  The  stomach  was  washed  out  with 
warm  water  and  a  large  quantity  of  very  sour, 
dark  and  offensive  fluid  mixed  with  mucus  evacu- 
ated. After  the  hot  water,  a  solution  of  boracic 
acid  and  bicarbonate  of  soda,  eight  grains  of  each 
to  the  ounce  was  injected  and  again  evacuated. 
The  patient  experienced  immediate  relief  from 
the  nausea,  and  the  procedure  was  repeated  daily 
until  January  12,  the  day  of  operation.  As  the 
diagnosis  was  not  doubtful,  the  examination  for 
hydrochloric  acid  was  not  made.  The  tempera- 
ture during  the  time  of  his  stay  in  the  hospital 


was  just  sufficient  to  cause  adhesion  of  the  sur-    previous   to   the   operation    ranged    high,    from 


faces  with  the  intervention  of  hardly  any  ap 
preciable  amount  of  exudation.  The  length  of 
the  orifice  formed  was  found  to  be  equal  to  that 
of  the  tissue  inclosed  in  the  knot.  Whether  sub 
sequent  contraction  with  partial  obliteration  of 
the  orifice,  such  as  has  happened  after  other 
methods  of  producing  anastomosis  would  follow 
in  course  of  time,  is  as  yet  uncertain.  Variations 
were  occasionally  found  in  the  course  described. 
I  have  seen  the  opening  completed  at  the  end  of 
the  third  day,  and  have  seen  it  incomplete  at  the 
end  of  the  fifth,  but  in  general  if  the  operation  is 
done  as  I  have  described  it,  the  result  will  be  as 
I  have  stated. 

In  my  first  series  of  experiments  I  operated  on 
twenty-four  dogs,  and  then  having  become  con- 
vinced of  the  perfect  feasibility  of  the  operation 
I  chose  it  in  preference  to  other  methods,  when 
called  upon  to  establish  an  anastomosis  between 
the  stomach  and  small  intestine,  in  a  case  of 
pyloric  cancer. 

Subsequently,  seven  dogs  were  operated  on  for 
the  purpose  of  studying  the  effects  of  the  opera- 
tion in  relieving  intestinal  fistulse  and  false  anus, 
and  eight  others,  for  the  production  of  fistulse 
between  the  gall-bladder  and  small  intestine. 
The  history  of  the  only  case  in  which  this  method 
of  operation  has  been  thus  far  employed  on  the 
human  subject  is  as  follows  : 

Mr.  Otto  Cook,  aged  59  years,  a  Belgian  by 
birth,  and  a  farmer  by  occupation,  by  the  ad- 
vice of  his  physician,  Dr.  Jno.  Monaghan,  since 
deceased,  entered  St.  Mary's  Hospital  on  January 
8,  1891,  to  place  himself  under  my  care  for 
cancer  of  the  pylorus.      He  had  been  perfectly 


99.5"  to  100.5"  F.  His  pulse  was  steady  at  about 
90  per  minute.  His  bowels  had  been  costive  but 
were  made  to  act  by  enemata,  and  rectal  injec- 
tions of  bovinine  and  brandy  were  given  three 
times  a  day,  to  supply  the  much  needed  nutri- 
ment. 

There  were  present  at  the  operation  Drs.  H.  O. 
Walker,  F.  W.  Robbins,  Pilcher,  Irving,  Mona- 
ghan and  Mr.  P.  M.  Hickey,  Mr.  A.  J.  Warren, 
and  others.  An  incision  was  begun  four  centi- 
meters above  the  navel,  in  the  median  line,  and 
extended  transversely  to  the  left,  for  a  distance 
of  four  inches.  The  pylorus  was  found  to  be  as 
expected,  the  seat  of  a  large  tumor,  adherent  to 
the  liver  and  absolutely  immoveable.  Excision 
was  out  of  the  question  and  I  proceeded  to  make 
an  anastomosis  with  the  small  intestine.  I  tried 
first  to  find  the  jejunum  by  grasping  it  at  its 
origin  but  failed  to  do  so,  and  then  followed 
Liicke's  advice  and  grasped  the  highest  coil  of 
small  intestine.  As  will  appear  later  I  had  cause 
to  regret  this  part  of  the  operation.  The  omentum 
was  very  thin,  atrophied  and  destitute  of  fat,  and 
was  pushed  to  the  left.  A  small  opening  through 
its  right  border  enabled  me  to  bring  the  stomach 
into  contact  with  the  intestine,  which  was  then 
sewed  fast  to  it  by  six  Lembert  sutures  in  a  line 
about  four  centimeters  in  length.  A  long  worsted 
needle,  armed  with  a  long  rubber  cord,  was  then 
passed  into  and  out  of  the  stomach,  the  in- 
cluded space  being  about  three  and  a  half  cen- 
timetres in  length.  It  was  then  carried  in  like 
manner  through  the  intestine  and  the  ligature 
tied  tightly  and  firmly  in  a  square  knot.  The 
ends  of  the  ligature,  which  were  cut  short,  were 


i89i.] 


ON  THE  USE  OF  THE  ELASTIC  LIGATURE. 


689 


then  secured  by  tying  them  together  with  a  silk 
thread,  which  had  been  passed  through  them, 
ami  mx  Lembert  sutures  were  inserted  above. 
The  stomach  and  intestine  were  thus  fastened  to- 
gether by  two  rows  of  Lembert  sutures,  and  by 
the  rubber  ligature  which  was  between  them  and 
hidden  from  view,  while  the  walls  of  the  viscera 
were  held  by  the  ligature  as  in  an  ever  tightening 
vise.  The  operation  of  anastomosis  was  con 
ducted  in  this  case  very  deliberately,  and  con- 
sumed after  the  exposure  of  the  stomach  eleven 
minutes  of  time.  The  most  of  this  was  occupied 
in  passing  the  fine  needle  armed  with  the  silk 
thread  through  the  rubber  in  order  to  secure  its 
ends.  This  is  quite  a  delicate  matter  as  the 
needle  must  be  passed  directly  through  the  mid- 
dle of  the  stretched  rubber  in  order  not  to  cut 
and  weaken  it  as  it  would  do  if  passed  too  near 
its  edge.  Since  adopting  the  suggestion  of  Mr. 
Hickey,  and  securing  the  knot  by  tying  the  silk 
thread  firmly  around  it,  I  have  been  able  to  ma- 
terially reduce  the  time  required  for  the  pro- 
cedure, and  can  now  do  it  on  the  dog  in  U 
three  minutes. 

The  peritoneum,  fascia  and  muscles,  and  skin 
were  sutured  separately,  and  the  wound 
with   usual  regard   for  asepsis.     The  patient  re- 
acted well  and  was  given  injections  of  bovinine 
and  brandy  every  six  hours. 

January  13.  Injections  continued.  Tempera- 
ture as  before  the  operation  ranging  from  99.5  F. 
to  100.5  F-  Pulse  was  stronger  than  before  the 
operation.  Patient  had  a  tendency  to  slight 
hacking  cough,  no  nausea,  nor  vomiting,  nothing 
was  given  by  the  mouth. 

January  14th.  No  pain,  tenderness,  nausea 
nor  tympanites.  Injections  of  bovinine,  brandy 
and  tincture  opii  even7  four  hours,  mouth 
and  tongue  moistened  with  water,  but  no  food 
nor  drink.  Morning  temperature  100.5;  evening 
temperature  103.8.  Ten  grains  of  quinine  in 
half  an  ounce  of  whiskey  were  given  by  mouth 
and  retained. 

January  15th.  Morning  temperature  1010; 
evening  temperature  100.  °:  pulse  90  and  good  but 
patient  felt  very  weak.  The  mouth  and  throat 
were  dry  and  the  cough  troublesome.  No  expec- 
toration, negative  results  on  auscultation  and 
percussion,  complained  of  acidity.  Is  given  tea- 
spoonful  doses  of  wine  and  water  ever}-  fifteen 
minutes.  For  the  first  and  only  time  since  the 
operation,  the  patient  vomited  a  mucus  mixed 
with  wine  and  water;  the  stomach  was  washed 
out  with  the  boracic  acid  solution. 

January  16th.  Morning  temperature  ioo°; 
evening  temperature  1010.  Patient  retained 
milk,  bovinine  and  wine  in  small  quantities. 
Bowels  moved  at  noon.  The  stool  was  thin,  dark 
colored,  and  offensive.  Ligature  could  not  be 
found,  wound  was  dressed  for  the  first  time  and 
found  to  have  healed  by  first  intention.     Bowels 


moved  three  times  on  the  night  of  January  16  and 
January  17.  Nutrient  enemata  altogether  dis- 
continued; patient  is  weak  and  very  homesick, 
and  complains  bitterly  of  his  cough.  Bismuth 
and  saccharated  pepsin  aa  grs.  v  was  given  ever)' 
three  hours.  Morning  temperature  99. 50;  even- 
ing temperature    100°. 

January  17th.  Patient  seems  brighter  and 
stronger.  Pulse  90,  good.  Morning  temperature 
99°;  evening  temperature  ioo°.  Milk,  beef- 
tea  and  brandy  are  taken  by  the  mouth  and  re- 
tained; no  nausea  nor  distress.  Cough  is  trou- 
blesome; bowels  moved  five  times  during  the  day; 
stitches  were  removed  from  wound  which  was  en- 
tirely healed.  The  pyloric  lump  seems  to  have 
decreased  in  size. 

January  18.  Morning  temperature  990;  even- 
ing temperature  100.5.  The  cough  is  very  an- 
noying, but  sounds  are  clear  over  both  lungs. 
The  cough  is  aggravated  by  drinking,  but  not  by 
swallowing  solids.  He  ate  baked  potatoes  and 
soft  boiled  egg  for  breakfast,  also  some  milk  toast, 
but  is  dejected  and  homesick.  Bowels  moved 
six  times  since  previous  evening.  The  passages 
were  dark  and  offensive. 

January  19th.  Morning  temperature  99s ;  even- 
ing temperature  100°;  cough  much  worse,  but 
no  expectoration.  Mouth  and  throat  are  very 
dry.  The  throat  is  red  but  not  swollen,  and  is 
covered  with  a  white  deposit,  which,  however, 
may  be  easily  wiped  off.  Has  difficulty  in  swal- 
lowing liquids  but  can  take  solids  with  ease. 
Throat  was  gargled  with  boracic  acid  solution. 
Internally,  tincture  ferri  chlorid,  in  five  drop 
doses.  Bowels  have  moved  seven  times  since  last 
evening. 

January  20th.  Morning  and  evening  tempera- 
ture ioo=.  Patient  is  growing  weaker  and  more 
homesick.  Pulse  90,  good;  mouth  is  not  quite  so 
dry  and  throat  is  somewhat  better.  The  pyloric 
tumor  has  apparently  disappeared.  Diarrhoea 
continues.  Twelve  passages  in  the  last  twenty- 
four  hours. 

January  21st.      No  material  change. 

January  22d.  Diarrhoea  continues  and  patient 
is  growing  weaker,  but  otherwise  no  marked 
change. 

January  25.     The  patient  insisted  on  going  to 
1  his  home  twelve  miles  in  the  country,  where  he 
died  on  January  27,  fifteen  days  after  the  opera- 
tion. 

On  January  28th,  I  drove  out  with  an  assistant 
and  succeeded  in  getting  permission  to  examine 
the  abdomen.  It  was  found  that  the  healing  had 
taken  place  with  absolute  asepsis,  the  wound  was 
firmly  and  completely  united.  There  was  no  in- 
flammatory exudate  whatever  in  the  abdominal 
cavity.  The  viscera  all  had  their  normal  appear- 
ance except  at  the  seat  of  disease.  There  was  a  py- 
loric tumor  as  large  as  a  hen's  egg  firmly  adherent 
to  the  under  surface  of  the  liver.     In  the  mesen- 


690 


ON  THE  USE  OF  THE  ELASTIC  LIGATURE. 


[May  16 


tery  underneath  there  were  numerous  enlarged 
lymphatic  glands.  The  stomach  and  underlying 
intestines  were  adherent  by  what  may  be  called 
primary  adhesion;  that  is,  their  surfaces  were  at- 
tached without  any  apparent  deposit  of  lymph.  I 
had  feared  on  watching  the  case  that  I  might 
have  made  the  anastomosis  too  near  the  ileo-ccecal 
valve  and  in  order  to  determine  the  exact  posi- 
tion of  the  operation,  I  was  obliged  to  separate 
the  stomach  from  the  surrounding  mass.  I  found 
that  the  seat  of  anastomosis  in  the  small  intes- 
tine was  about  91  centimeters  (three  feet)  from 
tbe  colon.  The  intestine  above  that  point  was 
empty;  below  it  full  of  partly  digested  food. 
The  cause  of  death  was  evidently  inanition. 
In  tracing  out  the  intestine  I  unfortunately 
tore  it  partially  apart  from  the  stomach  and 
thus  spoiled  the  specimen.  I  found,  however, 
that  the  anastomosis  had  been  complete.  In  the 
stomach  there  were  two  holes  through  the  mu- 
cous membrane  and  one  through  the  muscular  and 
serous  coats.  It  was  evident  that  in  passing  the 
needle  into  the  stomach  I  had  passed  it  too  near 
the  wall  of  that  organ,  and  instead  of  clearing  the 
mucous  coat  had  pierced  it,  altogether,  in  four 
places,  which  made,  on  the  completion  of  the  an- 
atomosis,  two  holes.  This  seemed  to  cause  no 
difficulty  in  the  passage  of  food  but  it  taught  me 
to  enter  the  needle,  in  the  future,  into  and  to  pass 
it  out  of  the  stomach  more  perpendicularly  to  the 
surface.  In  this  way  all  such  complications  may 
be  avoided.  The  orifices  in  the  intestine  and 
serous  and  muscular  coats  of  the  stomach  were 
three  and  a  half  centimeters,  (one  and  a  half 
inches)  long.  That  in  the  mucous  coat  of  the 
stomach  was  as  I  have  said  divided  in  two  by  a 
small  bridge  of  mucous  membrane.  It  must  be 
observed  that  neither  in  the  stomach  nor  intes- 
tine nor  peritoneal  cavity  was  there  the  slightest 
appearance  of  inflammation.  The  edges  of  the 
opening  between  the  cavities  were  healed  and  the 
mucous  membrane  of  the  small  intestine  was 
turned  around  the  edge  of  the  orifice  and  attach- 
ed. The  mucous  membrane  of  the  stomach,  ow- 
ing to  the  faulty  course  of  the  needle  through  it 
was  stretched  over  the  orifice  and  communicated 
with  it  by  means  of  the  two  openings. 

Although  in  transcribing  this  history  I  have 
not  taken  up  space  in  relating  unnecessary  de- 
tails of  treatment,  having  given  only  the  essential 
points,  enough  is  nevertheless  given  to  show  con- 
clusively that  it  is  entirely  practicable  to  produce 
intestinal  anastomosis  on  the  human  subject  by 
the  elastic  ligature.  The  failure  of  the  operation 
was  due,  not  to  the  method  of  making  the  anas- 
tomosis, which  was  highly  successful,  but  to  the 
misfortune  of  establishing  it  too  low  down  in  the 
ilium  for  the  purposes  of  nutrition. 

I  wish  to  call  especial  attention  to  the  follow- 
ing points  : 

1.  The   operation    caused  no  irritability  of  the 


stomach.  He  vomited  only  once  after  its  per- 
formance, viz.,  on  the  third  day  after  the  opera- 
tion, before  the  ligature  had  cut  through. 

2.  The  duration  of  that  part  of  the  operation, 
the  uniting  of  the  viscera  and  the  formation  of  the 
anastomosis,  was  only  eleven  minutes,  notwith- 
standing that  it  was  done  with  more  than  neces- 
sary deliberation  on  account  of  its  being  the  first 
case.  It  was,  besides,  unnecessarily  prolonged 
by  the  method  then  adopted  of  fastening  the  ends 
of  the  ligature  by  transfixing  them  with  needle 
and  thread  and  then  ligating.  The  method  now 
adopted  of  securing  the  knot  by  simply  tying  a 
silk  thread  around  it,  will  save  many  minutes. 

3.  Food  began  to  pass  from  the  stomach  into 
the  intestines  at  the  end  of  the  fourth  day  as 
shown  by  the  complete  tolerance  of  the  stomach 
after  that  time.  The  accident  of  transfixing  the 
mucous  membrane  of  the  stomach  by  carrying 
the  needle  too  nearly  parallel  to  its  surface,  made 
the  orifice  in  that  mucous  membrane  smaller  than 
it  should  have  been  and  may  have  delayed  the 
establishment  of  the  communication  between  the 
stomach  and  intestine. 

4.  The  autopsy  showed  the  anastomosis  to 
have  been  completed  with  a  minimum  amount  of 
irritation.  I  doubt  whether  it  would  be  possible 
by  any  other  method  to  produce  so  little  disturb- 
ance. 

Now,  if  we  ask  how  far  this  method  will  meet 
the  necessities  caused  by  the  various  pathologi- 
cal conditions  which  produce  intestinal  stenosis, 
wt  will  be  enabled  to  come  to  a  definite  conclu- 
sion as  regards  its  usefulness.  It  will  be  seen  on 
consideration  that  like  all  surgical  procedures, 
the  method  has  its  strict  limitations.  That  which 
limits  its  applicability  is  the  time  which  is  re- 
quired for  the  completion  of  the  anastomosis.  All 
cases  of  stenosis,  therefore,  which  demand  imme- 
diate relief  or  which  must  be  relieved  in  less  time 
that  four  days,  must  be  treated  by  other  methods, 
while  on  the  contrary  all  cases  of  partial  stenosis 
or  even,  as  regards  pyloric  tumors  and  cancers,  of 
complete  stenosis  in  comparatively  strong  pa- 
tients, may  be  operated  on  to  advantage  by  this 
method.  To  particularize  :  the  acute  stenosis  of 
volvulus  or  entanglement  of  Meckel's  diverticu- 
lum with  the  intestine,  or  that  caused  by  constric- 
tion by  false  membranes  or  by  strangulated  her- 
nia or  by  intussusception,  must  be  relieved  by 
other  means.  In  many  of  these  cases  an  incision 
into  the  bowel  which  permits  the  escape  of  con- 
tained fasces  is  a  necessary  part  of  the  treatment 
and  for  all  these,  Senn's  method  or  some  one  of 
its  innumerable  modifications  would  seem  indi- 
cated. But  in  obstruction  of  the  pylorus,  when 
the  patient  has  a  fair  amount  of  strength;  in  tu- 
mors of  either  intestine  with  partial  obstruction; 
in  the  partial  stenosis  caused  by  wounds  and  in- 
juries, in  the  narrowing  of  the  gut  by  cicatricial 
contraction;  in  operations  for  the   cure  of  false 


i89i.] 


ON  THE  USE  OF  THE  ELASTIC  LIGATURE. 


69  r 


anus  and  faecal  fistulae,  and,  finally,  in  impending 
mortification  of  the  intestine  in  strangulated  her- 
nia, I  believe  that  it  will  be  found  on  trial  supe- 
rior in  its  ease  of  application,  freedom  from  dan- 
ger and  efficiency,  to  any  other  method  now  in 
vogue.  In  tumors  either  of  intestines  or  of  neigh- 
boring parts  pressing  upon  or  involving  the  intes- 
tine, the  symptoms  of  obstruction  come  on  gradu- 
ally. In  all  of  these  cases,  early  operations  are 
indicated  either  for  excision  of  the  whole  trouble, 
or  if  that  is  impossible  for  relief  of  the  stenosis. 
In  either  case  the  production  of  anastomosis  by 
ligature  is  especially  indicated — in  excision,  after 
the  tumor  has  been  removed,  the  gut  evacuated 
and  the  resected  ends  turned  in. 

Wounds  of  the  large  intestine  are  much  more 
apt  than  those  of  the  small,  to  give  way  and  per- 
mit faecal  extravasation.  The  thickness  and  com- 
parative stiffness  of  its  walls  make  a  greater  strain 
upon  the  Lembert  stitches  which  hold  the  serous 
surfaces  in  contact,  while  the  faecal  masses,  by 
their  greater  solidity,  produce  more  friction  in 
the  bowel  and  a  more  prolonged  and  powerful  iru 
pact  upon  the  inner  line  of  the  wound.  In  the 
large  intestine  then  it  is  especially  desirable  that 
the  outer  surfaces  should  grow  together  before 
the  anastomosis  is  formed,  and  for  that  reason 
the  operation  by  elastic  ligature  would  seem  to 
offer  marked  advantages  over  other  methods. 
The  lapse  of  four  days  before  faecal  matter  could 
possibly  exude,  and  during  which  the  agglutina- 
tion of  the  serous  surfaces  would  become  firm, 
would  add  no  little  to  the  security  of  the  patient. 

The  advantage  of  the  method  in  another  class 
of  cases,  that  of  traumatic  stricture  of  the  small 
intestine,  has  forced  itself  upon  my  attention  as 
I  have  compared  the  results  of  my  operations  on 
dogs  with  the  history  of  a  case  of  resection  of  the 
gut  for  traumatic  stricture  which  occurred  in  my 
own  practice.  The  case  has  already  been  pub- 
lished in  the  Physician  and  Surgeon  for  June  and 
July,  1890,  and  I  will  give  here  only  a  resume  of 
it  in  illustration  of  the  advantages  promised  over 
the  old  methods  by  the  new  one  which  I  have 
suggested.  On  January  13,  18S9,  Barnard  Burns, 
age  28  years,  was  struck  violently  in  the  abdo- 
men by  a  falling  log.  Great  pain,  tenderness  and 
tympanites  ensued  and  lasted  for  three  or  four 
weeks.  There  then  developed,  gradually,  a 
cicatricial  contraction  of  the  jejunum  with  its  ac- 
companying symptoms  of  partial  obstruction, 
namely  repeated  attacks  of  great  colicky  pain 
with  irritability  of  the  stomach,  and  finally  faecal 
vomiting.  I  operated  on  him  on  May  30,  1889, 
four  and  one-half  months  after  the  reception  of 
the  injury.  I  found  the  jejunum  at  one 
place  contracted  to  such  a  degree  that  a  lead 
pencil  could  not  have  been  passed  through  it. 
The  intestine  had  evidently  been  badly  bruised, 
but  not  completely  ruptured.  Possibly  one  or 
the  other  of  its  coats  had  undergone  ulceration 


and  absorption  as  the  effect  of  the  injury.  I  ex- 
cised three  inches  of  the  bowel  and  joined  the 
ends  together  with  a  double  row  of  stitches,  one 
for  the  mucous  membrane  and  one  for  the  mus- 
cular and  serous  coats.  A  contracted  point  in 
the  mesentery  which  seemed  to  cause  too  much 
flexion  of  the  intestine  was  also  excised  and  re- 
united in  a  different  way  so  as  to  relieve  the  flex- 
ion. The  operation  lasted  one  hour  and  a  half, 
two-thirds  of  which  time  were  occupied  in  the 
section  and  suture  of  the  intestine.  At  its  close 
he  suffered  greatly  from  shock,  from  which  he 
did  not  recover  until  after  the  expiration  of 
thirty  six  hours.  After  that,  he  recovered  with- 
out any  further  drawback. 

What  I  wish  to  emphasize  in  this  history  is 
the  fact  that  this  patient  was  put  in  imminent 
danger  of  his  life  by  the  shock  produced  solely 
by  the  length  and  severity  of  the  operation 
although  everything  else  went  well.  In  treating 
such  a  case  again,  I  should  first  of  all  thoroughly 
and  repeatedly  wash  out  the  stomach.  This  pro- 
cedure has  been  shown,  repeatedly,  to  relieve  all 
of  the  symptoms  of  even  acute  and  complete  ob- 
struction without,  of  course,  curing  the  disease. 
The  stomach  and  small  intestine  are  thereby  put 
in  the  same  condition  as  the  stomach  in  pyloric 
obstruction.  The  canal  to  the  point  of  obstruction 
is  emptied  of  all  its  contents,  and  the  pain  and  in- 
testinal tenesmus  ceases  as  soon  as  the  gut  is  allowed 
to  rest.  The  reversed  peristaltic  action  in  these 
cases  assists  the  surgeon  in  his  efforts  to  relieve 
the  intestine  from  the  exhausting  and  futile  efforts 
to  force  its  contents  beyond  the  point  of  con- 
striction. Whether  the  small  intestine  could  be 
thus  relieved  at  whatever  point  in  its  length  it 
should  be  constricted  is  yet  to  be  seen.  It  is  of 
undoubted  service  in  constriction  of  the  higher 
parts  of  the  alimentary  canal.  In  partial  obstruc- 
tion the  relief  given  would  doubtless  be  suffi- 
ciently great  to  permit  the  surgeon  to  treat  the 
case  on  the  same  principles  as  in  pyloric  cancer, 
namely,  to  keep  the  mucous  surfaces  clean  by  fre- 
quent irrigation;  to  give  by  the  mouth  no  food 
or  drink  at  all  or,  if  any,  only  such  as  could  un- 
dergo immediate  absorption;  to  nourish  the  pa- 
tient by  rectal  enemata,  and  to  reestablish  the 
continuity  of  the  bowel  by  forming  an  anastomosis 
of  the  part  above  with  that  below  the  stricture. 

If  I  had,  instead  of  excising  the  gut,  passed  an 
elastic  ligature  through  the  central  and  distal 
portions,  immediately  above  and  below  the  con- 
striction, I  could  have  accomplished  in  a  few  min- 
utes what  occupied  a  whole  hour,  and  saved  the 
patient  the  enormous  shock  to  which  he  nearly 
succumbed. 

Although  I  have  not  ventured  to  recommend 
this  procedure  in  cases  of  acute  and  complete  ob- 
struction, I  am  nevertheless  by  no  means  sure 
that  it  may  not  prove  to  be  the  best  and  most 
promising  of  all  operations  in  acute  and  irremedi- 


692 


ON  THE  USE  OF  THE  ELASTIC  LIGATURE 


[May  16, 


able  obstructions  of  the  jejunum  and  duodenum 
if  the  case  is  operated  on  early,  before  the  patient 
has  become  exhausted.  It  must  be  insisted  on 
that  all  such  cases  shall  be  treated,  before  and 
after  the  operation,  by  the  frequent  washing  out 
of  the  stomach  with  the  rubber  syphon,  and  that 
alimentation  shall  be  accomplished  solely  through 
the  rectum. 

Another  class  of  cases  in  which  this  operation 
may  be  expected  to  be  of  great  utility  is  that 
which  includes  gangrenous  hernia,  faecal  fistula, 
and  artificial  anus.  It  occurred  to  me  in  think- 
ing over  the  various  methods  of  treating  the  mor- 
tified intestine  in  strangulated  hernia  that  the 
cure  of  the  false  anus  which  results  in  such  cases 
might  be  anticipated  by  making  at  once  an  anas 
tomosis  between  the  afferent  and  efferent  limb  of 
the  gut  in  sound  tissue.  By  passing  the  elastic 
ligature  through  the  two  portions  of  gut  an  ori- 
fice of  communication  would  be  formed  at  the 
end  of  the  fourth  day,  and  with  a  new  channel 
for  the  passage  of  faeces.  The  false  anus  would 
be  in  condition  to  be  healed  with  comparatively 
simple  means. 

I  operated  on  my  second  series  of  dogs,  seven 
in  number,  with  the  purpose  in  view  of  studying 
the  results  of  such  procedures.  The  experiments 
had  as  yet  yielded  no  practical  results  on  account 
of  the  great  mortality  of  the  animals  from  septic 
peritonitis,  when  I  received  the  second  part  of 
the  forty-first  volume  of  the  Archives  fur  Klin- 
ische  Chirurgie,  containing  an  article  by  Prof. 
Helferich,  of  Griefswald,  entitled  "Ausfiihring 
der  Herniotomie  bei  der  Gangrau  verdachtigeu 
Darm,"  I  found  myself  anticipated  in  the  idea 
and  practice  by  Prof.  Helferich,  who  had  already 
operated  on  and  recorded  two  cases  of  this  kind, 
in  which,  however,  he  had  made  the  anastomosis 
by  incising  and  stitching  the  intestines  together. 
One  of  the  two  cases  was  successful.  Some 
faeces  passed  for  a  few  days,  in  small  quantities, 
through  the  false  anus,  although  the  greater  part 
was  evacuated  through  the  rectum.  On  the 
ninth  day  the  protruding  perforated  coil  of  intes- 
tine was  excised,  and  the  cut  ends  turned  in  and 
sutured.  A  small  remaining  fistula  required  a 
further  and  final  operation  for  its  relief.  The 
second  case  ended  fatally  in  collapse. 

I  think  that  every  one  who  considers  for  a  mo- 
ment the  condition  of  things  in  a  gangrenous 
hernia  will  see  the  advantage  of  this  operation.  I 
should  not,  however,  subject  a  patient  to  the  long, 
tedious,  and  dangerous  operation  of  forming  an 
anastomosis  after  any  of  the  old  methods.  In 
these  cases,  when  once  the  constriction  of  the 
hernia  is  relieved,  the  operation  by  elastic  liga- 
ture could  be  accomplished  within  five  minutes 
It  would  indeed  require  lour  days  to  establish  the 
communication  between  the  intestines,  but  the 
patient  could  well  afford  to  wait  for  that  when  by 
so  doing  he  could  escape  the  dangers  of  collapse 


and  shock,  to  be  expected  of  any  long  operative 
procedure  under  such  circumstances. 

As  for  already  existing  faecal  fistula  and  false 
anus,  in  which  milder  measures  have  failed,  it 
would  be  proper  to  try  the  effects  of  the  elastic 
ligature  in  either  one  of  the  two  ways:  First  of 
all  the  ligature  might  be  used  to  destroy  the  pro- 
jecting spur,  which  in  so  many  cases  of  artificial 
anus  separates  the  afferent  from  the  efferent  gut. 
The  patient  should  be  put  in  Trendelenburg's 
posture,  with  elevated  hips,  to  permit  the  intes- 
tines to  fall  away  from  the  seat  of  operation.  The 
needle  armed  with  the  rubber  ligature  should 
then  be  passed  as  deeply  as  possible  through  the 
spur  and  tightly  tied.  The  spur  destroyed,  the 
case  could  then  be  treated  on  general  principles. 
If  the  formation  of  the  spur  should  be  such  as  to 
render  this  manceuver  impossible,  or  if  the  case 
were  one  in  which  no  spur  existed,  the  abdomen 
could  be  opened  and  an  anastomosis  be  formed  by 
the  ligature  between  the  afferent  and  efferent 
limbs  of  the  gut.  There  can  be  no  doubt  that 
relief  might  be  given  in  this  way  to  many  other- 
wise incurable  troubles  of  this  kind.  Besides 
these  operations  on  the  intestine,  1  made  some  ex- 
periments with  the  view  of  making  communica- 
tions in  the  same  manner  between  the  gall-blad- 
der and  the  small  intestine.  In  doing  so  I  met 
with  difficulties  which  did  not  occur  in  the  oper- 
ations on  the  intestines.  The  liver  and  gall-blad- 
der in  dogs,  owing  to  the  narrowness  of  the 
thorax,  is  somewhat  difficult  of  access,  and  the 
constant,  and  often  violent,  motion  of  the  dia- 
phragm as  the  animal  struggles,  vomits,  or  barks, 
prevents  that  delicate  manipulation  which  is  essen- 
tial to  success.  These  impediments  might,  it  is 
true,  be  overcome  by  a  sufficiently  large  abdom- 
inal incision,  but  this  in  turn  causes  greater  dan- 
ger from  shock  and  septic  poisoning.  The  oper- 
ations were  conducted  in  the  same  manner  as  in 
intestinal  anastomosis,  except  that  the  lesser  size 
of  the  gall  bladder  made  it  necessary  to  include 
less  tissue  in  the  ligature.  Whereas  in  the  intes- 
tinal anastomosis  the  thread  inclosed  from  three 
to  four  centimeters  in  length;  in  the  experiments 
on  the  gall  bladder  and  duodenum  there  were  in- 
cluded only  one  and  a  half  or  two  centimeters  of 
surface. 

Another  difference  in  these  operations  was  the 
tendency  of  the  bile  to  escape  alongside  of  the  lig- 
ature into  the  peritoneal  cavity,  an  accident 
which  never  happened  with  the  contents  of  the 
intestine.  This  was  due  both  to  the  thinness  of 
tin  wall  of  the  gall-bladder  and  the  thinness  of 
the  bile,  and  added  an  additional  danger  to  these 
operations.  Nine  dogs  were  operated  on,  of 
which  six  died.  One  from  intestinal  haemorrhage, 
oue  from  a  flexion  of  the  duodenum,  two  imme- 
diately after  the  operation,  apparently  from  shock, 
and  two  from  septic  peritonitis.  Of  the  three  that 
lived,    one  lived  sixteen,  one   fourteen,  and  oue 


I89i.] 


OX  THE  USE  OF  THE  ELASTIC  LIGATURE. 


693 


twelve  days  before  they  were  killed  for  examina- 
tion, and  I  hoped  to  prove  the  operation  to  be 
practicable.  In  this,  however,  I  was  sadly  dis- 
appointed. In  two  of  the  three  the  ligature  had 
disappeared,  but  the  orifice  of  communication  had 
disappeared  with  it,  and  there  was  nothing  left  to 
mark  the  spot  of  operation  but  the  scar.  In  the 
third  the  ligature  was  found  in  place.  It  had 
cut  through  the  intervening  tissues,  but  had  been 
prevented  from  escaping  by  the  surrounding 
structures,  which  had  contracted  around  it  and 
enclosed  it.  It  could  not  be  doubtful  that  this 
orifice,  too,  would  have  closed  like  the  others  by 
cicatricial  contraction  as  soon  as  it  had  been 
made  possible  by  the  escape  of  the  rubber. 

I  had  not,  until  this  time,  been  aware  that  Dr. 
Gaston,  of  Atlanta,  had  anticipated  me  in  this 
kind  of  work,  but  learned  of  the  fact  from  Dr. 
Senn.  Dr.  Gaston  kindly  sent  me  the  papers, 
excepting  the  first,  which  he  had  published  on 
this  subject,  beginning  in  September,  18S4.  Dr. 
Gaston  endeavored  to  establish  fistulae  between 
the  gall-bladder  and  duodenum  by  the  use  of  a 
ligature,  sometimes  of  silk  and  sometimes  of 
rubber.  The  main  features  of  his  method  were 
the  same  as  those  of  my  own.  The  gall-bladder 
was  fastened  by  Lembert  sutures  to  the  intestine, 
the  ligature  passed  through  both  viscera  and 
tied,  and  other  Lembert  sutures  again  above  and 
around  the  ligature.  Many  of  his  operations 
were  complicated  by  the  ligation  of  either  the 
hepatic,  cystic  or  common  gall  ducts,  and  in  all 
of  them,  as  nearly  as  I  can  judge  from  the  de- 
scription given,  the  amount  of  tissue  included  in 
the  ligatures  was  much  less  than  in  my  own  ex- 
periments. His  very  interesting  experiments 
were  the  first  of  their  kind,  and  he  can  un- 
doubtedly claim  the  priority  in  the  attempts  to 
make  channels  of  communication  between  hollow- 
viscera  by  means  of  ligatures,  although  I  can- 
not learn  that  he  ever  attempted  to  do  so  for  any 
other  purpose  than  to  make  a  duodeno  chole- 
cystostomy. 

I  wish  that  I  could  say  that  either  his  efforts 
or  my  own,  had  resulted  in  the  establishment  of 
a  practicable  procedure  for  this  purpose.  The 
results  of  our  experiments  in  this  direction  at 
present,  show  only  this  :  that  it  is  possible  by 
the  use  of  a  ligature  to  make  a  communication 
between  the  gall-bladder  and  duodenum  which 
may  last  for  two  or  three  months,  but  that  the 
procedure  is  so  exceedingly  dangerous  as  to  be 
inadvisable  on  the  human  subject.  The  most  of 
the  animals  operated  on,  died,  and  from  causes 
-which  we  might  not  be  able  with  all  care  to 
avoid.  It  is  exceedingly  difficult  to  prevent  the 
escape  of  bile  into  the  peritoneal  cavity  through 
the  hole  made  by  the  ligature,  and  this,  although 
not  necessarily  fatal,  is  nevertheless  a  grave  com- 
plication, if  for  no  other  reason  than  that  it  inter- 
feres greatly  with  that  union  by   first  intention, 


which  is  an  essential  element  of  success  in  this 
method.  Besides,  the  adhesion  of  the  surfaces, 
the  escape  from  all  fatal  complications,  and  the 
division  of  the  inclosed  structures  by  the  ligature 
does  not  insure  the  establishment  of  the  fistula. 
In  the  three  cases  of  my  own  which  lived,  the 
ligature  had  cut  through,  but  the  contraction  of 
the  tissues  had  already,  in  less  than  seventeen 
days,  obliterated  the  orifice,  which  it  had  made, 
although  not  less  than  one  and  a  half  centi- 
metres of  length  of  surface  had  in  each  case  been 
included  in  the  ligature.  It  is  possible  that  the 
total  obstruction  of  the  cystic  or  common  duct 
might  ensure  a  greater  permanency  of  such  a 
fistula.  In  one  of  Dr.  Gaston's  cases,  the  fistula 
persisted  for  nearly  three  months,  but  it  must 
not  be  forgotten  that  the  obstruction  of  the  com- 
mon duct  would  add  greatly  to  the  danger  of  the 
operation,  as  it  would  cause  an  enormous  dis- 
tension of  the  gall-bladder  with  extreme  thinning 
of  its  walls,  and  a  constant  pressure,  which  would 
cause  a  continuous  current  of  bile  through  the 
holes  made  by  the  needle  and  thread,  and,  if  it 
did  not  produce  a  fatal  peritonitis,  would  almost 
inevitably  prevent  union  between  the  gall-bladder 
and  duodenum. 

I  would  not  be  understood  as  despairing  alto- 
gether of  this  method  for  the  formation  of  a 
fistula  between  the  gall-bladder  and  duodenum, 
although  the  method  of  iucision  and  suture 
seems  to  me  to  be  safer,  but  I  cannot  regard  it 
vet  as  a  justifiable  operation,  whatever  may  be 
its  future  after  further  experimental  study.  In 
one  respect  I  should  differ  from  Dr.  Gaston. 
The  pathological  conditions,  which  would  make 
duodeno  cholecystostomy  proper,  are  such  as  are 
constantly  recurrent.  For  that  reason,  indeed, 
Langenbuch  recommended  the  excision  of  the 
gall  bladder,  in  order  to  prevent  the  formation  of 
gall  stones,  and  render  the  cure  permanent. 
It  should  therefore  be  the  aim  of  the  surgeon  to 
make  any  fistula  that  he  might  establish  endur- 
ing. This  can  only  be  hoped  for  if  the  opening 
between  the  viscera  is  originally  very  large  ;  even 
then  it  is  probable  that  the  tendency  to  contrac- 
tion in  so  loose  a  structure  as  the  gall-bladder 
would  be  greater  than  the  tendency  to  keep  the 
communication  open.  When,  therefore,  Dr. 
Gaston  says,  commenting  on  one  of  his  cases : 
"  Upon  stitching  up  the  duodenum  to  the  point 
of  opening,  it  was  evident  that  too  much  tissue 
had  been  included  in  the  ligature,  as  the  orifice 
was  unnecessarily  large  :  and  in  repeating  this 
experiment  I  would  suggest  that  the  needle  and 
ligature  should  only  include  so  much  of  the 
respective  wall  as  to  secure  an  orifice  from  the 
cavity  of  the  gall  bladder  into  the  alimentary 
canal,"  he  would  seem  to  me  to  be  urging  a 
practice  which  would  defeat  its  own  ends.  While 
it  is  not  impossible  that  a  small  fistula  would  re- 
main indefinitely  open,  to  make  that  event  even 


694 


FRACTURE  OF  THE  ASTRAGALUS. 


[May  i 6 


slightly  probable,  the  orifice  should  be  made  as 
large  as  possible. 

It  is  not  only  in  fistulas  of  the  gall-bladder  that 
this  tendency  to  contract  has  been  remarked,  but 
also  in  those  of  the  stomach  and  small  intestine. 
In  one  case  an  opening  of  three  centimeters  in 
diameter  between  the  stomach  and  small  intes- 
tines had  contracted  in  five  months  and  a  half  to 
less  than  half  a  centimeter,  and  in  another  case 
an  orifice  an  inch  long,  had  altogether  closed  in 
four  months  (Weir). 

It  becomes  important,  therefore,  to  study  the 
conditions  which  favor,  and  those  which  oppose 
this  undesired  process  of  healing.  It  can  hardly 
be  doubted  that  a  large  opening  would  be  less 
likely  to  close  than  a  small  one,  and  large  ori 
fices  may  be  made  by  all  methods,  by  that  of  the 
ligature  as  well  as  by  others.  There  are  proba- 
bly other  circumstances,  however,  which  also  in- 
fluence the  result.  One  of  these  must  be  the 
greater  or  less  perfection  with  which  the  mucous 
coats  are  united,  for  if  in  any  case  union  takes 
place  between  the  outer  surfaces  while  the  mucous 
membranes  are  left  unattached,  a  line  of  granulat- 
ing tissue  would  occupy  the  inner  edge  of  the 
orifice  which  might  be  expected  to  subsequently 
indefinitely  contract,  whereas  an  opening  lined  by 
a  continuous  layer  of  mucous  membrane  would 
tend  to  retain  its  shape  and  size;  so,  too,  any 
great  inflammator}-  deposit  on  the  outer  surface 
would  tend  to  produce  the  same  result  of  contrac- 
tion and  obliteration  of  the  orifice. 

It  is  not  then  a  matter  of  indifference,  by  what 
means  the  communication  is  completed.  Experi- 
ence alone  can  determine  the  value  of  the  differ- 
ent methods  in  this  respect,  but  after  careful  study 
of  pathological  specimens  from  my  own  cases,  I  feel 
hopeful  that  my  method  will  prove  of  especial  value 
in  making  permanent  openings  between  the  vis- 
cera, for  I  have  noticed  first  of  all,  that  during  the 
process  of  absorption  from  the  pressure  of  the 
cord  the  mucous  membranes  are  forced  in  on  both 
sides  until  they  meet,  so  that  the  ligature  leaves 
behind  it  a  smooth  edge  covered  with  the  inner 
lining,  and  second  the  irritation  of  the  serous 
membranes  by  the  ligature  is  just  sufficient  and 
no  more  than  to  cause  adhesion.  In  some  of  my 
experiments  I  used  silk  ligatures  instead  of  rubber 
and  found  that  they  too  would  cut  through  the 
tissues  and  leave  an  opening.  In  many  ways, 
however,  they  were  inferior.  They  wrould  soon 
lose  their  antiseptic  qualities,  act  as  setons  and 
cause  too  much  inflammation.  There  were  there- 
fore more  failures,  and  owing  to  the  too  great  de- 
posit of  lymph  the  intestines  were  apt  to  lemain 
puckered  up  with  a  small  contracting  opening, 
instead  of  a  large  one.  The  rubber,  on  the  con- 
trary, causes  barely  enough  irritation  to  cause 
union  of  tile  serous  sin  !. 

In  conclusion,  then,  I  will  sum  up  the  matter  as 
follows  : 


i.  Rubber  ligatures  can  be  used  advantageous- 
ly in  many  cases  to  produce  anastomosis  between 
two  hollow  viscera. 

2.  They  are  adapted  for  all  chronic  cases,  in 
which  it  is  possible  to  wait  four  days  for  the  com- 
pletion of  the  opening. 

3.  They  are  contraindicated  in  all  cases  of  acute 
obstruction  which  demand  immediate  relief. 

4.  In  using  them  for  this  purpose  they  should 
be  passed  through  the  opposing  viscera  in  such  a 
way  as  to  include  all  of  the  intervening  tissues, 
serous  and  muscular  coats  and  mucous  membranes 
in  one  tight  knot. 

5.  Union  takes  place  between  the  serous  sur- 
faces after  the  application  of  the  ligature  by  pri- 
mary adhesion  with  a  minimum  amount  of  irrita- 
tion. 

6.  The  method  of  thus  producing  an  intestinal 
anastomosis  excels  all  others  in  the  rapidity  of  its 
execution  and  in  its  freedom  from  danger  of  shock, 
fiecal  extravasation  and  septic  poisoning.  Its  sole 
drawback  is  the  length  of  time  required  for  its 
completion.  I  shall  be  glad  if  the  profession  will 
give  it  a  trial  in  appropriate  cases. 

I  take  pleasure  in  acknowledging  my  indebted- 
ness to  Drs.  Ives  and  Ireland  and  Messrs.  Hickey 
and  Warren  for  their  assistance  in  making  the 
necessary  experiments.1 


ORIGINAL  ARTICLES. 


FRACTURE    OF    THE    ASTRAGALUS. 
WITH  IRREDUCIBLE  DISPLACE- 
MENT OF  THE  FRAGMENT. 

A  Paper  read  before  the  Fourth  Annual  Meeting  of  the  National  As~ 
Surgeons,  held  at  Buffalo,  New  t'ork. 
April  jo,  and  May  :  am 

BY  R.  HARVEY  REED,  M.D., 

(university  pa.),  mansfield,  ohio. 

president   north  central   uhio   medical   society  ;    surgeox 

baltimore  .v  ohio  r.  r.;  member  national  association  of 

railway  surgeons;  american  medical  association; 

lssociation;  American  pchlic 

health  association;  honorary  member  d. 

vr.vrw    SURGICAL   SOCIETY.    PHILA- 
HIA   :      TEXAS    STATE    MEDICAL 
SOCIETY,    ETC. 

Fractures  of  the  astragalus  as  compared  in  fre- 
quency with  fractures  of  the  other  tarsal  bones, 
are  comparatively  rare  ;  whilst  fractures  of  this 
bone  with  irreducible  displacement  is  still  more 
uncommon. 

This  bone  being  largely  composed  of  cancel- 
lated tissue,  and  quite  irregular  in  form,  and  sur- 
rounded with  numerous  articulations,  affords  it  a 
greater  immunity  from  injury,  than  almost  any 
other  one  of  the  tarsal  bones. 

In  fact,  little  is  said  in  our  text-books  regard- 
ing this  important  complication,  which  to  the 
iurgeon  is  of  double  importance,  owing 
to  the  permanent  injury  it  produces,  and  the  con- 


i39i.] 


FRACTURE  OF  THE  ASTRAGALUS. 


69; 


sequent  dangers  this  form  of  injury  is  liaWe  to 
entail  on  the  railroad  company. 

Hamilton,  in  his  work  on  "  Fractures  and  Dis- 
locations," reports  ten  cases  of  fracture  of  the 
astragalus,  nine  of  which  were  caused  by  a  fall, 
and  one  by  crushing.  In  the  former  the  force 
was  largely  reflected  to  the  foot,  and  conducted 
to  the  astragalus  through  the  tibia,  causing  the 
fractures,  some  of  which  were  followed  by  dis- 
placement of  the  fragments. 

Ashhurst  says  it  is  almost  invariably  broken, 
by  the  patient  falling  from  a  height  and  alight- 
ing on  his  feet ;  and  that  he  only  knew  of  two 
cases,  where  there  had  been  a  fracture  of  this 
bone,  with  displacement  of  the  fragment ;  the 
one  was  a  case  reported  by  himself,  the  other  by 
Dr.  Norris. 

Agnew,  in  referring  to  fractures  of  the  tarsus, 
reports  seven  fractures  of  the  astragalus  ;  14  of 
the  calcaneum,  and  25  of  the  other  bones  of  the 
tarsus  ;  which  shows  that  fractures  of  the 
astragalus  only  occur  in  15  per  cent,  of  all  the 
fractures  of  the  various  bones  of  the  tarsus. 

Lougsdale,  Croly,  Neill,  Bryant,  Vollmar, 
MacCormac,  M.  Tavignot,  Malgaigne,  M.  Rog- 
netta,  Sir  Astley  Cooper,  Clark,  Norris,  Goyder 
and  John  Ashhurst,  Jr.,  each  report  a  case  of 
fracture  of  this  bone  ;  whilst  Sheppard  reports 
having  observed  four  fractures  of  the  astragalus, 
and  Mr.  Erichsen  two. 

The  testimon}'  of  these  surgeons,  proves  that 
it  is  usually  caused  by  falling,  in  which  the  pa- 
tient alights  on  some  solid  substance  on  the  feet, 
whereby  the  force  of  the  fall  is  extended  to  the 
astragalus  which  may  cause  a  simple  fracture, 
with  or  without  dislocation  of  the  fragment,  or  a 
comminuted  fracture  with  or  without  displace- 
ment of  the  fragments,  or  a  compound  com- 
minuted fracture,  with  or  without  displacement 
of  the  fragment  or  fragments.  The  fragment 
or  fragments  may  be  dislocated  anteriorly 
on  the  dorsum  of  the  foot,  or  downward  and  for- 
ward, or  downward,  outward  and  backward  under 
the  internal  malleolus  ;  and  one  case  is  reported, 
in  vvhich  the  displaced  fragment  found  its  way  to 
the  plantar  surface  of  the  foot. 

There  is  no  certainty  as  to  the  direction  of  the 
line  of  fracture,  which  is  as  varied  as  the  force  or 
forces  that  produce  it. 

The  reduction  of  these  displaced  fragments  is 
quite  a  difficult  task,  which  is  usually  attended 
with  absolute  failure,  especially  when  they  are 
displaced  downward  and  backward  under  either 
of  the  malleoli,  and  whilst  Dr.  Ashhurst  reports 
in  the  American  Journal  of  Medical  Sciences,  for 
April,  1862,  of  having  been  able  to  replace  a  dis- 
located fragment  of  a  fractured  astragalus,  yet  I 
believe  he  is  the  only  surgeon  who  has  been  able 
to  do  so  (and  has  reported  the  case),  to  the  best 
of  my  knowledge  at  least. 

The  anatomical  relations  of  the  astragalus  are 


such,  that  when  displacement  of  a  fragment  after 
a  fracture  occurs,  it  makes  it  evident  at  a  glance, 
that  its  reduction  will  be  attended  with  great 
difficulty  ;  especially  when  we  consider  its  shape 
and  structure,  together  with  the  numerous  liga- 
ments and  articular  surfaces  it  presents  ;  yet.  not- 
withstanding all  this,  I  consider  it  good  surgery 
to  make  an  honest  and  carefully  conducted  effort 
at  reduction  by  trying  to  so  manipulate  the  parts 
as  to  give  the  least  possible  resistance  to  its  re- 
turn ;  the  particular  manipulation  of  which,  will 
depend  largely  upon  what  part  of  the  bone  is 
fractured  and  displaced,  and  where  it  is  lodged. 
Operative  interference  for  the  removal  or  reduc- 
tion of  the  bone,  especially  after  prolonged  and 
diligent  efforts  had  failed  to  replace  it,  would 
very  naturally  present  itself  to  our  minds  next. 
In  this  connection,  we  can  find  but  little  data  to 
guide  us  ;  whilst  Bryant  and  Wythe  operated  and 
removed  the  displaced  fragment  with  recovery, 
yet,  on  the  other  hand,  a  similar  case  operated  by 
Dr.  Norris,  died.  These,  in  the  absence  of  ad- 
ditional reports,  would  show  a  mortality  of  33 
per  cent,  against  66  per  cent,  of  recovery,  and  at 
a  time  when  at  least  two  of  these  cases  (Norris' 
and  Bryants')  were  undoubtedly  operated  prior 
to  the  use  of  antiseptics,  and  whilst  we  have  no 
assurance  that  Wythe's  was,  although  it  is  more 
probable  than  either  of  the  other  cases. 

Some  operators  advise  the  replacement  of  the 
dislodged  fragment,  others,  the  removal  of  the 
entire  astragalus  (which  was  done  in  Wythe's 
case),  whilst  others  only  advise  the  removal  of 
the  displaced  fragment.  But  when  we  consider 
the  structure  of  the  bone,  which  is  made  up 
largely  of  cancellated  tissue,  and  consequently 
more  vascular,  and  hence  the  remaining  portion 
of  the  bone  is  more  liable  to  take  on  destructive 
inflammation  on  the  one  hand,  whilst  the  re- 
placed fragment  is  liable  to  become  necrosed  on 
the  other,  owing  to  the  interference  with  the 
blood  supply,  as  well  as  the  danger  of  the  intro- 
duction of  septic  germs,  which  makes  the  ques- 
tion of  replacement  by  operative  interference  a 
doubtful  procedure. 

Again,  if  the  displaced  fragment  is  allowed  to 
remain  out  of  place,  it  not  only  makes  a  perma- 
nent deformity,  but  a  permanent  disability  ;  but 
on  the  other  hand,  if  you  attempt  to  remove  only 
the  fragment,  you  take  the  chances  of  disease  of 
the  remaining  portion  of  the  bone  following,  and 
if  you  remove  the  entire  bone  there  is  more  or 
less  permanent  deformity  and  disability  from  that. 
From  this  it  would  seem  as  though  this  injury 
produced  a  fair  example  of  the  old  adage  of : 

"  Damned  if  you  do,  and  damned  if  you  don't. 
Damned  if  you  will,  and  damned  if  you  wont." 

From  this  it  would  appear  that  we  are  left  to 
the  choice  of  four  or  five  evils  :  1.  If  the  frag- 
ment can't  be  reduced  by  manipulation  (except- 


6g6 


FRACTURE  OF  THE  ASTRAGALUS. 


[May  15, 


ing  in  compound  or  compound  comminuted  frac- 
tures) to  simply  let  it  alone,  and  take  the  chances 
of  it  becoming  encysted. 

2.  To  remove  only  the  displaced  fragment,  by 
cutting  down  on  it,  and  extracting  it  anti- 
septically. 

3.  To  remove  the  entire  astragalus. 

4.  To  replace  the  displaced  fragment,  and  take 
the  chances  of  inflammation  and  destruction  of 
both  the  hard  and  soft  structures  of  the  surround- 
ing tissues. 

5.  To  remove  the  displaced  fragment  and 
thoroughly  cleanse  the  cavity  it  left,  and  put  all 
the  surrounding  parts  in  a  strictly  aseptic  condi- 
tion, after  which,  pack  the  cavity  with  Senn's 
antiseptic  decalcified  bone  chips,  which  I  believe 
is  better  than  replacing  the  detached  fragment  of 
bone  ;  as  it  is  very  hard  to  make  this  strictly  anti- 
septic, whilst  the  decalcified  bone  chips  are,  and 
hence  less  liable  to  set  up  infection  in  the  sur- 
rounding parts. 

REPORT    OF    CASES. 

Case  1. — George  M.,  aet.  55,  an  amanuensis; 
on  August  12,  1885,  was  riding  with  a  friend  in 
a  delivery  wagon,  when  the  horse  took  fright  and 
started  to  run  away.  Mr.  M.  became  alarmed, 
and  jumped  out  of  the  wagon  on  the  paved  street, 
sustaining  a  fracture  of  the  astragalus  of  the  left 
foot,  with  displacement  of  the  fragment  down- 
ward and  backward  under  the  malleolus  ;  the  in- 
ternal fragment  was  also  slightly  displaced  back- 
ward and  inward,  thus  lengthening  the  lateral 
diameter  of  the  ankle  quite  considerably.  The 
foot  and  ankle  soon  swelled  up  and  became  very 
painful ;  a  physician  was  called  who  pronounced 
it  a  bad  sprain  of  the  ankle,  and  treated  it  ac- 
cordingly. 

Some  months  subsequently  the  writer  was 
called  and  found  a  fragment  of  the  astragalus, 
about  two  inches  in  length,  and  nearly  as  wide, 
lodged  under  the  left  external  malleolus  ;  whilst 
the  depression  caused  by  the  displaced  fragment 
was  easily  detected,  just  beneath,  inward  and  in 
front  of  the  fibula.  All  attempts  at  reduction 
were  without  avail ;  but  notwithstanding  the 
marked  deformity,  the  patient  could  use  his  foot 
fairly  well  and  had  quite  a  considerable  degree  of 
motion  ;  but  it  was  more  or  less  painful  and  was 
a  source  of  inconvenience  to  him  all  the  time, 
and  especially  so  in  changeable  weather.  Later 
on  necrosis  of  the  external  metatarsal  bone  set  in. 
and  at  one  time  it  was  thought  that  the  entire 
foot  would  have  to  be  amputated  ;  an  excision, 
however,  of  the  external  metatarsal  was  all  that 
was  necessary  ;  since  which  time,  he  has  had  but 
little  trouble  with  it,  other  than  what  we  have 
already  mentioned. 

Under  all  the  circumstances,  I  considered  that 
conservative  surgery  in  his  case  was  a  choice  of 
the  least  evil,  and  hence  refrained  from  excising 


the  displaced  fragment.  The  result  is  that  this 
patient  is  now  able  to  walk  all  over  the  city  with 
the  aid  of  a  cane,  and  whilst  his  foot  and  ankle 
is  stiff  and  clumsy,  I  believe  it  is  better  than  to 
have  risked  an  operation  for  its  removal. 

Case  2. — Chas.  S.,  aet.  29,  a  brakeman  in  the 
B.  and  O.  yards  at  Mansfield,  O.,  was  thrown  off 
the  top  of  a  box  car  by  a  broken  brake  May  13, 
1889,  alighting  on  his  feet  on  the  end  of  a  tie; 
sustaining  a  fracture  of  the  astragalus  of  the  right 
foot,  with  displacement  of  the  fragment  under- 
neath the  internal  malleolus. 

I  was  called  shortly  after  the  accident,  and 
readily  diagnosed  the  nature  of  the  injury,  as  I 
could  easily  feel  the  displaced  fragment  beneath 
the  internal  malleolus,  whilst  beneath  and  in  front 
of  the  internal  half  of  the  tibia,  I  could  readily 
discover  the  depression  left  by  the  escaped  frag- 
ment of  bone.  In  addition  to  this  there  was  some 
spreading  of  the  tibia  and  fibula,  thus  materially 
increasing  the  lateral  diameter  of  the  ankle  ;  no 
doubt  due  to  the  tearing  of  the  ligaments,  and 
the  strain  produced  by  the  fall,  together  with  the 
escape  of  such  a  large  fragment  of  bone,  with  its 
associate  weakening  of  the  surrounding  parts. 

Here  again  we  were  confronted  with  the  ques- 
tion of  an  operation  for  the  removal  of  the  dis- 
placed fragment  of  bone,  which  no  ingenuity  or 
manipulation  the  author  could  devise,  was  able 
to  replace. 

In  its  present  location  we  recognized  a  degree 
of  support  to  the  tibia,  being  lodged  immediately 
underneath  the  internal  malleolus,  which  support 
would  be  lost  by  its  removal,  saying  nothing  of 
the  danger  attending  the  operation  to  the  sur- 
rounding structures;  and  again,  conservatism  got 
the  better  of  us  and  we  decided  to  let  well  enough 
alone.  The  result  is  a  more  or  less  painful  ankle 
at  times,  with  considerable  loss  of  motion,  and 
some  deformity ;  but  otherwise,  a  fairly  good  foot 
and  leg  which  enables  him  to  walk  reasonably 
well  and  earn  a  good  livelihood  for  his  family. 

Case  3. — Harry  D.,  a  stonemason,  aet.  33,  jump- 
ed off  a  freight  train  when  it  was  in  motion,  Oc- 
tober 8,  1889,  and  lit  with  one  foot  on  the  end  of 
the  tie,  producing  a  fracture  of  the  astragalus  of 
the  right  foot,  with  displacement  of  the  fragment 
underneath  the  external  malleolus.  The  author 
was  called  to  see  the  patient  a  short  time  after  the 
injury,  and  found  a  fragment  of  the  astragalus 
some  2  inches  in  length  by  1  inch  in  width, 
lodged  just  beneath  and  slightly  posterior  to  the 
coronoid  process  of  the  fibula.  A  marked  de- 
pression was  observed  just  below,  in  front  and 
internal,  to  the  external  malleolus,  which  was 
evidently  the  nidus  of  the  displaced  fragment  of 
the  bone.  In  the  absence  of  sufficient  data  to 
encourage  an  operation,  and  with  the  dangers 
that  might  attend  such  staring  me  in  the  face,  I 
again  resolved  to  pursue  the  conservative  method 
of  treatment,  until  something  better  presented  it- 


iSoi.] 


CHEMICAL  FACTORS  IX  CAUSATION  OF  DISEASE 


697 


self  to  my  mind  as  unquestionably  an  improve- 
ment on  the  conservative  methods  I  had  thus  far 
been  forced  to  adopt. 

The  results  in  this  case  are  much  better  than 
either  of  the  former  cases.  The  patient  lias  little 
or  no  pain,  except  when  the  weather  changes, 
and  is  not  inconvenienced  to  any  extent;  can 
walk  with  limping  but  little,  and  is  regularly  fol- 
lowing his  daily  avocation  as  a  stone-cutter. 

The  following  interesting  case  was  kindly  given 
me  for  this  paper,  by  my  friend  Prof.  Thome,  of 
Toledo,  O..  Surgeon  in  Chief  of  the  Toledo,  St. 
Louis  and  Kansas  City  R.  R.: 

Case  4. — H.  F.,  a  German,  set.  32,  weighing 
about  200  lbs.,  a  lager  beer  brewer,  and  given  to 
the  liberal  use  of  this  fluid,  whilst  at  work  slipped 
from  the  lower  round  of  a  ladder,  alighting  upon 
a  wet  floor.  The  peculiar  position  of  landing, 
together  with  the  great  weight  of  the  patient, 
were  such  as  to  result  in  a  fracture  of  the  astrag- 
alus of  the  left  foot,  forcing  the  outer  half  out 
from  its  normal  position,  and  causing  quite  a 
prominence  over  the  outer  portion  of  the  dorsum 
of  the  foot. 

A  corresponding  diagnosis  was  made,  and  the 
injury  treated  accordingly.  In  about  thirty  days 
after  the  accident,  complete  death  of  the  overly- 
ing structures  ensued,  necessitating  the  removal 
of  the  displaced  fragment  of  bone.  This  Was  fol- 
lowed by  decomposition  and  infection,  which  was 
no  doubt  encouraged  by  his  constitutional  condi- 
tion, and  the  result  of  his  intemperate  habits, 
until  it  was  necessary  to  amputate  his  leg  below 
the  knee,  in  order  to  save  his  life. 

Here  we  have  a  case  where  conservative  sur-  j 
gery  was  followed  with  disastrous  results  which 
probably  lost  the  patient  his  foot. 

In  summing  up  the  testimony  of  this  unfortu- 
nate injury,  we  have  found  that,  in  fractures  of 
the  astragalus  with  displacement  of  the  fragment: 

1.  That  reduction  is  the  rare  exception,  and 
not  the  rule. 

2.  That  total  failure  to  reduce  the  fragment,  is 
the  general  rule  in  this  class  of  cases. 

3.  That  these  cases  may  get  well  with  a  fairly 
good  and  useful  ankle  by  following  a  conserva- 
tive method  of  treatment. 

4.  That  a  conservative  line  of  treatment  may 
be  followed  with  disastrous  results. 

5.  That  a  fair  degree  of  recovery  may  follow 
the  excision  of  the  dislocated  fragment. 

6.  That  destructive  inflammation  of  the  re- 
maining portion  of  the  astragalus  may  follow 
with  necrosis,  necessitating  its  ultimate  removal. 

7.  That  a  fracture  involving  any  considerable 
portion  of  the  astragalus,  with  displacement  of 
the  fragment,  is  practically  if  not  almost  invari- 
ably followed  with  a  permanent  and  irreparable 
injury  ;  for  if  resolution  follows  without  an  oper- 
ation, there  is  a  permanent  deformity  with  asso- 
ciate disability,  or  if  the  fragment  is  removed  and 


the  patient  recovers,  there  is  a  permanent  disabil- 
ity ;  or  if  the  entire  astragalus  is  removed,  as  ad- 
vised by  some  authors,  there  is  still  a  fixed 
disability. 

It  seems  to  me  that  one  of  the  plain  lessons 
we  are  to  learn  from  the  study  of  these  cases,  is 
to  be  very  guarded  in  our  prognosis,  in  fractures 
of  the  astragalus  with  irreducible  displacement  of 
the  fragment ;  for  if  we  are  not,  we  may  rue  our 
rashness  under  the  lash  of  chagrin  and  disap- 
pointment. 

Another  plain  lesson  seems  to  be  stamped  upon 
the  clinical  history  of  this  class  of  cases ;  and 
that  is,  to  be  equally  guarded  in  operating  them, 
as  you  are  in  projecting  your  diagnosis 

But,  when  an  operation  for  the  removal  is  your 
plain  duty,  do  it  promptly,  under  the  strictest 
antiseptic  precautions,  and  if  you  have  any  doubt 
as  to  the  danger  of  necrosis  of  the  remaining  por- 
tion of  the  bone,  remove  that  also.  Where  this 
is  not  evident,  it  might  be  well  to  consider  the 
advisability  of  packing  the  cavity  produced  by 
the  displaced  fragment  of  bone,  after  thoroughly 
cleansing  it,  with  Senn's  decalcified  bone  chips, 
being  careful  to  remove  all  the  synovial  mem- 
brane before  packing  the  cavity ;  for  the  use  of 
these  decalcified  bone  chips  as  used  by  Prof.  Senn, 
after  the  removal  of  portions  of  dead  bone,  has 
been  so  satisfactory,  that  we  believe  their  use  in 
this  class  of  cases  would  be  followed  by  satisfac- 
tory' results  also. 

Mansfield,  O..  April  20,  1891. 


LECTURES. 

THE  CHEMICAL    FACTORS  IN  THE 
CAUSATION  OF  DISEASE. 

A  Course  of  Three  Lectures  delivered  at  the  Post-Graduate  Medical 
School  of  Chicago,  March  26.  2j  and  .  • 

BY  VICTOR  C.  VAUGHAN,  M.D.,   Ph.D., 

OF    ANN    ARBOR.  MICH. 
PROFESSOR   OF    HYGIENE    AND  PHYSIOLOGICAL  CHEMISTRY' AND  DI- 
RECTOR OF  THE  HYGIENIC  LABORATORY'  IN  MICHIGAN 
UNIVERSITY'. 

(Continued  from  page  6jo.~) 
LECTURE    III. — THE  AUTOGENOUS    DISEASES, 

All  living  things  are  composed  of  cells.  The 
simplest  forms  of  life  are  unicellular,  and  in 
these  all  the  functions  of  life  devolve  upon  the 
single  cell.  Absorption,  secretion  and  excretion 
must  be  carried  on  by  the  same  cell.  A  collec- 
tion of  unicellular  organisms  might  be  compared 
to  a  community  of  men  with  every  individual  his 
own  tailor,  shoemaker,  carpenter,  cook,  farmer, 
gardener,  blacksmith,  etc.  However,  only  the 
lowest  forms  of  life  are  unicellular  ;  all  others 
are  multicellular.  In  the  higher  animals  there  is 
a  differentiation  not  only  in  the  size  and  struc- 
ture of  the  cells,  but  in  the  labor  which  they  per- 
form.    The  body  of  man  may  be  compared  to  a 


698 


CHEMICAL  FACTORS  IN  CAUSATION  OF  DISEASE. 


[May  16, 


community  in  which  labor  has  been  specialized. 
Certain  groups  of  cells,  which  we  designate  by 
the  term  "organ,"  take  upon  themselves  the 
task  of  doing  some  special  line  of  work,  the  well- 
doing of  which  is  essential  to  the  health,  not 
only  of  that  group,  but  of  other  groups  as  well, 
or  of  the  body  as  a  whole.  There  is  an  interde 
pendence  among  the  various  organs.  Certain 
groups  of  cells  supply  the  fluids  or  juices  which 
act  as  digestants,  and  among  these  there  is  again 
a  division  of  labor.  The  salivary  glands  supply 
a  fluid  which  partially  digests  the  starch  of  our 
food;  the  peptic  glands  supply  the  gastric  juice 
which  does  the  preliminary  work  in  the  digestion 
of  the  proteids  ;  while  the  pancreatic  juice  com- 
pletes the  digestion  of  the  starches  begun  in  the 
mouth,  of  the  proteids  begun  in  the  stomach, 
and  does  the  special  work  of  emulsifying  the  fats. 
But  even  some  of  these  products  of  complete  di- 
gestion would  be  harmful  should  they  enter 
the  circulation  unchanged.  The  peptones  must 
be  converted  into  serum-albumin  by  the  ab- 
sorbing mechanism  of  the  walls  of  the  intestines, 
and  while  10  per  cent,  of  the  fat  of  the  food  is 
split  up  into  glycerine  and  fatty  acids  by  the  ac- 
tion of  the  pancreatic  juice,  a  much  smaller  per 
cent,  enters  the  thoracic  duct  in  this  divided  form. 
The  food  may  be  taken  in  proper  quality  and 
quantity  ;  the  digestive  juices  may  do  their  work 
promptly  and  properly,  but  if  the  absorbents  fail 
to  perform  their  functions  properly,  disease  re- 
sults. It  may  happen  that  the  failure  lies  in  im- 
proper or  imperfect  assimilation  and  the  result 
becomes  equally  disastrous,  and  with  the  effects 
of  non-elimination  we  are  fairly  conversant.  Of 
the  myriads  of  cells  in  the  healthy  human  body 
there  are  none  which  are  superfluous.  It  is  true 
that  among  these  ultimate  entities  of  existence, 
death  is  constantly  occurring,  but  in  health  re 
generation  goes  on  with  equal  rapidity  and  each 
organ  continues  to  do  its  daily  and  hourly  task. 
The  microscope  has  made  us  familiar  with  the 
size  and  shape  of  the  various  cells  of  the  body, 
and  the  students  of  pathology  have  described  the 
alterations  in  form  and  size  characteristic  of  vari- 
ous diseased  states.  But  we  must  remember  that 
in  the  study  of  these  ultimate  elements  of  life 
there  are  other  things,  besides  their  morpholog 
ical  history,  to  investigate.  They  are  endowed 
with  life,  and  the)',  as  well  as  the  germs  which 
we  have  been  studying,  have  a  physiology  and 
chemistry  which  we  know  but  slightly.  They 
are  influenced  beneficially  or  harmfully,  as  the 
case  may  be,  by  their  environment.  They  grow 
and  perform  their  functions  properly  when  sup- 
plied with  the  needed  pabulum.  They  are  not 
immune  to  poisonous  agents.  They  are  injured 
when  the  products  of  their  own  activity  accumu- 
late about  them. 

The  object  in  writing  this  lecture  has  been  to 
collect  what  evidence  I  may  concerning  those  dis- 


eases which  arise  from  imperfect  or  improper  ac- 
tivity of  the  cells  of  the  body,  not  due  to  the  in- 
troduction of  foreign  cells.  To  designate  this 
class  of  diseases  I  have  selected  the  word  autog- 
enous, and  I  understand  that  in  these  diseases 
the  materies  morbi  is  a  product  of  some  cell  of 
the  body,  and  not,  as  in  the  case  of  the  infectious 
diseases,  of  cells  introduced  from  without  the 
bod)'. 

It  is  true,  without  exception  so  far  as  I  know, 
that  the  excretions  of  all  living  things,  plants 
and  animals,  contain  substances  which  are  poison- 
ous to  the  organisms  which  excrete  them.  A 
man  may  drink  only  chemically  pure  water,  eat 
only  that  food  which  is  free  from  all  adultera- 
tions, and  breathe  nothing  but  the  purest  air,  free 
from  all  organic  mat'.er,  both  living  and  dead, 
and  yet  that  man's  excretions  would  contain 
poisons.  Where  do  these  poisons  originate? 
They  are  formed  within  the  body.  They  originate 
in  the  metabolic  changes  by  which  the  complex 
organic  molecule  is  split  up  into  simpler  com- 
pounds. We  may  suppose — indeed,  we  have 
good  reasons  for  believing — that  the  proteid 
molecule  has  certain  lines  of  cleavage  along 
which  it  breaks  when  certain  forces  are  applied, 
and  that  the  resulting  fragments  have  also  lines 
of  cleavage  along  which  they  break  under  cer- 
tain influences,  and  so  on  until  the  end  products, 
urea,  ammonia,  water  and  carbon-dioxide  are 
reached  ;  also  that  some  of  these  intermediate 
products  are  highly  poisonous  has  been  abun- 
dantly demonstrated.  The  fact  that  the  hydro- 
cyanic acid  molecule  is  a  frequent  constituent  of 
the  leucomaines  is  one  of  great  significance.  We 
know  t hat  chemical  composition  is  an  indication 
of  physiological  action,  and  the  intensely  poison- 
ous character  of  some  of  the  leucomaines  con- 
forms to  this  fact.  It  matters  not  whether  the 
proteid  molecule  be  broken  up  by  organized  fer- 
ments bacteria,  or  by  the  unorganized  ferments 
of  the  digestive  juices,  by  the  cells  of  the  liver 
or  by  those  still  unknown  agencies,  which  in- 
duce metabolic  changes  in  all  the  tissues — in  all 
cases  poisons  may  be  formed.  These  poisons 
will  differ  in  quality  and  quantity  according  to 
the  proteid  which  is  acted  upon,  and  according 
to  the  force  which  acts. 

Peptones  formed  during  digestion  do  not  in 
health  reach  the  general  circulation.  When  in- 
jected directly  into  the  blood  they  act  as  powerful 
poisons.  They  destroy  the  coagulability  of  the 
blood,  lower  blood-pressure,  and  in  large  quanti- 
ties cause  speedy  death.  Brunton  attributes  the 
lassitude,  depression,  sense  of  weight  in  the 
limbs  and  dulness  in  the  head  occurring  in  the 
well-fed,  inactive  man,  after  his  meals,  to  poison- 
ing with  peptones.  The  remedy,  which  he  pro- 
poses, is  less  food,  especially  less  nitrogenous 
food,  and  more  exercise.  That  some  substance 
resulting  from   the  proteids  of   the  food   is  the 


I89I.] 


CHEMICAL  FACTORS  IN  CAUSATION  OF  DISEASE. 


699 


cause  of  this  trouble  Bruuton  thinks  is  evidenced 
by  the  fact  that  the  weakness  and  languor  are 
Mtly  less  alter  meals  consisting  of  farina- 
ceous foods  only. 

That  peptone  finds  its  way  into  the  general  cir- 
culation frequently  is  shown  by  its  detection  in 
the  urine  in  many  diseased  conditions,  some  of 
which  are  infectious  and  others  autogenous  in 
character.  However,  propeptonuria,  or  albumo- 
suria, is  more  common  than  peptonuria,  and  we 
have  already  seen  that  many  of  the  bacterial  al- 
bumoses  are  among  the  most  highly  poisonous 
bodies  known,  but  the  action  of  the  albumoses 
formed  during  digestion  has  not,  so  far  as  I  know, 
been  studied.  The  valuable  work  of  Kiihne  and 
Chittenden  on  the  chemical  character  of  these 
bodies  should  be  supplemented  by  a  thorough  in- 
vestigation of  their  physiological  effects  when  in- 
jected into  the  blood.  It  is  more  than  probable 
that  valuable  information  would  be  secured  by 
such  studies.  That  albumose  is  frequently  found 
in  the  urine  is  shown  by  the  following  list  of  dis- 
eases in  which  it  has  been  observed,  given  in  the 
last  edition  of  the  work  of  Neubauer  and  Vogel 
on  the  urine.  Kbsner  has  found  it  in  sperma- 
torrhoea ;  Kbppen,  in  mental  diseases  without 
spermatorrhoea  ;  Kahler,  in  osteomalacia  ;  Bence 
Jones,  in  multiple  myeloma ;  Senator  and  others, 
in  dermatitis,  intestinal  ulcer,  liver  abscess, 
croupous  pneumonia,  apoplexy,  vitium  cordis, 
resectio  coxae,  parametritis,  endocarditis,  typhoid 
fever,  nephritis,  phthisis,  etc.;  Loeb,  in  measles 
and  scarlet  fever  :  I.eube,  in  urticaria  ;  and  Las- 
sar,  after  inunctions  of  petroleum.  Kottnitz, 
Fursti  er  and  others  find  albumose  frequently  in 
the  urine  in  mental  diseases.  Evidently,  there  is 
much  to  learn  from  the  study  of  the  conditions 
accompanied  by  the  elimination  of  the  albumoses 
in  the  urine.  It  is  more  than  probable  that  the 
acute  Bright's  disease  following  scarlet  fever, 
diphtheria,  and  the  other  acute  infectious  dis- 
eases, owes  its  existence  to  the  poisonous  al- 
bumoses of  these  diseases.  Prior  has  recently 
shown  that  uudi; jested  egg  albumin  is  sometimes 
absorbed  and  produces  marked  disturbances.  A 
boy.  after  eating  sixteen  raw  eggs,  had  a  high 
fever  accompanied  by  the  appearance  of  both  al- 
bumin and  haemoglobin  in  the  urine. 

Brieger  obtained  by  digesting  fibrin  with 
gastric  juice  a  substance  which  gives  reactions 
with  many  of  the  general  alkaloidal  reagents  and 
to  which  he  has  given  the  name  "  peptotoxine." 
A  few  drops  of  a  dilute  aqueous  solution  of  this 
substance  sufficed  to  kill  frogs  within  fifteen 
minutes.  The  frogs  became  apparently  paral- 
yzed and  did  not  respond  to  stimuli.  Slight 
tremor  was  perceptible  in  the  muscles  of  the  ex 
tremities.  Rabbits  of  about  one  kilogram  weight 
were  given  from  0.5  to  1  gram  of  the  extract  sub 
cutaneously.  About  fifteen  minutes  after  the 
injection,  paralysis  beginning  in  the  posterior  ex- 


tremities set  in  :  the  animal  fell  into  a  somnolent 
condition,  sank   and  died.      In  son-., 
eral  hours  elapsed   before  the   above  mentioned 
symptoms  appeared. 

Peptotoxine  was  found  by  Brieger  to  be  formed 

not  only  by  the  digestive  juice,  but  to  be  among 

t    putrefactive   products   of    proteids,    as 

fibrin,  casein,  brain  substance,  liver  and  muscle. 

It  is  highly  probable  that  many  of  the  nervous 
symptoms    which     accompany    some    forms    oi 
dyspepsia  are  due  to  the  formation  and  ab-< 
of  poisonous  substances. 

In  some  persons  the  tendency  to  the  formation 
of  poisons  out  of  certain  foods  is  very  marked. 
Thus,  there  are  some  to  whom  the  smallest  bit  of 
egg  is  highly  poisonous;  with  others,  milk  will 
not  agree  ;  and  instances  of  this  kind  are  suffi- 
ciently numerous  to  give  rise  to  the  adage,  "what 
is  one  man's  meat  is  another  man's  poison." 

Brunton  is  of  the  opinion  that  the  condition 
which  we  term  "  biliousness,"  and  which  is  most 
likely  to  exist  in  those  who  eat  largely  of  pro- 
teids, is  due  to  the  formation  of  poisonous  alka- 
loids ;  but  of  this  we  have  no  positive  proof. 

Whether  or  not  the  unorganized  digestive  fer- 
ments ever  find  their  way  into  the  blood  in 
quantity  sufficient  to  cause  deviations  from  health, 
we  are  not  in  a  position  to  state  definitely.  The 
older  physiological  chemists  teach  us  that  pepsin 
and  trypsin  are  frequent,  if  not  constant  constitu- 
ents of  normal  urine,  but  their  experiments  were 
made  without  any  reference  to  the  possibility  of 
the  ferments  which  they  found  being  formed  by 
the  bacteria  of  the  urine,  and  after  carefully 
going  over  the  literature  of  the  subject  I  am  not 
prepared  to  pass  judgment  ou  the  truth  of  their 
.statements.  However  this  may  be,  the  fact  that 
these  ferments  manifest  a  marked  toxicological 
effect  when  introduced  into  the  blood  is  of  great 
interest,  especially  at  this  time.  Hildebrandt 
has  recently  reported  the  results  of  some  experi- 
ments made  by  himself  upon  this  subject.  He 
finds  that  a  fatal  dose  of  pepsin  for  dogs  is  from 
0.1  to  0.2  gram  per  kilogram  of  body  weight. 
The  subcutaneous  injection  of  these  quantities  is 
followed  by  a  marked  elevatiou  of  temperature, 
which  he  designates  as  "  ferment  fever. "  This 
fever  begins  within  an  hour  after  the  injection, 
reaches  its  maximum  after  from  four  to  six  hours, 
and  may  continue  for  some  days.  On  the  day 
preceding  death,  the  temperature  generally  falls 
below  the  normal.  During  the  period  of  eleva- 
tion there  are  frequent  chills. 

The  symptoms  which  accompany  the  fever 
vary  somewhat  with  the  species  of  animal.  Rab- 
bits lose  flesh  notwithstanding  the  fact  that  they 
continue  for  a  while  to  eat  well,  become  very 
weak  and  death  is  preceded  by  convulsive  move- 
ments. Dogs  tremble  in  the  limbs,  become  un- 
certain in  gait,  and  vomiting,  dyspncea  and  coma 
are  followed  by  death. 


70o 


CHEMICAL  FACTORS  IN  CAUSATION  OF  DISEASE. 


[May  i 6, 


On  section  there  is  observed  parenchymatous 
degeneration  of  the  muscles  of  the  heart,  and 
similar  changes  in  the  liver  and  kidney.  There 
are  abundant  haemorrhages  in  the  intestinal 
canal,  in  Peyer's  patches,  in  the  mesenteric 
glands  ;  and  in  the  lungs  in  cats.  Thrombi  are 
frequently  found  in  the  lungs,  and  in  some  cases 
in  the  kidneys. 

The  effect  upon  the  coagulability  of  the  blood 
is  worthy  of  note.  At  first  there  is  a  period  dur- 
ing which  the  coagulability  of  the  blood  is  greatly 
lessened,  then  follows  a  period  of  greater  rapidity 
in  coagulating,  and  it  is  in  this  latter  stage  that 
the  thrombi  are  formed. 

These  experiments  are  interesting  not  only  as 
a  possible  explanation  of  the  cause  of  some  of 
the  autogenous  fevers,  which  will  be  discussed 
later,  but  in  view  of  the  present  tendency  to  in- 
ject such  complex  animal  solutions  as  Brown- 
Sequard's  elixir  and  Koch's  lymph  subcutane- 
ously,  and  they  will  probably  cause  us  to  exer- 
cise a  little  more  care  in  this  direction. 

That  certain  febrile  conditions  are  autogenous 
there  can  be  no  doubt.  These,  like  other  dis- 
eases originating  within  the  system,  may  be  due 
to  either  of  the  following  causes:  i.  There  may 
be  an  excessive  formation  of  poisonous  substances 
in  the  body.  Thus,  Bouchard  has  shown  that 
the  urine  excreted  during  the  hours  of  activity  is 
much  more  poisonous  than  that  excreted  during 
the  hours  of  rest.  Both  physical  and  mental 
labor  are  accompanied  by  the  formation  of  these 
deleterious  bodies,  and  if  the  hours  of  labor  are 
prolonged  and  those  of  rest  shortened,  there  will 
be  an  accumulation  of  effete  matters  within  the 
system.  2.  The  accumulation  of  the  poisonous 
matters  may  be  due  to  deficient  elimination.  3. 
Some  organ  whose  duty  it  is  to  change  harmful 
into  harmless  bodies  may  fail  to  properly  perform 
its  functions.  Illustrations  of  diseased  conditions 
arising  from  these  several  causes  will  be  given. 

First,  we  may  mention  fatigue  fever,  which  is 
by  no  means  uncommon,  and  from  which  the 
over  worked  physician  not  infrequently  suffers. 
One  works  night  and  day  for  some  time  ;  elimina- 
tion seems  to  proceed  normally  ;  but  after  a  few 
days  there  is  an  elevation  of  temperature  of  from 
one  to  three  degrees,  the  appetite  is  impaired, 
and  then  if  the  opportunity  for  rest  is  at  hand 
sound  and  restful  sleep  is  impossible.  The  tired 
man  retires  to  his  bed  expecting  to  fall  asleep 
immediately,  but  he  tosses  from  side  to  side  all 
night,  or  his  sleep  is  fitful  and  unrefreshing. 
The  brain  is  excited  and  refuses  to  be  at  rest. 
The  senses  are  alert  and  all  efforts  to  sink  them 
in  repose  are  unavailing.  Fatigue  fever  is  fre- 
quently observed  in  armies  upon  forced  marches, 
especially  if  the  troops  are  young  and  unac- 
customed to  service.  Mosso  has  studied  this 
fever  in  the  Italian  army.  He  states  that  in  fa- 
tigue the  blood  is  subjected  to  a  process  of  de- 


composition brought  about  by  the  infiltration 
into  it  from  the  tissues  of  poisonous  substances, 
which  when  injected  into  the  circulation  of 
healthy  animals,  induce  malaise  and  all  the  signs 
of  excessive  exhaustion.  It  is  possible  that  in 
this  decomposition  of  the  blood  the  fibrin- ferment, 
which  according  to  Schmidt,  is  held  in  combina- 
tion in  the  colorless  corpuscles,  is  liberated  ;  and 
it  has  been  shown  'by  Edelberg,  that  the  injec- 
tion of  small  quantities  of  free  fibrin-ferment  into 
the  blood  causes  fever,  while  the  injection  of 
larger  quantities  is  followed  by  the  formation  of 
thrombi,  as  has  been  demonstrated  by  the  ex- 
periments of  Edelberg,  Bonne,  Birk  and  Kohlar. 

Fatigue  fever  is  often  accompanied,  especiall}- 
during  the  period  of  elevation,  by  chilly  sensa- 
tions, and  consequently  it  is  pronounced  malarial 
and  quinine  is  administered,  but  it  does  no  good, 
often  harm  by  increasing  cerebral  excitement. 
The  proper  treatment  is  prolonged  rest  with 
proper  attention  to  elimination. 

Then  there  is  the  fever  of  exhaustion,  which 
differs  from  fatigue  fever  only  in  degree.  It  is 
brought  on  by  prolonged  exertion  without  suffi- 
cient rest  and  often  without  sufficient  food.  The 
healthy  balance  between  the  formation  and  elim- 
ination of  effete  matter  is  disturbed,  and  it  may 
be  weeks  before  it  is  reestablished  ;  indeed,  it 
may  never  be  regained,  for  some  of  those  cases 
terminate  fatally.  The  fever  of  exhaustion  may 
take  on  the  typhus  form,  delirium  may  appear, 
muscular  control  of  the  bowels  ma}-  be  lost  and 
death  may  result. 

That  the  fever  of  exhaustion  has  been  mistaken 
for  typhoid  by  some  of  the  ablest  clinical  teachers 
is  shown  by  Peter  in  the  following  quotation  : 
"  It  was  in  1852,"  says  he,  "  when  entering  upon 
my  clinical  studies,  and  ardent  in  my  attendance 
at  the  clinic  of  Chomel,  I  was  witness  of  the 
following  instance  :  A  young  man  was  received 
under  the  celebrated  professor's  charge,  suffering 
from  prostration,  muscular  pain  and  rachialgia. 
Chomel  made  the  examination  with  all  the  care 
and  attention  used  by  him,  then,  as  was  also 
usual  with  him,  in  the  presence  of  the  patient, 
he  gave  the  diagnosis  in  Latin,  which  was  aid 
f&bri:  pi  vii  \m  aid  ar-:i:i  ifii  />=:  ;;>-s  either  t"»  - 
phoid  fever,  or  incipient  small- pox.  I  felt  rather 
dissatisfied  at  a  diagnosis  so  little  precise,  by  one 
so  eminent  in  his  art.  The  truth  of  the  matter 
was,  though  Chomel  was  not  aware  of  it,  this 
young  fellow  in  a  state  of  destitution  had  walked 
from  Compeigne  to  Paris,  sleeping  by  the  way- 
side at  night  and  nourishing  himself  with  such 
refuse  food  as  chance  supplied.  It  was  under 
such  circumstances  the  patient  had  developed  fe- 
brile symptoms.  The  day  after  his  admission 
and  simply  from  rest  in  bed,  he  felt  better,  and 
the  day  following  he  was  altogether  well." 

That  all  cases  of  the  fever  of  exhaustion  do 
not  terminate  so  rapidly  as  that  instanced  above 


i89i.] 


CHEMICAL  FACTORS  IN  CAUSATION'  OF  DISEASE. 


by  the  great  French  teacher,  is  shown  by  one 
which  I  happen  to  have  under  my  care  at  the 
present  moment.  A  lady,  rather  frail  in  body, 
but  without  any  organic  disease,  spent  the  greater 
part  of  the  time  day  and  night  for  ten  days  in 
the  sick-room  of  her  child  who  died  with  diph- 
theria. Since  the  death  of  the  child,  the  mother 
has  been  confined  to  her  bed  with  a  fever  which 
varies  from  990  to  102. 50.  She  has  no  soreness 
of  throat  or  other  evidences  of  infection  with 
diphtheria.  She  has  no  symptoms  of  typhoid 
fever,  and  with  the  exception  of  slight  constipa- 
tion, which  has  been  easily  relieved,  her  bowels 
have  remained  in  good  condition.  She  took  but 
little  food  during  the  sickness  of  the  child  and 
has  had  no  desire  for  food  since.  Her  tempera- 
ture is  but  slightly  affected  by  two-grain  doses  of 
antifebrin  and  the  highest  point  reached  each 
day  is  very  variable.  The  mind  is  clear  and  she 
has  been  altogether  free  from  headache.  Her 
temperature  is  lowered  by  a  few  hours  sleep. 
This  condition  has  now  continued  for  nineteen 
days.  I  have  pronounced  this  a  case  of  fever 
from  exhaustion,  and  if  this  diagnosis  is  not  cor- 
rect, I  must  admit  that  I  do  not  understand  the 
nature  of  the  case. 

A  case,  similar  to  the  above,  I  saw  some  time 
ago  in  a  young  man  who  had  been  leading  quite 
an  inactive  life  as  a  student,  and  who  did  a  very 
foolish  thing  in  walking  one  day  a  distance  of 
more  than  thirty  miles.  The  next  morning  he 
had  a  fever,  which  varied  from  990  to  1030,  and 
which  continued  for  more  than  one  month.  The 
physician  in  charge  pronounced  this  a  case  of 
typhoid,  but  of  the  correctness  of  his  diagnosis 
there  was  not  the  slightest  evidence.  In  this  in- 
stance, quinine  was  first  employed,  but  it  in- 
creased the  wakefulness  and  restlessness,  and  was 
followed  by  an  elevation  in  the  temperature. 

I  have  known  at  least  one  case  of  this  kind  to 
terminate  fatally,  and  a  most  thorough  post  mor- 
tem examination  failed  to  reveal  any  definite  le- 
sion. 

Then,  again,  there  is  the  fever  of  non-elimina- 
tion, which  all  physicians  of  experience  have  ob- 
served. There  is  a  feeling  of  languor,  the  head 
aches,  the  tongue  is  coated,  the  breath  offensive, 
and  the  bowels  constipated.  The  physician  fears 
typhoid  fever,  but  finds  that  a  good,  brisk  cathar- 
tic dissipates  all  unpleasant  symptoms,  and  the 
temperature  falls  to  the  normal.  This  fever  is 
also  liable  to  appear  among  those  who  are  con- 
fined to  bed  from  other  causes.  Brunton  says  : 
"No  one  who  has  watched  cases  of  acute  dis- 
eases, such  as  pneumonia,  can  have  failed  to  see 
how  a  rise  of  temperature  sometimes  coincides 
with  the  occurrence  of  constipation,  and  is  re- 
moved by  opening  the  bowels."  The  surgeon 
and  obstetrician  have  often  had  cause  to  rejoice 
when  they  have  found  a  fever,  which  they  feared 
indicated  septicaemia,  disappearing  after  free  pur- 
gation. 


Bouchard  has  shown  that  normal  fseces  contain 
a  highly  poisonous  substance,  which  may  be  sep- 
arated from  them  by  dialysis,  and  which,  when 
administered  to  rabbits,  produces  violent  convul- 
sions. He  estimates  that  the  amount  of  poison- 
ous alkaloids  formed  in  the  intestines  of  a  healthy 
man  each  twenty-four  hours,  would  be  quite  suf- 
ficient to  kill,  if  it  was  all  absorbed.  He  pro- 
poses the  term  stercorsemia  for  that  condition 
which  results  from  arrest  of  excretion  from  the 
intestine. 

It  is  more  than  probable  that  the  poisons  of 
the  intestines  are  due  to  the  bacteria  which  are 
normally  present ;  but  this  would  not  exclude 
the  fever  of  non-elimination  from  the  list  of  au- 
togenous diseases.  The  bacterial  cells  which  are 
normally  present  in  the  intestines,  cannot  be  re- 
garded as  invaders  from  without. 

It  would  seem  from  some  recent  studies,  that 
not  all  surgical  fevers  are  due  to  bacterial  activ- 
ity. The  absorption  of  aseptic  blood  clots,  and 
of  disintegrated  tissue  in  cases  of  complicated 
fractures  and  contusions  of  the  joints,  is  accom- 
panied by  an  elevation  of  the  temperature  above 
normal.  A  like  result  ma}-  follow  the  intrave- 
nous injection  of  a  sterile  solution  of  haemoglo- 
bin, or  of  the  blood  or  another  animal.  The  caus- 
ative agent  in  the  production  of  these  fevers  re- 
mains unknown.  In  the  blood  of  twelve  out  of 
fifteen  patients  with  aseptic  fever,  at  the  clinic  of 
Nothnagel,  Hammerschlag  has  found  free  fibrin- 
ferment,  but  in  five  persons  without  fever  he 
found  the  same  substance  in  the  blood.  This 
leaves  the  causative  agent  in  the  production  of 
the  aseptic,  or  more  properly  speaking,  the  non- 
bacterial, fevers  unknown. 

The  chemical  theory  of  so-called  uraemia  has 
received  support  in  recent  researches,  notwith- 
standing the  fact  that  the  old  idea  that  urea  is 
the  active  poison,  and  the  theory  of  Frereiches, 
that  ammonium  carbonate  is  the  active  agent, 
have  been  abandoned.  Landois  laid  bare  the 
surface  of  the  brain  in  dogs  and  rabbits,  and 
sprinkled  the  motor  area  with  kreatin,  kreatinin 
and  other  constituents  of  the  urine. 

Urea,  ammonium  carbonate,  sodium  chloride 
and  potassium  chloride  had  but  slight  effect,  but 
kreatin,  kreatinin  and  acid  sodium  phosphate 
caused  clonic  convulsions  on  the  opposite  side  of 
the  body,  which  later  became  bilateral.  The 
convulsions  continued  at  intervals  for  from  two  to 
three  days,  when  growing  gradually  weaker,  they 
disappeared.  Landois  concludes  that  chorea 
gravidorum  is  a  forerunner  of  eclampsia.  These 
experiments  have  been  confirmed  byr  Leubuscher 
and  Zeichen. 

Falck  injected  into  both  sound  and  nephroto- 
mized  animals  fresh  urine,  urine  and  the  ferment 
of  Musculus  and  Lea,  and  urine  which  had  un- 
dergone spontaneous  decomposition,  without  pro- 
ducing  any  symptoms  which  were  comparable 


702 


MEDICAL  PROGRESS. 


[May  i 6, 


with  those  observed  in  uraemia.  However,  he 
did  find  that  if  a  few  drops  of  an  infusion  of  pu- 
trid flesh  was  added  to  the  urine  before  injection, 
all  the  typical  symptoms  of  uraemia  were  induced. 
That  the  infusion  of  putrid  flesh  alone  had  no 
effect,  was  also  demonstrated.  This  would  lead 
us  to  believe  that  some  ferment  in  the  infusion 
converts  some  constituent  of  the  urine  into  a 
highly  poisonous  body.  In  this  connection,  at- 
tention may  be  called  to  the  fact  that  kreatin 
may  be  converted,  by  the  action  of  certain  germs, 
into  methyl-guanidin,  which  produces  convul- 
sions. Whether  such  conversion  occurs  in  urae- 
mia or  not,  and  if  it  does  what  the  cause  of  it  is, 
are  questions  which  must  be  left  for  future  inves- 
tigations to  decide.  It  would  be  well  for  some 
one  to  test  the  brain  and  blood  of  a  person  who 
has  died  in  uraemic  convulsions  for  methyl-guan- 
idin. 


MEDICAL    PROGRESS. 


Therapeutics  ami  lMiarmaoolog-y. 

Simple  Method  for  Controlling  Epis- 
taxis. — Dr.  W.  W.  Parker,  of  Richmond,  Va., 
gays  in  the  New  York  Medical  Record ;  The  plan 
of  arresting  haemorrhage  from  the  nose,  which  I 
here  describe,  I  have  used  for  thirty  years  with 
out  one  failure.  When  I  first  began  to  practice 
I  used  Bellocq's  instrument,  but  found  it  painful, 
and  in  small  children,  exceedingly  troublesome 
of  application.  The  little  device  which  I  use  is 
made  of  fifteen  of  the  long  threads  of  patent  lint, 
size  three  and  one-half,  or  four  inches  long,  which 
I  double  on  themselves  and  tie  in  the  middle,  and 
let  one  end  of  the  string  be  six  or  eight  inches 
long  so  as  to  pull  the  plug  out  when  necessary. 
When  doubled  on  itself  it  looks  like  a  "comet" 
in  miniature,  with  a  nucleus  and  thirty  tails  or 
twice  the  number  of  threads  used.  A  probe  is 
pressed  up  against  the  centre,  and  is  passed  back 
upon  the  floor  of  the  nasal  cavity  and  pushed  on 
till  you  reach  the  posterior  nares.  This  will  be 
known  both  by  the  resistance  and  the  length  of 
the  probe,  or  the  depth  which  you  have  reached. 
Then  slowly  withdraw  the  probe  and  plug  the 
anterior  nares  and  you  have  arrested  the  bleeding. 
These  twenty  or  thirty  ends  floating  in  the  blood 
at  once  coagulate  it.  The  passage  of  the  soft 
lint  gives  no  pain  whatever.  If  lint  is  not  at 
hand  I  use  the  largest  size  spool  cotton.  The 
plug  is  removed  in  from  twenty-four  to  forty- 
eight  hours.  It  gives  no  pain  and  the  pa- 
tient is  willing  for  it  to  remain.  The  other 
methods  are  all  painful  in  execution,  and  the  dis- 
comfort, while  the  plug  remains,  is  very  con- 
siderable. 

Medleine. 

Bromism  and  Intestinal  Antisepsis. — In  a 
note  read  before  the  Societe  de  Biologie,  at   the 


meeting  held  January  24,  1891,  Dr.  Ferret 
continues  the  study  of  the  influence  of  intes- 
tinal antisepsis  on  bromism,  already  referred  to 
in  a  previous  number  of  the  Gazette  {La  Medicine 
Moderne,  February  5,  1891).  He  confirms  the 
statement  already  mentioned  that  not  only  may 
one  with  sufficient  doses  of  naphthol  and  salicy- 
late of  bismuth  prevent  cutaneous  manifestations 
of  bromism,  but  one  may  by  these  means  even 
cure  an  eruption,  if  already  so  produced.  He 
also  maintains  that  borax  also  may  produce  erup- 
tions quite  as  serious  as  those  which  follow  the 
administration  of  large  amounts  of  bromides,  and 
that  such  eruptions  may  be  likewise  treated  and 
cured  by  the  same  method.  He  believes  that  his 
experience  has  demonstrated  that  this  method 
should  be  generally  employed,  and  always  with 
a  prospect  of  success  in  the  treatment  of  the  cu- 
taneous manifestations  which  follow  the  inges- 
tion of  drugs  — Therapeutic  Gazette. 

Chronic  Rheumatism  and  the  Nervous 
System. — A  novel  and  suggestive,  if  somewhat 
revolutionary,  theory  in  reference  to  the  depend- 
ence of  chronic  rheumatic  joint  changes  on  a  mor- 
bid condition  of  the  central  nervous  system  is  ad- 
vocated in  a  work  by  Dr.  Wichmann,  of  which 
an  abstract  is  furnished  in  a  recent  number  of  the 
Centra.lbla.tt  fur  Klinische  Medicin.  The  author 
began  his  work  six  years  ago,  with  the  view  of 
explaining  the  nervous  symptoms  associated  with 
rheumatic  joint  affection,  and  the  dependence  of 
those  upon  a  central  cause  was  first  suggested  by 
the  occurrence  of  symmetrical  phenomena  such 
as  patches  of  erythema,  subcutaneous  nodules, 
etc.  Charcot  has  explained  the  occurrence  of 
contractures  in  rheumatism  by  supposing  that 
there  is  an  inflammation  of  the  articular  nerves, 
the  influence  of  which  is  transmitted  to  the  cen- 
tres in  the  cord,  there  giving  rise  to  irritation  of 
the  motor  roots  ;  and  the  fact  that  the  contracture 
is  usually  in  the  flexed  position  is  explained  by 
the  greater  power  of  flexors  as  contrasted  with 
extensors.  But  it  is  pointed  out  that  this  would 
not  explain  the  occasional  occurrence  of  extensor 
contraction,  and  that,  moreover,  in  other  condi- 
tions giving  rise  to  joint  affection,  such  contrac- 
tures do  not  take  place.  Further,  as  supporting 
the  theory  of  a  central  lesion  for  those  conditions, 
attention  is  directed  to  the  occurrence  of  arthro- 
pathies in  tabes  and  other  spinal  conditions,  and 
ii  is  contended  that  a  feasible  explanation  of  the 
vaso- motor  and  trophic  disturbances  —  such  as 
"  glossy  skin" — as  well  as  of  the  disturbance  of 
sensibility,  is  offered  by  such  a  hypothesis. —  The 
Lancet. 

Chlorosis  and  its  Treatment. — Dr.  Fred- 
erick Scholz,  of  Bremen,  has  published  a  re- 
markable work  on  chlorosis,  the  outcome  of 
observations  made  during  the  last  twenty  years. 


i89i-] 


MEDICAL  PROGRESS. 


703 


Instead  of  regarding  the  deficiency  of  iron  or 
haemoglobin,  or  even  that  of  the  red  corpuscles, 
as  the  primary  affection,  he  states  that  contrac- 
tion of  the  vessels  is  always  present  in  these  cases, 
as  indeed  was  observed  by  Bamberger,  Rokitan- 
sky  and  Yirchow  ;  and  this,  he  contends,  is  not 
to  be  regarded  as  a  complication  due  to  an  altered 
condition  of  the  blood,  but  as  the  primary  condi- 
tion which  is  followed  by  the  morbid  change  in 
the  blood.  As  a  matter  of  fact,  the  vessels  are. 
he  says,  too  full,  or  in  the  condition  termed  by 
the  older  physicians  plethora  ad  vasa,  the  blood 
being — or  becoming— abnormally  serous.  Long 
ago  his  attention  was  struck  by  the  cold  and  livid 
condition  of  the  skin  in  anaemic  subjects,  and  he 
was  led  by  this  to  employ  hot  baths,  together 
with  gentle  friction,  in  the  treatment,  with  the 
view  of  acting  directly  upon  the  Skin,  so  as  to 
improve  the  vitality  and  nutrition  generally.  The 
success  of  his  first  attempts  was  so  marked  that 
he  was  encouraged  to  persevere  in  this  line  of 
treatment,  and  he  has  since  had  many  opportuni- 
ties of  extending  his  experience  with  it.  Hot 
baths  diminish  the  plethora  by  relaxing  the  ten- 
sion of  the  vascular  system,  which  is  high,  quick- 
ening the  circulation,  and  thus  relieving  the  pal- 
pitation, dyspnoea  and  other  symptoms.  In  thirty 
cases  where  the  distress  of  the  patient  was  Very 
great.  Dr.  Scholz  has  gone  a  step  further  and 
supplemented  the  hot  bath  by  venesection.  Par- 
adoxical as  this  treatment  may  appear,  it  was 
followed  by  marked  benefit,  and  if  the  theory  of 
the  pathology  of  chlorosis  above  mentioned  be 
correct,  there  can  be  little  doubt  that  the  novel 
line  of  treatment  practiced  by  Dr.  Scholz  is  justi- 
fiable. —  Therapeutic  Gazette 

Snrg-ery. 

The  Treatment  of  Stricture  of  the 
Male  Urethra.  —  Dr.  J.  William  White 
{University  Medical  Magazine,  Vol.  iii.  No.  6, 
1891),  after  giving  his  views  in  extenso  as  to  the 
treatment  of  organic  stricture  of  the  male  urethra, 
summarizes  them  as  follows  : 

1.  Strictures  of  large  calibre — that  is,  of  more 
than  No.  15  French,  situated  at  or  behind  the 
bulbo-membranous  urethra — aie  to  be  treated, 
almost  without  exception,  by  gradual  dilatation. 

2.  Strictures  of  large  calibre,  occupying  the 
pendulous  urethra,  are  to  be  treated  by  gradual 
dilatation  when  very  recent  and  soft,  and  by  in- 
ternal urethrotomy  when  of  longer  standing,  dis- 
tinctly fibrous  in  character,  or  non  dilatable.  It 
is  to  be  remembered  that  the  great  majority  of 
so-called  strictures  of  large  calibre  of  the  pendu- 
lous urethra  are  merely  points  of  physiological 
narrowing. 

3.  Strictures  of  the  meatus  and  of  the  neigh- 
borhood of  the  fossa  navicularis  should  be  divided 
upon  the  floor  of  the  urethra  whenever  it  is  evi- 
dent that   they  are  real  pathological  conditions 


producing    definite  symptoms,    and  not    normal 
points  of  narrowing. 

4.  Strictures  of  small  calibre  (less  than  No.  15 
French  >  situated  in  advance  of  the  bulbo-mem- 
branous junction,  unless  seen  very  early  and 
found  to  be  not  usuaHy  soft  and  dilatable,  fur- 
nish the  typical  condition  for  internal  urethrot- 
omy, which  should  be  done  preferably  with  a 
dilating  urethrotome,  and  invariably  with  all  pos- 
sible antiseptic  precautions. 

5.  Strictures  of  small  calibre  (less  than  No.  15 
French)  situated  at  or  deeper  than  the  bulbo- 
membranous  junction  should  be  treated,  when- 
ever possible,  by  gradual  dilatation.  In  a  case 
of  resilient  irritable  or  traumatic  stricture  in  this 
region,  or  of  stricture,  which,  for  any  reasc:. 
the  occurrence  of  rigors),  is  non  dilatable,  ex- 
ternal perineal  urethrotomy  is  the  operation  of 
choice. 

6.  Strictures  of  the  deep  urethra  permeable 
only  to  filiform  bougies  should  be  treated  by 
gradual  dilatation  when  possible,  the  filiform  be- 
ing left  in  situ  for  some  time,  and  followed  by 
the  introduction  of  others,  or  used  as  a  guide  for 
a  tunnelled  catheter.  If  the  stricture  be  not  suit- 
able for  dilatation,  external  perineal  urethrotomy 
should  be  performed. 

7.  Impassable  strictures  of  the  deep  urethra 
always  require  the  performance  of  perineal  sec- 
tion.— American  Jour.  Med.  Sciences. 

What  Became  of  a  Soft  Rubber  Pessary. 
— According  to  a  report  of  the  St.  Louis  Medical 
Society  >Ciu.  Lancet  Clinic)  Dr.  W.  B.  Dor- 
sett  exhibited  fragments  of  a  soft  rubber  ring  or 
air  pessary,  with  the  following  history:  Patient 
over  50,  admitted  to  hospital  for  supposed  cancer 
of  uterus.  She  had  fever,  a  very  offensive  dis- 
charge from  the  vagina,  and  much  pain.  The  use 
of  a  syringe  revealed  a  hardened  pessary,  which 
required  to  be  broken  into  pieces  before  removal. 
The  pessary  had  been  introduced  one  month  be- 
fore, but  had  become  hard  and  inflexible  by  the 
action  of  the  vaginal  secretions,  causing  indirect- 
ly excoriations,  fissures  and  lacerations,  with  sep- 
ticaemia as  the  result.  Dr.  Jacobson  followed 
with  the  statement  that  he  had  removed  a  pessary 
reposited  about  five  months  before,  and  which 
had  been  closed  over  by  the  vaginal  walls.  A 
very  offensive  discharge  was  also  present  in  his 
case. 

l'atholorv. 

Etiology  of  Tetanus. — Tetanus,  as  distin- 
guished from  the  tetanic  spasms  of  strychnine 
poisoning,  and  the  opisthotonos,  etc.,  incident  to 
some  myelites.  has  generally  been  considered  as 
j  a  disease,  or  aggregate  of  phenomena,  consisting 
I  essentially  of  a  tonic  spasm  of  all  the  muscles  of 
j  the  body,  beginning  with  those  of  the  jaws  and 
I  neck,  and  ending  with  those  of  respiration.    Two 


7°4 


MEDICAL  PROGRESS. 


[May  16. 


forms  have  been  recognized — the  traumatic  and 
the  idiopathic ;  the  former  always  following  the 
reception  of  some  wound,  either  one  into  which 
dirt  has  entered,  or  which  has  taken  on  an  un- 
healthy character ;  the  other,  in  which  no  such 
cause  has  been  discovered,  has  been  attributed  to 
exposure  to  cold  and  wet — such  an  explanation 
being,  however,  based  on  negative  evidence. 

But  the  researches  of  Carle  and  Rattone,  Xico- 
laier,  Rosenbach,  Brieger,  Beumer,  Langer  and 
Eiselsberg,  leave  no  room  for  doubt  that  it  is 
properly  to  be  classed  among  specific  diseases, 
and  that  the  phenomena  are  caused  by  the  en- 
trance into  the  organism  of  a  microbe  which 
exists  outside  of  the  body,  and  is  widely  or  al- 
most universally  distributed  in  earth  and  dust. 
It  has  been  induced  in  animals  by  the  injection 
of  emulsions  of,  or  the  juice  expressed  from,  the 
sciatic  nerve  of  men  or  other  animals  that  have 
died  of  the  disease.  Nicolaier  used  common  gar- 
den soil  with  success,  though  the  same  earth, 
when  baked  or  otherwise  sterilized,  merely  set 
up  local  irritation  and  abscesses.  Rosenberg  dis- 
covered and  used  a  bacillus  present  in  the  sub- 
stance of  the  nerves  of  tetanic  individuals;  Brieger 
employed  a  chemical  product  derived  from  pure 
cultures  of  the  bacillus ;  Beumer  used  all  these 
means;  and  Eiselsberg  has  recently  reinvesti- 
gated the  whole  question. 

The  first  impulse  to  research  in  this  direction 
was  given  by  Drs.  Carle  and  Rattone,  who,  ob- 
serving an  extraordinary  proportion  of  cases  of 
tetanus  among  a  number  of  workmen  admitted 
to  the  hospital  in  consequence  of  injuries  received 
by  the  fall  of  some  old  buildings  in  course  of 
demolition,  concluded  that  there  must  have  been 
some  common  and  local  cause,  and  thought  that 
it  was  most  probably  to  be  found  in  the  dust  that 
had  entered  the  wounds.  Inserting  some  of  the 
dust  gathered  from  the  place  into  the  subcutane- 
ous connective  tissue  of  various  animals,  they 
produced  tetanus  in  the  larger  proportion. 

Langer  reported  the  cases  of  five  horses  who 
died  of  tetanus  after  castration  with  the  same 
ecraseur,  which,  having  been  subsequently  boiled 
in  oil,  was  used  without  ill  results. 

Eiselsberg,  haying  verified  by  experiment  the 
results  obtained  by  all  previous  observers,  comes 
to  the  conclusion  that  the  belief  in  the  spontane- 
ous origin  of  some  cases  of  tetanus,  like  those  of 
erysipelas,  is  based  on  errors  of  observation,  some 
abrasion  being  present  though  unnoticed. 

The  greater  frequency  of  tetanus  after  wounds, 
especially  lacerated  wounds  of  the  hands  and 
feet,  is  easily  accounted  for  by  the  fact  that,  in 
the  acts  of  grasping  or  treading,  such  wounds  are 
most  likely  to  be  attended  by  the  entrauce  of  dirt. 
— .  I  merican  Journal  Medical  Sciences. 

An  Early  Ataxic  Sign. — Weiss,  of  Vienna, 
says  that  an  early  symptom  of  locomotor  ataxia 


is  an  inability  on  the  part  of  the  patient  to  walk 
backward,  while  as  yet,  and  in  other  ways,  he 
may  be  able  to  walk  with  firmness  and  rapidity. 
Perron,  of  Bordeaux,  has  also,  as  we  stated  sev- 
eral weeks  ago,  recently  suggested  an  early  diag- 
nostic sign,  which  is  simply  a  modification  of  the 
Romberg  test  —  namely,  causing  the  suspected 
ataxic  patient  to  stand  upon  one  leg,  instead  of 
two,  with  the  eyes  closed.  If  the  patient  shows 
a  tendency  to  fall,  it  may  be  inferred  that  the 
spinal  trouble  has  begun  which  will  lead  on  to 
locomotor  ataxia,  even  if  the  Romberg  test  fails, 
as  it  not  infrequently  does  in  cases  that  are  not 
well  advanced. — New  York  Medical  Journal. 

Hemianopsia  as  a  Diagnostic  Sign  of  Brain 
Disease. — At  the  close  of  an  interesting  paper  on 
the  above  sulaject  the  author  says  ; 

The  following  propositions  embody  the  main 
points,  together  with  a  few  to  which  time  does 
not  permit  me  to  refer : 

i.  Lateral  homonymous  hemianopsia  is  always 
the  result  of  a  lesion  between  the  chiasm  and  the 
occipital  lobe,  situated  on  the  side  opposite  to  the 
blind  half  visual  fields. 

2.  Temporal  hemianopsia  is  invariably  the  re- 
sult of  a  lesion  involving  the  chiasm,  and  prob- 
ably always  its  central  mass,  though  possibly  its 
under  surface. 

3.  Xasal  hemianopsia  is  always  the  result  of 
arterial  disease,  or  possibly  two  symmetrical  mor- 
bid growths,  pressing  on  outer  margins  of  chiasm. 

4..  Horizontal  hemianopsia  may  be  the  result 
of  a  symmetrical  lesion  of  both  occipital  lobes, 
so  situated  as  to  involve  homologous  quadrants 
of  the  retina ;  or  possibly  a  lesion  pressing  upon 
the  under  or  upper  surfaces  of  the  optic  nerves. 

5.  Color  hemianopsia  is  always  of  cortical  ori- 
gin. 

6.  The  presence  of  the  pupillary  light  reflex  in 
the  blind  segments  of  the  retina,  proves  that  the 
lesion  is  back  of  the  basal  ganglia. 

7.  The  decussation  of  the  optic  fibres  in  the 
chiasm  is  partial,  but  varies  considerably  iu  de- 
gree, thus  explaining  the  variations  in  the  size 
of  the  blind  fields  in  lateral  homonymous  hemi- 
anopsia. 

S.  In  temporal  and  nasal  hemianopsia,  and  all 
other  cases  of  hemianopsia,  due  to  lesion  in  front 
of  the  basal  ganglia,  all  forms  of  vision  are  inva- 
riably lost. 

9.  The  macula  lutea,  and  a  variable  space 
around  it,  is  supplied  with  fibres  from  both  hemi- 
spheres, thus  explaining  the  pretty  constant  pres- 
ervation of  central  vision,  as  well  as  variations  of 
the  boundary  line  between  the  blind  and  sensi- 
tive fibres  of  the  retinae  in  cases  of  hemianopsia. 

10.  Choked  disc  can  no  longer  be  regarded,  as 
stated  by  a  recent  systematic  writer  (Ranney), 
as  an  absolute  contraindication  against  the  tre- 
phine.— McCaskey,  in  American  Lancet. 


'»9i.] 


EDITORIAL. 


705 


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Address 

Journal  of  the  American  Medical  Association, 
.'.'abash  ave.. 

Chicago.  Illinois. 
All  members  of  the  Association  should  send  their  Annual  Dues 
to  the  Treasurer,  Richard  J.  Dunglison.  M.D.,  Lock  Box  1274,  Phila- 
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London  Office,  57  and  59  Lcdgate  Hill. 


SATURDAY,   MAY    16.    1S91. 


THE  EDITORIAL  MANAGEMENT  OF  "THE 
JOURNAL." 

The  emphatic  endorsement  of  the  editorial  and 
business  management  of  The  Journal  by  the 
Association  in  general  session,  and  the  recom- 
mendation that  the  same  be  continued  were,  of 
course,  matters  of  extreme  satisfaction  to  those 
charged  with  these  duties,  as  was  the  unanimous 
concurrence  of  the  Board  of  Trustees  in  the  deci- 
sion to  continue  the  publication  of  The  Journal 
at  Chicago. 

A  very  large  number  of  the  members  supposed 
that  the  continued  publication  of  The  Journal 
in  that  city  also  ensured  the  continuance  of  its 
former  editorial  and  business  management.  Upon 
this  latter  question  its  Trustees  are  divided,  and 
not  being  able  to  reach  a  satisfactory  conclusion 
at  Washington,  a  special  meeting  is  called  to 
meet  at  Chicago  for  the  final  decision  of  the 
question. 

In  view  of  this  fact  we  wish  to  express  our  sin- 
cere thanks  to  the  profession,  and  especially  to 
the  medical  press,  for  the  very  cordial  considera- 
tion which  we  have  received  at  their  hands,  and 
to  state  that  with  this  number  of  The  Journal 
the  editorial  supervision  which  has  existed  for 
the  last  two  years  will  terminate. 


THE  FORTY-SECOND  ANNUAL  MEETING. 
The  annual  meeting  of  the  Association  at 
Washington  convened  on  May  5.  The  general 
sessions  were  held  in  Albaugh's  Opera  House, 
and  the  Sections  were  assigned  to  various  assem- 
bly rooms  in  the  city.     Dr.  D.  C.  Patterson,  as 


Chairman  of  the  Committee  of  Arrangements, 
was  everywhere  present  as  occasion  required, 
•  and  discharged  the  duties  incident  to  his  position 
in  a  manner  most  admirable. 

To  the  Honorable  John  W.  Ross,  one  of  the 
Commissioners  of  the  District  of  Columbia,  the 
Association  was  indebted  for  a  most  cordial  wel- 
come. In  the  course  of  his  Address  he  proceeded 
to  consider  the  fact  that  while  there  was  a  sacred- 
I  ness  of  relation  between  the  client  and  his  coun- 
sel barring  the  latter  from  the  communication  of 
knowledge  obtained  from  the  client,  no  such 
relation  and  restriction  existed  between  the  phy- 
sician and  his  patient.  He  expressed  his  surprise 
that  the  medical  profession  had  not  required  at 
the  hands  of  legislators  such  exemption  from  the 
requirement  to  divulge  professional  secrets  as 
obtains  with  the  legal  profession.  His  allusions 
to  the  Hippocratic  oath  were  with  words  well 
chosen,  and  the  eloquence  of  his  delivery  lent 
a  special  interest  to  the  opening  session. 

The  President's  annual  address,  delivered  by 
Dr.  W.  T.  Briggs,  of  Tennessee,  was  finely  con- 
ceived, concisely  expressed,  delivered  in  a  most 
creditable  manner,  and  was  received  by  the  Asso- 
ciation with  repeated  expressions  of  applause. 
He  spoke  of  the  desirability  of  a  unification  of 
the  entire  profession — referring  to  the  organiza- 
tion of  this  Association,  the  work  it  had  already 
accomplished,  and  paying  a  feeling  tribute  of 
respect  to  its  few  surviving  founders.  His  recog- 
:  nition  of  the  rapid  advances  made  in  this  country 
I  in  medical  education  was  highly  complimentary- 
1  to  our  medical  colleges,  and  his  anticipations  ot 
!  a  still  higher  standard  of  requirements  for  gradu- 
ation in  medicine  were  most  hopeful.  He  advo- 
!  cated  such  modifications  of  present  methods  as 
would  assure  more  of  science  and  less  of  business 
in  our  annual  meetings.  He  advocated  the  de- 
'  velopment  of  an  additional  Section,  to  be  devoted 
I  to  original  research.  He  spoke  at  length  upon 
the  question  of  the  further  development  of  The 
Journal  and  the  necessity,  by  means  of  ample 
remuneration,  of  securing  the  best  possible  repre- 
sentation both  of  talent  and  culture  in  its  edito- 
rial management. 

At  the  conclusion  of  his  address  a  committee 
was  appointed  to  consider  its  various  recommen- 
dations, and  report  upon  the  same  at  a  suitable 
time. 

The  President  acquitted  himself  in  a  manner 


706 


THE  VALUE  OF  KOCH'S  TUBERCULIN. 


[May  16, 


most  creditable  as  a  presiding  officer.  His  rulings 
were  prompt,  decisive  and  impartial,  and  com- 
manded universal  satisfaction. 

The  addresses  which  were  presented  in  the  suc- 
cessive morning  sessions  were  of  a  high  order  of 
merit,  as  might  have  been  anticipated  from  the 
known  ability  of  the  men  charged  with  their 
preparation.  But  interesting  as  they  were,  we 
cannot  refrain  from  expressing  the  conviction 
that  more  of  the  morning  hours  devoted  to  Sec- 
tion work  would  materially  enhance  the  value  of 
our  annual  sessions. 

Neither  time  nor  space  will  permit  reference  to 
the  special  work  in  the  Sections.  Our  readers 
are  referred  to  their  several  reports.  The  success 
in'  several  of  the  Sections,  both  in  the  securing  of 
valuable  papers  and  eliciting  able  discussions  of 
the  same,  has  been  beyond  previous  precedent. 
In  due  time  their  publication  will  attest  the  fact. 

The  receptions  and  entertainments  were  in 
keeping  with  the  well  known  hospitality  of  our 
Capital  City.  That,  given  by  the  physicians  of 
the  city,  at  the  Arlington,  was  largely  attended 
and  highly  enjoyable.  The  reception  given  by 
Dr.  W.  A.  Hammond  was  also  largely  attended 
and  a  most  cordial  welcome  was  fully  appreciated. 

The  report  of  the  General  Secretary  will  give 
the  details  of  the  meeting  in  full. 

Detroit  will  be  the  next  place  of  meeting  under 
the  presidency  of  Dr.  Henry  O.  Marcy,  of 
Massachusetts. 


THE  VALUE  OF  KOCH'S  TUBERCULIN. 
In  surgical  tuberculosis  tuberculin  has  given 
more  satisfactory  results  than  in  pulmonary  dis- 
ease. At  any  rate,  no  German  surgeon  has  spoken 
of  it  with  the  want  of  confidence  which  marks  a 
few  of  the  reports  from  clinics  for  internal  dis- 
ease. In  tuberculosis  of  bones  and  joints  it  has 
proven  a  valuable  remedial  adjunct  if  used  with 
discrimination.  Wherever  the  indications  are  that 
a  tubercular  joint  requires  operative  measures,  tu- 
berculin is  not  a  substitute  for  an  operation.  But 
in  the  early  stages,  where  conservative  treatment 
has  a  fair  chance,  the  desired  recovery  can  be  ob 
tained  with  much  greater  certainty  and  in  a  much 
shorter  time  by  the  use  of  tuberculin,  in  conjunc 
tion  with  rest  and  the  usual  means  of  conservative 
treatment.  This  observation,  made  by  many  sur 
geons,  proves  that  in  those  cases,  like  the  incipi 


ent  stages  of  joint  disease,  where  a  spontaneous 
disappearance  of  tubercle  can  occur,  the  natural 
mode  of  repair  is  powerfully  aided  by  the  remedy. 
On  the  other  hand,  it  is  not  unlikely  that  the  very 
object,  the  reabsorptiou  of  the  tubercular  infiltra- 
tion, without  destruction  of  tissue,  can  be  frustra- 
ted by  too  intense  reaction.  If  the  destruction 
has  gone  too  far  for  conservative  treatment,  tu- 
berculin alone  is  of  no  service.  Whether  its  ac- 
tion can  facilitate  a  subsequent  operation  by  al- 
lowing the  surgeon  to  distinguish  more  easily 
between  healthy  and  diseased  tissue,  on  account 
of  the  partial  necrosis  of  the  latter,  has  not  yet 
been  definitely  decided.  All  observers  agree  that 
the  action  of  tuberculin  shows  to  best  advantage 
after  operations  removing  the  tubercular  parts. 
For  now,  if  no  reaction  occurs,  a  definite  guar- 
antee of  freedom  from  tubercle  bacilli  is  given, 
which  the  most  thorough  operation  does  not  give 
with  equal  certainty.  If,  however,  the  parts  are 
still  infected,  the  wounds  heal  and  close  with  a 
rapidity  which  contrasts  favorably  with  the  fre- 
quent persistence  of  fistulas  and  the  not  rare  ne- 
cessity for  secondary  operation  after  treatment 
without  tuberculin.  The  published  reports  seem 
to  show  that  in  surgical  cases  without  internal 
complication,  tuberculin  is  more  manageable  in 
its  effect  and  evidently  a  less  dangerous  agent 
than   in  phthisis  and  other  internal  localizations. 

While  tuberculin  produces  a  decided  local  reac- 
tion in  tuberculous  glands,  followed  by  their 
shrinkage,  it  does  not  appear  as  yet  from  any  re- 
port that  such  glands  can  be  completely  cured,  at 
least  without  operation  Occasional^'  they  sup- 
purate after  injection,  and  can  then  be  opened, 
healing  in  this  way  quite  promptly. 

The  reaction  to  tuberculin  (local  as  well  as 
general),  has  proven  the  tubercular  nature  of  va- 
rious forms  of  disease,  hitherto  not  known  to  be 
such.  Koenigshoefer  and  Maschke  claim  to  have 
seen  local  reaction,  with  a  decided  curative  ten- 
dency, in  a  form  of  chronic  iritis,  as  well  as  in  a 
case  of  (non  syphilitic)  interstitial  keratitis.  Their 
reports,  however,  are  not  complete  enough  to  be 
convincing.  More  reliance  may  be  placed  in  the 
same  authors'  statements  concerning  the  curative 
effects  of  the  lymph  in  a  case  of  conjunctival  dis- 
ease, closely  resembling  trachoma.  They  also 
found  that  corneal  ulcers  in  scrofulous  children 
react  favorably  to  tuberculin.  The  same  obser- 
vation has  been  made,  as  to  the  reaction  of  cor- 


I89I.J 


THERAPEUTIC  VALUE  OE  SUSPENSION. 


707 


neal  infiltration  at  least,  in  some  of  the  scrofu- 
lous eases  by  Uhthof  (and  also  by  the  writer). 
Several  reports  from  other  hospitals  also  state  that 
in  a  few  instances,  under  the  tuberculin  treatment, 
an  ulcer  developed  in  the  cornea,  which  healed 
with  a  promptness  suggesting  its  tubercular  na- 
ture and  the  influence  of  the  agent  upon  it.  A 
very  striking  instance  of  tubercular  tumor  of  the 
uvea  is  described  by  Landgraf,  which  disappeared 
completely  by  absorption  in  consequence  of  thirty- 
five  injections  made  in  the  course  of  six  weeks. 

In  looking  for  an  explanation  of  the  action  of 
tuberculin  it  must  be  remembered  that  the  sub- 
stance does  not  directly  destroy  the  bacilli  in  the 
tissues.  This  statement  made  by  Koch  has  been 
corroborated  by  Israel,  Schimmelbusch  and 
others,  by  inoculating  animals  successfully  with 
tubercular  material  taken  from  patients  under 
the  tuberculin  treatment. 

As  Koch  stated  originally,  tuberculin  acts 
not  upon  the  bacilli,  but  upon  the  tubercular  tis- 
sue. Coagulation  necrosis,  which  Koch  referred 
to  as  the  result  of  the  remedy  upon  the  diseased 
part,  has  not  been  found  to  occur  in  the  human 
subject  except  as  the  result  of  an  excessively  in- 
tense reaction,  and  then  only  occasionally. 
Patches  of  skin  in  lupus  and  granulations  in  fun- 
gus joints  may  become  necrotic  in  mass,  but  this 
is  an  exception  rather  than  the  rule.  In  most  in- 
stances of  post-mortem  examinations  and  of 
specimens  taken  from  the  skin  of  lupus  patients 
under  the  action  of  the  agent  no  evidences  of  ne- 
crosis of  any  of  the  cells  constituting  the  tubercle 
have  been  found.  But  clinical  as  well  as  micro- 
scopical observation  shows  that  tuberculin  causes 
an  inflammatory  process  in  and  around  the  tu- 
bercular part.  There  is  intense  congestion  and 
effusion  of  serum  with  more  or  less  white  corpus- 
cles. The  effused  serum  forms  minute  vesicles 
under  the  epithelium  over  the  lupus  nodule,  and 
even  detaches  the  epithelium  ultimately.  When 
the  transient  inflammation  has  subsided  the  pre- 
vious histological  condition  is  apparently  restored. 
The  tubercles  and  the  bacilli  they  harbor  are  still 
there.  But  after  repeated  inflammatory  reactions 
Schimmelbusch  has  found  the  lupus  nodules 
gradually  shrinking.  More  advanced  reparative 
changes  have  been  found  by  Rindfleisch  in  tu- 
bercular ulcers  of  the  intestines  in  subjects  dying 
of  pulmonary  phthisis.  Here  the  characteristic 
grayish-yellow  coating  of  the  ulcers  was  disap- 


pearing or  had  disappeared,  and  their  surface 
was  livid  with  healthy-looking  granulations 
which  were  cicatrizing  from  the  margins.  The 
microscope  showed  still  the  presence  of  the  typi- 
cal cells  of  the  tubercle,  the  giant  and  epitheloid 
cells,  but  these  were  changing  their  shape  into 
that  of  a  spindle,  evidently  become  transformed 
into  connective  tissue.  Rindfleisch  interprets 
the  appearances  as  denoting  an  immunity  of  the 
tissue  against  the  destructive  action  of  the  bacilli. 
It  must  not  be  overlooked  that  tuberculin  ex- 
ercises an  influence  upon  the  the  entire  tubercular 
organism,  as  well  as  a  local  effect  upon  the  tu- 
bercular tissue.  The  tubercular  subject  suffers 
at  certain  stages  of  the  disease  from  constitutional 
symptoms,  like  the  loss  of  strength,  regular  and 
irregular  fever  and  night-sweats,  which  can  only 
be  construed  as  the  result  of  systemic  poisofjing 
by  the  products  of  the  tubercle  bacilli.  These 
symptoms  have  in  many  patients  been  stopped  by 
tuberculin  before  the  tubercular  infiltration  had 
disappeared.  It  must  hence  be  inferred  that  the 
remedy  either  checks  the  further  formation  of 
poisons  by  the  bacilli — a  view  not  supported  \>y 
any  other  evidence — or  that  it  renders  the  body 
insusceptible  to  their  action.  In  view  of  the  sim- 
ilar state  of  facts  as  proven  to  be  the  cause  of  ex- 
perimental immunity  in  tetanus  and  in  the  diph- 
theria, the  last  explanation  has  a  good  deal  of 
probability.  Unfortunately  we  cannot  predict  in 
every  case  that  tuberculin  will  lead  to  such  a  re- 
sult, or  that  such  immunity  from  poisoning  once 
established  will  be  permanent.  It  must  be  left 
to  future  researches  to  decide  what  special  condi- 
tions interfere  with  the  specific  curative  influence 
which  tuberculin  can  in  certain  instances  exert 
upon  tubercular  disease. 


THE  THERAPEUTICAL    VALUE  OF  SUSPENSION" 
IN  DISEASES  OF  THE  SPINAL  CORD. 

It  cannot  yet  be  said  that  the  question  of  the 
utility  of  suspension  in  treating  patients  afflicted 
with  posterior  spinal  sclerosis,  as  well  as  some 
other  diseases  of  the  spinal  cord,  is  settled.  Con- 
flicting reports  are  still  published  regarding  the 
influence  the  procedure  exercises  on  the  spinal 
cord ;  some  accepting  Horsley's  experiments 
that  showed  it  was  impossible  to  stretch  the  cord 
during  life  by  any  manipulation:  and  during  the 
past  year  Dr.  James  Cogney  published  a  paper  in 


708 


"CROWNER'S  QUEST  LAW." 


[May  i  6, 


which  he  reported  experiments  on  the  living  and 
dead  subject  that  showed  that  a  total  shortening 
of  the  spinal  cord  was  obtained  in  suspension, 
that  in  the  lumbar  region  the  cord  was  unaffected 
or  slightly  relaxed,  in  the  cervical  region  the 
membranes  were  slightly  stretched,  and  in  the 
dorsal  region  the  cord  was  shortened;  hence  sus 
pension  caused  relaxation,  not  stretching,  and 
the  former  possibly  acted  mechanically  by  break- 
ing down  adhesions  and  removing  impediments 
to  the  circulation.  This  reversal  of  the  generally 
accepted  theory  is  diametrically  opposite  to  the 
results  of  Bonuzzi's  experiments,  in  which  a 
body  lengthening  of  two  to  three  centimetres  was 
found  to  occur  in  suspension,  and  by  opening  the 
spinal  canal  a  needle  placed  in  the  cord  was  low- 
ered, from  eight  to  twelve  millimetres  during  sus 
pention,  the  cord  was  made  thinner  and  more  re- 
sistent  and  the  cauda  equina  very  tense;  the  ten- 
sion of  the  cerebro  spinal  fluid  was  increased  and 
there  were  venous  congestion  and  increased  rapid- 
ity of  the  circulation.  These  experiments  con 
cur  in  the  main  with  those  of  Motschutkovsky. 

Dr.  Eumbroso  has  experimented  with  animals, 
finding  a  very  evident  elongation  of  the  vertebral 
column  and  the  cord,  as  well  as  an  ansemia  with 
subsequent  vascular  congestion  of  the  meninges 
and  cord  that  attained  a  maximum  intensity  not 
at  the  moment  of  suspension,  but  afterward.  He 
advises  suspension  of  short  duration  as  the  spinal 
ansemia  observed  might  be  dangerous  if  pro- 
tracted ;  the  traction  should  be  graduated 
by  the  weight  of  the  patient ;  and  the  seance 
should  last  for  a  few  seconds  in  the  begin- 
ning, gradually  being  increased  to  one  or  two 
minutes,  each  seance  being  followed  by  an  inter- 
val of  from  forty-eight  to  seventy-two  hours.  Not 
only  has  this  treatment  benefited  ataxic  patients, 
but  also  patients  having  infantile  paralysis,  amyo- 
trophic lateral  sclerosis,  progressive  muscular 
atrophy,  etc. 

Altichikri  reported  during  the  past  year  one 
hundred  and  seventy-four  cases  of  ataxia  in  which 
suspension  improved  the  patient  in  one  hundred 
and  twenty-eight  cases,  produced  no  result  in 
twenty-six,  and  in  twenty  cases  the  treatment 
was  interrupted.  In  pseudo-tabes  and  impotence 
he  found  this  treatment  very  valuable;  while  in 
paralysis  agitans,  disseminated  and  lateral  scle- 
rosis, and  chronic  myelitis  his  results  were  too 
variable. 


Gilles  de  la  Tourette  finds  that  paralysis 
agitans  in  the  middle  period  of  the  disease,  chronic 
sciatica,  and  ataxia  are  benefited  by  suspension. 
In  the  latter  diseases  one  fourth  of  the  cases  are 
greatly  improved,  thirty-five  per  cent,  are  bene- 
fited moderately,  and  forty  per  cent  are  not  bene- 
fited. 

Rosenbaum  obtained  in  seventy-six  cases  of 
ataxia,  improvement  in  twenty-five,  doubtful  re- 
sults in  nine,  no  improvement  in  twenty-seven, 
and  in  fifteen  cases  treatment  was  interrupted. 
In  four  cases  of  myelitis,  three  of  paralysis  agi- 
tans, one  of  disseminated  sclerosis,  and  one  of 
lumbago,  no  benefit  followed  this  treatment. 

Benedikt  in  two  and  Tiberghien  in  twenty- 
six  cases  reported  favorable  results  from  suspen- 
sion. 

These  figures  show  that  during  recent  months 
the  therapeutic  application  of  suspension  has  not 
lapsed  into  desuetude,  and  a  more  careful  stud}' 
will  probably  indicate  what  class  of  cases  will  be 
most  benefited  by  it.  Certainly  anything  that 
will  ameliorate  more  or  less  distressing  symptoms 
in  sixty  per  cent,  of  ataxic  cases  should  not  be 
relegated  to  the  lumber-room  of  therapeutical  ap- 
pliances. 


"CROWNER'S  QUEST  LAW." 
A  New  York  daily  has  begun  to  stir  up  the 
coroner's  office  with  a  long  pole,  perhaps  with  no 
higher  aim  than  to  amuse  the  public  with  a  sen- 
sation, but  yet  some  good  may  result.  The 
charges  of  inefficiency,  ignorance  and  indifference 
are  somewhat  sweeping,  and  the  proposal  to  del- 
egate the  functions  of  the  office  to  the  police 
rather  preposterous.  The  intimation  that  autop- 
sies are  much  to  infrequent  may  be  true,  but  the 
time  was  not  long  ago  when  a  counter- charge  was 
on  the  popular  tongue,  and  special  legislation  was 
invoked  for  the  cutting  off  of  the  fees,  which  re- 
sulted in  making  searching  examinations  dis- 
cretionary. Increase  of  population  we  cannot  but 
admit  has  really  demanded  more  work  and  speed- 
ier dispatch  in  its  performance.  Besides,  too,  in 
communities  polyglot  in  character  and  of  a  some- 
what feeble  public  virtue,  political  plums  are 
expected  to  grow  on  every  tree.  Herein  lay  the 
root  of  the  evil. 

The  office  itself  is  a  relic  of  antiquity  and,  as 
the    name    imports,    originally    represented    the 


139I-] 


EDITORIAL  NOTES. 


709 


Crown,  its  sole  function  being  the  detection  of 
crime.  Thus  from  time  immemorial  a  glamour  has 
clung  to  it  like  a  nimbus  and  inspired  a  vague 
dread  of  consequences  to  the  extent  of  the  com- 
mon refusal  of  cutting  down  a  swinging  suicide 
with  the  remote  probability  of  saving  life.  Too 
much  legislation  has  been  wasted  in  attempting 
to  keep  up  this  office,  which  should  have  been 
left  to  expire  of  its  own  volition.  All  the  errors, 
according  to  our  idea,  belong  inherently  to  the 
office  itself  more  than  to  its  administration.  Cer- 
tain of  the  verdicts  rendered  have  partaken  of  the 
grotesque  and  have  profited  the  profession  very 
little, — the  officials  in  the  main  have  been  noin-« 
inated  on  account  of  their  party  zeal  and  not  for 
their  intelligence;  their  subordinates  have  been 
obliged  to  perform  their  responsible  duties  in  a 
perfunctory  way,  and  an  easy-going  public  have 
fallen  upon  the  conclusion  that  the  dead  need  no 
avengers.  The  remedy  lay  in  the  appointment 
of  physicians,  probably  avouched  for  by  health 
boards,  medical  examiners  in  very  truth,  such 
as  Massachusetts  has  set  up  as  models  by  way  of 
an  experiment.  The  world  has  become  wise 
enough  to  intrust  the  profession  with  these  its 
proper  duties,  and  so  give  opportunities  for  con- 
tributions to  pathology  by  all  those  incumbents 
who  are  content  to  exchange  emolument  for  the 
ambition  of  beneficence.  When  all  this  is  accom- 
plished the  verdict  "Heart  Failure"  will  take  its 
place  alongside  of  the  more  pious  one  of  "Visita-  ] 
tiou  of  God,"  and  floating  corpses  will  not  all 
have  once  been  animated  by  inebriates,  who  have 
tottered  down  into  the  sewer- tainted  rivers  of 
those  cities  whose  aspirations  are  chiefly  commer- 
cial. 


EDITORIAL  NOTES. 


A  Distant  Witness  for  Vaccination. — 
Small-pox  was  carried  by  a  vessel  to  Ooshooia, 
near  the  southern  extremity  of  Terra  del  Fuego. 
At  that  point  there  is  a  mission  settlement  con- 
taining about  150  natives,  under  the  care  of  Mr. 
E.  C.  Aspinall,  medical  superintendent,  and  five 
other  English  ladies  and  gentlemen.  A  single 
case  was  left  by  a  Buenos  Ayres  Captain,  near 
Ooshooia,  and  all  the  natives  were  made,  in  spite 
of  the  protest  of  Mr.  Aspinall,  to  load  the  vessel 
with  wood  for  its  return  to  Buenos  Ayres.  The 
consequence  was  an  epidemic  of    not  less  than 


sixteen  cases — the  disease  not  being  surely  spent 
at  the  time  of  the  last  writing — with  nine  deaths. 
The  mission  church  was  emptied  and  converted 
into  a  hospital.  In  order  to  keep  the  natives 
from  beiiiL;  exposed  to  the  sick  or  the  dead  the 
white  people  served  them,  did  the  nursing,  dug 
the  graves  and  buried  the  bodies.  Fortunately 
vaccine  was  not  wanting  and  it  was  applied  at 
Ooshooia  and  adjacent  plantations  among  both 
tht  Europeans  and  their  native  employes.  Not- 
withstanding the  vaccinations  some  of  the  natives 
have  taken  the  varioloid,  but  all  the  deaths  by 
small- pox  occurred  among  those  natives  who  had 
not  been  so  treated,  or  who  had  been  vaccinated 
after  the  infection  had  taken  place. 

The  Ebb  of  Influenza. — Influenza,  with  fatal 
results,  is  now  prevailing  throughout  Britain.  It 
has  not  shown  itself  so  much  in  London  as  in  the 
outlying  districts,  yet  there  is  ample  time  for  its 
extensive  prevalence  in  the  metropolis,  for  it  is 
only  in  the  first  stages  of  its  re-manifestation. 

Grants  for  Scientific  Investigations. — 
The  British  Medical  Association  announces  its 
readiness  to  receive  applications  from  its  members 
who  desire  aid  in  furthering  particular  research. 
This  patronage  of  a  great  association  is  no  small 
incentive  to  the  hardy  and  delving  medical  mind. 
and  certainly  will  not  be  without  its  honest  and 
far  reaching  outcome — more  noble  and  more 
comprehensive  than  mortal  sense  has  power  to 
appreciate. 

The  Therapeutic  Poverty  of  Fifty  Years 
Ago. — Dr.  John  Kent  Spender,  of  Bath,  a  very 
pleasing  writer  on  therapeutical  subjects,  has 
contributed  to  the  Practitioner,  London,  some  re- 
flections on  the  poverty  of  the  profession  fifty 
years  ago,  in  the  matter  of  drugs,  as  compared 
with  the  embarrassment  of  riches  now-a-days. 
Diseases  were  then  called  "incurable"  simply 
because  we  had  not  yet  discovered  the  means  of 
curing  them.  Our  medical  poverty,  in  and  about 
1S40,  was  such  that  when  "  crying  sufferers  en- 
treated us,  we  could  only  confess  our  impotence 
to  help  them.  There  were  whole  domains  of 
work  in  which  we  seemed  no  better  off  than 
Scott's  north-country  doctor,  who  boasted  of  his 
'  twa  simples  of  calamy  and  laudamy.'  And  we 
were  chilled  by  that  therapeutic  nihilism  which 
began  in  the  school  of  Vienna,  and  has  infected 
a  large  number  of  practitioners  in  all  parts  of  the 


710 


MEDICAL  ITEMS. 


[May  i  6 


world."  Pathology  with  its  microscope,  diag- 
nosis with  its  verifying  post-mortem,  and  a 
laughing  skepticism  ruled  the  courts  of  medicine, 
for  the  secrets  of  healing  had  not  been  disclosed. 
But  now  we  employ  our  therapeutic  possessions  as 
if  we  trusted  them,  and  we  lean  upon  the  rock  of 
physiological  experiment  and  clinical  observa- 
tion. The  doubter  and  the  scorner  may  be  with 
us  still,  but  they  have  become  reticent  and  retir- 
ing in  the  face  of  a  constantly  strengthening  ar- 
ray of  therapeutic  forces.  To  Sir  Thomas  Wat- 
son and  Dr.  Latham  the  profession  is  largely 
indebted  for  indoctrinating  that  more  humane 
philosophy  that  the  sick  have  the  rights  of  being, 
cured  by  earnestness  and  faithfulness  in  the  ap- 
plication of  remedies. 

"  International  Clinics."  —J.  B.  Lippincott 
Company  will,  beginning  with  April,  i-sue 
quarterly  thereafter  a  work  entitled  "Inter- 
national Clinics."  This  work  will  comprise  the 
best  and  most  practical  clinical  lectures  on  medi- 
cine, surgery,  gynecology,  pediatrics,  derma- 
tology, laryngology,  ophthalmology  and  otology, 
delivered  in  the  leading  medical  colleges  of  this 
country,  Great  Britain  and  Canada.  These  lec- 
tures have  been  reported  by  competent  medical 
stenographers  and  thoroughly  revised  by  the  pro- 
fessors and  lecturers  themselves.  The  object  of 
the  work  is  to  furnish  the  busy  practitioner  and 
medical  student  with  the  best  and  most  practical 
clinical  instruction  in  concise  form.  Each  volume 
will  consist  of  over  350  octavo  pages,  illustrated 
with  photographic  reproductions  of  important 
cases. 

The  Place  and  Value  of  Tuberculin. — It 
is  not  probable  that  this  question  will  long  remain 
in  the  present  indefinite  condition.  Reports  cov- 
ering many  hundreds  of  cases,  under  different 
hospital  management,  and  under  climatic  and 
general  hygienic  variations,  are  being  rapidly  ad- 
vanced. The  "sum"  will  show  the  "substance," 
and  the  eager  public,  as  well  as  the  earnest  physi- 
cian, will  have  the  foundation  of  experimental 
fact  upon  which  to  rest  their  prayerful  hopes  and 
sanguine  anticipations. 

The  Action  of  Cocaine  on  the  Circula- 
tion.— As  a  result  of  painstaking  study  in  the 
direction  of  ascertaining — experimentally  —  the 
exact  effects  of  the  drug  cocaine  upon  the  circu- 
latory system,  Dr.  Edward  T.  Reichert  (Ameri- 


can Lancet)  arrives  at  the  following  important 
conclusions:  1.  Very  much  depends  upon  the 
individual  susceptibility  in  noting  the  medicinal 
effects.  2.  Repeated  small  doses  first  decrease, 
then  increase,  and  finally  decrease  the  pulse- rate. 
3.  The  cardio  inhibitory  centres  are  always  af- 
fected. 4.  The  arterial  pressure  is  always  in- 
creased, unless  after  large  doses,  when  temporary 
decrease  may  happen.  This  increased  arterial 
pressure  may  continue  longer  than  the  period  of 
acceleration  of  the  heart  beat.  This  increase  is 
chiefly  due  to  stimulation  of  the  vaso  motor  cen- 
tres, to  some  stimulation  of  the  vessel-walls,  and 
to  the  increased  pulse-rate.  These  and  other 
noted  results  show,  5,  that  cocaine  is  a  decided 
circulatory  stimulant. 

MEDICAL  ITEMS. 

Honors  for  Virchow. — At  the  last  meeting 

of  the   German   Congress   of  Internal   Medicine, 

honorary  membership  was  extended  to  Virchow 

on  the  occasion  of  his  70th  birthday  anniversary. 

Goethe  as  an  Anatomist. — Recent  corre- 
spondence to  the  British  Medical  Journal  says. — 
"Professor  Bardeleben,  of  Jena,  has  found 
amongst  Goethe's  unpublished  papers  in  Weimar 
an  essaj"-  "On  the  Comparative  Anatomy  of  the 
Skull  of  Mammalia,"  written  throughout  in 
Goethe's  own  hand.     The  essay  is  dated  1794." 

Relative  Frequency  of  Gall-Stone  in 
the  Sexes. — Dr.  Furbinger,  in  his  paper  read 
before  the  last  session  of  the  German  Congress  of 
Internal  Medicine,  analyzed  the  histories  of  sixty- 
four  cases  of  gall-stone  treated  by  him  at  the 
Friedrichshain  Hospital,  and  of  this  number 
thirteen  were  males  and  fifty-one  females. 

Another  Consumption  Cure. — It  is  now  an- 
nounced that  M.  Germain-See  has  developed  a 
method  of  cure  for  this  great  bane.  Germain- 
See  places  his  patients  for  several  hours  daily  in- 
a  hermatically  closed  chamber  into  which  a  cur- 
rent of  compressed  and  medicated  air  is  slowly 
admitted.  The  air  is  medicated  by  passing  it 
through  a  mixture  of  creasote  and  eucalyptoh 
Results  are  to  appear  later. 

Quinine  BY  Synthesis. — Two  Frenchmen, 
MM.  Grimaux  and  Arnaud,  announce  that  they 
have  discovered  a  synthetical  method  of  preparing 
quinine. 


i89i.] 


AMERICAN  MEDICAL  ASSOCIATION. 


7" 


AMERICAN   MEDICAL  ASSOCIATION. 

Forty-second    Annual    Meeting,   held    al 
Washington,   D.  *  ..   M;..\  5-8,  1891. 

General  Session — First  Day. 

The  Association  assembled  May  5  at  Albaugh's 
Opera  House,  Washington.  D.  C,  at  10  a.m.  It 
was  called  to  order  by  Dr.  D.  C.  Patterson,  Chair- 
man of  the  Committee  of  Arrangements;  who  in- 
troduced Rev.  S.  M.  Newman,  D.D.,ofthe  First 
Congregational  Church,  who  offered  a  prayer. 
The  Hon.  John  W.  Ross.  Commissioner  of  the 
District  of  Columbia,  welcomed  the  Association 
to  Washington.  The  Chairman  of  the  Commit- 
tee 1  if  Arrangements,  announced  the  programme 
and  other  arrangements  for  the  meetings. 

The  President,  Dr.  William  T.  Briggs,  Tenn., 
took  the  Chair,  supported  by  Vice-President  Dr. 
C.  A.  I.  ;:i  ,  and  ex  Presidents  Drs.  T. 

G.  Richardson,  W.  W.  Dawson  and  P.  O.  Hooper. 

The  President  then  delivered  the 

ANNUAL    ADDRESS. 

page  649.) 

On  motion  of  Dr.  J.  C.  Culbertsou,  O.,  thanks 
were  tendered  the  President  for  his  able  address, 
and  a  committee  of  five  was  appointed  to  develop 
the  points  therein,  and  to  report  to  the  Associa- 
tion the  last  clay  of  the  meeting.  Committee — 
Drs.  Culbertson,  Hooper.  Mover,  Marcy  and  Con- 
nor. 

Dr.  Hooper,  of  the  Board  of  Trustees,  presented 
a  preliminary  report  from  that  body. 

To  the  President  and  Members  of  the  American 
Medical  Association  ; 

The  Board  of  Trustees  have  the  honor  to  make 
a  preliminary  report  on  the  question  of  location 
of  The  Journal. 

At  a  special  meeting  of  the  Board,  held  in  No- 
vember, 1S90,  the  Trustees,  having  individual 
views  as  to  the  best  method  of  strengthening 
The  Journal,  resolved  to  recommend,  first,  an 
established  home  ;  second,  that  that  place  of  per- 
manent establishment  be  the  National  Capital. 
After  free  discussion  and  interchange  of  views, 
it  was  resolved  to  submit  the  question  to  the 
members  of  the  Association,  through  the  columns 
of  The  Journal,  before  making  their  final  re- 
port. The  result  of  that  course  of  action  has 
been  to  convince  them  that  the  majority  of  the 
members  desire  that  the  place  of  publication  shall 
continue  to  be  in  Chicago.  They,  therefore,  in 
obedience  to  that  expressed  opinion,  hereby  re- 
port that  Chicago  is  the  undoubted  choice  of  the 
Association  as  the  place  of  publication  of  The 
Journal. 

The  undue  excitement  that  has  taken  place  in 
regard  to  the  matter,  and  the  sectional  antagon- 
ism that  has  been  engendered,  is  to  be  depreca- 


ted, but  the  controversy  has  strengthened  The 
Journal  by  increasing  the  subscribers,  and  stim- 
ulating the  interest  of  members  heretofore  luke- 
warm, and  they  make  this  preliminary  report  in 
1  order  to  promote  harmony  in  the  meeting,  quiet 
misapprehension,  and  give  due  notice  of  this  ac- 
tion in  advance  of  the  regular  report. 

P.  O.  Hooper,  Pres't. 

John  B.  Hamilton.  S 

On  motion,  the  report  was  received  with  thanks, 
and  unanimously  adopted. 

The  amendment  offered  by  Dr.  A.  L.  Gibon, 
U.  S.  Navy,  at  the  last  meeting,  was  then  taken 
up.  "To  amend  the  By  Laws  so  as  to  make  the 
General  Sessions  commence  on  Wednesday,  in 
place  of  Tuesday." 

A  motion  by  Dr.  N.  C.  Scott,  Ohio,  to  lay  the 
amendment  on  the  table,  was  lost. 

On  motion  of  Dr.  I.  N.  Quimby,  N.  J.,  the 
subject  was  laid  over  until  11.30  a.m.  on  Wed- 
nesday. 

Dr.  Barrington,  of  Ireland,  was,  on  motion  of 
Dr.  R.  Reyburn,  D.  C,  made  a  member  by  invi- 
tation. 

Dr.  N.  S.  Davis,  111.,  announced  that  the  Amer- 
ican Medical  Temperance  Association  would 
meet  at  G.  A.  R.  Hall  on  Thursday,  at  9  a.m.. 
and  invited  all  to  join  the  Association. 

Dr.  Gihon  then  read  the  report  of  the  Rush 
Monument  Fund. 

report  of  rush  monument  committee.' 
For  the  seventh  time,  after  as  many  years,  the 
Rush  Monument  Committee  are  only  able  to  re- 
port progress,  but  progress  so  slow  that  seven 
times  seven  years,  at  this  rate,  will  find  the  end 
still  unattained  which,  seven  years  ago.  seemed  to 
be  a  matter  of  only  as  many  months. 

Those  of  you  who  were  present  at  the  Wash- 
ington meeting  in  May.  1SS4.  when  the  idea. of 
this  monument  was  broached,  will  remember  with 
what  alacrity  the  proposition  was  received.  The 
large  body  of  delegates  and  members  in  atten- 
dance, at  that  meeting,  were  struck,  as  you  can- 
not fail  to  be,  when  you  visit  the  manifold  attrac- 
tions of  this  beautiful  Capital,  by  the  fact  that, 
in  this  city  of  monumental  memorials  of  the  dis- 
tinguished Fathers  of  the  Republic,  there  is  not 
one  of  any  medical  man.  Is  this,  repeating  lan- 
guage heretofore  used,  because  among  the  patri- 
otic builders  of  this  nation,  our  profession  has 
not  furnished  one?  Are  painters  and  sculptors, 
presidents  and  judges,  generals  and  admirals,  sci- 
entists and  discoverers,  teachers  and  divines,  phil- 
anthropists and  politicians  only  those  who  have 
deserved  this  recognition  from  their  country? 
Has  there  been  no  great  doctor  in  medicine  whose 
life  has  been  as  exemplary,  whose  patriotism  as 
exalted,  whose  fame  as  extended  as  any  of  these 
men  whose  marble  effigies  confront  us  in  whatever 
direction  we  look  in  this  sanctuary  centre  of  our 


712 


AMERICAN  MEDICAL  ASSOCIATION. 


[May  i 6, 


great  country?  Or  is  it  that  Medicine,  alone 
among  the  professions,  fails  to  honor  its  own  sons 
and  give  them  royal  acclaim  for  royal  deeds  ? 

During  the  seven  years  in  which  your  Com- 
mittee have  been  employed  upon  the  unwelcome 
task  of  soliciting  contributions  for  this  monu- 
ment, which  this  Association  has  year  after  year 
commended  with  enthusiasm,  two  facts  have  be- 
come patent:  first,  that  the  events  of  our  Na- 
tional history  of  which  the  achievements  of  Amer- 
ican physicians  were  important  parts,  are  not 
made  matters  of  medical  education,  else  the  name 
of  Benjamin  Rush  would  be  a  household  word  in 
every  doctor's  dwelling  in  the  county- ;  and  sec- 
ond, that  in  the  city  which  he  honored  with  his 
residence,  life-work  and  heroic  sacrifice  unto  death, 
petty  animosities  and  jealous  rivalries  have  sur- 
vived, in  the  descendants  of  men  of  lesser  light 
and  lesser  renown,  to  harden  their  hearts  and 
tighten  their  purse-strings,  in  refusing  to  honor 
the  name  and  perpetuate  the  memory  of  one  whom 
great  physicians  of  this  day  declare  to  have  been 
the  greatest  physician,  patriot,  philosopher  and 
philanthropist,  all  in  one,  which  this  country  has 
ever  produced. 

Disheartened  at  the  slow  increase  of  the  Rush 
Monument  Fund,  especially  when  statues  of  later 
inception  were  being  completed  to  men  of  other 
callings  in  this  country,  for  labors  that  were  not 
distinctively  National,  and  to  physicians,  in  for- 
eign lands,  whose  services  to  humanity  were  far 
less  valuable,  your  Committee  sought  advice  as 
to  better  or  more  practical  methods  of  operation. 
One  suggested  by  an  eminent  promoter  of  chari- 
table enterprises  seemed  to  them  worthy  of  trial 
— the  distribution  of  "  coin  cards,"  or  cards  con- 
taining a  space  in  which  a  silver  half  dollar  could 
be  placed  by  the  contributor.  To  spare  them  all 
trouble  whatsoever,  a  stamped  envelope,  printed 
with  the  Treasurer's  address,  was  printed,  that 
he  might  have  nothing  more  to  do  than  place  a 
half-dollar  in  the  space  in  the  card,  inclose  that 
in  the  envelope,  seal  and  drop  it  in  the  nearest 
mail  box. 

Your  Committee  deemed  it  expedient  to  begin 
the  distribution  of  these  cards  in  Philadelphia, 
with  which  the  name  of  Rush  is  identified,  in  the 
hope  that  there  where  his  active  life  was  passed, 
and  where  a  local  memorial — the  Rush  Library, 
recalls  his  prominence  in  medical  literature,  there 
would  be  such  generous  response  to  your  Com- 
mittee's application,  that  they  could  go  to  other 
cities  and  places,  with  these  first  fruits,  as  earnest 
of  what  might  be  done  everywhere. 

Accordingly,  the  following  letter  was  addressed 
in  my  own  hand  to  1,770  individuals  in  the  city 
of  Philadelphia : 

Dear  Doctor: — I  bey  t.>  make,  hereby,  a  final  appeal 
to  you,  as  a  member  of  the  medical  profession  in  tin- 
city  of  Philadelphia,  to  contribute  in  behalf  of  the  mon- 
ument to  be  erected  at  the  National  Capital  to  the  re- 
nowned patriot.  Dr.  Benjamin  Rush,  whom  one  of  your 


distinguished  colleagues  declares  to  have  been  the 
greatest  physician  this  country  has  ever  produced." 

The  liberality  with  which  Philadelphians  contribute 
to  this  memorial  of  one  of  the  greatest  men  to  whom 
their  city  has  ever  given  birth,  will  be  evidence  to  other 
sections  of  the  county-  of  the  esteem  iu  which  he  is  held 
by  the  people  of  his  own  home.  I,  therefore,  most  ear- 
nestly solicit  you  to  inclose  whatever  you  may  feel  dis- 
posed to  give,  whether  check,  banknote,  or  only  a  half 
dollar  coin  to  be  placed  in  the  space  in  the  card,  in  the 
within  envelope,  mailing  it  by  return  post  as  addressed. 
Should  you  have  already  contributed  all  you  intend,  or 
should  you  conclude  to  give  nothing,  will  you  kindly 
oblige  the  Committee  by  remailing  the  envelope,  with 
enclosed  card,  that  the  latter  may  be  used  elsewhere1 
Verv  respectfully,  for  the  Committee, 

Albert  L.  Gihon,  Chairman. 

But  notwithstanding  the  request,  "  should  you 
have  already  contributed  all  you  intend,  or  should 
you  conclude  to  give  nothing,  will  you  still  kindly 
oblige  the  Committee  by  remailing  the  envelope, 
with  inclosed  card,  that  the  latter  may  be  used 
elsewhere?"  and  the  fact  that  a  stamped  two  cent 
envelope,  bearing  the  Treasurer's  printed  address, 
was  inclosed  for  the  purpose,  more  than  1,600 
were  never  returned.  About  160  responded, 
making,  with  the  40  Philadelphians  who  had 
previously  contributed,  about  200  in  all,  or  only 
n  per  centum  of  our  profession  in  that  city,  who 
have  exhibited  any  interest  in  this  work.  The 
cost  of  circular  letter,  cards,  envelopes,  stamps 
and  folding,  was  S95,  the  sum  received  St  50,  a 
net  gain  of  about  S55.  a  not  very  encouraging 
yield  from  so  wide  a  field  of  operation  as  this 
million  peopled  city.  Being  a  Philadelphian.  the 
Chairman  of  your  Committee  was  absolutely  sure 
that  we  would  get  the  half-dollar  from  at  least 
1,500  of  the  physicians  addressed,  but  we  have 
actually  had  only  two  responses  from  the  doctors, 
who  rejoice  in  feminine  Christian  names,  who  we 
were  positive  would  outdo  their  brother  medicoes 
in  liberality,  as  they  do  in  all  the  other  virtues. 

In  the  light  of  this  experiment,  what  then  is 
to  be  done?  Abandon  the  undertaking?  Never! 
The  fund  already  accumulated  is  a  sacred  trust, 
which  can  be  diverted  to  no  other  purpose.  There 
is  no  reason  to  apprehend  that  Congress  will  be 
less  liberal  than  it  has  been  to  other  projects  of 
this  kind  ;  and  if  it  donate  a  pedestal  ap- 
propriate for  such  a  statue  as  the  medical  pro- 
fession of  106,000  members  ought  to  erect,  who 
will  care  to  see  a  S2,ooo  statue  surmounting  a 
pedestal  costing  $25,000  as  that  of  the  McPhersou 
statue  did,  or  $30,000  like  that  of  the  Garfield 
Monument? 

The  >eed  has  been  planted,  and  if  properly 
eared  for,  it  is  bound  to  grow,  and  except  you  be 
dissatisfied  with  our  tillings  of  the  soil,  we  shall 
persevere  through  this  and  many  summers  more. 
It  was  forty-three  years  from  its  inception  before 
the  beautiful  shaft  of  the  Monument  to  Washing- 
ton graced  the  twilight  sky  of  the  Potomac's 
banks,  and  though  some  of  us  can  not  hope  to 
live  until  forty-three  years  shall   have  passed  to 


I89i.] 


AMERICAN  MEDICAL  ASSOCIATION. 


13 


see  the  noble  features  of  this  great  physician, 
whose  name  one  need  not  hesitate  to  utter  where 
that  of  Washington  rings,  upon  the  genera- 
tion, which  shall  then  visit  the  Array  Medical 
Library  and  Museum,  and  find  his  effigy  its 
greatest  ornament  ;  still  while  we  may  live,  we 
ge  ourselves  to  labor  to  this  end,  so  long  as 
this  Association  shall  honor  us  with  its  steward- 
ship, aspiring  to  no  other  reward  than  to  have 
succeeded  in  rearing  in  imperishable  bronze  or 
enduring  stone,  the  figure  of  this  great  man,  the 
model  physician,  the  worthy  citizen,  the  brave 
patriot,  the  gallant  officer  and  broad-minded 
philanthropist,  whom  it  is  every  American  med- 
ical man's  duty  to  reverently  honor. 

Why  should  Americans  alone  among  the  phy- 
sicians of  the  world  be  indifferent  to  the  glorify- 
ing of  their  illustrious  dead  ?  The  Italians  have 
within  three  years,  erected  at  Milan,  their  monu- 
ment to  their  patriot  physician.  Agostino  Bertini, 
a  splendid  bronze  statue  by  their  great  artist 
Vela,  besides  placing  a  marble  tablet  011  the 
facade  of  his  home  in  Genoa.  The  recent  Con 
gress  of  Russian  medical  men  at  Moscow  de- 
termined, with  great  enthusiasm,  to  erect  a 
monument  as  a  national  memorial  to  Nicolai 
Ivanecoitsch  Pirogow,  the  Thinker-Surgeon, 
whose  71  years  ended  only  ten  years  ago.  A 
Committee  of  French  physicians  has  just  been 
organized,  with  Professor  Fourmier  as  its  Presi- 
dent, to  do.  as  we  have  been  so  long  striving. 
raise  a  monument  to  Philippe  Ricord.  and  sub- 
scriptions are  reported  to  be  coming  in  spontane- 
ously and  rapidly.  At  Giessen  in  Ober  He.-se. 
the  scene  of  his  famous  labors,  on  the  23d  of  last 
July,  a  white  marble  statue  was  erected  to  Lie- 
big,  larger  than  life  size  and  ornamented  with 
figures,  emblematic  of  science  and  culture,  and 
another  is  projected  at  Halle,  in  Saxon  Pr 
to  Professor  Richard  von  Yolkmann,  for  which 
subscriptions  are  being  gathered  in  America,  and 
to  which  one  American  Association  was  on  the 
point  of  contributing  when  a  member  pertinently 
suggested  that  at  least  an  equal  sum  be  con- 
tributed to  the  Rush  Monument — so  neither  got 
any.  A  few  days  ago,  the  papers  announced 
"contributions  have  been  made  already  in  and 
about  Boston  alone,  by  the  following  physicians." 
mentioning  twenty  names,  aggregating  S245.00 
for  the  Virchow  Testimonial  Fund.  German 
physicians  also  liberally  contributed  to  the  life- 
size  monument  in  bronze  to  the  late  Emperor 
Frederick  II,  erected  in  the  quadrangle  of  the 
Protestant  Hospital  at  Kaiserslantem. 

Why  should  physicians  alone  in  this  country- 
object  to  do  public  honor  to  their  conspieuouslv 
great  men  in  their  profession  ?  The  New  York 
Academy  of  Sciences  projects  a  monument  to 
Audubon,  and  eleven  members  at  once  subscribe 
Sioo  each,  and  in  a  time,  incredibly  brief  by 
comparison.  S2.733.50  are  collected.     The  Print- 


ers' I'nion  is  raising  funds  for  a  second  colossal 
statue  to  Greeley,  the  first  by  Ward  having  long 
adorned  the  entrance  to  the  Tribune  Building  in 
New  York.  Deaf-mutes  planned  and  executed 
their  monument  to  Gallaudet  standing  on  Kendal 
Green,  where  you  all  will  doubtless  see  it.  and 
this  since  we  have  been  talking  about  our  statue. 
The  members  of  the  legal  profession  have  their 
$40,000  monument  to  Chief"  Justice  Marshall,  at 
the  approach  to  the  Capitol,  and  Story's  classic 
figure  of  Professor  Henry  stands  near  Smithson- 
ian Institution  as  ours  of  Rush  should  stand  near 
the  National  Medical  Library  and  Museum.  A 
few  Brooklyn  Protestants  have  built  a  monument 
to  Beecher  and  in  one  night  $  .700  were  sub- 
scribed by  Roman  Catholics  in  New  York  City 
alone  for  the  bronze  statue  of  Archbishop 
Hughes  at  Fordham,  $20,000  being  promised  be- 
fore the  end  of  June. 

But  the  list  would  be  a  long  one  were  we  to 
enumerate  all  the  monuments  that  are  proposed 
ouxitry.  Your  Committee  have  not  ad- 
vocated a  monument  to  Rush. as  in  rivalry  to  any- 
other  man.  The  monument  is  not  to  Rush  the 
preeminent  individual,  as  to  Rush,  the  symbol  of 
medical  patriotism — the  visible  expression  of  the 
fact  that  the  profession  of  medicine  has  con- 
tributed its  great  man — are  of  its  great  men.  it 
you  please — clothed  in  his  professional  garb,  to 
uphold  the  standard  of  freedom  in  the  foremost 
rank  of  the  brave  defenders  of  this  new  nation, 
and  keep  it  there  through  all  the  strife  of  the 
Revolution.  This  Rush  did.  and  later  became 
one  of  the  rramers  of  that  venerated  instrument, 
on  which  the  fabric  of  our  nationality  is  built, 
the  Federal  Constitution.  For  this,  he  has  been 
chosen  to  have  a  place  among  the  sculptured 
heroes  of  that  time,  by  whose  silent  presence,  as 
by  their  fearless  speech  when  living,  they  may 
illustrate  to  posterity  what  the  purest  patriotism 
and  public  spirit  mean. 

Your  Committee  appeal  not  for  money  only, 
but  for  collaborators — for  volunteer  associates, 
who  will  act  with  them  as  fellow  Committee  men. 
each  in  his  own  town,  and  by  earnest  personal 
effort  aid  them  in  their  uphill  work.  The  As- 
sociation has  already  given  them  authority  to 
add  to  their  numbers,  and  your  Committee  now 
ask  such  of  you  as  care  to  do  this  labor  of  love 
to  give  your  names  and  addresses  to  their  Secre- 
tary-, Professor  Rohe,  with  the  assurance  of  your 
active  cooperation.  The  Washington  Monument 
was  mired  eleven  years.  The  Rush  Monument 
is  making  scarcely  greater  progress,  but  with 
your  willing  shoulders  to  the  wheel,  it  will,  in 
good  time,  soon  make  triumphant  advance. 

Albert  L.  Gihox. 
Medical  Director  V.  S--Navy,  Chairman  Rush  Monument 
Committee. 

On  motion  of  Dr.  H.  D.  Holton,  Yermont,  the 
report  was  received  and  the  committee  continued. 


714 


AMERICAN  MEDICAL  ASSOCIATION. 


[May  16, 


The  Permanent  Secretary  read  the  report  of 
the  Treasurer  : 

treasurer's  report. 

The  treasurer  has  the  honor  to  report  that  the 
balance  in  the  treasury  of  the  Association  is 
$9,427.21.  The  statement  of  the  account  will  be 
published  as  usual  in  the  columns  of  The  Jour- 
nal of  the  Association.  All  of  which  is  res- 
pectfully submitted. 

Richd.  J.  Dunguson,  Treasurer. 

May  5,  1891. 

On  motion  it  was  received  and  adopted. 

Dr.  L-  D.  Bulkley,  New  York,  as  Chairman  of 
Sectionou  Dermatology, etc., explained  why  no  pa- 
pers were  on  the  programme  for  that  Section,  and 
moved  that  said  Section  be  dispensed  with. 

As  this  would  have  required  an  amendment  to  the 
By-laws  it  was  laid  over.  (Subsequently  Dr.  B. 
announced  a  meeting  on  Wednesday  and  the  offer 
of  sundry  papers  for  that  Section.) 

On  motion  of  Dr.  C.  G.  Comegys,  Ohio,  it  was 

Resolved,  That  a  committee  of  three  be  appointed  by 
the  President  to  consider  the  question  of  petitioning  the 
next  Congress  to  create  a  cabinet  officer  to  be  known  as 
the  Secretary  of  Public  Health.  The  report  of  this  com- 
mittee to  be  presented  on  Thursday  morning. 

Committee — Drs.  Comegys,  N.  S.  Davis  and 
T.  G.  Richardson. 

On  motion  of  Dr.  L.  Connor,  Mich.,  it  was 
Resolved,  That  each  Section  at  this  meeting  be  re- 
quested to  appoint  a  committee  of  three  which  shall 
meet  at  the  Arlington,  May  6,  at  9  A.M.,  to  consult  as  to 
the  best  measures  for  promoting  the  interests  of  the  Sec- 
tions, and  the  best  means  for  securing  the  adoption  of 
the  same. 

On  motion  of  Dr.  Dudley  S.  Reynolds,  Ky.,  it 

was 

Resolved,  that  the  Supervising  Kditor  of  The  Jour- 
nal be  instructed  to  secure  stenographic  reports  of  the 
proceedings  of  each  of  the  several  Sections  of  this  Asso- 
ciation, and  that  the  Trustees  be  instructed  to  set  apart 
a  sufficient  sum,  not  exceeding  one  thousand  dollars, 
annually  for  that  purpose.  This  resolution  to  take  effect 
at  and  after  the  present  session. 

On  motion  of  Dr.  Chas.  A.  L.  Reed,  Ohio,  it 
was 

Resolved,     That    the    American     Medical    Association 
extends  a  cordial   invitation    to  the  medical  pro- 
fession of  the  Western  Hemisphere  to  assemble  in   the 
i   nited  StaU-s  in    a   Continental   American  Medical   Con- 

Resolved,  That  the  Committee  on  Nominations  be  aud 
is  hereby  instructed  to  nominate  one  member  for  each 
!  territory,  and  one  each  for  the  Army,  Navy, 
and  Marine-Hospital  Service,  who  shall  constitute  a 
committee  which  is  hereby  instructed  to  effect  a  perman- 
ent organization  of  the  proposed  Continental  American 
Medical  Congress  and  to  determine  the  time  and  place 
at  which  tin  same  shall  he  held. 

Resolved,  Thai  the  Committee  on  Nominations  be  and 

is    hereby  further    instructed  to   report   the   nominations 

n1  to  the  foregoing  resolution  at  the  general  ses- 

rhursday  morning, 

On  motion  a   recess   was   taken   to   allow   the 

i"  assemble  and  select  their   members  for 

tli<-  Nominating  Committee. 


Ala.,  J.  C.  Lagrange;  Ark.,  J.  M.  Keller;  Cal., 
Simmons;  Conn.,  C.  A.  Lindsley;  D.  C,  G.  W. 
Cooke;  Del.,  Win.  Marshall;  Fla.,  W.E.Ander- 
son; Ga.,  W.  F.  McRae;  111.,  G.  W.  Webster; 
Ind.,  A.  M.  Owen;  Iowa,  G.  F.  Jenkins;  Ky., 
W.  H.  Wathen;  La.,  T.  G.  Richardson;  Mass., 
A.  P.  Clark;  Md.,  T.  S.  Latimer;  Mich.,  H.  O. 
Walker;  Minn.  — ;  Miss.,  B.  A.  Duncan;  Mo.,  I.N. 
Love;  N.  C,  C.  J.  O'Hagan;  N.  H.,  Irving  A. 
Watson;  N.  J.,  B.  A.  Watson;  N.  Y.,  John 
Cronvn  ;  Neb.,  J.  O.  Carter;  Ohio,  C.  A.  L. 
Reed';  Pa.,  E.  Jackson;  S.  C,  T.  J.  McKie;  S. 
Dak.,  W.  M.  Kaull;  Tenn.,  G.  C.  Savage;  Tex.. 
J.  W.  Carhart;  Vt.,  D.  C.  Hawley;  Va.,  W.  L. 
Robinson;  W.  Va.,  G.  A.  Aschman;  Wis.,  J.  B. 
Whiting;  U.  S.  Army,-  ;  U.  S.  Navy,  J.  M.  Flint; 
U.  S.  Marine- Hospital  Service.,  J.  B.   Hamilton. 

After  some  discussion  on  motion  of  Dr.  Ham- 
ilton the  committee  was  requested  to  meet  at  the 
Arlington  at  7  this  evening. 

Second  Day,  May  6. 

The  Association  assembled  at  10  a.m.,  Presi- 
dent Briggs  in  the  chair. 

Prayer  was  offered  by  Rev,  Father  Richards,  of 
Georgetown  University. 

The  Chairman  announced  certain  additional 
arrangements  and  invitations. 

Dr.  E.  L.  Shurly,  Mich.,  read  the  Address  on 
Medicine  (see  page  721). 

The  Librarian  read  his  report,  which  was  re- 
ceived and  the  appended  suggestion  adopted. 

The  amendment  of  Dr.  Gihon  being  in  order 
he  again  addressed  the  Association.  After  much 
discussion  by  Drs.  Quimby,  Scott,  Davis, 
Vaughan,  Bishop  and  Ross,  on  motion  of  Dr. 
J.  H.  Murphy,  Minn.,  the  amendment  was  finally 
laid  upon  the  table. 

The  amendment  offered  by  Dr.  X.  C.  Scott,  Ohio, 
to  abolish  the  Committee  on  State  Medicine,  in- 
asmuch as  the  work  was  done  by  the  Section  on 
State  Medicine,  was  taken  up. 

Dr,  A.  N.  Bell,  N.  Y.,  moved  to  amend  by 
saying  that  this  Section  should  nominate  to  the 
Association  the  persons  to  constitute  the  commit- 
tee. Dr.  N.  S.  Davis,  111.,  offered  an  amendment 
which  was  accepted  by  Dr.  Bell,  that  the  nomina- 
tion be  changed  in  the  laws  from  the  Nominating 
Committee  to  the  Section  on  State  Medicine. 
This  was  unanimously  adopted. 

The  amendment  offered  by  Dr.  E.  A.  Wood, 
Pa.,  to  "omit  the  word  Physiology  from  the  title 
of  the  Section  on  Practice  of  Medicine,  etc.,"  and 
form  a  new  Section  on  Physiology  and  Dietetics, 
was  almost  unanimously  adopted. 

The  amendment  offered  by  Dr.  J.  C.  Culbertson, 
being  up,  Dr.  R.  Harvey  Reed.  Ohio, 
offered  to  amend  by  substitute,  when  Dr.  X.  S. 
Davis,  111.,  offered  the  following; 

,!.  That  the  proposed  amendments  concerning 

;i      1 iiia. 1,   oi   State  and  other  medical  societies  as 


i89i.] 


AMERICAN  MEDICAL  ASSOCIATION. 


7i5 


branches  of  the  American  Medical  Association  be  referred 
to  a  committee  of  live  to  be  appointed  by  the  President, 
and  that  said  committee  shall  confer  with  the 
other  societies  concerning  the  desirability  of  such 
change,  and  if  desirable,  as  to  the  collection  or  payment 
of  dues  and  other  details  necessarily  involved  in  the  pro- 
posed change,  and  report  at  the  next  annual  111 

This  was  unanimously  adopted. 

The  amendment  of  Dr.  W.  H.  Daly.  Pa.,  mak- 
ing the  permanent  members  equal  in  all  rights  to 
delegates  was.  on  motion  of  Dr.  J.  E.  Wood- 
bridge,  Ohio,  laid  on  the  table. 

The  following  from  the  State  Medical  Society 
of  West  Virginia  was  read  by  the  Permanent 
Secretary : 

To  the  American  .1/eJical  Association: 

At  the  annual  meeting  of  the  State  Medical  Society  of 
West  Virginia.  June  II,  1S90,  a  committee  was  appointed 
to  memorialize  the  State  Societies  of  adjoining  States, 
and  the  American  Medical  Association,  upon  the  subject 
of  the  relations  of  contract  surgeons  of  the  different  rail- 
road systems  to  the  general  profession,  and  to  ask  these 
Societies  to  consider  how  far  the  rules  adopted  by  rail- 
road corporations  for  the  government  of  the  surgeons  in 
their  service,  infringe  upon  the  rights  of  the  profession 
at  large,  as  set  forth  in  the  Code  of  Ethics  of  the  Ameri- 
can Medical  Association.  It  is  well  known  that  large 
bodies  of  men  are  in  the  employ  of  these  corporations: 
that  these  men  live  in  widely  scattered  communities,  and 
that  these  corporations  have  established  systems  of  con- 
tract surgeons  to  attend  to  employes  and  passengers  in- 
jured bv  accidents  occurring  while  in  their  empl 
care  as  passengers.  It  is  also  well  known  that  these  cor- 
porations have  adopted  rules  for  the  government  of  these 
surgeons  and  of  those  injured,  directing  that  these  sur- 
geons assume  entire  charge  of  such  employes  or  passen- 
gers, when  injured,  regardless  of  the  rights  of  any  outside 
medical  man  who  may  have  been  summoned  ,  and  is  in 
attendance  upon  such  persons  prior  to  the  arrival  of  the 
company's  surgeon,  even  if,  in  addition,  the  physician 
first  in  attendance  be  the  family  and  personal  attendant 
of  the  partv  injured,  and  in  most  cases  have  served  a 
notice  to  this  effect  on  the  general  profession.  For  in- 
stance: Section  4  of  General  Order  No.  2  of  the  Baltimore 
and  Ohio  Railroad  Relief  Department,  says:  "  Upon  the 
arrival  of  the  company's  surgeon  and  taking  charge  of 
the  patient,  the  called  surgeon,  if  one  has  been  called, 
shall  be  distinctly  notified  by  the  company's  surgeon, 
and  by  the  officer  in  charge,  that  the  company  will  be  no 
longer  responsible  for  his  attendance  or  service,  and  that 
they  are  no  longer  required."  In  Section  5  of  the  same 
company's  instructions,  it  says:  "Company's  surgeons, 
upon  arriving  at  the  place  of  accident,  will  take  exclusive 
charge  of  the  case,  and  entirely  relieve  any  surgeon, 
other  than  the  one  under  contract  with  the  company, 
from  further  care  or  attendance.  The  called  surgeon 
shall  be  distinctlv  notified  by  the  company's  surgeon 
and  the  officer  in  charge,  that  the  company  will  be  no 
longer  responsible  for  his  attendance  or  services.  Should 
the  patient  prefer  the  services  of  a  surgeon  other  than 
the  one  provided- by  the  company,  it  must  be  distinctly 
understood  by  the  patient  and  the  said  surgeon  that  nei- 
ther the  company  nor  the  Relief  Association  will  be  re- 
sponsible for  the  services  rendered." 

To  the  majority  of  the  State  Society  this  appears  to 
place  the  physicians  in  direct  conflict  with  Section  6  of 
Article  5  of  tie  Code  of  Ethics,  and  causes  infringements 
upon  the  rights  of  physicians  first  called,  who  charitably 
respond  to  such  calls,  while  knowing  the  rules  of  the 
company,  because  of  the  urgency  of  the  case. 

Again,  in  the  establishment  of  these  systems  of  con- 
tract surgeons,  we  believe  the  practice  of  accepting  passes 
as  compensation,  in  lieu  of  the  regular  fees  customary  to 


the  profession,  is  detrimental  to  the  best  interests  of  the 
profession,  by  lowering  ti.  the  values  o: 

gical  services,  and  further  demoralizing,  bee. 
to  these  wealthy  corporations  services  at  far  less  rates 
than  the  profession  charges  to  individuals  for  like 
vices,  and  further,  that  these  corporations  come  under 
that  part  of  Section  3  of  Article  1.  relating  to  the  duties 
of  the  profession  to  the  public,  and  vice  versa,  which  ex- 
empts institutions  endowed  by  rich  individuals,  societies 
for  mutual  benefit,  for  the  insurance  of  lives,  etc.,  from 
the  privileges  set  forth  in  Section  1  and  Section  2  of  the 
same  article. 

Further,  it  seems  to  your  memorialists,  that  if  members 
of  the  profession  are  left  to  make  contracts  to  furnish  an 
unlimited  service  of  the  kind  required,  for  passes,  and  in 
some  cases  small  fixed  money  payments,  with  these 
large  corporations,  without  affecting  their  ethical  stand- 
ing, all  stigma  of  unprofessional  or  unethical  conduct 
should  be  removed  from  those  of  the  profession  who 
contract  with  private  individuals  to  furnish  medical  or 
surgical  services,  including  medicines,  by  the  year  or 
month,  at  fixed  sums. 

In  conclusion,  we  hope  your  Society  will  consider  this 
subject,  and  if  agreeing  with  us  that  this  is  an  evil,  join 
us  in  bringing  this  to  the  American  Medical  Association 
for  it  to  decide  what  action,  if  any,  is  proper  under  the 
circumstances. 

The  foregoing  is  respectfully  submitted  in  behalf  of 
the  Committee  appointed  as  before  stated. 

Wesley  II.  Sharp.  M.D., 

Chairman  of  Committee. 

Parkersburg.  W.  Va.,  November  28,  1890. 

Dr.  J.  E.  Woodbridge  moved  to  refer  to  a  com- 
mittee of  one  from  each  State  Society  in  affilia- 
tion with  this  Association. 

Dr.  R.  Harvey  Reed  moved  to  amend  by  say- 
ing "  two,  one  of  these  to  be  a  railroad  surgeon.*' 
Thus  both  sides  could  be  heard. 

After  discussion  by  Drs.  Quimby  and  Scott,  on 
motion  of  Dr.  Adamson.  Kentucky,  the  amend- 
ment was  laid  on  the  table.  The  original  motion 
was  then  adopted. 

Dr.  Gihon  moved  that  the  address  of  the  Pres- 
ident of  the  Association  shall  be  delivered  at  the 
general  session  on  Wednesday. 

On  motion  of  Dr.  X.  C.  Scott,  this  was  laid 
on  the  table. 

Third  Day.  May  7. 

The  President  called  the  Association  to  order 
!at  10  a.m. 

Praver  was  offered  bv  Rev.  W.  A.  Bartlett, 
D.D.  ' 

The  Chairman  of  Committee  of  Arrangements 
announced  the  business  of  the  day. 

The  Permanent  Secretary  read 

THE  ADDITIONAL  REPORT  OF  THE  BOARD  OF 

TRUSTEES. 

The  Board  of  Trustees  of  the  American  Medi- 
cal Association  respectfully  submit  the  following 
report,  in  regard  to  the  financial  affairs  of  the 
Association,  and  of  The  Journal  for  the  year 
ended  March  31,  1S91.  The  Journal  has  been 
published  and  regularly  issued  at  its  place  of 
publication,  and  now  has  a  weekly  edition  of 
5,450  copies,  of  which  4.048  copies  are  supplied 


716 


AMERICAN  MEDICAL  ASSOCIATION. 


[May  i  6, 


to  members,  and   the  remainder  to  subscribers, 
advertisers,  exchanges,  etc. 

The  cost  of  publication  and  editorial  expenses 
for  the  year  has  been  $23  337.97.  The  receipts 
at  the  office  from  all  sources  amount  to  $14,464.59. 
Amount  drawn  from  treasury  of  the  Association, 
$8,909.38,  leaving  a  balance  in  the  hands  of  the 
Board  $762.40.  At  the  same  time  there  was  in 
the  hands  of  the  Association  Treasurer,  $4503.39. 
Making  a  total,  March  31,  1891,  available, 
of  $5,265.79.  Full  detailed  exhibit  of  receipts 
and  expenditures  accompany  this  report,  as  re- 
ported by  the  Treasurer. 

The  editorial  management  of  The  Journal 
has  continued  as  heretofore  under  the  direction 
of  the  Board,  uo  editor  having  been  appointed, 
the  resident  member  of  the  Board  acting  in  the 
capacity  of  supervising  editor,  and  employing 
such  editorial  writers  as  in  his  judgment  the 
occasion  required. 

The  Association  having  practically  passed  upon 
the  question  of  location,  it  is  still  the  opinion  of 
the  Board  that  a  suitable  building  for  The  Jour- 
nal Office  should  be  secured  as  soon  as  there  are 
sufficient  funds  available  for  that  purpose. 

In  conclusion  your  Board  respectfully  submit 
that  they  have  done  their  best  to  publish  as  good 
a  Journal  as  the  funds  would  permit,  and  they 
have  pleasure  in  stating  that  the  available  re- 
sources of  The  Journal  are  now  such  that  their 
intention  is  for  the  next  and  succeeding  years, 
to  raise  the  professional  and  literary  standard  of 
its  editorial  department  to  the  equal  of  any. 

John  B.  Hamilton,  P.  O.  Hooper, 

Secretary.  President. 

On  motion  it  was  received  and  adopted. 

Dr.  \V.  H.  Wathen,  Chairman,  read  the  report 
of  the  Committee  on  Nominations  : 

The  Nominating  Committee  begs  to  make  the 
following  report: 

For  President,  Dr.  H.  O.  Marcy,  of  Boston, 
Mass.;  First  Vice-President,  Dr.  Willis  P.  King, 
of  Missouri;  Second  Vice-President,  Dr.  Henry 
Palmer,  of  Wisconsin;  Third  Vice-President,  Dr. 
W.  E.  B.  Davis,  of  Alabama;  Fourth  Vice  Presi- 
dent. Dr.  W.  E.Taylor,  of  California;  Treasurer, 
Dr.  Richard  J.  Dunglison,  of  Pennsylvania;  Sec 
retary,  Dr.  W.  B.  Atkinson,  of  Pennsylvania; 
Librarian,  Dr.  Geo.  W.  Webster,  of  Illinois;  Trus- 
tees, I  >r.  W.  W.  Dawson,  of  Ohio,  Dr.  W.  W. 
Potter,  of  New  York,  Dr.  J.  H.  Rauch,  of  Illinois. 

Judicial  Council— Dr.  H.  O.  Walker,  of  Michi- 
gan, to  fill  vacancy;  Dr.  W.  T.  Bishop,  of  Pa.; 
I)r  G.  L.  Porter,  of  Conn.;  Dr.  las.  F.  Hibbard, 
of  Ind.;  Dr.  C.  H.  Hughes,  of  Mo.;  Dr.  Hunter 
McGuire,  of  Va. ;  Dr.  A.  M.  Owen,  of  Ind.;  Dr. 
II.  D.  Didama,  of  New  York. 

Place  of  meeting  rSp2—  Detroit,  Mich.;  time  of 
meeting  first  Tuesday  in  June. 

Chairman  of  Committee  of  Arrangements,  I  »r. 
H.  O.  Walker,  Detroit,  Mich.;  Address  on  Gen- 


eral Medicine,  Dr.  J.  S.  Cain,  of  Tennessee;  Ad- 
dress on  General  Surgery,  Dr.  John  B.  Hamilton,, 
of  Washington,  D.  C;  Address  on  State  Medi- 
cine, Dr.  C.  A.  Lindsley,  of  Conn. 

Committee  on  State  Medicine — J.  Cochran,  Ala.; 
T.  E.  Murrell,  Ark.;  Luke  Robertson,  Cal.;  T. 
H.  Crothers,  Conn.;  J.  R.  Logan,  N.  Dak.;  R. 
G.  Ellegood,  Dei.;  S.  S.  Adams,  D.  C;  R.  J. 
Nunn,  Ga.;  J.  P.  Wall,  Fla. ;  Harold  N.  Mover, 
111.;  J.  F.  Hibbard,  Ind.;  H.  Wright,  Iowa;  W. 
L.  Schenck,  Kans. ;  H.  Horace  Grant,  Ky. ;  C. 
B.  Belt,  Mass. ;  A.  J.  Stone,  Minn. ;  W.  F.  Breakey, 
Mich.;  W.Johnson,  Miss.;  Young  H.  Bond,  Mo.; 
Thos.  Wood,  N.  C;  Alfred  F.  Carroll,  N.  Y.; 
G.  P.  Conn,  N.  H.;  Goldberth,  Neb.;  R.  Harvev 
Reed,  O.;  L-  F.  Flick,  Pa.;  A.  A.  Moore,  S.  C; 
J.  P.  Walker,  Tenn.;  R.  M.  Swaringen,  Tex.; 
J.  H.  Hamilton,  Vt.;  R.  N.  Martin,  Va. ;  A.  F. 
Stifel,  W.  Va.;  Geo.  M.  Steele,  Wis.;  J.  R. 
Matos,  La.;  G.  S.  Beardsley,  U.  S.  A.;  W.  Wy- 
inan,  U.  S.  Marine-Hospital  Service. 

Committee  on  JVecro/o^r — J.  T.  Searcy,  Ala.; 
G.W.  Hudspeth,  Ark.;  W.  K.  Lindlev,  Cal.;  G.  R. 
Shepperd,  Conn. ;  L.  P.  Bush,  Del. ;  J,  M.  Toner, 
I).  C;  J.  D.  Fernandez,  Fla.;  G.  W.  Bailey, 
Ga.;  E.  P.  Cook,  111.;  J.  L.  Thompson,  Ind.; 
Brown,  Iowa;  W.  F.  Sawhill,  Kan.;  John  G. 
Brooks,  Ky.;  Asa  S.  Potter,  Mass.;  R.  C.  Leven- 
saler,  Me.;  A.  B.  Anker,  Minn.;  W  B.  Alvord, 
Mich.;  B.  F.  Ketrel,  Miss  ;  J.  D.  Griffith,  Mo.; 
W.  M.  Knapp,  Neb.;  H.  Capehart,  N.  Dak.;  N. 
Jacobsen,  N.  Y.;  J.  J.  Berry,  N.  H.;  S.  S. 
Thorue,  Ohio;  Jacob  Price,  Pa. :  F.  P.  Porcher, 
S.  C;  F.  M.  Sim,  Tenn.;  W.  H.  Wilks,  Tex.: 
Edw.  R.  Camden,  Vt.;  L.  E.  Harvev,  Va.;  Dr. 
Wilson,  W.  Va.;  H.  V.  Faville,  Wis  ;  Jas.  M. 
Flint,  U.  S.  N. 

Committee  of  Pan  American  Medical  Co?igress: 
— R.  F.  Saunders,  Ala.;  Ed.  Bentlev,  Ark.;  W. 
R.  Cluness,  Cal.;  C.  A.  Lindslev,  Conn.:  E.  M. 
Darrow,  N.  Dak.;  C.  H.  Richards,  Del.;  D.  W. 
Prentiss,  D.  C;  C.  R.  Oglesby,  Fla.;  James  Me 
Fadden  Gaston,  Ga.;  N.  S.  Davis,  111.;  A.  M. 
Owen,  Ind.;  H.  B.  Crowley,  la.;  J.  P.  Minnev, 
Kan.;  J.  N.  McCormack",  Ky.;  S.  T.  Chaille, 
La.;  Augustus  P.  Clarke,  Mass.;  P.  H.  Millard, 
Minn.;  C.  H.  Leonard,  Mich.;  Dr.  Kendell, 
Miss.;  I.  N.  Love,  Mo.;  Jno.  Cronyn,  N.  Y. :  Ir- 
vin  A.  Watson,  N.  H.;  K.  C.  Moore,  Neb.; 
Chas.  A.  L.  Reed,  Ohio;  Wm.  Pepper,  Pa.;  K. 
A.  Kinloch,  S.  C;  J.  R,  Buist,  Tenn.;  J.  W 
Carhart,  Tex.;  Henry  W.  Holton,  Vt.;  J.  S. 
Wellford,  Va.;  Jas.  H.  Brownfield,  W.  Va.;  Jas. 
P.  Reed,  Wis.  George  W.  Webster, 

Wm.  II.  WaTHEN,  Secretary. 

Chairman. 

The  announcement  having  been  made  that  Dr. 
S.  C.  Wood,  of  N.  Y.,  nominated  for  Judicial 
Council,  was  dead,  on  motion  the  name  of  Dr. 
11.  D.  Didama,  of  N.  Y.,  was  substituted. 

Dr.  II.  O.  Walker,  of  Mich.,  moved  to  strike 


I8yl.j 


AMERICAN  MEDICAL  ASSOCIATION. 


7i7 


out    Hot   Springs,   Ark.,  as  the  place   of  meet- 
ing and  insert  Detroit,  Mich. 

After  some  discussion.  Dr.  Simmons,  of  Cal., 
moved  to  insert  San  Francisco,  Cal.  On  motion 
of  Dr.  Caren,  111.,  this  was  laid  on  the  table. 

Dr.  Pawling,  Neb.,  moved  to  insert  Omaha, 
Neb.     This  w  ts  laid  on  the  table. 

A  motion  of  Dr.  J.  M.  Keller,  Ark.,  to  recom 
mit  the  whole  report  was  laid  on  the  table. 

Detroit,  Mich.,  was  then  adopted  as  the  place 
of  meeting  by  a  vote  of  143  to  105. 

Dr.  C.  W.  Brown  having  named  Dr.  W.  W. 
Potter.  N.  V.,  as  ineligible  for  Trustee  by  reason 
of  non  affiliation  with  the  Association,  by  the 
suggestion  of  Dr.  X.  S.  Davis,  111.,  the  matter 
was  referred  to  the  _,udicial  Council. 

The  whole  report  on  nominations  as  amended 
was  then  adopted  bv  a  large  vote  in  favor. 

Dr.  X.  C.  Scott,  Ohio,  named  Dr.  H.  O. 
Walker,  of  Mich.,  as  Chairman  of  the  Committee 
of  Arrangements,  in  place  of  Dr.  J.  M.  Keller, 
of  Ark.  Another  nominee  having  been  named 
as  ineligible,  Dr.  I.  X.  Love.  Mo.,  demanded  the 
objection. 

A  motion  by  Dr.  F.  Woodbury,  Pa.,  to  refer 
this  also  to  the  Judicial  Council  was  negatived. 

The  place  of  meeting  requiring  it.  on  motion 
of  Dr.  X.  S.  Davis  the  time  was  changed  from 
first  Tuesday  in  May  to  June. 

Dr.  J.  M.  Mathews,  Kentucky,  read  the  .  Id- 
dress  in  Surgery.     (See  page 

Dr.  W.  F.  liorner.  U.  S.  A.,  V.i  .  offered  the 
following  which  was  adopted  : 

Whkreas,  The  Code  of  Ethics  of  this  Association  de- 
clares, Art.  ii,  "The  benefits  occurring  to  the  public  di- 
rectly   and    indirectly    from    the    active    and    unwearied 

beneficence  of  the  profession , ' '  but since  its  original 

organization  has  never  considered  any  provision  for  the 
widows  and  orphans  of  deceased  Fellows. 

Whereas.  The  success  in  the  formation  of  Medical 
31  .-iations  in  our  large  cities  and  in  one  or  more  of 
the  Stales  of  our  Union  has  proved  a  practical  scheme  to 
succor  the  families  of  many  a  brother  physician,  stricken 
down  in  the  midst  of  apparent  success,  who  otherwise 
would  be  unprovided  for. 

Therefore,  be  it  resolved.  That  a  Committee  be  ap- 
pointed by  the  President  of  this  Association  to  consider 
and  report  upon  the  expediency  and  practical  advantages 
of  a  "Section  of  Benevolence"  in  connection  with  the 
work  and  aims  of  the  Association,  which  seeks  to  ameli- 
orate not  only  human  suffering  and  to  cure  disease,  but 
to  enlarge  the  influence  of  the  profession  by  showing  re- 
gard for  the  needs  of  the  widows  and  orphaus  of  our 
deceased  brethren. 

The  Permauent  Secretary  read  the  report  of  the 
Committee  on  a  Secretary  of  Public  Health. 

REPORT  OF    THE    COMMITTEE    OX    THE    OUESTION 
OF  A  CABINET   APPOINTMENT  OF  A    SEC- 
RETARY OF  PUBLIC  HEALTH. 

The  committee  appointed  to  consider  the  ques- 
tion of  petitioning  the  next  Congress  on  the  cre- 
ation of  a  Medical  Secretary  of  Public  Health, 
beg  leave  to  present  their  views,  and  a  resolution, 
for  your  adoption. 


The  undersigned  believe  that  the  time  has 
come  when  the  medical  profession  is  under  sol- 
emn obligation  to  seek  all  the  places  and  posi- 
tions in  the  State  that  will  promote  a  higher  de- 
gree of  public  usefulness  than  we  now  enjov. 
There  is  no  other  profession  that  excels  ours  in 
positive  efficiency  to  sustain  public  order,  com- 
fort and  virtue.  We  possess  vast  capacity  for 
the  direction  of  society  and  promotion  of  human 
happiness.  There  is  nothing  in  the  body  or  mind 
of  man  that  is  uot  in  the  purview  of  medical 
practice.  We  are  laboring  unceasingly  to  assuage 
the  ills  of  individuals  and  communities. 

At  this  time  the  profession  is  manifesting,  in  a 
higher  spirit  than  ever  before,  the  purpose  of 
ssing  contagious  and  infectious  diseases. 
This  work  was  begun  by  Jenuer  a  century  ago, 
and  the  awful  scourge  of  small-pox  has  been 
stamped  out  wherever  vaccination  is  compulsory. 
We  have  now  assumed  the  stupendous  task  of 
suppressing  all  the  terrible  diseases  that  desolate 
the  world. 

There  are  infectious  and  epidemic  diseases  that 
move  about  the  world,  almost  periodically,  which 
we  need  not  particularize  ;  they  are  often  the 
products  of  the  squallor  and  wretchedness  of 
peoples,  and  are  spread  far  and  wide  about  the 
lines  of  commerce.  These  invisible  foes  infest 
the  air.  the  waters,  and  the  very-  food  we  eat. 
From  the  grosser  foes  of  human  health,  cold, 
heat  and  tempest,  men  have  power  to  defend 
themselves :  but  in  regard  to  these  invisible 
agents  of  suffering  and  death,  for  want  of  higher 
knowledge,  they  are  largely  helpless.  In  their 
despair  they  turn  to  medical  science  for  help,  un- 
willing to  trust  in  the  brute  law  of  the  survival 
of  the  fittest. 

Governments,  in  a  certain  way,  have  alwavs 
done  something  to  aid  medical  men  in  their  en- 
deavors to  stay  the  pestilence  and  save  the  afflict- 
ed ;  but  never  adequately.  They  have  generally 
refused  to  make  the  medical  profession  a  perma- 
uent integral  part  in  the  administration  of  the 
State  ;  that  is,  in  the  making  and  the  execution 
of  sanitary  laws. 

What  laws  are  necessary  for  the  full  employ- 
ment of  our  beneficent  profession  ?  We  reply  : 
those  that  relate  to  the  social  state  of  the  people 
for  the  prevention  of  disease.  They  comprehend 
an  amplitude  and  purity  of  water  supply,  proper 
dwellings  for  the  lower  classes  without  over- 
crowding or  deficiency  of  light  and  air,  unadul- 
terated food,  complete  drainage  and  disinfection 
of  excrement,  the  preservation  of  rivers  and  small- 
er streams  of  water  from  pollution,  the  regulation 
of  the  hours  of  labor,  the  protection  of  childhood 
!  from  the  imposition  of  toil,  and  their  proper  edu- 
cation, cleanliness  of  streets  and  planting  of  shade 
1  trees  for  protection  from  intense  solar  heat,  and 
the  decomposing  power,  by  their  leaves,  of  dele- 
I  terious  gases  and  miasms  ;  the  establishment  of 


7i8 


AMERICAN  MEDICAL   ASSOCIATION. 


[May  i  6, 


public  baths,  the  operations  of  quarantine  to  pre- 
vent invasion  of  pestilence  and  lauding  of  immi- 
grants with  diseases  dangerous  to  others,  the  iso- 
lation of  persons  attacked  with  infectious  dis- 
ease  and  the  disinfection  of  localities,  the  con 
struction  and  management  of  general  and  special 
hospitals,  tbe  care  of  the  sick  poor  in  their  homes, 
the  prevention  of  consanguineous  marriages  and 
of  those  who  have  destructive  types  of  constitu 
tion,  the  warning  of  society  of  the  evil  conse- 
quences of  abuses  of  the  brain,  the  material  basis 
of  consciousness,  whereby  a  free  will  is  impaired 
and  the  sufferers  become  irresponsible  and  are  of- 
ten mentally  ruined  ;  and,  lastly,  the  regulation 
of  those  two  giant  evils  of  civilization,  intemper- 
ance and  prostitution. 

We  affirm  that  all  the  measures  for  public  re- 
lief on  these  important  subjects  should  be  under 
the  guidance  of  medical  men. 

It  is  not  the  mere  knowledge  of  the  human 
frame  as  a  diseased  thing,  or  a  mechanism,  that 
should  give  us  highest  consideration  in  the  State, 
but  rather  our  capacity  to  prevent  sickness  by 
securing  the  proper  administration  of  the  laws  of 
health.  At  present  we  occupy  positions  but  little 
better  than  mere  advisers  to  authoritive  bodies  ; 
our  soundest  suggestions  are  at  the  mercy  of  ig- 
norance and  prejudice  of  uninformed  legislation. 
The  medical  profession  holds  itself  ready  not 
only  to  diminish  the  fearful  destruction  of  life 
now  going  on,  but  ultimately  to  destroy  the  con- 
tagia  that  cause  it.  It  is  now  becoming  gener- 
ally known  that  infectious  diseases  and  toxic  el- 
ements are  disseminated  in  food.  An  infectious 
disease  in  the  family  of  a  dairy-man  may  be  as 
widely  diffused  as  his  distribution  of  milk.  The 
pollution  of  streams  of  water  and  wells  about 
towns,  villages  and  farmers'  homes,  we  know 
definitely,  subject  many  families  to  tedious  and 
destructive  diseases,  which  our  wise  sanitation 
can  overcome,  if  we  possessed  the  power  to  so 
act.  It  will  be  well  for  the  State  when  the  med- 
ical profession  is  represented  in  the  councils  of 
the  Nation  as  weightily  as  can  be  assumed  by 
official  places  and  conferred  dignities 

It  seems  to  your  committee  that  this  is  a  pro- 
pitious period  for  entering  upon  a  forward  move- 
ment that  will  place  our  profession  in  its  true  re- 
lation to  public  affairs  ;  and  that  the  first  and 
most  important  step  to  obtain  this  end.  is  to  ap 
peal  to  Congress  to  create  the  office  of  a  Medical 
Secretary  of  Public  Health. 

The  latest  addition  to  the  Cabinet  of  the  Pres- 
ident is  that  of  Secretary  of  Agriculture,  and  al 
ready  a  great  impulse  to  higher  intelligence  has 
been  inaugurated  by  the  practical  fanner  who  is 
at  its  head. 

What  part  will  a  Secretary  of  Public  Health 
play,  when  he  takes  his  place  in  the  Cabinet  ? 
Will  he  be  a  mere  figure  head,  or  will  he  be  able 
to  fulfil  important  duties  to  the  State?     The  an- 


swer is,  he  will,  by  virtue  of  his  position,  justly 
form  an  integral  part  of  the  councils  of  the  State; 
he  will  represent  the  medical  consciousness  of 
the  Nation,  and  be  one  to  whom  we  all  can  look 
for  the  exploitation  of  measures  that  will  direct 
continuous  scientific  and  collective  investigation, 
in  regard  to  endemic  as  well  as  epidemic  diseases 
lhat  afflict  the  people;  he  will  be  able  to  cooper- 
ate, coordinate,  unify  and  utilize,  in  the  discharge 
of  his  duty,  all  the  work  of  State  Boards  of 
Health,  now  so  well  organized  in  various  States 
of  the  Nation  ;  and  these  in  turn  will  find  them- 
selves strongly  reinforced  by  the  example  and 
authority  of  a  great  central  officer  who  will  be 
equal  in  function  and  opportunity  with  the  other 
members  of  the  President's  Cabinet. 

It  must  be  acknowledged  that  the  Government, 
through  the  operations  of  the  Surgeon- General 
of  the  Army,  Navy,  and  Marine  Department, 
and  by  the  action  of  the  Secretary  of  State,  has 
authorized  most  liberal  expenditures  for  the 
establishment  of  the  National  Medical  Library 
and  Museum,  the  issue  of  the  incomparable  In- 
dex Medicus,  and  for  original  researches  at  home 
and  abroad  on  the  origin  and  nature  of  the  fearful 
epidemic  brought  to  our  shores  by  immigrant 
and  other  ships.  Honorable  mention  is  due  to 
Surgeon  George  M.  Sternberg,  of  the  U.  S,  Army, 
for  his  investigations  in  regard  to  yellow  fever, 
and  to  Dr.  E.  O.  Shakespeare,  of  Philadelphia, 
for  his  study  in  India  and  Spain  of  Asiatic  cholera 
under  the  patronage  of  Secretary  Bayard  ;  of  the 
establishment  of  scientific  posts  by  the  Surgeon- 
General  of  the  Marine-Hospital  Service  at  Dry 
Tortugas  for  the  special  and  continuous  investi- 
gation of  the  causes  of  yellow  fever,  and  the 
Bacteriological  Laboratory  attached  to  U.  S.  Ma- 
rine-Hospitals at  New  York,  and  to  the  Surgeon- 
General  of  the  Navy  for  the  Navy  Museum  of 
Hygiene,  in  whose  laboratories  chemical  analyses 
of  water  and  food,  as  well  as  bacteriological  re- 
search,  are  constantly  going  on. 

The  more  recent  enactment  of  the  Inter-State 
Quarantine  Act  as,  truly,  says  Dr.  Walter  Wy- 
man,  of  the  Marine-Hospital  Service  ii:  Wash- 
ington, marks  an  epoch  in  the  history  of  national 
health  legislation.  The  Conventions  in  the 
quarantine  service,  in  the  last  few  years  have  se- 
cured great  progress  towards  a  uniformity  in 
quarantine  laws  in  time  of  epidemic  visitation. 
Uso  hi  extensive  correspondence  has  been  estab- 
lished by  the  Marine- Hospital  Surgeon  with  our 
Consuls  every  where,  so  that  our  quarantine 
service  is  constantly  advised  of  the  prevalence  of 
epidemics  in  countries  with  which  we  are  closely 
connected  in  a  commercial  way. 

A  Secretary  of  Public  Health,  by  the  aid  of 
associated  departments,  can  be  constantly  in- 
formed of  the  prevalence  of  epidemic  disease  in 
all  the  localities  of  our  country,  and  could  give 
public  warning  to  all  who  might  be  exposed  to 


i89i.J 


AMERICAN  MEDICAL  ASSOCIATION. 


719 


them,  and  thus  the  people  will  be  assured  that  a 
competent  Minister  of  State  surveys  the  whole 
field.  He  will  also  be  able  to  render  important 
assistance  to  Army,  Naval  and  Marine  Surgeons, 
by  the  fact  that  their  respective  Cabinet  officials 
cannot  be  in  professional  touch  with  them,  as 
would  be  a  Secretary  of  Public  Health. 

We  can  all  recall  what  this  Association  ac- 
complished for  the  elevation  in  rank  and  pay  of 
the  Army  and  Naval  Surgeons  from  the  lower 
plane  on  which  they  stood.  It  was  not  through 
the  active  support  of  the  President  or  his  Cabi- 
net ;  but  it  was  only  due  to  the  appeal  of  this 
Association  directly  to  Congress.  This  same 
effort  is  now  being  made  through  the  British 
Medical  Association  to  obtain  higher  rank  to  the 
medical  arm  of  the  Army  and  with  fair  hopes  of 
success. 

The  question  of  higher  medical  education  must 
also  occupy  a  Secretary'  of  Public  Health.  We 
all  know  the  great  progress  on  this  line  that  has 
been  made  in  the  last  twenty  years.  A  more 
thorough  preliminary  education  is  now  demanded 
by  our  best  medical  schools  for  matriculation  ; 
moreover,  diplomas  no  longer  give  in  some  States 
a  right  to  practice  medicine.  We  need  uniform 
laws  on  this  subject  in  all  the  States,  and  such 
legislation  can  be  greatly  promoted  by  a  Cabinet 
officer.  If  it  be  possible  to  compass  this  there 
should  be  a  universal  law  that  no  man  or  woman 
or  special  sect  of  physicians,  regular  or  irregular, 
and  no  specialist  shall  lawfully  practice  medicine 
or  surgery  until  they  have  given  satisfactory 
proof  before  a  Board  of  Examiners  that  they 
have  had  an  adequate  training  in  medi- 
cine and  surgery.  In  this  way  it  is  reasona- 
ble to  expect  that  at  length  a  race  of  Physicians 
will  be  developed  who  will  secure  universal  re- 
spect because  they  will  be  regarded  as  amongst 
the  best  educated  persons  in  a  community. 

The  only  true  way  of  suppressing  quackery 
among  regular  or  irregular  practitioners  is  by 
higher  education.  Thus  the  medical  profession 
has  gradually  unfolded  itself  in  the  procession  of 
the  ages,  and  will  continue  to  grow  stronger  and 
brighter  with  the  progress  of  civilization. 

It  is  perfectly  plain  that  a  Medical  Secretary  of 
State  will  be  as  fully  employed  as  any  other  offi- 
cer of  the  State,  and  his  duties  will  increase  all 
the  time.  It  is  a  well-known  biological  law,  that 
organs  grow  to  conditions  of  capacity  as  they  are 
continuously  exercised.  The  muscular  system 
and  all  the  organs  thus  increase  up  to  a  condi- 
tion of  status;  so  will  the  functions- of  the  pro- 
posed officer  grow  broader  and  stronger  in  adapt- 
ability to  the  needs  of  the  people  and  the  greater 
efficiency  of  our  profession,  also  to  this  Associa- 
tion, which,  whatever  it  may  have  achieved,  is 
still  upon  the  threshold  of  its  beneficent  mis- 
sion to  our  country. 

His  annual  reports  will  command  universal  at- 


tention, as  they  will  contain  everything  of  im- 
portance in  medical  progress. 

Finally,  the  unification  of  all  things  relating 
to  public  hygiene  in  the  States  through  the  aid 
of  State  Boards  of  Public  Health,  will  give  a 
solidity  and  usefulness  to  the  practice  of  medi- 
cine never  hitherto  attained. 

We  ask  for  the  adoption  of  the  following  res- 
olution : 

Resolved,  That  the  President  of  this  Association  ap- 
point a  committee  of  live  to  memorialize  Congress,  at 
its  next  session,  on  the  subject  of  creating  a  Cabinet  offi- 
cer to  be  known  as  the  Medical  Secretary  of  Public 
Health. 

All  of  which  is  respectfully  submitted. 
C.  G.  Comegys,  Ohio. 
T.  G.  Richardson,  Louisiana. 
N.  S.  Davis,  Illinois. 

On  motion  of  Dr.  J.  F.  Hibberd,  Indiana,  the  re- 
port was  received  and  the  resolution  was  adopted. 

Committee — Drs.  C.  G.  Comegys,  Ohio;  J.  C. 
Culbertson,  Ohio ;  W.  T.  Briggs,  Tennessee ;  J. 
F.  Hibberd,  Indiana ;  and  Wm.  B.  Atkinson, 
Pennsylvania. 

Dr.  I.  N.  Quimby,  New  Jersey,  offered  the  fol- 
lowing amendment : 

Whereas,  More  time  is  needed  in  the  various  Sec- 
tions to  enable  the  same  to  get  through  with  their  general- 
ly overburdened  duties;  and  whereas  one  of  the  morning 
sessions,  sav  Thursday,  could  be  omitted  without  any 
detriment  to  the  general  good  of  the  Association,  I  here- 
by offer  the  following  amendment  to  the  by-laws:  That 
Thursday  morning's  general  session  be  omitted  and  the 
time  be  devoted  to  moving  Sectional  work. 

Laid  over  under  the  rules  till  next  year. 

Dr.  Ouiinby  offered  the  following,  which  was 
adopted : 

Whereas,  About  Si, Soo  or  $2,000 has  been  contributed 
towards  the  Rush  Monument  Fund,  which  amount  is  on 
deposit  without  interest,  therefore  be  it 

Resolved,  That  this  Association  direct  its  Chairman, 
Secretary,  and  Treasurer  of  said  fund  to  be  constituted  a 
committee  of  investment,  who  are  hereby  empowered 
and  directed  to  invest  said  sum  at  interest  in  good  first 
mortgage,  real  estate  security,  or  other  first-class  securi- 
ties. 

VOTE    OF  THANKS  TO  THE  EDITOR    AND  BUSINESS 
MANAGER. 

Dr.  R.  Harvey  Reed,  Ohio,  offered  the  following: 

Whereas.  The  Journal  has  been  successfully  and 
satisfactorily  conducted  during  the  past  financial  year, 
enabling  the  Treasurer  of  the  Association  to  report  the 
largest  balance  in  the  history  of  the  Association,  of  over 
$5,000,  being  an  increase  of  nearly  100  per  cent,  over  the 
preceding  year;  and 

Whereas.  This  success  has  been  largely  due  to  the 
united  and  energetic  efforts  of  our  Editorial  and  Busi- 
ness representatives  at  Chicago;  be  it  therefore 

Resolved,  That  the  thanks  of  this  Association  be,  and 
are  hereby  giyen  Dr.  John  H.  Hollister,  the  Supervising 
Editor,  arid  Mr.  J.  Harrison  White,  the  Business  Man- 
ager; and  be  it  further 

Resolved,  That  this  Association  cordially  recommend 
to  its  Board  of  Trustees  the  retention  of  the  services  of 
these  gentlemen  for  the  present  year. 

A  motion  by  Dr.  Kendall,  Illinois,  to  lay  this 
on  the  table  was  negatived. 


720 


MISCELLANY. 


[May  i  6,  1891. 


After  much  discussion,  on  motion  of  Dr.  H.  D. 
Holton,  Vermont,  it  was  agreed  that  nothing  in 
this  action  should  be  construed  as  mandatory 
upon  the  Board  of  Trustees. 

Dr.  Paucoast,  of  Pennsylvania,  made  the  point 
of  order,  with  all  respect  to  the  President  and 
even-  faith  in  the  honor  of  the  delegates  to  the 
Association,  that  from  a  parliamentary  stand- 
point, the  President  and  the  Association  cannot 
tell  whether  the  vote  just  passed  was  a  legal  one 
according  to  oar  By-laws,  as  the  roll  of  delegates 
was  not  called. 

President  Briggs  replied,  that  the  decision  of 
the  chair  could  be  appealed  from. 

Dr.  Pancoast  declined  to  do  so,  saying  that  he 
did  not  wish  to  consume  time,  and  as  the  Perma- 
nent Members  are  not  allowed  to  vote,  he  would 
not  appeal  to  a  meeting  composed  only  of  dele- 
gates. 

Dr.  J.  S.  Marshall,  Chairman,  read  the 

REPORT    OF    THE     COMMITTEE    ON     CONFERENCE 
OF    SECTIONS. 

Your  Committee  of  Conference  of  Sections  ap- 
pointed in  consonance  with  the  resolution  of  Dr. 
Connor,  passed  by  the  Association  on  Tuesday 
morning,  beg  leave  to  report  as  follows :  That 
owing  to  the  limited  time  at  their  disposal,  and 
the  greatness  of  the  task  imposed  upon  them, 
they  have  been  unable  to  perfect  a  plan  for  the 
improvement  of  the  scientific  work  of  the  Sec- 
tions and  the  strengthening  of  the  weak  ones, 
that  seemed  at  all  satisfactory  to  your  Commit- 
tee. As  a  beginning,  however,  in  this  direction, 
your  Committee  recommend  the  passage  of  the 
following  resolutions : 

Resolved,  That  a  committee  of  five  be  appointed  br- 
each Section  to  supervise  and  revise  papers  submitted  to 
the  Sections,  and  to  perform  such  other  duties  as  may  be 
directed  by  the  Section;  of  this  Committee  the  Chairman 
and  Secretary  of  the  Section  shall  be  ex  officio  members. 

Resolved,  That  the  Committee  of  Conference  of  Sec- 
tions ask  to  be  continued,  that  the  work  already  begun 
may  be  further  perfected. 

On  motion,  the  report  was  received  and  the 
resolutions  were  adopted. 

Dr.  J.  G.  Kiernan  and  Dr.  H.  St.  Clair  Ash, 
Pennsylvania,  offered  the  following  amendment 
to  the  By-laws : 

Resolved,  That  the  Committee  of  Necrology  be  abol- 
ished, and  the  work  of  that  committee  be  made  the  duty 
of  the  editor  of  The  Journal. 

Dr.  W.  \V.  Parker,  Virginia,  offered  the  fol- 
lowing : 

ed,  That  the  next  meeting  of  this  Association  con- 
sider the  propriety  of  electing  a  practical  chemist  of  well- 
known  skill  and  high  character,  who  shall  as  soon  is  may 

D  the  analysis  of  the-  various  nostrums  m 
market  and  that  may  hereafter  appear,  and  publish  the 
result  in  The  Journal  of  the  Association,  or  in  an  inde- 
pendent journal  under  the  name  of  The  Moral  Detectiv* , 
or  Medical  Examiner,  or  such  other  title  as  the  Assoi  i- 
ation  may  select,  and  for  his  compensation  a  tax  of  fifty 
cents  per  annum  shall  be  assessed  upon  each  member  of 


this  Association.  The  chemist  so  elected  shall  have  the 
privilege  of  issuing  the  journal  to  other  persons,  not 
members  of  this  Association,  upon  such  terms  as  he  may 
think  proper. 

On  motion  this  was  laid  on  the  table. 

On  motion  the  Association  then  adjourned. 
( To  be  concluded.) 


MISCELLANY. 


A  Word  to  Aurists. — An  invitation  is  given  to  all 
aural  surgeons  to  send  a  brief  statement  of  their  views 
and  experience  concerning  the  operation  for  excision  of 
the  drum  head  or  ossicles.  A  prompt  contribution  to 
this  consensus  of  opinion,  for  early  publication,  will  be 
appreciated.    Address  S.  S.  Bishop,  70  State  St.,  Chicago. 

Other  journals  are  invited  to  insert  this  notice. 


The  British  Gynecological  Society. — The  meet- 
ing of  this  Society  will  be  held  at  Xewcastle-on-Tviie  on 
June  18  and  19,  under  the  presidency  of  Dr.  Robert 
Barnes.  The  meetings,  which  will  be  held  in  the  Col- 
lege of  Medicine,  will  be  open  to  all  registered  medical 
practitioners.  A  public  dinner  will  be  held  on  the  even- 
ing of  the  first  day.  All  communications  should  be  ad- 
dressed to  the  General  Local  Secretary,  R.  C.  Benning- 
ton, M.B.,  59  Osborne  Road,  Xewcastle-on-Tyne. 


Official  List  of  Changes  in  the  Stations  and  Duties  of  Officers  Serving 
in  the  Medical  Department,  U.  S.  Army,  from  May  2t  i&oi,  to 
Ma\  8,  1891. 

First  Lieut.  Julian  M.  Cabell,  Asst.  Surgeon,  is  relieved  from  duty 
at  Ft.  Niobrara,  Neb.,  and  will  report  in  person  to  the  command- 
ing officer.  Ft.  Buford,  N.  Dak.,  for  duly  at  that  post,  relieving 
Major  Valery  Havard,  Surgeon.  Major  Havard,  on  being  relieved 
bv  Lieut.  Cabell,  will  report  in  person  to  the  commanding  officer. 
Ft.  D.  A.  Russell,  Wyo.,  for  duty  at  that  post.  Par.  14,  S.  O.  102, 
A.  G.  O.,  May  5,  1S91. 

Capt.  Guy  L.  Edie,  Asst.  Surgeon,  is  relieved  from  duty  at  Ft.  Doug- 
la*?,  Utah,  and  will  report  in  person  to  the  commanding  officer, 
Ft.  Niobrara,  Neb.,  for  duty  at  that  post,  relieving  Major  T.  E.  Wil- 
cox, Surgeon.  Major  Wilcox,  on  being  relieved  by*  Capt.  Edie, 
will  report  in  person  to  the  commanding  officer,  Ft  Huachuca, 
Ariz.,  for  duty  at  that  post.    Par.  14,  S.  O.  102,  A.  G.  O.  May  5,  1S91. 

Capt,  William  P.  Kendall,  Asst.  Surgeon,  relieved  from  duty  at  Ft. 
D.  A.  Russell,  Wyo.,  and  will  report  in  person  to  the  commanding 
officer,  Ft.  Douglass,  Utah,  for  duty  at  that  post.  Par.  14,  S.  O. 
io2,  A.  G.  0.,  May  5,  1891. 

Capt.  Walter  D.  McCaw,  Asst.  Surgeon,  is  relieved  from  duty  at  Ft. 
McPherson,  Ga.,  and  will  report  in  person  to  the  commanding  ot- 
ficer.  Camp  Pilot  Butte,  Wyo.,  for  duty  at  that  post,  relieving  Capt. 
George  E.  Bushnell,  Asst.  Surgeon.  Capt.  Bushnell,  on  being  re- 
lieved bv  Capt.  McCaw,  will  report  in  person  to  the  commanding 
officer.  Ft.  McKinnev,  Wyo.,  for  dutv  at  that  post.  Par.  14,  S.  O. 
102,  A.  G.  0.,Ma>*5,  1891. 

First  Lieut.  Joseph  T.  Clarke  Asst.  Surgeon,  is  relieved  from  duty 
at  Ft.  Riley,  Kan.,  and  will  report  in  person  to  the  commanding 
officer.  Camp  Poplar  River,  Mont.,  for  dutv  at  that  station,  reliev- 
ing First  Lieut.  Jefferson  D.  Poindexter,  Asst.  Surgeon  First 
Lieut.  Poindexter,  on  being  relieved  by  Lieut.  Clarke,  will  report 
in  person  to  the  commanding  officer,  Ft.  Niobrara,  Neb.,  for  duty 
at  that  post.     Par.  14,  S.  O.  102,  A.  G.  O..  May  5,  1891. 

Capt.  Louis  A.  La  Garde,  Asst.  Surgeon,  is  relieved  from  duty  at  Ft. 
hue,  Mont.,  and  will  report  in  person  to  the  commanding 
officer.  Ft.  McHenrv,  Md.,  for  dutv  at  that  post,  relieving  Major 
Charles  B.  Byrne.  Surgeon.  Major  Byrne,  on  being  relieved  by 
Capt.  La  Garde,  will  report  in  person  to  the  commanding  officer, 
Ft.  Assiniboine,  Mont.,  for  dutv  at  that  post.  Par.  14,  S.  O.  102, 
\    ''.    <  >  .  May  5,  1891. 

Major  Joseph  B.  Girard,  Surgeon,  is  relieved  from  duty  at  Alcatraz 
Island.  Cal.,  and  will  report  in  person  to  the  commanding  officer, 
Benicia  Bks.,  Cal.,  for  duty  as  Post  Surgeon  at  that  post,  and  At- 
tending Surgeon  at  Benicia  Arsenal,  Cal.,  relieving  Major  John 
II.  Janeway,  Surgeon.  Major  Janeway,  on  being  relieved  by  Ma- 
jor Girard. 'will  repair  to  Philadelphia,  Pa.,  and  assume  the  duties 
of  attending  surgeon  and  examiner  of  recruits  in  that  city,  and 
in  addition  to  his  duties  in  Philadelphia,  will  perform  the  "duties 
of  Post  Surgeon  at  Frankfort  Arsenal,  Pa.  Par.  14,  S.  O.  102.  A. 
G.  O..  May  5,  i8qi. 

By  direction  of  the  Acting  Secretary  of  War,  par.  5,  S.  O.  24.  Janu- 
ary- 29,  1S9T,  from  this  office,  granting  Major  Julius  H.  Patozki. 
a  six  months'  leave  of  absence,  is  so  amended  as  to  grant 
said  leave  on  surgeon's  certificate  of  disability.  Par.  is,  S.  O.  99, 
A.  G.  O.,  Mav  1,  1891. 


The  Journal  of  the 

American  Medical  Association 


Vol.  XVI. 


CHICAGO,  MAY  23,   1891. 


No.  21. 


ADDRESSES. 


THE  ADDRESS  OX  MEDICINE. 

Delivered  at  the  Forty-second  Annual  Meeting  of  the  American  Medi- 
cal Association,  heldat  Washington,  D.C.,  May,  iSgi. 

BY  E.  L.  SHURLY.   M.D., 

OF   DETROIT.  MICH. 

Mr.  President  and  Members: — As  it  would  be 
improper  on  this  occasion  to  attempt  even  a  men- 
tion of  the  vast  number  of  interesting  and  in- 
structive ideas  and  observations  connected  with 
the'science  and  practice  of  medicine,  which  has 
been  evolved  during  the  past  year,  I  shall  present 
for  your  attention  only  some  points  bearing  on 

THE    RELATION    OF    MICROORGANISMS    AND    TOX- 

INES  TO  THE  SO-CALLED  ZYMOTIC  OR 

INFECTIOUS   DISEASES, 

and  as  this  subject  in  its  various  ramifications  is 
too  vast  for  a  detailed  consideration,  I  must  of 
necessity  confine  myself,  in  great  measure,  to  a 
generalization  upon  the  biological  and  chemical 
features  involved.  While  laboratory  work  has 
done  perhaps  more  than  any  other  branch  of  sci- 
ence toward  clearing  up  many  vexed  questions 
about  physiological  and  pathological  activities, 
yet  to  be  of  lasting  value  and  guidance  it  must 
agree  with  general  and  clinical  observations. 
While  this  has  been  the  case  more  often  than 
otherwise,  yet  there  are  instances  where  labora- 
tory observations  and  clinical  data  have  crossed 
swords ! 

Before  proceeding  to  an  examination  of  the 
topics  mentioned,  it  will  be  necessary  for  us  to 
keep  in  mind  the  fact,  that  the  organized  animal 
body  is  composed  of,  and  is  under,  the  operation 
(the  same  as  other  bodies)  of  the  three  elements 
of  the  Universe,  Ether,  Energy  and  Matter,  under 
various  forms  and  methods  of  combination ;  to 
which  may  be  added  what  is  known  as  ' '  Vital 
Force,"  which  some  scientists  regard  as  "  energy 
of  position  "  from  the  combustion  of  food.  Also 
that  this  fact  applies  to  a  condition  of  disease  as 
well  as  health  !  For  in  Somatic  death,  even,  i.  e.. 
death  of  the  whole  body,  there  are  certain  ele- 
mental tissues  which  die  first,  such  as  the  blood 
and  parenchymatous  tissue,  while  certain  other 
tissues,  such  as  the  epithelial,  resist  for  a  time,  at 
least,  the  destructive  or  resolving  power  of  Kinetic 


Chemical  energy.  In  fact,  the  only  difference 
between  life  and  death  from  a  physical  point  of 
view,  consists  of  changes  in  the  molecular  or 
atomic  arrangements  under  the  direction  of  chem- 
ical, calorific,  or  electric  energies.  For  matter  and 
energy  are  indestructible!  As  Shelley  says,  "I 
change,  but  I  cannot  die." 

To  understand  at  all,  the  range  of  pathology 
and  pathological  chemistry, — to  which  we  must 
undoubtedly  look  for  the  solution  of  many  of  the 
problems  of  the  present  day.  it  will  be  proper  to 
take  a  brief  survey  of  physiology  and  animal 
chemistry,  which  may  be  considered  the  founda- 
tion stones  of  our  art. 

To  sum  them  up  according  to  Mills,  Foster  and 
Kirk,  we  have 

The  Proximate  Principles,  which  are : 
Nitrogenous — Proteids. 

n„ -     i   x- ;. (  Certain  Crystalline  bodies. 

Organic  -    Non-mtrog-     Sugars  (^hydrates), 

(.Fats  i, Hydro-carbons). 

».,      t  •     '  Mineral  salts. 

The  Inorganic -lWater_ 

The  proteids  are  the  chief  constituents  of  liv- 
ing tissues,  including  the  blood  and  lymph. 

The  molecule  is  highly  complex,  consisting  of 
a  great  number  of  atoms,  and  is  formed  of  the  ele- 
ments C.H.X.O.S.  and  P.,  although  some  chem- 
ists think  that  we  are  still  in  ignorance  of  its 
exact  molecular  constitution.  The  proteids  are 
amorphous  and  non-diffusible,  excepting  the  pep- 
tones. They  are  soluble  in  strong  acids  and  al- 
kalies with  change  of  properties  and  constitu- 
tion. In  general,  they  are  coagulated  by  alcohol, 
ether  and  heat.     They  may  be  classified  into  : 

Native  Albumins:  Egg-albumin,  serum-albu- 
min. 

Derived  Albumins  (albuminates):  Acid- albu- 
min, alkali-albumin,  including  syntonin  (from 
muscle),  para- peptone,  and  casein. 

Globulins:  Globulin,  paraglobulin,  fibrinogen, 
myosin,  vitellin,  globin. 

Fibrin:     Coagulated  proteids. 

Peptones:  By  the  decomposition  of  proteids 
(albumin )  by  digestion  with  pepsin  we  obtain : 
Antialbumose.  anti- peptone  ;  and  with  trypsin, 
hemi-albumose,  hemi-peptone,  leucin  and  tyrosin. 

By  decomposition  with  acids,  we  get  with  hy- 
drochloric acid  :  antialbumate,  antialbumid,  hemi- 
albumose  and  hemipeptone. 


722 


THE  ADDRESS  ON  MEDICINE. 


[May  23, 


And  with  sulphuric  acid  we  get  antialbuinid, 
hemialbumose,  hemipeptone,  leucin  and  tyrosin, 
and  lardacein  (an  amyloid  substance). 

The  nitrogenous,  non-crystalline  bodies  allied 
to  proteids  are:  mucin,  chondrin,  gelatin  (or  glu- 
ten), elastin,  keratin,  nuclein,  chitin. 

Carbo-hydrates  (Sugars):  Dextrose,  maltose, 
lactose,  inosit,  dextrin,  glycogen,  tunicin. 

Fats,  Fatty  Acids,  etc.:    Formic  acid,  propionic 
acid,  acetic  acid,  butyric  acid,  valerianic  acid,  ea- 
proic  acid,  capric  acid,  caprylic  acid,  laurostearic 
acid,    myristic  acid,  palmitic  acid,  stearic  acid. 
The  Oleic  (Acrylic)  Acid  Series  :     Oleic  acid. 
The  Neutral  Fats:     Glycerin. 
The  Glycocholic  Acid  Series:     Glycol. 
The  Lactic  Acids: 

Bibasic  Acids  (  Oxalic  Acid  Series)  :  Oxalic 
acid,  succinic  acid. 

The  complex  nitrogenous  fats  (which  are  ob- 
tained from  nerve  tissues)  such  as  lecithin,  gly- 
cerin, phosphoric  acid,  protagon,  neurin,  cerebrin. 
The  Series  of  Bile  Acids,  etc.:  Cholic  (or  cho- 
lalic)  acid,  glycocholic  acid,  taurocholic  acid,  and 
cholesterin  ;  which  has  been  said  to  be  the  only 
free  alcohol  formed  in  the  body. 

The  Bile  Pigments:  Bilirubin,  biliverdin,  cho- 
letelin,  hydrobilirubin. 

The  Pigments  of  Urine:   Urobilin,  uroerythrin. 
The  Indigo   Series :     Indican,    indigo,   indol, 
skatol. 

The  Nitrogenous  Metabolites:  Urea,  urea  ni- 
trate, uric  acid,  creatin,  creatinin,  allantoin,  hy- 
poxanthin  (sarkine),  xanthin,  carmin,  guanin, 
kynurenic  acid,  glycin,  taurin,  leucin,  asparagin, 
amido  succinamic  acid,  aspartic  acid,  glutaminic 
acid  and  cystin  (an  amido- acid). 

The  Acids  of  the  Benzine,  o>  Aromatic  Series: 
Benzoic  acid,  hippuric  acid,  phenol,  tyrosin. 

In  addition,  we  must  include  the  leucomaines, 
for  the  discover}'  of  which  we  are  chiefly  indebted 
to  Gautier. 

According  to  Vaughn  and  Novy  there  are  three 
groups,  which  they  classify  as  follows  : 

The  uric  acid  group,  in  which  they  enumerate 
ten  bases.  The  creatinin  group,  consisting  of 
seven  bases,  and  a  third,  undetermined  group. 

Besides  these  Brieger,  Gautier,  Hoppe  Seyler 
and  others,  have  isolated  from  animal  and  vege- 
table organisms  in  various  states  of  decomposi- 
tion, about  forty  substances  called  ptomaines, 
some  of  which  exist,  and  are  formed,  at  times,  in 
the  human  economy — especially  in  the  intestinal 
canal.  Now,  when  we  contemplate  this  vast  array 
of  physiological  and  pathological  chemical  prod- 
ucts of  the  laboratory  of  the  animal  body,  some 
of  which  are  so  noxious  if  retained  in  certain 
situations  or  are  deflected  from  certain  courses, 
we  ought  not  to  be  surprised  at  the  ease  with 
which  that  equilibrium  of  the  functions — called 
Health — may  be  upset;  especially  as  the  so-called 
civilized  human  being  is  not  only  an    artificial 


animal  with  artificial  impulses,  and  a  great  range 
of  volitional  power ;  but  is  assailed  on  every  side 
by  enemies  of  a  parasitic  nature,  which,  if  suc- 
cessful in  the  ' '  universal  struggle, ' '  may  greatly 
hinder  the  molecular  and  chemical  coordination. 
Many  thinkers  have  maintained  that  the  biologi- 
cal were  not  distinctive  from  the  chemical  pro- 
cesses in  Nature ;  but,  although  intimately  con- 
nected, we  must  recognize  the  difference  between 
the  peculiarly  vital  character  of  molecular  and 
blastic  changes  concerned  in  cellular  movement, 
growth  and  development,  such  as  Karyokenesis  ; 
and  those  changes  which,  from  time  to  time,  take 
place  in  the  composition  of  the  proximate  princi- 
ples in  the  nature  of  fermentation  or  oxidation, 
which  are  strictly  chemical. 

We  know  that  certain  irritations  of  a  chemi- 
cal, mechanical,  electrical  or  calorific  nature 
may  be  transmitted  to  vessels,  so  as  to  pro- 
duce stasis  and  inflammation,  or,  directly  to 
leucocytes,  or  other  cellular  elements,  so  as 
to  induce  other  changes — degenerations — such 
as  the  albuminous,  amyloid,  waxy,  lardaceous, 
caseous  or  hyaline.  We  also  recognize  that  there 
are  various  degrees  of  susceptibility  and  resistance 
belonging  to  different  tissues,  and  at  different 
times  under  equal  provocation,  so  that  the  blood, 
leucocytes,  and  other  cells  which  under  the  influ- 
ence of  the  nervous  system,  are  the  most  impor- 
tant agents  in  carrying  on  the  oxidation  and  nutri- 
tion of  the  body,  may  become  the  agents  of  tissue 
destruction.  As  Armory  says,  speaking  in  a  gen- 
eral way  of  the  nutrition  and  formation  of  healthy 
tissue :  ' '  We  may  classify  these  under  two  prin- 
cipal heads.  That  of  metabolism,  which  com- 
prises the  whole  range  of  transformation  under 
the  influence  of  chemical  processes,  and  by  means 
of  which  proteid  substances  undergo  their  many 
changes;  and  that  of  cell  proliferation,  by  means 
of  which  the  cells  are  multiplied."  These  meta- 
bolisms, whether  of  the  constructive  or  destruc- 
tive character,  are  chiefly  performed  by  function- 
ally active  cells. 

Although  the  question  of  independent  trophic 
nerve  action  is  still  unsettled,  we  know  that  the 
influence  of  the  vaso-motor  system  over  the  blood 
and  nutrition  is  very  great ;  for  strong  external 
stimuli,  such  as  shock,  etc.,  will  produce  changes 
of  a  physical  character  in  the  blood.  Wertheim 
found  that  the  blood  of  animals  which  had  suffered 
severeh'  from  extensive  burns  showed  afterwards 
the  presence  of  foreign  bodies — yellowish  gran- 
ules, besides  increased  fluidity,  and  disintegra- 
tion of  the  red  blood  corpuscles. 

Concerning  animal  chemistry  there  is  but  com- 
paratively little  known!  However,  we  have  seen 
from  the  immense  variety  of  chemical  substan- 
ces already  discovered  to  be  results  of  fermenta- 
tion, or  chemical  action  and  reaction,  what  the 
probable  changes  are  !  Laboratory  experiments 
by  Kolb,  Muuk,  Peterson  of  New  York,  Shaw  and 


i89i.J 


THE  ADDRESS  ON  MEDICINE. 


others  show  that  electrical  energy  is  capable  of 
producing  great  chemical  transformation  and  de- 
ition  in  organic  substances,  outside  the 
They  show  also  that  similar  changes, 
either  primarily  or  secondarily,  may  be  produced 
in  living  tissue.      These  Live  thus  car- 

ried into  the  system  such  substances  as  iodine, 
strychnia-  and  quiuia,  in  proof  of  which,  these 
substances  were  found  in  the  urine  in  twelve  hours 
or  so  afterwards.  Zinselli  has  demonstrated  be- 
yond doubt,  physiological,  chemical,  and  calorific 
effects  upon  living  tissues  by  electrical  energy- 
electrical  osmosis — as  he  called  it. 

Protoplasm,  composed  of  carbon,  hydrogen, 
oxygen,  nitrogen,  sulphur  and  phosphorus,  ar- 
ranged into  a  very  complex  molecule,  which  is 
"the  physical  basis  of  life,"  as  Huxley  says,  and 
which  is  the  main  substance  of  all  animal  and 
vegetable  cells,  seems  capable  of  the  widest  de- 
gree of  change;  by  "its  universal  and  constant 
waste;  and  its  repair  by  interstitial  formation  of 
new  matter  similar  to  the  old." 

"Its  power  to  give  rise  to  new  forms  similar  to 
the  parent  ones  by  a  process  of  division.  Its 
manifestations  of  periodic  change  in  constitution 
developing  decay  and  death." 

Mills,  Foster  and  other  physiologists  state  that 
protoplasm  is  not  a  single  proteid  substance,  but 
a  mixture  of  such.  It  contains  often  also  starch, 
fat,  chlorophyl,  etc.  The  cellis  composed  of  proto- 
plasm, nuclein,  plasmine  and  chromatine  as  Dr. 
McCallum,  of  Toronto  (who  has  been  investiga- 
ting nutrition),  calls  the  coloring  matter  of  ani- 
mal cells.  Protoplasm  under  nerve  influence  con- 
structs a  certain  substance  which  is  antecedent  to 
another  final  product,  which  is  called  a  ferment. 
According  to  Vonjaksch,  when  fibrin  or  other 
proteids  are  acted  upon  by  pepsin  and  hydro- 
chloric acid  at  a  proper  temperature,  etc.,  the 
proteid  passes  through  several  stages  before  being 
finally  converted  into  peptone. 

The  proteid  molecule  seems  to  be  split  up  and 
the  albumoses  are  the  first  bodies  formed.  Kuhne 
describes  a  proto-albumose,  hetero-albumose,  and 
deutero-albumose.  Passing  to  the  blood,  which 
is  such  an  important  tissue  both  in  health  and 
disease,  and  so  involved  in  any  consideration  of 
protoplasm,  we  find  its  chemical  composition  to 
be  water,  proteids,  salines,  fats,  and  extractives. 
The  proteids  being  known  as  para-globulin, 
globulin,  serum-albumin  and  fibrinogen  ;  the 
principal  extractives:  urea,  creatin,  and  allied 
bodies,  sugar  and  lactic  acid — the  serum  contain- 
ing the  alkaline  salts.  The  different  corpuscles 
make  up  from  one-third  to  one-half  the  weight  of 
the  blood,  and  of  this,  the  red  corpuscles  may  be 
said  to  constitute  a  greater  part.  The  colorless 
cells  are  known  to  contain,  besides  protoplasm, 
peculiar  granules,  fats,  glycogen,  lecithin,  pro- 
tagon,  and  other  extractives.  One  especial  inter- 
est attaches  to  the  red  corpuscles,  on  account  of 


their  containing,  organically  or  intimately  com- 
bined, iron. 

There  have  been  very  many  interesting  studies 
in  relation  to  the  blood  and  nutrition,  of  late, 
which  we  have  not  the  time  to  notice.  Physiolo- 
gists have,  however,  found  different  actions  of 
globulins,  para-globulins  and  fibrinogen  in  serum. 
The  behavior  of  coagulation,  and  the  action  of 
so-called  fibrin  fermentation  is  not  without  inter- 
est from  a  pathological  point  of  view,  for  we  shall 
probably  find,  in  the  future,  that  in  many  of  the 
general  diseases,  characterized  by  parenchyma- 
tous inflammation,  such  as  lobar  pneumonia,  the 
disease  may  be  due  to  this-  vital  process — includ- 
ing chemical  changes  of  local  origin  and  influ- 
ence; for  it  must  strike  every  one  who  gives 
thought  to  it,  that  some  of  these  diseases,  at  least, 
affecting  organs  are  not  essentially  inflammations, 
but  are  diseases  of  the  blood,  as  has  been  found 
by  my  colleague,  Dr.  Gibbes,  in  some  investiga- 
tions now  being  made  upon  pneumonia.  What 
Virchow  terms  parenchymatous  inflammation, 
that  is,  cloudy  swelling  or  parenchymatous  de- 
generation, met  with  in  many  febrile  diseases, — 
especially  the  infectious  fevers  and  septicaemia, 
and  after  poisoning  by  arsenic,  phosphorus  or 
strong  mineral  acids  is,  probably,  due  initially  to 
some  local  change  in  the  blood  and  cells  of  the 
part. 

Dr.  \V.  C.  Glasgow,  of  St.  Louis,  pointed  out 
a  similar  pathological  condition  in  connection 
with  some  forms  of  acute  pulmonary  diseases 
a  few  years  ago. 

Payne  considers  the  granular  degeneration  so 
often  accompanying  febrile  or  inflammatorv  in- 
fections as  a  passive  and  not  an  active  process,  re- 
sulting from  the  action  on  the  epithelium  or 
parenchymatous  elements  of  a  part,  of  some  in- 
jur}7, which,  acting  on  the  vessels  and  connective 
tissues,  produces  hyperaemia  exudation  and  cell- 
diapedesis.  Another  supposition  is,  that  these 
molecular  changes  are  the  consequence  of  the 
high  temperature  to  which  the  tissues  are  sub- 
jected during  febrile  conditions. 

Concerning  the  typical  physiological  ferments 
contained  in  the  saliva,  gastric  juice,  pancreatic 
juice  and  bile,  we  ought  to  say  a  word.  Saliva 
is  composed  of  proteids,  mucous  and  salts.  Its 
principal  function  is  in  reducing  starchy  matters 
of  food  to  sugar.  It  produces  besides  dextrose 
and  maltose,  acrhrodextrine.  This  takes  place 
in  an  alkaline  solution;  but  a  feeble  acid  added 
will  be  sufficient  to  stop  the  action.  The  active 
ferment  of  this  fluid  is  pfyalin.  The  activity  of 
gastric  juice  is  due  to  the  ferment,  pepsin.  The 
exact  nature  of  the  process  by  which  proteid  is 
changed  to  peptone  is  not  known.  This  proteo- 
lytic action  is  possessed  by  some  vegetable  organ- 
isms which  are  said  to  form  a  para-peptone. 

Bile. — In  the  composition  of  human  bile  we 
have  bile  salts,  soap  and  fats,  cholesterin,  lecithin 


724 


THE  ADDRESS  ON  MEDICINE. 


[May 


and  glycocholates,  and  taurocholates,  also  waste 
products,  such  as  hcemoglobin  and  cholesterin. 
The  digestive  action  of  bile  consists  mainly  of  re- 
solving mucous  into  a  proteid  and  an  animal 
gum;  it  also  assists  pancreatic  fluids  in  the  emul- 
sifying process,  and  thus  allows  of  more  ready 
osmosis. 

Pancreatic  Juice. — The  organic  constituents  are 
alkali- albumin,  peptone,  leucin,  tyrosin,  fats  and 
soaps,  and  indol.  It  is  amylolytic,  proteolytic, 
and  steaptic.  These  powers  are  attributed  to 
three  ferments,  amylopsin,  trypsin,  and  steapsin. 
Proteid  digestion  is  carried  still  farther  than  by 
the  gastric  juice,  and  we  have  a  quantity  of  the 
non-crystalline  nitrogen  compounds  formed,  leu- 
cin, one  of  the  amido  groups  in  the  fatty  acid 
series,  and  tyrosin,  one  of  the  aromatic  series. 
Now  with  all  this  biological,  chemical,  molecular, 
and  fermentative  action  going  on  in  the  human 
body,  forming  a  great  number  of  simple  and  com- 
plex organic  substances,  not  only  inocuous  but 
poisonous,  being  ranked  as  tissue,  as  well  as 
functional  poisons,  may  we  not  find  abundant 
cause  for  disease?  Peptones  injected  into  the 
blood  of  a  healthy  animal,  according  to  Bruntou, 
will  cause  death.  Even  the  health}'  blood  of  one 
species  of  animal  injected  into  that  of  another, 
will  cause  death  from  non-adaptability,  accord- 
ing to  Mills. 

The  experiments  and  observations  of  Dr. 
Stockton,  of  Buffalo,  showing  the  deleterious 
effects  produced  by  the  entrance  of  the  Portal 
blood  into  the  systemic  circulation  is  highly  in- 
structive as  bearing  on  this  point. 

Microorganisms  and  many  enzymes  injected 
into  the  blood  are  readily  destroyed,  as  pointed 
out  by  Mitchell,  Prudden,  and  others.  Although 
there  is  a  parasite  (the  filaria  sanguinis  hominis) 
which  is  known  to  inhabit  the  blood.  Many  ob- 
servers believe  that  certain  febrile  states  are 
caused  by  the  absorption  into  the  blood  of  pep 
tones,  which  have  gone  through  and  not  been  split 
up  by  the  liver  into  globulin.  It  is  not  improb- 
able that  absorption  of  ptomaines  from  the  intes- 
tinal canal  (which  always  contains  some)  may 
account  for  many  of  the  so-called  "malarial  at- 
tacks" which  so  often  serve  as  mantles  of  reliei 
>  tto  our  bewildered  diagnostic  sense.  The  proof 
of  which  may  be  assumed  from  the  prompt  relief 
ich  ensues  from  a  brisk  cathartic  oftentimes. 
That  dangerous  condition  known  as  ammonaemia 
and  acetonemia  is  more  likely  due  to  the  absorp- 
tion of  ammonise  toxines  (the  result  of  perverse 
chemical  action)  than  to  the  presence  in  the  blood 
-of  a  special  micrococcus.  However,  it  is  argued  by 
hose  who  have  found  microbes  in  urine,  freshly 
■wooded,  in  that  diseased  condition  called  bacteruria, 
that  the  microorganisms  are  the  essential  cause.  It 
is  known  to  physiologists  that  after  severe  exercise 
the  alkalinity  of  muscle  juice  is  changed  to  acid, 
due  to  the  presence  of  sarco-lactic  acid.     May  we 


not  see  here  the  possibility  of  a  combination  with 
some  organic  base,  so  as  to  constitute  a  poison, 
the  absorption  of  which  determines  disease.  The 
chemical  examination  of  sputum  in  various  dis- 
eased states  of  the  respiratory  apparatus,  shows, 
according  to  Kossell,  Hoppe-Seyler,  Salomon, 
Yonjaksch,  Filehue,  Stonikow,  and  others,  the 
presence  of  peptone,  serum  albumin,  cholesterin, 
acetone,  acetic,  butyric,  and  caproic  acids.  Gly- 
cogen, and  ferments  resembling  pancreatic  fer- 
ments, besides  a  large  number  of  different  bac- 
teria. 

Bitter  and  Rietsch  have  shown  that  cholera  mi- 
crobes contain  and  elaborate  a  peptonizing  fer- 
ment, and  Hueppe  has  shown  by  experiment 
that  the  so-called  cholera  bacillus  produces  a 
toxine,  the  peculiar  properties  of  which  he  has 
demonstrated  on  healthy  animals. 

The  researches  of  Kossell  show  that  among  the 
decomposition  products  of  nuclein  are  found 
guainine,  which  occurs  in  plants  and  vegetables. 
The  tissue  of  some  animals  contain  adenine,  hy- 
poxanthine  and  xanthine.  Guainine  and  creatine 
are  said  by  Yaughan  and  Novy  to  mutually  re- 
place one  another.  Creatine  is  considered  by 
Hoppe-Seyler  as  an  intermediate  product  in  the 
formation  of  urea.  The  cholesterine,  found  in 
the  body  is  capable  of  many  chemical  substi- 
tution products.  An  analysis  of  the  thyroid 
gland  by  Bubnow  gave  hypoxanthine,  paralactic 
acid,  and  a  proteid  substance  which  he  named 
thryeoprotein. 

Nothnagel  found  that  the  bile  acids  taken  up 
into  the  circulation  interfered  with  nutrition, 
producing  fatty  degeneration  of  organs  or  lymph 
glands.  Among  other  poisons  called  by  Brieger 
toxines,  may  be  mentioned  the  so-called  cadaveric 
alkaloids,  such  as  neuridine,  cadavarine,  saprine, 
mydaleine,  putrescine,  muscarine,  choline,  and 
pepto-toxines.  We  obtain  also,  from  the  putre- 
faction of  albuminous  matters,  formic,  acetic, 
butyric,  valerianic,  palmitic,  acrulic,  acrotomic, 
glycolic,  lactic,  valero-lactic,  oxalic,  glutaminic, 
and  aspartic  acids,  and  various  ammonias,  besides 
numerous  amine  bases,  such  as  propylamine,  tri- 
methlamine,  etc.,  also  the  fixed  alkaloidal  bases, 
some  of  which  are  given  above.  Martin  and 
Wolfenden,  by  their  experiments,  show  that  the 
poisonous  property  of  jequirity  or  abrin  resides 
in  a  globulin  and  an  albumose.  They  also  show 
that  peptic  albumose  is  poisonous  to  dogs.  They 
give  an  interesting  table  of  comparison  of  these 
with  snake  poisons.  Poisonous  alkaloids  from 
articles  of  food  have  been  separated  by  Brieger 
and  others,  in  some  instances,  and  are  now  recog- 
nized as  probable  causes  of  disease.  The  ques- 
tion of  fermentation  as  set  up  by  microorganisms 
and  the  production  of  enzymes  and  toxines  by 
them,  is  a  leading  one,  and  as  yet  unsettled. 
We  have  seen  that  these  processes  go  on  in  na- 
ture in  all  instances  of  decomposition  and  putre- 


IS9I.] 


THE  ADDRESS  ON  MEDICINE. 


725 


faction.      The  chemical  effects  may  be  typically 

illustrated  by  the  action  of  toruli  and  other  yeast 
fungi,  which,  by  fermentation,  produce  alcohols, 
acetic  acid,  etc.,  from  saccharine  substances. 
Parvinski  has  published  the  clinical  history  of  a 
case  of  asthma  in  a  young  person  in  which  the 
urine  contained  a  large  quantity  of  acetone  dur- 
ing the  paroxysms.  A  similar  process  of  fer- 
mentation has  been  pointed  out  by  Brieger, 
Hueppe,  Yonjaksch,  and  others  in  relation  to  the 
cholera  bacillus,  as  shown  by  the  poisonous  ef- 
fects on  animals,  by  the  introduction  of  the  tox- 
ine  which  they  had  separated  from  the  bacillus 
culture,  and  which  they  believe  to  have  been  pro- 
duced by  the  bacillus.  Klebs  and  Loeffler  have 
also  discovered  that  the  diphtheria  bacteria  pro- 
duces a  ptomaine  which  may  be  the  cause  of  the 
general  infection,  the  microorganism  being  only 
local  in  its  operation,  a  theory  advocated  years 
ago  by  Oertel.  Loeffler  could  not  find  the  bacillus 
in  the  blood,  and  believes  that  it  always  reside- 
outside  the  body,  while  the  toxine  is  the  real  poison. 

Brieger  and  C.  Fraeilkei  have  shown  that 
diphtheria  bacteria  produces  two  poisons,  one  of 
which  acts  toxically,  while  the  other  secures  im- 
munity. Zuegler  claims  to  have  isolated  a  poi- 
sonous crystalline  alkaloid  from  tubercle,  which 
he  believes  capable  of  producing  the  disease. 
Herman  Scholl,  of  Prague,  confirms  the  con- 
clusions of  Brieger  and  Fraenkel  that  both  an- 
aerobic and  aerobic  bacteria  produce  poisons 
(toxines)  or  enzymes.  The  former  more  than  the 
latter.  Dr.  F.  Lydston,  of  Chicago,  has  shown 
that  the  evolution  of  venereal  disease  is  not  due 
to  a  coccus,  but  a  ptomaine  which  inhabits  the 
vagina,  proving  this  by  experiment.  Many  ob- 
servers, however,  claim  to  have  found  the  coccus 
of  gonorrhoea  in  the  joints.  There  is  much  doubt 
as  to  the  exact  part  played  by  the  bacillus  of  ty- 
phoid fever,  and  without  giving  the  controversy 
between  Klebs,  Eberth,  Koch,  Meyer,  Fried- 
lander,  Gaflky,  and  others,  it  is  probably  as  Ben- 
mer  and  Peiper  say.  not  really  pathogenic,  and 
that  the  disease  is  produced,  as  Brieger  suggests, 
by  a  toxine.  Dr.  Gibbes  and  myself  found  that 
sterilized  watery  extract  of  tubercle  would  kill  a 
newly  hatched  white-fish  in  fifty-five  seconds, 
completely  permeating  the  protoplasmic  mass, 
while  an  alkaline  extract  would  do  so  in  about 
sixty-five  seconds.  Mice  afterwards  injected  with 
the  fish  show  no  signs  of  septicaemia  or  other  dis- 
ease, but  die  if  injected  with  the  same  extract. 
Thus  showing  a  peculiar  affinity  between  proto- 
plasm and  tubercle  toxines. 

To  discuss  in  a  special  manner  the  saprophy- 
tic and  pathogenic  bacteria  concerned  in  a  full 
biological  stud}-  would  take  so  much  time  that  I 
can  only,  as  it  were,  allude  to  them. 

In  Eisenberg's  tables  of  known  bacteria  for 
laboratory  use  one  hundred  and  sixteen  species 
are  enumerated,  etc. 


We  have  found  that  when  guinea-pigs  were  in- 
jected subcutaneously  with  the  extracts  made 
from  the.lungs  of  monkeys  dead  of  1  their  1  ordin- 
ary phthisis  pulmonalis  (which  is  characterized 
by  marked  emphysema  I  the  only  effe.  : 
fever  with  catarrhal  symptoms,  lasting  about 
two  weeks.  On  the  other  hand,  when  in- 
jected with  an  extract  made  from  tuberculous 
>m  the  human  being,  general  tuberculosis 
followed.  The  morbid  anatomy  of  the  monkey 
lung  is  identical,  from  an  ordinary  view,  with 
that  of  human  phthisis  pulmonalis.  This  prob- 
ably illustrates  the  condition  which  all  patholo- 
gists recognize  now  as  pseudo-tuberculosis.  I  am 
aware  that  it  is  generally  accepted  that  bacteria 
or  their  spoie-  are  the  e.-sential  cause  of  most,  if 
not  all  of  the  infective  diseases.  And  the  results 
of  bacteriological  investigation  during  the  last 
few  years  would  seem  to  support  such  a  doctrine, 
for  the  following  reasons,  viz.:  That  they  can  be 
isolated  by  color  reaction  and  thus  directly  con- 
nected with  the  diseased  body  where  found. 
Moreover,  they  require  a  certain  time  forde%-elop- 
ment,  thus  corresponding  to  the  period  of  incu- 
bation of  such  diseases:  many  of  them  being  ecto- 
genic  and  saprogenic,  anaerobic,  or  aerobic,  can 
thus  live  until  the  opportunity  for  invasion  offers. 
Being  endowed  with  life  and  multiplying  enor- 
mously, they  can  strenuously  resist  destruction. 
Being  protoplasmic  (^composed  of  albuminous 
material )  and  microscopic  they  can  more  readih- 
affiliate  with  animal  fluids,  cells  and  tissues.  Ex- 
isting in  a  passive  or  quiescent  state  as  well  as 
an  active  one,  they  can  behave  like  vegetable 
seeds  and  spores,  and  preserve  a  long  period  of 
latency.  For  these,  as  well  as  other  reasons 
which  could  be  adduced,  we  are  led  to  believe 
that  bacteria  must  be  the  cause  in  some  way  or 
other  of  the  zymotic  or  infectious  diseases. 

But  the  question  arises,  how  do  they  accom- 
plish this?  By  mere  local  growth  for  a  parasitic 
life,  by  a  secretion  of  material  from  themselves, 
in  other  words,  are  they  secreting  cells  ?  or,  by 
inducing  at  once  chemical  changes  or  fermenta- 
tion of  a  destructive  character  with  the  formation 
of  new  substances — poisons  ? 

If  we  examine  carefully  into  the  basis  on  which 
certain  forms  of  organisms  stand  as  the  materies 
morbi  of  a  given  disease,  we  shall  find  that 
those  who  are  so  strong  in  their  faith  in  the  essential 
microbic  origin  of  disease  have  not  in  some  in- 
stances looked  fairly  into  the  status  of  affairs. 
For  instance,  take  the  case  of  the  comma  bacillus 
of  Koch,  Fraenkel,  in  his  text-book  of  bacteri- 
ology, third  edition,  says:  Xo  case  of  genuine 
cholera  has  as  yet  been  reported  in  which  the 
comma  bacillus  has  been  absent.  From  the 
context,  he  probably  means  in  the  intestines. 
This  has  been  undoubtedly  disproved  I  This 
illustrates  again  what  was  said  at  the  outset,  that 
all  of  these  questions  should  be  looked  at  without 


726 


THE  ADDRESS  ON  MEDICINE. 


[May  23. 


bias  as  far  as  possible,  without  regard  to  nation- 
ality, and  from  the  stand-point  of  clinical  as  well 
as  laboratory  experience. 

In  whatever  manner  their  life  history  is  exem- 
plified certain  effects  have  been  observed  connected 
with  them,  as  a  class.  Their  career  ad  interim 
from  one  animal  to  another  is  not  well  known 


The  various  facts  stated  of  a  toxiue  connected 
with  diphtheria,  typhoid  fever,  cholera,  suppura- 
tion and  abscess  (which  has  been  shown  to  be  in- 
dependent of  bacteria),  croupous  pneumonia, 
scarlatina,  phthisis  pulmonalis,  syphilis,  tetanus, 
gonorrhoea,  cobra  and  other  snake  poisons,  etc. , 
together  with  the  well  known  (chemical)  noxious 


(excepting    perhaps   the   bacillus   of    anthrax).  I  products  forming  constantly  in  the  body,  are  su 


Some  people  supposing  that  they  may  be  sapro 
genie  at  first,  and  thence  transformed  to  pathogen- 
ic.   In  the  case  of  many  of  them,  their  spores  have 
either  never  been  really  demonstrated  to  exist,  or 
their  behavior  formulated.     Most  species,  if  not 
all,  are  destroyed  by  the  healthy  fluids  or  tissues, 
and  hence  their  destiny  depends  upon  a  favorable 
nidus  or  pabulum,  which  means  disease.   It  is  ob- 
vious that  their  artificial  culture  in  media  outside 
the  body  or  in  the  lower  animals  can  only  ap- 
proximately reflect  their  real  natural  growth  and 
development,  tor  in  no  instance  is   it   possible  to 
transfer  the  artificially  cultivated  microorganism 
to  an   animal   with  the  absolute    certainty   that 
nothing  else  accompanies  the  bacterium.      Take, 
for  instance,  tubercle  bacilli,  the  study  of  which 
has  given  the  most  satisfactory  results.      We  are 
being  inoculated  day  by  day  with  tubercle  bacilli 
from  the  air.   Why  do  any  escape  ?    Because  some 
are  so  healthy  that  they  are  immune.     But  how 
is  it  that  every  guinea-pig  inoculated  gets  tuber- 
culosis?     The   radical  believers    in    microbiosis 
say,  because  they  are  all  susceptible.     But  the 
probable  explanation  is  (like  that  of  diphtheria), 
that  the  materies  morbi  is  introduced  and  carried 
away  by  the   lymphatics  and  sets  up  a  general 
chemical  change.      There  is  also   local  change, 
abscess,  at  the  situation  of  the  inoculation  from 
which  are  furnished  spores  which  may  flourish  in 
the  blood  or  lymph  fluid  afterward,  where  they 
will  now  find  suitable  pabulum  for  development, 
thus  showing   the  fact  that  certain   bacteria,  at 
least,  develope  or  act  under  certain  conditions 
only,  and  upon  a  particular  nidus.     Their  chem- 
ical composition  is  unknown  during  a  state  of  ac- 
tivity.    That  certain  species  only  appear  to  be 
pathogenic,  would  imply  a  state  of  specialization 
analogous  to  living  nucleated  cells.     That  their 
action  is  local,  primarily,  in  all  cases,   may  be 
assumed,  because  their  behavior  in  no  way  shows 
that  they  themselves  invade  or  maintain  their  ex- 
istence in  the  blood  or  lymph  fluids,  because  the 
blood  would  destroy  them.    For  there  are  but  few 
instances  recorded  of  any  one  having  found  bac 


cient,  it  seems  to  me,  to  show  that  the  etiological 
agency  of  bacteria  are  mediate  and  not  immediate? 
This  catalytic  action  coincides  with  clinical  ob- 
servations in  many  directions,  as,  for  instance, 
the  action  of  snake  poisons,  as  shown  by  Weir, 
Mitchell,  and  the  British  India  Sanitary  Reports. 
From  the  cobra  (one  of  the  most  deadly  of  ser- 
pents) an  alkaloid  as  the  active  principle  has  been 
separated,  but  how  far  its  virulence  has  been  test- 
ed we  do  not  know. 

There  are  formed  in  certain  plants,  as  we  know, 
very  poisonous  alkaloids  and  glucosides,  many 
of  them  corresponding  in  chemical  character  and 
physical  behavior  to  animal  alkaloids  and  col- 
loids; solanine,  for  instance,  is  a  basic  glucoside 
which  under  the  influence  of  dilute  acids  splits 
up  into  solanidine  and  sugar.  Both  of  these  active 
principles  are  blood  poisons  belonging  to  the 
group  of  sapro- toxines. 

I  would  say  that  the  experiments  of  Dr.  Gibbes 
and  myself,  point  to  the  same  thing  as  to  the  na- 
ture and  behavior  of  tubercle  when  cultures  or 
extracts  are  introduced  subcutaneously.  We 
have  also  observed  that  the  insufflation  of  sun- 
dried  sputum  (tubercular)  will  produce  phthisis 
pulmonalis,  while  the  inoculation  of  sputum 
(phthisis)  which  has  been  long  dry  from  age  will 
not  produce  tuberculosis.  This  seems  to  have 
been  confirmed  by  some  recent  experiments  made 
by  Dr.  Stone  in  the  Harvard  Laboratory,  who 
inoculated  guinea  pigs,  with  negative  results, 
with  sputum  which  had  been  long  dried,  and 
which  was  probably  from  a  case  of  phthisis  pul- 
monalis. We  are  now  carrying  on  an  investigation 
to  ascertain  the  effects  of  inoculating  guinea  pigs 
with  sputum  from  phthisical  patients,  which  spu- 
tum has  been  dried  in  the  sun  in  Southern  Cali- 
fornia, under  the  supervision  of  Dr.  Norman 
Bridge,  of  Chicago.  The  investigation  has  not 
proceeded  far  enough  to  show  just  what  effects 
it  will  have  in  the  production  of  tuberculosis, 
but  one  remarkable  result  has  ahead}-  been  ob- 
tained. Six  guinea  pigs  were  inoculated,  and 
within  thirty-six  hours  after  the  operation  two 


teria  in  the  blood,  unless  we  except  the  anthrax  ]  died  of  septicaemia,  showing  that  this  effect,  which 


bacilli.  Therefore  it  is  probable  that  pathogenic 
bacteria  develope  only  where  some  previous  dis- 
ease or  abnormal  state  of  the  body  suitable  to 
them  exists.  That  having  found  such,  they  take 
it  were,  and  there  by  catalytic  action 
primarily,  and  secondarily,  give  rise  to  a  particu- 
lar toxine  or  poison  which  in  turn  acts  selectively 
as  a  tissue  poison  ! 


is  a  frequent  result  of  inoculation  with  sputum 
taken  directly  from  patients,  is  probably  not 
caused  by  any  orgausim,  and  thus  coinciding  per- 
fectly with  observations  which  Payne  gives  in  his 
text- book  relating  to  the  occurrence  of  septicae- 
mia without  microorganisms  having  been  discov- 
ered in  connection  therewith. 

Concerning    the    tubercle    bacilli,    the    bacilli 


iS9i.] 


THE  ADDRESS  ON  MEDICINE. 


727 


immediately  produced  in  the  several  diseases 
known  as  tubercular,  why  would  any  previously 
prepared  nidus  be  necessary  ?  If  they,  or  their 
spores  (which  have  not  as  yet  been  satisfactorily 
demonstrated)  are  constantly  invading  us  (which 
is  undoubtedly  true),  they  must  at  once  be  de- 
stroyed, or,  if  gaining  access  to  the  fluids  of  the 
body,  would  set  up  mechanically  or  otherwise, 
inflammation  and  peculiar  effects  as  any  other 
foreign  body  would.  But  as  such  microorgan- 
isms must  find  just  the  proper  conditions  for  de- 
velopment or  not  develop,  we  may  assume  that 
such  conditions  imply  previous  disease,  such  as 
caseation,  whether  tuberculous  or  not.  We  have 
already  seen  what  complex  and  delicate  processes 
attend  the  changes  of  proteids,  and  how  easy, 
by  radical  or  atomic  substitution,  one  may  be 
changed  into  the  other  ;  we  can  therefore  see 
how  probable  it  is  that  these  microorganisms  op- 
erate by  a  peculiar  property  which  enables  them 
to  decompose  or  exercise  a  catalytic  action  on 
certain  states  and  kinds  of  proteids.  The  sub- 
ject of  immunity  and  susceptibility  of  course 
cannot  be  discussed  here — suffice  it  to  say  that 
the  ideas  and  experiments  of  Trudeau  of  New 
York,  and  McLaughlin  of  Texas,  in  this  direc- 
tion, are  worthy  of  careful  attention,  and  apply 
not  only  to  microbes  but  to  chemical  substances 
connected  with  them.  To  say  nothing  of  the 
chemical  action  and  products  normally  evolved,  as 
already  explained,  Abelous  has  obtained  sixteen 
species  of  microbes  from  the  empty  stomach  by 
lavage  ;  seven  of  these  were  well  known  varieties, 
ten  of  these  attacked  and  changed  albumin, 
twelve  fibrin,  and  nine  gluten,  ten  caused  transfor- 
mations of  lactose  into  lactic  acid;  thirteen  formed 
a  variable  quantity  of  glucose  from  starch;  rapid 
and  energetic  decomposition  with  evolution  of 
gas,  leucin,  ty rosin,  indol,  skatol  and  ammonia 
compounds  took  place  in  presence  of  saliva.  I 
do  not  know  that  all  of  these  observations  have 
been  confirmed.  But  we  have  confirmed  his  ex- 
periments regarding  albumin,  which  is  readily 
transformed  by  saliva  in  the  presence  of  microor- 
ganisms outside  the  body.  Experiments  with 
invertin,  a  ferment  found  in  the  intestinal  canal, 
have  shown  some  interesting  results  in  relation  to 
microbe  metamorphosis,  which  are  still,  however, 
su!>  fudici.  Jaccoud  finds  the  pneumococcus,  be- 
sides several  other  forms  of  bacteria,  in  diphthe- 
ria. He  believes  that  individual  reaction  is  what 
determines  the  disease. 

What  application  can  be  made  therapeutically 
of  the  facts  obtained  ?  It  is  manifest  that  the  dis- 
eases in  question  are  caused  in  some  way  by  the 
presence  or  entrance  of  microorganisms.  There- 
fore the  main  therapeutic  indication  is  to  attack 
them,  or  neutralize  their  operation.  We  have  seen 
that  bacteria  either  produce  for  themselves  or  from 
the  organic  substances  which  they  attack,  a  poison, 
or  enzyme,  and  that  this  can  be  cultivated  outside 


the  body  in  some  instances.  Pathological  chem- 
istry has  not  demonstrated  with  exactness  the  na- 
ture of  all  of  these  poisons,  or  classified  them, 
but  it  is  fair  to  believe  that  such  will  surely  take 
place  in  the  near  future.  Although  it  is  gener- 
ally supposed  that  the  inorganic  chemicals  are 
not  tissue  poisons,  but  act  only  upon  the  functions 
through  the  nervous  system,  yet  we  believe  that 
such  is  not  the  case  when  we  observe  the  tissue 
changes  produced  by  iodine,  bromine,  phospho- 
rus, arsenic,  the  silver,  gold,  platinum  and  cupric 
salts,  besides  some  of  the  vegetable  alkaloids. 
Dr.  Gibbes  and  myself  have  been  able  to  neutral- 
ize the  toxic  effect  of  tubercle  by  admixture  with 
chlorine  iodine.  Chloride  of  gold  combined  with 
glycerine,  salts  of  platinum  and  glycerine  and 
peroxide  of  manganese,  outside  the  body,  and 
with  the  chlorine,  iodine,  and  gold  and  sodium 
chloride  in  inoculated  animals.  That  certain 
chemicals  have  a  selective  action  on  tissues  can- 
not be  doubted  ;  take,  for  example,  the  hypoder- 
mic injection  of  cantharidiu  used  a  few  years  ago 
by  Cornil  and  Ranvier,  resulting  in  the  pro- 
duction of  inflammation  of  the  air  passage 
the  work  lately  of  Liebreich  in  injecting  canthar- 
adate  of  potassium  for  the  cure  of  phthisis  pul- 
monalis  and  tuberculosis,  which  he  believes  pro- 
duces exudation,  as  when  applied  to  the  skin. 
Also  the  selective  action  of  strychnia  and  atropia, 
the  latter  acting  on  the  secretory  cells  of  the  sali- 
vary glands,  stopping  secretion  notwithstanding 
the  induction  of  hyperemia.  Arecoline.  a  vol- 
atile liquid  alkaloid  from  the  areca  nut,  has 
a  selective  action  on  the  heart  and  is  excreted 
unchanged.  Haruack  probably  states  the  truth 
in  saying  that  the  action  of  drugs  is  molecu- 
lar and  fermentative.  On  account  of  the  changes 
which  remedies  are  apt  to  undergo  in  the 
stomach  and  intestines,  by  being  oxidized  or  other- 
wise changed  before  absorption  into  the  system, 
the  rational  way,  it  seems  to  me,  is  to  introduce 
the  agent  hypodermically  ;  in'  this  way  it  is  pos- 
sible to  get  effects  which  cannot  be  accomplished 
otherwise.  Dr.  Lauderer  has  obtained  beneficial 
effects  in  phthisis  from  hypodermic  injection  of 
balsam  Peru,  which  he  says  goes  at  once  to  the 
diseased  part,  thus  simulating  animal  fluids  or 
cultures,  as  exemplified  by  the  effects  of  Koch's 
lymph  and  similar  cultures  used  before  by  Pas- 
teur, Grancher,  Martin,  Rengi,  Gibbes  and  oth- 
ers. Dr.  Behring  has  lately  found  that  a  number 
of  chemical  substances  used  hypodermically,  such 
as  aurochloride  of  sodium,  naphthaline,  and  tri- 
chloride of  iodine,  were  capable  of  neutralizing 
the  poison  of  diphtheria  in  guinea  pigs,  but  the 
most  active  of  all  was  the  trichloride  of  iodine. 
He  also  practiced,  in  diphtheria  the  plan  of  vac- 
cinating the  animals  with  bacilli  cultures.  Prof. 
Merzolski  reports  much  better  effects  from  bro- 
I  mide  of  gold  used  hypodermically  (in  ]4'  and  >_■ 
I  gr.  doses),  than  by  the  usual  way  of  administra- 


728 


THE  ADDRESS  ON  STATE  MEDICINE. 


[May  23, 


tion  of  bromides.  The  prompt  effects  of  Samm- 
ter's  treatment  of  erysipelas  by  carbolic  acid  in- 
jections, are  well  known.  The  superior  effects 
of  the  treatment  of  syphilis,  by  hypodermic  in- 
jection of  cyanide  and  bichloride  of  mercury  and 
chloride  of  gold  and  sodium  are  striking,  as  we 
all  know.  Dr.  Zumbali,  of  Rome,  found  hypo- 
dermic injections  of  chlorodyne  in  profuse  diar- 
rhcea  particularly  superior  to  its  administration 
by  the  mouth  The  hypodermic  injection  of  ergot 
for  the  relief  of  haemoptysis  is  another  example. 
This  agent,  administered  in  considerable  quantity 
by  the  mouth,  will  often  fail,  whereas  one,  or  at 
most  two,  hypodermic  injections  of  TV  or  i  gr.  of 
ergotin  will  generally  stop  a  severe  attack.  Dig- 
italis also  acts  upon  the  cells  and  vascular  sys- 
tem more  certainly  when  so  administered.  I 
may  also  mention  the  beneficial  effects  of  strych- 
nia, used  hypoderruically,  in  typhoid  conditions. 
That  animal  poisons  can  be  neutralized  in  the 
body,  I  believe,  will  soon  be  more  generally  dem- 
onstrated. The  experience  of  Tyndall,  of  New 
York,  in  the  vaccination  process  for  the  cure  of 
tuberculosis,  promises  well.  Hemmeter  has 
stopped  the  course  of  diphtheria  by  the  vaccina- 
tion of  the  patient  with  an  erysipelas  toxine  ; 
and  Prof.  Grancher  states  that  persons  suffering 
from  tenia  tonsurans  are  immune  from  diphtheria. 
This  would  seem  toshow  that  there  must  be  a 
sort  of  antagonism  or  isomerism  between  animal 
and  chemical  poisons  ;  and  why  may  not  more 
universal  application  be  made  of  this  principle, 
with  a  view  of  obtaining  more  specific  therapeutic 
agents  and  effects?  The  ethereal  oils,  on  account 
of  their  diffusable  antiseptic  properties,  are  un- 
doubtedly applicable  to  the  neutralization  of  dis- 
ease when  used  hypodermically,  and  may  prove 
yet  of  great  value  in  the  zymotic  diseases.  We 
v  engaged  in  using  some  of  them  in  this 
way,  and  find  that  they  actually  provoke  the  li- 

•  ion  of  effused  products.  We  are  also  ex- 
perimenting with  members  of  the  benzoin  and 
formic  acid  series,  and  the  toluidines,  in  an  en- 
deavor to  learn  their  action  on  metabolism  and 
disease  poisons.  Dr.  Kmil  Schutz  believes  that 
'Tru^s  act  topically  on  the  secretions  by  precipi- 
tating albumin.  He  also  demonstrated,  '< 
that  tannic  acid  may  produce  urticaria  by  exter- 
nal application  alone.  Galezowski,  of  Paris,  has 
lately  discovered  a  new  bacteriacide,  by  the  de- 
composition of  an  aniline  dye,  which  has  the 
same  properties  as  pyoktania  on  the  tissues. 
In  this  direction  we  may  look  for  brilliants  re- 
sults, on  account  of  the  action  of  these  substances 
on  albuminates.  My  chief  object  is  to  awaken 
a  more  general  interest  in  physiological  and  pa- 
thological chemistry,  to  the  end  that  we  may  as 
speedily  as  possibl  scientific  chemical 

.  ami   thus   release   her  from  the  dungeon 

piricism,  where  she   has  been   imprisoned 
with  il  these  main-  years. 


THE    ADDRESS    ON   STATE    MEDICINE- 

Read  by   Title1  at  the  Forty-second  Annual  Meeting  of  the  American 
Medical  Association,  held  at  Washington^  D.C.,  May  , 


BY  W.   L.  SCHENCK,  M.D., 


|OF 


Mr.  President  and  Fellows  of  the  American 
Medical  Association : — While  I  appreciate  the 
honor  of  the  Address  on  State  Medicine,  I  com- 
prehend the  difficulty  of  doing  honor  to  a  position 
so  ably  filled  by  Dr.  Henry  I.  Bowditch,  Dr.  J. 
L.  Cabell,  Dr.  George  H.  Rohe,  and  other  dis- 
tinguished physicians  and  sanitarians.  I  am  as 
another  Ruth  in  the  already  well  gleaned  fields 
of  Boaz. 

If  the  importance  of  the  subject  assigned  to 
me  required  emphasis,  it  could  receive  no  stronger 
than  was  given  to  it  at  the  last  meeting  of  the 
Association,  when  its  honored  president.  Dr.  E. 
M.  Moore,  devoted  much  of  his  address  to  it, 
while  the  distinguished  Father  of  the  Associa- 
tion, Dr.  N.  S.  Davis,  in  the  Address  on  General 
Medicine,  dwelt  upon  the  same  theme. 

State  Medicine,  narrowly  defined,  is  the  con- 
trol of  disease  through  legislative  enactments. 
In  its  broader  signification  it  includes  all  that 
tends  to  the  prevention  of  disease  and  to  the  full- 
ness of  life. 

The  various  departments  of  medicine  exist  be- 
cause health  is  more  to  be  desired  than  disease. 
That  department  then  which  preserves  health 
and  prevents  the  development  of  disease  is  the 
peer  of  any  whose  function  is  to  remove  disease 
and  restore  health.  Hitherto  cure  has  been  the 
chief  thought  of  the  scientific  physician.  Hence- 
forth prevention  will  be  his  noblest  theme. 

While  no  new  discoveries  have  been  made  in 
this  important  field  during  the  past  year,  there 
has  been  a  notable  advance  along  the  whole  line, 
and  the  importance  of  aseptic  and  antiseptic  con- 
ditions has  been  more  and  more  pronounced. 

There  has  been  throughout  the  year  a  very 
commendable  diffusion  of  knowledge  by  sanitary 
conventions  and  journals,  and  through  State 
Boards  of  Health,  and  perhaps  some  good  has 
been  effected  through  the  laws  that  make  hy- 
giene, and  especially  the  relation  of  alcoholics  to 
disease,  a  part  of  our  public  school  education, 
1  it  has  often  proved  so  small  a  part  that  it 
might  hawbeen  eliminated  without  any  apprecia- 
1  ile  change.  Those  who  instruct  must  understand 
what  they  assume  to  teach  before  satisfactory  re- 
sults can  obtain,  and  the  public  must  comprehend 
the  importance  of  physiology  and  hygiene  before 
will  acquire  the  necessary  knowledge. 
In  America  health,  both  public  and  private,  has 
generally  been  left  to  take  care  of  itself,  and  the 
scientists  who  devote  their  lives  to  its  protection 
and  development  have  too  often  been  deemed  im- 
practicable cranks.      Cure  men   of   injuries   and 


[  On  accoint  [able  absence  of  its  author. 


i89i.] 


THE  ADDRESS  OX  STATE  MEDICINE. 


729 


diseases  and  they  will  at  least  load  you  with 
gratitude  ;  save  them  from  injury  and  disease, 
and  your  service  is  beneath  consideration,  and 
while  governments  have  been  disposed  to  pay 
and  honor  those  rendering  valuable  service  in 
other  departments  of  life,  too  often  neither  pay 
nor  honor  has  been  awarded  the  sanitarium. 
Thus  the  first  English  army  sent  to  the  Crimea 
was  decimated  through  want  of  sanitary  care. 
With  the  second  was  sent  a  special  sanitary  com- 
mission, and  after  the  campaign  it  returned  in  bet- 
ter sanitary-  condition  than  existed  among  the 
troops  at  home.  The  government  crowned  with 
honors  the  officers  through  whose  neglect  the 
first  army  was  lost,  but  did  not  even  commend 
those  through  whose  wisdom  the  second  was 
saved.  Whilst  this  course  has  been  the  rule, 
during  the  year,  Germany  has  made  a  commenda- 
ble advance  by  conferring  upon  Koch  a  Baronetcy 
for  distinguished  service  in  the  field  of  preventive 
medicine.  In  America,  most  of  the  States 
expect  scientists  to  devote  their  lives  to  sanita- 
tion, on  health  boards  and  elsewhere,  without 
fee  or  hope  of  reward,  and  to  save  the  community 
from  disease  without  adequate  legal  authority. 
Perhaps  when  sanitarians  charge  for  their  services 
they  will  be  considered  valuable,  as  mankind  are 
disposed  to  estimate  the  value  of  every  article  at 
what  it  brings  in  the  market.  While  practical 
sanitation  is  always  a  philanthropy  it  is  never  a 
charity.  Scarce  any  other  service  yields  so  valua- 
ble a  return.  "  An  ounce  of  prevention  is  worth 
a  pound  of  cure." 

While  in  sanitary  science  many  fields  remain 
unexplored,  and  some  differences  exist,  it  is  far 
in  advance  of  its  legally  authorized  application, 
and  far  enough  advanced  to  see  that  the  truth  is 
within  reach,  and  that  few  diseases  are  not  amena- 
ble to  its  methods.  If  legal  enactments  for  the 
preservation  of  health  and  life,  were  abreast  with 
sanitary  knowledge,  the  United  States  would  an- 
nually save  vast  sums  of  money,  thousands  of 
years  of  productive  labor  and  thousands  of  human 
lives.  The  recent  advance  in  the  department  of 
medical  education  is  full  of  encouragement. 
Since  the  organization  of  this  Association,  forty- 
four  years  ago,  the  burden  of  its  prayer  has  been 
a  higher  standard  of  medical  education.  After 
twenty  years  of  such  effort,  a  committee,  com- 
posed of  its  most  eminent  members,  Drs.  Gross, 
Bell,  Conde,  Pope  and  Bigelow,  reported,  "Its 
efforts  have  hitherto  failed  to  produce  any  very 
great  practical  results:"  and  at  the  same  meeting, 
another  committee  of  equally  distinguished  phy- 
sicians, Drs.  Alfred,  Stille  and  X.  S.  Davis,  re- 
ported resolutions  in  favor  of  a  better  education 
as  a  prerequisite  to  matriculation,  and  at- 
tendance upon  three  annual  graded  courses  of 
medical  instruction  before  admission  to  examina- 
tion for  a  degree.  During  the  past  two  decades 
the  praying  and  resolving  has  gone  steadily  for- 


ward, ably  seconded  by  the  American  Academy 
of  Medicine,  yet,  judging  from  a  paper  read  be- 
fore that  body  last  year  by  Dr.  Dunglison,  these 
more  than  forty  years  of  prayer  have  fallen  short 
of  the  Throne. 

The  statistics  of  the  past  year  are,  however. 
very  encouraging.  According  to  the  excellent 
report  of  that  eminent  sanitarian,  Dr.  John  H. 
Ranch,  in  18S2,  only  forty-five  colleges  in  the 
United  States  required  any  educational  qualifica- 
tion for  matriculation,  now  129  require  at 
least  a  good  English  education.  In  1882,  only 
twenty-two,  and  some  of  these  relapsed,  required 
three  full  courses  of  lectures  of  six  months  each: 
now  there  are  eighty- five,  one-fourth  of  them 
having  been  added,  with  others  that  have  taken 
action  since  the  publication  of  the  report,  during 
the  past  year.  In  18S2,  only  52  colleges  had  a 
chair  in  State  Medicine.  In  1891,  there  is  such 
a  chair  in  117  colleges.  "  Nothing  succeeds  like 
success."  Nothing  demonstrates  the  power  of 
prayer  like  the  demonstration.  When  we  mqj:e 
forward  toward  the  answer  it  comes  with  quick- 
ening power.  Until  then  it  remains 
"The  hidden  motion  of  a  fire 
Withm  the  human  breast." 

How  much  the  action  of  the  Illinois  State 
Board  of  Health,  requiring  a  three  years'  graded 
course  as  a  pre  requisite  to  the  acceptance  of 
diplomas,  and  the  results  of  the  examining  Boards 
of  Virginia,  North  and  South  Carolina,  Minne- 
sota, New  Jersey  and  Alabama  had  to  do  with 
hastening  the  answer,  we  will  not  stop  to  inquire, 
but  I  think  we  will  all  approve  their  action. 

This  advance,  wherever  honestly  made,  will 
tend  to  unify  medical  knowledge  and  destroy 
medical  sects.  "He  who  knows  it  half  speaks 
much  and  is  always  wrong."  Those  who  rest  on 
their  materia  medicas,  and  antagonize  the  regular 
profession,  which  seeks  to  look  at  therapeutic 
action  from  every  rational  standpoint,  though 
only  as  one  to  an  hundred,  are  chiefly  known  by 
their  clamor  for  equal  representation  on  public 
boards,  as  though  there  could  be  a  homoeopathic 
hygiene,  an  eclectic  etiology  or  a  Christian  sci- 
ence chemistry.  Therapeutics  is  the  roof  that 
covers  the  temple  ;  necessary  to  the  temple,  value- 
less without  it.  When  the  sciences  from  which 
spring  both  prevention  and  cure,  are  taught  in 
graded  courses,  and  absorb  the  thought  of  the 
physician,  he  will  not  thrust  himself  outside  the 
pale  of  scientific  medicine  for  such  irrational 
dogmas  as  Ars.,  Bel.,  Bry.,  etc.,  cure  whatever  is 
set  opposite  them  in  the  "  Symptoneum  Codex  " 
of  Hahnnemann. 

While  the  marvelous  progress  of  this  last 
quarter  of  the  century  has  in  many  departments 
of  life  created  contempt  for  the  slower  methods 
of  education,  in  medicine,  notwithstanding  the 
tendency  to  the  development  of  specialties,  there 
I  has  been  an  increased  demand  for  good  work, 


730 


THE  ADDRESS  ON  STATE  MEDICINE. 


[May  23. 


thorough  work,  from  all  who  cross  its  portals, 
both  because  there  has  been  a  truer  conception 
of  the  length  and  breadth  and  depth  of  medical 
science,  and  a  higher  appreciation  of  the  value  of 
human  life. 

And  we  may  well  notice  and  commend  the 
recent  evidences  among  the  people  of  increasing 
faith  and  interest  in  this  department  of  medicine, 
manifested  by  such  substantial  methods  as  the 
gift  of  Henry  C.  Lea,  of  Philadelphia,  the  effort,  I 
with  Mrs  President  Harrison  at  its  head,  to  en- 
dow a  Medical  Department  at  Johns  Hopkins, 
and  the  kind  words  of  Mrs  Gen.  John  A.  Logan, 
in  the  Home  Journal,  in  favor  of  endowing  a  med- 
ical department  to  the  University  about  to  be 
established  at  Washington. 

As  the  broader  possibilities  of  State  Medicine 
become  more  and  more  demonstrable  its  relations 
to  political  economy  and  true  statesmanship  are 
more  apparent. 

It  is  unnecessary  to  recount  before  this  Associ- 
ation the  loss  the  nation  sustains  through  pre- 
ventable diseases,  or  the  methods  by  which  they 
may  be  prevented.  While  there  may  be  errors  in 
diagnosis,  and  while  sanitary  methods  may  not 
be  infallible,  it  is  the  duty  of  the  government  to 
apply  sanitary  knowledge  as  fast  as  developed, 
and  to  develop  sanitary  science.  If  in  its  life 
destroying  service  it  rightly  says  "Better  that 
ten  guilty  men  escape  than  that  one  innocent 
man  perish,"  in  its  life  saving  service  it  may  well 
say,  better  an  hundred  innocent  detentions  than 
that  one  infection  laden  person  scatter  yellow 
fever,  cholera  or  small-pox,  disease  and  death, 
throughout  the  land,  especially  now  that  quaran- 
tine has  ceased  to  mean  forty  days  and  forty 
nights  of  fasting  and  prayer,  but  only  disinfec- 
tion and  detention  until  the  period  of  incubation 
has  passed.  If  the  citi/.en  is  entitled  to  protec- 
tion  against  injury  and  death,  accidental  or  de- 
signed, he  is  equally  entitled  to  protection  against 
the  more  numerous  and  dangerous  foes,  that  he 
can  neither  foresee  nor  avoid,  whose  poisons 
enter  his  body  with  necessary  air.  water  and  food. 
Every  intelligent  sanitarian  and  statesman  un- 
derstands the  power  of  State  Medicine  to  save 
from  disease  and  death  those  for  whom  the  State 
exists.  Scarce  two  centuries  have  passed  since 
small  pox  ravaged  the  earth  in  winter,  and  vari- 
ous plagues  decimated  it  in  summer.  In  London, 
then  perhaps  the  most  highly  civilized  city  in  the 
world,  with  a  population  of  only  half  a  million. 
during  the  winter  months  from  one  thousand  to 
fifteen  hundred  per  week  perished  from  small-pox, 
taking  its  victims  from  among  all  classes.  It  rob- 
bed William  the  Conqueror  of  his  beloved  Queen 
ainl  tilled  potters  fields  from  the  homes  of  the 
poor,  and  as  the  statesman  and  historian,  Macau- 
lay,  has  graphically  said : 

over  which  science  has  since  achieved  .1 
1  1  nt  victories  was  then 


the  most  terrible  of  all  the  ministers  of  death.  The  havoc 
of  the  plague  had  been  far  more  rapid,  but  the  plague 
had  visited  our  shores  only  twice  within  living  memory; 
and  the  small-pox  was  always  present,  filling  the  chureh- 
yards  with  corpses,  tormenting  with  constant  fears  all 
whom  it  had  not  stricken,  leaving  on  those  whose  lives 
it  spared  the  hideous  traces  of  its  power — turning  the 
lube  into  a  changeling  at  which  the  mother  shuddered, 
and  making  the  eyes  and  cheeks  of  the  betrothed  maiden 
objects  of  horror  to  the  lover. 

During  the  summer  of  different  years  from  eight 
to  ten  thousand  a  week  died  of  the  plague,  and 
when  the  city  was  not  visited  by  special  pests  and 
plagues,  the  death-rate  exceeded  that  of  the  mod- 
ern London  by  more  than  forty  per  thousand, 
nearly  twice  the  proportion  that  died  last  winter 
in  Chicago.  But  this  is  not  w'holly  a  history  of 
past  ages.  Wherever  the  same  unsanitary  con- 
ditions are  permitted  to  obtain  we  still  hear  the 
tramp  of  the  White  Horse.  Only  two  decades 
ago  the  yellow  fever  destroyed  in  our  own  Mem- 
phis an  equally  large  proportion  of  lives. 

The  committee  appointed  by  the  Forty-seventh 
Congress  to  investigate  and  report  the  best  means 
of  preventing  the  introduction  and  spread  of  epi- 
demic disease,  reported  : 

In  the  yellow  fever  epidemic  of  1S7S,  which  raged  so 
fearfully  and  fatally  at  New  Orleans,  Memphis,  Holly 
Springs  and  Grenada,  and  extended  far  up  the  Ohio  River, 
and  to  many  other  places,  the  actual  loss  to  the  people  of 
the  United  States  in  the  element  of  material  wealth,  to  saj 
nothing  of  impaired  health  and  loss  of  life,  is  variously 
estimated  b\  those  best  informed  on  the  subject,  at  from 
\ooo. 

President  Hayes,  in  his  message  to  Congress, 
December,  187S,  said  : 

It  is  impossible  to  estimate,  with   any  approach  to  ac- 
the  loss  to  the    country  occasioned  by  this  epi- 
demic.   It  is  reckoned  by  hundreds  of  millions  of  dollars. 

About  one  hundred  thousand  cases  are  believed  to  have 
occurred,  of  which   about  twenty  thousand,  accoi 
intelligent  estimates,  proved  fatal. 

Iii  a  report  made  by  the  very  efficient  Secretary 
of  the  Michigan  State  Board  of  Health,  Dr.  Henry 
B.  Baker,  he  says  : 

The  annual  saving  of  life  has  amounted  to  eleven 
hundred  lives,  representing  seven  thousand  cases  of  sick- 
ness. Estimating  each  of  these  lives  at  only  #500  each, 
about  half  the  value  of  an  adult  slave,  and  you  have  an 
annual  saving  of  $550,000.  This  the  known  savin,;  from 
three  diseases  only. 

Averaging  the  time  that  each  of  these  seven 
thousand  cases  would  have  been  unable  to  work 
at  a  fortnight,  and  there  was  an  annual  saving  of 
270  years  of  productive  labor.  Thus  we  begin  to 
see  the  possibilities  of  State  Medicine.  If  such 
results  can  obtain  with  crude  and  imperfect  sani- 
tary laws,  hindered  by  State  limitations,  and  in  a 
State  so  illy  appreciating  these  benefits  that  its 
Governor  could  formally  recommend  that  the 
Board  through  whose  efforts  the  results  were  ob- 
tained be  abolished,  what  may  we  not  hope  as 
sanitary  science  and  law  develop,  when  the  peo- 
ple   appreciate  their  importance,  and  when   the 


I89i.] 


THE  ADDRESS  ON  STATE  MEDICINE. 


73* 


National  Government  efficiently  cooperates  with  I  the  development  and  protection  of  its  varied  inter- 
the  several  States?  ests.     While  we  concede  the  importance  of  all 

But  what  a  comment  on  the  intelligence  of  the  these  and  of  those  created  through  the  develop- 
people,  when  the  Governor  of  a  great  State  falls  merit  of  other  interests,  we  naturally  inquire  for 
so  far  short  of  true  statesmanship  that  he  can  whom  do  they,  for  whom  does  the  State  ex 
recommend  the  abolishment  of  a  Board  that,  Is  the  thing  created  superior  to  those  for  whom 
through  its  most  efficient  Secretary,  has  produced  j  it  was  created?  Is  not  the  health,  the  develop- 
such  results.  ment,  the  life  of  the  people  its  highest  interest? 

Take  one  other  illustration  of  what  can  be  Surely  the  treasures  about  their  hearthstones,  the 
done,  of  what  should  be  done,  through  State  lives  of  friends  and  neighbors,  are  more  dear  to 
Medicine  :  Under  the  improved  sanitary  condi-  '  the  people  than  either-commercial  or  financial  in- 
tions  of  London  in  iSSS.  its  deaths  were  18.5  per  terests,  or  "the  cattle  upon  a  thousand  hills." 
1,000.  In  the  City  of  New  York  they  were  25.9.  While  all  civilized  nations  have  recognized  the 
Both  in  climate  and  location  nature  has  done  value  of  life,  inflicting  their  severest  punishment 
more  for  New  York  than  for  London,  and  its  upon  those  who  wantonly  and  maliciously  destroy 
death-rate  should  be  less.  If,  with  the  city  of  it,  no  adequate  provision  has  ever  been  made  for 
Brooklyn,  in  every  way  similarly  situated,  it  was  its  protection  against  the  causes  by  which  it  is 
reduced  to  that  of  London,  there  would  be  an  constantly  being  destroyed.  Is  there  not  incon- 
anuual  saving  of  15,988  lives,  and  if  two  persons  \  sistence  in  laws  that  destroy  the  life  of  him  who 
should  be  continuously  sick  for  each  one  dying,  [  wantonly  destroys  the  life  of  another,  while  for 


there  would,  by  reducing  the  sick-rate  to  that  of 
London,  be  an  annual  saving  of  nearly  32,000 
years,  and  if  the  expectation  of  these  lives  was 
counted,  what  innumerable  years  would  be  saved, 
to  say  nothing  of  the  expense  of  this  excessive 
sickness  and  death,  or  of  its  suffering  and  sorrow 


each  life  thus  destroyed  they  permit  the  destruc- 
tion of  an  hundred  or  a  thousand  by  preventable 
disease.  If  life  is  the  highest  interest  of  the  na- 
tion, the  dearest  right  of  the  citizen,  the  nation 
that  fails  to  make  even-  possible  provision  for  its 
protection  is  inexcusable.      Is  a  life  taken  by  the 


If  this  in  New  York  alone,  what  of  the  National    stiletto  or  the  bullet  a  greater  loss  to  the  nation, 
loss  that  State  Medicine,  properly  applied,  would   to  the  individual  or  to  his  friends,  than  when  de- 


save.'  Is  the  statesman  wise,  is  the  legislator  a 
statesman  or  a  philanthropist  who  permits  this 
preventable  loss  of  life  and  labor? 

One  of  America's  greatest  men  has  described 
this  as  a  Government  "  of  the  people,  by  the 
people,  for  the  people,"  a  nation  where  all  power 
emanates  from  the  people,  and  where  all  power 


stroyed  by  pestilence  or  plague  ? 

The  National  Government  has  recognized  from 
its  organization  its  authority  and  power  to  con- 
trol disease,  but  lack  of  sanitary  knowledge  on 
the  part  of  the  legislator,  whose  education  has- 
not  included  sanitary  science,  has  made  medical 
legislation  inefficient,  while  those  selected  to  ad- 


not  delegated  to  the  General  Government  remains   minister  the  law  have  too  often  been  appointed 
with  the  States,  the  intent  being  to  delegate  all  I  for  party  purposes. 


power  that  the  individual  States  cannot  efficiently 
exercise.  We  are  a  nation  of  nations,  with  the 
grandest  conception  of  rights,  and  the  broadest 
provision  for  their  protection  known  to  man,  as- 
suming that  "all  men  are  created  equal,"  not 
physically,  intellectually  or  morally,  but  equal 
before  the  law,  possessing  an  equal  right  to  exer- 
cise and  enjoy  every  natural  right,  an  equal  right 
to  "life,  liberty  and  the  pursuit  of  happiness." 
Life  and  all  its  possibilities  first,  for  in  its  preser- 
vation lie  all  other  rights,  and  in  its  development, 
physically,  intellectually  and  morally,  all  the  best 
interests  of  the  individual  and  the  State,  and  lib- 
erty, without  which  life  has  little  value — not 
liberty  to  do  wrong,  for  no  one  possesses  a  natu- 
ral, or  can  acquire  a  political  right  to  advance  his 
own  at  another's  expense  ;  not  liberty  "  to  secure 
the  greatest  good  to  the  greatest  number,"  but 
liberty  to  attain  the  greatest  possible  good  with- 
out injury  to  another. 

This  principle  not  only  lies  at  the  foundation 
of  State  Medicine,  but  of  all  good  government. 

At  the  organization  of  this  Government  vari- 
ous departments  were  created,  all  looking  toward 


In  February.  1776,  Congress  authorized  the 
President  to  assist  the  States  in  preventing  the 
admission  of  disease  from  foreign  countries.  Three 
yTears  later  the  authority  was  extended  and  placed 
under  the  control  of  the  Treasury  Department, 
not,  it  would  seem,  from  any  just  appreciation  of 
the  importance  of  saving  life,  or  from  any  natu- 
ral relation  between  health  and  finance,  but  be- 
cause quarantines  interfere  with  commerce,  and 
commerce  was  a  source  of  revenue,  and  so  reve- 
nue has  ever  been  deemed  better  than  health  by 
the  legislator. 

In  1798,  the  Marine- Hospital  Service  was  or- 
ganized, its  purpose  being  to  make  provision  for 
a  class  of  citizens  who  served  the  nation  on  the 
high  seas,  but  who  were  homeless  when  at  home. 
For  the  same  reason  this  too  was  placed  under  the 
care  of  the  Treasury. 

With  a  few  unimportant  provisions  the  status 
of  State  Medicine  remained  unchanged  for  more 
than  half  a  century.  After  Asiatic  cholera  had 
thrice  visited  our  shores,  carrying  death  wherever 
it  went,  and  after  civil  war  had  more  fully  demon- 
strated the  relations  of  medicine  to  public  health, 


732 


THE  ADDRESS  ON  STATE  MEDICINE. 


[May  23, 


Congress  authorized  the  Secretary  of  the  Treasury 
to  adopt  such  measures  as  would  guard  the  nation 
against  another  invasion  of  cholera,  and  placed 
at  its  disposal  an  ample  fund  for  the  purpose,  but, 
as  if  doubting  the  power  or  the  wisdom  of  pre- 
ventive measures,  it  only  provided  for  its  expen- 
diture during  the  seven  months  intervening  be- 
tween May  26,  1866,  and  January  1,  1867.  Though 
the  hastily  and  imperfectly  organized  measures  did 
not  keep  the  disease  from  the  country,  they  robbed 
the  destroyer  of  his  accustomed  victories,  and  il- 
lustrated the  possibilities  of  State  Medicine. 

Ten  years  later  Congress  authorized  the  appli- 
cation of  preventive  medicine  to  the  District  of 
Columbia,  and  this  beautiful  city  was  lifted  out 
of  the  mud  and  transformed  from  one  of  the  most 
unsanitary  to  one  of  the  most  healthy  cities  in 
the  world. 

Stimulated  by  the  ravages  of  yellow  fever,  in 
1878  Congress  provided  for  a  Health  Commis- 
sioner for  the  District,  and  a  health  officer  at  a 
salary  of  $3,000,  and  the  same  year  an  Act  was 
passed  requiring  the  Surgeon- General  of  the  Ma- 
rine-Hospital Service  to  make  rules  for  certificates 
by  foreign  consuls,  showing  the  condition  of  ves- 
sels and  cargoes  bound  for  the  United  States. 

Hitherto  all  action  looking  to  the  application 
of  State  Medicine  had  been  indirect,  both  National 
and  State  Legislatures  fearing,  apparently,  to  ac- 
knowledge its  power. 

In  1879  Acts  were  passed  creating  a  National 
State  Board  of  Health,  defining  its  powers,  and 
authorizing  it  to  prevent  the  introduction  of  con- 
tagious and  infectious  diseases,  its  most  impor- 
tant feature  being  the  acknowledgment  of  State 
Medicine  as  a  life-saving  service.  Hitherto  it  had 
been  a  "penny  wise"  affair,  placed  under  the 
Treasury  and  created  to  save  money.  The  Na- 
tional Board  of  Health  was  a  political  acknowl- 
edgment of  the  value  of  human  life,  and  was 
required  to  report  directly  to  the  President  of  the 
United  States.  Though,  like  many  of  the  State 
Boards,  which  were  the  prophets  of  its  birth,  it 
was  created  under  a  pressure  that  convicted  with- 
out convincing  the  legislator,  many  of  its  provi- 
sions were  crude  and  imperfect.  With  the  battle 
on,  it  was  thrown  into  action  with  the  informa- 
tion and  order  of  General :     "There  is 

good  fighting  all  along  the  line.  Go  in  any- 
where," but  it  achieved  a  success  that  will  make 
it  memorable  in  the  history  of  State  Medicine. 
Working  in  harmony  with  local  boards  of  health, 
it  strengthened  their  arms,  and  carried  hope  to 
their  people,  and  changed  the  plague- stricken 
Memphis  from  a  lazaretto  to  one  of  the  healthiest 
cities  of  the  South.  In  addition  to  illustrating 
the  control  of  sanitary  science  over  the  great 
American  plague,  it  published  many  valuable 
scientific  papers  and  demonstrated  the  possibili- 
ties of  preventive  medicine. 

While  great  credit  is  due  to  all  connected  with 


it.  its  powers  were  too  limited  and  ill-defined  and 
it  lacked  the  single  and  forceful  head,  as  essential 
in  our  conflict  with  the  hidden  foe  that  is  am- 
bushed in  the  dark  lanes  and  alleys  of  our  cities, 
and  in  every  swamp  and  bayou,  as  against  an 
army  with  banners.  While  legislation  in  the  in- 
terest of  health  has  often  been  liberal  when  some 
great  plague  has  struck  terror  to  all  hearts,  efforts 
at  such  times  are  like  attempts  to  stay  the  floods 
of  the  Father  of  Waters  when  the  levees  have 
broken  ;  or  to  fortify  a  city  with  the  enemy  in  its 
streets.  To  insure  success  provision  must  ante- 
date invasion.  There  must  be  permanent  author- 
ity with  power  to  act,  to  insure  protection  against 
zymotic  disease. 

The  Marine- Hospital  Service,  with  an  execu- 
tive head  clothed  with  the  energy  of  Surgeon- 
General  Hamilton,  has  still  further  illustrated  the 
vital  importance  to  the  nation  of  State  Medicine. 
But  this  Service  was  organized  for  a  narrow  sphere 
of  duty,  and  though  its  boundaries  have  been 
greatly  enlarged,  its  authority  comes  second-hand 
from  a  department  with  which  preventive  medi- 
cine has  nothing  in  common,  save  that  "public 
health  is  public  wealth."  It  is  only  an  indirect 
National  acknowledgment  of  the  possibility  of 
staying  the  ravages  of  disease. 

Boards  of  Health  have  been  organized  in  nearly 
every  State  in  the  Union,  and  wherever  they  have 
been  composed  of  scientific  sanitarians,  and  lifted 
above  the  narrow  lines  of  party  politics,  and  given 
authority  to  act,  they  have  been  active  factors  in 
the  development  of  State  Medicine.  But  the 
plagues  that  destroy  recognize  no  State  lines, 
know  no  State  rights,  and  when  the  several 
States  delegated  to  Congress  the  right  to  regulate 
commerce  with  foreign  nations,  and  among  the 
States,  they  planted  better  than  they  knew,  and 
gave  the  National  Legislature  authority  to  ex- 
clude from  the  country  the  great  plagues  that 
follow  commerce,  and  to  interdict  their  passage 
from  State  to  State;  but  if  the  Supreme  Court 
has  decided  correctly,  that  a  State  has  no  right 
to  prevent  alcoholic  liquors  from  crossing  State 
lines,  and  being  distributed  in  original  packages, 
a  State  has  no  right  to  prevent  original  packages 
containing  the  germs  of  septic  disease  from  being 
admitted  and  distributed  among  the  people.  To 
secure  the  full  force  of  State  Medicine  there  must 
be  a  National  head  with  power  to  cooperate  with 
State  and  local  boards  of  health. 

The  constitution  has  also  wisely  provided  that 
Congress  shall  have  power  to  provide  for  the  com- 
mon defense  and  general  welfare  of  the  United 
States.  Does  not  the  general  welfare  include  de- 
fense against  the  preventable  diseases  that  cause 
more  suffering  and  death  than  all  other  causes — 
diseases  that  "walk  in  darkness  and  waste  at 
noonday,"  against  whose  poisoned  arrows  the 
citizen,  in  his  individual  capacity,  is  powerless  to 
secure  protection. 


i89i.] 


THE  ADDRESS  ON  STATE  MEDICINE. 


733 


The  National  Government,  through  its  various 
departments,  collects  accurate  statistics  demonstra- 
ting the  condition  of  commerce,  manufactories, 
agriculture,  mines,  all  that  has  hitherto  been 
considered  the  important  factors  of  political  econ- 
omy, but  it  has  never  realized  that  vital  statistics 
are  its  only  means  of  measuring  the  life  wave  of 
the  nation,  of  keeping  the  life  account,  on  which 
rests  all  its  political  economy,  and  the  only 
foundation  of  sanitary  science.  Without  know- 
ing where  disease  exists,  its  disabilities  and 
deaths,  its  causes  and  means  of  prevention,  there 
is  no  possibility  of  knowing  when,  where,  or  how 
to  prevent  or  arrest  it. 

That  eminent  scientist  and  sanitarian,  Surgeon 
Billings,  with  most  commendable  zeal  and  great 
labor  has  endeavored  to  evolve  out  of  the  imper- 
fect data  furnished,  the  vital  statistics  of  the  na- 
tion, but  the  result  has  necessarily  been  imperfect 
and  unsatisfactory. 

Mind  and  morals  act  through  matter.  To  evolve 
healthy  mental  and  moral  action  there  must  be 
healthy  physical  organisms.  The  children  of  the 
nation  spend  a  long  portion  of  the  formative  pe- 
riod of  their  lives  in  its  schools.  Its  health 
interests  demand  their  scientific  sanitary  super- 
vision. 

The  National  Government  should  also  decide 
who  may  enter  its  life-saving  service.  It  requires 
the  attainment  of  a  certain  standard  or  qualifica- 
tion to  those  who  enter  this  service  in  the  Army 
and  Navy  and  Marine- Hospital.  Are  those  who 
serve  it  in  these  departments  any  more  important 
members  of  the  body  politic  than  the  citizen  who 
develops  the  industries  of  the  nation,  pays  its  ex- 
penses, makes  and  unmakes  its  officers  ?  It  may 
be  said  that  they  pa}-  for  the  services  they  receive, 
and  are  capable  of  judging  of  the  qualifications  of 
those  they  employ.  In  this  busy  world  few  men 
acquire  the  knowledge  that  will  enable  them  to 
judge  of  the  qualification  of  a  medical  adviser. 
The  general  welfare  of  the  United  States  demands 
that  the  government  establish  a  standard  of  med- 
ical education  which  shall  be  attained  by  those 
who  enter  its  life  saving  service,  that  every  citi- 
zen may  know  when  his  life  is  broken  by  disease 
or  injun',  that  the  government  only  permits  those 
worthy  and  well  qualified  to  administer  to  his 
wants.  The  fact  that  the  citizen  pays  for  the  ser- 
vice does  not  exonerate  the  State  from  providing 
that  he  shall  receive  that  for  which  he  pays,  and 
that  its  protection  shall  operate  wherever  its  flag 
may  float. 

The  medical  college  is  responsible  for  medical 
education.  While  great  honor  is  due  to  the  dis- 
tinguished men  who,  without  State  or  National 
aid,  have  built  up  their  medical  schools,  advanced 
the  standard  of  medical  education  and  performed 
the  most  important  educational  service  known  to 
the  nation,  the  preparation  of  those  who  have 
charge  of  the  life  and  health  of  the  people,  they 


have  too  often  been  compelled  to  snatch  their  lec- 
ture hours  from  an  exacting  and  poorly  paid 
practice,  and  to  lecture  without  the  aid  of  the 
original  investigation  and  research  essential  to 
true  progress;  and  unfortunately,  in  many  States, 
any  half  dozen  citizens  can  secure  a  charter  for  a 
medical  school  and  graduate  whomsoever  they 
will.  Does  not  "the  general  welfare"  demand 
that  the  National  Government  shall  establish  a 
standard  of  qualification,  and  that  the  State  shall 
provide  such  aid  to  this  important  branch  of  edu- 
cation as  will  enable  teachers  to  devote  them- 
selves to  its  interests  ? 

Government  is  as  much  bound  to  protect  the 
citizen  against  ignorant  pretenders  in  medicine  as 
against  preventable  disease,  and  as  much  bound 
to  extend  protection  against  disease  as  against 
death  from  any  other  cause.  This  can  only  be 
done  through  provision  for  original  research  in 
the  investigation  of  disease. 

While  progress  in  preventive  medicine  has 
been  slow,  perhaps  because  of  the  work  of  medical 
philanthropists,  who  in  preventing  disease  have 
limited  the  income  of  a  profession  that  lives  bv 
curing  disease,  have  done  the  work  for  nothing, 
gone  afoot  and  paid  their  own  fare,  the  progress 
has  been  sufficient  to  demonstrate  the  importance 
of  a  National  department  that  will  not  only  util- 
ize the  knowledge  already  acquired,  but  prose- 
cute such  further  investigations  as  will  secure 
richer  blessings. 

The  enlightened  statesman  knows  that  the 
strength  of  a  nation  lies  in  the  strength  of  its 
people,  and  that  the  highest  function  of  law  is 
the  protection  of  their  life,  health  and  develop- 
ment, that  'public  health  is  public  wealth." 
When  he  comprehends  that  the  great  epidemics 
that  destroy  mankind,  causing  untold  suffering 
and  immeasurable  financial  loss,  are  amenable  to 
State  Medicine,  may  we  not  believe  that  the  Na- 
tional Government  will  establish  A  Depattment 
of  Public  Health,  under  whose  protecting  aegis  it 
will  gather  the  Marine- Hospital  Ser\'ice.  the  Bu- 
reau of  Education,  of  Vital  Statistics  and  of  Ani- 
mal Diseases,  the  Climatological  and  Signal  Ser- 
vice, all  that  pertains  to  the  health  and  develop- 
ment of  the  people,  providing  that,  as  in  the 
Army  and  Navy,  its  appointments  shall  be  pre- 
ceded by  thorough  examination  and  made  for 
life.  In  such  a  department  there  would  be  en- 
rolled a  body  of  scientists  unequalled  in  the 
world,  working  in  harmony  for  the  highest  inter- 
ests of  mankind — the  prevention  of  disease,  the 
preservation  of  life  and  the  uplifting  of  human- 
ity, giving  dignity  to  State  Medicine  and  the 
highest  possible  physical,  intellectual  and  moral 
development  to  the  nation.  The  most  hopeful 
event  during  the  past  year  is  that  a  bill  looking 
to  this  end  was  introduced  into  Congress.  Such 
a  department  devoted  to  original  research  and 
lifted  above  political  mutations,  guided  by   the 


734 


IMPORTANCE  OF  CHEMICAL  STUDIES. 


[May  23, 


energy  and  intelligence  of  a  Hamilton,  a  Rauch 
or  an  Eaton,  will  be  an  honor  to  the  nation  and 
a  blessing  to  the  world,  and  will  hasten  the  day 
when  preventive  medicine  and  surgery  will  well 
nigh  cover  the  field  of  medicine,  when  health 
will  be  the  rule  and  disease  the  rare  exception, 
when  "The  days  of  man  shall  be  three  score 
years  and  ten  and  if  by  reason  of  strength  four- 
score years,"  nay,  five-score  years,  five  times  the 
length  of  his  development  period. 


ORIGINAL  ARTICLES. 


THE  GROWING  IMPORTANCE  OF  CHEM- 
ICAL STUDIES  IN  MEDICAL  EDU- 
CATION AND  IN  MEDICAL 
RESEARCH. 

Read  in  the  Section  of  the  Practice  of  Medicine  and  Physiology  at  the 

the  Forty-second  A  nnual  Meeting  of  the  A  merican  Medical 

Association,  at   Washington,  1 '  ( '.,  May  5, 1891. 

BY  VICTOR  C.  VAUGHAN,  M.D., 

OF    ANN   ARBOR,   MICH. 

Gentlemen  of  the  Section: — The  object  which  I 
have  in  view  in  the  selection  of  this  subject  is 
to  call  your  attention  to  the  present  impor- 
tance of  chemical  studies  in  the  elucidation  of 
medical  problems.  Chemical  theories  and  dis- 
coveries have  frequently  in  the  past  been  of  ser- 
vice to  medicine,  but  they  offer  much  greater 
promises  for  the  future.  With  the  past  services 
you  are  familiar,  and  I  desire  to  point  out  some 
of  the  most  important  problems  which  are  now 
being  investigated  or  which  only  await  careful 
study. 

Tht  Chemistry  of  the  Animal  Cell. — With  the 
form  and  size  of  the  various  cells  of  the  animal 
body,  both  in  health  and  in  disease,  we  are  fairly 
acquainted,  but  we  must  remember  that  these 
ultimate  entities  of  life  have  also  a  physiological 
and  a  chemical  history.  Their  function,  as  well  as 
their  form,  is  deserving  of  study.  Upon  what  do 
they  feed  ?  What  is  the  nature  of  their  secretions 
and  excretions  ?  These  and  many  other  ques- 
tions pertaining  to  their  life  history  are  worthy 
of  study. 

The  diverse  ways  in  wbich  the  various  cells  of 
the  body  and  the  several  parts  of  the  same  cell 
are  affected  by  staining  reagents  suggest  im- 
portant differences  in  chemical  composition.  Tin- 
work  of  Miescher1  and  Kossel2  has  given  us  much 
valuable  information  concerning  the  composition 
of  the  nucleus  of  the  cell.  They  have  shown  that 
certain  compounds  exist  as  characteristic  constit- 
uents of  the  nuclei.  These  belong  to  the  proteids, 
but  differ  from  other  members  of  this  group  inas- 

Chem.    (Jntersuctaungeu  ron  Hoppe-Sevler,  S 
Archiv.  f.  Aant.  mill  Physiology,  1881.    Anntoin.  Alitheil,  s.  icu. 

.■■■  i  hi  "in  .1:  jo;  B.  5,  s. 

152  and  267;   B  6,  S.  422;  B.  7,  S.  7;  B.  8,  S.  51 1 ;  B.  10,  S.  248. 


much  as  the  albumin  molecule  is  not  •  free,  but 
combined  with  phosphoric  acid.  This  combina- 
tion is  exceedingly  loose  and  can  be  broken  up 
by  boiling  with  water.  In  fact  decomposition 
occurs  at  ordinary  temperature  if  the  compound 
is  kept  moist.  This  substance  has  been  called  by 
Miescher  nuclein.  It  has  been  generally  sup- 
posed that  the  phosphoric  acid  in  the  body  exists 
as  inorganic  salts.  This  is  true  of  the  most  of 
that  contained  in  the  bones,  muscles  and  blood, 
but  not  of  that  of  the  glandular  organs.  Kossel 
has  shown  that  from  60  to  75  per  cent,  of  the 
total  phosphoric  acid  in  the  spleen  exists  as 
nuclein,  while  from  30  to  50  per  cent,  of  that  of 
the  liver,  and  50  per  cent,  of  that  of  the  pancreas 
is  found  in  the  same  combination.  The  smaller 
the  proportion  of  nucleated  cells  in  any  tissue, 
the  smaller  is  the  amount  of  nuclein.  In  the 
muscle  of  the  adult  animal  the  amount  of  phos- 
phoric acid  in  combination  with  albumin  is  only 
7  per  cent,  of  the  total  phosphoric  acid. 

It  will  be  seen  from  the  above  that  the  amount 
of  organically  combined  phosphoric  acid  is  a 
measure  of  the  nuclear  substance  in  a  given  tissue, 
and  this  can  be  isolated  and  weighed,  thus  giv- 
ing a  more  exact  estimate  than  that  obtained  by 
counting  the  nuclei  under  a  microscope.  This 
procedure  can  be  made  serviceable  not  only  in 
physiological  but  in  pathological  work.  Thus, 
Kossel  finds  that  while  the  amount  of  nucleiu- 
phosphoric  acid  in  normal  blood  is  too  small  to 
admit  of  quantitive  determination,  as  much  as 
51  per  cent,  of  the  total  phosphoric  acid  in  leu- 
cocythsemic  blood  may  exist  in  this  form.  Again, 
in  the  examination  of  pus,  the  chemical  method 
will  detect  degenerative  changes  in  the  corpus- 
cles before  they  can  be  recognized  by  the  micro- 
scopical examination  of  unstained  specimens. 

However,  albumin  and  phosphoric  acid  are  not 
the  only  constituents  of  the  nuclei.  Nuclein,  on 
I  being  artificially  decomposed,  furnishes  certain 
basic  substances,  as  adenine,  guanine,  hypo- 
xanthine  and  xanthine,  which  are  characterized 
j  by  the  large  amount  of  nitrogen  which  they  con- 
tain. Adenine  contains  no  oxygen,  is  a  polymer 
of  hydrocyanic  acid,  and  indicates  by  its  reactions 
that  it  belongs  to  the  cyanogen  compounds. 
Schindler3  has  shown  that  7  per  cent,  of  the  total 
nitrogen  of  the  thymus  gland  exists  in  adenine. 
The  large  amount  of  hypoxanthine  and  xanthine 
in  leucocythaemic  blood  arises  from  the  decom- 
position of  the  nuclein. 

Nuclein  seems  to  be  an  acid  which  in  the  va- 
rious tissues  is  combined  with  a  base  of  somewhat 
variable  composition.  This  basic  substance  is 
called  by  Kossel,  "histon,"  and  it  has  been  desig- 
nated by  Miescher  as  a  "basic  pepton." 

The  above  mentioned  facts  throw  much  light 
upon  phenomena  which  have  long  been  observed, 
but  not  understood,  by  histologists.  The  marked 

3  Berliner  klin.  Wochenschrift,  1889,  S.  416. 


iSgi.] 


IMPORTANCE  OF  CHEMICAL  STUDIES. 


tendency  of  the  nuclei  to  act  as  reducing  agents 
is  explained  by  the  presence  of  the  oxygen-free 
molecule  of  adenine,  and  the  molecules  of  guanine, 
hv]  'xanthine  and  xanthine,  whose  ready  trans- 
formation into  more  highly  oxidized  products  is 
well  known.  The  action  of  acetic  acid  on  nuclei 
is  due  in  part  to  the  precipitation  of  the  nuclein, 
and  in  part  to  the  fact  that  it  dissolves  out  the 
basic  substance. 

These  researches  have  also  been  of  service  in 
the  study  of  the  function  of  the  nuclei.  Kossel' 
has  shown  that  after  prolonged  hunger  the  nuclein 
is  not  diminished.  This  substance  does  therefore 
not  form  a  reserve  food  supply,  as  is  the  case 
with  glycogen,  fat,  and  in  part  with  albumin. 
He  has  also  demonstrated  that  the  nuclein  serves 
in  some  way  yet  unknown  in  the  building  up  of 
tissue.  The  muscles  of  the  young  animal  are 
rich  in  glycogen  while  those  of  the  adult  contain 
only  traces.  The  fact  that  adenine  belongs  to  the 
cyanogen  group,  already  mentioned,  is  suggestive 
in  this  connection.  Cyanogen  bodies  have  a  well 
tendency  to  transform  themselves  into 
.substances  having  a  complicated  constitution. 
Hydrocyanic  acid  changes,  on  standing,  into  a 
brown  mass,  known  as  azulmie  acid,  which  has 
a  complicated,  and  as  yet  unknown,  chemical 
structure:  and  adenine  undergoes,  under  certain 
conditions  which  obtain  in  the  body,  a  similar 
transformation.  This  offers,  at  least,  a  sugges 
tion  as  to  the  manner  in  which  the  animal  cell 
accomplishes  its  synthetical  work.  The  fact  that 
adenine  belongs  to  the  cyanogen  group  is  further 
suggestive  in  consideration  of  the  formation  of 
both  the  bacterial  and  metabolic  poisons  from 
proteids.  Adenine  itself,  in  quantities  of  one  gram 
and  slightly  less,  is  fatal  to  dogs  of  medium  size 
when  administered  by  the  mouth.  Xo  study  of 
its  effects  when  injected  subcutaneoush-  or  intra- 
venously has  yet  been  made,  so  far  as  I  know. 

After  a  study  of  the  facts,  which  I  have  briefly 
placed  before  you.  one  cannot  avoid  the  impres- 
sion that  continued  investigations  in  this  line 
may  lead  to  important  discoveries  which  will  be 
of  service  to  us  in  unraveling  the  mysteries  of 
cell  activity.  With  the  promise  of  such  a  re- 
ward the  labor  and  energy  of  a  lifetime  may  be 
given  to  this  work.  With  a  knowledge  of  the 
conditions  under  which  cells  multiply,  of  the  na- 
ture of  their  pabulum,  of  the  manner  in  which 
they  convert  foods  into  living  tissue,  what  a  great 
advantage  the  scientific  physician  of  the  future 
will  have  over  us.  his  ignorant  predecessors,  who 
are  yet  compelled  to  rely  so  largely  in  the  treat- 
ment of  disease  upon  empiricism. 

The  intelligent  chemist  of  to-day  does  not 
dream  that  by  the  aid  of  his  science  he  will  ever 
be  able  to  construct  a  living  cell,  but  he  does 
hope  to  ascertain  the  conditions  underwhich  cells 
thrive  and  multiply,  and  those  under  which  they 

4  Berliner  klin.  Wcchen sen  rift.  1880.  5.  *i=. 


die.  He  may  acquaint  himself  with  the  nature 
of  their  substance,  and  from  this  knowledge  he 
may  be  able  to  supply  them  with  proper  food. 
He  may  point  out  to  the  practitioner  the  effects 
of  certain  therapeutic  agents  upon  the  cells  of 
the  liver  and,  what  will  be  of  equal  importance, 
the  action  of  the  cells  of  the  liver  upon  the  thera- 
peutic agents.  We  are  at  present  wholly  igno- 
rant of  the  changes  wrought  by  the  chemistry  of 
the  body  in  the  majority  of  the  drugs  which  we 
employ.  We  know  but  little  of  the  form  in 
which  our  medicinal  agents  reach  the  diseased 
organ,  and  yet  without  any  knowledge  on  this 
essential  point  we  endeavor  to  effect  the  nutrition 
of  the  various  parts  of  the  body.  A  substance 
may  undergo  one  or  more  marked  changes  in 
chemical  composition  during  its  passage  through 
the  body.  Thus  camphor  C  H  0  :s  first  con- 
verted into  camphorol  C  H  OH  I )  by  tak- 
ing up  hydroxyl,  and  finally  is  eliminated  from 
the  body  in  combination  with  glycuronic  acid. 
Not  only  does  the  camphor  undergo  thesechanges, 
but  evidently  it  alters  tissue  metabolism.  Gly- 
curonic acid  ■  C  H.  O,  is  a  product  of  beginning 
oxidation  of  sugar,  and  in  normal  tissue  meta- 
bolism rapidly  goes  through  other  steps  in  the 
process  of  oxidation  and  breaks  up  into  carbonic 
dioxide  and  water,  but  when  brought  in  contact 
with  a  substance  not  readily  oxidized,  such  as 
camphor,  it  is  eliminated  from  the  body  un- 
changed. Changes  in  physiological  action  often 
follow  from  these  alterations  in  chemical  struc- 
ture. A  poison  may  be  rendered  inert,  or  an  inert 
bodv  may  be  converted  into  a  poison.  As  an  ex- 
ample of  the  former,  the  fact  that  a  certain 
amount  of  the  highly  poisonous  substance,  phenol, 
is  changed  into  phenol-sulphuric  acid,  which  is 
inert,  may  be  mentioned;  while  a  change  in  the 
opposite  direction  occurs  in  those  persons  to 
whom  a  bit  of  egg  or  some  article  of  common 
food  is  poisonous. 

With  some  of  the  synthetical  changes  brought 
about  by  the  living  cell,  the  labors  of  physio- 
logical chemists  have  already  made  us  familiar. 
The  work  of  Bunge  and  Schmiedeberg5  on  the  for- 
mation of  hippuric  acid  might  be  taken  as  a  model 
for  similar  investigations.  That  benzoic  acid  ad- 
ministered by  the  stomach  appears  in  the  urine  in 
the  form  of  hippuric  acid  was  first  observed  by 
Wohler  in  1S24.  Historically  this  fact  is  of  in- 
terest because  it  was  the  first  demonstration  of 
svnthetical  processes  in  the  animal  body,  and  was 
at  variance  with  the  then,  and  for  many  years 
thereafter,  dominant  theory  of  Liebig,  who  taught 
that  all  the  chemical  changes  in  the  animal  body- 
are  analytical.  Bunge  and  Schmiedeberg  insti- 
tuted a  series  of  experiments  with  the  view  of 
determining  what  cells  of  the  body  are  concerned 
in  the  synthesis  of  hippuric  acid.  First,  benzoic 
acid  and  glycocoll  were  injected  into  the  dorsal 

'.  Archir.  f.  Experiment.  Path,  und  Pharm..  B.  6,  S.  235. 


736 


IMPORTANCE  OF  CHEMICAL  STUDIES. 


[May  23. 


lymph-sacs  of  frogs  from  which  the  liver  had 
been  removed.  The  appearance  of  hippuric  acid 
in  the  urine  demonstrated  that  the  liver  was  not, 
at  least,  the  only  organ  in  the  body  which  syn- 
thesizes hippuric  acid.  It  was  next  shown  that 
hippuric  acid  is  not  formed  in  nephrotomized 
dogs.  From  this,  however,  it  could  not  be  posi- 
tively asserted  that  the  synthesis  occurs  in  the 
kidneys,  for  it  might  be  said  that  the  removal  of  | 
the  kidneys  had  so  disturbed  the  other  organs  of! 
the  body  that  they  did  not  perform  their  functions 
normally.  But  this  criticism  was  seen  and  pro- 
vided for  by  another  experiment.  It  was  found 
that  the  passage  of  defibrinated  blood,  to  which 
benzoic  acid  and  glycocoll  had  been  added  through 
a  kidney  after  its  removal  from  the  body,  was  ac- 
companied by  the  synthesis  of  hippuric  acid.  It 
was  thus  shown  that  the  extirpated  kidney  is 
capable  of  carrying  on  this  synthesis.  This  is 
found  to  be  true  even  after  the  excised  kidney 
has  been  kept  in  a  refrigerator  for  forty-eight 
hours.  Then  the  question  arose,  is  this  synthe- 
sis accomplished  by  the  living  cell  of  the  kidney 
or  by  some  lifeless  chemical  constituent  of  the 
organ  ?  Further  experiments  showed  that  the 
synthesis  does  occur  if  blood  containing  benzoic 
acid  and  glycocoll  be  allowed  to  stand  in  contact 
with  a  kidney  which  has  been  cut  into  pieces,  but 
does  not  occur  if  the  pieces  be  rubbed  up  in  a 
mortar  with  glass  into  a  homogenous  mass. 
From  this  it  is  concluded  that  the  activity  of  the 
living  cell  is  essential  to  the  performance  of  this 
function.  Furthermore,  it  has  been  demonstrated 
that  the  synthesis  will  not  occur  if  blood,  which 
has  been  freed  from  its  corpuscles,  is  employed, 
and  the  same  is  true  if  blood  in  which  oxygen 
has  been  displaced  by  carbonic  oxide  is  used. 

Equally  valuable  with  the  above  are  the  inves- 
tigations of  Schroder,0  by  which  he  has  shown 
that  urea  is  in  part  at  least  formed  in  the  liver 
from  ammonium  carbonate,  and'  the  labors  of 
Minkowski7  on  the  formation  of  uric  acid.  Both 
of  these  experimenters  have,  as  you  know,  dem- 
onstrated facts  which  are  of  importance  physio- 
logically, and  which  have  also  cleared  up  some 
hitherto  unexplained  observations  in  pathologi- 
cal states. 

It  may  not  be  out  of  place  to  point  out  the  de- 
sirability of  another  investigation  similar  to  those 
mentioned  above.  Physiological  chemists  are 
much  impressed  with  the  theory  that  kreatiu  is 
one  of  the  antecedents  of  urea.  However,  if  kre- 
atin  be  administered  by  the  mouth  or  injected  into 
the  blood  it  reappears  in  the  urine,  either  un- 
changed or  in  the  form  of  kreatinin.  This  is 
supposed  by  some  to  be  sufficient  proof  that  it  is 
not  an  antecedent  of  urea,  but,  as  Bunge*  states, 
this  is  not  necessarily  the  case,  because  the  kre- 


atin  formed  in  the  muscles  may  in  its  nascent 
state  be  converted  into  urea,  while  the  same  sub- 
stance injected  into  the  blood  may  escape  this 
transformation.  This  question  is  one  of  great 
practical  importance,  and  its  solution  promises  to 
throw  some  light  upon  so-called  uraemia,  the 
chemical  causation  of  which  has  recently  received 
some  confirmation,  although  the  old  idea  that  the 
retained  urea  is  the  active  poison,  and  the  theory 
of  Frereichs  that  ammonium  carbonate  is  the  harm- 
ful substance,  have  both  been  abandoned.  Lan- 
dois"  laid  bare  the  surface  of  the  brain  and  sprin- 
kled the  motor  area  with  kreatin,  kreatinin  and 
other  constituents  of  the  urine.  Urea,  ammonium 
carbonate,  sodium  chloride  and  potassium  chloride 
had  but  slight  effect;  but  kreatin  and  kreatinin 
caused  clonic  convulsions  on  the  opposite  side  of 
the  body,  which  later  became  bilateral.  These 
convulsions  continued  at  intervals  for  from  two 
to  three  days,  when,  growing  gradually  weaker, 
they  disappeared.  From  this,  Laudois  concludes 
that  chorea  gravidarum  is  a  forerunner  of  eclamp- 
sia. Now,  kreatin  is  chemically,  as  has  been 
shown  by  Volhard'"  and  Strecker,"  a  substituted 
guanidin,  and  it  only  needs  to  be  converted  into 
methyl- guanidin  in  order  to  produce  all  the  con- 
vulsive symptoms  observed  in  so-called  uraemia. 
Moreover,  Brieger12  has  shown  that  certain  bac- 
terial cells  are  capable  of  transforming  the  in- 
ert kreatin  into  the  powerful  convulsive  poison, 
methyl-guauidin.  The  probabilities  are  that  the 
cells  which  under  normal  conditions  convert  kre- 
atin into  urea  are  so  affected  by  the  accumulation 
of  their  own  product,  urea,  which  the  kidneys 
fail  to  properly  eliminate,  that  one  substituted 
guanidin,  kreatin  appears  as  another  member  of 
the  same  class,  methyl-guanidiu,  the  former  being 
a  physiological  product  and  not  harmful,  while 
the  latter  results  from  a  modified  and  abnormal 
action,  and  is  highly  poisonous.  I  will  admit 
that  this  theory  has  much  reason  in  it,  and 
I  am  now  pointing  out  some  of  the  medical 
problems  which  demand  chemical  studies  for  their 
elucidation,  and  I  would  suggest  that  an  examin- 
ation of  the  muscles  of  the  brain  of  one  who  has 
died  from  so-called  uraemic  convulsions  for  methyl- 
guanidin,  and  a  determination  of  the  amount  of 
kreatin  in  the  same  organ,  would  be  a  work  wor- 
thy of  the  time  given  to  it,  whatever  the  result 
may  be. 

The  statements  made  above  find  important  sup- 
port in  the  recent  highly  valuable  work  of  Drech- 
sel,"  in  which  he  has  prepared  lysatin  and  lysati- 
nin  directly  from  casein,  and  from  these,  urea. 
Lysatin  and  lysatinin  are  homologous  with  kre- 
atin and  kreatinin,  and  on  being  boiled  with 
baryta  will  yield  urea.     Although  we  have  long 


hiv.  f.  Exper.  Pathol,  und  l'liartn.,  B.  15,  S.  364,  and  B, 
S.  373- 

I      A.  21,  S.  41. 


-  Physiologische  Cheniic,  2d  Auflage,  S.  29!. 

Uraemia,  1890. 
'   Zeitschritt  f.  Chemic,  [869,  S-  318. 
"  Tahresbericht  iiher  die  Forschritte  der  Chemic,  iS: 

Bl  rlini  1  klin    Wmheilschrift,  H.  24.  S    S17. 
"Berichte  der  K.  Sarhs.  Gesellschaft,  Ami 


i89i.] 


IMPORTANCE  OF  CHEMICAL  STUDIES. 


737 


known  that  the  urea  eliminated  in  the  urine  mast 
have  its  origin  in  the  proteids  of  the  food,  Dres- 
chel  is  the  first  chemist  who  has  been  successful 
in  breaking  up  a  proteid  by  artificial  means  in 
such  a  way  as  to  produce  urea.  The  same  is  true 
of  the  formation  of  a  kreatin  from  a  proteid. 
This,  which  may  be  ranked  as  the  most  impor- 
tant of  recent  contributions  to  physiological  chem- 
istry, adds  greatly  to  our  knowledge  of  the  kreatin 
bodies,  and  suggests  a  possible  solution  of  the 
relation  existing  between  these  and  urea  in  the 
normal  metabolism  of  tissue.  The  physiological 
action  of  lysatin  has  not  been  as  yet  studied,  nor 
is  it  known  whether  or  not  it  would  reappear  in 
the  urine  as  urea  if  given  by  the  mouth  or  intra- 
venously. We  may  sum  up  the  positive  knowl- 
edge which  we  have  on  this  point  as  follows :  i. 
A  number  of  substances  belonging  to  the  kreatin 
group  are  formed  from  proteids  (some  in  the  body, 
as  kreatin,  kreatinin,  cruso-kreatinin,  xantho-cre- 
atinin  and  amphi-creatin,  and  some  by  artificial 
means,  as  lysatin  and  lysatinin);  2.  Kreatin  is  a 
substituted  guanidin  :  3.  Methyl-guanidin  is  a 
highly  poisonous  substance,  and  this  is  true  of 
both  that  obtained  from  putrefying  flesh  and  that 
prepared  from  kreatin.  It  produces  marked  dysp- 
ncea,  muscular  tremor  and  general  clonic  con- 
vulsions. 

That  there  is  a  marked  disturbance  of  tissue 
metabolism  caused  by  the  inhalation  of  vitiated 
air  has  been  shown  by  Araki."  In  the  urine  of 
animals  rendered  unconscious  by  being  kept  in  a 
confined  space  this  experimenter  found  albumin, 
sugar  and  lactic  acid.  If  the  animals  had  been 
kept  without  food  for  some  days  before  being 
subjected  to  this  experiment,  albumin  and  lactic 
acid,  were  found,  but  no  sugar  appeared.  This 
was  undoubtedly  due  to  the  fact  that  the  glycogen 
of  the  body  had  been  exhausted  by  the  fasting. 
Identical  results  were  observed  in  animals,  which 
were  poisoned  with  carbon  mon-oxide.  Dogs 
which  were  poisoned  with  curare,  and  in  which 
the  respiratory  movements  were  maintained  arti- 
ficially secreted  very  little  urine,  but  the  blood 
was  found  to  contain  considerable  quantities  of 
sugar  and  lactic  acid.  The  urine  of  frogs  in 
which  the  respiration  was  retarded  by  the  pro- 
duction of  tetanus  with  strychnia  secreted  urine 
containing  sugar  and  lactic  acid.  In  the  urine 
of  three  epileptics  there  were  found  albumin  and 
lactic  acid  directly  after  the  seizure.  The  factor 
common  to  all  these  cases  is  diminished  oxygena- 
tion of  the  blood,  and  to  this  is  ascribed  the  ap- 
pearance of  the  abnormal  constituents  of  the 
urine.  These  investigations  demonstrate  the  in- 
fluence of  impure  air  upon  the  chemistry  of  the 
living  cells  of  the  animal  body. 

The  chemistry  of  the  absorption  of  foods 
offers  an  interesting  chapter  in  the  study  of  the 
activity  of  the  animal  cell.     As  practitioners  of 


J  Zeitschrift  f.  physiologische  Chemic,  B.  15.  S. 


medicine  we  bestow  much  attention  upon  the 
subject  of  digestion.  We  administer  acids  and 
digestive  ferments,  often  without  effect.  The 
manufacturing  chemists  flood  the  market  with 
preparations  of  pepsin  and  pancreatine,  with 
their  so  called  malted  and  digested  foods,  and  I 
fear  that  we  too  often  are  deluded  with  the  idea 
that  it  is  only  necessary  to  supply  our  patients 
with  these  ferments  or  foods  in  order  to  build  up 
a  worn-out  body  and  restore  strength  to  weak 
muscles  and  exhausted  nerves.  There  is  a 
popular — I  fear  that  I  might  without  any  exag- 
geration say  a  professional  idea — that  peptones 
filter  through  the  walls  of  the  intestines  without 
let  or  hinderance,  and  pour  their  treasures  of 
strength  and  energy  into  the  blood-vessels. 
However,  scientific  experiments  have  shown  that 
this  is  altogether  erroneous.  In  the  first  place 
albumin  may  be  absorbed  without  having  been 
previously  converted  into  peptone.  Voit  and 
Bauer15  washed  out  loops  of  the  small  intestines 
in  living  dogs  and  cats,  ligated  both  ends  of  the 
loop,  injected  into  the  loop  albuminous  solutions, 
replaced  the  intestine  within  the  body,  and  after 
from  one  to  four  hours  determined  the  amount  of 
albumin  remaining  in  the  loop.  It  was  found 
that  the  amount  absorbed  during  this  time  was, 
for  egg-albumin  from  16  to  33  per  cent.,  and 
for  acid  albumin  from  muscles,  from  28  to  95  per 
cent.  Voit  and  Bauer  think  that  they  proved 
that  there  was  no  active  digestive  ferment  in 
these  loops  by  demonstrating  that  the  portion 
unabsorbed  contained  no  peptone. 

The  experiments  of  Eichhorst'-  have  led  him 
to  the  same  conclusion,  but  the  most  positive 
evidence  which  we  have  on  this  point  has  been 
furnished  by  the  investigations  of  Czerny  and 
Latschenberger.17  In  a  case  of  preternatural 
anus  at  the  sigmoid  flexure,  it  was  found  that 
albuminous  solutions  injected  into  the  thoroughly 
washed  piece  of  intestine  below  the  fistula  was 
absorbed  after  from  twenty-three  to  twenty-nine 
hours  to  the  extent  of  from  60  to  70  per  cent. 
Without  citing  further  experimental  evidence 
upon  this  point  it  is  sufficient  to  say  that  it  has 
been  conclusively  shown  that  albumins  may  be, 
and  often  are,  absorbed  to  a  marked  extent,  with- 
out previous  conversion  into  peptone.  It  should 
be  understood  that  I  do  not  claim  that  egg- 
albumin  is  ordinarily  absorbed  unchanged,  but 
as  Prior"  has  shown  even  this  may  occur  when 
excessively  large  amounts  of  egg-albumin  are 
taken  in  the  food.  (In  such  a  case  the  albumin 
is  not  apparently  utilized  by  the  tissue,  but  act- 
ing as  a  foreign  body,  it  is  eliminated  in  the 
urine.)  But  there  are  many  reasons  for  believing 
that  in  health  a  small  part  of  our  proteid  food  is 
never  converted  into  peptones,  but  is  fitted  for  its 


■5  Zeitschrift  f.  Biologic  B.  5.  S.  562. 
ispfluger's  Archiv..  B.  1.  S.  570. 
TVirchows  Archiv..  B.  59,  S.  161. 
■'Zeitschrift  f.  Klin.  Medicine.  B         -    - 


733 


IMPORTANCE  OF  CHEMICAL  STUDIES. 


[May  23, 


service  to  the  animal  economy  during  its  absorp- 
tion through  the  walls  of  the  intestines.  The 
active  agents  which  render  this  portion  fit  to 
enter  the  circulating  blood  are  not  the  unorgan- 
ized, digestive  ferments,  but  are  the  living  cells 
of  the  absorbing  mechanism. 

There  are  some  good  arguments  in  favor  of  the 
theory  that  all  the  proteid  which  is  utilized  in 
building  or  repairing  tissue  escapes  conversion 
into  peptones  in  the  alimentary  canal,  and  that 
proteids  which  have  been  converted  into  peptone 
can  serve  only  as  a  source  of  energ5%  but  cannot 
be  utilized  by  the  animal  cell  in  the  reconstruc- 
tion of  wasted  muscles.  If  the  defibrinated 
blood  of  one  dog  be  injected  directly  into  the 
veins  of  another  the  amount  of  urea  eliminated 
by  the  latter  is  not  materially  increased,  but  it 
the  defibrinated  blood  be  administered  by  the 
stomach  the  increased  amount  of  urea  is  large 
and  in  exact  proportion  to  the  quantity  of  the 
proteids  in  the  blood  administered. 

A  still  more  important  fact  is  the  demonstra- 
tion that  peptone  is  converted  into  serum  albumin 
during  absorption.  Should  the  peptones  reach 
the  circulation  unchanged  they  act  as  poisonous 
bodies.  Injected  into  the  blood  they  are  soon 
eliminated  unless  the  quantity  is  sufficiently 
large  to  cause  marked  toxical  effects.  The  con- 
version of  peptone  into  albumin  by  the  mucose 
of  the  walls  of  the  alimentery  canal  has  been 
beautifully  shown  by  Salvioli  working  under  the 
direction  of  the  veteran  physiologist,  Ludwig. 
A  loop  of  the  intestine  with  the  attached  rues- 
sentery  was  taken  from  a  dog.  In  the  piece  of 
the  intestine 'there  was  placed  one  gram  of  dis- 
solved peptone.  Then  the  collateral  branches 
having  been  ligated,  a  stream  of  defibrinated  blood 
diluted  with  salt  solution  was  caused  to  flow  for 
four  hours  through  the  attached  branch  of  the 
mesenteric  artery.  Duriug  this  time  the  fact 
that  the  cells  of  the-  intestine  retained  their  vi- 
tality was  shown  by  the  active  contractions  of 
the  piece.  At  the  expiration  of  the  given  time 
there  was  no  peptone  either  in  the  intestine  or  in 
the  blood.  A  further  experiment  showed  that 
peptone  added  to  the  injected  blood  did  not  dis- 
appear. Consequently  the  only  conclusion  which 
is  warranted  by  the  facts  is  that  the  peptone  is 
oonverted  into  albumin  during  its  passage  from 
the  lumen  of  the  intestine  into  the  blood. 

That  the  living  cells  of  the  mucous  membrane 
are  essential  to  this  conversion  has  been  shown 
by  destroying  their  vitality  by  dipping  the  piece 
of  intestine  into  water  at  6o°  C.  After  this  lias 
been  done,  the  intestinal  walls  become  in  fact 
what  it  is  generally  supposed  to  be  during  life. 
a  mere  filtering  metnbram  - 

It  is  true  that   a    very   small   per   cent,    of  the 

ton    formed  in  the   stomach    and   intestine    is 

not  changed  into  serum-albumin,  but  even  this 

mall  amount  does  not  exist   in   solution    in    the 


blood,  but  is  held  by  the  white  corpuscles.  The 
reconversion  of  the  fatty  acids,  set  free  by 
the  action  of  the  pancreatic  juice,  into  neutral 
fats  while  passing  into  the  thoracic  duct  is  an 
equally  important  and  interesting  fact. 

A  case  of  elephantiasis  of  the  left  leg  with  a 
lymph  fistula  has  recently  supplied  Munk  and 
Rosenstein  ™  with  an  opportunity  of  studying  the 
absorption  of  fats,  which  has  been  very  thorough- 
ly utilized.  From  their  studies  of  this  case  Munk 
and  Rosenstein  have  reached  the  following  con- 
clusions: 

1.  The  absorption  of  those  fats,  which  are  fluid 
at  ordinary  temperature,  reaches  its  maximum 
between  the  fifth  and  eighth  hour  after  a  meal, 
while  the  maximum  absorption  of  those,  which 
are  solid  at  ordinary  temperature,  is  reached  be- 
tween the  seventh  and  eighth  hours.  From  these 
hours  there  is  a  rapid  decrease  in  the  amount  of 
fat  in  the  lymphatics  until  from  the  eleventh  to 
the  thirteenth  hour,  when  the  lowest  point  is 
reached. 

2.  When  fatty  acids  are  administered  they  re- 
appear in  the  lymph  for  most  part  in  the  form  of 
neutral  fats.  In  this  case  the  body  must  furnish 
the  glycerine,  which  is  necessary  for  the  synthe- 
sis of  the  fatty  acids  into  neutral  fats. 

3.  The  form  in  which  the  fat  appears  in  the 
lymph  is  determined  by  the  nature  of  its  fatty 
acid.  Thus,  both  olive  oil  (triolein)  and  oleic 
acid  appear  in  the  lymph  as  triolein,  and  both 
tripalmatin  and  palmitic  acid  appear  as  tripalma- 
tin.  On  the  other  hand  if  a  fatty  acid  combined 
with  any  other  alcohol  than  glycerine  be  taken 
in  the  food  the  acid  appears  in  the  lymph  as  a 
glycerine  compound.  This  was  demonstrated  to 
be  the  case  by  feeding  the  patient  upon  fats  con- 
sisting ot  a  fatty  acid  combined  with  amylic  alco- 
hol and  at  another  time  spermaceti,  which  con- 
sists of  palmitic  acid  combined  with  cetylic  alco- 
hol. In  both  instances  the  fatty  acids  were  found 
in  the  lymph  in  the  form  of  glycerine  neutral 
fats,  while  no  trace  of  either  the  amylic  or  cetylic 
alcohol  could  be  found  in  the  lymph. 

From  these  facts  it  is  evident  that  the  cells  of 
the  absorbing  mechanism  of  the  intestine  synthe- 
size the  fatty  acids  and  in  every  case  the  synthe- 
sis consists  in  a  combination  of  the  acid  with  gly- 
cerine. 

There  are  many  other  interesting  and  valuable 
points  brought  out  in  this  research,  and  I  com- 
mend its  study  to  you. 

It  will  be  seen  from  the  above  that  all  the 
problems  of  nutrition  are  not  yet  solved,  and  we 
ate  now  in  a  position  to  at  least  know  wily  we  so 
often  fail  to  build  up  an  exhausted  body  by  the 
administration  of  digestive  ferments  and  predi- 
gested  food.  Indeed,  I  fear  that  we  may  some- 
times  do  harm  in  our  zeal  which  manifests  itself 
in  prescribing  peptones  indiscriminately.     It  is 


S.  230  and  4*4. 


1891.] 


IMPORTANCE  OF  CHEMICAL  STUDIES. 


739 


more  than  likely  fortunate  that  the  majority  of 
the  so-called  peptones  in  the  market  consist  for 
the  most  part  of  acid  albumins  and  are  often 
wholly  free  from  true  peptones, 

Here  is  another  medical  problem  which  de- 
mands chemical  studies  for  its  solution.  What  is 
the  exact  nature  of  the  change  wherein-  peptones 
are  converted  into  serum-albumin?  What  are  the 
conditions  under  which  the  cells  of  the  mucosa 
act  most  energetically?  Have  we  any  medicinal 
agents  which  may  affect  this  action  favorably,  or 
what  is  of  equal  importance,  are  we  at  present 
using  any  drugs  which  injuriously  influence  this 
activity?  All  of  these,  and  many  more  which 
might  be  asked,  are  questions  of  great  import- 
ance to  us  as  practitioners  of  medicine. 

Whether  or  not  the  digestive  ferments  ever 
find  their  way  in  any  considerable  quantity  into 
the  blood  I  do  not  know.  The  older  physiologi- 
cal chemists  have  taught  us  that  both  pepsin  and 
pancreatin  are  normal  constituents  of  the  urine; 
but  all  the  experiments  upon  which  this  state- 
ment rests  were  made  before  we  had  any  knowledge 
of  the  bacterial  ferments,  and  whether  the  peptic 
properties  of  the  urine  are  due  to  ferments  ab- 
sorbed from  the  digestive  organs  or  are  products 
of  bacterial  activity  in  the  urine  after  elimination, 
I  think  no  one  knows  positivelj'.  However  this 
may  be,  Hildebrandt  has  recently  shown  that  the 
■digestive  ferments,  when  injected  directly  into 
the  circulation  or  subcutaneously,  are  poisons  of 
marked  activity.  The  fatal  dose  of  pepsin  for 
dogs  is  from  o.  i  to  0.2  grams  per  kilogram  body 
weight.  They  produce  an  elevation  of  tempera- 
ture which  manifests  itself  generally  within  half 
an  hour,  reaches  its  maximum  within  from  four 
to  six  hours  and  may  continue  for  days.  The 
day  before  death  the  temperature  usually  falls 
below  the  normal. 

The  chemistry  of  the  liver  has  long  been  an  in- 
teresting subject  of  study,  and,  while  many  im- 


Macfayden.  Neoricki  and  Sieber  have  recently  [Arcbiv.  f.  ex- 
per.  Pathol,  and  Pharm.  V,  28,  S.  31]  made  a  valuable  contribution 
to  the  study  of  digestion.  On  account  of  necrosis,  due  to  an  incar- 
cerated hernia,  an  artificial  anus  was  formed  at  the  junction  of  the 
small  with  the  large  intestine,  the  excised  piece  consisting  of  10 
■centimeters  of  the  former  and  3  centimeters  of  the  latter.  The  pa- 
tient rapidly  recovered  from  the  operation,  ate  all  kinds  of  food  and 
discharged  the  intestinal  contents  through  the  artificial  anus  for 
six  mouths,  after  which  time  the  surgeon  joined  the  ends  of  the  in- 
testine and  the  natural  anus  again  became  the  point  of  exit. 

The  most  important  points  brought  out  iu  the  study  of  this  case 
may  be  condensed  and  stated  as  follows  : 

1.  The  contents  of  the  small  intestine  are  constantly  acid  and 
not  alkaline  as  has  been  generally  taught  and  believed. 

2.  The  acidity  is  due  to  organic  acids  produced  by  the  action  of 
bacteria,  or  the  carbo-hydrates  of  the  food. 

3.  Bacteria  were  found  constantly  present  in  the  small  intes- 
tine. 

4.  These  germs  have  but  little  effect  upon  proteids,  but  they 
produce  organic  acids  and  alcohol  by  their  action  on  carbohydrates. 

5.  Skatol.  indol.  and  phenol  are  not  formed  in  the  small  intes- 
tine as  has  been  supposed,  but  in  the  large  intestine. 

6.  The  same  is  true  of  the  place  of  formation  v(  hydrogen  sul- 
phide and  methylmercaptan.  Preparations  of  bismuth  are  not- 
blackened  in  the'small  intestine. 

"  A  large  amount  of  fluid  injected  into  the  rectum  flowed  out 
through  the  fistulous  opening.  This  happened  even  when  100 
grams  of  peptone  dissolved  in  100  cc.  of  water  were  injected  in  two 
portions.  But  five  eggs,  when  rubbed  up  to  a  homogenous  mass 
■with  a  0.6  per  cent,  solution  of  common  salt  (the  whole  measuring 
25 n  cc.  1  were  injected  into  the  rectum  in  three  portions  were  retain- 
ed and  absorbed. 


portant  facts  concerning  it  have  been  ascertained, 
there  yet  remains  much  for  us  to  learn.  We  know 
that  the  liver  converts  ammonia,  which  should  it 
reach  the  general  circulation  in  any  large  quan- 
tity would  be  poisonous,  into  the  practically  in- 
ert substance,  urea.  In  this  organ  the  poisonous 
aromatic  substances  of  the  intestines,  such  as 
phem  il .  are  rendered  harmless  by  being  conj  ugated 
with  the  alkaline  sulphates. 

In  studying  the  changes  wrought  in  the  blood 
during  its  passage  through  the  liver  certain 
marked  difficulties  arise.  The  volume  of  this 
blood  is  so  great  that  it  is  quite  impossible  at 
present  to  draw  any  conclusions  from  comparative 
analyses  of  the  blood  of  the  portal  and  that  of 
the  hepatic  vein,  except  in  the  case  of  sugar. 
Frogs  and  birds  live  for  some  time  after  excision 
of  the  liver,  or  after  it  has  been  cut  off  from  all 
communication  from  other  parts  of  the  body  by  liga- 
tures, but  in  mammals  this  operation  is  followed 
immediately  by  death.  By  means  of  experiments 
upon  birds,  it  has  been  shown  that  the  bile  pig- 
ments and  acids  are  formed  in  the  liver,  the 
former  from  the  haemoglobin  of  the  blood,  and 
the  latter  by  the  conjugation  of  glycocoll  and 
taurin  with  cholalic  acid.  It  is  believed  that  un- 
der certain  abnormal  conditions  blood-pigment 
may  be  converted  into  bile-pigment  outside  the 
liver,  thus  giving  rise  to  that  form  of  icterus 
known  as  haematogenous  or  chemical,  the  exist- 
ence of  which,  however,  has  been  seriously  ques- 
tioned by  the  experiments  of  Vinkowski  and 
Xaunyn.  Irou  is  a  constituent  of  haemoglobin 
but  not  of  bilirubin.  What  becomes  of  the  iron 
which  is  split  off  in  this  transformation  in  the 
liver  is  not  known  and  remains  as  one  of  the 
problems  of  hepatic  metabolism  awaiting  solu- 
tion. 

Of  the  chemistry  of  the  nerve  cell  we  know,  as 
yet,  practically  nothing.  Hodge,-  in  a  very  in- 
teresting series  of  experiments  has  shown  that 
stimulation  of  a  nerve  going  to  a  spinal  ganglion 
is  followed  by  marked  morphological  changes  in 
the  cells  of  the  ganglion.  The  nuclei,  after  be- 
ing stimulated  for  some  hours,  lose  forty  per  cent, 
of  their  bulk;  the  cells  themselves  decreased  but 
little  in  size,  but  their  protoplasm  became  ex- 
tremely vacuolated  and  the  nuclei  of  the  cell  cap- 
sule shrunk  to  a  noticeable  degree.  He  has  also 
noticed  that  after  the  stimulation  has  been  dis- 
continued the  cells  of  the  ganglion  slowly  recover 
their  normal  condition.  Stress  is  laid  upon  the 
fact  that  this  recover}-  is  very  slow,  and  this,  we 
who  have  in  charge  patients  who  are  nervously 
exhausted,  can  fully  appreciate.  There  can  be 
no  doubt  that  these  visible  changes  are  accom- 
panied by  chemical  reactions,  a  knowledge  of  the 
nature  of  which  would  be  of  great  sen-ice,  and 
this  forms  another  of  the  problems  which  require 
chemical  studies  for  their    solution.       The    re- 


American  Journal  of  Psychology,  Vol.  iii,  1S91. 


740 


IMPORTANCE  OF  CHEMICAL  STUDIES. 


[May  23, 


searches  of  Hodge  supply  a  scientific  basis  ior 
the  rest  treatment,  inaugurated  and  practiced  so 
ably  by  Weir  Mitchell.  When  we  can  ascertain 
what  food  and  what  drugs,  if  any,  best  promote 
the  recovery  of  exhausted  nerve  cells,  another 
step  in  advance  in  treatment  can  be  taken.  How- 
ever, this  cannot  be  done  until  we  ascertain  the 
chemical  alterations  of  which  the  observed  mor- 
phological changes  are  but  the  outward  manifest- 
ation. 

I  have  thus  briefly  pointed  out  some  of  the 
important  chemical  studies  of  the  nature  and 
activity  of  the  animal  cell.  The  number  of  these 
might  be  multiplied  many  times.  Indeed,  in  go- 
ing over  this  part  of  the  subject  I  have  been  em- 
barrassed by  the  number  of  illustrations  which 
could  be  offered,  but  I  hope  that  these  are  suffi- 
cient to  impress  upon  us  a  due  appreciation  of 
the  possibilities  which  lie  before  us  in  this  direc- 
tion. 

The  Chemistry  oj  Albumin. — Closely  allied 
with  the  study  of  the  chemistry  of  the  animal 
cell  is  the  investigation  of  the  constitution  of  the 
albuminous  molecule,  for  the  latter  is  an  essen- 
tial part  of  the  former.  The  researches  of  Schut- 
zenberger1  and  others  have  made  us  familiar  with 
some  of  the  decomposition  products  of  proteid 
bodies,  especially  with  those  obtained  by  the 
action  of  acids  and  alkalies.  Kiihne  and  Chitten- 
den" have  enlarged  our  knowledge  of  the  digest- 
ive products,  and  the  experiments  of  Schroder, -; 
Minkososki,"  and  others  have  enabled  us  to  trace 
some  of  the  proteids  through  the  animal  body. 
Bechamp  regarded  urea  as  an  oxidation  of  pro- 
duction of  proteids,  and  thought  that  he  had  pre- 
pared the  former  by  the  action  of  potassium  per- 
manganate on  the  latter  in  alkaline  solution. 
This  was  in  accord  with  the  doctrine  of  Liebig, 
who  held  that  all  the  changes  going  on  in  the 
animal  body  are  those  of  oxidation.  However, 
Stadeler  and  Loew  repeated  the  work  of  Bechamp 
with  negative  results,  and  Lossen  finally  demon- 
strated that  the  substance  which  Bechamp  had  mis- 
taken forurea  is guanidine.  Recently  Drechsel  has 
succeeded,  as  has  been  stated,  in  preparing  urea 
from  casein,  and  in  doing  so  he  has  shown  that 
it  is  not  an  oxidation,  but  a  hydrolytic  product. 

Harnack"6  has  obtained  chemically  pure  albu- 
min and  has  shown  that  its  properties  are  quite 
different  from   those  manifested  by  the  impure 


1  Bulletin  de  la  SocieU-  Chim.  T.  23,  p.  161,  et  scq. 
1  hrift  f.  Biologie,  B.  22,  S.  423  et,  seq. 
1  ".:   cit. 

ten  Chem  Gea  ischaft. 
*  The  study  of  the  products  formed  by  the  bacterial  splitting  up 
if  proteids  will  pi  rvice  in  ascertaining  the  constitu 

tion  of  the  albumin  molecule     Nencki  hasfound  that  en!. .in  an 
m  hi  albumin  the  three  aromatii 
pionii     hydn  ipa  1  n 
1     im  this  he  concluded  that  the  albumin  mole 
1  imatic  groups,  ty 
rosin,    phenylamldopropionic  acid,  and    skatolamidoac 

I-  a  accepted,  the  oci  urrence  of  the  various  aromatic  sub- 
stances, whii  h  have  been  t  tund  in  the  excretions  and  in  putrefac- 
tive pro - ;  i   nation. 


bodies  which  we  have  hitherto  studied.  Maschke,s,; 
Schmiedeberg,:;  Ritthausen,28  and  others  have 
formed  crystalline  proteids  in  various  vegetable 
tissue,  and  Hofmeister"  has  given  us  a  method  of 
obtaining  crystalline  egg-albumin.  With  these 
advances  it  is  within  bounds  to  predict  that  the 
constitution  of  the  albuminous  molecule  will 
soon  be  known.  This  will  furnish  us  with  the 
key  to  the  arch  of  animal  chemistry,  and  with 
this  in  hand,  isolated  facts  already  known,  but 
the  significance  of  which  is  not  understood,  will 
be  easily  placed  in  position,  and  many  new  and 
important  ones  will  soon  be  discovered.  The  ad- 
vice of  Ludwig,  "Study  the  albumins,"  is  being 
followed,  and  will  bear  fruit  in  a  better  and  more 
scientific  understanding  of  tissue  metabolism,  and 
this  will  be  followed  by  a  more  rational  thera- 
peutics. 

A  thorough  study  of  the  proteids  is  demanded 
at  present,  not  only  for  the  advanced  physiolo- 
gical knowledge  which  it  will  give  us,  but  in 
view  of  the  fact  that  the  most  potent  bacterial 
poisons  belong  to  these  bodies.* 

The  Value  of  Chemical  Research  in  Pathological 
Studies. — Much  of  the  pathological  work  of  the 
future  must  be  done  by  the  chemist.  In  the  first 
place  certain  chemical  agents  modify  the  growth 
and  development  of  cells.  This  has  long  been 
known  to  be  true  in  a  few  diseases.  The  influ- 
ence of  alcohol  beverages  in  the  production  of 
certain  abnormal  conditions  of  the  liver  might  be 
mentioned  as  an  illustration.  Chromic  acid  and 
the  neutral  chromates  cause  necrosis  of  the  cells 
of  the  uriniferous  tubules.  The  necrotic  cells 
lose  their  nuclei,  the  cell  protoplasm  becomes  a 
mere  net- work  and  the  dead  cells  from  tube  casts. 
Sodium  indigotin  sulphate  injected  into  the  jugu- 
lar vein  of  a  dog  which  has  been  treated  with  a 
subcutaneous  injection  of  a  chromate  does  not 
stain  the  injured  cells  of  the  tubules.  Corrosive 
sublimate  also  destroys  the  nuclei  of  the  cells  of 
the  uriniferous  tubules  and  produces  a  pseudo- 
diphtheritic  combination  of  the  intestines.  At 
the  same  time,  this  poison  produces  marked 
changes  in  the  medulla  of  the  bones  and  induces 
a  general  anaemia.  The  effects  of  lead  on  the 
cells  of  the  brain  have  been  frequently  observed  : 
Vulpian*"  found  colloid  degeneration  and  atrophy 
with  multiplication  of  the  nuclei;  while  Mona- 
kow, 31  Oppenheim5-  and  others  have  reported  ex- 
tensive degeneration  and  disappearance  of  the 
cells  of  certain  ganglia.  The  karyolitic  necrosis 
of  the  cells  of  the  uniferous  tubules  caused  by 
acetone  has  been  described  by  Albertoni  and  Pi- 
M'liti      and   explains  the   albuminuria  which  oc- 


he  Zeitung,  1859,  s.  .sir. 

\  Chemic.,  B.  i,  S.  205. 
i  ■a.  130. 

\  chemic,  B. 
3°  I.e  cons  sin  Irs  maladies  du  Svst.  Xerv.  T.  2,  p.  267. 
trchiv   1    Psychati  ie,  it   to,  s.  495. 
Real  1  a.  ■    ;   ]..  !i.  \ . n  Bulonburg 
13  Archiv.  f.  Exper.  Pathol   ami  Charm.  B 


i89i.] 


ACUTE  LOBAR  PNEUMONIA. 


74i 


curs  in  severe  cases  of  diabetes  mellitus.  The  ill 
effects  of  some  preparations  of  digitalis  is  explain- 
ed by  the  well  demonstrated,  poisonous  action  of 
digitoxine  on  certain  cells.  The  destructive  ef- 
fects of  many  chemical  substances  such  as  the 
arsenide  of  hydrogen,  bile  acids,  etc.,  on  the 
blood  corpuscles  is  well  known. 

These  and  many  other  substances  which  might 
be  mentioned,  cause  marked  changes  in  the  cells 
of  the  living  body,  and  new  interest  is  now  at- 
tached to  this  point  by  the  discovery  of  the  fact 
that  some  of  the  ptomaines,  those  of  cholera  for 
instance,  manifest  their  activity  in  this  direction. 
Since  it  is  now  generally  conceded  that  all  patho- 
genic germs  induce  their  characteristic  effects  by 
virtue  of  chemical  poisons  which  the  microorgan- 
isms elaborate,  the  chemist  and  histologist  must 
become  co  laborers  in  pathology.  The  bacteriol- 
ogist will  discover,  isolate  and  study  the  life  his- 
tory of  the  germ.  The  chemist  will  isolate  the  ac- 
tive poisons  produced  by  the  germ.  The  physiol- 
ogist will  study  the  effects  of  these  poisons.  The 
histologist  will  make  us  acquainted  with  the 
morphological  changes  produced  in  various  or- 
gans. Finally,  let  us  hope,  the  therapeutist  will 
gain  from  all  these  contributions  some  information 
which  will  make  the  practice  of  medicine  both 
more  scientific  and  more  successful  than  it  is  to- 
day. 

In  the  second  place,  we  have  positive  proof 
that  under  some  abnormal  conditions  the  chemi- 
cal activity  of  the  living  cell  is  perverted.  This 
perversion  may  manifest  itself,  1  by  an  abnor- 
mally abundant  production  of  certain  compounds, 
2,  by  failure  to  produce  changes  which  are  affect- 
ed in  health,  and  3,  by  the  elaboration  of  new  pro- 
ducts. 

The  increased  tissue  metabolism  of  the  acute 
fevers,  in  poisoning  with  phosphorous,  arsenic, 
antimony,  carbon  monoxide  and  chloroform,  and 
in  carcinoma,  are  illustrations  of  the  first  of  the 
above  mentioned  facts.  In  health  the  amount  of 
nitrogen  in  the  ingesta  and  that  in  the  egesta  are 
practically  the  same.  This  normal  condition  of 
"  nitrogen  equilibrium"  is  disturbed  in  the  above 
mentioned  abnormal  states.  The  agent  which 
causes  this  increased  disintegration  in  the  albu- 
minous molecule  is  certainly  not  the  same  in  all 
cases.  In  many,  its  character  remains  unknown 
and  we  must  depend  upon  the  researches  of  the 
chemist  for  information  in  this  important  field  of 
pathology. 

The  abnormally  large  amount  of  uric  acid  and 
allied  bodies  in  the  urine  in  leucocythaemia  is 
undoubtedly  due  to  the  increased  number  of  nu- 
clear cells,  but  what  the  active  agents  are  which 
lead  to  the  excessive  formation  of  nuclear  tissue 
we  do  not  know.  However,  that  they  are  chem- 
ical in  character  is  suggested  by  the  fact  that  a 
leucocythaemic  condition  is  produced  in  some  of 
the  acute  infectious  diseases  (diphtheria  for  in- 


stance) in  which  the  actual  materies  morbi  is  a 
chemical  poison. 

The  fact  that  cells  under  abnormal  conditions 
may  fail  to  elaborate  their  normal  products  is 
shown  by  the  absence  of  hydro-chloric  acid  in 
the  secretions  of  the  stomach  in  cancer;  while  the 
appearance  of  acetic  acid,  oxybutric  acid  and  ace- 
tone in  the  urine  in  diabetes  mellitus  is  an  illus- 
tration of  the  formation  of  new  products  in  dis- 
ease. 

The  causes  of  coma  in  diabetes,  pernicious  an- 
aemia and  carcinoma  are  unknown.  That  this 
coma  occurs  without  any  recognizable  morpho- 
logical lesion  in  the  brain  has  been  proved  by 
Oppenheimer, "  and  the  fact  that  all  of  these  dis- 
eases are  accompanied  by  increased  metabolism 
of  the  nitrogenous  tissue  renders  it  highly  proba- 
ble that  the  nervous  symptoms  are  due  to  the  ac- 
tion of  a  chemical  agent.3* 


THE  TREATMENT  OF  THE  FIRST  STAGE 
OF  ACUTE  LOBAR  PNEUMONIA. 

Read  in  the  Section  of  Practice  of  Medicine  and  Physiology,  at  the 
Forty-second  Annual  Meeting  of  the  American  Medical  Associa- 
tion, held  at  Washington,  D.  C,  May  5-8,  iSoi. 

BY  J.  W.   SMALL,  M.D., 

OP  NEW  YORK.  N.  V. 
FELLOW  NEW  YORK   COUNTY  MEDICAL   ASSOCIATION;   FELLOW    NEW 


YORK    STATE    MEDICAL    ASSOCIATION  :    FELLOW    AMERICAN- 
MEDICAL   ASSOCIATION;   FELLOW    NEW    YORK    ACAD- 
EMY   OF    MEDICINE. 

In  an  editorial  article  in  one  of  our  leading 
medical  journals  an  eminent  writer  has  recently 
said  that  the  "  treatment  of  acute  lobar  pneumo- 
nia is  still  a  reproach  to  our  art,  even  more  so 
than  phthisis  pulmonalis,  and  there  is  no  subject 
which  deserves  more  earnest  study."  To  the  truth 
of  this  statement  every  practical  physician  who 
reads  the  current  literature  upon  this  subject  can 
testify.  The  pathology  of  this  disease  is  indeed 
very  well  understood,  but  the  diversities  in  the 
methods  of  treatment  applied  are  almost  as  many 
as  the  physicians  who  employ  them. 

In  presenting  this  subject  for  your  consideration 
in  this  paper,  I  propose  to  deal  only  with  the  first 
stage,  or  that  preceding  the  stage  of  red  hepati- 
zation. The  very  simple  treatment  outlined  does 
not,  indeed,  do  any  harm,  but  often  much  good, 
if  used  after  the  affected  portion  of  the  lung  is 
solidified,  but  of  that  I  do  not  propose  to  treat. 
but  simply  record  the  results  of  my  own  experi- 
ence in  treating  the  first  stage  as  a  local  conges- 
tion and  inflammation  of  lung  tissue.  So  many 
methods  have  been  tried  and  remedies  used  to 
abort  this  disease,  that  it  would  be  impossible  for 
me  to  enumerate  all  of  them,  but  I  will  consider 
a  few  before  describing  the  very  simple  method 
of  treatment  with  which  I  have  succeeded  in  ar- 


HChurite  Annuolen. 

35  It  was  the  intention  on  beginning  this  papet  to  devote  a  con- 
siderable portion  of  it  to  the  chemistry  of  therapeutics,  but  this  sub- 
•eet  is  now  reserved  for  a  future  paper. 


742 


ACUTE  LOBAR  PNEUMONIA. 


[May  23, 


resting  it.  And  my  method  is  so  simple  that  I 
fear  many  of  my  professional  brethren  will  throw 
this  paper  by  with  a  feeling  of  contempt ;  yet  not, 
I  hope,  until  they  have  made  a  thorough  trial  ol 
the  method  described.  Is  it  not  a  fact,  my  breth- 
ren, that  we  are  too  apt  to  overlook  those  simple 
remedies  and  methods  of  treatment  with  which 
we  are  perfectly  familiar,  and  reach  out  for  these 
specifics  with  large-sounding  names  which  are 
recommended  by  those  high  in  the  profession, 
and  which  we  so  often  find  to  be  fallacies  that 
sadly  disappoint  us.  The  name  of  a  Brown- Se- 
quard  or  a  Koch  has  a  peculiar  fascination  for  us, 
while  the  patient  life-work  of  a  humble  practi- 
tioner, containing  practical  lessons  of  the  richest 
value,  is  entirely  overlooked  and  soon  forgotten. 

Probably  the  remedy  which  has  been  most  fre- 
quently tried  to  abort  this  disease  is  quinine,  given 
in  doses  of  from  10  to  100  grs.  and  repeated  ad 
libitum.  This  has  no  doubt  been  given  with  the 
idea  that  the  disease  is  one  of  malarial  origin. 
But  Dr.  J.  H.  Ripley,  in  a  paper  read  before  the 
New  York  Academy  of  Medicine,  and  reported 
in  the  Boston  Medical  and  Surgical  Journal  for 
1887,  Vol.  cxvi,  p.  212,  has  shown  us  that  he  has 
found  by  careful  experiments  made  at  St.  Francis' 
Hospital,  that  quinine  does  not  abort  the  disease 
and  does  not  act  as  an  antipyretic,  but  has  a  bad 
effect  upon  the  appetite  and  digestion,  is  liable  to 
produce  cardiac  weakness,  profuse  cold  perspira- 
tion and  profound  nervous  debility.  This  testi- 
mony is  corroborated  by  Dr.  H.  Corsen  in  the 
Medical  and  Surgical  Reporter  for  1887,  Vol.  lvi, 
pp.  644-647.  My  own  experience  has  not  been 
favorable  to  its  use  in  the  first  stage  of  this  disease. 

Dr.  H.  S.  Duncan,  in  the  Nashville  Journal  of 
Medicine  and  Surgery  for  18S5,  Vol.  xxxv,  pp. 
154-160,  recommends  blisters  on  the  affected  side 
with  calomel  and  veratrum  viride.  This  treat- 
ment has  been  largely  used  by  physicians,  but 
never  to  my  knowledge  with  the  effect  of  short- 
ening the  disease,  but  may  modify  its  severity. 
Dr.  F.  L,-  Benham,  in  the  Medical  Times  and  Ga- 
zette, London,  1885,  Vol.  1,  pp.  73-76,  makes  an 
argument  in  favor  of  blood-letting  and  antimony 
— withdrawing  at  the  first  venesection  from  10  to 
1 2  ozs.  of  blood,  and  repeating  the  process  in 
from  twelve  to  twenty-four  hours.  This  treat- 
ment is  based  upon  the  old-fashioned  antiphlo- 
gistic theory  of  blood-letting  for  inflammation, 
but  is  not  claimed  to  abort  the  disease,  but  simply 
modify  it.  To  the  employment  of  venesection  in 
any  form  I  should  have  very  serious  objections,  as 
I  consider  it  a  measure  calculated  to  produce  ex- 
treme prostration  of  the  system  by  depriving  it  of 
what  little  vital  fluid  is  left  after  its  depletion  by 
the  disease,  and  after  the  commencement  of  the 
second  stage  I  regard  it  as  positively  dangerous. 

Some  writers   in    the    London    /.once/,  and    l>i 
idt,  writing  in  Duodecim,  a  Finnish  medical 
journal,  have  advocated  the  application  of  ice  lo- 


cally over  the  affected  portion  of  lung  by  means 
of  rubber  bags  filled  with  it,  and  giving  opium 
expectorants  and  stimulants  internally.  With 
this  treatment  it  is  claimed  that  only  three  deaths 
occurred  in  one  hundred  and  six  cases,  but  it  is 
not  claimed  that  it  materially  shortens  the  disease. 

In  a  case  reported  in  the  London  Lancet  for 
1889,  Vol.  i,  p.  730,  Dr.  H.  E.  Counsell  shows 
the  apparent  abortion  of  pneumonia  in  its  first 
stage  in  a  patient  aged  21  by  a  single  dose  of  15 
grs.  of  antipyrin  given  at  bedtime.  As  this  is 
the  only  case  which  I  can  find  recorded  where 
the  inflammation  has  been  broken  up,  and  as  it 
so  much  resembles  many  of  my  own  cases,  I  have 
strong  hope  that  this  class  of  antipyretics  may 
render  valuable  assistance  in  the  treatment  of  this 
disease. 

I  will  now  give  in  detail  my  own  theory  and 
practice  in  this  disease ;  one  which  I  have  used 
for  twenty  years  and  in  several  hundred  cases, 
and,  when  the  patient  has  been  seen  before  the 
second  stage,  with  always  the  result  of  breaking 
up  the  disease  within  twenty-four  or  forty-eight 
hours. 

Upon  the  causation  and  pathological  character 
of  pneumonia  all  medical  authorities  are  well 
agreed.  Previous  to  that  time  when  the  air  cells 
become  occluded  with  an  inflammatory  exudation 
consisting  of  fibrillated  fibrin,  pus  cells,  red  glob- 
ules and  changed  epithelial  cells,  the  affected  por- 
tion of  lung  tissue  is  in  a  state  of  active  congestion 
or  pulmonary  engorgement.  Could  we  examine 
the  fine  capillary  blood-vessels  of  the  alveoli  and 
minute  bronchi,  we  would  find  them  distended  to 
their  utmost  capacity  with  blood,  venous  blood, 
which  instead  of  passing  through  the  pulmonary 
circulation  and  becoming  oxygenized,  remains  lo- 
calized, thus  impeding  the  process  of  respiratiou 
and  taking  on  inflammatory  action.  The  temper- 
ature of  the  affected  portion  of  lung  is  far  above 
normal ;  its  action  is  obstructed  so  that  it  is  im- 
possible for  the  blood  to  become  aerated,  and  the 
only  relief  which  can  possibly  come  to  the  over- 
burdened lung  tissue  is  that  which  Nature  offers 
by  throwing  into  the  alveoli  and  bronchi  the  in- 
flammatory products  of  the  blood,  thus  placing 
the  affected  part  at  rest  while  Nature  takes  time 
to  undo  the  mischief  she  has  wrought  in  her  ef- 
forts for  self-preservation.  But  is  there  no  way 
to  bring  relief  to  the  overburdened  lung  except 
the  one  which  Nature  adopts?  I  answer  posi- 
tively, yes.  There  is  a  way,  and  a  certain  way. 
to  remove  this  localized  congestion,  if  made  use 
of  before  these  pathological  changes  have  taken 
place  which  fill  the  alveoli  and  bronchi  with  in- 
flammatory products,  and  it  is  accomplished  upon 
the  well  known  principle  that  congestions  within 
tlie  thorax  or  abdomen  are  always  relieved  by 
ai  tively  stimulating  the  venous  and  arterial  cap- 
illary  blood-vessels  upon  the  surface  of  the  body 
1  he  extremities.     This  active  stimulation 


i89i.] 


TREATMENT  OF  SPASMODIC  ASTHMA. 


743 


of  the  surface  capillaries  quickly  removes  from 
the  part  the  blood  pressure  by  bringing  the  blood 
to  the  surface  of  the  body  and  thus  equalizing  its 
circulation.  In  order  to  accomplish  this  prac- 
tically I  have  prepared  a  tub  or  pail  partially 
filled  with  bot  mustard  water.  .Seating  my  pa- 
tient on  a  chair,  or  the  edge  of  the  bed,  I  have 
him  thoroughly  covered  with  blankets.  Then  I 
have  the  feet,  legs,  thighs  and  arms  thoroughly 
rubbed  with  the  hot  water,  using  it  as  hot  as  it 
can  be  borne  and  gradually  working  the  feet  into 
it,  rubbing  them  until  quite  red;  then  putting 
the  patient  into  bed  and  covering  warmly  with 
blankets,  with  a  rubber  bag  or  jug  filled  with  hot 
water  at  his  feet.  I  then  have  made  three  large, 
hot  poultices  of  flaxseed  meal,  or  rye  flour  well 
sprinkled  with  mustard  and  a  little  ginger  and 
covered  with  a  piece  of  thin  muslin.  One  I  have 
placed  over  the  thorax  in  front,  one  behind,  be- 
tween the  shoulder  blades,  and  the  third  upon 
the  affected  side  over  the  region  of  the  pain.  I 
keep  my  patient  well  covered  with  an  extra  quan- 
tity of  bed  clothing,  being  very  particular  to  have 
him  keep  his  arms  and  hands  well  covered,  and 
watch  results.  In  from  one-half  hour  to  two  or 
three  hours  he  will  be  in  a  profuse  warm  prespira- 
tion,  and  in  from  twelve  to  fifteen  hours  the  pulse, 
respiration  and  temperature  will  be  reduced  to 
nearly  normal.  In  the  great  majority  of  cases  I 
"believe  this  treatment  alone  sufficient  to  break 
up  the  congestion  and  pyrexia  if  adopted  early. 
But  it  has. usually  been  my  practice  as  soon  as 
my  patient  is  in  bed  after  the  foot  bath  to  give  a 
powder  composed  of  equal  parts  of  nitrate  of 
potassa  and  Dover's  powder — for  an  adult  five 
grains  of  each,  and  repeat  in  three  hours  if  free 
prespiration  does  not  occur.  I  have  recently  ob- 
tained good  results  from  a  powder  of  fifteen  grains 
of  antipyrin  used  once,  but  not  repeated,  as  I 
have  found  the  repetition  apt  to  produce  an  un- 
favorable action  upon  the  stomach  and  great  de- 
pression. In  fifteen  minutes  after  giving  the 
powder  I  commence  with  tr.  aconite  rt. ,  in  doses 
of  from  gtt.  ss.  gtt.  iss.,  with  spts.  aeth.  nit.  gtt. 
xv  and  water  to  one  teaspoonful.  These  doses  I 
give  every  half  hour  or  hour  as  the  urgency  of 
the  case  demands  until  I  have  given  six  or  seven 
doses,  then  repeat  at  intervals  of  two  hours. 
With  children,  instead  of  the  poultices  of  flax- 
seed and  mustard,  I  have  used  onions  and  lard 
with  excellent  results.  In  other  respects  their 
treatment  has  been  precisely  similar.  This  treat- 
ment, when  used  early,  I  have  never  known  to 
fail,  and  I  have  sometimes  used  it  with  success 
two  days  after  the  initiatory  chill.  When  called 
to  a  patient  in  the  afternoon  or  evening  I  have 
found  the  next  morning  the  pulse  reduced  from 
1 20  to  80  or  85,  the  temperature  from  1030  to  990 
and  all  symptoms  of  fever  disappearing  within 
the  next  twenty- four  hours. 


THE  TREATMENT  OF  SPASMODIC 
ASTHMA. 

Read  in   the  Section  of  Practice  of  Medicine  and    i 
Forty-second  annual  Meeting  of  the  A  met  ican 
ciatiun,  held  at  Washington 

BY  J.  V.  JENKINS,   M 

OF  TECUMSEH,    MICH. 

In  dealing  with  this  subject,  it  will  be  un- 
necessary for  me  to  enumerate  the  many  remedies 
which  are  in  vogue  in  the  treatment  of  this  obsti- 
nate and  distressing  disease ;  neither  will  it  be 
necessary  to  mention  the  beneficial  results  which 
are  often  produced  upon  the  patient's  health  by 
a  change  of  climate. 

My  object  in  the  preparation  of  the  paper  is  to 
bring  to  your  notice  a  remedy  which  has,  within 
the  last  few  years,  been  prescribed  for  the  purpose 
of  mitigating  the  attacks  of  asthma.  The  remedy 
alluded  to  is  euphorbia  pilulifera,  a  plant  which 
grows  by  the  way-side  in  Australia,  and  which, 
according  to  Australian  medical  literature,  has 
been  used  as  a  domestic  remedy  in  the  treatment 
of  asthma  and  bronchial  affections  by  the  in- 
habitants of  that  island. 

The  universal  experience  of  all  who  have 
practiced  the  healing  art  for  a  number  of  years  is, 
that  old  and  tried  remedies  frequently  fail  to 
give  relief,  and  we  are  frequently  driven  from  one 
remedy  to  another,  in  order  to  mitigate  the  suffer- 
ings of  a  patient  who  is  undergoing  an  attack  of 
spasmodic  asthma,  and  who  is  bound  to  get  re- 
lief, if  not  from  the  profession,  he  will  seek  the 
advertised  charlatan,  or  the  quack  nostrums  of 
the  day. 

In  order  to  make  my  remarks  as  brief  as  pos- 
sible, and  to  make  this  paper  practical  without 
being  verbose,  it  will  be  necessary  to  give  the 
clinical  history  of  a  few  of  the  cases  which  have 
come  under  my  observation,  and  have  been 
treated  by  this  drug. 

Case  1. — George  S.,  age  45  years,  Came 
under  my  observation  January  9,  of  this 
year.  He  states  that  he  has  had  frequent 
attacks  of  asthma  during  the  past  ten  years, 
years,  and  during  the  last  three  years,  the  parox- 
ysms have  been  more  frequent  and  severe.  After 
a  careful  examination  of  the  chest,  there  was  no 
evidence  of  structural  changes  in  either  heart  or 
lungs.  The  kidneys  were  in  a  health}-  condition, 
the  appetite  good,  and  the  bowels  regular.  In 
fact,  he  was  in  the  enjoyment  of  good  health  (as 
he  expressed  it),  if  it  were  not  for  these  periodical 
attacks  of  asthma.  He  was  ordered  a  mixture  of 
equal  parts  of  the  fluid  extract  of  euphorbia 
pilulifera  and  glycerine,  with  directions  to  take 
a  teaspoonful  every  four  hours  during  the  day, 
and  to  report  in  the  course  of  a  week  or  ten  days. 
When  he  returned  to  my  office,  he  stated  that  he 
slept  well  at  night ;  has  had  no  return  of  parox- 
ysms of  asthma  ;  found  one  or  two  teaspoonfuls 


744 


FOREIGN  CORRESPONDENCE. 


[May  23, 


a  day  sufficient  to  ward  off  the  attacks.     States 
that  he  has  not  slept  so  well  for  years. 

This  patient  has  been  under  observation  up  to 
within  a  few  days,  and  has  been  thus  far  relieved 
from  the  annoying  paroxysms  of  asthma. 

Case  2. — Mrs.  Z.,  age  50  years.  An  American 
by  birth.  Has  usually  had  fair  health,  but  dur- 
ing the  past  seven  years  has  had  frequent  attacks 
of  asthma.  During  the  past  year,  she  states 
that  the  attacks  have  been  more  frequent  and 
severe,  especially  during  the  autumn  and  spring. 
No  organic  disease  of  either  heart  or  lungs  could 
be  detected  upon  examination  of  the  chest. 
There  were  no  structural  changes  in  the  kidneys. 
Appetite  and  digestion  fair.  This  patient  had 
been  previously  under  treatment  for  asthma,  and 
at  that  time  the  paroxysms  were  mitigated  by  a 
combination  of  grindelia  robusta  and  iodide  of 
potassa.  At  this  time  she  was  given  a  mixture 
of  the  fluid  extract  of  euphorbia  pilulifera  and 
o-lvcerine,  equal  parts,  of  which  she  was  to  take 
a  teaspoonful  every  four  hours  during  the  day, 
and  in  the  course  of  a  week  to  report.  When 
the  patient  returned  to  my  office  she  stated  that 
the  paroxysms  of  asthma  had  ceased  under  the 
influence  of  the  medicine,  and  that  she  had 
rested  quietly  all  night  in  the  recumbent  posture, 
while  heretofore  it  was  impossible  to  sleep  with- 
out being  propped  up  in  bed. 

Case 3.— Mrs.  A.,  age  43  years,  weight  about 
two  hundred  pounds.  American  by  birth.  Has 
frequent  attacks  of  asthma.  Heart  and  lungs 
sound.  Appetite  and  digestion  good.  Suffers 
more  from  asthmatic  attacks  during  autumn  and 
winter  than  any  other  seasons  of  the  year.  Fre- 
quentlv  obtains  relief  by  inhaling  the  fumes  of 
burning  nitre  of  paper.  Prescribed  the  fluid  ex- 
tract of  euphorbia  pilulifera  and  glycerine,  equal 
parts,  of  which  the  patient  was  to  take  a  tea- 
spoonful  every  three  hours.  Her  husband  re- 
ported that  the  medicine  had  no  effect  on  the 
paroxysms  of  asthma,  and  that  his  wife's  asth- 
matic breathing  was  relieved  by  smoking  cubeb 
cigarettes. 

Case  4.—  Miss  R.,  age  13  years,  has  suffered 
from  asthma  from  early  childhood.  Has  received 
treatment  from  all  sorts  of  physicians,  from  the 
cultured  physician  as  well  as  the  travelling 
mountebank,  and  has  obtained  very  little  benefit 
from  any  of  them.  No  organic  disease  could  be 
detected  of  either  heart  or  lungs,  upon  examina- 
tion of  the  chest.  No  structural  changes  in  the 
kidneys.  Appetite  and  digestion  fair,  and  the 
patient  well  nourished.  She  was  prescribed  a 
mixture  of  equal  parts  of  the  fluid  extract  of 
euphorbia  pilulifera  and  glycerine,  with  direc- 
tions to  take  a  teaspoonful  morning,  noon,  and 
night.  Her  mother  reports  that  the  daughter 
has  breathed  better,  and  suffered  less  from  asthma 
than  at  any  period  for  several  years. 

Within   the  past  year  thirteen  cases  of  spas- 


modic asthma  have  come  under  treatment,  and  in 
each  case  the  fluid  extract  of  euphorbia  pilulifera 
has  been  prescribed  with  satisfactory  results,  ex- 
cept in  one  or  two  cases  where  it  failed  to  relieve, 
although  no  cause  could  be  assigned  for  its  fail- 
ure. There  were  no  complications,  but  the  drug 
failed,  like  many  others  which  have  a  decided  in- 
fluence in  the  treatment  of  spasmodic  asthma. 
In  one  instance,  where  mitral  lesions  were  pres- 
ent, a  pill  containing  one  one-hundredth  of  a 
grain  each  of  trinitrin  and  strophauthin,  night 
and  morning,  in  connection  with  half  a  drachm 
of  the  fluid  extract  of  euphorbia  pilulifera  every 
four  hours  during  the  day,  gave  the  patient  re- 
lief from  the  paroxysmal  attacks  of  asthma,  which 
were  no  doubt  of  neurotic  origin. 

Finally,  permit  me  to  briefly  state  the  conclu- 
sions arrived  at  by  Dr.  John  Aulde,  of  Philadel- 
phia, who  has  prescribed  euphorbia  pilulifera  in 
twenty- five  cases  of  spasmodic  asthma:  "Euphor- 
bia is  a  remedy  of  special  value  in  the  treatment 
of  all  forms  of  asthma.  In  the  absence  of  organic 
changes  in  the  pulmonary  and  renal  structures, 
and  when  the  atmospheric  conditions  are  favor- 
able, relief  will  usually  be  afforded  after  taking 
the  first  dose.  Being  excreted  largely  by  the 
liver  and  kidneys,  the  condition  of  these  organs 
must  be  taken  into  consideration  when  estimating 
the  probable  effect  of  the  drug.  It  has  no  special 
action  in  controlling  the  sudden  attacks,  but  may 
be  depended  upon  in  young  and  robust  individ- 
uals to  effect  a  radical  cure,  providing  they  will 
continue  to  reside  in  an  atmosphere  that  is  dry 
and  bracing,  situated  in  a  moderately  elevated 
locality,  where  there  are  no,  or  comparatively 
few,  sudden  changes." 


FOREIGN    CORRESPONDENCE. 


LETTER  FROM  LONDOX. 

(from  our  own  correspondent.) 

The  late  Mr.  Richard  Middkmore—The  Statis- 
tics of  the  German  Government  on  the  Koch  Rem- 
edy—The  Oldest  Living  Surgeon— Prof .  Victor 
Horsley  on  Hydrophobia — Tne  Effects  of  Fog  on 
the  Manchester  Atmosphere — Discussion  on  Stran- 
gulated Hernia  —  Report  of  the  Trustees  of  the 
Pea  body  Fund. 

Mr.  Richard  Middlemore,  of  Birmingham,  who 
died  in  his  eighty-seventh  year,  was  a  leading 
ophthalmist,  and  author  of  a  treatise  regarded  as 
the  handbook  of  ophthalmology,  to  promote  the 
knowledge  and  practice  of  which  in  Birmingham 
he  contributed  with  his  efforts  and  his  purse.  Iu 
1877  he  founded  a  prize  to  be  awarded  triennially 
by  the  Council  of  the  British  Medical  Association, 
for  the  best  essay  on  "The  Scientific  and  Practical 


i89i.] 


FOREIGN  CORRESPONDENCE. 


745 


Value  of  Improvements  in  Ophthalmic  Medicine 
and  Surgery." 

Official  reports  on  Dr.  Koch's  much  contested 
remedy  somewhat  correct  the  reaction  which  has 
set  in  against  the  treatment.  The  German  Gov- 
ernment has  obtained  statistics  from  fifty-five  hos- 
pitals, where  during  eight  weeks  2,172  patients 
were  treated  with  17,500  injections  of  the  lymph. 
The  maximum  injections  for  one  person  were 
fifty-four,  and  the  largest  dose  3.826  grams.  Of 
1,061  patients  suffering  from  internal  tuberculosis 
13  were  cured,  171  much  improved,  194  slightly 
improved,  586  no  better,  and  46  died.  Out  of 
70S  sufferers  from  external  tuberculosis  15  were 
cured,  148  much  improved,  237  slightly  improved, 
258  no  better,  and  9  died.  Owing  to  the  reported 
failures,  the  "tuberculin"  is  in  little  demand 
from  the  Berlin  chemists,  while  at  Madrid  the 
committee  appointed  to  examine  the  treatment 
have  checked  any  further  experiments.  The 
only  success  reported  from  Spain  is  stated  to  have 
been  with  lepers  and  persons  suffering  from  lupus 
of  the  face. 

Mr.  William  Salmon,  of  Prullyne  Court,  Cow- 
bridge,  Glamorganshire,  has  just  attained  his 
101st  birthday.  Mr.  Salmon  is  the  only  known 
centenarian  Freemason,  and  there  can  be  little 
doubt  that  he  is  now  the  oldest  member  of  the 
craft.  Mr.  Salmon  is  also  thought  to  be  the  old- 
est living  member  of  the  Royal  College  of  Sur- 
geons,    He  was  born  March  16,  1790. 

Professor  Victor  Horsley  has  given  a  discourse 
at  the  Royal  Institution  on  "  Hydrophobia." 
The  professor  began  by  remarking  that  it  was 
Pasteur  who  first  proved  that  hydrophobia  was 
due  to  a  "germ."  These  germs,  when  numer- 
ously developed  in  a  dog,  might  be  communi- 
cated by  the  saliva,  but  it  had  been  observed  that 
dropped  faliva  speedily  lost  its  power  of  commu- 
nicating rabies  on  drying.  The  time  from  inocu- 
lation to  the  development  of  the  disease  was  not 
less  than  six  weeks,  but  it  might  be  two  years, 
and  it  was  this  dreadful  suspense  that  formed  one 
of  the  horrors  of  receiving  a  bite  from  a  dog  suf- 
fering from  rabies.  Professor  Horsley  considered 
there  were  two  well-marked,  distinct  forms  of  hy- 
drophobia, the  excitable  and  the  comatose.  In 
rabbits  it  always  took  the  comatose  form.  Dogs 
might  have  either  form,  and  at  the  Brown  Insti- 
tute and  the  Dog's  Home  he  had  studied  both 
forms.  In  the  turious  form  an  animal,  however 
domesticated,  runs  away,  and  it  was  by  these 
stray  dogs  that  the  disease  was  spread.  The  pro- 
fessor gave  some  details  of  the  symptoms  a  dog 
shows,  and  alluded  especially  to  the  entire  change 
in  appetite.  The  professor  pointed  out  that  wher- 
ever the  muzzle  had  been  long  in  force  the  disease 
had  been  stamped  out.  A  diagram  for  English 
deaths  showed  that  there  was  a  fall  in  deaths 
from  rabies  after  1885,  when  the  muzzle  was  ob- 
ligatory, and  a   rise  after  1886,  when  the  order 


was  withdrawn.  There  was  also  a  fall  after  1889, 
when  the  muzzle  was  again  ordered.  The  expe- 
rience of  Vienna  was  the  same.  Prussia  had 
maintained  the  muzzle,  and  had  but  two  deaths 
when  in  England  there  were  eighty.  He  hoped 
the  Government  would  re-order  the  muzzle.  When 
rabies  had  once  developed  there  was  no  known 
cure.  Pasteur's  method  of  inoculation,  he  said, 
had  saved  94  per  cent,  of  bitten  people  from 
having  rabies. 

The  effects  of  fog  have  been  very  disastrous 
this  winter  on  the  Manchester  atmosphere.  Ac- 
cording to  observations  taken  during  three  days 
of  fog,  nearly  six  hundred  weight  of  sulphuric 
acid  per  square  mile  was  deposited  around  the 
Infirmary,  besides  two  hundred  weight  of  hydro- 
chloric add  and  two  tons  of  blacks.  The  leaves 
of  plants  growing  out  of  doors  near  the  hospital 
yielded  a  deposit  of  from  6  to  8  per  cent,  of  sul- 
phuric acid,  and  5  to  7  per  ceut.  of  hydrochloric 
acid. 

In  a  discussion  at  the  recent  meeting  of  the 
Royal  Medical  and  Chirurgical  Society  on  the 
treatment  of  strangulated  hernia  when  the  intes- 
tine is  gangreuous  or  ulcerated,  Mr.  Treves,  re- 
ferring to  the  occasion  iu  18S5  when  Mr.  Mitchell 
Banks  had  brought  up  the  same  subject,  said 
everyone  must  have  been  struck  with  the  remark- 
able differences  of  opinion  then  expressed.  No 
doubt  this  was  due,  he  thought,  to  the  fact  that  in 
any  individual's  experience  such  cases  were  com- 
paratively rare.  The  statistics  of  mortality  be- 
tween the  old  method  and  primary  resection  were 
not  comparable.  The  first  series  with  a  mortal- 
ity of  90  per  cent,  was  absolutely  perfect,  being 
taken  straight  from  hospital  records,  but  the 
second,  taken  from  McCosh's  tables,  with  a  mor- 
tality of  50  per  cent.,  were  selected  cases.  Mr. 
Treves  thought  the  mortality  after  resection  was 
at  least  90  per  cent.,  for  if  the  mortality  after  re- 
section was  only  50  per  cent,  it  would  be  about  the 
same  as  that  of  the  ordinary  operation.  It  was  highly 
improbable  that  it  was  no  more  dangerous  to  re- 
sect than  to  to  open  the  sac.  Surgical  instinct 
was  always  opposed  to  resection,  although  the 
two  first  recorded  cases — the  first  by  Ramdorh, 
in  1727,  and  the  second  by  Arhand,  in  1732, 
which  represented  the  old  method,  were  both  per- 
fectly successful.  Mr.  Dean,  of  the  London  Hos- 
pital, looked  up  for  him  the  cases  of  strangulated 
hernia  which  he  had  operated  upon;  there  were  73 
in  all.  Of  these  six  were  gangrenous  and  all  had 
died.  Two  were  left  on  account  of  there  being 
general  peritonitis.  In  one  the  bowel  was  opened 
and  in  the  others  the  whole  of  the  gangrenous 
parts,  two  inches,  three  inches,  and  eighteen 
inches  respectively  he  had  resected.  In  McCosh's 
tables  the  average  duration  of  the  operation  for 
resection  was  from  one  and  a  half  to  two  hours, 
and  often  had  to  be  performed  when  the  parts 
were  bathed  in  putrid  pus.      He  thought  that  in 


:4f> 


STATE  MEDICINE. 


[May  23, 


acute  intestinal  obstruction  the  less  done  the  bet- 
ter the  result,  as  the  patients  were  not  dying  of 
gangrene  but  of  obstruction.  Mr.  Treves  went 
on  to  say  that  he  had  come  to  the  conclusion  that 
the  best  and  simplest  way  was  merely  to  open  the 
sac  and  divide  the  stricture  so  as  to  relieve  the 
obstruction.  If  the  intestine  was  found  to  be 
gangrenous  it  should  be  brought  gently  down  and 
attached  by  sutures  to  the  abdominal  wall  and 
then  either  open  the  gut  or  let  it  open  itself.  To 
pull  down  the  gut  he  had  found  to  be  a  very  dan- 
gerous proceeding. 

To  read  the  twenty-sixth  annual  report  of  the 
trustees  of  the  Peabody  Fund  is  to  realize  what  a 
gigantic  work  it  is  to  properly  house  the  poor  of 
London.     Mr.  Peabody's  benefactions  amounted 
to  a  total  of  .£500,000.     To  this  round  sum   the 
trustees  have  added  by  way  of  rent  and  interest  j 
£523,446,  and  they  have  expended  in  all,  includ-  ! 
ing  money  borrowed,  £1, 233, 845.     The  result  is 
the  provision  of  11,275  rooms  occupied  by  20,462  j 
persons.     The  average  rent  paid  is  2s.  1  54d.     As 
a  rule  the  health  of  the  model  dwellings  is  better 
than  that  of  London  generally,  but  owing  to  the 
epidemic  of  last  spring,  from  which  many  of  the 
tenants  suffered,  the  death-rate  in  1890  is  slightly 
above  the  average  of  the  metropolis. 

The  Chair  of  Anatomy  at  the  Royal  Academy 
has  been  conferred  upon  Mr.  William  Anderson, 
of  St.  Thomas'  Hospital.  Mr.  Anderson  was  for 
some  years  medical  director  of  the  Imperial  Med- 
ical College  of  Japan,  and  is  well  known  as  the 
author  of  a  classical  work  upon  the  early  Japan- 
ese artists. 

The  Hospitals'  Association  has  just  established 
their  fiftieth  street  ambulance  station  in  the  por- 
tico of  the  Royal  Exchange.  The  Association  is 
now  largely  extending  its  organization  and  the 
committee  have  under  consideration  the  es- 
tablishment of  twenty-seven  additional  stations 
suggested  by  the  chief  commissioner  of  the  metro- 
politan police,  on  the  recommendations  of  the  su- 
perintendents of  the  different  divisions.  These 
stations  are  in  various  quarters  of  the  metropolis, 
but  mainly  in  the  East  End,  in  which  district 
the  association's  organization  is  as  yet  least  com- 
plete. The  completion  of  these  new  stations  will 
see  the  whole  of  London  furnished  for  the  first 
time  with  a  complete  street  ambulance  service. 


STATE  MEDICINE. 


TO  REMOVE  THE  PIGMENTATIONS  OF  PKKGNANCV. 
In  the  Journal  de  Midecine  de  Paris,  Januarv 
4,  1 89 1,  the  following  ointment  is  recommended 
to  be  rubbed  into  the  affected  parts  twice  daily 
to  remove  the  pigmentations  which  so  often  dis- 
figure pregnant  women  : 

R.     Cocoa  butter.  _ 

Castor  oil,  aa  5  ij  \  . 

< txide  of  /inc.  gr.  v. 

Yellow  oxide  of  mercury.  j»r.  ij. 

Essence  of  roses  enough  to  perfume. 


Michigan  State  Board  of  Health. 

The  annual  meeting  of  the  Michigan  State 
Board  of  Health  was  held  at  the  Capital,  Lan- 
sing, Mich..  April  14,  1891.  Prof.  Fall,  Drs. 
Avery,  Hazlewood,  Vaughan  and  Baker  were 
present.     Dr.  Avery  was  reelected  president. 

Dr.  Vaughan  reported  that,  at  the  State 
Laboratory  of  Hygiene,  he  has  made  analyses  of 
all  the  different  kinds  of  baking  powder  found  in 
the  market,  also  of  one  hundred  and  twelve 
samples  of  water  from  different  parts  of  the  State, 
and  that  he  was  ready  to  report  tbe  results,  also 
of  his  researches  on  typhoid  fever. 

Dr.  Baker  reported  that  he  had  worked  out 
the  cause  of  influenza.  He  said  its  greatly  in- 
creased prevalence  during  the  last  three  months 
is  alarming  because  so  many  other  diseases  follow 
that  disease,  and  increase  after  it  increases,  the 
diseases  which  so  increase  being  consumption, 
pneumonia,  cerebro-spinal  meningitis,  rheu- 
matism, osteo- myelitis,  etc.,  influenza  seeming  to 
bring  in  its  train  all  of  these  most  important  dis- 
eases. Dr.  Baker  explained  the  causation  of  in- 
fluenza. He  stated  that  the  germs  of  influenza 
are  generally,  at  all  times,  present,  and  the  germs 
of  pneumonia,  tuberculosis,  and  of  the  other 
specific  diseases  are  somewhat  widely  dissem- 
inated ;  but  that  there  must  be  certain  coincident 
meteorological  conditions  to  irritate  the  throat 
and  air-passages  sufficiently  to  let  the  germs  gain 
an  entrance  to  the  body.  These  meteorological 
conditions  in  this  instance,  were  the  excessive 
prevalence  of  north  and  northeast  winds,  and 
the  excessive  amount  of  ozone  during  the  past 
three  mouths. 

The  prevention  of  influenza  and  of  the  coin- 
cident rise  in  the  other  more  dangerous  diseases,. 
has  not  been  possible,  because  of  ignorance  of 
the  causes.  Now  the  causes  are  known,  and  the 
study  of  the  measures  for  the  prevention  can 
■  begin. 

How  to  get  more  thorough  disinfection  after 
contagious  diseases,  was  brought  up  by  Dr. 
Hazlewood,  also  by  letter  from  Dr.  Nicholson,  of 
the  Upper  Peninsula,  and  also  by  other  corre- 
spondence of  the  office  of  the  board.  It  seems 
to  be  made  plain  that,  if  the  Bill  now  before  the 
Legislature  (Senate  Bill  257,  House  Bill  640) 
shall  become  a  law,  making  a  small  appropriation 
to  enable  the  State  Board  of  Health  to  send  an 
inspector  to  the  localities  where  most  needed,  to 
aid  in  the  final  disinfection  after  cases  of  danger- 
ous diseases,  the  spread  of  those  diseases  can  be 
very  greatly  lessened,  and  hundreds,  and  possi- 
bly thousands  of  lives  can  be  saved  in  Michigan 
in  every  year. 


HO 


EDITORIAL. 


747 


Journal  of  the  American  Medical  Association 

PUBLISHED  WEEKLY. 


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Address 

Journal  of  the  American  Medical.  Association, 
Wabash  Ave., 

Chicago.  Illinois. 
All  members  of  the  Association  should  send  their  Annual  Dues 
to  the  Treasurer,  Richard  J.  Dunglison,  M.D.,  Lock  Box  1274,  Phila- 
delphia, Pa. 


London  Office,  57  and  59  Ludgate  Hill. 


SATURDAY,  MAY   2;,,    1S91. 


THE  ADJOURNED  MEETING  OF  THE  TRUSTEES. 

The  Trustees  of  the  Association  met  in  Chi- 
cago on  Wednesday,  May  13th,  all  being  present 
except  Dr.  Shoemaker,  who  was  represented  by 
proxy.  The  question  of  appointment  of  Editor 
being  taken  up,  Dr.  J.  C.  Culbertson,  for  many 
years  editor  of  the  Lancet  and  Clinic  of  Cincinnati, 
was  placed  in  nomination  and  received  the  unan- 
imous vote  of  the  Trustees. 

Dr.  Culbertson  was  also  instructed  to  act  as 
Business  Manager. 

On  Thursday,  May  14th,  the  Trustees,  in  com- 
pany with  the  newly  elected  editor,  inspected 
The  Journal  office,  and  he  was  formally  placed 
in  charge. 

The  Trustees  bespeak  for  Dr.  Culbertson  the 
same  kindly  consideration  that  has  been  extended 
to  his  predecessors,  and  they  feel  sure  that  the 
results  of  the  new  management  will  show  the 
wisdom  of  their  selection. 

By  direction  of  P.  O.  Hooper,  President  of  the 
Board.  John  B.  Hamilton,  Secretary. 


MEDICINE  AND  THEOLOGY. 
It  is  in  the  best  sense  commendable  for  every 
physician  to  j'oin  some  church  of  his  choice,  and 
by  example  and  act,  do  all  he  can  to  build  up 
the  higher  life  of  the  community,  and  also  en- 
courage its  ethical  culture  and  growth.  When 
the  physician  becomes  a  church  partisan,  and  ar- 


dent defender  and  propagator  of  certain  creeds  or 
doctrines,  he  must  to  some  degree  lay  aside  his 
scientific  training  and  reputation.  When,  on  the 
other  hand,  the  physician  ignores  all  church  in- 
fluences, and  assumes  skepticism  and  doubt,  sneer- 
ing at  all  church  efforts,  and  teachings  of  the 
Bible,  he  very  clearly  exhibits  his  narrow  judg- 
ment and  scientific  incompetency. 

The  physician  should  never  forget  that  he 
should  be  a  student  of  all  science,  in  the  broadest 
meaning  of  that  term.  In  that  position  he  must 
accept  the  general  facts  and  principles  of  theology, 
as  clearly  settled  as  any  other  knowledge  in  the 
world.  He  may  not  be  convinced  of  this  or  that 
form  of  church  doctrine,  or  interpretation  of  Bib- 
lical teachings,  but  he  should  ever  hold  the  sub- 
ject open  for  further  evidence,  and  always  show 
a  readiness  to  hear  all  sides  of  the  topic. 

The  majority  of  medical  men  have  long  ago 
taken  this  position,  and  where  they  do  not  be- 
come active  members  of  some  regular  church, 
are  reverential  believers  and  supporters  of  the 
fundamental  principles  of  Christian  religion.  It 
is  only  the  minority,  which  happily  are  growing 
less  every  year,  who  are  skeptics,  and  who  hide 
their  weakness  under  the  pitiful  expression  of 
Agnosticism.  These  men  are  always  urging  the 
idea  of  conflict  between  science  and  religion, 
which  every  true  student  of  science  denies,  and 
every  new  truth  of  nature  flatly  contradicts. 
Learned  theologians  and  scientists  find  no  con- 
flict or  clash  of  the  great  truths  of  nature  and 
theology ;  only  the  small,  weak,  half-learned 
men  are  troubled  by  such  possibilities. 

Medical  men  are  more  fortunately  situated  than 
others  to  realize  and  understand  the  higher  ranges 
of  physical  and  physiological  laws,  which  are  ac- 
tive in  the  formation  of  life  and  character,  and 
the  many  unknown  forces  which  enter  into  the 
religion  of  life  in  its  higher  sense.  We  believe 
no  class  of  professional  men  are  more  reverential 
and  so  profoundly  impressed  by  the  operation  of 
nature's  laws,  and  the  spirit  forces  of  the  world. 

A  noted  New  York  surgeon  whose  reckless, 
abrupt  manner  was  the  subject  of  comment,  was 
giving  a  clinical  lecture  when  the  patient  sud- 
denly died.  Being  a  jocular  man,  who  saw  the 
grotesque  in  all  things,  every  one  was  hushed  in 
expectation  of  some  remark.  He  stood  silent  a 
few  moments,  then  turned  to  the  class  with  tears 
in  his  eyes,  and  in  a  choked  voice  said:    "You 


748 


THE  PROBLEM  OF  WATER  PURIFICATION. 


[May  2; 


have  witnessed  a  phenomenon  which  will  be  a 
reality  to  each  one  of  you,  some  day.  If  you  are 
true  men  and  live  right,  it  will  be  welcomed,  and 
not  dreaded,"   and  walked  out. 

These  remarks  are  suggested  by  the  sad  com- 
ment of  a  noted  college  President,  that  medi- 
cal men  are  becoming  more  skeptical  and  dan- 
gerous to  the  growth  of  ethical  truth.  In  reality 
this  is  the  exact  opposite  of  the  facts.  Sta- 
tistics will  show  that  more  physicians  are  both 
active  and  passive  church  members,  than  ever 
before.  In  every  town  and  city  in  the  country 
medical  men  will  be  found  actively  supporting 
almost  every  Christian  and  philanthropic  move- 
ment for  the  elevation  of  the  people.  The  real 
students  of  all  the  writings  of  Darwin,  Huxley, 
Spencer  and  others,  will  never  be  skeptics  or  ob- 
structionists to  ethical  truth.  The  half-learned 
are  the  only  dangerous  men.  Medicine  and  the- 
ology will  never  be  in  conflict  or  suffer  except 
from  this  class.  Both  medicine  and  theology  are 
rapidly  changing,  and  breaking  away  from  much 
of  the  narrow  superstition  of  the  past. 

The  province  of  the  physician  is  more  and 
more  a  teacher,  and  less  a  dealer  of  drugs.  The 
clergyman  is  coming  nearer  the  physician,  and 
both  are  pointing  out  and  applying  the  higher 
laws  of  physical  and  spiritual  life,  and  urging 
men  to  live  in  accordance  with  them.  The  high- 
est form  of  theology  points  out  the  realm  of  the 
spiritual,  from  the  physical,  and  shows  the  laws 
and  forces  which  govern  the  life  here  and  here- 
after ;  and  the  highest  form  of  medicine  indicates 
the  reign  of  physical  laws,  their  scope  and  influ- 
ence, over  organic  and  tangible  life. 

While  theology  carries  the  range  of  study  far- 
ther on,  it  is  no  less  obscure  or  doubtful  than 
medicine  of  to-day.  The  dogmatic  medical  man 
who  assumes  that  he  possesses  positive  knowl- 
edge of  physiology,  pathology  and  therapeutics, 
is  (in  the  same  range  of  the  theologian  who  teach- 
es the  completeness  of  all  spiritual  truth.  Both 
are  incompetent  to  judge  of  the  rauge  of  study  of 
the  other,  and  both  fail  to  comprehend  the  spirit 
of  truth,  or  understand  the  great  principles  oi 
evolution  and  growth,  and  human  conceptions  of 
truth. 

The  unfortunate  church  war  which  is  going  on 
in  an  Eastern  city,  in  which  a  number  of  physi- 
cians have  become  involved,  has  no  medical  or 
theological  significance,  but  merely  reflects  the 


weakness  of  both  sides,  and  can  result  in  no  pos- 
sible good  whatever.  Toleration,  generosity,  a 
spirit  of  benevolence,  and  full  recognition  of  the 
right  of  private  belief,  should  exist  in  both  cler- 
gymen and  physicians.  Happily  this  is  the  rule, 
of  which  only  a  few  exceptions  occur.  The  cler- 
gyman and  physician  should  draw  nearer  with 
every  advance  of  science.  The  mutual  influence 
of  one  upon  the  other  would  go  far  towards  ele- 
vating the  race  and  lessening  the  tides  of  disease 
and  misery. 


THE  PROBLEM  OF  WATER  PURIFICATION. 

Perhaps  the  most  important  sanitary  question 
now  pressing  for  solution  is  that  of  a  pure  water 
supply  for  our  towns  and  cities.  As  this  country  be- 
comes more  populous,  the  streams  and  lakes  receive 
more  refuse  and  sewage,  until  the  purification  of 
the  water  supply  for  a  given  locality  has  become 
the  crying  need.  Statistics  show  that  at  least  55 
per  cent,  of  the  waters  supplied  to  cities  and 
towns  are  obtained  from  surface  sources  and  are 
necessarily  liable  to  more  or  less  contamination. 
Various  remedies  have  been  sought  for  this  con- 
dition, the  most  practical  thus  far  suggested  is  to 
prevent  the  contamination,  by  carefully  guarding 
the  lakes  or  rivers  from  which  the  supply  is  ob- 
tained. It  is  at  once  apparent  that  only  a  cer- 
tain degree  of  security  is  reached  in  this  way,  as 
it  is  clearly  impossible  to  perfectly  guard  an  ex- 
tended water  shed. 

Aside  from  organic  or  infectious  pollution,  sur- 
face waters  frequently  contain  fine  particles  of 
inorganic  matter  in  suspension,  or  they  are  more 
or  less  discolored  and  so  rendered  unsightly  and 
distasteful.  This  is  especially  true  of  many  river 
waters,  even  when  they  are  wholesome  so  far  as 
health  is  concerned.  Natural  springs  with  deep 
wells  have  been  considered  the  best  sources  of 
water  supply,  but  unfortunately  their  range  is 
limited  and  they  offer  no  practical  solution  of  the 
water  supply  of  our  larger  towns.  If  we  consider 
for  a  moment  the  sources  of  spring  water  we  find 
that  it  was  originally  precipitated  upon  the  sur- 
face, but  as  it  percolates  through  the  sand,  gravel 
and  stratified  rocks  it  gradually  looses  its  sus- 
pended matter  and  becomes  clear  and  sparkling. 
The  earth  acts  as  a  great  natural  filter  and  waters 
found  at  any  considerable  depth  are  usually  free 
from  dangerous  contamination,  unless  there  has 


i89i.] 


EDITORIAL  NOTES. 


749 


been  sufficient  pollution  of  the  surface  to  extend 
some-  depth  into  the  soil. 

In  the  treatment  of  polluted  waters  this  natu- 
ral process  should  as  far  as  possible  be  imitated, 
and  we  believe  that  it  is  precisely  upon  these 
lines  that  the  solution  of  our  water  supply 
problem  is  to  be  reached.  Filtration,  however 
modified,  has  always  been  based  upon  one  prin- 
ciple, that  of  forcing  water  through  a  substance 
with  pores  sufficiently  fine  to  entangle  the  sus- 
pended organic  and  inorganic  matter.  Almost 
every  conceivable  porous  substance  has,  at  one 
time  or  another,  been  used  in  filtering  water. 
These,  however,  may  be  divided  into  two  classes: 
first,  those  consisting  essentially  of  a  porous  plate 
or  bed,  such  as  saudstone  or  unglazed  porcelain ; 
and  secondly,  those  in  which  a  porous  mass  is 
formed  by  a  substance  in  a  fine  state  of  subdivi- 
sion, such  as  sand,  gravel  or  charcoal.  So  far  as 
we  know,  the  first  class  have  never  been  used  on 
a  large  scale,  though  good  results  have  been  ob- 
tained where  but  a  limited  supply  of  water  is  re- 
quired. The  chief  objection  to  filters  of  this 
class  is  that  the  interior  of  the  bed  or  plate  can- 
not be  cleaned.  Laboratory  experience  shows 
that  bacteria  soon  make  their  way  through  plates 
of  this  kind.  A  further  serious  objection  is  that 
they  cannot  be  adopted  for  the  filtration  of  water 
upon  a  large  scale. 

The  sand  filter  in  its  various  modifications  is 
the  only  one  that  has  been  adopted  in  the  filtra- 
tion of  waters  for  towns  and  cities.  Excellent 
results  may  be  obtained  by  simple  beds  of  sand, 
allowing  the  water  to  flow  over  the  surface  and 
percolate  through  to  a  suitable  collecting  cham- 
ber below.  Filters  arranged  upou  this  plan  purify 
most  of  the  water  supplied  to  the  city  of  London. 
The  chief  objection  to  gravity  sand  filters  is  their 
great  size,  and  cost  of  maintenance.  The  outer 
layer  of  sand  must  be  removed  every  few  days 
and  fresh  sand  substituted ;  and,  unless  the  bed 
is  carefully  prepared  and  the  water  evenly  distri- 
buted over  tbe  surface,  crevices  will  form,  through 
which  the  water  flows  without  filtration. 

A  modification  of  the  sand  filter  is  one  in  which 
the  bed  is  surrounded  by  a  shell,  and  the  water  is 
forced  through  by  hydraulic  pressure  ;  this  force 
if  sufficient  forms  the  sand  into  an  evenly  re- 
sistant compact  mass,  comparable  to  a  very  soft 
sand-stone.  A  filter  constructed  upon  these 
principles  and  filled  with   fresh   clean   sand   will 


give  a  pure  sparkling  water  for  some  hours,  but 
the  outer  layers  soon  become  foul  and  clogged, 
and  little  or  no  water  can  be  passed  through  ;  it 
is  therefore  necessary  to  either  renew  the  sand. 
or  to  have  some  means  of  thoroughly  and  effi- 
ciently cleaning  it.  It  is  just  at  this  point  that 
inventors  and  engineers  have  failed.  It  is  ap- 
parent that  a  filter  constructed  upon  such  princi- 
ples, if  the  bed  cannot  be  thoroughly  cleaned,  is 
worse  than  useless,  it  becomes  indeed  a  positive 
source  of  danger ;  it  is  this  defect  that  has 
rendered  some  of  the  devices  now  on  the  market 
worthless. 

It  has  been  demonstrated  that  a  simple  bed  of 
sand  arranged  in  this  way  will  remove  all  sus- 
pended matter  and  most  of  the  bacteria.  Can 
we  not  look  for  mechanical  devices  that  will 
easily  and  cheaply  cleanse  this  sand  ?  This  once 
accomplished,  one  of  the  greatest  sanitary  prob- 
lems of  the  age  will  be  solved,  and  public  health 
have  taken  a  long  step  in  advance. 


EDITORIAL  NOTES. 
Some  of  the  ways  adopted  by  other  large  as- 
semblies and  organizations  may  be  profitably 
imitated  in  future  meetings  of  the  American 
Medical  Association,  as  indicated  by  the  ease 
with  which  ill-digested  resolutions  are  sometimes 
passed  in  our  general  sessions  suggests  the  neces- 
sity of  having  in  amendment  to  the  By-Laws  of 
the  Association,  whereby  all  resolutions  before 
being  voted  upon,  shall  have  been  previously  in- 
troduced and  referred  to  a  committee  on  resolu- 
tions. By  having  such  a  committee  it  would  be 
quite  impossible  to  pass  resolutions  under  the 
spur  of  insufficient  time  for  consideration.  No- 
body would  be  wronged  by  such  a  course,  for  the 
committee  by  the  terms  of  its  organization  should 
be  required  to  report  back  to  the  Association, 
either  by  favorable  or  adverse  report,  all  resolu- 
tions referred  to  them  not  later  than  the  morning 
hour  of  the  last  day  of  the  session. 

To  be  Tried  Under  the  Code. — A  San 
Francisco  physician,  member  of  the  San  Francisco 
County  Medical  Society,  read  a  paper  before  that 
body  and  the  following  day  extensive  abstracts  of 
his  contribution  appeared  in  the  daily  public 
press,  presumably  with  bis  knowledge,  consent 
and  assistance.  Charges  were  promptly  brought 
against  him  for  a  violation  of  the  Code  of  Ethics, 
and  his  trial  was  set  for  an  early  date. 


75Q 


AMERICAN  MEDICAL  ASSOCIATION. 


[May  23, 


AMERICAN   MEDICAL  ASSOCIATION. 


Forty-second   Annual    Meetim 
Washington,  1).  C,  May  5-8 


,   held    al 
1891. 


Fourth  Day — Friday,  May  8. 

The  President  called  the  Association  to  order 
at  10  a.m. 

Prayer  was  offered  by  Rev.  Dr.  John  H.  Elliott, 
D.D. 

The  Permanent  Secretary  read  the  names  of 
the  committee  to  petition  Congress,  as  per  resolu- 
tion, on  a  Secretary  of  Public  Health. 

Committee  :  C.  G.  Comegys,  Chairman,  Ohio; 
J.  F.  Hibberd,  Indiana;  N.  S.  Davis,  Illinois;  J. 
C.  Culbertson,  Ohio;  T.  G.  Richardson,  Louisi- 
ana; Wm.  B.  Atkinson,  Pennsylvania;  Chas  A. 
Lindsley,  Connecticut;  C.  A.  Hughes,  Missouri; 
Wm.  T.  Briggs,  Tennessee;  H.  D.  Didama,  New 
York;  Thos.  B.  Evans,  Maryland;  Alex.  J.  Stone, 
Minnesota;  J.  P.  Logan,  Georgia;  W.  W.  Kerr, 
California;  Chas.  Denison,  Colorado ;  \Y.  L. 
Schenck,  Kansas;  P.  O.  Hooper,  Arkansas;  H. 
J.  Swearingen,  Texas;  Wirt  Johnson,  Mississippi; 
Thos.  F.  Wood,  North  Carolina;  J.  N.  McCor- 
mack,  Kentucky;  J.  T.  Reeve,  Wisconsin;  H.  O. 
Walker,  Michigan. 

Officers  of  Section  on  Obstetrics  and  Gynecology — 
Chairman,  E.  E.  Montgomery,  Pa.;  Vice-Chair- 
man, Bedford  Brown,  Va.;  Secretary,  F.  H. 
Martin,  111. 

The  following  resolution  was  unanimously 
adopted  by  the  Section  : 

Resolved,  That  in  the  future  the  papers  to  be  presented 
to  this  Section  shall  be  limited  to  forty,  and  the  chair- 
man shall  have  full  discretionary  power  in  selecting 
such  papers  from  those  offering. 

Dr.  Thos.  F.  Wood,  N.  C,  read  the  report  of 
the  Committee  on  the  Centeunary  of  Vaccination. 
(Report  not  received.) 

On  motion  of  Dr.  J.  F.  Hibberd,  Ind.,  it  was 
'     f/hat  the  Committee  on  the  Jenuer  Centen- 
nial lit-  continued  for  another  year,  anil  that  at  the  next 

i this    Association  the  Committer  re- 

iming  suitable  persons,  known  to  be  students  of 

va.  cinology,  to  form  a  standing  committee  to  whom  the 

abject    be    entrusted,    anil    that   the    i.|th    day   of 

<    chosen    and    set    apart   as   the    day    upon 

which  we  will  celebrate  the  centennial   of  the  discovcrv 

<>f  vacinnation. 

ed,  I'm  tlier.  that  the  meeting  of  this  Association 
>  be  so  arranged  as  to  include  the  above  date. 

REPORT  OF  COMMITTEE  ON  PRESIDENT'S 

ADDRKSS. 

Dr.  Culbertson,  Ohio,  presented  the  following: 
Your  Committee,  to  whom  was  referred  the  sug- 
gestions contained  in  the  President's  Address,  beg 
leave  to  recommend  the  adoption  of  the  following 
resolutions: 

business  matters  of  the  A 
red  without  discussion  or  comment  to  an  execu- 


tive committee  composed  of  two  members  to  be  ap- 
pointed by  each  State  Society  in  affiliation  with  this 
Association,  who  shall  carefully  consider  and  recommend 
such  action  thereon  as  they  may  deem  most  advisable. 

Resolved,  That  the  time' of  meeting  of  the  Sections  be 
from  9  a.m.  to  12  M.  and  from  2  to  6  p.m.,  and  that  the 
time  of  the  general  sessions  shall  begin  at  12  M.  and  con- 
tinue until  adjournment. 

Signed,  P.  O.  Hooper, 

J.  C.  Culbertson, 
Leartus  Connor, 
Henry  O.  Marcy, 
Harold  N.  Mover. 

This  was  laid  over  as  an  amendment  to  the 
By-laws. 

Dr.  A.  L.  Gihon  offered  an  amendment  to  the 
By-laws,  making  Wednesday  the  day  for  the  de- 
livery of  the  President's  address. 

THE  INCORPORATION  OF  THE  ASSOCIATION. 

Dr.  Harvey  Reed,  Ohio,  offered  the  following: 
Whereas,    The   American    Medical    Association  has 
never  been  incorporated,  and  has  inconsequence  no  legal 
existence,  therefore  be  it 

Resolved,  That  a  committee  of  seven  be  appointed  1\ 
the  I 'resident  to  proceed  at  once  to  procure  its  incorpora- 
tion; and  that  said  committee  of  incorporation  be  and 
are  hereby  instructed  to  name  the  Judicial  Council  of 
this  Association  for  the  Trustees  of  said  incorporation. 

A  motion  of  Dr.  J.  E.  Woodbridge,  Ohio,  to 
lay  this  on  the  table  was  negatived. 

After  much  discussion,  on  motion  of  Dr.  J.  F. 
Hibberd,  Ind.,  the  motion  was  amended  to  read 
that  the-  committee  be  appointed  to  devise  a  plan 
for  the  incorporation  of  the  Association  and  re- 
port their  action  at  the  next  annual  meeting. 

The  question  then  being  on  the  amendment  as 
amended.  Dr.  Hibberd  offered  as  a  substitute  for 
all  that  was  before  the  house, 

That  a  committee  of  seven  be  appointed  to  devise  a 
plan   of  incorporation  and  report  next  year. 

This  was  unanimously  adopted. 

The  Permanent' Secretary  announced  the  pres- 
ence in  the  house  of  Mr.  W.  Taylor,  President  of 
the  American  Pharmaceutical  Association,  and 
Prof.  Joseph  Remington,  a  delegation  from  that 
body,  and  mentioned  the  fact  that  Mr.  Taylor  had 
been  engaged  in  work  on  the  Pharmacopoeia  for 
forty  years.  On  motion  these  gentlemen  were 
invited  to  seats  on  the  platform. 

Messrs.  Taylor  and  Remington  were  received 
and  accorded  seats,  and  Prof.  Remington  earnest- 
ly thanked  the  Association  for  their  courtesy  and 
for  the  formation  of  the  Section  of  Materia  Med- 
ica  and  Pharmacy,  as  follows  : 

WHEREAS,  The  American  Medical  Association  has  or- 
ganized a  Section  of  Materia  Medica  and  Pharmacy,  and 
has  invited  twenty-five  members  of  the  American  Phar- 
maceutical Association  to  meet  with  them  and  discuss 
questions  of  mutual  interest.  The  Section  having  been 
inized,  and  numerous  papers  having  been  read 
and  subjects  considered,  to  the  satisfaction  ami  benefit 
of  the  members  attending,  it  is  therefore 

Resolved,  That  the  delegation  from  the  American  l'har- 
i utii  al  Association  express  their  high  sense  of  appre- 
ciation  of  the     1.I1011   of  the   American  Medical  Associa- 


i89k] 


AMERICAN   MEDICAL  ASSOCIATION. 


75« 


tinn,  and  sincerely  trust  that  the  movement  which  has 
been  inaugurat*  ma;    redound  to  the 

advantage  <>f  the  profi  i  licine  and  pi 

The    Permanent  Secretary,  in   the    absence  ofj 
Dr.  W.  L.  Schenck,  KLans.,  arose  to  read  the  Ad- 
dress on  Stale  Medicine.     On  motion  of  I>r.  J.  G. 
Kiernan,  Illinois,  it  was  read  by  title. 

Dr.  F.  Woodbury,  Pennsylvania,  from  the  Sec- 
tion of  Materia  Medica  and  Pharmacy,  offered  the 
following  : 

Resolved,  Thai  the  Government  of  the  United  States 
be  memorialized  by  the  American  Medical  Association  in 
favor  of  the  plan  proposed  by  Dr.  F.  E.  Stewart,  whereby 
the  valuable  work  of  the  laboratories  of  the  Army,  Navy, 
Marine-Hospital  Service,  Smithsonian  Institution,  Cus- 
toms Service,  Agricultural  Department  and  other  depart- 
ments of  the  public  service,  in  the  line  of  identification 
and  analysis  of  drugs  may  be  facilitated  and  made  of 
more  general  utility,  by  the  publication  of  their  results, 
so  that  the  information  thus  gathered  may  be  dissemina- 
ted for  the  general  benefit  of  the  professions  of  medicine 
and  pharmacy. 

On  motion  this  was  adopted. 
Dr.  Win.  H.   German,  Illinois,  offered  the  fol- 
lowing : 

Resolved^  That  a  committee  of  three  be  appointed  by 
the  President,  to  report  at  the  next  general  session  of  this 
Association,  to  draft  a  memorial  for  presentation  to  the 
Congress  of  the  United  States,  in  accordance  with  the 
suggestion  of  the  Hon.  John  C.  Ross  in  his  Address  of 
Welcome  to  this  Association,  asking  that  the  common 
law  be  so  amended  that  confidential  communications  be- 
tween physician  and  patient  shall  be  respected  in  the 
same  manner  as  those  between  attorney  and  client. 

'On  motion  of  Dr.  Kiernan  this  was  adopted. 

The  report  of  the  Section  on  State  Medicine, 
by  Dr.  Benjamin  Lee,  Pennsylvania,  was  read  by 
the  Permanent  Secretary  and  accepted. 

A  paper  by  Dr.  W.  W.  Parker,  Virginia,  on 
Intelligence  in  Man  and  Animals,  was  offered  and 
read  by  title. 

The  Permanent  Secretary  announced  the  offi- 
cers of  the  Sections  for  next  year  as  follows  : 

Practice  of  Medicine — Chairman,  ;  Sec- 
retary,   

Surgery  and  Anatomy — Chairman,  J.  McF. 
Gaston,  Georgia;  Vice  Chairman,  M.  Price,  Penn- 
sylvania ;  Secretary,  W.  F.  Mann,  Michigan. 

Medical  Jurisprudence  and  Neurology — Chair- 
man, H.  N.  Moyer,  Illinois :  Vice-Chairman,  J. 
E.  Emerson,  Michigan;  Secretary,  G.  D.  Straw- 
bridge,  Pennsylvania. 

Obstetrics  and  Diseases  of  Women — Chairman, 
■ ;  Secretary, 

Diseases  of  Children — Chairman,  E.  F.  Brush, 
New  York;  Secretary,  B.  A.  Waddington,  New 
Jersey. 

Dermatology  and Syphilography — Chairman,  L. 
D.  Bulkley,  New  York;  Secretary,  J.  C.  McGuire, 
District  of  Columbia. 

Oral  and  Dental  Surgery — Chairman,  J.  Paft, 
Ohio;  Secretary,  E.  S. "Talbot,  Illinois. 

Otology  and  Laryngology — Chairman,  ; 

Secretary,  


Ophthalmology — Chairman, 


■:  Seep 


Materia  Midi, a  and  Pharmacy  —  Chairman, 
Frank  Woodbury,  Pennsylvania;  Secretary.  W. 
L-  Whelpley,  Missouri. 

Medicine — Chairman,  Benjamin  Lee,  Penn- 
sylvania; Secretary,  L.    F.    Flick,  Pennsylvania. 

Physiology  and  Dietetics — Chairman,  C.  11.  A. 
Kleinschmidt,   District  of  Columbia ;  Secretary, 


A  motion  to  amend  the  title  of  the  Section  of 
Neurology,  etc.,  by  adding  Psychiatry,  was  laid 
on  the  table  by  a  large  vote. 

Committee  on  Medical  Aid  Association  (Reso- 
lution by  Dr.  Horner),  Frederick  Horner,  U. 
S.  X.:  Benjamin  Lee,  Pennsylvania;  John  II. 
Hollister,  Illinois. 

The  report  of  the  Judicial  Council  having  been 
asked  for  Dr.  N.  S.  Davis,  explained  that  time- 
was  needed  to  investigate  the  matters  referred, 
and  the  report  would  be  offered  at  next  session. 

Dr.  I.  X.  Love,  Missouri,  moved  that  it  be  the 
sense  of  this  Association  that  Dr.  \V.  W.  Potter 
should  have  no  hesitation  in  serving  on  the  Board 
of  Trustees. 

The  President  decided  this  not  in  order. 

As  several  members  had  applied  to  be  appointed 
delegates  abroad,  the  President,  after  some  re- 
marks on  the  subject,  announced  that  he  would 
appoint  them  to  all  save  the  British  Medical 
Association. 

After  some  discussion,  and  a  motion  that  no 
appointments  be  made  to  the  British  Medical  As- 
sociation, on  motion  the  whole  subject  was  laid 
on  the  table. 

On  motion  of  Dr.  J.  E.  Woodbridge,  Ohio,  the 
President  and  Permanent  Secretary  were  author- 
ized as  usual  to  issue  credentials  abroad  to  such 
societies  as  were  deemed  proper. 

The  Permanent  Secretary  read  the  following  : 

Proctor.  Vt.  ,  May  6,  1S91. 
Dr.  N.  S".  Lincoln,  Washington.  D.  C. 

My  I  'ear  Sir: — Am  very  sorry  not  to  be  in  Washington 
this  week  to  be  of  any  help  in  my  power  in  entertaining 
the  medical  society,  but  I  find  it  impossible  to  be  with 
you.     Very  truly  yours. 

Redfield  Proctor. 

On  motion  of  Dr.  W.  K.  Sheddon,  Tennessee, 
it  was 

Resolved,  That  the  thanks  of  the  Association  were 
tendered  to  the  local  committee  of  arrangements,  and 
the  other  physicians  and  citizens  of  Washington,  to  the 
trustees  of  the  different  museums  and  art  galleries,  and 
to  the  hotels  and  railroads  for  their  many  kindnesses  and 
favors  shown  to  the  members  during  their  stay  here,  and 
that  this  motion  be  passed  by  a  rising  vote. 

The  vote  was  adopted  by  the  entire  assemblage 
rising. 

Dr.  J.  E.  Woodbridge,  Ohio,  said  : 
"It   has  been    my  good  fortune   to  have    at- 
tended man)-  meetings  of  the  American   Medical 
Association,  but  never  before  have  I  seen  the  As- 


752 


AMERICAN  MEDICAL  ASSOCIATION. 


[May  22 


sociation  so  honorably  and  agreeably,  yet  so 
firmly  and  well  presided  over  as  at  the  present 
meeting,  and  the  duties  of  the  President  and  of 
the  Permanent  Secretary  so  satisfactorily  per- 
formed, therefore  I  move  that  the  thanks  of  this 
Association  are  due  and  are  hereby  tendered  to 
Dr.  Briggs,  of  Tennessee  and  Dr.  Atkinson,  of 
Pennsylvania."     Carried  unanimously. 

The  President  then  introduced  Dr.  H.  O. 
Marcy,  Massachusetts,  the  President-elect,  who 
accepted  the  duties  of  his  office  in  a  speech  allud- 
ing to  the  venerable  ex-presidents,  Drs.  Bowditch, 
and  Storer,  both  of  Boston,  Mass.,  in  terms  of 
profound  respect  and  regret  that  they  had  not 
been  with  the  Association  this  year. 

On  motion  of  Dr.  F.  Woodbury,  Pennsylvania, 
it  was 

Resolved,  That  the  Permanent  Secretary  be  directed  to 
send  telegrams  to  our  venerable  ex-presidents,  Drs. 
Henry  I.  Bowditch  and  D.  Humphreys  Storer,  of  Boston, 
expressing  the  high  esteem  in  which  we  continue  to  hold 
their  former  labors  in  the  American  Medical  Association, 
and  of  our  continued  personal  regard ;  and  greatly  re- 
gret that  they  were  unable  to  be  present  with  us  at  the 
present  meeting. 

The  retiring  President,  Dr.  W.  T.  Briggs,  then 
alluded  to  the  pleasure  he  had  enjoyed  in  presid- 
ing over  the  meeting,  thanking  the  members  for 
their  support  and  bade  them  good  bye  and  God 
speed. 

On  motion  of  Dr.  N.  S,  Davis,  the  Association 
then  adjourned  to  meet  in  Detroit,  Mich.,  on  the 
ist  Tuesday  of  June,  1892. 

William  B.  Atkinson, 

Permanent  Secretary. 


librarian's  report. 

Mr.  President : — I  have  the  honor  to  present 
the  catalogue  of  additions  to  the  Library  of  the 
Association  during  my  term  as  Librarian  of  the 
American  Medical  Association. 

This  report  shows  the  addition  of  45  Periodicals, 
24  Reports  of  various  kinds,  14  Society  Transac- 
tions, 5  Hospital  Reports,  16  Dissertations  and 
Papers,  and  8  College  Announcements. 

I  would  suggest,  on  account  of  the  crowded 
condition  of  the  library — one  of  the  towers  of  the 
Smithsonian  Institute  Building — that  other  quar- 
ters  l>c-  selected  for  its  habitat.  The  tower  is  now 
overcrowd ed,  the  shelving  space  all  used  up,  and 
the  new  material  must  be  piled,  layer  over  layer, 
on  the  floors,  where  it  is  not  only  inaccessible, 
but  where  no  one  cares  to  seek  it.  I  would  also 
suggest  that  the  subscription  to  the  Inde  \  Medi- 
•  the  current  year  be  continued,  and  the 
sum  of  $10  be  appropriated  for  that  purpose. 

.::      mi      ADDITIONS     i"     'ill.    ui:k\ry    OF    THE 

AMERICAN      MEDICAX    ASSOCIATION,     BV     DONATION. 

1         .i      \\|i  SUBSCRIPTION,  1  ROM    mas    I, 
1S9O,  TO  MAY  I,    1S9I. 
REPORTS. 
Consular  Reports  (U.  S.),  Nos.  114-125. 


Consular  Report,  Special.  Fruit  Culture  in  Foreign 
Countries,  1890. 

Consular  Report,  Special.  Carpet  Mau'f.  in  Foreign 
Countries,  1890. 

Consular  Report,  Special.  Malt  and  Beer  in  Spanish 
America, 

Consular  Report.  Index,  1S90. 

American  Statistical  Association,  Report,  1890. 

Biological  Laboratory  of  Johns  Hopkins  University, 
Report,  Vol,  iv.  No.  7,  1S90. 

I'.ureau  of  Education,  Reports,  1S90. 

;n  Relation  of  the  United  States,  18S9. 

Illinois  State  Board  of  Health,  Report,  1S90. 

Index  Catalogue  of  the  Library  of  the  Surgeon-Gen- 
eral's Office,  U.  S.  A.,  Vol.  xi. 

International  American  Conferences,  Report  and  Rec- 
ommendations, 1S90. 

Red  Cross  Society,  Report,  1S90. 

COLLEGES. 

Alumni  Association,  Philadelphia  College  of  Pharma- 
cy, 1890. 

Baltimore  University,  Annual  Announcement.  189 1. 

Baltimore  Medical  College.  Announcement,  1S91. 

National  University,  D.  C.  Annual  Announcement, 
1S90. 

McGill  University,  Canada,  Annual  Announcement, 
1 891. 

Tulane  University,  Louisiana,  Annual  Announcement, 
1S90. 

University  of  Pennsylvania,  Philadelphia,  Annual  An- 
nouncement, 1S90. 

Women's  Medical  College,  Philadelphia,  Annual  An- 
nouncement, 1890. 

DISSERTATIONS  AND  PAPERS. 

Baker,  Henry  B.,  Sanitation  in  1890. 

Bishop,  ,S.  S.,  Imperfect  Auditory  Canal,  1S90. 

Boylan,  J.  E.,  Simple  and  Effective  Method  of  Anaes- 
thetizing the  Pharyngeal  Tonsil. 

Bulkley,  L.  D.,  Psorospermosis  Follicularis  Cutis. 

Bulkley,  L.  D.,  On  Dangers  arising  from  Syphilis  in 
the  Practice  of  Dentistry. 

Cutter,  Ephraim,  Food  in  Motherhood. 

Eastman,  Jos.,  Abdominal  and  Pelvic  Surgery. 

Johnson,  J.  T. ,  Abortion  and  its  Effects. 

Judson,  A.  B.,  A  Criticism  of  Willett's  Operation  for 
Talipes  Calcaneus. 

Goner,  A.  J.,  The  Causes  and  the  Remedies  for  Suits 
for  Malpractice. 

Lamphear,  New  Treatment  of  Peritonitis. 

Morton.  Win.  J.,  The  Frauklinic  Interrupted  Current. 

Remondino,  P.  C,  Longevity  and  Climate. 

Senn,  TwoCasesof  Resection  of  Ciecum  for  Carcinoma. 

Senn,  Diagnosis  and  Operative  Treatment  of  Gun  Shot 
Wounds  of  the  Stomach  and  Intestines. 

Johns   Hopkins   University,   Studies   from    Biological 
Laboratory,  Vol.  v.,  No.  1,  Vol.  iv..  No.  5. 
HOSPITALS. 

Butler  Hospitals  for  Insane,  Report.  Providence, 
1890,  1891. 

Johns  Hopkins,  Vol.  ii,  No.  1,  1890. 

New  York  Hospital   and  Bloomingdale  Asylum,  1889. 

Northampton  Lunatic  Hospital,  No.  21,  1S90. 
PERIODICALS. 
Belgium— Archives  Medicales  Beiges. 
Cauada  Medical  Record. 
Montreal  Medical  Journal. 
L'Union  MeMical  du  Canada. 
France     Vrchives  de  M6d€cine  Navale. 

Journal  de  Mcdccine  et  de  Chirm  -ie. 
Sweden — Nordiskt  Medicinskt  Archiv. 
United  States — Alienist  and  Neurologist. 

American  Journal  of  Insanity. 

American  Lancet. 

American  Practitioner  and  News. 


i89i.] 


SOCIETY  PROCEEDINGS, 


753 


American  Veterinary  Review. 

Arc)  i  istry, 

Atlanta  Medical  and  Surgical  Journal. 
Buffalo  Mi  dical  an  !  Surgical  Journal. 
Cincinnati  Medical  New  s. 
Columbus  Medical  Journal. 
Denvei  Medii  il   I 
ii   '  razette. 
[lard  i        ouri 

Index  Medicus. 
International  Dental  Journal. 
Journal  of  the  American  Medical  Association. 
Journal  of  Balneology 
Journal  of  Nervous  and  Mental  Diseases. 
Medical  Ag< . 
Medical  Brief. 
Medical  Bulletin. 
Medical  Standard. 
Medical  Summary. 
Medical  World. 

Nashville  Journal  of  Medicine  and  Surgery. 
New  England  Medical  Monthly. 
New  Orleans  Medical  and  Surgical  Journal. 
New  York  Medical  Journal. 
North  Carolina  Medical  Journal. 
Notes  on  New  Remedies. 
Pacific  Medical  Journal. 
Physician  and  Surgeon. 
Pittsburgh  Medical  Review. 
St.  Louis  Medical  and  Surgical  Journal. 
Southern  Clinic. 
Southern  Practitioner. 
University  Medical  Magazine. 
Virginia  Medical  Monthly. 

SOCIETIES. 
France — Bulletin  del'Academie  de  Medecine. 

Bulletin  et  Memoires  de  la  Societe  Med.  des   Hopi- 

taux  de  Paris. 
Bulletin  de  la  Societe  Clinique  de  Paris. 
Germany — Physikalisch  Med.  Societat  in  Krlangen,  1S90. 
Great  Britain— Obstetrical  Soc.  of  Loudon.  Transactions, 
Vol.  xxxi,  Part  iii  and  iv,  1889. 
Obstetrical  Soc.  of  London,  Transactions,  Vol.  xxxii. 

Part  i,  ii  and  iii.  1890. 
Pathological  Society  of  London,  Transactions,  Vol. 
xli.  1S90. 
United   States — American   Association    of  Obstetricians 
and  Gynecologists,  Trans.,  Vol.  iii.  1S90. 
American   Gynecological    Society,   Trans.,  Vol.   xv, 

1890. 
Iowa  State  Medical  Society.  Vol.  viii,  1890. 
Medical  Society  State  of  New  York,  Trans.,  1S90. 
Medical  Society,  New  Jersey.  Trans..  1S90. 
New  York  State  Pharmaceutical  Assn 
S.  Carolina  Med.  Association,  Trans.,  1890. 


SOCIETY   PROCEEDINGS. 


Fort  Wayneilnil.i  Academy  of  Medicine. 
Regular  Session,  March  jo,  1891. 

Dr.  L.  K.  McCullocgh  read  the  paper  of  the 
evening,  entitled 

shurly's  treatment. 

The  essayist  gave  an  outline  of  the  present 
treatment  of  Shurly  and  Gibbes,  and  appended 
the  history  of  four  eases.  The  essayist  suggests 
that  inasmuch  as  chlorine  gas  is  irrespirable,  pro- 
ducing spasmodic  closure  of  the  glottis,  it  would 


oetrate  the  bronchial  tubes  of  medium  cal- 
Lbre,  to  saj  noth  ir  cells;  that  if  chlo- 

rine gas  is  1  0  prevent  caseation  and  the 

formation  of  the  ptomaine-  toxalbumin,  it  might 
be  gotten  into  the  tissue-  through  rectal  insuf- 
flation. 

Case  /.—Mrs.  C,  set.  33  years,  since  birth  of 
last  child,  eighteen  months  ago,  has  been  in  fail- 
ing health.  January  3,  is  in  last  stage  of  phthi- 
sis. Daily  injections  of  iodine  for  ten  days,  and 
five  more  on  alternate  days  :  inhalation  of  chlo- 
rine gas  caused  so  much  distress  that  it  was  aban- 
doned. Patient  was  better  subjectively,  object- 
ively no  improvement.  Now  failing  rapidly,  and 
will  soon  die. 

Case  2. — I.  A.,  cigar  maker,  set.  27.  Family 
history  good.  For  past  fourteen  months  patient 
thinks  he  has  been  out  of  health.  Has  had  three 
separate  haemorrhages ;  slight  cough  :  general 
condition  fair  :  appetite  good.  Dec.  29,  right 
lung  no  abnormal  signs  ;  on  left  side  infra-cla- 
vicular space  gave  tubular  breathing  ;  dulness  on 
percussion  and  crackling  rales  on  deep  inspira- 
tion. Temp.  99.50 ;  no  expectoration.  Iodine 
injections  daily,  gr.  2\,,  increased  to  rVi  given  for 
fifteen  days.  No  chlorine  inhalation.  Beech- 
wood  creasote  gr.  -.;  t.i.d.  Hypophosphites  and 
malt  were  used.  Patient  has  gained  eight  pounds 
in  weight.  Coughs  scarcely  any,  temp,  normal, 
physical  signs  improved,  but  probably  due  to 
disappearance  of  local  congestion. 

Case  3.— Mt.  25;  incipient  stage  ;  treatment 
two  weeks  ;  no  change. 

Case  4. — J.  P.,  set.  38;  tubercular  history; 
husky  voice ;  congestion  of  larynx  for  past  two 
years  ;  sputum  shows  bacilli.  Lost  a  brother  re- 
cently from  phthisis.  Expectoration  very  pro- 
fuse. Since  treatment  expectoration  has  ceased, 
till  at  present  time  can  not  get  enough  for  exam- 
ination. Chlorine  gas  inhalations  not  used. 
Chloride  gold  was  used  for  a  time  but  was 
was  discontinued  on  account  of  pain  and  nodula- 
tion  at  site  of  puncture.  Arytenoid  ragged;  no 
abscess  has  followed  injections;  rubbing  relieves 
pain  of  puncture. 

Dr.  Proegler  said  he  was  acquainted  with 
case  4,  and  the  tubercular  history  is  undoubted. 
Since  six  weeks  patient  has  improved  very  rapid- 
ly. Gold  injections  makes  patient  feel  very  tired. 
At  present  there  is  no  expectoration;  no  night- 
sweats;  appetite  improving,  and  now  walks  sev- 
eral blocks  where  before  was  unable  to  go  out. 
Right  lung  has  cleared  up  aud  rales  not  appreci- 
able. Patient  had  continued  beechwood,  creosote, 
hypophosphites  and  malt. 

Dr.  Whery  :  It  would  be  difficult  to  say  that 
results  were  due  entirely  to  injections.  Am  bet- 
ter impressed  with  Shurly's  treatment  than  with 
Koch's  because  it  produces  no  reaction. 

Dr.  Schilling  :  Have  had  no  experience  with 
the  Shurly  method. 


754 


NECROLOGY. 


[May  23 


Dr.  Wheelock  :  Aui  interested  indirectly  in 
the  treatment  on  account  of  the  possibility  of  cur- 
ing those  secondary  tubercular  affections  of  the 
eye*  found  in  patients  with  phthisical  antecedents. 

Dr.  McCaskey  :  Have  had  some  experience 
with  iodine  injections,  but  not  enough  to  base  a 
definite  opinion  upon.  Maximum  dose  of  iodine 
as  used  by  essayist  seems  small.  I  think  it  may 
be  safely  carried  to  y?  gr.  My  injections  have 
been  followed  by  pain,  hence  I  use  sol.  cocaine. 
The  treatment  shows  that  irritating  injections 
may  be  used  with  perfect  safety  and  without  dan- 
ger of  suppuration. 

Dr.  Proegler:  I  think  there  is  a  psychical 
element  in  the  injections,  and  that  after  the 
weary  routine  of  reconstructives  the  injections  act 
upon  the  mind  as  well  as  physically. 

Dr.  McCullough  :  Am  not  prepared  to  offer 
any  opinion  as  to  the  real  value  of  the  treatment, 
and  can  not  till  more  statistics  have  been  brought 
forward. 


BOOK  REVIEWS. 


Die  Wirksamkeit  des  Kochschen  Heilmit- 

tels  gegen  tuberculose. 

For  some  years  it  has  been  the  custom  of  the 
minister  of  medical  affairs  in  Germany  to  issue  a 
year  book,  in  which  are  published  the  official  re- 
ports of  the  directors  of  different  clinics.  This 
volume  forms  a  supplement  for  the  regular  vol- 
ume and  contains  thirty-three  reports  of  the  re- 
sults obtained  with  Koch's  method  up  to  the 
close  of  December,  1890,  or  about  eight  weeks' 
experience — too  short  a  time  to  come  to  any  con- 
clusion as  to  the  permanent  value  of  the  method. 
The  majority  of  opinions  are  more  or  less  favor- 
able as  to  the  diagnostic  and  therapeutic  value  of 
the  method,  but  in  many  instances  an  opinion  is 
reserved  or  guardedly  expressed.  Of  1,010  pa- 
tients with  tuberculosis  of  the  internal  organs 
who  were  subjected  to  the  treatment,  only  13  are 
said  to  have  recovered,  365  were  benefited,  586 
remained  stationary,  and  46  died.  Of  the  13  cases 
reported  cured,  10  were  in  the  first  stage,  and 
267  of  those  reported  improved  were  either  in  the 
first  stage,  or  eke  the  disease  had  made  but  little 
progress. 


PIPERAZIDINE  AS  A  SOLVENT  FOR  URIC  ACID. 

It  is  stated  in  a  German  pharmaceutical  jour- 
nal that  piperazidine  dissolves  uric  acid  more 
readily  than  any  other  substance  of  a  basic  na- 
ture. Urate  of  lithia  requires  368  times  its  own 
weight  of  water  to  dissolve  it,  but  urate  of  piper- 
azidine dissolves  in  fifty  times  its  weight  of  water. 
It  may  therefore  be  that  this  drug  will 

a  fashionable,  let  us  hope,  too,  an  effi- 
cient remedy  in  gout  and  allied  diseases. 


NECROLOGY. 


Necrology  Report  for  the  state  of 
Connecticut. 

Hartford  County. — The  following  members  of  the  State 
Medical  Society  have  died  during  the  year:  Geo.  E. 
Markham,  East  Hartford;  R.  B.  Watkins,  So.  Manches- 
ter; ].  S.  Butler,  Hartford;  S.  W.  Rockwell,  So.  Windsor; 
Casper  Barstowe,  E.  Hartford. 

Tolland  County. — Joel  Addington  Warren,  M.D.,  born 
at  Irisburgh,  Vt.,  February  15,  1S34;  died  at  Ellington 
Corner,  December  25,  1S90.  Graduated  from  the  Albany,. 
N.  Y.,  Medical  School  in  1S59. 

Fairfield  County.— Jatnes  R.  Cumming,  M.D.,  of  Bridge- 
port. 

New  London  County. — Robert  A.  Mainwariug,  M.D., 
of  New  London;  died  September  1,  1890. 

Respectfully  submitted, 

W.  A.  M.  Wain-wrighT,  M.D. 


Sidney  Allan  Fox,  M.D. 

The  following  memoir  of  the  late  Dr.  Sidney  Allan 
l-ox,  member  of  the  Kings  County  Medical  Association, 
was  read  at  the  stated  meeting,  March  10,  1S91: 

Dr.  Sidney  Allan  Fox  died  of  pneumonia,  at  his  resi- 
dence, 22  Cambridge  Place,  Brooklyn,  on  Saturday,  Jan- 
uary 10,  1S91,  aged  34  years,  6  nios.  and  26  days.  He  was 
born  at  Mount  Sterling,  Ky.,  graduated  from  the  Univer- 
sity of  Kentucky,  and  pursued  the  study  of  medicine  at 
Bellevue  Hospital  Medical  College,  New  York  City,  re- 
ceiying  the  diploma  of  that  institution  in  1S80. 

He  served  one  year  each  as  interne  in  the  Charity  Hos- 
pital and  the  New  Y'ork  Hospital  for  the  Relief  of  Rup- 
tured and  Crippled,  and  came  to  Brooklyn  in  1882.  He 
was  Surgeon  to  the  Brooklyn  Elevated  R.  R.,  and  Sur- 
geon in  Chief  to  the  Brooklyn  Dispensary  for  the  treat- 
ment of  the  Diseases  of  the  Nose,  Throat  and  Lungs. 
He  joined  this  Associatiou  in  January,  1S88,  and  always 
took  an  active  interest  in  its  proceedings.  He  was  espe- 
cially interested  in  the  diseases  of  the  respiratory  system. 
By  his  death  the  Association  has  lost  a  valuable  member, 
and  the  profession  one  of  the  ablest  of  its  younger  men. 
The  members  of  this  Associatiou  unite  in  expressing 
their  profound  regret  at  the  death  of  Dr.  Fox,  and  tender 
to  the  bereaved  family  their  sincere  sympathy. 

WM.  WaTERWORTH, 

F.  C.  Raynor, 

Committee. 


Richard  Gundry,  M.D. 

Dr.  Richard  Gundry,  a  member  of  the  faculty  of  the 
Baltimore  College  of  Physicians  and  Surgeons,  died  at 
Spring  Grove,  Md.,  on  April  23,  1891.  He  was  born  in 
England,  near  London,  about  sixty-two  years  ago,  the 
son  of  a  talented  clergyman.  In  1845  he  went  to  Canada, 
and  soon  afterwards  began  his  medical  studies.  He  grad- 
uated five  years  later  from  the  medical  department  of 
Harvard  University.  He  began  medical  practice  at  Roch- 
ester,  N.  Y.,  but  in  1S54  removed  to  Columbus,  O.,  to  be- 
come an  assistant  physician  in  the  Lunatic  Asylum.  h> 
[857  he  went  to  Dayton  to  occupy  a  similar  position,  and 
became  Superintendent  of  that  institution  in  1N62.  He- 
was  afterwards  identified  with  the  care  of  the  insane  at 
Athens,  (>..  and  again  at  Columbus,  and  later  at  Catous- 
ville,  .Md.  Dr.  Gundry  superintended  the  building  of 
two  or  more  large  asylums,  and  was  the  author  of  nu- 
merous reports  on  improving  the  care  of  the  insane, 
removal  to  the  vicinity  of  Baltimore,  he  ac- 
cepted the  chair  of  materia  medica,  therapeutics  aud 
mental  diseases  in  the  college  above   named.     His   final 

llllUSS   \\    1 


i89i.] 


MISCELLANY. 


755 


MISCELLANY. 


In  OCR  last  issue  the  name  of  Dr.  J.  C.  LeGrand,  of 
Alabama,  should  appear  instead  of  Lagrange,  as  mem- 
ber of  the  Nominating  Committee. 


New  York  Post-Graduate  Medical  School  and 
Hospital. — At  the  meeting  of  the  Directors  of  the  New 
York  Post-Graduate  Medical  School  and  Hospital,  H.  J. 
Boldt.  M.D.,  was  made  Professor  of  Diseases  of  Women, 
William  James  Morton,  M.D.,  Professor  of  Electro- 
Therapeutics  and  Aug.  Caille,  M.D.,  Professor  of  Dis- 
eases of  Children.     Clarence  C.  Rice,  Secretary. 


South  Dakota  State  Medical  Society.— The  tenth 
annual  meeting  of  the  South  Dakota  State  Medical  So- 
ciety will  be  held  at  Chamberlain,  South  Dakota,  on 
Wednesday,  Thursday  and  Friday,  June  10,  u  and  12, 
1891.  Members  of  the  medical  profession  are  cordially- 
invited  to  attend. 

Program. — Business  sessions  will  be  held  at  Masonic 
Hall.  Wednesday,  June  10,  1S91,  S  P.M.  Call  to  order. 
Prayer,  Rev.  D.  B.  Nichols,  M.D.  Address  of  Welcome, 
Mayor  John  T.  Anderson.  Response,  W.  E.  Duncan, 
M.D.  President's  Annual  Address,  J.  W.  Freeman.  M.D. 
Report  of  Committee  of  Arrangements. 

Thursday,  a.m.  Report  of  Censors  and  Admission  of 
New  Members.  Appointment  of  Committees.  Report 
of  Secretary.  Report  of  Treasurer.  Report  of  Standing 
Committees.  Reports  of  Delegates  to  American  Med- 
ical Association  and  other  Societies. 

Sections. — Report  on  Medicine,  Dr.  I.  R.  Spooner, 
Chairman.  Report  on  Medicine.  Dr.  C.  J.  Cummings, 
Secretary. 

Report  on  Surgery,  Dr.  G.  W.  Moody.  Chairman. 
Report  on  Surgery,  Dr.  S.  J.  Coyne,  Secretary. 

Report  on  Obstetrics  and  Diseases  of  Women.  Dr.  H. 
YanBuskirk,  Chairman.  Report  on  Obstetrics  and  Dis- 
eases of  Women,  Dr.  A.  H.  Bowman,  Secretary. 

Report  on  Nervous  Diseases,  Dr.  S.  B.  McGlumphy, 
Chairman.  Report  on  Nervous  Diseases,  Dr.  H.  H. 
Stoner.  Secretary. 

Report  on  Hygiene,  Dr.  S.  A.  Brown,  Chairman.  Re- 
port on  Hygiene,  Dr.  J.  B.  Graham,  Secretary. 

Thursday,  p.m.  Report  on  Endemic  Diseases.  Dr.  Fred. 
Treon,  Chairman.  Report  on  Endemic  Diseases,  Dr. 
R.  E.  Buchanan,  Secretary. 

Report  on  Microscopy,  Dr.  H.  S.  Sevey,  Chairman. 
Report  on  Microscopy,  Dr.  G.  E.  Martin.  Secretary. 

Report  on  Diseases  of  Children,  Dr.  F.  B.  Bullard, 
Chairman.  Report  on  Diseases  of  Children.  Dr.  F.  P. 
Smith,  Secretary. 

Report  on  Diseases  of  Eye  and  Ear.  Dr.  A.  Shaw, 
Chairman.  Report  on  Diseases  of  Eye  and  Ear,  Dr.  W. 
J.  Nolan,  Secretary. 

Report  011  Dermatology  and  Yenereal  Diseases,  Dr.  M. 
Ware,  Chairman.  Report  on  Dermatology  and  Yenereal 
Diseases,  Dr.  R.  T.  Dott.  Secretary. 

Report  on  Yital  Statistics,  Dr.  F.  A.  Spafford,  Chair- 
man. Report  on  Yital  Statistics.  Dr.  O.  O.  Sawyer, 
Secretary. 

Report  on  State  Legislation,  Dr.  W.  M.  Kaul.  Chair- 
man. Report  on  State  Legislation,  Dr.  A.  H.  Tufts, 
Secretary. 

Papers. — Laceration  of  Cervix  Uteri,  Trachelorrhaphy, 
and  relation  to  Conception  and  Pregnancy.  Dr.  J.  S. 
Johnson. 

Ophthalmologv  and  its  Relation  to  General  Practice, 
Dr.  A.  Shaw. 

Diseases  of  Children,  Dr.  F.  B.  Smith. 

Also  papers  bv  Drs.  I.  R.  Spooner,  F.  A.  Spafford,  S. 
J.  Coyne.  W.  J.  Nolan,  0.   W.   Phelps,  G.  W.  Moody,  J. 


B.  Graham.  S.  B.  McGlumphy.  Yolunteer  Papers  and 
Report  of  Cases. 

Thursdav  Evening.  Unfinished  Business.  Report  of 
the  Nominating  Committee.  Election  of  Officers.  Ap- 
pointment of  Committees  and  Sections  for  Ensuing  Year. 
Reading  of  the  Minutes.     Adjournment. 

Officers. — President.  Dr.  J.  W.  Freeman  ;  Yice-Presi- 
dent,  Dr.  M.  Ware  ;  Second  Yice-President,  Dr.  A.  H. 
Tufis ;  Secretarv,  Dr.  R.  C.  Warne ;  Assistant  Secre- 
tary.  Dr.  S.  L.  Halverson;  Treasurer,  Dr.  J.  C.  Morgan. 

Trustees.— Dr.  F.  Andros,  Dr.  S.  B.  McGlumphv,  and 
Dr.  F.  B.  Bullard. 

Committee  01  Arrangement. — Dr.  R.  H.  Goodrich,  Dr. 
S.  L.  Halverson,  Dr.  May,  Dr.  Cook,  Dr.  Lloyd. 

Notes. — Article  III  of  the  Constitution,  Section  4: 
"  Permanent  members  shall  be  regular  practitioners  of 
medicine  in  the  State,  shall  be  graduates  of  a  medical 
college  in  good  standing,  shall  be  members  of  the  local 
society  where  they  reside  where  such  society  exists.  .  . " 

"  Even-  application  shall  be  accompanied  by  the  sum 
■  >  membership  fee.  .  .  ." 

The  society  has  largely  increased  as  to  membership 
and  attendance  the  past  few  years,  and  the  interest  in  our 
societv  work  has  increased  in  proportion.  It  is  wished 
that  all  the  physicians  in  the  State  will  join  in  the  good 
work. 

The  railroads  refuse  reduced  rates  so  that  each  one  will 
probablv  find  it  the  best  to  buy  round  trip  tickets. 

The  hotels— "  Hotel  Taft."  "  Wright  House,"  "Brule 
House,''  and  "Merchants  House,"— kindly  make  a  rate 
of  51.50  per  day. 

I  Capt.  H.  J.  King  extends  an  invitation  to  the  society 
for  a  pleasure  trip  on  the  Missouri  river  sometime  during 
the  meeting. 

The  committee  on  arrangements  promise  all  a  good 
time. 

The  Golden  Belt  in  the  Capital  City  of  Kansas. 
— The  Golden  Belt  District  Medical  Societv  of  Kansas  con- 
vened in  regular  quarterly  1  annual  I  session  in  the  club 
rooms  in  the  National  Hotel,  in  Topeka,  April  9.  in  re- 
sponse to  an  invitation  by  the  physicians  of  the  capital 
citv.  who  entertained  the  visitors  royally  and  attended 
the  sessions  in  a  body.  The  attendance  was  very  large 
and  the  programme  unusually  interesting,  especially  so 
bv  virtue  of  the  liberal  discussions  of  the  papers  read. 
j  the  cases  reported,  and  the  difficult  operation  performed 
by  Dr.  Emory  Lanphear,  of  Kansas  City,  Mo.,  who  ex- 
hibited great  skill  as  operating  surgeon  in  demonstrat- 
ing upon  a  dog  recent  improvements  in  intestinal  sur- 
gery. The  programme  carried  out  was  as  follows: 

Dr.  J.  H.  Garvey,  of  Wisley,  ''Chronic  Cystitis  with 
Report  of  Cases." 

Dr.  C.  H.  Guibor,  of  Topeka,  "Report  of  Cases  of 
I  Adenoid  Growths  in  the  Throat." 

I  Dr.  Emory  Lanphear.  of  Kansas  City,  Mo..  "Some  Re- 
ceut  Improvements  in  Intestinal  Surgery,  with  Demon- 
strations upon  a  Dog." 

Dr.  H.  Cordier,  of  McPherson,  "Phimosis,  Local  and 
Remote  Results." 

Dr.  Chas.  W.  Adams,  of  Kansas  City.  "Peri-Uterine  In- 
flammation." 

Dr.  P.  Daugherty,  of  Junction  City,  President.  "Annual 
Address." 

Dr.  L.  H.  Berger.  of  Kansas  City,  "Use  of  Obstetric 
Forceps." 

Dr.  Hal.  Foster,  of  Kansas  City,  "Report  of  a  Case  of 
Submucous  Haemorrhage  of  the  Larynx." 

This  being  the  annual  meeting,  officers  for  the  ensuing 
vear  were  elected  as  follows: 

President,  Dr.  Wm.  B.  Dewees,  of  Salina. 

First  Yice-President.  Dr.  Z.  T.  Harvey,  of  Council 
Grove. 

Second  Yice-President,  Dr.  T.  N.  Gunn,  of  Chapman. 

Secretary,  Dr.  F.  B.  Browne,  of  Salina. 

Treasurer,  Dr.  E.  Kaufiman,  of  Abilene. 


756 


MISCELLANY. 


[May  23,  1891. 


The  new  president  was  introduced  formally  by  the  re- 
tiring president  who,  upon  taking  the  chair,  made  a  brief 
address  in  which  he  thanked  the  members  for  the  honor 
conferred  upon  him.  A  vote  of  thanks  was  tendered  the 
retiring  president.  It  was  agreed  by  vote  to  accept  the 
invitation  of  the  retiring  president  to  hold  the  next  meet- 
ing at  Junction  City  in  July.  The  Golden  Belt  is  one  of  the 
three  most  prosperous  societies  in  the  State  of  Kansas. 
The  attendance  at  this  meeting  numbered  over  seventy, 
and  included  a  large  number  of  the  leading  practitioners 
and  teachers  of  medicine  in  Kansas,  and  five  from  Kan- 
sas City,  Mo.  The  meeting  was  the  most  interesting  and 
profitable  one  in  the  history  of  the  Society. 


Jackson.  Tenu.,  Dr.  W.  F.  Rochelle. 

Justin,  Texas,  R.  J.  Allison. 

Louisville,  Ky.,  Cal.  Fig  Syrup  Co. 

Lyons,  Neb.,  Dr.  M.  L.  Hildreth. 

Minneiska.,  Minn.,  Dr.  D.  F.  Brooks. 

Morgansfield,  Ky.,  Dr.  J.  W.  Muir. 

Morristown,  lnd.,  Dr.  F.  F.  Whetzel. 

Mount  Vernon,  N.  Y.,  Dr.  E.  S.  Tuley. 

Nashville,  Tenu.,  Dr.  W.  T.  Briggs. 

New  York  City,  G.  E.  Stechert,   Dr.  A.  E.  Rockey,  Dr 
Wiggin  J.  H.  Bates.  Geo.  P.  Rawell  &  Co.,  Douchy  &  Co. 

Oak  Cliff.  Texas,  Dr.  R.  G.  Williams. 

Onargo.  111..  Dr.  W.  M.  Barritt. 

Philadelphia,  University  of  Pa.  Press,  Dr 
J.  Dunglison,  Dr.  J.  H.  Packard. 


Warder,  Dr.  R. 


New  York  State  Medical  Association,  Fifth 
District  Branch. — The  seventh  annual  meeting  of  the 
Fifth  District  Branch  will  be  held  in  Wurzler's  Building, 
315  Washington  street  (over  the  Post  Office),  Brooklyn, 
on  Tuesday,  May  26,  1891. 

The  morning  session  will  be  called  to  order  at  11  A.M., 
and  will  be  devoted  to  the 

President's  Address,  "Opiates  in  the  Treatment  of 
Acute  Peritonitis." 

Business  of  the  Branch. 

Biographical  sketches  of  the  late  Dr.  James  Bathgate, 
by  John  Shrady,  M.D.;  Dr.  W.  N.  Blakeman,  by  Mr.  A. 
N.  Blakeman;  Dr.  John  P.  Garrish,  by  W.  T.  White,  M.D. 
Scientific  papers  on 

"Cathartics  in  the  Treatment  of  Acute  Peritonitis,"  by 
A.  Palmer  Dudley,  M.D. 

"The  Treatment  of  Hydrocele  by  Carbolic  Injection 
versus  the  Radical  Operation,"  by  Samuel  E.   Milliken, 
M.D. 
Adjournment  at  1  P.M.  for  lunch. 

The  afternoon  session  will  be  called  to  order  at  2  P.M., 
and  will  be  devoted  to  the  remaining  scientific  papers: 

'Scarlatinal  Diphtheritis  and  its  Treatment,"  by  E.  G. 
Rave,  M.D. 

"Practical  Results  of  the  Operation  for  Lacerated  Cer- 
vix Uteri,"  by  H.  W.  Mitchell,  M.D. 

"Objections  to  the  Ordinary  Axis-traction  Instruments, 
also  the  Advantages  of  the  Use  of  the  Anticraniotomy 
Forceps  over  Version  in  Pelvic  Deformities,  by  T.  J. 
McGillicuddy,  M.D. 

"A  Case  of  Obstinate  Neuralgia  Following  Fracture 
Relieved  by  Operation,"  by  Reginald  H.  Sayre,  M.D. 

"Acute  Prostatitis  and  Prostatic  Abscess,"  by  William 
R.  Ballou,  M.D. 

The  Nominating  Committee  will  then  make  its  report 
of  members  of  the  Executive  Committee  for  the  ensuing 
year. 

The  present  accumulation  of  interest  from  the  Perma- 
nent Fund  will  enable  the  Branch  to  furnish  lunch  to  all 
in  attendance  without  charge. 


LETTERS  RECEIVED. 


Albany,  N.  Y.,  Dr.  A.  Marsh. 

Alexandria,  S.  Dak.,  Conlin  &  Maytum. 

Alma,  Wis.,  Dr.  Geo.  Seiler. 

Ashland,  Me..  Dr.  Kinney. 

Baltimore,  M.I.,  I>r.  II,  Friedenwald. 

Boston,  Mass.,  Damrell  .S:  I'pham. 

Charlton,  Ala.,  Dr.  T.  T.  Glover. 

Chicago.  111.,  Dr.  S.  C.  Fliimmer,  Dr.  J.  M.  Dodson. 

Chilhowee,  Mo.,  Dr.  C.  T.  Sweeney. 

Cincinnati,  O.,  A.  \V.  Whelpley. 

Claytona,  O.,  Dr.  John  Kraps. 

Cll  Ireland,  0.,  Dr.  H.  W.  Quirk. 

1    ill.,  M.  Goodbrake. 
Cohoes,  N.  Y.,  Dr.  B.  Egan. 
Columbus,  0.,  Siebert  &  Lilley. 
1    plumbus,  Texas,  R.  C.  Stafford  &  Co. 
Denver,  Colo.,  Dr.  w.  (*..  Sprague. 

>il    Mich.,  Dr.  T.  A.  McC.raw,  Park,  Davis  &  Co. 
Fairfield,  la.,  Dr.  J.  V    1 
Fitchburg,  Mass.,  Dr.  A.  W.  Sidney. 
Galena   fll..  El  - 

,j, ids    Mich.,  Dr.  L.  A.  Roller. 
ik.  111.,  The  Tyndale  Eucalyptus  Co. 
Irving  Park.  111.,  Dr.  Ed.  l'vucllon. 


Official  List  of  Changes  in  the  Stations  and  Duties  of  Officers  Serving 
in  the  Medical  Department,  U.  S.  Army,  from  May  9,  jSoi,  to 
May  is,  1801. 

Lieut.  Col.  James  C.  McKee,  Surgeon,  having  been  found  incapaci- 
tated for  active  service  by  an  Army  Retiring  Board,  is,  by  direction 
of  the  Acting  Secretary  of  War,  granted  leave  of  absence  until 
further  orders  on  account  of  disability.  Par.  11,  S.  O.  106,  A.  G.  O., 
Washington,  May  9,  i8q[. 

Capt  Henry  P.  Birmingham,  Asst.  Surgeon,  the  extension  of  the 
ordinary  leave  of  absence  granted  in  S..O.  81,  A.  G.  O.,  April  10, 
1891,  from  this  office,  is  changed  to  leave  of  absence  on  account  ot 
sickness,  to  date  from  May  I,  1891.  By  direction  of  the  Acting  Sec- 
retary of  War.    Par.  4,  S.  O.  108,  A.  G.  O.,  May  12,  1891. 

Lieut.  Col.  Dallas  Bache.  Surgeon,  is  relieved  from  duty  as  a  mem- 
ber of  the  Army  Medical  Examining  Board,  New  York  City,  and 
will  return  to  his  proper  station,  Omaha,  Neb.,  and  resume  his 
duties  as  Medical  Director,  Dept.  of  the  Platte.  By  direction  of 
the  Acting  Secretary  of  War.  Par.  5,  S.  O.  108,  A.  G.  O.,  May  12, 
1891. 

Official  List  of  Changes  in  the  Medical  Corps  of  the  U.  S.  Navy,  for 

the  Two  Weeks  Ending  May  16, 1891. 
P.  A.  Surgeon  W.  H.  Rush,  detached  from  "  Saratoga  "  and  prepare 

for  sea. 
P.  A.  Surgeon  S.  W.  Atlee,  detached  from  Navy  Yard,  League  Island, 

and  to  "Saratoga." 
Asst.  Surgeon  C.  De  W.  Brownell,  ordered  to  Navy  Yard,  League  Is- 
land, Pa.  a        . 
Surgeon  T.  H.  Streets,  detached  from  Naval  Examining  Board  and 

prepare  for  sea. 
Surgeon  B.  S.   Mackie,  ordered  as  member  of  Naval  Examining 

Board. 
P.  A.  Surgeon  L.  W.  Curtis,  detached  from  Naval  Academy  and  to 

the  Practice  ship  "  Constellation." 
P.  A.  Surgeon  Philip  Leach,  orders  to  U.  S.  Practice  ship  "  Constel- 
lation "  revoked. 
Surgeon  G.  P.   Bradley,  detached  from  "  Mohican  "  and  placed  on 

waiting  orders. 
Medical  Inspector  T.  C.  Walton,  Surgeon  Geo.  A.  'Bright,  and  P.  A. 
Surgeon  J.  M.  Steele,  ordered  to  Naval  Academy  to  examine  ap- 
plicants physically  for  admission. 
Surgeon  S.  H.  Dickson,  ordered  to  the  "Constellation." 
P.  A.  Surgeon  W.  H.  Rush,  detached  from  "Saratoga,"  and  await 

duty  to  sea. 
P.  A.  Surgeon  L.  W.  Atlee.  detached  from  Navy  Yard,  League  Is- 
land, and  to  the  "Saratoga." 
Asst.  Surgeon  C.  D.  W.  Brownell.  ordered  to  Navy  Yard,  League 
Island. 

Official  List  of  Changes  of  Stations  and  Duties  of  Medical  i  >ffii  r> !  of 
the  U.  S'.  Marine-Hospital  Service,  for  the  Three  Weeks  Ending 
May  p,  i8ql. 
Surgeon  H.  W.  Austin,  detailed  as  chairman  of  Board  for  physical 
examination  of  candidates  for  appointment.  Revenue  Marine  Ser- 
vice.    May  q,  1S91. 
P.  A.  Surgeon  P.  M.  Carrington,  granted  leave  of  absence  for  twen- 
ty-three days.     May  5.  1891. 
P.  "A.  Surgeon  W.  D.  Bratton,  when  relieved  at  Portland,  Ore,  to 

proceed  to  Chicago  for  dutv.     May  9,  1891. 
P.  A.  Surgeon  G.  M.  Magruder.  detailed  as  recorder  of  Board  for 
physical  examination  of  candidates  for  appointment,  Revenue 
Marine  Service.    May  9.  1891. 
Asst.  Surgeon  A.  W.  Condiet,  relieved  from  dutyat  Chicago,  III.;  or- 
dered to  Portland,  Ore.     May  q.  1891. 
Asst.  Surgeon  H.  D.  Geddings,  to  proceed  to  New  York  on  special 

dutv.  May  9,  1891. 
Asst.  Surgeon  B.  W.  Brown,  to  report  to  commanding  officer,  Reve- 
nue Str.  "Rush,"  on  the  14th  inst.  May  7,  1891. 
Surgeon  H.  W.  Austin,  detailed  as  member  of  Board  of  Examiners. 
Marine-Hospital  Service,  April  21,  1891.  Detailed  as  chairman  of 
Board  for  physical  examination  of  officers  and  candidates,  Reve- 
nue  Marine  Service,  April  29,  1891. 

i);  ..hi    1..I111  Godfrey,  detail  as  member  of  Board  of  Examiners 

April  21, 1891. 

I    lirfax  Irwin,  detailed  as  recorder  of  Board  for  physical 

examination  of  officers  and  candidates,  Revenue  Marine  Service. 

April  29,  1891 , 

1'.  A.  Surgeon   IV    M.  Carrington,  to  proceed  to  Fernandina  and 

Jacksonville,  Fla,  us  inspector,     Mav  1 
Asst,  Surgeon  w  G.  Stimpsou,  when  relieved,  to  proceed  to  Savan- 
nah,  Ga.,  for  temporary  duty.     May  2,  1891. 
fl  ..in    I'i  ,  mi  .us  l.ist; 
Asst.  Surgeon   II.  W.   Brown,  detailed  as  medical    officer,  Revenue 
Str.    'Rush,"  duritg  summer  cruise.     April  14,  1S91. 


The  Journal  of  the 


American  Medical  Association 


Vol.  XVI. 


CHICAGO,  MAY  30,    1S91. 


No.  22. 


ORIGINAL  ARTICLES. 


MEDICAL   PROGRESS. 


Read  b\   Till,-  in  the  Section  of  Medicine  and  Physiology,  at  the  Forty- 
Second  Annual  Meeting  of  the  American  Medical  Association, 
held  at  Washington,  DC.  .May,  1891. 

BY  C.  R.  EARLEY,  M.D., 

OF    RIDGWAY.    PA. 

My  time  is  so  limited  that  I  can  only  make  a 
very  slight  review  of  the  practice  of  medicine, 
showing  the  progress  made  during  so  many  years. 

The  present  time  can  boast  of  great  progress  ; 
yet  we  have  much  to  regret  as  to  the  failures  to 
come  up  to  the  standard  of  olden  times  in  many 
respects.     We  should  look  well  to  this. 

Medicine  has  its  history,  its  philosophy,  its 
politics,  its  literature,  of  which  the  world  at  large 
knows  nothing.  It  has  its  arts  and  occupations; 
it  has  its  organizations  and  institutions,  and  dis- 
sentions,  not  always  amenable  to  logic  or  to  the 
learning  of  the  schools.  In  ethics,  traditions 
and  superstitions  it  dates  anterior  to  the  Church. 
Being  in  use  before  the  civil  law,  is  it  any  wonder 
that  the  members  of  our  profession,  drawn  to- 
gether by  such  ties,  should  unite  as  a  brother- 
hood ?  Such  has  ever  been  their  course. 
The  Druid  of  early  Gaul  and  Britain,  the 
Asclepiades  of  Greece,  the  Priests  of  Egypt, 
the  Lamas  of  Central  Asia,  the  Fraternities  of 
the  Middle  Ages,  and  up  to  this  time  medical 
societies  and  colleges  in  our  own  and  other 
countries  devoted  to  the  healing  art,  are  the  proof 
of  this.  Wherever  freedom  has  existed,  or 
tyranny  would  permit,  organization  and  develop- 
ment have  been  the  rule  of  our  profession. 

With  these  facts  before  us  our  duty  is  plain. 
Continue  this  good  work  and  improve  every  day, 
and  show  ours  to  be  a  progressive  profession. 
Let  us  look  back  for  ages  and  review  its  history 
up  to  our  time,  that  we  may  the  better  under- 
stand, and  may  know  how  far  we  have  advanced, 
and  to  what  we  owe  our  progress.  The  labor 
before  us  is,  how  we  can  best  elevate  the  profes- 
sion for  those  who  are  to  follow. 

Among  the  early  Egyptians  were  a  large  and 
influential  body  of  priests,  who  received  about 
one  third  of  the  income  of  the  nation.  There 
were  several  orders  of  them.  A  majority  of  them 
were  skilled  in  medicine,  and,  as  many  supposed, 


practiced  gratuitously  among  the  people.  (See 
Schultze,  page  24,  from  Diadorus. 

"  Each  physician  applies  himself  to  one  disease 
and  not  more."  Every  place  was  full  of  physi- 
cians ;  some  for  the  eyes,  others  for  the  head, 
some  for  the  teeth  and  others  for  internal  diseases 
— what  we  call  specialists.  The  embalmers 
were  also  of  this  class,  and  their  skill  and  stand- 
ing are  generally  respected  to  this  day.  The 
skill  of  the  Egyptian  priests  or  doctors  made 
them  very  popular,  not  only  among  the  Egyp- 
tians, but  the  rulers  of  the  surrounding  nations 
called  for  them.  Cyrus  sent  for  the  ablest  ocu- 
list of  Egypt.  We  learn  from  Aristotle  that  the 
practice  of  the  Egyptian  priests  was  in  conformity 
with  a  law  prescribed,  yet  the  physicians  were 
allowed  to  alter  the  mode  of  cure,  which  the  law 
prescribed  to  them,  after  the  fourth  day,  but  if 
they  did  sooner  the}-  acted  at  their  own  peril. 

The  youth  who  were  destined  for  the  profession, 
if  not  the  sons  of  the  initiated,  were  not  allowed 
to  begin  until  after  the  completion  of  their 
preparatory  education,  from  their  seventeenth  to 
their  twentieth  year.  But  the  sons  of  the  phy- 
sicians began  earlier,  and  with  both  the  course  of 
training  continued  to  about  their  twenty-fifth 
year.  The  admission  or  initiation  of  those  who 
had  passed  the  preliminary  examination  con- 
sisted of  the  three  grades. 

The  ceremony  of  the  first  grade  was  called 
illumination,  or  the  study  of  theories,  logic  and 
philosophical  or  abstract  principles  and  rites. 
The  second  grade  was  styled  inspection,  which 
included  the  looking  on  or  practical  studies,  or 
the  examination  of  diseases  in  the  houses  and  at 
the  bedside.  The  third  grade,  which  was  the 
end  of  their  study,  and  the  design  of  the  other 
two,  was  called  the  binding  of  the  head,  or 
coronation.  The  binding  of  the  head  was  equiva- 
lent to  what  we  call  graduation,  and  never  took 
place  before  the  completion  of  the  fifth  year.  It 
will  be  remembered  that  not  all  presenting  them- 
selves for  admission  as  students  were  accepted, 
as  a  thorough  examination  was  made  as  to  their 
preliminary  qualifications  and  education,  their 
general  character,  mcral  and  intellectual.  They 
must  be  perfectly  free  from  all  physical  deform- 
ities, and  have  a  clear  and  good  voice  and  no  im- 
pediment of  speech. 


758 


MEDICAL  PROGRESS. 


[May  30, 


We  are  informed  by  Hippocrates,  in  reference 
to  his  profession,  that  "  Things  which  are  sacred 
are  to  be  imparted  only  to  sacred  persons,"  and 
that  "  It  is  unlawful  to  impart  them  to  the  pro- 
fane until  after  their  initiation  into  the  mysteries 
of  the  science."  With  reference  to  purification, 
or  the  training  which  should  precede  illumina- 
tion, he  says:  "Whoever  is  to  acquire  a  com- 
petent knowledge  of  medicine  ought  to  possess 
the  following  advantages  :  A  natural  disposition, 
a  favorable  position  for  study,  early  tuition,  love 
of  labor  and  leisure."  Writing  to  his  son,  the 
author  of  the  Hippocratic  Letters  says  :  "  Give 
due  attention,  my  son,  to  geometry  and  arith- 
metic, for  such  studies  will  not  onh'  render  your 
life  illustrious  and  useful  to  your  fellow  beings, 
but  your  mind  more  acute  and  perspicacious  in 
arriving  at  fruitful  results  in  everything  pertain- 
ing to  your  art." 

The  candidate  having  passed  the  first  ordeal  of 
preparation,  and  commencing  the  ceremonies  of 
illumination,  was  obliged  to  subscribe  to  the 
oath,  which  was  a  formula  analogous  to  that 
which  was  enjoined  among  the  Pythagoreans, 
and  was  in  the  following  words  :  "I  swear  by 
Apollo,  the  Physician,  by  -Esculapius,  by 
Hygeia,  by  Panacea  and  all  the  gods  and  god- 
desses, that  according  to  my  ability  and  judg- 
ment, I  will  keep  this,  my  oath  and  stipulation, 
to  reckon  him  who  teaches  me  this  art  equallv 
dear  to  me  as  my  parents,  to  share  my  substance 
with  him  and  to  relieve  his  necessities  if  re 
quired  ;  to  look  upon  his  offspring  on  the  same 
footing  as  my  own  brothers,  and  to  teach  them 
this  art,  if  they  shall  wish  to  learn  it,  without 
fee  or  stipulation,  and  by  precept,  lecture  and 
every  other  mode  of  instruction.  I  will  impart 
a  knowledge  of  this  to  my  own  sons,  to  those  of 
my  teachers  and  to  my  disciples,  bound  by  stipu- 
lation and  oath  according  to  the  law  of  medicine, 
but  to  none  others.  I  will  follow  that  system  of 
regimen,  which  according  to  my  ability  and 
judgment,  I  consider  for  the  benefit  of  my  pa- 
tients, and  abstain  from  whatever  is  deleterious 
and  mischievous.  I  will  give  no  deadly  medi- 
cine to  any  one,  if  asked,  nor  suggest  any  such 
counsel ;  and  in  like  manner  I  will  not  give  a 
woman  a  pessary  to  produce  an  abortion.  With 
purity  and  holiness  I  will  pass  my  life  and  prac- 
tice my  art.  I  will  not  cut  persons  laboring 
under  a  stone,  but  will  leave  this  to  be  done  by 
men  who  are  practitioners  of  this  work.  In 
whatsoever  house  I  enter  I  will  go  into  them  fir 
the  benefit  of  the  sick,  and  will  abstain  from  any 
seduction  of  females  and  males,  of  freemen  and 
slaves.  Whatever  in  connection  with  it  I  see  or 
hear  I  will  not  divulge,  as  reckoning  that  all 
such  should  lie  kept  a  secret.  While  I  continue 
to  keeji  this  oath  inviolate,  may  it  be  granted  to 
me  to  enjoy  life  and  the  practice  of  my  art,  re- 
spected by  all  men  and  at  all  times  ;    but  should 


I  trespass  and  violate  this  oath,  may  the  reverse 
be  my  lot."  See  Adam's  Hippocrates,  Vol.  II, 
page  779. 

The  course  of  education  among  the  Asclepiades 
was  in  conformity  with  the  national  habits. 
After  subscribing  to  this  oath  the  pupil  was  al- 
lowed to  proceed  to  the  business  of  illumiuation, 
which  consisted  of  the  committing  to  memory 
certain  traditions  and  orecepts,  in  listening  to 
his  instructor,  in  the  description  and  manage- 
ment of  diseases  within  the  temple  or  at  the  bed- 
side of  the  sick,  and  combining  with  the  knowl- 
edge thus  obtained  a  general  acquaintance  with 
the  rules  of  health.  Next  in  order  came  the 
business  of  inspection.  It  immediately  preceded 
coronation;  this  had  relation  to  practical  subjects, 
probably  the  treatment  of  diseases  under  the  im- 
mediate supervision  of  the  instructor.  The 
ceremony  of  coronation  took  place  at  the  com- 
pletion of  the  term  of  study,  as  the  ceremony  of 
graduation  takes  place  in  our  colleges  at  the 
present  time. 

In  those  days  medicine  was  principally  taught 
orally  or  by  tradition  and  example,  therefore  the 
requirements  could  not  have  been  very  extensive. 
This  main  study  of  the  treatment  of  acute  dis- 
eases was  the  regulating  of  the  diet,  etc.  Epi- 
demic diseases  were  looked  upon  as  of  divine  dis- 
pensation, with  which  they  dare  not  interfere. 
A  knowledge  of  the  general  rules  of  health  and 
the  influence  of  diet,  exercise,  climate  and  lo- 
cality attracted  much  of  their  attention.  Why 
should  not  the  same  attention  be  paid  to  the  sub- 
ject at  this  day  ? 

In  the  management  of  injuries  and  external 
diseases  they  were  but  little  behind  those  of  the 
present  day.  Their  remedial  agents  were  the. 
laucet,  active  cathartics,  emetics  and  diuretics, 
cataplasms,  ointments,  escharotics  and  mechan- 
ical appliances.  They  had  but  little  knowledge 
of  anatomy  and  physiology  ;  they  did  not  inter- 
fere to  an>-  extent  with  chronic  diseases. 

I'p  to  the  days  of  Herod  icus,  one  of  the  teachers 
of  Hippocrates,  he  recommended  in  chronic  dis- 
eases, exercise  and  regulated  diet.  This  inno- 
vation was  very  unpopular.  Plato  upbraided 
him  for  his  course,  and  declared  that  no  attempt 
should  be  made  to  cure  a  thoroughly  diseased 
system,  and  thus  continue  a  long  and  miserable 
life  to  the  man  himself,  as  well  as  to  his  de- 
scendants. Asclepiusdid  not  think  a  man  ought 
to  be  saved  who  could  not  live  in  the  ordinary 
course,  as  he  would  be  of  no  service  to  himself  or 
the  State. 

Hippocrates  can  properly  be  called  the  father 
of  the  medical  profession.  He  was  born  460 
years  before  the  birth  of  Christ  :  was  a  few  years 
older  than  Plato  and  younger  than  Socrates. 
eived  his  professional  education  under  his 
father,  Heraclides,  at  Asclepion  of  Cos,  in  his 
youth,  at  Athens  and  other  places.     He  had  the 


r89i.J 


MEDICAL  PROGRESS. 


759 


instruction  of  the  best   teachers  in  science  and 
philosophy. 

Hippocrates  in  his  book,  "Air,  Water  and 
Places,"  inquires  into  the  effect  of  particular  ex- 
posures of  the  seasons  and  their  vicissitudes  ;  the 
influence  of  winds  and  properties  of  water.  He 
refers  to  diseases  prevalent  in  different  places  and 
during  different  times  of  the  year.  He  calls  at- 
tention to  diet  and  exercise,  showing  how 
excess  or  deficiency  in  either  may  prove  the 
cause  of  disease.  If  practitioners  of  this  day 
would  only  follow  this  noble  example  and  in  all 
cases  look  well  to  the  surroundings,  location, 
diet,  water  used,  drainage,  cleanliness,  as  well  as 
habits  of  the  patients,   it  would  do   great  good. 

From  the  time  of  Hippocrates  and  immediate 
followers  to  the  present  time,  a  system  of  vacil- 
lations and  changes  in  the  theories  and  practice 
of  medicine  and  surgery  has  been  going  on. 
Every  day  we  see  in  print  some  new  invention  or 
theory  suggested  by  members  of  the  profession 
upon  the  diseases  of  the  day.  One  cures  all  dis- 
«ases  by  cathartics  and  emetics,  claiming  they 
are  generated  or  produced  by  accumulations  in 
the  stomach  and  bowels  ;  others  that  all  diseases 
can  be  cured  by  heat,  as  one  specialist  of  the 
kind  advocated,  giving  as  his  reason,  cold  is 
death  and  heat  is  life,  therefore  as  long  as  we 
can  keep  up  the  heat  in  the  body  the  patient  will 
live  and  must  rally  under  its  influences.  Others, 
from  the  days  of  old  to  the  present  time,  spring 
up  to  cure  all  diseases  by  bleeding,  frequent  and 
profuse  depletion,  and  tints  relieve  congestion  of 
different  parts  of  the  body  from  excess  of  blood. 
Aretaeus,  who  had  written  eight  books,  was  an 
advocate  of  the  free  use  of  hellebore  as  the  great 
remedy  for  nearly  all  diseases.  He  also  advo 
cated  the  system  of  drastic  medicines,  and  was 
among  the  first  to  recommend  cantharides  for 
blistering.  Sydenham,  born  in  1624,  differed 
greatly  from  his  predecessors  in  their  modes  of 
treatment.  He  published  his  work  entitled 
"  Methodus  Curandi  Febris,"  in  1666,  and  it  was 
he  that  first  directed  cool  air  and  other  anti- 
phlogistics  in  the  treatment  of  small-pox  and 
eruptive  fevers. 

The  Brunonian  system  was  based  on  the  views 
of  Dr.  John  Brown,  of  Edinburgh.  He  arranged 
diseases  under  two  divisions,  sthenic  and  asthenic. 
He  maintained  that  all  agents  operate  on  the 
body  as  stimuli,  so  we  had  only  to  increase  or 
diminish  the  force  of  these  according  to  circum- 
stances. At  the  head  of  stimulants  he  places 
wine,  brandy  and  opium,  in  the  recommendation 
of  which  he  is  very  liberal,  and  especially  be- 
trays his  partiality  to  them  by  assertions  con- 
trary to  universal  experience.  He  found  them  in 
his  own  person  the  best  preventative  of  gout,  and 
is  said  to  have  prepared  himself  for  his  lectures 
by  large  doses  of  laudanum  in  whisky,  and  thus 
aroused  himself  to  a  degree  of  enthusiasm  bor- 


dering on  frenzy.  The  novelty  and  im] 
j  simplicity  of  his  doctrines  procured  him  at  first 
I  quite  a  numerous  class,  but  being  irregular  in 
his  attendance,  and  his  habits  of  intemperance 
increasing,  his  class  fell  <AY  by  degrees,  and  he 
was  at  I  inbarrassed  as  to  b 

I  leave  Edinburgh  in  1786.  He  then  setl 
London,  but  met  with  little  success,  and  in  about 
two  years  after  died.  His  opinions  found  many 
supporters  in  this  country  as  well  as  in  others, 
but  they  appear  to  have  nearly  fallen  into  de- 
served oblivion. 

Baerhaave's  system  was  founded  on  the  teach- 
ing of  Dr.  Herman  Boerhaave,  who  claimed  to 
have  selected  his  mode  and  manner  of  treating 
diseases  from  all  systems  and  theories  of  those 
that  preceded  him,  consequently  he  was  called  or 
styled  an  Eclectic. 

As  we  have  seen  heretofore  in  this  report,  many 
of  the  old  practitioners  depended  greatly  upon 
depletory  measures,  particularly  blood-letting. 
In  most  of  the  fevers  of  that  day,  as  we  are  told 
by  Rush  and  others,  the  sheet-anchor  in  the 
treatment  was  considered  to  be  bleeding  and  dras- 
tic purgatives.  This  was  kept  up  by  one  class 
and  denounced  by  another,  we  may  say,  up  to 
within  the  last  forty  or  fifty  years,  since  which 
time  we  have  made  great  progress  in  omiting  the 
use  of  the  lancet.  In  scarlet  fever  bleeding  was 
the  practice  of  many  of  our  most  renowned  phy- 
sicians. 

My  own  recollection  of  scarlet  fever  dates  back 
to  when  I  was  a  boy  of  seven  years.  Dr.  Dana, 
a  physician  of  high  standing  of  Friendship,  X. 
Y.,  and  my  father's  family  physician  during  a 
scourge  of  that  disease,  used  the  lancet  freely  in 
all  cases,  except  two  bo3-s.  The  reason  they 
were  not  bled  the  doctor  and  mother,  in  each  in- 
stance, were  unable  to  hold  the  two  bad  boys  as 
they  kicked,  screeched  and  hollowed,  arousing 
the  neighbors,  when  the  doctor  said:  "We  will 
have  to  give  it  up;  they  will  die  but  I  cannot 
help  it,  we  have  done  all  we  can."  They  recov- 
ered without  any  sequel  while  the  other  cases 
died;  and  here  is  one  of  the  boys. 

My  first  year's  practice  of  medicine,  in  1845, 
was  in  that  village,  and  the  old  doctor  referred  to 
had  retired  from  practice  and  spent  much  of  his 
time  in  our  office,  and  often  repeated  and  laughed 
about  his  experience  in  the  cases  alluded  to,  stat- 
ing that  from  that  time  he  never  used  the  lancet 
in  scarlet  fever. 

In  my  first  practice  and  experience  it  was  con- 
sidered malpractice  to  omit  bleeding  in  pneu- 
monia, pleurisy  and  diseases  of  like  character.  I 
shall  never  forget  the  last  case  I  bled  and  the 
first  I  did  not  bleed  in  pneumonia.  April  12. 
1846,  I  was  called  to  treat  a  young  man  with 
pneumonia,  in  Ridgway,  Pa.,  and  as  I  had  been 
educated  a  physician  in  the  state  of  Xew  York 
and  my  first  practice  had  been  there  also,  where 


760 


MEDICAL  PROGRESS. 


[May  30, 


the  thumb  lancet  was  always  used,  I  took  it  to 
bleed  the  patient,  but  all  the  friends  refused  to 
have  it  used,  calling  it  a  "butcher  knife,"  and, 
unlike  my  usual  decided  position,  I  stepped  into 
a  store  and  bought  a  spring  lancet, — which  was 
not  considered  a  surgical  instrument — and  snap- 
ped it  several  times  without  effect  on  account  of 
fear,  as  I  could  not  guide  it,  but  succeeded  at  last 
in  bleeding  the  patient  About  an  hour  after 
this  I  was  called  to  see  another  young  man  with 
the  same  disease,  which  was  prevalent  at  this 
time — as  the  raftmen  had  exposed  themselves  to 
the  inclemency  of  the  weather  going  down  the 
river.  I  drew  my  lancet  and  met  with  the  same 
positive  protest  against  the  use  of  it;  so  I  took 
the  spring  lancet  the  second  time  and  let  it  snap. 
The  blade  broke  and  flew  across  the  room.  I  went 
to  the  door  and  threw  the  balance  of  it  as  far  as  I 
could,  and  said  if  he  could  not  be  bled  with  my 
instrument  he  might  go  without  and  die,  as  I  was 
not  responsible. 

Under  a  treatment  of  small  doses  of  ipecac  and 
the  solution  of  antimonium  tararizatum,  and  free 
bathing  with  salt  water,  with  thorough  friction 
of  the  body,  three  times  a  day,  in  two  and  one- 
half  days  my  patient  expectorated  easily  and 
freely,  the  surface  was  generally  moist,  and  in 
five  days  was  about  his  room,  and  in  a  few  days 
well;  while  the  one  whom  I  bled,  equall}7  as 
stout  and  robust  a  young  woodsman,  in  six  weeks 
began  to  walk  out  a  little  on  pleasant  days. 
From  that  time  to  the  present  I  have  never  re- 
sorted to  bleeding  in  pneumonia,  nor  in  any  case 
save  apoplexy  or  puerperal  convulsions,  or  where 
immediate  danger  required  it. 

In  1793  94  Dr.  Benjamin  Rush,  Professor  of 
the  Institutes  and  of  Clinical  Medicine  in  the  Uni- 
versity of  Pennsylvania,  took  bold  grounds 
against  yellow  fever  being  caused  by  contagion. 
He  says:  '"  I  expected  the  fevers  of  the  summer 
and  autumn  would  be  of  a  violent  and  malignant 
nature.  I  was  the  more  disposed  to  entertain 
this  opinion  from  observing  the  stagnating  filth 
of  the  gutters  of  our  city;  for  the  citizens  of  Phil- 
adelphia, having  an  interest  in  rejecting  the 
proofs  of  the  generation  of  the  epidemic  of  1793 
in  their  city,  had  neglected  to  introduce  the  reg- 
ulations that  were  necessary  to  prevent  the  pro- 
duction of  a  similar  fever  from  domestic  putrefac 
tion. 

"  From  none  of  them  had  I  observed  the  fever 
to  be  propagated  by  contagion,  and  therefore  I 
took  no  steps  to  alarm  my  fellow-citizens  with 
the  unwelcome  news  of  its  being  in  town. 

"On  the  25th  of  the  month,  1794,  two  mem- 
bers of  a  committee  appointed  by  the  Govern- 
ment of  the  State  for  taking  care  of  the  health  of 
the  city,  called  upon  me  to  know  whether  the 
yellow  fever  was  in  town.  I  told  them  it  was, 
and  mentioned  some  of  the  cases  that  had  come 
under  my  notice;  but  informed  them  at  the  same 


time  that  I  had  seen  no  case  where  it  had  been 
contagious. 

"  As  I  considered  the  filth  of  the  gutters  and 
the  stagnating  water  in  the  neighbcrhood  of  the 
city  to  be  the  remote  causes  of  this  fever,  I  ad- 
vised the  committee  to  have  them  both  removed, 
and  thereby  to  prevent  the  spreading  of  the  dis- 
ease. ' ' 

Dr.  John  Brown,  in  his  writings  on  the  subject 
of  yellow  fever  in  America,  says:  "It  appeared 
six  different  times,  and  all  about  the  same  time  in 
the  year,  about  the  first  to  the  middle  of  August, 
and  declined  or  ceased  about  the  middle  of  Octo- 
ber. 

"In  the  years  1732,  1739,  1745  and  1748111 
Charleston;  in  1791  in  New  York,  and  in  1793  in 
Philadelphia,  and  in  every  locality  and  season  it 
has  been  proved  beyond  a  doubt  that  the  disease 
was  caused  by  the  influence  of  the  weather,  or 
the  vicissitudes  or  surroundings  of  that  particu- 
lar locality,  and  not  from  contagion.  Let  a  person 
in  the  height  of  a  pestilential  disease  be  removed 
from  the  atmosphere  which  occasioned  it  to  one 
more  pure,  he  will  communicate  the  infection  to 
no  one."  He  then  quotes  Dr.  Rush  in  speaking 
of  yellow  fever  in  Philadelphia,  when  Rush 
says:  "  This  fever  did  not  spread  in  the  country, 
even  carried  there  by  persons  who  were  infected 
and  afterwards  died  with  it."  This  position 
taken  by  Drs.  Rush,  Brown  and  others  of  olden 
date  was  fully  sustained  during  the  last  scourge 
of  yellow  fever  in  the  southern  cities.  Refugees 
from  the  south  were  received  in  man)'  cities  and 
towns  of  the  north,  middle  and  western  States, 
but  were  not  allowed  to  bring  with  them  any  of 
their  household  goods  or  clothing.  - 

The  following  preamble  and  resolutions  were 
unanimously  passed  by  the  Mississippi  Valley 
Medical  Association,  held  in  St.  Louis  in  Sep- 
tember, 1888: 

"WHEREAS,  The  existing  deplorable  conditiou  of  a 
considerable  portion  of  our  southern  territory,  induced 
by  the  spread  of  epidemic  disease  and  the  alarm  thereby 
caused;  believing  it  to  be  the  duty  of  this  Association,  in 
view  of  the  pressing  exigency,  to  take  every  step  possi- 
ble to  allay  panic  and  reassure  alarmed  communities  and 
states;  therefore,  be  it 

Resolved,  That  a  committee  of  not  less  than  five  persons 
be  appointed  by  the  president  to  consider  the  present  sit- 
uation and  report  to  this  Association  at  a  subsequent  ses- 
sion what  action  in  their  judgment  should  betaken  to  se- 
cure the  desired  end." 

The  committee  on  yellow  fever  presented  the  following 
report,  which  was  unanimously  agreed  to  : 

Resolved,  That  it  is  the  sense  of  this  meeting  that  vel- 
low  fever  is  not  contagious  in  the  ordinary  sense  of  the 
term;  that  it  cannot  be  communicated  from  the  sick  to 
the  well. 

"  That  the  mildness  of  the  present  yellow  fever  inva- 
sion ;uid  lateness  of  the  season,  warrant  us  in  stronglv 
deprecating  the  fear  now  existing  in  many  southern  com- 
munities, the  present  rate  of  mortality  being  not  greater 
than  that  which  ordinarily  obtains  in  typhoid  fever. 

"  That  the  self  imposed  quarantine  regulations  now  in 
force  in  the  States  north  of  the  infected  districts  are  not 


IS9I.] 


MEDICAL  PROGRESS. 


only  absunl,  but   inhuman  anil  unworthy  of  the  age  in         In  May,    i>>~6,  I    was  called  to    B ,  by     Dr. 

"'"'ThaT.luarautine  regulations,  to  be  effective,  should  **•'  to  consult  and  advise  with  him  in  his  course 

apply  to  baggage,  clothing  and  effects,  rather  than  to  the  ot    treatment    of   diphtheria.      On    my    arrival   I 

person  of  the  individual.  *"  found    that   eighteen   had  died  and   twenty-two 

"That  when  such  effects  come  from  infected  districts  were  sick.      The  treatment  in   use  was    mereurv 

Sdfrom  publ^S1 '"'  **  '"'"'  th°  °""er  rei,n-  "tenudly  and  the  local  use  of  tincture  of  iron  to 

"That  cities  and  towns  to  the  north  of  such  districts  the  membrane.   This  treatment  was   at   once  dis- 

and  upon  lines  of  travel  may  safely  provide  hospitals  for  continued  and  my  usual  constitutional  treatment 

the  reception  and  care  of  the  sick!    George  Homan.  M.  adopted— chlorate  of  potassa,  chloride  of  sodium, 

%£.  MouDn;  t^S^SSs^S^SStSi hlcarb-  ,of  so^-  rmne' iron  and  stlmuli- as  the 

A.    Collamer,    M.D.,   Ohio;  George    X.  Kreider,    M.D.,    ease  indicated;  also  free  bathing,  etc. 

Illinois:  A.  I'.  Waterfield,  M.D.,  Tennessee,  and  A.  \V.        The  great  mystery  to  be  solved  by  the  doctor 

Williams,  M.D.,  Hot  Springs.  Arkansas.  Committee."        and  citizens  was  where  the  contagion  came  from, 

Being  a  member  of  that  Association,  I  was  as  there  was  no  other  case  of  diphtheria  in  the 
present  and  greatly  interested  in  the  candid,  fear-  I  surrounding  country,  and  no  one  had  been  away- 
less  and  able  discussion  that  followed  those  reso-  j  or  any  stranger  known  to  have  visited  the  place 
lutions.  Many  of  the  members  were  well  posted  during  the  spring.  After  a  preliminary  inspec- 
in  the  disease,  having  had  practical  experience;  tion  of  the  location,  to  settle  all  questions.  I  call- 
while  the  secretary  of  the  Illinois  State  Board  of  ed  them  to  a  mill-race  leading  from  a  dam.  situ- 
Health  was  present,  being  on  his  way  home  from  ated  above  the  town,  to  a  saw  and  flouring  mill 
a  full  investigation  of  yellow  fever  in  the  south,  at  the  river  below.  This  dam  was  used  to  hold 
and  delivered  a  very  able  and  clear  address  be-  i  water  for  the  mills,  and  logs  were  floated  down 
fore  the  Association  on  the  subject.  the  stream  and  held  in  the  dam  to  be  passed  out 

.On  my  way  home  from  St.  Louis,  September  in  the  race  as  required.  The  mills  required  re- 
2S,  I  visited  Louisville,  which  city  had  opened  I  pairs  and  the  water  had  been  shut  off  from  the 
hospitals  for  the  reception  of  yellow  fever  patients  ■  race,  which  was  close  by  and  parallel  with  Main 
brought  from  the  infected  places  south.  Those  street,  in  the  bed  of  which  were  found  rotten 
sick  were  placed  in  the  hospital  without  any  wood,  dead  animals,  in  fact  all  kinds  of  filth  and 
household  goods,  or  clothing  worn  by  them  at ;  vegetable  matter  in  an  advanced  stage  of  decom- 
home,  and  no  person,  nurse  or  physician  attend-  position.  The  air  was  filled  with  noxious  odors, 
ing  the  cases  had  the  disease  in  any  of  its  forms,  j  which  were  almost  intolerable.  Their  attention 
Of  course  I  visited  them  while  there  to  post  my-  being  called  to  this  condition  of  things,  all  ques- 
self  in  the  disease.  tion  as  to  the  cause  of  contagion  was  considered 

We  have  a  great  craze  on  other  diseases  which  j  settled.  I  at  once  directed  that  this  mass  of  filth 
are  now  pronounced  contagious.  Phthisis  pul-  be  raked  up  and  burned,  the  bed  of  the  race  strewn 
monalis,  pneumonia,  and  many  other  diseases  of!  with  fresh  lime,  fences,  outbuildings  and  cellars 
like  character  are  pronounced  contagious,  yet  all  whitewashed,  and  quicklime  placed  in  the  rooms 
practitioners  of  experience  must  agree  that  they  I  of  each  house  and  allowed  to  air  slack.  The  re- 
are  not  propagated  by  contagion.  |  suit:  One  of  the  twenty-two  patients  then  sick 

For  the  last  thirty  years  many  of  our  most  died,  one  other  case  developed  about  this  time, 
earnest  medical  gentlemen  insist  that  diphtheria  ,  who,  with  all  the  others,  recovered.    Of  a  total  ot 


is  a  contagious  disease,  and  in  place  of  educating 
our  citizens  to  look  well  to  cleanliness  of  the  sur- 
roundings and  purity  of  the  air  breathed,  the  wa- 


fortyone  cases  nineteen  died,  and  twenty- two  re- 
covered. 

We  can  truly  say   the  same  of  cerebro-spinal 


ter  for  drinking,  cooking,  etc.,  as  well  as  to  the  I  meningitis.  Are  we  progressing  in  thus  ignor- 
purity  and  healthy  condition  of  food  used,  they ;  ing  science  and  even'  principle  of  hygiene? 
are  taught  to  shut  themselves  up  in  their  damp.  Many  other  diseases  of  this  day  are  treated  in 
musty  houses  and  not  allowed  either  good  air  or  i  the  same  way,  by  depletion  and  local  means,  as  if 
sunlight,  and  no  one  allowed  to  go  into  their ;  they  were  merely  a  local  disease,  and  calomel, 
dwellings,  to  give  aid  and  assistance  to  the  sick  mercury  and  opiates  used  when  tonics,  stimuli 
and  their  families,  and  also  public  funerals  pro-  and  constitutional  means  should  be  employed 
hibited.  Why  all  this?  Why  not,  on  being  call- 1  during  the  entire  course.  Let  us  think,  use  rea- 
ed  to  a  house   where    diphtheria  exists,    at  the  I  son  and  act  at  once. 

very  first  investigate  and  examine  the  house  [  Among  the  medicines  resorted  to  in  many 
from  garret  to  cellar  and  all  the  surroundings  of  cases  by  the  old  practitioners  was  the  free  and 
the  house,  supply  of  water,  outhouses,  drainage,  '  excessive  use  of  opium.  It  was  freely  given  in. 
etc.?  We  all  know  that  this  disease  i :  a  filth  dis- 1  nearly  all  cases,  especially  inflammatory  diseases, 
ease,  caused  by  bad  air,  water  and  food,  one  or '  and  was  recommended  strongly  in  the  treatment 
all.  and  that  it  is  a  constitutional  or  blood  (poi- ;  of  yellow  and  other  fevers.  In  the  old  Brnnon- 
son)  disease.  I  will  refer  to  the  condition  of  one  ian  system  it  was  carried  to  a  fearful  extent.  Dr. 
small  town  of  about  200  inhabitants.  j  Parr  says  the  effect  of  opium  on  the  living  body 


762  MEDICAL  PROGRESS.  [May  30, 


has  been  represented  in  very  opposite  contradic- 
tory terms.  It  has  been  keenly  disputed  whether 
it  was  a  stimulant  or  a  sedative.     If  by  stimulant 


the  bone  thoroughly,  carefully  and  freely,  using 
washes  and  disinfectants,  it  soon  healed  from  the 
bottom,  and  up  to  this  day  he  has  never  had  any 


is  meant  a  medicine  which,  by  its  action   on  the  '  pain  or  further  trouble  with  the  knee  joint.     I 


stomach,  will  increase  the  heat  of  the  body  and 
quickness  of  the  pulse,  it  by  no  means  deserves 
the  title.     If  given  to  a  healthy  person  the  pulse 


knew  a  case  about  three  years  ago  of  a  young 
man  who  had  cut  his  leg  while  working  in  the 
woods.     This  cut  was  filled  with  morphia  before 


and  heat  are  both  lowered,  and  if  the  dose  is  in- 1  dressing  it,  which  of  course  produced  stupor,  and 
creased  nausea,  faintness  and  headache  follow,  he  remained  unconscious,  constantly  rolling  his 
when  the  influence  of  the  medicine  is  at  an  end,  [  head  and  moaning  until  he  died. 
This  brings  it  within  the  class  of  narcotics.  When  The  effects  and  results  of  the  abuse  of  opium 
the  change  in  the  ideas  of  the  circulating  fluids  !  could  be  multiplied  from  my  own  experience  to 
was  abandoned  it  was  doubted  whether  it  acted  j  pages,  but  will  refer  you  to  what  Pomet  says:   "Its 


upon  the  stomach  or  heart,  and  the  second  Mon- 
roe has  published  some  experiences  which  seem 
to  say  that  its  chief  effect  is  on  the  latter  (heart) . 
This,  however,  only  proved  that  when  opium  is  in- 
jected into  the  sanguiferous  system  it  produces  no 
effect  at  all  until  it  reaches  the  heart. 

If  fevers  consist  in  debility  and  irregular  ac- 
tion, and  opium  is  a  sedative,  producing  also  ir- 
regular action,  it  will  appear  that  no  medicine  is 
so  unsuitable  to  the  disease.  This  was  the  opin- 
ion of  Dr.  Parr. 

All  authorities  agree  that  opium  acts  as  a  seda- 
tive or  narcotic.     It  has  been  given  to  allay  pain 


effects  are  always  narcotic,  whether  used  exter- 
nally or  given  internally;  given  in  clysters  it  op- 
erates quicker  than  by  the  mouth;  applied  to  the 
eyes  and  ears,  it  has  caused  blindness  and  deaf- 
ness, and  a  plaster  of  it  on  the  head  has  caused 
death.  It  ought  not  to  be  given  to  plethoric  per- 
sons without  first  bleeding  them,  nor  at  all  to 
women  at  time  of  the  menses,  etc.,  nor  even  upon 
a  full  stomach,  for  it  prevents  digestion."  (Po- 
met's  History  of  Drugs,  Fourth  Ed.,  page  216, 
A.D.  1748). 

We  have  quoted  what  Parr  says  on  the  use  of 
opium,  also,  and  in  this  it  will  be  seen  we  have 


produce  stupor  and  sleep,  but  the  drug  was  used  made  but  little  progress,  but  are  falling  back  into 
promiscuously  by  the  old  practitioners  of  one  a  worse  condition  and  habit  of  practice  than  has 
hundred  years  or  more  ago,  and  now,  more  espe-  existed  in  all  the  history  of  medicine.  Can  it  be 
daily,  its  use  is  being  revived  to  a  fearful  extent.  |  reformed  ?  Can  we  progress  from  this  time  011- 
It  is  employed  by  practitioners  of  respectability,  I  ward? 

I  may  say  in  nearly  all  the  cases  they  meet  with.  At  this  time  the  country  is  crowded  with  those 
It  is  used  to  save  trouble  of  investigating  and  ex-  j  practicing  medicine  under  some  system  they  claim 
amining  into  the  cause,  remote  or  exciting,  of  to  be  the  only  one  founded  on  reason  and  science, 
the  disease  they  may  be  called  to  treat.  Patients  I  The  Thompsonian  practice  was  advocated  by 
have  been  kept  under  the  influence  of  hypoder-  j  Thompson,  of  New  England.  He  claimed  the 
mic  injections  of  morphia,  not  only  for  days  but !  human  body  is  composed  of  four  elements,  earth, 
weeks,  without  investigating  the  cause  of  sick- ;  air,  fire  and  water,  and  that  metals  and  minerals 
ness.  When  visiting  a  patient  they  should  never  j  are  in  the  earth,  and  these  materials  being  taken 
leave  the  bedside  until  satisfied  what  indications  i  from  the  earth,  have  a  tendency  to  carry  all  back 
they  have  to  meet,  and  what  will  meet  the  indi-  into  the  earth  who  use  them;  and  as  the  tendency 
cations  and  thus  remove  the  cause,  and  not  stu- 1  of  all  vegetables  is  to  spring  up  from  the  earth, 
pefy  or  parah'ze  the  actions  of  the  heart  and  all  j  and  therefore  to  keep  mankind  from  the  grave, 
organs  of  the  body,  and  deprive  them  of  their  all  medicine  must  be  vegetable.  We  all  reinem- 
ability  to  perform  what  nature  has  designed  them  j  ber  how  they  scattered  their  hot  drops,  No.  six, 
to  perform.  It  is  time  the  profession  frown  upon  j  and  vegetable  composition,  over  the  country, 
such  evasions  of  duty.  Daily  I  am  called  to  see  Homoeopathy  is  a  system  which  maintains  that 
patients  that  have  been  under  the  treatment  of  j  disease  in  the  human  body  must  be  cured  by  pro- 
either  opium,  morphia  or  hydrate  of  chloral  by  ducing  other  disordered  actions  of  like  kind  (sim- 
the  mouth,  of  morphia  or  cocaine  by  hypodermic  |  ilia  similibus),  and  this  is  to  be  accomplished  by 
injections,  without  an}-  regard  to  the  cause  of  the  infinitesimal  doses,  and  really  nothing  but  sugar 
disease  or  the  effects  that  these  drugs  are  produc-  of  milk  at  that.  The  whole  practice  and  system 
ing.     Some  years  ago  I  was  called  to  see  a   pa-  j  is  visionary. 

tient  who  had  been  treated  about  three  months  Hydropathy  is  another  system,  which  is  found- 
for  what  they  called  rheumatism  of  the  knee  joint,  ed  upon  the  treatment  of  all  diseases  with  water, 
by  a  constant  course  of  hypodermic  injections  of  packing  in  wet  sheets,  etc.  Yet  this  also  has  its 
morphia   at    the    knee.      I    investigated    the    leg    followers  and  advocates. 

above  the  knee  and  found  the  patient  suffering  Vitapathy,  Vita — Life  vs.  Pathy — Disease.  Of 
from  carious  bone:  I  at  once  cut  down  to  the  fe-  later  years  we  have  this  system,  which  puts  on 
nn:r  on  the  inside  of  the  leg  and  obtained  a  free  more  nonsense  than  all  theothers.  Its  advocates 
discharge  of  thick  offensive  pus.     By  scraping   say  they  have  the  only  true  system  of  health  and 


I89i.] 


MEDICAL  PROGRESS. 


763 


life,  and  the  American  Health  College  in  Cincin- 
nati gives  the  highest  diploma  of  any  college  in 
the  United  States. 

There  are  many  new  things  in  Yitapathy.  For 
instance,  "our  electromagnetic  warm  air  bath 
surpasses  all  hot  springs,  magnetic  springs,  elec- 
tro-thermal, Turkish,  or  any  kind  of  vapor,  heat 
or  electric  baths,  as  it  combines  all  those  and 
much  more,  uniting  oxygen,  heat,  li L^ht.  electrici- 
ty and  vital  magnetism  all  in  one  luxurious, 
cleansing,  purifying,  invigorating  and  vitalizing 
process,  developing  youth,  invigorating  age,  in- 
creasing beauty  and  prolonging  life.  This  bath 
is  used  mostly  for  colds,  rheumatism,  neuralgia, 
fever  and  ague,  malarial  and  bilious  diseases, 
nervous  and  chronic  diseases  generally.  Heal- 
ing by  the  laying  on  of  hands,  together  with  the 
new  discoveries  in  Yitapathy,  makes  a  grand, 
successful,  powerful  treatment.  This  is  what  we 
practice  and  what  we  preach,  and  with  a  full 
knowledge  and  faith  in  this  doctrine  can  annihilate 
disease,  banish  wrong,  open  wide  the  gates  of  life, 
break  down  the  walls  of  hell,  kill  the  devil,  per- 
fect our  manhood  and  make  this  world  a  paradise. " 

The  above  is  a  slip  cut  from  one  of  the  notices 
announcing  their  system,  etc. 

Eclectic  practice  has  had  its  day  under  that 
name.  They  claimed  to  elect  the  best  means 
used  to  treat  disease  from  all  systems  up  to  their 
day.  Eclectics  were,  and  are  now,  nothing  more 
or  less  than  a  combination  of  the  old  botanic  or 
root  doctors  and  Thompsonians.  and  under  this 
name,  eclectics,  their  school  or  so-called  college 
for  this  country,  was  at  Cincinnati.  Agents  often 
canvassed  the  country  with  diplomas  filled,  ex- 
cept the  name  of  the  person  they  graduated,  and 
filled  them  out  for  those  that  would  pay  twenty- 
five  dollars. 

Botanic  System.  There  were  also  persons  who 
claimed  to  be  doctors  and  treat  diseases  with 
roots,  herbs  and  barks. 

When  I  came  to  Elk  county  in  1846,  four  were 
in  active  practice.  They  usually  took  with  them 
a  school  basket  filled  with  "catnip"  fnepeta 
cataria),  "  mullen  leaves"  (folia  melezomun), 
"smart  weed"  (polyganum  hydropiper  punc- 
tatum),  "boneset  leaves"  (folia  eupatorium 
perfoliatum),  "mandrake  root"  (rad  podo- 
phyllum peltatum),  "  butternut  bark  "  (cortex 
juglans  cinerea),  "  pennyroyal "  (mentha  pule- 
gium),  "tanasia  or  tansy  "  (tanaeetum'  .  "  dande- 
lion root "  (leoutodon  taxaxacum  rad),  "skunk 
cabbage  root"  (rad  dracontium  foetidum),  "ele- 
campane root  "  (rad  inula  helenium),  "cranes- 
bill  root"  (rad  geranium  maculatam),  "pipsis- 
siwa  leaves  "  (folia  chimaphila  umbellata),  and 
a  host  of  other  weeds  and  roots. 

Christian  Science,  etc.  Every  age  has  its  de- 
lusions and  their  victims,  including  our  own,  not- 
withstanding the  growth  of  knowledge  and  the 
rapid  and  boasted  advancement  we  are  making 


in  our  system  of  education.  Some  of  these  de- 
lusions, frauds  and  humbugs  are  now  perpetrated 
under  the  shelter  of  the  words.  "  Christian  Sci- 
ence. "  This  system  of  concentrated  nonsense 
has  been  invading  our  country  and  has  its 
followers.  There  are  different  schools,  and  they 
do  not  agree  in  all  particulars,  but  unite  in  one 
thing,  there  is  no  such  thing  as  matter :  all  is 
"  mind."  They  contend  all  disease  is  an  error  ; 
that  we  are  not  sick,  but  think  we  are  sick  :  that 
we  do  not  die,  but  think  we  die.  Strictly  speak- 
ing, there  is  no  such  thing  as  "  disease."  What 
men  imagine  to  be  disease  is  an  error  of  the:r 
own  minds.  Then  comes  the  Faith  Cure ;  a 
class  of  pretenders  who  have  many  followers  and 
believers,  who  forsake  their  physicians  at  home, 
allow  themselves  to  be  humbugged  for  a  time  by 
what  are  called  ' '  Faith  Cure  Doctors. "  In  even- 
case  I  have  known,  patients  suffering  from  dis- 
ease, return  to  their  homes  for  treatment. 

We  also  have  Pasteur.  Brown-Sequard,  Koch, 
and  others,  with  their  "isms  and  cisms." 

By  referring  to  the  early  writers,  there  was  a 
class  of  physicians  then  that  we  of  this  day  call 
specialists.  Each  physician  applied  himself  to 
one  disease  and  not  more.  This  system  in  days 
of  the  limited  facilities  for  medical  education, 
especially  in  anatomy,  physiology,  materia 
medica.  therapeutics,  chemistry,  etc.,  was  very 
proper,  but  at  this  time  even.-  student  should  be 
thoroughly  educated  in  all  the  diseases  of  the 
body,  all  the  surroundings  of  these  diseases,  and 
be  ready  to  meet  each  indication. 

In  the  country  we  see  the  evil  of  the  present 
system  of  specialism  to  a  greater  extent  than  is 
seen  in  cities.  Daily  we  meet  with  cases  sent  to 
cities  for  special  treatment,  such  as  affections  of 
the  eyes  or  the  ears,  headache,  rheumatism, 
tumors,  ulcers,  lungs,  rectum,  bowels,  stomach 
or  liver,  and  female  diseases,  and  returned  after 
a  long  stay  with  no  improvement,  and  often  in  a 
much  worse  condition  than  when  they  left  home. 
Why  ?  The  treatment  was  for  a  symptom  and 
not  the  disease.  They  extensively  advertise 
their  specialty.  Some  call  themselves  cancer 
doctors  and  draw  many  to  them  for  that  disease, 
and  finding  a  tumor  on  some  part  of  the  body, 
pronounce  it  cancer  and  use  the  knife  to  remove 
it,  when  if  they  would  stop  and  think  a  moment 
and  call  to  mind  the  cause  of  these  tumors  and 
ulcers,  would  never  use  the  knife  until  the  sys- 
tem was  prepared  by  constitutional  treatment. 
In  a  malignant  tumor  or  ulcer,  why  remove  the 
symptom  and  leave  the  cause  to  reproduce  it  ? 
They  do,  however,  and  take  their  money.  We 
all  know  if  they  are  cancers  they  will  in  even- 
case  return,  in  due  time,  unless  treated  by  some 
regular  physician  constitutionally,  thus  purifying 
the  blood  generally  by  getting  the  malignant 
disposition  of  the  body  eradicated.  Another 
class  of  these  doctors  use  caustics  and   plasters, 


764 


MEDICAL  PROGRESS. 


[May  30 


as  they  say,  to  eat  them  out,  with  the  same  or 
worse  results.  We  should  remember  what  Hip- 
pocrates says  on  cancer:  "It  is  better  not  to 
cure  hidden  cancers,  for  the}'  who  are  cured 
quickly  perish  ;  whilst  they  who  are  not  cured 
live  longer."  Then  why  tamper  with  human 
life,  under  the  name  of  "Specialist?" 

Thus  it  will  be  seen  that  the  medical  profes- 
sion at  this  day  have  the  same  trouble  with 
quacks  and  quackery  as  is  referred  to  in  the 
•writings  of  Hippocrates,  Herodicus  and  others, 
when  it  was  said:  "Even  at  this  day  there 
were  designing  men  who  were  physicians  only  in 
•name,  and  who  gave  themselves  up  to  disreputa- 
ble practices  ;  against  whom  the  regularly  initi- 
ated had  no  redress. ' '  Are  we  not  placed  in  some- 
what the  same  condition,  and  with  no  other  hope 
or  redress  than  to  stand  together  as  a  band  of 
brothers,  in  our  regular  Medical  Society,  County, 
State,  District,  American  and  International  Med- 
ical Congress,  and  advocate  the  elevation  of  the 
profession,  not  by  legislation  of  States  or  Con- 
gress of  the  United  States,  but  by  requiring  a 
superior  education  of  all  applicants  for  "  illu- 
mination, inspection  and  coronation, ' '  also  honesty 
■of  purpose  and  devotion  to  their  duties,  etc.? 
Thus  standing  together  as  one  educated  body, 
let  lis  frown  upon  every  effort  to  bring  down  our 
high  standing  to  the  level  of  those  before  referred 
to.  If  we  expect  protection  by  legislation,  re- 
member laws  passed  by  the  legislature  or  Con- 
gress of  one  year  may  be  undone  in  another,  and 
we  must  expect  to  be  ever  in  doubt  as  to  our 
standing. 

How  are  we  to  elevate  the  profession 
of  medicine  and  surgery?  Is  it  to  be  done 
by  passing  laws  reflecting  upon  the  honesty  and 
ahility  of  our  medical  colleges,  and  declaring  the 
diplomas  granted  by  them  worthless  and  to  be 
treated  as  so  much  waste  paper  ? 

The  several  States  have  chartered  medical 
colleges  in  their  respective  States,  and  granted 
them  full  power  to  receive  students  and  graduate 
them,  or  confer  the  degree  of  Doctor  of  Medicine, 
-which  diploma  should  be  good  all  over  the  world. 
The  requirements  of  these  colleges  for  receiving 
students  and  conferring  the  degree  of  Doctor  of 
Medicine,  etc.,  should  be  the  same  in  every  State 
■of  the  Union,  and  should  be  marked  out  by  the 
American  Medical  Association,  and  all  colleges 
required  to  fully  carry  out  the  rules  and  require- 
ments, and  see  them  faithfully  enforced  as 
follows  :  The  American  Medical  Association  di- 
rections to  be  strictly  observed  by  the  medical 
colleges  of  the  several  States.  To  regulate  the 
study  of  medicine  and  surgery,  and  defining  the 
duties  of  students,  preceptors  and  the  medical 
colleges.  Be  it  resolved,  by  the  American 
Medical  Association   at  its   annual  meeting  held 

at on day  of month,    A.    D. ,   and 

it  is  hereby  declared  by  the  authority  of  the  same, 


that  from  and  after  the  first  day  of month, 

the  medical  colleges  of  the  United  States  of 
America  shall  require  all  students  of  medicine 
and  surgery  to  present  to  the  Dean  of  the  college 
he  or  she  proposes  to  attend,  a  sworn  statement 
that  he  or  she  commenced  the  study  of  medicine 

and  surgery  in  the  office  of ,  M.D.,  practicing 

physician    and   surgeon,    on    the day  of 

A.D. ,  and  studied  two  years  in  his  office  and 

under  his  directions  and  instructions.  Also  the 
student  to  present   an   affidavit  of  his  preceptor  : 

I, M.D.,  practicing  physician  and  surgeon  of 

the ,     County    of State     of ,     having 

made  a  full  and  thorough  examination  of , 

of ,  of ,  and  State  of- ,  whose  name  is 

written  in  his  own  proper  handwriting  on  the 
margin  of  this  certificate,  do  hereb)'  certify  that 
he  was  found  well  qualified  in  respect  to  moral 
character,  learning  and  ability  to  be  admitted  as 

a  student  of  medicine   and  surgery,  and  on 

day  of ,  A.D. ,  he  was  duly  received  in 

my  office  as  a  student  of  medicine  and  surgery, 
and  continued  under  my  instruction  and  inspec- 
tion for  the  term  of  two  years  to  the day  of 

— A.D. ,  and  during  that  time  has  proved 

himself  in  every  way  worthy. 

Signed, M.D., 

Practicing  Physician  and  Surgeon. 

Sworn  and  subscribed  before  me  this dav 

A.D. . 

In  the  country  it  is  well  known  that  a  young 
man  working  in  the  woods  or  acting  as  clerk,  at 
the  time  of  the  opening  of  a  course  in  a  medical 
college,  leaves  for  college  and  returns  at  its  close, 
begins  the  work  he  was  engaged  in  before,  and 
finally   returns  an   M.D.      He   is  recorded   as  a 

student  of  Dr. ,  whom,  as  is  frequently  the 

case,  the  doctor  never  knew. 

Students  should  be  required  to  read  the  med- 
ical authorities  under  the  inspection  and  direc- 
tion of  their  preceptors,  and  thus  be  able  to 
understand  and  know  what  our  professors  are 
talking  about.  Shall  we  allow  our  medical 
colleges  to  be  treated  as  frauds  and  humbugs  ? 
All  of  which  is  respectfully  submitted. 


Diphtheria. — H.  Wo\i(Fortsch.  d.  Med.,  1890, 
8,  954)  has  used  a  combination  of  menthol  with 
sugar  in  the  proportion  of  1  or  2  to  20  in  the 
treatment  of  diphtheria.  This  powder  he  rubs 
upon  the  parts  affected  by  the  disease.  The  de- 
posit often  sticks  to  the  brush  and  is  removed  by 
it.  The  brush  is  then  again  carried  into  the 
throat  and  the  menthol-sugar  thoroughly  rubbed 
into  the  part.  This  procedure  is  carried  out  two 
or  three  times  daily.  Even  by  the  second  or 
third  day  the  dirty-gray  appearance  disappears, 
and  a  clean  excavated  ulcer  remains  which  quick- 
ly heals  under  the  continuance  of  the  treatment. 
To  control  the  fever  he  employs  antipyretics. 


i89i.] 


ANTISEPTICS. 


765 


ANTISEPTICS 

Jtmit  in 

ntl  Annual  Meetii 

turn,  •'■■ 

BY  HIR  \M  CORSON.  M.I).. 

OF  PLYMOUTH    Mil   11 

There  has  been  a  decided  tendency  for  the  past 
few  years  on  the  part  of  persons  affected  by  the 
antiseptic  and  germ  theories,  to  make  it  impera- 
tive on  those  who  practice  midwifery,  to  obey  the 
rigid  antiseptic  rules  laid  down  by  teachers.  I 
saw  somewhere  that  in  a  discussion  on  the  neces- 
sity for  antiseptic  measures  during  parturition, 
and  their  continuance  during  the  lying-in  period, 
a  prominent  physician  said  "  that  if  he  should  be 
called  on  to  testify,  in  a  prosecution  for  malprac- 
tice where  death  had  occurred  during  confinement 
and  antiseptic  precautions  had  not  been  used,  he 
would  certainly  testify  that  it  was  criminal  mal- 1 
practice."  This  was  an  alarming  threat,  as  it  i 
placed  practitioners  of  midwifery  in  constant 
peril,  and  it  impelled  me  to  speak  to  our  County 
Medical  Society  about  it,  and  to  urge  them  to 
make  some  preparation  for  such  an  emergency. 
The  Society  then  appointed  me  to  procure  from 
practitioners  of  long  experience — men  who  had 
attended  hundreds,  and  even  thousands  of  women 
in  labor  —  statistics  in  relation  to  the  fatality 
caused  by  peritonitis,  during  their  many  years  of 
attendance  on  puerperal  women.  While  a  stu- 
dent of  medicine  in  1827  I  had  my  first  case  of 
labor.  Then  there  was  no  dread  of  puerperal 
fever  being  caused  by  germs,  introduced  into  the 
uterus  or  vagina  by  the  hand  of  the  accoucheur, 
but  the  few  cases  which  did  occur  were  attributed 
to  the  powerful,  long- continued  uterine  contrac- 
tions, or  to  injury  by  the  forceps,  with  laceration 
and  subsequent  inflammation  of  the  parts,  and  to 
■extension  to  the  peritoneum.  What  obstetrician 
has  not  known  how  sore  and  tender,  on  pressure, 
the  womb  ofttimes  was,  when  pressed  upon  soon 
after  childbirth — even  before  Crede  began  his  un- 
necessary and  heartless  wrenching  and  punching 
of  it — and  yet  rarely  did  puerperal  fever  occur. 
So  with  this  view  of  things  I  started  in  this  spe- 
cialty and  kept  at  it  for  sixty  years,  attending 
more  than  three  thousand  women,  ever  amazed 
by  the  fact  presented  to  me  of  the  rare  instances 
of  mortality  attendant  on  gestation  and  child- 
birth ;  the  latter  process  and  after-treatment  of 
the  mother  being  often  attended  by  conditions 
which  would  now  be  considered  extremely  peril 
ous  to  life,  in  almost  every  instance,  by  those  who 
are  pressing  on  us  the  use  of  antiseptics,  to  secure 
safety  to  puerperal  patients.  In  those  days  our 
■education  in  midwifery  was  little  more  than  the 
details  needed  to  conduct  an  ordinary  labor.  Oh! 
how  poorly  I  was  fitted  to  aid  the  patient  in  her 
apparently  perilous  work;  and  after  the  labor  was 
over,  how  worse  than  useless,  even  dangerous 
were   some  of  the  well-meant    measures    of  the 


nurse.  As  soon  as  the  child  was  born,  a  bowl  of 
"tiff" — gin  and  water,  or  whisky  and  water 
sweetened — was  given  to  the  patient — nor  was 
the  doctor  Forgotten — and  then  for  many  days 
drink,  hot  teas,  balm,  pennyroyal  and  others, 
but  not  a  drop  of  cold  water.  Such  was  the  cus- 
tom, but  never  mine.  Forbidden  as  it  was,  I  in- 
sisted on  cold  water  as  drink.  I  had  attended  a 
good  many  cases  and  had  often,  on  my  after  vis- 
its, been  met,  on  entering  the  room,  by  an  odor 
recognized  as  that  of  putrid  blood,  and  so  offen- 
sive that  it  was  unpleasant  to  remain  there.  I 
spoke  of  it  to  the  nurses,  but  they  said  it  was  al- 
ways so,  and  as  I  was  a  mere  boy,  when  com- 
pared with  the  venerable  matrons  who,  in  those 
days,  ministered  to  the  lying-in  women,  who  were 
so  neat  and  clean  in  their  own  persons,  I  conclu- 
ded that  the  "cloth"  had  perhaps  remained 
there  too  long,  and  that  its  removal  would  do 
away  with  the  fetor ;  so  gave  directions  to  have 
afresh  one  applied,  and  went  away.  So  things 
went  on  in  most  of  the  cases  for  a  year  or  two. 
'  As  a  general  thing  the  fetor  was  very  evident  for 
a  week  or  more,  and  finally  was  so  bad  in  one 
case,  that  I  determined  to  see  what  condition  the 
patient  was  in  :  when  lo  !  I  found  that  she  had 
not  had  a  single  washing  of  the  genitals  and  con- 
1  tiguous  parts,  or  a  removal  of  soiled  clothes  since 
the  end  of  the  labor,  though  a  whole  week  had 
elapsed.  On  expressing  my  surprise  and  disgust 
that  the  nurse  had  left  her  in  that  condition,  and 
without  a  regular  cleansing  every  day,  I  was  told 
that  it  was  not  the  custom  to  do  so,  through  fear 
that  the  washing  and  change  of  clothes  would 
cause  her  to  "  take  cold."  I  had  succeeded  an 
aged  practitioner  in  that  region,  and  so  I  suppose 
the  practice  had  gone  on  during  many  years  with 
the  'nurses  for  the  majority  of  lying-in  women. 
If  these  women  thus  treated,  with  no  antiseptic 
measures  before  labor,  none  during  it,  nor  after- 
ward for  the  proverbial  "nine  days"  which  were 
to  complete  the  lying-in  period,  passed  safely 
through  this  ordeal,  and  repeated  it  again  and 
again,  not  one  in  many  hundreds  suffering  from 
puerperal  fever,  is  it  reasonable  that  other  pre- 
cautions are  more  needed  than  those  of  cleanli- 
ness obtainable  without  the  use  of  antiseptics, 
which  are  now  so  much  used,  and  which,  from 
their  poisonous  nature,  have  in  some  cases  caused 
the  death  of  the  patient? 

From  the  first  days  of  my  practice  up  to  the 
present  time,  in  threatened  abortions  or  miscar- 
I  riages,  when  there  was  slight  haemorrhage  going 
!  on,  a  like  fetor  has  been  noticed  in  nearly  every 
case  (when  the  clothes  were  raised  in  order  to  ex- 
amine the  patient),  day  after  day  until  the  ovum 
was  cast  off:  the  vagina  being  filled  with  clotted 
and  putrid  blood.  The  justly  celebrated  Profes- 
sors, Dr.  Chalkly  James  and  Dr.  Wm.  P.  Deucer. 
teachers  of  midwifery  in  the  University  of  Penn- 
sylvania sixty-two  years  ago,  directed  us  in  those 


766 


ANTISEPTICS. 


[May  30, 


cases  to  tampon  the  vagina,  so  that  the  woman 
would  be  safe  during  the  absence  of  the  physician, 
but  every  day  to  remove  it,  and  have  a  fresh  one 
to  take  its  place,  or  the  same  one  washed  and 
soaked  in  vinegar  and  then  replaced.  Thus  I 
have  sometimes  had  cases  go  on  from  day  to 
day  for  nearly  or  quite  a  week,  before  the  uterus 
was  sufficiently  opened — we  did  not  force  it  open 
then — to  remove  the  ovum  ;  and  seldom  have  I 
known  anything  more  offensive  than  the  sponges 
and  putrid  blood  which  were  in  the  vagina,  when 
I  attempted  their  removal,  and  yet  in  not  a  single 
case  in  all  my  sixty  years  of  practice  did  any  of 
these  patients  suffer  from  puerperal  fever,  or  peri- 
tonitis, or  an}'  other  fatal  affection  of  the  pelvic 
organs.  In  such  cases  the  woman  was  often  ex- 
amined to  ascertain  whether  or  not  the  abortion 
was  likely  to  occur,  or  whether  the  ovum  could 
be  removed,  and  it  was  sometimes — often,  indeed 
— necessary  to  remove  the  ovum,  or  the  secun- 
dines  through  which  the  fcetus  had  slipped,  leav- 
ing them  in  the  womb,  but  the  patient,  though 
sometimes  pale  and  weak,  would  soon  rally  and 
be  herself  again. 

Why  then,  I  ask,  if  by  such  practice — whether  it 
was  right  or  whether  it  was  wrong- — no  harm  came 
to  the  patient,  so  far  as  life  was  concerned,  need  we 
now,  when  we  have  good  nurses  and  great  clean- 
liness enforced,  use  antiseptic  precautions  and 
measures  or  be  in  danger  of  criminal  prosecutions 
based  on  the  testimony  of  obstetrical  experts,  who 
see  infectious  germs  under  every  finger-nail,  yet 
who  have  never  attended  half  a  dozen  cases  of 
labor  and  do  not  know  that  we  object  to  the  use 
of  antiseptics  because  several  women  have  lost 
their  lives  by  the  use  of  them  as  directed  by  the 
germites,  though  thousands  of  women  in  our 
State  suffered  abortions  every  year  and  got  well 
without  a  set-back.  Two  days  ago,  a  physician 
who  has  practiced  for  twenty  years  and  has  had 
a  large  practice,  five  cases  last  week,  wrote  to  me: 
"  As  for  germs,  if  they  are  as  numerous  and  as 
rampant  as  writers  and  teachers  would  have  us 
believe,  then  almost  every  puerperal  woman  in 
the  country  ought  to  die  of  peritonitis.  The 
scrubbiugs  and  squirtings  may  be  ail  well  for 
hospitals,  but  in  communities  of  decent  people, 
they  seem  to  me  useless  and  worse  than  useless." 
Very  recently  a  writer  has  given  us  his  opinion, 
that  the  physician  should  take  charge  of  every 
woman,  whom  he  expects  to  attend  during  labor, 
at  least  three  months  before  the  time  of  expected 
labor,  and  direct  her  diet,  and  baths,  and  every- 
thing that  aids  in  keeping  the  infectious  germs  at 
a  distance.  And  about  two  years  ago  another 
physician  gave  a  caution  to  those  of  us  who 
might  find  it  necessary  to  use  a  rectal  injection, 
to  be  careful  not  to  let  the  germs  in  by  that  back- 
door. Why  these  great  fears?  Are  not  women 
now  as  they  were  fifty  or  sixty  years  ago  and  have 
always  been  since  that  time?     And  did  not  they 


then  pass  through  the  labor  process  under  less 
favorable  conditions  than  now,  and  yet  without 
peritonitis  in  more  than  one  of  a  thousand  cases? 
and  even  that  one  perhaps  the  result  of  violence 
and  not  caused  by  germs.  And  yet  were  not  the 
germs  as  numerous  then  as  now?  Ah  !  here  the 
germites  possibly  have  me ;  for  half  a  century  ago 
farmers  grew  potatoes  without  difficulty  ;  they 
put  the  cuttings  in  the  ground  and  they  grew 
amain.  Nothing  disturbed  them  ;  but  now  what 
a  change!  They  are  planted,  send  up  their  stalks 
and  leaves  and  give  promise  of  a  crop;  when  lo! 
in  a  single  night,  the  potato-bug.  The  beautiful 
black  and  gilded  germs  fasten  on  the  growing 
plant,  and  if  the  Paris-green,  the  germicide,  be 
not  at  hand,  the  plant  dies  from  the  destruction 
of  its  lungs.  So,  it  is  plain  that  one  generation 
may  have  no  secret,  deadly  enemy  to  bring  death 
to  happy  homes,  and  yet  the  next  have  one.  But 
is  it  so  here  ?  Certainly  not.  The  man  who  prac- 
tices alongside  of  the  frightened  antiseptic  doctor 
sees  not,  fears  not  any  venomous  germs,  and  his 
patients  rise  from  their  beds  happy  in  their  love 
of  offspring. 

Counting  but  ten  miscarriages  to  even-  hun- 
dred labors,  I  must  have  had  more  than  three 
hundred  in  my  practice,  very  many  of  them — in- 
deed, nearly  every  one  of  them,  being  in  the  con- 
dition described  above — the  vagina,  and  some- 
times the  uterus,  containing  putrid  blood  for 
man}r  days,  and  yet  not  in  a  single  case  did  peri- 
tonitis occur.  The  same  conditions  have  been 
presented  to  thousands  of  other  physicians  in 
cities  as  well  as  in  the  country. 

As  we  are  now  directed  by  teachers  to  use  the 
rigid  antiseptic  measures  of  the  present  day,  even 
when  attending  the  healthiest  woman,  and  though 
no  infectious  disease  prevails  in  the  neighbor- 
hood— and  threatened  with  prosecution  if  we  do 
not — it  is  pertinent  to  inquire  what  has  been  the 
result  in  the  last  fifty  years  in  the  practice  of 
physicians  who  took  no  precautions  against  car- 
rying infectious  diseases  from  patients  whom  they 
were  attending  to  those  women  to  whom  they 
were  called  when  in  labor. 

As  I  was  not  more  successful  in  my  obstetrical 
practice  than  other  doctors,  an  account  of  my  ex- 
perience in  this  branch  of  our  business  will  fairly 
represent  the  practice  and  results  of  the  profession 
for  the  whole  sixty  years  during  which  I  was  in 
active  practice,  1828  to  1888.  When  attending 
patients  ill  with  measles,  scarlet  fever,  small-pox 
or  erysipelas,  I  visited  my  other  sick  people,  in- 
cluding puerperal  ones,  the  same  as  though  I 
were  not  attending  an  infectious  disease.  There 
were  but  few  cases  of  small-pox  came  under  my 
care — not  more  than  15  or  20  perhaps,  in  all  my 
long  practice,  and  only  two  proved  fatal.  One, 
who  recovered,  I  not  only  visited  as  a  physician, 
but  through  the  refusal  of  the  "Poor  Directors" 
to  receive  him  at  the  almshouse,  and  the  fear  of 


i89i.] 


ANTISEPTICS. 


7   1 


the  family  in  whose  house  he  was,  I  felt  com- j  On  the  20th  I  was  called  in  haste,  as  she  believed 
pelled  to  visit  him  twice  daily  and  attend  to  all ;  labor  was  approaching,  but  as  the  pains  were 
his  wants  during  all  his  illness.  I  visited  fam-  trifling  I  left  her,  after  waiting  a  couple  of  hours, 
ilies  without  taking  any  precautions  against  con-  and  from  that  time  was  frequently  with  her  until 
veying  the  iufection  to  puerperal  or  other  pa-  the  23rd,  when  the  child  was  born  alive.  The 
tients.  labia  were  then  greatly  discolored  and  before  her 

Scarlet  fever  prevailed  greatly  at  times  during  j  death,  on  the  29th,  sloughed  badly.  Peritonitis 
my  first  thirty  years  of  practice.  In  a  severe  epi- !  was  evident  soon  after  her  labor  terminated,  and 
demic  of  it,  one  winter,  I  had  more  than  eighty  i  was  the  cause  of  her  death, 
cases.  Even-  day  of  that  winter  I  was  in  attend- 
ance on  them,  and  during  that  time  had  many 
obstetrical  cases,  and  in  my  sixty  years  of  prac- 
tice I,  of  course,   had  many  hundreds  of  cases, 


Xow,  between  January  17,  the  day  of  my  first 
visit,  and  the  20th,  when  I  was  with  her  two 
hours,  I  attended  two  other  women — Mrs.  Hen- 
derson on  the  17th  and  Mrs.  W.  on  the  19th.  And 
and  yet  I  did  not  carry  any  scarlet  fever  germs  to  on  leaving  Mrs.  Rev  on  the  20th,  at  eleven  o'clock 
infect  a  single  lying-in  woman,  though  I  some- 1  p.m.,  was  in  attendance  on  Mrs.  Righter  at  one 
times  went  directly  from  attendance  on  these  cases  j  a.m.  on  the  21st,  and  assisted  in  her  parturition. 
to  the  woman  in  labor.  Even  more  than  that; '  From  this  statement  it  appears,  not  only  that  I 
when  my  children,  nine  in  number,  had  the  dis-  was  visiting  and  in  attendance  on  the  first  three 
ease  at  different  times,  two  or  more  at  a  time,  during  their  labors,  while  in  daily  attendance  on 
and  I  nursed  them  and  slept  in  the  room  with  the  erysipelatous  case,  and  that  in  two  hours 
them,  I  went,  if  called  to  a  case  of  labor,  straight  after  I  had  examined  Mrs.  Rev,  or  had  attempted 
to  the  patient  without  taking  any  precautions  to  do  it,  but  failed  because  the  tabia  were  so 
against  conveying  the  disease  to  the  woman,  j  swelled  that  I  could  not  succeed  in  reaching  the 
Some  persons,  even  at  that  time,  inclined  to  the  i  os  uteri  with  my  finger,  I  was  in  attendance  on 
belief  that  the  infection  of  measles,  scarlet  fever,  j  Mrs.  Righter,  and  continued  with  her  for  some 
small-pox,  and  notably  erysipelas,  might  be  J  hours,  occasionally  examining  to  mark  the  pro- 
carried  from  the  infected  houses  in  the  clothes —  gress  of  the  case.  And  after  this,  when  Mrs.  Rev's 
not  under  the  finger  nails — and  therefore  changed  labor  terminated,  I  continued  to  visit  Mrs.  Righter 
their  clothes  if  attending  small-pox  patients.  At  ]  and  the  others  as  often  as  was  my  usual  custonv, 
that  time  the  dirt  under  the  nails  was  not  known  and  they  all  did  well.  I  know  full  well  that  all 
to  be  the  nidus  of  germs,  and  washing  and  scrub-  this  is  not  conclusive  proof  that  the  poison  of  in- 
fectious diseases  cannot  be  carried  from  one  per- 


bing  the  hands  for  the  special  purpose  of  dislodg- 
ing them  was  an  unheard  of  process. 

I  believe  as  fully  in  the  infectious  nature  of 
measles  and  scarlet  fever  as  I   do  in  the  conta- 


son  to  another  in  the  usual  way  of  visiting  pa- 
tients, and  in  labor  of  handling  them,  but  it  is 
strongly    against   such    a   probability.       I    have 


giousness  of  small-pox,  and  yet  in  my  visits  to '  merely  stated  facts,  carefully  recorded  during 
families  where  the  children  had  never  had  these !  many  years  of  practice,  for  the  consideration  of 
diseases,  I  never  carried  it  to  them  from  other  in-  readers.  When,  in  1863,  1  published  two  thou- 
fected  patients.  If  there  be  danger  or  a  possibil-  j  sand  three  hundred  and  thirty-seven  cases  (after- 
ity  of  the  infection  being  thus  conveyed  by  a  I  wards  swelled  to  three  thousand  and  thirty-six)  I 
physician,  I  think  my  exemption  irom  being  a  discovered  that  few,  if  any,  physicians  in  our  pop- 
carrier  of  it  must  have  been  due  to  the  short  time  ulous  country  had  careful  records  of  their  cases, 
spent  in  the  sick  room,  or  to  the  sometimes  long  but  that  they  had  to  depend  on  their  memory  if 


ride  in  the  open  air  to  the  next  place  visited. 
Even  more  dreaded  than  the  three  diseases  is  ery- 
sipelas as  a  cause  of  puerperal  fever.  As  with 
the  others.  I  took  no  precautions.  If  attending 
a  case  of  erysipelas,  if  a  call  were  made  on  me  to 


they  wished  to  speak  of  them  in  after  years. 
What  I  have  written  here  is  from  a  careful  record 
made  thirty  years  ago,  when  I  had  no  expecta- 
tion that  I  should  ever  again  have  need  to  refer 
to  the'se  facts.     And  now  when  I  add  that  in  all 


go  to  an  obstetric  case  I  went  at  once  without  this  long  practice  of  sixty  years,  and  in  profound 
using  other  precautions  than  with  the  other  three  ignorance  of  poisonous  germs  being  carried  in 
diseases.  my  clothes,  or  in  the  dirt — when  there  was  am- 

Here  allow  me  to  report  a  single  case:  January  — under  my  finger  nails,  that  though  in  attend- 
17,  1S60.  I  was  called  to  Mrs.  Rev,  a  young  wife  ance  on  3,036  women  in  labor,  I  never  once  car- 
within  a  few  days  of  her  expected  labor.  I  found  \  ried  an  infectious  disease  to  them.  I  feel  that  I 
her  with  enormously  swelled  oedematous  labia,  might  rest  my  case  here.  But  I  prefer  to  add  the 
which  kept  her  limbs  widely  separated.  There  j  experience  of  some  experienced  physicians  in  re- 
was  an  erysipelatous  redness  covering  them,  lation  to  the  occurrence  of  puerperal  peritonitis  in 
Measures  were  used  to  relieve  her,  though  with  lying-in  women.  Professor  Traill  Green.  M.D., 
little  change  in  the  size  of  the  swelling,  while  the  of  Easton.  Pa.,  known  to  the  profession  eveiy- 
erysipelatous  redness  increased  in  intensity  and  where  in  our  country,  has  practiced  fifty  vears. 
extended  to  the  contiguous  parts  of  the  thighs.  |  and  on  enquiring  of  him  in  relation  to  the'  now 


768 


ANTISEPTICS. 


[May  30, 


dreaded  puerperal  fever  he  replied:   "I  have  been   with  my  aid  delivered  a  dead  body,  to  be  followed 


so  happy  as  to  have  no  case  of  puerperal  fever, 
and  I  think  it  has  been  very  rare  in  the  practice 
of  fellow  practitioners."  Would  it  be  possible, 
think  you,  to  convince  this  experienced  man  who 
has  watched  by  the  bedside  of  suffering  women 
during  half  a  century,  that  it  is  now  necessary 
for  him  to  begin,  three  months  before  a  patient's 
expected  labor,    to  visit  and  prescribe   for  her, 


in  a  few  days  to  the  land  of  shades  by  the  mother. 
In  this  case  all  needful  antiseptic  precautions 
were  taken." 

Dr.  D.  Colvin,  of  Clyde,  N.  Y.,  replies  as  fol- 
lows: "Though  compelled  to  relinquish  active 
practice  for  a  time,  yet  I  can  report  attendance  on 
1,279  cases,  exclusive  of  consultations.  I  have 
never  lost  but  one  woman,  and  she   died  a  few 


regulate  her  diet,  direct  the  times  for  taking  ex-  j  minutes  after  the  placenta  was  removed.  In  not 
ercise,  advise  her  when  to  bathe,  etc.,  healthy  so  one  single  case  have  I  ever  used  antiseptic  treat- 
she  be,  and  when  the  labor  has  begun,  to  scrub  his   ment,  and  have  never  had  a  case  of  puerperal 


always  clean  hands,  dip  them  in  a  solution  ofcorro 
sive  sublimate, bathe  the  genitals  of  his  patient  with 
it,  throw  some  of  it  into  the  vagina,  and  even 
into  the  uterus,  keep  it  by  his  side,  so  that  he 
may  dip  his  hands  in  it  every  time  before  "touch- 
ing" his  patient;  and  then  when  the  child  has 
come  and  the  placenta  been  removed,  to  throw  a 
solution  of  corrosive  sublimate,  by  means  of  a 
powerful  syringe,  into  the  cavity  of  the  womb  "to 
wash  out  the  blood  clot?"  I  repeat,  do  you 
think  he  would  believe  such  proceedings  neces- 
sary?— even  if  we  had  never  heard  of  the  many 
deaths  which  have  occurred  from  antiseptics  hav- 
ing been  used  to  wash  out  the  uterus  after  de- 
livery ? 


peritonitis,  but  have  seen  two  or  three  in  the  prac- 
tice of  others. 

"When  I  think  of  the  hundreds  of  women 
whom  I  have  delivered  in  log-houses  and  board 
shanties,  long  before  the  antiseptic  treatment  was 
thought  of,  and  have  seen  those  women  up  in  a 
few  days,  and  caring  for  their  children,  with  their 
health  unimpaired,  not  one  of  them  dying,  it 
teaches  me  that  the  caution  given  to  us  by  our 
old  professor  of  midwifery:  '  Beware  of  Meddle- 
some Midwifery,'  was  timely  and  proper. 

"My  father,  too,  was  in  practice  from  1817  to 
1876,  and  I  know  of  only  one  case  of  puerperal 
peritonitis  in  his  practice." 

Thus  could  I  go  on  with   just  as  strong  testi- 


But  let  me  pass  to  other  testimony.  Another ;  mouy  from  a  thousand  country  physicians,  but  it 
friend  of  mine,  a  graduate  of  the  University  of  1  is  not  necessary,  for  I  would  be  told  of  the  won- 
Pennsylvania,     35    years    ago,   a    man    of    un-   derful  achievements  of  our  present  surgeons,  due 


doubted  truth,  writes:  "What  nonsense  is  all 
this  stuff  about  perineal  pads  and  douching  the 
vagina  before  and  after  labor,  and  antiseptics  in 
obstetric  practice?  However  useful  and  neces- 
sary a  certain  amount  of  it  may  possibly  be  in 
lying-in  establishments,  it  seems  useless  here.  I 
have  never  had  a  fatal  case  of  puerperal  disease, 
and  have  seen  but  three  or  four  in  consultations." 


mainly,  as  the  germites  believe,  to  the  use  of  an- 
tiseptics in  their  operations.  Their  success  has 
been  marvelous;  but  was  it  due  to  antiseptics? 
Are  there  not  many  successful  surgeons  and  gyne- 
cologists who  do  use  them?  What  stronger  tes- 
timony can  be  given  for  the  success  of  surgeons 
who  use  antiseptics,  than  have  been  given  by  our 
own  Goodell,  Sutton,  and  Joseph  Price,  and  Law- 


Dr.  Wilson,  of  this  county,  and   a  member  of  >  son  Tait  of  England,  of  their  unrivaled  success 


the  County  Society,  writes:  I  have  been  in  con 
tinuous  practice  for  twenty  years  and  have  always 
had  a  large  obstetric  practice,  my  cases  number- 
ing between  one  thousand  and  fifteen  hundred, 
and  have  never  lost  a  woman  (italics  mine).  I 
have  never,  as  a  rule  paid  much  attention  to  anti- 
septics. In  fact  I  have  always  looked  upon  labor 
as  a  physiological  process,  and  the  less  it  was  in- 
terfered with  the  better  the  results. 

Dr.  J.  B.  Carroll,  of  our  society,  writes:  "In 
fourteen  years'  practice  there  has  only  been  one 
case  of  puerperal  fever." 

Dr.  J.  B.  Walter,  of  Bucks  County,  says:  "In  22 
years'  experience  I  have  had  considerable  obstet- 
rical business — five  cases  last  week — and  only  two 
cases  of  peritonitis.  One  of  them  arose  from  a 
lacerated  cervix;  was  very  ill,  but  recovered. 
The  other  was  a  metro-peritonitis,  resulting  pri 


in  surgical  and  gynecological  operations,  by 
cleanliness,  without  the  use  of  antiseptics  in  the 
surgical  treatment  of  puerperal  and  non-peurper- 
al  women? 

As  their  testimony  is  not  at  hand  I  quote  from 
Dr.  George  Dean,  of  Spartansburgh,  S.  C, 
who  spent  some  days  on  a  visit  to  the  Gyneccan 
Hospital,  in  Philadelphia,  under  the  supervision  of 
Dr.  Joseph  Price  and  Dr.  Charles  Penrose.  "This 
hospital  is  a  model  in  its  way.  It  is  new  and 
small  and  lacks  many  conveniences  of  some  other 
hi  ispitals,  but  the  lack  of  them  is  more  than  coun- 
terbalanced by  the  skill  and  enthusiasm  of  its 
chiefs,  and  their  determination  to  achieve  a  suc- 
cess for  it  second  to  none  in  the  world.  It  al- 
ready stands  at  the  head  of  such  institutions  in 
Mi  I'm  ted  States.  I  witnessed  many  operations 
there — abdominal  sections  and  plastic  operations 


larily  from  over-sniartness.  and  secondly  from  upon  womb  and  perineum;  success  in  every  case 
unjustifiable  battering  and  bruising  of  the  uter-  followed.  I  have  seen  pustules  as  large  as  small 
ne  tissues,  by  a  rather  eminent  man,  who  need-  intestines,  adhesions  so  great  that  the  bowel 
essly,  after  two  hours  successfully  turned,  and  |  would  tear   before  the  adhesions  would  break, 


t89i.] 


ANTISEPTICS. 


769 


and  all  anatomical  relations  obliterated  in  the 
pelvis,  and  yet  .these  patients  made  an  uninter- 
rupted recovery."  To  this  I  may  add  that  in  the 
Gyneccan  Hospital  in  a  series  of  80  consecutive 
cases  there  was  not  a  single  death — and  that  in 
one  hundred  sections,  done  in  alleys  and  courts 
in  the  service  of  the  Phil.  Dispensary,  but  a  single- 
death  occurred,  and  that  was  done  by  an  assistant. 
In  not  a  single  case  were  chemicals  used.  There 
is  a  disposition  in  some — many — eminent  physi- 
cians to  discredit  the  statistics  of  those  general 
practitioners  in  the  country  who  report  a  light 
mortality  in  their  hundreds  of  cases.  They  will, 
I  feel  assured,  question  the  testimony  of  Dr. 
Traill  Green  and  the  others  cited  by  me,  and  I 
desire  to  add  a  few  more  to  the  above,  just  as  re- 
liable. Dr.  Kemper  of  Muncie,  Ind.,  in  Medical 
and  Surgical  Reporter \  June  22,  1889,  reports  900 
cases  of  which  only  two  women  died,  one  of  puer- 
peral convulsions,  the  other  of  pneumonia.  He 
also  reports  that  Dr.  J.  T.  Chenowith  had  1,600 
labors  with  only  one  death;  Dr.  N.  T.  Chenowith 
708,  2  deaths;  Dr.  A.  H.  Farquar  500,  2  deaths; 
Thomas  Botkin  525,  5  deaths;  Dr.  J.  S.  Blair, 
419,  2  deaths;  total,  3,752  with  12  deaths;  less 
than  one  death  in  300  attended— and  no  antisep- 
tic precautions  taken.  He  pertinently  remarks, 
"  I  have  the  honor  of  a  personal  acquaintance 
with  the  physicians  mentioned,  and  I  trust 
them  as  implicitly  as  I  do  physicians  in  lying-in 
hospitals.  I  am  not  aware  that  a  country  prac- 
titioner is  more  prone  to  exaggeration  than  his 
city  brothers,  or  that  falsity  was  indigenous  to 
rural  localities." 

Dr.  William  F.  Mitchell  in" Reporter"  of  Oct.  5, 
1889,  gives  the  following  testimony.  That  he  has 
been  in  practice  24  years,  has  had  more  than  700 
cases;  has  never  administered,  or  caused  to  be  ad- 
ministered to  any  woman  any  antiseptic  remedies 
before  or  after  parturition,  and  has  never  lost  but 
one  woman,  and  she  was  confined  prematurely 
and  under  all  the  circumstances  could  not  have 
expected  to  live.  I  prefer  generally  to  present 
the  testimony  of  others  rather  than  my  own,  but 
I  may  say  here  that  my  3,036  cases  are  confirma- 
tory of  what  has  already  been  given  by  the  prac- 
titioners alluded  to.  A  detailed  account  of  them 
may  be  found  in  New  York  Medical  Journal  for 
May  15,  22  and  29,  1886. 

Tedious  as  I  have  already  been,  I  must  go 
further,  as  this  is  an  important  subject,  and  get 
some  testimony  from  "  abroad."  In  the  Ameri- 
can Medical  Association  Journal  of  December 
28,  1889,  we  have  Dr.  Bantock's  views  of  Lister- 
ism.  Allow  me  to  briefly  state  some  of  his  facts. 
He  says,  that  in  1881  only  Mr.  Lawson  Tait  and 
himself  dared  perform  operations  without  using 
the  rigid  listerian  details;  but  in  1889,  in  Eng- 
land, it  was  a  rare  thing  to  see  the  spray  used  at 
all;  and  in  the  Samaritan  Free  Hospital  it  has 
been  discarded  by  all  his  colleagues  with  one  ex- 


ception, and  that  this  is  due  to  the  superior  re- 
e  he  resorted  to  a  more 
rational  and  simile  method.  Speaki 
otonn  he  records  it  as  a  fact,  that  from  April 
1883,  to  October  1888,  3'.  years,  he  did  not  lose 
a  case  in  the  ba  naritan  Free  Hospital  in  a  series 
of  90  cases,  while  during  this  period  the  deaths 
under  the  listerian  system  exceeded  12  per  cent., 
and  his  patients  recovered  with  less  pyrexia  than 
did  those  under  the  carbolic  acid  treatment.  For 
his  hands,  sponges  and  instruments,  he  uses  no 
antiseptic— only  plain  water — regards  water  that 
is  fit  for  household  use,  suitable  for  the  purpose 
of  any  operation,  and  has  no  hesitancy,  if  too 
warm  for  his  hands,  to  cool  it  with  cold  water 
fresh  from  the  tap — as,  for  instance,  when  wash- 
ing out  the  abdominal  cavity.  As  a  covering  to 
the  wound  he  uses  simple  absorbent  gauze,  inno- 
cent of  an}'  germicide,  and  such  is  his  belief  in 
its  harmlessness,  that  were  it  not  for  other  con- 
siderations he  would  leave  all  his  wounds  ex- 
posed to  the  air,  as  he  has  sometimes  done  in  am- 
putations of  the  breast.  He  attributes  the  bad 
results  which  so  often  occur  from  washing  the 
peritoneum  to  the  employment  of  antiseptic  ma- 
terial in  the  water,  which  becomes  absorbed,  or 
in  some  way  poisons  the  patient.  We  know  full 
well,  that  some  persons  are  peculiarly  sensitive 
to  the  toxic  action  of  corrosive  sublimate  and  that, 
though  in  a  majority  of  cases  no  harm  may  re- 
sult, yet  occasionally  a  case  is  met  with  in  which 
this  idiosyncrasy  exists.  This  is  the  only  ration- 
al way  of  accounting  for  the  large  number  of 
deaths  due  to  the  use  of  carbolic  acid,  and  more 
especially  to  corrosive  sublimate. 

He  therefore  protests  against  the  use  of  so- 
called  germicides  in  flushing  the  peritoneum:  and 
cannot  insist  too  strongly  on  confining  the  sur- 
geon to  plain  water  as  at  once  perfectly  innocuous 
and  thoroughly  efficient. 

It  appears  from  what  I  have  written,  that  there 
is  real  danger  to  the  woman  from  the  use  of  an- 
tiseptics— more  danger  than  there  is  in  the  practice 
of  the  physicians  who  do  not  use  them.  As  con- 
firmatory of  this,  let  me  refer  to  what  has  hap- 
pened in  the  Nurses'  Home  and  Lying-in  Charity 
Hospital  at  the  corner  of  Eleventh  and  Cherry- 
streets,  Philadelphia;  a  new  building  erected  for 
the  special  purpose,  I  have  been  told,  of  illustrat- 
ing the  value  of  listerian  treatment.  Quite  re- 
cently it  had  to  be  closed,  because  of  a  virulent 
epidemic  which  occurred  within  its  walls.  Sur- 
gery was  done  there  as  well  as  obstetrics,  and  re- 
liance was  placed  upon  chemical  solutions,  and 
everything  done  was  under  the  supervision  of 
careful  and  able  surgeons  and  gynecologists. 
How  does  this  compare  with  the  Gyneccan  hos- 
pital? Not  at  all.  The  success  of  the  latter  is  in 
direct  contrast  with  the  failure  of  the  former. 

Need  more  be  said?  No.  The  testimony  of 
Dr.  Traill  Green,  known  as  he  is  everywhere  as  a 


7?o 


SOME  CLINICAL  EXPERIENCES  WITH  EUCALYPTOL.         [May  30. 


man  of  truth  and  honor,  who  has  practiced  mid- 
wifery for  half  a  century,  should  convince  every 
right-minded  man,  that  there  is  no  need  that 
country  physicians  should  take  the  precautions 
against  germs,  so  strongly  urged  by  the  advocates 
of  listerism.  But  Dr.  Green  is  sustained  by  other 
good  men  whom  I  have  named  and  thousands  of 
others  whom  I  could  name.  No,  I  need  say  no  more, 
for  if  one  were  to  rise  from  the  dead  and  give  like 
testimony,  the  antiseptic  enthusiasts  and  labora- 
tory practitioners  would  still  discredit  the  testi- 
mony of  the  bed-side  practitioner. 


SOME    CLINICAL    EXPERIENCES    WITH 
EUCALYPTOL. 

Jiead  by  Title  in  the  Section  of  Medicine  and  Physiology  at  the  Forty- 
Second  Annual  Meeting  or  the  American  Medical  Association, 
held  at  Washington,  D.  C.  May  5,  iSor. 

BY  I.  N.  BRAIXKRD.  M.D.. 

OF   ALMA,    MICH. 

During  the  last  ten  years  I  have  often  pre- 
scribed eucalyptol  in  bronchial  and  pulmonary 
troubles.  From  this  experience  I  have  learned 
to  put  a  high  therapeutic  value  upon  it  in  some 
respirator}'  affections,  viz.:  chronic  bronchitis, 
persistent  cough,  chronic  interstitial  pneumonia, 
and  to  a  less  degree  in  tuberculosis. 

The  following  list  of  cases  taken  from  my  later 
experience,  furnishes  a  reasonable  amount  of 
proof  of  its  utility: 

Case  1. — Miss  Bellard,  aged  19.  This  lady  called  upon 
me  in  August,  1SS8.  She  complained  of  malaise,  and 
some  pain  in  the  left  lung.  She  had  only  a  moderate 
cough  and  a  limited  expectoration.  The  temperature 
■was  99°.  Auscultation  revealed  a  harsh  and  catchy  res- 
piration in  the  upper  lobe  of  the  left  lung.  A  trifling 
dulness  on  percussion  could  be  discovered  in  this  region. 
I  gave  the  girl  eucalyptol,  and  had  her  visit  my  office 
every  fortnight  for  half  a  year.  She  so  far  improved  as 
to  lend  expectation  of  her  recover}-.  Then,  school  be- 
ginning, she  started  to  school.  As  cold  weather  came 
on,  she  was  chilled  one  day  in  school,  and  developed  a 
severe  croupous  pneumonia.  For  this  she  was  treated 
by  a  physician  in  her  town,  but  not  recovering,  I  was 
called  to  see  her.  Resolution  did  not  take  place  as  it 
should,  and  I  advised  the  mother  that  the  girl  would 
never  recover  from  this  sickness.  After  a  few  weeks  she 
died.  I  believe  that  except  for  this  intercurrent  pneu- 
monia, this  girl  would  have  continued  to  progress-  t<>  a 
recovery  from  the  phthisis.  For  a  whole  yea: 
proved  until  she  felt  nearly  as  well  and  strong  as  ever. 
Then  she  sickened  with  pneumonia  and  died  in  two 
months. 

Case  2.  —  Mrs.  Thompson,  aged  30.  This  lady  called 
upon"  me  in  Septembi  1 

skeleton,  had  hectic  fever,  pulse  about  90,  cough  with 
some  expectoration,  and  tenderness  on  percussion  over 
both  lungs.  The  respiration  was  catchy  and  frequent. 
She  had  almost  a  loathing  for  food  ami  scarcely  strength 

to  come  to  my  office.     She  had  been  ill  :■ 
months.     I   put  her  upon  eucalyptol   and  cod 
She  rapidlv  improved  in  all  respects,  and  ceased  to     isil 

me  after  about  two  months.  I  had  her  undei 
tion  until  all  the  objective  symptoms,  includ 
catchy  I.  ised.     I  see  hei  occasionally,     She 

Says  my  prescription  has  made  a  new  creature  of  her. 
She  is  in  her  usual  flesh  and  is  doing  her  own  work. 


Case 3. — Mrs.  Morton,  aged  26,  called  upon  me  in  Sep- 
tember, 1SS9.  She  had  a  miscarriage  in  the  spring. 
Upon  rising  from  this  sickness  she  took  cold  and  devel- 
oped a  cough  and  soreness  through  the  lung,  from  which 
she  did  not  recover  all  summer.  Neither  did  her  menses 
reappear.  She  is  from  a  consumptive  family.  These 
things  alarmed  her  somewhat,  and  she  applied  to  me  for 
aid.  Her  respirations  were  harsh  and  catchy,  and  her 
cough  was  quite  troublesome.  I  gave  her  a  prescription 
containing  eucalyptol.  aud  have  had  her  under  observa- 
tion ever  since.  Her  respiratory  murmur  is  all  right  aud 
she  has  menstruated  ouce  or  twice  since,  and  now  seems  to 
have  gone  into  her  menopause  at  this  early  age.  She  is 
in  perfect  health. 

Case  4. — Mr.  Bradford,  aged  30,  called  upon  me  in  De- 
cember, 1SS9.  He  complained  of  a  pain  in  his  chest  and 
an  inability  to  take  deep  inspirations  with  ease.  Work 
involving  the  use  of  the  pectoral  muscles,  as  chopping, 
sawing,  husking  corn,  etc. ,  was  painful.  He  was  grow- 
ing poor  and  emaciating.  Physical  examination  of  the 
chest  revealed  a  little  dulness  on  percussion  over  the  up- 
per parts  of  both  lungs,  and  a  harsh  catchy  respiration. 
I  put  this  man  upon  eucalyptol,  and  watched  the  case  for 
a  year  and  more.  The  patient  still  complains  at  times  of 
lameness  in  the  thoracic  parietes,  but  he  now  has  less  of 
the  catchy  respiration  and  none  of  the  dulness  on  per- 
cussion. 

Case 5. — Miss  McLaren,  aged  16.  In  February,  1890, 
I  was  called  to  see  this  girl.  I  found  her  in  bed.  She 
had  a  temperature  of  1020,  a  pulse  of  120.  respiration  30, 
cough  and  expectoration.  She  had  la  grippe  a  few  mouths 
before  and  had  fallen  into  this  state.  Her  respirations 
were  harsh,  tubular  and  catchy.  I  treated  her  symptom- 
atically  and  put  her  upon  cod-liver  oil  at  once.  After 
about  a  month  she  began  to  walk  out.  aud  then  I  gave 
her  eucalyptol  besides  her  cod-liver  oil.  She  continued 
to  improve  for  some  months,  when  I  permitted  her  to 
go  from  my  care  to  Ohio,  where  she  has  since  remained. 
When  I  first  saw  her,  she  was  much  emaciated,  but  now 
she  weighs  150  pounds.  The  cough  and  expectoration 
have  ceased,  and  she  is  now  perfectly  well.  Several 
children  in  this  family  have  already  died  of  consump- 
tion, aud  I  believe  this  girl  had  incipient  phthisis.  The 
only  thing  lacking  in  the  evidence  is  the  demonstrated 
presence  of  the  tubercle  bacilli.  I  made  no  search  for 
them. 

Case  6. — Mrs.  Pulfrev,  aged  34,  visited  me  in  Februarv. 
1S90.  She  had  been  failing  for  some  months.  She  com- 
plained of  pain  in  her  right  lung.  The  percussion  note 
was  normal,  but  the  respiratory  murmur  was  catchv.  I 
put  her  upon  eucalyptol  aud  Phillip's  wheat  phosphates. 
She  soon  began  to  revive  in  every  way.  The  catchy  res- 
pirations have  ceased  and  the  patient  has  nothing  to  re- 
mind her  of  her  former  condition  except  her  feeble  en- 
durance. 

— Mr.  Young,  aged  27.      In  the  latter  part  of 
1SS9  this  man  was  taken  sick  in  Boston.     He  was  treated 
for  bronchitis,  but  finally  had  to  go  into  a  hospital.  Here 
he  heard  the  visiting  physician,  a  college  professor,  sav 
to  a  class  of  medical  students:   "We  don't  gel  hold  of  this 
case."     After  a  few  weeks'  stay  in  the  hospital  he  came 
to  Michigan  to  accept  the  hospitalities  of  his  brother.   In 
February,  1S90,  I  was  called  in  to  see  him.      I  fouud  him 
greatly   emaciated,   with   a  temperature    of   1010,  pulse 
about  90,  respiration    28,    and   a  violent  cough,    raising 
;:it  a  day  of  frothy,  bloody  sputa,  containing  mu- 
■  aud  blood.     The  sputa  had  a  rank,  gangrenous 
;;  ited  into  two  layers,  one  of  fluid  aud  one 
of  foam.     This  was  enough  to  make  a  diagnosis  of  gan- 
grene of   the    lung.     Physical    exploration   revealed   a 
small  area  oi  flatness  at  thelowei  point  of  the  right  lung. 
The  te-t  of  the  lung  was  a  little  super-resouaut  because 
ling  compensatory  work.     On  several  01 

;  had  alarming  haemorrhages.   I  put  him  upon 
Ol  and  cod-liver  oil.     He  gradually  improved  un- 
der this  treatment,  and  went  to  Canada  to  live  upon   his 


i89i.] 


SOME  CLINICAL  EXPERIENCES  WITH  EUCALYPTOL. 


-;r 


father's  hospitality.  Improvement  continued,  and  now, 
after  one  year,  lie  says  he  is  as  well  as  ever. 

Case  8. — Mr.  Brown,  aged  about  60,  consulted  me  in 
April,  1S90.  He  is  asthmatic,  had  the  grippe  a  few 
months  before  and  was  left  with  a  very  aggravating 
cough.  He  had  consulted  three  or  four  other  physicians 
without  benefit  before  he  came  to  me.  I  prescribed  an 
emulsion  of  eucalyptol  and  hyosciamns,  and  was  grati- 
ii.  d  i"  Hear  from  his  own  lips  "the  next  morning  that  he 
had  spent  the  best  111  I  months.    The  cough 

i'i  ased  at  once. 

Case  9. — Mr.  Adams,  aged  aboul  1  .  This  patient  first 
came  into  my  hands  in  July,  [890.  lie  was  emaciated, 
had  a  consumptive  look,  complained  of  pain  in  both 
lungs,  anil  coughed  some  in  the  morning.  He  had  just 
buried  a  brother  from  consumption.  His  respirations 
were  jerky  and  the  area  of  hepatic  flatness  was  enlarged. 
His  greatest  complaining  was  about  a  circumscribed 
point  of  tenderness  in  the  greater  curve  of  the  stomach. 
This  I  believed  to  be  a  tubercular  ulcer.  I  put  this  man 
upon  eucalyptol  and  bismuth  mixtures,  in  separate  bot- 
tles, and  kept  him  under  observation  for  a  few  months; 
but  as  he  would  not  believe  there  was  anything  wrong 
with  his  lungs,  and  as  his  stomach  was  not  bettered,  he 
desisted  from  the  treatment.  It  is  to  be  said,  however, 
that  the  respirations  nearly  ceased  to  be  jerky  during  the 
latter  part  of  the  time  that  he  remained  under  treatment. 

Case  10. — Mr.  Hayt,  aged  27,  applied  to  me  iu  January, 
1891.  He  had  had  influenza  and  had  been  left  in  a  con- 
dition of  prostration,  and  with  pain  in  both  lungs.  I 
found  the  respirations  catchy  and  both  lungs  dull,  espe- 
cially in  their  lower  portions.  Strange  to  say  the  tem- 
perature was  normal,  the  pulse  64,  and  the  respiration  16. 
Four  vears  before  an  eminent  physician  told  him  that 
something  was  wrong  with  his  lungs.  He  had  been 
obliged  to  quit  work,  and  since  had  done  but  little  work. 
He  is  about  five  feet  and  eleven  inches  tall  and  weighs 
only  135  pounds.  He  has  a  consumptive  look.  I  put 
this  man  upon  eucalyptol  and  cod-liver  oil.  Almost  full 
resonance  has  been  restored  to  the  lungs  and  the  respira- 
tions are  but  slightly  interrupted.  There  never  was  any 
expectoration.  My  diagnosis  in  this  case  was  chronic 
interstitial  pneumonia. 

Case  11. — Miss  Taylor,  aged  29.  I  was  called  to  see  this 
patient  in  January,  1S91.  She  had  bad  pneumonia  in 
Grand  Rapids,  Michigan,  and  had  come  to  her  sister's  a 
week  earlier  than  her  physician  had  told  her  she  might. 
She  took  cold  upon  the  train.  This  prevented  resolution. 
I  found  her  with  a  temperature  of  1010  and  respirations 
24.  The  lower  lobe  of  the  left  lung  was  flat  upon  per- 
cussion, and  the  breathing  was  tubular.  This  was  some 
two  months  after  the  onset  of  her  pneumonia.  The  ex- 
pectoration was  lnuco-purulent  and  abundant.  I  pre- 
scribed eucalyptol  and  cod-liver  oil  for  her.  She  has 
steadily  improved  and  her  prospects  for  an  ultimate  re- 
coverv  are  fairlv  good. 

Case  is.—  Miss^Reid,  aged  21.  On  the  second  day  of 
March,  1S91.  I  was  called  off  from  the  road  to  see  this 
girl.  About  Christmas  time  she  was  taken  with  the  in- 
fluenza. She  partially  recovered  from  this,  and  made 
two  attempts  to  go  back  to  school.  Twice  she  failed, 
and  twice  went  home.  She  was  treated  by  another  phy- 
sician, and  discharged  as  cured.  Three  or  four  days  later 
I  was  called,  as  stated  at  the  beginning  of  this  paragraph, 
and  found  the  following  conditions:  Temperature  103, 
pulse  130,  respiration  24.  free  and  muco-purulent  expec- 
toration, night-sweeats,  anorexia,  and  great  prostration. 
Her  respiration  was  catchy  in  both  lungs,  and  accom- 
panied by  large  and  small  moist  rales  on  both  sides. 
The  percussion  note  was  somewhat  dulled  on  both 
sides,  especiallv  in  the  lower  lobes.  I  believed  that  the 
girl  had  slid  from  the  influenza  into  catarrhal  pneu- 
monia, and  was  likely  to  fall  into  acute  miliary  tuber- 
culosis, and  so  informed  the  mother.  I  administered 
autipvretics  and  tonics,  and  later  put  her  upon  eu- 
calvptol  and  cod-liver  oil.     A  later  examination  of  the 


sputum  revealed  swarms  of  the  bacillus  tuberculosis. 
The  case  has  been  in  my  care  now  two  months.  The 
temperature  averaged  the  first  month  about  102°.  the 
second  month  1010.  The  expectoration  has  grown  much 
less.  The  respirations  fell  in  two  weeks  to  normal  and 
have  so  remained  ever  since.  The  pulse  has  fallen  from 
130  to  96.  where  it  stays.  This  may  be  normal  for  her, 
for  the  tw  ters   have  the  same   rate  of  heart- 

beat, ami  they  are  perfectly  well.  Her  appetite  is  return- 
ing and  the' bacilli  have  nearly  disappeared  from  her 
sputa.  The  patient  is  still  bedfast  and  in  a  pi' 
condition.  Whatever  the  outcome  may  be,  the  fact  is 
patent  that  the  eucalyptol  has  done  her  much  good.  It 
looks  as  if  it  had  averted  the  acute  miliary  tuberculosis, 
but  also  as  if  the  patient  were  settling  into  a  rapid  phthisis, 
though  no  signs  of  cavities  can  be  found,  and  110  rales 
are  now  heard.  The  respiration  has  ceased  to  be  catchy, 
and  has  become  smooth  in  all  the  lung  except  in  the  up- 
per lobe  of  the  left  lung,  where  it  is  harsh  and  tubular 
at  this  writing.  It  has  been  better  here  until  a  few  days 
ago.  when  a  sudden  increase  iu  the  expectoration  indi- 
cated the  rupture  of  a  tubercle.  She  has  not  menstru- 
ated for  four  months. 

. — Mr.  Allison,  aged  20,  came  into  my  hands  the 
first  of  April,  1S91.  This  case  is  far  gone  with  consump- 
tion. He  had  a  temperature  of  102°,  pulse  no.  and  res- 
pirations 32.  His  expectoration  was  profuse  and  swarm- 
ing with  bacilli.  He  had  night-sweats,  tubular  and  jerky- 
respiration  in  the  left  lung,  pectoral  pains,  and  was 
greatly  emaciated.  I  had  no  expectation  of  producing 
any  abiding  change  in  the  patient,  but  at  once  put  him 
upon  eucalyptol  and  cod-liver  oil.  In  a  fortnight  his 
night  sweats  were  stopped  and  the  expectoration  re- 
duced one-half.  The  patient  has  been  benefited  by  the 
treatment,  but  will  die.  He  has  had  one  haemorrhage 
since  he  has  been  in  my  care. 

I  am  not  putting  eucalyptol  forward  as  a  speci- 
fic for  consumption,  for  it  is  not;  but  this  expe- 
rience has  led  me,  as  said  in  my  opening  para- 
graph, to  put  a  high  therapeutic  value  upon 
eucalyptol  in  persistent,  irritable  cough,  chronic 
bronchitis,  chronic  interstitial  pneumonia,  and  to 
a  less  degree  in  tuberculosis.  Cases  1,12  and  1 3 
were  certainly  tubercular.  There  can  be  but  lit- 
tle doubt  that  case  5  was  tubercular.  Five  is 
well;  there  is  some  prospect  that  12  will  get  well; 
13  will  die,  and  1  is  already  dead.  Case  7  was  a 
case  of  gangrene  of  the  lung,  and  is  recovered. 
Cases  2,  3,  4,  6,  9  and  10  had  symptoms  of  in- 
cipient phthisis.  All  are  living,  and  in  as  good 
or  better  health  than  they  were  a  year  ago.  Case 
8  was  a  case  of  irritable  cough.  Case  10  is  a  case 
of  chronic  interstitial  pneumonia.  Eight  is  cured, 
and  10  is  much  improved. 

Eucalyptol  is  very  permeating.  It  is  elimin- 
ated by  the  lung,  the  skin  and  the  kidneys.  It 
can  be  smelled  upon  the  breath,  upon  the  clothes 
when  changed,  and  in  the  urine.  It  is  antiseptic. 
It  has  a  healing  effect  upon  bronchial  epithelium 
and  a  sedative  effect  upon  the  peripheral  nerves 
in  the  respiratory  tract.  It  is  because  of  these 
physiological  effects  that  the  therapeutic  results 
are  produced. 

I  administer  it  in  five  to  ten  minim  doses,  in 
emulsion,  even-  four  hours. 


772 


THERAPEUTIC  ACTION  OF  TOXICA  WATER. 


[May  30 


THE  THERAPEUTIC  ACTION  OF  TOXICA 

WATER.      WITH    THE   HISTORY   OF 

TWEXTY-SIX    CASES  WHERE  IT 

HAS  BEEX   USED. 

Read  in  the  Section  of  Practice  of  Medicine  and  Physiology,  at  the 

and  Annual  Meeting   .if  the  Anleiiean   Mcdica       I 
lion,  held  at  Washington,  D.  C.  May-  1891. 

BY  J.  W.  SMALL,  M.D., 

OF  NEW  YORK. 

Water,  as  an  agent  in  the  treatment  of  disease, 
is  a  remedy  which  should  not  be  too  lightly  esti- 
mated, as  it  is  more  or  less  concerned  in  all  those 
changes  which  take  place  in  inorganic  matter, 
and  is  essential  to  the  life  and  growth  of  all  liv- 
ing organisms,  whether  animal  or  vegetable. 
When  taken  into  the  stomach  it  acts  by  its  tem- 
perature, its  bulk,  its  absorption,  and  as  a  solvent 
for  mineral  and  vegetable  matters  which  other- 
wise could  produce  no  beneficial  action  in  the 
animal  economy.  When  natural  spring  waters 
are  so  far  impregnated  with  foreign  substances  as 
to  have  a  decided  taste  and  a  peculiar  therapeutic 
action,  they  are  classed  in  the  Pharmacopoeia  as 
mineral  waters,  and  are  divided  into  five  classes : 
the  carbonated,  alkaline,  sulphuretted,  saline  (in- 
cluding magnesiau,  chalybeate  and  chlorinated), 
and  silicious.  The  name  of  each  of  these  classes 
suggests  its  peculiar  impregnation  ;  but  analysis 
of  the  water  of  nearly  all  mineral  springs  shows 
a  combination  of  the  ingredients  of  two  or  more 
of  these  classes,  and  some,  like  the  one  I  describe, 
the  whole  of  them. 

The  Tonica  mineral  water  is  an  alkaline,  car- 
bonated, sulphuretted,  silicious,  chalybeate  water 
which  comes  from  the  earth  in  its  natural  purity 
at  Highland  Park,  Conn.,  ten  miles  from  Hart- 
ford, on  the  X.  Y.  and  X.  E.  R.  R.  Its  analysis, 
made  at  the  Massachusetts  Institute  of  Technol- 
shows  it  to  contain  to  the  U.  S.  gallon : 

sulphate  of  potassium 0.355    Sr- 

Carbonate  of  potassium 0.1S0    " 

Chloride  of  sodium 0.215     " 

Carbonate  of  sodium 0.345    " 

Carbonate  of  lime 0.512     " 

Carbonate  of  magnesia 0.234    " 

Bicarbonate  of  iron 0.970    " 

Phosphoric  acid 0.051     " 

Silica 0.61S    " 

Alumina 0.093    " 

oxide  of  manganese a  trace. 

Sulphuretted  hydrogen a  trace. 

Organic  and  volatile  matter 0.510   gr. 

Making  a  total  of 4.083  grs. 

This  water  also  contains  carbonic  acid  gas  in 
solution. 

It  will  be  seen  from  this  analysis  that  the  in- 
gredient which  enters  most  largely  into  its  coni- 
position  is  bicarbonate  of  iron,  of  which  each 
gallon  contains  0.970  gr. ;  the  next  is  silica,  0.618 
gr.;  and  the  third  carbonate  of  lime,  0.512  gr. 
0  contains  0.051  gr.  of  phosphoric  acid,  a 
trace  of  oxide  of  manganese,  sulphate  and  ear 


bonate  of  potassium,  and  chloride  and  carbonate 
of  sodium. 

Therapeutic  Action. — This  water  is  not  an  ac- 
tive cathartic,  but  rather  a  mild  aperient.  By 
the  stomach  and  bowels  it  is  easily  retained,  ab- 
sorbed and  assimilated.  It  does  not  constipate 
the  bowels,  as  do  many  of  the  waters  which  con- 
tain iron,  and  does  not  produce  or  increase  acid- 
ity, being  alkaline  in  its  reaction.  If  taken  in 
large  quantity  it  will  produce  free  catharsis  at  first, 
but  its  cathartic  action  diminishes  with  its  use. 
It  is  at  all  times  an  active  but  gentle  diuretic,  in- 
creasing the  frequency  of  micturition  and  the 
amount  of  urine  excreted  by  the  kidneys.  It 
increases  the  appetite,  promotes  digestion,  and 
gives  a  feeling  of  warmth,  tonicity  and  buoyancy 
to  the  whole  system.  It  has  a  slightly  sulphur- 
ous, earthy  but  not  unpleasant  taste,  and  is  read- 
ily taken  by  the  most  fastidious.  But  its  most 
valuable  therapeutic  action  is  upon  the  blood, 
upon  which  it  exerts  all  the  beneficial  effects  of 
an  iron  tonic,  without  any  of  those  disagreeable 
results  which  attend  and  follow  the  continued 
administration  of  iron  in  other  forms.  In  all 
conditions  of  the  system  characterized  by  a  de- 
praved condition  of  the  blood,  as  constitutional 
syphilis,  scrofula,  chronic  albuminuria,  phthisis, 
anaemia  and  chlorosis,  its  revivifying  action  is  soon 
apparent  in  the  increasing  bright,  healthy  color 
which  it  brings  to  the  lips  and  cheeks,  and  its 
favorable  action  upon  the  appetite  and  digestion. 

Mode  of  Administration. — In  commencing  the 
use  of  this  water  I  have  usually  begun  with  a 
pint  each  day  in  divided  doses  taken  before,  dur- 
ing, or  directly  after  meals,  two  or  three  times 
per  daj%  and  increased  the  amount  gradually  to 
one  quart,  and  then  diminished  the  quantity  per 
day  if  the  necessities  of  the  case  seemed  to  so 
require.  In  diabetic  cases  I  usually  commence 
with  a  quart  or  three  pints  and  gradually  dimin- 
ish. If  a  quart  is  taken  the  first  day  it  is  usually 
followed  by  a  free  cathartic  action  of  the  bowels 
and  free  diuresis.  But  if  a  smaller  quantity  be 
taken  at  first  and  the  amount  gradually  increased, 
only  a  gentle  stimulation  of  the  bowels  and  kid- 
neys is  perceived,  and  the  same  beneficial  results 
are  attained.  In  cases  where  wine  is  indicated,  I 
give  the  wine  with  three  or  four  times  its  quantity 
of  the  water,  making  a  very  pleasant  and  agree- 
able beverage.  Upon  my  own  table  I  always  use 
it  in  this  manner.  It  is  also  a  very  agreeable 
vehicle  for  bitter  tinctures  or  infusions. 

During  the  last  year  I  have  been  enabled  to 
make  an  extended  use  of  this  water  in  a  large 
variety  of  chronic  cases  of  disease,  and  also  upon 
myself  personally.  In  connection  with  three 
other  physicians  I  have  noted  its  use  in  about 
sixty  cases.  Only  a  few  can  be  described  in  a 
paper  like  this,  but  I  have  selected  twenty  six 
Cases  in  which  its  use  has  been  attended  with  the 
best  results,  and  present  their  history  herewith. 


i89i.] 


THKRAPEUTIC  ACTION  OF  TOXICA  WATER. 


773 


disc  i. — Chronic  parenchymatous  nephritis, 
Cystitis  and  prostatitis.  Mr.  J.  F.  C,  age  62 
years.  Contracted  syphilis  five  years  ago.  Two 
years  ago  had  syphilitic  orchitis,  resulting  in  sar- 
coma of  right  testicle,  which  was  removed  by  a 
surgeon.  When  he  came  under  my  observation 
he  was  suffering  from  chronic  parenchymatous 
nephritis,  the  amount  of  albumen  in  his.  urine 
being  very  large  and  containing  fatty  and  hyaline 
casts.  Also  had  chronic  cystitis  and  catarrh  of 
the  bladder.  Prostate  gland  very  much  enlarged 
and  micturition  impossible  without  the  use  of  the 
catheter.  Acute  syphilitic  orchitis  of  left  testicle, 
which  was  enormously  swollen.  After  the  in- 
flammatory symptoms  had  subsided  I  gave  him 
Tonica  water,  directing  him  to  drink  an  ordinary 
quart  bottle  full  each  day.  At  first  it  produced 
free  catharsis  and  increased  considerably  the 
amount  of  urine  excreted  by  the  kidneys.  At 
the  end  of  one  month  marked  improvement  was 
visible,  with  albumen  reduced  one-half.  At  the 
end  of  two  months  albumen  about  one- fourth, 
and  after  three  months  one-eighth  the  original 
amount.  Appetite  and  digestion  improved  from 
the  first,  so  that  instead  of  being  confined  to  the 
house,  he  is  now  performing  all  the  duties  of  an 
active  business  life.  This  patient  had  been  una- 
ble to  take  any  of  the  ordinary  forms  of  iron  on 
account  of  their  constipating  and  irritating  effects 
upon  the  bowels. 

Case  2  — Obesity,  gout  and  rheumatism.  Mr. 
E.  F.,  a  clerk  and  a  man  of  sedentary  and  indo- 
lent habits,  age  50.  Height  5  ft.  5  in.,  weight 
at  commencement  of  treatment  220  lbs.  Chest 
contained  a  large  amount  of  tat,  which  materially 
weakened  the  action  of  the  heart.  Considerable 
dyspnoea  upon  slight  exertion,  as  upon  going  up 
a  long  flight  of  stairs.  Specific  gravity  of  urine 
1010,  and  contained  considerable  albumen.  After 
some  preliminary  treatment,  I  gave  Tonica  water 
in  doses  of  one  pint  each  day,  with  meals,  gradu- 
ally increasing  the  amount  to  one  quart  each  day 
and  keeping  it  at  the  latter  amount  for  one  month, 
then  gradually  decreasing.  At  the  end  of  one 
month  all  symptoms  of  gout  and  rheumatism 
were  gone  and  albumen  had  disappeared  from 
his  urine.  Weight  reduced  10  lbs.  Appetite  and 
■digestion  were  much  improved  and  abnormal  heart 
symptoms  had  disappeared.  At  the  end  of  three 
months  had  lost  10  lbs.  more  in  weight.  It  is 
now  five  months  since  I  first  ordered  Tonica  for 
this  patient,  and  he  has  lost  about  25  lbs.  of  flesh, 
-while  his  general  condition  has  improved  very 
much.  The  only  change  I  made  in  his  diet  was 
to  order  him  to  abstain  from  saccharine  and  amy- 
laceous foods,  tea  and  coffee,  partake  of  but  one 
course  at  a  meal,  and  have  plenty  of  exercise  in 
the  open  air. 

Case  j. — Obesity  and  membranous  dysmenor- 
rhea. Mrs.  E.  B.,  housewife,  age  45,  height  5 
ft.  4  in.,  weight  226  lbs.    Heart  sounds  weak  and 


somewhat  irregular,  and  great  dyspnoea  upon  ac- 
tive exertion.  Symptoms  of  fatty  degeneration 
of  muscular  tissue  of  heart.  Had  suffered  for 
two  years  from  membranous  dysmenorrhcea.  the 
pain  each  month  being  intense  and  continuing 
from  two  to  three  days,  and  passage  of  membrane 
followed  by  very  excessive  menstrual  flow.  Gave 
a  pint  of  Tonica  each  day.  with  injections  into 
the  uterus  of  sol.  ac.  carb.  and  tr.  iodine  once  a 
week  during  the  intermenstrual  period,  commen- 
cing first  injection  two  days  after  cessation  of 
menses.  Regulated  diet  and  exercise  as  in  the 
preceding  case.  The  result,  after  three  months" 
treatment,  has  been  a  loss  of  20  lbs.  in  weight, 
with  complete  cure  of  dysmenorrhcea.  Condition 
of  blood  and  general  system  very  much  improved. 

Cast:  4. — Anaemia,  chronic  bronchitis  and  asth- 
ma. Mrs.  J.  W..  age  42,  housekeeper,  has  suf- 
fered several  years  from  chronic  catarrh  of  nose 
and  throat,  chronic  bronchitis,  anaemia  and  asth- 
ma. Applied  local  treatment  to  nose  and  throat 
and  gave  one  pint  Tonica  each  day  for  three 
months.  At  the  end  of  that  time  the  condition 
of  this  patient  was  very  much  better:  catarrh  and 
bronchitis  wholly  gone  and  no  more  attacks  of 
asthma.  Improvement  in  quality  of  blood  very 
noticeable.  I  had  previously  given  her  iron  in 
the  form  of  a  tincture  and  also  a  syrup  of  the 
albuminate,  and  combined  with  quinine  and 
strychnine,  but  the  effects  were  not  lasting,  as 
these  seem  to  be. 

Case  5. — Diabetes  mellitus.  Mr.  E.  R.,  age 
40,  engineer,  had  suffered  for  two  years  with 
gradual  loss  of  weight,  intense  thirst  and  in- 
creased appetite.  Former  weight  180  lbs. ;  weight 
at  beginning  of  treatment  with  Tonica  145  lbs. 
Amount  of  sugar  in  urine  13  grs.  to  oz.  Specific 
gravity  of  urine  1042.  I  had  previously  limited 
this  patient  to  a  strict  anti-diabetic  diet  and  tried 
all  the  usual  diabetic  remedies,  with  the  effect  of 
reducing  the  specific  gravity  of  the  urine  to  1037 
and  the  amount  of  sugar  somewhat,  but  not  ma- 
terially arresting  the  disease.  In  December,  1S90, 
I  commenced  giving  him  Tonica  water,  giving 
him  three  pints  each  day  and  no  other  liquid,  but 
continuing  the  anti- diabetic  diet.  At  the  end  of 
January,  1S91,  I  found  the  amount  of  sugar  in 
the  urine  reduced  to  5  grs.  per  oz.  and  specific 
gravity  1031,  with  marked  diminution  of  thirst 
and  appetite.  March  3,  I  found  the  amount  of 
sugar  reduced  to  3  grs.  per  oz.,  specific  gravity 
1029,  with  a  gain  in  flesh  of  10  lbs.  At  the  pres- 
ent time  (April  20,  1891),  there  is  only  a  trace  of 
sugar  in  the  urine,  its  specific  gravity  is  reduced 
to  102 1  ;  weight  of  patient  is  increased  to  165  lbs. 

Case  6. — Hypertrophy  and  valvular  lesions  of 
heart.  Mr.  R.  W.,  55  years  old,  shoe  manufac- 
turer, has  taken  a  pint  of  Tonica  each  day  for 
two  months,  with  general  improvement  of  blood 
and  circulation,  and  disappearance  of  cardiac 
murmurs. 


774 


THERAPEUTIC  ACTION  OF  TONICA  WATER. 


[May  30, 


Case  7. — Anaemia  and  neurasthenia  following 
"la  grippe."  Mr.  J.  R.,  artist,  age  42,  had  a 
very  severe  attack  of  epidemic  influenza,  which 
was  followed  by  general  nervous  weakness  and 
anaemia.  Gave  one  pint  Tonica  each  day  for 
two  months.  At  the  end  of  that  time  I  find  pa- 
tient's general  condition  greatly  improved,  appe- 
tite and  digestion  good,  and  no  remains  of  the 
inaladjr  apparent. 

Case  8. — Anaemia  and  intercostal  neuralgia. 
Mrs.  E.  F.  J.,  age  43.  Three  years  ago  had  two 
severe  haemorrhages  from  left  lung.  Has  suffered 
since  from  anaemia  with  periodical  attacks  of  in- 
tercostal neuralgia,  these  attacks  occurring  at  in- 
tervals of  a  month  or  six  weeks.  Gave  Tonica 
water,  a  pint  each  day  for  three  months,  with  the 
effect  of  materially  increasing  the  red  corpuscles 
of  the  blood  and  improving  the  appetite  and  di- 
gestion. It  has  been  now  five  months  since  I 
first  gave  this  treatment,  and  for  the  last  three 
months  she  has  had  no  neuralgia. 

Case  9. — Amenorrhcea,  chlorosis.  Emma  B., 
age  16,  had  never  menstruated,  but  had  attacks 
of  periodical  headaches,  recurring  each  month  ; 
is  anaemic  and  poorly  developed,  skin  yellow, 
complains  of  weakness  and  difficulty  of  breathing 
upon  slight  exertion,  and  shows  symptoms  of  hy- 
pertrophy of  heart.  Gave  one  pint  Tonica  each 
day  for  three  months,  and  ordered  her  to  take 
plenty  of  exercise  in  the  open  air,  with  good 
nourishing  diet,  which  soon  established  the  men- 
strual flow,  built  up  the  blood  and  regulated  the 
action  of  the  heart  and  circulation. 

Case  10. — Chronic  dyspepsia,  chronic  constipa- 
tion, acute  rheumatism.  Mrs.  S.  L,.,  age  56, 
housewife,  has  had  acid  dyspepsia  with  trouble- 
some flatulency  for  years,  with  occasional  attacks 
of  acute  rheumatism.  Is  pale,  anaemic,  poorly 
nourished,  and  bowels  constipated.  Gave  Tonica 
each  day  for  three  months,  with  disappearance  of 
dyspeptic  and  rheumatic  symptoms  and  general 
improvement  of  blood  and  digestion.  Action  of 
bowels,  after  once  established,  remains  good. 

In  a  paper  written  by  R.  M.  Griswold,  M.D., 
of  Portland,  Conn.,  a  physician  who  lives  in  the 
vicinity  of  the  springs  and  has  had  large  oppor- 
tunities for  testing  the  medicinal  qualities  of  the 
water,  and  entitled,  "  The  Medicinal  Use  of  High- 
land Tonica  Water  in  various  diseases,  but  espe- 
cially in  Dyspepsia  and  Diabetes  Mellitus,"  I  find 
a  very  interesting  history  of  its  use  in  thirteen 
cases,  of  which  five  were  cases  of  chronic  dyspcp 
sia  complicated  with  malaria  and  anaemia,  one  of 
acute  malarial  fever  with  acute  gastritis,  one  of 
chronic  cystitis,  one  of  chronic  eczema  in  a  child 
5  years  old,  and  five  cases  of  diabetes  mellitus. 
Dr.  Griswold  claims  such  good  results  from  tin 
use  of  this  water  in  these  cases,  and  the  history 
of  the  five  cases  of  diabetes  mellitus  is  so  very 
interesting,  that  with  his  permission  I  have  copied 
them  from  his  valuable  paper.    Dr.  Griswold  says: 


I  will  now  notice  five  cases  of  diabetes  mellitus  treated 
with  Tonica  water  after  all  other  means  of  treatment  had 
failed.     In  three  of  these  cases  the  disease  had  not  been 

I  even  arrested  by  treatment.  In  the  other  two  it  had  at 
times  apparently  been  arrested,  but  there  was  no  perma- 

J  nent  improvement.  Three  of  them,  before  coming  under 
my  observation,  had  been  limited  to  the  most  approved 
anti-diabetic  diet;  the  others  had  not  been  so  strictly  di- 
eted. In  all  five  cases  the  diagnosis  was  not  to  be  doubt- 
ed, as  sugar  in  large  amount  was  found  in  the  urine  re- 
peatedly, both  by  physicians  who  had  previously  treated 

j  them,  by  myself,  and  by  two  experts  in  urinary  analysis. 

J  The  treatment  in  all  these  cases  was  similar,  and  consisted 
first,  of  a  strictly  anti-diabetic  diet  as  follows:  plain  soups, 
oysters,  clams,  beef,  poultry,  bacon  and  ham,  all  kinds  of 

I  vegetables  except  potatoes,  turnips,  carrots,  parsnips, 
peas,  beans  and  tomatoes.  Cheese,  butter,  unsweetened 
custards,  buttermilk,  dry  and  sour  wines,  as  claret  and 
shefrv,  acid  fruits,  as  lemons,  currants,  etc.  Tea,  cream, 
coffee  without  sugar,  gluten  bread  from  flour  made  by 
Farwell  &  Rhines,  of  Watertown,  N.  Y.  In  each  case 
everything  of  a  saccharine  or  farinaceous  nature  was 
carefully  excluded,  also  all  malt  or  spirituous  liquors 
except  the  wines  mentioned,  and  no  water  other  than 
Tonica  allowed.  But  it  should  be  remembered  that  in 
three  of  these  cases  the  diet  had  before  been  as  carefully- 
regulated,  but  with  no  apparent  benefit. 

Case  1. — Quarryman,  35  years  old,  Swede.  Weighed 
when  in  health  190  lbs.,  present  weight  130  lbs.  Has 
been  able  to  do  no  work  for  five  months.  Passes  from 
4  to  6  quarts  of  urine  per  day.  Excessive  thirst,  mark- 
edly increased  appetite.  Pains  in  back,  arms  and  legs, 
constant  headache.  Sugar  14  grs.  to  the  oz.,  spec.  gr. 
1042.  This  case  came  under  my  observation  in  July,  18SS. 
He  was  put  upon  red  sulph.  arsenic  gr.  1-50  after  meals, 
and  limited  to  three  pints  of  Tonica  water  per  day  for 
drink.  At  the  end  of  one  month  a  second  examination 
of  the  urine  showed  sugar  5  grs.  to  the  oz.,  sp.  gr.  1032. 
In  three  months  the  amount  of  sugar  was  the  same  and 
the  sp.  gr.  had  not  decreased,  but  there  was  a  marked 
diminution  of  thirst  and  desire  for  food,  a  slight  gain  in 
flesh,  and  improvement  in  the  general  condition.  In  five 
months  the  sugar  had  decreased  to  2  grs.  to  the  oz.  and 
the  sp.  gr.  to  1028,  and  there  was  a  gain  of  S  lbs.  in  flesh. 
From  this  time  on  the  improvement  was  steady,  and  the 
gain  in  weight  correspondingly  so,  and  in  April  of  the 
next  year  he  resumed  his  work,  when  no  sugar  could  be 
detected  in  his  urine,  although  the  sp.  gr.  still  was  above 
normal — 1025.  He  had  gained  25  lbs.  in  flesh  and  was 
apparently  well.  He  remained  under  my  observation 
until  the  autumn  of  1S90,  when  he  returned  to  Sweden, 
at  that  time  weighing  170  lbs. 

Case  2,  in  nearly  every  respect  similar  to  Case  1,  came 
under  observation  in  September,  1888.  Previous  weight 
when  in  health  i6olbs.,  present  weight  12S  lbs.  Amount 
of  sugar  in  urine  not  noted,  sp.  gr.  1042.  Treatment  the 
same  as  in  previous  case.  At  the  end  of  six  months, 
sugar  3  grs.  to  the  oz.,  sp.  gr.  1031,  gain  in  flesh  8  lbs. 
August,  [889,  sugar  H  gr.,  sp.  gr.  [028,  gain  in  weight  13 
lbs.  Since  that  time  I  have  examined  the  urine  at  inter- 
vals of  about  three  months.  At  each  examination  traces 
of  sugar  are  found,  and  the  sp.  gr.  remains  a  little  above 
normal,  1022  to  1026,  but  lie  feels  well  ami  maintains  his 
present  weight  of  about  150  lbs. 

'  ast '.,'.  —  Quarryman,  Swede,  age  52.     Previous  weight 

[80  lbs.,  present  weight  140  lbs.     Not  able  to  work  for 

seven  months.     Came  under  observation  January,  1890. 

Treatment  as  in  previous  cases.     At  time  of  first   obser- 

iorj  was   passing  80  OZS.    of  urine   pel    day.     Sugar  20 

grs.   per  oz.,  sp.  gr.  1041.      At  last   observation,  January, 

■  sin,  he   had  gained  24  lbs.    in    flesh,  sugar  3  grs.  to  oz., 

[028.     He  is  working  every  day   ind  feels  well. 

Banker,  aged 54.     Had  diabetes  for  six  years. 

First  seen  in   February,  1S90.     Weight  --even  years  ago 

[92  lbs.,  present  weight  r 42  lbs.     No  note  of  amount  of 

sugar,  sp.  gr.  1038.    Treatment  as  in  previous  cases.    <  me 


.] 


EXPERIMENTS  WITH  TUBERCULIN. 


775 


year  from  date,  weight  165  lbs.,  sugar  none,  sp.  gr.  102 1. 
Cases- — Merchant,  age  47.    Disease  first  diagnosed  two 
years   before.     Came   under    observation    March,    1S90. 
Weight  124  lbs.,  previous  weight  ir  14  grs. 

to  oz.,  sp.  gr.  1037.     June.  1890,  sugar  11  grs.  to  oz.,  sp. 
gr,    1031.     September,  1S90,  sugar  4  grs.  to  oz.,  sp.  gr. 
lin  in  weight  24  lbs. 

.  4  and  5  arc  still  under  observation.  They  are 
now,  and  have  been  for  more  than  a  year,  using  from  one 
to  three  pints  of  Tonica  water  per  day.      I 

..is  discontinued  in  from  three  to  six  mouths 
from  the  commencement  of  its  use.  The  anti-diabetic 
mtinued.  but  in  each  case  1  attribute  the  much 
more  than  usually  favorable  results  to  the  Tonica  water, 
as  in  each,  but  more  especially  in  three  of  the  cases,  the 
same  treatment  had  been  faithfully  followed  for  periods 
of  from  six  months  to  six  years,  but  without  the  Tonica, 
and  in  none  of  them  had  there  been  any  improvement, 
and  in  all  but  two  the  disease  was  progressing  rapidly  to 
an  apparently  fatal  termination. 

My  friend,  Dr.  James  Tibbetts,  of  Hyde  Park, 
Mass.,  has  sent  me  the  history  of  two  cases  of 
gout  and  rheumatism  and  one  of  chronic  cystitis, 
in  which  he  has  used  Tonica  water  very  success- 
fully, but  for  the  sake  of  brevity  I  will  omit  the 
details. 

At  this  date  it  does  not  require  any  argument 
to  convince  the  medical  profession  of  the  utility 
and  value  of  iron  as  a  nutrient  tonic  for  the  blood. 
Of  its  peculiar  action  in  anaemia  Stille  says:  "The 
red  blood  discs  appear  to  be  the  organ  to  which 
iron  is  especially  directed,  and  by  which  the  ac- 
tivity of  animal  life  as  well  as  of  organic  life  is 
sustained  at  the  highest  point.  These  bodies  it 
is  which  by  contact  with  the  inspired  air  in  the 
lungs  attract  and  become  impregnated  with  oxy- 
gen, the  essential  agent  in  all  the  compositions  and 
decompositions  which  sustain  life  in  the  tissues, 
acquiring  thereby  the  scarlet  hue  of  arterial  blood, 
which  they  lose  with  their  oxygen  in  their  pas- 
sage through  the  tissues  to  the  venous  system. 
Thus  it  would  appear  that  the  activity  of  nutri- 
tion, and  probably  also  of  calorification,  is  de- 
pendent upon  the  iron  in  the  blood ;  and  that 
when  the  red  blood  discs  which  contain  it  are 
most  abundant,  all  of  the  functions  of  the  econ- 
omy attain  their  highest  degree  of  activity  and 
vigor."  And  in  his  theory  of  the  operation  of 
iron  he  says :  "  Iron,  on  entering  the  blood-ves- 
sels, combines  immediately  with  the  discs  which 
have  not  yet  acquired  or  have  lost  more  or  less  of 
their  ferruginous  element.  It  enters  the  blood  as 
a  chloride,  is  decomposed,  combines  with  the  discs 
as  a  carbonate  of  the  protoxide  of  iron,  and  in  the 
lungs  gives  up  carbonic  acid  and  absorbs  oxygen, 
and  is  thereby  converted  into  a  peroxide.  The 
white  corpuscles  are  destitute  of  iron,  but  when 
once  saturated  with  it  neither  they  nor  the  red 
corpuscles  can  receive  any  more." 

But  in  order  to  obtain  in  the  system  the  effects 
of  iron  as  a  specific  nutrient  tonic  it  is  necessary, 
in  persons  of  a  bilious  temperament  or  those  suf- 
fering from  stomach  or  intestinal  indigestion,  or 
torpidity  of  the  kidneys,  to  gently  stimulate  these 
organs,  thereby  increasing  their  activity  and  their 


powers  of  absorption,  assimilation  and  excretion, 
as,  without  a  healthy  action  of  these  organs,  most 
preparations  of  iron  prove  inert  and  act  as  a  clog 
upon  the  system  ;  and  also  to  present  the  iron  to 
the  system  in  an  exceedingly  soluble  condition, 
so  that  it  may  be  easily  absorbed  and  assimilated 
by  the  stomach  and  bowels. 

Judging  from  my  own  experience  with  this 
water,  it  meets  both  these  requirements  more  per- 
fectly than  any  other  ferruginous  preparation  which 
I  have  ever  found,  and  for  that  reason  is  a  most 
valuable  adjuvant  to  other  remedies  in  the  treat- 
ment of: 

1.  Anaemia,  amenorrhcea  and  chlorosis. 

2.  All  menstrual  derangements  attended  with 
periodical  haemorrhages. 

3.  In  organic  disease  of  the  heart. 

4.  In  nervous  affections  complicated  with  anae- 
mia, as  neuralgia,  chorea,  etc. 

5.  In  depraved  conditions  of  the  blood,  as 
constitutional  syphilis,  chronic  albuminuria,  and 
scrofula  with  anaemia. 

6.  In  phthisis,  chronic  bronchitis  and  chronic 
catarrh. 

7.  As  an  alterative  and  nutrient  tonic  after 
eruptive  fevers,  as  measles,  scarlet  fever,  and  in 
the  anaemia  following  epidem  c  influenza. 

8.  In  chronic  malarial  poisoning. 

9.  In  errors  of  malassimilation  and  malnutri- 
tion, as  diabetes  mellitus,  obesity,  etc. 

10.  In  chronic  constipation  complicated  with 
acid  dyspepsia  and  anaemia. 


A  REPORT  OF  THE  EXPERIMENTS  WITH 
TUBERCULIN  AT  THE  GOOD  SA- 
MARITAN HOSPITAL  IN  CIN- 
CINNATI. 
BY  S.  P.   KRAMER.  M.D., 

OF    CINCINNATI,  O. 

The  following  is  a  report  of  the  experiments 
with  tuberculin  in  the  treatment  of  tuberculo- 
sis, carried  on  in  conjunction  with  Prof.  Whit- 
taker  at  the  Good  Samaritan  Hospital  in  Cincin- 
nati. 

The  work  was  begun  on  January  14th  and  has 
been  continued  up  to  the  present  time.  Fifteen 
weeks'  experience  with  the  remedy  is  but  a  short 
time  during  which  to  gather  material  that  shall 
give  us  definite  results.  This  is  offered  as  the  re- 
sult of  observation  during  that  time,  to  be  taken 
for  what  it  is  worth.       » 

I  shall  report  only  those  cases  in  which  the 
remedy  was  used  systematically  as  treatment, 
leaving  out  the  cases  in  which  it  was  used  for  di- 
agnostic purposes. 

The  injection  of  tuberculin,  and  nutritious 
diet  and  alcohol,  constituted  the  only  treatment 
used. 

In  all.  then,  there  are  twenty-nine  cases.     Two 


?76 


EXPERIMENTS  WITH  TUBERCULIN. 


[May  30, 


of  these  were  cases  of  tuberculosis  of  the  lym- 
phatic glands  primarily.  As  they  present  many 
points  of  interest,  I  shall  dwell  on  them  some- 
what in  detail. 

The  first  is  the  case  of  a  young  man,  age  24. 
Since  childhood  he  had  suffered  from  repeated  at- 
tacks of  quinsy,  and  chronic  inflammation  of  the 
tonsils  and  pharynx.  Three  years  ago  he  be- 
gan to  be  troubled  with  enlargement  of  the  cervi- 
cal lymphatics.  This  continued  and  led  to  the 
formation  of  three  sinuses,  which,  when  he  was 
admitted,  were  discharging  a  slight  quantity  of 
thin  serous  fluid.  Eighteen  months  ago  he  be- 
gan to  notice  cough,  with  mucous  expectoration. 
This  was  followed  by  night-sweats,  haemoptysis 
and  loss  of  weight. 

Examination  revealed,  besides  the  general  en- 
largement of  the  cervical  lymphatics,  dulness  on 
percussion,  with  rude  inspiration  and  prolonged 
expiration  over  the  right  apex.  Tubercle  bacilli 
was  found  in  the  sputum. 

The  result  here  has  been  very  satisfactory.  The 
glands  have  diminished  in  size,  cough  and  expec- 
toration have  disappeared,  the  patient  has  gained 
ten  pounds  in  weight  and  the  anaemia  has  been 
greath-  ameliorated. 

The  other  case  is  one  of  four  years  duration. 
The  trouble  began  in  the  lymphatics  of  the  right 
neck,  extended  to  the  left,  involving  the  entire 
chain.  About  eighteen  months  ago  there  occur- 
red an  enlargement  just  beneath  the  left  clavicle; 
it  suppurated,  was  opened,  and  the  sinus  formed 
Still  remains.  This  sinus  is  found  to  communi- 
cate with  a  small  cavity  in  the  left  apex.  On 
forced  expiration  air  escapes  from  the  opening. 
With  the  exception  of  the  left  apex  the  lungs 
seem  to  be  free  from  disease.  The  pulmonary 
symptoms  began  after  the  disease  in  the  glands. 

The  progress  in  this  case  has  been  slow  but 
appreciable.  The  glands  have  diminished  in 
size.  The  cavit}'  is  diminishing  in  extent,  the 
sides  seemingly  granulating  and  filling  it  up. 
After  every  dose  of  tuberculin  the  discharge 
from  the  sinus  is  increased  in  amount,  in  cellular 
elements  and  bacilli 

Both  these  cases  illustrate  the  infection  of  the 
lungs  and  pulmonary  lymphatics,  from  the  lym- 
phatics higher  up.  In  the  one  the  infection  prob- 
ably took  place  in  the  tonsils  or  pharynx. 

The  importance  of  attacking  such  cases  in  their 
incipiency  is  self  evident. 

The  remaining  twenty-seven  are  cases  of  pul- 
monary disease.  Of  th^se,  17  were  in  the  ad- 
vanced stages,  of  the  kind  in  which  but  little  im- 
provement is  to  be  hoped  for.  Four  of  these 
have  died;  but  neither  clinically  nor  post-mortem 
was  there  any  sign  of  an  acute  exacerbation,  or 
that  the  treatment  had  hastened  the  end. 

Ten  have  remained  unchanged.  That  is,  the 
natural  course  of  the  disease  has  not  been  influ- 
enced to  any  permanent  degree. 


Three  of  these  cases  show  marked  improve" 
ment.  They  have  gained  in  weight,  and  strength- 
The  cough  and  expectoration  have  diminished- 
Night-sweats  have  ceased  and  their  general  health 
has  been  improved.  This  is  not  due  to  the 
psychic  effect.  Because,  as  it  has  been  our  expe- 
rience that  all  the  cases  do  well  for  the  first  few 
weeks,  cases  have  only  been  counted  as  improved 
in  which  the  improvement  has  lasted  beyond  the 
first  few  weeks. 

The  other  ten  cases  are  cases  in  the  first  stage. 
That  is,  before  signs  of  breaking  down  can  be  ob- 
served. Three  of  these  remain  unchanged.  In 
these  cases  while  there  are  no  signs  of  cavities, 
yet  the  presence  of  considerable  hectic,  and  chills, 
denote  that  the  pus  micrococci  are  responsible 
for  a  considerable  part  of  the  'symptoms,  and 
against  these  the  fluid  has  no  effect. 

The  remaining  seven  have  all  improved.  They 
all  show  a  marked  diminution  in  cough,  expector- 
ation, and  night-sweats.  The  dulness  of  percus- 
sion still  remains,  but  the  bronchial  catarrh  has 
for  the  most  part  disappeared.  The  bacilli  in  the 
sputum  have  become  less.  They  have  gained  in 
weight  and  strength. 

Three  of  these  cases  have  improved  to  a 
marked  degree,  and  were  it  not  for  the  fact  that 
there  still  may  be  found  an  occasional  bacillus  by 
the  Biedert  method,  they  might  be  called  cured. 

We  must,  however,  be  very  careful  in  speaking 
of  the  cure  of  tuberculosis.  This  is  not  accom- 
plished in  a  few  weeks,  and  relapses  are  the  rule. 

Thus  it  will  be  seen  that  the  surgical  and  in- 
cipient cases  do  the  best.  Yet  there  are  excep- 
tions to  the  rule,  and  if  we  do  our  patients  no 
harm,  it  is  but  just  to  give  them  the  benefit  of 
the  doubt. 

In  regard  to  the  diagnostic  value  of  the  reme- 
dy: This  property  of  the  fluid  has  been  called  in 
question  of  late.  In  judging  of  this  point  we 
must  bear  in  mind  that  only  a  local  reaction,  a 
reaction  at  the  seat  of  the  disease,  is  of  diagnostic 
value.  A  mere  rise  of  temperature  is  of  no  value 
at  all. 

We  must  take  a  decided  stand  against  the 
opinion  that  the  use  of  the  fluid  is  not  justifiable 
for  diagnostic  purposes.  On  the  contrary,  a^ 
Prof.  Koch  has  said,  in  the  future  the  physician 
who  fails  to  use  it  and  thus  neglects  to  give  his 
patients  the  benefit  of  an  early  diagnosis  will  be 
guilty  of  gross  negligence  to  say  the  least.  One 
of  the  greatest  sources  of  good  will  spring  from 
this  property  of  the  fluid.  For  by  its  use 
alone  will  we  be  able  to  discover  the  very  incip- 
ient stages  of  tubercular  disease  and  then  treat 
them  to  advantage. 

In  the  use  of  the  fluid  we  have  observed  cer- 
tain contra  indications  and  phenomena  that  are 
u  01  thy  of  notice. 

First,  in  regard  to  technique. 

The  Koch  syringe  has  been  adhered  to  as  very 


i89i.] 


EXPERIMENTS  WITH  TUBERCULIN. 


easily  kept  clean,  and  on  account  of  the  accuracy 
with  which  the  dosage  is  obtained. 

Second,  as  to  dosage. 

As  a  rule  we  l>egin  i  mg.  and  repeat  this  as 
often  as  it  causes  any  rise  of  temperature  what- 
ever. The  dose  is  then  slowly  increased  i  mg.  at 
a  time,  avoiding  all  reaction.  This  plan  has 
proven  to  be  the  wisest.  The  febrile  reactions  are 
not  at  all  necessary,  and  they  cannot  but  dimin- 
ish the  patient's  strength.  At  first,  before  we  saw 
the  wisdom  of  this  method,  we  had  very  severe 
reactions  and  the  progress  was  very  materially 
hindered. 

By  following  the  plan  advised  above,  the  pa- 
tients by  a  careful  and  nutritious  diet  may  be 
made  to  gain  in  weight  from  the  beginning, 
which  they  will  not  do  if  severe  reactions  are  pro- 
duced. Indeed  those  cases  have  done  the  best  in 
which  there  were  scarcely  any  rise  of  tempera- 
ture produced  during  the  entire  treatment. 

The  fluid  seems  to  be  contra-indicated  in  cases 
■with  intestinal  complications.  Clinically  these 
cases  do  poorly,  the  diarrhoea  is  increased  and  the 
patients  diminish  in  weight  and  vitality.  Post- 
mortem examinations  reveal  that  perforation  is 
often  rendered  dangerously  imminent,  although 
few  such  accidents  are  on  record. 

In  cases  in  which  there  is  a  considerable  hec- 
tic, accompanied  with  chills,  giving  evidence 
that  the  complication  is  due  to  a  septic  process 
•caused  by  the  presence  of  the  pus  micrococci,  the 
remedy  does  little  if  any  good. 

This,  however,  does  not  include  all  cases  with 
an  evening  rise.  Thus,  I  have  repeatedly  seen 
in  patients  where  the  evening  temperature  reach- 
ed 101- 102  before  treatment,  after  a  few  weeks 
treatment  the  hectic  disappears,  there  being  no 
fever  except  that  caused  by  the  injection.  Pro- 
bably in  these  cases  the  fever  was  caused  by  the 
tubercular  process  and  not  by  the  entrance  of  the 
micrococci. 

Haemoptysis  occurring  during  the  treatment 
seems  to  indicate  the  remission  of  the  remedy  for 
a  time.  When  we  consider  the  histological 
changes  caused  by  the  fluid,  the  force  of  not  pro- 
ducing an  acute  congestion  in  these  cases  strikes 
us  at  once.  This  complication  occurred  in  one  of 
our  patients.  The  treatment  was  remitted  for 
two  weeks  and  the  haemorrhage  not  recurring, 
the  treatment  was  resumed.  There  was  no  further 
haemorrhage  and  the  progress  of  the  case  is  favor- 
able. 

Perhaps  it  would  be  wise  in  all  cases  to  remit 
the  treatment  for  a  week  at  a  time  occasionally, 
sending  the  patient  from  the  hospital.  We  have 
noticed  the  efficacy  of  this  in  a  number  of  cases. 

The  following  is  a  case  showing  the  extreme 
irregularity  of  the  action  of  the  remedy.  The 
patient  is  a  woman  of  thirty,  pulmonary  tubercu- 
losis, primary  stage,  at  the  left  apex. 

On  January  25,  the  first  injection  of  2  mg.  was 


given;  no  reaction.  January  27,  5  mg. ;  marked 
local  reaction,  cough,  dyspnoea,  chill,  tempera- 
ture 102 

January  29,  5  mg. ;  local  reaction  slight,  tem- 
perature IOi 

After  this  the  dosage  was  gradually  increased 
g.  on  February  15.  At  no  time  during 
is  there  any  reaction.  February  iS, 
6  eg.  were  given  and  there  followed  a  very  sharp 
reaction  indeed,  marked  dyspnoea,  cough,  nausea, 
and  vomiting;  temperature  104.  The  next  day 
the  temperature  had  fallen  to  the  normal,  expec- 
toration being  greatly  increased  and  bacilli  more 
numerous.  February  21,  5  eg.;  no  reaction. 
February  23,  6  eg.;  no  reaction. 

As  seen  from  the  above  report  we  cannot  be  too 
careful  in  increasing  the  dose  even  though  the  re- 
actions be  not  present. 

And  now  a  few  remarks  as  to  the  opinion  in  the 
minds  of  the  profession  and  laity  as  to  the  efficacy 
of  the  treatment. 

The  pendulum  has  swung  to  the  other  side  and 
unlike  the  mechanical  pendulum  it  has  perhaps 
gone  further  to  the  left  than  to  the  right.  But 
like  its  mathematical  brother  it  will  swing  back 
and  continue  to  oscillate  until  it  comes  to  its  true 
point,  to  the  calm  and  quiet  of  the  middle  line. 
L,et  me  seriously  warn  against  throwing  the  rem- 
edy away.  It  is  too  early,  we  have  not  had  suf- 
ficient time  to  pass  final  judgment.  The  most 
careful  observation  and  study  of  years  will  alone 
give  us  that. 

That  the  remedy  is  a  specific  against  tubercu- 
lar disease  no  one  who  has  seen  its  action  in  a 
case  of  lupus  will  doubt.  In  so  far  as  regards  the 
science  of  medicine,  the  specific  character  of  the 
remedy  may  be  considered  a  settled  fact.  The 
cure  of- one  case  of  lupus  is  sufficient  evidence  for 
this. 

Everything  else,  the  determination  of  suitable 
cases,  surgical  aid,  prevention  of  accident,  are  de- 
tails to  be  settled  by  the  physician's  art.  As 
Professor  Koch  said,  "In  all  cases,  the  art  of  the 
physician  must  be  allowed  free  scope  in  that  we 
shall  carefully  individualize,  and  all  means 
known  to  the  physician  or  surgeon  shall  be 
brought  to  the  aid  of  the  remedy.'' 

This  is  not  to  be  done  in  a  day.  We  have  but 
to  remember  our  experience  with  mercury  and 
iodine  as  specifics  against  lues.  These  remedies 
have  been  known  to  medicine  for  centuries,  but 
it  is  only  within  the  present  generation  that  we 
have  learned  the  proper  use  of  them.  Perhaps 
the  full  benefits  of  the  remedy  will  be  scarcely  felt 
by  the  present  generation. 

To  continue  the  above  analogy:  May  it  not  oc- 
cur that  the  history  of  tuberculosis  in  the  course 
of  a  century  will  undergo  the  same  change?  That 
the  disease  will  lose  much  of  its  virulence  and 
that  the  advanced  cases  with  such  extreme  de- 
struction of  tissue  will  become  a  rare  occurrence? 


778 


ARSENIC  AS  A  DOMESTIC  POISON. 


[May  30, 


This  is  what  we  must  look  forward  to  and  aid 
with  all  our  powers  as  physicians. 

The  objection  has  been  raised  that  the  treat- 
ment has  in  some  cases  caused  a  spreading  of  the 
disease  and  acute  tuberculosis.  Lkbmann  has 
stated  that  he  has  found  tubercle  bacilli  in  the 
blood  of  patients  treated  with  the  fluid.  These 
examinations  have  been  repeated  by  Professors 
Ewale  and  Guttmann  in  a  number  of  cases,  and  no 
bacilli  found.  A  careful  examination  of  Lipp- 
mann's  slides  have  revealed  the  fact  that  the 
glasses  used  contained  traces  of  old  sputum.  They 
had  not  been  sufficiently  cleaned. 

To  the  charge  that  the  fluid  contained  tubercle 
bacilli,  and  that  we  were  in  danger  of  giving  our 
patients  acute  tuberculosis  by  its  use,  Dr.  Lib- 
bertz  has  replied  that  there  were  a  few  tubercle 
bacilli  in  the  preparation,  but  that  they  had  been 
killed  by  repeated  boiling. 

Inoculation  experiments  have  confirmed  this 
statement. 

The  injection  of  2  eg.  under  the  skin  of  the 
speaker   gave    rise    to  the  following  symptoms: 

Four  hours  after  the  injection  of  2  eg.  under 
the  skin  of  the  left  forearm,  I  experienced  severe 
headache,  backache,  malaise  and  nausea.  The 
temperature  rose  to  99.8,  pulse  full,  108.  The 
rate  of  breathing  was  also  increased  to  about  30. 
These  symptoms  continued  for  four  hours,  when 
the  thermometer  registered  98.  That  night  I  slept 
comfortably;  the  following  morning  the  arm  was 
sore  and  tender  and  swollen.  There  developed  a 
lymphangitis  which  lasted  for  48  hours.  Dur- 
ing this  time  the  thermometer  reached  102.  I 
suffered  from  severe  headache  and  malaise.  The 
trouble  subsided,  however,  leaving  absolutely  no 
symptoms  whatsoever.  The  effect  of  the  fluid 
had  passed  off  after  twelve  hours.  The  subse- 
quent lymphangitis  I  attribute  to  the  fact  that 
the  syringe  used  was  not  sterilized,  and  secondly 
that  the  forearm  was  not  a  well  chosen  place  for 
the  injection. 

I  have  learned  these  points  from  this  experi- 
ence: 

i .  To  adhere  to  the  Koch  syringe,  rather  than 
the  ordinary  hypodermic  which  I  had  used  in  my 
own  case. 

2.  To  appreciate  the  wisdom  of  Koch's  recom- 
mendation to  use  the  interscapular  region  as  the 
site  of  the  injection. 

3.  That  the  injection  of  tuberculin  does  not 
produce  any  deleterious  effects  in  healthy  peo- 
ple. I  would  like  to  state  that  mine  was  the  only 
case  in  my  experience  in  which  there  occurred 
any  trouble  at  the  site  of  the  injection. 

Perhaps  in  a  number  of  cases  where  acute  tu- 
berculosis was  found,  the  remedy  had  lighted  up 
a  number  of  latent  tubercular  points,  rather  than 
that  they  had  been  produced  by  a  scattering  of 
the  bacilli  from  the  older  lesions.  Further  study 
and  observation  may  lead  us  to  avoid  such  cases 


in  the  future.  Above  all,  we  are  to  remember  the 
work  and  instruction  of  Professor  Koch,  and  that 
the  chapter  on  the  treatment  of  tuberculosis  is  not 
a  closed  one  by  any  means. 


ON  THE  CHARACTER  OF   THE  EVI- 
DENCE AS  TO  THE  INJURIOUS- 
NESS  OF  ARSENIC  AS  A  DO- 
MESTIC POISON. 

Read  in  the  Section  of  Practice  of  Medicine  and  Physiology,  at  the 

Forty-second  Annual  Meeting  of  the  American  Medical  AssO' 

ciation,  held  at  Washington,  D.  C.  May  58,1891. 

BY  JAMES  J.  PUTNAM,  M.D., 

OF    BOSTON,    MASS. 

This  communication  is  an  attempt  to  place  in 
as  clear  a  light  as  possible,  the  credibility  of  the 
evidence  that  symptoms  of  arsenical  poison  may 
occur  as  a  result  of  the  ordinary  exposures,  such 
as  are  met  with  in  domestic  or  civic  life. 

I  shall  not  try  to  indicate  the  frequency  with 
which  such  poisoning  occurs,  but  only  the  possi- 
bility that  it  may  occur  ;  for  the  question  as  to 
frequency  can  only  be  satisfactorily  answered 
when  a  large  body  of  facts  have  been  accumu- 
lated, especially  those  relating  to  the  obscurer 
forms  of  chronic  poisoning.  The  first  thing  to 
be  done,  would  seem  to  be  to  disprove  the 
opinion  which  has  so  much  weight,  even  among 
those  who  would  otherwise  credit  the  evidence  of 
domestic  poisoning,  tha^  not  enough  arsenic 
could  possibly  reach  the  tissues  to  cause  serious 
effects. 

For  this  purpose  I  shall  show :  first,  that 
urine  analyses  indicate  beyond  cavil  that  the  ex- 
posures of  civic  life  are  a  very  frequent  cause  of 
arsenical  contamination  ;  next,  that  our  knowl- 
edge of  the  laws  of  elimination  indicates  that 
the  excretion  of  the  small  quantities  which  pass 
off  with  the  urine  day  after  day  for  months  and 
years,  in  the  case  of  many  persons  in  the  com- 
munity, implies  the  presence  by  accumulation  of 
much  larger  quantities  in  the  tissues.  The 
dangers  attending  domestic  exposure  might,  in 
fact,  be  fairly  compared  with  the  dangers  attend- 
ing the  medical  use  of  arsenic,  and  I  shall  show 
that  these  dangers  are  usually  underestimated. 
If  in  the  cases  of  domestic  exposure,  the  single 
doses  are  smaller,  yet  on  the  other  hand,  the 
period  of  exposure  is  much  greater  ;  the  patient 
is  not  under  the  watchful  care  of  a  physician  ; 
the  character  of  the  arsenical  compounds  some- 
times brings  special  clangers  ;  the  place  of  ab- 
sorption is  often  the  lungs  and  not  the  stomach  ; 
and  there  is  some  reason  to  believe,  that  there  are 
certain  very  chronic  and  exceptional  forms  of 
poisoning,  following  the  repeated  use  of  minute 
doses,  with  which  we  are  not  yet  thoroughly 
familiar,  and  which,  in  the  absence  of  signs  of 
acute  poisoning,    are    likely    to   be  overlooked. 


I89i.] 


ARSENIC  AS  A  DOMESTIC  POISON. 


779 


The  dangers  attending  the  medicinal  use  of 
arsenic  have  been  underestimated  by  physicians, 
partly  because  of  their  relative  infrequency  ; 
partly  because  the  first  indications  of  them 
(redema  of  the  face,  irritation  of  the  mucous 
membranes,  etc.,)  are  so  familiar,  and  usually  so 
amenable  to  treatment,  that  they  are  hardly 
looked  upon  for  what  they  are,  namely,  impera- 
tive signs  that  symptoms  of  more  serious  import 
are  not  far  off  (as  shown  by  the  experiments  of 
Vaudrey). 

Again,  the  effects  of  habituation,  the  storage 
of  the  arsenic  in  a  temporarily  innocuous  form 
(albuminoid  compounds  of  arsenic ;  Dogiel, 
International  Congress,  Copenhagen,  1886),  and 
constitutional  indifference  to  the  poison  confer  as 
a  rule  such  complete  immunity,  that  those  not 
so  fully  protected  by  nature,  or  with  whom  the 
protection  ceases  after  a  time,  for  one  or  another 
cause,  stand  in  all  the  greater  danger  on  account 
of  the  false  impression  of  security  which  is  spread 
abroad,  and  which  makes  physicians  impatient 
of  studying  the  obscurer  indications  of  poisoning. 

The  most  important  collateral  facts  bearing  on 
the  question  of  the  quantity  of  arsenic  absorbed 
in  domestic  poisoning  cases,  are,  as  above  stated, 
those  obtained  by  urine  analyses,  of  which  large 
numbers  have  been  made  by  the  chemists  as- 
sociated with  Harvard  University.1    , 

To  speak  of  only  the  most  recent  and  con- 
clusive series  of  experiments.  Dr.  C.  P.  Worces- 
ter, of  Harvard  University,  a  skilled  chemist  and 
•with  large  experience  in  this  particular  analysis, 
has  examined  for  my  brother  and  myself  one 
hundred  and  fifty  urines,  taken  from  patients 
most  of  whom  presented  certain  obscure  symp- 
toms, but  not  such  as  would  have  justified  the 
diagnosis  of  arsenical  poisoning,  and  has  found 
arsenic  in  more  than  thirty  per  cent.,  in  quanti- 
ties varying  from  a  trace  to  upwards  of  .05  mg. 
to  the  litre. 

About  half  of  these  patients  were  private, 
-while  the  other  half  were  from  the  clinic  for  Dis- 
eases of  the  Nervous  System  of  the  Massachusetts 
General  Hospital,  and  many  of  the  latter  were 
chosen  as  presenting  no  arsenical  sj-mptoms. 

These  results  conclusively  show  :  first,  that 
the  community  is  exposed  to  arsenical  contam- 
ination on  a  very  large  scale,  so  that  the  oc- 
casional occurrence  of  poisoning,  due  perhaps  to 
special  susceptibility,  unusual  exposure,  failure 
of  elimination,  etc.,  need  occasion  no  surprise, 
and  ought  to  be  carefully  sought  for  by  every 
physician  ;  second,  that  the  mere  finding  of  arsenic 
in  the  urine  in  a  doubtful  case  does  not  prove 
that  the  symptoms  were  of  arsenical  origin. 

What  does  the  elimination  of  these  small 
quantities  indicate  as  to  the  amount  present  in 
the  tissues  ? 

•  Especiallv  Profs.  E.  S.  Wood,  C  Harrington.  W.  B.  Hills.  C.  R. 
Sanger,  mow"  of  Annapolis  Naval  Academy),  H.  B.  Hi'.'.  C.  V 
Worcester.  A.  M.  Cornev. 


It  was  formerly  believed  that  arsenic  differed 
from  lead  in  being  eliminated  rapidly  and  in  not 
uniting  with  the  tissues.  Both  of  these  opinions 
are  now  disproved.  Arsenic  has  been  found  in 
the  liver  bones  (Gibbj  six  months  after  the  ces- 
sation of  a  course  of  arsenical  treatment  (which, 
by  the  way,  led  to  the  patient's  death);  it  has 
been  found  in  the  urine  even  nine  months  after 
the  apparent  removal  of  the  patients  from  ex- 
posure in  "domestic"  cases;  and  Prof.  E.  S. 
Wood  has  recently  found  traces  in  the  urine  as 
long  as  three  months  after  cessation  of  a  short 
course  of  arsenical  treatment  (these  experiments 
are  not  yet  concluded,  and  I  quote  a  verbal  state- 
ment only  as  relating  to  one  or  two  cases). 

Arsenic  does  then,  in  some  cases  at  least,  tend 
to  accumulate,  and  the  daily  elimination  of  .03 
to  .3  mg.  (gr.  jircTf  to  TJ5,  computed  by  suppos- 
ing two  litres  of  urine  to  be  excreted  daily,  and 
to  contain  two-thirds  of  the  whole  elimination  of 
the  arsenic),  must  indicate  the  presence  in  the 
tissues  of  quantities  quite  large  enough  to  cause 
poisoning,  provided  it  should  become  active  all 
at  once,  or  provided  that  for  any  reason  the 
elimination  should  be  checked. 

That  the  effects  of  arsenic — like  those  of  lead, 
and  phosphorus — are  in  a  measure  dependent 
upon  the  action  of  the  stored  up  poison,  is  shown 
by  the  fact  that  the  symptoms  of  medicinal  poi- 
soning often  appear  only  when  a  given  dose  has 
been  taken  for  some  time,  after  which  the  patient 
is  apt  to  show  an  increased  sensitiveness  (though 
this  is  not  regularly  the  case*.  In  the  case  of 
lead  it  is  a  matter  of  common  knowledge  that 
sudden  outbreaks  may  occur  after  lead  drinking 
water  has  been  used  for  a  long  time,  as  well  as 
among  the  workers  in  lead  mines.  In  the  case 
of  arsenic,  it  is  quite  common  to  find  the  paralytic 
symptoms  breaking  out  days  or  weeks  after  a 
single  large  dose  or  repeated  smaller  doses. 

Is  the  use  of  arsenic  in  maximum  therapeutic 
doses  unattended  with  danger? 

This  is  by  no  means  the  case,  although  the 
doses  used  are  far  less,  at  their  largest,  than  those 
taken  by  the  Styrian  peasants  with  impunity. 

Habituation  to,  large  doses  may  by  care  be 
brought  about,  but  in  the  attempt  to  do  this  the 
lesser  symptoms  of  poisoning  are  frequently  ex- 
cited, and  the  graver  symptoms  occasionally. 

No  doubt  there  are  but  few  physicians  who 
have  had  these  graver  symptoms  in  their  own 
practice,  but  this  is  certainly  because  they  have 
taken  pains  to  avoid  them,  for  the  experiments 
of  Vaudrey  upon  himself  and  others,  have  shown 
that  by  increasing  a  little  further  the  doses  which 
excite  the  lighter  symptoms,  serious  prostration 
and  local  symptoms  regularly  follow.  A  few 
years  ago  I  collected  a  number  of  the  severer 
cases  of  medicinal  poisoning,2  and  I  give  here  a 
few  of   them    in    brief    outline.     The   cases   of 

=  Boston  Medical  and  Surgical  Journal.  Marc!1.  - 


780 


ARSENIC  AS  A  DOMESTIC  POISON. 


[May  30 


paralysis  are  especially  noteworthy  because  these 
are  now  known  to  occur  frequently  in  arsenical 
poisoning  of  a  certain  grade,  and,  as  we  shall 
see,  they  reappear  among  the  cases  of  "domestic" 
poisoning. 

1.  Gaillard:  Typical  arsenical  paralysis  follow- 
ing full  closes  of  Fowler's  solution,  increased  to  the 
limits  of  tolerance  and  administered  for  five 
weeks. 

2.  Canada  Med.  and  Surg.  Journ.,  1886-1887, 
v.  15,  p.  716.  Arsenical  paralysis,  ending  fatally, 
after  large  doses  ("Ixx  to  xxx)  of  Fowler's 
solution.  The  autopsy  showed  the  presence  of 
neuritis. 

3.  Hastings  :  Arsenical  paralysis  with  neuritic 
symptoms,  following  "l  iij  to  v  of  Fowler's 
solution  continued  for  some  weeks. 

4.  Gibb :  Eong  course  of  arsenical  treatment 
ending  in  neuritis,  causing  disorders  of  sensi- 
bility, pain,  and  paralysis.  The  patient  died  six 
months  later,  having  taken  no  arsenic  in  the  in- 
terval, and  traces  of  arsenic  were  found  in  the 
liver  and  bones. 

5.  Dublin  Quarterly  Jr.,  v.  36,  p.  474.  "liij  of 
Fowler's  solution,  were  taken  daily  for  ten  or 
twelve  months,  at  the  end  of  which  time  "symp- 
toms of  acute  arsenical  poisoning"  came  on, 
ending  rapidly  in  death. 

6.  C.  E-  Dana  :  Arsenical  paresis  with  ataxia. 
"Ixxx  of  Fowler's  solution  three  times  daily,  in 
spite  of  the  fact  that  the  dose  had  been  gradually 
increased. 

7.  Hooper :  "l  v  of  Fowler's  solution  were 
given  three  times  daily  for  eight  months.  Toward 
the  end  of  this  time  the  following  symptoms 
came  on  and  increased,  ending  three  months  later 
in  death  ;"  conjunctivitis  with  oedema,  tachy- 
cardia, tremor,  excessive  and  progressive  prostra- 
tion, insomnia,  irritation  of  the  trachea  and 
lar.  nx. 

8.  Jones  :  1  y  to  x  v  of  liquor  arsenicalis 
given  three  times  daily  ;  at  the  end  of  a  month, 
intense  gastro-intestiual  irritation,  scanty  urine, 
trophic  changes  in  the  legs,  sensory  and  motor 
paresis. 

9.  Burne,  cited  by  Taylor:  Gr.  fa  of  arsenious 

lily   for  four   days;    then,  inflammation  of 
the  stomach,  delirium,  debility  and  exhaustion. 

10.  Taylor:  Gr.  fo  of  arsenious  acid  taken 
twice  daily  for  seven  days,  then,  "sickness,"  ir- 
ritation of  the  skin,  and  eczema  over  the  whole 
body. 

11.  Taylor:  "l  xof  liquor  arsenicalis  chloridi 
(said  to  be  a  very  poisonous  preparation)  taken 
three  times  in  the  course  of  twenty-four  hours  ; 
then,  constriction  in  the  throat,  pain  and  irrita- 
tion of    the  stomach   and  bowels,   tingling   and 


ilv  shown  by  the  history  of  acute  arsenical 
that  symptoms  once  in 

irsenic  is  taken.     The-  paralysis,  foi   ex- 
pear  for  days  or  weeks,  and  even  months. 


numbness  of  the  hands  and  feet,  with  paresis  ; 
extreme  depression  ;  gradual  recovery. 

12.  Personal  Observation:  "I  iv  to  v  of  Fowler's 
solution  taken  three  times  daily  for  six  weeks  ; 
then  there  came  on  extreme  prostration,  pains  of 
severe  character  in  the  extremities,  widespread 
muscular  atrophy,  and  paralysis,  so  severe  that 
the  patient  was  helpless  for  many  months.  Dur- 
ing the  worst  of  his  illness  he  inhabited  a  room 
with  a  highly  arsenical  paper.  I  consider  this 
case  as  especiall}'  important  because  it  was  possi- 
ble to  eliminate,  as  satisfactorily  as  this  can  ever 
be  done,  all  the  other  causes  of  neuritis.  The 
patient  was  a  gentleman  in  good  circumstances, 
not  syphilitic,  not  tuberculous,  with  no  lead  in 
the  urine.  He  had  had  no  acute  diseases,  no 
grippe,  no  anaemia  ;  and  the  symptoms  came  on 
during  the  pleasant  weather  of  June. 

Of  course  this  handful  of  cases  does  not  prove 
that  arsenical  paralysis  is  common  from  medicinal 
doses,  but  only  that  it  occurs. 

There  are,  however,  three  obvious  reasons  why 
we  do  not  have  more  such  reports:  1.  The 
watchfulness  of  physicians  ;  2.  The  failure  to 
recognize  the  nature  of  the  cases  seen  ;  3.  Un- 
willingness to  report  unfavorable  results. 

Imbert  Gourbeyre  says  that  many  cases  of 
paralysis  occurred  in  the  last  century  when 
arsenic  was  used  so  freely  in  the  treatment  of 
intermittent  fever.  He  does  not  give  references, 
however,  and  I  have  not  yet  fully  studied  this 
point. 

Dr.  Winkler,  of  Altenburg,  writing  in  181 1, 
quaintly  reports  a  case  of  paralysis  of  the  legs 
occurring  in  the  practice  of  a  colleague,  after  an 
arsenical  treatment  of  intermittent,  but  "does 
not  believe"  it  was  due  to  arsenic,  and  is  ob- 
viously wholly  unfamiliar  with  the  characteristics 
of  arsenical  paralysis,  now  so  well  known. 

This  would  be  a  suitable  place  to  introduce, 
by  way  of  comparison,  the  recorded  cases  of 
paralysis  due  to  domestic  exposures. 

I  have  not,  however,  undertaken,  in  this  paper, 
to  bring  forward  the  clinical  evidence  indicating 
the  frequency  with  which  arsenical  symptoms 
occur,  but  only  such  as  would  present  as  strongly 
as  possible  the  fact  that  they  do  occur. 

I'oi  this  reason  I  shall  confine  myself  to  my 
own  experience  in  speaking  of  arsenical  paralysis 
(and  other  signs  of  neuritis").  I  will  note,  how- 
ever, that  a  number  of'such  cases  are  on  record. 
Alexander,  of  Breslau,'  for  example,  in  a  recent 
pathological  monograph  on  arsenical  paralysis 
(1889),  considers  nine  cases  to  have  been  of 
"domestic"  origin,  out  of  fifty-eight  which  he 
selected  from  a  much  larger  number  of  general 
analysis. 

The  cases  which  I  have  seen  myself,  several  in 

.  were  mainly  light  cases,  as  might  be 

expected,  and  for  that  reason  less  conclusive.     I 


1  Boston  Medical  and  Surgical  Journal,  March  7,  1S89. 


i89i.] 


ARSENIC  AS  A  DOMESTIC  POISON. 


781 


therefore  report  but  two,  one  of  which  has  been 
published/  (Atwood.)  This  is  the  ease  of  a; 
lady  43  years  old,  and  of  naturally  good  health," 
except  that  for  a  year  or  two  she  had  suffered 
from  severe  colds  and  from  "indigestion.'' 

The  new  symptoms  began  about  six  weeks 
after  her  return  from  a  vacation,  at  which  time 
she  had  moved  into  new  rooms,  which  were 
afterwards  found  to  be  papered  with  a  highly 
arsenical  paper. 

The  symptoms  consisted,  first,  in  severe  ab- 
dominal neuralgia,  recurring  every  morning  and 
passing  away  in  the  afternoon,  and  not  attended 
with  signs  of  indigestion.  This  continued  for 
nine  months,  but  before  the  end  of  this  period 
she  began  to  lose  sleep  and  appetite,  and  to 
notice  tingling  sensations  in  the  fingers,  lips, 
tongue  and  feet.  The  hands  and  wrists  became 
sensitive  on  pressure,  and  whenever  she  was  re- 
cumbent the  arms  used  to  "go  to  sleep." 
Writing,  formerly  easy,  became  a  labor. 

The  dynamometer  registered  R.  55,  L.  17,  in- 
stead of  30  to  50  as  might  have  been  expected  ; 
hyperextension  of  the  right  hand  and  fingers  was 
very  poor  ;  there  was  tremor  of  both  hands  ;  the 
electrical  reactions  of  the  extensors,  especially 
those  of  the  right  arm,  were  markedly  impaired. 

The  patient  has  been  under  observation  for 
the  past  two  years,  and  had  been  known  to  me 
for  several  years  before.  Arsenic  (but  no  lead) 
was  found  in  the  urine  three  or  four  times  at 
intervals  of  many  months,  at  first  in  relatively 
large  amounts,  afterwards  in  traces,  until  finally 
it  disappeared. 

The  health  gradually  improved  after  removal 
from  exposure,  except  that  a  moderately  severe 
facial  spasm  has  been  present  ever  since.  The 
general  health  has  once  or  twice  given  way  to 
some  extent  under  hard  work,  but  the  special 
symptoms  have  never  returned.  I  omitted  to 
say  that  at  one  time  the  sensibility  of  the  right 
finger  tips  was  found  slightly  less  than  that  of 
the   left.      The  dynamometer   finally  registered 


I  consider  this  case  of  special  value  for  the 
reason  that  while  evidently  an  instance  of  neu- 
ritis, the  morbid  conditions  would  certainly  have 
been  overlooked  but  for  careful  examination. 
Careful  electrical  examinations  in  doubtful 
cases  would  very  likely  reveal  slight  changes 
of  great  diagnostic  importance,  since  we  know, 
both  from  experimentation  with  animals,  and 
from  clinical  observation,  with  both  lead  and 
arsenic,  that  there  is  a  period  when  neuritis 
is  latent  as  regards  paralysis,  and  yet  is  discovera- 
ble by  electrical  tests  and  by  the  microscope. 

Far  more  numerous  than  these  characteristic 
cases  of  arsenical  neuritis,  are  of  course  the  lesser 

5  Inaugural  Diss,  on  Arsenical  Paralysis.    1SS9. 

6  For  details  see  the  published  report.  Boston  Medical  and 
Surgical  Journal.  March  ; 


and  obscurer  symptoms,  and  they  are  also  really 
of  far  greater  importance  just  because  they  are 
obscure.  I  shall  not  occupy  space  by  discussing 
them,  because  physicians  at  large  are  not  yet  in 
the  mood  to  consider  them  without  prejudice,  and 
my  present  object  is  solely  to  allay  that  prejudice. 
I  will  only  remark  that  we  have  good  rea 
believe,  not  only  from  the  history  of  domestic 
poisoning,  but  from  medicinal,  and  accidental, 
and  homicidal  cases,  that  in  chronic  arsenical 
poisoning,  or  in  the  chronic  remains  of  acute 
poisoning,  two  tendencies  are  occasionally  mani- 
fest; one  to  relatively  isolated  impairment  of 
special  organs  or  functions  (tachycardia,  sexual 
impotence,  loss  of  voice,  irritation  of  the  kidney, 
localized  neuralgia,  herpes  zoster  and  other  affec- 
tion of  the  skin,  etc.,);  the  other  to  ansemia,  or 
the  impairment  of  the  general  nutrition,  without 
marked  local  symptoms. 

This  latter  tendency  has  seemed  to  me  espe- 
cially important  as  occurring  among  infants.  I 
have,  however,  also  seen,  in  consultation,  in  a 
child  of  two  years,  a  generalized  neuritis,  with 
impairment  of  the  electrical  reactions,  apparent- 
ly due  to  arsenical  poisoning.  What  is  the  source 
of  the  arsenic  in  the  cases  of  domestic  poisoning; 
and  in  what  form  does  it  act? 

These  questions  are  still  unanswered,  but  no 
candid  person  can  doubt  that  papers  (mainly 
those  of  older  date)  and  fabrics  are  mainly  respon- 
sible. Probably  it  comes  little  by  little  from 
many  sources  and  acts  after  accumulation.  In 
the  case  of  a  lady,  under  my  own  care,  a  severe 
eruption,  of  inflammatory  vesicular  character, 
broke  out  all  over  the  face  and  neck.  She  was 
seen  by  an  experienced  dermatologist  who  pro- 
nounced the  eruption  not  eczematous,  and  found 
traces  of  arsenic  in  the  scales  removed  from  the 
skin.  I  found  traces  of  arsenic  in  the  urine  and 
a  large  quantity  in  the  covering  of  a  reclining 
chair  in  which  she  habitually  sat.  The  patient 
was  subject  to  universal  eczema,  and  had  proved 
susceptible  to  arsenic  given  internally.  Perhaps 
for  these  reasons  the  skin  was  unusually  sensi- 
tive. 

The  theory  that  the  arsenic  sometimes  occurs 
in  a  gaseous  form  cannot  yet  be  set  aside;  and 
the  mode  of  introduction  (i.  e.,  by  the  lungs) 
may  perhaps  increase  its  immediate  violence,  just 
as  Alexander  (I.e.)  found  that  when  injected  un- 
der the  skin  of  the  shoulder  in  animals  it  had 
more  constitutional  effect  than  when  injected  in- 
to the  peritoneal  cavity.  At  any  rate,  the  urine 
analyses  prove  that  it  comes  from  somewhere  and 
accumulates  in  quite  a  quantity;  and  the  clinical 
analyses  prove  that  it  may  cause  serious  and 
characteristic  symptoms,  and  a  great  many  more 
slight  but  very  troublesome  and  often  chronic 
and  obscure  effects. 


782 


MEDICAL  PROGRESS. 


[May  30, 


MEDICAL    PROGRESS. 


Obstetrics  and  Diseases  of  Women. 

Dangers  of  Vaginal  Injections.  —  Dr. 
Roulin,  {Journal  de  Medecine  de  Paris,  December 
13,  1890),  describes  three  cases  where  women  suf- 
fered from  severe  symptoms  after  the  use  of 
vaginal  injections,  administered  by  themselves 
when  in  a  sitting  position.  The  first  used  the 
douche  can, — fixing  it  rather  high  on  the  wall. 
Immediately  after  the  injection  violent  hypogas- 
tric and  lumbar  pains  set  in,  followed  by  vertigo 
and  vomiting.  The  abdomen  was  not  sensitive 
■on  pressure,  though  the  pain  was  intense.  Metror- 
rhagia followed  and  lasted  for  two  or  three  days, 
but  the  pain  ceased  in  twenty-four  hours.  The 
second  case  was  almost  precisely  similar,  except- 
ing that  the  patient  had  used  a  hand  syringe, 
and  the  symptoms  were  less  severe.  The  third 
case  also  used  a  hand  syringe.  She  felt  a  pain 
like  a  blow  across  the  belly,  but  continued  the 
injection;  when  it  was  ended  lumbar  and  abdom- 
inal pains  came  on  severely  with  rigors  and  chat- 
tering of  the  teeth,  but  no  vomiting.  The  symp- 
toms recurred  on  the  next  day  when  the  patient 
got  up,  but  on  the  third  day  she  felt  well  and 
free  from  pain.  Dr.  Roulin  employs  laudunum 
enemata  for  these  cases.  The  cause  of  the  pain 
is  obscure.  The  fluid  rushing  into  the  uterine 
cavity  may  act  as  a  foreign  body  and  set  up  con- 
ditions sometimes  provoked  by  catheterism.  The 
admission  of  air  into  the  uterine  sinuses  has  been, 
according  to  Depaul,  the  cause  of  sudden  death 
during  douching  of  the  cervix  to  produce  abor- 
tion. Dr.  Roulin  believes  that  water  may  have 
entered  in  his  cases.  He  insists  that  patients 
must  be  taught  how  to  administer  vaginal  injec- 
tions to  themselves.  The  patient  must  lie  on  her 
back  and  only  introduce  the  nozzle  for  a  short 
distance;  nor  must  she  play  too  strong  a  jet  of 
fluid  into  the  vagina. —  Archives  of  Gynecology. 

Pathology. 

The  Pigment  of  Melanosis. — Dr.  Felix 
Lagrange,  in  a  paper  read  before  the  Societe  d'- 
Anatomie  et  de  Physiologie  de  Bordeaux,  Dec.  8 
of  last  year,  described  some  investigations  he 
had  made  as  regards  the  distribution  of  the  pig- 
ment in  two  melanotic  tumors.  One  case  was 
that  of  a  melanotic  sarcoma  which  had  been  re- 
moved from  the  orbit,  and  the  other  was  a  tumor 
of  the  eyelid.  Microscopic  examination  showed 
the  same  structure  in  both  cases,  but  the  tumor 
which  had  developed  in  the  orl.it  was  more  deep- 
ly pigmented  than  the  other,  though  the  distri 
bution  of  the  pigment  was  morphologically  the 
same  in  each  case.  Sections  oi  both  tumors  ex 
hibited  fusiform  cells  and  many  embryonic  ele- 
ments. A  few  vessels  were  seen,  but  there  were 
iagic  foci.  The  pigment  was  intra- 
cellular.     In  some  cells  it  was  completely  absent, 


whilst  others  were  so  full  as  to  lose  their  charac- 
teristics, and  to  appear  as  black  round  masses  ; 
other  cells,  again,  contained  in  their  protoplasm 
fine  black  granules.  In  order  to  study  the  na- 
ture of  this  pigment  it  was  necessary  to  isolate 
it  from  the  cellular  elements.  By  treating  a  sec- 
tion with  sulphuric  acid,  the  cellular  elements 
were  partially  destroyed.  Under  the  influence  of 
this  reagent  the  sarcomatous  tissue  became  shriv- 
elled, remaining  as  a  translucent  structureless 
mass,  in  the  centre  of  which  was  the  pigment. 
Nitric  acid  was  next  tried  ;  but,  although  the 
structure  of  the  tumor  was  completely  destroyed, 
there  still  remained  a  whitish  residue  in  which 
the  pigment  remained  entangled.  In  order  to 
obtain  a  pure  preparation  of  melanine  the  follow- 
ing process  was  adopted  with  success  :  Having 
treated  a  portion  of  the  tumor  in  which  the  pig- 
ment was  abundant  with  pure  sulphuric  acid,  it 
was  placed,  still  saturated  with  the  reageut,  for 
twenty- four  hours  in  a  moist  chamber.  In  this 
way  the  now  plastic  tissue  was  partially  liquefied, 
some  glycerine  was  then  added,  and  the  contain- 
ing vessel  closed  for  forty- eight  hours.  At  the 
end  of  that  period  there  remained  nothing  but 
the  pure  pigment.  It  presented  three  principal 
forms  :  1 .  Some  black  masses,  evidently  formed 
by  the  union  of  a  series  of  granules,  separated  by 
unequal  intervals,  the  spaces  being  filled  by  a 
transparent  cement  which  had  been  unaffected  by 
the  acid.  These  masses  were  the  remains  of 
those  cells  which  had  appeared  to  be  entirely 
filled  with  pigment.  2.  Fine  disseminated  gran- 
ules, which  were  rounded  and  very  numerous. 
3.  Small  irregularly  shaped  particles,  for  the  most 
part  angular,  but  presenting  considerable  varia- 
tions in  their  form  and  size. —  The  Lancet. 

Dermatology. 

Dr.  L.  Brocq,  (Journ.  of  Cu/an.  and  Genito- 
Urin.  Dis.,  No.  102,  March,  1891),  presented  to 
the  French  Society  of  Dermatology  and  Syphil- 
ography%  December  11,  1890,  a  patient  affected 
with  a  band  of  scleroderma  extending  from  the 
upper  third  of  the  right  arm  to  the  thumb,  form- 
ing a  plaque  3  to  6  centimetres  in  width,  and  of 
great  thickness.  The  patient,  a  cutter,  could  use 
his  scissors  only  with  great  pain.  Treated  by  Dr. 
Besnier  in  several  ways  without  result,  he  was 
referred  to  Dr.  Brocq  in  June,  1890,  who  up  to 
December  1,  gave  him  fourteen  sittings  of 
electrolysis,  each  treatment  comprising  twelve  to 
sixteen  punctures,  principally  in  the  lower  por- 
tion of  the  plague,  but  sometimes  in  the  median  por- 
tion. The  affection  was  arrested  and  has  not 
since  increased.  The  arm  moves  more  freely  and 
the  plague  ha.s  diminished  one-half.  Treatment 
was  interrupted  through  August  and  September, 
but  the  affection  did  not  increase,  thus  proving 
that  it  is  not  necessary  to  make  the  sittings  close 
U  igether. — British  Medical  Journal. 


i89i.] 


EDITORIAL. 


783 


Journal  of  the  American  Medical  Association 

PUBLISHED  WEEKLY. 


kiptio.n  Price,  Inch-ding  Postage. 

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letters. 

Address 

Journal  of  the  American  Medical  Association, 

No.  6S  Waiiash  Ave.. 

Chicago,  Illinois. 
All  members  of  the  Association  should  send  their  Annual  Dues 
to  the  Treasurer,  Richard  J.  Dunglison,  M.D..  Lock  Box  1274,  Phila- 
delphia, Pa. 


London  Office,  57  and  59  Ludgate  Hill. 


SATURDAY,  MAY  30,    1891. 


YOUR  MANUSCRIPT,  PLEASE. 
The  primary  province  of  this  journal  is  to  pub- 
lish the  proceedings  of  the  annual  meetings  of 
the  American  Medical  Association,  and  in  order 
that  all  the  members  and  readers  of  The  Jour- 
nal may  see  the  papers  and  discussions  at  the 
earliest  possible  date,  it  is  necessary  that  the 
Chairmen  and  Secretaries  of  each  of  the  Sections 
shall  at  once  transmit  to  the  Editor  of  The  Jour- 
nal all  matter  in  their  hands  for  publication. 

If  this  is  done  immediately,  it  will  enable  us . 
to  publish  all  the  matter  of  each  Section  in  con- 
secutive issues,  and  then  to  make  a  separate  re- 
print of  the  work  of  the  several  Sections  for  the  I 
special  use  of  those  who  attended  the  meeting 
and  are  recorded  as  taking  part  in  the  Section 
work. 

This  will  add  very  much  to  the  value  and  in- 
terest taken  in  a  work  that  should  reflect  the 
thought,  observations  and  researches  of  many  of 
the  ablest  men  in  our  profession. 

The  success  of  the  purpose  will  depend  entirely 
upon  the  active  cooperation  of  the  officers  of  the 
Sections. 

We  want  all  the  matter  now,  while  it  is  fresh 
and  of  immediate  interest. 

The  member  who  is  holding  his  paper  for  revi- 
sion and  completion,  and  is  also  possessed  of  an 
idea  that  the  adoption  of  such  a  plan  will  cause 
an  early  shortness  of  copy  in  The  Journal  of- 
fice, is  away  off  in  his  estimate  of  the  amount  of 
scintillations  that  are  constantly  emanating  from 
the  brains  of  more  than  eighty  thousand  prac- 
ticing physicians. 


BTJSD 

Business  is  business,  at  least  that  is  what  all 
busine-s  men  say,  and  the  merchant,  manu- 
facturer, trader  or  professional  man  who  can  in 
one  year  double  the  value  of  his  business  by 
making  a  grand  effort  and  don't  do  it,  is  usually 
regarded  either  as  a  little  off,  or  entirely  too  slow 
to  catch  on  to  the  good  things  that  are  gliding 
by  on  a  rapid  transit  motor. 

There  is  in  this  country  a  grand  body  of  more 
than  eighty  thousand  members  of  the  regular 
medical  profession,  every  one  of  whom  is  in 
some  degree  a  debtor  to  the  American  Medical 
Association,  and  either  directly  or  indirectly 
claims  an  affiliation  with  this  organization. 
Those  who  directly  claim  the  benefits  have  be- 
come permanent  members.  This  number  has 
now  reached  six  thousand.  These  six  thousand 
members  own  a  valuable  property  in  this  Journal, 
each  holding  a  single  share  of  stock  and  no 
more.  It  is  possible  and  very  easy,  for  every 
one  of  the  six  thousand  shareholders  to  induce 
one  of  the  indirect  beneficiaries  to  become  en- 
rolled as  an  active  owner  of  this  valuable  prop- 
erty. The  simple  addition  of  six  thousand  more 
members  will  very  much  more  than  double  the 
value  of  the  present  property,  and  another  possi- 
ble and  similar  increase  will  send  The  Journal 
ahead  and  beyond  any  similar  publication  in  the 
world. 

This  is  a  reasonable  and  easy  thing  to  do. 
Not  to  do  it  is  to  be  counted  a  "little  off"  and. 
too  slow  to  take  advantage  of  a  good  thing 
within  easy  reach. 

This  is  business,  and  business  is  business. 


HOUSE  BUILDING  AND  SANITATION. 
With  the  growth  of  population  in  cities  there 
is  a  corresponding  increase  in  the  value  of  real 
property.  This  increased  value  of  real  estate  is 
naturally  followed  by  high  rents,  and  in  order  to 
realize  the  largest  possible  revenue  from  a  limited 
number  of  square  feet  of  ground,  the  owner  feels 
justified  in  erecting  a  building  that  is  fairly  a 
sky-scraper.  And  this  without  the  slightest  re- 
gard for  the  rights  of  his  next  door  neighbor  or 
the  general  public.  Such  buildings  effectually 
darken  adjacent  structures  by  shutting  off  a  good- 
ly portion  of  God-given  sun-light.  They  also 
impede  a  free  circulation  of  air. 


784 


THE  MEDICAL  CONGRESS  OF  CUBA. 


[May  30. 


In  the  outskirts  of  the  business  section,  ele- 
gant and  inviting  apartment  houses  are  built,  and 
in  which  are  said  to  be  found  all  modern  conven- 
iences, such  as  bath,  water-closet,  etc.  These 
are  necessary  belongings  in  every  modern  city 
house,  and  in  order  to  insure  the  health  of  the 
inmates,  the  location  and  construction  of  the 
plumbing  work  of  such  apartments  is  of  the  very 
first  importance. 

Our  attention  has  been  drawn  in  this  direction 
by  observing  the  great  frequency  with  which  the 
water-closet  is  stuck  in  an  absolutely  dark  and 
unventilated  niche  or  corner,  and  in  many  in- 
stances opening  directly  into  the  kitchen  or  pan- 
try. Physicians  visiting  patients  ma}'  with  per- 
fect propriety  inquire  as  to  the  arrangement  of 
the  bath  and  water  closet,  and  condemn  or  ap- 
prove as  his  judgment  may  dictate.  Many  cases 
of  sickness  are  directly  traceable  to  just  such 
causes. 

One  of  the  building  inspectors  should  be  a  phy- 
sician who  is  not  only  skilled  in  sanitary  affairs, 
but  who  is  also  endowed  with  a  knowledge  of 
architecture  so  far  as  it  pertains  to  all  sanitary 
conditions  of  any  building. 

Practicing  physicians  are  more  or  less  accus- 
tomed to  uninviting  sights  and  noisome  odors, 
but,  for  one  moment  think  a  little, — just  a  very 
little  of  the  wafting  odors  of  a  freely  used  and 
unventilated  water  closet  opening  into  a  kitchen 
where  an  omelet,  or  batter  for  griddle  cakes  are 
being  prepared;  or  into  the  pantry  where  the  but- 
ter and  milk  are  acting  as  sponges  in  silently 
mopping  up  the  foulness  in  the  air. — Bah! 


The  preliminary  program  announced  for  next 
meeting  shows  an  important  selection  of  topics. 
"  The  Etiology,  Prophylaxis  and  Treatment  of 
Yellow  Fever,"  is  an  inexhaustible  theme  for 
Cubans.  "The  Influence  of  Malaria  upon 
Pregnancy,  Parturition  and  the  Puerperium,"  is 
a  subject  of  vast  importance,  not  only  to  peoples 
of  the  tropics,  but  to  the  inhabitants  of  peludal 
districts  in  the  temperate  zones.  "  The  Experi- 
mental and  Clinical  Study  of  Chronic  Diarrhoea  " 
will  doubtless  comprise  a  report  of  value  to  all 
practitioners.  "The  Abuse  of  Alcoholic  Bever- 
ages in  Cuba"  will  no  doubt  elicit  about  the 
same  state  of  affairs  that  we  find  in  this  country, 
particularly  when  the  subject  is  studied  as  is 
purposed  with  reference  to  "  common  causes  and 
pathological  manifestations."  "The  Pathology 
of  Diphtheria  and  its  Relation  to  Treatment" 
suggests  a  theme  in  rational  therapeutics  that  is 
of  wide-spread  interest.  In  addition  to  such 
formal  discussions  papers  will  be  presented  on 
topics  in  every  department  of  medical  practice. 
The  practice  of  announcing  subjects  for  discussion 
ten  months  in  advance  of  the  meeting  is  a  good 
one,  and  might  be  emulated  with  profit  by  med- 
ical associations  in  the  United  States. 


THE  MEDICAL  CONGRESS  OF  CUBA. 
The  second  Medical  Congress  of  Cuba  will  be 
held  in  Havana  in  January,  1892,  under  the 
presidency  of  Dr.  Juan  Sartos  Fernandez. 
This  new  organization  is  one  of  very  high  order 
and  represents  the  strongest  professional  elements 
of  the  country.  The  published  regulations  show 
that  the  qualifications  for  membership  are  very 
high,  requiring  in  addition  to  medical  gradua- 
tion, the  possession  of  either  an  academic  degree 
or  the  record  of  original  work  meriting  the  ap- 
probation of  the  Congress.  The  Congress  meets 
every  two  years  in  the  month  of  January.  Papers 
arc  limited  to  fifteen  minutes  and  discussion  to 
five  minutes  for  each  speaker.  Papers  may  be 
read  in  Spanish,  French,  or  English. 


HIGHER  MEDICAL    EDUCATION. 

At  a  meeting  of  the  Board  of  Trustees  of  the 
University  of  Pennsylvania  held  May  21,  Dr  Pep- 
per made  an  offer  of  $50, 000  towards  an  endowment 
fund  of  $250,000  and  of  $1,000  annually  towardsa 
guarantee  fund  of  $20, 000  annually,  for  five  years, 
conditioned  upon  the  establishment  of  an  obliga- 
tory graded  four  year  course  of  medical  study. 
This  was  accompanied  by  a  communication  from 
the  medical  faculty  pledging  themselves  to  carry 
out  this  proposal  and  to  enter  upon  the  four-year 
course  in  September,  1893.  It  was  also  reported 
that  the  members  of  the  medical  faculty  had 
themselves  subscribed  $10,000  annually  for  five 
years  to  the  endowment  fund.  The  Board  of 
Trustees  expressed  approval  of  the  proposed  ad- 
vance in  medical  education,  but  postponed  their 
assent  until  the  success  of  both  funds  had  been 
demonstrated. 

Dr.  Pepper  and  his  associates  in  the  faculty  of 
the  medical  department  of  the  University  of  Penn- 
sylvania are  evidently  determined  to  do  their 
part  in  solving  the  vexed  question  as  to  the  best 
method  of  giving  and  attaining  a  higher  medical 
education.  It  is  with  a  good  degree  of  pleasure 
that  we  note   the  disposition  manifested  on  the 


i89i.j 


SOCIETY  PROCEEDINGS. 


785 


part  of  the  best  medical  colleges  to  form  practical 
connections  with  established  universities.  This  is 
the  first  step  necessary,  before  making  an  appeal 
for  endowments  of  chairs,  scholarships,  and  labor- 
atories. 

The  medical  department  of  a  University  with 
an  ample  endowment,  ensures  a  proper  prelimi- 
nary examination,  a  thorough  course  of  instruc- 
tion, followed  by  the  granting  of  a  degree  that 
means  something. 


EDITORIAL  NOTES. 
Small- pox  in  Havana.  — The  last  issue  of  the 
Revista  de  Ciencias  Medicos  of  Havana  announces 
fifteen  deaths  from  small-pox  in  that  city  during 
the  month  of  April.  Dr.  Laguardia,  of  the  Sani- 
tary Department,  announces  that  the  disease  is 
spreading. 

High  Buildings. — We  are  glad  to  observe 
that  a  discussion  is  going  on  among  the  architects 
and  engineers  of  Chicago,  relative  to  the  safet}- 
of  the  extremely  high  buildings  which  are  in 
course  of  construction  in  this  and  other  large 
cities.  This  is  a  subject  of  the  utmost  conceiva- 
ble importance.  The  fall  of  such  a  structure 
when  filled  with  an  army  of  workers  would  be  a 
calamity  of  the  greatest  magnitude. 

While  we  are  ever  ready  to  utter  an  encourag- 
ing word  to  those  who  are  engaged  in  all  lauda- 
ble enterprises,  profound  consideration  must  be 
given  to  any  conditions  which  jeopardize  and 
hazard  human  life. 

The  sanitary  arrangements  of  such  buildings 
are  usually  first  class  and  as  perfect  as  art  can 
make  them. 


SOCIETY   PROCEEDINGS. 


American  Academy  ol  Medicine. 

The  sixteenth  annual  meeting  of  the  American 
Academy  of  Medicine  was  held  at  the  Arlington 
Hotel,  Washington.  The  opening  session  was 
on  Saturday,  May  2,  the  meeting  continuing 
through  Monday  the  4th.  The  wisdom  of  hold- 
ing the  sessions  of  the  Academy  in  connection 
with  those  of  the  American  Medical  Association 
was  demonstrated  by  the  attendance:  it  was  the 
largest  meeting  in  the  last  seven  years.  The  at- 
tention of  the  Fellows  was  directed  to  those  three 
items,  the  Reports  of  Committees,  the  reading 
and  discussion  of  papers,  and  executive  business. 


Dr.  J.  K.  Emerson,  of  Detroit,  reported  for  the 
committee  on  Eligible  Fellows,  of  which  he  is 
chairman.  The  practical  resultsof  theworkingsof 
this  committee  is  seen  in  the  list  of  Fellows  elec- 
ted, most  of  whom  were  investigated  and  invited 
by  the  committee.  The  committee  emphasizes 
in  their  report,  the  necessity  of  every  Fellow  con- 
sidering himself  a  coadjutor  of  this  committee. 

The  Committee  on  the  preparation  of  a  cata- 
logue of  Fellows,  submitted  two  forms  for  arrang- 
ing the  names  and  the  facts  to  be  presented,  ask- 
ing directions  from  the  Academy  before  addition- 
al work  should  be  done. 

The  Committee  on  the  publication  of  transac- 
tions suggested  the  issuing  of  an  occasional  Bul- 
letin containing  such  papers,  reports  or  informa- 
tion as  the  Academy  would  from  time  to  time  de- 
sire to  publish. 

The  Committee  on  the  comparative  value  of 
Academic  degrees  presented  a  voluminous  report. 
This  committee  had  addressed  a  circular  letter  to 
all  the  colleges  in  the  land  asking  for  certain  facts 
■  and  opinions.  The  report  endeavored  to  tabulate 
the  replies  from  over  a  hundred  of  them.  The  re- 
1  ports  were  referred  to  the  Council,  who  subse- 
quently made  certain  recommendations  to  the 
Academy,  as  will  be  seen  a  little  later. 

The  only  paper  read  on  Saturday  was  entitled 
"The  American  Practitioner  Abroad."  It  de- 
scribed the  present  status  of  an  American  physi- 
cian who  desires  to  practice  in  Great  Britain, 
called  attention  to  the  fact  that,  while  parliament 
enacted  that  after  a  date  to  be  fixed  by  her  Ma- 
jesty's Council,  certain  foreign  qualifications 
would  be  admitted  to  registration,  the  Council 
had  never  fixed  the  date  and  the  enactment  was 
a  dead  letter.  The  paper  suggested  that  the  Acad- 
emy endeavor  to  secure  reciprocity  in  the  matter. 

The  more  important  papers  were  read  at  the 
session  on  Monday  morning,  the  first  by  Lewis 
H.  Steiner,  M.D.,  of  Baltimore,   Md.,   entitled 

WILL  A  SHORTENING  OF  THE    COLLEGE  CURRICU- 
LUM CONDUCE  TO  BETTER  PREPARATION  FOR 
THE  STUDY  OF    MEDICINE. 

i.  We  are  told  that  one  great  advantage  will 
result  from  a  shortened  course,  viz.,  the  student 
can  begin  his  professional  studies  at  an  earlier 
age  and  so  assume  the  responsibilities  of  practice 
while  yet  young.  But  is  it  not  a  well  known 
fact  that  youth  is  frequently  cast  up  against  the 
young  doctor  as  an  unpardonable  defect  in  his 
professional  make-up?  Experience  is  sought  for 
by  a  prudent  public.  There  is  now  no  greater 
urgency  for  this  rapid  creation  of  doctors  than 
has  existed  for  years,  although  there  is  a  demand 
from  the  medical  profession  and  the  laity  that  the 
best  preparation  possible  should  be  had  by  the 
intending  doctor — that  he  should  be  a  man  of 
broad,  well-rounded  general  culture  and  thorough- 
ly trained  in  the  principles  of  the  profession. 


786 


SOCIETY  PROCEEDINGS. 


[May  30, 


2.  It  is  said  that  the  period  of  study  must  be 
diminished  because  students  enter  college  now  at 
a  more  mature  age  than  in  former  years.  But 
President  Angell,  of  the  University  ol  Michigan, 
says  that  the  age  of  entrance  in  his  institution  is 
not  increasing  but  diminishing.  Probably  Ann 
Arbor  fairly  represents  in  this  particular  the  great 
body  of  American  colleges.  If,  however,  the 
statement  be  correct  it  would  not  affect  the  sub- 
ject very  materially.  Indeed,  the  question  of  age 
has  not  been  raised  by  the  advocates  of  full  aca- 
demic preparation.  It  is  one  solely  of  preparation, 
and  this  is  believed  to  be  best  secured  by  the 
training  that  has  heretofore  produced  satisfactory 
results.  The  routine  of  work  must  be  adapted  to 
the  average  man.  The  brilliant  scholarly  mind 
will  compass  it  easily  and  will  be  able  to  supple- 
ment it  with  other  important  additions  to  his 
preparation  for  subsequent  professional  study, 
while  there  may  be  some  who  cannot  keep  abreast 
of  the  lowest  requirements,  and  who  must  neces- 
sarily drop  out  of  the  struggle.  This  unequal 
contest  must  be  expected  and  should  the  mental 
capacity  in  any  case  be  too  small  to  compass  the 
college  curriculum,  what  kind  of  addition  to  the 
medical  profession  would  its  owner  ordinarily 
make?  The  present  need  is  not  that  of  mere 
numbers.  Quality  and  not  quantity  is  looked 
for.  Possibly  in  this  country  we  are  so  impatient 
of  slow  processes  that  our  tendency  is  to  super- 
ficiary. The  English,  the  German  and  the 
French  are  more  content  to  work  slowly.  The 
result  of  this  is  better  all-around  preparation  for 
whatever  they  undertake. 

The  plan  proposed  will  not  conduce  to  the  fa- 
vorite object  of  the  academy.  It  will  accomplish 
nothing  but  an  increase  of  college  graduates. 
The  value  of  the  "  A.  B."  degree  will  become  an 
uncertain  quantity. 

This  conclusion  must  be  reached — that  there 
must  be  some  general  consensus  among  medical 
colleges  as  to  the  nature  and  amount  of  the  pre- 
liminary study  and  that  the  fact  whether  suffi- 
cient acquaintance  with  it  has  been  attained  by 
the  applicant  must  be  determined  by  some  exam- 
ining board.  Should  such  board  be  composed  of 
the  faculties  of  medical  colleges,  or  of  professional 
men  who  are  invested  by  the  state  with  authority? 

Charles  McIntire,  A.M.,  M.D.,  of  Eastoii, 
Pa.,  read  a  paper  on 

AX  ATTEMPT  TO  DETERMINE  THE  IDEAL  PREPAR- 
ATORY COURSE  OF  STUDIES  FOR  THE 
LEARNED  PROFESSIONS. 

College  education  should  train  the  mind  and 
provide  an  amount  of  general  information.  The 
pupil  himself  and  the  personality  of  the  teachers 
are  important  factors  in  an  educational  scheme, 
but  as  they  cannot  be  weighed  they  must  be 
treated  as  a  constant  factor  in  a  mathematical 
problem.      The  educational  world    in  Germany 


and  England  as  well  as  in  the  United  States  is 
in  a  state  of  unrest.  With  us  the  assigned  cause 
is  that  it  takes  too  long  for  a  man  to  take  a  com- 
plete course  and  to  enter  upon  professional  life. 

The  plan  suggested  in  this  paper  was  gleaned 
from  the  opinions  of  a  large  number  of  college 
presidents  obtained  by  private  correspondence. 
The  American  system  of  education  is  not  a  system 
organized  by  a  previous  plan,  but  we  should  re- 
member that  every  prolonged  educational  train- 
ing should  comprise  the  study  of  the  essential 
studies  for  an  educated  man,  having  but  one 
course  so  that  upon  its  completion  one  can  either 
go  into  business  or  enter  college,  as  the  case 
might  be.  This  would  rather  shorten  this  period, 
but  the  pupil  would  enter  without  break  into  col- 
lege, and  in  one  of  several  courses  pursue  his 
studies  with  a  view  of  mental  discipline  and  gen- 
eral information.  His  special  studies,  whether 
professional  or  otherwise,  would  be  continued  in 
the  universities,  and  no  candidate  would  be  ad- 
mitted for  a  university  degree  unless  they  already 
possessed  a  college  degree  or  could  pass  an  ex- 
amination upon  the  college  studies.  The  con- 
clusion emphasized  the  fact  that  the  paper  was 
but  an  imperfect  representation  of  the  thoughts 
of  others. 

The  third  paper  was  on  the 

GENERAL  EDUCATION  OF  THE  PHYSICIAN, 

by  David  Starr  Jordan,  A.M.,  M.D.,  Presi- 
dent of  the  University  of  Indiana,  Bloomington, 
Ind. 

The  A.B.  degree,  as  generally  understood,  is 
an  index  of  general  culture.  With  the  improve- 
ment of  our  educational  methods  the  require- 
ments for  this  degree  have  been  steadily  ad- 
vanced. The  result  is  that  the  student  who  has 
spent  all  his  life  in  the  schools  is  not  through 
college  before  the  age  of  22,  and  the  man  who  is 
forced  for  any  reason  to  interrupt  his  school  work 
may  be  anywhere  from  25  to  30  on  graduation. 
This  fact  has  led  to  a  demand  for  the  shortening 
of  the  college  course  in  the  interests  of  practical 
life.  That  the  college  course  is  too  long  is  prac- 
tically the  verdict  of  the  medical  colleges  and  of 
the  great  body  of  physicians  themselves.  The 
medical  colleges  have  made  the  preliminary  train- 
ing a  matter  of  luxury  rather  than  of  necessity 
by  putting  into  the  same  classes  the  graduates  of 
colleges  and  persons  who  come  from  the  country 
district  school. 

The  physicians  of  our  country  say  the  same 
thing,  for  the  number  of  college-bred  men  in  med- 
icine is  lower  than  in  almost  any  other  profession 
(clergymen  1  in  4,  lawyers  1  in  5,  physicians  r 
in  12).  Of  all  classes  of  students  those  in  medi- 
cine are,  as  a  rule,  the  most  reckless  in  their 
mode  df  life,  and  the  most  careless  of  the  laws  of 
hygiene  and  of  decencies  in  general.  This  is  not 
so  true  now  as  it  was  a  few  years  ago,  and  for 


i89i.] 


SOCIETY  PROCEEDINGS. 


787 


this  change  the-  rising  standards  of  our  medical 
school  arc  certainly  responsible. 

A  writer  has  lately  maintained  that  a  man 
without  independent  means  should  not  study 
medicine.  The  physician  can  no  Longer  be  sure 
of  earning  his  living  in  our  cities,  on  account  of 
the  competition  of  free  dispensaries.  But  skill 
and  wisdom  will  always  be  valued  and  paid  for. 

It  is  said  that  physicians  are  not  taking  their 
share  in  the  progress  of  science.  If  this  be  true. 
and  if  they  are  deficient  in  general  culture,  may 
not  these  facts  be  associated?  May  we  not  have 
here  the  relation  of  cause  and  effect  ?  Is  not  the 
remedy  to  bring  in  better  men  ?  To  shut  out 
the  ignorant,  trifling  and  unambitious,  the  tinker 
and  the  job  worker,  and  reserve  the  training  of 
our  medical  schools  to  those  who  can  bring  to 
their  work  the  instincts,  the  tradition  and  the 
outlook  of  the  scholar  ?  The  general  culture  of 
the  physician  should  have  its  roots  in  the  work 
of  the  college.  If  we  require  or  recognize  colle- 
giate attainments  at  all,  the  A.B.  degree  fur- 
nishes the  only  available  method  by  which  gen- 
eral culture  might  be  indicated.  This  standard 
is  not  absolute.  It  means  something  different  in 
one  college  from  what  it  does  in  another.  It  does 
not  mean  to-day  what  it  did  ten  years  ago,  or 
what  it  will  mean  ten  years  hence.  The  value  of 
the  degree  is  not  to  be  determined  by  the  per- 
centage of  required  work  in  any  stud\\  The  essen- 
tial fact  is  the  extent  to  which  the  spirit  of  the 
scholar  has  been  inspired  in  the  student,  and 
this  varies  in  every  case  with  the  difference  of 
teacher  and  scholar. 

Is  the  standard  of  the  A.B.  degree  too  high  for 
professional  work  ?  No  such  viewT  can  be  sus- 
tained by  statistics.  The  educated  physician  is 
the  man  of  science;  the  uneducated  the  empiric, 
the  quack.  Our  medical  schools  seem  to  think 
otherwise,  for  if  general  training  is  important  the 
schools  should  insist  upon  it.  This  condition  of 
things  has  two  causes:  1.  Most  of  our  medical 
schools  are  scantily  endowed.  When  a  medical 
school  is  well  endowed  it  can  exact  the  standard 
the  good  of  the  profession  requires.  2.  The  med- 
ical student  has  shunned  the  college  because  of 
the  tremendous  waste  involved  in  any  course  ot 
study  ^inflexibly  pre-arranged.  This  waste  is 
threefold:  a.  The  time  spent  on  subjects  in  no 
wise  concerned  with  the  future  study  of  the  sub- 
ject, b.  The  time  spent  on  subjects  for  which  the 
student  has  no  aptitude,  c.  The  waste  of  sub- 
jects taught  by  dull  teachers,  dry,  dreary,  or 
mechanical. 

If  our  medical  schools  cede  four  years  to  the 
culture  of  the  colleges  they  have  the  right  to  ask 
that  the  colleges  waste  no  time.  The  college 
should  furnish  such  means  of  study  that  the  fu- 
ture student  shall  not  go  to  the  medical  school 
ignorant  of  the  use  of  the  scalpel  and  the  micro- 
scope.    He  should  also  know  the  general   facts 


and  theory  of  chemistry,  and  tho  processes  of 
chemical  manipulation.  The  elements  of  botany 
Id  be  in  his  possession,  and  the  facts  of  com- 
parative anatomy,  the  great  laws  of  life  of  hered- 
ity, variability,  and  response  to  external  stimu- 
lus which  form  the  basis  of  organic  evolution. 
He  should  know  what  is  meant  by  scientific  in- 
vestigation and  should  know  how  to  use  it.  He 
should  be  able  to  write  and  speak  good  English 
and  must  read  French  and  German.  If  the  col- 
lege permits  the  medical  student  to  get  a  fair  re- 
turn for  every  hour  he  spends,  the  requirement  of 
a  college  degree  at  the  door  of  the  medical  school 
will  shut  out  no  unworthy  man,  nor  will  it  hold 
back  any  in  the  race  for  life. 

We  may  fairly  regard  the  various  degr* 
B.,  B.  S.,  etc.  J  given  by  the  various  colleges  as 
alike  in  value,  and  leave  the  adjustment  of  their 
relation  to  the  colleges  themselves.  Against 
spurious  degrees  the  Academy  of  Medicine  must 
be  on  its  guard.  Scholars  can  be  made  neither 
by  driving  nor  by  coaxing.  In  any  profession 
the  inspiration  and  example  of  educated  men  is 
the  best  surety  that  the  generation  which  suc- 
ceeds them  will  be  likewise  men  of  culture. 

The  discussion  of  these  papers  was  opened  by 

'Dr.  F.  R.  Gerrish,  of  Portland,  Me.,  and  contin- 

i  tied  by    Drs.    Herdman,    of  Ann    Arbor,    Mich. ; 

1  Marcy,  of  Boston ;  Connor,  of  Detroit ;  Hill,  of 

Iowa ;  Snidsley,  of  Kentucky,  and  others. 

The  Annual  Address  was  delivered  by  the  re- 
tiring   President,   Theophilus    Parvin,   A.M., 
M.D.,    LL.D.,    of   Philadelphia.      Dr.    Parvin's 
"  ruling  passion  was  strong  in  death,"  his  sub- 
ject  being    "Miscarriages."      Unfortunately,    it 
.  is  a  paper  that  does  not  bear   abstracting,  it  is 
too    concise    in    its  entirety.     The    miscarriages 
1  spoken  of  were  those  of  medical  books,  medical 
journals,  the  work  of  medical  societies,  of  medi- 
cal colleges  and  of  medicine  itself.     Of  medical 
books  but  one  fifth  give  any  recompense  to  the 
author,  and  at  the  best  but  a  dollar  a  page.     A 
still  smaller  proportion   of  medical  journals  pay- 
even  indirectly,  and  many  of  them  likewise  fail 
!  in  the  true  work  of  journalism. 

Medical  societies,  while  organized  for  the  pur- 
1  pose  of  general  professional  improvement,  some- 
times are  made  to  promote  individual  interests. 
As  to  medical  colleges,  even  in  the  best  sometimes 
an  unworthy  man  secures  his  doctorate.  And 
even  in  medicine  itself,  sometimes  there  is  a  fail- 
ure to  cure.  Methods  of  treatment  come  into  the 
world  but  to  die  because  of  imperfect  development. 
Bacteriology,  perhaps,  has  received  more  attention 
than  it  deserves,  and  in  the  years  to  come  it  will 
not  be  as  prominent  as  now.  The  address  was 
concluded  by  an  argument  against  vivisection  as 
a  method  of  medical  investigation,  since  its  re- 
sults are  not,  without  clinical  confirmation,  reli- 
able, and  that  clinical  observation  is  and  has 
proved  itself  to  be  amply  sufficient  for  the  purpose. 


DOMESTIC  CORRESPONDENCE. 


[May  30, 


In  its  executive  sessions  the  Academy  elected 
to  Fellowship  the  following  gentlemen : 

Drs.  A.  B.  Dundor,  P.  J,  Surtam,  N.  W. 
Richard,  L.  P.  Smock,  A.  H.  Halberstadt,  of 
Pennsylvania  ;  G.  A.  Hare,  J.  W.  Lash,  G. 
E.  Smith,  F.  House,  C.  L.  Van  Pelt,  of  Ohio; 
Christian  Fenger,  B.  M.  Behrens,  C.  M.  Han- 
sen, A.  Holmboe,  L.  H.  Mettler,  of  Illinois ;  W. 
W.  L.  Phillip,  H.  R.  Baldwin,  George  Peck, 
of  New  Jersey  ;  W.  Rider,  J.  C.  Edgar,  M.  N. 
Bemus,  G.  W.  V.  Van  Voast,  M.  Filter,  Chas. 
G.  Cumer,  of  New  York ;  S.  W.  Turner,  J.  K. 
Mason,  of  Connecticut ;  J.  B.  Brasseur,  R.  Peter- 
son, V.  C.  Vaughan,  J.  N.  Martin,  of  Michigan; 
A.  H.  Wright,  of  Canada  ;  J.  R.  Lewis,  of  Iowa; 
W.  H.  Harris,  of  Kentucky;  A.  C.  Rogers,  J.  H. 
Darcy,  of  Minnesota;  Willard  Springer,  of  Dela- 
ware ;  Charles  Denison,  of  Colorado ;  W.  R.  Clu- 
ness,  J.  R.  Smith,  of  California;  J.  F.  Keeney, 
of  District  of  Columbia;  J.  T.  Green,  of  Arizona; 
and  D.  A.  Sargent,  of  Massachusetts. 

There  were  three  amendments  to  the  Consti- 
tution proposed,  two  of  which  were  postponed  for 
a  year;  the  other,  permitting  the  election  to  of- 
fice of  Fellows  not  present,  was  adopted. 

Two  years  ago  an  amendment  was  adopted  per- 
mitting the  Council  to  accept  other  evidence  of  a 
preliminary  medical  education  than  the  degree  of 
A.B.  This  year,  at  the  recommendation  of  Coun- 
cil, the  Academy  adopted  the  suggestion  of  the 
Committee,  defining  the  nature  of  the  evidence. 
Applications  upon  the  equivalent  clause  must 
show  that  they  have  had  a  period  of  residence  at 
some  college  of  arts  or  sciences.  If  they  are 
graduates,  then  the  degree  possessed  must  be,  in 
the  opinion  of  the  Faculty,  fairly  equivalent  to 
the  A.B.  degree.  If  the  applicant  has  not  grad- 
uated, then  there  must  be  a  certificate  from  the 
Faculty  of  the  college  as  to  the  standing  of  the  ap- 
plicant while  in  college,  and  the  time  of  residence. 

Steps  were  also  taken  for  the  adoption  of  a 
minimum  standard  for  the  degree  of  A.B. 

The  officers  for  the  ensuing  year  are  : 

President— PhineasS.  Conner,  of  Cincinnati,  O. 

Vice-Presidents— R.  Lowry  Sibbet,  of  Carlisle, 
Pa.;  George  J.  Fisher,  of  Sing  Sing,  N.  Y.;  Hen- 
ry M.  Lyman,  of  Chicago,  111.;  Louis  S.  McMur- 
try,  of  Louisville,  Ky. 

Secretary— Charles  Mclntire,  Easton,  Pa. 

Assistant  Secretary— E.  M.  Green,  Easton,  Pa. 

Treasurer— J.  Cheston  Morris,  Philadelphia. 

After  a  satisfactory  disposition  had  been  made 
of  the  weightier  matters,  the  Fellows  in  a  lighter 
vein  indulged  in  reminiscences  of  former  spreads, 
and  enjoyed  the  good  things  placed  before  them 
in  the  spacious  banquet  hall  of  the  Arlington. 

The  time  and  place  of  the  next  meeting  will 
be  determined  by  the  Council. 


DOMESTIC  CORRESPONDENCE. 


Observations  011  "Koch's  Lymph." 

156  Washington  ave.,  cor.  Camp  st. 
New  Orleans,  La.,  April  2S,  1S91. 
His  Excellency  Benjamin  Harrison,  President  United 

States  of  America,  Washington,  D.  C. 

Sir: — I  have  the  honor  to  acknowledge  the  following: 
"Executive  Mansion,  Washington,  D.  C, 
January  19,  189 1. 
Professor  Joseph  Jones,  Charity  Hospital,  New  Orleans, 

La. 

My  Dear  Sir: — At  the  President's  direction  I  beg  to 
send  you  by  express,  to  day,  one  vial  of  Koch's  lymph 
for  such  use  as  you  may  deem  wise  to  make  of  it. 

It  was  forwarded  to  the  President  by  the  American 
Minister  in  Germany.     Very  truly  yours, 

E   W.  Halford,  Private  Secretary." 

I  beg  leave  respectfully  to  submit  to  your  Excellency 
the  following  brief  report  on  this  vial  of  Koch's  lymph. 

The  small  vial  of  Koch's  lymph  containing  about  five 
grams  (about  seventy-six  drops)  of  a  dark  brownish  red 
liquid,  accompanied  by  directions  for  its  use,  signed  by 
Dr.  A.  Libbertz,  of  Berlin,  Germany,  was  delivered  to  me 
in  person,  at  my  office,  36  University  Place,  by  the  ex- 
press agent. 

Holding  that  your  Excellency  designed  this  humane 
bequest,  not  for  private  ends,  but  for  the  benefit  of  suf- 
fering humanity,  and  the  promotion  of  scientific  inquiry, 
I  placed  a  portion  of  "Koch's  lymph"  contained  in  the 
small  vial,  at  the  disposal  of  the  medical  and  surgical 
staff  of  the  Charity  Hospital,  of  Louisiana,  as  will  be 
seen  from  the  following  correspondence: 

[Official  business.]     36  University  Place, 

New  Orleans,  La.,  Jan.  22,  1S91. 
Professor  A.  B.  Miles,  M.D.,  President  Surgeon  Charity 

Hospital,  New  Orleans,  La. 

My  Dear  Doctor: — On  the  22nd  inst.  I  received  by  ex- 
press a  small  vial  of  "Koch's  lymph,"  together  with  the 
enclosed  communication  from  the  private  secretary  of 
his  Excellency  President  Harrison 

I  respectfully  tender  to  the  Surgeon  in  Charge  of  the 
Charity  Hospital,  and  through  him  to  the  medical  and 
surgicial  staff,  a  portion  of  the  "lymph,"  for  the  treat- 
ment of  the  patients  in  the  wards  of  the  Charity  Hospital  , 
provided  that  I  be  furnished  with  accurate  reports  of  each 
and  every  case  thus  treated.  Respectfully  your  ohedieut 
servant,  Joseph  Jones,  M.D., 

Visiting  Physician  Charity  Hospital. 
Charity  Hospital,  State  of  Louisiana, 

New  Orleans,  Jan.  26,  1S91. 
Prof.  Joseph  Jones.  M.D.,   Visiting  Physician  Charity 

Hospital. 

.1/1  Deaf  Doctor: — I  beg  to  acknowledge  receipt  of 
your  favor  of  the  22nd  inst.,  tendering  to  the  Surgeon  in 
Charge  of  the  Charity  Hospital,  and  through  him  to  the 
medical  and  surgical  staff,  a  portion  of  the  lyiifph  which 
you  have  received  from  President  Harrison. 

V.CCI  pt  my  thanks  for  your  courtesy  in  this  matter. 

I  will  inform  the  members  of  the  medical  and  sur- 
gical staff  of  your  kind  offer,  and  refer  to  you  those  who, 
desire  to  experiment  with  the  lymph  in  their  ward  ser- 
vice.     Yours  very  truly.  A.  B.  MILES, 

House  Surgeon. 

We  extract  the  following  from  the  official  pro- 
ceedings of  the  Board  of  Administrators  of  the 
Charity  Hospital,  April,  1891: 

Dr.  Miles  reported  relative  to  "Koch's  lymph," 
in  which  he  said  the  world  was  taking  interest. 

Dr.  Joseph  Jones  had  received  a  vial  and  ten- 
dered it  to  the  hospital.     He  had  placed  a  notice 


:89i.]  DOMESTIC  CORRESPONDENCE  7»9 


on  the  bulletin  board,  inviting  others  to  use  it  in   ical  and  microscopical  manipulation  of  the  small 

safe  bounds,  if  they  thought  proper.   No  one  had   amount  of  material. 

applied  to  us.  it.     For  himself  he  did  not  care  to  PROPERTIES  OF   "koch's  LYMPH." 

use  it  yet,  as  he  did  not  deem  the  lymph  or  its 

substance  sufficiently  understood.     It  may  yet  be        i.   Reddish  brown  liquid,  with  oily  movement 

used  in  the  hospital,  but  it  would  be  best  to  await   and  consistency  of  thin  glycerine. 

further  results  from  it.  2.   Clear,  with  a  few  minute  floculi. 

Assisted  by  my  Chiefs  of  Clinics  Dr.  Stanhope       3.   Musty  odor  like  that  of  stale  beef  extract. 
Jones  and  Dr.  J.  M.  Elliott,  I  examined  the  cases       4.   When  burned  in  fiameof  alcohol  lamp  emits 
in  the  wards  under  my  care  in  the  Charity  Hos-   an  odor  like  burning  beef  extract, 
pital  daily,  up  to   the  middle  of  March,  with  a        5.   Reaction  strongly  alkaline, 
view  to  the  use  of  "Koch's  lymph"  in  the  diag-        6.  When  a  drop  of  the  undiluted  liquid   was 
nosis  and  treatment  of  phthisis   pulmonalis  and   placed  in  the  eye  of  a  living  animal  it  appeared 
other  forms  of  tubercular  disease.  to  cause  a  disagreeable  sensation,  attended  with 

That  this  agent  or  drug  was   not  used  in  the  closing  of  the  lids  temporarily,  but  it  induced  no 
treatment  of  diseases  under  my  care  in  the  wards   permanent  irritation  or  inflammation, 
of  the  Charity    Hospital,   of    New  Orleans,  was       A  repetition  of  this  experiment  caused  no  per- 
due to  the  following  causes:  ceptible  injury  to  the  eye  or  animal. 

a.  No  case  presented  itself  which  I  deemed  7.  No  appreciable  effects  were  induced  by  the 
suited  to  the  application  of  Koch's  treatment  "lymph"  when  administered  internally  by  the 
without  danger  to  the  welfare  of  the  patient.  mouth  to  living  animals. 

b.  No  case  presented  itself  of  which  the  diag-  The  fluid  in  its  innocuous  effects,  when  ap- 
nosis  was  so  obscure  as  to  require  the  institution  plied  to  living  mucous  membrane,  differed  from 
of  a  doubtful  experiment.  the  poisonous  alkaloids,   and  from  hydrocyanic 

c.  Without  exception   the  patients  under  my   acid  and  the  cyanogen  compounds. 

treatment  and  care  "in  the  wards  of  the   Charity        8.   Mingles  rapidly  and  freely  in  all  proportions 

Hospital  declined  to  submit  to  this  mode  of  treat-   with  distilled  water. 

ment.  9.  When  injected  with  varying  degrees  of  di- 

d.  The  extensive  prevalence  of  influenza,  in  a  lution  with  distilled  water  (50  per  cent.,  25  per 
severe  and  often  fatal  form,  and  which  attacked  cent.,  10  per  cent.,  1  per  cent,  and  o.  1  per  cent.) 
with  especial  violence  those  suffering  with  phthisis  into  the  subcutaneous  tissues  of  living  animals, 
pulmonalis,  rendered  the  injection  of  an  irritating  cats,  rabbits,  and  guinea-pigs,  only  slight  local 
agent  into  the  living  human  body  hazardous.  irritation,  and  no  sloughing,  was  induced  at  the 

In  accordance  with  what  I  conceived  to  be  the  points  of  injection.  The  injections  were  followed 
humane  and  charitable  intention  of  your  Excel-  by  fever  of  greater  or  less  intensity  and  duration, 
lency,  I  have  held  the  small  vial  of  "Koch's  The  animals  appeared  to  regain  their  normal  con- 
lymph"  sacred  to  scientific  and  charitable  inves-  ditions  in  varying  periods  of  four  to  seven  days, 
t'igations.  but  were  reserved  for  future  observations.      The 

I  have  received  a  number  of  applications  from   liquid  appeared  to  be  far  inferior  in  its  immediate 
physicians  and  private  individuals  for  the  use  of  effects,  when  injected  subcutaneously,  to  prussic 
this  "Koch's  lymph"  in  private  practice  and  in   acid,   strychnine,   and   serpent  poison.      Neither 
institutions  other  than  the  Charity  Hospital  of  did  it  manifest  effects  identical  with  septic  poison. 
Louisiana',  and  I  have  uniformly  refused  such  ap-        10.   Uncoagulated  by  heat, 
plications.      Such  applications   appear  to    have        1 1 .   Uncoagulated  by  nitric  acid, 
been  based  upon  a  misapprehension  of  the  inten-        12.  Uncoagulated  by  heat  and  nitric  acid, 
tion  of  your  Excellency,  and  upon  ignorance  of       13.   Chemically    pure  absolute   alcohol    threw 
the  therapeutic  value  and  power  of  a  quantity  of  down  from  the  "lymph"  a  flocculent  whitish  de- 
liquid  too  small  to  supply  more  than  one  drop  and  posit. 

a  half  to  each  one  of  the  fifty-two  wards  of  the        14.   Solution  of  nitrate  of  silver  threw  down  a 
Charity   Hospital,  with   a  daily   average  of  550  heavy   white    deposit,   showing  the  presence  of 
and  an  annual  average  of  about  7,000  cases  of  chlorides  in  considerable  amount. 
all  diseases.  15-   Soluble  baryta  salts  gave  slight   precipi- 

tates. 

OUTLINE     OF     RESULTS     OF     CHEMICAL    AND     MI-  Stannous    salts     gave     n0    evidence   of    the 

CROSCOPICAL     EXAMINATION     OF     THE  presence  of  the  Salts  of  gold. 

contents  of  vial  of  •  eoch  s  Microscopical  examination    of    the  undi- 

luted  "Koch's  lymph,"  with  objectives  ranging 

The  objectives  employed  in  the  following  ob-   from  one-fifth  to  one- fifteenth  of  an  inch,  revealed 

servations  ranged  from  one-fifth  to  one-fifteenth   the  presence  ofminute  ovoid  and  rod- shaped  bodies, 

of  an  inch.     Due  precautions  were  taken  to  se-   resembling  the  spores  and  bacilli  of  the  bacillus  tu- 

cure  such  results  as  were  possible  in  the  chem-   berculosis.  as  originally  described  by  the  eminent 


79Q 


DOMESTIC  CORRESPONDENCE. 


[May  30, 


microscopist,  Professor  Robert  Koch.  These  mi- 
croorganisms, in  their  size,  structure,  and  be- 
havior with  staining  agents,  corresponded  with 
the  bacillus  tuberculosis. 

18.  When  the  "lymph"  was  diluted  with 
boiled  distilled  water,  and  preserved  in  chemically 
clean  test  tubes,  the  mouths  of  which  were  carefully 
and  completely  guarded  by  antiseptic  cotton 
wool,  the  fluid  became  turbid.  Microscopical 
examination  revealed  the  fact  that  the  turbidity 
was  due  to  the  multiplication  of  microorganisms 
presenting  physical  and  chemical  properties  sim- 
ilar to  those  of  bacillus  tuberculosis. 

19.  The  addition  of  a  drop  of  the  "lymph" 
to  Pasteur's  sterilized  liquid  was  followed  by  the 
development  of  the  spores  and  slender  rod-shaped 
organisms   resembling  the  bacillus  tuberculosis. 

20.  The  spores  and  bacilli  of  "Koch's  lymph" 
were  cultivated,  with  the  necessary  precautions 
to  exclude  all  external  germs  from  the  atmos- 
phere and  external  objects,  upon  various  sub 
stances  or  media,  as  serum,  blood,  boiled  Irish 
potato,  boiled  and  coagulated  white  of  egg,  and 
boiled  aseptic  crystallized  sugar. 

2 1 .  The  cultivations  in  fresh  blood  were  strong- 
ly alkaline,  those  of  the  Irish  potato,  white  of 
egg  and  sugar  were  acid. 

22.  When  a  small  quantity  of  the  "lymph'' 
was  added  to  a  carefully  sterilized  solution  of 
crystallizable  sugar,  the  clear  solution  became 
turbid  from  the  development  of  bacilli,  and 
emitted  a  distinct  sweetish  acid  odor,  similar  to 
that  which  I  have  often  observed  to  be  exhaled 
by  patients  suffering  from  phthisis  pulmonalis  in 
the  advanced  stages. 

CONCLUSIONS, 

a.  The  active  principles  of  "Koch's  lymph" 
appear  to  reside  in  a  colloid  nitrogenized  com- 
pound coagulable  by  absolute  alcohol,  and  in 
living  germs,  microorganisms,  spores  and  bacilli, 
similar  to  those  of  the  bacillus  tuberculosis,  and 
capable  of  multiplying  within  and  without  the 
living  organism. 

b.  The  potent  effects  of  "Koch's  lymph"  when 
introduced  into  the  blood  of  healthy  and  diseased 
human  beings  may  be  referred  in  part,  at  least,  to 
the  rapid  multiplication  and  action  of  micro- 
organisms similar  to,  if  not  identical  with,  the 
bacillus  tuberculosis. 

<-.  The  results  of  the  chemical  and  microscopical 
examination  of  the  contents  of  this  vial  of  "Koch's 
lymph"  have  led  me  to  exclude  this  liquid  from 
the  list  of  remedial  agents. 

I  beg  to  be  permitted  to  say  that  in  the  effort 
in  discharge  what  appeared  to  be  my  duty  1  li  •>< 
endeavored  to  serve  the  art,  and  not  the  trade  of 
ae,  believing  that  honorable,  legitimate 
medicine  has  no  secrets  to  conceal,  and  holds  no 
remedy  which  is  not  the  common  heritage  of  the 


glorious  brotherhood    of  the    noble  republic  of 
science. 

With  great  respect,  and  with  many  thanks  for 
the  generous  consideration  of  your  Excellency,  I 
have  the  honor  to  remain  your  obedient  servant, 
Joseph  Jones,  M.D. 


Letter  from  Dr.  W.  II.  Daly,  Pittsburgh,  Pa. 

To  the  Editor: — Replying  to  a  letter  on  page  647 . 
May  2,  1S91,  of  The  Journal  of  the  Associa- 
tion, permit  me  to  say,  that  at  the  last  meeting  of 
the  Association  in  Nashville,  I  was  invited  to 
open  the  discussion  on  the  medical  treatment  of 
diphtheria. 

The  time  limit  is  ten  minutes ;  I  occupied  but 
six,  as  can  be  verified  by  reading  my  remarks 
in  The  Journal  of  October  11,  1890.  Now  it 
is  scarcely  possible  for  one  to  be  exhaustive  on 
that  subject,  in  so  short  a  time.  Much  must  be 
omitted,  and  I  omitted  much.  Yet  there  was 
probably  not  a  person  who  did  me  the  honor  to 
listen  to  me  at  the  meeting,  nor  one  who  read  my 
remarks  in  The  Journal  of  the  Association, 
with  the  possible  exception  of  Dr.  Kornig,  who 
did  not  fully  know  and  understand  that  I  had  al- 
ready in  the  paper  to  which  I  referred,  not  only 
again  drawn  the  attention  of  the  profession  to  the 
value  of  the  calomel  treatment  of  diphtheria  un- 
der the  title  of  "  the  simplest  and  most  efficient 
treatment  of  diphtheria,"  which  I  read  before  the 
congress  of  the  American  Laryngological  Asso- 
ciation in  Philadelphia  in  1886.  A  reprint  of 
that  article,  I  beg  herewith  to  hand  you,  that 
you  may  see  the  following  quotations  are  unmis- 
takably correct. 

You  will  see  that  I  therein  stated  the  plan  was 
>iot  new  and  in  verification  I  quoted  a  case  of  the 
child  of  the  celebrated  author,  Divine  and  wit, 
Rev.  Sydney  Smith,  who  was  treated  by  Dr. 
Hamilton  in  1797  in  Edinburg,  Scotland,  by  ad- 
ministering 2  grains  of  calomel  every  hour — the 
child  recovering. 

You  will  see  that  I  further  gave  my  deceased 
friend,  Dr.  M.  C.  Reiterof  Pittsburgh,  full  credit, 
which  is  well  known  not  only  to  the  estimable 
family  of  Dr.  Reiter,  but  to  the  entire  pro- 
fession (unless  possibly  to  the  writer  of  that  let- 
ter in  the  last  issue  of  The  Journal).  I  now 
quote  from  my  remarks  in  that  paper. 

"  Now,  briefly,  as  to  the  credit  for  the  practice  of  the 
calomel  treatment  of  diphtheria  in  modern  medicine. 
To  Dr.  William  C.  Reiter,  of  Pittsburgh,  a  gentlemen 
who  was  learned  in  other  sciences  as  well  as  in  medicine, 
11  is  due.  He  was  the  apostle  of  this  plan  of 
treatment  of  diphtheria,  and  he  fur  main-  vears  persist- 
ently practiced  the  treatment,  and  promulgated  the  doc- 
trine to  his  brethren,  many  of  whom  were  at  first  unbe- 
was  an  earnest  and  honest  observer,  fearless 
in  the  practice  and  assertion  of  what  lie  deemed  right. 
He  had  large  experience  and  ripe  judgment,  and,  as  he 
1  m\   j  ens  almost  alone  111  the  advocacy  of  the 


i89i.] 


MISCELLANY. 


7  ■' 


plan,  he  deserves  still  more  our  respectful  praise  and  free 
acknowledgment. 

"In  medical  works  the  various  mercurial  plans  of  treat- 
meut  are  mentioned,  of  late  years,  without,  so  far  as  I  have 
observed,  according  to  Dr.  Reiter,  the  credit  of  having 
advocated  and  practiced  the  method  of  treating  diph- 
theria by  the  exhibition  of  calomel.  I  regard  all  the 
other  mercurial  preparations  as  mere  excuses  or  ineligi- 
ble substitutes  for  this  best  of  all  mercurials  in  diphtheria 
—  viz.,  calomel.  To  any  one  caring  to  see  the  brochure 
of  Dr.  Reiter,  which  is  little  known  of.  and  is  so  peculiar 
in  its  style  as  to  entitle  it  to  be  considered  an  oddity  in 
medical  literature,  I  will  say  that  it  was  published  by  J. 
B.  Lippincott  &  Co..  in  1S7S,  and  is  entitled  "  A  Mono- 
graph on  the  Treatment  of  Diphtheria  based  upon  a  New- 
Etiology  and  l'athologv."  by  William  C.  Reiter,  A.  M.. 
M.D." 

The  widest  publicity  was  given  to  that  paper, 
through  the  kind  consideration  of  the  medical 
press,  and  it  was  reprinted  in  extenso  in  several 
American  and  European  journals,  and  in  some  of 
the  latter  in  an  abbreviated  form.  There  were  al- 
so 3,000  reprints,  sent  to  members  of  the  profes- 
sion, especially  to  my  fellow  members  of  the  Al- 
legheny Co.  Medical  Society,  of  which  the-  writer 
of  that  letter  was  then  a  member.  Consequently, 
my  disavowal  of  originality  in  the  matter,  as  well 
as  my  just  encomiums  upon  my  deceased  friend 
were  well  published,  and  well  known,  and  I  can- 
not understand  how  Dr.  Kornig,  whose  name  is 
advertised  in  the  columns  of  a  medical  journal  as 
a  co- editor,  could  have  failed  to  have  read  the 
article  somewhere. 

The  readers  of  The  Journal  of  the  Associa 
tion  have  probably  all  heard  of  the  man  "  who 
on  first  hearing  the  story  of  the  Crucifixion,  hit 
the  first  Jew  on  the  nose  that  he  happened  to 
meet  thereafter,  and  on  being  remonstrated  with, 
in  that  the  event  had  occurred  nearly  2000  years 
ago,  justified  himself  on  the  ground  that  he  had 
just  heard  of  it,  and  was  determined  to  wreak  ret- 
ribution." 

The  readers  of  that  letter  can  scarcely  have 
failed  to  have  also  read  between  the  lines,  and  dis- 
covered a  lurking  animus.  Altogether  it  presents 
another  case  of  a  man  who  has  sat  down  with 
no  chair  behind  him.  Very  respectfully, 

W.  H.  Daly. 

135  5th  Ave,  Pittsburgh,  Pa. 


MISCELLANY. 


Ohio  State  Medical  Society. — Forty-sixth  Annual 
Meeting  at  Sandusky,  Ohio,  June  17,  iS,  and  19,  1S91. 

Officers.— President,  W.  J.  Conklin,  Dayton.  Vice- 
Presidents:  D.  N.  Kinsman,  Columbus;  B.  L.  Millikin, 
Cleveland:  D.J.  Snyder.  Scio;  Orpheus  Everts.  College 
Hill.  Secretary.  G"  A.  Collamore,  Toledo.  Assistant 
Secretary,  J.  A."  Spence,  New  Philadelphia.  Treasurer 
and  Librarian,  T.  W.  Jones,  Columbus. 

Committee  of  Arrangements. — S.  S.  Thorn,  A.  J. 
Gawne,  H.  A.  Tobey,  \Vm.  Caldwell,  F.  D.  Bain. 

First  Session—  Wednesday,  June  17. — 1.  Call  to  order. 

2.  Report  of  Committee  of  Arrangements. 

3.  Business  which  requires  early  consideration. 


4.  Annual  Reports  of  Treasurer.  Librarian  and  Secre- 
tary. 

5.  Reports  of  Standing  Committees  :  Committee  on 
Admissions  and  Medical  Societies.  Committee  on  Fi- 
nance. Committee  on  Publication.  Committee  on 
Legislation.     Committee  on  Ethics. 

6.  Reports  of  Special  Committees  :  Committee  on 
"  Act  providing  for  the   Protection    of  Physicians,  etc." 

:ier,  Chairman.  Committee  on  Organization  of 
County  Societies  and  their  Relation  to  the  State  Medical 
Society.     T.  A.  Kearny,  Chairman. 

7.  Reports  from  Delegates  to  the  American  Medical 
Association  and  other  Societies. 

8.  Appointment  of  Committee  on  Nominations. 

9.  Papers:  "The  Surgical  Treatment  of  Chronic 
Catarrhal    Appendicitis  :"     R.  Harvey  Reed,   Mansfield. 

•  n  the  Treatment  of  Syphilis:"  W.  T.  Corlett, 
Cleveland.  "  A  Plea  for  a  More  Extended  Supervision 
of  the  Parturient  Woman:"  D.  R.  Silver.  Sidney. 
"Hernia:"  Dudley  P.  Allen,  Cleveland. 

Evening  Session. — 1.  Papers:  "  Carcinoma,  a  form  of 
Perverted  Nutrition  :"  H.  J.  Herrick,  Cleveland.  "A 
Rare  Case  of  Pelvic  Dropsy  :  Operation  ;  Cure  :"  J.  F. 
Baldwin,  Columbus.  "Spinal  Supports:"  S.  I..  Mc- 
Curdv,  Denmson.  "  Compound  Ganglia  ;  Treatment  by 
Operation  :"  C.  S.  Hamilton,  Columbus.  "Three  Cases 
Radical  Cure  of  Hernia  by  the  Use  of  the  Buried  Anti- 
septic Animal  Suture  :"  F.  C.  Larimore.  Mt.  Vernon. 

Tuesday,  June  iS— Morning  Session— \.  Reports  of 
Committees. 

2.  Papers  :  "A.  C.  E.  Mixture  :"  J.  C.  Reeve,  Dayton. 
"Anaesthetics  :  the  Dangers  in  the  Use  of  Chloroform  as 
compared  with  Sulphuric  Ether:"  E.  H.  Hyatt,  Dela- 
ware. -Tuberculin  in  the  Treatment  of  Tuberculosis:" 
J.  T.  Whittaker,  Cincinnati.  "  Influenza:"  D.  N.  Kins- 
man, Columbus.  "Convergent  Squint  and  its  Cure:" 
C.  \V.  Tangeman,  Cincinnati'.  "  Some  Facts  every  Prac- 
titioner ought  to  know  about  Squint  :"  A.  R.  Baker, 
Cleveland.  "  The  Treatment  of  Retention  from  Hyper- 
trophy of  Prostate:"  N.  P.  Dandridge,  Cincinnati. 
"Fracture  of  Dorsal  Vertebrae:"  A.  \V.  Ridenour, 
Massillon. 

Afternoon  Session— \.  Reports  of  Committees. 

2.  Election  of  Officers. 

3.  Selection  of  the  Place  for  the  next  Meeting. 

4.  Papers:  "  Report  of  Cases,  with  Comments:"  T.  A. 
Reamv,  Cincinnati.  "  Removal  of  Uterine  Appendages: 
Supplemental  Report :"  R.  B.  Hall,  Cincinnati.  "Op- 
erative Treatment  of  Uterine  Cancer  :"  D.  Tod  Gilliam, 
Columbus.  "High  Amputation  of  Cervix  :"  B.F.Hart, 
Marietta.  "  Cases  of  Extra-Uterine  Gestation  :"  \V.  D. 
Hamilton  and  C.  S.  Hamilton,  Columbus.  "The  Value 
of  Draining  the  Pelvis,  in  Case  of  Bleeding  after  Opera- 
tion :"  M.  Stamm,  Fremont. 

Evening  Session.— President's  Address.  "  A  Page  of 
Medical  History  ;  Moliere  and  the  Doctors :"  W.  J. 
Conklin,  Davton. 

Friday.  June  ig— Morning  Session.— I.  Reports  of 
Committees. 

2.  Papers  :  "  Modern  Methods  of  Treatment  for  Nose 
and  Throat  Diseases  accessible  to  the  General  Practi- 
tioner :"  Jas.  E.  Nichols.  N.  V.  City.  "Tonsillotomy 
and  After-Treatment :"  T.  V.  Fitzpatrick,  Cincinnati. 
"  Intubation  :"  Geo.  Goodhue.  Dayton.  "  Papilloma  of 
Larvnx  ;  Case:"  A.  B.  Thrasher,  Cincinnati.  "Ks- 
plofatorv  Incisions  of  Knee  Joints  :"  B.  Merrill  Ricketts. 
Cincinnati.  "Gonorrhoea  in  Women:"  C.  N.  Smith, 
Toledo.  "Home  versus  Hospital  Treatment  of  the  In- 
sane :"  A.  B.  Richardson,  Cincinnati. 

Afternoon  Session— \.  Reports  of  Committees. 

2  Papers:  "Hvperemesis  Gravidarum:"  W.  A. 
Dickev.  Tiffin.  "Tests  for  Albumen:"  W.  B.  Davis, 
Cincinnati.  "  The  Limitations  of  Dermatology  :"  Ed- 
ward Preble,  Cleveland.  "Spinal  Concussion  :"  G.  W. 
Crile,  Cleveland.  "Salpingitis;  with  a  Report  of  two 
Cases  :"  A.  B.  Walker.  Canton.     Volunteer  Papers. 


792 


MISCELLANY. 


[May  30,  1 89 1. 


3.  Oral  Communications. 

4.  New  Business. 

5.  Unfinished  and  Miscellaneous  Business. 

As  the  program  contains  a  large  number  of  papers,  the 
attention  of  readers  is  called  to  Section  V,  of  Bv-Laws  : 
•'  Not  to  exceed  thirty  minutes  shall  be  allowed  for  the 
reading  of  any  paper." 

The  Sessions  of  the  Society  will  be  held  at  the  Hall 
corner  Washington  Row  and  Jackson  Street;  first  Session 
at  2  P.M.,  Wednesday,  June  17. 

Hotels. — West  House  ;  Sloane  House,  $2.00  and  up- 
ward per  day. 


degree  of  polish  than  any  optical  glass  hitherto  manu- 
factured. Thus  microscopes  can  be  made  which  will 
render  objects  of  the  diameter  of  only  the  one-eight  mil- 
lionth of  a  millimetre  visible,  whereas  with  the  best  in- 
struments now  in  use  the  diameter  of  the  smallest  object 
that  can  be  seen  is  one-sixteenth  thousandth  of  a  milli- 
metre.— Lancet. 


Dr.  Samuel  O.  L.  Potter,  Professor  of  Medicine  in 
the  Cooper  Medical  College  of  San  Francisco,  and  a 
graduate  of  Jefferson  Medical  College  of  Philadelphia 
(with  first  prize,  'S2),  recently  passed  the  required  exam- 
ination and  was  admitted  on  April  30  last,  a  Member  of 
the  Royal  College  of  Physicians  of  London,  forming  one 
of  a  class  of  nine  candidates,  all  of  which  were  M.D.'s 
of  British  Universities,  viz.:  three  of  Cambridge,  one  of 
Oxford,  one  of  Edinburgh,  two  of  London,  one  of  Aber- 
deen. 

Those  who  understand  the  peculiar  rank  of  British 
qualifications  will  recognize  the  M.R.C.P.  of  London  as 
the  "  hall-mark  "  of  the  British  medical  profession,  and 
that  it  is  a  coveted  one  may  be  seen  from  the  fact  that  all 
the  candidates  therefor  were  previous  M.D.'s  or  M.B.'s  of 
universities — asking  this  as  an  additional  honor.  The 
qualification  of  this  college  given  at  the  ordinarv  final 
examination  of  students  is  the  license,  "L.R.C.P."  Lon- 
don, and  does  not  admit,  as  does  the  membership,  to  the 
college  itself. 

The  only  other  Americans  holding  this  qualification 
are  Prof.  Osier,  of  Baltimore,  and  Dr.  Robinson,  of  San 
Francisco.  It  is  also  held  by  two  English  practitioners 
in  California,  and  one  in  Washington,  one  in  Canada, 
and  one  in  British  Columbia. 

We  understand  that  Dr.  Potter  left  his  bed  in  conva- 
lescence from  broncho-pneumonia  to  undergo  the  exam- 
inations of  the  week  ending  April  30,  and  that  he  has 
since  had  a  relapse  and  is  dangerously  ill. 


The  American  Medical  Association. — The  meeting 
of  the  Association  which  has  just  closed  at  Washington, 
was  in  many  ways  a  success.  With  such  a  man  as  Dr. 
Briggs  in  the  chair,  and  master  minds  like  Shurly  and 
Mathews,  to  give  the  principal  addresses,  the  general 
sessions  could  not  but  be  interesting.  Those  who  have 
read  the  thoughtful  addresses  already  published  must 
feel  proud  of  the  men  who  can  so  grace  our  guild  by 
word  and  deed. 

The  reports  of  the  sections  are  not  as  yet  ready,  but  it 
is  safe  to  anticipate  their  reception,  and  say  that  each 
year  there  is  a  growing  demand  for  more  and'  better  work 
in  each  section.  Sometimes,  indeed,  it  seems  that  the 
main  drift  of  the  Association  is  political,  that  the  main 
chance  is  with  the  committee  on  nominations  and  the 
chief  prizes  are  the  leading  offices  ;  just  then  some  grand 
work  will  be  announced,  some  reliable  conclusion  given, 
or  some  valuable  research  reported  and  the  scientific 
worth  of  the  Association  will  again  be  in  the  ascendency. 

Thus,  as  in  all  progress,  there  is  an  ebb  and  flow  and 
we  are  satisfied  if  only  the  tides  does  not  run  too  low,  as 
it  sometimes  threatens  to  do.  We  confidently  believe, 
however,  in  the  great  field  of  usefulness  which  the  Ameri- 
can Medical  Association  is  to  occupy.  Some  changes 
must  be  made  for  the  greater  economy  of  time  and  the 
proper  selection  of  material  ;  some  advantages  may  be 
gained  by  the  formation  of  local  branches,  and  some 
new  enthusiasm  aroused  by  holding  out  inducements  for 
scientific  research  and  original  investigation. 

The  American  profession  is  pledged  to  the  support  of 
the  American  Medical  Association  and  there  must  be  its 
hindrance  to  its  progress  and  no  prostitution  of  no 
purposes. — Editorial  in  The  St.  Louis  Clinique. 


Officers  of  Kansas  State  Medical  Society  for 
ensuing  year:  President— J.  E.  Oldham,  M.D.,  Wichita, 
Kan.;  First  Vice  President— A.  H.  Cordier,  M.D.,  Mc- 
pherson, Kan.;  Second  Vice-President  —  J.  T.  Axtell, 
M.D.,  Newton,  Kan.;  Treasurer— L.  A.  Buck,  M.D.,  Pea- 
body,  Kan.;  Secretary— W.  S.  Lindsay,  M.D.,  Topeka, 
Kan.     Xext  place  of  meeting,  Ft.  Scott,  May,  1S92. 


The  Sounds  of  Colors. — A  beam  of  sunlight  is  made 
to  pass  through  a  prism  so  as  to  produce  the  solar  spec- 
trum or  rainbow.  A  disc,  having  slits  or  openings  in  it, 
is  made  to  revolve,  and  the  colored  light  of  the  rainbow- 
is  made  to  break  through  it  and  fall  on  silk,  wool,  or 
other  material  contained  in  a  glass  vessel.  As  the  col- 
ored light  fails  upon  it,  sounds  will  be  given  by  the  dif- 
ferent parts  of  the  spectrum,  and  there  will  be  silence  in 
other  parts.  If  the  vessel  contains  red  worsted,  and  the 
green  light  flashes  upon  it,  loud  sounds  will  lie  given. 
Only  feeble  sounds  will  he  heard  when  the  red  and  blue 
parts  of  the  rainbow  fall  upon  the  vessel. —  Times  and 
Register. 


Official  List  of  Changes  in  the  Stations  and  Duties  of  Officers  Serving 
in  the  Medical  Department.  U.  S.  Army,  from  Mav  10,  1S91,  to 
May  -'.?,  1891. 

Capt.  Marshall  W.  Woods.  Asst.  Surgeon  U.  S.  A.,  is  hereby  granted 
leave  of  absence  for  one  month,  to  commence  on  or  about  the  23d 
inst.    Par.  1,  S.  O.  104,  Div.  Atlantic,  May  20,  1S91. 

Capt.  George  McCreery,  Asst.  Surgeon,  is  relieved  from  dutv  at  Ft. 
Clarke,  Tex.,  and  will  report  in  person  to  the  commanding'officer, 
Ft.  Mcintosh,  Tex.,  for  dutv  at  that  post.  By  direction  oi  the  Sec- 
retary of  War.     Par.  4.  S.  O.  114,  A.  G.  O.,  May  19,  1891. 

Capt.  William  B.  Banister.  Asst.  Surgeon,  is  assigned  to  dutv  as 
medical  officer  with  Troop  B.  Sixth  Cavalry,  while  en  route  from 
Ft  Myer.  Va.,  to  Ft.  Washakie,  Wyo.  On 'arrival  of  the  troop  at 
its  destination,  Capt.  Banister  will  return  to  his  station  at  Wash- 
ington Bks.     Par.  3,  S.  O.  104.  Div.  Atlantic,  May  20,  1891. 

Capt  John  A.  Skinner.  Asst.  Surgeon  D.  S.  A.,  Ft.  Davis,  Tex.,  will 
proceed  at  once  to  Ft.  Clarke,  Tex.,  and  repjrt  to  the  command- 
ing officer  for  temporary  duty.  Par.  1,  S.  O.  44.  Dept.  of  Texas, 
May  13,  1S91. 

By  direction  of  the  Secretary  of  War,  the  following  assignments  oi 
recently  appointed  medical  officers  are  ordered:  First  Lieut.  Wil- 
liam F.  Lippitt.  Jr.,  Asst.  Surgeon,  will  report  in  person  to  the 
commanding  officer,  Ft.  McPherson,  Ga.  First  Lieut.  Benjamin 
\~st  Surgeon,  will  report  in  person  to  the  commanding 
officer.  Ft.  Riley,  Kan.  First  Lieut.  Meritte  W.  Ireland,  Asst.  Sur- 
geon,  will  proceed  from  Columbia  City,  Ind.,  to  Jefferson  Bks., 
Mo  .  and  report  in  person  for  dutv  lo  the  commanding  officer  of 
I  First  Lieut.  George  M.  Wells,  Asst.  Surgeon,  will  pro- 
ceed from  Paoli,  Ind..  to  Columbus  Bks.,  O.,  and  report  in  person 
for  duty  to  the  commanding  officer  of  that  post.  Par.  7,  S.  O.  115, 
A.  G.  O.,  May  20,  1891. 


Important  Improvement  in  Microscopic  Lenses. 
— It  is  stated  that  an  immense  improvement  has 
been  effected  in  the  manufacture  of  glass  for  optical  in- 
struments, by  means  of  the  addition  to  the  ordinary  ma- 
terials of  phosphorus  and  chlorine,  which  in  some,  as 
yet  unexplained,  way  cause  the  glass  to  be  very  much 
more  trans  parent,  and  enable  it  to  receive  a  much  higher 


Official  List  of  Changes  in  the  Medical  Corps  of  the  U.  S.  Navy,  for 

the  li  'ttk  Ending  May  ij,  i$oj. 
Surgeon  Geo.  A.    Bright,  detached  from  u.  S.  S.    "Omaha,"  and 

three  months'  leave  of  absence. 
r     \    Surgeon  V.  C,  B.  Means,  detached  from  U.  S.  S.  "  Omaha" 

mted  three  months'  leave  of  absence. 
ft.sst    Surgeon    las,   F.  Keeney,  ordered  for  examination  prelimi- 
nary to  promotion  to  P.  A.  surgeon. 


f>3 


The  Journal  of  the 

American  Medical  Association 


Vol.  XVI. 


CHICAGO,  JUNE  6,   1891. 


No.  23. 


ORIGINAL  ARTICLES. 


THE    CONSIDERATION    AND    CURE    OF 
CHRONIC  TUBERCULAR  CONSUMP- 
TION OF  THE  LUNGS. 

Read  in  the  Section  of  Pi  act  ice  oj    ! 
Forty-second  Annual  Meeting  of  the  American  Medical  Associa- 
tion, held  at  Washington.  D.  C..  May,  tSgi. 

BY  ASA  F.   PATTEE,   A.M.,   M.D., 


In  the  preparation  of  this  paper  I  have  en- 
deavored to  be  as  concise  as  possible  consistent 
with  clearness ;  I  have  employed  the  terms 
phthisis,  tuberculosis  and  pulmonary  consump- 
tion as  expressing  the  same  pathological  con- 
dition. 

The  progressive  tendency  of  the  tubercle  of 
phthisis  is  of  a  fibrous  nature,  or  a  leaning  to- 
ward healing  or  health  ;  becoming  through  this 
means  a  self-limiting  condition.  The  direct  re- 
verse of  the  tubercle  of  cancerous  and  other  in- 
flammatory ulceration. 

I  have  for  many  years  maintained  by  theory, 
and  shown  by  actual  results,  that  pulnionary 
tuberculosis  may  be  cured,  even  after  extensive 
degeneration  of  lung  tissue  has  taken  place  ; 
provided  the  constitution  has  not  become  vitiated 
by  disease  or  other  causes,  or  its  recuperative 
powers  destroyed  by  old  age. 

We  now  find  this  assertion  copiously  substanti- 
ated by  eminent  authority.  Given  suitable 
handling,  in  all  that  the  term  implies,  and  the 
extent  of  the  depredation  will  take  care  of  itself; 
it  will  make  little  difference  whether  prognosis 
has  limited  the  life  of  the  patient  to  a  certain 
number  of  weeks  or  months. 

It  is  the  cowardly  attitude  of  settling  down  to 
palliative  measures  that  has  wrought  the  mis- 
chief in  the  past.  Such  means  exclude  all 
recuperative  agents,  and  serve  to  deprive  every 
organ  of  its  normal  activity  in  the  performance 
of  its  functions,  as  a  result  favoring  the  destruc- 
tion already  going  on. 

This  idea  that  a  person  must  be  doomed  to  die 
of  phthisis  because  one  of  his  parents  were  its 
victims  seems  now  about  to  be  thrown  into  the 
rubbish  of  the  past,  and  the  sooner  this  absurdity 
can  be  removed  from  the  mind  of  the  public  the 
better. 


GENERAL  TREATMENT. 

My  thesis  written  in  1857  was  entitled,  Pure 
Air,  Pure  Water,  Cleanliness  and  Exercise.  Their 
importance  in  the  prophylaxis  and  cure  of  disease. 

From  the  time  I  commenced  practice  these 
agents  have  been  my  best  allies.  In  my  surgery, 
air,  water  and  cleanliness  have  been  my  anti- 
septics, pure  water  doing  for  me  what  corrosive 
sublimate,  iodoform,  etc.,  have  accomplished  in 
the  hands  of  others. 

In  1862,  I  first  read  Chamber's  Lectures  on 
the  Renewal  of  Life,  and  so  impressed  was  I 
with  the  truth  of  his  reasoning  that  I  have  kept 
that  object  in  view  in  the  treatment  of  disease  in 
every  form  ever  since.  The  number  of  cases  of 
chronic  pulmonary  tuberculosis  that  have  come 
into  rny  hands  for  treatment  are,  according  to 
my  reckoning,  about  3,000,  exclusive  of  those  I 
had  in  the  United  States  Army.  Every  case 
shows  me  yet  more  plainly  the  folly  of  attempt- 
ing to  adopt  a  routine  which  shall  be  applicable 
to  all  tuberculous  patients.  The  treatment  of 
every  patient  must  be  a  problem  unto  itself. 

By  no  means  is  it  essential  for  the  same  un- 
favorable elements  to  combine  in  order  to  bring 
about  certain  results.  The  susceptibility  of  the 
individual  to  certain  conditions  must  be  con- 
sidered. We  must  meet  every  condition,  phys- 
ically, mentally  and  morally,  and  in  this  way  re- 
gard his  case  as  entirely  distinct  from  any  other. 

While  the  various  theories  as  to  predisposing 
causes,  hereditary  tendencies,  and  the  means  of 
combating  them  have  not  embraced  all  the  ele- 
ments of  success,  still  the}'  have  given  us  all  the 
light  we  have  had  upon  this  dark  subject,  and 
so  far  as  hygienic  influences  have  been  recog- 
nized they  are  deserving  of  our  highest  consid- 
eration. 

Until  the  bacillus  made  its  shadow  upon  the 
screen  of  our  observations  (whose  office  it  seems 
to  me  should  be  regarded  as  that  of  a  very  lively 
interrogation  point,  rather  than  as  a  period  to  all 
future  questionings),  the  trend  of  the  past  few 
years  had  been  towards  recognizing  in  Nature  a 
powerful  factor  in  the  prevention  and  cure  of 
consumption. 

Let  us  not  get  bacilli  mad  !  Cannot  we  have 
a  case  of  pulmonary  tuberculosis  on  our  hands 
\  and  not  yet  be  able  to  find  these  little  fellows  ; 


794 


CONSUMPTION  OF  THE  LUNGS. 


[June  6, 


the  very  recent  knowledge  of  whose  existence 
seems  to  have  wrought  a  condition  in  our  brains 
as  disastrous  as  their  presence  is  credited  to  pro- 
duce in  the  lungs  of  our  patients? 

Let  us  not  forget  our  modest  days  of  small 
things,  before  bacilli  were  known,  and  thus  care- 
fully avoid  the  danger  which  now  seems  to  be 
threatening  of  ignoring  all  other  means  of  diag- 
nosis in  our  frantic  search  for  the  revelations  of 
the  microscope. 

Nor  will  we  permit  this  to  let  us  slight  the 
premonitory  warnings  of  the  approach  of  this 
disease,  and  thus  encourage  the  baneful  tendency 
to  dismiss,  with  some  simple  opiate,  a  slight 
cough,  protracted  cold,  irritable  throat,  etc.,  be- 
cause as  yet  the  expectorations  have  failed  to 
yield  the  little  wriggler  whose  presence  only 
shall  determine  the  tuberculous  condition. 

If  tuberculosis  must  owe  its  existence  to  this 
alone,  then  I  shall  maintain,  at  the  expense  of 
paradox,  that  he  who  would  cure  chronic  pul- 
monary tuberculosis  must  begin  the  cure  before 
he  finds  the  disease  in  his  patients. 

Build  up  the  general  health  of  the  consump- 
tive so  that  his  chemico-vitalizing  function  will 
be  sufficient  to  destroy  the  bacilli.  In  fact,  put 
every  patient  into  such  a  degree  of  health  that 
he  shall  be  his  own  bacilli-killer. 

Bacilli  cannot  exist  in  perfectly  healthy  lung 
tissue.  It  must  become  diseased  before  it  can 
offer  sufficient  inducement  for  him  to  live  and 
propagate  in  it,  and  upon  its  resumption  of  health 
the  tenant  vanishes. 

HYGIENIC    INFLUENCES. 

A  perfect  familiarity  with  the  daily  life  of  our 
patient  must  be  our  first  consideration.  Our  sur- 
roundings make  us  what  we  are,  physically  as 
well  as  morally  and  socially.  Man  is  like  the 
chameleon,  ever}7  part  of  his  nature  partakes  and 
is  made  up  of  his  surroundings.  "Show  me 
your  friends  and  I  will  tell  you  what  you  are." 
This  is  as  true  of  the  physical  as  of  the  moral 
man. 

If  our  treatment  could  begin  with  the  birth  of 
the  patient,  in  99  per  cent,  we  should  have  no 
tuberculosis  to  treat,  no  matter  about  the  family 
history. 

Fear  is  a  powerful  provocative  to  physical  de- 
generation. Take  the  condition  of  the  poor.  It 
is  not  generally  their  immediate  wants  which 
cause  the  catastrophe.  People  who  are  habit- 
ually poor  are  not  necessarily  feeble,  but  those 
who  have  lost  their  wealth  are  the  sufferers. 
lo  tlie  immediate  future  for  themselves 
or  others;  with  this  instinctive  nervous  shock 
ly  shrinks,  all  the  organic  functions  are 
disturb  illy  is  this  true  of  the  respiratory 

functions.  Fear  of  any  sort  lias  a  depressing 
upon  tin-  respiratory  centre.  This  is  as 
true  of  animals  as  of  men.  Anxiety  is  but  a 
i(  -  of  fear. 


It  is  futile  for  us  to  shut  our  eyes  to  the  reflex 
action  which  the  mind  throws  upon  the  physio- 
logical powers.  We  see  proofs  of  it  every 
instant,  yet  dispute  it,  and  call  it  unscientific. 
What  are  we  striving  to  accomplish  in  our  treat- 
ment of  disease  ?  Is  it  not  our  aim  to  coax,  by 
all  manner  of  means  known  to  us,  this  vital 
principle  called  Life  to  tarry  yet  a  little  longer  in 
its  diseased  encasement  ?  Then  give  its  presence 
a  just  recognition  by  attributing  to  it  a  capability 
both  creative  and  destructive,  a  reality  though 
intangible. 

EXERCISE. 

The  various  mechanical  arrangements  now  in 
vogue  for  indoor  exercise  are  generally  to  be 
commended.  The  patient  must  be  imbued  with 
the  determination  to  get  well.  He  must  be  made 
to  understand  that  much  depends  upon  himself. 
That  he  must  exercise  as  well  as  eat.  The  ex- 
ercise must  be  accumulative,  doing  a  little  more 
every  day,  and  the  nourishment  must  also  be  ac- 
cumulative. The  amount  of  exercise  he  can 
bear  will  depend  upon  the  amount  of  strength- 
giving  food  he  can  assimilate,  and  vice  versa. 

RECREATION. 

The  recreations  should  be  of  a  nature  that  will 
inspire  an  interest  on  the  part  of  the  invalid  in 
their  accomplishment.  •  There  should  be  an  im- 
portance attached  to  them  requiring  some  thought. 
The  unemployed  mind  is  a  powerful  depressant 
to  the  nervous  forces.  Let  the  daily  walks  and 
rides  have  some  purpose,  if  nothing  more  than' 
the  performance  of  the  domestic  errands  of  the 
family.  If  he  loves  art  and  music  his  tastes 
should  be  gratified.  There  should  be  a  moder- 
ate indulgence  in  out-of-door  sports,  as  bicycling, 
ball,  surf  bathing  when  allowable,  horseback 
riding  and  skating.  Our  lady  patients  have  their 
gymnastics,  tricycle,  horse- back  riding  and  skat- 
ing, and  of  great  importance,  their  vocal  gym- 
nastics. This  will  expand  the  lungs  and 
strengthen  the  pectoral  and  respiratory  muscles. 
Being  a  pleasant  recreation,  and  at  the  same  time 
a  most  excellent  means  of  bathing  the  air-cells 
with  oxygen  and  teaching  the  vocal  organs  the 
proper  performance  of  their  functions.  After  a 
tew  weeks  of  judicious  practice  the  dimensions 
of  the  chest  will  be  found  to  have  increased  from 
four  to  five  inches. 

Practicing  at  the  piano,  needle- work  or  any 
employment  which  requires  close  application  and 
necessitates  contraction  of  the  chest  walls  in  its 
performance,  should  be  forbidden. 

DAILY    CARE    OF    THE    PATIENT. 

<)ur  phthisical  invalid  should  have  the  constant 
attention  of  a  well-trained  nurse.  His  room 
must  be  sunny,  with  pleasant  prospect  from  the 
windows.  No  stuffy  furniture,  no  carpets,  no 
fancy  articles  hanging  or  standing   about,  ready 


iSoi.] 


CONSUMPTION  OF  THE  LUNGS. 


795 


upon  their  slightest  agitation  to  disseminate  the 

accumulated  dust  of  .stagnation  and  disease.  If 
possible,  the  walls  of  the  room  should  be  painted. 
They  can  then  be  wiped  off  occasionally  with 
some  disinfectant,  as  borax  water  or  Piatt's  chlor- 
ides. Place  pine,  spruce  or  fir  boughs  about  the 
room  and  under  the  bed  the  patient  occupies  ; 
this  will  impart  to  the  atmosphere  an  agreeable 
odor,  and  has  undoubtedly  the  effect  of  calmin^ 
laryngo-bronchial  irritation  and  diminishing  the 
frequency  of  the  cough.  I  am  convinced  of  the 
benefit  ol  breathing  this  air.  It  is  also  well  to 
spray  some  agreeable  antiseptic  about  the  room, 
as  essence  of  cinnamon,  clove,  gaultheria  euca- 
lyptus, etc. 

The  bedstead  should  be  of  metal,  having  a 
fine  wire  spring,  hair  mattress  and  fine  wool 
blankets  ;  no  draperies. 

If  possible,  let  the  artificial  lighting  be  of 
electricity,  but  if  gas  must  be  used,  see  that  the 
burner  is  a  proper  one  to  consume  all  the  gas  as 
it  is  forced  through.  Avoid  lighting  or  heating 
by  kerosene  oil ;  a  kerosene  lamp  or  heater  con- 
sumes more  oxygen  than  the  patient  does  himself. 
The  temperature  of  the  room  should  be  equa- 
ble, ranging  from  68°  to  700,  and  in  the  damp 
and  rainy  days  of  summer  it  must  be  made  dry- 
by  a  grate  fire  or  some  other  form  of  heating. 

The  underclothing  of  the  patient  should  be  of 
wool  the  year  round,  and  changed  every-  day. 
There  is  no  necessity  of  encasing  him  in  very 
thick,  unyielding  flannel ;  it  seems  rather  to  pro- 
duce a  weakening  effect  by  preventing  the  free 
escape  of  the  exhalations  of  the  body;  those 
which  are  loosely  worn  and  of  light  weight  and 
soft  texture  serve  a  better  purpose. 

The  nurse  must  be  able  to  manipulate  the  pa- 
tient's body,  rubbing,  lightly  pounding  or  patting 
and  beating  with  a  whisk  broom.  In  beating 
the  surface  in  this  manner  it  has  a  direct  stimu- 
lating effect  upon  the  peripheral  nerve  endings, 
and  produces  a  vitalizing  influence  that  cannot 
be  obtained  in  any  other  way  ;  for  in  the  broom 
we  have  anywhere  from  1,000  to  2,000  twigs  of 
different  sizes,  and  this  beating  of  course  pro- 
duces as  many  different  vibrations  upon  "the 
nerves  and  nerve-centres,  therebv  increasing 
wonderfully  the  power  of  the  skin  in  appropriat- 
ing oxygen  and  nutrition. 

The  bowels  should  be  kneaded  ;  a  most  ex- 
cellent process  for  obstinate  constipation.  Rub- 
bing with  flannel  may  at  times  replace  the  bath 
when  the  patient  feels  a  repugnance  to  water. 
The  limbs  should  always  be  rubbed  towards  the 
body.  Rubbing  with  flannel  charges  the  person 
with  an  amount  of  electricity  which  cannot  be 
produced  in  any  other  way. 

In  women  patients  there  must  be  absolute 
freedom  from  dragging  skirts,  tight  bindings  and 
garters.  The  dress  must  allow  perfect  liberty  of 
action  in  chest  and  limbs.     I   do  not  object   to 


corsets  if  they  are  worn  loose,  if  the  patient  in- 
sists that  they  are  a  support  to  her  ;  in  the  place 
ol  injury,  I  think  they  are  a  benefit:  but  they 
must  be  worn  loose  enough  to  not  interfere  with 
1  the  movements  of  the  diaphragm.  She  should 
wear  felt  shoes,  neither  laced  nor  buttoned  tight 
around  the  ankles  ;  cold  feet  at  night  invariably 
follow  the  wearing  of  closely- buttoned  boots  dur- 
ing the  day. 

FOOD. 

While  pure  air  may  be  prescribed  without 
limit,  and  the  same  sanitary  surroundings  are 
equally  beneficial  to  all,  yet  when  we  come  to  the 
question  of  diet,  we  cannot  prescribe  in  a  general 
way  ;  we  must  be  guided  by  the  likes  and  idio- 
syncracies  of  our  patients.  We  raav  find  one  to 
thrive  on  pure  milk  and  occasionaflv  one  who 
can  take  cod-liver  oil  with  benefit,' while  the 
digestive  organs  of  another  will  be  thrown  into 
a  terrible  state  of  disorder  by  these  agents. 

The  patient  must  have  regular  times  for  eating- 
solid  food.  It  must  be  taken  at  least  every  four 
hours,  and  drinks  between  times,  of  milk,  beef 
tea,  aromatic  teas,  gruels,  fruit  juices,  etc.  Milk 
when  well  borne  and  assimilated  is  nourishing 
strengthening,  and  fattening,  and  we  have  cn-eat 
occasion  to  be  glad  when  we  find  it  can  be  taken 
in  large  quantities  and  digested.  Unless  we  can 
get  milk  that  is  fresh  from  the  cow,  the  con- 
densed milk  without  sugar  is  preferable  to  old 
milk. 

Infusions  of  malt,  when  properlv  made,  may 
be  taken  by  nearly  every  one.  And  instead  of 
undertaking  the  digestion  of  thick  malt  extracts 
a  simple  infusion  like  the  following  will  be  much 
better  :  Malt  in  coarse  powder,  4  ounces.  Water 
heated  to  about  86°  F.,  12  ounces.  Macerate  for 
four  hours  at  a  temperature  of  about  ioo°  F 
Then  gradually  raise  it  to  about  130°  for  half  an 
hour  ;  strain  this  infusion  with  strong  expression 
and  add  one  grain  of  salicvlic  acid.  This  quan- 
tity can  be  taken  every  dav  ;  it  can  be  flavored 
at  any  time  by  adding  a  drachm  of  hops,  chamo- 
mile flowers,  or  any  of  the  aromatic  herbs.  This 
will  be  found  far  superior  to  anv  of  the  thick 
malt  extracts.  I  do  not  advocate  the  use  of  cod- 
liver  oil  ;  as  a  usual  thing  it  will  derange  the 
stomach  and  prevent  the  patient  from  takin°-  a 
due  amount  of  suitable  food.  Cod-liver  oil  can- 
not supply  the  place  of  meat,  bread  and  butter, 
but  meat,  bread  and  butter  can  more  than  supply 
the  place  of  cod- liver  oil. 

Man  being  omuiverous,  should  have  variety  in 
his  food.  Juices  of  meat,  and  the  fat  of  newly 
made  butter  and  sweet  cream.  Also  vegetables 
cooked  with  some  good  fat  meat  should  form  a 
part  of  his  diet,  but  in  very  small  quantities.  The 
expressed  juice  of  different  kinds  of  berries,  pine- 
apple, etc. ,  may  also  be  partaken  of.  The  con- 
census of  opinion  has  been  that  meat  is  better  the 


796 


CONSUMPTION  OF  THE  LUNGS. 


[June  6, 


longer  it  has  been  kept,  but  I  contend  that  the 
sooner  meat  is  eaten  after  it  is  slaughtered  the 
more  health  and  life-giving  properties  it  has;  the 
same  is  true  of  milk,  the  sooner  it  is  drank  after 
being  drawn  from  the  udder  the  better. 

All  food  should  be  disintegrated  when  eaten 
with  copious  draughts  of  pure  water  or  some 
agreeable  aromatic  tea.  This  I  have  always 
maintained,  through  the  long-drawn  misery  of  | 
the  dry  food  mania,  at  the  expense  of  severe  cnt-  j 
icism  from  my  professional  brethren.  The  pa- 
tient should  consume  at  least  three  pints  of  water 
in  the  twenty-four  hours,  and  more  if  necessary. 
We  know  that  water  forms  three-fourths  of  our 
animal  economy,  that  it  enters  in  the  same  pro- 
portion into  all  animal  life,  hence  consumptive 
patients  must  take  a  large  amount  of  liquids. 
We  also  know  that  water  has  solvent  powers, 
that  it  will  often  overcome  the  most  obstinate 
constipation,  that  it  is  also  a  powerful  medium 
for  removing  effete  matter  from  the  body,  acting 
on  the  alimentary  canal  both  mechanically  and 
chemically  by  changing  their  atonic  condition 
and  enabling  the  absorption  of  nutritious  food. 
The  addition  of  one- third  to  one-half  parts  of  pure 
-water  to  milk  has  been  more  effectual  in  prevent- 
ing the  formation  of  curd  than  lime-water,  and  a 
mixture  of  equal  parts  of  water  and  milk,  or  in- 
fusion of  malt,  will  quench  the  thirst  of  phthisi-  j 
cal  patients,  reduce  the  temperature,  and  have  a  ; 
quieting  effect.  Not  unfrequently  this  can  be  | 
borne  better  than  either  separately.      . 

Ice-cream  made  from  rich  cream  and  milk  may  | 
be  eaten  sparingly  when  the  patient  is  feverish 
and  craves  cold"  food  and  drinks.  The  pepton- , 
ized  milk  of  Reed  &  Carnrick  is  good,  and  adds 
to  the  variety,  also  their  beef  peptonoids.  Never  I 
allow  the  patient  to  eat  yeast-made  bread,  it 
must  be  made  from  cream-of-tarter  baking- 
powder,  and  twice  baked,  {i.e.  lightly  toasted). 

The  food  must  be  varied;  surprises  in  the  way 
of  unexpected  dishes  are  a  stimulant  to  the  appe- 
tite. Fresh  beef  broiled,  or  scraped  and  eaten 
raw,  or  made  into  little  pats  and  nicely  seasoned 
and  sparingly  broiled  over  the  coals;  or,  have 
the  lean  meat,  free  from  fat  and  fibrous  tissue,  chop- 
ped in  an  enterprise  chopper  and  to  each  pound 
cofmeat  add  one-fourth  pound  of  fat  breakfast  ba- 
con. This  can  be  carefully  broiled,  salted  and 
flavored  to  the  taste  and  makes  a  most  toothsome 
morsel.  The  patient  rarely  tires  of  it.  He  should 
eat  from  two  to  three  pounds  of  this  during  the 
twenty-four  hours. 

Pig  meat  is  not  the  worst  kind  to  eat  by  any 
manner  of  means.  I  have  no  reference  to  the  New 
England  hog  fed  on  slops,  wallowing  in  filth, 
shut  up  in  a  seven  by  nine  box  without  fresh  air 
from  birth  to  the  day  of  slaughter.  I  refer  to  the 
much  maligned  western  hog,  that  knows  not 
what  filth  is,  that  from  its  earliest  predecessors 
ias  had  pure  air  and  cleanliness,  and  been  fed  on 


nuts,  corn  and  wheat.  Such  meat  is  healthy  and 
digestible.  One  or  two  teaspooufuls  of  gluten 
may  be  included  in  the  diet,  cooked  or  uncooked, 
as  suits  the  stomach.  Fish  can  be  partaken  of 
once  a  week,  also  oyster  and  clam  juice. 

The  patient  should  not  be  made  to  eat  alone  in 
his  room;  the  pleasures  attendant  upon  eating 
have  much  to  do  with  results.  Shut  off  from  a 
life  of  activity,  the  feeling  will  come  sooner  or 
later  according  to  his  temperament,  that  he  is  a 
doomed  man.  There  is  always  a  tendency  in  the 
person  suffering  from  any  chronic  ailment  to  fos- 
ter the  idea  that  he  is  of  no  account  in  the  world 
because  of  his  debility. 

The  object  of  the  diet  should  be  to  nourish, 
strengthen  and  fatten.  When  we  find  our  patient 
digesting  his  food,  picking  up  in  flesh  and  getting 
;  stronger  every  day,  we  have  reason  to  believe  his 
j  recovery  is  not  only  possible,  but  probable. 


SLEEP. 

"The  death  of  each  day's  life, 

Sore  labor's  bath, 
Balm  of  hurt  minds." 

Sleep  is  but  another  form  of  food,  and  is  not 
less  essential  than  the  food  we  take  into  our 
stomachs. 

No  matter  what  the  disease,  we  know  its  ma- 
lignancy has  yielded  when  the  periods  of  long, 
sound,  natural  sleep  advance.  As  a  prophylaxis, 
sleep  ranks  among  the  most  important.  Only 
through  sleep  can  the  nerve-centres  relax  and  re- 
cuperation begin. 

During  the  night  of  healthy  sleep  the  scaven- 
gers of  the  body  are  working  noiselessly  with 
their  implements  of  conveyance,  preparing  for  the 
morrow's  labors. 

Darkness  is  the  period  of  perfect  rest.  Until 
the  human  mind  discovered  the  means  of  substi- 
tuting by  artificial  light  that  of  the  sun,  mankind 
retired  with  its  declining  rays.  Children— of 
j  whom  it  has  been  said,  their  life,  as  it  develops, 
give  a  fair  representation  of  the  lines  of  human 
progress — naturally  seek  repose  at  sunset  Na- 
ture herself  at  this  time  seems  to  be  hushing  all 
animated  life  to  sleep  upon  her  bosom. 

How  different  is  man  under  the  influences  of 
civilization  !  Insomnia  and  neurasthenia  are  the 
terrible  beasts  born  of  his  enlightenment.  Lash- 
ing their  victim  night  and  day  until  he  would 
willingly  offer  his  soul  in  exchange  for  the  sound 
healthy  sleep  of  the  barbarian  ! 

Insomnia  is  to-day  the  most  familiar  foe  we 
j  meet,  so  prolific  in  its  capacity  that  without  ex- 
aggeration or  fancy  we  can  ascribe  to  it  the  com- 
mon beginning  of  a  vast  part  of  our  chronic  ail- 
ments. It  has  come  to  have  an  individuality,  and 
is  no  longer  a  symptom  only.  One  of  the  common 
causes  of  this  is  the  artificial  light  which  is  found 
in  the  majority  of  sleeping-rooms  during  the 
night,  not  only  of  lamps  and  gas,  but  the  rays  of 


i89i.J 


CONSUMPTION  OF  THE  LUNGS. 


797 


the  electric  light  stream  through  our  windows. 
Although  the  eyes  may  be  closed,  we  are  con- 
scious of  the  changes  in  its  flickering  glare.  The 
patient  becomes  accustomed  to  it  and  feels  that 
he  cannot  have  it  excluded,  and  so  we  have  add- 
ed another  to  the  "  necessities  of  civilization." 

Not  the  sleep  to  be  had  during  the  day.  but  the 
repose  at  night  must  lie  encouraged  in  the  pa- 
tient. Discipline  will  do  much  toward  capturing 
this  sly  visitor,  other  things  being  equal. 

The  patient  must  retire  early,  he  should  not 
exercise  his  brain  by  reading  or  talking  after 
seven  o'clock.  Iii  summer  he  should  be  in  bed 
for  the  night  by  eight  o'clock,  and  in  winter  by 
seven  o'clock.  In  the  summer  he  should  rise  in 
the  morning  between  five  and  six  o'clock,  and 
from  seven  to  eight  o'clock  in  the  winter.  The 
room  should  be  of  a  proper  temperature,  so  he  ex- 
periences no  chill  in  bathing  and  dressing. 

The  nightdress  of  the  patient  should  be  of 
sufficient  thickness  to  protect  the  body  and  allow 
perfect  freedom  of  movement  and  position  with- 
out risk  of  chill.  The  flannel  undervest  worn 
during  the  day  should  be  removed  at  night  and 
one  of  lighter  weight  substituted.  Bathing  be- 
fore retiring  has  a  tendency  to  induce  sleep.  It 
should  be  accomplished  in  a  manner  the  least 
calculated  to  task  the  patient's  strength.  If  the 
temperature  is  normal,  a  wet  cloth  passed  over 
the  body  and  wrung  out  in  fresh  water  may  take 
the  place  of  the  bath;  rub  the  skin  wyell  after- 
wards. 

If  the  feet  are  cold  they  must  be  made  warm 
and  kept  so;  the  means  to  be  employed  for  this 
purpose  are  very  numerous.  Among  the  best 
are,  the  wrapping  each  foot  in  flannel  separately, 
and  the  hot  water  bag  (but  the  old-fashioned  hot 
soap-stone  is  better).  These  are  only  palliative; 
for  the  removal  of  this  condition  there  is  nothing 
equal  to  manipulation  done  after  the  following: 
Begin  at  the  nape  of  the  neck,  placing  the  ends 
of  the  first  and  second  fingers  firmly  on  each  side 
of  the  spinal  column,  carrying  them  firmly  and 
evenly  downwards  its  whole  length;  repeat  this 
several  times.  After  this  rub  well  the.  soft  hol- 
lows in  the  ankles  each  side  of  the  heels  and 
around  the  joints.  The  patient  will  soon  begin 
to  feel  the  blood  rushing  into  his  feet,  and  ere 
many  nights  he  will  have  the  satisfaction  of  see- 
ing a  healthy  circulation  established  in  these 
parts. 

Beef  tea,  beef  peptonoids  or  some  other  light 
form  of  food  should  be  served  the  patient  direct- 
ly on  his  awakening  in  the  morning. 

PURE  AIR. 

When  practicable  the  person  should  be  sent 
into  a  hilly  district  where  he  cau  have  the  advan- 
tages of  a  high  and  dry  atmosphere.  Avoid  lakes 
and  all  bodies  of  fresh  water.  Otherwise  as  good 
air  can  be  obtained  in  the  city  as  in  the  country. 


Boston  is  particularly  fortunate  in  this  respect. 
We  should  be  grateful  for  the  easterly  winds, 
though  they  have  given  our  town  an  unfavorable 
notoriety.  Their  salty  breath  cool  and  purify  the 
atmosphere  and  render  it  a  habitable  city  in  the 
summer,  even  in  the  meanest  localities. 

I  believe  the  bedrooms  of  the  populace  are 
generally  tolerably  well  ventilated. 

A  certain  class  of  enthusiasts  upon  the  subject 
of  ventilation  have  fallen  into  the  error  of  over- 
doing the  thing,  or  in  doing  it  so  badly  that  it 
becomes  an  injury,  by  allowing  the  air  to  come  in 
stratas,  making  a  draft  upon  the  sleeper,  whose 
powers  of  resistance  are  diminished. 

It  is  a  good  plan  to  have  the  ventilation  come 
through  the  windows  of  an  adjoining  room  when 
possible.  As  the  sleeping  person  does  not  re- 
quire so  much  air  as  when  he  is  up  and  around, 
it  is  not  necessary  that  he  should  be  deluged  in  a 
constantly  changing  current. 


The  superficial  application  of  moisture  to  the 
body  which  the  patient  receives  at  night  is  not 
for  cleanliness.  He  should  have  a  daily  bath, 
adding  to  every  quart  of  water  a  teaspoonful  of 
powdered  borax  or  tablespoonful  of  aqua  am- 
monia. Also  use  soap  having  an  agreeable  per- 
fume. After  he  has  been  well  wiped  with  a  rough 
towel  he  should  be  anointed  with  nice  fresh  lard 
thoroughly  beaten  to  a  creamy  consistency  and 
perfumed  to  suit  the  fancy  of  the  patient.  In- 
stead of  the  lard,  petroleum,  coca-butter,  cotton- 
seed oil,  can  be  used,  perfumed  by  the  addition 
of  some  agreeable  essential  oil.  The  Turkish 
bath,  shower-bath,  cold  pack,  all  have  their 
place,  and  the  hot  spinal  rubber  bag  for  haem- 
optysis. 

MEDICAL  TREATMENT. 

It  would  be  impossible  for  me,  in  a  paper  of 
this  nature,  to  enter  into  details  of  treatment  for 
ever}-  tubercular  condition,  so  I  have  grouped  in 
the  following  lists  the  remedies  I  use  for  the  vari- 
ous requirements  of  the  disease,  employing  them 
singly  or  in  combination  as  occasion  ma}-  require. 

The  first  thing  to  be  considered  for  our  con- 
sumptive is  his  power  of  digestion  and  assimila- 
tion.    His  food  must  nourish  and  strengthen. 

I  find  in  the  majority  of  cases  it  is  beneficial  to 
begin  treatment  by  giving  from  one  to  five  grains 
of  calomel  at  night,  followed  in  the  morning  by 
one  or  two  drachms  of  sulphate  of  soda.  This  I 
should  do  whether  the  tongue  be  clear  or  foul, 
whether  there  be  diarrhoea  or  constipation.  Re- 
peat for  two  or  three  nights  as  indicated;  at  the 
same  time  he  must  sip  one-half  pint  of  hot  water 
slowly  at  least  half  an  hour  before  meals.  If 
there  is  tendency  to  constipation  after  the  calomel 
and  soda  have  passed  off,  give  one  or  more  of  the 
following  remedies: 


798 


CONSUMPTION  OF  THE  LUNGS. 


[June  6, 


FOR  CONSTIPATION. 

Sodium  phosphate, sodium  sulphate, magnesium  , 
sulphate,  oleum  ricini,  rhamnus  frangula,  rhamnus 
purshiana,  euonymus,  atro-purpurius,  juglandis 
einera,  sulphur.  Appropriate  doses  after  meals 
of  one  or  more  of  these  remedies,  not  only  act  as 
peristaltic  stimulants,  but  they  favor  the  process 
of  nutrition;  the  patient  gains  in  appetite  and 
strength. 

After  the  whole  alimentary  tract  has  been 
bi ought  into  the  best  condition  possible,  so  that 
the  patient  has  a  good  appetite  and  is  digesting 
his  food  well,  the  following  pill  may  be  given: 
Zinci  cyanidi,  aurei  cyanidi,  zinci  oxidi,  thirty 
grains;  extract  cannabis  iudica,  six  grains;  ex- 
tract ignatia,  three  grains,  glucose  quantitj'  suf- 
ficient to  make  thirty  pills.  Give  one  pill  after 
the  three  principal  meals. 

Among  the  appetizers  I  have  used  the  follow- 
ing infusions :  Absinthium  berberis,  calumba, 
cannabis  indica,  benzoin  odorifirum,  baldo,  cal- 
isaya  bark,  gentian  and  quassia. 

For  the  general  cachetic  condition  of  the  pa- 
tient's body  (after  the  condition  of  assimilation 
has  been  accomplished),  I  have  employed  on  dif- 
ferent occasions  the  following,  using  them  singly 
or  in  combination,  as  occasion  seemed  to  demand: 
Aurum  et  sodium  chloridum,  aurum  cyanidum, 
calcium  chloride,  calcium  iodide,  calcium  sulphur- 
atum,  cuprum  arsenicum,  sodium  arsenicum,  hy- 
drargyri  cyanidum,  hydrargyri  corrosivum  chlor- 
idum, hydrargyri  bin  iodidum,  sulphur,  ferrum 
cyanidum,  zinci  cyanidum,  potassii  sulphuretum, 
nitro- muriatic  acid,  phosphoric  acid,  malic  acid, 
creosote,  guaiacol,  terebene. 

INFUSIONS. 

Rhamnus  purshiana,  rhamnus  frangula,  lep- 
tandria,  hydrastis,  euonymus,  populus  tremu- 
loides,  pyrus  mallus,  pyrus  Americana,  stilliugia 
sylvatica,  rumex  crispus,  Phytolacca  decandra, 
alnus  rubra,  beubenis  aquifolium. 

FOR    THE  DIARRHOEA. 

The  following  infusions  may  be  given:  Black- 
berry root,  sumach  bark,  pulverized  coto  bark, 
logwood.  Also  tincture  of  ipecac,  and  bismuth 
subnitrate,  bismuth  salicylate,  acidum  carbol- 
icum,  salol,  zinci  oxidum,  cuprum  arsenitis,  ole- 
um ricini,  and  enemas  of  warm  water  with  hy- 
drastis. 

I  have  also  used  the  following  powder  a  great 
deal:  Zinci  oxidi,  two  grains;  sodii  bicarb.,  five 
grains;  pulverized  coto  bark,  one  grain,  mix. 
This  makes  one  powder.  Take  this  amount  after 
every  meal.  Also  give  cooling,  healing  drinks, 
as  flax-seed  tea,  slippery  elm,  etc. 

The  hot  stomach  pad  is  of  great  benefit  in  all 
stomach  and  bowel  diseases.  It  removes  flatu- 
ency,  pain,  distension,  etc.,  and  is  valuable  in 
nducing  sleep  at  night.     It  is  made  by  taking 


i.  Eight  thicknesses  of  thick  cotton  crash,  12 
x  6  inches. 

2.  A  cotton  flannel  binder,  12-14  inches  wide, 
and  long  enough  to  go  around  the  body,  with 
tapes  sewed  on  the  ends  to  secure  it. 

3.  A  duplicate  of  the  latter  made  of  waterprooi 
or  mackintosh. 

4.  The  same  made  of  flannel. 

The  pad  must  be  put  into  boiling  salt  water  in 
proportion  of  one  ounce  to  a  pint,  then  wrung 
out  and  applied  to  the  stomach  and  abdomen  as 
hot  as  can  be  borne.  Tie  the  flannel  binder,  the 
waterproof,  and  lastly  the  outs'ide  flannel  tightly. 
When  cold  it  must  be  removed,  put  through  the 
hot  water  again  and  re-applied.  This  can  be 
worn  two  or  three  hours  every  day  after  meals,, 
or  if  much  pain  is  present,  it  must  be  worn  con- 
stantly. It  will  improve  digestion  and  promote 
assimilation  to  a  wonderful  degree. 
DIGESTIVE  FERMENTS. 

We  have  two  animal  ferments,  pepsin  and  ex- 
tractum  pancreatis;  our  selection  must  be  gov- 
erned by  the  nature  of  the  indigestion.  Of  the 
vegetable  ferments  we  have  a  variety;  among 
them  are  juice  of  the  carica  papaya  (South  Amer- 
ican paw  paw);  asimina  triola,  juice  of  the  un- 
ripe fruit;  anassa  satina  (pineapple),  juice  of  the 
ripe  fruit;  infusion  of  ficus  carica  (fig),  drosera 
rotundifolia;  musa  sapientum  (banana),  juice  of 
ripe  fruit. 

For  the  fever  of  the  first  stage  I  have  found  selec- 
tions from  the  following  to  be  all  that  were  re- 
quired, used  either  singly  or  combined,  according 
to  conditions:  Norwood's  tincture  of  veratrum 
veride,  tinctures  of  aconite,  gelsemium,  lycopus 
virginica,  comicifuga,  also  antimonii  et  potassii 
tartras. 

I  find  these  give  better  results  than  the  newer 
antipyretics,  as  acetanilid,  antipyrin,  etc. 

Fever  of  the  second  stage:  Salicylic  acid,  sali- 
cina,  acetanilid,  antipyrin,  phenacetin,  quinia 
hydra-bromate,  salicylate  of  ammonia. 

For  the  night  sweats  :  Atropia  sulphate,  picro- 
toxin,  malic  acid,  zinci  oxidum,  zinci  cyanidutn,. 
tincture  cocculus  iudicus,  sage  tea. 

For  the  sore  mouth  and  the  follicular  ulceration- 
of  the  mouth  and  pharynx  .  Touch  the  ulcerated 
spots  with  a  sulphate  of  copper  crayon,  and  rinse 
the  mouth  with  a  solution  of  chlorate  of  potash 
of  the  strength  of  eight  grains  to  the  ounce  of 
water,  and  one  drachm  of  glycerine.  (But  a  few 
spots  should  be  treated  at  one  time.)  In  the  sore 
mouth  where  the  mucous  membrane  looks  red 
and  shining,  an  infusion  of  rhus  glabra  or  prinos 
verticillatus,  or  hydrastes,  alnus  rubra,  and  salix 
nigra  may  be  used  with  glycerine,  one  drachm  to 
the  ounce.     Rinse  the  mouth  freely. 

If  the  secretion  of  saliva  is  scanty,  the  addition 
of  a  vegetable  acid  to  the  infusion  will  be  neces- 
sary. If  profuse,  add  an  alkali,  as  the  bicarbon- 
ate of  sodium  or  potassium. 


i89i.] 


CnXSlWlPTION  OF  THK  LUNGS. 


799 


For  the  cough  :  The  general  constitutional 
treatment  with  the  mouth  washes,  gargles  and 
inhalations,  will  he  all  that  is  necessary  unless  it 
should  be  so  troublesome  that  the  patient  cannot 
sleep  at  night.  In  that  case,  give  one-third  of  a 
grain  of  codeina,  with  one-twentieth  of  a  grain  of 
apomorphia  hydrochlorate,  at  bed  time.  I  give 
preference  to  the  simple  codeina  to  any  of  its 
salts.     I  find  it  works  better. 

For  a  loose  cough  :  Nitrate  of  sanguinaria,  one 
grain;  sodii  phos  phus,  one-half  drachm,  simple 
elixir,  glycerine,  of  each  two  ounces;  tincture 
phosphora,  one  drachm;  mix  and  give  from  one- 
half  to  one  teaspoonful  every  three  hours,  in  an 
infusion  of  pine  bark  tea. 

For  asthmatic  cough:  Xitrate  of  sodium,  nitro- 
glycerine, weak  alcoholic  tincture  of  grindelia 
robusta,  inhalations  of  nitrate  of  potash  paper. 

For  the  intercostal  neuralgia  the  following  lini- 
ment will  give  great  comfort  and  relief:  Olei 
ricini,  olei  terebinth,  olei  eucalypti,  of  each  one 
ounce,  camphor,  two  drachms,  chloroformi,  four 
drachms.  Mix  and  apply  morning  and  night, 
with  long  continued  friction. 

For  inhalation  :  Guaiacol,  styrone,  olei  euca- 
lypti, of  each  two  drachms:  alcohol  one  ounce, 
chloroformi  two  drachms,  mix. 

This  should  be  used  with  a  perforated  zinc  in- 
haler, for  fifteen  minutes  at  a  time,  every  two  or 
three  hours  during  the  day.  Or  the  following: 
Balsam  tolu,  balsam  peru,  balsam  storax,  olei 
eucalyptus,  of  each  one  ounce,  alcohol  twelve 
ounces. 

Digest  for  six  days  and  filter,  add  to  this  mix- 
ture one  ounce  of  beech- wood  creosote  and  one 
ounce  of  chloroform.  Put  fifteen  drops  on  a  per- 
forated zinc  inhaler  and  use  fifteen  minutes  every 
two  hours  during  the  day. 

Another  good  inhalant  is  cold  infusion  of  primus 
virginica,  four  ounces;  oil  of  bitter  almonds,  two 
drops;  hydrocyanic  acid,  dilute  two  drachms; 
chloroform,  half  a  drachm. 

Mix  and  inhale  five  minutes  every  two  hours 
during  the  day,  through  a  Laforme  or  similar 
inhaler. 

SPECIFIC    HYPODERMIC    AND    PARENCHY- 
MATOUS   TREATMENT. 

Hydrargyri  chloridi  corrosivi,  one  grain,  sodii 
chloridi,  one-half  ounce,  aqua  fervens,  dist.  four 
ounces.  Mix  and  filter.  Begin  by  giving  five 
minims  subcutaneously  into  the  cellular  tissues 
every  day,  increasing  one  minim  a  day  until  fif- 
teen minims  are  reached  ;  then  go  back  to  the 
five  minims  and  increase  as  at  first.  I  have  used 
this  for  the  last  ten  years  in  the  various  stages  of 
chronic  pulmonary  consumption.  I  have  also 
used  the  solution  of  chloride  of  gold  and  soda  as 
recommended  by  Drs.  Shurly  and  Gibbs,  but  I 
very  much  prefer  this.  There  is  no  doubt  in  my 
mind  but  it  has  a  direct  effect  upon  the  bacilli  in 
the  lungs. 


This  hypodermic  injection  can  be  used  per 
rectum  in  doses  of  five  drops  in  half  an  ounce  of 
water,  three  times  a  day,  increasing  one  drop  a 
day  until  thirty  drops  have  been  reached.  Then 
go  back  to  the  five  drops  and  increase  as  before. 

The  rectum  must  be  washed  out  with  tepid 
salt  water  before  each  injection.  Administered 
in  this  way  it  will  be  taken  directly  into  the  cir- 
culation unaltered. 

The  two  methods  can  be  alternated  in  any  case 
where  it  is  not  feasible  to  give  it  either  hypo- 
dermically  or  per  rectum ;  commencing  with  ten 
drops  and  increasing  up  to  thirty,  and  then  go 
back  to  the  original  dose  as  before.  This  should 
be  given  directly  after  the  three  principal  meals. 

All  vegetable  remedies  should  be  given  in 
infusions  when  practicable,  made  from  the  fresh 
bark,  leaves  or  roots,  and  to  every  pint  of  the  in- 
fusion add  one  grain  of  salicylic  acid  and  ten 
drops  of  chloroform.  As  the  patient  is  about  to 
drink  it,  let  him  put  into  every  ounce  one  tea- 
spoonful  of  glycerine. 

The  infusion  should  be  made  every  day  and 
drank  cold. 

Epidermic  medication  should  also  be  practiced, 
using  as  a  base  either  pure  lard,  coco  butter,  pet- 
rolatum, cod  liver  oil,  or  fresh  butter,  variously 
combined  with  resorcin,  quinine,  aromatic  oils 
and  resins. 

I  will  close  by  giving  one  case  which  I  had  in 
February,  1883.  The  symptoms  may,  I  think, 
be  considered  as  typical,  and  the  treatment  shows 
in  a  general  way  my  ideas  of  the  manipulation  of 
tuberculosis. 

Miss  Page,  blonde,  aged  21.  Family  history 
showed  the  father  and  mother  to  have  died  of  tu- 
berculosis, together  with  a  brother  and  sister  and 
several  uncles  and  aunts  on  both  sides  of  the 
house.  She  had  been  ailing  for  three  months 
when  I  first  saw  her.  Lost  considerable  flesh,  was 
coughing  morning  and  night.  Sputa  frothy, 
pulse  120,  temperature  1020  in  the  afternoon. 
Had  slight  haemoptysis.  Percussion  sh<  >wed 
slight  dulness  over  the  apex  of  left  lung  and 
rough  respiration.  There  was  intercostal  neural- 
gia and  general  tenderness  over  the  whole  chest. 
Appetite  poor,  bowels  constipated,  urine  scant, 
passing  about  one  pint  in  the  twenty-four  hours, 
with  specific  gravity  1030.  The  skin  was  very 
dry  and  scurfy. 

I  began  treatment  by  giving  three  grains  of 
hydrargyri  chloridimite  at  night,  in  the  morning 
two  drachms  of  sulphate  of  soda  in  a  pint  of  hot 
water,  and  one  pint  of  spearmint  tea  before  din- 
ner and  supper,  and  a  borax  bath  in  the  middle 
of  the  afternoon  to  be  followed  by  inunction 
made  of  four  ounces  of  pure  lard  and  one  drachm 
of  oil  of  bergamot,  alternating  this  with  an  in- 
unction of  resorcin  one  drachm,  dilute  alcohol 
two  drachms,  petrolatum  one  ounce,  oil  of  gaul- 
tharia  one  drachm.     Mix  and  use  as  above. 


Soo 


INSTINCT  AND  INTELLIGENCE  CONTRASTED. 


[June  6, 


I  ordered  a  suppository  at  night  made  of  iodo- 
form twelve  grains,  coco  butter  three  drachms, 
creosote  and  oil  of  cloves  of  each  two  drops.  This 
amount  makes  twelve  suppositories. 

For  inhalation,  balsams  of  Peru  and  storax, 
oil  of  sassafras,  of  each  one  ounce,  alcohol  twelve 
ounces.  Digest  six  days,  filter  and  add  one  ounce 
of  chloroform.  Make  a  paper  funnel  and  place  in 
it  a  wad  of  absorbent  cotton.  Put  from  fifteen 
to  twenty  drops  of  this  mixture  into  it  and  in- 
hale five  minutes  every  three  hours.  For  the 
constipation,  infusion  of  rhamnus  purshiana, 
p.  r.  n. 

I  gave  the  following  to  the  patient  after  meals 
as  an  antiseptic  touic  : 

Chloride  of  sodium  four  drachms,  chloride  of 
potassium  two  drachms,  corrosive  sublimate  half 
a  grain,  water  four  ounces.  Give  one  teaspoon- 
ful  after  the  three  principal  meals,  in  two  ounces 
of  water  or  aromatic  tea. 

As  an  appetizer  the  following  was  all  that 
could  be  wished  :  Extract  cannabis  indica  six 
grains,  extract  ignatia  two  grains,  salicin  fifteen 
grains,  phosphate  of  calcium  half  a  drachm. 
Make  into  thirty  tablets  and  take  one  thrice 
daily. 

This  not  only  created  an  excellent  appetite, 
but  kept  the  bronchial  mucous  membranes  free 
from  undue  irritation. 

For  the  high  temperature  she  had  the  follow- 
ing :  Tincture  veratrum  veride  one  drachm,  hy- 
drocyanic acid,  dilute,  one  drachm,  tincture 
prunus  virginica,  four  ounces  (made  from  the 
green  bark,  alcoholic  strength  one  to  six),  put 
four  ounces  of  the  bark  into  sixteen  ounces  of 
the  menstruum,  give  of  this  from  twenty  to  thirty 
drops  three  times  daily,  in  water,  or  an  aromatic 
tea. 

The  diet  was  rare  meat,  not  less  than  one 
pound  in  the  twenty-four  hours,  and  from  that  up 
to  three  pounds,  condensed  milk,  bread  made 
from  cream  of  tartar  baking  powder,  soft  boiled 
rice,  infusion  of  malt  (made  in  the  manner  de- 
scribed), pineapple  juice  and  orange  juice,  plenty 
of  nice  butter,  fresh  cream. 

The  principles  of  hygiene  that  I  have  formu- 
lated were  fully  carried  out. 

The  patient  was  under  my  treatment  for  six 
months  and  perfectly  recovered,  and  is  now  in 
good  health. 


A  MIXTURE    FOR    H.EMOPTYSIS. 

Bamberger  is  said  to  have  approved  of  the  fol- 
lowing mixture  in  haemoptysis  : 
R.    Turpentine,  la  5  j. 

Oil  of  sweet  almonds,  aa  3  j. 
Mucilage  of  acacia,  fin  %  iv. 
Simple  syrup,  fifi  3  iv. 
I listilled  water,  .^  v.     m;. 
One  teaspoon ful  of  this  mixture  may  be  given   every 
1  iur. 


INSTINCT  IN   ANIMALS   AND   INTELLI- 
GENCE IN  MAN  CONTRASTED. 

WITH  AN  EXAMINATION  OF  DARWIN'S  DICTUM  OF 

THE   "MISSING  LINK"  AND  LINN.EUS'  DOGMA 

"  NATURA  NON  FACET  SALTUS,"  WITH  A 

FEW    ORIGINAL  OBSERVATIONS 


Read  by  Title  in  the  Section  of  Medicine  and  Physiology  at  the  Forty- 
Second  Annual  Meeting  of  the  A»:e>  jean  Medical  Association 
held  at  Washington,  D.  C,  May  5,  1891. 

BY  WILLIAM   W.  PARKER,   M.D., 

OF    RICHMOND,    VA. 

Instinct  in  animals  is  a  matter  of  daily  obser- 
vation by  every  class  of  mind,  and  has  alwrays 
been  a  subject  of  great  interest,  nevertheless  it 
seems  still  little  understood.  Writers  in  psychol- 
ogy are  not  yet  agreed  even  upon  its  definition. 

Ribot,  a  modern  French  writer,  sa3's  it  em- 
braces "all  those  psychological  phenomena  oc- 
curring in  animals,  and  all  forms  of  mental  ac- 
tivity, inferior  to  those  iu  men."  A  German  con- 
temporary says  "It  is  an  act  conformed  to  an 
end,  but  without  consciousness  of  that  end. ' '  Dar- 
win's definition  is  more  elaborate,  but  scarcely 
more  definite;  by  reason  of  its  length  it  is  more 
open  to  criticism.  He  says  "  Instinct  is  an  action 
which  we  otherwise  would  require  experience  to 
perform,  when  performed  by  an  animal,  more  es- 
pecially by  a  very  young  one,  without  any  expe- 
rience, and  when  performed  by  many  individuals 
in  the  same  way  without  their  knowing  for  what 
purpose  it  is  performed."  This  definition  is  cer- 
tainly at  fault  when  it  claims  that  actions  under 
the  direction  of  instinct  are  performed  "without 
knowing  for  what  purpose  they  are  performed." 
The  dog  that  went  once  a  week  many  miles  to 
market  alone  certainly  knew  for  what  purpose  he 
went  there.  The  horses  in  Richmond  that  quick- 
en their  pace  at  midday  when  their  heads  are 
turned  towards  their  stables,  know  why  they 
prefer  to  go  in  that  direction. 

It  may  be  impossible  in  a  few  set  phrases,  how- 
ever carefully  considered,  to  differentiate  clearly 
human  intelligence  from  what  we  call  animal  in- 
stinct. Their  manifestations  are  so  varied  and 
numerous,  and  so  interlocked,  that  like  the  lights 
and  shadows  in  the  landscape  we  cannot  say 
where  the  line  of  separation  really  begins. 

Why  there  should  be  such  reluctance  among 
modern  writers  in  granting  intelligence  to  ani- 
mals is  rather  hard  to  say.  The  analogy  in  anat- 
omy and  physiology  of  man  and  the  lower  ani- 
mals is  very  remarkable.  The  laws  of  digestion, 
assimilation,  circulation,  etc.,  are  very  much  the 
same.  We  endeavor  by  vivisection  to  unravel 
the  mysteries  of  digestion  or  indigestion  in  man. 

In  the  brain  of  the  animal  we  see  analogy  in 
structure;  why  may  not  there  be  analogy  in  func- 
tion' 

But  to  return.     It  seems  to  me  sufficiently  defi- 


i89i.] 


INSTINCT  AND  INTELLIGENCE  CONTRASTED. 


So  i 


nite  to  say  that  "Instinct  in  the  animals  is  a 
strictly  limited  knowledge  or  intelligence  suffi- 
cient only  first,  for  self  preservation;  second,  for 
the  propagation  of  the  species;  and  third,  to  se- 
cure their  usefulness  to  mankind.'' 

SELF- PRESERVATION. 

i.  Of  self-preservation.  Love  of  life  is  an  in- 
stinct universal  in  man  and  all  animals.  The 
she-bear  beats  her  cubs  and  drives  them  up  the 
tree  at  the  sound  of  the  dogs.  The  "danger 
cry"  of  the  hen  sends  her  chickens  to  shelter. 
Not  to  furnish  the  animal  with  sufficient  intelli- 
gence to  protect  itself  and  its  young  would  have 
been  both  a  cruel  and  fatal  mistake  in  the  Crea- , 
tor.  This  point  needs  no  further  argument  or  | 
illustration. 

2.  An  equally  fatal  error  would  have  been  not 
to  make  provision  for  the  propagation  of  the  spe- 
cies. To  do  this  requires  far  more  intelligence 
in  the  animal  than  was  needful  for  self-preserva- ; 
tion.  What  man  with  his  teeth  and  feet  can 
build  a  bird's  nest?  Where  is  the  man  who  can 
with  his  hands  construct  the  delicate  cells  of  the  j 
honey  bee?  or  spin  the  attenuated  spider's  line. 

How  each  cell  is  measured  so  that  all  its  sides 
and  angles  are  equal.  What  foreknowledge  in 
the  squirrel  to  provide  in  summer  for  the  wants 
of  winter,  and  yet  how  indispensible  this  knowl- 
edge. 

There  is  no  end  of  illustrations  in  this  line,  fa- , 
miliar  to  all  who  think  at  all.     But  let  it  be  re- 
membered that  no  bird  can  build  for  another. 
Each  bee  must  work  in  its  own  hive. 

How  could  the  animal  kingdom  be  useful  to 
man  without  first,  a  good  memory;  second,  a 
knowledge  of  persons;  and  third,  some  knowl-  j 
edge  of  property,  but  all  limited.  I  think  much 
of  the  remarkable  ability  of  the  horse  and  other  ' 
animals  to  find  their  way  home  is  due  to  memory. 

But  this  does  not  meet  every  case.  Some  years 
ago,  I  visited  a  patient  six  miles  from  the  city; 
there  was  a  private  pathway  leading  across  a 
field  cutting  off  a  mile  to  the  house,  shown  me 
by  the  messenger;  it  was  winter,  and  the  path 
could  be  very  well  seen.  Five  years  after  I  vis- 
ited the  same  patient  in  the  summer;  the  way 
was  lined  on  either  side  by  high  grass  and  weeds 
so  that  it  w?as  impossible  to  see  the  path.  I  was 
riding  the  same  horse,  and  I  looked  hopelessly 
for  the  path,  but  the  moment  I  got  opposite  to  it 
the  horse  darted  from  the  middle  of  the  road  and 
struck  the  path  exactly.  I  could  not  see  it  till  I 
got  some  distance  in  the  woods,  and  supposed  he 
had  made  a  mistake.  Here  was  a  mathematical ; 
exactness,  marvelous  and  incomprehensible;  it 
was  as  exact  as  the  magnet.  Can  there  be  any  of 
this  magnetic  power  in  animals  in  regard  to  the 
cardinal  points?  guiding  them  with  unerring  cer- 
tainty? What  philosophy  will  solve  this  prob- 1 
lem?    And  vet  how  necessarv  this  exactness.     If  | 


the  bird,  five  miles  from  its  nest,  did  not  know- 
its  exact  locality,  how  could  it  ever  get  tjie  in- 
formation? There  must  be  no  uncertainty  here, 
the  least  deviation  would  be  fatal  to  the  bird  and 
its  young.  This  knowledge  is  impossible  to  man; 
he,  however,  can  inquire  the  way  when  lost.  The 
bird  must  know  certainly,  or  his  creation  is  a 
failure.  So  doth  God  work!  We  all  have  daily 
illustration  how  the  horse's  memory  is  exercised 
here  in  the  city;  if  you  visit  a  patient  in  the 
morning  and  have  to  pass  the  same  house  a  dozen 
times  the  same  day,  he  will  wish  to  stop  every 
time.  This  is  memory  without  reason,  a  low 
form  of  intelligence. 

An  equally  important  factor  in  the  value  of  the 
animal  to  man  is  his  recollection  of  persons;  the 
dog  knows  every  one  in  the  family,  children  and 
servants,  knows  them  day  or  night,  knows  their 
names  and  often  their  voices,  otherwise  he  would 
be  of  no  value  as  a  guard.  He  would  be  worse 
than  useless,  he  would  be  dangerous. 

3.  The  animal,  to  be  useful  to  man,  must  also 
have  some  knowledge  of  property.  I  bad  once  a 
very  clever  dog.  I  have  seen  him  kill  three  moc- 
casin snakes  in  ten  minutes;  he  would  take  them 
by  the  middle,  shake  them  violently,  drop  them, 
pick  them  up  again  and  shake  them  until  they 
were  dead;  to  do  this  successfully  and  safely  re- 
quired great  dexterity.  He  seemed  to  know  as 
well  as  I  did  that  the  bite  would  be  fatal  and 
hence  he  used  the  greatest  precaution.  I  one 
day  threw  an  old  basket  up  a  tree  and  it  lodged 
there.  I  tried  for  some  time  with  rocks  and  sticks 
to  dislodge  it  but  without  success;  this  dog  was 
with  me;  he  remained  under  the  tree  all  night 
and  till  the  afternoon  of  the  next  day,  fasting 
and  guarding  my  property. 

The  dog  will  take  the  market  basket  home  and 
guard  it  from  robbery,  but  to  show  the  distinc- 
tion between  instinct  and  reason,  if  you  put  rocks 
and  sticks  into  it  instead  of  beans  and  beefsteak 
he  will  carry  it  to  the  cook  all  the  same. 

We  all  know  that  the  shepherd  dog  knows  his 
master's  sheep,  and  knows  if  one  is  missing,  and 
he  will  protect  them  with  his  own  life.  Is  not 
this  "  knowledge  of  property?" 

Dogs  are  very  much  attached  to  their  homes 
and  will  make  journeys  of  hundreds  of  miles  to 
return  to  them,  and  by  ways  that  they  never 
traveled  before.  Though  carried  on  the  cars  300 
miles  they  will  return,  but  not  by  the  railway- 
track. 

SOME  REMARKABLE    CASES  OF    INTELLIGENCE    IN" 
ANIMALS. 

Mr.  Locke,  in  his  essay  on  the  Human  L'nder- 
standing,  gives  the  case  of  a  parrot  owned  by  a. 
Spaniard  in  a  seaport  town  in  South  America, 
who  said  to  her  master,  ' '  What  are  all  these  offi- 
cers doing  here?"  The  company  was  startled, 
and  some  one  replied.  "  and  what  are  you  doing 


802 


INSTINCT  AND  INTELLIGENCE  CONTRASTED. 


[June  6, 


here?"     The   parrot   said.    "I  mind   chickens," 
and  at,  once  began  to  cluck  like  a  hen. 

A  gentleman  was  once  driving  into  the  coun- 
try and  his  horse  suddenly  stopped  at  a  black- 
smith shop;  his  master  said,  "What  is  the  matter 
with  you,  Tom?"  and  got  for  answer  the  uplifted 
hind  foot,  a  sudden  shake  and  the  rattle  of  a  loose 
shoe. 

We  had  a  parrot  who,  when  he  stole  preserves 
and  heard  my  mother's  footstep  on  the  stairway, 
would  fly  to  the  top  of  the  bed  post  and  begin  to 
cry  out  with  fear  before  accused  of  the  theft.  He 
was  fond  of  musical  sounds,  and  would  take 
small  pebbles,  put  them  into  a  saucer  and  toss 
them  up  to  hear  them  jingle. 

I  have  a  cat  that  has  been  in  the  family  for 
eight  or  nine  years,  the  only  cat  I  ever  fancied. 
She  has  three  methods  of  getting  into  my  cham- 
ber in  the  morning,  and  she  always  pursues  them 
in  regular  order,  the  simplest  first,  and  the  most  i 
complex  last.  First,  to  cry  at  the  door,  then  to 
scratch;  second,  to  go  back  three  or  four  feet  and 
throw  herself  violently  against  the  door.  When 
this  fails  she  gets  out  on  the  front  porch  where, 
by  opening  the  slats  to  the  blinds,  she  can  see  me 
in  bed,  and  then  she  rattles  or  scratches  the 
blinds  to  attract  my  attention.  Here  is  reason, 
beyond  question.  I  was  at  a  loss  at  one  time  to 
account  for  her  second  method,  but  I  think  she 
got  this  idea  from  seeing  the  children  chasing 
each  other  from  room  to  room  in  play,  and  when 
those  inside  were  holding  the  door,  those  with- 
out would  run  against  it  and  push  with  all  their 
might  to  get  in.  The  third  and  last  way  to  en- 
ter was  due  to  the  fact  that  the  cat  had  often  in 
summertime,  when  my  window  was  open,  been  in 
the  habit  of  entering  my  room  through  it.  When 
a  child  is  badly  hurt  and  cries  aloud  this  cat  will 
run  with  the  other  children  and  get  up  into  the 
lap  of  the  injured  child  in  apparent  sympathy. 

Dogs  know  when  they  do  well  and  when  they 
■do  ill;  the>r  like  praise  and  dislike  censure. 

We  have  all  seen  the  wonderful  effects  of  care- 
ful training  in  some  animals;  this  knowledge  is 
secured  by  imitation.  A  child  of  one  year  can 
make  great  progess  in  this  line. 

It  presupposes  a  very  little  knowledge. 

OPINION     OF   SOME     DIVINES    OF    THE    LAST 
CENTURY. 

The  idea  that  the  lower  animals  will  be  resur- 
rected, as  was  insisted  by  many  distinguished  di- 
vines of  the  last  century,  is  not  tenable.  We 
may  fairly  suppose  that  animals  possess  no  power 
of  introspection,  retrospection,  or  antispection.  if 
I  may  coin  a  word,  or  anticipation  of  the  future. 
I  use  these  expressions  in  their  broadest  sense. 
This  knowledge  would  require  "  abstraction,"  a 
power  not  belonging  to  animals,  as  is  generally 
agreed. 

IDENTITY. 

Can  we  suppose  that  the  animal  has  any   idea 


of  identity?  1  think  not.  Identity  is  arrived  at 
by  a  review  of  the  past,  a  tracing  of  one's  history 
backwards  link  by  link,  to  childhood,  and  a  ca- 
pacity to  join  these  links,  and  show  their  congru- 
ity  resulting  in  what  we  call  consciousness.  We 
cannot  concede  this  power  to  brutes. 

INSANITY  IN  ANIMALS. 

Another  new  question,  perhaps,  is  this:  can  the 
animal  become  insane?  I  think  not,  as  insanity 
is  the  breaking  of  the  chain  of  identity.  If  the 
animal  does  not  have  it  of  course  he  cannot 
break  it.  When  broken  in  man  we  say  he  has 
"  lost  his  mind."  He  has  broken  the  link  that 
binds  him  to  the  past.  He  has  lost  his  identity 
and  by  consequence  his  consciousness.  I  use  this 
word  in  its  broadest  sense. 

Rabies  in  the  animal  bitten  by  a  dog  is  not, 
pathologically,  insanity.  It  is  a  blood  poison 
leading  always  and  speedily  to  death;  in  the  dog 
himself  it  is  a  specific  disease  not  at  all  analo- 
gous to  insanity  in  man. 

It  is  singular  how  opposed  some  people  are  to 
granting  even  limited  reason  to  animals.  But 
Job  allowed  them  this  in  his  day.  He  says  "God 
deprived  the  ostrich  of  knowledge  and  under- 
standing, and  hence  she  foolishly  laid  her  eggs 
in  the  sand  and  the  foot  of  man  and  beast  will 
crush  them."  The  knowledge  of  animals  to  that 
of  man  is  as  zero.  It  is  like  the  knowledge  of  A 
BC  to  that  of  the  English  language.  No  animal 
could  ever  understand  one  of  the  simplest  axioms 
in  mathematics,  which  might  be  said  to  be  below 
the  plane  of  reason,  as  they  do  not  need  reason 
for  their  acceptation.  Training  of  the  most  saga- 
cious animals  through  ten  generations  could  not 
bring  one  of  them  up  to  this  point.  They  have 
no  inventive  power  outside  of  their  own  necessi- 
ties. None  could  be  made  to  comprehend  the 
principles  of  the  simplest  art  or  science.  The  dog 
and  horse  of  a  thousand  years  ago  are  the  dog 
and  horse  of  to-day. 

This  knowledge  is  stationary;  when  brought 
in  contrast  with  man's  it  seems  as  nothing;  a 
drop  of  water  to  the  ocean,  a  grain  of  sand  to  the 
endless  beach,  its  elements  are  memory  and  imi- 
tation. There  is  one  exception,  and  that  is  their 
knowledge  of  places.  This  is  marvelous,  as  be- 
fore said,  but  without  this  special  endowment  the 
whole  race  would  perish  with  the  first  generation. 
Here  is  wisdom  and  goodness ! 

The  dog,  the  horse  and  the  cow  are  man's  three 
best  friends.  The  dog  is  the  farmer's  "night 
watchman."  No  bad  treatment  or  change  in  for- 
tune in  his  master  alienates  his  affection.  A  med- 
ical friend  once  said  to  me,  in  this  connection,  I 
have  more  faith  in  my  dog  than  in  many  men 
What  in  these  days  of  "condensed  milk"  would 
lected  infant  do  without  the  cow?  The 
goat's  milk  is  no  substitute,  as  we  all  know. 
While  fashionable  women  are  turning;  their  backs 


I89i.] 


[NSTINCT  AND  INTELLIGENCE  CONTRASTED. 


S03 


upon  their  own  offspring,  willing  that  they  should  and  a  debauchee  in  practice,  or  a  Joseph  in  puri- 

perish  rather  than  forego  the  theatre   and   ball  ty  and  entirely  ignorant  of  even  the   simplest  ru- 

rootn,  the  faithful  cow  is  the  only  recourse.    She  diluents  of  philosophy. 

saves  thousands  of  human  lives  annually.     The       Attempts  were  made  by  the  <  pecially, 

absence  of  milk  for  one  day   in    London   would  to  define  these  moral  principles,  and  direct  them 


bring  more  distress  than  the  failure  of  Baring  & 
Bro. ,  and  a  half  dozen  other  big  hou 

The  horse,  "  whose  neck  is  clothed  with  thun- 


into  right  channels,  but  they  always  remind  me 
of  men  groping  in  the  dark,  or  of  one  looking 
through    a    low  power    microscope  in  search   of 


der."   who  mocketh  at   fear  and    "smelleth  tl  to  find  only  a  mass  of  debris;  the  closer 


battle  afar  off.  the  thunder  of  the  captains  and  the 
shouting,"  is  guided  by  the  whistling  lad  in  the 
fresh  furrow  and  the  little  child  leads  him  to  the 
watering. 

Having,  as  we  think,  defined  the  limits  of  ani- 
mal intelligence,  let  us  endeavor  to  get  an  idea  of 


he  looks  the  greater  seems  the  confusion.  How 
vast  is  the  field  of  morals!  It  includes  the  study 
of  the  laws  of  truth,  justice,  love,  faith  aud  all 
their  various  products,  as  mercy,  meekness,  pa- 
tience, gentleness,  forbearance,  honest}-,  etc. 
How  beautiful  is  the  search  for  truth  in    a  great 


man's  mental  capacities,  and  see  if  there  is  one  or  ,  criminal  case  :    Astute  lawyers,  sheriffs  aud   de- 


many  links  between  the  two.  For  this  purpose  I 
propose  a  new  method  of  analyzing  the  human 
mind  or  classifying  its  capacities,  or,  if  you 
please,  giving  its  dietetics,  the  food  on  which  it 
feeds,  in  which  ample  place  will  be  found  for  its 
powers  of  imagination,  etc.  For  simplicity  it  may 
be  regarded  as  a  trinity,  but  not  the  trichotomy 
of  the  Egyptians  and  Greeks.  The  modem 
theory  of  Sir  William  Hamilton  is  far  too  com- 
plex. In  proposing  to  be  original  I  hope  I  show 
no  want  of  respect  for  learned  authority.  Too 
much  subserviency  to  authority  blocks  progress 
in  all  art  aud  science  as  well  as  in  philosophy.  It 
is  proposed  in  this  paper  to  consider  the  mind, 
1st.  In  its  moral  perceptions  or  its  power  of  com- 
prehending moral  truths. 

2nd.  Its  immoral  perceptions  or  passions. 

3rd.  Its  cosmotic  powers  or  conceptions  of  the 
natural  world,  the  Cosmos  of  Humboldt,  includ- 
ing, if  you  please,  all  physical  science.  It  is  very 
natural  that  this  last  division  of  the  subject,  from 
its  vastness,  should  have  beeu  most  attractive  to 


tectives  follow  a  small  thread,  attenuated  as  a 
spider's  web,  through  fens  and  fogs,  over  valleys 
and  mountains,  over  seas  and  oceans,  in  the  heat 
of  summer  and  the  cold  of  winter,  holding  on  to 
this  delicate  thread  till  at  last  it  becomes  a  cord, 
a  chain  that  binds  the  strong  man  in  prison  walls. 

What  a  golden  shield  justice  throws  over  inno- 
cence when  attacked  by  lion-hearted  tyranny,  or 
the  viper  tongue  of  slander  '.  With  what  a  steady 
hand  does  she  hold  the  scales.  What  a  deaf  ear 
she  turns  to  flattery  and  fame.  She  heareth  the  cry 
of  the  prisoner  and  breaks  his  bands  asunder. 
The  cry  of  the  troubled  widow,  and  gives  "beau- 
ty for  ashes,  the  oil  of  joy  for  mourning." 

But  what  shall  we  say  of  love?  Though  I  should 
"speak  with  all  the  tongues  of  men  and  angels," 
I  could  not  describe  her.  The  faith  that  removes 
mountains  is  not  equal  to  her;  the  benevolence 
(so-called)  that  would  give  all  its  goods  to  feed 
the  poor,  is  not  her  equal.  In  honor  she  "  pre- 
ferreth  another,  she  hopeth  all  things,  endureth 
all  things,"  seeketh   not  her  own,    thinketh    no 


mankind.      It  was  visible,    tangible,  always  and   evil,  rejoiceth  in  the  truth.    What  more  shall  we 
everywhere.    It  could  not  escape  us.    The  fool  as  say  of  her.     Love  would  open  every  jail  and  pen- 
itentiary,  drv  every   tear,   clothe  every    ragged 


well  as  the  wise  man  had  eyes  and  hands  and 
must  needs  use  them.  But  one  of  the  Greek 
philosophers  had  the  true  idea  when  he  said  the 
greatest  wisdom  was,  "  Nothe  se  auton."  (Know 
thyself.) 

Moral  philosophy  is  more  important  than  nat- 
ural philosophy  or  science.  Man's  happiness  is 
more  involved  in  this  Greek  aphorism  than  in  all 
La  Plaice's  and  Newton's  discoveries. 

The  wonderful  dome  that  we  carry  on  our 
shoulders  poised  so  delicately,  is  marvelous  be- 
yond description  and  the  most  marvelous  and 
valuable  endowment  are  its  moral  perceptions. 
In  its  study  is  involved  man's  highest  happiness. 
A  man  must  know  very  little  of  himself  who  is 
disposed  to  question  this  proposition.  Not  only 
is  man's  individual  happiness  involved  in  it,  but 
the  happiness  of  the  entire  race. 

It  is  a  curious  fact  that  there  is  no  necessary 
connection  between  morals  or  goodness,  and  in-, 
telligence.     A  man  may  be  a  Bacon  in  learnin 


child,  heal  every  broken  heart. 

But  what  shall  we  say  of  faith  ?  Faith  in  your 
doctrines,  faith  in  your  friends,  faith  in  your  God. 
It  binds  men  together  with  hooks  of  steel.  It  has 
laid  delicate  women  calmly  upou  the  block,  and 
tied  them  joyfully  to  the  burning  stake.  But 
what  says  the  great  philosopher,  Paul,  of  it . 
"  Through  faith  we  understand  the  worlds  were 
framed  by  the  word  of  God."  "Without  faith  it 
is  impossible  to  please  God."  " Faith  subdues 
kingdoms,  stops  the  mouths  of  lious,  quenches 
the  violence  of  fire."  Men  out  of  weakness  are 
made  strong,  wax  valiant  in  fight,  snd  turn  to 
flight  the  army  of  the  aliens.  The  highest  com- 
pliment ever  paid  to  man  by  great  authority  was 
to  men  of  great  faith,  of  whom  it  was  said,  "The 
world  was  not  worthy."  There  can  be  no  peace 
without  it,  no  commercial  progress,  no  domestic 
happiness,  society  would  go  to  pieces  without  it 
and  chaos  reign  supreme;  what  need,   then,   for 


8o4 


INSTINCT  AND  INTELLIGENCE  CONTRASTED. 


[June  6, 


the  exhortation,  "have  faith  in  man  and  have 
faith  in  God."  The  man  who  has  no  faith  in  the 
former  has  no  faith  in  the  latter.  This  is  not 
generally  admitted,  but  can  be  logically  proved. 
In  morals,  as  in  nature,  there  are  grand  massive 
truths  as  well  as  microscopic  beauties. 

Even  the  Christian  world  has  little  idea  to  what 
delicate  refinement  these  great  principles,  Faith, 
Justice,  Love,  Truth,  the  four  corner  stones  of 
God's  great  temple,  can  attain.  They  can  be 
seen  in  the  look,  the  tear  drop,  the  tender  tone, 
the  sigh,  in  the  infant's  tottering  step,  and  the 
widow's  dying  smile.  They  are  like  four  great 
rainbows,  spanning  the  Heavens,  and  beckoning 
us  to  the  skies.  And,  better  still,  they  are  pro- 
gressive, so  that  by  steady  and  persistent  effort 
we  may  attain  the  dream  of  the  poet  and  have 

"  A  heart  in  every  thought  renewed 

And  full  of  love  divine, 
Perfect,  and  right,  and  pure,  and  good, 

A  copy,  Lord,  of  thine." 

It  is  pleasant — to  change  the  figure — to  con- 
template the  final  triumph  of  these  four  sturdy- 
warriors,  of  God's  good  Providence,  as  they 
march  forward  to  the  conquest  of  the  world. 
Do  we  not  feel  the  conflict  within  us  to-day  in 
every  man,  the  "war  among  the  members?" 
Volumes  have  been  and  many  more  volumes  will 
be  written  on  this  branch  of  my  subject,  but  I 
must  turn  to  the  consideration  of  the  second  part, 
to-wit:  the  immoral  perceptions  and  passions  of 
the  mind.  Alas  !  what  a  foul  nest  of  foul  birds  ! 
what  a  den  of  fierce  wild  beasts  !  The  great 
apostle  of  the  Gentiles  sums  them  up  thus;  adul- 
tery, fornication,  uncleanness,  lasciviousness, 
idolatry,  witchcraft,  hatred,  variances,  emula- 
tions, wrath,  strife,  seditions,  heresies,  envyings, 
drunkenness,  revellings  and  such  like.  Seven- 
teen indictments.  Of  felony,  alas  !  how  many  mis- 
demeanors !  man's  charges  against  his  brother, 
aye  against  himself,  marvellous  honesty!  There 
may  be  no  witchcraft  in  these  clays,  but  there  are 
watered-stocks,  futures,  and  trusts  worse  than 
witchcraft. 

Suppose  it  were  heralded  over  the  land  to- 
morrow that, the  people  of  Paris  had  become  so 
debauched  that  no  boy  under  fourteen  years 
could  venture  from  home  at  night  except  with  a 
gendarme  by  his  side,  without  danger  of  assassi- 
nation. What  horror,  what  indignation,  would 
fill  every  man's  breast,  and  yet  it  has  become  so 
well  known  that  it  causes  no  surprise,  even  in 
this  age  of  boasted  Christian  civilization,  that  no 
girl  however  pure  and  spotless,  can  go  out  at 
night  alone,  without  danger  of  an  assault,  every- 
where regarded  in  the  Bible  as  worse  than  mur- 
der. It  will  be  noticed  that  of  the  seventeen 
felonies  above  enumerated,  this  crime  stands  at 
the  head  of  the  list,  while  murder  isput  near  the 
foot.  This  classification  is  quite  usual  in  the 
Bible.     He  who  knew  the   human  heart  better 


than  we  ourselves,  said,  "  Let  him  that   is  with- 
out sin  cast  the  first  stone." 

Unfortunately  for  man,  he  cannot  sin  without 
consent,  and  hence  he  is  responsible.  It  has 
been  proven  that  some  of  the  bad  pleasures  of 
man  cannot  be  enjoyed  without  intelligent  con- 
sent. Animals  cannot  sin  because  they  have  no 
moral  nature,  and  consequently  cannot  be  im- 
moral, in  any  sense.  The  shame  sometimes  ex- 
hibited arises  from  fear  of  remembered  punish- 
ment by  their  masters.  Here  there  is  a  bridge- 
less  chasm  between  man  and  brute.  These  hu- 
man passions  are  said  to  be  instinct,  but  while 
that  is  true  in  one  sense,  yet,  as  before  said,  they 
are  intelligent  and  under  the  control  of  a  healthy 
will,  and  are  generally  exercised,  strange  to  say, 
under  the  protest  of  conscience,  when  enlighten- 
ed. How  is  it  possible  to  explain  this  strange 
incongruity?  It  finds  no  analogy  in  the  war 
among  the  elements  in  chemistry.  Where  is  the 
philosopher  who  will  give  us  the  solution? 

But  I  must  hasten  on  to  the  third  proposition, 
to-wit:  The  cosmotic  perception,  or  the  mathe- 
matics of  the  mind  and  of  nature's  laws.  While 
the  study  of  nature  has  been,  as  said  before,  al- 
ways more  attractive  than  the  study  of  morals,  it 
is  nevertheless  not  so  abstract.  Nature  is  tangi- 
ble, visible,  some  of  her  laws  are  written  upon  ■* 
the  stones  and  others  in  the  stars.  We  find  met- 
rical motions  in  the  one  and  methodical  "  meas- 
ures" in  the  other.  To  man  is  given  the  meas- 
ure of  all  the  spheres,  in  the  circle,  without  this 
there  would  be  no  astronomy.  The  "span"  is 
the  unit  of  measure,  the  parted  fingers  the  idea 
of  "  dividers"  and  angles,  in  mathematics. 
Without  the  eye  or  without  the  hand  there  would 
be  no  art,  refined  or  gross,  but  without  either, 
what  worlds  of  beauty  were  built  by  Milton.  We 
degrade  ourselves  when  we  exalt  the  natural 
above  the  moral.  Nature  gives  no  help  to  mor- 
als, virtue  seems  not  a  child  of  earth. 

But  let  me  hasten  to  the  main  object  I  have  in 
view,  to-wit,  the  contrast  between  animal  and 
human  intelligence.  There  can  really  be  no  com- 
parison. It  is  a  matter  of  contrasts  of  antithesis. 
In  the  animal,  intelligence  is  limited;  in  man  un- 
limited. 

In  the  animal,  intelligence  is  N;  in  man  the 
great  complex  problem  of  mathematics.  In  the 
animal,  intelligence  is  a  drop;  in  man  the  ocean. 
In  the  animal  it  is  a  single  thread;  in  man  the 
bolt  of  cloth.  In  the  animal  it  is  only  one  stone; 
in  man  the  great  edifice.  In  the  animal  there  is 
no  identity;  in  man  perfect  identity.  In  the  ani- 
mal no  morality;  in  man  it  is  the  highest  quality. 
In  the  animal  satisfaction  with  the  world;  in  man 
dissatisfaction.  In  the  animal  congruity;  in  the 
man  incongruity.  In  the  animal  no  progression; 
in  man  endless  progression.  In  the  animal  in- 
sanity is  impossible;  in  man  quite  common.  We 
urprised  at  the  tricks  of  animals  and  infants 


i89i.] 


FORCED  "RESPIRATION . 


805 


simply  because  we  did   not  expect  any   intelli- 
gence. 

To  say,  therefore,  with  Darwin,  that  there  is 
one  link  or  two  'missing  links"  between  animal 
and  human  intellig  -peak  without  rea- 

son. 

Man's  highest  qualities  or  perceptions  have  no 
existence  even  in  embryo  in  animals.  You  can- 
Id  wood  and  iron,  the  chain  must  be  of  the 
same  material.  A  few  changes  in  th«  anatomy  oi 
the  chimpanzee  would  make  him  a  man  in  form, 
but  what  changes  in  his  capacities,  would  make 
him  man's  equal  in  intellect.  One  is  the  intelli- 
gent master,  the  other  the  ignorant  slave. 

A  block  of  wood  may  be  of  the  same  shape  as 
a  block  of  marble;  a  piece  of  glass,  of  the  form  of 
a  diamond;  the  form  of  an  object  has  nothing  to 
do  with  its  quality  or  character. 

Other  animals  besides  the  chimpanzee  have 
similar  organs  to  those  of  men;  this  is  true  of 
birds  also;  the  pattern  may  be  the  same,  but  the 
material  without  one  item  of  resemblance;  one 
might  be  of  brocade,  the  other  of  paper. 

LJmneus'   dogma,  "Natura  non  facet  saltus," 
may  be  true  of  the  vegetable  kingdom,  but  finds 
one  notable  exception  in  the  animal  kingdom.     I 
do  not  think  that  it  will  ever  be  proved  that  any ! 
fortuitous  concurrence  of  atoms,  or  arrangement  i 
of  cells,  can  produce  moral  intelligence. 

It  is  not  proposed  in  this  paper  to  discuss  its  j 
origin,  but  I  would  respectfully  call  attention  to 
the  Psalmist's  reasonable  answers  to  his  own 
three  pertinent  questions,  to-wit:  He  that  form- 
eth  the  eye,  shall  he  not  see?  He  that  planteth 
the  ear,  shall  not  he  hear?  He  that  taught  man 
knowledge,  shall  not  he  know? 

But  to  conclude:  I  have  endeavored  to  show 
that  animal  intelligence  is  zero;  to  multiply  it  by 
itself  you  have  zero. 

I  have  also  said  it  is  strictly  limited,  and  if 
multiplied  b}'  itself  the  result  is  limited.  But  the 
powers  of  the  human  mind  are  unlimited;  not  one, 
not  a  thousand  links  can  bridge  the  chasm  be- 
tween the  intelligence  of  animals  and  the  intelli- 
gence of  man. 


TWO  INTERESTING   CASES  OF  FORCED 
RESPIRATION. 

AV,:./  i«  the  Section  of  J'  >it  and  Physiology,  at  the 

Forty-second  A  nnnal  Meeting  of  the  A  merican  Medical  Asso- 
ciation, held  at  It'as/itriglon,  D.  C,  M 

BY  GEORGE  E.  FELL,  M.D., 

OF  BUFFALO,    N.    Y. 

Sunday  morning,  March  1,  at  3-120  a.m.,  I  was 
called  to  the  residence  of  Dr.  Harrington,  on 
Franklin  St.,  and  there  found  a  young  lady  who 
had  taken  a  large  dose  of  morphine.  At  3  a.m., 
Mr.  Harrington,  Sr. ,  had  noticed  stertorous 
breathing.  He  arose,  looked  at  the  patient,  but 
concluded  that  it  was  nothing  more  than  a  very 


deep  slumber.  The  condition  continuing,  how- 
ever, he  called  Dr.  Harrington,  who  examined 
the  patient,  finding  her  in  a  comatose  condition, 
cyanotic;  pupils  markedly  contracted;  and  a 
bottle  of  morphia  upon  the  table.  She  had  writ- 
ten two  or  three  letters  which  clearly  indicated 
the  cause  of  the  trouble. 

I  immediately  proceeded  to  forced  respiration 
with  the  face-mask,  which  resulted  in  overcom- 
ing the  cyanosis  and  producing  an  improvement 
heart  action.  We  continued  forced  res- 
piration with  the  face-mask  until  6:30  a.m., 
when  it  was  observed  that  the  cyanosis  was  again 
increasing,  and  the  condition  of  the  patient  grow- 
ing more  and  more  desperate.  No  evidences  of 
consciousness  were  present.  By  hollowing  into 
the  ear,  ocular  reflexes  were  noticed  in  a  con- 
tracting of  the  orbicularis  muscles.  There  ap- 
peared to  be  no  hope  of  recovery  at  this  time. 

With  Dr.  Harrington's  assistance  we  made 
tracheotomy,  and  inserted  the  tracheotomy  tube, 
as  arranged  for  forced  respiration,  into  the 
trachea.  Connection  was  then  made  with  the 
apparatus,  and  forced  respiration  kept  up.  The 
improvement  on  the  employment  of"  forced  res- 
piration per  tracheotomy,  over  that  produced  by 
the  face-mask,  was  evident.  The  chest  move- 
ments were  greater,  and  the  results  were  more 
satisfactory  in  many  respects.  However,  of  so 
serious  a  nature  was  the  condition  of  the  patient 
at  this  time  that  not  one  present  expected  other 
than  a  fatal  termination.  No  pulse  existed  at 
either  wrist ;  auscultation  could  detect  no  heart 
movement,  either  on  the  part  of  Dr.  Harrington, 
myself,  or  the  students  present.  Two  conditions, 
however,  appeared  to  indicate  that  life  was  not 
extinct.  The  pupils  continued  contracted,  and 
cyanosis  did  not  supervene.  The  glassy  stare  of 
the  eyes  was  present,  and  outside  of  the  two  fa- 
vorable indications  mentioned,  it  appeared  that 
death  could  not  be  far  off.  At  this  point  Dr. 
Harrington's  father  made  the  remark  that  if  this 
young  lady  was  made  to  live,  it  would  be  indeed 
a  "miracle."  However,  I  ke»t  up  the  forced 
respiration,  saying  that  I  would  do  so  a  little 
while  longer,  "just  for  the  fun  0/  it."  In  a 
short  time  auscultation  on  the  part  of  Dr.  Har- 
rington gave  us  the  satisfactory  information  that 
the  heart  was  beating.  In  the  course  of  a  few 
hours  these  reflexes  were  more  and  more  marked, 
and  consciousness  supervened.  Forced  respira- 
tion was  continued  through  the  forenoon,  and 
until  quite  late  in  the  afternoon,  making  some 
twelve  to  fourteen  hours  of  continual  forced  res- 
piration before  the  patient  could  be  allowed  to 
breathe  for  herself. 

She  has  made  a  good  recovery. 

In  this  case  artificial  respiration  would  at  no 
time  have  been  of  any  avail  to  the  patient. 

Oxygen  gas  used. 

Sunday,  March  15,  at  11:30  a.m.,  I  was  called 


8o6 


TUBERCULIN. 


[June  6 


to  attend  Joseph  Altiere.  A  prescription  con- 
taining phenacetin,  morphine  and  cocaine,  in 
small  quantity,  had  been  prescribed  by  the  at- 
tending physician,  for  neuralgia  of  the  stomach. 
The  patient  had  taken  repeated  doses,  without 
regard  to  instructions  upon  the  prescription,  un- 
til a  large  poisonous  dose  of  these  very  danger- 
ous drugs  had  been  taken.  At  11:30  a.m., 
forced  respiration  with  the  face-mask  was  com- 
menced, and  quickly  overcame  the  marked  cyano- 
sis, which  was  intensified,  undoubtedly,  by  the 
phenacetin.  With  the  face-mask  forced  respira- 
tion was  kept  up  all  the  afternoon,  the  patient  at 
times  becoming  conscious.  The  cyanotic  condi- 
tion seemed,  however,  to  increase,  owing  to  the 
base  of  the  tongue  falling  back  and  occluding 
the  larynx.  A  ligature  was  placed  through  the 
tongue,  and  the  organ  was  pulled  well  up,  with 
the  result  that  the  lungs  were  more  readily 
inflated. 

In  this  case  oxygen   gas  was  administered,  in 
connection  with  the  forced  respiration  apparatus, 
it  being  supplied  in  greater  or  less  quantities,  as 
seemed  to  be  desirable.     At  times  the  amount  of 
air  passing  to  the  stomach  and  the  bowels  was  so 
great  as  to  markedly  distend  them,  thus  interfer- 
ing to  a  certain  extent  with  the  inflation  of  the 
lungs  by  the  forced  respiration,    and  indicating- 
one  of  the  difficulties  to  be  met  with  in  forced 
respiration  with  face  mask.     In  the  afternoon  the 
patient   became    comatose,   and  responded  very 
little  to  the  respiratory  work.     During  the  even- 
ing it  was  evident  that  the  patient  was  not  pro- 
gressing satisfactorily,  the  influence  of  the  poisons 
being  peculiar  in  their  action,  there  not  appearing 
to  be  any  elimination  of   the  drugs — although 
the  catheter  was  used  as  often  as  was  necessary, 
and  the  antidotes  which  seemed  to  be  indicated, 
and  stimulants,  such  as  digitalis  and  alcohol,  in- 
jected   hypodermically.      At    10   p.m.,    Sunday 
night,  I  made  tracheotomy,  and  forced  respira- 
tion was  then  kept  up  by  the   direct   method. 
The  result,  as  in  the  former  case,  indicated  the 
very  great  readiness   with   which    the    method 
could  be  used  in  the  direct  inflation  of  the  lungs, 
and  the  patient  was  apparently  holding  his  own. 
I  left  for  home  at  11  P.M.,  trusting  that  the  pa- 
tient would  be  in  good  condition  in  the  morning. 
An  army  of  students  was  present  to  assist  in  the 
work  of  respiration,   and  with   Dr.    Harrington 
they  kept  faithfully  at  work  through  the  night, 
until  5:30  in  the  morning.     At  this  time  the  pa- 
tient was  breathing  with  comparative  ease,  and 
the  prospects  looked  encouraging.     However,  a 
spasmodic  contraction  of  the  stomach  occurred  ; 
it's   contents    were   ejected    with    force.      Every 
effort  was  made  to  prevent  any  of  the  vomited 
matter  from  passing  into  the  lungs,  but  the  spasm 
resulted,  however,  in  the  ceasing  of  the  action  of 
the  heart ;  and  the  labor  of  eighteen  hours  was 
thrown  away. 


The  necessity  for  something  other  than  manual 
labor  in  the  forcing  of  a  column  of  air  into  the 
lungs,  was  strongly  demonstrated  in  this  case. 
Although  there  were  plenty  of  persons  present, 
what  with  the  students  and  the  relatives  of  the 
patient,  who  performed  all  the  labor  required, 
no  one  who  has  not  witnessed  a  case  of  forced 
respiration  can  really  appreciate  the  amount  of 
energy  expended  in  respiring  for  a  human  being, 
be  it  even  so  easy  comparatively  as  by  the  method 
used  in  forced  respiration. 

This  is  the  first  extended  case  in  which  oxygen 
gas  was  administered  in  conjunction  with  the 
forced  respiration.  The  results  were  satisfactory, 
but  the  odds  against  which  we  were  fighting — 
the  combination  of  deadly  drugs  which  had  been 
taken — were  too  much  for  even  an  expectation 
that  success  would  crown  our  efforts.  With 
morphia  alone  in  large  quantity,  I  believe  the 
patient  would  have  been  saved. 

Bat  these  cases  have  demonstrated  again  all 
that  has  been  claimed  heretofore  as  to  the  value 
of  forced  respiration  :  and  I  repeat  that  the  phy- 
sician who  has  not  seen  the  results  of  forced  res- 
piration, cannot  conceive,  even  with  his  knowledge 
of  physiology,  its  value  in  the  resuscitation  of 
human  beings  in  asphyxia,  generally. 


TUBERCULIN. 

ITS  VALUE    AS    A    SCIENTIFIC    DISCOVERY,  APART 
FROM    ITS    THERAPEUTIC    IMPORTANCE  ;    TO- 
GETHER WITH  A  CONSIDERATION  OF  THE 
MOST  RATIONAL   MODE   OF  EMPLOY- 
ING THE  PRINCIPLE   INVOLVED 
IN   IT. 

Read  in  the  Section  of  Practice  of  Medicine  ami  Physiology,  at  the 
>n!  Annua!  Meeting  of  the  American  Medical  Associa- 
tion, he/J  at  Washington,  D.  C,  May  58, 1S01. 

BY  S.    K.   JACKSON,   M.D., 

OF  NORFOLK.  VA. 

Whatever  may  be  the  estimate  formed  of  Koch's 
lymph— whether  or  not  it  shall  be  determined  to 
have  a  curative  influence  in  the  class  of  diseases 
for  which  it  has  been  proposed,  it  must  be  recog- 
nized as  of  incalculable  value  in  illustrating,  or 
rather,  I  should  say,  in  demonstrating,  the  truth 
of  one  of  the  most  important  principles  of  biolog- 
ical science. 

It  is  running  but  little  risk  to  prophesy  that 
this  generalization  will,  before  long,  revolution- 
ize the  practice  of  medicine,  by  compelling  a  re- 
sort to  Nature's  mode  of  curing  disease;  that  is, 
by  using  the  means  that  Nature  employs  for  in- 
hibiting or  arresting  the  life- processes  of  organ- 
isms which  are  known  to  be  the  causative  factors 
in  the  production  of  certain  diseases. 

While  recent  clinical  records  have  caused  a 
great  distrust  in  Koch's  method  as  a  safe  remedy 


t89i.] 


TUBERCULIN. 


807 


in  pulmonary  tuberculosis,  no  one  has  doubted, 
or  questioned,  its  power  of  producing  a  rapid  ne- 
crosis of  the  diseased  tissue.  The  modus  operandi 
by  which  this  necrosis  is  effected,  is  the  important 
physiological  and  philosophical  fact  which  invests 
it  with  the  value  which  we  now  propose  to  con 
sider;  and  if  itself  should  not  prove  to  be  the 
efficient  curative  agent  for  which  we  have  been 
looking,  it  furnishes  a  most  valuable  suggestion 
for  the  treatment  of  this  most  refractory  condi- 
tion, and  confirms  the  theory  which  was  first 
enunciated  by  me  some  twelve  years  ago,  and 
upon  which  is  based  the  practice  which  I  have 
pursued  ever  since,  and  with  most  remarkable 
results. 

If  tuberculosis  were  a  self-limiting  condition, 
and  conferred  an  immunity  from  a  second  attack, 
then  Koch's  lymph  would  be  of  inestimable  value 
as  a  prophylactic,  and  second  only  to  vaccination 
as  a  blessing  to  the  human  race.  But  as  such  is 
not  the  case,  it  must,  for  the  present  at  least,  be 
relegated  to  its  position  as  a  scientific  fact,  with- 
out the  practical  value  it  was  at  first  supposed  to 
possess,  so  far  as  is  known  at  this  time. 

Let  us,  for  a  moment,  consider  the  nature  oi 
Koch's  remedy,  and  see  how  far  it  conforms  to 
the  biological  law  to  which  I  have  alluded. 

It  is  a  poison  formed  as  a  consequence  of  the 
life-processes  of  the  bacillus  tuberculosis,  pre- 
served in  glycerine  to  prevent  further  decomposi 
tion.  In  other  words,  it  is  the  effete  excretory 
product  of  the  microorganism  causing  tubercu- 
losis employed  for  the  purpose  of  inhibiting  its 
life  processes,  and  thereby  arresting  its  work  of, 
destruction,  on  the  principle,  or  in  accordance 
with  the  law,  that  "  no  organism  can  live  in  its 
own  excreta." 

I  acknowledge  that  this  is  not  the  universalh- 
accepted  idea  concerning  it,  for  Dr.  Solis-Cohen, 
in  The  Journal  of  the  Amehicax  Medical 
Association,  xvi.  11,  p.  370,  speaks  of  it  as  the 
product  "  of  a  mutual  reaction  of  the  bacillus  and 
the  tissue,  dissolved  in  glycerine,  and  by  the  for- 
mation of  which  the  microbes  are  deprived  of  food 
and  starve  to  death."  This  ignores  the  poison- 
ous effects  upon  the  microbes. 

That  we  may  be  sure  of  giving  a  fair  interpre- 
tation of  it,  let  us  refer  to  Koch's  own  account  of 
its  nature  and  modus  operandi,  and  use  his  own 
•words. 

In  his  November  paper,  Koch  gives  the  follow- 
ing explanation  of  the  process  :  "  The  tubercle 
bacilli,  produced  when  growing  in  living  tissue, 
the  same  as  in  artificial  cultivation,  contain  cer 
tain  substances  which  variously  and  notably  un- 
favorably influence  living  elements  in  their  vi- 
cinity. Among  these  is  a  substance  which,  in  a 
certain  degree  of  concentration,  kills  or  so  alters 
living  protoplasm,  that  it  passes  into  a  condition 
that  Weigert  describes  as  a  coagulation  necrosis. 
In  tissue  thus  become  necrotic  the  bacillus  finds 


such  unfavorable  conditions  of  nourishment  that 
ow.no  more,  and  sometimes  dies."  Or 
as  expressed  in  McDill's  translation  of  Koch's 
January  paper:  "The  bacillus  then  finds  such 
unfavorable  conditions  of  nutrition  that  it  is  un- 
able to  keep  on  growing,  and  under  certain  cir- 
c.umstancts  even  dies  off. "  That  he  considered 
the  microbe  effectually  disabled,  if  not  killed,  is 
evident  from  the  closing  words  of  his  August  pa- 
per. He  says:  "  I  am  only  able  to  draw  one  con- 
clusion from  these  researches,  viz.:  the  possibility 
which  exists  from  this  way  of  paralyzing  absolute- 
ly the  action  of  the  microbes  in  the  animal." 

Were  it  not  for  testimony  which  he  subse- 
quently furnished,  we  might  suppose  that  he  had 
changed  his  mind  by  the  time  his  November  pa- 
per was  published  ;  in  this  he  says  "  The  neces- 
sary histological  investigations  are  not  yet  com- 
plete :  but  this  much  is  certain,  that  there  is  no 
question  of  a  destruction  of  the  tubercle  bacilli 
in  the  tissues,  but  that  only  that  the  tissue  en- 
closing the  tubercle  bacilli  is  affected  by  the 
remedy." 

We  might  be  in  doubt  as  to  the  meaning  of 
this  faulty  English,  were  it  not  for  the  following 
einphaUc declaration  :  "To  recapitulate,  the  rem- 
edy does  not  kill  the  tubercle  bacilli,  but  the  tu- 
berculous tissue,  and  this  gives  us  clearly  and 
definitely  the  limit  that  bounds  the  action  of  the 
remedy." 

It  is  difficult  to  reconcile  this  statement  (which 
may  be  attributed  to  incomplete  histological  re- 
search) with  the  following:  "As  a  rule,  the  num- 
ber of  the  bacilli  decreased  only  when  the  expec- 
toration began  to  present  a  mucous  appearance. 
They  then  entirely  disappeared,  but  were  again 
observed  occasionally  until  expectoration  com- 
pletely ceased." 

This  positive  assertion  is  worth  more  than  mere 
speculation,  and  leaves  us  in  no  doubt  as  to  the 
death  of  the  bacillus. 

In  reference  to  this  point  Dr.  Ernest  Laplace 
remarks  (Times  and  Register,  January  \~.  1S91): 
"Koch  has  determined  that  the  treatment  does 
not  destroy  the  bacillus,  the  seed  of  the  disease. 
What  is  destroyed  is  that  which  has  developed 
from  the  tissues  under  the  irritation  of  the  bacil- 
lus. If  the  remedy  only  did  this.  Koch's  object 
would  not  be  reached."  And  further:  "There 
is  one  means  left  for  curing  the  tuberculous  pro- 
cess ;  that  is,  that  the  lymph  should  so  act  upon 
the  system  as  to  render  it  unsuited  to  let  the  ba- 
cilli of  tuberculosis  develop  in  it."  "In  other 
words,  Koch  hopes  that  the  remedy  will  confer 
immunity  against  tuberculosis  in  man,  as  he  says 
it  does  in  the  guinea  pig."  And  further  :  "We 
have  all  reasons  to  surmise  that  the  lymph  is  di- 
rectly or  indirectly  the  result  of  cultures  of  the 
bacillus  tuberculosis.' 

From  these  extracts  from  Koch's  several  papers 
it  is  evident  that  he  considered  this  substance, 


TUBERCULIN. 


[June  6, 


which  is  the  result  of  the  life-processes  of  the  the  life-process,  what  better  agent  have  we  for 
bacilli  (their  excreta),  as  furnishing  a  medium  arresting  that  process  than  alcohol  itself?  and 
unfavorable  to  their  nutrition,  and  even,  some-! how  generally  is  it  used  for  that  purpose!  If 
times,  causing  them  to  die.  This  conclusion,  it  sulphuretted  hydrogen  be  the  exhaled  excretion, 
will  be  seen,  corresponds  precisely  with  the  law   all  acknowledge  the  efficacy  of  sulphur  and  its 


enunciated  by  me  in  the  year  1879. 

In  my  report  on  Advances  in  Hygiene,  etc. 
(Trans,  of  Medical  Society  of  Virginia,  1879,  p. 
56),  occur  these  words:  "It  is  not  wholly  for 
want  of  pabulum  that  it  dies,  but  it  is  actually 


compounds  in  arresting  the  decomposition  giving 
rise  to  it.  So  also,  if  ammonia  be  the  result  of 
the  vital  processes  of  an  organism,  as  is  claimed 
in  the  case  of  typhoid  fever,  then  by  this  law, 
we  have  a  right  to  infer  that  ammonia  is  the 


destroyed  by  the  products  of  the  decomposition,    proper  and  efficient  germicide.     This  furnishes 
whatever  be  the  products,  etc.''     In  a  foot-note  :  us  with  an   additional  indication  for  employing 


I  claim  that  this  furnishes  "an  additional  indi- 
cation for  the  employment  of  ammonia  iu  the 
treatment  of  typhoid  fever,  not  only  to  restore 
the  nitrogenous  waste,  etc.,  but  also  to  saturate 
the  system  with  what  the  organism  producing  the 
disease  is  known  to  exhale,  and  thereby  diminish- 
ing or  destroying  its  vitality."  And  further,  on 
page  72,  in  speaking  of  the  gaseous  products  of 
putrefaction  and  fermentation,  I  say:  "These 
gases  may,  if  the  air  be  sufficiently  saturated  with 
them,  arrest  the  decomposition  of  which  they  are 
the  result,  by  destroying  the  life  of  the  organism, 
on  the  principle  stated,  viz.:  that  life  cannot  be 
sustained  in  its  own  excretions." 

Again,  in  my  report  on  Advances  in  Practice 
to  the  Medical  Society  of  Virginia  in  1883,  pub- 
lished in  the  Transactions  of  that  year,  p.  66,  oc- 
curs this  passage,  p.  75 :  "If  the  theory,  first 
enunciated  by  me,  as  far  as  I  know,  at  our  Alex- 
andria meeting  (in  1879),  be  a  law,  this  may  fur- 
nish us  with  a  guide  in  the  selection  of  our  ger- 
micides. If  it  be  a  law  that  'no  organism  can 
live  in  the  effete  products  of  its  own  life,  in  its 
own  excreta,'  then  the  most  rational  means  of 
destroying  it,  would  be  to  saturate  it  with  the 
resulting  products  of  its  vital  processes ;  for,  as 
has  been  shown,  these  products  become  poisons 
and  arrest  the  growth  and  development  of  the 
organism  which  generated  them,  and  finally  cause 
their  death."  Then  follow  some  illustrations  of 
this  principle,  e.  g.,  the  effects  of  carbonic  acid  on 
the  organism  producing  fermentation — of  sulphu- 
retted hydrogen,  of  ammoniacal  gas,  etc. 

Again,  this  principle  is  further  insisted  on  in  a 
paper  on   "The  Treatment  of  Typhoid  Fever," 
11  fore   the   American    Medical   Association 
(Washington  meeting),  in  [884,  in  which  paper, 
published  in  The  Journal  of  August  16,  1884, 
-.  occurs  this  passage: 
[n   '  paper  recently  read  before  the  Virginia 
State  Medical  Society,  I  have  contended  that  we 
are  furnished  with  a  key  to  the  selection  of  ger- 
micides by  a  law  which,  as  far  as  I  know.  I  have 
been  the  first  '.o  enunciate.     I  claim  that  it  is  a 
law  that  no  organism  can  live  in  its  own  excreta, 

in  the  products  of  its  own  vital  processes.  When  incut,  requires  a  minute  study  of  diseases  of  zy- 
carbonic  acid  gas  is  the  excretory  product,  how  liiotie  origin,  and  may  necessitate  a  new  treat- 
certaini  ■<     acid    destroy    the    lifi  ed  to  the  destruction  of  the  particular 

that  produced  it.     If  alcohol  he  the  product  of  |  organism  which  may  be  ascertained  to  be  the  pa- 


the  salts  of  this  nitrogenous  base,  for  it  not  only 
supplies  the  nitrogenous  waste,  as  we  have  con- 
tended, but  also  destro3-s  the  vitality  of  the  or- 
ganism which  causes  it." 

Iu  an  editorial  of  The  Journal  of  the  Amer- 
ican Medical  Association,  October  10,  18S5,  p. 
405,  occurs  the  following  allusion  to  this  doctrine, 
with  au  extract  from  the  same  paper  on  the  Am- 
monia Treatment  of  Typhoid  Fever :  "  Why  or 
how  it  (nitrate  of  ammonia)  reduces- the  temper- 
ature of  enteric  fever,  cannot  be  definitely  stated; 
but  he  (Dr.  Jackson)  thinks  that  '  it  is  by  inhib- 
iting the  life-processes  of  the  microbe,  by  satu- 
rating it  with  the  products  of  its  own  life,  thus 
either  crippling  its  vitality  or  altogether  destroy- 
ing its  life,  on  the  principle  enunciated  by  him 
several  years  ago — no  organism  can  exist  in  its 
own  excretions,  the  product  of  its  own  life-pro- 
cesses.' " 

I  hope  I  may  be  excused  for  producing  another 
extract  on  this  important  subject. 

In  a  paper  read  before  the  Ninth  International 
Medical  Congress  of  1S87,  on  "Natural  Agen- 
cies inhibiting  the  Life-processes  of  Pathogenic 
Organisms,  considered  with  a  view  to  their  ther- 
apeutic employment,"  published  in  the  Trans- 
actions of  said  Congress,  Vol.  iii,  p.  396,  I 
have  insisted  on  this  as  one  of  these  agen- 
cies, thus:  "Next  to  the  destructive  effects  of 
extremes  of  temperature,  the  most  clearly  recog- 
nized natural  agency  which  affects  the  vitality  of 
pyrogenic  organisms  is  the  production,  in  the 
medium  in  which  they  live,  by  means  of  their 
vital  processes,  of  substances  which  are  poison- 
ous to  them  and  cause  them  to  die ;  that  is,  they 
are  killed  by  the  products  of  their  own  life-pro- 
cesses." "No  living  being  can  long  be  kept 
alive  when  so  confined  in  the  medium  in  which  it 
exists,  as  to  absorb  the  products  of  its  own  life- 
processes,  its  own  excreta,  etc.,  illustrated  by  fish 
in  unchanged  water,  and  by  plants  cultivated 
continuously  on  the  same  soil,  etc.  The  excre- 
tions, then,  of  all  living  organisms  are  inhibitory 
to  their  life-processes,  and  to  avail  ourselves  of 
this  law  with  a  view  to  its  therapeutic  employ- 


i89i.]     AX  UNDESCRIBED  PATHOLOGICAL  CONDITION  OF  THE  LUNGS.  809 


thogenie  factor  in  each  of  them.'  If  any  one  is 
disposed  to  doubt  the  general  proposition  upon 
which  this  study  is  founded,  let  hirn  examine 
closely  any  one  of  the  various  fermentations,  etc. 

Then  follow  instances  it:  which  this  plan  of 
treatment  might  be  adopted,  and  also  an  enumer- 
ation of  anti-ferments — quinine,  rlaimed  to  act 
on  this  principle:  dyspept  ins  with  eruc- 

tations of  sulphuretted  hydrog- 11.  relieved  by  con- 
diments containing  sulphur,  e.g.,  garlic,  onions, 
asafcetida,  etc.,  or  by  the  salts  of  sulphurous  acid; 
the  saturation  of  the  system  with  ammonia  in  the 
typhoid  state,  as  there  is  known  to  be  nitrogenous 
waste  with  ammoniacal  exhalations.  And  further, 
what  is  now  more  to  the  point,  in  elucidating  the 
treatment  of  the  tuberculous  state,  I  allude  to  the 
exhalation  of  sulphuretted  hydrogen  from  the  de- 
composition of  the  sputum  of  tuberculous  sub- 
jects, which  probably  suggested  Bergeon's  plan 
of  infusing  into  the  system  this  very  gas,  and 
also  to  my  own  treatment  by  the  free  use  of  the 
salts  of  sulphurous  acid  and  the  sulphides.  I  do 
not  know  whether  subsequent  experience  has  es- 
tablished the  efficacy  of  Bergeon's  method,  but 
with  regard  to  my  own.  the  results  in  eight  cases, 
up  to  this  time,  have  satisfactorily  proved  its  value. 

I  admit  that  the  importance  of  this  subject  de- 
mands a  much  more  extended  investigation  than 
I  have  been  able  to  give  it.  My  inference  as  to 
the  sulphurets  being  required,  was  derived  merely 
frorn  perceiving  the  odor  of  sulphuretted  hydro- 
gen from  decomposing  sputa. 

That  these  sulphur  salts  have  a  most  decided 
effect  upon  the  hectic  paroxysms,  any  one  can 
determine  for  himself.  In  a  very  marked  case 
which  I  was  able  to  watch  closely,  I  could  read- 
ily prevent  the  return  of  the  hectic  chill,  fever 
and  colliquative  sweating  by  means  of  the  bisul- 
phite of  soda. 

The  eight  cases  which  I  could  report  as  either 
absolutely  cured  or  decidedly  improved  up  to  this 
time,  afford  a  good  demonstration  of  the  correct- 
ness of  the  principle  for  which  I  am  contending. 

While  the  means  above  alluded  to  were  my  re- 
liance for  the  control  of  the  hectic  condition,  other 
means  were,  of  course,  used  for  general  nutrition 
and  building  up  of  the  system,  the  relief  of  dysp- 
noea, diarrhoea,  etc.  Cod-liver  oil  has  been  but 
little  used  in  an}'  of  my  cases,  and  alcoholic  stim- 
ulants only  at  periods  of  extreme  prostration. 

Besides  the  constant  use  of  the  sulphur  salts, 
the  chief  means  employed  were  Parrish's  syrup 
of  the  phosphates,  inhalations  of  vapor  of  tur- 
pentine with  carbolic  acid  and  iodine,  which  lat- 
ter was  found  to  materially  relieve  the  dyspnoea. 

This  plan  of  treatment.  I  contend,  effectually 
arrests  the  tuberculous  process  by  crippling  or 
destroying  the  bacillus,  without  causing  the  ne- 
crosis of  the  diseased  tissue,  which  is  so  fatal  to 
the  success  of  Koch's  method. 

I  do  not  pretend  to  claim  that  sulphuretted  hy- 


drogen is  the  only  exhalation  from  the  bacillus 
tuberculosis  which  might  furnish  an  indication 
for  treatment,  for  it  is  not  only  possible,  but  high- 
ly probable,  that  a  minute  chemical  study  might 
reveal  some  other  product  resulting  from  the  life- 
processes  of  this  organism,  which  might  suggest 
some  other  agent  which  would  be  still  more  effi- 
cacious in  arresting  its  vitality  and  check 
predatory  attacks  upon  the  system. 

A*ll  I  contend  for  is,  that  it  is  upon  this  princi- 
ple the  treatment  should  be  conducted,  and  upon 
this  line  we  should  search  for  the  agent  most  de- 
structive to  its  life. 

This  also  appears  to  be  the  conclusion  arrived 
at  by  Koch  and  his  collaborators,  and  it  is  curi- 
ous to  note  the  similarity  of  the  language  em- 
ployed by  them  in  the  year  1890.  to  that  used  by 
me  in  1S79.  at  least  three  years  before  the  bacillus 
tuberculosis  was  discovered. 


A  PATHOLOGICAL  CONDITION  OF  THE 

LUNGS,    HITHERTO    UNDESCRIBED 

IN  THIS  COUNTRY,  BUT  WHICH 

IS  NOT  INFREQUENT. 

Read  bv  Tittt  in  the  Section  of  the  Practice  of Medicine  and  Physiology 
at  the  Forty-second  Annual  Meeting  of  :'  "  ical  As- 

sociation, at  Washington.  D.  C 

BY  F.  PEYRE  PORCHER,  A.B.,  M.D.. 

ONE  OF  THE  rHYSICIAXS  TO  THE  CITY  HOSPITAL,  CHARLESTON    5    C. 

During  the  course  of  a  very  prolonged  service 
in  hospitals,  I  have  repeatedly  observed  a  condi- 
tion of  the  lungs  which  is  markedly  distinct  and 
characteristic,  which  I  have  not  seen  described. 

A  full  account  of  this  appeared  in  the  New 
York  Medical  Record,  October  19.  18S9.  I  will 
give  here  a  succinct  review  of  the  main  features 
and  symptoms,  in  order  that  we  may  decide 
whether  it  is  only  a  pathological  state,  or  wheth- 
er it  should  rank  as  a  distinct  disease. 

Patients  presented  the  following  symptoms : 
Dulness  or  sub-dulness,  generally  at  the  middle, 
lateral  or  posterior  portions  of  the  chest ;  there 
imperfect  respiration  ;  scarcely  any 
rale  present,  or  if  so  sparsely  disseminated,  and 
generally  the  subcrepitant :  or  perhaps  there  was 
only  rough  breathing.  The  condition  was  con- 
sequent on  antecedent  morbid  states,  and  was 
discoverable  weeks  before  death,  if  a  fatal  result 
ensued.  There  was  not  necessarily  fever  or  ele- 
vation of  temperature:  there  did  not  ex: 
dence  of  any  acute  inflammation,  or  any  of  the 
well-known  diseases  of  the  chest — no  phthisis, 
pneumonia,  bronchitis,  pleurisy,  emphysema,  hy- 
drothorax,  etc.  The  positive  physical  signs  of 
these  diseases  were  all  absent — there  were  no 
crepitant,  or  sibilant,  or  crackling  rales  :  neither 
were  there  pain  or  rubbing  sounds.  So  all  the 
diseases  which  the-  .cheated  had  to  be 

excluded. 


8io        AN  UXDESCRIBED  PATHOLOGICAL  CONDITION  OF  THE  LUNGS    [June  6, 


To  continue  the  citation  of  positive  and  nega- 
tive symptoms:  The  respirator}'  murmur,  though 
not  .normal,  was  not  absent,  for  the  king  was  still 
pervious  to  air ;  the  vocal  resonance,  or  what  I 
prefer  to  call  the  reverberation  of  voice,  was 
slightly  affected  ;  some  complementary  respira- 
tion might  be  present,  but  this  was  not  very  de- 
cided, because  there  was  no  absolute  consolida- 
tion. Scarcely  any  dyspnoea  may  exist,  and  the 
cough  may  be  moderate  or  absent.  Hepatization, 
solidification  and  asthma  had  also  to  be  excluded, 
for  there  was  no  absolute  dulness,  complementary 
or  puerile  respiration  characterizing  the  two  first, 
or  crepitant  rales  to  indicate  the  last.  The  crep 
itant  rale,  the  fever  or  the  rusty-colored  sputa 
essential  to  pneumonia  were  not  present.  There 
were  no  frothy,  watery,  blood  stained  expectora- 
tion, blueness  of  lips,  lividity,  or  cold  extremities, 
as  in  extreme  cases  of  cedemas ;  no  pure  hypere- 
mia— for  in  our  cases  we  have  blood  and  serum 
mixed ;  no  pulmonary  congestion,  for  there  is 
"no  copious,  watery  ^  bloodstained  expectora- 
tion "  which  accompanies  this,  which  is,  besides, 
an  acute  disease. 

Whenever  an  autopsy  was  afforded  in  such 
cases,  the  physical  evidences  of  the  diseases 
above  cited  were  absent,  and  there  was  invariably 
present  a  large  a  mount  of  bloody  serum  exuding  from 
the  cut  surfaces,  and  it  wouldflow  mostfre'ely  when 
the  lung  icas  squeezed.  There  was  plainly,  there- 
fore, a  gross  morbid  fact  which  was  the  chief 
feature,  which  had  to  be  noted  and  accounted  for, 
and  which,  if  a  name  was  required,  must  neces- 
sarily be  embraced  under  such  appellation. 

The  conditions  with  which  our  cases  would  be 
most  likely  to  be  confounded  would  be  the  hypo- 
static congestion,  or  the  hypostatic  pneumonia  of 
recent  authors,  or  infiltration  of  the  lungs.  But 
there  are  none  of  the  physical  signs  of  pneumo- 
nia present;  and  the  term  infiltration  is  too  vague 
and  undefined— for  infiltration  may  either  follow 
pneumonia  or  be  tubercular,  and  our  cases  were 
neither  of  these. 

We  must  also  decidedly  exclude  the  term  hy- 
postatic congestion  in  the  old  sense  of  the  term, 
which  implied  a  condition  of  stasis  just  preceding 
death,  dependent  upon  recumbency,  position,  etc. 
A  name  was  needed  for  the  symptoms  which 
had  been  isolated,  and  I  long  since  began  to  des- 
ignate the  disease  referred  to  as  "  engorgement 
of  the  lungs" — serum  being  always  mixed  with 
blood.  I  was  compelled  to  the  use  of  these  terms 
because  they  only  were  true,  applicable,  and  essen- 
tial in  describing  and  interpreting  the  condition. 
My  cases  of  engorgement  of  the  lungs  exist  for 
days  and  weeks,  and  do  not  depend,  as  was  stated, 
upon  the  accidences  of  position,  recumbency,  sta- 
sis of  the  blood,  age  of  patient,  or  want  of  vital- 
ity— for  the  powers  of  life  are  not  specially  en- 
feebled. 

I  published  a  note  in  the  American  Journal  of 


the  Medical  Sciences,  as  far  back  as  October,  1869, 
under  the  caption :  ' '  Frequency  of  Serous  En- 
gorgement of  the  Lungs, ' '  but  have  at  last  been 
able  to  get  some  confirmation  of  the  probable 
correctness  of  my  observations  in  Jaergensen's 
paper  entitled  "Diseases  of  the  Respiratory  Or- 
gans" (Ziemssen's  Cyclopaedia,  Vol.  v,  p.  236). 
In  this  Piorry  is  quoted  as  having  pointed  out  a 
distinct  form  of  disease,  corresponding  in  great 
measure  with  my  own  observations  as  stated  above. 
It  is  best  to  quote  what  Juergenseu  says  (Joe. 
cit.  Sup.):  "Hypostatic  pneumonia,  and  hypo- 
static conditions  of  the  lungs,  were  first  recog- 
nized as  a  distinct  form  of  pulmonary  disease 
through  the  labors  of  the  French  writers.  Pre- 
eminent among  them  is  Piorry,  who  handles  the 
subject  with  great  clearness,  and  whose  teachings 
are  based  upon  a  rich  experience.  He  likewise 
gave  the  disease  its  name."  "  Piorry  proved  by 
experiments  that  a  hypostatic  condition  diagnos- 
ticated during  life,  did  not  alter  its  location  after 
death,  under  the  laws  of  gravitation.  As  Piorry 
made  his  diagnosis  long  before  death,  it  was  evi- 
dent that  this  condition  did  not  result  during  the 
death  struggle.  By  means  of  these  experiments 
hypostasis  ceased  to  be  a  condition  of  but  little  pat k- 
al  significance." 
To  quote  still  from  Juergensen  :  "Does  an 
inflammation  of  the  lung  actually  exist?  Is  the 
term  '  hypostatic  pneumonia  '  correct?  Here  we 
must  agree  with  Piorry,  who  answered  this  ques- 
tion in  the  negative  in  his  nomenclature,  and 
afterwards  still  further  confirmed  this  opinion." 
"  He  calls  this  form  of  c\\sea.se  pneumone/nie  hypo- 
statique,  and  gives  as  a  synonym  cngouement  pul- 
monaire ." 

So  I  am  sustained  by  Piorry,  not  onl}'  as  re- 
gards the  existence  of  a  special  disease,  and  in 
the  ni>n-existence  of  an  inflammation  of  the  lung, 
but  also  in  the  use  of  the  identical  designation, 
engouement  pulmonaire,  which  may  be  equivalent 
to  "engorgement  of  the  lungs." 

Desiring  to  be  brief,  I  will  yet  introduce  the 
following  from  the  paper  cited  above,  and  wThich 
may  be  compared  with  my  own  observations: 
"The  local  symptoms  of  hypostasis  demonstrable 
by  physical  examination  are  the  following:  At 
first  diminished  resonance  on  percussion,  begin- 
ning at  the  lower  angle  of  the  scapula,  and  on 
auscultation  a  lessening,  sometimes  a  cessation, 
of  the  respiratory  murmur,  which  is  vesicular,  or 
may  be  quite  indefinite  in  character.  At  the  point 
of  attack  the  local  fremitus  is  weak.  If  hypo- 
stasis is  complicated  with  a  local  catarrh,  new 
features  foreign  to  the  former  disease  will  appear. 
Mucous  rales,  for  example,  are  usually  absent  in 
simple  hypostasis.  The  dulness  on  percussion 
and  the  auscultatory  signs,  as  a  rule,  extend 
slowly  from  below  upwards.  There  is  a  period  at 
which  absolutely  no  breathing  is  to  be  heard  over 
the  consolidated  portion  (Piorry).     Then  mucous 


i89i.] 


DIGITALIS  IX  PNEUMONIA. 


8n 


rales  gradually  become  audible,  those  in  the 
larger  tubes  appearing  first.  In  ease  of  a  fatal 
termination  extensive  oedema  of  the  lungs  super- 
venes, accompanied  by  auscultatory  signs  pecu- 
liar to  that  condition."  I  have  not  been  able  to 
confirm  this  latter  observation,  never  finding  the 
crepitant  rale,  which  Laennec  taught  us  is  dis- 
tinctive of  cedemas,  as  it  is  of  pneumonia,  and 
the  congested  area  around  a  hemorrhagic  spot, 

Piorry  does  not  mention  the  causes  of  the  con- 
dition he  describes.  In  my  paper  in  the  Amer. 
four,  of  the  Med.  Sciences,  I  described  them  as 
"  the  result  of  neglected  catarrhs,  previously  ex- 
isting bronchitis,  or  pneumonia  in  a  chronic  form, 
and  sometimes  the  engorgement  is  partly  hypo- 
static ;  but  this  term  should  be  reserved  for  post- 
mortem changes,  or  those  occurring  just  before 
death." 

Both  of  us,  therefore,  recognized  and  marked 
out  a  collection  of  symptoms  which  are  often 
found  associated,  but  which  had  not  previously 
been  designated  as  characterizing  a  special  dis- 
eased condition.  This  collection,  in  my  opinion, 
•can  have  no  other  name  than  "engorgement  of 
the  lungs;  "  and  all  such  terms  as  pneumonias, 
hyperaemias,  congestions,  cedemas,  etc.,  must  be 
rejected. 

The  merit  of  Piorry  consists  in  his  freeing  hy- 
postatic processes  from  the  imputation — ancient 
and  deep  grounded  in  all  writings — of  occurring 
just  before  death ;  and  giving  it  its  true  place  as 
a  diseased  condition  of  variable  duration,  to  be 
recognized  during  life. 

If  my  cases  of  engorgement  of  the  lungs  are 
alleged  to  be  only  forms  of  hypostasis,  which  I 
do  not  believe  to  be  true,  I  also  recognized  them 
as  unconnected  with  position,  the  decubitus,  or 
the  death  struggle,  defined  their  ante-  and  post- 
mortem characteristics,  as  existing  and  to  be 
studied  and  treated  long  before  dissolution. 

Auscultation  and  percussion  being  a  true  sci- 
ence, founded  on  variable  physical  and  morbid 
conditions,  there  is  no  obscurity  or  difficulty  about 
the  symptoms  furnished  by  the  disease  we  are  dis- 
cussing. These  symptoms,  as  in  every  other  af- 
fection of  the  chest,  arise  out  of  and  correspond 
necessarily  with  the  internal  morbid  changes 
which  exist,  viz.:  engorgement  of  the  lungs. 


THE  MEDICAL  LAW  OF  ALABAMA. 

The  penalty  bill,  as  it  passed  the  legislature,  provides 
that  any  person  practicing  medicine  or  surgery  in  that 
State  without  having  first  obtained  a  certificate  of  quali- 
fication from  one  of  the  authorized  Boards  of  Medical 
Examiners  of  the  State,  shall  be  guilty  of  a  misdemeanor, 
and  on  conviction  thereof,  shall  be  fined  not  less  than 
twenty-five  dollars  nor  more  than  one  hundred.  Pro- 
vided, that  this  act  shall  not  apply  to  any  doctor  practic- 
ing  medicine  in  Alabama  who  is  a  graduate  of  a  reputa- 
ble medical  college,  and  who  has  complied  with  the  law 
bv  having  his  diploma  recorded  by  the  judge  of  Probate 
in  the  county  in  which  he  is  practicing. 


DIGITALIS  IX  Till-  FIRST  AXD  SECOND 
STAGES  l  >i-   PNEUMONIA. 

SOt  10 

BY  J.  \V.  CARHART.    M.D.,  CM..   D.D., 

[PASAS,   TEXAS. 
MEMBER   OF   AMERICAN   MEDIC  -    STATE 

MEDICAL  ASSOCIATIO  I  KICT     MEDICAL   AS- 

SOCIATION ;   AUTHOR   OF    SINNY    HOVK- 
AND  POETRY  OF  THE  !1  : 

VI    \KS   OS    V.  HEELS,    ETC. 

Ziemsseu  gives  50  per  cent,  of  deaths  from 
pneumonia  following  measles.  He  lost  one- half 
of  his  pneumonia  patients  under  one  year  of  age  ; 
two-fifths  of  those  from  one  to  three  years ;  and 
one-fourth  of  those  above  three.  The  ratio  of 
deaths  from  pneumonia  among  those  of  advanced 
years,  and  enfeebled  by  age  is  even  greater. 
The  disease  prevails  to  an  alarming  extent  in  the 
State  of  Texas,  particularly  at  certain  seasons  of 
the  year ;  and  as  a  consequence,  I  have  been  led 
to  make  somewhat  careful  investigation  into  the 
nature  and  treatment  of  the  disease,  and  the 
cause  of  the  very  large  death  rate  amongst  us. 
which,  I  have  no  doubt,  will  equal  that  reported 
by  Ziemsseu.  Whilst  there  are  many  factors 
that  contribute  largely  to  swell  the  mortality 
record  in  this  disease,  such  as  insufficient  cloth- 
ing, uncomfortable  dweilings,  exposure  in  camp- 
life,  improper  sanitation,  inefficient  nursing. 
bad  habits  as  it  regards  the  use  of  tobacco  and 
alcoholic  stimulants,  the  one  I  have  chosen  for 
discussion  in  this  short  paper  is  not  the  least  of 
them  all.  I  am  persuaded  that  the  use  of  dig- 
italis in  the  first  and  second  stages  of  this  dis- 
ease is  responsible  for  the  death  of  multitudes  in 
my  State,  Texas ;  and  I  hope,  through  this 
means,  to  call  the  attention  of  the  profession  to 
the  subject,  and  thus  save  many  valuable  lives 
and  relieve  much  suffering. 

In  order  to  a  clearer  comprehension  of  our  sub- 
ject, it  will  be  well  for  us,  in  the  first  place,  to 
consider  the  physiological  action  of  the  drug  in 
the  condition  of  health.  Here  we  find,  not  only 
a  variety  but  a  decided  conflict  of  opinion  among 
writers  :  a  conflict  which  is  unfortunate,  not  to 
say  unjustifiable.  There  are  many  established 
facts,  however,  upon  which  most,  if  not  all, 
writers  are  agreed. 

"  Fish  placed  in  a  weak  infusion  of  the  plant 
die  in  spasms,  with  the  ventricle  of  the  heart 
contracted.  Digitalin  used  hypodermically  in 
frogs  occasions  a  tetanoid  rigidity  of  the  muscles 
and  an  irregular,  tonic  contraction  of  the  left 
ventricle  of  the  heart,  with  slowness  and  un- 
steadiness of  its  rhythm.  The  auricle  does  not 
seem  to  participate  in  this  action  of  the  ventricle, 
but  becomes  distended  as  the  capacity  of  the 
ventricle  diminishes.  At  the  same  time,  the 
pulse  rate  declines  and  the  blood-pressure  in- 
creases  Experimental    investigation    has 

demonstrated  that  large  doses  of  digitalin  pro- 


DIGITALIS  IN  PNEUMONIA. 


[June  6, 


duce  marked  contraction  and  even  a  complete 
closure  of  the  capillary  vessels,  a  condition  which 
necessarily  involves  an  increased  blood- pressure 

in   the  larger  arteries The  auricle  does 

not  participate  in  the  contraction  affecting  the 
ventricle,  but  becomes  distended  by  the  accumu- 
lated blood Digitalis  is  held  to  act  on 

the  vaso-motor  centre,  and  thus  to  produce  con- 
traction of  the  peripheral  arterioles." 

In  small  doses,  digitalis  and  its  preparations 
primarily  increase  pulse-rate  and  tension,  and  if 
continued  will  lower  the  pulse-rate  without  di- 
minishing the  tension.  The  supply  of  arterial 
blood  is  everywhere  diminished  under  the  influ- 
ence of  the  drug,  owing  to  the  tonic  contraction 
of  both  the  left  ventricle  and  of  the  arteries 
themselves. 

All  the  heart-muscles  are  not  subject  to  con- 
traction in  an  equal  degree,  under  the  influence 
of  digitalis,  but  chiefly  those  of  the  left  ventri- 
cle. It  thus  tends  to  obstruct  cardiac  circulation; 
and  by  preventing  free  passage  of  blood  through 
the  heart  tends  to  produce  death  from  syncope. 

It  certainly  depresses  the  entire  nervous  system, 
if  administered  in  sufficient  doses  to  produce  any- 
thing like  its  physiological  action  ;  impairs  di- 
gestion, diminishes  urination,  retards  respiration 
and  interferes  with  the  nutrition  of  the  heart 
itself. 

Digitalis  as  an  antipyretic  is  valueless.  If  any 
antipyretic  effects  should  be  produced  it  would 
be  accompanied  by  disquieting  results,  and  a 
tendency  to  heart  paralysis. 

The  result  of  various  experiments  proves  that 
digitalis  does  not  in  the  least  modify  favorably 
any  acute  inflammation,  and  especially  pneu- 
monia, pleurisy  and  pericarditis  ;  but  that,  on 
the  contrary,  it  exposes  the  patient  to  the  risk  of 
sudden  death. 

It  is  now  in  order  for  us  to  get  as  clear  an  idea 
as  possible  of  the  pathological  conditions  in 
pneumonia  that  we  may  understand  the  effects 
of  digitalis  in  the  first  and  second  stages. 

It  will  not  be  necessary,  for  our  present  pur- 
pose, to  discuss  the  fine  distinctions  that  arc 
made  in  this  disease,  such  as  bronchial  pneu- 
monia, catarrhal  pneumonia,  and  lobular  pneu- 
monia. 

The  term  broncho-pneumonia  will  sufficiently 
indicate  the  form  adapted  to  our  purpose  in  this 
discussion. 

The  lungs  are  made  up  of  bronchi,  air-passages, 
alveoli,  pulmonary  pleura:,  and  connective  tissue 
stroma,  containing  blood-vessels,  lymphatics  and 
nerves. 

In  pneumonia,  of  the  type  under  consideration, 
the  common  course  is  for  the  inflammatory   in 
vasion  to  proceed  from  the  larger  to  the  smaller 
air  tubes,  thence  to  advance  into  the  fin 

pillary  bronchi,  whence  it  communicates 
the  inflammation  to  the  terminal  air  passages, 
and  alveoli. 


This  process  of  invasion  may  be  almost  simul- 
taneous and  rapid  ;  or  it  may  take  several  days 
or  weeks. 

The  result,  sooner  or  later,  is  the  involvement 
of  the  bronchi  and  more  or  less  lobules  of  pul- 
monary hepatization  and  possibly  atelectasis. 

I  am  aware  that  from  a  strictly  pathological 
standpoint  we  may  not  speak  of  the  three  stages 
of  the  disease  as  the  stage  of  inflammation  and 
engorgement,  the  stage  of  infiltration  and  red 
hepatization,  as  the  result  of  engorgement ;  and 
the  final  or  third  stage  of  resolution,  in  favorable 
cases  ;  or  that  of  gray  hepatization  and  possibly 
atelectasis  premonitory  of  dissolution  ;  and  yet, 
clinically,  this  division  would  seem  to  be  correct, 
and  to  be  very  serviceable. 

In  order  to  a  fuller  understanding  of  our  sub- 
ject, let  us  consider  the  condition  and  function 
of  the  lungs  in  the  first  and  second  stages  of  the 
disease  ;  and  the  resultant  effect  upon  the  circula- 
tory apparatus. 

In  the  early  stages  the  bronchi  contain  more 
morbid  secretions  in  the  form  of  clear  viscid 
mucus,  whilst  in  subsequent  stages  they  are  filled 
with  creamy  pus.  There  are  sometimes  found 
subpleural  accumulations  of  somewhat  inspicated, 
yellow  secretions,  contained  in  dilated  alveoli,  or 
in  small  globular  dilatations  of  terminal  bronchi- 
oles. They  are  probably  caused  by  the  secretion 
of  particles  of  bronchial  secretions  into  the 
alveoli  in  the  forcible  inspiratory  effects  which 
follow  paroxysms  of  cough. 

"The  lung  itself,"  says  Pepper,  "exhibits,  as- 
sociated in  varying  degrees,  congestion,  oedema, 
emphysema,  collapse,  and  pneumonic  consolida- 
tion." 

Juergensen  showed,  twenty  years  ago,  that 
there  was  stagnation  in  the  lungs  rather  than  an 
active  hyperemia,  which  results  in  the  weaken- 
ing of  the  heart  He  also  showed  that  the  lung 
consolidation  not  only  presented  more  or  less  ob- 
struction to  the  pulmonary  circulation,  and  hence 
necessitated  increased  action  on  the  part  of  the 
right  ventricle  ;  but  owing  to  the  diminished 
respirator}'  surface,  this  ventricle  is  obliged  to  do 
more  work  in  order  that  the  proper  interchanges 
of  gases  may  be  effected  in  the  lungs. 

It  is  important  for  us  now  to  consider  the  effect 
of  the  above  conditions  of  the  lungs  on  the  heart 
and  circulation  and  we  shall  then  be  prepared  to 
study  the  effects  of  digitalis  in  these  cases. 

It  matters  but  little,  so  far  as  our  present  pur- 
pose is  concerned,  whether  pneumonia  be  consid- 
ered a  systemic  disease,  with  local  manifestations 
in  the  lungs,  or  whether  it  be  regarded  as  pri- 
marily affecting  the  lungs  with  systemic  conse- 
quences. 

We  find  as  a  clinical  and  pathological  fact,  the 

lungs  engorged,  swollen  and  hot,  whatever  may 

be  the  etiology;  with  blood  stains;  followed   by 

infiltration,    and   a  consequent 


I89i.] 


DIGITALIS  IN  PNEUMONIA. 


813 


bstru  ction  of  circulation  in   the  fine  network  of 
apill  aries. 

result  of  this  condition  of  things  we  find 
a  lack  of  aeration  of  the  blood  with  consequent 
carbonic  acid  poisoning  of  the  whole  system. 

In  consequence  of  tlie  obstruction  to  the  pas- 
sage of  blood  through  the  lungs  the  pulmonary 
-  inadequately  supplied  even  with  a  par- 
tially aerated  blood  stream.  The  blood  coming 
to  the  left  auricle  and  ventricle  is  hot  in  conse- 
quence of  the  extraordinary  heat  in  the  lungs. 
This  hot,  partially  aerated  blood  stream  stimu- 
lates the  heart  to  greater  activity,  whilst  its 
nourishment,  furnished  through  the  corrinary 
arteries,  is  inadequate  to  its  overworked  condi- 
tion. 

"The  longer  this  condition  exists  the  more 
rapidly  the  heart  will  be  overworked.  As  the  ir- 
ritability of  the  excito-motor  ganglia  and  the  tone 
of  the  vagus  also  reduced  by  the  defective  oxygen 
supply." 

Owing  to  the  back  pressure,  so  to  speak,  upon 
the  venous  blood  stream,  from  the  right  heart, 
caused  by  the  blood  stasis  in  the  lungs,  we  have 
extreme  venous  tension,  and  intense  strain  upon 
the  right  heart. 

In  the  onset  of  the  disease  we  have  a  contract- 
ed condition  of  the  capillaries,  particularly  of  the 
periphery  of  the  body,  which  adds  to  the  venous 
tension. 

We  now  have  labored  respiration,  owing  to 
Nature's  effort  to  compensate  for  the  restricted 
active  lung  area;  we  have  a  diminished,  and  in- 
tenseh-  inadequately  aerated  blood  stream  from 
the  lungs,  through  the  pulmonary  vein  to  the 
left  heart — we  have  a  heart  stimulated  to  fright- 
ful tension,  in  most  cases,  by  the  overheated 
blood,  and  inadequately  nourished  by  viciated 
blood  through  the  corrinary  arteries — we  have 
an  inadequate,  deteriorated  arterial  supply,  with 
capillan'  and  venous  engorgement. 

With  this  condition  of  things  we  are  told  to 
give  digitalis  to  relieve  the  dyspnoea  and 
strengthen  the  heart. 

Dr.  A.  L.  Loomis,  writing  on  croupous  pneu- 
monia, in  Pepper's  system  of  medicine,  Vol.  3,  pp. 
346,  347  says:  "  A  careful  study  of  the  pathology 
of  pneumonia  not  only  leads  one  to  the  convic- 
tion that  venesection  must  do  harm,  but  it  strong- 
ly contra-indicates  the  employment  of  all  those 
remedial  agents  which  have  been  used  to  arrest  a 
simple  pulmonary  inflammation." 

He  further  says,  "Yeratria  is  claimed  to  be  a 
cardiac  depressant:  and  this  fact  should  make  us 
hesitate  before  we  administer  it  in  pneumonia. 
It  acts  promptly  in  slowing  the  pulse  but  its  ef- 
fects are  only  temporary,  and  when  used  for  a 
couple  of  days  the  large  doses  that  are  necessary 
to  bring  about  the  desired  results  interfere  with 
the  nutrition  of  the  patient,  often  causing  vomit- 
ing and  diarrhoea.     Aconite  is  also  a  cardiac  sed- 


ative, but  my  experience  with  it  has  convinced 
me  that  it  is,  in  all  respects,  inferior  to  veratria. 
Digitalis,  which  may  be  regarded  as  a  cardiac 
stimulant,  is  to  be  preferred  to  either  veratria  or 
aconite.  It  not  only  lowers  temperature,  but  les- 
sens the  frequency  of  the  pulse,  steadies  it.  and 
produces,  in  the  majority  of  cases,  its  well  kr. 
tonic  action  upon  the  heart. 

use  in  children  is  sometimes  followed  by  an 
intermittent  pulse,  but  it  is  a  symptom  of  no  dan- 
gerous import." 

Barring  the  cases  of  pneumonia  in  children,  in 
anaemic  and  in  aged  persons,  I  would,  with  all 
respect  for  Dr.  Loomis,  ask  him  why  not  practice 
venesection  in  extreme  venous  tension  in  the 
stage  of  engorgement  ?  We  are  certain  that  the 
procedure  discreetly  used,  has  saved  many  valu- 
able lives,  and  if  practiced  in  New  York  City 
would  reduce  the  fearful  death-rate  there  from 
this  increasing  disease. 

I  will  now  quote  an  authority  of  equal  eminence 
with  Dr.  Loomis,  in  reply  to  his  theory  that  med- 
ical agents  should  not  be  used  to  lower  the  tem- 
perature in  this  disease;  and  against  his  advo- 
cacy of  the  use  of  digitalis. 

This  authority  says,  speaking  upon  the  very 
same  subject,  croupous  pneumonia,  "In  all  se- 
vere types  of  croupous  pneumonia  there  are  two 
prominent  sources  of  danger ;  heart-insufficiency 
and  high  temperature.  There  are,  consequently, 
two  prominent  indications  for  treatment,  viz.:  to 
sustain  the  heart  and  reduce  the  temperature." 
The  same  authority  further  says,  "Digitalis  of 
late  years  has  been  extensively  used  to  counter- 
act heart  insufficiency,  but  it  is  very  uncertain  in 
its  action  in  the  heart-insufficiency  of  pneumonia, 
and  has  seemed  to  me  more  frequently  to  do  harm 
than  good.  The  nervous  element  of  the  heart 
failure  contra-indicates  its  use." 

You  may  be  curious  to  know  who  my  authori- 
ty is,  so  plainly  and  positively,  and,  as  I  think, 
unanswerably  contradicting  Dr.  Loomis:  and  I 
11  you  that  it  is  Dr.  Loomis  himself,  writ- 
ing subsequently  to  the  first  quotation  I  have 
made  from  him. 

We  are  told  that  digitalis  reduces  temperature. 
is  a  heartstimulant,  slows  and  steadies  the  heart's 
action  in  pneumonia  and  relieves  dyspnoea,  and 
consequently  should  be  use'd,  even  in  the  first  and 
second  stages  of  this  disease. 

It  is  yet  to  be  proven  that  it  lowers  temperature 
under  any  circumstances,  except  where  it  kills. 
It  also  remains  to  be  proven  that  it  slov 
steadies  the  heart's  action  in  the  first  and  second 
stages  of  the  disease,  and  that  it  relieves 
!  dyspnoea. 

On  the  other  hand,  I  affirm,  and  on  the 
ity  of  eminent  observers  coupled  with  my  own 
experience,  that  in  mbst  cases  in  the  first  and  sec- 
ond stages  it  increases  dyspncea.   stimulates  an 
already  over-stimulated  heart,  renders  the  pulse 


H4 


FATTY  URINE. 


[June  6, 


unsteady  and  intermittent,  as  Dr.  Loomis  has 
said,  tends  to  produce  heart-paralysis,  contracts 
the  capillaries  and  thus  adds  to  the  blood  stasis 
in  the  lungs  with  increased  venous  tension  and 
all  its  consequent  train  of  evils.  If  pushed  in  the 
conditions  to  which  I  have  referred  it  will  almost 
inevitably  produce  death. 

Yeratria,  with  morphia  and  atropia,  until  the 
third  stage  commences,  in  most  cases,  slows  the 
heart's  action  without  depression;  dilates  the 
capillaries,  thus  relieving  the  venous  tension  and 
the  right  heart — relieves  dyspnoea — conserves 
the  vital  forces — reduces  temperature  and  lessens 
the  inflammatory  process. 

If  there  is  dicrotic  pulse,  and  especially  from 
the  use  of  digitalis,  veratria,  morphia  and  atropia 
will  relieve,  as  I  have  witnessed  in  multitudes  of 
cases. 

They  should  neither  be  pushed  to  their  un- 
pleasant consequences,  since  the  desired  results 
can  usually  be  obtained  without. 


THE  REPORT   OF   A    CASE   OF  FATTY 
URINE    ACCOMPANYING    AN    AB- 
SCESS   IN    THE    RIGHT    ILIAC 
FOSSA— RECOVERY. 

lion  of  Practice  of  Medicine  and  Physiol 
Forty-second  Annual  Meeting  of  the  American  Medical  Associa- 
tion, held  at  Washington,  D.  C.  May,  lSc,i. 

BY  J.  P.  CONNELLY,   M.D., 

OF  WILLIAMSPORT,  PA. 

Mrs.  W.,  colored,  aged  27,  born  in  Pennsylva- 
nia, and  never  resided  outside  the  borders  of  the 
State.  Gave  birth  to  a  living  child  at  16;  has 
never  been  pregnant  since.  Had  good  health  for 
the  first  five  years  following  the  birth  of  her  child. 
During  the  last  six  years,  has  had  irregular  chills 
followed  by  fever  lasting  from  two  to  five  days. 
No  disturbance  of  the  menstrual  functions.  Bow- 
els have  always  been  regular,  and  she  never  had 
pain  in  the  region  of  the  caecum.  On  Thursday, 
January  9,  1890,  she  was  taken  with  headache 
and  backache,  and  then  a  severe  rigor  followed 
by  high  fever.  I  saw  her  on  Saturday,  January 
11.  She  had  then  temperature  1040,  pulse  120, 
a  heavy  white  coat  on  tongue,  and  in  addition  to 
the  general  symptoms  accompanying  fever,  com- 
plained of  a  pain  in  the  right  iliac  region,  where 
a  deeply  seated  tumor,  giving  an  obscure  sense  of 
fluctuation,  could  be  felt.  It  was  about  the  size 
of  a  croquet  ball,  slightly  ovoidal  in  shape,  and 
dipped  down  into  the  pelvis,  displacing  the  ute- 
rus to  the  left. 

She  stated  that  since  Tuesday,  January  7.  two 
days  before  the  rigor,  she  had  noticed  fat  in  her 
urine,  and  showed  me  some  which  contained 
large  broken  pieces  resembling  tallow. 

To  avoid  a  possible  error,  the  patient  was  re- 
quested to  pass  urine  in  my  presence,  which  was 


done.  Floating  upon  the  surface  of  the  warm 
urine,  could  be  seen  large  quantities  of  fat,  re- 
sembling castor  or  olive  oil.  It  rapidly  solidified 
upon  cooling,  to  the  consistency  of  beef  tallow, 
and  was  of  a  yellowish  white  color. 

The  amount  of  urine  passed  in  twenty  four 
hours- was  24  fluid  ozs.  In  this  the  fat,  when 
collected  and  warmed,  measured  4^  fluid  ozs., 
aud  weighed,  when  moulded  into  a  cake,  3*2  ozs. 
avoirdupois. 

The  urine  was  clear,  without  sediment,  color 
amber,  reaction  acid,  specific  gravity  1020.  No 
albumen,  tests  used  were  heat  and  nitric  acid  and 
Heller's  test.     No  sugar. 

Fat  was  passed  in  about  the  same  quantity  for 
eight  days,  when  a  large  amount  of  pus  was  sud- 
denly discharged  with  the  urine.  The  fat  then 
immediately  and  entirely  disappeared. 

Pus  was  passed  in  gradually  diminishing  amounts 
for  about  three  months. 

The  patient  slowly  improved  and  in  about  five 
months  was  apparently  restored  to  health,  and 
has  remained  so  to  the  present. 

No  cod-liver  or  other  oil  had  been  taken  before 
or  during  this  period. 

The  blood  was  frequently  examined  for  falaria, 
but  always  with  negative  results. 

So  far  as  m}'  knowledge  goes  the  case  is  unique, 
in  the  amount  of  fat  passed,  the  time  at  which  it 
was  passed,  and  in  the  subsequent  recover}-  of 
the  patient. 

In  the  previously  recorded  cases,  the  fat  seems 
to  have  been  passed  in  small  amounts,  except  iu 
the  cases  of  Dr.  Johnson  and  of  Dr.  Cushing. 
Dr.  Geo.  W.  Johnson's  case  was  one  of  calcare- 
ous disease  of  the  pancreas,  published  in  the 
American  Journal  of  the  Medical  Sciences,  Octo- 
ber, 1883,  p.  427,  where  the  fat  is  said  to  have 
passed  in  such  quantities  as  to  "  float  when  cool 
in  greasy  flakes  on  the  surface.'.' 

Dr.  E.  W.  Cushing  published  in  the  Boston 
Medical  and  Surgical  Journal,  February,  18S1,  p. 
242,  the  report  of  a  case  of  abscess  in  the  left 
iliac  region,  in  which,  several  days  after  the  ap- 
pearance of  foul  pus  in  the  urine,  "at  the  end 
of  catheterization  pure,  clear  oil  ran  out,  iu  vol- 
ume about  one-fifteenth  of  the  urine."  This  con- 
tinued, with  occasional  intermissions,  for  three 
days.  One  week  after  its  first  appearance,  death 
ensued.  "  On  opening  the  abdomen  a  large,  foul 
collection  of  pus,  containing  an  abundance  of  pure 
oil  and  large  strings  and  pieces  of  sloughing  fat, 
was  encountered  in  the  left  abdominal  and  iliac 
region.  Near  the  exit  of  the  left  ureter  was  a 
small  openiug  communicating  with  the  abscess." 

My  patient,  unlike  Dr.  Cushing's,  passed  the 
fat  not  during  but  before  the  appearance  of  pus, 
and  it  seems  impossible  for  it  to  have  been  due, 
as  in  his  case,  to  sloughing  adipose  tis--' 
cause  during  the  passage  of  the  fat,  there  was  ab- 
solutely no  trace  of  albumen  or  pus  iu  the  urine. 


i89i.] 


THE  OPTICIAN  AND  OPHTHALMOLOGY. 


8i5 


While  unable  to  explain  the  phenomenon,  it 
seems  to  us  to  have  been  a  pressure  symptom,  as 
it  occurred  only  the  last  week  prior  to  the  open- 
ing of  the  abscess,  and  ceased  when  the  pressure 
was  relieved. 

Neither  are  the  conclusions  of  Dr.  dishing 
borne  out  "that  such  cases  are  sure  to  terminate 
fatally,  unless  by  opening  and  counter- opening,  a 
free  drainage  and  disinfection  can  be  carried  out." 


THE  OPTICIAN  AND  OPHTHALMOLOGY. 
BY   GEORGE  M.  GOULD,  M.D., 


The  paragraph  by  Mr.  Henry  A.  Riley,  in  The 
Journal  of  May  2,  entitled  Cosmetics  and  Spcda 
cles  in  Court,  is  one  of  a  thousand  illustrations 
constantly  reappearing  with  sorry  monotony,  of 
the  fact  that  when  a  layman  tries  to  say  anything 
about  medicine,  he,  with  the  most  delicious  un- 
consciousness, takes  the  side  of  ignorance  and 
untruth,  makes  a  mess  of  what  he  tries  to  say, 
and  if  his  words  have  any  weight  he  injures  the 
cause  of  scientific  medicine.  It  is  a  strange  fa- 
tality akin  to  that  of  the  success  of  the  patent 
medicine  man,  and  the  enthusiastic  acceptance  by 
otherwise  intelligent  men  of  the  impudent  non- 
sense of  homoeopathy,  faith  cure,  etc.  Mr.  Ri- 
lev's  words  are  few,  but  as  representative  of  the 
half-formed  opinion  of  perhaps  many  others,  they 
should  have  been  excluded  from  the  pages  of  a 
journal  caring  for  scientific  medical  progress,  and 
hence  require  a  dozen  words  of  contradiction. 

The  first  sentence  is  true,  but  not  as  supposed 
by  the  gentleman.  The  optician  does  "hold  a 
doubtful  position  in  regard  to  the  practice  of 
medicine,"  and  it  is  because  homoeopathy  holds 
such  a  position,  and  because  supposedly  intelli- 
gent people  encourage  the  continuance  of  this 
doubtful  position,  go  to  an  optician  who  knows 
nothing  about  this  work  for  correction  of  optical 
defects  of  the  eye,  instead  of  going  to  one  who 
with  the  study  of  a  lifetime  can  learn  but  a  small 
part  of  the  desirable  knowledge  on  the  subject. 
The  "doubtful  position"  should  be  ended  at 
once  by  the  enaction  of  laws  on  the  "narrow, 
technical  theory  "  that  your  correspondent  tells 
us  the  French  courts  have  found  right.  Until 
that  is  done  opticians  will  go  on  ruining  eyes  and 
health,  as  all  oculists  have  bitter  experience  al- 
most daily  in  trying  to  undo  and  correct  the  in- 
jury done  their  patients  who  have  first  passed 
through  the  hands  of  the  optician. 

If  he  furnishes  a  customer  glasses  to  cure  errors 
in  sight — if  he  investigates  the  troubles  of  the  eye, 
if  he  determines  the  errors  in  refraction  and  if  he 
prescribes  a  combination  of  lenses  such  as  -will  rem- 
edy the  affection,  etc.  The  gentleman  evidently 
never  heard  of  the  Teutonic  maiden  who,  while 


drawing  beer,  fell  into  a  delightful  revery,  imag- 
ining all  the  years  of  splendor  and  happiness  that 
would  follow  if  she  should  marry  the  Prince.  In 
the  meantime  the  beer  filied  the  pitcher  and  ran 
all  over  the  floor. 

The  trouble  all  lies  in  the  if.  In  order  to  be 
perfectly  safe,  and  also  to  have  a  loophole  to 
crawl  out  of  if  some  ignoramus  with  fiery  eyes 
avers  that  //;•  can  do  it,  I  will  say  that  there  is 
but  one  optician  fn  the  United  States  who  can 
"give  a  customer  glasses  to  cure  errors  in  - 
or  who  is  competent  to  "  determine  errors  of  re- 
fraction and  prescribe  a  combination  of  lenses 
such  as  will  remedy  the  affection."  There  is 
only  one  optician  who  can  do  this ;  the  other  ten 
thousand  cannot  do  it. 

The  limit  of  the  ridiculous  is  finally  reached 
in  the  very  amusing  supposition  that  "  the  opti- 
cian may  be  a  physiologist. ' '  This  bit  of  fustian 
spoken  before  a  convention  of  opticians  would 
certainly  be  considered  the  joke  of  the  day.  It 
is  too  absurd  to  answer.  If  we  seek  the  funda- 
mental reasons  for  the  delusion  into  which  such 
logicians  as  your  correspondent  fall,  we  find  them 
somewhat  as  follows : 

1.  A  complete  misconception  on  the  part  of 
the  general  public,  and  too  often  on  the  part  of 
some  general  physicians,  as  to  the  role  of  eve- 
strain  in  our  modern  life.  Without  a  medical 
education  (and  with  it  the  optician  would  neces- 
sarily cease  to  be  an  optician),  the  spectacle-ven- 
dor cannot  know  anything  of  the  pathological 
relations  to  the  eye  and  the  general  system.  The 
eye,  it  is  true,  is"  a  camera  obscura,  but  it  is  a 
living,  not  a  dead  or  mechanical,  one.  Every- 
pair  of  lenses  worn  by  every  person  in  the  world 
has  a  medical  and  pathological  significance.  This, 
to  be  sure,  seems  to  the  laity  an  outrageous  exag- 
geration, but  it  is  la  zraie  lerite. 

2.  The  same  medisevalism  of  logic  would  deny 
the  medical  profession  a  locus  standi  or  justifica- 
tion of  existence.  If  the  optician  can  do  all  it  is 
said  he  may  do,  then  the  doctor  should  hand  his 
diploma  to  the  pharmacist  and  go  out  of  business; 
because  the  druggist,  as  a  general  rule,  is  far  and 
away  more  competent  to  prescribe  the  proper 
drugs  in  a  case  of  disease  than  the  optician  is  to 
prescribe  the  proper  glasses.  That  may  also  seem 
an  exaggerated  statement,  and  again  it  is  very 
truth. 

3.  It  is  a  sneaking,  ill  concealed  belief  on  the 
part  of  many  that  this  opposition  on  the  part  of 
"allopaths,"  "  the  old  school,"  "  the  blue- mass 
old  fogies,"  to  quackery  of  all  forms,  to  adver- 
tisers, to  prescribing  druggists  and  prescribing 
opticians,  is  a  matter  of  low  cunning,  self-inter- 
est and  envy.  Those  who  secretly  harbor  such 
thoughts  or  feelings  simply  illustrate  their  ina- 
bility to  perceive  facts  correctly.  They  are  vic- 
tims of  their  own  vanity. 

4.  If  to  opticians  is  to  be  given  the  function  of 


8i6 


AMERICAN  MEDICAL  TEMPERANCE  ASSOCIATION. 


[June  6, 


prescribing  for  refractive  errors,  the  law  should 
require  of  them,  as  it  does  of  druggists,  an  edu- 
cation in  their  calling,  a  diploma  that  they  are 
opticians,  if  not  "  physiologists,"  "pathologists," 
etc.  Viewing  the  eye  simply  as  a  dead  camera 
obscura,  as  having  no  other  laws  than  optic  laws, 
I  have  never  seen  a  pair  of  glasses  prescribed  b}' 
an  optician  that  were  correct.  I  have  had  hun- 
dreds of  suffering  patients  abused  by  the  opti- 
cian's supposed  ability  to  prescribe,  and  never 
ingle  pair  of  lenses  correct  optically  speak- 
ing. They  did  not  neutralize  the  patient's  optical 
error.  There  is  one  optician,  of  course,  who 
never  makes  these  mistakes.  As  a  matter  of 
fact,  with  the  one  exception,  opticians  enter  their 
calling  either  from  the  jewelry  business  or  from 
the  work-bench  of  the  spectacle-maker  and  lens- 
grinder.  Neither  one  of  these  callings,  honorable 
enough  indeed  in  themselves,  necessarily  imply 
an  education  in  the  laws  of  optics  or  the  physi- 
ology and  pathology  of  the  eye. 

5.  Not  only  do  all  errors  of  refraction  have 
medical  and  pathological  significance,  but  if  the 
optician  is  to  treat  all  errors  of  refraction,  he  must 
perforce  be  a  physician  ;  because  many  diseases, 
most  serious  and  dangerous  ones  too,  can  only  be 
recognized  by  a  physician,  are  not  recognized  by 
the  patient  as  other  than  a  call  for  spectacles,  and 
could  not  be  recognized  by  the  optician.  Every 
oculist  has  had  instances  of  glaucomatous  patients 
going  to  the  optician  for  spectacles.  As  the  dis- 
ease progresses  changes  in  the  spectacles  must 
frequently  be  made,  until  finally  blindness  is  the 
walking  monument  of  the  non-existence  of  the 
' '  narrow  technical  theory  ' '  of  the  French  courts, 
and  the  dominance  of  the  "broader  principle  of 
legal  construction ' '  your  correspondent  hopes  will 
have  sway  heje.     Gott  bewahr! 

It  seems  doubly  strange  to  hear  an  intelligent 
gentleman  arguing  in  this  way  iu  the  face  of  the 
fact  that  the  best  opticians  are  ashamed  of  the 
hypocrisy  and  the  wrong  they  are  forced  to  do  by 
the  competition  of  unprincipled  spectacle- vendors. 
An  optician  of  any  intelligence  and  honesty  knows 
he  does  wrong  in  prescribing  glasses.  Even  the 
worst  of  them  are  vaguely  conscious  of  the  fact. 
The  better  class  will  not  prescribe  except  in  cases 
of  presbyopia,  and  even  then  free  their  consciences 
by  advice  to  go  to  the  ophthalmologist  instead. 
The  very  highest  class  of  opticians,  men  of  con-  j 
science  and  intellect,  will  never  sell  a  pair  of  spec- 
tacles except  upon  a  physician's  prescription.  In 
this  direction  lies  the  elevation  of  the  optician's 
profession,  scientific  and  humane  progress;  in  the 
way  counseled  by  your  correspondent  lies  the  de- 
gradation of  the  optician's  profession,  and  a  return 
to  mediaevalism  in  medicine. 


AMERICAN  MEDICAL  TEMPERANCE 

ASSOCIATION. 

BY  T.  D.  CROTHERS,  M.D., 

HARTFORD,  CONX. 


This  Association  was  organized  at  Washington, 
May  7,  1S91,  in  pursuance  to  call  by  Dr.  N.  S. 
Davis,  of  Chicago,  111.,  inviting  all  persons  inter- 
ested to  meet  and  confer  on  the  need  of  such  an 
association.  Sixty-one  physicians  were  enrolled  as 
original  members,  and  a  constitution  and  by-laws 
adopted,  a  board  of  officers  elected,  and  thus  a 
new  medical  organization  was  auspiciously  startea. 

The  purpose  and  object  of  this  new  society  is 
outlined  in  the  following  statement  offered  by 
Dr.  Davis: 

"The  object  of  this  Association  is  to  advance 
the  practice  of  total  abstinence  in  and  through 
the  medical  profession,  and  to  promote  investiga- 
tion as  to  the  action  of  alcohol  iu  health  and  dis- 
ease, and  it  aims  at  being  a  bond  of  union  among 
medical  abstainers  scattered  all  over  our  country. 
It  admits  as  members  regular  medical  practi- 
tioners who  are  practical  abstainers  from  all  alco- 
holic liquors  as  beverages.  Members  are  not  re- 
quired to  sign  any  pledge,  but  if  such  for  an}'  rea- 
son cease  to  become  total  abstainers  it  is  expected 
that  they  will  withdraw  from  the  Association. 
The  liberty  of  members  to  prescribe  alcohol  is  en- 
tirely uncontrolled." 

From  this  it  will  be  apparent  that  the  central 
purpose  of  this  society  is  to  study  and  investigate 
the  action  of  alcohol  as  both  a  beverage  and  med- 
icine. The  only  qualification  required  is  to  be  a 
regular  medical  practitioner,  and  total  abstainer 
from  alcohol  as  a  beverage.  It  will  be  apparent 
that  the  last  qualification  is  more  or  less  a  scien- 
tific necessity  for  good  work  in  this  field.  It  is 
assumed  rightly,  that  all  physicians  interested  in 
this  problem  of  alcohol  should  approach  it  from 
J  the  scientific  side  alone,  unbiased  by  any  personal 
considerations  of  custom  or  habit,  political  or 
religious  belief,  with  no  object  other  than  to  as- 
certain the  facts  concerning  alcohol,  irrespective 
of  all  possible  conclusions.  This  is  the  spirit 
and  purpose  of  the  Association. 

In  England  a  similar  association  composed  of 
members  of  the  British  Medical  Society  has  been 
in  existence  many  years.  Their  regular  meeting 
occurs  at  the  same  time  with  the  British  Medical 
Association,  and  the  value  and  usefulness  of  their 
work  is  recognized  in  all  scientific  circles.  In  this 
country  a  society  called  the  Association  for  the 
Study  and  Cure  of  Inebriety  has  been  in  exist- 
ence for  twenty  years.  It  is  composed  largely  of 
specialists  and  persons  engaged  in  treating  inebri- 
ety as  a  disease.  While  it  has  done  grand 
work,  and  built  up  a  very  suggestive  literature 
through  its  Journal  of  Inebriety,  it  has  not  taken 
up  the  popular  medical  discussion  of  alcohol, 
which  this  new  society   proposes  to  do.     These 


i89i.] 


MEDICAL  PROGRESS. 


817 


two  societies  will  lie  closely  allied  in  both  work 
and  purpose.  Oik-  will  have  for  its  object  the 
grouping  and  harmonizing  the  diverse  theories  of 
physicians  concerning  alcohol  and  its  action,  and 
the  other  the  study  of  the  inebriate  and  his  mala- 
dies. 

The  Medical  Temperance  Association  in  the 
former  work  will  be  most  heartily  welcomed  by 
all  scientific  men.  The  alcoholic  problem  has 
reached  such  proportions,  and  has  become  a  sub- 
ject of  such  intense  interest  in  all  political,  social, 
and  religious  circles  as  to  demand  scientific  study. 

Medical  men  in  every  community  are  called 
upon  to  determine  the  facts  concerning  alcohol, 
and  the  necessity  for  medical  study  and  agree- 
ment concerning  the  general  truths  are  apparent 
to  every  one.  For  this  purpose  the  Medical  Tem- 
perance Association  invite  the  cooperation  and 
aid  of  every  physician,  not  for  the  propagation  of 
any  theory,  but  for  the  gathering  and  grouping 
of  facts  concerning  the  action  of  alcohol. 

The  Association  is  entirely  independent  of  any 
other  object  except  the  purely  scientific  question 
of  alcohol.  The  Executive  Committee  has 
power  to  hold  meetings  in  any  part  of  the  country 
•where  the  medical  interest  seems  to  demand  it. 
The  regular  annual  meeting  will  be  held  at  the 
same  place  and  time  of  the  American  Medical 
Association.  Papers  and  discussions  will  be  pre- 
sented at  this  time.  While  this  Association  is 
the  culmination  of  an  idea  long  entertained  by 
Dr.  Davis,  and  held  until  medical  sentiment 
would  fully  sustain  it,  it  is  apparent  that  it  is  an 
expression  of  medical  advance,  of  the  scientific 
spirit  of  the  times,  that  would  rise  above  the 
theories  and  precedents  of  the  past  for  the  facts 
concerning  alcohol. 

This  Association  appeals  to  every  physician, 
not  as  propagandists,  but  as  scientists,  for  facts 
and  clinical  experience.  It  appeals  to  them  as 
the  only  competent  authority  to  determine  the 
alcoholic  problem.  It  appeals  to  the  physician 
to  guide  and  direct  public  sentiment,  and  to 
make  this  Association  the  great  central  power  for 
the  study  and  propagation  of  the  facts  and  laws 
relating  to  alcohol,  and  its  use  and  abuse. 

The  following  are  the  officers  elected  for  the 
first  year: 

N.  S.  Davis,  M.D.,  President,  Chicago,  111. 

For  Vice-Presidents,  I.  N.  Quimby,  M.D.,  Jer- 
sev  City,  N.  J.;  J.  B.  Whiting,  M.D.,  Janesville, 
Wis.;  F.  E.  Yoakum,  M.D.,  Shreveport,  La.: 
J.  Taft,  M.D.,  Cincinnati,  Ohio. 

Secretary,  T.  D.  Crothers.  M.D.,  Hartford, 
Conn. 

Treasurer,  G.  W.  Webster,  M.D.,  Chicago,  111. 

For  by-laws  and  constitution,  and  application 
for  membership,  address  the  Secretary,  at  Hart- 
ford, Conn. 


MEDICAL   PROGRESS. 


On  vnox  ix  Disorders  ok  Di- 

.. — The  pathology  and  treatment  of  di- 
gestive disorders  has  of  late  been  engaging  the 
attention  of  many  observers  in  France.  The  bril- 
liant writings  of  G.  See,  G.  Lyon,  Huchard  and 
others  have  done  much  to  disseminate  a  more 
thorough  knowledge  of  the  causation  of  dyspep- 
sia. In  this  matter  Germany  was,  until  recently, 
far  in  advance.  The  "  French  treatment "  was 
far  too  uniform,  and  sufficient  allowance  was  not 
made  for  the  many  varying  forms  of  the  disease. 
The  routine  treatment  was  either  to  send  the  pa- 
tient to  Vichy  for  a  course  of  the  waters,  or  alka- 
lies in  some  other  form  were  prescribed,  to  coun- 
teract the  "acidity."  Of  course,  many  derived 
much  benefit  from  these  measures,  but  in  others 
they  failed  completely.  In  order  to  understand 
the  principle  of  the  modern  treatment,  the  fol- 
lowing physiological  details  must  be  understood: 
The  granular  cells  of  the  stomach  form  a  sub- 
stance named  propepsin,  which  is  secreted  con- 
tinuous!}',  and  in  presence  of  the  gastric  acid  is 
converted  into  pepsin.  This  pepsin  is  used  up 
during  digestion,  and  one  of  the  most  frequent 
disturbances  of  the  process  is  due  to  the  fact  that, 
although  the  supply  of  propepsin  is  practical  ly 
inexhaustible,  yet  the  gastric  acid  may  not  be 
secreted  in  quantity  sufficient  to  convert  enough 
of  this  into  pepsin.  Both  propepsin  and  acid  are 
necessary  for  digestion;  neither  is  of  use  by  itself. 
If  there  be  excess  of  functional  work  and  increase 
of  total  acidity,  we  are  in  presence  of  a  "hy- 
per-hydrochloric" dyspepsia.  This  condition  is 
probably  rare,  and  only  occurs  under  special  cir- 
cumstances, as  in  ataxia  and  some  other  neuroses. 
Diminution  in  the  quantity  of  acid,  "hypo- 
hydrochloric"  dyspepsia,  exists  in  the  greater 
number  of  dyspeptics,  the  first  effect  of  chronic 
disorders  of  digestion  being  to  weaken  the  chem- 
ical operations  of  the  stomach  and  to  diminish 
the  gastric  acid.  This  diminution  may  even  go 
so  far  as  to  lead  to  its  complete  disappearance. 
' '  ana-hydrochloric  dyspepsia, ' '  which  occurs  prin- 
cipally in  neurasthenia,  and  in  the  later  stages  of 
cachexia  from  cancer  of  the  stomach,  etc.  As  a 
consequence  of  the  diminution  of  acid  we  have 
fermentations  occurring,  leading  to  pain,  flatu- 
lence, vomiting,  and  the  other  well-known  symp- 
toms of  dyspepsia.  These  facts  once  ascertained 
— and  methods  for  determining  them  have  already- 
been  described  in  our  pages — it  naturally  occurs 
that  the  correct  treatment  is  to  supply  the  stom- 
ach with  the  acid  in  which  it  is  deficient.  The 
problem  is,  however,  by  no  means  so  simple ;  we 
must  not  lose  sight  of  the  other  agents — mucus, 
rennet-ferment,  duodenal  secretion,  etc.,  which 
may-  also  be  subject  to  morbid  alterations.  Atony 
or  hypersthenia  of  the  muscular  tissue,  leading 


Si8 


MEDICAL  PROGRESS. 


[June  6, 


respectively  to  dilatation  or  hypersesthesia,  give 
rise  also  to  their  own  peculiar  train  of  symptoms. 
With  the  increase  in  our  knowledge,  we  must  not 
shut  our  eyes  to  all  these  and  many  other  condi- 
tions, which  would  certainly  not  be  uniformly 
benefited  by  acid  medication. 

Indications  for  Alkaline  Medication. — Until  re- 
cently the  plan  of  treatment  most  in  vogue  in 
France  has  been  quite  the  opposite  to  this,  and 
alkaline  medication  has  been  the  method  par  ex- 
cellence: regime,  alkalies,  artificial  ferments,  ton- 
ics, laxatives,  Vichy  water,  etc.,  have  benefited 
many.  But  at  least  half  receive  no  benefit  from 
this  plan,  and  others  who  get  temporary  relief  are 
not  freed  for  long  from  their  old  enemy.  Still, 
there  is  a  class  of  cases  which  will  be  cured 
by  such  treatment.  Imperfect  mastication,  pri^ 
vation,  overwork,  mental  anxiety,  or  an  excess 
of  some  sort,  may  have  been  followed  by  flatu- 
lence, vomiting,  etc.,  and  the  patient  seeks  ad- 
vice. Here  the  production  of  acid  is  diminished, 
but  the  glands  themselves  may  be  healthy ;  and 
in  eight  cases  out  of  ten  they  only  require  the 
stimulus  of  an  alkali  to  make  them  secrete  their 
acid  in  the  proper  quantity.  In  these  temporary 
conditions  alkalies  are  the  true  remedy. 

I>i  di cat  ions  for  Acid  Medication. — There  is  an- 
other class  of  patients  who  say  that  they  are 
rheumatic,  and  only  digest  well  when  there  are 
pains  in  their  limbs.  In  their  own  language, 
"  their  rheumatism  flies  to  the  stomach."  Such 
are  the  patients  with  gastric  catarrh  from  exces- 
sive secretion  of  mucus,  and  duodenal  juice.  This 
fluid,  if  secreted  in  too  great  abundance,  forms  a 
coating  over  the  gland  surfaces,  interposing  itself 
between  these  and  the  food,  and  thus  weakening 
or  abolishing  the  power  of  the  gastric  juice.  No 
amount  of  alkaline  medicines  will  be  of  service 
—  they  are  victims  of  the  ' '  rheumatoid  diathesis, ' ' 
and  urgently  require  acid  treatment.  The  condi- 
tion has  nothing  to  do  with  rheumatism  properly 
so-called,  and  is  produced  especially  in  the  inhab- 
itants of  damp  and  cold  climates  like  our  own. 
Its  symptoms  are  as  follows  :  Uniform  whiteness 
of  the  tongue,  anorexia,  wasting,  and  loss  of 
strength;  digestive  troubles,  with  or  without  vom- 
iting ;  alternate  constipation  and  diarrhcea  ;  wan- 
dering pains,  rendered  worse  by  changes  of  tem- 
perature ;  frequent  coryza,  pruritus,  and  skin 
eruptions ;  no  true  rheumatic  antecedents.  To 
such  cases  strong  mineral  acids  are  a  necessity. 
Others  to  whom  it  is  almost  equally  useful  are 
the  patients  with  dilated  atonic  stomachs,  which 
allow  of  fermentative  changes ;  neurotic  and  an- 
Eemic  girls  ;  old  men  with  enfeebled  gastric  pow- 
ers;  the  anaemic  dwellers  in  tropical  climates. 
Such  cases  often  improve  remarkably  under  acid 
treatment. 

Centra-indications  of  Acids. — The  conditions  in 
which  acids  are  formally  contra-indicated  may 
be  thus  enumerated  :    "  Hyperchlorhydric,"   pure 


dyspepsia,  irritative  dyspepsia,  febrile  or  inflam- 
matory affections,  gout  and  rheumatism,  milk 
diet. 

How  Is  Employ  Acids. — As  hydrochloric  acid 
was  found  to  be  the  natural  acid  of  the  stomach, 
it  was  naturally  thought  that  this  would  be  the 
best  to  use.  In  practice,  however,  it  has  been 
found  that  its  powers  fall  far  short  of  what  might 
be  expected.  Small  doses  are  useless,  and  large 
doses  are  both  inconvenient  and  irritating.  Bou- 
chard gave  as  much  as  3j  of  strong  acid  daily  to 
his  patients,  diluted  in  a  quart  of  water,  and  this 
was  often  the  minimum  efficient  quantity  pc r  meal. 
Others  tried  vegetable  acids — lactic,  tartaric,  ace- 
tic. All  these,  as  might  be  expected,  did  nothing 
but  harm.  Aqua  regia  is  much  employed  in  this 
country,  and  enormous  doses  are  often  taken  with 
benefit.  Some  patients,  however,  cannot  stand 
this,  and  the  author  prefers  a  compound  acid  pre- 
pared in  the  following  way  :  H.  Acid  sulphuric 
(pure),  28  pts. ;  acid  nitric  (pure)  8  pts. ;  spt. 
vini  (800  ),  180  pts.,  by  weight,  to  be  mixed 
gradually  in  ice.  This  is  his  "  acide  sulphonitrique 
rabelise."  It  should  be  prepared  long  before  re- 
quired for  use ;  in  fact,  the  older  the  better.  No 
violent  reaction  should  be  allowed  to  occur  during 
its  preparation,  and  the  product  when  ready  for  use 
will  contain  sulphovinic  acid,  and  a  small  quan- 
tity of  nitric  ether,  which  gives  it  a  most  pleasant 
odor.  The  dose  is  about  20  drops,  after  meals, 
given  in  water,  wine  or  beer.  According  to  the 
author  no  acid  gives  better  results  than  this, 
which  agrees  well  whenever  acids  are  indicated. 
— Bull.  Gen.  de  Therap. 

Combination  of  Paraffin  with  Lanolin. 
— Paschkis  has  found  that  the  special  advantages 
of  lanolin  are  increased  when  diluted  with  paraf- 
fin. The  formula  which  he  found  best  for  a 
basis  is : 

B.     Lanolin  66  parts. 

Liquid  paraffin,  6  parts. 

Ceresin,  I  part. 

Distilled  water,  65  parts.     «£. 

Infantile  Constipation. — Bouchut  employs 
the  following  syrup: 

R.     Podophyllin,  gr.  j. 

Alcohol,  f3jss. 
Syrup  altluea,  fj  jv.     "R. 
S.     Dessertspoonful  daily. 

—  Union  Medicate. 

Fissured  Nipples. — Dr.  Barton  C.  Hirst 
(l'nii\  Mag.,  March,  1 891)  suggests  the  follow- 
ing application : 

ft.     Bismuth  subnitrat. 
Olei  ricini,  aa  5  j. 

The  nipple  and  adjacent  skin  must  be  carefully 
cleansed,  and  the  ointment  then  rubbed  on  liber- 
ally. 


I89i.] 


EDITORIAL. 


819 


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Address 

Journal  of  thf.  American  Mkdical  Association, 
No.  68  Wabash  avi:  , 

Chicago,  Illinois. 
All  members  of  the  Association  should  send  their  Annual  Dues 
to  the  Treasurer,  Richard  J.  Dunglison,  M.D.,  Lock  Box  1274,  Phila- 
delphia, Pa. 


London  Office,  57  and  59  Ludgate  Hill. 


SATURDAY,  JUNE  6,    1891. 


MASSAGE  OF  THE  GENITAL  ORGANS. 

Objection  again  comes,  from  a  high  authority, 
to  the  use  of  massage  in  affections  of  the  female 
reproductive  system. 

This  question  admits  of  two  distinct  and  separ- 
ate views  based  upon  the  results  which  follow 
under  those  of  widely  different  organism  and 
nervous  trend.  And  the  query  arises :  How 
can  we  foresee,  in  a  given  patient,  debilitated  by 
a  neurotic  condition  involving  the  genital  organs, 
or  laboring  under  some  other  morbidity  more 
directly  touching  the  structural  harmony  of  the 
parts,  the  unfortunate  consequences  which  are 
sometimes  observed,  and  upon  which  the  strenu- 
ous objections  rest? 

It  becomes  at  once  a  metaphysical  inquiry,  and 
runs  off  into  fields  of  moral  philosophy.  The 
mind  and  will  of  the  individual,  upon  whom  the 
restorative  powers  of  massage  is  to  be  tried, 
should  first  be  studied,  and  from  such  study  the 
probable  outcome  is  to  be  weighed.  And  not 
alone  the  present  state,  but  the  past  life  of  the 
patient  as  well,  should  be  looked  into.  Ques- 
tions of  delicacy  at  once  present  themselves  and 
should  have  prompt  and  straight- forward  solu- 
tion. 

When  the  medical  adviser  can  fully  fortify 
himself  with  a  clear,  unquestioned  knowledge  of 
the  entire  mental,  moral  and  physical  make-up 
of  his  patient ;  when,  so  far  as  the  patient  is  con- 
cerned, he  feels  there  is  nothing  to  fear  from  the 
application  of  massage,  but  that  on  the  contrary 
there    is    everything    to    gain,    then,    and    not 


until  then,  do  we  feel  there  is  justification  in  the 
resort  to  this  remedial  measure. 

And  yet  the  half  has  but  been  said  !  The 
masseur  !  Here,  again,  must  there  be  a  display 
of  the  keenest  circumspection.  If  the  physician, 
after  possessing  the  insight  above-mentioned,  is 
to  act  as  masseur,  or  if  massage  is  to  be  applied 
under  his  immediate  supervision,  then  we  have 
but  little  to  add.  Conscientiousness  here  is  the 
outgrowth  of  the  previous  carefulness.  If,  how- 
ever, a  professional  masseur  must  be  selected, 
under  whose  charge  the  patient  is  to  quite  en- 
tirely rest,  then  the  two-fold  character  of  the  case, 
and  the  physician's  responsibility,  becomes  at 
once  apparent. 

Here,  again,  must  a  solution  of  the  mental  and 
moral  integrity  of  an  individual  be  made,  not  in 
the  weakness  of  the  body,  but  under  the  condi- 
tion of  physical  strength.  Here,  as  well,  must 
there  be  a  diversion  of  will  power  into  paths 
leading  away  from  the  sensual.  Here,  again, 
must  there  be  the  buoyant  feeling  of  hope,  to- 
gether with  that  determination  towards  success 
in  the  relief  of  the  patient  which  plays  so  im- 
portant a  part. 

Too  much  attention  can  scarcely  be  given  this 
subject  of  the  proper  and  peculiar  fitness  of  the 
operator  ;  and  when  this,  and  the  other  factors, 
are  duly  considered  we  feel  that  this  system  of 
treatment  will  be  largely  bereft  of  the  odium 
which  now  surrounds  it. 


THE  WATER  WE  DRINK. 

There  is  no  problem  in  science  more  definitely 
settled,  than  the  one  pertaining  to  the  drinking 
of  impure  water  as  a  cause  of  enteric  disease.  In 
the  large  cities,  efficient  boards  of  health  with 
skilled  men  employed  as  chemists  and  sanitary 
officers  stand  as  watchful  guardians  over  the 
water  supply  of  the  people. 

In  country  districts  the  conditions  are  quite  the 
reverse ;  there  are  neither  health  boards,  nor 
paid  sanitary  officers,  and  usually  the  only  man 
in  the  vicinity  who  has  any  knowledge  of  the 
subject  is  the  neighborhood  physician,  and  upon 
him  devolves  a  solution  of  all  causes  of  preventa- 
ble disease  within  the  territory  in  which  he 
labors. 

In  many  parts  of  the  country  typhoid  fever  and 
dysentery    appear  with  the  same  regularity   as 


320 


SOCIETY  PROCEEDINGS. 


[June  6, 


the  seasons,  and  always  with  the  variability  of  the 
water  supply.  Frequently  the  priceless  spring  is 
located  on  a  little  lower  level  than  the  farm-house 
and  barn-yard;  and  although  it  may  bubble 
forth  in  a  stream  of  clearest  crystal  water,  may 
be  so  laden  with  poisonous  microbes,  as  to  be- 
come the  involuntary  purveyor  of  the  germs  of 
disease  and  death. 

Contaminated  water  may  be  the  only  drink  of 
the  milk  cows  and  through  this  channel  produce 
and  foster  an  epidemic  of  disease. 

Physicians  engaged  in  country  practice  have 
many  opportunities  for  making  valuable  observa- 
tions in  this  direction,  while  such  studies  enable 
them  to  become  educators  of  the  people. 


A  "HEALTHERIES"  AT  NEW  YORK. 
An  imitation  of  the  London  Healtheries  has 
been  set  on  foot  in  New  York  City,  having  its  of- 
fices in  the  vicinity  of  Madison  Square.  Its  pro- 
jectors claim  that  while  the  primary  operations  of 
the  Healtheries  will  be  directed  toward  the  pro- 
curement of  a  purer  food-supply,  the  general  in- 
fluence of  the  movement  will  be  exercised  over 
all  departments  of  the  public  health.  The  com- 
pany intends  to  have  exact  chemical  and  micro- 
scopical examinations  made  upon  suspected  arti- 
cles of  food  and  drink  that  are  offered  to  the 
public,  and  promises  to  inform  the  individual 
consumer,  upon  application,  of  the  results  of 
such  investigations.  Inasmuch  as  a  recent  Food 
Exhibition  yielded  a  net  profit  of  $10,000,  it  is 
probable  that  much  of  the  scientific  work  above 
referred  to  can  be  accomplished  free  of  cost  to  the 
general  public.  A  certain  proportion  of  the  an- 
nual profits  will  be  laid  aside  as  a  fund  for  a  per- 
manent building.  A  weekly  or  monthly  food 
journal  will  probably  soon  be  issued,  for  the  pur- 
poses of  publishing  the  results  of  analyses,  and 
of  announcing  the  new  foods  in  the  markets. 
There  will  be  at  the  outset  a  board  of  three  well 
known  chemists ;  all  analyses  made  for  the  com- 
pany must  be  signed  by  two  or  more  of  the  board. 


LEPER  COLONY  IN   BRITISH  COLUMBIA. 

An  isolation  of  all  lepers  found  at  large  in  the 

towns  of  British  Columbia  has  been  ordained  by 

the  Dominion   government.     An   island  off  the 

coast,  called  Darcy's  Island,  has  been   set  apart 


and  will  immediately  be  prepared  for  the  recep- 
tion of  the  leper  colony,  composed  chiefly  of 
Chinese.  The  authorities  have  also  ordered  that 
an  immediate  investigation  shall  be  made  as  to 
the  alleged  rapid  increase  of  leprosy  in  and  about 
Vancouver,  and  for  that  purpose  Dr.  Smith,  su- 
perintendent of  the  leper  colony  of  Tracadie, 
New  Brunswick,  has  been  appointed  as  an  expert 
commissioner  to  examine  and  report  the  true 
status  of  leprosy  on  the  Pacific  slope  of  the   Do- 


SOCIETY   PROCEEDINGS. 

Medical  and  Chiriivgical  State  Faculty  of 
Maryland. 

Ninety-third  Annual  Session,  held  at  the  Hall  of 

the  Faculty,  Baltimore,  April  28,  29  and 

30,  1891. 

Dr.  T.  A.  Ashby,  President,  in  the  Chair. 

Drs.  G.  L.  Taneyhill,  Robert  T.  Wilson  and 
William  B.  Canfield,  Secretaries. 

The  ninety- third  annual  session  of  the  Medical 
and  Chirurgical  State  Faculty  of  Maryland  was 
called  to  order  at  the  Hall  of  the  Faculty,  corner 
St.  Paul  and  Saratoga  Sts.,  April  28,  at  12  o'clock 
noon. 

Rev.  G.  F.  M.  Ellis  opened  with  prayer,  after 
which  the  minutes  of  the  previous  meeting  were 
read,  corrected  and  adopted.  After  some  prelim- 
inary announcements,  Dr.  T.  A.  Ashby  deliv- 
ered the  President's  Address,  on  the  subject : 

THE  RELATION  OF  THE  MEDICAL  AND  CHIRURGI- 
CAL FACULTY  TO  PROFESSIONAL  ORGANIZA- 
TION IN  AMERICA. 

The  Faculty,  one  of  the  oldest  State  organiza- 
tions extant,  was  now  entering  on  its  ninety-third 
year.  It  had  had  seasons  of  prosperity  and  ad- 
versity. In  its  early  life  in  the  colonial  histo- 
ry of  our  country,  and  later  during  civil  strifes, 
it  had  suffered  and  lost  strength.  At  one  time, 
it  practically  went  out  of  existence.  It  had  at 
one  time  the  full  power  to  license  all  practition- 
ers in  the  State.  This  power,  which  had  fallen 
into  disuse,  was  now  entirely  lost,  through  the 
efforts  of  irregular  practitioners.  Whether  it 
could  be  recovered  was  a  question.  If  the  body 
could  be  strengthened,  the  membership  increased, 
and  all  the  respectable  members  of  the  profession 
of  the  State  brought  into  unity  of  thought  and 
action,  much  of  the  lost  power  might  be  regained. 
The  Faculty  was  now  meeting  under  auspicious 
circumstances.  The  semi-annual  meetings  re- 
cently  held  in  Hagerstown  and  Cambridge  had 
not  only  added  a  large  number  of  new  members, 
but  had  excited  renewed  interest  in  various  parts 


i89i.] 


SOCIETY  PROCEEDINGS. 


821 


of  the  State,  the  result  of  which  was  the  forma- 
tion of  local  societies.  The  lessening  of  the  an- 
imal dues  had  had  a  good  effect.  The  Faculty 
has  always  had  a  very  poor  home.  Now  it  is  well 
housed,  and  the  library  which  it  possesses  is  in 
good  condition  and  well  taken  care  of,  but  the  fact 
that  we  only  rent  this  hall,  gives  it  a  feeling  of 
uncertainty.  We  should  have  our  own  hall.  For 
this  an  endowment  would  be  necessary,  and  this 
could  only  be  obtained  by  exciting  interest  among 
the  members.  Such  a  fund  would  be  started  as 
soon  as  possible.  The  future  outlook  of  the  Fac- 
ulty was  never  better.  If  we  cannot  have  the 
power  to  license,  we  can  strengthen  ourselves, 
and  form  a  respectable  State  Medical  Association. 
Dr.  Randolph  Winslow  read  a  paper  entitled: 

INJt'RIKS  TO  THE   KIDNEYS. 

A  man  33  years  old,  weighing  170  lbs.,  while- 
driving  very  fast,  was  thrown  out,  and  fell  vio- 
lently to  the  ground.  He  was  much  shocked  and 
nervous.  Had  much  pain  in  right  flank.  No 
bladder  symptoms.  Next  morning  there  was 
hternaturia  which  lasted  a  week  or  more.  This 
with  other  symptoms  disappeared,  and  then  his 
left  scrotum  and  cord  were  attacked  with  great 
pain,  left  leg  was  swollen,  phlebites  occurred. 
These  symptoms  gradually  disappeared  and  case 
recovered.  A  careful  study  of  all  the  symptoms, 
and  the  history  of  previous  cases,  pointed  to  a 
diagnosis  of  rupture  of  the  kidney.  A  sudden 
and  heavy  fall  may  cause  rupture  of  the  intestinal 
organs,  and  the  kidney  has  been  frequently  so 
torn.     Extirpation  may  be  necessary. 

Dr.  John  D.  Blake  read  a  paper  entitled, 

SOME  CONDITIONS   OF  THE    URETHRA    REQUIRING 
PERINEAL    SECTION. 

In  the  discussion  which  followed,  Dr.  J.  E. 
Michael  said  he  agreed  in  some  points  and  dis- 
agreed in  others.  When  operation  is  used  as  a 
temporizing  means,  it  is  a  good  thing,  and  when 
the  instrument  is  used  with  proper  antiseptic  pre- 
cautions, there  is  no  danger.  He  is  skeptical  with 
regard  to  electricity.  He  had  been  very  success- 
ful in  his  operation  for  deep  perineal  section,  and 
felt  safer  in  this  than  in  attempting  to  pass  bou- 
gies and  other  instruments,  causing  chills,  shocks, 
etc.  A  free  incision  is  attended  with  very  little 
shock. 

Dr.  J.  D.  Blake  said  he  had  been  much  pleased 
with  the  use  of  electricity,  and  related  a  case  to 
prove  his  point. 

Dr.  L.  McLane  Tiffany  read  a  paper  entitled 
Indications  for  Treatment  in  Malignant  Diseases 
of  the  Mamma. 

Dr.  John  W.  Chambers  read  a  paper  entitled 
Some  Observations  in  Injuries  of  the  Ce>~cical  Por- 
tion of  the  Spinal  Cord. 

Dr.  Wm.  H.  Welch,  of  the  Johns  Hopkins 
University,  then  delivered  the  Annual  Address. 
The  subject  was 


THE  CAUSATION  OF  DirHTHERIA. 

The  subject  is  an  exceedingly  important  one. 
and  has  been  much  discussed  in  the  medical  jour- 
nals of  the  day,  but  many  of  the  facts  are  so  new 
that  they  can  with  advantage  be  brought  up 
again.  Although  the  advantages  are  principally 
bacteriological,  the  points  brought  out  will  be 
chiefly  those  which  illustrate  the  application  of 
these  discoveries  to  a  fuller  and  more  correct 
knowledge  of  the  nature,  etiology,  pathology, 
prevention  and  treatment  of  diphtheria. 

The  questions  to  be  answered  are,  Is  diph- 
theria primarily  local  or  constitutional  in  its  ori- 
gin ?  Are  all  pseudo-membranous  inflammations 
of  the  throat  not  directly  referable  to  caustic  ir- 
ritants, diphtheria?  Is  there  a  purely  local,  non- 
contagious, pseudo-membranous  laryngitis,  called 
croup,  distinguishable  from  diphtheria?  Are  the 
pseudo- membranous  anginae  secondary'  to  scarla- 
tina, and  less  frequently  to  measles,  and  some 
other  infectious  diseases,  identical  with  diphthe- 
ria? Is  there  any  relation  between  tonsillitis  and 
diphtheria?  May  diphtheria  occur  in  a  mild  form 
as  a  simple  catarrhal  inflammation  of  the  throat? 
Are  pneumonia,  acute  nephritis,  suppuration  of 
the  glands  in  the  neck,  etc.,  referable  to  the  direct 
action  of  the  diphtheritic  virus?  In  other  words, 
what  lesions  belong  to  the  disease  and  what  are 
complications?  Shall  reliance  be  placed  chiefly 
upon  local  or  upon  general  treatment?  These  are 
important  practical  questions,  which  a  careful 
study  of  the  disease  has  not  yet  answered.  Our 
most  recent  knowledge  on  the  subject  has  come 
through  the  discovery  of  the  microscopic  germ 
which  is  the  specific  cause  of  diphtheria.  There 
is  perhaps  no  other  disease,  with  the  exception 
of  tuberculosis,  upon  which  greater  light  has 
been  shed,  by  the  discovery  of  its  specific  cause, 
than  upon  diphtheria.  The  specific  bacillus  is 
called  the  Klebs-Loffler  bacillus.  There  are  three 
difficulties  in  the  way  of  proving  this.  One  is 
the  uncertainty  as  to  what  is  diphtheria,  as  dis- 
tinguished from  the  various  anginae  associated 
with  scarlet  fever,  measles,  etc.  Thus  different 
investigators  working  with  different  kinds  of  an- 
gina? would  obtain  different  results.  Genuine 
cases  only  should  be  studied.  A  second  difficulty 
is  the  large  number  of  bacteria  found  in  the  diph- 
theritic membrane.  It  must  be  determined  which 
of  these  are  constantly,  and  which  are  inconstant- 
ly present  and  absent  in  other  conditions.  We 
maj-  preume  this  is  the  specific  cause,  and  the 
presumption  becomes  a  certainty,  when  we  can 
reproduce  the  disease  experimentally.  The  third 
difficulty  is  to  prove  that  our  experimental  dis- 
ease is  identical  with  human  diphtheria.  As  by 
various  agencies  we  can  produce  on  the  mucous 
membrane  of  the  tonsils,  pharynx,  etc.,  a  fibrinous 
pseudo-membrane  which  is  not  diphtheritic,  we 
cannot  rely  on  the  membrane  alone  as  pathogno- 
monic. 


822 


SOCIETY  PROCEEDINGS. 


[June  6, 


Oertel  has  demonstrated  that  the  diphtheritic 
virus  is  a  most  peculiar  poison  to  the  cells  of  the 
human  body,  and  that  it  produces  areas  of  cell 
death,  not  only  on  the  surface  of  the  mucous 
membrane,  but  also  in  deep  parts,  in  various 
lymphatic  glands  at  a  distance  from  the  local  le- 
sion, and  in  the  spleen.  These  changes  can  be 
shown  by  histological  demonstration.  Now  if 
our  suspected  germ  produces  the  membrane,'  and 
all  these  changes  too,  and  muscular  paralysis, 
then  we  have  strong  evidence  that  it  is  the  spe- 
cific cause  of  diphtheria.  All  these  difficulties 
were  not  overcome  at  once,  but  it  is  needless  to 
go  over  each  step.  It  will  only  be  necessary  to 
say  that  the  Klebs  Eoffler  bacillus  has  been  ac- 
cepted as  the  specific  bacillus  of  diphtheria.  Dr. 
Welch  and  Dr.  Abbott  had  proved  this,  in  "a  se- 
ries of  cases  occurring  here.  The  practical  value 
of  this  discovery  will  come  later. 

The  specific  germ  of  diphtheria  is  a  bacillus 
devoid  of  independent  motility,  averaging  in 
length  about  that  of  the  tubercle  bacillus.  It 
presents  itself,  both  in  diphtheritic  membranes 
and  in  cultures,  in  such  bizarre  forms  that  these 
belong  to  its  most  characteristic  morphological 
properties.  It  grows  upon  various  culture  media 
and  in  milk.  It  grows  readily  outside  of  the 
body.  It  has  no  spores,  but  is  very  resistant,  a 
fact  which  is  shown  in  the  viability  of  the  disease 
in  old  clothes,  rooms,  etc.,  after  many  years. 
Diphtheria  is  without  doubt  a  local  disease.  It 
is  only  found  in  the  upper  part  of  the  mem- 
branes. The  constitutional  symptoms  are  due  to 
the  reception  into  the  system  of  a  chemical  sub- 
stance, a  poison  produced  by  the  bacillus.  The 
germs  are  combed  by  bits  of  membranes,  saliva, 
secretion,  etc.,  but  the  disease  is  not  as  easily 
spread  as  scarlet  fever,  nor  is  the  danger  from 
infection  through  drinking-water  as  great  as  with 
typhus  fever.  The  toxic  substances  produced  by 
the  bacilli  are  very  complex,  and  worthy  of  care- 
ful study.  The  difference  in  epidemics,  mild  or 
severe,  is  not  easily  explained.  Similar  differ- 
ences are  noted  in  experimental  diphtheria.  The 
discovery  has  not  yet  reached  the  diagnostic  im- 
portance of  the  tubercle  bacillus ;  that  is,  it  can- 
not be  so  easily  put  to  use,  but  for  one  skilled  and 
equipped  in  bacteriological  research,  or  in  a  large 
hospital,  such  a  method  is  inestimable.  As  bac- 
teriological methods  become  more  generally  un- 
derstood, such  means  of  diagnosis  will  be  used. 
The  anginae  occurring  with  scarlet  fever,  etc.,  are 
not  diphtheria,  as  the  bacteriological  examination 
would  show.  Other  bacteria  are  frequently  but 
not  constantly  found.  Diphtheria  may  be  com- 
municated from  animals  to  man,  and  vice  versa; 
also  by  milk.  Much  elaboration  is  necessary  ln- 
fore  this  discovery  becomes  of  general  practical 
use. 

Naturally,  our  methods  of  prophylaxis  and 
treatment  will  not  be  materially  changed.     The 


peculiar  character  of  the  toxic  substances  pro- 
duced by  the  diphtheritic  bacillus  furnish  the 
strongest  indication  for  the  earliest  possible  local 
treatment  of  diphtheria  by  germicidal  agents,  and 
that  an  equally  urgent  indication  is  the  destruc- 
tion of  the  poisons  circulating  in  the  blood,  and, 
in  the  existing  absence  of  any  such  antidote,  sup- 
porting means  of  treatment  should  be  used,  to 
render  the  system  capable  of  withstanding  the 
injurious  effect  of  the  poison. 

Dr.  Wm.  Osler  read  a  paper  entitled 

THE  HEALING  OF  TUBERCULOSIS. 

That  pulmonary  tuberculosis  is  curable,  is  de- 
monstrated clinically  by  the  recovery  of  patients 
in  whose  sputa  elastic  tissue  and  bacilli  had  been 
found,  and  anatomicalh-  by  the  existence  of  le- 
sions in  all  stages  of  healing.  Caseous  areas  may 
be  impregnated  with  lime  salts,  or  the  tubercu- 
lous masses  may  be  encapsulated  b}'  fibrinous  tis- 
sue, in  which  case  the  substance  remains  quies- 
cent, unci  the  disease  is  not  cured.  Perfect  healing 
does  not  occur  after  cavities  are  formed.  A  cavity 
may  be  much  reduced  in  size,  but  is  not  often 
closed.  Laennec  did  much  good  work  in  this  di- 
rection. He  recognized  the  cicatrices  completes 
and  the  cicatrices  fistulenccs,  and  suggested  that 
as  tubercle  growing  in  the  glands,  which  we  call 
scrofula,  often  healed,  why  should  it  not  do  the 
same  in  the  lungs.  In  a  large  number  of  autop- 
sies healed  or  quiescent  tubercular  lesions  have 
been  found  in  the  lungs.  This  was  noticed  in 
1880  by  Palmer  Howard,  who  called  attention  to 
the  great  frequencj'  of  puckering  at  the  apices  of 
the  lungs  in  elderly  persons. 

The  following  is  noted  of  the  apices:  1.  Thick- 
ening of  the  pleura,  usually  the  posterior  surface 
of  the  apex,  with  perhaps  subjacent  indication  of 
the  lung  tissue,  for  the  distance  of  a  few  milli- 
metres. 2.  Puckered  cicatrix  at  the  apex,  depres- 
sing the  pleura,  which  may,  or  may  not  be  here 
thickened.  On  section,  there  is  a  fibrous  scar 
much  pigmented,  the  bronchioles  in  the  neighbor- 
hood dilated,  but  no  tubercles  or  cheesy  masses. 
Such  structures  are  extremely  common,  and  may 
in  some  cases  indicate  a  healed  tubercular  lesion. 
3.  Puckered  cicatrices  with  a  cheesy  or  cretaceous 
central  nodule,  and  with  scattered  tubercles  in  the 
vicinity.  4.  The  cicatrices  fislulence  of  Laennec, 
in  which  one  or  more  cavities  have  become  qui- 
escent, surrounded  with  fibroid  tissue  and  com- 
municating with  the  bronchi.  At  1,000  autopsies 
of  his  over  59  cases,  or  5.05  per  cent.,  were  found 
in  which  persons  dying  of  other  diseases  presented 
undoubted  tubercular  lesions  in  the  lungs.  Of 
the  59  cases,  the  causes  of  death  were :  Cancer 
of  various  organs,  12:  cirrhosis  of  the  liver,  7; 
accidents  and  operations,  85;  acute  fever,  9;  urae- 
mia*, 5;  diseases  of  the  head  and  arteries,  5; 
other  affections,  13.  The  ages  of  those  cases  : 
Under  10  years,  4 ;  from  10  to  20,  2  ;  from  20  to 


I89i.] 


SOCIETY  PROC' 


823 


30,  8  ;  from  30  to  40,  10 ;  from  40  to  50,  14  ;  from 
50  to  60,  14;  from  60  to  70,  5;  above  70,  2.  Heit- 
ler,  of  Vienna,  found  in  16,562  cases  in  which  the 
deaths  were  not  directly  caused  by  phthisis,  there 
were  780  instances  of  obsolete  tubercle,  or  47  per 
cent.  The  simple  fibroid  induration  should  be 
excluded.  With  each  decennial  period  up  to  the 
sixtieth  year,  the  number  of  cases  increased. 
Bollinger  found  in  27  per  cent,  in  400  bodies  evi- 
dences of  tubercular  lesions  in  the  lungs.  Stau- 
dacker,  in  737  cases,  found  apex  cirrhosis  in  202. 
Massini  found  evidences  of  healing  in  39  per  cent, 
in  223  bodies  examined.  Harris,  of  Manchester, 
found  in  139  cases  54,  or  38. S4  per  cent.,  in  which 
there  were  relics  of  former  active  tuberculosis. 
The  greater  number  of  these  were  in  the  third, 
fourth  and  fifth  decades.  In  the  Paris  Morgue, 
it  is  said  that  75  per  cent,  of  suicides  and  those 
accidentally  killed  present  evidences  of  old  tu- 
bercular lesions. 

These  facts  demonstrate,  first,  the  widespread 
prevalence  of  tuberculosis  ;  and  secondly,  the  fact, 
as  shown  by  the  above  figures,  that  at  least  one- 
fourth  of  all  infected  persons  recover  spontane- 
ously. In  the  great  majority  of  cases,  the  disease 
was  very  limited  and  had  made  no  progress,  and 
could  not  have  given  rise  to  physical  signs.  But 
even  in  cases  further  advanced,  arrest  is  by  no 
means  infrequent,  and  if  not  cured,  the  condition 
of  arrest  is  consistent  with  comparatively  robust 
health. 

Once  infection  has  occurred,  there  are  three  in- 
dications :  first,  to  place  the  person  in  surround- 
ings most  favorable  for  the  maintenance  of  a 
maximum  degree  of  health  ;  second,  to  take  such 
measures  as  in  a  local  or  general  way  influence 
the  tuberculous  process ;  and  third,  to  alleviate 
symptoms  which  are  necessarily  associated  with 
the  disease.  The  environment  is  of  the  first  im- 
portance. Trudeau's  experiments  with  free  and 
confined  rabbits  prove  this.  A  patient  confined 
to  the  house  in  close,  overheated  rooms,  or  in  the 
stuffy,  ill- ventilated  dwellings  of  the  poor,  or  even 
in  hospitals,  does  not  stand  the  chance  with  the 
patient  in  the  fresh  air  and  sunshine  all  day  long. 
The  home  treatment  of  consumption  is  important. 
Fresh  air  and  sunshine  are  all-essential.  Altitude 
is  a  secondary  consideration  in  comparison  with 
these. 

Koch's  lymph  or  tuberculin  has  a  very  limited 
use.  1.  In  a  limited  number  of  cases  with  early 
local  lesions,  and  not  much  constitutional  dis- 
turbance, its  use  seems  beneficial ;  the  cough  dis- 
appears; the  patient  gains  in  weight,  and  the  local 
signs  improve.  In  none  of  these,  however,  after 
a  four  months'  treatment,  can  we  say  there  is  a 
cure.  2.  In  cases  with  more  advanced  lesions, 
particularly  with  consolidation,  the  febrile  reac- 
tion induced  is  severe,  the  local  condition  is  ag- 
gravated, and  the  patients  lose  ground,  often  with 
rapidity.    3.  In  advanced  cases,  with  cavities  and 


irregular  pyrexia,  the  remedy  is   most  injurious, 
and  aggravates  every  feature  of  the  disease. 

Of  measures  which  influence  the  general  con- 
dition, apart  from  hygiene  and  diet,  there  are  four 
which  have  stood  the  test  of  experience — cod-  liver 
oil,  the  hypophosphites,  arsenic  and  creosote,  all 
of  which  net  by  improving  the  nutrition,  and  ren- 
dering the  tissues  more  resistant,  the  soil  less 
suitable,  for  the  growth  and  development  of  the 
tubercle  bacilli. 

In  the  discussion  which  followed,  Dr.  Wm.  II. 
WELCH  said  there  were  two  points  of  importance 
to  be  considered  :  What  is  our  interpretation  of 
the  lesions  at  this  apex?  What  are  these  fibroid  ■ 
thickenings  at  the  apex?  The  most  frequent  le- 
sion found  at  the  apex  is  a  thickening,  a  slate- 
colored  induration.  This  contained  no  caseous 
nodules,  nor  calcareous  products.  Are  these 
healed  tuberculosis?  If  so,  then  the  number  of 
healed  cases  is  large.  We  cannot  say.  But  even  if 
we  leave  these  out,  we  have  many  genuine  cases 
of  healed  tuberculosis,  where  there  were  tubercle 
bacilli  in  the  sputum.  Does  it  all  depend  upon 
the  character  of  the  soil  on  which  the  bacilli  have 
to  grow?  There  is  some  doubt  on  this  point. 
They  may  vary  in  their  virulence,  and  some  may 
be  of  an  attenuated  character.  As  high  an  au- 
thority as  Koch  does  not  admit  this,  and  this  has 
great  weight.  Trudeau  has  reported  a  case  of 
miliary  tuberculosis  in  which  the  bacilli  were  of 
a  very  weak  character,  and  Xuttall,  in  the  Johns 
Hopkins  Pathological  Laboratory,  found  a  few 
instances  in  which  the  inoculation  of  genuine 
pure  culture  of  tubercle  bacilli  in  guinea  pigs, 
usually  very  susceptible  animals,  simply  caused 
a  localized  tuberculosis. 

Dr.  Joseph  T.  Smith  thought  the  importance 
of  the  home  treatment  could  not  be  too  strongly 
emphasized. 

Dr.  Wm.  Osler,  in  reply  to  Dr.  Branham,  said 
in  treating  cases  with  Koch's  tuberculin,  he  used 
no  other  therapeutic  means.  These  cases  in  the 
hospital  now  are  all  doing  well.  In  no  case  have 
the  bacilli  disappeared,  but  he  was  glad  to  say 
that  no  case  had  died  under  his  treatment  there, 
which  was  probably  because  all  cases  treated  there 
had  been  carefully  picked,  and  only  those  in  the 
earliest  stages  had  been  treated. 

Dr.  Joseph  T.  Smith  then  read  a  paper  en- 
titled 

THE  TREATMENT  OF  DIPHTHERIA, 

in  which  he  discussed  the  following  points :  1. 
The  effect  of  isolation  and  disinfection  in  the 
spread  of  the  disease.  2.  The  need  of  alcohol 
and  iron  to  influence  for  good  the  heart  and  blood- 
vessels, and  the  value  of  milk  as  the  article  of 
diet.  3.  The  need  of  quiet  or  rest  in  bed,  and 
the  importance  of  looking  upon  these  as  govern- 
ing our  choice  of  applications  to  the  throat  and 
other  forms  of  medication.     4.  The  necessity  of 


824 


SOCIETY  PROCEEDINGS. 


[June  6, 


calling  earl}-  upon  the  surgeon  when  the  disease 
invades  the  larynx.  5.  The  value  of  as  great 
cleanliness  of  the  pharynx  and  nares  as  the  con- 
dition of  the  patient  will  permit. 

There  are  three  vexed  questions  which  still 
await  answer:  1.  How  shall  the  membrane  be 
dissolved?  2.  How  shall  the  bacilli  be  destroyed 
at  the  seat  of  infection?  3.  What  is  the  antidote 
to  the  poison  ?  This  paper  was  discussed  by  Drs. 
A.  K.  Bond,  W.  A.  B.  Sellman  and  W.  Brunton. 

Dr.  J.  E.  Michael  read  a  paper  on  Obstetrical 
Antisepsis,  which  was  discussed  by  Drs.  Geo.  H. 
Rohe,  J.  M.  Craighill,  J.  D.  Blake,  J.  G.  Wilt- 
shire, A.  Friedenwald  and  W.  S.  Gardner. 

Dr.  W.  S.  Gardner  read  a  "paper  entitled 
Milk  Fever,  which  was  discussed  by  Dr.  J.  E. 
Michael. 

Dr.  Robert  T.  Wilson  read  a  paper  entitled 
Circumscribed  Peritoneal  Dropsy  simulating  (  Ova- 
rian Dropsy. 

Dr.  Geo.  H.  Rohe  read  a  paper  entitled  The 
Sanitary  Importance  of  Free  Baths. 

Dr.  H.  Newell  Martin  read  a  paper  entitled 
Recent  Discoveries  in  the  Physiology  of  Ganglion 
Cells. 

Dr.  J.  C.  Hemmeter  read  a  paper  entitled 
The  Influence  of  Digitalis,  Ergot  and  Alcohol  on 
the  Blood  Fluid. 

Dr.  H.  N.  Martin  read  a  paper  entitled  The 
Vaso- Motor  Nerves  of  the  Heart. 

Dr.  W.  T.  Councilman  read  a  paper  entitled 

THE  FORM   OF  DYSENTERY  PRODUCED  BY  THE 
AMCEBA  COLI. 

Dysentery,  as  a  word,  was  first  used  in  a  clini- 
cal sense.  It  meant  tenesmus.  It  is  an  inflam- 
mation of  the  large  intestine.  The  pathological 
lesions  are  exceedingly  numerous  and  varied.  It 
would  be  absurd  to  suppose  that  all  forms  of 
dysentery  come  from  the  same  cause,  just,  as  in 
pneumonia.  The  pulse  is  rapid.  The  case  may 
last  several  months.  In  the  anatomical  lesions 
which  are  produced  there  is  much  variation. 
Some  die  before  ulceration  begins,  and  other  cases 
are  not  so  virulent.  The  lesions  are  in  the  sub- 
mucous tissue.  Clinically  the  disease  is  chronic. 
It  begins  with  a  diarrhoea.  It  is  intermittent  in 
character,  may  last  for  a  month,  stop,  and  then 
break  out  again.  There  is  no  pain  in  the  earlier 
stages,  but  later  there  is  pain  ;  the  diarrhoea  be- 
comes worse,  and  there  is  tenesmus.  The  stools 
are  mixed  with  blood.  There  is  usually  no  fever 
in  the  entire  course  of  the  disease,  emaciation 
still  goes  on.  The  duration  may  be  from  three 
to  six  months.  Towards  the  last  the  complexion 
assumes  a  dull,  earthy-like  color.  There  is  noth- 
ing distinctive  in  the  stools;  they  are  always 
fluid,  and  considerable  in  amount.  When  these 
patients  die,  the  anatomical  lesions  are  exceed- 
ingly characteristic.  There  is  entire  absence  of 
diphtheritic  exudation,   which    one  finds  in  the 


acute  cases,  and  the  surface  of  the  bowel  shows 
numerous  ulcerations.  These  ulcers  are  relatively 
small,  and  the  surface  is  mammilated.  There  is 
a  small  loss  of  substance  at  the  apex  of  these 
elevations,  and  an  abscess  cavity,  and  on  this  a 
depression  is  filled  with  an  opaque  greyish,  gelat- 
inous-looking mass.  The  entire  intestine  is  much 
thickened,  the  muscular  coat  thickened.  Then 
large  ulcers  can  be  found  which  run  into  each 
other,  so  that  we  may  have  long,  sinuous  passages 
running  through  the  intestines  in  various  direc- 
tions, and  the  membrane  becomes  undermined, 
sloughs  and  falls  off.  It  extends  to  the  mucosa 
and  the  muscular  ccat,  and  large  sloughs  are  cast 
off.  The  microscopic  characteristic  appearance  is 
evident.  The  amount  of  sloughing  is  often  ex- 
treme, some  as  large  as  the  hand. 

This  is  interesting  from  the  complications.  The 
most  frequent  is  the  abscess  of  the  liver.  He  had 
seen  at  the  Johns  Hopkins  Hospital  eleven  cases 
of  this  form,  of  which  five  died  and  three  are  still 
under  treatment.  Of  these  eleven  cases,  four 
deaths  occurred  from  liver  abscess,  and  one  case 
of  liver  abscess  is  still  under  treatment.  The 
abscesses  of  the  liver  are  fully  as  characteristic 
as  in  the  intestinal  ulceration.  The  liver  ab- 
scesses are  filled  with  a  gelatinous-looking  mass. 
If  they  are  larger  they  may  have  a  distinct  fibrous 
form,  and  look  like  other  forms  of  abscess. 

The  next  most  common  complication  is  abscess 
of  the  lung.  The  formation  of  abscess  of  the 
lung  is  interesting.  In  four  cases  at  the  hospital, 
three  had  abscesses  of  the  lung.  The  lung  ab- 
scess comes  from  the  liver  abscess.  The  liver 
abscess  is  on  the  upper  surface  of  the  liver.  There 
is  an  adhesive  pleuritis  and  the  lung  abscess  fol- 
lows. It  is  very  insidious  in  its  outset,  there  is 
always  pyrexia,  abdominal  pain  and  much  sweat- 
ing. When  the  lung  complication  takes  place, 
the  appearance  of  the  sputum  is  characteristic — 
tough,  of  dingy  cherry-red  color,  as  in  acute  pneu- 
monia, so  that  the  spit-cup  can  be  turned  up  with- 
out the  sputum  running  out.  The  sputum  also 
contains  small  masses  of  necrotic  tissue,  lung  tis- 
sue. The  cause  of  the  disease  has  long  been  sus- 
pected. Davaine,  in  1853,  described  the  cerco- 
monas  in  the  stools.  Then  Lauder,  in  Prague, 
found  small  amcebas  in  the  stools  of  a  child  which 
of  dysentery,  also  in  cholera.  Cholera 
patients  in  India  by  Cunningham  and  Lewis. 
Lersch,  of  St.  Petersburg,  was  the  first  to  describe 
this  as  we  now  know  it.  .  It  is  an  amoeba  y,,1,,,,  to 
-$\-„  of  an  inch  in  length.  It  is  either  round  oris 
undergoing  movements.  The  outer  part  is  a  ho- 
mogeneous mass,  and  the  inner  part  is  filled  with 
granular  matter.  The  movements  are  active,  and 
its  large  size  makes  it  easy  to  study  under  a  low- 
power  microscope.  It  may  be  seen  to  change  its 
form  and  shape  under  the  microscope.  It  puts  out 
its  pseudopodia  and  draws  them  in  again.  It  is 
found  in  the  stools,  in  the  abscess  of  the  liver  and 


iSgi.] 


SOCIETY  PROCEEDINGS. 


825 


lung.  We  find  in  it  things  which  the  organism  has 
taken  up  for  fond,  as,  for  example,  red  blood-cor- 
puscles. The  organism  may  he  seen  in  the  mi- 
crophotographs  which  are  passed  around.  He 
thought  this  form  of  disease  was  not  so  uncommon 
as  many  thought.  He  had  tried  to  find  the  geo- 
graphical range  of  the  disease.  Woodward  also 
had  written  largely  on  dysentery,  had  recorded 
693  deaths  from  intestinal  affection. 

Dr.  Wm.  OSLER  thought  the  form  very  pecul- 
iar and  destructive.  He  referred  to  one  case  he 
had  seen  in  consultation. 

Dr.  A.  FriEDEMWALD  thought  that  Wood- 
ward's cases  died  too  soon  to  have  the  abscess 
occur.     They  develop  late  in  the  disease. 

Dr.  J.  C.  Hemmeter  asked  if  the  amoebae  had 
been  clarified,  and  if  they  had  been  artificially 
cultivated. 

Dr.  W.  T.  Councilman  said  that  Cunning- 
ham, in  1S79,  had  cultivated  them,  not  in  pure 
culture,  and  had  possibly  found  these  forms.  He 
used  a  strong  solution  of  cow  dung.  Another 
investigator  had  obtained  a  pure  culture  and  pro- 
duced the  disease  iu  cats.  Most  animals  are  im- 
mune from  injection  of  the  stools.  He  regarded 
the  amoeba  as  the  undoubted  cause  of  the  disease. 
Dr.  Hiram  Woods  read  a  paper  entitled 

BLINDNESS    IN  THE  UNITED  STATES. 

in  which  he  quoted  numerous  statistics  to  show 
increase  in  blindness,  particularly  among  the  poor, 
principally  from  ophthalmia  neonatorum.  He 
recommended  the  more  widespread  caution  to  the 
poor  that  could  be  distributed  throughout  the 
city,  in  the  hospitals,  dispensaries  and  station- 
houses.  At  his  suggestion,  the  President  ap- 
pointed Drs.  Hiram  Woods,  A.  Friedenwald,  J. 
E.  Michael  and  G.  H.  Rohe,  a  committee  of  four 
to  attend  to  this. 

Dr.  Friedenwald  thought  it  was  the  best 
paper  he  had  ever  heard  on  the  subject.  The 
difficulty  is  not  want  of  knowledge,  but  careless- 
ness, which  causes  blindness  in  the  newborn. 

Dr.  Geo.  H.  Rohe  referred  to  the  absence  of 
ophthalmia  neonatorum  at  the  Maryland  Mater- 
nite,  in  a  large  number  of  births. 

Dr.  R.  L.  Randolph  thought  that  emphasis 
should  be  laid  especially  ou  the  quantity  of  the 
silver  nitrate  used.  Too  strong  a  solution  acts 
as  a  caustic.  Iu  a  child,  the  secretion  of  tears  is 
scant,  and  there  is  less  chance  of  an  excess  of  the 
agent  being  neutralized.  More  than  one  drop 
should  not  be  used. 

Dr.  W.  T.  Cathell  then  read  a  paper  on  En- 
larged Tonsils  and  their  Detrimental  Effect  on 
Health  and  Development. 

Dr.  J.  W.  Humerichouse,  of  Hagerstown, 
read  a  paper  entitled  Four  Cases  of  Diphtheritic 
Laryngitis  in  which  intubation  was  performed 
with  one  recovery,  and  one  case  of  recovery  with- 
out operation. 


The  following  volunteer  papers  were  read : 
"The  Physical  Training  of  the  Feeble-minded, ' ' 
by  Dr.  Samuel  J.  Fort. 

"The  Revival  in  Physical  Training  and  Hygi- 
ene."  by  Dr.  Edwin  M.  Shaeffer. 

A  Second  Series  of  100  Cases  of  Labor  at 
the  Maryland  Maternite."  by  Drs.  Geo.  H.  Rohe 
and  Samuel  H.  Allen. 

'Two  Cases  of  Bilateral  Homonymous  Hemi- 
anopsis,"   by  Dr.  Geo.  J.  Preston. 

"  Acute  Miliary  Tuberculosis  treated  with  Tu- 
berculin. "   by  Dr.  Jno.   C.   Hemmeter. 

"Certain  Pathological  Effects  of  Aneurism,'' 
by  Dr.  N.  G.  Kierle. 

'  "  Iutra-uterine  Diseases  of  the  Eye,''   by  Dr. 
J.  J.  Chisolm. 

"The  Function  of  the  Omentum,"  by  Dr.  How- 
ard A.  Kelly. 

"Two  Obstetric  Cases,"  by  Dr.  W.  Brintou. 

' '  A  Case  of  Cancer  of  the  Bladder ' '  (with  spec- 
imen), by  Dr.  Jas.  Brown. 

"  Supra- vaginal  Hysterectomy,"   by  Dr.  Thos. 
Opie. 

The  following  were  elected  for  the  ensuing  year: 

President— Dr.  W.  H.  Welch. 

Vice-Presidents  —  Drs.    J.    W.    Humerichouse 
and  David  Street. 

Secretaries— Drs.  G.  L.  Taneyhill,  R.  T.  Wil- 
son, J.  T.  Smith  and  Wm.  B.  Canfield. 

Treasurer— Dr.  W.  F.  A.  Kemp. 


st.  Louis  Medical  .Society. 

Stated  Meeting  Saturday,  January  ji,   1891. 

The   Vice-President,    Dr.    J.    C.    Mulhall, 
in  the  Chair. 

[Abstracted  f  ft  The  Journal;. 

Dr.  H.  C.  Dalton  presented  the  following 
specimens  with  sketches  of  the  corresponding 
cases : 

diaphragmatic  hernia,  traumatic. 

The  case  was  a  man,  aet.  26,  who  received  a 
stab  wound  two  and  one-half  years  before,  in  the 
left  thorax  at  the  seventh  intercostal  space  and 
two  inches  posterior  to  mammary  line.  Patient 
entered  hospital  at  the  time  of  this  injury,  and 
was  discharged  apparently  cured  in  a  few  days. 
January  22,  1S91,  he  was  readmitted  to  hospital, 
suffering  greatly.  Pulse  90,  temperature  103. 
Five  days  before  admission  he  had  severe  pain  in 
umbilical  region,  and  bowels  had  not  moved, 
despite  efforts  to  that  end.  Vomited  first  day  of 
attack,  not  since.  Abdomen  swollen  and  hard. 
Pain  constant  and  increased  on  pressure.  Con- 
sulting surgeons  advised  laparotomy,  though  a 
clear  diagnosis  was  not  made  previous  to  the 
operation. 

Abdomen  was  opened  and  a  general  peritonitis 
found.     Upon   search  a  diaphragmatic  opening 


826 


DOMESTIC  CORRESPONDENCE. 


[June  6, 


was  discovered  through  which  all  the  omentum 
and  twelve  or  fifteen  inches  of  the  colon  had 
passed  into  the  left  thoracic  cavity.  Efforts  to 
withdraw  the  mass  were  fruitless,  and  a  slight  in- 
cision of  the  diaphragm  was  made,  when  reduc- 
tion at  once  occurred.  Patient  was  very  weak 
after  the  operation,  and  died  in  four  hours.  Un- 
doubtedly the  diaphragm  was  cut  through  at  the 
time  of  the  stab  injury  over  two  years  since, 
leaving  a  weakened  cicatrix  which  eventually 
gave  way  in  front  of  abdominal  pressure. 

The  specimen  was  presented  showing  the 
pathological  condition. 

In  commenting  upon  the  case  Dr.  Dalton  said 
the  literature  upon  the  subject  of  diaphragmatic 
hernia  was  very  meagre,  surgical  authorities  re- 
ferring to  it  but  briefly. 

LACERATION     OF     MESENTERY ;     RESECTION     OF 
ILEUM. 

Patient  aged  48.  Eleven  and  one-half  hours 
before  admission  to  hospital  patient  fell  from  a 
wagon,  and  while  on  the  ground  a  companion 
jumped  from  the  wagon  landing  on  patient's  ab- 
domen with  both  feet.  Great  pain,  abdomen 
swollen  and  tender.  T.  103,  P.  132.  Lapa- 
rotomy. Two  quarts  of  blood  were  washed  out  of 
the  peritoneal  cavity.  Mesentery  of  ileum  was 
found  torn  entirely  through  for  about  a  foot 
parallel  to  and  about  two  inches  from  the  gut. 
Intestine  was  dark,  and  showed  commencing 
gangrene.  One  foot  of  ileum  was  resected  by 
V-shaped  incision  and  circular  enterorrhaphy. 
Patient  died  ten  hours  after  operation. 

Uterine  Fibroid. — Delivered  from  vagina  after 
strong  expulsive  efforts  of  uterus  and  adjunct 
muscles.  Attached  to  fundus  uteri  by  small  pedi- 
cle, which  was  broken  and  mass  removed  with 
but  little  haemorrhage. 

TREPHINING    FOR    SEVERE   HEADACHE. 

Dr.  T.  F.  Prewitt  presented  a  case  in  which  not 
only  was  the  pain  relieved,  but  a  restoration  of 
the  function  of  the  eye  was  had  after  blindness 
had  continued  for  nine  years. 

Dr.  Williams  inquired  what  were  the  oph- 
thalmoscopic appearances  of  the  optic  disc  ? 

Dr.  Bremer  replied  that  the  eye  was  abso- 
lutely normal  so  far  as  could  be  seen. 

Dr.  A.  B.  Shaw  thought  the  result  rather 
tended  to  confuse  the  location  of  the  centre  of 
sight,  the  opening  in  this  case  being  much  above 
either  the  anular  gyrus  or  cuneus,  high  up  over 
the  first  occipital  convolutions  in  the  region  of 
the  posterior  fontanelle.  The  speaker  felt  that 
in  the  light  of  our  present  returns  regarding 
cerebral  surgery  a  greater  boldness  was  per- 
missible. 

Dr.  Dickinson  said  that  a  few  sources  of  the 
origin  of  the  optic  nerve  are  distinct  and  demon- 
strated, but  the  entire  number  is  infinite.  The 
entire  cerebral  cortex  doubtless  contributes. 


The  President  spoke  at  considerable  length 
and  with  much  clearness  about  the  case,  havin°- 
had  a  knowledge  of  the  peculiarities  previous  to 
the  operation.  He  said  the  question  of  hysteria 
could  be  eliminated  entirely,  and  that  the  out- 
come of  the  operation,  as  to  the  restoration  of 
sight  to  the  patient,  was  indeed  a  wonderful 
achievement.  The  operation  was  done  for  the 
relief  of  the  intense  pain,  and  without  a  thought 
of  any  effect  upon  the  vision.  The  case  should 
be  carefully  watched,  and  the  permanency  of  the 
results  noted. 


DOMESTIC  CORRESPONDENCE. 


Ovariotomy  as  a  Prophylaxis^ andCure 
for  Insanity. 

To  the  Editor: — I  wrote  au  article  on  this  subject  in 
March  of  this  year.  I  further  report  concerning  the  same- 
case. 

Miss  Ada  N.,  age  2S,  had  been  insane  for  13  years, 
when  on  February  4,  1891,  I  made  my  first  ovariotomy 
upon  her,  with  the  result  as  shown  in  my  article  of 
March,  1891.  The  young  lady  continues  to  improve  men- 
tally ami  physically.  Hers  was  a  case  of  hysterical  in- 
sanity, although  the  case  had  beeu  for  13  years  pro- 
nounced a  case  of  dementia.  As  stated  in  my  first  arti- 
cle she  had  had  scarlet  fever  at  13  years  of  age;  just  at 
the  tinie  when  the  ovaria  were  developing  iuto  active 
maturity,  and  were  consequently  checked  and  diseased. 
She  complained  of  ovarian  paiu  for  years,  increased  at 
each  menstrual  epoch.  Now  here  isone  of  those  cases 
wherein  the  sympathetic  nervous  system  was  at  fault  and 
not,  as  was  frequently  diaguosed,  "mental  disease."  This 
case  illustrates  beautifully  the  reflex  effect  of  disease  of 
the  generative  organs. 

The  patient  is  now  undergoing  an  "artificial  change  of 
life." 

Her  present  condition  and  symptoms  are  precisely 
{hose  of  the  menopause.  She  has  not  uttered  one  irra- 
tional word  since  the  removal  of  the  ovaria.  Her  former 
pain  and  symptoms  have  entirely  subsided.  She  talks 
freely  and  rationally,  and  is  daily  gaining  strength,  r 
should  like  to  hear  from  some  of  the  readers  of  The; 
Journal  upon  this  case. 

Diagnosis: — I  believe  too  much  care  cannot  be  exercis- 
ed in  discriminating  between  real  and'psuedo-insanity.  Iu 
this  case  of  Miss  N.,  there  was  abundant  evidence  in  "favor 
of  the  theory  that  scarlet  fever  was  the  cause  of  her  insani- 
ty,as  having  produced  structural  lesion  in  the  brain;  but  at 
the  same  time  there  appeared  positive  evidence  of  ovar- 
ian irritation  which  hacf  been  present  from  the  verv  be- 
ginning of  menstruation;  yet  the  fact  appears  to  "have- 
been  lost  sight  of  by  every  medical  man  under  whose 
eye  the  girl  had  passed.  I  am  compelled  to  sav,  and  that 
without  egotism,  I  trust,  that  specialists  are  too  liable  to, 
lose  sight  of  general  symptoms  and  signs  and  form  or 
base  their  opinions  upon  points  or  signs  peculiar  only  to. 
their  respective  specialities,  thereby  being  not  infrequent- 
ly mislead  from  a  lack  of  power  in  generalizing  such 
cases. 

I  shall  report  the  future  condition  of  this  lady  frota 
time  to  time  and  acquaint  the  readers  of  this  Journai. 
with  her  future  state  of  mental  and  chvsical  health. 

Case  2.— Miss  J.  W.,  Elizabeth,  111?,  age  2S  vears.  Fair 
health;  medium  height;  blonde.  Has  been  iu  poor 
health  since  menstruation  made  its  appearance. 

I  was  called  to  Elizabeth,  111.,  on  March  1st,  of  this 
year,  to  examine  and  pass  my  opinion  upon  this  lady's 
case.     I    found  a  fine  looking  young  lady    confined  in 


i89i.] 


XECROLGY. 


827 


auironcage.     Miss  Y.  confined  for  something 

over  two  years;  sin-  had  not  a  stitch  of  clothing  on  her  per- 
son, nor  had  she  been  able  to  keep  any  clothing  on  her 
for  two  years.  She  would  tear  every  thing  in  the  way  of 
cloth  to  shreds;  even  carpets  they  could  not  keep  tacked 
to  the  floor.  She  had  a  mania  for  tearing  ami 
ing  things  that  were  placed  in  her  cage;  therefore  the' 
only  article  in  the  shape  of  cloth  that  she  could  not  mu- 
tilate was  the  heaviest  sailing  cloth,  and  of  which  cloth 
her  mattress  (that  being  the  only  article  movable  in  her 
cage  was  made,  also  one  very  tough  sheep  skin  which 
constituted  her  sole  bed  covering.  In  this  condition  I 
found  Miss  W.  Her  language  was  continually  abusive, 
profane  and  obscene.  She  appeared  to  possess  a  grudge 
against  all  men.  The  presence  of  a  man  would  always 
excite  obscene  and  profane  language.  She  was  constant- 
ly, during  the  day  time,  climbing  to  the  ceiling  of  her 
cage  and  would  drop  herself  down  on  her  hip  to  the  floor, 
seemingly  endeavoring  to  kill  herself  or  hurt  herself  in 
order  to  get  relief  from  her  pain.  She  would  turn  com- 
plete summersaults  forward  or  backward;  she  would  run 
up  and  down  her  cage,  scream,  swear  and  tear  her  hair 
and  in  every  way  possible  abuse  her  body.  When  quiet, 
she  would  lie  down,  doubled  up  like  a  four  legged  ani- 
mal; showing  conclusively  that  a  relaxation  of  the  abdom- 
inal muscles  was  a  relief  to  her  pain.  She  would  go  for  j 
days  without  a  bite  to  eat.  She  would  defecate  on  the 
floor  most  of  the  time:  having  only  straw  on  the  floor  it ' 
was  periodically  removed,  and  this  could  be  done  only  by 
the  help  of  several  attendants.  In  this  terrible  plight  I 
first  saw  Miss  W. 

Diagnosis: — With  the  assistance  of  three  strong  men  I 
entered  her  cage  to  examine  her.  she  being  thrown  down 
and  her  face  covered  with  an  ordinary  base  ball  mask,  and 
hands  and  feet  bound  down  and  held  by  the  attendants.  I 
proceeded  to  examine  the  case.  I  found-the  heart  very 
much  hypertrophieut,  from  over  exercise.  Lungs  sound. 
Bowels  tender  and  mesenteric  glands  very  much  enlarged; 
both  the  ovaries  were  large,  tender  and  very  much  dis- 
placed downward.  Upon  touching  the  finger  against  the 
clitoris  and  vagina,  she  began  to  work  up  and  down  as  in 
the  act  of  intercourse  and  began  a  volley  of  obscene  lan- 
guage, which  she  kept  up  during  the  digital  examination.  1 
I  could  come  to  no  other  conclusion  than  that  this  was  a 
case  of  ovarian  disease  with  that  nymphomaniac  tend- 
ency which  were  in  all  probability  the  primary  causes  of 
her  insanity. 

The  history  of  the  case  from  the  very  beginning  of 
menstruation  tended  to  show  that  there  was  ovarian  dis- 
ease, but  she  had  been  simply  regarded  as  a  little  cranky 
from  girlhood  up  to  23  years  old,  when  she  had  a  low  af- 
fair with  a  young  doctor  who  they  claim  had  probably  in- 
sulted her,  when  all  at  once  she  became  demented  and 
was  submitted  to  Elgin,  111.,  asylum,  where  she  remain- 
ed two  years. 

Treatment. — Having  diagnosed  this  a  case  of  ovarian 
trouble,  I  suggested  an  immediate  operation  of  removing 
the  offending  organs.  Accordingly  with  my  first  assist- 
ant I  started  from  Racine.  March  1st.  and  proceeded  to 
Elizabeth,  111.,  where  on  March  2nd,  I  performed  the  op- 
eration of  ovariotomy. 

I  found,  as  predicted,  both  ovaries,  with  their  tubes, 
badly  diseased,  being  in  a  nbro-cyslic  condition;  both 
tubes  were  four  times  the  usual  size,  congested  and  in  a 
state  of  pyosalpinx.  There  was  downward  dislocation  of 
both  organs  with  extensive  adhesions.  The  peritoneum 
in  the  region  of  the  orgaus  was  much  thickened  and  con- 
gested, presenting  a  yellowish  pink  color,  showing  con- 
clusively a  congestion  of  long  duration;"the  effect  of  the 
operation  wore  away  in  a  few  hours,  when  she  emerged 
from  it  feeling  weak  ami  tired.  She  presented  a  differ- 
ent facial  aspect  within  forty-eight  hours;  that  peculiar 
idiotic  terrible  set  expression  had  gone.  She  talked  quite 
rationally  most  of  the  time  for  ten  days,  calling  for  the 
bed  pan  and  otherwise  showing  a  great  change.  She 
talked  of  many  things  which  had  happened  years  ago. 


She  recognized  all  her  relatives  and  seemed  quite  ration- 
al. She  would  ask  pleasantly  for  food  and  drink,  and 
express  her  thanks  when  anything  was  done  for  her 
comfort.  Her  family  generally  expressed  their  feeling 
that  reason  had  indeed  resumed  her  sway.  Her  former 
obscene  language  and  profanity  had  entirely  been  for- 
gotten. Her  actions  were  quite  right.  She  did  not  need 
to  be  tied.  After  the  fifteenth  day  she  began  to  tear  a 
lough  she  used  no  bad  language  nor  talked  in- 
sauely.  After  twenty-one  days,  which  time  was  her  usual 
time  for  menstruation,  she  appeared  to  grow  more  nor- 
mal mentally,  but  nothing  of  her  former  trouble  has  yet 
shown  itself.  I  should  like  to  hear  the  opinion  of  the 
profession  upon  this  case. 

I  shall  write  again  upon  this  case  and  give  full  partic- 
ulars. I  do  not  attempt  here  to  offer  anything  original 
or  new  in  the  treatment  of  insanity,  nor  revise  the  long 
since  tried  treatment  of  ovariotomy  forinsanity,  but  sim- 
plv  to  show  what  may  be  accomplished  in  certain  cases. 

I  am  a  voung  and  inexperienced  surgeon  and  am  open 
to  any  criticism  my  professional  brethren  may  see  fit  to 
offer.  This  is  my  fourth  ovariotomy  for  insanity.  The 
third  case  I  shall'  endeavor  to  report  next  month,  it  be- 
ing one  of  marked  diagnostic  interest. 

Dr.  Robert  A.  Kirro. 


Idiosyncrasy  Towards  Eggs. 
To  the  Editor. — I  desire  to  place  on  record  the 
following:  A  lady  27  years  of  age,  has  since  a 
child  never  been  able  to  eat  an  egg  without  suf- 
fering an  attack  of  cholera  morbus  (to  all  appear- 
ances). The  same  condition  occurs  when  she 
eats  them  in  any  form,  as  cake,  etc.,  or  any 
method  of  preparing  them.  The  lady  is  in  all 
other  respects  normal  and  in  good  health  and  de- 
velopment. J.  Ch.  Doods,  M.D. 
Denver,  Col. 


NECROLOGY. 


I.  Ii.  Drake.  M.D. 

At  the  regular  meeting  of  the  Lebanon  Medical 
Society,  held  in  Lebanon,  Ohio,  May  26,  1891, 
the  following  resolutions  were  unanimously 
adopted : 

Whereas.  It  has  pleased  Almighty  God  to  remove 
from  his  earthly  sphere  our  worthy  professional  associate, 
Dr.  I.  L.  Drake,  of  Lebanon,  Ohio,  one  of  the  oldest, 
ablest,  most  devoted  and  useful  members  of  this  society; 
we,  his  surviving  brothers,  deeply  conscious  of  the  loss 
we  have  sustained,  wish  formally  to  record  our  high  ap- 
preciation of  his  character,  his  work  and  his  worth  :  be 
it.  therefore, 

Resolved.  That  we  hereby  express  our  sincere  grief  for 
the  sadlv  sudden  death  of  our  friend ;  an  elegant,  culti- 
vated, affable  gentleman  :  active,  earnest,  patient  in  his 
search  after  truth  :  constant,  courageous  and  firm  in 
maintaining  the  right  as  lie  saw  it ;  an  honest  christian 
man.  In  obedience  to  the  Almighty  power  that  rules  the 
-  of  men,  that  can  build  up  or  cast  down,  that 
can  give  or  take  away,  we  bow  in  humble  submission 
about  the  bier  of  our'  departed  fellow  member  and  pro- 
fessional brother. 

Resolved.  That  we  most  heartily  tender  to  Dr.  Drake's 
bereaved  family  and  relatives  this  expression  of  our  pro- 
found svmpath'y.  and  the  acknowledgement,  that  in  his 


828 


MISCELLANY. 


[June  6,  1891. 


death  we  lose  a  true  and  cherished  friend  and  co-laborer; 
and  be  it  further 

Resolved,  That  a  copy  of  these  resolutions  be  sent  to 
the  family  of  the  deceased,  and  that  they  be  furnished  to 
the  papers  of  Lebanon,  the  Cincinnati-Lancet  Clinic, 
and  to  The  Journal  of  the. American  Medicai,  As- 
sociation. 

B.  H.  Blair,  R.  S.  Michel,  Jno.  Wright.  E.  J.  Tichenor, 

H.  J.  Death,  S.  S.  Scoville. 

Dr.  Karl  Braun  von  Fernwald,  the  emi- 
nent professor  and  author,  of  the  Vienna  Uni- 
versity, died  during  the  last  week  in  March.  He 
was  appointed  to  the  chair  of  midwifery  and  be- 
come the  head  of  the  famous  gynecological  Klinik 
over  thirty  years  ago.  His  writings  have  been 
among  the  most  sought  after  of  those  devoted  to 
his  chosen  subjects  and  he  enjoyed  a  pre- 
eminent popularity  among  the  Viennese  students. 
He  was  in  the  seventieth  year  of  his  age  and  the 
fortieth  year  of  obstetric  teaching,  at  the  time 
his  death. 


situation  of  threatened  danger  from  epidemic  disease, 
are  familiar  to  every  reader  of  current  history. 

Many  regrets  will  be  expressed  at  his  retirement  from 
a  position  where  his  services  have  been  of  inestimable 
value  to  the  entire  country,  while  his  appointment  as  one 
of  the  faculty  of  Rush  cannot  but  add  to  the  already  pros- 
perous condition  of  this  well-known  school  of  medicine. 

Dr.  Walter  Wyman  is  the  legitimate  successor  of  Dr. 
Hamilton,  and  will  no  doubt  fully  sustain  the  enviable 
reputation  of  his  predecessor. 


Washington  State  Medical  Society.— The  second 
annual  meeting  of  the  Washington  State  Medical  So- 
ciety, held  in  Seattle,  May  6  to  8,  was  largely  attended. 

Papers  on  the  following  subjects  were  read  and  ordered 
printed  with  the  proceedings  of  the  meeting: 

Annual  Address,  by  C.  K.  Merriam,  Spokane. 

Anatomv,  Dr.  E.  E.  Heg,  North  Yakima. 

Physiology.  Dr.  H.  P.  Tuttle. 

General  Surgery,  Dr.  N.  Fred.  Essig,  Spokane. 

Abdominal  Surgery,  Dr.  E.  L.  Smith,  Seattle. 

Surgery  of  the  Brain,  Dr.  J.  B.  Wintermeuth,  Tacoma. 
_         .  TT  ,,.,.,.  I      Genito-Urinarv    Surgerv,    Dr.    C.    H.    Willison,    Port 

Dr.  Alfred  Hosmer,   who  died  May    14,    at  Townsend.         '  " 


Watertown,  Mass.,  was  one  of  the  ex-presidents 
of  the  Massachusetts  State  Medical  Society,  and 
formerly  a  member  of  the  State  Board  of  Health 


Report  on  Obstetrics  and  Gynecology,  by  Dr.  J.J.  Mc- 
Kone,  Tacoma. 

"Do  Maternal  Impressions  Affect  the  Foetus  in  Utero?" 


,  ,M  '   ..  „  c  .,      r         ,  ,,,        k  Dr.  T.  V.  Goodspeed,  Seattle, 

and  Lhanty.     He  was  one  of  the  founders  of  the     --Treatment  of  the  Insane,"  Dr.  J.  W.  Waughop,  Steil- 
Medico- Legal  Society  and  a  medical  examiner  acoom. 


for  fourteen  years.  He  was  also,  for  many  years, 
the  post-surgeon  of  the  United  States  Arsenal  at 
Watertown.  He  was  a  frequent  contributor  to 
the  medical  journals  on  obstetrical  and  medico- 
legal subjects.     He  was  in  his  sixtieth  year. 

Dr.  Otis  Stanton,  of  Washington,  D.  C, 
died  April  9,  inhis  fifty-third  year.  He  was  a 
native  of  Strafford,  New  Hampshire,  having 
been  born  there  October  22,  1837.  He  obtained 
his  medical  education  at  the  Bowdoin  College, 
graduating  in  the  class  of  1862.  In  that  same 
year  he  became  acting  assistant  surgeon  and 
served  in  and  around  Washington  until  the  latter 
part  of  1865.  He  then  took  up  practice  at  that 
city,  giving  special  attention  to  gynecology.  He 
was  a  member  of  the  board  of  directors  of  the 
Columbia  Hospital  for  Women  and  Lying-in 
Asylum.  He  was  a  corresponding  member  of 
the  Gynecological  Society  of  Boston.  His  death 
took  place  after  a  brief  illness  by  pneumonia 
superinduced  by  epidemic  influenza. 


MISCELLANY. 


'Analgesia  of  the  Insane,"  Dr.  W.  J.  Redpath,  Steila- 
coom. 

"On  the  Existence  of  an  Intellectual  Center,"  Dr.  G. 
S.  Armstrong,  Olympia. 

"Increased  Reflexes  and  Allied  Phenomena,"  Dr.  C.  W. 
Sharpies,  Seattle. 

'Importance  of  Free  Nasal  Respiration,"  Dr.  A.  B. 
Kibbe,  Seattle. 

The  following  officers  were  elected  for  the  ensuing 
year: 

President,  H.  C.  Willison,  Port  Townsend. 

First  Vice-President,  G.  W.  Libby,  Spokane. 

Second  Vice-President,  H.  P.  Tuttle,  Tacoma. 

Secretary,  Elmer  E.  Heg,  North  Yakima. 

Treasurer,  James  B.  Eagleston.  Seattle. 

Next  meeting  will  be  held  in  North  Yakima,  Washing- 
ton, beginning  the  second  Wednesday  in  Ma}-,  1S92,  and 
continue  for  three  days.  Elmer  E.  Heg,  Sec'y. 


Resignation  and  Appointment. — Dr.  J.  B.  Hamil- 
ton, Surgeon-General  of  the  United  States  Marine-Hos- 
pital Service,  has  resigned  in  order  to  enable  him  to  accept 
■  ■I  the  Professorship  of  Principles  of  Surgery  in  Rush 
Medical  College.  Dr.  Walter  Wyman  succeeds  Dr.  Ham- 
ilton in  the  National  Service. 

Dr.  Hamilton's  marked  success  as  a  sanitarian,  and 
ability  to  grasp  at  once  and  meet  the  necessities  of  any 


Official  List  of  Cttanges  in  'tie  Stations  and  Duties  of  Officers  Serving 
in  the  Medical  Department.  U.  S.  Army,  from  May  2J,  1801,  to 
May  20,  1891. 

Capt.  Paul  R.  Browu,  Asst.  Surgeon  U.  S.  A.,  is  granted  leave  of  ab- 
sence for  one  month,  with  permission  to  apply  for  an  e\t<  nsion 
of  one  month.  Par.  4,  S.  O.  ^9,  Dcpt.  of  the  Missouri,  St.  Louis, 
May  26,  1891. 

Capt.  Marlborough  C.  Wyeth,  Asst.  Surgeon,  granted  leave  of  ab- 
sence for  three  months,  on  surgeon's  certificate  of  disability.  By 
direction  of  the  Secretary  of  War.  Par,  6,  S.  0. 119.  A.  G.  (.1  Wash- 
ington, May  25,  1S91. 

I  of  Changes  of  Stations  and  Duties  of  Medical  Officers  of 
the   U.   S.   Marine-Hasp.  .  Weeks   Ending 

May  21,  1S01. 
Surgeon  John  Vansant,  granted  leave  of  absence  for  seven  davs. 

May  22 
Surgeon  Fairfax  Irwin,  granted  leave  of  absence  for  twenty-one 

daj  S.     May  11,  l§gl. 
Asst.  Surgeon  G.   M.  Guiteras,  relieved  from  special  duty  at  New 

York  City;  ordered  to  San  Francisco,  Cal.     May  11.  1891. 
Asst.  Surgeon  J.  F.  Groenevelt,  relieved  from  duty  at  New  Verk 

Marine-Hospital;  ordered  to  Gulf  Quarantine.    May  22,  iSgi. 
Asst.  Surgeon  G.  B.  Young,  granted  leave  of  absence  for  thirty  davs. 
May  11,  1S91, 

PROMOTIONS. 


'.  A.  Surgeon  T.  n.  Perry.com 

Mav  23,  1891. 
'.  A.  Surgeon  R.  M.  Woodward  com 

ideut,  May  23,  1S91. 


issioned  as  such  by  the  President, 
issioned  as  such  by  the  Pres- 


■l3 


The  Journal  of  the 

American  Medical  Association 


Vol.  XVI. 


CHICAGO,  JUNE  13,   1891. 


Xo.   24. 


ORIGINAL  ARTICLES. 


THE    PREVALENCE     OF    ALBUMINURIA 
IN  PERSONS  APPARENTLY  HEALTHY. 

Read  in  the  Section  of  Practice  of  Medicine  and  Physiology,  at  the 
Fortx-second  Annual  Meeting  of  the  Am  it  Associa- 

tion, held  at  Washington.  D.  C.  May 

BY  WILLIAM   E.    DAVIS.   A.M.  M.D.. 

OF  C1NCINN 

I  read  a  paper  before  the  American  Medical 
Association  at  its  Forty-first  Annual  Meeting, 
held  in  Nashville.  Tenn..  May  20th.  1890.  on  the 
subject  of  'Functional  Albuminuria,  or  Albumi- 
nuria in  Persons  Apparently  Healthy,"  in  which 
I  reported  a  case  which  had  been  under  my  ob- 
servation for  five  years.  On  March  5th  of  this 
year.  1S91,  I  made  a  careful  urinalysis  of  this  per- 
son's twenty-four-hours'  urine,  examining  separ- 
ately each  specimen  as  voided,  and  then  mixing 
them  together  and  again  examining  a  sample  of 
the  whole  quantity.  The  tests  used  weie  cold 
nitric  acid, — contact  method. — and  boiling,  then 
adding  a  drop  or  two  of  nitric  acid  and  again 
boiling.     The  following  are  the  results,  viz.: 

COLOR.  .™"        ^J^'        ALBrMEX. 


Trine  passed  at 


7  a.m.  Dark   straw 
11  a.m.  Straw. 

115  p.m. 

P.M. 

p.m.  Dark  Straw 
P.M.  Straw. 


030  Xo  albumen. 
020  Faint  trace. 
02S  Faint  trace. 
C20  Faint  trace. 
02S  Small  quantity 
020  A  trace. 


Whole  amount  of  twenty-four  hours'  urine.  32 
ounces;  reaction,  acid;  color,  dark  straw;  specific 
gravity,  1.025;  albumen,  a  faint  trace.  With- 
out the  addition  of  the  9  p.m.  urine,  albumen  was 
not  discoverable.  The  9  p.m.  urine  was  the  only 
sample  which  gave  any  deposit  of  sediment  after 
standing  twenty-four  hours.  A  microscopical  ex- 
amination of  this  sediment  resulted  as  follows, 
viz. : 

1.  Casts.     Only  an  occasional  hyaline  cast. 

2.  Crystals.  Calcium  oxalate  crystals  present 
in  great  numbers. 

3.  Epithelium.  Pavement  and  small  round 
bladder  epithelial  cells  present  in  small  numbers. 

Another  examination  of  his  urine  was  made  on 
March  21st,  1891,  with  about  the  same  results, 
except  that  less  reaction  was  obtained  than  on 
any  former  examination.     The  night  urine  con- 


tained no  albumen,  and  the  urine  passed  two  . 
hours  after  his  mid-day  lunch  contained  the  most 
albumen:  after  standing  twenty- four  hours  it  con- 
stituted one-twentieth  of  the  urine  in  the  test 
tube.  The  specific  gravity  of  the  twenty-four 
hours'  urine  was  1.028.  reaction  acid,  color  dark 
straw.  During  the  six  years  he  has  been  under 
my  observation  his  twenty-four  hours'  urine  has 
never  exceeded  40  ounces  in  quantity  and  the 
specific  gravity  has  never  been  lower  than  1.020. 
His  early  morning  urine  has  never  contained  al- 
bumen, although  it  has  invariably  been  present 
in  small  quantity  at  some  hour  later  in  the  day. 
He  has  always  been,  and  still  is  in  the  best  of 
health  seemingly.  He  has  not  had  a  day's  illness 
in  ten  years.  He  has  not  had  rheumatism,  gout, 
lead  poisoning,  syphilis,  nephritis,  dyspepsia  or 
dropsy.  No  member  of  his  family  has  had  any 
of  the  above  diseases  or  any  history  of  Bright' s 
disease.  In  his  case  there  is  no  increase  of  vas- 
cular tension,  no  cardiac  hypertrophy,  palpita- 
tion or  dyspnoea,  and  no  retinal  symptoms.  He 
is  36  years  of  age,  temperate  in  all  his  habits, 
happily  married,  prosperous  in  his  business,  re- 
sides in  a  suburban  home  where  he  spends 
his  time  after  business  hours.  This  case  of  al- 
buminuria, which  I  present  to  you,  is  not  a  hy- 
pothetical,— a  supposititious  case,  such  as  our 
learned  brethren  of  the  bar  are  accustomed  to 
fire  at  the  unfortunate  disciples  of  -Esculapius, 
\vhen  they  get  them  at  short  range  upon  the  wit- 
ness stand,  but  he  is  a  living  being,  like  our- 
selves, who  has  been  under  my  observation  for  the 
past  six  years.  His  case  is  not  an  exceptional  one, 
but  a  typical  one,  and  has  been  observed,  studied 
and  recorded  the  world  over.  Pavy  designates 
this  condition  as  "cyclical  albuminuria.''  Sena- 
tor, who  fully  endorses  Pavy's  observations,  pre- 
fers the  term  "paroxysmal,"  while  other  equal- 
ly eminent  observers  believe  that  "intermittent" 
is  the  best  name  for  it.  I  shall  not  consume  any 
time  in  the  discussion  of  the  merits  of  these  par- 
ticular names,  but  shall  speak  of  this  form  of  al- 
buminuria, and  the  other  forms  which  may  oc- 
cur in  persons  apparently  health}-,  as  "functional 
albuminuria." 

Now  what  is  the  clinical  significance  of  the  al- 
buminuria in  a  case  like  this?  If  this  man  had 
not  made  application  for  life  insurance  six  years 


830 


THE  PREVALENCE  OF  ALBUMINURIA. 


[June  13, 


ago,  no  one,  up  to  this  date,  would  have  known, 
or  even  suspected  that  anything  was  the  matter 
with  him.  For  all  practical  purposes  he  was  and 
is  a  perfect  specimen  of  manhood.  During  these 
six  years  he  has-  become  the  father  of  three 
healthy  children,  has  amassed  a  fortune  in  his 
business,  is  a  public  spirited  citizen,  and  prom- 
inent in  all  benevolent  and  church  work. 

During  the  past  fifty  years  albuminuria  has 
been  regarded  as  the  one  infallible  symptom — if 
not  synomyn — of  Bright' s  disease.  As  a  con- 
sequence, the  patient  in  whose  urine  albumen 
was  found,  was  regarded  as  a  doomed  man,  as 
Bright' s  disease  was  believed  to  be  necessarily 
fatal.  After  a  time,  however,  it  was  found  ihat 
albuminuria  was  frequently  present  in  other  dis- 
eases, as  for  example,  pregnancy,  the  puerperal 
state,  zymotic  and  other  febrile  diseases,  lead  poi- 
soning, etc.  These  discoveries  modified  its  sig- 
nificance somewhat,  but  did  not  materially  re- 
duce the  gravity  of  its  presence  in  other  cases. 
Then,  such  a  veteran  authority  as  Prof.  Geo. 
Johnson  asserted  that  albumen,  to  a  large  amount, 
may  be  constantly  present  in  the  urine  of  men, 
women  and  children  who  are  apparently  in  good 
health,  and  he  even  went  so  far  as  to  say  that  "it 
has  been  proven  by  abundant  experience  that  the 
mere  fact  of  albumen,  even  in  large  amount,  fil- 
tering through  the  walls  of  the  malpighian  cap- 
illaries does  not  seriously,  if  at  all,  interfere  with 
the  proper  excretory  function  of  the  convoluted 
tubes. ' ' 

Then,  Finlayson,  Mahomed,  Fraser,  and  other 
eminent  authors,1  demonstrated  that  structural  dis- 
ease of  the  kidneys,  or  Bright's  disease  may  actually 
be  existant  without  albuminuria,  and  Prof.  Fraser 
informs  the  profession  that  "albumen  is  only  one 
symptom"  and  that  all  forms  of  Bright's  disease 
are  accompanied  by  other  symptoms. 

Then,  Prof.  Grainger  Stewart  makes  the  re- 
markable statement  "that  cases  of  Bright's  dis- 
ease do  not  account  for  one- half  of  the  cases  of 
albuminuria  met  with  in  practice,"  and  Dr. 
Saundby,  in  his  recent  work  on  Bright's  disease, 
makes  this  astounding  utterance:  "The  practical 
outcome  of  the  study  of  the  incidence  of  albu- 
minuria in  the  sick  and  the  healthy  should  be  to 
extinguish  altogether  the  pernicious  doctrine 
that  albuminuria  means  organic  disease  of  the 
kidneys,  a  doctrine  less  harmful  than  the  equally 
fallacious  one  that  organic  disease  of  the  kidneys 
is  a  rapidly  fatal  disease."  And  then  the  British 
Medical  Journal ',  in  a  leading  editorial  makes  the 
broad  announcement  that  "albuminous  urine  is 
no  longer  the  equivalent  expression  for  Bright's 
disease,"  and  says  "the  attention  of  the  profes- 
sion,  during  the  last  few  years,  has  been  called 
to  the  fact,    by  repeated   observations,    that  al- 


Chicago,  in  r88s,  collected  from  Guj  sand  othei 

spital  reports,  25 F  chronic  Bright's  diseasi   in  which  al 

men  was  present  in  mil,        ,  \    ,    inj es   uearly  74 

cenl     in  which  albumen  wasabsenl 


bumen  may  be  found  in  the  urine  of  persons  who 
do  not  exhibit  any  of  the  general  symptoms  of 
Bright's  disease,  nor  even  any  evidence  of  any 
deterioration  of  health."  Finally,  Prof.  Moxon, 
after  relating  the  various  causes  which  will  pro- 
duce temporary  albuminuria,  says:  "Albuminuria 
becomes  in  relation  to  disorders  of  the  renal  sys- 
tem what  neuralgia  is  to  disorders  of  the  nervous 
system,  or  what  dyspncea  is  in  disorders  of  the 
respiratory  system — a  name  of  a  symptom — 
which  is  on  the  very  outskirts  of  an  intimate 
knowledge  of  any  case,  and  thus  albuminuria,  as 
Dr.  Bright  knew  it,  becomes  by- gone  and  his- 
toric." 

These  utterances  from  such  authoritative 
sources  are  sufficient  to  warrant  the  opinion  that 
the  significance  of  albuminuria,  as  first  an- 
nounced, was  overestimated ;  nevertheless,  its 
grave  significance  is  so  thoroughly  ingrained  in 
the  profession  that  we  can  scarcely  admit  of  any 
other  condition  than  a  pathological  one  as  being 
compatible  with  its  presence. 

Prevalence  of  Albuminuria. — Until  a  few  years 
since,  it  would  have  been  considered  rank  heresy 
for  any  person  to  have  suggested  that  albumi- 
nuria was  compatible  with  any  other  condition 
than  that  of  organic  renal  disease,  and  a  physi- 
cian would  have  been  looked  upon  as  somewhat 
unbalanced  in  his  mind  who  would  have  asserted 
that  albuminuria  would  occasionally  be  found  in 
persons  apparently  healthy,  but  now  the  medical 
press,  in  both  Europe  and  America,  claim  that  it 
has  been  found  in  a  large  percentage  of  people 
otherwise  healthy;  and  this  claim  has  been  sup- 
ported by  so  many  eminent  physicians  the  world 
over,  that  there  seems  to  be  no  doubt  of  its  cor- 
rectness. 

In  our  country  Shepherd  found  albumen  in  the 
urine  of  2  per  cent,  of  35,471  persons  examined. 
Washburn,  of  Milwaukee,  found  it  in  5.91  of  33S 
examinations  of  healthy  persons  for  Life  Assur- 
ance. Munn  found  it  in  11  per  cent,  of  a  large 
number  of  individuals  "who  considered  them- 
selves perfectly  healthy."  Edes  states  that  the 
presence  of  albumen  in  minute  traces,  or  some- 
thing that,  gives  a  similar  reaction  with  the  most 
delicate  re- agents,  is  much  more  common  than  its 
absence,  and  the  amount  detectable  by  heat  and 
nitric  acid  may  be  approximately  stated  as  from 
10  to  20  per  cent,  of  persons  examined. 

In  Great  Britain  and  in  Europe  larger  percent- 
ages have  been  found.  Grainger  Stewart,  in  a 
report  to  the  Royal  Society  of  Edinburgh,  stated 
that  he  found  albumen  present  in  31  per  cent,  of 
407  urines  from  healthy  individuals  and  he  con- 
cluded his  report  by  saying  "that  albuminuria 
is  much  more  common  among  presumably  healthy 
.people  than  was  formerly  supposed,  tests  having 
demonstrated  its  presence  in  nearly  one  third  of 
the  population." 

Dr.  Turner.   Medical  Officer  of  Essex  County 


1891.]  THE  PREVALENCE  OF  ALBUMINURIA.  831 

Insane  Asylum,  England,  found  albumen  in  the  nuria  in  persons  apparently  healthy  when  corn- 
urine  of  40.2  per  cent,  of  200  male  inmates,  and  pared  with  those  of  our  British  and  Continental 
in  another  Insane  Asylum,  Kleudgen  found  al-  cousin-.  I  asked  Dr.  Victor  C.  Vanghan,  Prof,  of 
bumen  in  43  per  cent,  of  the  healthy  nurses.  Chemistry  in  the  University  of  Michigan,  why  it 
Stirling  found  it  in  44  per  cent,  of  461  healthy  was  that  physicians  in  Great  Britain  and  Europe, 
adults  examined  by  him;  Capitan  found  it  in  45  men  of  undoubted  ability  and  world  wide  fame, 
per  cent,  and  in  children  89  per  cent.:  De  la  Celle- .  were  finding  albumen  in  the  urine  of  20,  30,  50, 
Chateauberg  says  it  may  be  found  at  times  in  the  70  and  100  percent,  of  healthy  persons  examined 
urine  of  76  per  cent,  to  100  per  cent,  of  healthy  by  them,  when  the  highest  per  cent,  reported  in 
persons,  both  young  adults  and  children;  Posner  our  country  was  but  from  10  to  20  per  cent?  In 
asserts  that  he  has  proven  the  existence  of  albu- ;  reply  to  my  inquiry  he  wrote:  "I  will  agree  to  the- 
men  in  all  normal  urine,  and  his  experiments  statement  that  proteids  are  frequently  found  in 
have  received  the  stamp  of  approval  from  such  :  the  urine  of  the  healthy,  or  those  who  so  far  as- 
men  as  Senator,  Duden,  Leube  and  V.  Xoorden.  |  they  themselves  or  any  one  else  may  know,  are 
Washburn,  of  Milwaukee,  in  The  Medical  News  healthy",  and  he  called  my  attention  to  an  arti- 
April  5th,  1890,  says  that  in  order  to  verify  theieleon  "  The  Proteids  of  the  Urine,  with  a  compar- 
claim  of  Posner,  he  tested  with  picric  acid  by  the  ison  of  the  Tests  for  Albumen*'  by  F.  G.  Novy, 
contact  method,  and  also  with  the  phenic  acetic  MS.,  Instructor  in  Physiological  Chemistry, 
test,  and  with  a  solution  of  citric  acid  of  a  speci-    University  of  Mich.  ws,  Vol  53,  1SS8), 

fie  gravity  of  i.coS  by  the  same  method,  samples  ;  and  said  "  you  will  see  from  this  article,  to  which 
of  urine  from  fifty  persons  in  perfect  health,  all  I  have  referred  you,  that  with  some  of  the  pro- 
living  in  good  sanitary  surroundings,  and  "in  posed  tests  you  can  find  albumen  in  the  urine  of 
every  instance,  at  the  line  of  contact  of  the  two  ;  almost  any  one."  In  this  article  Mr.  Novy  calls 
fluids,  the  characteristic  cloud  appeared  with  more  attention  to  the  fact  that  serum-albumen  is  the 
or  less  distinctness  indicating  the  presence  of  an  ''  only  proteid  which  the  average  physician  ex- 
albuminoid."  pects  to  find  in  the  urine.  Whereas,  globulin, 
Prof.  Senator,  of  Berlin,  in  his  recent  work  en-  hemi-albumose  (Bence  Jones  albumen)  and  pep- 
titled  "Albuminuria  in  its  Physiological  and  tone,  are  also  frequently  present.  In  the  ordi- 
Clinical  Relations"  Berlin,  1890,  says  "the  more  nary  methods  for  testing  for  albumen,  all  of  these 
complete  methods  of  investigation  and  the  appli-  proteids  but  peptone  may  be  readily  mistaken  one 
cation  of  delicate  tests  have  had  as  a  result  the  {"or  another,  and,  indeed,  he  says,  "  this  has  been 
discovery  that  albumen  is  frequently  found  in  the  rather  the  rule  than  the  exception."  Serum- al- 
urine  of  men  who  exhibit  neither  objective  nor  bumen  is  generally  considered  to  be  indicative  of 
subjective  symptoms  of  disturbances  of  health,  structural  disease  of  the  kidneys,  but  the  other 
and  who  after  a  long  continued  observation,  ap-  proteids  have  no  such  grave  significance,  never- 
pear  to  be  perfectly  healthy."  From  the  reports  |  theless  serum  albumen  is  usually  accompanied 
of  a  number  of  the  best  authors,  he  says:  "we  are  by  larger  or  smaller  quantities  of  globulin,  and 
warranted  in  believing  that  albumen  is  found  in  in  some  instances,  even  peptones  may  be  present, 
the  urine  without  any  other  discoverable  patho-  "our  ordinary  tests  for  serum- albumen  are  also 
logical  changes,  in  a  surprising  number  of  cases,  responded  to  by  globulin  and,  hence,  when  ap- 
Forty-one  out  of  every  one  hundred  healthy,  plied  to  an  albuminous  urine,  they  indicate,  as  a 
strong  men,  especially  soldiers,  under  ordinary  rule,  a  greater  amount  of  serum  albumen,  than 
circumstances  have  albuminuria."  Senator  holds  I  that  actually  present." 
that  we  may  regard  the  appearance  of  albumen       Globulin  usually  accompanies  serum-albumen 


in  the  urine  of  healthy  men  as  the  "Physiologi- 
cal albuminuria,  just  as  there  exists  a  physiolog- 
ical glycosuria,  oxaluria  and  indigouria." 

Sir  Wm.  Roberts  says  it  has  been  both  affirmed 
and  denied,  on  high  authority,  that  traces  of  se- 
rum-albumen exist  in  normal  urine.    "I  have  sat- 


and  may  be  present  in  almost  all  varieties  of  al- 
buminuria, though  in  variable  quantity.  Accord- 
ing to  Hammaisten,  it  constitutes  from  8.13  to 
60. 24  per  cent,  of  the  total  proteids  in  albuminous 
urine.  The  more  recent  investigations  of  Maguire 
indicate  that  globulin  can  exist  in   the  urine   by 


isfied  myself"  he  says,  "that  concentrated  urines  itself,  even  without  serum-albumen  being  present, 
from  persons  in  undoubted  health  are  compara-  and  he  reports  three  cases  of  cyclic  or  functional 
tively  rarely  free  from  traces  of  albumen,  detecta-  albuminuria,  and  one  of  puerperal  albuminuria, 
ble  by  direct  testing.     In    ordinary  processes  of  where  he  found  the  proteid  of  the  urine  to  con- 


testing urine,  these  traces  are  naturally  overlook- 
ed, but  they  certainly  exist  very  frequently,  and 
.their  existence  shows  how  nearly  on  the  verge  of 
a  sensible  albuminuria  healthy  people  are." 

The  Proteids  of  the  Urine. — It  is  somewhat  re- 
markable that  the  recorded  observations  in  our 


country  show  a  very  low  percentage  of  albumi-    Association  May  22d,  1S90,  viz 


sist  solely  of  globulin.  Novy  also  mentions  one 
case  of  functional  albuminuria  which  came  under 
his  observation  where  globulin  alone  was  found 
in  the  urine.  These  reports  accord  with  the 
statement  I  made  in  my  paper  on  "Functional 
Albuminuria"  read  before  the  American  Medical 


832 


ELECTRICITY  AS  A  THERAPEUTIC  AGENT. 


[June  13 


"The  present  line  of  investigation  is  pointing 
strongly  toward  globulin  as  the  form  of  albumen 
which  is  likely  to  be  found  in  the  various  forms 
of  functional  albuminuria  when  chemistry  will 
furnish  us  with  simpler  methods  and  more  relia- 
ble reagents  for  its  discovery." 


ELECTRICITY   AS    A   THERAPEUTIC 

AGENT.     WHAT  IS    NEEDED  TO 

DETERMINE  ITS  MERITS? 

Read  in  Hi,'   Section  of  Practice  of  Medicine  and  Physiology,  at  the 
.  .    ;,a'!  M-etnve  o't  the  American  Medical  Associa- 
tion, h  m,D.C,  May,  iSgi. 

BY  \Y.  J.  HERDMAX,  31. D.. 

OF   ANN-   ARBOR,  MICH. 

There  are  few  subjects  toward  which  the  mind 
of  the  medical  practitioner  is  more  in  need  of 
proper  adjustment  than  that  of  the  use  of  electric- 
ity as  a  therapeutic  agent.  It  is  now  more  than 
a  century  since  a  professor  of  anatomy  in  the 
University  of  Bologna  announced  to  the  profes- 
sion—that is  daily  puzzling  its  brains  over  the  va- 
rious ills  that  flesh  is  heir  to— that  he  had  discov- 
ered, in  the  association  of  dissimilar  metals  with 
the  legs  of  decapitated  frogs,  a  force  was  generated 
capable  of  acting  as  a  substitute  for  nerve  im- 
pulse in  causing  muscular  contraction. 

Electro- physiological  inquiry  received  a  new 
impulse  from  this  "discovery  of  the  effects _  of  a 
continuous  or  galvanic  currenton  living  tissue, 
and  from  that  time  on  there  has  been  an  unceas- 
ing activity  displayed  by  many  of  the  best  minds 
in  the  profession,  in  adding  to  our  knowledge  of 
the  power  of  electricity  in  modifying  and  control- 
ling the  vital  processes  going  on  in  animal  struc- 
ture, until  medical  and  scientific  literature  is  bur- 
dened with  the  rich  fruit  of  their  researches. 

Many  of  the  discoveries  in  electro-physiology 
suggest  valuable  additions  to  our  therapeutics, 
andwhile  there  have  not  been  wanting  examples 
of  able  men  in  the  profession,  like  Remak,  Du- 
chenne,  von  Zeimssen,  Erb  and  De  Watteville, 
who  have  used  their  best  energies  to  gain  for  elec- 
tro-therapeutics the  recognition  which  its  impor- 
tance deserves,  its  power  as  a  curative  agent  is  as 
yet  but  imperfectly  understood  by  the  vast  major- 
ity of  physicians.  The  reason  for  this  is  readily 
explained.  The  work  of  the  physiologist,  though 
indispensable  as  antecedent  to  rational  therapeu- 
tics, is  often  in  too  crude  a  state  to  be  readily 
made  available  by  the  busy  practitioner.  A  hia- 
tus exists  between  the  discoveries  of  pure  science 
and  their  practical  application  to  the  requirements 
of  everyday  life.  Men  are  rare  who  have  either 
the  time,  the  opportunity  or  the  ability  to  acquire 
such  experience  in  both  fields  of  research  as  to 
adapt  the  discoveries  of  the  one  to  the  needs  of 
the  other.  Electric  physics,  physiology  and  pa- 
thology, each  are  so  comprehensible  in  their  scope 


that,  with  the  best  facilities,  a  lifetime  is  spent  in 
acquiring  a  knowledge  of  what  is  known  of  each. 
It  is  no  wonder,  then,  that,  during  the  past  cen- 
tury, in  which  so  much  has  been  revealed  con- 
cerning the  mysterious  working,  both  on  the  or- 
ganic and  inorganic  world,  of  that  strange  force 
we  call  electricity,  so  little  practical  use,  has  been 
made  of  it  by  the  physician,  and  that  it  has,  in 
common  with  many  other  discoveries,  in  the  twi- 
light of  their  early  dawn,  been  seized  upon  by  the 
impostor  and  charlatan  as  suitable  instruments 
with  which  to  prey  upon  the  minds  and  pockets  of 
a  credulous  and  expectant  world;  and  when,  in  ad- 
dition to  this,  we  recall  the  fact  that  there  has  ex- 
isted among  those  who  have  attempted  to  direct  our 
minds  toward  the  therapeutical  application  of  elec- 
tricity, the  greatest  diversity  of  opinion  as  to  the 
form  of  currents  that  should  be  used,  and  the  meth- 
ods for  applying  them,  and  that  no  attempt  has 
been  made  at  uniformity  even  in  the  instruments 
employed  for  this  purpose,  it  is  not  surprising  that 
electricity  as  a  therapeutic  agent  has  been  looked 
upon  as  of  rather  doubtful  efficiency  by  the  ma- 
jority of  physicians.    But,  fortunately,  while  these 
causes  have  operated  to  bring  electricity  into  dis- 
repute in  the  minds  of  conscientious  practitioners 
1  of  medicine,  the  rapid  strides  it  has  made  in  other 
fields  of  usefulness  have  raised  it  in  importance 
and  esteem,  so  that  its  power  and  efficiency  must 
be  everywhere  recognized  by  the  man,  be  he  med- 
ical or  lav,  whose  daily  life  is  so  dependent  on  its 
labor.     It  now  requires  but  little  argument  to 
convince  any  man  that  electricity  may  probably 
effect  some  change  in  the  disordered  state  of  his 
bodily  economy,  who,  every  hour  of  the  day,  is 
depending  upon  this  selfsame  force  to  aid  him  in 
the  minutest  details  of  his  daily  life.     Nor  does 
the  physician  now  entertain  that  same  contempt 
which"  once  he  might  have  done  for  an  agency 
which,  in  these  latter  days,  lights  lip  his  house, 
washes  his  linen,  stitches  his  clothes,  prints  his 
newspapers,  cooks  his  meals,  transports  him  to 
his  office,  and  brings  him   into  communication 
with  his  patients,  far  or  near,  while  sitting  at  his 
desk.     So  insidiously  have  the  commercial  uses 
of  electricitv  crept  in  upon  us,  and  so  indispen- 
sable have  "they  become  already  to  our  comfort, 
that  were  we,  as  a  people,  thrown  back  on  the 
resources  of  even  a  decade  ago,  we  would  feel 
somewhat  the  same  uneasiness  and  discomfort 
that  Rip  Van  Winkle  expressed  on  waking  from 
his  long  sleep.     While  the  profession  at  large  has 
given  but  little  or  no  attention  to  the  therapeu- 
tic uses  of  electricity,  there  has  been  a  skirmish 
line  in  advance  of  the  main  body,  that  has  not 
been  idle,  and   along    this  line   there   have  not 
been  wanting  bold  and  self-reliant  spirits  who, 
with  the  directness  of  aim   and  the  clearness  of 
observation  of  the  sharpshooter,  and  with  a  genius 
for  experiment  and  fertility  for  invention  seldom 
excelled,  have  done  efficient  work  in  making  in- 


i89i.J 


ELECTRICITY  AS  A  THERAPEUTIC  A' 


833 


roads  on  diseases  that  have  not  yielded  t 
modes  of  treatment:  or,  if  so,  with  far  less  readiness. 

We  do  not  question  that  claims  have  been  made 
for  electro  therapeutics  that  are  fallacious  and  un- 
sound, but.  granting  this,  the  work  of  the  last 
fifteen  or  twenty  years  leaves  much  that  can  with- 
stand severest  criticism,  and  will  compare  favor- 
ably with  the  results  obtained  by  any  other  method 
for  treatment  of  disease,  that  receives  the  unqual- 
ified approval  of  the  profession.  The  work  of 
such  men  as  Erb,  De  Watteville,  Apostoli,  Keith. 
Beard,  cannot  be  turned  aside  with  a  sneer;  while 
the  universal  testimony  of  the  neurologists  that 
this  agent  is  indispensable  to  the  successful  treat- 
ment of  a  long  range  of  diseases  coming  under 
their  management,  challenges  our  acceptance  and 
respect. 

The  therapeutic  effects  of  electricity,  as  far  as 
they  have  been  determined  by  physiological  and 
clinical  observations,  may  be  classified  as  stimu- 
lant, or  electro-tonic,  sedative,  electrolytic  and  cata- 
phoric. To  these  should  be  added  the  cauterizing 
action,  since  the  galvano  cautery  has  a  range  of 
therapeutical  application  peculiar  to  itself. 

STIMULAXT  ACTIOX. 

The  stimulant  and  electro-tonic  influence  of  cer- 
tain forms  of  electrical  application  is  readily  de- 
monstrable, and  is  applicable  to  a  great  variety  of 
conditions  of  bodily  derangement.  Where  muscu- 
lar tissue  lacks  tone,  whether  it  be  voluntary  or  in- 
voluntary, striped  or  unstriped.  it  can  be  readily 
subjected  to  the  stimulating  influence  of  the  elec 
trie  current,  and  in  a  variety  of  ways.  For  this  pur- 
pose we  can  employ  the  static  machine,  the  cath- 
ode of  a  continuous  current,  or  the  induced  current 
completely  interrupted  or  alternating,  and,  by  the 
selection  of  one  or  the  other  of  these  forms,  ac 
cording  as  it  seems  best  adapted  to  the  condition, 
the  functional  vigor  can  be  aroused  in  an  organ 
in  which  such  muscular  tissue  forms  an  essential 
p-irt.  And  how  universal  are  such  tissues  through- 
out the  body  !  Thus  the  circulation  in  any  part 
may  be  quickened,  passive  congestions  overcome, 
congested  organs  relieved,  and  the  evil  results  of 
malnutrition  from  excess  or  lack  of  blood  in  a 
part,  or  from  feeble  efforts  at  elimination,  may  be 
corrected  by  this  action  of  the  electric  current. 
Functional  disorders  due  to  failure  in  vaso-motor 
control  are  especially  benefited  by  such  applica- 
tions. 

The  good  effects  of  such  currents  are  daily 
demonstrated  in  the  clinic  by  increased  growth  in 
paralyzed  limbs,  relief  of  pain,  improved  action 
of  the  viscera,  and  an  increased  sense  of  well- 
being  manifested  by  the  patient's  manner  and 
action.  A  torpid  liver,  a  congested  spleen,  con- 
stipated bowels  due  to  lack  of  secretion  or  feeble 
peristalsis,  a  congested  or  subiuvoluted  uterus. 
chronic  congestion  of  the  ovaries,  exhausted  nerve 
centres  with  attendant  hyperaemia  or  anaemia,  pro-  | 


ducing  those  perplexing  states  of  neurasthenia  or 
spinal  irritation,  are  all  conditions  that  can  be 
helped  by  electric  stimulus.  And  what  have  we 
to  look  to  in  our  materia  medica  that  will  accom- 
plish like  good  results  with  less  damage  to  the 
organism  as  a  whole?  What  can  you  a] 
introduce  that  will  reach  the  offending  spot  with 
as  much  precision,  or  do  less  damage  by  its  pres- 
ence while  it  gives  the  needed  help?  It  certainly 
adds  energy  where  energy  is  wanting,  and  when 
its  work  is  done  it  leaves  no  debris  behind  to  clog 
the  further  working  of  the  part.        ■ 

SEDATIVE  ACTION. 

As  a  iempomry  sedative,  both  the  induced  cur- 
rent and  the  anode  of  a  mild  continuous  current 
are  of  service.  They  calm  the  neuralgic  pains  of 
many  functional  and  organic  disorders ;  they  re- 
lieve headaches  due  to  congestion  or  migraine; 
they  allay  the  pains  of  muscular  rheumatism,  of 
pleurodynia  and  painful  menstruation,  and  the 
lightning-like  pains,  so  common  in  locomotor 
ataxia,  are  often  more  promptly  and  permanently 
controlled  by  this  than  by  any  other  means.  The 
manner  of  action  through  which  this  effect  is 
brought  about  by  the  electric  current  is  open  to 
speculation.  It  may  be  in  one  of  a  variety  of 
ways:  by  subduing  a  congestion  which  is  the 
cause  of  the  pain ;  by  stimulating  absorption  or 
elimination  of  some  deleterious  effete  substance ; 
possibly  by  hastening  the  decomposition  of  an 
irritating  product  which  is  formed  as  the  result 
of  imperfect  or  misplaced  metabolism  ;  or  the 
purely  physical  influence  of  vibrating  movement 
induced  in  the  nerve  structure  may  account  for 
the  soothing  effect.  Whatever  it  may  be,  the 
calmative  influence  of  these  methods  of  electric 
application  is  daily  exhibited  in  a  great  variety 
of  painful  affections,  and  sufferers  of  all  ages  and 
temperaments  bear  grateful  witness  to  its  effi- 
ciency in  affording  them  relief. 

ELECTROLYTIC    ACTION. 

The  electrolytic  action  of  the  continuous  cur- 
rent— that  is.  the  power  it  has  to  bring  about 
chemical  decomposition  and  change  the  atomic 
arrangement  iu  the  composition  of  compound 
substances,  is  credited  with  very  important  ther- 
apeutic effects. 

Electrolysis,  by  freeing  the  acid  constituents  of 
the  tissues  at  the  anode,  and  the  alkaline  at  the 
cathode,  is  a  convenient  means  for  producing 
styptic  or  caustic  action,  which  can  be  readily- 
applied  and  accurately  limited,  and  has  of  itself 
a  wide  range  of  application  in  the  diseased  body. 
But  if,  as  is  claimed,  it  can  be  proved  bv  actual 
experiment  or  from  clinical  data,  that  all  tissues 
lying  between  the  rheophores  of  a  continuous 
current  are  directly  modified  in  nutrition  and 
vital  action  by  its  influence,  according  to  the 
quantity  or  intensity  of  the  current,  who  is  there 
so   rash    as  to    attempt,   ia  this   the    infancy  of 


834 


ELECTRICITY  AS  A  THERAPEUTIC  AGENT. 


[June  13. 


the  rational  use  of  electricity  as  a  therapeutic 
agent,  to  mark  out  the  limitations  of  its  powers? 
Xo  matter  where,  upon  or  within  the  body,  dis- 
ease has  begun  its  bavoc,  the  continuous  electric 
current  may  be  made  to  traverse  the  part  and 
work  such  change  as  comes  within  the  province 
of  its  powers.  What  these  powers  are  over  living 
tissues  the  physiologist  and  clinician  must  deter- 
mine, but  may  it  not  be,  with  some  reason,  antici- 
pated that  normal  tissue  will  be  found  to  be  stim- 
ulated to  more  vigorous  action  and  resistance  by 
its  aid,  whil^  abnormal  processes  are  checked,  and 
substances  foreign  to  the  part,  as  effete  matter  or 
germ  colonies,  will  be  found  unable  to  withstand 
the  additional  energy  of  this  opposing  force.  If 
such  change  can  be  proved  to  be  wrought  by  this 
mvsterious  agent  in  tbe  secret  laboratory,  where 
cells  and  blood  carry  on  their  incessant  interchange 
in  harmony  or  discord,  then  no  one  will  den}'  that 
in  the  continuous  current  we  have  a  therapeutic 
agent  which,  for  many  disorders  within  the  realm 
of  both  medicine  aud  surgery,  surpasses  all  other 
means  at  hand,  and  testimony  in  medical  litera- 
ture is  accumulating  in  such  abundance  and  from 
such  high  sources,  as  the  result  of  accurate  meth- 
ods and  critical  observation,  to  the  effect  that  here- 
in we  have  a  resource  which  will  cure  where 
hitherto  we  have  only  been  able  to  destroy  tbe 
part  affected,  that  it  challenges  investigation,  if 
not  adoption,  by  every  member  of  the  profession. 

CATAPHORIC    ACTION. 

The  cataphoric  action  of  the  continuous  cur- 
rent gives  promise  of  aiding  us  materially  in  many 
ways.  The  introduction  of  medicinal  agents  into 
the  body  through  the  skin  is  oftentimes  desired, 
and  any  method  that  will  accomplish  this  with 
greater  certainty  than  those  now  in  use  will  be  a 
valuable  acquisition.  The  discovery  of  lanolin 
as  an  excipient  for  remedies  applied  b}'  inunction 
was  a  great  advance.  But  if,  by  employing  the 
anode  of  the  continuous  current,  we  can  hasten 
this  process  of  absorption,  and  cause  medicines 
to  penetrate  the  cuticle,  and  thus  reach  directly 
the  offending  tissues,  it  will,  in  many  instances, 
be  of  great  service.  This  power  to  increase  or 
reserve  osmosis  which  the  continuous  current  is 
said  to  possess  will,  if  true,  have  abundant  duties 
assigned  to  it  in  the  removal  of  dropsical  effusions 
from  cellular  tissues,  joints  and  cavities.  The 
contributions  of  Munk,  von  Bruns,  Corning,  Pe- 
terson and  others,  have  furnished  us  with  much 
interesting  information  on  what  they  claim  is  the 
cataphoric  action  of  electricity  in  carrying  reme- 
dies and  anaesthetics  through  the  skin,  and  it  has 
even  been  suggested  by  a  well  known  and  highly 
esteemed  surgeon,  in  a  recent  article,  "  that  the 
principle  of  the  process  that  causes  absorption  or 
diminution  of  the  bulk  of  an  uterine  fibroid  treated 
in  this  manner  (/.  e . .  by  the  constant  electric  cur- 
rent), must  be  looked  for  in  some  form  of  electri- 
cal osmosis." 


CAUTERY    ACTION. 

The  advantages  offered  by  the  galvano-cautery 
over  any  other  surgical  procedure  are  chiefly 
found  in  the  removal  of  growths  of  vascular  or 
fungous  character,  or  in  arresting  the  progress  of 
ulcers  and  malignant  disease  in  passages  of  the 
body  narrow  and  remote  from  the  surface,  like 
the  nasal  fossa,  the  Eustachian  tube,  the  pharynx, 
larynx  aud  external  auditory  meatus,  the  blad- 
der, urethra  and  uterus.  By  this  method  the 
cautery  snare,  or  knife,  or  scoop  may  be  nicely 
adjusted  to  the  necessities  of  the  case,  and  when 
all  is  in  readiness  the  heat  is  generated  in  the 
cauteri/.ing  tip  with  a  definiteuess  of  application 
and  rage  of  intensity  perfectly  under  control.  In 
skilled  hands  its  action  is  perfect  and  for  such 
cases  all  other  methods  of  treatment  are  but 
bungling  substitutes. 

Let  us  briefly  enumerate  a  few  of  the  results 
attained  by  electricity  which  have  directly  ad- 
vanced the  science  of  medicine  and  surgery.  The 
physiologist,  by  the  discovery  of  the  laws  of  elec- 
tro-tonus,  has  made  it  possible  for  us  to  determine 
the  condition  of  a  paralyzed  muscle,  thus  greatly 
advancing  the  accuracy  of  diagnosis  after  injury 
or  disease  of  brain,  or  cord,  or  nerve. 

For  the  increase  of  our  knowledge  of  cerebral 
localization,  with  the  marvelous  results  in  cerebral 
surgery  which  have  followed  so  rapidly  in  its 
train,  we  are  almost  wholly  indebted  to  the  elec- 
trical experiments  upon  the  brains  of  animals  by 
a  host  of  investigators.  As  a  remedial  agent  it 
is  claimed  that: 

It  restores  the  action  and  increases  the  growth 
of  paralyzed  parts;  it  arouses  vital  action;  it  im- 
proves nerve  conductivity;  it  contracts  muscle;  it 
hastens  osmosis  and  absorption;  it  excites  secre- 
tion; it  quickens  the  circulation;  it  aids  elimina- 
tion; it  allays  pain;  it  makes  hypodermic  medi- 
cation possible  without  puncturing  the  skin;  it 
destroys  superfluous  hairs,  removes  warts,  moles, 
sebaceous  cysts  and  epitheliomas;  it  checks  the 
ravages  of  lupus  and  other  ulcers;  it  heals  bed 
sores;  it  arrests  keloid  growths;  it  dissolves  away 
cicatrices  in  the  skin  and  along  mucus  channels 
forming  strictures;  thus,  stricture  of  the  lachry- 
mal duct;  thus,  stricture  of  the  Eustachian  tube; 
stricture  of  the  oesophagus;  stricture  of  the 
os  uteri;  stricture  of  the  rectum;  stricture 
of  the  urethra,  are  all  amenable  to  this  treat- 
ment. "Not  long  ago  physicians  and  surgeons 
of  repute  flouted  the  treatment  of  urethral 
strictures  by  electrolysis,  now  it  is  so  generally 
and  successfully  practiced  that  scarcely  any  op- 
pose it There  is  no  comparison  between 

the  treatment  of  strictures  of  the  urethra  by  the 
ordinary  methods  and  its  treatment  by  electroly- 
sis. Should  the  permanency  of  the  good  results 
prove  to  be,  as  a  rule,  not  so  great  as  those  re- 
corded,  still  the  calibre    of  the  stricture  remains 


I8yl.] 


ELECTRICITY  AS  A  THERAPEUTIC  AGENT. 


835 


■enlarged  for  a  longer  space  of  time  than  after  any 
other  form  of  treatment."  ' 

Like  testimony  from  reliable  sources  as  to  its 
superiority  over  all  other  methods  for  the  relief 
of  strictures  and  the  disorders  consequent  upon 
them  in  the  other  localities  named,  is  not  wanting. 

It  coagulates  the  blood  in  aneurisms,  naevi  and 
varicose  veins. 

Dr.  John  Duncan,  surgeon  to  the  Edinburgh 
Royal  Infirmary  declares  "  I  have  no  hesitation  in 
saying  that  the  only  justifiable  method  of  treat- 
ment for  cirsoid  aneurism  is  electrolysis." 

We  all  know  the  claims  of  Apostoli  and  his  fol- 
lowers for  the  treatment  of  uterine  fibro-myomata 
by  electrolysis,  and  il  needs  but  be  said  that 
larger  experience  and  improved  methods  have  but 
confirmed  and  rendered  more  positive  his  earlier 
view,  i.e.,  that  it  is  a  method  for  treating  the  ma- 
jority of  cases  superior  to  all  othets,  and  in  this 
he  is  ably  backed  by  Keith  and  numerous  lesser 
lights.  Keith's  latest  conclusions  are  thus  stated 
in  his  own  -words: 

"  This  treatment  almost  always  relieves  pain. 
It  almost  always  brings  about  diminution  of  the 
tumor,  sometimes  rapidly.  It  almost  always  stops 
hemorrhage,  sometimes  rapidly.  The  results  are 
almost  a/wa ^permanent  and  the  growth  of  the  tu- 
mor, if  it  be  not  lessened,  is  stopped.  The  gener- 
al health  is  immensely  improved.  By  almost  al- 
ways I  mean  nineteen  cases  out  of  ercrv  twenty? 

The  prostate  gland,  homologous  in  structure 
with  the  uterus  and  subject  to  like  abnormal 
growth,  has  proved  a  perplexing  problem  when 
enlarged.  Both  physician  and  surgeon  have  ex- 
pended upon  it  their  best  endeavors  with  but 
small  reward;  but  some  encouragement  may  now 
be  held  out  to  the  sufferer  and  his  physician,  for 
recently  it  has  been  said,  by  one  whose  experi- 
ence and  opportunity  for  observation  give  weight 
to  his  words,  "  We  have  no  hesitation  in  defin- 
ing this  as  the  only  truly  remedial  treatment 
known  for  the  hypertrophy  of  this  gland  ii 
at  ion  of  its  function,  operative  procedure,  looking, 
as  is  evident,  to  its  greater  or  less  destruction." 

Such  an  array  of  victories  claimed  in  the  name 
of  electricity  demands  of  the  profession  proof  or 
disproof. 

But  How  are  we  to  go  about  separating  truth 
from  error  in  these  claims,  and  by  what  means 
can  we  determine  with  accuracy  the  capacities 
and  limitations  of  this  powerful  force  in  nature 
for  the  treatment  of  disease?  Hitherto  we  have. 
for  the  most  part,  acted  like  children  in  our  deal 
ing  with  the  matter,  for,  armed  with  the  trifling 
toys  so  often  furnished  for  medical  batteries,  as 
heterogenous  in  their  variety  and  construction  as 
the  weapons  of  our  revolutionary   forefathers  in 


■  Electrolvsis  in  the  Treatment  of  Urethral  Strictures  New 
Hug.  Med.  Monthly,  Dec.  1S89 

-  W.  E.  Steavenson,  M.D..  Woods  Monographs.  "  Use  of  Elec- 
tricity in  Snrgerv." 

3  Brit.  Med.  jour.,  Feb.  14.  1891. 


their  first  contests  with  the  King's  regulars,  we 
attempted  a  crusade  against  the  hidden  mysteries 
of  disease  with  a  force,  in  its  essence  powerful,  it 
is  true,  but  hampered  by  our  ignorance  and  the 
conditions  under  which  we  sought  to  operate  it. 
:  ier  that  failure  in  cure  followed  such 
crude  applications  and  that  rumors  of  better  re- 
sults were  met  with  incredulity. 

We  believe  we  are  about  to  enter  upon  a  more 
thoughtful  age  and  are  now  as  a  profession  pre- 
pared to  soberly  seek  out  and  conform  to  those 
conditions  which  are  indispensable  for  determin- 
ing the  effects  of  this  all  prevailing-force  on  the 
human  body,  both  in  health  and  disease. 

THE  FIRST  REQUIREMENT. 

The  first  requirement  for  a  rational  electro- 
therapeutist  is  that  he  who  undertakes  to  prac- 
tice it  should  be  well  drilled  in  electric  physics 
and  physiology. 

In  no  branch  of  practical  medicine  and  surgery 
can  a  knowledge  of  the  fundamental  principles  of 
the  natural  sciences  be  safely  ignored,  but  nowhere 
is  such  knowledge  so  indispensable  to  success  as 
in  the  practice  of  electro-therapeutics,  and  yet 
how  many  of  our  medical  colleges  demand  even 
an  elementary  training  in  physics  as  a  condition 
for  entrance?  And  how  few  furnish  any  instruc- 
tion worthy  the  name  in  the  regular  curriculum  ? 

How  many  physicians  who  are  daily  making 
use  of  electricity  in  their  practice  could  explain 
the  construction  of  the  apparatus  they  are  em- 
ploying or  the  conditions  it  must  comply  with  in 
order  to  generate  a  current?  I  have  known  a 
physician  in  high  standing,  a  professor  in  a  med- 
ical college,  to  use  a  galvanic  batten-  of  simple 
construction  for  a  period  of  three  months  in  mak- 
ing daily  applications  to  a  patient,  and  during 
that  entire  time  there  was  no  current  passing 
through  the  conducting  cords,  he  having  failed 
to  join  the  proper  connections.  And  such  morti- 
fying instances,  discreditable  to  the  pro: 
could  be  related  ad  nauseum. 

One  who  makes  use  of  an  electric  battery- 
should  be  as  familiar  with  its  construction  and 
action  as  an  oculist  with  his  ophthalmoscope  or 
an  engineer  with  his  engine;  but  how  many  ex- 
pensive batteries,  do  we  see  lumbering  up  physi- 
cian's offices,  useless  and  set  aside  because  of  a 
corroded  connection  or  a  broken  wire  1  It  is  per- 
haps fortunate  so  many  accidents  do  happen  to 
medical  batteries,  for  electricity  is  a  dangerous 
tool  in  the  hands  of  one  who  knows  so  little  of 
the  conditions  upon  which  its  action  depends. 

Hand  in  hand  with  ample  knowledge  of  elec- 
tro physics  should  go  a  familiarity  with  the  ac- 
tion of  electric  currents  on  the  normal  living  tis- 
sues. The  laws  of  electro-tonus;  the  effects  pe- 
culiar to  the  anode  and  the  cathode;  the  varia- 
tion in  resistance  of  different  tissues,  all  are  essen- 
tial factors  in  the  information  requisite  to  an  in- 


836 


ELECTRICITY  AS  A  THERAPEUTIC  AGENT. 


[Junk  13, 


telligent  use  of  electricity  in  therapusis.  Practi- 
cal demonstrations  and  practical  experience  in 
electro-physiology  as  laboratory  work  under  com- 
petent instructors,  can  alone  fit  the  student  for 
practicing  intelligently  this  occult  science.  As 
reasonably  might  the  physician,  or  he  who  dig- 
nifies himself  by  that  title,  attempt  a  cure  by 
dealing  out  unknown  drugs  from  his  medicine 
case  as  to  use  electricity  on  his  patients  without 
such  antecedent  preparation. 

THE   SECOND    REQUIREMENT. 

The  second  requirement  for  securing  a  rational 
scientific  position  for  electricity  among  therapeu- 
tic agencies  is  a  uniformity  in  the  means  employ- 
ed for  its  application  to  the  bod}-. 

We  have  at  present  no  less  than  fifty  manufac- 
turers of  electric  batteries  and  appliances  for  med- 
ical use,  and  no  two  of  them  have  adopted  the 
same  pattern  or  means  for  generating  currents. 
On  the  contrary,  trade  enterprise  has  stimulated 
inventive  ingenuity  to  produce  diversity  rather 
than  uniformity  in  order  that  it  might  be  made 
an  additional  argument  for  the  sale  of  that  par- 
ticular variety  of  instrument.  Many  physicians 
in  this,  as  in  many  other  therapeutical  measures, 
take  suggestions  from  non- medical  men  as  to 
what  instruments  they  require  and  how  their  pa- 
tients should  be  treated.  Those  members  of  the 
profession,  who  have  from  personal  experience, 
discovered  the  essentials  of  a  medical  battery 
rather  than  the  instrument  maker,  should  be 
looked  to  for  information  as  to  what  are  the  best 
and  most  suitable  forms  of  batteries  for  therapeu- 
tical purposes.  Some  standard  should  be  adopt- 
ed for  a  constant  current  battery,  an  induction 
coil,  a  volt  meter  and  a  milliamperemeter. 

It  is  rare,  if  any  two  physicians  at  the  present 
time,  who  daily  employ  electricity  in  their  prac- 
tices, do  it  in  like  manner.  They  cannot  there- 
fore compare  results  since  they  are  not  assured 
that  in  the  treatment  of  similar  diseases  they  have 
subjected  their  patients  to  the  same  conditions. 
Should  I  in  Michigan  wish  to  test  upon  my  pa- 
tient the  effects  of  electric  treatment  claimed  by  a 
fellow  practitioner  in  New  York  or  elsewhere  to 
be  successful,  how  can  I  know  that  my  "Mcin- 
tosh" is  furnishing  the  same  current  that  he  used 
from  his  "Kidder,"  since  our  milliamperemeters 
have  never  been  compared,  and  the  voltage  and 
resistances  are   not  reported  ? 

Recently  effects  have  been  reported  in  a  prom- 
inent journal  by  an  eminent  electric  therapeutist 
as  hi  ving  been  brought  about  by  the  use  of  the 
induction  current  that  seems  to  me  incredible, 
but  am  I  justified  in  denying  his  statements  un 
till  know  what  form  "t  instrument  he  made  use 
of,  and  have  myself  used  the  same  in  like  manner 
and  so  determined  the  inaccuracy  of  his  conclu- 
sions ? 

Nothing  differs  more  than  the  intensity  of  the 


currents  generated  by  induction  coils;  therefore, 
without  a  standard  instrument,  which  is  the  same 
wherever  used,  no  progress  toward  uniform  re- 
sults can  be   made. 

Until  within  a  few  months  there  has  seemed 
to  be  no  way  open  for  securing  this  much  desired 
harmony  and  uniformity  in  electro-therapeutical 
appliances,  but  the  organization  of  an  American 
Electro-  Therapeutical  Society  in  January  last  gives 
promise  of  better  things,  and  may  we  not  hope 
that  through  the  labors  of  this  organization  we 
will  soon  receive  definite  instructions  as  to  the 
best  instruments  to  make  use  of  and  the  best 
methods  for  applying  them  ? 

In  this  connection  let  me  suggest  that  the 
tendency  should  be  toward  the  simplest  and  least 
expensive  instruments  consistent  with  efficiency. 
Many  of  the  obstacles  to  the  progress  of  electro- 
therapeutics lsave  arisen  from  the  high  price, 
complexity  and  frailty  of  the  instruments  furnish- 
ing the  current. 

One  drawback,  and  that  perhaps  the  most 
fruitful  in  retarding  good  work,  lies  in  the  use 
of  fluid  batteries  for  generating  both  constant 
currents  and  the  primary  circuit  for  induction 
currents.  Many  of  the  annoyances  arising  from 
this  source,  such  as  the  deterioration  of  the 
fluids,  the  consumption  of  the  elements  when  the 
battery  is  not  in  use,  the  corrosion  of  connec- 
tions in  the  circuit,  can  now  be  overcome  by  us- 
ing a  dry  cell.  I  have  for  months  made  use  of  a 
dry  cell  for  running  induction  coils  and  found  it 
very  satisfactory.  You  who  have  occasion  to  use 
portable  batteries  can  readily  appreciate  the  ad- 
vantages to  be  derived  from  substituting  a  dry 
for  a  wet  cell  in  all  portable  machines.  Even 
for  stationary  work  the  dry  cell  is  superior  on  ac- 
count of  its  cleanliness,  but  in  matter  of  durabil- 
ity it  requires  some  improvement. 

Nothing,  in  my  opinion,  will  eventually  be 
found  so  convenient  for  office  work  as  the  use  of 
commercial  currents. 

The  Edison  incandescent  current  with  its  con- 
stant voltage  of  near  no,  affords  an  admirable 
source  of  electric  power  for  electrolysis,  cata- 
phoresis,  inductive  stimulation,  and  cautery  pur- 
poses. By  a  very  simple  appliance  for  changing 
the  voltage  I  have  used  this  current  in  rtfy  office 
for  more  than  two  years,  and  the  same  method 
applies  quite  as  well  to  the  currents  of  equal  or 
less  voltage  from  other  sources,  whether  they  be 
alternating,  as  the  Thomson-Huston  dynamo,  the 
storage  battery,  or  any  form  of  primary  batter}' 
plant  that  has  sufficient  electro- motive  force. 

To  sum  up,  therefore,  the  ideal  conditions  for 
establishing  electro-therapeutics  on  a  scientific 
ba^is,  they  are: 

1.  A  source  of  electric  power,  as  a  dynamo  or 
storage  battery  with  a  constant  unvarying  vol- 
tage, from  which  the  current  is  conveyed  to  hos- 
pitals, physicians'  offices  or  patient's  houses. 


iSoi.] 


RELATION  OF  GYNECOLOGY  TO  NEUROLOGY. 


" 


2.  A  current  regulator,  rheostat  or  modiifyer  by 
which  the  strength  of  the  current  may  be  adapted 
to  the  required  needs  of  individual  cases,  and  this 
should  be  of  convenient  size,  durable  in  construc- 
tion and  simple  in  arrangement.  The  simplicity, 
economy  and  efficiency  of  such  appliance  would 
insure  its  being  readily  adopted  by  the  profes- 
sion. 

3.  A  -which  should  be  con- 
structed according  to  a  fixed  standard  as  to  size 
and  shape,  and  they  should  be  made  of  material 
which  is  cheap,  readily  conducting,  and  nonpo- 
larizable. 

4.  All  should  make  use  of  a  standard  milliam- 
peremeter  for  determining  "  strength  of  current" 
and  a  colombmeter  for  "  quantity"  or  dose. 

Complying  with  such  conditions  as  these,  prog- 
ress in  determining  the  limitations  of  electricity 
as  a  therapeutic  agent  would  advance  with  rapid 
strides.  The  incandescent  electric  light  plants 
with  low  electro-motive  force  are  very  common 
throughout  the  country.  The  physician  and 
dentist  finds  the  current  extremely  useful  in  his 
office.  It  illumines  his  apartments,  it  runs  his 
motors,  it  lights  the  tiny  lamps  with  which  he 
explores  the  cavities  of  the  body.  It  heats  the 
water  for  his  sprays  and  douches.  It  will  not  be 
long  before  it  will  be  made  use  of  by  the  many  as 
it  has  been  for  some  time  by  the  few.  for  all  the 
applications  of  electricity  to  the  human  body. 
since  it  does  away  with  a  host  of  difficulties  that 
have  up  to  the  present  been  of  such  magnitude  as 
to  make  electric  applications  either  a  burden  or  a 
farce. 


RELATION    OF    GYNECOLOGY  TO 
NEUROLOGY. 

the  Stction   of  C 
Forty-second  Am 

lion,  held  at  Washington,  D.  C.  May, 

BY  WM.   B.  DEWEES.  A.M..  M.D., 

OF  SALIN'A.     KANSAS. 

The  intimate  relationship  which  exists  be-  [ 
tween  diseases  of  the  organs  in  the  female  pelvis 
and  the  general  nervous  system  has  not  yet  been  ■ 
elucidated.  Though  as  early  as  1S58  Brown- 
Sequard  pointed  out  the  dependence  of  insanity, 
epilepsy,  hysteria  and  other  affections,  upon  or- 1 
ganic  disease  of  the  female  generative  organs. 
Baker  Brown  put  these  teachings  into  practice 
and  furnished  clinical  proofs  of  their  correctness. 
He,  however,  fell  a  martyr  to  the  professional 
bigotry  which  his  doctrine  excited.  Now,  how- 
ever, that  the  rancor  of  that  day  has  died  away, 
his  book  on  "The  Curability  of  Certain  Forms 
of  Insanity,  Epilepsy.  Catalepsy  and  Hysteria  in 
Women,"  can  be  read  with  interest  and  modified 
by  the  later  revelations  of  science,  his  teachings 
can  be  followed  with  safety.1 

1  Dr.  Charles  A.  L.  Reed,  of  Cincinnati,  O.  Bufialo  Medical  and 
Surgical  Journal.  May    i    - 


The  influence  of  the  unhealthy  uterus  and 
ovaries  upon  the  development  of  the  diseases  of 
other  organs  of  the  body  by  virtue  of  the  neuric 
forces  through  the  intermeddling  of  the  complex 
generative  nerve-circle,  the  sympathetic  and  the 
cerebro  spinal  systems  of  nerve?,  is  a  matter 
which  I  am  led  to  believe  has  received  very  little 
attention  at  the  handsof  practitioners  as  evidenced 
by  the  fact,  that  I  mailed  a  carefully  prepared 
letter  of  inquiry  to  two  hundred  and  fiftj-  of  the 
most  noted  practitioners  of  the  United  States. 
and  the  only  responses  came  from  Dr.  Charles 
A.  L.  Reed,  of  Cincinnati,  O. ;  Drs.  Barton  Cook 
Hirst.  William  Goodell,  James  Tyson,  John  V. 
Shoemaker  and  R.  J.  Dunglison,  of  Philadelphia, 
Pa. ;  Drs.  Trail  Green  and  Charles  Mclntire,  of 
Pa.:  Dr.  C.  Henri  Leonard,  of  Detroit, 
Mich.;  Dr.  Henry  O.  Marcy,  of  Boston,  Mass. ; 
Drs.  J.  Taber  Johnson  and  Irving  C.  Rosse,  of 
Washington,  D.  C. ;  Dr.  R.  H.  Thomas,  of  Balti- 
more. Md.:  Dr.  P.  Bryce,  of  Tuscaloosa,  Ala., 
and  Dr.  Alexander  B.  Shaw,  of  St.  Lou 
I  had  hoped  to  be  able  to  present  valuable  data 
from  this  source,  but  the  responses  being  too 
limited  in  number,  and  too  meagre  with  facts,  to 
be  of  any  material  value  to  science,  they  have 
therefore  been  omitted. 

For  more  than  a  decade  my  attention  has  been 
directed  to  the  interdependence  between  diseases 
of  the  female  pelvic  organs  and  diseases  of  other 
organs.  Which  is  the  cause  and  which  the  re- 
sult is  not  always  possible  to  determine,  the  , 
relationship  evidently  varying  in  different  cases, 
for  while  in  a  large  percentage  of  cases  of  neuro- 
sis in  the  female,  interdependence  of  diseased 
conditions  through  the  neuric  forces  could  be  dis- 
tinctly traced  and  finally  lucidly  established,  by 
the  subsequent  course  and  termination  of  those 
cases  :  in  other  cases  the  causes  could  be  seen  to 
depend  upon  a  condition  of  malnutrition  alone. 

My  authority  for  coming  to  this  conclusion 
may  fairly  be  questioned,  and  therefore  I  give  my 
reasons.  If  I  am  consulted  by  a  female  patient 
complaining  of  voice,  heart,  brain  or  other 
troubles  in  whom  examination  reveals  physical 
signs  of  diseases  of  these  organs,  and  if  in  the 
same  patient  I  find  uterine  or  ovarian  disease, 
and  if  the  voice,  lung,  heart,  brain  and  other 
troubles  disappear  upon  treatment  of  the  uterine 
or  ovarian  disease  without  any  other  medical 
aid,  it  is  but  logical  to  conclude  that  the  voice, 
heart,  brain  and  other  troubles  were  dependent 
upon  that  of  the  womb  or  the  ovaries.  This 
being  conclusively  shown,  by  a  few  illustrated 
cases  selected  from  a  large  number  and  appended 
hereto,  it  follows  that  what  may  have  been  a  co- 
incidence becomes  a  sequence,  and  the  conclusion 
at  which  I  have  arrived  is  inevitable. 

Far  be  it  from  me  to  assert  from  my  experience 
that  all  cases  of  neurosis  in  the  female  are  de- 
pendent upon  lesions  of  the  generative  organs  ; 


838 


DELATION  OF  GYNECOLOGY  TO  NEUROLOGY. 


[June  13, 


but  that  a  very  large  percentage  of  the  neurosis 
are  dependent  upon  local  disease  within  the 
pelvis  is  fulh'  warranted.  It  is  not  my  intention 
to  theorize  upon  the  subject,  to  waste  useful  time 
in  useless  conjectures,  my  object  being  only  to 
draw  attention  to  the  clinical  fact  and  to  en- 
deavor to  awaken  the  medical  mind  to  its  great 
practical  importance. 

The  hindrances  to  the  true  understanding  of 
the  relation  of  gynecology  to  neurology  are  to 
be  found  in  : 

1.  The  unsettled  state  of  physiological  and 
pathological  history. 

2.  The  absence  of  a  thorough  knowledge  of 
the  anatomy  of  the  reproductive  nervous  system, 
and  of  data  regarding  the  interdependence  of 
menstruation  and  ovulation  ;  and  last,  but  by  no 
means  least, 

3.  The  existing  ignorance  concerning  the 
neurosis  attendant  on  lesions  of  the  female  re- 
productive organs. 

Confronted  with  these  facts  we  must  acknowl- 
edge that  we  grcpe  for  the  truth  like  the  blind, 
and  are  at  a  loss  for  philosophical  explanations 
based   on   historical  and  experimental  research. 

Every  experienced  gynecologist  will  upon  re- 
flection admit,  that  there  is  nothing  very  extra- 
ordinary in  the  implication  of  distant  organs  in 
connection  with  and  dependent  upon  utero- 
ovarian  disease  through  the  neuric  forces,  since 
in  the  practice  of  all  such,  instances  are  not 
wanting  wherein  tissue- changes  have  been  pro- 
duced at  a  distance  by  ovarian  or  uterine  irrita- 
tion. Medical  literature  is  full  of  examples  of 
acne  rosacea,  pharingitis,  bronchitis,  e] 
catalepsy,  hysteria,  melancholia,  mania,  insanity, 
diseases  of  the  joints  and  muscles  of  the  extrem- 
ities, lesions  of  the  heart  and  lungs,  paralysis, 
etc.,  superinduced  by  reflex  irritability  of  the 
intrapelvic  organs.  It  is  quite  true  that  the 
number  of  women  dying  from  these  complica 
tions  is  now  much  less  than  formerly.  We  have 
learned  better  to  differentiate  and  treat  disease. 
but  it  is  doubtful  if  we  fully  appreciate  the  con- 
sequental  relations  which  one  abnormal  condi- 
tion bears  to  another.  While  in  main-  of  these 
interdependent  complications  relative  to  the  sub- 
ject, the  disease  of  distant  organs  bears  to  intra- 
pelvic disorders  the  relation  apparently  of  effect 
,  and  you  can  observe  for  yourself  the 
fact,  yet  the  manner  in  which  the  chan 
brought  about  may  remain  an  open  question. 

Neurosis  may  be  defined  as  an  exaggerated  in- 
tensity of  both  the  sensor  and  the  motor  forces, 
and  may  be  induced   by   a,    developmental,  or  1; 
tological  causes. 

il  causes  may  act  by  an  impression- 
fixed  by   an   active 
fancy  or  imagination,  producing  a  diseas 
dition  of  the  imagination, "  whencesoever,  ideali- 
zation produces  neuric  inipu 


b.  Developmental  causes  may  act  by  the  rapid 
and  .-welling  growth  of  the  intrapelvic  organs 
as  manifested  by  gestation. 

c.  Pathological  causes  may  act  by  a  fluxionary 
movement,  as  in  suppressed  menstruation  ;  the 
presence  of  the  neoplasm  of  the  ovaries  or  uterus; 
misplacement,  engorgement  or  inflammation  of 
these  organs.  Pathological  causes  may  also  be 
produced  by  muscular  laxity  of  the  abdominal  or 
spinal  muscles,  or  both — unquestionably  the  most 
prevalent  foreruuner  of  all  causes — destroying 
the  primitive  erectness  of  the  body,  the  normal 
obliquity  of  the  pelvis,  the  maintained  ascendent 
position  of  the  internal  viscera  from  below  up- 
wards, resulting  in  a  mechanical  displacement  of 
the  visceral  status,  involving  a  train  of  both 
physical  and  functional  derangements  of  the 
pelvic  organs. 

All  of  these  causes  may  and  do  pervert  the 
normal  forces  of  the  complex  generative  nerve- 
circle  to  disturb  the  whole  economy,  and  the  per- 
sistence and  permanence  of  these  causes  may  de- 
velop the  emotional  influences  to  an  uncontrol- 
lable degree,  as  evidenced  by  that  undefinable 
neurasthenia  known  or  designated  by  the  term 
hysteria,  or  finally  affect  the  mind  and  even  de- 
stroy reason,  as  evidenced  by  melancholia  or  in- 
sanity. Thus  we  have  the  sympathetic  neurosis. 
hysteria,  as  the  enalogue  of  that  cerebral  neurosis, 
insanity,  both  alike  dependent  upon  pelvic  neu- 
rosis, which  fact  goes  to  prove  conclusively  the 
interdependence  between  gynecology  and  neu- 
r<  ilogy. 

[n  the  language  of  Dr.  Chas.  A.  L.  Reed,  of 
Cincinnati,  O.,  who,  speaking  of  the  female  or- 
gans of  generation,  says:  "It  may  not  be  amiss. 
however,  to  recall  the  fact  that  all  of  these  organs 
have  intimate. connection  with  both  the  sympa- 
thetic and  spinal  systems  of  nerves,  and  that 
these  systems  of  nerves  in  turn  communicate  with 
each  other.  Through  these  instrumentalities 
morbific  impulses  originating  in  diseased  condi- 
tions of  the  intra-pelvic  viscera  may  be  tele- 
graphed, as  it  were,  either  to  those  centres  which 
preside  over  nutrition,  or  to  those  other  centres 
which  govern  sensibility  and  motion.  In  the 
former  instance  the  sympathetic  system  furnishes 
the  route  of  transit,  and  the  result  may  be  ob- 
served in  the  modified  calibres  of  all  the  blood- 
vessels generally;  in  the  perverted  activity  of  all 
idularorgans;  in  the  unrhythmical  move- 
ments of  all  the  other  viscera  and  glaud  ducts,  or 
in  a  more  or  less  marked  interference  with  ulti- 
mate tissue  nutrition.  In  the  latter  instance  the 
cerebro-spinal  system  of  nerves  is  involved  and 
the  results  are  pain,  and  may  be  motor  disturb 
ances  of  either  the  voluntary  or  reflex  character. 
In  either  case  the  brain  is  reached,  and  we  can- 
11  y  that  impressionable  organ  receiving  an 
impulse  in  excess  of  normal  without  sustaining 
more  or  less  functional  disturbance,  whether  that 


I89i.] 


RAPID  DILATATION  AND  CURETTING. 


839 


disturbance  be  manifested  by  psychic  phenomena 
or  not.  The  perpetuation  of  this  disturbing  in- 
fluence through  the  persistence  of  the  initial  le- 
sion in  the  distant  viscera  is  sufficient  to  convert 
the  functional  disturbance  of  the  brain  into  an 
organic  change  involving  that  organ." 

Here  let  me  digress  to  state  in  this  connection 
that  I  regard  thought  and  all  mental  actions  to 
be  the  results  of  brain  elimination,  and  in  pro- 
portion to  the  quantity  and  quality  of  tl 
matter  of  the  brain  so  will  be  the  intellectual 
capacity  of  the  individual.  Any  change,  either 
progressive  or  retroprogressive,  in  the  metamor- 
phosis of  the  ultimate  cell  structure  of  the  brain 
will  upset  that  symmetrical  balance  of  action 
known  as  sanity,  and  the  various  grades  of  in- 
sanity are  developed.  I  regard  the  brain  as  the 
being— the  man— all  else,  limbs  and  organs,  as 
servants  moved  and  compelled  to  do  duty  by  the 
nervous  mass.  Okeu  asserts  "that  the  animal  is 
naught  but  nerve."  Can  you  gainsay  him? 
From  the  nervous  mass  called  brain  issue  two, 
and  only  two  forces,  one  sensor  and  the  other 
motor. 

Returning  to  our  subject,  it  may  again  be 
argued  that,  first,  there  is  a  derangement  and  im- 
pairment of  the  complex  nervous  system  and 
neuric  function  from  the  utero-ovarian  or  pelvic 
diseases,  followed  by  impaired  digestion  and  rual- 
assimilation  as  a  natural  consequence.  Then 
comes  the  persistence  of  disordered  hepatice, 
renal,  etc.,  circulation,  the  invasion  of  the  con- 
tents of  the  digestive  tract  by  the  torula  cerevisits 
and  consequent  fermentation  with  its  attendant 
disorders  constantly  increasing.  Finally,  by  ex- 
cessive irritability  of  the  nerve-circle  presiding 
over  the  orgasm  function  there  is  developed  a 
morbid  sympathetic  or  cerebro  spinal  action, 
which  may  be  curable  because  there  is  simply 
supernatural  reflex  irritability, — a  sympathetic 
or  cerebral  neurosis  dependent  upon  pelvic 
neurosis. 

APENDIX  OF  CASES. 

Case  1. — Tu  May,  jssn.  I  was  summoned  to  take  under 
care  the  wife  of  a  farmer,  aged  54  years,  and  the  mother 
of  two  sous,  who  had  passed  the  menopause  at  46,  and  al- 
ways enjoyed  good  health  up  to  about  eighteen  mouths 
prior  to  my  seeing  her,  when  she  received  some  injuries 
by  being  thrown  from  a  carriage  by  a  run-away  horse. 
Her  suffering  then  being  confined  chiefly  to  her  knees, 
which  had  become  very  swollen  and  painful,  presenting 
all  the  local  characteristics  of  acute  articular  rheumatism, 
for  which  disease,  .the  husband  stated-,  nine  different 
physicians  had  treated  her  during  the  eighteen  months 
of  her  confinement  to  bed,  without  any  apparent  benefit, 
aside  from  the  temporary  relief  of  pain.  A  timely  and 
careful  examination  revealed  a  complete  protrusion  of 
the  uterus,  greatly  congested,  from  the  vulva  of  the  pa- 
tient, who  was  lying  on  her  back,  and  both  her  knees 
swollen  to  three  times  their  normal  size,  red  in  appear- 
ance  and  very  painful  to  the  touch,  so  much  so  that  the 
bed  clothes  had  to  be  supported  above  them.  She  was 
very  much  emaciated  by  her  long  suffering  and  confine- 
ment. I  noted  my  diagnosis  procidentia  "uteri,  compli- 
cated with  neuristhenic  insufflation  of  both  knees — hys- 


terical knees.     I  reposited  the  uterus  and  retained  it  by 
!  port  and  painted  the  knee  joints 
;.    with  oil  of  peppermint,  which 
attention  instituted  tl 

treatment.      The   patient  made  a   raj 

within   six   weeks  to  leave  her  bed  an'.. 
my  office,  a  distance  of  ten  miles,   with  all  the  appear- 

.    .ell  ever 
since. 

-Miss supported  into 

by  her  fathei  ,_;0.  The 

history   given  to  me  of  her  case  was  thai 
then  under  treatment   for  consumption  and   hvsl 
ars,  without  benefit,  but  on  the 

The  girl's  appearance  was  pitia- 
ble in  the  extreme.     1  sweat  bathing 
ore  a  livid  hue,  with  an  ex- 

abdomen  distended  until  it  had  becornelpainful. 
she   had   been   having  frequent   haemoptyses  with  dys- 
linful   chest   and   great   in  1  akness. 

Back-ache,  irregular  and.  painful  menstruation,  leucor- 
rhcea,  anorexia,  hacking  cough,  anda  weak  husky  voice. 
She  was  now  seized  with  a  hystero-epileptic  convulsion, 
and  I  had    to   defer    f  :    u,nj]    jt    na<| 

After  which  auscultation  revealed  areas  of 
dulness  with  sibilant  ronchus  over  both  lungs,  prolonged 
expiration  and  feeble  heart  imination  per 

vaginam  showed  a  prolapsed  retn  inflamed 

uterus.  The  treatment  consisted  of  specicd  attention  to 
the  uterine  condition,  rest  in  bed  for  several  months,  hot 
water  douches  and  nourishing  diet,  with  finally  placing 
a  Smith  Hodge  pessary,  and  her  recoverv  was  complete 
in  six  months,  she  being  robust  and  well"  ever  since. 


RAPID    DILATATION    AND  CURETTING. 

Read  in  theStclion  ofObstetrics  and  Diseases  of  Women  at  lite  Forty- 
second  Annual  Meeting  of  the  A  -.lion, 

BY  J.  G.  CARPENTER,  M.D., 

OF  STANFORD,    KY. 

This  is  a  subject  of  no  little  importance  to  the 
profession;  the  voice  of  warning  has  already  been 
raised  against,  it  might  be  said,  the  wholesale  use 
of  rapid  dilatation  and  curetting  or  the  practice  of 
these  in  the  hands  of  those  who  are  unskilled  in 
their  use  and  are  poor  diagnosticians  of  intra 
pelvic  disease;  in  fact,  these  therapeutic  meas- 
ures have  been  severely  condemned  by  distin- 
guished abdominal  and  pelvic  surgeons,  chief  of 
whom  is  Dr.  Joseph  Price  of  Philadelphia.  He 
has  written  a  most  excellent  paper  on  "  Certain 
Causes  of  Major  Pelvic  Troubles  Traceable  to 
Minor  Gynaecology. ' ' 

That  they  have  been  severely  condemned  is  no 
argument  against  their  proper  use;  that  they  have 
been  shown  to  be  instruments  of  great  harm  in 
the  hands  of  the  rotenist»the  inexperienced,  and 
unskilful,  and  met  with  so  great  censure  by  intra 
pelvic  surgeons  so  eminent,  will  deter  many  from 
their  former  practice  and  save  the  female  the  or- 
deal of  abdominal  sections.  It  may  be  truthfully- 
stated  that  when  the  intra  pelvic  affections 
threatening  life,  arising  from  rapid  dilation  and 
curetting,  as  well  as  the  improper  use  of  the  uter- 
ine sound  and  trachelorrophy,  and   abuse  of  pes- 


840 


RAPID  DILATATION  AND  CURETTING. 


[June  13", 


saries  and  caustic  applications  to  the  endomet- :  rapid  dilatation  or  curetting,  etcetera  etcetera, 
rium,  are  realized  and  appreciated  by  the  so-call-  That  the  general  practitioner  too  often  generalizes 
ed  pseudo,  or  minor  gynaecologist,  there  will  be  [  in  place  of  specializing,  and  the  specialist  too  often 
fewer  case's  with  their  ovaries  and  tubes  in  bot- 1  specializes  instead  of  generalizing,  there  can  be 
ties,  instead  of  their  normal  habitat.  I  no   doubt,    and   that   the   minor    gynaecological 

Unfortunatelv  for  humanity  so  many  gradu- '  tinker,  tinkers  with  his  patients  until  major  pel- 
ates  as  well  as  senior  members  of  the  profession  :  vie  troubles  arise,  and  his  patients  pass  into  the 
appropriate  to  themselves  the  stupendous  title—  j  hands  of  the  pelvic  surgeon  is  self-evident.  These 
Gynaecologist,  and  seem  to  think  the  essentials  ;  major  pelvic  troubles,  many  of  them  like  Banquo's 
to' a  successful  practice  and  fortune  are  the  spec- 1  ghost,  will  continue  to  arise,  because  they  will 
ulem,  uterine  sound,  curette,  Goodells'  dilator  and  |  not  down  or  cease  until  the  pseudo-gynaecologist 
Thomas'  retroversion  pessarv,  and  handle  the  :  ceases  to  tinker.  These  questions  may  be  asked, 
sound  with  as  much  recklessness  as  the  dude  i  are  forcible  dilatation  and  curetting  ever  essen- 
twirls  his  cane,  and  imagine  all  intra  pelvic  dis-  tial,  and  when  are  they  indicated  ?  Answer,  yes. 
eases  are  uterine.  The  ultima  thule  is  fewer  and  !  When  and  by  whom  should  they  be  used?  They 
better  practitioners,  less  number  of  medical  stu-  ',  should  be  used  by  the  aseptic  physician,  or  sur- 
dents,  fewer  and  better  medical  schools  with  en-  j  geon,  who  has  been  taught  by  practical  experi- 
larged  hospital  experience,  and  instead  of  a  three  j  ence  and  differentiation  the  pros  and  cons  for 
years  course  of  studv  being  compulsory,  make  it  \  these  measures,  and  as  a  dernier  resort;  but  some 
"five  years  or  longer,  with  abundant  clinical  or  j  times,  as  in  case  of  haemorrhage  and  putrid  pla- 
hospital  experience  and  gvnaecology  learned  and  !  cental  infections,  their  use  as  means  of  primary 
taught  before  it  is  put  into  practice.  Unfortu-  j  remedial  importance  must  be  considered,  in  order 
nately  only  the  minority  of  every  graduating !  to  save  life  and  prevent  sepsis;  and  with  the 
class 'have  "had  proper  clinical  experience  to  be-  aseptic  instruments,  through  the  aseptic  vagina, 
gin  practice;  the  majoritv  seldom  reach  medioc- '  os,  and  cervix  and  when  dilatation  or  curetting 
rity;  they  start  wrong,  go  wrong  and  end  wrong.  [  is  accomplished,  make   the  endometrium  aseptic 

There  "are  cases  demanding  rapid  dilatation,  or  1  with  hot  water,  the  bichloride  or  boric  solutions, 
curetting,  or  both,   and  the  physician  would  be  iodine  and  glycerine  mixture   (Churchill's  tinc- 


direlect  of  duty  not  to  use  them.  Their  proper 
use  must  be  commeuded,  their  improper  use  con- 
demned. 


ture  of  iodine,)  the  liquid  vaseline  and  oil  of 
eucalyptol,  or  menthol  solutions,  the  insufflation 
of  bismuth,  subnitrate,   or  iodiform;  the  vagina 


The   scriptural  adage,     "be  temperate    in   all   kept   aseptic    "  pro-re-nata"    by    hot    antiseptic 
things"  is  highly  appropriate  and  essential  in  the  '  douches  and  aseptic  vulva  pad  to  prevent  decotn- 


practice  of  minor  gynaecology.  That  the  minor 
gynaecologist  too  often  ignores  or  is  incompetent 
to  detect  existing  iutra-pelvic  diseases  when 
practicing  these  methods,  or  by  the  practice  pro- 
duces intra- pelvic  diseases,  there  can  be  no  doubt, 
just  in  the  proportion  to  the  abuse  of  rapid  dila 


position  of  the  uterine  discharge  and  infection. 
Before  forcible  dilatation  or  curetting  are  resorted 
to,  the  patient  should  be  given  a  hot  water  and 
soap  bath,  purged  freely,  and  placed  in  bed  at 
rest  twenty-four  or  forty-eight  hours,  and  the  va- 
gina douched  with   hot  antiseptics  every  six  or 


tation  and  curetting  and  other  minor  measures  j  twelve  hours.  After  the  operation,  the  patient 
does  he  become  a  feeder  to  the  major  gyneecolo-  \  should  be  kept  in  bed  one  or  more  days,  until  all 
gist  or  abdominal  and  pelvic  surgeon,  only  a  few  j  manifestations  of  a  local  or  constitutional  reae- 
weeks  observation  and  study  and  analysis  of  cases  |  tion  have  subsided  and  the  patient  free  from  dan- 
in  the  practice  of  men  in  the  profession  like  Drs.  ger;  the  operation  should  never,  never,  be  done 
Joseph  and  M.  Price,  Charles  B.  Penrose,  E.  E.  in  the  private  or  consulting  office,  and  never  by 
Montgomery  and  Hoffman  of  Philadelphia,  and  the  pseudo-gynaecologist;  nor  more  than  intervals 
T.  A.  Emmet  of  New  York,  would  convince  any  of  ten  or  fourteen  days,  at  least  five  days  before 
"  doubting  Thomas"  that  "  certain  causes  of  ma-   and  after  the  menses,    and  when  the  disease  is 


jor  pelvic  trouble  are  traceable  to  minor  gynae- 
cologv." 

One  class  of  patients,  you  will  find  the  major 
pelvic  trouble  traceable  to  a  dirty  confinement, 
or  too  early  leaving  bed,  and  resuming  household 
duties  or  hardships,  or  other  minor  imprudences 


limited  to  the  uterus  per  se,  an  entire  absence   ol 
disease  in  the  pelvis. 

These  measures,  though  sometimes  indicated 
and  though  no  intra  pelvic  inflammation  is  pres- 
ent, may  and  have  done  incalculable  harm  In- 
setting up  pelvic  disease  even  though  slight;  no 


to  imprudences  during  the  menstrual   molimen  dilatation  or  curetting  should  be  practiced  unless 

and  frequent  abortions"  others  have  had  a  gonor-  i  absolutely  required  by  patient  to  save  life.   Rapid 

rhceal  infection  or  sexual  abuse;  others  date  ori-  dilatation  or  curetting  are  distinct  traumatisms, 

gin  of  the  ailment  to  an  improperly  adjusted  pes-  and  all  the  dangers  incident  to  septic  absorption 

sary;  to  the  use  of  the  sound  or  probe;  caustic  may  attend  them  that  follow  any  other  violent 

application  to  the  endometrium  or  os;  others  to  procedure.     Dr.  Joseph  Price  states  in  reference 

operation  on  cervix  (trachelorraphy);  others  to  to    rapid   dilatation:   "This   conclusion    reached 


i89i.] 


RAPID  DILATATION  AND  CURETTING. 


841 


inferentially  has  been  abundantly  confirmed  on 
the  operating  table  by  much  of  my  later  pelvic 
work.  In  a  number  of  cases  with  a  history  of 
preceding  dilatation,  the  after-operation  has  ex- 
hibited an  inflammatory  condition  of  affairs  as 
complicated  as  any  other:  in  my  experience  some 
of  the  dilatations  were  done  with  pre  existing 
disease  which  was  made  worse  by  the  interfer- 
ence, while  others  were  done  simply  to  relieve 
the  dysmenorrhea  and  resulted  in  the  establish- 
ment of  a  complicated  surgical  disease  in  which 
operation  was  necessary  to  S3ve  life.  All  in  all. 
I  believe  that  judged  simply  by  its  remoter  effects, 
the  operation  of  rapid  dilatation  is  a  dangerous 
one  and  results  oftener  in  subsequent  harm  than 
in  lasting  good.  The  surgical  injury  to  the  cer- 
vix which  it  is  the  intention  to  remedy  by  Em- 
met's operation.  Dilatation  with  curetting  of  the 
uterus  have  placed  to  their  credit  a  long  series  of 
major  operations." 

The  writer  saw  a  unilateral  laceration,  left  side, 
caused  by  the  dilator,  extend  almost  to  the  for- 
nix vaginae.  No  doubt  many  experienced  phy- 
sicians have  dilated  with  good  results,  such  men 
as  Emmet,  Gilwily,  Goodell,  DaCosta,  Baldy, 
Ashton,  Noble  and  others  who  are  not  so  emi- 
nent, but  they  have  been  taught  gynaecolog}'  in 
all  its  relations  and  know  the  when,  and  how 
and  the  pros  and  cons.  Dr.  DaCosta  states:  "Dr. 
Goodell  has  reported  to  this  society  (Philadelphia 
C<  lunty  Medical  Association)  many  cases  in  which 
forcible  dilatation  has  been  used  with  grand  re- 
sults. I  have  used  forcible  dilatation  in  many 
cases  and  have  never  had  bad  results.  The  rea- 
son is  that  when  I  began  the  study  of  gynaecol- 
ogy I  was  taught  how  to  use  it  properly,  and  not 
to  use  it  in  even-  case.  The  dilator  is  a  surgical 
instrument  and  one  which  must  be  handled  care- 
fully. You  must  know  how  to  do  your  work  be- 
fore you  attempt  to  use  it.  My  teaching  is, 
when  there  is  violent  inflammation  in  the  pelvis 
not  to  do  any  operation  on  the  uterus  and  to  hes- 
itate to  use  the  sound."  (He  should  have  said 
never  use  the  sound.) 

Dr.  William  E.  Ashton:  "The  question  of  the 
use  of  the  dilator  depends  on  one  or  two  facts. 
First,  as  to  the  condition  of  the  uterine  append- 
ages and  their  surroundings:  secondly,  properly 
selected  cases.  I  believe  that  when  we  have  the 
pelvis  perfectly  free  from  local  disease  in  cases 
where  the  uterus  is  strongly  antiflexed  and  per- 
fectly movable,  and  upon  the  introduction  of  the 
sound  we  find  there  is  a  point  of  intense  pain  at 
the  internal  os,  we  shall  find  in  a  certain  propor- 
tion of  cases  that  good  results  are  obtained  by  the 
dilator.  The  vast  majority  of  cases  of  dysrnen- 
orrhcea  are  cases  which  have  a  distinct  tubal  or 
ovarian  origin.  It  would  be  absurd  to  rapidly 
dilate  in  such  cases.  It  should  go  on  record  that 
the  uterine  sound  should  only  be  used  by  men 
who  have  a  thorough  knowledge  of  the  pathol- 


ogy of  the  pelvis  and  who  can  appreciate  the 
great  danger  incident  to  inflammatory  troubles  in 
the  utt- 

Dr.  C.  P.  Noble:  "I  should  be  loth  to  give  it 
up  (rapid  dilatation);  I  have  never  seen  any 
harm  follow  rapid  dilatation  in  any  case.  This 
is  due  to  the  fact  that  dilatation  has  been  used  in 
cases  in  which  the  disease  is  limited  to  the  uterus. 
I  agree  that  it  is  useless  and  dangerous  to  dilate 
the  uterus  when  tubal  disease  is  present.  In 
uterine  disease  it  is  capable  of  a  great  deal  of 
good." 

Dr.  J.  M.  Baldy:  "I  should  be  loth  to  give  up 
forcible  dilatation  in  certain  cases.  It  should 
not  be  done  in  every  case  of  dysmenorrhcea,  for 
the  vast  majority  of  cases  are  due  to  ovarian  or 
tubal  disease.  I  believe  that  in  the  vast  majority 
of  cases  where  trouble  follows  the  use  of  the  di- 
lator, there  has  been  pre-existing  pelvic  trouble. 
I  do  not  think  that  a  carefully  done  dilatation  in 
a  health}-  pelvis  will  do  harm.  It  is  admitted 
that  it  will  tear  uterine  tissue,  but  that  this  can 
cause  trouble  unless  the  wound  becomes  septic  I 
am  not  prepared  to  admit." 

Dr.  Price,  in  refermg  to  the  article  of  a  minor 
gynaecologist,  states  in  debate  (Philadelphia 
County  Medical  Society).  "He  is  the  great 
mischief  doer.  He  tinkers,  dilates,  curettes, 
passes  the  sound  and  in  four  to  six  weeks  he  (Dr. 
Price)  gets  a  telegram  to  come  and  open  the  ab- 
domen to  save  the  patient's  life;  that  the  woman 
is  leaking;  that  she  has  a  pulse  of  130  to  140, 
with  temperature  of  io4:.  This  recurs  weekly; 
also  stated  of  specimens  in  that  jar  removed  dur- 
ing the  month  of  August,  50  per  cent,  followed 
dilatation,  closure  of  cervix,  the  use  of  the  sound 
and  currette.  These  specimens  have  come  from 
four  clinics  in  this  city  (Philadelphia),  and  from 
ten  prominent  gynaecologists.  They  all  had  sec- 
tions to  save  life  and  all  were  greatly  complicated 
operations.  These  fibroids  in  the  jar  had  pus  in 
them,  the  result  of  electricity.  This  private 
office  work  has  a  great  deal  to  do  with  it.  Many 
of  these  men  are  simply  cervix  feelers,  and  never 
find  anything  above  it.  There  may  be  a  mass 
larger  than  the  uterus  on  one  or  both  sides  which 
they  fail  to  find.  They  are  not  anxious  to  find 
them  and  would  not  be  troubled  by  them  or  capa- 
ble of  dealing  with  them  if  they  struck  them  acci- 
dentally." 

This  state  of  affairs. existing  in  Philadelphia. 
The  havoc  wrought  by  the  minor  gynaecologist 
could  be  doubtless  estimated  ad  infinitum  through- 
out the  world.  Dr.  Joseph  Hoffman  states.  I  have 
put  on  record,  in  the  Obstetric  Society,  a  case 
where  the  uterus  was  perforated  by  the  curette.  I 
have  seen  to-day  two  patients  that  have  been 
treated  by  the  curette  and  from  whom  I  have  re- 
moved the  appendages.  In  one  case  that  I  know 
of  the  uterus  was  torn  by  the  dilator,  then  a 
sponge  tent  was  put  in  and  allowed  to  remain,   I 


342 


RAPID  DILATATION  AND  CURETTING. 


[June  >3 


do  not  know  how  long.  You  know  the  rest.  In 
the  case  in  which  the  uterus  was  perforated  by 
the  curette,  the  operation  was  done  by  a  gynaecol- 
ogist of  considerable  experience.  Nevertheless 
the  uterus  was  ruptured  and  peritonitis  was 
brought  en  and  abdominal  section  was  necessary 
to  save  life.  I  have  to  day  two  other  women 
who  were  treated  by  minor  gynaecologists;  they 
were  both  left  miserable.  In  one  the  vagina  is 
much  contracted  and  the  pelvic  viscera  are  cer- 
tainly affected.  In  one  of  these  cases  especially 
electricity  was  used  ad  nauseam.  The  history  is 
this:  fir.it  dilatation  and  scraping;  then  closure 
of  the  perineum;  and  then  the  opening  of  the 
abdomen.  Dr.  Emmet  for  a  decade  or  more  gave 
the  danger  signals  of  minor  gynaecology  ignor- 
antly  and  thoughtlessly  practiced,  but  the  warn 
ing  has  only  been  heeded  and  appreciated  by  the 
few.  The  many,  it  might  be  truthfully  said,  have 
gone  on  their  way  in  mid  night  darkness  causing 
pain  and  anguish,  destroying  important  organs, 
wrecking  constitutions  and  lossof  life.  Emmet's 
(Principles  and  Practice  of  Gynaecology)  is  re- 
plete with  aphorisms  of  wisdom  lightening  the 
pathway  all  along  the  line  and  is  to  the  major 
gynaecologist  a  "sermon  on  the  mount,"  but  the 
pseudo-gynaecologist  or  gynaecological  tinkers  are 
deaf  and  myopic  and  would  not  turn  from  the 
error  of  their  way  "though  they  had  Moses  and 
t*ie  Prophets  to  warn  them."  Dr.  DaCos-ta 
states,  ' '  then  in  regard  to  the  curette,  these  usual- 
ly have  a  sharp  cutting  edge.  Such  an  instru- 
ment is  hardly  safe  for  an  able  practitioner  to  use 
and  is  not  safe  in  the  hands  of  the  unskilled  per- 
son; when  inflammation  extends  from  the  uterine 
cavity  to  the  tubes  after  tne  use  °f  tne  curette,  it  is 
not  so  much  the  instrument  as  the  man  who 
uses  it."  Dr.  Hoffman  states  "the  curette  in  some 
cases  is  a  necessary  evil  wThich  we  cannot  do  with- 
out. I  have  found  it  useful  in  getting  rid  of  putrid 
debris  from  miscarrying  uterus  in  the  early  weeks 
of  pregnancy,  when  the  use  of  the  finger  is  thor- 
oughly clumsy  and  painful;  if  not  impossible, 
without  previous  dilatation  with  tent,  I  can  say 
I  have  had  no  bad  results  I  know  of." 

Dr.  Baldy:  "The curette,  I  think  is  a  valuable 
instrument,  but  it  is  abused  and  used  indiscrim 
inately.  -\  fter  abortion  I  found  it  most  valuable. 
In  some  cases  of  chronic  endometrial  disease  it 
is  valuable.  I  believe  it  will  remove  almost  all 
necessity  for  intra  uterine  treatment.  I  think 
the  dull  curette  useless.  The  only  rational  treat- 
ment is  the  sharp  curette.  The  sharp  curette 
can  be  used  with  as  little  danger  as  any  other 
instrument  if  used  properly  in  skilled  hands." 

Dr.  C.  P.  Noble:  "Why  we  should  give  up 
the  curette,  I  cannot  understand.  There  are 
many  cases  of  haemorrhage  of  the  uterus  due  to 
uterine  disease  purely,  where  there  is  no  ovarian 
or  tubal  disease.  In  such  cases,  the  curette  will 
permanently  control  the  haemorrhage."       (The 


ci  msensus  of  opinion  is  that  the  dilator  and  cur- 
ette are  valuable  instruments  in  skilled  hands, 
but  otherwise  are  agents  of  potent  evil.) 

When  so  skilful  and  erudite  a  surgeon  as  Dr. 
Emmet  has  had  harmful  results  follow  forcible 
dilatation  and  curetting,  with  all  his  care,  diag- 
nostic and  operative  skill,  painstaking  and 
prophylactic  measures,  one  is  forced  to  believe 
inferentially  that  the  gentlemen  who  have  been 
quoted  would  certainly  have  had  experience 
similar  to  Dr.  Emmet  had  they  followed  up  their 
cases,  corralled  them,  and  hunted  for  after  claps 
or  evil  results.  I  have  found  it  often  (uterine 
dilatation)  very  serviceable  for  arresting  haemor- 
rhage, particularly  wheu  due  to  soft  growths,  or 
tp  some  diseased  condition  of  the  caual.  It  is  of 
great  value  after  a  tent  has  been  used  to  increase 
the  dilatation  at  the  time  of  operating  for  the  re- 
moval of  an  intra  uterine  tumor.  Ten  or  fifteen 
minutes  will  often  be  sufficient  to  effect  the  neces- 
sary dilatation  for  purposes  of  exploration,  but 
as  already  stated,  rapid  dilatation  should  never 
be  employed  unless  the  case  is  urgent.  If  preg- 
nancy exists  and  a  tent  has  already  been  used, 
or  if  there  should  be  a  haemorrhage,  there  will  be 
|  less  risk  from  rapid  dilatation.  Under  other 
circumstances,  it  is  always  attended  with  the 
danger  of  existing  inflammation.  (Page  36,  Em- 
met's Principles  and  Practice  of  Gynaecology.) 
In  hospital  practice,  when  I  could  control  the 
movements  of  the  patients,  I  have  long  em- 
ployed sponge- tents  to  bring  about  a  reduction  in 
I  the  size  of  the  often  enlarged  uterus.  This  mode 
of  practice  is  original  with  me,  and  from  long 
experience  I  have  found  it  most  satisfactory 
whenever  employed  under  proper  circumstances. 
The  object  is  to  bring  about  by  pressure  an  alter- 
ative effect  in  the  mucous  membrane  and  indur- 
,  ated  tissue,  to  excite  contractions  of  the  whole 
organ  and  to  lessen  the  circulation  in  the  uterus 
by  means  of  the  profuse  watery  discbarge  which 
is  invoked.     (Page  140.) 

It  is  equally  beneficial,  if  not  more  so,  when 
there  exists  no  enlargement,  since  the  disease  is 
1  then  confined  chiefly  to  the  cervix,  or  at  least  to 
1  that  portion  of  the  caual  below  the  internal  os. 
i  By  dilating  the  canal  thoroughly  in  these  cases, 
it  will  open  at  the  rugae,  so  that  the  agent  ap- 
plied can  be  brought  directly  in  contact  with  the 
mouth  of  each  crypt,  and  every  portion  of  the 
mucous  membrane.  This  cannot  be  done  under 
ordinary  circumstances,  and  the  fact  will  explain 
the  negative  result,  frequently  observed  after  op- 
erations made  through  the  undilated  os,  for  the 
nearer  the  uterus  approaches  to  a  natural  state 
the  deeper  will  these  folds  be  found,  In  reference 
to  local  treatment  Emmet  states  :  "  We  should 
always  have  the  fear  of  cellulitis  before  us." 
No  portion  of  the  body  has  suffered  more  from 
the  over- zealous  interference  of  ignorant  practi- 
|  tioners,  and  from  the  carelessness  of  those  who. 


i89i.] 


RAPID  DILATATION  AND  CURETTING. 


843 


though  not  ignorant,  fail  to  make  such  a  thorough 
investigation  of  their  cases  as  is  essential  to  their 
successful  management.  Under  the  guise  of 
surgery,  the  uterus  has  been  subjected  to  a  de- 
gree of  malpractice,  which  would  not  be  toler- 
ated  in  any  other  portion  of  the  body.  Its  cav- 
ity has  been  and  is  to  day  made  the  receptacle 
for  agents  so  destructive,  that  it  seems  difficult 
to  understand  how  their  evil  effects  have  escaped 
observation.  But  I  trust  we  have  already  passed 
the  heroic  age,  and  that  in  the  treatment  of  uter- 
ine diseases,  we  may  be  hereafter  governed  by 
the  same  rational  methods  as  should  apply  in 
every  branch  of  medicine,  that  is,  we  may  simply, 
as  we  term  it  in  this  country,  exercise  our  "  com- 
mon sense." 

Indications  for  Dilatation. — Dysmenorrhcea  due 
to  cervical  stenosis  ;  its  cause  should  be  readied 
by  exclusion.  There  is  sometimes  primary 
stenosis ;  all  conditions  being  normal  :  the 
mucous  membrane  engorged  at  the  menstrual 
nisus,  constricts  the  internal  os,  and  when  there 
is  endocervical  and  corporeal  mentritis  in  the 
virgin  or  nullipara,  the  stenosis  may  become 
much  aggravated,  especially  if.  in  addition  to  the 
hypertrophy  and  hyperdistention  of  the  mucous 
crypts  with  closed  orifices  and  pent-up  sections, 
there  is  hyperplasia  of  the  submucous  connective 
tissue.  To  one  familiar  with  the  occlusion  ot 
the  nasal  chambers  from  chronic  and  hypertrophic 
rhinitis,  it  can  be  readil)-  perceived  how  a  similar 
condition  of  the  uterus  mucous  membrane  couid 
ind  aggravate  a  stenosis  of  the  internal  os, 
and  how  the  displaced  uterus  in  the  form  of  vis- 
ions, flexions  and  obliquities,  single  or  combined, 
could  cause  stenosis  like  the  flexed  or  dislocated 
portion  of  the  nose,  and  be  amenable  to  restitu- 
tion and  dilatation  to  straighten  the  uterine 
canal,  making  it  more  patulous  ;  the  pressure 
opening  the  orifices  and  emptying  the  di 
crypts  of  their  contents,  allowing  their  walls  to 
collapse,  besides  causing  absorption  of  effused 
fluid  and  unorganized  lymph,  and  by  straighten- 
ing the  uterus,  also  straighten  the  arteries,  allow- 
ing increased  nutrition,  by  rectifying  the  veins, 
relieve  passive  congestion,  removing  the  engorge- 
ment from  the  over-loaded  capillaries,  and  in  a 
similar  way,  increase  the  functions  of  the  lymph 
channels.  Not  only  may  an  enlarged  uterus  be 
benefited  this  way,  but,  also  a  uterus  of  natural 
size  afflicted  with  endomitritis.  When  the  walls 
of  a  displaced  uterus  are  straightened  by  dilata- 
tion the  womb  is  much  more  easily  retained  in 
normal  position,  gets  more  patulous  at  the  in- 
ternal os.  Some  operators  would  recommend 
dilatation  for  infantile  uteri,  to  increase  their  nu- 
trition and  size,  but  we  doubt  the  expediency 
and  believe  the  weight  of  authority  is  against  it, 
since  their  cause  is  tubal  and  ovarian.  After 
dilatation  the  distended  crypts  can  be  scarified  or 
punctured  ;    dilatation  is  often  essential  for  diag- 


nosis of  intra-uterine  growths  and  foreign  bodies, 
and  as  a  preparatory  step  to  curetting.  Emmet 
speaks  of  the  beneficial  effects  of  forcible  dilata- 
tion fur  malarial  congestive  hypertrophy  of  tke 
uterus.  We  can  also  often  obtain  the  pressure, 
size  and  positions  of  intra-uterine  growths,  and 
use  it  as  a  preparatory  step  to  removal  of  these 
growths  of  foreign  body.  Dilatation  is  essential 
to  wash"  out  the  uterus  when  there  is  sepsis,  and 
in  conjunction  with  curetting  to  remove  septic 
material  and  arrest  haemorrhage.  Rapid  dilata- 
tion should  never  be  used  unless  the  cause  or 
case  demanding  it  is  urgent.  (Emmet  states  if 
pregnancy  exists  and  a  tent  has  been  already- 
used,  or  if  there  should  be  haemorrhage,  there 
will  be  less  risk  from  rapid  dilatation  than  under 
other  circumstances  ;  it  is  always  attended  with 
the  danger  of  exciting  inflammation.) 

Indiratiojis  for  Curetting  for  Diagnosis. — 
Presence  or  absence  of  growths  or  tumors  in 
uterus.  Removal  of  portions  from  cavity  of 
uterus  for  inspection.  (Skene.)  In  chronic  endo- 
metritis, the  removal  of  granulation  tissue,  as  in 
granular  conjunctivitis  to  open  the  engorged  and 
distended  crypts,  and  relieve  them  of  their  con- 
tents and  free  the  lumen  of  the  canal;  to  remove 
fungous,  or  foreign  growths,  and  retained  septic 
placenta;  to  arrest  haemorrhage.  In  malignant 
disease  of  the  cervix,  after  removing  all  growth 
possible  with  the  scissors,  the  Sims  curette,  or 
Thomas'  wire  scraper,  followed  by  the  paquelin 
cautery,  becomes  a  valuable  adjunct.  Emmet 
states  Sim's  scraper  has  too  sharp. a  curetting 
edge  and  causes  much  bleeding.  When  the 
follicles  of  Xaboth  undergo  cystic  degeneration 
and  are  detected  by  their  rough  and  uneven 
surface  they  should  be  ruptured  with  the  curette, 
used  with  mild  force  over  their  surface.  In 
diagnosis  of  intra  uterine  growths,  the  curette  is 
claimed  by  some  to  be  a  valuable  diagnostic 
measure,  but  it  removes  both  diseased  and  normal 
tissue. 

Thomas'  wire  curette,  and  Emmet's  scissors- 
shaped  or  forcep  curette  are  recommended  as  the 
safest  and  most  expeditious.  The  dull  or  wire 
curette  from  the  friction  or  pressure  effect  pro- 
duced, may  change  the  nutrition  of  the  affected 
parts  by  retraction  and  absorption  of  exuberant 
tissue,  and  soft  villous  growths.  In  cases  of  old 
cervical  lacerations  with  multiple  papilloma  and 
warty  excrescences,  the  sharp  curette  has  proven 
a  most  valuable  instrument  and  did  beautiful 
work  by  removing  them  ;  chronic  anhydrous  acid 
was  then  applied  to  the  bases  with  the  best  re- 
sults, and  no  evil  sequelae,  in  the  uterus  of  a 
woman  70  years  old,  in  the  fall  of  1889;  patient  is 
still  living  and  enjoying  good  health.  Emmet's 
forceps  curette  can  only  remove  the  growths  pro- 
jecting above  the  uterine  surface  ;  it  crushes  the 
diseased  tissue  in  its  immediate  grasp  ;  in  addi- 
I  tion,  too,  it  can  be  used  as  a  dilator  when  neces- 


S44 


WHEN  IS  ANTISEPSIS  A  FAILURE? 


[June  13, 


sary.  Of  the  Recamier  curette  modified  by  Sirup- 
son,  Simou  and  Simms,  it  is  said  that  the  ingenuity 
of  man  has  never  devised  one  capable  of  doing 
more  injury.  Women  suffering  with  intra- 
uterine growths  are,  as  a  rule,  quite  anaemic,  and 
very  susceptible  to  septicaemia  and  peritonitis 
after  curetting.  Emmet  states  that  he  has  known 
peritonitis,  cellulitis,  and  pelvic  abscess  and  even 
death,  to  occur  on  removing  these  growths  from 
the  uterine  canal  with  the  curette,  and  in  every  1 
instance  the  operator  was  dextrous  in  the  use  of 
the  instrument.  Inflammatory  disease  may  ex- 
tend by  continuity  of  tissue  into  the  tubes,  ovaries 
and  peritoneum  from  the  uterus,  producing  peri- ; 
or  parametritis,  or  these  can  be  caused  by  intra- 1 
uterine  instrumentation,  per  se,  or  the  dilator  and 
curette.  If  uteri  free  from  intrapelvic  complica- 
tions only  were  dilated  and  curetted  under  proper 
conditions,  and  were  a  thorough  and  intelligent, 
digital  and  conjoined  manipulation  made  in  every 
case,  before  instrumental  treatment  is  used, 
pelvic  disease  would  be  detected,  and  non-inter- 
terence  would  be  the  rule,  and  major  pelvic  op- 
erations to  save  life  would  be  less  frequent. 

When  the  minor  gynaecologist  ceases  to  tinker 
there  will  be  far  more  tubes  and  ovaries  remain 
in  the  pelvis.  It  is  to  be  hoped  that  the  millen- 
nium is  at  hand,  that  the  "  goats  will  be  separ- 
ated from  the  sheep,"  and  to  the  pseudo-gynae 
cologist  the  scriptural  injunction  proclaimed 
"  depart  ye  cursed,  I  never  knew  you,"  will  be 
fulfilled,  and  that  woman  will  keep  her  normal 
uterine  appendages  instead  of  having  them  re- 
moved and  placed  in  bottles.  The  more  ex- 
perienced and  skilled  the  diagnostician  is,  the 
less  often  will  he  resort  to  dilatation  and  curett- 
ing ;  conversely,  the  more  ignorant  and  unskilled 
the  operator,  the  ofteuer  will  he  use  these  meas- 
ures and  greater  will  be  the  disaster  to  health, 
happiness  and  life. 


WHEN  IS  ANTISEPSIS  A  FAILURE? 

i    He  in  tin- Section  o/Obstetria  and  Disease  of  Worn,  n .  at  the 
I  nnual  Meeting  of  the  American  Medical  Asso- 
ciation, held  at  Washington,  D.  C.  Mays  S.iSgi. 

BY  JOHN  ERETY  SHOEMAKER,   M.D., 

OF   PHILADELPHIA. 

Outside  of  a  comparatively  small  circle  of  sur- 
geons there  are  heard  from  time  to  time  sugges- 
tions which  occasionally  appear  in  print,  that  the 
system  of  "  Listerism,"  so-called,  is  a  failure. 
Strange  as  it  may  seem,  it  is  not  very  uncommon 
to  hear  some  one  say  that  in  a  given  case  "every 
antiseptic  precaution"  was  adopted,  but  the  re- 
sult was  bad.  The  speaker  would  have  you  be- 
lieve that  he  had  done  his  part  and  that  the  sys- 
tem was  at  fault. 

Now,  it  is  worth  while  to  consider  briefly 
where  the  difficulty  lies:  and  without  entering 
the  discussion  of  asepsis  as  opposed  to  antisepsis 


— absence  of  dirt  versus  sterilization  of  dirt, — 
without  advocating  special  methods  or  dressings, 
attention  may  be  drawn  to  practical  difficulties 
which  lead  to  misunderstanding. 

A  few  men,  like  Mr.  Tait,  vigorously  attack 
the  theory  of  Listerism,  while  they  themselves 
carry  out  the  principles  underlying  its  success. 
The  reputation  of  Mr.  Tait,  however,  rests  upon 
his  operative  work,  and  not  upon  his  opinions  or 
his  explanations.  When  in  characteristic  style 
he  says  {British  Medical  Journal,  Sept.  27,  1890, 
p.  728):  ....  "The  tone  and  attitude  adopted 
by  Sir  Joseph  Lister  at  Berlin  clearly  shows  that 
the  whole  sad  business  is  on  its  last  legs,"  etc. 
Also  (p.  729):  "I  venture  to  say  that  before  the 
present  generation  has  run  out  the  word  'antisep- 
tic' will  be  all  that  is  left  to  represent  this  strange 
structure."  The  harm  that  he  can  do  is  not  great 
among  the  men  who  are  doing  the  best  work  in 
surgery,  especially  in  general  surgery.  These 
cannot  work  for  a  day  without  discovering  for 
themselves  that  their  results  are  better  or  worse, 
according  to  their  greater  or  less  microscopic 
and  chemical  cleanliness  in  operating.  Active 
surgeons  do  not  care  how  Mr.  Tait  explains  his 
good  results.  He  might  refuse  to  believe  in  the 
law  of  gravitation  if  he  choose,  but  as  long  as  he 
did  not  violate  it,  as  long  as  he  refrained  from 
walking  out  of  windows  or  off  precipices,  his 
opinion  as  to  the  law  would  make  little  differ- 
ence. Most  men  care  little  that  he  denies  the 
evil  potency  of  germs  and  relies  upon  removing 
decomposable  material  from  his  wounds.  They 
remember  that  he  deals  with  a  peculiar  mem- 
brane and  its  neighborhood,  that  he  is  extremely 
clean  in  his  work,  and  they  will  permit  him  to 
attack  Sir  Joseph  Lister  personally,  and  his  im- 
pregnable principles,  to  his  heart's  content;  prin- 
ciples of  the  widest  practical  application.  The 
harm  Mr.  Tait  can  do  is  to  unsettle  the  mind  ot 
the  man  who  is  beginning  his  work;  and,  worse 
than  that,  his  writings  tend  to  salve  the  con- 
science of  those  who  have  had  no  training  in 
genuine  aseptic  methods,  who  fail  consequently 
to  fully  carry  them  out,  and  who  joyfully  bail 
any  champion  who  even  seems  to  justify  their  in- 
difference. 

But  even  among  the  better  trained  class  of 
men,  does  not  one  often  see  a  lamentable  failure 
to  grasp  the  essential  ideas  of  surgical  cleanli- 
ness ? 

There  are  hundreds  of  men  to-day  who  appar- 
ently persuade  themselves  that  mopping  a  1  to 
20  carbolic  acid,  or  1  to  2,000  bichloride  of  mer- 
cury solution  about  a  wound  area  constitutes 
using  "  every  antiseptic  precaution,"  as  the 
phrase  goes.  There  are  also  men  who  will  use 
chemicals  upon  a  septic  patient  but  neglect  to 
change  infected  bedding.  There  are  men  who 
will  go  to  an  operation  with  the  points  of  their 
scissors,  the  locks  and  serrations  of  their  hasm- 


I89i.] 


WHEN  IS  ANTISEPSIS  A  FAILURE? 


845 


ostatic  forceps,  the  eyi  s  of  their  needles,  choked 
with  dried  blood  or  worse  material  from  the  last 
operation.  They  never  boil  an  instrument.  Their 
conscience  is  satisfied  with  the  carbolic  acid  in 
the  instrument  pan  n  wash  their  hands 

before  an  opei  ition  no  better  than  before  dinner. 
When  an  instrument  or  a  sponge  drops  to  the 
floor  they  may  rapidly  rinse  it  in  the  pan  and 
use  it  at  once.  There  are  other  men  who  have 
trained  nurses,  sterilized  dressings  and 
instruments,  but  who,  after  they  have  washed 
for  the  operation,  shake  hands  with  a  spectator, 
put  a  hand  in  a  pocket,  remove  instruments  from 
an  old  blood  stained  case,  help  carry  a  table, 
handle  dusty  bottles,  or  use  a  handkerchief,  and 
yet  say  they  use  every  antiseptic  precaution. 
Many  men  know  better.  What  is  lacking  is  care- 
ful self-training  and  what  may  be  called  an  asep- 
tic conscience.  What  is  wanted  is  a  realizing 
sense  of  the  real  difficulty  in  getting  things  clean 
and  then  keeping  them  so.  Carbolic  acid  solu- 
tions as  practical  sterilizers  are  a  delusion  and  a 
snare.  They  work  slowly  at  best.  Unless  too 
strong  for  comfortable  or  safe  handling  they  do 
little  good,  and  they  do  enormous  harm  by 
quieting  the  conscience  of  the  man  who  ought  to 
spend  more  time  cleaning  his  hands;  yet  how 
many  times  do  we  see  them  relied  upon  when 
they  only  cover  dirt.  Many  tex.t- books,  even  the 
revised  editions  of  standard  works,  are  written 
from  a  carbolic  acid  standpoint.  Antisepsis  is  a 
failure  when  it  is  superficial. 

In  a  recent  case  of  laparotomy,  referred  to  by 
the  author's  permission,  the  stitches  cut  out  and 
the  wound  opened,  though  it  afterwards  united 
by  granulation.  The  operator  had  been  cleanly, 
but  the  fault  was  traced  to  a  nurse  who  had 
handled  the  previously  sterilized  silk  with  in- 
fected fingers.  In  another  case  the  paraphernalia 
were  elaborate  and  the  preparations  minute. 
The  chief  assistant  seized  a  falling  ether  bottle, 
old  and  very  dirty,  and  without  the  slightest 
effort  to  cleanse  the  hand  again  it  was  soon  in 
the  abdominal  cavity.  The  patient  died  two 
days  later  of  peritonitis,  which  may  have  been  a 
coincidence. 

A  few  days  ago,  in  a  hospital,  a  major  operation 
was  in  progress.  The  lecturer  had  dilated  upon 
the  beauties  of  the  antiseptic  methods.  The  cat- 
gut ligatures  proving  defective,  he  called  for  silk. 
There  was  a  scurrying  of  nurses  and  an  ancient 
open  box  of  silk  was  brought.  A  spectator  with 
unwashed  hands  threw  a  card  of  silk  into  the  in- 
strument pan,  from  which  a  piece  wras  taken 
when  scarcely  wet  and  placed  on  one  of  the 
largest  arteries  in  the  body.  A  weak  link  breaks 
a  strong  chain. 

In  a  hospital  case  of  my  own,  requiring  careful 
dissection  about  the  face,  an  assistant,  unknown 
to  the  operator,  obtained  an  instrument  which 
had  been  used  a  few  minutes  before  in  opening  a 


suppurating  bubo.     In  two  days  the  wound  area 
was  an  abscess  under  st<  1  --iugs. 

Not  long  ago,  in  an  emergency,  the  writer 
asked  at  a  drug  store  for  antiseptic  gauze.  The 
druggist  instantly  opened  a  beautifully  decorated 
and  labeled  tin  box,  unrolled  quite  a  quantity  of 
gauze  and  offered  it  for  inspection.  He  was,  of 
course,  told  that  while  that  might  have  been  an- 
jauze  once  it  was  ruined  as  such  by  his 
handling;  a  proposition  which  failed  completely 
to  enter  his  mind.  No  doubt  that  identical  roll 
of  gauze  will  be  retailed,  and  the  writer  fears  that 
there  are  physicians  who  would  buy  it  measured 
by  the  yard  on  his  counter,  and  yet  hardly  realize 
that  it  was  worthless  as  a  clean  dressing  or  pack- 
ing. But  why  multiply  instances  to  show  that 
"antisepsis,"  when  neutralized  by  some  single 
mistake,  is  a  failure.  Which  should  be  blamed, 
the  system  or  the  application  ? 

The  war  about  asepsis  as  opposed  to  antisepsis 
is  a  minor  issue.  The  great  fact  remains  that 
the  principles  of  cleanliness,  though  adopted 
theoretically  throughout  the  world,  are  really 
carried  out  very  imperfectly  by  most  nurses,  most 
hospital  internes,  some  general  practitioners  in 
town  and  country,  even  (must  it  be  said  ?  iby  many 
otherwise  most  excellent  and  estimable  surgeons. 

This  is  not  the  place  to  bring  forward  the  over- 
whelming evidence  in  favor  of  surgical  cleanli- 
ness in  saving  life  and  promoting  swift  recovery 
from  operations  impossible  without  it.  This 
work  has  been  done  again  and  again.  Many  of 
us  see  it  daily. 

Let  no  one  be  misled  by  the  war  of  methods 
into  suspecting  the  truth  of  principles.  Let  each 
of  us  train  himself  constantly  to  make  his  work 
clean.  Only  by  long  practice  can  this  be  well 
done. 

In  regard  to  the  use  of  chemicals,  it  is  known 
that  in  abdominal  operations  they  are  not  neces- 
sary. In  general  surgery,  including  railroad  and 
machinery  accidents,  better  results  can  be  ob- 
tained by  the  use  of  sublimate.  Perfect  as 
though  it  should  be  aimed  at,  is  almost  impos- 
sible as  a  practical  measure.  The  assistant  of  the 
moment  is  often  untrained,  and  can  neither  be 
relied  upon  nor  narrowly  watched;  nurses  may 
be  new  to  the  work,  derelict  or  incompetent;  the 
wound  is  frequently  infected  before  it  is  seen. 
The  best  results  in  general  surgery  are  obtained 
with  least  trouble  by  combining  the  aseptic  with 
chemical  methods. 

Further,  let  no  man  venture  to  criticize 
methods  which  he  has  never  fairly  tried;  let  him 
also  bear  in  mind  that  his  trial,  though  honest, 
may  be  superficial,  and  therefore  faulty  through 
his  lack  of  patient  personal  training. 

In  conclusion  then,  in  answer  to  the  question: 
When  is  antisepsis  or  asepsis  a  failure  ?  one  may 
say,  never  if  real,  always  if  imperfect. 

There  is  no  doubt  that  the  great  principle  of 


846 


PATHOLOGICAL  ANTEFLEXION  OF  THE  UTERUS. 


[June  13 


cleanliness  in  surgery,  whether  obtained  by  soap, 
hot  water,  dry  heat  or  chemicals,  has  come  to 
stay,  and  the  sooner  all  of  us  act  thoroughly 
upon  that  principle,  ignoring  personal  discussion, 
the  better. 

3727  Chestnut  street. 


PATHOLOGICAL  ANTEFLEXION  OF  THE 
UTERUS. 

JtraJ  in  the  Section  oj  i  ibsteti  n  s  an</  /</  v,7a,  .  or'  1 1  'omen,  at  >h<-  Forty- 
i1 '.'..'    1/       "  I  oh  1  t\\ui  Medical  Association,  hetd 

at  Washington,  D.  C,  May,  1&91. 

BY  ELIZA  C.   MIXARD,   M.D., 

OF  BROOKLYN,  N.  V. 

"  Plastic  operation  to  straighten  the  anteflexed 
uterus." 

Accepting  the  opinion  held  by  the  most  ad- 
vanced gynecologists,  that  anteflexion  is  a  deform- 
ity, and  belongs  to  the  group  of  pathological 
conditions  which  govern  that  order  of  lesion, 
there  will  be  no  place  to  discuss  the  old  terms 
and  divisions,  which  have  controlled  the  discus 
sions  and  treatment  of  anteflexions  for  a  term  of 
years  past. 

That  this  lesion  is  amenable  to  the  laws  and 
rules  which  govern  the  treatment  of  deformities. 
is  self  evident. 

Any  malformation  is  not  usually  meddled  with 
unless  it  disturbs  the  mental  or  physical  balance 
of  the  wearer.  It  must  be  malignant,  painful, 
unsightly,  or  interfere  with  personal  comfort  or 
happiness. 

The  discovery  of  this  deformity  comes  after 
puberty ;  and  whether  the  cause  is  congenital 
non-development  from  malnutrition,  or  acquired, 
through  inflammation,  or  from  the  result  of  other 
affections,  such  as  adhesions,  pressure  or  tumors, 
the  lesion  is  a  fact,  the  symptoms  and  suffering  a 
certainty.  The  mischief  is  done  before  the  case 
reaches  the  surgeon. 

The  points  to  be  considered  when  such  a  case 
presents  itself  are :  the  amount  of  deformity,  the 
complications,  and  the  direct  or  indirect  effect 
which  it  has  or  will  have  upon  the  health,  cir- 
cumstances and  happiness  of  the  individual. 

The  family  physician  has  exhausted  the  me- 
chanical modes  of  treatment  taught  by  his  col- 
lege professor,  for  dysmenorrhcea,  endometritis, 
pelvic  peritonitis,  diseases  of  the  tubes  and  ova- 
ries, partial  stenosis  and,  if  married,  sterility. 
He  has  witnessed  the  failure  of  the  drugs  to  re- 
lieve which  are  extolled  so  highly  and  which 
bear  the  trademark  of  our  own  and  foreign  chem- 
ist,; for  professors  still  teach  that  flexions  are 
normal  conditions,  and  are  not  to  be  considered 
of  much  account  in  pelvic  lesions. 

The  gynecologist  begins  at  the  beginning,  and 
pursues  the  beaten  course  of  treatment ;  dilata- 
tion—rapid or  slow — curetting,  drainage,  poste- 
rior section,  with  glass,  rubber,  or  silver  wire  stem 


pessary,  intra-  or  extra- uterine  support,  and  oper- 
ation for  imperfect  invagination,  without  success. 
Months  and  years  pass,  surgeons  come  and  go, 
till  at  last  abdominal  sections  for  diseased  tubes 
give  the  science-tossed  sufferer  rest,  if  not  here, 
in  the  grave. 

Accepting  the  three  forms  of  flexion :  that  of 
the  body,  the  neck,  and  that  of  the  body  and 
neck,  I  have  selected  the  third  form  to  illustrate 
the  plastic  operation  which  I  believe  will  work 
much  good  to  suffering  womanhood,  and  if  done 
in  time,  will  prevent  the  necessity  of  abdominal 
section  in  some  cases.  I  take  this  because  it 
came  to  me  unsought,  and  the  greater  will  in- 
clude the  lesser  in  most  treatments. 

The  operation  known  as  "aplastic  operation 
to  strengthen  the  uterus,"  by  E.  C.  Dudley,  of 
Chicago,  which  has  been  so  clearly  and  ably  de- 
scribed in  the  February  number  of  the  American 
Journal  of  Obstetrics  of  1 891.  This  case,  which 
has  proved  so  successful  in  my  hands — and  my 
first  one  at  that — is  a  typical  one  of  a  severe  type, 
taken  after  others  had  failed  and  hospitals  refused 
admittance. 

Mrs.  M.  C,  aged  25  years,  has  been  married 
six  years  without  having  children.  She  had  been 
a  stout,  rosy  girl  before  marriage,  and  had  men- 
struated without  pain  or  discomfort  for  three 
years  before  her  marriage.  Three  months  after 
marriage  she  began  to  have  pains,  and  the  flow 
became  scant}'.  She  was  compelled  to  go  to  bed 
every  mouth.  Gradually  she  grew  worse  and  lost 
flesh.  She  took  on  an  anxious,  scared  look,  though 
of  a  happy,  cheerful  temperament  when  she  aroused 
herself.  Her  home  surroundings  were  easy,  and 
her  husband  kind  and  anxious.  The  desire  for 
children  and  the  great  suffering  induced  her  to 
seek  treatment  after  six  years  of  marital  misery. 
She  had  followed  treatment  faithfully  for  six 
months  without  improvement  save  in  general 
health.  When  she  had  spent  her  little  savings, 
she  sought  treatment  at  my  free  clinic.  The  dys- 
menorrhcea had  become  well  nigh  maddening, and 
life  had  become  a  burden.  She  came  to  the  clinic 
at  the  summer  vacation,  and  my  substitute,  Dr. 
Mary  W.  Faunce,  treated  her  for  a  severe  pelvic 
peritonitis.  On  my  return  I  found  her  quite  well 
of  the  inflammation,  and  as  I  bad  had  reasonably 
good  success  in  this  line  of  uterine  lesions,  I  pre- 
pared to  dilate.  Upon  careful  examination  I  found 
anteflexion  of  the  third  form—  flexion  of  body  and 
cervix — of  an  acute  angle,  and  fundus  resting 
upon  the  bladder.  Any  attempt  to  pass  the  sound 
caused  great  pain,  as  the  point  of  the  sound  im- 
pinged against  the  posterior  wall  of  the  canal. 
When  the  cervix  was  well  pulled  back  only  a 
small  sized  sound  would  pass.  As  it  was  near 
her  monthly  period,  I  resolved  to  dilate  and  drain. 
As  she  lived  out  of  the  city,  she  made  arrange- 
ments to  stay  in  town,  and  with  the  usual  aseptic 
precautions,  and  under  cocaine,  I  did  rapid  dila- 


I8$i.] 


PATHOLOGICAL  ANTEFLEXION  OK  THE  UTERUS. 


'•- 


tation.  It  was  tedious  work  to  introduce  tbe  first 
instrument.  It  was  done  thoroughly,  and  with 
>.;  of  a  grain  of  morphia  in  form  of  suppository; 
she  left  the  office  to  remain  in  bed  at  a  friend's 
home.  She  returned  the  next  day  looking  pale 
and  nervous.  I  introduced  another  suppository, 
gave  her  a  tonic,  and  she  left  for  her  home.  She 
wrote  me  a  happy  letter,  saying  she  had  passed 
the  monthly  period  without  pain  for  the  first  time 
since  the  third  month  after  her  marriage. 

After  the  next  period  she  came  to  my  clinic, 
saying  she  had  suffered  more  severely  than  before 
the  dilatation,  and  she  seemed  so  broken  up  that 
I  sent  her  to  my  office  from  sheer  pity.  Before 
the  next  period  I  had  her  come  into  town  and 
remain  for  a  week.  I  dilated  the  second  time, 
and  put  in  an  Onterbridge's  silver  wire  stem  pes- 
sary, under  the  same  aseptic  conditions  and  with 
cocaine.  The  stem  remained  three  days,  when 
uterine  contractions  forced  it  out.  She  remained 
in  bed,  and  suffered  from  the  stem  so  much  as  to 
require  hypnotics  and  narcotics.  She  passed  the 
period  in  bed,  without  pain,  and  a  full  flow,  last- 
ing three  days.  There  was  some  pelvic  tender- 
ness, which  passed  away  under  treatment.  She 
returned  home,  and  gained  in  flesh  and  spirits. 
But  her  experience  had  been  so  unhappy  that  she 
sought  hospital  treatment,  and  wrote  me  to  meet 
her  at  a  New  York  hospital  of  note. 

The  physician  in  charge  met  us  kindly  and  ap- 
pointed a  time  for  admittance.  It  was  here,  while 
discussing  the  case,  that  the  assistant  physician 
mentioned  this  plastic  operation  of  Dr.  Dudley's, 
and  agreed  to  do  it.  When  the  time  came  for 
entering,  an  examination  was  made  by  the  visit- 
ing physician,  who  decided  that  the  case  would 
be  too  tedious,  as  there  was  some  pelvic  peritoni- 
tis, and  there  were  more  urgent  cases  needing  the 
bed,  and  she  was  sent  home.  I  was  thoroughly 
disgusted,  and  hoped  I  had  been  relieved  of  fur- 
ther anxiety.  But  she  returned  to  me,  stating 
that  her  husband  had  decided  with  her,  that  as  I 
had  given  her  the  most  relief,  they  wished  I  would 
do  the  operation  discussed  at  the  hospital,  or  any 
other  operation  I  deemed  proper,  for  her  relief,  as 
she  feared  she  would  be  driven  to  suicide  if  it  went 
on  longer. 

I  called  in  consultation  Dr.  Faunce,  who  had 
seen  her  first,  and  described  the  operation  I  wish- 
ed to  do  and  sought  her  help.  She  entered  into 
my  views  with  enthusiasm,  and  we  made  ready 
to  operate.  Upon  a  thorough  physical  examina- 
tion we  found  the  left  ovary  and  ligament  quite 
tender,  and  an  abdominal  aneurism  as  complica 
tions.  The  heart  at  times  was  heavily  over- 
worked,   but  no  organic  lesion. 

The  uterus  was  of  normal  size,  high  up.  lying 
over  upon  the  bladder,  and  the  cervix  bent  for- 
ward, making  an  acute  angle.  The  neck  meas- 
ured i  T4  inch  in  length  to  the  bend,  which  was 
at  the  internal  os.    There  was  a  profuse  discharge 


and  a  severe  endometritis.  The  sound  would  not 
pass.  The  anterior  lip  was  long,  the  angles  of 
flexion  were  immovable,  and  the  cervix  could 
not  be  straightened  out.  The  anterior  wall  was 
thinned,  and  there  was  evidently  obstructed  cir- 
culation. The  overburdened  heart  was  acting  in 
sympathy  with  the  disturbed  nervous  action.  The 
case  was  not  an  encouraging  one.  The  Obstetri- 
cal Journal  arrived  at  this  junction,  and  Dr.  Dud- 
ley's article,  so  ably  written,  was  scanned  with 
intense  interest.  The  more  we  discussed  and  read 
the  more  we  decided  that  this  was  the  operation, 
and  our  enthusiasm  increased.  The  patient  aided 
us  by  her  courage,  and  urged  us  not  to  wait  over 
another  period.  The  complication  of  the  aneu- 
rism damped  our  ardor  somewhat,  but  after  a 
week's  rest  and  treatment,  we  put  her  on  the  op- 
erating table,  and  with  the  usual  aseptic  care, 
etherized,  dilated,  curetted,  washed  out  the  cav- 
ity with  solution  of  carbolic  acid  ;  then  divided 
the  posterior  lip  with  scissors  to  the  junction  ot 
the  wall  of  the  vagina  with  cervix,  and  carried 
the  incision  up  to  the  interior  os  with  the  bis- 
toury, then  bent  the  cut  surface  upon  itself  and 
stitched  the  external  os  to  the  point  of  the  cut 
angle   near  the  internal   os,  with  silkworm  fibre. 

We  cut  out  a  portion  of  the  anterior  lip  from 
the  external  os  to  the  vaginal  wall,  and  enclosed 
the  wound.  The  operation  resembled  a  fine  lac- 
erated cervix  which  had  been  done  in  an  aseptic 
manner.  A  Peasley  sound  entered  readily,  and  a 
new  canal,  pointing  backward,  formed  an  entrance 
into  the  uterus  at  a  slight  curve.  The  uterine 
discharge  ceased  from  that  day. 

She  rallied  from  the  ether  and  operation  well. 
She  did  not  vomit,  nor  was  much  sick.  The  usual 
toilet  and  diet  was  given.  The  aneurism  gave 
some  trouble  and  much  anxiety,  and  was  con- 
trolled by  opiates.  The  operation  gave  no  trou- 
ble— the  stitches  were  removed  the  eighth  day. 
The  healing  was  good  ;  the  Peasley  sound  passed 
easily  without  much  discomfort.  She  was  kept 
in  bed  till  after  her  monthly  period.  She  was 
kept  under  observation  till  the  second  period, 
when  she  was  allowed  to  return  to  her  home,  and 
a  letter  came  before  I  left,  stating  that  she  was 
living  a  new  life,  and  had  had  but  one  heart  attack. 

The  limited  time  will  not  allow  me  to  discuss 
causes  and  reason  for  operation.  The  author  of 
the  operation  has  so  candidly  and  conservatively 
done  this  in  his  paper  that  there  is  no  need  to  do 
so.  All  will  receive  gladly  any  added  treatment 
which  will  lessen  the  suffering  of  the  dreaded 
!  dysmenorrhcea  and  that  of  sterility.  I  would  not 
I  have  the  old  treatment  ignored.  All  means  should 
be  used  to  cure.  It  is  as  easy  to  do  as  a  posterior 
section,  adding  a  few  minutes  for  stitching  ;  and 
more  safe  with  its  aseptic  wound  than  rapid  dila- 
tation. In  well  chosen  cases  it  must  succeed  more 
or  less,  whether  the  indications  are  wholly  or  in 
part  mechanical. 


S43 


ATMOSPHERIC  CONDITIONS. 


[June  13, 


Whatever  may  be  the  complications,  there  can 
be  no  harm  in  making  a  clean,  open  canal  for  the 
easy  flow  of  the  menstrual  fluid ;  to  place  the 
uterus  upon  a  higher  plane,  and  relieve  the  pres- 
sure of  the  rectum  and  the  irritability  of  the 
bladder. 

I  will  be  pardoned  if  I  am  seemingly  a  little 
over  enthusiastic  for  such  relief  to  my  suffering 
sex,  and  if  I  place  the  author  of  this  operation — 
though  wholly  unknown  to  me — among  the  other 
benefactors  of  my  sex,  Sims,  Emmet  and  Sir 
Spencer  Wells,  it  is  because  as  a  physician  I  ap- 
preciate results. 


THE  RELATION  OF  ATMOSPHERIC  CON- 
DITIONS TO  INTERMITTENT  FEVER. 

Read  by  Title,  in  Ike  Section  of  Practice  of  Medicine  and  Physiology, 

at  the  Foitv-seamJ  Annual  Mcfttiit;  of  Hi,      I  ../.-,, v.,  n  MrJi.al  A  *-' 
sociation,  held  at  ll'as/iin^lon,  D.  C,  May.  1801. 

BY  HENRY  BIXBY  HEMENWAY,  A.M.,  M.D., 

OF    F.VANSTON,  ILL. 

Among  the  various  State  Boards  of  Health, 
perhaps  none  have  done  more  to  raise  the  stand- 
ard of  the  medical  profession,  and  to  defend  the 
public  against  impostors,  than  that  of  Illinois. 
None  has  probably  done  more  for  the  science  of 
medicine  than  that  of  Michigan.  What  is  said 
of  the  Boards,  applies  especially  to  their  execu- 
tive officers,  who  have  given  the  distinctive  char- 
acter to  the  bodies  of  which  they  are  members. 
Dr.  Henry  B.  Baker's  laborious  care  in  collecting 
statistics,  and  zeal  in  spreading  information  are 
well  known,  and  his  work  is  highly  valued.  Like 
other  mortals,  he  is  liable  to  errors  of  judgment, 
and  we  fear  that  in  such  an  error  originated  his 
articles  on  "  Malaria  and  the  Causation  of  Inter- 
mittent Fever,"  published  in  The  Journal  of 
the  American  Medical  Association  (Vol.  xi, 
p.  651,  etc.,  and  Vol.  xv,  p.  561,  etc.),  having 
been  read  before  the  appropriate  Sections  in  18S8 
and  1890. 

The  first  article,  coming  from  so  high  a  source, 
commanded  attention  ;  its  repetition  demands  the 
most  careful  investigation.  If  the  conclusions  are 
fallacious,  the  fallacies  should  be  clearly  exposed. 
If  his  reasoning  is  correct,  the  discovery  is  im- 
portant, for  it  shows  that  the  individual  can  easily 
protect  himself  from  the  disease  by  wearing  suit- 
able clothing,  and  keeping  his  surroundings  as 
even  as  possible — keeping  the  house  warmed  by 
tires  at  night,  for  example.  On  the  other  hand, 
coming  from  so  high  an  authority,  by  many  the 
ideas  will  be  regarded  as  facts  until  proved  other- 
wise. 

The  articles  in  question  do  not  show  the  judi- 
cial spirit  of  impartial  investigation  usually  found 


Note.  —  For  tables  and  diagrams  1  to  12,  inclusive,  see 
Dr.  Henry  B.  Baker's  paper  on  "  Malaria  and  the  Caus- 
ation of  [ntermittent  ]'<•..,  r,"  published  in  this  journal, 
Vol.  xi,  p.  651. 


in  Dr.  Baker's  studies,  but  rather  show  a  labored, 
and,  as  Dr.  Lee  characterized  it  when  the  article 
was  first  read  (The  Journal,  Vol.  xi,  p.  653), 
"  ingenious  "  argument  to  demonstrate  a  pet  the- 
ory. They  show  how  unconsciously  a  careful 
student  may  sometimes  be  misled  and  blinded  by 
impressions.  That  the  results  reached  are  con- 
sistent, neither  with  each  other,  nor  with  facts, 
we  shall  try  to  point  out-. 

His  first  conclusion  is  that  "intermittent  fever 
is  proportional,  either  directly  or  indirectly,  to 
the  average  daily  range  of  atmospheric  tempera- 
ture." This  sounds  well,  but  reminds  one  of  a 
test  for  flour  once  given  by  a  good  lady  :  "Take 
a  pinch  of  the  flour  and  throw  it  against  the  wall. 
If  it  is  good  it  will  stick — or  else  it  won't."  If 
the  proportion  is  sometimes  direct  and  sometimes 
inverse,  does  it  not  seem  that  any  argument  based 
upon  it  lacks  stability?  If  we  grant  that  this 
double  relationship  is  a  possible  cause  of  the 
fever,  has  the  author  presented  sufficient  proof  of 
the  existence  of  such  a  fact?  The  proof  is  in 
the  form  of  tables  and  diagrams,  which  we  will 
examine. 

Figure  1  of  Dr.  Baker's  series  shows  that  dur- 
ing the  late  war,  the  number  of  cases  of  inter- 
mittent fever  in  the  United  States  Army,  and  the 
average  daily  range  of  temperature,  both  in- 
creased up  to  May.  In  June  we  find  a  much 
greater  rise  in  the  curve  of  cases,  but  a  fall  in  the 
daily  range  of  temperature.  In  July  there  is  a 
steep  decline  in  the  curve  of  cases,  but  a  rise  in 
the  other  line.  The  daily  range  of  temperature 
continues  to  rise  until,  in  August,  it  reaches  its 
highest  mark.  From  July  the  number  of  cases 
increases  until  September.  From  their  highest 
points,  both  lines  decline  until,  in  December,  they 
touch  bottom.  It  will  be  seen  that  part  of  the 
time  the  lines  go  in  the  same  direction,  but  that 
during  much  of  the  time  the  case  line  variations 
are  a  month  behind  the  other.  This  Dr.  Baker 
explains  by  saying  that  it  is  due  to  the  accumu- 
lation of  old  cases. 

There  are  two  elements  of  fallacy  in  this  table. 
Reference  to  figure  2  shows  that  the  line  repre- 
senting the  daily  range  of  temperature  in  Lan- 
sing is  very  different  from  that  for  the  average  of 
the  State  of  Michigan.  The  case  line  in  Fig.  1 
represents  a  wide  range  of  countrj' — wherever  the 
National  troops  were  stationed.  Some  were  in 
Texas,  some  suffered  in  Florida,  Many  shook 
at  Charleston,  and  some  were  taken  sick  in  the 
Northern  cities.  If  Lansing  atmosphere,  in  the 
interior  of  the  State  of  Michigan,  is  not  to  be 
taken  as  a  basis  of  comparison  for  the  State  of 
Michigan,  how  much  less  should  the  sickness  in 
the  whole  army  be  compared  with  the  atmospheric 
1  onditions  around  a  single  building,  in  one  corner 
of  the  battlefield. 

Secondly.  Fig.  1  is  a  partisan  table.  Such  a 
study  as  we  are  now  engaged  in  is  not  a  control 


[89i.]                                          ATMOSPHERIC  CONDITION.-. 

experiment.     If  it  could  be  shown  that  intermit- 
tent fever  increased  and  diminished,  either  exact- 
ly with  or  inversely  with  the  daily  range  of  tem- 
perature,   keeping  other   conditions  stable,   one 
might  perhaps.be  justified  in  making  deductions 
therefrom.    Since  other  conditions  cannot  be  kept 
stable,  they  must  be  carefully  examined,  and  elim- 
inated as   possible  elements  before  drawing  con- 
clusions, especially  if  the  variation  in  case  and  ' 

low  the  crisis  of  the  temperature,  which  it  does 
in  this  case.     The  fall  in   number  of  ca- 
June  to  July,  without  corresponding  changes  in 
either  of  the  other  lines,  clearly  intimates  to  the 
student  that  there  is  some  other  element  which 
must  be  considered.     This  I  think  is  humidity, 
and  perhaps  ozonic  changes  also  have  an  influ- 
ence. 

daily  range  of  temperature  lines  do  not  bear  a 
constantly  definite  relationship  to  each  other.     It 
must  be  remembered  that  post  hoc  is  by  no  means 
always  propter  hoc.    We  would  therefore  have  ex- 
pected at  least  a  report  on  the  mean  monthly  tem- 
perature,  and   should   have  liked   to  have  seen 
some  reference  perhaps  to  the  mean  monthly  max- 
imum and  minimum   temperature,  and  absolute 
and  relative  humidity  of  the  atmosphere. 

From  the  "  Tables  of  Differences  of  Mean  Tem- 
perature,"   published    in   "Smithsonian   Contri- J 

^U^i  s       s     £     s     ■?    =i     ■»     -5    ■?     =5     °     ^J     5 

butions  to  Knowledge,"    I  obtained  the  average 

monthly  temperature  of  the  following  fourteen 
points,  intended  to  fairly  cover  the  field  occupied 
by  our  army  :   New  York  City,  Baltimore,  Wash- 
ington, Charleston,  Cincinnati,  St.  Louis,  Chica- 
go, New  Orleans,  Knoxville,  Atlanta,  Louisville, 

-  -- 

■ 
-    - 

Fortress  Monroe,  Ft.  Morgan  (Mobile),  and  Gal- , 
veston.     From  the   same  source  I   obtained  the 
mean  daily  range  of  temperature  at  Ft.  Morgan 
(Mobile  Point,  Ala.),  Washington  and  Philadel-  i 

-• 

phia,  and  from  Dr.  Baker's  paper  I  took  the  daily 
range  of  temperature  for  Memphis.    These  reports 
each  represent  a  series  of  years  and  are  substan- 
tially correct.     I   could  wish   that,   as  for  daily 
range  of  temperature,  I  might  have  found  more  i 
data  available.    From  the  means  above  mentioned 

I  obtained  mean  daily  range  of  temperature  and , 

mean  temperature  by  months,  for  comparison  with 
the  number  of  cases  of  intermittent  fever  in  the ' 
army,  as  shown  in  table  and  diagram  13.     It  will 
here  be  noticed  that  the  daily  range  line    rises 

| 

from  the  low  point  in  January  to  the  highest 
point   in    May.     From    May  it   slowly    declines 
about  a  degree  to  July,  and  then  rises  less  than 
half  a  degree   to  September,  from  which  latter 
point  it  declines  to  January.     The  mean  temper- 
ature curve  rises  to  its  highest  point  in  July,  re- 
maining nearlj-  stationary  until  August,  and  then 
declining  to  January.    The  case  line  starts  to  rise 
from  December,  and  reaches  its  first  crisis  in  June, 
from  which  it  falls  to  July,  and  then  reaches  its 
highest  point  in  September.     Its  low  point  is  be- 
fore the  low  point  of  both  the  mean  temperature 
and  daily  range.     Its  high  point  is  four  months 
behind   the  daily  range   crisis,  and  two  months 
after  the  highest  mean  temperature.     If  the  dis- 
ease is  the  direct  result  of  atmospheric  conditions 
of  temperature,  we  should  expect  its  crisis  to  cor- 
respond with  the  crisis  of  one  of  the  other  lines. 
If  the  fever  is  an  indirect  result  of  the  tempera- 
ture conditions,  we  should  expect  its  crisis  to  fol- 

Diagram  No.  15.  showing;  average  temperature  (14  stations); 
average  daily  range  temperature 
termittent  fever  in  l\  S.  Army.     [Yearly  means  horizontal  lines.) 

That  the  fall  in  the  daily  range  of  temperature 
from  May  until  June  is  not  responsible  for  the 
fall  in  number  of  cases,  is  shown  by  the  fact  that 
even  in  July  (giving  the  advantage  of  two  months 
fall)  the  daily  range  of  temperature  is  fa 
the  average  for  the  year,  but  in  July  the  number 
of  cases    of  fever   is  beloii'   the  yearly  average. 
Further:  although    the   case   line  from  June  to 
Julv  is  about  five-sixths  of  case  line  from  May  to 
June,  the  daily  range  of  temperature  line  from 
May    to  July  is  only  about  three-sixths  of  the 
daily  range  line  from  April  to  May. 

A  comparison  of  figures  2  and  3,  clearly  inti- 
mates that  the  disease  in  question  is  much  more 
closely  related  to  the  absolute  temperature  than 
to  its  daily  range,  for  the  per  cent,  of  reports  of 
intermittent    fever    in  Michigan  has  its  highest 

85o 


ATMOSPHERIC  CONDITIONS. 


[June 


and  lowest  points  exactly  corresponding  with  the 
maximum  temperature,  and  throughout  the  lines 
do  not  antagonize.  On  the  other  hand,  from 
February  to  March  the  average  daily  range  of 
temperature  decreases  without  a  like  change  in 
the  case  line;  and  the  daily  range  line  reaches  its 
climax  two  months  earlier  than  the  case  line,  and 
the  lowest  point  for  daily  range  is  a  month  be- 
fore the  lowest  number  of  cases. 

In  studying  Michigan  tables,  it  must  be  re- 
membered that  the  per  cent,  of  reports  does  not 
necessarily  represent  the  per  cent,  of  cases. 
Blanks  are  sent  to  correspondents  of  the  State 
Board  of  Health,  asking  them  to  report  simply 
the  presence  or  absence  of  the  diseases  mention- 
ed. If  ninety  per  cent,  of  these  correspondents 
have  only  one  case  each  the  report  would  be 
greater  than  if  seventy  of  every  hundred  averaged 
five  cases  each  and  the  other  thirty  per  cent,  had 
none.  The  importance  of  this  word  of  caution 
may  be  seen  from  a  study  of  the  annual  reports 
of  "the  State  Board  of  Health.  They  divide  the 
State  into  eleven  divisions,  for  the  ten  years  from 
1877  to  1886  the  reports  of  intermittent  fever 
from  the  upper  Peninsula  were  only  9  per  cent., 
while  from  the  Northern  Division  of  the  South- 
ern Peninsula  they  were  27  per  cent.,  and  from 
the  Southwestern  Division  81  per  cent.,  and  from 
Southeastern  Division  71  per  cent.  In  the  South- 
eastern Division  in  a  single  month  there  are  prob 
ably  more  cases  of  intermittent  fever  than  dur- 
ing an  entire  year  in  the  upper  Peninsula. 

From  the  Michigan  State  Board  of  Health  Re- 
port for  1888,  I  compiled  table  and  diagram  14, 
showing  the  mean  monthly  temperature,  abso- 
lute and  relative  humidity,  day  and  night  ozone 
for  a  series  of  years,  compared  with  the  per  cent, 
of  reports  of  intermittent  fever  as  given  in  Dr. 
Baker's  article.  It  will  here  be  noticed  that  the 
curves  representing  the  mean  temperature  and 
absolute  humidity  correspond  closely  with  the 
percent,  of  cases.  Secondly:  That  in  the  main 
as  the  per  cent,  of  night  azone  increases  the 
per  cent,  of  cases  decreases  and  vice  versa. 
Thirdly:  The  same  is  true  of  day  ozone,  though 
not  so  exactly.  Lastly:  The  relative  humidity 
does  not  seem  to  have  any  relationship  with  the 
per  cent,  of  cases. 

The  reports  for  Memphis,  Tenn.,  (table  41 
strengthen  the  idea  that  the  absolute  temperature 
and  not  the  daily  range  of  temperature  is  instru- 
mental in  the  production  of  the  fever.  The 
mean  temperature  and  number  of  cases  both  reach 
their  climax  in  July,  two  months  after  the  great- 
est daily  range  of  temperature.  There  are,  more- 
over, decided  changes  in  thedaily  range  line  with- 
out any  appreciable  effect  upon  the  number  of 
cases. 

In  Cincinnati  (table  5)  the  climax  in  the  daily 
range  line  comes  in  May.  That  of  temperature 
in  July,  and  that  of  cases  in  August.     We  find  a 


great  increase  in  the  number  of  cases  following 
the  spring  floods.  There  are  very  great  variations 
in  the  daily  range  line  without  corresponding 
variations  in  the  number  of  cases. 

The  San  Francisco  diagram  (No.  6)  shows  all 
lines  reaching  their  highest  point  in  September, 
but  here  again  the  case  line  follows  the  mean 
temperature  more  closely  than  the  daily  range. 
The  relationship  of  the  lines,  especially  from  May 
until  August,  clearly  shows  that  there  is  some 
other  factor  besides  temperature  which  produces 
the  disease. 


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am  11.     Michigan.    Showing  average,  r,  temperature  (10 
/one,  day  and  night  (10  years);  ;..  relative  humidity  (g 
grains  of  vapor  per  cubic  foot  of  air  no  \ 
cent,  reports  intermittent  fever. 

Diagrams  7  and  8  representing  New  York  City 
and  State,  each  show  daily  range  line  highest  in 
June.  Mean  temperature  highest  in  July,  but  the 
highest  number  of  deaths  from  intermittent  fever 
in  September.  It  must  be  noticed  that  while 
other  tables  all  refer  to  sickness,  the  data  here  re- 
fer to  deaths.  Since  sickness  must  precede  death 
we  should  expect  the  greatest  number  of  deaths 
at  least  one  month  after  the  highest  temperature, 
if  high  temperature  is  the  cause  of  the  disease. 

Evidently  the  meteorological  data  in  the  State 
diagram  are  those  of  New  York  City.     The  daily 


iSgi.J 


ATMOSPHERIC  CONDITIONS. 


•■ 


range  is  exactly  the  same  as  in  the  table  7,  and  low  temperature  would  kill  the  young  plant  while 
the  variation  1  less  than  half  a  degree)  in  the  mean  the  old  one  might  thrive.  So  while  a  tempera- 
monthlv  temperature  arises  from  the  fact  that  for  ture  of  56^  does  not  favor  the  development  of  the 
one  tat  the   figures    are   obtained    by    fever,  neither  dues  it  stamp  out   the  developed 

taking  the  reports  from  1S70-S3,  and  in  the  other  disease. 

■  1  the  reports  used  are  from  1S71-85.  Re- 
lieving that  this  did  nut  represent  the  fai  I 
York  City  being  about  150  miles  south  of  the 
centre  of  the  State,  I  prepared  table  and  diagram 
No.  15.  using  for  comparison  reports  for  a  series 
of  years  at  Mohawk, '  which  is  almost  exactly 
in  the  centre  of  the  state. 

In  table  9  we  again  find  the  greatest  daily 
range  of  temperature  in  May.  four  months  before 
the  greatest  sickness,  and  the  highest  tempera- 
ture in  July.  This  table  is  probably  the  most 
correct  of  any  in  the  series  which  cover 
more  than  a  limited  area.  It  illustrates,  however, 
how  difficult  is  such  a  table  to  prepare.  If  we 
ten  posts  placed  upon  the  same  meridian, 
and  each  one  of  the  nine  southern  posts  having 
1000  men,  while  the  one  northern  post  has  9000, 
the  mean  temperature  of  the  ten  posts  would  not 
give  the  average  temperature  surrounding  the 
men.  To  get  the  correct  figures  the  mean 
of  the  nine  southern  posts  must  be  aver- 
aged with  the  one  northern  post.  Here,  as  in 
the  New  York  tallies,  it  is  to  be  regretted  that 
the  Doctor  did  not  state  his  authority,  giving  the 
names  of  the  stations  used. 

Tables  10.  11,  and  12  quite  contradict  Dr. 
Baker's  previous  argument,  and  tables  10  and  1 1 
representing  India,  also  show  that  high  temper- 
ature does  not  produce  the  disease.  Here  we  find 
the  highest  temperature  in  May  and  June,  the 
greatest  daily  range  of  temperature  in  February, 
and  the  least  in  August,  but  the  most  sickness 
in  November. 

It  we  suppose  the  daily  range  of  tempera- 
ture is  equally  above  and  below  the  mean  tem- 
perature, we  may  get  approximately  the  mean 
maximum  and  minimum  temperature.  This 
may  be  seen  in  table  and  diagram  No.  16. 


showing  number  of  deaths  from  intermittent 
feverinNew  -  md  mean  and  daily  range  of  temperature 

at  Mohawk. 

There  is  another  potent  factor  not  shown  in 
these  tables.   In  '  'Hirsh's  Handbook  of  Geograph- 
It  will  be  noticed  that  in  most  places  heretofore   ical   and   Historical   Pathology,"  Vol 
studied  in  this  article  malarial  fever  is  most  com-    we  read:   "In  the  malarious  regions  of  the  tropics 
mon  at  a  temperature  between   6o°  and  ear  as  a  rule   at  the  beginning  ot 

especially  at  about  700.  Neither  extreme  heat  the  rainy  season.  They  increase  in  extent  and 
nor  extreme  cold  are  favorable  for  the  disease.  A  severity  with  the  increasing  rainfall,  remitting 
glance  at  diagram  16  shows  that  until  April  the .  usually  at  the  height  of  the  rains,  especially  if 
mercury  every  day  went  below  6o;.  From  April  they  be  very  heavy,  and  reappear  towards  their 
to  June  each  day  it  went  above  95?.  As  soon  as  cessation  or  directly  after  the  rainy  season,  which 
the  minimum  went  above  603  the  cases  of  sick-  is,  as  a  whole,  the  season  when  the  conditions 
ness  increased,  and  when  the  maximum  came  are  most  unfavorable  to  health."  Again,  on 
down  to  S73  there  was  a  much  greater  increase,  page  269:  "The  production  of  malaria  takes 
Every  gardener  know-s  that  the  young  plant  re-  place  on  the  largest  scale  where  the  soil  is  con- 
quires  much  more  favorable  surroundings  than  it  stantly  saturated  or  periodically  inundated."  A 
does  at  a  later  period.     An  occasional   high  or  friend  residing  in  Lucknow  informs  me  that  from 

about  June  15  until  September  20,  it  rains  almost 

con'ribu-^nV^Knowied5 f Mea"  Temperature"  in  Smithsoni«n   daily,  but  from  September  until  June  all  the  rain 

Note.— I  have  searched  for  meteorological  data  for   Irdia.  but  j  pUt  tOSfether  WOuld  not    make    SL    good     Michigan 
•id  more  than  generalizations.    I  have   therefore  been  ob-    r,  _ 

ise  the  tables  of  Dr.  Baker— his  auth  jrity  not  stated.  i  ShOWer. 


852 


ATMOSPHERIC  CONDITIONS. 


[June  13 


Table  12,  to  my  stupid  mind,  shows  nothing, 
unless  it  be  that  the  daily  range  of  temperature 
has  nothing  to  do  with  the  disease.  As  drawn, 
the  lines  coincide  in  but  one  place,  August. 
There  are  most  marked  changes  in  the  daily 
range,  without  a  corresponding  variation  in  the 
number  of  cases.  Not  being  able  to  obtain  the 
mean  temperature  of  Ft.  Apache,  I  took  that  for 
Camp-  McDowell,2  shown  in  table  and  diagram 
17.  ■  Camp  McDowell  is  near  Ft.  Apache,  and 
practically  on  the  same  isothermal  line. 


^       Tempr. 

l 

1 

s 

? 

Q 

? 

5    1 

S 

i 

1    1     1 

Ijl-S  1  •£ 

5. 

■5 

•^ 

to 

<§ 

s 

. 

'    1 

< 

)0  100 

JO   90 

0    80 
1 

0    70 

! 

0\60 

90 
80 
70 
60 
50 

90 
30 
70 
60 
50 

/ 

/ 

\. 

\ 

\ 
\ 

1 

/ 

' 

.- 

— 

/ 

'-'- 

\ 

I 

i 

~~ 

1 
/ 

/ 

1 

\ 

\ 

\ 

- 

; 

\ 

1 

Diagram  Xo.  16.  India.  Showing  average  maximum,  mini- 
mum and  mean  temperature,  and  cases  of  intermittent  fever 
among  native  troops. 

Dr.  Baker's  second  conclusion  is  that  "the 
controlling  cause  of  intermittent  fever  is  expo- 
sure to  insidious  changes,  or  changes  to  which 
one  is  unaccustomed,  in  the  atmospheric  temper- 
ature." If  this  is  true,  why  is  the  disease  so 
much  more  prevalent  in  hot  countries  than  in 
those  that  are  cooler?  If  this  is  true,  why  does 
not  the  sickness  follow  closely  the  daily  range? 
This  many  of  the  diagrams  studied  show  that  it 
does  not.  A  patient  under  the  care  of  the  writer 
since  this  article  began,  was  exposed  to  decided 

=  Mean  1866-70.  "Tables  of  Differences,"  Smithsonian  Contri- 
butions. 

Small  variati  ins  in  1 
■of  the  small  number  of  c 


variations  of  atmospheric  temperature.  For  two 
days  she  was  obliged  to  be  where  the  temperature 
was  quite  uniform  through  the  twenty-four  hours. 
She  had  no  chill  until  after  these  two  days  of  un- 
usually even  surroundings.  This  case  is  illustra- 
tive of  many. 

"The  daily  range  (of  temperature)  diminishes 
from  about  lat.  400  in  either  direction,  north  or 
south.  The  precise  latitude  of  maximum  range 
cannot  yet  be  given."  *  If  conclusion  two  is  true, 
there  would  be  more  malaria  around  Philadelphia 


Q 

Tj, 

II  1  ° 

Febry. 
March 
April 

s 

1 

•^ 

-" 

Co 

a 

4  - 

6 

4 
i 

:. 
: 

1 

0- 

0 
0 

0 

00 

45 

'/ 

[ 

7.0 

40 

: 

60 

i 

; 

. 

5;' 



\ 

' 

\ 

/ 

, 

1 

Diagram  No.  17,  showing  average  temperature  at  Camp  Mc- 
Dowell. Ariz  .  and  dailv  range  temperature,  and  cases  of  intermit- 
tent fever  at  Ft.  Apache,  Ariz. 

than  around  Charleston — more  in  Connecticut 
than  in  Florida.  Is  that  the  fact?  If  so,  I  for 
one  am  greatly  mistaken.  In  Michigan,5  the  av- 
erage daily  range  of  temperature  at  Detroit  is 
r5-79°;  at  Kalamazoo  16.930;  at  Marquette  17.20°; 
Traverse  City  19. 13°.  If  the  disease  is  due  to 
daily  range  of  temperature,  we  should  find  more 
of  the  fever  around  Marquette  than  near  Kala- 
mazoo, and  more  near  Traverse  City  than  in  De- 
troit. I  do  not  understand  that  to  be  the  fact. 
If  the  daily  range  of  temperature  is  an  impor- 

4  Report  of  State  Board  of  Health,  Michigan,  iSSS,  p.  25. 

3  of  Differences  of  Mean  Temperature,"  p   [56,  Smdth- 
s  tnian  Contributions  to  Knowledge. 


i89i.] 


AT.M(  (SPHERIC  COXDITIOXS. 


853 


tant  element  in  the  production  of  intermittent 
fever,  why  should  a  change  of  climate  develop 
the  fever?  Dr.  Biker  says:  "  It  is  a  common 
observation  that  persons  who  travel  northward 
or  to  a  colder  climate,  where  ague  is  compara- 
tively rare,  not  infrequently  hive  one  or  more 
paroxysms  of  chills  and  fever  soon  after  the 
change.'1  During  the  war  I  noticed  this  on  a 
large  scale  after  movements  of  troops  from  the 
South."7  Dr.  Baker's  explanation  is  not  a  rea- 
sonable one  for  me.  for  the  reason  that  the  tem- 
perature changes  are  perhaps  less  in  the  Northern 
than  in  the  Southern  home.  In  Michigan,  for  ex- 
ample, Dr.  H.  T.  Calkins,  one  of  the  oldest  practi- 
tioners in  the  northern  part  of  the  State,  and  a  close 
observer,  tells  me  that  at  Petoskey  they  never  have 
malarial  fever,  except  in  persons  recently  from  a  ma- 
larious country.  I  am  told  the  same  of  Mackinac. 
If  this  is  true,  it  is  a  most  important  fact,  and  my 
own  observation  leads  me  to  accept  it.  An  indi- 
vidual going  from  Southern  to  Northern  Michi- 


The  explanation  of  these  phenomena  which  I 
have  adopted,  I  think  was  first  suggested  by  Dr. 
Bowditch,  of  Boston,  though  not  in  this  exact 
form.  The  malarial  poison,  whether  chemical  or 
germ,  acts  upon  the  liver  in  such  a  manner  as  to 
slow  the  elimination  of  effete  matter.     The  elim- 

:  ination  of  effete  matter  is  accomplished  through 
the  liver,  skin,  kidneys  and  lungs.  In  the  state 
of  health  these  organs  assist  each  other,  keeping 
a  normal  balance.      If  an  individual  goes  from  a 

j  warm  to  a  cold  climate,  the  elimination  through 
the  skin  and  lungs  is  decreased.  If  the  liver  and 
kidneys  are  healthy,  no  harm  results.  If,  how- 
ever, as  in  the  case  of  the  malarial  person,  the 
liver  is  sluggish,  it  will  be  unable  to  do  the  work 
devolving  upon  it,  and  the  system  is  poisoned 
with  the  non-eliminated  effete  matter.  This  irri- 
tates the  brain  and  produces  the  chill  and  increase 
in  temperature.  This  theory  exactly  agrees  with 
my  clinical  experience.  Antipyretics  have  little 
effect  upon  the  disease  until  the  liver  is  cleared. 


TABLES  FROM  WHICH  THE  ACCOMPANYING   DIAGRAMS  WERE  DRAWN. 
-Average  Temperature,  14  Stations.     Average  Daily  Range  Temperature.    Intermittent  Fever.  D    S.  A 


Average  Temperature  .  . 
Daily  Range  Temperature 
Sickness ■   .   .   . 


39-12 
9.70 
19.4 


14-13 
11.51 
19.6 


March.    April.  1    May.      June.      July. 


204      I    23.6 


66.1:        73.59 

14-39        '3-75        l3-6o 

24.5      '    30.6  25.6 


■85  59-29 
13.62  14.04  13.45 
32.        I    3S.5         36-S 


4S.99 
11.69 


40.S6 

"" 
'9-3 


61.19 

i--5; 


Xo.  14.— Michigan  Day  and  Night  Ozone.    Relative  and  Absolute  Humidity.     Average  Temp.     Percent.  Int.  Fever. 


Day  Ozone 

Night  Ozone 

Relative  Humidity  .  .  . 
Absolute  Humidity  .  .  . 
Average  Temperature  . 
Per  Cent.  Fever 


20.56 


1. 51 
2362 
60.8 


1. Si 
29.80 

62.75 


3-21 
3-56 
.69 
2-75 
44-33 
7Q-4 


3-91 
56.0S 

7i! 


5-27 
65.10 

77-S 


6.07 
70-52 


6S.I4 
79.0 


2.74 


61^7 


2-99 

.76 

3-71 

50.83 

76.1 


3-lS 
3-55 
.S2 
1-73 
26.60 


3-44 

46.11 
7°-4 


No.  15.— Deaths  New  York  State  from  Intermittent  Fever. 

Average  Temperature  3 

nd  Daily  Range 

Mohawk. 

Average  Temperature 20.87        22.51    1    2S.7S 

Daily  Range  Temperature    .   .        7.2:         9.27       11.06 

4233 
13.72 
225, 

54.89 
15-72 

20V 

04.59 

1S.04 

191. 

69.64 
204. 

" 
15.85 
25S. 

54-77         -'  J4 
11.03 

325-        1  297. 

34.06 
6.49 
247. 

2312       44.27 
6.2S 
216.       |  22-. 

No.  16. — India.    Av   Maximum  and  Minimum  and  Mean  Temperature.    Intermittent  Fever  Native  Troops. 


Av.  Max.  Temp. 
Av.  Min.  Temp. 
Mean  Temp  .   .   . 
Sickness  .... 


7*0      I    *3-° 
41.2  39-S 

58.6      I    61.4 


56.4  61.1 

77-3  79-= 

181.        I  19s. 


95-4 

'-.I 

S6.4 

S7.0 

82.1 

63.0 

66.9 

66.6 

59-2 

50-5 

43-8 

79.2 

77-0 

76.5 

76.8 

73-1 

65.3 

60.6 

207- 

307. 

5'7- 

537- 

535- 

537- 

244. 

-Average  Temp.  Camp  McDowell.     Daily  Range  Temp,  and  Intermittent  Fever  Ft.  Apache,  Arizona. 


Average  Temperature  .  .  . 
Daily  Range  Temperature 
Sickness 


50-36 
30.56 
4-62 


69.69 

- 


SS.60 
41.34 
17.06 


33-S4 

25-59 


73.22  I  60.90  I  52.49 
32.04  35-22  30.70 
40-73        26.69    1      7.70 


23  ^: 


gan  will,  unless  specially  protected,  generally 
within  from  four  to  ten  days  show  clear  indica- 
tions of  malarial  poisoning.  The  first  symptom 
is  not  a  chill,  nor  a  fever,  but  a  copper  colored 
skin.  The  purer  air  causes  the  blood  at  first  to 
flow  more  freely  through  the  cutaneous  capilla- 
ries, which,  showing  through  the  jaundiced  skin, 
misleads  the  victim  to  report  excess  of  tan.  A 
few  days  later  and  a  chill  occurs,  followed  by  a 
fever,  and  if  left  to  itself,  the  disease  progresses 
until  it  assumes  a  typhoid  type.  For  the  pro- 
duction of  this  condition  I  am  confident  that  it 
is  not  necessary  to  bring  in  a  typhoid  fever  germ. 


Catharsis  is  not  the  essential  factor,  because  com- 
pound cathartic  pills  and  other  like  drugs  may  be 
given  until  the  patient  is  exhausted,  without  any 
material  benefit.  On  the  other  hand,  if  the  case 
is  seen  early,  calomel  may  be  given  in  so  small 
doses  as  to  effectually  clear  the  skin,  without 
producing  catharsis. 

If  a  person  residing  in  a  malarious  country, 
not  being  sick  at  the  time,  takes  a  thorough  mer- 
curial treatment  before  going  to  the  North  or  to 
the  sea  shore,  he  will  probably  escape  the  usual 
sickness.  While  I  would  emphasize  the  impor- 
tance of  extra  care  as  to  clothing  in  making  this 
change  of  climate,  I  regard  the  preparatory  treat- 
ment as  the  more  important.     In  fact,  a  person 


S54 


ATMOSPHERIC  CONDITIONS. 


[June  13 


whose  liver  is  active  will  need  less  clothing  for 
comfort  than  if  his  liver  is  sluggish.5  In  some 
cases,  it  is  necessary  to  continue  small  doses  of 
the  chloride  or  iodide  for  some  time. 

The  usefulness  of  this  treatment  is  generally 
known,  and  is  admitted  by  Dr.  Baker  in  conclu- 
sion seven.  If,  however,  his  theory  is  correct,  any 
cathartic,  decreasing  the  tension  of  the  portal  cir- 
culation, or  heavy  clothing  would  prevent  the 
outbreak,  as  well  or  better. 

How  does  a  mercurial  decrease  the  tempera- 
ture? It  certainly  has  an  antipyretic  influence 
upon  a  malarial  fever  or  upon  diphtheria,  but  it 
does  not  have  any  appreciable  effect  upon  a 
healthy  person.  This  effect  is  certainly  not  de- 
rived through  increased  heat  elimination,  and  it 
must  therefore  be  by  reducing  the  production  of 
heat.  Since,  however,  it  does  not  materially  check 
the  production  of  heat  in  a  healthy  person,  this 
result  must  be  the  incidental  result  of  the  remov- 
al or  neutralization  of  the  irritating  cause  of  the 
fever.  If  this  is  true  the  fever  following  a  chill 
is  not  the  result  ot  non-eliminated  heat  being 
stored  up,  as  Dr.  Baker  suggests.  Further,  if  I 
am  not  mistaken,  the  experiments  of  Osier  show 
that  in  intermittent  fever  there  is  increased  heat 
production 

With  regard  to  conclusions  three  and  four  it 
might  be  asked,  how  does  Dr.  Baker's  theory  ex- 
plain the  cause  of  delay  in  reaction  from  cold. 
The  healthy  person  would  react  promptly ; 
therefore  this  delay  in  reaction  shows  that 
neither  the  chill  nor  the  fever  represent  the  be- 
ginning of  the  disease.  The  mechanical  effect  of 
a  chill  may  be  a  local  congestion,  but  as  soon  as 
the  cause  is  removed  the  system  reacts  and  the 
only  results  are  local  primarily.  If  the  intermit- 
tent fever  is  the  result  purely  of  the  daily  range 
of  atmospheric  temperature,  since  the  body  is 
daily  exposed  to  the  cold,  the  chill  and  fever 
would  always  be  of  the  remittent  type. 

I  am  surprised  to  see  conclusion  six  repeated. 
"In  our  climate  those  measures,  such  as  drainage, 
which  enable  the  soil  to  retain  warmth  during 
the  night  and  thus  reduce  the  daily  range  of 
temperature  immediately  over  such  soil,  tend  to 
decrease  intermittent  fever  among  residents  there- 
on." Does  drainage  enable  the  soil  to  retain 
warmth  ?  Almost  any  boy  will  tell  you  that 
sand  in  the  sun  is  hot,  but  as  soon  as  a  shadow 
is  thrown  upon  it  it  cools  off.  The  rich  black 
loam  heats  slowly  and  cools  slowly.  Dry  cli- 
mates are  those  most  subject  to  great  range  of 
temperature.  In  northwestern  Texas  the  travel- 
er may  suffer  extremely  from  the  heat  by  day, 
but  at  night  he  covers  himself  with  a  thick  blanket 
and  places  a  little  water  in  a  saucer  from  which 
he  skims  a  thin  layer  of  ice  in  the  morning.  In 
India    we   have   already  seen    that  there  is  the 


greatest  range  of  daily  temperature  when  the 
ground  is  dry.  Dr.  Chas.  Denison  took  the  rec- 
ords of  25  dry  and  25  moist  climates  and  obtain- 
ed therefrom  the  mean  daily  range  of  temperature 
for  four  classes  of  places  as  follows:' 

1.  I  Extreme  dryness,      36.51°}     pahr 

2.  \  Moderate  dryness,    20.63°  • 

3.  1  Moderate  moisture,  17. 09^  )     p_i,r 

4.  I.  Extreme  moisture,   13.61°) 

On  the  contrary,  then,  drainage  increases  the 
daily  range  of  temperature,  and  so  if  Dr.  Baker's 
theory  is  correct  it  ought  to  favor  the  production 
of  intermittent  fever. 

On  page  417  of  the  Report  of  the  Michigan 
State  Board  of  Health  for  1880,  I  found  the  fol- 
lowing report  from  one  of  the  correspondents  of 
the  board.  "  During  the  first  half  of  the  month 
(August)  the  moisture  in  the  air  was  as  abun- 
dant and  the  temperature  so  uniformly  high,  that 
unhusked  corn  in  the  shock,  also  corn  in  the  corn 
cribs  began  to  grow  vigorously.  During  the  third 
week  of  the  month  malarial  diseases  rapidly 
arose,  which  I  think  was  partially  due  to  the 
prolonged  uniform  heat  and  moisture.  There  was 
also  one  half  less  azone  during  the  first  half  than 
during  the  last  half  of  the  month."  This  report 
is  for  Washington,  in  the  southeast  part  of  the 
State.  From  the  same  report,  pages  317,  321,  326,. 
344,  and  349,  I  get  the  mean  temperature,  abso- 
lute humidity,  day  and  night  ozone  at  Washing- 
ton, and  mean  daily  range  of  temperature  at  De- 
troit as  follows  (having  no  like  data  for  Wash- 
ington). 

TABLE  IS. 


TEMFERATVRE. 

OZONE. 

MONTH. 

MEAN. 

DAILY 
RANGE. 

HUMIDITY. 

NIGHT. 

DAY. 

Ju»e 

July 

August      .... 
Annual  Mean 

64.21 

7-'. 47 

46.44 

lS.43 
18.84 

1S.74 
]6.6o 

S.2I 

0  31 

5  17 

2.42 

1. 21 
0.S5 
3°7 

2.22 

2.  CO 
1.65 
2.97 

I    11 1  lui  aril  v  prescribe  two  cathartic  doses  of  calomel  combined 
be  taken  a  week  before  startii 
lavs  after. 


It  will  be  noticed  that  during  these  three 
months  of  summer  the  thermometer  kept  con- 
stantly within  the  range  we  have  before  found  the 
most  favorable  for  the  production  of  malaria. 
While  the  daily  range  of  temperature  was  higher 
than  the  average  it  was  not  as  great  as  in  May 
(22.480). 

A  monograph  by  Dr.  G.  H.  Wilson,  of  Meri- 
den,  Conn.,  member  of  the  State  Board  of  Health, 
published  several  years  ago,  gives  an  account  of 
the  progress  in  a  definite  direction  from  south- 
west to  northeast,  of  intermittent  fever.  This 
seems  to  be  strong  evidence  that  the  disease  is 
due-  to  a  specific  poison  or  germ. 

From  clinical  evidence  and  meteorological  in- 
vestigations therefore  it  appears: 

1.  That  intermittent  fever  is  due  to  a  specific 
germ. 

Transactions    of    Ninth    International     Medical    Congress, 
Vol.  v.  p.  40. 

-  of  vapor  in  cubic  foot  of  air.     Average  for  9  mouths. 
No  report  for  January,  February  and  March. 


i89i.] 


MEDICAL  PROGRESS. 


85 


:.  That  the  development  of  this  germ,  and 
hence  the  production  of  the  fever  is  favored  by  a 
most  atmosphere  ranging  in  temperature  between 
6oc  and  Sy  F. 

3.  That  the  germ  is  taken  into  the  body  by  in- 
halation or  through  drinking  water. 

4.  That  the  fever  is  the  result  of  irritation  of 
the  heat  producing  centre  of  the  cerebrum.  This 
irritation  is  perhaps  partially  due  to  the  direct 
effect  of  the  specific  germ,  but  it  is  also  due  to 
the  retention  in  the  circulation  of  effete  matter. 

5.  That    under  favorable  conditions    the   true 
malarial  fever  may  assume  the  character  of  a  gen- 
uine typhoid  fever,  without  the  agency  of  a  ty- ' 
phoid  germ. 

6.  Exposure  to  an  average  temperature  below 
that  to  which  the  person  is  accustomed,  may  de- 
velop a  latent  malarial  condition,  but  exposure  to 
cold  does  not  produce  the  disease. 

7.  There  being  no  definite  and  constant  rela- 
tionship between  intermittent  fever  and  the  daily 
range  of  atmospheric  temperature,  we  must  con- 
clude that  daily  variations  in  atmospheric  tem- 
perature are  not  essential  for  the  production  of 
the  disease. 

Ozone  is  a  potent  germicide.  It  seems  to  the 
writer  that  its  influence  upon  the  disease  is  inci- 
dental and  negative.  When  ozone  is  abundant 
it  attacks  the  germs  in  the  air  and  deprives  them 
of  their  virulency.  There  is  less  ozone  over 
swamps  than  in  the  open  fields;  less  in  the  winds 
filtered  through  the  underbrush,  than  in  the 
same  winds  before  reaching  the  woods.  There  is 
more  malaria  on  the  windward  than  on  the  lee 
side  of  a  swamp.  Conditions  favorable  to  the 
growth  of  malaria  are  therefore  destructive  of 
ozone. 

That  the  presence  of  ozone  in  the  atmosphere 
does  not  greatly  increase  the  power  of  the  human 
organism  to  withstand  the  effects  of  the  germ,  I 
am  led  to  think  from  the  fact  that  a  person  go 
ing  from  a  malarious  region,  where  the  amount  of 
ozone  is  small,  to  a  colder  region,  where  the 
amount  of  ozone  is  greater,  is  almost  sure  to  have 
strong  signs  of  malarial  poisoning  soon  after  ar- 
rival. " 

The  occurrence  of  the  fever  at  high  altitudes 
and  in  cold  weather  are  sometimes  mentioned  as 
arguments  against  the  paludal  theory  of  the  eti- 
ology of  the  disease.  Let  me  simply  hint  at  an 
explanation.  One  day  after  clambering  up  the 
crags  on  the  coast  north  of  Larne,  Ireland,  I  was 
surprised  to  find  myself  in  a  bog  while  still  close 
to  the  edge  of  the  high  cliff.  Again:  the  upper 
plateau  of  Mackinac    Island  is  295  feet    above 


:  Pr.  Baker  calls  attention  to  the  fact  that  persons  exposed  to 
night  air  over  low  lands  are  more  liable  to  the  disease  than  if  they 
are  exposed  onlv  through  the  day.  It  is  suggestive  that,  according 
to  Table  14.  in  Michigan^  the  months  showing  the  most  intermittent 
-  show  less  night  than  day  ozone,  but  generally  there  is 
more  night  than  day  ozone.  Does  light  have  any  influence  on  the 
growth  of  the  germ  ? 


the  water's  edge,  and  yet  there   one   may    find 
marshy  ground. 

The  heating  of  the  house  in  winter  draws  air 
from  the  ceMar.  The  air  of  the  house  is  [ 
rich  in  oxygen  as  that  out  of  doors.  One  may 
therefore  find  in  the  house  in  winter  the  neces- 
sary heat,  moisture,  and  decaying  vegetation 
—all  the  atmospheric  conditions  known  to  be  es- 
sential. 


MEDICAL    PROGRESS. 


Mode  of  Entry  of  the  Tubercular  Pois 
into  the  Body. — A  very  good  summary  of  the 
various  paths  of  infection  adopted  by  the  tubercle 
bacillus  is  given  by  C.  Bollinger  in  the  Mioi- 
chcncr  Mai.  Wochenschrift,  1890,  No.  43.  He 
considers  that  the  frequency  of  infection  through 
the  skin  has  been  under-estimated.  Several  cases 
have  been  recorded  of  direct  inoculation  by 
wouuds  received  from  broken  spittoons,  etc.,  by 
bites,  after  circumcision,  by  morphia  syringes, 
and  earrings.  Eczema  and  impetigo  increase  the 
susceptibility  of  the  skin.  No  case  has  as  yet 
been  attributed  to  vaccination,  and  it  would  ap- 
pear that  the  tubercle  bacilli  are  unable  to  live 
in  the  vaccine  lymph.  They  also  appear  unable 
to  pierce  the  pores  of  the  skin  as  do  some  of  the 
pyogenic  organisms.  The  susceptibility  of  the 
mucous  membrane  is  increased  by  inflammatory 
processes,  such  as  otitis,  rhinitis,  conjunct!  v 
pharyngitis,  etc  ;  from  thence  the  poison  travels 
to  the  submaxillary  glands  and  those  of  the  neck, 
and  generally  causes  local  tuberculosis  of  the 
glands.  The  chief  point  of  infection  is  of  course 
the  lungs.  Local  predisposition  is  best  exhibited 
by  apices  which  have  been  before  diseased,  but 
have  undergone  a  healing  process.  The  move- 
ment is  deficient  both  in  expiration  and  inspira- 
tion, and  the  liability  to  reinfection  is  increased 
by  anaemia,  irritants  (such  as  coal  and  metallic 
dust),  constitutional  influences,  such  as  dial, 
disturbances  of  digestion,  and  unhealthy  sur- 
roundings. The  poison  may  pass  through  the 
lungs  and  attack  the  bronchial  glands,  under 
which  circumstances  the  disease  may  be  very  in- 
sidious. The  predisposition  of  the  lungs  again 
exhibits  itself  in  metastasis;  not  every  tubercular 
disease  of  these  organs  is  due  to  inhalation  of  the 
bacilli  or  their  spores.  As  regards  primary  tu- 
berculosis of  the  testicles,  joints,  and  bones,  Bol- 
linger considers  that  a  latent  hasmatogenic  infec- 
tion must  be  understood,  which  leaves  as  little 
trace  of  its  point  of  entry  as  does  a  primary  septic 
endocarditis  or  an  osteomyelitis.  Tubercular  dis- 
ease of  the  larynx  depends  upon  an  autoinfection 
through  the  sputum.  The  rarity  of  this  disease 
in  children  is  explained  by  the  infrequenc 
I  pulmonary  cavities  in  the  rapid  forms  of  phthisis. 


S.s6 


MEDICAL  PROGRESS. 


[June  13, 


Primary  tuberculosisof  the  intestine  generally ,  com- 
bined with  an  affection  of  the  mesenteric  and  retro 
peritoneal  glands, is  usually  occasioned  by  means  of 
vitiated  food  and  contaminated  feeding  utensils. 
Secondary  tuberculosis  of  the  intestine  depends 
upon  an  autoinfection.  The  tubercular  poison 
passes  through  to  the  intestine  unaltered  by  the 
juices  of  the  stomach  and  attacks  the  Peyer's 
patches  and  solitary  follicles.  Tuberculosis  of 
the  peritoneum,  which  is  three  or  four  times  as 
common  in  men  as  in  women,  can  arise  directly 
from  ulcers  of  the  intestine,  from  tubercular  ab- 
dominal glands,  or,  especially  in  women,  from 
the  urogenital  tract;  further,  through  contagion 
from  the  lungs  and  pleura,  and  finally  in  the 
course  of  miliary  tuberculosis,  or  from  caseous 
bronchial  glands.  Primary  tuberculosis  of  the 
peritoneum  is  rare  (3  to  4  per  cent,  of  all  cases). 
As  regards  the  infection  from  milk,  this  is,  in 
Bollinger's  opinion,  undoubtedly  due  to  the  ud- 
der of  the  cow  being  affected  with  the  disease. 
Infection  through  the  milk  of  tuberculous  women 
has  not  yet  been  proved.  In  tabular  form  the 
organs  of  the  body  are  thus  affected,  beginning 
with  those  most  frequently  diseased:  1,  lungs, 
2,  the  lymphatic  glands,  3,  intestine,  4,  serous 
membranes,  5,  larynx,  6,  spleen,  7,  joints,  8, 
bones,  9,  liver,  10,  kidneys,  11,  the  genital  tract, 
12,  the  skin,  13,  the  brain  and  spinal  cord,  14, 
muscles. —  The  Lancet. 

Eiirlich's  Test  in  Typhoid  Fever. —This 
test,  which  has  been  known  for  a  number  of 
years,  has  till  recently  been  regarded  by  many 
rather  as  a  medical  curiosity  than  as  of  diagnostic 
value.  Dr.  C.  E.  Simon,  of  the  Johns  Hopkins 
Hospital,  has  recently  shown  that  by  carefully 
following  the  precise  directions  for  its  use,  valu-J 
able  information  may  be  derived.  The  test  con- 
sists of  two  solutions.  1.  A  saturated  solution 
of  sulphanilic  acid  in  five-per-cent.  hydrochloric 
acid,  and  2.  A  five-per-cent.  solution  of  sodium 
nitrate.  These  are  to  be  mixed,  just  before  use, 
in  the  proportion  of  40  cc.  of  (1)  to  1  cc.  of  (2). 
If  this  mixture  be  added  to  urine  from  a  case  of 
typhoid  fever,  the  further  addition  of  ammonia 
will  produce  a  play  of  colors  varying  from  an 
eosine  rose  to  a  deep  garnet  red.  The  best 
method  of  applying  the  test  is  to  take  a  few  cen- 
timetres of  urine  in  a  test-tube,  adding  an  equal 
quantity  of  the  sulphanilic  acid  mixture  and 
shaking  thoroughly;  1  cc.  of  ammonia  is  then 
run  carefully  down  the  side  of  the  tube.  At  the 
junction  of  the  two  liquids  there  will  be  observed 
a  ring  of  the  characteristic  color,  which  is  pro- 
duced in  scarcely  any  other  disease  than  typhoid 
fever.  Dr.  Simon's  conclusions  may  be  thus 
summarized:  1.  The  reaction  may  be  obtained 
in  typhoid  fever  from  the  fifth  to  the  twenty- 
second  day  of  the  disease.  2.  Its  absence  from 
the  fifth  to  the   ninth   day  indicates   a  very  mild 


attack,  save  in  children,  although  this  rule  is- 
not  an  absolute  one.  3.  As  it  occtws  previous 
to  the  appearance  of  the  rash,  it  is  a  very  useful 
aid  in  the  diagnosis  of  typhoid  fever. —  T/ierapetc- 
tic  Gasctte. 

Cardinal  Points  in  Bacteriology. —  The 
Bacteriological  World  says  : 

The  words  germ,  bacteria,  microbe  schizomy- 
cetes  are  used  in  our  present  literature  almost  as 
synonymous  terms,  but  microbe  seems  preferable 
to  germ  or  bacteria,  and  schizomycetes  is  a  better 
scientific  term  than  either. 

That  these  are  unicellular,  and  assimilate 
nourishment,  seemingly  by  absorption  in  the 
media  in  which  they  live,  but  they  must  trans- 
form (alter)  the  foods  found  proper,  and  yet  un- 
fit in  nature,  for  their  use  and  appropriation. 

Bacteria  living  on  dead  matter  encounter  no 
living  resistance,  whilst  those  feeding  on  living 
tissues,  or  fluids  in  living  tissues,  meet  the  living 
cells  of  the  body  and  have  to  combat  them. 

The  diastases  secreted  by  the  various  beings, 
whether  highly  organized,  or  unicellular  and  mi- 
croscopic, have  something  in  common  as  to  their 
respective  objects,  and  their  properties  of  trans- 
forming matter. 

The  role  of  microbes  in  the  world  is  complex 
and  necessary,  though  some  are  injurious.  They 
act  as  scavengers,-  return  to  the  air  and  water  the 
organizable  elements  abstracted  daily  by  the 
vegetables  of  the  globe,  and  indirectly  by  ani- 
mals, and  indispensable  to  life. 

The  bacteria  that  invade  living  organisms 
which  happen  to  be  fit  for  their  nourishment  and 
growth,  are  in  a  sense  parasites  just  as  much  as 
the  tapeworm  is. 

Spontaneous  generation  of  living  organisms,  no 
matter  how  little,  is  a  fallacy. 

Effects  of  Strychnine  on  the  Stomach. 
— The  effect  of  nitrate  of  strychnine  on  the  func- 
tional activity  of  the  stomach  has  been  recently 
made  the  subject  of  a  careful  research  bj'  Dr. 
Gamper,  of  St.  Petersburg,  who  employed  for  the 
purpose  of  his  experiments  four  healthy  young 
hospital  assistants.  He  found  that  strychnine 
increased  the  amount  of  gastric  juice  secreted, 
the  general  acidity,  and  the  quantity  of  free 
acid  in  the  secretion.  It  also  hastened  the  ab- 
sorption from  the  stomach,  and  strengthened  the 
mechanical  movements.  Its  effect,  too,  con- 
tinued for  some  time  after  its  administration 
had  been  stopped.  Like  many  other  Russian 
observers,  Dr.  Gamper  seems  to  have  been  high- 
ly impressed  by  the  value  of  strychnine  in  chronic 
alcoholism,  declaring  that  it  is  the  most  effective  of 
all  drugs  in  such  cases.  The  thesis  contains  a  long 
li.;t  of  references  to  the  literature  of  stomach 
affections,  published  in  six  or  seven  languages 
during  the  last  ten  years. 


[8QT.] 


EDITORIAL. 


857 


[ournal  of  the  American  Medical  Association 

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Address 

Journal  of  the  American  Mi  1  i'     1    1     ociation, 
Wabash  Ave., 

Chicago,  Illinois. 
All  members  of  the  Association  should  send  their  Animal  Dues 
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London  Office,  57  and  59  Litdgate  Hill. 


SATURDAY,  JUNE   13,    tSgi. 


MEDICINE  IN  JAPAN. 
The  progressive  spirit  of  the  Japanese  people — 
and  particularly  in  the  direction  of  medicine — has 
of  late  been  abundantly  shown  to  Mr.  Ernest 
Hart,  editor  of  our  justly  distinguished  contem- 
porary across  the  seas,  the  British  Medical  Jour- 
nal. 

.Mr.  Hart  has  been  temporarily  sojourning  in 
the  land  of  jestheticism  and  flowers,  and  he  finds 
very  much  to  praise,  but  little  to  criticise,  and 
an  opportunity  for  suggestion,  which,  if  wisely 
cultivated,  may  prove  no  less  meritorious  and 
successful  in  Japan  than  has  maintained  under 
the  sterner  regime  of  the  Anglo  saxon. 

In  the  way  of  gratification  and  commendation 
the  observer  found  the  emergence  of  the  nation 
as  a  unit  from  a  vast  superstitious  thralldom  of  a 
not  greatly- distant  past;  the  rapid  acceptance 
and  appreciation  of  Science  in  its  wonderful  on- 
ward march;  the  newer  systems  of  government; 
the  improved  architecture;  and  the  advanced 
provisions  in  learning. 

Upon  the  latter  condition,  it  may  be  said — the 
advanced  provisions  in  general  learning — the 
former  manifestly  and  entirely  depend.  They 
are  simply  results,  sequences,  as,  indeed,  has  been 
the  case  the  world  over. 

The  Imperial  University,  with  departments  ot 
law,  medicine,  engineering,  literature  and 
science,  each  thoroughly  equipped,  and  especial- 
ly—as trite  to  a  medical  mind — the  department 
of  medicine  with  a  faculty  of  no  less  than  fifty- 
five  professors  and  assistant  professors,  many  of 


whom  had  attained  distinction  in  foreign  coun- 
tries previous  to  taking  upon  themselves  the  re- 
sponsibilities of  leading  onward  the  minds  of 
their  countrymen,  very  much  impressed  the  Eng- 
lishman. 

A  light  criticism  rested  upon  the  system  of 
training  nurses;  upon  bathing  facilities  in  hospi- 
tals; and  upon  the  general  care  and  comfort  of 
hospital  patients,  all  of  which  was  offered  in  the 
most  friendly  spirit. 

Then  as  to  suggestions,  which  were  in  the  line 
of  a  national  medical  association,  and  a  benefi- 
cent organization  possibly  in  connection  there- 
with. 

The  value  of  such  creations  were  exhibited  by 
a  clea»  statement  of  the  organization,  objects, 
method,  and  condition  of  the  British  Medical  As- 
sociation; together  with  a  rehearsal  of  what  the 
British  Medical  Association  had  accomplished, 
and  the  position,  usefulness,  benefits,  and  general 
scope  of  the  British  Medical  Journal.  Also  the 
insurance  feature  which  has  been  so  well  planned 
and  carried  out  under  the  patronage  of  the  Asso- 
ciation during  the  past  few  years. 

Then,  with  a  candor  equal  to  that  taken  while 
in  the  attitude  of  representative,  critic  and  teach- 
er, the  English  physician  craved  knowledge  from 
his  hearers,  the  strange  new  people — a  knowl- 
edge which  he  all  but  admitted  could  only  come 
from  them,  however  high  a  degree  of  scientific 
skill,  or  prolonged  a  research  might  be  required 
for  its  development. 

Among  the  questions  the  profession  in  Japan  is 
asked  to  decide  are  these,  viz.,  the  etiology  and 
communicability  of  leprosy;  the  pathology  and 
prevention  of  beri-beri;  the  influence  of  prolonged 
lactation  upon  the  mother's  health,  upon  infant 
mortality,  and  the  rate  of  increase  of  population; 
the  comparative  immunity  of  the  Japanese  from 
scarlet  fever,  and  the  rarity  of  its  spread;  the  na- 
ture of  senile  (?)  gangrene  so  commonly  found  in 
middle  age  in  Japan;  the  influence  of  the  custom- 
ary hot  baths,  particularly  in  infantile  pneu- 
monia; the  apparent  unimportance  of  haemor- 
rhages in  typhoid  fever;  and  the  real  place  of 
massage  as  a  therapeutic  measure. 

Many  of  these  are  very  pertinent  inquiries,  and 
if  the  Japanese  physicians,  working  under  the  en- 
couragement offered  by  the  royalty,  and  the  stim- 
ulus which  comes  from  the  earnest  watchfulness 
ami  waiting  of  a  great  race,  can  effect  a  reasona- 


853 


HIGHER  MEDICAL  EDUCATION 


[June  13, 


ble  solution  to  any  or  all  of  them,  then  will  the 
finer  genius  of  the  amalgamation  of  minds  mould- 
ed, it  may  be,  by  irrelative  race  characteristics, 
become  more  patent. 

Mr.  Hart  said  in  his  address  before  the  Medi- 
cal Faculty  of  Tokio:  "These  are  among  the 
subjects  011  which  we  should  be  pleased  to  offer 
you  the  hospitality  of  our  medical  periodicals, 
and  as  to  which  we  should  be  glad  to  receive 
communications  at  the  meetings  of  our  British 
Medical  Association." 

To  this  desire  for  a  broader  interchange  of 
thought,  to  this  wish  for  a  closer  union  of  scien- 
tific minds  whose  objects  remain  the  same  despite 
the  vast  distance  which  divides,  and  the  different 
blood — commonly  speaking — which  gives  its 
nourishment,  the  profession  in  America  may  earn- 
estly unite. 

It  is  really  a  little  surprising  that  the  Japanese 
mind  has  so  quickly  reacted  to  the  impulse  of 
learning,  and  is  to-day  so  far  advanced  as  to  pro- 
voke not  alone  the  plaudits  of  the  more  preten- 
tious, but  to  create  an  appeal  to  her  scientific 
possibilities;  and  although  digging  into  the 
depths  of  recondite  medicine  is  not  at  all  confined 
by  national  margins,  and  should  not  be,  yet  inas- 
much as  the  eyes  of  the  medical  world  have 
pointed  eagerly  towards  England,  towards 
France,  towards  America,  and  lately  towards 
Germany,  it  is  not  without  the  limits  of  probabil- 
ity that  we  may  all  yet  look  with  like  eagerness 
in  the  direction  of  promising  Japan. 


HIGHER  MEDICAL  EDUCATION. 

The  promotion  of  all  efforts  to  advance  and 
raise  the  standard  of  medical  education  is  always 
a  vital  subject  with  those  who  have  at  heart  the 
best  interests  of  our  profession.  And  it  is  with 
a  sense  of  gratification  that  we  note  from  year  to 
year  a  visible  improvement  in  the  standard 
adopted  and  approved  by  the  leading  educators 
of  our  country. 

An  encouraging  feature  at  this  time  is  the 
effort  that  is  being  made  to  affiliate  and  more  or 
less  directly  connect  the  best  medical  schools 
witli  established  universities. 

'I'll  is  works  advantageously  to  all  such  institu- 
tions; it  enables  students  in  the  academic  course 
to  so  arrange  their  studies  as  to  make  the  last 
two  years  in  the  latter  count  as  the  first  two  in 
their  more  strictly  professional  studies. 


A  young  man  who  has  pursued  his  studies  in 
this  manner  has  much  the  advantage  of  those 
who  enter  a  medical  college  with  an  indifferent 
preparation.  In  fact  the  one  represents  the 
trained  roadster,  that  easily  skips  along  and 
reaches  the  goal  in  good  condition.  While  his 
fellow,  of  equally  good  blood  and  breeding,  that 
that  has  had  little  or  no  grooming,  stumbles  over 
the  slightest  obstacle,  shies  at  imaginary  hinder- 
ances,  indifferently  obeys  the  guiding  lines, 
frets,  sweats,  and  is  a  good  deal  blown  at  the 
wind  up  on  the  home  stretch. 

The  following  circular  issued  by  the  Illinois 
State  Board  of  Health  sets  forth  the  situation  of 
this  subject,  and  very  properly  solicits  the  aid  of 
practical  teachers  in  making  up  a  science  course 
that  can  be  adopted  as  a  standard : 
Illinois  State  Board  of  Health,   Office  of  the 

Secretary. 

Springfield,  June  6,  1891. 

Dear  Sir: — There  is  a  demand,  from  medical  teachers 
and  young  men  that  intend  to  study  medicine,  for  a  lit- 
erary course  preparatory  to  the  study  of  medicine.  This 
demand  has  been  met  by  a  few  of  the  literary  institutions 
in  the  United  .States,  and  it  is  hoped  and  believed  that  it 
will  be  much  more  generally  met  during  the  next  two 
years.  The  following  institutions  now  offer  science 
courses  for  students  that  intend  to  study  medicine,  or 
that  intend  to  teach  or  otherwise  engage  in  biological 
work:  1.  University  of  Wisconsin;  2.  University  of 
Pennsylvania;  3.  Johns  Hopkins  University;  4.  Univer- 
sity of  Notre  Dame;  5.  Yale  University;  6.  Cornell  Uni- 
versity; 7.  Princeton  University;  S.  Lake  Forest  Univer- 
sity; 9.  Northwestern  University;  10.  West  Virginia 
University;   11.   University  of  Kansas. 

As  must  lie  obvious,  such  a  course  should  be  based  on 
biology,  and  should  include  thorough  work  in  this  sci- 
ence, as  well  as  in  osteology,  comparative  anatomy  and 
chemistry,  with  English.  French,  German,  some  Latin, 
claj  modeling,  free-hand  drawing,  mineralogy,  mathe- 
raatics  through  trigonometry,  mechanics,  logic,  general 
and  pharmaceutical  botany,  and  (in   the   last  year)  psy- 

It  is  of  course  understood  that  botany,  being  a  branch 
of  biology,  should  have  a  prominent  place  in  the  course. 
The   catalogues  of  the  universities  mentioned  contain 
the  list  of  studies  offered  in  their  science  courses. 

Such  a  course  should  extend  over   four  years.      This 

will   involve   no  loss   nor   waste   of  time  to  the  student. 

The  Illinois  State  Board  of  Health   now  requires   that 

students  of  medicine  matriculating  in  the  autumn  of  tSoi 

or   thereafter  must    study  medicine  four   years  and  must 

attend  three  courses  of  lectures, — no  two  in  the  same 

nth,  in  order  to  obtain  a  license  to  practice  in 

Illinois.     This  rule  will  apply  also  in  some   other  States. 

The  Illinois  State  Hoard  will,  however,  recognize  a  thor- 

course    in    science,    such    as    indicated    above,    as 

lit  to  two  years'  study  and  one  course  of  lectures, 

bling  the  student  to  enter  the  second  class  in  the 

1 1 1  >  dical  college.      This  makes  the  full  time  of  study  sis 

\aais   in  the  literary  and  medical   schools,  or  two  years 

[ess  than  is  required   of  the    student  pursuing   a   strictly 

1  OUrse.      Not  only  will  time    he  thus  saved,  but 

e  student  will  be  much  better  prepared  to  enter 

md  course  "I   the  medical  school  than   will  the 

liter  the  first  1 

^tate  Board  wishes  to  make   up  a  science 

course  that  can  be  recommended  to  any  college  wishing 


l89I.] 


SOCIETY  PROCI'KDIXGS. 


859 


to  adopt  such  a  course,  and  having  but  little  time  to 
study  the  subject.  [  desire  to  enlist  your  aid  and  have 
your  advice  in  the  matti  course  as 

practical  and  as  beni  fi  ible.  Will  your  faculty, 

iicli    a   course  as  it   think  ! 

iose,  ami  semi  it  to  tin-  Secretary  ol  th< 
The  demand  from  medical  teachers  ami  from  students 
of  medicine  havii  el  by  some  universities,  must 

lie  met  h\  all  that  would  continue  to  hold  a  h 

iurs  of  young  men  for  the  work  of  life.     Such 
a  course  is  also  the   bi  ttion   for  the  study  of 

veterinary  science.     Resp  ctfully, 

John  11.  Rai  CH,  M.D.,  31 


SOCIETY    PROCEEDINGS. 


New  York  Academy  of  Medicine. 

SECTION     OX    ORTHOPEDIC    SURGERY. 

Stated  Meeting,   May  ij,  1S91. 
Samuel  Ketch,  M.D.,  Chairman. 

Dr.  T.  Halsted  Myers  presented  a  case  of 
marked  rickets,  called  congenital  on  the  mother's 
positive  assertion  that  the  greatly  enlarged 
epiphyses  of  the  tibiae,  femora,  and  radii  were 
present  when  she  fust  examined  the  child  a  few 
days  after  birth.  The  sternum  at  that  time,  she 
noted,  also  was  abnormally  prominent.  She  had 
been  in  very  good  health  all  through  gestation, 
and  the  father  was  a  healthy  man.  No  specific 
history  could  be  obtained. 

At  present,  the  child  is  six  years  of  age,  and 
presents  all  the  deformities  of  rickets  in  a  marked 
degree,  except  that  the  head  is  well  shaped,  and 
there  is  a  marked  increase  of  the  normal  dorsal 
curve  of  the  spine,  rather  than  the  dorso-lnmbar 
kyphosis  usually  found  in  these  cases.  An  un- 
usual degree  of  permanent  knee  and  hip  flexion 
also  exists,  and  the  patient  assumes,  when  rest- 
ing, the  hand-to-knee  position  of  Pott's  disease. 
The  epiphyseal  tenderness  present  seemed  to  in- 
dicate an  active  stage  of  the  disease.  After  be- 
ing nursed  nine  months,  the  child  had  a  mixed 
diet,  not  especially  starchy,  nor  lacking  in  ani- 
mal fats. 

The  Chairman  thought  it  not  improbable  that 
the  spinal  symptoms  were  the  result  of  an  acute 
lesion  occurring  coincidently  with  this  diathesis. 
In  cases  of  simple  kyphosis  which  "he  had  exam- 
ined, one  of  the  points  in  the  differential  diagno- 
sis had  been  the  absence  of  psoas  contraction, 
and  in  most  of  these  cases  the  curve,  unlike  this 
one,  disappeared  when  the  patient  was  in  the 
prone  position. 

Dr.  John  Ridlon  exhibited  the  photograph  of 
a  patient,  nineteen  years  old,  who  had  had  ex- 
actly this  position  all  his  life.  There  were  addi- 
tional curves  in  both  the  tibije  and  femora,  which 
had  developed  gradually  during  his  growth.  It 
was  worthy  of  note  that  psoas  contraction  was  al- 
so present  in  his  case. 


Dr.  Newton  M.  Shaffer  h 

traction  in  these  cases  of  rachitis.    The  cas 
presented  was  not,  in  his  opinion,  one  of  tubercu- 
lar disease  of  the  spine,  but  a  sensitive  condition 
of  the  cancellous  structure   in   the   bodies   of  the 
vertebrae  which  simulates  pott's  disease.     He  had 
ii  a  case  which  he  could  consider  one  of 
tal  rachitis,  and  he  was  inclined    to   look 
upon  this  one  as  an  instance  of  rachitis  acquired 
at  a  very  early  age.      It  was  not    uncommon    to 
find  in  rachitic  patients  a  condition  of  the  mus- 
tnbling  that  found  in  tubercu- 
lar joints.      He  was  reminded  of  a  case  which  he 
had  seen  in  St.  Luke's  Hospital,  in  which   there 
was  a  very  sensitive  joint,  associated  with  muscu- 
lar symptoms  which  might  suggest  hip-joint  dis- 
1  these  were  simply  due  to  hypercemia  of 
the  epiphysis  occurring  in  a  rachitic  subject,  and 
in  due  time,  with  proper  attention  to    nutrition, 
these  symptoms  disappeared. 

Dr.  Ridlon  said  that  he  had  expected  to  pre- 
sent a  patient  illustrating  certain  peculiar  condi- 
tions found  in  persons  who  had  the  caissi 
ease.  His  patient  had  been  working  in  com- 
pressed air  for  sixteen  years,  and  during  the  past 
year,  had  had  forty  or  more  attacks  of  the  cramps 
which  are  peculiar  to  this  disease.  Associated 
with  these  were  stiffness,  gradual  shortening, 
and  outward  rotation  of  the  right  lower  extra  mi- 
ty,  with  a  direct  upward  dislocation  of  the  hip  for 
a  distance  of  three-quarters  of  an  inch.  This 
man  had  informed  him  that  he  knew  of  a  num- 
ber of  others  who  had  been  working  in  compres- 
sed air,  who  had  paralysis  with  shortening  of  the 
limb. 

The  Chairman  said  that  he  had  seen  a  man.  40 
years  of  age,  who  had  been  a  caisson  worker  and 
diver,  and  who  presented  an  affection  of  both 
hips.  There  was  very  little  motion  except  in 
abduction.  There  was  no  history  of  rheumatism, 
or  other  constitutional  disorder. 

Dr.  Shaffer  had  recently  seen  at  the  Ortho- 
pedic Dispensary  a  caisson  worker,  who  present- 
ed bilateral  hip  symptoms,  and  who  was  scarcely 
able  to  walk.  In  this  case,  the  symptoms  were 
those  of  a  pronounced  rheumatic  type,  and  the 
changes  were  apparently  due  to  rheumatic  ar- 
thritis. 

Dr.  Ridlon  also  exhibited  photographs  of  the 
latest  modification  of  Grattan's  osteoclast,  and  of 
some  of  the  cases  which  this  surgeon  had  treated 
by  means  of  the  instrument.  He  now  used  it 
for  forcibly  correcting  club-feet,  and  in  the  opin- 
ion of  the  speaker,  it  was  the  handiest  and  most 
efficient  contrivance  of  its  class  that  he  had  seen. 

NON-UNION  AFTER  OSTEOTOMY  IN  A  CASE  OF 
SEVERE     RACHITIS. 

The  Chairman  presented  a  little  girl  with  a 
very  exaggerated  form  of  rickets,  whose  s>  mp- 
toms  indicated  that  the  disease  was  still   active. 


86o 


DOMESTIC  CORRESPONDENCE 


[June  13. 


The  chief  point  of  interest  was  the  fact  that 
about  three  years  before,  a  skillful  surgeon  had 
performed  osteotomy  upon  her  for  the  correction  of 
a  severe  form  of  bow-legs,  and  this  had  resulted  in 
non  union.  This  case  showed  the  folly  of  op- 
erating in  the  presence  of  such  a  virulent  form  of 
rachitis.  The  treatment  in  his  hands  had  con- 
sisted in  the  application  of  a  coaptation  splint, 
and  of  a  perineal  crutch,  which  b}r  means  of  a 
snap  joint  allowed  motion  at  the  knee,  but  pre- 
vented dangerous  traumatism,  and  favored  loco- 
motion. The  idea  of  the  apparatus  was  to  favor 
locomotion  rather  than  to  attempt  to  secure 
union. 

Dr.  Royal  Whitman  doubted  if  this  treat- 
ment would  lead  to  union  of  the  fragments,  for 
the  end  of  the  bones  in  such  cases  become  ex- 
tremely hard,  and  usually  require  to  be  removed 
before  union  can  be  secured. 

Dr.  R.  H.  Sayre  thought  the  non-union  in 
this  case  might  have  resulted  from  the  fact  that 
the  deformity  was  so  great,  that  in  order  to  cor- 
rect it,  a  considerable  interval  must  have  been  left 
between  the  ends  of  the  bone  after  the  osteotomy. 
(7o  be  concluded.} 


DOMESTIC  CORRESPONDENCE. 


LETTER  FROM  BALTIMORE. 

Judged  by  numbers,  the  late  session  of  the  medical 
schools  of  this  city  was  a  great  success.  The  following 
was  the  attendance  and  the  number  of  graduates: 


College  of  Physicians  and  Surgeons 
University  of  Maryland 

Baltimore  Medical"  College 

Baltimore  University 

Woman's  Medical  College 


Total 


MEDICAL       MEDICAL 

MATRICU-        GRAI'T- 

LATES.  ATEs. 


The  attendance  has  been  equally  good  at  the  dental 
schools.  The  Baltimore  College  of  Dental  Surgery  hav- 
ing about  226  students  and  77  graduates,  and  the  Dental 
Department  of  the  University  of  Maryland  about  163 
and  64  respectively.  The  Maryland  College  of  Phar- 
macy had  ab  mt  us  students  and  29  graduates.  So  that 
the  total  number  of  students  and  graduates  in  medical 
aud  allied  schools  in  this  medical  centre  (not  includ- 
ing the  biological  and  preliminary  medical  at  the  Johns 
Hopkins  University  and  the  post-graduate  at  the  Johns 
Hopkins  Hospital  1  is  about  1.366  of  the  former  and  457 
of  the  latter,  ligures  the  size  of  which  I  suppose  few  out- 
siders would  suspect. 

Tlu-  Maryland  College  of  Pharmacy  has  just  celebrated 
the  semi  centennial  anniversary  of  its  foundation.  Its 
lectures  were  at  first  delivered  at  the  University  of  Mary- 
land, which  set  apart  quarters  for  its  accommodation. 
Besides  the  commencement  and  commemoration  meeting 
of  the  college,  the  exercises  included  a  magnificent  re- 


ception with  music  and  lunch  at  the  college  building, 
and  a  banquet  at  night.  There  were  visitors  from  New 
York,  Philadelphia  and  other  cities.  The  college  is  now 
in  a  very  prosperous  condition,  has  a  large  new  build- 
ing, well  equipped,  and  has  a  high  reputation  for  honest 
and  faithful  work  in  training  young  men  for  the  pharma- 
ceutical profession. 

The  College  of  Physicians  and  Surgeons  introduced  a 
novelty  at  their  commencement  this  year,  which  has 
elicited  criticisms  both  favorable  and  the  reverse.  It 
was  the  adoption  for  the  graduates  of  the  English  cap 
and  gown.  The  effect  was  very  pretty,  and  the  manifest 
advantages  of  having  a  cheap  and  uniform  attire  cannot 
be  questioned.  The  college  furnished  the  suits,  charg- 
ing a  nominal  sum  for  their  use  by  the  students.  There 
does  not  appear  to  have  been  any  difficulty  or  opposi- 
tion to  the  adoption  of  ihg  innovation.  An  attempt  was 
made  last  winter  to  introduce  the  custom  at  the  Hop- 
kins, but  it  met  with  little  favor,  only  President  Oilman 
appearing  in  cap  and  gown  at  the  anniversary  exercises 
February  22. 

Miss  Mary  Garrett  has  given  another  evidence  of  her 
liberality  and  interest  in  the  higher  education  of  her  sex 
by  offering  to  contribute  an  additional  $  10,000  to  the  en- 
dowment fund  of  the  proposed  Johns  Hopkins  Medical 
School.  In  a  letter  dated  April  27,  addressed  to  Presi- 
dent Dobbin,  of  the  Board  of  Trustees,  she  makes  this 
offer  payable  October  1,  1S92,  subject  to  the  following 
conditions:  That  by  February  I,  1S92,  the  trustees  raise 
the  remainder  of  the  sum  necessary  to  bring  the  endow- 
ment up  to  $500,000 — the  minimum  limit  proposed  by 
the  trustees — and  further  that  the  trustees  shall  give 
notice  in  February,  1S92,  that  they  will  open  the  school 
in  (  Ictober,  1S92,  and  shall  actually  open  it  then.  The 
committee  of  ladies  organized  to  raise  $100,000,  having 
accomplished  their  object,  has  disbanded.  The  follow- 
ing represents  the  present  status  of  this  endowment: 
The  entire  sum  raised  by  the  committees  of  lathes  of 
Baltimore  and  elsewhere  aud  paid  over  to  the  trustees 
May  1  was  $111,000:  there  were  already  in  hand  addi- 
tional funds  sufficient  to  raise  this  amount  to  $178,780. 
In  order  to  avail  of  Miss  Garrett's  offer,  it  is  therefore 
necessary  to  raise  $221,219.  The  trustees  have  accepted 
her  offer  aud  have  resolved  to  endeavor  to  raise  the  bal- 
ance required.  There  is  no  doubt  that  her  interest  is  so 
great  that  she  will  extend  the  required  time  should  it  be 
necessary  to  do  so.  Of  the  ji  1 1,300  raised  by  the  ladies, 
Baltimore  contributed  $6S,SS2;  the  next  largest  contribu- 
tion Boston's  $20,231,  and  Philadelphia's  $8,075. 

Dr.  George  F.  H.  Nuttall,  of  San  Francisco,  a  graduate 
of  the  University  of  Gottiugen.  has  been  appointed  to  the 
vacancy  in  the  bacteriological  aud  hygienic  department 
at  the  Johns  Hopkins  Hospital,  occasioned  by  the  ac- 
ceptance by  Dr.  Alexander  C.  Abbott  of  the  directorship 
of  the  new  Hygienic  Institute  of  the  University  of  Penn- 
sylvania. 

The  death  of  Dr.  John  Frederick  May,  of  Washington, 
recalls  the  fact  that  in  early  life  he  held  the  Chair  of 
Surgery  in  the  Trustees'  Faculty  of  the  University  of 
Maryland,  at  the  time  when  that  school  was  split  into 
two  schools  (1S37-39). 


iSgi.J 


DOMESTIC  CORRESPONDENCE 


861 


The  Sisters  of  Mercy  are  erecting  a  four-story  addition  ( 
to  the  City  Hospital  (connected  with  the  College  of  Phy- 
sicians and  Surgeons  .  for  the  use  of  their  colored  pa- 
tients, at  a  cost  of  520,000. 

Dr.  James  Carey  Thomas,  one  of  the  Trustees  of  the 
Johns  Hopkins  University  and  Hospital,  has  gone  to  Eu 
rope,  and  one  of  the  chief  objects  of  his  journey  is  stated 
to  be  to  examine  into  the  structure  and  architecture  of 
European  medical  schools,  with  the  purpose  of  utilizing 
the  information  in  the  construction  of  the  Hopkins 
school. 

The  use  of  the  Koch  lymph  is  gradually  falling  into 
desuetude  here  as  elsewhere.  There  never  was  much 
gush  over  it  here,  and  its  use  at  the  Hopkins  was  con- 
fined to  lupus  and  incipient  cases  of  pulmonary  tuber- 
culosis. A  judicious  skepticism  and  timidity  character- 
ized the  attitude  of  our  physicians  towards  it  from  the 
start,  and  consequently  we  have  had  no  deaths  or  bad 
results  to  report.  The  results  as  a  whole  bav< 
appointing,  and  although  a  few  cases  are  still  under 
treatment,  the  probabilities  are  that  ere  long  it  will  be- 
come a  matter  of  the  past. 

The  death  of  Judge  George  \V.  Dobbin,  at  his  country- 
seat  near  Baltimore,  on  the  2Mb  of  May.  at  the  age  of  Sf, 
has  removed  from  our  midst  one  of  our  most  distinguished 
and  public-spirited  citizeus.aud  one  who  has  been  very  act- 
ive in  the  cause  of  education.  Among  theposilionshe  held 
at  the  time  of  his  death  were  Regent  of  the  University 
of  Maryland  and  Dean  of  its  Law  School,  Trustee  of  the 
Peabody  Institute  and  of  the  Johns  Hopkins  University 
and  Hospital.  From  1S67  to  1SS2  he  held  office  as  Judge 
of  the  Supreme  Bench  of  Baltimore,  and  fjr  many  years 
had  been  President  of  the  Board  of  Trustees  of  the  Johns 
Hopkins  University.  He  was  a  most  courteous  gentle- 
man with  a  cultivated  mind  and  scientific  tastes,  and  he 
enjoyed  the  respect,  veneration  and  love  of  the  entire 
community. 

Another  death  which  is  deeply  felt  among  us  is  that  of 
Dr.  Richard  Gundry,  the  able  specialist  on  iusanity  and 
superintendent  of  our  State  insane  asylum,  which  took 
place  from  Bright's  disease,  on  April  23.  He  was  a  na- 
tive of  England  and  60  years  old.  He  took  charge  of 
the  asylum  here  in  1878,  having  held  similar  positions 
previously  in  <  (hio.  He  was  also  Professor  of  Materia 
Medica  and  Mental  Diseases  in  the  College  of  Physieitus 
and  Surgeons  of  Baltimore  since  1SS2.  He  was  an  en- 
lightened physician,  a  man  of  scholarly  attainments  and 
high  professional  standing. 

Professor  Win.  C.  Jarvis,  of  the  University  of  New 
York,  delivered  the  annual  address  before  the  Alumni 
Association  of  the  University  of  Maryland,  on  April  1st, 
the  subject  being  "Glimpses  of  Metropolitan  Life." 

A  verv  successful  concert  in  the  interest  of  the  L'niver- 
sitv  of  Maryland  Hospitals  was  held  on  April  10,  under 
the  auspices  of  the  ladies  counected  with  the  Faculty  of 
that  institution.  The  object  was  to  raise  a  fund  for  the 
increase  of  free  beds,  the  hospitals  being  without  en- 
dowment. Vladimir  de  Pachman,  the  pianist,  was  the 
chief  attraction,  and  the  entertainment  was  a  great  suc- 
cess, nearly  *2,ooo  being  cleared.  The  chief  hospital  of 
the  Uuiversitv  (formerly  known  as  the  Baltimore  Infir- 


"iie  of  the  oldest  college  hospitals  in  the  coun- 
try, having  been  erected  and  opened  in  1823.  and  being 
entirely  under th  the  Faculty,  and  immediately 

adjoining  the  University  building,  it  has  by  its  clinical 
advantages  enabled  the  institution  to  take  a  high  rank 
among  the  medical  schools  of  America. 

The  ninety-third  annual  meeting  of  the  Medical  and 
Chirurgical  Faculty  of  Maryland  was  held  April  28-30, 
under  the  Presidency  of  Professor  Thos.  A.  Ashby.  who 
delivered  a  stirring  address  on  the  need  of  better  profes- 
sional organization  in  Maryland.  The  paper  of  the  meet- 
ing was  undoubtedly  that  of  Professor  Win.  H.  Welch, 
on  th.e  "Causation  of  Diphtheria."  It  has  since  been 
published  in  full  in  the  Medical  News,  and  should  be 
read  by  every  one  w  ho  wishes  the  latest  information  on 
this  disease  from  a  master  hand.  In  honoring  Prof. 
Welch  with  the  Presidency  of  the  Society  for  the  ensu- 
ing year,  the  Faculty  has  conferred  still  greater  houor 
upon  itself. 

Dr.  Randolph  Winslow,  Professor  of  Surgery  in  the 
Woman's  Medical  College  here,  has  been  elected  to  the 
chair  of  Anatomy  and  Clinical  Surgery  in  the  V: 
of  Mankind,  in  which  lie  was  formerly  Demonstrator. 
Dr.  I.  K.  Trimble  has  been  elected  Professor  of  Anatomy 
in  the  Woman's  Medical  College,  vice  Prof.  Jay,  trans- 
ferred to  the  chair  of  Practice  of  Surgery.  There  are 
rumors  of  approaching  changes  in  the  personnel  of  the 
Johns  Hopkins  medical  staff.  It  is  announced  that  the 
organization  of  the  "  Southern  Homoeopathic  Medical 
College  "  of  this  city  has  been  perfected  by  the  election 
of  a  Professor  of  Surgery  (from  Washington  1.  and  that 
the  lectures  will  begin  in  October  next  in  a  rented  build- 
ing. When  the  Hopkins  opens  in  1S92  we  will  have 
seven  medical  schools  here! 

It  is  to  b;  hoped  that  the  action  of  the  American  Medi- 
cal College  Association  in  Washington,  in  reaffirming  by  a 
large  majority  its  determination  to  exact  a  preliminary 
Latin  requirement,  will  settle  that  matter  for  the  future 
with  the  medical  schools  of  the  country, and  that  those  who 
voted  for  it  and  against  reconsideration  were  sincere  in 
their  action.  The  only  two  schools  here  that  did  so  were 
the  University  of  Maryland  and  the  Baltimore  University. 
The  former  institution  is  making  ready  for  the  institution 
of  the  three  year  graded  course  in  the  fall,  by  the  insti- 
tution of  histological  aud  chemical  laboratories.  It  has 
not  been  announced  yet  who  will  take  charge  of  the 
former. 

I  send  you  the  following  compositions  on  George  Wash- 
ington, which  are  veritable  curiosities  iu  the  way  of  pre- 
liminary accomplishment,  showing  as  well  as  anything 
could  the  need  of  some  standard  at  least  of  requirements 
in  those  who  undertake  the  study  of  medicine.  They 
were  handed  in  by  two  candidates  for  matriculation  in 
one  of  our  medical  colleges,  one  of  whom  had  been  a 
teacher  of  a  public  school.  I  am  glad  to  say  both  were 
rejected. 

I.  "  George  Washington  When  a  boy  could  not  tel  a 
bov  could  not  tel  a  lie  he  cut  one  of  his  fathers  Chury 
trees  with  his  hatchet  when  Father  called  him  aud  aske 
who  cut  the  tree  he  said  I  cut  it  with  my  hatchet  he  be- 
came a  man  of  zeal  aud  industry  was  belove  by  all  who 


862 


DOMESTIC  CORRESPONDENCE. 


[June  13, 


knew  him  he  fought  many  battels  aud  by  his  cunning 
defeated  Xepoleon  he  maried  became  the  first  president 
of  the  United  states  lived  to  a  good  old  age.     Oct  1st." 

II.  "jeueral  Washiuton  was  born  in  Virginia  he  was  a 
truthfull  Boy  a  good  Chresttian  a  noble  man  in  war  &  in 
peace  he  was  the  firist  President  of  the  United  States  of 
Amarica  he  was  and  considered  the  fathar  of  our  coun- 
try By  his  bravery  whe  are  a  free  and  independent  peo- 
ple to  think  and  act  as  whe  think  Best  he  was  honest  in 
all  his  wa\  s.  " 

I  give  them  as  near  literally  as  I  can.     Yours  trulv, 

E.  F.  c. 


LETTER  FROM  PHILADELPHIA. 

(FROM   Or'R   OWN  CORRESPONDENT.) 

Although  la  grippe,  influenza,  dengue,  horse-distem- 
per, "it,"  the  great  unknown,  or  by  whatever  name  it 
may  be  known  to  future  medical  historians,  has  not  fa- 
vored Philadelphia  this  spring  with  such  obvious  marks 
of  attention  as  it  has  some  other  cities  of  the  Atlantic 
sea-board,  yet  this  may  be  explained  by  the  fact  that  it 
committed  such  ravages  a  year  ago  that  the  susceptible 
material  was  largely  exhausted.  However,  we  have  had 
sufficient  number  of  these  cases  to  supply  clinicians  with 
abundant  material  for  study.  In  addition  to  typical  cases 
of  the  disease,  which  are  comparatively  few  this  year, 
there  are  large  numbers  of  abortive  cases,  showing  the 
poison  is  still  with  us,  and  is  responsible  for  a  large 
amount  of  general  ill  health  and  lowered  vitality  in  the 
community.  In  one  respect  this  epidemic  differs  from 
epidemics  of  dengue.  The  late  Prof.  Samuel  H.  Dickson, 
formerly  of  Charleston,  Va.,  noticed  the  fact  that  dengue 
was  self-protective  aud  that  persons  who  had  an  attack 
would  not  be  liable  to  suffer  at  the  next  appearance  of 
the  epidemic.  Quite  a  number  of  persons  who  had  influ- 
enza last  year  have  it  again  this  year  although,  it  is  true, 
as  the  rule,  in  a  milder  form.  In  the  treatment,  quinine 
seems  of  little  use  and  only  adds  to  the  patient's  discom- 
fort. Antipyrin,  acetanilide,  sulphonal  and  other  agents 
of  the  aromatic  group,  can  only  be  used  cautiously,  if  at 
all,  on  account  of  the  tendency  to  lower  the  action  of  the 
heart,  but  where  the  pyrexia  is  marked,  salicylic  acid  or 
phenacetiu  in  small  doses  (gr.  iii,  v)  given  every  hour 
or  two,  is  decidedly  useful.  Small  doses  of  Dover's 
powder,  with  a  little  camphor,  or  of  the  compound  mor- 
phine powder  for  restlessness;  ice  to  the  head  if  there  is 
headache;  small  pieces  of  ice  swallowed  when  there  is 
nausea,  and  a  dose  of  calomel  with  jalap  or  rhubarb,  for 
constipation,  are  often  followed  by  marked  relief.  In 
addition  to  this,  a  good  elixir  of  coca  i  Lorini)  orthe  well- 
known  Mariani  wine  or  caffeine  citrate  will  be  generally 
Deeded  to  support  the  weak  heart,  aud  nervous  system. 
During  convalescence,  ignatia  or  mix  vomica  should  be 
an  appropriate  remedy;  but  patients  seem  very  suscepti- 
ble to  strychnine  and  some  complain  of  cramps  and  mus- 
cular pains.  The  hypophosphites  with  iron,  form  a  good 
tonic,  but  the  best  restorative  after  all  is  a  change  of  ail 
to  the  mountains  or  seashore,  with  nourishing  food  given 
only  in  moderate  quantity  and  at  regular  times.  The 
above  brief  outline  of  treatment  has    proved    uniformly 


successful  in  the  experience  of  the  writer,  who  has  had 
uo  deaths  and  few  complications.  In  delicate  nervous 
cases  it  contributes  very  much  to  their  comfort  to  dis- 
pense with  linen  sheets  and  to  substitute  woolen  ones, 
or  just  put  the  patients  between  blankets. 

A  movement  is  on  foot  to  increase  the  endowment  of 
the  Medical  Department  of  the  University  of  Pennsylva- 
nia. The  Trustees  have  accepted  the  offer  of  the  Faculty 
to  contribute  5>o,ooo,  and  of  the  Provost,  Dr.  Pepper,  to- 
give  550.1100,  towards  a  fund  for  additional  endowment 
of  Medical  Department  of  $250,000,  and  will  lengthen 
the  term  to  four  years  when  the  fund  is  made  up;  it  is 
expected  to  be  raised  within  five  years.  It  is  possible 
that  this  fund  will  be  raised  aud  that  the  University  will 
be  placed  in  a  position  to  extend  the  course  in  medicine 
so  as  not  to  fall  behind  in  the  race  with  Harvard  aud 
Johns  Hopkins.  The  death  of  Prof.  Joseph  Leidv  was  a 
severe  loss  to  the  school  and  to  the  community;  but  the 
Board  of  Trustees  seem  in  110  hurry  to  fill  the  vacancy. 
The  prospects  at  present  are  that  the  Chair  will  be  divid- 
ed into  surgical  anatomy,  for  which  Dr.  John  B.  Deaver 
is  an  eligible  candidate;  aud  historical  anatomy  which 
rnay  be  offered  to  Dr.  Harrison  Allen,  who  was  formerly 
Professor  of  Physiology  in  this  institution  and  resigned. 

At  a  meeting  held  June  2,  iScjr,  the  following  appoint- 
ments were  made:  Dr.  George  A.  Piersoll  was  elected  to 
the  Chair  of  Human  Anatomy,  Dr.  Harrison  Allen  to  that 
of  Comparative  Anatomy,  J.  P.  Grover  Griffith,  Prof,  of 
Diseases  of  Children,  in  place  of  H.  A.  Hare,  resigned. 
Dr.  Edward  Martin  was  elected  Professor  of  Geuito-Urin- 
ary  Diseases,  John  D.  Deaver  was  made  Assistant  Pro- 
fessor of  Applied  Anatomy. 

The  Jefferson  Medical  College  has  lost  within  a  short 
time  two  of  its  most  distinguished  professors:  Prof.  Bar- 
tholow  and  J.  M.  DaCosta.  The  place  of  the  former  was 
promptly  filled  by  the  election  of  Dr.  H.  A.  Hare;  that 
of  the  latter  is  still  vacant.  Drs.  J.  C.  Wilson,  Frederick 
P.  Henry,  both  of  Philadelphia,  and  Jas.  T.  Whittaker  of 
Cincinnati  and  several  others,  have  been  discussed  as 
candidates,  but  the  issue  is  uucertaiu.  The  Medico- 
Chirurgical  College  also  has  a  vacant  chair,  Dr.  'Win.  T. 
Waugh,  Prof,  of  Practice  of  Medicine,  having  resigned. 
It  is  understood  that  he  is  not  without  hope  of  a  trans- 
fer to  the  identical  chair  at  Jefferson. 

There  is  a  prospect  that  the  state  of  Pennsylvania  will 
give  the  Medico  Chirurgical  Hospital  $70,000,  to  enlarge 
its  buildings;  the  legislature  has  passed  the  bill  which 
only  awaits  the  signature  of  the  Governor. 

The  medical  societies  of  this  city  keep  up  their  scien- 
tific work  manfully  in  spite  of  the  influenza  and  unfavor- 
able weather.  At  the  College  of  Physicians'  meeting  last 
week  (June  3),  Dr.  Oscar  H.  Aliis  read  a  paper  on  Frac- 
ture of  the  Condyles  of  the  Humerus  treated  by  Exten- 
sion— with  a  suit  for  malpractice  and  a  verdict  for  the 
defendant,  who  was  C.  E.  Kurts  of  Bellaire,  Ohio.  The 
last  meeting  of  the  County  Medical  Society  was  enliven- 
ed by  a  tilt  between  the  operating  gynaecologists,  lead  by 
Joseph  Price,  and  the  disciples  of  Apostoli,  and  his  elec- 
trical  treatment  for  uterine  growths,  of  which  Dr.  Bettoa 
Massey  is  an  able  exponent.  The  conflict  has  been  go- 
ing on  for  several  years  but  the  ardor  of  the  contestants 


I89i.] 


DOMESTIC  CORRESPONDENCE. 


863 


seems  to  be  increasing  ratbei  than  abating;  to  outsiders 
it  is  quite  entertaining. 

The  Society  of  the  State  of  Pennsylvania,  during  the 
past  week,  (Jum        ..  ,  ind  >  been  holding  its  forty- 

first  annual  session  in  the  city  of  Reading,    about  sixty 
miles  from  Philadelphia,  in  the  coal  and  iron  region.      I: 

as  largely  attended  as  usual.  The  prii 
dresses  wen  that  of  the  President.  Dr.  Allen  Craig,  of 
Columbia;  that  on  Medicine.  J.  Chris.  I.ange,  of  Alle- 
gheny City;  on  Mental  Disord  :rs,  Samuel  Avers,  of  Pitts- 
burg; on  Ophthalmology  by  J.  A.  Lippincott,  of  Pitts- 
burg, and  on  Obstetrics  by  J.  Milton  Duff,  also  of  Pitts- 
burg. 


LETTER   FROM    NEW  YORK. 

(from  our  own  CORRESPONDENT. J 

The  recent  annual  meeting  (its  seventh)  of  the  Fifth 
District  Branch  of  the  New  York  State  Medical  Associa- 
tion was- oue  of  the  best  attended  and  most  attractive 
that  it  has  yet  held,  and  its  varied  scientific  proceedings 
were  of  a  high  order.  The  President,  Dr.  Stephen  Smith, 
took  for  the  subject  of  his  address  "  Opiates  in  the  Treat- 
ment of  Acute  Peritonitis,"  and  it  was  devoted  princi- 
pally to  a  detailed  and  graphic  accouut  of  the  introduc- 
tion into  Bellevue  Hospital,  by  the  late  Prof.  Alonzo 
Clark,  of  the  opium  treatment  of  puerperal  peritonitis. 
In  the  course  of  it  he  quoted  the  following  passage  from 
Dr.  Clark's  description  of  the  outbreak  of  puerperal  fever 
at  Bellevue  in  the  year  1851.  "In  three  or  four  days 
seven  cases  were  sent  me  from  the  lying-in  wards.  One 
was  returned  for  error  in  diagnosis,  and  six  put  under 
treatment.  Having  proved  that  prudence  was  so  much 
more  conspicuous  in  any  house  physician  than  courage, 
another  house  officer,  who  combined  them  both,  was  se- 
lected to  be  in  almost  constaut  attendance.  The  instruc- 
tions were  iu  these  words:  'I  want  you  to  narcotize 
those  women  within  an  inch  of  their  lives.'  He  did  it, 
and  saved  every  one  of  them.  This  gentleman  is  now 
known  over  the  whole  land  as  a  learned  and  distinguished 
surgeon.  I  feel  called  upon  to  give  his  name  in  this  con- 
nection, that  he  may  be  a  wituess  to  the  facts  I  state, 
and  for  the  admiration  with  which  his  nerve  and  pru- 
dence impressed  me."  Dr.  Smith  said  that  not  withstand- 
ing this  assertion  Professor  Clark  failed  to  give  the  name 
of  the  surgeon  referred  to,  but  as  lie  himself  was  then  a 
resident  student  at  Bellevue  Hospital,  and  had  charge  of 
the  six  cases  mentioned,  he  assumed  that  he  was  the 
person  meant,  and  would  take  this  occasion  to  witness  to 
the  facts  recorded. 

Up  to  this  time  mortality  from  puerperal  fever  at  Belle- 
vue had  been  appalling.  Of  21  cases  reported  by  Dr. 
Vache,  the  resident  physician  in  1840,  19,  or  nearlv  90 
per  cent.,  proved  fatal.  This  death  rate,  he  said,  was 
not  unusual  at  that  period,  aud  the  treatment  was  so 
mixed  that  it  was  difficult  to  draw  any  conclusions  as 
to  the  efficiency,  or  rather  inefficiency,  of  any  one 
remedy.  Still  it  was  noticeable  that  in  17  of  the  21 
cases  purgatives  were  actively  employed,  and  that 
in  twelve  of  these  calomel  and  turpentine,  two 
approved   antiseptic  agents,  were   administered   freelv. 


Up  to  the  time  when  the  opium  treatment  was  adopted, 

-or  Clark  remarks,   "peritonitis  was  a   fearful 

word;  a  large  proportion  ol  those  attacked  by  it  died  of 

it."  Dr.  Smith  described  in  detail  the  treatment  of  the 
six  cases  placed  under  his  charge  by  Professor  Clark, 
who  gave  the  most  particular  directions  as  to  their  care. 
At  the  outset  each  patient  received  1  gr.  of  opium,  or  its 
equivalent,  every  hour  for  three  doses.  Xo  effect  being 
perceptible,  the  dose  was  increased  to  2  grs.  every  hour, 
and  continued  for  three  doses.  Failing  with  this  dosage, 
the  opium  was  im  reased  to  3  grs.  every  hour.  In  short, 
he  was  especially  charged  not  to  be  governed  by  the 
amount  administered,  but  by  the  effects  produced.  In 
four  cases  the  last  mentioned  dose  had  the  desired  effect, 
and  the  opium  was  continued  in  that  quantity.  In  one 
of  the  remaining  cases  it  had  to  be  increased  to  4  grs. 
every  hour,  and  in  the  other  to  12  grs.  every  hour.  This 
case  proved  an  anomaly  in  tolerance  of  opiates.  During 
twelve  days  the  patient  took  the  equivalent  of  1.950  grs. 
of  opium,  and  yet  at  no  time  was  she  so  narcotized  that 
she  coidd  not  be  roused  by  a  touch  ou  her  wrist. 

The  recovery  of  these  six  consecutive  cases  naturally 
produced  a  profound  impression,  and  as  the  cases  were 
typical  of  those  ordinarily  occurring  in  Bellevue,  and  as 
opiates  were  the  sole  remedies  employed,  it  was  apparent 
that  a  new  era  in  the  treatment  of  this  affection  had 
begun.  From  this  time  forward  opium  continued  for 
twenty  years  to  be  the  chief  remedy  used  in  peritonitis 
in  this  hospital,  and  with  satisfactory  results.  Opium  in 
peritonitis  came  into  use  generally  iu  the  city  of  New 
York,  and  Professor  Clark  stated  that  in  private  practice 
the  drug  had  been,  perhaps,  more  eurative  than  in  the 
hospital.  Happily,  in  these  latter  days,  said  Dr.  Smith, 
autisepticism  had  greatly  diminished  the  frequency  of 
this  formidable  disease,  especially  the  puerperal  form, 
and  in  the  meantime  the  remedial  measures  had  been 
greatly  increased.  One  of  the  most  important  results  of 
recent  investigations  was  the  differentiation  of  the  types 
of  peritonitis  caused  by  various  ageucies;  and  as  there 
were  many  types  of  this  affection,  having  their  causation 
iu  various  conditions  (some  being  of  microbic  and  oth- 
ers of  nou-microbic  origin  \,  it  was  as  yet  by  no  means 
certain  where  the  line  was  to  be  drawn  between  the  med- 
ical aud  surgical  treatment.  Whatever  might  be  the  pos- 
sibilities of  the  art  of  surgery  in  the  treatment  of  perito- 
nitis, the  question,  he  thought,  might  be  pertinently 
asked,  Has  any-  remedy  or  combination  of  remedies  in 
the  hands  of  the  physician  given  results  equal  to  or  bet- 
ter than  opium,  in  a  series  of  cases  similar  to  those  re- 
corded in  this  paper?  And  if  it  be  true  that  by  employ- 
ing opium,  as  recommended  by  Professor  Clark,  more 
than  50  per  cent,  of  cases  of  peritonitis,  as  met  with  in 
practice,  cau  be  saved,  should  not  this  method  of  treat- 
ment be  at  once  adopted  in  all  cases,  and  the  resources 
of  surgery  be  applied  when  the  manifestations  of  the  dis- 
ease indicate  the  necessity  of  its  additional  remedial 
measures? 

An  interesting  discussion  followed  the  address,  but  it 
was  greatly  regretted  that  Dr.  A.  Palmer  Dudley,  who 
had  been  announced  to  read  a  paper  on  "  Cathartics  in 
the  Treatment  of  Acute  Peritonitis."  failed  to  make  his 


864 


MISCELLANY. 


[June  13,  1891. 


appearance.  In  the  course  of  the  discussion  Dr.  H.  L. 
Carroll  remarked  that  it  was  noticeable  that  the  advocacy 
of  saline  cathartics  in  peritonitis  came,  as  a  rule,  from 
the  abdominal  surgeons,  such  as  Lawson  Tait,  for  in- 
stance; and  Dr.  T.  H.  Manley,  in  referring  to  the  discus- 
sion on  the  management  of  peritonitis  in  the  Surgical 
Section  of  the  American  Medical  Association,  at  its  New- 
port meeting,  spoke  of  the  extreme  opposition  with  which 
everything  in  the  way  of  palliative  treatment  was  met  on 
that  occasion.  For  his  own  part,  he  said,  his  experience 
had  led  him  to  regard  the  opening  of  the  peritoneal  cavity 
as  a  more  serious  matter  than  many  seemed  to  regard  it, 
and  it  was  his  belief  that  in  the  next  ten  years  there 
would  be  fewer  laparotomies  performed  for  the  relief  of 
inflammatory  conditions  than  had  been  the  case  during 
the  past  ten  years.  So  much  interest  was  manifested  in 
the  subject  that,  at  the  suggestion  of  Dr.  Gouley,  it  was 
determined  to  request  that  at  the  general  meeting  of  the 
State  Association  in  October  next,  a  discussion  on  the 
treatment  of  peritonitis,  to  be  opened  by  a  paper  from 
the  President,  Dr.  Smith,  should  be  arranged  for. 

P.  B.  P. 

( To  be  concluded.) 


much  in  two  winters  as  a  European  can  in  five  years. 
There  is  but  one  way  out  of  the  matter,  and  that  is  to 
lengthen  the  course  of  study,  and  prosecute  the  bogus 
diploma  man.     Respectfully, 

Fred  Byron  Robinson. 
Birmingham,  Eng. ,  May  26,  1S91. 


MISCELLANY. 


"M.D.,  Indianapolis." 

To  the  Editor: — During  the  past  few  weeks  a  case  was 
brought  up  in  the  courts  of  this  city  which  induced  very 
free  remarks  relative  to  the  requisite  standing  of  a  man 
in  the  States  to  possess  the  title  M.D.  S.  E.  L.  Smith, 
of  this  town,  was  registered  as  a  licentiate  of  the  Society 
of  Apothecaries,  which  gave  him  rights  to  practice.  But 
said  Smith  assumed  the  title  of  "M.D.,  Indianapolis," 
and  he  was  summoned  into  court,  fined  the  maximum 
fee  of  $100,  with  probably  a  quarter  as  much  costs.  Mr. 
Smith  produced  in  court,  during  the  trial,  a  document 
which  gave  him  the  title  of  "M.D.,  Indianapolis."  It 
was  said  to  have  cost  him  $30.  The  medical  man  who 
prosecuted  the  case  said  that  such  a  title  could  only  be 
one  of  those  foreign  or  American  titles  which  could  be 
got  for  a  dollar  or  two. 

It  might  be  well  for  the  young  men  of  the  States  to 
know  something  of  this  "$;oM.D.,  Indianapolis"  mill. 
1  Lilly  recommend  it  to  the  proud  men  in  the  city 
of  that  name.  Mr.  Smith  was  prosecuted  and  fined  be- 
cause he  assumed  the  title  of  Medical  Doctor  (M.D.). 
The  titles  M.D.,  etc.,  said  the  prosecutor,  enable  the 
public  to  distinguish  between  qualified  and  unqualified 
practitioners.  The  assumption  of  a  title  would  mislead 
the  public.  We  are  sorry  to  hear  of  the  "  bogus  diplo- 
ma" again,  and  thought  it  died  a  natural  death  in  Phil- 
adelphia. It  chagrins  a  medical  man  of  the  States  to 
listen  to  the  English  courts  ridicule  our  medical  titles  as 
being  worth  "a  dollar  or  two."  But  we  cannot  help 
thinking  that  we  deserve  it  to  some  extent.  A  student 
in  England  studies  five  years  of  about  eight  months  a 
year  to  get  his  title.  I  know  scores  of  medical  men  in 
tin  States  who  got  their  title  in  two  winters'  study  of 
live  months  each.  Certainly  we  cannot  expect  very  high 
regard  from  a  European  court  toward  titles  so  easily  ac- 
quired.  It  is  an  unconsoling  argument  to  say  that  the 
American   student  is  such  a  genius  that  he   can   learn  as 


An  International  Medical  Congress. — The  man- 
agers of  the  National  Prohibition  Park,  of  Staten  Island, 
invite  representative  medical  men  from  all  localities  in 
the  United  States  and  Canada  to  meet  in  conference  on 
the  15th  and  16th  of  July  next,  in  the  great  Auditorium 
Building  of  the  Park.  The  chief  object  of  the  meeting 
is  to  be  the  comparison  of  views  on  the  relationship  of 
physiology  and  alcohol.  Among  the  questions  to  be  dis- 
cussed will  be  the  following  : 

What  are  the  Hereditary  Effects  of  Drunkenness? 

Are  there  any  Hereditary  Effects  that  Follow  Moderate 
Drinking? 

To  what  Diseases  are  Inebriates  More  Especially  Ex- 
posed ? 

Is  Alcohol  a  Poison  ? 

is  Alcohol  in  Any  Sense  a  Food  ? 

What  are  the  Proper  Uses  of  Alcohol  as  a  Medicine  ? 

Is  there  Danger  of  Producing  the  Drink  Habit  from 
the  Prescribing  of  Alcoholic  Medicines  ? 

How  Large  a  Percentage  of  Deaths  May  be  Attributed, 
Directh'  or  Indirectly,  to  the  Use  of  Strong  Drink  ? 

Should  Alcoholic  Liquors  ever  be  Used  Except  under 
the  Direction  of  a  Medical  Adviser  ? 

At  this  Conference,  all  views  will  be  given  an  impar- 
tial hearing.  No  restraint  will  be  placed  upon  the  dis- 
cussion save  that  of  the  time  limit.  Many  well-known 
medical  men  have  already  signified  their  willingness  to 
participate  in  such  a  conference.  No  harm,  but  much 
good,  may  come  from  this  conference  of  views  by  lead- 
ing physicians. 


Official  List  of  Chanties  in  the  Stations  and  Duties  of  Officers  Serving 
in  the  Medical  Department,  ^t\  S.   Army,  from  Ma\    10,1801,  to 
Junes.iSgi. 
Capt.  Jefferson  R.  Kean,  Asst.  Surgeon,  is  granted  leave  of  absence 

for  one  month,  to  take  effect  after  the  return  of  Major  Robert  H. 

White,  Surgeon,  to  duty  at  Ft    Mver,  Va.     Par.  i,  S.  O.  123.  A.  G. 

I  >      Max 
Major  David  I.    Huntington,  Surgeon,  is  granted  leave  of  absence 

ior  three  months,  to  lake  effect  on  or  about  June  15,  1891.     With 

approval  of  the  Secretary  of  War.     Par.  2,  S.  O.  124,  A.  G.  O.,  June 

Capl    1  award  C.  Carter,  Asst.  Surgeon,  will  proceed  without  delay 
to  Ft.  Canby,  Washington,  and  report  to  the  commanding  officer 
for  temporary  duty,  relieving  Major  John  D.  Hall,  Surgeon,  who 
will  proceed  to  Ft.' Sherman,  for  duty  as  Post  Surgeon.     Par.  1,  S. 
Dept.  of  the  Columbia,  May  : 
Capt.  Henry  P.  Birmingham,  Asst.  Surgeon,  extension  of  leave  of 
absence  on  account  of  sickness  granted  in  S.  O. 
from  this  office,  is  further  extended  to  June  21,  1891,  on  surgeon's 
certificate  of  disability.     Ity  direction  of  the  Secretary  of  War. 
Par,  6,  S   ').  125,  *■•  G.b..  June 
Major  John  I).  Hall,  par.  I,  S.  O.  74,  Dept.  of  the  Columbia.  May  32, 
1891.  transferring  him  from  Ft.  Canby  Washington,  to  Ft.  Sher- 
[aho,  is  confirmed.    Bydirectioii  of  the  Secretary  of  War. 
I'm    1   s,  o.  126,  A.  G.  O.,  June  3,  1891. 
Cap!.  Van  R.  lloff,  Asst.  Surgeon,  is  relieved  from  duty  as  a  mem- 
bei  "1  the  board  of  medical  officers  to  which  he  was  assigned  bj 
(i    78,  April  :,  1891,  from   this  office,  and  will,  upon  the 
ion  of  the  duties  assigned  him, by  par.  6,  S.  o.  110,  May  14. 
return  to  his  proper  station,  Ft.  Riley,  Kan, 
la  direction  of  the  Secretary  of  War.    Par.  11,  S.  O.  126,  A.  G.  O., 
June 
Capt.   feiferson  R.  Kean   Asst   Surgeon,  is  assigned  to  temporary 
duty  at  Ft.  Myer,  Va.,  until  the  return  of  Major  Robert  H.  White, 
Surgeon,  to  duty  at  that  post.     By  direction  of  the  Secretary  of 
Par.  8,  S.  O.  I2»,  A.  G.  O.,  Mo 

-  of  Changes  in  the  Medical  Corps  of  the  U.  S 
the  Week  Ending  June  6,  i$or. 

r.  Gravatt,  detached  from  Naval  Hospital,  Yokohama. 
]  a'  .  1    and  ordered  home. 

detached  from   special  duty,  Norfolk. 
v.i    and  i"  Yokohama  Hospital 


The  Journal  of  the 

American  Medical  Association 


Vol.  XVI. 


CHICAGO,  JUNE  20,   1891. 


No.  25. 


ORIGINAL  ARTICLES. 


PRACTICAL    EXPERIENCE    IN    THE 

TREATMENT   OF    ACCIDENTAL 

ABORTION. 

Read  in  the  Section  of  Obstetrics  and  Diseases  of  Women,  at  the 
Forty-second  Annual  Meeting  °.r  tin-  American 
ciation,  held  at  Washington,  D.C.,  M,: 

BY  BEDFORD    BROWN,  M.D., 

OF  ALEXANDRIA,  VA. 

EX-PRESIDENT  OF  THE  -MEDICAL  SOCIETY  OF  VIRGINIA;    MEMBER  OF 

THE  MEDICAL  EXAMINING    HOARD  OF    VIRGINIA;    MEMBER  OF 

THE    SOUTHERN    SURGICAL    AND   GYNECOLOGICAL 

ASSOCIATION. 

The  facts  and  statements  presented  in  this 
paper  are  based  exclusively  on  the  personal  ob- 
servation of  some  two  hundred  or  more  cases  of 
accidental  abortion  which  occurred  at  various 
times  during  the  past  forty- two  years  of  my  pro- 
fessional life.  And  I  have  endeavored  to  make  it  as 
practical  in  character  as  possible.  It  has  been  my 
custom  of  late  years,  when  first  called  to  attend 
a  case  of  threatened  abortion,  accompanied  with 
uterine  pain  and  indications  of  haemorrhage,  in 
the  beginning  to  give  a  hypodermic  of  ]4  gr.  of 
morphia,  7V  of  atropia,  and,  if  there  is  much  de- 
pression from  haemorrhage,  ^  gr.  of  strychnia, 
and  20  minims  of  the  fluid  ext.  of  ergot.  This 
quantity  of  ergot  is  just  enough  to  constringe  the 
arterioles  without  stimulating  contraction  of  the 
uterine  vessels.  In  two  or  three  hours  this  prac- 
tice may  be  repeated,  if  found  necessary,  and  will 
aid  materially  in  arresting  the  progress  of  abortion. 

The  fact  may  be  recalled  here  that  the  causes 
of  this  accident  are  of  a  varied  and  complex  na- 
ture, and  of  course  require,  to  a  certain  extent,  a 
modification  in  our  preventive  treatment  suitable 
to  the  peculiar  nature  of  the  existing  cause.  Take 
a  given  number  of  cases  of  abortion,  and  we  will 
find  in  one  that  it  is  simply  and  purely  of  the 
nature  of  a  neurosis,  having  its  cause  in  unusual 
mental  or  nervous  excitement  acting  on  the  con- 
tractile fibres  of  the  uterus.  At  other  times  it  is 
eminently  reflex  in  its  character,  the  current  of 
nervous  action  being  reflected  from  some  other 
organ  on  the  cord,  and  thence  on  the  uterus ; 
while  in  other  cases  still  it  is  due  to  temporary 
increase  of  blood  pressure,  the  result  of  over- 
exertion, sudden  injury,  high  lever.    When  pure- 


ly of  a  neurotic  origin,  the  uterine  conti 
begin  previous  to  signs  of  haemorrhage.  But 
when  from  increase  of  blood  pressure,  the  haem- 
orrhagic  symptoms  usher  in  the  case.  Then 
again,  it  may  be  due  to  a  variety  of  blood  poisons 
acting  on  the  nutrition  and  growth  of  the  pla- 
centa and  cord,  and  also  on  the  foetus,  as  the  in- 
fection of  syphilis,  of  typhoid  fever  and  scarla- 
tina. My  next  procedure,  as  a  preventive  measure, 
is  to  cause  the  vagina  to  be  thoroughly  douched 
with  water  at  a  temperature  of  1  io°,  containing 
1  gr.  of  permanganate  of  potash  to  the  oz.  And 
then,  if  haemorrhage  be  present,  to  order  a  vagi- 
nal douche  of  a  pint  of  hot  water  containing 
1  or  I'.-  oz.  of  pulverized  alum  to  the  pint 
of  water.  This  very  active  astringent  causes 
prompt  contraction  of  the  os,  and  forms  a  firm 
clot,  which  fills  the  cervix  and  arrests  bleeding 
without  the  necessity  of  a  tampon,  which  is  ob- 
jectionable at  this  stage.  The  viburnum  and 
kindred  remedies  I  use.  but  have  found  uncertain. 
In  my  personal  experience  of  all  methods  for  the 
prevention  of  abortion,  rest,  absolute  and  con- 
tinuous, is  the  most  valuable.  Rest  of  mind  and 
body  in  the  recumbent  position,  without  ever  as- 
suming the  erect  or  semi-erect  attitude  for  a  sin- 
gle moment,  for  any  purpose  whatever,  has  ac- 
complished more,  in  my  hands,  than  any  other 
single  method.  With  absolute  rest,  and  one  of 
the  bromides  in  10  or  20  gr.  doses  three  times 
daily,  as  the  bromide  of  lithia,  and  if  nervous  or 
circulator}'  excitement  are  present,  2  drops  of  the 
tincture,  of  aconite  root,  many  imminent  cases 
may  be  averted.  The  bromide  of  lithia  and  aco- 
nite give  a  quietude  of  mind  and  body  that  pre- 
disposes the  patient  to  a  state  of  composure  and 
comfort,  and  not  only  renders  her  less  amenable 
to  existing  influences,  but  subdues  undue  arterial 
pressure,  and  nervous  erethism,  and  enables  her 
to  bear  confinement  with  more  philosophy  and 
less  irritation.  While  copious  haemorrhage  in 
the  early  stages  of  abortion  is  exceedingly  dan- 
gerous to  the  life  of  the  foetus,  I  have  yet  to  wit- 
ness a  fatal  case  to  the  mother,  and  I  ha\ 
repeatedly  instances  where  the  patient  was  blanch- 
ed, cold,  and  for  a  time  pulseless.  Yet,  under 
proper  restoratives,  they  would  react.  But  I  have 
seen  fatal  cases,  the  result  of  septicaemia  from  re- 
|  tention  of  placenta,  before  the  introduction  of  our 


866 


TREATMENT  OF  ACCIDENTAL  ABORTION. 


[June  20, 


admirable  modern  antiseptic  methods.     For  the 
arrest  of  the  genuine  neurotic  contractions  of  the 
uterus  without  hemorrhage,  the  chloral  enema 
composed  of  3ss  and  20  grs.  of  bromide  of  potash' 
three  times  a  day,  exerts  the  most  potent  effect 
on  the  lower  spinal  cord   and  the  reflex  pelvic 
nerves,  of  any  other  remedies  in  my  knowledge 
There  comes  a  period  in  the  progress  -of  abor- 
tion "when  it  becomes  dangerous  longer  to  tamper 
with  preventives,  and  when  it  even  becomes  de- 
sirable to    complete  that  process  as  speedily  as 
possible.     The  use  and  application  of  the  tampon 
at  this  stage  are  questions  of  infinite  importance 
and  delicacy.     It  will  save  the   mother   but  as 
surely  condemn  the  foetus  to  death.     Its  primary 
action  is  to  arrest  haemorrhage,  and  its  secondary 
is  to  put  the  whole  process  of  abortion  through 
its  various  stages  to  completion,  as  a  rule,  prompt- 
ly and  speedily.     Otherwise,  in  this  stage   it  can 
do  no  harm,  and  is  a  power  for  good.     But  when 
applied  111  retained  placenta  with  haemorrhage   it 
is  not  unattended  with  danger.     It  will  seal  up  a 
decomposing  placenta  in  a  cavity  at  a  temperature 
of   100  ,  and  conduce  in  every  way  to  the  gener- 
ation of  active  septic  poison,  which  may  be  seri- 
ous, or  it  may  be  mild,  but  nevertheless  it  will 
generally  be  developed.     I  have  never  applied  a 
tampon  for  haemorrhage  in  retained  placenta  for 
twenty-four  hours,  that  it  was    not  followed  by 
more  or  less  septic  fever,  and  occasionally  pelvic 
peritonitis  or  salpingitis.     The  type  of  fever  may 
be  exceedingly  mild  and  the  local  inflammation 
exceedingly  limited,  the  area  not  covering  more 
than  a  square  inch.     But  there  is  usually  a  rise 
of  temperature  and  acceleration  of  pulse      But 
occasionally  they  are  of  a  more  serious  character 
In  my  experience,  this  mild  form  of  septic  fever 
has  so  often  followed  the  sealing  up  of  an  offen- 
sive, putrid  placenta,  that  I  always  anticipate  it 
In  the  first  stage  of  abortion,  previous  to  the 
expulsion  of  the  foetus,  for  the  tamoon  to  prove 
efficient,  the  vagina  should  be  thoroughly  washed 
out  with   a  warm   solution    of  permanganate  of  1 
potash    2  grs.  to  the  oz.     The  patient  is  then  laid 
across  the  bed  near  the  edge,  in  the  lithotomy 
position,  and  a  large  bivalve  speculum  introduced   ' 
through  which  halls  of  cotton  or  iodoform  gauze 
as  large  as  walnuts,  with  small  cords  tied  around 
their    middle,   which    are  permitted  to   protrude 
from  the  vagina.     These  pellets  are  pressed  up 
with  dressing  forceps  against  and  around  the  os 
Uteri  in  the  roof  of  the  vagina  firmly,  until  that 
3  firmly  packed  with  the  pledgets,  and  Hun 
a  soft  catheter  is  inserted  into  the  urethra      The 
attending  physician   may  now  leave  his  patient 
and    resf    assured  that  there  will  be   no  furthi  - 
>rrhage    until  their  removal,  and   that  the 
patient  will  be  preserved  in  an  aseptic  stati    foi 
twelve  hours. 

A  tampon  well  timed  and  executed  is  a  blessing 
to  both  physician  and  patient.    Bui  one  ill 


badly  prepared  and  inefficiently  applied   is  a  curse 
to  all  concerned.     In  my  judgment,  the  tampon 
cannot  be  properly  applied  without  the  use  of  the 
speculum,  and  in  my  experience,  the  best  form  for 
this  purpose  is  the  large  bivalve.     With  this  in- 
strument no  assistant  is  needed,  as  with  that  of 
Simons.     I  have  repeatedly   been  called  in   the 
dead  hours  of  night  to   cases  of  abortion   with 
alarming  haemorrhage,  and  after  placing  the  pa- 
tient in   position,  inserted  my  bivalve    and  with 
my  iodoform  gauze  pledgets  packed  the  roof  of 
the  vagina  around  and  over  the  os,  then  fil'ed  up 
the  vagina  firmly  with  pledgets  of  absorbent  cot- 
ton, gave  a  hypodermic  of  morphia,  atropia  and 
strychnia,  and  returned  to  my  bed,  with  perfect 
confidence  that  in  the  morning  I  would  find  my 
patient  in  a  satisfactory  state,  and  in  all  probabil- 
ity a  foetus   and  secundines,  partially  or  wholly 
expelled,  in  the  vagina.     But  in  the  event  that 
the  os  uteri  is  contracted,  the  fcetus  in    a  dead 
condition,  and  is  retained  and  gives  rise  to  ex- 
hausting haemorrhages,  what  is  the  proper  course 
of  procedure  in  this  condition  ?     Ergot  alone    in 
this  state  of  affairs,  only  causes  increased  con- 
tractions of  the  os,  without  facilitating  the  ex- 
pulsion.    The  method  which  I  have  adopted  of 
late  years,  in  cases  of  this  kind,  is  to  dilate  the 
os  and  cervical  canal  with  an   antiseptic  cotton 
wool   or  iodoform  gauze  tampon,  wrapped  in  a 
conical  form  around   a   metal  instrument  in  the 
form  of  a  conical  screw,  and  inserted  by  a  rotary 
motion  until  the  os  is  dilated  to  the  extent  of  1 
inch    or  1  }4   inch  in  diameter,  and  permitted  to 
remain  while  3ij  or  more  of  Squibbs'  fl.  ext   of 
ergot  is  injected  by  enema  into  the  rectum     The 
ergot  acts  very  powerfully  on  the  muscular  fibres 
of  the  body  of  the  uterus,  while  the  fibres  of  the 
cervix  and  os  remain  in  an  inert  condition  be- 
cause of  the  presence  of  the  dilator,  and  the  fcetus 
and  secundines  are  usuallv  promptly  and  easily 
expelled  through  the  expanded  os.     The  ergot 
.given  in   this  way,  with  5  grs.   of  quinine  inter- 
nally, acts  on  the  cord  and  muscular  fibres  of  the 
uterus  with  great  promptness   and  force.     The 
rotary  dilators  which  I  use  were  prepared    at  mv 
suggestion,  some  ten  years  ago,  by  the  Messrs. 
/leinssen,  and  when  associated  either  with  carbo- 
lated  or  iodoform  vaseline,  the  absorbent  cotton 
or  gauzeis  wrapped  around  in  the  form  of  a  cone 
and  gradually  inserted  by  turning  the  instrument 
to  the  right.    When  this  is  completed,  the  instru- 
ment is  simply  turned  to  the  left,  and  the  threads 
of  the  screw  gradually  liberate  it  and  permit  the 
tampon  to  remain.    The  advantages  of  this  meth- 
od are  that  the  body   of  the  uterus  is,  as   a   rule 
except  111  adherent  placenta,  enabled  to  expel  the 
contents  entire. 

I"    a   certain  proportion   of  cases  of  abortion 

1  ^pulsion  of  the  rcetus,  the  placenta,  either 

adherent,  is  retained  in  utero.    I  think 

tnat  the  profession  will  k  ai  mi    .mi  in  the  asser- 


1891.]  TREATMENT  OF  ACCIDENTAL  ABORTION.  867 

tion  that  the  retained  placenta  in  abortion  gives  ;  placenta  can  be  easily  removed.  Or,  if  it  should 
rise  to  more  evil  consequences  to  the  patient,  and  be  adherent,  it  can  be  peeled  off  and  raked  out 
more  anxiety  and  annoyance  to  the  attendant,  than  without  difficulty.  The  sensitive  and  intelligent 
any  other  feature  in  its  management.  In  truth,  fingers  are  the  best,  the  safest,  the  most  efficient 
the  pathology  of  the  retained  placenta  is  the  piv-  curette  in  our  profession.  And  I  am  convinced 
otal  point,  largely,  on  which  the  favorable  or  un-  that  the  entire  process  of  curetting  the  uterus 
favorable  prognosis  will  depend.  We  can,  in  a  with  the  fingers,  while  the  patient  is  under  chlo- 
certain  proportion  of  cases,  prevent  the  occur-  reform,  is  far  less  dangerous  than  the  use  of  in- 
rence  of  abortion.  If  not,  we  can,  as  a  rule,  struments.  Up  to  the  fourth  month,  with  the 
promptly  expel  the  foetus.  But  when  the  secun-  uterus  pressed  low  down  into  the  pelvic  cavity, 
dines  are  retained  or  adherent,  we  have  a  more  the  hand  in  the  vagina  and  the  fingers  in  utero, 
complex  case,  that  may  entail  a  long  line  of  evils  |  the  secuudines  can  be  removed  without  much 
in  the  form  of  haemorrhages,  septicaemia",  inflam-  difficulty.  But  subsequent  to  this  stage — that  is, 
niation,  as  pelvic  peritonitis,  phlebitis,  salpingitis  1  after  the  fourth  month,  this  method  of  procedure 
and  metritis.  The  ideal  method,  in  my  judgment,  is  r.ot  practicable.  Then  it  becomes  a  very  grave 
in  the  delivery  of  the  retained  secuudines,  is  to  question  for  consideration,  whether  the  entire 
discard  all  instruments,  as  hooks,  forceps  and  cu-  hand  can  be  introduced  with  perfect  safety  and 
rettes,  and  to  rely  upon  the  hand  and  its  prehen-  ease  into  the  cavity  of  the  uterus  for  the  removal 
sile  extremities,  and  an  occasional  dilator.  To  of  the  retained  or  adherent  placenta.  This  is  an 
attain  proficiency  and  success  with  the  fingers  in  interesting  and  important  question.  On  a  num- 
these  cases,  certain  preliminary  and  cooperative  ber  of  occasions  I  have  introduced  the  hand,  dis- 
arrangements are  necessary.  In  the  first  place,  infected,  into  the  uterus  at  the  fourth  month  or 
the  patient  must  be  placed  on  the  back  across  the  alter,  for  the  removal  of  retained  or  adherent  pla- 
bed,  with  the  pelvis  on  the  edge,  and  the  limbs  centa,  with  the  patient  under  chloroform,  with 
drawn  up  as  in  the  position  for  turning.  An  in-  ,  perfect  ease  and  safety,  and  successfully,  without 
telligent  assistant  must  press  the  womb  well  down  any  ill  consequences.  I  have  never  introduced  it 
in  the  pelvic  cavity  and  keep  it  there,  and  the  os  at  an  earlier  period  than  this,  though  it  is  possi- 
can  usually  be  brought  within  i1..  inch  of  the  ble  that  it  could  be  accomplished  in  mnltiparae  at 
vulva.  If  the  os  is  rigid  and  contracted,  nothing  an  earlier  period. 
can  be  accomplished  without  the  use  of  an  anses-  \      For  the  purpose  of  more  clearly  illustrating  the 


thetic,  and  the  greater  my  experience  increases, 
the  more  I  am  convinced  that  these  cases  justify 
the  employment  of  anaesthesia,  and  the  more  I 
am   convinced,  also,    of  the   importance  of  the 


statements  made  in  relation,  to  the  treatment  of 

retained  placenta,  I  will  cite  the  following  cases : 

Case  1. — Mrs.  T.,   a   young   married  woman, 

aborted  with  her  first  child  at  the  fourth  mouth. 


prompt  and  early  removal  of  the  retained  secun-  ,  The  dead  foetus  was  expelled,  but  the  secundiues 
dines.  With  all  mental  and  physical  resistance  at  i  were  retained,  and  there  was  no  haemorrhage  fol- 
an  end,  the  soft  and  dilatable  vagina  and  os  uteri !  lowing  the  expulsion.  The  umbilical  cord  was 
can  be  invaded  with  the  fingers,  and  the  hand  if1  found  in  an  atrophied  condition.  Various  meth- 
necessary,  with  impunity,  and  the  operation  com- 1  ods  were  resorted  to  for  the  expulsion  of  the  pla- 
pleted  without  difficulty.  This  operation  should  j  centa,  but  without  effect.  The  patient  was  then 
he  preceded  by  the  permanganate  douche,  and  the  \  placed  under  chloroform,  laid  across  the  bed  in 
hands  of  the  attendant  washed  in  a  sublimate  so-  the  position  for  turning,  with  limbs  drawn  up, 
lution.  When  the  secundines  have  been  success-  and  my  assistant  directed  to  press  the  uterus 
fully  removed,  there  is   an    end  of  the  trouble,    down  forcibly  in  the  pelvis,  and  my  right  hand, 


As  previously  stated,  the  tampon  in  retained,  pu 
trescent  placenta  is  dangerous,  though  it  will  ar- 
rest haemorrhage.  I  have  in  times  past  seen  a 
sealed  up  placenta,  from  the  use  of  the  tampon 


after  disinfection  with  sublimate,  introduced  into 
the  vagina  and  then  into  the  relaxed  uterus  with 
perfect  ease.  I  was  surprised  to  ascertain  with 
what  ease  and  rapidity  this  operation  could  be 


keep  up  haemorrhage  and  septic  fever  for  weeks,  performed  at  the  fourth  month,  and  how  thor- 
when  all  of  this  could  have  been  avoided  by  its  oughly  relaxed  were  both  the  vagina  and  uterus, 
prompt  removal.  Then  I  am  satisfied  that  ad-  The  placenta  was  found  to  be  entirely  adherent, 
herent  placenta  is  a  frequent  occurrence  in  the  which  accounted  for  the  absence  of  haemorrhage, 
early  months  of  pregnancy,  which  cannot  well  be  1  It  was  cautiously  peeled  off  and  raked  out  of  the 
removed  by  instruments.  In  certain  cases,  par-  j  cavity  with  the  hand.  The  patient  suffered  for 
ticularly  after  the  second  mouth,  the  fingers  can-  ten  days  with  slight  septic  fever,  which  yielded 
not  well  reach  the  cavity  of  the  uterus  without '  to  antiseptic  treatment.  In  twelve  months  from 
the  entire  hand  being  introduced  into  the  vagina,  this  time  this  woman  became  pregnant  again,  and 
When  necessary,  I  never  hesitate  to  do  this,  and  aborted  at  four  and  one-half  months.  The  dead 
find  that  it  can  be  accomplished  with  perfect  ease  foetus,  with  an  atrophied  cord,  was  expelled,  and 
and  impunity  to  the  patient.  Then  we  have  en-  the  secundines  retained  as  in  the  previous  case, 
tire  command  of  the  situation,  and  the  retained .  I  had  no  hesitation  now  in  resorting  promptly  to 


TREATMENT  OF  ACCIDENTAL  ABORTION. 


[June  20, 


the  same  treatment  as  in  the  first  instance.  The 
placenta  was  again  found  adherent  and  effectually 
removed.  The  patient  also  had  a  similar  attack 
of  septic  fever,  but  of  less  duration.  As  an  im- 
portant part  of  the  history  of  this  case,  it  should 
be  stated  here  that  this  woman,  soon  after  mar- 
riage, contracted  syphilis  from  her  husband,  for 
which  I  treated  her  in  the  primary  stage  before 
pregnancy.  The  infection  had  undoubtedly  lin- 
gered in  the  system,  and  was  the  cause  of  adherent ' 
placenta,  atrophy  of  the  cord  and  abortion.  Sub- 
sequently I  treated  this  patient  for  several  months, 
until  she  became  pregnant  a  third  time,  by  means 
of  iodide  of  potassium  and  bichloride  of  mercury. 
This  pregnancy  went  to  the  full  term,  when  she 
was  delivered  of  a  healthy  child.  There  had 
been  no  signs  of  quickening. 

Case  2. — Mrs.  M.,  a  young  married  woman, 
contracted  syphilis  from  her  husband  soon  after 
marriage.  She  was  treated  for  this,  it  was  sup- 
posed successfully.  She  became  pregnant  in 
twelve  months,  and  aborted  at  the  end  of  the 
fourth  month.  The  foetus  was  still- born,  and  the 
placenta  was  retained.  After  resorting  to  the 
usual  methods  of  removing  the  afterbirth,  I  was 
unsuccessful,  and  then  placed  the  patient  under 
chloroform,  directed  the  nurse  to  press  the  womb 
down  into  the  cavity  of  the  pelvis,  and,  the  woman 
being  in  the  proper  position  across  the  bed,  the 
hand,  after  disinfection,  was  with  perfect  facility 
and  impunity  introduced  into  the  uterus,  and  the 
placenta,  which  was  adherent,  removed  without 
difficulty.  The  practice  has  been  inculcated  by 
many  high  authorities  that  the  secundiues  can  be 
left  in  the  uterus  before  the  second  month,  there 
to  be  decomposed  and  escape  in  a  disintegrated 
state  with  perfect  safety-.  I  regard  this  as  erro- 
neous in  theory  and  practice.  And  while  it  is 
true  that,  in  a  certain  proportion  of  cases,  nature 
seems  to  resist  infection,  there  are  others  in  which 
the  results  are  deplorable.  I  have  had  a  small 
adherent  placenta  of  six  weeks  old  give  me  infi- 
nite trouble  for  many  weeks  and  months,  from 
haemorrhage,  irritation,  septic  infection  and  sub- 
involution. In  my  experience,  the  earlier  the 
retained  placenta  is  removed  the  better.  If,  in 
these  cases,  I  am  not  certain  that  every  shred  of 
secundines  is  removed,  and  the  slightest  trouble 
recurs,  I  swab  the  cavity  of  the  uterus  out  every 
day  or  two  with  carbolic  acid  and  tincture  of 
iodine,  and  wash  the  vagina  out  with  the  per- 
manganate solution.  To  indicate  what  disas- 
trous results  may  follow  the  neglect  of  this  rule, 
I  will  cite  the  following  case: 

Mrs.  E.,  a  married  woman,  had  a  miscarriage 
at  the  sixth  week  in  her  fourth  pregnancy.  She 
had  retention  of  the  afterbirth  and  but  little  haem- 
orrhage. When  seen  some  two  days  subsequently 
id  had  a  chill,  followed  by  lever.  There 
was  pain  and  tenderness  in  the  right  inguinal  re- 
gion, and  very  soon  extensive  phlebitis,  then  ex- 


tensive oedema  of  the  limb,  then  erysipelas  of  the 
thigh,  and  suspension  of  circulation  in  the  foot 
with  symptoms  of  incipient  gangrene,  followed 
by  death  from  septicaemia — all  originating  from 
retention  of  a  small  placenta  only  six  weeks  old. 
In  certain  cases  I  have  pursued  a  still  different 
course  in  the  delivery  of  the  placenta.  In  the 
past  six  years  two  very  remarkable  cases  of  re- 
tained placenta,  accompanied  with  extensive  and 
dangerous  concealed  haemorrhage,  have  come  un- 
der my  observation  and  care,  one  of  which  was 
reported*  at  the  time  in  the  Virginia  Medical 
Monthly,  the  history  of  which  I  will  present  on 
this  occasion : 

Case  j. — Mrs.  S.,  a  married  woman,  became 
pregnant  with  her  second  child,  and  while  in  a 
country  neighborhood,  aborted  at  the  third  month. 
The  attendeut  supposed  the  entire  contents  had 
been  expelled,  and  for  a  period  of  two  weeks  sub- 
sequently there  was  no  trouble.  Then  the  abdo- 
men began  to  enlarge  rather  rapidly,  while  there 
was  no  discharge  whatever  from  the  vagina,  which 
enlargement  was  accompanied  with  pain  and  sore- 
ness of  the  abdominal  parietes.  Just  at  this  time 
the  health  and  strength  of  the  woman  began  to 
decline  in  a  marked  manner.  She  came  to  our 
city,  and  I  was  called  hurriedly  to  see  her.  I 
found  a  woman  completely  exsanguined,  cold  and 
almost  pulseless,  and  suffering  great  abdominal 
pain.  There  were  all  the  general  indications  of 
excessive  loss  of  blood,  but  no  discharge  from 
the  vagina  or  intestines.  The  uterus  was  about 
the  size  of  that  of  a  woman  at  her  sixth  month 
of  pregnancy.  After  learning  the  history  of  her 
previous  condition,  I  was  convinced  in  my  own 
mind  that  I  had  a  case  of  dangerous  concealed 
haemorrhage  to  deal  with,  and  that  it  required 
prompt  and  efficient  measures  to  save  my  patient. 
In  the  first  place,  a  hypodermic  of  J^  gr.  of  mor- 
phia, TV  gr-  °f  atropia  and  strychnia  was  admin- 
istered. Then  the  os  uteri,  which  was  closely 
contracted,  was  dilated  with  a  conical  tampon  of 
iodoform  gauze  well  coated  with  carbolated  vase- 
line, inserted  on  the  rotary  dilator,  and  permitted 
to  remain  while  oiij  of  fluid  extract  of  ergot  was 
administered  by  enema  per  rectum,  and  the  vagina 
washed  out  with  permanganate  solution .  In  thirty 
minutes  active  uterine  contractions  began,  and  in 
an  hour  from  commencement  of  treatment  there 
wi  -  expelled  more  than  a  half  gallon  of  tough, 
whitish-colored,  fibrinous  concretions,  and  a  large 
quantity  of  coagulated  blood,  when  the  uterus 
was  rapidly  reduced  to  its  small  dimensions.  In 
this  mass  of  fibrinous  concretions  and  coagula  a 
three  months  old  placenta  and  cord  wen 
embedded,  in  a  perfect  state  of  preservation.  This 
patient  gradually  regained  her  usual  health  under 
1 1  eatment. 

A  paper  on  the  treatment  of  abortion  would 
hardly  be  complete  without  allusion  to  the  man- 
agement of  the   collapse   so   often    arising  from 


i89i.] 


TREATMENT  OF  ACCIDENTAL  ABORTION. 


869 


haemorrhage  in  the  progress  of  that  affection,  when  there  is  comparatively  nothing  for  it  to  act 
The  onset  of  collapse,  in  its  suddenness  and  de- '  upon.  But  if  we  will  but  give  this  jaded  heart 
gree,  depends  largely  on  the  rapidity  with  which  something  substantial  to  act  upon,  we  will  see 


blood  is  withdrawn  from  the  circulation,  and  the 
inability  of  the  heart  and  arteries  to  accommo- 
date their  calibre  to  the  sudden  diminution  of  the 
circulatory  volume.  To  meet  this  new  condition 
of  affairs  we  have  two  leading  objects  before  us: 
one  is  to  maintain  and  even  increase  the  contrac- 
tility of  the  heart  and  arteries,  so  as  to  establish 
this  accommodation  which  is  lost,  and  thereby 
prevent  that  paresis  of  the  vaso  motor  system 
which  is  present  in  all  cases  of  fatal  collapse,  but 
also  to  increase  the  circulating  volume  by  adding 
new  serum  in  sufficient  quantity  to  make  up,  in 
part,  for  the  deficiency.  On  a  moment's  reflec- 
tion in  the  treatment  of  collapse,  we  will  observe 
that  mos,t  of  our  general  remedies  are  such  as  are 
addressed  to  the  vaso-motor  system,  and  partake 
of  the  nature  of  stimulants  of  that  system..  Mor- 
phia, atropia,  strychnia  internally  or  hypodermi 


how  promptly  it  will  respond  to  -timulants. 

In  calculating  the  dangers  and  advantages  of 
the  respective  methods  of  treating  retain' 
centa  in  abortion,  namely  :  the  expectant,  by 
which  nature  is  left  unaided  ;  the  use  of  instru- 
ments, or  its  removal  by  manipulation  with  the 
fingers,  an  experience  covering  some  three  hun- 
dred cases,  during  a  professional  life  of  forty  two 
years,  sustains  me  in  the  opinion  that  the  latter 
is  the  safest,  easiest,  and  the  most  effectual  of  all 
methods.  And  I  have  found  that  anaesthesia  adds 
greatly  to  the  facility  of  these  operations,  and  in 
truth  is  a  necessity  to  success  and  very  greatly 
increases  the  security  of  the  patient's  life  and 
health.  In  a  majority  of  cases  of  retained  pla- 
centa, anaesthesia  is  not  only  necessary  to  com- 
plete the  operation  of  removal,  but  the  neglect  of 
ts  influence  has  often  led  to  imperfect  and  incom- 


cally,  and   nitroglycerine    internally,  constitute  j  plete  operations  that  have  practically  defeated  the 
some  of  our  most  potent  agents  for  sustaining  object 


vaso  motor  action,  and  for  the  prevention  of  pa- 
resis of  the  heart.  And  these  agents,  do  meet 
the  emergencies  of  the  case  better  than  any  other 
in  our  profession,  A  heart  and  artery  whose  con- 
tractility cannot  be  excited  by  agents  are  certainly- 
dead  to  all  other  stimulants,  including  alcohol. 
But  to  cooperate  fully  with  the  action  of  these 
vaso  motor  stimulants,  it  is  of  the  utmost  impor- 
tance to  increase,  if  possible,  the  circulating  vol- 
ume of  blood  by  adding  to  its  aqueous  constitu- 
ents. This  I  have  been  enabled  to  accomplish 
without  much  difficulty.  My  custom  now,  in 
the  treatment  of  all  forms  of  collapse  in  abor- 
tion, in  cholera  morbus,  post-partum  or  haemor- 
rhage from  any  cause,  is  to  have  injected  into  the 
rectum  a  pint  of  beef- tea,  or  if  not  convenient, 
a  similar  quantity  of  warm  water.  Then,  by 
means  of  a  hypodermic  syringe  containing  an 
ounce,  hot  water  at  1050  or  no°  is  injected  under 
the  skin  twelve  or  fifteen  times,  which  is  equal  to 
another  pint.  A  quart  of  warm  fluid  thus  sud- 
denly added  to  the  general  circulation,  exerts  an 
astonishing  effect  in  the  process  of  restoration. 
To  this  warm  water  I  add  a  small  quantity  of 
chloride  of  sodium  and  bicarbonate  of  soda.  In 
certain  cases  of  collapse  where  these  methods 
have  been  put  into  execution,  it  has  been  exceed- 
ingly interesting*,  during  the  progress  of  reaction, 
to°  observe  the  increased  arterial  pressure  and  of 
cardiac  action,  the  return  of  warmth  to  the  sur- 
face, the  increased  power  of  nervous  action,  the 


With  thorough  anaesthesia  we  have  absolute 
command  of  the  situation,  without  in  any  way 
adding  to  its  dangers.  Without  the  influence  of 
anaesthesia  there  is  danger  of  lacerating  the  rigid 
os  uteri.  With  it  the  os  and  cervix  are  thorough- 
ly relaxed,  and  in  no  danger  of  laceration.  It  is 
equally  true  of  the  perineum.  A  perineum  and 
vagina  that  will  yield  only  to  two  fingers,  under 
ansesthesia  affords  no  resistance  to  the  entire  hand. 
And  a  womb  contracted  as  hard  as  a- ball,  fully 
under  chloroform  becomes  a  soft,  relaxed,  unre- 
sisting bag  to  the  hand  when  inserted. 

It  is  certainly  our  duty  to  prevent  abortion  if 
possible.  If  not  possible,  then  it  is  equally  our 
duty  to  bring  it  to  a  conclusion  in  the  speediest 
and  safest  manner  possible.  Hypodermics  of 
morphia  or  opiates  internally  have  not,  in  my  ex- 
perience, accomplished  much  to  arrest  the  uterine 
pains  of  abortion,  nor  has  ergot  done  much  to 
control  haemorrhage.  Thirty  grs.  of  chloral  by- 
enema  and  20  grs.  of  bromide  of  lithia,  with  a 
teaspoonful  of  ft  ext.  of  viburnum  prunifolium 
every  two  or  three  hours,  will  allay  this  spas- 
modic actio*h  better  than  opiates.  This,  in  con- 
nection with  absolute  rest  of  mind  and  body  in 
the  recumbent  position,  without  the  patient's 
ever  assuming  the  erect  or  semi-erect  position  for 
a  moment,  constitute  the  most  effectual  preven- 
tives in  my  knowledge  of  the  act  of  abortion. 
In  alluding' to  the  positive  advantages  of  rest  of 
mind    and  body,    and  quietude    of   the    nervous 


u  of  consciousness  and  interest  in  life  and  system,  in  prevention  of  abortion,  I  recall  the 
surrounding  objects,  the  disappearance  of  pallor  history  of  a  case  which  occurred  some  seventeen 
and  emaciation  and  that  contraction  of  the  fea-  years  ago.  Tins  young  woman,  in  the  third 
tures  in  extreme  cases  of  this  kind.  In  the  treat-  month  of  her  second  pregnancy,  had  frequent 
ment  of  collapse  from  haemorrhage,  it  is  needless  and  severe  uterine  pains  and  repeated  haemor- 
to  continue  in  our  efforts  bv  powerful  stimulation  rhages  for  some  four  weeks  She  during  this 
to  lash  an  exhausted  heart  to  increased  action,  I  time  had  numerous  enemata  of  30  grs.  ot  chloral 


870 


GYNECOLOGIST  AND  ALIENIST. 


[June  20, 


after  failure  of  opium,  and  20  grs.  of  bromide  of 
lithia  every  four  or  five  hours,  with  absolute  rest 
of  mind  and  body  in  the  recumbent  position.  The 
foetus  was  not  only  retained  until  the  full  term, 
but  was  healthy  and  vigorous  at  birth,  and  is  now 
a  healthy  young  man. 


CAN  THE  GYNECOLOGIST  AID  THE 

ALIENIST  IN  INSTITUTIONS  FOR 

THE  INSANE? 

Read  in    the   Section  of    Obstcti  ics    and  Diseases  of    Women,  al  the 
Forty-second  Annua:  Meeting  of  the  American  Medical  Associa- 
tion, held  at   Washington ,  D.  C,  May  1891. 

BY  I.  S.   STONE,  M.D., 

OF   WASHINGTON.   D.  C. 

This  question  should  receive  an  affirmative  an- 
swer without  debate.  There  are,  however,  many 
who  refuse  to  be  convinced  of  the  necessity  for 
special  treatment  of  the  various  ailments  to  which 
the  insane  are  subject,  claiming  as  they  generally 
do,  that  the  local  or  peripheral  cause,  or  factor, 
must  yield  if  at  all,  to  such  treatment  as  may  in- 
fluence directly  the  central  lesion.  The  question 
is  asked  by  the  gynecologist  briefly  thus:  Are 
there  not  in  every  community  of  from  one  hun- 
dred to  five  hundred,  many  cases  of  uterine  or 
pelvic  disease?  Is  it  not  true  that  in  a  commun- 
ity of  five  hundred  sick  women,  sick  mentally 
often  because  of  bodily  infirmity,  that  the  state- 
ment should  be  doubly  true  ?  This  statement  is 
made  ex  cathedra.  But  taking  the  words  of  va- 
rious alienists,  besides  the  proof  offered  by  the 
gynecologists,  there  is  a  place  for  gynecology 
right  here.  We  wish  to  note  in  the  beginning  of 
this  paper,  that,  as  many  are  insane  from  any 
cause  influencing  and  reducing  the  standard  of 
health,  the  appropriate  treatment  of  the  special 
organ  involved  may  have  as  good  proportionate 
result,  in  the  insane  as  in  the  sane.  It  is  not 
necessary  to  question  the  ability  of  a  specialist  to 
detect  disease  in  his  department,  however  much 
difference  there  may  be  as  to  treatment.  Taking 
these  suggestions  as  a  basis  for  investigating  the 
question  at  issue,  let  us  see  what  the  alienists 
have  to  say  first.  Bucknill  and  Luke  recognize 
ovarian  insanity,  and  say  such  form  is  commonly 
associated  with  ovarian  and  sometimes  uterine 
diseases.  Dr.  Bucknill  says:  "There  can  be  no 
doubt  that  uterine  disorders  constitute  one  of  the 
most  frequent  remote  causes  of  insanity  with 
which  we  are  acquainted.  If,  therefore,  the  phy- 
sician can  ascertain  that  his  patient  has  suffered 
or  is  suffering  from  gastric,  hepatic,  intestinal  or 
uterine  disease,  he  will  have  discovered  a  well 
known  and  frequent  cause,  the  existence  of  which 
must  be  allowed  to  exercise  its  influence  in  the 
diagnosis."  Mandsley  says:  I  saw  melancholia 
of  two  years  disappear  after  cure  of  prolapsus 
uteri,  also  another  cure  after  relief  of  inversio  uteri. 


Griesenger  reports  two  cures  from  hysterical  in- 
sanity by  local  treatment,  after  failure  of  all  other 
measures.  These  cases  of  inversion  and  prolap- 
sas  uteri  I  believe  to  produce  insanity  by  the 
consequent  effect  upon  the  ovaries. 

Dr.  Mayer  of  Berlin  reports  numerous  illustra- 
tive cases. ' 

Esquirol  says:  "Menstrual  anomalies  make  up 
a  sixth  part  of  all  the  causes  of  insanity.  In  6000 
cases,  18.97  Per  cent,  without  and  81.03  percent, 
with  menstrual  irregularities."  Schroder  Yan- 
derkolk  reports  a  case  of  melancholia  from  pro- 
lapsus uteri,  promptly  cured  by  replacement. 
Boyer  relates  a  case  of  a  woman  insane  during  her 
first  pregnancy.  Ten  years  later,  her  mental 
alienation  having  returned  it  was  thought  she 
was  again  pregnant.  Examination  revealed 
uterine  polypus,  the  removal  of  which  cured  her 
at  once.  Schlager  says  "  in  67  of  100  cas*es  of  ir- 
regular menstruation  in  insane  women,  there  were 
present  the  various  minor  disturbances  so  often 
observed.  In  the  remaining  33  there  were  un- 
doubtedly traces  of  actual  disease.  Insane  per- 
sons who  were  quiet  and  gentle  during  the  inter- 
val, fell  into  maniacal  raving  during  the  men- 
strual flow,  not  infrequently  of  an  erotic  charac- 
ter." H.  R.  Storer2  says  of  "  probable  causes  of 
derangement  in  New  York  State  Insane  Asylum 
Report  for  1852,  in  366  cases  of  insanity  occur- 
iug  in  both  sexes,  in  87  or  nearly  one-fourth  the 
whole  number,  are  reported  to  have  arisen  from 
causes  directly  connected  with  the  reproductive 
system.  Same  report  for  1853  shows  JI7  cases 
out  of  424  cases, or  more  than  one-fourth  the  whole 
number."  Of  the  many  gynecologists  who  are 
on  record  as  favoring  the  affirmative  of  this  ques- 
tion, in  the  front  rank  stands  Dr.  Robt.  Barnes,  of 
London,  whose  admirable  study  of  the  "  Corela- 
tion  of  the  Sexual  Functions"  and  Menstrual  Dis- 
orders of  Women, "3should  be  read  by  every  alien- 
ist and  gynecologist.  His  exhaustive  paper  de- 
serves far  more  than  mention  in  this  brief  paper, 
as  arrayed  in  favor  of  giving  every  insane  woman 
as  much  right  to  relief  from  disease  of  the  ovaries 
and  uterus  as  her  sane  sister  has. 

Dr.  Thos.  Savage,  in  his  address  of  1890,  de- 
livered in  the  Section  of  Obstetrics  branch  of  the 
British  Medical  Association,  speaking  of  "  Gyne- 
cology in  its  relation  to  Insanity,"  gives  us  no 
uncertain  sound  as  to  his  opinion.  "There  is 
one  more  point  I  should  like  -to  refer  to,  and 
that  is  the  necessity  or  otherwise  that  exists  for 
most  and  certainly  all  large  lunatic  asylums,  to 
have  a  gynecologist  as  a  member  of  their  medi- 
cal staff.  Among  the  causes  of  insanity  in  women, 
heredity,  intemperance  and  the  vicissitudes  of  fe- 
male life  are  said  to  be  the  most  frequent,  and  it 
has  long  occurred   to  me,  as  I  know  it  has  to 

v.  rhandlungen  .ler  Gesellsch.  Fur  Gehurtsli.  1869. 

1  nsanity  in  Women. 

Brit,  1.  vii    Jnir.,  .Nov.  1S90. 


i89i.] 


GYNECOLOGIST  AND  ALIENIST. 


871 


Others,  that  in  regard  to  the  latter  element  as  a 
cause,  much  good  might  result,  if  everj  1 
which  there  was  the  least  doubt  were  thoroughly 
overhauled  and  investigated  by  an  experienced 
gynecologist.  Everyone  knows  that  occasional- 
ly, although  rarely,  a  case  of  insanity  has  been 
cured  by  the  application  of  a  properly  adjusted 
pessary  to  a  displaced  uterus.  Then  in  regard  to 
the  influence  upon  the  mental  state  which  is  pro- 
duced by  the  presence  or  absence  of  the  ovaries, 
little  is  known.  Observation  on  this  point  has 
not  been  sufficiently  extended  or  pursued.  In 
500  double  oophorectomies  four  cases  of  insanity; 
three  cured;  one  suicide.  I  have  never  seen  in- 
sanity follow  removal  of  one  ovary  or  any  other 
pelvic  operation.  The  insanity  of  the  climacteric 
period,  and  of  the  puerperal  period,  may  or 
may  not  be  dependent  upon  some  occult  in- 
fluence seated  in  the  ovaries,  the  exact  nature 
of  which,  if  or  where  it  exists,  has  yet  to  be 
investigated."  Dr.  Goodell's  work  in  rescu- 
ing women  from  insanity  is  well  known.  He  as- 
serts that  oophorectomy  may  be  relied  upon  gen- 
erally to  cure  insanity  limited  to  the  .menstrual 
period,  and  urges  early  operation  in  ovarian  in- 
sanity. * 

Dr.  Betty  has  cured  numerous  cases  of  insanity 
by  his  operation.  Dr.  Reed,  our  honored  chair- 
man, has  reported  six  cases  of  insanit}-  cured  by 
such  operations  as  oophorectomy, ovariotomy  and 
uterine  diltation.  Dr.  Mauton5  reports  a  case  of 
ovarian  tumor  with  insanity  greatly  relieved  by 
operation.  Dr.  C.  N.  Hay.  of  New  Jersey  (an 
alienist),  reports  a  case  of  insanity  cured  by  re- 
moval of  an  ovarian  abscess.  °  Dr.  Kitto,  of  Ra- 
cine, Wis.,  a  case  of  long  standing  (13  years)  in- 
sanity cured  by  salpingo  oophorectomy.  The  pa- 
tient had  pyosalpinx.  Time  too  recent  for  defi- 
nite result.  Dr.  J.  B.  Cummins,  of  Arkansas,  an- 
other case  with  suicidal  and  homicidal  tendency 
cured  in  seven  months  by  oophorectomy.  Im- 
mediate relief;  ovaries  were  enlarged;  adherent; 
subinvolution  of  uterus.7  Dr.  Cotterell  reports  a 
case  of  menstrual  insanity,  melancholia,  of  iS 
years  standing,  cured  by  removal  of  small  but 
painful  ovaries. 

Dr.  O.  G.  Pfaff  reports  a  case  of  insanity  cured 
by  removal  of  double  pyosalpinx.  Patient  re- 
turned to  her  home  in  a  month  and  continued  to 
improve  until  cured.9 

The  writer  has  cognizance  of  three  operations 
done  indirectly  for  the  mental  condition.  One 
ovariotomy  a  cure,  one  oophorectomy  a  cure,  and 
one  in  which  oophorectomy  was  followed  by  sui- 
cide in  about  six  months,  owing  to  persistent  in- 
somnia. Many  additional  cases  may  be  men- 
tioned, but  these  should  suffice  to  prove  thatgyn- 


4  Medical  New?,  May  17.  1S90. 

i  American  Journal  Obstetrics.  Vol.  ii,  1S89. 

6  Medical  Record,  Xew  York.  November  15,  1S90. 

Memphis  Journal  Medical  Science. 
8  Maryland  Medical  Journal,  from  Lancet,  February  28,1891. 


;-.  do  frequently  encounter  and  relieve 
this  dread  disease  among  women.   We  claim  that 

try  more  pelvic  causes  of  insanity  exist 
than  are  found,  owing  to  the  difficulty  of  mak- 
ing a  diagnosis  in  these  cases.  No  fact  is  better 
understood  than  that  any  disease  of  the  abdomi- 
nal organs  may  favor  insanity  even  by  interfer- 
ence with  nutrition  alone.  How  much  more 
does  it  seem  probable  that  disease  of  the  organs 
peculiar  to  women,  which  so  much  more  than  the 
corresponding  organs  in  men,  have  to  do  with 
her  physical  and  mental  condition,  may  cause 
psychical  derangement.  It  is  unfortunate  that 
in  the  past  some  misdirected  efforts  to  secure 
gynecological  supervision  and  treatment  in  asy- 
lums caused  a  general  indisposition  on  the  part 
of  alienists  to  accord  the  gynecologist  a  place  in 
cooperation  with  them.  There  was  said  to  have 
been  too  keen  a  desire  to  try  oophorectomy  as  a 
panacea  for  all  kinds  of  insanity  in  women. 
There  was  also  an  effort  made  to  introduce  fe- 
male physicians  upon  this  tide  of  so-called  neces- 
sity, and  thus  were  blended  disadvantageously 
questions  of  public  policy,  or  expediency,  with 
what  should  have  been  scientific  inquiry.  Dr. 
Spitzka's  contemptuous  allusion  to  gynecologists 
shows  the  animus  of  his  disbelief  in  any  cause 
for  insanity  outside  the  cranium.  Although  he 
readily  (elsewhere)  admits  that  insanity  is  inten- 
sified by  pelvic  disorders.  He  refers  to  one  case 
of  ill-advised  oophorectomy  by  way  of  enforcing 
his  criticism,  and  in  general  denies  the  claims 
urged  by  the  gynecologist.  Dr.  Reed  has  point- 
edly suggested  some  improvement  in  asylum 
management.  Especial  reference  is  made  to  in- 
adequacy of  the  medical  staff  in  view  of  amount 
of  work  required.  To  this  I  add  my  endorsement, 
and  respectfully  suggest  that  the  number  of  phy- 
sicians is  generally  much  less  in  asylums  than  in 
regular  hospitals.  The  reverse  should  be  the 
rule.  There  is  also  much  difficulty  in  ascertain- 
ing how  much  care  is  taken  when  patients  are  ad- 
mitted, to  examine  the  pelvic  organs  for  disease. 
I  learn  that  in  some  asylums  this  is  carefully 
done,  as  for  instance  in  Harrisburg  and  Norris- 
town,  Pa.,  hospitals.  Is  it  asking  too  much  that 
in  any  doubtful  case  a  specialist  be  called  to  as- 
sist in  the  investigation  ?  Some  asylum  reports 
show  excellent  work  done  in  the  pathological 
department.1 

But  we  do  feel  some  regret  that  a  full  and  com- 
plete history  of  the  post-mortem  appearances  of 
all  the  organs  of  the  body  is  not  forthcoming 
from  the  pathological  department  of  our  various 
asylums,  in  order  that  comparisons  may  be  made 
with  a  view  to  distinguish  the  effect  of  insanity 
upon  the  various  organs,   as  well   as  to   observe 


iris  Weekly  Medical  Record.  October  11,  1S90. 
-  is  especially  true  of  one  asylum.  St.  Elizabeth.  Washing- 
ton. D.  C.  although  inquiry  was  made  with  special  reference  to 
epileptic  and  dementia  cases. 


872 


GYNECOLOGIST  AND  ALIENIST. 


[June  20, 


the  possible  relation  of  their  disease  to  the  men- 
tal condition.  This  paper  would  not  be  complete 
without  a  remark  about  the  propriety  of  urging 
examinations  and  especially  surgical  procedures 
upon  the  insane.  Sir  Spencer  Wells  was  once 
consulted  as  to  legality  of  operating  upon  a  lun- 
atic, and  he  referred  the  question  to  Sir  William 
Harcourt,  the  Home  Secretary,  who  replied,  "If 
she  is  incapable  of  judging  for  herself  treat  her  as 
an  infant."  In  the  case  in  question  the  operation 
was  done  and  the  patient  recovered  her  reason, 
and  she  was  afterwards  married. 

The  following  circular  letter  was  sent  to  twenty 
of  our  representative  asylums,  generally  address- 
ed to  the  superintendent   or  physician  in  charge. 

Dear  Doctor:  Will  you  kindly  answer  the  following 
questious,  to  be  embodied  in  a  paper  which  I  am  prepar- 
ing for  the  approaching  meeting  of  the  American  Medi- 
cal Association. 

1st.  Have  you  a  gynecologist  on  your  staff  of  physi- 
cians or  connected  with  your  institution? 

2d.  Do  you  have  any  apparent  need  for  such  treat- 
ment, and  do  you  find  any  cases  of  insanity  due  to  dis- 
ease of  the  pelvic  organs  of  women? 

An  immediate  answer  will  be  highly  appreciated. 

Boston  Lunatic  Hospital. — "  We  have  no  gyne- 
cologist. 

Very  little  need  for  gynecological  treatment. 
Very  few  cases  of  insanity  due  to  disease  of  pel- 
vic disease  in  women." 

\Vo)ccstcr  Lunatic  Hospital. — "In  an  experi- 
ence of  nearly  twenty  years  I  have  failed  to  see 
any  case  of  insanity  due  to  disease  of  pelvic  or- 
gans of  women.  The  female  member  of  the 
staff  (appointed  under  the  law  of  Moss),  does  not 
find  any  notable  amount  of  gynecological  work 
to  do." 

The  female  attendant  writes  thus:  "  As  I  have 
held  the  position  of  gynecologist  in  this  institu- 
tion for  some  years,  the  superintendent  has 
asked  me  to  reply  to  your  questions,  which  I 
am  pleased  to  do,  as  follows:  There  is  a  resi- 
dent gynecologist  on  the  staff  of  the  hospital. 
There  is  undoubtedly  need  for  such  treatment, 
and  while  I  am  not  convinced  that  uterine  dis- 
ease is  often  the  sole  cause  of  insanity,  yet  I  think 
it  is  frequently  one  of  the  factors,  the  remedying 
of  which  assists  greatly  in  the  recovery  of  the 
patient." 

Danvers  Lunatic  Hospital.  —  "Your  letter  re- 
ceived  I  wish  to  add  that  the  prac- 
tice in  Massachusetts  of  having  a  woman  doctor 
in  each  Insane  hospital  meets  my  hearty  ap- 
proval." 

The  gynecologist  of  this  institution  at  the  re- 
qm  t  of  the  superintendent,  writes  thus:  "Al- 
though examination  is  made  of  all  new  cases,  few 
L  >n^  foi  surgical  work, 

There  are  often  cases  which  could  be  relieved 

otnfort  by  operative  treatment,   but  it    is 

not  attempted,  owing  to  expense  and  subsequent 

care,  which  would   be  difficult  in  pauper  class. 


It  is  not  evident  that  many  cases  of  mental  dis- 
turbance are  due  to  uterine  lesions.  That  the 
functional  activity  of  the  uterine  system  has  a 
close  inter-relation  with  psycho- pathological 
states  is  patent  to  the  least  experienced  psychiat- 
rist. That  a  wise,  legitimate  activity,  in  gyne- 
cology, (not  a  wholesale  use  of  invalids  to  swell 
the  records  of  the  tyros)  is  called  for,  the  constant 
questioning  of  the  last  decade  from  every  quarter 
renders  apparent.  There  also  seems  needed  full 
sustained  authority,  and  complete  provision,  in 
order  to  overcome  the  well-known  difficulties 
clue  to  the  mental  status  of  the  patients.  This 
implies  expense  and  attention,  which  the  hospi- 
tals of  to-day  are  not  prepared  to  give." 

Westborough  Insane  Hospital,  Mass.: — "We 
have  a  female  physician  on  staff  as  required  by 
law  of  Massachusetts.  She  has  every  day  some 
cases  under  treatment,  out  of  nearly  three  hun- 
dred women.  There  are  always  some  that  are 
benefited  by  her  care.  Treatment  is  useful  and 
comforting,  rather  than  curative.  Cases  of  in- 
sanity due  to  pelvic  disease  rare." 

Taunton  Lunatic  Hospital: — "  Have  a  gynecol- 
ogist, sometimes  find  cases  of  insanity  in  women 
due  to  disease  of  the  pelvic  organs  but  they  are 
quite  infrequent." 

McLean  Asylum,  Mass.: — "One  member  of  staff 
has  had  gynecological  training.  No  greater  need 
for  gynecological  work  in  insane  than  in  same 
number  of  sane  women.  A  specialist  in  this  de- 
partment called  when  required." 

Warren^  Pcnn ..  State  Hospital  for  the  Insane: — 
"No  gynecologist;  not  cases  enough  to  justify 
such  an  appointment.  Agrees  with  Dr.  Goodell 
that  the  large  majority  of  uterine  troubles  are 
nervous,  requiring  little  or  no  operative  interfer- 
ence. Very  few  cases  of  insanity  arise  from 
uterine  troubles  simply." 

Pennsylvania  Hospital  for  Insane,  Harrislnirg : 
— "  We  have  two  female  physicians  who  do  con- 
siderable gynecological  work." 

The  physician  in  charge  of  female  department 
writes  thus:  "  I  think  there  are  some  cases  of  in- 
sanity which  are  apparently  referable  to  pelvic 
disease,  and  man}-  more  complicated  and  intensi- 
fied by  such  troubles.  Many  of  our  patients  are 
drawn  from  a  class  of  people  who  from  ignorance 
or  neglect,  have  often  not  had  proper  attention 
during  or  after  confinement,  and  suffer  from  the 
ills  consequent  upon  neglect,  privation,  or  over- 
work. Some  of  our  puerperal  cases  furnish  the 
best  illustration  of  the  need  of  gynecological 
treatment  and  the  benefit  resulting  from  it.  We 
always  have  a  large  number  of  patients  here  un- 
der treatment  and  find  that  they  are  always  more 
01  less  improved  by  relief  from  suffering  of  that 


Dr.  Go  111  rally  thus  misun- 

d   rs(  >..,]      Would  ii  not   l»    bi  w<  r  to  sa;  ti  riue  trou- 

bles."   Tli.  of  uterine  disease"  an    generally  yyellun- 

j    ecologists,  who  perl 


ilh  Dl    I !•  11. 

I 


i89i.] 


GYNECOLOGIST  AND  ALIENIST. 


873 


sort.  From  my  experience  I  am  decidedly  of  the 
opinion  that  there  is  room,  yes,  necessity  for  the 
work  of  the  gynecologist  anion-  insane  women. 
.  .  W'e  know  the  frequency  of  pelvic  dis- 
orders among  more  fortunate  people,  and  it  fol- 
lows that  among  this  class  such  diseases  will  he 
found  in  greater  proportion  than  in  the  general 
population." 

Pennsylvania  Hospital  for  Insane.  Philadelphia: 
— "We  have  a  female  consulting  gynecologist. 
Non-resident.  Examinations  for  suspected  preg- 
nancy or  pelvic  disease.  Insanity  due  to  disease 
of  pelvic  organs  extremely  rare.  I  will  not 
say  they  never  occur,  as  some  are  of  the 
opinion  they  do  occur.  Examinations  have  a  neg- 
ative value." 

Philadelphia  Hospital  for  Insane:— Blockley. 
"  No  gynecologist  on  staff.  Cases  now  and  then 
admitted  who  need  treatment  of  their  pelvic  or- 
gans, but  such  cases  are  rare.  Have  seen  no 
cases  of  insanity  due  to  disease  of  pelvic  organs." 
Friends  Asylum,  Frankford,  Pa.:— "Have  a 
non-resident  gynecologist.  No  more  need  of 
gynecological  treatment  than  in  any  hospital 
where  same  number  of  women  are  congregated. 
Never  saw  a  case  of  insanity  in  which  I  could 
say  it  was  entirely  due  to  diseased  condition  of 
the  pelvic  organs'  Such  disease  of  pelvic  organs 
often  complicated  with  nervous  disorders  which 
have  ultimate  relation  with  mental  condition  and 
may  be  improved  by  treatment." 

State  Hospital,  Norristown,  Pa..— Physician  in 
charge   of  female  department  sa3's:   "I    do  not 
know  of  any  hospital  where  there  is  a  gynecolo- 
gist proper.     Po  not  see  why  the  regular  attend- 
ants should  not  do  such  work.     My  impression 
is  that  but  little  is  done.     Hospitals  as   a   rule 
overcrowded;  often  the  number  of  physicians  too 
small,  and  so  far  as  I  know  anything  about  it. 
physical   examinations  even  in   some  reputable 
hospitals  are  not  made  at  all.     The  questions  im- 
plied in  the  title  of  your  paper  must  be  answered 
affirmatively,  irrespective  of  what  has  or  has  not 
been  done.  '  It  is  a  question  of  what  ought  to  be 
done,  and  I  think  we   shall  never,  know  much 
about  insanity  until  underlying  bodily  conditions 
are  more  carefully  studied.     Here  every  patient 
is  examined  upon  admission;  not  many  cases  due 
entirelv  to  disease  of  generative  organs.     An  oc- 
casional  case     is   positively   benefited  by   such 
treatment.     In  a  very  large  number  of  cases  the 
local  trouble  is  one  of  many  depressing  causes  and 
■we  believe  that  appropriate  treatment' aids  often." 
Pennsylvania  Hospital  for  the  Insane,  Danville: 
—"We  have  no  gynecologist.     There   is   same 
need  for  a  gynecologist  as  for  an  occulist,  or  sur- 
geon, and  no  more.     Cases   do   occur  where    a 
gynecologist     on   staff    would    be     of    service. 
Cases   occur   showing   marked   sexual  derange- 
ment as  far  as  their  history  and  conduct  indicate, 
nothing  found  on  examination,  and  they  recover 


under  other  than  gynecological  treatment.  I  be- 
vnecological  treatment  would  be  of  disad- 
vantage in  some  cases.  Disease  of  pelvic  organs, 
as  of  any  other  organs  of  body,  such  as  heart,  etc. , 
may  be  a  factor  in  the  causation  of  insanity,  but 
uterine  disease  is  not  likely  more  frequently  a 
cause  than  disease  of  other  organs." 

/  rtica,  New  York,  State  Hospital.—" There  is  no 
gynecologist  on  the  staff.-  Thus  far  no  need  lor 
one.  Very  few  cases  of  insanity  directly  tracea- 
ble to  disease  of  pelvic  organs  of  women  " 

Binghatnton,  Xeze  York  State.  Hospital: —  We 
have  a  female  physician  who  looks  alter  gym 
logical  cases.  We  doubt  not  that  in  certain  cases 
treatment  of  this  character  is  desirable,  and  bene- 
ficial Of  course  there  are  cases  of  insanity  more 
'  or  less  intimately  connected  with  diseases  of  pel- 
vic organs  in  women." 

Anna,  III.,  State  Hospital  for  Insane:—  We 
have  no  gynecologist  on  our  staff.  The  physi- 
cian in  charge  of  female  department  attends  all 
diseases  pertaining  to  the  female  organs,  that 
come  into  the  hospital,  and  there  are  a  good  many 
in  the  course  of  the  year.  There  are  a  few  cases 
where  insanity  appears  to  be  brought  about 
through  reflex  influence  of  the  nervous  system 
as  there  are  no  other  marked  or  well  founded 
causes  known,  and  under  treatment  for  this  mor- 
bid condition  of  the  genital  organs,  many  im- 
prove." ... 

Illinois  Eastern  Hospital  for  the  Insane:—  \\  e 
have  female  gynecologist.  There  are  many  pa- 
tients who  need  and  are  benefited  by  such  treat-  _ 
ment.  I  have  not  seen  any  cases  however,  in 
which  I  attributed  the  insanity  exclusively  to 
disease  of  the  pelvic  organs 

Illinois  Central  Hospital.— "We  have  no  spe- 
cial gynecologist;  nevertheless  much  gynecolog- 
ical work  is  done.  . 

We  think  there  is  great  need  of  gynecological 
treatment  and  for  the  same  reasons  that  it  would 
be  needed  outside  of  a  hospital  for  the  insane.  I 
presume  pelvic  disease  does  to  some  extent,  exert 
an  influence  upon  the  mind  through  the  nervous 
system."  . 

'  The  answers  above  quoted  are  as  briefly  given 
as  possible,  and  although  received  after  the  body 
of  the  paper  was  written,  show  that  some  of  the 
conclusions  were  correctly  drawn.  It  will  be 
plainly  observed  that  the  majority  do  not  agree  that 
insanity  is  often  caused  by  pelvic  disease.  On  the 
other  hand  very  many  admit  that  gynecological 
treatment  is  important  as  assisting  in  the  cure. 
One  verv  marked  and  positive  conclusion  is  drawn 
from  this  paper,  that  the  gynecologist  can  aid  the 
alienist,  as  shown  by  the  very  positive  statements 
of  those  who  have  the  actual  work  of  caring  for 
those  unfortunates.  In  conclusion,  I  must  again 
call  attention  to  Dr.  Barnes'  valuable  paper  and 
also  give  him  credit  for  much  information  embod- 
ied in  this  article. 


S74 


PAPILLOMATOUS  CYSTOMA  OF  THE  OVARY. 


[June  20, 


PAPILLOMATOUS  CYSTOMA  OF  THE 

OVARY,   WITH  REPORT  OF  A 

CASE. 

f Obstetrics  and  Diseases  of  Women  attheForiv 

*       ■  >         •       4    7f  2;/' 

at  Washington,  D.  C,  May,  ,-.,/. 
BY  A.    E.   WALKER,  M.D., 

OF  CANTON,    O. 

Papillary  cysts  of  the  ovary  are  quite  rare  com- 
pared to  other  varieties  of  ovarian  cysts      They 
are  composed  of  small  cysts,  inultilocular'in  form 
The  smaller  cysts   are  usually  irregular  in  size' 
and  have  villous  growths  and   papillarv  vegeta- 
tions   attached  to  the  inner   surface  of'the°cvst 
wall      Papilhform  growths  are  frequently  found 
on  the  outer  surface  of  the  cyst.     The  fluid  con- 
tents of  these  cysts  vary  in   color  from   a  li^ht 
straw  to  a  dark  wine  color.     These  cysts  mav&be 
birS      the  Slandular  and  Papillary  types  com- 
These   papillary  cystoma    of  the    ovarv    as  a 
rule,  are   claimed  to  take  their   origin  from  the 
traces  left  of  the  Wolffian  tubules  in  the  hilum 
of  the   ovary,   and,   as   with    all    other  growths 
grow  in  the  direction  where  there  is  the  least  re- 
si  tance,  which  in  this  case  would  be  between  the 
io.ds  of  the  broad  ligament  instead  of  in  the  stro- 
ma of  the  ovary.     They  may  grow  to  be  quite 
large,  filling  the  pelvic  cavity,  and  if  unilateral 
the  uLerus  will  be  pushed  to  one  side,  while  if  bi- 
lateral, the  uterus  will  be  completely  hidden  from 
view ;  or  they  may  push  their  way  up  into  the 
•   abdominal  cavity,  either  single  or  double   at  the 
expense  of  the  anterior  or  posterior  portion    of 
the  broad  ligament,  and  still  be  extraperitoneal 
growing  in  front,  behind  or  between  the  folds  of 
the  peritoneum.     They  may,  very  earlv  in  their 
growth,  break  through  into  the  peritoneal  cavity 
and  become  intraperitoneal,  growing  then  anion* 
the  intestines  and  other  abdominal  organs,  or  they 
may  take  their  origin  primarily  from  the  intra- 
peritoneal surface  of  the  ovary  and  start  as  an- 
other ovarian  cystic  tumor,  either  direct  from  a 
Oraafian  follicle,  or  from  a  dropsical  follicle  •  but 
why  these  cysts  should  take  on  the  papillarv  form 
is  as  yet  unknown  to  pathologists.     It  was  for- 
merly thought  that  papillomata  were  only  to  be 
found  where  papillae  were  found,  as  the  skin   mu-  ! 
cous  membrane  and  the  like  ;  but  that  view  was 
soon    changed    and  we  now  find  that  papilloma 
may  develop  from  any  epithelial  surface      It  is  ! 
rare,  however,  to  find  them   taking  their'  origin 
serous  surface.     As  condylomata  and  vil- 
lous growths,  tumors  of  the  variety  of  papilloma 
arc    caused  by  erosive    fluids  or  irritant  matter 
When  they  are   found  on  the  genital  organs    whv 
not  attribute  the  origin  of  papillarv  cystoma  of  the 
intraperitoneal  surface  of  the  ovary  to  the  same 
cause,  winch  ,n  this  case  the  irritant  matter  may 
escape  from  the  fimbriated  e  xtremities  of the  Fal- 
lopian tube  during  gonorrhceal  infections   pyosal- 


1  or  tubercular  pus,  or  of  other  irritating  mate- 
rials that  may  gain  admission  in  this  way 

These  papillomatous  cysts  are  very  liable  to 

rupture ;  in  fact,  a  papillomatous  growth  within 

the  cyst  greatly  increases  its  liability  to  rupture 

but  as  the  fluid  is  benign,  there  is  no  danger  from 

its  presence  either  in  or  on  the  peritoneum,  but 

alter  the  rupture  of  one  or  more  of  the  cvsts   the 

I  growths   are    very  likely  to  become  attached  to 

,  any  organ  or  organs  they  may  come  in  contact 

i  with.     This  is  true  in  particular  of  the   cauli- 

|  flower  form.     These   ovarian  papillomatous  tu- 

.  mors  are,  as  a  rule,  benign,  and  are  not  likely  to 

return  after  their  removal.     The  only  trouble  to 

1  fear  is  from  their  extensive  attachments  to  the 

abdominal  organs,  which  may  be  so  great  as  to 

preclude  their  removal,  for  they  are  quite  brittle 

and  vascular.     In  cases  reported  where  all  of  the 

growths  could  not  be  removed,  the  portion  left 

was   seemingly  absorbed.     It  caused  no  further 

trouble,    at   least,    and    the   patients    recovered 

These   tumors,  like  other   cystic  tumors  of  the 

ovary,  should  be  promptly  removed. 

vrTh*/°iIO??ng  CaSe  came  uPin   my  practice: 
Mrs   Al,  R.  H.,  a  bright  and  intelligent  woman 
aged  44  years,  married,  wife  of  a  farmer,  mother  of 
three  children,  family  history  good,  enjoyed  fair 
health  until  birth  of  first  child  twentv-four  years 
;  ago,  after  which  time  she  complained  of  distress 
I  and  pain  through  uterus  and  ovaries.  After  having: 
;  an  attack  of  typhoid  fever  eight  years  since,  su* 
ered  from  pain  across  lower  part  of  bowels  and 
through  her  back.    About  this  time  she  noticed 
uterus  to  be  retroflected  and,  as  her  condition  con- 
tinued to  grow  worse,  she  consulted  a  physician 
two  years  later,  who,  after  examination,  claimed 
that  her  cervix  was  lacerated  and  was  the  cause  of 
all  the  trouble,  and  recommended  an  operation 
Six  months  later  another  physician  was  consulted" 
and  claimed  all  her  trouble  came  from  endo-cervi- 
citis,  and  gave  several  treatments  for  same,  without 
any  improvement  whatever.     Three  years  ago  a 
third  physician  diagnosed  a  small  tu'mor  in  left 
side,   and  recommended  an  operation,  but  there 
being  such  a  difference  of  opinion,  the  fourth  phy- 
sician was  consulted,  who  claimed  that  she  had'a 
fibroid  tumor,  and  advised  that  it  be  let  alone    He 
beingan  aged  man.a  physician  of  much  experience 
hisadvicewastakenuntillastNovember,  when  she 
became  so  miserable  and  increased  in  size  that  she 
finally,  through  the  advice  of  friends,  went  to  a 
hospital  in  Ann  Arbor,  Mich.,  where  she  remain- 
ed nve  weeks  for  treatment,  which  consisted  of 
two  examinations  before  a  class  of  students  and 
very  free  purgation,  with  no  relief.     The  opinion 
01  the  physicians  there  was,  that  she  had  a  ma- 
lignant tumor  or  growth  connected  with  the  liver 
probably  cancerous,  and  that  her  case  was  not 
one  for  an  operation. 

About  January,  1S00,  she  noticed  herself  be- 
coming larger,  and  that  she  was  losing  in  flesh. 


i89i.] 


PREVENTION  OF  PUERPERAL  ECLAMPSIA. 


87 


The  1  st  of  February,  1S91,  I  was  called  to  visit 
her,  when  I  found  her  very  thin  and  emaciated, 
with  a  very  large  abdomen.  The  enlargement 
was  marked  and  resembled  ascites.  She  was  suf- 
fering with  procidentia.  The  whole  of  her  uterus 
and  posterior  cul-de-sac  protruding,  the  mass  to- 
gether being  as  large  as  a  fatal  head.  She  stated 
that  this  mass  had  been  out  and  enlarging  sjuce 
before  her  visit  to  the  hospital,  and  that  no  at- 
tempt had  been  made  to  replace  it.  The  free 
purgation  she  was  subjected  to  there  made  it 
much  worse.  Two  abrasions  the  size  of  a  silver 
half-dollar  were  on  the  posterior  part  of  this  mass. 
She  was  simply  ekeing  out  a  miserable  existence, 
growing  larger  daily  at  the  expense  of  her  flesh 
and  strength.  I  replaced  the  mass  in  about  two 
minutes  by  placing  her  in  the  genito-pectoral  po- 
sition, and  had  it  retained  in  place  with  a  large 
cotton  ball  covered  with  vaseline  in  vagina,  and 
a  T  bandage.  But  little  time  was  spent  in  mak- 
ing a  further  examination,  as  I  had  learned  from 
past  experience  that  a  positive  diagnosis  could 
not  be  made,  in  particular  where  the  abdomen 
contained  so  much  fluid.  Felt  satisfied,  how- 
ever, that  the  trouble  originated  with  the  uterine 
organs,  and  that  it  was  in  no  way  connected  with 
the  liver.  After  an  examination  of  her  heart, 
lungs,  urine,  etc.,  decided  to  make  an  explora- 
tory incision,  and  remove,  if  possible,  the  cause 
of  her  trouble.  After  a  thorough  preparation  of 
the  patient,  I  opened  her  abdomen  on  the  12th  of 
February  last,  assisted  by  Dr.  E.  O.  Morrow,  of 
Canton,  O.,  and  Dr.  G.  E.  Hambleton,  of  Louis- 
ville, O.  The  abdominal  wall  was  very  thin,  a 
marked  absence  of  adipose  tissue.  When  the 
peritoneum  was  opened  about  three  gallons  of  as- 
citic fluid  were  removed,  which  was  of  straw  color, 
which  then  enabled  us  to  get  at  the  real  cause, 
which  proved  to  be  a  large  papillomatous  tumor 
of  the  left  ovary,  attached  to  the  ovary,  Fallopian 
tube  and  broad  ligament.  With  but  little  diffi- 
culty we  succeeded  in  grasping  the  Fallopian 
tube  and  broad  ligament  close  to  the  cornua  of 
the  uterus  with  a  large  ovarian  forcep.  where. 
with  a  knife,  the  growth,  weighing  3^  lbs.,  was 
removed.  The  pedicle  being  quite  broad,  was 
first  transfixed,  then  tied  with  a  Xo.  12  braided, 
iron-dyed,  silk  ligature.  The  abdomen  was  then 
thoroughly  cleansed  with  warm  distilled  water, 
and  closed  with  No.  8  iron-dyed  sutures.  The 
operation  was  aseptic  in  every  particular,  and 
lasted  three-quarters  of  an  hour.  The  patient 
rallied  well,  and  seemed  to  experience  but  little 
shock.  Ether  was  administered,  its  administra- 
tion preceded  by  a  hypodermic  injection  of  mor- 
phia '4  gr.,  and  atrqpia  yi-j  gr.,  and  an  ounce  of 
brandy  internally.  Next  day  after  operation, 
13th  of  February,  10  a.m.,  pulse  124,  tempera- 
ture 100.20.  The  14th  01  February,  10  a.m., 
pulse  130,  temperature  990,  very  weak,  vomited 
for  the  first-time,  stomach  would  not  tolerate  any 


food  or  milk,  when  we  were  necessitated  to  give 
rectal  injections  of  beef  Juice,  eggs,  peptonized 
milk  and  brandy  to  sustain  life. 

February  15,  patient  much  better  and  stronger, 
pulse  100,  temperature  99.4,  some  disturbance  of 
bowels  during  the  evening,  which  was  promptly 
removed  with  enema  of  hot  water  and  the  passage 
of  a  long  rectal  tube. 

February  16,  pulse  92,  temperature  100. 20, 
strength  returning.  A  discharge  of  blood  from 
uterus  noticed,  which  continued  thirteen  hours. 

February  18,  10  a.m.,  pulse  84,  temperature 
99. 50,  still  gaining  in  strength. 

February  19.  10  a.m.,  pulse  88,  temperature 
100.  Wound  dressed  for  the  first  time,  which 
looked  well.  Union  by  first  intention.  Every 
other  suture  was  removed.     The  20th,  no  report. 

February  21.    10  a.m.,  pulse  80,   temperature 

99-4°- 

February  22,  10  a.m.,  removed  the  remaining 
sutures.     Pulse  84,  temperature  99. 40. 

Februarv  23,  10  a.m.,  pulse  84.  temperature 
98.60. 

February  24.  10  a.m.,  pulse  80,  temperature 
99-2°. 

February  25,    10  a.m.,  pulse  84,    temperature 

99°- 

She  made  a  good  recovery.  Sat  up  for  the  first 
time  on  the  twenty-first  day,  and  weighed  84  lbs. 
Her  menses  have  appeared  regularly  since.  Her 
uterus  remains  in,  but  is  drawn  over  to  the  left 
side.  She  now  weighs  105  lbs.  and  feels  better 
than  since  birth  of  her  first  child. 

A  microscopical  examination  of  this  tumor, 
made  by  Dr.  C.  H.  Evans,  of  our  city,  showed 
that  the  entire  tumor  was  composed  of  small  pa- 
pillae and  multiple  cysts. 

45  West  Tuscarawas  St. 


PREVENTION  OF  PUERPERAL  ECLAMP- 
SIA BY  THE  INDUCTION  OF  PRE- 
MATURE LABOR. 

Read  in  the  Section    of  Obstetrics   and  Diseases  of  Women  at  the 

>nd  Annual  Meeting  of  the  American  Afedical 

lion,  hetdat  Washingt  »;.  D.  C.  May,  iSor. 

BY  HEXRY  D.  FRY,  M.D., 

OF  WASHINGTON,   D.   C. 

In  February,  1S83,  I  presented  a  paper  to  the 
Washington  Obstetrical  and  Gynaecological  So- 
ciety on  the  etiology  and  prophylactic  treatment 
of  puerperal  eclampsia,  and  I  desire,  with 
your  permission,  to  quote  the  conclusions  arrived 
at  by  a  study  of  the  subject  offered  at  that  time. 

They  were  : 

1.  Albuminuria,  occurring  during  pregnancy, 
is  the  sign  of  a  pathological  change,  or  of  patho- 
logical changes,  indicative  of  a  predisposition  to 
eclampsia. 

2.  The  prophylactic  treatment  of  eclampsia, 


876 


PREVENTION  OF  PUERPERAL  ECLAMPSIA. 


[June  20 


therefore,  includes  measures  adopted  to  prevent 
the  occurrence  of  albuminuria.  These  are,  to 
improve  the  condition  of  the  blood  by  the  ad- 
ministration of  tonics,  iron,  and  a  liberal  dietary; 
and  to  relieve  the  renal  congestion  by  attention 
to  the  functions  of  the  skin  and  by  prohibiting 
the  wearing  of  tight  clothing. 

3.  The  urine  of  all  pregnant  women  should  be 
systematically  examined  for  albumen  after  the 
fifth  month  of  utero-gestation,  and  earlier  if  any 
suspicion  be  entertained  of  renal  complication. 

4.  With  the  recognition  of  the  affection  treat- 
ment should  be  directed  to  its  relief.  This  is 
divided  into  general,  dietetic,  medicinal,  and 

5.  Obstetrical.  The  latter  comprises  the  graver 
cases  of  the  disease  which  not  yielding  to  treat- 
ment, demand,  by  the  urgency  of  their  symptoms, 
prompt  operative  interference.  During  the  years 
that  have  elapsed  since  that  paper  was  written, 
I  have  carried  out  the  conclusions  above  pre- 
sented, and  have  not  had  a  single  case  of  puerperal 
eclampsia  to  occur  in  my  own  clientele.  Al- 
bumen was  found  in  the  urine  of  a  certain  pro- 
portion of  the  cases,  but  by  treatment  it  either 
disappeared  or  remained  small  in  amount  and 
gave  rise  to  little  apprehensions,  except  in  a  few 
instances.  These  few  instances  form  the  subject 
of  my  present  observations  and  bring  up  the 
question  of  operative  interference  in  the  class  of 
cases  referred  to  obstetrical  treatment.  The 
amount  of  albumen  in  the  urine  does  not  alone 
furnish  evidence  of  the  gravity  of  the  case.  Con- 
vulsions have  been  noted  when  no  albumen  ex- 
isted in  the  urine,  and  yet  post-mortem  examina- 
tion revealed  serious  organic  disease  of  the  kid- 
ney. The  total  quantity  of  urine  passed  in 
twenty- four  hours,  the  amount  of  solid  ingredi- 
ents contained,  together  with  the  symptoms  of 
the  patient,  furnish  criteria  for  action.  Serious 
toxsemic  symptoms  may  manifest  themselves 
when  only  a  trace  of  albumen  in  the  uriue  had 
produced  a  feeling  of  security. 

Examinations  of  the  urine  should  be  made 
every  few  weeks  and  oftener  if  there  be  any  in- 
dication of  renal  insufficiency.  The  specimen 
examined  should  be  taken  from  the  entire  quan- 
tity passed  in  twenty-four  hours,  this  amount 
must  be  ascertained,  and  the  specific  gravity  esti- 
mated. These  results  furnish  evidence  whether 
further  investigation  (microscopic,  etc.),  is  called 
for. 

When  serious  symptoms  develop  and  treat- 
ment has  proved  unavailing,  the  induction  of 
premature  labor  offers  the  hope  of  saving  mother 
and  child.  Fortunately  the  question  of  ending 
gestation  is  rarely  brought  up  for  consideration, 
before  the  seventh  month.  The  child  is  then 
viable  and  has  a  better  chance  of  surviving  if  born 
prematurely  than  if  allowed  to  remain  and  be 
nourished  by  the  poisoned  blood  of  the  mother. 

The  nearer  gestation  has  approached  its  normal 


duration  before  labor  begins,  the  better,  but  if 
the  symptoms  are  threatening  it  is  unwise  to  delay 
on  this  account.  Better  act  a  little  too  soon  than 
too  late. 

The  use  of  the  couveuse  increases  materially 
the  chances  of  survival  of  the  premature  or  feeble 
infant.  Out  of  829  premature  children  whose 
average  weight  was  four  and  a  half  pounds,  662 
lived,  and  recentl}'  infants  have  been  saved  by 
use  of  the  couveuse  when  only  six  months  ad- 
vanced in  intra-uterial  life.  By  the  employment 
of  artificial  feeding  or  gavage  in  combination 
with  the  couvetise,  the  viability  of  the  infant  may 
be  placed  at  six  months. 

By  these  means  Tarnier1  has  succeeded  in  sav- 
ing children  at  6  months,  30  percent.;  children 
at  7  months,  63.6  per  cent. ;  children  at  8  months. 
85.7  per  cent. 

The  following  case  recently  came  under  my 
observation  and  represents  the  advantages  of  this 
line  of  treatment. 

Mrs.  X.,  set.  30,  a  primipara,  was  placed  under 
my  care  by  Dr.  N.  S.  Lincoln,   on   November  4, 
1890.      She   had    arrived  in  Washington  a  few 
days  before  after  a  very  trying  journey  across 
the  continent.     Until  she  reached  Chicago  she 
had  entire  charge  of  an  invalid  mother,  and  bs- 
ing  compelled  to  wait  on  her  at  night  she  con- 
tracted a  cold.     When  I  saw  her  she  complained 
of   shortness  of  breath,    loss  of  voice  and  sore 
J  throat.     She  also  suffered  from  insomnia,  head- 
ache, uausea,  and  at  times  vomiting.     She  was 
anarsarcous.     Pregnancy  had   advanced    to   the 
,  seventh    month.       Foetal    movements   were  dis- 
!  tiuct,  the  heart  sounds  normal  and  situated  be- 
low and  to  left  of  the  umbilicus. 

On  the  next  day,  November  5,  a  specimen  of 
]  urine  was  obtained  and  on  examination  was 
found  to  contain  21  per  cent,  of  albumen.  The 
microscope  revealed  the  presence  of  hyaline  casts 
J  in  large  quantities.  The  patient  was  kept  in 
'bed,  a  hot  bath,  temperature  of  ioo°  given  daily 
and  flannel  worn  day  and  night.  The  bowels 
were  moved  daily  by  sulphate  of  magnesia. 
Diet  consisted  of  skimmed  milk. 

I      November  6,  24  5  urine  passed,  sp.  gr.,  1010,  albumen 
21  per  cent. 
J      November  7,  165  urine  passed,  sp.  gr.,  101S,  albumen 
19  per  cent. 

Novembers,  145  urine  passed,  sp.  gr.,  1016,  albumen 
21  per  cent. 

November  9,  175  urine  passed,  sp.  gr..  1026,  albumen 
;  31  per  cent. 

November  10,  223  urine  passed,  sp.gr.,  1018,  albumen 
]  24  per  cent. 

November  II,  24  5  urine  passed,  sp.  gr.,  1023,  albumen 
27  per  cent. 

November  12,  145  urine  passed^  sp.  gr.,  1017,  albumen 
■  iS  per  cent. 

November  13,  125  urine  passed,  sp.  gr.,  1023,  albumen 
j  27  per  cent. 

As  the  condition   of  the  patient  did  not  im- 

'  Budin  :  quoted  in  Amer.  Sys.  of  Obstet.,  Vol.  ii,  p.  201. 


i89i.] 


PREVENTION  OF  PUERPERAL  ECLAMPSIA. 


877 


prove  under  treatment,  and  the  amount  of  urine 
excreted  each  24  hours  remained  so  much  below 
normal,  I  feared  to  delay  longer.  The  short 
breathing,  which  was  particularly  distressing  at 
night,  I  attributed  to  uraemic  poisoning  of  the 
nerve  centres.  The  lungs  were  perfectly  clear. 
The  insomnia,  nausea  and  headache  were  unre- 
lieved. My  suggestion  to  induce  labor  met  with 
Dr.  Lincoln's  approval,  and  after  conferring  with 
the  husband  of  the  patient,  and  at  his  request, 
Dr.  J.  Taber  Johnson's  counsel  was  sought. 

Dr.  Johnson  saw  the  patient  with  me  on  No- 
vember 13,  and  considered  favorably  the  propri- 
ety of  inducing  labor. 

Preparations  having  been  made  already,  the 
patient  was  placed  in  position  and  the  parts  ex- 
posed with  a  Sirum's  speculum.  After  cleaning 
the  vagina  and  cervix,  with  a  carbolized  solution, 
a  bougie  was  passed  full  length  between  the 
membranes  and  uterine  walls. 

Pains  set  in  after  six  or  seven  hours  and  con- 
tinued with  varying  intensity  during  Thursday 
night.  The  head  presented  in  first  position  and 
beyond  a  slight  descent  into  the  pelvic  cavity, 
little  change  took  place  during  Friday.  The 
cervix  retained  its  full  length  and  was  dilated 
sufficiently  to  pass  the  finger  to  the  internal  os. 
Early  Friday  night  the  membranes  ruptured 
spontaneously  ;  later,  the  internal  os  dilated  and 
the  cervical  canal  became  obliterated.  The  ex- 
ternal os  dilated  irregularly ;  the  half  on  the 
right  side  remained  thick  and  undilated.  The 
left  half  became  thin  and  retracted.  The  open- 
ing, in  consequence,  was  situated  on  one  side, 
and  the  thickened  right  edge  occupied  the  mid- 
dle of  the  vaginal  passage.  At  8  o'clock  Satur- 
day morning  the  os  was  about  two  inches  in 
diameter,  and  as  I  feared  to  temporize  longer,  I 
requested  that  Dr.  Johnson  should  see  the  patient 
again. 

He  arrived  promptly,  and  after  making  an  ex- 
amination, considered  it  advisable  to  apply  the 
forceps  and  employ  it  for  the  purpose  of  dilating 
the  os.  The  patient  was  put  under  the  influence 
of  chloroform  and  the  right  blade  inserted  be- 
fore the  left.  The  blades  were  applied  in  this 
manner  because  the  adjustment  of  the  right 
blade  brought  the  displaced  os  into  the  centre  of 
the  vaginal  passage  and  facilitated  the  applica- 
tion of  the  second  branch. 

Intermittent  traction  was  made  until  the  os 
had  dilated  and  delivery  was  then  effected  with- 
out further  trouble.  The  perineum  was  un- 
injured, but  there  was  a  slight  tear,  about  one 
ihch  in  extent,  of  the  vaginal  mucous  membrane 
on  the  right  side  of  the  median  line  posteriorly. 
This  was  closed  with  a  continuous  silk  suture. 

The  infant,  a  female,  measured  eighteen  inches 
in  length  and  weighed  five  pounds  and  a  half. 
It  was  asphyxiated  at  birth,  but  soon  responded 
to  peripheral  irritation  and  cried  lustily. 


The  mother  had  a  normal  convalescence  and 
on  the  second  day  after  childbirth,  the  amount 
of  albumen  in  the  urine  had  decreased  to  8  per 
cent.  The  total  quantity  passed  each  twenty- 
four  hours  varied  from  50  to  70  ounces.  Exam- 
ination of  the  urine  made  recently  failed  to  de- 
tect any  albumen  or  casts,  and  the  mother  has 
fully  recovered  her  health. 

The  infant  was  placed  in  the  couveuse  and  the 
temperature  maintained  at  ioo°  F.  for  ten  days, 
and  then  at  900  for  three  weeks  longer.  At  the 
end  of  the  fourth  week  it  was  sufficiently  de- 
veloped to  be  removed  from  the  apparatus. 

The  mother  being  unable  to  nurse  the  baby, 
the  food  consisted  of  diluted  peptonized  milk 
with  the  addition  of  cream.  Later,  the  propor- 
tion of  cream  was  increased  and  milk  sugar 
added.  At  first  half  an  ounce  was  administered 
at  a  time  and  subsequently  the  amount  increased 
in  proportion  to  its  needs.  Sterilized  milk  was 
finally  substituted  for  the  above  and  gave  better 
results. 

At  the  end  of  the  first  week  the  baby  had  lost 
half  a  pound ;  at  the  second  its  weight  was  the 
same  ;  at  the  third  it  had  gained  half  a  pound, 
and  from  this  time  it  increased  in  weight  at  the 
rate  of  one-half  to  three-eighths  of  a  pound 
weekly. 

To  further  emphasize  the  value  of  this  method 
of  treatment,  I  wish  briefly  to  mention  the 
following  additional  cases  that  came  under  my 
observation. 

On  June  17,  1888,  I  induced  labor,  at  the 
thirty-fourth  week  under  the  following  circum- 
stances. 

Mrs.  F.,  at  her  third  pregnancy,  had  consider- 
able albumen  in  her  urine  and  some  evidence  of 
toxfemia.  I  felt  no  little  apprehension  when  her 
labor  came  on,  but  she  passed  safely  through  the 
ordeal.  Her  convalescence  was  extremely  pro- 
tracted owing  to  co-existent  cardiac  disease. 

The  fourth  pregnancy  and  labor  were  very  simi- 
lar to  the  preceding,  and  convalescence  likewise 
protracted. 

In  the  fifth  pregnancy  the  conditions  were  very 
much  aggravated  in  spite  of  energetic  treatment. 
Violent  headache  and  impaired  vision  were 
prominent  symptoms.  At  eight  months  and  a 
half,  as  stated  above,  labor  was  induced  by  the 
introduction  of  a  bougie.  The  uterus  responded 
after  a  few  hours  delay  and  the  child  was  born 
without  the  appearance  of  any  alarming  symp- 
toms in  the  mother.  Convalescence  was  rapid 
and  she  sat  up  on  the  tenth  da}-.  In  this  case 
organic  disease  of  the  kidneys  was  compatible 
with  fairly  good  health,  except  when  pregnancy 
existed.  Each  succeeding  pregnane}-  presented 
graver  symptoms. 

Of  the  three  children  born  in  these  labors,  the 
only  one  living  at  present  is  the  one  prematurely 
born  by  induced  labor.      Both  the  others  died 


878 


PREVEXTIOX  OF  PUERPERAL  ECLAMPSIA. 


[June  20, 


from  intestinal  diseases  when  a  few  months  of  age. 

The  next  two  cases  were  seen  with  Dr.  W.  W. 
Johnston,  and  occurred  within  two  weeks  of  each 
other. 

Mrs.  M.,  a  primipara,  advanced  about  eighth 
month,  presented  serious  ss'tnptoms  despite  treat- 
ment directed  for  relief  of  albuminuria.  Nov. 
27,  1888,  labor  was  induced  by  the  introduction 
of  a  bougie  into  the  uterine  cavity.  Unusual 
difficulty  was  met  with  in  performing  this  little 
operation  on  account  of  the  existence  of  what 
has  been  so  fully  described  by  Dr.  Busey,  as 
cystokolpocele.  The  red  tumor  formed  by  the 
projection  of  the  vesico-vaginal  wall  so  com- 
pletely blocked  the  genital  passage,  that  it 
baffled  all  efforts  to  insert  the  instrument.  One 
variety  of  speculum  after  another  was  tried  and 
abandoned.  Filially,  by  touch  the  bougie  was 
placed  in  position.  Labor  pains  came  on  in  due 
time,  and  when  the  os  had  dilated  the  child  was 
delivered  by  forceps  applied  to  the  breech. 

Mother  and  child  recovered. 

The  last  case,  also  a  Mrs.  M.,  a  primipara,  pre- 
sented alarming  symptoms  during  the  latter  part 
of  her  pregnancy.  On  December  10,  188S,  the 
bougie  was  placed  in  position.  The  uterus  fail- 
ing to  respond  to  the  irritation,  it  was  removed 
and  a  second  one  inserted  in  a  different  direction. 
Feeble  uterine  action  was  supplemented  by  dila- 
tation with  Barnes'  bags,  the  smallest  size  being 
replaced  after  a  few  hours  by  the  largest.  When 
the  os  had  dilated,  labor  was  terminated  with  the 
forceps.  Several  hours  afterwards  the  mother 
had  convulsions  and  for  a  time  was  in  a  critical 
condition.  She  finally  recovered  and  the  child 
lived. 

These  four  cases  offered  every  reason  to  fear  an 
outbreak  of  eclampsia,  and  only  after  energetic 
treatment  had  been  directed,  without  success,  to 
the  relief  of  the  renal  complication,  was  pre- 
mature labor  induced.  This  result  emphasizes  the 
value  of  the  induction  of  premature  labor  for  the 
prevention  of  eclampsia.  While  the  concensus 
of  opinion  may  be  said  to  favor  such  action,  it  is 
nevertheless  true  that  some  eminent  authors  fail 
to  endorse  operative  interference. 

The  safest,  simplest,  and  consequently,  at 
present,  the  best  method  of  exciting  uterine'  con- 
traction is  the  insertion  of  a  bougie  between  the 
membranes  and  the  uterine  wall.  The  term 
catheterization,  which  is  often  employed  to  signify 
this  method,  should  be  discontinued,  as  the 
catheter  is  an  unsuitable  instrument  to  use  for 
the  purpose.  Being  hollow,  with  a  hole  at  both 
ends,  it  is  easily  soiled  and  with  difficulty 
cleaned.  Even  if  aseptic  when  used,  secretions 
accumulate  within  the  tube  and  readily  undergo 
decomposition.  The  bougie  should  be  prepared 
by  soaking  for  twenty-four  hours  in  bichloride  of 
mercury  solution  1  to  1,000,  and  then  washing  in 
boiled  water  just  before  use. 


I  prefer  to  insert  it  by  exposing  the  parts  with 
Sim's  speculum  and  steadying  the  cervix  with 
the  aid  of  a  tenaculum.  The  end  of  the  bougie 
is  bent  at  an  obtuse  angle  and  guided  around  the 
curve  of  the  lower  uterine  segment.  A  boricated 
cotton  tampon  is  placed  in  the  vagina  to  prevent 
slipping  of  the  bougie,  and  to  absorb  the  dis- 
charges. 

If  this  treatment  fails  to  excite  uterine  action 
the  instrument  can  be  removed  and  a  fresh  one 
inserted  in  a  different  direction.  The  majority 
of  cases  will  meet  with  success,  but  occasionally 
the  organ  is  provoked  to  contract  with  great  diffi- 
culty. Other  means,  familiar  to  all,  can  be  re- 
sorted to  for  the  purpose  of  exciting  action. 

A  method  recently  suggested  by  Schrader  is 
worthy  of  trial.  It  is  the  alternate  application 
of  hot  and  ice  cold  fomentations  to  the  abdomen, 
changes  being  made  every  five  minutes.  Lomer' 
has  reported  a  case  in  which  he  succeeded  in  in- 
ducing labor  by  this  means  for  impaired  vision 
resulting  from  albuminuria.  Pain  developed  in 
two  hours  and  in  six  the  child  was  born. 

Full  doses  of  quinine  and  hot  vaginal  douches 
I  are  useful  to  strengthen  uterine  pains  after  they 
1  have  been  started  by  other  means. 

Agents  to  soothe  the  nervous  system  and 
J  deaden  sensibility  are  valuable  during  labor  to 
J  diminish  the  liability  to  convulsions.  The  best 
of  these  are  morphia  hypodermatically,  chloral 
by  the  rectum,  and  the  inhalation  of  chloroform. 
Morphia  should  not  be  employed  too  early  as  it 
might  arrest  uterine  action.  Chloroform  given 
only  to  the  obstetrical  degree  meets  the  indi- 
cation and  aids  the  dilatation  of  the  os.  When 
dilatation  progresses  slowly,  the  early  application 
of  forceps,  as  advocated  by  the  late  Isaac  Taylor 
is  a  justifiable  procedure.  If  labor  pains' are 
strong  and  no  delay  arises  the  completion  ot 
labor  should  be  left  to  nature. 

If,  in  any  case,  operative  interference  be  de- 
manded, chloroform  should  be  the  anaesthetic 
employed.  Ether  will  increase  the  renal  conges- 
tion and  might  precipitate  what  we  have  used°all 
our  efforts  to  avoid. 

In  conclusion  it  may  be  well  to  suggest  one 
other  precaution  to  be  taken  in  these  cases.  The 
impaired  function  of  the  kidneys  increases  greatly 
the  dangers  of  using  corrosive  sublimate  and  car- 
bolic acid  solutions  for  vaginal  or  intra-uteriue 
irrigation. 


Congress  of  American  Phvsicians  and 
Surgeons.— The  meetings  of  the  Congress  of 
American  Physicians  and  Surgeons  will  be  held 
111  Washington,  from  3  to  6  p.m.,  September  22, 
23,  24,  and  25,  1891. 


Centralblatt  f  Gynak,  Ni 


l89i-J  TREATMENT  OF  EXTRA-UTERINE  PREGNANCY. 


THE    OPERATIVE    TREATMENT   OF  |  bed  for  two  weeks  and  necessitated   her  stay  at 

EXTRA-UTERINE    PREGNANCY  h""1L'   l,,r  two   weeks  longer.     During  this  time 

AT  OR  NEAR   TERM    WITH  her  temperature  was  normal. 

RT7PDRT  ns   a    pact?  Between  the  filth  and  tenth  of  August,  while 

XJii-UKl    u*   A   L\Mv  in  bed   with   lhjs   apparent  attack  of  peritonitis, 

e/ore  the  Illinois  stale Maiicai  Society,  May  ,o,  189,.  she  first  felt  foetal  movements,  faint  at  first,  later 

BY  CHRISTIAN   FENGER,  M.D.,  stronger.     These  continued   to  be  felt  until  De- 

.     OF  CHICAG°.  ■"••  cember  29.     Uterine  haemorrhage  with   passage 

It  is  not  my  intention  in  this  paper  to  give  an  of  a  decidual  membrane    was    never   observed. 

exhaustive  expose    of   all    the    details  and   the  During  September,  October  and   November,  she 

questions  that  arise  in   late   extrauterine  preg-  ( was  able  to  be  up  and   about  attending  to  her 

nancy,  but  merely  in   connection  with  a  case  of  work  in  school,   but  almost  every  evening  she 

this  kind,  which  terminated   fatally,   to  describe  would  have  pain  in  the  abdomen',  which  would 

the  thoughts  and  reflections  that  presented  them-  be  aggravated  on  change  of  position,  and  would 

selves  to  me  in  connection  with  the  case.  prevent  her  from  sleeping  in  the  early  part  of  the 

I  shall,  then,  first  describe  the  case,  the  differ-  night.     In  the  second  week  of  December  the  ab- 

ent   methods  of  operation  and  their  prognoses,  dominal  pain  increased  and  also  came  on  during 


and  later,  review  the  more  important  point 
the  management  of  such  cases  from  my  own  ex- 
perience and  from  the  literature  as  far  as  I  have 
been  able  to  obtain  it. 


the  day,  so  that  for  fear  the  pain  would  come  on, 
she  did  not  dare  go  out  of  the  house. 

December  31,  spurious  labor  set  in  with  severe 
pain  in  the  left  side  of  the  abdomen  increasing 


Case. — Mrs.  C,  34  years  of  age,  married  thir-  toward  night,  which  lasted  for  two  days.  At 
teen  years.  Healthy  as  a  child  ;  first  menstru- 1  this  time  fetal  movements  ceased.  She  remained 
atedat  the  age  of  14;  always  regular;  three  j  in  bed  three  weeks,  during  which  time  the  ab- 
days'  duration  ;  for  the  past  ten  years  two  days  domen  commenced  to  decrease  in  size.  Febru- 
only;  never  very  abundant.  A  slight  leucorrhcea  j  ary  10,  1891,  six  weeks  after  the  death  of  the 
for  a  few  days  following  menstruation.  Married  ,  child,  there  was  a  sudden  recurrence  of  the  ab- 
at  21  ;  a  year  later,  after  a  normal  pregnancy,  dominal  pain  with  vomiting  and  rise  of  pulse  and 
was  delivered  of   a  female  child  who  lived  only  j  temperature. 

ten  days.  Labor  was  difficult,  but  forceps  were  February  n,  I  made  an  examination.  The 
not  used.  Slight  laceration  of  perineum.  She  patient  was  in  bed,  somewhat  pale,  pulse  100, 
was  in  labor  from  midnight  until  half-past  ten  temperature  100.  °  She  had  been  suffering  from 
the  next  morning.  She  had  puerperal  fever  and  :  pain  and  vomiting  for  two  days,  but  at  this  time 
pelvic  cellulitis  which  confined  her  to  bed  for  the  vomiting  had  ceased.  The  mammary  glands 
three  months.  She  had  a  slow  convalescence,  were  large,  areolae,  pigmented  and  abundance 
not  being  well  until  three  months  later.  Menstru-  of  milk  coming  from  the  nipples  on  pressure, 
at  ion  returned  five  months  after  the  birth  of  the  The  abdomen  was  enlarged  to  about  the  size  of 
child,  and  since  that  time,  about  ten  years  ago,  pregnancy  at  term,  but  more  prominent  on  the 
has  been  always  regular.  She  has  occasionally  left  side,  with  an  area  of  dull  percussion  up  to 
had  slight  leucorrhcea,  but  otherwise  has  had  no  ,  the  body  of  the  ninth  rib,  while  on  the  right  side 
symptoms  of  disease  of  the  genital  organs  ex-  ;  it  did  not  extend  to  within  two  inches  of  the 
cepting  sterility.  lower  border  of  the  ribs.     Tympanitic  percussion 

March  20,  1890,  she  had  her  last  normal  t  in  the  epigastric  and  both  lumbar  regions  ;  dull 
menstruation.  Two  or  three  weeks  later,  in  percussion  over  the  umbilical,  hypogastric  and 
April,  she  felt  sick,  wanted  to  eat,  but  after  eat- ,  inguinal  regions. 

ing  would  often  feel  nauseated.  May  15,  at  noon  Through  the  abdominal  wall  could  be  felt  a 
she  suddenly  felt  a  severe  pain  through  the  an-  harder,  round  portion  of  the  tumor  to  the  right 
terio*-  part  of  the  abdomen  and  the  rectum,  of  and  above  the  umbilicus— the  fetal  head. 
followed  by  vomiting.  These  symptoms  lasted  '  Over  the  remainder  of  the  tumor  no  distinct 
for  ten  days,  during  which  time  she  was  obliged  fetal  parts  could  be  felt.  In  the  territory  below 
to  stay  in  bed.  No  fever,  no  symptoms  of  haem-  a  line  extending  from  the  border  of  the  right 
orrhage.  The  symptoms  then  disappeared  and  ribs  downward  and  inward,  to  midway  between 
after  three  weeks  she  resumed  her  work  of  teach-    the    umbilicus    and   symphisis  pubis,   and   from 


ing  school.  She  was  well  until  July  when  a  sud- 
den attack  of  pain  which  came  on  at  night  while 
she  was  in  bed,  necessitated  her  keeping  quiet 
for  a  few  days.     After  this  time  pain  would  often 


here  to  the  outer  third  of  the  left  Poupart's  liga- 
ment, a  distinct  placental  souffle  could  be  heard, 
most  pronounced  in  the  right  hypogastriurn. 
On  vaginal  examination,    the  vaginal  portion 


come  on  during  the  night,  extending  from  the  of  the  uterus  was  shown  to  be  somewhat  flaccid, 
abdomen  down  to  the  knee,  more  severe  in  the  standing  high  up  and  directed  forward  against 
light  leg.  August  5,  she  had  a  sudden,  severe  the  symphysis  pubis.  The  posterior  lacuna  was 
attack  of  pain  and  vomiting  which  kept  her  in  :  pushed  downward  into  the  vagina  by  a  doughy, 


TREATMENT  OF  EXTRA-UTERINE  PREGNANCY. 


[June  20, 


immovable  tumor,  probably  the  placenta,  as  no 
fcetal  parts  could  be  felt.  The  patient  com- 
plained of  frequent  micturation,  that  she  was 
obliged  to  pass  water  every  hour  except  when 
asleep.  The  urine  was  normal  in  quantity  and 
color  and  contained  neither  pus,  sugar  nor 
albumin. 

I  resolved  to  wait  for  the  cessation  of  the  pla- 
cental circulation,  as  might  be  indicated  by  the 
placental  souffle,  keeping  the  patient  in  bed  and 
under  symptomatic  treatment. 

February  10.  Area  of  placental  souffle  di- 
minished about  one-half. 

February  22.  No  placental  souffle  could  be 
heard.  The  patient  was  removed  to  the  Emer- 
gency Hospital  for  operation,  which  was  fixed 
for  a  week  after  her  arrival  there. 

February  25.  Diarrhoea  set  in  with  slightly 
bloody  stools,  the  passages  soon  becoming 
chocolate-colored.  On  microscopic  examination 
no  pus  cells  were  found,  but  fecal  matter,  fine 
granular  matter  and  blood  corpuscles.  Pulse  and 
temperature  increasing. 

February  28.  Pulse  no;  temperature  1030. 
She  had  several  passages  of  a  dark,  reddish- 
brown  color.  Concluding  from  this  that  perfor- 
ation of  the  sac  into  the  bowel  had  taken  place, 
and  consequently  that  sepsis  had  commenced  to 
appear  in  the  sac,  operation  at  once  became  neces- 
sary. 

March  1.  Operation.  In  the  presence  of  the 
doctors  from  the  Policlinic,  Dr.  Bellinger,  of 
Council  Bluffs,  Iowa  ;  assisted  by  Drs.  Bernauer, 
Hall  and  Brohm.  Chloroform  given  by  Dr.  Rosa 
Eugert.  Percussion  at  this  time  over  the  entire 
tumor  was  tympanitic  where  it  had  formerl)-  been 
dull,  showing  the  presence  of  air  in  the  foetal  sac 
from  perforation  of  the  intestines. 

An  incision  was  made  in  the  linea  alba,  seven 
inches  long,  from  a  point  midway  between  the 
symphysis  pubis  and  umbilicus,  to  three  inches 
above  the  umbilicus.  The  parietal  peritoneum 
was  loosely  adherent  to  the  wall  of  the  sac  down- 
ward ;  above  was  the  free  peritoneal  cavity.  The 
sac  was  here  covered  with  omentum  containing 
a  large  number  of  dilated  vessels,  some  of  the 
veins  two  or  three  lines  in  diameter,  while  most 
of  the  adipose  tissue  of  the  omentum  had  dis- 
appeared. The  parietal  peritoneum  was  united 
by  sutures  to  the  skin.  As  the  adhesions  be- 
tween the  parietal  peritoneum  and  the  omentum 
were  incomplete,  I  separated  the  remaining  ad- 
hesions with  the  hand,  and  packed  large  sponges 
into  the  peritoneal  cavity  all  around  the  incision, 
or  lather  around  the  territory  where  the  opening 
of  the  sac  was  to  be  made. 

Ou  account  of  the  numerous  and  large  ves- 
sels, double  ligature  of  which  would  have  taken 
too  long,  I  opened  thesac  with  a  Paquelin  cautery 
knife.  This  was  used  only  at  red  heat.  There 
was  considerable  haemorrhage  from  the  om 


necessitating  numerous  ligatures.  On  opening 
into  the  sac  there  was  an  escape  of  fetid  air,  and 
later  on  a  discharge  of  a  thin,  grayish,  fetid  fluid 
of  fecal  odor.  During  this  time  the  patient  was 
turned  on  the  side  and  the  wound  flushed  with 
warm  sterilized  water. 

The  incision  was  now  prolonged  six  inches. 
The  child  presented  with  the  back  and  left 
shoulder  in  the  wound.  The  left  arm  was  first 
drawn  out,  but  as  it  was  found  impossible  to  de- 
liver the  head,  the  arm  was  replaced  and  the  left 
leg  drawn  out,  then  the  right  leg,  and  thus  the 
child  was  delivered.  After  incising  the  tympan- 
itic abdomen,  which  collapsed  after  the  escape  of 
the  gases,  extraction  was  now  easy  without  vio- 
lence to  the  wall  of  the  sac.  The  umbilical  cord 
was  tied  two  inches  from  the  placenta,  at  the 
lower  border  of  the  wound.  The  fcetal  cavity- 
contained  fetid,  chocolate- colored  fluid  and 
smegma.  The  patient  was  now  turned  on  the 
side  and  warm  sterilized  water  poured  in  from  a 
pitcher  to  flush  the  cavity  until  it  became  reasona- 
bly clean,  the  water  being  mopped  off  with  large 
sponges.  The  large  placenta  entirely  filled  the 
small  pelvis  and  the  right  iliac  fossa  up  over  the 
surface  of  the  transverse  colon.  The  uterus 
could  not  be  seen,  as  it  was  covered  by  placenta. 
The  cord  was  attached  down  near  the  symphysis 
pubis,  was  of  a  whitish-gray  color  and  macerated 
on  the  surface,  showing  no  signs  of  circulation. 
The  foetal  surface  of  the  placenta  was  smooth 
and  bluish- gray,  looking  as  if  the  circulation  had 
ceased. 

An  attempt  to  cleanse  the  inside  of  the  sac  by 
means  of  soft  sponges  on  long  artery  forceps,  the 
borders  of  the  sac  being  held  apart  by  the  hand, 
was  immediately  followed  by  a  sudden  gush  of 
bright  red  arterial  blood  from  the  borders  of  the 
placenta,  which  necessitated  immediate  packing 
of  the  cavity  with  large  pieces  of  gauze.  The 
deepest  part  of  the  sac  was  in  the  left  iliac  fossa 
where,  to  the  left  of  the  placenta,  the  distinct 
contour  of  loops  of  large  intestine,  probably  the 
descending  colon  and  sigmoid  flexure,  were  dis- 
tinctly seen.  They  were  felt  to  be  covered  with 
a  layer  of  tissue  so  thin  as  to  indicate  that  no 
sac  wall  existed.  No  perforation  into  the  bowel 
could  be  seen  at  any  point  and  no  escape  of 
gases  from  the  bowel  into  the  sac  was  noticed, 
but  the  contents  of  the  sac  had  a  distinctly  fecal 
odor.  A  thorough  search  for  the  opening  into 
the  intestine  was  not  made,  as  even  the  slightest 
manipulation  caused  copious  haemorrhage  from 
the  borders  of  the  placenta. 

The  large  sponges  were  now  removed  from  the 
peritoneal  cavity,  which  was  then  cleansed  by 
means  of  smaller  sponges  on  long  forceps,  and 
the  borders  of  the  sac  united  to  the  skin  by 
sutures.  Strips  of  iodoform  gauze,  for  capillary 
drainage,  were  introduced  between  the  sutures  at 
six  different  places  to  a  depth  of  about  two  inches 


I89i.] 


TREATMENT  OF  EXTRA-UTERINE  PREGNANCY. 


between  the  sac  and  the  abdominal  wall.  One 
strip  at  the  right  upper  border  of  the  wound  was 
introduced  four  inches,  up  under  the  liver.  A 
handful  of  a  mixture  of  equal  parts  of  salicylic 
and  tannic  acids  was  strewn  over  the  inner  wall 
of  the  sac  and  the  whole  cavity  packed  loosely 
with  sterilized  gause  impregnated  with  the  same 
powder,  of  which  four  ounces  in  all  was  used. 
The  wound  of  incision  into  the  sac  was  left  open 
and  over  the  packing  an  antiseptic  dressing  was 
applied. 

The  child  was  a  normally  developed  male  at 
full  term.  Instead  of  commencing  maceration, 
the  epidermis  was  covered  with  smegma,  and  in 
many  places  was  loosened  from  thecorium,  which 
presented  a  brownish-red,  discolored  surface. 

At  the  end  of  the  operation,  which  lasted  an 
hour  and  a  half,  the  pulse  was  150.  and  reasona- 
bly strong  ;  color  natural.  Half  an  hour  after 
the  operation,.pulse  120.  Seven  p.m.:  temperature 
100°;  pulse  120  ;  no  vomiting  ;  the  patient  has 
some  pain  in  the  sac  and  the  wound  ;  skin  moist, 
expression  natural.  She  has  slept  for  a  short 
time  and  does  not  complain  much. 

March  2.  No  vomiting:  has  slept  a. little  and 
taken  some  boiled  milk  ;  pulse  120  :  temperature 
1010.  The  outer  dressing,  which  contained  a 
great  amount  of  thin,  grayish  fluid  of  fecal  odor, 
was  changed. 

March  3.  A  very  little  discharge  in  the  dress- 
ings. Pulse  no:  temperature  ioi°.  She  takes 
liquid  nourishment  and  has  a  moderate  amount 
of  pain,  which  can  be  controlled  by  morphine. 

March  5.  Two  stools  of  a  chocolate-colored 
fluid  containing  many  small  clots  of  blood. 
Yen-  little  secretion  from  the  dressings. 

March  6.  Three  copious  evacuations  of  a 
bloody  fluid  containing  several  clots  as  large  as 
a  hen's  egg. 

March  7.  Last  night  and  this  morning  several 
large  coagula  and  liquid  blood  passed  through 
the  rectum.  The  patient  is  pale,  extremely 
anaemic,  conjunctiva  pale,  exsanguinated,  pulse 
130,  weak;  temperature  99. 50.  The  patient  is 
fully  conscious,  and  complains  of  extreme  weak- 
ness. Skin  cf  extremities  and  face  cold.  In- 
fundation  of  sixteen  ounces  of  slightly  alkaline, 
saccharated  saline  solution  into  the  cephalic  vein. 
In  the  evening  pulse  120,  stronger,  and  the  ex- 
tremities warm  after  the  application  of  hot  water 
bottles. 

March  8.  During  the  night  there  was  another 
haemorrhage  from  the  bowel,  after  which  the  pa- 
tient became  semi- conscious,  dozing  most  of  the 
time  and  complaining  but  little.  Extremities 
and  face  cold.  Pulse  150.  weak;  temperature 
980.     Died  at  midnight. 

March  9.  Autopsy,  ten  hours  after  death. 
No  blood  in  the  dressings  or  in  the  cavity  of  the 
sac.  The  packing  of  the  cavity  is  almost  dry. 
The  cavity  of  the  sac  has  diminished  to  one- 


quarter  of  the  size  at  time  of  operation,  partly 
by  retraction  of  the  walls,  partly  by  filling  in. 
:  After  removal  of  the  gauze,  the  placenta  was 
'  found  in  place  on  the  posterior  wall  of  the  sac. 

The  autopsy  revealed  an  opening  at  the  upper 
insertion  of  the  placenta,  between  the  sac  and 
the  transverse  colon.  This  opening  was  so  cov- 
ered by  the  border  of  the  placenta  as  to  make  the 
]  blood  pass  down  into  the  bowels,  and  not  out 
into  the  sac.  The  sac  was  of  very  different 
thickness  in  its  different  portions.  On  the  an- 
terior surface  it  was  about  one-quarter  of  an 
inch  thick,  corresponding  to  the  surface  where 
the  foetus  was  covered  with  omentum,  and  con- 
sisted in  fact,  of  the  thickened  omentum.      The 

■  remainder  of  the  foetal  cavity  was  entirely  sur- 

■  rounded  by  loops  of  intestines,  small  intestine 
'  and  colon,  and  here  the  sac  wall  was  extremely 

thin,  in  some  places  cobweb-like,  in  other  places 
slightly  thicker,  and  everywhere  more  or 
timately  adherent  to  the  wall  of  the  intestine. 
These  adhesions  were  the  result  of  a  plastic 
peritonitis  commencing  at  the  time  of  the  pri- 
mary rupture  into  the  peritoneal  cavity,  and  ex- 
tending as  the  fcetus  increased  in  size. 

The  placenta  extended  from  the  posterior  sur- 
face of  the  uterus,  entirely  filling  Douglas'  fossa, 
I  more  than  six  inches  upward  to  the  transverse 
colon.  The  placental  area  of  the  sac  was  very 
thin  in  some  places  :  so  much  so  that  it  tore  into 
shreds  on  even  so  slight  a  manipulation  as  that 
required  for  the  removal  of  the  intestines  en 
masse  during  the  autopsy. 

Summary  of  History. — We  find,  in  a  patient 
34  years  old.  who  had  had  one  child,  child-bed 
being  followed  by  pelvic  cellulitis,  and  who  was 
then  sterile  for  eleven  years,  an  extra-uterine 
pregnancy  characterized  by  the  following  course: 

In  the  eighth  week  after  last  menstruation, 
j  probable  rupture  of  a  tubal  pregnane}-,  indicated 
by  sudden  pain  and  vomiting  ;  that  is,  symptoms 
of  peritonitis,  lasting  for  ten  days.  In  the  six- 
teenth week  a  similar  attack,  less  severe.  In 
the  nineteenth  week  another  severe  attack  of 
peritonitic  symptoms  keeping  the  patient  in  bed 
for  one  month.  In  the  fifth  month  she  felt  life. 
In  the  second  week  of  the  ninth  month  a  moder- 
ate attack  of  peritonitis.  At  the  end  of  the 
ninth  month  spurious  labor  and  death  of  the 
child,  indicated  by  cessation  of  foetal  movements. 
In  the  fifth  week  after  the  death  cf  the  child,  the 
placental  souffle  began  to  diminish,  and  two 
weeks  later  it  had  ceased  entirely.  Six  week- 
after  the  death  of  the  child  another  severe  attack 
-.ied  with  peritonitic  symptoms.  In  the 
eighth  week  perforation  of  the  sac  into  transverse 
colon.  At  beginning  of  ninth  week,  operation  ; 
death  six  days  later  from  haemorrhage  through 
the  bowel. 

Remarks. — This  case  undoubtedly  belongs  to 
E  cases  consisting  of  an  original  tubal 


TREATMENT  OF  EXTRA-UTERINE  PREGNANCY, 


[June  20. 


pregnane}''  which  secondarily  becomes  an  ab-  in  such  cases,  total  extirpation  of  the  sac  is 
dominal  pregnancy  with  the  placenta  and  fcetus  possible. 

located  in  the  abdominal  cavity.  In  the  great  Entire  absence  of  the  sac,  the  fcetus  lying  in 
majority  of  cases  where  a  tubal  pregnancy  rup-  the  free  peritoneal  cavity  between  intestines 
tures  at  the  end  of  the  second  or  in  the  third  which  are  not  matted  together  with  adhesions,  is 
month,  the  fcetus  dies  and  disappears,  and  if  the  a  rare  occurrence.  Such  cases  have,  however, 
patient  survives  the  haemorrhage,  both  fcetus  and  been  described  by  King,  Lawson  Tait  and 
placenta  are  removed  by  absorption.  In  a  small  Goetsch.  In  the  case  of  Lawson  Tait,  the  in- 
proportion  of  cases  after  this  rupture  the  develop-  testines  protruded  immediately  after  the  extrae- 
lnent  of  the  fcetus  is  continued,  and  the  placenta,  tion  of  the  fcetus  through  an  opening  made  in 
still  partially  connected  with  the  old  site  in  the  the  posterior  cul  de-sac  of  the  vagina.  In  the 
tube,  keeps  on  growing  and  implants  itself  on  case  of  Goetsch,  at  the  time  of  laparotomy,  a 
the  walls  of  the  peritoneal  cavity,  from  the  small  full  grown  child  was  found  free  amongst  the  in- 
pelvis  upward  on  the  anterior,  posterior  or  lateral  testines,  but  yet,  strange  as  it  may  seem,  fresh 
abdominal  wall.  When  the  rupture  has  given  and  not  decomposed,  although  laparotomy  was 
rise  to  no  symptoms  of  haemorrhage  a  plastic  not  performed  until  two  years  and  a  half  after  the 
peritonitis  takes    place  which  quickly  forms  a   spurious  labor. 

barrier  between  the  territory  occupied  by  the  Symptoms. — I  shall  hot  enter  into  a  considera- 
fcetus  and  placenta,  and  the  remainder  of  the .  tion  of  all  the  symptoms  of  extra-uterine  preg- 
peritoneal  cavity.  The  product  of  this  plastic  ,  nancy,  because  these  are  to  be  fou.nd  in  the  text- 
peritonitis  is  probably  first  a  fibrinous  exudate,  books.  There  are,  however,  two  symptoms  in 
later  on  organized  into  connective  tissue  which  this  case  to  which  I  wish  to  call  attention,  mainly 
forms  the  so-called  sac.  This  probably  does  not  on  account  of  their  prognostic  significance  ;  first, 
differ  in  any  respect  from  the  connective  tissue  the  repeated  attacks  of  peritoneal  irritation,  and 
layer  found  in  the  wall  of  any  other  localized  or,  second,  the  final  symptom  of  perforation  into  the 
as  it  is  called,  encapsulated  peritoneal  exudate,    bowels — the  bloody  diarrhoea. 

As  the  growth  of  the  fcetus  and  placenta  con- ,  We  notice  in  this  case  repeated,  severe  attacks 
tinues,  more  and  more  space  is  required,  rupture  of  symptoms  of  peritonitis,  so  severe  as  to  keep 
of  the  sac  occurs  into  a  new  territory  of  peri-  the  patient  in  bed  sometimes  for  a  month  at  a 
toneal  cavity  up  to  this  time  intact,  and  this  time,  and  characterized  by  intense  abdominal 
territory  is  again  limited  by  a  plastic  peritonitis  pain,  vomiting  and  occasionally  tympanitis, 
resulting  in  an  enlargement  of  the  sac  sufficient ,  These  attacks  necessarily  caused  progressive  loss 
for  the  needs  of  its  contents  for  some  time.  This  of  strength  and  emaciation,  and  thus  the  patient's 
procedure  gives  rise  to  symptoms  of  peritonitis,  condition  became  gradually  less  and  less  favora- 
acute  in  its  onset,  but  which  gradually  subside,  ble  for  operation.  In  this  class  of  cases  early  op- 
In  certain  forms  of  purulent  peritonitis  we  find  a  :  eration,  irrespective  of  the  condition  of  the  child 
similar  method  of  intermittent  extension  giving  or  of  the  placenta,  would  be  likely  to  give  a  bet- 
rise  to  successive  attacks  of  peritonitis  with  free  ter  prognosis  for  the  mother, 
intervals  between  the  attacks.  The  final  catastrophe,    perforation  of  the  sac 

This  mode  of  development  makes  it  natural ,  into  the  intestines,  bladder  or  vagina,  is  charac- 
that  the  sac  should  vary  in  thickness  and  re-  terized  by  a  discharge  of  the  liquid  contents  of 
sistance  in  different  parts.  Thus  we  would  ex-  the  fcetal  sac, -liquor  amnii  or  pus;  usually  mixed 
pect  to  find  it  thicker  in  the  space  between  two  with  blood.  Perforation  into  the  intestinal  tract 
intestinal  loops  or  between  a  loop  of  intestine  is  by  far  the  most  common,  as  the  intestinal  wall 
and  one  of  the  viscera,  than  on  the  convexity  of,  furnishes  only  slight  resistance,  and  as  a  large 
the  wall  of  these  organs.  The  greatest  thick- 1  area  of  the  fcetal  sac  must  necessarily  be  formed 
ness  of  the  sac  will  be  found,  as  in  this  case,  j  of  loops  of  intestine.  Diarrhoea,  usually  bloody, 
where  the  omentum  has  participated  in  its  forma- ,  is  the  first  symptom,  rapidly  followed  by  symp- 
tion.  This  would  naturally  occur  on  the  an-  toms  of  sepsis  due  to  microbic  invasion  of  the 
terior  surface  of  the  foetal  sac.  The  thinnest  sac.  Rapid  pulse  and  high  temperature  corn- 
portion  of  the  sac  wall  will  be  found  on  the  con-  mence  within  twenty-four  hours  of  the  rupture, 
vexity  of  the  loops  of  intestine,  and  this  is  the  An  especially  characteristic  symptom  and  one 
place  where  rupture  into  the  intestine  takes  well  marked  in  this  case  and  caused  by  the  en- 
place,  either  spontaneously  or  during  attempts  at '  trance  of  gases  from  the  intestinal  tract  into  the 
extirpation  of  the  sac.  [  sac,  is  tympanitic  percussion  over  the  area  where 

In  extra-uttrine  pregnancy  where  a  uniformly  formerly  dull  percussion  was  found.  This  symp- 
thick  sac  wall  is  found,  it  is  natural  to  suppose  torn  is  of  course  absolutely  pathognomonic  of 
that  rupture  of  the  tube  has  not  taken  place,  but    rapture  into  the  bowel. 

rather  a  uniform  dilatation.  These  are  probably  Rupture  into  the  bowel  is  a  common  occur- 
the  cases  in  which  one  layer  of  the  wall  of  the  rence,  as  out  of  one  hundred  and  thirty-two  cases 
sac  is  composed  of  organic  muscular  fibres,  and  ]  collected  by  Hecker,  cited  by  Bandl,    the  fcetus 


i89i.] 


TREATMENT  OF  EXTRA-UTERINE  PREGNANCY 


883 


was  eliminated  through  the  rectum  in  twenty- 
eight  instances  with  recovery  of  the  mother.  It 
is  not  too  much  to  assume  that  this  condition  was 
present  in  at  least  a  corresponding  proporti' 
the  forty- four  cases  in  which  the  mother  died 
without  an  operation  having  been  performed,  as 
sepsis  must  invariably  follow  the  perforation. 

tosis. — The  prognosis  is  always  grave, 
varying  in  the  older  statistics  between  a  mortali- 
ty of  forty-two  and  eighty-eight  per  cent.  Heck- 
er  forty  two  per  cent.,  Kiwisch  eighty-two  per 
cent.  Henic,  eighty-eight  per  cent. 

Operative  treatment. — Asepsis  in  operating  has 
recently  given  a  mighty  impulse  toward  the 
amelioration  of  the  prognosis  of  this  grave  con- 
dition, and  the  successful  results  as  regards  sav- 
ing the  lives  of  the  mothers  has  made  the  opera- 
tions for  extra- uterine  pregnancy  to  be  counted 
by  hundreds  during  the  last  four  or  five  years, 
while  formerly  they  were  only  sporadic  occur- 
rences. 

The  greatest  success  is  accomplished  by  the 
operation  in  the  early  months  of  pregnancy,  but 
it  must  be  acknowledged  that  operations  at  or 
near  term  are  at  present  not  nearly  so  dangerous 
as  they  were  in  former  years.  A  strict  line  of 
distinction  must  be  drawn  between  the  operations 
in  the  beginning,  and  those  toward  the  end  of 
extra-uterine  pregnancy.  The  two  conditions, 
although  only  different  stages  of  the  same  ano- 
maly, present  such  vitally  different  anatomical 
conditions,  chiefly  on  account  of  the  difference  in 
the  size  of  the  territory  and  the  difficulty  of  the 
operation, that  comparison  is  impossible.  The  early 
operation  is  technically  no  more  difficult  than  the 
extirpation  of  the  normal  non-adherent  uterine 
appendages;  the  operation  toward  the  end  of 
pregnancy,  however,  by  which  we  mean  the  to- 
tal removal  of  ovum  and  its  contents,  is  always 
formidable  and  often  technically  an  absolute  im- 
possibility. 

Early  in  pregnancy,  whether  before  or  after 
rupture  of  the  tube,  which  is  almost  always  the 
primary  seat  of  extra-uterine  pregnancy,  the  op- 
eration presents  no  technical  difficulties.  The 
adhesions  are  slight  or  not  present,  for  the  tumor 
rarely  exceeds  the  size  of  an  orange  or  a  large 
fist.  Haemorrhage  is  easily  controlled  by  liga- 
tion of  the  vessels  of  the  broad  ligament,  which 
can  always  be  found  without  difficulty.  The 
prognosis  of  the  operation  is  always  good  if  the 
mother  is  in  good  condition;  that  is.  is  not  ex- 
sanguinated by  copious  intra-abdominal  haemor- 
hhage  from  a  previous  rupture  of  the  tube. 

The  operation  in  the  latter  half  or  at  the  end 
of  pregnancy  is  usually  formidable.  The  extir- 
pation of  a  sac  which  often  fills  the  greater  part 
of  the  abdominal  cavity,  with  adhesions  to  innu- 
merable loops  of  intestines,  the  walls  of  the  sac 
varying  in  thickness  and  consistency  from  that 
of  tissue   paper   to  quarter  of  an  inch,  together 


with  the  danger  of  haemorrhage  from  a  full  grown 
placenta  which  may  be  divided  by  the  incision 
into  the  sac,  or  if  not  divided  may  even  by  slight 
detachment  at  its  border  cause  a  gush  of  blood 
which  would  fill  the  sac  in  a  minute;  such  condi- 
tions put  to  a  most  severe  test  the  presence  of 
mind  of  even  the  most  experienced  operator. 

The  considering  the  operation  in  the  latter 
half  of  extra- uterine  pregnane}-  we  distinguish 
between  laparotomy  with  living  child,  the  so- 
called  primary  laparotomy,  and  laparotomy  after 
the  death  of  the  child,  the  so  called  secondary 
laparotomy.  This  distinction  has  no  technical, 
but  only  a  prognostic  value  for  the  child  and 
mother. 

From  another  point  of  view,  we  distinguish 
between  the  radical  operation,  removal  of  the 
whole  of  the  fcetal  sac  with  its  contents,  child 
and  placenta,  and  the  non-radical  operation  or 
incision  of  the  sac,  a  linear  opening  into  the  sac 
large  enough  for  the  delivery  of  the  child,  and 
the  union  of  the  borders  of  this  incision  with  the 
opening  in  the  abdominal  wall.  As  regards  this 
latter  operation,  we  make  a  further  distinction 
between  the  operations  where  the  placenta  is  re- 
moved at  the  operation  and  those  in  which  it  is 
left  to  come  away  spontaneously  later  on,  or  as 
in  very  rare  instances  to  remain  in  the  peritoneal 
cavity,  where  it  partially  disappears  by  absorp- 
tion, or  may  be  transformed  into  a  mass  of  cica- 
tricial tissue,  as  has  been  observed  by  Goetsch 
and  Braithwaite,  on  the  outer  wall  of  the  uterus. 

It  is  evident  from  what  has  been  already  stated 
that  the  radical  operation  is  technically  the  most 
difficult  one,  for  on  account  of  the  nature  of  the 
so  called  sac.  its  total  removal  is  usually  difficult, 
and  very  often  impossible.  Thus  the  choice  be- 
tween incision  and  extirpation  would  require 
very  serious  consideration  in  the  individual  case, 
and  the  surgeon  will  often  find  himself  in  a  very 
serious  dilemma  in  this  regard. 

Thus  in  a  number  of  instances,  extirpation  of 
the  sac  has  been  commenced,  but  after  the  oper- 
ation has  been  partially  performed  the  extirpa- 
tion had  to  be  abandoned  on  account  of  the  im- 
possibility of  proceeding  further.  In  such  cases 
a  part  of  the  wall  has  been  extirpated  and  part 
united  with  the  abdominal  wound;  in  other  in- 
stances the  connection  of  the  sac  with  the  uterus 
has  made  it  necessary  to  amputate  the  latter,  in 
order  to  accomplish  the  total  removal  of  the  sac. 
The  advantage  of  the  total  removal  of  the  sac, 
even  if  it  involve  so  serious  a  complication  as  ab- 
dominal supra-vaginal  amputation  of  the  uterus, 
lies  in  the  control  of  haemorrhage  by  ligation  of 
the  uterine  arteries,  and  in  the  greater  security 
against  sepsis  or  intoxication  from  a  non-removed 
sac  and  placenta. 

The  prognosis  of  the  operation  as  given  by  the 
statistics  from  the  literature  up  to  date  shows  a 
remarkable  decrease  in  mortalitv  in  the  last  five 


TREATMENT  OF  EXTRA-UTERINE  PREGNANCY. 


[June  20, 


years.  Primary  laparotomy  was  attended  by  a 
very  great  mortality  up  to  the  end  of  1886.  Thus, 
Werth  reports  eight  cases  with  seven  deaths,  a 
mortality  of  eighty-five  per  cent.;  Litzmann,  ten 
cases  with  nine  deaths,  ninety  per  cent.;  Harris, 
thirty  cases  with  twenty-five  deaths,  eighty-three 
percent.  From  1887  to  1890  inclusive  we  find 
reported  by  Leopold  Meyer  seventeen  cases  with 
five  deaths,  a  mortality  of  thirty  per  cent.  This 
ma}-  be  fairly  considered  as  the  present  rnortality 
of  primary  laparotomy  for  this  condition. 

Up  to  1 886  the  mortality  of  secondary  laparotom  y 
was,  as  Litzmann  states,  to  a  great  extent  depend- 
ent upon  the  presence  or  absence  of  placental 
circulation.  The  operations  before  cessation  of 
placental  circulation  had  a  high  mortality.  In  ten 
cases  in  which  the  operation  was  done  within  the 
first  five  weeks  after  the  death  of  the  fcetus  there 
were  eight  deaths,  a  mortality  of  eighty  percent. ; 
while  later  operations,  from  six  weeks  to  a  year 
after  death  of  the  foetus,  had  a  much  less  mortal- 
ity; Litzmann  reports  twenty-three  cases  with 
six  deaths,  a  mortality  of  twenty-six  per  cent., 
and  Werth,  twenty-five  cases  with  eight  deaths, 
a  mortality  of  thirty-two  per  cent.  This  great 
difference  in  the  mortality  led  Litzmann  to  ad- 
vise against  operation  immediately  after  the 
death  of  the  fcetus  and  to  advocate  delay  until 
after  cessation  of  the  placental  circulation. 

For  the  last  four  years,  the  statistics  of  secon- 
dary laparotomy  show  a  still  better  prognosis. 
Leopold  Meyer  reports  seventy-two  cases  with 
twelve  deaths,  a  ruortality  of  only  eighteen  per 
cent.  As  far  as  can  be  observed,  the  secondary 
laparotomies  during  the  last  four  years  have  not 
been  performed  with  strict  regard  to  the  cessa- 
tion of  placental  circulation.  It  is  likely,  how- 
ever, that  Litzmann's  advice  has  caused  many 
operators  to  postpone  the  operation  as  long  as 
possible. 

The  prognosis  of  extirpation  as  compared  with 
incision,  so  far  as  the  statistics  of  the  last  four 
years  enable  us  to  judge  of  this  question,  shows 
very  little  difference  in  the  mortality  of  the  two 
operations.  Thirty-six  cases  of  extirpation,  or 
the  radical  operation,  have  been  reported,  with  six 
deaths,  a  mortality  of  sixteen  and  seven-tenths 
per  cent.;  and  sixty- four  cases  of  incision,  or  the 
non  radical  operation,  with  twelve  deaths,  a  mor- 
tality of  eighteen  and  seven-tenths  per  cent. 
Four  cases  were  reported  in  1890  of  partial  extir- 
pation; that  is,  cases  in  which  extirpation  was 
attempted  but  could  not  be  completed  on  account 
of  the  impossibility  of  freeing  the  sac,  with  two 
deaths,  a  mortality  of  fifty  per  cent.  It  will  thus 
be  seen  from  the  statistics  that  incision  has  been 
performed  nearly  twice  as  often  as  extirpation. 

In  the  non  radical  operation,  incision,  the 
question  has  been  raised  as  to  what  should  be 
done  aboul  the  placenta,  whether  it  should  be  re- 
moved or  left  in  situ.     The  attempt  to  remove  it 


had  its  justification  in  the  desire  to  obviate  the 
danger  of  sepsis  or  intoxication  from  the  consid- 
erable amount  of  dead  tissue  of  the  decomposing 
placenta.  The  danger  of  removing  the  placenta 
at  the  time  of  operation  is  on  account  of  the  diffi- 
culty or  impossibility  of  controlling  the  haemor- 
rhage from  the  sac  of  the  placenta.  It  has  been 
proposed  that  those  who  perform  the  radical  op- 
eration should  control  the  haemorrhage  in  one  of 
the  following  three  ways: 

1.  By  previous  ligature  of  the  spermatic  and 
uterine  arteries  before  removal  of  the  placenta. 

2.  By  ligature  e?i  masse  of  the  bleeding  parts 
of  the  placental  territory  of  the  sac  after  the  re- 
moval of  the  placenta. 

3.  By  pressure  from  packing  the  sac  full  of 
sterilized  gauze  impregnated  either  with  iodo- 
form or  with  a  mixture  of  salicylic  and  tannic 
acids. 

Ligation  of  the  spermatic  and  uterine  arteries 
can  be  done  only  in  cases  where  the  broad  liga- 
ments are  accessible.  This  is  probably  of  com- 
paratively rare  occurrence,  as  in  most  cases  in 
which  the  sacs  are  not  well  defined,  the  broad 
ligaments  and  uterus  are  hidden  below  the  pla- 
centa. 

Ligature  en  'masse  of  the  placental  territory  of 
the  sac  is  extremely  difficult  and  often  impossible, 
partly  because  of  the  enormous  haemorrhage 
from  this  territory  and  partly  because  of  the  dan- 
ger of  injury  to  the  intestines  if  in  close  proxim- 
ity to  the  bleeding  placental  site. 

Pressure  by  packing  the  sac  with  gauze  is  un- 
reliable, as  we  have  to  deal  with  a  cavity  which 
has  no  firm  walls  against  which  to  make  pres- 
sure. 

The  statistics  for  the  last  four  years  show 
twelve  cases  in  which  the  placenta  was  removed, 
with  four  deaths,  a  mortality  of  thirty-three  per 
cent.;  and  twenty-nine  cases  in  which  the  pla- 
centa was  left  undisturbed,  with  five  deaths,  a 
mortality  of  seventeen  per  cent.  Thus  we  may 
conclude  that  it  is  at  the  present  time  more  safe 
to  leave  the  placenta  intact,  as  was  done  in  the 
majority  of  cases,  or  at  any  rate,  to  limit  the  at- 
tempt to  remove  the  placenta  to  those  special- 
ly favorable  cases  where  the  afferent  vessels  can 
be  found  and  secured  before  its  removal. 

Fuial  Remarks. — The  most  important  points 
to  consider  in  extra-uterine  pregnancy  advanced 
beyond  four  months  are: 

1.  When  shall  we  operate? 

2.  And  what  operation  shall  be  done? 

The  question  of  the  time  for  operation  cannot 
be  solved  merely  by  looking  at  the  mortality 
from  the  statistics.  The  fate  of  the  child  I  shall 
leave  entirely  out  of  consideration,  as  I  believe 
that  very  few  operators  of  to-day  agree  with  Law- 
sou  Tait  in  weighing  the  life  of  the  child  against 
thai  of  the  mother, 

The  maternal   mortality  as  seen  in  the  statis- 


i89i.] 


TREATMENT  OF  EXTRA-UTERINE  PREGNANCY. 


88  s 


tics,  shows  as  stated  above,  a  great  difference  be- 
tween primary  and  secondary  laparotomy,  a  'lit 
ference  of  twelve  per  cent,  in  favor  of  the  latter. 
Notwithstanding  this,  a  number  of  modern  oper- 
ators are  inclined  to  give  up  the  secondary  oper- 
ation and  operate  as  early  as  the  diagnosis  is  made 
irrespective  of  the  child  or  of  the  placental  circu- 
lation. 

Certain  operators,  such  as  Olshausen,  Lawson 
Tait,  Thornton,  Werth,  Lusk,  Wilson,  Doran, 
Hart,  Martin,  and  others,  advocate  operating  as 
early  as  possible.  To  explain  this,  notwith- 
standing the  apparently  greater  safety  of  the  late 
operation,  there  must  be  a  fallacy  in  the  conclu- 
sions drawn  from  the  statistics.  This  fallacy  is 
the  following:  A  number  of  patients,  especially 
those  having  recurrent  attacks  of  peritonitis 
die  either  from  peritonitis  or  from  perforation  and 
sepsis  before  the  time  for  the  late  operation  has 
arrived.  If  these  cases  of  speedy  death  after  rup- 
ture were  included  in  the  statistics  of  the  mortal- 
ity of  the  secondary  operation,  its  percentage 
would  be  materially  increased. 

During  extra-uteiine  pregnancy  the  mother  is 
in  danger  all  the  time,  from  rupture  with  haem- 
orrhage and  sepsis.  It  is  impossible  to  know 
when  this  will  occur  and  it  has  often  been  ob 
served,  as  it  was  in  my  case,  that  rupture  has 
taken  place  during  the' time  of  waiting,  before 
the  day  set  for  the  operation. 

Rupture  is  always  followed  by  sepsis,  and  an 
operation  of  necessity  in  the  case  of  a  septic  pa- 
tient has  of  course  a  bad  prognosis.  Sometimes 
even,  death  will  come  so  suddenly  that  it  would 
have  been  impossible  to  perform  an  operation,  as 
in  an  instance  mentioned  by  Harris  in  which  the 
patient  died  half  an  hour  after  perforation  had 
taken  place. 

It  remains  true  that  a  number  of  extra-uterine 
pregnancies  go  through  to  full  term  without  rup- 
tare  or  even  after  term  for  months  or  years  :  It 
also  remains  true  that  the  longer  after  the  death  of 
the  foetus  the  operation  is  performed,  the  less  is 
the  mortality.  But  it  is  impossible  to  foresee  in 
a  given  case  whether  or  not  the  patient  will 
escape  rupture  and  sepsis.  Hence  the  conclusion 
to  operate  as  early  as  possible  as  a  prophylactic 
measure.  As  early  as  possible  means  as  early  as 
the  diagnosis  is  made,  and  this  I  consider  to  be 
the  standpoint  of  to-day  in  this  regard. 

If  the  future  repeats  the  history  of  the  past  we 
may  confidently  expect  that  the  prognosis  of  the 
early  operation  will  be  still  better  than  hereto- 
fore. Future  clinical  observations  should  enable 
us  to  maks  a  differential  diagnosis  between  two 
distinct  classes  of  cases :  The  one,  those  in 
which  perforating  peritonitis  does  not  take  place 
and  the  patient  is  in  no  danger  at  any  period  be- 
fore or  after  term  ;  the  other,  those  in  which  the 
patient  is  exposed  to  the  dangers  of  perforation 
and  sepsis  at  any  time.     When  this  stage  of  pro- 


gress has  been  reached  the  late  operation  may 
again  have  a  legitimate  field. 

The  question  of  the  choice  between  extirpation 
and  incision  is  much  more  difficult.  The  ain; 
equal  mortality  from  these  operations,  as  shown 
above  in  the  statistics,  helps  us  very  little  in  this 
respect,  as  it  does  not  indicate  by  any  means  an 
equal  choice  between  the  two  procedures. 

The  radical  operation,  desirable  as  it  is,  as  far 
as  control  of  sepsis  and  haemorrhage  is  concerned, 
can  be  done  only  in  a  limited  number  of  cases 
where  the  sac  is  so  uniformly  strong  and  the  ad- 
hesions so  favorably  arranged  as  to  make  this 
operation  possible.  In  a  large  number  of  cases 
incision  would  have  to  be  done  as  a  matter  of 
dire  necessity,  in  cases  in  which  the  condition  of 
the  sac  and  extensive,  short  adhesions,  especially 
to  the  intestines,  have  made  extirpation  im- 
possible. 

The  choice  between  the  two  operations  is  much 
more  difficult  after  the  sac  has  been  opened  and 
the  child  delivered,  for  it  is  often  impossible 
to  determine  whether  an  attempted  extirpation 
can  be  finished  or  not.  The  unfinished  operation, 
the  so-called  partial  extirpation,  has  a  mortality 
of  fifty  per  cent. 

A  difficult  radical  operation  will  tax  the  skill 
of  the  most  experienced  operator  to  its  utmost, 
and  the  attempt  to  loosen  the  sac  from  the  in- 
testines has  in  several  instances  resulted  in 
multiple  intestinal  wounds  followed  by  death 
from  shock  and  haemorrhage,  and  this  result  may 
follow  too  bold  an  attempt  in  this  direction  even 
during  the  operation.  Slight  manipulations  of 
the  sac  have  often  caused  such  a  formidable  and 
sudden  haemorrhage  from  the  placenta  that 
further  operating  has  been  rendered  well  nigh 
impossible. 

The  future  will  have  to  decide  whether  rapid 
removal  of  the  placenta,  and  hasmostasis  after  its 
removal,  can  be  advocated  as  a  justifiable  and 
safe  procedure. 

The  non-radical  operation  has  the  advantage 
of  being  easy  of  performance,  of  requiring  only 
a  slight  amount  of  operating  and  of  taking  but 
little  time.  Thus  it  would  seem  natural  that  this 
operation  should  be  preferred  by  less  experienced 
operators  in  all  cases. 

The  placenta  should  not  be  removed  in  the  op- 
eration of  incision  excepting  in  those  very  late 
cases  where  it  has  been  already  detached  and  lies 
loose  in  the  sac. 

BIBLIOGRAPHV. 


Ernst  Herman,  Obstetrical  Transactions.  Vol.  xxix, 
1SS7  Leopold  Meyer,  Copenhagen.  Litteratur  Over- 
sigt     Gvnakoloaiske     og    Obs  Meddelelser 

uderone  of  Prof.  F.  Howitz.  Band  ;.  Heft.  1.  2.  5.  Ibid, 
Baud  S.  Heft.  1,  2.  Bandl.  Deutsche  Chirurgie,  hirferung 
^9.  1SS6.  Harris.  American  Journal  of  the  Medical 
Sciences,  iSSS. 


[June  20, 


THE  JENNER  CKXTKXXI  VJ 

Tf  UPT^°{JkfnCrmm-ittee.  °"  the  Resolution  of  DR 
e  "n  centennial  of  the  Discovery  of  Vaccina- 
^n,6yfenner,  with  the  Opini/ofthT 

Members  of  the  Committee. 

thefort??3?06  '"^  3  resolution  introduced  at 

Medica?A  a?nUaI  meetin-  of  the  American 
-Medical  Association,  at  Nashville,  a  circular  J 

fenneTcent1"  T^  °f  the  ComnStTefof  T£ 
ion  v  frT  °f  th<LDis«>very  of  Vaccina- 
tion, by  the  Chairman,  Dr.  J.  M   Toner   s^Hncr 

ou„drT1UtJ0n  Up°n  "hich  the  SquirfwS 
founded,  and  sitting  forth  in  a  series,  nine  specific 
interrogatories,  which  are  hereby  appended  I 

C'''Z'n\r0rhe,Mrnbers  °Stke  Committee  of  the  4meri 
can  ^dtcalAssocjaHon  on  the  Jenner  CenUnnia'1 
of  the  Discovery  of  I  'am nation. 


under  revLw  a?5  ■  ^    ^ccmation   in  this  countrv 

for  £  oiSS^JKdJSSff  °f  thlS  ASSOCiati°n' 

resoriut?onAR  hD<lCT,ORrUnder  the  Vr^mUe  and 
dent  of th  a  hCadS  this  drcuIar>  the  ^Sl- 
immed t  Amer,cau  Medical  Association  has 
ui  eC°mrttee  thUS  auth°nzed.  of  which 
;    U  are  one-      Jt  is   an   agreeable  duty  for  me  to 

5on°ofnSet0  y°U  thlS  faCt  (althon*h  tbe  conTt  tu°: 
ton  of  the  committee  has  already  been  published 

your  eaJr°nUersntaI  °f  the  Associati°»).  an/to  solicit 
jour  earnest  cooperation  and  advice  in  the  mat 
ers  submitted  to  us,  that  we  may  co llect  the 
views  of  each  other  by  writing,  as  it  s  mani- 
festly   impracticable  to  have  a    meet  nl  J  th- 

could  attend  ;  but  by  a  correspondence   we  mav 

SSSitTi'h1*^  based  up°n  the  ^s°f  a 

ma onty   to  be  submitted  to  the  American  Med* 

view'of  ayieSire/°  aid  iH  takinS  a  comprehensive  I 

EveLZh011;   a'ld  the  benefit   which   »*s 
^coverj  has  been  to  the  world,  as  well  as  how 

mo  *  appropriately  the  medical  profession  of  th, 

»    > 0 v  of    h     Can  ^PrCSS   itS   ^ratitude  to  'he 
i  i  "!  thefgr?f  dls™™rer,  and,  at  the  same 

dSc'tifns  twV°  ■    ,Uie  bought  in   these 
•ons,  the  following  inquiries  are  formulated 
'»»  the  suggestions  of  the  preamble  and  resolu- 
tion creating  ftis  committee  ;  and  are  submitted 


for  your  considerate.     As   they  embrace  some 
ot  the  more  essential  points  of  the  project  specific 
j  replies  are  requested   to  each  of  these  inquiries 
j  in  their  respective  order. 

I  But  I  entreat  you  to  bear  in  mind  that  the 
,  whole  subject  embraced  in  the  resolution  is  sub- 
|  milted  for  our  consideration,  and  recommenda- 
ition  to  the  Association;  therefore,  take  these 
queries  only  as  spurs  to  reflection,  and  freely  sug- 
gest whatever  you  may  deem  important  and 
which  in  your  judgment,  will  add  interest  and 
value  to  this,  m  many  respects  the  most  im- 
portant event  in  the  history  of  medicine 

Inquiry  1     Is  it  desirable  and  feasible  for  the 
medical  profession  of  the  United  States  to  take 
special  notice  of  the  approaching  centennial  of 
the  discovery  of  vaccination  by  Dr.  Jenner,  and 
it  so,  to  do  it  in  so  considerate  and  thorough  a 
manner  as  to  give  to  the  occasion  a  pronounced 
professional,    scientific    and    historic   character  > 
JJTT  Judplent  approves  of  the  purposes  indi- 
cated in       Inquiry  i,"    please  give   briefly  the 
chief  reasons  which  occur  to  you  for  such  action 
on  the  part  of  the  profession.      Designate  your 
answers  to  ' '  Inquiry  1  • '  «,  b,  c,  d,  e.     But  if  your 
judgment  be  against  "Inquiry    ,,"   please  give 
briefly  your  reasons  for  such   a  conclusion  and 
designate  them  as  No.  1,  a,  b,  c,  d,  e. 
K;t^qUf'ry  2"  If  >'ou. approve 'the  general  propo- 
sition for  a  systematic  observance  by  the  medical 

fhat  the°nA     thC  Un^d, St3teS'  is  il  ^0"^  opinion 
that  the  American   Medical  Association  should 
I  dignify   the  occasion   by  providing  for  compre- 
|  hensive  reports  on  vaccination  from  all  the  States 
and    devote    at    least   one   day    that   year    (say" 
J  Ihursday,  during  the  annual  session),  for  their 
consideration,   embracing  an  eulogy  on  Jenner 
j  and  addresses  and  papers  from  special  students 
I  on  vaccination,  and  by  the  members  of  the  Cen- 
;  tenn.al  Committee,   or  parties  selected  by  them 
from  the  several  states,  with   voluntary   papers 
etc.,  covering  the  practical,  as  well  as  the  popul 
lar  side    in    the    history    of  vaccination  in    our 
own  country  during  the  century. 

Inquiry  3.  The  approval  of  the  general  project 
of  course  carries  with  it  the  necessity  of  outlin- 
ing with  some  degree  of  definiteness,   the  scope 
1  "I,, -,  tIdleS  and  'nqmries  proper  to  be  made,  and 
whi  h  may  tend  to  honor  Jenner  and  redound  to 
j  the  credit  of  the  profession  of  the  United  States 
i  tn       a°swe"nS  "Inquiry  3,"   you  are  requested 
to  outline  the  scope  and  extent  of  the  inquiries 
you  would  deem  it  desirable  to  have  made,     a, 
How  and  by  whom  collected  ?     b,    Is  it  best   to 
have  one  person  in  each  State  responsible  for  the 
work  in  Ins  own  State,   with  such   assistance  2 
He  may  evoke  to  collect  the  data?     c.    Would 

characte? or"  !    "eDtenniaI    *™s    assume    the 
™ t  £         symposunn,   where   each   partici- 

wr it  rrU'd  TP0Ud   l°  a"    aSS''£"ed   thei»e  »»  a 
written  report  or  paper,  and  thus  cover  the  whole 


i8yr.] 


THE  JENNER  CENTENNIAL. 


887 


field  for  each  and  every  State,  city  and  county  in 
the  Union?  for  the  Array,  the  Navy  and  the  Ma- 
rine-Hospital Service  :  or  d,  would  you  central- 
ize and  ignore  State  lines,  the  Army,  the  Navy, 
etc. ,  aud  speak  in  general  terms  for  the  country 
as  a  unit  and  a  Nation  ? 

Inquiry  4.  Is  it  desirable,  aud  would  you  ad- 
vise, that  an  effort  be  made  to  collect  as  far  as 
possible,  all  the  facts  relating  to  the  history  of  j 
vaccination  in  our  country,  and  have  them  em- 
braced  in  a  history  of  the  progress  and  practice 
in  each  of  the  several  States,  counties,  cities  and 
municipalities  of  our  country,  by  forming  com- 
mittees in  each,  who  should  procure  copies  of  all 
the  laws  and  regulations  which  have  once  been 
in  force,  as  well  as  the  existing  laws  and  regula- 
tions, whether  advisory  or  compulsory  in  the 
several  States  and  cities  in  the  United  States,  the 
Array,  the  Navy  and  the  Marine-Hospital  Service, 
to  be  embraced  in  a  report  to  be  made  by  the 
Jenner  Centennial  Committee  to  the  American 
Medical  Association  in  our  centennial  year. 

If  you  approve  of"  Inquiry  4,"  please  give 
briefly  the  chief  reasons  for  your  conclusions,  and 
record  them  as  Xo.  4,  a,  b,  c. 

If  you  disapprove  "Inquiry  4."  please  give 
briefly  the  reasons  for  your  conclusions,  and  re- 
cord them  as  Xo.  4,  a,  b,  c. 

Inquiry 5. — Is  it  practicable,  and,  if  practica- 
ble, would  it,  in  your  opinion,  be  of  historical 
value  to  the  profession  to  collect,  as  far  as  possi- 
ble, copies  of  all  documents  and  publications 
which  have  been  in  any  way  connected  with  vac- 
cination, whether  appearing  in  book  form, 
pamphlet,  report,  newspaper,  journal,  broadside, 
etc..  which  have  appeared  in  any  State  or  city  in 
the  Union  since  the  discovery  of  vaccination?  a — 
Where  printed  copies  cannot  be  had  should  man- 
uscript copies  be  made;  or,  b,  exact  titles  of  them, 
when  and  where  printed,  be  made  ? 

If  you  approve  of  "  Inquiry  5."  please  state 
the  chief  reasons  in  its  favor  and  record  them  as 
Xo.  5,  a,  b,  c,  d. 

If  you  disapprove  of  "Inquiry  5,"  please  state 
chief  reasons  for  such  conclusions  and  record 
them  as  No.  5.  a,  b.  c.  d. 

Inquiry  6. — Is  it  desirable  to  have  a  wide  dis- 
cussion on  the  practical,  as  contra-distinguished 
from  the  historical,  side  of  vaccination  in  the 
proposed  Centennial,  to  include  the  most  approv- 
ed methods  to  secure  the  fullest  benefits  of  the 
operation  ? 

a — The  advantages  of  bovine  virus  over  that 
which  has  passed  through  the  human  system: 

b — The  cause  of  alleged  failures  of  vaccination 
to  protect  against  small-pox: 

c — The  advisability  of  compulsory  laws  to  se- 
cure general  and  universal  vaccination: 

d — And,  in  view  of  the  fact  that  disparaging 
remarks  are  occasionally  made  and  published  by 
people  of  education  and  influence,  should  we  not, 


in  the  most  positive  and  unqualified  manner,  de- 
clare our  confidence  in  bovine  vaccination  as  a 
complete  protection  against  small-pox?  What 
othtr  subjects  would  you  admit  to  the  discussion? 

If  you  deem  it  desirable  to  have  the  practical 
side  of  vaccination  discussed,  please  give  briefly 
the  chief  reasons  in  its  favor  and  record  them  as 
Xo.  6,  a,  b,  c. 

If  you  deem  it  inadvisable  to  discuss  this  prac- 
tical side  on  such  an  occasion,  assign  the  chief 
reasons  which  present  themselves  to  you  and  re- 
cord them  as  Xo.  6.  a,  b,  c. 

Inquiry  7. — From  your  acquaintance  with  the 
medical  gentlemen  of  your  State,  what,  in  your 
opinion,  is  the  best  method  of  engaging  their 
hearty  cooperation  in  collecting  such  information 
as  will  make  the  proposed  Centennial  of  Jenner's 
great  discover  at  once  an  ovation  to  his  memory, 
a  credit  to  your  State,  and  a  benefit  to  the  medi- 
cal profession  of  America? 

Here  give  your  views  as  to  the  efficiency  of  the 
cooperation  which  may  be  expected  from  proper 
applications  to  your  organized  medical  societies, 
State,  count}-  and  city. 

b — Make  suggestions  as  to  any  method  of  ob- 
taining the  historical  data  for  your  State  which 
may  occur  to  you. 

c — Have  you  one  or  more  authors  or  experts  on 
vaccination  whose  appointment  on  a  committee 
would  command  the  confidence  of  the  profession 
of  your  State  and  secure  the  cooperation  of  their 
medical  brethren  ? 

d — Should  the  committees  to  collect  data  in  the 
several  States  consist  of  one  or  more  members? 

Inquiry  S. — Unfortunately,  State  Medical  So- 
cieties do  not  exist  in  all  the  States,  nor  do  local 
societies  exist  in  all  the  counties  in  those  States 
where  there  are  State  Medical  organizations,  al- 
i  though  the  theory  on  which  the  American  Med- 
ical Association  is  formed,  contemplates  the 
count}'  medical  society  as  the  unit  of  organiza- 
j  tion,  whose  delegates  shall  constitute  and  form 
the  State  Medical  Society.  Where  County  Med- 
ical Societies  exist,  should  they  in  ever}-  case  be 
applied  to  for  aid  ?  To  what  extent,  in  your 
opinion,  can  these  be  relied  upon  to  cooperate  in 
the  collection  of  the  data  required  for  the  reports 
suggested? 

Here  express  your  own  views,  and  for  your  own 
State. 

Inquiry  p. — Where  County  Medical  Organiza- 
tions do  not  exist,  and  where  existing  County 
Medical  Societies  fail  to  cooperate  when  request- 
ed, what  expedient  can  be  adopted  to  secure  from 
these  localities  the  data  required? 

T6  meet  such  contingencies,  would  it  be  expe- 
dient aud  desirable  to  have  lodged  with  the  Chair- 
man of  the  General  Centennial  Committee  the 
power  to  appoint  one  or  more  reputable  physi- 
cians as  a  committee  in  such  counties  to  furnish 
the  desired  information? 


THE  JENNER  CENTENNIAL. 


[JUNE-20, 


Give  your  view  of  the  desirableness  of  the 
power  asked  for  in  this  "Inquiry  9."  As  a  mem- 
ber of  the  committee,  volunteer   whatever  su; 


to  take  special  notice  of  the  approaching  centennial  of 
Jenner's  great  discovery,  Hay  14,  1896,  a,  as  honoring 
the  meuiorv  of  a  great  man  and  a  noble  philanthropist; 
b,  to  give  renewed  public  confidence  in  the  prophylactic 


gestions    vou    think   may  serve    to    dignify    and  |  virtue  of  vaccination,  in  refutation  of  the  teachings  of 
make  profitable  the  proposed  Centennial  of  the  \  the  anti-vaccinationists;  c,  for  the  purpose  of  convincing 

7:  ^  ,  5  a  4-t,« :i      the  public  of  the  mischievous  writings  for  the  public  of 

discovery  of  vaccination,  and  secure  the  compil- 1  Dr  £has  Creii?hton  in  the  Encyclopedia  Brittanica  and 
ation  of  as  complete  a  history  of  the  beneficence 


of  its  practice  in  the  United  States  as  practicable 
You  are  earnestly  requested  to  give  to  this  sub- 
ject an  early  consideration.     A  want  of  uniform- 
ity in  responses,  with  the  new  and  valuable  sug- 
gestions not  here  presented  or  as  yet  thought  of, 
will  require  much  correspondence,    and  the  re- 
polling  of  views  so  as  fairly  to  embrace  the  judg- 
ment of  the  majority  of  our  committee  in  a  report. 
You  are  particularly  requested  to  number  your 
responses  to  all   inquiries  as  suggested,   so  as  to 
facilitate  the  work  of  tabulating  the  views  and 
recommendations  of  the  several  members. 
Mail  your  answers  to  Dr.  J.  M.  Toner, 

Chairman  of  Committee  of  American  Medical 
Association. 

615  Louisville  Ave.,  Washington,  D.  C. 

Replies  were  received  from  twenty-two  States, 
as  follows:  Alabama,  Connecticut,  Delaware,  Dis- 
trict of  Columbia,  Florida,  Indiana,  Iowa,  Illi- 
nois, Kentucky,  Kansas,  Maryland,  Missouri, 
Michigan,  Minnesota,  Massachusetts,  Nebraska, 
New  Jersey,  New  Hampshire,  North  Carolina, 
Ohio,  Pennsylvania,  Wisconsin  and  Yirginia. 

Your  Committee  have  thought  best  to  present 
the  substance  of  the  replies  which  have  come  in 
from  the  different  States,  in  order  to  place  the 
matter  fairlv  before  the  Association. 

Reply  to  Inquiry  1. — "Is  it  desirable  and  feasible  forthe 
medical  profession  in  the  United  States  to  take  special  no- 
lice  of  the  approaching  centennial  of  the  discovery  of 
vaccination  bv  Dr.  Jenner?"  etc.,  was  answered  in  the 
affirmative  bv  Alabama,  Connecticut,  Delaware,  District 
of  Columbia, "Florida,  Indiana,  Iowa,  Illinois,  Kentucky, 
Kansas,  Maryland,  Michigan,  Missouri,  Minnesota,  Mas- 
sachusetts, New  Hampshire,  New  Jersey,  North  Carolina, 
Ohio,  Pennsylvania,  Virginia  and  Wisconsin,  the  lan- 
guage of  each  being  emphatic  in  tone,  as  a  few  extracts 
will  show: 

Dr.  Jno.  R.  Quinan,  of  Maryland  (since  dead)  writes: 
"A  centennial  celebration  of  the  discovery  of  vaccina- 
tion is  highly  desirable,  a,  as  an  evidence  of  our  grateful 
remembrance  of  Jenner:  b,  as  an  additional  proof  of  our 
entire  and  abiding  confidence  in  the  efficacy  of  vaccina- 
tion; c,  as  a  means  of  calling  the  attention  of  the  public  to 
its  advantages,  and  teaching  it  anew  the  lasting  and  ines- 
timable debt  it  owes  to  our  profession  in  the  discovery  of 
the  greatest  boon  ever  offend  to  the  human   race." 

I'rof.  C.  A.  Lindslev,  of  Connecticut,  says:  "The  rec- 
ognition of  the  discovery  of  vaccination  at  its  centennial 
anniversary  has  my  most  hearty  approval,  a,  because  it 
has  contributed,  moreto  the  welfare  of  mankind  than  any 
other  disco  mse  it  is  justly  due  to  the  great 

discoverer  that' the  lustre  of  the  name  of  Jenner  be  made 
to  shine,  that  all  men  may  pay  it  deserved  homage";  c, 
because  in  these  days  of  centennial  celebrations,  an  omis- 
sion would  be  discreditable  to  our  profession,  and  would 
uragement  to  those  aberrant  and  erratic  minds 
who  would  defame  Jenner,  and  deny  the  value  of  vacci- 
nation." 

Dr.  Jno.  P.  Ware,  of  Florida,  says:    ".   .  it  is  desirable 


cyclopsedi; 
in  the  Arena  magazine." 

Dr.  Jas.  F.  Hibberd,  of  Indiana,  says:  "Yes,  it  seems 
both  desirable  and  practicable  for  the  profession  in  the 
United  States  to  take  special  notice  of  Jenner  and  vacci- 
nation at  the  centennial  of  his  discovery,  a.  It  will  be 
a  suitable  and  favorable  time  to  freshen  up  the  subject, 
and  impress  the  people  of  this  country  with  the  nature 
and  value  of  vaccination;  b.  Dr.  Jenner's  memory  should 
have  distinguished  consideration  forthe  acumen  that  led 
him  to  discover  vaccination,  and  for  the  courage  with 
which  he  wrought  out  the  problem  to  a  demonstration  in 
the  face  of  great  discouragement;  and  Americans  should 
do  this  honor  as  testifying  to  their  appreciation  of  the 
imperishable  fame  that  attaches  to  the  name  of  Jenner, 
and  at  the  same  time  constituting  an  expression  of  Amer- 
ican admiration  for  pluck,  and  as  an  encouragement  to 
young  scientists  who  may  encounter  similar  stumbling- 
blocks." 

The  only  qualified  approval  was  from  a  distinguished 
student  of  vaccination  in  New  York,  who  believes  "it 
would  be  better  for  the  American  profession  to  cooperate 
w'ith  their  colleagues  in  other  countries  than  to  celebrate 
on  their  own  account." 

Reply  to  Inquiry  2.  —  "If  you  approve  the  general 
proposition  for  a  system  of  observance  by  the  medical 
profession  of  the  United  States,  is  it  your  opinion  that 
the  American  Medical  Association  should  dignify  the  oc- 
casion by  providing  for  comprehensive  reports?"  etc. 
All  the  reporters  agree  with  the  general  proposition,  ex- 
cept that  a  few  think  three  days  little  enough  time  to  de- 
vote to  such  a  great  question.  The  late  Dr.  Quinan.  who 
is  among  this  number,  says:  "  While  heartily  endorsing 
the  efforts  of  the  American  Medical  Association  in  this 
regard,  I  do  not  think  one  day  sufficient  to  do  justice  to 
anv  programme  of  exercises  at  all  worthy  of  the  occa- 
sion. Three  days  at  least  ought  to  be  devoted  to  it.  The 
first  day's  exercises  should  embrace  the  history  and  liter- 
ature of  vaccination,  including  eulogies  on  the  life  and 
labors  of  Jenner;  of  Waterhouse,  of  Massachusetts.  Sea- 
man, of  New  York,  James  Smith  and  others  of  Mary- 
land, J.  R.  Cox,  of  Philadelphia,  Dr.  Gantt.  of  Washing- 
ton, Dr.  Wardlaw,  of  Virginia,  Dr.  Ramsay,  of  South 
Carolina;  a  report  on  the  literature  of  vaccination;  the 
statistics  and  scientific  aspects  of  vaccination.  The  third 
dav  to  be  devoted  to  papers  on  the  practical  results  and 
blessings  to  the  public." 

Report  on  Inquiry  j,  as  to  the  "scope  and  extent  of 
the  inquiries  you  would  deem  it  desirable  to  make,"  etc. 
Maryland  would  select  a  representative  man  from 
each  State  to  collect  the  data  required,  except 
where  the  small  size,  contiguity  of  territory  and  simil- 
aritv  of  history  in  regard  to  vaccination  admits  of  group- 
in:;  them;  hence  he  would  have  but  one  appointee  from 
New  England,  one  from  New  Jersey  and  Delaware,  one 
from  District  of  Columbia,  but  one  forthe  territories,  and 
one  from  the  Pacific  States,  the  other  states  should  have 
one  each. 

Alabama  "Suggests  one  able  and  competent  person 
collect  the  data  wanted  with  the  assistance  of  one  per- 
son in  each  State.  Thinks  there  should  be  only  one  per- 
son from  a  State,  and  that  it  would  be  desirable  to  cen- 
tralize  and  speak  for  the  country  as  a  unit."  etc. 

Wisconsin  thinks  a  committee  from  each  State  would 
be  advisable,  and  the  experts  might  be  invited  to  prepare 
papi  1  ■■;  would  centralize  and  treat  the  whole  country  as 
a  unit. 

thinks  the  scope  of  enquiry  might   be  modified 
by  the  character  of  the  investigation  being  made  by  the 


1 891.] 


THE  JKXNER  CENTENNIAL. 


889 


Royal   Vaccination  C mission,  Great  Britain;  not  ad- 

visable  to  follow  in  their  track. 

Massachusetts:  \  ■  ul onji  nner  and  reading  of  pa- 
pers on  different  phases  of  the  question  by  special  stu- 
dents of  vaccination.  Special  Btudents  should  prepare 
papers — these  being  selected  by  the  committee  or  being 
volunteers  approved  by  the  committee. 

North    Carolina:  The   inquiries   should    be   b 
statistical  and  scientific. 

Pennsylvania  thinks  that  every  phase  of  knowledge  ol 
vaccination  should  be  inquired  into.  The  prophylactic 
power;  the  duration  of  protection,  and  the  value  of  re- 
vaccination;  the  unfortunate  results  of  vaccination  ami 
how  to  guard  against  them;  the  relative  value  of  bovine 
and  humanized  lymph;  a  discussion  of  the  question 
whether  or  not  could  vaccination  be  made  more  gen- 
eral by  a  compulsory  law. 

New  Jersey:  Dr.  K/.ra  M.  Hunt.N.  J., answers  yes!  "That 
the  claims  of  Jennerto  recognition  are  being  disputed  by 
those  of  scientific  and  professional  reputation,  and  that 
this  disputation  involves  the  whole  subject  of  vaccina- 
tion. 

"The  article  of  Dr.  Creighton  in  the  Encyclopaedia 
Brittanica,  his  utterances  since,  his  testimony  before  the 
parliamentary  commission  that  vaccination  is  of  no  value; 
the  two  wonderful  volumes  of  Prof.  Crookshanks  and 
his  concurrence  in  this  opinion,  and  the  position  of  the 
anti-vaccinationists  generally  is  such  that  however  much 
we  assert,  their  views  must  be  met  by  facts  and  counter 
evidence." 

Investigation  should  be  made  by  State  Medical  Soci- 
ety. State  and  city  boards  of  health.  The  headships  of 
committees  should  be  given  to  one  who  has  time  and  ac- 
curate capacity,  not  for  long  rhetoric  or  long  essay,  but 
collective  investigation  with  authorities  attached.  The 
best  evidences  of  the  value  of  vaccination  in  its  best 
form,  by  a  full  committee  formed  of  the  chairman  of  the 
local  committee  named,  who  in  order  for  success  should 
have  for  a  year  or  more  a  paid  secretary. 

Michigan:  Would  have  one  person  to  summarize  in 
general  for  the  country  as  a  unit  and  a  nation. 

New  Hampshire:  Thinks  the  investigation  and  the 
history  of  the  introduction  into  the  United  States  should 
be  by  one  man. 

Missouri:  Thinks  that  the  question  as  to  the  nature  of 
the  investigation  may  be  best  left  to  a  central  committee, 
but  that  to  secure  system  and  coherence  the  same  com- 
mittee should  direct  the  preparation  of  assigned  themes, 
reports,  etc. 

Kansas:  Physicians  should  be  appointed  to  the  work. 
Definite  topics"  should  be  assigned  to  those  selected,  that 
the  whole  ground  may  be  covered  and  repetitious 
avoided.  States  might  be  dealt  with  individually  and  a 
member  might  be  selected  from  Army.  Navy  and  M.-H.  S. 
/  'irginia: — Would  select  the  State  Vaccine  agent, 
where  there  is  such  an  officer  to  be  chosen  of  State  com- 
mittee ou  Centennial.  Would  not  require  State  lines  in 
the  inquiry. 

Kentucky: — Would  entirely  ignore  State  local  lines  and 
limits.  Has  little  confidence  in  the  attempt  to  gather 
statistics  from  various  States  and  smaller  political  divis- 
ions. 

Iowa: — Would  have  a  committee  from  each  State  col- 
lect data  presenting  condition  of  laws  regarding  vaccina- 
tion, and  make  arrangements  for  a  general  address  by  a 
speaker  by  them  selected. 

Delaware: — Would  be  desirable  to  condense  and  tabu- 
late all  facts  and  papers  received,  on  history  of  the  dis- 
covery, benefits  derived  from  it,  necessary  legislation  re- 
quired to  make  it  effective. 

Indiana: — Scheme  should  embrace  a  succinct  history 
of  the  use  end  progress  of  vaccination  in  England,  and 
in  a  general  wav  the  world  over.  When  its  introduction 
spread  over  the"  United  States.  All  of  this  should  be 
conducted  under  the  superintendence  of  one  person 
thoughtfully  selected  by  American  Medical  Association,    charge 


1  to  select  his  own  advisers  and  assistants. 

)Dil<: — Would  centralize  and   ignore   State  lines, 
the  army,   the  navy,    the    marine    hospital    service,    and 
in  general  terms  for  the  country  as  a  unit  and  as  a 
nation. 

Connecticut: — The  work  could  by  a  small 

committee,  yet  in  large  States  a  different  plan  might  be 
preferred.  Vaccination  applies  to  all  mankind. 
Inquiry  4. 
"Is  it  desirable  .  .  .  that  an  effort  be  made  to  collect 
as  far  as  possible  all  the  facts  relating  to  the  history  of 
vaccination  ?  in  our  country  ....  by  forming  com- 
mittees in  States,  counties,  cities,  etc." 

Connecticut: — It  would  make  a  large  library. 
New  York: — Would  be  exceedingly  bulky  and  of  little 
value. 

Indiana: — It  would  be  impracticable  to  get  material 
for  each  county,  etc.  Would  be  a  waste  of  time  and  hunt 
for  two  grains  of  wheat  in  two  measures  of  chaff. 

Alabama: — Impracticable  to  embrace  much  minute 
matter  in  the  report. 

Michigan: — Would  not  deal  with  counties  or  cities  ex- 
cept a  few  of  the  largest. 

New  Hampshire: — For  the  purpose  of  historical  pre- 
servation research  should  be  made,  but  by  one  man. 

Missouri: — Desirable   to    have    the   history  but   don't 
know  if  it  is  practicable.    Would  make  the  effort. 
Kansas: — Thinks  it  ought  to  be  done. 
Iowa: — Would  make  a  memorial  volume,  and  let  com- 
mittee control  the  continent. 

Delaware: — It  would  be  desirable  to  condense  histori- 
cal matter. 

North  Carolina: — Thinks  it  desirable  to  make  the  his- 
torical research. 

Pennsylvania: — Approves  of  the  research  but  advises 
no  printing  tedious  details. 

New  Jersey:  -Would  by  all  means  make  the  effort. 
Virginia: — Thinks  as  it  is  a  historical  commemoration 
that  all  the  historical  facts  should  be  collected. 

Massachusetts: — A  general  history  of  vaccination 
should  be  obtained  for  this  country. 

Ohio: — Thinks  it  desirable  to  collect  a  sufficient  num- 
ber of  data  to  establish  the  history  and  nature  of  the  laws. 
Wisconsin: — Don't  think  it  would  be  practicable  to 
collect  details. 

Maryland: — Thinks  that  historical  data  should  be  col- 
lected and  sets  forth  the  heads  of  subjects  to  be  investi- 
gated historically. 

inquiry  5. 
"  Is  it  practicable  to  collect  books  and  documents,"  etc. 
New  York  auswers  negatively. 
Maryland  does  not  think  it  practicable. 

INQUIRY  6. 
"Is  it  desirable  to  have  a  wide  discussion  on  the  prac- 
tical as  contradistinguished  from  the  historical   side  of 
vaccination?  " 

New  Ybrk  thinks  it  would  not  be  profitable. 
Maryland  thinks  it  would  if  judiciously  done,  etc. 
New  Jersey  thinks  discussion  will  be  desultory. 
North  Carolina  thinks  it  uot  well.     The  well  informed 
would  agree,  but  the  erratic  might  make  it  a  time  to  air 
hobbies  of  anti-vaccination. 

INQUIRY  7. 
"  From  your  acquaintance  with  medical  gentlemen  of 
your  State,  what  is  the  best  method   of  engaging  their 
hearty  cooperation?" 

Kansas: — "  By  personal  application  and  through  local 
State  Societies  they  will  all  cooperate  mildly.  Give  one 
charge  of  the  work,  with  power  to  appoint  assistants." 
Delaware  "thinks  through  local  societies." 
Iowa: — State  Medical  Society  is  an  active  body.  He 
knows  of  no  experts  in  Iowa.  Knows  a  hundred  scien- 
tific physicians  who  would  give  their  experience. 

Kansas: — Xo   available   statistics.     Give   one   person 


890 


THE  JEXNER  CENTENNIAL. 


[June  20, 


Missouri  thinks  the  general  profession  will  take  little 
interest  in  it.  Facts  can  only  be  had  bv  enlisting  clerks 
of  Boards  of  Health  and  engaging  the  interest  of  secre 
taries  of  reputable  vaccinologists. 

Neu 'Hampshire: — Very  little  information  outside  of 
the  brief  history  of  introduction  could  be  obtained  from 
New  Hampshire.     No  one  has  given  special  attention. 

Michigan: — "Has  an  impression  that  the  Committee 
does  not  need  the  cooperation  of  the  practitioners  in  gen- 
eral of  that  State,  but  the  careful  painstaking  of  the  few, 
perhaps  not  more  than  one  or  two  in  each  State." 

Indiana: — "  There  would  be  an  uncertain  amount  of 
good  material  obtained  through  the  State  Medical  Soci- 
ety; best  results  would  be  obtained  bv  submitting  it  to 
the  consideration  of  County  Societies  "through  State  So- 
cieties. He  knows  of  no  expert  in  Indiana.  Best  results 
would  be  obtained  by  committing  the  affairs  in  each 
State  and  Territory  to  one  competent  person,  who  would 
work  under  a  plan  formulated  by  a  chief." 

New  Hampshire:— By  circular  letters  submitted  to 
such  members  of  the  profession  as  would  be  most  likely 
to  be  interested  and  render  active  assistance. 

-  Ua6ama:—"The  State  Board  of  Health  of  Alabama 
is  the  proper  source  from  which  to  gather  all  necessarv 
matter." 

New  York: — "  I  would  deal  with  individuals  and  not 
with  societies,  to  one  man  in  each  State;  in  New  York 
to  the  Surgeon  General  of  the  State." 

New  Jersey:— Knows  of  no  man  who  could  be  called 
an  expert,  but  selection  could  be  made  bv  the  State  Med- 
ical Society  of  the  best  persons  for  the  purpose. 
inquiry  S. 
"Where  County  Medical  Societies  exist  should  they  in 
every  case  be  applied  to  for  aid?" 

This  query  is  answered  mostly  under  7th  inquiry. 
inquiry  9. 
"Would  it  be  expedient  and  desirable  to  have  lodged  with 
the  Chairman  of  the  General  Centennial  Committee  the 
power  to  appoint  one  or  more  reputable  phvsicians  as  a 
committee  in  such  counties  to  furnish  the  desired  infor- 
mation." 

North  Carolina:— It  would  be  best  to  invest  a  Central 
Committee  with  the  function  of  making  selections  of  the 
fittest  men  for  the  work  by  consultation  with  the  State, 
county,  city  medical  organizations  and  with  medical  li- 
brarians, or  others  acquainted  with  acquirements  of  med- 
ical scholars. 

New  York: — Thinks  data  would  be  useless,  therefore 
does  not  advise  means  to  collect  them. 

Indiana:— "The  Chairman  in  chief  of  the  General 
Committee  should  be  empowered  to  make  appointments 
such  as  alluded  to  in  this  inquiry  and  should  also  be 
authorized  to  delegate  this  power  of  appointment  to 
others  where  in  his  judgment  it  would  further  the  pur- 
pose of  the  undertaking." 

Connecticut:— "Give  the  Chairman  of  the  General  Com- 
mittee power." 

'.■<■;■/.•— "Believes  that  power  to  appoint  should  be 
vested  in  the  general  chairman." 

Alabama:— Would  suggest  the   appointment   of  one 

man  in  each  State  and  allow  him  to  exercise  his  own  pre- 

111  gathering  data;  and  the  State  reporter  could 

draw  upon  any  physician  he  wishes  as  an  individual. 

Kansas:— The  general   subject  is  put  in  the  hands  of 

al  Committee.     It  is  impracticable  to  have  meet. 

entirely  willing  to  impose  upon  the  Chairman 

such  members  as  lie  may  call  to  his  assistance. 

Hampshire: — Let  the  men  appointed  to  read  pa- 
pers  do  it  entirely  in  their  own  way,  and  let  til 
sponsible  for  their  work. 

Delaware: —  "Where  there  are  no  societies  the  duty 
might  fall  on  health  boards,  college  faculties,  or  eminent 
members  oi  the  profession." 

Iowa: — In  the  event  of  no  societies,  he  would  call  on 
indh  iduals. 


Pennsylvania:— Would  give  Chairman  of  Centennial 
Committee  power  to  act,  adopting  anv  means  he  sees  fit 
to  collect  information  from  any  State  or  territorv. 

/  'irginia:— Better  to  leave  the  appointment  of'the  best 
men  for  the  work  to  a  State  Committee  or  State  Medical 
Society. 

Florida:— Think  it  would  be  well  to  leave  it  to  Chair- 
man of  Centennial  Committee  to  appoint. 

Massachusetts:— -It  would  be  best  to  leave  to  Centen- 
nial Committee  Chairman. 

Ohio:— Let  the  Centennial  Committee  appoint  in  each 
State  and  territory  a  State  Committee  of  three  and  where 
there  is  a  State  Medical  Society  appoint  the  Secretary-  or 
President  of  Society  a  member  of  this  committee.  "Let 
the  State  Committee  appoint  a  committee  of  three  in  each 
county,  and  where  a  county  society  exists  appoint  the 
President  or  Secretary  a  member  of  the  committee  etc 
etc. 

THE  JEXNER  CENTENNIAL  COMMITTEE. 

Drs.  J.  M.  Toner,  Washington;  C.  H.  Franklin,  Union 
Springs,  Fla.;  P.   O.   Hooper,   Little  Rock,  Ark.-  G   G 
Tyrrell,  Sacrameuto.Cal.;  P.W.  Carlin,  Denver,  Col.;  C  \ 
Lmdsley,  New  Haven,  Conn.;  F.  P.  Kenyon, Fargo   Dak  • 
W.  B.   Reynolds,  Wilmington,   Del.;  J.  "P.  Wall,  Tampa' 
Fla;  Eugene  Foster,  Augusta,  Ga.;  J.  H.  Ranch,  Sprint 
field,  111.;  J.  F.  Hibbard,  Richmond,  Ind.;  W.  F    Peck 
Davenport,  Iowa;  W.  L.  Schenck,  Osage  Citv,  Kan.- J  N 
McCormick,  Bowling  Green,  Kv. ;  Joseph  Jones   New  Or- 
leans; F.H.  Gerrish.Portland.M'e.J.R.  Quinan,  Baltimore 
Md.;  S.  C.  Martin,  Boston,  Mass.;  H.  B.  Baker,  Lansiu" 
Mich.;  Perry  H.  Millard,  St.  Paul,  Minn.;  Wirt  Johnson' 
Jackson,  Miss.;  W.  A.  Hardaway,  St.  Louis;  W.C.  Bryant' 
Omaha,   Neb.;  G.   P.   Conn,   Concord,  N.  H.-  Ezra  m' 
Hunt,  Trenton,  N.  J.;  J.  P.  Raster,  Albuquerque,  N.  M  • 
F.   P.   Foster,  New  York,  N.  Y.;  Thos.  F.    Wood    Wil- 
mington,  N.   C;  C.   O.    Probst,    Columbus,   O  ;  W.    D 
Baker,   Astoria,   Ore.;  W.   H.   Welch,   Philadelphia-    G 
D.  Hersey,  Providence,  R.  I.;  H.  D.   Fraser,  Charleston, 
S.   C;    F.   L.  Sim,   Memphis,   Tenn.;    S.   D.    Thruston 
Dallas,Tex.;  F.H. Bascom. Salt  Lake  Citv.Utah;  H.  D.  Hal- 
ton,  Battleborough,  Vt;  L.  B.  Edwards,  Richmond    Ya 
N.  F    Essig,  Spokane  Falls,  Wash.;  C.  T.   Richardson; 
Charlestown,  W.  Ya.;  B.O.Reynolds,  Lake  Geneva   Wis  ■ 
Chas.   Smart,  V.  S.  A..  Washington,  D.    C;  J.   W.   Ross' 
U.  S.   X..  IVnsacola.   Fla.;  Walter  Wyman,  U.  S   M  -H 
S.,  Washington,  D.  C. 
Committee  from  American  Public  Health  Association. 


OCTUNE  OF  CONCLUSIONS  FROM  THE  WHOLE 
MASS  OF  REPORTS. 

1.  The  members  of  the  committee  are  nearly 
unanimous  in  their  opinion  as  to  the  appropriate- 
ness of  the  celebration  of  the  centennial  of  Jen- 
ner's  discovery.  2.  That  the  celebration  should 
embrace  the  collection  of  historical  and  statistical 
reports  with  a  proper  eulogy  of  Jeniier  and  his 
work.  3.  As  to  the  scope  and  extent  of  the  in- 
quiries desirable  to  make  there  was  some  diversity 
01  views,  and  some  difference  of  opinion  as  to  the 
value  of  the  collective  reports  when  made.  4. 
As  to  the  effort  to  collect'as  far  as  possible  all  the 
facts  relating  to  the  history  of  vaccination  in  our 
country  by  forming  committees  in  State  and 
county  societies,  it  was  the  general  opinion  it 
would  be  impracticable  to  embrace  the  minutiae 
ol  tin.  past  ami  present  of  vaccination.  5.  The 
ibility  of  collecting  books,  documents,  etc., 
pertaining  to  vaccination  was  answered  by  nearly 
lively.  6.  As  to  the  desirability  of  hav- 
ing a  discussion  on   the  practical   as  contra-dis- 


'89I-] 


NEW  INSTRUMENTS. 


891 


tinguished  from  the  historical  side  of  vaccination, 
it  was  generally  conceded  that  it  would  not  be 
ile.  7.  As  to  the  prospects  of  obtaining 
material  through  local  and  State  societies,  the 
question  was  answered  affirmatively  or  negative- 
ly, according  to  the  activity  of  the  societies  in 
the  locality  in  which  the  reporter  lived.  8. 
Should  county  societies  be  applied  to  for  infor- 
mation where  they  exist  is  answered  mostly  in 
the  previous  enquiries.  9.  Most  of  the  commit- 
tee were  of  the  opinion  that  to  the  Chairman  of 
the  Centennial  Committee  should  be  left  the  ap- 
pointment of  the  man  or  men,  and  devise  the  plan 
for  the  general  work  of  the  preparation  for  the 
centennial. 

It  was  deemed  proper,  therefore,  after  this  con- 
sensus of  opinion  as  to  the  feasibility  and  pro- 
priety of  celebrating  the  centennial  of  the  discov- 
ery of  vaccination  by  Jenner,  to  set  apart  the  ///// 
day  of  May \  1S96,  for  the  proper  commemoration 
of  the  life  work  of  Jenner,  and  signalize  the  im- 
mense gift  which  vaccination  has  been  to  the  hu- 
man family  by  the  presentation  of  an  eulogy  of  the 
great  discoverer,  and  by  the  reading  of  specially 
prepared  papers  on  the  history  of  introduction, 
statistics,  practice  of  vaccination,  propagation  of 
vaccine  virus,  and  such  other  topics  as  may  be 
selected  by  the  committee. 

In  order  to  carry  out  this  design,  it  is  hereby 
recommended  :  1.  That  the  meeting  of  the  Amer- 
ican Medical  Association  be  so  timed,  if  possible, 
as  to  include  the  14th  day  of  May.  2.  That  the 
Central  Committee  on  the  Centennial  Celebration 
should  make  such  selections  of  persons,  through 
the  assistance  of  State,  county,  and  city  medical 
societies,  medical  college  and  medical  and  other 
librarians,  as  to  constitute  a  corps  of  collaborators 
to  work  under  the  general  guidance  of  the  Com- 
mittee 3.  That  this  Committee  should  select  an 
eulogist,  to  deliver  such  a  tribute  to  the  life  and 
work  of  Jenner  as  would  be  suited  to  a  popular 
audience.  4.  That  an  editor  and  compiler  should 
be  chosen  by  the  Committee  from  the  expert  vac- 
cinologists  in  the  United  States,  upon  whom  shall 
devolve  the  work  of  digesting,  compiling  and 
preparing  all  the  collected  material,  and  that  all 
the  literary  and  scientific  part  of  the  work  shall 
be  under  his  direction.  5.  That  such  material  as 
the  Committee  deemed  best  should  be  collected 
and  printed  in  a  sumptuous  volume,  with  appro- 
priate illustrations.  6.  That  the  editor  and  com- 
piler should  be  allowed  a  clerk  for  such  part  of 
the  time  as  he  maj'  be  needed,  not  to  exceed  5200 
a  year.  7.  That  all  the  preparation  of  the  de- 
tails of  the  celebration  should  be  under  the  man- 
agement of  the  Central  Committee  or  their  suc- 
cessors. 

In  presenting  this  provisional  outline  of  the 
plan  for  the  celebration  proposed,  the  Committee 
desires  to  impress  the  Association  with  the  great- 
ness of  the  undertaking,  and  bespeak  the  hearty 


cooperation  of  every  organized  society  repre- 
sented in  this  body.  Your  Committee  would 
add,  that  the  American  Public  Health  Associa- 
tion, by  formal  resolution  at  their  meeting  last 
December,  in  Charleston,  selected  a  committee  to 
confer  with  this  Association  upon  the  properplan 
for  the  celebration  of  the  great  event. 


NEW  INSTRUMENTS. 


AX  AUTOMATIC  TUNING-FORK 

HAMMER. 

BY  S.  S.   BISHOP,  M.D., 

OF   CHICAGO. 

The  automatic  tuning-fork  hammer  shown  in 
the  cut  is  for  the  purpose  of  making  the  fork  as 
accurate  an  instrument  for  testing  the  hearing  as 
the  watch  is,  and  especially  for  use  in  those  cases 
where  the  watch  is  useless. 

The  hammer  and  operating  springs  can  be  at- 
tached to  any  large  fork  an  aurist  may  happen  to 
have.  The  hammer-head  is  made  of  soft  rubber, 
so  as  not  to  require  too  large  a  room  for  its  use. 

In  determining  the  hearing  distance  the  same 
rules  are  observed  as  in  using  the  watch.  The 
ear  is  -radually  approached  from  a  distance,  with 
the  fork  vibrating,  until  the  patient,  with  eyes 
closed,  signifies  that  he  hears  it.  This  experi- 
ment is  repeated  until  we  find  by  measurement 
the  exact  distance  at  which  he  hears  it  each  time. 
Every  time  a  sound  is  produced  the  hammer- 
handle  should  be  pressed  down  to  touch  the  fork- 
handle,  so  that,  as  it  is  allowed  to  slip  from  under 
the  pressing  thumb  or  finger,  the  hammer-head 
strikes  the  fork  with  an  unvarying  blow. 

One  of  my  forks  can  be  heard  8  feet  in  a  quiet 
room.  I  refer  now  to  the  musical  note.  The 
other  sound  that  always  accompanies  a  blow,  and 
which  we  will  call  the  dull  percussion  sound,  can 
be  heard  in  the  same  place  16  feet  by  a  normal 
ear. 

Taking  this  as  an  example  in  one  of  those  nu- 
merous cases  in  which  the  watch  cannot  be  heard, 
if  the  musical  note  can  be  perceived  at  30  inches, 
we  can  express  the  hearing  distance  approxi- 
mately correctly  by  the  fraction  ):;„"„.  or  30  per 
centum  of  the  normal,  showing  a  loss  of  70  per 
centum. 

There  are  not  a  few  instances  in  which  I  have 
found  no  perception  of  the  musical  note,  except 
on  contact  of  the  fork  with  the  mastoid  process, 
when  the  dull  percussion  sound  was  distinctly 
heard  at  a  certain  distance.  This  distance  is 
easily  ascertained  by  causing  the  patient  to  keep 
his  eyes  closed  during  the  test,  and  to  raise  the 
hand  at  every  stroke  of  the  hammer  he  hears. 

The  proportion  of  hearing  power  lost  and  finally 
regaiued  can  be  accurately  determined  by  these 


TOPICS  OF  THE  WEEK. 


[June  20, 


careful  experiments.     The}'  eliminate  the  inaecu- 


It  is  not  the  province  of  this  Journal  to  question 
,-  whether  these  proposals  were  voted  upon  strictlv  on 
racies  of  the  ever-varying  quantity  and  quality  oi  their  merits  bv  [he  Overseers,  or  whether  owing  to"their 
sounds  emitted  by  the  ordinary  fork  when  Struck  relation  to  other  proposals,  regarded  by  some  as  kindred, 
on  objects  of  differing  density  with  varying  de-  they  shared  a  common  fate.  It  is,  however,  legitimate 
°rees  of  force  ^or  us  to  sPecu'ale  whether  such  a  vote  fairly  represents 

•»•..•■  ,,  ,  ■      1      xi       the  tendency  of  thoughtful  sentiment  to-dav  among  col- 

It  is  impracticable   to   record    unerringly  the   ltrge.bred  men  and  aufong  our  educated  communities,  in 


hearing  distance  by  means  of  the  voice.  The 
watch-sounds  are  often  not  perceived  at  all,  and 
the  best  instrument  of  precision  for  this  purpose 
is  the  tuning-fork,  so  constructed  as  to  produce 
sounds  of  unvarying  volume  and  pitch. 

In  devising  this  acoumeter  I  do  not  claim  for  it 
any  new  principle — simply  the  practical  applica- 
tion of  very  old  ones  to  convert  an  uncertain  in- 
strument of  diagnosis  into  an  accurately  reliable 
one. 

After  considerable  experimenting  with  different 
materials  and  devices,  and  after  using  these  forks 
in  clinical  work  for  some  time,  I  have  come  to 
look  upon  them  as  indispensable  for  precision  in 
aural  practice. 

They  are  made  by  Charles  Truax,  Greene  & 
Co.,  of  Chicago. 


TOPICS  OF  THE  WEEK. 


ARE  AN'ATOMY  AND  PHYSIOLOGY  LIBERAL  STUDIES' 

At  a  recent  meeting  of  the  Board  of  Overseers  of  Har- 
vard College  a  supplementary  report  of  the  Special  Com- 
mittee on  Changes  in  the  Academic  Department  and  in  its 
relations  to  the  professional  schools,  was  under  consider- 
ation, and  certain  propositions  offered  by  this  Committee 
were  voted  on.  Two  of  these  propositions  especially  con- 
cerned medical  education,  namely: 

That  the  Board  of  Overseers  recommends  the  mod- 
ification of  the  present  Regulations  of  the  College 
Faculty  in  accordance  with  the  following  preposition: 

That  a  Senior  intending  to  enter  the  Medical  School 
and  to  take  the  full  four-years'  course  therein  may,  un- 
der proper  supervision,  include  in  the  requirements  for 
the  degree  of  Bachelor  of  Arts  the  courses  on  physioloj 
and  anatomy  required  in  the  first  year  of  the  Medical 
School,  each  of  said  courses  to  count  as  one  full  elective 
course. 

That,  in  the  opinion  of  the  Board  of  Overseei- 
visable  that  the  Faculty  facilitate  the  attainment  '•!  the 
1    Arts,  upon   petition,  in   less  time 
than  four  years,  especially  by  those  students  intending 
to  take  professional  or  graduate  courses  of  studi 

involve  either  a  reduction   in  the 
or  difficulty  of  the  courses  required  for  the  de- 
r  an  undue  hurrying  of  the  students'  work. 

Both  of  these  propositions  were  i  he  Ovi  ■ 

teen,  tin-  Presi 
dent  of  the  University  voting  in  the  negative,  and  the  lat- 
ter by  a  sin li lav  vote,  the  Pn 
tive. 


regard  to  professional  studies  and  professional  schools. 
V\"e  find  it  difficult  to  believe  that  it  does. 

The  present  relation  of  professional  studies,  and  espe- 
cially of  medical  studies,  to  an  academic  course,  is  con- 
cisely given  in  a  short  article  entitled  :  "Is  the  Study  of 
Medicine  a  Liberal  Education  ?"  by  Prof.  D.  W.  Cheever, 
of  the  Harvard  Medical  School,  published  in  our  last 
issue.  It  is  very  difficult  to  comprehend  the  mental  attitude 
of  one  who,  in  the  latter  part  of  the  nineteenth  century, 
is  unable  to  regard  such  studies  as  anatomy,  physiology, 
or  constitutional  law  as,  in  the  widest  acceptation  of  the 
term,  "liberal"  studies.  Latin,  Greek,  Mathematics  and 
Hebrew  may  equally  be  regarded  as  "bread  and  butter" 
studies  for  men  who  become  teachers  or  clergymen. 
Chemistry  and  Physics  and  Political  Economy  are  cer- 
tainly such  studies  for  a  large  number,  if  measured  by 
any  "illiberal"  estimate. 

The  truth  is,  some  way  must  be  found  to  lengthen 
rather  than  to  shorten  professional  education,  and  espe- 
cially medical  education.  The  medical  graduate  with 
an  academic  degree  is  already  too  old,  and  it  is  plain  that 
if  young  men  cannot  be  liberally  educated  on  such 
studies  as  those  we  have  mentioned,  many  of  them,  if 
modern  social  life  follows  its  present  directions,  must 
be  illiberally  educated  without  some  of  those  studies 
which  have  hitherto  claimed  the  title  of  "liberal"  by 
right  of  inheritance. — Boston  Med.  and  Stag.  Journal. 


THE  INFLUENZA  OF    1S90  AND  A  DEPRESSED  TONE  OF 
HUMAN    VITALITY. 

In  our  Edinburgh  correspondent's  notes  last  week 
interesting  extracts  were  given  from  the  report  submit- 
ted by  Dr.  Clouston  upon  the  Royal  Edinburgh  Asylum 
for  the  past  year.  They  had  reference  more  espeeially 
to  some  evidence  produced  by  Dr.  Clouston  as  to  the  ex- 
istence of  an  exceptionally  low  tone  of  human  vitality 
during  the  year  iSqo.  in  relation  to  the  epidemic  of  in- 
fluenza. Whether  it  was  the  influenza  in  the  early  part 
of  the  year  that  had  perceptibly  lowered  human  vitality, 
or  whether  the  prevalence  of  the  influenza  merely  show- 
ed that  European  humanity  was  in  a  lowered  state  of 
vitality,  so  being  a  lit  nidus  for  the  influenza  germs  to 
itf  in,  or  whether  it  was  the  sunless,  summerless 
general  character  of  the  year,  Dr.  Clouston  could  not 
not  say.  He  distinctly  connected,  however,  the  influ- 
enza in  some  way  with  the  unprecedented  number  of 
melancholic  patients  sent  to  Morningside  Asylum.  He 
goes  on  to  say,  and  we  think  with  truth,  that  he  believes 
tlie  epidemic  of  influenza  left  the  European  world's 
nerves  and  spirits  in  a  far  worse  state  than  it  found  them, 
and  that  they  scarcely  yet  had  recovered  their  normal 
tone.  Many  others  have  expressed  themselves  in  the 
same  sense,  and  we  look  upon  the  subject  as  one  of  deep 
■it  opportunity  will  be  given  our 
asylum  superintendents,  at  this  season  of  preparation  of 
1 1 111  or  otherwise  this  expres- 
sion of  opinion  on  the  part  of  Dr.  Clouston. — Lancet. 


I89i.] 


EDITORIAL. 


893 


Journal  of  the  American  Medical  Association 


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Address 

Journal  of  the  American  Medical  Association, 

No.  6S  W ABASH  Ave., 

Chicago.  Illinois. 
All  members  of  the  Association  should  send  their  Annual  Dues 
to  the  Treasurer,  Richard  J.  Dunglison,  M.D.,  Lock  Box  1274,  Phila- 
delphia, Pa. 


London  Office.  57  and  59  Ludgate  Hill. 


SATURDAY,  JUNE   20,    1891. 


THE  PROVINCE  OF  WOMAN  IN  .MEDICINE. 

Mr.  Lawsox  Tait  is  reported  to  have  said : 
"  For  the  greater  part  of  my  life  I  have  been  en- 
gaged in  the  study  of  and  practice  amongst  the 
special  diseases  of  women,  and  no  conclusion  is 
more  firmly  rooted  in  my  mind  than  a  devout 
thankfulness  that  I  belong  to  the  other  sex." 
"  From  the  cradle  to  puberty  they  seem  to  be  on 
fairly  equal  terms  with  men,  but  from  that 
moment,  through  the  whole  of  the  period  of 
active  life,  their  existence  is  one  of  prolonged 
suffering."  "The  great  function  of  their  lives 
is  led  up  to  by  troubles,  and  from  it  endless '. 
suffering  springs." 

Such  a  view — and  such  expressions — from  one 
whose  life  work  has  made  him  so  thoroughly 
acquainted  with  the  subject  of  the  sexual  charac- 
teristics of  the  female,  must  receive  the  consid- 
eration which  is  its  due,  and  from  it  may  be 
drawn  conclusions  and  arguments  which  a  less 
authoritative  basis  might  render  fallacious,  or, 
in  given  directions,  sentimental. 

Although  we  do  not  propose  to  enter  into  this 
subject  from  the  many  different  points  of  study 
it  clearly  permits,  and  which  would  quite  fill  a 
volume — yet  there  is  one  medical  aspect  to  which 
the  professional  mind  may  briefly  turn,  aud  which 
constitutes  one  of  the  living  topics  of  the  hour, 
namely,  woman  in  medicine. 

Two  arguments,  based  upon  Lawsox  Tait's 
exposition,  at  once  present  themselves:  i.  Can 
unfortunate,  pain- afflicted  woman  ever  occupy  a 
sphere  of  unquestioned  usefulness  in  medicine, 


where  physical  and  mental  vigor,  fortitude,  and 
endurance  are  eminently  requisite,  and  where 
the  strong  must  help  the  weak,  help  them  by 
virtue  of  their  strength,  to  healthier  and  stronger 
states?  or,  2.  Can  the  power  of  sympathy— op- 
erating from  the  intelligence  of  affliction,  and  the 
possible  comfort  of  relief — together  with  knowl- 
edge and  discrimination,  pass  from  a  medical 
woman  to  her  suffering  sex  with  a  probability  of 
extenuating  their  distress  equally  as  great  as 
would  maintain  under  the  fulness  of  power 
mentioned  in  the  first  proposition? 

Such  is  the  question,  the  argument  of  which 
has  been  before  the  medical  profession  for  some 
time,  but  the  solution  of  which  may  not  be  said 
to  have  as  yet  been  reached. 

This  much  remains  clear,  however,  woman  has 
yet  to  achieve  any  greatness  in  the  rank--  of 
medicine,  and  if  such  is  to  be  her  future  portion 
it  must  be  in  the  direction  of  relief  to  her  own 
sex.  She  must  become  a  Lawsox  Tait.  a 
Spencer  Wells,  a  Battey,  Thomas,  Price  ; 
or  if  that  be  impossible,  under  the  outlines  of 
the  first  great  general  question,  and  the  con- 
clusions of  Lawsox  Tait,  then  must  she  .est,  in 
the  unsought  weakness  of  her  nature,  as  a 
follower  of  man,  and  under  the  privilege  of  that 
sympathy  which,  if  properly  fortified,  may  reach, 
if  not  greatness,  that  degree  of  usefulness  the 
medical  world  cannot,  with  reason,  gainsay. 


THE  RELATION   OF   THE    COLUMBIAN  EXPOSI- 
TION TO  THE  MEDICAL  PROFESS 

Or  it  might  better  be  said :  The  value  and  op- 
portunities afforded  by  the  World's  Fair  to  the 
profession  of  medicine.  It  amounts  to  quite  the 
same,  however,  whichever  way  it  is  put. 

Physicians  from  all  points  of  the  compass,  and 
from  the  most  remote  corners  of  the  earth,  will 
be  attracted  to  the  United  States,  to  the  City  of 
Chicago,  to  the  home  of  The  Journal  of  the 
American  Medical  Associatiox. 

These  facts  force  thoughts  of  the  vast  opportu- 
nities thus  offered  for  the  realization  of  many 
long-expressed  desires,  for  the  establishment  of 
needed  reforms,  and  for  the  opening  of  those 
paths  to  a  broader  knowledge,  and  a  closer  touch 
of  interests,  which  this  day  and  age  demands. 

1.  The  proposed  Pan-American  Medical  Con- 
It  is  contemplated  to  hold  this  meeting 


S94 


EDITORIAL  NOTES  AND  ITEMS. 


[June  20, 


during  the  World's  Fair,  and  from  its  success  we 
may  look  for  many  important  considerations,  such, 
indeed,  as  a  representative  body  of  this  nature 
may  pertinently  and  wisely  sit  upon. 

2.  The  untold  advantages  for  personal  improve- 
ment and  a  knowledge  of  the  great  advances  made 
in  all  branches  of  the  science  of  medicine.  This 
will  come  from  the  exhibitions,  from  study,  from 
contact  with  others,  and  from  the  proximate  seats 
of  learning  which  may  be  easily  visited. 

3.  The  teaching  of  the  period,  aside  from  the 
results  already  attained,  and  upon  which  the 
great  future  progress  is  to  rest.  Methods  of  med- 
ical teaching  will  be  particularly  interesting  to 
foreigners,  and  many  of  our  own  older  practition- 
ers who  have  been  secluded  for  years  by  the  con- 
straints of  a  rural  constituency. 

4.  The  scope,  usefulness,  and  grand  possibili- 
ties of  the  American  Medical  Association.  A 
duty  and  an  opportunity  obviously  rests  here, 
which  in  due  time  will  no  doubt  be  developed 
and  formulated. 

5.  The  contact  with  fellow  laborers  from  every 
clime,  and  the  mutual  good  which  follows  the  free 
interchange  of  views  and  experiences.  This  com- 
munion of  thought  is  the  bulwark  of  our  science, 
and  its  strengthening,  upon  this  occasion  of  the 
World's  Fair,  will  not  be  without  happy  results. 

In  a  brief  notice  we  can  only  hope  to  generalize 
the  advantages  promised.  From  time  to  time, 
however,  we  trust  to  speak  of  progress  in  this 
direction,  and  to  dwell  more  specifically  upon 
matters  </  propos. 


the  latter  should  be  seized  bj-  means  of  two  hook- 
shaped  forceps  and  brought  into  view  as  well  as 
possible.  The  pedicle  of  the  tumor  excised  along 
with  a  portion  of  the  subjacent  bladder  wall.  Dr. 
Guyon  does  not  advocate  the  complete  suturing 
of  the  bladder  at  the  point  of  the  supra- pubic 
wound,  but  favors  the  introduction  of  a  drainage- 
tube  at  both  ends  of  the  incision  and  the  suturing 
of  the  intervening  portion.  The  writer  has  not 
found  that  the  integrity  of  the  resulting  cicatrix 
is  interfered  with  by  this  method  of  dealing  with 
the  surgical  wound. 


VESICAL  NEOPLASMATA  AND  THEIR  REMOVAL. 

Dr.  Guyon,  in  the  Gazette  des  Hopitaux,  re- 
ports a  case  of  neoplasm  of  the  bladder,  in  a  male 
aged  30,  and  its  removal  by  supra  pubic  opera- 
tion. He  presents  some  useful  considerations  in 
regard  to  the  diagnosis  and  treatment  of  vesical 
tumors.  Positive  diagnosis  by  means  of  the 
endoscope  should  be  considered  of  the  first  im- 
portance. The  symptom  of  hcematuria  is  incon- 
clusive as  an  aid  to  the  diagnosis  of  the  size  or 
character  of  the  tumor,  since  a  comparatively 
small  papilloma  will  often  give  rise  to  a  very  con- 
siderable hsemorrhage.  The  supra-pubic  opera- 
tion seems  to  him  to  offer  the  best  advantages  in 
the  ablation  of  tumors  of  this  class.  After  the 
:i   has  been  made   and  the   tumor  located 


EDITORIAL  NOTES  AND  ITEMS. 
New  Emeritus  Professors. — The  intelli- 
gence was  chronicled  not  long  since  of  the  cessa- 
tion of  the  active  labors  of  those  two  brilliant 
men  in  medicine,  Drs.  Bartholow  and  Da  Costa, 
and  now  comes  the  news  of  tribute  due  them — 
election  to  emeritus  professorships — under  which, 
with  greater  leisure  and  unrestricted  facilities, 
they  may  yet  pursue  those  studies  from  which 
the  world  has  derived  much  benefit. 

Inebriety  Legally  Disqualifies  the  Phy- 
sician.— The  Secretary  of  the  State  Board  of 
Health  of  Iowa  announces  that  he  is  convinced 
that  habitual  drunkenness  constitutes  "palpable 
evidence  of  incompetency,"  as  the  law  reads, 
and  that  therefore  the  physician  bound  by  in- 
ebriety should  be  shorn  of  his  certificate  entitling 
him  to  practice  in  that  State. 

Influenza  in  England. — This  disease,  which 
has  been  reprevailing  throughout  the  British 
Islands,  is  now  reported  to  be  somewhat  on  the 
decline.  The  epidemic  has  been  particularly 
severe  and  widespread,  and  as  here,  received 
much  attention  from  the  medical  and  lay  press. 
Theories  are  advanced,  and  forms  of  treatment 
recommended  ;  but  there  yet  remains  much  to 
learn  regarding  this  somewhat  remarkable  affec- 
tion. 

Late  reports  are  that  the  disease  is  just  touch- 
ing certain  points  in  France. 

The  Pre-Conyulsive  Period  in  Pregnancy. 
— Dr.  Everard  H.  Richardson,  of  Atlanta,  Ga., 
leclares  (Atlanta  Medical  and  Surgical  Journa 
the  following  rule  :  "In  all  cases  of  pregnancy, 
whenever  albumin  in  the  urine  is  persistently 
found  in  large  quantities,   with  or  without  the 


I89i.] 


SOCIETY  PROCEEDINGS. 


895 


presence  of  any  variety  of  casts,  and  not  yielding 
promptly  to  treatment,  whenever  decided  symp- 
toms of  profound  uraemia  appear  and  continue  un- 
abated, then  J  unqualifiedly  recommend  and  ad- 
vise, as  the  safest  course  to  be  pursued  in  the  in- 
terest of  the  mother,  the  induction  of  labor." 

Counting  Tubercle  Bacilli.— In  the  last 
issue  of  the  Bulletin  of  Johns  Hopkins  Hospital, 
G.  H.  F.  Nuttall,  M.D.,  gives  an  improved 
method  for  "  the  estimation  of  the  actual  number 
of  tubercle  bacilli  in  tuberculous  sputum."  The 
plan  is  illustrated  and  carefully  worked  out ;  the 
author  maintaining  :  "  With  such  organisms  as 
the  tubercle  bacillus,  this  method  will  enable  the 
experimenter  to  determine  the  number  he  is  in- 
oculating into  an  animal  in  a  way  that  has  not 
been  possible  hitherto.  Inoculations  under  such 
conditions  will  clearly  show  the  difference  in  de- 
gree of  virulence  possessed  by  various  organisms. 
It  will  clear  up  any  relation  which  tnay  exist  be- 
tween the  number  of  tubercle  bacilli  in  sputum 
and  the  progress  of  the  disease,  and  bring  us  a 
step  nearer  to  solving  the  problem  of  the  signifi- 
cance of  involution  and  degeneration  forms  of 
bacteria." 

Non- Uniformity  of  Nux  Vomica  Prepara- 
tions.— Recent  assays  of  this  important  and 
very  frequently  used  drug  go  to  show  that  a 
wide  degree  of  difference  exists  between  the  pro- 
ducts of  rival  manufacturing  chemists.  This  is 
a  subject  which  deeply  concerns  every  member  of 
the  profession,  and  should  have  early  and  effec- 
tive attention. 

Upon  an  examination  of  five  different  samples 
of  commercial  fluid  extract  of  nux  vomica  an 
extractive  difference  of  from  3  to  1 1  per  cent, 
was  found  ;  while  eight  samples  of  the  extract 
varied  in  alkaloidal  strength  between  15  and  24 
per  cent. 

Profits  in  Food- Products. — It  is  frequently 
asserted  that  manufacturers  of  prepared  foods 
reap  enormous  harvests.  An  instance  of  the 
truth  of  this  statement  is  given  in  a  recent  issue 
of  the  Medical  Press,  which  quotes  the  following 
figures  in  regard  to  the  Liebig's  Extiact  of  Meat 
Company,  of  London.  The  annual  production  of 
extracts  was  not  less  than  $1,200,000  worth,  and 
the  shareholders  received  a  17.5  per  cent,  dividend 
for  the  year  1890.  The  Press  states  further  that 
these  articles  of  nutriment  bearing  the  name  of 


Liebig  have  an  exceptionally  large  consumption 
in  Great    Britain    and   constitute   an    important 

item  in  the  dietetics   of  the   sick-room  and   the 
nursery. 

Installed.—  Prof.  J.  B.  Hamilton,  who,  con- 
jointly with  Prof.  Nicholas  Senn,  is  to  occupy 
the  Chair  of  Surgery  at  Rush  Medical  College, 
Chicago,  was  introduced  by  his  honored  con- 
frere, Prof.  Senn,  to  a  mixed  audience  of  pro- 
fessors, practitioners,  and  students  at  the  Surgical 
Clinic  of  Saturday,  June  13. 

Prof.  Hamilton  enters  a  large  and  well-organ- 
ized clinic,  and  the  lustre  it  already  holds  will 
scarcely  suffer  at  the  hands  of  the  two  dis- 
tinguished surgeons  who  will  hereafter  have  its 


New  York  Academy  of  Medicine. 

section  on  orthop.edic  surgery. 

Stated  Meeting  May  15,  1891. 

Samuel  Ketch,  M.D.,  Chairman. 

{Continued  from  page  860.) 

WHEN    SHALL    WE    DISCONTINUE    MECHANICAL 

TREATMENT  IN   HIP- JOINT  DISEASE?  WITH 

REMARKS     ON     THE     SYMPTOMS     AND 

TREATMENT. 

The  paper  of  the  evening,  bearing  the  above 
title,  was  read  by  Dr.  Newton  M.  Shaffer. 

The  writer  called  attention  to  the  difficulty 
which  often  existed  in  deciding  this  question,  and 
entered  a  strong  protest  against  the  use  of  an  an- 
aesthetic as  an  aid  in  reaching  a  conclusion.  Ether, 
it  was  claimed,  would  remove  the  reflex  muscular 
protection  of  the  joint  in  osteitic  disease,  and  with 
Nature's  protection  removed,  undue  traumatism 
might  be  inflicted,  and  under  the  influence  of  this 
traumatism,  encysted  tubercular  material  might 
be  broken  up,  and  a  fresh  infection  occur.  He 
recognized  the  fact  that  tubercular  disease  must 
run  a  long  course,  and  he  had  long  since  ceased 
to  expect  any  "short  cut"  in  the  treatment  of 
these  conditions.  Scientific  mechanical  treatment 
places  the  joint  under  the  best  local  conditions  for 
repair,  and  aids  Nature,  by  climatic  and  other  in- 
fluences, in  reaching  the  period  of  self-limitation, 
but  after  disintegration  of  the  joint  had  once  oc- 
curred, there  was  no  apparatus  that  would  cure 
hip  disease,  any  more  than  a  splint  would  cure  a 
fractured  thigh.  Reference  was  made  to  the  re- 
port by  Dr.  Lovett  and  the  author  on  "The  Ul- 
timate Results  of  the  Mechanical  Treatment  in 
Hip-joint  Diseases,"  published  in  1887.  Not- 
withstanding the  great  care  exercised,  and  the 
four  years'  limit  which  governed  the  investiga- 


SOCIETY  PROCEEDINGS. 


[June  20, 


tion  of  the  cases  reported  upon,  there  had  been 
several  relapses. 

Attention  was  then  called  to  the  fact  that  niany 
surgeons  ignore  the  neuro-muscular  symptoms  of 
hip  joint  disease,  and  to  the  fact  that  the  anaes- 
thesia removes  the  true  reflex  muscular  spasm; 
that  the  absence  of  pain  was  not  a  safe  criterion; 
that  the  absence  of  abscess  afforded  no  positive 
evidence  of  the  cessation  of  the  disease ;  and  that 
the  patient  could  stand  a  very  severe  concussion 
of  the  joint  without  pain  or  flinching,  and  yet  be 
suffering  from  extensive  and  progressive  tubercu- 
lar disease;  that  abscesses  and  sinuses  might  exist 
(unconnected  with  the  joint),  and  yet  the  patient 
be  free  from  the  necessity  of  mechanical  treat- 
ment; and  that  sinuses  might  close,  and  abscesses 
disappear,  with  active  disease  present. 

The  author  then  stated  that  only  two  elements 
existed  upon  which  a  positive  opinion  could  be 
based,  viz.:  1,  the  gait  and  attitude  of  the  pa- 
tient ;  and  2,  the  character  of  the  resistance  to 
joint  motion  thus  obtained.  He  divided  the  limp 
into  three  classes:  1,  the  limp  of  true  disease;  2, 
the  limp  of  a  vulnerable  joint  in  the  convalescent 
stage ;  and  3,  the  limp  of  shortening  and  disease 
— all  of  which  were  described. 

The  important  element,  however,  was  the  neu- 
ro-muscular protection  of  the  articulation.  He 
described  it  as  a  purely  involuntary  and  instinc- 
tive effort  on  the  part  of  Nature  to  prevent  trau- 
matism. Without  this  element  present,  we  are 
unable,  as  a  rule,  to  make  a  diagnosis  of  hip  dis- 
ease, and  if  it  were  not  present,  there  would  be 
no  deformit\r.  The  mechanical  treatment  should 
be  directed  not  only  to  the  deformity,  but  to  the 
disease,  and  the  necessity  of  controlling  the  knee 
was  pointed  out.  The  author's  experience  led 
him  to  advise  the  use  of  the  old  Taylor  traction 
splint,  with  the  rigid  pelvic  band,  and  double 
perineal  pad,  in  securing  the  proper  modification 
of  traumatism  at  the  hip,  and  in  controlling  the 
knee ;  and  he  spoke  rather  disparagingly  of  any 
splint  in  the  stage  of  convalescence  which  per- 
mitted motion  at  the  knee.  He  also  stated  that 
we  need  not  fear  the  effect  of  prolonged  mechan- 
ical treatment  as  much  as  the  unheeded  cry  of 
the  diseased  joint  for  proper  protection. 

The  following  conditions  contraindicated  the 
removal  of  the  apparatus:  If  manual  concussion 
produces  pain  or  flinching ;  if  there  is  consider- 
able deformity  without  anchylosis;  if  there  is  a 
true  joint  limp,  or  if  there  are  abscesses  or  sinuses 
counected  with  the  joint ;  or  if  there  is  a  true  re- 
flex muscular  spasm  limiting  movement  slightly 
in  all  directions;  if  there  is  almost  perfect  flexion, 
with  the  other  movements  considerably  or  mark- 
edly limited;  if  flexion  and  abduction  and  adduc- 
tion are  excellent,  with  rotation  and  extension 
limited;  and  finally,  if  all  the  movements  are 
nearly  normal  except  rotation  inward  during 
flexion  (.the  limitations  being  due  to  the  neuro- 


muscular protection),  it  is  not  safe  to  discontinue 
mechanical  protection.  Rotation  inward  during 
flexion  is  always  the  last  motion  to  recover,  and 
this  ma}^  remain  for  several  years  after  all  the 
other  signs  have  disappeared,  and  in  many  cases 
it  still  remains  after  the  joint  had  recovered;  but 
in  the  latter  case,  its  reflex  character  disappears. 

Attention  was  called  to  the  fact  that  after  the 
limp  had  entirely  disappeared,  a  relapse  may  oc- 
cur. A  recent  case  occurring  at  St.  Luke's  Hos- 
pital, was  cited  as  an  example.  From  this  and 
other  similar  cases,  the  author  draws  the  conclu- 
sion that  there  is  a  recognizable  stage  of  hip-joint 
disease  which  antedates  the  limping  stage. 

Excising  the  joint  was  then  referred  to,  and  the 
conclusion  reached  that,  in  the  absence  of  signs 
and  symptoms  by  which  we  can  exactly  determine 
the  extent  ol  the  lesion,  and  with  the  great  diffi- 
culty, not  to  say  impossibility,  of  a  complete  ex- 
cision of  the  acetabular  portion  of  the  joint,  exci- 
sion was  an  unsatisfactory,  and  in  many  cases  an 
unsafe  operation,  and  that  mechanical  treatment, 
while  more  difficult,  and  requiring  more  special 
training  to  make  it  successful,  promised  more  sat- 
isfactory results,  both  as  to  life  and  the  usefulness 
of  the  affected  member. 

The  conclusions  were  as  follows : 

In  the  first  apparent  stage  of  tubercular  disease 
of  the  hip-joint,  when  there  is  no  deformity  pres- 
ent, and  where  we  have  only  the  neuromuscular 
signs  or  the  slight  limp,  or  both,  to  guide  us,  as 
well  as  in  the  more  severe  forms  of  the  disease, 
where  tubercular  disintegration  of  the  joint  had 
commenced,  and  when  the  muscular  protection  of 
the  articulation  is  more  pronounced,  the  only  safe 
guides  for  discontinuing  mechanical  treatment  are: 
1 ,  the  absence  of  the  expressive  attitude  and  gait  of 
tubercular  osteitis  of  the  hip-joint ;  and  2,  an  es- 
sential modification  or  an  abolition  of  the  neuro- 
muscular protection  of  the  articulation ;  3,  that 
in  all  but  exceptional  cases,  a  relapse  as  to  the 
deformity,  or  the  disease,  or  both,  is  likely  to 
occur  as  the  result  of  the  traumatism  of  locomo- 
tion, unless  proper  mechanical  protection  is  main- 
tained until  the  articulation  is  free  from  true  reflex 
muscular  spasm,  or  is  anclnlosed. 

Dr.  A.  B.  Judson  shared  in  the  general  wish 
for  more  certain  indications  in  the  convalescent 
period.  He  agreed  with  Dr.  Shaffer  in  thinking 
that  the  reflex  or  neuro-muscular  signs  are  by  far 
the  most  valuable  indications  of  the  condition  of 
the  joint.  He  never  resorted  to  the  use  of  ether 
in  examining  the  joint,  or  to  the  more  atrocious 
barbarism  of  striking  the  patient's  heel  till  pain 
is  produced.  A  patient  of  his  had  described  the 
sensation  of  reflex  action  by  saying  that  it  re- 
sembles the  general  sensation  felt  in  a  swing  when 
the  descent  from  the  highest  point  begins. 

As  hut  few  of  the  superficial  muscles  are  found 
by  palpation  to  be  contracted,  he  thought  it  likely 
that  the  intrinsic  muscles,  those  beyond  the  reach 


i8qi.] 


SOCIETY  PROCi'.Kl  . 


897 


of  palpation,  are  chiefly  affected,  and  suggested  edly  for  six  weeks  after  all  pain,  deformity,  and 
that  probably  the-  muscles  exhibiting  thes'e  phe-  limp  had  disappeared,  and  the  reflex  muscular 
nomena  are  those  which,  like  the  adducb  asm  was  always  detected.     He  had  found  the 

their  origin  and  insertion  in  the  bones  which  suggestion  of  Dr.  Shaffer  to  carefully  avoid  out- 
enter  directly  into  the  composition  of  the  joint,  ward  rotation  during  flexion  test--,  a  verv  practi- 
The  patient  or  the  mother  is  sometimes  alarmed  cal  and  valuable  one,  had  aW>  noted  that  the 
by  the  discovery  of  the  rigid  adductor  muscle,  :  same  care  should  be  used  in  testing  abduction  to 
which  is  thought  to  be  a  morbid  growth,  or  an  avoid  outward  rotation,  as  the  reflex  muscular 
abnormal  bone,  till  it  is  shown  that  a  similar  spasm  at  times  could  only  be  detected  at  the  verv 
thing  is  produced  on  the  well  side,  when  an  extremes  >.f  motion.  Dr.  Myers  said  that  during 
effort  is  made  which  throws  the  adductors  of  tint  his  observation  of  hip-joint  disease  under  the  tu- 
side  into  tonic  contraction.  berculin  treatment  at  St.  Luke's  Hospital,  he  had 

He  thought  it  well  to  note  the  variety  of  these  made  daily  careful  examinations,  and  had  come  to 
reflexes.  Fixation  of  the  joint  is  produced  by  a  the  conclusion  that  the  reflex  muscular  spasm  was 
tonic  contraction,  but  motion,  especially  in  the  the  first  symptom  affected.  In  the  more  marked 
early  and  convalescing  periods,  is  asserted  at  a  cases,  the  symptoms,  though  lasting  but  a  few 
varying  point,  when  a  considerable  arc  has  been  days,  exactly  resembled  the  usual  exacerbation 
traversed,  by  a  muscular  spasm  often  recognized  '  of  the  disease,  with  increase  of  reflex  spasm,  less 
by  the  patient.  Dr.  Fayette  Taylor,  observing  motion,  or  even  deformity,  increase  of  pain,  and 
with  still  greater  refinement,  had  classed  "  reluc-  sensitiveness,  and  recurrence  of  night  cries.  In 
tance  to  relax,"  shown  by  the  circumarticular  [  less  marked  reactions,  several  times  the  reflex 
muscles,  among  the  reflex  signs  of  incipient  os- !  muscular  spasm  became  more  alert  though  there 
teitis.  was  no  rise  of  temperature,  nor  appreciable   in- 

Dr.  R.  H.  Sayre  said  that  if  the  signs  of  re-  ■,  crease  of  joint  sensitiveness,  or  decrease  of  mo- 
flex  spasm  continued,  there  was  but  little  doubt  i  tion.  He  believed  with  the  reader  of  the  paper, 
that  an  unprotested  joint  would  become  deformed,  that  this  spasm  was  the  first  and  last  symptom 
An  experimental  removal  of  the  apparatus  seemed  in  hip-joint  disease.  The  tubercular  process  he 
to  be  the  only  way  of  deciding  about  discontinu-  thought  was  self-limited,  and  therefore,  the  indi- 
ing  mechanical  treatment.  It  was  true,  that  the  cation  to  avoid  traumatic  reinfection  was  impera- 
late  Mr.  Thomas  said  that  any  one  who  could  not  tive. 


tell  the  day  and  hour  when  the  disease  stopped, 
ought  not  to  treat  joint  diseases;  but  his  remark- 
able insight  would  appear  to  be  quite  exceptional. 
The  existence  of  internal  rotation  and  flexion  he 
did  not  consider  to  be  so  significant  as  the  author 
stated,  for  a  hip  which  recovered  with  impaired 
motion  was  not  necessarily  a  vulnerable  one.  It 
was  highly  important  to  distinguish  carefully  be- 
tween the  limitation  of  motion  resulting  from  a 
deposit  around  the  joint,  and  that  due  to  reflex 
spasm.  In  the  former,  there  was  not  likely  to 
be  any  damage  to  the  joint  from  the  removal  of 
protecting  apparatus. 


Dr.  Samuel  Lloyd  referred  to  a  case  of  hip- 
joint  disease,  which  he  had  had  under  observa- 
tion, in  which  there  was  a  recurrence  after  a  pe- 
riod of  nearly  nine  years.  The  proper  time  for 
the  removal  of  apparatus  could  only  be  determin- 
ed by  experiment  in  each  case.  Lately,  he  had 
been  endeavoring  to  assist  the  mechanical  treat- 
ment of  suppurative  cases,  by  injecting  a  ten  per 
cent,  emulsion  of  'iodoform  in  glycerine,  and  the 
results  so  far  had  been  quite  beneficial. 

The  Chairman  thought  that  the  question  of 
the  soli-limitation  of  tubercular  disease  would  ac- 
count very  satisfactorily  for  the  varying  results 


Dr.  Whitman  thought  the  case  cited  in  the  obtained  in  the  removal  of  apparatus.  The  only 
paper,  which  proved  fatal  as  a  result  of  prolonged  absolutely  reliable  guide  was  the  existence  of  re- 
suppuration,  should  have  been   treated  by  exci- '  flex  muscular  spasm,  and  although  he  had  stud- 


sion,  for  he  had  seen  a  number  of  apparently 
hopeless  cases  of  this  kind  recover  after  such  an 
operation. 


ied  this  symptom  carefully  for  many  years,  he 
was  compelled  to  admit  that  in  a  certain  propor- 
tion of  cases,  it  was  very  easily  confounded  with 


Dr.  H.  W.  Berg  thought  that  reflex  muscular  the  mechanical  resistance  resulting  from  changes 

spasm  was  an  unconscious  as  well  as  a  conserva-  about  the  joint.     The  cases  of  so-called  relapse, 

tive  effort  of  nature,  and  therefore  he  could  not  he  was  inclined  to  consider  as  a  development  ot 

understand  how  a  description  could  be  given  by  new  foci  of  the  disease. 

Dr.  Judsou's  patient  of  the  sensation  produced  He  had  been  interested  in  the  author's  remarks 


by  this  spasm, 

Dr.  Jtdsox  replied  that  the  reflex  action  in 
question,  when  spasmodic,  resembles  the  ordinary 
reflexes,  such  as  respiration  and  nictitation,  in 
being  recognizable  by  the  patient. 

Dr.  Myers  said  that  the  case  at  St.  Luke's 
Hospital,  referred  to,  had  been  examined  repeat- 


about  the  fallaciousness  of  the  other  test,  and  the 
useless  traumatism  often  inflicted  upon  joints  by 
improper  manipulation  and  examination. 

Dr.  Shaffer,  in  closing  the  discussion,  said 
with  reference  to  the  sensations  of  the  patient  re- 
sulting from  reflex  spasm,  that  as  long  ago  as 
1S76,  a  very  intelligent  gentleman  had  compared 


DOMESTIC  CORRESPONDENCE. 


[June  20, 


this  sensation  to  that  experienced  upon  attempt- 
ing to  dodge  a  blow  aimed  at  the  stomach.  The 
intrinsic  muscular  element  would  not  explain  the 
phenomena  of  reflex  spasm,  as  was  shown  in  knee 
joint  disease,  where  the  gastrocnemius  muscle  re- 
sists attempts  at  moving  the  knee  joint,  but  al- 
lows of  motion  at  the  ankle  joint.  He  believed 
that  reflex  spasm  required  for  its  development  a 
peculiar  specific  irritation  within  the  joint,  proba- 
bly of  the  nerves  in  the  epiphysis.  The  very  fact 
that  this  spasm  is  beyond  the  control  of  the  pa- 
tient's will  renders  it  such  a  reliable  guide  in 
diagnosis  and  in  deciding  when  to  remove  the 
apparatus.  As  regards  the  question  of  excision 
in  the  case  referred  to,  he  had  not  presented  the 
full  history  of  the  case,  and  consequently  had 
omitted  to  say  that  the  father  absolutely  refused 
to  give  his  consent  to  this  operation.  He  thought 
all  orthopedic  surgeons  recognized  the  self-limita- 
tion of  tubercular  disease,  especially  since  the 
able  paper  published  some  years  ago  by  Dr.  Aus- 
tin Flint.  With  regard  to  relapses,  he  felt  that 
the  traumatism  of  locomotion  was  sufficient  in 
many  cases  to  destroy  the  encysted  condition  of 
the  tuberculous  deposit  about  the  joint,  and 
hence,  to  produce  a  fresh  infection  with  tubercu- 
lar material  of  the  vulnerable  tissues  in  the  cap- 
sule. 

IRON   CASTS   AND  COAPTATION  SPLINTS. 

Dr.  Whitman  spoke  of  the  advantage  of  em- 
ploying iron  splints  in  cases,  particularly  about 
the  feet,  where  perfect  opposition  is  desirable.  A 
rough  cast  of  the  part  is  taken  in  plaster  of  Paris, 
and  sent  to  the  iron  founder,  who  produces  an 
iron  cast  at  an  average  cost  of  one  dollar.  On 
this  cast,  very  light  metal  splints  can  be  readily 
and  accurately  moulded. 


LETTER  FROM    NEW  YORK. 

(FROM   OUR   OWN  CORRESPONDENT.) 

{Concluded  from  page  66 /.) 
Dr.  S.  E.  Milliken  read  a  paper  cm  "Treatment  of  Hy- 
drocele by  Carbolic  Injection,  versus  the  Radical  Opera- 
tion," in  which  he  said  that  the  objection  to  cutting  op- 
erations such  as  Yolkman's  was,  that  although  they  wen 
usually  successful  in  relieving  the  hydrocele,  they  neces- 
sitated the  use  of  an  anaesthetic  and  confinement  to  bed 
for  a  week  or  more  if  suppuration  occurred.  On  the  other 
hand,  the  method  of  Levis  by  carbolic  injection  was 
practically  painless,  confinement  to  bed  was  in  no  sense 
essential,  and  unless  an  inordinate  amount  of  carbolic 
acid  (in. ire  limn  30  minims)  was  used,  sloughing  ought 
never  to  occur.  When  from  5  to  25  miuums  of  pure  car 
bolic  acid  dissolved  in  an  equal  quantity  of  glycerine  was 
distributed  over  the  whole  serous  surface  (2  or  3  minims  in 
each  place),  nothing  more  than  a  sense  of  warmth  was 
experienced  by  thi  patient.  Of  54  cases  thus  treated  by 
Dr.  Milliken,  g  were  neverseeu  after  the  first  injection,  5 
paid    one    visit    within    the  first  week  only,    and    1   are 


present  under  observation.  All  the  remaining  36  could 
be  set  down  as  completely  cured;  and  of  these,  27  had 
on"e  injection,  4  had  two  injections,  and  5  had  three  in- 
jections. In  no  case  did  sloughing  occur,  and  not  one  of 
the  patients  lost  more  than  24  hours  from  business. 

In  the  case  of  laboring  men  he  generally  made  the  injec- 
tion on  Saturday  afternoon,  so  that  the  patient  could  go 
to  his  work,  as  usual,  on  Monday  morning.  From  his 
experience  he  had  reached  the  following  conclusions: 

1.  Carbolic  injection  is  a  safe  method  for  the  cure  of 
hydrocele. 

2.  It  is  practically  painless. 

3.  The  patient  can  attend  to  business  without  more  than 
one  day's  delay. 

4.  The  disagreeable  effects  of  an  anaesthetic  are  avoid- 
ed. 

In  the  discussion  on  the  paper  Dr.  John  Murphy  spoke 
of  a  case  he  had  seen  in  which  he  believed  that- fatal 
carbolic  poisoning  resulted  from  injection  of  a  hydrocele. 
He  did  not,  however,  know  the  quautity  of  carbolic  acid 
which  had  been  injected,  and  the  evidence  which  he  pre- 
sented that  death  was  due  to  this  cause  was  not  regarded 
as  conclusive  by  those  present.  Dr.  Win.  R.  Ballou  re- 
ferred to  the  bad  effects  sometimes  observed  from  the 
injection  of  iodine,  and  Dr.  Milliken  said  that  in  using 
iodine  he  should  not  be  so  much  afraid  of  the  slough- 
ing liable  to  be  oaused  by  it  as  of  iodine  poisoning.  As 
regards  the  injection  of  carbolic  acid  he  preferred  to  use 
10  to  20  minims,  and  repeat  the  injection  a  second 
or  even  a  third  time,  if  necessary,  rather  than  to  use  a 
large  quantity  a  single  time.  In  cases  where  the  trouble 
returned  itwas  always  noticeable  that  the  hydrocele  was 
never  as  large  as  it  had  been  originally. 

Dr.  Wm.  R.  Ballou  read  a  paper  on  "Acute  Prostatitis 
and  Prostatic  Abscess,"  in  which  he  stated  that  in  one 
thousand  cases  of  urethritis  in  various  stages  seen  bv 
him  in  hospital  and  dispensary  practice  during  the  past 
five  years,  he  had  observed  only  three  cases  of  prostatitis 
resulting  in  an  abscess  of  the  gland,  though  many  that, 
were  of  a  milder  grade.  After  describing  the  pathology, 
symptoms,  and  treatment  of  prostatitis  he  gave  the  notes 
of  the  three  cases  of  abscess  referred  to.  In  one  the  ab- 
scess had  discharged  spontaneously  into  the  rectum  be- 
fore the  patient  came  under  observation;  in  another  it 
was  tapped  with  a  trocar  through  the  rectum;  and  in  the 
third,  an  incision  was  made  from  the  rectum  after  the  in- 
troduction of  a  Sims  rectal  speculum.  Even  if  fluctua- 
tion were  not  distinct,  Dr.  Ballou  advised  a  free  and  deep 
perenneal  or  rectal  incision  in  case  abscess  were  suspected. 
The  President  thought  that  in  the  earlier  stages  it  was 
preferable  to  make  the  perineal  rather  than  the  rectal 
incision,  011  account  of  the  danger,  with  the  latter,  of  the 
opening  remaining  permanently,  and  also  of  infiltration 
"sues.  If,  however,  the  case  were  seen  later,  and 
the  abscess  was  evidently  pointing  towards  the  rectum 
he  saiil  he  would  perform  rectal  incision.  He  regarded 
the  passage  of  a  metallic  instrument  into  the  bladder  with 
the  idea  of  causing  rupture  of  the  abscess  into  the  urethra 
as  a  dangerous  and  unjustifiable  procedure. 

Incidentally  in  his  paper  Dr  Ballou  had  referred  to  the 
local  use  of  weak  solutions  of  permanganate  of  potas- 


i89i.] 


DOMKSTIC  CORRESPOXDKXCE. 


899 


sium  in  the  treatment  of  acute  urethritis;  and  in  reply  to  tance  and  the  proper  amount  of  force  to  use,  and  could 

a  question  from  one  of  the  Fellows  he  now  stated  that  he  readily  use  it.     He  believer,  that  when  this  instrument 

was  in  the    hal  it  of  prescribing  at   first  bi-hourly   injec-  cannot  deliver  a  living  child,  there  is  no  other  operative 

lions  of  permanganate  solu  strength  of  one-  alternative  but  Cesarean  section,  as  he  does  not  consider 

eighth  to  om   tenth   of  a  grain  to  the  ounce  of  distilled  craniotomy  in  the  living  fcetns  justifiable. 

ridge-fulls  being  used  at  each  injection.  In-       The  last  paper  was  by  Dr.   Reginald  II.  Sayre,  and  it 

ternally  he  generally  gave  some  alkali,  and  if  the  trouble  was  devoted  to  a  case  of  "  Obstinate  Neuralgia  following 

were  deep-seated,   hyoscyamus  in  addition.     Afier  from  Fracture   Relieved  by  Operation."     The  patient  was  a 

four  to  eight  days    the  permanganate  was  increased  to  young  man  of  19,  who  between  the  ages  of  5  and  1  3  suf- 

one-sixth  of  a  grain  to  thi   ounce,  and  snip  'ate  fered  from  three  successive  fractures  of  the  right  thigh 

of  zinci  (one  grain   to  thi   01  ded  to  the  injec-  in  its  upper  third.     After  the  third  fracture  the  bo 

tion.     This  treatment  ha  1  proved  extremely  satisfactory,  which  there  had  previously  been  straight  onion 

and  he  constantly  employed  it.     Dr.   McCollom  having  at  an  angle,  causing  a  very  marked  curving  of  the  thigh 

I  that  such  weak  solutions  of  permanganate  were  and  between   2  and  3  inches  of  shortening;  and  there 

hardly  germicidal,  Dr.  Ballou  replied  that  he  did  not  be-  then   resulted  a   constant  ueuralgia  of  the  limb,  which 

litre   that  the   gonococcus  was  regarded  as  of  quite  as  finally  became  so  aggravated  that  he  could  not  obtain 

much  importance  at  the  present  time  as  it  had  been  for-  any  relief  except  from  morphia,  and  so  became  addicted 

merly.  to  the  opium  habit.     The  pain  was  the  most  intense  at 

Dr.  II.  \V.  Mitchell  read  a  paper  on  ''Practical  Results  the  point  of  greatest  deformity,  which  was  just  in  the 

of  the  Operation  for  Lacerated  Cervix  Uteri."     While  the  line  of  the  external  cutaneous  nerve.     All  remedies  hav- 

operation  of  trachelorraphy,   he  said,  was  aimed  primar-  ing  failed  in  giving  any  permanent  benefit,  and  several 

ily  to  restore  the  contour  of  the  cervix,  its  most  import-  surgeons  concurring  in  the  opinion  that  there  was  a  large 

ant  and  highest  object  was  to  insure  its  future  usefulness  exostosis  pressing  upon  the  vein.  Dr.  Sayre,  on  June  10, 

iu  performing  its  normal  functions      With  proper  atten-  1888.  operated  under  antiseptic  precautions.     He  found, 

tion  on   the   part  of  the   surgeon,    healing   by   primary  to  his  surprise,  that  part  of  the  vastus  externus  muscle 
union  could  almost  invariably   be   securtd.  and  in    200  I  was  so  twisted  ou  itself  as  to  turn  at  right  angles  to  the 

operations  performed  by  him   this  was  the  result  iu  all  long  axis  of  the  femur,  but  that  there  was  no  exostosis 

but  two,  where  the  healing  took  place  by  granulation,  present,  with  the  exception  of  a  most  minute  point  which 

Of  these  200  cases  he  had  been   able  to  follow  up  21  in  could   scarcely  be  considered   abnormal,  but  which  he 


which  subsequent  confinements  had  taken  place,  all  of 
which  were  personally  attended  by  himself;  and  of  these 
21  cases,  eight  had  had  more  than  oue  subsequent  con- 
finement.    All  were  of  a  severe  form  of  laceration  and  in 


nevertheless  removed.  He  then  passed  his  finger  com- 
pletely around  the  femur,  stripping  up  the  muscles  for  an 
extent  of  2  or  more  iuches;  but  failed  to  find  any  sharp 
projection,  or  anything  else  to  account  for  the  pain.    Con- 


seven  the;e  was  laceration  of  the  perineum  in  trary  to  his  anticipatious  under  these  circumstances,  he 
addition.  Re^aceratiou  of  the  cervix  during  subse-  found  that  the  patient  was  completely  cured  by  the  oper- 
quent   labors   occurred   in  only    two   of  the  cases,  arid    ation  of  the  neuralgia  from  which  he  had  been  suffering 


in  both  it  was  so  very  slight  as  not  to  impair  the  use- 
fulness of  the  cervix  or  render  a  second  operation  neces- 
sary. .  Judging  from  these  cases,  he  thought  he  could  say 
with  truth  that  the  operation  in  question  was  proper 
and  successful  and  accomplished   the   following  results: 

1.  Diminish  the  pain   and  irritation    following   upon 
such  a  distressing  lesion. 

2.  Relieve  the  seuse  of  bearing  down. 


for  six  years,  and  which  had  resisted  a'l  kinds  of  treat- 
ment. On  January  29,  1S91,  he  received  a  letter  from 
the  patient,  in  which  the  latter  stated  that  he  still  re- 
mained entirely  free  from  pain,  without  the  use  of  mor- 
phia or  any  other  drug. 

One  of  the  points  of  interest  in  this  case  to  which  Dr. 
Sayre  called  attention,  was  the  simulation  of  an  exostosis 
by  what  was  presumably  a  tense  fibre  of  the  fascia  lata. 


3.  Cure  the  exhausting  leucorrhceal  discharge,  restore  which  had  become  so  much  bound  down  as  to  press  on 
the  parts  to  their  normal  condition,  and,  above  all,  restore  i  the  muscles  of  the  thigh,  and  which,  by  girdling  them, 

the  cervix  so  that  future  pregnancies  and  labors  will  take  apparently  caused  the  pain.     He  said  he  did  not  clearly 

place  in  a  natural   manner  and   without   a  relaceration  understand  how  to  account  for  the  abolition  of  the  paiD. 

calling  for  the  repetition  of  the  procedure.  He  did  not  consider  the  point  of  bone  he  removed  large 

Dr.  T.  J.  McGillicuddy  then  read  two  short  papers,  one  enough  to  have  caused  the  trouble,  and  he  did  not  think 

on  "Objections  to  Ordinary  Axis-traction,"  and  the  oth-  that  when  he  passed  his  finger  around  the  femur  he  tore 

er  on  the  "Advantages  of  the  Anti-erauiotoiny  Forceps  loose  any  nerve  fibres  from  the  cicatrix.     The  explaua- 

over  Version  in  Pelvic  Deformities."  in  connection  with  tion,  he  suspected,  was  to  be  found  iu  the  relief  of  ten- 

which  he  exhibited  the  admirable  axis-traction  forceps  sion  given  by  splitting  up  the  fascia  lata,  which  certaiuly 

and  the  "  anti-craniotomy  "  forceps  which  he  presented  bound  the  muscles  very  tightly.    The  length  of  time  that 

in  the  Obstetrical  Section  of  the  American  Medical  As-  had  elapsed  since  the  operation  (nearly  three  y. 

sociation  at  the  recenj  meeting  in  Washington.     The  lat-  thought  was  sufficient  guarantee  that  the  cure  would  be 

ter,  he  said,  was  not  a  cephalotribe  or  cranioclast,  but  a  permanent,  especially  as  the  patient  had  been 

conservative,  life-saving  forceps,  to  be  used  in  cases  of  to  the  opium  habit,  and  he  would  undoubtedly 

considerable  pelvic  deformity.     With  the  axis-traction  sumed  the  use  of  the  drug  if  any  return  ef  pain  had  af- 

handles,  one  could  determine  the  exact  amount  of  resis-  forded  him  a  pretext  for  so  doing. 


900 


MISCELLANY. 


[June  20,  1891. 


Dr.  Squibb,  the  efficient  and  energetic  Secretary  of 
the  Branch,  to  whose  self-denying  labors  the  marked 
success  of  its  meetings  ever  since  its  organization  has 
been  to  so  large  an  extent  due,  was,  of  course,  reelected 
to  his  old  position. 

During  the  last  few  months,  the  inhalation  of  vapor 
produced  by  the  sublimation  of  calomel,  according  to 
the  reports  of  the  attending  physicians,  has  proved  a 
powerful  auxiliary  to  intubation  at  the  New  York  Found- 
ling Asylum,  and  in  some  cases  has  apparently  prevented 
the  necessity  of  a  resort  to  this  procedure.  Now,  as  soon 
as  hoarseness  is  observed  in  a  diphtheritic  case  in  that 
institution,  the  child  is  placed  in  its  crib,  and  a  tent  made 
over  it  about  3  feet  in  height,  by  means  of  a  sheet  stretch- 
ed over  sticks  fastened  to  the  corner  posts.  Placed  in  a 
wash  bowl,  below  the  feet  of  the  child,  an  alcohol  lamp 
is  lighted,  and  over  it,  upon  a  dish,  from  10  to  40  grs.  of 
calomel  are  slowly  vaporized.  This  is  repeated  every  two 
to  four  hours,  according  to  the  urgency  of  the  case.  It 
is  said  that  a  Sister  of  Charity  and  nurses  in  the  ward 
have  been  salivated  by  the  fumes  of  the  calomel;  but,  so 
far  as  known,  none  of  the  patients  have  been  injured  by 
it  in  the  slightest  degree.  On  the  other  hand,  in  some 
instances  patients  have  recovered  without  tracheotomy 
or  intubation,  when,  from  the  persistence  of  obstructive 
symptoms,  it  was  highly  probable  that  pseudo  mem- 
brane had  formed  in  the  larynx.  Dr.  J.  Lewis  Smith, 
•who  is  now  on  duty  at  the  Foundling  Asylum,  states  that 
since  the  vapor  of  calomel  has  been  used  in  this  way,  the 
percentage  of  recoveries  after  intubation  has  been  de- 
cidedly greater  than  was  the  case  previous  to  its  employ- 
ment, and  that  when  the  next  statistics  are  published 
from  this  institution,  the}'  will  show  very  gratifying  re- 
sults, p.  B.  p. 


MISCELLANY. 


name  a  familiar  one  on  both  sides  of  the  Atlantic.  He 
was  one  of  the  founders  of  the  American  Gynecological 
Society — and  the  first  President — of  the  State  Woman's 
Hospital  and  of  Rellevue  Hospital  Medical  College.  His 
greatest  service  to  the  medical  profession  in  recent  years 
was  seen  in  his  loug  tenure  of  the  office  of  President  of 
the  Academy  of  Medicine  of  New  York,  in  which  posi- 
tion his  faithful  labors  resulted  in  the  building  up  of  a 
fund  for  a  fireproof  and  attractive  home  for  Medicine, 
not  only  for  the  metropolis,  but  free  in  many  respects  to 
the  whole  continent — a  nucleus  and  intellectual  centre  of 
modernized  medical  thought.  He  was  a  persuasive  and 
eloquent  speaker,  and  despite  his  vocal  insufficiency,  was 
as  welcome  an  orator  before  large  audiences  in  foreign 
countries  as  he  was  before  his  own  fellow-citizens.  He 
was  a  tower  of  strength  to  every  medical  cause  in  which 
he  became  thoroughly  enlisted. 


Medicolegal  Society  of  Chicago. — At  the  Animal 
Meeting  held  at  the  Grand  Pacific  Hotel,  June  6th,  Judge 
O.  H.  Horton,  was  unanimously  elected  President  forthe 
coming  year;  Dr.  D.  R.  Brower,  Vice-President;  Dr. 
James  Burry,  Second  Vice-President;  Dr.  Joseph  Matte- 
son,  Treasurer;  Dr.  Archibald  Church,  Secretary. 

Dr.  Henry  M.  Lyman,  Dr.  VV.  Franklin  Coleman,  Dr. 
A.  Holmboe  and  Dr.  L.  T.  Potter  were  elected  to  active 
membership.  Archibald  Church,  M.D.,  Sec'y. 

805  Pullman  Building. 


,\fl, 


5  Serving 
,  1S91,  to 


Generous  Gift  to  Tui.ane  University. — Mrs.  T. 
G.  Richardson  Donates  $100,000  for  a  New  Build- 
ing at  New  Orleans.  The  medical  department  of  Tu- 
lane  University  was  made,  June  13,  the  recipient  of  a  gen- 
erous donation  from  Mrs.  Richardson,  wife  of  that  emi- 
nent physician  and  dean  of  the  college,  Dr.  T.  G.  Rich- 
ardson, of  #100,000.  The  entire  donation  is  intended  to 
be  used  in  erecting  a  new  college  on  Canal  street,  between 
Villere  and  Robertson,  the  site  for  which  was  bought  a 
few  days  ago  for  $35,000  by  the  Educational  Board. 

The  faculty  of  the  medical  department  of  the  universi- 
ty has  selected  Dr.  Edmoud  Souchon,  professor  of  anat- 
omy and  clinical  surgery,  as  the  representative  of  the 
faculty  in  the  selection  of  the  proper  sort  of  building  for 
the  purpose  intended.  Dr.  Souchon  will  leave  in  a  few 
or  tin- Xortli  and  East  to  examine  various  colleges 
to  guide  him  in  the  selection  of  a  building  that  will  be 
best  suited  to  the  wants  of  the  local  institution. 


Dr.    FoRDYCE    BARKER,  of  New  York  City,  departed 
this  life  in  the  seventy  third  year  of  his  age,  after  a  short 
ami  ovei  powering  seizure  by  apoplexy,     ilis  eminenci 
it  m  tin-  obstetric  ait  lias  made  h 


/  List  of  Changes  in  the  Stations  and  Duties  of  Offtc 
the  Medical  Department,   U.  S.   Army,  from  June 
June  12,1891. 

Major  Philip  F.  Harvey,  Surgeon,  leave  of  absence  for  seven  days 
granted  by  order  96  c.  s.,  Ft.  Keogh,  Mont.,  is  extended  fourteen 
days      Par.  2,  S.  O.  98,  Dept.  of  Dakota,  June  5,  1891. 

Major  Samuel  M.  Horton,  Surgeon,  leave  of  absence  on  surgeon's 
certificate  of  disability,  granted  in  S.  O.  49,  March  4,  1S91,  from 
this  office,  is  extended  three  months,  on  surgeon's  certificate  of 
disability.  By  direction  of  the,  Secretary  of  War.  Par.  6,  S.  O. 
129,  A.  G.  O.,  June  4,  1S91. 

Lieut.  Col.  Charles  T.  Alexander,  Surgeon,  Attending  Surgeon  in 
New  York  City,  is,  in  addition  to  his  other  duties,  assigned  to 
duty  as  examiner  of  recruits  in  that  city.  Bv  direction  of  the  Act- 
ing Secretary  of  War.     Par.  21,  S.  O.  132,  A.  "G.  O..  June  10,  1891. 

Major  Charles  B.  Byrne,  Surgeon,  granted  leave  of  absence  for  fif- 
teen days,  to  take"  effect  on  being  relieved  from  duty  at  Ft.  Mc- 
Henry.'Md.  With  the  approval  of  the  Acting  Secretary  of  War. 
Par.  14,  S.  O.  130,  A.  G.  O.,  June  8,  1891. 

First  Lieut.  Freeman  V.  Walker,  Asst.  Surgeon  U.  S.  A.,  leave  of  ab- 
sence for  seven  days  granted  by  order  100  c.  s.,  Ft.  D.  A  Russell, 
Wyo.,  is  extended  t "wen tv-three  days.  Par.  6,  S.  O.  6S,  Dept.  of  the 
Platte,  JuneS,  1891. 

Official  List  of  Changes  in  the  Medical  Corps  of  the  U.  S.  Navy,  for 
the  Week  Ending  June  ij,  1891. 

Asst.  Surgeon  A.  R.  Alfred,  from  Naval  Hospital,  Norfolk,  and  to 
the  "  Fern." 

Asst.  Surgeon  James  Stoughton,  to  duty  at  Naval  Hospital,  Nor- 
folk, Va. 

Asst.  Surgeon  L.  L-  S.  Y'oung,  to  duty  at  Naval  Station,  Port  Royal, 
S.  C. 

Surgeon  F.  H.  Streets,  ordered  to  duty  on  the  U.  S.  S.  "  Benning- 
ton." 

Medical  Inspector  A.  A.  Hochling.  ordered  as  member  Naval  Medi- 
cal Examining  Board. 

Medical  Director  P.  S,  Wailcs,  ordered  as  delegate  to  represent 
Medical  Corps  of  the  Navy  at  the  International  Congress  of  Hy- 
giene and  Demography,  at  London,  Eng. 

( Official  List  of  Changes  of  Stations  and  Duties  of  Medical  Officers  of 
thr  ('.  S.  Marine-Hospital  Service,  for  the  Two  Weeks  Ending 
June  6,1891. 
Surgeon  C.  S.  1).  Fessendeu,  granted  leave  of  absence  for  thirty 

days.    June  6,  1891. 
Surgeon    Fairfax    Irwin,   leave  of  absence  extended   seven   days. 
June  4,  1891. 

w    Mead,  when  relieved  at  Chicago,  111.,  to  proceed  to 
Washington,  D.  C,  and  report  to  the  Supervising  Surgeon  Geu- 
eral  for  duty.     May  29,  1S91. 
I'    A   Surgeon  G.  M.  Magruder,  granted  leave  of  absence  for  five 

days      tun. 
a^i    Surgeon  »'.    B.  Young,  leave  of  absence  extended  fifteen  days 
on  account  of     ickni  ss.    June  6.  1S91. 


P 


CORRIOENDI  M. 
first  colur 


The  Journal  of  the 

American  Medical  Association 


Vol.  XVI. 


CHICAGO,  JUNE  27,   1891. 


No.  26. 


ORIGINAL  ARTICLES. 


REPORT  OX  AX  EPIDEMIC  OF  CEREBRO- 
SPINAL MENINGITIS. 

Read  in  the  Section  of  the  Practice  of  Medicine  and  Physiology,  at  the 
Forty-second  Annual  Meeting  of  the  American  Medical  Asso- 
ciation, held  at  Washington,  D.C.,Ma 

BY  J.  S.  NOWLIN,  M.D., 

OF  SHELBYYILLE.    TENX. 

In  presenting  the  subject  of  Cerebro- Spinal 
Meningitis,  the  first  thought  I  offer*  is  that  our 
nomenclature  in  this  as  in  many  other  diseases 
leads  to  an  erroneous  view  of  the  pathology  and 
treatment. 

Our  authors  have  almost  universally  written 
as  though  the  inflammatory  action  found  in  the 
coverings  of  the  brain  and  spinal  column  was 
the  original  lesion  to  be  combated.  It  will  not 
be  necessary,  for  the  purposes  designed  in  this 
paper,  to  deny  the  fact  that  an  inflammatory  action 
mav  be  found  in  many  cases. 

The  error,  as  I  conceive  it  to  be,  and  to  which  I 
would  direct  attention,  is  that  the  inflammation,  if 
it  does  exist,  in  a  given  case,  is  not  the  disease  to 
be  treated,  but  a  sequence. 

It  is  only  necessary  to  call  attention  to  the 
great  number  of  deaths  occurring  within  five 
days,  with  no  exudation  in  these  tissues  evincing 
inflammation.  It  is  a  self-evident  proposition 
that  the  cause  of  death  is  not  inflammation. 

Realizing  the  thorough  knowledge  of  the  mem- 
bers of  this  Association  with  the  literature  of  this 
subject,  I  shall  not  burden  you  with  quotations  to 
prove  this  and  other  facts  which  I  shall  present. 
I  mention  however,  that  Dr.  Alfred  Stille,  allud- 
ing to  this  question,  says,  ' '  There  ought  to  be  no 
doubt  whether  epidemic  cerebro- spinal  menin- 
gitis should  be  classed  with  general  diseases  or 
with  inflammation.  It  is  excluded  from  the  lat- 
ter class  by  the  total  absence  of  any  tangible  ex- 
ternal cause,  as  well  as  by  its  frequent  fatal  ter- 
mination before  the  characteristic  signs  of  inflam- 
mation have  had  time  to  form,  or  because  the 
peculiar  type  of  the  disease  prevents  their  devel- 
opment." It  is  clear  to  my  mind  that  it  is  a 
non-inflammatory  trouble  and  that  the  inflamma- 
tion is  only  concomitant. 

I  remark  further  that  the  impress  of  the  cause. 


whatever  it  may  be,  is  made  upon  the  nerve  cen- 
tres, but  before  noticing  directly  the  etiology,    I 
submit  the  histon' of  five  cases  which  I   sa- 
1888. 

In  December,  Mr.  H.,  aged  44,  was  attacked. 
He  had  not  been  well  for  two  or  three  weeks,  suf- 
fering each  day  with  pains  in  shoulder  and  neck, 
and  in  arms  and  back.  He  kept  up  work  on  his 
farm,  and  attributed  his  pain  to  rheumatism.  On 
Saturday  he  came  to  Shelbyville,  and  returned 
home,  a  distance  of  four  miles.  During  the  day 
his  nose  bled  freely.  This  had  occurred  at  differ- 
ent times  previously.  He  complained  somewhat 
the  same  way  on  Sunday,  atS  p.m.  had  a  chill,  and 
head,  neck,  and  eyes  pained  him  intensely,  and 
he  suffered  excessive  pain  in  his  knee  joints. 
His  throat  was  sore,  and  in  less  than  an  hour  he 
was  delirious  and  almost  entirely  deaf.  Dr.  A. 
P.  Ryall  was  called  to  see  him  and  found  a  bound- 
ing pulse,  temperature  ico°,  and  he  could.be  kept 
in  bed  only  by  the  greatest  effort  of  three  strong 
men.  He  gave  him  bromides  with  heavy  mer- 
curial purgatives,  and  large  doses  of  morphia. 
He  cupped  him  and  poured  large  quantities  of 
well-water  on  his  head.  I  saw  him  at  eleven 
o'clock  Monday  night,  after  he  had  been  sick 
twenty-four  hours.  He  was  hardly  conscious  of 
his  surroundings,  his  mind  was  entirely  obscured, 
and  he  was  deaf.  He  could  see  with  difficulty 
and  there  was  ptosis  of  the  lid  of  left  eye.  One 
pupil  was  much  more  dilated  than  the  other,  and 
both  responded  to  light  slowly.  He  was  continu- 
ously tossing  and  when  still  for  a  moment,  was 
on  the  side  and  never  on  the  back.  There  was 
constant  desire  to  micturate,  but  the  urine  was 
voided  with  difficulty.  Red  spots  appeared  on 
his  face,  body  and  arms  from  the  size  of  a  pin's 
head  to  that  of  a  five  cent  piece.  His  knuckles 
and  wrists  were  especially  red,  and  the  skin  in 
the  highest  state  of  hyperaesthesia;  pressure  upon 
the  hand  producing  contraction  of  the  muscles 
of  the  face.  There  was  an  herpetic  eruption  on 
the  lips;  the  head  was  slightly  drawn  backward: 
he  had  distressing  nausea  and  vomiting  from  the 
beginning. 

We  gave  him  six  drops  of  veratrum  viride  every 
three  hours  and  ten  grains  of  quinine  even,-  hour 
until  six  in  the  morning. 

Although  he  vomited  frequently,   we  thought 


902 


CEREBROSPINAL  MENINGITIS. 


[June  27, 


he  had  retained  most  of  the  quinine.  At  that  several  times.  The  cold  stage  was  followed  by 
hour  his  symptoms  were  greatly  improved.  He  contraction  of  the  muscles  of  the  arms  and  hands, 
was  rational  and  could  see  fairlv  well,  though  one   spells  of  difficult    and   panting   breathing   were 


eye  squinted.  His  stomach  was  quiet  and  he  had 
slept  some.  He  drank  some  milk  and  had  a  free 
and  copious  action  from  the  bowels.  The  qui- 
nine was  suspended  until  evening,  the  veratrura 
was  not  given  after  four  in  the  morning.  Mor- 
phia, potassium  bromide  and  tincture  "of  gelsemi- 
1111111  were  given  through  the  day.  He  passed 
through  the  day  Tuesday  much  better  than  Mon- 
day, but  as  night  approached  his  ugly  symptoms 
all  returned,  and  notwithstanding  the  quinine 
and  all  other  available  means  were  pressed 
through  the  night,  it  was  quite  evident  on  Wed- 
nesday morning  that  he  must  die,  which  he  did 
that  night  at  nine  o'clock. 

On  the  following  Friday  afternoon  the  little 
daughter  of  Mr.  H.,  aged  5  years,  apparently  in 
good  health,  and  out  in  the  yard  at  play,  came 
hurriedly  to  her  mother  complaining  of  pain  in 
the  region  of  the  umbilicus.  She  soon  had  shiv- 
ering followed  by  pain  in  the  head  and  neck, 
pulse  140;  breathing  rapid,  with  an  occasional 
sigh;  temperature  1030,  delirium  and  sick  stom- 
ach; opisthotonos  marked;  skin  hyperaesthetic; 
blind  in  one  eye  from  infiltration  of  the  cornea, 
which  was  perfectly  white.  She  had  a  red  erup- 
tion. She  was  bathed  in  warm  water,  given  gel- 
seminum,  quinine  in  large  doses,  and"  nothing 
left  undone  that  promised  relief.  She  died  on 
the  following  Monday  night. 

On  Tuesday  her  brother,  13  years  old,  had  a 
chill,  followed  by  pains  in  nape  of  neck,  sick 
stomach,  headache,  sore  throat,  pain  in  back  and 
a  peculiar  pain  about  the  joints  of  the  lower 
limbs.  He  was  given  quinine  and  calomel,  and 
recovered  in  a  few  days  with  but  little  trouble. 
He  had  a  similar  epistaxis  to  that  of  his  father, 
but  there  was  no  eruption.  This  family  lives  on 
the  side  of  a  considerable  hill.  The  front  of  the 
house  is  three  or  four  feet  above  the  surface  while 
the  rear  rests  flat  on  the  ground. 

The  soil  on  the  south  side  and  in  the  rear  of 
the  house  was  at  that  time  continually  damp. 
The  drinking  water  was,  for  the  most  part,  from 
a  spring  which  had  been  dry  during  the  summer 
months.  Long  preceding  this  it  had  been  wall- 
ed with  wood,  which  at  this  time  was  in  a  state 
of  decay.  The  washings  of  soil,  leaves  and 
grass,  and  every  conceivable  thing  had  lodged 
within  this  enclosure  for  years.  When  the  stream 
began  to  run  in  Autumn  il  was  very  sluggish. 
Here,  in  my  opinion,  is  the  source  of  the  sickness 
in  this  family. 

<m  March  6th,    1889,    Win.  G..    aged   21.  was 
id  with  shivering,  followed  by  intec 
in  the  head,  neck,  back,  and  especially  the  bow- 
els.     His   knee-joints  were   painful   and  he  had 
sore  throat.      He  h  [uite  unwell 

vs  precedin  I  his  nose  had  bled 


frequent,  his  pulse  and  temperature  were  normal. 
He  was  boisterously  delirious,  had  sick  stom- 
ach, spots  on  the  face,  herpes  labialis.  He  was 
given  anodynes,  bromides  and  calomel.  He  also 
had  large  doses  of  quinine  and  morphia.  The 
morphia  did  not  affect  him  pleasantly.  In  eight 
hours  he  was  given  80  grains  of  quinine.  He 
also  had  every  four  hours  one  drop  of  carbolic 
acid  and  three  drops  of  tincture  of  iodine  in 
water.  He  had  large  quantities  of  cold  water 
poured  on  his  head  at  first,  but  it  was  soon  noticed 
that  hot  water  had  a  more  desirable  effect,  as  it 
quieted  him  for  the  time  being.  He  recovered  in 
twelve  days.  I  may  mention  that  after  being  up 
a  few  days  and  walking  a  quarter  of  a  mile  he 
had  a  relapse  in  which  man}'  of  the  first  symp- 
toms recurred.  His  sister  had  the  same  symp- 
toms, but  not  so  severe,  and  she  also  recovered. 

On  March  24,  1889,  G.  E.,  aged  21,  living  in 
Shelbyville,  had  a  chill  followed  by  a  fever,  pain 
in  the  head,  neck,  back  and  limbs,  especially  in 
the  calves  of  the  legs  and  knee-joints,  hyperes- 
thesia of  the  skin,  sick  stomach,  temperature 
1030,  pulse  100,  tongue  broad  and  coated.  He 
had  red  spots  on  both  hands,  particularly  the 
knucMes,  and  on  the  wrists  and  bod}'.  I  saw 
him  at  10  p.m.  of  the  24th;  at  that  time  he  was 
only  partially  delirious.  He  had  10  grains  of 
calomel  and  40  grains  of  quinine  during  the 
night,  with  sufficient  morphia  to  keep  him  quiet. 
On  the  25th  his  temperature  was  lower  and  his 
pulse  90,  pain  in  head  more  intense,  patient 
somewhat  stupid,  considerable  deafness,  and 
muttering  delirium. 

He  was  given  bromides,  gelseminum,  ergot  and 
calomel.  The  tincture  of  iodine  and  carbolic 
acid  mixture  was  also  given.  Quinine  was 
pressed  as  rapidly  as  possible.  On  the  afternoon 
of  the  26th  he  had  a  convulsion,  and  during  the 
night  the  convulsions  recurred  several  times. 
His  right  side  was  paralyzed.  He  died  on  the 
afternoon  of  the  29th,  having  been  sick  five 
days. 

These  cases  were  of  the  most  malignant  type. 
Quite  a  number  of  cases  more  mild  were  treated 
during  the  mouths  of  January,  February  and 
March.  They  had  the  erratic  pains  which  were 
felt  in  different  parts  of  the  body,  headache,  and 
pain  in  the  nape  of  the  neck  and  lower  limbs, 
Many  cases  had  redness  of  skin  on  hands  and 
wrist  ;  some  had  fever  three  or  four  days,  others 
much  shorter  time.  I  could  if  necessary  give 
their  history  in  detail.  There  can  be  no  doubt 
that  the  original  lesion  of  this  trouble  is  to  be 
found  in  the  nerve-centres.  The  rational  signs 
point  unmistakably  in  that  direction,  and  the 
physical  symptoms  lead  the  same  way.  The  im- 
press of  the  poison,  whatever  it  may  be,  is  made 


I89i.] 


ABDuMIXAI.  SECTION*. 


903 


originally  on  the  nervous  system.  I  conclude 
from  observations  made  not  only  in  the  years 
1888-18S9,  but  from  the  cases  that  I  treated  in 
the  years  from  i860  to  1863,  that  the  real  cause 
of  this  disease  is  malaria.  The  symptoms  of 
malarial  blood  poison  are  as  protean  in  their 
manifestations  as  the  shades  of  the  chamelion. 

The  three  cases  in  the  family  of  Mr.  H.  cov- 
ered the  extremes  of  these  manifestations.  The 
prodromata  i:i  the  father's  case  was  clearly  indi- 
cative of  nerve  lesion,  the  same  as  usually  pro- 
duced by  malaria. 

The  shifting  and  shooting  pains  in  the  body, 
the  headache,  pain  in  back  and  limbs,  all  point 
in  that  direction. 

The  epistaxis  was  evidently  dependent  on 
malarial  toxaemia. 

A  bleeding  nose  in  the  early  history  of  a  fever 
is  strong  evidence  of  malarial  origin.  Herpes 
labialis  is  also  often  observed  in  the  milder  types 
of  malarial  trouble.  If  we  take  the  three  com- 
mon types  of  malarial  fever,  intermittent,  re- 
mittent, and  pernicious,  we  have  extremes  wide 
enough  to  cover  all  the  phenomena  and  peculiar- 
ities of  the  so-called  cerebro-spinal  meningitis. 
The  young  man,  Mr.  C,  had  just  one  week 
previous  to  his  fatal  attack,  the  most  intense  pains 
in  his  legs  and  knee-joints:  the  red  eruptions 
on  the  knuckles  of  his  hands.  This  all  subsided 
within  twenty-four  hours  and  he  was  at  his  usual 
occupation  for  the  succeeding  week.  I  observed 
this  periodic  return  of  the  symptoms  in  several 
cases.  While  the  ordinary  types  of  malaria  are 
developed  in  the  autumn  and  spring,  and  seldom 
in  the  winter,  it  is  true  that  the  pernicious  cases 
are  as  apt  to  be  developed  in  February  and 
March  as  at  any  other  season.  I  do  not  think 
the  fact  that  cerebrc-spinal  meningitis  has  been 
observed  in  mid  winter,  is  sufficient  argument 
against  its  malarial  origin.  If  I  have  succeeded 
in  showing  some  facts,  proving  that  inflammation 
is  not,  and  should  not.  be  the  o%-ershadowing 
symptom,  and  that  it  must  not  control  the  treat- 
ment, and  further,  if  the  cause  is  found  iu  ma- 
laria, then  the  line  of  treatment  is  plain. 

The  practitioner  who  has  confronted  this 
dreaded  disease,  and  who  has  looked  through  the 
pages  of  the  best  authorities,  must  feel  that  he 
goes  into  the  battle  with  au  uncertain  guide  and 
a  trembling  hand.  Uncertaintv  as  to  cause,  and 
an  evident  want  of  confidence  in  the  remedies 
recommended,  mark  the  written  history  of 
cerebro-spinal  meningitis. 

A  disease  so  bold  and  rapid,  and  fatal  in  its 
results,  must  be  met  by  no  faltering  hand.  It  is 
no  new  thought  that  malaria  is  the  cause,  but  I 
insist  that  the  fact  has  not  been  fully  recognized, 
and  that  the  treatment,  both  prophylactic  and 
curative,  has  not  been  thoroughly  tested  because 
of  this  want  of  recognition. 

No  disease  of  malarial   origin   can   be   satis- 


factorily treated  upon  general  principles.  It  is  a 
I  specific  disease  and  requires  specific  treatment. 
Quinine  is  the  antidote,  and  without,  no  success 
can  be  expected.  There  are  many  adjuvants 
which  must  be  used ;  calomel  in  large  and  re- 
peated doses,  venesection  and  veratrum,  are 
among  the  best  arterial  and  nerve  sedatives,  and 
at  the  same  time  they  favor  the  absorption  of 
other  medicines,  and  the  elimination  of  blood- 
poison. 

The  bromides,  chloral,  and  morphia  are  to  be 
used  freely.  The  quinine  should  be  used  hvpo- 
dermicaily  iu  not  less  than  5  grain  doses,  and  at 
not  longer  intervals  than  one  hour ;  the  bi- 
sulphate  is  the  best  for  this  purpose  and  can 
readily  be  dissolved  in  warm  water.  There  are 
a  few  cases  which  cannot  be  controlled  in  every 
epidemic  of  any  disease,  but  they  all  have  their 
prodroma,  and  if  the  medicines  are  given  in 
time  many  cases  can  be  prevented  from  reaching 
the  grave  type.  This  is  eminently  true  of  cerebro- 
spinal meningitis.  It  is  as  a  prophylactic  that 
quinine  is  to  be  the  greatest  boon.  When  it  is 
threatening  to  be  epidemic  the  physician  should 
warn  his  patients  that  the  first  shooting  pain  and 
the  earliest  uneasy  aching,  the  slightest  head- 
ache or  slightest  arthralgia,  must  be  met  with 
quinine.  It  is  here  that  the  inflammatory  theory- 
has  done  its  greatest  harm  by  withholding  the 
hand  in  the  fear  of  exciting  it. 

t  be  remembered  that  malaria  :> 
the  patient,  and  not  inflammation.  If  the  patient 
survives  the  deadly  touch  of  the  blood- poison 
then  there  will  be  plenty  of  time  to  treat  the  in- 
flammation, which  is  one  of  the  sequalae  of  the 
perverted  blood  vessels  caused  by  an  influence 
exerted  through  the  nervous  system. 


REPORT  OF  SIX  CASES  OF  ABDOMINAL 
.ION. 

Read  in  the  Section   of  Obstetrics  and  Diseases  of  Il\  ■ 
tion,  held  at  '■: 

BY  A.  C.  WILSON,  M.D.. 

OF     YOrXG5TOWN.   OHIO. 

Case  i. — Mrs.  J.  W..  aged  2S  years,  married 
ten  years,  has  had  two  children,  elder  S  years. 
younger  6  years.  She  has  had  two  miscarriages, 
one  four  years  and  the  other  two  years  ago.  Her 
labors  were  always  long  and  tedious,  and  her  re- 
coveries slow.  Menstruated  first  at  the  age  of 
15  years.  Always  suffered  great  pain  at  these 
times.  Since  the  birth  of  the  last  child,  she  has 
been  a  constant  sufferer  from  severe  pelvic  pain, 
and  a  dull  aching  in  the  lower  part  of  the  back, 
rendering  her  able  to  walk  but  a  short  distance. 
She  was  treated  one  year  for  the  pains  with 
tonics  and  nervines,  and  also  locally  by  painting 
the  vault  of  the  vagina  with  tr.  iodine,  and  with 
glycerine  tampons.      She  received  no  relief  by 


904 


ABDOMINAL  SECTION. 


[June  27, 


this  treatment.  Her  suffering  was  so  constant 
and  extreme  that  the  removal  of  Ihe  uterine  ap- 
pendages was  proposed  and  gladly  consented  to. 
On  October  30,  1S89,  assisted  by  Dr.  H.  A. 
Kelly,  of  Baltimore,  Md.,  the  tubes  and  ovaries 
were  both  removed.  She  made  a  rapid  recovery 
without  an  unfavorable  symptom.  There  has 
been  no  pelvic  pain  since  the  operation.  She 
got  up  the  fifteenth  day,  and  in  six  weeks  began 
doing  her  own  work.  She  is  now  able  to  walk 
without  discomfort,  aud  is  well  in  every  respect. 

Case  2. — Mrs.  F.,  aged  49  years,  married  and 
has  had  eleveu  children,  all  still-born,  except  two 
who  died  soon  after  birth.  Two  years  before  I 
saw  her,  she  received  an  injunr  in  the  lower  part 
of  the  abdomen  which  caused  an  inflammation, 
and  confined  her  to  bed  for  several  weeks.  Since 
then  she  suffered  constant  pain  in  that  region, 
and  a  small  tumor  could  be  indistinctly  made  out 
at  that  point  in  the  abdominal  cavity.  She  was 
treated  for  her  trouble  by  her.  family  physician 
for  a  long  time  with  no  benefit.  An  explorato^y 
operatiou  was  performed  Nov.  20,  1889,  to  de- 
termine the  character  of  her  trouble.  The  small 
tumor  proved  to  be  a  mass  of  adhesions  matting 
together  the  omentum  and  bowels.  The  less 
firm  adhesions  were  broken  up  by  the  fingers, 
freeing  the  bowels  as  much  as  possible  from  con- 
strictions. The  abdominal  cavity  was  well 
washed  out  with  hot  distilled  water,  and  care- 
fully sponged  out,  and  the  abdominal  wound 
closed.  The  patient  had  no  previous  prepara- 
tion, and  had  partaken  of  a  hearty  meal  but  a 
couple  of  hours  before  the  operation.  The  sur- 
roundings of  the  patient  were  bad,  the  rooms 
small  and  filth}-,  but  she  made  a  good  recovery 
from  the  operation.  Although  she  still  suffers 
some  inconvenience,  yet  she  has  been  much  im- 
proved. 

Case  j. — Mrs.  J.  S.,  aged  28  years,  married 
seven  years.  Has  one  child  6  years  of  age.  Has 
had  four  miscarriages,  the  last  in  February,  1890. 
She  first  menstruated  at  the  age  of  14.  Since 
the  birth  of  her  child  she  has  been  a  constant 
sufferer.  She  was  first  seen  in  March,  1890, 
menstruation  was  then  occurring  every  two 
weeks.  On  examination  I  found  the  uterus 
slightly  retroverted,  the  left  ovary  enlarged,  pro 
lapsed,  and  very  painful  to  the  touch.  At  that 
time  she  was  weak  aud  anaemic.  Tonics  includ- 
ing iron  were  prescribed.  Locally  she  was 
treated  with  iodine  and  glycerine  tampons.  Her 
general  constitution  became  better,  but  the  ovary 
showed  no  improvement.  Its  removal  was  ad- 
vised, and  consented  to,  with  the  understanding 
that  the  right  one  should  be  left,  unless  it  be 
found  so  far  diseased  as  to  be  entirely  useless. 
The  operation  was  performed  May  26,  1890. 
The  adhesions  binding  the  left  ovary  were  broken 
up  and  it  was  removed  with  the  tube.  It  was 
about  the  size  of  a  hen's  egg,  containing  an  ab- 


scess filling  almost  the  whole  ovary  with  pus. 
The  right  ovary,  being  healthy,  was  left.  The  ab- 
domen was  closed  and  she  made  a  rapid  recovery. 
Her  menses  came  on  the  latter  part  of  June.  In 
July  they  failed  to  appear.  In  August  she  con- 
sulted me  about  her  condition.  She  had  morn- 
ing sickness ;  after  questioning  her  closely,  I 
concluded  she  must  be  pregnant  and  advised  her 
to  remain  quietly  at  home.  After  a  couple  of 
weeks  she  became  quite  comfortable.  About  the 
1 2th  of  September,  the  next  day  after  a  ride  of 
several  miles  over  a  rough  road,  in  a  not  easy 
riding  vehicle,  I  was  called  to  see  her.  She  had 
severe  pain  and  profuse  haemorrhage  ;  in  short  I 
found  her  suffering  from  a  miscarriage.  The 
membranes  came  awaj-  easily,  and  in  two  week's 
time  she  was  able  to  b'e  up  again.  After  a  couple 
of  months,  she  began  to  suffer  a  great  deal  of 
pain  in  the  right  ovary,  which  as  yet  I  have  not 
been  able  to  relieve,  and  I  very  much  fear  that  a 
second  operation  for  the  removal  of  the  right 
ovary  will  be  necessary. 

Case  4. — Mrs.  E.  W.  D.,  aged  30  years,  has 
two  children,  the  elder  7  years,  the  younger  2)2 
years.  One  miscarriage  five  years  ago.  Labors 
have  always  been  protracted  and  severe,  and  re- 
coveries slow.  She  first  menstruated  at  the  age 
of  16,  which  has  always  been  painful.  Has 
suffered  more  pain  since  the  miscarriage  five 
years  ago.  Since  the  birth  of  her  last  child  she 
has  menstruated  every  two  or  three  weeks,  con- 
stant pain  in  back  and  pelvis.  Has  headache 
nearly  all  the  time  and  is  very  nervous.  First 
examined  her  in  May,  1S89.  Uterus  slightly 
retroflexed,  and  both  ovaries  exceedingly  painful 
to  the  touch.  She  was  also  very  weak  and 
ansemic.  She  was  treated  with  tonics,  and  also 
with  appropriate  local  applications  for  a  year. 
Her  general  condition  was  improved,  but  there 
was  no  relief  to  the  pain.  In  August,  1890,  she 
became  very  much  worse  with  the  pain  and  was 
confined  to  her  bed.  The  removal  of  the  uterine 
appendages  was  advised.  Consequently,  Septem- 
ber 18,  the  operation  was  performed.  Both  tubes 
and  ovaries  were  adhered  by  bands  of  adhesions 
to  the  surrounding  parts,  but  were  easily  re- 
moved. The  ovaries  were  enlarged  but  con- 
tained no  abscesses. 

The  tubes  presented  a  granular  appearance, 
and  exuded  a  thin  blood}'  pus.  The  patient 
made  a  good  recovery,  and  began  doing  her  own 
work  and  caring  for  a  family  of  five  members, 
the  following  January,  and  still  continues  to  be 
well. 

Case  5. — Mrs.  M.,  aged  39  years.  Has  had 
four  children,  the  youngest  4  years  of  age.  The 
last  labor  very  long  and  difficult,  and  was  fol- 
lowed by  puerperal  fever,  from  which  she  made 
a  slow  recovery,  which  was  never  complete. 
Since  then  she  has  had  constant  pelvic  pain,  and 
also   pain   in  the   lower   part  of  the  back,    and 


■] 


ABDOMINAL  SIXTH  »N. 


905 


menses  appearing  every  two  or  three  weeks. 
She  never  was  treated  for  her  trouble  until  the 
summer  of  1890,  when  she  became  unable  to 
work,  and  was  confined  to  her  bed.  She  re- 
ceived appropriate  treatment,  both  local  and  con- 
stitutional, from  her  physician  during  the  sum- 
mer and  early  fall  of  1890.  She  was  first  seen 
by  me  in  August.  Both  ovaries  were  very  pain- 
ful to  the  touch,  the  left  one  prolapsed  and  lying 
behind  the  uterus.  The  removal  of  the  tubes 
and  ovaries  was  advised.  October  10,  the  opera- 
tion was  performed.  The  ovaries  were  adherent, 
but  the  adhesions  were  easily  separated  and  both 
tubes  and  ovaries  were  removed.  The  ovaries 
were  small  and  sclerotic,  the  tubes  enlarged  and 
exuded  a  thick  yellowish  serum.  The  patient 
made  a  good  recovery.  After  three  weeks  she 
went  home  and  went  to  work,  caring  for  her 
family,  which  very  much  retarded  her  complete 
recovery.  She  has  continued  to  improve,  until 
now  she  is  comparatively  well. 

Case  6. — Miss  J.  R.,  aged  20  years.  In  May, 
1S89,  she  had  a  large  cyst  of  right  ovary  re- 
moved by  Dr.  A.  Kelly.  The  left  ovary  at  that 
time  was  in  perfectly  normal  condition  and  was 
not  removed.  She  recovered  very  nicely  from 
this  operation.  She  was  well  until  July,  1890, 
when  she  had  an  attack  of  dysentery;  after  this 
she  complained  of  severe  pain  in  the  lower  part  of 
trie  abdomen  and  pelvis.  She  was  treated  with 
tonics  for  some  time  with  little  benefit.  In 
August  an  examination  of  the  pelvis  and  ab- 
domen was  made.  Bands  of  adhesions  could  be 
felt  in  the  right  ovarian  region.  These  ex- 
tended from  the  womb  and  right  broad  ligament, 
and  seemed  to  be  connected  with  the  bowels. 
She  complained  of  much  pain  in  that  region, 
and  especially  when  the  bowels  were  about  to 
move.  The  uterus  was  slightly  movable,  seem- 
ing to  be  fixed  by  bands  of  adhesions  to  the  line 
of  the  old  cicatrix.  The  right  ovary  was  en- 
larged, painful,  and  slightly  movable.  She  grew 
gradually  worse  during  the  latter  part  of  the 
summer.  In  the  fall  she  became  bed-fast.  The 
pain  in  the  pelvis  became  so  intense  that  it  be- 
came necessary  to  give  her  opiates  for  her  relief. 

On  December  27th,  laparotomy  was  performed 
for  her  relief.  An  incision  three  inches  in  length 
was  made  at  the  right  and  close  to  the  old  cica- 
trix. Some  difficulty  was  experienced  in  open- 
ing the  peritoneal  cavity,  because  of  the  adhe- 
sions of  the  bowel  and  omentum  to  the  old  cica- 
trix. At  the  right  of  the  uterus,  there  was  a  mass 
of  adhesions  matting  the  viscera  in  this  region 
all  together.  These  were  broken  up.  The  stump 
of  the  old  pedicle  from  which  the  cyst  was  re- 
moved two  years  ago  was  found,  with  the  liga- 
ture about  it,  but  apparently  as  it  was  left  at  the 
former  operation,  a  year  and  a  half  before.  This 
was  left  as  it  was.  The  left  ovary  and  tube  were 
finnlv  bound  down  and  were  removed  with  diffi- 


culty. There  was  a  great  deal  of  haemorrhage, 
but  the  abdominal  cavity  was  flushed  with  hot 
distilled  water  and  it  soon  ceased.  The  abdomi- 
nal cavity  was  then  carefully  sponged  out  and 
closed  without  a  drainage  tube.  I  regretted  af- 
terwards that  a  drainage  tube  was  not  used,  as 
there  was  a  great  deal  of  pain  and  some  disten- 
sion of  the  abdomen,  which  gave  me  a  great  deal 
of  uneasiness  for  fear  there  was  more  oozing  of 
blood  than  the  peritoneum  could  take  care  of. 
Nevertheless  she  recovered  slowly,  and  is  now 
nearly  well.   She  suffers  no  pain  and  walk 

inconvenience,  and  is  improving  rapidly. 

These  operations  were  all,  except  Case  5,  per- 
formed at  their  dwellings.  Case  5,  was  done  at 
the  Youngstown  City  Hospital.  The  rooms  in 
which  the  operations  were  done  and  where  the 
patients  were  subsequently  cared  for,  were  all 
carefully  cleaned,  carpets  and  furniture  removed, 
!  work  carefully  washed  with  a  1  to  1000 
sublimate  solution.  This  was  done  in  all  cases 
except  Case  2,  which  had  no  preliminary  prepar- 
ations whatever.  All  except  Case  3,  previous  to 
the  operations,  were  given  saline  cathartics  and 
the  bowels  thoroughly  emptied.  They  were 
carefully  bathed,  the  abdomen  and  genitals  thor- 
oughly washed  in  1  to  1000  sublimate  solution. 
The  hands  of  both  the  operator  and  assistant 
were  thoroughly  scrubbed  with  hot  water  and 
soap,  and  then  immersed  in  1  to  1000  sublimate 
solution  for  a  few  minutes.  Nothing  but  hot 
distilled  water  was  used  in  cleansing  the  abdomi- 
nal cavity  or  the  wound. 

Silk  ligatures  were  used  for  both  the  pedicle 
and  the  closing  of  the  abdominal  wound.  These 
were  prepared  by  boiling  for  fifteen  minutes  in 
distilled  water,  and  then  placed  in  1  to  1000  sub- 
limate solution  for  two  hours,  and  preserved  in 
alcohol.  Nothing  but  liquid  food  was  given  for 
a  couple  of  days  before  the  operation,  and  no 
food  or  drink  except  weak  tea  was  given  for  two 
days  after  the  operation.  The  temperature  of 
none  of  these  cases  ever  rose  above  100.  No 
stitch  abscesses  occurred  in  any  of  the  cases. 

Hypodermics  of  morphia  were  given  the  first 
three  days  after  the  operation  to  relieve  the  pain, 
except  in  Cases  1  and  2. 

The  results  obtained  in  these  cases  have  been 
entirely  satisfactory.  Before  the  operations  they 
were  great  sufferers,  unable  to  attend  to  their 
household  duties.  To  day  they  are  doing  their 
own  work  at  home,  and  with  the  exception  of 
cases  2  and  3  who  were  greatly  improved,  are 
well  and  happy  women. 

Youngstowu,  O..  May  1st,  1S91. 


Dr.  james  N.  Martin  has  been  appointed  to 
the  chair  of  Obstetrics  and  Diseases  of  Women 
in  the  University  of  Michigan,  which  he  has 
filled  since  the  death  of  Dr.  Duuster. 


906 


A  CHILD'S  ARM  ENGAGED  IN  THE  FENESTRUM. 


[June  27, 


A  CASE  OF  DOUBLE  UTERUS  AND 
VAGINA. 


Read  in  the  Set  lion  of  Odsteti  ics  and  Diseases  of  Women,  at  the  Forty- 
second  Annua!  Meeting  of  tire  American  Medical  Association,  held 
at  Washington,  D.  C,  May,  i8or. 

BY  M.  GUHMAN,  M.D., 

OF  ST.  I.OVIS,  MO. 

Mrs.  A.,  28  years  of  age,  married  six  years, 
well  developed.  First  pregnancy  four  years  after 
marriage — there  was  nothing  unusual  during  her 
term  of  pregnancy.  Dr.  Langan  and  I  delivered 
her  on  February  6,  1889,  under  the  influence  of 
chloroform,  of  a  living  female  child.  It  was  a 
breech  presentation,  and  never  entered  the  infe- 
rior strait,  and  followed  by  a  complete  inversion 
of  the  uterus,  which  I  reported  to  the  St.  Louis 
Medical  Society.  On  April  25,  1890,  I  was  sum- 
moned again  to  deliver  her  the  second  time.  Upon 
examination  I  found  it  another  breech  presenta- 
tion. Labor  progressed  favorably  until  entering 
the  inferior  strait,  and  then  it  became  firmly  lodged. 
I  sent  for  Dr.  Langan  and  my  son  to  assist  me. 
Under  the  influence  of  chloroform  and  in  position, 
I  proceeded  to  deliver  her.  I  introduced  my  fin- 
gers in  the  vagina,  but  to  my  surprise  I  could  not 
detect  any  child,  nor  could  I  find  the  mouth  of 
the  uterus.  I  could  feel  a  something  through  a 
partition,  but  I  did  not  know  what  that  partition 
was.  I  was  under  the  impression  that  from  the 
change  of  the  position  of  the  woman,  and  under 
the  influence  of  chloroform,  the  uterus  with  its 
contents  was  displaced,  and  the  mouth  of  the 
uterus  was  out  of  my  reach,  although  thinking 
that  such  a  state  of  affairs  was  impossible.  I  in- 
troduced my  finger  backwards  and  forwards,  with 
always  the  same  result.  I  asked  Dr.  Langan  to 
make  an  examination.  He  also  got  his  finger  in 
the  same  canal,  and  we  still  were  not  aware  that 
we  had  to  deal  with  a  double  vagina  and  uterus. 
We  could  not  detect  the  neck  or  mouth  of  the 
empty  uterus  No.  2,  it  was  also  drawn  out  of  our 
reach.  Being  perplexed  at  finding  such  unusual 
complications  which  we  could  not  account  for, 
we  agreed  to  send  for  Dr.  Mooney,  who  resided 
near  by.  We  kept  our  patient  under  the  influ- 
ence of  chloroform.  When  Dr.  Mooney  came,  he 
also  got  his  fingers  into  the  empty  vagina.  We 
concluded  to  make  an  ocular  examination,  which 
revealed  a  septum  arising  from  the  orifice  of  the 
urethra,  and  extending  along  the  median  line  to 
the  fourchette,  completely  separating  the  vagina 
into  two  canals.  We  introduced  our  hand  into 
the  vagina  leading  to  the  impregnated  uterus, 
and  delivered  the  woman  of  a  living  female  child. 
After  delivery'  the  condition  of  the  woman  was 
such  that  we  did  not  think  it  prudent  to  make 
any  further  examination.  Our  patient  improved 
rapidly,  and  on  May  11,  1890,  Dr.  Mooney  and  I 
made  another  examination,  and  found  things  as 
above  described.  In  each  vaginal  cavity  we  found 
a  well  developed  cervix ;  we  introduced  a  uterine 


sound  in  the  left  uterus  to  a  depth  of  2^  inches. 
On  account  of  some  blood  flowing  from  the  ute- 
rus after  our  examination,  and  only  sixteen  days 
after  delivery,  we  abstained  from  any  further  ex- 
amination. Since  I  introduced  a  sound  in  the 
other  (right)  uterus,  and  also  found  its  depth 
about  21/:  inches.  From  our  examination  and 
observation,  it  seems  that  both  uteruses  have 
been  impregnated,  the  right  first,  and  the  left 
second ;  she  did  not  menstruate  during  either 
pregnancy.  It  is  my  opinion  that  we  have  more 
double  vaginas  and  uteruses  than  we  are  aware 
of,  because  it  is  only  by  accident  that  we  find  these 
anomalies.  I  have  treated  my  patient  in  my  of- 
fice, after  her  marriage,  for  a  slight  flexion  of 
one  of  the  cervixes,  with  a  speculum,  made  digital 
examination,  and  delivered  her  once;  and  I  only 
found  her  condition  by  accident  at  her  last  con- 
finement. All  other  such  cases  of  which  I  have 
read  were  found  by  accident.  For  the  develop- 
ment of  anomalies  of  vaginas  and  uteruses,  I 
would  refer  you  to  some  of  our  text-books. 
Gentlemen,  I  thank  you  for  your  kind  attention. 


REPORT    OF    A    CASE   IN    WHICH    THE 

CHILD'S  ARM  BECAME  ENGAGED 

IN  THE  FENESTRUM  OF  THE 

OBSTETRIC  FORCEPS. 

Read  by  Title,  in  the  Section   of  Obstetrics  and  Diseases  of  Women . 
at  the  Forty-second  A  nnual  Meeting  of  the  American  Medical  As- 
sociation, held  at  Washington,  D.  C  May,  iSai. 

BY  DAN  MILLIKIN,  M.D., 

OF  HAMILTON,  O. 

Nearly  a  year  ago  I  attended  a  woman  who 
had  borne  four  dead  children  after  severe  and 
complicated  labors,  each  time  under  the  care  of 
a  different  physician.  She  had  also  borne  one 
living  child,  which  owed  its  existence  to  the  fact 
that  it  was  very  small,  and,  probably,  was  prema- 
turely born.  This  woman,  half  through  her 
sixth  pregnancy,  came  to  me,  and  consented  to 
the  induction  of  premature  labor.  Thereupon 
she  passed  from  my  notice,  changed  her  plans 
upon  ill  advice,  and  summoned  me  when  labor 
at  term  had  progressed  for  two  or  three  hours. 

When  the  cervical  tissues  were  in  proper  con- 
dition, a  careful  examination  of  the  case  was 
made  under  an  anaesthetic.  Finding  a  head  of 
moderate  size  above  the  brim  of  the  pelvis  in  left 
occipito- anterior  position,  I  was  sure  that  I  could 
deliver  it  with  forceps  in  spite  of  a  slight  asym- 
metry, and  a  shortened  an tero- posterior  diameter 
of  the  pelvis.  In  this  opinion  I  was  all  amiss, 
for  it  was  afterwards  demonstrated  that  the  child 
could  not  be  delivered  in  that  position,  and  it. 
also  appeared  that  it  could  be  delivered  easily  feet 
foremost.  But  this  error  of  judgment  is  some- 
what apart  from  my  present  business. 

Four  fingers  were  passed,  and  the  forceps  were 


A  CHILD'S  ARM  ENGAGED  IN  THE  FENESTRUM. 


907 


carefully  guided  to  the  sides  of  the  child's  head. 
They  were  easily  locked  and  manifested  no  dis- 
position to  slip  during  the  attempted  extraction 
of  the  child.  It  may  also  be  remarked  that  thev 
were  my  pet  instruments,  with  broad  blades  and 
strong  curves,  cephalic  and  pelvic. 

Xo  effort  was  made  to  induce  pains  by  traction. 
The  pains  were  very  vigorous  but  separated  by 
unusually  long  intervals.  For  this  reason,  and 
because  the  woman's  general  condition  w.as  ex- 
cellent, the  effort  to  deliver  by  forceps  was  much 
prolonged. 

When,  finally,  it  was  determined  to  essay  de- 
livery by  podalic  version,  a  state  of  affairs  was 
presented  which,  so  far  as  I  can  learn,  was 
unique  in  obstetric  practice.  The  upper  blade 
of  the  forceps — that  one  which  passed  to  the  right 
side  of  the  woman's  pelvis — would  not  come  out ! 
The  lower  blade  was  withdrawn  first,  and  with- 
out difficulty,  but  still  the  other  would  not  come 
away.  Then  my  hand,  passed  into  the  uterus, 
revealed  the  fact  that  the  child's  right  hand  had 
passed  through  the  fenestrum  of  the  blade  and 
that,  in  fact,  the  blade  hung  on  the  bend  of  the j 
elbow,  as  a  basket  hangs  on  one's  arm.  The; 
blade  could  not  have  been  withdrawn  without  in- 
ternal manipulation. 

Presently,  when  the  child  had  been  delivered 
by  the  feet,  it  was  seen  that  violence  had  been ' 
done  to  the  forearm  alone,  and  that  the  injury, 
was  near  the  elbow.  Xo  bones  were  broken,  but : 
the  soft  parts  were  terribly  crunched.  Undoubt- 1 
edly,  if  the  instrument  had  been  long  and  stiff, 
and  if  it  had  appeared  proper  to  compress  the  1 
head  very  severely,  the  arm  would  have  been 
completely  chewed  off. 

Endeavoring  to  draw  some  warning  from  such 
a  sorry  job,  we  may  note,  in  the  first  place,  that! 
the  accident  could  only  occur  when  a  supra-  \ 
pelvic  application  of  the  forceps  is  made.  To 
attain  the  odd  position  in  which  I  found  it,  the 
arm  must  have  lain  for  a  moment  with  its  palmar 
surface  on  the  convex  surface  of  the  forceps  blade  I 
as  it  was  about  to  be  applied  to  the  head,  then 
the  hand  must  have  dropped  into  the  fenestrum, 
and  finally,  the  forearm  must  have  been  flexed 
upon  the  arm  by  the  final  thrust  of  the  blade  I 
home  to  its  position.  All  of  these  evolutions  re-  j 
quire  room,  and  could  only  occur  above  th 

In  the  second  place.  I  would  remark  that  the 
accident  cannot  possibly  be  diagnosed  unl 
head  and  arm  are  above  the  ordinary  size.  In 
my  case  the  forceps  were  easily  introduced  and 
locked  with  the  greatest  ease:  the  handles  were 
approximated  as  much  as  in  the  average  case; 
there  was  no  disposition  to  slip,  neither  when  the 
forceps  were  in  my  hands  nor  in  the  hands  of  ray 
skilled  associate,  Dr.  Geo.  C.  Skinner;  the  child's 
head  and  the  points  of  the  forceps  were  repeatedly 
and  carefully  palpated  through  the  thin  abdom- 
inal and  uterine  tissues,  and  no  suspicion  of  this 


unique  complication  arose  in  our  minds.  I  can- 
that  the  most  expert  and  experienced 
obstetrician  could  have  detected  the  presence  of 
the  arm  in  the  fenestrum  until  he  attempted  the 
withdrawal  of  the  instruments. 

For  this  reason  I  am  in  the  humor  to  inquire 
whether  the  fenestrum  has  any  reason  to  exist. 
What  is  it  good  for,  anyway  ?  It  has  been  said 
in  most  of  the  systemic  treatises  that  the  fenes- 
trum gives  lightness  to  the  forceps,  but  this 
proposition,  which  is  at  first  glance  very  plaus- 
ible, admits  of  question.  Give  to  me  a  solid 
blade  that  is  admittedly  too  heavy,  and  I  can 
lighten  it  either  by  cutting  out  a  fenestrum  or 
by  grinding  it  thinner.  If  I  cut  out  the  fenes- 
trum I  weaken  the  blade,  past  question,  and 
may  need  to  thicken  the  remaining  metal  t> 
store  the  lost  strength.  Any  instrument  shop 
will  furnish  samples  of  forceps  which  have  passed 
through  this  line  of  development;  that  is  1  - 
they  are  light  blades  with  generous  fenestra  and 
metal  altogether  too  thick.  And  after  all,  what 
signifies  weight  in  obstetric  forceps?  Ordinary 
forceps,  fenestrated  or  non- fenestrated,  need  not 
weigh  more  than  a  pound,  and  it  is  easy  to  make 
a  long  pair  of  crushing  instruments  with  a  pound 
and  a  half  of  steel.  Surely  the  brother  who  can- 
not carry  a  pair  or  two  of  this  weight  is  not  stout 
enough  to  be  out  at  night,  much  less  to  use  for- 
ceps. 

On  behalf  of  the  fenestra  it  has  been  said,  fur- 
ther, that  they  permit  prominent  parts  of  the 
head  to  engage  in  them — the  parietal  eminences, 
for  example — in  such  a  manner  that  the  forceps 
occupy  no  available  room,  take  a  much  better 
hold  upon  the  head,  and  obviate  the  tendency  to 
slip.  To  this  it  may  be  responded  in  the  way  ot 
argument,  that  it  is  a  remarkable  streak  of  luck, 
and  nothing  but  luck,  when  the  prominences  on 
a  child's  head  project  into  the  fenestra.  It  may 
be  said,  further,  that  forceps  rightly  chosen  and 
rightly  used  for  the  case  in  hand  do  not  occupy 
any  available  room  nor,  when  in  use,  increase 
the  diameter  of  the  child's  head  measured  be- 
tween the  blades.  Fenestrated  or  non- fenestrated, 
they  make  room,  moulding  the  head  by  compres- 
sing it  to  such  a  degree  that  were  they  of 
double  thickness  they  would  find  room.  And, 
finally,  as  to  the  slipping  of  the  forceps,  it  may- 
be said  that  when  they  show  an  inveterate  ten- 
dency to  slip,  either  the  forceps  or  the  operator 
should  be  changed;  there  is  something  amiss  in 
the  fit,  the  application  or  the  manipulation. 
Fenestra  will  not  prevent  slipping  when  the  for- 
ceps have  not  been  placed  upon  the  child's  head, 
nor  when  they  are  used  merely  as  tractors. 

And  it  may  be  urged,  further,  that  when  we 
cut  fenestra  in  our  forceps  we  increase  the  total 
amount  of  edge  surface.  This  is  a  positive  dis- 
advantage which  should  be  atoned  for  by  some 
verv  srreat  advantage.     Examining  the  head  of  a 


908 


EXTRA-UTERINE  PREGNANCY. 


[June  27, 


child  which  has  been  the  subject  of  a  severe  for- 
ceps extraction,  one  will  find  that  the  narrow 
rim  of  metal  about  the  fenestrum  has  shown  a 
tendency  to  actually  cut  into  the  tissues  of 
the  scalp.  Not  only  the  outer,  convex,  mar- 
ginal edges  make  their  mark,  but  also,  in 
lesser  degree,  the  inner,  concave  edges  which 
bound  the  fenestrum.  Looking  at  such  a  speci- 
men one  would  incline  to  the  opinion  that  the 
fenestrum  is  an  evil. 

But  waiving  the  question  as  to  whether  the 
fenestrum  has  any  reason  to  exist,  I  think  that 
my  mishap  in  the  case  cited  gives  us  reason  to 
cease  operating  above  the  brim  with  forceps  hav- 
ing wide  fenestra. 


EXTRA-UTERINE  PREGNANCY. 

Read  in  the  Section  of  Obstetrics  and  Diseases  of  Women,  at  the  Fm  t\  - 

second  Annual  Meeting  of  the  American  Medical  Association, 

Washington,!}.  C,  May  5,  iSyr. 

BY  DONNEL  HUGHES,  M.D., 

OF    PHILADELPHIA. 

In  discussing  the  subject  of  extra-uterine  preg- 
nancy, it  is  advisable  to  begin  by  directing  our 
attention  to  the  locations  at  which  fecundation 
takes  place.  There  are  three  sites  at  which  it  is 
supposed  to  occur,  viz. :  the  Fallopian  tubes,  the 
ovaries,  and  in  the  peritoneal  cavity. 

There  are  several  varieties  of  the  three  species 
just  alluded  to.  The  tubo-ovarian  is  that  variety 
in  which  the  germ  is  arrested  in  the  pavilion  (the 
tube  adhering  to  the  ovary). 

The  tubo- abdominal,  in  which  the  germ  is  ar- 
rested in  the  same  place  as  the  tubo-ovarian,  but 
instead  of  the  tube  being  adherent  to  the  ovary, 
it  is  adherent  to  any  of  the  neighboring  viscera. 

The  tubal -proper  is  that  form  in  which  the 
germ  is  arrested  in  any  part  of  the  oviduct  be- 
tween the  pavilion  and  that  portion  of  the  Fallo- 
pian tube  that  is  surrounded  by  the  uterine  walls. 

The  tubo-uterine,  or  interstitial  variety,  is  that 
form  of  gestation  in  which  the  ovum  is  arrested 
in  the  part  of  the  tube  that  is  surrounded  by  the 
uterine  walls. 

Abdominal  pregnancy  is  usually  divided  into 
primary  and  secondary  varieties.  In  primary  ab- 
dominal pregnancy  the  germ  is  arrested  in  the 
peritoneal  cavity.  In  secondary  abdominal  preg- 
nancy the  germ  is  arrested  in  the  Fallopian  tube 
or  ovary,  and  the  cyst  ruptures  and  allows  the 
ovum  to  escape  into  the  abdominal  cavity,  where 
it  continues  to  live  and  develop. 

Ovarian  pregnancy  is  that  form  of  gestation  in 
which  the  ovum  is  developed  in  the  ovary. 

By  far  the  most  frequent  variety  is  tubal  preg- 
nancy, and  the  most  common  causes  of  this  vari- 
ety arc  supposed  to  be  inflammation  of  the  mucous 
membrane  that  lines  the  Fallopian  tubes  and  de- 
stroys its  ciliated  epithelium,  thereby  leaving  a 
denuded  surface  for  the  fecundated  egg  to  adhere 


to;  flexion  of  the  tubes,  which  prevents  the  ovum 
from  entering  the  uterus ;  hernial  pouches  pro- 
duced by  dilatation  of  the  oviduct.  When  the 
impregnated  ovum  is  arrested  and  remains  for 
any  length  of  time  in  the  tube,  the  mucous  mem- 
brane becomes  hypertrophied,  surrounds  the  egg, 
forms  a  decidua,  and  a  placenta  is  developed,  very 
similar  to  that  which  is  found  in  normal  pregnancy. 
When  the  product  of  conception  is  situated  in  the 
free  part  of  the  tube,  rupture  almost  invariably 
takes  place  before  the  thirteenth  week,  and  some- 
times as  early  as  the  fourth  or  fifth  week  ;  when 
it  does  occur,  it  is  either  into  the  peritoneal  cav- 
ity or  between  the  folds  of  the  broad  ligament. 
When  rupture  takes  place  into  the  peritoneal  cav- 
ity, death  is  almost  certain  within  a  few  hours, 
unless  the  abdomen  is  promptly  opened,  the  bleed- 
ing vessels  secured,  and  all  foreign  substances  re- 
moved. When  rupture  takes  place  into  the  cavitjr 
of  the  broad  ligament,  the  prognosis  is  not  so 
grave,  as  the  product  of  conception  may  be  dis- 
posed of  in  several  ways,  viz.:  it  may  remain 
between  the  folds  of  the  ligament,  go  to  full  term, 
and  be  removed  when  viable  as  a  living  child,  or 
it  may  die  and  be  absorbed,  or  it  may  die  and 
suppurate,  and  be  discharged  through  the  vagina, 
the  rectum,  bladder  or  abdominal  walls,  or  it  may 
lie  quiescent  as  a  lithopcedian,  or  it  may  become 
intra-peritoneal  through  secondary  rupture. 

Tubo-uterine,  or  interstitial  pregnancy,  is  of 
rare  occurrence.  Rupture  usually  takes  place 
before  the  fifth  month,  and  when  it  does  occur  it 
is  into  the  peritoneal  cavity. 

Ovarian  pregnancy  undoubtedly  has  existed, 
but  is  extremely  rare.  A  few  cases  have  been 
recorded.  The  earliest  of  which  I  can  find  any 
record  is  that  of  M.  de  St.  Meurice  in  the  year 
1682.  Marinus  has  reported  three  specimens, 
which  are  in  the  pathological  museum  of  Wurz- 
burg,  which  he  has  examined,  and  believed  them 
to  be  impregnated  ovaries.  J.  G.  Porter  reported 
a  case  of  ovarian  gestation  in  the  year  1853.  The 
autopsy  showed  the  left  ovary  enlarged  and  con- 
taining a  gravid  sac,  the  Fallopian  tube  on  the 
same  side  being  free  from  adhesions  Kammerer 
exhibited  a  specimen  of  ovarian  pregnancy  to  the 
Pathological  Society  of  New  York  in  the  year 
1865.  Spiegelberg  also  records  a  case  of  preg- 
nancy in  the  right  ovar}'. 

After  carefully  reviewing  the  literature  of  the 
subject  of  abdominal  pregnancy,  I  have  arrived 
at  the  conclusion  that  primary  abdominal  preg- 
nancy has  not  been  proved  by  any  well  authenti- 
cated cases  to  have  existed  ;  nor  does  it  seem 
possible  for  a  fecundated  ovum  to  remain  for  a 
long  enough  time  in  any  one  position  to  contract 
an  adhesion  that  is  sufficiently  firm  for  its  devel- 
opment ;  and  furthermore,  if  it  did  so,  its  absorp- 
tion or  digestion  would  be  very  likely. 

I  believe  that  most,  if  not  all,  abdominal  preg- 
nancies are  secondary,  fecundation  usually  occur- 


i89i.] 


EXTRA-UTERINE  PRFGNANCY. 


909 


ring  in  the  oviduct,  escaping  from  thence  through 
a  rupture  into  the  abdominal  cavity,  and  there 
becoming  adherent  to  any  surface  with  which  it 
comes  in  contact. 

The  uterus  in  extra-uterine  pregnancy  is  sub- 
ject to  a  variety  of  changes,  similar  in  many  re- 
spects to  those  that  occur  when  the  product  of 
conception  is  contained  within  its  cavity.  It  al- 
ways undergoes  certain  changes  which  prepare  it 
for  the  reception  of  the  ovum.  Its  cavity  is  often 
lined  with  decidua,  or  I  might  say,  always,  be- 
cause in  many  cases  it  is  thrown  off  in  small 
shreds  and  is  passed  without  being  observed  ;  in 
other  cases  it  is  expelled  en  »iassc,  often  leading 
one  to  suppose  that  an  abortion  is  in  progress ; 
the  cervix  frequently  contains  a  plug  of  thick 
mucus  similar  to  that  found  in  normal  pregnancy. 
The  whole  organ  becomes  more  vascular,  enlarged 
and  softened — or,  in  other  words,  prepares  itself 
for  parturition. 

The  impregnated  germ,  from  the  beginning  to 
the  end  of  its  growth,  is  not  abnormal  in  any 
way,  except  in  its  location.  A  portion  of  the 
foetus  may  be  in  the  uterus  while  the  remainder 
is  in  the  abdominal  cavity,  as  in  a  case  reported 
by  M.  Mondat,'  in  which  the  head  of  the  child 
was  in  the  uterus,  while  the  trunk  occupied  the 
Fallopian  tube. 

Bell  narrates  a  case--'  that  was  verified  by  a  post- 
mortem, in  which  the  foetus  was  in  the  uterus  and 
a  portion  of  the  placenta  was  within  the  Fallopian 
tube.  On  the  other  hand,  the  placenta  may  oc- 
cupy the  normal  position  and  the  foetus  may  be 
contained  within  the  tube  or  abdomen,  as  was 
shown  by  Hey,'  Putua'  and  Hofmeister5  in  sep- 
arate autopsies  where  the  child  was  found  free  in 
the  abdomen,  the  cord  extending  through  the 
tube  to  the  interior  of  the  uterus,  where  the  pla- 
centa was  attached. 

A  number  of  cases  have  been  recorded  in  which 
foetuses  have  been  found  in  hernial  sacs.  Gouley, 
Geuth,  Muller  and  others  have  reported  such 
cases,  the  greater  number  of  which  were  found 
in  inguinal  hernias. 

Twin  conception  is  another  variety  of  extra- 
uterine pregnancy.  It  is  a  very  uncommon  co- 
incidence to  find  both  children  in  the  same  local- 
ity ;  one  is  generally  uterine,  while  the  other  is 
extra- uterine.  Normal  pregnane}'  may  take  place 
while  extra-uterine  pregnancy  already  exists,  and 
gestation  advance  to  full  term  and  labor  take 
place  without  any  unusual  occurrence,  provided 
that  the  pelvic  outlet  is  not  obstructed  by  the 
extra- uterine  fcetus.  Gordon  reported  a  case  in 
which  a  woman  gave  birth  to  five  living  children 
while  carrying  one  that  had  become  encysted. 

The  positive  diagnosis  of  ectopic  gestation  in 


1  Archives  Generates  de  Med.,  Tome  it.  2d  Series,  p.  67. 

■  London  and  Edinburgh  Med.  Jour.,  November,  1S45,  p.  S17. 

3  Med.  and  Obst.  Jour.  Vol.  viii,  Loudon,  1796,  p.  341. 

4  Cayaux,  loc.  citat.,  p.  590. 

5  Rusto  Magazine,  1823,  Vol.  xv,  p.  126. 


the  early  stages  is  almost  impossible  in  every 
case.  There  are  no  regular  symptoms  that  occur 
during  the  first  few  weeks  that  are  not  frequently 
found  in  normal  gestation.  If  from  any  cause 
one  is  led  to  believe,  or  even  to  suspect,  that  any- 
thing is  unusual,  a  physical  examination  should 
be  made.  The  size  of  the  womb  should  be  com- 
pared with  the  size  it  should  be,  at  the  supposed 
period  of  pregnancy.  A  careful  search  should  be 
made  in  the  neighborhood  of  the  Fallopian  tubes, 
fundus  of  the  womb  and  ovaries.  If  an  enlarge- 
ment is  discovered,  so  much  is  gained.  The  ques- 
tion then  arises,  to  what  is  that  tumor  due?  Is 
it  a  pyosalpinx,  a  hsematosalpinx,  a  hydrosal- 
pinx, a  subperitoneal  fibroma,  a  cystic  ovary  or 
an  extra- uterine  pregnancy  ?  These  questions 
will  have  to  be  decided  by  an  inquiry  into  the 
previous  history  of  the  case,  and  by  carefully 
comparing  the  symptoms  of  the  disease  which  it 
might  resemble  with  the  symptoms  of  pregnancy. 
The  size  of  the  tumor  should  be  compared  with 
the  size  that  the  fcetal  sac  should  be  at  the  sup- 
posed time  of  gestation.  If  the  following  symp- 
toms are  present,  I  think  that  one  is  justified  in 
treating  the  case  as  extra-uterine  pregnancy  : 

1.  A  previous  history  of  sterility,  or  if  a  long 
period  has  elapsed  since  the  birth  of  the  last  child. 

2.  Amenorrhoea  followed  in  six  or  seven  weeks 
by  irregular  bcemorrhages. 

3.  A  tumor  in  either  Fallopian  tube. 

4.  Slight  enlargement  of  the  uterus,  with  soft- 
ening of  the  cervix. 

5.  The  presence  of  decidua.  The  latter  symp- 
tom is  of  great  importance.  A  small  portion  of 
the  decidua,  if  present,  can  often  be  obtained  by 
passing  a  pair  of  dressing  forceps  into  the  womb, 
pressing  them  against  its  lining,  then  closing  and 
withdrawing  them.  Great  care  and  gentleness 
must  be  exercised  in  their  introduction,  and  if 
the  slightest  obstruction  should  be  encountered 
they  must  immediately  be  withdrawn. 

If,  in  addition  to  the  foregoing  symptoms,  there 
is  a  plug  of  thick  mucus  in  the  os  uteri,  morning 
sickness,  enlargement  of  the  breasts  with  altera- 
tion of  the  areola,  one  is  justified  in  passing  a 
sound  cautiously  into  the  womb  for  the  purpose 
of  ascertaining  the  presence  or  absence  of  a  fcetus. 

The  diagnosis  cannot  be  made  with  certainty 
until  after  the  fourth  month,  when  the  outlines  of 
the  child  can  be  distinguished  and  the  movements 
felt.  Generally,  the  first  time  we  are  called  upon 
to  see  the  case,  we  find  the  patient  complaining 
of  an  agonizing  pain  in  the  lower  part  of  the  ab- 
domen, with  symptoms  of  shock  and  internal 
haemorrhage,  which  very  clearly  tells  us  that  rup- 
ture has  taken  place.  If  death  does  not  follow, 
peritonitis,  either  localized  or  general,  is  sure  to 
develop.  If  the  woman  survives  the  attack,  it  is 
very  likely  to  be  repeated  within  a  short  time. 
When  rupture  takes  place  within  the  folds  of  the 
broad  ligament,  the  symptoms  are  not  so  severe 


910 


ELECTRICITY  IN  DYSMENORRHEA. 


{June  27, 


or  alarming ;  in  fact,  the  pain  in  some  instances 
has  been  so  slight  as  not  to  have  been  observed 
by  the  patient  herself.  This  form  of  rupture  is 
very  rarely,  if  ever,  followed  by  peritonitis.  If 
the  foetal  sac  ruptures,  the  foetus  dies ;  if  it  does 
not  rupture,  gestation  continues  until  full  term, 
unless  it  is  interrupted  by  secondary  rupture  into 
the  peritoneal  cavity.  If  this  accident  should 
happen,  the  symptoms  are  the  same  as  those  that 
occur  in  primary  rupture  into  the  peritoneal  cav- 
ity, except  that  they  are  much  more  severe,  and 
death  is  certain  to  follow  unless  operated  on  im- 
mediately. If  the  foetus  is  carried  to  full  term, 
a  spurious  labor  will  set  in.  and  if  the  woman  is 
not  delivered,  the  child  will  die. 

If  our  knowledge  of  the  differential  diagnosis 
of  the  various  forms  of  ectopic  gestation  was 
more  exact,  the  treatment  would  be  comparative- 
ly simple.  If  we  could  distinguish  tubal  from 
abdominal  pregnancy  in  the  early  stages,  the  for- 
mer could  be  relieved  and  the  latter  allowed  to 
progress  until  viable. 

Many  forms  of  treatment  have  been  devised 
and  practiced  at  different  times.  Among  these 
may  be  mentioned  hypodermic  injections  of  vari- 
ous narcotics  and  poisons  into  the  foetal  sac,  and 
even  into  the  foetus  itself;  syphilization  of  the 
mother  with  the  hope  of  destroying  the  child ; 
puncturing  the  sac  through  the  vaginal  or  ab- 
dominal walls  and  drawing  off  the  liquor  amnii ; 
the  passage  of  an  electric  current  through  the 
foetus  with  the  hope  of  killing  it.  It  is  needless 
to  say  that  these  and  many  other  devices,  too  nu- 
merous to  mention,  are  hazardous  to  the  mother, 
and  in  many  instances  ineffectual  in  the  destruc- 
tion of  the  child. 

In  my  opinion,  the  only  sensible  and  rational 
treatment  in  extra-uterine  pregnancy  is  laparot- 
omy. The  proper  plan  of  treatment  to  be  pur- 
sued in  all  cases  of  extra- uterine  pregnancy,  ex- 
cept those  in  which  the  foetus  is  contained  within 
the  folds  of  the  broad  ligament,  no  matter  at  what 
period  of  gestation,  is  to  open  the  abdomen  and 
remove  the  tube  that  contains  the  foetal  sac.  I 
will  go  still  further,  and  say  that  in  a  case  in 
which  a  tumor  has  been  discovered  in  the  tube, 
and  we  are  led  to  suspect  the  existence  of  extra- 
uterine pregnancy,  an  exploratory  laparotomy 
should  be  performed,  and  if  it  is  then  found  that 
the  tube  does  not  contain  a  foetus,  the  tumor, 
whatever  it  may  be,  can  be  removed.  Too  much 
emphasis  cannot  be  laid  upon  the  propriety  of 
early  operation,  for  we  all  know  that  the  tube  is 
sure  to  rupture,  sooner  or  later,  and,  in  most 
cases,  cause  the  death  of  the  woman,  if  an  im- 
mediate operation  is  not  performed. 

When  the  foetus  is  contained  within  the  broad 
ligament,  it  should  be  allowed  to  remain  there 
until  it  becomes  viable,  unless  secondary  rupture 
occurs,  or  it  should  die  in  the  meanwhile.  When 
rupture  lias  taken  place,  the  abdomen  should  be 


immediately  opened,  all  foreign  substances  re- 
moved, and  the  bleeding  vessels  ligated.  The 
peritoneal  cavity  should  be  thoroughly  irrigated 
with  warm  water  that  has  been  boiled,  and  a 
glass  drainage  tube  placed  in  the  lower  angle  of 
the  wound.  When  pregnancy  is  far  advanced, 
and  the  child  is  either  viable  or  dead,  its  removal 
becomes  necessary.  This  is  best  accomplished 
by  abdominal  section.     The  incision  should  be 

1  made  directly  over  the  foetal  sac,  if  possible,  as 
by  so  doing  the  foetus,  in  many  instances,  can  be 
removed  without  opening  the  peritoneal  cavity. 
The  child  should  be  removed  from  the  sac,  and 
the  cord  cut  as  close  as  possible  to  the  placenta. 
If  the  placenta  be  not  firmly  adherent,  it  should 
be  removed.  If  the  haemorrhage  from  the  sur- 
face of  the  sac  which  contained  the  placenta  can- 

-  not  be  controlled  with  warm  water,  a  sponge  wet 
with  Monsell's  solution  should  be  applied  to  the 
bleeding  surface.  This  failing,  the  sac  should  be 
packed  with  a  strip  of  iodoform  gauze,  the  end 
of  which  should  be  brought  out  at  the  lower 
angle  of  the  wound,  by  the  side  of  a  glass  drain- 
age tube.  In  from  twenty-four  to  thirty-six  hours 
the  gauze  should  be  removed,  and  the  drainage 
tube  allowed  to  remain  until  all  discharges  have 
ceased.  If  the  placenta  is  firmly  adherent,  it 
should  not  be  removed. 

After  thoroughly  cleansing  the  interior  of  the 
sac  and  removing  all  loose  membranes,  the  stitches 
should  be  so  arrauged  that  when  the}'  are  tightly 
drawn  the  sac  will  be  air-tight.  If  at  any  future 
time  the  placenta  should  show  evidences  of  suppu- 
ration, the  wound  must  be  reopened,  the  placenta 
removed,  and  the  interior  of  the  sac  thoroughly 
irrigated  and  drained. 

It  is  needless  to  say  that  in  all  these  operations 
the  strictest  antiseptic  precautions  should  be  ob- 
served in  their  minutest  details. 


ELECTRICITY    AS    A    THERAPEUTICAL 

AGENT    IN    THE    TREATMENT    OF 

DYSMENORRHEA  AND  PELVIC 

INFLAMMATIONS. 

Read  tilth,-  Annual  Meeting  of  the  Illinois  Stale  Medical 
M 

BY  F.  J.   PARKHURST.  M.D., 

OF  DANYERS.  ILL. 
EX-PHESIDENT  M'LEAN  COUNTY  MEDICAL  SOCIETY. 

As  a  therapeutical  agent,  electricity  has  a  wider 
range  of  usefulness  than  any  other  one  agent 
known  to  the  medical  profession  to-day.  A  great 
deal  of  good  can  be  done  with  it  when  properly 
and  carefully  used.  The  ancients  had  a  limited 
knowledge  of  its  power  to  cure  disease.  Their 
batteries  were  furnished  them  in  the  form  of  an 
electrical  fish,  the  raja  torpedo,  found  in  the 
Mediterranean  Sea.  Shocks  from  these  torpe- 
does  were  often   used  in   the   treatment   of  dis- 


I89i.] 


ELECTRICITY  IX  DYSMENORRHEA. 


911 


l 
ease.  Since  Galvani  discovered  galvanism  in  the  This  battery  will  run  two  hours  a  day  for  two 
year  1786,  advancement  has  been  made  in  the  I  years,  equal  to  about  two  cents  and  a  half  per 
•study  and  use  of  it.  The  past  sixty  years  and  day,  and  furnish  a  strong  current.  Next,  a  mil- 
more,  especially  the  past  twenty  years,  it  has  re-  liamperemeter,  used  to  accurately  measure  the 
ceived  much  attention  at  the  hands  of  the  medi-  strength  of  the  current.  The  custom  with  some 
cal  profession.  The  past  seven  years  it  has  espe-  physicians,  of  estimating  the  strength  of  the  cur- 
cially  been  used  in  the  treatment  of  diseases  of  rent  by  the  number  of  cells  employed,  should 
women.     At  the   present  time  it  is  being  lauded   never  be  resorted  to,  as  it  is  unreliable,  and  may 


to  the  skies  as  a  panacea  by  members  of  the  pro- 
fession, and  equally  denounced  as  worthless  by 
others. 

One  reason  for  the  latter  opinion  may  be  found 
in  my  own  experience  with  the  agent.     A  short 


bring  about  dangerous  results.  To  produce  cer- 
tain results  an  accurate  strength  of  current  is  re- 
quired, and  can  only  be  measured  accurately  by 
the  milliamperemeter.  Next,  the  abdominal  elec- 
trodes, which  should  be  large  enough  to  cover 


time  alter  commencing  the  practice  of  medicine,  the  whole  abdominal  surface  from  the  umbilicus 

ten  years  ago,  I   purchased  a   24-cell   combined  to   the  pubes.     The  first  abdominal  electrode  I 

battery.     Used  it  for  two  years  or  more  as  I  know  present  is  the  Apostoli  clay  electrode,  made  very 

some  physicians  are  using  it.    In  time  denounced  easily.     Have  a  tin-smith  cut  out  a  piece  of  zinc 

it  as  worthless,  as  any  physician  will  who  uses  it  5  or  6  inches  long  and  3  or  4  wide,  and  solder  on 


similar  way.  Was  careless  about  keeping 
my  battery  in  good  condition,  did  not  study  the 
subject  thoroughly,  was  ignorant  of  its  methods 
of  influencing  living  tissues,  of  the  selective 
points  for  applying  the  electrodes,  paid  little  at- 
tention to  the  strength  and  duration  of  the  cur- 
rents employed.  Did  poor  work  and  received 
poor  results.  My  battery  in  time  got  out  of  run- 
ning order  for  want  of  proper  attention,  and  was 
placed  at  one  side  in  my  office,  where  it  was  soon 
covered  with  dust.     For  two  years  or  more  made 


a  binding  post,  get  some  clay,  moisten  and  mould 
it  to  the  proper  consistence  and  size,  bury  the 
zinc  in  the  clay  and  cover  with  thin  cotton  cloth; 
it  is  easily  kept  moist  and  warm.  The  next  is 
the  Martin  abdominal  membrane  electrode,  a 
very  good  substitute  for  the  Apostoli  clay  elec- 
trode. The  object  in  having  these  electrodes  so 
large  is  to  so  diffuse  the  current  that  a  large  dose 
can  be  used  without  pain.  The  internal  or  active 
electrodes  are  composed  of  metal,  and  may  be  of 
various  shapes  and  forms  to  suit  the  fancy  of  the 


no  use  of  it.  During  this  time  remarked  that  I  operator.  There  is  a  difference  in  the  polarity  of 
had  no  use  for  electricity,  and  had  but  little  con-  j  the  internal  electrodes  that  is  always  well  to  bear 
fideuce  in  it  as  a  therapeutical  agent,  that  it  did  |  in  mind — one  coagulating,  hardening;  the  other 
not  come  up  to  the  claims  made  for  it,  and  have  ;  liquefying,  softening.  You  turn  on  a  very  strong 
heard  more  than  one  physician  make  similar  re-  current,  and  apply  an  electrode  to  the  mucous 
marks  during  the  past  year.  membrane,  which  is  connected  with  the  positive 

In  May,  1886,  attended  the  meeting  of  the  |  pole  of  the  battery,  and  the  mucous  membrane 
American  Medical  Association,  held  in  St.  Louis,  [becomes  hardened,  as  if  cauterized  with  an  acid, 
and  heard  a  paper  read  by  Dr.  F.  H.  Martin,  of ,  If  a  similar  current  is  turned  on  and  the  electrode 
Chicago,  on  Galvanism  in  Gynecology.  It  was  attached  to  the  negative  pole  of  the  battery,  and 
an  excellent  paper,  and  was  well  and  ably  dis- ;  applied  to  the  mucous  membrane,  the  effect  upon 
cussed.  After  hearing  this  paper,  came  to  the  I  the  membrane  is  that  of  solution,  similar  to  that 
conclusion  that  I  knew  but  very  little  or  nothing!  produced  by  caustic  alkali.  Having  a  correct 
at  all  about  electricity,  and  went  home  resolved  [  understanding  of  the  action  of  the  poles,  it  is 
to  become  better  informed  on  the  subject.  And  1  seen  that  to  cure  a  profuse  cervical  leucorrhoea, 
I  am  pleased  today  that  I  can  contribute  some  to  check  and  stop  profuse  uterine  haemorrhage  in 
thino-,  in  a  practical  way,  of  the  benefits  to  be '  uterine  fibroids  and  polypoid  growths  of  the  ute- 
gained  by  the  proper  use  and  administration  oflrus,  etc.,  the  positive  intra-uterine  electrode  is 
this  wonderful  agent.     To  use  it  successfully,  a  *1 


physician  must  have  one  or  more  of  the  standard 
text  books  on  electricity  in  his  library,  and  study 
them.  He  should  have  a  good  battery,  and  keep 
it  in  good  condition.     He  should  select  suitable 


the  one  to  be  used.  Where  fibroid  tumors  are  to 
be  broken  down,  a  subinvoluted  uterus  reduced 
in  size,  hardened  exudates,  inflammatory  depos- 
its, etc.,  removed,  the  negative  pole  should  be 
employed.    Before  going  into  details,  let  me  state 


cases   for   treatment,   and  be   careful    about  the   that  antiseptic  precautions  in  the  use  of  instru- 
strength  and  duration  of  the  current  employed,  j  ments  and  washing  out  the  vaginal  and  uterine 

I  have  brought  with  me  the  battery  and  instru- ,  cavities,  should  be  carried  out.     The  first  case  I 
ments  used  in  the  treatment  of  the  cases  I   am ,  report  is  one  of  sterility  and  dysmenorrhoea. 
about  to  report.  Mrs.  C,  married,  age  23,  consulted  me  August, 

A  good  24  cell  battery  will  furnish  a  current  of!  1890,  and  gave  the  following  history:  She  had 
sufficTent  strength  for  all  purposes,  even  to  break-  J  been  married  four  years  without  becoming  preg- 
ing  down  large  uterine  fibroid  tumors.  I  have  nant,  and  was  anxious  to  have  children.  Men- 
here  a  so  cell  Barrett  chloride  of  silver  battery,  i  struatiou  commenced  at  the  age  of  15,  and  was 


912 


ELECTRICITY  IN  DYSMENORRHEA. 


[June  27, 


normal,  lasting  about  four  days.  About  eleven 
months  before  marriage,  one  day  while  out  riding 
and  returning  home,  on  getting  out  of  the  buggy, 
she  stepped  on  the  top  of  the  wheel  of  the  buggy 
and  jumped  to  the  ground.  She  immediately  felt 
as  if  something  had  given  way  in  the  lower  part 
of  her  bowels,  was  taken  with  a  severe  pain  in 
the  lower  part  of  her  back  and  in  her  limbs ;  was 
unable  to  walk  and  had  to  be  helped  into  the 
house  and  to  bed,  where  she  remained  for  three 
weeks.  After  this  accident,  when  menstruation 
came  on,  it  was  painful;  that  she  had  been  slowly 
getting  worse,  and  at  the  present  time  was  a  great 
sufferer  at  her  menstrual  periods.  Her  suffering 
was  so  great  she  was  compelled  to  go  to  bed  and 
take  opium  to  relieve  pain.  Since  marriage,  in 
some  ways  she  had  grown  worse — she  had  a  bad 
leucorrhcea,  menstruation  now  lasted  seven  or 
eight  days,  was  profuse,  leaving  her  weak  and 
exhausted;  almost  constant  backache,  dragging 
sensations  in  the  pelvis.  Eife  seemed  a  burden, 
and  at  times  was  gloomy  and  despondent.  She 
stated  that  she  had  consulted  several  different 
physicians,  had  received  constitutional  and  local 
treatment  with  only  temporary  relief.  An  exam- 
ination revealed  an  enlarged  and  engorged  cervix 
pressing  against  the  bladder,  a  profuse  leucor- 
rhcea, a  retroverted  uterus  bordering  on  second 
degree  of  displacement,  bound  down  by  adhesions 
and  immovable.  M3'  diagnosis  was  displacement 
with  inflammation,  plastic  exudation,  resulting  in 
adhesions,  brought  on  by  the  injury  done  when 
jumping  from  the  buggy.  The  repeated  conges- 
tions incident  to  married  life,  and  also  from  men- 
struation, constantly  aggravated  the  trouble  and 
made  it  worse.  Galvanism  was  the  remedy  pre- 
scribed to  relieve  pain,  and  break  up  the  adhesions 
binding  down  the  displaced  uterus.  The  large 
abdominal  electrode  was  selected  for  the  external 
or  positive  electrode.  The  negative  vaginal  elec- 
trode, covered  with  wet  absorbent  cotton,  was 
crowded  well  up  into  Douglas'  cul-de-sac,  in  close 
proximity  to  the  displaced  portion  of  the  uterus. 
These  electrodes  being  held  firmly  in  their  places, 
the  current  was  gradually  turned  on  until  it 
reached  a  strength  of  100  milliamperes.  This 
treatment  lasted  five  minutes,  and  the  current 
turned  off.  These  applications  were  continued 
every  other  day  for  the  first  three  weeks,  and 
three  times  a  week  the  remaining  six  weeks  of 
the  treatment,  in  all  twenty-nine  treatments.  At 
the  end  of  the  second  week  menstruation  came 
on,  with  decided  relief  in  all  the  symptoms.  The 
relief  from  pain  was  such  that  no  opium  was  re- 
quired. Menstruation  hardly  lasted  six  days, 
and  the  amount  of  the  flow  greatly  checked. 
The  second  menstruation  was  free  from  pain,  and 
the  flow  stopped  the  fifth  day.  An  examination 
revealed  the  uterus  to  be  movable,  so  much  so  it 
could  nearly  be  replaced  to  its  normal  position. 
The  third   menstruation  was  normal  in  every  re- 


spect.    One  month  later,  she  became  pregnant. 

Case  2. — Miss  N.,  age  21,  came  under  ruv  cart 
March,  1889,  and  gave  the  following  history? 
vShe  began  menstruating  at  14  years,  and  has 
never  missed  a  menstruation  since.  Her  men- 
struations were  always  accompanied  with  pain, 
and  for  the  past  three  years  the  pain  had  been 
getting  worse,  and  "that  she  lived  in  terror 
of  each  menstruation."  Her  suffering  was  so 
great  she  had  used  anodyne  rectal  supposito- 
ries, and  later  morphine  and  chloroform.  During 
the  inter-menstrual  period  she  had  bearing-down 
pains  over  lower  part  of  abdomen.  Her  appetite 
was  poor,  bowels  constipated,  and  over-exeition 
was  sure  to  bring  on  a  severe  nervous  headache. 
She  had  been  treated  by  several  physicians.  An 
examination  was  consented  to,  which  revealed  a 
retrofiexed  uterus;  the  ovaries  were  low,  enlarged, 
tender  and  movable.  The  treatment  used  was  the 
galvanic  current.  The  abdominal  clay  electrode 
was  attached  to  the  positive  pole,  the  vaginal 
electrode  to  the  negative.  The  current  employed 
was  mild,  and  of  longer  duration  from  thirty 
M.A.,  and  used  twenty  minutes  every  day.  Af- 
ter each  application  of  electricity,  a  small  roll  of 
iodoform  gauze  was  crowded  up  against  the  fun- 
dus uteri,  the  patient  directed  to  remove  it  the 
next  day,  and  use  a  carbolized  warm  water  vagi- 
nal injection  every  second  day  before  coming  for 
treatment.  This  treatment  was  continued  every 
day,  with  the  exception  of  three  days,  until  April 
12,  when  menstruation  came  on  with  but  very 
little  pain,  the  patient  remaining  quiet  in  bed. 
April  19  the  patient  returned,  and  the  same  treat- 
ment carried  out.  The  ovaries  were  not  so  tender 
and  higher  up,  nearer  their  normal  position.  The 
next  menstrual  period  was  free  from  pain,  she  not 
being  obliged  to  remain  in  bed.  The  treatment 
was  continued  two  weeks  longer  after  this  men- 
strual period.  On  examination  the  ovaries  had 
regained  their  normal  position,  and  the  uterus 
found  in  a  better  position  than  at  first.  The  pa- 
tient had  gained  in  flesh,  had  a  good  appetite, 
and  could  stand  fatigue  without  bringing  on  the 
nervous  headaches.  Two  years  have  passed  since 
this  patient  received  her  last  treatment,  and  she 
tells  me  that  ' '  her  menstrual  periods  have  been 
free  from  pain,  that  life  seems  a  paradise  to  what 
it  used  to  be,  and  that  she  is  stronger  and  healthier 
than  at  any  time  since  menstruating." 

Case  j. — Mrs.  M.,  married,  consulted  me  June, 
1890;  has  had  four  children;  date  of  last  confine- 
ment four  years  ago.  Never  had  a  tedious  labor. 
Three  years  ago  had  typhoid  fever,  complicated 
with  cellulitis  confined  to  right  side.  Convales- 
cence very  slow.  Menstruation  did  not  come  on 
for  six  months  after  getting  up  from  the  fever, 
and  \v;i*  very  painful.  The  pain  being  princi- 
pally in  the  ovarian  region  on  the  right  side.  She 
stated  that  for  two  and  three  days  preceding 
menstruation,  and  during  the  first  day  of  the  flow 


i89i.J 


ELECTRICITY  IN  DYSMENORRH 


9'3 


in  was  intense,  and  sometimes  whtn  the 
flow  checked  the  pain  would  come  back  as  bad 
as  ever,  and  remain  so  until  she  Sowed  again.  1 
Morphine  in  large  doses  only  gave  relief.  She! 
took  her  bed  sometimes  a  day  or  two  preceding 
menstruation  and  remained  during  the  entire- 
time.  Every  menstrual  period  left  her  exhausted 
and  very  nervous.  She  also  complained  of  fre-  j 
quent  painful  micturition  and  severe  and  annoy- 
ing pruritus  vulvae  often  preceding  and  lasting  a 
week  or  more  after  menstruation.  She  had  re- 
ceived constitutional  and  local  treatment  from 
different  physicians;  -aid  she  believed  there  was 
no  help  for  her  and  that  she  was  tired  of  doctor- 
ing. An  examination  revealed  the  uterus  sym- 
metrically enlarged  nearly  twice  the  normal  size. 
The  uterine  sound  passed  to  the  depth  of  three 
and  three-quarters  inches:  the  cervix  lacerated  to 
the  left  almost  to  cervico  vaginal  junction,  and 
the  mucous  membrane  of  the  vagina  was  some- 
what thickened  and  pale  in  color.  There  was 
considerable  tenderness  over  the  right  ovary  and 
there  was  thickening  of  the  broad  ligament.  Con- 
sidering the  case  carefully,  the  character  of  the 
pain  as  connected  with  the  flow,  I  concluded 
that  the  right  ovary  must  be  surrounded  by  non- 
elastic  layers  of  an  exudate  thrown  out  at  the 
time  of  the  cellulitis.  Treatment  was  commenced 
by  using  galvanism  in  strong  doses.  The  large 
abdominal  membrane  electrode  attached  to  the 
positive  pole,  and  the  vaginal  electrode  applied 
to  the  right  of  cervix  uteri,  and  crowded  well  up 
in  close  proximity  to  the  right  ovary  as  possible. 
The  object  being  to  produce  absorption  of  the 
exudate  enveloping  the  ovary.  Treatment  was 
given  four  times  a  week  the  first  three  weeks, 
and  three  times  a  week  for  the  last  five  weeks. 
At  the  end  of  the  third  week  menstruation  came 
on  with  decided  relief  in  all  the  symptoms. 
There  was  but  little  pain,  no  trouble  about  the 
bladder  and  slight  pruritus  vulvae.  The  second 
menstruation  was  normal.  The  fourth  meustru- 
ation  passed  with  no  abnormal  symptoms,  and 
two  mouths  ago  she  informed  me  that  there  had 
been  no  return  of  pain  at  her  menstrual  periods, 
and  I  have  every  reason  to  believe  the  patient 
permanently  cured. 

Case  /. — Was  called  to  see  Mrs.  X.  November 
la-t.  1890.  She  had  been  married  eleven  years, 
had  three  children,  one  miscarriage,  and  one  pre- 
mature birth.  The  premature  birth  had  occurred 
nine  weeks  previous  to  my  seeing  her,  and  dur- 
ing all  this  time  she  had  been  confined  to  the 
bed.  I  found  her  pale,  anaemic,  nervous,  no  ap- 
petite, verv  restless  at  night,  suffering  with  cysti- 
tis, which  was  mechanical;  two  or  three  times  a 
week  she  was  obliged  to  take  morphine  to  obtain 
relief  from  pain  which  was  confined  to  lower  part 
of  abdomen.  An  examination  revealed  a  large 
flabby  subinvoluted  uterus  crowding  against  the 
bladder,  causing  the  cystitis.     There  was  a  great 


amount  of  soreness  over  the  lower  part  of  the  ab- 
domen,   but    very    little    pressure  causin. 
The  patient  had  been  unable  to  lie  on  eittai 
1  ;  atulous,  and  the  sound  read- 

•  :>th  of  four  and  a  quarter  in- 
She  had  received  good  nursing  and  been 
on  good  tonic  treatment,  and  also  received  ergot 
and  vib.  three  times  a  day.  I  stopped  giving  all 
medicines  of  any  kind,  and  directed  that  the 
bladder  be  washed  out  once  a  day  with  one  quart 
of  warm  water  in  which  2  gm.  borac  acid  had 
been  previously  dissolved.  Galvanism  was  the 
treatment  advised  and  carried  out.  The  large 
abdominal  clay  electrode  was  attached  to  the  pos- 
itive pole  and  the  uterine  cup  electrode  to  the 
negative  pole.  This  electrode  was  firmly  applied 
to  the  cervix  uteri.  The  current  used  was  mild, 
30  M.  A.,  and  used  twenty  minutes  even-  day. 
After  the  first  treatment  the  patient  remarked: 
"  I  feel  as  if  I  could  go  off  to  sleep.  I  have  faith 
this  is  going  to  help  me."  The  improvement 
was  rapid  and  very  gratifying.  After  the  third 
treatment  the  patient  could  lie  on  either  side  and 
the  pain  and  soreness  rapidly  disappeared.  In 
seven  days  the  patient  had  a  good  appetite,  slept 
well  at  night,  became  cheerful,  and  by  the  tenth 
day  was  able  to  sit  up  in  a  chair  for  the  first  time 
since  becoming  sick.  The  treatments  were  con- 
tinued every  day  for  four  weeks,  and  three  times 
a  week  for  four  weeks.  Forty  treatments  in  all. 
At  the  time  of  the  last  treatment  the  womb  had 
returned  to  nearly  its  natural  size.  I  saw  the 
patient  last  week,  she  was  looking  well,  had  in- 
creased in  weight,  was  able  to  walk  and  ride  out. 
I  have  selected  and  reported  these  four  cases 
because  they  were  cured  by  galvanism.  Xo 
other  remedy  being  employed  in  their  treatment 
and  cure  b3r  me.  My  list  contains  others  per- 
manently cured,  some  greatly  benefited,  and 
some  not  helped  at  all.  The  fact  is  mentioned  in 
connection  with  each  case  that  they  had  all  re- 
ceived at  different  times  first-class  treatment, 
constitutional  and  local,  with  no  relief.  In  the 
first  case  there  was  a  displaced  uterus  bound 
down  by  inflammatory  exudates,  interfering  with 
the  function  of  the  organ.  In  the  second  case 
repeated  congestions  had  resulted  in  hypertrophy 
and  displacement  of  the  ovary.  In  the  third 
case  an  unyielding  exudate  interfered  with  the 
function  of  the  right  ovary,  and  severe  pain  the 
result  until  the  congestion  was  relieved  by  a  flow 
of  blood  from  the  uterus.  In  the  fourth  case  the 
uterus  from  some  predisposing  or  exciting  cause, 
or  both,  had  failed  to  contract  to  normal  size, 
and  remained  a  large,  soft,  flabby  cnass,  filling 
the  pelvic  cavity.  The  indication  in  each  case 
was  the  removal  of  the  products  of  congestion 
and  inflammation,  and  the  cure  of  pain  the  re- 
su'.t.  This  was  accomplished  by  the  passage  of 
electricity  through  the  diseased  tissues.  I  wish 
to  state  in  closing,   that   I   am    not   in   favor  of 


9i4 


ABDOMINAL  UTERINE  TUMOR. 


[June  27, 


using  strong  currents  as  I  used  to  be.  My  ex- 
perience and  observation  have  led  me  to  believe 
that  the  same  electrolytic  action  can  be  obtained 
from  a  mild  current  for  a  longer  time  than  a 
strong  current  for  a  short  time,  and  with  less 
dangerous  and  more  pleasant  effect  upon  the  pa- 
tient. There  is  an  interesting  field  of  observa- 
tion here,  and  with  the  means  we  have  at  hand  for 
actual  measurement  of  the  currents  by  the  M.A., 
we  can,  before  man}-  months,  arrive  at  definite 
conclusions  as  to  the  effect  of  the  strong  and 
mild  currents  in  the  treatment  of  our  cases. 

I  am  no  specialist,  but  a  general  practitioner 
in  a  small  town,  in  McLean  County,  and  only 
use  electricity  as  it  is  indicated  in  general  practice. 
Some  of  the  most  gratifying  results  in  my  ex- 
perience as  a  practitioner  have  come  from  an  in- 
telligent and  proper  use  of  this  agent. 


REPORT  OF  A  CASE  OF  ABDOMINAL 

UTERINE  TUMOR. 

BY  EDWARD  BORCK,  A.M.,  31. D., 

OF  N.  ST.  LOUIS,  MO. 

History. — Mrs.  C.  N.,  a  farmer's  wife  from 
Kansas,  was  sent  to  me  by  her  family  physician 
in  Ma}-,  1885 ;  she  was  41  years  of  age,  five  feet 
6  inches  high,  natural  weight  96  lbs.,  brown  hair 
mixed  with  gray,  blue  eyes.  Had  always  been 
in  good  health,  quiet  temperament,  menstruation 
regular,  of  late  years  some  leucorrhoea.  A  small 
tumor  in  pelvic  cavity,  of  about  two  years'  growth. 

Diagnosis.  —  Fibroid  of  the  uterus.  Ovaries 
not  implicated. 

Refused  to  operate,  advised  the  patient  to  go 
home  and  wait  until  her  climacteric  period  had 
passed ;  if  by  that  time  the  tumor  had  not  in- 
creased very  much,  and  she  would  be  well  other- 
wise, then  the  tumor  would  very  likely  cease 
growing,  or  even  atrophy,  after  she  had  passed 
the  critical  period,  and  need  no  interference.  If, 
however,  the  tumor  should  become  larger,  to  re- 
turn, and  we  would  see  what  would  be  best  to  be 
done. 

May  15,  1891,  six  years  later,  Mrs.  C.  N.  ar- 
rived again  at  my  Private  Surgical  Home.  She 
came  determined  to  have  the  tumor  removed  and 
get  well;  she  could  not  stand  it  any  longer,  some- 
thing must  be  done  for  her,  as  the  tumor  had  in- 
creased in  size  considerably.  Menstruation  had 
ceased  for  some  time. 

Examination. — Patient's  weight   121    lbs.,  cir- 
cumference over  umbilicus  48  inches.      Otherwise 
the  patient  was  in  very  good  condition,  >:■< 
spirits,  tranquil,  and  not  the  least  afraid. 

tosis  before  Operation. — Fibro-cystic  tumor 
of  the  uterus,  left  ovarj  not  involved,  right  ovary 
may  be  cystic  degenerated,  no  adhesions  except 
to  pedicle.  Taking  all  the  circumstances  into 
consideration,  I  advised  the  operation. 


May  17,  at  bedtime,  she  took  calomel  gr.  x, 
followed  the  next  morning  with  a  Seidlitz  powder. 

May  18,  before  retiring,  a  warm  bath. 

May  19,  in  the  morning,  a  cup  of  milk  and  a 
slice  of  bread  ;  a  copious  enemata  of  warm  soap 
water,  which  cleaned  the  bowels  thoroughly.  A 
vaginal  douche  of  warm  water  was  given,  and  she 
was  put  to  bed.  At  1 1  o'clock  morphine  sulph.  gr. 
ss,  and  warm  water  bottles  to  limbs  and  body  to 
keep  her  moist,  she  slept.  At  12  o'clock  she  tosk 
the  chloroform  with  ease.  I  operated  in  my  usual 
manner,  Drs.  Wm.  \Y.  Graves  and  Henry  Summa 
assisting:  present,  Dr.  L.  \Y.  Gerling,  Mr.  Heide- 
man,  M.S.,  and  Miss  Henrietta  A.  Stoffregen,  the 
nurse. 

After  opening  the  abdomen  by  an  incision  ex- 
tending from  the  pubis  to  about  1)2  inch  beyond 
the  umbilicus,  a  large  round,  solid  tumor  was  ex- 
posed. No  adhesions  anywhere,  the  ovaries  not 
involved,  though  both  degenerated.  On  the  right 
side  of  the  tumor  were  several  small  bunches  or 
protrusions  from  the  tumor,  and  more  soft  or 
cystic-like,  and  closely  surrounding  the  right 
ovary.  The  uterus,  elongated,  formed  the  pedi- 
cle proper,  the  fundus  involved  in  the  tumor. 

I  ligated  both  ovaries  with  a  single  silk  liga- 
ture, separated  the  peritoneal  covering  all  around, 
bringing  into  view  the  pedicle  proper,  introduced 
through  the  uterine  pedicle  one  of  my  cyst  ele- 
vators (double  needle),  tied  a  strong  silk  ligature 
below  the  needle  and  around  the  pedicle,  ampu- 
tated ovaries  and  tumor  with  a  pair  of  serrated 
scissors,  stopped  all  haemorrhage  thoroughly, 
which  was  very  little — she  lost  in  all  not  over 
one  ounce  of  blood.  The  abdominal  cavity  was 
cleansed  and  flushed  with  the  artificial  serum.  I 
then  touched  or  amalgamated  all  the  blood-vessels 
with  the  actual  cautery,  and  stitched  the  two  peri- 
toneal folds  together  with  interrupted  fine  silk 
ligatures,  covering  and  inclosing  the  pedicles, 
again  flushed  the  cavity  with  warm  artificial  se- 
rum, and  closed  the  abdominal  wound  with  deep- 
seated  and  superficial  silk  ligatures,  thus  obtain- 
ing a  clean  shut  peritoneal  pack.  Dressed  abdomen 
in  the  usual  manner.    The  patient  rallied  well. 

Progress  of  the  Case. — In  the  evening  after  the 
operation,  her  temperature  was  one  degree  below 
normal,  pulse  weak  but  regular,  respiration  slow. 
She  had  been  a  little  nauseated  for  a  few  hours, 
but  had  suffered  hardly  any  pain,  and  slept  at 
intervals. 

May  20,  morning.  Temperature  100. 50,  pulse 
90,  respiration  24.  Some  accumulation  of  gas  in 
the  intestine.  A  glycerine  rectal  suppository  re- 
li<  ved  her  almost  immediately. 

Evening.  Temperature  normal,  pulse  72,  res- 
piration 18.  Otherwise  in  a  good  condition  and 
spirits.  From  this  time  on  she  kept  at  this  stage 
and  slowly  improved.  Evacuation  of  bladder  and 
S  natural. 

On    the  third  day.  May   22,    I  removed  every 


i89i.] 


FIBROID  TUMORS  OF  THE  WOMB. 


915 


Other  deep-seated  ligature:  the  wound  was  closed 
and  perfectly  dry.  By  the  seventh  day  all  the 
ligatures  were  out,  uot  a  drop  or  sign  of  any  pus, 
patient  was  up.  On  the  fourteenth  day  the  pa- 
tient walked  out  to  the  dining-room  and  took  her 
meal  with  the  family .  For  the  first  two  days 
after  the  operation  she  wis  fed  on  oatmeal  gruel, 
beef-tea,  brandy,  ice.  according  to  circumstances. 
After  that  milk,  meat,  eegs.  vegetables,  etc.,  in 
addition. 

The  tumor  weighed  20  lbs.  7  ozs.  I  presented 
it  to  the  St.  Louis  Medical  Society,  with  a  -hurt 
history,  on  the  evening  of  the  23d  of  May,  and 
made  a  section  of  the  tumor  in  the  presence  of 
the  members,  and  would  say  that  to  all  appear- 
ance the  mass  was  colloid,  showing  beautifully 
the  uterine  tissue,  that  is  the  upper  part  of  the 
fundus  of  the  uterus,  from  where  the 
originated,  with  both  degenerated  ovaries  at- 
tached. 

General  Remarks. — It  will  be  observed  that  I 
took  all  possible  aseptic  precautions.  Nothing 
but  clean  distilled  warm  and  cold  water  was  used, 
and  the  artificial  serum  for  the  abdominal  cavity, 
instruments  aud  ligatures.  In  my  early  opera- 
tions I  followed  a  strict  antiseptic  plan,  carbolic 
acid  spray,  etc.  In  time  I  have  learned  better, 
and  instead  prefer  the  aseptic  method,  cleanliness 
and  discipline.  No  opium,  no  medicine  of  any 
kind  was  used,  nor  was  it  needed  in  this  case. 
This  patient  was  an  admirable  patient- — quiet, 
obedient,  good  spirits,  with  faith  in  her  recovery. 
I  am  especially  pleased  that  she  took  my  advice 
in  1885. 

This  is  my  sixty-ninth  case  of  ovarian  or  ute- 
rine tumors  operated  upon,  exclusive  of  all  other 
laparotomies  for  other  causes.  Out  of  my  first 
twenty -five  cases  I  lost  four  patients  ;  out  of  the 
next  twenty-five  cases  I  lost  but  one  patient.  See 
report  in  September,  1885. 

Remarks  on  Abdominal  Surgery,  with  Fifty  Cases. 
Read  before  the  Mississippi  Valley  Medical  Society, 
Evausville,  hid.,  September,  1SS5.  In  full  in  the  Medi- 
cal Record,  September  26,  1885,  Vol.  xxviii,  No.  [3,  whole 
No.  777.  W.  Wood  &  Co.,  Publishers,  56  and  5S  Lafay- 
ette Place.  New  Vork  City.  Abstract  from  same  in 
Journal  or  the  Amer.  Med.  Assoc.  Vol.  v.  No.  14, 
October  3,  1SS5,  65  Randolph  St..  Chicago,  111.  Med. 
and  Surg.  Reporter.  November  2\  1885,  Vol.  liii,  No. 
22,  Philadelphia,  Pa. 

Out  of  last  nineteen  cases  up  to  date  I  lost  two 
patients ;  these  two  were  operated  upon  at  their 
houses.  The  other  seventeen  cases  were  operated 
upon  and  kept  under  my  own  immediate  and  con- 
stant observation  at  my  Private  Surgical  Home, 
no  death. 

I  would  also  refer  the  interested  reader  to  my 
papers  on  : 

Ovarian  Tumors:  At  what  Stage  of  the  Disease  is  it 
the  Troper  Time  to  Operate?  Cincinnati  Obstetric  Ga- 
zette, March,  1SS0.     101  Inquiries. 

Ovarian    Tumors    (Two   Lectures):  Diagnosis   of.   and 


Operation.     Part   I.    Cincinnati  Obst.  Gaz..  September, 

Tumors.     Diagnosis  and  Operation. 

and   Revised  Edition,  with   Si\-  W 1-cuts.     Pamphlet. 

Cyst  Elevator:    Description  of,  and  Method  • 
ating.     Three   Illustrations.     Cincinnati  Obst.    Gazette, 
February,  1S79;  also  Illust.  Vierteljahrschrifl  der  arztli- 
chen  I'olytechnick.      Bern  u.  Leipzig. 

I   cheerfully   admit  that  I   carefully  select  my 
cases  I  operate  upon. 


I  IN  THE  TREATMENT  OF  FIBROID 

TUMORS  IN  THE  WOMB  BY  THE 

INJECTION  OF   ERGOT  INTO 

THEIR   SUBSTANCE. 

V  Illinois  State  Medical 
BY  J.   SCHEXCK,    M.D., 

OF   MT.  CARMKL,  ILL. 

Fibroid  growths  in  the  walls  of  the  womb  pro- 
duce such  serious  symptoms  and  cause  so  great 
an  amount  of  suffering  that  I  believe  that  any 
method  of  treatment  which  has  afforded  relief  or 
produced  a  cure  should  be  placed  before  the  pro- 
It  has  been  repeatedly  demonstrated  that  fibroid 
tumors  in  the  walls  of  the  womb  may  be  either 
checked  in  their  growth,  strangulated  until  local 
necrosis  is  produced,  or  forced  out  of  the  uterine 
walls  by  contractions  produced  by  the  free  and 
long  continued  use  of  ergot.  The  methods  by 
which  the  remedies  have  been  administered  are. 
b\-  hypodermatic  injections;  by  the  mouth;  or  by 
suppositories  per  rectum  or  vaginum. 

The  inoculation  of  a  virus  to  prevent  or  mod- 
ify threatened  diseases,  has  been  practiced  for 
about  two  hundred  years.  The  most  familiar  ex- 
amples are  those  against  small- pox.  anthrax, 
hydrophobia,  cholera,  scarlet  fever,  and  finally, 
tuberculosis.  Hypodermatic  medication  has  been 
on  trial  for  forty-eight  years,  and  is  to-day  recog- 
nized as  one  of  the  speediest  methods  of  carrying 
medicines  into  the  system. 

The  profession  has  also  had  extensive  experi- 
ence with  injections  of  various  substances  into 
diseased  tissues  and  abnormal  growths,  as  in  the 
treatment  of  carbuncle,  haemorrhoids,  hernia,  hy- 
drocele, goiter,  naevus  and  vascular  tumors.  But 
I  have  been  unable  to  find  record  of  a  remed5' 
having  been  injected  directly  into  the  morbid 
growth  itself  in  the  treatment  of  fibroid  tumors  of 
the  womb.  I  have  administered  it  in  this  man- 
ner in  several  cases  with  satisfactory  effects,  and 
in  this  communication  propose  to  present  a  sum- 
mary of  the  results: 

. — The  first  case  occurred  in  18S0.  in  the 
person  of  a  German  woman.  She  was  about  52 
years  old;  otherwise  in  good  health,  had  borne 
five  children:  the  last,  twenty  years  previous.  On 
examination  I  found  a  tumor  in  the  posterior 
wall  of  the  womb,  of  about  the  size  of  a  goose- 


9i  6 


FIBROID  TUMORS  OF  THE  WOMB 


[June  27 


egg.  It  had  tilted  the  womb  backwards  until 
that  organ  was  entirely  inverted;  the  os  being- 
high  up  under  the  pubes,  while  the  fundus  and 
tumor  had  fallen  backwards  and  downwards,  and 
were  dangling  between  the  thighs,  a  constant 
source  of  pain  and  annoyance.  I  injected  one- 
half  drachm  doses  of  fluid  extract  of  ergot  into 
the  substance  of  the  tumor,  once  a  week,  for  two 
months;  at  the  end  of  this  time  the  tumor  began 
to  suppurate  and  in  a  short  time  had  entirely  dis- 
charged. After  the  suppuration  ceased,  I  replaced 
the  womb,  and  retained  it  in  position  with  a 
large  sized  Hodge's  pessary;  which  the  patient 
wore  for  several  months,  when  it  was  removed. 
She  is  to-day  a  health}-  old  lady  and  suffers  no 
inconvenience  from  her  former  trouble. 

Case  2. — I  was  called,  in  December,  1886,  in 
consultation,  to  visit  Mrs.  C.  She  was  then  42 
years  old,  had  always  lived  a  quiet,  industrious 
life  on  a  farm.  Menstruation  commenced  at  14 
years.  She  was  married  at  36;  bore  her  first  and 
only  child  in  her  40th  year.  Menstruation  had 
always  been  normal  up  to  the  pregnancy;  but  five 
months  afterward  metrorrhagia  began,  which 
gradually  grew  more  profuse,  although  ergot  was 
given  freely  by  the  mouth.  An  examination  re- 
vealed a  well  defined  intra-mural  tumor  in  the 
anterior  wall  of  the  womb,  encroaching  on  the 
cervix,  and  about  the  size  of  an  ordinary  orange. 
I  advised  injections  of  ergot  into  the  tumor.  Mr. 
J.  D.  Kingsbury,  the  attending  physician,  sub- 
stantially sends  me  the  following  report: 

"  I  injected  half-drachm  doses  of  Squib's  fluid 
•  extract  of  ergot  each  day  for  eighteen  days,  then 
every  second  or  third  day  for  ten  times  more,  at 
the  end  of  which  time  the  metrorrhagia  had 
ceased.  She  has  taken  ergot  irregularly,  by  the 
mouth,  ever  since,  although  there  have  been  no 
indications  of  haemorrhage.  Menstruation  is 
regular  and  free  but  not  abnormal ;  general  health 
excellent. 

Case 3. — In  May  1888,  I  was  called  to  see  Mrs. 
T.  She  was  then  in  her  42nd  year;  had  always 
lived  on  a  farm;  had  borne  nine  children;  the  last 
two  years  previous.  Menstruation  had  been  un- 
usually profuse  since  that  confinement,  except 
during  the  last  three  months,  when  it  had  been 
suppressed. 

On  the  day  I  was  called,  profuse  haemorrhage 
had  begun,  and  in  a  short  time  after  my  arrival 
she  had  a  miscarriage,  of  twins,  at  about  the 
third  month.  Haemorrhage  was  very  free  but 
was  controlled  after  the  womb  was  emptied. 
Shortly  after  her  recovery  from  the  miscarriage 
metrorrhagia  set  in,  which  was  not  controlled 
by  the  free  use  of  ergot,  by  the  mouth.  About 
three  months  after  the  miscarriage,  I  made  an 
examination  and  found  a  hard  tumor  about  the 
size  of  a  child's  head,  in  the  right  lateral  wall  of 
the  womb.  By  using  an  aspirator  needle  I  was 
I    to     inject    into    its    substance    one-half 


drachm  doses  of  fluid  extract  of  ergot,  which  I 
did  once  a  week  for  nearly  five  months;  this  kept 
the  haemorrhage  under  controj  during  this  period. 
At  the  end  of  this  time  the  tumor  was  found  to 
be  submucous,  lifted  up  on  a  thick  peduncle  and 
protruding  itself  through  the  mouth  of  the  womb. 
In  January,  1889,  five  months  from  the  time  the 
injections  were  begun,  I  removed  the  tumor  with 
an  ecraseur.  It  was  so  large  that  the  wire  would 
not  reach  over  it,  so  I  was  compelled  to  take  it 
away  in  three  portions;  haemorrhage  was  not  seri- 
ous. The  vascularity  of  the  tumor  had  evident- 
ly been  greatly  lessened  by  the  injections  of  er- 
got. The  substance  of  the  tumor  was  soft  and 
friable  and  would  probably  soon  have  broken 
down  in  suppuration  in  a  short  time. 

I  have  not  observed  any  serious  effects  result- 
ing from  these  injections;  in  a  few  instances  a 
slight  chill  accompanied  by  moderate  fever  fol- 
lowed the  use  of  the  syringe;  but  these  symptoms 
subsided  in  the  course  of  a  few  hours.  I  have 
employed  this  method  of  treatment  in  several 
other  cases  with  similar  results,  so  far,  but  they 
are  still  in  hand. 

The  most  convenient  instrument  with  which  to 
administer  the  injections  is  the  ordinary  hypoder- 
matic syringe  with  a  long  needle. 

In  a  few  instances  I  have  used  a  small  aspira- 
tor as  a  syringe.  The  injections  are  always  given 
through  the  vagina.  I  attempt  to  place  the  er- 
got as  near  the  center  of  the  tumor  as  possible. 


THE  STRUGGLE  FOR  LIFE  AT  THE  WRECK  OF  THE 
"  UTOPIA." 

In  The  Times  of  March  25,  there  appears  from  an 
officer  on  board  the  Anson  a  most  graphic  account  of  the 
■  iisaster,  evidently  written  while  the  terrible 
scene  was  fresh  in  his  memory  and  its  horror  still  vivid 
before  him.  While  the  officers  of  H.M.S.  Anson  van- 
dressing  for  dinner  the  "officers'  call  "  sounded,  and  all 
were  speedily  at  their  posts.  The  Utopia  was  sinking 
fast,  and  the  waves  washing  over  her  were  sweeping 
.sway  people  by  dozens  into  the  sea  around.  Every  wave 
that  passed  over  the  ship  lessened  the  numbers  strug- 
gling for  life.  There  was  one  man  hanging  by  one  leg 
to  some  rope  aloft  quite  dead  and  nearly  naked,  and 
around  were  others  clinging  and  shrieking  for  help.  An- 
other man  had  lashed  himself  to  the  sails  for  security, 
and  was  drowned  standing  up.  while  some  of  those  free. 
and  apparently  in  greater  danger,  were  saved.  One  poor 
fellow,  when  the  Utopia  first  sank,  got  so  excited  that. 
crying  out  " Oh  !  I  can't  stand  this,"  he  jumped  over- 
board.  The  cold  water  brought  him  to  his  senses,  and 
lie  was  picked  up  and  saved,  but  he  had  no  recollection 
of  what  he  did.  Here  is  an  instance  of  the  effect  of 
shock  on  the  senses  suddenly  depriving  the  individual 
of  the  power  of  using  them  even  to  save  his  own  life. 
We  are  apt  sometimes  to  under  estimate  the  effect  of 
shock  in  accidents  less  appalling,  and  it  is  only  bv  such 
a  circumstance  as  is  here  described  that  we  can  judge  by 
comparison  of  those  lesser  instances  of  shock  to  the 
nervous  system,  which  w  e  are  so  often  called  on  to  relieve 
o-  to  estimate  the  bearing  of  with  regard  to  the  future 
life  of  an  individual  ;  especially  is  this  so  in  railway  ac- 
!  which  shock  to  the  nervous  system  often  forms 
the  most  serious  part  of  the  injury.  —  The  Lancet. 


iSgi.] 


EDITORIAL. 


917 


Journal  of  the  American  Medical  Association 

PUBLISHED  WEEKLY. 


mptios  Price,  Including  Postage. 
Per  Annum,  in  Advance $5.00 

IO  CENTS. 


iption  may  begin  at  any  lime.  The  safest  mode  of  remit 
tance  is  by  postal  or  express  money  order,  drawn  to  the  order 
of  The  JOURNAL.  When  neither  is  accessible,  remittances  may  be 
made  at  the  risk  of  the  publishers,  by  forwarding  in  Registered 
letters. 

Address 

Journal  of  the  American  Medical  Association, 

W ABASH  Ave., 

Chicago.  Illinois. 
All  members  of  the  Association  should  send  their  Annual  Dues 
to  the  Treasurer ,  Richard  J.  Dunglison,  M.D.,  Lock  Box  1274,  Phila- 
delphia. Pa. 


London  Office,  57  and  59  Ludgate  Hill. 


SATURDAY.  JUNE    27,    1S91. 


PRESENT  ASPECTS  OF  DISINFECTION. 
Mr.  Wyxter  Blyth  has  lately  addressed  the 
Society  of  Medical  officers  of  Health  of  England, 
regarding  the  latest  improvements  in  disinfec- 
tion. He  finds  that  the  basis  of  the  scientific 
use  of  disinfectants  is  changing  year  by  year  as 
our  knowledge  of  disease  causation  advances. 
At  the  beginning  of  the  last  decade,  when  the 
first  results  began  to  be  revealed  as  to  the  rela- 
tion of  microorganisms  to  disease,  it  was  the  gen- 
eral inference  that  pathogenic  microbes,  or  those 
concerned  in  the  propagation  of  diseases  of  an 
infectious  character,  were  almost  wholly  those  of 
the  sporogenic  type,  and  that  since  the  spores  of 
all  such  organisms  are  possessed  of  a  high  degree 
of  inherent  vitality,  no  so  called  process  of  disin- 
fection could  be  considered  adequate  and  thor- 
oughly efficient  which  did  not  have  the  power  of 
destroying  the  vitality  of  the  spores  of  the  bacil- 
lus anthracis,  the  most  resistant  of  them  all. 
More  recently,  however,  the  field  of  vision  has 
been  clarified  and  it  is  no  longer  necessary  to  as- 
sume that  there  is  the  same  degree  of  vitality  in 
all  specific  disease- germs  as  exists  in  that  of  an- 
thrax. By  degrees  the  pathogenic  microbes  of 
very  many  of  the  specific  infectious  diseases  have 
been  identified  and  shown  to  be  non-sporiferous, 
as  in  the  case  of  the  well-known  forms  of  cholera, 
uteric  fever,  erysipelas,  septicaemia  and  epidemic 
diarrhoea:  have  been  shown  to  occur  as  bacilli, 
streptococci  or  micrococci  and  to  be  very  feebly  re- 
sistant to  heat  and  chemical  agents.  In  this  new 
view,   therefore,  it   has  become    unnecessary    to 


have  recourse  to  those  powerful  chemical  sub- 
stances, the  use  of  which  was  attended  by  ob- 
vious practical  difficulties.  In  a  paper  before 
the  Royal  Society,  Mr.  Blyth  has  already 
pointed  out  the  important  relations  of  tempera- 
ture, space  and  time  as  factors  in  the  contest  with 
the  germs  of  disease,  showing  that  under  appro- 
priate conditions,  even  such  simple  means  as  lime- 
washing  and  aeration  were  competent  to  remove 
infection.  Behring  and  PPUHL  have  recently 
published  an  account  of  their  experiments  with 
lime,  showing  its  efficacy.  Boer  has  observed 
that  while  the  addition  of  very  small  quantities 
of  lime  to  culture  fluids  favored  the  development 
of  bacteria,  larger  quantities — as  well  as  equiva- 
lents of  potash  or  soda,  producing  an  alkaline  re- 
action, equal  to  what  is  known  as  500  of  normal 
acidity — were  speedily  destructive  to  all  patho- 
genic microbes,  in  any  other  form  than  that  of  the 
spore.  Hence  we  learn  that  the  old-fashioned 
soft  soaps,  strongly  charged  with  alkali,  are  in 
many  cases  far  better  germicides  than  the  much- 
vaunted  soaps  of  carbolic  acid,  thymol,  and  tere- 
bene;  and  that  the  stripping  of  the  wall-paper, 
lime-washing  the  walls  and  ceiling,  and  the 
scrubbing  of  the  wood-work  with  soft  soap  may 
be  relied  upon  as  generally  sufficient  for  the  dis- 
infection of  rooms  or  wards  that  require  cleans- 
ing. Lime  also  becomes  useful  from  its  absorb- 
ent property,  taking  up,  as  it  does,  the  sulphur 
compounds  and  other  offensive  gases,  without 
itself  becoming  offensive;  it  is  especially  suitable 
in  regard  to  the  handling  of  disinterred  bodies 
and  for  the  purification  of  the  contents  of  street 
gutters,  and  in  nearly  all  cases  where  it  will  not 
cause  the  evolution  of  ammonia.  Dr.  Tykes,  of 
London,  has  reported  his  experience  of  the  im- 
mense value  of  quicklime  in  the  removal  of  over 
two  thousand  bodies,  and  many  thousand  tons  of 
very  offensi%-e  soil,  from  a  cemetery  in  the  parish 
of  St.  Pancras  to  an  extramural  burial-place;  as 
fast  as  the  ground  was  opened,  quicklime  was 
thrown  in  and  the  stench  at  once  ceased;  the 
coffins  were  placed  in  larger  wooden  cases  with 
a  plenty  of  lime  and,  at  first,  lime  was  spread 
over  the  surface  of  the  loads  of  offensive  earth, 
after  the  carts  were  loaded,  but  some  complaints 
having  been  made  by  citizens  along  the  line  of 
streets  through  which  the  carts  were  driven,  he 
substituted  a  top-layer  of  clean  earth,  when  no 
more  complaints  were  sent  in;  this  cemetery  had 


9i8 


A  NEW  THEORY  OF  "URAEMIA." 


[June  27, 


been  closed  for  twenty  years  and  the  condition  of 
putrefaction  in  the  bodies  were  so  variousl}'  and 
markedly  offensive  that  without  the  lime  the  re- 
moval would  have  been  well  nigh  impracticable. 
For  the  disinfection  of  mortuaries  lime  may  be 
used,  but  some  health  officers  give  a  preference 
to  a  fifty  per  cent,  dilution  of  the  Burnett  fluid, 
which  is  a  solution  of  zinc  chloride,  containing 
four  per  cent,  of  the  chemical.  In  the  disinfec- 
tion of  sickrooms,  sulphur  fumigations  have  had 
a  variable  reputation,  and  while  they  should  not 
be  allowed  to  supersede  lime  washing  and  the  al- 
kaline scrubbings,  they  should  still  be  regarded 
as  a  serviceable  addition  to  those  measures.  For 
the  deodorization  of  excreta  and  stable  refuse,  the 
acid  sulphates,  which  would  fix  the  ammonia 
and  at  the  same  time  not  detract  from  the  value 
of  the  fertilizer,  have  the  preference  over  carbolic 
powders,  but  there  are  many  sanitary  officers 
who  adhere  to  the  use  of  solutions  of  corrosive 
sublimate,  especially  for  the  disinfecting  of  enteric 
excreta.  Touching  the  disinfection  of  fomites  by 
heat,  Dr.  Blyth  insisted  that  all  recent  researches 
tended  to  show  that  time  was  a  most  important 
factor.  Given  an  indefinite  period  of  time,  com- 
paratively low  temperatures  have  been  found  ef- 
fective, and  intermittent  heatings  below  212°  F. 
may  very  well  be  employed  in  the  purification  of 
those  articles,  such  as  kid  gloves,  which  are  dam- 
aged by  higher  temperatures.  In  the  refuges  es- 
tablished last  winter  in  Berlin,  the  use  of  a  steam- 
chamber  was  relied  upon  for  the  disinfection  of 
the  clothing  of  the  lodgers,  while  the  persons  of 
the  latter  were  being  treated  to  a  bath;  and  re- 
cent German  researches  appear  to  establish  the 
superiority  of  current  steam  over  pressure  steam, 
the  steam  being  admitted  at  the  upper  part  of  the 
chamber  and  its  temperature  observed  at  its  point 
of  exit  below.  In  regard  to  the  carriage  of  in- 
fection by  persons  who  are  convalescent  from  in- 
fectious diseases,  the  discovery  of  Oertel  must  not 
be  forgotten.  He  reports  that  he  has  found  the 
bacillus  of  diphtheria  in  the  throats  of  patients 
even  as  late  as  three  weeks  after  recovery  and  dis- 
charge from  attendance.  It  is  possible  that  .1 
like  condition  may  obtain  after  scarlet  fever  and 
may  explain  the  propagation  of  the  disease  by 
discharged  patients  notwithstanding  the  careful 
exercise  of  every  ordinary  precaution  of  disinfec 
tion,  clothing  and  persons  at  the  time  of  their  dis- 


A  NEW  THEORY  OF  "UR.EMIA." 

There  is  no  more  obscure  subject  in  pathology, 
than  the  various  clinical  phenomena  grouped 
under  the  general  head  of  ursetnia.  Of  all  the 
theories  that  have  been  advanced,  it  must  be 
confessed  that  none  of  them  offer  a  complete  ex- 
planation of  its  varying  conditions. 

For  years  the  most  generally  accepted  doctrine, 
and  one  that  contributed  the  name  to  this  symp- 
tom complex,  regarded  it  as  simply  due  to  an  ex- 
cess of  urea  in  the  blood  ;  this  view  was  then 
followed  by  that  of  Frerich's,  who  taught  that 
carbonate  of  ammonia  was  the  toxic  substance. 
Further  observations  gave  the  coup  de  grace  to 
these  earlier  views,  and  apparently  demonstrated 
that  various  excrementitious  substances  such  as 
xanthine,  creatin,  etc.,  were  the  morbid  agents. 
Perhaps  the  most  generally  accepted  view  now 
(Jaccoud),  is  that  any  or  all  of  these  substances 
may  be  present,  and  in  part  responsible.  The 
most  striking  fact  against  the  acceptance  of  the 
view  that  uraemia  is  dependent  upon  the  reten- 
tion of  normal  excrementitious  substances  in  the 
blood,  is  that  animals  or  man  suffering  from  fatal 
obstructive  suppression  of  urine  present  a  very 
different  clinical  picture  from  those  affected  with 
ursemia,  the  result  of  Brights'  disease.  This  has 
given  rise  to  the  theory  of  REESE,  which  has 
been  accepted  in  part  by  Mahomed,  that  the 
phenomena  of  ursemia  were  dependent  upon 
capillary  haemorrhages  or  serous  effusion,  due  to 
changes  in  the  blood  and  altered  vascular  pres- 
sure. It  is  obvious,  however,  that  these  same 
changes,  may  be,  and  often  are,  present  in  other 
diseases,  that  are  never  attended  by  coma  and 
convulsions. 

Perhaps  the  majority  of  clinicians  incline  'to 
the  view  that  this  condition  is  essentially  a  tox- 
aemia, though  the  exact  nature  of  the  offending 
substance  has  not  been  determined.  Heretofore 
all  researches  have  been  conducted  upon  the 
theory  that  it  was  some  substance,  either  changed 
or  unchanged,  that  is  under  normal  circum- 
stances excreted  by  the  kidneys. 

Recently  Dr.  C.  J.  Radkmaker  (Amer.  Prac. 
and  News),  May  9,  1891,  has  announced  the  dis- 
covery of  a  crystalline  organic  compound,  differ- 
ing from  all  constituents  of  normal  urine,  that 
he  has  uniformly  found  in  albuminous  urine. 
This  substance  upon  ultimate  organic  analysis 
was  found  to  have  the  same  formula  as  urethane, 


i89i.J 


ACKNOWLEDGMENT. 


919 


and  to  present  the  same  general  chemical  reac- 
tions. As  the  writer  points  out.  urethane  belongs 
to  the  class  of  narcotic  poisons,  and  he  suggests 
that  urcemic  symptoms  may  be  due  to  the  pres- 
ence and  retention  of  this  toxine. 

Whether  in  this  discovery  we  have  at  least 
cleared  up  the  doubtful  pathology  of  uraemic 
coma,  remains  for  further  observation  and  study. 
Certain  it  is  that  it  suggests  a  new  Hue  of  inquiry 
that  apriori  is  full  of  promise,  and  one  which, 
apparently,  is  capable  of  reconciling  the  wide- 
variation  in  the  observed  symptoms  in  acute 
urinary  suppression  and  Bright's  disease. 


FOURTH  OF  TCLY  SURGERY. 
The  usual  number  of  Fourth  of  July  accidents 
may  be  expected  this  year,  especially  in  the  large 
cities  and  among  our  patriotic  boys  from  ten  to 
sixteen  years  of  age.  In  former  times,  the  toy 
cannon  used  to  figure  very  largely  in  the  etiology 
of  the  injuries  liable  to  keep  the  practitioners 
busy  on  the  great  holiday,  but  during  recent  years 
the  giant  cracker  has  forced  its  way  to  the  front 
as  the  champion  among  dangerous  playthings. 
The  iujuries  inflicted  by  these  crackers  very  com- 
monly have  their  situation  in  the  right  hand, 
splitting  open  the  thumb,  at  or  near  its  base,  and 
causing  a  compound  dislocation  of  the  proximal 
joint  of  the  first  metacarpal  bone,  tearing  the  lat- 
ter away  from  the  trapezium,  so  that  the  thumb 
and  its  metacarpal  are  connected  with  the  hand 
only  by  the  soft  parts.  Sometimes  the  explosion 
affects  the  ungual  phalanx,  severing  it  from  the 
hand.  In  the  report  of  the  surgical  work  per- 
formed at  the  Boston  City  Hospital  on  the  Fourth 
of  July,  of  last  year,  there  were  twenty-one  cases 
brought  to  the  hospital  as  the  result  of  explosions, 
the  majority  of  which  were  due  to  the  giant  fire- 
cracker. 


PURE  CULTURES  OF  THE  GOXOCOCCUS. 
Von  Schrotter  and  Winkler  report  that 
they  have  recently  employed  plover*s  egg  albu- 
men iu  the  cultivation  of  the  gonococeus  of 
Neisser.  The  coccus  is  obtained  from  the  ure- 
thra with  all  possible  precautions.  The  glans  is 
first  washed  with  alcohol  and  corrosive  sublimate, 
then  some  of  the  infected  pus  is  conveyed  by  a 
sterile  needle  to  the  coagulated  albumen.  The 
culture  is  placed  in  a  brood  oven  at  a  tempera- 


ture of  380  C.  At  the  end  of  six  hours  a  thin, 
whitish,  transparent  layer  appears,  that  extends 
itself  rapidly  over  the  albumen.  There  is  some 
growth  at  ordinary  temperatures,  but  it  is  much 
less.  Experiments  with  egg  albumen  of  the  com- 
mon fowl  were  negative.     Centralblatt  fur  Bakte- 

und  Parasilenkunde,  May  23,  1891. 

to  be  regretted  that  some  more  readily 
obtainable  culture  medium  was  not  found  than 
plover's  egg.  Still,  even  with  this  disadvantage, 
it  is  to  be  hoped  that  pure  cultures  of  the  gono- 
coceus may  materially  advance  our  knowledge  of 
this  important  iuficiens. — Ref.) 


MEDICAL    F.nUCATIONAL  INTERESTS. 
The  following  circular  has  a  melodious  ring 
that  clearly  says :    Attention,   right   dress,    for- 
ward march.     Straggling  and  getting  out  of  line 
are  strictly  forbidden: 
State  Board  of  Health,  Kentucky, 

June  19,  1891. 
To  the  Editor: — I  am  instructed  by  this  Board 
to  transmit  to  you  for  publication  the  following 
self-explanatory  resolution,  which  was    adopted 
at  its  recent  meeting  held  in  Louisville  : 

Resolved,  That  the  Secretary  be  instructed  to  place 
upou  the  list  of  medical  colleges  whose  diplomas  are  to 
be  certified  and  endorsed  for  registration  under  the  laws 
of  this  State  only  such  colleges  as  shall,  after  the  session 
of  1S91-2,  exact  of  matriculates  aud  candidates  for  gradua- 
tion a  minim  of  requirements  not  less  than  those  re- 
quired by  the  American  Medical  College  Association. 
Very  respectfully, 

J.   N.   McCORMACK.  Sec  V. 


ACKNOWLEDGMENT. 

For  the  many  generous  expressions  of  good- 
will on  the  part  of  the  editors  of  almost  the  en- 
tire medical  press  of  this  country,  as  well  as  from 
an  army  of  friends  of  The  Journal,  we  express 
our  most  hearty  appreciation,  and  very  warmest 
thanks. 

The  Journal  of  the  American  Medical 
Association  is  neither  the  rival  nor  an- 
tagonist of  any  part  of  the  medical  press,  but  in 
all  good  work  for  the  elevation  aud  betterment  of 
our  profession  in  every  section  of  our  couniry.it 
r,  counted  upon  as  giving  a  strong  support, 

aud  in  utterances  of  no  uncertain  sound.    Whether 


920 


EDITORIAL  NOTES  AND  ITEMS. 


[June  27, 


we  are  able  to  realize  the  exalted  hopes  which 
have  been  so  lavishly  expressed  or  not,  our  friends 
may  rest  assured  that  we  are  here  to  do  our  level 
best  to  promote  every  laudable  interest  and 
purpose  of  the  medical  profession.  In  such  gen- 
erous, out-spoken  expressions  of  support  and 
tender  of  aid  as  have  come  to  us,  we  recognize 
a  determination  to  place  this  Journal  away  in  ad- 
vance of  its  present  status,  even  to  the  making 
it  the  largest  and  best  of  its  kind. 


editorial  notes  and  items. 
The  French- Canadian  Invasion  of  New 
England. — There  has  been  established  a  new. 
medical  journal  in  French,  edited  by  E.  Sirois, 
M.D.,  of  Three  Rivers,  Mass.  It  is  the  official 
organ  of  the  Socieie  Medico  chirurgicale  Canadi- 
cnnc-F)  ancaisc  de  laNouvelle  Angleterre,  that  was 
founded  in  Worcester,  Mass.,  in  1887.  The  mem- 
bership now  numbers  over  thirty,  mostly  from 
Massachusetts. 

Dr.  Alt's  Connection  with  the  St.  Louis 
Miracle  (!)  : — The  so-called  "  miraculous  "  case 
of  Sister  Mary  Philomena  at  St.  Louis  not  long 
since,  and  with  which  it  has  been  reported  that 
Dr.  AdolphAlt,  editor  of  the  Journal  of  Ophthal- 
mology, was  in  some  way  professionally  connected, 
is  disposed  of  by  Dr.  Alt  in  the  current  issue  of 
the  journal  over  which  he  presides. 

I  >r.  Alt  denies  in  unequivocal  terms  having  any 
connection  with,  or  knowledge  of,  any  miracle. 
Dr.  Alt  said  he  was  called  upon  one  occasion — 
previous  to  the  reported  miracle — and  found  a 
congested  upper  eyelid  in  the  patient,  with  a  his- 
tory of  bleeding  from  the  part — presumed  haetuo- 
phila.  He  then  adds:  "  This  is  all  I  know  of 
the  miracle  case.  I  saw  the  Sister  only  that 
once.  I  did  not  do  anything  for  her.  I  had 
nothing  to  do  with  the  subsequent  alleged  mira- 
cle, and  could,  therefore,  not  vouch  for  it,  even 
if  I  believed  it." 

Tiik  British  Medical  Association. — The 
fifty  ninth  annual  meeting  will  be  held  at  Bourne- 
mouth on  Tuesday,  Wednesday,  Thursday  and 
Friday,  July  28,  29,  30,  and  31,  under  the  presi- 
dency of  Willoughby  Francis  Wade,  B.A.,  M.B., 
F.R.C.P.,  J. P.  The  address  in  Medicine  will  be 
delivered  by  T.  Lauder  Brunton,  M.D.,  F.R.S.; 


the  address  in  Surgery  by  John  Chieue,  M.D., 
F.R.C.S.,  Ed.;  the  address  in  Public  Medicine, 
by  Edward  Cox  Seaton.M.D. 

The  scientific  work  is  divided  into  nine  sec- 
tions, viz. ,  Medicine,  Surgery,  Obstetric  Medi- 
cine and  Gynecology,  Public  Medicine,  Psychol- 
ogy, Pathology,  Ophthalmology,  Diseases  of 
Children  and  Therapeutics,  and  already  an  aver- 
age of  eight  papers  in  each  section  has  been  an- 
nounced. 

A  brief  description  of  the  place  of  meeting 
will  be  of  interest,  especially  to  those  who  have 
lately  enjoyed  the  beauties  of  our  National  Cap- 
itol at  the  meeting  of  the  American  Association. 

Bournemouth  is  a  happily  situated  watering- 
place  on  the  southern  English  coast.  A  valley 
of  about  two  miles  or  more  in  extent,  beautifully 
cultivated,  and  through  which  winds  a  small 
stream,  gives  a  place  for  pretty  homes,  and  one 
of  those  quiet  English  towns  so  famous  in  the 
literature  of  the  country — the  literature  of  the 
English-speaking  world. 

A  broad  beach  of  white  sand,  wooded  hills,  the 
sparkling  sea  ;  together  with  the  calm,  joyful  sur- 
roundings made  by  the  haud  of  man,  and  the 
smile  of  the  summer's  sun,  should  all  conduce  to 
the  success  of  the  occasion,  and  we  doubt  not 
that  such  will  be  the  case.  Various  points  of 
interest  and  pleasure  are  within  easy  distance, 
and  excursions  have  been  arranged,  giving,  there- 
fore, a  decidedly  sociable  trend  and  interest, 
other  than  purely  scientific,  to  the  gathering. 

Medicine  vs.  Surgery. — Viewing  the  height 
to  which  the  science  and  art  of  Medicine  and 
Surgery  is  advancing,  and  the  struggle  of  both 
branches  to  attain  the  higher  meed  of  praise; 
looking  over  the  whole  field  of  progress  and  pos- 
sibility through  the  glasses  of  "A  Quinquennial 
Retrospect,"  Dr.  Gri gg,  in  an  inaugural  address 
before  the  British  Gynecological  Society,  said: 
"The  greatest  operative  skill  that  ever  man  pos- 
sessed must  pale  before  the  discovery  of  a  drug 
or  of  an  agent  which  can  arrest  or  destroy  the  ef- 
fects of  pathological  changes.  We  are  on  the 
threshold  of  great  discoveries.  Another  century 
will  not  pass  without  increasing  our  therapeuti- 
cal resources  at  the  expense  of  the  surgeon's  art." 

Artificial  Infant  Foods. —Dr.  C.  W.  Earle, 
of  Chicago,  maintains  strongly  against  the  pre- 
pared infant  foods — the  commercial  foods  so  much 


I89i.] 


DOMESTIC  CORRESPONDENCE. 


921 


advertised  and  used.  Above  all  else,  of  course, 
he  contends  that  the  mother*s  milk  is  the  food 
par  excellence  for  the  infant's  stomach  and  bow- 
els. If  this  is  not  of  sufficient  quantity,  then  a 
prepared  food  may  be  resorted  to  only  to  fill  out 
the  deficiency  in  quantity.  If  it  becomes  imper- 
ative, then  a  prepared  food  may  be  wholly  used. 
Condensed  milk,  properly  diluted  with  rice-water 
or  toast-water,  and  sterilized,  has  been  used  under 
his  care  with  the  best  results.  He  strongly  ad- 
vises the  sterilization  of  all  infant  artificial  food, 
and  the  use  of  the  improved  "feeders."  The 
old-time  nursing  bottle  he  denounces  as  a  thing 
of  evil. 

A  Viable  Child  at  Six  and  One-Half 
Months. — Dr.  Herman  L-.  Col  Iyer  reports  {Arch. 
of  Gynecology,  June,  1891  1  a  child  born  before  six 
and  one  half  months  of  uterine  life  had  been 
reached.  The  dates  were  well  distinguished; 
that  is,  the  time  of  conception  was  well  ascer- 
tained, and  the  progress  of  the  case  from  such 
time  was  carefully  watched.  At  birth  the  child 
weighed  two  pounds  and  two  ounces.  The  fin- 
ger-nails were  just  beginning  to  show,  while  the 
toe-nails  had  not  yet  shown  development.  The 
cranial  bones  were  soft,  the  sutures  overlapped, 
while  the  frontal  suture  was  open.  The  child 
immediately  after  birth  was  carefully  wrapped 
and  nursed,  and  continued  to  live. 

Viable  children  at  this  age  are  very  uncommon, 
and  even  when  one  is  reported,  the  chances  of  an 
error  in  calculation  render  it  difficult  for  positive 
statements. 

The  Composition  and  True  Nature  of  Tu- 
berculin.— It  is  said  that  Prof.  Koch,  having 
returned  to  active  laboratory  work  at  Berlin,  will 
soon  announce  full  particulars  regarding  the  prep- 
aration and  essential  characters  of  tuberculin. 

The  St.  Louis  Surgical  Society. — This  is 
the  title  of  a  new  organization  of  the  working 
members  of  the  profession  in  St.  Louis — those 
working  members  to  whom  surgery  has  made  an 
especial  appeal,  and  who  feel  called  upon  to  reply 
with  their  choicest  gifts  and  the  day  and  night 
toil  of  their  minds  and  hands. 

The  American  Society  of  Microsqopists. 
— This  Society  will  meet  at  Washington,  D.  C, 
August  11.  In  1878  the  first  organization  was 
effected,  beginning  with  about  seventy-five  mem- 


Since  then  it  has  grown  until  now  its 
membership  list  shows  upwards  of  four  hundred 
names.  Vet  the  number  is  not  what  it  should 
be,  aud  a  plea  has  been  presented  by  the  Secre- 
tary for  more  interest — for  a  larger  list  of  mem- 
bers, and  an  increased  activity  on  the  part  of  those 
already  belonging  to  the  I 

The  indispensable  value  of  the  microscope  to 
medicine,  together  with  the  fascination  of  the 
study,  should  invite  many  physicians  to  show 
their  zeal  along  this  line  by  rendering  such  as- 
sistance as  is  within  their  power  to  this  National 
organization. 

Advanced  Strgery. — M.  Figueira,  M.D.,  of 
New  Vork  City,  believes  an  operation  for  foreign 
bodies  at  or  below  the  bifurcation  of  the  trachea 
can  be  made  from  the  posterior  thoracic  region — 
between  the  posterior  scapular  margin  and  the 
vertebra.  He  is  convinced  that  vital  structures 
could  here  be  avoided  and  the  roots  of  the  lungs 
reached.  The  sad  case  of  the  Rev.  Dr.  Both  well, 
regarding  which  the  country  is  aware,  has 
prompted  him  to  undertake  experiments,  the  re- 
sults of  which  he  promises  soon  to  make  known. 


DOMESTIC  CORRESPONDENCE. 


Tuberculin. 

To  the  Editor: — I  note  the  report  of  Dr.  Joseph  Jones, 
of  New  Orleans,  La.,  upon  the  analysis  and  examination 
made  by  him  of  Professor  Koch's  lymph,  now  called 
tuberculin,  which  appeared  in  your  issue  of  May  30. 

Without  in  the  least  desiring  to  appear  as  the  champion 
for  the  lymph,  the  extraordinary  statements  made  bv 
Dr.  Jones  in  this  report,  led  me  to  reply  to  his  claims  of 
having  found  living  tubercle  bacilli,  or  at  least  such  as 
resembled  and  behaved  similar  to  the  bacilli  of  tubercu- 
losis. 

Many  similar  analyses  have  been  made  and  published 
before  and  since  Dr.  Jones  began  his  investigations,  but 
strange  to  say  in  none  of  the  numerous  experiments 
made  in  the  physiological  and  bacteriological  labora- 
tories of  Europe  and  other  countries  have  ever  any 
living  germs  been  found  to  be  present  in  the  fluid. 

Dr.  Jones  says,  that  upon  the  dilution  of  the  lvmph 
with  boiled  distilled  water  and  preserved  in  chemically 
cleau  test  tubes,  the  fluid  became  turbid,  and  that  micro- 
scopic examination  showed  the  turbidity  to  have  been 
due  to  the  multiplication  of  organisms  presenting  the 
physical  and  chemical  properties  similar  to  those  of  the 
bacillus  of  tuberculosis. 

He  does  not  state  the  degree  of  dilution  and  the 
length  of  time  it  required  for  the  turbidity  to  occur. 
I  Boiled  distilled  water  may  and  may  not  be  sterilized 


922 


DOMESTIC  CORRESPONDENCE. 


[June  27, 


water,  and  chemically  clean  test  tubes,  may  not  be 
sterilized  and  may  not  be  clean  in  a  bacteriological  sense. 
Neither  does  he  show  that  the  turbidity  could  not  also 
have  been  due  to  the  development  and  growth  of  the 
germs. 

The  care  and  facilities  for  correct  and  unassailable  in- 
vestigations in  these  matters  are  such,  that  a  lack  or  the 
slightest  deficiency  in  either  direction  would  make  any 
conclusions  certainly  very  doubtful,  if  not  valueless.  I 
have  myself  kept  such  a  10  per  cent,  solution  for  over 
five  mouths,  and  without  all  the  precautions  necessary 
to  prevent  error,  and  the  fluid  has  uot  become  turbid, 
neither  can  the  most  careful  examination  show  the 
presence  of  bacilli,  dead  or  alive.  I  have  kept  half,  i 
and  5  per  cent,  solutions  without  especial  precautions 
for  a  number  of  weeks  and  they  were  perfectly  clear  at 
the  end  of  such  time. 

Now  as  to  the  results  of  culture  as  obtained  by  Dr. 
Jones  they  are  certainly  remarkable,  and  it  would  be  of 
the  greatest  interest  if  the  report  contained  exact  data  of 
the  steps  and  modes  of  his  procedures,  the  way  in  which 
the  culture  media  were  prepared  and  kept  after  inocula- 
tions, and  the  time  and  the  precautions  under  which  he 
made  his  final  examinations. 

Dr.  Jones  being  until  now  a  stranger  in  the  field  ot 
experimental  bacteriology,  it  would  not  be  unreasonable 
to  ask  of  him  evidence  for  the  remarkable  statements 
which  he  makes,  the  more  so  inasmuch  as  men  who  have 
at  their  command  the  perfect  equipments  of  bacterio- 
logical laboratories  of  Europe  and  other  countries,  and 
who  have  earned  a  world-wide  reputation  in  this  special 
field  of  scientific  labor,  and  who  have  made  similar  in- 
vestigations with  Koch's  lymph,  have  never  found  any 
tubercle  bacilli  capable  of  growth  and  multiplication,  in 
that  fluid. 

That  the  lymph  contains  dead  or  inert  bacilli  has  been 
well  knowu  since  the  first  introduction,  andean  be  found 
especially  in  the  sediment  of  occasional  specimens,  but 
heretofore,  so  far  as  I  know,  all  culture  and  inoculation 
experiments  have  failed,  and  from  the  mode  of  prepara- 
tion we  must  expect  them  to  fail,  if  no  germs  are  ad- 
mitted by  error  or  oversight  from  without.  These  dead 
bacilli,  are,  however,  not  fouud  so  plentifully  even  in 
the  sediment  from  a  bottle  of  tuberculin  as  one  might 
suppose  from  Dr.  Jones'  report  ;  only  here  and  there  we 
find  a  bacillus  in  the  field,  and  more  often  none  at  all. 
Their  presence  and  inertness  were  known  to  Professor 
Koch  and  his  associates,  from  the  beginning  has  been  re- 
ferred to  in  the  medical  literature  again  and  again,  and 
the  mode  of  preparation  with  prolonged  exposure  to  in- 
tense- heat  of  the  fluid,  ami  its  preservation  in  glycerine 
after  filtration  through  porcelain,  is  a  sufficient  guarantee 
that  we  have  nothing  to  fear  from  them.  Moreover, 
every  vial  before  being  sent  out  of  the  laboratory  is 
especially  tested  and  examined. 

Dr.  Jones  should  or  could  have  known  of  the  presence 
of  inert  bacilli,  and  of  the  negative  experiments  of  other 
experiments  before  he  undertook  the  examination  o 
vial  submitted  to  him,  and  certainlj  before  he  published 
his  report. 

This  question,  which  in  Burope  funis  now  no  further  at- 


tention, having  come  up  in  America,  it  would  certainly  be 
interesting  if  Dr.  Jones  would  repeat  his  experiments, 
and,  if  from  the  same  sample  some  well  known  bacteri- 
ologist, as  for  instance  Professor  Sternberg,  or  Ernst, 
could  be  induced  to  make  control  experiments,  for  such 
matters  require  to  be  definitely  settled  in  the  interest  of 
science  as  well  as  that  of  the  profession  and  patients. 

It  is  certainly  not  intended  that  living  tubercle  bacilli 
should  be  contained  in  the  tuberculin,  and  contrary  to 
Dr.  Jones'  conclusions  its  action  does  not  depend  upon 
their  presence,  and  this  Dr.  Jones  must  also  have  known 
when  he  made  his  report.  To  me  his  concluding  remarks 
are  entirely  unnecessary  or  hardly  in  good  faith  when  he 
refers  to  the  remedy  as  a  secret  medicine,  Dr.  Koch  hav- 
ing given  the  temporary  secret  of  its  source  and  compo- 
sition to  the  world  before  Dr.  Jones  came  into  possession 
of  his  vial.  In  the  meanwhile  those  who  use  the  remedy, 
if  influenced  by  Dr.  Jones'  report,  can  make  assurance 
doubly  sure,  by  subjecting  every  solution  for  clinical  use 
to  prolonged  boiling,  which  in  no  wise  interferes  with  its 
action,  and  which  I,  and  as  far  as  I  know,  others  who 
have  applied  it,  have  always  done. 

The  addition  of  l/2  per  cent,  of  carbolic  acid  can  also  be 
increased  to  any  desired  strength,  as  for  instance,  the  10 
per  cent,  solution  of  tuberculin  which  we  make  from  the 
original  vial  can  contain  5  per  cent.,  or  50  per  cent,  of  car- 
bolic acid  may  be  added  to  the  lymph,  audits  1  percent,  so- 
lution would  then  still  only  contain  l/>  per  cent,  of  car- 
bolic acid  as  originally  intended. 

I  here  also  found  that  tuberculin  solutiou  containing 
as  much  as  1  or  2  per  cent,  of  carbolic  acid  crystals  are 
not  specially  painful  or  objectionable  for  hypodermic 
use.  There  can  be  no  doubt,  that  the  preparation  of  the 
tuberculin  is  in  reliable  hands,  and  that  any  findings 
justifying  even  the  remotest  suspicion  as  to  the  presence 
of  active  tubercle  bacilli  or  other  microorganisms  would 
promptly  lead  to  a  revision  of,  and  increased  pre- 
cautionary measures  in  its  preparation,  for  indeed,  it 
cannot  be  a  matter  of  great  difficulty  to  sterilize  the 
remedy,  and  control  experiments  are  daily  being  made 
in  the  laboratory  of  its  production. 

Respectfully  yours, 

Karl  von  Ruck,  M.D. 

Winyah  Sanitarium,  Asheville,  N.  C,  June  3,  1891. 


Vote  of  the  Missouri  .State  Medical  Associa- 
tion upon  tlie  "Tliree  Years  Course." 

To  the  Editor: — As  a  part  of  the  medical  history   of 
the  West,  the  attitude  of  Missouri  towards  the  great  ques- 
tion of  educational  reform    now  agitated   all   over   the 
country,  must  attract  general  interest.     In   The  Jour- 
nal, April  11,  1S91,  an  account  was  given  of  the  history 
ol   thi     1'hree  Years'  obligatory  Medical  Course  Bill  in 
the  Missouri  Legislature:     Indorsed  in    a  memorial  by 
ictors  from  all  over  the  State,  and  by  a  large  ma- 
jority of  the  fourteen   medical  colleges   chartered  by  the 
Bill  was  unanimously  recommended  for  passage 
"iimittees  of  both  House  and  Senate.   The  House 
passed  the  Bill  by  a  vote  of  S5  to  22;  it  came  before  the 


l8yl.] 


FOREIGN  CORRESl'i  >NDENCE. 


923 


Senate  during  the  last  hours  of  the  session,  and 

feateil  by  a  vote  of  5  majority — a  number  of  the  Senators 

me  home,  including  friends  of  I 
A  more  flagrant  violation  of  the  principles  of'!' 
nee   of  the  will  ol 

I.     At  the  am  the  Mis- 

souri St  a.  ion,  the  following  r 

was  introdui 

That  th  on    urge   upon  the  E 

Health  that  it  define  the  statutory  phrase  "college  in 

lue  of  diplom 

mts  for  license  to  practice  medicine),  to  apply 

only  to  such  coll  .aire  attendance  upon  three 

annual    courses   of  lectures   and   clinics,   of  six   months 

opj  of  this   resolution   be  sent  to  the 

Governor  of  the  State,  and  to  the  State  board  of  Health. 

This  emphatic  resolution  was  adopted  by  a  vote  almost 
unanimous,  after  all  had  time  to  take  part  in  th< 
sion.  Thus  the  representatives  of  the  profession  in  Mis- 
souri have  placed  the  State  absolutely  on  record  as  de- 
sirous of  the  reform,  and  at  the  same  time,  they  have 
put  the  stamp  of  their  condemnation  upon  those  who, 
through  political  juggling,  have  for  the  moment  defrauded 
the  State  of  nei  '  I  ayed  the  cause 

of  science  and  of  the  people. 

As  proof  of  the  complete  unanimity  of  opinion  in  the 
State  upon  this  subject,  the  homoeopaths,  in  convention 
at  Kansas  City,  April  22,  passed  a  resolution  identical  in 
spirit  with  the  one  above  given.  The  following  is  taken 
from  the  organ  of  the  eclectics,  the  American  Medical 
Journal,  St.  Louis,  April,  1S91: 

"  In  the  senate  it  (the  Three  Years  bill  I  was  defeated. 
This  strange  procedure  may  be  understood  in  this  way: 
If  the  Bill  had  passed  the  Senile,  the  Governor  would 
have  to  sign  or  veto  it.  To  veto  would  have  incurred  the 
displeasure  of  the  great  majority  of  physicians  through- 
out the  State,  as  well  as  that  of  the  Senate.  It  would 
not  have  been  the  policy  under  the  existing  crisis.  To 
sign  the  Bill  would  have  offended  some  special  friends." 

That  the  influence  of  politics  upon  science  is  notori- 
ously harmful,  the  events  briefly  summed  up  in  this  com- 
munication afford  one    more    glaring    illustrai 
spectfully.  Charlks  A.  Top:>.  M.D. 

Chairman  Com.  Scientific  Communications,  Missouri 
State  Medical  Association. 

St.  Louis,  June  6,  1891. 


FOREIGN    CORRESPONDENCE. 


LETTER  FROM  LONDON. 

■'i    OtJR   OWN   CORRESPONDENT.) 

In  several  instances  of  late  pneumonia  has  been  most 
successfulh-  treated  by  large  doses  of  digitalis.  By  some 
medical  men  the  expectant  method  of  treating  pneumo- 
nia is  thought  to  be  not  only  irrational,  but  even  dan- 
gerous, and  that  the  assumption  that  there  is  a  definite 
cycle  of  progress  in  pneumonia  is  not  warranted,  and 
from  experience  obtained  at  the  leading  London  hospi- 
tals, the  disease  may  be  jugulated  or  cut  short  by  an  en- 
ergetic, rational  mode  of  treatment,  especially  if  the 
method  is  inaugurated  at  the  onset  of  the  disease,  and 


the  claim   is  supported  that  the  treatment 
of  pneumonia  with  '  bet- 

tits  than  those   obtainable  by  any  other   mode  of 
ire. 

iwn  attention  to  some  useful  precau- 
the  extraction  of  broken  need'  that 

it  is  most  unpleasant,  after  cutting  and  probing  with  the 
1  to  tell   a  patient  that 
further  attempts   are   useless,  and  that  the   fragment  is 
still  th  '  m  he  adopts  is  very  simple,  pail 

and  reliable.  In  the  first  example  which  he  gives,  the 
■  a  young  lady,  had  been  unable  to  rest  her  left 
be  floor  in  walking  for  some  weeks,  as 
broken  a  needle  into  her  left  heel,  and  the  slightest  touch 
;t  pain.  The  point  of  entrance  was  visible  in 
the  middle  line,  over  the  os  calcis.  The  end  of  the 
>uld  be  recognized  through  the  skin,  but  the 
slightest  pressure  caused  it  to  recede.  Dr.  Steele  applied 
two  thick  felt  corn  plasters,  one  on  the  other,  with  the 
puncture  occupying  the  central  hole,  and  orb 
patient  to  walk  freely  am!  bear  well  upon  the  heel.  This 
site  did  with  perfect  ease,  and  after  ten  days  the  needle 
presented  and.  was  easily  withdrawn.  Dr.  Steele  points 
out  that  the  ball  of  the  thumb  and  the  wrist  are  not  un- 
frequently  punctured,  and  if  the  fragment  enters  oblique- 
ly, and  lies  close  to  arteries  or  lierves,  and  cannot  be 
forced  into  prominence,  attempts  at  extraction  are  unde- 
sirable, whereas  by  adopting  this  simple  method,  and 
producing  pressure  with  an  elastic  ligature  or  light  steel 
spring  like  a  small  truss,  the  fragment  will  work  out,  and 
not  give  pain  from  any  knocks  while  under  the  skin. 

Sir  Arthur  Mitchell  and  Dr.  Buchan  have  discussed  the 
influenza  epidemic  of  the  first  three  months. of  last  year 
in  a  paper  on  "  Influenza  and  Weather  of  London,''  pub- 
lished in  the  latest  issue  of  the  journal  of  the  Scottish 
Meteorological  Society.  In  the  forty-five  years  from  1S45 
down  to  the  end  of  March,  1S90,  the  total  number  of 
deaths  attributed  to  influenza  registered  in  London  was 
4.690,  an  average  of  104.2  per  annum.  It  will  surprise 
manv  that,  strange  as  the  epidemic  was  thought  to  be 
during  its  advance  from  the  East  towards  the  close  of 
1SS9,  deaths  from  this  particular  malady  have  been  regis- 
tered in  London  every  year  from  1S45.  There  were  in 
all   five   epidemic   outbursts,    viz.:    December, 

[8,  1,631  deaths;  March  to  May,  1 
January  to  March,  1855,  130  deaths;  November.  1S57.  to 
January,  1S5S,  123  deaths;  and  January  to  March,  1S90, 
545  deaths.  These  visitations,  therefore,  cost  2/ 
leaving  2,003  to  be  distributed  over  the  non-epidemic 
forty  years.  Latterly  there  was  a  great  diminution  of 
the  yearly  totals,  the  six  years  to  the  close  of  1SS9  having 
only  twenty-five  deaths  between  them.  The  distribution 
of  the  deaths  over  the  fifty-two  weeks  of  the  year  shows 
that  the  numbers  registered  in  the  three  months,  Decem- 
ber to  l-'ebruary,  were  enormously  in  excess  of  those  reg- 
istered from  May  to  September,  so  that  there  was  a 
stronglv-marked  winter  maximum,  and  a  summer  mini- 
mum. A  secondary  maximum  was  also  shown  towards 
the  end  of  March  and  beginning  of  April.  The  authors 
enter  into  details  connected  with  the  five  epidemics,  and 
decide  that,  although   the   visits  occur  generally  in  the 


924 


BOOK  REVIEWS. 


[June  27, 


winter  months,  they  are  not  related  to  very  cold  weather, 
but  to  periods  of  high  temperature  which  manifests  itself 
both  before  and  during  the  visitation.  Information  has 
also  been  collected  bearing  upon  eighteen  other  influenza 
epidemics  between  the  years  1510  to  1637,  but  as  to  most 
of  them,  owing  to  the  imperfect  nature  of  the  records, 
there  was  little  if  any  real  value  that  could  be  ascertained. 
They  were  made  up  of  winter,  spring  and  summer  epi- 
demics, the  weather  being  of  a  very  varied  description; 
the  1762  visitation  being  accompanied  by  unseasonable 
and  intolerable  warmth,  and  the  summer  epidemic  of 
1767  being  preceded  by  uncommonly  cold  weather.  So 
far  as  can  be  gathered  from  the  records  from  165S  to  1S90, 
the  complications  and  sequels  which  result  from  winter 
attacks  appear  to  be  chiefly  diseases  cf  the  respiratory 
organs  and  circulatory  systems,  the  nerve  centres  having 
a  tendency  to  be  more  affected  by  the  spring  than  by  the 
winter  epidemics,  while  summer  influenza  induces  a  prev- 
alence of  diarrhoea,  coiucidently  and  subsequently.  The 
epidemic  of  1S31  was  the  only  summer  one  of  the  present 
century. 

A  German  medical  man  has  noticed,  in  a  great  number 
of  cases,  that  tuberculous  granulations  completely  disap- 
pear if  the  wounds  be  thoroughly  covered  with  fat.  This 
has  led  him  to  the  thought  that  in  man}-  infectious  dis- 
eases, the  mechanism  of  the  taking  up  of  microbes  by 
the  white  blood  corpuscles  or  leucocytes  sufficed  to  ex- 
plain the  curative  influence  of  various  agents.  Restora- 
tion of  cells  and  avoidance  of  injury  to  the  tissue  is  es- 
pecially to  be  regarded,  he  says.  If  uow  the  leucocytes 
can  be  increased  in  the  tissue  itself,  without  the  latter 
being  affected,  certainly  the  diseased  condition  will  be 
altered  for  the  better.  The  remedy  must  be  taken  up  by 
the  leucocytes  in  the  same  manner  as  bacteria  are  taken 
up.  As  regards  fat,  this  process  is  thought  to  be  best  ob- 
tained by  the  free  use  of  olive  oil. 

A  special  Indian  Committee  has  been  formed  in  con- 
nection with  the  International  Congress  of  Hygiene,  to 
be  held  in  London,  under  the  presidency  of  the  Prince 
of  Wales.  Sir  Douglas  Galtou  is  chairman  of  the  organ- 
izing committee.  Dr.  Clave  Shaw  has  contributed  a 
highly  interesting  memoir  to  the  new  volume  of  the  St. 
Bartholomews'  Hospital  Reports  under  the  title  "Fract- 
ured Ribs  in  the  Insane."  In  his  eudeavor  to  throw 
some  light  on  the  pathology  of  broken  ribs  in  the  in- 
sane, he  has  made  experiments  as  to  the  weight  required 
to  cause  fracture  of  the  rib.  He  has  come  to  the  con- 
clusion that  a  considerable  difference  exists  not  only  in 
the  weight  of  the  ribs  on  the  two  sides  of  the  bod}-,  but 
also  in  the  average  breaking  weight.  He  has  frequently 
found  that  a  tight  rib  will  bear  the  heavier  weight,  and 
also  that  there  is  no  proportion  between  the 'weight  of 
the  rib  and  the  number  of  pounds  that  it  is  capable  of 
sustaining,  therefore  it  is  probable  that  physical  condi- 
tions of  structure  have  more  to  do  with  the  strain-resist- 
ing power  than  chemical  change.  Dr.  Shaw  has  also 
noted  that  patients  suffering  from  advanced  phthisis, 
frequently  have  ribs  that  support  a  strain  much  above 
the  average,  whilst  persons  suffering  from  disease  of  the 
heart  or  blood-vessels  invariably  bear  less  strain  than 
others.     When  a  fracture   is  caused   by  a  blow,  it  is  de- 


pendent not  so  much  on  the  weight  of  the  rib  and  its 
power  of  bearing  strain  as  upon  other  conditions.  Dr. 
Shaw  does  not  agree  with  the  idea  that  the  ribs  of  the 
insane  are  generally  more  brittle  than  those  of  the  sane. 
Where  extreme  brittleness  does  exist  it  is  almost  con- 
fined to  those  affected  with  degeneration  of  the  circula- 
tory system. 

Mr.  George  Holt  has  sent  the  council  of  University 
College,  Liverpool,  ^,'10,000  for  the  endowment  of  a  chair 
of  physiology.  It  has  been  decided  to  request  Mr.  Holt 
to  permit  his  name  to  be  permanently  attached  to  the 
professorship.  The  present  holder  of  the  chair  has  sent 
a  letter  resigning  the  position  in  consequence  of  increas- 
ing work  of  other  kinds. 

Dr.  Alexander  Fraser's  new  "Guide  to  Operation  of 
the  Brain,"  contains  photographs  of  the  human  brain 
which  have  been  made  upon  the  following  plan:  After 
suitable  hardening  and  preparation  the  head  was  photo- 
graphed, and  then  dissected  layer  by  layer,  each  layer 
being  photographed  in  its  turn.  Further,  the  art  of 
composite  photography  has  been  utilized,  so  that  one  is 
enabled  to  gaze  through  the  shadow  of  the  superficial 
structures  upon  those  which  are  deeper.  Thus  at  a 
glance  the  clearest  notion  of  the  position  of  the  con- 
volution of  the  island  of  Reil,  of  the  cornua  of  the 
lateral  ventricles  of  the  corpus  stratum,  can  be  obtained, 
each  in  their  respective  relation  to  the  surface. 

G.  o.  M. 


BOOK  REVIEWS. 


Practical  Points  in  the  Management  of 
the  Diseases  of  Children.  By  I.  N.  Love, 
M.D.  The  Physician's  Leisure  Hour  Series. 
Detroit :  Geo.  S.  Davis. 

The  author  states  the  raison  d'etre  of  this  little 
volume  is  to  group  together  a  number  of  practical 
points  pertaining  to  various  disturbances  of  child- 
hood which  have  come  under  the  direct  observa- 
tion of  the  writer.  It  is  not  advanced  with  the 
idea  of  completeness,  nor  to  take  the  place  of  the 
various  larger  works ;  it  is  rather  to  supplement 
them,  as  it  contains  many  excellent  and  practical 
suggestions  that  will  be  looked  for  in  vain  in 
more  ambitious  treatises.  The  work  bears  abun- 
dant evidence  that  it  was  written  by  one  enthusi- 
astic in  his  subject,  and  almost  wholly  from  the 
standpoint  of  personal  observation.  Whatever 
has  been  gleaned  from  other  writers  has  been 
sublimed  in  the  crucible  of  experience,  and  re- 
ceived the  stamp  of  the  writer's  originality  and 
and  experience. 

In  a  book  bristling  with  good  points,  it  would 
be  perhaps  invidious  to  single  out  some  for  spe- 
cial  mention,  but  we  cannot  let  the  occasion  pass 
without  referring  to  the  close  of  the  chapter  on 
artificial  feeding,  in  which  the  writer  says:  "  We 
must  always  bear  in  mind  that  every  baby,  like 


i89r.] 


BOOK  REVIEWS. 


925 


every  other  individual,  is  a  law  unto  itself,  and 
there  can  be  no  stereotyped  rule  for  the  artificial 
feeding  of  infants."  Again,  under  the  general 
chapter,  we  find  the  following:  "We  should 
make  it  the  object  of  our  lives  to  teach  the  pa- 
rents of  the  children  under  our  care  that  an  in- 
definite amount  of  prevention  is  better  than  an 
indefinite  amount  of  cure.  Every  day's  sickness 
checks  the  proper  development  of  the  child,  aid- 
ing in  the-  direction  of  a  delicate  organization 
rather  than  a  strong  one." 

The  work  is  excellently  arranged,  easy  of  ref- 
erence, and  has  a  good  index. 

De  la.  Tuberculose  Mammaire.  Par  le  Dr. 
Adrien  W.  Roux.  Geneve:  Henri  Stapel- 
mohr. 

This  small  monograph  on  tuberculosis  mammae 
is  an  example  of  useful  compilation.  While  it 
adds  nothing  especially  new,  yet  it  arranges  and 
classifies  our  knowledge  of  a  particular  subject 
in  such  manner  that  it  is  readily  accessible. 

The  work  is  divide  into  two  portions.  The 
first  deals  with  the  history,  etiology,  pathological 
anatomy,  symptomatology,  diagnosis,  prognosis 
and  treatment  of  the  affection.  The  secoi 
consists  of  an  abstract  of  thirty- one  previously 
published  cases,  to  which  the  writer  has  added 
three  observed  by  himself.  The  work  is  illus- 
trated by  three  excellent  plates,  one  of  which  is 
colored. 

The  International  Medical  Annual  and 
Practitioner's  Index;  A  Work  of  Refer- 
ence for  Medical  Practitioners.  Ninth 
year.      1S91.     Forty  eminent  contributors. 

The  present  volume,  from  the  well  known 
house  of  E.  B.  Treat,  New  York,  5  Cooper 
Union,  and  Chicago,  199  Clark  street,  fully  main- 
tains the  hitherto  well  earned  reputation  of  this 
series  of  annuals.  The  present  work  contains 
about  600  pages  octavo,  and  is  afforded  at  the  re- 
markably low  price  of  $2.75. 

Part  first  contains  a  review  of  the  therapeutic 
progress  for  the  year  1890,  by  Percy  Wild,  M.D. 
Antipyretics,  hypnotics  and  analgesics  are  well 
considered,  the  first  fifty  pages  of  the  work  be- 
ing devoted  to  the  discussion  of  new  remedies. 

The  body  of  the  work  is  given  to  the  consid- 
eration of  diseases,  the  subjects  being  arranged, 
alphaberically,  and  the  recent  and  most  accepted 
methods  of  treatment  are  briefly  given. 

This  feature  of  the  work  renders  it  especially 
valuable  to  the  busy  practitioner  as  a  book  of 
ready  reference,  and  at  a  small  cost  adding  much 
valuable  information  on  a  great  variety  of  sub- 
jects for  the  use  of  those  whose  means  and  libra- 
ries are  as  yet  limited. 

Among  the  subjects  which  are  considered  as 
monographs,  and  which  will  repa\r  perusal,  are 
"The   Motor  Centres  of  the   Brain,"  by  W.  H. 


Elam  :  "The  Diagnosis  of  Functional  and  Or- 
ganic 1  >iseases  of  the  Heart,"  by  I>rs.  Learning 
and  Jpckson,  of  New  York:  "The  Sputa  as  a 
Means  of  Diagnosis,"  by  Dr.  F.  J.  Wetherd; 
"The  Hand  as  a  Diagnostic  Feature  in  Diseases 
of  the  Nervous  System,"  etc. 

Chapters  upon  Sanitary  Science,  Climatology 
and  Hygiene,  Alcoholic  Inebriety.  Pharmacy 
and  New  Inventions  conclude  the  work.  As  a 
risumi  of  medical  progress  for  the  year  it  will  be 
found  valuable,  and  will  many  times  repay  its 
cost. 

[Materia  Medica  and  Therapeutics.  By 
John  Y.  Shoemaker.  A.M.,  M.D.,  Professor 
of  Materia  Medica,  Pharmacology,  Therapeu- 
tics and  Clinical  Medicine,  and  Clinical  Profes- 
sor of  Diseases  of  the  Skin  in  the  Medico-Chir- 
urgical  College  of  Philadelphia;  etc.  Volume 
II.  Phila.  and  London:  F.  A.  Davis.  1891. 
Price,  S3- 50. 

This  is  the  second  and  final  volume  of  a  work 
which  has  engaged  the  attention  of  the  author 
for  some  time.  We  have  noted  quite  every  page 
of  the  volume,  and  feel  pleased  and  benefited  for 
so  doing.  As  in  the  first  edition  of  all  other  ef- 
forts, so  here  there  is  a  demand  for  the  critic's 
pen.  And  yet  there  is  not,  we  confess,  that 
i  shortcoming  we  had  rather  prepared  ourselves 
for.  Rapid  authorship  does  not  usually  conduce 
to  thoroughness,  and  that  weighing  of  evidence 
which  a  medical  text-book  should  have;  and  for 
this  reason,  if  no  other,  we  were  inclined  to  be 
l  unsparing  in  search  and  statement. 

To  the  writer — who  has  turned  almost  daily  to 
J  Baitholow's  Materia  Medica — the  most  serious 
fault  in  the  make-up  of  Dr.  Shoemaker's  work,  is 
the  absence  of  an  index  of  diseases. 

The  amount  of  space  given  to  prescriptions, 
and  to  a  description — however  brief — of  many 
!  drugs  which  were  long  since  obsolete,  cannot 
have  our  commendation.  To  the  early  student, 
however,  we  can  see  where  both  of  these  points 
may  be  of  value. 

The  alphabetical  arrangement  of  drugs  we 
like.  The  clear  description  of  the  recent  rem- 
edies makes  it  at  once  quite  indispensable  to  the 
wide-awake  and  progressive  physician. 

Sexual  Neurasthenia.  By  George  M.  Beard, 
A.M..  M.D.,  formerly  Lecturer  on  Nervous  Dis- 
eases in  the  Universitv  of  the  City  of  New  York, 
etc.  Edited  by  A.  D.' Rockwell,  A.M..  M.D., 
Professor  of  Electro-Therapeutics  in  the  New 
York  Post- Graduate  Medical  School  and  Hos- 
pital, etc.  Third  edition.  New  York :  E.  B. 
Treat.    1S91.     Price,  $2.75. 

The  third  edition  of  a  work  which  has  become 
standard  in  its  line.  The  subject  is  one  of  much 
importance,  though  one  of  difficulty  and  delicacy. 
Notwithstanding  this,  however — the  difficulty  and 


926 


MISCELLANY. 


[June  27,  1891. 


delicacy— Drs.  Beard  and  Rockwell  have  given 
the  profession  a  work  to  which  it  may  refer  with 
a  confidence  of  the  latest  and  most  scientific  light 
upon  a  topic  which  quackery  has  forced  into  un- 
due public  prominence. 

Medical  Symbolism.     By  Thomas  S.  Sozin- 
Sky,  M.D.,  Ph.D.,  Author  of  "The  Culture  of 
Beauty,"  etc.     Illustrated.     Philadelphia  and 
London.  F.A.Davis.    1891.     Price,  $1. 
For  the  student  in  this  line— for  he  who  has 
time  for  the  less  practical  side  of  medicine— in- 
terest and  profit  will  follow  the  perusal  of  the 
pages  of  this  little  volume.     Without  attempting 
to  advise  the  hurried  man  of  to-day,  yet  we  may 
say  that  to  the  average  mind  a  healthfulness  of 
thought  obtains  from  comparisons,  even  remote 
though  they  be ;  and  a  comparison  between  the 
old— the  very  old— and  the  new— between  my- 
thology and  fact— in  the  realms  of  medicine  'is 
afforded  in  the  study  before  us. 


MISCELLANY. 


The  Phii.adei.phia  Polyclinic  and  College  for 
Graduates  in  Medicine  continues  to  reach  out  fo?  addi- 
tional facilities  in  the  way  of  study  and  research  for  its 
large  class  of  students.  It  has  just  elected  five  new  lec- 
turers. Dr.  H.  R.  Wharton,  who  is  Surgeon  to  the 
Children  s  HospUal  and  to  the  Presbyterian  Hospital 
has  been  elected  Lecturer  on  Surgical  Diseases  of  Chil- 
dren, a  part  of  his  course  being  Tracheotomy  and  Intu- 
bation. 

Dr.  C  P.  Noble,  surgeon  in  charge  of  the  Kensington 
Hospital  for  Women,  has  been  elected  Lecturer  on  Gyne- 
cology. 

Dr.  James  K.  Young,  surgeon  to  the  Orthopcedic  De- 
partment of  the  University  Hospital,  has  been  elected 
Lecturer  on  Orthopcedic  Surgery. 

Dr.  G.  Betton  Massey,  one  of  the  physicians  to  the 
Howard  Hospital,  has  been  elected  Lecturer  on  Gyneco- 
logical Electro-Therapeutics,  and  Dr.  Lewis  H.  Adler 
Lecturer  on  Diseases  of  the  Rectum 

Through  the  recent  election  of  Professor  J.  M.  Baldy 
the  valuable  special  field  of  the  Gynecean  Hospital  has 
been  made  available  to  physician  pupils  who  attend 
The  I  olyehmc."  The  addition  of  the  above  lecturers 
as  an  auxiliary  to  the  twenty  members  of  the  faculty  will 
make  the  entire  course  of  instruction  cover  i  ,o  hours 
every  week  from  which  may  be  selected  the  portion  de- 
sired by  each  physician  pupil. 


Guard  will  be  held  in  Milwaukee,  June  20  1891  The 
proposed  meeting  of  the  Surgeons  of  the  National  Guard 
oi  the  United  States,  which  was  to  have  been  held  in 
Chicago  next  July,  has  been  postponed  until  September 
iSor.  At  that  time  every  effort  will  be  made  to  organise 
an  Association  of  Military  Surgeons  of  the  National 
Guard. 

About  four  hundred  throughout  the  United  States  have 
more  than  expressed  a  willingness  to  attend  Judging 
from  the  correspondence  so  far,  the  future  of  the  Associ- 
ation will  be  very  bright,  and  promises  to  be  of  much 
profit  and  interest  to  every  one. 

At  its  first  meeting  papers  will  be  read  by  Surgeon 
General  Bryant,  New  York  National  Guard;  Surgeon 
General  Yaudell,  Kentucky  National  Guard;  Surgeon 
General  Senn,  Wisconsin  National  Guard;  Surgeon  Gen- 
eral of  Illinois  National  Guard. 

The  Association  will  be  entertained  in  Chicago  by  the 
local  Guard.     (Signed) 

Surg.  Gen.  Senn,  W.  N.  G, 

Pres.  Ass'n.  Mil.  Surg.,  W.  N.  G 
Asst.  Surg.  Rush  Chandler,  W.  N.  G, 

.    Sec'y  Ass'n.  Mil.  Surg.,  W.  N.G. 

135  Grand  Ave.,  Milwaukee,  Wis. 


W  hereas,    Dr.    Chas.    G.    Bacon,  of  Fulton,   N.   Y 
aged  76  years,  and   whose  connection  with  the  Oswego 
County  Medical  Society  the  records  show  to  have  been 
since  the  year  1841  ;  and 

Whereas,  the  proceedings  of  this  Society  show  his 
continued  presence  and  participation  each 'and  every 
year  for  the  past  fifty  years  without  a  break  or  excuse'; 

Whereas,  He  has  occupied  everv  office  in  the  ojft  of 
this  Society,  for  most  of  the  time"  being  its  financial 
banker  and  treasurer  ;  therefore,  be  it, 

Resolved,  That  we  round  out  the  semi-centennial  of 
Dr.  C.  G.  Bacon,  and  declare  him  most  cordially  and 
unanimously  elected  our  Presiding  officer  for  the  ensu- 
ing year ;  and 

Resolved,  That  the  Secretary  be  authorized  to  send  a 
copy  of  the  above  to  the  Medieal  Record,  and  The  Jour- 
nal of  the  American  Medical  Association  as  a 
direct  challenge  to  any  County  or  State  Society  to  beat 
this  record. 


1  1  1  Mississippi  Valley  Medical  Association  will 
hold  its  seventeenth  annual  session  at  St.  Louis  Wed- 
nesday Thursday  and  Friday,  October  14,  1  sarnie  [8qi 
d  rates  and  an  excellent  programme  willibrine  out 
a  arge  attendance.  The  medical  profession  1.  respect- 
fully invited  rhe  officers  are  as  follows;  C.  H.Hughes, 
M.D.,  President,  500  v  fefferson    We.,  St.   Louis;  E.  S 

McKee  M.D.,  Secretary.  57  W.  Seventh  St.,  Cincinnati, 
"■;  1.  N.  Love,,  M.D.,  Chanman  Committee  of  Arrange- 
ments, 501  X.  Grand  Ave.,  St.  Louis  Mo. 

:  1 '"'-■  op  Military  Si  rgeons,  Wiscon- 
sin Nationai,  (.1  ard.  The  regular  meeting  ol  the  As 
soctation  of  Military  Surgeons  of  the  Wisconsin  National 


"^"if/h'^f/F'V'Kl  '"//le  Sta!;°"s  ""'"■  "<"">  Of  Officers  Serving 
In  !••  Department,    U.  S.   Army,  from  June  .';,  t8gi,    to 

Ca^,'„  J?lai,?'  T*y}°,r'  Atst-  Su'Se°n.  is  granted  leave  of  absence  for 

i.    onh^Ii^ri.Tu^  ,asb°C,e  Uth  Pr°X-     Par'  3'  S' 

loseph  C  Baity.  Asst.  Medical  Purveyor  is  granted  leave 

or  absence  lor  two  months,  on  surgeon's  certificate  oi  disabilitv 

en  eV1n!""r1""  : "  pt'  '  f  T«:IS-  :"">  authority  to 

f,  ,,L ,,,'!  A;'">'a".'i  Navy  General  Hospital,  Hot  Springs,  Ark., 

ie  aAh  ' "      ;  '  '""'  "f  "'"■'  !»«'>tli-     By  direction  of 

June  ,2  X  y  °        ar-     Par-  I2'  8    u'  '33.  Washington, 

H."*!'  iCr01'  J-\"ies  c-  McKee,  Surgeon,  having  been  found  incapaci- 
•  led  loi  active  service,  on  account  of  disabilitv  incident  to  the  ser- 
vice is  bj  direction  oi  the  President,  retired  from  active  service 
this  date,  under  the  provisions  of  section  1251    R    s      Par  j   s  O 

'37,  A.  G.  O.,  June  [6,  I     a 

0ffi1h!mik/Enlt"ijuiV!0:%fafcatCorps  of""  r-s  ' 

ichedfrom  v.  s.  s.  "  Newark  »  and  grant- 
United States  "'X  months.  witn Permis  iontoli  ,1     tfa, 
!    Bri  rhi   orderedtothe  i     S    S,  "Newark." 

"  M    k    ''"-■  '"■  "">'  '«'  to  the  f.  s.  s.  receiving  ship 

'"v  lit",'!,  ,'t!  ■''    '''  "  '  l!     ,!'  biclicd  IVom  Naval  Hospital,  Chelsea,  and 
reon    J.  M.   Steele,  ordered  to  Naval  Hospital,  Chelsea, 


CORRIGENDA. 

,      ■  second  column,  the  foot- 

ll,"1    l"""1    I  should  I-        ■:    !  i„,„;,i  |„.  .,.      ,„,    . 

^paragraph  7,  lin.    9,  th.    words  windward,  and  lee  w. 

.V'.'i.1 for  John  Erety  Shoemaker,  read 


INDEX  VOLUME  XVI. 


Abdominal  section,  report  of  sis 

I  9«3 

surgery   the   ten  commandments  of  131 
uterine  tumor,  report    I 

1      practical    experience    in    the 

treatment  of  accidental S65 

I  the  lung 335 

i 642 

Abstainers,  health  and  longevity  in  ...    171 
Abstinence,  the  physicial  advantages  of.  391 

Acetanilid  as  an  antiseptic 641 

Acknowledgment 919 

Acne,  resorcin  in 679 

rosacea,  application  for 641 

Acromegaly,  a  case  of 524 

f  the  skin 234 

Addison's  disease,  the  treatment  of,  with 

Koch's  remedy 

Advertising,  doctors  and 275 

African   fevers,  earth-worms  and  .    .    .    .     130 

Alabama,  the  medical  law  of 811 

Albuminuria  in  pregnancy  .  .    200 
the  prevalence  oT    in  persons  appar- 
ently healthy 

the  relation  of,  to  puerperal  eclarnp- 

*in 205 

Alcoholic  entailment,  the  psycho-paetic 

ices  of  hereditary 9 

627 

Alopec;a,  pomade  !   1      631 

Ameden,  Dr.  Archibald  O.,  death  of..  .   .    143 
American  Academy  of  Medicine 20 

American  Dental    Association 562 

Electro-Therapeutic  Society 2S2 

Electro-Therapeutic  Association,  the  313 

Medical  Association 250-500 

Medical  Association,  Plan  of  organi- 
zation—Title of  the  Association— 

members 441 

Meetings— officers 442 

Standing     Committees— Funds     and 
appropriations  —  Provisions     for 

amendment 443 

By-laws— Order  of  business,  Sections  444 
Standing  Committees— The  publica- 
cation  of  papers  and  reports— As- 
sessment! Del  m  the 
medical  staffs  of  the  army,  navy  and 
marine-hospital  service— lie! 
to  foreigu  medical  societies— Duties 
of  members— Condition  excluding 

representation 44^ 

Of  the   previous    question— Judicial 


PAGE. 

Apothecaries,  lady 640 

a  ...  233 

Appendicitis 558 

Appendix  caxi.  the  pathology  and  treat- 
ment of 51S 

Arteriosclerosis,  report  on  the  ophthal- 
mic examination  of  Dr.  Pres- 
ton's cases  of 622 

the  effect  ot  .upon  the  central  nervous 

system 61S 

fissured  nipples 
Arkansas      Industrial      University,    the 

new  building  of  the 

Army  medical  examination 277-322 

Army  U.  S.,  official  list  of  changes  in  the 
stations  and  duties  of  officers  serv- 
ing in  the  medical   departm    1 
the.    - 
324.  360.  396.  : 

612,  648,    684,    720,   756,    792,    S2S,  864, 

900,  924 

Arsenic  and  pemphigus 125 

as  a  domestic  poison,  on  the  charac- 
ter of  the  evidence  as  to  the  injuri- 
ousness  of 778 

Arthritis,  acute  infantile ^7^ 

■■■  1  hoica 448 

Artificial  respiration,  the  influence  of,  on 

the  heart  of  the  newly-born    ....    307 

Association,  Section,  meetings  of  the..  .    309 

the  incorporation  of  the 750 

Asthma 458-493 

euphorbia  pilulifera  for 34 

spasmodic,  the  treatment  of.  .   .   .   .    743 

the  oil-silk  jacket  in 233 

Astragalus,  fracture  of  the.  with  irreduc- 
ible displacement  of  the  fragment  694 

Ataxic  sign,  an  earlv 704 

Athletics^  the  heart 'in 22 

Augusta.  Dr.  Alexander  T.,  death  of.   .    178 


Bacilla  of  anthrax  and  "  blue  pus/'  an- 
tagonism  between 95 

Bacilli  tuberculosis  in  the  sputum.  .   .   .    205 
Bacteria,  action  of  living  blood  o 


the 


344 


PAGE. 

Bichloride  of  mercury,  the  curability  of 

cancerous  tumors  by  injections  of  304 
Bigelow.  Dr.  Henry  J.,  and  the  discovery 

of  anaesthesia      .       

Biliary  calculus,  large,  discharged  thro' 

an  umbilical  fistula  .   .       2-6 

Bishop.  Dr.  S.  S.,  an  automatic  tuning- 

fork  hammer Sqj 

Bladder,  extirpation  of  the  .... 

irritable i20 

irritable,  the  treatment  of. 631 

male,  foreign  body  in  the 

Blepharospasm,  treatment  of  .    . 
Blindness  in  the  United  states  .    , 
B  naphth.  >]                               if  bismuth  as 
a  disinfectant  in  the  internal  treat- 
ment of  typhoid  fever 530 

Bond.  Dr.  Young  H.,  a  knowledge  or  a 
time  requirement,  a  plea  for  a 
more    radical    system    of   medical 

ion  ...'..._ 625 

Dr.   Young   H.,   ectopic    pregnancv, 
with  presentation  of  specimen.  .   .    397 

Bones,  dislocation  of  long ^22 

id  and  massage  in  pannus  .  .    "S2 
Borck,  Dr.   Edward,  report  of  a  case  of 

abdominal  uterine  tumor  .....    014 


Boutelle,  Dr.  Nathaniel  K.,  death  of 
Bovee.  Dr.  J.    Wesley,  spontane 

bilical  hemorrhage  in  newly-born" 


5-- 


:i  fan 


of  anthrax,  of  the  positive  polar  ac- 
tion of  the  constant  galvanic  cur- 
rent on  microbes,  and  more  par- 

ticalarly  on  the 17 

pathogenic,  the  products  of 235 

pruttinsand  their  relation  toinflam- 

mation  and  pus  formation       .    .   .    561 
the  relation  ofT  to  practical  surgery.  5°5 

nances 446    Bacteriological  research  in  India  ....    239 

Medical      Association  ;     preliminary  researches  .   .    .  T 167 

programme    of     the    forty-second  Bacteriology,  cardinal  tests  in     .    . 

annual  meeting 6ofi     Baillarger,  Dr.,  the  late 

physicians  in  Berlin,  association  of..   561     Baker/Dr.  Henry  B.,   sanitation  in  1890,     73 

Amoeba coli  researches  up-  Dr.  Milan,  death  of. 61 

on  the 406     Balfour,  Surgeon-General,  the  death  of.   239 

Amputations,  major,  the  management  of  185    Baltimore,  letter  from S60 

Amylhvdrate 280     Batiga.   Dr.    Henry,   ectopic    pregnancy. 

Amemia.  acute,  the  treatment  of.    ...      07  with  report  of  two  cases  .    .   .    .121,  134 

acute,  the  treatment  of.  by  infusion..  389     Barber-surgeons  of  London,  the.  - 

Aneesthesia,    Dr.    Henrv  J.  Bigelow   and  Barker.  Dr.  Fordyce,  death  of. S99 

the  discovery  of 170    Baruch,    Dr.    Simon,   note  on   the  bath 

of  the  skin,  to' produce 35a  treatment  of  typhoid  fever  369 

Anaesthetic  mixtures  . 45S  Dr.  Simon,  on  the  Koch  lymph  treat- 

tics  modified  bv  altitudes,   the  nient 425 

effects  of     322    Baths,  public,  for  winter  use.  .   .   .  6S 

Anatomv  and  phvsiologv  liberal  studies,  Bazaars,  the  new  fashion  of  naming.      .    391 

are?  ...'....'. S92  :  Bed-sore,  treatment  of. 670 

Aneurism,    thoracic,  on  the  sign  called         \  Beef-tea  as  a  nutrient 26 

"  tracheal  tugging  '  in 4S6    Beer-drinking  extraordinary 279 

Angina  pectoris,  for     641     Belgium,  medical  education  in 171 

Annual  meeting  the  fortv-second.  ...    705    Belladonna,  night    terrors    successfully 

Antifebrin,  treatment  of 'high  tempera-  treated  by 2S0 

ture  m  typhoid  fever— and  phthisis  Bemis.  Dr.  N.  M.,  death  of. 320 

pulmouum    with  small   frequently  Bergmann,  von.  accident  to 312 

repeated  doses  of. 198    Beriberi  in  the  Grand   Banks    fishing 

Antisepsis  a  failure,  when  is 844  fleet 99 

Antisepsis 765     Berlin,  from 4'9 

for  midwives 164  letter  from 104 

Apoplectiform  neuritis 23  the  situation  at 21 


Brain,  a  large  

abscess,  aphasia,  operation  .   . 
disease,  hemianopsia  as  a  diagnostic 

1 

rest.  Sir  James  Crichtou  Brown  on  .    s;o 

surgery  

Brainerd.  Dr.  I.  N.,  some  clinical  experi- 
ences with  eucalyptol 770 

Brayton.  Dr.  Forrest  \V.,  death  of.    .    .    .    42S 
Briggs.  Dr.  Win.  T..  the  President's  ad- 

649 

Bright's  disease,  acute  epidemic    ....      14 

disease,  diet  in 3IO 

British  army,  low  death-rate  in  the 

Medical  Association,  the 920 

Medical  Association,  the  meeting  of 
the  pathological  and  clinical  sec- 
tion of  the s66 

Bromides  in  vomiting  of  pregnancv    .   .    2^4 

Bromiform ^49 

exhibition  of 14 1 

Bromism  and  intestinal  antisepsis.   .   .    -02 

Bronchial  asthma 172 

Bronchitis,  acute 679 

Brower,  Dr.  Daniel,  a  clinical  lecture  on 

insanity 

Brown,  Dr.  Bedford,  practical  experience 
in  the  treatment  of  accidental  abor- 
tion     

Burnett.  Dr.  Swan  X.,  the  physician  as  a 

man  and  a  citizen 14^ 

-muth  treatment  for 244 

the  treatment  of. 133,  319 

Business 7S3 


Callan,  Dr.  Peter  A.,  migraine  and 
functional  headaches  from  eve 
strain " .    , 

Cancer  of  the  uterus,  a  plea  for  early  vag- 
inal hysterectomy  for  ....... 

the  microorganisms  of 

Cancerous  tumors,  the  curability  of.  bv  ' 
injections  of  bichloride  of  mercury 

Cantharidin,  additional  observations  up- 

Cantharidinate  of  potash  iu  tuberculosis 

of  potash  in  tuberculosis 

Carbuncle,  an  ointment  for 

treatment  of     .   .  ... 

Carhart,  Dr.  J.  \V..  digitalis  in  the  first 
and  second  stages  of  pneumonia  . 

Carcinoma  mamma; 

Carpenter.  Dr.  J.  G..  rapid  dilatation  and 
curetting 


;59 


INDEX. 


165 


PAGE 

Casselberrv,  Dr.  W.   E.,  cystoma  of  the 
arytenoid    region    of   the    larynx, 

with  report  of  a  case oi' 

Catarrh,  for  nasal -35 

treated  by  peroxide  of  hydrogen  and 

aristol °3 

Cerebral  cortex,  effect  of  strychnine  on    52 
surgery    .............. 

Cerebrospinal    meningitis,   microbe 

epidemic 3°° 

meningitis,  report  on  an  epidemic  of  901 
Cervical    sympathetic    and     sympathic 

ganglia,  recent  experiments  on  the  519 
Chemical  studies  in   medical  education 
and  in  medical  research,  the  grow- 

ing  importance  of 734 

Chicago  as  a  place  for  doctors 169 

China,  the  fevers  of 386 

Chloramid,  prescription  of 5°3 

Chloroform  administration.death  during  232 

another  death  from 347 

lis,  test  of  complete 553 

the  antiseptic  properties  of 64 

treatment  of  typhoid  fever  with    .   .    343 

versus  ether 5° 

Chlorosis  and  its  treatment 7°2 

Chorea 63r 

fibrillary •   •   233 


of. 


566 


596 


Cholecystotomy,  a  successful 
Cholera  in  Japan   .... 

intelligence 

poison,  the 

nostras 

simple  treatment  lor. 
Chromic  acid  treatment  of  chronic  en- 
largement of  the  tonsils 24: 

Chrysarobvi  in  hemorrhoids 17: 

Church,  Dr.  Archibald,  Morvan's  disease; 

with  the  clinical  report  of  a  case  .    33' 

Circumcision,  painless 271,  60, 

I 11    Augustus  P.,  some  of  the  le- 
sions induced  by  typhoid  fever  .  .    47 
Dr.  Augustus  I'.,  the  influence  of  the 
position  of  the  patient  in   labor  in 
causing  uterine  inertia  and  pelvic 

"      disturbances 433.  459 

Clarke's  (Sir  Andrew)  patent;  a  clinical 

sketch 202 

Clinical  art 029 

Clitoris,  inflammation  of  the 412 

Cocaine  incompatibles 594 

the  action  of,  on  the  circulation..  .   .    710 

Coffee,  its  use  and  abuse  .   ....   .   .   •   .219 

Cohen,    Solomon  Soli,-,   Koch  treatment 

of  tuberculosis 37° 

Cohn    Ferdinand,  and  Robert  Koch.  .   .    170 
Cold  in   the  head,  what  shall  be   done 

for  a 605 

Colic   a  mixture  for  simple 3°7 

Colitis  of  infants,  the  .......      84 

urriculum,  will  a  shortening  of 
the,  conduce  to  better  preparation 
for  the  study  of  medicine.  . 
Colors,  the  sound    of 
Compulsory     revaccii 
ami  pharmaceut 
Connelly.  Dr   J.  P.,  tl 
of'fatty    urine, 
abscess  in  the   r 

covery  

Constipation,  chronic '33 

in  women £20 

infantile ...   818 

Consumptives,  a  Koch  institute  for..  .   .    425 

umptioti,  another  cure  for 281 

1  1   ,  he  Inn-,    the    consideration  and 

i  chronic  tubercular 793 

tin   philosophy  of "...   ■    •   •    4<« 

Convul-i  ,ns,  infantile,  dry  cupping  for..    64 
,1  ulcers  a  simple  treatment  of.....  594 
treatment  of,  by  the  actual 

lUt<   IV ;      • t"0 

Coroner  system    in   the   United   States, 

the.' 29 

the  office  of            ........  ...  276 

Corpus  callosum,  results  of  section  of  the  343 


PAGE. 

Crothers,   Dr.  T.    D.,   American  Medical 

Temperance  Association 816 

Dr.  T.   D.,  the  relation   of  life  insur- 
ance to  inebriety t87 

"  Crowner's  quest  law'' 9°8 

Cuba,  the  medical  congress  of. 7*4 

Curve  of  health,  the 242 

Cystic  goitre, electro-puncture  of  a;disap- 

pearance  of  both  cyst  and  goitre...  390 

Cystitis,  acute 493 

injections  of  pyoktanin  in 199 

DALY,  Dr.  Wm.  H.,  letter  from 79° 

Danger,  a  new  social l3l 

Davis.  Dr.  John,  death  of 178 

Dr.  N.  S.,  the  basis  of  scientific  med- 
icine and  the   proper    methods  of 

investigation JI4 

Dr.  Win.  B.,   the  prevalence  ol  albu- 
minuria   in     persons    apparently 

healthy S29 

Deafness  for  high  notes 131 

Delirium  tremens  mixture 244 

Dental  caries 641 

Depopulation  from  disease 524 

Dewees,  Dr.  Wm    B.,  relation  ol   gyne- 
cology to  neurology S47 

Diabetes 6S2 

sulphonal  in l72 

Diabetic  coma,  treatment  of 125 

Diagnosis,  disputed 239 

Diarrhcea,  infantile 

Dietetic  management  of  children,  points 


Empyema 47° 

Endocarditis  during  measles 674 

Endometritis,  chronic 643 


Digestion,  on 


Em: 


,  for 


nal.tr 


ted  bv  posture  .  .   .   .    ; 
Epidemic  influenza,  an  analysis  of  the 
statistics  of  41, 500  cases  of     .... 

Epileptic  mixture : 

Epistaxis 

simple  method  for  controlling  .   .    .    ; 
Equino-varus  (double!,  congenital    .   .    .    1 

Erysipelas : ' 

and  eczema,  creoliu  in 

treatment  of ■   ■  ;    '. 

treatment  of,  with  glycerole  of  sali- 
cylate of  sodium  ' 

Ether  drinking  in  Ireland 39'.  ' 

the  consumption  of,  bv  the  Irish      .    ■ 
Etheridge,  Dr.  J.  H  ,  medico-legal  rela- 
tions of  laparotomies  ........ 

Ethics  of  experimentation  upon  living 


uals,  the 


Eucalyptol,   some    clinical    experiences 

with 770 

Euphorbia  pilulifera  for  asthma    ....      34 

Evacuation  of  a  psoas  or  lumbar  abscess 
through  the  vagina,  a  case  of  sup- 
posed      - 

Exalgme,  poisoning  bv P. 

Extirpation  of  the  pancreas,  the  effects 


of. 


•  I 


ation  of  medical 
cal  students  .  . 
e  report  of  a  case 
accompanying  au 
q-ht  iliac  fossa, 


814 


199 
. id  medication  in  disor- 
ders of 

the  influence  of  exercise  on  . 
Dilataticn  and  curretting,  rapid 
Diphtheria  at  Halifax,  N.  S  .    . 

the  causation  of, 

treatment  of 594  823 

Diphtheretic  membrane,  solvent  for  .   .    172 
Disease,  the    chemical    factors    in    the 

causation  of 6l3 

Disinfectant,  a  new 124 

Disinfection  of  the  hands 26 

present  aspects  of 9J7 

Distinguishing  mark,  a 4'S 

Diuretic,  a   new '33 

Doctors  and  adveilising 275 

and  politics.   .   . j     r56 

Dowling,  D 
myopi 
Drainage,  i_  ... 

we  use;  and  the  present  position  of 

antiseptic  surgery      229,  245 

Drake,  Dr.  I.  W.     death   of 827 

Dropsv  of  the  belly,   enormous 173 

Dunglison,  Dr.  Richard  J.,  report  of  laws 

regulating  medical  practice 109 

Durall,  Dr.  Mafius,  death  of. 428 

Dwight,  Dr.  Henry  E-.  the  influence  of 
German  Universities  upon  our  pro- 
fession   43s 

Dysentery,  the  form  of,  produced  by  the 

amoeba  coli S24 

Dysmenorrhea    and    pelvic    inflamma- 
tions, electricity  as  a 
agent  in  the  treatn 
Dyspepsia,  a   powder  fa 


.  Francis,  the  prevention  of 
.  what  class  of  wounds  shall 


1  orson,  Dr.  Hiram  R.,  antiseptics.  . 

I  ortii  al  blindness .  .   . 

,,        ;,  ;     |,i,sciiplion   lor  a.  . 
(  owdry,  i"    St.  ph.  ..■  ...  death  of. 

.  , 1  .hi  in  England,  progri  ss  of . 

Liverpool 


765 


Extra-uterine  pregnane} — exhibition  of 

specimens 

retro-peritoneal    pregnancy    in    the 
eighth  month,  a  case  of .   .  .   . 

Eye    strain,    migraine     and    functional 

headaches  from 435 

Eyes  during  school  life,   what  can    be 

done  to  save  the 2S 

Eyraud,  post  guillotine  phenomena  ob- 
served in  the  body  of 355 


Facta  nou  verba i 

Faith  cure  in  Africa 

Fasting,  forty-five  days  of. 

Fayerweather  will  to  hospitals,  the  be- 
quests under  the    .   .   . * 

Fell,  Dr.  Geo.  E..  forced  respiration  .    .    ; 

Femur,  a  compound,  comminuted  com- 
plicated fracture  of  the  distal  ex- 
tremity of 

Feuger,  Dr.  Christian,  the  operative 
treatment  of  extra-uterine  preg- 
nancy at  or  near  term,  with  report 


Eari-EY,  Dr.  C.  R  .  medical  progress  .    .    ; 
Ectopic  pregnancy;  with  presentation  of 

specimen : 

pregnancy,  with  report  of  two  cases 


itable  condition  of  the 


ski 


oi  dentition,  solution  for  the 172 

of  infants,  bismuth  for    .... 

Editor   and  business  manager,  vote  of 
thanks  to  the 719 

Editorial   management   of  "The  Jour- 


nal' 


-05 


',    gastroenteritis 493 

In  erysipelas  and  eczema  ....        .     T- 
Criminals,  anomalies  of  brain  and  skull 


s  of  the  medical  press,  502, 

539j  573 
Edmunds  bill,  a  French  rejoinder  to  the  281 

1    i,  idiosyncrasy  towards 827 

Egypt,  Dr.  Koch  in 489 

Ehrlich's  test  in  typhoid  fever 856 

Electrii    light,  the      241 

light  and  human  ailments,  thi 
Electricity  as  b  th.    ip.  <•■<  ■■  ageul    what 

is  needed  to  determine  .is  merits?  832 
contractions  of  the  uterus  induced  by     15 
Embryonal  cloaca,  persistence  of  the,  in 

n  adult  woman 15 

Emmenag  igue,  an 6S2 


Fernwald,  Dr.  Karl  Braun  von,  death  of  82S 
Fever,   intermittent,  the  relation  of  at- 
mospheric conditions  to B48 

Fibroid  tumors  in  the  womb,  on  the 
treatment  of,  by  injections  of  er- 
got into  the  substance 915 

Filaria  sanguinis  hominis,  the  lesson  of 

the. 345 

Fire-arms,  loss  of  life  by '15 

Fistula;,  vesico-vaginal 3'6 

Flat-foot,  aggravated 423 

Foetus  papvraceus 140 

Fo"  the  effects  of,  on  Manchester  atmos- 
phere     744 

Food-products,  profits  in 595 

Foot,  a  case  of  crushed 4^5 

the  abuse  of  the 451 

Forced  respiration 

respiration,  two  interesting  cases  of  S05 
Fortign  diplomas,  the  barring  out  of,  by 

the  Illinois  State  Board  of  Health  386 

Fractures,  ununited 163 

Fox,  Dr.  Sidney  Allen,  death  of.    ...    .    734 

Fragilitas  ossium •   .  .    203 

France,  the  population  question  111  .   .   .    078 
French,  Dr.  Jas.  M.,  the  colitis  of  infants    S4 
Fry   Dr   Henry  D  ,  prevention  of  puer- 
'      peral  eclampsia  by  the  inducti.  a 

of  premature  labor S75 

Funeral  reform,  dangers  of  Decoration 

day 346 

Furuucular  affections,  for 352 


Galacton  hcea      53 

Galbraith.  Dr.  w.  J.,  a  remarkable  case.  407 

.  ;all  bladder,  surgi  iy  oi  the 453 

Hailstones,  the  treatment  of . 

...   tri.   juice,  germicide  action  of  the.   . 


rg.  i\    ten  years'  experience  of. 
,  ,     tro-enti  ritis,  acute,  creoliu  in. 
G astro-intestinal  diseases    ol   children, 

salol  in ■ 

Generative   organs,    female,  report   or  a 
malformation  of  the  .... 


INDEX. 


PAGE. 


of  the.       •  .nic  acid  antidotal  to  tubcrcu 

German  universities,  the   influence   of, 

upon  oui  proli  5Si   n  -     Hydrocele     ti 

gov 

phthisis 
Gill,  Dr.  Henry  Salviu,  death  of. 


by     injections     of 
chloral  hydrate      . 

;,Ton 


l.  Dr.  Koch  and  the 

pathology    of 

a  p<  ne  at  the  hairdi 

in  France 

in   Philadelphia 


in  of  the    . 

Bell  in  the  capital  citj 
Gonococcus,  free  cultures  of  the    .... 



an  injection  for  |  .; 


ichthyol  in  the  treatment    . 

in  the  female,  treatment  of i>>2 

Gonorrhoeal  rheumatism, iodide    ('potas- 
sium in 

Gould,    Dr.  Geo.    M..  the  optician' and 

ital 

Granular    conjunctivitis 


i  .  rtrophy  of  one  half  of  the  face    .   .    161 

:  nal 9i\ 

Hynotism 561 

its  former 
practitioners 

;:iinst 22 


ll    W.  W.,  a  case  of  extra-ulcr- 
'ne  n  pregnancy  in 

•  spas-  " 




22 


stbma  . 

Jenner  and    Koch 

:     the    winter 
death  of.  '   3^6 


Journal,  the  61 


short  leg  of  hip 


nptire.  as  a  cause  of  disease.    ...    241 
sublimate  treatm    nl  1 

Grief,  pathology  of 

irthe turpentine.    4S-, 

of preliminary  work ^9 

salus  67. 

Guaiacum  and  hili   u- 1     -  -  Robert  A." 

Gunman,  Dr.  M.,  a  caseofdoubi    vagina 

4,6 

i^- 
the  relation  of  life  insurance 


and  uterus 

Gulick,  Dr.  Luther  Halsej     : 

Gull  studentship  in  pathology,  the  .   .   .    -,91 

Gundry,  Dr.  Rich 

Gynecological  disorders,  voice  in  female 

:  by ,        -:':' 

progress,  the  annual   add:-  tge  in  newly-born 

Gynei  01 

relation  of.  to  neurologv - 


•     I 
statistics 


Kay,  Dr.  Thomas  \\\  a  study  of  sterility 
its  causes  and  treatm 

■      Joshua,  death  of.  .         '  t7X 

my  as  a 
e  for 

f.  ma'le 

nd  his  critics 
Dr.,  and 

204 

cperimental  . 

lymph.    New  York    physicians   and 


the  . 


Hemianopsia,  double  sided    i  c 
Haemophilia  at  the  menstru 
Hasmoptvsis,  a  mixture  i   1 

Haemorrhoids 2S0 

chrysarobin  in 

—  utuient  for 420 


epidemic  in  Africa  an.':  A 
New  York  City 


1  tone  of 

human  vitality sn 

in  England 

the  pathology  of iq 

use  of !   417 

transmissibilitv  of 637 

treatment  of.    . g-. 

vngeal  papii- 
in   a  child   three   years  of 

removal  ...    194 

Ingrown  nail,  treatment  of 3S7 

Inhalations,   locating    consumption    by 
means  of 

Healtheries  "at  New  York,  a  !   .'.'.'.    820    Injections 


treatment  of. 

treatment  ofby  cold  water.  . 

Harper  Hospital.  Detroit 312 

Haussmann.  Baron 242 

Baron,  death  of 2M 

Headache,  severe,  trephining  for 


■  inunications 
ning  a  remedi 
remedy      statistics  of  the    German 
iment  on  the 
nt  combined  wil 

procedures,  the 

treatment  in  Germany,  present  - 

of  the 2i6 

'■'"iiph,  action  of,  on  healthy  ani- 


Health  and  longevity  1:1  abstainers  . 

in  Michigan  .   .  ". 144 


Helmholtz.  honors  to 41; 

Hemenway.  Dr.  Henry   Bixby,  the  rela- 
tion  of  atmospheric  conditioi 

intermittent  fever 

Hemianopsia    as   a  diagnostic 

brain  disease    .   .   .   . 
Hemicephalus  with  hydramniou  .   .    .   .    564 
Herdnian.   Dr.    W.    J.,    electricity  as    a 
therapeutic  agent.  What  is  needed 
to  determine  its  met  it- 
Hernia,  diaphragmatic,  traumatic  .   .   .    825 

High  buildings 7SJ 

temperature  in  typhoid  fever  and 
phthisis  pulmonum,  treatment  of. 
with  frequently  repeated  doses  of 

antifebrin 

Hip  disease,  the  prevention  of  the  short 

5>° 

lisease,  wheu  shall  we  discon- 
tinue mechanical  treatment  :-.: 
dislocation  of  the,  reduced  by  man- 
ual extension  ....    211 

Historical  club,  the 31 

Holmes.  Dr.  Bayard,  empyema 476 

Dr.  C.  R.,boracic  acid' and  massage 


aginal,  ...   344 

Insane,    can    the    gynecologist  aid  the 
alienist  in  institutions  tor  the 

in    the   State   of  New    York,   a    his- 
tory of  legislation  for  the      ....      6S 

poor,  care  of  the 644 

a  clinical  lecture  on 371 

commitments,  legal  view  of 392 

commitments,  the  legal   view  of.   .    279 
ovariotomy    as    a    prophylaxis    and 

curV  f°r  

Instinct   tu  animals  and  intelligence  in 

man  contrasted 

Internal  organs,    the  effects  of  Koch's 
remedy  upjn  the.  . 

International  clinics 710 

medical  congress  an 

medical  congress  at  Berlin,  the  tenth, 

■  iw  it 

Intestinal  obstruction,  case  of  acute.  .   .    515 
perforations  and  disturbances.  .   .   .    566 
surgery  of  th-.  upon  the  use 


rua'ls 

lymph,  death  from..   . 

lymph  in  the  hospitals  and  labora- 
tories of  Paris 

lymph,  observation  - 

lymph,  the  composition  of. 

method  in  pulmonary  tuberculosis  '    10s 

methi  d.  recent  -  -si 

new  laboratory  .   .  . 

remedy  and  its  results  .'.'.  !  --- 

remedy,  results  with 

remedy,  the  debate  on,  at  the  Berlin 
Medical  Society  . 

treatment  .   .   .   .' ' 

treatment;  experiments  on  call 

treatment:  general   re>: 

Irent  motl  !,,     !>,-,, ^,-:.,     ~A:..:_,    . 


1  fticial  report 


treatment 

of  the  res:.' 
treatment   of  tuberculosis;    general 

enVc:  ~  .......     9 

treatment,  the  risks  of.  .   . 
tuberculin  in  pulmonary  tuberculosis  4*s 
tuberculin,  the  value  of.  £2 

S.P.,a  report  of  the  ex'peri- 

ments  with  tuberculin  at  the  Good 

Samaritan  hospital  at  Cincin: 


82 


Dr.  O.  W.,  on  academies 

Holt,  Dr.  A.  I-'.,  death  of  .    .    . 

Hosmer.   Dr.  Alfred B28 

Hospital.  Saturday  and  Sunday  Associa- 
tion       : 

Hospitals,  faulty  construction  of  ....    638 
public,  the  establishment  of    ....    644 


Intest 

of  the  elastic  ligature  fn  the  . 

Intracranial  tumor 

Intra-uterine  diseases    their    diagnosis 

and  treatment 

Iodideof  iron  in  lead  poisoning 420 

Iodoform  and  aristol ~ 679 

the  deodorization   of,  by  creolin  .   .    605 
Iron  and  manganese,  biological  action 

of ......  .  .   .   .    562 

nd  coaptation  -■  lints 

Is  insanity  a  crime? sos 

Ischuias  scholiotica 161 

physicians..  .    103 


Lady  Duflferin  Zenana  hospital.  Calcutta 
the  hygiene  of  school 


100 


the  use  and  abuse  of 24    Italian  honors  to  Germ 

Hughes.  Dr.  C.  M.,  the  psycophatic  se- 
quences of  hereditary  alcoholic  en- 
tailment         9 

Hughes.  Dr.  Donnel,  extra-uterine  preg- 
nancy  90S 

Human  system .  wonderful  recuperative 

power  of  the 174 

Hydatid  cyst  of  the  spleen 15 

Hydrarthrosis 424 

Hydroceleof  the  cord,  enevsted 423 


Jackson,  Dr.  Edward,  tests  for  visual 
acuteuess:  their  illumination:  and 
the  standard  of  normal  vis:,  : 
Dr.  S.  K..  tuberculin  us  value  as  a 
specific  discovery  apart  from  its 
therapeutic  importance:  together 
with  a  consideration  of  the"  most 
rational  mode  of  employing  the 
principle  involved  it:  it  .  ".    .  .  .  .    I 


Lamb,  Dr. 

Lancaster,  Dr.  Chas.  C,  death   of'  ,,* 

Laparotomies,  medico-legal  relations  of  404 

Laparotomy 

-.tra-uterine     pregnancy    two  ^  ' 
months  after  death    of    fic'tus  at 

term _- 

for  peritoneal  tubercu.   -  5 

Larynx, cystoma  of  the  arytenoid 

of  the,  with  report  of 

napillomata  in  a  child  three 
I   age:  endo-lan-ngeal  I0. 

phthisis,  rapid  effects  of  Koch's  rem- 


edv 


tuberculosis,  the  surgical  treatment 

of 

Larynx,  results  of  intubation  of  the 

Latin  1  should   physicians  study 

Laws    regulating  medical   practice    .^ 

Ports  of ' 

Learned  professions,  an  attempt  to  d'eter- 
:  he  ideal  preparatory  course 
of  studies  for  the " 


41S 


IND£X. 


PAGE. 

Lee,  Dr.  Benjamin,  an  analysis  of  the 
statisticsof  41,500  cases  of  epidemic 

influenza 366 

Legal  pronouncement,  an  important  .   .    zSi 
Leopold,  extreme  antiseptic  views  of.   .    453 

Leper  colony  in  British  Columbia &20 

Leprosy  commission  in  India,  the  .    .66,  101 

in   Russia 279 

treatment  of,  with  Koch's  lymph  .    .    412 

Leprous  village,  a 315 

Leucorrhcea  and  bleuorrhcea  in   women     26 

Leukaemia,  microorganisms  in 236 

Librarian's  report 752 

Library  of  a  French  doctor  in  1609..  .   .    355 

Life-values,  the  advance  in 132 

Lister's  method  discarded  by  Lister  .    .     132 
Literary  intelligence 103 

physician,  a 523 

Liver,  determination  of  the  lower  bor- 
der of  the      670 

removal  of  the  left  lobe  of  the 412 

resection  of  the 205 

Lobar  pneumonia,  acute,  the  treatment 

of  the  first  stage  of 741 

London  Lancet,  the 35° 

Longevity,  a  lesson  in 347 

Love,  Dr."  I.  N.,  coffee,  its  use  and  abuse.  219 

Lumbo-colotomy,  case  of 17  3 

Lunacy,  the  N.  V.  State   commission   on     6S 

Lung. "abscess   of  the 335 

Lungs,  a  pathological  condition  of,  hith- 
erto undescribed  in  this  country, 
but  which  is  not  infrequent  ....    S09 

infectious  inflammation  of  the,  ...      14 
Lupus,  death  after  inoculation  for 243 

death  following  inoculation  for  .   .   .      60 
Koch's  treatment  in;  fatal  results.  .    161 
Lyman,  Dr.   Henry  M.,  monomania.  .    .    190 
Lymphatic  glands,  tuberculous,  the  re- 
sults of  operations  upon 519 


PAGE. 

Medical  legislation,  proposed 4S2 

legislation,  a  plea  for  a  more  radical 
system  of,  a   knowledge  or  a  time 

requirement 623 

licensing  boards,  convention  of  .   .   .    540 

literature  and  philosophy 633 

men  and  literature 491 

practice  in   certain   States,   onerous 

restrictions   on 100 

practitioners  in  Paris 492 

profession,  an  act  pending  in  Con- 
gress of  interest  to  the 35s 

progress 757 

profession,  the  relation  of  the  Col- 
umbian Exposition  to S93 

schools  must  be  endowed 171 

societies,  meeting  of.  for   1891  .   .   .   .    360 
subjects,  discussion  of,  in  the   news- 
papers   103 

Medicine  and  theology 747 

in  Japan S57 

pedagogy  in 166 

the  address  on 721 

the  graduating  age  in 413 

the  highlands  of 237 

the  possibilities  of 603 

vs.  surgery 920 

Medico-legal  notes 342 

Melanosis,  the  pigment  of 7S2 

Membership,  the  increase  of  our  ....    556 

Menstrual  colic 133 

epoch,  the  management  of  the  .   .   .    235 

Menstruation,    excessive 172 

Menthol  in  the  vomiting  of  pregnancy..    26 

Mercury,  salicylate  of 563 

Mesentery,   laceration    of;    resection   of 

ileuiu S26 

Messersmith,   Dr.  John   S.,  death  of.   .    428 

Methyl  violet 302 

Michigan,  proposed  medical   legislation 

130 


Major  amputations,   the  management 

of.   .   . 1S5 

Malaria,   researches  on 62 

Male  fern,  fatal  poisoning  with 16 

nurses,  Bellevue    hospital    training 

school   for 644 

Malic  acid  lozenges,  as  an  anticatarrhal 

remedy 133 

Marcy,  Dr.  Henry  O.,  in  what  class  of 
"wounds  shall  we  use  drainage?  and 
the  present  position  of  antiseptic 

surgery 229-245 

Marine-hospital  service,  U.  S.,  official 
list  of  changes  of  stations  and  du- 
ties of  officers  of  the — 36,  226,  2SS 

432,468,576,  64S,    756,828 900 

Maritime  medical  association,   the.   .    .    16S 
Marshall,  Dr.  John  S.,  aneurismal  tumor 
of  the  right  alveolar  process  and 
vaultofthe  mouth  treated  by  in- 
jection   217 

Martin,  Dr.  Franklin  H.,  a  plea  for  early 
vaginal  hysterectomy  for  cancer  of 

the  uterus 152 

Martin,  Surgeon  Henry  M.,  death  of.        178 
Mason,  Dr.  L.  D.,   etiology   of  alcoholic 

inebriety 627 

Massage  of  the  genital  organs 819 

Mastei  -  influence,  a 4H 

Mastitis,  chronic,  simulating  carcinoma  163 
Mastoid  process,  indications  for  trephin- 
ing the  632 

Mathews,  Dr.  Joseph  M.,  the  address  on 

surgery ■    .    -    654 

Maltison  prize,  the 35 

Mayence,  the  seige  of 315 

McClure,  Dr.  Wm.  J.,  death  or         ...    320 
n     Dr.  Wm.,  phthisis  pulmona- 
le   361 

McGraw,  Dr.  Theo.  A.,  upon  the  use  oi 
the  elastic  ligature  in  the  surgery 

Oi   the  int.  -tines 685 

■'M   D      Indianapolis"  .....■'"..     864 

\i.  ad,  1  m     fohn   \  .  death  ol 428 

:  1  m  -  cholera  and  the  ... 

Medical  I  faculty,  the  rela- 

tion  oi  trgani- 

zal  11  'ii  in   \ni'  til  .  1 S20 

Medical  cases  in  the  courts,  recent .   .   .    193 
cases  in  Che  courts 629 

Class  in  Japan 63 

congress,  a  Pan-American 569 

Editor's  Association 379 

education,   higher 

education  the  report  on 273 

1  ducational  inter*  sts 9'9 

Russia     -             25 

legislation  in  the  5tat(   <>i  Mi— mi  .  ■.-■ 


State  board  of   health 746 

Microscope,  the  century  of  the 677 

lenses,  important  improvement  in..  792 
Microscopists,  the  American  Society  of  921 
Middle  ear,  remarks  on  the  treatment  of 

proliferous  inflammation   of  the.    547 
Middlemore.the  late  Mr.  Richard..   .   .    744 

Midwives  registration  bill,   the 319 

Migraine 352 

and  functional  headaches  from  eye 

strain 435 

Milk  in  the  new-born,  secretion  of.  .   .   .      16 

infection  from 41Q 

statistics,  some 3s6 

Miller,  Dr.  Charles  A.,  death  of 178 

Medical   Director  Jonathan   Dickiu- 

son,  death  of 320 

Millikin,  Dan.  report  of  a  case  in  which 
the  child's  arm  became  engaged  in 
the  fenestrum  of  the  obstetric  for 


eps 


306 


Minard    Dr.  Eliza  C,   pathological  ante- 
flexion of  the  uterus S46 

Dr.  E.  J.  Chapin,  the  tenth  inter-na- 
tional medical  congress   at    Berlin, 

as  I  saw  it 588 

Minnesota,  medical  practice  in 120 

Monomania 190-20S 

Morphinism,  cure  for 244 

Morvau's  disease    with  the  clinical  re- 
port of  a  case 330 

Mouth  wash 679 

Munchausen's  mantle, has  Omaha  found?  534 

Myopia,  the  prevention  of 42 

Myxo-sarcoma  of  the   kidney 423 


Narcotic  inebriety,  prevention  of  .    .    .    349 

Nasal  douche,  a  new iS 

pi  vomiting,  to  relieve 352 

Naval  medical  service,  the 604 

Navy,  U.  S.,  officiallist  of  changes  in  the 
medical  11.  180, 

226,  288,  .^.  684, 

024 

Neoplasmata,  vesical,  and  their  removal  S94 
Necrology  report  for  the  State  of  Con- 

11   1  ticul 754 

Nervous    <li    :    1    ■    ■  nsion  ■  in     the 

1  uent  of 553 

Vw  disease,  a 523 

social  remedies 127 

New  York  County  Medical  Association  .    4?^ 

lettei  From.  863,  898 

State  Board  of  Health,  the  seventh 

annual  report  of  the 357 

State  Medical  Association,  Fifth  Dis- 

tricl  Branch 7<;6 

Nipph  s,  fissured SiS 


PAGE. 

Nowliu,  Dr.  J.  S.,  report  on  an  epidemic 

of  cerebrospinal  meningitis.  .   .   .    901 

Nurses,  provision  for 204 

Nursing,  lectures  on 319 

profession,  cooperation  and  the.    .   .    319 

Nux  vomica  preparations,  non-conform- 
ity iu 895 


Obstetrical  paralysis,  a  case  of  .   .   .   .    566 
Obstetric  forceps,   report    of   a  case   in 
whicn  the  child's  arm  became  en- 
gaged in  the  fenestrum  of  the    .   .    906 

Obstetrics,  cases  in 676 

perfected 102 

Odor,  measuring  the  perception  of.  .   .    677 
CEsophagus,  cancerous  strictures  of  the    34 

diverticulum  of  the 319. 

Ohio  Medical  University,  the 100 

State  Medical  Society 791 

Operations,  the  time  of  clay  for 132 

Ophthalmia  in  a  puerperal  woman.    .   .    164 
Ophthalmoscope    in    nervous    diseases, 

the 559 

Optician  and  ophthalmology,  the.   .   .   .    S15 
Osteotomy,  non-union  after,  in  a  case  of 

severe  rachitis 859 

Otitis  media,  acute 526 

media,  microbes  in 96 

Ovarian  cyst,  treatment  of  with  the  in- 
duced current 13 

Ovariotomy  as  a  prophylaxis  and  cure 

for  insanity 616 

during  pregnancy 449 

simple 159 

Ovary,  papillomatous  cystoma   of  the, 

with  report  of  a  case S74 

Ovulation  and  menstruation, 642 

Ozsua,  inhalations  for 420- 


Paget's  new  book  of  cases 4SS 

Pan-American  medical  congress,  the  pro- 
posed     600 

Pancreas,  the  effects  of  the  extirpation  of 

the 94 

Pannus,  boracic  acid  and  massage  in  .   .      S2 

Panophthalmitis 449 

Paraffin  with  lanolin,  combination  of.    .    818. 
Paralysis,  general  surgical  treatment  of  671 

Parasitic  disease,  is  cancer  a 452 

Paris,  last  winter's  emergency  in  .  .   .   .    522 
Parker.  Dr.   W.  W.,  instinct  in   animals 

and  intelligence  in  man  contrasted  Soo 
Farkes,  Dr.  C.  T.,  death  during  chloro- 
form administration.   . 232 

Dr.  Chas.  *i\.  uterine  myopia, 
renal  calculus,  and  surgical  oper- 
ations upon  the  kidneys  ....  46,    86 

Prof.  Charles  T.,  death  of 500 

Parkhurst,  Dr.  F.  J.,  electricity  as  a 
therapeutical  agent  iu  the  treat- 
ment of  dysmenorrhea  and  pelvic 

inflammations 910 

Parrish,  Dr.  Joseph,  death  of 179, 

Pasteur  institute  at  New  York 239 

institute  of  Paris 56 

Patella,  a  historical  record  of  the  devices 
used  in  the  mechanical  treatment 

of  simple  fracture  of  the 292 

Pathological  drama,  the  new 562 

specimens 246 

Pattee,  Dr.  Asa  F.,  the  consideration  and 
cure  of  chronic  t  ubercular  consump- 
tion of  the  lungs  .  . 793 

Pauper  insane  of  New  York  Stale,  the  .    279 
Peabody  fund,  report  of  the  trustees  of 


the 


:\A 


Pedagogy  in  medicine 

Pelvis,  traumatic  suppuration  of  the  .   .  14 

Pemphigus,  arsenic  and 125 

Percussion  reflex,  the  penis  in 343 

Perin,  Dr.  Glover,  death  of 143 

Perineal  shield,  exhibition  of 565 

Perineum,  immediate  repair  of  the.    .    .  54 

ruptured,  Kinkead  on 125 

Peritonitis,  experimental 16 

Perityphlitis,  the  operative  treatment  of  595 

Permanent  members 72 

Peroxide  of  hydrogen  iu  cutaneous  ther- 
apeutics'    244 

of  hydrogen,  inhalations  of 37s 

pfaff.Di    <>   G.t  simple  ovariotomy .   .   .  159 

phenacetin  in  sciatica 679 

Philadelphia,  letter  from 86a 

Polyclinic,  the 360 

Phlegmasia,   the    thermometer    in    the 

eai  iv  recognition  <<i     26 

tph  iu  medicine,  the 604 

Phthisis  and  pneumonia,  statistics  of.    .  6S 

pulmonalis 361 


IXDKX. 


thology  of .   .   .    253 
: 

n  the  treatment 
sails,  with  especial  reference 

to  propl  6*3 

the  treatment  of MO 

Pi  5"9 

1  1  education  of  the.  .   .    7S6 

a  man  and  a  citizen  . 
I  . 

Pilocarpin  in  chronic  rheumatism.  .    .    .    343 

in  ski:'    '  1$$ 

P                                                                       ...    279 
Placenta  previa,  the  treatment 
retained,    :n    miSC  11 1  !■•-;'      !' 
wetreat  such 
Pneumoeoccus     as     a     ferment,     Fried- 
lander's    .  678 

-00 

digitalis    in    the    first     and     second 

-  "f Sii 

i)i.'  blood  in 

treatment  of 642 

ed  by  elderly  males  .      94 
g  lead,  treated*  by  iodide  of  iron  44S 
Police    surveillance    of    railroad    street 

sines 463 

United  States 

Dr.  IV-vre.  a  pathological  con- 
dition of  the  lungs  hitherto  un de- 
scribed in  this  country,  but    ■ 

is  not  infrequent S09 

Portable  field-dressings  for  French  sol- 
diers   355 

Porter.  Dr.  William    abscess  of  the  lung  335 

Potter,  Dr.  Samuel  0 792 

Pott's  disease,  the  importance  of  thor- 
ough examination  in  suspected      .    424 
Powers  of  perception  of  children  .  .    520 

Practice  of  medicine  in  the  United  States 
and  Canada,  annual  report  of  the 

laws  regulating  the 2S 

"Practical  Note,''  a 323 

Pregnancy,  albuminuria  in 200 

ectopic;  with  presentation  of  speci- 
men    397 

ectopic,  with  report  of  two  cases,  121,  134 

extra-uterine 9°^ 

extra-uterine,  a  case  of.  ... 
extra-uterine,    the    operative    treat- 
ment of,  at  or  near  term,  with  re- 
port of  a  case    379 

sextuple 3°S 

the  pre-convulsive  period  in $94 

vomiting  in 244,  412 

Prescription,  the  ownership  of  the,  131,  600 
President's  address,  report  of  committee 

750 


address,  the 1,  649 

Preston.  Dr.  George  J.,  the  effect  of  arte- 
rio-sclerosis  upon  the  central 


of 


241 


medicine,  the  Imperial  Russian  In 

stituteof 241 

Progress  in  the  right  direction 351 

Prophylaxis 274 

Prurigo 420 

Pruritus  essentialis S3 

hiemalis 563 

of  the  anus  and  vulva.au  ointment 


for  . 


352 


Psoriasis,  chrysarobin  in 64 

Public  schools,  sanitary  condition  of  the  425 
Puerperal  eclampsia,  prevention  ot\  by 

the  induction  of  premature  labor  .    S75 
eclampsia,  severe;  the  immediate  in- 
duction of  labor:  recovery    ....    461 

harmorrhage.  caffeine  in 595 

Pulmonary"  cavities,  surgical  treatment 


cavities,  the  open  treatment  of  .  .  .  5x8 
tuberculosis,  Koch's  method  in  .  .  .  105 
tuberculosis.  Koch's  tuberculin  in    .    4S5 

Purpura,  acute 53 

Purulent  ophthalmia  in  the  new-born, 

prevention  of 

Putnam,  Dr.  Jas.  J.,  on  the  character  of 
the  evidence'as  to  the  injuriousness 
liic  as  a  domestic  pois^ 

Pyoktauiu 13.  "5 

in  cystitis,  injections  of- 199 


CUJATN,  Sir  Richard 3[9 

Quarantine  against  cholera c: 

Questions  of  importance  to  the  members 

answered 557 

Quiuan,  Dr.  John  R.,  death  of 3* 


;-ra-renalcap- 

235 
a   de- 
parting    - 

-   >f  the  240 
Randall.    Dr.    B.    Alex 

ts  in   the  correction  of  refrac- 
tion errors 37 

E&aynor,  1  >■ 

■>>lructiou 

207 

t    Pierson,  death  of  .  .  . 
Reed.  Dr.  R,  Harvey,  fracture  ol   I 
tragalus,    with    irreduceable 
placement  of  the  fragment  ....    694 
Refraction,  determination 

errors,  some  disputed  points  in  the 

correction  of 37 

Remarkable  case,  a 407 

Remote  results  of  shortening  the 

ligaments     for    uterine    displace- 
-  by  the  newer  direct  m-  I 
Removal,  the  'que-:: 

.    .     648 

of  the  Journal  to  Washington,  did  a 
majoritv  of  the  Board  of  Trustees 

vote  for  the 56S 

Renal  circulation,  the  effect  of  certain 

drugs  on  the  .  ...    630 

ton  and  appointment S2S 

593 

Respiration,  experiments  to  determine 

the  centre  of. 484 

forced 325,  353,  683,  703 

Resuscitative  efforts  in  the  new-born.    .    453 
Reviewer  in  1S31,  the 131 


Reviews. 

Beard.    Sexual  Neurasthenia 925 

Die   Wirksamkeit  des  Kochschen    Heil- 

mittels  gegen  Tuberculose.  . 
Garrod.  A  Treatise  on  Rheumatism  and 

Rheumatoid  Arthritis 464 

Gross.    A  Practical  Treatise    on   Impo- 
tence,Sterility  and  Allied  Disorders 
of  the  Male  Sexual  Organs  ....    179 
Hare.  A  Text-Book  of  Practical  Thera- 
peutics   321 

Hare,  Epilepsy;  its  Pathology  and  Treat- 
ment .   ." 179 

Hatfield.    A  Compend    of  Diseases    of 

Children 500 

Love.     Practical  Points  in  the  Manage- 
ment of  Disease 924 

Martindale.  The  Extra   Pharmacopoeia.  321 
Mimons.     A  Text-Book   of  Comparative 
Physiology  for  Students  and  Prac- 
titioners of  Comparative  (Veterin- 
ary) Medicine 

Rauch.  Illinois  State  Board  of  Health..  .    499 
Roux,     De  la  Tuburculose  Maminaire.  .    925 

Senn.  Principles  of  Surgery 250 

Shattuck.  Auscultation  and  Percuss 
Shoemaker.     Materia  Medica  and  Ther- 
apeutics   925 

Sozinsky.     Medical  Symbolism 926 

Talbot.  Irregularities'of  the  Teeth  and 

their  Treatment 1^0 

The  International  Medical    Annual   and 

Practitioner's  Index  for  [890,  .   .    .    179 
The  International   Medical  Annual  and 
Practitioner  s                                irk    of 
Reference  for  Medical  Practitioners  925 
Tyson    A  Guide  to  the  Practical  Exami- 
nation of  Urine 535 

Rheumatism,  chronic,   and  the  nervous 

system 

chronic,  pilocarpin  in 343 

Rheumatoid  arthritis 424 

Rhichet.   the  anti-tuberculosis    inocula- 
tion treatment  of 

Riley.    Henry  A.,  medical  cases  in   the 

I93>  629 

Henry  A.,  medico-legal  notes, 

■    ■   •    563 
Roberts.  Dr.  John  B..  the  relation  of  bac- 
teria to  practical  surgery.  .   . 

Rodent  ulcer,  resorcin  in 593 

Rotter's  antiseptic 3*7 

Rush  Medical  College,  the  chair  of  sur- 
gery in 

monument  committee,  report 


H.   malignant   smal.  | 
form  hitherto  i 

Saccharin,  preparation  of .   ... 

Saliciu  and  the  salicylate  of  sodium,   a 

1  ween 

Salicvlic  acid  for  the  prcv- 

'let  fever 

...    563 

Salpingiti-  .  17 

k. death   of.   . 
Sanitarv  undertake 
Sanitation  and  bacteriology  in  Ru  — 

-j 

Santoninexine  . 

■ 

Scabies  among  the  Chinese 4^9 

Scarlatinal  cirrhosis 

Scarlet  fever,  for  itching  in  ...   . 
Schenck,  Dr.  W.  I.  ,  the  address  on  State 

ine 72S 

Schenck.  Dr.  J.,  on  the  treatment  of 
fibroid  tumors  in  the  womb  by  the 
injection  of  ergot  into  their  sub- 
stance   915 

Scholl  on  investigations  iutocholera-tox- 

ines 

:  lies,  the  hygiene  of.   . 
Sciatica  tablets  .   .  2S0 

Scientific  medicine,  the  basis  of.  and  the 

proper  methods  of  investigation  .    114 
Secretaries  of  Sections,  notice  to.  .       .   .    464 
Secretary  of  public  health,  report  of  the 
committee  on     the  question  of  a 
cabinet  appointment 
Section  meetings  of  the  Association.   .    309 
Sections,  report  of  the  committee  on  con- 
ference of 

the  further  development  of  the 

Sedative  for  babies 679 

Seminal  emissions 2S0 

Senn,  Dr.   N.,   the  chair  of  surgery-  in 

Rush  Medical  College 
Senn's  method  of  establishing  lateral  in- 
testinal   anastomosis,  a  niodifica- 

of 199 

Seymour,  Dr.  William  Wotkyns,   treat- 
ment of  gallstones  . 
Shoemaker,  Dr.  Geo.  Er^ty,  when  is  an- 
tisepsis a  failure?.   ...... 

Short  leg  of  hip  disease,  the  prevention 

of  the -:: 

Shurly.  Dr.  E.  L-,  the  address  on  medi- 
cine   

Dr.  E.  L-,  the  treatment  of  phthisis..  250 

Shurly'S    treatment 753 

Skeletons,  ornamented 489 

Skin  diseases,  some  common  errors  in 

diagnosing 40t 

diseases  pilocarpin  in 198 

tubercular    affections  of  the,   treat- 
ed by  Koch  s  lymph 4:1 

Societies  and  Associations. 

Allegheny  County  Medical  Societ> 
-American  Medical  Association  .  392,  500, 
6o6,  711 
Academv  of  Medicine 
Buffalo  Medical  and  Surgical  Association  553 

Chicago  Medico-Legal  Society 20S 

Clinical  Societv  of  Louisville,  the 
Gynecological  "Society  of  Chicago.  1 

Societv  of  Boston 

Harlem  Medical  Association 65 

Medical  and  Chirurgical  State  Facultv  of 

Maryland    .    . 
New  York  Academy  of  Medicine.  3 

Omaha  Medical  College 611 

Philadclohia  Electro-Theraoeutic    Soci- 

395 

County  Medical  Societv 
Medical  Societv 
State  Medical  Society 

Small.  Dr.  1.  W.,  the  ther 

of  tonica  water,  with  the  history  of 
twent  1  e  it  has  been 

used  . 
Dr.  J.  W..  the  treatment  of  the  first 
if  acute  lobar  pneumo: 
in    Havana  ... 

malignant;  a  form  hitherto  fa-, 
prevention  of  pitting  in  .   .   .  - 

Snake-bit.:  cure  for  .   .   .    4S8 

Soft  rnbbtr  ■ 


INDEX. 


Some  disputed  points  in  the  correction 

of    refraction  error  .    .  -,7 

Sonnenburg,  Dr.,   the   Koch    treatment 

combined  with  surgical  procedures  289 
South  Dakota  State  Medical   Society  75s 

Spasmodic  dysmenorrhoea  .   .   .   .   "  66 

Spinal  cord,  differential  criticism 

of  the '     ,», 

cord,  the  therapeutic  value' of  suspen- 
sion  in  diseases  of  the  .   .  707 

Spine,  concussion  of  the..  .  '    [s- 

Spleen,  hydated  cvst  of  the         A 

resection  of  the '    .,j 

Splenic  leucocythemia 522 

Spurious  Koch's  fluid .61 

Sputum,  tuberculous,  disinfection  of         577 

Stanton,  Dr.  Otis 828 

State  Medical  Society  meetings  in  1S91 
regulation  of  professional  conduct 
medicine,  the  address  on  . 
Sterility,  a  study  of  its  causes  and  treat 

_.        "iellj  '   ■ 1S1,   222,  265 

Stewart,  Dr.   James  L.,  death  of.  179 

Stephens,  Dr.  Henry  William,  death  of.    576 
Stillman,  Dr.  Chas.  F,  a  historical  record 
of  thedevices  used  in  the  mechani- 
cal treatment  of  simple  fracture  of 

the  patella ,Q, 

stomach    resection  .   .   .  Jfg 

Stone,  Dr.  I,  S.,  can  the  gynecologist  kid 
institutions   for   the 

.    S70 


.    468 
.    468 

72S 


the  alienist  i 


Strangulated  hernia,  discussion  c. 
Strictures  of  the  male  urethra,  treatment 


744 


of. 


of  the  oesophagus,  cancerous  !!".''      J 
Strychnine  effects  of,  on  the  stomach...  856 

students  and  doctors,  good  points  for 639 

Subacute,  cervical  adenitis  of  intestinal 

origin 

Sublimate  solutions,  warm  .  '       '      ',, 

Sulphichth  ,-olicacid  and  its  preparations 
111  the  treatment  of  inflammatory 
diseases  of  women  S6 

Sulphonal,  a  new  mode  of  exhibiting.  '    2-0 

in  diabetes s        \'" 

Sulphur  fumigation,  d'isinfect'ing'power 

Summer   diarrhoea.. '    55g 

Surgical  treatment  of  general  paralysis  671 
he  new -16 


Surgeon-General, 


•  gerv,  cerebral, 
fourth  of  July  ....'.'.'.'.'.''''„ 
gastric,  ten  years  experience  of  '  6 
old  age  as  a  factor  in.  ...  6, 


Tousils.chromicacid  treatment  of  chron- 
ic enlargement  of  the 247 

Trained  nursing  for  the  poor  ...  -139 

Traumatic  suppuration  of  the  pelvis  .   .      14 
Trendelenberg's    flexible  dressing  ...      64 

Tribute  to  the  profession,  a 25 

Trichloracetic  acid 518 

Trustees  board  of,  the  additional  report 

of  the 7,s 

notice  to  the  Board  of.   .   .  555 

the  adjourned  mec'ing  of  the      ...    747 
tubal  pregnancy  with  two  ora  in   same 

Fallopean  tube  ...  .  564 

Tubercle  bacilli,  counting .    805 

bacillus,  media  for  cultivation    of  .   .    450 
bacillus,    practical    communications 

regarding  the 4I0 

bacillus,  the  alkaloid  obtained  from 

the 

bacillus,  the  morplioiogv.  cultivation 
and  toxic  products  of'the  .   .       .       314 

bacillus,  virulence  of 344 

poison,  mode  of  entry  of,   into  the 

body 8s- 

astitis  of  the  hip-joint.  .   .       423 


632 


Tubercul 
Tuberculin 

a  report  of  the  experiments  with, "at 
the  Good^  Samaritan     hospital   at 


l.rine,  fatty,  the  report  of  a  case  of  ac- 
companying an  abscess  in  'the 
.  nSht  lhac  fossa  ;  recovery.  .  «., 

Uterine    carcinoma,    inoperable,   treat-      4 
ment  of,  with  chloride  of  zinc  « 

dilator,  exhibition  of  new  '    '    ct? 

inertia  and  pelvic  disturbances,  the 
influence  of  the  position  of  the  pa- 
tient in  labor  in  causing.  .   .      .,,    ,%a 
medication  and  uterine  surgery'    3J'  20? 
myopia,  renal  calculus  and  surgical 
operations  upon  the  kidneys.  .  46     S6 
Uterus,  absence  of.    .    .  .,, 

ana  vagina,  aborting  c-vv/sr  cf  lit 

contractions  of  the,  induced  by  elec- 


tricity 
J-rtial  inversion  of  the  frcm  tri'-.'ue 

causes  ....  s-" 

pathological  anteflexion  of  the  .'  .'  .'    846 
-ptusduplex  et  vagina  duplex,  dou- 

a  case  of.  ...   ,    163 
a  case  of.  ...   .    9o6 


ble  pregnancy  i_ 
and  vagina,  double 


Cincinnati 
Dr.  John  P.  Gray's  experiment  with  51 
111  Germany  and'  Italy,  official  regu- 
lations as  to 4g 

its  value  as  a  scientific  discovery, 
apart  from  its  therapeutic  impor- 
tance; together  with  a  considera- 
tion of  the  most  rational  mode  of 
employing  the   principle  involved 


•    31 


practical,  the  relation  of  bacteria  to  m 
the  address  on  ...  .  i_. 


the  progress  of,  in  1800  .   . 
Sweating  of  the  feet,  a  case  of  .   .  .   .'   '    ,L 
Sycosis -to 

vulgasis.  treatment' of.  '.'.  ' 
Syphilis,  digital, of  medical  practitioner's  ,ii 

the  suppression  of.   .    ....    .  27' 

^,.„'i''ie-,t-rea,tmCnt.of'  duri"K  pregnancy.   5S7 
syphilitic  ulcerations,  treatment  of..  .  ".    420 


'"    '  Nil ,cR 

'fait,  Mr.  I.awson    .         *g 

alcott,  Dr.  Alvin,  death  of! •£, 

Taste,  investigation  of  the  sense  of.'   '   '      s6 
Taylor,  Medical  Director  John   Y  '    20s 

leething,  convulsions  of  ,,„ 

Temperance  Association.  American  Med- 

ical s  - 

Temperance  medical  men  in  England!    457 
society    an  American   Medical  .    .        „2 

Tetanus,  etiology  of 4Ig_f£ 

pathogenesis  of.   .    .   .  ™R 

That      remarkable  case" *„ 

"The  Journal,"  the  purpose  of.   '.'..'.    „o 
the  monkey  solve-  the  problem.   .   .   .    640 
Thomas,  Dr.  Hugh  Owen,  death  of.   .   .     78 
"'"'  ■'•■ ."'    Beelys  apparatus  for  meas- 
uring  the  .   . 

ine  and        ,5, 

te  of  theMis- 
soun  St..!     ,,,.  ,    „  u_ 

on  the  .   .  „•>* 

: : :  I 

nt  of       so4 

Iti,     1CI 

with    the    historj 

ed  77a 


Koch's,  the  value  of 672,  706 

living  microorganisms  in 492 

the  dangers  of .   .   .  .  634 
Tuberculosis,  a  suggestion  bearing  upon  637 
additional  communications  concern- 
ing a  remedy  for 262 

canthandiuate  of  potash  in  .   .      4s6    ss2 
Dr.  J.  Blake  White's  treatment'of     .'  425 
hydrocyanic  acid  antidotal  to 
injections  of  dog's  serum  in 
Koch's  treatment  of   ....  \,     --,, 

Koch's  treatment  of;  general' results  409 
laryngeal,  the  surgical  treatment  of  s? 
of  the  larynx,  Koch's  remedy  in.  .  306 
of  the  liver  ....  „Q 

Prof.  Koch's  treatment  of. '. Jq, 

Prof.  Liebreich's  remedy !   '    44S 

the  etiology  of .   .  '  „« 

the  healing  of.   ..'.'.' S2* 

Tubo-ovarian  disease  ...  42" 

Tulaue  University,  generous  gi'ft'to  .' .'.  S99 
Tumor,  aneurismal  of  the  right  alveolar 
process  and  vault  of  the    mouth 
treated  by  injection  ....  2,7 

Tuning-fork  hammer,  an  automatic  .   .    891 
Turkish  bath  as  a  remedy,  the.    .  sss 

Turpentine,  treatment  of  icterus  with.    SB 
Tyndale,  Dr.  J.  H.,  and  the  treatment  of 

tuberculosis  by  inoculation  ....      68 
the  treatment  of 630 


Vaccination,  a  distant  witness  for.  709 
Vaccine  lymph,  treatment  of  tuberculo- 

sis  with 0 

Vaginal  injections,  dangers  of.  .  '.  '.  344,  782 
Vaginitis  simple,  can  it  be  distinguish- 

1.  __°™  lllat  °^  gvnorrhceal  origin  596 


Variola 

Vaughau,    D 

factors 


ulosi 


238 


Victor   C,   the  chemical 
1  the  causation  of  disease, 

6|3.  664,  697 
the   growing    impor- 
aical  studies  in  medi- 

aedical  research  734 


Dr.  Victor  C, 
tance  of  chei 
cal  education 
on  the  chemical  study  of  the  "sun 

"er  diarrhceas  of  infancy.  162 

ntous  insertion  of  the  cord  .   .       564. 

■    ■    346 


Vela 
Venesect 

Ventilation  of  churchesj  the. 
Vesico-vaginal  fistulas.   .  '  116 

■   -  portrait  of.   .   .   .  .'  \   '  "       '    |i8 

Profs 315 

>69 


Virch. 

and  Hel 

Professo 

testimonial  to  .    .   . 
Visual  acuteness,  tests  for;  their  illumi- 
nation ;  and  the  standard  of  nor- 
mal vision "... 

Volume,  the  new .    .    . 

Vomiting  of  pregnancy,  bromides  in  ! 

of  pregnancy,  uncontrollable 


64 


Tvphliti; 
Typhoid 


bacillus  Is.-. 

bacillus,  efFeet  of  high  temperature 

on  the  ....  6 

baciii„s  in  drinking  w.1)er  /   ' 

etiology  and  treatment  of. 469 

adage  regarding      ...    k.7 


fever, 

fever,  Ehrlich 

fever  germ 

Pterin 

feve; 


fants,  cases  of. 


m  the  bath  treatment  of  369 
of  the  lesions  induced  by  47, 


fever,  some  of  the  lesions  induced  by  4- 
feyer,  treatment  of,  with 

ughan's  all 1 


"lymph,"    Prof. 
1 ery  of  a . 
Typhus  fever,' in. i! 


Umbilicai     : 

Unique" IrisS   cfston'     """ M''  ss7 

*wi: : : : :  y 

r *' 

tequir- 
:"  '      "  ■'  '  821 

-  1I..1  in  the  treatment 
oi  diseases  of  the.  .  -„ 


Wagner,  Dr.  A.  L.,  etiology  and  treat- 
ment of  typhoid ,69. 

Walker,  Dr.  A.  U.,  papillomatous  cysto- 
ma of  the  ovary,  with  report  of  a 

case 8-, 

Warner,  Dr.  Joseph  H.,death'of.  .'    .'    .'    .'    612. 

Warts 493 

venereal  mixture  for, ^J, 

Washington  State  medical  societv.  .    .        S28 
Water  purification,  the  problem  of  7j8 

we  drink,  the '   '    810 

Welch,  Prof,  on  the  etiological  relation-      " 
ship  of  the  Klcbs-Licffler  bacillus 

to  diphtheria 4«6- 

"  -edicine  be  taken?.  .'.'.'.   352 

igh,  arrest  of,  bv  manipu- 

of  the  hyoid  bone 2S0 


shall  1 


,  report  of  six  cases  of 


inhalation 
Wilson,  Dr.  A.  C 
abdominal 
Wisconsin  National  Guard,  the  ai 
,  ,„.  Vou  of  military  surgeons  of  the.  .    33S 
Wisdom  ;f  K;ch  th;  '« 

Women  in  medicine,  the  province  of.    .    S93 
medical  practitioners  in  China,  the 

sphere  of. ,g2 

Word-blindness  with  unusual  features.  .    604 
World's     Columbian     Exposition,     the 

orld's  congress  auxilliary  of  the  276 
'"      H.    V.,    remarks    on 
nt   of   proliferous  in- 


Wiirdemai 

the    treati 

flamniation  of  the  rniddfeear 
Wyeth    Dr.  John  A.,  the  management 

of  major  amputations 


547 


Vour  manuscript,  please. 


i>r.  Joseph,  some  common  er- 
ni  diagnosing  diseases  of  the 
skin  .... 

Zyzigium  i  11111,0!  , im, n  ''.'.'.'.'. 


BINilN NHT   10  iwo 


R 
15 
ft./„3 
v.16 
cop.  2 


American  Medical  Association. 
Journal 


Biologic*! 
Jt   Medical 
SwiaU 


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