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Full text of "The Medical news"

in ike J^ucalti. of JiU- ii > c i . n- 






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THE 



MEDICAL NEWS. 



SV iDccklu iltcbical Journal* 



Edited by 



GEORGE M. GOULD, A.M., M.D. 



VOLUME LXVIL 



JULY-DECEMBER, 1895. 




.^5^^ 
^ 



PHILADELPHI.\: 

LEA BROTHERS & CO. 

1895- 



// 









Entered according to the Act of Congress in the year 1895 by 

LEA BROTHERS & CO., 

In the Office of the Librarian of Congress at Washington. All rights reserved. 



A. 



CONTRIBUTORS 



VOLUME SIXTY-SEVEN 



Lewis H. Adler, Jr , M.D., of Philadelphia. 
Clarence O. Arey, C.E., M.D., of Cleveland, O. 
W. F. Arnold. M.D., U. S. Navy. 
P. M. AsftBURN, M.D., of Batavia, O. 
William S. Bagot, M D., of Denver, Col. 
F. P. Ball, M D., of Lock Haven, Pa. 
M. V. Ball, M.D., of Philadelphia. 
Paul J. Barcus, M.D., of Crawfordsville, Ind. 
Lewellys F. Barker, M.D., of Baltimore, Md. 
Wesley W. Barkwell, M.D.. of Chicago, 111. 
Paul Bartholow, M.D., of Philadelphia. 
Roberts Bariholow, M.D., of Philadelphia. 
Harvey Bashore, M.D., of West View, Pa. 
James Beckett, M.D., of Chicago, 111. 
Lloyd B. Bergen, M.D., of Highland Park, 111. 
A. L. Benedict, M.D., of Buffalo, N. Y. 
Henry J. Berkley, M.D., of Baltimore, Md. 
Henry W. Bettmann, M.D., of Cincinnati, O. 
Henry G. Beyer, of Annapolis, Md. 
Herman M. Biggs, M.D.,of New York. 
John S. Billings, M.D., U. S. Army. 
Emma L. Billstein, M.D., of Philadelphia. 

A. M. Bleile, M.D., of Columbus, O. 

Arthur Ames Bliss, A.M., M.D., of Philadelphia. 

B. M. Bolton, M.D., of Philadelphia. 

E. ZiEGLER Bowers, M.D., of Scranton, Pa. 
W. F. Breakey, M.D., of Ann Arbor, Mich. 
Samuel Brickner, M.D., of New York City. 
J. A. Broberg, M.D., of Delavan, Minn. 
Dillon Bkown, M.D., of New York City. 
George S. Brown, M.D., of Birmingham, Ala. 
J. J. Brownson, M.D., of Dubuque, la. 
Albert P. Brubaker, M.D., of Philadelphia. 
William E. Bruner, A.M., M.D., of Cleveland, O. 
Henry Dickson Bruns, M.D., of New Orleans, La. 
Charles H. Burnett, M.D., of Philadelphia. 

F. C. BuscH, M.D., of Buffalo, N. Y. 

J. Abbott Cantrell, M.D., of Philadelphia. 
J. S. Carpenter, M.D., of Pottsville, Pa. 
Charles Cary, M.D., of Buffalo, N. Y. 
Solomon Solis-Cohen, M.D., of Philadelphia. 
Thos. Luther Coley, A.B., M.D.,of Philadelphia. 
A. J. CoMSTOCK, M.D., of Ventura, Cal. 
David H. Coover, M.D., of Denver, Col. 
M. A Crockett, A.B., M.D., of Buffalo, N. Y. 
Charles Greene Cumston, M.D., of Boston. 
John C. Da Costa, M.D., of Philadelphia. 
J. Chal.mers Da Costa, M.D., of Philadelphia 
Isabel M. Davenport, M.D., of Kankakee, 111. 

G. G. Davis, M.D., M.R.C.S. Eng., of Philadelphia. 



John B. Davis, M.D., of Allegheny, Pa. 
John B. Deaver, M.D., of Philadelphia. 

F. X. Dercum, M.D., of Philadelphia. 
Theodore Diller, M.D., of Pittsburg, Pa. 
Williams. Disbrow, M.D., Ph.G., of Newark, N.J. 
George Dock, M.D., of Ann Arbor, Mich. 

P. S. Donnell\n, M.D., of Philadelphia. 
W. A. N. Dorland, M.D., of Philadelphia. 
L. A. Duhring, M.D., of Philadelphia. 
William H. Dukeman, M.D., of Los Angeles, Cal. 
Charles VV. Dulles, M.D., of Philadelphia. 
Arthur R. Edwards, A.M., M.D., of Chicago, 111. 
Philip Elkin, M.D , of Pittsburg, Pa. 
Augustus A. Eshner, M.D., of Philadelphia. 
J. T. Eskridge, M.D., of Denver, Col. 
W. Knowles Evans, M.D., of Chester, Pa. 
Henry M. Fisher, M.D., of Philadelphia. 
Louis Frank, M.D., of Louisville, Ky. 
Melvin M. Franklin, M.D., of Philadelphia. 
Robert Fletcher, M.D , of Washington, D. C. 
T. B. Fletcher, M.D, of Baltimore, Md. 
Leonard Freeman, B.S., M.D., of Denver, Col. 
A. Bradley Gaither, A.M., M.D., of Baltimore. 
Hermon C. GoRDiNiER,A.M.,M.D.,of Troy.N. Y. 
George M. Gould, .A..M., M.D., of Philadelphia. 
Schuyler C. Gr.^ves, M.D., of Grand Rapids, 

Mich. 
Charles L. Greene, M.D.,of St. Paul, Minn. 
J. P. C. Griifith, M.D., of Philadelphia. 
George G. Groff, of Lewisburg, Pa. 
J. N. Hall, M.D., of Denver, Col. 
Howard F. Hansell, M.D., of Philadelphia. 
H. A. Hare, M.D., of Philadelphia. 
George Byrd Harrison, M.D., of Washington, DC. 
Robert W. Haynes, M.D.,of Los Angeles, Cal. 
C. F. Hersman, M.D., of St. Louis, Mo. 

G. A. Himmelsbach, M.D., of Buffalo, N. Y. 
Guy Hinsdale, M.D., of Philadelphia. 

C. S. Hoff.m.\n, M.D., of Keyser, W. Va. 
Bayard Holmes, M.D., of Chicago, 111. 
J. Mason Hundley, M.D., of Baltimore, Md. 
Woods Hutchinson, M.D., of Iowa City, Iowa. 
C. M. Hyde, M.D., of Augusta, Miss. 
Lawrence Irwell, of Buffalo, N. Y. 
M. Iversen, M.D., of Stoughton, Wis. 
Chevalier Jackson, M.D., of Pittsburg, Pa. 
Edward Jackson, A.M., M.D., of Philadelphia. 
Wvatt Johnson, M.D., of Montreal, Can. 
Philip Mills Jones, M.D., of San Francisco, Cal. 
Edwin O. Jord.\n, Ph.D., of Chicago, 111. 



-\ W. W. Keen, M.D., of Philadelphia. 

Howard A. Kelly, M.D., of Baltimore, Md. 
T. W. Keown, A.B., M.D., of Baltimore, Md. 
A. T. Kerr, M.D., of Buffalo, N. Y. 
Emil King, M.D., of Fulda, Minn. 
William C. Krauss, M.D., of Buffalo, N. Y. 

D. Braden Kyle, M.D., of Philadelphia. 
J. E. Laberge, M.D., of Montreal, Can. 
Frank L. Lapsley, A.B., M.D., of Louisville, Ky. 
Alfred Leffingwell, M.D., of Cambridge, Mass. 
Henry Leffmann, M.D., of Philadelphia. 

W. M. Leszynsky, M.D., of New York. 
A. H. Levings, M.D., of Milwaukee, Wis. 
John A. Lichtv, M.D., of Clifton Springs, N. Y. 
James Hendrie Lloyd, M.D., of Philadelphia. 

E. W. Ludlow, M.D., of Urbana, Ohio. 
Ogden C. Ludlow, M.D., of New York City. 
Louis Mackall, Jr., M.D., of Washington, D. C. 
W. F. Martin, M.D., of Colorado Springs, Col. 
William Martin, M.D., of Bristol, Pa. 
Claudius H. Mastin, M.D., LL.D., of Mobile, 

Alabama. 
Joseph M. Mathews, M.D-, of Louisville, Ky. 
H. A. McCallum, M.D., of London, Canada. 
J. E. McCuaig, M.D., of Topeka, Kan. 
Hunter McGuire, M.D., of Richmond, Va. 
Peter McKechnie, M.D., of Talawakela, Colombo. 
H. W. McLauthlin, M.D., of Denver, Col. 
W. M. Memminger, M.D., of Chester, Pa. 

C. K. Mills, M.D., of Philadelphia. 

J. K. Mitchell, M.D., of Philadelphia. 
S. Weir Mitchell, M.D., of Philadelphia. 

D. W. Montgomery, M.D., of San Francisco, Cal. 
H. B. Moore, M.D., of Colorado Springs, Col. 
Thos. S. K. Morton. M.D., of Philadelphia. 
William P. Munn, M.D., of Denver, Col. 

J. B. Murphy, A.M., M.D., of Chicago, 111. 
G. Natanson, M.D., of Brownsville, Texas. 
James E. Newcomb, M.D., of New York. 
Charles P. Noble, M.D., of Philadelphia. 
Frederick G. Now, Sc.D., M.D., of Ann Arbor, 

Mich. 
William Osler, M.D., of Baltimore, Md. 
Lambert Ott, M.D., of Philadelphia. 

F. A. Packard, M.D., of Philadelphia. 
R0.SWELL Park, A.M., M.D., of Buffalo, N. Y. 
Clayton Parkhill, M.D., of Denver, Col. 
W. H. Patterson, M.D., of Reno, Nevada. 



I William Pepper, M.D., of Philadelphia. 

George D. Perkins, M.D., of Ann Arbor. Mich. 

Robert L. Pitfield, M.D., of Philadelphia. 

Miles F. Porter, A.M., M.D., of Fort Wayne,Ind. 
I George J. Preston, M.D., of Baltimore, Md. 

B. K. Rachford, M.D., of Cincinnati, O. 
• VVendell Reber, M.D., of Pottsville, Pa. 

Boardman Reed, M.D., of Atlantic City, N. J. 

John B. Roberts, M.D., of Philadelphia. 

F. Byron Robinson, M.D., of Chicago, 111. 
i DeLancey Rochester, M.D., of Buffalo, N. Y. 
I Edmund J. A. Rogers, M.D., of Denver, Col. 
I Dunbar Roy, A.B., M.D., of Atlanta, Ga. 

W. ScHEPPEGRELL, A.M., M.D., ot New Orleans,La. 

C. J. Seltzer, M.D., of Philadelphia. 
Julius Selva, M.D., of Boston, Mass. 
Nicholas Senn, M.D , of Chicago. 

Caspar W. Sharples, MD., of Seattle, Wash. 

Harris A. Slocum, M.D. , of Philadelphia. 

Simeon Snell, Prist >1, England. 

Edmond Souchon, M.D., of New Orleans, La. 

A. E. Spaulding, M.D., of Luverne, Minn. 

A. H. Stewart, M.D., of Philadelphia. 

Alfred Stille, M.D., of Philadelphia. 

Charles G. Stockton, M.D., of Buffalo, N. Y. 

Howard S. Straight, M.D., of Cleveland, Ohio. 

Frank Wistar Thomas, M.D., of Germantown.Pa. 

John A. Thompson, M.D., of Cincinnati, Ohio. 

Henry E. Tuley, M.D., of Louisville, Ky. 

Frank P. Vale, M.D., of Washington, D. C. 

Weller Van Hook, A.B., M.D., of Chicago, 111. 

Victor C. Vaughan, M.D., of Ann Arbor, Mich. 

E. W. Watson, M.D., of Philadelphia. 

Carl Weiland, M.D , of Philadelphia. 

J. C. Welch, M.D., of Bellevue, Pa. 

Edward F. Wells, M.D., of Chicago, 

Thompson S. Westcott, M.D., of Philadelphia. 

H. G. Wetherhill, M.D., of Trenton, N. J. 

Frances Emily White, M.D., of Philadelphia. 

J. William White, M.D., of Philadelphia. 

H. Augustus Wilson, A.m., M.D., of Philadelphia. 

J. C. Wilson, M.D., of Philadelphia. 

W. Reynolds Wilson, M.D., of Philadelphia. 

Casey A. Wood, M.D., of Chicago, 111. 

H. C. Wood, M.D., of Philadelphia. 

James Wood, M.D., of Brooklyn, N. Y. 

James K. Young, M.D., of Philadelphia. 



THE MEDICAL NEWS 

A WEEKLY JOURNAL OF MEDICAL SCIENCE. 



Vol. LXVII. 



Saturday, July 6, 1895. 



No. I. 



ORIGINAL ARTICLES. 

DIPHTHERIA : ITS BACTERIAL DIAGNOSIS AND 
TREATMENT WITH THE ANTITOXIN} 

BY HENRY W. BETTMANN, M.D., 



In 1884 Loeffler announced the cause of diph- 
theria, but the medical world was little interested. 
Five yedrs later Roux declared that the bacterial 
diagnosis of suspected cases was of the greatest im- 
portance, and Baginsky added further proof, and 
still the medical world heeded little. In 1894 
Roux and Behring announced independently that 
they had discovered a cure for diphtheria, and in 
six months the medical world is aflame. 

The scientific structure is complete : the etiology 
first, the bacterial diagnosis second, the prophylaxis 
and cure the capping-stones. The task before the 
medical profession is to see if the structure can 
stand. If it stands, it is the highest achievement of 
the new medical era, and a glorious and memorable 
tribute to scientific medicine. 

I shall say nothing about the etiologic relation 
between the Loeffler bacillus and diphtheria. In 
the minds of all except the ultra-skeptical, the cause 
of the vast majority of cases of Bretonneau's diph- 
theria is the Loeffler bacillus ; this fact was incon- 
trovertibly demonstrated years ago, and need no 
longer form the basis of discussion. The questions 
that concern us to-night are far more practical and 
more important to us as physicians. They may be 
enumerated as follows : 

1. What clinical significance has the bacterial 
investigation of throat-exudates ? 

2. Can diphtheria be cured by the antitoxin? 

3. Can diphtheria be prevented by the antitoxin ? 

4. Is the antitoxin a specific remedy for diph- 
theria in the sense advocated by Behring, Aronson, 
and Roux? 

I. The Clinical Significance of Bacterial Itivcsti- 
gation of Throat-exudates. My conclusions are 
based on the bacterial investigations of 122 throat- 
cases. These studies were made in the laboratory 
of the Cincinnati Hospital by Dr. A. H. Freiberg 
and myself, with the generous assistance of Dr. 
Charles H. Castle. We are also indebted to the 
assistance of Superintendent Hendley, who first 

1 A paper read before the Cincinnati Academy of Medicine, 
June 3, 1895. 



suggested the investigation. Our methods were 
copied from those of the New York City Board of 
Health, and our way of distributing, collecting, and 
examining tubes was modelled after that of New 
York. Altogether we examined about 160 inocu- 
lated tubes. A majority of the local profession did 
not avail themselves of the opportunity for diag- 
nosis that was offered. On the other hand, a large 
number realized the value of the bacterial examina- 
tion and lent us their support and their interest. 
The vast majority of the tubes examined were sent to 
us in January, February, and March of this year. 

In all cases we used Loeffler's serum for diagnos- 
tic purposes. This is by far the best medium with 
which to demonstrate the presence of the Loeffler 
bacillus. Investigators who use glycerin-agar, 
peptone-agar, or even plain blood-serum cannot 
expect reliable results.' As a rule, we were able to 
make a diagnosis after the tubes had remained in 
the incubator from twelve to sixteen hours ; and 
if the inoculation was at all successful, twenty-four 
hours sufficed in all cases. With some experience 
it is possible to distinguish diphtheria-colonies from 
cocci-colonies macroscopically, diphtheria-colonies 
of sixteen hours' duration looking gray and small as 
compared with the larger and whiter cocci-colonies ; 
of course, it is best in all cases to resort to micro- 
scopic examination with alkaline methylene-blue. 
Early in January we were puzzled occasionally by 
the appearance in the cultures of short, thick bacilli, 
and very long, slender, evenly staining ones. We 
soon found out, however, that these colonies devel- 
oped in imperfectly sterilized tubes, and later ruled 
out all doubt by sterilizing the serum more perfectly. 
After this we were never seriously puzzled to know 
whether a tube contained Loeffler bacilli or not." 
After the statistical report of the New York Board of 
Health, covering 561 1 cases, it might seem super- 
fluous for us to report our series of 122. Yet even 
so small a series is full of interest and instruction. 

The Loeffler bacillus was present in forty-seven 
cases;of these, eight, or 17 per cent., died. The bacil- 
lus was absent from seventy-five cases ; of these, three 
(4 per cent.) died. In one of these fatal cases the ex- 
amination was made after the disease had existed two 

1 C. Fraenkel : Die Aetiologische Bedeutung des LoefBer'sche 
Bacillus ( Deutsche med. Woch., 1895, No. n). .AlsoSilberschmid: 
Miinchener med. Woch., Feb. 26, 1895. Compare also the defec- 
tive results obtained by Vierordt (Deutsche med. Woch., 1895, 
No. II, p. 169), by use of plate-cultures of glycerin-agar. 



DIAGNOSIS AND TREATMENT OF DIPHTHERIA. 



[Medical News 



weeks, and proved negative ; in another, on the 
eighth day, two days before death, and it was also 
negative. Everyone familiar with the subject knows, 
and the New York report has sufficiently emphasized 
the fact, that examinations made quite late in the 
disease are not reliable, and we may properly ex- 
clude these two last-mentioned cases from our 
consideration. Thus, out of seventy-three cases in 
which no Loeffler bacilli were found under proper 
conditions of examination, only one proved fatal, 
or nearly ly^ per cent., while 17 per cent, of those 
died in whom the Loeffler bacillus was found. This 
teaches one important lesson, viz., the presence of 
the Loeffler bacillus in the throat adds very seri- 
ously to the gravity of our prognosis. 

But mortality is not the only test of severity. A 
few weeks ago I sent postal cards to the physicians 
who had had cases examined, asking for clinical 
data, laying special stress upon the duration of the 
disease, the presence of alarming symptoms, the oc- 
currence of sequelae and complications, and the con- 
dition of the heart. I received complete data con- 
cerning forty-one cases, in which the Loeffler bacil- 
lus had been found ; in eighteen of these (just 40 
per cent.) the physicians reported the patients as 
dangerously sick, in many cases from weakness of 
the heart ; of the non-diphtheric cases, aside from 
the three that died, only one patient was reported as 
having been in danger, and that one from laryngitis; 
/. e., seventy-one out of seventy-five cases froin which 
the Loeffler bacillus was absent ran a mild course 
without arousing any alarm. 

Can anything be more convincing than that the 
bacillary sore-throat is a very different disease from 
the non-bacillary sore-throat ? So much for gross 
figures. I think, however, that examination into 
the details of several series of cases will prove still 
more striking and show still more forcibly the value 
of bacterial diagnosis. 

On January 5th a tube was sent with the diagnosis 
of tonsillitis. The physician in charge said that there 
was no suspicion of diphtheria, and the patient was 
not isolated. Two days later the child's brother 
contracted an angina. Bacterial examination of the 
first case revealed the presence of many cocci and 
few Loeffler bacilli ; the second throat contained 
almost a pure culture of Loefller bacilli. Both 
children were markedly prostrated, out of all pro- 
portion to the apparent throat-lesion ; the first child 
was weak for a month after recovery; the second 
child was in great danger from heart-failure for a 
week, and suffered later from paralysis of the 
pharyngeal and ocular muscles. 

On February 14th a tube was sent with the diag- 
nosis of severe tonsillitis. Examination revealed 
almost a pure culture of Loeffler bacilli. The case 
ran a very mild and favorable course for four days ; 
on the fifth the patient, sixteen years old, died very 
suddenly from heart-failure. 



In January a tube was sent with the diagnosis of 
non-diphtheric croup. No membranes were visible 
in the throat, and the temperature was normal. 
Intubation was performed. Bacterial examination 
revealed the Loeffler bacillus ; stenosis returned, 
tracheotomy was performed, large tough mem- 
branes were found occluding the trachea, and the 
child died on the ninth day, after extension of the 
membrane to the lungs. 

In March a tube was sent, and Loeffler bacilli 
were found in abundance. The first physician in 
attendance had diagnosticated catarrhal laryngitis, 
and had let the case run on from bad to worse for 
several days. He was then discharged. The second 
physician immediately had the case examined 
microscopically, and intubation was performed, but 
death followed after sixteen hours. 

In all of these cases ^zxXy bacterial examination 
would have thrown much light on the diagnosis 
and prognosis, and lives might have been saved. 
Other similar cases might be cited, but those de- 
tailed are sufficiently striking to show the great 
value to the clinician of bacterial investigation. 

A few words in regard to the fatal cases in which 
no Loeffler bacilli were found. One was in a child, 
fourteen months old, that suffered from purulent 
coryza for two weeks, laryngeal stenosis and pro- 
found sepsis being present on its admission to the 
hospital. Only cocci were found after a minute 
examination. The antitoxin was used, and the 
child revived considerably. Cultures were made 
at intervals of two days, and no Loeffler bacilli were 
ever found. The child died seven days after ad- 
mission to the hospital. 

Case No. II occurred in a family in which several 
members suffered from true Loeffler diphtheria. All 
the cases were malignant, and this one fatal, 
although no Loeffler bacilli were found. Only one 
culture was made, and lam inclined to believe that 
I must have made an imperfect examination, as 
Loeffler bacilli were found in other members of the 
same family. 

Case No. Ill was the one referred to. A six- 
months-old baby suffered with large extensive mem- 
branes in the throat ; no culture was made until the 
eighth day, two days before the fatal issue. I am 
not informed as to whether the cause of death was 
croup or sepsis. There is no doubt that some cases 
of diphtheria occur in which Loeffler bacilli play no 
role. Fischer' reports a case of septic diphtheria 
in which cultures made daily for seven consecutive 
days failed to discover the Loeffler bacillus, and even 
a post-mortem culture revealed nothing but cocci. 
Fraenkel- admits also that there is such a thing as 
coccus-diphtheria, although its occurrence is quite 
rare. For the present we must simply shrug our 

' N. Y. Med. Rec, April 6, 1895, p. 420. 
*•' Log. cit. 



July 6, 1895] 



DIAGNOSIS AND TREATMENT OF DIPHTHERIA. 



shoulders at these rare and unfortunate cases, and 
leave their explanation to further investigation. 

I approach with some diffidence the subject of 
the therapeutic effects of the antitoxin. Veterans 
in medicine have tried it in a large series of cases, 
and have been reticent as regards the scientific value 
of their results. Rapidly, however, a large litera- 
ture on the subject is accumulating, and it behooves 
us at least to keep in touch with the advanced 
thought. No one, I think, can follow what has been 
written on the subject during the past six months 
and regard it with indifference. Certainly no one 
can read the calm judicial testimony of medical 
experts in all parts of the world that classes of cases 
that formerly died do now recover, that a smaller 
percentage of cases die than formerly, and that 
severe cases now recover without need of operative 
interference, without wishing in his heart that such 
testimony is true. When men of world-wide repu- 
tation range themselves one after the other on the 
side of the new remedy we are compelled, with all 
our natural skepticism, to be encouraged. The 
names of Virchow, Escherich, Ganghofner, Ranke, 
Vierordt, all on one side, are strong testimony of 
themselves. In February of this year Foster' col- 
lected statistics of 2740 cases treated with antitoxin ; 
of these 1S.5 per cent, died ; also of 4445 cases 
treated without antitoxin ; of these 45 per cent. died. 

I shall not load down your minds with bald statis- 
tics. Nothing is more tiresome or unprofitable. 
Since January of this year I have had occasion to 
observe closely seventeen cases of diphtheria. Dur- 
ing February and March Dr. Forchheimer very 
generously placed his diphtheric patients at the 
City Hospital under my charge, and I am greatly 
indebted to him for the cases treated in that insti- 
tution. 

In January two brothers were admitted to the hos- 
pital suffering from a very severe form of diphtheria. 
The younger brother, four years old, had been sick 
eight days and had a very intense nephritis, with 
weak heart and complete anorexia. Many Loeffler 
bacilli were present ; two days later they were absent 
from the throat. No antitoxin was used, owing to the 
condition of the kidneys and the advanced stage of 
the disease.- The nephritis grew worse daily, notwith- 
standing active treatment, and the child died twelve 
days after admission. The older brother, aged eight 
years, had contracted the disease three days before 
admission. At first he presented indications of only 
a moderately severe pharyngeal diphtheria and re- 
ceived tonic treatment. Soon, however, he de- 
veloped a marked nephritis, like his brother, and 
five days after admission had severe symptoms of 
laryngeal stenosis; his temperature rose to 103.8°, 
and his condition became very critical. Ten c.cm. 



' Foster : THE MEDICAL News. Philadelphia, Feb. 2, 1895. 
* Neither of these conditions, however, is a contraindication 
against the use of antitoxin. 



of the Roux antitoxin were injected in the inter- 
scapular space. During the next twenty-four hours 
the temperature fell steadily, the pulse-rate and 
frequency of respiration remained about the same, 
and the dyspnea was markedly moderated, recurring 
only for short intervals. The further course was 
favorable, the albuminuria lasted two weeks, Loeffler 
bacilli persisted only two days after the injection, 
and the boy made a slow but complete recovery. 
This, my first case, made a very favorable impression 
on me. 

A week later a child aged fourteen months was 
brought to the hospital in an apparently moribund 
condition ; the pulse was scarcely palpable ; opis- 
thotonos was marked, and the fetid odor from the 
throat scarcely endurable. The mother at first 
refused treatment, saying she did not wish the 
child uselessly tormented, and death seemed a ques- 
tion of only a few hours. We injected, however, 
5 c.cm. of Behring's antitoxin. No. 2, and were 
much astonished to see in the course of twelve 
hours a remarkable change in the child's condition. 
It now sat up in bed and took nourishment greedily, 
but during the course of the day relapsed into its 
former condition. Injections of the antitoxin were 
repeated twice, both times causing a very marked 
and unmistakalDle change for the oetter. On the 
fourth day we were inclined to make a favorable 
prognosis; the heart, however, became very weak, 
the respirations rapid, fetid diarrhea set in, and the 
child died with high fever on the seventh day. 
Repeated examinations in this case failed to reveal 
Loeffler bacilli. Here was a case ending fatally, 
which, nevertheless, afforded to the few of us who 
witnessed it the greatest encouragement regarding 
the value of the antitoxin. 

A few days later five children were placed under 
my charge at once. Two sisters, Mary and Gertrude 
E., aged respectively six and nine years, had exten- 
sive exudations with almost pure cultures of Loeffler 
bacilli, and yet the local and constitutional symp- 
toms were so slight that no treatment was instituted, 
except rest in bed and light diet. Both cases 
developed albuminuria of moderate degree, which 
persisted sixteen days. 

Three other sisters, aged respectively four months, 
four years, and six years, all had extensive exuda- 
tions in which the Loeffler bacillus was demon- 
strated. One case ran so favorable a course that 
no antitoxin was used ; on the second day the 
infant's temperature rose to 103 S'' and the mem- 
branes extended. Five c.cm. of Behring's No. 2 
were injected at 10 p.m., and the change for the 
better began in a few hours, and after that the tem- 
perature remained below 100° F., and no threaten- 
ing symptoms recurred. The oldest sister received 
two injections of the antitoxin, each 5 c.cm., which 
seemed to affect the course of the disease very 
favorably. These children also had albuminuria 
lasting two weeks, the one in which no antitoxin 
had been used no less than the others. 

I shall not detail all the cases treated. One child, 
aged ten years, received 10 c.cm. of the antitoxin 
for laryngeal obstruction present on admission, and 



DIAGNOSIS AND TREATMENT OF DIPHTHERIA. 



[Medical News 



died four hours afterward from sudden increase of 
stenosis. All the other cases recovered, some with 
and some without the antitoxin. Altogether, nine 
cases received the antitoxin ; two of these died, as 
already recited. Of the seventeen cases observed, 
three died, representing a mortality of 17.6 per cent. 

The mortality in the city during January, Febru- 
ary, and March was 26 per cent. I do not lay any 
stress on the results obtained by us in the hospital. 
The number of cases is too small to be convincing. 
All who saw the cases treated with the antitoxin felt 
sure that we had in our possession a wonderful 
remedy. This subjective feeling of trust in the 
value of the antitoxin is almost universal among 
those who have tried it in any number of cases, and 
speaks more in favor of the remedy than the published 
figures. I shall reserve for another occasion a 
critical estimate of the antitoxin-literature thus far 
published. 

Of some things I am convinced : 

1. That the antitoxin does undoubtedly affect 
favorably a large number of diphtheria-cases. 

2. That it is the duty of physicians to use the anti- 
toxin early in every case of severe diphtheria 
occurring in children. 

3. That the mortality from diphtheria is destined 
to be largely diminished by prompt use of the 
antitoxin. 

I cannot urge upon physicians too strongly to use 
the antitoxin early in their cases of diphtheria. 
The testimony is universal that the earlier the remedy 
is used the more certain is its curative effect. In 
Foster's table, of the 44 cases injected on the first 
day none died ; of 106 cases injected on the second 
day 3 died. Later the mortality ranged from 10 
per cent, to 40 per cent. In Ganghofner's table,' 
of 68 cases treated during the first three days 5 
died ; of 42 cases treated after the third day 10 
died. In Kossel's well-known table, of 82 cases 
treated during the first four days only 2 died ; of 35 
cases treated after the fourth day 11 died. To wait 
for sepsis or laryngeal stenosis before using the anti- 
toxin is folly. The chances of success are greater 
the sooner the remedy is used. All observers agree 
that when the antitoxin is used in pharyngeal 
diphtheria the larynx is not thereafter affected. 

Bad effects from the antitoxin we did not see, 
although about twenty injections were made. I 
prefer the fleshy part of the thigh as the seat of 
injection. Pain was remarkably slight or wholly 
absent, and absorption took place in a very few min- 
utes. One child had a slight erythema after the 
fifth day. 

Can we prevent diphtheria with the antitoxiti ? 
The published reports of prophylactic injections 
are not very encouraging. As the antitoxin does 

' Ganghofner: Prag. med. Woch.. 1895, Nos. i, 2, 3. 



not prevent the growth of the bacillus, it is hard to 
understand how it can prevent diphtheria. It has 
been noted thatrelapsesaftercureby the antitoxin are 
not infrequent; this itself is a strong argument 
against belief in any prophylactic virtue of the new 
medicine. As a matter of fact, diphtheria is not a 
highly contagious disease. Henoch says that in 
seventeen consecutive years only one attendant 
caught diphtheria in his diphtheria-pavilion. It 
is, therefore, a very difficult question to decide, 
especially as diphtheria occurs not infrequently in 
those prophylactically injected. Brewer' injected 
two children for the purpose of prophylaxis. One 
of them developed a membrane the next day, the 
other in six days after inoculation. Richter' made 
72 preventive injections, and 7 of the persons were 
nevertheless affected. Sonnenburg" made 16 in- 
jections; diphtheria occurred in 2 of the cases. 
Hager' immunized 35 children and 3 took sick. 
Brunstein^ immunized 28 cases and i took sick. 
PearP immunized 67 persons between the ages of 
four months and fifteen years ; 13 contracted diph- 
theria and 2 died. 

Summing up these reports we find that of 220 
persons injected, 28 (12.7 per cent.) v/ere never- 
theless affected. This is certainly not a good show- 
ing. If one out of eight people had smallpox, 
Jenner's name would not be celebrated as it is to- 
day, and smallpox is far more contagious than 
diphtheria. On the whole, we are compelled to say 
that evidence of the value of prophylactic injec- 
tions of the antitoxin is still wanting. 

Is the antitoxin a specific against diphtheria in the 
sense advocated by Behring and Roux ? By the 
question we mean, does the antitoxin neutralize the 
effects of the disease in the system and thereby in- 
sure recovery ? In one thing all authors agree, i.e., 
that the antitoxin does not kill the Loeifler bacillus 
or prevent its further development. In several of 
our hospital-cases the bacilli persisted in the throat 
for days and even weeks, notwithstanding the use 
of the antitoxin. Other observers have demon- 
strated that the bacilli not only persist in the throat 
but also retain their virulence for guinea-pigs.' 
Therefore the antitoxin cannot be called a specific 
for diphtheria in the sense that quinin is a specific 
for malaria. It certainly does not destroy the cause 
of the disease. 

Mercury is called a specific for syphilis without 

' Brewer: THE MEDICAL News, Philadelphia, Jan. 19, 1895. 

' Richter: Deutsche med. Woch.. 1S95, No. 7.I 

' Sonnenburg; Deutsche med. Woch., 1894, No. 50. 

* Hager : Therap. Monatsh., February, 1895, p. 91.' 

^ Brunstein: Wiener klin. Woch., 1895, No. 3. 

f' Pearl : Ibid. 

" Virulence for guinea-pigs should by no means be made the 
test for human beings, as it is in no sense conclusive. Each species 
of animal is a law only unto itself. 



July 6, 1895] 



COMMISSIONS TO PHYSICIANS. 



presumably destroying the cause of syphilis ; in 
some way it neutralizes for the time being the syph- 
ilitic virus. It is difficult to say just to what extent 
this is true of the antitoxin of diphtheria. The 
children seem certainly to improve under its use, as 
every eye-witness can testify. And yet there is 
much evidence to show that the poison is not neu- 
tralized. Diphtheric nephritis and post-diphtheric 
paralysis are commonly assumed to be the result of 
the action of the diphtheric virus on the kidneys and 
nervous system respectively. Certainly the poison 
that leads to nephritis and paralysis is not neutral- 
ized by the antitoxin ; so in the sense of mercury 
for syphilis, we can scarcely speak of the antitoxin 
as a specific for diphtheria. In a word, all our the- 
orizing about the antitoxin is as yet without avail. 
The clinical fact is plain that a larger percentage of 
cases recover with it than ever did under any other 
form of treatment. This is the one practical fact, 
testified to almost universally, that makes the use of 
the antitoxin a matter of duty in cases of diphtheria 
in children. 

And now a few words regarding the relations of 
the city to the question of the bacterial diagnosis of 
diphtheria. Modern custom has relegated to the 
city officials all over the world the task of dealing 
with the health-questions of the respective cities. 
The more advanced cities in Europe and America 
have already established disinfecting bureaux and 
stations for the destruction or disinfection of con- 
tagious material. Cincinnati has done little that is 
efficient in that regard. New York was the first city 
in the world to make adequate arrangements for the 
control of diphtheria and tuberculosis by means of 
bacteriologic examinations. The fact has been made 
perfectly plain that only by repeated bacterial ex- 
aminations of the throat can we test whether a case 
of diphtheria has became free from infecting power 
or not. It is known that Loeffler bacilli remain in 
the throats of diphtheria-convalescents for many 
days and even weeks. One series of examinations 
at the City Hospital revealed the presence of the 
germ up to the fortieth day of convalescence ; and 
repeatedly have we found the germ at the end of the 
third week. Nothing is more evident than that our 
present mode of placarding houses is not only un- 
just to the occupants, but also inadequate for public 
safety ; many a family is seriously discommoded, its 
children kept from the schools — because the physi- 
cian assumed a simple angina to be diphtheric. It 
has been my fortune more than once during the 
past five months to see cases which other physicians 
had called diphtheria, and which proved to be non- 
diphtheric. Patients have a right to demand bac- 
teriologic examination before submitting to weeks 
of isolation, often with considerable detriment to 
business and always to convenience and comfort. 
The ipse dixit of the attending physician is by no 



means sufficient, be he who he may. On the other 
hand, placards are removed from houses four days 
after the physician signs a certificate that the patient 
is well, no matter whether the patient still be a 
source of public danger or not. The only possible 
control is the bacterial control — and it is now a 
matter of public necessity that every municipal 
health-department should be under the management 
of a professional and expert bacteriologist, with as- 
sistants and clerks who should devote all their time 
to the work in hand. 

Cincinnati has recently applied salve to its own 
conscience by providing for the expenditure of 
^500 to pay for apparatus, office-work, and the 
salary of the city bacteriologist ; while everyone 
knows that that sum is ridiculously inadequate to 
supply what is needed. Other cities have out- 
stripped us. Brooklyn has adopted the same sys- 
tem as New York. In Boston the work has been 
done for the past seven months. In November and 
December of 1894 1002 cultures were examined by 
the city bacteriologist, who was relieved of all 
other work; in January, 1895, 842 cultures were 
examined. Boston has also provided for the manufac- 
ture of antitoxin, and has seven horses under treat- 
ment. The Philadelphia Board of Health has ap- 
propriated g 1 5, 000 to establish a bacteriologic 
bureau. In St. Louis the City Board of Health 
has for some months been examining for tubercle- 
bacilli and Loeffler bacilli, having established 
eighteen stations in the city for the receiving of 
specimens. New Orleans has for more than a year 
had a fully equipped and active bacteriologic bureau. 
Cleveland is supplied with antitoxin from the 
Western Reserve University. Buffalo has two pro- 
fessional bacteriologists who devote all their time to 
the work. Tubes for diphtheria-diagnosis are dis- 
tributed to the thirteen police-stations of the city, 
and examinations are also made for tuberculosis. 
The tap-water and reservoir-water are examined 
daily ; the mik and ice at proper intervals. Detroit 
has begun the work of bacterial diagnosis, and In- 
dianapolis will fall into line this autumn. 



COMMISSION S TO PHYSICIANS UPON THE 

SALE OF ORTHOPEDIC APPARATUS, 

FROM THE MANUFACTURERS 

STANDPOIN T. 

BY H. AUGUSTUS WILSON, A.M., M.D., 

:L1NICAL PROFESSOR OF ORTHOPEDIC SURGERY. JEFFERSON MEDICAL COE. 
lege; PROFESSOR OF GE 



In the Philadelphia Polyclinic for September, 
1894, I published a paper entitled " Can Physicians 
Honorably Accept Commissions from Orthopedic 
Instrument-makers ? " in which I presented the 
subject from the standpoint of the physician. The 
position taken in that article is concisely stated in 



COMMISSIONS TO PHYSICIANS. 



[Medical News 



the closing paragraph, in which I said: "If it is 
honest so to defraud the patients submitted con- 
fidingly to the care of the physician, it is just as 
right to ignore totally every point in the Code of 
Ethics that indicates to the contrary. If it is dis- 
honest, and what physician can dispute it? are we 
not obliged, by the very words and spirit of the 
Code, so to proclaim it ? " 

A further consideration of the subject demon- 
strated that there is another standpoint from which 
the subject should be considered, namely, from that 
of the manufacturer or the business-man. I there- 
fore sent a copy of my paper referred to, to a large 
number of manufacturers of orthopedic apparatus, 
artificial limbs, and trusses, with the request that 
they favor me with their views and opinions can- 
didly expressed. The replies, from which extracts 
are used, form the basis of this article and are of 
great value in showing that too often physicians per- 
mit themselves to be classed, as Dr. Solomon Solis- 
Cohen has tersely denominated, "sales-agents." ' 

Illustrative of this I quote from the Winkley 
Artificial Limb Co. : 

"We receive almost daily several letters from physi- 
cians, in apparently good standing, asking us how much 
commission we will pay them if they will send us a 
patient or an order for an artificial leg, and that they would 
like to have the limb, if purchased, either sent directly 
to them with one bill in full to show the patient, and 
one to them personally, less the commission ; or that 
the limb be sent directly to the patient for the full amount 
and the commission sent to them. We recently received 
a letter from a surgeon having a large practice which 
read as follows : ' I now have five patients with ampu- 
tated legs who are either ready or soon will be to wear 
artificial legs. I am going to have them place their 
orders with the firm that will pay me personally the 
largest commission. I do not care where they purchase 
their limbs so there is something in it for me. If you 
will pay me a larger commission than other firms, I will 
have them each and all place their orders with you.' 
We simply answered the latter by stating that we allowed 
no commission whatever, etc." 

If this were a single instance, it would properly 
be considered as coming from some contemptible 
man besmirching the profession, the dignity of 
which it was his duty to uphold, and consequently 
beneath notice. In a number of replies from 
manufacturers, however, it is stated that they have 
had numerous requests from physicians for commis- 
sions ; therefore the whole matter appears to come 
back to the starting-point, that in reality it is the 
physicians that make these commissions necessary. 
This view is substantiated by Sharp &: Smith, who 
state : 

" Would say if commissions are paid to them it is 
because it is agreeable to the physician who controls 
the order. We believe the whole matter rests with the 
physician." 



' "Shall Physicians Become Sales-agents for Patent Medi- 
cines?'' by Solomon Solis-Cohen, M.D. Read before the Phila- 
delphia County Medical Society, April 27, 1892. 



George R. Fuller, of Rochester, New York, says : 

" The custom amongst the profession of anticipating, 
accepting, and, I might say, exacting a commission on 
artificial limbs, trusses, etc., as a rightful legitimate fee, 
has become nearly universal, and 1 am glad to know 
that there is one of them who has the courage to brand 
the custom as a fraudulent one, an outrageous breach 
of the faith and confidence extended by the patient, 
and a violation of the Code." 

The object of this paper is to reach those physi- 
cians who may not fully comprehend the importance 
of upholding the dignity of their profession, and 
who are acting as "sales-agents" in obtaining 
money under false pretence, and exposing the pro- 
fession to just censure. 

Mr. Frederick M. Bush says : 

" I would divide physicians into three classes in the 
matter of orthopedics. First, those who know what 
they wish to do and how to do it, including the general 
mechanical design. Second, those who know what 
they want to do, but don't know how to do it, and leave 
the designing of the appliance to the instrument-maker. 
Third, those who don't know anything about it. For 
the first class, and the smallest, it is sufficient that the 
instrument-maker knows enough to follow the measure- 
ments and directions given, with perhaps an occasional 
suggestion from him on points strictly of mechanical 
detail. With such a physician it is ordinarily unneces- 
sary for the instrument-maker to see the case ; con- 
sequently all the business is transacted through the 
physician and the appliance is charged directly to him. 
Now his bills with his instrument-maker are probably 
settled monthly, and if his patients pay on the same 
terms, well and good. But suppose he is not always so 
fortunate, and some of his accounts run three, six, 
twelve months, and some he never gets. Physicians' 
bills are not always collected ; where does he get the 
interest or make up the deficiency ? Must he lose it out 
of his pocket because he has been unfortunate enough 
to have to advance cash ? Is it not better and more 
equitable that he charge sufficiently more for such ap- 
pliances to enable him to have a sort of sinking-fund 
from which he can reimburse himself for losses so caused ? 
It seems so to me, and where is the need of secrecy ? 
Business is business the world over, a church or a doc- 
tor's office, a theater or a dry-goods house should all be 
run on a business basis, and, though the superficial forms 
of advertising and dispensing commodities may differ, 
the same sound principles underlie success in any case. 

" But does a solid conservative business concern take 
risks without hope of remuneration ? Assuredly, no. 
Somebody has to pay ; and the pay is proportional to 
the risk ; and there is no thought of concealment. 

"The second class of physicians should be governed 
by the rules which govern the first and third class. The 
more ability the physician requires of the instrument- 
maker and the less financial risk that is run, the less 
pay should the physician expect and the more should 
the instrument-maker get out of the work. The third 
class is not very hard to dispose of, because if they 
don't know anything, they can't do anything, and if 
they can't do anything they are not worth anything. 
Of course, a good many of the second class and all the 
third class had better not fool with orthopedics." 

Of the duties of physicians to each other and 
the profession at large. Art. I ("Duties for the 
Support of Professional Character") of the Code 
of Medical Ethics says : 



July 6, 1S95] 



COMMISSIONS TO PHYSICIANS. 



"Ever>- individual, on entering the profession, as he 
becomes thereby entitled to all its privileges and im- 
munities, incurs an obligation to exert his best abilities 
to maintain its dignity and honor, to exalt its standing, 
and to extend the bounds of its usefulness." 

Art. II. : 

" There is no profession from the members of which 
greater purity of character and a higher standard of 
moral excellence are required than the medical ; and to 
attain such eminence it is a duty every physician owes 
alike to his profession and to his patient. It is due to 
the latter, as without it he cannot command their respect 
and confidence ; and to both, because no scientific attain- 
ments can compensate for the want of correct moral 
principles." 

The following expressions of opinion condemn- 
ing commissions are worthy of consideration : 

" We would be glad to see all commissions abolished, 
as it opens, the door to many methods which are rank 
injustice to patient, merchant, and doctor." — C. W. 
White & Co. 

" We have never under any circumstances allowed a 
commission on apparatus or appliances to anybody, in 
a business career of over fifty years, although we have 
had numerous recjuests to do so, and have likely lost a 
number of cases in consequence." — J. H. Gemrig & 
Son. 

'■ I wish to inform you that we are heartily in sympathy 
with the stand you have taken concerning this subject. 
We beheve that the practice, prevalent as it is, of pay- 
ing and receiving commissions, either from a business 
or professional standpoint, is radically wrong.'' — The 
WiNKLEY Artificial Limb Co. 

" A physician has a right to be paid for his services, 
a lawyer his fee, a real-estate agent his percentage, a 
merchant for his ware. But when a physician is paid 
for his services and then demands a commission for 
sending his patient to an instrument-maker for an ap- 
pliance, to such Dr. Solomon Solis-Cohen's term 
' sales-agent ' is properly applied. I have been strug- 
gling against it for years and probably lost the trade of 
numerous doctors on this account." — William Auten- 

RIETH. 

" We have read your pamphlet with interest and 
think the salient points well taken." — J. C. Schnoter & 
Son. 

" It gives us great pleasure to indorse your views in 
regard to physicians taking commissions from instru- 
ment-makers. The correction of this abuse will enable 
all interested to retain their self-respect." — ^D. W. Kolbe 
& Son. 

■' I have never conducted my business on any per- 
centage plan, and, unless I am requested by the physi- 
cian, never pay him any. I have met with not a few 
who have asked for 'their' percentage, and have paid 
it rather than lose their influence." — A. Gustav Gef- 
vert. 

" I enjoy the patronage of many a doctor who desires 
the welfare of his patient only, but also others who will 
not advise the use of my truss without expecting a com- 
mission. What will a man in my position do ? Say no ? 
1 cannot well afford to give a commission, but losing the 
sale is out of the question on account of the influence 
felt afterward. " — H. Klixger. 

"We do not offer commissions to physicians ; how- 
ever, when demanded, we are obhged to comply. When 
he orders an article and it is supplied by us as a piece of 
merchandise, it is sold as such ; but when we must fit it, 
then in a business sense it is not mercantile to under- 
handedly offer or give a share of the profit." — Anony- 

iMOUS. 

" It seems to us that surgical instrument-makers are 
about the last ones whose opinions toward the rest of 

I* 



the world are of any account on this subject. No one 
believes more fully than we in the old saying, ' Let him 
who is guiltless throw the first stone." Imperfection 
pervades mankind to such an extent that it is not reason- 
able to require absolute, simple purity in any one re- 
spect. Moreover, that which disposes of the whole 
subject, in our minds, is that the medical profession, as a 
whole, occupies in the social body a position so re- 
spected that it behooves itself only through its properly 
constituted bodies to lay down each and every feature of 
its Code of Ethics." — John Reynders & Co. 

"A few years ago I reduced the prices of artificial 
limbs about one-third and made an effort to keep the 
prices unvarying, without reduction or commission to 
anyone. 1 soon found that in order to get any business 
from the profession it would be necessary to allow a 
discount, and 1 have since made a practice of discount- 
ing 10 per cent, from the quoted prices on artificial legs. 
Taking a financial view of it, I am satisfied that it was 
a mistake to reduce the prices. I believe that I could 
more easily sell an artificial leg through the average 
practitioner at Sioo with a 25 per cent, discount than I 
could by placing the advertised price at 560 or 570 with 
a 10 per cent, discount, with every assurance that the 
construction of the limbs would be the same. 

" It is unquestionably true, however, that many physi- 
cians give the patients the benefit of the discount. 
Knowing that it is the rule for physicians to expect a 
commission or discount from the published prices of 
Aeir products, it is perfectly natural that instrument- 
makers should make provision for it. These abuses 
are the result of the growing selfishness and corruption 
of the age, v;hich, to a greater or lesser degree, enter 
into all classes and professions, and it will undoubtedly 
continue to increase so long as the possession of wealth 
is thechief ambition of mankind." — George R. Fuller. 

"In some instances where physicians claimed that 
they had been allowed concessions of this nature by 
other instrument-manufacturers, 1 granted them. To 
such an alarming extent has the practice been carried 
that patrons have become aware of it (as they justly 
should) and have asked me to give them the benefit of 
the physician's commission. Requests of this nature, 
on many occasions, have put the physician, as well as 
myself, in a questionable position. Considered either 
from a professional or a commercial standpoint, the 
practice, I am convinced, is a most reprehensible one, 
and an immediate, earnest, honest effort should be made 
for its abolishment."— William Snowden. 

Only three manufacturers have frankly and can- 
didly written advocating the giving and receiving 
of commissions, and they do it by classing physi- 
cians, drug-houses, instrument-houses, and commis- 
sion-houses as their profitable sales-agents. 

" The legitimacy of authorizing drug-houses, instru- 
ment-houses, and commission-houses to obtain orders 
upon commissions has always been recognized and has 
never been placed within the pale of criticism. It has 
proved to be the most economical way by which articles 
of great benefit, service, and necessity can be made ob- 
tainable, with the least inconvenience to the parties 
needing them. Commissions are granted as compensa- 
tion for time and labor expended in taking measurements, 
attending to the details of ordering goods, receiving 
them when finished, and properly delivering them to 
the parties for whom they are intended, and not as a 
bribe for favoritism, as 1 construe your paper to imply. 
I cannot see why physicians should not have the same 
privileges and obtain the same compensation if they 
perform the same services, especially as the commissions 
allowed do not affect the cost of purchase to the wearer. 
There is one strong argument in favor of granting com- 



COMMISSIONS TO PHYSICIANS. 



[Medical News 



missions to physicians which should not be lost sight of, 
that is, that a very large proportion of physicians who 
receive commissions on orders for artificial limbs turn 
those commissions over to their patients, and thus place 
the cost of an artificial limb at a lower price than the 
patient would be able to buy if he bought directly from 
the manufacturer or if he passed the order through a 
commission-house, druggist, or shopkeeper." — A. A. 
Marks. 

"After duly considering the subject I will give you my 
candid opinion in the matter, ' Can Physicians f^onor- 
ably Accept Commissions from the Manufacturers to 
Whom They Send Their Patients ? ' They can do so in 
many cases without the patients paying one cent more 
for the article than they would if they purchased it 
themselves. My opinion being based upon the follow- 
ing facts: The manufacturer produces an article which 
he finds he can produce at a certain price ; to that he 
must add at least twenty-five per cent, so that he will 
have a profit, as it will cost him at least ten to fifteen 
per cent, to sell the article by agents, advertising, etc. 
Now we have the wholesale price. To give the retailer 
a profit there must be added another twenty-five per 
cent, on the wholesale price so that he can live. Now 
this twenty-five per cent, that is put on to protect the 
retailer is generally given in part, or the whole of it, to 
such people that can bring you trade, which people are 
generally considered by the manufacturer as his agents." 
— Chari.ks a. Bickei.. 

" Being a member of the noblest profession in the 
world, you are aware of the fact that, though physicians 
frequently go to considerable trouble in getting an ap- 
paratus made which will suit the case, they quite often 
receive but little if any remuneration for their services. 
This being the case, we believe that they are entitled to 
a commission, providing the patient or his relatives can 
afford to pay a good price for the apparatus. Should 
the patient and his relatives, however, belong to that 
class who are obliged to work hard for their daily bread, 
we believe that it is the duty of the attending physician to 
notify the manufacturer to that effect, renounce his com- 
mission, and leave the whole matter to the judgment of 
the manufacturer." — Thk R. Hyde Co. 

The relative position of physician and manufac- 
turer is very difficult to define either from a profes- 
sional or manufacturer's standpoint, for the reason 
that comparatively few physicians are sufficiently 
familiar with mechanics to order definitely an ap- 
paratus, or adjust it alter it is made. Therefore 
the orthopedic-apparatus maker cannot be classed 
exactly like the apothecary or manufacturer of phar- 
maceutic preparations — nor can his services be 
entirely dispensed with by those physicians who 
even dispense their own prescriptions. 

For instance, a physician having a patient re- 
quiring some form of apparatus, is very likely to 
send the patient to the manufacturer with a note 
saying, in effect ; "I know my patient requires an 
apparatus of some kind, and I will ask you to apply 
what you think will accomplish the desired pur- 
pose." The physician's act in such a case would 
be to make the instrument-maker prescribe for the 
patient, i.e., to practise medicine, but without a 
licence to do so. The instrument-maker, imbued 
with the idea that the physician does not wish to 
direct or prescribe mechanical appliances, is ready 
to assume full charge of the patients sent to him 



by a physician or coming to him through some 
otlier patient. 

Many patients remain under the care of the in- 
strument-maker for periods of months and years, 
never once having their physician see them to decide 
•whether the mechanical requirements of the case 
are being properly fulfilled. Instrument-makers 
have told me that in cases, for instance, of rachitic 
bow-legs, when a correcting apparatus was applied 
and the patient sent back to the physician for ap- 
proval, that he has told the patient to go to the 
instrument-maker if the apparatus got out of order. 
I have known cases of this kind to wear an apparatus 
for a year without any adjustment whatever, and 
yet is it not natural to suppose the growing child 
would change and improvement in the deformity 
would demand frequent adjustment which should 
be directed by the physician ? 

Many truss-makers tell me that they consider it 
impossible for physicians accurately to prescribe or 
adjust a truss because they do not carry a large stock 
from which to select. If this is true, it is difficult 
to understand how a physician can accurately ad- 
just a splint for a fracture or a pessary for a deflected 
uterus. Again, there are instrument-makers who 
deprecate this assumption of authority. Mr. Fre- 
derick M. Bush, for instance, says : 

" As to the instrument-maker turning doctor : He has 
no more right to do so than has the doctor to become 
instrument-maker. The functions of the two are 
totally different, and while the one may have ability 
of as high an order as the other, their educations 
so differ that they cannot become one and yet retain 
highest efficiency in either sphere. The physician should 
know the iiuxhanical theory and the therapeutic details ; 
the instrument-maker should know the therapeutic 
theory and the vieclianical details. The physician takes 
the responsibility of prescribing the right thing ; the 
mechanic takes the responsibility of correctly making 
the physician's nrescription. A man brought in a steam 
whistle to have repaired and at the same time said he 
wanted me to make a brace for his child. He would 
not go to a physician, but wanted a brace after his own 
ideas plus what I might suggest. All right, said 1, I am 
not repairing many whistles nowadays, but I will fix your 
whistle and make your brace, but when they are both 
done I don't care whether you put the whistle on the 
engine and the brace on the child, or whether you put 
the brace on the engine and the whistle on the child. I 
wash my hands of the whole matter. I don't want to 
play with things I don't understand, and it seems to me 
no one else should do so simply for the money there is 
in it. Outside of the honor and morality of the thing, it 
looks to me like very poor and shortsighted business, 
though I am well aware that the general public is fearfully 
gullible ; however, ' you can fool some of the people all 
the time, and all the people some of the time, but you 
can't fool all the people all the time.' And when the 
instrument-makers try to do that, it results in their 
being found out by the intelligent public and winning 
the distrust and dislike of the decent physicians who 
would otherwise be their patrons." 

The proper relationship of patient and physician 
is clearly defined in reference to all other thera- 
peutic measures, and, by inference, also in reference 



July 6, 1895] A NEW METHOD OF TREATING PERSISTENT VOMITINC, 



to mechanical appliances, both by the Code of 
Medical Ethics and by the medical laws of the 
various States. Sec. 15 of the medical laws of 
Pennsylvania states : 

" Nothing in this act shall be construed to interfere with 
the manufacture of artificial eyes, limbs, or orthopedical 
instruments or trusses of any kind, or fitting such in- 
struments on persons in need thereof." 

The three conspicuous features of this clause are, 
first, that the medical laws of this State must not 
interfere with the manufacture of these instruments 
referred to. Second, there shall be no interference 
with the fitting of these appliances, presumably by 
the maker or seller. The third feature describes 
the class of people for whom the appliances are 
made and upon whom they are to be fitted without 
interference "on persons in need thereof. 

The question as to who is to decide what persons 
are in need of appliances is necessarily not dis- 
cussed, for the clause referred to is part of an act, 
a part of the title of which says " to provide for 
the examination and licensing of practitioners of 
medicine and surgery, to further regulate the prac- 
tice of medicine and surgery." 

For example, Sec. 9 of the laws of .\rkansas says : 

" That any persons who shall prescribe or administer 
medicine for or shall in any way treat diseases or wounds 
for pay shall be deemed physicians and surgeons under 
this act, and therefore entitled to all the privileges and 
penalties which are defined by the law. " 

With diff"erent wording, but the same idea, the 
same condition exists in Arizona, California, Colo- 
rado, Delaware, District of Columbia, Illinois, Iowa, 
Minnesota, Missouri, Montana, Nebraska, New 
Jersey, New Mexico, New York, North Dakota, 
Oklahoma, Oregon, Pennsylvania, South Dakota, 
Utah, Vermont, Washington, West Virginia. 

Georgia is especially explicit in Sec. 2 of its 
medical laws : 

" Be it further enacted, that for the purpose of this act 
the words ' practise medicine ' shall mean to suggest, 
recommend, prescribe, or direct for the use of any per- 
son any drug, medicine, appliance, apparatus, or other 
agency, whether material or not material for the cure, 
relief, or palliation of any ailment or disease of the 
mind or body, or for the cure or relief of any wound, 
fracture, bodily injur)', or other deformity, after having 
received or with the intent of receiving therefor, either 
directly or indirectly, any bonus, gift, or compensation.'' 

If these extracts from the medical laws of twenty- 
five States mean anything, they mean that when a 
patient goes confidingly to a physician it is for the 
reason that the patient believes his physician to be 
of that high order that everyone esteems and honors. 
He naturally believes that in the event of his phy- 
sician not feeling sufficient confidence in his own 
knowledge, experience, or ability, he will consult 
with some other physician, and that he will then 
direct, prescribe, or order such form of remedial 



measures as will be of benefit in the patient's case. 
He should not believe, nor should he have cause to 
believe, that his physician will order for his patient 
mechanical appliances from that manufacturer who 
will secretly pay him the largest commission. 
Equally reprehensible is it to permit a mechanician 
to endanger the life and health of any patient by 
prescribing apparatus, the requirements for which 
can only be disinterestedly comprehended by one 
learned in the laws of disease. 



A SUGGEST! ON BEARING UPON THE TREAT- 
MENT BY A NEW METHOD OF PERSISTENT 
VOMITING. 

By CHARLES L. GREENE, M.D., 

OF ST. PAUL, MINN. ; 

HE UNIVERSITY OF 



It is with considerable diffidence that I propose 
a method of treating a condition that has ever been 
a reproach to the medical profession. Each year 
jces patient after patient die from the effects of 
uncontrollable vomiting, and no means at present 
within our reach meets our need in the really severe 
and dangerous cases. The following plan of treat- 
ment is crude and undeveloped, and the plan is sug- 
gested because I have been vainly awaiting for the 
past year an opportunity to test its real value, 
and because, should it prove useful, further delay 
would be inexcusable. Cases of this kind are un- 




Sliowing special tube and ordinary tube. Full size. 

common, and my practice is along lines which make 
them of even greater rarity to me than would be the 
case if I were in general practice. 

It is evident that in casting about for a way to 



A NEW METHOD OF TREATING PERSISTENT VOMITING. [Medical News 



overcome this forn-.'.dable disease or s)mptomwe 
must first consider the means through which it 
proves fatal. These are chiefly two : 

(a) Actual exhaustion from the violent and per- 
sistent retching. 

(b) Starvation from the lack of power to secure 
and retain a proper amount of nourishment. 

Rectal feeding may partially overcome the latter, 
but is unsatisfactory and inefficient, while in many 
cases no known measure will overcome the former. 
The treatment, to be efficacious, must, therefore, 
prevent the act itself, and thereby insure the recep- 
tion and retention of food. 

In considering the anatomy and physiology of 
vomiting we find a suggestion that when followed 
out may furnish us with a practical means of satisfy- 
ing our needs in this direction, for whatever may be 
the cause of the act, whether local or reflex influ- 
ences excite it, the actual process remains the same, 
and consists simply (a) in a slight contraction of the 
muscular fibers of the stomach itself, bringing 
about closure of the pylorus and opening of the 
cardiac orifice ; (b) a coincident and vigorous con- 
traction of the muscles of the belly-wall ; and (c) a 
rapid and forcible inspiration, with closure of the 
glottis, which fixes the diaphragm and furnishes a 
rigid surface, against which the stomach is vigor- 
ously compressed and thus relieved of its contents. 
Now, it appears to be admitted by modern physiolo- 
gists that unless a stomach be overfull, overflowing 
in fact, vomiting cannot be brought about in adults 
without fixation of the diaphragm, and this fixation 
we find to be dependent upon the rigid ribs and 
pressure excited by the deep inspiration, and the 
column of air retained by the closed glottis. If, 
then, this be correct, and we open the trachea, our 
patient certainly cannot vomit, and if we could se- 
cure the patency of the trachea by intubation we 
would soon have a means of partial or complete 
control. 

Acting upon this theory the modified tube, here- 
with represented, has been constructed by Tiemann 
after the plan submitted by me, and would seem to 
meet the indications in so far as preventing glottic 
closure is concerned, and it is also intended to pre- 
vent complete descent of the epiglottis, which in 
the ordinary O'Dwyer tube would close the upper 
opening and thus defeat its purpose. 

It will be noticed that the tube is like that of 
O'Dwyer's in its general outline, but the head is very 
much greater in height and there is an opening 
upon its anterior face, or rather its posterior aspect, 
as viewed in situ. This opening is intended to allow 
free egress and ingress of air whatever the position 
of the epiglottis. Applied to the cadaver this tube 
fully meets the indications, and should be borne, 
one would suppose, with little more discomfort than 
would be caused by a tube of the ordinary pattern. 



O'Dwyer's articles have amply demonstrated the 
remarkable tolerance of the laryngeal structures, 
and many instances are cited by him in which tubes 
of large caliber were borne with little discomfort 
for a long period. The tube figured is probably 
too long in the shank and too heavy, and, as sug- 
gested by Tiemann, should properly be made of 
vulcanite rather than of metal. 

The association between the center for glottis- 
closure and that of vomiting is so intimate as to 
suggest the possibility that mere prevention of ap- 
proximation of the bands would prevent the proper 
carrying out of the remainder of the act, and if 
this were the case the ordinary tube would be the 
proper one to use. It would seem probable, how- 
ever, that any closure of the air-passage through 
whatever means brought about would admit of the 
completion of the act, and that it were absolutely 
necessary to secure a clear passage for the air and 
thus rob the diaphragm of its rigid base of support. 

The applicability of this method of intubation to 
severe cases of hiccough or pertussis would also 
suggest itself. 

The process of intubation is so simple and well 
understood at the present time as to offer no diffi- 
culties to most of us, and but little hardship would 
be inflicted upon a patient by this procedure. 

I have experienced much difficulty in securing a 
substantial basis for the theory advanced, and con- 
fess myself doubtful upon several important points. 
The observations of surgeons upon the occurrence 
of vomiting after tracheotomy would be of especial 
value here, and will, it is hoped, be forthcoming, 
for should the tube fail through improper construc- 
tion, or for other reasons, I believe that tracheotomy 
would certainly be a justifiable procedure in the 
terrible disease or symptom under discussion. 

There are many factors that will prevent any very 
positive statements for or against the proposed treat- 
ment until the test of actual experience has been 
instituted. Dr. Henry Sewell, of Denver, whose 
work in physiology is widely known, has cautioned 
me against a too ready acceptance of expressed 
views of authorities, and calls particular attention 
to the separate existence of the center of glottic 
closure and that of the act of vomiting itself, indi- 
cating the possibility of independent action, though 
so far as one can ascertain they are supposed to be 
invariably in harmony. The want of definite patho- 
logic knowledge, the possibility of overaction of 
the pharyngeal constrictors, and many other things 
may be thought of as possible disturbing factors, 
yet, nevertheless, it will be seen that there axe pos- 
sibilities in the line of treatment submitted, and the 
opportunity to test it will not be lacking to some of 
us in the near future. The tubes may be obtained 
from Tiemann, and the introducer is that ordi- 
narily used. 



July 6, 1895] 



A CASE OF LUPUS VULGARIS. 



I conclude with an apology for this necessarily 
indefinite and incomplete report, and the hope that 
we shall find something of real utility in the appli- 
cation of intubation or tracheotomy to cases of 
severe and intractable vomitina;. 



CLINICAL MEMORANDUM. 

A CASE OF LUPUS VULGARIS} 

BV LOUIS MACKALL, Jr., M.D.,, 

OF WASHINGTON, D. C. 

When I first saw this patient I thought that her case 
would be an interesting one, and I had a photograph 
taken to show her condition at that time. The follow- 
ing is the history : 

Ida E. , aged eighteen years, resides in a canal-boat 
at the Maryland Dock. About six years ago she was 
treated at the Emergency Hospital for nasal catarrh. 
She described her nose as then being slightly swollen, 
and very much stopped up with crusts. The physicians 
there gave her various snuffs to use. She then went to 
Hancock, Md., to live. While there, about five years 
ago, she says the present condition began on the left ala 
of her nose as a pimple that rapidly formed into a crust. 
The doctor that treated her there told her that she had a 
" cancer," but made no effort to remove it. It is my 
opinion, though I have no absolute proof of it, that this is 
one of those interesting cases in which the disease com- 
menced on the mucous membrane of the nose, and that 
the catarrh for which she was treated at the Emergency 
Hospital was the result of the lupous condition already 
existing. The entire nose disappeared in about three 
months, the left side being eaten away first, then the 
right ; then the disease attacked the rest of the face, and 
continued to spread up to the time she came under my 
care, when the face was one immense scar covered with 
crusts and nodules. The entire nasal cavity was filled 
with crusts and tuberculous ulcerations. There was a 
cleft in the horizontal portion of the palatal bone and in 
the palatal process of the superior maxilla. She says 
that she did not have this cleft when she was a child. 
We are informed by all authorities that lupus does not 
attack the bones. I suppose that they would account 
for the cleft in this case by saying that the soft parts 
ulcerated and left the bones exposed, and that these 
necrosed as a result. When I first saw her there were 
some periosteal nodes on the right ulnar and left tibial 
bones. These disappeared for a time ; but those on her 
leg returned, and again disappeared under treatment. 
During the period of her illness she has been confined 
to bed only three days. I mention the fact to illustrate 
how much these patients can endure and yet go about. 
She menstruated for the first time last month. The 
family history does not furnish any information. The 
girl says that her mother died of dropsy at the age of 
forty-nine years, and that she had a cough when she 
died. Her only sister is living and presents a very 
healthy appearance. She has no signs of pulmonary or 
of laryngeal trouble. She has been under my treatment 
for several months past, and though she comes to my 

* Read before the Clinico- Pathological Society of Washing- 
ton, D. C. 



office very irregularly she has continued to improve very 
rapidly. 

I shall not weary you with a detailed statement of my 
treatment, which has nothing unusual in it ; but I will 
only give a brief synopsis of the method adopted. I 
have been giving her tonics of various kinds, alteratives, 
and as nutritious a diet as possible in her station. I re- 
moved all crusts, and then applied Unna's plaster to her 
face, and a solution of salicylic and carboUc acids of 
the same strength to her nasal cavity until the tubercles 
were completely broken down ; I then dressed the raw 
surfaces with a solution of hydrogen dioxid. 




There have been several classifications ol lupus ; but 
the one generally accepted divides it into two broad 
classes, lupus vulgaris and lupus erythematosus. It is 
not always so easy to decide to which of these two simple 
classes some examples belong. I have seen patients in 
the clinics of Sir Jonathan Hutchinson which even he 
was not able to classify. I consider the most simple 
classification of a disease always the best. Lupus is one 
of the few true tuberculous ulcerations of the skin. It 
is an infectious disease caused by a specific micro-organ- 
ism, the bacillus tuberculosis. Koch has proved this 
fact by finding the baciUi in small number in the nodules 
characteristic of the disease. The bacilh, according to 
Moullin, occur in the shape of very thin non-motile rods 
from two to eight micromillimeters in length, and are 
found in the interior of the giant-cells and epithehal cells, 
but they are so few that many distinguished authorities 
deny that they can be the cause of such a destructive 
ulceration. Both forms are very chronic. 



NEW DEVICE. 



[Medical News 



Lupus vulgaris is very common in England. It is 
even estimated to form about 2 per cent, of all cases. 
But I think that statistics on that point are not reliable. 
Both forms of the disease are rare in this country. 
Lupus vulgaris is much more common than lupus 
erythematosus, and, as my case belongs to the former 
class, I shall confine myself to the description of that 
variety. 

Lupus vulgaris, as a rule, begins in childhood, very 
rarely commencing after the fourteenth year, although 
there are some few cases on record beginning as late as 
the thirtieth year of life. 

The disease generally begins on the face, attacking 
first the cheek or nose. It is usually unilateral, although 
sometimes it presents as symmetrical an appearance as 
lupus erythematosus. It sometimes attacks the limbs, 
buttocks, and mucous membranes. There is a case 
reported by Mathews Duncan in which it attacked the 
vulva, but authorities generally believe this to have 
been a case of syphilis. The face is the favorite locality 
for all forms of lupus, and it generally takes for its victim 
one who has a fair complexion. It is more common 
among females than among males. Crocker describes 
a typical case as commencing with a few scattered or 
grouped spots about the size of a pin-head, of a dull-red 
color, on the level, depressed, or raised, above the 
normal skin. They do not disappear on pressure. 
These spots are gradually developed into small tuber- 
cles which have a semi-translucent aspect and are of a 
brownish color and present the appearance of apple- 
jelly. 

These tubercles, sometimes rapidly, sometimes slowly, 
are developed into a red patch or patches raised dis- 
tinctly above the skin, and having a firm edge. At 
this period there is generally a scaliness present. The 
growth of the disease varies considerably. It has vari- 
able periods of improvement ; the older one gets, the more 
frequent is there a tendency to quiescent periods. I 
think that this is so because the patients learn to take 
better care of their general health, and learn by bitter 
experience to avoid exposure of all kinds. Associated 
with the lesions on the face at a later period of the 
disease they often present on the limbs subcutaneous 
nodules that finally become adherent to the skin itself. 
In those who have a strumous diathesis they often 
present abscesses, periostitis, caries, etc. Joints some- 
tim.es become crippled from the contraction of tendons 
in the cicatrices. 

The age of the patient, the scarring, the apple-jelly 
nodules, and the persisting spreading render the diag- 
nosis easy. 

It is very seldom that there is a complete cure after 
the places are apparently healed up. If the patient 
becomes a little run down in health the disease recurs 
each time, destroying more tissue until the face becomes 
one complete scar. 

Early diagnosis is of extreme importance, for it is 
only in those cases in which it is made that we may hope 
to cure the disease by prompt eradication. 

The treatment is divided into constitutional and local. 
The latter is, by far, the more important ; but the consti- 
tutional should not be neglected, and everything possi- 
ble to improve the general health should be done. Im- 
provement in assimilation is the great aim. As nutri- 
tious a diet as is permissible with perfect assimilation 



should be allowed. The patient should be surrounded 
by good hygienic conditions, and he should avoid ex- 
posure to the weather, as cold is considered one of the 
predisposing causes. Cod-liver oil, iron, hyphophos- 
phites, and other tonics {when they agree with the ali- 
mentary system) are often beneficial, because the disease 
is so often associated with the strumous diathesis. For 
a long time past all attention has been given to local 
treatment. 

Koch's lymph has revived great interest in the gen- 
eral treatment. The great object aimed at is complete 
removal of the tuberculous tissue. We endeavor to do 
this by many different methods ; but the principle of 
them all is the same. Some surgeons use the Volk- 
man spoon. Perhaps this is the most popular method. 
When the spoon is used great care should be taken to 
use it thoroughly at the margins of the sore. The actual 
cautery is applied by some after using the spoon, and by 
others it is applied without the previous use of the spoon. 
Afterward the sore should be dressed with one of the 
various antiseptics. Various chemicals have been em- 
ployed by different surgeons. Among those which are 
most deserving of mention is Unna's plaster, which con- 
sists of salicylic acid and phenol as its principal ingre- 
dients. The phenol is used because of its anesthetic 
power. This plaster is called after the celebrated Unna 
(of Hamburg), who used it a good deal. The application 
should be renewed frequently until the nodules break 
down and free suppuration sets in. Some antiseptic 
ointment should then be applied to the sore. Some 
surgeons use chromic acid and others caustics. The 
result does not so much depend upon the caustic selected 
as upon the care taken by the physician. Recently 
some experimenters have endeavored to produce ery- 
sipelas in the sore, and they claim that the experiments 
have produced some good results ; but I have had no ex- 
perience with this method. There can be no doubt that 
Koch's lymph has proved beneficial in some cases. It 
has rarely failed to produce either a general or local 
reaction, and generally both. Some of the London sur- 
geons have combined the surgical method and Koch's 
treatment with very good results. 



NEW DEVICE. 

A NEW EXTRACTOR FOR THE REMOVAL OF 
INTUBATION-TUBES FROM THE LARYNX} 

By DILLON BROWN, M.D., 

OF NEW YORK. 

The greatest difficulty in the technique of intubation 
is the removal of the tube, and it is almost always during 
eft'orts at extraction that the larynx or neighboring soft 
parts are injured. Either the sharp point of the extrac- 
tor is forced into the soft tissues and a false passage is 
made or the tip fails to enter the tube and passes along 
the outside of it, within the larynx, so that when the 
blades of the extractor are widely opened and withdrawn 
they divulse the larynx, and the tube sinks out of reach. 

On account of these objections many have entirely 
abandoned the operation ; others remove the tube by 
position and by pressure over the trachea ; and others 

' This device was exhibited to the .■\merican Pediatric Society, 
May 27, 1895. 



July 6, 1895] 



MEDICAL PROGRESS. 



13 



remove it by the string, one end of which is attached to 
the tube and the other fastened to a tooth or brought out 
through the nose. The dangers and disadvantages of 
such methods are obvious. 

These serious drawbacks to this most briUiant opera- 
tion have led me to modify the tubes and to devise the 
extractor which is described and illustrated in this paper. 
A wide experience in teaching men who are unfamiliar 
with the operation has demonstrated to me that a large 
proportion of them find much difficulty in removing the 
tube with the old extractor, and many of them never 
succeed in doing it quickly and skilfully. With the new 
instruments rarely does a man have any trouble in 
quickly extracting the tube — even in the beginning, and 
without practice. And it seems to me that a nurse could 
be easily taught to take out the tube after a few minutes' 
instruction pn the cadaver. 

The new tube is as efficient as the old one ; it does not 



the tube. Pulling on this string brings the ends of the 
metal ring together and holds it firmly on the finger, and 
it is kept steady by wrapping the string once around the 
index finger and grasping the wooden handle in the palm 
of the hand. The string can be sufficiently shortened 
by means of the screw to enable one to do this with ease. 

On feeling the tube, and pressing firmly down and 
back, it is almost impossible for the eye to avoid slipping 
between the finger and the hook^ and the shape of the 
latter prevents it from escaping. On withdrawing the 
finger the tube must come with it. It is evident that 
this extractor not only greatly simplifies the removal of 
the tube, but makes it impossible to do any damage to 
the larynx during this procedure. 

These tubes and extractors are made by Mr. George 
Ermold, 312 East Twenty second Street, New York, and 
my thanks are here extended to him for the skilful man- 
ner in which he has carried out my suggestions. 





The Dillon Brown Extractor. 



increase the difficulties of deglutition — rather the reverse 
— and it does not interfere with the older methods of ex- 
traction. It has a stiff wire loop attached to its head (see 
illustration), which is firmly fastened to one side, rises 
about one-eighth of an inch, closely follows the posterior 
edge of the head of the tube, and is finally fastened to 
the corresponding point on the opposite side. This 
makes an eye, bent posteriorly, which is easily and 
almost unavoidably caught, and which does not inter- 
fere with the opening in the tube or with the epiglottis. 
The posterior part of the head of the tube is scooped 
out, making an antero-posterior groove, which still fur- 
ther facilitates the catching of this eye. 

The extractor is a simple hook fastened to the finger 
(see illustration), so that the tip is held moderately firmly 
against its palmar surface, and far enough away from the 
ball to prevent its interfering with the sense of touch. 
The hook is fastened to the finger by the flexible metal 
ring, and is removed by the string after it has caught 



MEDICAL PROGRESS. 

The Cerebral Fissures of Two Philosophers. — In a paper 
read by title before the American Neurological Associa- 
tion, Dr. Burt G. Wilder stated some results of a study 
of the brains of two philosophers, Chauncey Wright and 
James Edward Oliver. These men were recognized as 
superior in character and mental power. They were 
mathematicians, and thought deeply upon the broadest 
questions. Wright was more a writer and general critic ; 
Oliver was more a teacher of advanced mathematics. 
The latter was slight in frame and alert in action, the 
former was large in person and slow of speech and move- 
ment. Wright's brain weighed i5i6grams(53.5oounces), 
Oliver's 1416 (49.94 ounces). Although above the aver- 
age of male brains (about 1400 = 49-4 ounces), greater 
weights are not uncommon even among less intellectual 
persons. In both, the frontal region is unusually high 
and wide; the unprecedented squareness of Wright's 



MEDICAL PROGRESS. 



[Medical News 



suggests some post- mortem pressure, of which, however, 
there is no record, in both, the supertemporal fissure is 
longer than common. Oliver's fissures present seve- 
ral individual variations from the common type, but none 
comparable with the two rare conditions in Wright's, 
already noted by Dwight {.Imer. Acad. Arts and Sci- 
ences, Proceedings, xiii, 210-215, 1877), and by Wilder 
(Joum. Nerv. and Menta! Disease, xvii, 753-4; Amer. 
Neurol. Trans., 1890; Ref. Handbook Med. Sciences, 
viii, 158-159, ix, 108). The complete interruption of the 
central fissure has been observed in a dozen cases or more. 
The simplicity of the fissures and the width and flatness 
of the gyres are paralleled in the Cornell collection only 
in the much smaller brain of an unknown mulatto (No. 
322, Ref. Handbook, viii. Fig. 4767). Some approach 
to this condition occurs in Ruloff, a murderer ( No. 965), 
and perhaps in a German shown by Wagner (" Vorstu- 
dien " Taf. vi. Fig. 2) after Huschke (" Schadel, Him und 
Seele," Taf. v. Fig 2). If fissural simplicity and gyral 
width and flatness are family characteristics, or corre- 
lated with Wright's mental and physical deliberateness, 
then light may be thrown upon the problem by the con- 
ditions to be observed in his blood relations or in others 
similarly "slow but sure" in thought, speech, and act. 
As a close mate for the brain of Chauncey Wright has 
not been found in that of James Edward Oliver, the con- 
templated full account of it need not longer await the 
death of other moral and intellectual compeers. Such 
exceptional cases will always command attention. But 
all estimates of the extent and significance of their pe- 
culiarities will be only provisional until the careful com- 
parison of many average brains supplies one or more 
types or standards. This necessity should be kept in 
the public mind. 

Fatal Hematemesis from Ulceration of a Gall-stone into the 
Duodenum. — Duffett {British Medical Journal, No. 
1794, p. 1090) has reported the case of a man, fifty-two 
years old, who had suffered from biliary colic for nine 
years. On several occasions, after the attacks had sub- 
sided, gall-stones were found in the stools. The last 
attack had occurred nine months before coming under 
observation, and had been exceptionally severe. An 
operation had been advised, but had been declined. 
The patient came under observation for an attack of 
hematemesis, in which more than a pint of dark, clotted 
blood was ejected. The skin and conjunctivae were 
jaundiced, and there was intense irritation of the skin. 
The abdomen was flaccid and easily palpable, but no 
enlargement of the liver or gall-bladder could be made 
out. The bowels were constipated, the stools clay- 
colored, and the urine contained bile pigment. Shortly 
afterward, after overexercise, the man vomited up a pint- 
and-a-halfof semifluid, dark blood, and two hours later 
an additional half-pint ; besides, the bowels moved 
unconsciously and the stools contained partially decom- 
posed blood. On the following day the patient com- 
plained of faintness and dimness of sight, and soon after- 
ward vomited three pints of clotted blood, one clot rep- 
resenting a distinct cast of the pyloric end of the stom- 
ach and the upper part of the duodenum. A further 
hemorrhage was followed by death. Upon partial post- 
mortem examination the liver was found hard and slightly 
contracted. The stomach contained a quantity of blood, 
its mucous membrane was thick, and there was no trace 



of ulceration. The pylorus was normal. The gall- 
bladder was small and contracted and empty, and its 
walls thickened. A finger introduced into the gall-blad- 
der passed easily into the duodenum. Lying loose in 
the duodenum was an unfacetted gall-stone with a quan- 
tity of blood. The edges of the opening were soft and 
probably of recent date. The gall-stone measured three- 
quarters by one-half inch, and weighed when dry forty 
grains. 

Endogenous Formation of the Malarial Parasite. — Leon- 
ard (I?itcrnational Medical Magazine, vol. iv, No. 4, p. 
265) has been able to study the endogenous formation of 
the malarial parasite by means of photomicrographs pre- 
pared from fresh malarial blood, kept at the temperature 
of the body with the aid of a warm stage, and magnified 
two-thousand diameters. The free, non-pigmented, 
hyaline am.eboid form is a minute globular hyaline 
mass, of a slightly different density from the surround- 
ing medium, varying in size, but seldom exceeding one- 
fifth the diameter of a red corpuscle. It is found at- 
tached to a red corpuscle, and may be seen in active 
ameboid motion within the red corpuscle. It represents 
the first stage of the life-cycle of the malarial hema- 
tozoon. The intra-corpuscular pigmented form is devel- 
oped from the non-pigmented ameboid form after it has 
entered the red corpuscle, and contains a pigment — 
melanin, which is a derivative of the hemoglobin of its 
host collected in a granular form. It varies in size, 
sometimes gradually increasing until it occupies the 
entirecorpuscle. The extra-corpuscular pigmented form 
is the intra-corpuscular pigmented body which has come 
out of the red corpuscle, either by the extrusion of the 
individual or by the formation of a number of these 
bodies within a corpuscle and its subsequent rupture. 
The crescentic body or malarial crescent is probably a 
resting or spore-form, and is found generally in cases of 
malarial cachexia. 



A Pregnancy of Ten Months. — At a recent meeting of 
the Chicago Gynecological Society Dr. F. A. Stahl re- 
ported the case of a German- Bohemian woman in which 
the fifth pregnancy terminated 302 days after the last 
menstruation. Twenty days before there had occurred 
pains similar to those of labor, but they gradually 
ceased. The sacral promontory was exaggerated, and 
the antero-posterior pelvic diameter of the inlet in con- 
sequence diminished. The fetus was large and occupied 
the first position. V'ersion was with difficulty effected, 
and the passage of the after-coming head through the 
superior strait required expression and traction, during 
which the child died. The mother suffered a deep la- 
ceration of the perineum, involving an inch of the wall 
of the rectum. 

Recovery from Hyperpyrexia Accompanying Pleurisy and 
Pneumonia. — Stanley {British Medical Journal, No. 
1794, p. 1 144) has reported the case of a woman, thirty 
years old, in which in an attack of pleurisy and pneu- 
monia the temperature rose on two occasions to 114°. 
At these times the patient complained of complete loss 
of sensation in the hands and feet, and requested to 
have have them rubbed. Absence of delirium was noted. 



July 6, 1S95] PERFECTION AND RESOURCES OF THE HUMAN MACHINE. 



'5 



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SATURDAY, JULY 6, 1895. 



THE PERFECT ION AND THE RESOURCES OF 
THE HUMAN MACHINE. 

It is so easy to notice defects, either in others or 
in ourselves. In others they seem to stand out in 
bold and cheerful relief, while in ourselves they 
thrust themselves upon our notice in the most an- 
noying manner. When we agree with the Psalmist 
that "we are fearfully and wonderfully made," it is 
our fearful liability to break down or get out of 
order that we are chiefly thinking of. Perhaps this 
is but natural, for it is always the evil in things that 
most sharply impresess us. Comfort is a passive, hazy 
sort of sensation compared with the clear-cut acute- 
ness of pain. Besides which there's no need to 
pay any attention to the good qualities of things. 
They'll never bother you. " Well enough " can be 
safely "let alone." Ill, however, demands our in- 
stant attention and action. 

Health will take care of itself, disease must be 
cured at once if possible. A healthy man doesn't 
know that he has such a thing as a stomach ; a dys- 
peptic doesn't know that he has anything else. 
Hence pain is the great educator, the chief spur to 
investigation. If there were no suffering there'd 
be no medicine, no anatomy even ; pathology is the 



starting-point of physiology. So long as all goes 
well and smoothly we care nothing about our in- 
terior make-up, but let "dys-" anything develop, 
and the digging and probing begin at once. 

Does not this state of affairs have a strong, though 
unconscious, influence upon our mental attitude as 
a profession toward the human machine ? We are 
kept so continually engaged in patching and tinker- 
ing at it that we are in danger of coming to look 
upon it as a bundle of defects. The laryngologist 
declares that a healthy (or artistically symmetrical) 
nose or throat is rare ; the gynecologist deplores 
the faulty plan of construction of the uterus and 
vagina ; the oculist announces that a " normal eye " 
is to be found only in the text-books ; and the bac- 
teriologist regards the young human body merely as 
a congenial culture-medium for the Klebs-Loeffler 
and the adult one for the Eberth bacillus. We are 
prone to rate our patients much as Falstaff" did 
his recruits, "Tush, tush; mortal men, food for 
powder, food for powder!" only the grains of 
our "powder" are alive and wiggle, and assume 
a variety of comma-shapes. Even as sanitarians 
we seem to delight in populating the heavens 
above, the waters, the earth beneath, the dust of 
our streets, the food upon our tables, with hosts 
and swarms of tiny savages to whom the human 
body is a helpless prey whenever pounced upon. 
Existence would be impossible but for germicides, 
say we. It is positively dangerous to be alive ! In 
short, we often forget that the human body is not a 
pulpy victim of circumstances, but the toughest, 
most resisting, most marvellously adaptable, and 
most ferocious organism that the sun shines upon. 
It can flourish where nothing else can, and fatten 
on a diet of any other organism that can be men- 
tioned, not excepting the pathogenic bacilli. 

In the first place, the lesson that the school- 
ma'am is so fond of impressing upon the infant 
mind, "Man is physically the feeblest of all ani- 
mals, but by his superior brain he masters all," is 
utterly untrue. Man is physically the finest, most 
dangerous animal in the world. Not a bird or beast 
or even fish that he can't beat at its own game, if 
he sets himself about it. The Blackfoot Indian will 
run down a deer, knife in hand; even the " tireless 
wolf" can be overtaken and killed if you can only 
keep on his trail. The negroes of Mozambique 
spring right into the water and attack sharks, 
armed only with a short knife. The Sikh will face 
a tiger with his short, heavy scimeter, and a thous- 



i6 



PERFECTION AND RESOURCES OF THE HUMAN MACHINE. [Medical News 



and tests abundantly demonstrate that civilized man 
is as much superior to the savage as the latter is to 
the animals. Club or sword in hand, man is a 
match for the most ferocious beast of prey in a fair, 
stand-up fight, and the club or its descendant is as 
much a part of us as our bones or skin ; but for it 
we should never have allowed our teeth and claws 
to degenerate into such feeble objects. Its use has 
made us right-handed ; right-handedness has special- 
ized the cortex to such a degree that speech was 
possible, and speech makes thought possible. So 
that our mental superiority is purely an outgrowth 
and a part of our muscular superiority. In the 
language of Tommy Atkins in Kipling's ballad, 
homo sapiens is "a pore benighted heathen, but a 
fust-class fitin'-man," and two-thirds of his virtues, 
moral, physical, and mental, are the fruits thereof. 
And yet we talk of him professionally as if he were 
a clam without a shell. 

In the second place, there is no known organism 
that can defy the elements as he can. Any zoologist 
will tell us that no other mammal and no bird has 
one-half the geographic range that the human species 
has. His faithful friend, the dog, will accompany 
him almost everywhere, but only by having his food, 
shelter, and even clothing provided for him by 
the superior species. We speak of being " as rugged 
as a bear," but it takes three distinct species of 
Ursus to keep pace with man from the tropics to the 
pole. A dozen or more species of deer are required 
for the same match. Even the domestic animals 
when carefully housed and fed by him are far in- 
ferior in toughness, and one of the greatest obstacles 
to his progress in many regions is the impossibility 
of finding any beast of burden or milk-giver that 
will live in the climate with him. The only species 
that can even enter the lists with him is the blue- 
winged teal, and he is disqualified at once by the 
fact that he is the "very moral " of a fashionable 
valetudinarian, spending his summers in Labrador 
and his winters in Florida. 

Much of this faculty is, of course, due to man's 
power of constructing shelter and clothing for him- 
self, but still more to his worldwide range of food- 
materials. Look at him in the tropics, subsisting on 
rice and fruits, only sawdust and shavings under his 
boiler, so to speak ; in the Arctic regions, gorging 
upon seal-meat and whale-blubber, firing his engine 
up to the explosion-point. His instinct meets the 
situation. A Hindoo would look with loathing on 
the eighteen-or-twenty-pound meal of seal blubber 



of the Eskimo, and we carnivora of the temperate 
zone would hesitate about attacking it. Yet a pro- 
fessional friend of ours has assured us that on a 
mid-winter trip with dog-sledges near the Alaskan 
shores of the Arctic Ocean he positively lost all ap- 
petite for bread, lean meat, fruit, sugar, etc., and 
cared for nothing but the unsalted dried salmon 
and rancid seal-oil which formed the food of both 
his Eskimo guides and their dogs. A pint of 
the latter beverage carried in the uncured skins of 
the animal, he declared, was as refreshing and appe- 
tizing after a long day's run as hot coffee with 
cream. When we remember that the whole party 
was sleeping out on the ice every night, in a 
temperature of from 30° to 60° below zero, with 
no shelter save their reindeer-skin, night-bags, and 
their sleds piled up on the windward side of them, 
we begin to see the reason for this almost pure 
hydro-carbon diet. There was not room in the 
human stomach for enough of any other material 
to furnish heat to keep up the bodily temperature 
against such fearful odds. But think of the splendid 
adaptability of the creature ! Our respect for the 
human machine becomes immeasurable. At the 
other extreme, look at Stanley and his Somalis, 
laboring forward day after day in heat and fever- 
fog through the jungles of the Congo, everything 
carried on the heads of the men (no horses, oxen, 
or even asses could stand the work and the climate), 
all on a diet of roasted bananas, sugar-cane, and 
green corn. 

The same toughness and faculty of adjustment 
manifest themselves even more strongly when we 
come to consider the unfavorable environment in 
which man places himself in the various occupations 
of civilized life and the strain of city surroundings. 
Scarcely a trade or occupation can be mentioned 
in which most of those engaged in it are not vigor- 
ous, healthy, and long-lived. We speak of "occu- 
pation-diseases ;" it is true there are such, but none 
of them ever affects more than a small percentage 
of those engaged. Even when they occur they are 
symptoms of lowered vitality, either local or general, 
on the part of the sufferer in most cases. Many of 
them can be avoided entirely by cleanliness and 
observance of the ordinary laws of health. "Paint- 
ers' colic," for instance, is caused entirely by eating 
the mid-day lunch with unwashed hands or upon 
spattered boards or tables, and can be completely 
escaped by always thoroughly cleaning the hands 
before eating. "Phosphorus-necrosis" never at- 



July 6, 1895] 



NERVOUS DISEASES AND MODERN LIFE. 



17 



tacks a healthy mouth or jaw, and can be pre- 
vented by the prompt filling or removal of decaying 
teeth. " Chimney-sweeps' cancer " finds a perfect 
prophylactic in the daily use of soap and water. It 
was long supposed that in " miners' consumption " 
and "printers' phthisis" and "knife-grinders' 
asthma" we had a group of diseases, practically 
necessary risks of the three occupations, but the 
first is completely out of the list now, first, because 
the death-rate from tuberculosis is no higher among 
miners than in the rest of the community, and, 
second, because a similar carbonized condition of 
the lungs is being found to exist in a considerable 
proportion of dwellers in manufacturing towns and 
smoky cities without any corresponding increase in 
the prevalence of pulmonary tuberculosis. It is also 
more than suspected that the irregular hours and 
worse habits of the " typo " have much more to do 
with his " consumptive " tendency than the dust of 
dried printers' ink in which he works. 

Of all occupations probably none has had a 
blacker reputation for unhealthfulness, both popu- 
larly and professionally, than that of the coal- 
miner. Working as he does hundreds of feet under 
ground, in wretched little burrow-like passages, in 
an atmosphere foul with coal-dust, fire-damp (CH^), 
" choke-damp " (CO,), and powder-smoke, exposed 
to the most frightful accidents by explosion, by 
water, by falling rock, surely no mortal organism 
can long resist the pressure. When we further re- 
member that in the English mines the galleries in 
which he works scarcely average yi??//" feet in height, 
and that in coal-getting (" holing under" the seam) 
he often works for yards at a stretch in a space t7ifo 
feet or less in height, so that he has to lie flat on his 
side to swing his pick ; that the mine is usually both 
warm and damp, so that he emerges dripping wet at 
the pit-mouth into an atmosphere from 30° to 60° 
lower; that his dwelling is a mere barrack, usually 
badly built, badly drained, and overcrowded ; that 
his wages are so irregular that life with him is gen- 
erally "either a feast or a famine," we marvel that 
the breed doesn't become extinct. No wonder it 
was for long years rated as an extremely unhealthy 
occupation. The question has been carefully inves- 
tigated within the last ten years, however, with the 
astounding result that " the comparative mortality- 
figure of these laborers is considerably below that 
of all males, and, if we exclude accidents, only 
slightly exceeds that of the most healthy class, the 
agriculturalists." (Dr. Ogle, Census Statistics of 



1881.) The same authority also reports that "his 
mortality from phthisis is remarkably low." The 
Labor Commission sums up its findings in the sen- 
tence : " The weight of evidence seems to be against 
the idea that coal-mining is an unhealthy occupa- 
tion." That veteran gladiator, the human body, 
has risen to the emergency again and conquered just 
as it used to do in the ages when it lived on bear- 
meat and ground-nuts by choice, mussels and sea- 
weed by necessity, and sucked its paws when it 
could get neither. 

The soap-renderer, the hide-scraper, the tanner, 
the refuse-sorter literally spend their lives amid the 
most offensive odors and putrefying materials, and 
yet their mortality is scarcely perceptibly height- 
ened thereby. The workers in our foundries, our 
smelters, and our engine-rooms live at terrific tem- 
peratures for hours at a stretch with comparative 
impunity. The Swansea copper smelter, for in- 
stance, works hard for seven or eight hours a day in 
a temperature of from io2°-iio° Fahrenheit, ex- 
posed to a glare, when the doors are opened, of 
from 350° to 400°, drinking from two to three 
gallons of water a day to supply his loss by per- 
spiration, and yet he is a hale, hearty fellow, and 
lives to a good old age. 

In fact, man can accustom himself to work with 
safety and even comfort at almost any temperature, 
pressure, degree of moisture or dryness, in almost 
any position or atmosphere, providing he is reason- 
ably well fed and housed, and maintains a fair gen- 
eral condition of health. 

And it were well for our bacteriologic brethren, 
indeed, for all of us, to remember that the tough- 
ness and resisting-power of the human body are just 
as great against disease and all its germs as against 
any other unfavorable influence; that the fixed 
cells of our own bodies are to the deadliest bacilli 
as a regiment of British infantry to a swarm of 
Hottentots ; that the hottest place a disease-germ 
can get into is a healthy bronchus or stomach. 

Our chief aim in the cure of disease should ever 
be to "give Nature a chance." 



NERVOUS DISEASES AND MODERN LIFE. 

The foregoing is the caption of a most interesting 
and brilliant contribution to the Contemporary Re- 
view by Dr. T. Cliff"ord Allbutt, in which it is most 
cheering to find him vigorously opposing the pre- 
vailing impression that our nerves are going to rack 
and ruin under the strain of civilization. He first 



NERVOUS DISEASES AND MODERN LIFE. 



[Medical News 



points out that most of those who indulge themselves 
upon this subject are in the habit of arguing some- 
what in a circle to the effect that, firstly, nervous 
diseases are on the increase, therefore modern life 
must be injurious, and secondly, that modern life is 
mischievous, therefore nervous maladies must be 
increasing. 

The stock-in-trade argument in support of the 
first proposition is the alleged increase of insanity. 
This, Dr. Allbutt considers at some length, and 
concludes that the " figgers " are in reality mislead- 
ing when certain other facts are taken into account. 
First of all, our lists of the insane are much more 
complete than they could be twenty years ago, and 
a very much larger proportion of them are cared for 
in asylums of some sort ; the days of the village 
"innocent" or the household "deficient" are over. 
Second, the life-terms of these unfortunate creatures, 
no longer permitted to roam at large in all weathers 
and beg their food, protected against their own folly 
or violence and carefully nursed and treated in ill- 
ness, have been greatly prolonged, so that a much 
larger number of them would be living at any given 
time. Indeed, from his own observation and his in- 
quiries of experts Dr. Allbutt is inclined to believe 
that insanity is actually slightly on the decline, 
although apparently (from the causes named) on the 
increase. He further questions whether modern con- 
ditions are in any way responsible for the mass of our 
existing insanity. The greatest increase noticeable, 
for instance, comes from the agricultural laboring 
class, who are, of all others, least subject to the bustle, 
strain, and excitement of civilized life. No class or 
profession can be said to be more liable to insanity 
than any other; indeed, some of the highest percent- 
ages are to be found in the illiterate classes. His- 
tory abundantly shows that possession by devils, 
frenzies, epidemic manias, etc., are and have been 
at least as common among savage tribes as similar 
mental disturbances among civilized peoples. 

The doctor next takes up the question of the in- 
crease of nervous diseases generally. He shrewdly 
opens with the remark that it is commonly alleged of 
nearly all chronic diseases that they are on the in- 
crease nowadays, carcinoma, heart-disease, and gout, 
for instance. Much of this he regards as due to the 
simple fact that, to use a Hibernicism, " more people 
live to die of them. " Our great advances in hygiene, 
dietetics, quarantine, and therapeutics have greatly 
decreased infant-mortality and the infection death- 
rale, which, of course, leaves a larger proportion of 



individuals surviving to adult or middle life subject 
to the diseases named, "for die we must somehow," 
as he quaintly remarks. Then, again, we are becoming 
much more attentive to symptoms of disease or dis- 
comfort than formerly, less inclined to resign our- 
selves to things, more determined to have a name 
and a cure for our ailments. The " patient invalid " 
of exemplary piety is no longer our ideal ; but " our 
neurotics have begun, like ghosts, to walk, and we 
exclaim that the earth is full of them." As a result 
of this impatient resistance we are so much better 
fed, housed, exercised, and treated that the physique 
of all classes has been greatly improved, and particu- 
larly that of the upper and middle classes. 

There is a delightful ring of sturdy sense in 
Dr. Allbutt's protest that most of the results 
attributed to "overwork" and "overstrain" are 
really due to the bad physical habits of the 
worker, and senseless methods in which the work is 
done, such as under-feeding or over- feeding, hurried 
eating, stuffy rooms, insufficient air, exercise, and 
recreation, etc., and not to the work itself. We are 
only just beginning to know how to work intelli- 
gently. Our medical courses, even their surround- 
ings, are a disgrace to the age, and "business- 
methods " are even worse. 

And now comes the most interesting position ot 
the whole paper, and, in our judgment, the most 
impregnable : that the popular belief that because 
the greatest demands of the age fall upon the 
nervous system the latter is injured thereby is 
entirely fallacious. On the contrary, it is strength- 
ened and invigorated by exercise, just as any 
other part of the organism. The whole life of 
civilized man is becoming so much wider and 
healthier and happier that his nervous system is 
becoming really stronger and better balanced every 
year. The nineteenth-century nerves are better 
able to bear the demands upon them than were 
those of the eighteenth century in their time. The 
age is better, broader, more humane, saner in every 
way, mentally, morally, and physically than it was 
a century ago. Such brutal coarseness and obscen- 
ity as Hogarth's pencil and Swift's pen sketched 
on every highway and parlor-carpet could hardly 
be found nowadays save in Whitechapel or Five 
Points. Insanity is a disease of the narrow, igno- 
rant, untrained mind, rather than of the contrary. 
(Farmers' v.i'/es, for instance, in this country furn- 
ish the largest female quota.) 

Of course, this great development has necessarily 



July 6, 1895] 



EDITORIAL COMMENTS. 



>9 



been accompanied by a higher degree of nervous 
excitability. But, as Allbutt neatly puts it, " it 
is the business of nerves to be excitable." It is 
an essential part of their sensitiveness, of their 
fineness of organization, which alone makes all 
this progress possible. Fancy a poet, a violinist, 
a statesman, a general even, without sensitive 
nerves. Most of the "over-excitability " of which 
we complain is due to und^r-exercise instead of 
overwork, just as a mettlesome horse becomes 
absolutely uncontrollable if kept too much in the 
stable, and frets himself into a lather when harnessed, 
instead of settling down to work. Just give our 
wailing neurotics plenty of work of interest, of re- 
sponsibility even, and their ailments and " nervous- 
ness" will in most cases disappear as by magic. 
Not only this, but the neurotic is often actually 
under-sensitive rather than the contrary, absolutely 
apathetic, if not mentally anesthetic, in many re- 
spects. Indeed his excitability is not seldom due 
to lack of inhibition of the first impulse by some 
balancing sensation and motive. He is unbal- 
anced from a deficiency and not from an excess of 
" nerves." 

As to the senseless claim that we are fast becom- 
ing " degenerates " (the pseudo-scientific equivalent 
of "cranks," and like it so charmingly applicable 
to anybody we do not happen to approve of) under 
the strain, and that most of our so-called "genius" 
is a mild form of insanity, our authority briefly but 
effectively remarks that its advocates appear to 
have little real knowledge and no clear idea of 
either genius or insanity, and, he might have added, 
of history, either, for with these charlatans it 
is the exception that proves their rule with a 
vengeance. "In the hands of these gentlemen a 
man of mark is not admitted into the ranks of 
genius unless he can show some claims to insanity; 
while on the other hand a streak of this malady 
insures for very dull dogs a welcome into the inner 
circle." And he closes this section with the pithy 
reflection, "I will not inquire where the malady 
may lie between the observer and the observed." 

In short, most of our "nervousness" is really 
due to defective control, lack of sufficiently keen 
and powerful balancing impulses, to narrowness, 
feebleness, and one-sidedness of development, and 
insufficiency of work and demand, rather than to 
the opposite. Superficial sensitiveness is often 
due to absence of real depth and breadth of feeling, 
while through wider sympathy, deeper passion, 



and more vigorous exercise of all our powers come 
both health and, what is better, progress. "It is 
in the battle rather than in the fruits of victory that 
we find the precious extract that is the medicine for 
the malady of our generation." 



EDITORIAL COMMENTS. 

Medical Abuses in New Yorl<. — The medical profession 
of New York City appears to be awakening to a realiza- 
tion of some of the abuses of which medical men are 
made the victims. At a recent meeting of the New 
York County Medical Association attention was forcibly 
directed, among other things, to the discourtesy with 
which physicians are sometimes treated by the lay trus- 
tees of semi-public hospitals, and to the injustice to the 
members of the profession from the free treatment in the 
numerous dispensaries of persons able to pay for medi- 
cal attendance, and the treatment in hospitals of patients 
of comfortable means and more, without charge for 
professional attendance. The frequency was pointed 
out with which attending physicians are merely dropped 
from the medical staff without a word of notice or e.\- 
planation. A committee was appointed with instructions 
to meet during the summer to prepare a report and to 
propose suitable remedies. The abuses referred to have 
been frequently discussed in these columns, and we are 
glad to see them receive official cognizance by a power- 
ful and representative medical body. Active agitation 
of the subject must result in good, and the necessary 
remedy would be easy of application in the hands of an 
organized and united medical profession. 

Selections from Medical Journals. — Our sprightly and 
enterprising contemporary. The Medical Fortnightly, 
recently took occasion to say that The Medical News 
in its Medical Progress "always prints a collection of 
extracts from English, French, and German medical 
pubhcations — rarely one from an American journal." 
Conscious of both the inaccuracy of this statement and 
of the injustice of the imputation contained in it, we have 
analyzed our Medical Progress and Therapeutic Notes 
for the past thirteen weeks and find that of ninety-two 
abstracts twenty-three were prepared from American 
journals and proceedings of American medical societies 
and the remainder from English, German, Austrian, 
Swiss, and French. As a matter of fact, all of the ab- 
stracts in the issue of June 22 were from American pub- 
lications. We trust the fealty of The Medical News 
to the American medical profession is too well estab- 
lished and their community of interests too obvious to 
require defence from hasty and ill-considered state- 
ment. 

The State Board of Veterinary Medical Examiners of Penn- 
sylvania. — Act 55, approved May 16, 1895, provides for 
the establishment of a Board of Examiners to regulate 
the practice of veterinary medicine and surgery in the 
State of Pennsylvania. The Board is to consist of five 
members appointed by the Governor, who shall be 
graduates of recognized veterinary colleges and of at 
least five years' practice. This most commendable Act 
goes into force on the first Monday in September, 1895, 



CORRESPONDENCE. 



[Medical News 



after which no one shall enter upon the practice of vet- 
erinary medicine and surgery unless he has been duly 
licensed and registered, and no licence will be granted 
until the applicant has submitted to a theoretic and 
practical examination, including the following subjects ■. 
Veterinary anatomy, surgery, practice of medicine, 
obstetrics, pathology, chemistry, veterinary diagnosis, 
materia medica, therapeutics, physiology, zootechnics, 
sanitary medicine, and meat-and-milk inspection. 
Heavy penalties are imposed for violation of the Act. 

Sweat Bake shops. — In an investigation undertaken by 
the Women's Union, a society of women interested in 
the labor-movement, shops have been discovered where 
bread is baked under most filthy conditions. These 
shops are usually in cellars where vermin and rats are 
in abundance, and in which the bakers sleep when off 
duty. Such shops are not confined to any special 
district, but may be found all over the city. 

Public opinion can do much in bringing about a 
change, both in this and sweat-shop clothing, by demand- 
ing cleanliness in the manufacture of such articles. We 
understand the Union is about to publish a list of 
bakeries where proper sanitary conditions are enforced ; 
a label has also been adopted which will be a guarantee 
of well-made bread. 

The Report of the Trial of Amick vs. Reeves. — A distin- 
guished correspondent writes us, apropos of the editorial 
in The Medical News of June 29th, that perhaps suffi- 
cient publicity was not given to the appeal for subscrip- 
tions to the fund for the purpose of publishing in pam- 
phlet-form the report of the trial of Amick vs. Reeves at 
Chattanooga, Tenn. The appeal appeared both in the 
Philadelphia Polyclinic and The Medical News of 
April 27th, and we hope that our recent remarks will 
meet with an unequivocal response. The Medical News 
will be glad to receive and acknowledge subscriptions of 
fifty cents and over. We have received $1.00 from Dr. 
R. S. Wallace. 



CORRESPONDENCE. 

LEGAL PROTECTION OF PROFESSIONAL 
CONFIDENCES. 

To the Editor of The Medical News, 

Sir: It will probably interest readers of The Med- 
ical News to know the exact wording of a law passed 
by the Legislature of Pennsylvania at its last session 
and signed by the Governor on June i8th, which was 
meant to provide protection for physicians called as 
witnesses in civil suits against questions the answers to 
which would injure the good name of their patients. 

Here is the text of the law ; 

" An Act to Prevent Physicians and Surgeons from 
Testifying in Civil Cases to Communications made to 
them by their Patients. 

" Section i. He it enacted by the Senate and House 
of Representatives of the Commonwealth of Pennsyl- 
vania in general assembly met, and it is hereby enacted 
by the authority of the same. That no person authorized 
to practise [sic) physics {sic) or surgery shall be allowed 
in any civil case to disclose any information which he 
acquired in attending a patient in a professional capacity, 



and which was necessary to enable him to act in that 
capacity, which shall tend to blacken the character of 
the patient, without his consent." 

The courts will probably construe this law in the sense 
in which it was intended. But this sense might have 
been much better expressed, as any shrewd lawyer could 
easily juggle with the new law so that its object would 
be wholly defeated ; and, as'it contains no penal clause, 
there is nothing to prevent a physician (if moved by 
malice or carelessness) from doing precisely what it 
forbids. 

Medical men may note that the law affects the posi- 
tion of a witness in ci-'il suits only, and that it does not 
leave the medical witness any choice, but (so far as it 
may be operative) forlnds him from violating professional 
confidences. Just how far the courts will rely upon the 
judgment of a physician-witness who objects to a ques- 
tion on the ground that a particular answer, if given, 
would "tend to blacken the character" of his patient 
remains to be seen. Meanwhile this law is a movement 
toward an end long desired by medical men, and it is to 
be hoped that it may accomplish what has been desired. 
Respectfully, 

Charles W. Dulles. 

DETERIO RATION OF DIPHTHERIA-TOXIN. 

To the Editor of The Medical News, 

Sir : In your issue of June i, 1895, in a footnote on 
page 600 of Dr. Howard's article on the treatment of 
diphtheria with antitoxin, he refers to my test of the 
antitoxin and the finding of a strength of 60 antitoxin- 
units to the cubic centimeter. Since these tests were 
made the flask of toxin that was used has been found to 
have lost its toxic properties to a great extent. When 
this change took place 1 do not know, but if it took 
place after the strength of the toxin was ascertained and 
before the antitoxins were tested, it of course invalidates 
the experiments. 

Aronson's antitoxin was tested at the same time and 
found to have a strength of 100 antitoxin-units to the 
cubic centimeter, as reported by Aronson. This would 
tend to show that the toxin lost its properties after the 
tests. The only other flask of antitoxin in the labora- 
tory was ruined by the laboratory-janitor carelessly mis- 
taking the bottle and pouring some waste ether into it. 
.\t present we have no diphtheria-cultures in the labora- 
tory of sufficient virulence to make new toxin and check 
the test. Very respectfully yours, 

Clarence O. Arev. 

Pathologic Laboratory, Western R 
Cleveland, Ohio. 



A CEREBELLAR TUMOR. 

To the Editor of Thk Medical News, 

Sir : Some of those who read my paper on " Brain- 
Syphilis," published in The Medical News, January 
19, 1895, may be interested to learn the result of the 
autopsy in Case 111, which revealed a tumor the size of 
a large English walnut, situated on the anterior border 
of the right cerebellar lobe and attached to it by a pedi- 
cle. Unfortunately no microscopic examination was 
made, so that it is unknown whether or not the growth 
was specific. 

The diagnosis was partly right and partly wrong. It 



July 6, 1S95] 



AMERICAN NEUROLOGICAL ASSOCIATION. 



was correct in locating a tumor at the base of the brain 
on the right side, but wrong in not recognizing the in- 
volvement of the cerebellum. It was thought at the 
time I saw the patient that the ataxia could be accounted 
for by the diplopia which was present. But the situation 
of the tumor adequately explains the symptoms. 

From the practical standpoint, however, the behef that 
the tumor was inoperable was fully justified. 

Yours respectfully, Theodore Diller. 

WssTiNGHOuSH Building, Pittsburg. 



VERATRUM VIRIDE IN THE TREATMENT OF 
PUERPERAL ECLAMPSIA. 

To the Editor ofXwB. Medical News, 

Sir : Mrs. S., a multipara, aged twenty years, was 
seized with convulsions at the commencement of labor 
and was in the midst of her sixth attack when I reached 
her. No examination of the urine was made. The 
patient was very edematous. The usual remedies were 
tried without improvement. The pulse was 140 and 
bounding. 1 gave, hypodermically, six drops of vera- 
trum viride, diluted with a little water, every half-hour 
till the pulse was brought to normal, when the convul- 
sions ceased. The os was fully dilated by this time and 
a living child was soon afterward born. The patient 
had no reLurn of the convulsions. The only after-effect 
of the remedy was a very sick stomach, which soon wore 
off. I gave three doses of the remedy in all. 

Respectfully, C. M. Hyde. 



SOCIETY PROCEEDINGS, 

AMERICAN NEUROLOGICAL ASSOCIATION. 

Twenty-first Annua/ Meeting, Held at Boston, June j, 
6, and 7, iSgj. 

(Concluded from page 740.) 

Dr. Charles K. Mills opened a discussion on the 
subject of 

CORTICAL localization in the light of recent 
researches into the minute anatomy of the 
cortex. 

He said that the different theories as to the separate 
cortical locahzation of movements and of cutaneous and 
muscular sensation, which had been the subjects of so 
much controversy, have again become prominent in the 
light of the researches founded upon the methods of 
Golgi, and particularly those made by Raymon y Cajal, 
Von Gehuchten, Schafer, Andriezen, and others. Those 
who contend against the doctrine that the Rolandic cor- 
tex is a purely motor region beheve that they have re- 
ceived additional support for their views. The varying 
hypotheses with reference to the functions of the cortex 
were reviewed. He held that, as shown by Forel and 
Nansen, we have been too long handicapped by prevail- 
ing ideas of cell-action and by theories of the parts 
played by the cell-bodies as originating centers. Im- 
pulses are transmitted and transferred by processes as 
well as by cell-bodies, and the function of the latter is 
chiefly trophic. The new researches and theories, he 



believed, did not compel abandonment of former views 
as to special localizations, although different standpoints 
had been taken. Disregarding theory entirely, he be- 
lieved that the subdivision of the cerebrum into physio- 
logic lobes — higher psychic, motor, sensory (meaning 
for the representation of cutaneous and muscular sensa- 
tions), visual, auditory, olfactory, gustatory, and naming 
— remained for the practical purposes of the physician 
and surgeon the best ; while the whole of the cortex in 
some of its strata may be regarded as a sensory expanse, 
if the Rolandic portions and particularly the convolutions 
cephalad of the central fissure constitute a region that 
is related to specialized movements of various parts of 
the body. One calls it motor, another kinesthetic, 
another sensorimotor, and another executive ; but for 
the purposes of the physician and surgeon it is a motor 
sphere, the irritation of which causes specialized move- 
ments, while its destruction impairs or abolishes these 
movements. He did not believe with Andriezen that it 
is necessary to regard the ambiguous and great pyramidal 
cells of this region, whose apical processes received the 
terminals of the fillet-radiations, as the first sensory cells 
of the cortex. Indeed, he regarded it as important to 
rid ourselves entirely of the idea of sensory cells and 
motor cells. The cortex contains localized areas. To 
abandon separate sensory and motor localization would, 
he believed, necessitate the abandonment of visual, 
auditory, gustatory, and other subdivisions of the cortex. 
The cerebral sensory area — that is, the area of represen- 
tation for skin-sensations and muscle-sensations, both 
cortical and subcortical — from his point of view, would 
be that part of the cerebrum where the fillet-radiations 
in their most compact forms are nearest to the surface 
of the brain, and therefore this region might continue to 
be described, as it had been by him, as in the postero- 
parietal, quadrate, and fornicate convolutions. Destruc- 
tion of this region, especially if bilateral, caused more 
or less impairment of sensation. He referred to cases 
as confirming this view. In the cerebrum, as in the 
spinal cord, were fields of junction between so-called 
cortical areas, and lesions of these fields of conjunction 
or at the terminations of the sensory projection-fibers 
might give rise to temporary phenomena ; but persistent 
sensory disturbances were found only when the lesions 
involved the convolutions included by him in the gen- 
eral sensory area. 

Dr. Dana said that he had collected a number of other 
cases, and added some of his own, and it is because he 
cannot explain the clinical facts or the pathologic facts 
by any other hypothesis than by supposing that the motor 
and sensory functions are practically united that he still 
holds to that view. He asked Dr. Mills to explain why, 
when one cuts away a section of the midcentral, precen- 
tral convolution, he finds tactile anesthesia and muscular 
anesthesia the next day, with paralysis, on any theory 
except that these two functions are united in that spot. 
These cases are extremely numerous in the literature of 
neurology. If one carefully shaves off" the anterior, pre- 
central convolution in the middle part, he will get sensory 
disturbances and anesthesia. Dr. Mills may not perhaps 
be aware that in the hving subject the motor cortex has 
been directly irritated, also in front of the fissure of Ro- 
lando, producing sensory and motor disturbances. The 
whole weight of clinical evidence is in favor of this view — 
the surgical operations, the tumors, the softenings ; all are 



AMERICAN NEUROLOGICAL ASSOCIATION. 



[Medical News 



facts that cannot be explained on any other hypothesis 
so far as he knew than that the two functions are essen- 
tially identical anatomically. 

It is a plausible theory that the visual centers, the cen- 
ter for visual sensation and auditory and gustatory sen- 
sations are separate from the motor sensations ; these 
and cutaneous and muscular sensations would naturally 
have separate centers, but it does not at all hold against 
any actual facts ; and when we come to analyze it, it is 
not so necessary or plausible after all. The visual sen- 
sations are not so closely related to motions as are the 
cutaneous and muscular sensations. For the perform- 
ance of co-ordinated movement we must have a very 
close anatomic relationship between the muscular and 
cutaneous sensations. They must be close together 
anatomically for the purposes of a perfect machine, 
otherwise we could not make rapid motions ; and he 
believed it is for that reason that nature had gradually 
shifted the sensory receptive cells so that they are in 
approximately close relations with the motor cells. He 
beheved that perhaps if we were all agreed as to exactly 
what is meant by sensations, and exactly what tests we 
use for making sensations, and were agreed about the 
terminology of our discussions, we would not perhaps 
have so much discussion about this matter. He agreed 
with Dr. Mills that sensations are not closely localized, 
and he agreed that we should speak of sensory areas, but 
did not believe that we have sensory areas separate from 
the motor ones back in the post-central and parietal 
lobes or in the gyrus fornicatus. He does not accept Dr. 
Starr's view that the sensory centers are back of the 
fissure of Rolando, for, from the evidence that he has 
been able to collect, there is just as much proof that 
the precentral convolution has sensory functions as that 
the post-central one has. 

Dr. Putnam thought Dr. Dana's closing sentence 
must be accepted as absolutely certain, that the convolu- 
tion in advance of the fissure of Rolando, which we 
ordinarily associate with the localized movements, has 
as much to do with sensation as convolutions anywhere 
else. In support of that fact he mentioned one case 
among many in which Dr. Warren excised a minute piece 
of the cortex of a young man with epilepsy beginning 
in one hand — a piece a few millimeters in diameter — 
with the result of producing paresis of the hand, paraly- 
sis in the beginning, and also a disturbance of the sensi- 
bility of the whole hand. It seemed to him that this 
showed that in some way the function of sensibility is 
closely related to the same centers with the function of 
motion. We are still decidedly lacking in a sufficiently 
adequate physiologic or psychologic conception of what 
we mean by these various terms. The function of sen- 
sibility must be very widely distributed. 

For example, an enormous tumor was removed, almost 
as large as an orange, which lay directly in the motor 
tract, so that the whole of the motor area was removed 
with a good part of the internal capsule. Nevertheless 
that patient still has a very considerable degree of sensa- 
tion left, of course modified, but he feels in a very high 
degree, so that although the removal of the motor con- 
volution has affected the sensibility of the limb it has 
not by any manner of means destroyed it. Nerves will 
stand a high degree of injury, sufficient to destroy en- 
tirely their motor functions, without material interference 
with their sensory functions. The same thing is true as 



to the cord ; a minute portion of it will convey centri- 
petal impressions. 

Although we must admit that the function of sensi- 
bility is closely related to the function of localized mo- 
tion, we must admit that it is closely related to a great 
many other functions, and it remains to be seen whether, 
as in the case of the relation of the muscles of articula- 
tion to the function of speech, there is any center that is 
highly specialized. He had in mind several cases in 
which the sensory functions have been disturbed in con- 
nection with paresis of one hand, in which he seemed to be 
able to detect a greater degree of loss of sensibility or 
impairment of sensibility on the side of the ulnar part 
of the hand on the median portion. 

Dr. Starr said we certainly have facts that Dr. 
Dana has stated that are indisputable, and those who 
are constantly seeing cases of cerebral surgery and ex- 
secting cysts and portions of the cortex by clots that 
can be removed are perfectly positive that a small 
limited area of the so-called motor zone does inevitably 
produce in almost every case more or less disturbance 
of sensation. He said he was completely mistaken in 
1890, when he maintained that sensations were only to 
be referred behind the fissure of Rolando. He believed 
with Dr. Dana completely to-day that there are sensa- 
tions produced by small lesions anterior to the fissure of 
Rolando, and that the sensory area of the body corre- 
sponds exactly with the motor area of the body so far 
as we can determine clinically. He thought it would be 
a mistake to draw too broad a conclusion from these 
facts. 

It is perfectly evident that the term diffusion of sensi- 
bility is a capital one, and our present anatomy shows 
why it is ; it is because the sensory fibers terminate in 
brush-like expansions, so that we must conceive of a 
sensory fiber as virtually terminating in a long region 
of the nervous system ; in fact, almost throughout its 
entire length. Now suppose that with the continued 
passage of sensations over these fibers diffusing them- 
selves in general directions habit opens the way in one 
direction rather than in another, that a sensation coming 
in might be diffused from the arm over the entire parie- 
tal arm-center and also diffused over the motor center, 
but inasmuch as we guide our movements by touch ha- 
bitually the result is that a greater passage is opened out 
to the motor zone. Diffusion of the sensibility in vari- 
ous areas gives an explanation for the fact that a few 
cases are on record in which we get sensation 
lost alone, and the vast majority of cases show that 
sensation and motion are lost together. We must 
abandon the idea that consciousness and conscious per- 
ception, and perhaps to some extent conscious motion, 
are associated with the particular cells. It is just as 
reasonable to believe that they are associated by as- 
sociation fiber-action with the combined activity of 
various areas of the brain as they are with single cells, 
and he thought we will come down finally to the fact 
that a cell is to be regarded more as a trophic center 
than as a motor or sensory center. 

Dr. Dercum said that the stand that had been taken 
enables us to explain certain other phenomena not al- 
luded to here, namely, the fact that the cuneus atro- 
phies in cases of bhndness lasting for many years. 
Certain it is that we have no right to conclude from these 
facts that the cuneus only sees. It is probable it does 



July 6, 1895] 



AMERICAN NEUROLOGICAL ASSOCIATION. 



23 



other things. The various centers of the cortex, as we 
know them clinically and pathologically, are simply 
highways of ingress and egress to the general cortex. 
It gives us no right to say that this portion of the brain 
may do this special thing and that portion that special 
thing. General biologic considerations also would 
negative the sharp differentiation of cells into special 
functions. Nerve-protoplasm reacts to certain forces ; 
to say one cell would react to one mode of motion and 
another to another is unphilosophic and not borne out 
by general biologic considerations. 

Dr. Richardson said, in reference to the tumor of 
which Dr. Putnam spoke, that so far as he knew 
there was no destruction of the motor areas except by 
pressure of the growth. The tumor was very large. It 
took up a very large portion of the left hemisphere. 
But so far as he knew, there was no destruction of brain- 
tissue by manipulation during the operation. The man 
is now doing very well. 

Dr. Collins recently had a case of cerebral surgery 
in which the development of sensory and motor defects 
was rather peculiar. The young man had had his first 
attack of Jacksonian epilepsy in November, and the 
movements were contraction of the finger and thumb. 
When he saw him in March he had had three seizures. 
In conjunction with Dr. Sachs, Dr. Gerster operated on 
the patient over the superficial cortical thumb-and- 
index-finger center. As the patient bore the anesthetic 
very badly, it was necessary to postpone the operation 
after the skull had been opened ; that is, cutting into the 
cortex was deferred. That night he had an extremely 
severe attack, which had been preceded a short time by 
a very high temperature and loss of consciousness for a 
long time. The following morning he had paresis of 
the right upper extremity and loss of sensation ; that is, 
loss of tactile sense, loss of sense of position, and loss 
of muscular sense in the right hand. Three or four 
days afterward the dressings were opened and a good 
deal of distention was found from effusion into the sur- 
rounding cellular tissue, but otherwise where the opera- 
tion had been done it seemed very much like normal. 
Then a large part of the cortex was cut out. An old 
pachymeningitis was present, and the Nissl stain revealed 
degeneration of the cortical cells. He was put to bed 
and his hand tested for sensibility that evening. The 
disturbances of sensation had all disappeared. These 
observations were made with extreme care. 

Dr. Angell, of Rochester, corroborated Dr. Collins 
because he had had a similar case. He made the predic- 
tion that there would be paralysis for five or six days at 
least, and to his surprise, when the boy recovered from the 
ether two or three hours after the operation, he tested him 
thoroughly and found sensory paralysis. Within twenty- 
four hours there was absolutely no sensory paralysis or 
sensory disturbance. He did not believe it possible to 
make an impression upon any center of the brain closely 
related to another center without affecting temporarily 
that sensory center. Whether or not this will explain 
the reason why we have a short paralysis of sensation 
when we remove the motor cortex is, of course, beyond 
our power yet to determine. It may be by cutting into 
the cortex that we affect the rootlets of the radicles 
from the sensory tract which we suppose reach over 
and produce this diffusion of sensation that has been re- 
ferred to. 



Dr. Prince, of Boston, said there is a third fact 
that Dr. Starr had left out of consideration, and that is 
the fact that in many cases which had been referred to 
by other gentlemen there had been no loss of sensation. 
These must be exceptional cases that must be taken into 
consideration in order to find a law. A great many 
could be mentioned. He referred to two which he 
thought were of great importance. In one case he first 
scooped out a piece of the brain equal in size to half an 
orange, leaving a hole two inches in depth, involving a 
very large portion of the upper part of the descending 
convolutions, caudate lobule, and some part of the 
parietal convolution. Before the operation there was 
hemianesthesia with paralysis ; after operation there was 
absolutely no loss of sensation whatsoever tested in the 
most minute way. A case like that, it seemed to him, is 
a crucial case, and if the word center has any meaning 
whatsoever it must mean a portion of brain the function 
of which is destroyed when taken away. 

These cases show that a large portion of the motor 
cortex can be destroyed without loss of sensation. 

Dr. Putnam, of Boston, said that no one would speak 
clinically or anatomically of the sense of hearing and 
comprehension of spoken words as located in the same 
part of the brain, but we know that these two functions 
lean on each other internally so closely that not only do 
we get more or less aphasia from disturbance of the center 
for hearing, but we also get to a less degree a great 
deal, as is also the case with sensory phenomena, of dis- 
turbance of centers of comprehension in most forms of 
motor aphasia. In short, cerebral functions do not exist 
in themselves ; they exist as related to other functions, 
and one cannot destroy one without more or less 
impairing others, although it may be only for a brief 
time. 

The President added that the whole of our knowl- 
edge of the neuron goes to show the very pronounced 
dependence of the motor neuron upon the sensory neu- 
ron. In the primary neurons it has been clearly proved 
that the terminal processes of the axis-cylinder of the 
sensory neuron are closely connected with the apical 
process of the motor neuron in the cord. The develop- 
ment of fibers in the cortex, in the brain itself, shows that 
the sensory tract passes distinctly upward toward the 
central convolution, the parietal region, rather than 
downward and inward toward the gyrus fornicatus, where 
Ferrier some time ago located the sensory centers, and 
where Dr. Mills still has a leaning toward placing it. 
In other words, judging from all the analogies in the 
anatomy of the brain, the higher sensory neurons must 
either pass upward directly to connect by their axis- 
cylinder processes with the cells of the motor neuron, 
or there must be association-tracts from these axis- 
cylinders going up to the motor processes. We find 
no association-tract passing up from the gyrus fornicatus 
to the central fissures ; and, furthermore, although Dr. 
Prince had just brought up the negative cases of lesion 
of the central convolution without injury to sensation, 
there have been in the past a very large number of so- 
called negative cases about the central convolution with 
absolutely no motor disturbance. Most of those, with 
our increasing knowledge, have been explained away, 
and ten negative cases do not afford as much evidence 
as one positive case. The positive cases of sensory dis- 
turbances following lesions behind and in front of the 



24 



AMERICAN NEUROLOGICAL ASSOCIATION. 



[Medical News 



fissure of Rolando are increasing in number and become 
very conclusive. The positive cases of lesion in the 
neighborhood of the gyrus fornicatus are very few and 
far between. 

Dr. Mills, in closing, claimed that this discussion 
confirmed the standpoints he had always taken. It 
seemed to him astounding that Dr. Dana and others 
here speak of the cases in which physiologic or patho- 
logic lesion of the motor cortex as exceptionally pro- 
ducing alone motor symptoms. Every one of us must 
admit the cases referred to by Dr. Starr and Dr. Dana, 
and by Dr. Putnam and Dr. Knapp's case, because we 
know they have been well studied and well recorded ; 
that is, cases in which sensory phenomena of some sort 
have accompanied the motor phenomena in cases of 
destructive lesion of the pre-Rolandic cortex. We must 
also admit the two or three cases in which certain ex- 
periments upon the cortex in life have caused peculiar 
temporary disturbances of sensation at the time. These 
cases of sensory disturbance from strictly limited lesion 
of the motor cortex, cases in which the symptoms were 
motor alone instead of sensory, are as one-hundred to 
one, and we do not think it longer worth while to col- 
lect these cases. In a score of these cases the patients 
have been examined in life with the greatest care and 
the lesions located in death, and in cases of operation 
the greatest care had been taken in studying sensory 
phenomena, and those sensory phenomena had not been 
present. He mentioned two cases in which the motor 
phenomena persisted day after day, and day after day 
changes were noted until the patient was largely restored 
as regards motion, sensation not having disappeared at 
all. He did not think it worth while, therefore, to pit 
these cases which Dr. Dana had collected as an argument 
of great value against the very numerous cases that teach 
the other thing. However, he must acknowledge the 
other cases. Have we no explanation for these cases ? 
He would suggest three or four explanations for these 
cases in which destructive lesions cephalad of the sen- 
sory area have given rise to sensory disturbance. One 
explanation, which may seem far-fetched, is that these 
cases are somewhat of the nature of the cases in which we 
have sensory disturbances in hystero-traumatisms. Cer- 
tainly the traumatism inflicted by the surgeon's knife, or 
by injury or disease, in acute cases, or by operation such 
as Dr. Dana refers to, is greater than that which we have 
in these other cases. Another explanation is that he 
suggested in 1888, and which grows out of these later 
researches on cortex anatomy. Undoubtedly every area 
of the cortex, visual, auditory, gustatory, sensory, etc., 
must be related to and anatomically connected with the 
motor regions of the cortex. Now it is through the de- 
struction of these terminals of the fiUet-radiations, 
whether they be continuous with the apical process of the 
pyramidal cells or simply constitute a field of conjunc- 
tion, we have a separation between the motor and sen- 
sory areas, and at least temporary disturbances of sensa- 
tion would very likely in many instances result. It is a 
great cortical sensory expanse in this sense, but there is 
one region in the brain in which these fillet-radiations 
are placed between the cortex, and which for the sur- 
geon's and physician's purpose should be regarded as 
the sensory region. It is next to the motor region and 
between the motor and great sensory region. It has a 
separation, and one which is practical for our purposes. 



The remarks made by Dr. Starr, he thought, were on 
the whole confirmatory of what he had stated. It would 
seem, therefore, that the weight of argument and the 
weight of the evidence advanced here are still in favor of 
the localizations to which he had always clung, and which 
w6re believed in by Charcot, Ferrier, and others. He 
had never claimed that the gyrus fornicatus was the sole 
region of common sensibility in the cortex of the brain. 
His own position has always been that the sensory cor- 
tex proper includes at least a portion of the gyrus forni- 
catus, the quadrate lobule, and the posterior parietal con- 
volutions, and the arguments he advances must stand for 
the motor region, and not for a part of it. 

Dr. Dana asked if Dr. Mills would state specifically 
whether he denies that the central convolutions have 
any sensory function ; if he absolutely excludes sensory 
function from the central convolution. 

Dr. Mills replied that for our purposes and for 
our practical idea of a center or area he believed the 
central convolution or convolution cephalad of the cen- 
tral fissure had no sensory function ; he believed the pos- 
terior central convolution and the posterior parietal and 
the region he had named perhaps take part in sensory 
phenomena, that is, the sensory region posterior to the 
central fissure. 

TUMOR OF cerebellum, WITH AUTOPSY, 

was the title of a paper read by Dr. E. D. Fisher, of 
New York. The interesting features of the case were 
the absence of any symptoms that could be directly re- 
ferred to the cerebellum. There was no inco-ordination 
— nor any staggering in the gait. The pain was situated 
principally over the right orbit. The only well-defined 
cranial lesion was that of the eighth nerve on the right 
side, there being absolute deafness. There was possi- 
bly a slight involvement of the seventh nerve on the 
right side, and the patient said she had complete loss of 
smell. The general symptoms of a cerebral tumor — /. c, 
headache, convulsion, and optic neuritis — were pres- 
ent. A lesion at the base of the brain was suggested by 
the cranial nerve lesion, with involvement of the cere- 
bellum ; the absence, however, of cerebellar symptoms 
and the localization of the pain so definitely over the 
right orbit led to an exploratory operation in that sit- 
uation. The tumor was not found at the time, but there 
was a complete relief from the pain and the convulsions 
until the time of death, eleven weeks later, which was 
caused by a septic basilar meningitis. Autopsy revealed 
a glioma involving the right cerebellar hemisphere. 
Dr. Preston, of Baltimore, related 

three cases of tumor of the brain, with 
autopsy. 
The first case was that of a boy, aged thirteen years. 
For a year he had what looked like ordinary epileptic 
attacks, which were very much lessened by the bromids. 
Then he suddenly developed diplopia, with some neuro- 
retinitis. Vision was greatly reduced, and there was at 
first left lateral achromatopsia, and afterward left hemi- 
anopsia. Gradually he lost entirely both sight and 
hearing. The rellexes, both superficial and deep, were 
lost. He complained of most intense headache, and 
there was gradual failure of mental power. The autopsy 
revealed a large tumor, involving the entire right tem- 
poral lobe ; the occipital lobe was softened and broken 



July 6, 1S95] 



AMERICAN NEUROLOGICAL ASSOCIATION. 



25 



down, but the cortical portion of the occipital lobe was 
not involved. The tumor was a sarcoma. The second 
case was interesting from the fact that the tumor, a 
small papilloma, not larger than a partridge-egg, bury- 
ing itself in the right superior occipital convolution, 
produced intense headache, with double optic neuritis. 
The third case showed a large sarcomatous tumor in- 
volving the temporal lobe, all except the first convolu- 
tion, the greater part of the occipital lobe, and the lateral 
lobe of the cerebellum. The symptoms were not very 
well marked, except headache and mental disturbance. 
It was interesting to note that the first temporal convo- 
lution was not involved, though the rest of the lobe 
was virtually destroyed, and in accordance with our ac- 
cepted views concerning the auditory center there was 
deafness. 

A specimen of 

BRAIN-TUMOR 

was presented by Dr. G. L. Walton, of Boston. The 
main interest was the question whether an operation 
might have proved successful. The patient was fifty-three 
years of age, and complained of frontal headache only 
two months before his death. Attacks of vertigo, loss 
of speech, and severe general convulsions preceded 
and followed. Aphasia, agraphia, right hemiplegia, and 
right hemianopsia were present, with double optic neu- 
ritis and loss of superficial reflexes on the right. The 
tumor occupied the angle between the Rolandic and 
Sylvian fissures. Extension forward under the healthv 
cortex reached beyond the transverse frontal sulcus. It 
was fairly well defined, but with no distinct capsule. 
The center was necrotic. The symptoms suggested so 
extensive infiltration that operation was considered to 
offer small hope, but the extension backward was not 
so great as the hemianopsia would indicate, a fact which, 
together with recently published cases of removal of 
large infiltrating gliomata, would lead, perhaps, to a 
somewhat more hopeful prognosis in another case of this 
nature. 

The three preceding papers were discussed together. 

Dr. Starr referred to a case of infiltrating glioma in 
the arm-area of the motor zone. Symptoms developed 
in the course of a year : Headache, optic neuritis, spasm 
of the right hand and arm, and later paresis and loss of 
sensation. Operation revealed a glioma, very extensive 
and very vascular. It was impossible to remove it safely. 
Death followed within a few hours. He mentioned a 
case of suspected tumor of the corpora quadrigemina. A 
flap of bone was removed from the parietal region, and 
an attempt to puncture the ventricles was unsuccessful. 
There was no relief of pain. He concluded that opera- 
tion under such conditions was useless. He agreed with 
Dr. Fisher that the position of pain is of no value in 
localization. 

Dr. Dana said that the use of the chisel upon chil- 
dren and infants is a bad method of operation. He 
recommended the use of the improved revolving elec- 
tric saw, as used by Dr. Powell, of New York. 

Dr. George W. J.acoby, of New York, had witnessed 
two operations upon adults in which the electric saw 
was used. He considered the method objectionable, as 
there was more hemorrhage, and a wedging of the saw 
interfered with the operation. He spoke favorably of 
Quincke's lumbar puncture for relief of intracranial 
pressure. 



Dr. Dercum spoke in favor of a perpendicular bun- 
worked by a dental engine. 

Dr. Collins had seen a case in which, after each 
series of blows from the mallet and chisel, the pulse fell 
from 60 or 70 to 35 or 40. 

Dr. G. M. Hammond had witnessed one operation 
with the electric saw upon an adult and many upon 
children. The saw as now used has a greater electro- 
motive force to operate it than formerly, and this obvi- 
ates the earlier difficulties as mentioned by Dr. Jacoby. 

Dr. Dercum had noticed the same symptoms follow- 
ing the use of the chisel as described by Dr. Collins. 

A case of 

INJURY OF the angular GYRUS FROM FRACTURE OF 
THE SKULL 

was reported by Dr. C. Eugene Riggs, of St. Paul. 

HEREDITARY CHOREA, WITH AUTOPSY, 

was the title of a paper by Dr. Charles L. D.\na, of 
New York. 

Dr. Mills looked upon the case as very important. 
It suggested the true explanation of a large class of 
cases (such as Friedreich's ataxia, hereditary chorea, 
spastic paralysis), that these are teratologic. 

Dr. H. a. Tomlinson, of St. Peter, read a paper on 

INSANITY and PHTHISIS, THEIR TRANSMUTATION, CON- 
CURRENCE, AND COEXISTENCE. 

He considered that pulmonary tuberculosis and insanity 
are equally potent factors in the production of brain-in- 
stability. The preponderance of degeneration among 
those having an heredity of tuberculosis is significant, 
as indicative of the influence of this disease in one 
generation, in determining a defective nervous system 
in the next, and his tables also indicated that the more 
direct the heredity the greater is the probability of trans- 
mutation. Disease-processes which are constitutional or 
diathetic attack primarily one or other form of tissue, 
with the result of progressive degeneration and disinte- 
gration if the tissue be epithelial. However, if the con- 
nective tissue is the seat of a disease-process, it either 
increases rapidly in amount, and remains permanently 
increased, or undergoes liquefaction. 

The most common form of degeneration among the 
insane is the connective-tissue type, or the premature 
and excessive manifestation of the changes which ordi- 
narily occur in senility. The preponderance of imper- 
fectly developed connective tissue in one generation im- 
plies the excessive development of functional tissue in 
the next, thus accounting for the transmutation of dis- 
ease-tendency. These changes are abundantly illus- 
trated in the tuberculous and defective children of neu- 
rotic or syphilitic parents. 

Third Day— June /th. 
Dr. Wm. N. Bullard, of Boston, read a paper on 

the DIAGNOSIS OF PACHY.MENINGITIS INTERNA H.EM- 

orrhagica. 

He considered the pathology of this affection as yet un- 
settled, though he believed the weight of evidence to be 
in favor of a non-inflammatory origin. There are several 
forms of subdural hemorrhage, but consideration was 
given only to the apparently spontaneous, non-traumatic 



26 



AMERICAN NEUROLOGICAL ASSOCIATION. 



[Medical News 



affection occurring in aaults. The points of differential 
diagnosis between this condition and other forms of in- 
tracranial hemorrhage are as follows: (i) subdural hem- 
orrhage is peculiarly common in paralytic dements and 
in the chronic insane, and not rare in chronic alcoholics ; 
(2) the onset is often more gradual than in ordinary in- 
tracranial hemorrhage, and the irritative stage lasts un- 
usually long; (3) the symptoms of irritation are promi- 
nent. General epileptiform convulsions and localized 
convulsive movements are lilcely to occur. (4) The pe- 
culiar rigidity occurring in one limb in connection with 
symptoms of hemorrhage, and when no affection like 
tuberculous meningitis exists, is very significant. The 
treatment in this condition is removal of the clot. In 
all more serious cases this should be done as soon as the 
disease is recognized. A case was reported in which 
operation was performed and the clot removed, although 
too late to save the life of the patient. 

Dr. T0MLIN.S0N thought the term pachymeningitis a 
misnomer. The primary condition is noninflammatory. 
In syphilitic cases there are no signs of active inflam- 
mation, but changes in the bloodvessels. 

Dr. Fisher believed that the blood comes from newly 
formed vessels which have resulted from inflammation, 
and asked what the special indications were for opera- 
tive interference. 

Dr. Bullaru answered that operation was indicated 
when symptoms of pressure existed. The question as 
to the origin of the disease remains sub judice. 

Dr. E. W. Taylor, of Boston, presented a case of 

TABES AND MULTIPLE SCLEROSIS. 

There had been probable syphilitic infection twenty 
years before. The patient first noticed a tremor of the 
hands fourteen years ago, followed by pain of a lancin- 
ating character in the legs, associated with general mus- 
cular weakness. There were gradual increase of these 
symptoms, with occasional paresthesia of the legs ; gir- 
dle-sensation and difficulty in micturition ; loss of knee- 
jerk ; Argyll-Robertson pupil; lancinating pains; dis- 
turbances of sensibility ; so that the diagnosis of tabes 
dorsalis was unquestioned. In addition there were slight 
nystagmus, spasm of the posterior thigh-muscles, mus- 
cular weakness, hesitating speech, and absolutely char- 
acteristic intention-tremor masking the little ataxia 
present. 

Dr. Prince then presented microscopic specimens 
from a case of 

cerebro-spinal syphilis. 

Dr. Joseph Collins, of New York, read a paper 
on the 

PATHOLOGY AND MORBID ANATOMY OF AMYOTROPHIC 
LATERAL SCLEROSIS. 

He referred to the moderately constant clinical pic- 
ture of amyotrophic lateral sclerosis, and the variable 
pathologic conditions on which it has been found to be 
dependent, and pointed out that the number of cases in 
the literature that were well substantiated by autopsy 
were fewer than one might be inclined to think. Refer- 
ence was also made to the different views held by the 
followers of Charcot and Erb on one hand, and of 
Cowers, Leyden, and others on the other hand, as to 
whether the disease is primarily of the pyramids, with 



secondary involvement of the anterior horns, or whether 
it is but a variation of the common form of progressive 
muscular atrophy. The case was reported of a man, 
thirty-three years of age, in which after death atrophy 
of the ganglionic cells throughout the cord was found, 
Throughout the cord, but especially in the cervical and 
dorsal regions, there were evidences of excessive vascu- 
larity, in the shape of large, thickened bloodvessels, 
especially in the gray matter, and there were spaces from 
which the vessels had disappeared. In the cervical 
cord, corresponding to the place of apparent softening 
in the recent state, was found great disorganization of the 
ground-substance of the anterior horns. In the medulla 
there was degeneration of the nuclei throughout the 
entire extent, with the exception of the extreme caudal 
end. There was also slight degeneration in the tenth 
and common vago-accessorio-glosso-pharyngeal nucleus, 
but none in the pyramids of the medulla. The root of 
the twelfth nerve was small and delicate. A second case 
occurred in a male, forty-eight years of age. Cultures 
made from a piece of cord from the cervical region re- 
vealed the presence of the tubercle-bacillus in consider- 
able numbers. In the cervical region there was degen- 
eration in the crossed and direct pyramidal tracts, with 
almost complete destruction of the anterior horns. In 
the dorsal region there were sclerosis of the crossed 
pyramidal tracts, slight sclerosis of the ascending cere- 
bellar tract, diffusedly distributed dilated bloodvessels, 
some with very much thickened walls ; extensive atrophy 
of the cells of the anterior horns, some degeneration of the 
lumbar and sacral regions, and in the dorsal, but in 
less degree. In the medulla atrophic changes were 
found in the nucleus of the twelfth nerve. A hemor- 
rhage of ancient date was present in the dorsal region. 

Dr. William C. Krauss, of Buffalo, read a commu- 
nication entitled 

peroneal muscular ATROPHY, WITH AUTOPSY. 

He reported the case of a man, seventy-eight years of 
age, who, at the age of eighteen, began to notice a 
weakness of the leg-muscles. This weakness was ac- 
companied by atrophy in the peroneal and hamstring 
muscles of both legs and extended to the muscles of the 
thigh, the left thigh being much more affected than the 
right. Double club-foot of the/« varus variety resulted, 
and also a double genu valgutn. The tendon-reflexes 
were absent on the left side, and also on the right, with the 
exception of the knee-jerk. Fibrillary contractions and 
sensory disturbances were entirely wanting. There 
were present lordosis and scoliosis of the lumbo-sacral 
region. The muscles of the upper extremities were un- 
affected. The patient gave no history of any infantile 
disease or of poliomyelitis, and ascribed the affection 
to an accident. The patient died from uremia. Micro- 
scopic examination of the spinal cord revealed atrophy 
of the anterior horns, especially on the left side, extend- 
ing from the caudal part of the thoracic region to the 
conus medullaris. The multipolar cells of the antero- 
lateral group were visibly affected, in places having dis- 
appeared, in others undergone atrophy or degeneration, 
while the median group was less affected. The white 
matter was somewhat sclerosed, particularly in the 
antero-lateral and posterior columns, but not more than 
the age of the patient would warrant. 



July 6, 1895] 



NEWS ITEMS. 



27 



Dr. Collins remarked that unless Dr. Krauss estab- 
lishes that this was not a case of chronic anterior polio- 
myehtis, then it should not be accepted as one of the 
peroneal type of muscular atrophy. 

Dr. J. W. Putnam, of Buffalo, reported a case of 
writer's cr.\mp 

in a telegrapher. The man had previously had teleg- 
rapher's paralysis of the wrist, but later the symptoms 
increased to such an extent that the mere suggestion of 
writing, or the thought of writing, would bring on the 
spasm. This involved, in addition to the arm-muscles, 
the trapezius and the sterno-mastoid of the left side. 
The result was that,' in attempting to write, the head 
would twist round to such an extent that the man was 
unable to see the paper. The patient was treated by 
hypnotism and deep muscular injections of atropin, with 
complete recovery after the lapse of two months. 

Dr. Riggs related that he had seen a similar case, 
but that the trapezius was not involved. Much relief 
was obtained from the use of hyoscin hydrobromate. 

Dr. Leszvnsky asked whether the favorable result 
was due to hypnotism or to atropin. 

Dr. Putnam replied that he attributed the recovery 
to suggestion through hypnotism. 

Dr. Smith Baker said that he had come to consider 
the associated contractions (those of the shoulder, head, 
etc.) as natural outcomes of the habitual attitude assumed 
by everyone whenever they intend to do any particular 
thing whatever. They may be designated as associated 
intention-contractions. The origin of these undoubtedly 
dates back to the time of either learning to write or of 
some position incidentally assumed for comfort, or other 
favoring result. The cure may come about through any 
means whereby the associations are broken up. Possibly 
writer's cramp itself is most frequently of purely psychic 
origin, and so rest, or hypnotism, or any other efficient 
psychic impression kept up long enough will result in 
recovery. 

Dr. Smith Baker, of Utica, read a paper on 

AUTOMIMESIS, 

which he defined as the process whereby impressions 
from the outside world or conceptions arising in the 
mind are first set as copy-models, and then automati- 
cally reproduced more or less indefinitely, until results 
detrimental or otherwise are attained. As usually con- 
sidered, imitation means the reproduction of features 
found in other individuals. Automimesis or self-mimicry 
means the serial reproduction of characteristics domi- 
nant at some particular time in one's own mind. How 
such a copy-model first comes to be set and subsecjuently 
followed is often a mystery, but a pain, or shock, or 
word, or muscular tension, or unusual idea, or any inci- 
dental experience undoubtedly affords the requisite sug- 
gestion — imitative impulse. This is often seen in the 
development of hysteria, neurasthenia, melancholia, in- 
sistent ideation and allied states and tendencies, while 
evidence is accumulating to show that the succeeding 
automimetic series is a quite natural outcome of such an 
imitative impression. Cases illustrating automimetic 
development of disease were given, and the conclusion 
reached that possibly in this way there have been opened 
up points of view both as to etiology and therapy which 
are of value to neurologists. 



Dr. Ralph L. Parsons, of Sing Sing, presented draw- 
ings and photographs illustrative of a new system of 
baths inaugurated at the institution with which he is 
connected. 

Dr. G. L. Walton, of Boston, read a paper on 

OBSTETRIC PARALYSIS. 

He said that it is assumed that this condition is due to 
a stretching of the brachial plexus at a spot above the 
origin of the supra-scapular nerve. This does not ac- 
count for the escape of the branch to the pectoralis 
major, which passes off immediately below. The same 
difficulty presents itself in the theory of pressure against 
the clavicle. It was suggested that the supra- scapular 
nerve is probably bruised independently against the 
supra-scapular notch or spine of the scapula, while the 
plexus below is bruised against the clavicle. The branch 
to the pectoralis major escapes through having no bony 
point of fixation. Probably rotation of the face away 
from the shoulder that is caught at the brim of the pelvis 
aids the stretching, as well as the drawing away of the 
head, already described in this connection. 

The following papers were read by title : " Home- 
treatment of Insanity," by Dr. H. M. Bannister, of 
Chicago; "The Dual Action of the Brain," by Dr. 
Samuel B. Lyon, of Bloomingdale ; "An Operative 
Procedure for the Relief of Basilar Meningitis Limited to 
the Posterior Fossa," by Dr. J. T. Eskridge, of Denver ; 
" Fissural Studies of the Brain of Two Philosophers, " 
by Dr. Burt G. Wilder, of Ithaca; "The Association 
of Tabes and Paretic Dementia," by Dr. Theodore 
Diller, of Pittsburg; "Must Acute Paranoia be Admitted 
into Our Nomenclature ?" by Dr. William Noyes, of Fox- 
boro ; "The Conservative Value of the Play -impulse," 
by Dr. Irving G. Rosse, of Washington ; " Telegrapher's 
Paralysis," by Dr. James Hendrie Lloyd, of Philadel- 
phia ; "Case of Multiple Neuritis in an Infant," by Dr. 
Graeme M. Hammond, of New York ; " Pseudo-neuras- 
thenia," by Dr. Morton Prince, of Boston. 

The following were elected to active membership : Dr. 
Hugh F. Patrick, of Chicago; Dr. Edward Wyllys Tay- 
lor, of Boston ; Dr. Leopold Stieglitz, of New York ; Dr. 
John Jenks Thomas, of Boston ; Dr. H. L. Worcester, 
of Danvers ; Dr. B. Onuf, of Brooklyn, N. Y. ; the fol- 
lowing were elected to honorary membership : Dr. S. 
Weir Mitchell, of Philadelphia ; Dr. Camillo Golgi ; Dr. 
L. Edinger; of Frankfort ; Dr. Ramon y Cajal, of Bar- 
celona ; Dr. Dejerine, of Paris. 

The following officers were elected for the ensuing 
year : President, Dr. F. X. Dercum, of Philadelphia ; 
Vice-Presidents, Dr. George J. Preston, of Baltimore, and 
Dr. C. E. Riggs, of St. Paul ; Secretary and Treasurer, 
Dr. G. M. Hammond, of New York. 



NEWS ITEMS. 

The American Orthopedic Association will hold its ninth 
annual meeting at Chicago, September 17, 18, and 19, 
1895. The following papers have already been prom- 
ised ; On Forcible Correction, and Corrective Jackets, 
in the Treatment of Scoliosis, by Dr. Barnard Bartow, 
of Buffalo ; Idiopathic Osteoarthrosis, by Dr. Wallace 
Blanchard, of Chicago ; ( i ) The Use of the Plaster Jacket 
in Caries and the Effect of Position on the Spine. (2) 



28 



NEWS ITEMS. 



[Medical News 



Caries in Adults, by Dr. E. G. Brackett, of Boston; (i) 
Operative Measures in Caries of the Spine. (2) Treat- 
ment of Slipping Patella, by Dr. E. H. Bradford, of Bos- 
ton ; On the Surgical Treatment of Congenital Disloca- 
tions, by Mr. Bernard Brodhurst, of London, Eng.; Some 
Cases of Osteoclasis with the Lorenz Osteoclast, by Dr. 
F. S. Coolidge, of Chicago ; Improved Osteoclast, by Dr. 
Nicholas Grattan, of Cork, Ireland ; title not announced, 
Dr. V. P. Gibney, of New York ; New (anterior) Spine 
Brace, with Exhibition of Patients, by Dr. A. E. Hoad- 
ley, of Chicago ; title not announced, Dr. A. B. Hosmer, 
of Chicago ; The Deformity of Hip-disease, by Dr. A. B. 
Judson, of New York ; The Causative Relation of Suppu- 
ration to Tuberculous Meningitis in Joint and Spine 
Disease, by Dr. Samuel Ketch, of New York ; Ambulatory 
Treatment of Pott's Disease, by Dr. R. W. Lovett, 
of Boston ; Club- foot, by Dr. R. W. Lovett and Dr. John 
Dane, of Boston ; (i) Congenital Absence of Radii, with 
Operation. (2) Exhibition of Hip-joint Brace. (3) 
Plaster-of- Paris in Orthopedic Surgery. (4) Specimens 
of Tuberculous Bone-disease, by Dr. S. L. McCurdy, 
of Pittsburg; (i) The Rawhide Corset Spinal Brace. (2) 
A Review of the Treatment of Hip-disease, by Dr. B. 
E. McKenzie, of Toronto ; Spasmodic Wry-neck, by Dr. 
T. H. Myers, of New York ; title not announced, Dr. C. 
B. Packard, of Denver ; The Deformities Produced by 
Acute Inflammatory Lesions in Bone, by Dr. Roswell 
Park, of Buffalo ; (i) The Report of a Case of Congenital 
Dislocation of the Shoulder, and an Operation for its 
Relief. (2) The Treatment of Fracture from an Ortho- 
pedic Standpoint. (3) How the Orthopedic Surgeon 
Should Treat Abscesses (tuberculous and purulent), by 
Dr. A. M. Phelps, of New York ; The President's Address, 
by Dr. John Ridlon, of Chicago ; One-thousand Cases of 
Lateral Curvature of the Spine Treated by Posture 
and Exercise, by Dr. Bernard Roth, of London, Eng. ; 
The Anterior Spine-brace, by Dr. J. C. Schapps, of Brook- 
lyn ; Some Considerations of the Mechanical Arrange- 
ments Around the Hip-joint, by Dr. H. M. Sherman, 
of San Francisco ; several papers, titles not announced, 
Mr. Noble Smith, of London, Eng. ; A Case of Double 
Congenital Knee-luxation, by Dr. H. L. Taylor, of New 
York; (t) Pain in the Back. (2) Metatarsalgia. (3) 
The Use of Mechanical Support in the Treatment of 
Scoliosis, by Dr. L. A. Weigel, of Rochester ; Observa- 
tions on Weak-foot, with particular reference to its Pre- 
disposing Cause, its Diagnosis, and its Cure, by Dr. 
Royal Whitman, of New York ; A Report of Seventy 
Cases of Splicing of the Tendo-Achillis, by Dr. H. Aug. 
Wilson, of Philadelphia ; The Treatment of Scoliosis by 
Light Gymnastic Exercises, by Dr. J. K. Young, of Phila- 
delphia. 

Papers have also been promised, if there is time for 
their reading, by Drs. L. L. McArthur, Weller Van 
Hook, Robert Tilly, Joseph Zeisler, H. P. Woley, and 
other gentlemen of Chicago, but these papers will not 
be presented except by vote of the Association. 

The Colorado State Medical Society held its twenty-fifth 
annual convention in Denver, June iSth, 19th, and 20th, 
and elected the following officers for the ensuing year : 
President^ Dr. I. B. Perkins, of Denver ; First Vice-Presi- 
dt'tit. Dr. A. J. Robinson, of Aspen ; Second Vice-Presi- 
dent, Dr. Lee Kahn, of Leadville ; Third Vice-President, 
Dr. Mary Ambrook, of Boulder; Corresponding Secretary, 



Dr. E. R. Axtell, of Denver; Recording Secretary, Dr. 
Laura Liebhart, of Denver ; Assistant Recording Secre- 
tary, Dr. H. H. Bucknum, of Denver ; Treasurer, W. F. 
McClelland, of Denver. The meeting was the largest and 
best the society has ever held. Over a hundred- and-fifty 
members were present. Sixty papers were presented, 
and addresses were delivered by Professors Ridlon and 
Vaughan. A number of social features were introduced, 
and the meeting was voted a success. Sixty-two new 
members were added to the membership list. 

Meetings of State, national, and International Medical 
Societies : 





Meets. 


Next meeting. 


American Drrmatological 


Sept. 17, 1895 


Montreal, 


Association. 




Can. 


American Electro-Thera- 


Sept. 3, 1895 


Toronto, Can. 


peutic Association. 






American Medical Associ- 


May 5-8, 1896 


Atlanta, Ga. 


ation. 






.American Microscopical So- 


August 21-23, 


Ithaca, N. Y, 


ciety. 


189s 


" 


.American Ophthalmological 


July 24, 1895 


New London, 


Society. 




Conn. 


American Orthopedic Asso- 


Sept. 19-21, 1895 


Chicago, 111. 


ciation. 






British Medical Association. 


July 30-Aug. 2, 


London. 




1895 


England. 


Canadian Medical Associ- 


Aug. 28-30, 189s 


Kingston, Ont. 


ation. 






Idaho State Medical Society. 


Sept. 9-11, 1895 


Boise City, Id. 


Illinois State Medical So- 


May 19, 1896 


Ottawa, 111. 


ciety. 






International Congress of 


August 4-8, 1896 


London, Eng. 


Dermatology. 






International Congress of 


September, 1896 


Geneva, 


Gynecology & Obstetrics. 




Switzerland. 


International Congress of 


189s 


Ostend. 


Hydrobalneolherapy. 






International Congress of 


Sept. 23-26, 189s 


Florence, 


Otology. 




Italy. 


International Medical Con- 


August, 1896 


Moscow, 


gress. 




Russia. 


Medical Association of 


April 15, 1896 


Augusta, Ga. 


Georgia. 






Medical .Association of the 


April, 1896 


Montgomery, 


State of Alabama. 




Ala. 


Medical Society of the State 


Jan. 28, 1896 


Albany, N. Y. 


of New York. 






Medical Society of Virginia. 


September 3 


Wytheville.Va. 


Mississippi Valley Medical 


September 3-6 


Detroit, Mich. 


Association. 






New Mexico Medical Society. 


July 10, 1895 


Las Vegas, 

N. M. 


New York State Medical 


October 15-17 


New York City 


Association. 






Ohio State Medical Society 


May 27-29, 1896 


Columbus, 0. 


Texas State Medical Society. 


April, 1896 


Ft. Worth, 
Texas. 


Tri-State Medical Society of 


Oct. 1-4, 1S95 


Des Moines, 


Illinois, Iowa, and Mis- 




Iowa. 


souri. 






Vermont State Medical So- 


October 10, 11 


Burlington, 


ciety. 




Vt. 



Medical Director Albert C. Gorgas, U.S.N. , died June 29th, 
at Germantovvn, Philadelphia, at the age of sixty years. 
He entered the navy as an Assistant Surgeon in 1S56. 
From 1SS9 to 1893 he was in charge of the Naval Hos- 
pital at Philadelphia, and after this was on duty at the 
Naval Museum of Hygiene at Washington. 

The Medical and Surgical Reporter has removed from 
Philadelphia to New York. 



THE MEDICAL NEWS 

A WEEKLY JOURNAL OF MEDICAL SCIENCE. 



Vol. LXVII. 



Saturday, July 13, 1895. 



No. 



ORIGINAL ARTICLES. 

THE ETIOLOGY OF DIPHTHERIA} 
By FREDERICK G. NOVY, Sc.D., M.D., 

OF ANN ARBOR, MICHIGAN. 

Of the infectious diseases there is scarcely one 
that has passed through as interesting and as re- 
markable a history as diphtheria. Numerous in- 
vestigators attempted, at quite an early date, to 
throw light upon the cause of this dreadful dis- 
ease. Their efforts, however, were largely unsuc- 
cessful, owing to the extreme difficulties presenting 
themselves at that early period in the study of bac- 
terial affections. In the normal individual the 
mouth harbors a large number of micro-organisms, 
and in diseases of the mouth or throat the number 
and kind of micro-organisms are still further in- 
creased. No wonder, then, that this abundant and 
luxuriant flora of the mouth served to divert and 
nonplus the early pioneers in this important study. 

One thing, however, was certain, namely, that the 
cause of diphtheria was a microbe — a living organ- 
ism. It is only too well known that diphtheria is a 
communicable disease, that it is transmissible from 
one individual to another. This fact can be ex- 
plained in but one way, and that is that a living 
organism is transmitted from one person to another. 
The attribute of life is essential to the cause of an 
infectious disease, and diphtheria certainly occupies 
a front rank in this class. 

Our present knowledge regarding the microbic 
causeof diphtheria may be said to begin in 1883, when 
Klebs found, by microscopic examination of a 
number of cases of diphtheria, the bacillus that to- 
day is known throughout the world as the cause of 
diphtheria. During the following year Loeffler suc- 
ceeded in isolating the bacillus in absolutely pure 
culture. He was therefore able to describe mi- 
nutely its morphologic, tinctorial, cultural, and 
biologic properties, and by so doing furnished a 
firm, permanent, reliable foundation on which sub- 
sequent workers could build with that confidence 
which has brought about one of the greatest achieve- 
ments in medicine. 

Loeffler confirmed the observations of Klebs re- 
garding the presence of this bacillus in the false 
membranes of this disease. In twenty-seven diph- 
theric membranes examined he found the bacillus 

1 Read before the Michigan State Medical Society, June 5, 1S95 



present in about one-half. On the other hand, in 
5ome of the sections examined the bacillus could 
not be found — a failure due undoubtedly, as he 
himself points out in 1890, to the fact that some 
of the early cases studied were not typical cases of 
diphtheria. Between 18S4 and 1890 he examined 
twenty-one fresh cases of diphtheria, and in every 
one of these the characteristic bacillus was de- 
monstrated. Inoculations with pure cultures of 
this bacillus into the trachea of rabbits, guinea- 
pigs, chickens, and doves produced a croupous-like 
condition, due to the formation of false membranes. 
Similar results were obtained by vaginal inocula- 
tions in guinea-pigs, and also by applications to the 
conjunctiva and pharynx. When injected subcu- 
taneously into guinea-pigs a hemorrhagic edema 
with grayish-white exudate formed. 

The fact that the bacilli were always found in 
guinea-pigs at the point of inoculation, and not within 
the organs, led Loeffler to conclude that the micro- 
organisms produced a powerful poison which was ab- 
sorbed and carried throughout the body. This view 
was subsequently established by Loeffler's own re- 
searches in 1887 and 188S on the poisonous products 
of the bacillus, and, above all, by the classic re- 
searches of Roux and Yersin in 1888 and of Brieger 
and Fraenkel in 1890. 

Notwithstanding the frequent presence of this 
bacillus in the disease, and the diphtheria-like re- 
sults obtained by inoculating animals with pure 
cultures of the bacillus, Loeffler, with characteristic 
modesty and reserve, with the true spirit of a scien- 
tific investigator, refrained from designating it as the 
cause of diphtheria. This hesitation was due to sev- 
eral reasons. In the first place, he had found the 
same bacillus, identical morphologically and phys- 
iologically, in the mouth of a healthy child. Again, 
the typical diphtheric paralyses observed in man 
were not reproduced in animals ; also, when ap- 
plied to the uninjured raucous membranes of ani- 
mals, the cultures had no effect. Furthermore, as 
already stated, the bacillus was not always found in 
the sections of membranes examined ; and, lastly, 
the bacilli showed a different arrangement in the 
false membranes from animals compared with those 
from man. In view of these facts, Loeffler came to 
the conclusion that, while the bacillus was probably 
the cause of diphtheria, more investigation would be 
necessary to prove this relationship definitely. 

The doubt expressed by Loeffler as to the relation 



3° 



THE ETIOLOGY OF DIPHTHERIA. 



[Medical News 



of the bacillus to diphtheria unquestionably con- 
tributed to discourage other investigators, for during 
the next three years practically no further studies 
were made. In his second paper, in 1887, Loefifler 
pointed out the constant presence of the germ in ten 
cases, and at the same time discovered the pseudo- 
diphtheria-bacillus, which differed from the bacillus 
first studied, in addition to slight morphologic and 
cultural differences, in the absence of any patho- 
genic power with respect to guinea-pigs. 

In the following year Hofmann, whose untimely 
and tragic death will ever remain in the memory of 
bacteriologists, studied the occurrence of the Klebs- 
Loeffier bacillus in diphtheria. He succeeded in find- 
ing the bacillus in six out of eight cases, but he 
failed to establish any specific relation between the 
bacillus and the disease, for much the same reasons 
that led Loeftler to question the correctness of his 
own interpretations. Thus Hofmann met with the 
non-pathogenic, pseudo-diphtheria-bacillus in diph- 
theric membranes and also in twenty-six out of 
forty-five diseased but not diphtheric mucous mem- 
branes. He likewise demonstrated a marked vari- 
ation in the virulence of the Loeffler bacillus ob- 
tained from different cases, and from old cultures. 
Furthermore, the virulent bacillus was found in a 
case of measles, and in one individual out of eleven 
in whom no throat-complication existed. 

In December, 1888, Roux and Yersin published 
their first memoir on diphtheria, in which they 
were able to take the definite stand that the Klebs- 
Loeffler bacillus was the specific cause of diphtheria. 
They considered themselves justified in taking this 
position because: (i) they found the Loefifler bacil- 
lus present in each one of the fifteen cases of diph- 
theria examined; (2) by means of pure cultures of 
the bacillus they reproduced false membranes in 
animals, just as Loeffler had done; (3) they suc- 
ceeded with pure cultures in producing paralyses in 
animals similar to the post-diphtheric paralyses in 
man ; (4) they demonstrated that the bacillus gives 
rise to poisonous products which, when injected into 
animals, produced either death or paralyses, ac- 
cording to the dose. This publication of Roux and 
Yersin attracted widespread attention, and led num- 
erous workers to take up the subject of the etiol- 
ogy of diphtheria. The result of these investigations 
was the confirmation of Roux and Yersin's conclu- 
sions, and, with this achievement once accom- 
plished, it became possible for Behring to enter 
definitely upon that research which has given, and 
will give, invaluable benefits to mankind. 

Let us consider now, in a somewhat general way, 
the evidence that has been brought forward during 
the past ten years regarding the etiology of diph- 
theria. In the first place, in order that a micro- 
organism shall be considered as the cause of a dis- 
ease, the requirement is exacted that it shall be 



found in every case of that disease. This so-cailed 
first rule of Koch, framed at a very early period in 
the history of the etiology of infectious diseases, 
assumes some things that, in the light of our present 
knowledge of the role of micro-organisms in infec- 
tion, cannot be disregarded. Thus, that which for 
clinical or anatomic reasons is described as a defi- 
nite disease may in reality be far from being an 
entirety. A rational or natural classification in gen- 
eral biologic science is based upon natural, intimate 
relationships, and not upon mere appearance or 
form. The division of diseases by the clinician, 
based on mere clinical observations, or by the 
pathologic anatomist, based on anatomic relations, 
are largely classifications of convenience, and in no 
wise bring out the relation that is closest and most 
intimate to the disease — that of the cause. It does 
not require much reasoning to show that what is 
clinically or anatomically designated as a disease 
may have only one cause or may have several dis- 
tinct causes. In the latter case, what was called a 
disease becomes, through the study of its etiology, a 
group of diseases. The old typhoid fever has 
passed through such a history, and we may say in 
advance that diphtheria has recently experienced a 
similar development. 

We may now ask ourselves. Is the Loeffler bacillus 
present in every case of diphtheria? Is the first rule 
of Koch demonstrated ? From the earliest investi- 
gations of Klebs in 1883, and of Loeffler in 1884, 
until the present day, it is evident that the Loefifler 
bacillus is present in a very large proportion of the 
cases of clinical diphtheria. In the following table 
an effort is made to compile all available reports of 
bacteriologic examinations, from outside the United 
States, of diphtheria, made in ten cases or more, 
showing the number of cases examined and the 
number of times the Loefifler bacillus has been found : 



Rtux & Yersin, 
Kolisko & Paltai 



'■{ 



Zarniko, 1889 
Babes, 1890 

Brieger & Frocnkel, 

1890 
Beck, i8go 

D*Espine, 1890 
Escherich, li'go* 
Klein, 1890 

Locfller, 1890 
Roux & Yersin, 189c 
-Spronck, 1890 
Morel, 1891 

Plelzer, 1891 
Concelti, 1892 
Heubner, 1892 
Janson, 1893 



53 


5= 


15 




" 


21 


80 


61 


8^ 


96 


21 


>fe 


■'3 


77 


83 


03 


200 


137 


19 


13 


iS 


i3 



I' Baginsky, 1893 
I' Hoppe-Seyler, 1P92 
j Loeffler & Strilbing, \ 
:l 1894 \ 

Plant, 1894 

Riiter, 1894 
I: Phillip— Baginsky, ) 
1894 / 

ChaiUou & Manin, 1 
1894 \ 

Roux,Chaillou, and ) 

"" " 894 ; 



1894 
1894 
1894 



Feer, 
Kossel, 
Katz, 
H.lbert, 
Bernheim, 1894 
Bergmann, 1S94 
Schmorl, 1894 

Fraenkel, 1895 



Percentage, 



July 13, 1895] 



THE ETIOLOGY OF DIPHTHERIA. 



31 



From this table it will be seen that in 2846 cases 
examined by European workers the Loeffler bacillus 
was met with 2344 times, or 82.4 per cent. The 
result is somewhat higher than that obtained by 
American investigators, who, it will be observed, 
largely through the efficient support of the Board 
of Health of the City of New York, examined 
nearly twice as many cases as given in the preceding 
table. 



No. ofca 

Park, iS-^z 140 

Park, 1893 104 

Park and Beebe, 1S94 . . . 4795 

Morse, 1894 301 



Percentage 



No. of times 

Loeffler bacillus 

found. 



If we now combine the results obtained by 
American and European workers, we shall have 
8186 cases, in which the Loeffler bacillus was 
found 5943 times, or in 72.6 per cent, of the 
cases. 

These two tables contain the results obtained by 
a large number of investigators, in different labora- 
tories and in different countries, employing at times 
methods more or less different. In many instances, 
the cases examined are described as suspicious or 
very suspicious. The degree of suspicion, as Welch 
has pointed out, is a relative one, depending on the 
physician, for when one physician considers a case 
to be highly suspicious, another may regard it as 
very doubtful. Accurate, positive clinical diagnosis of 
diphtheria in many of the foregoing cases is lacking, 
and the low percentage that these statistics furnish 
may in part at least be explained by this dilution 
with suspicious cases. For purposes of diagnosis, 
of course, the examination of suspicious cases is ex- 
tremely valuable, but in statistics intended to show 
the frequency of the Loeffler bacillus in diphtheria 
they can have but one effect, that of lowering the 
percentage. This is true in the two tables already 
given and in the third table, which serves as an ex- 
cellent comparison with the work of the American 
bacteriologists, giving the results obtained by the 
French investigators of the Pasteur Institute of 
Paris. 

These results, it will be observed, are obtained 
by men working in the same laboratory, employ- 
ing the same methods of research, and studying 
cases in one and the same hospital. These figures 
are already included in the first table. It will be 
seen from this table that the Loeffler bacillus was 
found in 73 per cent., which coincides closely with 
the percentage-frequency in all cases examined. 
Bearing in mind that these French bacteriologists 
are all skilled workers, it will be evident that this 
percentage is low because of errors in diagnosis by 
the internes of the hospital. 



c and Ye 



Chaillou and M.irtin, XS94 . . 198 155 

Roux, Chaillou, and Martin, 1894 448 320 

960 701 

Percentage 73 

The available statistics then show that 73 per cent, 
of all clinical and suspicious cases of diphtheria con- 
tain the Loeffler bacillus. That this percentage will 
be higher when greater care is taken in diagnosis, ex- 
cluding suspicious or doubtful cases, is evident. Fur- 
thermore, there are other conditions that bear upon 
the detection of a given micro-organism in disease, 
and all of these factors tend to lower the percen- 
tage. Thus, in the first place, the accuracy and 
skill of the individual in detecting the Loeffler bacil- 
lus are to be considered. The more experience one 
has in this kind of work, the more easily and fre- 
quently will the bacillus be found. Again, much 
will depend on the method of staining and on the 
method of cultivation. Certain stains are prefer- 
able to others, and the same is true of the medium 
on which the germ grows. Again, failure of detec- 
tion may result from conditions over which the bac- 
teriologist has no control. Thus, the material which 
is removed from the throat may not be from that 
portion where the Loeffler bacillus is present. Mere 
touching or scraping of the surface of the mem- 
brane does not necessarily carry with it the bacillus, 
which may, however, be present in the membrane. 
Again, the Loeffler bacillus may be present, but out- 
grown by the large number of foreign germs that may 
be present. In such cases the detection of the 
germ becomes a mere accident. Further, the bacil- 
lus may be inhibited or even prevented in its growth 
on culture-media by a previous application of anti- 
septics to the throat. That such cases may and do 
occur has been shown recently by Plaut. 

There is reason, therefore, to believe that the per- 
centage of cases of diphtheria in which the Loeffler 
bacillus exists is greater than that given in the pre- 
ceding statistics. With proper care in diagnosis 
and in the removal of portions of membrane from the 
throat, supplemented by skilled investigators using 
reliable, well-tried methods, the percentage of cases 
in which the Loeffler bacillus is found may rise to a 
marked extent, as seen from the following table. 

-^j f No. of times 

N o. ot cases ^^^f^^^ bacillus 

examinea. found. 

Phillips (Baginsky) . . .333 332 

Bernheioi ..... 12 11 

Hilbert n " 

Katz ...... 128 128 

Kossel 117 "7 

Loeffler and Striibing . . . 100 75 

Ritter 225 225 

Bergmann 4* 4^ 

Fraenkel .... about too in all but few 

972 945 

Percentage . 97.2 



32 



THE ETIOLOGY OF DIPHTHERIA. 



[Medical News 



These figures are already included in the first table. 
They were all obtained during the past year (1894) 
by German workers. Plaut's results are omitted 
because most of his cases were diagnosticated as 
"suspicious " or " very suspicious." 

In connection with the presence of the Loeffler 
bacillus in diphtheria it should be emphasized, con- 
trary to Hansemann, that there are cases in which the 
bacillus is present in perfectly pure culture, unac- 
companied by any other germ. This is especially 
true if the examination be made at an early stage, as 
has been demonstrated by Martin, by Chaillou and 
Martin, by Fraenkel, and by others. Subsequently, 
as the disease progresses, other bacteria, especially 
cocci, make their appearance, and may not only 
outnumber but even suppress the Loeffler bacillus. 

These bacteriologic studies with reference to the 
frequency of the Loeffler bacillus in diphtheria 
demonstrate clearly that this bacillus is present in 
more than the 75 percentage of all cases of real clin- 
ical diphtheria, as stated by Loeffler and conceded 
even by Hansemann. There remain, however, still 
a sufficiently large percentage of clinical diphtherias 
from which the Loeffler bacillus is unquestionably 
absent. In these cases, which, in many respects, 
are undistinguishable clinically from those in which 
the Loeffler bacillus is present, other micro-organisms 
are found. These forms of diphtheria may be due 
to several other micro-organisms, as has been shown 
by Roux, Chaillou, and Martin in their researches. 
They cannot be said to be proved to be causes of 
such diphtherias, but, nevertheless, there is much 
reason to believe that such is the case. 

The French bacteriologists divide anginas into 
two groups: First, diphtheric anginas, those in 
which the Loeffler bacillus is present ; and, second, 
non-diphtheric anginas, those in which it is absent 
and which, as stated, are undoubtedly due to other 
micro-organisms, above all to cocci. Thus in 112 
anginas examined by Martin, 69 were found to 
be diphtheric and 43 non-diphtheric. The most 
common organism found in the latter group in 
25 cases was a coccus. The next most common 
organism was the streptococcus, found in S cases, 
and in a few others the staphylococcus albus, 
aureus, and other cocci predominated. 

In a second series by Chaiilou and Martin, 99 
anginas were examined, and 70 were found to 
be diphtheric and 29 non-diphtheric. Of the latter, 
II had the small coccus of Brisou, 11 had strepto- 
cocci, and 4 had staphylococci. In the 448 cases 
examined last year by Roux, Chaillou, and Martin, 
128 were found to be non-diphtheric. The study 
of croup by these same observers has likewise de- 
monstrated that all croups are not diphtheric. They 
may likewise be divided into diphtheric and non- 
diphtheric croups. The latter, as in the case of 
the anginas, may be due to the Brisou coccus. 



the streptococcus, the staphylococcus, and other 
organisms. As seen from the subjoined table, 
the number of non-diphtheric croups is much less — 
nearly one-half — than the non-diphtheric anginas : 

No. of n{„i,.i,. ■.. Non- 

A«gi«as: cases. D'Phthenc diphtheric. 

Martin .... 112 69 43 

Chaillou and Martin 99 70 29 

211 130 72 

Percentage 34.1 

Martin .... 88 68 20 

Chaillou and Martin . 99 85 14 

187 ~-i ~T, 

Percentage . ... ... 18.2 

The bacteriologic examinations show clearly, 
therefore, that diphtheria, as it is commonly 
understood, may be due to several causes — in 
other words, that we have a group of diseases that 
clinically often cannot be distinguished, but that, 
nevertheless, are etiologically different. It has been 
proposed to designate those cases in which the 
Loeffler bacillus is present as true diphtheria, or 
bacillar diphtheria, or diphtheria, for short ; while 
those cases in which it is not present are spoken of 
as false diphtheria or pseudo-diphtheria, coccus- 
diphtheria, or diphtheroid. 

Inasmuch as those cases in which the Loeffler 
bacillus is present are most numerous and most 
fatal, this form of diphtheria above all requires our 
attention. What evidence do we possess, then, that 
the Loeffler bacillus is actually the cause of those 
cases of diphtheria in which it occurs? 

In order to prove this relationship it is necessary 
to obtain the bacillus in perfectly pure culture, free 
from all oiher micro-organisms. This can readily 
be accomplished, thus satisfying the second rule of 
Koch. The pure cultures thus obtained, when 
inoculated into susceptible animals, must now pro- 
duce the same disease, with all its symptoms and 
pathologic changes, and in the animal thus artifici- 
ally infected the germ is to be found distributed the 
same as in the natural case. This severe require- 
ment is rarely complied with, for the reason that 
the animals which are used for experimentation, 
while susceptible to the action of the germ, can 
scarcely be expected to reproduce all the details of 
the disease as it exists in man. Thus the bacillus 
of glanders, which has been shown to be the cause 
of glanders in the horse, producing in that animal 
typical glanders, will, if inoculated into a field- 
mouse, produce death, but without the slightest 
resemblance to the disease in the horse. In other 
animals, as the guinea-pig, the bacillus docs pro- 
duce effects strikingly like those of glanders. Other 
instances might be cited to show that when experi- 
menting with bacteria on animals other than those 
in which the disease naturally occurs, variations are 
met with and must be expected. What, then, is 



July 13, 1895] 



THE ETIOLOGY OF DIPHTHERIA. 



33 



the effect of the Loeffler bacillus when inoculated 
into susceptible animals ? 

Fortunately, the results obtained by such inocu- 
lations are so striking and bear so great a resemblance 
to the natural disease in man as to leave no doubt 
in the minds of those who are at all familiar with 
the work that has been done in this direction. The 
production of experimental diphtheria in animals 
by Loeffler, and above all by Roux and Yersin, 
is in itself sufficient to show that the Loeffler 
bacillus is the cause of diphtheria. Guinea-pigs, 
pigeons, and rabbits are most susceptible to the 
Loeffler bacillus. Subcutaneous injections of a viru- 
lent culture into these animals almost invariably 
produce death in from twenty-four to forty-eight 
hours. A more or less extended gelatinous edema 
forms at the point of inoculation ; a grayish pseudo- 
membrane forms and the glands are enlarged. 
Serous effusions in the pleura are common in the 
guinea-pig, but very rare in rabbits. On the other 
hand, the liver in guinea-pigs is apparently un- 
affected, whereas in the rabbit fatty degeneration 
takes place. The inoculations on the mucous 
surfaces are especially characteristic. In order to 
succeed, the mucous membrane must first be 
slightly injured ; otherwise infection does not result. 
Inoculations in the pharynx, trachea, conjunctiva, 
and vulva of animals are followed by the formation 
of false membranes, general intoxication, and death. 
In tracheal inoculations the false membranes may 
spread, as Fraenkel points out, covering the entire 
walls of the air-passages even as far as the large 
bronchi. The tissues are edematous and the glands 
swollen. A more striking resemblance to the natural 
disease can hardly be expected in animals that are 
not naturally susceptible to the disease. 

The post-diphtheric paralyses observed in man 
have also been reproduced in animals by Roux and 
Yersin, Brieger and Fraenkel, and others. These 
paralyses are especially well marked in pigeons, 
rabbits, and dogs that have been inoculated with a 
quantity of the germ insufficient to kill in a short 
time. In from six days to two or three weeks from 
the inoculation typical paralyses develop and the 
animal either recovers or eventually dies. The 
production of false membranes on mucous surfaces 
and subsequent paralyses in animals complete the 
resemblance to the natural disease to such an extent 
as to establish the specific relation of the Loeffler 
bacillus to diphtheria. 

Not only can pure cultures of the bacillus cause 
the paralyses in animals, but the chemic products of 
the bacillus can accomplish the same result. The re- 
searches of Roux and Yersin on the poison produced 
by the Loeffler bacillus mark a new era in the study 
of diphtheria. The filtered, germ-free cultures of 
the Loeffler bacillus, when injected into rabbits in 
doses not sufficient to kill in a short time, produce 



typical paralyses. That similar poisons are elaborated 
in the body of diphtheria-patients has been demon- 
strated by these investigators and by others. Thus, 
the spleen and urine of a child dead of diphtheria 
were shown to contain the same or similar poisons 
that, when injected into a rabbit, were followed by 
prolonged paralysis and death. 

The effect of pure cultures of the Loeffler bacil- 
lus and of its chemic products on animals may 
be said to establish its relation to diphtheria. There 
are, however, two other facts that still further em- 
phasize this relation. In the first place, the high 
mortality of those cases of diphtheria in which the 
Loeffler bacillus is present is in striking contrast with 
the mortality of those cases in which it is absent. 
This is no accident, much less a myth, as Hanse- 
mann would believe. 

In the 80 cases studied by Roux and Yersin 
in 1890, the Loeffler bacillus was present in 61 
cases and absent from 19. All of these 19 re- 
covered, whereas of the 61 cases in which the 
bacillus was present 30 died. Again, of the 200 
cases examined by Martin in 1892, the Loeffler 
bacillus was found in 137 cases and was absent from 
63 cases. Of 55 non-diphtheric anginas and croup 
7 died ; 4 of these, however, became infected with 
the Loeffler bacillus in the hospital, subsequent to 
tracheotomy, and i died of broncho-pneumonia. 
Of 137 diphtheric anginas and croups 72 died. The 
study of the 198 cases presented by Chaillou and 
Martin in 1894 develops the same remarkable dif- 
ference in the mortality of the two groups. Thus, 
in the 198 cases of angina and croup mentioned, 
the Loeffler bacillus was found 155 times and was 
absent from 43 cases. Of the 43 non-diphtheric 
cases 4 died, 3 of these as a result of subsequent 
infection in the hospital with the Loeffler bacillus. 
Of the 155 cases in which the Loeffler bacillus was 
present 83 died. Again, of the 448 cases reported 
on by Roux and his coworkers last year, treated with 
serum, 109 died ; 320 of these cases had the Loeffler 
bacillus, and gave a mortality of 98 ; 12S did not 
have the Loeffler bacillus, and gave a mortality 

of II. 

These figures are brought together in the following 
table, and furnish an interesting subject for study : 











U 














s? 








SS 




^ 


s^ 




« 




0,1 i? 


.c 


s 


"032 


.c 


u 






3 


u 


0" J^ 


V 


u 




z;-; « 


a 


a. 


Z~ a 


p 


a. 
















Roux and Yersin . 


6l 


30 


40-2 


•9 








Martin 


•37 


7= 


.S2.6 


55 


7 


12.7 


Chaillou and Martin . 


155 


«3 


53-5 


43 


'' 


9-3 


Average 


353 


185 


S2-4 


i "7 


" 


9.4 












Roux. Chaillou, and Martin 


300 


78 


26.0 




" 





34 



THE ETIOLOGY OF DIPHTHERIA. 



[Medical News 



The bacteriologic examination of clinical diph- 
theria, therefore, shows clearly that the mortality in 
those cases in which the Loeffler bacillus is present 
is about 50 per cent. On the other hand, those 
forms that are clinically undistinguishable from the 
preceding, but do not contain the Loeffler bacillus, 
possess a mortality of 10 per cent., which, however, 
includes those that died of subsequent infection 
with the Loeffler bacillus. Deducting these, assum- 
ing that all would recover, the mortality would sink 
to less than 4 per cent. Certainly no more re- 
markable evidence of the etiologic relation of the 
Loeffler bacillus to diphtheria can be presented 
than that shown from the study of the relative 
mortalities. 

As a final proof of the relation of the Loeffler bacil- 
lus to diphtheria, we will mention in ageneral way the 
results obtained from the use of the antitoxic serum. 
First of all, it is desirable to emphasize the experi- 
mental fact that the serum of animals rendered arti- 
ficially immune to the diphtheria- bacillus or its pro- 
ducts will protect absolutely animals against many 
times the fatal dose of the diphtheria bacillus or of 
its poison. This fact is as well established by direct 
experimentation on animals as the chemic fact that 
sodium hydroxid and hydrochloric acid neutralize 
each other. Secondly, it will be remembered that 
in diphtherias in which the Loeffler bacillus is pre- 
sent, poisons the same as those formed in pure cul- 
tures are produced and can be found in the organs, 
as has been done by Roux and Yersin and others. 
The antitoxic serum that protects animals against 
infection with the Loeffler bacillus must likewise pro- 
tect the person afflicted with diphtheria due to the 
Loeffler bacillus. That it actually does protect is 
abundantly demonstrated by treatment of diphtheria 
during the past year. 

To emphasize the statement already made, it will 
be sufficient to present one or two instances. Of 
the 300 cases treated with the antitoxic serum and 
reported on by Roux, at Budapest, last September, 
only 78 died, giving a mortality of 26 per cent. 
These results were obtained in the same hospital 
in which Chaillou and Martin established the fact 
that in diphtheria in which the Loeffler bacillus is 
present the mortality is above 50 per cent. 

Furthermore, showing the specific action of the 
antitoxic serum on the Loeffler bacillus and its 
products, it will be seen, from results already cited, 
that in 1 28 non-diphtheric cases treated the mortality 
was 8. 6 per cent, against 9. 4 ])er cent, in non-treated 
cases. The serum is, therefore, without any effect 
in cases in which the Loeffler bacillus is not present, 
and in those cases in which it was present the mor- 
tality was reduced by one-half, that is, 25 per cent, 
were saved. Since then the mortality-record has 
been lowered considerably. Thus, in 128 cases of 
diphtheria containing the I^oeffler bacillus, treated 



by Katz, only 17 died, giving a mortality of 13.2 
per cent.; 117 cases treated by Kossel gave 1 3 deaths, 
a mortality of ii.i per cent. 

Because the protection against the Loeffler bacil- 
lus is absolute in animals, it must not be expected 
that similar results will be obtained in man. A cer- 
tain mortality will necessarily exist, owing to con- 
ditions over which the physician can have no 
control. In experiments on animals, three factors 
are involved : the animal body, the Loeffler bacillus 
or its poison, and the antitoxic serum. It is well 
known from experiments that an animal cannot be 
saved when the duration of the disease or of the 
intoxication has been too long. Irreparable injury 
has already been done. The same results must, 
therefore, be expected in the human subject when 
the disease has progressed beyond a certain point. 

Furthermore, in the human subject, in addition 
to the three factors mentioned, another one is to be 
considered, and that is the association of the Loeffler 
bacillus with other micro-organisms. It is to-day a 
well established fact in bacteriology that a given 
pathogenic germ may be favored or retarded in its 
action by the presence of other organisms. In diph- 
theria, both of these conditions are not infrequently 
met. Roux and Yersin have shown that the viru- 
lence of the Loeffler bacillus, with respect to animals, 
is increased by associating it with the streptococcus 
of erysipelas. The statistics furnished by Chaillou 
and Martin are especially valuable in this regard. 
In their researches, as already stated, the cases of 
clinical diphtheria were divided, on the strength of 
the bacteriologic examination, into diphtheric and 
non-diphtheric. The diphtheric anginas and croups 
were subdivided into (i) pure diphtheric forms, in 
which the Loeffler bacillus was present in a pure or 
almost pure condition; (2) diphtheric forms with 
microbic associations. The latter associations may 
vary. At one time there is present a small diplo- 
coccus, the coccus of Brisou ; at another time a 
streptococcus; at another time a staphylococcus. 
In a few words, the same germs that are found in 
non-diphtheric forms may be associated with the 
Loeffler bacillus in real diphtherias. 

The following table, compiled from the results 
obtained by Martin in 1892, and by Chaillou and 
Martin in 1894, demonstrates clearly the effect of 
microbic associations. All these cases contained 
the Loeffler bacillus. Those designated as "pure 
diphtheric" contained the Loeffler bacillus in almost 
pure culture, the number of foreign germs lieing very 
small, if at all present. In those cases designated as 
coccus-angina or croup, the predominating foreign 
germ, beside the Loefller bacillus, was a small diplo- 
coccus. It will be observed that the percentage- 
mortality in this group is much less than in the 
group of pure diphtheric affections. In other words, 
the presence of a large number of cocci of this 



July 13, 1895] 



TREATMENT OF CATARRHAL DEAFNESS. 



35 



kind tends to counteract the effect of the Loeffler 
bacillus. In the third group are included those 
cases in which, in addition to the Loefifler bacillus, 
streptococci or staphylococci predominate. Here 
it will be noticed that the percentage-mortality is 
much greater than in the pure diphtheric forms. 
The streptococci and staphylococci, therefore, either 
increase the pathogenic powers of the Loeffler bacil- 
lus directly, or by their own products give rise to 
additional intoxication, and, therefore, increased 
mortality : 

XT t XT r Perct. both 

No. of No. of p aneinas 

mufti H^Tih*; ^crct. anginas 

Ananas: "^"- ""'""'■ and croups. 

Pure diphtheric ... 96 38 40 

Diphtheric with coccus . . 14 1 7 

Diphtheric with streptococci ( ^g 
or staphylococci > 

Croups : 

Pure diphtheric ... 67 44 66 50.3 

Diphtheric with coccus . . 19 5 26 18.2 

Diphtheric with streptococci) ^ g 

or staphylococci J ' 

There are a number of other interesting points 
regarding the LoefBer bacillus, such as the presence 
of this germ in the throats of healthy children ; it-s 
occurrence in fibrinous rhinitis ; in wound-diph- 
therias ; its persistence in the throat after recovery 
from diphtheria ; its relation to the non-virulent 
pseudo-diphtheria-bacillus, etc. These facts, how- 
ever, have but little significance, so far as the proof 
of the relation of the Loeffler bacillus to diphtheria 
is concerned, and I shall, therefore, avoid their dis- 
cussion. 

Summarizing briefly the leading points brought 
out in this paper, it will be seen, _firs/, that the 
Loeffler bacillus is present in much more than 73 
per cent, of real clinical diphtherias ; second, that 
pure cultures introduced into animals reproduce 
false membranes, paralyses, and other ill-effects ob- 
served in diphtheria ; third, that the chemic pro- 
ducts of the bacillus produce paralyses, diarrhea, 
intoxication, and death, completing the resemblance 
to the natural disease ; fourth, that the mortality is 
vastly greater in those cases in which the Loeffler 
bacillus is present than in those from which it is 
absent ; fifth, that the antitoxic serum, which 
possesses a specific action toward the Loeffler 
bacillus and its poison, reduces the mortality in 
those cases in which the Loeffler bacillus is present 
and is without effect in those from which it is 
absent. 

It is this overwhelming evidence that fully justifies 
us in stating that whenever the Loeffler bacillus is 
found in a disease it is diphtheria. It was with 
genuine pleasure that Loeffler could make the defi- 
nite announcement at Budapest last year, ten years 
after his pioneer work of 18S4, that "The cause 
of diphtheria is the diphtheria-bacillus." 



A NOTE ON THE TREATMENT OF CATARRHAL 

DEAFNESS BY P N E U M 0-M A S SAG E AND 

PHONO-MASSAGE. 

By C. jay seltzer, M.D., 



YNGOLOGIST TO ' 



HOSPITAL. 



Deafness due to catarrhal inflammation comes 
on so insidiously that the impairment of hearing is 
not noticed in most cases until the conduction of 
sound is greatly impaired in one ear, if not in both 
ears. A desire to secure relief without resort to 
surgery calls for many efforts to devise some form of 
mechanism by means of which the delicate mem- 
branes and bony arches may be restored to their 
normal condition of elasticity and mobility. This 
can be best accomplished by a process of exercise or 
massage, associated with constitutional and local 
medication. 

The Edison phonograph, the vibrometer, and the 
vibrophone have all been before the medical pro- 
fession for some time, with strong claims urged for 
each of them. These instruments fulfil the indica- 
tions in part by producing a series of aerial impulses 
which are conveyed to the ear by means of tubes 
attached to an artificial drum in the instrument, and 
terminating in suitable bulbs that closely fit the ex- 
ternal meatus. The diaphragm of the artificial drum 
being put into vibration causes a similar movement 
of the membrana tympani and associated ossicles in 
the middle ear, thus breaking up some of the adhe- 
sions due to deposits of plastic material and inspis- 
sated mucus. This movement generally relaxes, and 
if sufficiently long continued permanently lessens 
the tension caused by such adhesions, and at the 
same time frees the drum of the inspissated mucus 
which mechanically interferes with sound-conduc- 
tion. This continued action upon the drum, more- 
over, tends to stimulate the normal secretion of 
mucus, and thus slowly softens the inspissated masses, 
which may be dislodged and expelled into the upper 
pharynx. At the same time it admits of freer ven- 
tilation of the middle ear, and consequent equal- 
ization of air-pressure inside and outside of the 
drum, thereby removing one source of tinnitus. 

The vibrophone does not possess sufficient force to 
produce more than very mild impacts, and is, there- 
fore, much inferior to the vibrometer or the phono- 
graph. The vibrometer has one advantage over 
other instruments in that the vibrations produced by 
one or the other of the banjo-strings possess a pitch 
and tone that are agreeable to the patient and suffi- 
ciently mild to admit of long sittings. The best 
instrument for the purpose, however, is the phono- 
graph, which, with the proper diaphragm attached, 
possesses the maximum of force with the minimum 
of sound. Such a diaphragm, with the attachment 
for the stylus, was devised some four years since, 
and although very delicate in construction, makes a 



36 



ADDRESS IN MENTAL DISORDERS. 



[Medical News 



sufficiently strong attachment for use on the grooved 
wax-cylinders ordinarily used on the phonograph.' 

With this diaphragm, and the cylinders grooved 
as the operator may desire, very forcible impacts with 
greatly reduced noise can be produced, and can be 
easily regulated to suit the conditions in each case. 
This is accomplished with comfort and safety for the 
patient owing to the movement of the diaphragm 
which causes the drum to retract, thereby producing, 
or tending to produce, a partial vacuum by first 
drawing out the membrana tympani and relieving 
the internal ear from pressure, and then alternating 
the pressure as the diaphragm returns to its original 
position, thus rapidly and continuously putting in 
motion the membrana tympani and the ossicles, with- 
out increasing the pressure on the oval window, and 
without possible harm to the internal ear. 

The phonograph has an additional advantage in 
that the confusion sometimes complained of when 
long-continued applications of massage have been 
made is nicely relieved by substituting a musical 
cylinder, which is both entertaining and soothing, 
especially stringed-instrument records, such as of the 
banjo. The vocal cylinders can be used to deter- 
mine the quality of sound-conduction as well as the 
hearing-value, and the orchestral musical cylinders 
in determining the pitch and kind of instruments 
best heard and recognized. We may also note the 
degree of improvement as shown by the additional 
words and tones recognized and repeated from time 
to time. The phonograph is, therefore, decidedly 
the best and neatest instrument for producing what 
is called pneumo-raassage and phono massage, with 
the single exception of certain gentle musical vibra- 
tions which can be best obtained from the banjo- 
strings of the vibrometer. 

The cases should first be carefully examined, to 
determine as nearly as possible the seat of patho- 
logic change, the character of deafness as regards 
the quality of sound, and the sensitiveness both to 
pain and sounds caused by the instrument in pro- 
ducing vibrations. The instrument is then started at 
a low speed, which is increased until discomfort or a 
tendency to vertigo is felt, at which point the maxi- 
mum limit is reached. The speed is then reduced 
to a velocity at which comfort is expressed, and re- 
tained at that point for several sittings, but may be 
gradually increased at subsequent sittings. The 
sittings should be regulated in length of time by the 
sensations of the patient, so as to avoid mental and 
physical discomfort (usually from ten to twenty-five 
minutes), and end by an agreeable musical cylinder, 
thus diverting attention to pleasant sensations, and 
at the same time securing mild auditory exercise. 

1 Messrs. Hawthorne & Sheble, the Edison phonograph 
agents of Philadelphia, 604 and 606 Chestnut Street, have been 
preparing these cylinders and diaphragms for this purpo.se after 
the original model made by Mr. Leeds. 



The results of this method, in conjunction with 
proper alteratives and tonics, and local treatment 
consisting of applications of tannic acid and gly- 
cerol, or weak silver-solutions to the naso-pharynx, 
antipyrin, and compound tincture of benzoin to the 
nose (especially over the lower turbinated bone), 
followed by camphor and menthol in liquid vaselin, 
and when stenosis from engorgement exists the 
galvano-cautery applied, will result in marked im- 
provement in many cases of deafness in which the 
loss of delicacy in motion of the conducting bony 
chain is caused by pathologic changes not destruc- 
tive to the continuity of soft or bony tissue. A 
thorough trial of this method in a large series of 
cases covering a period of twelve months has con- 
vinced me that an absolute cure or return of normal 
hearing-power in a large proportion of these cases 
may not be possible, but a considerable number 
will show the most marked improvement, while in 
the remaining cases an arrest of progress may at 
least be expected. Associated tinnitus is likewise 
relieved or cured in many cases, but a few will yield 
in neither deafness nor tinnitus in the period men- 
tioned. 

The disadvantages of this method are the length 
of time required and the number of applications 
necessary to accomplish the desired result ; but, not- 
withstanding these faults, it promises at present the 
greatest degree of success with the least amount of 
injurious effects of any method yet proposed, and is 
altogether our surest method of relief when used in 
connection with the proper inflation of the middle 
ear and the necessary local and constitutional 
treatment. 

ORIGINAL ADDRESS. 



UDDRESS IN MENTAL DISORDERS} 

By K. .X. DERCUM, M.D., 

CI-INICALPROFESSOKOF NERVOUS DISEASES, JEFFERSON MEDICAL COLLEGE; 

NEUROLor.lST TO PHILADELPHIA HOSPITAL; CONSULTING PHYSICIAN 

TO THE HOSPITAL FOR THE CHRONIC INSANE AT 

WERNERSVILLE, PENNA. 

For many years the public mind in dealing with the 
problem of insanity has approached it almost exclusively 
from a practical and utilitarian point of view. The 
reasons are obvious. The position that insanity and all 
that pertains to it has occupied in the past has been most 
peculiar. For ages the insane had been treated as a class 
that required not only the isolation of the leper, but also 
the punitive treatment of the evil-doer. In the lay mind 
insanity involuntarily excited abhorrence and disgust, 
and was closely associated with ideas of blame and 
punishment. Indeed, in this day it is by most people 
regarded as a disgrace if one of their relatives become 
insane, and often the fact is as much as possible kept 
concealed. By some unaccountable action of the human 
mind this pecuUarity attaches to no other class of diseases; 



' Read before the Medical Society of the State of Pennsylvania, 
at Chambersbiirg, May, 1895. 



July 13, 1895] 



ADDRESS IN MENTAL DISORDERS. 



37 



at least not in the same degree. It is not strange in view 
of these facts that the first attempts at the management 
of the insane in bulk consisted mainly in their housing, 
and made no other provision for their welfare. Even 
in these days, when the insane are placed under the care 
of physicians, the latter are assigned rather the duties 
of housekeepers, stewards, and executive officers than 
those of medical attendants. When we consider the 
attitude of the public mind that obtains more or less to 
this day, and when we consider the inherent difficulties 
of the subject, we caii readily understand why the 
science of insanity, especially its pathology, has re- 
mained a veritable Africa to medical men. 

We must, however, frankly admit that in the practical 
care of the insane an enormous advance has been made 
— an advance that has continued unceasingly ever since 
the days of Pine!, of Tuke, and of Rush. We, too, 
often look with eyes of reproach upon the science and 
forget the great practical good that has been accom- 
plished in other directions. Surely the pathway through 
the jungle had first to be cleared, a semblance of order 
had first to be established, a knowledge of clinical forms 
had first to be acquired, before the explorers of this 
dark continent could devote their time to purely scien- 
tific study. In this struggle, in this gigantic task, the 
alienist is still engaged. 

We cannot be surprised that more has not been ac- 
complished when we reflect that the asylum of today is 
only the refined madhouse of former times, and that in 
it but few opportunities for scientific research are to be 
found ; and, further, to repeat, that the physicians are 
burdened with executive duties such as should not come 
within the province of medical men, and of which medi- 
cine as a science can take no cognizance. 

For this condition of affairs medical men are not to be 
held strictly accountable. The insane-hospital is for the 
most part a public institution, and its organization, the 
plan upon which it is conducted, the financial system 
upon which it is based, is a reflection of public opinion. 
The practical politician fails to see the advantages re- 
sulting from purely abstract scientific investigation, and 
yet it is very probable that an increased knowledge of 
the pathology of insanity will diminish not only the cost 
of maintaining the insane, but also the actual number to 
be maintained. 

Another and still more serious obstacle has confronted 
the student of psychiatry, indeed the greatest obstacle 
of all, and that is the inherent difficulty of the subject. 
The alienist has been in the unfortunate position of 
being able to observe surface-indications only, while of 
the actual underlying principles he could of necessity 
have no knowledge, inasmuch as both the structure and 
the function of the gray cortex, except in their grossest 
relations, were unknown. As a consequence, meta- 
physical reasoning and vague speculation for a long 
time took the place of fact and scientific observation. 

At last the difficulty promises to be removed ; the 
dawn of a better day is at hand ; the marvellous methods 
of research of Golgi and of Ramon y Cajal, in the hands 
of such men as Lloyd Andriezen,' are revealing the 
actual, the detailed structure of the human cortex. The 
beginning has been made of associating structure with 

' Brain, Winter Number, 1S95 ; also 1894 Journal of Mental 
Science, p. 673, abstract. 



mind-action, and the recognition of the fact that mind- 
action cannot be separated from ordinary brain-action 
must henceforth be accepted as an indisputable fact. 
Uoubt, prejudice, preconceived notions of all kinds 
must yield to scientific truth. 

Andriezen has analyzed and separated the various 
elements of which the gray cortex is composed, and the 
relations of the structures to each other are such that 
their function seems evident. The incoming, the af- 
erent, fibers, which bring information to this vast ex- 
panse of ganglionic matter, the gray cortex, terminate 
not in ganghon-cells, but in the uppermost layer, the 
molecular layer, of the cortex. Here their minute divis- 
ions come in contact with the minute branches and 
delicate tufts of the various cortical cells. Significant is 
it, too, that the insulating material that encircles this 
afterent fiber is lost when the fiber enters the cortex, so 
that there is no interference with the proper diffusion, 
either by contact or induction, of the current which it 
conveys to surrounding structures. The current, what- 
ever its mode of motion may be, is transferred from cell- 
process to cell-body and thence perhaps to afferent 
fibers, or more frequently to countless numbers of other 
cells — cells whose business it is to associate, to combine, 
to separate, and to store up impressions. 

The hmits of the time at my disposal will not permit 
me to enter into a more detailed statement of these dis- 
coveries, but their significance is redoubled when we 
learn that Andriezen obtained the most interesting re- 
sults when he directed his attention to one of the 
simpler forms of insanity, namely, one in which the 
cause is definitely known, and in which the symptoms 
are well established and relatively simple in character : 
I refer to alcohoHc insanity. Andriezen found, first of 
all, that the neurons showed changes in the cell-bodies 
and in the nuclei. There were swelling and indistinct 
staining of the intercellular chromatin-rods. There were 
also coarseness and increased staining of the nucleus, 
changes that indicate that in alcoholic insanity the cell- 
protoplasm and cell-nuclei are the seat of serious nutritive 
disturbances. Especially, however, did Andriezen note 
alteration and destruction of the fine naked collaterals 
and nerve-terminals of the molecular layers of the 
cortex — the very layer in which afferent impressions are 
first communicated to the nerve-cells of the cortex. 
There were also swelling and softening of the very mi- 
nute protoplasmic granules attached to the special pro- 
cesses in the superficial quarter of the cortex. These 
changes, "dynamical changes," as Andriezen calls 
them, doubtless explain the diminished sensitiveness 
and alertness of the alcoholic to incoming sensory im- 
pressions, and similarly a diminution of the spread of 
the excitation from one area to associated areas. To 
these changes and to the changes in the cell-body are 
also to be relegated the amnesia of the alcoholic state. 
We have here the first instance in the history of insanity 
in which it has been possible to correlate closely cause, 
structural change, and symptom. Surely a beginning 
has been made in this brilliant research that augurs well 
for the future. 

It is to be hoped that these results will everywhere 
stimulate the foundation of laboratories in hospitals for 
the insane. To be sure, a few such laboratories already 
exist, but too often the pathologist meets with but scant 
support both from the Boards of Trustees and from the 



38 



ADDRESS IN MENTAL DISORDERS. 



[Medical News 



medical officers of the institutions. Everyone should 
realize that there is no longer an excuse for the ignorance 
that exists in reference to the changes in the cortex of 
the insane. The methods of Golgi and of Ramon y 
Cajal, as Andriezen has shown, are capable of revealing 
the most astounding secrets, and one of the most urgent 
demands upon the time of the alienist should be histo- 
logic and pathologic research. 

The story, however, does not end here. A second 
field of work is beginning to claim attention — a field 
more wide, more vast even than that which has been 
opened up by Andriezen. After all, whilst the detailed 
study of the sane or insane cortex will enable us to cor- 
relate structure with function and change of structure 
with change of function, it cannot, save in special in- 
stances, as in the case of alcohol, where the cause is clear 
and self-evident — it cannot of itself reveal the under- 
lying or initial causes that effect these changes. Even 
if it be possible to correlate the symptom.s in the case of 
mania or of melancholia with dynamic changes in the 
cell and its processes, it cannot be expected that the 
agent which produces these changes can be brought to 
light by this method. After all, the changes that we see 
are but effects, and are in many instances purely ter- 
minal results. 

The conviction is steadily growing in the medical 
mind that the actual agents which produce tissue-changes 
are chemic agents, toxic substances of one kind or 
another, no matter what their origin — in one instance 
absorbed or ingested from without, in another the poison 
elaborated by bacteria, and in another the poison of 
altered tissue- metabolism, of abnormal and deranged 
visceral function. 

Unfortunately, we can to-day say little that is fixed 
and definite upon this subject, and yet enough is known 
to indicate that we have here vast fields of undiscovered 
truth. That toxic substances are formed in the blood, 
that toxic substances are excreted by the urine is well 
known. This is true both of substances formed by 
normal and abnormal tissue-metabolism. We need here 
only allude to the writings of Bouchard upon this subject 
to recall how the retention of well-known products may 
cause such symptoms as asphyxia, uremia, uricemia, 
cholemia, glycemia, etc. A number of French observers, 
among them Bouchard, Lepine, and Guerin, have iso- 
lated alkaloidal substances from normal urine, while 
Selmi and others have isolated basic substances from 
pathologic urine. Griffiths, for instance, has obtained 
ptomains from the urine of scarlet fever, diphtheria, 
pneumonia, whooping-cough, measles, glanders, and 
epilepsy. None of these substances exists in normal 
urine. Luff has isolated a ptomain from the urine of 
typhoid fever. Albu has discovered ptomains in various 
pathologic urines, whilst Ewald isolated ptomains from 
the urine in cases of carcinoma of the stomach, of uremia, 
and of Addison's disease. It is also known that the 
urine in melancholia has an increased toxicity, while in 
mania the toxicity of the urine is decreased while that of 
the blood is increased. Enough, therefore, is known to 
justify us in discussing the probable relation of these 
toxic substances to the nervous system. 

That the nervous system is markedly influenced by 
the presence of toxic substances in the blood is, of course, 
well known. It remains only to outline a classification 
of these agents. To begin, certain toxic substances are 



normal constituents of the blood and urine, and only 
under certain circumstances are present in excess, when 
they assert their toxic action. Thus Mosso demonstrated 
the toxicity of the blood of fatigued animals, while 
Arbelous demonstrated the same fact not only as regards 
the blood, but also as regards the muscles of fatigued 
animals. Lepicque and Marette demonstrated in addi- 
tion that fatigue increased the toxicity of the urine. It 
is probable that in these facts is to be sought a partial 
explanation of some of the phenomena of neurasthenia 
and of those graver forms of nervous exhaustion that 
eventuate in insanity. In other words, we have an in- 
toxication of the nervous system in such cases from 
the mere accumulation of tissue-waste ; or, to put it in 
scientific language, the products of excessive tissue- 
metabolism. 

Closely allied to these substances are those that are 
present in the various diathetic insanities in which toxins 
are present, some of which may in smaller quantity be 
normal to the urine, while others are new and foreign. 
Thus in the insanity of gout we have doubtless to deal 
with uric acid, a substance normally present in the blood 
in small proportion, whilst in rheumatism we deal with 
a substance new and foreign. This is also true of the 
toxins of diabetic and of carcinomatous insanity. Re- 
garding carcinoma, it may be stated that the toxicity of 
the urine is always in excess of the normal, proving 
thus the presence of some poisonous substance. 

Next in order come the various toxic insanities due to 
disordered visceral action. Regarding these we have 
but little information. Enough is, however, known re- 
garding the diseases of the kidneys and of the liver to 
indicate that the insanities associated with these affec- 
tions are in all probability the result of autointoxication, 
the poisons being generated in consequence of the dis- 
ordered action of the viscera. It is not at all improbable 
that disease of other viscera — probably of all of the 
viscera — is attended with the elaboration of substances 
that have a toxic action upon the nervous system, i e,, 
autotoxins. 

Next we should consider the introduction of toxic sub- 
stances from without, and for the present we shall ex- 
clude all poisons ingested as such. From much that we 
know, we have reason to infer that under certain patho- 
logic conditions poisons are formed in the stomach and 
intestines which act profoundly upon the nervous system. 
Massetti, who has especially studied this subject, comes 
to the following conclusions ; First, that if there be a 
change in the process of gastric digestion by which, as 
a result of abnormal fermentation, noxious substances 
are produced, these when absorbed may in a predisposed 
individual cause disturbance of function of the nerve- 
centers. Secondly, disturbance of the gastric function 
secondary to disturbance of the nervous centers may in 
certain cases lead to the absorption of abnormal ma- 
terials from the gastro-intestinal tube, which may aggra- 
vate a pre-existing mental malady and may retard 
recovery. Thirdly, the stomach, like the rest of the 
digestive tube, is, among other things, an organ for 
the elimination of a toxic principle pre-formed and 
circulating in the blood. Unfortunately, here, as else- 
where, our knowledge is as yet too indefinite to enable 
us to speak with precision, and yet the occurrence of 
intoxication from the intestinal contents is of itself not 
open to question. 



July ij, 1895] 



COMPOUND FRACTURE OF THE SKULL. 



39 



We have still to consider briefly the toxic conditions 
resulting from infection : for example, influenza, typhoid 
fever, the eruptive fevers, erysipelas, septicemia, etc. 
Here the action of the toxic agents resolves itself, as 
Regis points out, into two separate conditions, depending 
entirely on the period at which the symptoms of intoxi- 
cation make their appearance. If these appear during 
the acute febrile state, they assume ordinarily the form 
of acute delirium ; whilst when they occur during the 
post-febrile period they produce a mental condition in 
which confusion, stupidity, stupor, and psychic asthenia 
are the prominent symptoms. It is not improbable that 
the symptoms occurring both during the acute febrile 
period and during the post-febrile state are due to the 
toxins elaborated by the bacteria of the disease, and are 
in a sense comparable, the first to the stage of acute 
alcoholic intoxication, the second to the mental impair- 
ment and asthenia of the chronic alcoholic period. 

It appears that the various intoxications of the nervous 
system resolve themselves into two great groups^irsf, 
the autointoxications, properly speaking, which embrace, 
first, the substances normal to the blood and secretions, 
but present in excess ; secondly, those substances due to 
the general disturbance of tissue-change met with in 
diathetic conditions ; and, thirdly, the poisons formed 
by the disturbed action of special viscera. 

In the second group we have, first, those substances 
absorbed from the intestinal tract, some of which are 
produced, as we have seen, by disordered chemic action 
and morbid fermentation of its contents, and others 
normally excreted by the intestinal tract, but under ab- 
normal conditions reabsorbed ; secondly, we have the 
poisons that are the direct results or accompaniments 
of infection. 

While we know comparatively little of the detailed 
chemistry of these poisons, we are justified in stating 
the following proposition, namely : that the most diverse 
agents may produce the same or at least similar clinical 
phenomena. For instance, the toxic action of alcohol 
resembles very closely the toxic action of the poison of 
an infection. The delirium of the febrile period of an 
infection may closely resemble alcoholic delirium. 
Again, the insanities coming on in the post-febrile or 
convalescent period, the so-called asthenic forms of 
insanity, in which weakness, stupor, and depression are 
the cardinal features, so closely resemble each other as 
to be practically indistinguishable. Nevertheless they 
may result from widely differing infections. 

The determination of the toxicity of the urine, of the 
blood, or of other tissues and secretions implies of neces- 
sity experiment upon animals. If an alkaloidal sub- 
stance be isolated from the urine, its toxicity can alone 
be demonstrated by experiment. The toxicity of the 
blood can only be proved by its injection into the veins 
or into the peritoneal cavity of some animal— a mouse 
or a guinea-pig. It is to be feared that attempts in this 
country to prosecute such lines of research may meet 
with opposition. "Public opinion," which too often is 
synonymous with pubHc ignorance and public prejudice, 
may for a time prevent the establishment of experi- 
mental laboratories in hospitals for the insane. But 
perhaps at no very distant day, when it becomes clear 
that the pecuniary outlay demanded of the State for the 
care of its insane will eventually be diminished by the 
prosecution of just such researches, the opposition may 



be withdrawn. As a matter of fact, every asylum, 
every hospital for the insane should have attached to 
it not only a laboratory for the study of the microscopic 
changes in insanity — changes that by the improved 
methods now at hand, notably those of Golgi and 
Ramon y Cajal, promise to yield great results, but also 
for the determination of the various toxic substances, 
their origin, their chemistry, and their mode of action 
upon the nervous centers. As we have already stated, 
the microscope can at best reveal only the wreckage in 
the path of the storm, whilst the chemistry of the tis- 
sues and of the excretions and experiments upon living 
animals will enable us to determine the actual causes 
and the actual sequence of the changes. 

That consideration of the pathology of insanity from 
the standpoint here taken has a practical bearing there 
can, I think, be no doubt. If it be true that certain of 
the psychoses are due to intoxication through the stom- 
ach, certainly one of the first indications is lavage and 
other local treatment of the stomach. Indeed, to my 
mind, it seems good therapeutics to practise lavage in 
the majority of cases of the depressive forms of in- 
sanity, for instance in melancholia and in the various 
stuporous forms of insanity, not because we believe at 
this day that these insanities are due to the direct ab- 
sorption of substances formed by abnormal chemic 
changes in the stomach, but because it is exceedingly 
probable that toxic substances even normally excreted 
by the stomach may, in these conditions, be reabsorbed. 
Again, if it be true that the psychoses are so largely due 
to the action of toxins, certainly hydrotherapy, so grossly 
neglected, acquires a value altogether unexpected. Its 
application should embrace not only the stimulation of 
the skin by baths and douches, but also the ingestion 
of large quantities of diuretic waters. Finally, if the 
psychoses are due to the action of toxic substances, we 
shall be in a better position to treat these affections 
when the action of these toxic agents is known — we 
shall be in a better position to suggest the proper reme- 
dial agents. 

CLINICAL MEMORANDUM. 

COMPOUND FRACTURE OF THE SKULL. WITH 

SEVERE LACERATION OF THE BRAIN, IN 

AN INFANT TWO MONTHS OLD, WITH 

RECOVERY. 

By CLAUDIUS H. MASTIX, M.D., LL.D. Univ. Penna., 

The following interesting case of severe injury to the 
brain of an infant, less than two months of age, is not 
without interest, but is worthy of record in the archives 
of surgical literature. It shows the tolerance of very 
young children to severe wounds, even when such in- 
juries implicate vital organs. Although familiar with the 
histories of very many severe injuries to the skull and the 
brain itself, I am not able to find among surgical records 
a single case in which so young a child has met with so 
severe an injury and made so rapid a recovery— i f 
indeed there has been recovery after such an injury. 

The following notes, carefully and correctly taken at 
the time of the injury, will suffice to lay the case before 
the profession. 



4° 



COMPOUND FRACTURE OF THE SKULL. 



[Medical News 



On Sunday, April 21, 1895, I was hastily summoned 
in consultation to see an infant boy, a child of Mr. E. 
H., the Imperial German Consul at this port. The 
child had been born February 26, 1895, and was conse- 
quently on the day of the accident just fifty-four days 
old — less than two months. The parents having gone 
to attend services at church, the nurse, with whom the 
child had been left, placed it in its little carriage and 
rolled it upon the front gallery, which is elevated 
from the ground eight feet, and reached by a flight 
of rather steep steps, eleven in number. She care- 
lessly left the infant in charge of two little children 
upon the gallery and went to the rear of the house for 
some purpose ; whilst she was absent, it is supposed the 
little ones, in play, pushed the carriage toward the land- 
ing of the steps, over which it toppled and fell to the 
bottom and out upon the walk. The child was thrown 
out at the time the carriage upset, and, in falling, the 
little steel rod which supports the sunshade struck the 
frontal bone just above the orbital ridge over the right 
eye, penetrating the skull and entering the brain to the 
distance of about three-quarters of an inch. (I estimated 
this depth from the stain of blood and brain remaining 
upon the rod.) Entering the skull with much force, it ap- 
peared to have torn itself outwardly as the child, which 
evidently had been impaled upon the rod, fell away from 
the carriage. The wound extended upward and outward 
on the right side of the frontal bone, from just above the 
orbital ridge, near to the sagittal suture, a distance of 
very near, if not entirely, two inches. The rod meas- 
ured three-eighths of an inch in diameter, and at the 
point was rough and jagged, just such an instrument as 
would be calculated to inflict such an injury. There was 
considerable loss of blood, and at least a dessertspoonful 
of brain-substance was scattered upon the inside of the sun- 
shade, upon which the child had fallen ; besides, an equal 
amount had been smeared upon the face and some con- 
siderable quantity oozed from the wound. The wound 
was a horrid, lacerated gash, and from it was trickling a 
flow of dark-colored venous blood, to all appearances 
coming from the longitudinal sinus. There was no de- 
pression of the skull, but rather an eversion of the torn 
integuments, with a bulging outward of the edges of the 
fracture, as if they had been forcibly turned out by the 
rod of steel after penetrating the skull and then ripping 
up. 

The shock was profound, and the child was almost in- 
sensible, deathly pale, and pulseless. To all appearances 
the case was hopeless and surgical efforts were seem- 
ingly of little avail — in fact, the child was apparently in 
articulo mortis. Unwilling to abandon the case to a 
certain death, I concluded to wipe away the extruding 
brain and close the rent in the forehead, more with the 
intent of making it a less repulsive corpse than with any 
hope of effecting a cure ! To this end I closed the wound 
with interrupted silk sutures carried through the scalp 
and including the pericranium, down upon the skull 
itself. I was not able, except by pulling aside the edges 
of the skull, to catch up the dura, else I should have also 
closed that membrane before closing the integuments. 
At the point of entrance of the rod, where the integu- 
ments were perforated, I left it open for drainage, if 
perchance the wound should unite. The skull was so 
soft, very little firmer than a dense sheet of cartilage, 
that it was an easy matter to bring the edges in close 



apposition and retain them there by a compress of iodo- 
form-gauze, with a bandage carefully adjusted. As stated, 
the shock was so profound that the child did not cry or 
give evidence of the least pain during the introduction 
of the sutures or in the adjusting of the dressing, being 
as quiet as if under the influence of an anesthetic. This 
was about one o'clock in the afternoon, and I had little 
thought that the child would live through the night. 
When I again called late in the evening 1 was aston- 
ished to find that reaction was almost complete, with an 
absence of fever, and that the child had rested quietly 
and nursed from its mother as it had usually done. 

During the night the child suffered a good deal from 
colic and the temperature had run up to 102°. The in- 
fant was restless and irritable. I ordered quiet, and 
phenacetin, gr. ss, every two-and a-half or three hours 
until the temperature came down. 

On April 23d the temperature had fallen during the 
night to 99°, the babe had rested quietly, its functions 
were normal, the bandages were saturated with cerebro- 
spinal fluid. I readjusted the bandages and found that 
the flow of fluid was rather profuse, as it ran out and 
trickled down the child's face. 1 instructed the mother 
to absorb it as well as she could, but to avoid any 
pressure upon the wound. 

On April 24th the morning temperature was 984°. 
There was no appreciable change in condition of wound 
or child. The noon temperature was 99° and at 3 o'clock 
P.M. it had increased to 100°, but at 7 P.M. had fallen 
under the administration of phenacetin to 98.4°. 

In the morning of April 25th the child was evidently 
more comfortable, and with the exception of a slight 
attack of colic during the night had got along very well. 
At noon the temperature was 99", and at 6 p.m. it had 
risen two-fifths of a degree. The wound appeared 
healed, save at the drainage-point, from which a con- 
tinued flow of cerebro spinal fluid issued. The child's 
functions were normal, and it appeared as well as if no 
accident had happened to it. 

On April 26th the child was evidently doing well, and 
nursed regularly and slept quietly ; the temperature re- 
mained at 98.4°. The wound appeared soundly healed, 
save at a small point in the lower angle, from which there 
continued a rather profuse flow of cerebro-spinal fluid. I 
concluded to try to arrest this by pressure over the spot, 
and, having dusted it thickly with boric acid and put on 
a little compress of gauze, I confined it by a narrow 
strip of rubber plaster and a bandage. This proved of 
no avail, for the fluid continued to flow and saturate the 
dressings, and, as the bandage and plaster seemed to 
give the little patient discomfort, I concluded to remove 
all dressing, save a simple fold of gauze to absorb the 
fluid, and to leave the treatment to the unaided efforts 
of Nature. The sutures had been removed on the sixth 
day, and as the wound was entirely closed, save at the 
minute opening from which the fluid issued, there were 
no indications to be fulfilled other than quiet, good 
nursing, and waiting for developments. The next three 
days, the 27th, the 28th, and the 29th, were passed 
without any change, with the exception of the night of 
the 29th, at which time the fluid ceased to flow, and 
the little opening on the morning of the 30th was closed 
as tightly as the entire line of wound. 

I visited the child again on May ist and 2d, and find- 
ing it perfectly well, with only a narrow line marking 



July 13, 1895] 



MEDICAL PROGRESS. 



41 



the place where the rent had opened the skull, I con- 
cluded to discharge the case from my list. 

A few days ago I called to see the little patient and 
met the nurse with it in the yard. The mother informed 
me that it had never had a single bad symptom, that all 
its functions were normal, that it nursed and slept as all 
her children had done. When questioned as to whether 
the child was as bright as children usually are at his 
age, now going into its fourth month, she replied : 
"Doctor, I think my little boy is the brightest child I 
have had ; he laughs, and plays, and cooes, and is the 
dearest little fellow in the world." 

Such is the outline of this case, which I record as in- 
teresting on account of the gravity of the injury, and 
being followed by such speedy and satisfactory an issue. 
I might mention the profuse discharge of fluid as ex- 
ceeding my expectation, although it was not possible to 
measure the quantity lost, as it was absorbed by the 
dressings as it issued from the wound ; judging from the 
saturated condition of the gauze, bandages, and httle 
cap which was put on to keep the dressing in place, I 
feel safe in esiiinating it to have been not less than six 
or eight fluidounces. 



BACTERIOLOGIC NOTE. 



A CULTURE-MEDIUM FOR BACTERIA. 



By a. M. BLEILE, M.D., 



. COLUMBUS, 



To the already long list of culture- media I wish to 
add the formula of another. White of egg is thoroughly 
shaken with ten volumes of water, and for every hun- 
dred c.cm. of this mixture one c.cm. of hydrochloric 
.acid is added, with a few grains of pepsin, and the whole 
is kept in the incubator at 40° C. for four hours. The 
mixture is then neutralized with a solution of equal 
parts of sodium hydroxid and potassium hydroxid, 
boiled, and from 10 to 12 per cent, of gelatin or i J^ per 
cent, of agar added, again boiled and neutralized if 
necessary, and then filtered. 

This medium has been in use in our laboratory for 
more than a year and has given general satisfaction. It 
presents several points of advantage over the ordinary 
media. In the first place, in the summer-time it is diffi- 
cult to keep the meat-infusion the prescribed time with- 
out ice. The egg-medium has the advantage of a greater 
initial freedom from spores and bacteria ; it does away 
with the use of the somewhat expensive peptone ; it re- 
quires less weighing and only one filtering ; it is fully as 
rich in nitrogenous matter as the meat-infusion ; and it 
is richer in salts. 

NEW DEVICE. 

A NEW PLEXIMETER. 

By BOARDMAX REED. M.D.. 

OF ATLANTIC CFTV, N. J. 

In determining the position, size, and exact boundaries 
of the accessible abdominal organs, indirect percussion 
offers distinct advantages over direct percussion. It 
enables the physician to detect more delicate shades in 
the percussion-note, such as those between the reso- 
nance over the stomach and that over the empty colon, 



and in determining the boundaries between the colon 
and the small intestine. 

For the new specialty of diseases of the digestive 
organs, which is now assuming such great importance 
in the medical world, a good percussor and pleximeter 
are therefore indispensable. The percussors found in 
the instrument-stores are generally satisfactory, but not 
so the pleximeters. All that I have seen hitherto are 
inconvenient to use, and very awkward to carry in the 
pocket. The following cut represents a pleximeter I 
have devised to overcome these defects : 



It is made of rubber of medium hardness, so as to be 
moderately elastic and yet rigid enough to permit of 
being pressed firmly against the part percussed. The 
ends are of unequal size, the smaller end usually serv- 
ing as the handle, but in percussing between the ribs of 
children, above the clavicle, or in any place where very 
delicate percussion is necessary, the larger end may be 
used as the handle, while the smaller serves as the 
pleximeter. 

MEDICAL PROGRESS. 

Tonic Blepharospasm Simulating Ptosis. — Pershing 
{Aiiit'ric-aii Medico- Surgical Bulletin, June i, 1895, p. 
662) has reported the case of a lawyer, fifty-four years 
old, who complained of inability to keep the eyes open, 
developing in the sequence of excitement and anxiety, 
in conjunction with excessive smoking and great physi- 
cal exercise. At first an extra effort was sufficient to 
raise the lids, but soon the forehead had to be wrinkled 
and the head thrown back, and sometimes the lids had 
to be held open with the fingers. For a time the diffi- 
culty occurred only in using the eyes in near work, or 
when they were irritated by the wind. To the patient it 
seemed that the lids were forcibly held together, and he 
discovered that pressure on a certain point on each 
cheek was nearly as efficient in keeping them open as 
actually holding them apart. Some astigmatism and 
hyperopia existed, but the muscular balance was perfect. 
The drainage of tears through the lacrymal duct was 
imperfect, and their accumulation provoked the spasm. 
The instillation of a drop of distilled water into either eye 
also caused contraction. Under the anesthetic influence 
of cocain the difficulty of keeping the eyes open disap- 
peared. No evidence of organic disease could be de- 
tected, and the conclusion was reached that the condi- 
tion was one of tonic blepharospasm of the orbicularis. 

Gonorrhea of the Rectum with Uro-genital Blenorrhea in 
an Infant.— Lewi (A'rliizu-s of Pediatrics, vol. xii. No. 
6, p. 4i7) has reported the case of an infant, six years 
old, who, after treatment in a public institution for right- 
sided empyema, presented a discharge from the vulva 
and the anus. Just within the anal ring were small 
erosions, evidently ulcers in the rectal wall. On intro- 
duction of a speculum, the mucus membrane for several 
centimeters above the anal opening was found swollen, 
angry, spongy, and bleeding easily. Thickened pus, 
greenish in hue, came from the parts above, indicating 



42 



THERAPEUTIC NOTES. 



[Medical News 



involvement of the rectum higher up. There was a 
history of rectal tenesmus, with four or five passages 
daily. Not only were these movements attended with 
a purulent discharge, but the pus seemed to flow from 
the rectum in the intervals. The urethral opening was 
swollen, angry-looking, and discharged pus. The parts 
about the vulva were much inflamed, and thick greenish 
pus flowed from the vagina. Bacterioscopic examina- 
tion of pus from both vagina and rectum disclosed the 
presence of gonococci. The infection is ascribed to 
carelessness on the part of a nurse in ordinary ablution, 
or in the use of an unclean syringe. 

Fatal Cerebellar Hemorrhage in a Young Woman, with Gly- 
cosuria. — Oliver {Lance/, No. 3742, p. 1237) has re- 
ported the case of a woman, nineteen years old, who, 
while apparently in good health, suddenly lost conscious- 
ness. The pupils were contracted and equal, and did 
not react to light, and there was no paralysis. The pulse 
was 22 and the respirations 10 per minute. No cardiac 
murmurs were detected, and there was no peculiar odor 
of the breath, and no evidence of poisoning. The urine 
was withdrawn by catheter and contained no albumin, 
but a large quantity of sugar. Despite active treatment 
death ensued thirteen hours after the first symptoms. 
Upon post-mortem examination the only lesion found 
was a blood-clot in the middle lobe of the cerebellum. 
The superior surface and the posterior surface adjoining 
the inferior surface of the middle lobe were lacerated, 
exposing the clot, which was found to extend across the 
center of the organ, approaching quite close to the sur- 
face of either side and splitting the cerebellum into an 
upper and lower layer, though there was no evidence of 
a new-growth. 

Supernumerary Urethra. — At a recent meeting of the 
Academie de Medecine P6an {La Presse Medicate, 
June I, 1895) presented a girl, fifteen years old, who had 
suffered with dribbling of urine from birth. On exami- 
nation a prominence was found upon the anterior wall of 
the vagina, increasing in volume with physical effort, 
and diminishing in the recumbent posture. Upon com- 
pression of this swelling with the finger urine was ob- 
served to escape, not from the normal urethra, but from 
a second opening, about 3 mm. below. A stylet 
introduced into this opening penetrated into a cavity 
from which also urine escaped. On occlusion of the 
lower opening with the finger and compression of the 
tumor this was reduced in size and the patient felt a 
desire to pass urine. It thus appeared that there ex- 
isted a diverticulum of the bladder with a supernumerary 
urethra, as a result of which, in the absence of a sphinc- 
ter, there was dribbling of urine. The condition was 
relieved by exposing and excising the supernumerary 
parts. 

The Nature and the Treatment of Pernicious Anemia. — 
Stockman {British Medicat Journat, No. 1794, p. 
10S5) expresses the opinion that pernicious anemia is 
not a special disease, but is secondary to numerous 
exhausting conditions. These induce an initial anemia, 
which is followed in certain cases by degenerative 
changes in the bloodvessels. Capillary hemorrhages 
result and induce an excessive degree of anemia. Some 



cases are due chiefly to external bleeding, which accounts 
for the characteristic symptoms and post-mortem ap- 
pearances. The treatment should, therefore, be based 
on etiologic considerations. 



THERAPEUTIC NOTES. 



Methylene-blue for Filaria Sanguinis Hominis, with Chy- 
luria. — Flint {iVew Yortc Medicat Journat, June 15, 
1895, p. 737) has reported the case of a well-developed 
colored man, twenty-two years old, born in the West 
Indies, engaged as a bar-porter, and residing in the 
United States for ten months, who presented himself 
with headache, pain in the sacral region, slight elevation 
of temperature, and a history of rapid emaciation and 
muscular weakness. The urine looked like rich milk, 
being perfectly opaque, with no tendency to precipita- 
tion. Its specific gravity was found to be 1.014, its reac- 
tion acid. After filtration approximately 2 per cent, of 
albumin was found present, but no sugar. Upon agita- 
tion with ether the urine became perfectly clear. Micro- 
scopic examination disclosed the presence of large quan- 
tities of finely divided fat-globules, chyle-corpuscles, 
and a considerable quantity of apparently broken-down 
matter. No casts were discovered, but there were a few 
blood-corpuscles. Examination of blood removed from 
the right ear at 12.30 a.m. disclosed the presence of 
embryonic filariae. The patient was given two grains of 
methylene-blue at intervals of four hours, and on the 
following night the number of filarise was found dimin- 
ished, their movements sluggish, and their bodies, as 
well as the blood-plasma, to some extent stained blue. 
The urine lost its milky and turbid appearance, and 
became perfectly transparent, although deeply stained a- 
characteristic greenish-blue. The treatment was then 
discontinued, but the urine became milky, and contained 
filariffl. The patient was again given methylene-blue, 
and three days later dead and partially disintegrated 
filarias were found in the blood, deeply stained with blue. 
Treatment was discontinued at the expiration of five 
days, and no further symptoms appeared. Reference is 
made to the successful use of methylene-blue in the 
treatment of cases of gonorrhea, as well as malarial fever. 

The Treatment of Whooping-cough with Cocain. — Wells 
and CARRi: {Lancet, No. 3745, p. 1429) report the treat- 
ment of 323 cases of whooping-cough during the autumn 
and early winter of 1894 with cocain hydrochlorate dis- 
solved in water in doses (gr. -js-gr. ^) based on the 
standard of a one-grain dose for an adult, three or four 
times a day, by the mouth. Among the whole number 
there were two deaths, both in infants under six months of 
age — one from broncho-pneumonia, and one from per- 
sistent vomiting. In no case were evil effects observed. 
The only prominent manifestation was in some cases 
slight relaxation of the bowels. The average duration 
of the disease under this mode of treatment was about 
three weeks, and in mild cases about a fortnight or less. 

For the Relief of Stings of Insects. — 

B. — Solution of ammonia . . 7 parts. 

Collodion 3 " 

Salicylic acid . . .0.3 part. 

— American Journat of Pharmacy. 



July 1,5, 1S95] 



DEMON-POSSESSION AND ALLIED THEMES. 



43 



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SATURDAY. JULY 13, 1895. 



DEIHOtl-POSSESSION AND ALLIED THEMES. 

"The age of miracles is past" has become a 
proverb, but like all proverbs it is hardly half-truth. 
Miracles are occurring all the time if we had but 
the " eye of faith " to perceive them. In civilized 
communities they are unknown ; they are unnecessary 
since the spread of the Gospel, say the orthodox — 
but other lands are more fortunate. China, for in- 
stance, still rejoices in them, in the form of genuine 
"simon-pure casting out of devils" by the humble 
possessors of the true light, according to the Rev. 
J. C. Nevins, D. D., whose 500-page volume is that 
of this article. Probably if we were blessed with 
the same degree of civilization as "The Flowery 
Kingdom," we should see similar wonders. Like 
the ignis fatuus , all they require is sufficient darkness 
to enable their light to be seen. The Reverend Dr. 
Nevins had no need to go to China in search of 
such marvels as his pages are filled with ; the bottom- 
lands of Flat Crick and the gullies of the Great 
Smoky Mounting would have yielded an even 
richer trove of specimens to the expert miracle- 
stalker. 

The book is a most extraordinary composition. 
Nothing but the evident sincerity and devoted 
philanthropy of its author, who gave his whole life 



to missionary work and literally died in the harness, 
would enable us to take it seriously. Going to China 
in early life a complete disbeliever in ghosts, " pos- 
session," etc., according to his own statement, he 
meets so many fearful and mysterious instances of 
demoniac opposition that he gradually becomes 
puzzled, and finally a complete believer in the 
supernatural character of these phenomena. He 
addresses circular-letters to many of his co-workers 
and finds them in different stages of the same con- 
viction or bewilderment, and hence comes to the 
conclusion, " by the inductive of study of phenom- 
ena" (deliver us from our own terms!), that the 
same state of affairs obtains in China now as did 
in Judea at the dawn of Christianity (which is 
probably correct), and thereupon boldly proceeds to 
cast out devils himself and instructs his converts 
how to do so. He even mentions the particular 
passages of Scripture found most effective in the 
connection. He feels himself transported to the 
days of the Apostles, and refers complacently to 
the "intimate connection with the progress of 
Christianity in the neighborhood" of these feats. 
He declares that " from a large correspondence 
and personal acquaintance with missionaries in 
China ... I have only known two who have 
expressed positive unbelief in the reality of these 
possessions." 

A number of illustrative cases are given in sup- 
port of this startling position, and then our " induc- 
tive investigator" proceeds to fill up the remaining 
four fifths of his volume with chapters on remarkable 
instances of " Possession (of a most familiar order) 
in India," " in Christian Countries," "Evolution 
and other Theories," "Spiritualism," "Teachings 
of Scripture," and "The Literature of the 
Occult," etc. 

The only original part of the book is the small 
portion of personal experiences and responses to a 
circular-letter, and is of a most disappointing nature. 
Beginning with a simple haunted house, which was 
rented very cheaply as a mission-station on that 
account, and then the demon driven out by hold- 
ing evening-prayer, only, however, to enter another 
house in the near neighborhood. Of this the poor 
inhabitants not unnaturally complained and came 
with praiseworthy thriftiness to demand damages 
therefor from the native mission-teacher. The 
latter dignitary was equal to the emergency and 
proceeded at once to the house with a New Testa- 
ment and a prayer printed on a large card. The 



44 



TREATMENT OF SNAKE-POISONING. 



[Medical News 



Testament was read, the woman affected promptly 
restored, the prayer posted on the walls as a pre- 
ventive. The result, in Dr. Nevins' own words, was 
that " they were not troubled afterward, though the 
spirit was heard of trying to gain an entrance into 
other families in the neighborhood" (!). This is 
a fair sample of all that follows. Possession by 
" foxes," by badgers, by snakes (with which latter 
form we are only too familiar, and also with their 
evil spirit, whose mystic symbol is C^H^O), in Japan 
and India. The cases in "Christian lands" are 
even worse, plain hysteria, catalepsy, double per- 
sonality, etc., some of them being actually quoted 
from Griesinger's Mental Pathology. 

Spiritualism and theosophy are neatly brought 
into line of support and disposed of at the same 
stroke by being attributed to the activity of genuine 
evil spirits, to whom the mediums are "sold" in 
good old medieval style, while even " Dr. Jekyll 
and Mr. Hyde " and " Khalid " are dragged at the 
wheels of the argumentative chariot. Of course, 
the unspeakable W. T. Stead is not forgotten, and 
when anyone has to cite Mr. Stead as evidence it 
is a severe reflection upon the direness of his logical 
extremity. 

In all seriousness and with a genuine respect for 
the author's devotion and evident sincerity, it seems 
wellnigh incredible that any man of his intelligence 
and education could extract the smallest atom of 
solid conviction from such a frothy mass of self- 
evident ghost-stories and fairy- tales, or could even 
relate them with seriousness. 

The only way it can be accounted for is the in- 
fluence of a life-long exposure to an atmosphere of 
belief in thera. The instances in themselves are 
trivial, but the impressiveness of a vivid acceptance 
and dread of them by absolutely everyone by whom 
one is surrounded is overwhelming. Even Rud- 
yard Kipling, that hard-headed Philistine of the 
twentieth century, has caught the infection and 
reveals traces of a belief that " other influences are 
at work in India," which is more than half genuine. 
The unconscious influence of environment is far 
greater than we imagine. How quickly one picks 
up the accent and idioms of a people by living 
among them, and habits of thought are wellnigh as 
infectious as habits of speech. There seems little 
doubt that constant association with the insane 
favors the development of eccentricities in their 
attendants, and even physicians. The moral tone 
of great criminal lawyers is said often to sink nearly 



to the level of that of their clients. And it would 
seem that even the missionary is unconsciously 
tinged by the heathenism among which he spends 
his life. 

This work emphasizes a truth that has been grow- 
ing in importance and recognition, that is, not only 
should our missionaries be medically educated, but 
they should have practical and clinical courses in 
mental diseases. A course of scientific study, how- 
ever limited, would teach the differential diagnosis 
between "demon-possession" and mental abnor- 
malism. Psychiatry kills superstition. 



THE TREATMENT OF S N A H E- P I S N I N G 
AND THE ESTABLISHMENT OF IMMU- 
NITY BY MEANS OF THE BLOOD- 
SERUM OF IMMUNIZED ANIMALS. 

The question of the treatment of snake-poison- 
ing has at different times engaged the brightest 
minds in medicine in clinical research and experi- 
mental investigation, with the hope of discovering 
an antidote for this fatal form of intoxication. A 
new impetus has been given the subject by the 
recent developments in connection with the treat- 
ment of infectious diseases by means of the blood- 
serum of animals rendered immune through gradu- 
ally increased dosage with virulent cultures of the 
respective micro-organisms. In a line with these 
observations are the results of an experimental 
inquiry undertaken by Professor Fraser' and embod- 
ied in a communication presented at a recent meet- 
ing of the Royal Society of Edinburgh. This paper 
dealt with the consideration of methods for render- 
ing animals immune to the venom of various poison- 
ous snakes, and of the use of the serum of such ani- 
mals for transmitting immunity and also of combat- 
ting the effects of snake poisoning. 

Having determined the lethal dose of the respec- 
tive venoms for lower animals, these were treated with 
a succession of gradually increasing non-lethal doses, 
until the actual minimum lethal dose was determined. 
The treatment was then continued until a dose far 
in excess of the ordinary lethal dose was tolerated 
without serious reaction or injury on the part of the 
animals. So successful were the experiments that, 
notwithstanding the various natural difficulties, it 
was possible to give rabbits by subcutaneous injec- 
tion as much as ten, twenty, thirty, and even fifty 
times the minimum lethal dose without causing ob- 
vious symptoms of poisoning, the only observable 

' British Medical Journal, No. 1798, p. 1339. 



July 13, 1895] 



EDITORIAL COMMENTS. 



45 



phenomena being a rise in bodily temperature, con- 
tinuing for a few hours, and loss of appetite, with 
decline in bodily weight. Not only was it possible 
thus to immunize animals against a specific venom, 
but it further appeared that animals thus immunized 
are capable of resisting the lethal action of other 
venoms, though in less degree. It was incidentally 
discovered that the protection thus conferred lasts 
for, at least, a considerable period of time, even 
when the last protective dose was not a large one. 
The explanation of these remarkable facts is believed 
to reside either in the production in the body by 
the influence of the venom of productive sub- 
stances, or in the presence of these substances as 
an actual part of the venom itself, gradually ac- 
cumulating with repeated administrations, whereas 
the lethal and toxic constituents of the venom are 
more rapidly destroyed or eliminated. 

Having thus succeeded in inducing a high degree 
of protection in animals against the toxic effects of 
serpent's venom, the blood-serum of such immune 
animals was passed through a Chamberland filter 
and placed over sulphuric acid in the receiver of 
an air-pump. A perfectly dry and easily pulver- 
izable solid was thus obtained, which could be kept 
unchanged for probably an indefinite length of time, 
and to which the name "antivenene" has been 
given. Four series of experiments were undertaken 
in which {a) the venom was mixed outside of the 
body with the antivenene, and the mixture injected 
under the skin of the animal ; (<^) the venom and 
the antivenene were injected almost simultaneously 
into opposite sides of the body; (c) the antivenene 
was injected a considerable time before the venom ; 
(r/) the antivenene was injected thirty minutes after 
the venom. The results of these experiments go 
to show that the blood-serum (antivenene) of 
animals protected against large doses of snake- 
venom is capable under varying conditions of 
administration of preventing lethal doses of the 
venom of the most poisonous serpents from pro- 
ducing death in non-protected animals. For the 
actual application of the antivenene to the treatment 
of snake-poisoning in man an endeavor is being 
made to obtain the large quantity that is requisite 
from a horse now receiving considerable lethal doses 
of cobra-venom, and from the same source it is hoped 
that a sufficient quantity will be obtained to allow of 
the examination of the chemic properties of the an- 
tivenene, with the object of discovering the constit- 
uents by which the antidotal effects are produced. 



Results of a confirmatory character have been 
obtained by Dr. Calmette,' the head of the bacteri- 
ologic station at Saigon, China, whose methods 
were analogous to those of Professor Eraser. He, 
too, found that the venom of different animals is 
capable of conferring general immunity, though in 
varying degree. Rabbits rendered immune to 
snake-venom proved also resistant to abrin, while 
animals protected against abrin acquired a certain 
degree of immunity to snake-poisoning, diphtheria, 
ricin, and anthrax. In immunized animals injec- 
tion of the venom is attended with hyperleukocy- 
tosis, while in untreated animals hypoleukocytosis 
develops. It was further discovered that snake- 
poison is rendered innocuous by admixture with a 
solution of calcium, hydrochlorid or of gold chlorid. 

The mortality from snake-poisoning in some parts 
of the world, notably in India and Australia, is 
very considerable, and a great saving of life must 
be effected by the conduct of Professor Eraser's 
investigation to a successful termination. We have 
here a further illustration of the yet not sufficiently 
recognized fact that the solution of no scientific 
problem is without practical bearing and utility. 
Even empiricism must have some sort of scientific 
basis, and the more strictly the practice conforms to 
the science the more permanent and successful will 
it be. 

EDITORIAL COMMENTS. 

The Treatment of Diphtheria with the Antitoxin. — Favor- 
able reports of the use of the antitoxin in the treat- 
ment of diphtheria continue to be published, but it is 
observable that the latest are couched in cautious and 
conservative language. The data appear not yet suffi- 
cient for a final conclusion, but it cannot be denied that 
the preponderance of sentiment, as well as the weight 
of statistics, tends to sustain the hope held out as to the 
efficacy of the antitoxic serum. 

One of the most interesting and important contribu- 
tions to this subject has recently been made by Leich- 
TENSTERN and Wendelst.^dt (Miinchener mcdicinische 
Wochenschrift, 1895, No. 24, p. 553), in which they pre- 
sent the results of a careful analytic study of cases of 
diphtheria coming under observation during a series of 
years at the Augusta Hospital at Cologne. This article 
is to be commended for its judicial tone and for the dis- 
passionate manner in which it deals with a subject con- 
cerning which much has been written within a short 
time, and even more enthusiasm has been displayed. 
Wliile expressing themselves in favor of the utility of the 
new remedy, they point out its limitations and call 
attention to certain fallacious conclusions that have been 
reached without mature deliberation. 

The study embraces a series of 123 cases treated with 

1 Vide British Medical Journal, p. 1339. 



46 



EDITORIAL COMMENTS. 



[Medical News 



the antitoxin during 1894-95. With this they compare 
eleven series of similar numbers seen consecutively 
before, from 1892 to 1S94. During the period preceding 
the use of the antitoxin the average mortality of all cases 
was 30.9 per cent, (with a minimum of 25 and a max- 
imum of 39), while during the antitoxin-period it fell to 
20.3 per cent. — a considerable reduction in the mortahty. 

During the antitoxin-period tracheotomy was re- 
quired in 30 per cent, of the cases, with a mortality of 
43.2 per cent., while in the previous periods operative 
interference was required in 32 per cent, of the cases 
{from 21 to 38.3 per cent,), with a mortality of 64 per 
cent, (from 56 to 76 per cent.). It is thus clear that 
while the use of the antitoxin exercised but little influ- 
ence upon the proportion of cases in which tracheotomy 
was required, it caused a material reduction in the 
mortality among cases operated upon. 

Among the 70 per cent, of cases not requiring opera- 
tion during the antitoxin-period there were 10.4 percent, 
of deaths, while among the 68 per cent, of similar cases 
(from 61 to 79 per cent.) seen previously, death occurred 
in 15 per cent, (from 9.2 to 27 per cent.). Both the pro- 
portion of cases in this group and the mortality were 
thus approximately the same, whether the antitoxin was 
used or not. 

The net result of these figures is that the diminution 
in the mortahty of cases of diphtheria treated with the 
antitoxin is attributable to the number of cases saved in 
which tracheotomy is required. Special attention is 
called to the fact that no evil results were observed from 
the use of the antitoxin, and the claim is sustained that 
the agent is totally innocuous. 



The Treatment of Tetany with Thyroid Extract. — One can- 
not avoid being moved with admiration of the consecu- 
tiveness of the steps — so like the solution of a mathematic 
problem — by which was reached the conclusion that led 
to the employment of preparations of the thyroid gland 
in the treatment of myxedema and alMed conditions ; 
and the success that has been attained has quite opened 
a new field in therapeutics. Of the diseases related to 
or dependent upon disordered function of the so-called 
ductless glands we have much to learn, and such knowl- 
edge must surely bring enlarged therapeutic resources. 
Thyroid therapy has shown itself capable of a useful 
influence not only in myxedema and cretinism, but also 
in some cases of exophthalmic goiter, in some of akro- 
megaly, and in some of psoriasis. To this list we may 
now add tetany, which, in some cases at least, further 
observation may show to be a thyroid disease. Bram- 
WELL {British Medica! Journal, No. 1796, p. 1196) has 
made a number of interesting observations upon the 
employment of thyroid extract in the treatment of 
tetany. In the case of a patient in whom tetany had 
developed after removal of the thyroid gland, and who 
was being treated with small doses of thyroid extract, 
he advised that the remedy be pushed in much larger 
doses. In the course of a short time, the tetany and other 
symptoms disappeared and the patient made a rapid 
and complete recovery. Expression is given to the 
opinion that operative tetany is merely one manifesta- 
tion of acute myxedema resulting from arrest of thyroid 
excretion, and of this opinion the experience reported is 
considered to be confirmatory. On another occasion, on 



being consulted about a boy of eight years, who had previ- 
ously been under his observation for tetany, Bramwell 
advised the internal administration of thyroid extract, with 
the result that in the course of three weeks the improve- 
ment seemed "almost phenomenal." The attack had 
existed for nearly a year-and-a-half and had been vari- 
ously treated with arsenic, chloral, antipyrin, bromid, 
cod-liver oil, etc. The child had had whooping-cough 
and influenza, and several months before the onset of 
the tetany had been knocked down by swinging jute. It 
has been pointed out that cold seems to aggravate 
tetany and to induce relapses, and that the disease is 
much more frequent in winter and spring than in sum- 
mer and autumn, and these facts are viewed as denoting 
another important point of relationship between tetany 
and myxedema, for it has been shown also that cold pre- 
disposes to the production of myxedema. On account of 
the association of tetany in infants with rickets and 
laryngismus stridulus, it is further suggested that thyroid 
extract may also prove of therapeutic utility in these 
two conditions. Should this utility be demonstrated, the 
conclusion would be reasonable that these several dis- 
orders are attributable to a deficiency or a modification 
of the thyroid secretion. 



The Index Medicus. — Every medical man interested in 
the welfare and progress of both his science and his art 
will have learned with deep regret of the unwillingness 
of Mr. George S. Davis to continue longer the publica- 
tion of the Index Medicus. It now remains to be seen 
whether the profession will permit such an important, we 
may say indispensable, record of current literature to 
die or will unite in some concerted movement to sustain 
and carry on the great work. As a matter of fact, the 
duty really belongs to the government, but in default of 
such a satisfactory and logical disposition of the matter 
it devolves upon the medical body to advance the neces- 
sary means and provide the requisite support. 

The subject is one that concerns not only the profes- 
sion in America, but medical men throughout the world. 
In recognition of this fact the resident librarian of the 
Royal Medical and Chirurgical Society of London urges 
in the British Medical Journal scientific societies and 
scientific workers to subscribe to a fund for the continu- 
ance of the Index. He proposes that every English 
medical society should annually contribute at least two 
guineas for the support of the Index, and believes that 
sufficient could additionally be obtained from individual 
medical men to make an English guarantee-fund of not 
less than ^400. 

Dr. C. E. Sajous, of Philadelphia, sends from Paris to 
the editor of the New York Medical Journal twenty -dve 
dollars, and suggests that two-hundred subscribers agree 
to contribute an equal sum annually. Mr. Davis has ex- 
pressed himself in sympathy with this movement and 
offers to undertake the publication of the Index again, 
without profit or remuneration, provided a guarantee-fund 
be established that would secure him as publisher against 
loss. Should a surplus be realized it would be divided 
pro rata among the guarantors. We hope these efforts 
to save the Index will succeed beyond peradventure. 
The medical profession cannot afford to have them fail. 
We commend every one interested — and all should be — 
to communicate with Mr. Davis at Detroit. 



July 13, 1895] 



REVIEWS. 



47 



Live-stock Sanitation in Pennsylvania. — Act No. 66, of 
the Pennsylvania Legislature, approved May 21, 1895, 
provides for a Live-stock Sanitary Board, whose pur- 
pose it shall be to endeavor to control and suppress 
" dangerous, contagious, or infectious diseases of do- 
mestic animals." The Board is to consist of the Gov- 
ernor, the Secretary of Agriculture, the State Dairy and 
Food Commissioner, and the State Veterinarian, and is 
empowered to enforce and regulate quarantine of animals, 
destroy them if deemed necessary, and regulate the 
movements of their products. The Board is author- 
ized at any time to enter any premises, farms, fields, 
pens, abbatoirs, slaughter-houses, buildings, cars, or 
vessels where any domestic animal is at the time quar- 
tered, or wherever the carcass may be, for the purpose 
of examination. It shall also take such proper measures 
as may be deemed necessary for the protection of the 
milk-supplies from contamination. If this Board will 
carefully perform the duties with which it is charged, we 
may speedily hope to see a better milk-supply in this 
State, and perhaps some solution of the vexed question 
of the relation of tuberculosis in cattle to human tuber- 
culosis. 

The Number of Physicians and Surgeons in the United 
States. — According to the Bulletin on "occupations" 
of the eleventh census, just issued, there were in the 
United States, in the year 1890, 104,803 physicians and 
surgeons, or about i to every 600 of the population. 
The total number of wage-earners of all occupations is 
placed at 22,735,661. There were 89,630 lawyers, 
88,295 clergymen, 58,090 nurses and midwives, 17,498 
dentists, and 9900 undertakers. 



SELECTION. 

THE AMERICAN MEDICAL ASSOCIATION AND 
PATENT MEDICINES. 

There is no doubt that the members of the medical 
profession, as a class, are opposed to patent medicines. 
The encouragement these remedies occasionally receive 
from physicians is usually due to carelessness or inex- 
cusable ignorance. 

The American Medical Association, at its May meet- 
ing in Baltimore, placed itself clearly on record in regard 
to this subject, and in a manner that is highly commend- 
able. It involves a much-needed reform in the Associa- 
tion's journal, as is shown by the following extract from 
the report of the Board of Trustees concerning that 
journal : 

" During the year no advertisements of secret remedies 
have been accepted that were not accompanied by a 
formula, but to still further comply with what appears 
to be the desire of a large number of those interested in 
the success of the Journal, the editor, with the termina- 
tion of present contracts, has been instructed to accept 
no advertisements of medicinal preparations, the proprie- 
tors of which do not give a formula containing the official 
or chemic name and quantity of each composing ingre- 
dient to be inserted as a part of the advertisement." 

This report was adopted with considerable enthusiasm, 
and we think the Board need not have used the guarded 
language it did by saying they proposed to "comply 
with what appears to be the desire of a large number," 



for the sentiment of those present not only appeared to 
be, but actually was unanimous. 

As many of the advertisements in the above-mentioned 
journal, as well as in many other medical journals, have 
long been a standing disgrace to the profession they 
represent, we, more than a month after the meeting, 
made an examination of the adverdsing pages of the 
Association's /fwrwrt/, but were unable to notice that any 
decided change had taken place. We, therefore, con- 
cluded that the advertisers' contracts had not expired. 

There were, however, a number of advertisements in 
which the formulse were given, and the conclusion was 
that their contracts had expired, or else they were pre- 
paring to renew. 

Two of these formulas were so unique, and at the 
same time so interesting, that we venture to enlighten 
our readers by reproducing them here, as follows : 

" ANTIKAMNIA. 

"Formula. A combination of coal-tar derivatives of the 
series CuHsn-c, into which the amines have entered, form- 
ing the various amido-compounds. Antikamnia has as 
its base the derivadves of the amido-benzoles, so com- 
bined as to obviate the bad effects caused by many of 
this series of organic bodies whem administered alone." 

" CAMPHO-LVPTUS. 

" Composition. Eucalyptol, campho-thymic acid, 
hydrous chloral." 

No possible good can result from publishing such 
formulas as these. They are simply ridiculous, and the 
Journal of the American Medical Association, by ad- 
mitting them, lays itself open to the possibility of being 
considered the most "gullible " medical journal on the 
face of the earth. 

There is no secret about the faculty necessary to de- 
cide what should be admitted. We could name a dozen 
members of the medical profession who possess that 
inborn knowledge which would enable them to decide 
almost in a moment on the admissibility of an adver- 
tisement. The result, however, would be such a " clean 
sweep" in the advertising pages of the Association's 
Journal as to be apparent to the most casual reader. 

There is another lesson to be derived from these so- 
called formula;. We have heard a great deal in the past 
few years about legislation to control the manufacture 
and sale of patent medicines, and nearly all of the sug- 
gestions are based on the publication of the formula on 
the label. But the experience of the American Medical 
Association shows us that it will be necessary to define 
whall shall constitute a formula. — A)nerican Journal of 
Pharnuicy, July, 1895. 



REVIEWS. 

Personal Reminiscences and Recollections of 
Forty-six Years" Membership in the Medical 
Society of the District of Columbia. By 
Samuel C. Busey, M.D., LL.D., etc. 8vo., pp. 373. 
Washington, D. C, 1895. 

This is the most interesting volume of medical atia 
that we have seen for a long time. The author tells us 
that he has not attempted to wTite an autobiography, but 
he was a conspicuous actor in many of the ethical con- 



REVIEWS. 



[Medical News 



troversies which he describes, and incidentally gives a 
good deal, though not enough, of information about his 
own personality. 

Beginning the study of medicine in 1845, in the old- 
fashioned way, by entering the office of an old-fashioned 
doctor, he learned enough in his first year to know that 
private pupilage in an office in Georgetown, without a 
book more recent than 1820, and with only two or three 
rusty scalpels and a pair of tooth-pulleykins, did not 
supply the opportunities he desired, and therefore in 
1846 he came to Philadelphia and entered the office of 
George B. Wood as a private pupil. 

His chapter on the life of a student of medicine in 
those days, including a description of the methods of 
Dr. Wood with his private pupils, contains some graphic 
pictures, and makes it clear that such pupils had to 
study. He commenced practice in Washington in 
1848, and the old residents of that city must enjoy his 
description of the condition of things there at that time. 
There were but two streets that were even partly paved, 
garbage was thrown into the alleys, and swine were 
the privileged and protected public scavengers. To 
jostle against or drive over one of these municipal 
functionaries when out on his tour of sanitary inspection 
insured a cash penalty or brief servitude in the work- 
house. 

A large part of the book is occupied with the history 
of the Medical Society of the District of Columbia, of 
which the author has twice been President. Special 
attention is called to the active part taken in the work 
of the society in its early days by medical officers of the 
army and navy. One chapter is devoted to the dis- 
turbances that arose in connection with the proposition, 
in 1869, to admit physicians of .African descent to mem- 
bership in the Medical Society, disturbances that ex- 
tended to the American Medical Association, and that 
lasted for several years. 

Another chapter treats of some of the effects of the 
rule of the Medical Society that its members shall not 
consult with physicians not members of the society, and 
of some of the trials for violations of ethics, of some mem- 
bers of the society. This will be curious reading fifty 
years hence. Dr. Busey says, " There remain some 
regulations which fall short of the more advanced con- 
ception of medical ethics. These, at least some of them, 
are, perhaps, justifiable, in view of the peculiar environ- 
ments of the profession in the District of Columbia. 
The absence of a medical practice law makes it neces- 
sary to retain the limitation of consultation to member- 
ship, and to those, not members, to whom it has been 
legally extended by definite designation. The District 
of Columbia is now the common rendezvous of the 
impostors and charlatans driven from the States by the 
enactment of medical practice laws, and some sharp and 
incisive mark of distinction between such refugees, both 
of the itinerant and permanent class, has become of 
imperative necessity, as well for the protection of the 
community as for the maintenance of the honor and 
dignity of a scientific profession. The retention of a 
fee-bill schedule, with its minimum and maximum 
charges for every distinct and definite professional ser- 
vice, partakes too much of the ill-advised rules of trades 
unions, which demand the same wages for the incom- 
petent as for the skilled artisan ; offers protection to the 
ignorant, in that it holds his services equal in value to 



those of the learned and skilled, and invites a class of 
unfit men to sneak into a benevolent and scientific pro- 
fession who could not earn a decent livelihood as ordi- 
nary mechanics. The regulation in regard to fees and 
consultations, as did the organization of the Medical 
Society in 1819, and Medical Association in 1833, grew 
out of the necessity of protection from the wrongs, inju- 
ries, and disreputable practices of the horde of irre- 
sponsible and ignorant charlatans that infested and 
desecrated the infant city ; and it is probable they 
will be continued in operation as long as such protec- 
tion and distinction are made obligatory by the failure 
of Congress to enact a suitable medical practice law." 

Dr. Busey has made a substantial contribution to the 
history of medicine in this country, and his book should 
be of interest to all members of the medical profession. 

The Transactions of the Sixteenth Annual 
Meeting of the American Laryngological 
Association for the Year 1S94. New York ; D. 
Appleton & Co., 1895. 

This volume contains many valuable and instructive 
papers. Among those especially interesting is the paper 
by Dr. Jonathan Wright, of Brooklyn, on " Papillary 
Hypertrophy of the Nasal Mucous Membrane, Compared 
with a True Papilloma." This is of especial interest from 
a diagnostic and pathologic standpoint. The accompa- 
nying plates are clear and well defined. There is an 
interesting report by Dr. Charles M. Shields of a case 
of a foreign body (cocklebur) in the larynx and its 
removal intact by means of Schrotter's tube-forceps. 
Casselberry has an admirable paper showing the asso- 
ciation of nasal polypus with ethmoiditis, and recom- 
mends treatment by resection of the middle turbinated 
body. French makes some valuable observations as to 
results in cutting operations on the nasal septum, show- 
ing that with proper care the heahng process goes on 
rapidly ; also that there is httle danger of weakening the 
septum. The case of compound foUicular odontoma 
reported by A. W. de Roaldes is interesting from a 
pathologic standpoint, as it is an extremely rare condi- 
tion. The accompanying plates are instructive. Dr. 
Harrison Allen's paper, " Demonstrations of Skulls, 
Showing the Effect of Cretinism on the Shape of the 
Nasal Chambers," is one of the most valuable papers 
contributed. 

Addresses, Papers, and Discussions, Section on 
Surgery and An.\tomy at the Forty-eighth 

Annual Meeting of the American Medical 
Association, 1894. 

This volume contains much of interest and value. 
John B. Roberts contributes an interesting paper, in 
which he combats the operative frenzy that has seized 
upon so many surgeons during the past few years. 
Wyeth discusses inoculations' with septic or toxic agents 
in the treatment of malignant tumors, and concludes 
that sarcoma may be cured by septic infection. AUis 
contributes a'n able article in which he favors treating 
fractures of the lower end of the humerus in extension. 

Amongst numerous interesting articles we note especi- 
ally : Conner upon fractures of the lower end of the 
humerus ; Deaver upon vesical tumors ; Gaston on 



July 13, 1895] 



AMERICAN LARYNGOLOGICAL ASSOCIATION. 



49 



anal fistula ; Bonwill on the surgical engine ; Belfield 
on prostatic enlargement ; Lovett on the operative 
treatment of joint-tuberculosis ; and Reginald Sayre on 
the conservative treatment of tuberculous joints. 

The publication of these Transaciions in a book small 
enough to be conveniently handled is commendable. 

FORMULAIRE DES MEDICAMENTS NOUVEAUX ET DES 

Medications Xouvelles pour 1895. Par H. Boc- 
QUiLLON-LiMOUSiN, pharrhacien de ire classe, laureat 
(medeille d'or) de I'ecole de pharmacie de Paris. 
Introduction par le Dr. Huchard, medecin des hopi- 
taux. Sixieme edition, i vol. in i8de 340 pages. 

The 1895 edition of this familiar work contains a 
large number of new articles, among which may be 
noted the following : Alangin, .A.lphol, Antipyonin, Bro- 
methylformin, Cathartenic Acid, Chloralose, Cristal- 
lin, Diaphtol, Diiodoform, Ferratin, Glycozene, lodo- 
formin, Medicated Milks, Loretin, Lycetol, Menacin, 
Paraform, Resol, Salumin, Serotherapy, Pulmonary 
Juice, Tannal, Thioform, and \'asogene. There are also 
here contained a large number of colonial and exotic 
plants that have been recently introduced into thera- 
peutics, and which have not, as yet, found place in any 
other formulary, however recent. The book is a valu- 
uable little aid to practical medicine up to date. 

The Retrospect of Medicine. A Half-yearly Jour- 
nal Containing a Retrospective View of Every Dis- 
covery and Practical Improvement in the Medical 
Sciences. Edited by James Braithwaite, M.D. 
Lond. Volume no. July-December, 1894. (Issued 
January, 1895.) London : Simpkin, Marshall, Ham- 
ilton, Kent & Co., Limited. Edinburgh : Oliver & 
Boyd. Dublin: Hodges, Figgis & Co.; and Fannin 
& Co. Leeds : W. Brierly, Bond Street. 
We have only to repeat concerning the one hundred- 
and-tenth volume of Braithwaite's Retrospect the good 
opinion we have uniformly expressed of its predecessors. 
The judgment exhibited in selection, the preservation of 
the exact language of the authors quoted, the good index, 
and the wide range of reading represented by the jour- 
nals cited, render it one of the best books of reference to 
current literature in the market. 

Temperature-chart. Prepared by D. T. Laine, M.D. 
Copyrighted by W. B. Saunders, Philadelphia. 

This chart is evidently intended as a record for cases 
of fever treated with cold baths according to the method 
of Brand. Provision is made for thirty- two observations 
of temperature, pulse, and respiration in the course of 
twenty-four hours, as well as for notes upon the excre- 
tion of urine, the evacuation of the bowels, the amount 
of food, and other matters that may be considered 
important or interesting. Upon the reverse side of the 
sheet is a description of the method of Brand for the 
treatment of typhoid fever. • 

The Year-book of Treatment for 1895. A Critical 
Review for Practitioners of Medicine and Surgery. 
Octavo, pp. 490. Philadelphia : Lea Brothers & Co., 
1895. 
This issue of the Year-book maintains the reputation 



established by previous issues. Its contents naturally 
do not include everything new that has developed during 
the past year, but the attempt has been made to select 
that which is practical and promises to be of permanent 
value, and omit that which appears unimportant. The 
work has been done by twenty- three contributors whose 
names are well known in Enghsh medical literature. 
The name of the editor, however, does not appear. 

Atlas und Grundriss der Ophthalmoskopie und 
Ophthalmoskopischen Diagnostik. Mit 5 Text 
und 102 Farbigen Abbildungen auf 64 Tafeln. Von 
Dr. O. Haab, Professor an der Universitat und 
Direktor der Augenklinik in Ziirich. Miinchen, 1895. 
Verlag von J. F. Lehmann. 

This excellent manual of ophthalmoscopic pictureswill 
be welcomed by all ophthalmologists, by reason of the 
convenient size of the book, and because of the large 
number of capital illustrations of typical diseases of the 
eye-ground. An introduction treating of ophthalmo- 
scopy is noteworthy, and a page of explanatory text ac- 
companies each plate. 



SOCIETY PROCEEDINGS. 

AMERICAN LARYNGOLOGICAL ASSOCIATION. 

St-venteenth Annual Meetiiit;, held at Rochester, N. K, 
June 77, 18, and ig, iSgj, 

First Day— June i/TH. 

Dr. John O. Roe delivered the President's Address, 
the subject of which was 

the relation of damp air to diseases of the 
upper air-passages, especially in the lake 

REGION. 

He pointed out that no one region is good for all ail- 
ments. That beneficial for respiratory affections is gen- 
erally bad for biliary troubles, and z'l'ee versa. The 
effect of any climate is due partly to its direct influence 
on internal organs and partly to its indirect influence 
upon the habits of the individual. In the Lake region 
diseases of the air-passages are very common, while 
the biliary disorders are comparatively infrequent. The 
region is characterized by great humidity, with sudden 
temperature- variations and a low mean animal temper- 
ature. 

The amount of watery vapor in the atmosphere de- 
pends largely on the soil. It is relatively small where 
the soil is sandy and porous and drains quickly, even 
after heavy rainfalls ; and it is relatively large where the 
soil is heavy, with an underlying stratum of clay. In the 
Lake region both soils are found. Cultivated soil signi- 
fies less moisture than uncultivated. The Lake region 
soil is highly cultivated and in so far beneficial in reduc- 
ing the atmospheric humidity. The temperature is 
affected by the cold air that sweeps down from the great 
lakes. The changes of temperature are frequent and 
rapid. The early warm days of spring are followed by 
chilling blasts from the North. The amount of cloudi- 
ness is considerable, averaging six-and-one-tenth days 
out of ten for the past twenty-five years. The average 



50 



AMERICAN LARYNGOLOGICAL ASSOCIATION. 



[Medical News 



rainfall of the Rochester district is 27 inches, the mean 
annual temperature 40°. Other localities possessing the 
same general characteristics may be free from the cold- 
air currents and thus present a very different resulting 
climatic condition. 

Damp air is injurious to the body in that it checks 
insensible perspiration, and hence there result endos- 
mosis through the mucous membrane and a checking 
of elimination, both of which lead to turgescenre, hyper- 
emia, and hypernutrition. The nose bears the brunt 
of this bad influence, owing to both its direct exposure 
and its normally abundant vascular supply. 

A peculiarly pernicious habit is that of sleeping in cold 
weather with the window wide open. The body is sub- 
jected to the influence of damp air at a time when its 
natural reactionary resistance is low, and the patient sleeps 
in a temperature that would be undesirable if he were 
awake. Hence we have that frequent naso-pharyngeal 
tumescence, with its characteristic symptom-group, 
known as the " American Disease.'' 

We must learn to drain our lands and houses thor- 
oughly and how properly to ventilate our sleeping- 
rooms. 

Dr. E. Fletcher iNG.'iLS, of Chicago, read a paper 
on 

DESICCATED THYROIDS IN GOITER. 

He related that during the past fifteen years he has 
treated eighty-one cases of bronchocele and exophthal- 
mic goiter. He gave potassium iodid thrice daily in 
doses of from five to ten grains. If no improvement 
resulted in two or three weeks, he gave tincture of 
iodin in doses of from five to twenty-five drops in capsule, 
followed by a large draft of water, or, in connection with 
this, injections of from 3 to 5 per cent, solution of car- 
bolic acid in glycerin and water, from twenty to fifty 
minims being injected once a week. 

For the past four years he has used the thyroid prep- 
arations and the desiccated preparations in his last six 
cases of goiter. Six grains of this represent one entire 
gland. All of his cases, except one, are still under treat- 
ment, and had been previously treated according to the 
old method. In addition, Dr. Ingals has obtained re- 
ports of forty-four cases treated by other physicians. 
Of one series of twenty-five, all but seven were im- 
proved. The neck was reduced in size, but the remedy 
seemed to cause headache in 30 per cent., dizziness in 
37 per cent., and increasing rapidity of the pulse in 25 
per cent. Out of the whole number of fifty cases the 
size of the neck was reduced in thirty-eight. Out of 
seven cases of myxedema improvement was noted in 
five. In addition to the unpleasant symptoms noted 
previously, there have also been observed trembling, 
backache, weakness, nausea, loss of weight, and in one 
instance uterine contractions. 

Dr. Ingals summarized his conclusions as follows : 

1. Thyroid preparations show powerful physiologic 
effects on the nervous and circulatory systems. These 
symptoms result from the daily use of from one-and- 
one-half to two glands, and there is reason to believe 
that too large quantities might produce fatal results. 

2. The desiccated preparations are best. Internal use 
yields as good results as does hypodermic injection, and 
the initial dosage of the preparations should be two grains, 
which may gradually be increased to eight. 



3. The effect on bodily weight is uncertain, varying 
not only in different patients, but also at different times 
in the same individual. Alleged disturbances from the 
remedy may be due to incidental digestive disorders. 

4. The remedy is useful in myxedema. 

5. In non-exophthalmic cases the cardiac condition is 
sometimes aggravated rather than relieved. Cystic con- 
ditions are not affected. 

6. Outside of the foregoing conditions there is none in 
which thyroid therapy promises any good results. 

In discussing this paper, Dr. E. L. Shurly, of De- 
troit, expressed disappointment at his own results in 
some eighteen or twenty cases subjected to thyroid treat- 
ment. He mentioned the case of a boy from whose 
neck a large thyroid was removed by operation. The 
patient seemed to develop somewhat, but did not grow 
in size, and three or four years later he was mentally 
apathetic and had a peculiar piping voice. Laryngeal 
examination showed normal movement of the arytenoids 
and the bones, but the latter did not assume the normal 
tension in phonation. Thyroid feeding for two years 
improved the throat-condition, though previous hypo- 
dermic use of the remedy had been without effect. 
He would condemn the total extirpation of the gland in 
view of the bad condition that may follow such a radical 
procedure. The leaving of a small portion seemed to 
prevent such an untoward result. 

Dr. W. E. Casselberry, of Chicago, had treated 
one case of exophthalmic goiter with fresh thyroid 
gland, with improvement, but not cure. He alluded to 
a recent paper by Paul Bruns, who had found that the 
younger the patient the better the result. Thus of the 
cases in the first decade of life all were cured ; in the 
second decade, 75 per cent, were cured; but after this 
age the results were less satisfactory, and after the fortieth 
year decidedly unsatisfactory. 

Dr. Ingals, in closing, said that the drinking of dis- 
tilled water should be insisted upon in this disease, as 
bad water seemed to be in many instances the distinct 
etiologic factor. 

Dr. W. E. Casselberry read a paper on 

electrolysis by a current-controller for the 
reduction of spurs of the nasal septum, 

and described a special apparatus to be used with the 
Edison (continuous) current. The ideal electrolytic cur- 
rent should be one of moderately high tension (voltage) 
He employed the bipolar method instances of from six 
and of comparatively low current-strength (amperage), 
to eight minutes and with from fifteen to forty milliam- 
peres. His needles were made of irido-platinum. His 
personal experience consisted of ten cases, which, for 
this purpose, he divided into three types : 

1. Strictly cartilaginous spurs. These can be removed 
by electrolysis, but the method is more tedious and less 
brilliant than other procedures. It is free from hemor- 
rhage, but is not a universal substitute for time-honored 
surgical methods. • 

2. Spurs made up of both cartilage and bone. These 
will reduce in size in proportion to the amount of carti- 
laginous element present. 

3. Spurs wholly bony. These cannot be reduced by 
electrolysis. Needles will not penetrate them, and the 
process will not resolve bone. 



July 13, 1895] 



AMERICAN LARYNGOLOGICAL ASSOCIATION. 



51 



4. Deviations cannot be remedied by this method. 

Dr. W. H. Daly, of Pittsburg, condemned electrol- 
ysis as a mere theory rather than a fact. He prefers 
the usual surgical procedures, especially the trephine 
driven by the De Vilbiss motor. He contended that 
Dr. Casselberry's apparatus, moreover, could not be used 
with the customary alternating current. 

Dr. Jonathan Wright, of Brooklyn, thought the 
method had a field of usefulness in cases in which pul- 
monary tuberculosis or other debilitating condition was 
present and a serious result might follow the usual sur- 
gical methods. 

Dr. Ingals said that the soft anterior septal spurs 
could be removed by the galvano-cautery point heated 
to whiteness. 

Dr. S. Hartwell Chapman, of New Haven, thought 
Dr. Casselberry's apparatus faulty in that it did not 
subdivide the current finely enough to prevent shock 
when used in the nose. 

Dr. a. B. Thrasher, of Cincinnati, inquired if the 
bipolar method was less painful than the monopolar. 

Dr. Casselberry replied that it was. He admitted 
the force of Dr. Chapman's criticism and hoped to 
remedy this defect of his apparatus. 

Dr. George B. Hope, of New York, read by title a 
paper entitled 

IS acute tonsillitis in any way dependent on 
the rheumatic state? 

He took the ground that the theory of acute tonsillitis 
being very generally attributable to an underlying 
rheumatic or gouty diathesis has not been substantiated 
by clinical observation. It was contended that patients 
subject to attacks of tonsillitis do not commonly give a 
history of rheumatism, proximate or remote, and that, on 
the other hand, the rheumatic individual rarely suffers 
from tonsillar inflammations. It is noteworthy that in 
later life the tonsils become less and less disposed to 
acute attacks, while the rheumatic tendency becomes 
more confirmed. Moreover, as a local acute manifesta- 
tion, rheumatism selects a sero-fibrous rather than a 
muco-fibrous or lymphatic structure, as the tonsil. It 
was also maintained that suppurative peri-tonsillitis is 
clearly infectious and frequently a sequel of intranasal 
operations. 

The conclusion was reached that the favorite anti- 
rheumatic treatment, as guaiac or the salicylates, ad- 
dressed to the condition is either erroneous in practice or 
acts independently and by methods not clearly under- 
stood. Such remedies should not be considered specifics, 
but should be used in accordance with the varying con- 
ditions of the subject. Moreover, it has not been proved 
that the treatment does abort or mitigate the course of 
the disease. 

Various new instruments were then exhibited by mem- 
bers of the Association, and the following papers were 
read by title ; 

foreign bodies in the esophagus, 

by Dr. Harrison Allen, of Philadelphia ; 

the influence of chronic diseases of the throat 
upon certain defects of speech, 

by Dr. D. Bryson Delavan, of New York. 



Second Day — June i8th. 

Dr. John A. Farlow, of Boston, reported 

two cases of lipoma. 

One was in a boy, aged two years, who presented a 
hpoma of the inner side of the right cheek. Nothing 
had been noticed till one day the child seemed to have 
a little blood in his mouth. Examination showed a red- 
dish lobulated growth, soft and movable, looking like 
parotid glandular tissue, and pedunculated, just opposite 
the mouth of Stenon's duct. Removal was effected with 
the cold-wire snare, and was unattended with hemor- 
rhage. The second case occurred in a man, aged sixty- 
six years, who had had a tumor in his mouth for fifteen 
years. Seven years previously a " piece was removed 
with scissors." When first seen the man presented a 
mass in the front part of the mouth, but evidently at- 
tached a good ways back. He was obliged to wrap a 
piece of cloth around it and hold it away from the teeth 
to prevent injuring it. Suffocative attacks occurred from 
a piece of the mass falling down between the vocal 
bands into the trachea. With the cold-wire snare and 
scissors quite a large piece was removed. The patient 
was then lost sight of, but returned a year or so later 
with recurrence of the growth and return of the former 
symptoms. With the galvano-cautery snare the entire 
mass, which was just above and in front of the right 
arytenoid, was now removed. 
Dr. Farlow made 

some remarks on the removal of the tonsils, 

dealing with the choice of operative methods. It is 
necessary first to break up adhesions between the faucial 
pillars. Then if there are present the usual large pro- 
jecting tonsils of childhood, with adenoids in the vault, 
anesthesia should be secured, the tonsils removed with 
the cold-wire ecraseur, and the adenoids taken out. All 
this would be easy enough if large tonsils always oc- 
curred in large mouths. Unfortunately, however, they 
frequently occur in small mouths with narrow jaws. A 
special instrument was exhibited which is a modification 
of Hooper's snare, having a straight canula and a re- 
inforcement of weak points. The wire is the usual No. 
5 or No. 7 piano-wire. The tonsil should be pushed out 
from its bed by external pressure, and can, as a rule, be 
very quickly removed. Cocain is applied if no adenoids 
are to be removed, and ice is used freely after the oper- 
ation. 

Dr. Farlow has also had good results with Ruault's 
punch-forceps, though they seem very large and clumsy, 
and their use occasions so me pain ; also with Hart- 
mann's conchotome, though it was devised for intra- 
nasal work. The latter is especially serviceable in get- 
ting out the deep-seated tonsillar tissue high up between 
the faucial pillars. He also uses small curved knives to 
cut up the surface of the tonsil so as to render the tissue 
available for seizing with the forceps. The galvano- 
cautery he has found very tedious. 

In discussingthe paper. Dr. F. H. Bosworth, of New 
York, said that the more we regarded the tonsil as only 
diseased tissue the more rational would be our treatment 
of these cases. He had learned to expect possible 
bleeding whenever he cut into lymphoid tissue. In 
children this did not occur. Large rounded tonsils 



52 



AMERICAN LARYNGOLOGICAL ASSOCIATION. 



[Medical News 



could easily be guillotined, but the removal of those 
spread out, and with adhesions to the faucial pillars, 
was a more difficult matter. These must be dug out, 
and no one instrument will answer for every case. 

Dr. Ingals had seen bleeding from small tonsils 
whose removal seemed indicated, but which were not 
large at the time of operation. Cocain did not anesthe- 
tize to any great extent, and it did promote bleeding. 

Dr. Carl Seiler, of Philadelphia, alluded to the 
canalization of the vessels in the indurated tissue as a 
cause of bleeding. He believed that the long diameter 
of the tonsils was horizontal rather than vertical, a fact 
overlooked by our instrument-makers. 

Dr. J. C. MuLHALL, of St. Louis, laid stress upon the 
necessity of breaking up all adhesions between the fau- 
cial pillars. 

Dr. Daly thought that more bad surgery had been 
done on the tonsils than on any other part of the body. 
They form no part of the normal throat. The ordinary 
Mackenzie tonsillotome only partially accomplishes the 
desired result. We must finish by trimming with the 
knife and forceps. He had had four or five cases of 
alarming hemorrhage. 

Dr. Casselberry believed that children do bleed 
severely at times, and whenever removing the tonsils 
with the guillotine always has a reliable galvano-cautery 
ready to use if hemorrhage occurs. It is difficult to 
separate the pillars, but if he can get the muscular ele- 
ment of the latter free he does not mind if he sacrifices 
a little mucous membrane. 

Dr. Shurly thought that in every case we should 
first form an idea of the nature of the tonsils and the 
amount to be removed. We may have bleeding from 
an abnormal distribution of arterial twigs. In using 
ignipuncture he does not put the point of the cautery 
directly into the crypts, but burns diagonally across 
them, including the lymph-spaces. He endeavors to 
substitute an acute inflammation for an old proliferative 
process. He differed decidedly from Dr. Seiler as to the 
direction of the greatest diameter of the tonsil. 
Dr. Bosworth, of New York, reported a case of 
melancholia cured by intranasal oper.\tion. 
It occurred in a man, aged forty-two years, who suf- 
fered from depressive melancholia, at first periodic, but 
later constant, and became unfitted for business. He 
complained of the eyeballs feeling as if too large for the 
sockets, and of a bursting pain between the eyes. He had at 
different times been operated on for varicocele, stricture, 
ligation of the pudic artery, removal of the testicles, and 
hemorrhoids. He had worn glasses, had his eye-muscles 
cut, and one eye enucleated. He had been circumcised, 
had his spine cauterized, and worn a seton in his neck. 
Examination of the nose showed the right nostril nearly 
occluded by a thickened bulging of the cartilaginous 
septum and the left middle turbinate thickened, with 
myxomatous degeneration, and evidences of ethmoid 
disease. The nostrils were freed with saw and snare, 
and all symptoms quickly disappeared. The man has 
since remained perfectly well. 

Dr. Bosworth also reported 
a case of suppurative ethmoid disease, followed 
BY invasion of the sphenoidal sinus, abscess 
OF the brain, and death. 
A dentist, aged thirty-three years, suffered from an 



offensive discharge from the left nostril, and later from 
the right, with severe headache and neuralgia of the left 
side of the head, without fever. Pus flowed down be- 
tween the left middle turbinate and the septum. A 
diagnosis of old ethmoid disease with probably recent 
involvement of the sphenoid sinus was made. Free 
drainage was established with a sharp gouge, and for six 
days marked improvement of all symptoms was noted. 
Later they grew worse, and with a three-sixteenth-inch 
burr an attempt was made to penetrate the sphenoid, 
though it was not possible to say whether or not the 
sinus was actually entered. On the following day a 
chill occurred, with a temperature of io6°, the develop- 
ment of semicoma, and paralysis of the left arm and 
face. A second rigor occurred, and was followed by 
death. No autopsy was held, but it was thought that 
death was due to a brain-abscess. The lesson of this 
case was that, while ethmoid disease is not directly dan- 
gerous as a rule, it may become so indirectly. Dr. 
Bosworth believes that most of the so-called sphenoid 
disease is really ethmoid. He has seen one-hundred - 
and-fifty cases of the latter, but only two of the former, 
and both were fatal. 

Dr. J. H. Bryan, of Washington, presented 

a further contribution to the study of suppura- 
tive disease of the accessory sinus. 

He reported cases of abscess of the right maxillary 
sinus resulting from dental caries ; suppurative elhmoid- 
itis terminating in caries of the anterior ethmoidal cells ; 
abscess of the left frontal sinus resulting from nasal polypi 
and hypertrophic rhinitis ; and abscess of the frontal, eth- 
moidal, and maxillary sinuses, with caries of the fronto- 
ethmoidal cells. The last was especially interesting, 
inasmuch as a communication existed between the fron- 
tal sinus and the antrum. It was uncertain whether this 
was the result of disease or an anatomic anomaly. The 
condition has been found a few times in the dissecting- 
room. 

Dr. Wright related the history of a case of antrum- 
disease in which it was impossible to discover the origin 
of the pus. He would condemn too early operation in 
this class of cases. 

Dr. Ingals thought the best way to open the sphenoid 
sinus was from below rather than anteriorly. This it 
was possible to do with an instrument used by dentists, 
in which the revolving drill worked at right-angles to 
the shaft of the instrument. 

Dr. Gleitsmann preferred to open the sinus with a 
Schaeffer's probe passed four-and-one-half inches upward 
along the side of the middle turbinate, about one-eighth 
of an inch below its lower border. 

Dr. Shurly had seen many cases of nasal discharge 
which he had thought due to neuritis, secondary to 
organic disease of the brain, which had affected the 
olfactory bulbs. 

Dr. Daly thought it preferable to slit up one side of 
the nose and lay it over on the face. In this way we 
could reach the sphenoid sinus more easily and much 
more safely. 

Dr. Mulhall thought that the brain was better pro- 
tected from injury in the sphenoid region than in the 
ethmoid. Sphenoid disease apart from ethmoid he 
believed to be rare. 



July 13, 1895] 



AMERICAN LARYNGOLOGICAL ASSOCIATION. 



53 



Dr. Thrasher related a case somewhat similar to Dr. 
Bosworth's case of melancholia relieved by intranasal 
operation. 

Dr. W. K. Simpson, of New York, read a paper en- 
titled 

A CONSIDERATION OF SOME OF THE MORE IMPORTANT 
PRINCIPLES OF INTRANASAL SURGERY. 

He said that the more accurately we could apply sur- 
gical principles to the treatment of nasal disease the 
greater would be our success. Conservative surgery 
might be defined as " knowing when not to interfere." 
We make mistakes occasionally, but they should serve 
as landmarks to guard against further error. He spoke 
particularly of the treatment of obstructive and hyper- 
trophic rhinitis. The nose has a natural protective in- 
fluence, and there is a pre-surgical or preoperative 
period, during which we should do all we can by diet, 
clothing, habits, and a regulation of the general environ- 
ment. In cases with a tendency to atrophy we should 
be very cautious about operating, and if we did operate 
we should endeavor to leave perfect symmetry and a 
smooth surface, with as little destruction of tissue as 
possible, and the least possible shock, hemorrhage, and 
danger of septic infection. The operation-wound should 
be treated as antiseptically as possible. Nasal surgeons 
are prone to be careless in minor details. Especial care 
should be taken to keep the left thumb and forefinger 
clean, as with these we wrap the cotton that goes on the 
applicator into the nose. Much of the " grippe," 
" severe cold," etc., after operation is nothing but mild 
sepsis. 

Dr. Mulhall believed that if we would use the 
cautery at a white heat and never allow it to cool in si/u 
we would have no bad after-effects. He used a saturated 
solution of sodium bicarbonate to neutralize the effects 
of the radiated heat on the nasal mucosa. 

Dr. James E. Newcomb, of New York, read a paper on 

LUDWIG'S ANGINA, 

which is generally defined by modern writers as a diffuse 
phlegmonous inflammation of the floor of the mouth and 
of the intermuscular and subcutaneous cellular tissue of 
the submaxillary region. The specific identity of the affec- 
tion has always been a disputed point. Ludwig gave as 
its characteristic features : i. A peculiar wooden indura- 
tion of the tissues which does not receive impressions. 
2. A uniform spread of this induration in such a way 
that it is always sharply bordered by a zone of entirely 
unaftected cellular tissue. 3. A hard, sublingual swell- 
ing, with a bolster-like mass around the interior of the 
lower jaw, of a deep-red or a bluish-red color. 

It is impossible to harmonize the various conflicting 
statements, but it seems fair to regard the disease as an 
intensely infectious phlegmon, occurring under peculiar 
anatomic conditions. No pathognomonic germ has ever 
been discovered, only the ordinary bacteria of suppura- 
tion. Fatal cases show a general tissue-disorganization, 
with sloughs, ichor, or offensive pus. 

Predisposing causes favoring the entrance of infection 
are dental eruption and caries, tonsillitis, disease of the 
buccal glands, and labial herpes. Cold, so frequently 
invoked as an exciting cause, is often but an undeter- 
minable infection. 

In the true Ludwig's disease the pus originates in a 



pyramidal space, the apex of which, situated below, cor- 
responds to the point where the mylo hyoid muscle bor- 
ders the genio-glossus, and the base of which, situated 
above, stretches along under the tongue. The internal 
face of the inferior maxilla and the mylo-hyoid muscle 
form its external (oblique) wall, and the genio-glossus 
and mylo-glossus its internal (vertical) wall. The germs 
first invading the sublingual may also penetrate the sub- 
maxillary sheath, or the latter may be attacked by the 
sublingual pus which has disassociated the fibers of the 
mylo-hyoid muscle. 

The local and general symptoms are those of pus- 
formation, with subsequent pressure on surrounding 
parts. Special stress is laid upon the appearance at the 
inner aspect of the dental arcade of a pad or button- 
like area of induration. A differential diagnosis must 
be made from simple submaxillary adenophlegmon, 
osteomyelitis of the jaw, and Fleischmann's hygroma. 

Statistics of 58 cases are sufficiently accurate for 
analysis. Of these 44 occurred in males, g in females, 
and 5 in infants whose sex was not stated. The maxi- 
mum age was sixty-six years, and the minimum three 
months ; 40 per cent, occurred between the ages of 
twenty and thirty years. Recovery is noted in 33 and 
death in 25. Bacteriologic findings in 9 instances were : 
Cocci of erysipelas, 2 ; streptococcus pyogenes, 4 ; 
staphylococcus pyogenes aureus, i ; and albus, i. In 
one instance there was found a bacillus a little longer 
and narrower that the B. coli communis, but distinguish- 
able from the latter by culture-reactions. 

Treatment may be summed up as early incision, subse- 
quent rigid antisepsis, and general support. 

Very recently Semon has advanced the proposition 
that this malady and acute edema of the larynx, 
edematous laryngitis, phlegmonous pharyngitis, and 
pharyngeal erysipelas are all but different varieties of 
septic inflammation of the throat, diftering only in local- 
ization and grade of severity, but all having the same 
general etiology. He maintains that this view consti- 
tutes a simple clinical application of bacteriologic prin- 
ciples to this group of septic inflammations. 

Dr. H. p. Swain, of New Haven, thought that some 
cases of peritonsillar suppuration of the Ungual tonsil 
gave a symptom-group very much like that described. 

A discussion on 

TUBERCtTLOSIS OF THE UPPER AIR PASSAGES 

was opened by Dr. Jonathan Wright, of Brooklyn, 
who spoke of the etiology. Recent advances in bac- 
teriologic knowledge have led us to modify greatly the 
postulates of Koch. We now know that bacteria can 
penetrate epithelial surfaces. Some of them are de- 
stroyed by phagocytosis and others by the fibroid in- 
duration that they themselves excite. It is believed that 
tuberculous infection can take place through the adenoid 
tissue at the base of the tongue, but it is conjectural 
whether the bacilli are actually found in the tissue itself 
or in the papilte. 

Much of our experimentation on animals is not in 
exact accord with the actual problems of clinical medi- 
cine, and we cannot reason directly from the results that 
follow the injection of tuberculous material into the 
bodies of animals by means of the syringe. All of us 
receive some tubercle-bacilli. Autopsies show evidences 
of arrested tuberculosis in one out of every two or three 



54 



AMERICAN LARYNGOLOGICAL ASSOCIATION. 



[Medical News 



bodies examined. Tlie fatality is due not so much to 
the bacilhis as to the bad general environment in which 
people live. Physicians come in contact with the bacil- 
lus daily, and yet the death-rate among them from pul- 
monary tuberculosis is not high. The bacillus alone is 
not enough to cause the disease. 

As to laryngeal infection, the old corrosive-sputa 
theory of Louis has been abandoned. As to its fre- 
quency we are somewhat uncertain, for in pulmonary 
tuberculosis the larynx is often not examined ; thus 
many lesions escape observation, and in many tuber- 
culous ulcers are seen only when the patient is in ex- 
Iremis. Pyogenic cocci first make a breach in the epi- 
thelium, and then the bacillus enters. The bacillus 
itself cannot cause an abscess. Infection through 
glandular epithelium is a matter of dispute. There 
seems to be a wavy arrangement of the epithelium in 
the larynx that allows of its stretching during vocal 
effort, so that its protective influence is continuous. 
Lesions of the pharynx generally occur late in the dis- 
ease or with acute miliary tuberculosis ; nasal lesions 
generally at the end of pulmonary disease. 

Dr. C. C. Rice, of New York, presented a paper on 

DIAGNOSIS. 

A'asal Tuberculosis. WiUigk found only one instance 
among 476 autopsies. It may occur either as an ulcer- 
ation of the septum and floor of the nose, or as small 
papillary outgrowths, generally from the turbinates. It 
is doubtless frequently overlooked or it may coexist with 
specific septal disease. Nasal ulceration, with concomi- 
tant lung-disease, not yielding to potassium iodid, should 
awaken suspicion. 

Tuberculosis of the Pharynx and Larynx. One case 
of the former and 237 of the latter were found in Willigk's 
series of 1307. Dr. Rice believed that faucial tubercu- 
losis was associated more generally with acute miliary 
tuberculosis than with the usual chronic disease of the 
lungs. It may appear in the soft palate before it under- 
goes ulceration, but probably all parts of the system are 
invaded at the same time. 

Tuberculosis of the Larynx. Eighty per cent, of all 
cases can be easily recognized. Of the remainder per- 
haps one-half require the microscope and administration 
of potassium iodid to determine definitely their nature. 
Unusually we have the typical semi-edematous, semi- 
inflamed conditions of the tuberculous infiltrations and 
the surface-ulceration, with its "moth-eaten'' look. 
Such lesions are generally symmetrical and are situated 
upon an anemic base. 

In incipient tuberculosis we find localized anemias of 
the hard and soft palate in throats otherwise healthy, 
and this with enlarged capillaries converging from the 
different portions of the palate toward the uvula. In 
addition we have elevation of the papillary layer in the 
inter-arytenoid commissure and feeble action of the 
internal laryngeal abductors. Dr. Rice regards recur- 
ring papilloma of the vocal bands as a suspicious circum- 
stance, pointing toward tuberculosis. Arytenoid con- 
gestion or the slightest appearance of bogginess should 
also put us on our guard. 

Then, finally, are the irregular cases with the frequent 
coexistence of syphilis and tubercle, or syphilis in the 
larynx and tubercle in the lungs. Rarely do we have 
with tubercle what is common enough with specific dis- 



ease — adhesive inflammation between the anterior por- 
tions of the vocal bands. We may also have : i 
Granular hyperplasias or ordinary granulation-tissue 
2. The frequently seen inter-arytenoid water-hke excres 
cences closely allied to papilloma of the larynx. 3 
Small rounded tuberculoma beneath the mucosa, found 
to consist of true tubercle-tissue usually containing 
bacilli. 

Dr. Shurly spoke of the 

MEDICINAL TREATMENT. 

He doubted whether much of the alleged post-mortem 
evidence of tuberculosis was entitled to credence. We 
may have "phthisis " without tuberculosis. The treat- 
ment is either local or general. Locally iodoform has 
given the speaker the best results. He uses ice freely. 
Climate and rest of voice were insisted upon. To mod- 
ify pharyngeal and laryngeal ulceration chlorin gas, 
sodium formate, and iodoform are the most serviceable. 
As a specific plan iodin with gold and sodium chlorid 
has given good results ; also oil of cloves and oil of 
castor. Gavage will enable the system to withstand the 
ravages of the disease and will also lower the temper- 
ature. We should never give meat-extracts alone, but 
always combined with vegetable foods in the form of 
gruel, which can be passed through a tube (sago, 
tapioca, etc.). Alcohol is generally too irritative for 
cases of laryngeal tuberculosis. Locally a mixture of 
eucalyptus, morphin, and cocain will greatly relieve 
pain. Tracheotomy is useless. So also in his hands 
were scarifying and curetting. 

Dr. I. W. Gleitsmann, of New York, considered the 

SURGICAL treatment. 

He considered curettement with the single or double 
instrument. Surgical treatment is, broadly speaking, 
either endo-laryngeal or extra-laryngeal. The former in- 
cludes incision with knife or scissors, curettement, sub- 
mucous injection, electrolysis, or the galvano-cautery ; 
the latter, laryngotomy, with excision of diseased parts, 
extirpation of the larynx, and tracheotomy. 

Dr. Gleitsmann has found on record eight total and 
seven partial extirpations of the larynx for tuberculous 
disease. In four of the cases of total laryngectomy the 
diagnosis was made before operation ; in two the oper- 
ation was performed on account of lupus and two had 
been considered carcinomatous ; of the cases of partial 
laryngectomy, the operation was performed in five for 
tuberculosis, in one for lupus, and in one for supposed 
carcinoma. 

Only six out of some seventy authors consulted speak 
disparagingly of curettement. It cannot, of course, exert 
a favorable influence on concomitant lung-disease, but 
we are justified in calling a case cured when, even if the 
lung-process continue", the laryngeal symptoms subside, 
the larynx looks normal, and no trace of the disease is 
found post mortem. 

Contraindications are advanced lung-disease and 
hectic, disseminated laryngeal tuberculosis, leaving little 
or no area of healthy tissue, and extensive infiltration 
producing steriosis. Under the latter conditions trache- 
otomy is indicated. The claim made that curette- 
ment hastens the pulmonary disease is not supported. 
Hemorrhage, which, in any considerable amount is rare, 
can be checked by a mixture of lactic acid and ferric- 



July 13, 1895] 



NEWS ITEMS. 



55 



chlorid solution. Pain is avoided by the repeated use 
of strong solutions of cocain. 

Curettement is analogous to the excision of a tuber- 
culous joint. It removes a focus of infection which is a 
constant drain on a weakened system, and is in properly 
selected cases the best procedure at our command. 
The double curet will often remove at one setting the 
arytenoid infiltration, which is the great cause of dysp- 
nea. Such procedure also lessens pain, through its re- 
moval of the abundant nerve-proliferation. The indi- 
cations are as follows : 

1. Primary tuberculous disease without lung-compli- 
cation. 

2. Cases with concomitant lung-disease, either incip- 
ient or which has stopped short of softening or hectic. 

3. Especially circumscribed ulcerations and infiltra- 
tions. 

4. Dense, hard swelling of the arytenoid region, 
ventricular band, posterior wall, tuberculous tumors, 
and affections of the epiglottis. 

5. In advanced lung-disease with distressing dys- 
phagia from arytenoid infiltration. 

Heryng's single curets are best suited for cleaning 
and scraping ulcerations, and Krause's double curets 
and Heryng's rotary curets for excision of tuberculous 
infiltrations. Subglottic lesions can be operated upon 
with Scheinmann's forceps, and with laterally bent for- 
ceps an attempt may be made to reach the ventricles. 
Post-operative quiet is absolutely necessary. Lactic 
acid or pyoktanin, i or 2 per cent,, should be applied 
daily until cicatrization is complete. The latter process 
occurs in from one to five weeks. Well-defined ulcer- 
ations do better than shallow and extensive ones ; 
dense infiltrations, which are generally localized, better 
than edematous conditions. 

Dr. Gleitsmann's own cases numbered twelve, all 
with lung-complications. Two operations were for in- 
filtration of the posterior wall alone ; one for such infil- 
tration with affection of the ventricular band combined ; 
fourarytenoidectomies ; three arytenoidectomies, and ex- 
cision of the ventricular band; and two of the latter 
alone. Arytenoidectomy had to be performed twice on 
each of the ten patients on account of recurring infiltra- 
tion. One patient died from heart-failure, and another 
from advanced lung-disease. Four are w-ithout recur- 
rence of laryngeal disease from six to ten months. One 
of these had an affection of the posterior wall, another 
of the ventricular band, and two of the arytenoid 
region. 

(To be concluded.) 



NEWS ITEMS. 

The Examinations of tfie Illinois State Board of Health. — 
The following preamble and resolution were unanimously 
adopted by the Illinois State Board of Health at a meet- 
ing held at Chicago on June 25, 1S95 : 

IVhert'as, The faculty of the Northwestern University 
Woman's Medical College adopted a set of resolutions 
criticising the Illinois State Board of Health for having 
issued to three non-graduate students of said college the 
State certificate entitling them to practise medicine, 
whom they claim were not entitled to receive them, and 
charging the Board with having adopted a lax policy in 



numerous other instances, thereby seriously detracting 
from the usefulness of the Board ; and 

U '/wre a s, AXihough the resolutions were " ordered to 
be placed before the Illinois State Board of Health," 
they were furnished to the various medical publications 
of the country simultaneously with their presentation to 
the Board, and before the Board had opportunity to 
make any defence ; and 

\Vlie7-eas, The said college has not made any investi- 
gation of the methods or policy of the Board, and could 
not be in possession of information upon which to found 
such serious charges ; and 

]\'liereas. The secretary of the faculty admitted to the 
secretary of the Board that the resolutions were adopted 
without due consideration, and were not so applicable to 
the present Board ; and 

Whereas, In the past two years no certificate has been 
granted to any applicant upon an average rating of less 
than 80 per cent, on all branches, and the questions and 
examination papers and a tabulated record of all ex- 
aminations are preserved, and are matters of record in 
the office ; and 

Whereas, It is not in the province of the Board to 
adopt any policy regarding the admission to its examin- 
ations of non-graduates, the law prescribing that "non- 
graduates shall submit themselves for examinations," 
and further prescribing that " the examinations shall be 
of an elementary and practical character." Therefore, 
be it 

Resoh'ed, That justice demands that the faculty of the 
Northwestern University Woman's Medical College, and 
all others interested, inform themselves as to the methods 
and policy of the Illinois State Board of Health in con- 
ducting its examinations, with a view to the establishment 
of the charges made, or of making such withdrawal, 
alteration, or explanation of the charges as the facts may 
warrant ; and, further, that the faculty inquire as to 
whether any individual interest or personal animosity 
prompted the drafting and circulating of the resolutions. 
(Signed) B. i\I. Griffith, M.D., 

Sarah Hackett Stevenson, M.D. 

For the Prevention of Blindness. — The following is the 
text of the legislation recently enacted in the State of 
Pennsylvania and approved by the Governor : 

Section i. Be it enacted by the Senate and House of 
Representatives of the Commonwealth of Pennsylvania 
in General Assembly met, and it is hereby enacted by the 
authority of the same, that should one or both eyes of 
an infant become inflamed or swollen or reddened at 
any time within two weeks after birth it shall be the 
duty of the midwife or nurse or other person having the 
care of such infant to report in writing within six hours 
after the discovery thereof to the health-officer or legally 
qualified practitioner of the city, town, or district in 
which the mother of the child resides the fact that such 
inflammation or swelling or redness exists. 

Section 2. That it shall be the duty of said health- 
officer immediately upon receipt of said written report 
to notify the parents or the person having charge of said 
infant of the danger to the eye or eyes of said infant by 
reason of said condition from neglect of proper treat- 
ment of the same ; and he shall also enclose to them 
directions for the proper treatment thereof. 

Section 3. Every health officer shall furnish a copy 



56 



NEWS ITEMS. 



[Medical News 



of this act to each person who is known to him to act as 
midwife or nurse in the city or town for which such 
health-officer is appointed, and the Secretary of State 
shall cause a sufficient number of copies of this act to 
be printed and supply the same to such health-officers 
on application. 

Section 4. Any failure to comply with the provisions 
of this act shall be punishable by fine, not to exceed two- 
hundred dollars, or imprisonment, not to exceed thirty 
days, or both. 

Doctor of State Medicine. — Rush Medical College of 
Chicago offers a degree in State medicine to graduates 
of not less than one year's standing who shall pass a 
rigid examination, including State medicine and hygiene, 
chemistry, physics and meteorology, engineering, mor- 
bid anatomy, vital statistics, medical jurisprudence, and 
law, after having completed six months' practical instruc- 
tion in a laboratory approved by the faculty, and studied 
practically out- door sanitary work for four months under 
an approved officer of health. 

The Medical Profession in Belgium. — The total number 
of qualified practitioners in Belgium is 2950. Of these, 
S84 dispense their own medicine. The proportion of 
doctors to population is I in 2122. The number of 
practitioners in Brussels is 558, being in the proportion 
of I to 1370 inhabitants. The proportion at Liege is i 
to 1771 ; at Ghent, i to 2186; and at Antwerp, i to 2251. 
There are in Belgium 2372 midwives, or i to every 2640 
of population. — British Medical Journal. 

A Medical School for Women in Russia is to be established 
at St. Petersburg, with means supplied from private re- 
sources. The curriculum is to correspond with that 
adopted by other foreign universities, and is to extend 
over a period of five years. Women under the age of 
twenty-one can only matriculate on the written permis- 
sion of parents or guardians ; married women on that 
of their husbands. 

Professor Thomas H. Huxley, the distinguished scientist, 
died June 29th at Eastbourne, England, at the age of 
seventy years. He contributed liberally to a wide 
range of scientific subjects, and was an ardent disciple 
of Darwinian principles. Among his works are " Lec- 
tures on Comparative Anatomy" and "Lectures in 
Elementary Physiology." 

Honors to Dr. Roswell Park and Dr. George Dock. — ^The 
degree of A.M. honoris causa has been conferred by 
Harvard College upon Dr. Roswell Park, of Buffalo, 
and Dr. George Dock, of Ann Arbor. 

State Board of Medical Examiners of New Jersey. — At the 
June examinations of this Board over 40 percent. (11 
out of 26) of the candidates examined for licence to 
practise medicine in this State were rejected. 

Professor Ewald Hering, of the University of Prague, 
has been made Professor of Physiology in the University 
of Leipsic as the successor to the late Carl Ludwig. 

Dr. Luther F. Halsey, a prominent physician of Swedes- 
boro, N. J., died suddenly on July 7th of angina pectoris, 
at the age of sixty-three years. 



For the Report of the Trial of Amick 7's. Reeves we have 
received from Dr. G. R. Fowler, $1.00; Dr. B. F. Miller, 
51.00; Dr. Edmond Souchon, S5.00; Dr. George E. 
Jones, $2. 00. 

Dr. Ernest Laplace, of Philadelphia, has had the degree 
of LL.D. conferred on him by Georgetown University, 
of Washington, D. C. 

Professor Mikulicz has been designated the successor of 
Trendelenburg in the Chair of Surgery in the University 
of Bonn. 

Dr. Frederick T. Roberts has been appointed Professor 
of Medicine in University College, London. 

Dr. Edward R. Palmer, of Louisville, lost his life in a 
bicycle collision on July 5th. 



BOOKS AND PAMPHLETS RECEIVED. 

Sectarianism in Medicine. Distinctive Features of Existing 
Medical Sects. By Edwin J. Kuh, M.D. Reprinted from the 
Journal of the American Medical Association, 1894. 

Two Months' Service at the Methodist Episcopal Hospital, 
Philadelphia. By Edmund W. Holmes, M.D. Pamphlet. Read 
before the Philadelphia County Medical Society, 1S94. 

Report of a Case of Bifid or Double Uvula. By Hal Foster, 
A.B., M.D. Reprinted from the Western Medical Journal, 1894. 

History of a Case of Indurated (Hunterian) Chancre of the 
Eyelid. By Charles A. Oliver, A.M., M.D. Reprinted from the 
Codex Medicus Philadelphiae, 1894. 

Description of an Artificial Eye Intended for the Study of 
Ophthalmoscopy and the Objective Determination of .Ametropia. 
By Charles A. Oliver, M.D. Repnnted from the American Oph- 
thalmological Society Transactions, 1894. 

Some Additional Studies upon the Clinical Value of Repeated 
Careful Correction of Manifest Refractive Error in Plastic Iritis. 
By Charles A. Oliver, A.M., M.D. Reprinted from the University 
Medical Magazine, 1894. 

Adenoids, with a Description of New Instruments for their 
Excision. By Arthur G. Hobbs, M.D. Read before the Tri- 
State Medical Association, Atlanta, 1894. 

Scopolamin Hydrobromate. By Arthur G. Hobbs, M.D. Re- 
printed from the Atlanta Medical and Surgical Journal, 1894. 

The Droitwich Brine Baths as Therapeutic Agents in Various 
Diseases. By W. H. Tomlins, L.R.C.P. (Lond.), M.R.C.S. 
(Eng.). Pamphlet. London: H. K. Lewis, 1895. 

Lues Venera. By Henry Alfred Robbins, M.D. Reprinted 
from the Virginia Medical Monthly, 1895. 

Vital Statistics of the City of Binghamton, N. Y. Annual State- 
ment for the Year Ending December 31, 1894. By Daniel S. Burr, 
M.D., Health Officer and Registrar of Vital Statistics. 

Kongenitale iibermassige Entwickelung des S. romanum, 
Darmverschluss. Von Dr. H. Eisenhart. Sonder-Abdruck aus 
dem Centralblatt fur innere Medicin, 1894, No. 49. 

Festschrift zum fuenf-und-zwanzig-Jaehrigen Jubilaeum des 
Vereins Deutscher Aerzte zu San Francisco, Californien, 1869- 
1894. San Francisco, Cal. : Druck von Schmidt Label and Litho. 
Company. 

Surgical Nursing. By Bertha M. Voswinkel. With in illus- 
trations. Philadelphia: P. Blakiston, Son & Co., 1895. 

Neudorfer's Method of Amputating Extremities, with a Report 
of Two Thigh-amputations. By A. H. Meisenbach, M.D. Re- 
printed from the Annals of Surgery, 1894. 

Last One-hundred Abdominal Sections for Removal of Ova- 
rian Tumors and' Diseased Uterine Appendages. By R. Stans- 
bury Sutton, M.D. Reported by J. P. Hunter, M.D. Reprinted 
from the Pittsburg Medical Review, 1894. 

Biographical Sketch of Prof. John M. Scudder, M.D. By J. 
U. Lloyd. Pamphlet. Cincinnati, Ohio, 1895. 



THE MEDICAL NEWS. 

A WEEKLY JOURNAL OF MEDICAL SCIENCE. 



Vol. LXVII. 



Saturday, July 20, 1895, 



No. 3. 



ORIGINAL ARTICLES. 

ACUTE PLASTIC IRITIS. 

A Self-limited Disease. ' 
BY HENRY DICKSON BRUNS, M D., 



PROFESSOR I 



I PATHOLOGIST 



Definiiioii : An inflammation of the anterior, 
variously colored portion of the uvea or middle 
coat of the eyeball. This middle coat, depending 
from the ciliary body posterior to the cornea, is 
visible through it, and is separated from it by the 
aqueous humor. It lies in front of and in contact 
with the crystalline lens under all conditions save 
that of extreme dilatation of the pupil. 

Varieties : Serous, plastic, and purulent iritis. 
Serous iritis is, I believe, never a primary disease, 
but is always secondary and indicative of a cho- 
roidal affection. Any iritis may become purulent 
if the grade of inflammation rise sufficiently high. 
This is probable after a septic wound of the cornea, 
the iris, or the ciliary body. So an iritis may 
become subacute or chronic as the inflammation 
dies ofif, but not entirely out. It most often 
happens when some complication arising during 
the course of the disease prevents the restoration 
of the inflamed iris to a condition anatomically 
and functionally normal. Plastic iritis is character- 
ized by the escape of plasma and white blood- 
corpuscles (lymph) from the engorged bloodvessels ; 
this e.xudate, coagulating, obscures and clogs the 
tissue of the iris and glues it to the anterior face of 
the lens. 

ACUTE PLASTIC IRITIS. 



Acute plastic iritis is, therefore, the common and 
typical disease. 

Cause : The predisposing causes are race, sex, and 
age. The negro is especially liable to iritis, as he 
is to all diseases of the uvea, either by reason of the 
saturation of the race with syphilis or from the em- 
bryologic relation between the uvea and his highly 
developed and functionally very active skin. Out 
of 173 unselected cases of acute, plastic, non-trau- 
matic iritis recorded at my clinic in the Eye, Ear, 
Nose, and Throat Hospital, during the past two 



' Read before the Mississippi Medical Society at its annual 
meeting, April ii, 1895, at Jackson, Miss. 



years, 73, or rather more than 42 per cent, were 
negroes, while people of African blood formed only 
27 per cent, of the 4500 or more in attendance 
during the same period of time. 

Men are more liable than women. Out of the 
total 173 cases 123 were males and 50 females — 
only 28 per cent., yet females form rather more 
than 50 per cent, of the total attendance at my 
clinic. 

Out of 262 unselected cases the youngest was 
ten, the oldest seventy-one years old. The 
average age was thirty. I have taken the aver- 
age of so many groups of cases that I feel per- 
fectly safe in asserting the correctness of this 
figure. 

Syphilis is by far the commonest exciting cause 
of the disease. Of 262 cases 115, more than 43 per 
cent., were undoubtedly of syphilitic origin; but 
the percentage, were it possible to determine it with 
certainty, is probably much greater. Rheumatism 
and gout are reckoned as causes next in fre- 
quency, yet only four out of 262 cases could with 
certainty be traced to this source. Rheumatic 
cases are certainly more common than this in 
private practice, and I suspect that most of these 
cases among the lower classes find their way into 
the general hospitals. Exposure to cold and damp- 
ness, especially local exposure, as, sitting by an 
open window duirng a railroad journey in inclement 
weather, can, and does, undoubtedly, excite a 
limited number of cases ; but I doubt if this ever 
happens in a truly healthy person. Extension from 
adjacent structures, malaria, variola, scrofula, and 
tuberculosis are also causes cited. 

Prognosis : The average duration of iritis, prop- 
erly treated, is thirty days. Individual cases may 
recover in a week, or drag on for four or five months. 
This depends chiefly upon the presence or absence 
of complications, and this in turn hinges upon the 
severity of the initial attack and the promptness 
with which appropriate treatment is instituted. 

Description : The degree of inflammation may 
vary from mildness to extreme severity. All the 
visible portion of the eyeball except the cornea, 
"the white of the eye," is injected, the injec- 
tion being of a crude, raw-meat, red color, most 
marked immediately around the cornea. The cor- 
nea itself is usually very faintly hazy. This hazi- 
ness, together with the presence of the exudate on 
and in the iris, gives it a dull, thick look, and in the 



ACUTE PLASTIC IRITIS. 



[Medical News 



case of light-colored eyes causes a marked dif- 
ference in hue between the inflamed and the unaf- 
fected organ. A blue or gray iris looks greenish ; 
a hazel one becomes a darker reddish-brown. The 
pupil {sphincter iridis) is contracted, or at any rate 
never larger than that of the healthy eye. Its 
movements are sluggish, or it is absolutely fixed. 
This is due not only to the congestion and to the 
presence of products of inflammation, but to the 
actual gumming down of the iris to the lens by the 
exuded lymph. To decide this point the patient is 
seated facing a window, and one eye covered with 
a rolled-up handkerchief pressed upon it with the 
flat of the hand, while the other eye is alternately 
exposed to or shaded from the light by the hands of 
the surgeon. Pain is a marked symptom, though in 
rare instances it is slight, or even conspicuous by its 
absence. In character the pain is neuralgic, 
aching, or gnawing, and comes in paroxysms or 
outbursts, with more or less lengthy intervals of 
freedom and rest. Following the course of the fifth 
nerve, it radiates over the forehead and temple, 
around the orbit, down the side of the nose, or 
causes the whole side of the head to throb with in- 
tolerable anguish. The whole eyeball may ache or 
feel sore, and it is, as a rule, tender to touch. The 
pain is usually much worse at night. There is 
usually a little flinching from light (photophobia), 
and sight is nearly always bedimmed (acuity of 
vision diminished). 

Co7nplications : Owing to the gumming down of 
certain points of the pupillary margin to the lens, 
while the intermediate portions remain free to dilate, 
the pupil may have an irregular shape. This be- 
comes much more conspicuous after the use of a 
mydriatic. These points of attachment of the iris 
to the lens {posterior synecliid) are almost certain 
to occur if the pupil is not well dilated at the be- 
ginning of an attack. If the entire circumference 
of the pupil is sealed to the lens, we have circular 
posterior synechise and exclusion of the pupil, a con- 
dition which seriously interferes with the proper 
nutrition of the eyeball. Anterior synechise are due 
to penetrating wounds or ulcers of the cornea, giv- 
ing escape to the aqueous humor, which carries 
the iris with it into the corneal wound, where it 
remains entangled. Corneal wounds are, of course, 
very common in traumatic iritis, while all severe 
corneal affections are likely to bring about secondary 
iritis. White or yellowish white exudate (lymph) 
from the iris may occupy more or less of the pu- 
pillary area (occlusion of the pupil), and the 
presence of such false membranes, together with 
posterior synechias, enables us to declare with 
certainty that iritis once existed. Blood some- 
times escapes from the engorged vessels of the 
iris, and ])us may be formed. The former is of 
course most common in traumatic iritis ; the latter, 



in infected wounds of the tissue, in cases complicated 
with severe corneal ulcers and when gummata of 
the iris are breaking down. The fluids collect at the 
bottom of the anterior chamber, are more or less 
(disturbed by movements of the head, and are 
known respectively as hypohema (hyphema) and 
hypopyon. 

Diagnosis : There are only three conditions with 
which an acute iritis might be confounded : acute 
conjunctivitis, inflammatory glaucoma, and an 
acute corneal affection. The best method of defin- 
ing and emphasizing the items of a differential 
diagnosis is by means of the " deadly parallel," so 
effectively employed by DaCosta in his now classic 
Medical Diagnosis. I have, therefore, drawn up the 
following scheme : 

Acute Iritis. Acute Conjunctivitis. 

The injection is red, most The injection is red. but is 

marlied near the cornea, much much less marked near the cor- 

less toward the conjunctival nea and most toward and in 

culs-de-sac. the conjunctival culs-de-sac. 

The vessels run deeply and The vessels are superficial, 
straight toward the corneal mar- tortuous, and irregular in dis- 
gin (ciliary region). tribution. 

Conjunctiva not much thick- The conjunctiva is thickened, 

ened, and distribution of vessels especially on the everted lids, 

on everted lids clearly seen; it where the distribution of vessels 

is not readily thrown into folds is concealed in the general red- 

by working the lower lid over ness; it is easily thrown into 

the ball with the finger. folds. 

There is no considerable hy- There is hypersecretion of 
fiersecretion of mucus. mucus ; it is seen in flakes on 

the cornea or rolled in the con- 
junctival culs-de-sac, and dried 
on the eyelashes ; the eyes are 
glued together by it in the morn- 
ing. 

Pain is neuralgic and parox- Pain is not severe ; the eye- 
ysmal ; usually severe and worse balls smart, burn, and feel 
at night; eyeball is tender and "sandy" and dry .ill the time; 
slight photophobia. there is no tenderness and no 

photophobia if the cornea is un- 
affected. 



The iris appears normal. 



The iris is thick and dull-look- 
ing, and, if light, is discolored. 

The pupil is small, sluggish, The pupil is normal. The 
or fixed; irregular, not round. cornea is clear if not second- 
arily affected ; vision is normal. 

Keratitis. 

The injection is rose-pink ; 
the vessels run straight and 
break into a fine network in the 
immediate vicinity of the cornea, 
where alone injection is con- 
spicuous. The bulbar and pal- 
pebral conjunctivas are not thick, 
and there is no hypersecretion. 

Pain is moderate and pretty 
constant, sticking or lancinat- 
ing ; the eyeball is not ten- 
der ; photophobia is severe and 
conspicuous : there is free 
lacrymation usually. The iris 
and pupil are normal, but sight 
of them is obscured in whole or 
in part by turbidity, opacities, 
scratches, roughnesses, foreign 
bodies, wounds or ulcers of 
cornea. 



July 20, 1895] 



ACUTE PLASTIC IRITIS. 



59 



Acute Iritis. Keratitis. 

The cornea is clear unless The depth of the anterior 

there is a corneal ulcer or some chamber is normal. Sight is 

other corneal complication. usually impaired by more or 

less corneal turbidity or opacity. 

Acute Glaucoma. 
The injection is red and the 
vessels distributed much as in 
iritis ; the conjunctiva is not 
thickened : nor is there hyper- 
secretion. The pain is of the 
'same character as in iritis, but 
more severe ; is not markedly 
worse at night. 

The eyeball is tender and 
very hard to the touch ; the iris 
is discolored if light : the pupil 
is more or less dilated, sluggish 
or fixed ; not black, but usually 
sea-green. 

The anterior chamber is shal- 
low; the iris and lens are pushed 
close to the cornea ; the cornea 
is hazy, steamy, or ground- 
glass-looking (this may be very 
sUght). 

Corneal sensitiveness is di- 
minished (if touched with 
camel's-hair brush or a wisp of 
cotton). 

Sight has been suddenly lost, 
or greatly dimmed with onset 
of the attack. 



The eyeball does not feel 
hard to the touch. 



The anterior chamber is of 
normal depth. 



Corneal sensitiveness is not 
diminished. 



Vision not suddenly impaired; 
never completely lost, though 
sometimes dimmed. 



Atropin soothes, eserin Atropin-sohition greatly ag- 
greatly aggravates the pain. gravates, eserin mitigates all 

symptoms. 

Treatment: Local anti constitutional.' Local 
treatment consists in the instillation of a strong 
solution of atropin sulphate, in hot bathing of the 
closed eye and adjacent parts, and in the application 
of leeches. The constitutional remedies employed 
will depend upon the cause of the disease. If rheuma- 
tism be the cause we prescribe, of course, salicylates, 
iodids, change of climate, a visit to Hot Springs, 
or whatever may be our favorite means of combat- 
ting the diathesis. If syphilis be to blame I prefer 
mercury in the form of calomel and Dover's 
powders, as this helps to relieve pain ; but for a 
busy man who has to be much "in evidence," par- 
vules and triturates are very convenient. I also 
give potassium iodid freely — not less than a dram a 
day — in plenty of water or milk. The Turkish bath 
is very useful in enabling the patient to take the 
drug without unpleasant effects. The usual common 
sense measures of regulating the bowels and avoid- 
ing undue exposure will, of course, be employed. 
Rest in bed for a day or two may be sometimes 
necessary, but as a rule the patient provided with dark 
glasses goes about as usual, and is probably the 
better for the out-of-door exercise and the distrac- 
tion of his attention. It is to the vigorous and 
exact application of local measures, however, that 
attention should be persistently directed. The 



* .\\\ cases of " neuralgia " of one side of the head, accom- 
panied by inflammation of the eye, must be regarded with e.\- 
treme suspicion ; they are usually cases of iritis or glaucoma. 



solution of atropin, our " sovereignest remedy," 
should not be weaker than one grain to the dram, 
and it should be instilled at least once an hour for 
the first twelve or thirty-six hours until the pupil is 
widely and smoothly dilated, and thereafter as fre- 
quently as may be necessary to maintain extreme 
dilatation. The first thirty-six waking hours are 
meant, for no one should awaken a patient with iritis 
from his all too broken sleep for any reason. If 
full dilatation is not obtained within this time it 
is rarely secured. When the instillation is made 
the patient should be lying down, or have the head 
thrown very far back, and the lids should be held 
apart for a minute or more to insure thorough applica- 
tion and absorption of the drug. The instillation 
of atropin should be followed by bathing the closed 
eye and neighboring parts with the very hottest 
water the skin can stand. Iritis is not a disease to 
be trifled with; the atropin-solution must be of full 
strength, it must be used promptly and effectively, 
and the water must be stinging hot, not warm, if the 
patient is to receive his eye from the hands of the 
surgeon, so to speak, anatomically and functionally 
restored. Few who are not especially experienced 
seem to realize the importance of this vigorous use 
of atropin in iritis and the sinister effect of per- 
manent posterior synechiae upon the future health 
and perfection of the organ. Once the pupil is 
fully and freely dilated, no matter how severe 
the suffering may have been, no matter how the 
case may have dragged along, when recovery 
does take place the disease is truly cured ; but 
let permanent synechia; be formed by too long 
delay, or by feebleness of attack on the part of 
the physician, and the weary road of relapse, 
of chronic inflammation, of plastic exudation, and 
pathologic cataract lies before the patient. When 
leeches are employed, three or four should be put 
on near the outer canthus, and the bleeding 
should be free. This and the other local measures 
markedly relieve the pain, for which purpose the 
inunction of a salve of one ounce of mercurial 
ointment to a dram of belladonna extract on the 
forehead is also very useful. Opiates are to be 
avoided if possible. It must be borne in mind, 
however, that this free use of atropin may bring 
about poisoning by the drug, an accident especially 
common in elderly persons, when opiates at once 
occupy the highest place of usefulness. 

There can be but little doubt that constitutional 
treatment is very effective in removing the tendency 
to relapse in syphilic iritis, and we should be equally 
successful in rheumatic cases did we possess as cer- 
tain means of exorcising the poison ; but — and this 
is the most unorthodox portion of ray paper — I am 
without evidence to show that the best and fullest 
constitutional treatment has the slightest effect in 
abridging the duration of iritis, while I have some 



6o 



GOITER IN MICHIGAN. 



[Medical News 



facts to show, what I have long suspected, that 
acute, non-traumatic iritis is a self-limited disease. 
By this I mean that while we prevent permanent in- 
jury, squeeze the blood from the iris, insure rest, 
and soothe pain, by the use of atropin, and so ren- 
der the course of the disease shorter than if, utterly 
neglected, it were allowed to run through all the 
tedious stages of plastic adhesion and chronic in- 
flammation, we do not, so far as I know, by the 
addition of the best constitutional treatment shorten 
the course of a case that is being locally treated. 
We can in such matters speak, of course, only of 
averages. I have now complete notes of 105 unse- 
lected cases of acute, non-traumatic, plastic iritis. 
They were treated by myself and others until they 
were discharged as fully cured. In 1893 I published 
a preliminary note on 69 of these cases in the 
Transactions of the Louisiana State Medical So- 
ciety. At that time I found the average duration of 
46 cases treated by both local and constitutional 
measures to be 30^^ days, and the average duration 
of 23 cases treated by local measures alone to be 
242% days. 

The 105 cases were collected in two groups : One 
of 63 cases at the Charity Hospital, from 1883 
to 1891, and one of 42 cases at the Eye, Ear, and 
Nose Hospital, during the years 1 893-1 894. In 
group No. I, 19 cases treated locally had an 
average duration of 20 days, while 44 cases treated 
both locally and constitutionally had an average 
duration of 39 days. In group No. 2, 33 cases 
treated locally had an average duration of 27 days, 
while 9 cases treated both locally and constitu- 
tionally, had an average duration of 29 days. Com- 
bining the two groups so as to get larger and, 
therefore, fairer figures, we find that 52 cases 
treated by local measures alone had an average 
duration of 25 days ; while 53 cases locally and con- 
stitutionally treated had an average of 34 days. 
Or, having some regard to causation, we find 
that of 44 non-specific cases those treated locally 
had an average duration of 23 days ; those locally 
and constitutionally an average of 37 days; of 61 
syphilitic cases those treated by local measures 
alone had an average duration of 27 days ; those 
locally and constitutionally an average of 31 days. 
The accompanying table shows these figures at a 
glance, and also shows all the possible combina- 
tions by which these results might be varied, and 
yet there is no material variation, twist and turn 
them as we may. 

Group No. I, local treatment only, average 20 days -\- 27 
days (average of Group No. 2) ^~ 47 days ; mean = 23 days. 

Group No. I, local and general treatment, aver.ige 39 days -(- 
29 days (average of Group No. 2)=68 days ; mean 34 days. 

All cases under local treatment only, 52 cases, average 25 days ; 
all cases under local and general treatment, 53 cases, average 34 
days; total, 103 cases. 



All non-specific cases, 44 ; local treatment only, average 23 
days, mean 25 days ; local and general treatment, average 37 
days, mean 34 days. 

All specific cases, 61 ; local treatment only, average 27 days, 
mean 34 days; local and general treatment, average 31 days, 
mean 34 days. 

It cannot be denied that a larger number of 
cases might lead to a different conclusion, but I do 
not think it probable, in face of the fact that the 
two groups collected at different times in distinct 
hospitals, and subject to the treatment of different 
surgeons, give practically identical results, and that 
the first obtained 69 cases analyzed in 1893 did not 
show essentially varying conclusions. The only fair 
deduction from this table is : 

Non-traumatic, acute, plastic iritis runs an ever- 
age course of thirty days' duration (twenty-five to 
thirty-five) ; variation in duration may be deter- 
mined by the severity of the initial attack and by 
the length of time the disease is neglected, and 
(hence) by complications that arise (posterior 
synechias, etc.), but extreme dilatation of the pupil 
having been secured (by atropin and hot bathing), 
other treatment is powerless to abridge this average 
duration. 



GOITER IN MICHIGAN} 

By GEORGE DOCK, M D., 

Very soon after beginning medical work in 
Michigan I had occasion to call attention in clinical 
demonstrations to the frequent occurrence of goiter, 
and within a few weeks I saw more cases than I had 
seen in several years, with more material, in either 
Philadelphia or Ga'.veston. Visits to some of the 
most promising goitrous districts failed of realization 
for several years, but in the summer of 1894, through 
the kindness of Dr. E H. Pomeroy and his associ- 
ates on the medical staff of the Calumet and Hecla 
Mining Company, at Calumet, Michigan, I saw a 
large number of very interesting cases. Since then 
I have sent out question-blanks to a large number 
of physicians in all parts of the State. From the 
answers to these, and from my own observations on 
patients in my clinic, I have obtained the data on 
which the following remarks are based. 

Records of goiter in the United States are curi- 
ously rare. Since the beginning of the century, 
following the monograph of Barton," no general 
survey of the subject seems to have been made, and 
even accounts of local endemics are rare. I have 
limited my own investigations to Michigan, although 
I have found from observation and inquiry that 
parts of Ohio and Indiana, still more the States 



' Read before the .Association of American Physicians, May 31, 

1895. 

- A memoir concerning the disease goiter as it prevails in 
different parts of North America. Philadelphia, iSoo. 



July 20, 1895] 



GOITER IN MICHIGAN 



61 



(including parts of Canada) bordering on Lakes 
Michigan, Superior, and Huron, contain a good 
many cases. The prevalence of goiter in Canada 
has been mentioned by several writers. An im- 
portant reference to the subject is contained in 
Dr. Osier's report on " Sporadic Cretinism in Amer- 
ica.'" 

Goiter occurs in all parts of Michigan. It is 
most prevalent in the northern part (both penin- 
sulas), but the southern part of the lower peninsula, 
especially the lower two tiers of counties from lake 
to lake, shows a large proportion. In Calumet, the 
physicians of the company kindly made a census 
and found fifty well-marked cases in a population of 
14,000. At the Central Mine, a few miles away, 
my friend, Dr. John MacRae, found ten cases 
among less than 2000 people. In Adrian, in the 
southeastern part of the State, Dr. M. R. Morden 
reports thirty cases in a population of less than 
9000. In Gaylord, Otsego County, Dr. N. I. Par- 
mater writes that of all children b3rn there, and 
reaching puberty, bne-fourth have goiters. I have 
seen a number of cases from the counties directly 
adjacent to Otsego, but they are so sparsely settled 
that it is difficult to get definite information. I 
have not attempted to make a census of cases, as 
many of my correspondents do not give figures. 
Fifty-two reporters give a total of 477 cases, not 
including the cases in the copper-region. The 
extent of the disease, as shown by the figures, does 
not compare with that in the goitrous regions of 
Europe, but is, nevertheless, a matter of importance 
and interest. 

In a large majority of cases the goiters affect na- 
tives of America, and usually also natives of the dis- 
trict. Immigrants of all nationalities, and many of 
these are represented in Michigan, are frequently 
affected. Among others, the French-Canadians 
must be mentioned. I made a special effort to dis- 
cover the conditions as regards Indians, many of 
whom live in different parts of the State. Among 
the older writers there is a want of harmony con- 
cerning goiter in Indians. This may be due to a 
fact I have noticed, that the red man seems to repel 
scientific investigation. Most of the reporters liv- 
ing near Indians could say nothing about them. 
However, Dr. R. B. Armstrong reports goiter as 
common among the Indians near Charlevoix. Dr. 
J. Wells Church, of Druraniond, Chippewa County, 
says they have it, but rarely. Dr. H. B. Hatch, of 
Hart, Oceana County, has seen a number of cases ; 
and other cases have been observed by Drs. G. C. 
Hafford, of Nahma, Delta County ; E. B. Patterson, 
of Michigamme, Marquette County ; John W. 
Decker, of Lake City, Missaukee County ; O. L. 



' American Journal of the Medical Sciences, November, 1893. 
P- 503- 



Ramsdell, of Petoskey ; C. N. Sower, of Pentwater, 
Oceana County ; and L. A. Harris, of Vanderbilt, 
Otsego County. 

In Michigan, as elsewhere, goiter develops most 
frequently about puberty, next in early middle life. 
No age is exempt. No case has come under my 
observation in which the goiter was congenital, 
though I hive known of several in very early child- 
hood. Goiter frequently affects the parents, espe- 
cially the mother, and also children. I have seen a 
family in which a mother and eight grown-up 
children had goiters. 

As regards sex, females seem to predominate. 
In most cases the goiters are comparatively 
small, not causing an increase of more than two or 
three inches in the circumference of the neck. Oc- 
casionally they are larger, and I am told of some 
"as large as a man's head," and of one that extends 
to the chin. I have never seen these myself, and 
even the largest native goiter I have seen would ex- 
cite little interest in Savoy. Owing to this there is in 
most cases comparative symmetry in the growths, 
and I have seen but one case in which the tumor 
had a grotesque shape, so common in Switzerland. 
No histologic examinations have been made, but the 
tumors have all the physical characteristics of various 
forms of benign struma. 

I have endeavored to learn of cases of cretinism, 
and, although I am told of one case, I have not seen 
it m)'self, and cannot vouch for the diagnosis. An 
interesting case coming under my own observation 
was that of an idiot girl, of eleven years, with a 
large goiter affecting the isthmus and both lobes. 
The goiter was of long standing. None of the 
physical peculiarities of cretinism was present. 

No case of myxedema has come under my imme- 
diate notice. On the occasion of the report of a 
case before the Michigan State Medical Society in 
1894, by Dr. J. A. Wessinger, I spoke of the extent 
of goiter in Michigan and the advisability of look- 
ing up cases of myxedema ; but so far as I can learn 
no other case has been reported. It is well known 
that in certain places where goiter is endemic myx- 
edema is rare or absent. 

Exophthalmic goiter seems to be unusually preva- 
lent in Michigan, but without any evident relation 
to simple goiter. I have not included the latter in 
this study. 

Goiter affects the lower animals almost always 
where it is common in man. Horses seem most 
frequently affected, then dogs, calves, and lambs. 
Cows and sheep do not seem to have goiter as often 
as the others. In a short time, on one day, in Cal- 
umet, I saw six goitrous horses and heard of a num- 
ber of others. Most of the goiters were small and 
unilateral, not as large as a man's fist, but I was told 
of larger ones. Dr. Morden, of Adrian, reports 
what was perhaps a cystic goiter in a squirrel. 



62 



GOITER IN MICHIGAN. 



[Medical News 



Of all the numerous factors supposed to be con- 
cerned in the production of goiter, the only one re- 
garding the existence and importance of which 
there is now any probability is some unknown sub- 
stance in drinking-water. That water is the cause 
of endemic goiter is one of the oldest and one of 
the most universal beliefs, but the peccant material 
has been differently conceived at different times. 

All the older ideas, according to which goiter was 
thought to be due to lime, magnesia, or other min- 
eral in the water, have gone the way of the glacial 
water theory and the " bronchin " of Vest, and 
now, in accordance with current knowledge, the 
pathogenic substance is supposed to be either a 
microbe or a toxin. Nothing definite, however, is 
yet known in this connection. The relations of 
goiter in Michigan are such as to make all other 
causes doubtful, even if they had not been disposed 
of before. Here are no glaciers, no deep valleys, 
no long-continued mists and fogs, no carrying of 
heavy loads on the head, no inter-raarrying. The 
cases come from all classes of society, but even 
in the poorest the hygienic conditions are no 
worse than in many places where goiters are never 
seen. Many cases that I have seen have lived amid 
unusually favorable hygienic surroundings. As for 
the geologic formation, sometimes looked on as im- 
portant, we find goiters here as well on the drift as 
on the Laurentian, and in many intermediate for- 
mations. 

In the cases of goiter that I have seen in 
Michigan a very large proportion of the patients 
have used well-water, and almost without exception 
my correspondents state that the same is true of the 
cases they report. Near Ann Arbor, where goiter 
is not so common as in some other parts of the 
State, one of my patients, a girl of sixteen years, de- 
veloped goiter a few months after a new well was put 
in use, and I was told that several others who used 
the water got goiters about the same time. In re- 
sponse to my inquiry as to change of water and its 
results. Dr. N. H. Taylor, of Ludington, writes 
that goiter has become much less frequent there 
since lake-water was substituted for well-water. An 
opportunity for observing the effect of change of 
water is now being given at Calumet. Formerly 
all drinking-water there was derived from wells, 
but recently an abundant supply has been obtained 
from Lake Superior, the inlet being in a place as 
free from contamination as possible. The result of 
this investigation must be awaited with great interest. 

Although it is not within the scope of this paper 
to consider the clinical features of goiter, I wish to 
add what testimony I can to a diagnostic feature 
that does not seem to be generally appreciated. 
Guttmann' has called attention to the fact that in 

' In his Lehrbuch, and in the Deutsche medicin. Wochenschrift, 
1893, No. II, p. 254. 



the goiter of Graves' disease there is an arterial 
murmur over the tumor, which is not the case in 
other forms of goiter. Kocher expresses himself in 
accord with this view. For nearly four years I have 
paid attention to this sign, and have not yet seen a 
case of simple goiter in which there was a murmur, 
even in the case of very rapidly growing tumors. 
I have once heard a systolic murmur over the goiter 
of a horse. The growth was very hard, and I think 
the murmur must have been due to pressure. It had 
a blowing character, different from that heard over 
the goiter of Graves' disease, regarding which I agree 
with Guttmann. In cases of Graves' disease from 
which exophthalmos is absent this sign can, there- 
fore, I think, be used with advantage. 

I do not intend to speak now of the medical treat- 
ment of goiter. The difference of opinion expressed 
on that subject by my correspondents is character- 
istic of a disease like goiter, which in some cases can 
be removed by the royal touch, and in others with- 
stands everything but the knife. I have made some 
trials with dried thyroid, kindly furnished me by 
Messrs. Parke, Davis & Company and by the Armour 
Company. The cases treated are too few to allow 
me to draw any conclusions, but lead me toward 
those reached by Bruns, Kocher, and others, viz. : 
that in young persons the remedy is useful, and 
should be tried further. The following observation, 
made on a recent case, is so interesting that I give 
it now : 

A man of sixty-six years came to my clinic 
with a goiter which he said had grown in six weeks. 
Both lobes and the isthmus were enlarged, forming 
a symmetrical tumor, increasing the size of the neck 
more than two inches. The most remarkable thing 
about the tumor was that it was extremely hard, 
evenly nodular, and grew downward, so that the lower 
end could not be freed from the sternum and clavi- 
cles, and the growth hardly moved at all with the 
movements of swallowing. There was neither thrill 
nor murmur over the growth. The upper rings of 
the trachea were pressed in by the growth to a con- 
siderable degree. lodin, internally and locally, 
including ointment of mercuric iodid, had been 
used without influencing the size of the tumor. 
Fiom the alleged rapidity of growth and other feat- 
ures I suspected malignant disease, and advised the 
patient to remain under observation for a few days. 
He was put on gram-doses of thyroid powder three 
times a day. After taking this for two days with- 
out unpleasant symptoms, the patient was obliged to 
go home on account of business. The thyroid 
powder was stopped. A week later the man wrote 
that the goiter had disappeared, that the neck meas- 
sured 15^^ inches, one-half inch more than normal, 
and that tlie symptoms of pressure on the trachea 
had disappeared. 

The sudden disappearance of goiters in young 
persons, especially vascular goiters, is of course com- 



July 20, 1895] EXTIRPATION AND COLOTOMY FOR CARCINOMA OF RECTUM. 



63 



mon. In this case, however, I think the medication 
must have had something to do with the change. 

Although in most cases of goiter there are no 
symptoms and treatment is never asked for, in 
some unpleasant, dangerous, or fatal results occur, 
so that measures should be taken to check the dis- 
ease, and the more important factors in prevention 
should be known. 

In addition to improvement in the surroundings 
of the patient, when needed, there are two things to 
which attention maybe drawn, sterilizing the drink- 
ing-water and removal of the patient to a non- 
goitrous district. The effect of change from well- 
water to lake-water, or river-water, should be more 
thoroughly tested. In the meantime all drinking- 
water in the goitrous districts should be boiled. For 
a long time I have advised goitrous patients to 
use boiled water, but, as they also used medxal 
treatment, the effect cannot be determined. At the 
Congress of the Pyrenese Association in 1891 a 
memorial was addressed to the Minister of Instruc- 
tion, in which the general use of filters was advo- 
cated. This may, no doubt, be of some additional 
value, but boiling alone can be practised more gen- 
erally and more safely than the use of filters. 

In my experience removal of a patient with a 
growing or intractable goiter to a part of the country 
where the disease is less common has been followed 
by complete disappearance of the tumor, and some 
of my correspondents have had similar experience. 

I wish to express here my thanks for the useful 
information furnished by a large number of cor- 
respondents impossible of enumeration in the paper. 



EXTIRPATION AND COLOTOMY IN CASES OF 
CARCINOMA OF THE RECTUM} 



By lewis H. ADLER, Jr., M.D.; 



POLYCLINIC i 



EPISCOPAL HOSPITA 



CoLOTOMV and extirpation are two recognized 
procedures for the relief of malignant disease of 
the rectum. Both operations offer the patient a 
chance of prolonging life ; and, in addition, extir- 
pation holds out the possibility, in selected cases, 
of effecting a radical cure. 

The choice between these two methods is a ques- 
tion of uncertainty only in a relatively small group 
of cases. Extirpation is not to be considered in 
the majority of instances, for the reason that the 
disease is usually an incurable one, and, by virtue 
of its concealed position within the rectum, its 
presence is not revealed or even suspected until the 
growth has existed for some time. Furthermore, it 
is rare for carcinoma of the rectum in its incipiency 

' Read before the Surgical Section of the American Medical 
Association at Baltimore, Md., May, 1895. 



to manifest itself by any symptom pointing to a 
lesion within the bowel. This is a familiar obser- 
vation to all surgeons. 

It frequently happens that a patient comes com- 
plaining of slight diarrhea or other mild rectal 
trouble, and an examination unexpectedly reveals 
the fact that carcinoma is present to such an extent 
that it is obvious that the neoplasm has existed for 
a considerable period. Consequently its complete 
removal is often rendered impossible. Again, the 
patient's vitality is such that so grave an operation 
as excision, requiring considerable time for its per- 
formance, is contra-indicated. 

In arguing thus I would not convey an impres- 
sion that I am opposed to extirpation for malignant 
disease of the rectum in suitable cases. On the 
contrary, I firmly believe it to be a perfectly justi- 
fiable operation when the growth is circumscribed 
and confined to the lower four or five inches of the 
bowel ; provided, however, that the tumor does not 
involve all the coats of the intestine, that it has not 
attacked the viscera which are intimately associated 
with the anterior wall of the rectum, that it has not 
invaded the pelvic glands or, by metastasis, any of 
the other organs of the body, and, finally, that its 
growth be not rapid or have a tendency to spread 
widely. From these considerati ons it naturally 
follows that the number of patients who can be 
benefitted by excision of the disease is comparatively 
small. 

Colotomy, on the other hand, is indicated in a 
large number of instances in which it is quite im- 
practicable to attempt an excision. The advantages 
of the operation lie partly in the relief it affords to 
symptoms and partly as a means of retarding the 
growth of the neoplasm. 

To indicate the relief afforded such patients by 
colotomy I cannot do better than quote the opin- 
ion of Kelsey on the subject, as expressed in the 
fourth edition of his work, Diseases of the Rec- 
tum and Anus} This authority is not only a 
strong advocate of the operation, but is also in a 
position to judge of its merits by reason of his 
large experience. He thus states his views : 

"As to the benefits arising from the operation 
too much can scarcely be said. That it prolongs 
life by the relief of pain, the preventing of obstruc- 
tion, and retarding the growth of cancerous disease, 
is beyond question. That it substitutes in many 
cases a painless death for one of great agony is 
indisputable. The idea that it is as well to let a 
patient die as to subject him to a colotomy has no 
supporters among surgeons who have had any ex- 
perience with these cases. Indeed, I think that the 
practitioner who to-day sat by and allowed a patient 
to die of obstruction because of any sentiment 
against this procedure would hardly be held blame- 

^ Pp. 409 and 410. 



64 



AMYOTROPHIC LATERAL SCLEROSIS. 



[Medical News 



less. I can only say that, after trying every other 
means of treatment and being obliged to admit the 
fruitlessness of them all, I have come, with most 
others, to admit the great benefits of colotomy, and 
have never performed it in any case in which either 
the patient or myself has afterguard regretted it. ' ' 
(Italics mine.) 

In another article Kelsey' mentions even more 
minutely the advantages of this operation, as fol- 
lows : 

" Colotomy, especially inguinal colotomy, re- 
lieves pain ; does away with the constant tenes- 
mus and discharge from the rectum, which, by 
their exhausting effects are the immediate cause of 
death ; delays the development of the disease by 
preventing the straining and congestion of defeca- 
tion ; prevents absolutely the complication of in- 
testinal obstruction, which is another cause of 
death ; enables the patient to sleep, eat, and gain 
flesh, and often makes him think himself cured in 
spite of the plainest prognosis to the contrary. 
Instead of passing his days and nights upon the 
commode, wearing out his life in the effort to free 
the bowel from the irritation, he has one or, per- 
haps, two solid fecal evacuations from the groin in 
twenty-four hours.' ' 

In conclusion, I would allude to one more topic, 
to wit : The choice of sites of opening the colon. 
I mention this subject with the sole purpose of elic- 
iting the present views of the members of this 
society. My own belief is that the inguinal region 
is to be preferred in the majority of cases. Its 
advantages over the lumbar operation are, to my 
mind : 

1. The smaller incision and lesser depth of the 
wound requisite to reach the colon, and the mini- 
mum amount of disturbance of the structures over- 
lying the seat of operation, 

2. The greater facility offered for the exploration 
of the abdomen, when such a procedure is required. 

3. The better position for safe anesthesia during 
the operation. 

4. The comparative ease with which the colon 
may be identified in this position and the little 
difficulty experienced in fixing the bowel to the 
skin without undue tension on the stitches. 

5. The greater readiness with which a good spur 
may be formed. 

6. The convenience to the patient of the site, for 
purposes of cleanliness and for the adjustment of 
pads ; and 

7. Recent statistics seem to indicate that it is 
the less dangerous operation. 



Dr. John Cuiferas, at the request of the Surgeon of the 
Marine-Hospital Service, has gone to Tampa, Fla., to 
aid the government in formulating and effectuating 
rigid quarantine-regulations against yellow fever. 

' New York Medical Journal, November, 1892. 



CLINICAL MEMORANDA. 

AMYOTROPHIC LATERAL SCLEROSIS IN A MAN 

SIXTY-EIGHT YEARS OLD, SIMULATING 

AT FIRST PARALYSIS 

AGITANS. 

By WILLIAM C. KRAUSS, M.D., 

OF BUFFALO. N. V. ; 

PROFESSOR OF NERVOUS DISEASES IN THE MEDICAI, DEPARTMENT OF THE 

NIAGARA UNIVERSITY ; NEUROLOGIST TO THE ERIE CO. HOSPITAL. 

C. B., aged sixty-eight years ; height, 5 icetSyi inches; 
weight, igo pounds; occupation, lawyer; was an ex- 
judge of the Superior Court of B. His father died at 
the age of sixty-two years ; his mother is living at the 
age of eighty-eight years. His grandparents Uved to 
old age. He passed through a severe attack of measles 
when five years old, and made a perfect recovery. Some 
years later he was stricken with pneumonia and recovered 
fully ; otherwise his early youth and manhood were 
passed without any noteworthy occurrences. He gradu- 
ated from the University of Michigan when twenty-three 
years old, taught school for several years, and then 
began the study of law. He was eminently successful 
in his profession, and was elected Judge of the Superior 
Court of r.., later becoming its Chief Justice. He was 
highly respected by men of all parties, possessed a rare 
legal talent, good judgment, and an opinion that was 
much sought after by his fellow-townsmen. He was a 
hard worker and a careful student, the early morning 
hours greeting him many times before his bed. He lived 
well, though not sumptuously, never indulged in excesses, 
was a moderate drinker, an ordinary smoker, took con- 
siderable exercise, and paid reasonable attention to his 
physical health. For seven years he had been affected 
every autumn with articular rheumatism, involving the 
joints of the lower extremities, while those of the upper 
remained exempt. Sometimes a gouty tendency was 
present, though not frequently. For seventeen years 
there had developed a subconjunctival hemorrhage- 
sometimes in the right eye, sometimes in the left eye 
These hemorrhages would be absorbed in the course 
of a week or ten days and would reappear the following 
fall. 

During the summer of 1893 he was troubled with 
vague symptoms which he ascribed to influenza, but he 
paid little attention to them. While in Chicago, attending 
the Fair, he noticed that it was hard for him to step over 
the gutters, his limbs seemed so stiff and "loggy." He 
tired easily while walking about the grounds, could not 
ascend the steps, and had to take his time in going from 
building to building. This was the first he observed 
of any difficulty in locomotion, and as he had some 
rheumatic pains in his limbs he naturally thought it was 
the result of his rheumatism. On his return home he 
still experienced the same difficulty in walking, and was 
obliged to take a carriage in going to or coming from 
his office. This continued to grow worse, and on Janu- 
ary 9, iSg4, I was called in consultation. 

Although I had seen the man on the streets and in the 
court-room several times previously, I nevertheless was 
struck by his changed appearance, and, at first sight, 
made a diagnosis of paralysis agitans without tremor. 
So sure was I of my diagnosis that I communicated the 
result of my examination to the family physician, who 



July 20, 1895] 



AMYOTROPHIC LATERAL SCLEROSIS. 



65 



informed me that he was also of the same opinion. The 
same diagnosis was made by a fellow-neurologist of 
Buffalo, and by another physician whose practice is a 
large and varied one. 

Upon examination, I found a large and muscular man, 
with gray hair and whiskers, whose face wore the heavy 
masked expression so common to Parkinson's disease. 
The movement of the facial muscles was mechanical 
and measured, so that one could almost observe an in- 
terval of time between the volition or intention to move 
the muscles and their actual obedience to the will. His 
head was inclined forward, the shoulders were rounded 
and drooping, his hands lay motionless in his lap, but in 
the " bread-crumbling " or " holding-a-pencil " position, 
while his feet rested heavily on the floor. His speech 
was slow, solemn, deliberate, and in a monotone, very 
much unlike his natural delivery, which was rapid, for- 
cible, and undulating. He complained of no pain, no 
disturbance of sensation, and " if I could walk better," 
he said, " I would be all right." His locomotion and 
station were identical with those of paralysis agitans, /. <?., 
the head and body were well inclined forward, the arms 
were held close to the body, the legs were stiflened and 
slightly flexed at the knees, and he moved them in a 
shuffling, obstinate manner, hardly taking the feet off the 
floor — resembling very much the gait of a surly, sulky 
child. Once started, it was difficult for him to stop un- 
less he grasped something to support himself (propul- 
sion). 

Retropulsion was also present, but to a much less 
degree. The movements of the arms and head were 
slow, and accomplished as if trying to overcome some 
obstacle. There was nothing abnormal about sensation ; 
the rectal and vesical reflexes were unimpaired ; the 
organs of special sense functionated normally, except, 
of course, his speech. The tendon-reflexes and the 
muscular reflexes were neither exaggerated nor dimin- 
ished ; the muscular power was well preserved for a man 
of his age, and his mind was as clear and unobscured 
as in former days of activity and usefulness. The pulse 
ranged betiveen 70 and 80; the temperature was never 
increased ; the appetite was good, the bowels regular, 
and the urine normal ; but his sleep was not the same 
restful sleep to which he had formerly been accustomed. 
Occasionally his attendants would notice a faint flush on 
his cheeks, and at night he would feel heated. I kept 
a careful watch over him in the hope of being able to 
discover the tremor as soon as it appeared, but instead 
of a tremor I observed other symptoms coming to the 
surface that seemed to shake my confidence in the 
former diagnosis. In the summer of 1 894 the man be- 
gan to complain of difficulty in breathing and of cough- 
ing, and his laughter was at times uncontrollable. 
Instead of the healthy inspiring laughter innate in a 
judge, it was a sickly puerile laughter without force or 
character. He was troubled greatly in swallowing, and 
had to eat very slowly and deliberately ; sometimes in 
eating he would choke and have fits of coughing. His 
voice became husky, and the words were mumbhng and 
hardly understandable to an outsider. His legs and 
arms were weakening rapidly, so that in the space of a 
few months he possessed hardly any control over them. 

On December i, 1-894, an examination revealed the 
following condition : 

The muscles about the shoulder, as the deltoid, trape- 



zius, the rhomboids, major and minor ; the arm-muscles, 
as the biceps, triceps, coraco-brachialis, the flexors, ex- 
tensors, supinators, and pronators ; and the handmus- 
cles, as the interossei, and the muscles of the thenar and 
hypothenar eminences, had undergone marked atrophy. 
The man could no longer raise the hands to his mouth, 
and the grip of the hands was nil. The shoulder-muscles 
were equally powerless. Contractures of the flexors of 
the fingers were present in the right hand, less in the left, 
and the right hand was beginning to assume the main en 
i;r>'i/^ appearance. Fibrillary contractions were present, 
more on the right than on the left side. The triceps and 
the biceps tendon-reflexes were greatly exaggerated, and 
likewise the muscular and periosteal reflexes. The 
masseter reflex could not be elicited. Sensation to touch, 
pain, heat, cold, and pressure was unaffected. Vasomotor 
disturbances were not present ; the hands and feet were 
continually warm. The legs had become nearly power- 
less, and the man was unable to make much headway in 
walking, and none at all unless supported on both sides. 
The loss of power was not due to the wasting of the 
muscles, because, although considerable atrophy had 
taken place, the leg-muscles were still large and well 
preserved. 

An electric examination of the muscles was not made. 
The patellar tendon-reflexes were greatly exaggerated ; 
ankle-clonus was present, but only within the previous 
few weeks had it appeared. The rectal and vesical 
reflexes were unimpaired. Sensory disturbances were 
wanting. 

An examination made on February i, 1895, resulted 
as follows ; The condition of the patient had grown 
steadily worse, and he now presented the typical picture 
of amyotrophic lateral sclerosis with implication of the 
medulla. The bulbar phenomena consisted in an unintel- 
ligible mumbling, with an occasional word or two clearly 
spoken, permitting the nurse to care for his wants. The 
labials and Unguals could not be pronounced ; the gut- 
turals, however, could be pronounced quite distinctly, 
especially when the patient was not fatigued. The voice 
was hoarse, husky, and explosive. The movements of 
the tongue were restricted, the tip scarcely reaching the 
lips when protruded ; it had also undergone some 
atrophy, although not to such an extent as I have occa- 
sionally seen in these cases. The lips, at first slightly 
swollen and compressible, were now weak and flabby, 
requiring some effort to keep them closed. During a 
paroxysm of coughing they flapped like the sails of a 
boat under an adverse wind. The peculiar appearance 
of the lower face, that of "unpleasant astonishment," 
caused by the drooping of the lower hp and deepening 
of the naso-labial folds, was well illustrated. The 
pharynx and larynx were in part afiected, as manifested 
by the escape of fluids through the nostrils, foreign 
bodies, especially food entering the glottis, causing fits 
of coughing, etc. The disturbance of respiration was 
very pronounced, consisting of dyspnea and difficulty 
in coughing. Singultus had never been present. No 
paresis of the upper face-muscles or of the eye-muscles 
could be proved, nor disturbances of the motor or sensory 
branches of the trigeminus nerves. The atrophy of the 
muscles of the shoulder, arm, and hand was complete, 
rendering the upper extremities absolutely helpless. 
Fibrillary contractions were well marked in the affected 
muscles, and contractures implicating the elbow, the 



66 



A REMARKABLE CASE OF THEAISM. 



[Medical News 



wrist, and the hand-joints had made their appearence. 
The superficial and deep reflexes, hkewise the tendon- 
reflexes, were greatly exaggerated. Sensory disturb- 
ances of all kinds were absent. The muscles of the 
lower extremities were less atrophied than those of the 
upper, but were equally powerless. The rectal and 
vesical reflexes were intact. 

Urinary examination showed nothing abnormal ; ex- 
amination of the blood showed a great diminution in 
the quantity of hemoglobin. The heart's action was 
feeble, but regular and uniform. The greatest distress 
seemed to come from the respiratory organs ; a bronchitis, 
having developed within the preceding week, occasioned 
great annoyance, provoking fits of coughing and con- 
sequent general prostration. 

On the morning of February 26, 1895, the patient was 
able to sit in a chair for a short time, complaining of 
great dyspnea and difficulty of raising mucus, but was 
otherwise in his usual condition. At noon of the same 
day respiratory failure supervened, and death ensued 
without any great struggle. 

An autopsy was not permitted. 

The case is worthy of publication for several reasons, 
even if amyotrophic lateral sclerosis were a common in- 
stead of a very uncommon affection. In my hospital- 
practice and private practice I have seen but two such 
cases in Buffalo, in a period of five years ; one in con- 
sultation with Dr. Pohl, occurring in a man thirty-eight 
years of age, who presented a typical picture of this 
disease, enabling a positive diagnosis to be made from 
the very beginning. 

The case just reported assumed for a period of six 
months the syndrome of paralysis agitans without 
tremor. The age of the patient, his gait and posture, the 
muscular rigidity, and the variability of the reflexes, all 
pointed to Parkinson's disease, and, although lacking 
the tremor, 1 did not hesitate to call it such. The 
beginning atrophy with exaggeration of all the reflexes, 
together with the symptoms of medullary disease, con- 
vinced me of the fallacy of my first diagnosis, and made 
the final diagnosis more positive with each succeeding 
day. 

Charcot's disease occurring in a man sixty-eight years 
of age is a very rare occurrence, and in a cursory ex- 
amination of the literature on this disease 1 find no case 
reported in an individual of such an advanced age. 
As a rule, amyotrophic lateral sclerosis makes its appear- 
ance between the thirtieth and forty-fifth years, and runs 
a course covering a period of from two to five years, 
death supervening as the result of medullary involve- 
ment. 

The etiology of the disease, like that of many of the 
system-affections of the spinal cord, is still sub judice, and 
nothing occurring in the course of the disease of the 
patient can add anything to solve this perplexing ques- 
tion. Syphilis, alcoholism, excesses, heredity, spinal 
injury, all were absent, and the only factor that may 
have had some influence, if a cause must be found, 
was the rheumatic tendency of the patient, and to this I 
cannot subscribe. 

At the present time there is a movement, as yet inci- 
pient, to class all forms of muscular atrophy under one 
head, and especially to ignore the autonomy of amyo- 
trophic lateral sclerosis. In formulating a classification. 



the course and duration of a disease should be given as 
much weight if not more than the symptomatology. It 
would be folly to insist that the Duchenne-Aran type, or 
the Erb type, of muscular atrophy is essentially the same 
disease as amyotrophic lateral sclerosis, even if the 
symptomatology were exactly alike. The fact that the 
former runs a course covering many years, terminating 
through some superadded affection, generally acute, 
while the latter always terminates through bulbar en- 
croachment, after a lapse of a few years, is sufficient 
proof of their complete pathologic dissimilarity. 



I\ R EMARKABLE CASE OF THEAISM. 

By JAMES WOOD, M.D., 



During investigations lately carried on to determine 
the existence of a tea-drinking habit, its frequency and 
the effects of the constituents of the tea- leaf upon the 
human body, a very remarkable case was encountered. 
I had become accustomed to meeting individuals who 
drank from ten to fifteen pints as their daily amount, 
but when the case to be reported presented itself it was 
thought rare enough to report. 

Case 306 was a tall blond, twenty-six years of age, who 
had come to this country from Ireland when quite a 
young girl. She was married in her eighteenth year to 
a strong, burly man, much addicted to the use of alco- 
holic beverages. One year after marriage their first 
child was born, and from this time she commenced to 
use tea. Why she should have begun at this particular 
time she could not explain. At first she said the amount 
was very small, but the quantity necessary has grown 
greater and greater. In all, four children have been 
born to her, and while nursing them she has always kept a 
quart-pitcher of tea by her side from which she frequently 
regaled herself. She said that she had become more 
irritable and cross every year, and found it harder to 
content herself with her husband and his drinking- 
habits, and that in consequence domestic infelicities had 
increased in number yearly. She had also found that 
tea would take the place of food, and when not particu- 
larly hungry, or too busy to prepare meals, she had 
recourse to the teacup with complete satisfaction. 

This is briefly the history of the patient when she pre- 
sented herself for treatment for, as she said, nervousness 
and sleeplessness. 

At the time of her first visit she had paroxysms of 
what she termed "cruel and fierce " headaches, either 
temporal, frontal, occipital, or general, persistant neu- 
ralgia of the face and neck, and dull, heavy pains in the 
lumbar region. She had also attacks of vertigo, mental 
disquietude and confusion, and was conscious of increas- 
ing forgetfulness. After these attacks she would have 
periods of despondency, alternating with great anxiety, 
a feeling of impending accident and death, either to her- 
self or children. There would be times when her sleep 
was restless and troubled ; nightmares and dreams 
were frequent ; after which there would ensue insomnia, 
at times cojnplete, and of several nights' duration. She 
was very nervous, easily startled, and very prone to be 
hysterical. The hallucinations usually met with in cases 
of tea-intoxication were also present in her case. She 
had at times an almost irresistible desire to look around 



July 20, 1S95] 



FRACTURE AT THE BASE OF THE SKULL. 



67 



or under the bed, because she imagined that some one 
was in the room. She said that when she stopped to 
think she " Icnew it was not so, but that she iiiusf look 
and see." When walking on the street there seemed to 
be shadows on the sidewalk beside her, as if made by 
some huge animal. 

This is a brief detail of the most prominent nervous 
symptoms so-called. Her bowels were very much con- 
stipated, several days elapsing without an evacuation. 
She had no appetite, was subject to attacks of severe 
cardiac palpitation, and complained of a sinking sensa- 
tion at the pit of the stomach. Her menses occurred 
every three weeks and lasted about eight days, and 
at this time all of the symptoms were much aggravated. 

The amount of the infusion of the tea-leaf drunk by 
this woman is astonishing, and the case is for this reason 
by far the most remarkable one in a large collection of 
tea-inebriates. 

When asked how much tea she drank a day, she 
hesitated, and then said, " Oh, I drink about thirty cups 
aday. " After closer questioning by both my associate, 
Dr. Alexander C. Howe, and myself, she confessed that 
she drank five cups before and five at breakfast, but did 
not know how many during the day, because she drank 
from a pitcher or bowl, as drinking from a cup was 
too slow a process and unsatisfactory. She said that her 
husband, who did not use tea, would let her buy only two 
pounds a week. From this she could make about seven 
" pots " of tea per day. The teapot, she e.vplained, had 
a capacity of two quarts. 

Here, then, is a woman who drank on an average 
twenty-eight pints of the infusion of tea every twenty-four 
hours, and who said that she could have drunk more 
had not her husband prohibited such an extravagance. 
From the history and from her own story the reason for 
drinking tea in this large amount lay solely in its 
stimulating effects. From a study of the physiologic 
action ' of thein and the essential oil on the system, this 
is not surprising, nor could a better and at the same time 
more pernicious non-alcoholic agent be found in com- 
mon use. 

HOSPITAL NOTE. 

FRACTURE AT THE BASE OF THE SKULL. 
BY ROSWELL PARK, A.M., M.D.. 

PROFESSOR OF SURGERY IN" THE MEDICAL DEPARTMENT OF THE 
UNIVERSITY OF BUFFALO. 

( Clinic at the Buffalo General Hospital.) 

The patient who is to be brought before you is a 
young man who fell on the ice three days ago, striking 
on the back of his head. Dr. Appell saw him on the 
ground, and noted a profuse hemorrhage from the left 
ear. The doctor douched the ear freely with an anti- 
septic solution, and then made aseptic occlusion of the 
auditory canal. The patient complained of nausea, and 
tried to control it till a basin that he called for could be 
procured. I mention this apparently trivial incident to 
show that he was conscious after the injury. There was 
also bleeding from the nostrils, which are now plugged 
with iodoform-gauze. Early this morning he had a 
slight headache, but he has none now. He feels like 

^ American Medico-Surgical Bulletin, September i, 1894. 



sitting up, but of course this would not be advisable. 
There is still hemorrhage from the left ear. 

The question to be considered involves at once both 
diagnosis and prognosis as the latter depends largely on 
the former. Ordinarily, when we have a history of in- 
jury, especially of the back of the head, with bleeding 
from the ears or nostrils, the diagnosis is of fracture at 
the base of the skull. Nose-bleed may come from a 
much less serious injury, but bleeding from the ear 
usually indicates quite serious mischief, though not 
necessarily fracture at the base of the skull. It is con- 
ceivable that the hemorrhage may come from the 
middle ear or from a rupture of the artery of the 
drum, on the same principle that rupture of a little 
vessel in the nose may cause epistaxis. The only rea- 
son for deciding against fracture at the base of the skull 
is that the man feels so well, and that he has no eleva- 
tion of temperature. But the time for the development 
of serious symptoms is not yet past. There are many 
symptoms that are considered characteristic of fracture 
at the base of the skull that are lacking here, though 
their absence is no reason for excluding such an injury. 
There is no protrusion of the eyes, no ecchymosis of the 
lids, no subconjunctival ecchymosis indicating hem- 
orrhage into the orbit. It is quite possible that these 
symptoms may develop in the next day or two, and, in 
that case, there would be positive reasons for favoring 
the diagnosis of fracture. There was certainly concus- 
sion of the brain, and, probably, contusion, as shown by 
the vomiting. 

The prognosis is good. There is no positive evidence 
of fracture at the base of the skull, and even if that con- 
dition exists, not every case is fatal. The symptom to 
be most carefully watched is the temperature, and this 
will be noted three times a day. If it rises we shall be 
apprehensive that our diagnosis, and. therefore, our 
prognosis, must be revised. In case the temperature 
should rise antiphlogistic measures would be indicated. 
We may apply an ice-cap to the head ; in many in- 
stances leeches have proved life-saving, and I shall 
direct that if his temperature rises leeches be appHed 
behind the ears. At present we shall simply maintain 
asepsis about the ears and nose. The danger to guard 
against is the travelling of infection from the passages 
outside the cranium into the cranial cavity. If the 
hemorrhage from the ear is due to a crack of the petrous 
portion of the temporal bone you can readily compre- 
hend that the same crack may admit germs from with- 
out. Even if the fissure and the middle ear are filled 
with blood-clot, there is ample opportunity for infec- 
tion of the clot through the Eustachian canal, even if 
the membrane of the drum be not broken. Bac- 
terial growth may begin in the blood-clot within 
an hour after the injury, and, after the clot has been 
broken down by the germs, the same activity may 
extend to the layer of blood-clot in the fissured 
bone, and then it is but a step to the formation of a 
septic embolus in one of the sinuses, and septic sinus- 
phlebitis results. On account of the prompt appli- 
cation of the proper antiseptic measures in this case I 
do not apprehend such a succession of events, but you 
can readily understand what might have happened had 
not the attending physician acted as promptly as he 
did, and if, in spite of his excellent treatment, there had 
been bacteria in the middle ear or Eustachian canal, 



68 



PHIMOSIS-HOOK 



[Medical News 



which could not have been prevented from developing. 
Aseptic occlusion of the nasal passages, which we are 
trying to carry out, cannot be made absolute, because 
of the contamination of the air through the mouth, but, 
realizing this fact, we are wise to make an effort in the 
right direction. 

There is another phase of this case to be considered. 
How is it that a man may have a fracture at the base of 
the skull and yet be in as good general condition as this 
patient seems to be ? The serious nature of these cases 
is not due to the crack in the skull. There is no reason 
why that should be more serious than a similar injury 
to another bone. The real trouble lies in the danger of 
injury to and infection of the brain and its membranes. 
The brain here is evidently not severely injured. So long 
as there is no marked alteration in the anatomic rela- 
tions to cause pressure on some part of the brain, and 
so long as pyogenic germs do not enter, the injury is of 
comparatively minor importance. 



TOXICOLOGIC NOTE. 

TOXIC EFFECTS OF TR IKRESOL. 

By clarence O. AREY, C.E., M.D., 



During some experiments made recently in the labor- 
atory with a flask of toxin of the diphtheria-bacillus I 
obtained some results that at first seemed strange, but 
that were afterward explained as being caused by the 
action of the trikresol contained in the solution. This 
special flask of toxin was the one mentioned in The 
Medical News of July 6, 1895, p. 20, which, for some 
reason, had decreased in its powers. In ascertaining 
this reduction in this direction enormous doses, ranging 
from 10 to 13 c.cm. of the toxin were given. The symp- 
toms resulting were identical in all cases, with very un- 
important exceptions. 

Three guinea-pigs were injected with this diphtheria- 
toxin containing 0.5 per cent, of trikresol, and a fourth 
guinea-pig was injected with a solution of the same 
strength of trikresol in distilled water. The doses given 
and the weights of the guinea-pigs were as follows : 

The first guinea-pig experimented upon weighed 373 
grams and received 1 1 c.cm. of the toxin mentioned. 
The second pig weighed 377 grams and received 12.5 
c.cm. of the toxin. The third pig weighed 406 grams 
and received 12 c.cm. of the toxin. The fourth pig 
weighed 343 grams and received 12.5 c.cm. of a 0.5 per 
cent, aqueous solution of trikresol. These figures give an 
average weight of 375 grams and an average dose of 
12 c.cm. of the solution, or 0.06 grams of trikresol itself; 
equivalent to 0,16 grams of trikresol per kilogram of 
body-weight. This would be equivalent to giving a 
man of 150 pounds avoirdupois about 150 minims of 
pure trikresol in aqueous solution. The solutions were 
in all four cases administered hypodermically. 

The symptoms resulting from the injections were as 
follows : 

Within the first three minutes after the injection the 
animal commenced to tremble. This trembling was 
accompanied by a peculiar rhythmic motion, commenc- 
ing at the head and running down to the hind feet, 
starting very much like the jerk of a hiccough. Putting 



the hand on the left side of the chest at the same time 
the heart was felt to have a fluttering motion, in time 
with the trembling and rhythmic jerk. 

About five minutes after the injection the animal 
commenced to lose control of the hind legs, and a few 
moments later complete paralysis of these extremities 
developed. In from one to ten minutes after this the 
animal commenced to lose control of the front legs, but 
these extremities were much slower in reaching the stage 
of complete paralysis. While passing into this stage, 
however, the animal kept drawing them forward, with a 
slow swimming motion, in a vain endeavor to regain 
his feet. At the same time the animals chin kept 
dropping lower and lower, till, as he lost entire control 
of the front extremities, the head rested limply upon the 
table. This stage occupied about ten minutes, during 
which time the rhythmic tremors were becoming more 
severe. Picking the animal up at this stage, the whole 
body was perfectly limp and flaccid. The animal now 
lay upon the table in very much the position that the 
hunter stretches the skin of a small animal on the wall 
to dry, and remained in this stage for ten or fifteen min- 
utes, when a slight diminution in the severity of the 
tremor could be noticed. This became less and less 
severe, till about forty-five minutes after the injection 
the animal tried to regain his feet, which he succeeded 
in doing a few minutes later, the tremor still continuing, 
although slighter. At the end of an hour the tremor 
was almost imperceptible, and putting the animal into 
his cage he commenced to eat. No after-effects were 
noticed. 

These experiments would tend to show that trikresol 
is a very safe antiseptic, as no such quantities as were 
employed here would ever be introduced into the body 
in the proportions that are used in antiseptic mixtures. 



NEW DEVICE. 

A NEW PHIMOSIS-HOOK. 

BY G. NATANSON, M.D., 

In performing the operation of circumcision, as is well 
known, the lamina interna or mucosa of the prepuce 
must be fixed and put on the stretch, together with the 
integumental parts, before the foreskin is cut. Among 
the various instruments used for this purpose the most 
ingenious and most serviceable are the phimosis-forceps of 
Levy and of Girdner, the illustrations of which are given 
in T'lema^nn'iArmaJiiirn/driiim Cliirurgicum of 1SS9, pp. 
336 and 337, and in some other catalogues of surgical 
instruments. But these two forceps are not conveniently 
used together with the glans-guard, as, for instance, 
the Knox phiniosis-clamp or forceps. While the screw 
of Levy's and the spring of Girdner's forceps tend to 
separate the opposite parts of the prepuce, the tendency 
of the guard is to bring them together. Besides, the 
strong spring of Girdner's forceps may easily rupture 
the often very delicate prepuce of infants, as, for in- 
stance, in cases of ritual circumcision, if not used with 
great cautiofi, which cannot be expected of every un- 
trained assistant holding the forceps. The serrated 
surface of Levy's forceps may sometimes not safely 
enough fix the mucous membrane. 



July 20, 1895] 



MEDICAL PROGRESS. 



69 



An instrument that I have devised for the purpose in 
question consists of two double-hooked tenacula, each 
about four inches long, the lower part of the tenacula 
being grooved. In the groove passes a slide, ending in 
a very small cylinder with two notches on its surface. 
When the slide is lowered (pushed down) the cylinder 
comes in contact with the hooks, which fit completely 
into the notches, as is clearly shown in the illustra- 
tion. The cylinder (c in Fig. B) is about two milhmeters 
high and one-and-a-half millimeters in diameter. The 
hooks thus being hidden in the notches, the peripheral 
end of the instrument can be easilv introduced into the 




preputial cavity as deeply as desired and moved around, 
as may sometimes be required for breaking up adhesions, 
without fear of doing harm to the glans. 

After introducing into the preputial cavity the guarded 
hooks, which I place to the right and left of the glans, 
the slide is removed and the hooks come in contact 
with the mucous membrane. Slight pressure is then 
sufficient to push them through both layers of the pre- 
puce, which are thus put on the stretch simultaneously. 
The guard is then applied and the operation performed 
in the usual manner. The same guarded hooks can be 
easily brought under the remaining portion of the mu- 
cous membrane and fix it well enough to facilitate the 
removal of this portion by the scissors. The instrument 
is made according to my design by Messrs. Geo. Tie- 
mann i.\: Co., of New York. 



MEDICAL PROGRESS. 

Perforation of the Bowel by a Fish bone, with the Forma- 
tion of an Intra-abdominal Abscess. — Mayl.^rd [G/asj^iKij 
Medical Journal, vol. xliii, No. 5, p. 350) has reported 
the case of a tuberculous patient, thirty-four years old, 
who presented a rounded tumor in the right inguinal 
region, on a level with the anterior superior spine of the 
ilium, about two-and-three-quarters inches to the right 
of the median line. This was tender on pressure, of 
firm consistence, and could be outlined by palpation, 
and over it the skin was freely movable. The sweUing 
gradually increased, both in size and tenderness. There 
was little or no elevation of temperature. There was 
some tendency to looseness of the bowels. The case 
was believed to be one of appendicitis with suppuration, 
and a vertical incision was made over the spot where 
fluctuation was suspected. About half an ounce of 
thick, creamy pus escaped, devoid of fecal odor. The 
forefinger was introduced with the object of opening up 
what was beheved to be a large abscess-cavity situated 
deeply. As, despite the utmost care, the adhesions sur- 
rounding the abscess-cavity were broken through and a 
communication with the peritoneal cavity established, 
the incision was enlarged with the view of removing the 
appendix and thoroughly washing out the peritoneal 
cavity. The abdominal wall was enormously thickened. 



in one place measuring three inches. The appendix 
was discovered at the lower part, being perfectly free 
and normal. The floor of the abscess was formed by a 
ragged, thickened mass of tissue on the surface of the 
colon externally, and a coil of small intestine internally, 
which were intimately united together. During the 
manipulations a small fragment of bone was discovered 
lying loose. The abdominal cavity was irrigated and 
the wound stitched up, except the lower part, where a 
drainage-tube was inserted. The foreign body was 
about three-quarters of an inch long, and had all the 
appearances of a fish-bone, and on microscopic exami- 
nation presented numerous well-marked lacunae and 
Haversian canals. 

Successful Celiotomy in a Child of Sixteen Months with 
Appendicectomy. — Hauck {Mfdical Review, June 15, 
1895, p. 463) has reported the case of a girl, sixteen 
months old, still nursing, who, after the ingestion of a 
small piece of banana and a little meat during the day, 
was seized at night with vomiting, which continued at 
short intervals. There was no diarrhea, but the intes- 
tinal evacuations contained mucus and blood. On ex- 
amination of the abdomen a tumor, of the size and 
shape of a small lemon, was found immediately below 
the ribs and to the right of the median line. The patient 
was pale and somnolent ; the pulse feeble and rapid ; the 
hands and feet cool ; the head warm ; and the vomiting 
had become stercoraceous. A diagnosis of obstruction 
of the bowel, probably due to intussusception, was made, 
and operation advised and consented to. Through a 
median incision, two inches long, from the umbilicus 
downward, a finger was introduced, and a tumor felt 
encircled by a coil of intestine. During the manipula- 
tion the strangulat ion was relieved, and the cecum 
slipped out through the wound. This part of the bowel 
and the ascending colon were much congested and 
thickened by edema, the vermiform appendix being as 
thick as the little finger and ecchy mosed. The last was, 
therefore, removed, the cut edge being inverted by 
means of three fine silk sutures, and the opening closed 
completely. The bowel was returned, and the abdom- 
inal wound approximated with a line of buried sutures, 
two deep and two superficial, and appropriate dressings 
applied. The child reacted well from the operation, 
and was soon on its way to permanent recovery. The 
bowels were moved a day after the operation by means 
of a glycerol-suppository, followed by three one-eighth- 
grain doses of calomel, given every two hours. 

Spontaneous Laceration of the Stomach. — Brayn and 
Ridley (British Medical Journal, No. 1795, p. 1145) 
have reported the case of a strong, well-nourished 
woman, thirty-seven years old, who after dinner vomited 
a small quantity of blood, rapidly became unconscious, 
and died in about half-an-hour. Upon post-mortem 
examination the abdominal cavity was found to contain 
ten ounces of bloody serum, the stomach was much dis- 
tended, and on the anterior wall at the cardiac extremity 
was a disrinct rent, about one quarter of an inch long, 
through the serous coat only. The direction of the 
laceration was downward and to the right. The inte- 
rior of the organ was filled with coagulated blood, which 
when broken up was found to contain pieces of imper- 
fectly masticated meat and other material which ap- 



70 



THERAPEUTIC NOTES. 



[Medical News 



peared to be bread. The mucous membrane was free 
from signs of disease and appeared perfectly healthy, 
only a slight redness, such as normally exists during 
digestion, being apparent. The walls of the stomach 
were thick and strong, and displayed no appearances 
of degeneration or softening. The diaphragm and mus- 
cular walls of the abdomen were also very strong and 
well-developed, and the remainder of the abdominal, 
as well as the thoracic organs were normal. The 
rupture of the stomach is attributed to violent con- 
traction of the viscus upon a mass of undigested food, 
accelerated by the action of a strongly developed dia- 
phragm and abdominal muscles. 

A Case of Severe and Persistent Hiccough. — Wightman 
(Lance/, No. 3744, p. 1364) has reported the case of a 
man, fifty-eight years old, who had been having hic- 
cough for forty-eight hours. He was a total abstainer, 
but was in the habit of drinking much tea. He had 
smoked half an ounce of tobacco daily for a number of 
years, and was a very small eater. Chloral and bromid 
were prescribed at bedtime, but after five hours' sleep 
the hiccough recommenced. Pressure over the region 
of the phrenic nerves, at the lower and front part of the 
neck, controlled the spasm for a short time. Larger 
doses of chloral and bromid were followed by a quiet 
night, but the hiccough was worse in the morning. The 
contractions of the diaphragm were violent and frequent, 
often one hiccough being represented by five or six 
consecutive contractions. The hiccough occurred eight 
or ten times in a minute, sometimes more frequently. A 
blister three inches square was applied over the region 
of the diaphragm in front, as well as ice to the nape of 
the neck and spine. Despite active and assiduous 
treatment with various drugs, including camphor, bel- 
ladonna, zinc sulphate, morphin, valerian, and amyl 
nitrite, the hiccough continued with varying severity 
for twelve days, and for a time pronounced nervous 
symptoms were present. 



THERAPEUTIC NOTES. 

Tiie Treatment of Fetid Expectoration with the Vapor of 
Coal-tar Creosote. — Chaplin {British Medical Journal, 
No. 1799, P- 137'). observing the freedom from pul- 
monary affections enjoyed by those employed in the 
manufacture of coal-tar creosote, was led to employ this 
substance in the treatment of various conditions at- 
tended with fetid expectoration. For this purpose he 
utihzed a small chamber about seven feet square by 
eight feet high, made as air-tight as possible, and in the 
center of which on a pedestal was placed a spirit-lamp, 
and over this a flat, open dish into which was poured 
the creosote. When the lamp was lighted the room 
soon became filled with the characteristic pungent 
fumes. The patient sat in the chamber and inhaled 
the vapor, at first with only a gentle heat apphed. As 
time went on, however, the patient was able to stand the 
inhalation with impimity. To obviate the irritating and 
smarting effects of the vapor upon eyes and nose, the 
former were covered with watch-glasses fixed with adhe- 
sive plaster, and the latter was plugged with cotton- 
wool. A towel pinned over the head and a loose dress- 



ing-gown protected the hair and clothing from the odor 
of the creosote. The first inhalation lasted a half-hour ; 
the latter an hour or an hour-and-a-half. The treat- 
ment was repeated daily, and the course lasted from six 
to twelve weeks. Altogether six cases were thus treated, 
a seventh being still under observation. Expectoration 
was facilitated, the quantity at first increasing, but later 
diminishing and the offensiveness disappearing. Breath- 
ing became easier, and the general condition distinctly 
improved. 

The Treatment of Morphin-poisoning with Potassium Per- 
manganate. — Humphreys (Ac7t> Orleans Medical and 
.Surgical J<}!<rnal,]\.\ne, 1895, p. 861) has reported the 
case of a negress, eleven years old, whose mother had 
given her a No. 2 capsule packed full of morphin, 
thinking it was quinin. By comparison with a similar 
capsule the amount taken was estimated at six grains. 
When seen five hours later the child was collapsed, 
lying perfectly motionless, with the pupils tightly con- 
tracted, the respirations 4 to the minute and sighing, and 
the pulse hard, full, regular, and 138 to the minute. The 
girl could not be aroused. Hot water with mustard 
and other domestic emetics had already been given, 
but without avail ; and also copious drafts of coffee. 
Strychnin sulphate (gr. J^^^ and atropin sulphate (gr. ■^^) 
were injected beneath the skin, and as soon thereafter 
as it could be prepared z'yi grains of potassium perman- 
ganate were given. In the course of an hour the per- 
manganate was repeated, and in a short while the 
patient opened her eyes and turned over voluntarily. 
The respirations had increased to 12 and the pulse had 
fallen to 1 10. After the lapse of another hour perman- 
ganate was again injected, and gave rise to considerable 
pain. Soon afterward the child arose from bed and 
walked across the room to get some water. The im- 
provement thus continued, another dose each of strychnin 
and atropin and potassium permanganate being given. 
Ultimate recovery was perfect. 

In the Treatment of Lichen Urticatus. Neebe {Monats- 
hefte fi'ir praktische Dermatologie, B. xx. No. 12, p. 
672) points out that two indications are to be met: (i) 
relief of the itching; (2) improvement in the general 
condition and treatment of the associated rachitis. For 
the itching a 2 per cent, ointment of betanaphthol may 
be employed, vigorously applied for ten minutes. The 
general treatment includes principally the correction of 
digestive disorders. Laxatives, as calomel or tincture of 
rhubarb, may be given and the diet restricted to simple 
soups, bouillon, and wheaten bread. Ordinary diet may 
be resumed after the stools have lost their offensive 
odor. Internally for the itching the following formula 
is useful : 

li. — Antipyrin 3ss. 

Syrup of orange-peel 1 . faJ.-M. 

Distilled water j •'■' 

Sig. — One or two teaspoonfuls are to be given at night. 

For the rachitis the following may be employed : 

R. — Phosphorus . . . . gr. ^',^. 
Cod-liver oil . . . . f5J. — M. 
Sig. — A teasponful is to be taken once or twice a day. 



July 20, 1895] 



COMPETITION AND MEDICAL ETHICS. 



71 



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SATURDAY, JULY 20, 1895. 



COMPETITION AND MEDICAL ETHICS. 

We publish to-day a letter from a valued corre- 
spondent to which we are earnestly requested to 
reply. We do so somewhat reluctantly, because we 
shall be compelled to leave untouched a number of 
what we deem errors on the part of our correspond- 
ent, and because these discussions are of little use in 
convincing anybody. Moreover, all such questions 
almost inevitably and finally narrow themselves 
down to personalities, the sum and substance of 
them being: "How much personal honor and 
sense of self-respect have you, or how much will 
you sacrifice honor to money-getting and success- 
gaining ? We shall, therefore, warn intending 
correspondents that we cannot give our space to 
further letters upon the subject. 

If we apprehend our correspondent correctly he 
criticises or would abrogate the Code of Ethics : 

1. Because some men, many men, break it. 

2. Because the breakers are not, and cannot be, 
punished. 

3. Because competitton must, he so intimates, 
make all physicians breakers. 

I. Now as to the first point, we cannot see that 
any rule of social life, of ethics, of business, or of 
religion, K,perse, the worse, or to be criticised, or 



to be abrogated, because broken every day by indi- 
viduals, few or many. The question lies behind 
the sad fact of the breakages, and consists in the 
fact of the Tightness or unrightness of the rule. 
Does our correspondent think the spirit and in- 
junctions of the Code good? He says he is an 
"admirer of the Code." Is it the less admirable 
because many men break it ? This assertion of 
admiration of the Code, coupled with continual 
carping at it, instead of at its breakers, betrays, at 
least, a very strabismic " admiration" and a very 
suspicious allegiance. Would it be well for the 
profession and for society if the provisions of the 
Code were obeyed by all physicians ? In so far as 
these injunctions are disregarded and broken, are 
not both profession and the public the worse, and 
the worse off? In so far as a physician is a gentle- 
man will he not act from the same spirit as that 
which inspired the writing of the Code, even if he 
never read a word or never even heard of that docu- 
ment ? We have many times said that the only 
argument the Code-smashers have is the fact that so 
many physicians break it, but what asinarian logic 
is that ! This whole argument seems designed 
finally to end in a resolve of the few sane in a world 
of fools — they who have escaped wetting by the 
fool's rain, to hunt up a puddle of the rain-water, 
plunge in and be happy — happy in a uniformity of 
foolishness with their grinning fellows. Down 
comes the question to one of personality : Do you 
prefer to be among the breakers or among the law- 
abiding — if you press it — among gentlemen ? 

2. Punished? The question betrays the sorry 
confession that, to the correspondent's mind, there 
is no genuine punishment except an objective one. 
But except a subjective one there is no punishment 
for any lapse from the higher ideals of justice, kind- 
ness, and honor. So far as one can see, progress in 
civilization consists in progress in character-building, 
in the establishing of sentiments within the individual 
breast, the abuse of which can be "punished" only 
by one's own conscience and sense of degradation. 
If one has not such sentiments and character, he 
may be happy in his life, and happy in choosing as 
his companions those that are like-minded, but he 
will find that others are different-minded and that 
they will choose different companions. And this, 
we suppose, includes the idea of punishment of our 
correspondent, the criticism that medical societies 
do not exclude the Code-breakers — the majority of 
the members of which are sometimes even breakers. 



72 



EDITORIAL COMMENTS. 



[Medical News 



Supposing it to be so, does that supply sufficient 
reason for not preserving one's own self-respect? 
Would it not be better to work for the execution of 
the Code rather than for its abrogation ? Supposing 
the Code were abolished, what earthly difference 
could it make in the facts? Gentlemanliness would 
still remain admirable, and all the Code-smashers 
would only make it more admirable, whilst one would 
still be compelled to choose his friends, or would be 
chosen by them, then just as now. When the med- 
ical societies and associations become so degraded 
that a majority of their members, individually and 
officially, habitually disregard those ordinary prin- 
ciples of kindness, honor, courtesy, and good 
breeding, upon which the poor Code is founded, 
then so much the worse, and gentlemen will not 
wish to be members — ^just as many men already do 
not care a button for membership in some medical 
societies. Down to a personality again comes the 
discussion : Do you prefer to be of the breakers or 
of the practisers of ethical conduct ? If of the 
latter class you certainly cannot care whether there 
is a Code or not; you will obey it whether objec- 
tively the rule of societies, or whether smashed to 
smithereens by all societies. As to "punishment," 
we have no sort of doubt that the supposed breaking 
of the Code will sooner or later be found to be only 
a breaking of the breaker. As the Code prescribes 
nothing but simple common courtesy, benevolence, 
and self-respect, the Code will remain quite un- 
broken though the whole world deludes itself into 
the belief that it breaks it. 

3. Competition will certainly make all those 
physicians breakers of the Code who find no inner 
reason for not breaking it. But the fundamental 
question lying behind this, and, indeed, behind all 
three criticisms, is: Does it pay to break? And 
this question, of course, is followed by the counter- 
query: What do you consider "pay?" That 
would involve a sermon on the value of money and 
success ; on the idiotic overvaluation of both by 
the little-souled and the mean-minded. If you 
think them worth the price some pay for them, for 
Heaven's sake buy, or beg, or steal them. Sensible 
men know better, and nothing but bitter experience 
will teach you better. If you think that at the end 
of your life you will, by breaking, be more honored 
by your fellow-men, more satisfied with your life- 
work, that you will leave the world better for your 
life of breaking, then look a bit to your logic — we 
think you deceive yourself— but if you conclude so, 



then, by all odds, go ahead at the breaking busi- 
ness. But if it be said that despite average ability, 
proper education, and due diligence, one cannot, 
while obeying the spirit and even the letter of " the 
Code," make a comfortable living, and raise one's 
family decently and honorably, then, fortified with 
the testimony of thousands of lives so lived, we can 
only say. It is a lie! 

As to our correspondent's division of life and 
character into hard-and-fast compartments and 
divisions, with no interactions and influences^this 
labelled medical practice, another ethics, that law, 
the other religion — well, this is simply poor and 
wearisome nonsense. Ethics, principles, honor, 
religion, if a man actively have these qualities, are 
not " totally different things ;" they are only mul- 
tiple phases of one indivisible psychic reality ; each 
interpenetrates and influences the other, and from 
them, as a composite whole, spring the motives that 
incite and the methods that realize all conduct. 



EDITORIAL COMMENTS. 

Accidents Due to Railroad and Trolley. — Chicago has been 
called the " most blood-guilty city on earth ," because of 
the great number of lives annually lost through rail- 
road-accidents. The Chicago Commissioner of Health 
reports, in 1894, 354 deaths from this cause, and he 
blames the "grade-crossings" for the mortality. In 
Philadelphia the number of deaths from railroad-acci- 
dents recorded by the Coroner in the year 1S94 was 236 ; 
in 1S93 it was 216 ; and in 1892, 208. For the six months 
ending July i, 1895, 106 cases are reported. In Chicago 
nearly 50 additional fatal railroad-accidents were not 
recorded as such, but were returned to the Board of 
Health under the head of " fracture of the spine,'' 
" surgical shock," etc. 

Of the 354 fatal accidents occurring in Chicago, about 
45 were from street-cars, and the balance from steam- 
railroads. Of the 236 deaths in Philadelphia in 1894, 
67 were from street-cars ; and for the six months of 
•'^95. 55 deaths on the Coroner's books are charged to 
the street-railways, including the trolleys. Many of the 
cases investigated by the Coroner occur among the em- 
ployes of the road, and are included in these statistics. 
The city of Brooklyn has but 70 deaths from railroad- 
accidents recorded on its Coroner's books for the year 
1894, and yet during the late railroad-strike in that city 
its surface trolley-companies were accused of great reck- 
lessness and gross disregard for human life, and the 
Coroner's clerk in a letter to us has limited his figures to 
the records in /lis office. 

Chicago has 3000 streets crossed at grade by steam- 
cars. In Philadelphia we have not quite so many 
grade-crossings, and yet several hundred more than 
we ought to have. The trolleys have added a consider- 
able number of deaths to the mortality-list, but the 
grade-crossings continue to furnish the greater number. 
While the trolley is deadly on the one hand, it is on the 



July 20, 1895] 



EDITORIAL COMMENTS. 



73 



other hand a therapeutic agency of no little value, and 
must exercise a beneficial influence upon the life and 
health of the community. What was formerly only 
possible to the wealthy, namely, a ride into country, can 
now be indulged in by the poorest inhabitant — and what 
can be more health-giving, after the hard work of a hot 
day, than a long ride in an open car out into the sur- 
rounding country ? The young people have trolley-ex- 
cursions instead of dancing-parties. The children of 
the poor districts are taken on an airing instead of 
sweltering in hot rooms, and thousands are benefitted 
that never were before. 

While we bemoan every unnecessary death, and be- 
lieve that every precaution should be taken by the rail- 
road-companies to prevent accidents, yet we feel that the 
newspapers are more interested in the sensation created 
by their records of trolley-deaths than in the real welfare 
of the people. If they would as faithfully and as graphi- 
cally record each death from diphtheria, or typhoid fever, 
or tuberculosis, deaths as clearly preventable as trolley- 
deaths, and due largely to neglect on the part of both 
the individual and the community, they would do a 
good that would be wider-reaching and that would aid 
in materially lessening the mortality-rate of our city. 

Deaths Among Medical Men. — In the June number of the 
Brooklyn Medical Journal Dr. J. L. Kortright writes 
of the causes of death among medical men, basing his 
conclusions on the record of deaths of 450 physicians 
occurring in the cities of New York and Brooklyn dur- 
ing the years 1884-1892. He found the average age at 
death to be 54.6 years. This is rather a high average, 
although compared with that of Presbyterian ministers 
(sixty-nine years) it is quite low. Clergymen have 
always had a greater longevity than most other people, 
while doctors are ranked with brewers, saloon-keepers, 
and butchers. 

Three per cent, of the deaths were from suicide — a 
ratio somewhat higher than is found in the population 
generally, but not so great as Dr. Kortright states, as he 
has reckoned on the entire male population, whereas he 
should have considered only males between the ages of 
twenty-one and sixty-five. 

The diseases connected with sclerotic changes in the 
arteries, namely, those of the heart and kidneys, and 
which Dr. Kortright groups under the term " arterial 
sclerosis," caused 35 percent, of the deaths, and he there- 
fore terms this group the " doctor's disease." No at- 
tempt is made to show whether or not medical men are 
more liable to die from such diseases than other profes- 
sional men, yet the warnings given are timely and worth 
heeding: "When you find your arterial tension in- 
creasing, your temporal artery becoming tortuous, your 
radial hardening, .... know that old age is upon 
you, curb your ambition. Be content with a small prac- 
tice. Reduce your expenses. Give up your night-work. 
Decline confinements. Take a long vacation in sum- 
mer." How many physicians who enjoy a fair compe- 
tence persist in doing work that overtaxes them and 
which they could readily assign to others. If the doctor 
does not care about his own health, he owes it to his pa- 
tients that he should not overwork himself Can a 
medical man do honest work when after attending a 
confinement at night he visits his outside cases in the 
morning, returns at 2 o'clock, takes a hurried lunch, and 



treats office-patients until 5 or 6 o'clock and has another 
batch from 7 to 9, with perhaps an hour of hospital- 
work and an hour of teaching fitted in somewhere dur- 
the day. This picture is taken from real life. Such a 
man can afford to decline confinements, need not have 
evening office-hours, and ought not to do charity-work 
in hospitals. 

Medical teaching will some day, we hope, be a spe- 
cialty in itself, just as teaching in other departments of 
knowledge already is. A teacher cannot do his duty to 
his pupils and at the same time attend to a large practice 
and hospital-work besides. As his work increases the 
physician should confine himself more and more to 
special cases and allow his assistants and younger col- 
leagues to assume some share of the burden. He should 
mingle more with the world around him, with his family, 
and even take a part in the affairs of State. Why should 
not the teachers and wardens of health show the world 
by their own lives how to live. Doctors owe it to them- 
selves and to the community to use every means to re- 
duce their own mortality-rate. 

Report of the Department of Health of Chicago. — A very 
interesting and valuable report is the one just issued by 
the Department of Health of the City of Chicago for the 
year ending December 31, 1894. The growth of these de- 
partments in large cities and the variety of duties 
assumed render this work important, especially if re- 
corded in a scientific manner. The Commissioner of 
Health, Dr. Arthur R. Reynolds, gives a summarv of 
the work in the first thirty-six pages, and then follow 
two papers, one on "The Water-Supply of Chicago" 
and the other on " Needed Sanitary Legislation." 

The tables of deaths are very complete and present 
some new and valuable features. Twelve per cent, of 
all the deaths reported took place in hospitals and other 
public institutions. The total death-rate of the city was 
15.24 per loco — the lowest death-rate, be it observed, of 
any city in the world with a population over 200,000. 
The other lake-cities, Detroit, Milwaukee, Cleveland, 
and Buffalo follow Chicago very closely, and the com- 
missioner suggests the influence of the Great Lakes as 
being important in this connection. 

The work during the smallpox epidemic, according to 
the report, was enormous. The returns showed that 59 
per cent, of the persons attacked were unvaccinated ; that 
nearly 30 per cent, of the school-population required 
vaccination. Over 1,000,000 free vaccinations were 
performed in a few months. 

The increase and decrease in diseases is graphically 
shown, and the period covered is long enough to 
draw conclusions from it. Carcinoma has increased 
greatly, both in relation to the population and to the 
number of deaths from other causes. From 1851 to 
1865 the deaths from carcinoma in 10,000 of the popula- 
tion averaged about 0.50, from 1S66 to 1890 it increased 
to 280, and from 1S81 to 1894 to 3.90. For Philadel- 
phia the rate in the past few years has been over 5 in 
10,000 of the population. 

Whether carcinoma shall be proved contagious or 
not, the recommendations of the Commissioner in re- 
gard to the disinfection of dressings and discharges are 
worth heeding. 

The other features of the report are all worthy of 
special study and are very suggestive. Factory-inspec- 



74 



EDITORIAL COMMENTS. 



[Medical News 



tion and smoke-nuisance inspection are portions of the 
work of the Health Department of Chicago. 

The diseases reported as generally diminishing in the 
mortality-rate are tuberculosis, croup, diarrhea, diphthe- 
ria, dysentery, malarial fevers, measles, puerperal fever, 
scarlet fever, typhoid fever, and pertussis, while nephritis, 
bronchitis, carcinoma, cholera infantum, heart diseases, 
nervous diseases, and pneumonia are increasing. 

In Philadelphia typhoid and tuberculosis furnish a 
decreasing death-rate from year to year, while pneumo- 
nia, bronchitis, and diseases of the heart return a higher 
mortality each year. In this connection it were well if 
our own department of health, would in its reports, com- 
pute the rates on the number of inhabitants, as has 
been done in the Chicago report. 



The Influence of Removal of the Ovaries upon the Bodily 
Metabolism. — While there are few organs whose function is 
absolutely essential for the maintenance of life, there is 
probably none whose functional activity is not without 
influence upon that of other organs and structures. Of 
the validity of this proposition we have of late years had 
an abundance of evidence. Perhaps the most conspicuous 
illustration is to be found in the thyroid gland, to whose 
absence or atrophy or disease is attributed the group of 
diseases comprising myxedema and cretinism and per- 
haps also exophthalmic goiter. One practical outcome of 
arecognition of this inter-relation resides in the therapeu- 
tic employment of preparations of the thyroid gland of 
one kind or another. Clinical observation has shown 
also that the ovaries have a not insignificant influence 
on the metabolic processes of the body. Thus over and 
above the changes, psychic and physical, that are at 
times observed at the menopause, occurring naturally 
or induced artifically by removal of the ovaries, it has 
been shown that the rather uncommon disease, osteo- 
malacia, will in many instances yield to the operation of 
oophorectomy. An additional contribution to this in- 
teresting chemico-physiologic subject has recently been 
made by Curatulo and Tarulli ( Ceiitralblatt fiir 
Gynlikologie, 1895, No. 21, p. 555), who report the re- 
sults of a series of observations upon the metabolic 
changes that follow removal of the ovaries. After having 
fed dogs with food so adjusted in quantity and quality 
that a fairly unvarying amount of nitrogen and phos- 
phates was excreted, it was found that after removal of 
ovaries, the other conditions remaining the same, the 
amount of phosphates eliminated was diminished con- 
siderably for some time, the amount of nitrogen under- 
going little change. The inference is drawn that this 
diminution in the excretion of phosphates is to be 
attributed to the lessened oxidation of the phosphorus 
present in the tissues in organic form, and which in 
combination with earthy bases is in health deposited in 
the bony structures as calcium and magnesium phos- 
phates. In this way, it is believed, is to be explained the 
improvement that follows removal of the ovaries in 
cases of osteomalacia. 



Misrepresentation of Professional Opinion. — Some time 
ago the American Humane Association addressed a cir- 
cular to a large number of prominent men, teachers, 
editors, professors, ministers, and physicians as to the 



advisability of illustrating in the public schools physio- 
logic truths and teachings by vivisection-experiments. 
A pamphlet of the replies has been published, and 
among them we find but four from men having the de- 
gree of M.D. Of these four three are against the prac- 
tice of vivisection-experiments before children. Two of 
these medical men are editors, and the other two are 
non-practising physicians. One of these latter thus 
writes : 

" I certainly think that children and everyone ought 
to be familiarized with the sight of blood, the pangs of 
disease, and the solemn event of dying. Death and 
pain should not be concealed ; they are the greatest ot 
all educators ; for they alone teach us the value of life 
in its highest measure. 

" The whole tone of your circular is, in my opinion, 
contrary to the spirit of true education." 

We wish first to protest against these atrocious senti- 
ments /<>?• j6', and secondly against them as at all repre- 
sentative of the opinion of the profession — of the prac- 
tising physician. Any clinical experience with disease, 
with sufifering persons, instils into normal hearts a senti- 
ment that shudders with horror at the thought that 
" children should be familiarized with the sight of blood, 
the pangs of disease, and the solemn event of dying." 
This is simply hideous, and we did not wish to let the 
opportunity pass without denying that this is medicine 
or medical opinion. Why did the instigator and editor 
of this pamphlet not secure the opinions of representa- 
tive and practising physicians upon this question ? Was 
it the secret desire of antivivisection extremism to stig- 
matize the medical profession with such a wretched 
travesty of its genuine feeling ? 



Purulent Parotiditis Due to the Typhoid-bacillus. — The 
localization of the bacillus of typhoid fever in the sec- 
ondary lesions of the disease has been demonstrated in 
a considerable number of instances. The micro-organ- 
isms are naturally not to be looked for in the lesions de- 
pendent upon intercurrent affections. Among the rarer 
complications of typhoid fever is inflammation of the 
parotid gland. It is possible that in some instances this 
may arise by invasion through Stensen's duct, while in 
others it may be due to metastatic deposit of typhoid-ba- 
cilU through the circulation. Of the second mode of 
origin an interesting example has recently been placed 
on record ; 

Janowski {Centralhlatt Jul- Bakteriologie mid Para- 
sitenkunde, Band xvii, No. 22, p. 785) has reported a 
case that presented itself for post-mortem examination 
with a clinical diagnosis of hemorrhagic nephritis of un- 
known origin. The patient had been ill for seven weeks 
with febrile symptoms. During the last week a painful 
swelling appeared in the region of the right parotid 
gland, but palpation failed to detect the presence of pus. 
Upon post-mortem examination the intestinal lesions of 
a recent attack of typhoid fever were found. On sec- 
tion the right parotid gland was found infiltrated with 
pus, bacteriologic examination of which disclosed the 
presence of typhoid-bacilli in pure culture. 



Gonorrhea Among Convicts. — Of 230 convicts recently 
examined in the State of Pennsylvania, 156 acknowl- 



July 20, 1895] 



REVIEWS. 



75 



edged having had gonorrhea once or oftener. Of 500 
examined in 1894, over 200 confessed to having had an 
attack of this disease. Of those who denied infection 
it is probable that many were not telling the truth. 
While these figures are obtained from a class that it 
would be expected would be given to debauchery, yet 
the prevalence of gonorrhea in all classes of life is ex- 
cessively great — how great it is impossible to learn, 
though one need not have a very large experience with 
worldly men to form an opinion. Statistics on this 
question are badly needed. 



The Bicycle vs. the Horse. — In many small towns the 
bicycle has taken the place of the country doctor's 
buggy. In the western part of Pennsylvania, up to ten 
years ago, doctors were compelled to make journeys 
over a considerable distance of territory, but to-day 
every village has its one or two physicians, and the 
suburban and interurban trolleys have brought the 
farmhouse quite near, so that the young doctor settUng 
in a small community will be able to forego the expense 
of keeping a horse, unless he goes West, where, on 
account of the bad roads, two and three horses are often 
required in a small practice. 

REVIEWS. 

Transactions of the Antiseptic Club. Reported 
by Albert Abrams, a Member of the San Francisco 
Medical Profession. Illustrated. New York : E. B. 
Treat, 1895. 

Alas, for the microbe — the real serious microbe — the 
one that " Dr." Radam kills with his club, when medi- 
cal men who have been his discoverers, who have ele- 
vated him to position and place, begin to make fun of 
him. Could Columbus have ever regarded America as 
a joke, or could we conceive of Morse splitting his sides 
over the electric telegraph ? And so one starts at a dis- 
advantage in making fun over serious medical problems, 
and expecting the serious Doctor to immediately die 
laughing. Dickens, in " Bob Sawyer," was more of a 
success than most of his imitators, and now the day of 
that kind of student has passed, and he is almost paleo- 
lithic and unreaUzable. The "Antiseptic Club," how- 
ever, has no designs upon the risibles of students, but 
aims at producing a series of smiles on cheeks furrowed 
by thought, and night-bells, and lips compressed with 
caution, responsibility, and the fear of inhaling germs. 
And these lips will never curl the right way at a satire 
of their own peculiar methods or a joke on their pet 
hobbies ; but, after all, it is unsafe to say what men will 
laugh at. The point we miss may penetrate the anat- 
omy of a brother and elicit a yell, while we sit silent. 

One can smile at the straightening of the Leaning 
Tower of Pisa with " testiculin," or the timid Doctor 
who resorted secretly to the juice of a lion ; or he who 
became a brilliant extractor of cataract after using ex- 
tract of cats ; or the man who used to be a gentleman 
till he tried " porcine fluid" and stole cases and rose to 
eminence. And there is much that is funny in the dis- 
sertation on Peyer, "the memory of whose name was 
confined to the unhallowed intestinal walls," or the celi- 



otomist's method of advertising, and Smith's success- 
ful cough-mi.xture that gave an expectorating cup with 
each bottle, and a bed-pan with the pills. 

But these are not the cream of the book extracted 
with a separator. Oh, no ! The reader must read for 
himself the Antiseptic Club and look at its funny 
pictures and find his own jokes to laugh at, and grow 
solemn and silent when his own corns feel a sudden and 
heavy tread. 

Difficult Labor. A Guide to Its Management for 

Students and Practitioners. By G. Ernest 

Herman, M. B. Lond. F.R.C.P. Pages 443, with 

162 Illustrations. New York : William Wood & Co., 

1S94. 

Dystocia, unfortunately, is too often to the ordinary 
practitioner of medicine practically an unknown quan- 
tity. As long as Nature decrees a normal sequence of 
events he prides himself upon his ability as an ac- 
coucheur. Let there exist, however, some disturbance 
of the fundamental principles underlying eutocia, and 
the self-estimated "skilled " accoucheur rapidly degen- 
erates into a demoralized attendant, absolutely unable to 
cope with the problem presented. While such a state of 
things exists such able books as the one under review 
cannot be too cordially welcomed. The high standing 
of the author and the excellent quality of his previous 
work at once insure a respectful and sanguine recep- 
tion of his later work. As we glance over the subject- 
matter of the volume we find that, while not arranged in 
any systematic order, all of the essential conditions 
giving rise to difficulty at the time of parturition — with 
possibly one exception — have been ably presented. If 
placenta pravia be considered worthy of mention as a 
complication of labor we cannot see why puerperal 
eclampsia should be denied this honor. The one is as 
much a portion of dystocia as the other, although neither 
is exclusively confined to the time of parturition at 
term, and, in our opinion, both would properly be 
treated as abnormahties of pregnancy. The chapter on 
pelvic contraction is excellent and exhaustive, and the 
illustrations throughout the book are instructive and 
well selected. The indexing is complete, the type clear, 
and the text explicit. 

The Physician's German Vademecum. A Manual 
for Medical Practitioners for Use in the Treatment of 
German Patients. By Dr. Richard S. Rosenthal. 
Part I. Gynecology and Obstetrics.. Pp. 177. Price 
js2. Part 2. General Practice. Pp. 268. Price $2. 
Chicago : The Rosenthal Publishing Company. 

This publication should prove useful to physicians 
whose work lies to any extent among German-speaking 
people, and who are not sufficienly grounded in that 
language to readily learn the facts and clearly give 
instructions in cases occurring among a not inconsider- 
able proportion of the population of our large cities. The 
subject-matter is arranged in questions, which have, as 
far as possible, been so constructed as to require either 
yes or no in answer. While this arrangement is most 
convenient it has the disadvantage of making the ques- 
tions " leading.'' The pronunciation is indicated by the 
marks in common use, and is satisfactory as far as 



76 



REVIEWS. 



[Medical News 



it is possible to thus indicate the sounds of German 
words. Proper pronunciation in any language is only to 
be acquired through the sense of hearing. Both the 
working and the literal meaning of every sentence is 
given. In addition, rules and examples bearing upon 
forms of German construction have been introduced, so 
that the book is not without use for persons even totally 
unacquainted with the language. The drawback to 
the practical utility of this work, as of all others of its 
class, is the difficulty of always at once finding the sen- 
tence one wants, or the necessity of memorizing the 
whole. As an adjunct to the thorough study of German 
it should, however, find a wider field of usefulness. 



Text- BOOK and Manu.4l of Prescription-writing, 
with a List of the Official Drugs and Preparations, and 
also Many of the Newer Remedies Now Frequently 
Used, with Their Doses. By E.O. Thornton, M.D. 
Ph.G. Pages 334. Philadelphia : W. B. Saunders, 
1895. Price, Si. 25. 

This valuable manual fills a special place in medicine, 
and will be peculiarly of service to the younger men in 
the profession to whom the art of prescription-writing is 
still more or less of a mystery. In looking through the 
book there appear but two objectional features, and even 
one of these may be queried. While it is perfectly proper 
to present sample prescriptions for the purpose of teach- 
ing, the learning of formuke for specific purposes cannot 
be too highly deprecated. We fear that many of those 
into whose hands this book must fall will, from the mul- 
tiplicity of the formula;, be tempted to memorize and 
ignore the higher object of the author. The graver 
defect is an inconsistency. While strongly recommend- 
ing the adoption of the metric system, and while giving 
rules for the conversion of other systems into this, the 
author gives all of his formuliii in the system in vogue in 
this country. We would suggest that in the next edition 
the French method might be put on an equality with 
the elder system in the sample formulje in the book. 
The tables of solubility, doses, and incompatibility are 
valuable. 



Transactions of the New York State Medical 
Association for the Year 1894. Vol. xi. Edited 
for the Association by E. D. Ferguson, M.D. Pub- 
lished by the Association. 

This handsome octavo volume of 750 pages, with its 
valuable and varied contents, is a distinct credit to the 
body irom which it emanates, and bespeaks the high 
scientific character of the Society's membership. It 
would be difficult and perhaps invidious, even were there 
space, to select from among the forty-five communica- 
tions that principally constitute the Transactions any 
for special comment or criticism. In scanning the pages 
of the volume we have, however, been struck by the 
following, which we can merely mention : An elaborate 
memoir on " The Differential Diagnosis of Traumatic 
Intra-cranial Lesions," by Dr. Chas. Phelps; a "Dis- 
cussion on Tuberculosis," participated in by Drs. H. 
M. Biggs, E. K. Dunham, E. G. janeway, L. F. Flick, 
J. H. Huddleston, J. D. Bryant, W. H. Park, J. G. 



Truax ; " Some Recent Studies on the Communicability 
and Treatment of Diphtheria and Pseudo-diphtheria," 
by Dr. W. H. Park; "A Practical Study of Serious 
Abdominal Contusions, with a Clinical Report of Twenty- 
'one Cases," by Dr. T. H. Manley; " Intestinal Anasto- 
mosis, with the Report of a Case," by Dr. F. H. Wig- 
gin ; " Brief Comments on the Materia Medica, Phar- 
macy and Therapeutics of the Y'ear Ending October, 
1894," by Dr. E. Squibb. 



A German-English Medical Thesaurus, or Treas- 
ure OF Single and Compound Medical Words 
AND Terms, with Dialogues, Idiomatic Phrases, 
and Proverbs, etc., and German and English 
Indexes, for Physicians and Medical Students. 
By Rev. Henry Losch, M.D. Svo, pp. 323. Phila- 
delphia : Published by the Author, 1895. Pr'ce, $2.50. 

The need for a good modern, working German- 
English medical dictionary has long been felt, and this 
the present work will in large measure supply. It has 
been written by one familiar, through education and ex- 
perience, with the wants of students of language, and 
especially medical language. The book is divided into 
three parts. The first and second include a systematic 
presentation of single and compound medical terms in 
their various relations, and to this 146 pages are devoted. 
In the third part are contained dialogues, the declensions, 
and a complete list of irregular verbs; while 136 pages 
are given up to an index of German and English words 
and medical terms, to the number of about 20,000, ar- 
ranged alphabetically. 

The work has been well done and is complete within 
its obvious limitations. It should serve not merely as a 
word-book, but as a useful aid to the comprehension of 
a language which is a most important medium of scien- 
tific communication. 



Mikroscopie und Chemie am Krankenbett. 

Clinical Microscopy and Chemistry. By Dr. 
Herman Lenhartz, Professor of Medicine and 
Director of the Hospital at Hamburg. 2d edition. 
Svo, pp. XV, 331. Berlm : Julius Springer, 1895. 
Price, 8 M. (S2.00). 

This little book is the outcome of the author's teach- 
ing-experiences in connection with the medical clinic at 
Leipsic. It does not aim to be exhaustive, but deals 
succinctly and clearly with such matters as are likely to 
present themselves in the every-day work of the clini- 
cian. The first edition was disposed of in less than 
two years, and this, the second, has been revised and 
amplified. After an introduction detailing the apparatus 
and adjuncts necessary for clinical microscopic and 
chemie examination, the following subjects are con- 
sidered in detail: (i) vegetable and animal parasites; 
(2) the blood ; (3) the sputum ; (4) the secretions of the 
mouth and the gastric and intestinal contents ; (5) the 
urine ; (6) fluids obtained by puncture. The work is 
illustrated with sixty-three cuts in the text and three 
admirably executed colored plates. It commends itself 
as a safe guide and useful companion for student and 
practising physician. 



July 20, 1895] 



CORRESPONDENCE. 



77 



Index of Medicine : A Manual for the Use of 
Senior Students and Others. By Seymour 
Taylor, M.D., Member Royal College of Physicians, 
Senior Assistant Physician to the West London Hos- 
pital. Large i2mo, pp. 794 and xii. Cloth, S3. 7 5 
Philadelphia: Lea Brothers & Co., 1894. 
This volume is a condensed practice of medicine, and 
as such may fulfil its chief object, of aiding students 
preparing for their final examinations. We are inclined 
to believe, however, that iis usefulness will be limited, 
for it will help least those who need it most, and those 
whom it could help will not need it. The statements 
and expositions contained in the book are good and re- 
liable so far as they go ; the weakness of the work lies 
in the omissions. Thus, in the treatment of typhoid 
fever the use of the cold bath according to the method 
of Brand is not even referred to; nor under diphtheria 
is the subject of the antitoxin mentioned. Space is de- 
voted to typhlitis and perityphlitis, but not a word is 
said of appendicitis. No description is given of the 
modern methods of examination of the blood or gastric 
contents. We further fail to find descriptions of akro- 
megaly, syringomyelia, and Morvan's disease. 

Clinical Lectures on the Prevention of Con- 
sumption. By William Murrell, M.D., F.R.C.P. 
London : Bailliere, Tindall & Cox, 1895. 
No subject is more important than the one treated in 
these lectures, and the prevailing views are clearly and 
concisely set out. We differ from the author in placing 
more stress upon the physical education of the individual 
than upon the measures adopted to prevent contagion, 
though the latter are, of course, of considerable im- 
portance. 

We are glad to see that the author believes that " for- 
cible legislation (on the subject of notification) is a mis- 
take unless backed up by popular opinion." 

Dr. Murrell wisely calls attention to the dangers of 
travel on land and sea from being shut in close, ill- 
ventilated apartments in company with a tuberculous 
fellow-traveler, or following the use of the apartment by 
such a one. Effective measures to prevent this means 
of contagion are within the reach of legislation, and such 
legislation might well be adopted and enforced. 

Lectures on Hygiene and Sanitation. By Seneca 
Egbert, A.M., M.D., Professor of Hygiene, Medico- 
Chirurgical College. Svo., 177 pages. Philadelphia: 
Franklin Publishing Co. 

Dr. Egbert has succeeded very well in accomplishing 
the task that he states in his preface was in view in the 
preparation of his book, namely, to furnish a syllabus 
of his lectures, and at the same time sufficient treatment 
of the various topics to make it of value to others. The 
extended and extending field of hygiene has been well 
considered, being naturally presented in its relations to 
medicine. It is often overlooked that the important de- 
partment of public hygiene has an engineering aspect, 
but it, of course, is not the function of this book to con- 
sider that phase. In the more technical features of the 
science Dr. Egbert has consulted the recent manuals, 
and thus has kept the work up to date. It is well written 
and well printed. We regret that it contains no index 
and only a very brief table of contents. 



CORRESPONDENCE. 

COMPETITION AND MEDICAL ETHICS. 

Ill /ht- Editor of Thk Medical News, 

Sir : I dislike disputes, and especially this one, Init 
I trouble you with this letter merely because I would 
like to see discussed in a dignified manner the real diffi- 
culty of the question as regards medical ethics. It is 
always omitted or evaded. The two things that to my 
mind militate against the Code of Ethics are : 

o. Competition involved in the practice of medicine 
as a means of gaining a Uvelihood. 

i>. Total absence of any provision for effective punish- 
ment against infringement of the Code. 

There is no comparing of the practice of medicine 
and the rules that may guide it with such totally different 
things as common ethics, religion, and law. In not one 
of these, so far as I can see, does competition enter to 
the slightest degree. Ethics has to do solely with pri- 
vate conscience, and as soon as it widens out enough to 
affect one's neighbors it has to do with law or govern- 
ment (always, however, with restraining penalties at- 
tached). A man may lie or not to his neighbor ; it is a 
matter of his own conscience and maintenance of his 
own reputation. If he steals from his neighbor the law 
steps in and punishes him. Ethics says " thou shalt not 
lie ; but if you do, settle it with your own conscience ; if 
you become known as a habitual liar, you may lose in 
the long run ; but whatever you do, you are always your 
own free agent, under the constraint only of your own 
individual conscience. You are not competing with 
anybody but yourself." 

The ethical ideal is a variable thing. Not many ap- 
proach the ethical ideal of the early Christian martyrs. 
The ethics of the Hottentots differs from that of the 
North American Indians. The ideal of ethics is a per- 
sonal, an individual ideal, and largely a matter of edu- 
cation. Its mandates will be followed, therefore, solely 
in accordance with the view the individual conscience 
takes. Another may consider wrong what I consider 
right, and vice versa, and each will act accordingly. 
One may consider it wrong to take a patient from an- 
other physician ; the other, reasoning from another 
standpoint, may consider it quite legitimate ; for it is 
solely a question of personal competition. Each will 
act, therefore, in accordance with his own particular view 
of the ethics of the case. If by so doing one injures him- 
self, that is all right, he then has only himself to blame ; 
but if by his act he injures the other he should be pun- 
ished, and the question ceases to be one of pure ethics, 
and becomes one of law. And that is my contention — 
that the Code of Ethics, to be effective, should be made 
after the manner of a law, with penalties attached ; for 
as a mere expression of ethics it loses its force, as 
ethical questions are, to a large extent, controversial. 
The field of ethics is a broad one, and ranges all the 
way from the law of self-preservation at its lowest point 
to heroism and martyrdom at its highest. A child is 
caught in a burning house ; two men with their families 
stand outside. It is certain death to enter the house and 
try to rescue the child. One man says, " I will not go ; 
my family and my own little ones are dependent upon 
me and are first in importance to me." (Law of self- 



78 



AMERICAN LARYNGOLOGICAL ASSOCIATION. 



[Medical News 



preservation.) The other man says, " I will go in and 
try to save the child." (Heroism.) He is killed. 
Which was the better ethically ? Was not each right, 
reasoning from his individual standpoint ? 

We admire the hero, but we are not justified in de- 
spising the other. One soldier leaves all and rushes to 
death in battle (admirable) ; another thinks of his home 
and its need of him (I am not referring to the personal 
coward who merely runs on account of personal fear) 
and sends a substitute to the front (not very admirable, 
but certainly not despicable, either). Both soldiers may 
be entirely right ; but if the government really wants the 
second man to fight for it, the question is taken out of 
the sphere of controversial ethics and lifted into that of 
law ; the man is compelled to go to the front or be se- 
verelv punished in some way. 

I shall not even speak of rehgion and its tenets ; that 
is so absolutely a matter of private opinion that I never 
for one moment suspected anyone of imagining that 
religious truths and beliefs were to be compared with 
any human code. Religion is a matter between a man 
and his Creator ; the Code of Ethics is a rule of expe- 
diency between men. Pray, where does competition 
enter in a man's religion ? A Jew and Gentile may live 
most amicably together, but in their bartering (compe- 
tition) they may wrangle like the Kilkenny cats. 

As an admirer of the Code of Ethics, I do wish it 
were discussed more intelligently and practically by its 
staunch supporters. As a pretty piece of ethical writ- 
ing, it is all right ; as an effective rule for the profession, 
it is valueless for the reasons given. 

Sincerely yours, M. 



LAW FOR THE PKEV ENTION OF OPHTHALMIA 
NEON A T DRUM. 

To the Editor of The Medical News, 

Sir : In view of the recent attempt of the Legislature of 
Pennsylvania to meet the wishes of many physicians by 
passing a law protecting professional confidences of 
medical men, readers of The News note with interest 
what it has done for those who desired legislation to 
combat the ravages of ophthalmia neonatorum. 

The law on the subject just passed and printed in 
The Medical News, July 13, p. 55, contains several 
blunders which prevented its indorsement by the 
CoUege of Physicians of Philadelphia, after it had been 
fully discussed by both the Council and the College, 
and which should have been eliminated before the bill 
was passed. The omission from Section i of the (prob- 
ably intended) article "a" before the words " legally 
qualified practioner " [sic, in the copy of the law sent 
out from the State Department — practitioner evidently 
meant) robs part of the law of its obvious significance. 
Then the duty of notification in writing is put upon a 
" midwife or nurse or other person.'' This might mean 
a bed-ridden mother with only a neighbor to help her, 
and it is rather hard on those who cannot write. 

Sections 2 and 3 are probably inoperative because no 
money-provision is made for carrying out their man- 
dates. If operative, they are otherwise defective, for 
Section i does not fix a time within which the Health- 
officer shall do what he is commanded (the word imme- 
diately being too vague) ; and Section 3 commands the 
Health-officer to furnish copies of the Act to those who 



are " known to him " to act as midwives or nurses — and 
how may that be ascertained, in case complaint were 
lodged against him for neglecting his duty ? Then, again, 
how much time has he to do this in ? And, finally, when 
a Health-officer sends out his " directions for the proper 
treatment " of ophthalmia neonatorum, shall he give the 
treatment rationally, or homeopathically, or eclectically, 
or hydropathically, or physio-medically ? or will faith- 
cure or Christian science teachings stand for a dis- 
charge of his duty ? or must he furnish all methods, and 
let each " midwife or nurse or other person " select ? 

It is a pity, after all the effort made by those who 
would check the progress of ophthalmia neonatorum, 
and all the resolutions of County and State Medical 
Societies, that they should get nothing from the Legis- 
lature more plain, practical, and effective than this law. 
Yours truly, 

Charles W. Dulles. 

SOCIETY PROCEEDINGS. 

AMERICAN LARYNGOLOGICAL ASSOCIATION. 

Seventeenth Annual Meetim;, held at Rochester, X. Y., 
June ly, 18, and ig, iSqj. 

(CoDCluded from page 55.) 

Third Day — June iqth. 

Dr. T. Morris Murray, of Washington, continued 
the discussion on " Tuberculosis of the Upper Air- 
passages." He related that his experience with lactic 
acid in the treatment of laryngeal and phar)ngeal ulcer- 
ation had been on the whole disappointing, though good 
results were occasionally observed. One case had re- 
mained healed for five years. 

Dr. Ingals thought that in an equal number of cases 
operated on and not operated on, the latter would show 
more cures, presupposing the usual topical treatment. 
He has seen ulcerations heal under lactic acid without 
curetting. It is of doubtful propriety to cut away large 
masses of tissue when there is deep infiltration. lodin 
trichlorid has been of great value, used in a solution of 
gr. i-ij to the ounce. Cocain depresses the ner\-ous 
system, and he prefers a mixture of tannic and carbolic 
acids with morphin. 

Dr. Daly had obtained the best results with iodo- 
form, with which he saturates the patient, using also 
creosote in large doses, and inhalations, together with 
special attention to the diet. 

Dr. Wright expressed skepticism as to the possi- 
bility of cunng laryngeal tuberculosis. Of course cases 
will occasionally heal under curetting and lactic acid. 
He thought that too much attention had been given to 
one single etiologic factor. The disease may cause no 
symptoms whatever, even when the deeper parts ate 
involved. The cases reported cured have been in the 
first stages of the disease. 

Dr. Shurly added that he had used Dr. Ingals' 
sedative formula, but had had great difficulty in making a 
permanent solution of its different ingredients. He 
therefore used them separately. Creosote is a good dis- 
infectant, but he has been disappointed in the results 
from its internal administration. He could not see how 
it was of any use to curet a few ulcerations when there 
were others present in accessible localities. 



July 20, 1S95] 



AMERICAN LARYNGOLOGICAL ASSOCIATION. 



79 



Dr. a. B. Thrasher, of Cincinnati, read a paper on 

NECROSIS OF THE MIDDLE TURBIN.^TE. 

He said that while the lower turbinate was more fre- 
quently inflamed in acute rhinitis than the middle, the 
position of the latter with reference to the orifices of all 
the accessory sinuses was such that they were easily 
closed up when the bone became inflamed and their 
mucous contents became purulent. 

Ethmoiditis is a frequent disease, but middle-turbinate 
necrosis is rare ; although there is no a priori reason for 
this rarity. Given a case of ethmoiditis and a polyp 
springing from under the middle turbinate, the condi- 
tions are certainly favorable for the development of 
necrosis of the latter structure. On the other hand, it is 
possible that a polyp may spring from a membrane 
bathed in the purulent discharge of an ethmoiditis. The 
same conditions may be observed in connection with 
aural polypi developing in the course of a purulent otitis 
media. 

Dr. Thrasher narrated the case of a woman who a 
year after an attack of influenza presented severe pain 
on the left side of the (slightly swollen) nose, radiating 
over the side of the face and head, with constant but 
regular exacerbations. There was an offensive dis- 
charge, and the anterior extremity of the left middle 
turnbinate pressed upon the septum and upon the 
lower turbinate. On removal of the middle turbinate 
with the cold snare dead bone was exposed. The ad- 
jacent ethmoid cells were curetted and there was no re- 
currence in four years. A second case was observed in 
a man, twenty-six years old, who had suffered for two 
years with neuralgia in the right supra-orbital and 
infra-orbital regions. The right middle turbinate ap- 
peared as a large rounded mass, filling up the middle 
meatus and pushing out the outer wall of the nose. On 
attempting to remove the whole mass a large open cavity 
was crushed into and fragments of necrosed bone were 
removed. 

The general symptoms of the condition are : i, pain, 
referred to the orbit or above or below, and sometimes 
to the ear ; 2, discharge, often offensive ; 3, nasal obstruc- 
tion and anosmia, but it must be remembered that the 
breathing is sometimes unimpeded even in severe dis- 
ease of the middle turbinate ; 4, obstruction of the 
mouths of all the accessory sinuses ; 5, external deform- 
ity ; 6, various reflex disturbances. 

In mild cases alkaline sprays, cocain, scarification, 
and, if necessary, incision are employed. In older cases 
the cold snare, trephine, drill, or saw-tooth scissors may 
be required. Prompt removal of the oftending tissue is 
to be advocated. 

Dr. Thrasher also related the history of a case of 

CONGENITAL OSSEOUS STE.N'OSIS OF THE NARIS. 

The patient, a male child, aged eighteen months, was 
well nourished, but a mouth-breather. There was a 
muco-purulent discharge from the right nostril. Adenoids 
in the vault of the pharynx were removed under chloro- 
form. A probe passed through the right nostril struck 
an obstacle just before reaching the finger in the naso- 
pharynx. No opening could be found through it ; but 
pressure with a nasal curet easily broke through. It 
seemed to be a thin web of bone, thicker at the septum, 



running across and thinning out just opposite the tur- 
binate bone on the lateral wall. 

Dr. L. W. Langmaid, of Boston, said that he had 
seen three cases of congenital nasal occlusion. Such 
noses are incapacitated for immediate performance of 
physiologic function after operation. Hence mouth- 
breathing is likely to continue for a certain length of 
time. 

Dr. Ingals remarked that many cases of adenoids 
presented partial closure of the posterior nares, and in 
every operation he makes it a point to ascertain the 
potency of the nares by passing a probe back into the 
naso-pharynx before the patient emerges from the anes- 
thesia. 

Dr. Jonathan Wright, of Brooklyn, read a paper 
on 

CYSTS OF the NASO PHARYNX AND ORO-PHARYNX AND 
FIBROMA PAPILLARE OF THE NASAL SEPTUM. 

He contended that cysts of the naso-pharynx and 
sinuses of its mucosa are very rare. The pharj^ngeal 
"bursa" is not a normal occurrence. It and the cysts 
result from the agglutination of the folds and projections 
of the membrane, as these latter occur in infancy. 
Hence a partially or completely closed cavity results, 
from which drops out mucus or which is gradually dis- 
tended. Transverse section through the folds of the 
na3o-phar)'ngeal mucosa of a newborn child discloses 
oblong spaces in the lymphoid or connective tissue, or 
just at their junction. These spaces, presumably lymph- 
spaces, are lined by a single layer of endothelial cells, 
and it is probable that cysts can arise from their gradual 
dilatation. Dr. Wright related the case of a woman, 
aged twenty-eight years, who had complained of nasal 
obstruction for seven years. A soft pedunculated freely 
movable vascular mass presented in the left nostril in 
front, and was removed with the cold-wire snare with 
only moderate hemorrhage. It was attached to the 
upper part of the cartilaginous septum, about 2 cm. 
behind the columna. This site coincides with an area 
subjected to the attrition of the upper end of the tri- 
angular cartilage forming the ridge known as the " plica 
vestibuli." In this case it rubbed against the septum, 
when the lower edge of the triangular cartilage was 
rolled out by muscular action in the dilatation of the 
ala nasi during inspiration. The base was cauterized, 
and in nine months there had been no recurrence. 

Dr. Newcomb stated that he had recently removed a 
similar formation with the cold snare, and without hem- 
orrhage. There was still a mass in situ, and presumably 
he had a mukilocular condition to deal with. 

Dr. Langjiaid had recently seen a naso-pharyngeal 
cyst the attachments of which were such as to forbid 
the use of the wire snare. It was accordingly removed 
by avulsion. When recurrence occurs in these cases, it 
is possible that the cyst-wall has not been thoroughly 
extirpated. 

Dr. W. H. Daly, of Pittsburg, opened the discussion 
upon the 

relation OF VASO.MOTOR DISTURBANCES TO DISEASES 
OF THE UPPER AIR TRACT. 

He pointed out that the nasal mucosa may be pallid 
and permit a leakage of serum. His own cases showed 
cures by intra-nasal operation in 63 per cent, of catarrhal 



PHILADELPHIA ACADEMY OF SURGERY. 



[Medical News 



and hay-fever asthmas, and 40 per cent, of the spasmodic 
variety. His general conclusions were : i. Abnormal 
disturbances of vasomotor origin may be primary or 
secondary. 2. Both may be coactive and progressive. 
3. The surest and quickest relief comes in those cases 
in which surgical interference finds its proper election. 

Dr. Mulhall remarked that there is a pallid as well 
as a turgescent variety of nasal vasomotor disturbances, 
just as some people get white and others red when angry. 
The mode of living has much to do with the production 
of these conditions. Proper diet and exercise will do 
much to relieve them. Dr. Mulhall advocated daily 
cold-water frictions, mild galvanism, atropin, gr. yi^j, 
on rising, and one-drop doses of liquor potassii arsen- 
itis after meals. 

Dr. Simpson thought that if patients were examined 
more carefully it would be found in most instances that 
the cause of disturbances in the upper air-passages lay 
very near the seat of the disease to be treated, instead of 
being a so-called " reflex." 

Dr. J. C. Mulhall, of St. Louis, read a paper en- 
titled 

THE CIGARET-HAIilT. 

He said that the smoker, chewer, and snuff-taker all 
experience a different kind of satisfaction from their re- 
spective habits. The cigarjtsmoker soon becomes an 
inhaler. The smoker of a cigar or pipe rarely in- 
hales. The smoke probably does not enter below the 
first division of the bronchi, and not the lungs proper. 
A cigaret either stronger or milder than the one gen- 
erally used does not give the customary satisfaction to 
the tracheal and laryngeal mucosa. The effect of in- 
halation is really a pleasurable excitation of the laryngeal 
and tracheal filaments of the pneumogastric nerves. 
The amount of absorption from smoke varies, of course, 
according to the extent of surface, and it has been esti- 
mated that in inhalers this surface is three times as large 
as in non-inhalers. The frequency and ease with which 
cigarets can be smoked very properly leads to the desig- 
nation of the habit as " deadly." Moreover, the small 
amount and frequency of tobacco-consumption are 
analogous to the effects of giving a certain amount of 
drug in divided doses. 

The evils of cigaret-smoking are local and constitu- 
tional. The latter are identical with those of all forms 
of tobacco, always nicotinism in greater or less degree. 
In the young these evils are very great. Cigarets are so 
cheap that they may be said to teach the use of tobacco. 
The first cigaret never nauseates, as does the first cigar. 

Locally, cigarets may aggravate a previously existing 
condition, but they do not originate any throat-disease 
worthy of the name. The most that results is a mild 
hyperemia, or even a slight catarrh, with the ejection by 
a single effort of pearly whitish masses. Occasionally 
a few rales, wholly bronchial, are heard. The murderer 
Maxwell inhaled forty cigarets daily, and, while he was 
a total wreck as to his nervous system, he had no laryn- 
geal or tracheal disease, as was determined by post- 
mortem examination. 

Dr. Ingals took issue as to the harmlessness of 
tobacco on the throat. He has seen pronounced tracheal 
cough from its use. 

Dr. Carl Seiler, of Philadelphia, stated that smok- 
ing is harmless if the patient does not spit, and thus 
keep up an abnormal dryness of the pharynx. 



Dr. Langmaid regarded the greatest bad effect of 
tobacco on the young to be its power of destroying con- 
secutive thought. Pipe-smoking is not so harmless as 
is generally supposed, owing to the heat of the stem, 
which is kept up by the relatively large mass of fire in 
the bowl. 

The following papers were read by title : 

CVST OF THE MAXILLARY SIXUS, 

by Dr. Charles H. Knight, of New York; 

PEMPHIGUS OF THE PHARYNX AND LARYNX, 

by Dr. H. R. Brown, of Chicago ; 

COMPENSATORY ARYTENOID MOVEMENT, 

by Dr. William Porter, of St. Louis ; 

A STUDY IN DIPHTHERIA, 

by Dr. S. Hartwell Chapman, of New Haven. 

In executive session the following gentlemen were 
elected to active Fellowship, their theses being respec- 
tively as follows : Dr. Thomas Hubbard, of Cleveland, 
" Treatment of Acute Laryngitis ;" Dr. J. E. H. Nichols, 
of New York, " Intra-nasal Causes of Headache;" Dr. 
J. E, Boylan, of Cincinnati, " Herpes Chronica Pharyn- 
gitis;" Dr. F. E. Hopkins, of New York, "Edema of 
the Larynx, with report of a Case." 

The election of officers for the ensuing year resulted 
in the choice of Dr. W. H. Daly, of Pittsburg, for 
President, and Dr. H. L. Swaix, of New Haven, for 
Secretary. The next meeting will be in Pittsburg in 
!Su6, the exact date to be determined bv the Council. 



PHILADELPHIA ACAD EMY OF SURGERY. 

Stalfd Meeting, June j, /Sqj. 

The President, Dr. Thomas G. Morton, in the chair. 
Dr. a. Hewson exhibited several instruments. 

I. A DIVIDED spring FOR HEAVY BONE-CUTTING 
FORCEPS. 

The forceps presented has been used in four laminec- 
tomies with very great success, the ease with which the 
spinous processes and the lamina: were cut having been 
remarkable. The forceps is of the general style of the 
costatome, and, in addition to the purpose already men- 
tioned, it is useful for cutting off plaster bandages. 
The blades, are set at an obtuse angle to the handles so 
as to facilitate cutting the lamina;. The upper cutting- 
blade is serrated like the teeth of a saw. The lower, 
which is also a cutting-blade, has at its extremity a hor- 
izontal projection, similar to that on the bandage-shears, 
which is to be inserted beneath the lamina; and serves 
to keep the blade in position while cutting the bone. 
The handles are much longer, to give greater leverage. 
The new point to which attention was directed is the 
divided spring. All the other instruments of this kind 
are provided with a single spring, which keeps the 
blades apart. In this instrument the spring is divided 
so that it can be turned back when not in use, and when 
extended we get the full power of the spring to open the 
blades. It is useful upon both the living and the dead 
body. It greatly facilitates opening the spinal column 
for removing the cord, and for this purpose is much 
better than the spinal saw. 



July 20, 1S95] 



PHILADELPHIA ACADEMY OF SURGERY. 



81 



11. PORTABLE LIGATURE-TUBE HOLDER. 

This holder resembles a gigantic test-tube holder, 
made of sheet iron, painted white. It consists of two 
uprights and three shelves. The uprights are g}( x 45^5 
inches, having three hollow blocks, lyi x J^ x )4 inches, 
placed on the inside at the base 2}4 and S^i inches there- 
from, leaving one inch above the top shelf. The three 
shelves are i3fVxi4j\ inches. The first, or upper 
shelf, has five holes for ligature-tubes, i J-z inches in 
diameter. The second, or middle shelf, has the same 
number of holes, i ]:( inches in diameter. The third, or 
bottom, is without holes. The difference in diameter of 
these holes gives equilibrium to the tubes when in place. 
On the under surface of each shelf at the extremity 
is a block with a projection which fits into the hollow 
block of the uprights. These blocks are opposite to 
those on the uprights, so that the projections may be 
pushed in when the holder is ready for use. The space 
occupied by the whole when apart is 13/ijx 4j% x i_5^ 
inches, and weighs in its present crude form eight 
pounds. 

When in use the corks of the tubes are removed and 
placed in a proper antiseptic solution and the orifice of 
each tube is covered with mercuric-chlorid gauze. The 
assistant removes the ligature as required with a pair of 
forceps, so that it passes directly from the solution to the 
hand of the operator without handling. This mode of 
procedure has been in operation at the Jefferson College 
Hospital for two years past, and has given great satis- 
faction. The original thought of this mode of handling 
ligatures was brought about by having each ligature in 
a separate tube, but this was found to be a cause of in- 
fection, as it was impossible to insure the aseptic condi- 
tion of a fine glass tube for each ligature; and too much 
time was consumed in the preparation of such tubes. 

III. SET OF ANATOMIC INSTRUMENTS. 

This set of anatomic instruments is of interest from a 
historic standpoint of view, as it contains a syringe for 
fine injection of lymphatic vessels, used by William 
Hewson, F.R.S., in 176S, in his preparations. This 
brass syringe is in a perfect state of preservation, with 
four gold-pointed nozzles. It has been recently used in 
preparing fine injections of the lymphatics, as in that 
exhibited to the Academy about a year ago. The large 
brass syringe was used by the late Addinell Hewson, in 
his preparations during his student days, and by means of 
which, with the various attachments, he prepared sub- 
jects for fine dissection. The sternum-dilator gives the 
greatest width possible for aortic injection (6x8 inches). 
In making tallow-and-soap-injections it has been found 
that veins injected from the heart will hold one-quarter 
more material than the arteries injected by the aorta, 
and still some of the cutaneous veins of the extremities 
will not be filled owing to their finer valves. In intro- 
ducing the preservative fluid the hydrostatic method is 
used, the subjects taking from three to five gallons of 
fluid. The saw is the ordinary fine carpenter's pattern, 
with an upright handle about three inches from its 
extremity on the upper mar.Lrin. The cutting-edge 
has been lunated anteriorly, while the posterior or 
handle extremity is at right angles. This is a modifica- 
tion of the Forbes' saw, the cutting-edge of which is 
lunated. The object attained by the modification is that 



it enables the instrument to be used in either sawing the 
cranial bones or the lamina, which is not the case with 
the entirely lunated margin. The forceps just described 
is superior to the saw for the lamin;e, giving greater 
space and more rapidity of action, besides avoiding all 
risk of injury to the spinal nerves. The case contains, 
in addition, spaces for two balls of twine (large and 
small). Hay's saw, enterotome, brain-knife, blowpipe, 
hammer, chisel, large incision-knife, student's dissec- 
tion-case with its accompaniments, and stopcock-pipes 
of various sizes for immediate introduction into the 
vessels. 

Dr. Charles W. Dulles made some 

REMARKS ON FRACTURES OF THE SKULL. 

He called attention to a point in regard to fractures 
of the skull that he believed does not receive in this 
country, or anywhere except in Germany and Russia, 
the attention that it deserves, /. <?., the mechanism ot 
indirect fractures. This has much more than a purely 
scientific interest ; it may be an important factor in our 
application of the art of surgery as well. Reference was 
made to a paper,' read eight years ago, in which was 
oxpounded, the theory known as the " bursting-theory,'' 
of indirect fractures. 

The bursting-theory of indirect fractures of the skull 
may be invoked to clear up many difficulties of diag- 
nosis in fractures of the skull, and should invariably be 
invoked before conclusions of a medico-legal character 
are reached. 

Both in the living and in the dead the application of 
the "bursting-theory" has furnished very instructive 
suggestions in regard to the diagnosis of accidents to the 
skull, making them much clearer and the treatment 
much more satisfactory. An appreciation of the burst- 
ing-theory also often clears up the perplexities of cases 
in which, without detectable fracture of the skull, there 
is found a rupture of bloodvessels and hemorrhage 
within the cavity of the skull, either extra-dural or intra- 
dural. 

Briefly stated, the bursting-theory may be outlined as 
follows : The skull is a hollow case, of a somewhat 
ellipsoid form, the wall of which is formed of bone, 
varying in thickness and density in difterent parts, and 
of a peculiar conformation, and with peculiar contents 
and coverings. When such a case is struck, or when it 
strikes upon a resisting body, it is compressed in a direc- 
tion in the line of the force and counter-pressure (which 
latter may depend wholly on vis i>ie7-ii(E). The result of 
this compression is to shorten the prime diameter, and 
of necessity to lengthen the transverse diameters. As 
illustrating this first phase of action. Sir Charles Bell, in 
the early part ot this century, made an experiment 
(which it is easy to repeat), in which he placed movable 
balls inside and outside of a hoop and touching it, and 
found that a blow upon any part of the hoop caused the 
ball immediately under it and that immediately opposite 
it to move toward the center of the hoop, while those 
distant ninety degrees from it moved away from the 
hoop. If this experiment were to be modified so as to 
meet the conditions of a hollow sphere instead of a cir- 
cle, we might place half of a hollow sphere upon a re- 
sisting surface, and striking it on the upper pole would 



' Tr.-ins. Coll. of Phys. of Philadelphia, iSS'i 



82 



PHILADELPHIA ACADEMY OF SURGERY. 



[Medical News 



find that this pole would approach the resisting surface 
and the circumference would be elongated and describe 
a larger circle. In such an experiment, made upon an 
elastic substance, the compression and elongation would 
be followed by a corresponding expansion and shorten- 
ing. The first compression and elongation spoken of 
are of the chief importance in indirect fractures of the 
skull, and in them we have (to use a simple illustration) 
conditions similar to those when an umbrella is raised. 
In the latter case it is plainly seen what takes place, 
namely, that, as the pole is brought nearer to the equa- 
tor, this is elongated and the space between the merid- 
ians (the ribs of the umbrella) is increased. This in- 
crease being expected and provided for by material 
which lies in folds between the meridians, this is simply 
spread out. In a body with no such provision, how- 
ever, any force that would bring its poles near together, 
and consequently lengthen its equatorial circumference 
and separate its meridians, would at once set up a strug- 
gle between the force applied and the cohesion of the 
particles lying along and between the meridians. If the 
power of cohesion were sufficient, there would be no dis- 
ruption ; if, however, it were not, then there would be a 
split beginning at some point near the equator, where 
the strain is most severe, and passing in opposite direc- 
tions toward the poles. This is what would take place 
in a perfectly symmetric homogeneous elastic body. 
What naturally takes place in the skull is shown by 
observation and experiment to be this, modified by the 
peculiar structure, formation, contents, and surroundings 
of the skull. 

This is what is known as the " bursting-theory," and 
its bearing upon practice wdl be appreciated by those 
who apply it. It provides the surgeon — not with cer- 
tainty of diagnosis, but with suggestions of probability, 
which will increase his chances of making a reliable 
diagnosis. The inferences from it, which are of a prac- 
tical nature, as are follows : Force applied to the skull, of 
sufificient violence and rapidity of action, will produce 
what is known as a direct fracture — a fracture at a point 
where the violence was applied. In these cases the 
rapidity of action is a very important element, as it is a 
well-known fact in physics that time enables cohesion 
to resist a disruptive violence, which, if instantaneously 
applied, would at once overcome cohesion. Force less 
sudden and less extreme applied to the skull will bring 
actively into play the elastic properties of the skull, and 
if violent enough will lead to a fissure at some distance 
from the point at which the violence was applied, and 
usually in a line meridional to the point where the force 
was applied. Study of a large number of accidental and 
experimental fissures indicates that blows upon the fore- 
head directly in the middle line are likely to produce a 
fissure of the skull, passing from front to back in or near 
the middle line, and more frequently at the base of the 
skull than in the vault. Blows applied to the forehead 
on one side or the other are hkely to produce fissures in 
a line with the direction of the force, and crossing the 
skull to the other side. Such fissures occur almost 
always at the base, and they usually terminate in the 
middle cerebral fossa, though they sometimes cross the 
foramen magnum and traverse the cerebellar and pos- 
terior cerebral fossae. Force applied to the middle of 
the occiput usually produces a fissure passing in the 
direction of the force around the occiput, laterally or 



perpendicularly, sometimes separating the lambdoid 
suture, sometimes splitting the lower part of the occip- 
ital bone and going into the foramen magnum, and 
sometimes crossing the petrous bone, breaking it trans- 
versely and passing into the foramen lacerum medius. 
Such fissures may pass straight down to the foramen 
magnum and (crossing over) split the body of the sphe- 
noid bone and extend into the ethmoid or frontal bone. 
(Such fissures furnish typical illustrations of the correct- 
ness of the bursting-theory.) Force applied to the side 
of the head, in almost all cases, produces a fissure pass- 
ing through the base of the skull in the middle cerebral 
fossa. Such a fissure sometimes traverses this fossa 
completely and may pass completely through the base 
and vault, dividing the skull into two halves. In some 
cases the fissure passes directly through the coronal 
suture ; in many cases it splits the petrous bone longi- 
tudinally. In some cases force applied to the side of 
the head causes a splitting off of the posterior clinoid 
processes — an occurrence that is explicable only upon 
the supposition that the tentorium cerebelli, which is 
attached here and to the occipital bone, is put upon the 
stretch when the skull is elongated antero-posteriorly 
and drags these portions from the body of the sphenoid. 
Force applied to the side of the head frequently pro- 
duces fissures passing around the side of the head, 
through the parietal and squamous bones, and often 
passing to the basi-sphenoid, but rarely dividing it com- 
pletely. In some cases force applied directly to the 
vertex produces a fissure in the long axis of the skull. 
Such a fissure may be of very great extent and may even 
divide a skull into two symmetric halves. Longitud- 
inal (antero-posterior) fissures occur more frequently 
at the base of the skull than at the vault. 

An interesting form of violence, applied to the skull, 
is that due to falls upon the feet, where the momentum 
of the body is suddenly arrested by the resistance of the 
earth. In such a case a ring of bone surrounding the 
condyles may be driven into the skull, or — as observa- 
tion and experiment show — the process of the sphenoid 
bearing the posterior clinoid processes may be broken 
off by the pull of the tentorium cerebelli, when momen- 
tum and resistance lessen the diameter from condyles to 
vertex and lengthen the diameter from occiput to 
sinciput. 

There are fractures that cannot be accounted for by 
the bursting-theory. There are some fractures in which 
the force applied is so great and acts in such a manner 
that the skull is crushed so as to hide any evidence of 
the play of its elastic properties, the fracture being of a 
comminuted sort ; and there are others in which one 
segment of the skull seems to be shoved over the other 
by forces of pressure and counter-pressure which require 
some study before their mode of operation can be under- 
stood. For this reason it is of importance to learn in 
every case the position which the skull has held in rela- 
tion to the spinal column or to any body capable of 
exerting counter-pressure. No less is it important not 
to overlook the counter-pressure that is caused by the 
simple -c'l's incrtiic of the skull and its contents. 

The conviction was expressed that the supreme law 
governing the production of indirect fractures is that 
which depends upon the fact that the skull is practically 
a hollow elastic case approximately oval in shape, and 
which may be briefly formulated as follows : When a 



July 20, 1895] 



NEWS ITEMS 



83 



sufficient force is applied to any curvilinear part of the 
skull, if this part do not give way immediately, the axis 
of the skull lying in the same line as that of the applied 
force is shortened, and all the axes lying in planes at 
right angles to this line are correspondingly lengthened, 
with a proportional lengthening of their circumferences 
and separation of their meridians, so that the direct de- 
pressing force is converted into an indirect disruptive 
force acting at right angles to the direction of the former. 
The etlect is to produce a fissure or fissures which will 
have a general meridional direction. 

The application of this law is subject to certain mod- 
ifications due to anatomic and architectonic peculiarities 
of the skull, its coverings and contents, and to certain 
exceptions due to the amount and velocity of the force 
applied as well as the coming into play of peculiar 
counter-forces. 

DISCUSSION. 

The President asked if the alteration in the con- 
formation of the skull, the shortening of the axis in the 
direction of the applied force, and the lengthening of 
the transverse axes had been accurately determined by 
measurement. 

Dr. Dulles replied that the alteration had been 
carefully measured, and there was an appreciable dif- 
ference, the amount of which is mentioned in the earlier 
paper. 

Dr. Hewso.v asked if, in connection with the remarks 
upon the fractures of the clinoid processes, the fact had 
been taken into consideration of the difference in the 
height of the free concave margin and anterior attached 
extremities to the posterior clinoid processes ? Owing 
to this, the portion of the tentorium open for the passage 
of the nervous substance is triangular, with curved sides, 
and this is much higher than its attached anterior ex- 
tremities to the posterior clinoid processes. The direc- 
tion of the free margin of the tentorium is pointed 
upward over the superior vermiform process of the cere- 
bellum, this margin being higher than its anterior 
attachment. It was also asked if the direction of the 
traction upon the posterior clinoid processes contributes 
anything to the fracture ? Has any laceration of the 
margins of this opening been observed ? 

Dr. Dulles said that whether or not the posterior 
clinoid processes are higher than the arch of the tento- 
rium depends much on the way in which the skull is 
held. Under ordinary circumstances, when the head is 
held erect, they are about on the same level. 

Dr. Hewson said that the tentorium arches upward. 

Dr. Dulles added that he had not overlooked this 
fact in his study of fractures of the skull. Under ordi- 
nary circumstances the curve of the tentorium would 
supply an amount of slack material which would pre- 
vent any pull on the clinoid processes. But it must be 
remembered that the tentorium rests upon the cerebel- 
lum and is held tense by the falx cerebri above the 
cerebellum, and is so attached that the latter occupies a 
closed, unyielding case. The brain-substance is so largely 
made up of water that it is almost as incompressible as 
water [which is practically entirely incompressible], and 
the cerebellum will hold up the tentorium almost as 
effectually as if it were made of marble, and so cause a 
pull at its posterior part to be transmitted to its anterior 
attachments. 



NEWS ITEMS. 

The Third International Congress of Physiologists will 
be held at Berne, from September 9 to 13, 1895. 
Membership of the Congress shall be open to all pro- 
fessors and teachers of biologic science, belonging to 
a medical faculty or any other similar scientific body, 
as well as to all scientific men engaged in biologic 
research. 

The sessions of the Congress shall be devoted 
to physiologic communications and demonstrations. 
Further, communications relating to original research 
in anatomy, general pathology, and pharmacology 
are acceptable in so far as they present features of gen- 
eral biologic interest. 

It is desirable to keep the communications as far 
as possible demonstrational and experimental in char- 
acter. 

The languages recognized as official at the Congress 
are English, French, and German. 

Each person who makes a communication shall sign 
the protocol of his own communication. 

The length of a communication may not exceed fifteen 
minutes. 

The press shall not be officially admitted to the Con- 
gress ; each member is free to send private communica- 
tions to scientific journals. 

Professor Kronecker, Director of the Physiological In- 
stitute of the University of Berne, has kindly expressed 
his readiness to afford to members of the Congress all 
facilities for demonstration and experiment, as well as 
for the exhibition of scientific apparatus. 

In connection with the Congress, an exhibition of 
physiologic apparatus will be held. Exhibits may be 
contributed by all members of the Congress, by the 
directors of physiologic laboratories, and by makers 
recommended by any member of the Congress, or by 
the director of a physiologic laboratory. The exhibi- 
tion of apparatus will open two days before the Congress, 
and will close two days after the Congress. 

Those intending to be present should kindly notify 
their acceptance, and, if possible, the title of their com- 
munications, either to Professor Hugo Kronecker, Berne, 
or to C. S. Sherrington, General Secretary for the 
English Language, 27 St. George's Square, S. W. 
London. 

Titles of communications may also be sent to Frederick 
S. Lee, Secretary of the American Physiological So- 
ciety, Columbia College, New York Citj'. 



Hospitals for Tuberculosis. — At the recent meeting of 
the American Climatological Association the following 
preamble and resolution were unanimously adopted : 

Whereas, Since tuberculosis has been demonstrated 
to be a communicable disease, it has become doubly de- 
sirable that hospitals for the reception of the poor afflicted 
with this disease should be established, 

Resolved, That the American Climatological Associ- 
ation recommend the estabhshment of such hospitals in 
every State, not only for the relief of the great suffering 
attending this disease among the poor, but also as a 
protection of the community against its spread. 



84 



NEWS ITEMS. 



[Medical News 



Relative Standing of the Graduates of tfie Various Medical 
Colleges, examined by the State Board of Medical Ex- 
aminers representing the Medical Society of the State 
of Pennsylvania, June 18-21, 1S95: 



Medical College from which applicant 
graduated. 


No. 
ined. 


No. 
failed. 


Per ct. 

of 
failures 


Aver, 
grade. 


University of Pennsylvania . . . 
Jefferson Medical College . . . 
Medico-Chirurgical Coll., Phila. . 
Western Pennsylvania, Pittsburg . 
Baltimore Medical College . . . 
Coll. of Phys. and Surg., Baltimore 
Woman's Med. Coll., Philadelphia 
Miscellaneous Colleges .... 


136 
65 
41 
61 
4 
24 

25 

33 


I 
3 
5 
9 
I 
6 
7 
9 


0.73 
4.68 
12.19 
14.92 
25.00 
25.00 
26.92 
27.27 


86.41 
85.28 
80.65 
80.68 
81.58 
81.00 
80.01 
79.16 


Total 


390 


41 


10.48 


83-83 



Highest average obtained 94.86 

The Fifth International Congress of Otology will be held at 
Florence, Italy, from September 23d to 26th, The Com- 
mittee of Organization includes the following American 
names : Drs. C. J. Blake and Orne Green, of Boston ; 
A. H. Buck, H. Knapp, and St. John Roosa, of New 
York ; C. H. Burnett and Laurence Turnbull, of Phila- 
delphia. 

Dr. Bransford Lewis, of St. Louis, has resigned his po- 
sition in the Missouri Medical College, and has been 
elected Professor of Genito-urinary Surgery in the Col- 
lege of Physicians and Surgeons, and Genito-urinary 
Surgeon to the Baptist Hospital. 

For the Report of the Trial of Amick vs. Reeves we have 
received, additionally, from Drs. John Elfers Si, C. R. 
Pickering $1, E. Kush $1. P. M. Jones $1, W. Osier $10. 
Dr. Reeves has received besides from Drs. J. T. Whit- 
taker $5, S. Solis-Cohen $2.50. 



BOOKS AND PAMPHLETS RECEIVED. 

Vaginal Extirpation of the Uterus and Adnexa in Pelvic Sup- 
puration and Septic Puerperal Metritis and Peritonitis. By H. 
J. Boldt, M.D. Reprinted from the American Journal of Ob- 
stetrics and Diseases of Women and Children, 1895. 

Second Annual Report of the Chester Hospital, with a List of 
Contributors and Donations, and President's Annual Report. 
From October i, 1893, to October i, 1894. 

Materia Medica and Therapeutics. By John B. Biddle, M.D. 
Thirteenth edition, revised, rearranged, and enlarged. By 
Clement Biddle, M.D. Philadelphia : P. Blakiston, Son & Co., 
1895. 

Annual Report of the Health Officer of the Port of New York 
for the Year 1893. Albany : James B. Lyon, State Printer, 1894. 

Fifteenth Annual Report of the State Hospital for the Insane, 
S. E. District of Pennsylvania, Norristown, Pa , for the Year 
ending September 30, 1894. The Hospital Printing Office, 1894. 

Clinical Gynecology, Medical and Surgical, for Students and 
Practitioners. By Eminent American Teachers. Edited by John 
M. Keating, M.D.. LL.D., and by Henry C. Coe, M.D, 
^LR.C.S. Illustrated. Philadelphia: J. B. Lippincott Com- 
pany, 1895. 

Transactions of the American Orthopedic Association. Eighth 
Session, held at Washington, D. C. May 29, 30, and .^i, 1894. 
Vol. VII. Philadelphia: Published by the Association, 1895. 

Acetanilid as an Antiseptic ; with Observations upon its Use in 



One-thousand Surgical Cases. By Thomas S. K. Morton, M.D. 
Reprinted from the Transactions of the Philadelphia County Med- 
ical Society, 1894. 

Case of Gunshot Wound of Liver and Lung. By Thomas S. 
K. Morton, M.D. Read before the Section on Surgery of the 
Philadelphia College of Physicians, 1894. 

Kocher's Method of Reducing Subcoracoid Dislocations of the 
Shoulder; with Cases of Fracture Incident to the Procedure in 
Old Displacements. By ThomasS. K. Morton, M.D. Reprinted 
from the Philadelphia Polyclinic, 1894. 

Chicago Summer School of Medicine, Chicago, 111. Spring 
and Summer Graduating Course. Co-educational. Regular 
Session, opening March 6th and closing September 4th. An- 
nouncement, 1S95. 

Tumor of the Cerebellum ; with Bulimia and Recurrent Apo- 
plectiform Seizures. By J. T. Eskridge, M.D. Reprinted from 
the Boston Medical and Surgical Journal, 1895. 

Hygiene of the Anus and Contiguous Parts. By J. Rawson 
Pennington, M.D. Reprinted from the Journal of the American 
Medical Association, 1895. 

The Importance of a Knowledge of the Diphtheria Culture- 
test. By A. P Ohlmacher, M.D. Reprinted from the Cleve- 
land Medical Gazette, 1895. 

Explanation and Demonstration of the Infiltration (Schleich) 
Method of Anesthesia. Preliminary paper, with 10 illustra- 
tions. By H. V. Wtirdemann, M.D. Reprinted from the 
Journal of the American Medical Association, 1894. 

Phenolic Substances in Tuberculosis (Nascent Phenio Acid, 
Carbolic Acid, Creosote, Guaiacol, and Benzoyl of Guaiacol). 
By Roland G. Curtin, M.D. Reprinted fom the University 
Medical Magazme, 1894. 

Mental Inhibition, or Self-control ; and its Relation to Legal 
Responsibility. The Tenth Annual Address before the Amster- 
dam Medical Society. By Charles Stover, M.D. 

Note on Hydrogen Dioxid as Furnished to Practising Dentists. 
By Henry Leffmann, M.D., D.D.S. Reprinted from the Inter- 
national Dental Journal, 1895. 

.N'otes on Movable Kidney and Nephrorrhaphy. By George 
M. Edebohls, A.M., M D. Reprinted from the American Journal 
of Obstetrics, 1895. 

The Technique of Vaginal Hysterectomy. By George M. Ede- 
bohls, A.M., M.D. Reprinted from the American Journal of the 
Medical Sciences, 1895. 

Bacteriological Study of Four Cases of Diphtheria Treated with 
Antitoxin by Dr. Louis Fischer at the Municipal Hospital, Phila- 
delphia. By D. Braden Kyle, M.D. Reprinted from the Amer- 
ican Journal of the Medical Sciences, 1895. 

Evidence of Mr. Bickerton (Liverpool), given before the Presi- 
dent of the Board of Trade, February i, 1895, on the Board of 
Trade Tests for Eyesight and Color- blndness in the Mercantile 
Marine. Pamphlet. 

Cylindroma Endothelioidcs of the Dura Mater, Causing Local- 
izing Symptoms and Early Muscular .-^trophy. By L. Bremer, 
M.D., and N. B. Carson, M.D. Reprinted from the Americari 
Journal of the Medical Sciences, 1895. 

A Peculiar Case of Esophageal Stricture Caused by a Benign 
Tumor. By Thomas Brooks, M.D. Reprinted from the Medical 
Herald, 1895. 

Dott. Filippo Rho Medico di i classe nelle Regia Marina. 
Malattie Predominant! nei paesi caldi e temperati. Supplemento 
mensile agli Annali di Medicina Navele, Anno i — Gascicolo 11,. 
1895. 

On Digestive Proteolysis. Being the Cartwright Lectures for 
1894. Delivered before the Alumni Association of the College of 
Physicians and Surgeons of New York. By R. H. Chitteuden, 
Ph.D. New Haven, Conn. : Tuttle, Morehouse & Taylor, Pub- 
lishers, 1895. 

Transactions of the Medical Society of the State of North Caro- 
lina. Forty-firs; Annual Meeting, held at Greensboro, N. C, 
1894. Wilmington, N. C. : Jackson & Bell, 1894. 

The State Board of Charities. Annu.al Report of the Board of 
Managers of the Craig Colony for Epileptics to the State Board 
of Charities. 



THE MEDICAL NEWS 

A WEEKLY JOURNAL OF MEDICAL SCIENCE. 



Vol. LXVII. 



Saturday, July 27, 1895. 



No. 4. 



ORIGINAL ARTICLES. 

ABNORMALITIES IN THE COLOR OF THE HUMAN 

HAIR} 

With a Report of Cases. 

By J. ABBOTT CANTRELL, M.D., 



JE FOR GRADUATES IN MEDICINE; DERMA- 
THE PHILADELPHIA HOSPITAL AND 
TO THE SOUTHERN DISPENSARY. 

According to the literature of the subject, I find 
that the abnormalities in the color of the human 
hair are found to be gray or white, blue, green, 
yellow, red, brown, black, and that peculiar condi- 
tion in which one hair has segments differing from 
others of the same hair. I also find that a number 
of instances have been recorded wherein the change 
has been periodic, without any known cause, or 
in which season has seemed to be a predisposing 
factor ; and still others in which the hairs have re- 
gained their normal color after several years or more 
of abnormalism. 

The abnormal color may be congenital, as in the 
many cases of albinism, and, while this condition is 
more prone to be seen in the negro race, it often 
occurs in whites. It may be complete, and gen- 
erally it is the offspring of albinos that show this 
condition ; but an example is mentioned by Hutch- 
inson of an albino child being born to parents who 
themselves were dark. This is the only case on 
record that I can find, although Kaposi said, in 
1874, that it was a well-known fact. In my search 
I could find no reference to any case of albinos 
giving birth to other than albino children. Cases 
have been recorded wherein this condition has been 
partial, as in those mentioned by Godlie and Mor- 
gan, in which a tuft of white hair was mingled with 
the normally colored ones, this peculiarity being 
inherited as late as the fourth generation. Ander- 
son refers to a similar example occurring through 
the third generation. There are many examples in 
which this change has occurred in the colored race, 
as that of the so-called leopard-boy, who was ex- 
hibited in museums. A case appeared at my clinic 
some years back in which a colored woman, thirty 
years of age, presented a tuft of white hair imme- 
diately in the median line of the forehead which 

' Read at the meeting of the Philadelphia County Medical 
Society, .April lo, 1895. 



had a diameter of two inches or more ; the woman 
also presented a difference in the color of the eyes, 
one being of a bluish tinge, while the other was 
brown. This woman was accompanied by her 
daughter, who had exactly the same condition of 
the hair as well as of the eyes. 

The premature loss of color in the hair is no less 
an important condition, and whether it is a family 
predisposition or whether it takes place more or less 
suddenly, whether it is caused by some derangement 
of the nervous system or accompanying some de- 
pressing or grave disease, it is nevertheless abnor- 
mal enough to claim our attention. 

I have made no attempt to collect those cases in 
which family predisposition has been a possible 
cause, as all are aware that this takes place, and I 
feel that it would be a waste of time to give more 
than a passing notice to that condition. 

In many cases this condition of graying or whiten- 
ing of the hair has been more or less sudden, and 
the cause has been one of the conditions enumerated. 

Of the many cases in which the change occurred 
in a few hours or a few days, I include those of many 
writers. Mention may be made of those in which 
the change took place in a very few moments, as 
the persons were either brought out to execution or 
were awaiting the hangman's noose or the knife of 
the guillotine. Darwin, quoted by Walter Smith, 
mentions a man whose hair while being brought out 
for execution changed color before the eyes of the 
spectators. Laycock refers to a Sepoy who became 
gray in one-half hour. Parry states that a prisoner 
became white-haired within fifteen minutes while 
confined in the guard-house. Wilson refers to a 
young lady who was awaiting her affianced to come 
home to conclude his marriage ceremony, and who 
suffered the same effect on hearing of his sudden 
death. Smilie speaks of another case, that of a 
young man awakening and finding a grizzly bear 
lapping the blood which was flowing from a wounded 
arm. Dewees found gray hair on the forepart of a 
woman's head during her accouchement, which re- 
turned to the natural color in four or five days. 
Boyle met with this sudden change in a young man 
who was seized by the guards and was, as he thought, 
to be put to death. Miner witnessed it in a young 
boy who had learned of his mother's death. Sir 
John Forbes, who had gray hair, suddenly became 
white, which condition remained for a year, and at 
the end of which time it again returned to the gray. 



ABNORMALITIES IN THE COLOR OF THE HUMAN HAIR. [Medical News 



Other cases are mentioned by Schenk, Hahne- 
mann, Pechlin, Birsch-Hirschfeld, Nicholaus Floren- 
tinus, Borelli, Callius Rhodiginius, Eulenberg, Se- 
ligmueller, Marcellus Donatus, Fabricius Hildanus, 
Camerarius, Scalinger, and others. 

There are other cases in which the change was 
less sudden, such as that of Brovvn-Sequard, who 
noticed the change day by day in his own person ; 
of Sir Thomas Moore, the Chancellor of Henry 
VIII ; of Henry of Navarre, who changed in 
twenty-four hours; the Monk Ubipertus, who had 
to become gray in one night to obtain a bishop's 
miter ; Louis of Bavaria, who had condemned his 
wife to death ; the well-known Perat, the wife of 
Laclere, who had to give testimony before the Peers 
in the case of Louvel ; Marie Antoinette, but whom 
Charcot proved had gray hair before the death of 
her husband ; the case of Smyth, in which a light- 
haired young man became gray in some places and 
jet-black in others; those of Landois and Pye-Sraith, 
in which the change was noted after a debauch or 
delirium tremens ; Ludwig Sforza, who had fallen 
into the bad graces of Louis XII ; a man who turned 
gray in one night after military service in very cold 
weather, as referred to by Hardy ; Smythe's patients, 
who turned gray in some parts while others became 
black, the skin also changing to a bronze ; that of 
Banks, in which a young woman showed the condi- 
tion on the eyelashes ; Smilie's case of a young man, 
who had staked his all on the fortunes of a card, 
and who winning found on the next morning that 
his hair had become gray ; Fowler's case of a girl 
who was chlorotic and who had a gray spot, two 
inches square, on the occipital region ; the friend 
of Ferguson, who changed after business losses; a 
young girl of thirteen, who, according to Howe, 
awoke one morning and found a spot one-half inch 
in breadth on one side of her head, the other show- 
ing the change soon after, and the whole head 
undergoing the change in seven years; this writer 
also refers to a girl of eight years who had light hair 
on one side and dark-brown on the other ; Ander- 
son saw a case affecting the upper eyelid, in which 
this part, with the left whisker, was also white and 
of some years' duration ; Thornton gives the notes 
of the case of a young lady in whom the eyebrow 
and lash became white within a week after a sudden 
fright ; Faldenheim speaks of a change beginning 
at the age of twenty and being complete at thirty- 
three. Cases occurring in four or five days are also 
recorded by Richter, Bichat, and Moleschott. 

Villerme records that in a girl of thirteen the lost 
hair was replaced by a woolly growth on part of the 
head and by brown hair on the other, which after a 
time faded into gray, some of which fell out and left 
a sad condition of affairs. Brandis has seen one 
side of the beard white, while the other retained its 
natural color. Of the many cases in which disease 



has been a predisposing factor I include that of 
Crocker, in which the eyelashes became white con- 
sequent to a sympathetic ophthalmitis, after removal 
of the opposite eye ; and still other instances of this 
are spoken of by Nettleship, Hutchinson, Jacobson, 
and Schenkl. Cases following neuralgia are men- 
tioned by Wilson and Paget, and in the latter there 
would be a return to the natural color in four or five 
days, Berger's being witnessed after a hemiplegia 
on the right side of the head and face ; Murray met 
with it after the removal of a fibroid tumor of the 
uterus, and in this case it occurred after a severe 
neuralgia during the night, being confined to the 
internal half of one eyebrow and the corresponding 
eyelash. It has also been noted as occurring with 
epilepsy by Marselli and Beigel ; with locomotor 
ataxia by Bulkley, Debove, and Bartholomy ; coinci- 
dent with cerebral tumor by Bourneville and Poirier; 
following typhus by Joannet ; and in malignant fever 
in a case of Compagne, the hair was noticed to turn 
completely gray by the sixth day, but on the seventh 
it commenced to turn dark, and on the fourteenth 
it had become its original black color. Raymond 
observed this condition in a woman of thirty-eight, 
who parted with her son and who afterward lost 
money; during an attack of neuralgia she found 
upon the upper part of the head that the hair had 
turned red, while the remainder was completely 
white. Lorry says that graying of one side some- 
times follows severe toothache; Wallenberg refers 
to a child having scarlatina, in whom the hair and 
nails fell out, and were replaced by a milky-white 
skin and albinotic hair; Naylor also speaks of a 
similar cause in his case; Ludwig has known the 
eyelashes to change color after smallpox. 

Following this condition we have another in 
which we are confronted with the so-called ringed 
hairs, and several cases of this very interesting 
abnormality are recorded by Wilson, of a boy of 
seven years in whom the normal or brown segments 
were one-fiftieth of an inch long, and the white and 
abnormal segments were about half this length. To 
be mentioned also is Lesser's case of a child of four- 
and-a-half years, who was born without any hair, 
excepting the eyebrows, which were normal, and 
soon after the scalp presented the appearance of 
goose flesh. The hair began to grow by the second 
year, the color being brown; the longer hairs were 
normal , while the short hairs were generally ringed. 
In this case there was also trichorrexis nodosa. 
Karsch has referred to a case in which the rings 
were not of uniform size ; Crocker speaks of the 
moustache of a gentleman, aged thirty-nine years, 
which was also associated with trichorrexis nodosa ; 
Richelot mentioned a chlorotic girl, in whom the 
hair became gray for two or three inches at its root, 
the parts beyond being unchanged. The chlorosis 
was cured by iron, and the hair-pigment was again 



July 27, 1S95] ABNORMALITIES IN THE COLOR OF THE HUMAN HAIR. 



87 



secreted, so that after a time she had brown hair at 
the roots and ends, the center still remaining white. 
Smith, Spies, Landois, G. Simon, and Thomson also 
have seen this condition ; Unna speaks of a case of 
white nails, in which there were also ringed hairs. 

In the following illustrative case the patient was 
a man of forty-seven years of age, who was brought, 
about the middle of the year 18S9, to my clinic by Dr. 
John A. Fell, of Doylestown, Pa. I obtained the fol- 
lowing history : His paternal grandparents lived to be 
eighty-two and eighty-four years of age, respectively, 
and his father was eighty years of age at the time of his 
death. He had two paternal uncles, one dying at the 
age of sixty-five of pneumonia, and the other of dissipa- 
tion ; there were two paternal aunts, one of whom died 
at the age of seventy, from a fall down stairs, and the 
other at the age of sixty-five years. All had good heavy 
hair, which was of a dark-brown color, the man's 
father having very few gray hairs at the time of his 
death. Of the maternal grandparents, his grandmother 
lived to be quite aged ; his mother lives still at the age 
of eighty years. Of three aunts, one died before the 
birth of the patient, and consequently he was not aware 
of her state of health ; another died during parturition 
at the age of forty years, and the remaining one in old 
age. The uncles were quite aged at the time of their 
death, being seventy-eight and sixty- five, respectively. 
The members of this branch of the family were of a 
sandy complexion, their hair turning gray or white at 
an early age in every instance. The patient had three 
brothers living at the ages of fifty-six, forty-nine, and 
forty-two, respectively, and one sister at the age of fifty- 
five years. In all of these the hair had not undergone 
much change, although in the eldest there was a slight 
tendency to become gray. 

The members of both famiUes, from the grandparents 
down to the present generation, had always enjoyed the 
best of health, with the exception of the patient's 
mother, who had always been a sufferer from temporal 
neuralgia. 

The patient was born in Pennsylvania, October 22, 
1842, and was, therefore, forty-seven years of age. He 
had two sons living at the ages of twenty and sixteen, 
respectively, there having been a stillborn daughter 
between the males. His habits have always been 
steady; he was never a drinker, or otherwise "fast;" 
he had never suffered from gonorrhea or syphilitic 
infection. At the age of four years he had typhoid 
fever. 

During the War of the Rebellion he was wounded on 
September 17, 1S62. suffering a compound comminuted 
fracture of the fibula, caused by a Minie-ball. He was 
confined in a hospital for five months. He suffered from 
iritis in both eyes, the marks of the cupping still being 
visible in both temporal regions. Since the war he has 
been troubled with " army diarrhea.'' He was a moder- 
ate smoker. 

The trouble for which he sought advice began in 
November, 18S8. He complained of severe pains in his 
head (no particular portion), from which he was unable 
to sleep except in short naps ; he could not describe 
these pains accurately. During the day he was almost 
unable to keep a hat on his head, although it was of 
light weight, because it felt as if a stone. 

These symptoms continued through the winter and 
summer until July, 1S89, about the middle of the month, 
when, on going to the mirror one morning to comb his 
hair, he found a white streak on the right side of his 
moustache. The following day this side of his mous- 
tache was perfectly white, the left side showing no ten- 
dency to change. Within the next ten days the hair, 
formerly dark brown, charged color in its entirety, and 



gradually fell out until there remained only about one- 
third of the normal amount. At this time he gave me 
two pictures, which illustrate the appearance of the man 
just before and just after the changes occurred. 

He says that when he goes to bed he is sleepy, but 
that when he reaches the bed he lies awake for several 
hours. 

On January 5, 1895, I found that there was no 
change in the color of the hair, except as regards 
the portion in the occipital region, where the new 
hair is of the normal color before this change took 
place. The color of the other portion reiiiains as 
white as stated in the previous notes. The man told 
me that he had just about enough hair upon his face 
to make it necessary to shave once a week. 

In bringing this case to the attention of the So- 
ciety I wish to show plainly that this sudden blanch- 
ing of the hair does occur. I cannot understand 
why so many of our medical teachers state positively, 
even to this day, that it is impossible. Kaposi said 
in 1S74 that there was no such thing as sudden 
blanching of the hair, and that if the cases had been 
examined previously to this so-called change it 
would have been seen that the condition was grad- 
ually taking place — that is, that the pigment was 
losing its power of giving normal color to the hairs. 
This writer was not alone in this assertion, as such 
men as Haller, Barensprung, Reisner, and Hebra 
were counted in the list. I therefore feel great 
trepidation in reviving the subject at this time. 

The condition of sudden change must certainly 
have been known, for if we refer to the words of 
Lord Byron they are certainly conclusive : 

" My hair is gray, but not with years; 
Nor grew it white 
In a single night. 
As men's have grown from sudden fears." 

( Prisoner of Chilton. ) 

The question remains. Why in one instance a per- 
son will have brown hair, or red hair, and in still 
another it will be black ? This can only be deter- 
mined by the number and size of the air-bubbles 
that are contained within the hair. In the black 
hairs we have the air-bubbles in minute quantity, 
while in those of brown hairs we have them in some 
slight increase, and they are found in larger quanti- 
ties still in the red hairs. Taking these points into 
consideration and examining the refractive power 
of the hairs in this connection, we can readily un- 
derstand how one person will have color differing 
from another. And the same explanation may be 
applied to this sudden loss of color in its structure. 
We have, perhaps, through nervous shock or some 
unknown cause, the collection of air-bubbles in 
large quantities throughout the entire hairy system, 
and, as the refractive power of the hair becomes 
changed, we are confronted with this apparent loss 
of color. 



ABNORMALITIES IN THE COLOR OF THE HUMAN HAIR. [Medical News 



Pfaff has stated that the pigment is not dimin- 
ished until advanced age, but I am of the opinion 
that, except in albinos, the hair is never devoid of 
this coloring-matter. If the theory is correct that 
we have a loss of pigment in advanced age, how can 
we account for the return of normal color of the 
hair in very old persons? I do not think that re- 
formation of pigment will ever take place, the 
color not being transmissible, but is due to the 
amount of air-bubbles contained within the hair. 

If the statement be true that air-bubbles are the 
direct cause of this condition, it would appear that 
the cases recorded by Prentiss, in which one of the 
patients was treated with jaborandi and the other 
by pilocarpin for some intercurrent malady, and in 
whom the normal color of the hair returned, would 
tend to prove it ; and the experiments of Pohlman 
with pilocarpin, in which he obtained the return of 
color in certain cases, and yet was unable to secure 
it in an albino rabbit, would add testimony in this 
direction rather tlian disprove it. 

Blue Hair. — Many cases are recorded in which 
the change has been to a blue in those who are 
workers in cobalt-mines or who are employed in 
the manufacture of indigo ; thus Borellus records 
the case of a man who had worked in the manufac- 
ture of indigo for twenty-five years, and whose hair 
had been blue for at least twenty years. In the case 
of Beigel, the blue color did not penetrate into the 
substance of the hair, but particles of indigo were 
deposited in an irregular manner upon the cuticle 
of the hair. 

Green Hair, — Green hair has been witnessed in 
those who are employed in copper-mines, as in tha 
case of Petri, of a man of seventy-eight years, in 
whom the hair of the scalp was green, but in whom 
the hair became its natural color after washing in 
solution of caustic ammonia. Billi refers to a man 
with ringworm of the scalp, who was treated with 
corrosive sublimate and an ointment of yellow mer- 
curic oxid, and in whom the hair became green. 
Another case is recorded by Orsi, of a railroad- 
workman who became suddenly green-haired, the 
green hairs being mixed with the gray; washing 
with ether, alcohol, or a dilute solution of potash 
did not affect it, but the hair on being cut grew out 
again gray. Clapton met with cases of green hair in 
copper-workers, and Wiltshire in those who were pin- 
makers. Joseph Frank also observed it. Rommel 
met a man of thirty years thus affected, but who had 
never worked in a mine. Borellus records the case 
of a young man who had green hair and green per- 
spiration. Blue hair is also seen in those who work 
in brass. Leonard, Bouchardat, and Posner be- 
lieve that the colors, both blue and green, are only 
superficial, and can be easily rubbed off; but Elbe, 
who has made a comprehensive study of this condi- 
tion, states that this discoloration is not alone con- 



fined to the superficial part of the hair, but is inti- 
mately connected with its entire substance and can- 
not be rubbed off. The recorded cases disprove 
the latter assertion of Elbe. 
' Ykllow Hair. — Smyly records the case of an in- 
fant of four months whose hair changed from its 
usual mouse-color to that of a reddish-yellow. The 
right eyebrow and the skin of these parts, as well as 
that of the right hand, were icteric ; the pillow also 
was saturated with a reddish-yellow perspiration. 
Walter Smith tells of a boy in whom the lobe of 
each ear was of a sulphur-yellow, the downy hairs 
being also a bright yellow, while the hair of the head 
was brown. Many cases have been seen in which 
chrysarobin and chlorin gas have produced this 
same condition. Hydrogen dioxid, as is well 
known, is used to bleach the hair. 

Red Hair. — McMurray mentions a man having 
a hemihyperidrosis of neurotic origin and herpes 
zoster of the corresponding side, in which the hair 
of the affected side was of a light red, while that of 
the other was dark. Squire referred to a deaf-and- 
dumb boy of sixteen who had dark-brown hair in 
some places and auburn in others, and which to 
some extent resembled a tortoise-shell cat. Isoard 
describes a young lady, who was deaf and dumb 
from birth, and who every time she had a certain 
fever the hair, which was of a pleasing blond, be- 
came a dusky red ; but that so soon as the febrile 
symptoms diminished the hair became natural. 
Alibert records an almost similar example ; he also 
refers to a case in which after a severe illness a head 
of brown hair became one of bright red. Mention 
may also be made of the offspring of parents who 
are dark and who show a tendency to reddish hair. 
Congenital redness has been witnessed in members 
of the colored race. Leonard speaks of a young 
man who had brown hair, and which afterward be- 
came a positive red after a few years' residence in 
the hot climate of Sumatra. 

Brown Hair. — Wilson cites an instance of a man 
whose white hair turned to a brown and back to 
gray again before his death, at the age of one-hun- 
dred-and-fourteen years. Belcher refers to a woman 
of ninety-five, who had been insane for fifty years, 
and who at her death had brown hair, there being 
not a single gray hair on her head. 

Black Hair. — Pyrogallic acid will make the hair 
black. Wilson records an example of the change 
to black in a woman of ninety-five, whose gray 
hair turned to black, and which became gray again 
before her death, at one-hundred-and five years. 
The cases recorded by Prentiss are indeed unique : 
the one in which a woman of seventy-two was 
given pilocarpin, and the other of a woman of 
twenty-five who had taken jaborandi, in both of 
whom the hair became black. Sykes referred to a 
man of eighty-one, who had white hair which in 



July 27, 1S95] ABNORMALITIES IN THE COLOR OF THE HUMAN HAIR. 



89 



a few years became black, and Bruley to a woman 
of sixty years, who had naturally white and trans- 
parent hair, which became jet-black four days before 
her death. Albert alludes to a person in whom 
the hair, from having been previously brown, became 
deeply black. Copeland remarks that in a number 
of instances gray hair has become black. Beigel 
refers to this change taking place after typhus fever ; 
this was witnessed in a won)an who had blond hair, 
which was replaced by coal-black hair. 

Periodic Chaxges. — Warner records the case 
of a gentleman whose hair turned from black to 
white and back again three times in thirty years ; 
the change from black to white was always rapid, 
while that in the other direction was slow and took ! 
some five years for completion. There would be a 
pause of some years when the color was normal, 
and then it would become white again. Reinhard 
gives the notes of a case wherein, in an idiot, the 
change was periodic, being from a reddish to a 
blond yellow. Rauber records a case of this 
change in an epileptic. Wilson saw it gray in 
winter and natural in color in summer. 

Return of Color. — Isdell refers to a man of 
sixty-two, with gray hair, and when eighty-three it 
was of its former normal color. Allanson Abbe 
speaks of a case returning from gray to quite dark, 
and even black in places, mingled with gray hair. 
Graves records many examples ; one was blistered, 
and the hair came in black, and remained so. An- 
other was bald on the vertex, forehead, and temples ; 
this was blistered, and a growth of hair occurred in 
a ring. There was also a girl who had several bald 
spots remaining after a tinea ; in this case common 
gas-water was used, and the hair regained its natural 
color. Still another was that of an army-officer who 
had been in the East. Sir John Sinclair mentions a 
Scotchman dying at the age of one-hundred-and- 
ten, in whom the hair regained its normal color. 
Joannet speaks of several instances, one of which 
was in a man who had been campaigning in the 
East, and in whom, upon remaining home for a year, 
the normal color of the hair returned ; another 
patient took a sea-voyage for a year, with the same 
result. Hoffman records the case of a gentleman 
who was an incessant user of tobacco, and whose 
hair became gray ; upon relinquishing the tobacco 
the hair again became black. W. O'Neil refers to 
a man who was gray and bald ; three-and-one-half 
years after hemiplegia, and at the age of sixty-two, 
he noticed that dark hair was growing on the bald 
spots, and the gray hairs fell out and gave place to 
dark-brown hair. 

I recall the case of a friend of about sixty-three 
years of age, whom I have known to be gray for at 
least fifteen years, and during the past year or two 
the normal black color of the hair is showing itself 
in the new-formed hairs. 



Miscellaneous. — Hauptmann refers to a case of 
a body which had been exhumed more than twenty 
years after burial, in which the hairs appeared red, 
whereas the hairs of the individual at the burial had 
been dark brown. Leonard speaks of a case in 
which, after death, a head of red hair changed in 
the course of a few hours to blond, and within 
thirty hours to gray. 

Oesterlin has recorded a case wherein the hairs 
were more intensely pigmented toward their roots. 

If any reported cases are not included in this list, 
I beg indulgence, owing to my inability to obtain 
data. 



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Simon: Hautkrankheiten. Berlin, 1851, p. 382. 

I Vilson, B. : Case of Ringed Hair. Musee de Hunter, No. 535. 

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Hildanus, Fabricius. Cameraritis, Donatus. Marcellus, Scal- 
inger: Quoted by Hebra, vol. iii, p. 194. 



90 



ABNORMALITIES IN THE COLOR OF THE HUMAN HAIR. [Medical News 



Griffith : Canstatt und Eisenmann's Jahresb., Eriangen, 1849, 

P-34- 

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Jackson, George Thomas : Journal of Cutaneous and Venereal 
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Petri: Ueber die Griine Farbung der Haare bei Aelteren 
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Bourchardat and Possner : Quoted by Petri. Loc. cit. 
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(The Susceptibility of the Hair and Skin Changing Color With- 
out any Known Cause.) 

Lorry : De Morbis Cutanis, edit.. Cavelier, 1777, p. 602. 
Syies : Change of Color in the Hair. St. Louis Medical and 
Surgical Journal, 1845-46, iii, p. 310. 

Smilie, E. R. : Blanched Hair from Sudden Emotions. Boston 
Medical and Surgical Journal, 1851, xliv, 438-440. 

Ferguson, J. : Sudden Canities. Canada Journal of the 
Medical Sciences, 1882, vii, 113, 

hoard : Quoted by Wilson, Philadelphia, 1854. Loc. cit. 
Belcher, T. W. : A Short Biological Sketch of a Remarkable 
Case of Insanity. Dublin Quarterly Journal, February, 1864. 

Hoffmann, B. B. : Tobacco as the Cause of Gray Hairs and 
Baldness. Pacific Medical and Surgical Journal, 1868. 

Capton : Journal of Cutaneous Medicine, January, 1870, p. 515. 
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nal, September 18, 1869. 

McMurray, W. : Notes on Some Abnormal Conditions of the 
Hair. Australasian Medical Gazette, July 15, 1892, p. 279. 

Prentiss, D. W. : Remarkable Change in the Color of the 
Hair from Light Blond to Black in a Patient Under Treatment 
by Pilocarpin. Philadelphia Medical Times, July 2, 1881. 

Change in the Color of the Hair from the White Hair 

of Old Age to Black, Produced by Jaborandi. Therapeutic 
Gazette, April 15, 1889, p. 238. 

Godlie : Hereditary White Patch of Hair. Medical Times 
and Gazette, 1884, i, 180. 

Morgan: British Medical Journal, 1890, ii, 1883. 
Turner, Daniel: A Treatise of Diseases of the Skin. London, 
1736, 51h edition. 

Laycock : Medical Times and Gazette, 1862. 
Pye-Smith, P. H. : Diseases of the Skin. Philadelphia, 1893, 
p. 368. 

Raymond: Un Cas du Decoloration Rapide de la Cheval- 
ure. Revue de Med., 1882, ii, p 770. 
Thornton, B. : Quoted by Crocker. 

Anderson, McC: A Treatise on Diseases of the Skin, 1887, 
p. 76. 

Van Harlingen : Handbook of Skin Diseases, 2d edition, 
1889. p. 65. 
Brown-Sequard : Archives de Physiol., 1869, p. 442. 
Crocker, H. R. : Diseases of the Skin, 2d edition, Philadelphia, 
1893, 790. 791- 

Nettleship, Hutchinson, Jacobson : Quoted by Crocker. Loc. 
cit. 

Wallanberg : Ein Fall von Bleibender Veranderung des Haars 
und der Hautfarbe nach Scharlachfieber. Vrtljschr. f. Derm, und 
Syph., 1876, i. 63. 

Naylor : Diseases of the Skin, London, 1874, p. 10. 
Smith, IV. G. : On a Rare Nodose Condition of the Hair. 
British Medical Journal, 1879, "> 291, and 1880, i, 654. 

Behrend, G. : Lehrbuch der Hautkrankheiten, 2d edition. 
Berlin, 1883. 

Warner: Relapsing Canities. Quoted by Jackson. 
Reinhard, C. : Ein Fall von Periodischem Wechsel der Haar- 
farbe. Arch. f. Path. Anat., Berlin, 1883, xcv, 337-351. 

Isdell : Case of the Restoration of the Natural Color of Human 
Hair after having been Gray for Several Years. Medical Times 
and Gazette, 1884, ii, 680. 



Jackson, George Thomas: A Dermatological Bibliography. 
New York, 1891. 

Diseases of the Hair and Scalp, 1887. 

Hyde, James Nevins : Diseases of the Skin, 3d edition, 1893, 
p. 63, et seq. 

Morrow : System of Genito-Urinary Diseases, Syphilology, and 
Dermatology, 3d vol., 1894. 

Forbes, Sir John : Quoted by Crocker. Loc. cit. 

Wilson, E. : Lectures on Dermatology, 1878, p. 166. 

Compagne : Handb. d. Anat. v. E. Hildebrandt. Herausge- 
geben v. Weber, 4 Aufl., S. 200. Braunschweig, 1830. 

Spies: Henle und Pfeiffer's Zeitschr. f. Rat. Med., Bd. ix, S. 
302. 

Ziemsscn : Handb. d. Hautkrankheiten, p. 153. 

Leloir and Vidal : France M^dicale, No. 16, April 18, i8qo. 

Ein Fall von Ringelhaaren : Edward Lesser. Vrtljahrschr. f. 
Derm. und. Syph , 1886. No. 18, p. 51. 

Lesser, Edward : Ueber Ringelhaare, Allg. Wien. med. Zeit., 
1885, xxt, p. 441. 

Birsch-Hirschfcld : Lehrb. d. Pathol. Anat., Leipzig, 1876, p. 
654. 

Berger, Eulenherg, Seligmueller, Paget : Quoted by Ziemssen. 
Loc. cit. 

Billi: Un Case di Tricolorsi Gior. Ital. d. Pelle., 1872, xiii, 
343; Abst. Ann. d. Derm, et Syph., 1872-73, iv, p. 13S. 

Orsi: Griine Haare (abst.). Virchow's Jahresbericht, 1871, 

Leonard C. H: The Hair: its Growth, Care, Diseases, and 
Treatment. Philadelphia, Lippincott, 1880. 

Oesterlein : Das Menschliche Haar. Tiibingen, 1874. 

Pohlman : Buffalo Medical Journal (abst.); Druggists' Circular, 
1884, p. 57- 

Schenk : Quoted by Vogel. Loc. cit. 

Thomson, Anthony, Todd: A Practical Treatise on Diseases 
Aflfecling the Skin. London, 1850, p. 418. 

Richclot: Annales des Maladies de la Peau et de la Syphilis 
par Cazenave, t. i, p. 224. 

Joannet: Le Poil Humain, 1878. Paris, Theses, p. 68 et seq. 

Bichat: Anatomic Generale, t. i, p. 813. 

Moleschott,J. : Physiol. Skizzenbuch. Giessen, 1861, p. 432. 

Perry, P. : Dublin Medical Press. May. i85r , No. 8, p. 332. 

Hauptmann : Rothwerden Dunk'er Haare Einer Leiche bet 
der Verwesung, Arch. f. Path. Anat., etc. Berlin, 1869. xlvi, p. 

503- 

Sonnenschein : Quoted by Hauptmann (loc. cit.). 

Graves, R.J.: Cases in which Gray Hair Regained Natural 
Color. Dublin Quarterly Journal of the Medical Sciences, 1847, 
iii, pp. 339-347- 

How, R. : Case of a Girl whose Hair and Complexion Sud- 
denly Changed from a Dark to a Light Color. Memoirs of the 
Medical Society of London, 1792, iii, p. 515. 

Dewees W. P. : Singular Case of the Alteration of the Color 
of the Hair During Parturition. Philadelphia Medical Museum, 
1807, iii, pp. 219-222. 

Boyle: Exper. Philos., vol. i, p. 90. 

Smith, Walter : Times and Gazette, London, 1883, i, p. 340. 

Allanson, Abbe : Sudden Change in the Color of the Hair. 
Boston Medical and Surgical Journal, 1852-53, xlviii, p. 406. 

Bruley : Notice sur un Changement Subit de Cheveux, qui de 
Blancs sont Devenus Noirs. Rec. Period. Soc. de MCd. de Paris, 
1778, iv, 290-292. 

Copland: Boston Medical and Surgical Journal, vol. ix, p. 169. 

Leonard: American Journal of Pharmacy. 

Miner, J. F. : Change of the Color of the Hair in a Night. 
Buffalo Medical and Surgical Journal, 1864-65, vol. iv, p. 93. 

Beigel, H. : Blaue Haare. Arch. f. Path. Anat., etc., 1867, 
xxxviii, p. 324. 

Beigel: Human Hair: Structure, Growth, Disease, etc. Ren- 
shaw, London, L869. 

Villerme : Quoted by Leonard's Text-book. Loc. cit. 

Ehrmann, S.: Ueber Das Ergrauen Haare, etc. Allg. Wien. 
med. Ztg., 1884, xxix,33i. 

Untersuchungen ueber die Physiologie und P.ithologie 



July 27, 1895] THE MENTAL STATE AS CONDUCIVE TO ORGANIC DISEASE. 



91 



des Hautpigmenls. Vrtljahr, f. Derm, und Syph., 1885, xii, 507; 
1886. xiii, 57. 

Pincas, J. : Ueber das Plotzliche Ergrauen. Deutsche Klinik, 
Berlin, 1873, x-"^^'.- P- 9- 

Der Einfluss des Haarpigments und des Markcanals auf 

die Farbung des Haare. Arch. Derm, und Syph., 1872, ii, p. i. 

Leioir and Vidal : La France Medicale, p. 245 et seq 

Unna : Leuconychia und Leucotrichia. Intern. Atlas, pi. 19. 

Ludwig : Prim. Linese .^natom. Pathol., p. 29. 

Brandis : Versuch. ueber Metastasen, p. 172, note. 



THE MENTAL STATE AS CONDUCIVE TO 
ORGANIC DISEASE} 

Bt GEORGE S. BROWN, M.D., 



That we are at present in the dawn of the age 
of preventive medicine is accepted by all think- 
ing medical men ; hence, the scientific facts sus- 
taining this conviction need no elaboration and but 
brief mention in a paper of this kind. We recog- 
nize that as the accumulation of histologic and 
pathologic facts has gone on, the medical mind has 
grown more and more modest in its claims as to the 
curability of disease. This accumulation of facts 
has shown, first, that many diseases, from their very 
nature, are incurable, and at last the old egotism 
of ignorance entirely gives way when it is seen that 
all living organisms possess within themselves an 
inherent vital force, capable, to a large extent, 
of stamping out and keeping out the causes 
of disease. With the possession of this knowl- 
edge naturally comes the effort to conserve and 
further the action of this vital force by the de- 
velopment of these means, which are comprehended 
in the term preventive medicine. 

While we have learned that death lurks not only 
in the cup, but in the bowl, the dish, and the milk- 
can, in the miasma of the night-air and the dust of 
the busy street, we have also learned that so long as 
the general health of the human body is maintained, 
its inherent vital force, through the agency of the 
phagocytes, is able, for the most part, to resist suc- 
cessfully the invasion of the germs of disease. This 
inherent vital force, this essence, which is the 
measure of the desire and ability to live, is doubt- 
less the resulting strength and vigor of the com- 
bined sperm cell and germ-cell at the time of con- 
ception, conserved, added to, or wasted, as it is 
variously affected by the million factors that influ- 
ence its existence from the time of conception to 
old age. Every individual possesses it in a different 
degree, and its variations range all the way from 
the weaklings that die in utero or live an hour, week, 
or month after birth, to those high e.xamples of 
physical and mental strength that carry on the 
work of the world. 

1 Read before the Alabama State Medical Association, at 
Mobile, April 17, 1895. 

4« 



The utility of this vital force maybe impaired in 
a variety of ways. In the order of their importance 
they may be divided thus : First, ignorance of the 
mental and physical laws of right living. Second, 
mental shock and strain, and physical accident or 
exposure, which are unavoidable. For instance, a 
man living in perfect health in a malarial region 
breaks his leg. The lowered resistance of his vital 
force is overcome by the malarial germ, and he 
develops malarial fever. Mental shock may so 
depress the vital force as to invite the germs of 
disease and cause the body to fall an easy victim, 
or, failing that, may, by its impression on the nerv- 
ous system, so disorder the bodily functions as to 
cause in time organic changes. 

In the first class of the causes of lowered vital 
force (those due to ignorance of the moral laws) 
we need not dwell upon the fact of thousands fall- 
ing victims yearly owing to the ignorance of them- 
selves and others regarding the laws of physical 
sanitation and hygiene, but it is to the mental state 
and the position it occupies in the causation of 
disease through ignorance of the laws of right living 
that I wish to invite attention more specifically. 

The human mind or brain-function probably 
never rests entirely, but it must have its equivalent 
relaxation in a healthful variety of subject, pleasur- 
able change. The business-man, when prosperous, 
has the excitement of his affairs and his hours of 
ease and pleasure at his fireside. His drudging 
clerk, having no family ties, and possessing no 
artistic or social tastes of the higher order, must 
resort to cards, billiards, or worse, with others of 
his kind, while the ignorant negro laborer is 
limited for mental relaxation to the banjo, the 
dance, and the crap game, whisky, and the razor. 

This mental relaxation, however obtained or 
whatever the form it takes, is absolutely essential 
to the healthy performance of the bodily functions. 
Conversely, high mental tension on any subject, con- 
tinuing long enough, will cause disordered function, 
which will in time surely be followed by organic 
change. The business or professional man laboring 
under financial stress or overwork is a good exam- 
ple of physical breakdown from mental strain, 
but the sub-class of cases that I wish to speak of 
more particularly includes women who are born 
with, or through long years have slowly acquired, 
the worrying or fretting habit. This usually begins 
in childhood. Under the false but popular protec- 
tion-system of training, egotism and selfishness are 
encouraged at the expense of self-reliance and 
self-restraint. I beg indulgence while I report two 
ideal cases that I have personally encountered, and 
which will, perhaps, better illus'.rate my meaning : 

A woman, aged thirty-two years, married fourteen 
years, with one delicate child, a boy of thirteen years. 



92 



THE MENTAL STATE AS CONDUCIVE TO ORGANIC DISEASE. [Medical News 



had always, as a child, girl, and young lady, been 
regarded as delicate, although she had never had 
any serious illness. Through childhood she had 
been indulged in every desire and protected from 
every irritation by an overfond and self-indulgent 
mother, and had never learned the meaning of self- 
restraint. As she grew up, her wants became harder, 
and finally impossible, to supply, and then the little 
irritations and deprivations began to cause fret, 
worry, and general mental suffering. Since her 
earliest recollection everything in the household had 
constantly bent to her wishes, and her mind had 
unconsciously taken the attitude that everything 
in the world should be made to do the same. Her 
egotism was developed ; her view was distorted by 
this artificial breeding, until, like primitive man, 
she thought the universe was made for her. When 
she came in contact with the world, and life became 
more complex, the ordinary little irritations, against 
which she had been protected so unwisely, pressed 
so thick and fast that husband and mother were 
unable to shield her entirely, and her mind became 
gradually fixed in a fret upon her woes, the least of 
which was more important to her than the real 
troubles of other people. 

This woman's husband was a physician, with a 
good income, but spending it all in his hopeless 
endeavor to supply her ever- increasing demands. 
For five years she was an almost helpless invalid 
from nervous disorder, with its inevitable train of 
headache, loss of appetite, sleepless nights, constipa- 
tion, and indigestion. It should be remembered 
that all her life she had had all the creature-com- 
forts, had been protected from every extreme of 
heat and of cold, her stomach had never been called 
on to digest plain food, and, as a consequence, for 
ten years she had been under the high mental ten- 
sion of worrying about the thousand little disturb- 
ances of muscles, nerves, and digestion that inevit- 
ably follow a habit of little physical and mental 
exercise, fresh air, and refreshing sleep. After five 
years of almost complete invalidism her husband 
suddenly died. She was left sick abed, with a deli- 
cate child, an invalid mother, and without a dollar 
in the world. 

What follows proves conclusively that this woman's 
sum of unhappiness was due solely to her mother's 
mistaken notion of kindness in never allowing her 
daughter to learn the necessary lesson of self-reli- 
ance, and having taught her instead to be depen- 
dent, selfish, and miserable. The mother thought 
she was doing the best, but she really was engaged 
in a most vicious and immoral form of self-indul- 
gence ; she was pleasing herself, but wrecking her 
daughter's future health and happiness. In spite of 
this life of selfishness, this daughter had many 
friends, was attractive, educated, and highly accom- 
plished in music, painting, and needlework, all 
pursuits for which she had a natural talent, and 
which really, no doubt, saved her life. 

When her husband died, and stern necessity stared 
her in the face, she had a hard struggle with her 
pride, and no doubt suffered a great deal mentally 
and physically ; but whatever the effort cost her she 
made it, and when I saw her a year later she was 



keeping boarders, teaching music and painting, 
and making a good living for the three. Several 
years after that she was strong and well, had gained 
thirty or forty pounds, and did not have time to 
be sick. 

This was a case of cultivated invalidism pure and 
simple, and, if the early conditions had been main- 
tained for a while longer, some organic trouble 
would undoubtedly have followed — tuberculosis, 
general nervous exhaustion, or what not. 

An ancient Eastern sage once said: "In the 
course of my long life I have often noticed that 
men were more like the times they lived in than they 
were like their fathers," meaning thereby that he- 
reditarytendenciesare overwhelmed by the influence 
of environment or training, when the two happen 
to work in opposite directions. And so in the case 
I have just reported. Naturally the woman, that 
is, her mental and physical heredity, offered the 
poorest possible material out of which to make an 
invalid. She was bright, forceful, and intelligent, 
with every inherent quality to make an energetic, 
useful member of society, which she finally became 
by accidentally escaping the usual final conse- 
quences of her early training. 

I must beg further indulgence while I relate 
briefly another somewhat similar case, but in which 
the natural qualities were more favorable to the 
success of similar vicious early training: 

This case also was in a woman, aged twenty-six 
years, married five years, with no children. The 
same protective system had been carried out, first by 
the mother and then by the husband, until all interest 
in everything but her own petty ills and irritations 
had been blotted out. At the time I first saw her 
she had the appearance of robust physical health, 
but was in a never-ending fret about her husband, 
her household cares, and the thousand functional 
disturbances of nerves, muscles, and digestion which 
constantly attend, as both cause and effect, such 
mental states as hers ; a never-ending list of wants ; 
reproaches for all, in place of thanks and kindly 
feeling ; the interciliary ridges denoting extreme 
anxiety, high mental tension being never absent. 
This selfishness and total absence of all self-restraint 
and self reliance were her masters, and although no 
physical disaster had yet been wrought, the result 
was inevitable. 

Physical examination revealed no organic dis- 
order, except a small cyst of the left ovary, which 
caused no inconvenience other than mental. This 
state of worry, of high mental tension, however, 
with its attendant train of bad physical habits, no 
exercise, no fresh air, no refreshing sleep, indiges- 
tion, headache, and constipation, and last, and 
most important of all, no healthful mental change, 
her mind on one eternal strain about herself, 
did the work, and five years later she died a phys- 
ical and mental wreck. Seeing her again in con- 
sultation after this lapse of five years, I could 



July 27, 1895] THE MENTAL STATE AS CONDUCIVE TO ORGANIC DISEASE. 



93 



recognize mental symptoms, such as fretting about 
trifles, which at first would have been amusing, ex- 
cept for the grave tendency, now grown most pitiable 
in the intensity of the mental anguish they caused. 
She had no waking moment for weeks prior to her 
death that was not filled with the most acute mental 
and physical suffering. Self-pity and most pathetic 
charges of injustice and neglect, which she felt to 
be just, she showered on all about her. These made 
up her mental agony, and the long-starved-out and 
abused and exhausted nervous system, crying out as 
physical pain in every final nerve-distribution, was 
none the less real. She died with a frown of re- 
proach for all who had loved her and cared for her, 
and the cause of her general exhaustion, I am con- 
vinced, was primarily mental. 

The post-mortem examination showed beginning 
tuberculosis in both lungs and slightly advanced 
interstitial nephritis. The cyst of the ovary had 
grown little or not at all ; there was no organic 
change sufficient to cause death, which was due 
simply to an exaggeration of the mental symptoms 
present five years, or ten years, or twenty years be- 
fore, to a point at which the exhausted brain and 
nervous system could no longer furnish life to the 
tissues. 

These two women had the same vicious early 
training, and but for an accident in the environ- 
ment of the former the results would have been the 
same. The first case was not naturally so bad as 
the second, because the woman had natural tastes 
that asserted themselves, and, combined with her 
maternal affections, took her out of her own thoughts 
for hours together, thus relaxing the nervous ten- 
sion, smoothing out the brow, and giving the mind 
an occasional much-needed rest. It would only 
have taken a little more time, however, to balance 
these advantages, and she would have gone the same 
road as the second. The second woman had no 
inherent healthy force, no tastes, no talents, although 
pretending to all ; no attractive qualities, and, con- 
sequently, no friends, and no affection for anyone 
but herself. Her mental tension never relaxed, 
except when overcome by sleep, and of that she had 
little ; consequently there was nothing to obstruct 
the rapid progress toward nervous ruin. 

To my mind these cases tend inevitably in one 
of three ways : either some acute organic disease 
steps in and ends the struggle ; or this goes on unob- 
structed to the end, as in the second case ; or some- 
thing occurs that brings about a radical change of 
habit that effects a cure, as in the first case. Case 
I could have been cured at any time by a little 
patient, judicious teaching and intelligent help. 
Her case was due solely to ignorance on the part of 
her husband and mother. Case II, with a bad 
heredity and no redeeming qualities, would have 
been a harder case to manage ; would have re- 
quired, no doubt, a wise attendant and adviser from 
her natal hour. 



In the management of these cases the intelligent 
physician can do much, if he will leave his saddle- 
bags at home, and study the mental condition 
closely, and rely on his ability as an educator. 
The "Weir Mitchell" rest-cure is successful in 
many of the milder cases. It puts away all medi- 
cine, and excludes all garrulous friends and over- 
anxious mothers ; but, combined with this, after the 
patient's confidence has been gained, she should, I 
believe, be made to understand the mental source 
of her trouble. She must understand that not only 
is her co-operation necessary, but that the entire 
burden and responsibility of the cure are on her ; that 
no miracle can be wrought for her ; that there is no 
royal road to her cure ; that her condition is the re- 
sult of long training and self-indulgence in bad men- 
tal habits, and that only by long and patient work 
in the opposite direction can she be benefitted ; 
that the mistakes and evils of her youthful training 
cannot be wiped out by a pill or a prayer devised by 
someone else, but that she herself must long and 
patiently atone. Those cases can be cured that, like 
the first case I have reported, have some good left 
to appeal to— if that something good is appealed to, 
and the conditions honestly explained, to the end 
of gaining the patient's confidence and enlisting 
her co-operation ; m.iintaining the strictest of dis- 
cipline over her, or rather helping her to do so 
herself, and showing a most honest sympathy and 
concern for her welfare, and finally throwing the 
entire responsibility for the success of the treatment 
on her. On the other hand, if she has not any 
stronger desire than amplifying her symptoms in 
order to revive the waning sympathy of long-suffering 
friends or to stagger the new doctor with the im- 
portance of her case, if she has no reason, tastes, or 
aspirations left to appeal to, or if she is over fifty 
years of age, and "sot in her ways," she and her 
friends w-ill get more peace and happiness from a 
hypodermic syringe and a bottle of Magendie's 
solution than from anything else. Cases of this kind, 
which cannot be dealt with honestly, whose con- 
fidence cannot be gained nor co-operation en- 
listed ; in short, those who have little reason and 
no will- power left, receive but temporary benefit 
from bread-pills, hypnotism, hoodooism, charms, 
fetishes, and prayers. Such treatment, in fact, has 
made these cases what they are. 

The two cases I have detailed are typical of the 
conditions I wished to illustrate, but, like all pure 
types, are seldom met with. By far the most com- 
mon form of this acquired or cultivated state with 
which we have to deal is a variable and ever- varying 
combination of the two. In brief, it is a state of 
high mental tension, mental overwork, brought 
about by a selfish, worrying habit ; worse at one 
time, better at another, as it is influenced by the 
thousand healthful and unhealthful factors of en- 



94 



THE MENTAL STATE AS CONDUCIVE TO ORGANIC DISEASE. [Medical News 



vironment, but, on the whole, gradually growing 
worse as the years of youthful frivolity, change, and 
excitement are replaced by the more monotonous 
period of middle life. This state persisting, with its 
accompanying indoor existence, poor air, poor 
exercise and sleep, dyspepsia, headache, constipa- 
tion, and no mental relief, the rule is constant ; the 
weakest point gives way to organic disease, or the 
patient succumbs to pure nervous exhaustion. 
Again, a monotonous home-life is often responsible 
for conditions that have in turn been charged to 
perversity of the liver, uterus, or ovaries. House- 
wives who suffer from the persistent waywardness of 
husbands and children, from poverty, confinement, 
and hard work, with no hope of relief or pleasur- 
able mental change, in ten, fifteen, or twenty years 
go the way of nervous wrecks, and many wonder 
why. 

These cases are peculiar to women, not because 
they have ovaries, but because they are so often the 
delicate hot-house pets of mothers or the uncon- 
sidered and unpitied slaves of men. In one case 
the girl is often completely under the vicious influ- 
ence of an indulgent and ignorant mother. Her 
brothers are never beyond a certain age. Neglect 
a boy's training in self-reliance and develop his 
egotism to the utmost, and one game of marbles or 
ball, perhaps, will knock it all out of him. The boy, 
sooner or later, always has companions who estimate 
him at his real value, and force him to accept it. 
They teach him self-reliance as well as self-restraint ; 
they inure him to personal irritation ; he sees the 
world as it is, and early learns that biologic prin- 
ciple that the individual must mold himself to his 
surroundings. 

The girl, brought up under the protection-system, 
thinks the surroundings can be cut to fit the indi- 
vidual, and working, or rather fretting, under this 
hypothesis, she grows up unhappy and unhealthy, 
and with her ovaries threatened by every new doctor 
she calls. As I have mentioned, this state of high 
mental tension is often acquired by business-men 
who have allowed their affairs to grow beyond their 
strength to handle. Such men, ignorant of or in- 
different to the laws of mental hygiene, can, by 
ignoring the loud clamors for rest for the weary 
brain, bring about that state of low physical resist- 
ance so inviting to infectious or organic disease. 
The physician's duty in all these cases is almost 
entirely educational. Such cases in men are easily 
treated, the condition being obviously a late ac- 
quirement. A few months of mental rest will effect 
a cure. 

To an unfortunate woman, whose state is the 
result of early training, worry is more nearly 
natural, and to attempt to cure would be to attempt 
to bring about an actual revolution in her character, 
and those onlv can be cured who have some reason 



and understanding left to appeal to. Let such a 
woman be told that she has nervous prostration, 
but let it be explained to her what is meant by that ; 
Jet her be shown its cause, and be impressed with all 
the sympathetic eloquence at the physician's com- 
mand that there is no royal road to her cure ; that 
her improvement will be speedy or slow in propor- 
tion as she recognizes her condition ; that her phy- 
sician and attendants can only remind, encourage, 
and direct, but not cure. She must be warned that 
this fixed habit, the result of years of bad mental 
hygiene, can be changed only after long and patient 
work in developing and reviving the latent and atro- 
phied forces that still remain. Cases that have 
passed a point where reason, will, and understanding 
have been all but annihilated may eke out a toler- 
able existence with anodynes in a continual warfare 
with the weaknesses that have flourished too long. 

To benefit these cases in the line I have indicated 
there is obviously necessary a state of confidence in 
the physician, and a faith in the wisdom of his 
view of her condition. This is difficult of attain- 
ment at all times, and after the patient has reached 
a certain age, or her condition a certain degree, 
it passes all possibility. Such cases there are, and 
we have all seen them, who, inheriting this ten- 
dency to worry, this lack of will-power and self- 
reliance and reason, and having been subjected to 
the ignorant and vicious protection-system of early 
training, followed by a procession of female sym- 
pathizers to encourage every little selfishness and 
physical and mental ill, and accompanied by medical 
treatment as comprehensive as it is vague, ranging 
all the way from bread-pills and asafetida to ovari- 
ectomy, have at last reached a point where they 
have not one force left with which to cope with the 
tenderest possible conditions of life. The drawn 
mouth, the emaciation, the quick, nervous eye, the 
interciliary ridges and furrows, together with the 
never-ending list of complaints, will recall cases that 
have fallen victims to infectious or organic disease, 
or have faded away as simply unfit to survive. 

The prophylactic measures that the foregoing 
ideas suggest obviously comprehend certain advice 
to the mother of each newborn babe that opens a 
field too broad for me to enter and a responsibility 
too great for me to assume. 



To Prevent Thirst after Celiotomy Humiston {.hiwrt- 
can Journal of Obstetrics and Diseases of Women and 
ChildrcJi, July, 1895, p. 89) has the patient drink for 
three days previous to the operation a pint of hot water 
an hour before each meal and also on retiring, the last 
pint to be taken three hours before the time set for oper- 
ating. In this way is restored to the stomach the large 
amount of fluid lost by the free catharsis. This method 
has been followed in twelve cases, the patients present- 
ing a moist tongue, active renal function, and freedom 
from thirst. 



July 27, 1S95] 



CHRONIC ABSCESS OF THE BRAIN. 



95 



CLINICAL MEMORANDA. 

THREE CASES OF CHRONIC ABSCESS OF THE 
BRAIN. 

By J. T. ESKRIDGE, M.D., 

OF DEN-\-ER. COL. ; 
PROFESSOR OF NERVOUS AND MENTAL DISEASES IN TI 



Case I. — William E., thirty-one years old, white, 
ranchman by occupation, was admitted to St. Luke's 
Hospital on the evening of January 22, 1895, with sup- 
posed typhoid fever. It was impossible to obtain any 
facts in regard to the family history, and the patient's 
mind was so clouded that the personal history was very 
imperfect. He had led a very irregular, dissipated life, 
had indulged in alcohol for a number of years, and had 
contracted syphilis four years previously. It was learned, 
after his death, from a brother who had come from a 
distance, that several months before he had received a 
blow on the right side of the head which rendered him 
partially unconscious for some time, and that after re- 
covering from the immediate effects of the blow he 
returned to work on a ranch, but frequently complained 
of dizziness and great weakness. It is important to re- 
member that this information relating to the blow on 
the head was not given until after the patient's death, 
and was obtained by the brother of the patient from the 
friends of the sick man with whom the latter was stay- 
ing at the time of the injury. 

The only history that I could obtain on the patient's 
admission to the hospital, other than a meager account 
of his habits and syphilitic infection, was that he had 
suffered from headache for about two months. About 
the middle of December, 1894, his headache became 
intense, almost constant, and the pain was localized on 
the right side of the head, principally in the frontal 
region, but occasionally extending back to the occipital. 
Soon after this he was confined to his bed in an out-of-the- 
way place, where he could obtain no regular medical 
attention, and up to the time he was brought to the hos- 
pital he had remained in this condition, suffering from 
headache, loss of appetite, and great prostration. During 
this time he had emaciated rapidly and was supposed 
by his friends to be suffering from typhoid fever. To 
get him to the hospital it was necessary to bring him a 
distance of thirty-five miles, during intensely cold 
weather, in a wagon that was only partially covered. 
He was at first placed under the care of the general 
meaical attendant, but, on account of the patient's severe 
headache and paresis of one side of the body, I was 
asked to see him in consultation with Dr. Sewall, the 
attending physician at the hospital at the time, and Dr. 
Munn, who was called in because it was found impossi- 
ble to pass a catheter into the bladder on account of an 
old stricture. 

An examination was undertaken at about 10 p.m., two 
hours after the patient was brought to the hospital. 
When left alone the man lay in bed, breathing quietly 
and apparently sleeping ; on being spoken to he would 
rouse up for a moment and answer a question, but 
mental concentration was found to be impossible. His 
attention could only be secured for a few seconds at a 
time, when he would again relapse into a semi-conscious 
condition. The left arm and leg were much weaker 



than the right, with a tendency to flexor contraction of 
the arm at the elbow. The face did not seem affected. 
The right knee-jerk was increased ; the left greatly ex- 
aggerated. Ankle-clonus was absent on the right, but 
decided and continuous on the left. The right plantar 
reflex was very slight, the left absent. The right cre- 
masteric was present, the left absent. The e.xtensor 
reflexes of the forearms were normal on the right ; ex- 
aggerated on the left. The biceps and triceps reflexes 
were normal on the right ; exaggerated on the left. On 
account of the man's mental condition it was found im- 
possible to test the acuity of vision, but he was found 
completely hemianopic in the left half of each visual 
field. All of the external and internal ocular muscles 
seemed to be about normal, except that the pupils re- 
sponded slowly to light. Careful test was made for 
Wernicke's pupillary reflex, but this was not found. 

All forms of sensation seemed to be lessened or almost 
destroyed in the left arm and leg and throughout the 
left side of the trunk, but slight irritation of the left side 
of the face was felt ; sensation was, so far as I could de- 
termine, normal on the right side. Hearing with the 
watch, R. = 1/2; L. = 1/4; the tuning-fork was heard 
be'^ter with the right than with the left ear. The man 
was able to smell asafetida with either nostril, but the 
mental condition was too much obscured to compare 
the acuity of smell on the two sides : neither was it pos- 
sible to test satisfactorily the sense of taste. Dynamom- 
eter : R. = 112; L. = o. On further examination the 
left arm was found firmly adducted to the chest by con- 
tractures of the pectoral muscles, and this continued 
during sleep. Both optic nerves showed slight swelling, 
with considerable atrophy, narrowing of the arteries, 
slight tortuosity of the veins, and almost complete ob- 
literation of the normal line of demarcation between the 
nerve and the retina. The swelling of the optic disc 
amounted to one diopter in each eye. The temperature 
was 97.4^ ; the pulse 40 ; the respirations 16. 

There was a very tight stricture of the urethra, and, on 
account of the difficulty of inserting a catheter. Dr. 
Munn fastened one in the bladder. The urine contained 
pus, albumin, and renal casts. 

The man was placed upon inunctions of blue oint- 
ment and rapidly increasing doses of potassium iodid, on 
the supposition that his brain-lesion was due to syphilis. 
The next morning it was found almost impossible to 
arouse him. The temperature was gy° in the right 
axilla and 98° in the left ; the pulse 52 ; the respirations 
12. By noon unconsciousness was complete and be- 
ginning Cheyne-Stokes respiration was apparent. At 
I P.M. the temperature in the right axilla was 97', in the 
left 98° ; the pulse 46 ; the respirations 16. The left arm 
and leg had become rigid, and the man soon passed 
into a state of deep coma, and gradually sank, and died 
on the morning of the 2Sth, about five days after I first 
saw him. 

During the first three days of the patient's stay in the 
hospital his temperature was subnormal by 1° or 1.5° on 
the unaffected side, and about 0.5° on the paretic side, 
whose muscles were contractured and rigid. Pulse and 
respiration were slow, the latter at times being only ten 
per minute. During the first three days the pulse was 
never found above 50, the average frequency being 
about 44, although occasionally it was as low as 40. At 
no time was there complete paralysis of the arm or leg. 



96 



CHRONIC ABSCESS OF THE BRAIN. 



[Medical News 



but both were in a paretic condition, and the muscles 
rigid and contractured, and this condition increased up 
to a day or two before dissolution. On the fourth day 
the temperature reached normal, the pulse 64, the res- 
pirations 20. On the fifth day the temperature was 100.4°, 
the pulse 136, the respirations 48. On the morning of 
death the temperature was 104.6°, the pulse uncountable, 
and the respirations 56. 

An autopsy was held six hours after death by Drs. 
Axtell and Freeman. The dura was normal in appear- 
ance and in attachment to the bones, and no adhesions 
between it and the thin membranes existed. The superior 
longitudinal sinus contained a soft white clot in its 
anterior portion. The coagulum was an inch-and-a-half 
long and non-adherent. All the other sinuses were free 
from clots or other evidences of disease. On removing 
the dura the cortical veins over the left convexity were 
found to contain dark non-adherent clots. All the cor- 
tical veins were distended with fluid blood. No evidence 
of disease of the pia was apparent. The walls of the 
right middle cerebral artery presented several thickened 
areas before giving off the nutrient arteries to the great 
ganglia. On exposing the interior of the right cerebral 
hemisphere by several longitudinal incisions a large 
abscess, oblong in shape, about two-and-a-half inches 
in width, was found encapsulated in the centrum ovale 
of the temporal and parietooccipital region. The puru- 
lent accumulation extended forward from the cortex of 
the posterior portion of the occipital lobe to a point 
half-an-inch or more in front of the parieto-occipital 
fissure. About a quarter-of-an-inch of brain-substance 
intervened between the abscess and the posterior horn 
of the lateral ventricle. Neither the ganglia nor the 
cortical substance of the brain was directly invaded by 
the abscess. The capsule was dark, almost black, quite 
thick and had not ruptured. The pus, thin in certain 
portions and rather thick in other places, especially 
near the walls of the capsule, was light olive-green in 
appearance, and of a very offensive odor. The brain- 
substance was softened from the posterior portion of the 




Encapsulated abscess in centrum ovale of right cerebral 
hemisphere. 

occipital lobe forward to the region of the insula. The 
softening included both the cortical and the white 
substance, and to some extent also the great ganglia. 
The left hemisphere, the ventricles, the cerebellum, 
pons, and medulla showed no evidence of pathologic 
change. The bones of the nose and ear, on careful ex- 
amination, were found free from disease. Unfortunately 
the body had to be shipped a considerable distance for 



burial and permission could not be obtained to examine 
any organs besides the brain. I neglected to have cul- 
ture-tests made with the pus. 

The difficulties in the diagnosis of the exact nature of 
this case, even if aided by an accurate history, would 
have been very great, but in the absence of this impor- 
tant aid they proved insurmountable, although, on 
learning, after the patient's death, the history of the 
injury to the head, I was not surprised to find an abscess 
at the post-mortem examination. 

The three pathologic conditions discussed in attempt- 
ing to reach a diagnosis were thrombotic softening, 
tumor, and abscess. The history of syphilis was in 
favor of thrombosis, but the severe headache, extending 
over a period of one or two months, the rapid emacia- 
tion, and the slow pulse and respiration seemed suf- 
ficient to exclude such a lesion. Normal or subnormal 
temperature may be associated with slow softening fol- 
lowing occlusion of a cerebral vessel. From a number 
of observations, extending over a period of several 
years, I have been led to conclude that a sustained 
temperature of from a half to one degree higher on the 
paralyzed side than on the unaffected side, several weeks 
after the paralysis has become manifest, points to an 
irritative lesion of the brain as the cause of the paralysis. 
The choking of the discs was conclusive evidence of 
increased cerebral pressure, and I did not hesitate to 
exclude a vascular lesion from this symptom alone. 
Gowers states that choked discs may sometimes follow 
embolic occlusion of an artery, but such an occtirrence 
must be exceedingly rare, as I have not observed it, 
although I have for more than fifteen years carefully 
and repeatedly examined the fundi of the eyes of every 
patient coming under my observation suffering from 
embolism of a cerebral artery. 

The history of syphilis and of severe headache was 
in favor of a syphilitic growth, but the swelling of the 
optic discs was less than is commonly found associated 
with tumor. The marked emaciation and the low 
typhoid state could not be accounted for by the pres- 
ence of a cerebral growth, but such phenomena are fre- 
quent results of renal disease, and these had their origin 
in this case, in all probability, in the stricture of the 
urethra and a sequential cystitis. Low temperature is 
common in tumor or abscess of the brain, and I have 
not infrequently found the temperature higher on the 
paralyzed side in hemiplegia of several months' dura- 
tion, caused by a growth in the brain. In the absence 
of any obtrusive cause of suppuration a provisional 
diagnosis of a syphilitic tumor of the brain was made, 
■T^nd the patient was treated accordingly. I have 
larely found muscles that were paretic, or almost com- 
pletely paralyzed, become rigid and remain so for sev- 
eral days from the irritation of a cerebral growth, al- 
though I have observed this condition in several cases 
of abscess of the brain. The rigidity of the weakened 
muscles was well marked in this case, and it increased 
in intensity until a few hours before the patient's death. 
After obtaining, subsequent to the patient's death, the 
history of a blow on the head and an account of the 
symptoms that followed, including mental dulness, a 
confused feeling, and severe pain in the head, together 
with dizziness and emaciation, I was not surprised at the 
autopsy to find an abscess instead of a tumor. 

The right lateral homonymous hemianopia, hemi- 



July 27, 1895] 



CHRONIC ABSCESS OF THE BRAIN. 



97 



paresis, and partial hemianesthia, without the involve- 
ment of the other special senses, enabled me quite 
definitely to locate the lesion. Had an abscess been 
diagnosticated on the patient's admission to the hospital, 
his extreme prostration and renal and cystic complica- 
tions precluded any hope for relief from evacuating the 
contents of the abscess. 

The probable source of infection was an injury to the 
tissues of the scalp, although this is merely speculative 
in the absence of a more thorough post-morlem exami- 
nation, which was not possible under the circumstances. 

Case II. — John S., seventy-five years of age, white, a 
widower for a number of years, born in Ireland, by oc- 
cupation a laborer, of large physique, resident in Colo- 
rado since 1S70, was admitted to the Arapahoe County 
Hospital, January 22, 1895. The family history, so far 
as I was able to learn, was unimportant. His health in 
childhood had been good, and he had had no serious 
illness until his seventieth year. Earlier in life he had 
indulged rather freely in alcohol, but only rarely during 
the preceding five years. He denied syphilis, but ad- 
mitted an attack of gonorrhea twenty years ago. He 
received a bullet- wound in the left shoulder in 1S61 
while in the army. With the exception of the time dur- 
ing which he was disabled on account of the wound he 
said that he was never sick a day in his life, until twelve 
years ago, when he was kicked on the left shin. The 
injury was attended with great pain. Later a large ulcer 
developed, which nearly healed at times, but for a num- 
ber of years he had had a large open sore on this leg. 
One month before coming to the hospital, however, the 
ulcer completely healed, leaving a large, dark-colored, 
rough cicatrix which was very tender upon pressure. For 
some years the man had suffered from vague rheuma- 
toid pains in thelegs, especially in the knees and ankles, 
and in the entire left leg he had had a feeling of numbness 
for about five years. This leg seemed to him awkward, 
but he was able to walk with the aid of a cane. For a 
number of months there has been partial inability to 
control the bladder, and frequently he would soil the 
bedding and his clothes, and had to evacuate the blad- 
der several times during the night. The patient says 
that he was struck over the lower portion ot the back 
and nates by a cable-car early in January of the present 
year. He was able to rise and walk immediately after- 
ward, and he did not think that he had sustained much 
injury, although pressure over the lower portion ol the 
back gave him considerable pain. From the time of 
the accident he lost all control over the bladder, and the 
left leg was very weak. The left arm had been noticed 
to be weaker than the right. The patient had been ob- 
stinately constipated for a number of months. The 
right pupil, which was widely dilated and immobile, had 
been so for a number of years in consequence of an in- 
jury to this eye received eleven years before. 

On examination, January 22, 1895, it was found that 
the man was unable to stand on account of the weak- 
ness of the left leg, and the examination had to be con- 
ducted while the patient was lying in bed. An old scar 
was observed on the anterior surface of both legs below 
the knees, and was evidently the result of old ulcera- 
tion. The arteries of the extremities were hard and un- 
yielding. The left leg was very weak, but could be moved 
at all the joints, although the power was feeble and the 
movements were ataxic. The muscles of the ankle of 



the left leg were weaker than those of the knee, and the 
latter weaker than those of the hip. Muscular power 
seemed to be fairly good in the right leg. The left arm 
was weaker than the right. Dynamometer: right, loo; 
left, 40. There was slight rigidity in the left arm, with 
a tendency to hold the arm close to the side of the 
chest and flexed at right-angles at the elbow. The men- 
tal condition seemed feeble ; concentration of mind was 
very difficult; and it was almost impossible to keep the 
attention on one subject for more than a few minutes at 
a time. There was considerable loss of sensation 
throughout the left side, apparently more pronounced 
in the arm and leg than in the face. The knee-jerks 
were present, the left slightly increased, while the right 
was less than normal. The plantar reflexes and the 
tendo-Achillis reflex were present; ankle-clonus was 
absent. The cremasteric and the abdominal reflexes 
were absent. The external ocular muscles seemed to 
act normally. The right eye was cataractous, the pupil 
being widely dilated and not responding to light or in 
accommodation. The left pupil was very small, and 
did not respond to an active mydriatic, so that an exam- 
ination of the fundus of either eye was not possible. 
There was apparent left lateral hemianopia of the left 
eye ; the fields of the right could not be tested on ac- 
count of the presence of the cataract. The mental 
hebetude was too great to permit of an accurate exami- 
nation of the special senses. 

The temperature was 98.2° ; the pulse 60 ; the respi- 
rations 24. During the first week of the man's stay in 
the hospital his temperature varied from 98° to 99.2°, 
usually being about 98.4° in the morning, and from 98.8° 
to 99° in the evening ; the pulse ranging from 54 to 90, 
only falling to 54 on one occasion, to 60 on three, and to 
66 on two, the usual variation being from 72 to 88 ; the 
respiration varied less than the pulse, ranging, except 
on two evenings, from 18 to 20. A record of tempera- 
ture, pulse, and respiration was made twice daily. Dur- 
ing this week the man gradually failed both mentally 
and physically. He soon lost all continuity of thought, 
and his mind was a complete blank for any event of 
recent occurrence. He ate but little, emaciated rapidly, 
and passed the discharges from the bladder and the 
bowels into the bed. During the second week, from 
January 29th to February 4th, there was continued 
gradual failure. The temperature ranged from 98° to 
99.4° ; the pulse between 60 and 80 ; the respirations be- 
tween 18 and 20. During the third week prostration 
increased rapidly, and the mind became a total blank. 
The temperature was a little lower than during the pre- 
ceding week, rising above 98.4° only once, when it 
reached 100° one evening, but most frequently it regis- 
tered 98°. The pulse varied from 70 to 96, averaging 
about 80, and was weak and compressible ; the respira- 
tion ranged from 20 to 36. The rigidity of the left arm 
and of the leg-muscles became more pronounced. On 
February 12th the patient passed into a deep comatose 
condition, the muscular rigidity began to relax, and at 
5 P.M. the temperature was 99°, the pulse 100, the respi- 
rations 24. The ne.xt morning at seven o'clock the tem- 
perature had reached loi.4-,thepulse 120, the respirations 
40 ; and at 5 p.m. the temperature was 105°, the pulse 130, 
the respirations 36. Death took place during the night. 
The post-mortem examination was made about 
twenty hours after death by Dr. Leonard Freeman, 



CHRONIC ABSCESS OF THE BRAIN. 



[Medical News 



pathologist to the hospital. The dead-room was cold 
and the body thoroughly frozen. Unfortunately, only 
the contents of the cranial cavity were examined. The 
adhesion of the dura to the bones was not abnormal. The 
membranes and the cortical surface of the brain, on both 
the convex and basilar surfaces, showed no evidence 
of disease. The vessels were atheromatous, but not to 
a pronounced degree for one seventy-five years old. On 
sectioning the left cerebral hemisphere no gross patho- 
logic change was found, but in the right hemisphere an 
encapsulated cavity, about two inches in diameter, con- 
taining a foreign substance presenting an appearance 
almost identical with orange water-ice, was found in the 
centrum ovale of the parieto-occipital region. The greater 
portion of the pathologic process had taken place in the 
occipital lobe. The lateral ventricle had not been 
broken into, but only a very thin partition of brain-sub- 
stance intervened between the cavity and the posterior 
horn of this ventricle. None of the cortical substance 
of the brain had been directly involved by the foreign 
substance, which was so situated as to exert pressure on 
the right internal capsule. Dr. Bane, at my request, made 
a drawing of the cavity, /;; situ, before its contents were 
allowed to thaw. 

Fig. 2. 







I. Abscess. 2. Posterior horn of lateral ventricle. 

No evidence of gross disease was found in any other 
portion of the brain. In the frozen state it was impos- 
sible to determine whether the lesion was a cyst or an 
old abscess. The melted contents of the cavity pre- 
sented the appearance of a watery straw-colored liquid, 
and seemed to be the product of a cyst, but the micro- 
scope showed numerous granular and broken-down 
pus-cells, proving the lesion to be a chronic abscess. 
There was no odor. After warming the brain the right 
hemisphere was found to be much softer than the left, 
but the extent of the ante-mortem softening could not 
be determined, as brain-substance softens so rapidly on 
being warmed after it has been frozen. The bones of 
the ears showed no evidence of disease. 

Although I had had an opportunity of studying this 
case for a period of three weeks, the presence of an 
abscess of the brain had not been suspected before 
death, and the discovery of one at the autopsy was a 
great surprise to me. The age of the patient, the ather- 
omatous condition of the radial arteries, and the 
comparatively sudden onset of the paretic condition 



with the subsequent symptoms of cerebral softening, 
led me to diagnosticate arterial thrombosis. The tem- 
perature was normal or nearly so, as is common to both 
.abscess and slow necrotic softening taking place after 
occlusion of a cerebral artery. I regret that I did not 
make a careful comparison of the temperature in each 
axilla. It is probable that the temperature would have 
been found higher on the paralyzed than on the unaf- 
fected side. In hemiplegia from necrotic softening it is 
likely that this difference of temperature in the two 
axillte does not exist to a marked degree, and when 
present is not persistent, except possibly when the lesion 
causing the softening is an irritative one, as sometimes 
happens in acute softening from obstruction of large ves- 
sels. The history of a fall did not militate against throm- 
bosis, as the head did not appear to have been injured 
at the time, and it is not infrequent for occlusion of a 
cerebral artery in the aged to be preceded by increased 
physical exertion, which may or may not be a contribut- 
ing influence in the final closure of a narrowed vessel. 
As it was impossible to obtain a view of the ocular 
fundi, the condition of the discs could not be ascer- 
tained. The absence of headache was in favor of a 
vascular lesion, and against abscess or tumor. 

In a man seventy-five years of age, presenting a hemi- 
plegic lesion, in the absence of a growth or the history 
of one in other portions of the body, the presence of 
tumor of the brain will not be suspected. 

While no age is probably exempt from abscess of the 
brain, the infrequency with which it occurs in extreme 
old age made it improbable that I should meet with it 
in a man seventy-five years old. Of 223 cases of ab- 
scess of the brain, only one was found at the seventieth 
year or over. (Cowers.) There was no discoverable 
cause for cerebral suppuration. There was no discharge 
from the ear and no history of any. The nose seemed 
to be free from infective material, and no evidence of a 
purulent accumulation in the thoracic or abdominal 
cavity was detected. In reviewing the history of the 
case after the autopsy revealed an abscess of the brain, 
it has occurred to me that the large open sore on the leg 
might have furnished the portal of entry for the infec- 
tive material with which the brain-substance became 
infected. The ulcer had given trouble for a period of 
twelve years, but it had entirely healed, the man said, a 
month before he came to the hospital. The appearance 
of the cicatrix indicated that the sore had been healed 
several months. It is probable that as his memory for 
recent events was greatly impaired on his entering the 
hospital, events that occurred months or years before 
appeared to his mind of a later date. This loss of time- 
sense is common in dementia, especially of the senile 
variety. We must remember that the left leg had ap- 
peared numb, weak, and awkward for a period of five 
years, and for a number of months the man had lost 
partial control of the bladder. The capsule of the ab- 
scess and its contents indicated that several months at 
least had elapsed since the cerebral suppuration had be- 
gun. What part the blow upon the lower portion of the 
spine had to do with causing the abscess it is impossible 
to say. No tenderness of this portion of the spine was 
detected at the time of my examination. If the blow 
was received only two weeks before the man entered the 
hospital, as he states, it is quite evident that it played no 
1 part in the causation of the cerebral suppuration, but, as 



July 27, 1S95] 



CHRONIC ABSCESS OF THE BRAIN. 



99 



before stated, his time-sense for recent events was im- 
paired and no reliance could be placed upon his state- 
ments relating to time, especially for things of compara- 
tively recent date. 

Had the diagnosis of cerebral abscess been made on 
the patient's admission into the nervous wards of the 
hospital, I should have urged a surgical operation, as no 
hope could be entertained without the evacuation of the 
abscess, although the extreme ^ge and prostration of the 
patient would seem to have precluded almost the possi- 
bility of recovery under such unfavorable circumstances. 

Case III. — E. P., a male, thirty-seven years of age, 
born in Germany, a tailor by occupation, had lived in 
Colorado four years. The family history shows tuber- 
culosis, renal and cardiac troubles in several members 
of the family. The patient's health in childhood was 
fairly good; he suffered from measles and scarlet fever 
when a child, but never had any ear-trouble. His 
habits have been bad ; he has been a free drinker ; has 
suffered several times from gonorrhea, and contracted a 
hard chancre about ten years ago. He never received 
a blow upon the head or a severe blow upon any portion 
of the body, so far as he knows. About eighteen months 
before 1 saw him he suffered from a severe " cold," and 
this was followed by prolonged purulent bronchial ex- 
pectoration. Soon after this he began to complain of 
headache. His general health failed ; he lost health 
and strength, and his mental power was weakened. He 
consulted a physician, who, on account of his syphilitic 
history and head-pains, treated him with potassium 
iodid for a number of months. His head-pains greatly 
lessened, but did not entirely subside, and he continued 
rather weak. His appetite was poor and vacillating, 
his bowels were constipated, and he was unequal to his 
work, both mentally and physically. He found it an 
effort to perform the merest routine duties of his shop, 
and it was distressing to him to make any mental effort. 
He continued in this condition for some fourteen or 
fifteen months, when his headache again increased, 
mental confusion became greater, and he felt a sense of 
physical prostration continually. Sleep was poor; he 
passed restless nights, became very much emaciated, 
and the headache was at times distressing. The man 
was again treated for syphihs of the brain, and again 
temporarily, but only slightly, improved in health. He 
became drowsy and had to discontinue his work. With 
the exception of taking occasional short walks, he re- 
mained in his room the most of the time for two or three 
days. After passing a rather restless night he arose in 
the morning to dress himse'f, but before he had com- 
pleted his toilet he fell to the floor, and when found, 
several hours afterward, he was mentally confused and 
unable to rise. 

I saw the man a few hours later, when he was lying 
quietly in bed, apparently sleeping. There was a little 
stertor in his respiration ; his temperature was about one 
degree below normal in the right axilla and half a de- 
gree in the left. The pulse was 60, full and strong ; 
and the respiration was 12 per minute. He was easily 
roused from his soporose condition, and seemed for 
a moment to appreciate what was said to him ; but if 
left alone, he almost immediately relapsed into an un- 
conscious state. The left arm and leg were almost com- 
pletely paralyzed, the paralysis being more pronounced 
in the leg than in the arm, but the face did not seem to 



be affected, and the tongue was protruded in the median 
line. 

It was impossible to test the general sensory phenom- 
ena, but, so far as I was able to determine, sensation was 
less acute on the left side than on the right. Both knee- 
jerks were increased, the left to a greater degree than the 
right. The plantar reflexes were absent. Ankle-clonus 
was slight on the right and well pronounced on the left. 
The cremasteric and abdominal reflexes were barely 
perceptible on the right side and absent on the left. The 
pupils were equal and rather widely dilated, and reacted 
but feebly to light. There was no paralysis or paresis 
of the external ocular muscles. Both optic nerves were 
slightly atrophied, with some swelling of the discs, greater 
on the right side than on the left. There was apparent left 
lateral homonymous hemianopia, but it was difficult to 
test the visual fields accurately on account of the blunted 
mental state of the patient. The urine was free from 
albumin and sugar, and no rales were detected in the 
lungs. Headache was not spontaneously complained 
of, but on rousing the man and asking him if he had any 
pain, he said " yes," and pointed to his head. The stupor 
gradually deepened into coma ; the temperature con- 
tinued subnormal for several hours ; respiration rapidly 
increased ; the pulse became frequent ; and death took 
place twenty-four hours after the first manifestations of 
hemiplegic symptoms. The temperature before death 
was 103° in each axilla. 

The autopsy, which was held a few hours later, re- 
vealed an encapsulated chronic abscess in the centrum 
ovale on the right side. The abscess was oblong in 
shape, about two-and-a-half inches in its long diameter 
by two inches in its transverse. It was surrounded by 
dense fibrous walls, and extended posteriorly well into 
the occipital lobe, and anteriorly into the centrum ovale 
of the tempero-sphenoidal and parietal lobes. The 
cortex of the brain was not directly involved, nor was 
the internal capsule, but a thin layer of brain-substance 
intervened between the lateral ventricle and the abscess. 
The pus was thick, greenish, and offensive. The entire 
right side of the brain presented an edematous appear- 
ance. No pathologic changes besides these were found in 
the brain. On examination of the mastoid cells and the 
interior of the petrous portion of the temporal bones no 
evidence of disease was discovered. Permission was not 
granted to examine any other portion of the body. 

It is impossible to discuss the probabilities of arriving 
at a diagnosis during the time of the formation of the 
abscess, which possibly dated back some fifteen or 
eighteen months before the patient's death, or about the 
time of the beginning of the head-symptoms following 
a purulent discharge from the lungs. When I first saw 
the man, a few hours previous to his death, the diagnosis 
lay between a vascular lesion, tumor, and abscess. The 
eye-changes were sufficient to exclude a vascular lesion 
as a cause of the prolonged symptoms. The syphilitic 
history and the marked amelioration of the symptoms 
from the use of potassium iodid pointed to a tumor of a 
syphilitic nature, but the choked discs presented less 
swelling than is commonly observed in cases of pro- 
gressive tumor of the brain. 1 have previously re- 
ported' a case whose history was somewhat similar to 
that in this case. In that patient the swelling of the 



I The Medical News, March 10, 1894. 



THE CONTINUED FEVER OF ENDOCARDITIS. 



[Medical News 



optic disc was well marked, a tumor was diagnosticated, 
and the autopsy revealed the presence of a growth, con- 
nected with which was a small focus of suppuration. 
Nothwithstanding the strong probabilities of a syphilitic 
growth, the history of a purulent bronchial discharge 
immediately preceding the development of cerebral 
symptoms and the slight swelling of the optic discs de- 
termined me to venture the diagnosis of chronic abscess. 

On first seeing the patient an operation was out of the 
question, as he was then dying from edema of the brain, 
which had resulted from the existence of the abscess. 
A post-mortem examination of the lungs would have 
been interesting and might have aided in determining 
the source of the infection, but unfortunately a thorough 
investigation was denied. 

The three abscesses, an account of which has been 
given in this paper, all occurred in the right cerebral 
hemisphere, all occupied nearly the same position in the 
centrum ovale, were all attended with left lateral homony- 
mous hemianopia, with great weakness of the left 
arm and leg, the loss of power being greater in the leg 
than in the arm, the face escaping almost entirely, and 
with sensory impairment on the left side. The infective 
material in two was probably derived from distant sup- 
puration, and in one from an injury of the scalp, 
although the incomplete post-mortem examination ren- 
ders this uncertain. 



THE CONTINUED FEVER OF ENDOCARDITIS.' 

By WILLIAM S. DISBROW, M.D., Ph.G., 

OF NEWARK, N. J. 

The subject to which I desire to call attention presents 
points of interest that I consider worthy of note, on ac- 
count of its rarity (judging from reported cases), the dif- 
ficulties associated in its diagnosis, the length of time it 
involves, and the various views held by different diag- 
nosticians of recognized reputation. 

The first case of which I find record is that of Dr. 
Mullin, of Hamilton, Ont., quoted by Professor Osier in 
his report of a case under his care, and which is in many 
respects closely similar to the one that I desire to report. 

In June, 1892, I was called to see a woman suffering 
from some slight pharyngeal trouble, but was unable to 
account for the rigors and fever with which it was asso- 
ciated, all out of proportion to what would be expected, 
even assuming the throat-condition to be other than 
benign in character. The patient had for three months 
previously been under the care of a physician of long 
experience and of sterling worth, who had recognized 
that she had valvular heart-disease, but owing to his ill- 
ness and death I became the medical attendant. She 
had at the time of my first visit a slight pharyngo-laryn- 
gitis, which soon yielded to proper treatment ; but I was 
surprised to find that the fever continued, together with 
marked debility, greater in degree than would be antici- 
pated in such an apparently trifling illness. 

On further inquiry it was learned that the woman was 
forty-five years old and married. Her father had died 
from pyemia, secondary to an accident to one of his 
fingers, and her mother had died at the age of fifty-six 
years, of pulmonary tuberculosis, secondary to pneu- 
monia. 

' Read before Practitioners' Club, March, 1895. 



About twelve years previously the patient had had a 
severe attack of articular rheumatism, from which she 
suffered for several weeks ; but from that time had been 
in fair health, with the exception of more or less pain in 
various joints of the body and stomach, and what had 
been diagnosticated as gastralgia by Dr. Janeway, of 
New York, whom she had consulted ; he at that time rec- 
ognized the valvular trouble, but considered it as the 
sequel of her rheumatism, and that it was not account- 
able for the pain from which she was then suffering. 

The fever continuing — constantly for days, then inter- 
mitting — latent tuberculous trouble was suspected, and 
a careful physical and bacteriologic examination was 
made, but nothing was found to indicate this as being 
the cause of the fever. 

Malarial toxemia was next considered, owing to the 
character of the fever ; the chills, which had become 
more numerous than before, sometimes recurring daily, 
and at other times being of a tertian type ; the tem- 
perature ranging from 102° to 102.5°, '^"' without inter- 
mission, occasionally in the morning 102° or 103°, but 
during the afternoon lower. Treatment for malaria was 
instituted, and pushed to the utmost limit for about a 
week, but with no result, the fever showing no appre- 
ciable change, while the chills, though slighter in char- 
acter, were not controlled. 

The symptoms having thus continued for about a 
month without improvement, Dr. Lippman, of New 
York, was called in consultation, but could find no ap- 
parent cause for the condition. 

Meanwhile the patient was able to be about, and had 
sufficient strength to walk, and even to take short rides 
into the country. It was thought advisable to send her 
out of the city, and this was done. Mt. Pocono was 
selected as being the most suitable place, but after stay- 
ing there for about three weeks she returned, but with- 
out improvement. She then for some time resided at 
Lakewood and also at Asbury Park, N. J., but with no 
resulting improvement, except a slight gain in appetite, 
and an altered mental condition, which had been tried to 
its utmost, and discouragement was now displacing hope. 

In August the woman complained of pain in the 
shoulder and ankle, which were slightly swollen, and 
soon more marked rheumatic symptoms developed, with 
an increased pulse and higher temperature, with occa- 
sional chills. These symptoms soon passed away, only 
to return again in a week or so, although at the time the 
treatment was of an anti-rheumatic character. 

Suspecting — although nothing indicated any trouble 
of a surgical character — that I might have overlooked 
some foci of suppuration. Dr. Weir, of New York, was 
called in consultation, and upon careful examination 
found no surgical cause for the trouble, and expressed 
his inability from his standpoint to enlighten me, but he 
favored the diagnosis of malarial poisoning. 

Dr. Edward J. Ill, of Newark, a gynecologist of wide 
experience and ability, was now called, but could find 
nothing in the genital organs to account for the very an- 
noying condition with which we were confronted. Dr. 
Ill and myself, upon examination of the chest, thought 
we could detect slight dulness in the right infrascapular 
region, and considered that it might be due to pleuritic 
adhesions, if not to some more extensive infiltration of 
the lung-substance, and again the question arose. Was 
the trouble not tuberculous ? 



July 27, 1895] 



THE CONTINUED FEVER OF ENDOCARDITIS. 



The valvular lesion was of course noted by all, but 
was not considered as bearing a causal relationship to the 
present illness. The fever continued without signs of 
abatement ; at times the temperature would show some 
indications of remaining at the normal, but only to rise 
to a higher level. 

In November, while in despair as to what to do, it 
struck me that the heart might be primarily at fault. I 
made a diagnosis of endocarditis, possibly ulcerative, on 
the ground of the well-known heart-trouble, the recur- 
rent attacks of rheumatism, the character of the fever, 
and by excluding all other conditions likely to give rise 
to similar symptoms. Salicylates were again tried more 
persistently, and for the first time since June the tem- 
perature was reduced for a few days to normal, and at 
times below normal, but it could not be kept down, 
rising on an average to 99° or 100^ during the day. 

Being now satisfied of the correctness of my diag- 
nosis, Dr. A. L. Loomis, of New York, was asked to see 
the case in consultation. Upon careful examination he 
found no evidence of tuberculous trouble, and, while ad- 
mitting that the valves of the heart were damaged, con- 
sidered that they had nothing to do with the fever, and 
that the case was one of autointoxication, due to a gouty 
or rheumatic condition of the patient, and recommended 
thorough intestinal antisepsis. All of these suggestions 
were carried out, but without result. The fever con- 
tinued the same; the urine was normal; the nutrition 
was fair, although the patient was getting weaker. These 
conditions continuing a few weeks longer. Dr. George 
S. Ward saw the case in consultation and considered 
malarial poisoning as the possible cause. 

In January, 1893, the patient began to fail rapidly. 
The temperature could be kept near the normal with 
salicylates or quinin, but the heart-sounds were rougher, 
and the condition was becoming alarming, the tempera- 
ture at times rising to 103° or 104°, and chills recurring 
every day or two. Everything that could be suggested 
was tried, but in vain. About one week previous to 
death the patient had a severe chill, followed by a tem- 
perature of 104. 5° ; the face became slightly edematous, 
the ankles and legs swollen, the pulse weaker and show- 
ing signs of failing compensation ; the urine scanty, 
albuminous, and bloody, and it was evident that the end 
was near. Dr. J. C. Young, of Newark, was in attend- 
ance the last few days of her life, and concurred with 
me in the diagnosis of endocarditis. 

On February 24th the mind was cloudy ; the urine 
became still more albuminous and bloody, the edema 
more pronounced, and death took place in coma on 
February 26, 1893. 

An autopsy was held nine hours after death, with the 
assistance of Dr. Young. The body was fairly well 
nourished. The liver and spleen were enlarged and 
hyperemic. The spleen weighed about twenty ounces, 
and upon its superior border was an old infarction about 
the size of a silver halfdollar. Lungs, pleura, and 
bronchial glands were normal. The pericardium con- 
tained about four ounces of fluid and was marked with 
some old inflammatory scars. 

The heart was hypertrophied ; the mitral valves were 
greatly eroded and studded with large granular deposits ; 
the chorda tendinea of the middle valve was so eroded 
as to be entirely severed, the free ends hanging into the 
cavity. 



The kidneys were engorged, and were of the large 
white variety. The rest of the body, with the exception 
of the brain, which was not examined, was to all appear- 
ances normal. 

With the post-mortem findings as noted, the only in- 
ference to draw is that in the presence of an old endo- 
carditis may we not have had an acute inflammation of 
an ulcerative character grafted upon it, and that the case 
is one of those rare instances in which long periods of 
fever are associated with indications of heart-trouble. 

Striimpell' states that " the recurrent form of acute en- 
docarditis consists of an acute increase of the endocar- 
dial process, brought on by some exciting cause in an 
organ already suffering from endocarditis. The acute 
disease may show all the gradations from the mildest 
grade to the severest forms. The mild cases often run 
their course without any special symptoms. To this 
form we must probably often refer the increase of fever, 
which lasts a longer or shorter time, and which we often 
see in patients with chronic valvular disease of the 
heart. In rarer cases the recurrent endocarditis comes 
on quite suddenly in the form of a severe acute disease. 
This sometimes seems to be clinically a primary, inde- 
pendent disease, especially if the previous chronic heart- 
disease has up to that time caused no special symptoms. 
The patient is attacked with general malaise, headache, 
chills and fever. The latter may be quite high — 104° 
(40' C.) and over — or moderate, varying between 100° 
and 102° (38°-39° C), or it may be entirely absent. In 
many cases it is intermittent when the increase is often 
associated with a chill. The symptoms in the heart 
may be quite pronounced, but in this form, too, they 
may be obscure and indefinite. The course is rarely 
rapid, and often lasts for weeks. In the further course 
of the disease we meet with cutaneous hemorrhages, 
retinal hemorrhages, articular swellings, large renal 
hemon-hages, or typical hemorrhagic nephritis — in short, 
just the same general type of disease as in the other 
malignant forms of acute endocarditis." 

In considering the history of these most interesting 
cases, we are prone to ask why they should be consid- 
ered as acute ; for certainly a valvular trouble lasting a 
year would be more appropriately classed as chronic, 
and on this point Osier, in commenting upon the case of 
Dr. Mullin, in which the fever lasted for more than a 
year, and in which the autopsy showed extensive vege- 
tations upon the mitral valves, states that the term acute 
is scarcely applicable to them, and further remarks that 
cases in which patients with chronic valve-disease are 
attacked with marked fever, and evidence of recent 
endocarditis, may present symptoms of a pyemic or a 
typhoid character and may run a most acute course, 
but those lasting weeks or months assume rather a 
chronic character. Quoting from Loomis, Osier states 
that when an individual already suffering from valvular 
disease of the heart is attacked with acute rheumatism 
the liability to acute endocarditis is increased, and even 
when rheumatism is absent acute endocarditis is liable 
to occur in the presence of old valvular disease. 

In reviewing the case here recorded, the temperature- 
range, extending over nine months to my personal 
knowledge, during which a careful record was kept, was 
the most pronounced feature, averaging from 101° to 

1 Text-book of Medicine. 



EXPERIMENTS WITH TEA. 



[Medical News 



101.5° throughout that time, the chills and the articular 
symptoms being concomitant and troublesome. 

Despite the old valvular trouble, followed by acute 
attacks of endocarditis, the cardiac compensation would 
possibly have continued for a still longer time had not 
the rupture of the heart-muscle brought on the crisis. 
The lesson to be learned from this case is that we must 
not be satisfied to ignore old valvular lesions of the 
heart, but should be watchful lest they assume renewed 
activity. 

151 Orcharu STRi:in. 

EXPERIMENTAL NOTE. 

SOME EXPERIMENTS WITH TEA. 

By peter McKECHNIE, M.D., 

The following results may be interesting to members 
of the profession. They represent the outcome of an 
inquiry into the action of tea on the digestive organs. 

The trial-experiments were carried on with test-tubes, 
a digestive fluid being prepared by making a glycerol 
extract of pepsin. The aliment used consisted of beef- 
fiber and egg-albumin. Measured quantities of each 
were used, and to six test-tubes containing the meat- 
fiber were added the glycerol extract and hydrochloric 
acid, also a measured quantity of tea, different lengths 
of time being given to each infusion, varying from five 
to twenty minutes, so that the different test-tubes each 
had a different degree of strength of tea. A seventh 
tube was used to fix the time required for the digestion 
of the meat-fiber alone, which proved to be about no 
minutes. With the tea added to the other test-tubes the 
time required for the digestion of an infusion of twenty 
minutes was the same as with one of five minutes, 
namely, 118.5 minutes. Another experiment was made 
on the same basis, but with the tannic acid precipitated 
by means of a gelatin solution. The result of this 
showed no appreciable difference in the time taken to 
digest that with tannic acid and that without tannic acid. 

The experiments were carried still further by means 
of a gastric fistula formed in a monkey's stomach. It 
was found on introducing the ingesta by the mouth that 
digestion was retarded about five minutes longer than 
when the ingesta and the tea were introduced through 
the mouth and the fistula respectively, thus showing that 
the tea exerts an inhibitory influence upon the salivary 
glands. When the tannic acid was precipitated and in- 
troduced in the same manner there was no difference in 
the time occupied in the digestion of the tea without 
tannic acid by the mouth as compared with that by the 
fistula, but there was an appreciable difference on the 
introduction of an infusion of twenty minutes without 
tannic acid as compared with an infusion of five min- 
utes with the tannic acid removed. The peristaltic 
action was retarded and the secretion of gastric juice 
diminished. I am of opinion that the tannic acid in the 
tea is not the injurious agent, but some of the less solu- 
ble extractive matters. 

With a view of ascertaining the value of the teas of 
different countries as dietetic agents I procured samples 
of Chinese, Ceylon, and Indian teas, and carried on ex- 
periments with them, an inlusion of equal quantities of 
each kind being used. The Indian and Ceylon teas 



gave a much stronger infusion in five minutes than the 
Chinese teas ; I found that digestion took place more 
quickly with the stronger infusions than with the weak. 
The secretion of gastric juice was increased consider- 
ably with the Indian and Ceylon teas. 

The reason 1 attribute for this is that Indian and Cey- 
lon teas contain a much higher percentage of caffein 
than Chinese teas, thus acting as a stimulant to the motor 
nerves and increasing the peristaltic action and flow of 
gastric juice. 

From the results of my observations I am inclined to 
think that the action of tea is not so injurious as some 
would like to make it out. It is greatly dependent on 
the method of infusing, whether its action is injurious or 
beneficial. Long-infused teas seem to extract some sub- 
stance, possibly an alkaloid, that has an inhibitory action 
on the nerves of the stomach. 1 may here state that an 
infusion of tea of twenty minutes with the tannic acid 
precipitated has the same bitter taste as the same tea 
with the tannic acid present, so that the bitterness in 
long-infused tea is not due to the tannic acid, but to 
some other ingredient. 

The method of preparation of the tea-leaf is another 
point that requires attention. Indian and Ceylon teas 
are prepared on a more highly scientific basis than those 
of Japan and China. The curling of the leaf is done in 
the first-mentioned countries by means of machinery, 
by which means the cell-walls are entirely broken up ; 
while in China and Japan the rolling is done by 
hand, which is a most imperfect method from an eco- 
nomic point of view, owing to the greater surface ex- 
posed. Through the entire breaking up of the cells in 
Indian and Ceylon teas, less tea requires to be used in 
order to get the same result as in Chinese tea ; thus with 
three pounds of either Indian or Ceylon tea the same 
amount of work can be done as with five pounds of 
China. In my experiments I found that an infusion of 
Indian and Ceylon teas in the proportion of forty-five 
grains to ten ounces of water gave a solution of the same 
specific gravity as an infusion of Chinese tea consisting of 
sixty grains to ten ounces. The experiments carried out 
with these infusions showed a marked superiority of the 
Indian and Ceylon teas in assisting digestion. On mak- 
ing a microscopic examination of the leaves after drying 
them, I found that in the case of the Ceylon and Indian 
leaf the water had extracted the free tannic acid, while 
in the Chinese teas there could be observed needle- 
shaped bundles within the interstices of the cells. 

I think that it would be advisable for medical men in 
studying the dietary of their patients to caution them 
against the use of long-infused teas. If a patient has 
tea which requires long infusion, there is something 
wrong, as the active principles can be extracted in five 
minutes from really good teas. Longer infusion is most 
injurious ; in fact, with Indian and Ceylon teas three 
minutes are quite sufficient. I shall continue my re- 
searches, and intend to study more of the chemistry of 
tea and its physiologic action on the nerve-centers. 



Eye, Ear, Nose, and Throat Clinic is the title of a new 
quarterly publication emanating from Kansas City, Mo., 
and edited by Drs. Flavel B. Tiftany and James E. 
Logan, and containing a department of neurology under 
the charge of Dr. John Punton. 



July 27, 1895] 



MEDICAL PROGRESS. 



103 



NEW DEVICE. 

A NEW COVER-SLIP FORCEPS. 

BY A. H.STEWART, M D., 



As the microscope comes into more general use by 
the physician, and as the study of bacteriology has be- 
come so necessary, new devices are constantly being 
brought forth to aid in research. Many new instruments 
are needed ; many old ones have become useless. 

There is no one instrument that is used by bacteriol- 
ogists so frequently as cover-slip forceps ; but every 
microscopist knows how inefficient are the cheap varie- 
ties and how comparatively expensive are the good 
ones, and none is entirely satisfactory. 

The forceps here illustrated has proved in my work 
more generally satisfactory than any other yet seen. It 
is made of coppered steel wire or German silver wire, 
and can be manufactured for about one-fifth the cost of 
the orignal Lindslay or the Cornet nickel-plated steel for- 
ceps, and is just as steady and durable. The spring is 
sufficiently strong to hold firmly a slide or cover-glass 
without allowing it to move from side to side and yet 




not powerful enough to break the glass. The blades of 
the forceps are locked, thus giving a perfectly steady 
movement and constant apposition when not in use. 
The extremities of the blades are small and circular and 
are made in such a way that the cover-slip held in posi- 
tion has a slight inclination downward away from the 
instrument, so that the stain when placed upon the 
cover-glass does not run down on the lower blade of the 
forceps, even when the blades are moist. 

When placed upon the table there is no tendency for 
the instrument to upset, the base being more than an 
inch wide, and when placed upon the side the cover- 
glass escapes injury, not striking the table because that 
end of the forceps is overbalanced by the other. 

The comparative cheapness and durability of this for- 
ceps will recommend it as a most valuable instrument, 
not alone for ordinary private work, but in large labor- 
atories where many men are at work, and large numbers 
of such instruments are required. 

It is manufactured by Bausch & Lomb, of Rochester, 
N. Y., and can be procured from dealers in microscopic 
supplies in Philadelphia. 

250 North Twelfth St. 

MEDICAL PROGRESS. 

In the Treatment of Fracture of the Patella Fowler 
(An?ui/s of Surgery, vol. xxi. No. 6, p. 627) recommends 
exposure of the fragments after the immediate effects of 
the injury have subsided, and before the occurrence of 
ligamentous union, for the purpose of clearing their sur- 
face of intervening soft parts, and the application of 
fixation-hooks somewhat lesembling Malgaigne's, ex- 



cept that a single instead of a double pair is applied. 
The parts are kept at rest for from fourteen to twenty- 
one days, or sufficiently long to permit of the subsidence 
of the effects of traumatism upon the surrounding 
structures, as well as the closure of a possible rupture 
of the upper recess of the capsule of the joint. During 
this period of waiting the time is advantageously occu- 
pied by daily cleansing of the parts with soap and water, 
and the application of gauze compresses wet with boro- 
salicylic solution, secured in position with a figure-of- 
eight bandage. 

The operation-wound, by which access is gained to 
the fracture, is placed either transversely or vertically ; 
if transverse, it commences at the inner edge of the 
patella slightly above its middle, curves sufficiently 
downward to include beneath the flap the line of frac- 
ture, crosses the front of the lower fragment just above 
the attachment of the ligamentum patellae, and ascends 
to terminate at a point opposite the place of commence- 
ment. The half-moon-shaped flap thus marked out is 
dissected back just far enough to expose the line of 
fracture and no further. Careful and systematic removal 
from between the fragments of the intervening mass, 
consisting of stretched and torn shreds of fibrous tissue 
and partially organized blood-clot, is now practised. 
This is greatly facilitated by first incising along the free 
margin of each fractured surface and loosening the 
mass at these points first. The blade is now slipped 
between the mass and the fractured surfaces, and the 
former freed from the latter without difficulty, and re- 
moved as one piece. Care is taken during this portion 
of the operation not to tilt or otherwise disturb the frag- 
ments, and to expose the joint-surfaces as little as pos- 
sible. No irritating fluid should be employed ; whatever 
portions ot the debris, blood-clots, etc., which may 
chance to fall into the gap between the fragments, and 
cannot be picked out by the dressing-forceps, may be 
removed with bits of sterihzed gauze grasped between 
the blades of hemostatic forceps. 

The fragments are now made to approximate each 
other as much as possible. One of the fixation-hooks 
is thrust into the bone at the site of the attachment of 
the ligamentum patelhe to the lower fragment. The 
other is pushed through the skin and into the bone at the 
site of the attachment of the rectus femoris to its upper 
border. With the fractured surfaces in perfect coapta- 
tion, as seen with the flap still turned back, the shanks 
of the fixation-hooks are drawn together and secured, 
and the fragments held in a most secure manner. Two 
or three very fine silk sutures may be employed to 
secure the edges of the soft parts along the line of frac- 
ture. The flap is now replaced and sutured with a con- 
tinuous subcuticular silk suture. Sterile gauze-dressings 
and non-absorbent cotton, secured in position by rollers, 
are applied ; and a plaster-of-Paris splint insures immo- 
bilization. If the curve of the transverse incision is prop- 
erly managed, the lower hook will be so placed as to 
secure the bone directly in the line of the incision, thus 
avoiding the passage of the former through a wound of 
its own in the skin. If the vertical incision is employed, 
both upper and lower hooks can be secured in the bone 
in the line of the incision. The transverse incision 
(U-shaped) gives better access to the parts if well 
curved. 

The fixation-hooks are permitted to remain for about 



I04 



THERAPEUTIC NOTES. 



[Medical News 



three weeks. Should it become necessary for any rea- 
son to remove them earlier, this can be done by opening 
the splint at the anterior knee-portion. The patient 
may recline, or sit, or go about in a wheel-chair during 
the convalescence. 

Colectomy. — Paul {Brilish Medical Journal, 1895, No. 
1795, p. 1 136) details eight cases of colectomy for vari- 
ous conditions, and summarizes his views as to those 
which are most suitable for operation and as to the best 
methods of accomplishing this. He believes that young 
subjects with a comparatively short history, who are 
passing mucus and blood in the stools, and in whom 
the tumor is large enough to be felt, are the cases in 
which the growth is most malignant. Unless very large, 
the affected part can be safely removed, but recurrence 
must be e.xpected. Older people, upward of forty-five 
years, with generally a longer history of gradually in- 
creasing constipation, frequently culminating in abso- 
lute and sudden obstruction, often have a ring-stricture, 
which is much less malignant, and when satisfactorily 
removed may undoubtedly be followed by permanent 
cure. Expression is given to a personal willingness to 
remove the growth in almost all cases in which there are 
no secondary deposits, but those who wish to select care- 
fully should be content with colotomy in the former 
class, and restrict colectomy to the latter. Attention is 
directed to the frequency with which the abdominal pain 
(colic) and vomiting of the earlier stages of chronic 
obstruction are mistaken and treated for dyspepsia. 
The sooner the disease is recognized the better is the 
surgeon's chance of success. 

The operation may be accomplished in two very dif- 
ferent ways, one by immediate and one by delayed ap- 
proximation, each being suitable for a certain class of 
cases. When the patient is in good condition, the abdo- 
men not distended, the tumor small, and the proximal 
end of the bowel not greatly hypertrophied, immediate 
approximation by Murphy's button-method is advised. 
When, however, the opposite of this condition prevails, 
it is strongly urged that the ends of the bowel should be 
brought out. The important steps of the operation are 
as follows; i. Exploration first in the middle line un- 
less the stricture has been located; 2, a sufficiently free 
incision over the site of the tumor; 3, after adhesions 
have been cleared away, ligation of the mesentery with 
the help of an aneurism-needle and sufficient division 
to free the bowel well beyond the growth on each side ; 
4, hanging the loop of bowel containing the growth or 
stricture out of the abdomen and sewing together the 
mesentery and the adjacent sides of the two ends. The 
stumps of the mesentery should lie beneath the bowel, 
where, if deemed advisable, it can be drained by pack- 
ing gauze down to it; 5, tight ligature of a glass intes- 
tinal drainage-tube into the bowel above and below the 
tumor and then cutting away the affected part ; 6, clos- 
ure of the ends of the wound with a few silkworm-gut 
sutures, passing through all the layers of the abdominal 
wall. The second stage of the operation, that of break- 
ing down the spur with an enterotome, should generally 
be undertaken about three weeks later. As soon as this 
has been satisfactorily accomplished, the artificial anus 
is closed by separating the roset of mucous membrane 
from the skin, turning it in, and bringing the freshened 
edges of the latter together over it. 



Absence of the Thyroid Gland in a Case of Cretinism Suc- 
cessfully Treated with Thyroid Extract and Fatal from Bron- 
cho-pneumonia. — BURCKHARDT {JifTiw M(di(.alc' de la 
Suisse Roiiiande, June 28, 1895, p. 341) has reported the 
case of a child, three years old, presenting a well-pro- 
nounced clinical picture of cretinism, in which marked 
improvement in the symptoms and physical character- 
istics followed the therapeutic employment of thyroid 
extract. The treatment had thus been continued for 
three months, when death ensued in the course of an 
attack of broncho-pneumonia. Upon post-mortem ex- 
amination most careful search failed to detect the pres- 
ence of thyroid tissue, the gland being replaced by adi- 
pose tissue. 

To Preserve Specimens of Urine, Leffmann {P/nladel- 
phia I\)lyclinic, vol. iv, No. 26, p. 271) has found chloro- 
form to answer most satisfactorily, from six to eight drops 
being added to each ounce. It yields with Fehhng's 
solution a reaction similar to sugar, but it does not react 
with the bismuth or the phenylhydrazin test nor prevent 
either of these when sugar is present. 



THERAPEUTIC NOTES. 

Forced Dilatation for the Relief of Diphtheric or Croupous 
Obstruction of the Larynx. — BoRS (XeiL' York Medical 
Journal, June 29, 1895, p. 822) has treated a series of 
cases of laryngeal obstruction arising in the course of 
diphtheria and croupous laryngitis by means of forced 
dilatation. F"or this purpose he uses an instrument 
consisting of a three-bladed, jointed dilating-canula, 
attached to a bent shaft contained in an introducing- 
handle. After the canula has been introduced into the 
larynx the blades are separated by means of a screw 
situated under the handle. The application occupies 
but a few moments, and in the majority of cases a single 
dilatation is sufficient. Should the growth of false mem- 
brane constantly recur, the manipulation should be 
undertaken every two or three hours for two or three 
days. The same procedure may be adopted in cases of 
laryngeal stenosis due to syphilitic and other cicatrices. 
The instrument is made in three sizes, of 2j<, 4, and 
5 mm. in diameter. 

A Simple Means of Preventing Nociurnal Enuresis. — 
Stumpf {MUncliener medicinische Wochcnschrijt, 1895, 
No. 24, p. 560), from physiologic and dynamic considera- 
tions, proposes to treat nocturnal enuresis by depressing 
the head and elevating the hips of the sleeping child, 
and has employed the method in some twelve cases in 
individuals of various ages and of both sexes with the 
best results. 

Pencils of Salicylic Acid. — 

R.— Salicylic acid .... 20 grams. 
While wax . . . . 25 " 

Lanolin . . . . • 55 " 

— America It Journal oj Pharmacy. 

In the Treatment of Aneurism CoHEN {^Philadelphia 
Polyclinic, vol. iv, No. 27, p. 282) employs hydrated 
calcium chlorid in doses of about a dram a day, in 
conjunction with rest and other suitable adjuvant meas- 



July 27, 1S95] COMPARATIVE STANDING OF AMERICAN MEDICAL PROFESSION. 



loS 



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SATURDAY. JULY 27, 1895. 



THE COMPARATIVE STANDING OF THE 
AMERICAN MEDICAL PROFESSION. 

We Americans have never been accused of being 
a too modest people. We have a due respect for our 
own achievements, and seldom hesitate to express it 
with vigor. But we are discriminating in our self- 
appreciation. We are just as keenly conscious of 
our defects as of our virtues, and as frank in bewail- 
ing them. 

That is the real difference between us and the 
Scotchman or the German, for instance. These 
seldom brag, but that is merely because they are so 
calmly confident of their overwhelming superiority. 
No word from them is needed. They and theirs 
speak for themselves, and simply overawe with con- 
viction any intelligent foreign mind. If you are not 
convinced, it's because you are not intelligent, and 
argument would be wasted on you. And they sel- 
dom or never invite the attention of the public to 
their defects, even when they see them, which isn't 
often. 

One of the things over which we are particularly 
fond of indulging in jeremiads is the " low stand- 
ing and standard of the profession in America." 
We bewail (and justly) the shortness of our college- 
courses, the lowness of our examination-require- 



ments, the abundance, shamelessness, and prosper- 
ousness of our charlatans, both in the profession 
and out of it, and the scandalous popularity of the 
patent medicine. All this is perfectly true, and its 
recognition is good Christian discipline for us. 
But, not content with this, we plunge further and 
declare that such a disgraceful state of affairs was 
never known in civilized country. As usual, " they 
order this matter better in France," say we, and 
proceed to declare that in England and on the Con- 
tinent all medical men are highly educated gentle- 
men, that self-advertising and violations of the Code 
are unheard of, and the patent-medicine nuisance 
almost abolished. And here is where we mistake. 
There is really no such tremendous difference as we 
imagine between the beam in our own eye and 
the mote in our European brother's. Each profes- 
sion has simply the defects of its surroundings. 

For instance, it is customary to declare that the 
quality of our profession must be poor because its 
numbers are so disproportionately large. We have 
actually one physician to every 500 inhabitants, 
four times as many as England (1:2000), six times 
as many as France, nearly eight times as many as 
Germany, and fourteen times as many as Russia or 
Spain (1:7000). Our low standards and the cheap- 
ness of our diplomas, we cry, have flooded us with 
a swarm of incompetent, half-educated men, whose 
numbers are the root of two-thirds of our troubles. 
If scientific Germany and decorous England are 
satisfied with one-fourth or one-sixth of our number, 
we must have a ruinous excess. 

But there are other factors to be taken into con- 
sideration, and legitimate ones, too. The law of 
supply and demand, for instance, and the density 
of population for another. One competent physi- 
cian is probably capable of properly performing the 
medical services required by 1500 or 2000 people, 
providing they are situated within a radius of three 
miles from his office, and for an even larger number 
within a mile ; but what about the district where he 
would have to drive forty miles to reach 500 people? 
A physician is just as absolute a necessity to a " cow- 
town " or mining-camp of 300 people, and no med- 
ical aid within fifty miles, as to a factory-village of 
5000. Indeed, many a " superfluous," poorly edu- 
cated, uncouth country doctor, out on the frontier, 
with his tiny clientele scattered over two counties, who 
loves his patients and his profession, commands as 
much of our admiration and respect, deserves as 
well of his country, and is as " necessary " in every 



io6 COMPARATIVE STANDING OF AMERICAN MEDICAL PROFESSION. [Medkai. News 



sense of the term as the most scholarly and polished 
consultant of a European center. If we were to 
divide this country and England each up into 
geographic settled districts, each requiring the 
residence of a physician, nearly two-thirds of our 
" excess of doctors" would disappear at once. 

A word in this connection in regard to our low 
standard of professional education. This, we must 
also recognize, has an economic basis which, in the 
past, has raised it to the dignity of a practical 
necessity. It is not merely due to our " natural 
slipshod tendency." Exactly the same state of 
affairs prevails among our merchants, our trades- 
men, our artisans — and for the same reason. In 
Europe a special education or years of apprentice- 
ship are considered necessary to fit a man for any 
occupation or trade, even for a farmer. Here the 
farmer turns merchant, the mechanic, lawyer, the 
ploughboy, preacher, at a few months' or even days' 
notice — and successfully, too, as our extraordinary 
material prosperity indicates. It is merely a ques- 
tion of supply and demand. With literally scores 
of new, independent, and widely separated commu- 
nities springing up every month, each one demand- 
ing a complete outfit of both brain-workers and 
muscle-workers, from judge to blacksmith, from 
bench to bellows, a rapid rate of production of 
"specialists" is absolutely necessary. The coun- 
try simply couldn't have been settled and kept 
civilized without it. The wonder is that, consider- 
ing the tremendous pressure under which the trans- 
formation took place, the results have been so good. 
On hunting-trips through the West ten or fifteen 
years ago it was a common experience for a doc- 
tor to be simply begged to stay in half the settle- 
ments he passed through ; office-rooms, building- 
lots, houses even, would be offered, and when de- 
clined the urgent request would be made for a 
member of the next graduating-class, an office- 
student even, " anyone who knows how to deliver 
a woman and set a broken leg, for there's no doctor 
short of the fort, sixty miles away." Our " rapid- 
process " doctors have really been filling a genuine 
civic need of great importance. The greater part 
of our territory has now been supplied with its 
"geographically necessary" medical staff, and 
behold the result! A rapid elevation of the 
standard of education and a unanimous lengthen- 
ing, nearly doubling of the course by almost every 
reputable medical school in the country. 

The motive which led to this elevation had, of 



course, no connection with the economic influences, 
but these latter rendered the triumph of the better 
element possible. Just as long as a " six-weeks 
doctor " can go West and pick up a living practice 
at once so long a certain class of schools will turn 
out that kind and no other. 

There is also another consideration in regard to 
our "oversupply" of physicians, which may seem 
at first sight fanciful, but which it seems to us has 
real weight. And that is, that the more highly 
civilized and the more intelligent a people the 
larger proportion of physicians will be needed. 
Not because disease becomes more common, but 
because a higher standard of health, comfort, and 
efficiency is demanded. There is little need for 
oculists, for instance, in an illiterate community, 
and the Cossack of the Don has little use for sanita- 
rians or health-officers. More than this, the sensi- 
tiveness of the organism counts for much; the peas- 
ant, artisan, and even middle classes of Europe will 
suffer ten times as much in the way of pain, disfig- 
urement, or disability, as our native Americans 
before they will consult a doctor. We seldom see 
"typical cases" of certain diseases described by 
our German and Austrian confreres, simply because 
they are not permitted to develop so long without 
interference from either medicine or soap. As an 
illustration of our meaning, it is a matter of com- 
mon observation by Americans abroad that even 
well-educated and well-to-do Europeans will toler- 
ate for years a condition of their teeth and gums 
which would be considered simply unendurable, if 
not actually disgraceful, here. 

In short, the number of physicians is a good 
index of the intelligence of a race. And as civiliza- 
tion becomes more complex, and the whole field of 
preventive medicine, scarcely surveyed as yet, is 
added to our domain, a still higher proportion of 
skilled, intelligent advisers will be demanded by 
the community. 

But, says someone, are we developing many such 
men or encouraging their development, or will not 
the mass of half-Hedged living-makers overwhelm 
the small minority of scholars and maintain a low 
professional tone and standard in spite of every- 
thing ? By no manner of means. The question is 
somewhat on the order of Carlyle's celebrated 
conundrum, " How can the united sagacity of 
fools constitute wisdom?" It is the best, the 
broadest, the most devoted men, from hamlet to 
metropolis, who sound the key-note and who set 



July 27, 1895] COMPARATIVE STANDING OF AMERICAN MEDICAL PROFESSION. 



107 



the pace. Partly because cream always rises to the 
top, but, in still larger degree, because the great 
mass of imperfectly prepared physicians are keenly 
conscious of their defects and anxious to remedy 
them. Some, of course, fossilize into the pompous 
walking-dictionary of their parish, the self-satisfied 
oracle of admiring grandmothers, with " sure cures" 
for everything; but they are few and absolutely 
without influence on the mass. A half-educated 
man, who knows himself to be so, is often a much 
more desirable member of the profession than a 
well-educated man who is thoroughly aware of the 
fact. The former has unconsciously attained the 
Socratic attitude, " I know nothing, e.xcept that I 
know nothing; others do not know even this." 
There is a striking difference between the European 
profession and our own in this respect. The aver- 
age British practitioner, college -bred and hospital- 
trained for five long years, with a couple of terms 
as interne added, usually buys himself a practice or 
a partnership and settles down for life. He reads 
his single medical journal, of course, attends his 
county society, goes to the British Medical Associa- 
tion when it comes within fifty miles of him, and 
occasionally revisits his old hospital, or attends a 
few clinics when in London with a patient. But 
as for post-graduate courses, even in London or 
Edinburgh, to say nothing of Paris or Vienna, he 
never thinks of such a thing. He has much to 
learn yet, of course, but his education is practically 
complete ; experience is all he needs. There is 
but one post-graduate course in all London, and 
that was gotten up for the benefit of Americans. 
There are many honorable exceptions, of course 
(the F.R.C.S. and M.R.C.P. men, for instance); 
but the English practicing physician who has studied 
abroad or taken up systematic work of any sort since 
his graduation is rare. Much the same state of 
affairs prevails in France, Germany, and Austria. 
Visit any great medical center and one will see ten 
American students to one of any other foreign 
nationality. The true Deutscher indeed would 
scorn to study outside of the Vaterland, and even 
consultants and teachers in Germany too often 
know little of and care less for the work which is 
being done in their own field elsewhere. 

With all its faults and pretentiousness our 
post-graduate course is one of our most useful 
institutions, and the resolute determination and 
enterprise with which the majority of our " two- 
year" men avail themselves of its privileges com- 



pel our respect and admiration. No sooner is the 
horse and buggy earned, and the first payments 
made on house and lot, than our country doctor 
begins to lay by money to take a winter course, or 
even an additional year in New York or Chicago. 
A few years later he goes abroad, and this habit is 
kept up more or less through the whole of his pro- 
fessional life. We can scarcely go into any middle 
or western town of 2000 people, or even rural dis- 
trict of the same population, without finding some 
doctor who has spent one or more winters or springs 
in Philadelphia or New York, and not infrequently 
in Vienna or Paris. It is true the majority of us 
are imperfectly educated, but we are not ashamed 
to admit it, and we are doing our best to remedy 
the defect. 

We are also accustomed to assume in the depths of 
our self-depreciation that our general ethical tone as 
a profession is far below the European one. Nothing 
could be further from the truth. From personal 
ex perience we do not hesitate to say that the tone 
of our profession as to courtesy, modesty, and 
ethical qualities generally is but little below that of 
England, and far above that of either Germany or 
Austria. The disgraceful promptness and certainty 
with which all new remedies and appliances get 
themselves patented in Germany is a case in point, 
as is also the attempt to cover Behring's antitoxin 
in the same manner. The German or Austrian is 
permitted to trumpet his own praises abroad, or 
denounce and belittle his rival brother in a way that 
would scandalize even the Bunkum County Medical 
Society. His titles and official rank are spread 
before the public at full length on every possible 
occasion, and woe betide the unlucky wight who 
omits the least of them in addressing him. The 
shower of abuse and vilification poured upon Sir 
Morrell Mackenzie by the court-physicians, in 
the case of the Emperor Frederick, even granting 
every possible provocation on his part, was a dis- 
grace to the entire German profession. Fancy 
Agnew and Hamilton abusing Bliss after that 
fashion in the Garfield case, no matter what he 
did! 

As to personal courtesies, it is no unusual thing 
for Austrian consultants to charge fees, and heavy 
ones, too, for services or even advice to visiting 
English and American physicians. When it comes 
to that truest test of a man's real breeding, his 
manner and behavior toward his hospital-patients, 
there is simply no comparison to be made between 



io8 



EDITORIAL COMMENTS. 



[Medical News 



the Continental and Anglo-American attitudes. It 
might be roughly summed up in one sentence : in 
America or England the chief object of interest 
and care is the patient, in Germany the disease. 

Last of all, we are apt to assume that quackery 
is a malady almost peculiar to our own soil, and 
that the official lists abroad represent all the healers 
of disease in their respective countries. It is true 
the fame of the American quack is world-wide, and 
his luster is unrivalled anywhere in Europe ; but, 
nevertheless, the fact remains that even the best- 
regulated countries in the world abound in "irreg- 
ulars " of every sort and description. First of all 
come the apothecaries, who in many parts of Eng- 
land, for instance, are more numerous than the 
physicians, and prescribe over their counters fully 
one-half of the medicine consumed in the country. 
The " pothecary " is the first resort of the vast 
mass of the laboring-classes, the doctor being far 
too expensive to be called, except as a last and 
direst necessity. Then come a horde of midwives, 
" bone-setters," " wise women," and so forth, down 
to the "seventh son of a seventh son," and the 
man who has bought or inherited a secret formula 
of magic value. 

As to patent medicines, although the term is one 
of our own coining, the goods it is applied to are 
cosmopolitan in their range. Though we use far 
more of them per capita here (as we do of all other 
luxuries), especially in prohibition communities, yet 
the sale of them in England, France, and Germany 
is simply enormous. Their advertisements swarm 
in every paper, appear upon every bill-board, street- 
car, and dodger, and would disfigure the landscape 
almost as horribly as they do on this side the At- 
lantic was not such defacement strictly forbidden 
by law. Indeed, in effrontery and in diabolical 
ingenuity of methods of thrusting their wares upon 
your notice, the French and English manufacturers 
are rapidly going ahead of our own. The columns 
of foreign papers and journals are coming to be even 
more heavily loaded with "ads" of this, and, in- 
deed, of all descriptions, than our home-ones. And 
this latter tendency is noticeable in even the medical 
journals. Even some models of British journalistic 
propriety carry heavier ballasts of legitimate adver- 
tisements in proportion to their canvas of reading- 
matter than would be considered entirely comme il 
faut by one of our first-class journals. 

In short, all professions, as all nations, have their 
shortcomings, and while we have many things to 



be heartily ashamed of, both as individuals and as 
a class, and should slacken our struggle for self- 
improvement not a whit, yet we think it only fair 
at times to take stock of our virtues as well as our 
vices, and to cheer ourselves with the thought that 
with all our shortcomings our intentions are good, 
our hearts in the right place, and our rate of progress 
distinctly appreciable. 



EDITORIAL COMMENTS. 

Hippophagy. — It is an ill wind that blows nobody good, 
and the late appalling fall in the price of horses, due to 
the introduction of the electric trolley and the bicycle, 
has turned the attention of our thrifty farmers to the 
question of the utilization of horse-flesh as an article of 
diet. None of them seems at all desirous to make the 
experiment himself, but they fail to see why it should not 
form an excellent and healthful food for somebody else. 
In fact, the project has been seriously considered just 
lately of shipping horses on the hoof to Germany, where 
they are sufficiently enlightened to have no prejudice 
against this luxury. According to Secretary Morton, 
nearly 10,000 horses are slaughtered every year in Ger- 
many alone for food purposes, a large proportion being 
used in the production of their favorite " horse-sausage." 
The average price paid by the butchers is about $35 a 
head, which would yield quite a good profit to the 
shippers. 

Now why should we not do likewise and save the poor 
ponies all the horrors of sea-sickness and transportation. 
We copy Germany as nearly as we can in pathologic 
matters already. Why not also in dietetic customs ? 
The only obstacle is mere popular prejudice against 
eating horse-meat. We might succeed in introducing a 
little of the sausage, because we are already accustomed 
to the use of man's next nearest four-footed companion, 
the dog, in that form, but as to coltsteaks and mare- 
cutlets there would be difficulty. 

Seriously, however, why should we not add horse-flesh 
to our bill-of-fare ? There is absolutely no physiologic 
or hygienic reason why it should not be as nutritious, 
healthful, and palatable a food as the flesh of the ox or 
the sheep. Indeed, there is abundance of evidence from 
all climes that it is the equal of beef and mutton in all 
three of these respects. The Tartar hordes of the Siber- 
ian steppes depend on their horses almost entirely for 
meat as well as milk and clothing ; as also did the 
Scythians of antiquity. In war and in times of scarcity 
horse-flesh has been used hundreds of times and with 
most satisfactory results. During the last siege of Paris, 
for instance, thousands of horses were consumed, and 
the meat was found so palatable that dozens of butcher- 
shops still do a large trade in it — a trade that is steadily 
increasing, especially among the laboring-classes. The 
meat is said to be almost indistinguishable from beef, 
though of finer grain and more marked flavor. This is 
extremely favorable when we remember that most of the 
animals killed have been such as through age or injury 
were incapacited for hard work. Curiously enough, 
mule-beef is said to be still juicier and better flavored. 



July 27, 1895I 



EDITORIAL COMMENTS. 



109 



In fact, the only objection that can be raised is on the 
score of expense, and that has now been completely re- 
moved, as many horse-raisers would be glad to get good 
" beef-prices " for all but their choicer stock. 

Besides being a valuable addition to the variety of our 
flesh-foods, in the light of recent bacteriologic develop- 
ments there would be another advantage that might 
make the use of horse-meat of great importance to the 
community. This is the almqst complete immunity of 
the horse to tuberculosis. If, in addition, a breed of 
horses could be developed with special reference to their 
milking- powers — equine Jerseys, as it were — and their 
milk substituted for that pernicious e.xtract of tuberculous 
bovines that at present fills our nursing-bottles and milk- 
pitchers, what a threatening shadow would be lifted from 
our national future ! By all means let us urge horse- 
flesh and mare's milk upon our patients if only to relieve 
the anxiety of our bacteriologic friends and save the 
babies from sterilized milk. Of course, from a purely 
scientific point of view they had better starve on that 
than grow fat on tuberculous lacteal fluid, but mothers 
and even doctors cannot see it so. Indeed, mare's 
milk should be a sure prophylactic against " mare's 
nests " of all kinds. 

Typhoid Fever and the Brand Method. — In the report of 
the German Hospital of Philadelphia, recently issued, 
we find the percentage of deaths from typhoid fever 
treated in that institution during the year to be l(>y^ per 
cent. — 78 cases with 13 deaths. The German Hospital 
has been the home of the so-called cold-water treat- 
ment in this country, and the beneficial results of the 
treatment in this institution in previous years have been 
largely quoted. The following table shows the number 
of cases of typhoid fever treated and the mortality from 
the year 1890. when the Brand method was introduced: 



1890 



1894 



106 
116 



14.8 
16.6 



In The Medic.\l News of November 26, 1892, Dr. J. 
C. Wilson reported one series of 160 cases, treated ac- 
cording to the method of Brand, with 8 deaths, or 5 per 
cent. ; and another series of 66 cases, with 4 deaths, or 
6 per cent. (These cases are included in the figures 
already given, though differently arranged.) It would be 
interesting to determine what has caused this unfavora- 
ble increase in the mortality-rate under the cold-water 
treatment. As far as we can learn, the methods have 
not been changed, and the disease in Philadelphia has 
not been especially virulent. The death-rate varies in 
different years. In the same hospital, previous to 1890, 
the mortality varied from 1 1 per cent, to 20 per cent. 

The Pennsylvania Hospital typhoid-fever statistics are 
as follows : 



1890 



1894 



No. ofcasi 
treated. 
. 126 
• 144 
. 104 



The Presbyterian Hospital reports show the following : 

^°:°llT^ Deaths. Percent. 



1893 
1894 

In the Pennsylvania and the Presbyterian hospitals 
the Brand method has been used in the majority of 
cases during the last two years. 

There is some danger of such a method of treatment 
becoming routine, to the exclusion of all other treatment, 
and this is always to be guarded against. The cold bath 
has decided advantages, and when carefully given and 
controlled, and each case judged by itself, it is a thera- 
peutic agency of great worth ; but if it is considered in 
the light of a specific agency, and each patient is sub- 
jected to it. the bulk of the work being left in the hands 
of the nurses, there is some liability to suffer from an 
increase in the mortality-rate. One of the good effects 
of the Brand treatment is the constant watching that is 
required, the frequent noting of the temperature, etc. 

Sixteen-and-twothirds per cent, mortahty is not a 
very favorable showing for the cold-water treatment, 
although the managers of the German Hospital in their 
report still seem to regard the results as most encour- 
aging, and give large praise to the treatment. It would 
be interesting to conduct a series of experiments in the 
same hospital, at the same time, with a sufficient num- 
ber of cases and extending over a considerable period 
of time, one group of cases to receive the Brand treat- 
ment only, another group to be treated with intestinal 
antiseptics, and a third group to receive the two com- 
bined ; the bath for its antipyretic effect, the antiseptics 
for their local action. 

Opium as a Food. — Facts are sometimes against the 
professional reformers. Alcohol, in spite of the evil it 
does, has certain uses, and is steadily winning its way 
back to the tables of our educated classes. Tobacco 
has been authoritatively declared to be a necessity of 
city life, and one of the great buffers of the shocks of 
the rush of the nineteenth century. And now even a 
royal commission in an elaborate report has asserted 
that the use of opium by the inhabitants of India has a 
rational hygienic basis, and is not merely one of the 
" horrors of heathenism." In the first place, it is, we are 
assured, a valuable household remedy for the intestinal 
diseases that swarm in that climate, as paregoric and 
blackberry brandy are used by our country-folk. It is 
also regarded by the natives as a most reliable preven- 
tive of malarial diseases, and though not so recognized 
by the profession it has been highly esteemed for this 
purpose by many explorers. The commission does not 
say anything about snake-bites, which proves that they 
are not merely engaged in furnishing excuses for the 
appetite of the gentle Hindoo. Further than all this the 
report declares that the regular consumption of opium 
in moderate doses fills a place in the dietary similar to 
that occupied with us by tea and coffee. In other words, 
opium is a genuine food of the " force-regulator " class 
(Prout), and of value especially in connection with a 
coarse and restricted diet and a life of hardship. Its 
value was proved after the grimmest fashion during the 



REVIEWS. 



[Medical News 



building of the railway across Panama. One of the 
contractors came to the conclusion, whether upon eco- 
nomic or philanthropic grounds is not known, that 
opium was a baleful luxury to his army of coolies. Ac- 
cordingly, he cut off the supply. The men began to 
flag and sicken at once, but to this he paid little atten- 
tion, regarding it partly as shamming and partly the 
mere pangs of a morbid appetite. In less than a week, 
however, two-thirds were too weak to work ; dysentery 
broke out, and before the frightened contractor could 
secure a new supply of opium, from a distant port, nearly 
half the poor wretches had died, and the remainder 
were months in recovering their strength. In some dis- 
tricts of India the drug is actually given to horses on 
long and severe rides by couriers, despatch-bearers, and 
others. The moderate user of opium, says the commis- 
sion, seems to be as healthy, happy, and long-lived as 
the average abstainer. Its excessive use is, of course, 
injurious, as also is that of tea or pie, but such excess is 
said to be exceptional. As to the mechanism of the 
alimentary service of these food-narcotics, we are com- 
pletely in the dark ; but then so we are also as to their 
medicinal effects. The facts seem, however, to be un- 
questionable. We have the unanimous testimony of 
humanity to both. There is not a nation upon the 
globe of whose regular dietary one or more of them do 
not form a part. This fact alone establishes for the 
naturalist a high presumption in favor of their useful- 
ness. He, at least, cannot bring himself to believe that 
all men are fools. '' What all men in all times have 
believed " is considered a weighty argument now, even in 
theology. 

A Recent Action of the Illinois State Board of Health is 
worthy of mention. At the June meeting a resolution 
was passed requiring all medical students in the State of 
Illinois to pass their entrance-examination before the 
Faculty of the State University. This is following out 
the plan of the Regents of the University of the State 
of New York. It will relieve the medical colleges of 
Chicago of the necessity of holding these examinations, 
and it will place them all upon the same footing. 

During the past few years a number of new schools 
of medicine have come into the field and made compe- 
tition for the medical students in Chicago more severe. 
The preUminary examination has become a crucial 
point with many of them. Minnesota, Wisconsin, 
Iowa, and Missouri are favorably situated to follow New 
York and Illinois in this movement. 

At the last meeting of the Association of American 
Medical Colleges a resolution was introduced which will 
be acted upon at the coming meeting in Atlanta, re- 
quiring all colleges members of this Association to place 
their entrance-examinations outside of their own con- 
trol. Thus we see that the Boards of Health are sec- 
onding the efforts of medical educators in relieving the 
colleges of the only stigma that remains upon them. 

It is one step further in the same direction to place 
the examinations of all candidates for the degree of 
Doctor of Medicine, and for the licence to practise med- 
icine, in the hands of the Faculty of the State Univer- 
sity. This examination must become the rule both for 
the protection of the public and for the self-respect of 
the schools. 



Sexual Physiology in the Girls' High School. — In the Girl's 
High School of Philadelphia physiology is one of the 
regular studies, and yet in this study the questions of 
sex and generation are practically ignored. It seems 
that those in authority (not the teachers) are afraid the 
young women may learn something that they ought to 
know. Where is a girl to derive her knowledge of these 
subjects, we ask? Her mother will not tell her, or may 
be as incapable of instructing her in the functions of the 
sexual organs as she is incapable of teaching her the 
functions of the heart and brain. In civihzed communi- 
ties natural instincts are not proper or trustworthy guides, 
and consequently the only teachers that remain are 
companions who have derived their knowledge in some 
haphazard and dangerous way, or from sensational and 
unreliable literature. Three or four lectures on com- 
parative embryology would suffice to give the students 
the requisite knowledge, and a lecture on the hygiene 
of the sexual functions might be added. These girls, 
who are to be the future mothers of the community, 
cannot know too much about themselves, especially if 
the knowledge imparted is of the right kind. 

Commercial Hydrogen Dioxid. — In the current number of 
the .hiit-rican Journal of Pliarinacy is published a note 
on the strength of commercial samples of hydrogen 
dioxid. Twenty, five samples were tested, showing an 
average strength of 9.94 volumes, the highest being 10.37, 
the lowest 9.03 volumes. Unfortunately, the samples 
are designated only by numbers, no clue being given as 
to the manufacturers. Analytic statements of this char- 
acter are of little professional value. The reports should 
state the brands tested, the condition under which sam- 
ples were obtained, and should indicate, at least briefly, 
the method of analysis. 

Removal of the Editorial Office of the Medical and Sur- 
gical Reporter. — We learn with regret that our most es- 
teemed contemporary, the Medico/ and Suvi^ica! Re- 
porter, in order to be nearer the printing-office of its 
new pubUsher, has removed its editorial offices to New 
York. We are sorry that business reasons should force 
it to exchange the medical atmosphere of its lifelong 
home for one of such uncongenial surroundings. It is 
indeed true that the footings of our clearing-house trans- 
actions do not equal those of our self-complaisant sister 
city. 

REVIEWS. 

l.NDIGESTION. AN INTRODUCTION TO THE StUDV OF 

Diseases oftheSto.mach. By George Herschell, 
M.D. Lond. Second edition. New York: G. P. 
Putnam's Sons. London : Bailliere, Tindall & Cox, 
1895. 

Heretofore no English writer has attempted to 
describe stomach diseases from the modern stand- 
point. In making the attempt our author necessarily 
has departed widely from the course adopted in the 
former edition. In some respects the arrangement of sub- 
jects is admirable, and admits of greater simplicity and 
brevity than is usual. It is to be regretted that the author 
has not taken full advantage of his plan. Briefly stated, 
there are described, ist, normal digestion ; 2d, disturbed 



July 27, 1895] 



REVIEWS. 



digestion ; 3d, methods of examination ; 4th, pathology 
of special diseases ; 5th, treatment. Here is an oppor- 
tunity for the avoidance of repetition, but unfortunately, 
under the heading " Interrogation of Patient," there is 
introduced a chapter of subjective symptoms, most con- 
fusing to the student, for whom the book purports to 
have been written. It appears to be a concession lo 
more antiquated ideas of investigation, proper enough in 
its place, perhaps, but too conspicuous here. 

The modern methods of examination are for the most 
part clearly stated, and are sufficiently complete for a 
book of this character. The author's ideas of treatment 
are acceptable, and much good must be accomplished 
by spreading his doctrine in Great Britain. 

It is unfortunate that in the interests of brevity the 
element of style has been so much dis regarded, and, 
aside from this criterion, it must be admitted that the 
diction is imperfect. For instance, it is said (p. 176): 
" Obstruction in the duodenum may be either a neo- 
plasm, a cicatricial contraction, or due to a flexion." 
Again (p. 177): "Neurasthenia and many other symp- 
toms are caused by the absorption of toxins from the 
dilated stomach." Again (p. 176) : " The stomach being 
unable to ever absolutely empty itself." Nearly every 
page exhibits similar experiments in construction. In 
the next edition it is hoped that the faults, which, by 
the way, are more conspicuous than harmful, will be 
ehminated, and there will remain a good short work on 
the stomach. 

The author recognizes the important etiologic influence 
of reflex irritation in the production of gastric neuroses, 
and justly commends the teachings of an American 
physician in this connection. A writer who shall assign 
full value to ametropia and heterophoria in the etiology 
of gastric disorders will become as useful as he is un- 
common. 

The Care of the Bai;y: A Manual for Mothers 
AND Nurses, containing Practical Directions 
for the Management of Infancy and Child- 
hood IN Health and in Disease. By J. P. Crozer 
Griffith, M.D. , Clinical Professor of Diseases of 
Children in the Hospital of the University of Penn- 
sylvania ; Professor of CUnical Medicine in the Phila- 
delphia PolycUnic and School for Graduates in Medi- 
cine; Physician to the Children's Hospital, to the 
Methodist Episcopal Hospital, and to St. Agnes's 
Hospital, Philadelphia ; Member of the American 
Pedriatic Society and of the Association of American 
Physicians. Philadelphia: W.B.Saunders, 1895. 

This book, of three-hundred-and-ninety-two pages, is, 
as its title indicates, designed as a guide to mothers and 
nurses in the care and bringing up of infants and chil- 
dren. That such a guide is essential, particularly to a 
mother with her firstborn, is evidenced by the gross 
ignorance of the simplest details in regard to the care 
of the child, and by the many popular fallacies in regard 
to infancy that have been handed down from time im- 
memorial by those who profess to be knowing and skilful 
nurses of babies ; and this is so not only among the 
poorer classes, but even among the well-to-do. Every- 
one who has seen much of children cannot but be 
struck by the joy with which a kind(?) neighbor im- 
parts her ignorance to an anxious, young, and inexpe- 



rienced mother, not only needlessly alarming the latter, 
but also doing absolute harm by her ignorant counsel. 
It is certainly of advantage to both mother and child that 
such a book as that before us should be available. 

The author devotes about a dozen pages to some useful 
information to the mother in regard to her life prior to 
delivery, and as to the preparations necessary for con- 
finement. The newborn baby is then described in suffi- 
cient detail as regards its superficial anatomy and 
its physiology. The manner and rate of growth and 
development of the teeth are fully dealt with in the suc- 
ceeding chapter. Chapters on the toilet and the clothing 
suitable for the different ages are followed by an ex- 
tremely good chapter on the diet. In the latter the 
author's views are not far different from those of other 
writers upon the selection of children's diet. He de- 
cidedly prefers the use of soda-solution to that of lime- 
water as an alkalinizing medium in the use of cow's 
milk. Sleep, exercise, and training, the baby's various 
nurses, and the baby's rooms finish the portion of the 
book devoted to the baby in health. The chapter on 
the sick baby occupies most of the rest of the volume. 
In it the author describes the features of disease, the 
management of the sick baby, and the disorders of 
childhood. The author is to be congratulated upon 
having written this chapter with such judgment that the 
mother will be aided in her ability to watch over her 
child properly without thinking herself capable of con- 
ducting the medical treatment through an illness. This, 
probably the most difficult chapter to write well, is one 
of the best in the book. 

In the appendix are given minute directions for 
preparing various articles of diet, descriptions of the 
different forms of local and general baths, directions for 
making some of the principal poultices and plasters, 
formula: of different lotions and powders for external 
use, formula; for a few simple domestic remedies for use 
in emergencies, and some miscellaneous directions in 
regard to massage and the administration of drugs. 

The writing of such a book must be difficult chiefly 
from the necessity for discri mination in regard to the 
extent to which it is judicious to enter into medical 
details. To us it seems that Dr. Griffith has well ac- 
complished his work in this respect, neither making too 
light of the appearances of illness nor unnecessarily 
causing alarm by mention of possible serious conse- 
quences. 

Pathology and Treatment of Diseases of the 
Skin. By Moriz Kaposi, Professor of Dermatology 
and SyphiUs in the Vienna University. Translation 
of the last German edition, under the supervision of 
James C. Johnston, M.D. Pp. 684. New York : 
William Wood & Co., 1895. 

The author of this work is so well known 10 readers 
of German interested in diseases of the skin that an 
introduction is unnecessary. Professor Kaposi (the 
worthy successor to Hebra the elder, in the chair of der- 
matology in the University of Vienna) presents in this 
work the principles and practice of dermatology as rec- 
ognized by the Vienna School of Medicine, of which 
he is now the chief exponent. The subject-matter is in 
the form of lectures, and is, therefore, didactic. Path- 
ology and pathologic anatomy receive much attention. 



NEWS ITEM. 



[Medical News 



As is well known, the Vienna school attaches but little 
importance to internal remedies in the treatment of cu- 
taneous diseases, and the American reader in perusing 
this book will look in vain for advice upon the use of 
the many internal remedies constantly employed by 
physicians in this country in treating such diseases as 
eczema and psoriasis. 

The distinguished author is a Viennese, and not a 
cosmopolitan, in his views. He pictures graphically 
diseases of the skin as they are met with in Austria, but 
accords scanty notice to the work that has been done in 
other countries during the last decade. Nevertheless, 
the book is one of the great works of the period, and 
is full of valuable information, the fruit of a hfelong 
and abundant e.xperience by an unusually accurate and 
keen observer. We are, therefore, pleased to see the 
work translated into English. 

The translation has been done freely rather than liter- 
ally, with here and there the omission of a sentence or 
a paragraph, doubtless with the view of condensation. 
We are somewhat in doubt as to whether Dr. Johnston 
is the translator or not, inasmuch as on the title-page it 
is stated that the translation has been done under his 
supervision. In one chapter the term knotchen is trans- 
lated nodule, instead of papule, as it should be. In 
conclusion, we may say that the book should be in the 
library of every physician interested in dermatology. 



NEWS ITEM. 

For the James E. Reeves Fund we have received from 
Drs. E. B. Doolittle, 50 cents; A. Cornish, %i ; G. W. 
H. Kemper, $1 ; H. M. Haskell, 50 cents. We quote 
the following paragraph from Dr. Haskell's letter : 

" Surely the professional conscience, and especially 
the journalistic, is not so seared as to turn a deaf ear to 
this call. There ought to be from 50,000 to 100,000 
copies sold, and the balance kept as a sinking or trust 
fund to defend similar cases in the future. " 



BOOKS ANB PAMPHLETS RECEIVED. 

Inebriety or Narcomania : its Etiology, Pathology, Treatment, 
and Jurisprudence. By Norman Kerr, M.D , F.L.S. Third 
edition. New York; J. Selwin Tait & Sons, 1894. 

Ripening of Immature Cataract by Direct Trituration. By 
Boerne Bettman, M.D. Reprinted from the Annals of Ophthal- 
mology and Otology. Vol. IV, No. i, 1895. 

On the Physiological Action of Antitoxin in Diphtheria. By 
G. P. Hackenberg, M.D. Reprinted from the American Practi- 
tioner and News, 1895. 

Ein Beitrag zur Aetiologie der contraren Sexualempfindung. 
Von Dr. Freiherrn v. Schrenck-Notzing. Beilage zur Wiener 
khnischen Rundschau, 1895, No. 8. 

The Possibility of Obtaining Marked Improvement in the Treat- 
ment of Diseases and Supposed Deaf-mntism by Acoustic Gym- 
nastics. .A System of Vocal Training of the Auditory Nerve, as 
Advocated by Professor Urbanschitsch, of Vienna. By Dr. M. 
A. Goldstein. Reprinted from the Archives of Otology, 1895. 

Hyperpyrexia in Broncho-pneumonia; Infantile Scurvy; Men- 
ingocele. By Edwin E. Graham, M.D. Reprinted from the Inter- 
nation Clinics, Vol. IV, Fourth Series 

.\ Case of Neurotic Edema. By Edwin E. Graham, M.D. 
Reprinted from the Annals of Gynecology and Pediatry, 1894. 

Nervous Diseases in Early Syphilis. By G. Frank Lydston, 
M.D. Reprinted from the Journal of the .American Medical 
Association, 1895. 



Tetany in America, with a Report of Five Cases. By J. P. 
Crozer Griffith, M.D. Reprinted from the American Journal of 
the Medical Sciences, 1895. 

Sixty-fifth Annual Report ot the Inspectors of the State Peni- 
■tentiary for the Eastern District of Pennsylvania. Philadelphia, 
1894- 

Forms of Paralysis in Children. By J. P. Crozer Griffith, M.D. 
Reprinted from the International Medical Magazine, 1895. 

Medical Gynecology. .A Treatise on the Diseases of Women 
from the Standpoint of the Physician. By -Alexander J. C. Skene, 
M.D. With illustrations. New York : D. Appleton & Co., 1895. 

Appendicitis. By George W. Gay, M.D. Reprinted from the 
Boston Medical and Surgical Journal, 1895. 

A Case of Lesion of the Thalamus. Death from Intestinal 
Hemorrhage. By Wharton Sinkler, M.D. Reprinted from the 
Journal of Nervous and Mental Disease, 1894. 

Sporadic Cretinism, and its Treatment by Thyroid Extract. By 
Wharton Sinkler, M.D. Reprinted from the International Med- 
ical Magazine, 1894. 

Pigmentum Chloralis Antisepticum. By Dr. John Broom. Read 
before the British Medical Association, .August, 1894. 

Left Hemiplegia. By J. T. Eskridge, M.D., with Remarks by 
Frederick Peterson, M.D. Reprinted from the New York Med- 
ical Journal, 1895. 

.A Study of Erysipelas. By Julius Selva, M.D. Reprinted from 
the New York Medical Journal, 1894. 

Free Hydrochloric Acid. Is its Absence from the Stomach a 
Sign of Cancer? By Richard B. Faulkner, M.D. Reprinted 
from the Journal of the American Medical .Association, 1895. 

Report of a Case of Pathological Separation of the LowerEpiph- 
ysis of the Femur. By A. H. Meisenach, M.D. Reprinted from 
the Annals of Surgery, 1895. 

The Abnormalities of Ocular Balance ; their Nature, Etiology, 
Conservative Management, and Operative Treatment. A Clinical 
Study. By S D. Risley, M.D. Reprinted from the University 
Medical Magazine, 1895. 

The External and Internal Use of Guaiacol, with Brief Reports 
of Cases. By J. M. Anders, M.D. Reprinted from the Thera- 
peutic Gazette, 1895. 

.A Report of Thirteen Cases of .Ataxia in Adults with Hereditary 
History. By Irwin H. Neff, M.D. Reprinted from the American 
lournal of Insanity, 1895. 

An Epidemic of Typhoid Fever at Bayhead, N. J., from Direct 
Infection of a Milk-supply. By W. H. Katzenbach, M.D Re- 
printed from the Medical Record, 1895. 

Demonstration of Skulls Showing the Effects of Cretinism on 
the Shape of the Nasal Chambers. By Harrison Allen, M.D. 
Reprinted from the New York Medical Journal, 1895. 

Morphology as a Fac'or in the Study of Disease. By Harrison 
.Allen, M.D. Reprinted-from the Transactions of the Congress 
of American Physicians and Surgeons, 1894. 

The Filtration of Public Water-supplies. By Henry Leff- 
mann, M.D. Reprinted from the Copyrighted Proceedings of 
the Engineers' Club of Philadelphia, 1895. 

Bicycling for Women from the Standpoint of the Gynecologist. 
By Robert L. Dickinson, M.D. Reprinted from the American 
Journal of Obstetrics. 1895. 

Purulent Fihro-myomata of the Uterus, and Professor Vulliet's 
Operation for their Extraction. By Charles Greene Cumston, 
B.M.S., M.D. Reprinted from the Annals of Gynecology and 
Pediatry, 1895. 

Thirty-fourth Annual Report of the Board of Managers of the 
Woman's Hospital of Philadelphia. January, 1895. 

Thirteenth Annual Report of the Children's Aid Society of 
Pennsylv,ania, 1894. 321 South Twelfth Street, Philadelphia. 

Some Remarks on Skiascopy, or the Shadow-test. By J. Thor- 
ington, M.D. Reprinted from the Annals of Ophthalmology and 
Otology, vol. iv, No. i, 1895. 

The Influence of the Eye on Character and Career. By Justin 
L. Barnes, B.S., M.D. Reprinted from the New York Medical 
Journal, 1895. 

Pyometra in a Cat. By T. S. Cullen, M.B. Reprinted from 
the .American Veterinary Review, 1894. 



THE MEDICAL NEWS. 

A WEEKLY JOURNAL OF MEDICAL SCIENCE. 



x>'^ 



Vol. LXVII. 



Saturday, August 3, 1895. 



No. 5. 



ORIGINAL ARTICLES. 

THE OCULAR SYMPTOMS OF LOCOMOTOR 
ATAXIA} 

By WILLIAM E. BRUNER, A.M., M.D., 

OF CLEVELAND, OHIO; 



Very important in the diagnosis of tabes dorsalis, 
and especially in the early stages of the disease, are 
the ocular symptoms. Every person in whom loco- 
motor ataxia is suspected should be subjected to a 
careful examination of the eyes, and not rarely it is 
the oculist whom the patient with developing pos- 
terior sclerosis first consults, and upon whom the 
responsibility rests of first detecting the oncoming 
disease in perhaps its very earliest stage, when, if 
at any time, it may be possible to check its progress. 
The ocular symptoms naturally arrange themselves 
into three groups : those pertaining to the internal 
muscles, especially the iris ; those concerned with 
the external eye-muscles ; and the changes in the 
optic nerve, or optic atrophy. 

The affections of the internal muscles reveal 
themselves chiefly in pupillary changes, and these 
are numerous. The most important are : i. Reflex 
iridoplegia. 2. Absolute iridoplegia. 3. Myosis. 
4. Inequality of the pupils. 

We should add to the pupillary symptoms mydri- 
asis, one form of which would indicate irritation of 
the cilio-spinal center, and would be analogous to 
the increased knee-jerk found by Weiss and some 
others at the beginning of tabes. Instead of spastic 
mydriasis we may have another form — paralytic 
mydriasis.'' Gowers states that the pupils may be 
even larger than normal, and then, he adds, the 
skin-reflex can be obtained, though the light-reflex 
cannot. Eulenburg,' among 64 cases, noted mydri- 
asis in 9, myosis in 28, and states that the simul- 
taneous occurrence of myosis and mydriasis occurs 
only in the late stages of the disease. Seguin found 
the mydriasis to be symmetric, differing in this re- 
spect from Mijller* and Schmeichler. Hutchinson* 
reports a case in which monocular paralytic mydri- 
asis preceded other ataxic symptoms by three years. 



1 Read in part before the Cleveland Medical Society, May lo, 
1895. 

2 Text-book of Nervous Diseases, vol. i. 

' Wood's Nervous Diseases and their Diagnosis, p. 340. 

* Centralblatt fUr die Gesammte Therapie. 

» Archives of Surgery (London), July, 1893, p. 54. 



Though not so characteristic as the other changes, 
pupillary inequality is, according to Schmeichler,' 
the most frequent, while reflex iridoplegia is next 
in frequency. " Each of these symptoms," he says, 
" when found in an individual justifies the physician 
in inquiring for tabes." Jessup' says that inequality 
is often found, andBerger found it in 27.6 percent, 
of his cases. 

The myosis frequently spoken of as spinal myo- 
sis is an important sign of disease of the posterior 
columns of the cord. The only other disease in 
which it occurs as frequently is progressive paralysis 
of the insane. In cases in which the cervical spinal 
cord is first attacked myosis occurs as a very early 
symptom. The pupils cannot be dilated ad maxi- 
mum by the energetic use of a strong mydriatic' 
.A. characteristic point in the myosis is the fact that 
the pupil dilated to medium width by atropin re- 
quires an unusually long time (frequently from four 
to five weeks) to become again as narrow as it was 
before the instillation of the mydriatic* The myo- 
sis is due to paralysis of the cilio-spinal center. It 
is explained by one authority" by the fact that par- 
alysis of this center, which sends the vasomotor 
fibers to the bloodvessels of the iris, allows these 
vessels to become relaxed and consequently filled 
with blood, and hence the small pupil results. The 
longer this condition remains the more slowly will 
passive dilatation occur. The very minute pupil 
sometimes seen is, according to Noyes," probably 
due to secondary contraction of the sphincter 
pupillffi. 

Total iridoplegia, the reaction in accommoda- 
tion as well as to light being lost, but accomodation 
itself remaining intact, is sometimes seen, but the 
most characteristic of all the pupillary changes is 
reflex iridoplegia, the pupil not responding to light, 
but reacting in accommodation. This condition is 
now familiarly known, in honor of the man who 
discovered it and brought it to the notice of the 
profession, as the Argyll-Robertson pupil." It is ex- 
plained as being due to paralysis of the cilio-spinal 
nerves, which were then regarded as the nerves 
supplying the sphincter iridis, but is now believed 

1 .\rchiv f. Ophth., 1883, xii, pp. 335 et seq. 

"- Ophth. Review, July, 1888. 

3 Norris and Oliver : Text-book of Ophthalmology, p. 484. 

' Schmeichler : op. cit. 

5 Schmeichler : op. cit. 

^ Diseases of the Eye, 2d edition, p. 435. 

" Edinburg Med. Journ., 1869, xiv, p. 669, and 1870, xv, p. 487. 



OCULAR SYMPTOMS OF LOCOMOTOR ATAXIA. 



[Medical News 



to be due to disease at some distance from the 
spinal cord, namely, in Meyiiert's' fibers, which 
connect the corpora quadrigemina with the nuclei 
of the third nerve. Disease in these fibers may 
exist by continuity with disease of the cord, and in 
fact the close relationship between the optic atrophy 
and the sclerosis of the posterior columns is similarly 
explained, as Stilling' has found fibers passing 
directly from the optic tract into the crus cerebri, 
and both he and Edinger assert that this bundle of 
fibers makes its way through the crus to the pons 
varolii, and thence to the posterior column of the 
cord. Noyes^ says that the Argyll-Robertson pupil 
may be due to disease of the fibers from the optic 
tract to the pons varolii, while Turner* holds the 
opinion that it is due to a lesion of the fibers con- 
necting the optic tract and the pupillary nucleus — 
a statement that accords with that made by Swanzy, 
though less definite. Mauthner's* explanation is 
that the fibers for the pupillary light-reflex, lying 
in the wall of the third ventricle, suffer from a 
chronic ependymitis and a consequent sclerosis, an 
opinion with which Berger" agrees. Kahler, Mendel, 
and Oppenheim found the oculomotor nucleus 
intact, with absence of the light-reaction. " Hence," 
says Knies,' "the lesion must be sought in the cen- 
tripetal fibers to the motor oculi nucleus or in their 
origin, unless the condition is due to a toxemia." 
Schmeichler," however, believes that we cannot 
attribute this reflex iridoplegia to any direct ana- 
tomic basis, but that we must assign it to the 
"generally reduced irritability of the brain due to 
a morbid process." The whole nervous system, he 
contends, is inclined to sclerosis, which is, however, 
most marked in the posterior columns and optic 
nerves. It is proper, he thinks, to speak of a 
" diminution of nervous excitability in tabetics, 
which, while too slight to produce coarse functional 
disturbances, suffices to disturb the sensitive reflex 
mechanism of the pupil." 

Usually in association with the Argyll-Robertson 
pupil we find, as was first observed by Erb, that the 
iris fails to dilate upon painful stimulation of the 
skin, especially of the skin of the neck. Reflex 
iridoplegia is sometimes accompanied by my- 
driasis and occasionally by paralysis of accom- 
modation, but most often by myosis, and not 
infrequently there is slight irregularity in the out- 
line of the pupil. Eventually the iris often fails to 

1 Swanzy: Diseases of the Eye, p. 281: Noyes : Diseases of 
the Eye, p. 436. 

2 Beilageheft zu Zehender's Monatsblatter, xvii, pp. 203-207. 
•1 Op. cit. 

■> Oph'h. Hosp. Reports, vol. xiii (Dec. 1892), p. iii, p. 328. 

6 Die nuclearen AugenmuskelUihmungen, p. 353. 

6 Archiv f. Ophth., 1890, vol. xix, p. 454. 

' The Eye in General Diseases, p. 192. 

8 Op. cit. 



react in accommodation as well as to light. Some- 
times we find decided torpor or sluggishness of 
the iris, but no paralysis ; in fact, if we could trace 
the pupillary condition from the beginning, we 
should often find this torpor, then loss of reaction 
to light, then to irritation of the skin, and finally 
total iridoplegia, 

I have said that reflex iridoplegia is the most 
characteristic of the pupillary changes. Wood 
says that it probably is pathognomonic of degen- 
eration of the upper spinal cord, including the 
medulla, and that it occurs also in progressive 
paralysis of the insane ; and Dana also says that it 
is found practically only in these two conditions. 
It occurs probably in some cases of nuclear dis- 
ease,' and possibly in disseminated sclerosis ; but 
so rarely is it found in any other condition that its 
presence alone, says Hansell,' would almost war- 
rant the assumption of a commencing posterior 
sclerosis. 

The pupil may rarely be unaffected in tabes. 
Gowers states that the reflex action to light is lost in 
more than five-sixths of all cases, and Berger," in a 
series of 109 cases, found good pupillary reaction in 
only four (3.7 per cent.), and only in one case with 
ataxia well marked. Vincent' found the Argyll- 
Robertson pupil 47 times in 50 patients. On the 
other hand, Nettleship* says : " We do not yet 
know how often it may occur in healthy persons, 
or without eventual spinal disease. It certainly 
has comparatively little significance in old per- 
sons." Uhthoff" found it in a case of carbon- 
disulphid poisoning. Its loss may be due to pre- 
ceding syphilis. Gowers' reports having seen 
several cases of loss of light-reflex in syphilitic 
patients without disease of the spinal cord, and his 
practical rule is that, apart from general paralysis of 
the insane, reflex iridoplegia always indicates either 
syphilis or tabes, and not infrequently both. Erb 
has described a similar case. So important, how- 
ever, is this symptom that Spitzka* says it " may be 
regarded as a rule in neuro-pathology that whenever 
reflex iridoplegia is at any time accompanied by 
other acute motor disturbance, it is either of spinal 
origin, or in exceptional cases due to disease of the 
pons varolii." It is one of the earliest signs of 
developing tabes. " It may be assumed with safety," 
says Spitzka, " that in 99 out of 100 cases both the 



I Norris and Oliver: Text-book of Ophthalmology, p. 543. 

■^ Journal of the American Medical Association, February 18, 
1893, p. 168. 

3 Op. cit., p. 450. 

* Des PhSnomenes Oculo-pupillaires dans I'ataxie locomotnce. 
These de Paris, 1877. 

5 Diseases of the Eye, fourth Ameiican edition, p. 452. 

» Graefe's. Archiv, vol. xxxi, i. 

' Lancet, January, 1891, p. 95- 

" Pepper's System of Medicine, vol. v. 



1 895] 



OCULAR SYMPTOMS OF LOCOMOTOR ATAXIA. 



IIS 



inability of the pupil to respond to light and the 
absence of the knee-jerk will be found long before 
ataxia is developed," though he states that the 
" loss of co-ordination and the reflex iridoplegia are 
the most important of the exact prodromal signs." 
In fact, he declares that one or both of these must 
be present to justify the diagnosis of incipient tabes; 
" not even the absence of the knee-jerk ranks as 
high as these two signs." When present this reflex 
iridoplegia is permanent and unvarying, and yet 
even in this regard there are rare exceptions, as 
Spitzka' has reported two cases in which this 
symptom disappeared, to reappear in two months 
in one case, and in eight months in the other case. 

Berger ■ reports two cases in which this condition 
was unilateral, and Gowers one such case. HanselP 
reports a case in which were found anisocoria 
(inequality of the pupils), unilateral Argyll-Robert- 
son pupil, limited color-field, partial loss of knee- 
jerk, and fleeting pains in the feet. Recently I 
myself had a similar case under observation. 

Paralysis of accommodation is occasionally met 
with as an early symptom. Galezowski has re- 
ported several such cases, and Berger * reports two 
without paralysis of the sphincter, but with reflex 
iridoplegia. In the latter stages of the disease this 
paralysis is more frequent, and Berger reports 23 
cases, in " only one-third of which was the paralysis 
of accommodation accompanied by mydriasis." 

The tabetic affections of the external eye-muscles 
may be divided into two groups, those occurring 
early in the disease and frequently transient, and 
those belonging to the later stages of the disease, 
and more often permanent, though either may 
occur at any stage. 

In regard to the relative frequency of the muscles 
or nerves affected, the third nerve is the most often 
paralyzed, the sixth less frequently, and the fourth 
only exceptionally ; but of individual muscles, the 
external rectus is most frequently affected, while 
ptosis from paralysis of the levator palpebrs 
superioris and paralysis of the internal rectus 
(causing external squint) are next in frequency. 
Several muscles may be involved, or we may have 
an "associated paralysis," as loss of convergence 
with loss of accommodation, although the internal 
recti act well under other conditions ; or a pro- 
gressive ophthalmoplegia or complete ophthalmo- 
plegia externa. Buzzard^ reports two cases of 
ophthalmoplegia externa in tabes, while Hutch- 
inson,*^ in commenting upon six cases of this con- 
dition, says : " There can be no doubt that opTithal- 

1 Ibid., p. 850. ^ Op. cit., p. 454. 

' Journal American Medical .Association, February l8, 1893, 
p. 168. 
* Op. cit. 5 Brain, April, 1882, p. 34. 

' Transactions Medico-Chirurgical Society, London, 1879. 



moplegia externa is sometimes a part of the general 
malady known as locomotor ataxia, especially when 
that disease is due to syphilis." 

As the result of paralysis of an external ocular 
muscle diplopia arises, which is homonymous when 
internal squint occurs, crossed when there is ex- 
ternal squint, vertical if an elevator or depressor is 
affected, or there may be a combination of the last 
with either of the former. 

Swanzy' declares that in "the premonitory stages 
of tabes dorsalis, ephemeral partial paralysis, affect- 
ing now one and again another of the orbital mus- 
cles, may sometimes be observed;" and Jeffries'' 
says : "In tabes, as has long been known, there has 
been frequently a history of transitory diplopia dur- 
ing the prodromal period. The origin of these fu- 
gacious paralyses is not known, but their significance, 
when combined with previous syphilitic infection, 
is gravely suggestive of tabes to follow." All author- 
ities agree that diplopia is not an infrequent early 
symptom, though they differ somewhat in regard to 
the percentage of cases showing this condition. 
Spitzka,' for example, found it in 58 out of 81 pa- 
tients recorded, and Berger* in 38 per cent, of his 
cases, while Erb' assigns 27 per cent, of eye-par- 
alyses to tabes, and Moli^ 39.6 percent. Sometimes 
the paralysis comes on gradually and is not noticed 
by the patient, but more often it causes very annoy- 
ing diplopia. This may be the first symptom to 
attract the patient's attention, as in a case that I 
saw some time ago, in which, however, the patient, 
upon examination, also exhibited loss of knee- 
jerk, some ataxia, and slight pains, with the light- 
reaction of the pupils preserved, but sluggish. 
Osier" says: "The early ocular palsies are of the 
greatest importance. A squint, ptosis, or Argyll- 
Robertson pupil maybe the yfrx/ symptom, and may 
exist with the loss only of the knee-jerk." Nettle- 
ship * also states that tabes may be preceded by 
paralysis of one or more muscles, and that " there 
may be for years nothing else to attract attention." 
Cromwell ' states that in tabes dorsalis the paralysis 
(of the eye-muscle) often precedes the other symp- 
toms some months, and, at times, years." This con- 
dition occurs very rarely, if at all, in any other 
form of spinal disease. The importance of this as 
an early symptom may be inferred from the declara- 
tion of Schmeichler'" that " if a pupillary disturb- 



' Diseases of the Eye, 3d ed.. p. 432. 
'•^ Boston Med. and Surg. Journ., Oct. 27, 1892. 
^ Pepper's System, vol. v. 
' Op. cit., p. 484. 

■• Deutsches Archiv fiir klinische Medicin, 1879. 
Archiv fiir Psychiatrie, Bd. xiii. Heft 3. 
■ Practice of Medicine, p. 842. 
8 Diseases of the Eye, p. 452. 
■' Amer. Journ, of the Med. Sciences, .•\pril, 188. 
i« Op. cit. 



ii6 



OCULAR SYMPTOMS OF LOCOMOTOR ATAXIA. 



[Medical News 



ance is added we are compelled to suspect tabes, and 
if lancinating pains appear the diagnosis of poste- 
rior spinal sclerosis may be accurately made." 
Pearce' reports a case, in the service of S. Weir 
Mitchell, of rapid onset, with sudden diplopia, due 
to paralysis of both external recti, as the first symp- 
tom. Hansell" cites one in which diplopia was the 
first symptom observed by the patient, and exami- 
nation showed an Argyll-Robertson pupil, with the 
optic nerve normal, the knee-jerk exaggerated, and 
an absence of ataxia and of pains. 

Hughlings Jackson found diplopia to be the first 
symptom in 6 out of 19 cases. 

Ptosis, either unilateral or bilateral, occurs at 
times as an early symptom, and not infrequently is 
associated with paralysis of one or more muscles of 
the eyeball. Six months ago a patient consulted 
me because of a slight drooping of the upper lid of 
the right eye. He gave a history of syphilis, and 
upon close inquiry said that he had sharp pains at 
times in his legs, and occasionally had "bladder- 
trouble," with pain in the epigastrium, frequent 
micturition, and scanty urine. (Urine-analysis was 
negative.) Argyll-Robertson pupil was present, but 
there was no ataxia, and the knee-jerk was normal. 
Vision was normal, as were also the fields for form 
and color. Two months later the man returned, 
complaining of diplopia, which was found to be 
due to paresis of the right internal rectus. Despite 
the normal patellar tendon-reflex and the absence of 
ataxia, I am inclined to believe this a case of begin- 
ning tabes. 

There seems to be a general impression among neu- 
rologists that paralyses of the eye-muscles, as mani- 
fested in ptosis, diplopia, and reflex iridoplegia, are 
more common in syphilitic patients. 

Sachs, ^ in a paper read before the American 
Neurological Association in 1893, in attempting a 
differentiation of the cases of tabes due to an active 
syphilitic process, considered among that group 
those that exhibited complete loss of reflex contrac- 
tility of one or both pupils, and ocular palsies. 
Spitzka,* on the other hand, states that the most ob- 
stinate and most severe diplopia he has met in a ta- 
betic patient was in one in which syphilis was posi- 
tively excluded, and Berger* says that he did not 
find luetic patients to be especially disposed to ocu- 
lar palsy, although they do show a greater tendency 
to permanent paralysis and to multiple paralyses. 

As to the anatomic cause of these paralyses, 
Berger says the lesion is nuclear ; Forster that they 
are due to disease in the floor of the fourth ventri- 
cle ; and Schmeichler" that they depend upon a 



' Journ. of Nervous and Mental Dis., 1895, p. 8 
2 Journ. of Amer. Med. Assoc, Feb. 1893, p. i63. 
* N. Y. Med. Journ., Aug. I2, 1893, p. 192. 
•> Op. cit. s Op. cit. " Op. cit. 



sclerotic process in the vertebral artery, which for- 
nishes the blood-supply to the nuclei of the eye- 
muscles, as well as the other basal ganglia, and also 
to the posterior columns of the cord, basing his 
opinion upon what Adamkiewicz has shown — that 
the path of tabetic sclerosis is determined by the 
course of these arterial vessels. Sachs,' in speaking 
along the same line, says that the chief cause of the 
degeneration of tabes is syphilis, which causes dis- 
ease of the bloodvessels of the spinal cord, and 
altered states of the blood may be the prime cause 
of these changes in the bloodvessels. 

Nystagmus has been observed, but is rare. It 
occurs chiefly with movements of the eyeballs, and 
is rarely persistent in continuous oscillation, as in 
multiple sclerosis. Rahlway^ speaks of having ob- 
served it late in ataxia. Berger' reports seven cases, 
one of them unilateral, and Freyer* one case in 
which this was the only ocular symptom. Knies 
states that these rarer forms are perhaps always due 
to complications. 

Another symptom that should not be ignored is 
epiphora, which usually is bilateral, but sometimes 
is unilateral. It is most probably due to weakness 
of the orbicularis, which may be explained, says de 
Schweinitz,^ by the intimate relation of the oculo- 
facial group of muscles to the nucleus of the third 
nerve, which is frequently disturbed in tabes ; for, 
according to Mendel," the upper twigs of the facial 
nerve spring from a separate nucleus, which is in 
close relationship to the oculomotor. 

According to Berger, however, hypersecretion is 
an important causative factor — a condition that 
has its analogy in the hyperidrosis of the face some- 
times seen in tabes. 

The relationship between optic atrophy and tabes 
is intiinate. As regards its frequency authorities 
differ, ophthalmologists, for example, naturally re- 
porting a higher percentage of cases with atrophy 
than neurologists. At the very least, 10 per cent, 
of the patients with locomotor ataxia exhibit more 
or less of optic atrophy ; Gowers says one-sixth ; 
Erb' 12 per cent. ; Spitzka says if we include the 
lesser degrees of atrophy the percentage certainly 
is higher; Dana,' 10 per cent, in his experience ; 
Moli, 13.5 percent.; Uhthoff^ (nervous clinic), 
20 per cent.; Berger,'" 51 in 109 cases (46-7 per 
cent.) ; Lofmarel,' 49 in 102 (48 per cent.) ; 



N. Y. Med. Journ., Aug. 12, 1893, p. 192. 

Archiv fiir Oplith.,vol. xxiv. No. 4, pp. 237-317. 

Op. cit., p. 484. 

Berliner klin. Wochenschr., 1887, No 6. 
' .^mer. lourn. of Oplitli., March, 1895, p. 82. 
■ Berliner klin Wochenschr., 1887, No. 48. 
' ■' Zur Pathologic der Tabes dorsalis," Deutsches Archiv fiir 
lische Medicin, 1879. 
' Text-book of Nervous Diseases. 
' Archiv fiir Psychiatric, Bd. xiii, Heft 3. 
' Op. cit., p. 455. " Quoted by Berger, op. cit., p. 455. 



August 3, 1895] 



OCULAR SYMPTOMS OF LOCOMOTOR ATAXIA. 



117 



Cyon,' 60 in 203 (29.5 per cent.) ; Schmeichler,^ 
from the cases seen in his eye-chnic, the medical 
clinic, and the Home for Incurables, 40 per cent. 
Buzzard' found it more frequently in disseminated 
sclerosis (43 per cent.), next in tabes (15.5 per 
cent.) and general paralysis of the insane. Calcu- 
lating the frequency of spinal disease in cases of 
optic atrophy, Uhthoff,* in an anal)fsis of 183 cases 
of optic atrophy from causes outside the eye, found 
it to be due to disease of the spinal cord in 59 
cases (32 per cent.). Charcot believed that almost 
all cases of so-calied simple atrophy ultimately pre- 
sent spinal symptoms; Gowers" about one-half; 
and Galezwoski about two-thirds. 

Peltesohn' finds about 40 per cent, of the cases 
of non-neuritic progressive optic atrophy in Hirsch- 
berg's clinic to be associated with spinal or cerebro- 
spinal disease, and among 486 cases' he found 
78 cases of tabes (15.7 per cent.). In a series of 
76 consecutive cases of progressive atrophy Nettle- 
ship* reports decided spinal symptoms in 58, and 
of the remaining 18 several showed one or more 
symptoms that were probably of spinal origin. He 
is furthermore of the opinion that in the cases with- 
out signs of spinal disease, if they could be followed 
for a sufficient number of years, symptoms of such 
involvement would eventually appear. 

Optic atrophy is usually an early, sometimes the 
initial, symptom of tabes. If the patient reaches 
the second stage without it, he will probably escape 
it altogether. There appears to be, as has been 
noted by many observers (Osier, Ferrier, Gowers, 
Buzzard), what might be termed an antagonism 
between the optic atrophy and the ataxia. When 
the former is an early and decided symptom ataxia 
is not likely to be marked, while in the cases in 
which the latter symptom is present the atrophy is 
rare or of very slight degree. Martin^ claims that 
" when blindness from atrophy of the optic nerve 
occurs at an early period, especially when it runs a 
rapid course, a slow course of tabetic symptoms 
proper may be expected." Benedikt'" is of the 
same opinion, and says that "it is a rule without 
exception, so far as my experience goes, that motor 
tabetic symptoms subside, however severe they may 
have been, as soon as atrophy of the optic nerve 
begins. The latter symptom, however, presents a 
very unfavorable prognosis." It may occur before 
any symptoms referable to the cord, as in a case 



■ Quoted by Berger, op. cit., p. 455. 

2 Archiv f. Opth., 1883, xii, p. 335. 

3 Brit. Med. Journ., Oct. 7, 1893, p. 779. 

* Graefe's Archiv f. Ophth., 1880. xxvi, Abth. i. 
= Text-book of Ophthalmoscopy, p. 141. 

* Quoted in Archiv f. Ophth., xvi, p. 142. 

' Centralblatt f. .■\ugenheilk., Bd. x, pp. 45, 75, and 106. 
8 Diseases of the Eye, p. 61. 
' Arch. f. Augenheilk., 1890, p. 122. 
10 Wiener med. Wochenschr., Aug. 14, 1887. 



mentioned by Gowers, in another by Bramwell,' and 
in seven cases by Berger.^ Buzzard' records a case 
of not infrequent type, in which the only other 
symptom was loss of knee-jerk. The atrophy some- 
times continues for years without any other symp- 
toms. 

Berger says that cases with ocular paralyses are 
slightly more disposed to atrophy, and the converse 
is also true. The left eye is oftener attacked than 
the right. " In general, paralyses of the external 
ocular muscles are found disproportionately oftener 
in cases showing optic atrophy than in cases uncom- 
plicated with optic atrophy ;" and " the cases with 
paralyses of the ocular muscles are more disposed 
to optic atrophy than the cases without paralyses.' ' 
The change is usually more advanced in one eye 
than in the other, but it is rare to find complete 
atrophy in one eye and a normal nerve in the other. 
Schmeichler says that he has " never observed in 
tabes that one optic nerve was completely atrophic 
vvhile the other eye enjoyed perfect vision." 

The first result of a developing atrophy is in the 
color-perception, as shown by contraction of the 
color-fields when measured by the perimeter. Green, 
which excites the fibers least, is the first to be affected 
and to disappear ; red follows, and the perception 
for blue is longest retained. The form-field then 
begins to suffer contraction and at the same time 
usually, or even a little earlier, vision begins to fail. 
Berger,* however, says that "contraction of the 
visual field precedes affection of the color sense " 
and declares also that " no relation exists between 
the contraction of the visual field, the color-fields, 
the disturbances of central vision and of color-per- 
ception ; " and with this opinion Leber" and Michel 
agree. My own experience does not accord with 
that of Berger, but agrees rather with that of Knies, " 
who holds that " central vision usually possesses a 
definite relation to the narrowing of the visual field, 
and is so much more impaired the more the bound- 
aries of the field approach the point of fixation." 
Thus, optic atrophy is usually a gradual process, 
but occasionally it may be rapid. In the most rapid 
case recorded by Berger the atrophy took place in 
two months, and in the slowest in seventeen years. 
Hirschberg' reports a case in which vision was al- 
most lost in eight weeks. It will usually progress 
to complete or almost complete blindness, with only 
light-perception remaining, but rarely it may ad- 
vance to a certain stage and then stop. The con- 
traction of the fields is usually concentric, though 
more marked at the temporal side (Forster) and 

1 Diseases of the Spinal Cord, 2d ed., p. 192, 

2 Op. cit. ' Brain, 1878. No. 2, p. 16S. 
^ Op. cit., p. 460. 

j Graefe and Saeraisch's Handbook, vol. vi, p. 864. 
■> The Eye in General Diseases, p. 185. 
' Klinische Beobachtungten, 1874. 



ii8 



MORTALITY AMONG THE NEWLY BORN. 



[Medical News 



somewhat irregular. Rarely, however, a sector-like 
defect is met with, as in a case reported by Gowers ' 
and in one by Uhthoff;' or one-half of the field is 
lost (Gowers,'' Treitel,' and Berger'j. Central loss 
of vision is even more rare, but a case of this kind 
is reported by Gowers", and Berry' also speaks of 
it. Bunge* reports a case, but does not go into de- 
tails ; Althaus' one case ; and Berger two cases, one 
undoubted, with peripheral contraction first and 
scotoma later. So rare, indeed, is this last that 
Forster'" says that if an atrophy begins with a 
central defect or central scotoma, it indicates that 
"we are not dealing with a tabetic atrophy." 

Although it is true, as Stellwag" says, that vision 
is not "in direct proportion to the ophthalmoscopic 
appearances," or, as Knies'' declares, that "there 
is often a disproportion in both directions between 
the visible atrophy of the nerve and the disturbance 
of vision," yet the condition of the veins can usu- 
ally be readily recognized, even before vision be- 
gins to fail much. The essential ophthalmoscopic 
change is the discoloration of the papilla, which be- 
comes of a grayish or bluish-white color. Mauth- 
ner" contends that the earliest and most impor- 
tant symptom in beginning atrophy is attenuation of 
the vessels, but Leber says that this is true only in 
neuritic atrophy and not in true primary atrophy. 
The vessels are about normal in size, except in the 
very late stage, when they often become narrowed. 
Schmeichler says that often one or more veins, usu- 
ally the lower, are larger than normal and may be 
even twice the normal width. 

The disc appears flat or slightly excavated, with 
its edges sharply defined, and is of an opaque bluish- 
gray color, while the dots of the lamina cribrosa be- 
come more visible, causing a " stippling," and the 
minute vessels of the disc are absent. 

Before concluding I shall briefly report a case in 
which the ocular symptoms formed an important 
element in the diagnosis : 

A. K., aged thirty-five years, was referred to me by 
Dr. H. S. Upson for examination. The patient had 
complete loss of knee-jerk ; station was bad, and 
the gait was markedly ataxic ; but there was no 
pain. The diagnosis lay between locomotor ataxia 
and multiple neuritis. Examination of the eyes 

' Ophthalmoscopy, p. 125. 

^ Archiv f. Ophth., i38o, vol. xxvi, p. 277. 

^ Ophthalmoscopy, p. 124. 

1 Archiv f. Ophth., 1879, ^ol- xxv, p. 61. 

'" Archiv f. Ophth., vol. xix, p. 471. 

s Ophthalmoscopy, p. 127. 

' British Med. Journ., Oct. 7, 1893, p. 784. 

* " Ueber Gesichtsfeld und Faserverlauf im opt. Leitungsap- 
parale,'' Halle, 1884, p. 13. 

' Krankheiten des Riickenmarkes, 1885, p. 104. 
'** Handb. v. Graefe-Saemisch, Bd. vii. 
^^ Lehrbuch der praktischen Augenheilkunde. 
'-' The Eye in General Diseases, p. i85. 
" Lehrbuch der Ophthalmoscopic, 1868. 



showed pupils that responded readily to light and 
in accommodation ; the external eye-muscles were 
normal ; the optic nerves presented not the slightest 
indication of atrophy. Not only was vision normal 
'after correction of the astigmatism, but the form- 
fields and, what was even more significant, the color- 
fields were perfectly normal. As a result of the eye- 
examination, multiple neuritis was suspected rather 
than tabes; and under treatment all the symptoms 
rapidly improved, the ataxia disappeared, and the 
knee-jerk returned to normal. 

In conclusion, then, we should never lose sight 
of the importance of the ocular symptoms in all 
suspected cases of locomotor ataxia, and their value 
both in diagnosis and prognosis. Such examination 
should have regard to (i) the internal eye-muscles, 
as shown by the size of the pupils and their mode 
of response to light and accommodation ; (2) the 
external eye-muscles (including the elevator of the 
upper lids), which so often are paralyzed, causing 
diplopia or ptosis; (3) the condition of the optic 
nerve, which in so large a percentage of cases under- 
goes more or less atrophy. 

282 Prospect Street. 



/5 THE PHYSICIAN IN ANY WAYRESPONSIBLE 

FOR THE HIGH MORTALITY AMONG 

THE N EW L Y BORN? ' 

By M. a. CROCKETT, A.B., M.D., 

ASSISTANT GVNECOLOGIST TO THE B 



In a recent address before the Society for the 
Protection of Children in France, the chairman. 
Dr. Rochard, stated that 250,000 infants perished 
annually, and that, in his opinion, 100,000 of these 
lives might be saved. The world knows that France 
is much alarmed over the fact that the nation is not 
increasing in numbers. Dr. Rochard points out 
that the country might be repopulated simply by 
diminishing this waste of infant-life. History fur- 
nishes several examples of the disastrous results fol- 
lowing diminution of a nation's numerical strength. 
Infant-mortality might become a national question 
of great importance, and the Sta:te has a right to 
demand from the medical profession the causes that 
annually deprive her of so many lives. 

In the first place, is it true that the mortality 
among the newly born is high ? The term newly 
born is applied to the infant during the first month 
or six weeks of its existence. Eross, taking sixteen 
large European cities as the basis for computation, 
states that 10 per cent, of children born alive die 
during the first four weeks of life. Oesterlen'' states 
that the mortality of the first month makes up 42 
per cent, of the deaths of the first year of life. 

' Read before the Buffalo Medical Club, April, 1895. 
' Handbuch der Med. Statistik, 1874. 



August 3, 1895] 



MORTALITY AMONG THE xXEWLV BORN. 



119 



Uffelmann' says that the mortality of the first four 
weeks is about equal to the mortality of the second 
and third years of life added together. One-quarter 
of all the deaths, up to the age of five years, occur 
in the first month of life. Smith* says that in Eng- 
land, where there is an accurate registration of 
births and deaths, among every 100 children born 
alive there are four or five deaths during the first 
month. He quotes a French'author who places the 
mortality of the first month at 10 per cent. 

In this country, owing to deficient registration 
of births, the statistics are unreliable, but all author- 
ities agree that during the first month the mortality 
is very heavy. Think of the loss to a community 
represented by the enormous mortality of the first 
year of life, and then bear in mind that the first 
two weeks in the first month form the most critical 
time in this year and the very time during which 
the child is likely to be under a physician's obser- 
vation. While there may be differences of opinion 
as to the exact mortality among the newly born, the 
facts show this mortality to be so great as to demand 
a positive answer to the question at the head of this 
paper. 

Undoubtedly the mortality of the first month of 
life will always be high, for many of the deaths are 
unavoidable. There is a marked tendency, how- 
ever, among physicians to ascribe to Divine Provi- 
dence results brought about by their own ignorance 
and neglect. If it can be shown that a large num- 
ber of the deaths among infants result from diseases 
that we usually consider preventable, we can no 
longer shield ourselves by casting the responsibility 
elswhere. 

To learn anything definite about the newly born 
a large number of children must be studied. Eross,^ 
of Budapest, has recorded observations of 1000 in- 
fants. These children were examined twice a day 
and sections were performed upon all that died. 
Upon each visit the temperature was taken, with 
the striking result that in 430 of the children fever- 
temperatures were noted. Being surprised at this, 
Erciss used the thermometer among his private 
patients. He selected forty-two infants that were 
so situated as to receive the very best of care, and 
in twelve instances found fever present. He states 
that in most of these children the rise of tempera- 
ture was the first sign of disturbance, and without 
the use of the thermometer his attention would not 
have been attracted to the infant. The lesson from 
this is obvious. 

In 79 of the 430 feverish infants no cause for 
the elevation of temperature could be found ; 



1 Handbuch der privat. u. oeffentlich. Hygiene des Kindes, 
884. 

2 Diseases of Children. 

^ Archiv ffir Gynakologie, Bd. .\liii, H. 2. 

5* 



220 presented evidences of disease of the cord 
or navel; loS suff'ered from dyspepsia or intes- 
tinal catarrh, which, in many of the cases, was 
due to septic infection. Other diseases found 
among these 430 were bronchitis, pleuritis, peri- 
tonitis, meningitis, etc. This report of Eross is full 
of valuable information, but the important facts for 
us are that 220 children showed disease of the cord 
and that many of the other diseases were those in 
which we recognize infection as a cause. 

The same authority,' in another article, reports 
the results of observations upon 1000 children re- 
garding diseases of the navel and the infections re- 
sulting ; 680 infants presented some abnormality in 
the healing of the navel-wound ; this abnormality, 
in many instances, being associated with serious 
disease of the organism. 

It is now generally admitted that septic infection 
plays a most important role in the loss of life among 
the newly born. Epstein- says that much may be 
done to diminish the death-rate from pyo-septicemia 
in the newborn, which is too common even in pri- 
vate practice and under the most favorable sur- 
roundings. The most common entrance for septic 
matter is the umbilicus. 

Fischl,' from a careful study of histories, sections, 
and bacteriology, in twenty-two newly born, comes 
to the following conclusions : 

1. During the first it^ weeks sucklings are not 
uncommonly infected by septic microbes. The 
clinical and anatomic signs of this infection may be 
those of an acute or subacute gastro-enteritis, capil- 
lary bronchitis, or lobular pneumonia. 

2. The grounds for classing these diseases in the 
group of septico-pyemias of the newborn is the 
close similarity, in histologic and bacteriologic con- 
ditions, between these affections and those diseases 
that, both clinically and anatomically, pass as 
septico-pyemic. 

3. The histologic character of the organic 
changes consists in necrosis of cells and interstitial 
inflammation, with a tendency to hemorrhages. 
The microscopic changes in the mucous membrane 
of, the gastro-intestinal canal may be slight or en- 
tirely wanting, even in cases in which the symptoms 
are most severe. 

4. By means of culture-tests and inoculation-tests, 
streptococci aud staphylococci are found in various 
organs, especially in the lungs. 

5. The paths of infection are the navel-wound, 
with or without alterations in its healing, the food, 
and inspiration. The latter way is one of the most 
common and leads to the development of prominent 
pulmonary symptoms. 

1 Archiv fur Gynakologie, Bd. xli, H. 3. 

- Jahrbuch fiir Kinderheilk. 

3 Zeitschrift fiir Heilkunde, Bd. xv, H. 1. 



MORTALITY AMONG THE NEWLY BORN. 



[Medical News 



6. Acute dyspeptic diseases and genuine pneu- 
monias are rare, and their prognosis is much more 
favorable than when gastro-intestinal or pulmonary 
symptoms accompany septic infection. 

Tavel and Quervain' describe two cases of hemor- 
rhage occurring in the newborn in which bacteriologic 
investigation of the blood was made. In the first case 
a purulent discharge from the umbilicus was noticed 
a few days after birth and multiple hemorrhages 
occurred ten days later. The post-mortem examina- 
tion showed double pneumonia, with blood-stained 
fluid in the pleural cavities. The examination of 
the blood and organs revealed the presence of large 
numbers of streptococci. In the second case death 
took place from pneumonia. Hemorrhages were 
found in the pericardium, brain, and beneath the 
dura. Large numbers of staphylococci were present 
in the blood. 

Escherich'^ says that trismus neonatorum is due 
to local infection of the umbilical wound. ■ He 
reports three cases, in each of which there was 
septic inflammation of the navel, with peritonitis in 
one case and pneumonia in two. 

Hirst' has reported the results of section in five 
children dying from septic infection through the 
umbilicus. In his opinion the average physician 
does not recognize the fact that septicemia of the 
newly born is common. 

If the study of large numbers of newly born 
children and the opinions of distinguishd specialists 
carry any weight, we must recognize septic infection 
as an important factor in infant-mortality. It is 
also important to remember that the symptoms pro- 
duced by this infection are varied and obscure. 

Every newborn child has a physiologic wound. 
As the umbilicus is a recognized highway for infec- 
tive bacteria, and may itself be the seat of septic 
inflammation, I make no apology for calling atten- 
tion to this small area of the body. 

Normally,* the amniotic sheath of the cord ends at 
a ring of skin upon the abdomen, but Wharton's 
jelly continues down to the subcutaneous and peri- 
vascular connective tissue. After the dead stump is 
cast off' the umbilicus should heal by granulation, 
like any other wound. There are, however, cer- 
tain reasons why infection is easy and the results 
serious : (i) the position of the navel-wound and 
its close relation to the peritoneum ; (2) it contains 
the mouths of three large vessels ; (3) its contact 
with moist, dead tissue. 

There are certain anomalies that result in pro- 
ducing a large wound or disturb its healing. The 
most common of these anomalies are prolongation 



1 Centralblatt fiir Bakteriologie. 

2 Wiener klinische Wochenschrift. 

:> The Medical News, Jan. 9, 1892. 
■' Doktor : Archiv fiir Gynakologie, Bd. 



,H.3. 



of the skin upward upon the cord, continuation of 
the amnion upon the abdomen, and a fleshy core 
projecting into Wharton's jelly. 

Among a thousand infants Eross found 22 per 
cent, suffering from navel-infection. Last year 
Doktor, of Budapest, showed how this percentage 
of infection could be lowered by more careful 
attention to the dressing of the cord. He studied 
1 200 children before he arrived at a satisfactory 
result. He found the following to be the best 
method : With a sterile ligature the cord is tied as 
close to the abdomen as possible, and with sterile 
scissors cut close to the ligature. Aseptic cotton 
is applied, and the dressing is not touched for three 
days. After the third day the dressing is changed 
every other day until the stump has dropped off. 
To insure rapid mummification the child is not 
bathed until the stump has separated, after which 
time there are daily bathing and dressing of navel. 
The care of the cord is carried out with the custom- 
ary surgical details as to antisepsis, and is intrusted 
to the physician instead of the nurse ; 230 children 
treated in this way showed a diminution of navel- 
infection from 22 per cent, to 3.46 per cent. 
Epstein condemns moist dressings and antiseptic 
powders. The navel-wound should be treated on 
ordinary surgical principles, namely, asepsis and 
avoidance of irritation. The physician has no right 
to leave this matter entirely to the nurse. 

It is true that the traditions of a hundred years 
are violated by postponing the first bath for several 
days, but this causes no harm to the child. Doktor 
found a proportionately greater increase in weight 
and less skin-irritation in infants whose bathing 
was deferred. In this connection some observations 
of Liebreich' are interesting : " The veriiix caseosa, 
which has hitherto been regarded as superfluous 
filth, cannot be taken as such. It is not a glycerin- 
fat, but consists ofcholesterin-ether. This substance 
is germ-proof and air-proof. From this we conclude 
that Nature has given the child a natural protection 
against bacterial infection. The first bath should 
allow a reasonable amount of vernix to remain as a 
protection to the pores of the skin." 

There does not seem to be much danger of 
hemorrhage in tying the cord so close to the abdo- 
men, as in only one case in one-hundred did Doktor 
notice even slight oozing. 

When the lying-in woman shows signs of sepsis, 
usually some one is to blame. During and after 
confinement we observe every antiseptic precaution, 
and, not content with this, on each visit we take 
the mother's pulse and temperature, recognizing 
the fact that forewarned is forearmed. Does the 
child usually receive so much attention from the 
physician ? Its care is the province of the nurse, 

' Medical Record, April 23, 1893. 



AiT.rsT 3, 1895] RUPTURE OF THE LONG HEAD OF THE BICEPS MUSCLE. 



perhaps an incapable one at that. Information about 
the child filters through the nurse or the mother to 
the physician. If the baby becomes ill enough to 
attract some one's attention, the doctor examines 
its condition, and perhaps discovers a disease 
already well advanced. The physician has never 
seen a case of septic infection in a newborn child 
for the same reason that the old practitioner never 
saw a ruptured perineum. Diseases of the newly 
born form a terra incognita, because the physician 
does not take the trouble to observe. Eross found 
that out of 496,000 deaths of newly born children 
45,000, or 9J/^ percent., wereascribed to congenital 
weakness. What more need be said to support the 
charge of ignorance and neglect on the part of the 
medical profession regarding the newly born? Exact 
observation shows that very many children become 
ill during the first eight or ten days of life, and that 
the term congenital weakness is on a par with heart- 
failure. 

The baby's life is held too cheaply, and too often 
the term " little stranger " expresses the feelings of 
the physician toward the newborn child. During 
pregnancy and confinement we are constantly re- 
minded that we have charge of two lives, and after 
delivery the responsibility is in nowise diminished. 

Instruction in our medical schools is lamentably 
deficient on diseases of the newly born. Can any 
recall many clinics devoted to this subject? In 
view of the high mortality among young babies are 
our schools not bound to furnish better instruction 
on this subject ? 

Long custom has intrusted the care of the new- 
born child almost entirely to the nurse. Cutting 
the cord and handing the child to the nurse are often 
a ceremony of great solemnity. To the mind of 
many a physician it represents the severance of his 
responsibility from the child and the formal trans- 
fer of his duties to another. There must be a re- 
form in this matter. The first step toward saving 
these children's lives is the awakening of a proper 
appreciation regarding the physician's responsibili- 
ties. I need merely remind you of the brilliant 
results obtained from the proper medical care de- 
voted to the healing of the umbilical wound alone. 

I am aware that I have by no means exhausted 
this subject. It would be perfectly proper to go 
back to the time of labor and show how the lack or 
improper use of obstetric measures may result in 
bringing forth a child in poor condition to begin 
the battle of life. That part of the subject is large 
enough to furnish an essay by itself. 

I will conclude by summing up some of the con- 
clusions that seem to be justified by facts : 

(i) The mortality of the newly born is both abso- 
lutely and relatively disgracefully high. 

(2) Septic infection causes a part of this mor- 
tality, and is preventable. 



(3) Asepsis should be observed about the new- 
born child. Dirty fingers or instruments should 
not be introduced into the child's mouth in cases 
of asphyxia. The child should not be allowed to 
ingest pus with its milk. 

(4) The navel should be treated on modern sur- 
gical principles and have the personal supervision 
of the physician. 

(5) The physician should take the child's tem- 
perature as well as that of the mother, bearing in 
mind that many of the septic diseases have an in- 
sidious approach, and that the importance of the 
thermometer cannot be overestimated. 

(6) The navel-wound may be the path of infec- 
tion without showing signs of local inflammation. 

(7) Close observation of the newborn infant will 
teach the physician much and benefit the child 
greatly. 

RUPTURE OF THE LONG HEAD OF THE BICEPS 

BR ACHII MUSCLE ASSOCIATED WITH 

RHEUMATOID ARTHRITIS.'^ 

By G. G. DAVIS, M.D., M.R.C.S. Eno.. 

SURGEON TO THE GERMAN AND ST. JOSEPH'S HOSPITALS, PHILADELPHIA. 

Recently two cases of rupture of the long head 
of the biceps muscle of the arm came under my 
notice which are of interest to physicians as well as 
to surgeons. Their histories are as follows : 

The first case is in a laboring-man, aged thirty- 
seven years, who has had pain in the left hip and leg 
and right shoulder-joint for the past six weeks. The 
trouble in the hip and leg was painful and annoy- 
ing, but has improved somewhat. The pain in the 
shoulder, on the contrary, has been very marked, 
and so disabled the patient as to cause him to apply 
for treatment. He has but little power in the arm. 



Six days ago he noticed a lump on his right arm, 
which became more marked when the elbow was 
flexed. He states that he has no knowledge of 
having strained the arm in any way, and is not able 
to connect the appearance of the lump with any 
muscular effort. On examination the shoulder ap- 
pears somewhat atrophied, and distinct grating can 

1 Read (and Patients Exhibited) before the College of Physi- 
cians of Philadelphia, May i, 1895. 



RITPTURE OF THE LONG HEAD OF THE BICEPS MUSCLE. [Medical News 



be felt and heard when the head of the humerus is 
rotated. On contracting the biceps muscle and 
flexing the elbow a marked lump occurs instead of 
the gentle swell of an intact muscle. This mass is 
evidently composed of that portion of the biceps 
attached to the long tendon. The unaffected por- 
tion of the muscle attached to the short tendon can 
readily be seen and felt to the inner side. The 
upper portion of the lump diminishes in a fusiform 
manner into the long tendon, which can be felt as 
a rounded cord disappearing in the axilla beneath 
the edge of the deltoid muscle. The shape of the 
enlargement varies according to the amount of the 
contraction of the muscle. The accompanying 
sketch shows its customary appearance. (See 
figure.) 

The second case occurred in a blacksmith, aged 
sixty years. When twenty-five years of age he had 
an attack of rheumatism, which began in the feet 
and then involved the knees and hips. He was 
confined to bed for four or five weeks. At this time 
his arms were not affected. Nine months ago he 
was seized with pain in the right shoulder, which 
was so severe as to prevent him from sleeping and 
to deprive him of all use of the arm ; so he stopped 
work, and has done none since. The pain lasted 
two months, and during this time there was nothing 
unusual seen about the arm. Four months ago, 
while under the care of Dr. Goodman, he noticed a 
lump on his right arm above the flexure of the 
elbow. This came without his knowledge, and did 
not supervene on any violent exertion. On exam- 
ination the shoulder-muscles are seen to be atro- 
phied, and the lump is evidently the long belly of 
the biceps muscle. Its upper portion can readily 
be felt to be prolonged into the long tendon, which 
disappears under the edge of the deltoid. The 
creaking and grating in the shoulder-joint, at 
first present, have now almost gone ; the pain, 
though lessened, has not entirely disappeared. The 
power of the arm is much weakened, though the 
man can flex and extend it readily. Yesterday he 
drew my attention to his left knee, complaining of 
pain in it. Examination revealed a tumor, three- 
quarters of an inch in size, at the upper and outer 
border of the patella, which seems at times to move 
with the patella, but is evidently quite closely con- 
nected with it and in all probability is one of the 
fibro-cartilaginous growths that occur in the fibrous 
structures in the neighborhood of joints in those 
affected with rheumatoid arthritis. 

Cases like these may come under the notice of 
either a physician or a surgeon. When the disease 
is somewhat obscure in its manifestations, particu- 
larly in its early stages and when several joints are 
affected, the patient, thinking he has rheumatism, is 
likely to apply for treatment to a physician ; when, 
however, the local symptoms are marked, particu- 
larly if confined to a single joint, then he is likely, 
as did these two patients, to apply to a surgeon. 

Rupture of one of the tendons of the biceps 
muscle is not particularly uncommon ; four of such 
cases have come under my notice. Three were of 



the long tendon and one of the tendon of insertion 
at the bend of the elbow. The rupture is likely to 
occur either suddenly from violent exertion, or it 
may only be made known by the finding of an un- 
usual lump at the seat of the muscular swell of the 
biceps in a patient suffering from disease of the 
shoulder-joint. 

The tensile strength of healthy tendon is so great 
that it is my belief that true rupture is much rarer 
than is usually supposed, and that when a tendon 
does rupture it is very likely to have been diseased. 
Some cases that result from violent muscular con- 
traction are, in reality, tearing loose of tendons 
from the muscular or bony tissue. One of the four 
cases I have seen was of that character. The patient 
was a young man, an athlete, who, while warding 
off a blow in sparring, felt a pain in the tendon of 
insertion of the biceps above the elbow, with loss 
of power in the arm. Dr. Beates, under whose care 
he was, stated that the belly of the muscle was drawn 
up, while the tendinous lower end could be dis- 
tinctly felt with the fingers lying beneath the skin 
to the inner side of its normal position. By gentle 
manipulation the man was able to bring the lower 
end of the tendon opposite to the upper end, which 
was also gently pressed down into position, and by 
means of a suitable dressing the parts were retained 
in place. I saw the patient many months afterward, 
when union had occurred, and he had such good 
functional results that he ventured again to put on 
the gloves. The cause of the rupture in this patient 
undoubtedly lay in the pathologic condition of the 
muscle, because he was at the time of the injury 
muscle-bound, and had been for some time. Had 
the tendon itself been ruptured its lower piece 
would have been too short to be manipulated 
as it was. Rupture of tendons occurs in children 
with extreme rarity, their tissues not yet having 
begun to degenerate. 

Bryant' details the case of a boy, aged eight years, 
with rupture of the biceps femoris tendon at the 
point of insertion into the fibula. Here again it 
is the point of junction of the tendon with the part 
to which it is attached that is involved, and not the 
tendon itself. 

The cause of rupture of tendons is usually their 
being weakened by the disease variously known as 
rheumatoid arthritis, arthritis deformans, rheumatic 
gout, osteo-arthritis, etc. Robert Adams, ^ to whom 
we are indebted for our most accurate knowledge 
of this disease, describes the condition that it pro- 
duces as follows : " Should we have an opportunity 
of examining the anatomical conditions of the ten- 
dons in and immediately around the shoulder-joint 
in any case in which the disease had existed in an 

1 Surgery, vol. li. 

2 Rheumatoid Arthritis, 1873. 



AfGl'ST 3, 1S95] 



THE AMERICAN MEDICAL WOMAN. 



123 



early stage, we shall find that these structures resem- 
ble tendons which had been for a long time macer- 
ating, and that they have their fibers widely separ- 
ated from each other, as if they were about to resolve 
themselves into their primitive elements." (P. 97.) 
" As to the tendon of the biceps, except in those 
cases in which an opportunity is afforded to us of 
examining a shoulder-joint in which the disease is of 
an early stage, we usually observe that the whole of 
the intra-articular portion of it has been removed. 
The remains of the portion of the tendon of the 
biceps external to the capsule will be found to have 
contracted firm adhesions to the summit and edges 
of the bicipital groove." (P. 98.) 

Rheumatoid arthritis is not a rapidly fatal disease, 
and just as Mr. Adams, as quoted, attributes absorp- 
tion of the biceps tendon to a late stage of the dis- 
ease, so likewise do his successors. That the tendon 
does rupture, and does become absorbed, is alluded 
to and well recognized by some writers, although 
many descriptions of this disease in medical works 
fail to make reference to this fact ; but they univer- 
sally associate it with more or less disorganization 
of the joint, and cause it to be considered as a late 
phenomenon in the progress of the affection. The 
contrary is true. It is likely to be a comparatively 
early symptom. Long before the marked change 
occurs that one sees in the familiar illustrations in 
the text-books the continuity of the tendon may be 
destroyed. In the first case reported here the dis- 
ease had only been present for five weeks when the 
rupture occurred, and that, too, without the patient 
being cognizant of it, thus showing that the solu- 
tion must have been nearly or quite complete. In 
the second case the disease had existed only five 
months when the rupture occurred. This is com- 
paratively early, considering that the disease lasts 
for many years. In both patients the disorganiza- 
tion of the joint could not have been so very exten- 
sive, considering the slight restriction of motion 
that existed. In some cases the affection seems to 
involve the interior rather than the exterior of the 
joint, and the changes proceed outward. One can 
readily see why the biceps tendon, lying inside of 
the capsule, and only separated from the main joint- 
cavity by a synovial sheath, should be early affected 
and destroyed. 

The line separating cases of rupture due to vio- 
lence from those due mainly to disease is not always 
so sharply marked as the three cases detailed would 
seem to indicate. This is shown by the fourth case, 
which I saw some years ago. It occurred in a man 
advanced in years, and supervened on some violent 
exertion. He was, however, the subject of rheuma- 
toid arthritis, and it is likely that in his case the 
tendon had been somewhat weakened by the disease 
and was partly absorbed, so that when the violent 
contraction of the biceps occurred it caused the 



weakened tendon to break. Is it not possible that 
the fibrous and tendinous insertion of muscles, par- 
ticularly those inserted close to the articulations, 
may become affected by rheumatoid disease and so 
weakened as to cause their rupture without other 
appreciable signs of the disease ? I am inclined to 
think so. 

Bryant' says : " When one tendon breaks the other 
usually follows at a later date, thereby clearly indicat- 
ingxhat they give way from some disease which affects 
their elasticity." Dr. J. Roberts Bryan informs me 
that he had a patient advanced in years who sustained 
a rupture of the quadriceps tendon just above one 
patella, which was followed several months later by 
rupture of the tendon on the opposite side at the 
same place ; yet no other evidences of rheumatoid 
disease were present. If it is a fact that such cases 
are due to a weakening of the tendon by rheuma- 
toid disease, it indicates the desirability of advising 
the patient to guard against any sudden, violent 
muscular effort, and may give us some clue to a cor- 
rect prognosis as to the future course of the affection. 

E. Pagenstecher" reports two cases of rupture of 
the biceps muscle, one occurring in a strong, mus- 
cular man while lifting a quarter of beef, and the 
other in an athlete. The histories are not complete 
enough to judge as to the causes favoring their oc- 
currence. 

255 South Sixteenth St. 



ORIGINAL ADDRESS. 

THE AMERICAN MEDICAL WOMAN.^ 

By FRANCES EMILY WHITE, M.D.. 



YSIOLOGY IN 



COLLEGE OF 



The present age is often called "the woman's age," 
and the woman of to-day is somewhat dubiously dubbed 
" the new woman." But, although the medical woman 
is a woman of to-day, she is not altogether new — not 
absolutely /« de siec/e. Isolated accounts of doctors of 
medicine who were also women are scattered through 
the medical annals of all ages. Even .Esculapius (whose 
history is obscured by the mists of mythology) is said 
to have been followed by disciples of both sexes, and a 
college of physicians of both men and women existed in 
Egypt in the eleventh century B.C. 

Women skilled in medicine also play conspicuous 
roh-s in the great dramatic poems of the Greeks. Thus 
Homer, in describing one of the characters of the I/iad 
(Prof. Blaikie's translation), says : 

" .\ leech was she, and well she knew 
X\\ herbs on ground that grew." 

From the eleventh to the thirteenth century, .A.D., 
the famous school of Salerno (said to form the bridge 

1 Surgery, vol. ii, p. 292. 

2 Berhner klinische Wochenschrift, .\pril 22, 1895. 

' .Address delivered to the graduating class of the Woman's 
Medical College, in the American Academy of Music, Philadel- 
phia, May, 1895. 



124 



THE AMERICAN MEDICAL WOMAN. 



[Medical News 



between ancient and modern medicine) boasted several 
renowned women-lecturers, and from that time to the 
present women have occasionally held chairs in various 
medical schools of Italy. 

France, also, has accorded royal recognition to her 
distinguished daughters, Mesdames Boivin and Lacha- 
pelle — names familiar to all readers of medical literature. 
But to the women of America, aided and abetted by 
justice-loving and generous American men, belong the 
distinction and the responsibility of inaugurating the 
first systematic effort toward the annexation of the med- 
ical field to the somewhat restricted territory recognized 
as lying within the legitimate sphere of woman. 

During the colonial period, much of the medical prac- 
tice in New England was in the hands of women 
whose sole qualifications are said to have been acquired 
in the rearing of large families, and there is no record 
of any serious conflict between the two kinds of activity. 
But as the practice of medicine became more scientific, 
there was an increasing tendency toward its restriction 
to those who had received a scientific training, and the 
practice of midwifery thus passed out of the " sphere of 
woman." But the promise and potency of the medical 
woman of to-day were latent in the conditions of the colo- 
nial age, and the Pilgrim mothers (who, as wittily pointed 
out by one of their remote sons, a citizen of Philadel- 
phia, not only endured the common hardships of the 
period, but also endured the Pilgrim fathers), those 
dauntless daughters of an exigent situation, were the 
logical as well as chronological predecessors of women 
destined to share both the burdens and the privileges 
of American, medical, professional life. 

In the history of the slow and difficult development 
of the untrained American midwife into the educated 
and legally qualified doctor of medicine the year 1849 
must ever remain luminous — a red-letter year — the year 
in which Elizabeth Blackwell acquired the degree of 
Doctor of Medicine in an American school — the Medical 
College of Geneva, New York. In being the first 
woman in America to receive the medical degree, 
EUzabeth Blackwell unwittingly became the mother 
of us all — "the baby figure of the giant mass of things 
to come" — for tradition has it that the difficulties that 
she had encountered and the grave uncertainties that 
hung around the future of other women-aspirants for 
the medical degree first turned the minds of certain men 
and women of Philadelphia toward the unprecedented 
project of a medical school for women. Be this as it 
may (for the fruitful germ of this enterprise has been 
ascribed to more than one source), the coming event 
cast its shadow forward upon the retreating footsteps of 
this herald of a new evangel for women as she passed 
through Philadelphia on her way to Europe for further 
study ; and the following year proved to be a second 
red-letter year in the history ot the American medical 
woman — the year 1S50 — a date that adorns and dignifies 
the modest front of the Woman's Medical College of 
Pennsylvania. 

There are two claimants to the distinction of being 
the first medical college for women in the world — the 
school in Philadelphia and a school in Boston, formerly 
" The New England Female Medical College." To this 
long-standing controversy I am able to contribute the 
following facts, obtained (in the case of the party of the 
other part) by myself from the archives of Massachu- 



setts, which are preserved at the State House in Boston, 
guarded by the classic cod-fish (emblem of an early 
Massachusetts industry), and sheltered by the great 
gilded dome that accentuates Beacon Hill and dominates 
the consecrated precincts of the Common. The facts 
obtained from this unimpeachable source are as follows: 

In the year 1848 there was organized in Boston a so- 
ciety of which the object was to provide women with the 
instruction necessary to qualify them for the practice 
of midwifery, which (as already explained) had long 
before passed into the " sphere of man." A school was 
opened and lectures on the subjects of midwifery and 
general medicine were provided. In April, 1850, this 
society was incorporated under the name of "The 
Female Medical Education Society " for the stated pur- 
pose of providing for the education of " midwives, 
nurses, and female physicians." But although the 
words "female physicians" occur in the act of incor- 
poration, the charter did not grant the right either of 
appointing a medical faculty or of conferring the degree 
of Doctor of Medicine, and in 1856 a new charter was 
obtained by " an act to change the name of the Female 
Medical Education Society to the New England Female 
Medical College, and to reorganize the same." Section 
4 of this act sets forth that " the trustees shall have 
power to appoint professors who shall constitute a med- 
ical faculty, and to confer the usual degree of Doctor of 
Medicine." The Medical Education Society thus became 
a medical college in 1856. 

The charter of the Woman's Medical College of Penn- 
sylvania was granted in March, 1850, and the first 
session of the school was opened the following October 
with a full faculty, organized for the instruction of 
women in the various departments of medicine, the 
corporation being authorized to appoint such a faculty 
and to confer the degree of Doctor of Medicine on grad- 
uates of the school. The college in Philadelphia thus 
antedates the college in Boston by more than six years, 
and even should the date of the incorporation of the 
society from which the Boston college sprung — April, 
1850 — be claimed as the date of the founding of the 
college (which seems to me wholly unjustifiable), the 
palm of priority must still be conceded to the college in 
Philadelphia chartered in March of the same year — a 
difference in its favor that might prove of immense im- 
portance in case, for example, some future millionaire 
should bequeath a fortune to the oldest medical college 
for women in the world. 1 would suggest, however, as 
a harmless precaution, that this future legal instrument 
contain the name of The Woman's Medical College of 
Pennsylvania in full ! 

Although our college had a less brilliant inauguration 
than the school in Boston (the Female Medical Educa- 
tion Society numbering more than 1500 members, 
many of them among the most influential citizens of 
New England), the subsequent history of the two insti- 
tutions well illustrates the significant saying that " the 
blood of the martyrs was the seed of the church." The 
prolonged struggle of the college in Philadelphia and 
the lifelong devotion to its interests of a few women 
(two of whom were members both of the Board of Cor- 
porators and of the Faculty) have borne a rich harvest 
in the high standing accorded to the college by the pro- 
fession at large, and in a world-wide reputation outside 
the profession. 



August 3, 1895] 



THE AMERICAN MEDICAL WOMAN. 



IZ5 



The New England College, on the contrary, soon after 
the death of Mr. Samuel Gregory (the leading spirit both of 
the Society and of the Board of Trustees of the College), 
repudiated the broad scientific principles on which it had 
been established, and became merged in the School of 
Medicine of the Boston University — a homeopathic, 
coeducational school — the university itself (a parvenu 
among universities) being too little known to confer any 
standing on the college, which had forfeited its claim 
on the regular profession by selling its birthright for a 
mess of homeopathic pottage. In this matter the Quaker 
City, like the proverbial tortoise, has thus completely 
distanced its fleeter rival, and the persevering daughters 
of William Penn have quietly secured the precedence 
over their more demonstrative Puritan sisters. 

In an admirable sketch of the practice of medicine by 
women, which appeared in the Internationa! Review 
for October, 1879, Dr. James R. Chadwick, of Boston, 
argues that, although the struggle of women to free 
themselves from the social fetters that have so long 
proved an obstacle to their pursuit of knowledge has of 
late been centered on the profession of medicine, the 
reason is not to be sought in any peculiar fitness of 
women for the practice of medicine, but rather in the 
fact that the movement has found support in certain 
sentiments common to all civilized communities — the 
sentiments of delicacy, fastidiousness, and modesty — 
which, Dr. Chadwick states, have been gaining in 
strength from the days of Queen Charlotte and the 
mother of Queen Victoria, both attended by midwives, 
while the court-physician waited in an ante-room in case 
of anything serious ; as there are those now who, in 
trivial ailments, resort to a certain class of practitioners 
because their medicines are easy to take, but fall back 
on the regular profession, heroically ready to swallow 
anything, when the case becomes urgent. 

The first impulse toward the medical education of 
women in this country may have been excited by the 
sentiment of propriety, for it appears to have been a 
reaction against what Mr. Gregory contemptuously 
styled " /«(;«-w/^Ti'//;'r)' " that led to the formation, in 
Boston, of the society to which I have referred, in order 
evidently that the female obstetrician demanded by deli- 
cacy might acquire the education demanded by science ; 
but to the argument from propriety was soon added 
another, founded on the excess of the female population — 
that distressing surplus, the despair of the political 
economist and the mockery of the moralist who regards 
it as the duty of every woman to marry — a surplus that 
in New England at that time amounted to 20,000 
women, many of whom, it was urged, might find in the 
practice of midwifery a useful, honorable, and remun- 
erative occupation — no small matter where 20,000 sur- 
plus, and hence superfluous, women were involved. 

Whether or not the woman-doctor microbe may be 
traced to this source, it was about this time that the 
affection broke out — the germ finding a congenial nidus 
in the minds of a few women whose ambitions were not 
to be appeased by the sop offered by the Female Medi- 
cal Education Society, however saturated with soothing 
suggestions of honorable usefulness and pecuniary com- 
petency ; and these women demanded the opportunity 
of becoming fully educated as physicians. Now, al- 
though the invasion of the medical profession by women 
had been opposed by the profession in Europe from a 



conviction (probably sincere) of the intellectual inca- 
pacity of women, the mass of the profession in America 
never urged this point (for what reasons I will not under- 
take to explain), but based their objection (also probably 
sincere) on the totally different contention of impro- 
priety' — a fatal mistake — for as the community gradu- 
ally awoke to the necessity of regarding the question of 
propriety from the point of view of the woman-patient 
rather than of the woman-doctor, the argument from 
propriety veered to the other side of the question, and 
those who had urged it against the study of medicine 
by women were quite unexpectedly " hoist by their own 
petard !'' — the supposed antitoxin only served to increase 
the virulence of the infection. 

I would that something of the history and motives of 
all the women concerned in precipitating this agitation 
upon an innocent and unsuspecting profession might be 
known to every graduate and student of medicine pres- 
ent ; but, among the number, the names of Elizabeth and 
Emily Blackwell and our own Ann Preston, of blessed 
memory, whose works do follow her, stand pre-eminent 
— for in this opening professional vista their prophetic 
souls seized on a more alluring anticipation than the 
mere preservation of propriety, however desirable this 
may have been deemed — and on a more blessed bene- 
faction than a merely remunerative occupation for a few 
women ; they descried for women an avenue of escape 
from the physical deterioration and intellectual inanition 
that ever lie in wait for the unoccupied — an outlet into 
an invigorating atmosphere of activity in which the 
possibilities of realizing the potential plenitude of her 
being as a member of the human hierarchy would be 
multiplied almost by infinity.' 

That the social environment plays a conspicuous part 
in all phases of social progress is a commonplace of 
social science, but that a certain degree of adaptability 
on the part of the individual is also essential is an 
equally controlling principle in evolution. 

The single element of a public sense of propriety 
(upon which Dr. Chadwick would put the entire onus of 
this movement) could never alone have led to the es- 
tablishment of women in the medical profession. In 
order that a professional field may be successfully occu- 
pied by women, it must offer the following conditions : 

1 . The work required must come within the scope ot 
their abilities — physical and mental. 

2. It must afford opportunity for the exercise of the 
qualities generally described as " peculiarly feminine.'' 

3. It must make such demands on both the physical 
and mental energies of women as shall serve to develop 
these energies in a satisfactory degree. 

4. It must afford such pecuniary compensation as 
shall enable those who pursue it to devote their best 
efforts to the work, which must therefore be acceptable 
to the community. 

That the medical profession fulfils these conditions in 
a high degree is proved by the fact that there are more 
than three-thousand women in this country alone en- 
gaged in the practice of medicine to-day — many times 

1 See article by Dr. Mary Jacobi in Woman's Work in America. 
New York : Hoyt & Co., 1891. 

2 See address by Elizabeth and Emily Blackwell, " Medicine as 
a Profession for Women," 1859; also " Reply to Manifesto of 
the Philadelphia County Medical Society," by Ann Preston, 
Medical and Surgical Reporter, Philadelphia, May 4, 1867. 



126 



THE AMERICAN MEDICAL WOMAN. 



[Medical News 



as many as of those engaged in all the other professions 
put together.' But the conspicuous success of women in 
this as compared with other professions can only be at- 
tributed to a "peculiar fitness" for the work of the 
medical profession — to the lack, in other professions, of 
equal opportunities for the exercise of those qualities 
that have become specialized in women — the " pecu- 
liarly feminine " qualities — and Dr. Chadwick's reason- 
ing evidently fails as an explanation of the woman- 
doctor. 

Notwithstanding the existence in this country at the 
present time of from thirty-five to forty coeducational 
medical schools, the greater number of women now 
practising medicine here are graduates of schools ex- 
clusively for women, although the number of women's 
colleges of recognized position is only four. The co- 
educational schools include the medical departments of 
eleven universities — those of Michigan, Iowa, Minne- 
sota, Colorado, California, Oregon, Buffalo, Syracuse, 
Boston, the District of Columbia, and the Johns Hopkins 
University of Baltimore. 

The preference shown by women for schools attended 
exclusively by women might be variously interpreted as 
depending, perhaps, on geographic convenience, on 
favorable financial conditions, or (as the licence to prac- 
tise as well as a medical education can be obtained 
only at a medical school) on less exacting educational 
requirements. 

On the point of geographic convenience, I will cite 
the fact that of the nineteen women practising medicine 
in the State of Washington only one is a graduate of 
the Willamette University, in the neighboring State of 
Oregon. The geographic argument is thus disposed of. 

The financial reason also fails as an explanation, as 
in the universities that receive State support the fees are 
notably less than in the colleges for women. 

On the third point — that of educational requirements 
— investigation has disclosed several facts that bear 
on it : 

1 . That the required term of study in the colleges for 
women is longer than in most of the coeducational 
schools — our own college and the college of the New 
York Infirmary having been among the first in this 
country to lengthen the college-year and to increase 
the term of study to three and later to four years. 

2. The results of competitive examinations for hos- 
pital-appointments, of examinations by State boards and 
for admission to State societies all show that women 
rank with the best when subjected to this test. 

At the first examination held by the State Board of 
Maryland, in 1893, the highest percentage was made by 
the only woman presenting herself — a graduate of the 
Baltimore school for women ; and in September last, at 
the State examination in New Jersey, a graduate of 
our own school took the highest rank. The records 
of competitive examinations for medical service in the 
Philadelphia and Polyclinic Hospitals in this city afford 
similar testimony. Thus the argument of less exacting 
educational requirements also breaks down as an ex- 
planation of the preference shown by women for their 
own exclusive schools. 



' These figures were obtained from Polk's Medical Register of 
the United States for 1893. A recent census-report places the 
number at a little more than five-thousand. 



The choice of a college is undoubtedly influenced by 
the clinical opportunities afforded in the localities con- 
cerned, and by the professional reputation of individual 
members of the various faculties. As to how much 
depends on the absence of male students — the degree of 
probability that inferior advantages and greater expense 
would be outweighed by this circumstance — must be 
left to the judgment of my hearers. A conclusive esti- 
mate of the influence of this factor could be reached 
only by a co?tscnsus of the views of those actually 
concerned — the students themselves; but in view of 
the general American confidence in the coeducational 
system (although it will be admitted that medical co- 
education presents some exceptional features), taken in 
connection with the fact that most female students 
attend the clinics of the public hospitals where male 
students are also in evidence, notwithstanding that 
the clinic affords the supreme test as regards the difficul- 
ties of coeducation, the inference seems justifiable that 
the schools for women ofifer better advantages than can 
be obtained in the coeducational schools. 

As the great medical schools of Philadelphia, New 
York, and Boston do not admit women, the only basis of 
comparison with these schools is that afforded by the 
statistics of results of competitive and other test examina- 
tions to which reference has been made and which bear 
especially upon these particular schools, as they are in 
the localities where such examinations are most in 
vogue ; and these statistics undoubtedly warrant the 
conclusion that the best of the women's schools com- 
pare favorably with these leading schools for men. The 
medical department of the Johns Hopkins University 
(to which the admission of women was secured by 
a /our de force in the guise of a third of a miUion of 
dollars supplied mainly by one woman) is of too recent 
date to throw much light on the question under discus- 
sion. This college opposes more rigid requirements to 
the entrance of students, and offers a more advanced 
schedule of study than any other medical school in this 
country, and yet, of the first class (which matriculated 
in 1893) one-sixth were women— a far higher proportion 
than is shown in the total number of medical students 
for the whole country — thus confirming my contention 
that the attendance of women at any particular school 
is not determined by the presence or absence of the co- 
educational feature. 

The claim here distinctly put forward, that the medical 
colleges for women stand among the most advanced of 
American medical schools, is not based entirely on the 
two points thus far mentioned, viz., the numbers in at- 
tendance as compared with the coeducational schools 
and the statistics of competitive and other test-examina- 
tions, but also on their requirements for admission, the 
character of their laboratory and other equipments, the 
courses of study pursued, the clinical advantages af- 
forded, the term of study required, and the hospital and 
other appointments secured by their alumnei:. On the 
question of curriculum, I may state that the Woman's 
Medical College of Pennsylvania and the Medical De- 
partment of the Johns Hopkins University are the only 
colleges in the United States, so far as known, in which 
work in the physiologic laboratory is required of every 
student, the former having been the first in this country 
to make this requirement. 

The chief disadvantages from which medical women 



August j, 1S95] 



THE AMERICAN MEDICAL WOMAN. 



127 



in this country now suffer arise from their exclusion 
(during their professional career) from the work of the 
great public hospitals. Ur. Emily Blackwell, of New 
York, in an unpubhshed paper which has come into my 
hands, calls attention to the fact that these public insti- 
tutions, equipped and endowed at public expense, are 
monopolized by men — although the hospital is no less 
important than the college in the training of doctors — 
that medical progress depends on the hospital and the 
laboratory, that the scientific writers and teachers, the 
great operators and other leaders in medicine are the 
hospital-men, and that the great journals are founded 
on hospital-records ; and she adds that women, being 
limited to the few small hospitals that they have them- 
selves established, are in the position of emigrants in a 
new territory, or, as might have been said, of the ad- 
vance-guard of an invading army, compelled to build 
their own roads and create their own facilities as they 
advance. 

This arraignment of the authorities who control the 
public hospitals is a most serious one ; but in estimating 
the significance of the marked preponderance of distin- 
guished men in the profession, as compared with dis- 
tinguished women, the immensity of the mass of medi- 
cal men, as compared with that of medical women, 
should not be overlooked. When the total number of 
great operators and other leaders in medicine is con- 
trasted with the whole number of men in the profession, 
the ratio of greatness seems less distinguishing, "the 
gray pre-eminence of man " (which gave pause to the 
ambitious princess of Tennyson's imagination) becomes 
less overwhelming to the female medical conscious- 
ness. In spite of the disadvantages pointed out by Dr. 
Blackwell, the female profession boasts distinguished 
teachers in both the scientific and the practical branches 
of medicine, of which Dr. Blackwell herself is an 
example ; brilliant operators in the surgical diseases 
of women, a field that presents some of the most diffi- 
cult situations in surgery ; skilful attendants in the mater- 
nal crisis that perhaps offers the supreme test of fer- 
tility of resource and presence of mind in the face of 
danger ; and a shining record in the care of the insane, 
a specialty that demands a high degree of intrepidity 
and coolness, as well as of gentle and sympathetic firm- 
ness. The number of contributions by women to medi- 
cal and scientific literature (judged by the ratio of 
writers to the whole number of the profession) is also 
creditable.' Without exaggeration, then, the medical 
profession may be said to show a goodly proportion of 
women who have " added the incident of learning to the 
accident of brains." 

The medical work actually done by women may 
be regarded from two points of view : its value to 
the community (this depending on its quality as well as 
on its peculiar acceptability on account of their sex) and 
its value to themselves as a means of individual devel- 
opment, the latter being the broader, the more impor- 
tant view, a view in which the word " medicine " is quite 
overshadowed by the word " woman." Into the con- 
sideration of this aspect of the subject the scientific 
character of th'iir work does not necessarily enter ; 
nevertheless, the question as to what proportion of medi- 
cal women maybe classified as "regular," " homeo- 

' See appendix to article by Dr. M. Putnam-Jacobi, loc. cit. 



pathic," " eclectic," etc. , is one of great sociologic in- 
terest, like that of how the majority of women would 
vote in case of obtaining the suffrage, whether intelli- 
gently and on the side of law and order, or in the spirit 
of partisanship and with an eye (or both eyes) to the 
spoils. 

In the city of Philadelphia (for many years, if not 
still, the civitas Hippocratica of America), of those en- 
gaged in the practice of systems not recognized by the 
mass of the profession as scientific medicine, systems 
the methods of which justify the opprobrious designation 
of quackery (which may be said to consist in using a 
remedy for the wrong reason or for no reason), the pro- 
portion is approximately the same for women as for men 
— about one-fifth. The statistics for the whole profession 
are not at hand, but of the entire number of legally quali- 
fied women engaged in the practice of medicine in the 
United States, made up of graduates of more than forty 
colleges, nearly one-fourth are graduates of the Woman's 
Medical College of Pennsylvania, and although I am com- 
pelled, most regretfully, to admit that this is nofan absolute 
guaranty of the scientific character of their practice, I 
believe that the proportion of the alumnaj of our College 
who have proved true to its principles and teachings, 
and have thus been added to the ranks of scientific 
medicine, is much higher than the ratio for the city of 
Philadelphia. 

The tide of modern medicine has set strongly in the 
direction of scientific methods, in which the balance and 
the retort, the microscope and the stethoscope, with the 
long list of their congeners, the thermometer, the pelvim- 
eter and numerous other instruments of precision, the 
culture-tube with the measures for the exclusion and de- 
struction of the ubiquitous microbe that have grown out 
of its use, and many other other sanitary measures — the 
results of modern study of the soil, the water, the air, 
and the chmate — all play a conspicuous part. To this 
enumeration must be added the study of the lower 
animals and of man, by means of the multitude of modern 
instruments for investigation of the physiologic and 
psychologic problems that underlie the vast field of 
pathology. Any system of medicine in which the treat- 
ment of disease is based on principles and theories de- 
rived from other than scientific sources is self-condemned. 
So far as the medical profession is concerned, the post 
/iOc\ ergo propter hoc method of reasoning has had its 
day, and some better evidence than the recovery of the 
patient must be forthcoming in favor of a particular 
plan of treatment in order that it shall secure the seri- 
ous attention of the profession ; unless the relation of 
cause and effect between treatment and recovery can be 
established, we have not science, but empiricism. 

In the relation which has so long existed between us 
of professor and student I have striven to infect your 
minds with the love of scientific truth ; but now, as this 
relation is about to be severed, I desire to express to you 
my profound conviction of the great truth that " learn- 
ing is but an adjunct to ourself ;" that while she who 
heals the sick, who makes the blind to see, and the lame 
to walk does well, and " though twice a woman shall be 
called a leech," she who exhibits in her own character 
the value of a broadening and elevating pursuit in the 
development of the liberality of mind and self-poise 
essential to a true appreciation of life in all its depth 
and fulness does better; and while students of soci- 



128 



RECTAL NEURALGIA. 



[Medical News 



ology are still perplexedly discussing the question of 
the desirability of an independent career for woman in 
the abstract, may you, individual women, each of far 
higher importance than any abstraction, fare bravely 
and womanly on to a future in which you shall have 
wrested from fate — the fate of the abstract woman — 
an assured position among the thousands of women 
already living enriched and ennobled lives as doctors 
of medicine, who are finding therein congenial occu- 
pation, intellectual growth, pecuniary independence, 
and a sphere of immense usefulness to their sex and 
hence to the entire circle of humanity that comes within 
the radius of their influence. 



CLINICAL MEMORANDA. 

THREE CASES OFRECTAL NEURALGIA, ONE 
WITH DOUBLE lUAMM I LLI T I S . 

By W. F. ARNOLD, M.D., 



Case I was met in the person of a rather delicate man of 
middle age, whose illnesses have mostly been ascribable 
to the common infectious diseases of the respiratory 
system that have been resisted with anxious difficulty, 
although no noteworthy sequels remained from any of 
them. He suffered severely some years ago from Mor- 
ton's (pressure) neuralgia in both feet ; this subsided 
upon the adoption of a less exacting life, without treat- 
ment, its nature appearing to have escaped observation. 
He is the subject of pruritus ani of so moderate a char- 
acter that applications of such simple remedies as citrine 
ointment and an ointment of calomel twice a week have 
served to obviate nearly all of its inconveniences. On 
account of this response to agents to which 1 am very 
loath to ascribe any other than a local (and most prob- 
ably a parasitic) action, I think the neurotic origin of 
this irritation is open to serious question. At the time of 
the single attack of rectal neuralgia that I witnessed, 
the pruritus had been in unusual abeyance ; and it con- 
tinued so for several months thereafter. He had gained 
much in weight about this time, and he frequently con- 
gratulated himself upon the beneficial effects of a recent 
change of cHmate. 

This attack came on without premonition during 
sleep, between one and two o'clock at night ; and in this 
manner and time of inception it e.xactly corresponds 
with the other two cases to be described, as well as in 
the reUef afforded by the passage either of feces or of 
flatus even in the smallest of quantities. I found the 
man upon the seat of the water-closet in a state of de- 
pression, nearly pulseless, of a death-like pallor, and 
sweating profusely. He evinced so much pain at that 
time that I gave him a medium dose of morphin subcu- 
taneously, notwithstanding his statement that it had 
grown distinctly less in the few minutes that had been 
required to summon me by the officer of the deck, who 
had first assisted him in a half-fainting state to the 
water-closet. 

No further attacks were observed in the course of our 
service together, which continued for a year; but no 
antineuralgic treatment was instituted. The man 
thought that the attacks were becoming less frequent. 

Case II occurred in a man about forty-five years old, of 
pronounced athletic tendencies. There is nothing more 



significant in his medical history than an obstinate attack 
of sciatica about five years ago. His seizures have not 
exceeded four in all, the first having taken place nearly 
two years ago. They seem, from the patient's account 
of them, to have been milder than the one to be de- 
tailed, but he is emphatic in declaring the pain to have 
been agonizing in character. All occurred between 
midnight and two o'clock a.m. The last one or two the 
man relieved by an extemporized suppository, as he had 
noticed that the presence of anything in the lower bowel 
abated the pain. 

In Case III the patient had suffered only two very 
light paroxysms of rectal pain. It is probable that they 
would not have been considered as characterizing a 
special form of neuralgia had attention not been aroused 
by the preceding cases. The victim is a medical man, 
about thirty-two years old. His history includes gastric 
neuralgia(?) at the age of ten, severe /U from exposure 
to cold in Glacier Bay, Alaska, and a confirmed predis- 
position to Morton's neuralgia in the left foot, which is 
kept within limits, permitting comfortable bodily activity 
by attending to the shape of the soles of his shoes. 
His health is good, although he consciously prejudices 
it by his persistence in sedentary employments, to the 
almost complete exclusion of regular exercise. There 
is nothing to be noted about his seizures, which he de- 
scribed to me minutely upon my suggesting their nature, 
that has not already been referred to. We agreed in 
declining to treat such an irregular, and, in this case, so 
mild a disorder. 

This gentleman has been subject since early boyhood 
to a peculiar form of irritation of the nipples and their 
areola;, which, as nearly as he can recall, is set up only 
by exposure to a strong, cool wind. He is reasonably 
certain that it is not a result of the direct, local action 
of a high degree of cold, inasmuch as it is not mani- 
fested at times of severe exposure to simple cold ; while 
the protection afforded these structures by the prevailing 
types of apparel is certainly opposed to this assumption. 
Besides, he has been driven by the inconveniences ex- 
perienced to adopt local protective measures that have 
proved to his mind to have been of no prophylactic 
value. The last instance of it, which he observed with 
minuteness, was due to four hours' exposure to a strong, 
topsail breeze from the northward early in April. His 
upper garments on this occasion — a literal wild-goose 
chase — were a leather shooting-coat, lined with cordu- 
roy, an otter-skin vest of southern Chinese pattern {/i/ 
est, nearly completely double-breasted), a light tlannel 
shirt, and a very heavy flannel undershirt. 

After twenty minutes' exposure to this wind from the 
right rear, soreness of both nipples appeared. The 
sensation is described as one of rawness, which causes 
the patient to shrink continually from the contact of his 
clothing, upon which contact, however, he is confident 
it is in no measure dependent. He says that it is more 
severe than simple contact of cloth with denuded cutis 
would be under ordinary circumstances ; and he claims 
for it a peculiar quality that is as invariable as it is 
elusive of description. No very evident tumefaction 
results, but a deepened color seems a constant accom- 
paniment. Careful search has not shown that the epi- 
thelium is eroded or that any exudation of any kind 
takes place. Hyperesthesia to touch and to the appli- 
cation of universal emollient agents, such as carbolized 



August 3, 1895] 



ACQUIRED PHIMOSIS. 



129 



vaselin and glycerol, remains for from one to three days 
after each attack. The severity of the attack appears 
to be directly in proportion to the violence of, and the 
length of exposure to, the wind, and the duration is 
proportioned by the severity. Protection from the wind 
mil arrest an attack at an early period after the incep- 
tion of the initial symptoms. Naturally, inflammation 
here is only surmised. 

Diligent inquiry has not developed a single case of 
this kind in either sex, save the one just related. It is 
perhaps desirable that I should add that there is not a 
suggestion of effeminacy about the subject of this, to me, 
unusual manifestation, which is a very real source of an- 
noyance to its involuntary victim, who has the addi- 
tional misfortune of being compelled to go to sea for a 
liveUhood. He considers that he suffers more from cold 
than do the majority of the inhabitants of temperate 
climates. He has no theory of its mode of origin, and 
I have no speculations as to this that 1 care to express. 

Regarding the rectal neuralgia, I have heard very 
little, and have seen even less in the commoner text- 
books on the practice of medicine, although Gowers de- 
votes a pointed paragraph to it in his Dist-nses of the 
Xeri'oiis Syslc/ii. If what I observed in Case I were 
frequently repeated, it might easily serve as the cause of 
sudden death from shock or from syncope. It may be 
well to state that none of these patients shows any 
obvious signs of gout. 

U. S. S. Petrel, Fourth-rate, Asi.vtic Station. 



SPONTANEOUS EXTRUSION OF A PIECE OF 
IRON THROUGH THE CORNEA.' 

By HOWARD F. HANSELL, M.D., 



CLINICAL PROFESSOR OP OPHTHALMOLOGY, JEFFERSON MEDICAL COLLEGE ; 
ADJUNXT PROFESSOR OF DISEASES OF THE EYE, PHILADELPHIA 

This case presents unique and distinctive interest on 
account of its exceptional rarity — such a termination of a 
similar accident, which is recognized as a serious one, is 
unknown to me in my experience or in literature; and, 
because of its suggestion of a possible prognosis in cases 
of wounds of the eyeball, and of foreign bodies and their 
retention in its interior, that has probably heretofore not 
been considered. When a foreign body, such as a frag- 
ment of metal, enters the eyeball, inflammation is excited 
by the direct violence of the traumatism, and later by 
the presence of the foreign body in the highly organized 
tunics ; and, secondly, by the introduction of germs 
and by the chemic changes that the substance under- 
goes through oxidation by the intra-ocular fluids. 

As soon as practicable after the injury the magnet 
and other means of extraction should be employed, in 
order to prevent destruction and atrophy of the globe 
and to save the patient from the disastrous effects of 
sympathetic inflammation. The traumatic inflammation 
may cause the formation of a capsule around the foreign 
body, in which it may lie innocuous for many years. 
This fortunate outcome, however, cannot be seriously 
considered, and, while it exceptionally solves the prob- 
lem, it does not alter the safe rule that a foreign sub- 
stance in the eye should be extracted with the least pos- 
sible delay and injury to the sight and to the globe. 



' Read before the Philadelphia County Medical Society, May 
IS. 1895- 



A. \V., aged thirty years, presented himself at the out- 
patient eye department of the Jefferson Hospital in 
March, 1895, complaining of pain due to the presence 
of a piece of iron in the left eye. I found projecting 
from the most inferior part of the cornea, just above the 
scleral margin, a dull, black, pointed object. Palpation 
with a spud showed that it was metallic, as a sharp chck 
could be easily heard and a grating sensation was felt as 
the point of the instrument passed over it. The pericor- 
neal vessels were markedly injected ; the cornea in the 
immediate neighborhood was opaque ; the anterior 
chamber was of normal depth ; the pupil was mobile 
and cone-shaped, the point of the cone below ; the iris 
was attached in one or two places to the anterior cap- 
sule and to the cornea at the site of the black point ; the 
capsule was slightly opaque, with a few streaks of opac- 
ity running backward through the lens. The patient 
stated that fifteen years before, while breaking rocks 
with a pick-axe, a minute fragment of the point of the 
axe flew into the left eye. Severe inflammation and 
partial loss of vision followed. The signs of inflamma- 
tion disappeared in the course of a few weeks, to recur 
with greater or less severity every few months. The 
man assured me that this was the only traumatism that 
had ever happened to that eye, and that he, his medical 
advisers, and his friends had known that the eye con- 
tained a foreign body from the time of the accident. He 
had hitherto declined all suggestions to have it removed. 
V = 20/50. Accommodation and the visual field were 
apparently undisturbed, though these points could not 
be accurately determined. The man was admitted into 
the hospital, and, after some fruitless attempts at re- 
moval, the foreign body was extracted by dissecting it 
out from the cornea. A four-volt battery, strong enough 
to extract the iron and to distort the cornea, was of no 
service in dislodging the body because its rough sur- 
faces and edges were firmly held by corneal and inflam- 
matory tissue. The patient recovered in a day or two, 
with vision unchanged. The piece of iron I have the 
pleasure of showing you weighs a little less than two 
grains. 

ACQUIRED PHIMOSIS. DUE TO UNSUS- 
PECTED VENEREAL WARTS, SIMULAT- 
ING GUMMA OF THE PENIS. 

By a. BRADLEY GAITHER, A.M., M.D., 



S'S HOSPITAL 



When a case of acquired phimosis is met with, it is 
often impossible to tell from the clinical history just 
what condition will be found after circumcision has 
been performed. Some cases, due to hard chancre, 
with an induration involving the whole prepuce, and 
having a thick discharge from the preputial cavity, show 
no marked points of ulceration after operation. Again, 
cases with moderate preputial discharge and swelling 
may show extensive ulceration and excavation on split- 
ting back the prepuce. 

Acquired phimosis, due to venereal warts, is rare, and 
almost invariably the patient will have noticed the 
growths, with their gradual increase in size and number, 
thus giving an immediate clue to the cause of the 
trouble. The following case may be of interest on ac- 
count of the negative history as to venereal warts, and 



130 OPIUM-POTSONING TREATED WITH POTASSIUM PERMANGANATE. [Medical News 



the clinical presence of gumma, or epithelioma, of the 
penis. 

John D., aged thirty years, an unmarried Irishman, 
presented himself at the Genitourinary Department of 
the Johns Hopkins Hospital Dispensary on May 6, 1S95, 
with the following history : He denied ever having had 
venereal disease and had never observed a sore or growth 
on his penis. From childhood the prepuce had been 
tight, but it could always be retracted without difficulty. 
The man had had sexual intercourse for the last time on 
December 21, 1894. On January 6, 1S95, he first noticed 
a discharge from the preputial cavity. At this time the 
prepuce was slightly swollen and painful, so that he did 
not retract it. In March he went to a hospital and was 
given medicine to take internally, and later an injection 
with which to wash out the preputial cavity. After two 
months' treatment, during which time his condition be- 
came progressively worse, he came to the Johns Hop- 
kins Hospital. One year before he had had sores on 
the scalp and some small pimples over the body, with 
slight alopecia. There had been no sore-throat, head- 
ache, or pain in the limbs. The glands in both groins 
were indolently enlarged. 

On examination, a condition of acquired phimosis 
was found to be present. The penis, from one cm. 
behind the corona to the meatus, was swollen to three 
times its normal size ; the prepuce could not be retracted 
at all, and was very tense. There was a free discharge 
from the preputial orifice. On the dorsum of the prepuce 
in the median line, just over the corona, there was an 
excavated ulcer of the size of a small bean, with a free 
purulent discharge and a bad odor. The cutaneous por- 
tion of the prepuce was bright-red in color, with a sharp 
line of demarcation one cm. behind the corona, from 
which point the appearance was normal. The sensation 
to the touch was that of a hard, uneven mass, as if the 
glans penis and prepuce were adherent ; yet in places 
there was the elastic pulpy feeling of a gumma. The 
edema and tension of the prepuce prevented a satisfactory 
examination. On irrigating the preputial cavity the 
fluid came slowly through the opening on the dorsum of 
the penis, apparently taking a roundabout course. 

From the clinical appearance 1 was in doubt as to 
whether the case was one of gumma or epithelioma of 
the penis. On the following day, under ether-anes- 
thesia, the prepuce was slit back in the median hne, 
through the sinus, and the condition found to be due to 
venereal warts. These were countless in number, and 
grew from every portion of the glans penis and mucous 
surface of the prepuce. They varied in size from a 
pin-head to a cherry. Under the favorable conditions 
present their growth had been so luxuriant as to put the 
prepuce under such tension that necrosis had set in. 
The warts were cut off as close as possible and cau- 
terized with nitric acid. The prepuce was then rounded 
off and an iodoform-dressing applied. On the subsid- 
ence of the edema it was found that a few warts had 
been missed. These were treated with the continued 
local application of fluid extract of euphorbia pilulifera, 
which gives very satisfactory results in this condition. 



Dr. Benjamin S. Mackie, U.S.N. , died at Philadelphia on 
July 25th, at the age of fifty years. 



TOXICOLOGIC NOTE. 

A CASE OF OPIUM-PO ISDN ING TREATED WITH 
POTASSIUM PERMANGANATE. 

Service OF GEORGE BYRD H.-^RRISON, M.D., Emergency 
Hospital, Washington, D. C. 

[Reported by jAMES R. CHURCH, A.M., M.D., 
of Washington, D. C] 

The following case was the last of a series of fourteen 
which came under my observation while an interne at 
the Emergency Hospital, and, I think, presents features 
to make it of interest to the profession. It is the only 
case in which a recovery was entirely attributable to the 
permanganate-treatment, and was to me a most satis- 
factory test of the efficacy of this antidote. 

M. S., a mulatto girl, nineteen years of age, was brought 
into the hospital at n.30 p. m., with the history of having 
taken twenty-cents' worth of laudanum (probably 25 
or 30 c.cm. ) about two hours previously. She had several 
epileptiform seizures while in the ambulance and one 
after admission to the hospital, but was easily roused 
from her stupor by pressure on the supraorbital nerves. 
She could not, or would not, talk, but was not in a con- 
dition of absolute coma. The pupils were pin-head in 
size, respiration was slightly accelerated, and the tem- 
perature was normal. 

The girl was treated with the usual line of opium- 
antidotes and antagonists, and, as coma was absent, she 
was given apomorphin hydrochlorate 0.005 hypodermi- 
cally, which had been preceded by 300 c.cm. of a solu- 
tion of potassium permanganate (0.30 to 500 c.cm. ot 
water). Two more injections of the apomorphin were 
given at intervals of about seven minutes, but none of 
them was effective. To be certain that the lack of 
action was not due to the defective qualities of the drug 
the second and third doses were each taken from a 
freshly opened bottle of tablets. Shortly after the last 
dose the girl's condition became rapidly worse. She 
lapsed into coma and the pulse went up to 134 and the 
respiration to 26, and became stertorous. The faradic 
current now had little effect, and 1 decided to rely en- 
tirely on the permanganate, as other treatment was un- 
satisfactory. 

The stomach-tube was passed, and, after the removal 
of the gastric contents and lavage with hot coffee, 
500 c.cm. of the permanganate-solution were thrown 
into the stomach and allowed to remain about five min- 
utes, being then withdrawn and replaced by a fresh 
solution. This was repeated until 2500 c.cm. of the 
solution had been used, when 250 c.cm., containing 0.30 
of the salt, were introduced and allowed to remain. 
After the second washing out the girl's condition began 
to improve, and after the last she was aroused by the 
battery with comparative ease. Her pulse dropped to 
104 and respiration became less frequent and fuller, 
and within three-quarters of an hour from the ingestion 
of the last 250 c.cm. of solution she was sent to the ward 
to bed, being then perfectly conscious and easily roused. 
She made an uninterrupted recovery and was discharged 
the next day, complaining only of slight pharyngeal irri- 
tation and general lameness, the latter due to efforts to 
rouse her. 

The points of interest in the case are, I think, the 



August 3, 1S95] 



MEDICAL PROGRESS. 



131 



convulsions, which I do not understand ; the bad effect 
of the apomorphin, which had about the influence of an 
equivalent of morphin, and, lastly, the entirely prompt 
and satisfactory rally after the permanganate was re- 
sorted to, at a time when the condition was extremely 
critical. 

I think my treatment open to criticism in deferring 
the use of the stomach-pump and in not immediately 
using the permanganate in larger dose than the first 
300 c.cm. I can unhesitatingly assert that the patient's 
recovery was due to the permanganate-treatment, and 
should not hesitate to use it in other cases in preference 
to other drugs. 
1706 Oregon Avenue. 



MEDICAL PROGRESS. 

Cerebral Softening with Hysterical Symptoms during Preg- 
nancy. — Barbour {Edinburgh Medical Journal, June, 
1895, p. 1092) has reported the case of a primipara, 
twenty years old, who in the fifth month of pregnancy 
became melancholic, and suddenly in the seventh month 
staggered, lost vision, and also power in the left leg, re- 
covering, however, in a few minutes. Two weeks later 
a similar attack occurred, beginning with emotional dis- 
turbance, tremors, and faintness, leaving loss of power 
in the left arm and aphonia. On the following day 
si.\ of these fits occurred, but always between them there 
was recovery of speech and of muscular power. The 
woman presented aphasia and partial aphonia, with 
some loss of power in the left hand. The knee-jerks 
were much increased, especially the left, as were also 
the plantar and abdominal reflexes. A month later 
another attack occurred, and was attended with invol- 
untary evacuations of urine and feces, and with diffi- 
culty in swallowing from paralysis of the soft palate. 
There were also ptosis of the right eyelid, contracture of 
the right biceps, firm flexure at the right elbow, and be- 
ginning rigidity of both lower limbs. Later partial anal- 
gesia and anesthesia of both lower limbs appeared, the 
degree and area varying constantly. There were also 
marked fugitive flushings, sweating, and pallor, but no 
wasting. The temperature and pulse were normal. 
The case was treated as one of hysteria, which it was 
thought might be relieved by inducing labor, but uterine 
contractions came on spontaneously. Each pain was 
attended with minor epileptiform spasms, and the fetus 
died during the progress of labor, forceps being re- 
quired for its extraction. For thirty-six hours afterward 
it appeared as if the woman would recover, but pulse 
and temperature rose, the reflexes became abolished, 
and the heart failed. 

Upon post-mortem examination an area of softening 
was found on the right side of the brain, involving part 
of the head of the caudate nucleus and the anterior 
hmb of the internal capsule. Many branches of the 
right middle cerebral artery were found to be throm- 
bosed, .'^n area of softening was also found in the 
middle of the pons, where the basilar artery was throm- 
bosed. The, kidneys contained commencing cortical 
miliary abscesses. The fetus presented contractions of 
all the limbs almost identical with those exhibited by 
the mother. 



Coma from ttie Application of Carbolic-acid Compresses to 
the Skin.— LvcAS and Lane {Lancet, No. 3744, p. 1362) 
have reported two cases in which symptoms of intoxica- 
tion resulted from the application to the skin of com- 
presses saturated with a solution of carbolic acid. 
The first occurred in a boy of fifteen years, who pre- 
sented several sinuses upon the right thigh as a sequel 
of suppuration in the course of an attack of typhoid 
fever. At noon a carbolic compress was applied over 
the seat of operation. In the evening the lad appeared 
sick, and at 2.30 a. m. on the following morning he was 
found insensible and breathing stertorously. The pulse 
could not be counted at the wrist, but the heart-beat was 
200 per minute. The pupils were moderately small, but 
reacted slightly to light. The corneal reflex was absent. 
There was general muscular resolution, but sharp stim- 
uli excited slight movements. Perspiration was profuse. 
After energetic treatment with brandy, strychnin, and 
hot-water bottles consciousness returned in the course 
of eight hours. The urine first passed was dark in color. 
For several days the patient felt sick and vomited from 
time to time. A week after the accident, when arrange- 
ments were again made to operate, a 3 per cent, solu- 
tion of carbolic acid was applied on lint to the affected 
part for a short time. Soon the boy was noticed to be 
sick and suffering and the skin was bathed in perspira- 
tion. The temperature fell below normal and the pulse 
became scarcely perceptible. For two days afterward 
the urine was dark in color. 

The second case occurred in a boy, six-and-a-half 
years old, who presented a swelling in the right ihac 
fossa, which it was proposed to explore. To the skin, 
over and in the vicinity of the mass, there was applied 
at 12.20 a compress moistened with carbolic lotion, one to 
twenty. At 1.30 the child was heard groaning and was 
found to be pale, collapsed, and comatose, with marked 
dyspnea, convulsive twitching of the eyelids and limbs. 
The condition improved upon injection of ether and 
atropin hypodermically, and brandy by the rectum and 
the application of blankets and hot-water bottles. The 
patient thereafter rapidly improved and was quite well 
after the lapse of several days. In this case repeated 
vomiting also occurred, and the urine presented a dark- 
green color, yielding the ordinary reactions for carbolic 
acid and its products in the urine. 

The Bacteriology of Acute Articular Rheumatism. — Singer 
( Wiener klinische Wochenschrift, 1895, No. 25, p. 449) 
has studied the urine in seventeen cases of acute articu- 
lar rheumatism, with the result of finding the staphylo- 
coccus pyogenes albus in ten (and twice in the blood) ; 
the staphylococcus pyogenes aureus in one ; the strepto- 
coccus pyogenes in three ; and the staphylococcus pyo- 
genes albus and the streptococcus pyogenes together in 
two. In one case, complicated with cystitis, an abun- 
dance of bacteria coli were found. Seven of these cases 
occurred in men ; ten in women. Nine were severe ; 
two moderately severe ; and six mild. None presented 
cardiac complications. 

Ch\-ostek ( Wiener klinische Wochenschrift, 1895, No. 
26, p. 469) has e.xamined the urine in twelve cases of ar- 
ticular rheumatism, with negative results in nine ; in the 
remainder the diplococcus urere was found in one, the 
staphylococcus pyogenes albus in the second, and large 



132 



MEDICAL PROGRESS. 



[Medical News 



plump cocci in the third. The urine in these cases was 
obtained with a catheter, and it is pointed out that 
staphylococci aijid streptococci have been found in the 
urethra; of healthy individuals. It was further insisted 
upon that the mere presence of micro-organisms in the 
urine is not necessarily indicative of any relation on 
their part to disease. Further examination of the blood 
and urine and the contents of the inflamed joints in 
various conditions yielded negative results in cases of 
rheumatism, alttiough organisms were found in cases of 
sepsis and goncjirrhea complicated by joint-involvement. 
The opinion is finally expressed that the articular lesions 
of acute rheumatism are not attributable to direct bac- 
terial invasion, but to the action of toxic substances 
present in the blood, due directly or indirectly to the 
activity of bacteria. 

Skin-grafting from the Lower Animals. At a recent 
meeting of the Edinburgh IVIedico-Chirurgical Society, 
Mr. Miles {Bri/is/i Medical Journal, No. 1795, P- 'Hg) 
presented a communication upon skin-grafting from the 
lower animals. The animals used were dogs, rabbits, 
kittens, and frogs. Dogs were preferred, and frogs were 
found the least satisfactory. In all instances but one, 
young animals were employed. The surface of the ulcer 
to be treated must be aseptic, and the patient in good 
health. In the majority of cases granulations were 
planted on. The animal was killed, or pithed, stretched 
out, and nailed down. The flanks and abdomen were 
shaved and washed with an antiseptic solution. Small 
pieces were cut out, the largest being six inches by one 
inch, but mostly much smaller. The subcutaneous tissue 
was always taken with the skin. The grafts were pressed 
on the tissue close to one another, then dressed with 
ordinary protective and iodoform-gauze. The first 
dressing should be seventy-two hours afterward, and this 
should be done very gently ; after that, every twenty- 
four hours, or at most forty-eight hours. Among the 
difficulties encountered was sloughing of a graft, usually 
due to too early dressing, though sometimes to hem- 
orrhage under the graft. Apparent sloughing of the 
graft was sometimes seen, though, after all, the skin grew 
quite well. The formation of pustules was sometimes 
observed ; sometimes granulations grew through the graft 
and destroyed it. Copper sulphate had been tried to 
prevent this, but without success, and a sharp spoon was 
used instead. Ulcers upon the abdomen and thorax 
responded less satisfactorily than ulcers situated else- 
where, on account of movement. For this reason a 
loose dressing is indicated. 

Treatment of Prostatic Hypertropfiy by Ligature and Divis- 
ion of t/te Has Deferens. — Isnardi {Ccntralhlatt fiir 
Chiruri;U', 1895, No. 28, p. 657) has reported the case of 
a man, seventy-two years old, who for a year had suf- 
fered with symptoms of prostatic hypertrophy, which 
had failed to yield to the usual therapeutic measures. 
Relief was afiforded by hgature and division of the vas 
deferens. Six-and-a-half weeks after the operation re- 
tention of urine and incontinence had disappeared, and 
the bladder was tolerant of urine for seven hours during 
the night. The urine, which had previously been puru- 
lent and at times hemorrhagic, had become clear and 
otherwise normal. The prostate itself, which, prior to 
the operation was of the size of a half-nut, became 



scarcely appreciable upon rectal examination. The vas 
deferens from the point of division pursued an irregular 
course and was thickened and nodular in places. The 
epididymis was smaller than normal, particularly at its 
distal extremity and in its body. The testicle itself was 
reduced about one-half in size. 

7Ae Toxicity of the Urine in Variola. — Auche and 
JON'CHERES [Rf-me de Medccinc, 1S95, No. 6, p. 480), as 
a result of the study of the urine in a series of cases of 
variola, found that in the discrete variety the absolute 
quantity of urine is variable in different cases, while the 
urinary curve is more nearly comparable, being rela- 
tively high in the eruptive stage, declining in the suppu- 
rative period, and again rising during defervescence. In 
several cases an apparent critical secretion of urine was 
observed. The toxicity of the urine remained about 
normal during the eruptive stage. It declined, and 
sometimes in notable degree, during the period of sup- 
puration, the fever increasing notably with the onset of 
defervescence, and again becoming normal at the end 
of from one to three days. Often there was at this time 
a veritable urotoxic discharge corresponding with the 
urinary crisis. In cases complicated by febrile disorders 
during convalescence the toxicity declined, but increased 
with the subsequent fall of temperature. The delirium 
of the acute period of the disease is believed to be of 
toxic origin, and in one case the oscillations in the 
urinary toxicity were found to correspond with the 
mental manifestations. In hemorrhagic variola the 
urinary curve and toxicity were low, almost up to the 
occurrence of death. 

The Relation of Endometritis to the Reproductive Process. 
— ."^t the meeting of the German Ciynecological Society, 
recently held at Vienna, Doderlein [Ctntralblall fiir 
Gy7idkologie, 1895, No. 26, p. 701) attributed pathologic 
importance to the presence in the uterine cavity of the 
puerpera of micro-organisms of any kind. The desig- 
nations catarrhal, purulent, diphtheric, and gangrenous 
puerperal endometritis may well be replaced by the 
etiologic qualifications pyogenic and sapremic. Pyo- 
genic endometritis is the most frequent affection of 
puerperal women. The profound constitutional infec- 
tions occurring during the lying-in are, as a rule, attribu- 
table to this condition. The cause is most often the 
streptococcus pyogenes, but it may be due besides to 
the staphylococcus, the gonococcus, and the bacterium 
coli. The micro-organisms of sapremic endometritis are 
as yet unknown. 

Influence of Ether and Chloroform upon the Kidneys. — As 
the result of an extended study conducted in the surgical 
department of the new General Hospital at Hamburg, 
EiSENDRATH, of Chicago {Deutsche Zeihchrift fiir 
Chirurgie, B. xl, H. 5 and 6, p. 466), arrives at the con- 
clusion that previously existing albuminuria is more fre- 
quently increased by ether than by chloroform ; and that 
albuminuria is more frequent after chloroform-anesthesia 
than after ether-anesthesia, and in the proportion of 32 
to 25. The influence of both anesthetics upon the 
amyloid kidney is alike. Cylindruria, with and without 
albuminuria, is equally frequent with chloroform-anes- 
thesia and ether-anesthesia, but disappears more rapidly 
after the latter than after the former. 



iS95] 



CONCERNING DYSPEPSIA. 



133 



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SATURDAY, AUGUST 3, 1895. 

CONCERNING "DYSPEPSIA." 

From the amount of pepsin on the market we 
would certainly be led to believe that so-called 
dyspepsia is a well-defined disease. There is a sort 
of poetic justice about the fact that the American 
hog, whose lard and pork are commonly held guilty 
of what is often spoken of as our national malady, 
should now furnish the popular remedy therefor. 
We might almost transpose " a hair of the dog that 
bit you" into "a stomach of the pig that upset 
you," for according to the popular view at least, 
"dyspepsia" is looked upon as a disease of the 
stomach. The public knows perfectly what " dys- 
pepsy " is and just what to take for it. Pepsin, in 
some form, is poured into our feeding-bottles at the 
dawn of our existence ; it is kept upon our pantry- 
shelves like sugar or soda; it surges and bubbles in 
our soda-water ; it lurks in our chewing-gum. We 
smuggle peptones into the economy with the bouil- 
lon that opens the banquet and in the jellies that 
crown its close. It looks as if the stomach would 
soon become a supernumerary organ, like the third 
molar — and the mammary gland of modern woman. 
Whence has arisen this deep-rooted idea? From 
the medical profession, of course. In fact, medical 
men are almost as fatuous as the community in re- 



gard to pepsin, prescribing it in every emergency 
as they used to prescribe calomel fifty years ago. 
And yet the dyspeptic is abroad in the land as never 
before. 

We are all proud, and justly so, of the rapid strides 
that have been made in the pathology of disease 
in the last thirty years. Probably no one principle 
has done more to clear our diagnosis, systematize 
our pathology, and advance our therapeutics than 
that of rigidly sifting and resifting the evidence 
until the one organ has been found that is chiefly 
responsible for any given disturbance. But have 
we not carried the process too far in some cases ? 
We do not refer simply to such wild-goose applica- 
tions of it, as, for instance, graduated tenotomy for 
epilepsy, cauterization of the turbinates for asthma, 
or repair of the cervix for neurasthenia, but to more 
rational and generally accepted results of the 
method. For instance, it was a great advance and 
triumph when Bright discovered that the complexus 
of symptoms that bears his name was caused by 
disturbances of the filtration-processes in the kid- 
neys. But does any thoughtful physician to-day 
regard so called Bright's disease as primarily and 
essentially a disease of the kidneys? Are these 
organs not simply vicarious sufferers for the short- 
comings of either the liver-cells or the muscle-cells, 
resulting in a poisoning of the arterioles in the 
body generally? The glomeruli simply suffer as 
part of the vascular system. Are we not also begin- 
ning to suspect something of the same sort in regard 
to pulmonary tuberculosis ? We know all about 
tubercle anatomically, and the bacillus has become 
one of our household gods, a word to conjure with, an 
explanation for everything; but why is it that this 
organism has in nine cases out of ten to attack the 
lungs before it can pull down his prey ? It effects 
an entrance into every part of the system, but in 
the lungs alone can it usually produce a fatal result. 
It would appear as if pulmonary tuberculosis were 
not so much a disease of the lungs as that the latter 
were a point of least resistance for the whole system. 

Something of the same sort appears to be true of 
the disturbance of digestion called dyspepsia. We 
use the term "dyspepsia" simply as one of con- 
venience, as describing not a disease, of course, but 
a well-known group of symptoms, usually referred 
to the condition of the gastric mucous membrane 
and contents. There can be little question that 
the stomach has been held responsible for far more 
than it deserves. In the first place, many of our 



134 



CONCERNING DYSPEPSIA. 



[Medical News 



worst dyspepsias are really, to coin a term for the 
moment, " dystrypsias," and dependent upon en- 
teric and pancreatic disturbances ; others again are 
of hepatic and even cholecystic origin ; while most 
cases of " gastralgia " are really anginal and of 
cardiac origin. But apart from all such confu- 
sions, is the stomach or its contents essentially and 
solely responsible in the large class of dyspepsias 
that are of "gastric" origin? Our enthusiastic 
bacteriologic friends say yes at once ; the contents 
alone are to blame. Tell them what germ has been 
ingested with the food and they will be able to state 
in advance what form of indigestion will result. 
They are now seriously proposing a classification of 
gastric troubles, lactic, butyric, gaseous, and yeasty 
dyspepsias, according to the germs that give rise 
to these various fermentations. Gastritis oidica 
albicans, gastritis lorulosa, sound well, but we 
think there are valid objections against regarding 
the gastric mucosa as simply a culture-plate for 
germs at the sweet will of the latter. On the other 
hand, the medical man is also inclined to blame the 
contents of the stomach, as his first question usually 
is, What have you been eating lately? and if pork, 
or pie, or cake is mentioned, he exclaims tri- 
umphantly, "That's what did it," and prescribes 
pepsin, followed by a saline ; forgetting that there 
are hundreds of men, women, and children in the 
rural parts of that very community who habitually 
have soda-biscuits and doughnuts for breakfast, 
fried pork and mince-pie for dinner, or baked beans 
and " oak-bark " tea for supper, and never find out 
that they have a stomach. 

We are supposed to be a nation of dyspeptics. 
This peculiarity is variously attributed to the use of 
the frying-pan, mince-pie, too rich foods, hurried 
meals, tobacco, and insufficient mastication. Aber- 
nethy held these views as to mastication, for his 
crusty advice to the rich American who consulted 
him for indigestion was simply to expend upon his 
food the jaw-power that he wasted upon his quid 
and the saliva that he squandered upon his carpets. 

Part of our troubles are no doubt due to the 
thoughtless way in which we revel in the cheapest, 
most varied, and abundant food-supply the world 
has ever seen. More may be traced to our sense- 
less neglect of the comforts and decencies of the 
table — and as of almost anything else — in our mad 
rush after the nimble dollar. 

But these causes alone are by no means adequate, 
for we must remember that if our American dietary 



is prodigally rich and varied, it is also the most 
abundant, the most nutritious, and, broadly con- 
sidered, the most easily digestible in the world. 
We know nothing of the insufficiency, the coarse- 
ness, the deadly monotony of European peasant 
and even middle-class diets ; while as for indigesti- 
bility and " unhealthiness," what have we to com- 
pare with sauer-kraut, boiled dough, cabbage-soup, 
black bread, unleavened " leather " cakes, and raw 
sausage? Our " twenty-minutes-for-dinner " style 
of eating is no doubt injurious, but even in this 
connection our cookery has been adapted to our 
habits and everything boned, minced, hashed, and 
cooked to a pulp, so that our teeth are actually de- 
caying from lack of exercise. It is the rush back 
to work after the dinner that does the mischief, and 
not the mere mechanical obstacle of imperfectly 
masticated food. 

But the most fatal objection to this theory lies in 
the fact that the mass of our dyspeptics are " diet- 
ers" to a man — or woman. They talk "health- 
foods" from dawn to dark; they abstain from bis- 
cuit, from fried cakes, from the pleasant pie and 
the juicy cabbage ; they shudder at the mention of 
pork, "anything that has lard in it" is as an un- 
clean thing to them. They mortify the flesh on 
Graham gems and similar atrocities, on oat-meal 
and germ-foods, on quarts of hot water and slops of 
every description — and still they suffer. The more 
carefully the diet is "regulated" the worse, as a 
rule, is the "dyspepsia." 

When any man attempts to substitute his own 
puny "reason" for the instructive wisdom of a 
thousand generations he usually makes a mess of 
it. Digestives give only temporary relief. The 
trouble is not with the food, nor yet with the 
stomach, but with the whole individual. Take 
one of these valetudinarians out into the open, 
put an oar or a fishing-rod into his hand, or a 
twelve-bore across his shoulder, and let him thrash 
the streams or tramp the uplands from dawn to 
sunset, and what of his dyspepsia? Within forty- 
eight hours he will be devouring the swimming salt 
pork, the substantial sausage, and the alkali biscuit 
of his farm-house fare with relish and impunity. 
His muscles loudly demand such pabulum, and their 
servant, the stomach, takes care of it, as ordered, 
without remonstrance. In short, in most cases of 
dyspepsia the stomach is the point of greatest stress 
and strain in a generally enfeebled and devitalized 
organism, and consequently the place where the 



AuGisr 3, 1895] 



EDITORIAL COMMENTS. 



135 



breakdown occurs. Let the business "hustler" 
and the model housekeeper relax the strain and 
tension and their dyspepsia will improve /lari passu. 

Discomfort here, as elsewhere, is a danger-signal 
that should be heeded and brakes whistled down 
at once, instead of being muffled by pepsin. Even 
regulating the diet is at best a mere palliative and 
a serious mistake ultimately. The pressure on the 
stomach is lightened thereby, but the strain on the 
whole system continues unchecked. More than 
this, "regulation " usually involves the substitution 
of less nutritious and substantial foods than before, 
and the circulus vitiosus is actually strengthened 
thereby. The stomach refuses to digest fats and 
proteids because its blood-supply is of poor quality ; 
it is humored with sugars, starches, milk, etc., and 
thus the blood is cut off from the very supplies out 
of which it might have repaired its deficiencies and 
sinks more deeply in the mire of degeneration. 

Pepsin and dieting in such cases are but little 
more rational than the use of opium. We ought to 
go to the root of the matter and never rest satisfied 
until our dyspeptic patient's stomach is in such con- 
dition that it will digest anything in reason that he 
puts into it. We should insist upon whatever pos- 
sible changes in his hours, responsibilities, habits, 
and recreations may be necessary to attain this 
standard. A dyspepsia cured by dieting is a dys- 
pepsia uncured. To relieve gastric distress in such 
cases by reducing and watering the diet is like 
easing a crushing machine by increasing the dis- 
tance between its rollers ; it continues in operation 
with less motive power, but what sort of work does 
it do ? A man may continue to exist on Graham 
bread, milk-toast, beef-tea and gruel, but he does 
not really live, still less grow and repair waste. 

Instead of encouraging our patients to avoid 
everything that "disagrees" with them, we should 
urge them to a persistent effort to make everything 
agree with them. Let us insist that they make 
themselves not merely "stomach-hungry," but 
"muscle-hungry" everyday, and all other things 
shall be added. Our standards of " dyspepsia " have 
been altogether too low in the past. Any sort of a 
diet that could be devised that a man could shuffle 
along upon, extracting a living out of it, without 
actual discomfort, has been considered sufficient. 
An able-bodied stomach, even less than this, a really 
"practical" digestion, must be capable of assimi- 
lating not only all digestible things, but a great 
many so-called indigestible ones as well. A cruiser 



that is to steam ten knots an hour as a routine pace 
must have a possible speed of at least fifteen knots 
under pressure. It would not be a bad idea to fix 
upon a "standard food" that our dyspeptic stom- 
achs should be required to digest before being al- 
lowed to consider themselves cured — -pork, for 
instance, for, leaving idiosyncrasy out of the ques- 
tion, any one who cannot digest this in the form 
of breakfast bacon or ham ought to be regarded as 
dyspeptic in posse, if not in esse, or, to borrow a 
term from circulatory pathology, as suffering from 
" gastric inadequacy." As a matter of fact, almost 
every Gentile whose dietary does not include pork 
in some form is either dyspeptic or will soon be- 
come so. Dyspepsia is emphatically a disease of 
under-feeding, instead of over-feeding. In prac- 
tice one will see more cases cured by pork than by 
pepsin. 

Dyspepsia should be treated as a symptom some- 
times — as we are at last learning — as a reflex neu- 
rosis, and essentially as a systemic instead of a gas- 
tric disease, and it will cease to be one of the oppro- 
bria medicin(E. 



EDITORIAL COMMENTS. 

"'Publishing the Formula'' is a delightful recreation of 
the fin de siecle nostrum-vendor. One wonders which 
most to admire, the enormous impertinence of the 
"publisher" or the gullibility of the public. Perhaps 
it may turn out that the egregious ascription of stupidity 
to the asinarian public, professional or lay, is the only 
thing to wonder at. For how can men think to hood- 
wink even the stupidest people nowadays by such a 
gambler's game of now-you-see-it-and-now-you-don't ? 
Can people be bamboozled by such nonsense, and can 
the bunco-men be guilty of such attempts as the jing- 
ling together of a lot of chemic names and calling that 
a formula ? Verily, men are driven to' desperate straits 
when they do such things. The latest instance is con- 
tained in a pamphlet now before us, entitled (of course) 
" a new consumption-cure." The author thus delivers 
himself: 

I may add that there is a further reason for reluctance 
in setting forth the claims herein presented. It is the 
inevitable violation of "the sanctities" of Medical 
Ethics — the excitement of prejudice on the part of many 
physicians — incident to advocating a so-called "Secret 
Remedy." For this, however, I can only express a 
sincere regret, without in the least apologizing for my 
position. 

I am not an M.D., and so not amenable to any pro- 
fessional Code of Ethics. The broader ethics of civil- 
ized humanity accord to every man proprietary rights 
in the discoveries as well as the creations of his own 
genius. The just sentiment of mankind in general as 
well as my own conscience will sustain me in retaining 
that right, at least for a time, through the only possible 
means — keeping my formulas and modes of manufac- 
ture to myself. I am, moreover, happy in the assurance 



136 



EDITORIAL COMMENTS. 



[Medical News 



that there are men, even in the ranks of regular medi- 
cine, broad-minded and generous- hearted enough to 
accord me that right without cavil. They will examine 
the evidence, and, upon proof, will acknowledge gladly 
the improvement made upon any methods known to 
them of combatting the worst disease with which they 
have to contend. Enough such men there are to afford 
me all the " moral support " needed in facing the oppo- 
sition of their more numerous, but less noble brethren. 
1 may be pardoned, too, for saying that the renunciation 
of '' secret and proprietary remedies " on the part of the 
medical profession is, I am informed, to a very large 
extent a virtue held more in theory than in practice. 
To a still larger extent it is a rule of faith, ignored as 
wholly obsolete. 

" Nine-tenths of the profession " — I quote from one 
of its own members who has ample knowledge of the 
facts — " nine-tenths of Medical Practitioners are daily 
using and prescribing drugs and compounds whose ex- 
act composition and mode of manufacture they do not 
know. These are practically ' secrets ' belonging to the 
pharmaceutists, who put forth these remedies with the 
most voluminous and attractive forms of advertisement 
possible." 

Thus the benevolent discoverer squares his conscience 
in accordance with that of the " broad-minded ?.nd gen- 
erous-hearted " secret-nostrum men, and against the 
"more numerous, but less noble brethren " .cho have 
no therapeutic secrets. (It is an interestinj; psychologic 
study to see how the lower one sinks in thj slime of sel- 
fishness and quackery and deceit, the more he prates of 
broad-mindedness and brotherly love, and swashes about 
in the slush of maudlin sentiment-^lism.) 

But a later pamphlet shows that our new-consumptive- 
cure man was not quite sa*ibned with his broad-minded- 
ness, etc., for here he makes a great hullabaloo in the 
Rocky Mountain News about publishing the secret. At 
last " The Formula is Here," and it reads thus : 

Up to this time we have not revealed the constituents 
of the gas, but feel that it is now time to do so, and learn 
whether or not, since it is open to the profession to know 
the truth without violation of ethics, they will take heed 
of it. I will take this step because a number of physi- 
cians who have witnessed the results of my work think 
it may be the opening of a new era to medicine. So, 
without attempting to detail all the steps of my discovery, 
1 name those elements which constitute the essential 
active principle in the Electro-Inhalent Consumption 
Cure. 

Formula — Calc. chloride, Potas. bromide, Potas. 
chlorate, sodium chlor., alum. c. p. oxygen. 

These elements, treated with static electricity, give 
rise to an antiseptic gas of the most peculiar form. It 
is unlike anything else hitherto known, both in nature 
and effect, etc. 

We would not have occupied so much space with this 
trash if the method of exploitation did not seem to run 
the danger of becoming fashionable, even in some so- 
called medical circles. 



Intrauterine Conveyance of Typhoid Fever. — While 
clinical evidence has not been wanting of the transfer- 
ence of disease from the pregnant mother to the fetus 
in ittero, the subject has been much enlightened with the 
progress of bacteriologic science. Although one can- 
not in strict construction speak of tuberculosis being in- 
herited, a number of observations have shown that the 
offspring of tuberculous mothers may be born tuberculous. 



We have in this instance, however, much the same kind 
of transmission of the disease as may occur at any time 
from one mfected person to another, albeit in the nature 
of things more direct — but this is not heredity. The con- 
veyance takes place through the intermediation of the 
placental blood, and in the same way as the infection 
of the mother took place, and is not developmental. 
The sjme processes are active in the infectious diseases 
as a group, but the demonstration has not yet been 
gene'ally made. In this connection an exceedingly 
interesting observation has been noted by Freund and 
Levy (^Berliner klinische Wochenschrift, 1895, No. 25, 
p. 539), who have reported the case of a woman, twenty- 
four years old, who in the fifth month of her third preg- 
rancy was attacked with typhoid fever. The highest 
temperature reached was 104°, and the variations for 
■.wo weeks ranged between this and 100.4°. In the 
fourth week of the disease, when the temperature rarely 
exceeded 101.3", the fetus was rather suddenly expelled. 
A single vaginal examination had been made with the 
greatest care, the hands being disinfected with mercuric 
chlorid, the external genitalia being washed with soap 
and water, and they and the vagina irrigated with lysol, 
followed by the application of a cotton pad. The fetus 
was directly received into a sterilized glass vessel, but 
lived for only a short time. There were no complica- 
tions and the woman went on to recovery. The uterus 
contracted well, and the placenta, which was expelled 
within a short time, was received into the same vessel as 
the fetus. The placenta was distinctly marginate ; the 
entire decidua remained in the uterus, but was readily 
detached with the finger. In the sixth week after de- 
livery the woman suffered a relapse of the fever, lasting 
ten days. Twenty minutes after the birth of the child 
cultures were made from the splenic fluid, the blood, 
and the placenta. In the course of three days a number 
of typhoid-colonies were found in the placental and 
splenic inoculations. Similar colonies also developed 
upon plates prepared from bouillon into which a portion 
of spleen had been thrown, and which had been kept 
in a thermostat for twelve hours at a temperature of 
98 6°. The fetal spleen was slightly enlarged and soft, 
but the intestines presented no lesion. Neither hemor- 
rhage nor infarction nor other noteworthy morbid change 
could be detected in the placenta. 

In this case the expulsion of the fetus must be attri- 
buted to the infectious process with its concomitant 
manifestations, for both the placenta and the fetus 
presented no well defined evidences of disease. 

The Bicycle-ambulance and the Bicycle. — From Germany 
comes the news of a novel utilization of the bicycle that 
seems likely to be of considerable interest and value to 
the medical profession. One of the ingenious city phy- 
sicians of Berlin has invented an emergency-ambulance 
consisting, roughly speaking, of a narrow spring-cot 
supported upon the frames of two bicycles and a third 
wheel. The cot is hung upon an elaborate set of springs 
and is provided with a water-proof coop-like cover of 
canvas stretched over steel bows, which can be readily 
lifted on and off like a lid. A seat is arranged at the 
head of the bed, over the third wheel, for the doctor, 
beside which is a box for remedies and dressings. Thus 
the physician (if young and active) and one attendant can 



August 3, 1895] 



EDITORIAL COMMENTS. 



137 



rapidly propel the machine to the site of the accident, 
while the patient is placed upon the cot with the doctor 
seated where he can give his whole attention to the former, 
and the outfit is propelled back to the hospital. The 
ambulance is so light and strong in construction that the 
run can be made at quite as high a rate of speed as is 
compatible with safety. The advantages are obvious — 
no horse, feed, or stable is required (the latter with its 
large space-requirements and qdors being quite an item 
in city hospital-premises). No shed is needed for the 
vehicle and horse to stand in while awaiting a call ; there 
are no delays, e.£:, in ordering by telephone from the 
stables, etc. The machine can be kept in the receiving- 
room or entrance corridor, and with wide doorways and 
a gangway at the entrance-steps can be pushed with its 
burden right into the ward and the patient lifted directly 
upon his bed. We are already much indebted to the 
bicycle as a most beneficially athletic substitute for the 
traditional " doctor's cart," as a new and attractive " oxi- 
dation-prescription " for our patients, as a means of giv- 
ing city-prisoners a knowledge of the country, etc. 
Perhaps there should not be omitted a word of praise to 
it as the only influence in nineteen centuries that has 
had the slightest appreciable effect in inducing women 
to make a rational modification in their attire. For this 
let us bow before " the wheel " with grateful respect, for 
it has done more in ten years than we have in as many 
generations — it has made an impression upon the fash- 
ion-plates. Will it bring about the abolition of the pet- 
ticoat-abomination ? The skirt, may we believe, is at 
last " divided against itself," and perhaps even the corset 
will be scheduled as the next to " go." One cannot 
"scorch" in a strait-jacket. All honor to the bicycle! 
It has made a breach — we will not say breeches — in a 
rampart against which the united forces of the profes- 
sion, the bench, and the pulpit have surged in vain. 

The Treatment of Typhoid Fever with the Serum of Immu- 
nized Animals. — We have on previous occasions cited ex- 
periments in the treatment of typhoid fever with the 
serum of convalescents' and with the products of bac- 
terial activity.- It was to be expected that the recent 
developments in the antitoxic treatment of diphtheria 
would stimulate renewed activity in this direction, even 
though it is not yet possible to reach a final conclusion. 

As a contribution to the progress in this field of inves- 
tigation Klemperer and Levy [Berliner klinisthe Moch- 
enschrift, 1S95, No. 28, p. 601) detail the results of a 
series of interesting observations upon the influence of 
the milk and serum ot immune animals in preventing 
typhoid fever and ameliorating an already existing at- 
tack. As, on account of the long course of the disease, 
repeated treatment would be necessary, it was at once 
seen that considerable quantities of the immunizing fluid 
would be required, the first experiments were undertaken 
with the milk of immune animals. This was readily 
obtained by immunizing a goat. It was found that this 
method was impracticable, as the immunizing influence 
of the milk was lost by ingestion through the stomach, 
and injection into the bowel, though efficient, is obvi- 
ously not feasible in typhoid fever. It was, therefore. 



1 The Medical News, Nov. 19, 18 
^ Ibid., Dec. 16, 1893. p. 691. 



I P- 583- 



finally concluded that resort would have to be had to 
blood-serum. With this end in view the dog, as having 
considerable natural immunity to the disease, was 
selected as the most suitable animal. By treating dogs 
with gradually increasing amounts of bouillon-cultures 
of typhoid-bacilli it was possible not only to immunize 
susceptible animals, such as mice and guinea-pigs, to 
the action of virulent typhoid-bacilli, but also to effect a 
cure of the attack when treatment was instituted some 
time after infection had been established. 

After it had been determined that the serum thus ob- 
tained was innocuous when administered to human 
beings in small quantities by subcutaneous injection, the 
treatment of five patients with typhoid fever was under- 
taken. Each of these received three injections on suc- 
cessive evenings. These were well borne and gave rise 
to no discomfort, or exanthem, or albuminuria. All of 
the cases were in the first week of the disease, and all 
pursued a mild course. It is admitted that the disease 
was not aborted by the treatment, although it was 
thought the attack was simplified and abbreviated, the 
natural immunity being hastened. At the same time the 
observations show that the treatment is perfectly harm- 
less. 

Chronic Inebriety and its Incurability. — In the annual re- 
port of the Walnut Lodge Hospital for Inebriates, Dr. T. 
D. Crothers gives a record of 66 patients that had been 
treated in the institution previous to 1885. Of this num- 
ber 21 are dead, having relapsed and brought on death 
by their excesses, 16 are living orderly temperate lives 
and can be considered cured, 4 are insane, 10 are hope- 
less inebriates, and 15 are given to occasional sprees. 
The small percentage of permanent cures is somewhat 
discouraging, though, as a rule, only the more chronic 
drunkards seek hospital-treatment. 

Of 58 inebriate patients treated in 1894. 43 had been in 
other institutions previously- The number of relapses 
from the so-called " gold-cure" is increasing, and Dr. 
Crothers finds symptoms of acute insanity common 
among such individuals. 

The chronic inebriate must be handled in a different 
wav from the acute alcoholic. Some States have a so- 
called Habitual Drunkard Act, under which persons ar- 
rested several times for drunkenness can be committed 
to an inebriate-asylum for an indefinite period of time. 
If all chronic drunkards were thus treated and kept 
under lock and key, the cost would no doubt be very 
great, and vet only a tithe of what it is at present. Per- 
sons have been sentenced to imprisonment thirty and 
more times a year for drunkenness. More than one-half 
of all arrests are for this cause. The chronic drunkard 
is a constant menace to society, a clog on the wheels of 
industry, and the amount of trouble that he causes is 
incalculable. He must be restrained, as the lunatic is, 
for the safety of society. 

A " Pathological Meeting." — According to a notice in 
7//^ Z,iz«c<Y of June 29. 1895, "A Pathological meeting 
of the Neurological Society will be held on July nth." 
And notwithstanding many such things, our humor- 
loving and kind-hearted British friends find much 
pleasure, to which, of course, they are heartily welcome, 
in measureless contempt and scorn of " Americanisms." 



138 



REVIEWS. 



[Medical News 



SELECTION. 

VIVISECTION AND KINDNESS TO ANIMALS. 

According to the biographic sketch of Professor 
Mosso, Ludwig, the greatest of vivisectors, was Presi- 
dent of the Leipsic Society for the Protection of Ani- 
mals, and remained to the last one of its most active 
members. Germany owes it to him that her horses and 
beasts of burden are now humanely treated. To him is 
due that awakening of the true humanitarian spirit 
toward the brute creation that culminated in the " Ver- ! 
band der Thierschutz-Vereine des Deutschen Reichs " 
(Union of German Societies for the Protection of Ani- 
mals). It was mainly from her sense of the gentler 
attitude to be encouraged toward animals on the part of 
the rising generation that Leipsic made him an honorary 
citizen on the fiftieth anniversary of his graduation in 
medicine. " No physiologist," continues Professor 
Mosso, " has ever sought with greater frankness than 
he to impose just limits on vivisection. The gates of 
his institute were ever open to all who wished to assure 
themselves that he, in the midst of his experiments, 
knew how to spare suffering. The vivisectors art at- 
tained such perfection in his hands that, having to sacri- 
fice an animal, he did not let it feel that it was even 
being tied. He would apply the muzzle and instantly 
proceed to the exhibition of ether or chloroform, 
which, in a few seconds, in a dog, for example, made it 
insensible." " It is an error," adds Professor Mosso 
wisely, "to believe that experiments can be performed 
on an animal which feels. The perturbation induced 
by pain in the functions of the organism is so pro- 
found as to render useless the experimenter's study. 
It was Ludwig who uttered the celebrated wo/ that some 
physiologists, to study the nervous system, act like him 
who fires a pistol into a watch to see how the chro- 
nometer works. Suffering ought to be entirely elimi- 
nated from physiological experiment, because the instru- 
ments we employ to-day are so delicate that they become 
unserviceable the moment the animal is agitated or 
moves," — Lancet, No. 374S, p. 1651. 



REVIEWS. 

A Treatise on the Nervous Diseases of Chil- 
dren, FOR Physicians and Students. By B. Sachs, 
M.D., Professor of Mental and Nervous Diseases in 
the New York Polyclinic, etc. Pp. 666, 162 illustra- 
tions. New York : William Wood & Co., 1895. 

This book, written by one of the ablest of American 
neurologists, is a valuable contribution to neurology and 
pediatrics. It contains much original material, and 
everywhere bears the impress of the author's experience. 

In an interesting introductory chapter are given the 
author's methods of investigating nervous disease in 
children, including various examination-schemes and the 
modes of testing vision, motion, sensation, and the hke. 

The general arrangement of the book is simple but 
good. Part I is devoted to general nervous diseases, 
under which head are included convulsions, epilepsy, 
hysteria, chorea, tetanus, tetany, headache, disorders of 
sleep, vasomotor affections, and trophoneuroses. Organic 



diseases of the nervous system are considered in Part II, 
chiefly under two heads, organic diseases of the spinal 
cord and organic diseases of the brain, but with two 
prefatory chapters on diseases of the peripheral nerves. 
As might be expected, the author has had considerable 
difficulty in determining what diseases to include and 
what to omit, as many of the nervous diseases of chil- 
dren also occur in adults. He has, however, exercised 
good judgment in this respect, very properly not discuss- 
ing tabes and some of the forms of sclerosis; on the other 
hand, considering such disorders as epilepsy, hysteria, and 
tetanus, which occur both in children and in adults, and 
in children have points of special importance. Hunting- 
ton's chorea and progressive muscular atrophy of the 
Aran-Duchenne type have also been properly given a 
place, these affections needing to be related to and con- 
trasted with the dystrophies, atrophies, and choreas and 
family forms of disease occurring in children. 

The chapters on diseases of the spinal cord and of the 
brain are introduced by careful but not too elaborate dis- 
cussions of their anatomy, physiology, and pathology, 
excellent judgment and discrimination being displayed 
in the selection of the material, which has been drawn 
from the work of the most recent investigators. 

In a brief appendix are given a few valuable thera- 
peutic suggestions. 

A notable and valuable feature of the work consists 
in the tables of differential diagnosis scattered through- 
out the volume, and evidenlly prepared with great care. 
They will prove of particular value to students and 
general practitioners. An especially valuable table for 
practical purposes is found in the introductory chapter, 
under methods of investigation. Beginning with the 
ciliary and sphincter iridis muscles and proceeding to 
the quadratus lumborum and abdominal muscles, this 
table gives in parallel columns the names of all the im- 
portant muscles with their normal functions, the symp- 
toms of deficient action, innervation, and the diseases in 
which the muscles are commonly involved. 

Space will not permit an analysis of the book worthy 
of its contents, and where there is so much to approve 
it is difficult to pick out special portions for commenda- 
tion. 

Many of the shorter articles, such as those on abscess 
of the brain and sinus-thrombosis, are compact yet 
lucid expositions of the subjects considered. The dis- 
cussion of infantile cerebral palsies is the best in any 
text-book, showing much original work, clinical, his- 
tologic, and pathologic. Muscular atrophies are thor- 
oughly discussed, the points of distinction between the 
spinal, neural, and myopathic forms being clearly 
brought out both in text and tables. 

LInder the head of hereditary or family diseases of the 
spinal cord are included hereditary ataxy, hereditary 
spinal paralysis, the family type of progressive muscular 
atrophy, etc. It would probably have been best to 
put in this same category of family diseases hereditary 
chorea, Thomsen's disease, and congenital paramyoto- 
nia, as, strictly speaking, these affections are not spinal 
or cerebral, but cerebro-spinal and of embryonal origin. 

The chapter on insanity is brief but sufficient for a 
general work on the nervous diseases of children. 

Particular attention has been given to the subject of 
arrested and aberrant development, and the evidences 
of this work are seen in several portions of the book, es- 



55] 



REVIEWS. 



139 



pecially in the chapters on defective development of 
the brain and on idiocy and imbecility. 

Short bibliographies are appended to each chapter. 
Although thoroughly acquainted with foreign neurologic 
literature, the author has not neglected the writings 
of his own country. The letter-press and illustrations 
are of the highest order. 

First Annual Report upon, the Births, Marri- 
ages, Divorces, and Deaths in the State of 
Maine for the Year ending December 31, 
1S92. Augusta: Burleigh & Flint, 1894. 

This report was compiled by the Secretary of the 
State Board of Health, Dr. A. G. Young, in accordance 
with an Act of Assembly approved in 1891. The statis- 
tical tables are accompanied by " Notes " elucidating 
the data presented, and containing instructive compari- 
sons and comments. 

The birth-rate for 1892 was 21.21 for each 1000 of the 
population ; and for each 100 girls born there were 106.7 
boys, a preponderance of the births of boys " which 
conforms with the results of the registration of births 
almost everywhere." The marriage-rate was 8.56 to 
every 1000, and there was nearly one divorce to every 
ten marriages solemnized ! 

The death- rate was 18.37 to every 1000 of population 
as returned by the census of 1890, and 18.30 on the 
estimated population for 1892. Among the causes of 
death tuberculosis, with a rate of 22.88 per 10,000, 
stands foremost, pneumonia following with a rate of 
21.56. The rate for influenza, which was epidemic dur- 
ing the winter, was 11.43 P^"" 10,000, which is partly 
accounted for by the fatality of this disease at the ex- 
tremes of life and the proportionately large number of 
the aged to the total population, due to the emigration of 
young men and women to the Western States. 

The number of deaths from whooping-cough exceeded 
that from scarlet fever, a fact that lends emphasis to the 
comment that the former is a more serious disease than 
the general public supposes it to be. 

The Human Element in Sex. Being a Medical 
Inquiry into the Relation of Sexual Physi- 
ology TO Christian Morality. By Dr. Eliza- 
beth Blackwell. New Edition. London : J. & A. 
Churchill, 1894. 

This small book is, in the main, a plea for the in- 
struction of parents in sexual physiology, as only 
through such knowledge can they appreciate their re- 
sponsibihties as guardians of the young, and avert the 
evils arising from ignorance or pernicious teaching re- 
garding the sexual faculty. 

" It is the predominance of the mental or spiritual 
element in our nature," says the author, " which is the 
characteristic fact of human sex," a radical distinction 
between the sexual faculty in man and the brute creation 
greater than any resemblance between ihem. In virtue 
of this difference — of this human element — " sex in the 
human race is capable of great development toward 
good or evil," an important fact that bears a positive 
relation to the well-being of succeeding generations. 

Chastity is a physiologic law imposed in the interests 
of society, a providential check on the blind, unre- 



strained use of the sexual impulse necessitated by our 
physiologic structure for the vigor and continuance of 
the race. It is an equal obligation of the sexes ; other 
reasoning (based on erroneous knowledge — misappre- 
hension of the equivalent functions of ovulation and 
spermation) implies inferiority in the male — less power 
of self-control and of self-adjustment than is possessed 
by the female. 

The Royal Victoria Hospital, Montreal. First 
Annual Report, for the Year ending December 31, 

1804. 

The first annual report of the Royal Victoria Hos- 
pital, Montreal, which has just been received, presents 
several features of interest. In the first place, the sec- 
retary and the management are to be congratulated 
upon the clean, clear appearance of the pamphlet, and 
the medical staff upon the admirable arrangement of 
the statistical report. During the year 1570 patients 
were treated, with a death-rate of 5.9 per cent. The 
expenditure of the year was a little over $65,000, which 
seems to be an extremely reasonable amount, consider- 
ing the extent of the hospital-plant. 

The statistical report has evidently been prepared 
with great care, and in addition to the usual columns of 
the admitted and discharged there is a third noting the 
number of days in hospital. 

It is interesting to note that on the medical side there 
were only two cases of appendicitis admitted, both of 
which were cured ; while on the surgical side there were 
forty cases admitted. On turning to the table of opera- 
tions one sees that thirty-six of the latter cases were 
operated upon, with three deaths. 

Of typhoid fever eighty-four cases were admitted, 
seventy-two discharged cured, and only three deaths, a 
remarkably low percentage. It would be interesting to 
know if systematic hydrotherapy was employed. 

We congratulate the management and the professional 
staff on the completion of the first year of what will 
doubtless prove a most beneficent work for the entire 
Dominion of Canada. 

Syllabus of Gynecloogy, based on the American 
Text-book of Gynecology. By J. W. Long, M.D. 
Pp.133. Philadelphia: W. B. Saunders. 1895. Price, 
gi.oo. 

Dr. Long's book is a tabulated synopsis of the 
American Text-book of Gynecology, interleaved for 
note-taking, and prepared with a threefold object : 
First, to be used as lecture-notes ; secondly, to enable 
the student more intelligently to follow and remember 
the lecture ; and, finally, as a convenient reference for 
physicians. The book is well adapted to the purpose 
for which it was intended, but shows evidence of 
haste in its preparation. Thus we read of H(7gar's 
colpoperineorrhaphy ; dysmenorrhea is spelled with an 
a- at one place and an e at another ; <rdema is used 
throughout, while ceXxolomy and gonnorhd?a receive the 
preference ; and colporraphy is spelled as here written. 
We are also told that the use of electricity in uterine 
fibroids is still sub jiidice. The book may be materially 
improved by the removal of such defects as those 
mentioned. 



NEWS ITEMS. 



[Medical News 



NEWS ITEMS. 

Prof. Rudolph Leuckart. — It is proposed to celebrate the 
fiftieth anniversary of the accession of Prof. Leuckart to 
the doctorate, on December 13, 1895, by the erection of 
a marble bust of the distinguished zoologist. 

William W, Browning, A.M., M.O. — The degree of Master 
of Arts was conferred on Dr. W. W. Browning, of 
Brooklyn, by Yale College at its recent commencement. 

Prof. Englisch has succeeded Prof. Dittel in the direction 
of the Third Surgical Clinic of the Vienna General 
Hospital. 

For the James E. Reeves Fund. — We have received from 
Dr. G. L. Magruder, $1. 

Meetings of State, H/ational, and International Medical Societies. 





Meets. 


Next meeting. 


American Association of 


Sept. 20, 189s 


Chicago, 111. 


Obstetricians and Gyne- 






cologists. 






American Dttrmatological 


Sept. 17, 1895 


Montreal, 


Association. 




Can. 


American Electro-Thera- 


Sept. 3. 189s 


Toronto, Can. 


peutic Association. 






American Medical Associ- 


May 5-8, 1896 


Atlanta, Ga. 


ation. 






American Microscopical So- 


August 21-23, 


Ithaca, N. Y. 


ciety. 


1895 




American Orthopedic Asso- 


Sept. 19-21, 1895 


Chicago, 111. 


ciation. 






Canadian Medical Associ- 


Aug. 28-30, 1895 


Kingston, Ont. 


ation. 






Idaho State Medical Society. 


Sept. 9-1 1, 1895 


Boise City, Id. 


Illinois State Medical So- 


May 19, 1896 


Ottawa, 111. 


ciety. 






International Congress of 


September, 1S96 


Geneva, 


Gynecology & Obstetrics. 




Switzerland. 


International Congress of 


189s 


Ostend. 


Hydrobalneolherapy. 






International Congress of 


Sept. 23-26, 1895 


Florence, 


Otology. 




Italy. 


International Medical Con- 


August, 1896 


Moscow, 


gress. 




Russia. 


Medical Association of 


April IS, 1896 


Augusta, Ga. 


Georgia. 






Medical Association of the 


April, 1896 


Montgomery, 


State of Alabama. 




Ala. 


Medical Society of the State 


Jan. 28, 1896 


Albany, N. Y. 


of New York. 






Medical Society of Virginia. 


September 3 


Wytheville.Va. 


Mississippi Valley Medical 


September 3-6 


Detroit, Mich. 


Association. 






New York State Medical 


October 15-17 


New York City 


Association. 






Ohio State Medical Society 


May 27-29, 1896 


Columbus, 0. 


Texas State Medical Society. 


April, 1896 


Ft. Worth, 
Texas. 


Tri-State Medical Society of 


Oct. 1-4, 189s 


Des Moines, 


Illinois, Iowa, and Mis- 




Iowa. 


souri. 






Utah State Medical Society. 


Oct. I, 2, 189s 


Salt Lake City. 


Vermont State Medical So- 


October 10, 11 


Burlington, 


ciety. 




Vt. 



BOOKS AND PAMPHLETS RECEIVED. 
A Brief Note on Some Cases Recently Admitted to the Surgical 
Service at the New York Cancer Hospital. By Charles A. Powers, 
M.D. Reprinted from the New York Medical Journal, 1894. 



Further Observations on the Physiological Occurrence of Coni- 
cal Stump after Amputation in Children. By Charles A. Powers, 
M.D, Reprinted from the Medical Record, 1894. 

Dermoid Cysts of the Orbit, with Report of a Case. By S. 
Potts Eagleton, M.D. Reprinted from the Codex Medicus Phila- 
delphias, 1894. 

Abscess(?) in the Urethro-vaginal Septum. By T. S. Cullen, 
M.B. Reprinted from the Johns Hopkins Hospital Bulletin, 1894. 

Papillo-cystoma of the Ovary. By T. S. Cullen, M.B. Re- 
printed from the Johns Hopkins Hospital Bulletin, 1894. 

Report of a Case of Epithehoma and of One of Sarcoma of the 
Larynx. By Arthur Ames Bliss, A.M., M.D. Reprinted from 
the New York Medical Journal, 1894. 

Diseases of the Female Bladder and Urethra. By Howard A. 
Kelly, M.D. Pamphlet. Baltimore. 

Official List of Medical Officers, Acting Assistant Surgeons, 
and Hospital Stewards of the U. S. Marine-Hospital Service: 
also List of U. S. Marine Hospitals and Quarantine-St.itions. 
W.ishington : Government Printing Office, 1895. 

Seventeenth Annual Report of the Presbyterian Eye, Ear, and 
Throat Charity Hospital. Baltimore, 1894. 

Contributions to the Physiology and Pathology of the Nervous 
System. By Isaac Ott, M.D. Part XII. Reprints from the 
Journal of Nervous and Mental Disease, 1892-93-94. 

Report of the Surgeon-General of the National Guard of the 
Stale of New York, 1894. 

United States Bureau of Education. Circular of Information, 
No. 2, 1894. Contributions to American Educational History. 
Edited by Herbert B. Adams. No. 19. History of Education 
in Maryland. By Bernard C. Steiner, Ph.D. (J. H. U.). Wash- 
ington : Government Printing Office, 1894, 

Magnesium Sulphate as a Purgative : An Explanation of its 
Action when Administered Hypodermically. By James Wood, 
M.D. Reprmted from the Therapeutic Gazette, 1895. 

Bromid of Ethyl as an Anesthetic in Oto-laryngological Prac- 
tice. By A. W. de Roaldes, M.D. Pamphlet. New Orleans: 
L. Graham & Son, 1894. 

Hysterical Pyrexia. By George J. Preston, M.D. Reprinted 
from the Maryland Medical Journal, 1894. 

Cerebral Edema. By George J. Preston, M.D. Reprinted 
from the Journal of Nervous and Mental Disease, 1894. 

Clinical Notes on the Diagnosis and Treatment of Apoplexy. 
By George J. Preston, M.D. Reprinted from the Maryland 
Medical Journal, 1894. 

A Case of Probable Meningeal Hemorrhage, with Symptoms 
Resembling General Paresis. By George J. Preston, M.D. 

The Value of a Medical Opinion. By J. Martine Kershaw, 
M.D. Reprinted from the Homeopathic News, 1895. 

Laminectomy for Paraplegia from Pott's Disease ; Tenotomy 
of Contractured Hamstring Tendons of Both Legs; Amputation 
at the Hip-joint: Appendicitis; Stone in the Bladder; Supra- 
pubic Lithotomy. By F. C. Schaffer, M.D. Reprinted from the 
International Medical Magazine, 1894. 

Transactions of the New Hampshire Medical Society at the 
One-hundred-and- third Anniversary, held at Concord, June 18 
and 19, 1894. Concord, N. H.: Printed by the Republican Press 
Association, 1894. 

Reports of the Trustees and Superintendent of the Butler Hos- 
pital for the Insane. Presented to the Corporation .at its Fifty- 
first Annual Meeting, January 23, 1895. Providence, R. I : The 
Providence Press, 1895. 

A Study of the Mode of Action of Ichthyol in Inflammatory 
Conditions. By D. Bradden Kyle, M.D. Reprinted from the 
Therapeutic Gazette, 1895. 

" Stammering of the Urinary Organs'' (Paget). By J. Henry 
C. Simes, M.D. Reprinted from the University Medical Maga- 
zine, 1895. 

Hysterical Syncope, Hemianesthesia, Rapid Respiration. By 
Charles W. Burr, M.D. Reprinted from the University Medical 
Magazine, 1895. 

Some Points in the Prevention and Treatment of Puerperal 
Fever. By Charles Rosewater, M.D. Reprmted from the Cleve- 
land Medical Gazette, 1895. 



THE MEDICAL NEWS 

A WEEKLY JOURNAL OF MEDICAL SCIENCE. 



Vol. LXVII. 



Saturday, August lo, 1895. 



No. 6. 



ORIGINAL ARTICLES. 

THE PRESENT ST ATUS F THE DIPHTHERIA- 
QUEST/ON. 

By henry \V. BETTMANN, M.D.. 

CURATOR AND MICROSCOPIST, CINCINNA 



Much can be learned from a study of the present 
status of the diphtheria-question. What is more 
important, a proper direction may thereby be given 
to future work. It is strange how the minutiae of 
diseases escape careful consideration until some 
special line of research calls for the most exact 
examination of all details. Future work on diph- 
theria can be made more rapidly productive of re- 
sults when the questions to be solved are accurately 
outlined. Certain it is that the diphtheria-problem 
cannot be reduced to the same simple formula in 
man as in the lower animals. In the artificial diph- 
theria of animals the Loeffler bacillus is the excit- 
ing cause, the antitoxin is the neutralizing agent — 
and there the matter ends. In man, however, 
many etiologic factors remain yet to be solved. 

The use of Loeffler's culture-serum for diagnostic 
purposes, though adapted to clinical ends, has 
led to scientific misconceptions. Throughout the 
recent literature we find the terms " pure culture " 
and " mixed infection " used haphazard. These 
terms lack scientific definiteness. No one knows 
exactly what " mixed infection " is, and there is 
reason to doubt if a " pure infection " ever occurs. 
Nothing can be more self-evident than that the 
question of mixed or pure infection cannot be 
solved by one culture-medium alone, especially if 
that medium is especially devised to favor the 
growth of one germ and retard the growth of others. 
To use Loeffler's culture-serum for diagnostic pur- 
poses is highly satisfactory ; to use it as a basis of 
scientific differentiation is clearly irrational. 

Silberschmidt' examined 91 cases of diphtheria 
with Loeffler's serum, bouillon, and glycerol-agar, 
and all but one showed the presence of strepto- 
cocci or staphylococci. Those who work with 
glycerol-agar alone will sometimes fail to detect the 
Loeffler bacillus when it is present in the throat ; 
and those who work with Loeffler's serum alone will 
fail to find other germs that could be demonstrated 
by other means. 

Bernheim" has shown that if streptococci and 

' Munchener medicin. Wochenschr., Feb. 26. 1895. 
2 Zeitschr. f. Hygiene, B. xviii, H. iii. 



Klebs-Loeffler bacilli are inoculated in the same 
tube the streptococci are retarded in development. 
Bernheim by the use of glucose-bouillon and 
Loeffler's serum demonstrated that none of his cases 
presented " pure infection." 

In a recent examination of over 120 throat-cases 
I failed to find any that might be considered a 
" pure infection." 

The term " mixed infection " is far from standing 
for anything definite. If every case in which 
streptococci or staphylococci are present at the 
site of infection is a case of mixed infection, then 
cases of pure diphtheria are rare indeed. The pre- 
dominance of one germ over another cannot be 
made the basis of scientific discrimination, espe- 
cially if only one culture-medium is used. In fol- 
licular tonsillitis staphylococci and streptococci are 
present. In a case of "mixed diphtheria" we 
should expect in addition to the symptoms due 
to the Klebs-Loeffler-bacillus those due to the 
streptococcus and the staphylococcus ; but this is 
notoriously untrue, as the symptoms (fever, head- 
ache, backache) of follicular tonsillitis are usually 
more severe than those of diphtheria. 

What is "mixed infection," and how can we tell 
that the cocci present in a diphtheric throat are 
playing any ro/e in the disease ? Certainly, to talk 
of the comparative value of the antitoxin in cases 
of pure and in those of mixed infection is thor- 
oughly irrational, as we do not know what is pure 
infection and what is mixed infection. A prog- 
nosis cannot be made from the bacteriologic exami- 
nation, as some cases die in which staphylococci 
predominate, others in which Klebs Loeffler bacilli 
predominate. It may be interesting to note here that 
Bernheim' has shown that if animals are inoculated 
with the filtrate of cultures of diphtheria-bacilli and 
streptococci, the disease runs a more violent and 
rapid course ; if, however, a filtrate of cultures of 
staphylococci is used in large quantity the disease is 
milder than in cases of pure diphtheria. 

The question of deciding the infectiousness of 
convalescent patients is not so easy as was supposed. 
When a pharyngeal culture fails to reveal the pres- 
ence of virulent Klebs-Loeffler bacilli the patient 
isusuallydismissed as no longer dangerous. Tezenas 
du Montcel" showed that when there is a nasal dis- 
charge the pharyngeal culture may repeatedly prove 
negative, and still virulent bacilli may persist in the 

1 Loc. cit. - La Province Med., August 5, 1893. 



142 



THE PRESENT STATUS OF THE DIPHTHERIA-QUESTION. [Medical News 



nose from one to eight weeks. Sevestre et M6ry' 
examined i8 cases from day to day in 1893. In 
one case non-virulent bacilli persisted in the pharynx 
several days ; one month later the bacilli were 
found to have regained virulence and a sister of the 
patient was seized with the disease. In two other 
cases virulent bacilli were found fifteen days after 
recovery, although intermediate cultures revealed 
only non-virulent bacilli. In two other cases phar- 
yngeal cultures were negative, though nasal cultures 
showed virulent bacilli, in one case up to the forty- 
ninth day. These researches prove that non-virulent 
bacilli may regain their virulence, and that an exist- 
ing nasal discharge should not be overlooked in 
declaring convalescents contagion-free. 

The relation of albuminuria and nephritis to 
diphtheria is another subject that requires clearing 
up. All writers have noted the great frequency of 
albuminuria in diphtheria, and most of them have 
used albuminuria and nephritis as interchangeable 
terms. Nothing has been made more clear by re- 
cent study than that in a large proportion of cases 
the albuminuria of diphtheria does not depend on 
nephritis. We are not justified in diagnosticating 
nephritis unless we find epithelium, casts, or blood 
in the urine. Anyone who takes the trouble to ex- 
amine diphtheric urine microscopically will be sur- 
prised to find how often albuminuria may exist 
without the presence of renal elements in the urine. 
Fischer- reports 141 cases of albuminuria without 
casts. I have myself frequently examined the al- 
buminous urine of diphtherics without finding evi- 
dence of nephritis. Schroeder-' reports 44 cases 
of albuminuria, only 6 of which presented evidence 
of nephritis. The Stadt Physikat of Triest* reports 
105 cases of diphtheria; 75 of these had albuminuria, 
but only one-half of these had casts in the urine. 
This rather startling clinical evidence is made more 
striking by post mortem observations. GoodalP 
reports 30 cases of suppression of urine in diph- 
theria, leading to a fatal issue in 27 cases. The 
common characteristics of these cases were : Severe 
local disease; marked albuminuria; never hematuria 
or sediment in the urine ; anuria more or less com- 
plete ; frequent vomiting and cardiac failure. Post- 
mortem examination of the kidneys showed them 
to be usually normal to the naked eye in every re- 
spect. Ten cases were examined microscopically 
and only trivial changes found. Nothing can be 
more conclusive than that marked albuminuria and 
renal insufficiency may be due to causes outside of 
the kidneys themselves. F. Siegert" reports a series 

• Revue des maladies de I'Enfance, Mars, 1895, pp. 108-118. 

2 Medical Record, April 6, 1895. 

3 Miinchener medicin. Wochenschr., .\pril 4, 1895. 
' Wiener klinische Wochenschr., 1893, No. 3, p. 55. 
6 Lancet, 1895, pp. 269-273. 

" Therapeutische Monatshefte, 1895, p. 123. 



of 100 tracheotomized diphtheria-cases; 27 of these 
had albuminuria, but nephritis was found post-mor- 
tem only three times; 10 patients had from 0.5 to 
'6.0 per cent, of albumin in the urine intra vitam ; 
very careful post-mortem examination failed to re- 
veal the presence of nephritis. 

In estimating the effect of the antitoxin on the 
kidneys, therefore, much more must be taken into 
account than the existence or the degree of album- 
inuria. In fact, a new subject is opened for in- 
vestigation, and the albuminuria of diphtheria has 
yet to be explained. One thing seems fairly certain, 
viz., that the antitoxin exerts no harmful influence 
on the kidneys. 

It is probable that the experiments of Mya' rep- 
resent the truth of the matter, viz., that the anti- 
toxin has no appreciable effect on heart, blood, or 
kidneys. This observer watched four children from 
eighteen months to six years of age. He kept them 
under very close observation for several days, 
noting pulse, diurnal temperature-variation, blood, 
and urine. Then he injected 30 c.cm. of the anti- 
toxin, and noted the changes during the succeeding 
hours and days. The first child, aged six years, 
convalescent from measles, presented the following 
conditions for several days before inoculation : The 
erythrocytes numbered 5,160,000; the leukocytes 
6916. The average quantity of urine for twenty- 
four hours was 660 c.cm.; the specific gravity was 
1014; the urea equalled 14.25 gm. ; there was 
present neither glucose nor albumin, but a trace of 
indican. The rectal temperature varied from 37.5° C. 
to 37.8° C. The injection of the antitoxin was 
followed in a few hours by a reduction of the 
erythrocytes to 3,541,666; an increase of the leu- 
kocytes to 9381. No variation was noted in pulse 
or temperature. The urine increased to 1280 c.cm. 
on the second day ; the secretion was free from 
albumin, glucose, and urobilin. All of these varia- 
tions were transitory, and in a few days the normal 
was regained. The results in the other three 
children were the same. The changes due to the 
antitoxin may be summarized as: i. Transitory 
diminution of the red blood-corpuscles. 2. Slight 
leukocytosis. 3. Polyuria. 4. Slight increase in 
the excretion of urea. 

That the oligocythemia was not due to destruc- 
tion of corpuscles is proved by the absolute absence 
of urobilin from the urine. It was probably due to 
dilution of the blood from the lymph-channels, as 
also evidenced by the leukocytosis and polyuria. 

These observations of Mya are very important, 
as they were conducted with great care. More- 
over, they agree with other clinical observations. 
Albuminuria is present in a majority of cases of 



' Suir azione fisiologica del siero antidiftero nell organissimo 
infantile. Lo Sperimentale, April, 1895. 



August io, 1895] THE PRESENT STATUS OF THE DIPHTHERIA-QUESTION. 



143 



diphtheria treated without the antitoxin, being vari- 
ously estimated by Henoch, Baginsky, and Eberth, 
as occurring in from 50 to 60 per cent, of all cases. 
Schwalbe' reports 470 cases of diphtheria in the 
Friedrichshain Hospital before the antitoxin-period ; 
albuminuria was found in 227, though examina- 
tions were made but once in each case. Kolisko' 
says that in 75 post-mortems of cases treated 
with the antitoxin the kidneys presented no de- 
viation from kidneys seen before the antitoxin- 
period. Ganghofner,^ in a most guarded paper, 
reports albuminuria, lasting any considerable time, 
as occurring in only 20 of no injected cases. Of 
^^ cases injected on the first or second day, none 
had severe albuminuria. In Cincinnati albuminuria 
occurs in nearly every severe case of diphtheria. I 
had the opportunity in March of making a curious 
observation of five children in two families, two of 
whom were treated with and three without the anti- 
toxin. The cases all ran a mild course, but all 
suffered from rather marked albuminuria. The cases 
lay side by side in a hospital-ward. The appetite 
was good in all, and there was no pain, no edema, 
no morphotic elements in the urine ; yet the album- 
inuria persisted in all, notwithstanding treatment 
for from two to three weeks. Authorities are almost 
unanimous in the belief that the antitoxin does not 
lead to increase in the proportion of albuminurics, 
some even noting a diminution. 

Testimony on the subject of the heart is variable, 
the vast majority of writers noting no bad effects 
on the heart. Some few, among whom is Bagins- 
ky, believe that the heart is unfavorably affected. 
Mya observed absolutely no variation in the rate, 
rhythm, or tension of the pulse, as shown by sphyg- 
mographic tracings. Observations of the blood 
have yet to be made. Certain it is that fear of bad 
effects need cause no one to abstain from the use of 
the antitoxin. 

It is yet impossible to determine the effects of the 
antitoxin on the paralysis of diphtheria. Exact 
figures are not available. The occurrence of par- 
alysis varies in different epidemics and in different 
regions. In Berlin it is very common (Henoch) ; 
in Munich it is not often met with (Seitz) ; in 
Halle it is uncommon (v. Mering). It seems in- 
credible that the use of the antitoxin should increase 
the proportion of cases attended with paralysis ; 
clinical reports, on the other hand, seem to show 
that the proportion is not reduced. Heubner' 
reported paralysis in 7.4 per cent, of 207 cases 
treated with the antitoxin ; C. Seitz^ injected 74 



^ Deutsche medicin. Wochenschr.. 1S94, No. 51. 
^ Therapeutische Monatshefte, February, 1895. 
^ Prager medizin. Wochenschr., 1895. Nos. i, 2, and 3. 
* Munchener medicin. Wochenschr., April 4, 1895. 
5 Ibid. 



cases on the first or second day of the disease, and 
encountered some very severe cases of paralysis. 
Hager" had 3 cases of paralysis among 20 under 
observation ; Washburn' 6 among 48 survivors ; 
Fischer 21 in 190 cases; Mya' 5 in 50 cases; Solt- 
mann* only 4 among 76 recoveries ; Germonig^ 
only 8 in 290 survivors; Siegert" 33 in 100 
tracheotomized cases ; and so on through a long 
list. It is advisable to look over old records of 
the pre-antitoxin-period and strike a general 
average for each locality, and then to follow up all 
new cases with watchfulness. This will require 
years of attention, and this is destined to be one of 
the last problems connected with the subject to be 
solved. 

When we come to the final question as to how far 
the antitoxin has reduced the mortality of diph- 
theria we enter upon a most perplexing field of in- 
quiry. When all is said and done, the statistical 
method is the court of ultimate appeal ; and yet 
just this method exposes us to a thousand errors. 
Here, too, it will be found profitable to seek the 
sources of error and eliminate them as far as possi- 
ble from future research and summaries. Up to the 
end of January over 3000 reported cases had been 
collected, with a mortality of 20 per cent. (Heub- 
ner), and reports since that time have given us 
about the same results. On its face-value this seems 
to give us a marked reduction in mortality as com- 
pared with former times, and yet a critical estimate 
bids us withhold our judgment. 

I should like to emphasize the following proposi- 
tions : 

I. Hospital-statistics considered by themselves 
are likely to be misleading. 2. Diphtheria treated 
under favorable conditions is not so fatal a disease 
(even in Europe) as is commonly supposed. 3. 
The bacterial criterion of diagnosis has a wide in- 
fluence on the results achieved. 

Regarding Hospital-statistics. Common observa- 
tion teaches us that agitation of new remedies 
among the populace leads to a rapid influx of 
patients suffering from that disease to the centers 
of treatment. In 1890 the tuberculous world flocked 
to Berlin and to the hospitals for tuberculosis. 
During the past year hospitals have dealt with vastly 
more cases of diphtheria than heretofore. We are 
indebted to Gottstein, of Berlin,' for some brilliant 
observations on this score. He compares the admis- 
sions and deaths in the Berlin hospitals with the 
municipal cases and deaths during the past five 



• Therapeutische Monatshefte, Feb. 1895, p. 91. 
- British Medical Journal, Dec. 22, 1894. 

■■ Lo Sperimentale, Feb. 21, 1895. 

* Deutsche medicin. Wochenschr., 1895, No. 4. 
'" Wiener klin. Wochenschr., May 23, 30, 1895. 
I" Loc. cit. 

'' Therapeutische Monatshefte, Jan. 1895, p. 33. 



THE PRESENT STATUS OF THE DIPHTHERIA-QUESTION. [Medical News 



years. From September 30th to November 24th 
there died of diphtheria in the Berlin hospitals, in 
1890, 131 cases; in 1891, 124 cases; in 1892, 178 
cases; in 1893, 197 cases; and in 1894 (antitoxin- 
period), 131 cases ; the admissions, however, dur- 
ing this period increased from 328 in 1890 to 712 
in 1894. The mortality in Berlin from diphtheria 
is less than half the mortality in the Berlin hos- 
pitals; /. e., the severest cases are sent to the hos- 
pitals. Now if all of the cases in Berlin were sent 
to the hospitals the mortality would, without any 
change of treatment, fall, eo ipso, 50 per cent. 

This is just what happened in the autumn of 
1894. The number of admissions more than 
doubled and the mortality sank 50 per cent. The 
total mortality, however, was not thereby reduced, 
and as many cases died in 1894 as in 1890, only 
the place of their dying was changed. In 1890 
there were 1591 deaths from diphtheria in Berlin, of 
which 6S2 (or 43 per cent.) occurred in the hos- 
pitals; in 1894, from January ist to November 
24th, there were 1281 deaths in Berlin, of which 
737 (o'' 57-5 per cent.) occurred in the hospitals. 
Gottstein concludes with complete justification as 
follows: I. The death-rate in hospitals was reduced 
50 per cent., because twice as many cases were ad- 
mitted. 2. The total mortality in hospitals in 1894 
(to November 24th) was already larger than for 
1890 or 1891. 3. The total mortality in the hos- 
pitals and the city was not at all reduced. 

This able analysis explains the apparent benefit 
of the antitoxin in many other hospitals, and we 
may justly doubt the value of the statistics of any 
hospital that has suddenly experienced a large incre- 
ment of patients. 

With very few exceptions it is true that the mor- 
tality from diphtheria in cities at large is very much 
less than in the diphtheria-hospitals, and hence any 
influx from the city to the hospital would of itself 
lower the mortality-percentage of the latter. This 
is exemplified in the reports from Trieste.' In 1893, 
no cases were treated in the hospital and 52.7 per 
cent, died ; in the first eight months of 1894, 149 
cases were treated and 46 per cent. died. Now 
came the antitoxin-period; in the next five months 
362 cases (! ) were admitted and the mortality was 
naturally reduced to 20 per cent. Hahn reports 
from the Friedrichshain Hospital that though the 
number of cases in 1894 was very much increased, 
the total mortality in the hospital was not reduced, 
but only the percentage. Thus we see that hospital- 
statistics per se are unreliable, and we should know 
in every case the number of cases treated as com- 
pared with the total number in the respective city. 
Diphtheria treated under favorable conditions is 

1 Germonig : Wiener klin. Wochenschr., May 23, 30, 1895 ; 
and Stadt-Physikat. Ibid., iSgS, No. 3. 



not SO fatal a disease as is commonly supposed. At 
the Congress of Internal Medicine, recently held in 
Munich,' Baginsky said that his contemplation of 
diphtheria in former years was among the most 
gloomy of all his experiences: "In the diphtheric 
pavilion I gained the impression that we were abso- 
lutely helpless in dealing with diphtheria, and that 
nursing did more than medicines." All this sounds 
dramatic, but we must remember that at the Munich 
Congress Baginsky was pleading the cause of the 
antitoxin. In 1891 his contemplations were not so 
gloomy, nor his results so bad as he has since de- 
picted them. In his Arbeiten aus dem Kaiser u. 
Kaiserin Friedrich Kinderkrankcnhausej' published 
in October, 1891, he thus sums up the work of the 
diphtheria-pavilion for the first year of the hos- 
pital's existence : 244 cases were treated ; the mor- 
tality was 40 per cent. ; thirty-seven of these cases 
were admitted with far-advanced septic and gan- 
grenous diphtheria and died soon after admission. 
"Subtracting these cases," says Baginsky (p. 246), 
" but including a larger number of those that were 
tracheotomized, we had a mortality of 23.1 per 
cent., a result in diphtheria with which we ought to 
be very well satisfied." In his recent book he re- 
ports 527 cases treated with the antitoxin, with a 
mortality of 15.6 per cent. 

Much stress is laid by the upholders of the anti- 
toxin on the fact that the sooner the cases are in- 
jected the better the prognosis ; and the brilliant 
achievements of the antitoxin in this particular are 
above dispute. It is, perhaps, not useless to call 
attention to the fact that before the antitoxin-period 
the prognosis was good in cases brought early for 
treatment. 

F. Siegert' gives his results in the treatment of 
diphtheria without the antitoxin in the children's 
clinic at Strasburg. He cites in detail 100 cases 
that required tracheotomy — hence all severe cases. 
Six were received on the first day of the disease — 
none died ; ten on the second day — two died. 
After the second day the mortality ranged from 31 
to 53 per cent. Siegert urges further that fatal 
complications do not arise, as a rule, until after the 
fourth day, and that, therefore, if cases are treated 
early the mortality will be reduced eo ipso. Of fifty 
fatal cases in his clinic, there died on the first three 
days of the disease none ; on the fourth day five ; 
on the fifth day eight, etc. Dangerous symptoms 
do not arise early ; parents wait until death seems 
imminent and then hurry their children to the hos- 
pital. During the antitoxin -period they take them 
early, and hence the percentage of recoveries is 
greater. 

' See Miinchener medicin. Wochenschr., April 2, 4, 9, 1895. 

- Stuttgart : Ferdinand Enke. 

■■' Therapeutische Monatshefle, March, 1895, pp. ii8 et seq. 



August io, 1895] 



A STUDY OF DEAF-MUTISM. 



145 



Ritter' states that in the two years preceding the 
use of the antitoxin he lost no case of pharyngeal 
diphtheria that was brought early for treatment, 
although he had had altogether ninety-one cases. 

Baginsky, Kossel, Ehrlich, and others emphasize 
the fact that after the injection of the antitoxin 
the membrane never spreads into the larynx. Gang- 
hofner,^ however, in an article friendly to antitoxin, 
cites his pharyngeal cases during 1893, ^"^ finds 
that in only two cases did the membrane spread to 
the larynx after treatment was instituted. The 
mortality among these pharyngeal cases was only 
15. S per cent. 

We learn from all these observations that diph- 
theria treated promptly under favorable conditions 
(hospital-hygiene, good nursing, food, and air) is by 
no means so fatal as we are taught to suppose, but 
that even in the pre-antitoxin-days the mortality 
was great only among neglected or improperly situ- 
ated patients. In private practice, in Cincinnati, 
at least, the percentage of fatal cases is small ; the 
mortality ranges here from 19 per cent, (in 1891) 
to ;^;^ per cent, (in 1888), but the death-rate among 
the upper classes is very much less. 

It is not true, as was first supposed, that all cases 
treated on the first or second day with the antitoxin 
will recover. Ganghofner had two cases that were 
injected on the second day to prove fatal ; Heubner'' 
reports failure in a few cases injected on the second 
or third day. Kohts' injected a case on the second 
day ; twenty-four hours afterward new and extensive 
membranes formed. In another case, injected on 
the second day, the larynx became involved later, 
and tracheotomy was required. In the Trieste 
hospital five cases died, though injected on the 
second day. 

Soltmann* had thirteen deaths among eighty-nine 
cases ; six of the fatal cases were injected during 
the first four days of the disease ; and in thirteen 
cases the membranes descended to the pulmonary 
alveoli, notwithstanding the antitoxin. 

Vierordt" reports eight deaths among fifty-five 
patients. Two of the fatal cases were injected on 
the second day and two on the third. Ritter de- 
tails the following history : He saw a strong child, 
aged three years, that had been taken sick only a 
few hours before ; on both tonsils circumscribed 
patches appeared; the temperature was 39.7°, the 
pulse between no and 120. Behring's antitoxin 
No. 3 was used. The membranes nevertheless 
spread, the larynx was invaded, tracheotomy was 
refused, and the child died on the sixth day. 

We are compelled to admit that the antitoxin fails 

1 Wiener medicin. Woohenschr., April 27, 1895, p. 778. 
^ Loc. cit. 3 Loc. cit. 

^ Miinchener medicin. Wochensciir., 1895, p. 343. 
^ Deutsche medicin. Wochenschr.. 1895, Xo. 4. 
* Deutsche medicin. Wocliensclir., March 14, 1893. 



to cure in a certain proportion of cases, notwith- 
standing the fact that all other conditions are favor- 
able. 

Finally, a few words are in order regarding the 
effect of the bacterial diagnosis on hospital-statistics. 
Formerly, at least in American cities, though all 
the fatal cases were reported, many mild cases were 
not. Now, that bacterial diagnosis and municipal 
supervision render diphtheria cases in a measure 
public property, many more cases will be brought 
to the notice of health-officers than formerly, and 
the mortality-rate will seem to sink. This is pret- 
tily illustrated in the recent health-report of Boston 
for the year 1S94. Boston has not only a Bureau 
of Bacteriology, but it also has an army of school- 
inspectors to examine school-children. With these 
combined means an enormous number of cases of 
diphtheria are ferreted out, cases that .formerly 
would have been called simple sore-throat. This 
statement is made in the report itself. Thus in 1894 
Boston had 3019 cases of diphtheria. The greatest 
number of cases any previous year was 1814. We 
would expect from this an enormous reduction in 
the mortality, but find that the mortality (27.06 
per cent.) is but slightly less than in preceding years 
— and yet the Boston authorities congratulate them- 
selves on having reduced the rate of mortality by 
means of the antitoxin. They have simply reduced 
the rate by means of bacterial diagnosis and school- 
inspection, while the absolute mortality is far in 
excess of former years. 

Enough has been written to show that the ques- 
tions concerning diphtheria and the antitoxin are 
still in their infancy, instead of nearing solution. 
It is well to know the pitfalls that are in the way of 
our attaining the truth. 

547 West Seventh St. 



CONTRIBUTION TO THE STUDY OF DEAF- 
MUTISM.^ 

By ARTHUR AMES BLISS, A.M., M.D., 

KVN'GOLOGIST TO THE CIEKMAN HOSPITAL ; LAKVNGOLOGIST AND AURIST 
NGOLOGICAL ASSOCIATION, 



The subject of deaf-mutism is one that does not 
appeal very strongly to the interest of the busy 
general practitioner, or, perhaps, even to the aurist. 
We think of the totally deaf as a class of individuals 
whose condition has removed them beyond the pale 
of aural treatment — an incurable class, to be rele- 
gated, if still young in years, to the attention of 
teachers in institutions for training in vocalization, 
as having passed beyond the range of the aurist's 
work. Clinical experience has shown clearly that, 



1 Read before the Medical Society of the State of Pennsylvania, 
May 24, 18 5. 



146 



A STUDY OF DEAF-MUTISM. 



[Medical News 



when total deafness has been found to exist, or when 
in mutes the degree of hearing is reduced to a vague 
sense of sound, the best interests of the child are 
considered when it is transferred to the care of oral 
teachers. 

The questions in connection with deaf-mutism, 
however, that cannot but have interest for the phy- 
sician, are those relating to the prevention of loss 
of hearing in early childhood. E.xaminations of 
deaf-mutes made by Holger Mygind, and others 
(including some observations of my own), show un- 
doubtedly that strictly congenital deafness is a far 
from common cause for failure in acquiring speech. 
By congenital deafness I mean the existence of ab- 
normalities within the tract of hearing that have 
appeared during the development of the fetus. 
That such conditions can exist has been proved by 
post-mortem examination, and there are in most 
institutions for the deaf and dumb instances of 
children that show such abnormalities in the exter- 
nal ears and in the contour of the skull that we can, 
with a fair degree of reason, believe that there have 
been corresponding failures or errors of develop- 
ment within the sound-perceiving apparatus. 

It has been a rather common practice to classify 
all children that have never spoken, and that have 
never given signs of having heard, as congenital 
deaf mutes ; but, considering the great number of 
conditions attending many forms of disease that 
may attack the infant in the first few months of life, 
and that may tend to involve the ears in an inflam- 
matory process, it seems to me that very many ele- 
ments of doubt must be cleared away before we can 
say definitely that a given case of deaf-mutism is 
congenital. In other words, in by far the majority 
of deaf mutes there were opportunities given the 
care-takers of the children for preserving the hear- 
ing, or for lessening the consequences of destructive 
processes that were annihilating one of the five 
senses. Thus coryza, the exanthemata, syphilis, 
asthenia after wasting diseases, may, in very early 
infancy, rapidly destroy the delicate aural tissues, 
while destruction is in progress, also, in other tracts 
of the body. This latter process may be noted and 
receive full attention from the children's care-takers, 
while the process within the ear is unnoted or 
ignored. The child recovers, and its disease leaves 
no impression on the organs whose lesions caused 
most anxiety to the medical attendant and to the 
family, yet the unnoticed aural complication has 
left permanent, perhaps total, deafness. 

I have seen a child, about thirteen months of age, 
that had suffered for weeks, during a hot summer, 
from enterocolitis. Little attention was paid to 
anything above the diaphragm. During the active 
stage of the illness the child had at frequent inter- 
vals given vent to what has been termed the 
" hydrocephalic cry," but which is not uncommon 



in young children suffering from pain within the 
ears. The child pulled feebly at the left auricle 
and pressed its head against the pillow. Eventually, 
a slight discharge from the meatus of this ear ap- 
peared, but soon ceased, to be followed by a swell- 
ing over the mastoid process of the same side. The 
aural complication had now progressed for two 
weeks without attracting attention from the abdo- 
men. Sweating, chills, and pyemic symptoms had 
been manifest, but not until a mastoid abscess 
bulged the left ear out like a horn from the infant's 
head did the attendants decide that the ear required 
any special care. A grave, destructive process, 
lessening the child's hearing, perhaps its power of 
speech for life, had progressed under the eyes of 
intelligent parents, nurse, and doctor. How fre- 
quent may not such instances be in the crowded, 
undisciplined homes of those whose children form 
the great number of our deaf mute pupils, and 
whose statements as to the origin of deafness are 
accepted and furnish the data for statistics re- 
garding the causes of deaf-mutism ! No objective 
symptoms may occur that would be noted by such 
persons ; yet an active destructive process may 
have caused total deafness, and the parents report 
that the child was " born deaf." 

In a series of pupils, numbering 546, examined at 
the Pennsylvania Institution for the Deaf and Dumb, 
it will be noted how many of the diseases charged 
with causing the deaf-mutism are common to child- 
hood or to early infancy : 



Scarlet fever 78 

Cerebro-spinal meningitis .... 44 

Meningitis ....... 39 

Measles ........ 19 

" Colds '' IS 

Convulsions ....... 12 

Traumatism . . . . . . .14 

Otitis media 11 

Typhoid fever 8 

Spin.-il meningitis 8 

Pneumonia ....... 4 

Catarrhal fever ...... 4 

Teething ........ 3 

" Malaria **....... 3 

Black fever (?) 3 

Cholera infantum 3 

Diphtheria 2 

Enteritis ...*.... 2 

Whooping-cough ...... 2 

Rachitis ........ 

Smallpox ...... 

Shock 

Mumps 

Bronchitis ....... 

Sunstroke 

Croup ........ 

Eczema ........ 

Unrecorded ....... 8 

Unknown cause 56 

" Deaf from birth " 200 



The cases marked as " deaf from birth," 200 in 
number, would doubtless be greatly lessened if the 



August lo, 1895] 



A STUDY OF DEAF-MUTISM. 



147 



parents had been more accurate in their reports. 
Ignorance and want of intelligence ma}' account for 
lack of more exact data. 

A study of the conditions revealed by an examina- 
tion of the ears of the 546 pupils is very suggestive 
of the results of destructive processes that may have 
been, and probably were, at first, limited to the 
sound-conducting apparatus. These lesions consist 
(i) of a sclerosing, non-suppurative process affect- 
ing, primarily, the sound-conducting apparatus, 
and resulting in immobilization of its various parts ; 
(2) of extensive destruction of the tympanic con- 
tents by a suppurative process, in many cases still 
active, which has destroyed the middle ear, and, 
probably, portions of the inner ear also, while, in 
some instances, it has caused exfoliation of the ossi- 
cles, destruction of the mucous lining of the tym- 
panum, denudation and necrosis of its bony walls, 
and the development of cholesteatoma. As one 
case not infrequently presented several lesions, it 
will be understood why the total number of cases 
reported exceeds the number of individuals exam- 
ined. 

1. Otitis media sclerotica, the drumheads being 

feebly iDovable ...... 191 

2. Otitis media sclerotica, with adherent and im- 

movable drumheads ..... 150 

3. Engorgement of the manubrial vessels, the 

drumheads being pinkish, suggestive of an 
active catarrhal inflammation of the mucous 
membrane of the tympanum . . .10 

4. Calcareous deposits in the drumhead . . 16 

5. Perforation of the drumhead, with active sup- 

puration ....... 46 

6. Cicatrized perforations 55 

7. .Impactions of cerumen ..... 57 

8. Atresia of the auditory meatus ... 2 

9. Undeveloped auricles, with absence of the ex- 

ternal auditory canal ..... i 

10. Foreign bodies in the external auditory canal . 7 

11. Desquamative inflammation of the external 

auditory canal ...... 4 

12. Drumheads appearing normal ... 51 

It will appear from this list that the great ma- 
jority of these conditions suggest a comparatively 
slow but destructive process, either with or without 
suppuration, tending to cause sclerosis by fibrous 
or bony changes within the sound-conducting ap- 
paratus. In other words, there are few of these 
conditions that might not have yielded to judicious 
treatment employed in the early stages of the aural 
disease. At the same time we must not be misled into 
the error of supposing that each of these conditions 
noted represents the cause of the total deafness in 
every case in which it has been noted. The abnor- 
malities of the posterior nares and pharynx in many 
of the pupils in this series indicate the possibility 
that middle-ear sclerosis may have developed grad- 
ually, in some instances, as a result of such nasal 
and pharyngeal disease, subsequent to a destructive 
process within the sound-perceiving apparatus that 
6* 



had itself already destroyed the sense of hearing. 
The aural lesions noted, however, cannot be disre- 
garded, even considering this possibility. 

The ages at which deafness is stated to have de- 
veloped is of considerable interest : 

At birth 200 

Under one year old 48 

From one to two years old . . . .84 

From two to three years old .... 62 

From three to four years old .... 56 

From five years old and over . . • - 55 

Uncertain ....... 41 

I have already referred to the uncertainty of a 
diagnosis of deafness at birth, while deafness suf- 
ficient to cause failure in acquiring speech may not 
be noticed until the second year of childhood. 
Considering this fact, and considering, also, the 
character and chronicity of the aural diseases sug- 
gested by the lesions observed in pupils whose 
deafness is dated from birth to the second year of 
childhood, I feel safe in grouping these periods to- 
gether, making 332 pupils out of the total, 546, 
whose aural disease developed in the years before 
the rudiments of speech are acquired. At this early 
age the child may be the victim, as well as the 
ward, of its care-takers. It can but imperfectly 
call their attention to many grave symptoms, and 
its feeble efforts at so doing may be unnoticed or 
ignored. We must exclude from this number the 
instances in which, from the personal and family 
history, as well as from the objective symptoms, 
it is reasonable to believe that deaf-mutism was in- 
deed congenital. I do not feel that our tests, at 
present, enable me to give the number of this latter 
class of pupils with any degree of certainty. The 
indications, as judged from the conditions found in 
the ears of the entire series of 546 pupils, favor the 
idea of deafness developed subsequent to birth, and 
with otitis media, resulting from many different 
processes, as a direct cause. 

Consanguinity of parents has been found by ob- 
servers to be one of the causes of deaf-mutism. In 
thirty-one instances among our series of 546 pupils, 
the parents were stated to be blood-relations. This 
is not a large percentage, yet it can scarcely be 
passed by unnoticed. The influence exerted by 
consanguinity of parents as a causative element in 
producing d eaf-mutism in their children is a subject 
involved in much obscurity. Where others have 
failed in explanation, I do not even attempt to do 
better. It must be commonly noted, however, by 
all physicians that blood-relationship in parents 
whose family has a strong predisposition to certain 
diseases of the pulmonary or nervous system, or to 
syphilis in its varying degrees of activity, is prone 
to result in the birth of children presenting many 
abnormalities of anatomic structure and physio- 
logic function. In such weaklings the structures of 



143 



A STUDY OF DEAF-MUTISM. 



[Medical News 



the ear are certainly no more proof against diver- 
gence from the normal than are the parts of the 
cerebro-spinal tract or the lymphatic system. Even 
in robust subjects, the tissues of the ear yield readily 
to inflammation ; much more readily must they 
yield in these strumous, feebly recuperating children 
of the class to which I refer. 

It is a question if the blood-relationship of 
absolutely robust parents, members of a sound, 
healthy family, would have a sinister influence 
upon the physical health of their children or be 
in any way a factor in producing deaf- mutism. 
The exaggeration of vicious physical defects, or 
of a tendency to grave disease by the intermar- 
riage of unhealthy relatives is certainly a very 
potent factor in causing deaf-mutism. A tendency 
to aural disease, or to catarrhal inflammation of the 
upper respiratory tract and ear, seems to be not un- 
common in the families of deaf mutes. One-fifth 
of the entire series of pupils studied belonged to 
families having other deaf mutes among their mem- 
bers. In fifteen instances the parents were them- 
selves deaf mutes. In 1 23 instances other children 
of the same family, cousins, aunts, or uncles, were 
partially or totally deaf or were also mutes. 

Among our series of cases are a few very startling 
instances of the general distribution of deaf-mutism 
through a family. In these an entire family may form, 
as it were, a community of deaf mutes. The existence 
of deaf-mutism among the near relatives of about 
one-fifth of the pupils in our series sufficiently indi- 
cates that a tendency to destructive diseases within 
the ear is common to certain families. In such in- 
stances it would appear that there must exist some 
inherent weakness, by reason of which the tissues 
fail to resist the influences of disease to a greater 
degree than is the case with more nearly normal 
subjects. The nature of such physical taint can 
scarcely be analyzed. It is probably very multiform 
in character, and may arise from any conditions 
that have made a deep impress upon the vital centers 
that control nutrition and growth. Syphilis, ex- 
treme alcoholism and debauchery, years of great 
poverty, with mental and physical suffering upon the 
part of a parental pair, may account for a progeny of 
defective men and women, among whom deaf-mutism 
claims a few victims, while struma, pulmonary tu- 
berculosis, locomotor ataxia, rheumatoid arthritis, 
idiocy, epilepsy, and insanity may have a greater 
number of subjects. In other words, deaf-mutism is 
only one of the phases of physical degeneration that 
may appear in members of a physically degenerate 
race. It is to such individuals that we may look 
with reason for instances of true congenital deaf- 
mutism, especially if taints of disease are concen- 
trated by the intermarriage of members of such 
stock. 

The lessons to be learned from these statistics, 



and those of other observers, bear relation mainly 
to the prevention of deafness in infancy and early 
childhood. We have seen that, excluding the un- 
fortunate victims of inherited weakness and disease, 
to whom the congenital deaf mutes probably belong 
as a class, we have large groups of individuals whose 
total deafness (and resulting mutism) has developed 
at an early age, and was apparently of such nature 
in the beginning as to have allowed of cure had the 
aural conditions been recognized in time and treated 
judiciously. 

The best methods of treatment are made manifest 
when we note the changes within the fauces and 
posterior nares of deaf-mute pupils. This ground 
has been gone over quite thoroughly by several ob- 
servers, including myself, and it is not necessary to 
repeat the details. Suffice it to say that the investi- 
gations of observers who have given attention to the 
upper respiratory tract and ears of deaf mutes show 
that hypertrophied and diseased tonsils and hyper- 
trophy of the lymphoid tissue within the post-nasal 
space are exceedingly common conditions. We 
know how commonly they exist in children whose 
hearing is still normal, and how intimately they are 
associated with catarrh of the middle ear. 

Such conditions, causing mouth-breathing, want 
of drainage of the excessive mucous or muco-puru- 
lent discharge resulting from the attendant catarrhal 
rhinitis, causing also pressure upon or closure of the 
Eustachian tubes, must be removed and the parts 
rendered as nearly normal as possible. Such meas- 
ures are of special importance in children whose 
family history indicates a tendency upon the part 
of their parents or other relatives to contract aural 
diseases, with the development of grave deafness. 
Otitis media, as a complication arising during the 
course of any illness in early childhood, requires 
early diagnosis and careful after-treatment. With 
the relief of the acute symptoms and the distressing 
pain, the treatment does not end. An uncared-for, 
acute, non-syphilitic inflammation may drift on into 
a slow, progressive, sclerosing process, binding the 
mobile parts of the middle ear in fibrous or bony 
union, and extending onward into the labyrinth, 
while an acute suppuration, with rupture of the 
drumhead, may continue until a chronic otorrhea 
has been established, with all its attendant dangers 
to the hearing-power, to the health, and even to 
the life of the child. 

The strange trust in time and circumstance, or, we 
might say, in fate, that expresses itself in the belief 
that otorrhea must not be cured, that aural symptoms 
will be "outgrown," that otitis media in subacute 
form is a natural aftermath of measles and scarlatina, 
and that some supernatural influence that brought it 
about will also lead to its cure while we look on, 
is not a rational trust in Providence ; nor can the 
doctor safely congratulate himself that the "con- 



August io, 1895] RECOGNITION AND TREATMENT OF PULMONARY TUBERCULOSIS. 149 



founded ear-trouble" is, for him as well as for his 
patient, at an end when "the gathering in the 
head" has broken. With the general practitioner 
rest the care and responsibility for the preventive 
treatment during the illnesses of early childhood. 
He should be on the lookout for aural symptoms ; 
should know the simple means at hand for their 
treatment, rather than have recourse to olive-oil, 
almond-oil, Harlem-oil, catfish-oil, kerosene-oil, 
all served hot or cold, with or without laudanum, 
as the child's grandmother may desire. A plug of 
raw onion need not be wedged into the affected 
ear, and yet the doctor may do his duty. The 
teachings of the professor of aural and rhino-laryn- 
geal diseases, now, after many years of stupid oppo- 
sition, arecognized member of the faculties of many 
of our medical schools, will tell of better things, 
and the physician in any city or large town can call 
an aural surgeon to his aid if the simpler methods 
fail him. 

THE EARLY RECOGNITION AND THE CLI- 
MATIC TREATMENT OF PULMONARY 
TUBERCULOSIS} 

By H. B. MOORE, M.D., 

OF COLORADO SPRINGS. COL. 

Each year's added experience with the high-alti- 
tude treatment of pulmonary tuberculosis impresses 
me freshly with the idea that certain very elemen- 
tary facts relating to this very valuable therapeutic 
method, although often detailed by interested stu- 
dents of the subject, are constantly lost sight of by 
physicians prescribing this mode of treatment. The 
most important of these relates to an early recog- 
nition of the true nature of the case, so that the 
altitude-treatment may be instituted at once, and to 
the desirability of a more or less prolonged resi- 
dence at the high altitude. Disregard of reason- 
able forethought in these particulars, more especially 
the first point, leads to great disappointment on the 
part of patients and friends and brings undeserved 
disrepute upon the treatment. I am willing to ad- 
mit that some of the blame for this should rest upon 
the shoulders of too enthusiastic admirers. A 
goodly portion of it, however, belongs properly to 
that large body of practitioners who no sooner 
read of a new cure than they proceed to try it in- 
discriminately upon every case of the malady com- 
ing under their observation. 

What is true of other diseases and their medical 
treatment is also true of the climatic therapeutics 
of pulmonary tuberculosis. It is far from wise to 
send every such case to Colorado to try the high- 
altitude treatment. The prospect for an arrest or 
cure of this disease diminishes very rapidly with its 
advance, and what has been a most favorable case may 

1 Read before meeting of the American Climatological Associa- 
tion, Hot Springs, Va., June 13, 1895. 



soon become inappropriate for this climate. Pro- 
phylaxis is always better than cure, and the family 
physician, seeing a rapidly growing boy or girl with 
imperfect chest-development, in a family predis- 
posed to tuberculosis, can o-ten avert a catastrophe 
by sending the child to a high altitude. The out- 
door life, sunshine, and rarefied air of these regions 
are the most rational and perfect preventives of 
which one can conceive. Such cases are common 
in the experience of all physicians, and a practical 
recognition of the truth of this statement will lead 
to most gratifying results. 

When too late for prophylaxis, and the disease is 
actually in progress, it seems to me (and my expe- 
rience in this line has been such as to create strono- 
convictions on the subject) almost criminal to keep 
the patient at home trying cough-medicines, creo- 
sote, guaiacol, cod-liver oil, hypophosphites, etc., 
during that valuable time, often so short, when 
climatic treatment is really capable of rendering 
radical assistance in the struggle with the invading 
enemy; but, alas, often, one might say usually, the 
patient is kept at home until the vital powers are 
weakened by advanced disease, and then, finally, 
it is decided to send the patient somewhere for his 
health. Is this reasonable, and can anyone who 
has the slightest grasp of the subject imagine, for 
an instant, that any climate will materially help a 
considerable percentage of cases of this kind ? The 
system is already poisoned with the products of sup- 
puration, and each day finds the cells less able to 
cope successfully with the already existing disease- 
area, to say nothing of its spread. This phlegmatic 
conception and management of tuberculosis is not 
rational and can never succeed. 

One must have a sharp, clear-cut appreciation of 
the fact that a great danger menaces every individ- 
ual whose tissues have become the site of the 
slightest degree of this form of bacterial invasion, 
and that, although some subjects are found to pos- 
sess a remarkable degree of tolerance for the dis- 
ease, as a rule the existence of any considerable 
amount of tuberculous tissue in the lungs constitutes a 
handicap too great for Nature to oppose successfully. 

One error probably oftener fallen into than any 
other, even by physicians, is the idea that a person 
who looks well, or fairly so, cannot have tubercu- 
losis. They cannot harmonize the appearance of 
an apparently healthy person before them with their 
conception of the pale and wan tuberculous patient, 
and forget that tuberculosis is an infective disease, 
which, like other diseases, has a beginning as well 
as an end, and if the symptoms are suspicious they 
think their science is at fault and call the disease 
" bronchitis " or a " cold that lingers," instead of 
by its right name. It would be interesting to know 
when, in the opinion of a large number of our 
professional brethren, these ailments ceased and 



ISO RECOGNITION AND TREATMENT OF PULMONARY TUBERCULOSIS. [Medical News 



actual tuberculosis began. I have had the misfor- 
tune to see large numbers of self-deceived, or doc- 
tor-deceived, human beings with tuberculous cavi- 
ties, hectic fever, etc., arrive in Colorado Springs 
as cases of "bronchitis," "protracted cold," etc., 
and die in due time. On the other hand, it is a real 
satisfaction to examine some of the patients sent to 
Colorado by men thoroughly conversant with the 
subject, who make an early diagnosis and act on it 
at once. As a case in point, of which I am glad 
to say there are many, that of a young man, al- 
ready becoming well known in our own profession, 
comes to mind. He had been an athlete in col- 
lege, and on arrival in Colorado Springs was a pic- 
ture of healthy vigor, broad, full-chested, and with 
a good, healthy color ; yet a little suspicious cough 
existed and examination of the chest revealed begin- 
ning slight trouble at an apex, and the sputum-ex- 
amination showed quite numerous tubercle-bacilli. 

Cases in which the tuberculous infection is dis- 
covered early, and there is scarcely more than a 
little infiltration at the seat of invasion, are ideal, 
and may be taken as models of what we should 
strive after. Often Nature comes to our aid and 
declares, by means of a small hemorrhage or a 
slight spitting of blood, that tuberculous invasion 
has occurred at some little point in a person who 
has not previously coughed or been unwell in any 
way. Such an occurrence, although very alarming 
to the patient, is really a most fortunate one if 
properly interpreted and acted upon by the physi- 
cian. Very often, however, the doctor discovers 
some point in the throat (usually) or the bronchial 
tubes the seat of alleged congestion, which he assures 
the patient caused the bleeding, and encourages the 
latter not to be alarmed, and so the probably valuable 
significance of the warning is lost and not thought of 
again until its repetition, or warnings of another 
character throw unpleasant light on the subject. 

It may be asked with propriety whether the very 
early cases are the only ones that it is wise to send to 
a high altitude, and whether conditions so efficacious 
in prophylaxis and in the early stage of the devel- 
oped disease are without efficacy in cases that are 
further advanced on first seeking advice as to the 
advisability of a change of climate. The reply to 
this question would be that the high-altitude treat- 
ment is the treatment suited especially to the earlier 
manifestations of the disease, the subjects of which 
still retain a large amount of their accustomed vigor 
and are able to avail themselves fully of the advan- 
tages of outdoor life in mountainous climates, which, 
from the very nature of things, are not very equable 
and which require a considerable amount of hardi- 
ness to withstand temperature-changes readily per- 
ceived by delicate anemics and subjects of hectic 
fever. At the same time every physician with ex- 
perience in elevated regions can recall many cases 



presenting relatively extensive areas of disease in 
subjects possessing a considerable degree of toler- 
ance for the disease and free from fever, who thrive 
in these regions and live many years. 

Actual cure, however, is rare in these cases, the 
disease being merely arrested and liable to begin 
afresh on return to damp, sea-level climates. A 
very extensive area of even inactive disease would 
constitute a decided contra-indication to the high- 
altitude treatment, as a considerable amount of 
good healthy breathing-space is necessary for a 
patient to obtain the requisite amount of oxygen in 
a rarefied atmosphere. It is rarely wise to send 
active febrile cases advanced beyond the first stage 
to a high altitude. The deeper breathing required 
and the exciting character of the climate are very 
likely to promote destruction of existing consolida- 
tion and increase fever. Many such cases are seen 
in Colorado, in which, so far from being aided, the 
end is undoubtedly hastened. 

As regards the other point to which I wish to call 
particular attention, viz., the necessity of a more 
or less prolonged residence at high altitudes, it is a 
serious error to give a patient going to Colorado on 
account of tuberculosis the idea that he is simply 
to go there for "two or three months," or "to 
spend the winter." It is very rarely that expecta- 
tions of this sort can lead to anything but dis- 
appointment, as the disease is of such an essentially 
chronic character that this length of time is 
scarcely more than sufficient to furnish an idea as 
to the probable efficacy of the climate in an in- 
dividual case. 

Right here arises a question that it is often dif- 
ficult to answer, viz., when is a patient cured of 
pulmonary tuberculosis and when is the disease only 
arrested and completely inactive ? and yet it is, to 
the last degree, important for the patient to have 
this question answered correctly if he wants to re- 
turn home. Some might say that a case may be 
looked upon as cured when the cough and expecto- 
ration have ceased entirely, when rales have disap- 
peared from the chest, and the weight and general 
bodily functions have become normal ; but it is a 
matter of every-day experience that under such 
conditions the patient frequently again begins to 
expectorate bacilli-laden sputa and to exhibit all the 
symptoms of renewed activity, showing that the 
disease was not cured and that the tissues had con- 
stantly contained live bacilli and larger or smaller 
areas of tubercle ready to soften at the proper time. 
It seems, therefore, as a rule, much wiser for the 
physician at home to be very conservative upon this 
point and to instil into the patient's mind, from 
the first, the idea that the contemplated change of 
climate, if found on trial to meet the patient's 
needs, must be a long and perhaps permanent one. 
If the patient hears this for the first time from his 



August io, 1S95] 



PENETRATING WOUNDS OF THE EYEBALL. 



151 



new physician after leaving home, he is naturally 
surprised at the lack of accord between this advice 
and what he had been led to believe previously, and 
feels home-sick and unprepared for so radical a 
change in his plans. 

The desirability of the change of climate being 
very long or permanent is especially manifest when 
the patient is right in the midst of what might be 
called the most vulnerable age ; when physique and 
family tendencies all indicate a subject of pro- 
nounced susceptibilities. Under these circum- 
stances a premature return home after arrest or cure (?) 
might lead to a fatal relapse. Colorado Springs 
has to-day hundreds of citizens who have lived here 
for years with a good practical degree of health, 
enjoying their share of the activities and pleasures 
of life, and yet they are not cured of their tuber- 
culosis and could not return to their former homes 
with safety. Many others have been completely 
cured and could live anywhere, but remain here 
from choice and the growth of local interests. 

With respect to this point of prolonged residence 
our American high-altitudes in Colorado possess 
most conspicuous advantages over high-altitude re- 
sorts abroad, like Davos Platz, St. Moritz, etc., 
which are purely and simply health-resorts, offering 
no opportunities for occupation to those who need 
it and having no permanent society or home-life. 
In short, a young tuberculous person who has 
been sent sufficiently early in the disease to Colo- 
rado soon finds that he has not been consigned to a 
health-resort for life, but that he has simply changed 
his residence to another portion of the country 
filled with communities with many attractions, 
where work and a career still await him. It must 
not be inferred from these statements that Colorado 
has more positions than people to fill them or that 
it is especially easy to get remunerative employment, 
for such is not the case. On the contrary, the 
unemployed poor are found here as everywhere ; 
but it is meant that talent and ability in all lines 
can find scope for their exercise here as promising 
as elsewhere, now, and with an encouraging pros- 
pect for future growth, often absent in the Eastern 
States. The lot of the very poor, who are at the 
same time ill, is a hard one anywhere, and must 
remain so until means are devised by the State or 
by individuals to relieve this most distressing form 
of need. 



PENETRATING WOUNDS OF THE EYEBALL} 

By C.^SEY a. wood, M.D., 

The responsibility assumed by the surgeon who 
undertakes the care of an eye whose envelops have 
been penetrated or ruptured is greatly increased by 

^ Read before the Illinois State Medical Society, May, 1895. 



the fact that not only the vision of the injured eye, 
but that of the second eye may be at stake. The 
dreadful possibility of sympathetic or migratory 
ophthalmia, as it is more properly called, should 
always be borne in mind. This disease runs such a 
chronic and painful course, and is so disastrous in 
its effects, that when once encountered it is never 
forgotten. The unfortunate subject of it must wait 
during long weary months of pain and semi-blind- 
ness before his medical attendant can assure him 
either that he will eventually retain some vision in 
the uninjured eye, or that the injured eye, as some- 
times happens, may be the more useful organ. It 
becomes, indeed, a question as to how long the 
emigrated micro-organisms, which are the essential 
agents in producing the lesions, will continue to 
multiply and poison the delicate structures within 
the second eye. 

It is not my purpose to enter upon a discussion 
of certain theories respecting the pathology of 
ophthalmia migratoria, but rather lo indicate, as 
well as I can, some of the principles commonly re- 
garded in dealing with certain ocular injuries, and 
to illustrate these with some cases that have come 
under my own observation. 

First of all, ocular traumatisms may be empiri- 
cally, and, I think, usefully and practically, divided 
into three classes: (ist) those that are serious or 
not, from the standpoint of sight only, in which we 
are mostly concerned in asking whether or not the 
patient is likely to have useful vision in the injured 
organ ; (2d) those that threaten the integrity of the 
second eye, quite apart from the fate of the injured 
eye, whose vision may at the time be fairly useful ; 
here the eventual vision of the injured eye must be 
subordinated to the protection of the fellow-organ ; 
(3d) those cases, probably the most numerous, in 
which sight is destroyed in the injured eye, and 
anxiety may be felt in respect to the vision of the 
other eye. 

I wish first of all to report the histories of three 
cases that fairly belong to the first class : 

In the summer of 1890 I was called in consulta- 
tion with Dr. Greenfield, of Chicago, to see a young 
man who, in a drunken affray, had been stabbed in 
the left eye. The point of the knife had entered 
the cornea at its scleral margin on one side, had cut 
into the iris and lens, and had emerged at about a 
corresponding point on the opposite corneal border. 
The torn iris, with pieces of lens-matter, presented 
in the wound, the shallow anterior chamber being 
filled with blood. We decided to try to save the 
eye; thoroughly irrigated the sac with 1:5000 
mercuric chlorid in a saturated solution of boric 
acid, carefully removed all the presenting lens- 
matter, blood, etc. ; applied an antiseptic bandage ; 
and were rewarded with having the corneal wound 
heal promptly and smoothly. There remained 
several posterior and anterior synechiae, it is true, 



152 



PENETRATING WOUNDS OF THE EYEBALL. 



[Medical News 



and the vision did not amount to much more than 
finger-counting, but the organ, even in this state, 
was undoubtedly better than an artificial eye. 

Another case was even more satisfactory : 

A child, aged four years, in the summer of 1892 
fell from his chair while eating at table, and in doing 
so knocked down a glass bottle standing at his side. 
A piece of the broken glass cut through the upper 
lid and penetrated the sclerotic at about the equa- 
tor, making a jagged wound about a centimeter 
long. The eye was carefully cleansed, and under 
chloroform a projecting bead of vitreous was snipped 
off; the edges of the conjunctival wound were care- 
fully sutured, the lesion of the lid was looked after, 
and a protective bandage applied. The wound 
healed nicely and there was no symblepharon. 
To-day the patient can read fine print and has 
nearly normal distant vision with the injured eye. 
There is, of course, a peripheral defect in the 
visual field, and with the ophthalmoscope some 
vitreous opacities may be made out, as well as the 
site of the injury to the choroid and retina, which 
is marked by a mass of pigment. 

Dr. Cory referred to me last March the following 
case : 

A boy, aged eleven years, was hit in the left eye 
with a splinter of glass from a window through which 
a stone had been thrown. I saw him on the morning 
following the accident. He did not complain of 
pain, and there was very little blood on the bandage 
that covered the eye. The cornea, iris, and lens 
were the seat of an irregularly horizontal wound. 
The sclero-corneal junction was not affected. There 
was prolapse of iris into but not through the corneal 
incision. The lens had come forward into the 
empty anterior chamber: V. L. = p. 1. Treatment 
consisted in careful antisepsis and asepsis, and the 
use of an ointment of atropin. The result was quite 
gratifying. The corneal wound healed very rapidly ; 
there was no incarceration of the iris ; and the lens 
underwent almost total absorption. There never 
was more than a slight pericorneal injection. 

In none of these cases has there developed any 
sign of sympathetic ophthalmia. 

As examples of the second class of cases, I shall 
also give, very briefly, three histories : 

A girl, aged five years, while playing with a pair 
of scissors, stabbed herself in the right eye with one 
of the blades. The wound was well within the 
sclera, near the corneal margin. Dr. E. L. Holmes, 
who was first consulted, very properly advised ex- 
cision of the globe, although for several weeks after 
the injury there was considerable vision in the eye. 
The friends of the patient refused to have the 
operation performed until it was too late. I saw 
the case more than a year after the accident, when 
the distracted parents were carrying the little girl 
from oculist to oculist, in the hope of getting relief. 
She had perception of light in the second eye, 
which, like the first, had been destroyed by a septic 
iridocyclitis. The injured eye had undergone 
atrophy and was perfectly sightless. 



A year ago last February a Polish Jew, working 
in a machine-shop, was sent to me for an injury in- 
flicted by a piece of steel that had entered the front 
of his eye at a point corresponding to the ciliary 
body, had passed behind the lens and vitreous, and 
had lodged in the posterior wall of the globe or had 
penetrated the ocular coats and escaped into the 
orbit, I am not in a position to say which. There 
was no marked disturbance of vision (V. = 2/7 and 
J. IV) when I saw the man a few days after the 
accident, but the eye was tender and injected, and 
there had been some intraocular bleeding. Here 
was a man who could ill afford to risk anything or 
even to remain from work for any great length of 
time. I accordingly explained to him, to his em- 
ployers, and to his rabbi the dangerous character 
of the injury, but he steadfastly declined operation. 
He left me, and I heard afterward that he became 
blind in both eyes. 

A young man, while chipping steel, in August, 
1892, was hit in the right eye with a flying frag- 
ment. The missile penetrated the cornea, iris, and 
lens, and its ultimate destination could not be de- 
termined owing to the traumatic cataract that fol- 
lowed. I removed most of the latter by a corneal 
incision and cut through, with a DeWecker's 
scissors, the tough membrane that remained, and 
was finally able to inspect the back part of the eye. 
The vitreous was cloudy and I could barely see the 
fundus. However, with a glass the patient had V. 
of 1/5, and I determined to try to preserve the eye, 
although symptoms of sympathetic irritation (lacry- 
mation, photophobia, and inability to read) were 
occasionally present. Under a general anesthetic 
the globe was pierced at its lower equatorial aspect 
with a Graefe knife and the point of a Hirschberg 
electro-magnet introduced through the wound into 
the vitreous. After some careful manipulation I was 
successful in fishing out an irregularly shaped piece 
of steel. The man made a good recovery ; both 
eyes became comfortable, and vision improved, so 
that he was able to work with ease. Within a year, 
however, he began to complain of his old symptoms 
in the better eye, and although he had nothing that 
to my mind justified excision of the injured eye, he 
saw another oculist, who, I understand, removed it. 

I am not prepared to say that this was not the 
wisest course to pursue, as workingmen cannot afford 
to give themselves the continued rest and care that 
should follow these electro-magnetic operations. 

An example, and I shall give but one, of what I 
have termed the third class of ocular injuries, is the 
following : 

A man, aged forty- five years, consulted me in 
June, 1 89 1, for watering of his left eye, with gen- 
eral discomfort. He thought his reading-glasses 
needed changing. The eye complained of was 
somewhat injected, but not tender. Both distant 
and near vision were normal. The right eye 
was sightless, the tension was -|- i, and the patient 
flinched when the globe was slightly pressed upon. 
There was some ciliary injection. The man said 
that lately the eye was occasionally tender and 



August io, 1895] 



SUDDEN DEATH FROM INTRA-UTERINE INJECTION. 



153 



sometimes got red like the other. Ten years before 
he had been hit in the left eye with a chip of steel 
that had penetrated the front of the eye, but had 
been extracted by a fellow-workman. After that he 
could not see out of it. There was a scar on the 
cornea, but nothing could be seen in the iris, except 
that it was of a dirty-brown color, while that of the 
sound eye was blue. There were posterior synechia 
and a whitish cataract. I enucleated the eye at 
once, and found a flattened piece of eroded and 
rusty steel 4 mm. long and i mm. wide, like the 
pointed extremity of a needle, imbedded in a 
brownish matrix of thickened vitreous, and lying 
close to the retina at the inferior aspect of the 
globe. The surrounding retina and vitreous were 
evidently stained with iron-rust. The man made a 
good recovery and has had no trouble since. 

To return to the classification with which I started 
and in conclusion of this paper, I may say that 
my treatment of such cases may be summed up as 
follows : The eye is never to be enucleated or 
eviscerated in injuries of the first class ; it is to 
be closely watched in all examples of the second 
class, and to be removed unless both eyes become 
and remain quiet. Lastly, injured eyes of the third 
class should always be removed. 

As an aid to prognosis and treatment, I would 
suggest the following rules : 

1. As long as the wound heals without difficulty, 
and no sympathetic irritation exists, I would treat 
with rest and antiseptics, and would not remove 
any eye whose injury is confined to the cornea, iris, 
and lens. 

2. I would not enucleate an eye containing a 
foreign body when the injury was confined to these 
tissues and the foreign body could be removed. 

3. I would not remove an eye containing a for- 
eign body if there were no injury in the ciliary 
region, and the missile had passed through the 
posterior wall of the globe. 

4. I would not immediately excise an eye injured 
by small shot (which are usually aseptic missiles), 
even if the wound were in the ciliary region, pro- 
vided the patient could be occasionally seen by an 
oculist. 

5. I would always excise an eye that contains a 
foreign body that could not be removed. 

6. I would excise an eye in which the ciliary 
body had been injured, even if the sight were not 
much affected thereby. The only exceptions I 
would make to this rule are small gunshot-wounds, 
cases in which the second eye is useless or had been 
removed, and those instances in which there is no 
continued uveitis of the injured eye, provided always 
that the patient could be frequently seen by an 
oculist. For the average man, however, excision 
or exenteration would be, by far, the safest pro- 
cedure in the last instance. When loss of sight 



goes along with ciliary involvement there can be 
no argument in favor of retaining the eye. 

7. When once ophthalmia migratoria has set in, 
it is wise to retain the injured eye, if there be any 
sight in it, as eventually it may be the better of 
the two. 

8. It is safe and proper to remove all continually 
tender or inflamed eyes of adults whose vision has 
been lost from a penetrating wound in whatever 
region of the globe. 

9. It is highly desirable to retain the eyeball in 
patients under twenty years of age, if it can be 
done with safety to the better eye, as earlier re- 
moval of the globe retards the growth and develop- 
ment of the corresponding orbit, and greatly alters 
and mars the facial expression. 



CLINICAL MEMORANDA. 

SUDDEN DEATH FROM SHOCK DUE TO THE IN- 
TRA-UTER INE INJECT ION OF A SOLU- 
TION OF LEAD ACETATE TO 
INDUCE ABORTIONS 

By PAUL J. BARCUS, M.D., 

OF CRAWFORDSVILLE, IND. 

On the afternoon of April 22, 1895, the dead body of 
Mrs. B. was found by a neighbor lying supine near a 
windov/ on the floor of a bedroom in her residence. The 
dress was but slightly disarranged ; the limbs were ex- 
tended. Upon the floor, and quite near the body, were 
several vessels more or less filled. Among these was a 
teacup containing a powder and perhaps a half-ounce of 
liquid. There were lying near, also, a wire stilet and a 
bulb-syringe, with a linen catheter attached to it by means 
of a screw and thread. The contents of the cup were 
ascertained to be lead acetate, and there was some of 
the same solution in the syringe. 

At the post-mortem examination, aftermakingthe usual 
median incision and grasping the fundus uteri, pressure 
would force from the vagina a fluid similar to that in the 
cup. None of the fluid could be found in the peritoneal 
cavity. On opening the uterus it was found to contain 
the product of a conception of about eight weeks' dura- 
tion. The membranes were unruptured and the endo- 
metrium was not wounded. 

The body presented the appearance of one having 
been in the enjoyment of perfect health. There was a 
history of good health — no heart-disease, no disease of 
any kind, so far as could be ascertained, to account for 
the sudden death. The woman had been talking to a 
neighbor at 11.36, and at 12.45 her dead body was 
found. 

It was shown that the deceased had been in the habit 
of self-inducing abortions, and that she had successfully 
accomplished this no less than twelve or fifteen times. 
About five years ago a physician had attempted to pro- 
duce an abortion for this woman by injecting pure tinc- 
ture of iodin into the uterus. The injection was imme- 
diately followed by shock, from which the woman re- 
covered, but which threatened for a time to terminate 

' Read before the Indiana State Medical Society, June 10, 1895. 



154 



NEW DEVICE. 



[Medical News 



fatally. About two years ago she induced another abor- 
tion herself, which was attended by severe uterine colic 
and great depression. 

Death must have been sudden and unattended with any 
marked convulsive movements, or some of the vessels 
near the body would have been overturned. The fatal 
result was due to the injection, as was shown by the his- 
tory, and was attributable to shock, as there were no 
wounds made by the catheter, rendering it possible for 
air or fluid to have been injected into uterine sinuses. 



A NEW METHOD FOR CORRECT ING 
DEFORMITY OF PROMINENT 
AURICLES. 



THE 



NEW DEVICE. 

A NEW AND SIMPLE METHOD BY WHICH 
CAUTERY-IRONS MAY BE ELECTRI- 
CALLY HEATED ALMOST IN- 
ST ANT A NEO USL Y} 

By W. SCHEPPEGRELL, a.m., M.D., 



PRESIDENT 



By WESLEY W. BARKWELL, M.D., AND 
JAMES BECKETT, M.D., 

OF CHICAGO. 

Cases of deformity of prominent auricles are so in- 
frequently met with and less frequently operated upon 
that it might be of general interest to relate a case and 
mode of operation. There have been three methods de- 
scribed for this operation : One by Ely, in which an 
oval piece is taken out of the entire thickness of the 
pinna, including skin and cartilage ; another by Monk, 
consisting of the removal of the skin alone from the 
back part of the ear ; and the last by Keen, in which a 
large oval piece is taken from the skin of the back of 
the auricle and a V-shaped groove taken from the carti- 
lage, but not cutting through the skin on the inner side. 
In a case in which we operated upon April 29th the 
cartilage was very thick and firm, and this condition 
might have been the reason for suggesting a slight dif- 
ference in the mode of procedure from any of those 
already mentioned. After preparing the patient in the 
usual way, by washing the ears and the surrounding 
parts with soap and water, an antiseptic solution, and 
then alcohol, we proceeded to outline an elliptic space 
on the back of the ears. This space measured in length 
about one-and-one-quarter inches, and in the center 
its greatest breadth three-eighths of an inch. It was 
our desire to take out this elliptic space without cutting 
through the skin on the front of the ears, and also that 
there should not be a redundancy of skin in this part. 
The knife was entered at one corner of the ellipse and 
the lower side cut out first, so that what little hemorrhage 
there might be would occasion no concern during the 
cutting of the other side. As the knife was drawn down 
toward the widest part of the elliptic space care was 
taken to slope the instrument gradually sideways more 
and more until it reached that point, and then gradually 
straighten it as it neared the other corner of the ellipse. 
This was done in order to take as narrow a piece as pos- 
sible out of the front side of the cartilage, thus leaving 
no redundancy of skin on that side. .Vfter inserting the 
sutures and drawing them, the apposition of the parts 
was so complete, without any apparent redundancy, 
folds, or tension on the fore part of the ear, that from a 
front view it would be almost impossible to detect any 
evidence of an operation. 

428 South California Avrnue. 



Dr. William C. Jarvis, Professor of Diseases of the 
Throat in the University of the City of New York, died 
at Willet's Point, L. I., on July 30th. 



While at the World's Fair I was much interested by 
a new method of heating metals by electricity, the nov- 
elty consisting not only in the rapidity with which the 
metals were heated, but also in the peculiar method of 
applying electricity for this purpose. The metal, such 
as, for instance, a soldering-iron, was dipped into a bucket 
or jar containing a watery solution of borax and sodium 
carbonate, and in a few seconds became red-hot. A 
large, flat iron file, held in the solution, rapidly became 
white-hot, the heated metal standing out in brilliant con- 
trast with the water ; if the file was kept still longer in 
the solution it commenced to fuse rapidly. 

A closer inspection showed that the bucket or jar was 
connected with the terminals of a 230-volt Edison cur- 
rent, the positive wire being attached to a plate of lead 
at the bottom of the jar, and the negative wire passing 
across the top of the jar. When used, the bar of metal 
was placed in contact with the negative wire, and the 
part to be heated was dipped into the solution, the heat- 
ing process, as stated, taking place with remarkable ra- 
pidity. 

It occurred to me that this method might be adapted 
to the heating of iron cauteries, which are still heated by 
the slow and cumbersome method of the charcoal-fur- 
nace or the blow-pipe oil-lamps. The heating of the or- 
dinary platinum electro-cauteries leaves little to be de- 
sired, but this method is adapted only to the smaller 
cauteries, and cannot be used for the larger cautery- 
irons. 

A series of experiments which I made with this method 
of heating cautery-irons has convinced me that it is not 
only simple and effective, but also quite economical. As 
a result of these experiments, I find that the average 
current required is 15 amperes at 230 volts, and the 
average time for heating the cauteries three seconds. 
The cost of each heating, as estimated for me by Mr. 
Coleman Reed, of the Louisiana Electric-Light Com- 
pany, was about one-twelfth of a cent for one heating. 

The apparatus is exceedingly simple. The vessel 
that I use is the jar of an ordinary bluestone battery, but 
any glass jar with a capacity of one or two quarts will 
answer the purpose. The jar is filled three-quarters 
with a solution of borax, I part; sodium carbonate, 10 
parts ; water, sufficient to make a density of i .060. 

A plate of lead, one inch wide, is coiled around the 
bottom of the jar, and to this is soldered the positive 
terminal. The negative wire is passed across the top of 
the jar, as shown in the accompanying illustration, and 
the apparatus is complete. The wires should connect 
with the Edison current-system of 230 volts, which is 
available in most cities in the United States and Europe. 
The ordinary cautery-irons may be used, the wooden or 
hard-rubber handles affording all the insulation that is 



Read before the Orleans Parish Medical Society, April, 189s. 



August io, 1895] 



MEDICAL PROGRESS. 



15s 



required for the hand. It will be noted that I first place 
the neck of the cautery in contact with the upper (nega- 
tive) wire, then as the point or knob of the cautery 
touches the solution it immediately becomes red-hot, 
and, if left longer in the solution, white-hot. To one 
who has never seen this method used before, the metal 
becoming heated on being immersed in a watery solu- 
tion, and showing its briUiant incandescence through the 
water, the effect is very astonishipg. 




When we investigate the cause of the heating effect 
the theory that it is due to the resistance of the metal, as 
in the ordinary platinum electro-cauteries, will not explain 
the effect in this case. Fifteen amperes at 230 volts for 
three seconds would certainly not heat this large cautery 
perceptibly ; and if it were a question of the resistance of 
the metal, it would become heated at the neck, where 
the resistance is greater, instead of at the large, rounded 
part. 

The passage of the current through the iron no doubt 
has a slight heating effect, but the intense heat generated 
is due to another cause. When the electric current is 
passed through the solution electrolysis is set up, o.xygen 
being liberated from the lead plate (positive terminal) 
and hydrogen from the immersed instrument, which is 
in contact with the negative terminal. This thin layer 
of hydrogen has a very high resistance, and at once be- 
comes intensely hot and communicates its heat to the 
metaUic instrument. The great heat of the hydrogen 
causes it to combine with the oxygen of the air, and 
this combustion adds to the heat of the cautery. 

In experimenting with various metals for this process 
I find that the ordinary cautery-irons, as sold by instru- 
ment-makers, will answer every purpose. If made of 
copper, however, a somewhat longer time is required to 
heat them, but they will retain their heat for a longer pe- 
riod of time. 

While the cautery-irons belong to the domain of gene- 
ral surgery, still I have found it serviceable to keep cer- 
tain ones on hand. Quite recently I found this method 
of heatiug a cautery-iron useful in controlling an alarm- 
ing hemorrhage after tonsillotomy, which the Paquelin 
thermo-cautery had failed to control. 

As most hospitals and offices are supphed with the 
Edison current for illuminating purposes, this apparatus 
may be introduced with but little expense. The ad- 
vantages of the method are its simplicity, reliability, and 
economy. 

3723 Prytania St. 



MEDICAL PROGRESS. 

The Palliative Treatment of Jaundice due to Malignant 
Obstruction.— KvsSELL {Edinburgh Medical Journal.^ 
July, 1895, p. 35) has reported a case of malignant dis- 
ease of the pancreas in a woman eighty-five years old, 
with obstruction of the common bile-duct, occasioning 
intense jaundice, with profound symptoms of cholemia. 
A proposition to reUeve the obstruction by operation was 
at first declined, and only consented to late in the dis- 
ease when the conditions were most unfavorable. The 
patient lived only thirty hours after the operation, and 
post-mortem examination disclosed the existence of pri- 
mary carcinoma of the head of the pancreas, without 
secondary involvement. The question is raised whether 
an operation for the relief of the misery and discomfort 
of a deepening cholemia is not so humane a procedure 
as tracheotomy for mahgnant laryngeal disease, as gas- 
trostotomy for malignant esophageal stricture, or enter- 
ectomy or enterostomy for malignant intestinal obstruc- 
tion. The advisability of operation would, of course, 
depend partly upon the possibility of making a diag- 
nosis that could reasonably be regarded as accurate or 
complete. If the obstruction to the bile-duct were above 
the cystic duct, operative interference would be ineffec- 
tual, but with obstruction below that point draining the 
gall-bladder would remove the jaundice. Thus, a dis- 
tended gall-bladder would indicate and warrant opera- 
tion. If the gastric symptoms were not only prominent, 
but clearly attributable to gross involvement of the 
stomach, the removal of the jaundice would not give 
sufficient relief to warrant operation. If, on the other 
hand, the gastric symptoms appeared to be due rather 
to the jaundice than to a coarse lesion the relief of the 
jaundice would be followed by gastric relief. The pres- 
ence of a duodenal lesion would not contraindicate 
operation. Even clear involvement of the liver would 
not necessarily be a contraindication so long as the dis- 
tention of the gall-bladder showed that the hepatic duct 
was not blocked. The most perfect cases for operation 
would, of course, be those in which the lesion was con- 
fined to the head of the pancreas. 

Extirpation of the Spleen for Echinococcus-cyst. — At a 
recent meeting of the Berlin Medical Society, Hahn 
{Berliner klinische Wochenschrift, 1895, No. 26, p. 576) 
reported the case of a woman, thirty-five years old, who 
presented a tumor as large as a child's head in the left 
hypochondrium, which had been noticed since the last 
labor, three months before. With the patient recum- 
bent, the tumor extended upward to the left costal arch 
and downward into the hypogastric region, but not 
beyond the median line. Its surface was smooth, and 
its lower portion presented a sharp border, with an in- 
dentation. The tumor was but little sensitive and very 
freely movable. Distention of the bowel was followed by 
restriction of the limits of the mass. The patient had lost 
greatly in weight and strength, and desired to be relieved 
by operation. Heart, lungs, and kidneys presented no 
abnormality. A long incision extending an equal dis- 
tance above and below the umbilicus disclosed a tumor 
in connection with the spleen, and provided with a 
pedicle of about the thickness of two fingers, constituted 
principally of vessels. The swelling conveyed a sense 



'56 



THERAPEUTIC NOTES. 



[Medical News 



of fluctuation. The capsule was thin, bluish-black in 
color, and in places presented yellowish-white spots of 
the size of a pea. It was concluded that the formation 
was either a hemorrhagic cyst, an echinococcus-cyst, 
or a cysto-sarcoma of the spleen, and after mature de- 
liberation its removal, with the spleen, was decided 
upon. Accordingly, the pedicle was doubly ligated in 
six or eight sections with fine silk, and the spleen and 
new-formation removed, the pedicle replaced, and the 
abdominal wound closed. There was no complication ; 
the temperature scarcely rose above the normal ; bodily 
weight was at first lost, but later considerably increased. 
The proportion of colorless to red blood-corpuscles on 
the day of operation was i to 1 60; in the succeeding 
days, I to 300 ; then i to 400 ; and four months after the 
operation, i to 600. No swelling of the thyroid gland 
or of the lymph-glands was observed, and also no pains 
in the bones. 



Dysphagia due to Abnormal Arrangement of the Great 
Vessels. — Kellock and Batten {Lancet, No. 3747, p. 
1579) have reported the case of a healthy boy, two years 
and ten months old, who was severely choked while eat- 
ing an apple, although nothing could be found in the 
larynx. The child was kept under observation for the 
night, but was dismissed quite well on the following 
morning. Nearly eight months later he was again hur- 
riedly brought under observation with the history that 
he had suddenly choked while eating dinner. He was 
cyanosed and breathing with some difficulty. While 
awaiting treatment he became much worse and ceased 
to breathe altogether. The trachea was opened at once 
and artificial respiration performed for two-and-one-half 
hours, but without restoring breathing. Upon post- 
mortem examination a small blood-clot was found in the 
trachea, which had been opened by division of the 
fourth, fifth, and sixth rings. A large mass of granular- 
looking material (probably sausage) was found lying 
fairly loosely at the back of the pharynx, but it is un- 
certain whether or not it occluded the upper opening of 
the larynx. On dissecting the arteries arising from the 
aorta the following arrangement was found : There was 
no innominate artery ; the two common carotids came off 
practically together, the left following the usual course, 
but the right crossing the trachea from the left side just 
above the sternal notch, to reach its usual position on the 
right side of the neck. The left subclavian came off 
from the arch of the aorta next, and followed a normal 
course ; then came the right subclavian, arising from the 
descending part of the arch, and crossing obliquely 
behind the esophagus between this and the spine and 
behind the right scalenus anticus muscle to its usual 
situation at the root of the neck. 

The Distinction of Syphilitic Neoplasms from Other New- 
growths. — At the recent meeting of the German Medical 
Congress, Esmarch {W'iener mcdisinische Blatter, 1895, 
No. 26, p. 413) dwelt upon the peculiarities of syphilitic 
neoplasms, of which he had recently seen some forty. 
The cases belonging in this category usually present 
other manifestations of past or present syphilis, or give a 
history of that disease in parents or brothers or sisters. 
All tumors developing in the voluntary muscles should 
be viewed with suspicion. These occur most commonly 



in the muscles that flex and extend the head, in the 
abdominal muscles, in those of the back and of the 
legs, and also in the tongue. Especially suspicious are 
those growths that recur at regular intervals after 
extirpation, and which may be dispersed by the admin- 
istration of potassium iodid in large doses. Likewise 
those growths should be viewed with doubt that disap- 
pear after the internal administration of arsenic, and 
also after attacks of erysipelas or the injection of the 
toxins of that disease. The mode of growth is not dis- 
tinctive, some attaining considerable size rapidly, par- 
ticularly after traumatism, while others grow slowly; 
neither is the consistency of the growth characteristic. 
Anatomically, syphilitic tumors present areas of fatty 
degeneration in the midst of grayish-red granulation- 
tissue. In case of suppuration the tumor should be 
removed surgically. Some syphilomata are not clearly 
distinguishable, even with the microscope, from round- 
cell or spindle-cell sarcomata. 



THERAPEUTIC NOTES. 

The Treatment of Human Tuberculosis with the Blood-serum 
of Goats Inoculated with Tuberculin. — At a recent meeting of 
the Soci6te de Biologie, Boinet {Compt. Rend. Hebdom. 
des Seances de la Soc. de Biologie, 1895, No. 25, p. 543) 
related that he had found in a series of experiments that 
the blood-serum of goats previously inoculated with tuber- 
culin had a controUing influence upon the development 
of human tuberculosis in guinea-pigs. Of a number of 
animals thus treated and subsequently inoculated with 
miliary tubercle the large majority resisted infection, a 
number of pregnant females even giving birth to healthy 
offspring. Upon the basis of these observations similar 
serum was next employed in the treatment of eight cases 
of tuberculosis in human beings. In three cases of slow 
progress, with dry cough or scanty expectoration, the 
results were favorable. In two cases in the second stage 
of the disease marked amelioration resulted. The treat- 
ment is thought to be of no avail in the advanced dis- 
ease, associated with excavation, but rather in tubercu- 
losis of slow course, with exacerbations, accompanied 
by fever, hemoptysis, night-sweats, and laryngeal com- 
plications. 

The Treatment of Diphtheria with the Antitoxin. — At a 
recent meeting of the Berlin Society for Internal Medi- 
cine, EuLENBURG [Deutsc/ie medicinische U'ochenschrift, 
1895, No. 29, p. 472) made a preliminary report of the 
results of a collective investigation as to the results of 
the treatment of diphtheria with the antitoxin. Of 10,240 
cases, 5790 were treated with the antitoxin, with a mor- 
tality of 9.5 per cent., while 4450 were treated without the 
antitoxin, with a mortality of 14.7 per cent. 

Pencils of Salicylic Acid and Chrysarobin. — 

R. — Chrysarobin .... 10 grams. 
SaHcylic acid . . . . 20 " 
White wax . . . 20 '' 

Lanolin . . . . . 50 " 

— .hnerican Journal of Pharmacy. 



August io, 1895] 



RECENT SANITARY LEGISLATION. 



IS7 



The Medical News. 

A WE E KL Y JOUR NA L 
OF MEDICAL SCIENCE. 



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SATURDAY, AUGUST 10, 1895. 



RECENT SANITARY LEGISLATION IN 
PENNSYL VANIA. 

Although sufficient time has not elapsed for the 
publication of the official volume comprising the 
acts passed by the Pennsylvania Legislature at 
its session just closed, we are advised through the 
Department of Agriculture of the approval of two 
acts having significant relations to the food-supply 
of the State. All attempts to secure an act con- 
trolling the n"'ilk-supply along the lines that have 
for a number of years been followed by the Board 
of Health of this city failed, partly from the organ- 
ized resistance of the milk-dealers and partly from 
the unwillingness of the farmer-contingent to accept 
regulations that seem to be based upon purely theo- 
retic views. By whatever motives of self-interest either 
of the opposing parties may have been influenced, 
it would probably have been more in the interest of 
the community at large if the Philadelphia officials 
had conceded something to the practical experi- 
ence of the producers and purveyors of milk. The 
farmer-element is too strong in almost every State 
in this Union to permit the passage of laws that 
appear as even slightly opposed to its interests. 

Some legislation, however, was secured concerning 
the milk-supply, namely, the passage of a brief act 



forbidding the addition of preservatives to milk. 
The terms of the act are comprehensive enough to 
exclude almost any article likely to be used for the 
purpose. It is generally known to sanitary chemists 
that the preservatives most commonly employed are 
boric acid and borax, with occasionally salicylic 
acid. There is much dispute as to the harmfulness 
of these ingredients, but as the law is specific in 
forbidding them, and as it is now pretty clearly 
established by numerous decisions of the United 
States Supreme Court that the right to declare a 
particular article injurious to the public health is 
reserved to the individual States in accordance with 
their laws, there is little doubt that the act can be 
used to prevent the use of these materials. That 
they are extensively employed, especially in the 
summer season, is well known. Many of them are 
sold as proprietary articles, without notice as to 
their composition, with more or less ingeniously 
worded certificates, from irresponsible chemists, as 
to harmlessness, and are used recklessly by the milk- 
dealers, of whom it may be said that while they are 
undoubtedly to blame for using anything that is 
foreign to the milk, they may in part be excused by 
the dependence which they are induced to place 
upon the indorsements furnished by the manufac- 
turers of the preservatives. 

In addition, however, to this specific act, a gen- 
eral food-law is now in operation, the enforcement 
of which is committed to the Department of Agri- 
culture, and not, as might have been expected, to 
the State Board of Health. This somewhat unusual 
arrangement has arisen from the fact that two years 
ago the Legislature created the office of Dairy and 
Food Commissioner as an agent of the State Board 
of Agriculture for the enforcement of the oleomar- 
garin-law. At the last session a Department of 
Agriculture was created, and the Dairy and Food 
Commissioner brought into that department. His 
powers were extended so as to include all the duties 
of supervising food-adulteration. The act is brief, and 
does not include specifically alcoholic beverages or 
drugs. In its phraseology it follows acts that have 
been passed elsewhere, and it is in slight conflict 
in one respect with the oleomargarin-act, inasmuch 
as the latter is absolutely prohibitory, and does not 
require the prosecuting officer to show a knowledge 
of the nature of the material sold, while in the 
recent act the prohibition applies generally to all 
kinds of food, and permits the sale of an article for 
what it is. Some interesting legal sparring may 



158 STATUS OF SURGICAL TREATMENT IN PUERPERAL SEPTICEMIA. [Medical News 



be expected when prosecutions begin under this 
law. 

All efforts in the direction of the prevention of 
food-adulteration must be regarded as merely ex- 
perimental. Not only are laws passed with too little 
knowledge of the facts to secure a practical protec- 
tion, but the interest of many manufacturing estab- 
lishments, employing large capital, and capable of 
exerting pressure upon legislators, will be arrayed 
against many phases of restriction. Then it must be 
borne in mind that the newspaper press of the coun- 
try is so completely subsidized by advertisers that 
no expression of public opinion contrary to the 
interests of such advertisers is to be expected. 
Acts, therefore, intended to secure publicity as to 
the composition of proprietary articles meet with 
the denunciation of all leading newspapers the 
moment the legislative situation becomes such as to 
suggest to the manufacturers of those remedies the 
necessity of opposition. 

Legislation has also been enacted in Pennsylvania 
providing for the inspection of cattle, mainly sug- 
gested by the dangers of tuberculosis. We shall 
probably derive more substantial benefit from this 
source than from the food-laws noted. 

THE STATUS OF SURGICAL TREATMENT IN 
PUERPERAL SEPTICEMIA . 

The treatment of puerperal septicemia has hith- 
erto been palliative and expectant, both on account 
of the difficulty in localizing the infective process 
in given cases and from the elusive character of the 
symptoms. Although there are instances in which 
surgical treatment is demanded, we still have to 
deal with cases that are entirely beyond the reach 
of surgery. In the first class either the point of 
origin of the infection or the area made continuous 
with it by means of the lymphatic circulation re- 
mains the seat of the developed process ; in the 
second class the toxemic element influences the 
aspect of the disease. 

There are two sources of error to be guarded 
against in the management of cases of puerperal 
septicemia amenable to surgical treatment: First, 
the difficulty in determining the seat of infection — 
whether it be extra-peritoneal or intra-peritoneal, 
the chance of drainage outward in the first instance 
and the necessity of either partial or total extirpa- 
tion of the pelvic organs in the second depending 
upon the accuracy with which we differentiate the 
seat of infection ; second, the choice of time for 



operation — whether in the early absorptive period 
of the disease or in the developed stage. 

Pathologically, the form of infection in these 
cases depends upon the character of the infecting 
elements and upon the degree of local resistance. 
If we were able to establish the relation between the 
symptoms and the pathologic process in each case 
we should be enabled to differentiate between those 
cases amenable to surgical treatment and those be- 
yond its aid. In this, however, the difficulty in 
treatment lies. 

The disease in its development assumes one of 
three forms, considered anatomically : First, a 
local infection, the result of necrotic endometritis 
extending by lymphatic involvement to the pelvic 
connective tissue. Second, a localized suppurative 
process terminating in either a phlegmon of the 
broad ligament or an ovarian abscess. Third, a 
general infection, expressed locally by a diffuse 
peritonitis, the res ult of active absorption by means 
of the lymphatics of infective material from the 
original seat of infection, and generally by the 
symptoms dependent upon pyemia. 

Surgery is applicable probably only to the second 
division of cases, and if we exclude curettage from 
the radical surgical procedures the field is extremely 
limited. Total extirpation of the uterus is recom- 
mended in puerperal parametritis with suppurative 
lymphangitis of the uterine tissue, and the class of 
cases in which this association appears might be in- 
cluded in the first division. In the last division of 
cases surgical treatment is inevitably fruitless. 

Practically, the landmarks by which we are to 
choose our way are misleading. This is best illus- 
trated by the character of the symptoms in acute 
septic toxemia (sapremia). In this form of the 
disease the physical signs, as well as the symptoms, 
may, on the one hand, point to a parametritis 
with uterine involvement, or on the other to a 
localized suppurative process, whereas the local 
process may be entirely subordinate to the general 
expression of the disease, so indistinctly do the diag- 
nostic points present themselves. Every practical 
obstetrician must have encountered cases in which 
the signs of a local infectious process have been 
present, namely, local infiltration, intestinal paral- 
ysis, and fetid lochia, perhaps together with the 
pain of peritonitis and the irregular temperature of 
suppuration, and yet post mortem not a single local 
indication is to be found that would have warranted 
surgical interference. 



August io, 1895] 



EDITORIAL COMMENTS. 



159 



In view of these facts it seems fitting to enter a 
plea for the closer study of diagnosis in connection 
with puerperal septicemia. Skill in diagnosis will 
depend largely upon two factors — always excluding 
the essential ability for painstaking observation, 
characteristic of the scientifically qualified practi- 
tioner — first, upon the amount of practical experi- 
ence to be counted among the resources of the 
diagnostician, and, secondly, the degree of general 
and special training he has received in the observa- 
tion of symptoms. 

As a rule, the men who are best able to operate 
are those who unfortunately are least able to separate 
mentally the operative from the non-operative cases, 
because they have usually met with only the former. 

May not our reliance, therefore, upon surgery 
yield in some degree to an appreciation of the art 
of diagnosis, whether diagnostic acumen be the 
criterion of either obstetric or surgical skill ? 



EDITORIAL COMMENTS. 

Trinity Ciiurch Tenements.— In a report before us, just 
issued by the Corporation of Trinity Church, New York, 
an effort is made to refute the charges laid before the 
Tenement-house Reform Commission last December, 
reflecting seriously on the management of the property 
held by that church. 

Mr. Frederick L. Hoffman, statistician, was engaged to 
study the death-rate and the causes of mortality among 
the population of the Trinity tenements, and his article 
forms the principal part of this report. 

Several previously published letters are appended, 
and one written by the rector of the church contains 
these words : " As to model tenement-houses the corpo- 
ration is not without experience. It has already erected 
ten such houses, not one of which has incurred the 
criticism of the committee ; but not one of them is full, 
and, if filled, they would not net more than 4 or 5 per 
cent., and in fact have not netted more than 3 per cent.'' 
A few lines further on it is said that " the trustees do 
not feel that it is their duty to engage in enterprises 
which do not commend themselves to busimss judg- 
ment." Here the whole matter rests. The world de- 
mands that a religious body, whose object is the further- 
ance of morality, shall conduct whatever it undertakes 
on ethical principles, no matter what the pecuniary 
consequences are, and when it ceases to do this it must 
submit to censure. A friend of Trinity in another letter 
published in the report reiterates the fact that Trinity 
Conducts its business as other business is conducted, and 
that it is " a harsh judgment which insists that the work 
of removing old and (unsanitary) rookeries and con- 
structing new buildings shall proceed faster than the 
interests of the corporation demand." 

Which interests we ask ? The business interests 
would never demand their removal, as the best-paying 
property is that which is the most unsanitary, namely, 
the hovels of the slums. 



Mr. Hoffman's work shows a careful study of the 
records, but is open to several criticisms, which, if just, 
would invaUdate his arguments that Trinity tenements 
are healthier than other houses in the same locality. 

We agree with Mr. Hoffman that it is wrong to com- 
pare the death-rate of a group of individuals situated in 
one part of the city with the death-rate of the entire 
population ; and also that it is not always fair to com- 
pare the health of one-thousand individuals with that 
of one-million, though living under similar conditions ; 
but we would add that it is not proper to compare one set 
of tenements with another set, though situated on the 
same street, without analyzing the elements in the 
population of each. Thus, if negroes inhabit one row 
of houses and Jews another, other things being equal, 
the sanitary condition of the two tenements may be 
equally good, yet the death-rate would be much smaller 
among the Jews than even the general death-rate, 
while among the colored it would be much greater. 

Another fact that Mr. Hoffman has ignored is the 
proportion of children living in Trinity tenements as 
compared with the proportion in other portions of the 
district. The greater the number of children under five 
years of age, in a given population, the greater the 
death-rate will be. 

The methods made use of by Mr. Hoffman to prove 
that Trinity tenements are more sanitary than other 
houses in the same locality, namely Ward 8, District A, 
are as follows : First, he compares the death-rate of 
Trinity population for the year 1891 with that of the dis- 
trict for the same year, and finds a difference in favor of 
Trinity ; but, as Mr. Hoffman states, the time-element 
is too limited, and so he makes use of other methods. 
Forty-one "selected tenements" are compared with 
eighty-three Trinity tenements for a period of two years, 
and again Trinity makes a favorable showing, although 
the specially selected tenements are not in the same 
locality. The third method used is the comparison 
between the mortality in Trinity tenements and the 
mortality of the district for a period of six years, although 
the periods are different, that for the tenements being 
from 1889 to 1894, and that for the district from 1885 to 
to 1 8 90. When a small population is concerned some 
slight epidemic in one year might materially alter the 
mortality-rate. 

In a table compiled by Mr. Hoffman, showing the 
causes of death in the tenements for the period 1S89-94, 
the zymotic diseases are shown to be less prevalent 
than in the wards of the city at large, and from this he 
concludes that the charges of the Board of Health that 
the unsanitary condition of the Trinity tenements is 
the cause of an excessive death-rate cannot be substan- 
tiated. 

That the property in question "is not so bad as it 
was painted" is probably proved by this private inves- 
tigation, but it would have been more convincing if the 
analyses were more complete, and if a commission of 
disinterested persons had been invited to make the 
investigation. 

The corporation has still to meet the charge that its 
tenements are not all that they should be. They may 
not be as unsanitary as they were reported to be, but are 
ihev as keaHJiy and as free from fault as they might be? 
is Trinity corporation like so many individual philan- 
thropists and churchmen, who preach morahty on Sun- 



i6o 



EDITORIAL COMMENTS. 



[Medical News 



day and endow hospitals and schools, while in their 
business relations they are as grasping and unbrotherly 
as they possibly can be, and, when they are taken to 
task for their hypocrisy, respond that business principles' 
are one thing and brotherly love principles something 
entirely different ? Their employes are bought in the 
cheapest market and taken advantage of whenever 
possible. Property must yield 5 per cent, per annum, 
no matter who suffers. 

The issuing of this report on the sanitary condition 
of Trinity Church tenements does not in the least satisfy 
the demands of public opinion, namely, that a pro- 
fessedly religious body should endeavor to conduct its 
business affairs on the same ethical basis as its spiritual 
affairs are conducted, and if it does not do so, then it 
deserves public censure. 

Orthographic Ignorance and Medical Ability. — There can 
be no question that men have shown ability to do good 
intellectual and social work of undoubted value to civil- 
ization who could not spell ten words correctly. It is 
said that there is in the United States Senate to-day a 
millionaire who was formerly the Mayor of his native 
village, and that in the town-records his signature to 
hundreds of documents exists with the official title 
"mare" (for J/iyo?), appended by himself. It needs 
only to be added that he was a good Mayor, and had 
at least good /lorse-stnsc, and is to-day a better legislator 
than most of his associates. Just as frankly may it be 
admitted that many a physician of the present, as of 
past generations, is unable to master the difficulties of 
English orthography. 

But, and here's the rub, that day is either past or 
should be past. It is by everyone admitted, and by 
none more fully than by the combined good physician 
and poor speller, that without the preliminary education, 
evidenced at least by correct spelling of one's native lan- 
guage, the modern physician is now and henceforth not 
only handicapped, but utterly outclassed in the race of 
life. It is not that knowledge of spelling will make one 
the better physician, but the lack of that knowledge 
certainly guarantees other lacks that squarely debar 
from the higher education essential at this day. It has 
been said that without money, or a certain amount of it, 
one cannot get what money alone cannot buy, and it is 
much the same with preliminary education. In the or- 
thographic ignorance of the recent graduate there is, 
moreover, a bit of hypocrisy to be exposed. Somebody is 
" uttering false paper," as the lawyers would say, or false 
sheepskins — or, in plain English, some one is lying. All of 
our medical colleges are pretending that their preliminary 
examinations are real and not tricky shams and frauds. 
What is the fact ? Have genuine preliminary examina- 
tions been held in the cases of men who spell after the 
manner of those cited herewith ? Nay, in their " final 
exams.," preparatory to graduating them, what was the 
condition of mind of their professorial examiners ? 

The following list of words is culled with exact spell- 
ing from the papers of those examined by the " Board 
of Medical Examiners, representing the State Medical 
Society of Pennsylvania," at its last examination. 
■'Some of these gentlemen," writes the examiner, who 
kindly sends us the list, " were graduated this year by 
medical colleges in Philadelphia :" 



Athromatous. 


Murmer. 


Adhear. 


Matress. 


AUways. 


Ment (meant). 


Araaloid. 


Nassuae (nausea). 


Apatite. 


Oscultation. 


Apetite. 


Profalactic. 


Accute. 


Phomates (fomites). 


Assleep. 


Purilent. 


Amediately. 


Posable (possible). 


Aeriated. 


Possiable. 


Alsow. 


Phremitis (fremitus). 


Breight. 


Phrematis ( " ). 


Brane. 


Parencamo (parenchyma 


Be did (done). 


Prespiration. 


Hurried. 


Pereferal (peripheral). 


Boath. 


Pacific (gravity). 


Brite. 


Puffey. 


Currants (of air). 


Pacient. 


Choryza. 


Pail (pale). 


Corhiza. 


Quarrentine. 


Cystolic. 


Quarenteened. 


Crysis. 


Quarintine. 


Caracteristic. 


Rhals. 


Clavical. 


Rahls. 


Consolodation. 


Rals. 


Chillie (chilly). 


Rhumatism. 


Countinence. 


Resoiver (reservoir). 


Cronic. 


Resivore ( " ). 


Cricis. 


Resivour ( " ). 


Cealing. 


Resinous (resonance). 


Drosiness (drowsiness). 


Resonence. 


Doeing. 


Rubish. 


Draft (draught). 


Read (blood-corpuscles) 


Dissease. 


Sess-pool. 


Dropsey. 


Sibylant. 


Diastallic (diastolic). 


Sheats(bed). 


Detale. 


Sturnum. 


Dillated. 


Surs](sewers). 


Extream. 


Suden (sudden). 


Embarissed. 


Sudent ( " ). 


Exhaels. 


Sleight (amount). 


Fatial (facial). 


Straighten. 


Faulse. 


Snezing. 


First str.ata. 


Sourse. 


Furnature. 


Sputem. 


Froothy. 


Sputtum. 


Filller. 


Steralise. 


Hyealin (casts). 


Stich (pleuritic). 


Herd (heard). 


Swoolen. 


Heigh (high). 


Stomack. 


Hedacke. 


Skinn. 


Indiscression. 


Sower (sour). 


Jerms. 


Tare (apart). 


Knapkins. 


Theraly (thoroughly). 


Klebs-Lefra (bacillus). 


Ulser. 


Clebs-Leffer. 


Vessles (blood). 


Layety. 


Vescles ( " ). 


Lisis. 


Virolent. 


Liberaly. 


Woolen. 


Malays (malaise). 


Wollen. 


Manuburm (manubrium). 


Yealds. 



Nostrum-advertising in Medical Journals. — The Medical 
Society of the State of Pennsylvania has sent out the 
following circular, to which we heartily subscribe : 

'lo Editors and Publishers of Medical Jourtiah : 

As a committee appointed for that purpose we desire 
respectfully to call your attention to the following ex- 
tracts from minutes showing the action taken by the 
Trustees of the American Medical Association and by 



August io, 1S95] 



EDITORIAL COMMENTS. 



161 



the Medical Society of the State of Pennsylvania, respec- 
tively : 

" Baltimore, Md., May, 1S95. 

" Report of the Trustees of the American Medical Asso- 
ciation. 

" During the year no advertisements of secret reme- 
dies have been accepted that were not accompanied by 
a formula, but to comply still further with what appears 
to be the desire of a large number of those interested in 
the highest success of the foiirnal the editor, with the 
termination of the present contracts, has been instructed 
to accept no advertisements of medicinal preparations 
the proprietors of which do not give a formula con- 
taining the official or chemic natne and quantity of each 
composing ingredient to be inserted as a part of the ad- 
vertisement." 

" Chambersburg, Pa., May, 1895. 

" Resolved, That the Medical Society of the State of 
Pennsylvania congratulates the American Medical Asso- 
ciation upon the decision of the Trustees to exclude un- 
ethical advertisements from the fournal of the Associa- 
tion." 

" Resolved, That a committee of three be appointed 
to communicate with the editors and publishers of medi- 
cal journals in the United States, calling their attention 
to this action of the American Medical Association, and 
requesting them to accede to the wishes of the profession 
by adopting a similar rule." 

Allow us also fraternally to state : That we believe that 
the best interests of medical men are coincident with scien- 
tific accuracy, so far as this can be obtained : That the 
practitioner of medicine should therefore know in all cases 
the character of the drug, and the formula of the prepara- 
tion or chemic compound that he prescribes : That the 
use of a secret preparation, or nostrum, is undeniably 
unscientific, and cannot be intelligently defended : That 
hence the advertisement of such preparations by scien- 
tific journals is out of place ; its effect being to promote 
quackery and discourage scientific prescribing ; That 
we believe the exclusion of such advertisements will aid 
the circulation of medical journals, and give them a 
dignity and character not obtainable without such ex- 
clusion : That the hearty manner in which the action of 
the Trustees of the American Medical Association and 
that of the Medical Society of the State of Pennsylvania 
was received shows the very cordial indorsement by 
the profession of the policy here recommended. We, 
therefore, most earnestly, ask your careful attention to 
this subject, hoping and in behalf of this society request- 
ing that you will adopt a similar rule to that of the Trus- 
tees of the American Medical Association. 
Very respectfully yours, 

S. S. TowLER, M.D., 

Marienville, Pa. ; 

J. J. Buchanan, M.D., 

1924 Penn Ave., Piusburg, Pa ; 

C. H. Thomas, M.D., 

1807 Chestnut St., Philadelphia, Pa. 
Special Cotnmittee. 

Ariificial Caffein. — Another triumph for the laboratory 
has just been recorded in the synthetic manufacture of 
caffein. This is an important advance not only in itself, 



but also in its suggestion of future progress. The pro- 
cess requires as yet such an elaborate series of chemic 
operations as to make the cost of the product consider- 
ably above that of natural caffein. But only a mere 
simpUfication of the process is required to remedy this, 
and that is sure to come with perseverance and practice. 
This field has been a most tempting but barren one to the 
chemist for generations past. For a long time it seemed 
absolutely hopeless to attempt to rival protoplasm in its 
transforming and constructive powers. When at last the 
synthesis of urea was achieved, some fifteen years ago, 
it was hailed as a great triumph. Slowly but painfully one 
product after another has been achieved, but so far these 
have been mainly the results of excretory metabolism. A 
few months ago, however, the formation from inorganic 
materials of something seemingly identical with albu- 
min was announced, and now such a complex and 
active body as caffein has been reached. It looks as if 
not merely a new field, but a new world of possibilities 
were opening up to us. No less an authority than M. 
Bertillon is most sanguine about the prospect, and de- 
clares that it is only a question of time — and a short 
time at that — when we shall be able to construct all of 
our food-materials directly out of the elements without 
the assistance of either plant or animal. At present, 
however, it is much simpler to throw a few seeds into 
the soil and let them work the miracle for us, and we 
seriously doubt whether, even if by straining to the ut- 
most, we can imitate Nature's results, we can ever 
hope to attain to the ease, simplicity, and beauty of 
her processes. Bertillon's prediction, however, is cer- 
tainly among the possibihties — and how it would delight 
our vegetarian and our "peace-principles" friends! 
There would then be no more excuse for slaughter of 
any sort, no more animal foods to heat our blood and 
excite us to deeds of violence. Plants may be grown 
for their beauty and animals for the pleasure of their 
companionship, and meat-eating will become as unne- 
cessary as cannibaHsm has almost become. What a real 
millennium it would be ! Not only could the lion lie 
down with the lamb, but the butcher with the kid. In 
that Utopia would the ghost of Malthus rise up to warn 
— or perhaps to enjoy ? 

S. Weir Mitchell, M.D., LL.D.— The American medical 
profession must feel a deep sense of pride in the honor 
conferred upon one of its most distinguished members 
by the University of Edinburgh in granting its honorary 
degree of Doctor of Laws to Dr. S. Weir Mitchell, as 
"the chief ornament to medical science in the New 
World." Dr. Mitchell is well known not only as an 
able neurologist, but as a practical physiologist, and a 
strong all-around medical man, not to speak of his lyric 
and general literary abilities. Himself a prodigious and 
tireless worker, with a most fruitful and suggestive mind, 
the force of his example and the aid of his counsel have 
had a most potent influence for good upon those who have 
been fortunate enough to be thrown into professional 
relations with him ; and he has created a school of 
younger men who promise to carry on the good work in 
scientific medicine that he has begun. Dr. Mitchell is 
already rich in the possession of the Doctor of Laws 
degree of our own Harvard and of an honorary degree 
of Doctor of Medicine from the University of Bologna. 



l62 



REVIEWS. 



[Medical News 



REVIEWS. 

The Eye in its Relation to Health. By Chalmer 
Prentice, M.D. Pp.214. Chicago : A. C. McClurg 
& Co., 1895. Price, $1.50. 

Ophthalmology nowadays seems literally to teem 
with new truths, as a dog is said to teem with fleas. The 
present remarkable book has added to the number im- 
mensely. In the short space of 200 pages we have a 
cock-sure theory of inflammation, of hypnotism, of eye- 
strain, of drunk-cure, of all disease in fact. Like Pico 
of Miradola, the author treats de omni re scibili et qui- 
busdam aliis, especially the quibusdam aliis. Patholo- 
gists will be interested in the certain settlement of all 
the problems that torment them, and Keeley must now 
look to his laurels and his dollars. Ophthalmologists 
will be pleased to learn how diabetes and all other evils 
of human flesh can be cured by " fogging" and "re- 
pression" and tenotomies of eyes without a trace of 
ametropia or of muscle-imbalance. The origin of myo- 
pia and of astigmatism, and their cure, are real gems 
of ophthalmic wisdom. The learned author has studied 
the eyes of the dead with much diligence ; why did he 
not raise the dead with some of his new truths ? Per- 
haps he has done so, but with praiseworthy conservatism 
is waiting until a greater length of time and a greater 
number of cases shall warrant reporting. To the special- 
ist and his journal must be left extended criticism of this 
unique work. It will be "nuts" to them. The author 
has got hold of the tail-end, as it were, of some genuine 
truths, but the chief use of the volume, we suspect, if it 
have any influence besides a mirth-provoking one, will 
be to make "American ophthalmology," that sweet 
morsel in the cheek of European ultra-conservatism, 
still more the butt of just and unjust ridicule. It will 
perhaps also entrench the native skeptic in a dogmatic 
reactionism as pernicious and as extreme, as regards 
genuine ophthalmologic progress, as this poor sinner is 
guilty of in his furious whimsicality. As to his two great 
great discoveries, "Fogging" and "Repression," he is 
certainly an adept in the first, and it only remains for 
the profession to put the latter truth in energetic practice. 
We catch a glimpse of the true etiology of the author's 
discoveries in his praise of " orificial surgery " and simi/ia 
similibus. Lest it be thought we are too severe we quote 
a few illustrative passages : 

"In glaucoma one of the most popular treatments is 
iridectomy, also division of the ciliary muscle, called 
cyclotoiiiy." 

" Disease (as ovaritis) is localized abnormal innerva- 
tion, and always central in the nervous system, being a 
lack or excess of motive force. The growth of tumors 
is due to abnormal innervation. A lesion is always a 
result (of disease) not a cause." 

" So-called cures of dipsomania perform whatever 
good they effect by temporarily relieving eye-strain " (by 
the mydriatic in the "jab "). 

" Look into the dim windows of the brain twenty-four 
hours after death and a deviation of the eyes from a per- 
fect position will always be found." 

" A large percentage of consumption takes its origin 
from irritation through the visual centers." 

" Latent hyperopia where mydriatics fail." 

" Nervous ailments are not so common in foggy 
climates, because the sight-centers are not exercised so 
much as in a clear, bright view." 



Defective Speech and Deafness. By LilheEgin- 
ton Warren. New York: E.S.Werner, 1895. 

In this little book Miss Warren shows that " fluent 
speech may be obtained and understood by all who 
suffer from the different phases of deafness and the 
different degrees of imperfect utterance." The little 
book contains, furthermore, many valuable hints for the 
physical, ethical, and moral training of any child, 
whether deaf or not. In Chapter I it is maintained that 
the "first positive proof of hearing is in the young 
child's outcry of pleasure when affected by music or 
other sound;" in Chapter II, that " through the sense 
of hearing the aft'ections are reached; " and in Chapter 
111, that talking aids thinking and further intellectual 
development. In Chapter IV is advanced the idea that 
"in the healthful exercise of the lungs (in speech) lies 
the prevention of pulmonary diseases to which the deaf 
mute is peculiarly subject." In Chapter V" the child 
suddenly deaf and the child growing deaf slowly" are 
considered. It is shown in this chapter that the most 
unjust treatment for a partially deaf or partially mute 
child is to remove it from school-association with chil- 
dren who hear and speak well. Deprived of such influ- 
ences the defective child grows worse. " A child pos- 
sessing but a small amount of aural power, who has 
once had a good perception of sound, could maintain 
his place in any ordinary school, if, from the first mani- 
festation of his deafness, he were taught to use his eyes 
in the place of his ears." 

In Chapter VI the very important fact that "the deaf 
child does not know what sound is," and the vital neces- 
sity, as well as the possibility, of " teaching the deaf to 
hear " with the hearing most of them still retain to at 
least a slight degree, are presented. In Chapter VII it 
is shown that the " hard-of-hearing adult," having, 
through hereditary influences, acquired language by the 
ear, may by educative means continue to enjoy conversa- 
tion by the eye. 

In Chapter VIII dull pupils, usually those "merely 
suffering from a defect in hearing," in Chapter IX "in- 
vented" or "pathological language," and Chapter X 
" lisping and careless speech in general," are consid- 
ered. In the latter chapter " the sentence-method of 
teaching pupils to read," says the author, " I fear will 
only increase the slovenly speech of American chil- 
dren." . . . " I would urge that teaching to read be 
an exercise founded on knowledge of the mechanism 
of speech." Chapters XI and XH treat respectively of 
" stuttering and stammering " and " cleft palates. " 

Obstetric Surgery. By Egbert H.Grandin, M.D., 
Obstetric Surgeon to the New York Maternity Hos- 
pital, Gynecologist to the French Hospital, etc. ; and 
George W. Jarman, M.D., Obstetric Surgeon to the 
New York Maternity Hospital, Gynecologist to the 
Cancer Hospital, etc. Royal octavo, 220 pages. 
Philadelphia: The F. A. Davis Co., 1895. 

Drs. Grandin and Jarman have written a thoroughly 
practical work upon a teaching-basis, and, therefore, 
necessarily one of paramount interest. There is much 
in it worthy of special note — far more than we have 
space to give to it — and a few points only that we can- 
not indorse. Fifteen photographic plates, showing the 



August lo, 1895] 



REVIEWS. 



163 



stages of the various obstetric operations as performed 
upon the manikin, are distributed throughout the book, 
and with the eighty-five illustrations in the text con- 
tribute materially to the teaching-value of the book. It 
is to be regretted, however, that the drawings could not 
have been largely taken from Nature. The advantages 
to be derived from thorough asepsis and antisepsis are 
ably set forth, and some valuable suggestions as to the 
perfection of the antiseptic management of labor are 
offered. Notably may we mention in this respect the 
preference shown for creolin as an obstetric antiseptic 
agent. Creolin, with the possible exception of lysol, is 
the safest and most efficient pharmacopeial agent in 
obstetric surgery, not only as a germicide, but also as a 
lubricant, and as such we can strongly indorse the posi- 
tion taken in the remark that " the vaselin-pot " — and 
we might add the lard-pot — " should once and for all 
be banished from the lying-in chamber." The section 
on pelvic deformities could very easily have been more 
thoroughly elaborated, but the various obstetric opera- 
tions are generally presented in a concise and practical 
manner. A certain degree of inaccuracy may be noted, 
especially in grammatic construction and in orthog- 
raphy. Thus, we are acquainted with Baudelocque's 
valuable work in obstetrics, but his name appears 
strangely unfamiliar when spelled Bt-audelocque, and 
sentences such as the following, on page 12, are, to 
say the least, not euphonic : " It cannot be emphasized 
too strongly that the physician is to-day not guiltless 
who, whenever it may be, does not practice pelvim- 
etry." Hypercriticism is never justifiable, but such 
defects as the foregoing mar perceptibly a truly valuable 
work. As it stands, the book must be recommended 
as a serviceable one for the student of obstetrics. 



Atlas des Gesunden und Kranken Nervensvstems 
Nebst Grundriss der Anatomie, Pathologie, 
UND Therapie Desselben. Von Dr. Christfried 
Jakob. Mit Einem Vorwort von Prof. Dr. Ad. v. 
Strumpell. Munich: J. F. Lehmann, 1895. 10 
marks ($2.50). 

This atlas of normal and morbid conditions of the 
nervous system, which is the ninth volume of the series, 
is largely the result of observations made at Striimpell's 
clinic at Erlangen, and contains seventy-eight plates, 
mostly colored, and fourteen woodcuts, with descrip- 
tive text. The illustrations cover serially the general 
morphology of the nervous system, its development and 
structure, its topographic anatomy, and its general and 
special pathology. The text proper, to which 194 pages 
are devoted, discusses, in addition to the subjects illus- 
trated, the anatomy and physiology of the more impor- 
tant nerve-paths, the general and special therapeutics of 
diseases of the nervous system, and, briefly, a number of 
diseases of unknown origin or localization, including 
exophthalmic goiter, myxedema, akromegaly, tetany, 
and tetanus. The concluding section comprises sugges- 
tions as to the best methods of preserving, preparing, 
and studying nervous tissue. Altogether the work ap- 
pears to be well and faithfully done, and should prove a 
useful aid to the student of diseases of the nervous sys- 
tem. 



Skiascopy and its Practical Application to the 
Study of Refraction. By Edward Jackson, 
AM., M.D., Professor of Diseases of the Eye in the 
Philadelphia Polyclinic, etc. With 26 illustrations. 
Philadelphia : The Edwards and Docker Co., 1895. 

All ophthalmologists will welcome Dr. Jackson's 
little manual. It is an authoritative and excellent ex- 
position of the subject with which it deals. We agree 
essentially with the author in his estimate of the value 
of this method, in the hands of those who have mastered 
it — a mastery, however, not easily obtained. The re- 
fraction ophthalmoscope and ophthalmometer do truly 
"give very inferior information." Of course, the only 
reliable test for the refraction of intelligent adults and 
young people is the subjective test with the test-types 
and test-lenses. But for children, for some amblyopic 
eyes, and for the stupid, skiascopy is the most trust- 
worthy objective method and has the field. Another 
use for it that may be found is in hospital and even in 
private practice, in the hands of those who have not the 
desire or the time to do the most accurate work by the 
subjective method — a method that requires patience, 
time, and care. 

Early Scoliosis, or Curable Curvatures of the 

Spine. By Percy G. Lewis, M.D., M.R.C.S., etc. 

Illustrated. Pp. 50. London : John Bale & Son, 1895. 

English monographs are often disappointing to 
.Americans on account of their small size, but, as they 
contain much practical information in a short space, 
one has but to read them carefully over and over to 
increase their value indefinitely. 

This little work before us contains much of real value 
upon the treatment of curable scoliosis, and this includes 
the majority of cases treated early and persistently. 

The importance attached to hygiene, especially fresh 
air ; exercise short of fatigue ; improved habitual posi- 
tions ; the discarding of supporting apparatus ; the de- 
velopment of groups of weakened muscles ; to be fol- 
lowed by a course of general gymnastics, are all to be 
heartily commended and indorsed. The relations of the 
surgeon to the gymnastic-master are well pointed out, 
but the importance of massage and Swedish movements 
appears to have been neglected. 

The Middlesex Hospital. Reports of the Medi- 
cal, Surgical, and Pathological Registrars for 
THE Year 1892. London : H. K. Lewis, 1894. Price, 
2/6 net. 

The medical and surgical reports comprise, each, a 
summary of diseases and abstracts of cases ; and as an 
appendix there follows a " Summary of Gynecological 
Cases." The extensive post-mortem tables of the patho- 
logic report contain the record of 296 cases, of which 
172 were medical and 124 surgical. 

Among the interesting abstracts of exceptional cases 
in the medical report is one of my.xedema in a woman, 
who was " placed under the 'thyroid' treatment" and 
recovered. 

Dr. Samuel S. Adams, of Washington, D. C, who has 
been Professor of Clinical Pediatrics in Columbian Uni- 
versity, has been elected to the Chair of Diseases of 
Children in the University of Georgetown. 



164 



BRITISH MEDICAL ASSOCIATION. 



[Medic\l News 



CORRESPONDENCE. 

SO-CALLED OTO-MASSAGE. 
To the Editor of The Medical News. 

Sir : Much has appeared within the past year in the 
medical periodicals, especially in the United States, 
upon so-called oto-massage, or passive motion in some 
form, applied to the ear for the improvement of hearing. 

The procedures described and advocated by the 
writers of these articles may be divided into two 
classes : first, methods of systematic acoustic exercise of 
the scnsi of hearing by repeating vowels and isolated 
words near the deaf ear — the method of Urbantschitsch, 
of \'ienna ; and, second, procedures consisting in the 
application of direct force by pressure-sounds, probes, 
etc., to the membrana tympani and the malleus, and the 
conduction of musical notes and simple vibratory motions 
by various apparatus directly into the auditory canal — 
so-called pneumo-massage and phono-massage. 

The first class of procedures, the only ones with an 
otologic status, are not new with Urbantschitsch, as he 
admits (\M,-ner mciiziiiische Pnssc, October 21, 1S94), 
having been already described and tried by Itard, 
Toynbee, and Benedikt long before. The improvement 
in hearing that Urbantschitsch has obtained in the ver)- 
deaf is marked in some cases ; but relapses, he states, 
ensue in all of them. The improvement he has eiTected 
by his acoustic exercises he regards as an intellectual 
rather than a sensorial one, as does also Benedikt {^Ber- 
liner k'inisdu- Woclunschrift .]\i\\ 30, 1S94). 

So far as concerns the second class, all forms of 
masseurs, it may be said they have absolutely no scien- 
tific otologic standing, and were pronounced useless, and 
even harmful, in a discussion on the subject at the meet- 
ing of the .American Otological Society, May, 1S94. 

AH forms oi direcl pressure on the membrana tympani 
must manifestly bruise and wound this structure, while 
the direct conduction of sound from vibrating instru- 
ments, etc., into the external auditor)- canal fatigues the 
ear very easily, as some of its promoters admit, and must 
necessarily have the same kind of effect upon any ear 
weakened by chronic catarrh as the noise of the tele- 
phone has, or as that of pounding rivets into place has 
on the catarrhal ear of boilermakers. It is plain, there- 
fore, that all procedures of the second class must do 
harm to the patients, and their exploitation, as of late 
in some American medical journals, savors of methods 
I hesitate to name. Truly yours, 

C. H. BURXETT. 

SOCIETY PROCEEDINGS. 

BRITISH MEDICAL ASSOCIATION:- 

Surly third Annua/ Meeting;, held at London, July jo 
and ji, August I and 2. /Sgj. 
First Day— July 30TH. 
Sir J. Russell Reynolds, delivered 

THE president's ADDRESS. 

After referring to the last meeting of the British Med- 
ical Association in London, in 1S73, presided over by the 

' From adv.ince-sheets kindly furnished by the British Medical 
Journal. 



late Sir William Fergusson, and when the address in 
medicine was delivered by the late Edmund .Alexander 
Parkes, he referred to the vast strides that had been 
made in the elucidation of both structure and function — 
such, for example, as in the researches upon the thyroid, 
the adrenal bodies, the spleen, and the liver ; the ad- 
vance of bacteriology ; the functions of the axis-cylinder 
of nerves ; ind the magnificent prospect of a new field 
of therapeutics in the serum-treatment of disease. 

Attention was called to that which may be considered 
the most striking fact of modern physiologic, pathologic, 
and therapeutic research, namely, the power of " living," 
things for both good and evil — namely, in the conserva- 
tion of health and in the prevention or cure of disease. 
The mineral and inorganic world has helped much, but 
now help and hope come mainly from organized pro- 
ducts and still living agencies. 

The delicate phenomena and suggestions of " li\'ing " 
and "chemic" functions are under minute sur\-ey, 
analysis, and detail — the points where they touch, the 
mode in which facts of either may be rendered in terms 
of the other : their bearings upon the life of animals and 
men, both as individuals and as parts of a community ; the 
diagnosis of the most obscure diseases, and the tenta- 
tive and more than tentative endeavors to counteract 
poisons, which can be separated but not destroyed, 
over-ruled but not abolished. 

In the schools there has been great improvement in 
the mode and scope of teaching ; and this especially in 
its being less didactic and more practical. Much of the 
old-fashioned, often dreary-, ''lecture" of an hour's 
duration has passed away, and in its place is a " demon- 
stration," an "object-lesson," a conversation, or exami- 
nation. These are more useful and therefore more 
attractive to the students ; and, at the same time, more 
tr\nng, but none the less efficiently rendered by the 
teachers. 

.Again, in clinical teaching there are much more and 
closer personal relationships, not only between physician 
and student, but between student and patient. The 
latter is not a mere " dummy " in a bed, exhibited as a 
specimen of this disease or that, but a " human being" 
to be spoken to and to help the student to find out 
whether or not the card at the head of his bed, on which 
the diagnosis of his malady is supposed to written, is 
correct, or as full as it might be. 

Then there is another point particularly noticeable 
when demonstrations are being gi\'en, either at the bed- 
side or in the laboratory, namely, the far greater interest 
and earnestness that characterize the student of to-day 
as compared with his predecessor. Much of this is due 
to the indulgence of a larger hope. Hidden as still are 
the great mysteries of life, there are yet definite facts to 
be gr.asped by the mind, to be seen and handled, not 
only imagined or asserted : and the pkace of these facts 
in the economy of Nature, their bearing upon others, 
and their relation to work yet to follow, give a precision 
and confidence to study that is, comparatively speaking, 
of modern growth. There was plenty of assertion and 
show of knowledge in the past ; but even the teachers 
did not believe the half of what they taught, nor com- 
prehend the half of their sage pronouncings. Nature 
has. as it were, taken man more into her confidence, and 
daily reveals so much, even while concealing more, that 
the learner stands fimilv on the ground he has gained, 



August io, 1S95] 



BRITISH MEDICAL ASSOCIATION. 



16; 



instead of trembling on a quagmire, the length, and 
breadth, and depth of which he could not see and did 
not care much to imagine or investigate. He felt sure 
of little then but of his own and his teacher's ignorance, 
but now he grasps much that is ascertained truth, and 
such as can be seen, shown, measured, and recorded 
with perfect accuracy. 

There are some points in the present state of scientific 
precision in which it would appear that but Httle ad- 
vance has been made. Much more is known about 
diseases, their origin, their anatomy, pathology, inter- 
relations, modes of ending, and their treatment; but 
with regard to nosology and nomenclature there is little 
of which to be proud. Groups of symptoms have been 
described by different observers as marking some tolera- 
bly distinct departures from recognized types of malady, 
and, for want of any nosologic position being assigned 
to them, they are called after their first describers' names, 
and so we have not only Bright's disease, Addison's, and 
Graves', but a host of others, often indeterminate in 
character, going by the name of Friedreich, Raynaud, 
Hodgkin, and others, until there is a fair prospect of 
every distinguished pathologist or clinical investigator 
being handed down to posterity as a disease, the name 
of which conveys no semblance of a meaning as to its 
nature. Still further, and more to be deplored, there 
are smaller groups of symptoms that are not honored 
by receiving the names of their describers as separate 
diseases, but the names of the observers are tied on to 
the symptoms ; and so Cheyne-Stokes' breathing, Cor- 
rigan's pulse, von Graefe's sign, somebody's else phe- 
nomenon, and a multitude of other like phrases are 
used, to the great confusion of the student, and not 
only so, but to his real and permanent injury. For 
what is easier to say than that there is "Cheyne-Stokes' 
breathing," except to feel a sense of rest in having made 
use of that learned phrase, and so practically to shut the 
door to further inquir)' as to what it means and how it 
comes about, what its diagnostic or prognostic value 
may be, and how it bears on therapeutics ? 

Of course, to give the proper name to a disease is to 
place it where it should be, nosologically, " at home,'' 
and understood ; but medicine is not a science yet suf- 
ficiently " ordinated " for this thing to be done, and so 
we grope about, and " gather dust and chaff," with little 
chance or hope of turning them to value ; and instead 
of making this the matter of most serious investigation, 
and finding the true relation between the new " group 
of symptoms" and those others which form the central 
facts, the backbone and whole skeleton of patholog)', 
we lay hold of the first piece of red tape ready to our 
hand, tie up the group of symptoms in a bundle, and 
label it Brown's, Jones', or Robinson's disease ! 

At the very time that there is this increasing use of 
loose phraseology, there is also — as is common enough 
in other departments of life — a marked tendency in the 
opposite direction, and that is to connote as diseases 
certain groups of symptoms by some short, or long, 
and often not very appropriate word or words, such as 
akromegaly, hypertrophic pulmonary osteo-arthropathy, 
appendicitis, pseudo-hypertrophic muscular paralysis, 
and others. There is abundant precedent for this ; 
some are time-honored and old enough to be allowed 
to live, such as pertussis, epilepsy, apoplexy, chorea, 
gout, and rheumatism, which have the merits of brevity 



and of meaning ; but there have crept into ordinary- 
conversation nowadays a number of expressions which 
aid us little, or not at all ; and such words as gastro- 
jejunostomy and laparotomy do httle more than lay 
us open to the satires of the playwrights of the last cen- 
tury in foreign countries, and its predecessors in our 
own. 

But whatever may be our failures — and they are small 
compared with our enormous successes — there is noth- 
ing that has happened during the past twenty years to 
be compared in importance with the new revelations that 
have been made of the potency and pre-potency of life 
— the power of life in life — in health, in disease, and in 
its treatment. These include the interpretation of much 
of the functions of certain organs, the existence of which 
had been known for many years, but the utility of which 
had been absolutely unknown, for example, the pitui- 
tary body, the thyroid gland, the suprarenal capsules, 
and others. 

The knowledge of the functions of the liver and the 
spleen has been gradually increasing for a long time, and 
only by slow degrees have the current notions of the meta- 
bolic properties of these organs taken the place of the older 
ideas of secretion of bile and balance of weight. It has 
been, on the other hand, although the outcome of serious 
investigation, but also somewhat by a fortuitous concourse 
of thoughts and events, that the most astounding revela- 
tions of modern physiology have been made. What 
we have come to know amounts to this in general terms 
— that the absence of certain organs, of the functions 
of which, until quite recently, we knew nothing defi- 
nite, leads to grave and diverse diseases of the body, 
whether this absence be brought about by surgical 
operation, or by disease more or less individual or 
specific in its character, and that, such being the case, 
the supply of the material of that organ as food, or some 
part of it, as an extract, to be introduced into the blood, 
removes the symptoms, acts with great promptitude, 
and, one might say, almost with some violence of dis- 
turbance of the whole economy. Not only so, but these 
extracts seem to possess a power reaching far beyond 
that which was first found to be their almost anticipated 
result — that is, in so modifying the action of the heart 
and the intravascular pressure, in a manner and to a de- 
gree entirely unlooked for, and requiring much further 
investigation ; in order to unravel the true nature of the 
functions of those organs in health, and the value they 
may have, by their products, on the processes and treat- 
ment of disease. As yet we are only on the threshold 
of still greater discoveries in regard to life, but we see, 
through the portal, ranges of facts which are trustworthy 
guides as well as sign-posts, and which will, we believe, 
lead us to a larger knowledge of those recondite pro- 
cesses of life in its most essential and characteristic 
features — namely, of the nutrition of all organs, of the 
way in which this is brought about, and of the interde- 
pendence of all tissues, so that, perhaps in a far higher 
sense than we have ever realized before, the truth may 
be revealed that " when one member suffers all the 
others suffer with it," and the reason of this may be ex- 
plained. 

A very obvious consideration which should " give us 
pause " in self-congratulation is this, that as in past 
days the functions of different parts of organs, the kid- 
neys, for example, were more or less clearly separated 



i66 



BRITISH MEDICAL ASSOCIATION. 



[Medical News 



by physiologists no longer with us now ; so we have 
seen recently that only certain portions of other organs 
have the physiologic effects just discovered, and thus 
that there may be in what we have regarded as much 
simpler organic components, even in quite simple tis- 
sues, some unconsidered element of function, some sine 
qua non of healthy life, some missing link in the phe- 
nomena of disease, so that it behooves us to keep the 
mental eyes wide open, to clear away all films of preju- 
dice or hasty complacency, to expect the unexpected, 
and so, without looking for it, to find our reward. 

Not less important than the matter just referred to is 
the recent development in " microbiology" and "all 
that therein is." The "germ-theory" of disease is not 
new. When it commenced, and who has the credit of 
its begetting, is not known. Probably, like ancient and 
modern heroes, it had many parents, and as many home- 
steads. It is quite clear that the great Harvey enter- 
tained it. Years later it was a hobby ridden by many, 
but without much convincing proof. 

The most important fact with regard to recent micro- 
biologic research is the gradually increasing appreciation 
of the fact that these lower forms of life exert, not ne- 
cessarily mischievous, but, indeed, benignant influences 
on the human body, and that although the mode of 
their operation is not fully explained, they take part in 
healthy processes, assisting normal functions, nay, in- 
deed, it would seem sometimes producing them and 
warding off the malign effects of other influences to 
which we are habitually exposed. These bodies to 
which we are indebted for this aid operate partly by 
chemic action and partly by what we must call a vital 
process, and by their cultivation outside the human 
body and their modification by passing through other 
organisms can be made to exert a malign or a beneficial 
agency on man. 

The third great revelation of the last twenty years is 
the wonderful protective and curative power of these 
living products. This, in a very wide sense, is not new. 
Of all the most powerful agents of destruction, the most 
violent have been derived from " living " things ; they 
are to be found in the animal and vegetable worlds, not 
in the mineral. In their most terrible malignity — such 
as in snake-bite, glanders, or hydrophobia — these need 
no human skill for their development ; they are pre- 
pared in the laboratory of Nature, and, alas, are only 
too ready to our hand. Next to these come the poisons 
of stinging things, and, after them, the more slowly 
operating and less deadly animal infections ; some with 
indeed beneficial influence, as " vaccinia ; " others with 
local effects on the skin, but not often great disturbance 
of the general health. 

The vegetable kingdom can produce potent poisons, 
such as belladonna-berries, aconite-root and leaves, 
poppy-juice, and the ignatia bean ; but in order to ren- 
der these more deadly the hand of man has to come in 
and prepare nicotin, strychnin, morphin, and the like ; 
just as it may produce from the mineral or quasi-mineral 
world such potent agents as hydrocyanic acid, concen- 
trated acids, and other dealers of destruction. 

The interest in these facts lies in the modern mode for 
their utilization. The great potency of living products 
has led to very fanciful notions in therapeutics ; and 
there have been those who, to cure diseases of organs, 
have given portions of the same but healthy organs of 



animals or of man or other animals. Again, the idea 
has been pronounced that even excreta were useful 
drugs, and that the diseased organs of man might effect 
a cure of those supposed to be afflicted in like manner. 

Curious as some of these details are, they are of real 
interest to us only as they lead up, through inoculation 
for smallpox, to Edward Jenner's discovery of vaccina- 
tion, and then, through the researches of Pasteur and 
Brown-Scquard, to our present state and plane of knowl- 
edge. It would seem now that there is scarcely any 
limit to what may be expected in the cure or prevention 
of disease ; and the most striking of all phenomena is, 
to my mind, the probability of rendering an animal im- 
mune by the introduction into its organism of a healthy 
constituent of the body of another. This, if fully con- 
firmed, will be the greatest veritable triumph of thera- 
peutic medicine, instituted and guided by extended in- 
quiry into comparative anatomy, physiology, and path- 
ology. As in the human race or species there exist, as 
is well known, what may be termed " idiosyncrasies" — 
by which is simply meant that as a matter of fact some 
people, and some people's families, escape epidemic 
diseases, whereas they are especially prone to take others 
to which they may be exposed — so in the great economy 
of Nature certain groups of animals have been shown to 
exhibit no capacity for " taking," or for even being 
" inoculated " with the poisons to which others are ex- 
posed, and from which they suffer, and that severely. It 
would seem, therefore, that use may be made of these 
animals, more or less naturallv immune from certain 
maladies, and that their immunity may be partially con- 
ferred on man. 

Quite recently a communication of the greatest im- 
portance has been made on the rendering of animals im- 
mune against the venom of the cobra and other snakes, 
and on the antidotal properties of the blood-serum 
of immunized animals. This subject has occupied at- 
tention during the last six years, and we must all look 
forward with expectancy and hope to the possible and 
probable diminution of a great national and imperial 
calamity. 

The outcome of all this is that the scattered fragments 
of knowledge and "guesses of truth" of many years 
have been gathered into a focus during the past twenty- 
five years ; that the vegetable life, extracting from the 
mineral world the materials it needs for growth and the 
production of powerful agencies for good in the form of 
food and medicines, and for evil in the form of poisons, 
has given itself up to the growth of animal life, with its 
much more complex organs, and for the cure of ills once 
thought beyond the reach of human aid ; but that, 
thanks to man's scientific ardor and industry, it has 
again shown itself to be our servant, our helper, and 
our protector. 

These are not dreams of the study, they are facts of 
the laboratory and of daily life; and in using that 
word " life '' again, emphasis is to be laid upon the belief 
that it is to living agencies and their employment that 
we must look for help in the care of infancy, the con- 
duct of education— moral, mental, and physical — the 
training up of character as well as of limbs ; that it is the 
guidance of living functions, in the choice of living oc- 
cupations, be they either of hard work or of amuse- 
ment ; it is to these we must appeal if we would see the 
mens Sana in corpore sano ; and then it will be to these 



August lo, 1S95] 



NEWS ITEMS. 



167 



that we may confidently look for help when the inroads 
of age or of disease are at hand, often to cure us of our 
trouble ; or, if not, to give us rest and peace. 

Speaking of the " professional " life, it was said that as 
physicians and surgeons, however numerous, we do not 
constitute a " body " of men unless we have some one 
prevailing spirit, common to us all. The profession may 
include its thousands and tens of thousands, but it is a 
crowd, a multitude, or a '' mob," unless there is in it an 
esprit dc corps ; and, thanks to our great seats of learn- 
ing, our universities and colleges, we have developed 
this uniting spirit now for many years. But our own 
special colleges of physicans and surgeons, our medi- 
cal societies, and especially this vast Association, have 
done more within the last fifty years to give real, unify- 
ing hfe to its individual members than was possible, or 
even expected to be possible, by our forefathers. 

That so large a body of men should be banded to- 
gether under one common name means that they have 
some common purpose and some common plan of co- 
operation to attain it. 

What that purpose is we know, namely, to render our 
profession of the highest service, not only to the indi- 
vidual but to the State, by taking our share and giving 
our advice in the making of our laws, so far as they af- 
fect us, as members of our profession ; by the regula- 
tion of our charities ; the guidance and control of labor ; 
the care of the pauper and the pauper child ; the luna- 
tic and the quasi-lunatic, or the habitual drunkard; by 
the care of our poorer brethren ; by the advance of sci- 
entific researches, and especially of those that require 
combined efforts and combined funds for their prosecu- 
tion ; by the promotion of useful and stable literature ; 
and by the elevation of all that constitutes the educa- 
tion of the man of science, the physician, the surgeon, 
or the guardian of the pubhc health. 

These noble purposes cannot be achieved, nor have 
any of them been carried to any useful extent, without 
self-sacrifice, as well as the sacrifice of time ; without a 
consideration of the views of others as well as an asser- 
tion of one's own ; without respectful regard to the feel- 
ings and positions of our colleagues, as well as a due 
estimation of those which we may occupy ; without pa- 
tience as well as work ; and an all-pervading sense of 
hope, in the midst of trying times and in the darkest 
hours. One thing, in addition, we should all most 
strenuously try to do, and that is to avoid waste of time. 
We may use it, or sacrifice it freely, but we cannot af- 
ford to throw away one moment ; whether it be on per- 
sonal ends, forlorn hopes, foregone conclusions, or 
threshed-out heaps of seedless fagots. 

Outside our professional life, but closely mixed with 
our daily work, is the " social " constitution, or, as some 
would call it, the " environment " in which we have " to 
live and move and have our being." Certainly it has 
changed much within the last twenty years, and it 
would be impossible to say in what ways we have ad- 
vanced, and in what others we have either retrograded 
or gone far, far out of the beaten track. The changes 
are on all hands, are pressing, importunate, and over- 
bearing. 

It would seem as if " reverence, that angel of the 
world," had from some regions taken flight, and that in 
her place were idols, or mocking shadows, or gorgeously 
apparelled lay figures. This absence of reverence shows 



itself everywhere, but, perhaps, it is possible to classify 
even such a negative quality and put its leading features 
under three great categories : (a) reverence for all that 
constitutes the religious element in life; (1^) for that 
which is the groundwork of " social " propriety, and one 
may say even of decency, as our predecessors would 
have thought ; and (6") for the constituted order of rela- 
tive dignity in " family " life. 

Finally, reference was made to the conduct of our 
profession to the "religious" element in our nature. 
Here we have nothing whatever to do with creeds, be 
they hoary with age or Hushed with the bloom of youth ; as 
members of the medical profession, we have to deal with 
those to whom these creeds mean much, and are, with 
what they entail to many, the be-all and end-all